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.

NACOGDOCHES COUNTY HOSPITAL DISTRICT 1204 MOUND ST NACOGDOCHES, TX 75961 Aug. 3, 2016
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
Based on chart reviews the facility failed to ensure physician's orders were written, signed, dated, and authenticated in 4 of 4 (#2, 4, 6, and 7) charts reviewed.

Review of patient #2's chart revealed, the inpatient admission order was a verbal order. The order was dated 12/4/15 but there was no time documented. There was no signature, date or time from the prescribing physician found.

Review of patient #7's chart revealed, the following orders and medication orders were administered but did not state if the orders were written or verbal. The orders were not electronically signed by the physician:

1.) 2/26/16 18:00 (6:00PM) Risperidone 0.5mg oral 2 x day for 30 days. Give at 6am and 6PM. Discontinued on 3/27/16

2.) 2/26/16 18:00 Exelon Patch 9.5mg 1 patch transdermal q 24h for 30 days.

3.) 2/27/16 21:00 (9:00PM) Temazepam 30mg oral bedtime for 10days.

4.) 2/28/16 20:45 (8:45PM) Olanzapine ODT (Zyprexa) 10mg oral one time for 1 days.

5.) 2/29/16 09:30 (9:30AM) Olanzapine ODT (Zyprexa) 10mg oral 1xday for 30 days.

6.) 3/1/16 18:00 (6:00PM) Risperidone 0.25mg oral 2 x day for 26days. Give at 6am and 6pm. There was no stop on the previous order in #1 until 3/27/16. There was no clarification order on the dosage the patient was to receive.

7.) 3/4/16 19:01 (7:01PM) Lisinopril 5mg oral 1xday for 30 days.

Review of patient #4's chart revealed, there were no physician orders for chemical restraints administered on 2/20/16 at 7:01PM and 2/22/16 at 1:34AM and 8:01PM.

Review of patient #6's chart revealed, the following medication orders were administered but did not state if the orders were written or verbal. The orders were not electronically signed by the physician:

8.) 12/31/15 9:00PM Invega 9mg oral bedtime for 18days.

9.) 1/1/16 8:35PM Lorazepam 2mg intramuscular one time for 1 doses.

10.) 1/3/16 2:11PM Lorazepam 2mg intramuscular one time stat and then routine, stat.

Review of the Medical by-laws under 4.4 ORDERS General Principles stated, "E. All orders for treatment shall be recorded in the medical record and authenticated by the ordering practitioner with his/her valid (as determined by CMS rules) signature, date, and time.

4.4.2 Verbal Orders - d. all verbal orders should be signed by the ordering practitioner or another practitioner involved in the patient's care within 48 hours unless State law specified a different time frame."
VIOLATION: GOVERNING BODY Tag No: A0043
The Governing Body failed to:


A.) ensure patient safety in 14 of 14 patient rooms. The rooms had drop down ceilings, unsecured light fixtures, and exposed glass light bulbs that placed all patients at risk for the likelihood of harm to self or others.

Refer to Tag A0144


B.) ensure Nursing:

1.) conducted a comprehensive patient assessment and documented evidence that the RN attempted a less restrictive restraint.

2.) performed assessments, monitoring, interventions, and care that was appropriate for that patient's needs.


3.) developed an individualized treatment plan for the chemical restraints and patient response in 2 (4 and 6) of 3 (4, 5, and 6) charts reviewed.


Refer to Tag A0160



4.) assess and evaluate the patient after the administration of a chemical restraint on an ongoing basis,

5.) assess, evaluate and report a patient's change in condition, and

6.) documenting the patient's response to interventions in 1 (4) of 3 (4, 5, and 6) charts reviewed.

Refer to Tag A0395


7.) develop nursing interventions, goals, ongoing assessments, response to interventions, and updates to the nursing care plans in 3 (7, 6, and 4) of 3 charts reviewed.

Refer to Tag A0396


C.) ensure physician's orders were written, signed, dated, and authenticated in 4 of 4 (#2, 4, 6, and 7) charts reviewed.

Refer to tag A0454
VIOLATION: PATIENT RIGHTS Tag No: A0115
The facilility failed to:


A.) ensure patient safety in 14 of 14 patient rooms. The rooms had drop down ceilings, unsecured light fixtures, and exposed glass light bulbs that placed all patients at risk for the likelihood of harm to self or others.

Refer to Tag A0144


B.) ensure Nursing:

1.) conducted a comprehensive patient assessment and documented evidence that the RN attempted a less restrictive restraint.

2.) performed assessments, monitoring, interventions, and care that was appropriate for that patient's needs.


3.) developed an individualized treatment plan for the chemical restraints and patient response in 2 (4 and 6) of 3 (4, 5, and 6) charts reviewed.


Refer to Tag A0160
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, chart review, and interview, the facility failed to ensure patient safety for patients in 14 of 14 patient rooms. The rooms had drop down ceilings, unsecured light fixtures, and exposed glass light bulbs that placed all patients at risk for the likelihood of harm to self or others.


These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.

A tour was conducted of the facility's geriatric psychiatric unit on 7/26/2016 with Staff #3 and #4. During the tour, the private patient rooms were found to have drop down ceilings. The ceilings were accessed easily by the surveyor. The surveyor stood on a chair and easily reached the ceiling tiles, moved the tiles, and pulled on the metal tracks that held the ceiling tiles. Staff #3 was asked if the florescent light fixtures in the patient rooms were able to be opened. Staff #3 stood on the chair and opened the lens of the light fixture exposing the bulbs.

Staff #3 reported that he said something to the facility's accreditation group about the ceiling's not being solid and hard. Staff #3 reported that the accrediting agent stated, "It's a geriatric unit. You don't have to have hardened ceilings with geriatrics." Staff #4 agreed with the findings.

Review of the 11 occupied patient rooms revealed the rooms were private, allowed patients to close the doors to their rooms without staff present, had unsecured ceilings, unsecured light fixtures, and exposed glass light bulbs that posed a risk of harm to themselves or others.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0160
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on chart reviews the Nursing failed to:

1.) conduct a comprehensive patient assessment and document evidence that the RN attempted a less restrictive restraint;

2.) perform assessments, monitoring, interventions, and care that were appropriate for that patient's needs; and


3.) have an individualized treatment plan for the chemical restraints and patient response in 2 (4 and 6) of 3 (4, 5, and 6) charts reviewed.

Review of patient #4's chart revealed, the patient was an [AGE] year old male, admitted on [DATE] at 17:34 (5:34PM), as a voluntary patient. Patient #4 was admitted with a diagnosis of Dementia with acute confusion and delirium. Review of the physician consult dated 2/17/16 revealed the patient was oriented to person, not to place or time.


Review of the "Clinical Notes Report" dated 2/20/16 18:35 (6:35PM) revealed, staff #13 documented,"CNA reported that patient agitated. I went to room & he was in his underwear pushing a chair into the hallway, almost falling down, stating lets go. Attempted to redirect him & was able to get his pants on. He was throwing blanket on me, tried to put pillow on instead of his pants. 2/20/16 19:01(7:01PM) Staff #12 (psychiatrist) reached notified off (sic) behavior new order received, then he came to nurses station & grabbed another female patient from behind at the waist. We directed him successfully away from her. Order for Benadryl 50mg/Haldol 5mg & Ativan 2mg all IM now." (sic)

Review of the policy and procedure "Seclusion and Restraint" stated, "Restraint and Seclusion are involuntary behavioral interventions. They should be used only as interventions of last resort following attempts to intervene in a less restrictive, less invasive manner. Voluntary preventative and de-escalating interventions such as clinical time out and quiet time should be attempted first when possible.

Initiating Restraint and Seclusion

1. Contact the physician immediately, or a clinically privileged nurse if a physician is not available, for initiation of restraint or seclusion in an emergency situation to prevent:

a. Imminent probable death or subsequent bodily harm to the patient because the patient overtly or continually is threatening to commit suicide or seriously bodily harm; or

b. Imminent physical or emotional harm to others because of threats, attempts of other acts the patient overtly or continually makes or commits, and preventive deescalating or verbal techniques have proven ineffective at diffusing the potential for injury. These situations may include aggressive acts by the individual, including serious incidents of shoving or grabbing others over their objections.

2. The physician or clinically privileged nurse will conduct a face to face assessment of the patient to determine whether the behavior requires restraint or seclusion, taking into account any applicable medical or psychiatric contraindications to restraint or seclusion, and may approve continuation of the procedure, if indicated.

3. Obtain a physician order."

Review of patient #4's Clinical Notes Report revealed, Staff #11 documented, "On 2/20/16 at 20:24 (8:24PM) did face to face with patient and he is resting quietly. Staff #11 did not document this information until 2/21/16 at 7:04AM, 11 hours later.

Review of the "BH Daily Assessment" dated 2/20/16 at 20:44 (8:44PM) revealed, staff #11 documented, "Requires 24hr/day medical/nursing supervision due to clinical severity. Patient is opositioning and threatening to staff and peers this shift. Staff #14 (LVN) gave patient IM cocktail of Haldol 5mg, Benadryl 50mg and Ativan 2 mg. 15 minutes later patient is resting quietly try to redirect patient before calling for prn medication. Patient slept 10.5 hours." There was no documented evidence that the RN attempted a less restrictive restraint. Review of the vital signs assessment dated [DATE] at 19:20 (7:20PM) revealed the patient's temperature as 97.8, pulse 86, respirations 20, blood pressure 104/56 *L* ( the *L* sign reveals the patient's blood pressure was low and out of normal range set for patient). There was no written evidence that the physician was contacted concerning low blood pressure. There were no further vital signs documented until 2/21/16 at 7:23AM; 12 hours later. There was no evidence found that the patient was assessed by a nurse after injections for 11 hours. There was no physician orders in the chart to administer the IM cocktail of Haldol 5mg, Benadryl 50mg and Ativan 2 mg. There was no Medication Administration Record ( MAR), or face to face in the patient's chart. Review of staff #11's personnel record revealed no evidence of face to face training or check off in employee file.

Review of patient #4's chart revealed, on 2/21/16 at 9:25AM staff #13 documented, "Behaviors, V/S reviewed with psychiatrist via telemedicine, new orders received. D/c Seraquel XR and Risperdahl (sic) 0.5mg PO at 8pm." There was no written evidence or physician progress notes found that the patient was seen in person by the physician.

"2/21/16 at 13:30 (1:30PM) attempted (sic) to get patient OOB (out of bed). Remains extremely lethargic, unable to stand, much assist to get to set up (sic), very little vergalization (sic) Puppils (sic) equal approx. 3mm. Lung sounds congested. Back to bed, bed in low position with bed alarms on.

13:58 (1:58PM) Staff #15 (MD) called notified of patient continues to sleep & difficult to arouse & last night activities requiring injection of Haldol 5mg, Benadryl 50mg & Ativan 2 mg IM, chest congested, pupils equal round, MAE, very little speaking with much stimuli. States he will see patient today." (SIC) There was no further evidence found that the physician saw the patient. There are no physician progress notes. Review of the Activities of Daily Living (ADL) sheet dated 2/21/16 revealed the patient had refused all meals and snacks. The RN documented the patient was drinking Ensure type drinks.

Review of the Intake and Output for 2/21/16 revealed the patient had only had sips of fluids. Voided urine section was blank. There was no documentation that the physician was aware.

Review of patient #4's Clinical Notes on 2/21/16 at 17:05 (5:05PM) revealed, staff #16 documented, "Pt too sleepy to take PO meds. Pt. lying in bed and difficult to arouse. Incontinent episode." There was no documentation that the physician or RN was notified of the patient's lethargy or difficulty to arouse. There was no vital signs or further documentation found.

The next nursing entry was at 2/22/16 at 1:34 AM, 8.5 hours later, which Staff #14 documented, "Pt agitated, gait unsteady, combative to staff, Lorazepam 1mg = 0.5 ml, IM, Stat, administered in left arm with pt's "consent." Review of nursing documentation revealed this patient was confused.

Review of the Mental Health Technician notes for 2/22/16 revealed, the patient was up at the nurse's station agitated and preoccupied from 1:15AM until 2:00AM. At 2:30AM LVN documented, "pt. lying in bed softly snoring, Appears Ativan effective." There were no physician orders in chart for Ativan. There were no physician progress notes or MAR.

Review of patient #4's chart revealed, on 2/22/16 at 8:01PM staff #14 documented, "pt. swinging trying to hit staff. RN called Dr., got n/o for cocktail. Halidol (sic) 5mg, Benadryl 50mg, and Ativan 1 mg, IM stat, administered in left arm with pt.'s consent for aggression and agitation. Pt said thank you afterwards. V/s before cocktail B/P 117/64, HR 106, RR 18, Temp 98.4, and O2 sat 96%. 1 hour eval after Ativan B/P 114/63, HR 71, RR18, Temp 97.9, O2 sat 94%."

Staff #17 documented, "patient became increasingly agitated and aggressive AEB swinging at and hitting staff. Attempts to redirect and reduce stimuli by removing from day area were unsuccessful as patient continued to hit staff and grab other patients. Nurse phoned staff #12 (psychiatrist) regarding behavior and an order was received to administer Haldol 5mg, Benadryl 50mg, and Ativan 1mg IM now. Order was placed in computer and medication administered without difficulty. Will monitor patient's status closely and remain available to assist with any needs." There was no physician orders, physician progress notes, or MAR in the patients chart. There was no face to face or follow up of the patient's condition.


Review of the vital sign sheet revealed, on 2/24/16 at 8:02AM patient #4's temp. 96.2, pulse 94, B/P 91/64 while in sitting position. The B/P was taken again and was 87/61, respirations 16 and O2 pulse Ox 93%. There was no further nursing documentation on the patient's status or if physician was called for elevated pulse, low blood pressure and low oxygen saturation.

Review of the clinical notes revealed within 49 hours patient #4 had been administered a total of 10mg of Haldol, 100mg of Benadryl, and 3 mgs of Ativan. There were no physician orders or MAR in chart to support the admnistration of the medications documented in the nursing notes.

Review of the Physical Therapist note dated 2/24/16 at 1:35PM stated, "PT went into patient room with nursing staff to see patient, patient unresponsive and not responding to sternal rub. Pt able to say "ya" when asked if he was ok but not looking at staff. Pt supine BP 109/73. Nursing staff left to tend to pt." There was no nursing documentation found for the assessment of the patient's condition, notification of the physician of patient's conditioned, or continued monitoring of patient's condition.

Review of the nursing treatment plan revealed there was no documentation of chemical restraints as an intervention on the treatment plan.


Review of patient #6's chart revealed the patient was a [AGE] year old female admitted on [DATE] at 1:38AM. Patient #6 was admitted voluntarily with Schizoaffective Disorder.

Review of patient #6's Clinical Nurses Notes dated 12/30/15 at 10:08AM revealed, staff #17 documented, "Upon arrival to unit this am, patient appeared extremely agitated as she called staff "bitches" while yelling and screaming as she continued to curse. When a tech attempted to offer her assistance with pericare, patient balled her fist and hit the tech on the right side of her jaw. Afterwards, the patient continued to yell and scream while verbally threatening to hit other staff members. Staff was unsuccessful in redirecting patient as she remained argumentative, oppositional and belligerent. Nurse phoned (Dr. _____) to discuss behavior and an order was received to give Geodon and Ativan to help with the agitation and psychosis. Medication was administered as IM. Will monitor behavior closely and will assist with any needs."

Review of the physician orders dated 12/30/15 at 7:59AM, "Geodon 20mg IM one time for 1 days, Give 20mg IM one time only stat." 12/30/15 at 8:00AM Ativan 2mg intermuscular one time for one days, give 2mg IM one time only stat." Review of the Violent/Self-Destructive Seclusion/Restraint Face to Face Evaluation Note (Face to Face) dated 12/30/15 at 9:00AM revealed the type of intervention was for a physical hold. There was no mention of the chemical restraint. There were no further interventions documented except for "redirecting" before administering a chemical restraint. Chemical restraints were not addressed in the treatment plan.

Review of patient #6's Clinical Nurses Notes dated 1/1/16 at 8:00PM revealed, staff #19 documented patient (#6) "has been talking loud non-stop during this shift about staff and other pt. causing them to become irritated. Several pt. have begans (sic) to complaint stating they cannot get any sleep and what are we going to do about it. Patient (#6) disruptive behaviors escalates to foul language when pt began to complain about her loud talking. She is closely monitored she has a history of violent behavior toward others. Attempted to redirect patient (#6) several times asking her to reduce the volume of her voice. She stated I can talk if I want to what are you going to do about it give me a shot, fine give me one I don't care it's not going to do anything. MD (Staff #12) was notified of the escalating behavior and ordered Haldol 10mg, benadryl 50mg, and Ativan 2mg to be given IM. Pt Allergy noted to Haldol order has been discontinued to prevent a life threatening allergic reaction. Patient (#6) continues to refuse all of her medication. MD was notified regarding medication refusal and noted allergy he ordered Geodon 20mg IM instead of Haldol." (sic)

Review of the physician orders dated 1/1/16 at 8:35PM,"Geodon 20mg Intramuscular one time for 1 days. Ativan 2mg intermuscular one time for one doses, Benadryl 50mg Intramuscular one time for 1 doses." There was no diagnosis or reason in the physician order for one time medication." There was no face to face evaluation noted in chart. There was no further interventions documented except for "redirecting" before administering a chemical restraint. Chemical restraints were not addressed in the treatment plan.

Review of the education files for the RN's on the geri-psych unit revealed the RN's did not have competencies for performing the restraint/seclusion face to face. Staff #3 confirmed they did not have competencies to perform the face to face.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on chart reviews and schedules Nursing failed to:


A. 1.) assess and evaluate the patient after the administration of a chemical restraint on an ongoing basis,

2.) assess, evaluate and report a patient's change in condition, and

3.) documenting the patient's response to interventions in 1 (4) of 3 (4, 5, and 6) charts reviewed.


Refer to Tag A0395


B.) develop nursing interventions, goals, ongoing assessments, response to interventions, and updates to the nursing care plans in 3 (7, 6, and 4) of 3 charts reviewed.


Refer to Tag A0396
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on chart review, nursing failed to:

1.) Assess and evaluate the patient after the administration of a chemical restraint on an ongoing basis.

2.) Assess, evaluate and report a patient's change in condition.

3.) Documenting the patient's response to interventions in 1(4) of 3 (4, 5, and 6) charts reviewed.

Review of patient #4's chart revealed, the patient was an [AGE] year old male, admitted on [DATE] at 17:34 (5:34PM), as a voluntary patient. Patient #4 was admitted with a diagnosis of Dementia with acute confusion and delirium. Review of the physician consult dated 2/17/16 revealed the patient was oriented to person, not to place or time.

Review of the "Clinical Notes Report" dated 2/20/16 18:35 (6:35PM) revealed, staff #13 documented,"CNA reported that patient agitated. I went to room & he was in his underwear pushing a chair into the hallway, almost falling down, stating lets go. Attempted to redirect him & was able to get his pants on. He was throwing blanket on me, tried to put pillow on instead of his pants. 2/20/16 19:01(7:01PM) Staff #12 (psychiatrist) reached notified off (sic) behavior new order received, then he came to nurses station & grabbed another female patient from behind at the waist. We directed him successfully away from her. Order for Benadryl 50mg/Haldol 5mg & Ativan 2mg all IM now." (sic)

Review of patient #4's Clinical Notes Report revealed, Staff #11 documented, "On 2/20/16 at 20:24 (8:24PM) did face to face with patient and he is resting quietly." Staff #11 did not document this information until 2/21/16 at 7:04AM, 11 hours later. Review of the "BH Daily Assessment" dated 2/20/16 at 20:44 (8:44PM) revealed staff #11 documented, "Requires 24hr/day medical/nursing supervision due to clinical severity. Patient is opositioning and threatening to staff and peers this shift. Staff #14 (LVN) gave patient IM cocktail of Haldol 5mg, Benadryl 50mg and Ativan 2 mg. 15 minutes later patient is resting quietly try to redirect patient before calling for prn medication. Patient slept 10.5 hours." There was no documented evidence that the RN attempted a less restrictive restraint. Review of the vital signs assessment dated [DATE] at 19:20 (7:20PM) revealed the patient's temperature as 97.8, pulse 86, respirations 20, blood pressure 104/56 *L* (the *L* sign reveals the patient's blood pressure was low and out of normal range set for patient). There was no written evidence that the physician was contacted concerning low blood pressure. There were no further vital signs documented until 2/21/16 at 7:23AM, 12 hours later. There was no evidence found that the patient was assessed by a nurse after injections for 11 hours. There was no physician orders in the chart to administer the IM cocktail of Haldol 5mg, Benadryl 50mg and Ativan 2 mg. There was no Medication Administration Record (MAR), or face to face in the patient's chart. Review of staff #11's chart revealed no evidence of face to face training or check off in employee file.

Review of patient #4's chart revealed, on 2/21/16 at 9:25AM staff #13 documented, "Behaviors, V/S reviewed with psychiatrist via telemedicine, new orders received. D/c Seraquel XR and Risperdahl (sic) 0.5mg PO at 8pm." There was no written evidence or physician progress notes found that the patient was seen in person by the physician.

* "2/21/16 at 13:30 (1:30PM) attempted (sic) to get patient OOB (out of bed). Remains extremely lethargic, unable to stand, much assist to get to set up (sic), very little vergalization (sic) Puppils (sic) equal approx. 3mm. Lung sounds congested. Back to bed, bed in low position with bed alarms on.

* 13:58 (1:58PM) Staff #15 (MD) called notified of patient continues to sleep & difficult to arouse & last night activities requiring injection of Haldol 5mg, Benadryl 50mg & Ativan 2 mg IM, chest congested, pupils equal round, MAE, very little speaking with much stimuli. States he will see patient today." (SIC) There was no further evidence found that the physician saw the patient. There were no physician progress notes. Review of the Activities of Daily Living (ADL) sheet dated 2/21/16 revealed the patient had refused all meals and snacks. The RN documented the patient was drinking Ensure type drinks. Review of the Intake and Output for 2/21/16 revealed the patient had only had sips of fluids. Voided urine section was blank. There was no documentation that the physician was aware.

Review of patient #4's Clinical Notes on 2/21/16 at 17:05 (5:05PM) revealed staff #16 documented, "Pt too sleepy to take PO meds. Pt. lying in bed and difficult to arouse. Incontinent episode." There was no documentation that the physician or RN was notified of the patient's lethargy or difficulty to arouse. There were no vital signs or further documentation found. The next nursing entry was at 2/22/16 at 1:34 AM, 8.5 hours later. Staff #14 documented, "Pt agitated, gait unsteady, combative to staff, Lorazepam 1mg = 0.5 ml, IM, Stat, administered in left arm with pt.'s consent." Review of nursing documentation revealed this patient was confused. A confused patient is unable to give consent for psychotropic medications or medications used to restrain the patient's behavior.

Review of the Mental Health Technician notes for 2/22/16 revealed the patient was up at the nurse's station agitated and preoccupied from 1:15AM until 2:00AM. At 2:30AM LVN documented, "pt. lying in bed softly snoring, Appears Ativan effective." There were no physician orders in chart for Ativan. There was no physician progress notes or MAR.

Review of patient #4's chart revealed, on 2/22/16 at 8:01PM staff #14 documented, "pt. swinging trying to hit staff. RN called Dr., got n/o for cocktail. Halidol (sic) 5mg, Benadryl 50mg, and Ativan 1 mg, IM stat, administered in left arm with pt.'s consent for aggression and agitation. Pt said thank you afterwards. V/s before cocktail B/P 117/64, HR 106, RR 18, Temp 98.4, and O2 sat 96%. 1 hour eval after Ativan B/P 114/63, HR 71, RR18, Temp 97.9, O2 sat 94%."

* Staff #17 documented, "patient became increasingly agitated and aggressive AEB swinging at and hitting staff. Attempts to redirect and reduce stimuli by removing from day area were unsuccessful as patient continued to hit staff and grab other patients. Nurse phoned staff #12 (psychiatrist) regarding behavior and an order was received to administer Haldol 5mg, Benadryl 50mg, and Ativan 1mg IM now. Order was placed in computer and medication administered without difficulty. Will monitor patient's status closely and remain available to assist with any needs." There was no documentation of the nurse attempting a 1:1 or seclusion before administering a chemical restraint. There were no physician orders, physician progress notes, or MAR in the patient's chart. There was no face to face or follow up of the patient's condition.

Review of the vital sign sheet revealed, on 2/24/16 at 8:02AM patient #4's temp. 96.2, pulse 94, B/P 91/64 while in sitting position. The B/P was taken again and was 87/61, respirations 16 and O2 pulse Ox 93%. There was no further nursing documentation on the patient status or if physician was called for elevated pulse, low blood pressure and low oxygen saturation.

Review of the Physical Therapist note dated 2/24/16 at 1:35PM stated, "PT went into patient room with nursing staff to see patient, patient unresponsive and not responding to sternal rub. Pt able to say "ya" when asked if he was ok but not looking at staff. Pt supine BP 109/73. Nursing staff left to tend to pt." There was no nursing documentation found of the patient's condition or transfer. There was no physician orders or physician discharge summary.

Review of patient #4's ADL's revealed, from 2/21/16 thru 2/24/16 the patient had refused 8 out of 10 meals in this time span. The two meals he consumed were on 2/22/16- breakfast and lunch 25-50%. There was no documentation if the patient was offered supplements. The Intake and output sheet revealed he had only sips of water, 22nd 456 ml, and 23rd 375ml, nothing documented on the 24th. There were no bowel movements documented from 2/18/16 to 2/24/16.

Review of the nursing treatment plan had no information documented on chemical restraints, refusal of meals, congested lungs, bowel movements, PT, OT, or unstable vital signs.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on chart reviews, Nursing failed to develop nursing interventions, goals, ongoing assessments, response to interventions, and updates to the nursing care plans in 3 (7, 6, and 4) of 3 charts reviewed.

1.) Review of patient #7's chart revealed, the patient was in the facility for medical issues to be resolved or stabilized before admission to the psychiatric unit. Patient #7 was diagnosed with the following issues:

a.) Urinary Tract Infection (UTI) placed on antibiotics.

b.) Hyponatremia and placed on fluid restriction.

c.) Candidiasis (thrush) in the mouth and placed on Diflucan po every day for 2 weeks on 2/27/16. There was no nursing care plan found concerning patient #7's active infections or fluid restrictions.

d.) Review of patient #7's chart revealed, the patient was admitted on [DATE] with a diagnosis of psychosis NOS and Alzheimer's. Review of the "Clinical Notes Report" on 2/28/16 at 19:55 (7:55PM) revealed staff #10 documented, "Patient loud and calling techs bitches and trying to hit them. Instructed she can not (SIC) act that way or talk that way to the staff she continues to curse. Staff #11 called and received and (SIC) order to give patient zyprexa zydis one time now. 2/28/16 20:30 (8:30PM) Patient took medication with no problem."

Review of patient #7's chart revealed, there was a physician's telephone order found for the administration of Zyprexa Zydis (an atypical antipsychotic) on 2/28/16. The order was not signed by a physician. The order was not stated as a written or verbal order. There was no documentation of the order read back or verified. Review of patient #7's Medication Administration Record (MAR) revealed no record of Zyprexa Zydis ordered or given. There was no psychoactive medication consent found. Review of the treatment plan revealed no information found of patient #7's behaviors or administration of Zyprexa Zydia.

Review of patient #6's chart revealed, the patient was a [AGE] year old female, admitted on [DATE] at 1:38AM. Patient #6 was admitted voluntarily with Schizoaffective Disorder.

Review of patient #6's Clinical Nurses Notes dated 12/30/15 at 10:08AM revealed, staff #17 documented, "Upon arrival to unit this am, patient appeared extremely agitated as she called staff "bitches" while yelling and screaming as she continued to curse. When a tech attempted to offer her assistance with pericare, patient balled her fist and hit the tech on the right side of her jaw. Afterwards, the patient continued to yell and scream while verbally threatening to hit other staff members. Staff was unsuccessful in redirecting patient as she remained argumentative, oppositional and belligerent. Nurse phoned (physician) Staff #12 to discuss behavior and an order was received to give Geodon and Ativan to help with the agitation and psychosis. Medication was administered as IM. Will monitor behavior closely and will assist with any needs."

Review of the physician orders dated 12/30/15 at 7:59AM, "Geodon 20mg IM one time for 1 days, Give 20mg IM one time only stat." 12/30/15 at 8:00AM Ativan 2mg intramuscularly one time for one days, give 2mg IM one time only stat." Review of the Violent/Self-Destructive Seclusion/Restraint Face to Face Evaluation Note (Face to Face) dated 12/30/15 at 9:00AM revealed the type of intervention was for a physical hold. There was no mention of the chemical restraint. There were no further interventions documented except for "redirecting" before administering a chemical restraint. Patient #6 was on 15 minute checks by staff but was not put on a 1:1 or put in seclusion before administering chemical restraints. Chemical restraints were not addressed in the treatment plan.

Review of patient #6's Clinical Nurses Notes dated 1/1/16 at 8:00PM revealed, staff #19 documented patient #6 has been talking loud non-stop during this shift about staff and other pt. causing them to become irritated. Several pt. have begans (sic) to complaint stating they cannot get any sleep and what are we going to do about it. Patient #6 disruptive behaviors escalates to foul language when pt began to complain about her loud talking. She is closely monitored she has a history of violent behavior toward others. Attempted to redirect patient #6 several times asking her to reduce the volume of her voice. She stated I can talk if I want to what are you going to do about it give me a shot, fine give me one I don't care it's not going to do anything. Staff #12 (MD) was notified of the escalating behavior and ordered Haldol 10mg, benadryl 50mg, and Ativan 2mg to be given IM. Pt Allergy noted to Haldol order has been discontinued to prevent a life threatening allergic reaction. Patient #6 continues to refuse all of her medication Staff #12 was notified regarding medication refusal and noted allergy he ordered Geodon 20mg IM instead of Haldol." (sic)

Review of the physician orders dated 1/1/16 at 8:35PM, "Geodon 20mg Intramuscular one time for 1 days. Ativan 2mg intramuscular one time for one doses, Benadryl 50mg Intramuscular one time for 1 doses." There was no diagnosis or reason in the physician order for one time medication." There was no face to face noted in chart. There was no further interventions documented except for "redirecting" before administering a chemical restraint. Patient #6 was on 15 minute checks by staff but was not put on a 1:1 or put in seclusion before administering chemical restraints. Chemical restraints were not addressed in the treatment plan.

Review of patient #6's clinical notes dated 1/23/16 at 3:15PM revealed, staff #16 documented, "Performed in-and-out catheter on pt to collect clean catch urine sample. Urine sample was cloudy pt voided approx.. 500cc, vaginal discharge noted." Staff #13 documented Dr. called re urinalysis, order for Levaquin 500mg po daily x 7 days received." Patient #6's diagnosis nor antibiotics were addressed in the treatment plan.

Review of patient #4's chart revealed, the patient was an [AGE] year old male admitted on [DATE] at 17:34 (5:34PM), as a voluntary patient. Patient #4 was admitted with a diagnosis of Dementia with acute confusion and delirium. Review of the physician consult dated 2/17/16 revealed the patient was oriented to person, not to place or time.

Review of the "Clinical Notes Report" dated 2/20/16 18:35 (6:35PM) revealed, staff #13 documented, "CNA reported that patient agitated. I went to room & he was in his underwear pushing a chair into the hallway, almost falling down, stating lets go. Attempted to redirect him & was able to get his pants on. He was throwing blanket on me, tried to put pillow on instead of his pants. 2/20/16 19:01(7:01PM) Staff #12 (psychiatrist) reached notified off (sic) behavior new order received, then he came to nurses station & grabbed another female patient from behind at the waist. We directed him successfully away from her. Order for Benadryl 50mg/Haldol 5mg & Ativan 2mg all IM now." (sic)

Review of patient #4's Clinical Notes Report revealed, Staff #11 documented, "On 2/20/16 at 20:24 (8:24PM) did face to face with patient and he is resting quietly. Staff #11 did not document this information until 2/21/16 at 7:04AM, 11 hours later.

Review of the "BH Daily Assessment" dated 2/20/16 at 20:44 (8:44PM) revealed, staff #11 documented, "Requires 24hr/day medical/nursing supervision due to clinical severity. Patient is opositioning and threatening to staff and peers this shift. Staff #14 (LVN) gave patient IM cocktail of Haldol 5mg, Benadryl 50mg and Ativan 2 mg. 15 minutes later patient is resting quietly try to redirect patient before calling for prn medication. Patient slept 10.5 hours." There was no documented evidence that the RN attempted a less restrictive restraint. Review of the vital signs assessment dated [DATE] at 19:20 (7:20PM) revealed the patient's temperature as 97.8, pulse 86, respirations 20, blood pressure 104/56 *L* ( the *L* sign reveals the patient's blood pressure was low and out of normal range set for patient). There was no written evidence that the physician was contacted concerning low blood pressure. There were no further vital signs documented until 2/21/16 at 7:23A, 12 hours later. There was no evidence found that the patient was assessed by a nurse after injections for 11 hours. There was no physician orders in the chart to administer the IM cocktail of Haldol 5mg, Benadryl 50mg and Ativan 2 mg. There was no Medication Administration Record ( MAR), or face to face in the patients chart. Review of staff #11's chart revealed no evidence of face to face training or check off in employee file.

Review of patient #4's chart revealed, on 2/21/16 at 9:25AM staff #13 documented, "Behaviors, V/S reviewed with psychiatrist via telemedicine, new orders received. D/c Seraquel XR and Risperdahl (sic) 0.5mg PO at 8pm." There was no written evidence or physician progress notes found that the patient was seen in person by the physician.

"2/21/16 at 13:30 (1:30PM) attempted (sic) to get patient OOB (out of bed). Remains extremely lethargic, unable to stand, much assist to get to set up (sic), very little vergalization (sic) Puppils (sic) equal approx. 3mm. Lung sounds congested. Back to bed, bed in low position with bed alarms on.

13:58 (1:58PM) Staff #15 (MD) called notified of patient continues to sleep & difficult to arouse & last night activities requiring injection of Haldol 5mg, Benadryl 50mg & Ativan 2 mg IM, chest congested, pupils equal round, MAE, very little speaking with much stimuli. States he will see patient today." (SIC) There was no further evidence found that the physician saw the patient. There are no physician progress notes. Review of the Activities of Daily Living (ADL) sheet dated 2/21/16 revealed the patient had refused all meals and snacks. The RN documented the patient was drinking Ensure type drinks.

Review of the Intake and Output for 2/21/16 revealed the patient had only had sips of fluids. Voided urine section was blank. There was no documentation that the physician was aware.

Review of patient #4's Clinical Notes on 2/21/16 at 17:05 (5:05PM) revealed, staff #16 documented, "Pt too sleepy to take PO meds. Pt. lying in bed and difficult to arouse. Incontinent episode." There was no documentation that the physician or RN was notified of the patient's lethargy or difficulty to arouse. There were no vital signs or further documentation found. The next nursing entry was at 2/22/16 at 1:34 AM, 8.5 hours later.

Staff #14 documented, "Pt agitated, gait unsteady, combative to staff, Lorazepam 1mg = 0.5 ml, IM, Stat, administered in left arm with pt.'s consent." Review of nursing documentation revealed this patient was confused. A confused patient is unable to give consent for psychotropic medications or medications used to restrain the patient's behavior.

Review of the Mental Health Technician notes for 2/22/16 revealed, the patient was up at the nurse's station agitated and preoccupied from 1:15AM until 2:00AM. At 2:30AM LVN documented, "pt. lying in bed softly snoring, Appears Ativan effective." There were no physician orders in chart for Ativan. There was no physician progress notes or MAR.

Review of patient #4's chart revealed, on 2/22/16 at 8:01PM staff #14 documented, "pt. swinging trying to hit staff. RN called Dr., got n/o for cocktail. Halidol (sic) 5mg, Benadryl 50mg, and Ativan 1 mg, IM stat, administered in left arm with pt.'s consent for aggression and agitation. Pt said thank you afterwards. V/s before cocktail B/P 117/64, HR 106, RR 18, Temp 98.4, and O2 sat 96%. 1 hour eval after Ativan B/P 114/63, HR 71, RR18, Temp 97.9, O2 sat 94%."

Staff #17 documented, "patient became increasingly agitated and aggressive AEB swinging at and hitting staff. Attempts to redirect and reduce stimuli by removing from day area were unsuccessful as patient continued to hit staff and grab other patients. Nurse phoned staff #12 (psychiatrist) regarding behavior and an order was received to administer Haldol 5mg, Benadryl 50mg, and Ativan 1mg IM now. Order was placed in computer and medication administered without difficulty. Will monitor patient's status closely and remain available to assist with any needs." There was no documentation of the nurse attempting a 1:1 or seclusion before administering a chemical restraint. There were no physician orders, physician progress notes, or MAR in the patient's chart. There was no face to face or follow up of the patient's condition.


Review of the vital sign sheet revealed, on 2/24/16 at 8:02AM patient #4's temp. 96.2, pulse 94, B/P 91/64 while in sitting position. The B/P was taken again and was 87/61, respirations 16 and O2 pulse Ox 93%. There was no further nursing documentation on the patient's status or if physician was called for elevated pulse, low blood pressure and low oxygen saturation.

Review of the clinical notes revealed, within 49 hours patient #4 had been administered a total of 10mg of Haldol, 100mg of Benadryl, and 3 mgs of Ativan. There were no physician orders or MAR in chart to reveal what other psychotropic medications the patient had been given along with these documented medications.

Review of the Physical Therapist note dated 2/24/16 at 1:35PM stated, "PT went into patient room with nursing staff to see patient, patient unresponsive and not responding to sternal rub. Pt able to say "ya" when asked if he was ok but not looking at staff. Pt supine BP 109/73. Nursing staff left to tend to pt." There was no nursing documentation found of the patient's condition or transfer. There were no physician orders or physician discharge summary.

Review of the nursing treatment plan had no information documented on chemical restraints.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
Based on chart reviews the facility failed to ensure:


ensure physician's orders were written, signed, dated, and authenticated in 4 of 4 (#2, 4, 6, and 7) charts reviewed.

Refer to tag A0454