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.

ALLEGIANCE SPECIALTY HOSPITAL OF KILGORE 1612 SOUTH HENDERSON BLVD KILGORE, TX 75662 Jan. 23, 2014
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on documentation review and interview, it was determined that the facility:

1. Failed to assess patients, failed to document nursing interventions, failed to follow protocols after patient falls, failed to follow hospital policies and failed to follow and/or obtain physician orders which compromised the safety 14 of 16 pt. (#1-#14) reviewed.
Refer to Tag A144

2. Failed to maintain current treatment/care plans and include the use of restraints for 4 of 16 patients identified. (Pt #1, #2, #5 and #10)
Refer to Tag A166

3. Failed to implement restraints in accordance with facility policy in 3 of 16 patient's (Pt) identified. (Pt #1, #2 and #10)
Refer to Tag A167
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review, the facility failed to assess patients, failed to document nursing interventions, failed to follow protocols after patient falls, failed to follow policies and failed to follow and/or obtain physician orders which compromised the safety of 14 of 16 pt. (#1-#14) reviewed.

Review of the Post Fall Assessment form revealed the following: Vital signs (V/S) were to be recorded q (every) 15 minutes x 2, q 30 minutes x 2, q 1 hour x 2 and q 4 hours x 2 for a total of 8 sets of vital signs consisting of blood pressure, pulse, respirations and temperature. Eight sets of neurological (neuro) assessments should also be recorded at the same intervals. The neuro assessments consisted of left and right, pupil size/reaction, eye lid response, verbal response, motor response, gag and swallow response and a Glasgow coma score. The physical assessment included musculoskeletal, pain, respiratory, cardiovascular, gastrointestinal Genitourinary and Integumentary assessment and an area for recording the notification of family, physician and administrative staff.

On 1/14/2014, at 9:15 AM, in first floor office, the medical records (MR) for pts #1- #16 were reviewed and revealed the following:

Pt #1 was an [AGE] year old male admitted on [DATE] with an admission diagnosis of [DIAGNOSES REDACTED]"2" observation, "line of sight, less than 20 feet at all times".

On 7/28/2013, at 0015 (military time), Registered Nurse (RN) #10 documented the following on the Quality Control Report (QCR): "...MHT (Mental Health Tech) told him to move his hand when the W/C (Wheel chair) was moving. He continued to put this hand in a place it was eventually injured (sic) on his left thumb...approximately 1 cm (Centimeter)." Pt #1 sustained a 1 cm (centimeter) laceration which was received while being pushed by a staff member in a wheel chair. No clinical assessment or nursing intervention was documented in the MR.

Continued document review revealed on 7/29/2013, at 1305, staff RN #23 documented the following on a QCR form: "Pt was out of gait belt. He stumbled backwards, fell to the floor and bumped his head extremely hard causing (sic) to break his scalp." The "Post Fall Assessment" revealed no Vital Signs (V/S) were recorded and the neurological assessment documented one entry at 1310. Further review revealed staff #23 documented "Bleeding to head." Staff #23 failed to document assessment of the patient's head wound as to length, width, depth, quantity or quality of bleeding. A telephone order from the physician dated 7/29/2013, at 1320, read "send to ---- ED" (local hospital Emergency Department). Staff #23 failed to document how pt. #1 was transferred to the ED or when he returned, and failed to document an assessment upon return from the ED.

Continued document review identified staff nurse #17's documentation on the QCR form as follows: "8/1/2013 0520, pt. #17 stated 'I knew that was going to happen'. (Staff #24) stood up and saw he (pt#1) was on the floor. Pt initially c/o (complained of) pain in Right arm, but upon getting pt. in W/C pt. stated arm was ok. No obvious injury." Review of the Post Fall Assessment form revealed the Post Fall Protocol was not followed and V/S and neuro checks were only documented 3 times at 30 minute intervals.

Further review of pt. #1's MR revealed the following staff RN #17's documentation dated 8/4/2013, at 1440, "this nurse called to day area. MHT states pt. fell out of his wheel chair and his finger is broke. Observed pt. already back in sitting position in wheelchair. Right ring finger noted to be clearly in unnatural position. Small skin tear noted as well on same finger. Sterile gauze lightly tucked between fingers and kerlix wrap very loosely applied. Care taken to not further manipulate finger." Staff #17 failed to obtain or transcribe a physician's order to send pt. #1 to the ED; however, preprinted literature from the ED for patient education regarding splint care was located in the MR indicating patient did go to the ED. Staff #17 failed to document a Post Fall Assessment and failed to assess pt. #1 upon return from the ED.



Pt. #2 was a [AGE] year old male admitted on [DATE], with a diagnosis of [DIAGNOSES REDACTED]". MR documentation revealed pt. #2 fell at 1459 on 7/23/2013, the day of admission. Staff RN #16's nursing documentation at 1459 hours reflected the following: "Pt became extremely agitated ...lunged toward female MHT ...brief personal hold administered by male MHT ...holding walker as if to hit staff ...brief personal hold, administered Haldol 2 mg IM ...began to escalate quickly...In attempt to administer meds, pt. quickly began retreating backward tripping over his own feet ....slowly went to floor ...brief personal hold per male MHT Ativan 2 mg given IM ..." The RN failed to document a Post Fall Assessment. There was no documentation of an injury, vital signs, or assessment in the nurses notes.

Further review of the Post Fall Assessment form for Patient #2 revealed a fall occurred 7/29/2013, at 1300 hours. Staff RN #8 failed to follow the Post Fall protocol, documenting 6 sets of vital signs and only 1 set of neuro assessments. Staff #8's clinical assessment was identified on the QCR form as follows: "Pt was out of gait belt. He walked forward stumbled twice and fell forward. Pt bumped his head as he hit the floor". Further documentation indicated the MHT was with the pt. at the time of the fall. There was no documentation of an injury or assessment of patient's condition following the fall.

Further document review revealed the following: 8/2/2013, at 0515, staff RN #18's documentation on the QCR form revealed: "0515 (V/S) 96.8 86, 20, 146/78, 96% room air. Amb (ambulatory) around nurse's station with sandals on fell to Lt.(left) side, denies pain no bruising or open areas present (sic) sit up on bottom nurse/tech able to assist standing up. Dr (doctor) in house, no new orders. Placed in w/c at station, neuro v/s done will continue to monitor will notify family and staff #3". Review of the Post Fall Assessment form revealed the Post Fall protocol was not followed with 3 sets of V/S documented 20 minutes apart and 1 incomplete set of neuro assessment documented. No clinical assessment was documented.

Continued review of Patient #2's MR dated 8/7/2013, at 2100, staff LVN #12 documented the following: "Tech came to nurse's desk and said she had found client inside nurse's station behind dining room. Assessment of client noted, no abnormalities ...moves all limbs ...denies pain ...This nurse and 2 techs help client off floor. No neuro changes ..." No Post Fall Assessment was documented in the MR.



Review of pt. #3's MR revealed she was a [AGE] year old female who was admitted on [DATE], and during the admission process staff RN #13's documentation reflected a ground level fall while obtaining pt. #3's weight. The Post Fall Assessment protocol was not followed with 1 set of V/S documented and no neurological assessment documented.



Review of pt. #4's MR revealed she was an [AGE] year old female. Her admission diagnosis included dementia with increased agitation and combative behavior. A Post Fall assessment dated [DATE], indicated a fall occurred at 1245 hours. Staff RN #23 failed to follow the Post Fall protocol documenting 2 sets of V/S and neuro checks on the Post Fall Assessment. The RN failed to document notification of the physician, family and administrative staff. The RN documented in the nurse's notes at 9/15/2013, at 1300, the following: "Patient taken to bathroom by staff.... Pt was sat (sic) back in chair. Staff member turned her back and patient stood up and fell . ...Patient sent to ER (emergency room ) for evaluation. 1500 hours, patient returned from ER.... No findings noted. Patient noted to have increased confusion...1700 hours remains awake and confused". The RN failed to obtain and/or transcribe a physician's order for transporting pt. #4 to the ED and failed to document a physical assessment of pt. #4 when she returned from the ED.



Review of the MR for pt. #5 revealed he was an [AGE] year old male admitted on [DATE], with a diagnosis of [DIAGNOSES REDACTED]. Review of a facility QCR form revealed staff RN #17's documentation: "9/5/2013, at 1155 AM, a staff member at ---- (local ED) called the unit (BH) to inform BH staff that a pt. was outside in front of the ER Department. Immediately upon investigation, Mr. (Pt #5) was discovered ambulating in the parking lot accompanied by members of the ER staff. The pt. was last seen on the BH unit at 1145-1150 and was escorted back...uneventfully at approximately 1155. Prior to the event the client had been wandering about the unit pushing on the exit doors". The Registered Nurse documented NO assessment of pt. #5 upon return to the BH unit and NO description of this event was found in pt. #5's MR. There was no documentation of an investigation as to how the patient eloped.



Review of pt. #6's MR revealed she was an [AGE] year old female who was admitted [DATE], with admission diagnosis of [DIAGNOSES REDACTED]. On 9/6/2013 at 1500 the staff RN #19 documented a Post Fall Assessment indicating pt. #6 had sustained a fall. The RN failed to follow the Post Fall protocol and documented V/S beginning at 1500 then 1515 and 1530. The RN documented no further V/S until the final set of vital signs which occurred at 1700. The RN failed to document the family was notified of the patient's fall. The RN documented 5 of 8 sets of neuro assessments. Review of the QCR form revealed the RN documented the following: On 9/6/2013, at 1500 hours, "Pt left group and went to the BR (bathroom) by herself. Heard someone calling for help. Found pt. lying in BR door and helped pt. up to WC, V/S taken."

Further review of pt. #6's MR revealed later, on 9/6/2013, at 2110 hours. "Pt sitting up in w/c at nurse's station c/o (complained of) that her chest hurts when breathing out. Pt stated she fell earlier and was concerned if she broke her ribs ...Charge nurse aware, MD (medical doctor) called...new order to sends pt. to ER for X-ray... " The RN failed to document assessment of pt. #6 prior to leaving for the ED or upon return.



Review of pt. #7's MR revealed he was a [AGE] year old male who was admitted on [DATE], with major depressive disorder. Staff RN #19's documentation reflected a Post Fall Assessment without date or time. Staff #19 failed to follow the Post Fall protocol documenting no V/S and only 6 of 8 sets of neuro assessments. The RN documented "Abrasion: right eyebrow" and "Bleeding: minimal." Review of the QCR revealed the following: "Pt was taken to BR by tech. Tech told him to hold on, going to get gloves. Heard a noise, pt. had fallen off commode. Right eyebrow has tiny cut that was bleeding. Pressure held and bleeding stopped." The RN documented no assessment in the pt. MR.



Review of MR for pt. #8 revealed she was an [AGE] year old female with admitting diagnosis of [DIAGNOSES REDACTED]. The MR revealed the RN documented a Post Fall Assessment but failed to follow the Post Fall protocol. The RN documented 1 set of V/S and neuro assessment. Review of the QCR revealed the following: On 10/8/2013, at 1545, "Thud heard, rooms checked. Pt found in shower having fallen. Pt stated she had used the BR alone and fallen trying to get back in W/C". A physician's telephone order was located in the MR to "Send to -----ED". The RN failed to assess pt #8 before leaving for the ED and upon return to the unit.



Review of the MR for pt. #9 revealed he was a [AGE] year old male admitted on [DATE], with a diagnosis of [DIAGNOSES REDACTED]. The RN documented "small laceration to forehead" on Post Fall Assessment form. Review of the facility QCR form revealed the following: "Upon entering the client's room, it was noted that he had a clot over his forehead and there was a small amount of blood on the floor. Upon further investigation the patient was found to have an irregular laceration to his forehead. According to the patient he became light headed and dizzy when returning to his bed from the restroom. MD notified and Metaprolol held due to decreased heart rate." Review of the MR revealed the RN failed to obtain and/or transcribe a physician's order to transfer pt. #9 to the local ED and failed to document assessment of pt. #9 prior to transfer to the ED or when he returned. MHT flow sheet documentation stopped at 0930 and "ER" was written for the rest of the shift.



Review of the MR for pt. #10 revealed patient was a [AGE] year old female admitted on [DATE], with a diagnosis of [DIAGNOSES REDACTED]"Aide was pushing Mrs. (pt. #10) around in her W/C. Aide stated that she started leaning forward and fell out of her wheel chair. Vital signs obtained, blood sugar checked ... ice pack applied to left side of forehead, also gave Tylenol for pain....assessed her neuro status..." Photos included in the MR showed pt. #10 with a black eye surrounding her left periorbital space. Bruising was not documented during nursing shift assessments. The RN failed to initiate or complete a Post Fall Assessment for this pt's fall.



Review of pt. #11's MR revealed pt. #11 was an [AGE] year old female admitted on [DATE], with a diagnosis of [DIAGNOSES REDACTED]#21 failed to follow the Post Fall protocol. Staff #21 documented 6 of 8 sets of V/S and 4 of 8 sets of neuro assessments. Review of staff RN #21's documented nurse's notes dated 11/5/2013, at 0315 hours, revealed the following: "Pt found on floor lying on left side beside bed in a puddle of urine. Stated that she was trying to urinate on water. C/O left forearm pain. Stated that left wrist was tender to touch and painful upon movement. Lt Wrist slightly edematous...., Ice pack applied to Lt Wrist and Lt Forearm elevated". Two hours and thirty five minute later on 11/5/2013, at 0555, staff RN #21's documented nurses note reflected "Dr #5 in to see pt's Lt. Wrist. New orders noted. X-ray to Lt Wrist ordered per MD's order to r/o (rule out) fracture." A review of physician orders found the corresponding physician's order for pt. #11 to have her Lt wrist X-rayed. Preprinted pt. education provided from the ED, for care of sugar tong cast to left wrist was found in the MR indicating pt. #11 was seen in the ED. The RN failed to document pt. #11 leaving the unit or assessment upon return.



Review of pt. #12's MR revealed she was an [AGE] year old female admitted on [DATE], with a diagnosis of [DIAGNOSES REDACTED]. V/S were documented 4 of 8 times and a neuro assessment was documented at 1835. Staff #9 failed to document the physician was notified. Staff #9's MR note revealed the following: "Pt found laying on floor-PCT (personal care tech) states that pt. stood up to answer phone and then fell . Pt denies any pain. No obvious injury noted. V/S monitored. Pt continues to complain of nausea."

Documentation between 1805 and 1900 indicated pt. #12 had 3 episodes of nausea with emesis. Review of the physician's orders identified a telephone order dated 11/28/2013, at 1950 "Send Pt to ER R/T (related to) N/V (nausea/vomiting) elevated B/P (blood pressure). At 1920 the nurse's notes reads "To ER via W/C with info, daughter notified". "Pt #12's MR ends after the preceding entry and without assessment. There was no documentation of the outcome of the ER visit, if patient was transferred, discharged , or expired.



Review of pt. #13's MR revealed the following: Pt #13 was an [AGE] year old female who was admitted on [DATE], with the diagnosis of [DIAGNOSES REDACTED]. She was admitted on fall precautions level 2, line of sight less than 20 feet at all times. Further MR review found staff RN #22 documented in the nurse's notes dated 12/7/2013 at 2030 the following: "Pt Amb. with walker to exit door....fell backward with walker...hit back of head-has 2-3 cm laceration to back of head. B/P 145/71, 66, 16. Son notified. To ER with W/C (wheel chair)....2145 returned to unit 2 staples present to head. All test negative per ER nurse." The Registered Nurse did not document notification of the physician or obtain a physician's order to support the transfer to the ED. The Registered Nurse failed to document a Post Fall Assessment.


Review of pt. #14's MR revealed the following: Pt #14 was a [AGE] year old female who initially was admitted for acute medical treatment of aspiration and later discharged to the behavioral health unit. She was admitted on [DATE], with dementia with behavioral problems with a tracheostomy secondary to vocal cord [DIAGNOSES REDACTED]. She was started on Depakote for her mood, then Seroquel. Review of nurses notes revealed staff RN #13 documented the following on 8/23/2013, at 1530: "Pt taken to shower, bruising noted on coccyx-approximately 5 x 5 cm dark blue to purple. Tender to touch, also bruising to right hip approximately 7 x 5 cm dark purple". This concluded staff #13's documentation in the MR. However the QCR form was reviewed and revealed further information. "Small bruise also noted to Lt Shoulder Approximately 3 x 3 cm that is light purple to yellow. Pt withdraws as if in pain when bruise on coccyx is touched. Pt stated she does not know how she got the bruises. Pt did not fall during this shift." Review of documentation revealed pt. #14 was admitted on level 2 falls precautions, line of sight less than 20 feet at all times. No nurse or MHT documented a fall by this patient nor documented any explanation of how this pt. obtained multiple deep bruises.


On 1/14/2014, at 9:00 AM, in a first floor office interview with staff #2 indicated the facility did not have a policy addressing assessment of falls but had a protocol titled "Post Fall Assessment". Staff #2 explained nursing staff had been educated, that any pt. that falls is to have a "Post Fall Assessment" completed. Staff #2 further explained the Post Fall Assessment form did not contain space for narrative documentation. Narrative documentation would be located in the nurse's notes. Staff #2 further explained that although the Quality Control Report (QCR) form would contain the same information as the nurse's narrative it was not part of the formal pt. MR and was used only for Quality Assessment and Process Improvement.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review the facility failed to maintain current treatment/care plans and include the use of restraints for 4/16 patient identified. (Pt #1, #2, #5 and #10)

On 1/14/2014 in a first floor office the medical record (MR) for patients (Pt) #1-#16 were reviewed and revealed:

Pt #1 was an [AGE] year old male admitted on [DATE] with an admission diagnosis of Parkinson's disease, peripheral neuropathy, Alzheimer's disease, dementia with behavioral disturbances and psychosis. On 7/29/2013 staff #23 documented "Pt was out of gait belt. He stumbled backwards, fell to the floor and bumped his head extremely hard causing (sic) to break his scalp". Review of the multidisciplinary treatment (MDT) plan found use of gait belt was not documented on the treatment plan.



Pt. #2 was a [AGE] year old male admitted on [DATE] with a diagnosis of Alzheimer's dementia with behavioral disturbance. Review of nursing documentation 7/23/2013 the afternoon of admission revealed two (2) personal holds were used to administered emergency IM drugs for violent aggressive behavior. One hold was used but not required for administration of drugs. The use of personal holds was not documented on the MDT plan.



Review of the MR for pt. #5 revealed he was an [AGE] year old male admitted on [DATE] with a diagnosis of Alzheimer's type dementia with behavioral disturbance. Admission documentation for 9/5/2013 reflected pt. #5 was on fall and elopement precautions.
Further review of the MAR revealed the following medications were documented as given:

9/5/2013 at 1240 hours (hrs) Haldol 2 mg IM (Antipsychotic with slow acting sedative effects)

9/5/2013 at 1900 hrs Zyprexa 10 mg IM (Atypical antipsychotic with moderate sedation properties)

9/8/2013 at 2100 hrs, Zyprexa 10 mg IM

9/9/2013 at 0127 Ativan 2 mg IM (tranquilizer high sedative effect)

9/9/2013 at 1630 Haldol 5 mg with Ativan 2 mg IM

Review of the MDT plan revealed the following: pt #5 was admitted with elopement precautions. After his elopement on 9/5/2013, MR review indicated the use of PRN (as needed) IM psychotropic medications. No explanation of use or changes were identified on the MDT for PRN IM drug use.



Pt. #10 who was a [AGE] year old female admitted on [DATE], with a diagnosis of Alzheimer's type dementia with behavioral disturbances, major depression and anxiety. Staff LVN #12 ' s documented on 10/22/2013 at 6140 the following: "...(pt #10) fell out of her wheel chair...Pt is now in Dining room sitting in her W/C... gait belt around her waist for protection...." Review of the MDT plan revealed the use of a gait belt was not included for intervention. Documentation reflected no physician order and no treatment plan for use of the gait belt while in the W/C.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview the facility failed to implement restraints in accordance with facility policy in 3 of 16 patient's (Pt) identified. (Pt #1, #2 and #10 )

On 1/14/2013 at 9:15 AM in a first floor office the medical records for pt's 1-16 were reviewed and revealed the following:

Pt #1 was an [AGE] year old male admitted on [DATE], with an admission diagnosis of Parkinson's disease, peripheral neuropathy, Alzheimer's disease, dementia with behavioral disturbances and psychosis. His admissions level of monitoring was level "2" observation, "line of sight, less than 20 feet at all times". On 7/29/2013, staff #23 documented "Pt was out of gait belt. He stumbled backwards, fell to the floor and bumped his head extremely hard causing (sic) to break his scalp". The RN failed to obtain and/or transcribe the physician's order for use of the gait belt.



Pt. #2 was a [AGE] year old male admitted on [DATE], with a diagnosis of Alzheimer's dementia with behavioral disturbance. His level of MHT observation was level "2- line of sight less than 20 feet at All times ". MR documentation revealed 7/23/2013, the day of admission. Staff RN #16 ' s nursing documentation at 1459 reflected the following: " Pt became extremely agitated ...lunged toward female MHT ...brief personal hold administered by male MHT ...holding walker as if to hit staff ...brief personal hold, administered Haldol 2 mg IM ...began to escalate quickly...In attempt to administer med's pt. quickly began retreating backward tripping over his own feet ....slowly went to floor ...brief personal hold per male MHT Ativan 2 mg given IM ... "

Further review of MR revealed the RN failed to document behavior between the time of admission and behavioral outburst, and failed to document interventions attempted prior to pt #2's escalation of behavior. Documentation revealed pt #2's worsening behavior and subsequent fall occurred after "brief personal hold"

Review of Policy CS1-10 (Restraints): The Administration, the medical staff, and the interdisciplinary patient care management team believe that patients have the right to be free from both physical and chemical restraint ....

Definitions: Physical restraint; any method of applying involuntary restriction on a patient ' s bodily movement or access to his or her body areas.

Use of Orders to initiate restraint use: For emergency situations in which no physician is present the registered nurse may direct that a patient be placed in restraint. If protective restraints are implemented in such a situation a verbal order must be authenticated within 24 hours.

Review of the restraint policy found no mention of "personal hold." It was not identified as a physical restraint nor was it identified as a treatment method utilized by the facility. One of three personal holds documented was not required for the administration of emergency IM medications. Review of the MR revealed staff #16 failed to obtain a verbal order for initial personal hold during pt. #2 ' s outburst.



Pt. #10 who was a [AGE] year old female admitted on [DATE], with a diagnosis of Alzheimer's type dementia with behavioral disturbances, major depression and anxiety. Staff LVN #12 ' s documented on 10/22/2013, at 6140, the following: "...(pt #10) fell out of her wheel chair...Pt is now in Dining room sitting in her W/C... gait belt around her waist for protection...." Review of the MR revealed no physician order for use of the gait belt while in the W/C.

Review of Policy 607.4 Postural Support....that patient who requires postural support for body aligmnet and safety must have a physician's order provided that outlines staff guidelines to follow for ordering use, and moitoing of all postural support fevices utilized. Documnetaion of assessment, order, consent, patient education, staff education, and RN supervision of device will occur using Postural Support Order and Documentation form.

On 1.14.2014, at 10:00 am, in the first floor office interview with Staf #3 revealed the facility did not maintain a restraint log because they did not use restraints. Further gait belts were used to secure a patient while seated in a W/C as a voluntary device.The pt could release it at any time and therfor was not a restraint. The device was considered a postural support. A physician's order would always acompany the use of the postural support. Staff #3 confimred there was no physician's order for the use of the postural support on pt #1 and no Postural Support Order and Documentation form located in pt #1 MR.
VIOLATION: PATIENT VISITATION RIGHTS Tag No: A0215
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review the facility failed to follow it visitation policy for 1 of 16 patient identified. (Pt #1)

On 1/15/2014, at 11:00 AM, in a first floor office interview with staff #3 revealed the visitation policy for the facility had an age restriction with no one younger than 16 allowed to visit inside the unit. Staff #3 was told the patient (pt) #1's family complained the unit staff would not allow the pt's [AGE] year old granddaughter into visit, no matter how they pleaded with the staff. The following remark was "Well was she really 16".

On 1/15/2014, at 11:15, in a firsts floor office the facilities visitation policy was reviewed and revealed the following: Policy 617.1 Behavioral Healthcare Patient Guidelines. Under procedure: e. Visiting hours and procedures are as follows:...No one under 16 is permitted on the unit.

On 11/25/2013, a written statement submitted by the family of patient #1 as follows: "He loved our [AGE] year old grand daughter so very much because she lives with us. We begged them to let him see her but they would not".

The facility failed to follow it's visitation policy. The facility failed to established a method to verify the age of visitors in the written policy.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on document review and interview the facility:

1. Failed to insure the Registered Nurse assessed the patient, supervised the care of the patient and obtain and follow physician's orders for 14 of 16 pt (#1-#14 of #1-#16)
Refer to A0395

2. Failed to updated treatment/nursing care plan in 15 of 16 patient's (pt) reviewed. (Pt #1,#2, #4 #15)
Refer to A0396

3. Failed to insure nursing staff followed physician's orders for emergency medications and failed to obtained physician's orders prior to the administration of emergency administration of injectable medications in 3 patient (pt) (pt #1, #2 and #5) of 16 patients identified.
Refer to A0405
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and document review the facility failed to assess patients, failed to document nursing interventions, failed to follow protocols after patient falls, failed to follow policies and failed to follow and/or obtain physician orders which compromised the safety of 14 of 16 pt. (#1-#14) reviewed.

Review of the Post Fall Assessment form revealed the following: Vital signs (V/S) were to be recorded q (every) 15 minutes x 2, q 30 minutes x 2, q 1 hour x 2 and q 4 hours x 2 for a total of 8 sets of vital signs consisting of blood pressure, pulse, respirations and temperature. Eight sets of neurological (neuro) assessments should also be recorded at the same intervals. The neuro assessments consisted of left and right, pupil size/reaction, eye lid response, verbal response, motor response, gag and swallow response and a Glasgow coma score. The physical assessment included musculoskeletal, pain, respiratory, cardiovascular, gastrointestinal Genitourinary and Integumentary assessment and an area for recording the notification of family, physician and administrative staff.

On 1/14/2014 at 9:15 AM in first floor office, the medical records (MR) for pts #1- #16 were reviewed and revealed the following:


Pt #1 was an [AGE] year old male admitted on [DATE], with an admission diagnosis of [DIAGNOSES REDACTED]"2" observation, "line of sight, less than 20 feet at all times". On 7/28/2013, at 0015 (military time), Registered Nurse (RN) #10 documented the following on the Quality Control Report (QCR): "...MHT (Mental Health Tech) told him to move his hand when the W/C (Wheel chair) was moving. He continued to put this hand in a place it was eventually injured (sic) on his left thumb...approximately 1 cm (Centimeter)." Pt #1 sustained a 1 cm (centimeter) laceration which was received while being pushed by a staff member in a wheel chair. No clinical assessment or nursing intervention was documented in the MR.

Continued document review revealed on 7/29/2013, at 1305, staff RN #23 documented the following on a QCR form: "Pt was out of gait belt. He stumbled backwards, fell to the floor and bumped his head extremely hard causing (sic) to break his scalp." The "Post Fall Assessment" revealed no Vital Signs (V/S) were recorded and the neurological assessment documented one entry at 1310. Further review revealed staff #23 documented "Bleeding to head." Staff #23 failed to document assessment of the patient's head wound as to length, width, depth, quantity or quality of bleeding. A telephone order from the physician dated 7/29/2013, at 1320, read "send to ---- ED" (local hospital Emergency Department). Staff #23 failed to document how pt. #1 was transferred to the ED or when he returned, and failed to document an assessment upon return from the ED.

Continued document review identified staff nurse #17's documentation on the QCR form as follows: "8/1/2013, 0520, pt. #17 stated 'I knew that was going to happen'. (Staff #24) stood up and saw he (pt#1) was on the floor. Pt initially c/o (complained of) pain in Right arm, but upon getting pt. in W/C pt. stated arm was ok. No obvious injury." Review of the Post Fall Assessment form revealed the Post Fall Protocol was not followed and V/S and neuro checks were only documented 3 times at 30 minute intervals.

Further review of pt. #1's MR revealed the following staff RN #17's documentation dated 8/4/2013, at 1440, "this nurse called to day area. MHT states pt. fell out of his wheel chair and his finger is broke. Observed pt. already back in sitting position in wheelchair. Right ring finger noted to be clearly in unnatural position. Small skin tear noted as well on same finger. Sterile gauze lightly tucked between fingers and kerlix wrap very loosely applied. Care taken to not further manipulate finger." Staff #17 failed to obtain or transcribe a physician's order to send pt. #1 to the ED; however preprinted literature from the ED for patient education regarding splint care was located in the MR indicating patient did go to the ED. Staff #17 failed to document a Post Fall Assessment and failed to assess pt. #1 upon return from the ED.



Pt. #2 was a [AGE] year old male admitted on [DATE], with a diagnosis of [DIAGNOSES REDACTED]". MR documentation revealed pt. #2 fell at 1459 on 7/23/2013, the day of admission. Staff RN #16's nursing documentation at 1459 hours reflected the following: "Pt became extremely agitated ...lunged toward female MHT ...brief personal hold administered by male MHT ...holding walker as if to hit staff ...brief personal hold, administered Haldol 2 mg IM ...began to escalate quickly...In attempt to administer meds, pt. quickly began retreating backward tripping over his own feet ....slowly went to floor ...brief personal hold per male MHT Ativan 2 mg given IM ..." The RN failed to document a Post Fall Assessment. There was no documentation of an injury, vital signs, or assessment in the nurses notes.

Further review of the Post Fall Assessment form for Patient #2 revealed a fall occurred 7/29/2013, at 1300 hours. Staff RN #8 failed to follow the Post Fall protocol, documenting 6 sets of vital signs and only 1 set of neuro assessments. Staff #8's clinical assessment was identified on the QCR form as follows: "Pt was out of gait belt. He walked forward stumbled twice and fell forward. Pt bumped his head as he hit the floor". Further documentation indicated the MHT was with the pt. at the time of the fall. There was no documentation of an injury or assessment of patient's condition following the fall.

Further document review revealed the following: 8/2/2013, at 0515, staff RN #18's documentation on the QCR form revealed: "0515 (V/S) 96.8 86, 20, 146/78, 96% room air. Amb (ambulatory) around nurse's station with sandals on fell to Lt.(left) side, denies pain no bruising or open areas present (sic) sit up on bottom nurse/tech able to assist standing up. Dr (doctor) in house, no new orders. Placed in w/c at station, neuro v/s done will continue to monitor will notify family and staff #3". Review of the Post Fall Assessment form revealed the Post Fall protocol was not followed with 3 sets of V/S documented 20 minutes apart and 1 incomplete set of neuro assessment documented. No clinical assessment was documented.

Continued review of Patient #2's MR dated 8/7/2013 at 2100 staff LVN #12 documented the following: "Tech came to nurse's desk and said she had found client inside nurse's station behind dining room. Assessment of client noted, no abnormalities ...moves all limbs ...denies pain ...This nurse and 2 techs help client off floor. No neuro changes ..." No Post Fall Assessment was documented in the MR.



Review of pt. #3's MR revealed she was a [AGE] year old female who was admitted on [DATE], and during the admission process staff RN #13's documentation reflected a ground level fall while obtaining pt. #3's weight. The Post Fall Assessment protocol was not followed with 1 set of V/S documented and no neurological assessment documented.



Review of pt. #4's MR revealed she was an [AGE] year old female. Her admission diagnosis included dementia with increased agitation and combative behavior. A Post Fall assessment dated [DATE], indicated a fall occurred at 1245 hours. Staff RN #23 failed to follow the Post Fall protocol documenting 2 sets of V/S and neuro checks on the Post Fall Assessment. The RN failed to document notification of the physician, family and administrative staff. The RN documented in the nurse's notes at 9/15/2013, at 1300 the following: "Patient taken to bathroom by staff.... Pt was sat (sic) back in chair. Staff member turned her back and patient stood up and fell . ...Patient sent to ER (emergency room ) for evaluation. 1500 hours, patient returned from ER.... No findings noted. Patient noted to have increased confusion...1700 hours remains awake and confused". The RN failed to obtain and/or transcribe a physician's order for transporting pt. #4 to the ED and failed to document a physical assessment of pt. #4 when she returned from the ED.



Review of the MR for pt. #5 revealed he was an [AGE] year old male admitted on [DATE], with a diagnosis of [DIAGNOSES REDACTED]. Review of a facility QCR form revealed staff RN #17's documentation: "9/5/2013 at 1155 AM, a staff member at ---- (local ED) called the unit (BH) to inform BH staff that a pt. was outside in front of the ER Department. Immediately upon investigation, Mr. (Pt #5) was discovered ambulating in the parking lot accompanied by members of the ER staff. The pt. was last seen on the BH unit at 1145-1150 and was escorted back...uneventfully at approximately 1155. Prior to the event the client had been wandering about the unit pushing on the exit doors". The Registered Nurse documented NO assessment of pt. #5 upon return to the BH unit and NO description of this event was found in pt. #5's MR. There was no documentation of an investigation as to how the patient eloped.



Review of pt. #6's MR revealed she was an [AGE] year old female who was admitted [DATE], with admission diagnosis of [DIAGNOSES REDACTED]. On 9/6/2013, at 1500, the staff RN #19 documented a Post Fall Assessment indicating pt. #6 had sustained a fall. The RN failed to follow the Post Fall protocol and documented V/S beginning at 1500 then 1515 and 1530. The RN documented no further V/S until the final set of vital signs which occurred at 1700. The RN failed to document the family was notified of the patient's fall. The RN documented 5 of 8 sets of neuro assessments. Review of the QCR form revealed the RN documented the following: On 9/6/2013, at 1500 hours, "Pt left group and went to the BR (bathroom) by herself. Heard someone calling for help. Found pt. lying in BR door and helped pt. up to WC, V/S taken."

Further review of pt. #6's MR revealed later, on 9/6/2013, at 2110 hours, "Pt sitting up in w/c at nurse's station c/o (complained of) that her chest hurts when breathing out. Pt stated she fell earlier and was concerned if she broke her ribs ...Charge nurse aware, MD (medical doctor) called...new order to sends pt. to ER for X-ray... " The RN failed to document assessment of pt. #6 prior to leaving for the ED or upon return.



Review of pt. #7's MR revealed he was a [AGE] year old male who was admitted on [DATE], with major depressive disorder. Staff RN #19's documentation reflected a Post Fall Assessment without date or time. Staff #19 failed to follow the Post Fall protocol documenting no V/S and only 6 of 8 sets of neuro assessments. The RN documented "Abrasion: right eyebrow" and "Bleeding: minimal." Review of the QCR revealed the following: "Pt was taken to BR by tech. Tech told him to hold on, going to get gloves. Heard a noise, pt. had fallen off commode. Right eyebrow has tiny cut that was bleeding. Pressure held and bleeding stopped." The RN documented no assessment in the pt. MR.



Review of MR for pt. #8 revealed she was an [AGE] year old female with admitting diagnosis of [DIAGNOSES REDACTED]. The MR revealed the RN documented a Post Fall Assessment but failed to follow the Post Fall protocol. The RN documented 1 set of V/S and neuro assessment. Review of the QCR revealed the following: On 10/8/2013 at 1545 "Thud heard, rooms checked. Pt found in shower having fallen. Pt stated she had used the BR alone and fallen trying to get back in W/C". A physician's telephone order was located in the MR to "Send to -----ED". The RN failed to assess pt #8 before leaving for the ED and upon return to the unit.



Review of the MR for pt. #9 revealed he was a [AGE] year old male admitted on [DATE], with a diagnosis of [DIAGNOSES REDACTED]. The RN documented "small laceration to forehead" on Post Fall Assessment form. Review of the facility QCR form revealed the following: "Upon entering the client's room, it was noted that he had a clot over his forehead and there was a small amount of blood on the floor. Upon further investigation the patient was found to have an irregular laceration to his forehead. According to the patient he became light headed and dizzy when returning to his bed from the restroom. MD notified and Metaprolol held due to decreased heart rate." Review of the MR revealed the RN failed to obtain and/or transcribe a physician's order to transfer pt. #9 to the local ED and failed to document assessment of pt. #9 prior to transfer to the ED or when he returned. MHT flow sheet documentation stopped at 0930 and "ER" was written for the rest of the shift.



Review of the MR for pt. #10 revealed patient was a [AGE] year old female admitted on [DATE], with a diagnosis of [DIAGNOSES REDACTED]"Aide was pushing Mrs. (pt. #10) around in her W/C. Aide stated that she started leaning forward and fell out of her wheel chair. Vital signs obtained, blood sugar checked ... ice pack applied to left side of forehead, also gave Tylenol for pain....assessed her neuro status..." Photos included in the MR showed pt. #10 with a black eye surrounding her left periorbital space. Bruising was not documented during nursing shift assessments. The RN failed to initiate or complete a Post Fall Assessment for this pt's fall.



Review of pt. #11's MR revealed pt. #11 was an [AGE] year old female admitted on [DATE], with a diagnosis of [DIAGNOSES REDACTED]#21 failed to follow the Post Fall protocol. Staff #21 documented 6 of 8 sets of V/S and 4 of 8 sets of neuro assessments. Review of staff RN #21's documented nurse's notes dated 11/5/2013, at 0315 hours, revealed the following: "Pt found on floor lying on left side beside bed in a puddle of urine. Stated that she was trying to urinate on water. C/O left forearm pain. Stated that left wrist was tender to touch and painful upon movement. Lt Wrist slightly edematous...., Ice pack applied to Lt Wrist and Lt Forearm elevated". Two hours and thirty five minute later on 11/5/2013, at 0555, staff RN #21's documented nurses note reflected "Dr #5 in to see pt's Lt. Wrist. New orders noted. X-ray to Lt Wrist ordered per MD's order to r/o (rule out) fracture." A review of physician orders found the corresponding physician's order for pt. #11 to have her Lt wrist X-rayed. Preprinted pt. education provided from the ED, for care of sugar tong cast to left wrist was found in the MR indicating pt. #11 was seen in the ED. The RN failed to document pt. #11 leaving the unit or assessment upon return.



Review of pt. #12's MR revealed she was an [AGE] year old female admitted on [DATE], with a diagnosis of [DIAGNOSES REDACTED]. V/S were documented 4 of 8 times and a neuro assessment was documented at 1835. Staff #9 failed to document the physician was notified. Staff #9's MR note revealed the following: "Pt found laying on floor-PCT (personal care tech) states that pt. stood up to answer phone and then fell . Pt denies any pain. No obvious injury noted. V/S monitored. Pt continues to complain of nausea."

Documentation between 1805 and 1900 indicated pt. #12 had 3 episodes of nausea with emesis. Review of the physician's orders identified a telephone order dated 11/28/2013 at 1950 "Send Pt to ER R/T (related to) N/V (nausea/vomiting) elevated B/P (blood pressure). At 1920 the nurse's notes reads "To ER via W/C with info, daughter notified". "Pt #12's MR ends after the preceding entry and without assessment. There was no documentation of the outcome of the ER visit, if patient was transferred, discharged , or expired.



Review of pt. #13's MR revealed the following: Pt #13 was an [AGE] year old female who was admitted on [DATE], with the diagnosis of [DIAGNOSES REDACTED]. She was admitted on fall precautions level 2, line of sight less than 20 feet at all times. Further MR review found staff RN #22 documented in the nurse's notes dated 12/7/2013, at 2030, the following: "Pt Amb. with walker to exit door....fell backward with walker...hit back of head-has 2-3 cm laceration to back of head. B/P 145/71, 66, 16. Son notified. To ER with W/C (wheel chair)....2145 returned to unit 2 staples present to head. All test negative per ER nurse." The Registered Nurse did not document notification of the physician or obtain a physician's order to support the transfer to the ED. The Registered Nurse failed to document a Post Fall Assessment.



Review of pt. #14's MR revealed the following: Pt #14 was a [AGE] year old female who initially was admitted for acute medical treatment of aspiration and later discharged to the behavioral health unit. She was admitted on [DATE] with dementia with behavioral problems with a tracheostomy secondary to vocal cord [DIAGNOSES REDACTED]. She was started on Depakote for her mood, then Seroquel. Review of nurses notes revealed staff RN #13 documented the following on 8/23/2013, at 1530: "Pt taken to shower, bruising noted on coccyx-approximately 5 x 5 cm dark blue to purple. Tender to touch, also bruising to right hip approximately 7 x 5 cm dark purple". This concluded staff #13's documentation in the MR. However the QCR form was reviewed and revealed further information. "Small bruise also noted to Lt Shoulder Approximately 3 x 3 cm that is light purple to yellow. Pt withdraws as if in pain when bruise on coccyx is touched. Pt stated she does not know how she got the bruises. Pt did not fall during this shift." Review of documentation revealed pt. #14 was admitted on level 2 falls precautions, line of sight less than 20 feet at all times. No nurse or MHT documented a fall by this patient nor documented any explanation of how this pt. obtained multiple deep bruises.


On 1/14/2014, at 9:00 AM, in a first floor office interview with staff #2 indicated the facility did not have a policy addressing assessment of falls but had a protocol titled "Post Fall Assessment". Staff #2 explained nursing staff had been educated, that any pt. that falls is to have a "Post Fall Assessment" completed. Staff #2 further explained the Post Fall Assessment form did not contain space for narrative documentation. Narrative documentation would be located in the nurse's notes. Staff #2 further explained that although the Quality Control Report (QCR) form would contain the same information as the nurse's narrative it was not part of the formal pt. MR and was used only for Quality Assessment and Process Improvement.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review the facility failed to establish comprehensive treatment/care plans and updated treatment/nursing care plan in 14 of 16 patient's (pt) reviewed. (Pt #1- #14)

On 1/14/2014, at 2:00 PM, in a first floor office, Staff #3 explained the treatment plan process as follows. The treatment team meets after all disciplines have evaluated the patient and as a multidisciplinary team, create a treatment plan for the patient.


On 1/14/2014, at 2:15, review of the facility policy for treatment/care planning was reviewed and revealed the following: Policy 223 "Treatment Team Staffing". The staffing is a meeting of the Attending Physician and members of the Interdisciplinary Treatment Team for the purpose of developing and monitory and individualizing treatment plan".

Procedure:

1. The staffing is chaired by the Charge Nurse or designee.

2. ALL members of the treatment team should be in attendance-Physician, Registered Nurse (RN), Therapist and pt if able.

3. The initial staffing will occur within 3 days of admission.

4. A treatment review staffing will be scheduled every 7 days following the initial staffing.


On 1/14/2014, in the first floor office at 1:00 PM the MR's for patient's 1-16 were reviewed and revealed the following:


Pt #1 was an [AGE] year old male admitted on [DATE]. His History and Physical (H&P) document his chief complaint as Increased aggression and agitation. The H&P included the following diagnosis; [DIAGNOSES REDACTED], reflux, BPH (Benign Prostatic Hypertrophy) peripheral neuropathy, Parkinson's, congestive heart failure, CVA (Cerebral Vascular Accident), carotid stenosis. The H&P also listed in the past medical history of [DIAGNOSES REDACTED]"this [AGE] year old male with the above mentioned diagnosis and admitted with dementia with behavior disturbances".

Review of the Multidisciplinary Master Treatment (MDT) Plan dated 7/29/2013, revealed the following: Level 2 monitoring with special precautions for falls and aggression. On 8/8/13, the Multidisciplinary Master Treatment Plan was reviewed by the team and revealed the following problems: Aggression, agitation, Impulsivity and med's (medications). No interventions were documented. Changes in medication included, "7/30/2013 Depakote 125 mg (milligrams) at night, Trazodone 25 mg at night. Stop Haldol".

Although the treatment plan documented pt #1 was on special precautions for falls. The treatment plan did not include risk for increased falls related to Parkinsonism, or peripheral neuropathy. The treatment plan did not include increase risk of falls related to emergency medications that were given intramuscular (IM). They were as follows:

7/28/13: Zyprexa 5 mg IM given at 2250 hours

7/29/13: Zyprexa 5 mg IM given at 1300 hours Pt #1 first fall occurred 7/29/13. No changes in intervention after this fall were identified on the treatment plan.

8/02/13: Zyprexa 5 mg IM given at 1018 hours Pt #1 second fall occurred 8/1/13. No changes in interventions were identified on the treatment plan after this second fall. Pt #1 third fall occurred 8/4/13. No interventions to reduce falls were recorded on pt #1 treatment plan.

8/05/13: Haldol 5 mg IM given at 0005 hours

8/07/13: Zyprexa 5 mg IM given at 0342 hours

8/09/13: Haldol 5 mg IM given at 0041 hours


Pt #1 had two falls which resulted serious injury, a laceration to the back of his head that required 6 staples to close, and a fractured ring finger. The third fall resulted in the pt c/o pain in his wrist but no fracture or skin tear. Pt #1 also received a skin tear not related to a fall. None of these injuries were care planned. No interventions were documented.



Review of pt. #3's MR revealed she was a [AGE] year old female who was admitted on [DATE], and during the admission process staff RN #13's documentation reflected a ground level fall while obtaining pt. #3's weight. Review of the MDT plan identified no mention of the fall or interventions.



Pt #2 was a [AGE] year old male admitted on [DATE]. The H&P identified increased agitation as the reason for admission. His past medical history included dementia, prostatic cancer, coronary artery disease, increased confusion, altered mental status, paranoia, hallucinations, diabetes and sleep apnea.

Review of pt #2's Multidisciplinary Master Treatment Plan listed a level 2 monitoring with special precautions for falls and aggression. The Multidisciplinary Master Treatment Plan review and update for 8/5/13 listed the following problems: Psychosis, Aggression, anxiety,impulsivity, cognitive decline, appetite disturbance, sleep disturbance and agitation. No interventions were documented. The following interventions were not identified on the MDT care plan:

7/23/13 Haldol 2 mg IM 1523 hours

7/24/13 Haldol 2 mg IM 1250 hours

7/26/13 Haldol 2 mg IM 1309 hours

7/26/13 Ativan 1 mg IM 1505 hours

7/27/13 Haldol 2 mg IM 1238 hours

7/28/13 Ativan 1 mg IM 2200 hours

7/29/13 Haldol 2 mg IM 1257 hours Pt #2 fell while out of gait belt struck head on floor.

7/31/13 Haldol 2 mg IM 1623 hours

7/23/13 Ativan 2 mg IM 1519 hours

8/01/13 Ativan 1 mg IM 2148 hours

8/02/13 Ativan 1 mg IM 1811 hours

8/03/13 Ativan 1 mg IM 1031 hours

8/03/13 Haldol 2 mg IM 1555 hours

8/05/13 Ativan 1 mg IM 1130 hours

8/05/13 Haldol 2 mg IM 1330 hours

8/06/13 Haldol 2 mg IM 1332 hours

8/06/13 Ativan 1 mg IM 1430 hours

8/07/13 Zyprexa 10 mg IM 1623 hours

8/08/13 Zyprexa 10 mg IM 1020 hours

Review of the MDT plan revealed none of the 19 emergency doses of IM medications were care planned. No description of pt #2 behavior was added to the care plan. The use of restraint was not identified as an intervention of the MDT plan.



Pt #4 was an [AGE] year old female. She was admitted on [DATE]. The H&P noted her chief complaint was increased anxiety and increased restlessness. She had a history of dementia, atrial fibrillation, pulmonary disease, chronic back pain, increased agitation, restlessness and combative behavior. Past medial history was significant for hypertension, insomnia. and had a recent fall 4 days prior to admission with head laceration.

Unable to review of the Multidisciplinary Master Treatment Plan as it was not identified in the MR for pt #4. However treatment plan updates were located in the MR for 9/10/2013. problems identified were Axis III medical diagnosis with interventions identified for Gastric reflux, and Chronic obstructive pulmonary disease. Medications were identified only as Ativan for anxiety, Seroquel for psychosis, Trazodone for insomnia. Behaviors were identified as aggression and anxiety with no changes were identified.

The following interventions were not identified on the care plan:

9/10/13 Ativan 2 mg oral every 4 hours initial dose given at 2005 hours upon admission. Pt fell while at nurses station.

9/11/13 Ativan 2 mg oral every 4 hours given with doses 0000 hour and 0400 hour doses not initialed as given.,0800 hours,1200 hours,1600 hours, 2158 hours were given.

9/11/13 Norco 5/325 was given oral (Narcotic pain medication)

9/11/13 Ativan 2 mg IM 2215 hours

9/12/13 Ativan 2 mg oral was given at 0000 hour, 0400, 0404, 0405 hour, 0800 hour, 1330 hour and 2003 hour.

9/12/13 Norco 5/325 oral was given

9/13/13 Ativan 2 mg oral was given 0207 hour, 0800 hour, 0923 hour, 1330 hour, 1409 hour and 2020 hour.

9/13/13 Norco 5/325 oral was given.

9/14/13 Norco 5/325 oral was given.

9/15/13 Norco 5/325 oral was given. Pt fell after being left unattended on bed side potty chair while nurse washed hands. 9/17/13 Norco 5/325 oral was given.

On 9/17/2013 pt #4 was discharged .



Pt #5 was an [AGE] year old male who was admitted on [DATE]. The H&P recorded the chief complaint as "agitated and very aggressive". The psychological evaluation recorded "The patient has been exit seeking and wandering around the nursing home". Pt #5 was physically ambulatory but unable to care for himself.

Review of the Multidisciplinary Master Treatment Plan dated 9/5/2013, documented level 2 monitoring with special precautions for falls and aggression. (exit seeking/elopement risk was not identified as an initial precaution), Preliminary discharge plan "needs placement in secure unit". On 9/12/2013, the MDT Plan was updated and problems listed were Anxiety, aggression, Agitation, impulsivity, sleep disturbance and Appetitive disturbance. No changes in diagnosis were identified and changes to the treatment/medication plan: dated 9/5/13, affected routine oral medications only. An update to the MDT plan dated 9/19/2013 listed Anxiety, Aggression, Agitation, Impulsivity, and Sleep disturbance as problems. Changes documented were oral medications routinely taken.

On the date of admission, pt #5 eloped from the secure unit and was found walking outside the ED (Emergency Department). ED staff notified the behavioral unit that a patient was walking outside with their staff for supervision. Pt #5 was returned to the secure unit without event. Review of pt #5's treatment plan did not reflect a change in the level of monitoring. However, the MHT did change their documentation to reflect level 1 within 6 feet of pt #5 at all times.

Further review of the Master Treatment Plan did not reflect the facilities use of PRN Psychotropic injectable medications as interventions. They are as follows:

Haldol 2 mg IM 9/5/13 at 1240 hours

Zyprexa 10 mg IM 9/5/13 at 1930 hours

Ativan 2 mg IM 9/5/13 at 2140 hours

Ativan 2 mg IM 9/6/13 at 1850 hours

Ativan 2 mg IM 9/8/13 at 1545 hours

Zyprexa 10 mg IM 9/8/13 at 2105

Ativan 2 mg IM 9/9/13 at 0127

Haldol 5 mg with Ativan 2 mg IM 9/9/13 at 1630 hours

Haldol 5 mg with Ativan 2 mg IM 9/12/13 at 1655 hours

Haldol 5 mg with Ativan 2 mg IM 9/10/13 at 2130 hours



Pt #6 was an [AGE] year old female who was admitted on [DATE]. Review of the H&P revealed the chief complaint was "chronic pain, does not want to live, has superficial cuts on her arms". Her past history was significant for dementia, [DIAGNOSES REDACTED], atrial fibrillation, and hypertension. Her Multidisciplinary Master Treatment Plan dated 9/2/2013 recorded her level of monitoring at 2, line of sight within 20 feet or less with fall and suicide precautions. Problems listed were Depressed mood, impulsivity, suicidal thought anxiety, and "meds". There were no special notations and the only changes were to routine oral medications.
Review of documentation reflected on 9/6/2013 pt #6 went to the bathroom unsupervised and fell . She was sent to the ED for evaluation. This fall and changes to staff interventions were not identified on the MDT plan.



Review of pt. #7's MR revealed he was a [AGE] year old male who was admitted on [DATE] with major depressive disorder. Staff RN #19's documentation reflected a Post Fall Assessment without date or time. The RN documented "Abrasion: right eyebrow" and "Bleeding: minimal". Review of the QCR revealed the following: "Pt was taken to BR by tech. Tech told him to hold on, going to get gloves. Heard a noise, pt. had fallen off commode. Right eyebrow has tiny cut that was bleeding. Pressure held and bleeding stopped". Review of the MDT plan did not reflect the fall, injury or nursing interventions



Review of MR for pt. #8 revealed she was an [AGE] year old female with admitting diagnosis of [DIAGNOSES REDACTED]. The MR revealed the RN documented a Post Fall Assessment. Review of the QCR revealed the following: On 10/8/2013, at 1545, "Thud heard, rooms checked. Pt found in shower having fallen. Pt stated she had used the BR alone and fallen trying to get back in W/C". A physician's telephone order was located in the MR to "Send to -----ED". Review of the MDT identified no documentation for the fall, injury or nursing interventions.



Review of the MR for pt. #9 revealed he was a [AGE] year old male admitted on [DATE], with a diagnosis of [DIAGNOSES REDACTED]"small laceration to forehead" on Post Fall Assessment form. Review of the facility QCR form revealed the following: "Upon entering the client's room, it was noted that he had a clot over his forehead and there was a small amount of blood on the floor. Upon further investigation the patient was found to have an irregular laceration to his forehead. According to the patient he became light headed and dizzy when returning to his bed from the restroom. MD notified and Metaprolol held due to decreased heart rate". Review of the MDT plan did not address the fall, injury,decreased heart rate change in Metaprolol or transfer from the unit.



Review of the MR for pt. #10 revealed patient was a [AGE] year old female admitted on [DATE], with a diagnosis of [DIAGNOSES REDACTED]"Aide was pushing Mrs. (pt. #10) around in her W/C...fell out of her wheel chair. Photos included in the MR showed pt. #10 with a black eye surrounding her left periorbital space. Review of the MDT plan did not identify the fall, nursing interventions, restraints or staff education related to allowing a patient to fall from a w/c while staff pushing w/c.



Review of pt. #11 MR revealed pt. #11 was an [AGE] year old female admitted on [DATE], with a diagnosis of [DIAGNOSES REDACTED]#21 indicated pt #111 fell . Review of staff RN #21's documented nurse's notes dated 11/5/2013, at 0315 hours, revealed the following: "Pt found on floor lying on left side beside bed in a puddle of urine. Stated that she was trying to urinate on water. C/O left forearm pain. Stated that left wrist was tender to touch and painful upon movement. Preprinted pt. education provided from the ED, for care of sugar tong cast to left wrist was found in the MR indicating pt. #11 was seen in the ED. Review of the MDT plan revealed the fall was not identified, nor was the fractured wrist or nursing intervention. There were no changes to the MDT plan documented.



Review of pt. #12's MR revealed she was an [AGE] year old female admitted on [DATE], with a diagnosis of [DIAGNOSES REDACTED]"Pt found laying on floor-PCT (personal care tech) states that pt. stood up to answer phone and then fell .
Documentation between 1805 and 1900 indicated pt. #12 had 3 episodes of nausea with emesis. Review of the physician's orders identified a telephone order dated 11/28/2013, at 1950 "Send Pt to ER R/T (related to) N/V (nausea/vomiting) elevated B/P (blood pressure). Review of the MDT plan identified no record of the fall, N/V, change in condition or transfer to the ED. There was no documentation of the outcome of the ER visit, if patient was transferred, discharged , or expired. The MDT did not reflect this change.



Review of pt. #13's MR revealed the following: Pt #13 was an [AGE] year old female who was admitted on [DATE], with the diagnosis of [DIAGNOSES REDACTED]. She was admitted on fall precautions level 2, line of sight less than 20 feet at all times. Further MR review found staff RN #22 documented in the nurse's notes dated 12/7/2013, at 2030, the following: "Pt Amb. with walker to exit door....fell backward with walker...hit back of head-has 2-3 cm laceration to back of head. B/P 145/71, 66, 16. Son notified. To ER with W/C (wheel chair)....2145 returned to unit 2 staples present to head. All test negative per ER nurse." Review of the MDT plan did not reflect documentation of this fall, injury, nursing intervention, or transfer the ED.



Review of pt. #14's MR revealed the following: Pt #14 was a [AGE] year old female who initially was admitted for acute medical treatment of aspiration and later discharged to the behavioral health unit. She was admitted on [DATE], with dementia with behavioral problems with a tracheostomy secondary to vocal cord [DIAGNOSES REDACTED]. She was started on Depakote for her mood, then Seroquel. Review of nurses notes revealed staff RN #13 documented the following on 8/23/2013, at 1530: "Pt taken to shower, bruising noted on coccyx-approximately 5 x 5 cm dark blue to purple. Tender to touch, also bruising to right hip approximately 7 x 5 cm dark purple". This concluded staff #13's documentation in the MR. However the QCR form was reviewed and revealed further information. "Small bruise also noted to Lt Shoulder Approximately 3 x 3 cm that is light purple to yellow. Pt withdraws as if in pain when bruise on coccyx is touched. Pt stated she does not know how she got the bruises. Pt did not fall during this shift". Review of documentation revealed pt. #14 was admitted on level 2 falls precautions, line of sight less than 20 feet at all times". Review of the MDT plan did not document injury of unknown cause changes to the plan, staff inntervention or education.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on document review the facility failed to insure nursing staff followed physician's orders for emergency medications and failed to obtain physician's orders prior to the administration of emergency administration of injectable medications in 3(pt #1, #2 and #5) of 16 patients identified.

On 1/15/2013 in a first floor office at 2:00 PM the MR for Pt #1-16 were reviewed.


Pt #1's MR revealed the medication administration record (MAR) indicated the following medication were administered:

8/5/2013 Haldol 5 mg IM given at 0005 hours (hrs)

8/9/2013 Haldol 5 mg IM given at 0041 hrs

Further review of the MR found no corresponding physician's order for Haldol 5 mg IM



Pt #2 revealed the medication administration record (MAR) indicated the following medication were administered:

7/23/2013 Ativan 2 mg IM given at 1519 (1 x only)

8/03/2013 Ativan 2 mg IM given at 1031 (PRN) No corresponding physician's order identified in the MR for this emergency IM medication.

8/07/2013 Zyprexa 10 mg IM 1 x now. No corresponding physician's order was located in the MR for this emergency IM medication.



On 1/15/2013 in a first floor office the MR for pt #5 was reviewed and revealed the medication administration record (MAR) indicated the following medication was ordered by physician but not documented as given by the nursing staff.
Dated 9/5/2013 at 2135 hours (hrs) Ativan 2 mg IM (Intramuscular), 1 time, NOW.

Further review of the MAR revealed the following medications were documented as given but no corresponding physician's order was located in the MR:

9/5/2013 at 1240 hours (hrs) Haldol 2 mg IM

9/5/2013 at 1900 hrs Zyprexa 10 mg IM

9/8/2013 at 2100 hrs, Zyprexa 10 mg IM

9/9/2013 at 0127 Ativan 2 mg IM

9/9/2013 at 1630 Haldol 5 mg and Ativan 2 mg IM