The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ACADIA GENERAL HOSPITAL 1305 CROWLEY RAYNE HIGHWAY CROWLEY, LA 70526 April 5, 2011
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the hospital failed to ensure the patient received care in a safe setting as evidenced by 1) failing to ensure staff from contracted staffing agency "a" were deemed competent to perform the duties to which they were assigned as evidenced by Certified Nursing Assistants (CNA) being assigned the one to one (1:1) observation of patient #13 by the Registered Nurse (RN) when the patient was deemed a suicidal risk and ordered 1:1 observation by the physician responsible for the care of the patient for 1 of 13 patients sampled. (#13) Findings:

1)

Review of the medical record of patient #13 revealed he was admitted on [DATE] at 1815 (6:15 p.m.) by S6MD, Psychiatrist. Review of the admission orders revealed the admitting diagnosis was Major Depression with Suicidal Ideation's. Further review of the admission orders revealed an order to "place patient (#13) on 1:1 - not allowed to go outside - no visitors."

Review of the psychiatric evaluation revealed it was dictated by S6MD, Psychiatrist, on 03/31/11 at 7:52 a.m. Further review of the document revealed "Chief Complaint: I stopped using Adderal, Crystal Meth, Lortab and alcohol about a week ago and since then I've been feeling extremely depressed, wanting to die. History of Present Illness: The patient is a [AGE] year old male who has an extensive history of polysubstance abuse...while he was at his mother's house, while he was in her presence, he took a knife and made some very superficial scratches to his left forearm and she brought him to the hospital and while he was actually in the emergency room , while the doctor and staff were present according to the patient, he grabbed the electrocardiogram cord and wrapped it around his neck. Since being here he does state that he still has suicidal ideation's. I did put him on one to one...Mental Status Examination:...He currently states that he feels suicidal, states that he will not hurt himself but could not promise."

Review of the hospital's staffing sheets/assignments for the physician ordered 1:1 observation of patient #13 revealed the following staff from contracted staffing agency "a" were assigned to patient #13:

03/30/11 S15CNA, contracted staffing agency "a", was assigned the 1:1 observation of patient #13 from 10:00 p.m. - 7:00 a.m. (03/31/11).

03/31/11 S17CNA, contracted staffing agency "a", was assigned the 1:1 observation of patient #13 from 7:00 a.m. - 1:00 p.m. S16CNA, contracted staffing agency "a", was assigned the 1:1 observation of patient #13 from 1:00 a.m. - 7:00 p.m.

03/31/11 S15CNA, contracted staffing agency "a", was assigned the 1:1 observation of patient #13 from 6:35 p.m. - 7:30 a.m. (04/01/11).

04/01/11 S17CNA, contracted staffing agency "a", was assigned the 1:1 observation of patient #13 from 7:00 a.m. - 7:00 p.m.

04/01/11 S21CNA, contracted staffing agency "a", was assigned the 1:1 observation of patient #13 from 10:00 p.m. - 6:00 a.m. (04/02/11).

04/02/11 S14CNA, contracted staffing agency "a", was assigned the 1:1 observation of patient #13 from 10:00 p.m. - 6:00 a.m. (04/03/11).

04/01/11 S17CNA, contracted staffing agency "a", was assigned the 1:1 observation of patient #13 from 7:00 a.m. - 7:00 p.m.

Review of the Facility Staffing Agreement contract with contracted staffing agency "a" revealed "...3. Duties and Obligations. The Company (contracted staffing agency "a") has contracted with qualified Independent Contractor's who will be able to provide services in Louisiana. Company can provide Facility with RN's, LPN's, and CNA's (the "Independent Contractor") on a contract basis...3.1.k Company agrees to verify that Independent Contractor's has had Crisis Prevention Training for psychiatric care..." Review of the entire contract revealed no evidence the contracted staffing agency could provide the hospital with MHT's.

Review of a hospital policy titled "Job Description. Title: Mental Health Technician" revealed in part: "...II. Duties and Responsibilities...D...demonstrates the ability to identify behaviors that require intervention. E. Appropriately cares for patients and demonstrates the knowledge of precautionary measures for: 1. Elopement Precautions 2. Close Observation 3. Suicidal Precautions. 4. One to One...J. Demonstrates the ability to set limits for patients and other de-escalation techniques. K. Assists with behavioral modification programs...M. Monitors environment for safety hazards, and/or potentials for self-abuse or assault..."

Review of information faxed to the hospital from contracted staffing agency "a" after the interview on 04/04/11 at 2:03 p.m. with S2CNO and S5Program Director revealed all five CNA's had Certified Nursing Assistant Competency Assessments which were self assessments and had no return demonstration of any skill. Further review revealed none of the Competency Assessments contained the following items listed in the hospital's "Job Description. Title: Mental Health Technician:...II. Duties and Responsibilities...D...demonstrates the ability to identify behaviors that require intervention. E. Appropriately cares for patients and demonstrates the knowledge of precautionary measures for: 1. Elopement Precautions 2. Close Observation 3. Suicidal Precautions. 4. One to One...J. Demonstrates the ability to set limits for patients and other de-escalation techniques. K. Assists with behavioral modification programs...M. Monitors environment for safety hazards, and/or potentials for self-abuse or assault..." Further review revealed only 2 of the 5 CNA's (S17CNA, S21CNA) had current CPI training per the contract.

Review of a hospital policy titled "Assignment of Patient Care", effective date 1/1/95, revised 3/24/2005, reads in part: "Subject: Pauline Faulk Center. Purpose: To establish a policy where by Registered Nurses will prescribe, delegate, and coordinate nursing care. Policy: Assignment of patient care...The Registered Nurse , with designated responsibility to assign care to nursing staff members within the patient care unit...Procedure: Employee's clinical skills will be taken into consideration prior to making assignments. All personnel having direct contact with patients will be CPR (cardiopulmonary resuscitation) certified every two years, and CPI (crisis prevention intervention) certified annually."

In an interview on 04/04/11 at 2:03 p.m. with S2CNO and S5Program Director both verified all five of the personnel who were assigned the 1:1 were CNA's. S2CNO and S5Program Director stated that the hospital had no documented evidence of the competency of the CNA's to function in the role of a Mental Health Technician (MHT) in accordance with the hospital's MHT Job Description and that the contracted staffing agency "a" could only provide current CPI training for 2 of the 5 CNA's. (S17CNA, S21CNA)
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the hospital failed to ensure staff from contracted staffing agency were deemed competent to perform the duties to which they were assigned as evidenced by Certified Nursing Assistants (CNA) being assigned the one to one (1:1) observation of patient #13 by the Registered Nurse (RN) when the patient was deemed a suicidal risk and ordered 1:1 observation by the physician responsible for the care of the patient for 1 of 13 sampled patients and 0 of 1 random patient. Findings:

Review of the medical record of patient #13 revealed he was admitted on [DATE] at 1815 (6:15 p.m.) by S6MD, Psychiatrist. Review of the admission orders revealed the admitting diagnosis was Major Depression with Suicidal Ideation's. Further review of the admission orders revealed an order to "place patient (#13) on 1:1 - not allowed to go outside - no visitors."

Review of the psychiatric evaluation revealed it was dictated by S6MD, Psychiatrist, on 03/31/11 at 7:52 a.m. Further review of the document revealed "Chief Complaint: I stopped using Adderal, Crystal Meth, Lortab and alcohol about a week ago and since then I've been feeling extremely depressed, wanting to die. History of Present Illness: The patient is a [AGE] year old male who has an extensive history of polysubstance abuse...while he was at his mother's house, while he was in her presence, he took a knife and made some very superficial scratches to his left forearm and she brought him to the hospital and while he was actually in the emergency room , while the doctor and staff were present according to the patient, he grabbed the electrocardiogram cord and wrapped it around his neck. Since being here he does state that he still has suicidal ideation's. I did put him on one to one...Mental Status Examination:...He currently states that he feels suicidal, states that he will not hurt himself but could not promise."

Review of the hospital's staffing sheets/assignments for the physician ordered 1:1 observation of patient #13 revealed the following staff from contracted staffing agency "a" were assigned to patient #13:

03/30/11 S15CNA, contracted staffing agency "a", was assigned the 1:1 observation of patient #13 from 10:00 p.m. - 7:00 a.m. (03/31/11).

03/31/11 S17CNA, contracted staffing agency "a", was assigned the 1:1 observation of patient #13 from 7:00 a.m. - 1:00 p.m. S16CNA, contracted staffing agency "a", was assigned the 1:1 observation of patient #13 from 1:00 a.m. - 7:00 p.m.

03/31/11 S15CNA, contracted staffing agency "a", was assigned the 1:1 observation of patient #13 from 6:35 p.m. - 7:30 a.m. (04/01/11).

04/01/11 S17CNA, contracted staffing agency "a", was assigned the 1:1 observation of patient #13 from 7:00 a.m. - 7:00 p.m.

04/01/11 S21CNA, contracted staffing agency "a", was assigned the 1:1 observation of patient #13 from 10:00 p.m. - 6:00 a.m. (04/02/11).

04/02/11 S14CNA, contracted staffing agency "a", was assigned the 1:1 observation of patient #13 from 10:00 p.m. - 6:00 a.m. (04/03/11).

04/01/11 S17CNA, contracted staffing agency "a", was assigned the 1:1 observation of patient #13 from 7:00 a.m. - 7:00 p.m.

Review of the Facility Staffing Agreement contract with contracted staffing agency "a" revealed "...3. Duties and Obligations. The Company (contracted staffing agency "a") has contracted with qualified Independent Contractor's who will be able to provide services in Louisiana. Company can provide Facility with RN's, LPN's, and CNA's (the "Independent Contractor") on a contract basis...3.1.k Company agrees to verify that Independent Contractor's has had Crisis Prevention Training for psychiatric care..." Review of the entire contract revealed no evidence the contracted staffing agency could provide the hospital with MHT's.

Review of a hospital policy titled "Job Description. Title: Mental Health Technician" revealed in part: "...II. Duties and Responsibilities...D...demonstrates the ability to identify behaviors that require intervention. E. Appropriately cares for patients and demonstrates the knowledge of precautionary measures for: 1. Elopement Precautions 2. Close Observation 3. Suicidal Precautions. 4. One to One...J. Demonstrates the ability to set limits for patients and other de-escalation techniques. K. Assists with behavioral modification programs...M. Monitors environment for safety hazards, and/or potentials for self-abuse or assault..."

Review of information faxed to the hospital from contracted staffing agency "a" after the interview on 04/04/11 at 2:03 p.m. with S2CNO and S5Program Director revealed all five CNA's had Certified Nursing Assistant Competency Assessments which were self assessments and had no return demonstration of any skill. Further review revealed none of the Competency Assessments contained the following items listed in the hospital's "Job Description. Title: Mental Health Technician:...II. Duties and Responsibilities...D...demonstrates the ability to identify behaviors that require intervention. E. Appropriately cares for patients and demonstrates the knowledge of precautionary measures for: 1. Elopement Precautions 2. Close Observation 3. Suicidal Precautions. 4. One to One...J. Demonstrates the ability to set limits for patients and other de-escalation techniques. K. Assists with behavioral modification programs...M. Monitors environment for safety hazards, and/or potentials for self-abuse or assault..." Further review revealed only 2 of the 5 CNA's (S17CNA, S21CNA) had current CPI training per the contract.

Review of a hospital policy titled "Assignment of Patient Care", effective date 1/1/95, revised 3/24/2005, reads in part: " Purpose: To establish a policy where by Registered Nurses will prescribe, delegate, and coordinate nursing care. Policy: Assignment of patient care...The Registered Nurse , with designated responsibility to assign care to nursing staff members within the patient care unit...Procedure: Employee's clinical skills will be taken into consideration prior to making assignments. All personnel having direct contact with patients will be CPR (cardiopulmonary resuscitation) certified every two years, and CPI (crisis prevention intervention) certified annually."

In an interview on 04/04/11 at 2:03 p.m. with S2CNO and S5Program Director both verified all five of the personnel who were assigned the 1:1 were CNA's. S2CNO and S5Program Director stated the hospital had no documented evidence of the competency of the CNA's to function in the role of a Mental Health Technician (MHT) in accordance with the hospital's MHT Job Description and that the contracted staffing agency "a" could only provide current CPI training for 2 of the 5 CNA's. (S17CNA, S21CNA)
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**







Based on interviews, record reviews, and policy reviews, the facility failed to protect 1 of 13 (#5) sampled patients from neglect as evidenced by:

1) failed to recognize injuries of unknown origin as evidenced by Patient #5, who was a high risk for falls, who experienced a fall on 10/24/10 at 1531 (3:31 p.m.), and was found lying on the floor with her head next to a chair for 1 of 13 sampled patients;
2) failed to protect a cognitively impaired Patient (#5), who was on an "unofficial 1:1 observation" and assessed as a "high risk for falls", from neglect when a staff member (S10LPN) turned her back to answer a telephone call in the nurse's station, and the patient got up, took two steps back, fell , and was found lying on the floor with her head next to a chair on 10/24/10, for 1 of 13 sampled patients;
3) failed to protect a cognitively impaired patient from an injury of unknown origin when a staff member assessed the patient as having a swollen right palm, which was later identified as a spiral fracture to the hand on 1/24/11 for 1 of 13 sampled patients;
4) failed to thoroughly investigate an injury of unknown origin on Patient #5 whose right hand was swollen and later diagnosed as having a spiral fracture to the hand, for 1 of 13 sampled patients; and
5) failed to report injuries of unknown origin for 1 of 13 sampled patients according to the DHH State laws of reporting abuse and neglect.
Findings:
Injury on 10/24/10:
1) The hospital failed to recognize injuries of unknown origin as evidenced by Patient #5, who was a high risk for falls, experienced a fall on 10/24/10 at 1531 (3:31 p.m.) and was found lying on the floor with her head next to a chair as evidenced by:
Patient #5 was admitted to the facility on [DATE] at 1945 (7:45 p.m.). The admission orders dated 10/14/10 and timed at 1945 (7:45 p.m.) revealed the diagnosis of [DIAGNOSES REDACTED]" Level I/Close Observation. " There was no further documentation in the Physician's Orders to indicate the level of observation was changed.
According to the "Admission Assessment Report" dated 10/14/10 and timed 1945 (7:45 p.m.), S8RN documented Patient #5 had a past medical history of [DIAGNOSES REDACTED]. Patient #5 was unable to sign some of the admission forms due to being psychotic and agitated. The precipitating event which warranted the admission reflected the patient was easily combative and agitated. S8RN also noted on the Admission Assessment Record (pg 5) that the patient was alert and cognitively impaired under Neurological assessment. S8RN assessed Patient #5 as having normal musculoskeletal limits, poor balance, and unsteady gait. S8RN assessed the patient as being hypertensive. Using the Morse Falls Scale assessment, S8RN noted the patient had a history of falling. Patient #5's past medical history consisted of Hypertension, Diabetes Mellitus, Cardiomegaly, [DIAGNOSES REDACTED], Seizure disorder, and Coronary Artery Disease. On the Daily Flow Sheet dated 10/25/10 and timed 1800 (6:00 P.M.) revealed patient 's Temperature 97.8 F, Pulse 65, Respiration 20, and BP 142/86.
On 10/24/10 at 1525 (3:25 p.m.), S9RN completed an incident report (Confidential Hospital Occurrence Report to HSLI and the Hospital Attorney) noting that Patient #5 was in the hallway near the nursing station, when she experienced a fall. S9RN documented that sedation could be the possible cause of the fall. In the Brief Factual Description section of the incident report, S9RN documented " Patient being monitored closely due to sedation. (S10LPN) had been sitting in hallway with patient when phone rang. (S10LPN) got up to answer the telephone. Patient (#5) attempted to get out of chair and fell to the floor. She was found on the floor lying on her right side with her head next to a chair. Skin tear/abrasion noted to left knee area. No other redness or swelling noted after initial exam. Patient responded appropriately but still sleepy. B/P 144/78, P. 70, Oxygen saturation 99%, R. 20." S9RN notified the physician at 1531 (3:31 p.m.) on 10/24/10, but the patient was not examined by the physician after being notified on 10/24/10.
During the investigation, S11RN (Unit Manager) interviewed S10LPN who wrote a witness statement, which reflected " On 10/24/10 at 1530 (3:30 p.m.), Patient (#5) was on an unofficial 1:1. Staff was near her through the whole shift. I (S10LPN) was sitting near her in the hallway and got up to answer phone in nursing station. I was away from her less than a minute. She then stood up and took a couple of steps and fell backwards. S9RN was in another patient's room and came running to assist me with (Patient #5). "
S11RN (Unit Manager) conducted an interview with S12RN about the incident. S12RN wrote a witness statement dated 10/29/10 at 0845 (8:45 a.m.), which noted " I, (S12RN), did see Patient (#5) a short time after the fall. She was sitting in chair by nurse's station with head down. Her finger nails were dusky and fingertips cool. O2 (oxygen) saturation was 99%. She was minimally responsive. In passing through unit on several occasions this weekend; patient was basically in the same condition prior to fall. "
S11RN (Unit Manager) conducted an interview with S8RN about the incident. S8RN wrote a witness statement which was dated and timed as to when the interview was conducted between S11RN and S8RN. S8RN wrote " When I arrived at work at 6:45 p.m. (patient #5) was in the day room sitting in the w/c (wheelchair); she was awake but very quiet. She appeared sleepy so we assisted her into the Geri chair next to the nurse ' s stated for closer observation. She was resting quietly respiration deep even and unlabored. Later that night she was incontinent of bowel and bladder. We escorted her to the shower per w/c, she appeared weaker, skin color pale and clammy-vital signs taken. Pulse rate was 44 and pulse oximetry was 84%. She was very weak and lethargic- unable to answer questions-only moaning. S6MD was notified-order to send to ER per ambulance ...A CT scan of the head revealed a subdural hematoma. I (S8RN) called her (patient #5 ' s) sister to inform her she would be transferred to another hospital for further care. "
After S11RN (Unit Manager) completed the investigation, on 11/4/10, she concluded " There is no indication in the Medical Record or report from staff that the patient hit her head."
On 4/4/11 at 11:50 a.m. in a telephone interview with S25, Radiologist, she explained to surveyors that an acute intracranial hemorrhage (bleeding in the brain) can occur within 24 hours of a head injury. A subacute intracranial hemorrhage can occur within a 2 week time frame from a head injury event. A chronic intracranial hemorrhage can occur over a 2-3 month time frame from a head injury. S25 confirmed patient #5 would have been experiencing mental status changes and a headache. S25, Radiologist confirmed the results of S26, Contracted Radiologist ' s STAT Preliminary Radiology Report, which indicated patient #5, had experienced a 17 mm (millimeter) shift of the right side of her brain to the left side and the blood which had accumulated in the brain was placing pressure on the [DIAGNOSES REDACTED]. S25, Radiologist stated patient #5 had a moderate to severe head injury.
On 4/5/11 at 10:45 a.m. in an interview with S10LPN, she stated Patient #5 was on an "unofficial 1:1 observation." She stated she did not see the patient hit her head. She stated the phone rang and she got up and entered the nurse ' s station to answer the telephone. While going around the nurse ' s station desk to answer the telephone, she stated she saw Patient #5 stand up, take two steps back, and then start falling. She confirmed the patient was in the process of falling when she was behind the nurse's station answering the telephone. She added by the time she hung up the phone, and walked around the nurse's station, the patient was already on the floor. She denied actually seeing the patient hit her head. During this interview, S10LPN stated S9RN had come out of a patient's room and assessed Patient #5. S10LPN stated S6MD was notified and the patient was sent to hospital " a ' s " emergency room because this was the usual protocol after a patient fell .
Record review of the electronic clinical record revealed patient #5 had the incident of falling and being found on the floor on her right side with her head next to the chair on 10/24/10 at 3:25 p.m. and was sent to the ED for evaluation on 10/29/10 at 2:25 a.m., approximately 5 days later.
In an interview on 04/05/11 at 9:35 a.m. with S18ER physician, he reviewed the emergency room (ER) record for Patient # 5 dated 10/29/10 and confirmed he was ER physician on duty when Patient #5 was sent to the ER on 10/29/10. S18ER physician confirmed his documented assessment findings that Patient #5 was unresponsive upon arrival. The ER physician stated he initially ordered routine lab work and medication levels and when the lab work was complete it revealed no explanation for the patient to be unresponsive. S18ER physician stated he went and reassessed Patient #5 and found a posterior scalp hematoma. The ER physician stated " I can see scalp Hematoma so probably she fell . " The ER physician stated he gave a verbal order for a CT (computed tomography) scan of the brain of Patient #5, which revealed an acute on subacute subdural hematoma. (Intracranial bleeding). S18ER physician was asked to define the terms acute and subacute. He stated an acute subdural hematoma indicates a recent (hours to a few days) intracranial bleed. He further stated a subacute subdural hematoma would be more than 5 days old. S18ER physician confirmed the acute subdural hematoma would be consistent with a fall.
On 4/5/11 at 1:00 p.m. in an interview with S6MD/Psychiatrist, he stated he had not ordered a 1:1 Observation for Patient #5. He also confirmed that no one had called and requested Patient #5 be placed on a 1:1 Observation.
On 4/5/11 at 2:40 p.m. in an interview with S2CNO (Chief Nursing Officer), she acknowledged S11RN's (Unit Manager) investigation revealed no one had witnessed Patient #5 's head hitting the floor. She also confirmed this was an injury of unknown origin since it was not witnessed. S2CNO confirmed the hospital did not have a policy regarding 1:1 observation. The only time 1:1 observation was found was in the orientation packet for new hires titled "One to One Guidelines": "There are a number of reasons why a person is ordered to be one to one. The three main reasons would be that a patient has either threatened or attempted suicide, they may be at a very high risk for falling, or it may be behavioral." Under the One to One Guidelines #3, "They are never to be left alone, even for a minute." S2CNO stated this was the only reference the psychiatric unit had for a procedure as to when a One-to-One should be initiated.
2) The hospital failed to protect a cognitively impaired patient (#5), who was on an unofficial 1:1 observation and assessed as a " high risk for falls " , from neglect when a staff member (S10LPN) turned her back to answer a telephone call in the nurse ' s station, and the patient got up, took two steps back, fell and was found lying on her right side with her head next to a chair (Confidential Hospital Occurrence Report to HSLI and the Hospital Attorney) as evidenced by:
On 4/5/11 at 10:45 a.m. in an interview with S10LPN, she stated Patient #5 was on an "unofficial 1:1 observation." She stated she did not see the patient hit her head. She stated the phone rang and she got up and entered the nurse's station to answer the telephone. While going around the nurse's station desk to answer the telephone, she stated she saw Patient #5 stand up, take two steps back, and then start falling. She confirmed the patient was in the process of falling when she was behind the nurse ' s station answering the telephone. She added by the time she hung up the phone, and walked around the nurse's station, the patient was already on the floor. She denied actually seeing the patient hit her head. During this interview, S10LPN stated S9RN had come out of another patient ' s room and assessed Patient #5. S10LPN stated S6MD was notified and the patient was sent to hospital " a ' s " emergency room because this was the usual protocol after a patient falls.
S11RN (Unit Manager) conducted an interview with S8RN about the incident on 10/24/10. S8RN wrote a witness statement, which was dated and timed as to when the interview was conducted between S11RN and S8RN. S8RN wrote " When I arrived at work at 6:45 p.m. (patient #5) was in the day room sitting in the w/c (wheelchair); she was awake but very quiet. She appeared sleepy so we assisted her into the Geri chair next to the nurse ' s stated for closer observation. She was resting quietly respiration deep even and unlabored. Later that night she was incontinent of bowel and bladder. We escorted her to the shower per w/c, she appeared weaker, skin color pale and clammy-vital signs taken. Pulse rate was 44 and pulse oximetry was 84%. She was very weak and lethargic- unable to answer questions-only moaning. S6MD was notified-order to send to ER per ambulance ...A CT scan of the head revealed a subdural hematoma. I (S8RN) called her (Patient #5 ' s) sister to inform her she would be transferred to another hospital for further care. "
S2CNO confirmed the hospital did not have a policy regarding 1:1 observation. The only time 1:1 observation was found was in the orientation packet for new hires titled "One to One Guidelines," which included: "There are a number of reasons why a person is ordered to be one to one. The three main reasons would be that a patient has either threatened or attempted suicide, they may be at a very high risk for falling, or it may be behavioral." Under the One to One Guidelines #3, "They are never to be left alone, even for a minute." S2CNO stated this was the only reference the psychiatric unit had for a procedure as to when a One-to-One should be initiated. S2CNO confirmed that S10LPN should not have left Patient #5 unattended to answer the telephone.
A record review of Hospital " a ' s " policy entitled Prohibiting Patient Abuse (pg 1 of 3), under Procedure notes " ...Physical abuse, verbal abuse, and abuse through neglect will not be tolerated. ..Neglect, for the purpose of this requirement, is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. "
Injury on 1/24/11:
3) The hospital failed to protect cognitively impaired Patient #5 from an injury of unknown origin when S4RN assessed Patient #5 on 1/24/11 at 11:30 a.m. and found Patient #5's right hand was edematous and had ecchymosis to inner aspect of the palm, which was later identified as a spiral fracture of the right finger as evidenced by:
Record review of Physician's orders dated 1/2/11 at 1500 (3:00 p.m.), revealed S6MD ordered 1:1-Close Observation. No documentation S6MD discontinued the order for 1:1-Close Observation throughout Patient #5's hospitalization until discharge at 1500: (3:00 p.m.) on 1/26/11.
A face-to-face interview was conducted on 4/5/11 at 1:40 p.m. with S2CNO. S2 indicated the Charge Nurse (S4) is totally responsible for ensuring the assigned MHT/CNA are providing 1:1 Observation monitoring as ordered by the Psychiatrist (S6MD). S2 verified there was no documented evidence of Patient #5's 1:1 Observation monitoring on 1/23/11 from 7:00 p.m. (1900) through 10:45 p.m. (2245) for about 3 hours and 45 minutes as per the physician's orders. S2 reported the RN (S4) charge nurse did not ensure the patient was monitored 1:1 by the assigned MHT/CNA as ordered by the physician. S2 confirmed there was no documented evidence in the " Daily Focused Assessments " and/or " Progress Notes " by the nursing staff of the patient ' s right hand edema or bruising. S2 indicated the patient's right hand edema and bruising was an injury of unknown origin. S2 confirmed the patient had a " spiral fracture " to the right finger as indicated on the 1/24/11 Xray from hospital " a " . S2 stated there was no documentation of an Incident/ " Occurrence Report " recorded by the nurse (S4) for Patient's (#5 ' s) right hand edema or bruising. S2 stated S4RN did not follow the " Incident Report " policy regarding reporting of all incidents that occur to patients immediately to the supervisor and physician.
Review of the policy titled, " Incident Reporting " , Date Effective: 7/09/03, Date Revised: 6/2009, revealed it is the responsibility of all nursing personnel to report all incidents. An incident report must be completed within 24 hours, or as soon as possible, to the Chief Nursing Officer (CNO)."
4) The hospital failed to thoroughly investigate an injury of unknown origin on Patient #5 whose right hand was swollen and later diagnosed as having a spiral fracture to the hand as evidenced by:
A face-to-face interview was conducted on 4/5/11 at 1:40 p.m. with S2CNO. S2 indicated the Charge Nurse (S4) is totally responsible for ensuring the assigned MHT/CNA are providing 1:1 Observation monitoring as ordered by the Psychiatrist (S6MD). S2 verified there was no documented evidence of Patient #5 ' s 1:1 Observation monitoring on 1/23/11 from 7:00 p.m. (1900) through 10:45 p.m. (2245) for about 3 hours and 45 minutes as per the physician ' s orders. S2 reported the RN (S4) charge nurse did not ensure the patient was monitored 1:1 by the assigned MHT/CNA as ordered by the physician. S2 confirmed there was no documented evidence in the " Daily Focused Assessments " and/or " Progress Notes " by the nursing staff of the patient's right hand edema or bruising. S2 indicated the patient's right hand edema and bruising was an injury of unknown origin. S2 confirmed the patient had a " spiral fracture " to the right finger as indicated on the 1/24/11 X-ray from hospital " a " . S2 stated there was no documentation of an Incident/ Occurrence Report recorded by the nurse (S4) for Patient #5 ' s right hand edema or bruising. S2 stated S4RN did not follow the " Incident Report " policy to report all incidents, which occur to patients immediately to the supervisor and physician.
Review of the policy titled, " Incident Reporting " , Date Effective: 7/09/03, Date Revised: 6/2009, revealed it is the responsibility of all nursing personnel to report all incidents. An incident to report must be completed within 24 hours, or as soon as possible, to the Chief Nursing Officer (CNO). The policy indicated licensed nurse will perform assessment including emergency care administered, persons notified and time incident occurred, and any needed follow-up. Report by end of shift on the day of the incident. State acting Supervisor ' s name on the report. Immediately notify attending physician."
5) The hospital failed to report 2 injuries of unknown origin for 1 of 13 patients (#5) according to the DHH State laws of reporting abuse and neglect as evidenced by:
Injury on 10/24/10:
After S11RN completed the investigation, on 11/4/10, she concluded " There is no indication in the Medical Record or report from staff that Patient (#5) hit her head. "
On 4/5/11 at 10:45 a.m. in an interview with S10LPN, she stated Patient #5 was on an "unofficial 1:1 observation." She stated she did not see the patient hit her head. She stated the phone rang and she got up and entered the nurse's station to answer the telephone. While going around the nurse ' s station desk to answer the telephone, she stated she saw Patient #5 stand up, take two steps back, and then start falling. She confirmed the patient was in the process of falling when she was behind the nurse ' s station answering the telephone. She added by the time she hung up the phone, and walked around the nurse ' s station, Patient was already on the floor. She denied actually seeing the patient hit her head. During this interview, S10LPN stated S9RN had come out of another patient ' s room and assessed Patient #5. S10LPN stated S6MD was notified and the patient was sent to hospital " a ' s " emergency room because this was the usual protocol after a patient falls.
On 4/5/11 at 2:40 p.m. in an interview with S2CNO (Chief Nursing Officer), she acknowledged S11RN ' s investigation revealed no one had witnessed Patient #5 ' s head hitting the floor. She also confirmed that this was an injury of unknown origin since it was not witnessed. According to S2CNO, no report was sent to DHH about this incident.
Injury on 1/24/11:
During a face-to-face interview on 4/4/11 from 3:05 p.m. through 3:50 p.m., S4, Interim Nurse Manager reviewed the " Daily Focused Assessment " and " Progress Notes " for 1/23/11 and 1/24/11. S4 verified she worked the day shift (7:00 a.m. to 7:00 p.m.) shift on 1/24/11. S4 verified there was no documented evidence of the patient ' s (#5 ' s) right hand edematous and ecchymosis to the inner aspect of the palm area was identified by the designated nursing staff on 1/23/11. S4 indicated that on 1/24/11 at 11:30 (11:30 a.m.) she observed Patient #5 ' s right hand edematous and ecchymosis. S4 notified the attending physician (S6) at this time of the patient ' s right hand. S4 verified there was no Incident/Occurrence Report written for the patient's right hand edematous and ecchymosis. S4 indicated an Incident/Occurrence Report is not completed for abnormalities. S4 stated an Incident/Occurrence Report is not recorded for a change in a patient's medical condition. S4 reported Patient ' s right hand with edematous and ecchymosis was a change in medical condition. S4 continued an Incident/Occurrence Report is not recorded because the nursing staff would be completing these reports continuously for all incidents that occurred with the psychiatric patients on the unit.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and record reviews, the hospital failed to ensure the registered nurse supervised and evaluated the nursing care for each patient as evidenced by:
1) failing to ensure nursing staff assessed patients' health statuses, specifically, the change in health status on Patient #5 from being alert to exhibiting sleepiness and lethargy as evidenced by the lack of accurate neurological assessments (i.e. documenting past medical history instead of current focused assessments) being done on Patient #5 who was found lying on her right side with her head next to a chair after taking two steps back and the falling backwards on 10/24/10 for 1 of 13 sampled patients;
2) failing to follow their policy and procedure for performing nursing assessments on a patient who had sustained an unwitnessed fall and was found with her head next to a chair on the floor as evidenced by no documentation the patient was assessed by a registered nurse from 10/24/10 at 3:25 p.m. until 10/25/10 at 11:08 p.m. (approximately 32 hours) for 1 of 13 sampled patients;
3) failing to ensure physician's orders for medication administration were followed as per policy as evidenced by a) having missed 16 medication administrations for Patient #5 on 10/24/10 for 1 of 13 sampled patients and b) Patient #5 refusing to take medications on 11 medication administrations on the following dates: 10/25/10, 10/26/10, 10/27/10 and 10/28/10 for 1 of 13 sampled patients; and
4) failing to ensure the Registered Nurse supervised and evaluated Patient #5's 1:1 observation monitoring as ordered by the attending physician (S6MD/Psychiatrist) by failing to have documented evidence from 1900 (7:00 p.m.) to 2245 (10:45 p.m.) for about 3 hours and 45 minutes of the patient's visual appearance and/or behavior monitoring on 1/23/11 for 1 of 13 sampled patients (Patient #5).
Findings:
1) The hospital failed to ensure nursing staff assessed patients' health statuses, specifically, the change in health status on Patient #5 from being alert to exhibiting sleepiness and lethargy as evidenced by the lack of accurate neurological assessments (i.e. documenting past medical history instead of current focused assessments) being done on Patient #5 who was found lying on her right side with her head next to a chair after taking two steps back and then falling backwards on 10/24/10 for 1 of 13 sampled patients.
On 10/24/10 at 1525 (3:25 p.m.), S9RN completed an incident report (Confidential Hospital Occurrence Report to HSLI and the Hospital Attorney) noting that Patient #5 was in the hallway near the nursing station, when she experienced a fall. S9RN documented sedation could be the possible cause of the fall. Under C, S9RN noted the Patient had been in a chair attended and had not received any sedatives in the last 4 hours. In the Brief Factual Description section of the incident report, S9RN documented " Patient being monitored closely due to sedation. (S10LPN) had been sitting in hallway with patient when phone rang. (S10LPN) got up to answer the telephone. Patient (#5) attempted to get out of chair and fell to the floor. She was found on the floor lying on her right side with her head next to a chair. Skin tear/abrasion noted to left knee area. No other redness or swelling noted after initial exam. Patient (#5) responded appropriately but still sleepy. B/P 144/78, P. 70, Oxygen saturation 99%, R. 20. " S9RN notified the physician at 1531 (3:31 p.m.) on 10/24/10, but the patient was not examined by the physician after being notified on 10/24/10.
In an interview with S9RN on 4/4/11 at 2:15 p.m., she stated that the Progress Notes Report was where the staff charts if there are any significant changes to the patient. She added there was a " Notification " tab in the electronic record where notification is placed. She added she realized she had not documented a post fall assessment on 10/24/10, so she went back into the computer on 10/29/10 at 13:56 (2:56 p.m.) and documented the post-fall assessment.
S9RN confirmed she had filled out the incident report on 10/24/10 after patient #5 fell . She added since the staffing was short on that day (it was a weekend); she placed Patient #5 on an "unofficial 1:1" Close observation status. She described the incident by saying patient #5 was sitting in a regular hard chair in front of the nursing station. Patient #5 had to have 2 people to assist her when ambulating. S9RN stated she saw Patient #5 already on the floor after she came out of another patient's room.
On 4/5/11 at 10:45 a.m. in an interview with S10LPN, she stated Patient #5 was on an unofficial 1:1 observation. She stated she did not see Patient #5 hit her head. She stated the phone rang and she got up and entered the nurse's station to answer the telephone. While going around the nurse's station desk to answer the telephone, she stated she saw Patient #5 stand up, take two steps back, and then start falling. She confirmed the patient was in the process of falling when she was behind the nurse's station answering the telephone. She added by the time she hung up the phone and walked around the nurse's station, the patient was already on the floor. She denied actually seeing Patient #5 hit her head. S10LPN stated S9RN had come out of another patient's room and assessed Patient #5. S10LPN stated S6MD was notified and Patient #5 was sent to hospital "a's" emergency room because this was the usual protocol after a patient falls. (Patient #5 went to the emergency room on [DATE] at 2:30 a.m.- 5 days later.)
In an interview with S4RN on 4/1/11 at 1:15 p.m., she stated the e-medical record has a drop down menu in which nursing staff can document daily assessments. She also confirmed the Daily Focus Assessment Report was for current daily assessments, not past medical history information.
In a second interview with S4RN, Interim Nurse Manager on 4/1/11 at 2:00 p.m., she stated if the emergency room physician orders neuro checks, then the nurses would perform a neurological check on a patient. She stated neurological checks are not done routinely when patients are found on the floor. She stated the patients could have placed themselves on the floor. S4RN confirmed if a patient was found on the floor, the nursing staff would assess the patient, check for orientation, vital signs, hand grasps, and pupillary reactions. She confirmed the physician would be notified and if the physician thinks it is necessary, the psychiatric unit will send the patient to the emergency department. The emergency room physician may order a neuro check. If the emergency department physician ordered something, the psychiatric unit will contact the psychiatrist to okay the orders. S4RN acknowledged documenting any changes to a patient ' s condition after a fall needs to be done daily. She confirmed documenting about falls is to be done daily if the patient has been assessed for falls. S4RN confirmed that Patient #5 had been assessed for falls during the admission assessment.
In a third interview with S4RN, Interim Nurse Manager, on 4/4/11 at 3:10 p.m., she stated the electronic clinical record has a tab, which can be pulled down so nurses can perform neurological assessments using the Glasgow Coma Scale.
In an interview with S24RN on 4/5/11 at 9:20 a.m., she confirmed she had documented " seizures " under the Daily Focus Assessment Review of Systems: Neurological. She also stated she did not remember Patient #5 as having any seizures. She stated she checked the word " seizures " under the Neurological assessment because the client had a history of seizures. S24RN also noted that S27RN had observed the client as being sedated; S24RN documented Patient #5 was lethargic.
In an interview with S28LPN on 4/5/11 at 10:30 a.m., she stated she documents current assessment in the Daily Focus Assessment section of the clinical record. After reviewing her documentation on 10/26/10 at 11:34 a.m., she confirmed she had documented " Seizures " under the Review of Systems: Neurological section because Patient #5 had a past history of seizures. S28LPN stated she did not remember Patient #5 having a seizure on 10/26/10. S28LPN stated she was taught to place past medical history information in the electronic medical record in the Daily Focus Assessment form during the training.
In an interview with S2CNO on 4/4/11 at 2:40 p.m., she stated the neuro assessment was part of the daily assessment and should have been documented with current information to accurately depict the patient. She also confirmed the nursing staff could have used the Glasgow Coma Scale to assess the patient neurologically after a fall.
2) The hospital failed to perform nursing assessments on Patient #5 who was observed falling and found with her head next to a chair on the floor once every 24 hours by a Registered Nurse as per policy by failing to have documentation from 3:25 p.m. on 10/24/10 until 11:08 p.m. on 10/25/10, approximately 32 hours later for 1 of 13 sampled patients;
Record review of the Daily Focus Assessment Report dated 10/24/10 through 10/29/10 revealed the following:
10/24/10 at 00:26 (12:26 a.m.) S13LPN documented under Review of Systems, Neurological, unimpaired, pupils equal/reactive. Under Group Note, S13LPN documented ... " required max prompting and assistance to consume medication. Pt would place them in mouth properly, allowing them to fall out or hang off her lip, etc. "
10/24/10 at 07:30 (7:30 a.m.) S9RN documented under Review of Systems, Neurological, unimpaired, Cardiovascular, edema feet.
10/24/10 at 22:16 (10:16 p.m.) S13LPN documented under Review of Systems, Neurological unimpaired, pupils equal/reactive.
S13LPN also documented at this time under Category Note: New skin tear that happened earlier today. " Knee, Left anterior " Skin tear.
10/24/10 at 22:16 (10:16 p.m.) S13LPN documented: " appeared to not know how to drink a cup of water, held it in her hand near her mouth but wouldn't ' put it to her lips, required assistance. "
10/25/10 at 14:30 (2:30 p.m.) S27 RN had no documented RN assessment.
10/25/10 at 17:10 (5:10 p.m.) S27RN had no documented RN assessment.
10/25/10 at 23:08 (11:08) S24RN documented under Review of Systems, Neurological " Lethargic. "
10/26/10 at 11:34 a.m. S9RN had no documented RN assessment.
10/26/10 at 10:13 a.m. S27 RN had no documented RN assessment.
10/26/10 at 11:34 a.m. S28LPN documented under Neurological " Seizures "
10/26/10 at 15:34 (3:34 a.m.) S27RN had no documented RN assessment.
10/26/10 at 23:17 (11:17 p.m.) S24RN documented under Review of Systems, Neurological " Seizures, Pupils Equal/Reactive. "
10/27/10 at 10:04 a.m. S29RN had no documented RN assessment.
10/27/10 at 14:01 (2:01 p.m.) S10LPN documented under Review of Systems, Neurological " Unimpaired, Pupils Equal/Reactive. "
10/27/10 at 22:30 (10:30 p.m.) S8RN documented under Review of Systems, Neurological " Disoriented. " Under Category Note, S8RN documented " pt is a total feed. "
10/28/10 at 11:03 a.m. S10LPN documented under Review of Systems, Neurological " Unimpaired. "
10/28/10 at 11:28 a.m. S9RN had no documented RN assessment.
10/28/10 at 09:20 a.m. S29RN had no documented RN assessment.
10/28/10 at 13:23 (1:23 p.m.) S29 had no documented RN assessment.
10/28/10 at 22:54 (10:54 p.m.) S8RN documented under Review of Systems, Neurological " Disoriented. "
Record review of documentation on the Progress Notes Report dated 10/24/10 through 10/29/10 revealed the following:
10/24/10 S9RN documented at 14:36 (2:36 p.m.) an assessment of Patient #5.
10/24/10 15:35 (3:35 p.m.) S9RN documented an RN assessment as a Late Entry on 10/29/10 at 13:58 (2:58 p.m.).
In an interview with S27RN on 4/4/11 at 4:40 p.m., he confirmed he had noticed a change of Patient #5 ' s mental status because the patient was sedated and he called the physician. He also confirmed he held a group meeting and did not document an RN assessment on Patient #5 on 10/25, 10/26, and 10/29.
In an interview with S28RN on 4/4/11 at 4:15 p.m., he confirmed he was charge nurse on 10/27/10. He stated his responsibility was to assess the patient daily, especially in the role of charge nurse. He added if he was not assigned to Patient #5, the only documentation he would be responsible for was documentation about his group. S28RN stated that S10LPN was assigned Patient #5; therefore, she performed the focused assessment and documented this information in the chart. S28RN confirmed it was the responsibility of the RN for the care of the patient.
Record review of the hospital's policy titled "Nursing Assessments" (pg 2 of 2) revealed: "All patients will be assessed by a Registered Nurse once in a 24 period."
3) The hospital failed to ensure nursing staff were following the physician's orders to administer medications as evidenced by the number of days and times Patient #5 either refused her medication or was unable to take the medication due to her altered mental status for 1 of 13 sampled patients.
Record review of Daily Focus Assessment Reports dated 10/14/10 through 10/23/10 (before the fall) revealed no documentation Patient #5 had refused or did not consume her medications.
Record review of Progress Notes dated 10/14/10 through 10/23/10 revealed no documentation Patient #5 had refused to take her medications or was unable to take the medication due to an altered mental status.
Record review of Daily Focus Assessment Reports dated 10/24/10 and timed at 00:26 (12:26 a.m.) revealed S13LPN documented under Group Note: " (Patient #5) rarely speaks to staff, usually monosyllable responses or noises ....required max prompting and assistance to consume medication. Pt would place them in mouth properly, allowing them to fall out or hang off her lip, etc. "
A second entry by S13LPN on 10/24/10 and timed 22:16 (10:16 p.m.) documented under Group Note: " cooperative with meds with minimal encouragement, appeared to not know how to drink a cup of water, held it in her hand near her mouth but wouldn't ' put it to her lips, required assistance. "
S13LPN also documented in Progress Report on 10/24/10 at 21:00 (9:00 p.m.) Patient #5 was cooperative with all of her meds except advair, she is unable to follow simple command on how to inhale properly, she cont. to just hold it in her mouth without trying to inhale or anything. "
Record review of Daily Focus Assessment Report dated 10/25/10 and timed at 14:30 (2:30 p.m.) revealed S28RN documented under Category Note: " (S6MD) here and lab reviewed. Tegretol (seizure medication) 7.2 ug/mL (normal values 10-20 ug/mL). Also, informed him of pt ' s meds being held due to sedation. "
Record review of Daily Focus Assessment Report dated 10/25/10 and timed at 23:08 (11:08 p.m.) revealed S24RN documented under Group Note: " Refused HS (hour of sleep) meds. "
Record review of Progress Notes Report dated 10/25/10 and timed at 06:10 (6:00 a.m.) revealed S13LPN documented " Pt is very sleepy and uncooperative at this time. Synthroid given as ordered at 0700 but Seroquel held due to pt.'s decreased energy level. Pt. tossing around in bed, legs over rail, legs hanging out of bed, mumbles sounds but not speaking, will not drink water on her own, requires staff to pour it in her mouth. She does make good eye contact and is alert but very sleepy and uncooperative. "
Record review of Progress Notes Report dated 10/25/10 at 21:00 (9:00 p.m.) revealed S23LPN documented " Refuses all HS meds this pm. Pushes med cup away from mouth, stating " No. "
Record review of Progress Notes Report dated 10/26/10 at 0700 (7:00 a.m.) revealed S23LPN documented " Refused 300 mgs po this am. "
Record review of Daily Focus Assessment Report dated 10/26/10 at 23:17 (11:17 p.m.) revealed S24RN documented under Group Note: " Refused meds. "
Record review of Progress Notes Report dated 10/26/10 at 16:15 (4:25 p.m.) revealed S28LPN documented " meds held sleeping easily aroused. "
Record review of Progress Notes Report dated 10/27/10 at 07:00 (7:00 a.m.) revealed S23LPN documented " Refused AM meds of Seroquel 300 mgs and Synthroid 50 mcgs. No reason given. "
Record review of Progress Notes Report dated 10/27/10 at 22:30 (10:30 p.m.) revealed S13LPN documented " Pt. refuses to open her mouth and consume her HS (Hour of Sleep) po (oral) medications. "
Record review of Daily Focus Assessment Report dated 10/28/10 at 22:54 (10:54 p.m.) revealed S8RN documented under Group Note: " she was uncooperative regarding med compliance, she kept her jaws clenched. "
Record review of Medication Administration Record dated 10/24/10 for the time period of 07:01-15:00 (7:00 a.m.-3:00 p.m.), S10LPN circled, Patient #5 did not receive the 0900 (9:00 a.m.) medications: Ascorbic Acid tablet, Aspirin Tablet chewable, Benztropine tablet, Carbamazepine tablet, Citalopram tablet, Clonazepam tablet scheduled for 1400 (2:00 p.m.).
S10LPN also documented Patient #5 refused famotidine tablet, ferrous sulfate tablet, Advair discus, furosemide tablet, Haldol, isosorbide mononitrate, metformin tablet, potassium chloride tablet, Seroquel tablet, topiramate tablet, and zinc sulfate capsule.
In an interview with S10LPN on 4/5/11 at 10:45 a.m., she confirmed she had circled these medications indicating Patient #5 did not receive these medications. S10LPN stated she would have told her charge nurse that the patient did not receive these medications; she would not have called the physician.
Record review of Medication Administration Record dated 10/25/10 for the time period of 07:01-15:00 (7:00 a.m.-3:00 p.m.) S28LPN circled the following medications: Ascorbic acid tablets, Aspirin tablet chewable, benztropine tablet, carbamazepine tablet in A.M., citalopram tablet, famotidine tablet, ferrous sulfate tablet, Advair diskus, furosemide tablet, haloperidol tablet, isosorbide mononitrate tablet sustained release 24 hr, metformin tablet, potassium chloride tablet sustained release, quetiapine tablet (A.M. dose), quetiapine tablet (HS dose), topiramate tablet, and zinc sulfate capsule. Also, on this date for the time period of 15:01 - 23:00 (3:01-11:00 p.m.), the following medications were circled indicating the patient did not receive these medications: Benztropine tablet, carbamazepine tablet, conjugated estrogens, famotidine tablet, ferrous sulfate tablet, klonopin tablet, haloperidol tablet, metoformin tablet, potassium chloride tablet, Seroquel tablet, and topiramate tablet.
In an interview with S28LPN on 4/5/11 at 10:30 a.m., she confirmed she had circled these medications indicating Patient #5 did not receive these medications. She also stated she would have told the charge nurse and the charge nurse would have told the physician.
In an interview with S29LPN on 4/5/11 at 11:40 a.m., she confirmed Patient #5 did not receive the medications listed on the Medication Administration Record on the date of 10/26/10- 10/27/10.
In an interview with S13LPN on 4/5/11 at 8:10 a.m., she confirmed Patient #5 had refused the medications scheduled on 10/27/10 and 10/28/10 for the time period 15:01-23:00 (3:00 p.m.-11:00 p.m.).
There was no documentation in the clinical record either in the Daily Focus Assessment or Progress Notes the physician was notified about Patient #5 either refusing medications or was unable to take her medication due to altered mental status (ie. Not being able to follow directions with Advair Diskus, holding medication in her mouth or on her lips, not being able to hold a cup of water to swallow medication, etc.)
In an interview with S6MD/Psychiatrist on 4/4/11 at 1:00 p.m., he stated he was not aware that Patient #5 had either refused her medication or did not receive her medication as he ordered.
4) The hospital failed to ensure the Registered Nurse supervise and evaluate Patient #5's 1:1 observation monitoring as ordered by the attending physician (S6MD/Psychiatrist) by failing to have documented evidence from 1900 (7:00 p.m.) to 2245 (10:45 p.m.) for about 3 hours and 45 minutes of the patient's visual appearance and/or behavior monitoring on 1/23/11 for 1 of 13 sampled patients (Patient #5).
Review of the " Admission Orders " dated/timed 1/2/11 at 1500 (3:00 p.m.) revealed the patient was admitted with diagnosis of Schizoaffective D/O (disorder) Bipolar Type. Further review revealed S6MD, admitting psychiatrist ordered " 1:1 (one-to-one) - Close observation " monitoring for Patient (#5).
Review of the " Daily Focus Assessment Report " recorded by the nursing staff on 1/22/11 at 22:00 (10:00 p.m.) and 1/23/11 at 08:59 (8:59 a.m.) and at 22:00 (10:00 p.m.) revealed the patient was on " 1:1 Observation " monitoring.
Review of the " Precaution Monitoring Sheet " revealed this sheet is used to monitor the patient ' s visual appearance and behavior every 15 minutes while the assigned MHT provides the patient with the 1:1 observation during the designated shifts. Further review revealed there was no documentation of the patient ' s visual appearance and/or behavior monitoring recorded by the Mental Health Technician (MHT) assigned to monitor Patient #5's 1:1 observation from 1900 (7:00 p.m.) through 2245 (10:45 p.m.) on 1/23/11.
The " Staffing " Sheet dated 1/23/11 was reviewed. Further review revealed there was no Mental Health Technician (MHT) recorded/assigned to provide a patient with 1:1 Observation for the night (7:00 p.m. to 7:00 a.m.) shift on 1/23/11.
Review of the " Assignment Sheet " for the MHTs on 1/23/11 for the day shift (7 A) 7:00 a.m. and night shift (7 P) 7:00 p.m. read, S7MHT was the MHT assigned to provide 1:1 observation monitoring to a patient for both shifts, day and night. Further review revealed there was no documented evidence of which patient S7MHT was assigned to monitor 1:1 observation during both shifts on 1/23/11.
During a face-to-face interview on 4/5/11 at 9:20 a.m. and 9:25 a.m., S24RN indicated she was the Registered Nurse on duty during the night shift from 7:00 p.m. through 7:00 a.m. on 1/23/11. S24 verified the patient was ordered 1:1 observation from time of admission on 1/2/11 through discharge on 1/26/11 as per the physician ' s (S6MD ' s/Psychiatrist ' s) orders dated 1/2/11 at 1500 (3:00 p.m.). S24 verified there was no documentation of the patient ' s (#5 ' s) visual appearance and/or behavior monitoring recorded on the " Precaution Monitoring Sheet " used to monitor the patient ' s 1:1 observation on the form from 1900 (7:00 p.m.) through 2245 (10:45 p.m.) for about 3 hours and 45 minutes on 1/23/11. S24 indicated the Registered Nurse (S24) is responsible to ensure all physician ' s orders are followed. S24RN stated there was no documented evidence of the physician ' s order for the 1:1 observation monitoring of the patient was followed from 7:00 p.m. through 10:45 a.m. on 1/23/11. S24 recalled the MHT (S7MHT named) was in the hallway that same night with Patient #5. S24 denied knowledge whether or not the MHT (S7) was assigned to monitor the patient ' s 1:1. S24 confirmed S7MHT worked the night shift on 1/23/11 as indicated on the " Staffing Sheet " . S24 verified S7MHT was assigned to provide a patient ' s 1:1 observation monitoring as per the " Staffing Sheet " for 1/23/11. S24 reported there was no documentation of which patient S7MHT was assigned to monitor 1:1 observation during the night shift on 1/23/11. S24 indicated S7MHT (MHT named) was the MHT that was assigned to provide Patient ' s (#5 ' s) 1:1 observation on 1/23/11.
On 4/5/11 at 10:20 a.m. in a face-to-face interview, S4, Interim Nurse Manager reviewed the " Precaution Monitoring Sheet " , for 1/23/11 and " Admission Orders " for 1/2/11. She verified S6MD/Psychiatrist had ordered 1:1 Observation for Patient #5.
In interview on 4/5/11 at 10:20 a.m., S4, Interim Nurse Manager verified S24RN worked the night shift (7:00 p.m. to 7:00 a.m.) shift on 1/23/11. S4 confirmed the patient was ordered 1:1 observation from time of admission on 1/2/11 through discharge on 1/26/11. S4 indicated there was no documented evidence of the patient ' s 1:1 observation monitoring by an assigned MHT from 7:00 p.m. (1900) through 10:45 p.m. (2245) for about 3 hours and 45 minutes on 1/23/11. S4 confirmed the physician ' s orders for 1:1 observation monitoring for the patient (#5) was not followed on 1/23/11. S4 indicated the Registered Nurse (S24) was responsible to ensure the physician ' s order for 1:1 observation is followed. S4 continued, the RN (S24) did not ensure the patient ' s 1:1 observation monitoring was maintained for about 3 hours and 45 minutes on 1/23/11. S4 stated there was no policy regarding 1:1 observation monitoring.
In interview on 4/5/11 at 2:40 p.m., S2CNO confirmed there was no documentation that the MHT provided the patient (#5) with 1:1 observation monitoring from 7:00 p.m. through 10:45 p.m. on 1/23/11. S2CNO later faxed to the surveyors a "One to One Guidelines" document, which was used during staff training. She stated this was as close as the psychiatric unit had to an explanation about when and how to conduct a One to One on a patient.