HospitalInspections.org

Based on interview and record review, it was determined that the hospital failed to promote and protect each patients' rights.

Findings include:

1. The hospital staff failed to follow their grievance policy and did not ensure patients who had a grievance were given the appropriate resources and guidance in the grievance process.
(Refer to Tag A-0118)

2. The hospital failed to ensure patients participated in the development and implementation of his or her plan of care for one of 10 sampled patients and 8 supplemental patients. (Refer to Tag A-0130)

3. The hospital failed to provide care in a safe setting. (Refer to Tag A-0144)

4. The hospital failed to ensure patients were free from seclusion. (Refer to Tag A-0154)

5. The hospital failed to ensure patients were not administered chemical restraints to manage a patient's behavior or restrict the patient's freedom of movement that was not a standard treatment or dosage for the patient's condition. (Refer to Tag A-0160)

Based on interview and record review, the hospital staff did not follow their grievance policy and did not ensure patients who had a grievance were given the appropriate resources and guidance in the grievance process for 1 of 11 sample patients and 1 of 7 supplemental patients . (patient identifier: 17 and 18)

Findings include:

On 3/14/2022, the incident log for month of March 2022 was reviewed.

Review of the log revealed the following incident:

"patient (patient 17) reported to staff that he heard two staff members arguing loudly in hall and that he asked them to please keep it down when one of the employees (registered nurse (RN) 3) walked toward him, grabbed his shoulders, and shook him. She then proceeded to follow him down the hall when he walked away. Additionally, the patient and a peer (patient 18) on the unit both reported seeing RN 3 on the unit with a vape pen and said that she was acting 'spacey and forgetful' and smelled like alcohol. This was reported to HR (human resources) and Nursing supervisor."

On 3/15/2022, the incident report and investigation for the incident dated 3/9/2022, involving patient 17, was requested. At that time the director of quality and risk (DQR) stated they were still in the process of investigating the incident but would provide information he had. The incident report indicated the following:

"(Patient 17) reported that night staff was arguing loudly when he asked them to keep it down he says that RN (RN 3) walked up to him, grabbed his shoulders and shook him, then proceeded to follow him down the hall. (Patient 18) states that (RN 3) seemed spacey, forgetfully generally inebriated. She also claims she smelled alcohol on her breath. Both (patient 18) and (patient 17) report her walking the halls with a vape in her hands."

A review of the investigation report completed by the DQR revealed the following documentation:

" ...spoke with (patient 17) on 3/9/2022 who stated that he should not ever be touched by a staff member in a mental health setting and that he felt that the nurse was in the wrong. I spoke with a peer (patient 18) as (patient 17) stated that she also saw the vape pen and erratic behavior from (RN 3). Human Resources was contacted on 3/9/2022 and (RN 3) was placed on suspension pending the outcome of our investigation."

A review of the hospital grievance policy was completed. The policy indicated "All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS (Center for Medicare Medicaid Services) requirements are considered to be a grievance."

On 3/15/2022 at 2:39 PM, an interview was conducted with the assistant director of nursing (ADON). The ADON stated she was aware of the incident; it was reported to her on 3/9/2022. When asked if there was documentation concerning the incident other than the medical record of patient 17, the ADON stated there were two grievance forms in the human resources office and she would have them sent to the surveyors.

On 3/15/2022 at 3:52 PM, a follow-up interview was conducted with the DQR. The DQR stated he had no completed grievance forms concerning the incident. He had no evidence that a grievance had been filed. He stated human resources would not keep grievance forms in their office. The DQR stated he was told about the incident, then he went to talk to the two patients involved. He stated he had talked with the patients but was not aware of any official grievance. He stated a nurse completed the incident report and brought it to him.

On 3/16/2022 at 11:49 AM, an interview was conducted with the patient advocate (PA). The PA stated that if a patient had a grievance, they may complete a grievance form and put it in the grievance box. She checked the grievance box every other day. If the patient was still in the hospital, she would talk to them about the grievance. Sometimes a patient did not want to fill out a grievance. She would talk with them and ask if they would not mind filling one out. She stated she would take notes about what happened and from their perspective and try to validate what they said and what transpired. The PA stated she was not aware of a grievance concerning staff abuse with patient 17. She stated she would only be aware of it if a grievance form had been completed. The PA stated that her name and number was posted on the window of the nurses station. If a patient had a grievance, they could call her. The PA stated the incident regarding patient 17 was not reported to her. She only found out about it through gossip about a nurse being inappropriate, a nurse or a behavior technician, she was not sure. If there was a verbal grievance and she was made aware of it, she would have gone straight to the patient at that moment.

On 3/16/2022 at 1:46 PM, an interview was conducted with the DQR and the administrator (ADM). The DQR and ADM stated the PA would have been informed of the incident if a grievance form had been completed. The PA would have eventually been made aware if there was a grievance. When asked why no one went to patient 17 and asked him if he wanted assistance in completing the grievance form, the DQR stated if the patient had requested assistance they would have provided it. When asked about helping a child complete the form, the DQR stated the nurse told him about the incident. He talked to the patient and completed an incident report, so basically a grievance but not written. They handle it the same.

The DQR and the ADM stated they were not aware that the hospital grievance policy indicated that an allegation of abuse was automatically considered a verbal/written grievance.

Based on interview and record review, it was determined the hospital did not ensure patients participated in the development and implementation of his or her plan of care for one of 11 sampled patients. Specifically, the hospital did not explain revisions to patient 17's plan of care and treatment to the patient nor his legal representative. (Patient identifier: 17)

Findings include:

Review of the patient observation documentation form for 3/9/2022 revealed patient 17 was placed on increased precautions for sexually acting out (SAO) until patient 17 was discharged on 3/11/2022. No documentation was provided to indicate the reason for the increased precautions.

An evening goal sheet dated 3/9/2022 was completed by the patient. His goal for the day was to be calm and don't get mad". He indicated he did not meet the goal. He also indicated that people were difficult or challenging to him that day. The section "My questions to staff (nurse, doctor, therapist, tech): WHY am I on SAE (sexually acting out precautions)"?

The morning goal sheet dated 3/10/2022 was completed by the patient. The section "My questions to staff (nurse, doctor, therapist, tech): WHY am I on SAE?"

A psychiatry progress noted dated 3/10/2022 at 4:00 PM, indicated the patient 17's chief complaint was "ok, Why am I on SAO?" There was no documentation to indicate the reason why patient 17 was on SAO.

A review of the physician orders revealed the following orders:

a. "D/C (discharge) patient to home." The order was signed by the practitioner on 3/11/2022 at 11:30 AM.

b. " SAO precautions". The indication was "previous inappropriate behavior/sexual nature." The order was signed by the practitioner on 3/11/2022 at 11:45 AM. Note: patient 17 was placed on SAO precautions at 9:00 AM on 3/9/2022 and discharged from the facility on 3/11/2022 at approximately 5:30 PM.

On 3/15/2022 at 3:15 PM, an interview was conducted with behavioral health technician (BHT) 2. BHT 2 stated she did not know why patient 17 was placed on SAO precautions - she stated she knew he kept asking why he was put on SAO and did not know why. The BHT 2 stated the staff prior to me did not know either. It was not in our shift-to-shift report.

On 3/16/2022 at 11:33 AM, an interview was conducted with registered nurse (RN) 4. RN 4 stated he was told by the practitioner after the interdisciplinary team meeting (IDT)on 3/9/2022 to place patient 17 on increase precaution for SAO. He stated he was not given a reason as to why the patient was being placed on SAO precautions.

On 3/16/2022 at 12:15 PM, an interview was conducted with the practitioner who had visited with patient 17 on 3/9/2022. She stated she was covering for the attending practitioner that afternoon since the attending had gone out of town. She had not attended the IDT meeting on 3/9/2022. She was not aware of the reasons for patient 17 being placed on SAO.

On 3/16/22 at 1:46 PM, an interview was conducted with the administrator (ADM) and the director of Quality and Risk (DQR). The ADM and DQR both stated they did not know the reason why patient 17 had been placed on SAO precautions. The DQR stated the information should have been discussed in IDT and shared with those who needed to know. The ADM stated the hospital did not take notes during IDT meetings so there would be no way to determined what was discussed in the meeting, but there should have been documentation as to why patient 17 had been placed on SAO precautions.

Note: No documented evidence was provided to indicate the hospital had informed Patient 17's legal representative of the change in the plan of care and treatment.

Based on observation, interview and record review, it was determined the hospital did not provide care in a safe setting for 1 of 11 sampled patients, 2 of 7 supplemental patients and one observed unidentified patient. Specifically: 1. The hospital staff did not provide cares and treatment to prevent the contamination of a patient with a staphylococcal infection. 2. The transmission of blood borne pathogens for a patient with a bloody nose and the hospital. 3. Two employees were arguing in front of 2 patients which caused emotional distress. 4. Therapy was not provided to the patients who experienced emotional distress to help them process through the incident. (Patient Identifier: 12, 17, 18, and one observed unidentified patient).

Findings include:

1. Patient 12 was admitted to the hospital on 2/22/2022 with a diagnosis of psychosis.

Patient 12's medical record was reviewed on 3/14/2022.

On 2/22/2022 at 11:53 PM, an intake staff member documented on a "HIGH RISK NOTIFICATION FORM," that patient 12 had a "staff (sic) infec. (infection) L (left) Leg."

A "NURSE TO NURSE REPORT" was documented on 2/22/2022 at 5:45 PM. The hospital nurse that received the report documented that patient 12 had a sore to the left knee that was open. It was further documented patient 12 was on Bactrim (dosage instructions were not documented) since 2/18/2022 and had four more doses left to take.

An "INTAKE INFECTIOUS DISEASE SCREENING FORM," was completed by an unknown employee (signature not legible) on 2/22/2022 at 11:04 PM. The employee marked that patient 12 did not have a bump or infected sore on the skin.

An impaired skin integrity care plan was developed on 2/22/2022 related to the left knee superficial wound infection. It was documented that the treatment for the left knee infection was Mupirocin 2%. The short-term goal was that patient 12 would comply with wound care and infection prevention measures as directed by staff.

A physician documented on 2/23/2022 at 10:30 AM, that patient 12 was assessed. The physician documented that patient 12 had no rashes or wounds.

A nursing assessment, initiated 2/23/2022 at 8:30 PM and completed on 2/26/2022 at 4:00 PM, indicated that patient 12 had a sore to the left anterior knee.

An interview was conducted with the assistant director of nursing (ADON) and the director of nursing (DON) on 3/14/2022 at approximately 10:30 AM. The ADON and DON were asked how the hospital manages a patient with a staphylococcal infection to prevent the spread of the infection to other patients. The ADON stated that the hospital did not admit patients to the hospital that required that level of care, since they were a psychiatric hospital. The DON stated that patient 12 frequently removed the dressing that had been placed on the left knee wound. The ADON and DON stated they would look into why the staphylococcal infection had not been communicated to the staff as well as why the Bactrim was not continued at the time of admission to treat the staphylococcal infection.

An interview was conducted with the director of nursing (DON) on 3/14/2022 at 3:00 PM. The DON stated that patient 12's staphylococcal infection to the left knee was not reported after the intake employee received the information. The DON stated the Bactrim was "dropped" and did not provide additional information as to why it was not continued.

2. On 3/14/2022 at 8:09 AM, an observation was made of a female adolescent who had a bloody nose. The adolescent was sitting at a table with two other adolescents. There was a stack of tissues with blood that had been placed on top of the table. At 8:18 AM, the nurse on the unit placed pressure on the bridge of the nose and had the female adolescent lean slightly forward. The female adolescent stated, "I dripped on the chair." When the bloody nose was stopped, the female adolescent placed the blood soaked tissues on top of the table. The nurse then collected the bloody tissues in her hand and removed her gloves. At no time was the table or chair cleaned to prevent the spread of blood borne pathogens.

An interview was conducted with the DON on 3/15/2022 at 3:00 PM. The DON stated that the table and chair should have been cleaned to prevent the spread of blood borne pathogens.


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3. Patient 17 was admitted to the adolescent unit of the hospital on 3/4/2022, with admitting diagnoses of major depressive disorder, autism spectrum, and suicidal ideation.

On 3/15/2022 patient 17's medical record was reviewed.

Review of the nursing documentation revealed following:

a. 3/9/2022 at 10:15 AM - "During my morning assessment a patient (patient 17) reported that he was awakened the previous night by two staff who were arguing in the hallway. He states that when he came out to express his disgruntleness (sic) the nurse approached him and put her hands on his shoulders and began to shake him. He reports that this made him upset to the point he wanted to hit her but managed to refrain. He also reported that the same nurse was seen several times on the unit with her 'vape' which was triggering to lots of other patients and him as well since they are not allowed to smoke. I reported these concerns to my immediate supervisor and made a phone call to the patient's grandmother to inform her of her grandson's claims."

b. 3/9/2022 at 12:00 PM, "Pt (patient 17) very agitated, caused by incident with night staff and a peer interaction ...."

c. 3/9/2022 at 8:47 PM - "PT reports having homicidal ideations but seems in a better mood and spirits compared to this morning."

d. A Group therapy progress note dated 3/9/2202 at 2:00 PM indicated "Pt was feeling very anxious and took a PRN (as needed medication) to help. Medication made him really tired and unable to stay awake for group."

e. A patient observation note dated 3/10/2022 indicated "during expressive therapy, pt. (patient 17) stated that being here (HRH) (Highland Ridge Hospital) made him 'worse'."

f. A psychiatry progress note dated 3/9/2022 at 5:40 PM, indicated patient 17 had a "rough day", complained of fatigue, and was positive for frustration and anxiety/depression. The patient was guarded, irritable, anxious, and depressed. The section "*Explain abnormal findings" was left blank.

g. A review of his crisis safety plan revealed one of his triggers or stressors was being touched.

On 3/15/22 at 3:15 PM, an interview was conducted with behavior health technician (BHT) 2. BHT 2 stated she and RN 3 were having a conversation. RN 3 was working as a BHT because they needed the help. RN 3 stated she was going to sign as the RN since she was filling out the paperwork. BHT 2 stated that another nurse was the RN that night and RN 3 should not sign as the nurse. BHT 2 stated RN 3 kind of blew up and told BHT 2 not to question her. BHT 2 stated she did not see what happened between patient 17 and RN 3. She was told about it the next day. BHT 2 stated was on and off the unit getting the stuff.

BHT 2 stated she worked the next night on the unit. Patient 17 was very upset about the incident. He and patient 18 were "pretty glued" to each other and very antisocial. She talked to them separately and told them that she was there for them if they wanted to talk. BHT 2 stated both patients were very shut down, and very withdrawn. Patient 17 was more agitated. She stated you could tell something was wrong and something was bothering him emotionally.

On 3/16/2022 at 11:33 AM, an interview was conducted with RN 4. RN 4 stated patient 17 reported that the prior night he was awaken by a loud noise in hallway with 2 staff, 1 nurse and 1 BHT, were arguing about who was in charge. Patient 17 asked them to keep it down and went back in his room. Patient 17 stated came back out again because of noise and the nurse that was teching (working as a BHT) came over and put her hands on his shoulder and shook him. He mentioned he had some trauma in his life and doesn't like people touching him. RN 4 stated he asked patient 17 if he was sure she shook him and he stated yes, "she put her hands on his shoulder and shook me". RN 4 stated he was not sure of anyone else talked with patients 17 and 18.

Multiple requests were made for patient 18's medical record. The records were not provided during the survey process.

No documented evidence was provided to indicate that staff had helped patients 17 and 18 process through the incident or provided therapy.

Based on observation, interview and record review, it was determined that 1 of 7 supplemental patients, were not free of seclusion. Specifically, patients were placed in seclusion in a low stimulation area (LSA) without a physician's order. (Patient identifiers: 12)

Findings include:

Patient 12 was admitted to the hospital on 2/22/2022 with a diagnosis of psychosis.

On 3/7/2022 at 9:18 AM, the surveyor observed patient 12 at the nursing station. She appeared to be very anxious and was demanding medication. None of the staff members had addressed her while the surveyor was present. At 9:24 AM, the surveyor went in a room with a staff member for an interview. At approximately 9:40 AM, the surveyor heard screaming and yelling for help in the hallway just outside the interview room. The staff member being interviewed made a comment stating, "It's okay, that's just (patient's name omitted), she has issues and they're putting her in LSA." Later, review of the medical record revealed patient 12 had been put in seclusion during the time of the interview.

On 3/14/2022, at 8:45 AM, observations were made of the seclusion rooms on the adult acute care units. The rooms contained no furniture such as a bed or chair. The door to the rooms contained a small window for observation of the patient. Observations of the interior of the door revealed there was no door knob to open the door from the inside of the room. There was a small metal plate covering the area where the door knob would have been placed.

At that time an interview was conducted with registered nurse( RN) 4. RN 4 stated staff would place the patient in the seclusion rooms if they were acting out, or just needed a break from the unit. RN 4 stated he did not realize the doors of the seclusion rooms did not have an interior doorknob.

Patient 12's medical record was reviewed on 3/14/2022.

The behavioral health technicians (BHTs) documented that patient 12 was in LSA or seclusion as follows:

a. 2/23/2022 from 12:00 AM to 2:25 AM.

b. 2/24/2022 at 8:00 AM, "spent some time in seclusion ..."

c. 2/24/2022 at 10:00 PM, "spent some time in seclusion."

d. 2/24/2022 from 10:30 PM to 11:55 PM.

e. 2/25/2022 from 12:00 AM to 2:25 AM.

f. 2/25/2022 from 10:45 PM to 11:55 PM.

g. 2/26/2022 from 12:00 AM to 4:40 AM.

h. 2/27/2022 from 8:45 AM to 9:05 AM.

i. 2/28/2022 from 5:35 AM to 4:40 AM; 8:30 AM to 8:40 AM; 9:00 AM to 9:25 AM; 7:40 PM to 7:55 PM; 8:20 PM to 8:30 PM, 9:20 PM to 9:30 PM; 10:10 PM to 11:30 PM.

j. 3/4/2022 from 12:00 AM to 4:30 AM.

k. 3/7/2022 at 9:45 AM.

The hospital policy and procedure related to the use of restraints was reviewed. A mechanical restraint was defined as "Mechanical restraint includes the restriction or limitation of body movement by use of bed restraints (up to 4 points) in a Seclusion Room with restraint beds..."

The procedures for the use of the restraint were as follows:

"1. A trained registered nurse may initiate restraint in the absence of a practitioner. The attending physician/covering practitioner will be contacted during the initiation of restraint or immediately after.

2. The order shall indicate the reason and maximum duration of restraint.

3. A psychiatric practitioner may order restraint for a period of time not to exceed fifteen (15) consecutive minutes.

4. The registered nurse will document behaviors which led to the need for the use of restraint. ...

6. The patient shall be monitored and reassessed through continuous in-person observation.

7. The nurse in charge will assign trained staff to continuously monitor the patient during the restraint event. Continuous means ongoing without interruption.

8. A practitioner or trained nurse shall conduct an in-person evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status. The in-person evaluation includes the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the intervention. The evaluation must be completed even if the physical restraint has been discontinued prior to the in-person evaluation.

9. The practitioner or trained registered nurse will make a determination to end the restraint.

10. The patient shall be debriefed by a staff person to determine the sequence of events or circumstances that precipitated the need for restraint. Debriefing will occur within twenty-four hours of the incident unless the patient refuses, is unavailable, or there is a documented clinical contraindication.

11. The legal representative or an immediate family member as requested by the patient shall be promptly notified of the restraint.

12. The treatment plan shall be reviewed and revised following the first episode of restraint to include measures to prevent recurrence. Additional review of the treatment plan, with revisions as indicated, will occur if the patient is restrained on more than one occasion.

13. Staff who witnessed the precipitating events and/or who were involved in the restraint process will participate in the staff team debriefing session. Staff debriefing is to be documented on the Staff Team Debriefing form. ..."

There was no further documentation as to why patient 12 had been placed in the LSA or seclusion or that the hospital followed the policy and procedure for restraints as documented above.

An interview was conducted with the director of nursing (DON) on 3/14/2022 at 3:00 PM related to patient 12 being placed in seclusion. The DON stated patient 12 "may have just had her go in there for a moment." No additional information was presented as to why patient 12 was in seclusion or LSA or why the hospital policy and procedure related to seclusion was not followed.

Based on interview and record review it was determined chemical restraints were administered to manage a patient's behavior or restrict the patient's freedom of movement that was not a standard treatment or dosage for the patient's condition for one of 7 supplemental patients. (Patient identifier: 12)

Findings include:

Patient 12 was admitted to the hospital on 2/22/2022, with a diagnosis of psychosis.

Patient 12's medical record was reviewed on 3/14/2022.

A new order was received on 2/23/2022 at 1:15 AM to administer Zyprexa 10 mg (milligrams) intramuscularly (IM). There was no documentation as to why the Zyprexa was administered or what interventions were implemented prior to the IM injection.

On 2/23/2022 from 3:00 AM to 4:00 AM, the behavioral health technician (BHT) documented patient 12, "became agitated when she couldn't shower. Staff assist was called pt (patient) was given IM - pt was yelling and lunging at staff ..." There was no additional information documented related to the use of the IM injection or that a "staff assist was called."

A new order was received on 2/24/2022 (time not legible) to give Geodon 20 mg IM agitation/psychosis. There was no documentation as to why the Geodon was administered or what interventions were implemented prior to the IM injection.

On 2/24/2022 at 7:18 PM, a registered nurse documented, " ...Became agitated and aggressive. Threw water on staff. Was given Geodon 20 mg IM."

On 2/25/2022 between 12:00 AM and 2:00 AM a BHT documented that a staff assist was called and an IM injection was administered because patient 12 was denied a shower.

A new order was received on 2/25/2022 at 3:30 AM, to administer Zyprexa 5 mg IM. There was no additional information documented as to why the Zyprexa was administered or what interventions were implemented prior to the IM injection.

On 2/25/2022 at 12:30 PM, a new order to administer Zyprexa 5 mg orally for agitation was received. There was no additional information documented as to why the Zyprexa was administered or what interventions were implemented prior to the administration.

A new order was received on 2/28/2022 at 4:52 AM, Ativan 2 mg. There was no additional information documented as to why the Ativan was administered or what interventions were implemented prior to the administration.

A new order was received on 3/5/2022 at 12:00 PM, to administer Zyprexa 10 mg IM for "severe agitation/agresssion (sic)". There was no further documentation as to what "severe agitation/aggression" meant or what interventions were implemented prior to the administration.

The hospital policy related to restraint usage defines a chemical restraint as "a drug or medication used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. These medications are used in addition to or in replacement of the patient's regular drug regimen to control extreme behavior during an emergency. PRN (as needed) medications related to the diagnosis and presenting condition, which are ordered in response to exacerbation of normally anticipated symptoms and included in the plan of care for the patient are considered standard treatment and would not be classified as a Chemical Restraint."

An interview was conducted with the assisted director of nursing (ADON) and director of nursing (DON) on 3/14/2022 at approximately 11:00 AM. The ADON and DON were asked about the hospital policy for administering as need psychotropic medication usage. The ADON stated the staff should be documenting interventions attempted prior to the administration of psychotropic medications.

Based on observation, interview, and record review, it was determined that the hospital failed to develop and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance program.

Findings include:

1. The hospital failed to promote and protect each patients' rights. (Refer to Tag A-0115)

2. The hospital's governing body failed to assume full legal authority and responsibility for the operations of the hospital. (Refer to Tag A-309)

3. The hospital failed to ensure nursing services were furnished in a way that adequately met the needs of the patients. (Refer to Tag A-0385)

4. The hospital failed to maintain a complete and accurate medical record for each patient. (Refer to Tag A-0431)

Based on interview and record review, it was determined the hospital's governing body did not assumed full legal authority and responsibility for the operations of the hospital. Specifically, the governing body and quality assessment and performance improvement (QAPI) program did not identify and address patient quality care and safety concerns.

Findings include:

1. On 3/14/2022, an interview was conducted with the quality risk director (DQR) concerning the delay in medication administration for newly admitted patients. The DQR stated this had been an issue they identified in October 2021. The DQR stated the hospital had developed a process improvement plan to address the medication administration concerns and improving documentation.

During entrance on 3/7/2022, the quality meeting minutes regarding patient safety for the prior 6 months was requested.

On 3/7/2022, the monthly QAPI meeting minutes for September through February were received and reviewed. There was evidence of performance improvement (PI) activity for medication variances and overrides in all 6 months of meetings. There was also a PI activity for medical record documentation concerning precaution orders matching observation forms.

On 3/16/2022, the Governing Body meeting minutes for the past year, and their process improvement plans for medication errors and improving documentation was requested.

A PI plan for medication variances was received. The plan revealed that in October 2021, data was collected on the number of medication variances and overrides to the Automated Dispensing System (Pyxis) and showed an increase that could potentially lead to medications being missed and/or adverse drug events. Due to the potential risk of harm to patients and staff, a multidisciplinary team was formed to create initiatives for decreasing the amount of overrides of the Med Dispense device. The plan did not address the delay in medication administration to newly admitted patients. It also did not address any of the documentation issues that had been identified during the survey. A PI plan dated 3/15/2022 was received. The PI plan had been developed after the survey start date.

The governing body meeting minutes received did not contain documented evidence concerning the delay in medication administration to newly admitted patients or any of the documentation issues that had been identified during the survey. NOTE: the governing body meeting minutes had identified medication variances and overrides back in March of 2021.

2. The governing body did not assume full responsibility and accountable for the following:

a. Did not ensure patients received their medications timely.

b. Did not ensure staff were following the hospital's grievance policy, and did not ensure patients who had a grievance were given the appropriate resources and guidance in the grievance process.

c. Did not ensure the patients participated in the development and implementation of their plan of care.

d. Did not ensure care was provided in a safe setting.

e. Did not ensure patients were free from seclusion.

f. Did not ensure patients were not being administered chemical restraints to manage a patient's behavior or restrict the patient's freedom of movement that was not a standard treatment or dosage for the patient's condition.

g. Did not ensure they were staffing nursing and other personnel according to the acuity of patients.

h. Did not ensure the treatment for a patient with a staphylococcal infection to the knee had dressing changes completed.

i. Did not ensure effective communication and coordination of care.

j. Did not ensure medications were prepared and administered in accordance with the orders of the practitioner responsible for the patient's care.

k. Did not ensure all patient medical records were legible and compete.

l. Did not ensure patients had properly executed informed consent forms for the administration of psychotropic medications.

Based on interview and record review, it was determined that the hospital failed to ensure that nursing services were furnished in a way that adequately met the needs of the patients.

Findings include:

1. The hospital failed to ensure nursing services was adequate to provide nursing care to all patients as needed. Specifically, (1) The hospital could not provide evidence they were staffing nursing and other personnel according to the acuity of patients; (2) The treatment for a patient with a staphylococcal infection to the knee did not have dressing changes completed; and (3) The hospital failed to ensure effective communication and coordination of care occurred. (Refer to Tag A-0392)

2. The hospital failed to ensure medications were prepared and administered in accordance with the orders of the practitioner responsible for the patient's care. (Refer to Tag A-0405)

Based on observation, interview and record review, it was determined the hospital did not ensure nursing services was adequate to provide nursing care to all patients as needed. Specifically, (1) The hospital could not provide evidence they were staffing nursing and other personnel according to the acuity of patients; (2) The treatment for a patient with a staphylococcal infection to the knee did not have dressing changes completed; and (3) Communication and coordination of care did not occur for 2 of 7 supplemental patients. (Patient identifier: 11,12.)

Findings include:

1. On 3/7/2022 at 9:18 AM, on the Psych 2-unit one patient was sitting alone in the day room and the behavioral health technician (BHT) was seen coming in and out of patient rooms with garbage. Surveyors were told the rest of the patients were in the gym. On the Psych 1-unit patients were seen in the dayroom and hallway, the BHT was found coming out of a patient's room also with garbage; the BHT stated she was cleaning the patients' rooms.

On 3/7/2022 at 9:24 AM, an interview was conducted with BHT 2. BHT 2 was asked if she felt there was enough staff available to meet the patient's needs. She stated it was manageable when all the patients were on every 15-minute (Q15) checks and they were staffed like they are supposed to be. BHT 2 stated, on days when she was the only BHT and she had 6 to 7 patients on every 5-minute (Q5) checks with 11 patients total and had to clean rooms and complete other tasks, it was impossible to chart on that many patients every 5 minutes. BHT 2 was asked what happened if she could not chart on the patients. She stated that was not an option or she would get in trouble. BHT 2 was asked if the nurses were available to help. She stated most the nurses did not help the techs, she continued stating, that some did but most did not.

On 3/7/2022 at 9:45 AM, an interview was conducted with patient 1. Patient 1 had stated he thought there needed to be more BHT's because they always seemed so busy and stressed out. He also stated, he wished the hospital offered more therapy.

On 3/7/2022 at 10:00 AM, an interview was conducted with BHT 3. BHT 3 stated there was not enough staff. She stated they need to hire more technicians. BHT 3 stated the hospital usually staffs 2 technicians for 15-16 patients. BHT stated they had 14 patients on the unit that day with 1 one to one (one staff to one patient) patient and 8 Q5's on the shift. BHT 3 stated it was impossible to check the rooms and do the normal technician duties and do 8 patients' Q5 checks.

On 3/9/2022 at 10:00 AM, an interview was conducted with the assistant director of nursing (ADON) regarding staffing. She was asked what the responsibilities of a BHTwere. She stated they primarily do safety rounds. Rounding on every patient every 5 or every 15 minutes. She stated, the BHT should be looking at the patient for at least respirations if they are in their room. The dayshift BHT was to do all those rounds in the day room; they do not let patients in their rooms during the day unless ordered. The ADON was asked about any other responsibilities of the BHT. She stated, they also run a couple of groups on each unit; do room checks once a shift to search for contraband; and clean and wipe down high touch surfaces and vital machines. The ADON was asked how the matrix changed with the acuity of patients. She stated, they will staff up based on acuity and the amount of every 5-minute checks they have. She also stated, that in the event people call out they will make adjustments if needed. She stated they will also try and cap units, but if they already have too many patients and not enough staff they were stuck between a rock and a hard place and would try and call-in other staff and offer incentives so that they were willing to come in. The ADON was asked for the hospital Matrix that changed with acuity, and she stated they did not have a separate matrix for acuity.

According to the ADON on 3/7/2022, the detox unit had 3 Q5's; the Psych 1-unit had 1 Q5; and the Psych 2-unit had 5 Q5's. According to the BHT's the Psych 1-unit had a one to one in addition to the Q5's, and the Psych 2-unit also had a one to one and 8 Q5's. According to the hospital's matrix all 3 units would have been staffed accordingly, but that matrix did not consider the acuity of patients on each of those units.

The surveyors were unable to determine if the hospital was staffing appropriately because the matrix provided did not take patient acuity into account.



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2. Patient 12 was admitted to the hospital on 2/22/2022 with a diagnosis of psychosis.

Patient 12's medical record was reviewed on 3/14/2022.

On 2/22/2022 at 11:53 PM, an intake staff member documented on a "HIGH RISK NOTIFICATION FORM," that patient 12 had a "staff (sic) infec. (infection) L (left) Leg."

A "NURSE TO NURSE REPORT" was documented on 2/22/2022 at 5:45 PM. The hospital nurse that received the report documented that patient 12 had a sore to the left knee that was open. It was further documented patient 12 was on Bactrim (dosage instructions were not documented) since 2/18/2022 and had four more doses left to take.

An "INTAKE INFECTIOUS DISEASE SCREENING FORM," was completed by an unknown employee (signature not legible) on 2/22/2022 at 11:04 PM. The employee marked that patient 12 did not have a bump or infected sore on the skin.

An impaired skin integrity care plan was developed on 2/22/2022 related to the left knee superficial wound infection. It was documented the treatment for the left knee infection was Mupirocin 2%. The short-term goal was that patient 12 would comply with wound care and infection prevention measures as directed by staff.

A physician documented on 2/23/2022 at 10:30 AM, that patient 12 was assessed. The physician documented that patient 12 had no rashes or wounds.

A nursing assessment, initiated 2/23/2022 at 8:30 PM and completed on 2/26/2022 at 4:00 PM, indicated that patient 12 had a sore to the left anterior knee. The size of the wound and a wound description was not documented. Furthermore, the nurse did not document a wound treatment.

An order for the treatment of the left knee wound was not received until 3/3/2022 at which time the nurses were to "Cleanse L knee wound with wound cleanser, apply Mupirocin Ointment 2% topically to wound bed. Cover with adhesive dressing. Measure wound daily."

The hospital nurses documented the following related to patient 12's left knee wound:

a. 2/23/2022 at 5:20 PM, it was documented there was no skin issues.

b. 2/24/2022 at 1:56 AM, " ...Wound on L leg, posterior (sic) aspect of lower leg." No dressing changes were documented.

c. 2/24/2022 at 9:00 AM, a nurse documented that patient 12 had an open wound to the left. There was no documentation of a dressing change being completed. At 7:18 PM, " ...Pt is obsessive over wound on knee. Constantly takes bandage off despite nurse advising to leave it on." At 11:00 PM, the nurse documented, " ...She is still obsessing over her knee wound." The nurse did not document that a dressing had been placed on the wound.

d. 2/25/2022 at 6:00 PM, it was documented that patient 12 had an open wound to the left knee. There was no documentation that the nurse did a dressing change to the open wound.

e. 2/27/2022 at 5:00 PM, it was documented patient 12 had an open wound to the left leg. There was no documentation that wound care was provided.

f. 3/1/2022 at 8:10 PM, it was documented patient 12 had an open wound to the left knee. A dressing change was not documented.

g. 3/3/2022 at 9:00 AM, a nurse documented patient 12 had an open wound to the left knee. The nurse did not document the size or description of the wound.

h. 3/3/2022 from 6:00 PM through 3/4/2022 at 6:00 AM, the nurse documented, "Completed wound care of L knee. Measurements: 1.3 cm (centimeters) X 1.4 cm X 0.4 cm. Wound bed has approximately 75% slough covering wound bed. Pt tolerated dressing change well."

i. 3/4/2022 at 5:20 PM and 11:00 PM, the size and description of the wound was not documented.

j. 3/5/2022 at 8:00 AM, a nurse documented patient 12's wound to the left knee was normal and warm. At 11:00 PM, a nurse documented "wound care" but did not document the size or description of the wound.

k. 3/6/2022 at 9:10 AM, the nurse documented, "Dressing was changed on R (sic) knee. Wound has defined edges with no redness or swelling." The size of the wound was not documented.

l. 3/7/2022 at 6:00 PM,a nurse documented, "No skin issues."

An interview was conducted with the director of nursing (DON) on 3/14/2022 at 3:00 PM. The DON stated that patient 12's staphylococcal infection to the left knee was not reported after the intake employee received the information. The DON stated the Bactrim was "dropped" and did not provide additional information as to why it was not continued. The DON was asked why wound care was not provided 2/23/2022, 2/24/2022, 2/27/2022, 2/28/2022 and 3/1/2022. The DON stated, "I think they were done" but could not provide evidence that dressing changes to the open wound on the left knee with a staphylococcal infection had been completed. Furthermore, the DON did not provide additional information as to why the treatment of the wound, specifically a description and size of the wound, was not documented as ordered.

3. 3. Patient 11 was admitted to the hospital on 2/28/2022, with admitting diagnoses of suicide ideation, schizophrenia and depression.

On 3/9/2022 patient 11's medical record was reviewed.

A progress note dated 3/1/2022 and documented by a behavioral health technician (BHT) indicated that patient 11 had complained of blood in his stool, his stomach hurt and he was afraid he had internal bleeding.

No further documentation was located that indicated the concern had been addressed.

On 3/14/2022 at 7:53 AM, an interview was conducted with registered nurse (RN) 3. RN 3 stated he was the nurse taking care of patient 11 on 3/1/2022. He stated the BHT did not tell him of patient 11's complaint of blood in the stool. He would have addressed the concerns and alerted the physician if he had known.

On 3/14/2022 at 8:30 AM, an interview was conducted with BHT 3. BHT 3 stated patient 11 told her he had blood in his stool and had abdominal pain. She documented the information in a progress note but did not talk to RN 3 about patient 11's concerns.

No documented evidence was provided to indicate that the physician had been notified nor the concerns had been addressed.

On 3/14/20 22 at 10:26 AM, an interview was conducted with the director of nursing and assistant director of nursing. They both indicated the BHT should have talked to the nurse about patient 11's concerns.

Based on interview and record review, it was determined that the hospital did not ensure medications were prepared and administered in accordance with the orders of the practitioner responsible for the patient's care for 3 out of 11 sampled patients and 2 of 7 supplemental patients. (Patient identifiers: 5, 6, 8, 12, and 13)

Findings include:

1. Patient 6 was admitted to the hospital on 3/7/2022, with diagnoses of depression and suicide ideation.

On 3/7/2022 at 9:30 AM, an interview was conducted with patient 6. Patient 6 stated he had been asking for his medications since he was admitted. He stated he had been at the hospital since last night, but no one would listen to him. Patient 6 stated he was very anxious and had not slept for a few days.

Patient's medical record was reviewed.

A review of the admission documentation revealed patient 6 had been admitted on 3/7/2022 at 1:25 AM.

Review of the physician admission orders dated 3/6/2022 at 10:02 PM, revealed an order for Vistaril 50 mg (milligrams) Q (very) 6 hours prn (as needed) for anxiety.

A medication order dated 3/7/2022 at 7:30 PM, indicated patient 6 was to receive Keppra 750 mg BID (twice a day) for seizures and Abilify 2 mg daily with the first dose to be given at HS (at bedtime).

A review of his medication administration documentation form revealed patient 6 received a short-term anxiety medication, Vistaril at 10:27 AM on 3/7/2022, 9 hours after patient 6 was admitted.

Further review revealed patient 6's Keppra and Abilify medications were documented as being given at 8:00 AM on 3/8/22. Note: This was 12 hours after the medications were ordered to be administered.

On 3/7/2022 at 9:45 AM, an interview was conducted with registered nurse (RN) 1. RN 1 stated the hospital had standing orders for some medications that can be used for when a patient is admitted, is agitated and needed something to calm them. They would verify the medications orders as soon as they could so the patient could get medications.

On 3/9/2022 at 10:00 AM, an interview was conducted with the assistant director of nursing (ADON) and the pharmacist. The ADON stated nighttime medications are not given until the next day after admission. The hospital had admission standing orders for adults and kids. When a patient came during the night, the nurse could give Vistaril for anxiety. The pharmacist stated if the physician wrote the order to give "now" then the medication should have been given that night, which was the case for the Abilify.

On 3/14/2022 at 7:52 AM, an interview was conducted with RN 2. RN 2 stated it was common for the nurses to not administer the evening medications until the day after a patient was admitted to the hospital.


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2. Patient 5 was admitted to the hospital on 3/6/2022 at 10:35 PM, involuntarily, with diagnoses which included suicidal ideation, major depressive disorder and anxiety.

An interview was conducted with patient 5 on 3/7/2022 at 9:35 AM. Patient 5 stated she was admitted to the hospital around 12:30 to 1:00 AM, this morning. She stated she had not had any medications since 3/5/2022 and that she needed her medications. Patient 5 stated she had not slept in days. She stated, "I really need my anxiety meds (medications)" and that she had been asking the nursing staff for her medications but that no one had given them to her. Patient 5 stated that she had been seen by three physicians but the nurses had not responded to her request.

Patient 5's medical record was reviewed.

a. Admission orders, dated 3/6/2022 at 8:15 PM, included to administer Zyprexa 5 mg every six hours as needed for psychosis and agitation, Colace 100 mg daily as needed, Mylanta 15 ml (milliliters) every 4 hours as needed, Motrin 800 mg every 8 hours as needed and Vistaril 50 mg orally every six hours as needed for anxiety. The physician signed the order on 3/7/2022 at 6:00 PM. The order was noted by a nurse on 3/7/2022 at 8:19 PM. Note: The admission orders were written approximately 2 hours prior to the patient being admitted to the hospital. The physician did not sign the orders until the next day, 3/7/22 at 6:00 PM.

b. A nursing reassessment, dated 3/7/2022 at 10:05 AM, documented " ...she did not have any AM meds yet. Went to group."

c. A Medication reconciliation was not completed until 3/7/22 at 10:40 AM. The physician signed the order on 3/7/22 at 6:00 PM but was not noted by a nurse until 3/7/2022 at 8:17 PM. It was documented that patient 5 was on Latuda 40 mg daily; Clonazepam 1 mg every 12 hours as needed; trazodone 50 mg at bedtime as needed and Wellbutrin XL 300 mg daily. It was documented that the medications were to be continued in the hospital. The Latuda and Wellbutrin were not administered until 3/8/2022 at 8:00 AM.

An interview was conducted with the ADON and DON on 3/14/2022 at approximately 11:00 AM. The ADON and DON were asked why patient 5's medications were not initiated timely. The DON responded by saying, "The patient patient was admitted on 2/6/2022 at 11:35 PM. The medications were reconciled on 3/7/2022 at 10:40 AM so the 8:00 AM medications defaulted to being administered on 3/8/2022."

3. Patient 8 was admitted to the hospital voluntarily on 11/16/2021 at 9:33 AM, with diagnoses which included suicidal ideation and idiopathic angioedema.

Patient 8's medical record was reviewed.

a. A medication reconciliation was not completed until 11/17/2021 at 7:00 AM, over 24 hours after patient 8 was admitted to the hospital. The nurse documented patient 8 was on: Singulair 10 mg at bedtime; Prazosin 1 mg three times a day as needed; Sertraline 100 mg daily; an Epipen; Hydroxychloroquine 200 mg twice a day; Hydroxyzine 25 mg every six hours as needed; Metronidazole 0.75% topically twice a day; Pantroprazole 20 mg daily; Bupropion XL 150 mg every morning; Oxcarbazepine 300 mg 2 tabs twice a day; Clonazepam 0.25 mg 1 twice a day as needed; and Zyrtec 10 mg twice a day. It was documented the Singular, Epipen, Hydroxychloroquine, Hydroxyzine, Metronidazole, Bupropion XL, Oxcarbazepine, and Zyrtec were to be continued during the hospitalization.

According to the November 2021 medication administration record (MAR), the only medication administered on 11/17/2021 at 8:00 AM was Bupropion XL, Zyrtec, Zoloft and Protonix. The Oxcarbazepine, was not administered until 11/17/2021 at 8:00 PM.

b. On 11/17/2021 at 7:00 AM, an order was written to administer Prazosin 1 mg at bedtime for post-traumatic stress disorder; Zoloft 150 mg daily for depression, Protonix 40 mg daily for gastroesophageal reflux disease, and Clonazepam 0.25 mg every 12 hours as needed for anxiety. The order was not noted until 11/17/2021 at 3:00 PM.

c. On 11/18/2021 at 7:00 AM, an order was written to start Bactrim 800/160 every 12 hour for fourteen days related to a urinary tract infection. Additionally, patient 8 was to be started on Oxcarbazepine 200 mg twice a day for depression and Claritin 20 mg twice a day. The order was not noted by a nurse until 11/18/2021 at 10:23 AM. The nursing staff documented that Oxcarbazepine 300 mg was administered on 11/18/2021 at 8:00 AM, before the order was received.

d. On 11/18/2021 at 7:20 PM, an order was written to change Trileptal to 300 mg twice a day. The order was not noted until 11/18/2021 at 9:15 PM.

4. Patient 12 was admitted to the hospital on 2/22/2022 with a diagnosis of psychosis.

Patient 12's medical record was reviewed on 3/14/2022.

The following orders were received to administer medications that were not implemented in a timely fashion:

a. Admission orders, dated 2/22/2022 at 3:45 PM, indicated the hospital nursing staff were to administer Vistaril 50 mg every 6 hours by mouth as needed for anxiety. Despite having an order to administer Vistaril as needed for anxiety on 2/22/2022, the first dose of Vistaril was not administered until 2/27/2022 at 8:50 AM after an antipsychotic was administered at 5:28 AM.

b. An intake assessment was completed on 2/22/2022 at 8:10 PM, by an unknown hospital employee. It was documented that patient 12 had been taking Saphris 10 mg BID. Patient 12 had auditory hallucinations, was paranoid, had delusional thought content and had racing thoughts/flight of ideas. The hospital employee documented that patient 12 was impulsive and had a sleep disturbance with too little sleep. The intake was signed by the medical director on 2/22/2022 at 11:52 PM. Although the physician signed the intake assessment, an order for the use of the Saphris was not received until 2/24/2022 at 7:00 AM.

c. On 2/23/2022 from 12:00 AM to 2:25 AM, a BHT documented patient 12 was in a low stimulus area (LSA).

An order was received on 2/23/2022 at 1:15 AM, to administer Zyprexa 10 mg IM (intramuscularly). The order was noted by the nurse on 2/23/2022 at 1:29 AM. The nurse did not document why the Zyprexa was administered or what interventions were attempted prior to the Zyprexa injection.

On 2/23/2022 from 3:00 AM to 4:00 AM, the BHT documented patient 12, "became agitated when she couldn't shower. Staff assist was called pt (patient) was given IM - pt was yelling and lunging at staff ..." There was no further information available for review that documented a staff assist had been called or what follow up documentation had been completed.

d. On 2/23/2022 at 5:00 PM, an order was received to administer Risperdal 0.5 mg orally three times a day and to verify when the last dose of aripiprazole intramuscularly was given. The first dose of Risperdal was not administered until 2/24/2022 at 8:00 PM.

e. On 2/24/2022 at 3:15 AM, an order was received to administer Tylenol 650 mg every 6 hrs (hours) PRN, Trazodone 150 mg at bedtime and Geodon 20 mg PO BID. The order was not noted by a nurse until 2/24/22 at 11:16 AM. The first dose of the Geodon was not administered until 2/25/2022 at 8:00 AM.

f. On 2/24/2022, the time documented was not legible, to administer Geodon 20 mg IM for agitation/psychosis. The order was noted by the nurse on 2/24/2022 at 8:52 AM. There was no further information available for review that indicated what interventions had been implemented prior to the administration of the Geodon IM. Note: The order for Risperdal received on 2/23/2022 at 5:00 PM and the order for Geodon received on 2/24/2022 had not been implemented.

g. A medication reconciliation was not completed until 2/24/2022 at 7:00 AM at which time a verbal order was given to administer Saphris 10 mg orally twice a day, with the first dose to be given on 2/24/2022 at 2:00 PM, and "Mupirocin 2% PO (sic) BID (twice a day)." The nurse noted the order on 2/24/2022 at 10:20 AM. Note: The medication reconciliation did not occur until two days after patient 12 was admitted to the hospital. The first dose of Saphris was not administered until 2/25/2022 at 8:00 AM.

On 2/24/2022 at 8:00 AM, a BHT documented, " ...spent some time in seclusion ..." An order for patient 12 to be in seclusion was not found in the medical record.

h. On 2/24/2022 at 10:17 AM, new order to was received to obtain an EKG (electrocardiogram). There was no documentation of the EKG being completed as ordered.

i. On 2/25/2022 between 12:00 AM and 2:00 AM, a BHT documented that a staff assist was called, and an IM injection was administered due to being denied a shower. There was no additional information found in the medical record which indicated what the IM injection was or what interventions were implemented prior to the IM administration.

j. On 2/25/2022 at 3:30 AM, new order to administer Zyprexa 5 mg IM was received. The Zyprexa was administered at 3:45 AM. There was no documentation as to why the IM injection was administered.

k. On 2/28/2022 at 4:13 AM, an order to administer Zyprexa 5 mg every morning at 4:00 AM was received. The first dose was to be administered "now". The order was noted by the nurse at 4:13 AM, but was not administered until 3/1/2022 at 4:00 AM.

l. On 3/3/2022, time not legible, an order was received to administer Risperidone 2 mg by mouth three times a day. The order was noted by the nurse on 3/3/2022 at 12:53 PM, but the Risperidone was not initiated until 3/3/2022 at 8:00 PM, 7 hours after the order was noted.

m. On 3/4/2022 at 11:40 AM, new orders to administer Geodon 80 mg orally twice a day and Propranolol 10 mg by mouth three times a day was received. The order was noted by a nurse on 3/4/2022 at 11:58 AM. The Geodon was not administered until 3/5/2022 at 8:00 AM and the Propranolol was not initiated until 3/5/2022 at 8:00 AM.

An interview was conducted with the ADON and DON on 3/14/2022 at approximately 11:00 AM. The ADON and DON were asked about the hospital policy for administering as need psychotropic medication usage. The ADON stated the staff should be documenting interventions attempted prior to the administration of psychotropic medications.

On 3/15/2022 at 9:06 AM, an email correspondence was received from the director of quality risk (DQR). The DQR stated the hospital "could not find EKG results."


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5. Patient 13 was admitted to the hospital on 3/2/2022 with a diagnosis of unknown psychosis not due to a substance.

A review of Patient 13's medical record was completed on 3/9/2022, and revealed the following:

a. There was no documented evidence that Patient 13's medications prior to admission had been verified until 3/6/2022; four days after her admission to the hospital.

b. It was documented that Temazepam 15 mg PO at bedtime was ordered to be continued by the hospital on 3/7/2022 at 12:00 PM. As of 3/9/2022 there was no documented evidence patient 13 had received any doses.

c. There was a physician order written on 3/16/2022 at 10:18 AM for mag citrate ½ bottle PO times 1 "now". It was documented the medication was not given until 12:00 PM.

d. There was an order written on 3/7/2022 at 1:40 PM for lactulose 20 grams, PO times 1 to be given at 2:00 PM that day. There was no documented evidence the medication was given on 3/7/2022. The first time there was documented evidence the lactulose was administered was on 3/9/2022.

6. An interview was conducted with the administrator (ADM), pharmacy director (PD), assistant director of nursing (ADON)
nursing supervisor (NS) 1, and the director of quality risk (DQR) on 3/9/2022 at 10:00 AM. The staff were asked what the hospital procedure was for verifying medications at the time a patient was admitted to the hospital. The PD stated the nursing staff was responsible for verifying medications at the time a patient was admitted to the hospital on a medication record form then fax the information to the pharmacy. The PD stated that when he received the information he would "look it over" to verify the medications and make sure the medications were signed off by the physician to either continue or discontinue the medications. The PD stated that a patient profile was then to be created in the pharmacy system. After all medications were verified, the nurse was to then access the medications from the medication dispensing unit.

The PD, ADM, DQR, ADON and DON were re-interviewed on 3/14/2022 at 3:00 PM related to the timeframe of transcribing orders received from the physician. The DQR stated there was no specific timeframe that had been established and that it "depends on what is going on" and that the nursing staff transcribe the orders when "they have time." The staff were further asked what the timeframe was for administering patient requests for as needed medications. The DQR stated that it was the "standard of practice for nurses to wait to give as needed medications" and that the priority was to administer scheduled medications before administering requested as needed medications.

Based on interview and record review, it was determined the hospital failed to maintain a complete and accurate medical record for each patient.

Findings include:

1. The hospital failed to ensure all patient medical records were legible and complete. (Refer to Tag A-0450)

2. The hospital failed to ensure patients had properly executed informed consent forms for the administration of psychotropic medications. (Refer to Tag A-0466)

Based on interview and record review, it was determined the hospital did not ensure all patient medical records were accurate, legible and compete for 6 of 11 sampled patients and 3 of 7 supplemental patients. (Patient identifiers: 2, 4, 6, 8, 9, 10, 11, 12 and 14 )

Findings include:

1. Patient 11 was admitted to the hospital on 2/28/2022 with admitting diagnoses of suicide ideation, schizophrenia and depression.

On 3/9/2022 patient 11's medical record was reviewed.

A review of the expressive therapy progress note dated 3/2/2022, indicated the following:

"The focus of the activity was learning how to use leisure activity as a coping skill. (name of another patient) was focused throughout the activity and showed her best effort. She understood the game and how to make adaptations to meet available resources. She understands that when things get out of control you can play a game or use another leisure activity to reduce the stress and regain control over your emotions." Note: Patient 11 is male and the progress notes were labeled with his name.

On 3/14/2022 at 10:26 AM, an interivew was conducted with the director of nursing and the assistant director of nursing. They both indicated that the therapist had documented in the wrong patient medical record.

2. Patient 14 was admitted to the hospital on 2/27/2022 with admission diagnoses of psychosis and schizophrenia.

On 3/10/2022 patient 14's medical record was reviewed.

The following documentation was not legible:

a. An order dated 3/3/2022 was not legible along with the signature of the practitioner.
b. The handwritten notes and practitioner signature for the psychiatry progress notes dated 2/27/2022, 3/3/2022, 3/7/2022, 3/8/2022 and 3/9/2022 were not legible.
c. The hand written note and signature on an increased observation note dated 3/2/2022 was not legible.

3. Patient 6 was admitted to the hospital on 3/7/2022 with diagnoses of depression and suicidal ideation.

A review of the medical record revealed a practitioner order written on 3/8/2022 at 9:00 AM. The order and the practitioner signature were not legible.

4. Patient 10 was admitted to the hospital on 1/8/2022 with a diagnosis of alcohol dependence.

A review of the medical record for patient 10 revealed a handwritten physician discharge note dated 1/18/2022. The discharge note was not legible.



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5. Patient 4 was admitted to the hospital on 3/4/2022 with an admitting diagnosis of alcohol abuse with intoxication.

Patient 4's medical record was reviewed on 3/9/2022.

The hand written Psychiatry Progress Notes, dated 3/6/2022, 3/7/2022 and 3/8/2022 were not legible in its entirety.

6. Patient 8 was admitted to the hospital on 11/16/2022 with an admitting diagnosis of suicidal ideation.

Patient 8's medical record was reviewed on 3/9/2022.

The following handwritten documents were not legible in its entirety:

a. Practitioner orders, dated 11/16/2021, 11/17/2021 and 11/18/2021;
b. The admission order, dated 11/16/2021;
c. The physician discharge note, dated 11/19/2021; and
d. The nursing reassessment, dated 11/17/2021 at 5:10 PM.

7. Patient 12 was admitted to the hospital on 2/22/2022 with an admitting diagnosis of psychosis.

Patient 12's medical record was reviewed on 3/9/2022.

The following handwritten documents were not legible in its entirety:

a. Practitioner orders, dated 3/2/2022 and 3/7/2022;
b. The physician discharge note, dated 3/7/2022;
c. The psychiatry progress notes, dated 2/24/2022, 2/25/2022, 2/28/2022, 3/1/2022, 3/2/2022, 3/3/2022, and 3/4/2022;
d. The nurse/MHT (mental health therapist) group progress note, dated 3/6/2022; and
e. The increased observation progress notes, dated 2/23/2022, 2/24/2022, 2/25/2022, 2/26/2022, 2/27/2022, 2/28/2022, and 3/1/2022.


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8. Patient 2 was admitted on 3/3/2022 with a diagnosis of alcohol use disorder.

Review of patient 2's medical record was completed on 3/10/2022, and revealed the following:

A social worker/activity therapy note dated 3/3/2022, contained documentation using another patient's name. The surveyor was unable to determine what patient the author was documenting about.

9. Patient 9 was admitted to the hospital on 11/28/2021, with diagnoses of psychosis, schizophrenia, schizoaffective disorder, and bipolar, type.

Review of Patient 9's medical record was completed on 3/14/2022, and revealed the following:

A social worker/activity therapy note dated 12/4/2021 contained documentation using another patient's name. The surveyor was unable to determine what patient the author was documenting about.

A social worker/activity therapy note dated 12/7/2021, documented, "(Another patient's name) was sleeping." There was no documentation about patient 9.

On 3/14/2022 at 10:26 AM, an interivew was conducted with the director of nursing and the assistant director of nursing. They both indicated that the staff member had documented in the wrong patient's medical record.

On 3/16/2022 at 1:46 PM, an interview was conducted with the director of quality and risk (DQR) and the administrator (ADM). The DQR and the ADM both indicated that they were aware of the problems with handwritten documentation and signatures not being legible. The DQR stated it was an ongoing issue. The ADM stated the hospital was were looking into get electronic medical records in the next two years.

Based on interview and record review, it was determined the hospital did not ensure patients had properly executed informed consent forms for the administration of psychotropic medications for one of 7 supplemental patients. (Patient identifier: 14)

Findings include:

Patient 14 was admitted to the hospital on 2/27/2022 with diagnoses of psychosis and schizophrenia.

On 3/10/2022, patient 14's medical record was reviewed.

A review of the Psychotropic medication consent form revealed the form had been signed by the patient on 2/27/2022. The form was blank except for patient 14's signature. Medication check boxes were unmarked. Check boxes were left unmarked that would indicate the patient had been informed of the medications she would be taking, the side effects and indicate the patient had the opportunity to ask questions and receive answers about the medications.

Further review of the medical record revealed the patient had been prescribed psychotropic medications.

On 3/14/2022 at 10:26 AM, an interview was conducted with the director of nursing and assistant director of nursing. They both indicated the form should have been completely filled out prior to the patient signing the consent.