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As a part of the patient's notification of rights the hospital failed to provide the patient or the patient's representative with a phone number and address for filing a grievance with the state regulatory agency.

The hospital provides patient rights information on admission in a folder given to the patient. The folder contains various documents and pamphlets about the general care provided, hand hygiene, discharge information and basic patient rights. The documents and pamphlets failed to provide the phone number and address for the state regulatory agency should the patient or family member wish to file a complaint or a grievance.

The Behavioral Health Unit (BHU) also provides patients with a unit based admission packet containing patient rights information. This packet also does not contain the appropriate contact information for the state regulatory agency should the patient or family member wish to file a complaint or grievance.

An interview with the Performance Improvement and Quality staff revealed that the discrepancies in the admission packets did not follow hospital policy and that the quality staff were not aware that the BHU provided a separate admission packet to their patients.

Review of 12 medical records revealed that the nursing staff failed to document the assessment of patients who required the administration of "as needed" (PRN) medications and also failed to document reassessments of the patients after the administration of the medications to determine their effectiveness. This was evident in 2 of the 12 records reviewed.

Patient #1 was admitted due to hallucinations and being a danger to self and others. The patient was ordered Ativan 1 mg by mouth (PO) or intramuscular injection (IM) every 4 hours as needed (PRN) for severe agitation and outbursts. The medication was administered on 9/20/2015 at 2014. Nursing staff failed to document why the medication was necessary or a description of the patient's behavior. Nursing staff then failed to document a reassessment of the patient after the medication had been administered.

Patient #2 was an involuntary admission to the hospital due to being a danger to self and others. This patient was ordered Ativan 1 mg PO or IM every 4 hours PRN for agitation. The patient received doses of Ativan PO on 9/28/2015 at 1836 and at 2246. Nursing staff failed to document why the medication was necessary or a description of the patient's behavior. Nursing staff then failed to document a reassessment of the patient after the medication had been administered.

Failure of the nursing staff to document the need for chemical interventions and the response to those interventions placed the patients at risk for improper revisions of care plans based on the effectiveness of the medications.

A tour of the Behavioral Health unit (BHU) was completed on 9/29/2015. During the tour expired emergency medication was observed in the unit's crash cart. Epinephrine, a medication used during a medical emergency, had an expiration date of 9/1/2015. The BHU charge nurse is responsible for reviewing the "crash cart log" daily to validate that all needed emergency equipment is functioning properly and supplies and medications are within their respective expiration dates. Since 9/1/2015 the log had been signed daily validating that all equipment, supplies, and medications had not expired even though the Epinephrine had expired on 9/1/2015. These findings were confirmed by the charge nurse and the Quality staff.

Failure to assure that all equipment and supplies are functioning and within their expiration dates placed the patient at risk for potential harm.