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Based on observation, record review and staff interview, the facility failed to ensure the patient right of care in a safe setting related to the use of movable furniture that could be used as a weapon and failed to ensure facility bathrooms are locked at all times when unattended by staff. The cumulative effect of these practices resulted in the facility's inability to ensure a safe setting for all 26 patients cared for in this 54 bed acute psychiatric treatment center.

Based on observations, record review and staff interview, the facility failed to ensure a safe environment for care related to the use of moveable chairs that could be used as a weapon and the failure to ensure bathrooms are locked at all times when unattended by staff. This finding had the potential to affect all patients cared for in this 54 bed acute psychiatric treatment center. The facility's census was 26.

Findings include:

1. Observation of the acute and dual diagnosis psychiatric units on 07/29/20 at 2:00 PM noted moveable plastic chairs that could be used as a weapon against patients or staff. Staff A confirmed 5 moveable plastic chairs in the dining area of Unit #52 and 1 moveable plastic chair in the sitting area. Moveable plastic chairs were also noted in Unit #53. Staff A confirmed 1 moveable plastic chair in the dining area of Unit #53, 2 moveable chairs in front of the nurse's station, 1 moveable plastic chair in front of patient room #524, and 2 moveable plastic chairs outside of a psychiatric physician's office.

Review of the medical record for Patient #6 revealed an admit date of 01/04/20 for diagnoses to include bipolar, anxiety, and substance abuse disorders. Review of the nursing documentation on 01/17/20 noted the patient was aggressive and threatening towards mental health staff. The nurse documented at 6:35 PM the patient was seen by the physician and then left the area throwing a chair and clothing. Further review of the nursing documentation at 11:00 PM noted the patient was agitated and a confrontation occurred in the dining area and the patient began throwing chairs.

2. Observation of an unlocked bathroom door was noted during tour on 05/28/20 at 12:45 AM of Unit 52 and 53. Staff A, the CEO, asked a staff member to check to ensure no patients were in the bathroom. The staff member informed the CEO that there were no patients in the bathroom. Again, the CEO requested that the staff member physically check the bathroom to ensure there were no patients in the bathroom. The staff member entered the bathroom, called out, and when there was no answer, he/she informed the CEO there were no patients.

Staff A was interviewed on 07/28/20 at 4:00 PM. He/She stated that all bathrooms should be locked. Staff A further explained that patients are educated to inform a staff member when they need to use the bathroom and when notified, staff members unlock the bathroom and wait outside of the bathroom door until the patient is finished. The CEO further explained that all bathroom doors should be locked at all times when unattended by staff.

Units 52 and 53 were toured again on 07/29/20 at 2:00 PM. A women's bathroom door in Unit #53 was noted to be partially open. There was no staff member outside of the door. When Staff A called into the bathroom, a voice answered back from one of the stalls.

The facility policy titled "Life Safety Construction Suitability" (Reference #1080), effective 08/01/10, was reviewed on 07/28/20 at 04:15 PM. According to the policy bathroom doors should be locked for patient and staff safety. These facts were confirmed with Staff A on 07/29/20 at 02:30 PM.

Based on observation, record review and staff interview, the facility failed to ensure nursing staff followed facility policies for medication administration and medication error. The cumulative effect of these practices affected Patient #11 and had the potential to affect all 26 patients cared for in this 54 bed acute psychiatric treatment center.

Based on observation, record review and staff interview it was determined the facility failed to ensure nursing staff followed facility policies for medication errors and medication administration. These findings affected one patient (#11) and had the potential to affect all patients cared for in this 54 bed acute psychiatric treatment center. The facility's census was 26.

Findings include:

1. The medical record of Patient #11 revealed the patient was admitted to the facility on 07/06/20. According to the physician's History and Physical (H&P), the patient had a history of schizoaffective disorder, autism spectrum disorder, moderate to severe intellectual disability, cerebral palsy, bipolar disorder, obsessive compulsive disorder, impulse control disorder, and aggression. The patient was transferred from a nursing home where he/she was noted to have aggression and behavioral issues. It was further noted that the patient had drug allergies to Geodon (an antipsychotic used to treat symptoms of schizophrenia and acute manic or mixed episodes associated with bipolar disorder), Heparin, and Abilify. The Initial Nursing Assessment also noted the patient's drug allergies to Geodon, Heparin, and Abilify.

A nurse's note on 07/08/20 stated the patient was in the dining area yelling with incoherent speech. It was noted that the patient "did better" with male staff so the patient's sitter was switched from a female to male PCA.

A nurse's note on 07/08/20 at 11:15 AM stated the patient refused toileting but instead urinated on him/herself. The patient then refused to allow staff to place depends on him/her. The patient was noted to be "screaming for underwear." The patient was further noted to become aggressive, kicking at the nurse and screaming loudly for minutes. At 12:35 PM, a nurse's note stated the patient was again, speaking incoherently. Patient #11 was further noted to throw a lunch tray across the dining room, bang on the table. Although staff attempted to provide emotional support, the patient continued to scream and shove at the table. A staff nurse notified psychiatry seeking orders for PO Ativan and Haldol for agitation as these medications were prescribed via injection.

A nurse's note on 7/10/20 at 1:00 PM stated Patient #11 urinated on self in dining room after being offered toileting, patient remains 1:1.

The MAR reveals Ativan 2mg/ml given at 12:00 AM 7/11/20, by Staff J.

On 07/11/20 at 7:15 AM, Staff B, dayshift nurse, documents in a timeline that he/she received reports from night shift that Patient #11 was with increased yelling and hitting. Night shift also reports patient received PRN Geodon IM and Ativan 2mg/IM. They were reported to be given at 10:30 PM 7/10/20. Staff B noted that patient has allergy to Geodon and that Ativan orders are 1 mg, not 2mg. At 8:20 AM, patient assessed by nurse and described the patient as "lethargic." Staff B notified the Director of Nursing and a psychiatric nurse practitioner and an order was given to hold all psychotropic medications. Neuro checks were initiated at 8:45 AM and were noted to be within normal limits. At 10:32 AM a psychiatric physician was notified and advised staff that he/she would come to the hospital to assess the patient. The physician was noted to be at the bedside of the patient performing an assessment at 10:40 AM. Neuro checks were discontinued and vital signs every four hours were ordered.

Staff A was interviewed on 08/05/20 at 9:15 AM and asked the process for medication errors. Staff A stated staff are required to complete a Medication Error Report form and it is reviewed on the last Wednesday of every month by the facility's Quality committee. Staff A was asked to provide this completed form. Staff A was also asked if a physician ordered the psychotropic medication. Staff A revealed there was no order for the medication.


The facility policy titled 'Medication Errors" (MM-0031), effective 03/01/20, was reviewed on 08/05/20 at 10:00 AM. According to the policy, the purpose of the policy is to assure that medication errors are identified, investigated, reported and that needed action is taken to minimize recurrence. The policy instructs staff to complete a Medication and Treatment Errors and Omissions form for all medication errors. Staff A was interviewed on 08/05/20 at 10:05 AM. It was confirmed there was no form generated to identify, investigate, and report this medication error.

Staff A responded to interview with an email dated 08/05/20 at 10:32 AM that stated he/she will be doing a full root cause of the issue you have brought to my attention regarding Patient 11's possible Geodon injection on July 11. The pharmacist saw a "pull" for Ativan and Geodon for Patient #11 but she also agrees it does not appear to be given.

Review of Nurse case notes DOS: 07/13/2020 revealed Staff J was caring for Patient #11 on the night 7PM to 7AM shift on 7/10 and 7/11. The patient exhibited a high enough level of agitation that PRN agitation orders, IM route were considered. This nurse reviewed clients medication and allergy information from the "ommini cell/medication ders" (electronic medical record system and medication dispensing system). Ativan 2 mg IM PRN and Ziprasidone 20 mg IM PRN both were and are currently prescribed and displayed as current medication orders. The action of overriding the system to any medication was not utilized, further indicating a dis-communication flaw between that system's information and the information in the EMR.

2. Observation on 05/28/20 at 12:45 AM of the locked medication room, located behind the nurse's station, on Unit 53 revealed medications for two patients were noted to be on the counter. Staff F, present during the tour, was asked if it was typical for patient medication to be left unattended in the medication room. Staff F stated that this is not the facility protocol and asked several nurses sitting in the nurse's station if anyone knew why the medication was lying on the counter. Staff E entered the medication room and explained that he/she had pulled the medication in anticipation of administering the medication at 2:00 PM.

The facility policy titled "Medication Administration" (Policy Number 6.01), effective 01/09/20, was reviewed on 07/28/20 at 3:00 PM. According to the policy staff are instructed to administer medication immediately after the medication is prepared without a break in process by the individual who prepares the dose. The policy also instructed staff to prepare medications for one patient at a time. These facts were confirmed with Staff A on 05/28/20 at 3:45 PM.

Based on observation made during a medication pass, facility policy review, and staff interview, the facility failed to ensure the current infection control policy related to wearing facial covering to prevent the spread of Covid-19 was followed. This had the potential to affect all patients in the facility. The facility's census was 26.

Findings include:

1. Staff B, a Registered Nurse, was observed performing a med pass on 07/29/20 at 10:30 AM. Staff B was noted to be wearing a surgical mask that covered only his/her mouth and chin. During the administration of the medication, the patient pulled his/her mask down past his/her chin in order to take the medication. Staff B and the patient were facing each other within two feet during administration of the medication. Staff B was also noted to assess the patient for suicide ideations. When the patient spoke that he/she did not have suicide ideations, his/her mask was positioned under his/her chin exposing the nose mouth, and chin and the mask of Staff B was positioned below the nose.

Covid-19 precautions were reviewed on 07/29/20 at 11:10 AM. According to the guidelines on how to wear a facial covering, staff are instructed to cover the nose, mouth, and chin. It was confirmed with Staff A, the CEO, and Staff F, the DON, present during the med pass, that leaving the nose exposed could allow the transmission of the virus directly into the respiratory system.