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.

LIFEWAYS HOSPITAL 8050 WEST NORTHVIEW STREET BOISE, ID 83704 Oct. 31, 2011
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observations, staff interview, and review of hospital policies, restraint documentation, and patient records, it was determined the facility failed to ensure patients were afforded privacy, their health and safety was protected, and that restraints were implemented in accordance with accepted standards of practice and facility policies. The cumulative effect of these failures resulted in the facility's inability to ensure patients' rights, health, and safety were protected. The findings include:

1. Refer to A143 as it relates to the facility's failure to ensure patients' rights to privacy were protected.

2. Refer to A144 as it relates to the facility's failure to provide care necessary to ensure the health and safety of patients who experienced suicidal ideation.

3. Refer to A167 and related standard level deficiencies as they relate to the facility's failure to ensure restraint policies were sufficiently developed, implemented, and monitored.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observations, staff interview, and review of hospital policies, credentials files, Medical Staff Bylaws, and patient records, it was determined the hospital's Governing Body failed to ensure it assumed responsibility for the conduct and operating direction of the hospital. This resulted in a lack of sufficient development, implementation, monitoring and oversight of appropriate systems and policies and procedures necessary to ensure patients were safe, their rights were protected, and that appropriate care was provided by sufficient numbers of qualified personnel. The findings include:

1. Refer to A046 as it relates to the Governing Body's failure to ensure the appropriate appointment of medical staff.

2. Refer to A049 as it relates to the Governing Body's failure to ensure it maintained accountability for the medical staff and for the quality of care provided to patients.
VIOLATION: MEDICAL STAFF - APPOINTMENTS Tag No: A0046
Based on review of credentialing files and Medical Staff Bylaws, and staff interview, it was determined the Governing Body failed to ensure the Medical Staff determined and made recommendations for the specific requested privileges appropriate to be granted to the members or potential members of the Medical Staff and allied health professionals when they sought to be appointed or re-appointed. This resulted in the potential for medical staff and allied health professionals to be providing services for which they were not credentialed. The findings include:

1. The hospital's credentialing files documented that the Medical Staff members, including the allied health professionals, requested privileges on the hospital's "Application for Appointment" form. Review of eight forms evidenced that one applicant was requesting membership as "consulting," one as "provisional," one as "allied health professional," and five as "active." Each applicant checked the requested privileges on each of the eight forms. However, there was no indication (such as a check mark) to show that these privileges were individually approved or denied by the Medical Executive Committee or the Governing Body.

On 10/28/11 at 1:50 PM, in an interview with the CEO, he stated the signatures on the "Application for Appointment" forms meant that the Medical Staff member had been approved for appointment or re-appointment with all privileges granted as requested.

However, a review of the hospital's Medical Staff Bylaws "Article VII Clinical Privileges 7.1 Exercise of Privileges" evidenced "... a member providing clinical services at this Hospital shall be entitled to exercise only those clinical privileges specifically granted."

The Governing Body failed to determine the specific privileges to be granted to the Medical Staff and allied health professionals based on consideration of each specifically requested privilege by each individual provider.
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based on review of medical records and facility policies, observation, and staff interview, it was determined that the Governing Body failed to ensure that the Medical Staff was accountable to the Governing Body for the quality of care provided to the patients. This resulted in 2 Conditions of Participation being not met. The findings include:

1. Refer to A115: Condition of Participation for Patient Rights and related standard level deficiencies as they relate to the Governing Body's failure to ensure patients were afforded privacy, their health and safety was protected and that restraints were implemented in accordance with accepted standards of practice and facility policies.

2. Refer to A385: Condition of Participation for Nursing Services and related standard level deficiencies as they relate to the Governing Body's failure to ensure sufficient development, implementation, monitoring and oversight of appropriate systems and policies and procedures necessary to ensure patients received appropriate care provided by sufficient numbers of qualified personnel.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observations, staff interview, review of personnel files and nurse staff competencies, and patient records, it was determined the hospital failed to have an organized nursing service that provided adequate, qualified nursing staff and appropriate oversight of the care being provided to the patients. This resulted in a lack of sufficient development, implementation, monitoring and oversight of systems and policies and procedures necessary to ensure patients received appropriate care provided by sufficient numbers of qualified personnel. The findings include:

1. Refer to A386 as it relates to the lack of oversight/supervision by the DON to ensure nurses were properly trained and competency tested , and the provision of patient care was monitored and evaluated.

2. Refer to A392 as it relates to the lack of adequate numbers of RNs, LPNs, and other nursing staff to ensure the patients' needs were met in a safe and timely manner.

3. Refer to A395 as it relates to the failure of the RN to provide adequate supervision and oversight and to evaluate the patient care provided by the nursing staff.

4. Refer to A396 as it relates to the failure to ensure that patients' care plans were individualized and kept current in order to consistently meet the needs of the patients.
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on record review, review of staffing schedules and personnel files, and staff interview it was determined the facility failed to ensure that there was adequate, qualified staff available to provide care and services to the patients. The facility failed to ensure that nursing staffs' competencies were assessed, and failed to provide in-service or additional education as needed in order to meet the needs of the patients for 17 of 17 personnel whose files were reviewed. This failure had the potential to negatively impact patient care. The findings include:

1. Review of the nursing schedules for June of 2011 through November of 2011 revealed that, starting in August of 2011 to the time of the survey, there were numerous night shifts when an RN was not scheduled to work, especially on Friday, Saturday, and Sunday.

On 10/28/11 at 3:45 PM, in an interview with the ADON, she verified that LPN B, who was now a Graduate Nurse (a nurse who was not licensed yet to function as an RN), had been placed in the RN position for the night shift. The ADON said when it was realized that the Graduate Nurse could not function in this role, numerous shifts were identified as needing RN coverage. Additionally, the ADON indicated that an RN who was working the night shift left the hospital, increasing the nursing coverage problems. The ADON stated that she herself worked extra to help fill the uncovered shifts.

Seventeen nursing staff personnel files were reviewed. The files lacked documentation to demonstrate nursing personnel were competency tested annually or that they were trained to address the specific needs of the patients who exhibited behaviors as follows:

- Three of the files lacked documentation of staff orientation. Two additional files contained the orientation checklists but lacked indication of what was completed off of the list.

- None of these files had current competency checklists in them.

- Six of the files contained competency checklists, dated from 2007 to 2010 (August).

- Four of the files lacked evidence of current CPR training. However, the DON was able to provide a copy of current CPR training for one of the four nursing staff.

Review of the "Licensed Nursing Staff (RN/LPN) Competency Checklist Initial and Annual" included sections relating to communication, physiological age changes, functional status, restraints, and geri-psych skills. These topics were pertinent to providing quality care to the geriatric population with behavioral issues, but did not include CPI training.

On 10/28/11, the DON was requested to provide current competency checklists for the nursing staff, as well as documentation of in-service training which had been provided to the nursing staff. The DON stated that these competencies had been done but she was not sure where the paperwork had been filed. She provided one initial competency checklist for RN C. However, it was dated 10/19/11, more than two months after RN C's hire date of 8/08/11. Review of the nursing schedules revealed that she was a RN working on the night shift.

The DON failed to ensure that nursing staffs' competencies were assessed, and failed to provide in-service or additional education as needed in order to meet the needs of the patients.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on record review, review of policies, and interview it was determined the facility failed to ensure adequate numbers of nursing staff, including CNAs, were available to supervise and provide care as needed for 10 of 20 patients (#1, #4, #5, #10 - #12, #14, #15, #20 and #39) whose "Special Precautions" data was reviewed. This resulted in lack of documentation of 15 minute checks and had the potential to result in patient needs not being met if the 15 minute checks were not conducted appropriately. The findings include:

1. The facility's policy "SPECIAL PRECAUTIONS/RESTRAINT FLOW SHEET," dated 9/27/04, stated accurate monitoring of each patient's physical location would be maintained at a minimum of every 15 minutes while at the facility. The policy specified that patient location would be documented at least every 15 minutes by a nursing staff member.

Staff completed a "SPECIAL PRECAUTIONS" form for each current patient on each day of their hospitalization . The "SPECIAL PRECAUTIONS" forms were reviewed, for all current patients, on 10/25/11 at 10:00 AM. The forms did not contain documentation of 15 minute checks being completed as follows:

a. Patient #14 was documented as being in her room at 5:45 AM and at 7:00 AM. Fifteen 15 minute checks had been missed at 6:00 AM, 6:30 AM, 6:45 AM, and from 7:00 to 10:00 AM.

b. Patient #1 was documented as being in her room at 9:00 AM. No further checks had been done. Four of the 15 minute checks had been missed.

c. Patient #4 was documented as wandering at 7:15 AM. No further checks had been done. Eleven of the 15 minute checks had been missed.

d. Patient #5 was documented as being in his room at 9:00 AM. No further checks had been done. Four of the 15 minute checks had been missed.

e. Patient #10 was documented as smoking at 7:00 AM. No further checks had been done. Twelve of the 15 minute checks had been missed.

f. Patient #11 was documented as in her room at 7:00 AM. No further checks had been done. Twelve of the 15 minute checks had been missed.

g. Patient #12 was documented as in her room at 7:00 AM. No further checks had been done. Twelve of the 15 minute checks had been missed.

h. Patient #15 was documented as being in the shower at 9:00 AM. No further checks had been done. Four of the 15 minute checks had been missed.

i. Patient #20 was documented as in the hall at 9:00 AM. No further checks had been done. Four of the 15 minute checks had been missed.

j. Patient #30 was documented as being in the group room at 9:00 AM. No further checks had been done. Four of the 15 minute checks had been missed.

In an interview on 10/25/11 at 10:10 AM, CNA H described the process of monitoring and documentation for the 15 minute checks. She stated the location of each patient was to be recorded on the "Special Precautions" record. CNA H stated due the workload of the CNA staff in the mornings, it was not always possible to document 15 minute checks on patients at the time of the check. She stated when the CNA had time to "catch up," they completed the documentation on the "SPECIAL PRECAUTIONS/RESTRAINT FLOW SHEET."

CNA H stated the patient load for day shift CNA's were eight patients for two CNA's. She described the CNA morning routine as including getting patients up in the morning, providing morning cares, getting them to the room for breakfast, assisting with the meal, and personal hygiene. She added that Tuesday mornings were particularly difficult, as they were additionally required to obtain weights for each patient before lunch. CNA H reviewed the "Special Precautions" records noted above and confirmed that it was not possible to determine if each patient's location had been verified every 15 minutes.

The facility could not ensure staffing levels were sufficient to provide for patient care activities as well as to maintain current documentation of such activities.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, observation, and staff interview it was determined the facility failed to ensure the RN provided adequate supervision and oversight necessary to ensure appropriate patient care was provided to 10 of 39 patients (#11, #12, #16, #22 - #27, and #36) whose records were reviewed. This resulted in inadequate care being provided. The findings included:

1. Patient #12's record documented she was an [AGE] year old female, admitted to the facility on [DATE], with a diagnosis of dementia.

A pressure ulcer was identified by the NP on 10/16/11 and again on 10/17/11. Patient #12's "PHYSICIAN'S ORDERS," on 10/17/11, indicated Patient #12 was to have Silvadene cream applied to the left heel until healed. Additionally, Patient #12's care plan for "Nursing Diagnosis: Impaired Skin Integrity: Actual" included the following nursing interventions with the date developed:

10/23/11 - "Wound #3 left heel dsg [dressing] change."

10/24/11 - "Wound #4 Bilaterally boggy heels - Float heels while in bed."

No other tracking and care planning for the pressure ulcer could be found in Patient #12's record.

Patient #12 was not provided with appropriate nursing care as follows:

a. On 10/24/11, the following observations of Patient #12 were made:

At 9:38 AM, she was in bed lying on her back. The heel protectors were lying on the wheelchair.

At 11:17 AM, she was lying in bed on her back with the heel protectors still lying on the wheelchair. No staff had been observed to enter Patient #12's room to reposition her.

On 10/25/11, at 11:37 AM, RN B was asked about the pressure ulcer tracking for Patient #12. She verified that there was no tracking or assessment sheet for Patient #12's skin issues.

On 10/25/11, the ADON said that LPN D measured Patient #12's pressure ulcer. LPN D clarified that she had not measured or assessed the size of the ulcer. Patient #12's medical record was reviewed with the ADON, who found that there was a note related to the left heel blister was written by NP A, on 10/16/11. On 10/17/11, the NP documented that the blister had broken and noted the size. The ADON confirmed that there were no pressure ulcers present on admission. She confirmed that pressure ulcers were to be measured weekly and documented.

At 11:50 AM, Patient #12 was in the same position as at 11:17 AM.

At 11:52 AM, CNA F said that she would be getting Patient #12 up in a few minutes.

At 12:05 PM, CNA F reported Patient #12 had slept from last night until now and she did not get up for breakfast. CNA F stated she had tried to get Patient #12 up to toilet her about one and a half hours ago, but Patient #12 would not wake up.

At 12:05 PM, Patient #12's heels were both dug into a pillow which was placed under her legs. There was a gauze dressing falling off of her left heel and no heel protectors were in place. The left heel was reddish purple (approximately 2 inches in diameter) and the center was open (approximately 1/2 inches in diameter with dry, peeling skin around the opening). The right heel was boggy to touch per CNA F and there was a small red area in the center of the back of the heel. The end of the left great toe was bright red. There a small black spot on the outer side of the right great toe. When Patient #12's brief was changed, the left buttock was bright red. The brief was observed to be wet with dark, strong smelling urine. The pad under Patient #12 was wet as well. CNA F changed the brief, laying the wet one on the floor, and wearing the same gloves to put on a new brief.

When CNA F sat Patient #12 up on the edge of the bed, Patient #12 complained of being dizzy. When the dizziness did not go away, CNA F placed Patient #12 back in bed so she could get another staff member (CNA I) to assist her. The two CNAs got Patient #12 up into the wheelchair by lifting under her arms and pulling up and holding her pants. Each time Patient #12 was moved in or out of the bed, her heels were noted to slide across the bed. Patient #12's heel protectors were then put on her feet. Patient #12's face was washed, her hair combed, and her teeth were brushed. However, Patient #12's hands were not washed before the CNA F took her to eat lunch. Additionally, CNA F was not noted to report Patient #12's ongoing complaints of dizziness to RN B.

On 10/25/11 at 12:15 PM, in an interview with LPN D, she stated was not aware that Patient #12's left heel was open. She confirmed that there was no skin breakdown tracking for Patient #12, including skin measurements or assessments.

At 2:00 PM, LPN D was observed while she changed the dressing on Patient #12's left heel. LPN D measured the pressure ulcer to be 5 cm by 3.75 cm and confirmed it was open in the middle. She stated that "It looked like a blister that popped." She cleaned the wound and applied Silvadene, Postform, and a Kling wrap. At this time, there was a red area on the inner mid section of the arch. When LPN D touched the area, Patient #12 moved. LPN D stated the center of the area felt hard. When LPN D looked at the end of left great toe, there was a small line in the middle of the red area. She thought the black spot on the other great toe was possibly a blood blister. LPN D felt the right heel and indicated that it was somewhat boggy.

The facility failed to ensure nursing care in the form of wound care, monitoring of wound status, and preventative measures to prevent the worsening of skin ulcers were provided for Patient #12.

b. Patient #12's medical record contained a "Bowel Care Protocol" with the following orders:

- MOM 30 cc in AM if no BM x 2 days
- Dulcolax Suppository PR in AM if no BM x 3 days
- Fleets enema PR in PM if no BM by PM on day 3
If no BM has occurred after these interventions contact MD for further orders.

Patient #12's records included CNA documentation that Patient #12's bowel care was not provided in accordance with orders as follows:

- 10/09/11 to 10/12/11 - No medications were documented as given even though there was no documentation of a BM during this time frame.

- 10/13/11 to 10/16/11- MOM 30 cc was given the morning of 10/15/11, the 3rd day of no documented BM.

- 10/17/11 to 10/21/11 - MOM 30 cc was given the morning of 10/19/11, the 3rd day of no documented BM.

The facility failed to ensure nursing staff properly evaluated and followed "Bowel Care Protocol" orders for Patient #12.

c. Patient #12's laboratory tests were not drawn per orders as follows:

Patient #12's "PHYSICIAN'S ORDERS" included an order for laboratory work, dated 10/20/11 at 3:30 PM, including a CBC, Chem 7, and BNP. The laboratory work was to be drawn in the AM on 10/22/11. On 10/23/11 at 2:15 PM., there was another order for laboratory tests to be drawn on 10/25/11.

On 10/26/11 at 10:55 AM, when the surveyor requested the laboratory results from both blood draws, RN B stated the 10/20/11 order for labwork was not noted by the nurse at the time of the order, and the 24 hour chart check failed to identify the order as well. Hence, RN B confirmed no blood draw had been done on 10/22/11.

There was no evidence found to show the physician/provider was notified the blood testing was not done as ordered.

The facility failed to ensure physician orders for laboratory tests were followed for Patient #12.

d. Review of Patient #12's "C.N.A. Daily Flow Sheet of Patient Care" revealed she had not showered from 10/16/11 until 10/22/11, a total of five days.

The facility failed to ensure nursing staff properly assessed and cared for Patient #12's bathing needs on a regular basis.

2. Patient #11's records documented an [AGE] year old female who was admitted to the facility on [DATE] with a diagnosis of dementia. Patient #11 was not provided with appropriate nursing care as follows:

a. Review of Patient#11's "MEDICATION RECORD," for 9/2011 and 10/2011, revealed staff were to monitor Patient #11's oral fluid intake and output beginning on 9/21/11. On the 10/2011 "MEDICATION RECORD," a note was written in to remind staff to document the fluid amounts using "ccs [cubic centimeters]." However, there were no documented amounts recorded for Patient #11's oral intake or output.

On 10/26/11 at 10:55 AM, RN B stated she was not certain that oral intake and output was to be monitored. She confirmed the information was not documented.

The facility failed to ensure nursing staff followed physician's orders of recording intake and output for Patient #11.

b. Review of Patient #11's "PRN/ONE TIME MEDICATION RECORD," for the time frame of 9/06/11 through 10/23/11, revealed Patient #11 was medicated numerous times with Ibuprofen 400 mg for pain. There was no indication the hospital's pain scale was utilized when assessing Patient #11's level of pain before and after the administration of the medication. Results were noted on the "PRN/ONE TIME MEDICATION RECORD" as "+," the same, or the symbol for none.

The facility had a form titled "PAIN MANAGEMENT TOOL," dated 10/2002. In addition, the facility had a second form titled "PAIN MANAGEMENT TOOL Non-Verbal Resident," which was undated. Both forms had sections related to the intensity level of the pain, which contained facial expressions, word descriptions, and numerical descriptions to describe pain. For example, a face with a smile indicated a numerical description of "0," or no pain. A face with a frown and tears indicated a numerical description of "4," and overwhelming pain. If patients were not able to rate their pain using the scale, nursing staff were able to assess pain using the facial expressions.

The facility failed to ensure nursing staff documented a pain score for Patient #11 before and after the administration of pain medication.





3. Patient #16 was an [AGE] year old female who was a patient at the facility from 8/24/11 to 9/06/11. Her admitting diagnoses included dementia and mood disorder with lots of irritability. Her "MEDICAL CONSULTATION," dated 8/25/11, indicated Patient #16 had a rash under her left breast caused by Candida (yeast). The NP recommended a treatment course of nystatin powder for 10 days.

Medication administration documentation indicated the nystatin powder was to be applied under the left breast twice a day for 10 days. The record contained documentation of the application of the nystatin powder as follows:

- 8/25/11: the evening dose was applied.
- 8/26/11: the morning dose was refused, no documentation related to the evening dose.
- 8/27/11: the morning dose was refused, no documentation related to the evening dose.
- 8/28/11: the morning dose was refused, no documentation related to the evening dose.
- 8/29/11: no documentation related to the morning dose, the evening dose was refused.
- 8/30/11: no documentation related to the morning dose, the evening dose was applied.
- 8/31/11: no documentation related to the morning dose, the evening dose was applied.
- 9/01/11: no documentation related to the morning dose, the evening dose was applied.
- 9/02/11: the morning dose was applied, no documentation related to the evening dose.
- 9/03/11: the morning dose was applied, no documentation related to the evening dose.
- 9/04/11: the morning dose was applied and the medication discontinued.

"PROGRESS NOTES," completed by the PA on 9/04/11, indicated the rash had resolved.

The medical record did not contain documentation of a nursing assessment of the skin between the dates of 8/25/11 and 9/04/11, when the rash was noted by the PA to be healed.

The ADON was interviewed on 10/28/11 at 3:20 PM. She reviewed Patient #16's medical record and stated that if the rash was a mild rash, she would not expect specific documentation of it. She stated that the head to toe assessments completed daily do not always permit the nurse to completely evaluate all skin areas. She stated the CNAs providing care to Patient #16 would be relied upon to notify the nurse if they noticed any problems. She stated she would have expected to see documentation that the physician was notified that Patient #16 refused the medication administration on numerous occasions. She confirmed that this documentation was not found in the record.

4. Patient #25 was admitted [DATE] with diagnoses of dementia and altered mental status possibly related to a urinary tract infection.

On 2/16/10, the physician ordered Norco 5/325 (a narcotic) if Patient #25's Oxygen saturation (a non-invasive test of oxygen in the blood) was less than 90%. The "PRN/ONE TIME MEDICATION RECORD" documented the medication was administered without an assessment of oxygen saturations as follows:

On 2/20/10 at 12:50 PM and on 2/24/10 at 2:00 AM, the nurse gave Norco 5/235 and did not assess the oxygen saturation levels according to the order. Additionally, the treatment record showed no monitoring of the oxygen saturation during the month of February 2010.

5. Patient #24 was a [AGE] year old male who was a patient at the facility from 10/21/10 to 10/30/10. His discharge diagnosis was dementia with behavior disturbance.

His medical record contained a verbal order, dated 10/29/10 at 9:50 AM, for Roxinol 10 mg sublingual q 2 hours PRN for pain/air hunger. The "PRN/ONE TIME MEDICATION RECORD" indicated Patient #29 received the following doses of Roxinol:

- 10/29/11 at 10:00 AM: Roxinol 10 mg was given for "RESP [respirations] & ANXIETY."
- 10/29/11 at 12:50 PM: Roxinol 10 mg was given for "RESP [respirations] & ANXIETY."
- 10/29/11 at 4:00 PM: Roxinol 10 mg was given for anxiety.
- 10/29/11 at 7:00 PM: Roxinol 10 mg was given for anxiety.
- 10/29/11 at 9:00 PM: Roxinol 10 mg was given for pain.
- 10/29/11 at 11:15 PM: Roxinol 10 mg was given for pain.
- 10/30/11 at 1:15 AM: Roxinol 10 mg was given for pain.
- 10/30/11 at 3:15 AM: Roxinol 10 mg was given for pain.
- 10/30/11 at 5:15 AM: Roxinol 10 mg was given for pain.

The "NURSING PROGRESS NOTES," for 10/29/11, did not contain documentation related to assessments made before or after administering the Roxinol until 11:00 PM. At 11:00 PM, the LPN documented Patient #24 "Is unresponsive to verbal stimuli. Has O2 [oxygen] on @ 2 L [liters] per NC [nasal cannula]. Is turned & repositioned q 2 [hours] and his medication [with] pain med [sic] q 2 [hours] appears to be comfortable [sic] will continue [with] current POC."

The next documentation in the "NURSING PROGRESS NOTES" was on 10/30/11 at 4:45 AM. The LPN documented Patient #24 "is unresponsive to verbal stimuli [sic] respirations even and unlabored [sic] Does have O2 [oxygen] on @ 2 L [liters] per NC [nasal cannula]. Medicated [with] Roxinol [sic] 10 mg q 2 [hours] [sic] appears to be comfortable [sic] skin pink [sic] warm [sic] & dry [sic] will cont. [continue] to monitor."

No additional documentation was found regarding assessments before and after administration of Roxinol.

The ADON reviewed Patient #24's medical record on 10/28/11 at 3:20 PM. She explained that the Roxinol was probably given every 2 hours prior to providing cares, in order to maintain Patient #24's comfort. She confirmed that there was minimal documentation to substantiate the repeated administration of Roxinol. She also stated the LPN who was responsible for the above medication administration and documentation no longer worked for the facility.

The RN failed to ensure adequate assessments were being performed and documented related to PRN medication administration.





6. The facility's policy titled "PRN MEDICATIONS," dated 5/21/01, stated "Within one hour, the medication action is to be assessed and the response to the medication noted on the PRN medication record."

The facility did not ensure nursing staff implemented the policy as follows:

a. Patient #22 was admitted to the facility 9/16/10 with diagnoses of episodic mood disorder and vascular dementia. Patient #22's responses to PRN/one time medications were not documented after the following medications were administered:

- 9/16/11 at 5:40 AM: Tylenol 1000 mg was given for pain.
- 9/19/10 at 8:50 AM: Norco 5/325 was given for pain.
- 9/21/10 at 5:25 AM: Norco 5/325 was given for pain.
- 9/21/10 at 10:30 AM: Norco 5/325 was given for pain.

b. Patient #23 was admitted to the facility 9/10/10 with diagnoses of severe dementia, mood disorder and psychosis. Patient #23's responses to PRN/one time medications were not documented after the following medications were administered:

- 9/12/10 at 12:00 AM: Tylenol 650 mg was administered without indication.
- 9/13/10 at 3:00 PM: Tylenol 1000 mg was administered for foot pain.
- 9/24/10 at 5:50 AM: Seroquel 200 mg was administered for increased anxiety.
- 9/29/10 at 1:15 PM: Methadone 5 mg was administered due to Patient #23 "moaning in pain."

c. Patient #26 was admitted to the facility on [DATE] with diagnoses of dementia, psychosis, a history of aggressive behaviors and hallucinations. Patient #26's responses to PRN/one time medications were not documented after the following medications were administered:

- 3/17/11 at 11:30 AM: Roxinol 5 mg was administered for pain.
- 3/19/11 at 12:30 PM: Roxinol 10 mg was administered for pain.
- 3/19/11 at 6:40 PM: Roxinol 10 mg was administered for pain.
- 3/20/11 at 4:00 PM: Roxinol 10 mg was administered for pain.
- 3/23/11 at 3:00 PM: Roxinol 10 mg was administered for pain.
- 3/23/11 at 5:30 PM: Roxinol 10 mg was administered for pain.
- 5/16/11 at 5:10 PM: Roxinol 10 mg was administered for pain.

d. Patient #27 was admitted to the facility on [DATE] with diagnoses of dementia and mood disorders. Patient #27's responses to PRN/one time medications were not documented after the following medications were administered:

- 5/13/11: Roxinol (one dose).
- 5/14/11: Roxinol (7 doses).
- 5/15/11: Roxinol (4 doses).
- 5/16/11 at 5:10 PM: Roxinol 10 mg was given.
- 5/16/11 at 8:30 PM: Roxinol 10 mg was given.
- 5/17/11 at 9:15 AM: Roxinol 0.5 ml.
- 5/17/11 at 11:30 AM: Roxinol 0.5 ml.
- 5/17/11 at 4:10 PM: Roxinol 0.5 ml.
- 5/17/11 at 6:30 PM: Roxinol 0.5 ml.

e. Patient #36 was admitted to the facility on [DATE] with diagnoses of mood disorder, chronic pain and pressure ulcers. Patient #36's responses to PRN/one time medications were not documented after the following medications were administered:

- 6/16/11 at 7:00 PM: Oxyfast 20 mg was administered for pain.
- 6/16/11 at 3:50 PM: Oxyfast 20 mg was administered for pain.
- 6/16/11 at 4:30 PM: Oxyfast 20 mg was administered for pain.
- 6/16/11 at 4:45 PM: Oxyfast 20 mg was administered for pain.
- 6/18/11 at 5:00 AM: Oxyfast 20 mg was administered for pain.
- 6/18/11 at 11:40 AM: Oxyfast 20 mg was administered for pain.
- 6/18/11 at 2:40 PM: Oxyfast 20 mg was administered for pain.
- 6/19/11 at 6:40 PM: Oxyfast 20 mg was administered for pain.
- 6/19/11 at 9:30 PM: Oxyfast 20 mg was administered for pain.
- 6/20/11 at 1:10 AM: Oxyfast 20 mg was administered for pain.
- 6/20/11 at 3:30 AM: Oxyfast 20 mg was administered for pain.
- 6/20/11 at 5:00 AM: Oxyfast 20 mg was administered for pain.
- 6/20/11 at 8:15 AM : Oxyfast 20 mg was administered for pain.

In an interview on 10/25/11 at 3:00 PM, the ADON described the facility policy of PRN medication documentation. She referred to the policy titled "PRN MEDICATIONS," dated 5/21/01, and stated "As a minimum standard, all nurses should document the response on the PRN medication record. If needed, additional documentation in the progress notes to supplement the PRN medication record could be done."

The facility failed to ensure the RN provided adequate supervision and oversight necessary to ensure appropriate patient care.

7. Refer to A179 as it relates to the facility's failure that one hour face to face assessments were consistently completed by qualified personnel after patient restraint was utilized.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, observation, and staff interview, it was determined the facility failed to ensure that patients' care plans were individualized and/or kept current in order to meet their needs for 6 of 39 patients (#1, #11 - #14, and #18) whose records were reviewed. Failure to individualize and maintain current POCs had the potential to impede coordination and provision of patient care. The findings included:

1. Patient #12 was an [AGE] year old female admitted on [DATE] with diagnoses including history of delirium, traumatic brain injury, non-insulin dependent diabetes, hypertension, and hypothyroid. The Physician's impression of Patient #12 listed "dementia thought to be vascular in type, probably multifactorial, mood disorder, rule out psychosis" and "conflicts of environment."

The POC was not kept current for Patient #12 as follows:

a. "Physician's Orders," dated 10/17/11, documented an order for Silvadene cream to be applied to Patient #12's left heel wound until healed. Patient #12's POC contained a section titled, "Nursing Diagnosis: Impaired Skin Integrity: Actual." The following nursing interventions were documented:

- On 10/23/11 - "Wound #3 left heel dsg [dressing] change."
- On 10/24/11 - "Wound #4 bilaterally boggy heels - Float heels while in bed."

On 10/24/11 at 12:05 PM, observations of care by CNA F revealed the left heel was reddish purple (approximately 2 inches in diameter) and the center was open (approximately 1/2 inches in diameter with dry, peeling skin around the opening). The right heel was boggy to touch per the CNA and there was a small red area in the center of the back of the heel. The end of the left great toe was bright red. There a small black spot on the outer side of the right great toe.

On 10/25/11 at 11:37 AM, RN B was asked about the pressure ulcer tracking for Patient #12. She verified that there was no tracking or assessment sheet for the patient's skin issues.

On 10/25/11 at 12:15 PM, in an interview with the patient's LPN D, she was not aware that the patient's left heel was open. She confirmed that there was no skin breakdown tracking for this patient, including skin measurements or assessments.

Patient #12's care plan for skin breakdown was not developed until a week after the order for treatment was written and did not include specific treatment plans for the wound care.

b. Patient #12's record included a preprinted care plan titled "Nursing Diagnosis: Anxiety - Actual," dated 10/05/11. All the nursing interventions were checked. However, as of 10/24/11, the care plan had not been updated.

The hospital's "Interdisciplinary Treatment Plan" policy, dated 1/15/08, stated initial patient treatment plans were to be completed within 72 hours of admission. The policy further stated treatment plans were to be reviewed and revised at weekly treatment team meetings and "Any major changes to the treatment plan prior to weekly treatment team meetings will be made during the weekday morning stand-up meetings."

A POC was not thoroughly developed and kept current for Patient #12.

2. Patient #11 was an [AGE] year old female admitted on [DATE] with diagnoses that included dementia, a history of anxiety disorder, hypertension, partial blindness, hard of hearing, history of seizures, history of urinary tract infections, and aggression.

The POC was not kept current for Patient #11 as follows:

Patient #11's record contained a pre-printed care plan, dated 8/22/11, with sections titled "Nursing Diagnosis: Anxiety - Actual" and "Nursing Diagnosis: Violence - Actual." All the nursing interventions were checked, including "Consider chemical restraint for out of control, violent patient." However, as of 10/24/11, the care plan had not been followed or updated for Patient #11.

3. Patient #13 was an [AGE] year old female admitted on [DATE] with diagnoses that included dementia with anxiety and paranoid ideation, insomnia, rule out urinary tract infection, left heel pain due to skin breakdown, atrial fibrillation, congestive heart failure, and history of falls.

The POC was not kept current for Patient #13 as follows:

a. Patient #13's medical record contained an admission assessment completed by an RN on 2/16/11. The RN noted the following issues related to the skin assessment:

- There was a dressing on the left heel. The RN indicated the top of left heel area was brown and measured 0.4 cm by 0.6 cm. The remaining tissue was white surrounded by dry skin.
- The left buttock was discolored but the skin remained intact. The RN documented the measurements as 1.8 cm by 0.1 cm.
- Patient #13's peri area was reddened with intact skin.
- The right inner ankle area had a discolored area measuring 8 cm by 3 cm.

Patient #13's medical record contained a POC dated 2/18/11. The section related to skin integrity noted staff were to inspect and chart skin integrity every day and monitor bruising until it was resolved. The care plan was not individualized to include specific interventions for the dressing noted above or additional care provided to the wounds found on assessment.

b. Patient #13's medical record contained dietary documentation that indicated Patient #13 needed additional nutrition and was offered supplements on a daily basis. On 2/22/11 at 3:07 PM, the Registered Dietitian documented "Supplements offered BID [twice a day]. Staff report patient very active, wheeling self up and down the hall. Will request to increase Boost Plus to TID [three times a day]."

Patient #13's POC, dated 2/18/11, contained a goal for her to "maintain adequate nutritional status while hospitalized ." The nursing intervention for weight loss was marked. However, the plan had not been updated to include the supplements.

The POC's for Patient #13 had not been updated to include nutritional and wound care needs.





4. Patient #1 was a [AGE] year old female, admitted to the facility on [DATE] with a diagnosis of dementia with aggressive behavior. The "NURSING ADMISSION ASSESSMENT," dated 10/18/11 at 2:45 PM, indicated Patient #1 had impaired hearing and wore hearing aids in each ear.

On 10/24/11 at 3:00 PM, Patient #1 was observed sleeping in her wheelchair in the group room as others participated in an activity. Her hearing aids were not being worn. CNA B was questioned about Patient #1's hearing aids, and stated she was not aware Patient #1 had hearing aids.

On 10/25/11 at 10:30 AM, Patient #1 was observed to be sleeping while in her wheelchair at a table during an activity. Upon intervention by this surveyor, LPN D directed CNA F to put in Patient #1's hearing aids. Patient #1 was noted to open her eyes and appeared to participate in the group activity after placement of the hearing aids.

On 10/27/11 at 10:00 AM, and again at 1:45 PM, Patient #1 was noted to be sleeping in her wheelchair in the group room. Her hearing aids were not in her ears.

During an interview on 10/27/11 at 2:00 PM, the Charge RN confirmed Patient #1 was not wearing hearing aids, and stated she was unaware that Patient #1 had hearing aids. The Charge RN stated hearing aids would not be added to the POC for patients, as it was routine practice for the CNA's to assist the patient with hearing aids, dentures, and glasses during morning cares.

The facility did not individualize Patient #1's POC to reflect her need for hearing aids to be in place each morning.

5. Patient #14 was a [AGE] year old female admitted to the facility on [DATE] with a diagnosis of paranoia, delusions, and hallucinations. The "MEDICAL CONSULTATION," dated 10/12/11, included documentation that Patient #14 had obstructive sleep apnea and used a CPAP machine at home to assist with breathing during the night. Her medical record contained "PHYSICIAN'S ORDERS," dated 10/12/11 at 4:00 PM, which read "May use own C-PAP [sic]." The following documentation regarding a CPAP machine was found in Patient #14's record:

- "NURSING PROGRESS NOTES," dated 10/13/11 at 5:00 AM, stated "...sleep apnea - CPAP machine from home."
- "NURSING PROGRESS NOTES," dated 10/14/11 at 11:00 PM, stated "CPAP is still not available."
- "PRN/ONE TIME MEDICATION ADMINISTRATION RECORD," dated 10/14/11 at 10:15 PM, "Refused to wear CPAP."
- A medical "PROGRESS NOTE," dictated 10/18/11, noted "We will continue CPAP machine."
- A medical "PROGRESS NOTE," dictated 10/24/11, noted "She does not have CPAP machine. Her family did not bring that in. We will discontinue it."

During an Interdisciplinary Team meeting on 10/24/11 beginning at 9:00 AM, Patient #14's status was discussed as well as for her plan for discharge. Her Physician stated Patient #14's son had been living in another state, and was relocating to this state in order to take care of his mother. The Physician stated Patient #14's family had not brought in her CPAP, therefore the order would be discontinued.

In an interview on 10/25/11 at 2:45 PM, Patient #14 stated she was supposed to be on CPAP at home, but it was uncomfortable and she did not wear it. She stated her physician allowed her to use oxygen via a nasal cannula during the night for her sleep apnea, and she also used it on an "as needed" basis for shortness of breath. Patient #14 described her oxygen at home as "... small green tanks and a big concentrator in my bedroom." Patient #14 stated her son would not have been able to bring in her CPAP because he had been in another state and had no way to get it.

In an interview on 10/28/11 at 5:15 PM, the ADON reviewed Patient #14's record and confirmed the CPAP had not been brought in by family. The ADON stated the nursing entry which stated Patient #14 refused to wear her CPAP was not correct. She stated the nurse had probably walked by Patient #14's room and saw she was not wearing the CPAP and concluded it had been refused. The ADON confirmed that while the use of the CPAP was on the POC, it had not been updated to reflect the fact that a CPAP machine was not available for use. The ADON confirmed there was no evidence of discussion with Patient #14 regarding her family's ability to bring in her device, or confirmation that she, in fact, used oxygen rather than the CPAP machine.

The facility did not individualize Patient #14's POC to accurately reflect her need for assistive breathing equipment and the inability of family to bring in her personal CPAP machine.





6. Patient #18 was a [AGE] year old female who was a patient at the facility from 2/26/11 to 4/04/11. Her primary diagnoses included dementia, psychosis, and rule/out mood disorder. The inventory of her personal effects upon admission to the facility included bifocals, both upper and lower dentures, and hearing aids for both ears.

"PROGRESS NOTES," completed by the Social Worker on 3/22/11, contained documentation that Patient #18's son voiced concern, that when he visited Patient #18, she did not have her hearing aids or her dentures in. He stated he wondered if not having her dentures in was affecting Patient #18's ability to eat appropriately.

The care plan for Patient #18 was reviewed. There was no documentation regarding Patient #18's need for glasses, hearing aids, or dentures to obtain improvements in vision, hearing, and eating.

The ADON was interviewed on 11/03/11 at 9:20 AM regarding Patient #18. She stated Patient #18 was often found removing her hearing aides and dentures, wrapping them up, and placing them in random locations (such as her pockets or the trash). She stated assistive devices such as hearing aids, glasses, and dentures are not routinely part of the POC. She stated the information is placed on the census sheet that all staff have and refer to regarding details of patient care. She also stated that putting in hearing aides and dentures, and putting on glasses, was part of the routine the CNAs followed when getting patients out of bed.

Patient #18's POC was not individualized to reflect her need for glasses, hearing aids, or dentures. The POC did not contain instructions for staff for monitoring Patient #18's habit of removing items and placing them in inappropriate locations.

7. Refer to A166 as it relates to the facility's failure to ensure patients' POC's were modified to reflect the use of chemical and physical restraint.

The facility failed to ensure nursing care plans were individualized and/or kept current in order to meet patients' needs.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0160
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policy, record review and staff interview, it was determined the facility failed to ensure the use of chemical restraints was recognized, and appropriately utilized and that complete information for the use of the restraints was documented in the patients' medical records for 6 of 17 patients reviewed (#7, #13, #15, #18, #21, and #24) for whom chemical restraints were used. This resulted in the potential for patients to be subjected to unnecessary chemical interventions. The findings include:

1. The hospital's "Seclusion and Restraint" policy, dated 11/04/08, defined a chemical restraint as "The involuntary administration of a medication used for rapid control of psychiatric symptoms or behaviors that represent a high potential for danger to the patient or others. Those medications that are designed to put a person to sleep and not treat the underlying condition are considered a chemical restraint (the medication renders the person unable to function as a result of the medication)."

The policy stated prior to initiating restraints, alternatives (e.g. distraction, redirection, decreasing stimulation, etc.) were to be considered. The policy further stated consideration was to be given to other factors, such as the patient's history of sexual or physical abuse, pre-existing medical conditions, etc., prior to restraint being initiated.

If it was determined that a restraint was needed, the policy stated, upon initiation of the restraint, the RN was to immediately obtain and document the restraint orders from the physician. The restraint orders were to include documentation of the rationale for the restraint and emergency medications that were to be administered.

Patient medical records were reviewed. The records documented patients received emergency medications for violent and aggressive behavior. However, no alternative measures prior to the use of restraint or rationale for restraint use was documented as follows:

a. Patient #21 was an [AGE] year old male who was a patient at the facility from 9/09/10 to 9/15/10. His discharge diagnoses included dementia, mood disorder, and psychotic disorder.

Patient #21's medical record contained verbal orders, documented on a "PHYSICIAN'S ORDERS" form dated 9/10/10 at 7:20 PM, for Haldol 10 mg PO/IM and Ativan 2 mg PO/IM, to be given at the time the order was obtained, for increased anxiety and agitation. A "PRN/ONE TIME MEDICATION RECORD" documented the medications were administered IM.

Patient #21's record did not document alternative measures implemented prior to the use of the chemical restraint or the rationale for the chemical restraint.

b. Patient #24 was a [AGE] year old male who was a patient at the facility from 10/21/10 to 10/30/10. His discharge diagnosis was dementia with behavior disturbance.

His medical record contained "PHYSICIAN'S ORDERS" for a verbal order for Haldol 5 mg and Ativan 1 mg IM, to be given at the time the order was obtained, for severe agitation on 10/25/10 at 10:00 PM. The LPN documented in the "NURSING PROGRESS NOTES" form for 10/25/10 at 10:00 PM, that Patient #24 was restless and noted to move around in his bed. Subsequent documentation at 10:45 PM indicated Patient #24 was calm following the medication.

Patient #24's record did not document alternative measures implemented prior to the use of the chemical restraint or the rationale for the chemical restraint.

c. Patient #7 was a [AGE] year old male admitted to the facility on [DATE]. His admitting diagnoses included dementia.

Additionally, the "PRN/ONE TIME MEDICATION RECORD" contained documentation that Haldol 10 mg IM was administered on 10/18/11 at 2:00 AM for agitation. On 10/20/11 at 3:45 AM, it was documented that Haldol 10 mg and Ativan 1 mg IM were administered for agitation, combativeness, biting, and kicking. On 10/22/11 at 6:40 PM, it was documented that Haldol 10 mg PO and Ativan (no dosage was documented) IM were administered for combativeness and agitation. On 10/22/11 at 8:00 PM, another dose of Haldol 10 mg PO and Ativan 1 mg PO were administered for agitation.

Patient #7's record did not document alternative measures implemented prior to the use of the chemical restraints or the rationale for the chemical restraints.

d. Patient #18 was a [AGE] year old female who was a patient at the facility from 2/26/11 to 4/04/11. Her discharge diagnoses included dementia, psychosis, and mood disorder.

On 2/28/11 at 9:00 PM, the RN documented on a "PHYSICIAN'S ORDERS" form, a telephone order for Zydis 10 mg sublingual, to be given at the time the order was obtained, for aggressive agitation. The "PRN/ONE TIME MEDICATION RECORD" indicated the medication was administered as ordered.

Patient #18's record did not document alternative measures implemented prior to the use of the chemical restraint or the rationale for the chemical restraint.





e. Patient #13 was an [AGE] year old female who was a patient in the hospital, from 2/16/11 to 3/04/11, with the diagnoses of dementia with anxiety and paranoid ideation, and insomnia.

Patient #13's "PHYSICIAN'S ORDERS" contained an order, on 2/16/11, for Ativan 1 mg PO twice daily PRN. On 2/23/11, additional instructions had been documented on the "PHYSICIAN'S ORDERS" sheet indicating that if Patient #13 refused to take Ativan 1 mg PO twice daily PRN for anxiety, the medication may be administered IM.

Patient #13's "PRN MEDICATION ADMINISTRATION RECORD" indicated Ativan had been administered on the following occasions:

- On 2/23/11 at 5:43 PM: Ativan 1 mg was administered IM for agitation.
- On 2/23/11 at 9:50 PM: Ativan was administered (route and the reason why the medication was given was not documented).

Patient #13's record did not document alternative measures implemented prior to the use of the chemical restraints or the rationale for the chemical restraints.





g. Patient #15 was an [AGE] year old male admitted to the facility 10/19/11 with diagnoses of Alzheimer's and dementia.

His medical record documented a telephone order on a "PHYSICIAN'S ORDERS" form, dated 10/20/11 at 1:15 AM, for Haldol 10 mg IM and Ativan 1 mg IM, to be given at the time the order was obtained, for aggressive agitation.

"NURSING PROGRESS NOTES," dated 10/20/11 at 4:40 AM, noted Patient #15 was "...Confused, wandering halls, not believing where his rm [room] was. Became combative trying to hit staff, not wanting to stay in bed, pushing at staff & yelling at them. Medicated as ordered by doctor, is presently resting quietly. Will cont. [continue] to [check] q 15" [minutes] & follow POC."

Patient #15's record did not document alternative measures implemented prior to the use of the chemical restraint.

Physicians A, B, and C were interviewed jointly, on 10/27/11 at 8:45 AM. Physician A stated he was aware that Haldol and Ativan ordered on a PRN basis were considered a restraint. Therefore, he requested staff contact him directly when there were issues, and he ordered specific medications based on the nurse's report of patient behavior. He stated the practicing physicians would rather be woken up in the middle of the night to ensure that appropriate medications were given in response to patients' symptoms. The intent was never to chemically restrain a patient, but to treat an acute agitation or psychotic state. If a second dose of a medication (such as a second dose of Haldol and Ativan in response to continued behaviors) was ordered, the intent was to get the patient the right amount of the medication to get the patient to a calm state.

Physician C stated it was never the intent to restrain patients. The goal was to get patients to a calm, alert and comfortable state. She stated that, based on the patient's response to the one time orders of medication, routine medications may be adjusted.

LPN H was interviewed, on 10/25/11 at 2:45 PM, regarding restraint issues. She stated if the physician ordered a one time medication for behaviors that were not part of the normal regime for the patient, it would be considered a chemical restraint. She confirmed that if a patient needed to be held down in order to safely administer an injection, it would be considered a physical restraint. She stated the RN had specific paperwork to complete when a restraint was used. She stated that no soft restraints were used in the facility and no one was placed in seclusion.

The DON was interviewed on 10/27/11 at 10:30 AM. She stated a medication could be considered a chemical restraint based on various criteria, such as what medication was given, how it was given, the reason it was given, and the response to the medication.

The ADON was interviewed on 10/28/11 at 12:50 PM. She stated a chemical restraint was a medication given to a patient that was above normal dosing, or outside of the normal routine medication administration for that patient. She stated the chemical restraint was implemented when less restrictive measures were not successful to alter the patient's behavior, especially if the patient posed a danger to themselves or others. She stated the call to the physician for a medication order was driven by the nursing assessment. She stated staff used to specifically ask the physicians if a medication was to be considered a chemical restraint, now it is up to the individual RN to make the determination. The ADON further stated it was expected that once a medication was determined to be administered as a chemical restraint, the face to face documentation was to be initiated. She stated descriptions of the behaviors were to be charted to assess for possible sources leading to the behavior. She stated that once a patient was administered a medication as a result of behaviors, the patient was to be monitored closely. She stated the medical record should contain documentation related to the response of the patient to the medications.

The hospital failed to ensure the use of chemical restraints were recognized, appropriately utilized and complete documentation regarding the use of the restraints was included in the patients' medical records.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on review of hospital policy, record review and staff interview it was determined the facility failed to ensure the patients' POCs were modified to reflect the use of restraint for 16 of 17 patients reviewed (#1, #2, #7, #11 - #15, #17 - #19, #21, #24, #29, #31 and #38) for whom restraints were used. This resulted in a lack of comprehensive, current information being available in the patients POC, and had the potential to result in inconsistent interventions being implemented. The findings include:

1. Patient records were reviewed and documented chemical and physical restraint use. However, the patients' POCs were not updated to reflect the use of restraints as follows:

a. Patient #19's record documented the following restraint use:

- 9/28/11 at 11:00 PM: Zyprexa 10 mg was administered for aggressive agitation.
- 9/28/11 at 11:45 PM: Haldol 10 mg and Ativan 1 mg were administered for aggressive agitation.
- 9/29/11 at 4:30 PM: Haldol 5 mg and Ativan 1 mg were administered for aggressive agitation.
- 9/29/11 at 9:45 PM: Haldol 5 mg and Ativan 1 mg were administered for aggressive agitation.
- 9/30/11 at 6:00 AM: Haldol 10 mg and Ativan 2 mg were administered for agitation and combativeness.
- 10/01/11 at 8:30 PM: Zyprexa 20 mg was administered for aggression.
- 10/01/11 at 11:00 PM: Haldol 10 mg and Ativan 1 mg was administered (no indication listed).
- 10/07/11 at 12:30 AM: Ativan 2 mg was administered for agitation and combativeness.
- 10/07/11 at 12:35 AM: a CPI hold was used for hitting and kicking.
- 10/13/11 at 9:30 PM: Ativan 1 mg was administered (no indication listed).

Patient #19's record documented 9 chemical and one physical restraint. However, no documentation of updates to Patient #19's POC reflecting the restraint use could be found.

b. Patient #17's record documented the following restraint use:

- 8/13/11 at 11:00 PM: Haldol 10 mg and Ativan 2 mg was administered for aggressive agitation.
- 8/16/11 at 10:00 PM: Haldol 10 mg and Ativan 2 mg was administered for aggressive agitation.
- 8/19/11 at 2:15 AM: Haldol 10 mg and Ativan 2 mg was administered for aggressive agitation.
- 8/20/11 at 8:40 PM: Haldol 5 mg and Ativan 1 mg was administered for aggressive agitation.
- 8/21/11 at 1:30 AM: Haldol 5 mg and Ativan 1 mg was administered for screaming.
- 8/24/11 at 9:30 PM: Haldol 5 mg and Ativan 2 mg was administered for aggressive agitation.

Patient #17's record documented 6 chemical restraints. However, no documentation of updates to Patient #17's POC reflecting the restraint use could be found.

c. Patient #38's record documented the following restraint use:

- 9/01/11 at 12:00 AM: Haldol 10 mg and Ativan 2 mg was administered for agitation and aggression.
- 9/02/11 at 9:25 PM: Zydis 10 mg was administered for aggressive agitation.
- 9/03/11 at 4:00 AM: Haldol 5 mg and Ativan 1 mg was administered for aggressive agitation.
- 9/04/11 at 2:10 AM: Haldol 10 mg and Ativan 2 mg was administered for agitation and aggression.
- 9/04/11 at 9:00 PM: Haldol 5 mg was administered for aggressive agitation.
- 9/05/11 at 6:00 PM: Haldol 5 mg and Ativan 1 mg was administered for aggressive agitation.
- 9/06/11 at 10:00 PM: Ativan 2 mg was administered for aggressive agitation.

Patient #38's record documented 7 chemical restraints. However, no documentation of updates to Patient #38's POC reflecting the restraint use could be found.

d. Patient #2's record documented the following restraint use:

- 10/10/11 at 8:30 PM: Haldol 5 mg was administered for anxiety, resistive, and confusion.
- 10/10/11 at 9:45 PM: Haldol 10 mg was administered for aggressive agitation.
- 10/10/11 at 11:15 PM: Haldol 10 mg was administered for aggressive agitation.
- 10/11/11 at 7:45 PM: Haldol 10 mg and Ativan 2 mg was administered for restless, yelling, agitation.
- 10/13/11 at 6:35 PM: Zyprexa 10 mg was administered for refusing to wear her oxygen.

Patient #2's record documented 5 chemical restraints. However, no documentation of updates to Patient #2's POC reflecting the restraint use could be found.

e. Patient #1's record documented the following restraint use:

- 10/18/11 at 3:30 PM: Zyprexa 10 mg was administered for aggressive agitation.
- 10/18/11 at 6:00 PM: Haldol 5 mg and Ativan 2 mg was administered for aggressive agitation.
- 10/18/11 at 9:30 PM: Haldol 5 mg and Ativan 2 mg was administered for aggressive agitation.
- 10/23/11 at 11:15 PM: Haldol 5 mg and Ativan 2 mg was administered (no indication listed).

Patient #1's record documented 4 chemical restraints. However, no documentation of updates to Patient #1's POC reflecting the restraint use could be found.

f. Patient #15's record documented the following restraint use:

- 10/20/11 at 12:40 AM: Haldol 10 mg and Ativan 1 mg was administered for agitation.
- 10/20/11 at 1:15 AM: Haldol 10 mg and Ativan 1 mg was administered for aggressive agitation.

Patient #15's record documented 2 chemical restraints. However, no documentation of updates to Patient #15's POC reflecting the restraint use could be found.

g. Patient #14's record documented the following restraint use:

- 10/12/11 at 1:15 AM: Haldol 5 mg and Ativan 2 mg was administered for screaming/agitation.
- 10/12/11 at 10:20 PM: Haldol 5 mg IM and Ativan 2 mg IM was administered for screaming/agitation.

Patient #14's record documented 2 chemical restraints. However, no documentation of updates to Patient #14's POC reflecting the restraint use could be found.





h. Patient #12's record documented the following restraint use:

- 10/05/11 at 9:00 PM: Zyprexa 10 mg was given now for anxiety and screaming.
- 10/06/11 at 1:30 PM: Zyprexa 10 mg was given for increased anxiety.
- 10/06/11 at 10:10 PM: Zyprexa 10 mg PO was given for yelling and screaming.
- 10/08/11 at 10:00 PM: Ativan 1 mg PO was given for increased anxiety.
- 10/10/11 at 9:45 PM: Zyprexa 10 mg PO was given for severe anxiety and yelling.

Patient #12's record documented 5 chemical restraints. However, no documentation of updates to Patient #12's POC reflecting the restraint use could be found.

i. Patient #11's record documented the following restraint use:

- 9/04/11 at 9:00 PM: Thiothixene (Navane) 5 mg PO was given for unspecified reasons.
- 9/04/11 at 9:50 PM: Ativan 2 mg IM was given for aggressive agitation.
- 9/04/11 at 10:40 PM: Zydis 10 mg PO was given for aggressive agitation.
- 9/04/11 at 11:15 PM: Haldol 5 mg was given for aggressive agitation.
- 10/12/11 at 12:45 AM: Ativan 2 mg PO was given for severe anxiety.
- 10/13/11 at 4:00 PM: Ativan 2 mg IM was given for severe anxiety.
- 10/16/11 at 10:30 PM: Ativan 1 mg IM was given for severe anxiety.
- 10/18/11 at 11:05 PM: Ativan 2 mg was given for agitation and paranoia.
- 10/20/11 at 12:40 AM: Ativan 2 mg was given for agitation and anxiety.
- 10/21/11 at 11:55 PM: Ativan 2 mg IM was given for agitation and anxiety.
- 10/26/11 at 2:20 AM: Ativan 2 mg IM was given for aggressive agitation.
- 10/27/11 at 11:10 PM: Haldol 5 mg and Ativan 2 mg was given for aggressive agitation.
- 10/28/11 at 12:45 AM: Ativan 2 mg was given for aggressive agitation.

Patient #11's POC for Actual Violence was dated 8/22/11. A Nursing Intervention was "Consider chemical restraint for out of control, violent patient." There was no further documentation to show that the medications given to the patient for violent behaviors were care planned as actual chemical restraints. Patient #11's POC did not include documentation to show that the medications utilized as chemical restraints were care planned or updated to reflect the use of the medications for control of behavior.

j. Patient #13's record documented the following restraint use:

- 2/23/11 at 5:43 PM: Ativan 1 mg IM for agitation.
- 2/23/11 at 9:50 PM: Ativan (no route and no reason given).

Patient #13's record documented 2 chemical restraints. However, no documentation of updates to Patient #13's POC reflecting the restraint use could be found.





k. Patient #21's medical record contained documentation of the following restraint use:

- 9/09/10 at 8:30 PM: Haldol 10 mg and Ativan 2 mg were given IM for agitation and danger to self and others.
- 9/09/10 at 9:30 PM: Ativan 2 mg IM for combativeness.
- 9/10/10 at 7:20 PM: Haldol 10 mg and Ativan 2 mg PO/IM were given for increased anxiety and agitation.
- 9/14/10 at 8:40 AM: Haldol 10 mg and Ativan 2 mg PO/IM were given for agitation and violent behavior.

Patient #21's record contained documentation of the use of 4 chemical restraints. However, no documentation of updates to Patient #21's POC reflecting the restraint use could be found.

l. Patient #31's medical record contained documentation of the following restraint use:

- 8/24/11 at 10:00 PM: Zyprexa 10 mg IM was given for aggressive agitation.
- 8/24/11 at 11:00 PM: Haldol 5 mg and Ativan 1 mg IM were given for aggressive agitation.
- 8/31/11 at 3:55 AM: Ativan 2 mg PO/IM were given for combativeness and agitation.

Patient #31's medical record contained documentation of the use of a 3 chemical restraints. However, no documentation of updates to Patient #31's POC reflecting the restraint use could be found.

m. Patient #7's medical record contained documentation of the following restraint use:

- 10/17/11 at 4:35 AM: Haldol 10 mg IM was given for agitation and combativeness.
- 10/18/11 at 2:00 AM: Haldol 10 mg IM was given for agitation.
- 10/20/11 at 3:45 AM: Haldol 10 mg and Ativan 1 mg IM were given for agitation.
- 10/22/11 at 6:40 PM: Haldol 10 mg PO and Ativan (no dosage was documented) IM were given for combativeness and agitation.
- 10/22/11 at 8:00 PM: Haldol 10 mg PO and Ativan 1 mg PO were given for agitation

Patient #7's medical record contained documentation of the use of 5 chemical restraints. However, no documentation of updates to Patient #7's POC reflecting the restraint use could be found.

n. Patient #18's medical record contained documentation of the following restraint use:

- 2/26/11 at 10:45 PM: Haldol 5 mg IM and Ativan 1 mg IM were given for hostile aggression and danger to self.
- 2/28/11 at 9:00 PM: Zydis 10 mg sublingual was given for aggressive agitation.

Patient #18's medical record contained documentation of the use of 2 chemical restraints. However, no documentation of updates to Patient #18's POC reflecting the restraint use could be found.

o. Patient #24's medical record contained documentation of the following restraint use:

- 10/25/10 at 10:00 PM: Haldol 5 mg and Ativan 1 mg IM were given for severe agitation.

Patient #24's medical record contained documentation of the use a chemical restraint. However, no documentation of updates to Patient #24's POC reflecting the restraint use could be found.

p. Patient #29's medical record contained documentation of the following restraint use:

- 6/16/11 11:30 PM: Haldol 10 mg and Ativan 2 mg IM were given for aggressive agitation.

Patient #29's medical record contained documentation of the use a chemical restraint. However, no documentation of updates to Patient #29's POC reflecting the restraint use could be found.

The hospital's "Seclusion and Restraint" policy, dated 11/04/08 stated when patient restraint or seclusion was used, a "debriefing" was to be conducted in an effort to obtain the patient's perspective regarding what happened and what might have been done differently, to allow staff to assess the trauma caused by the restraint and to counsel the patient as needed, and to allow the staff to problem solve with the patient in an effort to reduce recurrent use of restraint or seclusion. However, the policy did not include procedures for how the information would be considered or used to update the patients' POCs.

The hospital's "Interdisciplinary Treatment Plan" policy, dated 1/15/08, stated initial patient treatment plans were to be completed within 72 hours of admission. The policy further stated treatment plans were to be reviewed and revised at weekly treatment team meetings and "Any major changes to the treatment plan prior to weekly treatment team meetings will be made during the weekday morning stand-up meetings." The policy did not include definition or examples of what "major changes" were and the policy did not address treatment plan revisions being made as a result of restraint use.

Neither the hospital's "Seclusion and Restraint" policy nor the hospital's "Interdisciplinary Treatment Plan" policy, included procedures for updating patient POCs when restraints were used.

The ADON was interviewed on 10/28/11 at 12:50 PM. She stated that the POC was initiated on admission and contained a section related to behaviors. Interventions for the behaviors included administering medications as ordered by the physician. She stated this included medications ordered as needed to control behaviors. She confirmed that restraint usage, chemical or physical, was not added to the care plan when needed.

The facility failed to ensure patients' POCs were updated to reflect the use of restraint.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
Based on review of hospital policy and personnel files, and staff interview, it was determined the facility failed to ensure restraint policies were sufficiently developed, implemented and monitored for 17 of 17 patients reviewed (#1, #2, #7, #11 - #19, #21, #24, #29, #31 and #38) for whom restraints were used. This resulted in an inability of the facility to ensure chemical and physical restraints were implemented in a safe and effective manner. The findings include:

1. The hospital's "Seclusion and Restraint" policy, dated 11/04/08, defined physical restraint as "Any manual method, physical or manual device, material of equipment [sic] that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. The only acceptable physical restraints in use at [facility name] are the CPI Children's Control Position and the CPI Team Control Position. Wrist and ankle restraints as well as Posey vests are not to be used." The policy further stated, under the "Document in the narrative notes" section, that documentation was to be kept reflecting "Emergency medications administered and if the patient required a physical restraint to administer the medication."

CNA C was interviewed on 10/25/11 at 10:45 AM. He explained that all staff were trained in CPI restraint usage within 90 days of hire. He stated that occasionally, if it were safer for the patient, an IM injection may be given with the patient lying on the bed. If this were the case, the patients' hands and legs may need to be subdued for safety. He stated he was not sure this was documented in patients' records.

The DON was interviewed on 10/27/11 at 10:30 AM. She stated she usually considered a CPI hold as a restraint. She stated the CPI holds may be used to stabilize the patient for an injection but that this was not always documented. She stated staff did not lay patients down in bed to give injections.

The ADON was interviewed on 10/28/11 at 12:50 PM. She stated the only physical holds used in the facility were the CPI holds. She stated it was typically a standing hold to keep the patient in place or assist in escorting the patient to a safer location. She stated there was not a CPI hold for laying patients down.

The hospital's policy did not include the use of the restraint described by CNA C and no documentation of staff training could be found regarding the use of the restraint.

Additionally, review of 17 nursing staff personnel files revealed that the hospital did not have evidence to show the nursing staff were competency tested annually, or that they were trained to address the specific needs of the patients who exhibited behaviors. None of the files had current competency checklists in them.

On 10/28/11, the DON was requested to provide current competency checklists for the nursing staff, as well as documentation of in-service training which had been provided to the nursing staff. The DON stated that these competencies had been done, but she was not sure where the paperwork had been filed. She provided one "initial" competency checklist, which was dated 10/19/11, more than two months after the RN's hire date of 8/08/11.

The "Licensed Nursing Staff (RN/LPN) Competency Checklist Initial and Annual" included sections related to communication, physiological age changes, functional status, restraints, and geri-psych skills. These topics were pertinent to providing quality care to the geriatric population with behavioral issues. However, the use of CPI was not specifically listed as a competency that was evaluated.





The facility failed to ensure staff were sufficiently trained necessary to ensure restraints were implemented in accordance with facility policy.

2. Refer to A160 as it relates to the facility's failure to ensure the use of chemical restraints was recognized, appropriately utilized and documentation regarding the use of the restraints was included in the patients' medical records in accordance with facility policy.

3. Refer to A168 as it relates to the facility's failure to ensure physician orders were obtained for the use of all chemical and physical restraints in accordance with facility policy.

4. Refer to A175 as it relates to the facility's failure to ensure the condition of patients who were restrained was consistently assessed, monitored and re-evaluated in accordance with facility policy.

5. Refer to A178 as it relates to the facility's failure to ensure one hour face to face assessment were consistently conducted by qualified personnel for patients who were restrained, and in accordance with facility policy.

6. Refer to A179 as it relates to the facility's failure to ensure restraint policies were sufficiently developed necessary to ensure that one hour face to face assessments included all necessary information.

7. Refer to A182 as it relates to the facility's failure to ensure restraint policies were sufficiently developed necessary to ensure that the physician was notified of one hour face to face assessments results when such assessments were completed by another practitioner.

8. Refer to A184 as it relates to the facility's failure to ensure restraint policies were sufficiently developed necessary to ensure that the one hour face to face assessments were documented in the patients' records.

9. Refer to A188 as it relates to the facility's failure to ensure restraint policies were sufficiently developed necessary to ensure that the patients' responses to restraint and seclusion were consistently documented in the patient's medical records.

The facility failed to ensure restraint policies were sufficiently developed, implemented and monitored.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on review of hospital policy, record review and staff interview, it was determined the facility failed to ensure physician orders were obtained for the use of physical restraint. This directly impacted 3 of 17 patients reviewed (#1, #19, #21) for whom restraints were used, and had the potential to impact all patients who required physical restraint. This resulted in patients being subjected to physical restraint without an appropriate order. The findings include:

1. The hospital's "Seclusion and Restraint" policy, dated 11/04/08, stated upon initiation of a restraint, the RN was to immediately obtain and document the restraint orders from the physician.

Patient medical records were reviewed. The records documented patients being restrained without a physician order as follows:

a. Patient #21's medical record contained documentation of the following restraints:

- 9/09/10 at 8:30 PM: Haldol 10 mg IM and Ativan 2 mg IM were given for agitation and danger to self and others. The LPN documented, in the "NURSING PROGRESS NOTES" on 9/09/10 at 8:30 PM, that the Haldol and the Ativan were administered to Patient #21 using "CPI hold."

- 9/09/10 at 9:30 PM: Ativan 2 mg IM was given for combativeness and agitation. The LPN documented, in the "NURSING PROGRESS NOTES" on 9/09/10 at 9:30 PM, Ativan was administered to Patient #21 using "CPI hold."

The medical record did not contain an order for use of a CPI hold to administer the Haldol and Ativan.

The ADON was interviewed on 10/28/11 at 12:50 PM. She reviewed Patient #21's medical record and confirmed there was no order for the use of the CPI holds on 9/09/10.

b. Patient #1's record documented, on 10/18/11 at 3:30 PM, Zyprexa 10 mg IM was administered as ordered for aggressive agitation. The record contained documentation a "CPI hold" was used during the Zyprexa injection. Patient #1's record did not include physician orders for the physical restraint.

When asked about the restraint, during an interview on 10/28/11 at 2:45 PM, RN B confirmed no order for the physical hold had been documented.

c. Patient #19's record documented, on 10/07/11 at 12:30 AM, Ativan 2 mg was administered as ordered for combativeness and agitation. The record contained documentation a "CPI hold" was used during the Ativan injection.

Patient #19's record did not include physician orders for the physical restraint.

When asked about the restraint, during an interview on 10/28/11 at 2:50 PM, RN B stated the nursing staff, at times, required assistance when administering what she called "prn" medications.

The DON was interviewed on 10/27/11 at 10:30 AM. She stated she usually considered a CPI hold as a restraint. She stated the CPI holds may be used to stabilize the patient for an injection but that this was not always documented.

The ADON was interviewed on 10/28/11 at 12:50 PM. She stated orders for CPI holds, even for medication administration, were not routinely obtained. She stated the use of CPI holds was not always documented and staff may require further education related to appropriate documentation.

The facility failed to ensure physician orders were obtained for all restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policy, record review and staff interview, it was determined the facility failed to ensure restraint policies were sufficiently implemented and monitored for 17 of 17 patients reviewed (#1, #2, #7, #11 - #19, #21, #24, #29, #31 and #38), for whom restraints were used. This resulted in the potential for patients' emergent health and safety needs to be unaddressed. The findings include:

1. The hospital's "Seclusion and Restraint" policy, dated 11/04/08, stated "The condition of the patient who has been restrained or in seclusion must continually be assessed, monitored and re-evaluated. Physical and Psychological assessment are completed every 15 minutes by the RN or LPN for one hour. A C.N.A. will be assigned to the patient to assist the patient in meeting their needs, i.e.: hygiene, nutrition and hydration, elimination and comfort. This will be in place for a minimum of one hour and be charted on the observation sheet as a 1:1. The RN in charge, upon assessment of the patient will make the decision of when to discontinue the C.N.A. 1:1. The patient will then be monitored every 15 minutes by the C.N.A."

However, the policy did not include what CNA staff were to be monitoring (i.e. location, increases in maladaptive behaviors, signs and symptoms of distress, etc.). The facility failed to ensure the policy was sufficiently developed.

Additionally, patient medical records were reviewed. The records documented patients being restrained without documentation from the CNA or evidence of 15 minute monitoring by the RN or LPN as follows:

a. Patient #21 was an [AGE] year old male cared for by the facility from 9/09/10 through 9/15/10. His discharge diagnoses included dementia, mood disorder, and psychotic disorder.

His medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS." The form was dated 9/09/10 at 8:30 PM. The RN who completed the form indicated numerous non-pharmaceutical measures had been attempted to calm Patient #21. The RN documented Patient #21 was anxious, agitated, disoriented/confused, not able to follow instructions and a danger to himself and others. A verbal order was obtained for Haldol 10 mg IM and Ativan 2 mg IM for agitation.

A second "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS" form was dated 9/09/10 at 9:30 PM. Again, the RN indicated non-pharmaceutical measures were attempted prior to obtaining a verbal order for a behavior medication. The RN documented, in addition to the reasons listed above, that Patient #21 was anxious, agitated, disoriented/confused, not able to follow instructions, a danger to himself and others, and was combative. An order for Ativan 2 mg IM was obtained.

Nursing documentation by an LPN on 9/09/10 at 9:35 PM indicated Patient #21 became unsteady on his feet and lost his balance.

Additionally, Patient #21's "PHYSICIAN'S ORDERS" form dated 9/10/10 at 7:20 PM, documented a verbal order for Haldol 10 mg PO/IM and Ativan 2 mg PO/IM, to be given at the time the order was obtained, for increased anxiety and agitation. The "PRN/ONE TIME MEDICATION RECORD" documented the medications were administered IM and the LPN documented "+" results at 8:30 PM.

Patient #21's medical record contained another "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS" form, dated 9/14/10 at 8:40 AM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #21 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #21 was combative, grabbing, agitated, confused, unable to follow directions, unredirectable, refusing to take oral medications, was a danger to himself and others, and was violent. The physician authorized a verbal order for Haldol 10 mg and Ativan 2 mg PO/IM for agitation.

No documentation of CNA, LPN or RN monitoring after the use of the chemical restraints could be found in Patient #21's record.

b. Patient #24 was a [AGE] year old male cared for by the facility from 10/21/10 to 10/30/10. His discharge diagnosis was dementia with behavior disturbance.

His medical record contained documentation of a verbal order for Haldol 5 mg and Ativan 1 mg IM once now for severe agitation, on 10/25/10 at 10:00 PM. The LPN documented, in the "NURSING PROGRESS NOTES" form for 10/25/10 at 10:00 PM, that Patient #24 was restless and noted to move around in his bed.

The next documentation in the medical record was in the nursing progress notes, on 10/25/10 at 10:45 PM, by the LPN. The LPN indicated Patient #24 was calm after receiving the IM injection.

No additional documentation of CNA, LPN or RN monitoring after the use of the chemical restraint could be found in Patient #24's record.

c. Patient #29 was a [AGE] year old male cared for by the facility from 6/15/11 to 6/21/11. His discharge diagnoses included dementia, psychosis, and mood disorder.

His medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 6/16/11 at 11:30 PM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #29 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #29 was combative, grabbing, anxious, agitated, was a danger to himself and others, and was kicking and hitting. The physician authorized a verbal order for Haldol 10 mg and Ativan 2 mg PO/IM for aggressive agitation.

No documentation of CNA, LPN or RN monitoring after the use of the chemical restraint could be found in Patient #29's record.

d. Patient #31 was an [AGE] year old male cared for by the facility from 8/24/11 to 9/02/11. His discharge diagnoses included dementia and mood disorder with severe irritability and anger.

His medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 8/24/11 at 10:00 PM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #31 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #31 was combative, grabbing, anxious, agitated, disoriented, was a danger to himself and others, and was hitting, kicking, and throwing items. The physician authorized a verbal order for Zyprexa 10 mg IM now for aggressive agitation.

Nursing notes, completed by the LPN on 8/24/11 at 10:30 PM, indicated Patient #31 was resting but still restless after receiving the IM injection of Zyprexa.

A second "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS" form was dated 8/24/11 at 11:00 PM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #31 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #31 was combative, anxious, agitated, disoriented, screaming and hitting. The physician authorized a verbal order for Haldol 5 mg and Ativan 1 mg IM for aggressive agitation. The RN documented the physician indicated "May repeat in 1 [hour] if needed." The "PRN/ONE TIME MEDICATION RECORD" indicated the medictions were administered as ordered, but did not contain documentation related to the reponse to the medications.

A third "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS" form was dated 8/31/11 at 3:55 AM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #31 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #31 was combative, grabbing, anxious, agitated, disoriented, was a danger to himself and others, and was violent. The physician authorized a verbal order for Ativan 2 mg PO/IM for agitation. The "PRN/ONE TIME MEDICATION RECORD" indicated the mediction was administered IM and at 4:30 AM. Nursing staff documented it "helped some."

With the exception of the documentation by the LPN on 8/24/11 and 8/31/11, no documentation of CNA, LPN or RN monitoring after the use of the chemical restraints could be found in Patient #31's record.

e. Patient #16 was an [AGE] year old female cared for by the facility from 8/24/11 through 9/06/11. Her discharge diagnoses included dementia and mood disorder.

Her medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 8/24/11 at 9:30 PM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #16 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #16 was anxious, agitated, disoriented, was a danger to others, was hitting, kicking, biting, throwing, and was violent. The physician authorized a verbal order for Zyprexa 10 mg IM now for aggressive agitation.

Nursing progress notes contained documentation from the LPN on 8/24/11 at 10:30 PM. The LPN indicated that Patient #16 was now resting after the IM medication was given.

No additional documentation of continued physical and psychological monitoring by the CNA, LPN or RN could be found in Patient #16's record.

f. Patient #7 was a [AGE] year old male admitted to the facility on [DATE] and was a current patient at the time of the survey. His admitting diagnoses included dementia.

Patient #7's medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 10/17/11 at 4:35 AM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #7 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #7 was anxious, agitated, combative, disoriented, was a danger to self, was unable to follow directions, and was dismantling his room. The physician authorized a verbal order for Haldol 10 mg IM now for agitation and combativeness.

The LPN documented, in the nursing progress notes on 10/17/11 at 5:00 AM, "Pt [Patient] has been restless & combative pacing trying to remove air condition [sic], sink, toilet, closet doors. Pt was urinating on floor kept remove [sic] clothing & attends. Ativan 1 mg X 2, Zyprexa 10 mg X 2, & Haldol 10 mg per MD orders. Little to no effect. Pt is biting & hitting staff."

No documentation of continued physical and psychological monitoring by the CNA, LPN or RN could be found in Patient #7's record following the administration of chemical restraints. However, the ADON provided documentation of a one hour face to face assessment, completed by the RN at 5:30 AM, for the administration of the Haldol 10 mg at 4:35 AM on 10/17/11.

The "PRN/ONE TIME MEDICATION RECORD" for Patient #7 contained documentation that Haldol 10 mg IM was administered, on 10/18/11 at 2:00 AM, for agitation. On 10/20/11 at 3:45 AM, it was documented that Haldol 10 mg and Ativan 1 mg IM were administered for agitation, combativeness, biting, and kicking. No response to the medications were documented.

On 10/22/11 at 6:40 PM 3:45 AM the "PRN/ONE TIME MEDICATION RECORD" documented Haldol 10 mg PO and Ativan (no dosage documented) IM were administered for combativeness and agitation. In the results section of the record was a "+." On 10/22/11 at 8:00 PM, another dose of Haldol 10 mg PO and Ativan 1 mg PO were administered for agitation. There was no documentation regarding Patient #7's response to the medications administered.

The LPN documented in "NURSING PROGRESS NOTES," on 10/22/11 at 6:40 PM, that Patient #7 "wanders, intrusive, nonredirectable. punching CNAs & punching CNAs in walls. Intrusive." At 6:45 PM, the LPN documented Patient #7 was given Haldol 10 mg and Ativan 1 mg due to combativeness. The LPN documented, "Pt coop [sic] [with] med [medication] admin [administration]- will monitor for effectiveness." At 7:10 PM, the LPN documented, "Pt coop [sic] & quiet. meds were effective."

No additional documentation of CNA, LPN or RN monitoring after the use of the chemical restraints could be found in Patient #7's record.

g. Patient #18 was a [AGE] year old female cared for by the facility from 2/26/11 through 4/04/11. Her discharge diagnoses included dementia, psychosis, and mood disorder.

Her medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 2/26/11 at 10:45 PM. The RN documented Patient #18 had 1:1 supervision and staff attempted to use redirection to calm her prior to obtaining the verbal order for medical assistance. The RN indicated Patient #18 was agitated, combative, disoriented, disorganized, hitting, and was a danger to herself. The physician authorized a verbal order for Haldol 5 mg PO/IM and Ativan 1 mg PO/IM now for hostile aggression and danger to self.

Documentation in the "NURSING PROGRESS NOTES," on 2/26/11 at 11:00 PM, indicated Patient #18 was "hitting and slapping staff with any attempts to redirect or each time they catch her from falling...concern raised for her safety. [Physician] notified, orders for Haldol 5 mg and Ativan 1 mg [IM] received and administered...placed on 1:1." At 11:15 PM on 2/26/11, the RN documented a set of vital signs and noted Patient #18 was asleep.

On 2/28/11 at 9:00 PM, the RN documented a telephone order for Zydis 10 mg sublingual once now for aggressive agitation. The "PRN/ONE TIME MEDICATION RECORD" included documentation of administration of the Zydis and noted the medication had a "+" effect.

The LPN documented in the nursing progress notes on 2/28/11 at 10:00 PM, that earlier in the shift "pt was combative [with] staff....unable to redirect [sic] pt was given Zydis in which pt is calmer and 1:1 CNA is with pt, pt was walking."

No additional documentation of CNA, LPN or RN monitoring after the use of the chemical restraints could be found in Patient #18's record.

h. Patient #2 was an [AGE] year old female admitted to the facility 10/10/11 with a diagnosis of dementia with aggressive behavior.

Her medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 10/10/11 at 7:45 PM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #2 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #2 was anxious, agitated, disoriented, was a danger to herself and others, and was unable to follow directions. The physician authorized a verbal order for Haldol 10 mg IM now and Ativan 2 mg IM now for aggressive agitation.

A second "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS" form was dated 10/10/11 at 8:30 PM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #2 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #2 was combative, anxious, agitated, disoriented, and unable to follow instructions. The physician authorized a verbal order for Haldol 5 mg IM for anxiety, resistiveness and confusion.

A third "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," was dated 10/10/11 at 9:45 PM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #2 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #2 was grabbing, anxious, agitated, disoriented, was a danger to herself and others, was hitting, and unable to follow instructions. The physician authorized a verbal order for Haldol 10 mg IM now for aggressive agitation.

No documentation of CNA, LPN or RN monitoring after the use of the chemical restraint could be found in Patient #2's record.

i. Patient #1 was a [AGE] year old female admitted to the facility 10/18/11 with a diagnosis of dementia with aggressive behavior.

Her medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 10/18/11 at 3:30 PM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #1 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #1 was combative, agitated, was a danger to herself and others, hitting, kicking, biting, yelling and was unable to follow directions. The physician authorized a verbal order for Zyprexa 10 mg IM now for aggressive agitation.

A second "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS" form was dated 10/18/11 at 6:00 PM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #1 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #1 was combative, grabbing, agitated, disoriented, verbally abusive, violent, screaming, kicking, biting and unable to follow instructions. The physician authorized a verbal order for Haldol 5 mg IM and Ativan 2 mg IM for aggressive agitation.

No documentation of CNA, LPN or RN monitoring after the use of the chemical restraints could be found in Patient #1's record.

j. Patient #14 was a [AGE] year old female admitted to the facility 10/11/11 with a diagnoses of paranoia, delusions and hallucinations.

Her medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 10/12/11 at 1:15 AM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #14 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #14 was rolling on the floor, agitated, was a danger to herself and others, yelling and was disoriented. The physician authorized a verbal order for Haldol 10 mg IM and Ativan 2 mg IM for screaming/ agitation.

No documentation of CNA, LPN or RN monitoring after the use of the chemical restraints could be found in Patient #14's record.

k. Patient #15 was an [AGE] year old male admitted to the facility 10/19/11 with diagnoses of Alzheimer's and dementia.

His medical record contained a "PHYSICIAN'S ORDERS" form, dated 10/20/11 at 1:15 AM, contained a telephone order for Haldol 10 mg IM and Ativan 1 mg IM once now for aggressive agitation.

"NURSING PROGRESS NOTES," dated 10/20/11 at 4:40 AM, noted Patient #15 was "...Confused, wandering halls, not believing where his rm [room] was. Became combative trying to hit staff, not wanting to stay in bed, pushing at staff & yelling at them. Medicated as ordered by doctor, is presently resting quietly. Will cont. [continue] to [check] q 15" [minutes] & follow POC."

No additional documentation of CNA, LPN or RN monitoring after the use of the chemical restraints could be found in Patient #15's record.

l. Patient #17 was a [AGE] year old male who was cared for by the facility from 8/09/11 to 9/22/11 with diagnoses of mood disorder, psychosis and dementia.

His medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 8/13/11 at 11:00 PM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #17 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #17 was anxious, agitated, disoriented, was violent, hitting, a danger to himself and others, and was unable to follow directions. The physician authorized a verbal order for Haldol 10 mg PO/IM now and Ativan 2 mg PO/IM now for aggressive agitation.

No documentation of CNA, LPN or RN monitoring after the use of the chemical restraint could be found in Patient #17's record.

m. Patient #38 was an [AGE] year old male who was a cared for by the facility from 8/31/11 to 9/28/11 with the diagnoses of Alzheimer's, COPD, and mood disorder.

His medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 9/03/11 at 4:00 AM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #38 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #38 was combative, agitated, disoriented, was hitting, a danger to himself and others, and was unable to follow directions. The physician authorized a verbal order for Haldol 5 mg PO/IM now and Ativan 1 mg PO/IM now for aggressive agitation.

His medical record contained another order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 9/04/11 at 2:10 AM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #38 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #38 was combative, grabbing, agitated, disoriented, was violent, hitting, a danger to himself and others, and was unable to follow directions. The physician authorized a verbal order for Haldol 10 mg PO/IM now and Ativan 2 mg PO/IM now for aggressive agitation.

Patient #38's medical record contained a "PHYSICIAN'S ORDERS" form, dated 9/06/11 at 10:00 PM, contained a telephone order for Ativan 2 mg IM once now for aggressive agitation.

"NURSING PROGRESS NOTES," dated 9/06/11 at 10:00 PM, noted "pt noted to wake up and was pulling @ covers and was hitting & kicking the CNA. Pt attempted to crawl on floor...pt cont [continues] to kick out [with] redirection and charge RN in to assess. M.D. called...I.M. med given."

No documentation of CNA, LPN or RN monitoring after the use of the chemical restraints could be found in Patient #38's record.

n. Patient #12 was an [AGE] year old female admitted on [DATE] with the diagnoses of history of delirium, traumatic brain injury, non-insulin dependent diabetes, and dementia.

Her medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 10/05/11 at 9:00 PM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #12 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #12 had anxiety and was yelling, screaming, disoriented/confused, and unable to follow instructions. The physician authorized a verbal order for Zyprexa 10 mg once now for "anxiety, screaming."

Her medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 10/06/11 at 1:30 PM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #12 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #12 had anxiety and was yelling. The physician authorized a verbal order for Zyprexa 10 mg once now for "(symbol for) increased anxiety."

Her medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 10/06/11 at 10:10 PM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #12 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #12 had anxiety and was yelling, agitated, disoriented/confused, and unable to follow instructions. The physician authorized a verbal order for Zyprexa 10 mg PO once now for "yelling, screaming."

Her medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 10/08/11 at 10:00 PM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #12 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #12 had anxiety and delusion and was disoriented/confused. The physician authorized a verbal order for Ativan 1 mg PO once now for "(symbol for) increased anxiety."

Her medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 10/10/11 at 9:45 PM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #12 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #12 had anxiety and was yelling, and disoriented/confused. The physician authorized a verbal order for Zyprexa 10 mg PO once now for "severe anxiety/yelling."

No documentation of CNA, LPN or RN monitoring after the use of the chemical restraints could be found in Patient #12's record.

o. Patient #11 was an [AGE] year old female admitted to the facility on [DATE] with the diagnoses of Alzheimer with vascular mix dementia, anxiety disorder, partial blindness, hard of hearing, history of seizures, and aggression.

Her medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 9/04/11 at 2:45 AM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #11 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #11 had anxiety and was combative, danger to self and others, agitated, disoriented/confused, violent, hitting, and unable to follow instructions. The physician authorized a verbal order for Thiothixene 5 mg PO (reason not specified).

Her medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 9/04/11 at 9:50 PM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #11 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #11 had anxiety and was combative, grabbing, danger to self and others, agitated, disoriented/confused, violent, hitting, biting, and unable to follow instructions. The physician authorized a verbal order for Ativan 2 mg IM once now for aggressive agitation.

Her medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 9/04/11 at 10:40 PM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #11 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #11 had anxiety and was combative, grabbing, danger to self and others, agitated, disoriented/confused, violent, hitting, kicking, biting, throwing, and unable to follow instructions. The physician authorized a verbal order for Zydis 10 mg PO once now for aggressive agitation.

Her medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 9/04/11 at 11:15 PM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #11 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #11 had anxiety and was combative, grabbing, danger to self and others, agitated, disoriented/confused, violent, hitting, kicking, biting, throwing, trying to move furniture, and unable to follow instructions. The physician authorized a verbal order for Haldol 5 mg once now for aggressive agitation (PO or IM not specified).

Her medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 10/12/11 at 12:45 AM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #11 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #11 had anxiety and was grabbing, agitated, disoriented/confused, crying out, and unable to follow instructions. The physician authorized a verbal order for Ativan 2 mg PO once now for severe anxiety.

Her medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 10/13/11 at 12:10 PM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #11 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #11 had anxiety and was combative, danger to self, disoriented/confused, and unable to follow instructions. The physician authorized a verbal order for Seroquel 100 mg PO (reason not specified).

Her medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 10/13/11 at 4:00 PM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #11 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #11 had anxiety and was combative, grabbing, danger to self and others, agitated, disoriented/confused, hitting, kicking, biting, throwing, and unable to follow instructions. The physician authorized a verbal order for Ativan 2 mg IM once now for severe anxiety.

Her medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 10/16/11 at 10:30 PM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #11 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #11 had anxiety and panic and was fearful, disoriented/confused, and unable to follow instructions. The physician authorized a verbal order for Ativan 1 mg IM once for severe anxiety.

Her medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 10/18/11 at 11:05 PM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #11 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #11 had anxiety and was danger to self and others, agitated, disoriented/confused, violent, and hitting. The physician authorized a verbal order for Ativan 2 mg once for agitation, paranoia (PO or IM not specified).

Her medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 10/20/11 at 12:40 AM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #11 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #11 had anxiety and was combative, danger to self and others, agitated, disoriented/confused, and hitting. The physician authorized a verbal order for Ativan 2 mg once for agitation/anxiety (PO or IM not specified).

Her medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 10/21/11 at 11:55 PM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #11 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #11 had anxiety and panic and was agitated, disoriented/confused, unable to follow instructions, and fearful. The physician authorized a verbal order for Ativan 2 mg IM once now for agitation/anxiety.

Her medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 10/26/11 at 2:20 AM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #11 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #11 had anxiety and was combative, grabbing, danger to self and others, agitated, disoriented/confused, hitting, kicking, and unable to follow instructions. The physician authorized a verbal order for Ativan 2 mg IM once now for aggressive agitation.

Her medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 10/27/11 at 11:10 PM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #11 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #11 had anxiety and was combative, grabbing, danger to self and others, agitated, disoriented/confused, violent, hitting, and unable to follow instructions. The physician authorized a verbal order for Haldol 5 mg once now for aggressive agitation (PO or IM not specified) with Ativan 2 mg once now for aggressive agitation (PO or IM not specified).

Her medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 10/28/11 at 12:45 AM. The RN documented several non-pharmaceutical measures were attempted to calm Patient #11 prior to obtaining the verbal order for medical assistance. The RN indicated Patient #11 had anxiety and was combative, danger to self and others, agitated, disoriented/confused, violent, hitting, kicking, biting, screaming, and unable to follow instructions. The physician authorized a verbal order for Ativan 2 mg once now for aggressive agitation (PO or IM not specified).

No documentation of CNA, LPN or RN monitoring after the use of the chemical restraints could be found in Patient #11's record.

p. Patient #13 was an [AGE] year old female who was cared for at the facility from 2/16/11 to 3/04/11 with the diagnoses of dementia with anxiety, and paranoid ideation, and insomnia.

Patient #13's "PRN/ONE TIME MEDICATION RECORD" documented that the following medications were administered:

- 2/17/11 at 3:50 PM: Ativan 1 mg PO for anxiety.
- 2/21/11 at 4:00 PM: Ativan 1 mg IM for signs and symptoms of anxiety.
- 2/23/11 at 5:43 PM: Ativan 1 mg IM for agitation.
- 2/23/11 at 9:50 PM: Ativan (no route and no reason given).
- 2/26/11 at 1:15 PM: Ativan 1 mg PO for increased anxiety.

No documentation of CNA, LPN or RN monitoring after the use of the chemical restraints could be found in Patient #13's record.

q. Patient #19's record document
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
Based on review of hospital policy, record review and staff interview, it was determined the facility failed to ensure restraint policies were sufficiently implemented and monitored for 16 of 17 patients reviewed (#1, #2, #7, #11 - #13, #15 - #19, #21, #24, #29, #31 and #38), for whom restraints were used. This resulted in a lack of face-to-face assessments being completed by qualified practitioners for patients placed in restraints. The findings include:

1. The hospital's "Seclusion and Restraint" policy, dated 11/04/08, stated "The condition of the patient who has been restrained or in seclusion must continually be assessed, monitored and re-evaluated." The policy also stated, in the "One Hour Face to Face Evaluation Assessment" section, that a physician, LIP or Qualified RN must see and evaluate the need for restraint or seclusion within 1 hour after the initiation of restraint or seclusion.

Patient medical records were reviewed. The records documented patients being restrained without appropriate face to face assessments being conducted as follows:

a. Patient #21's medical record contained documentation of restraints as follows:

- 9/09/10 at 8:30 PM: Haldol 10 mg IM and Ativan 2 mg IM were given for agitation and danger to others.
- 9/09/10 at 9:30 PM: Ativan 2 mg IM was given for combativeness and agitation.
- 9/10/10 at 7:20 PM: Haldol 10 mg PO/IM and Ativan 2 mg PO/IM x 1 were given for increased anxiety and agitation.
- 9/14/10 at 8:40 AM: Haldol 10 mg and Ativan 2 mg PO/IM were given for violence and agitation.

There was no evidence a one hour face to face evaluation was performed for any of the above listed restraints.

b. Patient #31's medical record contained documentation of restraints as follows:

- 8/24/11 at 10:00 PM: Zyprexa 10 mg IM was given for aggressive agitation.
- 8/31/11 at 3:55 AM: Ativan 2 mg PO/IM was given for violence and agitation.

There was no evidence a one hour face to face evaluation was performed for either of the above listed restraints.

c. Patient #7's medical record contained documentation of restraints as follows:

- 10/13/11 at 9:00 PM: Zyprexa 10 mg PO/IM was given for agitation.
- 10/17/11 at 4:35 AM: Haldol 10 mg IM was given for agitation and combativeness.
- 10/18/11 at 2:00 AM: Haldol 10 mg IM was given for agitation.
- 10/20/11 at 3:45 AM: Haldol 10 mg and Ativan 1 mg IM were given for agitation and combativeness.
- 10/22/11 at 6:40 PM: Haldol 10 mg PO and Ativan (no dosage documented) IM were given for combativeness and agitation.
- 10/22/11 at 8:00 PM: Haldol 10 mg PO and Ativan 1 mg PO were given for agitation.

There was no evidence a one hour face to face evaluation was performed for any of the above listed restraints.

The ADON was interviewed on 10/28/11 at 3:20 PM. She stated that the face to face evaluations were reviewed by the DON and may not be in the chart. She subsequently submitted a face to face evaluation completed by the RN for the administration of the Haldol 10 mg IM given on 10/17/11 at 4:35 AM. She stated no other evaluation forms had been completed for Patient #7.

d. Patient #18's medical record contained documentation of restraints as follows:

- 2/26/11 at 10:45 PM: Haldol 5 mg PO/IM and Ativan 1 mg PO/IM were given for hostile aggression and danger to self.
- 2/28/11 at 9:00 PM: Zydis 10 mg sublingual was given for aggressive agitation.

There was no evidence a one hour face to face evaluation was performed for either of the above listed restraints.

e. Patient #24's medical record contained documentation of restraint as follows:

- 10/25/10 at 10:00 PM: Haldol 5 mg and Ativan 1 mg IM were given for severe agitation.

There was no evidence a one hour face to face evaluation was performed for the restraint.

f. Patient #29's medical record contained documentation of restraint as follows:

- 6/16/11 at 11:30 PM: Haldol 10 mg and Ativan 2 mg IM for were given for aggressive agitation.

There was no evidence a one hour face to face evaluation was performed for the restraint.

g. Patient #16's medical record contained documentation of restraint as follows:

- 8/24/11 at 9:30 PM: Zyprexa 10 mg IM was given for aggressive agitation.

There was no evidence a one hour face to face evaluation was performed for the restraint.

h. Patient #12's record included documentation of restraints as follows:

- 10/05/11 at 9:00 PM: Zyprexa 10 mg was given for "anxiety, screaming."
- 10/06/11 at 1:30 PM: Zyprexa 10 mg was given for increased anxiety.
- 10/06/11 at 10:10 PM: Zyprexa 10 mg PO was given for "yelling, screaming."
- 10/08/11 at 10:00 PM: Ativan 1 mg PO was given for increased anxiety.
- 10/10/11 at 9:45 PM: Zyprexa 10 mg PO was given for "severe anxiety/yelling."

There was no evidence a one hour face to face evaluation was performed for any of the above listed restraints.

i. Patient #11's medical record included documentation of restraints as follows:

- 9/04/11 at 9:00 PM: Thiothixene 5 mg PO (reason not specified).
- 9/04/11 at 9:50 PM: Ativan 2 mg was given for aggressive agitation.
- 9/04/11 at 10:40 PM: Zydis 10 mg PO was given for aggressive agitation.
- 9/04/11 at 11:15 PM: Haldol 5 mg was given for aggressive agitation (PO or IM not specified).
- 10/12/11 at 12:45 AM: Ativan 2 mg PO was given for severe anxiety.
- 10/13/11 at 12:10 PM: Seroquel 100 mg PO (reason not specified).
- 10/13/11 at 4:00 PM: Ativan 2 mg was given for severe anxiety.
- 10/16/11 at 10:30 PM: Ativan 1 mg IM was given for severe anxiety.
- 10/18/11 at 11:05 PM: Ativan 2 mg was given for agitation, paranoia (PO or IM not specified).
- 10/20/11 at 12:40 AM: Ativan 2 mg was given for agitation/anxiety (PO or IM not specified).
- 10/21/11 at 11:55 PM: Ativan 2 mg IM was given for agitation/anxiety.
- 10/26/11 at 2:20 AM: Ativan 2 mg IM was given for aggressive agitation.
- 10/27/11 at 11:10 PM: Haldol 5 mg was given for aggressive agitation (PO or IM not specified) with Ativan 2 mg for aggressive agitation. (PO or IM not specified).
- 10/28/11 at 12:45 AM: Ativan 2 mg was given for aggressive agitation (PO or IM not specified).

There was no evidence a one hour face to face evaluation was performed for any of the above listed restraints.

j. Patient #13's medical record included documentation of restraints as follows:

- 2/17/11 at 3:50 PM: Ativan 1 mg PO was given for anxiety.
- 2/21/11 at 4:00 PM: Ativan 1 mg IM was given for signs and symptoms of anxiety.
- 2/23/11 at 5:43 PM: Ativan 1 mg IM was given for agitation.
- 2/23/11 at 9:50 PM: Ativan was given (route and the reason why the medication was given was not documented).
- 2/26/11 at 1:15 PM: Ativan 1 mg PO was given for increased anxiety.

There was no evidence a one hour face to face evaluation was performed for any of the above listed restraints.





k. Patient #19's record documented the following restraint use:

- 9/28/11 at 11:00 PM: Zyprexa 10 mg was given for aggressive agitation.
- 9/28/11 at 11:45 PM: Haldol 10 mg and Ativan 1 mg were given for aggressive agitation.
- 9/29/11 at 4:30 PM: Haldol 5 mg and Ativan 1 mg were given for aggressive agitation.
- 9/29/11 at 9:45 PM: Haldol 5 mg and Ativan 1 mg were given for aggressive agitation.
- 9/30/11 at 6:00 AM: Haldol 10 mg and Ativan 2 mg were given for agitation, combative.

There was no evidence a one hour face to face evaluation was performed for any of the above listed restraints.

l. Patient #17's record documented the following restraint use:

- 8/13/11 at 11:00 PM: Haldol 10 mg and Ativan 2 mg was given for aggressive agitation.
- 8/16/11 at 10:00 PM: Haldol 10 mg and Ativan 2 mg was given for aggressive agitation.
- 8/19/11 at 2:15 AM: Haldol 10 mg and Ativan 2 mg was given for aggressive agitation.
- 8/20/11 at 8:40 PM: Haldol 5 mg and Ativan 1 mg was given for aggressive agitation.
- 8/24/11 at 9:30 PM: Haldol 5 mg and Ativan 2 mg was given for aggressive agitation.

There was no evidence a one hour face to face evaluation was performed for any of the above listed restraints.

m. Patient #38's record documented the following restraint use:

- 9/01/11 at 12:00 AM: Haldol 10 mg and Ativan 2 mg was given for aggressive agitation.
- 9/02/11 at 9:25 PM: Zydis 10 mg was given for aggressive agitation.
- 9/03/11 at 4:00 AM: Haldol 5 mg and Ativan 1 mg was given for aggressive agitation.
- 9/04/11 at 2:00 AM: Haldol 10 mg and Ativan 2 mg was given for aggressive agitation.
- 9/05/11 at 6:00 PM: Haldol 5 mg and Ativan 1 mg was given for aggressive agitation.
- 9/06/11 at 10:00 PM: Ativan 2 mg was given for aggressive agitation.

There was no evidence a one hour face to face evaluation was performed for any of the above listed restraints.

n. Patient #2's record documented the following restraint use:

- 10/10/11 at 9:45 PM: Haldol 10 mg was given for aggressive agitation.
- 10/10/11 at 11:15 PM: Haldol 10 mg was given for aggressive agitation.

There was no evidence a one hour face to face evaluation was performed for either of the above listed restraints.

o. Patient #1's record documented the following restraint use:

- 10/18/11 at 3:30 PM: Zyprexa 10 mg was given for aggressive agitation.
- 10/18/11 at 6:00 PM: Haldol 5 mg and Ativan 2 mg was given for aggressive agitation.
- 10/18/11 at 9:30 PM: Haldol 5 mg and Ativan 2 mg was given for aggressive agitation.

There was no evidence a one hour face to face evaluation was performed for any of the above listed restraints.

p. Patient #15's record documented the following restraint use:

- 10/20/11 at 1:15 AM: Haldol 10 mg and Ativan 1 mg were given for aggressive agitation.

There was no evidence a one hour face to face evaluation was performed for the restraint.

The DON was interviewed on 10/27/11 at 10:30 AM. She stated that when the physician is contacted for a medication to be given immediately in response to patient behaviors, it was expected that the RN implement the required paperwork for assessing and monitoring the patient.

The ADON was interviewed on 10/28/11 at 12:50 PM. She stated it was expected that once a medication was determined to be administered as a chemical restraint the face to face documentation was to be initiated. She stated descriptions of the behaviors were to be charted to assess for possible sources leading to the behavior. She stated that once a patient was administered a medication as a result of behaviors, the patient was to be monitored closely. She stated the medical record should contain documentation related to the response of the patient to the medications.

The facility failed to ensure face to face assessments were completed.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
Based on review of hospital policy and restraint documentation, and staff interview, it was determined the facility failed to ensure restraint policies were sufficiently implemented and monitored to ensure face to face assessments included all necessary information for 4 of 6 patients reviewed (#1, #2, #7, and #14) for whom face to face assessments were conducted. This resulted in a lack of comprehensive assessment information on which to base additional intervention and treatment decisions. The findings include:

1. The hospital's "Seclusion and Restraint" policy, dated 11/04/08, stated "The condition of the patient who has been restrained or in seclusion must continually be assessed, monitored and re-evaluated." The policy also stated, in the "One Hour Face to Face Evaluation Assessment" section, that "A physician, LIP, or Qualified RN must see and evaluate the need for restraint or seclusion within 1 hour after the initiation of this intervention." The policy stated the face to face assessment was to include the following:

- The patient's immediate situation.
- The patient's reaction to the intervention.
- The patient's medical and behavioral condition.
- The need to continue or terminate the restraint or seclusion.

Patient face to face assessments were reviewed. The assessments did not include all necessary information as follows:

a. A "Physician/LIP/RN One Hour Seclusion and Restraint Evaluation" form was completed for Patient #7, on 10/17/11, for medications administered on 10/17/11 at 4:35 AM. The RN did not document the following:

- The results of the physical head to toe assessment.
- If Patient #7 made eye contact.
- A description of Patient #7's speech rate and volume.
- A description of Patient #7's thought content.

The ADON was interviewed regarding completion of the forms used for the face to face assessments, on 11/02/11 at 9:00 AM. She stated the facility used the "Physician/LIP/RN One Hour Seclusion and Restraint Evaluation" form for documentation of face to face assessments. She confirmed the portion of the form related to the physical and psychological assessment was to be completed at the time of the one hour assessment. It was her expectation that each section of the form be addressed.





b. A form titled "Physician/LIP/RN One Hour Seclusion and Restraint Evaluation," was completed by the RN and documented Patient #1 received chemical restraints on 10/18/11 at 3:30 PM, 6:00 PM and 9:30 PM. However, all three episodes of restraint use were documented on one form, which was signed by the RN at 9:30 PM. Vital signs were documented, but as they were untimed, it was not clear when they had been obtained. The section of the form containing documentation for the head to toe and pain assessments was not completed.

Patient #1 received a chemical restraint on 10/23/11 at 10:30 PM. A form titled "Physician/LIP/RN One Hour Seclusion and Restraint Evaluation," was completed.
The section of the form containing documentation for the head to toe and pain assessments was not completed.

The form included a section titled "Criteria for Release from Seclusion/Restraint," with boxes to be checked, which listed "No Imminent Danger toward Self and Others," "Non-threatening towards Self or Others" and "Other," with a space for narrative documentation. The section was not completed.

During an interview on 11/03/11 beginning at 9:00 AM, the ADON reviewed the "Physician/LIP/RN One Hour Seclusion and Restraint Evaluation" forms for Patient #1. She stated the form dated 10/18/11 had been used incorrectly for the three incidents of chemical restraint. She stated the RN who had completed the form had tried to conserve documentation, which was an inappropriate practice. The ADON stated the RN had acted independently and not within the policy guidelines.

c. Patient #2 received a chemical restraint on 10/11/11 at 7:50 PM. A form titled "Physician/LIP/RN One Hour Seclusion and Restraint Evaluation," was completed. Medications used for the chemical restraint were not listed on the form. Vital signs did not include blood pressure. The section of the form containing documentation for the head to toe and pain assessments was not completed. In the sections related to "Behavior" and "Attitude," the RN documented Patient #2 remained uncooperative, belligerent, and agitated. However, elsewhere on the form the RN documented Patient #2 was sleeping.

The form included a section titled "Criteria for Release from Seclusion/Restraint," with boxes to be checked, which listed "No Imminent Danger toward Self and Others," "Non-threatening towards Self or Others" and "Other," with a space for narrative documentation. The section was not completed.

Patient #2 received a chemical restraint on 10/13/11 at 6:35 PM. A form titled "Physician/LIP/RN One Hour Seclusion and Restraint Evaluation," was completed. However, the form did not document when the one hour face to face assessment had been performed. The form was completed and signed by RN D on 10/13/11 at 6:35 PM, the time of the restraint initiation, rather than the follow up assessment. The section of the form containing documentation for the head to toe and pain assessments was not completed. In the sections related to "Behavior" and "Attitude," the RN documented Patient #2 remained uncooperative, belligerent, and agitated. However, elsewhere on the form the RN documented Patient #2 was sleeping.

Additionally, the form included a section titled "Criteria for Release from Seclusion/Restraint," with boxes to be checked, which listed "No Imminent Danger toward Self and Others," "Non-threatening towards Self or Others" and "Other," with a space for narrative documentation. The section was not completed.

During an interview on 11/03/11 beginning at 9:00 AM, the ADON reviewed the "Physician/LIP/RN One Hour Seclusion and Restraint Evaluation" forms for Patient #2. She stated the RN who completed the forms, on 10/11/11 at 7:50 PM and 10/13/11 at 6:35 PM, did not complete them correctly with complete and accurate documentation. She confirmed the documentation describing Patient #2's behavior as sleeping as well as belligerent, agitated, and uncooperative was confusing. The ADON stated the format of the form was confusing, and many staff had signed, dated, and timed the form when the restraint was initiated rather than the actual time the assessment was completed.

d. Patient #14 received a chemical restraint on 10/12/11 at 10:20 PM. A form titled "Physician/LIP/RN One Hour Seclusion and Restraint Evaluation," was completed at 11:45 PM. The form was documented as completed by RN D on 10/12/11 at 10:20 PM, which was the time the chemical restraint was initiated.

The form included a section titled "Criteria for Release from Seclusion/Restraint," with boxes to be checked, which listed "No Imminent Danger toward Self and Others," "Non-threatening towards Self or Others" and "Other," with a space for narrative documentation. The section was not completed.

Patient #14 received a chemical restraint on 10/12/11 at 1:15 AM. A form titled "Physician/LIP/RN One Hour Seclusion and Restraint Evaluation," was completed at 2:00 AM. The form contained a section titled "Reason for use of Seclusion and/or Restraint," that had not been completed. Pain and vital signs were not documented. The sections "Behavior" and "Attitude," included the descriptions that Patient #14 remained uncooperative, belligerent, and agitated, although the form also documented patient was sleeping.

During an interview on 11/03/11 beginning at 9:00 AM, the ADON confirmed the forms titled "Physician/LIP/RN One Hour Seclusion and Restraint Evaluation," on 10/12/11 at 1:15 AM and 10/12/11 at 10:20 PM, were incomplete.

2. Refer to A188 as it relates to the facility's failure to ensure restraint policies were sufficiently developed necessary to ensure that the patients' responses to restraint and seclusion were consistently documented in the patient's medical records.
The facility failed to ensure restraint policies were sufficiently implemented and monitored to ensure face to face assessments included all necessary information.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0182
Based on review of hospital policy, record review and staff interview, it was determined the facility failed to ensure restraint policies were sufficiently developed to ensure physician or LIP consultation was obtained after face to face assessments were completed by a trained Registered Nurse. This failure directly impacted 5 of 6 patients reviewed (#1, #2, #7, #14, and #19) for whom face to face assessments were conducted, and had the potential to impact all patients who were restrained at the facility. This resulted in the potential for patients to not receive additional interventions or treatments. The findings include:

1. The hospital's "Seclusion and Restraint" policy, dated 11/04/08, stated "The condition of the patient who has been restrained or in seclusion must continually be assessed, monitored and re-evaluated." The policy also stated, in the "One Hour Face to Face Evaluation Assessment" section, that "A physician, LIP, or Qualified RN must see and evaluate the need for restraint or seclusion within 1 hour after the initiation of this intervention."

The policy did not include parameters for consulting with the attending physician or LIP when the Qualified RN completed the face to face evaluation.

Patient face to face assessments were reviewed. The assessments did not include consultation with the physician or LIP as follows:

- On 10/17/11 at 4:34 AM, Patient #7 received Haldol 10 mg IM. A face to face assessment was completed by the RN on 10/17/11 at 5:30 AM. Consultation with the physician or LIP could not be found.

- On 10/18/11 at 3:30 PM, 6:00 PM and 9:30 PM, Patient #1 was administered chemical restraints. A face to face assessment was completed by the RN at 5:00 PM, 7:00 PM and 10:00 PM. Consultation with the physician or LIP could not be found. Additionally, on 10/23/11 at 11:30 PM, Patient #1 was administered a chemical restraint. A face to face assessment was completed by the RN at 12:30 AM. Consultation with the physician or LIP could not be found.

- On 10/11/11 at 7:50 PM, Patient #2 was administered a chemical restraint. A face to face assessment was completed by the RN at 8:50 PM. Consultation with the physician or LIP could not be found.

- On 10/01/11 at 8:30 PM, Patient #19 was administered a chemical restraint. A face to face assessment was completed by the RN at 9:45 PM. Consultation with the physician or LIP could not be found. Additionally, on 10/07/11 at 12:35 AM, Patient #19 was administered a chemical restraint. A face to face assessment was completed by the RN at 1:45 AM. Consultation with the physician or LIP could not be found.

- On 10/12/11 at 10:20 PM, Patient #14 was administered a chemical restraint. A face to face assessment was completed by the RN at 11:45 PM. Consultation with the physician or LIP could not be found. Additionally, on 10/12/11 at 1:15 AM, Patient #14 was administered a chemical restraint. A face to face assessment was completed by the RN at 2:00 AM. Consultation with the physician or LIP could not be found.

Physicians A, B, and C were interviewed jointly on 10/27/11 at 8:45 AM. They explained their expectation that staff contact the appropriate physician with any patient behaviors that warranted medical intervention. Any medications ordered were based on the reported nursing assessment of the patient. Physician C explained that occasionally the physicians were contacted more than once regarding a patient who continued to demonstrate dangerous or concerning behaviors. Additional medication would be ordered based on the subsequent nursing assessments.

The facility failed to ensure physician or LIP consultation was obtained after face to face assessments were completed by a trained Registered Nurse.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0184
Based on review of hospital policy, record review and staff interview, it was determined the facility failed to ensure restraint policies were sufficiently developed, implemented and monitored necessary to ensure face to face assessments were included in patient records for 5 of 6 patients reviewed (#1, #2, #7, #14 and #19) for whom face to face assessments were conducted. This resulted in a lack of comprehensive information being available in the patients' medical records. The findings include:

1. The hospital's "Seclusion and Restraint" policy, dated 11/04/08, stated "The condition of the patient who has been restrained or in seclusion must continually be assessed, monitored and re-evaluated." The policy also stated, in the "One Hour Face to Face Evaluation Assessment" section, that "A physician, LIP, or Qualified RN must see and evaluate the need for restraint or seclusion within 1 hour after the initiation of this intervention." The policy stated the assessment was to be documented on the "One Hour Face to Face Evaluation/Assessment" form. The policy did not include direction as to where the forms were kept once they had been completed.

Patient medical records were reviewed. None of the records included the "One Hour Face to Face Evaluation/Assessment" form. The ADON was interviewed on 10/28/11 at 3:20 PM. She stated that face to face evaluations were reviewed by the DON and may not yet be in the chart.

The ADON then provided copies of the completed "One Hour Face to Face Evaluation/Assessment" forms from the DON's office. The forms had been completed for the following patients:

a. Patient #7, who had received chemical restraint 10/07/11 at 4:35 AM.

b. Patient #1, who had received chemical restraint 10/18/11 at 4:00 PM and 10/23/11 at 11:30 PM.

c. Patient #2, who had received chemical restraint 10/11/11 at 7:50 PM and 10/13/11 at 6:35 PM.

d. Patient #14, who had received chemical restraint 10/12/11 at 10:20 PM and 10/12/11 at 1:15 AM.

e. Patient #19, who had received chemical restraint 10/01/11 at 8:30 PM and 10/07/11 at 12:35 AM.

The facility failed to ensure restraint policies were sufficiently developed, implemented and monitored necessary to ensure face to face assessments were included in patient records.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0188
Based on review of hospital policy, record review and staff interview, it was determined the facility failed to ensure restraint policies were sufficiently implemented and monitored for documentation in the medical records of patients' responses to restraints for 17 of 17 patients reviewed (#1, #2, #7, #11 - #19, #21, #24, #29, #31 and #38) for whom restraints were used. This resulted in the potential for patients to be subjected to the continued use of traumatic interventions unnecessarily. The findings include:

1. The hospital's "Seclusion and Restraint" policy, dated 11/04/08, stated "The condition of the patient who has been restrained or in seclusion must continually be assessed, monitored and re-evaluated." The policy also stated, in the "One Hour Face to Face Evaluation Assessment" section, that "A physician, LIP, or Qualified RN must see and evaluate the need for restraint or seclusion within 1 hour after the initiation of this intervention." The policy stated the face to face assessment was to include the patient's reaction to the intervention.

a. Patient face to face assessments were reviewed. The assessments did not include documentation of the patients' response to the intervention as follows:

- Patient #7: A face to face assessment was completed for Patient #7, on 10/17/11, for a chemical restraint administered on 10/17/11 at 4:35 AM. The assessment did not include documentation of Patient #7's response to the intervention.

- Patient #1: A face to face assessment was completed for Patient #1, on 10/18/11 at 9:30 PM, for a chemical restraint administered on 10/18/11 at 4:00 PM, 6:00 PM, and 9:30 PM. The assessment did not include documentation of Patient #1's response to the intervention.

- Patient #1: A face to face assessment was completed for Patient #1, on 10/24/11 at 12:30 AM, for a chemical restraint administered on 10/23/11 at 11:30 PM. The assessment did not include documentation of Patient #1's response to the intervention.

- Patient #2: A face to face assessment was completed for Patient #2, on 10/11/11 at 8:50 PM, for a chemical restraint administered on 10/11/11 at 7:50 PM. The assessment did not include documentation of Patient #2's response to the intervention.

- Patient #2: A face to face assessment was completed for Patient #2, on 10/13/11 (untimed), for a chemical restraint administered on 10/13/11 at 6:35 PM. The assessment did not include documentation of Patient #2's response to the intervention.

- Patient #19: A face to face assessment was completed for Patient #19, on 10/01/11 9:45 PM, for a chemical restraint administered on 10/01/11 at 8:30 PM. The assessment did not include documentation of Patient #19's response to the intervention.

- Patient #19: A face to face assessment was completed for Patient #19, on 10/07/11 at 1:45 AM, for a chemical restraint administered on 10/07/11 at 12:35 AM. The assessment did not include documentation of Patient #19's response to the intervention.

- Patient #14: A face to face assessment was completed for Patient #14, on 10/12/11 at 11:45 PM, for a chemical restraint administered on 10/12/11 at 10:20 PM. The assessment did not include documentation of Patient #14's response to the intervention.

- Patient #14: A face to face assessment was completed for Patient #14, on 10/12/11 at 2:00 AM, for a chemical restraint administered on 10/12/11 at 1:15 AM. The assessment did not include documentation of Patient #14's response to the intervention.

b. Patient medical records documented patients had been subjected to multiple restraints. However, documentation of face to face assessments could not be found and no other information documenting the patients' responses to the restraints (i.e. negative effects of being restrained such as physical, mental, or emotional trauma, etc.) could be found as follows:

- Patient #19's record documented 8 additional chemical restraints and one physical restraint. However, no documentation of Patient #19's response to the restraints was found.

- Patient #17's record documented 7 chemical restraints. However, no documentation of Patient #17's response to the restraints was found.

- Patient #38's record documented 7 chemical restraints. However, no documentation of Patient #38's response to the restraints was found.

- Patient #12's record documented 5 chemical restraints. However, no documentation of Patient #12's response to the restraints was found.

- Patient #13's record documented 5 chemical restraints. However, no documentation of Patient #13's response to the restraints was found.

- Patient #2's record documented 3 additional chemical restraints. However, no documentation of Patient #2's response to the restraints was found.

- Patient #1's record documented 2 additional chemical restraints. However, no documentation of Patient #1's response to the restraints was found.

- Patient #15's record documented 2 chemical restraints. However, no documentation of Patient #15's response to the restraints was found.

- Patient #21's record documented 4 chemical restraints. However, no documentation of Patient #21's response to the restraints was found.

- Patient #24's record documented 1 chemical restraint. However, no documentation of Patient #24's response to the restraint was found.

- Patient #29's medical record documented one chemical restraint. However, no documentation of Patient #29's response to the restraint was found.

- Patient #31's medical record documented 3 chemical restraints. However, no documentation of Patient #31's response to the restraints was found.

- Patient #16's medical record documented 1 chemical restraint. However, no documentation of Patient #16's response to the restraints was found.

- Patient #7's medical record documented 7 chemical restraints. However, no documentation of Patient #7's response to the restraints was found.

- Patient #18's medical record contained documentation of the use of a chemical restraint on two occasions. However, no documentation of Patient #18's response to the restraint was found.

2. The hospital's 11/04/08 "Seclusion and Restraint" policy stated within 24 hours of a patient being restrained or secluded, a "Debriefing" was to be conducted. The policy stated the debriefing was designed to facilitate the following:

- "...allows us to get the patient's perspective in regards to what happened and what might have been done to make the experience less traumatic."
- "Allows staff to assess the trauma caused by the restraint and to counsel patient [sic] as necessary."
- "It allows staff to problem solve with the patient (if cognitively able) to reduce recurrent use of restraint or seclusion."

The patients' medical records were reviewed and documented restraint use without evidence of "debriefing" as follows:

- Patient #19's record documented 10 chemical and physical restraints. However, no evidence of "debriefing" could be found for the restraint use.

- Patient #17's record documented 7 chemical restraints. However, no evidence of "debriefing" could be found for the restraint use.

- Patient #38's record documented 7 chemical restraints. However, no evidence of "debriefing" could be found for the restraint use.

- Patient #2's record documented 5 chemical restraints. However, no evidence of "debriefing" could be found for the restraint use.

- Patient #1's record documented 4 chemical restraints. However, no evidence of "debriefing" could be found for the restraint use.

- Patient #15's record documented 2 chemical restraints. However, no evidence of "debriefing" could be found for the restraint use.

- Patient #21's record documented 4 chemical restraints. However, no evidence of "debriefing" could be found for the restraint use.

- Patient #24's record documented 1 chemical restraint. However, no evidence of "debriefing" could be found for the restraint use.

- Patient #14's record documented 2 chemical restraints. However, no evidence of "debriefing" could be found for the restraint use.

- Patient #29's record documented 1 chemical restraint. However, no evidence of "debriefing" could be found for the restraint use.

- Patient #31's record documented 3 chemical restraints on. However, no evidence of "debriefing" could be found for the restraint use.

- Patient #16's record documented 1 chemical restraint. However, no evidence of "debriefing" could be found for the restraint use.

- Patient #7's record documented 6 chemical restraints. However, no evidence of "debriefing" could be found for the restraint use.

- Patient #12's record documented 5 chemical restraints. However, no evidence of "debriefing" could be found for the restraint use.

- Patient #3's record documented 5 chemical restraints. However, no evidence of "debriefing" could be found for any of the restraint use.

- Patient #18's record documented 2 chemical restraints. However, no evidence of "debriefing" could be found for the restraint use.

In an interview on 11/03/11 beginning at 9:00 AM, the ADON stated the debriefing forms were actually a second page of a packet for restraint documentation. The first page was the form "Physician/LIP/RN One Hour Seclusion and Restraint Evaluation," and the second page was titled "SECLUSION AND RESTRAINT DEBRIEFING FORM." A notation below the title read "Not a part of the Medical Record." The ADON stated the facility used the forms as an evaluation of staff performance during a restraint event, to indicate areas of potential education or retraining, and to determine if staff worked together well to accomplish the task in a safe and effective manner. She stated most of the time, patients who were restrained were not cognitive enough to interview regarding the experience. The ADON explained that because the debriefing form was used for personnel reasons, it was not part of patients' medical records.

The facility failed to ensure restraint policies were sufficiently developed and monitored for documentation in the medical records of patients' responses to restraints.
VIOLATION: PATIENT RIGHTS: SECLUSION OR RESTRAINT Tag No: A0214
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, it was determined the facility failed to ensure policies and procedures were adequately developed and implemented necessary to ensure the reporting of deaths associated with restraint use. This directly impacted 4 of 18 patients (#21, #24, #29, and #31) whose death records were reviewed, and had the potential to impact all deaths at the facility. This resulted in a lack of adequate analysis regarding patient deaths following restraint use and a failure to report appropriately. The findings include:

1. The hospital's "Patient Deaths" policy, dated 12/10/08, stated the hospital would report deaths to CMS as follows:

- "Each death that occurs while a patient is in restraint or seclusion."
- "Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion."
- "Each death known to the hospital that occurs within 1 week after restraint of [sic] seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patients [sic] death. 'Reasonable to assume' includes deaths related to restrictions of movement for prolonged periods of time, or deaths related to chest compression, restriction of breathing or asphyxiation."

Although the policy included reporting of deaths associated with restrictions of movement for prolonged periods of time, or deaths related to chest compression, restriction of breathing or asphyxiation, the policy did not include the reporting of deaths associated with other "reasonable to assume" causes (i.e. use of chemical restraint, etc.).

The policy also stated "Each death reviewed by the nursing staff and/or physician that meet these requirements must be reported to CMS by telephone no later than the close of business the next business day following knowledge of the patient's death. Staff must document in the patient's medical record the date and time of death was [sic] reported to CMS."

The policy did not specify how it was to be determined which patients deaths were to be reviewed, what information staff were to garner and from what source (record review, staff interview, review of restraint mechanisms, review of potential medication interactions, etc.), or how final "reasonable to assume" determinations would be made.

The CEO was interviewed, on 11/02/11 at 10:45 AM, regarding the facility's practice reviewing death records. He stated upon a patient's death, the RN contacted the DON with a report of the death. He stated based on the RN's report, an immediate review to determine possible connection between restraint use and death would be conducted. He stated if the facility experienced an unexpected death, it would cue the DON to review the record and report the death to CMS per requirements. He stated that when the DON was contacted, she asked the RN if chemical or physical restraints were used. The CEO confirmed both the RN and the DON reviewed the medical record for any medications given, and causal effects for a patient's demise. He stated the facility did not have a specific list of criteria to assist in evaluation of medical records related to chemical restraints and death, in order to consistently determine if deaths needed to be reported to CMS.

Patient death records were reviewed and included the following:

a. Patient #21 was an [AGE] year old male cared for by the facility from 9/09/10 through 9/15/10. His discharge diagnoses included dementia, mood disorder, and psychotic disorder.

"NURSING PROGRESS NOTES" contained documentation, on 9/14/11 at 11:00 AM, which included "Pt. [Patient] was agitated this am w/ [with] cares & was grabbing others. Pt. was wheeled down to dining room & threw a plate [with] food on it at a staff member and started grabbing staff. Refused P.O. meds. Called [physician] at 8:40 AM and received an order for Haldol 10 mg and Ativan 2 mg IM x 1 now." Documentation on the "PRN/ONE TIME MEDICATION RECORD" confirmed these medications were administered as ordered.

The next nursing note, found in "NURSING PROGRESS NOTES," was from 9/14/11 at 5:00 PM. "Pt slumped forward in w/c [wheelchair] cyanotic, diaphoretic and tachypneic...Family notified and they want [patient] to be on comfort measures only, MD agrees."

On 9/15/11 at 3:00 AM, the RN documented in the "NURSING PROGRESS NOTES, "Pt found unresponsive [without] a heart beat or respiratory effort."

No documentation that the death had been reviewed to determine whether it was reasonable to assume the chemical restraint was associated with Patient #21's death could be found. The death was not reported to CMS.

b. Patient #24 was a [AGE] year old male cared for by the facility from 10/21/10 to 10/30/10. His discharge diagnosis was dementia with behavior disturbance.

His medical record contained "PHYSICIAN'S ORDERS" with documentation of a verbal order for Haldol 5 mg and Ativan 1 mg IM, to be administered at the time of the order, for severe agitation on 10/25/10 at 10:00 PM. The LPN documented in the "NURSING PROGRESS NOTES," on 10/25/10 at 10:00 PM, that Patient #24 was restless and noted to move around in his bed. Subsequent documentation entered at 10:45 PM indicated, Patient #24 was calm after receiving the Haldol and Ativan.

An RN documented in the "NURSING PROGRESS NOTES," on 10/30/10 at 10:15 AM, that Patient #24 passed away "peacefully" at 9:07 AM. This was five days after the administration of Haldol and Ativan.

No documentation that the death had been reviewed to determine whether it was reasonable to assume the chemical restraint was associated with Patient #24's death could be found. The death was not reported to CMS.

c. Patient #29 was a [AGE] year old male cared for by the facility from 6/15/11 to 6/21/11. His discharge diagnoses included dementia, psychosis, and mood disorder.

His medical record contained an order sheet labeled "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS," dated 6/16/11 at 11:30 PM. The RN indicated Patient #29 was combative, grabbing, anxious, agitated, was a danger to himself and others, and was kicking and hitting. The physician authorized a verbal order for Haldol 10 mg and Ativan 2 mg for aggressive agitation. The "PRN/ONE TIME MEDICATION RECORD" indicated the medications were administered IM.

The "DISCHARGE SUMMARY," dated 7/11/11, indicated Patient #29 passed away at the facility on 6/21/11, five days after receiving the Haldol and Ativan.

No documentation that the death had been reviewed to determine whether it was reasonable to assume the chemical restraint was associated with Patient #29's death could be found. The death was not reported to CMS.

d. Patient #31 was an [AGE] year old male cared for by the facility from 8/24/11 to 9/02/11. His discharge diagnoses included dementia and mood disorder with severe irritability and anger.

A "DOCUMENTATION FOR USE OF BEHAVIORAL MEDICATIONS" form was dated 8/31/11 at 3:55 AM. The RN indicated Patient #31 was combative, grabbing, anxious, agitated, disoriented, was a danger to himself and others, and was violent. The physician authorized a verbal order for Ativan 2 mg PO/IM for agitation. The "PRN/ONE TIME MEDICATION RECORD" indicated the medication was administered as ordered

The "DISCHARGE SUMMARY," dictated by the physician on 9/10/11, indicated Patient #31 passed away on 9/02/11, two days after the administration of Ativan.

No documentation that the death had been reviewed to determine whether it was reasonable to assume the chemical restraint was associated with Patient #31's death could be found. The death was not reported to CMS.

The facility failed to ensure policies and procedures were adequately developed and implemented necessary to ensure the reporting of deaths associated with restraint.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, interview, and review of medical records and facility policies, it was determined the facility failed to ensure systems were developed for controlling infections and communicable diseases. This impacted all patients currently receiving care at the facility. Failure to develop a system to control infections and spread of disease had the potential to negatively impact patient health and safety. The findings include:

1. The policy "GERIATRIC PSYCH UNIT GENERAL SAFETY RULES," dated 11/04/04, indicated that "All equipment must be cleaned and disinfected before use for another patient."

Equipment was not appropriately cleaned as follows:

a. On 10/24/11 at 4:00 PM, a CNA was observed to obtain a dark colored bag which contained a thermometer, blood pressure cuff, oxygen saturation monitor and stethoscope. He was observed to use these instruments on Patient #7. Once vital signs had been obtained, he replaced the items in the bag without disinfecting. The bag was observed to be placed back in the area for use again and the items remained uncleaned.

b. On 10/24/11 at 4:20 PM, a second surveyor observed a different CNA taking vital signs on a patient who had fallen. The CNA retrieved a blood pressure cuff, oxygen saturation monitor, and stethoscope from a maroon colored bag. Once vital signs were obtained the equipment was placed back into the bag. After a while, the CNA removed the equipment, disinfected it, and placed it back into the bag (which had not been cleaned).

The facility failed to ensure equipment was cleaned properly between patient use.




2. The policy "HANDWASHING," dated 10/26/06, included instructions on when to perform hand hygiene which included, but was not limited to, before, between, and after patient contact, before and after preparing or administering medications, and after handling used equipment or contaminated items.

Hand hygiene was not appropriately performed as follows:

a. During an observation on 10/25/11 beginning at 10:30 AM, CNA F was observed to assist Patient #1 with placement of her hearing aids into each ear. CNA F returned the hearing aid case to a cabinet in the nursing station without washing her hands. She then sat down at the desk and wrote on a clipboard.

At 10:45 AM, Patient #14 came up to the desk area and requested CNA F assist her to make a telephone call. CNA F dialed the phone and handed it to Patient #14. No hand hygiene was performed.

At 10:50 AM, Patient #10 alerted CNA F that Patient #4 had entered her (Patient #10's) room and put a roll of toilet paper in the toilet. CNA F was observed to put on a pair of gloves and use a plastic trash bag to retrieve the wet toilet paper roll from the toilet. The CNA removed her gloves, placed them in the plastic bag, and was not observed to clean her hands. CNA F took Patient #4's hand and redirected her out of Patient #10's room. CNA F was observed taking the plastic bag to the trash storage area and wash her hands after disposing of the bag.

In an interview on 10/25/11 at 11:00 AM, directly after the observation, CNA F confirmed she had not washed her hands between providing care or assistance for the three patients.

b. During an observation on 10/23/11 beginning at 2:00 PM, LPN F was noted to have an elastic bandage wrap around her left palm and hand that extended to just below the elbow. The palm area of the bandage wrap was discolored. LPN F was noted to go into the medication storage area, and out to the group room to administer medication to patients on multiple occasions during the observation. LPN F was noted to touch patients with her wrapped hand, and hand hygiene was not observed.

During an interview on 10/23/11 at 4:30 PM, LPN F confirmed she had touched patients with her wrapped hand. LPN F demonstrated how she was able to wash her hands easily by pulling the wrapped bandage off the palm area, over her thumb, exposing her bared hand to the wrist. LPN F stated her hand hygiene in that manner was sufficient. She stated she had performed hand hygiene multiple times during my observation, but it was performed in the medication room out of this surveyor's site. LPN F stated she had not received medical care for her hand/wrist injury, and she had not discussed with her supervisor if wrapping her hand was acceptable during her work hours.

The "HANDWASHING" policy, dated 10/26/06, included a "PROCEDURE" section which instructed staff to wet the hands and wrists thoroughly, then use soap on hands and wrists. The procedure concluded with the drying of hands and wrists. The policy did not provide exclusion to individuals with bandages or wrapped hands/wrists for modified hand hygiene.

c. On 10/24/11 at 12:05 PM, CNA F was observed providing care to Patient #12. Patient #12's brief, and the underlying protective pad, was observed to be wet with dark, strong smelling urine. CNA F changed the brief and laid the wet one on the floor. Without changing gloves, CNA F was observed to place a clean brief on Patient #12. With the assistance of a second CNA, Patient #12 was transferred to a wheelchair. Then Patient #12's face was washed, her hair combed, and her teeth were brushed. Patient #12's hands were not washed before CNA F took her to eat lunch.

The Infection Control Officer was interviewed on 10/28/11 at 12:50 PM. She stated the facility lacked easy access to sinks for hand washing. She stated nursing staff could access the sink in the medication room, but typically CNA staff needed to use sinks in the patients' rooms. As a result, it was difficult to complete a hand hygiene audit without staff being aware they were being watched. She stated that each staff had access to alcohol based hand rub which could be kept in their pockets, but this was not required.

The facility failed to ensure staff followed infection control practices when providing patient care.





3. Refer to A724 as it relates to the facility's failure to ensure staff monitored and maintain the water temperature in the laundry and clean the public toilet facilities.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, review of policies, and staff interviews it was determined the hospital failed to ensure patients were provided privacy during personal care and treatment. This failure directly impacted 2 of 20 current patients (#2 and #12) whose care was observed, and had the potential to impact all patients receiving care at the facility. This resulted in patient vulnerability of exposure during sleep or other activities by visitors, hospital personnel and other patients. The findings include:

1. The hospital's "PATIENT'S LEGAL AND HUMAN RIGHTS" policy, dated 2/2004, stated "You have the right to privacy in your treatment, in your care, and in the fulfillment of your personal needs..."

a. On 10/23/11 at 1:15 PM, during a tour of the facility, it was noted patient rooms #101, #102, #201 and #202 were located close to the nursing station and had long narrow windows for visualization into patient rooms when the doors were closed. The rooms did not have privacy curtains or other methods to provide patients privacy from staff, visitors, and other patients during personal cares and treatments. During the tour, Patient #2 was observed being assessed by a nurse in room #202.

On 10/24/11 at 2:40 PM, RN B was interviewed. RN B stated patients that needed increased surveillance were placed in the four identified rooms. When asked about patient privacy, she demonstrated how she would provide patient privacy by placing two pieces of printer paper over the window. She stated she would, upon noting the patient needed privacy, return to the nursing station and obtain two pieces of paper, tape them to form a long sheet, and return to the patient room to place over the window. RN B stated she was not able to speak for methods other staff may have used to provide patient privacy.

When asked about privacy, during an interview on 10/24/11 at 2:15, Patient #2 stated she was embarrassed that the window to her room was not covered during her personal cares. She stated she was able to see into other patients' windows when she was walking down the hallway for meals and other activities, and it made her uncomfortable that others would see her as well.

In addition, Patient #2 was not able to close the door to her bathroom. Patient #2 stated although she was able to close the door to her room, she felt she did not have privacy as the bathroom door could not be closed when she used the toilet and the door to her room had the viewing window. The clearance space between her bathroom and bed did not allow the door to freely swing open or closed unless the bed was pushed at an angle. She stated during bathing, the staff would move the bed, allowing the bathroom door to be closed.

The facility did not ensure patient privacy was maintained.





b. Patient #12 was an [AGE] year old female, admitted to the facility on [DATE] with diagnoses that included history of delirium, traumatic brain injury, non-insulin dependent diabetes, hypertension, and hypothyroid.

On 10/25/11 at 2:00 PM, LPN D was observed while she changed the dressing on Patient #12's left heel. The nurse measured the pressure ulcer, cleaned the wound, and applied Silvadene, Optiform, and a Kling wrap. The door to the room was left open while the dressing change took place. The Chaplain came to the door and visited with the nurse while she was doing the dressing. After the Chaplain left, the nurse was asked to check Patient #12's buttocks due to the red area observed the day before. The nurse closed the door before she checked Patient #12's skin. The nurse commented that they usually close the doors, but this room was so far down the hall that almost no one comes down here.

Patient #12's bed was oriented such that the bed was against the wall and she faced the door. The nurse stood next to the side of the bed. This room arrangement allowed the dressing change to be visible from the doorway.

The facility did not ensure patient privacy was maintained.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, review of hospital policy, record review, and staff interview it was determined the facility failed to ensure suicide policies were sufficiently developed, implemented and monitored necessary to ensure the health and safety of 5 of 20 current patients (#2, #5, #10, #20 and #39), who experienced suicidal ideation and whose records were reviewed. This resulted in the inability of the hospital to ensure patients were not placed in immediate jeopardy from potential serious harm, impairment or death as the result of suicidal tendencies. The findings include:

1. During an interview on 10/23/11 at 3:05 PM, the ADON stated any patient who expressed feelings of suicide, just prior to admission or during their stay, was placed on suicidal ideation precautions. The ADON stated an "SI" was placed next to a patient's name on the census worksheet to indicate the patient had suicidal ideations. The ADON stated the census worksheet was not changed during the patient's stay, although the patient might no longer have ideations of suicide.

The daily census sheet, dated 10/23/11, included an "SI" for Patients #2, #5, #10, #20, and #39, indicating suicidal ideation precautions were in place.

However, when asked during an interview on 10/23/11 at 1:50 PM, LPN A stated she was not aware of any patients on suicide watch and that, typically, those patients were located closer to the nurses' station for closer watch.

The hospital failed to ensure all staff were aware of patients who were on suicide precautions.

2. The hospital's "Suicide Precautions" policy, dated 11/04/04, was reviewed and documented the following:

a. The policy stated patients would be placed on suicide precautions when their symptoms made it necessary. Criteria for "Suicidal/Self Injury Risk" were listed as follows:

- Thoughts of self harm.
- Threats of self harm.
- Suicidal/self injurious behavior.
- Recent threats or overt acts of suicide or self-injurious behavior.

The policy stated "All suicide precautions shall begin with assessing the patient's immediate environment for safety and removal of any objects that he/she might harm him/herself with." The policy included examples, such as glass containers, personal hygiene items, hangers, jewelry, etc., and stated "Refer also to Contraband List."

During an interview on 10/23/11 at 2:15 PM, the CEO stated, as a result of the previous CMS survey, the facility realized not all protocols in the suicide policy were being followed. The CEO stated patients were now going to sign a safety contract. He stated the facility also realized the "Contraband List" referred to in the policy did not exist. As a result, he and the Medical Director generated a Contraband List, and reviewed the information with nursing staff who then cleaned the rooms of contraband items. The CEO stated rooms of patients on suicidal ideation precautions had been inspected for contraband.

However, during a tour of the facility on 10/23/11 beginning at 2:00 PM, each of the 18 patient rooms, as well as the dining room, were observed to have louvered blinds with cords attached. Additionally, each of the patient rooms were observed to have plastic shower curtains and curtain rods. Further, Patient #10's roommate was observed to be wearing shoes with shoestrings, and Patient #2 was on oxygen by nasal cannula, which included tubing.

During an interview on 10/27/11 at 10:30 AM, RN B and LPN D both stated they did not know of a contraband list, and did not know where to find the policy and procedure for suicidal patients. RN B stated if a patient was actively suicidal, the staff would pull down the shower curtain and remove the shower rod from their room. RN B and LPN D both stated they did not consider the cords for the louvered blinds a risk to suicidal patients. LPN D also stated most patients at the facility were geriatric and wore shoes with Velcro fasteners, and shoestrings were not an issue.

The hospital failed to ensure suicide precautions were sufficiently developed and implemented necessary to ensure items which could be used for self harm were removed from suicidal patient access.

b. The policy stated patients were to sign a "Suicide Contract." The policy included a "No Harm Contract," dated 11/04/04, which stated "I understand I am under suicide precautions. I agree to talk with the nursing staff on duty if I have any feelings of wanting to harm myself or others. I agree not to injure myself or others for the next 24 hours..."

The policy did not specify criteria for re-evaluating the contract, or specify whether the contract was to be re-signed if the patient continued to be suicidal after the 24 hour period. Additionally, the policy did not include instruction to staff if the patient could not or would not sign the contract.

During an interview on 10/23/11 at 2:15 PM, the CEO stated the facility had initiated a form that day (10/23/11) called a "NO HARM CONTRACT," which patients with suicidal ideation would be required to sign daily on each shift.

However, when patient records were reviewed, the records did not include consistent documentation of the "No Harm Contract," specified in the hospital's 11/04/04 "Suicide Precautions" policy, as follows:

- Patient #10 was a [AGE] year old female, admitted from 10/17/11 to 10/28/11, with a diagnosis of suicide attempt. Her record did not contain evidence of a "No Harm Contract" for 10/24/11 or 10/25/11.

- Patient #5 was a [AGE] year old male, admitted [DATE], with a diagnosis of suicide attempt. His record did not contain evidence of a "No Harm Contract" for 10/23/11, 10/24/11, or 10/25/11. Additionally, the 11:00 PM to 7:00 AM section of his 10/26/11 "No Harm Contract" did not include signatures. A notation on the form stated "sleeping."

- Patient #20 was a [AGE] year old female, admitted [DATE], with a diagnosis of suicide attempt. The 11:00 PM to 7:00 AM section of her 10/26/11 "No Harm Contract" did not include signatures. A notation on the form stated "sleeping."

- Patient #39 was a [AGE] year old male, admitted [DATE], with a diagnosis of suicide attempt. A single "No Harm Contract," dated 10/24/11 and signed by the ADON, stated "unable to sign."

The facility did not ensure "No Harm Contracts" were consistently signed by all patients with suicidal ideations.

c. The policy stated patients were to be placed on "Moderate Suicide Observations - Checked every 15 minutes - Ideation with plan" or on "Severe Suicide Observations = 1:1 (one-on-one) or line-of -sight to prevent imminent - [sic] hurt or harm."

The policy did not specify which personnel were responsible for making the determination as to which level a patient was to be placed on, or the qualification of the personnel authorized to make such determinations.

Additionally, the "one to one observations" section of the policy stated the patient was to be in line of sight at all times. Staff were to observe breathing, position of the patient's hands, and the restlessness or the absence of movement.

However, the policy did not state what staff were to do if the patient wanted privacy for personal activities (such as using the bathroom or bathing) or how to intervene and who to notify if identified symptoms were observed (e.g., what to do if the patient was restless or still, how to intervene if the patient's hands were not visible for monitoring, etc.).

The "one to one observations" section of the policy also stated staff were to observe the environment for potentially harmful objects, such as "broken plastic, light bulbs, torn linens, hangers, chemicals, matches, pop cans, cords, shoelaces, etc." However, the policy did not state how or if staff were to intervene if such items were noticed.

Further, the "one to one observations" section of the policy stated staff were to listen for unusual noises and "Never ignore silences or noises." Staff were to also monitor the patient's medication adherence and ensure the patient was not hoarding medications.

However, the policy did not state how or if staff were to intervene if silence or unusual noises were heard, or if the patient was noticed not adhering to their medication regime and hoarding medications.

The hospital failed to ensure the suicide precautions policy was sufficiently developed.

d. During an interview on 10/27/11 at 10:30 AM, RN B stated the suicidal patient would be placed in one of the four rooms closest to the nursing station, each of which had viewing windows. RN B stated tag alarms would be removed from the patient room. RN B stated if a patient had denied suicidal ideations, the door to their room would be allowed to be closed.

Additionally, the ADON was interviewed on 10/23/11 at 3:05 PM. She stated those patients who were actively suicidal would be placed closer to the nursing station. She stated the number one intervention for suicide prevention was room placement.

However, during observations on 10/23/11 beginning at 1:15 PM, it was noted that Patients #5, #10, and #39 were not placed in the rooms closest to the nursing station.

Room placement was not addressed in the hospital's suicide precautions policy.

e. During an interview on 10/23/11 at 3:05 PM, the ADON stated the facility never discontinued a patient from suicide ideation precautions, even when the patient became stabilized.

However, patient records documented suicidal precautions were discontinued, by a telephone order on 10/27/11 at 2:45 PM, for Patients #5, #10 and #20. However, Patients #2 and #39 were not addressed at this time. There was no evidence of physician reassessment, or documentation of a change in patient status, to support the discontinuation of the precautions.

During an interview on 10/27/11 at 3:45 PM, RN B stated she had received the telephone order for the three above listed patients.

The policy did not include how patients' were to be reassessed, and by whom, to ensure they were no longer experiencing suicidal ideation.

The facility failed to ensure suicide precautions were sufficient to keep suicidal patients from being placed in immediate jeopardy from potential serious harm, impairment or death as the result of suicidal tendencies.

NOTE: The hospital was notified of the Immediate Jeopardy on 10/27/11 at 3:45 PM. The hospital submitted an immediate plan, dated 10/28/11, which stated the following:

- All pull cords on the blinds in all patient rooms and common areas were removed and rounds were completed to ensure any other hazards were identified and removed.

- The Suicide Precautions policy was revised to include an assessment process, the frequency of assessment, and a method for determining how the level of the suicide precautions would be changed.

- All staff were to be trained prior to working their next scheduled shift.

- All patients who were on suicide precautions were assessed and appropriate interventions were implemented to assure patients were receiving care in a safe setting.

On 10/28/11, based on observations of the environment and patients, staff interviews, review of the facility's revised policy, and review of the medical records for Patients #2, #5, #10, #20 and #39, it was determined the immediate jeopardy was abated on 10/28/11 at 9:00 AM.
VIOLATION: PHARMACY ADMINISTRATION Tag No: A0491
Based on review of medication logs and interview, it was determined the facility failed to ensure drug dispensation and tracking administration systems were sufficiently developed, implemented and monitored. This failure directly impacted 6 of 18 patients reviewed (#4, #7, #10, #14, #40, and #41) who received medications when a pharmacist was not at the facility, and had the potential to impact all patients receiving care at the facility. Lack of adequate systems resulted in the potential for patients to be given medications in error. The findings include:

On 10/25/11 at 3:30 PM, the Pharmacist was interviewed regarding the function of the pharmacy. She stated the pharmacy was usually staffed Monday through Friday for the day shift. She explained that when no pharmacist was on site (evenings and weekends), the nursing staff used a key to enter the pharmacy and dispense drugs as needed. She stated the nurses had been instructed to complete a log of medications dispensed and the pharmacist would check it on the next work day.

The untitled medication log, for the time frame of 9/27/11 through 10/25/11, was reviewed with the Pharmacist on 10/25/11 at 4:00 PM. The log had a space for: patient name, date/time, drug/dose, RN initials, pulled medication, lot number, and pharmacist initials. The instructions printed on the bottom of the log sheet stated, "Please leave an extra unit dosed medication out so the pharmacist can compare to the written order (i.e. if the RN needs a furosemide 40 mg, leave an extra one out next to the patients name." The Pharmacist added that if there was not any unit dosed medication available, the RN should write the lot number from the bottle in the space provided and the pharmacist would check it on the next business day.

The log listed 20 medications which had been dispensed from 9/27/11 through 10/25/11. The log was missing lot numbers for 11 of the 20 medications. There was no pharmacist initials for 7 of 20 medications. The following information was missing from the medication log:

- On 10/01/11, the nurse recorded that she took Vitamin B1 100 mg for Patient #40 and "no med left for pharmacy to check," was noted.
- On 10/19/11, the nurse recorded that she took Cipro 250 mg for Patient #14 and "nothing to check," was noted.
- On 10/21/11, the nurse recorded she took an Advair for Patient #41, but no pharmacist review was noted.
- On 10/22/11 at 9:00 PM, the nurse recorded she took two doses (dose not specified) of Haldol for Patient #4, but there was no pharmacist review recorded.
- On 10/23/11 at 8:00 AM, the nurse recorded she took two doses (dose not specified) of Haldol for Patient #4, but there was no pharmacist review recorded.
- On 10/23/11 at 8:00 PM, the nurse recorded she took two doses of Haldol 1 mg for Patient #4, but there was no pharmacist review recorded.
- On 10/23/11 at 9:30 PM, the nurse recorded she took Topivate for Patient #7, but there was no pharmacist review recorded.
- On 10/24/11 at 8:00 AM, the nurse recorded she took Haldol 2 mg for Patient #4, but there was no pharmacist review recorded.
-On 10/25/11 at 9:00 AM, the nurse recorded she took Carmex for Patient #10, but there was no pharmacist review recorded.

During the interview on 10/25/11 at 4:00 PM, the Pharmacist stated it was not unusual for nurses to forget to leave out a medication for pharmacist review. She agreed that the system would not prevent the nurse from giving the wrong medication since the pharmacist reviewed the information on the next working day.

The Pharmacist stated the list had not been completely reviewed by the Pharmacist and she did not know what medications had been dispensed if the nurse did not log it on the form. The Pharmacist stated she could not audit the forms against a medication count. There was no hospital wide count of the non-controlled drugs and the practice was to reorder drugs when the supply ran low.

Nursing staff had access to the pharmacy when the pharmacist was not there and the system to track drugs dispensed by the nurses was not followed. Staff dispensed medication without pharmacist review. The nursing staff did not follow established procedures and the pharmacist did not review the records promptly.

The facility failed to ensure the drug storage area was controlled by the pharmacist.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observations and interviews, it was determined the facility failed to ensure staff monitored and maintain the water temperature in the laundry and cleaned the public toilet facilities. Failure to wash laundry at appropriate temperatures creates the risk of cross contamination of microbes and parasites for all patients. Failure to provide clean toilet facilities increases the risk of cross contamination of microbes to outpatients, visitors, and staff who use the facilities. The findings include:

1. On 10/25/11 at 10:45 AM, the Maintenance Director was interviewed regarding the water temperatures in the facility laundry. The thermometer on the hot water intake line to the washer indicated a temperature of 105 degrees Fahrenheit. He stated he was not sure if that was the appropriate temperature for laundering but would check. He reported at 3:00 PM on 10/25/11, that according to facility policy, the temperature should be 140 degrees Fahrenheit.

On 10/26/11 at 9:00 AM, the CEO stated a plumber had just completed repairs to the plumbing system. Repairs had been made to a second hot water tank which was dedicated to the laundry system and the thermometer on the water intake line. The thermometer had not been working.

The facility failed to ensure staff monitored and maintain the appropriate water temperature for laundry.

2. The public restrooms were observed to be unclean on 2 separate occasions. The public restrooms were available to all the outpatients who visited the facility. Unclean toilets presented a risk of cross contamination of microbes. On 10/25/11 at 3:00 PM, and again on 10/26/11 at 10:25 AM, brown smeared material was observed on the toilet seat in the first public restroom.

The facility failed to ensure public toilet facilities were cleaned.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on record review, review of quality assessment documentation, and interviews it was determined the facility failed to measure, analyze and track quality indicators related to patients placed on comfort care. This was found for 18 of 18 patients reviewed (#21 - #38) who were place on comfort care. This resulted in the inability of the facility to effectively monitor its comfort care system. The findings include:

On 10/24/11 the facility provided records for all the patients who had died in the hospital over the last year. The records of 18 patients, Patients #21 - #38, were reviewed. Each patient was admitted for psychiatric care, later identified as needing comfort care and subsequently died in the facility. The deaths were considered expected deaths.

The quality assurance minutes for 2011 were reviewed. No review of comfort care as a process of care or a specialized hospital service was found. There were no measurements, analysis, or tracking related to quality indicators for the comfort care patients or the comfort care system

On 10/26/11 at 9:00 AM, and on 10/31/11 during an exit interview beginning at 2:00 PM, the CEO was asked to provide any additional quality assessment documentation that would support an analysis of comfort care patients or the comfort care system. No additional information was provided.

The facility failed to ensure comfort care processes were incorporated into the quality assurance program.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on record review, review of quality assessment documentation, and interviews it was determined the facility failed to measure, analyze and track quality indicators related to patients placed on comfort care. This was found for 18 of 18 patients reviewed (#21 - #38) who were place on comfort care. This resulted in the inability of the facility to effectively monitor its comfort care system. The findings include:

On 10/24/11 the facility provided records for all the patients who had died in the hospital over the last year. The records of 18 patients, Patients #21 - #38, were reviewed. Each patient was admitted for psychiatric care, later identified as needing comfort care and subsequently died in the facility. The deaths were considered expected deaths.

The quality assurance minutes for 2011 were reviewed. No review of comfort care as a process of care or a specialized hospital service was found. There were no measurements, analysis, or tracking related to quality indicators for the comfort care patients or the comfort care system

On 10/26/11 at 9:00 AM, and on 10/31/11 during an exit interview beginning at 2:00 PM, the CEO was asked to provide any additional quality assessment documentation that would support an analysis of comfort care patients or the comfort care system. No additional information was provided.

The facility failed to ensure comfort care processes were incorporated into the quality assurance program.