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.

SEARCY HOSPITAL (ACUTE CARE ADMISS UNIT) 725 EAST COY SMITH HIGHWAY MOUNT VERNON, AL July 13, 2012
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, policy and procedures and interviews it was determined the facility failed to ensure client care was provided in a safe environment, failed to ensure the client's emotional health and failed to protect a vulnerable client from potential physical abuse. This had the potential to affect all clients served by this psychiatric hospital and did affect Medical Record (MR) # 1.

Facility Policy:
Procedures Manual No. 7050-134
Subject: Observation

Procedure:
1. Mental Health Workers (MHW) duties on one-to-one and Continuos Observation
A. Assignment of mental Health Worker to client on one-to-one Continuous Observation Status will be made at the beginning of the shift by the Charge MHW/supervisor.
B. At the beginning of the assignment thoroughly search clients for possession of any potentially harmful items, remove any found... A skin assessment will also be conducted at each shift change by the on-coming and off-going MHW's together. The findings of the search and skin assessment will be documented in the comment section of the MHW flowsheet.
C. Never leave the client unattended under any circumstances. The assigned employee should not take a break or leave the client until relieved by another employee. The relief staff member is responsible for documentation etc. while in attendance to the client.
D. Notify the Registered Nurse (RN)/ Licensed Practical Nurse (LPN) immediately of any changes in the client's condition. The RN/LPN can notify the physician.


Procedures Manual No. 7050-140.1
Subject: Nursing Assessment- Admission

Procedure:
12. Skin Assessment
a. Complete skin assessment using anatomical drawings.
b. Describe all items noted on drawing.
c. Assess for any possible signs indicators of physical abuse.
d. If " yes", contact Security and document identified signs.

Procedures Manual No. 7050-140.2
Subject: Nursing Assessment- Transfer/Annual

Procedure:
11. Skin Assessment
a. Complete skin assessment using anatomical drawings.
b. Describe all items noted on drawing.
c. Any possible signs/indicators of physical abuse?
If " yes", contact Security and document identified signs.


Number: 430-30
Subject: Special Treatment Procedures
Title: Use of One to One in MI (mental illness) Facilities

I. Policy:
Patients of the Alabama Department of mental Health psychiatric facilities have the right to freedom of movement within the least restrictive environment. Patients may be placed on a one to one observation status only when:
a. necessary to prevent the patient from physically harming or causing harm to come to self or others,
b. after less restrictive alternative measures have been unsuccessful or are determined not to be feasible,
c. when authorized by a qualified physician, psychologist or registered nurse.

II. Definitions:

1. One to One Status: The patient is accompanied and observed at all times by an assigned staff member who remains within arms length or as otherwise specified by Physician's order.

III. Standards:

5. Staff assigned to monitor patients shall document observations every fifteen minutes. Registered nurses shall document on the condition of the patient every shift. A qualified physician/licensed psychologist shall assess the patient and document the need for continued one to one observations daily.

Number:430-30
Subject: MI (Mental Illness) Services- Psychiatric Services
Title: Searcy Hospital Supplement to 430-30 Use of One to One in MI Facilities

I. Policy

1. One to One Observation and Continuous Observation are to be used in conjunction with intensive treatment and frequent evaluation by the service team aimed at rapid stabilization and restoration of functioning of the client.

II. Definitions

1. One to One Observation: Defined in DMH (Department of Mental Health)/MR (Mental Retardation) Policy 430-30

2. Continuous Observation: The client is observed at all times by a staff member. The staff member can only be assigned two clients at a time.

III. Procedure

6. A qualified physician shall assess the client and document the need for continued observation status daily.

7. For clients who remain on an observation status for 7 days, a service team review will be held. The service plan will be modified to reflect the problems necessitating the observation status and to document plans to implement active treatment of those problems. The modified service plan is to include, on Part C, specific instructions and strategies developed by the service team to implement in managing the problems necessitating the observation status.

8. The service team shall review the service plan at 7 day intervals for the duration of the time the client remains on observation status. The review is to be documented in a service team note and will include documentation of the efficacy of and any needed changes to the client's general treatment and schedule interventions. The rationale for continuing or discontinuing observation status will also be documented in the service team note.



Medical Record findings include:

1. MR # 1 was admitted by court order 12/19/08 with an Axis I diagnosis of [DIAGNOSES REDACTED]


A review of the medical record revealed, the following information related to the client's behaviors and mental illness recorded by the nursing staff and mental health workers who provided care to the client on a regular basis.

The nurses progress note dated 1/4/12 at 3:55 PM documented that the client requested medication for agitation, Thorazine 50 mg (milligrams) administered IM (intramuscularly).

On 1/5/12 the client approached the nurses station at 9:00 AM, yelling that, " Jesus Christ is telling me that my heart is enlarged..." Thorazine 50 mg IM administered.

On 1/14/12 at 5:50 AM, the client stated that he was hearing voices and feeling agitated and requested a PRN ( as needed) medication. Thorazine 50 mg administered IM.

On 1/14/12 at 11:30 AM the client requested a PRN for, " feeling depressed". Thorazine 50 mg IM administered.

On 1/16/12 at 4:30 AM the nurse documented, " Client repeatedly coming to the nurses station demanding a shot. Client stated, " I'm agitated." Client refused to use other methods to control his behavior... Thorazine 50 mg IM..."

On 1/30/12 at 8:05 AM, the client had an altercation with another client on the same floor, received a bite to his wrist.

On 1/30/12 at 2:45 PM, the client came to the nurses station and asked for a PRN, client noted to be anxious by the nurse, Thorazine 50 mg by mouth administered.

The mental health workers documented daily during the month of January that the client was monitored for aggressive and self injurious behavior and that he alternated between calm and agitation.

On 2/2/12 at 9:50 AM, the client requested a PRN for feelings of restlessness and feeling anxious. Thorazine 50 mg by mouth was administered by the nurse.

On 2/5/12 at 9:35 PM, the client attacked another client for unknown reason. The physician and nurse were notified.

On 2/5/12 at 9:45 PM, the client was given a PRN for his aggressiveness toward other clients, Thorazine 50 mg IM.

On 2/10/12 at 2:00 AM client requested a pill for nervous anxiety. Thorazine 50 mg by mouth administered by the nurse.

On 2/10/12 at 6:30 AM, the client attacked another client in the day area. Client immediately calm after staff intervention and agreed to avoid close contact with other client.

On 2/28/12 at 6:30 AM, client began yelling at another client and then hit client in the facial area times 1 with his fist. Staff separated, client unable to state reason he had hit the other client. Thorazine 50 mg IM administered.

On 2/29/12 at 6:35 AM, client walking around day area cursing and yelling...The nurse tried to redirect to no avail. Thorazine 50 mg IM administered by the nurse.

The mental health workers documented daily during the month of February that the client was monitored for aggressive and self injurious behavior and that he remained calm according to the documentation on the Mental Health Worker documentation record/ flow sheet.

On 3/1/12 the nurses progress note documented at 6:40 AM, " Received Thorazine 50 mg IM for agitation."

On 3/3/12 at 8:15 PM, client was yelling and cursing in the day area and attacked another client striking him with hands and fists from behind. Thorazine 50 mg IM administered.

On 3/3/12 at 8:45 PM, client entered another client's room to use the bathroom and attacked the client. Escorted to nurses station, physician notified and client placed on CBO (continuous behavioral observation).

The mental health worker documented on the second shift for 3/3/12, " Client searched no bruises scratches or contraband found and was monitored for hostile behavior."

CBO cancelled 3/6/12.

On 3/24/12 at 7:45 PM, the nurse received a phone call from the client's aunt who related concerns saying she had just spoke with the client and he was very depressed and crying...the nurse visited the client in his room and he stated that he missed his family and he was hearing voices but denied wanting to harm himself or others. The nurse offered a PRN and it was accepted,Thorazine 50 mg IM administered for anxiety.

The mental health worker documented on 3/4/12, 3/5/12, and 3/6/12 for first and second shift client searched for contraband and skin for bruises nothing found except on 3/6/12 first shift documented, " no new findings."

The mental health worker documented the week of 3/7/12 through 3/13/12 monitored for hostile behavior with no mention of searching the patient or examining the skin for bruises or scratches.

The mental health worker documented the week of 3/14/12 through 3/20/12 monitored for hostile/ aggressive behavior with no mention of searching the patient or examining the skin for bruises or scratches.

The mental health worker documented the week of 3/21/12 through 3/27/12 monitored for hostile behavior with no mention of searching the patient or examining the skin for bruises or scratches.

On 4/2/12 at 3:50 PM, the client, MR # 1, was found in another client's room with both of his hands on the other client's neck ramming his head into the wall...

On 4/2/12 at 8:50 PM, Thorazine 50 mg IM for continued agitation from prior incident.

On 4/3/12 at 8:25 AM, client placed on CBO for 7 days.

On 4/3/12 at 2:30 PM, client was in the day area yelling and cussing... tried to punch another client.

On 4/3/12 at 2:35 PM, PRN of Thorazine 50 mg IM administered after trying to punch another client. Client remains on CBO.

The mental health worker documented on 4/3/12 for first shift, client searched no new cuts, bruises or contraband was found.

On 4/4/12 at 9:30 PM, client requested PRN for anxiety, Thorazine 50 mg by mouth administered by the nurse. Client remains on CBO status.

The mental health worker (MHW) documented on 4/4/12 for first and second shift, client searched no cuts, bruises or contraband was found.

On 4/6/12 at 2:00 AM, client pacing requested PRN, " Given Thorazine for complaint of agitation." Remains on CBO, MHW in attendance.

On 4/6/12 at 9:25 AM, client in day area making threats toward another client... unwilling to calm down PRN Thorazine 25 mg by mouth administered. Client remains on CBO.

The mental health worker (MHW) documented on 4/6/12 for first shift skin assessment performed no new findings.

On 4/7/12 at 6:03 AM, the MHW documented,"Client jumped on another client for no reason at all he hit him on the head and put small cut on his head. "

On 4/7/12 at 6:05 AM, the nurse documented, " Client continues to be agitated and made threats to hit staff, client refused to use other methods to control his behavior... Thorazine 50 mg IM... client was examined for injuries none found."

The MHW documented on 4/7/12 for second shift, client searched no cuts, bruises or contraband was found.

On 4/8/12 at 3:50 PM, client sitting in day area noted to have pressured speech, called client to nurses station to ask what was wrong. Client reported, " Am just agitated." Asked client did he need a PRN. Client replied, " Yes, I need a shot." Thorazine 50 mg IM administered.

On 4/8/12 at 8:15 PM, " Client continues to curse and threaten to spit on MHW. Client refused to use other methods to control his behavior... Thorazine 50 mg IM given..." Client remains on CBO.

The MHW documented on 4/8/12 for second shift, client monitored for aggressive behavior, no contraband cuts or new marks found on him.

On 4/12/12 at 6:30 PM client called the National Suicide Hotline in Connecticut. The nurse was notified and called the client to the nurses station and asked if he made the call. Client replied, " Yes, I called because I kept hearing voiced that are telling me that I have a bag and it's driving me crazy." The nurse explained to the client to let staff know when he's hearing voices and request a PRN... Thorazine 50 mg by mouth administered. Remains on CBO status.

The MHW documented on 4/12/12 for second shift, " Client searched for contraband with no findings, no cut or new marks on him."

On 4/19/12 at 12:30 AM, " Client anxious, continues to drink water and continuous prompts needed." Thorazine 50 mg by mouth administered PRN.

On 4/19/12 at 11:20 PM, " Client agitated... verbalized hopeless and helpless feelings was reassured of staff awareness to his situation." Thorazine 50 mg IM administered PRN.

The mental health worker documented the week of 4/18/12 through 4/21/12 monitored for aggressive and self injurious behavior. There was no mention of skin assessment being completed between shifts.

The MHW documented on 4/30/12 for first and second shift, " Client searched for contraband with no findings, no cut or marks on him."

The client remained on CBO status throughout April.

On 5/5/12 at 1:15 AM the client was standing at the nurses station stating, " I can't sleep, I feel agitated, can't I have a shot." The client refused to use other methods to control his behavior ( lying in bed and counting sheep to try to sleep or talking with staff). Thorazine 50 mg IM, PRN administered.
Client remains on CBO.

The MHW documented on 5/5/12 for first shift, " Client searched for contraband, skin assessment completed nothing found."

The MHW documented on 5/5/12 for second shift, " Client was searched no problems."

On 5/6/12 at 10:20 AM, " Client agitated requested a PRN." Thorazine 50 mg IM administered.

The MHW documented on 5/6/12 for first shift and second shift, " Client searched for contraband, nothing found."

The MHW documented 5/7/12, " Client searched for cuts, bruises and harmful objects none found."

On 5/11/12 at 9:40 AM, " Client up to desk stating the voices are telling him that we are poisoning him with Digoxin and that he needs to strike out- client stating I need a shot... Thorazine 50 mg IM administered without difficulty."

On 5/12/12 at 1:00 AM, client came up to nursing station and stated that he was very agitated and that he wanted a PRN to help him rest. 1:05 AM, Thorazine 50 mg IM administered.

On 5/12/12 at 2:50 PM, client requesting a PRN shot stated, " I hear the voices coming from the people and I need a shot." PRN of Thorazine 50 mg IM administered.

There was no MHW worksheet with the certified copy of the medical record the hospital gave to the survey staff for the time frame from 5/8/12 through 5/16/12.

The attending psychiatrist documented a progress note dated 5/16/12 which included the following information, " He is receiving the maximum recommended dose of Invega Sustenna, along with a significant dose of Seroquel and Klonopin. This has not relieved his symptoms and I believe a change is in order. Will switch from Seroquel to Haldol, but continue present dose of Invega Sustenna. Will also reduce and discontinue Vistaril as it doesn't seem necessary at this time." The physician wrote orders on 5/16/12 to titrate the patient off of Vistaril and Seroquel and gradually titrate to a therapeutic dose of Haldol. Also ordered was a complete blood count with differential and platelet count.

On 5/19/12 at 9:30 PM, client pacing around unit repeatedly asking for a shot. Client stated, " I feel agitated." Client refused to use other methods to control his behavior... Thorazine 50 mg IM PRN administered.

On 5/20/12 at 10:20 AM, requested a PRN complains of being and feeling anxious. Thorazine 50 mg IM administered.

On 5/20/12 at 4:05 PM, the client, MR # 1, took a drink from another client standing at the nurses station and started to drink from it. The client the drink was taken from hit this client, MR # 1, in the nose and it started to bleed. At 4:35 PM, on 5/20/12 the client was given a PRN of Thorazine for complaint of feeling nervous.

The MHW documented 5/20/12 on the first shift, " Client monitored for aggression, destroying property and self injurious behavior and med(medication) compliance, c/o (complaint of) feeling agitated this morning."

The MHW documented 5/20/12 on the second shift, " Monitored for hostile behavior."

On 5/24/12 at 3:30 PM, the nurse documented, client standing at nurses' station- requested a PRN stated, " I'm feeling nervous." PRN Thorazine 50 mg IM administered.

The mental health worker documented the week of 5/22/12 through 5/27/12 monitored for hostile behavior. There was no mention of skin assessment being completed between shifts.

On 5/28/12 at 10:05 AM, the nurse documented, client standing at nurses station. Requesting a PRN for agitation- PRN Thorazine 50 mg IM administered.

On 5/28/12 at 3:15 PM, the nurse documented, client standing at nursing station stating, " It's just not working am still agitated- I need another PRN." The nurse asked the client has he tried to stay calm on his own. Client replied, " Yes, I need another shot." Thorazine 50 mg IM administered.

On 5/29/12 at 4:00 PM, the nurse documented, " Client was sitting in day area and without warning hit client... in the throat, he was hit back on his left hand several times by client... they were separated by staff no apparent injuries."

A late entry for 5/29/12, documented at 4:30 PM, PRN Thorazine 50 mg IM per client's request for agitation.

On 5/29/12 at 11:30 PM, the nurse documented, " Client came to desk c/o (complaint of) being agitated hearing voices telling him to hit somebody, client requested PRN." Thorazine 50 mg IM administered.

The MHW documented on 5/29/12 first shift, " Monitor for med compliance."

The MHW documented on 5/29/12 second shift, " Client up half the night."

There was no mention of a skin assessment being completed by the MHW between shifts. The client had been involved in an altercation with another client during the day of 5/29/12.

On 5/30/12 at 12:30 AM, the nurse documented, " Client still walking pacing going into other clients rooms, slamming doors, continue to redirect. PRN not effective."

On 5/30/12 at 1:40 AM, the client tried to hit a MHW.

On 5/30/12 at 1:40 AM, the nurse documented, " Client came to desk requesting his Invega shot, client was told it was not time for Invega. I asked client what was wrong, he said voices telling him to hit somebody and he wished someone would just kill him... client went down the hall then ran back to day area naked charging at this writer and MHW. We both moved out of the way and asked client to calm down... Dr... notified ordered Haldol 5 mg IM and place in seclusion until calm. Haldol given in right gluteus maximus as ordered and placed in seclusion with mattress..."

On 5/30/12 at 2:20 AM, client remains in seclusion, the nurse documented, " Client in seclusion naked has been asked several times to put clothing shirt and shoes back on, urinating on floor. Client asked this writer for a cup of water. Client was given water as requested by charge MHW and this writer and another MHW standing by. Client attempted to throw water on staff. Client was reminded of criteria for release and then I closed the door."

On 5/30/12 at 2:30 AM, the nurse documented, " At approximately 2:27 AM, this writer heard a noise in seclusion room while I was monitoring from other side of the door. Client was banging his head up against the wall then stated ' I told you God said somebody got to die' client began ramming his head against the seclusion door. Staff quickly opened the door to intervene but client had already stopped. Dr... notified of incident received order to place in 4 point restraints for up to 4 hours for self injurious behavior.

The client was assessed by the nurse prior to being put in restraints at 2:30 AM, on 5/30/12, " Noted non open red areas on client forehead. Swelling at the crow of his head where he had been beating it against the door and small amount of blood was in his hair."

The client was released from restraints at 4:30 AM on 5/30/12.

On 5/30/12 at 10:55 AM, the nurse documented, " Haldol 5 mg/Ativan 2 mg IM for client trying to attack MHW."

On 5/30/12 at 12:15 PM, the nurse documented, " Continue on CBO, has continued to try to strike out at staff, overturned cart with lunch trays, call placed to Dr... returned call and ordered Haldol 5 mg/Ativan 1 mg IM."

The MHW documented on 5/30/12 first and second shift, " Monitor for med compliance." There was no documentation of skin assessment even though the patient had documented injuries to his forehead and the crown of his head from an earlier assessment. The hospital policy was not followed by staff to complete a skin assessment on clients while they are on CBO.

On 5/31/12 at 7:30 AM, the nurse documented, " Continue on CBO, with MHW in attendance."

The MHW documented on 5/31/12 first shift, " Monitor for med compliance." The MHW documented on 5/31/12 second shift, " Monitor for hostile and inappropriate behavior, search for contraband, none found." There was no documentation of a skin assessment.

On 6/1/12 at 8:20 AM, the nurse documented, " Requesting a PRN stated, I feel like hitting somebody."
Ativan 2 mg/Haldol 5 mg IM administered by the nurse 6/1/12 at 8:20 AM.

On 6/1/12 at 6:35 AM, the nurse documented, " Ativan 2 mg/Haldol 5 mg IM given per client request."

The MHW documented on 6/1/12 first shift," Client was searched for any new wounds and harmful objects, none were found."

The staff failed to document wounds, bruises or abrasions to compare any new areas when the skin assessment was documented by the MHW at shift change.

On 6/2/12 at 7:36 AM, the nurse documented, "Nursing assessment made on rounds on CBO with MHW at his side.

On 6/2/12 at 9:15 AM, the nurse documented, " Ativan 2 mg/Haldol 5 mg IM given for increased agitation. "

On 6/2/12 at 10:30 PM, the nurse documented, " Client pacing around the unit repeatedly saying I need a shot I feel agitated. Client refused to use other methods to control his behavior (going to a quiet area or talking with staff) Ativan 2 mg/Haldol 5 mg IM given. "

The MHW documented on 6/2/12 first shift," Client was searched for any new wounds and harmful objects, none were found."

The MHW documented on 6/2/12 second shift," Client was searched for contraband with no findings, no new cuts or marks on him."

On 6/3/12 at 7:38 AM, the nurse documented, "Nursing assessment made on rounds on CBO with MHW at his side."

On 6/3/12 at 7:45 AM, the nurse documented, "Client at nurses station complaining of feeling like hitting somebody... Ativan 2 mg/Haldol 5 mg IM given. "

On 6/3/12 at 7:30 PM, the nurse documented, "Client pacing around the unit threatening to hit staff and other clients. Client requested a PRN, Ativan 2 mg/Haldol 5 mg IM given. Client remains on CBO."

On 6/3/12 at 8:00 PM, the nurse documented, " While handing the client his oral medication the client hit the nurse in the face and knocked his medication on the floor. Dr... notified Haldol 5 mg and Ativan 2 mg IM , manual hold order obtained to administer the medication."

On 6/3/12 at 11:30 PM the client stated, " I'm having uncontrollable urges to hit someone and I can't control it." The nurse documented, " Dr... notified Thorazine 100 mg IM administered by the nurse."

There was no skin assessment documented by the MHW on 6/3/12 first or second shift and no first shift skin assessment for 6/4/12, the client was on CBO.

The nurse documented on 6/4/12 at 5:16 PM, " Client has made attempts to swing at staff several times today, but has been redirected, remains on CBO."

The nurse documented on 6/4/12 at 7:45 PM, " Pt. ( patient) while in day area attempted to strike staff and aggressively threaten peers. Emergency manual hold initiated and Haldol 5 mg and Ativan 2 mg IM... Pt noted to have bruising around both eyes, facial swelling generalized and bruises to neck, both collarbone areas and bilateral knees. Pt unable or unwilling to state origin of bruising to any area of body. Pt is being monitored 2:1 staff as CBO status for safety... Pt complained of being tired and sore all over but refused pain medication... Patient is to remain in manual hold until calm and cooperative..." The patient remained in a manual hold for one hour.

The MHW documented on 6/4/12 second shift," MHW searched by- have bruise and mark on his arm and leg."

The MHW failed to document the earlier findings the nurse had documented of multiple bruises see above.

On 6/5/12 at 9:25 AM, the nurse documented, "Client trying to attack staff by trying to pounce on staff- client states that he hears voices telling him to hit someone. PRN Haldol 5 mg/Ativan 2 mg IM."

On 6/5/12 at 9:30 AM, the nurse documented, " Client still trying to jump on staff- scratching self- has scratches located on right flank and left flank
noted abrasion to right hand middle finger and small finger 2 small scratches to right arm, has old bruising located on head from previous banging head but no new areas from banging head today. Has various old bruises throughout- client escorted up to restraint room has received PRN but still scratching self, placed in 4 way restraint."

The MHW documented on 6/5/12 first shift,"Client was checked for contraband nothing found. Client has some self abusive scratches to his right pinky and right index finger, also has one on right hip no other new bruises was found ."

The MHW documented on 6/5/12 second shift,"Client searched no contraband or new bruises were found, client slept well."

The nurses description of the injuries and bruises to the patient do no match the MHW observation on 6/5/12.

On 6/6/12 at 8:45 AM, the nurse documented, " Summoned to room by MHW client continues to try to fight asked client what was wrong- Client replied I feel like I need to hit someone can I please go in restraints."

On 6/6/12 at 9:00 AM, the nurse documented, " New order received to place client in 4 way restraints in supine position..." The client stayed in restraints until 12:00 PM.

On 6/6/12 at 12:25 PM, the nurse documented," While doing client's debriefing client stated I am starting to feel like I need a PRN, am starting to get agitated- PRN Ativan 2 mg/Haldol 5 mg IM... Remains on CBO status MHW in attendance."

On 6/6/12 at 1:18 PM, the nurse documented, " Dr... notified order received to place client on 2:1 CBO."

On 6/6/12 at 6:49 PM, the nurse documented, MHW asked the nurse for a PRN. Client states that he is feeling agitated, PRN Ativan 2 mg/Haldol 5 mg IM."

The MHW documented on 6/6/12 first shift,"Client searched no contraband found, no new cuts, bruises or scars found."

The MHW documented on 6/6/12 second shift,"Client at med pass, client has slept off and on all night."

The client had been in restraints and attempting to fight with staff and peers requiring 3 PRN medications on 6/6/12, no new bruises.

On 6/7/12 at 1:15 AM, the nurse documented," Client lying in bed stated 'I fell agitated and I need a shot '... Haldol 5 mg/ Ativan 2 mg IM PRN."

On 6/7/12 the MHW documented at 8:25 AM, " Client jumped out of bed trying to fight staff. Staff tried to tell ... to relax but he kept trying to fight. Client also stated that he wanted staff to kill him because he didn't want to live."

On 6/7/12 at 8:30 AM, the nurse documented, " PRN Ativan 2 mg/ Haldol 5 mg IM per pt (patient) request."

On 6/7/12 at 8:00 PM, the nurse documented, " Client lying in bed stated that I'm having thoughts of hitting someone and I need a shot. PRN Ativan 2 mg/ Haldol 5 mg IM per pt request."

The MHW documented on 6/7/12 second shift,"Client searched no contraband or new bruises were found client threatening staff and tempting to fight staff."

A second entry was made on 6/7/12 second shift by there MHW, " Monitor at med pass and also aggressive behavior, client searched nothing was found."

On 6/8/12 at 7:07 AM, the nurse documented, " PRN Ativan 2 mg/ Haldol 5 mg IM per pt request."

On 6/8/12 at 1:00 PM, the nurse documented, " MHW informed this writer that client jumped out of bed in an attempt to attack staff but fell and hit his right side of his forehead- noted client to have a raised area to the right side of forehead along with bruising. Remains on 2:1, MHW in attendance."

On 6/8/12 at 12:15 PM, the MHW documented, " Client showed threatening and aggressive behavior when ... jump out of his bed trying to hit staff members. Staff tried to stop... from attacking staff but ... fell out the bed hitting the right side of his forehead causing a knot over the left eye."

The MHW documented on 6/8/12 first shift," Monitored for aggressive behavior searched nothing found."

The MHW documented on 6/8/12 second shift,"Mon (monitor) for aggressive behavior searched nothing found."

There was no PRN medications documented in the nurses notes for 6/9/12.

The MHW documented on 6/9/12 first shift,"Resident searched no contraband or new cuts, bruises, scratches found."

The MHW documented on 6/9/12 second shift," Client searched for contraband no findings."

On 6/10/12 at 7:05 AM, the nurse documented, " Summoned to room per MHW noted client to be attempting to fight with staff, client jumped on bed staff able to prevent client from jumping off bed- PRN Zyprexa Zydis 10 mg by mouth... remains on 2:1."

On 6/10/12 at 7:45 AM, the client was placed in 4 point restraints and utilized manual hold to transport to the restraint room. Thorazine 100 mg IM administered.

On 6/10/12 at 9:45 AM, the nurse documented, " Remains in 4 point restraints at present... continues to pull at restraints trying to get to staff will continue to monitor..." The client was released from restraints at 11:45 AM.

The MHW documented on 6/10/12 first shift,"Resident searched no contraband or new cuts, bruises, scratches found."

The MHW documented on 6/10/12 second shift," Client searched for contraband no findings No new cuts, bruises found."

On 6/11/12 at 8:30 AM, the nurse documented, " Thorazine 100 mg IM... per client request."

On 6/11/12 at 5:45 PM, the nurse documented, " Thorazine 100 mg IM... per client request, the voices from the ceiling were telling him to hit somebody."

On 6/11/12 at 10:00 PM, the nurse documented, " Client restless asking for something to help him sleep. Vistaril 50 mg by mouth administered PRN."

The MHW documented on 6/11/12 first shift,"Client was searched for contraband, no new bruises found."

The MHW documented on 6/11/12 second shift," Client slept most of night but remains on CBO."

The client has continued to attack staff and try to harm himself by jumping off beds and beating his head on the floor, but nothing shows up on the assessment by the MHW and the nurses do not document any observation of injury.

On 6/12/12 at 11:41 AM, the MHW documented, " Client continues to try and attack staff members. Client asked for PRN to keep him calm." There was no documentation by the nurse on the nurse progress note for 6/12/12.


The MHW documented on 6/12/12 first shift,"Client searched no contraband found, skin assessment done nothing found."

The MHW documented on 6/12/12 second shift," Monitor for aggressive behavior, monitor for med pass."

On 6/13/12 at 1:30 AM, the MHW documented, " Client tried to attack staff in the middle of the night, trying to fight staff and run into another client's room, RN notified."

On 6/13/12 at 9:50 AM, the nurse documented, " Continues on 2:1 behavior observation with MHW's in attendance, continues to try to jump out of bed onto floor staff constantly intervening to keep client from injuring himself or others. Zyprexa 10 mg IM given."

On 6/13/12 at 11:30 AM, the nurse documented, " Client still jumping at staff states he wants to be put in seclusion. Dr... notified placed in 4 point restraints."

On 6/13/12 at 12:30 PM, the nurse documented, " Continue in 4 point restra
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and hospital policies, the facility failed to assure the medical record contained documentation of the Mental Health Worker's (MHW) skin assessments for clients on Continuous Behavioral Observation. This affected Medical Records (MR) # 1 and # 2 and had the potential to affect all clients served.
Findings Include:
Facility Policy:

Procedures Manual No. 7050-134
Subject: Observation

Procedure:
1. Mental Health Workers (MHW) duties on one-to-one and Continuous Observation
A. Assignment of mental Health Worker to client on one-to-one Continuous Observation Status will be made at the beginning of the shift by the Charge MHW/supervisor.
B. At the beginning of the assignment thoroughly search clients for possession of any potentially harmful items, remove any found... A skin assessment will also be conducted at each shift change by the on-coming and off-going MHW's together. The findings of the search and skin assessment will be documented in the comment section of the MHW flowsheet.
Medical Record Findings:
1.MR # 2 was admitted with an Axis I diagnosis of [DIAGNOSES REDACTED]

A review of the medical record revealed physician orders for MR # 2 to be placed on CBO (Continuous Behavioral Observation) starting on 2/07/12 for 7 days. A review of the Mental Health Worker (MHW) documentation for this time period revealed there were no documented skin assessments from 2/09/12 to 2/14/12, when the CBO order ended.

A review of the medical record revealed physician orders for MR # 2 to be placed on CBO starting 2/14/12 for days. A review of the MHW documentation for 2/14/12 and 2/15/12 revealed there were no documented skin assessments for MR # 2.





2. MR # 1 was admitted by court order 12/19/08 with an Axis I diagnosis of [DIAGNOSES REDACTED]

A review of the medical record revealed physician orders for MR # 1 to be placed on CBO (Continuous Behavioral Observation) dates as follows. A review of the Mental Health Worker (MHW) documentation for this time period revealed the following times when a skin assessment was not completed as while the client remained on CBO.



The mental health worker (MHW) documented on 4/6/12 for the second shift, client monitored for behavior, no skin assessment was performed.

The MHW failed to document on 4/7/12, first shift a skin assessment while the client remained on CBO.

The MHW failed to document on 4/8/12, first shift a skin assessment while the client remained on CBO.

The MHW failed to document on 4/12/12, first shift a skin assessment while the client remained on CBO.

The mental health worker documented the week of 4/18/12 through 4/21/12 monitored for aggressive and self injurious behavior. There was no mention of skin assessment being completed between shifts.

The client remained on CBO status throughout April.

The MHW documented on 5/5/12 for second shift, " Client was searched no problems."

The MHW documented on 5/6/12 for first shift and second shift, " Client searched for contraband, nothing found."

There was no MHW worksheet with the certified copy of the medical record the hospital gave to the survey staff for the time frame from 5/8/12 through 5/16/12.

The MHW documented 5/20/12 on the second shift, " Monitored for hostile behavior."

The mental health worker documented the week of 5/22/12 through 5/27/12 monitored for hostile behavior. There was no mention of skin assessment being completed between shifts.

The MHW documented on 5/29/12 first shift, " Monitor for med compliance."

The MHW documented on 5/29/12 second shift, " Client up half the night."

There was no mention of a skin assessment being completed by the MHW between shifts while the client remained on CBO.

The MHW documented on 5/30/12 first and second shift, " Monitor for med compliance." There was no documentation of skin assessment even though the patient had documented injuries to his forehead and the crown of his head from an earlier assessment. The hospital policy was not followed by staff to complete a skin assessment on clients while they are on CBO.

On 5/31/12 at 7:30 AM, the nurse documented, " Continue on CBO, with MHW in attendance."

The MHW documented on 5/31/12 first shift, " Monitor for med compliance." The MHW documented on 5/31/12 second shift, " Monitor for hostile and inappropriate behavior, search for contraband, none found." There was no documentation of a skin assessment.

There was no skin assessment documented by the MHW on 6/3/12 first or second shift and no first shift skin assessment for 6/4/12, the client was on CBO.

The client was placed on 2:1 CBO 6/6/12 through the current date.

The MHW documented on 6/6/12 second shift,"Client at med pass, client has slept off and on all night."

The MHW documented on 6/8/12 first shift," Monitored for aggressive behavior searched nothing found."

The MHW documented on 6/8/12 second shift,"Mon (monitor) for aggressive behavior searched nothing found."

The MHW documented on 6/9/12 second shift," Client searched for contraband no findings."


The MHW documented on 6/11/12 second shift," Client slept most of night but remains on CBO."

The MHW documented on 6/12/12 second shift," Monitor for aggressive behavior, monitor for med pass."

The MHW documented on 6/13/12 second shift," Client searched nothing found."

The MHW documented on 6/14/12 second shift," Monitor for aggressive behavior monitor for med pass."

The MHW documented on 6/15/12 second shift," Monitor for aggressive behavior monitor for med pass."

There was no entry from the MHW regarding a skin assessment on the first shift 6/15/12, while this client remains on 2:1 behavior observation.

There was no assessment documented by the MHW on 6/17/12 in the comment section of the flow sheet, no skin assessment between the MHW going off and coming on duty.

There was no documentation of a second shift assessment completed by the MHW for the second shift change over on 6/18/12.

The skin assessment was not completed as required by policy.