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Based on observation, record review, grievance record review, policy and procedure review, professional reference review, personnel file review, and staff interview, the Hospital failed to protect and promote each patient's rights by failure to promptly resolve grievances received by telephone (Refer to A118); failure to provide written notice of its grievance decisions (Refer to A123); failure to notify a minor patient's guardian of a change in medical condition, failure to obtain consent for administration of medications to minor patients, and failure to obtain treatment consents in a timely manner (Refer to A131); failure to ensure privacy during medication administration (Refer to A143); failure to provide care in a safe setting for a patient who experienced a seizure during hospitalization, for a patient while in a seclusion area, and for patients during medication administration, (Refer to A144); failure to obtain a physician signature for a verbal order within the appropriate timeframe (Refer to A168); and failure to ensure registered nurses performing one-hour face-to-face evaluations of restrained/secluded patients had completed the required training (Refer to A178). The result of these failures limited the Hospital's ability to protect and promote each patient's rights.

Based on policy review, record review, and staff interview, the Hospital failed to promptly resolve 1 of 1 grievance (on behalf of Patient #16) reviewed received by telephone. Failure to resolve grievances limits the hospital's ability to ensure quality care and the rights of patients.

Findings include:

Review of the policy "Grievances: Patient & Family; The Role of the Patient Advocate" occurred on 03/15/16. This policy, dated 05/2013, stated, ". . . Definition: For the purposes of this policy, grievances may include a formal or informal, written or verbal complaint that is made to the hospital by the patient or patient's representative regarding patient care. . . . Procedure: . . . 5. . . . The staff member receiving a verbal grievance must instruct the patient to fill out the Patient/Family Grievance Form . . . the form will be immediately given to the Patient Advocate (Monday through Friday), the House Supervisor (evenings, nights and weekends) or the Administrator-on-Call. 6. The grievance will be logged into the Grievance Log by the Patient Advocate or designee. 7. Time Frame: The staff person responding to the grievance should speak with the patient or patient's representative (or will designate a staff member to speak with the patient/patient's representative), within 24 hours of the receipt of the complaint to clarify the issues and inform the patient of the time frame for investigation and written response. . . . 8. Time frame for completion of the investigation is 72 hours after the receipt of the complaint, with written response within 7 days. . . . 9. Documentation of each step in the investigation must be recorded thoroughly and then forwarded to the Patient Advocate. . . ."

Reviewed on 03/16/16, documentation provided by the hospital, dated 03/01/16, stated Patient #16's mother called and talked to a staff member (#6) about concerns she had with the care her daughter (Patient #16) received as an inpatient. Staff Member #6 relayed the concern in writing to the [name] Director of Nursing, [name] Assistant Director of Nursing, and [name] Patient Advocate (responsible for grievances).

Reviewed on March 15-16, 2016, the hospital's grievance log lacked evidence of a grievance processed on behalf of Patient #16.

During an interview on 03/16/16 at 1:50 p.m., an administrative staff member (#4) responsible for grievances stated she had not followed up with Patient #16's mother, had not investigated concerns about Patient #16's care, and had not entered the complaint on behalf of Patient #16 in the grievance log.

During an interview on 03/16/16 at approximately 2:00 p.m., an administrative staff member (#1) stated he had not documented the results of his review of Patient #16's medical record in response to the complaint.

Upon request on 03/16/16 at approximately 2:10 p.m., the hospital failed to provide evidence staff considered the complaint from Patient #16's mother a grievance and failed to provide written documentation of an investigation of the complaint.

Based on policy review, grievance record review, and staff interview, the Hospital failed to provide written notice of its grievance decisions for 3 of 3 months (December 2015, January 2016, and February 2016) reviewed. Failure to provide written notice of its grievance decisions limits the hospital's ability to ensure patients' rights regarding grievances.

Findings include:

Review of the policy "Grievances: Patient & Family; The Role of the Patient Advocate" occurred on 03/15/16. This policy, dated 05/2013, stated,
". . . Procedure: . . .
10. Once the issue has been resolved, the staff person responsible for investigating and resolving the grievance will provide a written response within seven (7) days of the grievance/complaint being received. The response will include:
a) The name of the contact person,
b) The steps taken to investigate the grievance on behalf of the patient,
c) The results of the grievance process, how the grievance was resolved;
d) The date of completion of the investigation.
e) The process to follow if the patient/complainant is not satisfied with the response. . . ."

Review of the hospital's grievance records occurred on March 15-16, 2016. The December 2015 through February 2016 records included eleven grievances. The grievance records lacked evidence of written responses to the patient or their representatives.

During an interview on 03/16/16 at 8:20 a.m., an administrative staff member (#4) stated she does not always provide written responses for grievances.

Upon request on 03/16/16 at 8:20 a.m., an administrative staff member (#4) failed to provide evidence of written responses to the patient or their representatives for the eleven grievances reviewed.

THIS IS A REPEAT DEFICIENCY FROM THE COMPLAINT SURVEY COMPLETED ON 01/27/12.

NOTIFICATION OF GUARDIANS AND MEDICATION CONSENT

1. Based on policy and procedure review, record review, and staff interview, the Hospital failed to ensure staff notified the patient's guardian for 1 of 1 minor patient (Patient #16) in a closed record reviewed for a change in medical condition and failed to obtain consent for administration of medications including medications with a black box warning for 6 of 9 minor patient (Patients #1, #2, #3, #5, #6 and #7) records reviewed and 1 of 1 minor patient in a closed record (Patient #16). Failure to notify patients' guardians of changes in medical conditions and to obtain consent for medication administration limited the patients' and guardians' right to be informed and make decisions regarding the patients' care.

Findings include:

Review of the procedure titled "Medication Administration Procedure Sheet" occurred on 03/15/16. The procedure, dated 01/12, stated, ". . . Consent must be obtained by the patient or guardian prior to giving the first dose unless a specific 'May give without consent' order is received . . . in an emergency . . . * Telephone consent is obtained by a licensed nurse and witnessed by another staff member. Both staff members must document this action in the chart. * Consent obtained for patients under 18 years old and patients with a legal guardian is documented in the chart on the Medication Consent Log. . . ."

Review of a blank "Medication Consent Log" form occurred on 03/15/16. The form instructions stated, ". . . Document appropriate information below . . . [table utilized] . . . Consent obtained by: (include if by physician) 1 nurse & 1 witness for phone."

Review of the facility "Black Box Warning" form occurred on 03/15/16. The form instructions stated, "In the United States, a black box warning is a type of warning that appears on prescription drugs, that may cause serious adverse effects. . . . A black box warning means that medical studies indicate that the drug carries a significant risk of serious or even life-threatening adverse effects. The warnings are put on the medication so that the person taking the medication is aware of the risks that may exist. . . . I have discussed the above medications with the Psychiatrist/designee and I am aware of the potential benifets [sic] and side effects . . . I give consent to the following medication." The form stated the requirement of "2 Licensed Nurses for Telephone Consent."

- Review of Patient #16's medical record occurred on March 15-16, 2016. The hospital admitted Patient #16, a minor, on the afternoon of 02/09/16 due to a medication overdose. An undated and untimed "Needs Assessment" stated Patient #16 lived with her mother. A "Comprehensive Assessment Tool - Nursing Assessment: Child /Adolescent 0-17," dated 02/09/16, stated the patient and mother "provided necessary input to complete all the admission paperwork & procedure. No medical complications - will observe for post status OD [overdose] sx [symptoms]."

A progress note, completed by a staff nurse, dated 02/10/16 at 5:30 a.m., described the patient had a rapid heart rate and a seizure episode lasting between two and three minutes.

The medical record showed nursing staff did not notify the patient's parent. This resulted in the parent's lack of involvement in decision making for the patient's change in condition including need for treatment.

- Review of Patient #16's medical record occurred on March 15-16, 2016. The medical record identified a minor admitted on 02/09/16. The facility staff failed to verify verbal consent for the administration of medications from two staff members, prior to administration of ordered medication. The medication consent log included medications ordered on 02/09/16.

- Review of Patient #1's medical record occurred on March 15-16, 2016. The medical record identified a minor admitted on 03/06/16. The facility staff failed to verify verbal consent of the administration of medications from two staff, prior to administration of ordered medication. The medication consent log included medications ordered on 03/07/16 through 03/13/16.

- Review of Patient #2's medical record occurred on March 15-16, 2016. The medical record identified a minor admitted on 03/04/16. The facility staff failed to verify verbal consent of the administration of medications from two staff, prior to administration of ordered medication. The medication consent log included medications ordered on 03/04/16 through 03/14/16.

- Review of Patient #3's medical record occurred on March 15-16, 2016. The medical record identified a minor admitted on 03/10/16. The facility staff failed to verify verbal consent of the administration of medications from two staff, prior to administration of ordered medication. The medication consent log included medications ordered on 03/10/16 through 03/14/16.


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- Review of Patient #5's medical record occurred on March 15-16, 2016. The medical record identified a minor admitted on 03/03/16. The facility staff failed to verify verbal consent of the administration of medications from two staff, prior to administration of ordered medication.

- Review of Patient #1, #2, #3, #5, #6, #7 and #16's medical records occurred on March 15-16, 2016. Each medical record identified a minor admitted to the hospital. "Black Box Warning" forms, in each record, showed a consent signed either by the parent/guardian or a verbal consent from one licensed nurse for unidentified medication with a black box warning. Each form signed by a licensed nurse lacked a signature of a licensed nurse witness. Failure to identify the specific medication allows the unlimited administration of medications with black box warnings without consent.

During interview on 03/16/16 at 1:50 p.m., a supervisory staff member stated all verbal consents require evidence of two witnesses.


GUARDIAN TREATMENT CONSENT

2. Based on policy and procedure review, record review, and staff interview, the Hospital failed to ensure staff obtained treatment consents in a timely manner for 2 of 9 open records (Patients #4 and #6) reviewed of patients under 18 years of age. Failure to obtain consents limits the patients' and guardians' right to be informed and make decisions regarding the patients' care.

Findings include:

Review of the policy titled "Treatment Consent" occurred on 03/16/16. This policy, approved 01/09/07, stated, ". . . consent by patient and/or legal guardian is obtained prior to patient involvement in treatment, activities and programming, . . . In the case of voluntary emergency admission of a minor patient . . . we must obtain consent from the parent/guardian as soon as possible after admission. . . ."

- Review of Patient #4's medical record occurred on March 15-16, 2016. The medical record identified a minor with an admission date of 03/09/16. Staff obtained the following consents per telephone on 03/12/16 at 8:00 p.m.: Needs Assessment Consent & Authorization, Financial Policy, Patient's Bill of Rights, Confidentiality Notice to All Patients, and the Acknowledgement of Receipt Notice of Privacy Practices. Staff obtained consents three days after admission for Patient #4.

- Review of Patient #6's medical record occurred on March 15-16, 2016. The medical record identified a minor with an admission date of 03/05/16. Staff obtained the following consents per telephone on 03/11/16 at 12:21 p.m.: Needs Assessment Consent & Authorization, Patient's Bill of Rights, Confidentiality Notice to All Patients, and Acknowledgement of Receipt Notice of Privacy Practices. Staff obtained consents six days after admission for Patient #6.

During an interview on 03/15/16 at 5:04 p.m., an administrative nurse (#1) stated staff should obtain consents for all adolescents and minors as soon as possible from the time of admission and agreed staff should have obtained Patients #4 and #6's consents sooner.

Based on observation, review of a professional reference, and staff interview, the Hospital failed to provide privacy during medication administration for 6 of 10 patients (Patients #4, #8, #21, #22, #23, and #24) observed during medication pass. Failure to provide privacy limits the patient's basic right to respect, dignity, and comfort while in the hospital.

Findings include:

Kozier & Erb's "Fundamentals of Nursing, Concepts, Process, and Practice" 10th Edition, Pearson Education Inc., Upper Saddle River New Jersey, 2016, page 778, stated, ". . . All medications . . . Provide for client privacy. . . ."

- Observation on 03/15/16 at 3:06 p.m. showed a licensed nurse (#9) administer medications for Patient #22 in the activity room with other patients present. The nurse (#9) asked the patient for his first name and birth date and explained the medication to Patient #22 during administration.

- Observation on 03/16/16 at 8:00 a.m. showed a licensed nurse (#7) administer medications to 5 patients (Patients #4, #8, #21, #23, and #24), one at a time, while the other patients stood in line outside the medication room door. The nurse (#7) asked each patient for their full name and birth date and then explained each medication to the patients during administration.

During an interview on 03/16/16 at 2:00 p.m., an administrative nurse (#1) stated that during medication pass the other patients are to be eight feet away which is marked on the carpet and the patients need reminders to stand there for privacy.

THIS IS A REPEAT DEFICIENCY FROM THE COMPLAINT SURVEY COMPLETED ON 01/27/12.

PROVISION OF SAFE CARE

1. Based on record review, policy and procedure review, review of a professional reference, and staff interview, the Hospital failed to ensure the provision of care in a safe setting for 1 of 1 closed patient record (Patient #16) who experienced a seizure during hospitalization. Failure to ensure patients receive the necessary care and services following a change in condition had the potential for a negative outcome for the patient.

Findings include:

Review of the policy "Provision of Care" occurred on 03/16/16. The policy, dated 07/15, stated, "Scope: All Direct Care Staff
PURPOSE: To maintain the commitment to service excellence for each patient by recognizing and supporting individual needs of each patient and providing guidelines for observation and protection of patients exhibiting high risk behaviors.
POLICY: It is the policy . . . to support patients who exhibit high risk behaviors by placing them on appropriate precautions.
PROCEDURE:
ASSESSMENT:
Patients are assessed upon admission and reassessed throughout their hospitalization . . . Patients who require increased levels of supervision are placed on precautions through the following process:
EARLY IDENTIFIERS: . . .
9. Seizures - history of or propensity for seizures . . .
INTAKE ASSESSMENT:
Following assessment, the accepting physician is contacted and briefed on all relevant patient information. The physician will make a determination of disposition for the patient. . . .
NURSING/CLINICAL SERVICES:
1. Patients with high-risk behaviors are assessed by the unit RN [registered nurse] . . . and by the attending physician within 24 hours of admission. . . . Nursing staff must obtain a physician's order for each high risk behavior precaution identified upon admission or for any change to the high risk precautions during the course of treatment.
2. The following safety measures will be implemented for each category of high risk behavior. These safety measures may be implemented by the nurse on an emergency basis and then the physician's order will be obtained as soon as possible.
a. Staff must communicate in detail about patients with high risk behaviors.
b. If a patient's status becomes more severe the RN may place the patient on a higher monitoring level immediately and obtain the physician's order subsequently. . . .
c. All episodes of high risk behaviors will be fully noted and documented in the patient medical record
High Risk Behavior Precautions Interventions
The interdisciplinary team will implement specific behavioral interventions based on the high risk behaviors identified. . . .
E. The Medical Risk/Change in Patient Condition
1. Patients are continually assessed throughout their inpatient stay to identify medical risk factors or change in condition that require assignment of new precautions or an adjustment of existing precautions or levels of monitoring.
2. The nurse will notify the physician upon identified medical risk:
a. Changes in patient's condition . . .
I. Seizure Risk
1. On admission, the patient is assessed for seizure risk.
2. Seizure precautions are ordered by the physician for patients with a history of seizures, epilepsy, or an increased risk for having seizures. . . ."

The 35th Edition of the "Nursing 2015 Drug Handbook" stated "nortriptyline hydrochloride" overdose signs and symptoms include "Cardiac arrhythmias . . . seizures . . . ECG [electrocardiogram] changes, confusion, restlessness, disturbed concentration . . . stupor, drowsiness, muscle rigidity, vomiting . . ."

Kozier & Erb's "Fundamentals of Nursing," 10th edition, copyright 2016 by Pearson Education, Inc., pages 654-655, stated, ". . . A seizure is a single temporary event that consists of uncontrolled electrical neuronal discharge of the brain that interrupts normal brain function. . . . The etiology or cause of the seizure can be different . . . Seizures are classified into two categories: partial and generalized. . . . Each of these seizure categories includes different types of seizures, depending on the characteristics . . . e.g., loss of consciousness versus impairment to consciousness. . . . Thus, it is important for nurses to thoroughly describe their observations before, during, and after a client's seizure episode. . . . Report significant deviations from normal to the primary care provider."

- Review of Patient #16's medical record occurred on March 15-16, 2016. The hospital admitted Patient #16, a minor, on the afternoon of 02/09/16 due to a medication overdose (nortriptyline) following medical clearance from an acute care hospital. Admission physician orders, dated 02/09/16 at 1:43 p.m., included every 15 minute observation; suicide, self injurious behavior and fall precautions; and a medical consult within 24 hours of admission. An "Admission Summary & High Risk Notification Alert," dated 02/09/16 at 4:00 p.m., stated the patient's high risk factors included "Suicidal . . . Self Harm" and "Pt [patient] had a concussion in December 2015. Still has symptoms."

A progress note, completed by a staff nurse, dated 02/10/16, at 5:30 a.m., stated, "Around 0450 [4:50 a.m.] [patient's first name] started yelling in her sleep and got up out of bed. Staff went to check on pt [patient] and she said she 'felt funny.' Vitals were taken and pulse was in the 150s. Staff encouraged pt to take deep breaths and assessed pt. Vitals at that time were 125/68 [blood pressure], 155 [pulse], 20 [respirations], 97.7 [temperature], and 99% [oxygen level] on room air. [Patient] asked for a drink and then she started to have a seizure at 0454 [4:54 a.m.] and lasted until 0456 [4:56 a.m.]. Vital signs at 0457 [4:57 a.m.] were 113/66 [blood pressure] and pulse was 133. [Patient] stated she didn't hurt anywhere and was able to talk with staff. Pt said she has never had a seizure before. Pt was helped to an upright seating position. VS [vital signs] at 0501 [5:01 a.m.] were 128/83 [blood pressure] and pulse was 126. Pt had an emesis at 0505 [5:05 a.m.] x 1 [once], she stated she felt better after the emesis and asked to go back to bed. VS at 0510 [5:10 a.m.] were 117/65 [blood pressure], 118 [pulse], 17 [respirations], 97.7 [temperature], 99% [oxygen level] on room air. Will continue to monitor, seizure precautions added." A 24 hour nursing progress note, dated on 02/10/16 at 7:00 a.m., stated the patient was restless and yelling in her sleep. A vital signs record showed the patient's pulse upon admission (baseline) 105 beats per minute (bpm), and at 7:30 a.m. on 02/10/16 at 103 bpm.

On 02/10/16 at 5:30 a.m., a nursing staff member wrote a nursing order for seizure precautions. The record lacked evidence of medical provider notification and evidence nursing staff increased the frequency of patient observation following the seizure.

"Group Therapy Notes" showed Patient #16 attended therapy from 9:30 a.m. to 10:20 a.m. on 02/10/16 and ". . . reports feeling 'sick' & 'unlike [her] self.' She was quiet & did not talk & sat [with] her eyes closed." Another therapy group note from a session starting at 10:20 a.m. on 02/10/16 stated the "Pt came to group late. She actively participated but seemed anxious and more reserved during the entire group."

On 02/10/16 at 10:23 a.m. a certified physician's assistant wrote orders which stated "1) Pt not medically stable. Transfer to ER [emergency room] per ambulance." (Record review showed this second group therapy occurred at the same time as the medical provider wrote transfer orders).

A History and Physical (H&P), dated 02/10/16 at 10:10 a.m. stated, "Pt to be seen for H&P; however nursing staff reports seizure this a.m. @ [at]0454 [4:54 a.m.] [with] no hx [history] seizure d/o [disorder]. Pt here s/p [status post] Nortriptyline OD [overdose] . . . is nauseated, has pounding heart, and feels 'terrible.' Pt is medically unstable and will be transferred to [local hospital's] ER per ambulance . . ."

A progress note, completed by a staff nurse, dated 02/10/16 at 11:30 a.m., stated, "Pt transferred to [local hospital's] ER via ambulance 2-10-16 at 1100 [11:00 a.m.]. Pt has tachycardia [rapid heart rate - over normal], VS labile [unstable], seizure this morning and an emesis, pt has been groggy, and c/o [complains of] chest pain. Pt's mother was called to inform of the transfer and pt's condition but no answer . . ." Prior to this progress note, the nurses notes lacked documentation regarding the patient's complaints of chest pain.

An "INPATIENT PROGRESS NOTE," dictated by a hospital psychiatrist on 02/11/16, stated "Note: patient was admitted . . . on 02/09/2016 . . . She was initially admitted but discharged before being seen by this provider. A few hours following admission, she had a seizure and emesis. She was deemed to be unstable medically and consequently transferred back to [name of acute care hospital] for stabilization on 2/10/16."

The medical record included a "PHYSICIAN QUERY FORM," dated 02/16/16, which stated the reason for transfer: "New onset seizure s/p [status post - following] tricyclic overdose; with known high cardiovascular and neurologic [sic] morbidity and mortality associated with tricyclic overdose."

During interview on 03/16/16 at 1:50 p.m., a supervisory nursing staff member (#1) stated staff should notify the physician and family as soon as possible after a change in a minor patient's medical condition.


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SECLUSION MONITORING

2. Based on observation, review of a professional reference, and staff interview, the Hospital failed to provide a safe environment for 1 of 1 patient (Patient #4) observed in a seclusion area. Failure to maintain proper monitoring while in a seclusion area has the potential to lead to serious injury.

Findings include:

Kozier & Erb's "Fundamentals of Nursing, Concepts, Process, and Practice" 10th Edition, Pearson Education Inc., Upper Saddle River New Jersey, 2016, page 660, stated, ". . . Seclusion . . . lack of monitoring can lead to injury and death and psychological harm. . . ."

- Review of Patient #4's medical record occurred on March 15-16, 2016, and identified precautions for suicide, assault/aggression, sexual aggression, and self injurious behavior. Diagnoses included suicidal ideation with a plan to strangle or shoot self with documented attempts. Patient #4 had two episodes of seclusion/restraint use documented on 03/13/16. One episode identified the patient tied a piece of his torn shirt around his neck.

Observation on 03/15/16 at 2:55 p.m. showed Patient #4 in the seclusion hallway with the door closed. The patient exhibited loud, agitated behaviors by punching the wall and hitting his head on the wall. When questioned regarding the patient's monitoring, staff stated they check the patient when they complete their patient rounds every 8-15 minutes. A staff nurse (#8) stated the patient willingly entered the seclusion hallway with seclusion room doors locked because of the patient's prior attempt to strangle himself while in a seclusion room. An administrative nurse (#1) confirmed the seclusion hallway lacked cameras.

During an interview on 03/16/16 at 2:00 p.m., an administrative nurse (#1) stated staff failed to safely monitor the patient by keeping the hallway door open.


MEDICATION ADMINISTRATION

3. Based on observation and staff interview, the Hospital failed to provide care in a safe setting for 2 of 10 patients (Patients #4 and #21) observed during medication pass who received medications staff had dropped and handled with bare hands. Failure of staff to ensure administration of uncontaminated medications limits the hospital's ability to provide care in a safe setting.

Findings include:

- Observation of Patient #4's medication administration occurred on 03/16/16 at 8:00 a.m. A licensed nurse (#7) removed three medications from blister packs, dropped the medications on the floor, (noted to have debris and stains), picked up the medications with bare hands, placed them back in the cup, and administered the medications to Patient #4.

- Observation of Patient #21's medication administration occurred on 03/16/16 at 8:18 a.m. A licensed nurse (#7) removed medication from a blister pack, dropped it on the top of the medication cart, picked it up with a bare hand, placed it in the medication cup, and administered the medication to Patient #21.

During an interview on 03/16/16 at 2:00 p.m., an administrative nurse (#1) agreed staff should have destroyed the dropped medications and provided the patients with new medications.

Based on record review and policy review, the Hospital failed to obtain a physician signature for a verbal order within the appropriate time frame for 1 of 4 patients (Patient #6) reviewed placed in seclusion/restraint. Failure to obtain physician signatures within the appropriate timeframe limits the Hospital's ability to ensure staff document verbal orders correctly.

Findings include:

Review of the facility policy titled "Seclusion & Restraint Policy" occurred on 03/16/16. This policy, dated 07/15, stated, "The physician shall authenticate the telephone/verbal order within 72 hours, according to state law. . . ."

- Review of Patient #6's medical record occurred on March 15-16, 2016. The record identified an adolescent admitted on 03/05/16 with diagnoses of major depressive disorder and suicidal ideation. Staff obtained a physician's verbal order for restraint/seclusion on 03/10/16 at 7:15 p.m. The physician signed the order on 03/15/16 at 11:30 a.m.

The physician failed to authenticate the order for restraint/seclusion within 72 hours.

Based on policy review, record review, personnel file review, and staff interview, the Hospital failed to ensure 1 of 2 registered nurse's (RNs) (#5) personnel files reviewed who performed one-hour face-to-face patient evaluations after restraint/seclusion events had completed the required training to perform the evaluations. Failure to ensure RNs have the appropriate training to perform the one-hour face-to-face evaluations after restraint/seclusion events limits the hospital's ability to ensure the safety of restrained/secluded patients.

Findings include:

Review of the "Seclusion & Restraint Policy" occurred on 03/16/16. This policy, revised 08/2015, stated, ". . . Procedure: . . . 5.0 Face to Face Evaluation by the Physician, LIP [licensed independent practitioner], or trained RN/PA [physician's assistant]: Within one hour of the initiation of restraint or seclusion, the patient shall be evaluated in person by a physician, authorized LIP, or trained RN/PA. . . . 14.0 Staff Training and Competence Assessment: . . . Nurses and PAs authorized to conduct the 1-hour face-to-face evaluation will receive additional training and demonstrate competency to conduct both a physical and behavioral assessment of the patient. All records documenting completion of training and competency demonstration will be maintained in staff personnel files or credentials files. As part of orientation, before performing any of the actions outlined in this policy, and at least annually, training occurs as outlined below. . . . D. Training Requirements for RNs and PAs conducting one hour evaluation: . . . RNs and PAs who have received training and demonstrate competency in this requirement may conduct the one hour evaluation. . . .

Review of Patient #4's medical record on 03/16/16 revealed an RN staff member (#5) completed and signed the "Restraint/Seclusion Nursing Documentation 1. Post Intervention Evaluation (to be completed within 1 hour of initiation of intervention)" for two separate restraint interventions for Patient #4 at 1640 (4:40 p.m.) and 1715 (5:15 p.m.) on 03/13/16.

Reviewed on 03/16/16, Staff Member #5's personnel file lacked evidence of training to perform one-hour face-to-face patient evaluations after restraint/seclusion events.

During an interview on 03/16/16 at 12:50 p.m. a human resources administrative staff member (#3) confirmed Staff Member #5 did not have documented training to perform one-hour face-to-face patient evaluations after restraint/seclusion events.

Based on review of professional literature, policy and procedure review, record review, and staff interview, the Hospital failed to assess and document the effectiveness of medications given to patients on an as needed (prn) basis for 3 of 6 active adult inpatient (Patients #10, #11, and #12) records reviewed. Failure to evaluate the patients' responses to prn medications limited the nursing staff's ability to assess whether the medication achieved the desired effect or if the patients experienced any side effects or adverse reactions from the medication.

Findings include:

Berman and Snyder, "Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice," 9th ed., Pearson Education, Inc., New Jersey, 2012, page 862-870, states, ". . . Process of Administering Medications: When administering any drug . . . the nurse must do the following: . . . 6. Evaluate the client's response to the drug. . . . In all nursing activities, nurses need to be aware of the medications that a client is taking and record their effectiveness as assessed by the client and the nurse on the client's chart. . . . Skill 35-1 Administering Oral Medications: . . . Evaluation: Return to the client when the medication is expected to take effect (usually 30 minutes) to evaluate the effects of the medication on the client. Observe for desired effect . . ."

Review of the policy "Medication Administration" occurred on 03/16/16. This policy, revised December 2015, stated, ". . . Policy: Medications are administered . . . in accordance with . . . policies and procedures and accepted standards of practice. Procedure: . . . 5. Medication Administration Procedure: Before the administration of any medication, the Licensed Nurse will follow the Joint Commission standards as specified . . . See Medication Administration Procedure Sheet . . ."

Review of the "Medication Administration Procedure Sheet" occurred on 03/16/16. This procedure, revised January 2012, stated, ". . . Monitor the effects of the medication to ensure effective patient response within 4 hours after the medication is administered. . . ."

- Review of Patient #10's active medical record occurred on March 15-16, 2016 and identified the Hospital admitted the patient on 03/09/16 with diagnoses of psychotic and schizoaffective disorders. The record indicated the patient used prn medications for anxiety, aggression, agitation, psychosis, and headaches and showed the following physician orders:
*03/10/16 - hydroxyzine (used to treat anxiety or pain) 50 milligrams (mg) every six hours prn, trazodone (used for sleep) 50 mg at bedtime prn, and ibuprofen (used to treat mild pain) 600 mg every six hours prn.
*03/13/16 - Thorazine (used to treat anxiety/aggression/agitation/psychosis) 100 mg every six hours prn (discontinued on 03/14/16).
*03/14/16 - Thorazine 50 mg every six hours prn and Imitrex (used to treat headaches) 100 mg daily prn (may repeat in one hour).
*03/15/16 - clonazepam (used to treat anxiety and agitation) 1 mg every six hours prn.

Patient #10's medication administration record (MAR) showed the following administration times for the prn medication:
*ibuprofen
03/10/16 - 8:49 p.m.
03/11/16 - 8:09 a.m. and 5:13 p.m.
03/12/16 - 12:51 a.m. and 4:08 p.m.
03/13/16 - 11:44 a.m. and 5:46 p.m.
03/14/16 - 1:45 p.m. and 9:13 p.m.
03/15/16 - 3:20 p.m. and 9:31 p.m.
*hydroxyzine
03/11/16 - 2:09 a.m. and 4:45 p.m.
03/12/16 - 5:15 p.m.
03/14/16 - 4:33 p.m.
03/15/16 - 12:28 a.m., 8:02 a.m., and 7:08 p.m.
*Thorazine 100 mg
03/13/16 - 5:22 p.m.
*Thorazine 50 mg
03/14/16 - 2:53 p.m. and 9:35 p.m.
03/15/16 - 3:41 a.m., 10:53 a.m., and 10:36 p.m.
*clonazepam
03/15/16 - 5:30 p.m. and 11:33 p.m.
*Imitrex
03/14/16 - 2:05 p.m. and 3:18 p.m.
03/15/16 - 4:19 p.m.
*trazodone
03/14/16 - 11:11 p.m.

Review of Patient #10's medical record failed to include evidence nursing staff assessed and documented the effectiveness or the patient's response to the above listed prn medications.

- Review of Patient #11's active medical record occurred on 03/16/16 and identified the Hospital admitted the patient on 03/05/16 with diagnoses of psychosis and substance abuse. The record indicated the patient used prn medications for anxiety and psychosis and showed the following physician orders:
*03/06/16 - Zyprexa (used to treat psychosis) 10 mg every six hours prn.
*03/07/16 - hydroxyzine 50 mg every four hours prn (discontinued on 03/11/16).
*03/11/16 - hydroxyzine 100 mg every four hours prn.

Patient #11's MAR showed the following administration times for the prn medication:
*hydroxyzine 50 mg
03/07/16 - 7:08 p.m. and 11:42 p.m.
03/08/16 - 12:59 p.m. and 6:35 p.m.
03/09/16 - 7:31 a.m. and 1:05 p.m.
03/10/16 - 9:02 a.m., 1:01 p.m., and 6:56 p.m.
03/11/16 - 7:46 a.m. and 12:59 p.m.
*hydroxyzine 100 mg
03/11/16 - 6:26 p.m.
*Zyprexa
03/07/16 - 11:24 a.m. and 6:19 p.m.
03/08/16 - 4:37 p.m.
03/09/16 - 10:09 a.m. and 4:32 p.m.
03/10/16 - 10:15 a.m. and 5:01 p.m.
03/11/16 - 10:48 a.m.

Review of Patient #11's medical record failed to include evidence nursing staff assessed and documented the effectiveness or the patient's response to the above listed prn medications.

- Review of Patient #12's active medical record occurred on 03/16/16 and identified the Hospital admitted the patient on 03/12/16 with diagnoses of major depressive disorder, paranoia, and alcohol abuse. The record indicated the patient used prn medications for anxiety and pain and showed the following physician orders:
*03/12/16 - hydroxyzine 25 mg every four hours prn.
*03/13/16 - naproxen (used to treat mild pain) 500 mg twice a day prn.
*03/12/16 - Zyprexa 5 mg every four hours prn.

Patient #12's MAR showed the following administration times for the prn medication:
*hydroxyzine
03/14/16 - 4:15 p.m.
03/15/16 - 4:32 p.m.
*Zyprexa
03/14/16 - 2:21 p.m.
03/15/16 - 9:58 a.m. and 2:58 p.m.
*naproxen
03/13/16 - 2:41 p.m.
03/14/16 - 1:56 p.m.

Review of Patient #12's medical record failed to include evidence nursing staff assessed and documented the effectiveness or the patient's response to the above listed prn medications.

During an interview on 03/16/16 at 8:35 a.m., a nurse manager (#2) stated the Hospital required nurses to document the patient's response to prn pain medications on the MAR and other prn medications on the "24 hour nursing progress note." The nurse (#2) confirmed Patient #10, #11, and #12's medical records failed to include documented responses to the administered prn medications.

During another interview on 03/16/16 at 1:20 p.m., a nurse manager (#2) stated nurses should document the patient's response to prn medications an hour after administration, but confirmed the Hospital did not have a formal process or policy for this.