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Based on medical record review, facility policy review, and staff interview, it was determined the facility failed to protect and promote each patient's rights as evidenced by: failure to obtain consent from the patient before the administration of psychotropic medication (A0117) and failure to provide proper staff supervision resulting in a patient elopement (A0144).

Cross Reference:
482.13(a)(1) Patients Rights: Notice of Rights
482.13(c)(2) Patient Rights: Care in a Safe Setting

Based on medical record review, facility policy review, and staff interview, it was determined that for 1 of 7 patients (MR3) sampled, the Facility failed to obtain consent from the patient before the administration of psychotropic medication. Findings include:

Review of facility policy "Consent for Treatment with Psychiatric Medication", effective 10/2017 and revised 6/2023, revealed "MeadowWood Behavioral Health System obtains the informed consent from the patient...prior to initiating psychotherapeutic medications...This specifically includes any medication whose primary purpose in this use is the treatment of a psychiatric/mental health disorder..."

MR3

"Practitioner Order Sheet" dated 8/26/24 at 12:00 noon documented orders for:
- Zyprexa 5 mg (milligrams) by mouth every morning.
- Zyprexa 10 mg by mouth every night at bedtime.
- Zyprexa 10 mg by mouth every 6 hours as needed for agitation.
- Ativan 2 mg by mouth every 6 hours as needed for agitation.

"Medication Administration Record" revealed patient received:
- Zyprexa 5 mg by mouth on 8/27/24 at 9:00 AM.
- Zyprexa 10 mg by mouth on 8/26/24 at 9:00 PM.
- Zyprexa 10 mg and Ativan 2 mg by mouth on 8/26/24 at 9:30 PM.

There was no evidence of patient consent for treatment with these medications.

This finding was confirmed with EMP3 on 9/13/24 at 12:03 PM.

Based on facility policies, observations, interviews with staff, and a review of surveillance video, it was determined that for 6 of 6 patients (Patients #2, #8, #9, #10, #11, #12) observed, the facility failed to provide proper staff supervision resulting in a patient elopement. Findings include:

Review of facility policy "Nursing Accountability" dated 8/93 and revised 6/2023, revealed "...Inpatient nursing staff consists of Registered Nurses...and Behavioral Health Associates...Charge Nurse...delegates tasks and supervises the work of all nursing staff on the unit during the shift...All Licenses [sic] Nurse Staff are responsible for...the overall safety...of individual patients..."

Review of facility policy "Locked Units" dated 8/93 and revised 6/96, revealed "...The unit's outside doors are locked at all times...Staff members do not open the door if they feel insecure about controlling the patient(s) near the door. Instead, the staff member asks the patient(s) to leave the area. If patient(s) do not leave, the staff member gets extra staff to direct the patient(s) away from the door..."

Review of video surveillance from September 10, 2024, between 11:00 AM and 1:13:45 PM of the elopement incident revealed the exit door was unlocked and unstaffed from 11:38:11 AM to 1:13:45 PM (1 hour 35 minutes). Patient #2 is observed exiting the facility through the unlocked exit door at 12:59:48 PM. Five other patients can be seen walking in the hallway between 12:55:19 and 1:13:45 PM while the unlocked exit door was not staffed.

Inspection of unit D-East on 9/12/24 between 9:10 and 9:16 AM revealed the now secured exit door, which was the means of the patient elopement, at the end of the patient hallway.

Interview on 9/12/24 between 1:45 and 2:00 PM with EMP9, Charge Nurse, revealed the Nursing Coordinator notified him/her on 9/10/24 that the emergency exit door would be unlocked.

Interview on 9/12/24 between 2:13 and 2:25 PM with EMP18 revealed the delivery men notified him/her that the door was unlocked and before he/she escorted the patients to lunch at 12:30 PM, "a third-party person" told him/her they were done moving furniture so he/she thought the door was locked at that time.

On 9/13/24 at 9:57 AM, EMP2 confirmed that Patient #2 eloped through the unlocked and unstaffed emergency exit door on 9/10/24 at 12:59:48 PM. He/she also acknowledged that five other patients were seen walking in the hallway between 12:55:19 and 1:13:45 PM while the unlocked emergency exit door was not staffed.

Based on review of facility policies and documents, review of medical records, and interviews with staff, it was determined that the facility failed to maintain an organized nursing service as evidenced by: failure to ensure adequate numbers of nursing staff for 3 patient care units (A392); failure to complete patient observations as ordered (A395); and failure to ensure adherence to their medication administration policy (A405).

Cross Reference:
482.23(b) Staffing and Delivery of Care
482.23(b)(3) RN Supervision of Nursing Care
482.23 (c)(1),(c)(1)(i) & (c)(2) Administration of Drugs

Based on hospital document review, policy review, and staff interview it was determined that the Hospital failed to ensure adequate numbers of nursing staff for 3 (Unit D East, D West and G) of 3 patient care units. Findings include:

Review of facility policy "Nursing Accountability," effective August 1993, revised June 2023, revealed,"...Staff are assigned to units and patients by Registered Nurses based on assessment both of specific patient needs and staff competency...Inpatient nursing staff consists of Registered Nurses, Licensed Practical Nurses, and Behavioral Health Associates..."

Review of facility policy "Staffing Plan for Nursing Services," effective January 26, 2021, revised August 30, 2022, revealed, "...Core coverage includes ensuring there is 1 RN [registered nurse] on each unit at all times and that there is at minimum 2 staff on each unit at all times...The goal of staffing each nursing unit is to ensure patient safety in healthcare delivery..."

Interview conducted with EMP7 on 9/13/2024 from 11:09-11:15 AM. EMP7 stated, "Staffing ratios are 1:5 overall for 7A-3P and 3P-11P shifts and 1:10 overall for 11P-7A."

Surveyors reviewed hospital staffing records for the following dates:
2/11/2024
7/6/2024
7/7/2024
7/8/2024
8/30/2024
9/10/2024

The following units were missing staff on the following days:

Sunday 2/11/2024 7 PM to 11 PM: Unit D East; 19 patients. Staff: 1 RN, 2 BHA's [behavioral health associate]. Short 1 staff member.

Friday 7/7/2024 7 PM to 11 PM: Unit G; 17 patients. Staff: 1 LPN [licensed practical nurse], 2 BHA's. Short 1 RN.
Friday 7/7/2024 11 PM to 7 AM: Unit D West; 15 patients. Staff: 1 BHA. Short 1 RN.


Saturday 7/8/2024 11 PM to 7 AM: Unit D West; 16 patients. Staff: 1 BHA. Short 1 RN.


These findings were confirmed with EMP7 during an interview conducted on 9/13//2024 from 11:30-11:40 AM.

Based on review of medical records, review of facility policies, and interview with staff, it was determined that the Hospital failed to complete ordered patient observations for 2 out of 7 patients sampled (Patient #1 and Patient #5). Findings include:

Review of facility policy "Routine Observation Of Inpatients," effective June 2022, revised June 2023, revealed, "In order to maintain patient safety, the Hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner...Staff documents all pertinent information on each patient's observation form...Each entry is to include the following: Level of observation, Precaution, Location, Behavior, Activity, Time, Staff initial and Signature ..."


MR1

"Meadowwood Behavioral Health Admission Order" revealed "Date of Order: 2/9/2024...Time of Order: 8:40 PM... Level of Observation: Q 15 minutes..."

"Patient Observation Sheet," dated February 13, 2024, revealed no documentation of 15-minute patient observation at 4:00 AM, as ordered.

"Patient Observation Sheet," dated February 16, 2024, revealed no documentation of 15-minute patient observation at 3:00 PM, as ordered.

These findings were confirmed with EMP3 during an interview conducted on September 13, 2024, at 1:49 PM.


MR5

"Meadowwood Behavioral Health Admission Order" revealed "Date of Order: 12/15/23...Time of Order: 12:30 PM... Level of Observation: Q 15 minutes..."

"Patient Observation Sheet," dated February 11, 2024, revealed no documentation of 15-minute patient observation at 5:30 PM and 5:45 PM as ordered.

These findings were confirmed with EMP3 during an interview conducted on September 13, 2024 at 2:15 PM.


"Practitioner Order Sheet" revealed "Date Order Written: 2/11/24...Time Order Written: 7:00 PM... Order: Q 5 W/A [while awake] Q 15 W/S [while asleep] ..."

"Patient Observation Sheet," dated February 11, 2024, revealed no evidence of patient observations at:

7:05 PM to 7:10 PM (2 observations not documented)
7:20 PM to 7:25 PM (2 observations not documented)
7:35 PM to 7:40 PM (2 observations not documented)
7:50 PM to 7:55 PM (2 observations not documented)
8:05 PM to 8:50 PM (2 observations not documented)

These findings were confirmed with EMP3 during an interview conducted on September 13, 2024 at 2:15 PM.

Based on medical record review, hospital policy review, and staff interview, it was determined that the Hospital failed to ensure adherence to their medication administration policy for 1 of 7 patients (Patient #4) sampled. Findings include:

Review of facility policy "Medication Administration and Documentation", original date of issue August 8, 2020, revealed, " ...All ordered medications administered to patients will be documented on the Medication Administration Record ... Document on the MAR (Medication Administration Record) the following information in the appropriate column: Dose, time, route (if not PO [by mouth]), site (if appropriate), and initials ...Document all refused drugs on the patient's MAR (Medication Administration Record) ... If patient refuses the medication, circle your initials on the MAR (Medication Administration Record) and mark "refused"...Document physician notification in the Progress Note..."

Review of MR4 revealed:

- Physician orders dated 7/3/2024 at 1443 documented order Latanoprost 0.005% instill 1 drop in both eyes QHS (every night at bedtime).
- Medication Administration Record has omitted documentation for Latanoprost 0.005% on 7/7/2024 at 2100.
- Physician orders dated 6/30/2024 at 2315 documented order Vraylar 1.5mg PO (by mouth) QHS (every night at bedtime).
- Medication Administration Record has omitted documentation for Vraylar 1.5mg on 7/6/2024 and 7/7/2024 at 2100.
- Physician orders dated 6/30/2024 at 2315 documented order Carvedilol 12.5mg PO (by mouth) BID (twice a day).
- Medication Administration Record has omitted documentation for Carvedilol 12.5mg on 7/6/2024 and 7/7/2024 at 2100.
- Physician orders dated 7/2/2024 at 1036 documented order Losartan 100 mg PO (by mouth) daily.
- Medication Administration Record has omitted documentation for Losartan 100mg on 7/7/2024 at 0900.
- Physician orders dated 7/4/2024 at 1100 documented order Remeron 30mg PO (by mouth) QHS (every night at bedtime).
- Medication Administration Record has omitted documentation for Remeron 30mg on 7/6/2024 and 7/7/2024 at 2100.
- Physician orders dated 6/30/2024 at 2315 documented order Brimonidine ophthalmic 0.2% instill 1 drop both eyes Q8 (every 8 hours).
- Medication Administration Record has omitted documentation for Brimonidine ophthalmic 0.2% on 7/6/2024 and 7/7/2024 at 1600 and 2400.

During an interview on 9/13/2024 at 1100, EMP3 confirmed the omitted documentation of 6 out of 13 scheduled medications with no evidence of physician notification.

Based on medical record review, facility policy and document review, and staff interview, it was determined that for 1 of 7 patients (MR3) sampled, the Facility failed to ensure that a history and physical was completed. Findings include:

Review of facility policy "Timeliness of Documentation", effective 10/96 and revised 11/2015, revealed "Documented assessments...are completed...within the timeframes outlined below...History & Physical 24 hours..."

Review of facility document "Medical Staff Bylaws" effective 12/1/2022, revealed "...3.3.11 prepare and complete in a timely manner the medical...records...This includes the requirement for completing and documenting medical histories and physical examination for each acute services patient no more than...24 hours after admission..."

Review of MR3 for showed no evidence that a history and physical was completed for the 8/23/24 inpatient services admission.

This finding was confirmed with EMP3 on 9/13/24 at 12:26 PM.