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Based on medical record reviews, staff interviews and document reviews it was determined the facility failed to ensure nursing staff did not provide care above their scope of practice, failed to ensure the nursing staff followed their policy for verbal orders, and failed to notify the West Virginia (WV) Board of Registered Nurses (RNs) when nursing staff provided care above their scope of practice and falsified documentation. This failure was identified in eight (8) of ten (10) medical records reviewed (patient #1, 4, 5, 6, 7, 8, 9 and 10). This failure has the potential to adversely affect all patients receiving care at the facility

Findings include:

A review of the medical record for patient #1 revealed patient #1 was admitted on 4/22/19 with a diagnosis of aggressive behavior. A review of the medication administration record for 11/9/21 revealed an order for Zyrtec 10 milligrams (mg) to be given at 9:00 p.m., Zyrtec was given at 11:50 p.m. There was an order for melatonin 15 mg to be given at 9:00 p.m. on 11/9/21, melatonin was given at 11:49 p.m. A handwritten verbal order dated 11/9/21 at 11:50 p.m. stated, "Ok to give 11/9/21 PM meds at this time. T.O. [NP (Nurse Practitioner) #2], signed by [RN #1] on 11/10/21 at 7:30 a.m." No physician signature was noted on the order.

A review of the medical record for patient #4 revealed patient #4 was admitted on 11/4/20 with a diagnosis of bipolar. A review of the medication administration record for 11/9/21 revealed an order for Depakote 1,000 mg to be given at 9:00 p.m., Depakote was given at 11:35 p.m. There was an order for Seroquel 200 mg to be given at 9:00 p.m. on 11/9/21, Seroquel was given at 11:39 p.m. There was an order for Zocor 20 mg to be given at 9:00 p.m. on 11/9/21, Zocor was given at 11:40 p.m. A handwritten verbal order dated 11/9/21 at 11:50 p.m. stated, "Ok to give 11/9/21 PM meds at this time. T.O. [NP #2], signed by [RN #1] on 11/10/21 at 7:30 a.m." No physician signature was noted on the order.

A review of the medical record for patient #5 revealed patient #5 was admitted on 11/4/20 with a diagnosis of bipolar. A review of the medication administration record for 11/9/21 revealed an order for Depakote ER 1,500 mg to be given at 9:00 p.m., Depakote ER was given at 10:44 p.m. A handwritten verbal order dated for 11/9/21 at 11:50 p.m. stated, "Ok to give 11/9/21 PM meds at this time. T.O. [NP #2], signed by [RN #1] on 11/10/21 at 7:30 a.m." No physician signature was noted on the order.

A review of the medical record for patient #6 revealed patient #6 was admitted on 5/19/21 with a diagnosis of paranoid schizophrenia. A review of the medication administration record for 11/9/21 revealed an order for Restoril 7.5 mg to be given at 9:00 p.m., Restoril was given at 11:50 p.m. A handwritten verbal order dated for 11/9/21 at 11:50 p.m. stated, "Ok to give 11/9/21 PM meds at this time. T.O. [NP #2], signed by [RN #1] on 11/10/21 at 7:50 a.m." No physician signature was noted on the order.

A review of the medical record for patient #7 revealed patient #7 was admitted on 11/5/20 with a diagnosis of schizophrenia. A review of the medication administration record for 11/9/21 revealed an order for Lipitor 10 mg to be given at 9:00 p.m., Lipitor was given at 11:56 p.m. An order for Clozaril 200 mg to be given at 9:00 p.m. on 11/9/21, Clozaril 200 mg was given at 11:56 p.m. An order for Clozaril 50 mg to be given at 9:00 p.m. on 11/9/21, Clozaril 50 mg was given at 11:55 p.m. A handwritten verbal order dated for 11/9/21 at 11:50 p.m. stated, "Ok to admin 11/9/21 PM meds at this time. T.O. [NP #2], signed by [RN #1] on 11/10/21 at 7:50 a.m." No physician signature was noted on the order.

A review of the medical record for patient #8 revealed patient #8 was admitted on 11/5/20 with a diagnosis of antisocial personality disorder. A review of the medication administration record for 11/9/21 revealed an order for Depakote ER 1,000 mg to be given at 9:00 p.m., Depakote ER was given at 11:59 p.m. An order for melatonin 10 mg to be given at 9:00 p.m. on 11/9/21, melatonin was given at 11:59 p.m. An order for Paxil 30 mg to be given at 9:00 p.m. on 11/9/21, Paxil was given at 11:59 p.m. A handwritten verbal order dated for 11/9/21 at 11:50 p.m. stated, "Ok to give 11/9/21 PM meds at this time. , T.O.(telephone order) [NP #2], signed by [RN #1] on 11/10/21 at 7:55 a.m." No physician signature was noted on the order.

A review of the medical record for patient #9 revealed patient #9 was admitted on 2/4/21 with a diagnosis of schizophrenia. A review of the medication administration record for 11/9/21 for patient #1 revealed an order for blood glucose monitoring to be completed at 9:00 p.m., no blood glucose monitoring was completed. An order for docusate sodium 100 mg to be given at 9:00 p.m. on 11/9/21, no docusate sodium was given. An order for Neurontin 300 mg to be given at 9:00 p.m. on 11/9/21, no Neurontin was given. An order for Metformin 1000 mg to be given at 9:00 p.m. on 11/9/21, no Metformin was given. An order for Bacid 2 each to be given at 9:00 p.m. on 11/9/21, no Bacid was given. An order for Zyprexa 20 mg to be given at 9:00 p.m. on 11/9/21, no Zyprexa was given. An order for Invega 12 mg to be given at 9:00 p.m. on 11/9/21, no Invega was given. A handwritten verbal order dated for 11/9/21 at 11:50 p.m. stated, "Ok to give 11/9/21 PM meds at this time. T.O. [NP #2], signed by [RN #1] on 11/10/21, [no time on nurse's signature]." No physician signature was noted on the order.

A review of the medical record for patient #10 revealed patient #10 was admitted on 5/21/20 with a diagnosis of schizoaffective disorder. A review of the medication administration record for 11/9/21 revealed an order for Seroquel 800 mg to be given at 9:00 p.m., no Seroquel was given. An order for Lasix 40 mg to be given at 9:00 p.m. on 11/9/21, no Lasix was given. An order for Lipitor 20 mg to be given at 9:00 p.m. on 11/9/21, no Lipitor was given. An order for Albuterol inhalation 2 puffs to be given at 9:00 p.m. on 11/9/21, no Albuterol was given. A handwritten verbal order dated for 11/9/21 at 11:50 p.m. stated, "Ok to give 11/9/21 PM meds at this time. T.O. [NP #2], signed by [RN #1] on 11/10/21 at 7:50 a.m." No physician signature was noted on the order.

An interview was conducted with the Patient Advocate on 1/10/22 at 1:55 p.m. The Patient Advocate stated, "The patient complained they were not getting the medications until midnight. I met with [RN #1] once about the computer system, [RN #1] wasn't very tech savvy. The complaint was followed up with education. No issues with med pass since [RN #1] resigned. They had met with [RN #1] multiple times."

An interview was conducted with the Nurse Manager (NM) of Adult Services on 1/10/22 at 2:04 p.m. The NM of Adult Services stated, "I met with [RN #1] prior to 11/15/21 about medications. We talked about time management. Inpatient psych was new to [RN #1]. [RN #1] is a single task person, not a multitask person. [RN #1] did not take constructive criticism well. [RN #1] did not take any accountability to what had happened. [RN #1] wrote orders, not appropriate orders. The providers said they did not give the orders. We have done staff meetings, memos about med passes and medication orders since the incident. The time frame for passing medications is one (1) hour before or one (1) hour after the scheduled time of a medication order. [RN #1] had given medications at 2:00 a.m. and not informing anyone she was giving at this time. [RN #1] had held a patient's insulin because the patient's blood sugar was eighty (80). I talked to [RN #1] about long-acting insulin and short acting insulin. This is basic nursing issues. No issues with medications since [RN #1] quit. [RN #1] was not very receptive, was confrontational with other staff. [RN #1] tried to get other staff to give medication [RN #1] did not give. Providers got involved when they noticed meds were not given."

An interview was conducted with the Director of Pharmacy on 1/11/22 at 8:51 a.m. When asked about tracking medications given, the Director of Pharmacy stated, "We do not have a tracking mechanism in the electronic medical record (EMR) for all medications given daily. The facility gives fifty thousand (50,000) medications monthly. An initial review of all medications to be given is completed to ensure all medications have appropriate orders. When pharmacy is not at the facility, two (2) licensed practitioners will give medications to verify orders and that meds are given correctly. When pharmacy is onsite, pharmacy verifies all medications given, every order verified by pharmacy. All handwritten verbal orders not entered into the EMR would have a pink carbon copy sent to pharmacy for verification."

An interview was conducted with the Chief Nursing Officer (CNO) on 1/11/22 at 9:20 a.m. When asked if RN #1 was reported to the WV Board of Nursing for writing medication orders, the CNO stated no, due to [RN #1] resigned. The CNO stated, "We did not get the opportunity to educate [RN #1] to see if she understood the education. [RN #1] was resistant to training and education. Staff matrix for the unit was one (1) RN p.m. to a.m. [RN #1] was ambiguous with the investigation. [RN #1] said they were not going to argue with this. I was told [RN #1] called the provider to get the order to give the meds. The provider said I'm not going to give you orders for all these meds, just do your job. The provider wanted to talk to the supervisor and told the supervisor to just give the meds. I was told by the supervisor the provider said it was ok to give the meds. So, [RN #1] wrote the orders. The other nurse working refused to give the meds until an order [paper verbal order] was given. This has happened more than once. We did not know the orders were written until weeks later. When we found the orders, [NP #1], [NP #2] and [NP #3] came to me and said, "[RN #1] needs to be fired." When asked if RN #1 followed policy for giving medications, the CNO stated, "No." When asked if RN #1 followed policy for verbal orders, the CNO stated, "No." The CNO stated, "We were aware of issues since 10/28/21 with [RN #1]. No other issues with nurses giving evening medications now."

A telephone interview was conducted with NP #1 on 1/11/22 at 9:50 a.m. NP #1 stated, "Prior to 11/14/21 the patients were complaining of getting the medications really late. The first time it occurred, I thought it was a bad night. The second time it occurred, I emailed or texted the supervisor or CNO. I am unsure which I emailed or texted. They had talked to [RN #1] and was going to speak to her again but missed her that day. I told the CNO or supervisor the patients were complaining of not getting meds appropriately. I told them three (3) times. [NP #2] had been on call on 11/9/21, a stack of orders [verbal orders] were there for [NP #1] to sign. [NP #2] said no verbal orders were given to give meds that late, so she did not sign them. The first incident with [RN #1] was they did not put an order in the computer for Eliquis. The second incident with [RN #1] was they held a patient's Lantus medication without an order. The patient was given a sliding scale coverage due to medication was held. The third incident with [RN #1] was after they started writing paper orders."

An interview was conducted with NP #2 on 1/11/22 at 10:03 a.m. NP #2 stated, "[RN #1] called and said, "I don't have time to pass out meds." I told [RN #1] to call the supervisor for help. I did call the supervisor and told them, "You may want to go help [RN #1]." "I don't recall ever telling the supervisor to give the meds. I told the supervisor to find out what is going on."

An interview was conducted with the Patient Advocate on 1/11/22 at 10:12 a.m. The Patient Advocate stated, "We are unable to speak to the house supervisor for 11/9/21 due to she is off, she is very ill."

An interview was conducted with the Medical Director on 1/11/22 at 10:28 a.m. The Medical Director stated, "This is an isolated incident. It was a nursing problem, not a physician problem. We assume all medications are given correctly. We don't do paper orders unless the system is down. We only see meds not given if the nurse flags the medication. This was a major problem with the medications not being given correctly."

An interview was conducted with NP #3 on 1/11/22 at 11:11 a.m. NP #3 stated, "I did not know about the paper orders [for 10/28/21] until several weeks later. I took my concerns to the CNO about these orders when I was made aware of them. I did not give these orders. I did not document about not giving these orders due to I did not know about it until several weeks later."

An interview was conducted with the CNO on 1/11/22 at 12:10 p.m. The CNO stated, "One to one (1:1) education was completed on 10/27/21 with [RN #1], a meeting with everyone was on 11/2/21 and [RN #1] got up and left. On 11/15/21 the NM and myself attempted to talk to [RN #1] and they resigned. [RN #1] had requested the meeting on 11/2/21. There was a lot of confusion around the orders, they were not appropriate. I am unsure if orders were given. The providers were saying no order was given, the house supervisor and [RN #1] said orders were given to give the medications late. The house supervisor said the provider said [RN #1] has the orders, just give the medication, just do your job. [NP #2] told me the same thing a couple of times. I think there is errors on both sides. We needed to go through all the medications. I told [RN #1] and the house supervisor the orders were not appropriate. The feedback to the nurses was to do your job. The nurses were just going to do that." When asked if RN #1 was reported to the Board of Nursing, the CNO stated, "What I do know, nothing to report on her. Do I think she falsified MD orders, not the case. The supervisor verified the orders were given. They were told to do their job, not specifically to give a medication at that time." When asked about the read back on the verbal order, the CNO stated, "No read back verification was on the verbal orders." The CNO stated the supervisor should have written the orders.

A telephone call was made to RN #1 on 1/11/22 at 1:28 p.m. A message was left requesting a return call before 2:30 p.m. (A return call was received on 1/12/22 after exit from the facility on 1/11/22).

A review of the personnel file for RN #1 revealed an employee corrective action report dated 10/28/21. The corrective action plan stated in part: "Concerns were brought forth from MD/APRN (Advanced Practice Registered Nurse) and patients regarding hs (at bedtime) medication pass. Patients were complaining of receiving their medications late. Discuss and educate with [RN #1] medication times, notifying the physician of any held or refused medications." The employee corrective action report was signed on 10/28/21 by RN #1. A meeting was held on 11/2/21 with the CNO, NM, Nurse Supervisor, RN #1, and RN #2, and per documentation, the meeting was requested by RN #1. During the meeting on 11/2/21, RN #1 left the meeting. An employee corrective action report dated 11/15/21 stated in part: "Met with [RN #1] on 11/11/21 and discussed medication management, nursing practice standards, patient care and med errors. Consistently giving medications significantly late (several hours) after the one (1) hour time frame allotted per RPH (River Park Hospital) medication policy (PH-054). Discussed concerns brought forth both providers regarding administering late medications. Specifically, providers being called late to give orders to administer medications not given on time. Paper orders were found for 11/1/21 and 11/10/21 in patient's charts and reported by providers they did not give those orders to [RN #1]. [RN #1] could not explain why she had written orders vs not documenting in HCS (Health Care System) appropriately. Writing orders not given by providers is considered falsification of documentation. Informed employee she was expected to administer medications per policy, educated on policies and time frames. Instructed [RN #1] that her lack of performance is resulting in unsafe nursing practices and potentially jeopardizing patient's well-being. [RN #1] is expected to correct deficiencies immediately. Expectations include but are not limited to the following: 1. Provide safe patient care: administer medications on time in accordance with RPH policies (attached, listed below). 2. Document appropriately: all documentation is to be in the electronic medical record system (HCS) unless downtime procedures are implemented. 3. [RN #1] is not to falsify documentation. Any verbal orders given must be read back to the provider. 4. [RN #1] is to seek out assistance from supervisor with any questions or when clarification of duties is needed. Failure to correct the above deficiencies will lead to further disciplinary up to and including termination." It is documented RN #1 refused to sign and resigned. The NM and CNO signed the corrective action report on 11/15/21. A resignation letter was sent to the NM on 11/16/21 via email from RN #1.

A review of the policy titled "Medication Process, effective date 11/00, stated in part: "Verbal orders may be given to either an RN or LPN (Licensed Practical Nurse). Verbal orders taken by a RN/LPN will be repeated to the physician to verify accuracy. The RN/LPN will check the read back alert in the electronic medical record, verifying that the orders were read back and verified."

A review of the West Virginia Board of Examiners for Registered Professional Nurses document titled "SCOPE OF PRACTICE FOR LICENSED NURSES AND GUIDELINES FOR DETERMINING ACTS THAT MAY BE DELEGATED OR ASSIGNED BY LICENSED NURSES stated in part: "Registered professional nursing shall mean "the performance for compensation of any service requiring substantial specialized judgment and skill based on knowledge and application of principles of nursing derived from the biological, physical and social sciences, such as responsible supervision of a patient requiring skill in observation of symptoms and reactions and the accurate recording of the facts, or the supervision and teaching of other persons with respect to such principles of nursing, or in the administration of medications and treatments as prescribed by a licensed physician, a licensed dentist, or a licensed advanced practice registered nurse, or the application of such nursing procedures as involve understanding of cause and effect in order to safeguard life and health of a patient and others." (West Virginia Code §30-7-1).

A review of the policy titled "Medication Administration Times, effective date: 11/00 stated in part: "Medications that are ordered to be given as regularly scheduled meds will be administered at the following dose times: For Adult and Adolescent units: Daily (QAM) 0800, BID 0800 & 2100, TID 0800 - 1500 - 2100, QID 0800 - 1200 - 1600 - 2100, Q 4hr 0400-800 - 1200- 1600 - 2000 - 2400, Q 6hr 0600 - 1200 - 1800 - 2400, Q 8hr 0800 - 1600 - 2400, Q 12hr 0800 - 2100, Bedtime 2100, etc ..."

The CNO concurred RN #1 wrote verbal orders to give medications without talking to the providers.

The complaint is substantiated with one (1) related standard level deficiency cited at A 398.