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A. Based on a review of the medical record and staff interviews it was revealed nursing failed to notify the physician of a patient's change in condition. This failure was identified in one (1) of twenty-eight (28) medical records reviewed (patient #4). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #4 revealed patient #4 was admitted on 5/3/21 with a diagnosis of Bipolar. On 5/3/21 nursing assessment documentation revealed patient #4 had an injury to her head from an assault three (3) days ago. On 5/4/21 at 11:50 a.m. nursing documented nursing assisted the patient to the bathroom. Patient #4 had a strong, foul odor noted after urination. Patient #4 was showered and placed in bed. Patient #4 was complaining of pain with palpation to suprapubic area and all four (4) quadrants. Patient #4 also complained of a headache. No documentation was noted in the medical record the physician was notified in the change of condition for patient #4. Patient #4 was sent to a local emergency department (ED) on 5/4/21 at 3:30 p.m. for an evaluation. Patient #4 has not returned to the facility.

2. An interview was conducted with the Corporate Vice President of Quality and Compliance on 5/12/21 at approximately 9:00 a.m. She concurred the nursing staff failed to notify the physician of a change in condition for patient #4 as per expectation.


B. Based on a review of the medical record, staff interviews and document review it was revealed nursing staff failed to complete a nursing assessment as per policy. This failure was identified in one (1) of twenty-eight (28) medical records reviewed (patient #13). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #13 revealed patient #13 was admitted to the facility on 5/10/21 at 6:43 p.m. The initial nursing assessment was completed on 5/11/21 at 12:00 p.m. after the surveyor arrived at the facility. A nursing plan of care was noted in the medical record for 5/10/21.

2. A review of the policy titled "NURSING ASSESSMENT/REASSESSMENT, revised 2/17, stated in part: "An Initial Nursing Assessment will be performed by a registered nurse within eight (8) hours of the patient's arrival on the unit."

3. An interview was conducted with the Director of Quality and Patient Compliance on 5/11/21 at 12:12 p.m. He concurred the nursing assessment for patient #13 was not completed as per policy. He stated a nursing assessment must be completed within eight (8) hours of admission to the facility.

4. An interview was conducted with the Corporate Vice President of Quality and Compliance on 5/12/21 at approximately 9:00 a.m. She concurred the nursing staff failed to complete a nursing assessment for patient #13 as per policy.

Based on a review of medical records and staff interviews it was revealed case management (CM) failed to document in the patient's medical record as per expectation of the facility. This failure was identified in four (4) of twenty-eight (28) medical records reviewed (patient #7, 14, 15 and 22). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #7 revealed patient #7 was admitted on 4/29/21 with a diagnosis of Psychotic Depression. Patient #7 was discharged on 5/10/21. No CM documentation was noted in the medical record until the day of discharge. On the day of discharge, the case manager documented the discharge planning on the master treatment plan (MTP).

2. A review of the medical record for patient #14 revealed patient #14 was admitted on 4/13/21 with a diagnosis of Paranoid Schizophrenia. Patient #14 is currently an inpatient. CM documentation was not noted in the medical record until the surveyor arrived at the facility. On 5/11/21 the case manager documented the discharge planning on the MTP.

3. A review of the medical record for patient #15 revealed patient #15 was admitted on 3/9/21 with a diagnosis of Bipolar Affective Disorder. Patient #15 is currently an inpatient. CM documentation was noted in the medical record on 3/17/21 and 3/23/21. No other CM documentation was noted in the medical record until 5/11/21 after the surveyor arrived at the facility. On 5/11/21 the case manager documented the discharge planning on the MTP.

4. A review of the medical record for patient #22 revealed patient #22 was admitted on 4/19/21 with a diagnosis of Schizophrenia. Patient #22 is currently an inpatient. No CM documentation was noted in the medical record until the surveyor arrived at the facility. On 5/12/21 the case manager documented the discharge planning on the MTP.

5. An interview was conducted with the Corporate Vice President of Quality and Compliance on 5/12/21 at approximately 9:00 a.m. She concurred the case manager failed to document appropriately as per expectations of the facility.

6. An interview was conducted with the Director of Clinical services on 5/12/21 at 11:00 a.m. She concurred no CM documentation was noted in the medical records for patient #7, 14, 15 and 22 as per expectations of the facility.

Based on a review of the medical record and staff interviews it was revealed the facility failed to have an updated treatment plan for all patients. This failure was identified in one (1) of twenty-eight (28) medical records reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed patient #1 was admitted on 4/22/21 with a diagnosis of Aggressiveness and Suicide Ideations. Patient #1 was documented as having capacity on 4/22/21. A nutritional consult was ordered on 4/29/21 due to patient #1 refusing to eat or drink. It is documented patient #1 as eating and drinking on and off during her admission. The physician documented patient #1 as having lack of capacity on 4/30/21 due to the patient's inability to weigh benefits/risk of her decisions. Patient #1 was refusing to eat or drink, to take medications and have lab work. The physician transported her to a local emergency department (ED) for evaluation. Per the physician, all labs were normal, patient #1 was not dehydrated and returned to the facility. No update to the master treatment plan (MTP) was noted in the medical record for poor nutritional intake. On 5/4/21 the physician documented communication with the medical power of attorney (MPOA) (son) concerning discharge and possible need for a gastric tube if the patient continues to not eat. He discussed the discharge for 5/5/21 with the son. The physician documented the son will notify the daughter of the conversation regarding discharge on 5/5/21. Discharge planning was noted for the discharge to her daughter's home via taxi due to the daughter not having a car for transportation. The patient was discharged on 5/5/21 at 10:20 a.m.

2. An interview was conducted with the Director of Clinical Services on 5/10/21 at 1:15 p.m. When asked about the update of the MTP for patient #1, concerning the poor nutritional intake, she stated anything medical the nurses are to update the MTP, anything else the therapist and case management would update the MTP. She concurred the MTP should have been updated to poor nutritional intake as a problem and not just listing it as a weakness.

3. An interview was conducted with the Corporate Vice President of Quality and Compliance on 5/12/21 at approximately 9:00 a.m. She concurred the nursing staff failed to update the MTP for patient #1.