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.

MOUNTAIN VIEW CENTER FOR GERIATRIC PSYCHIATRY 500 POLK STREET EAST KIMBERLY, ID Aug. 11, 2014
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on staff interviews and review of medical records, meeting minutes, and quality documents, it was determined the hospital failed to protect and promote patients' rights. This resulted in adverse patient outcomes and the potential for similar events to occur in the future. Findings include:

Refer to A144 as it relates to the failure of the hospital to ensure patients received care in a safe setting.

The inability of the hospital to protect patients from harm, seriously impeded the ability of the hospital to provide services of sufficient scope and quality.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, facility policies, accident and incident reports, and staff interviews, it was determined the hospital failed to ensure 4 of 8 patients (#1, #2, #4, and #7) whose records were reviewed, received care in a safe setting. This resulted in the inability of the hospital to ensure hospital staff correctly administered medications, monitored patients, and protected patients from injury. Findings include:

1. A facility policy, "ADMINISTRATION OF MEDICATIONS," revised 2/2013, stated

Medication orders must include:

- Date and Time,
- Patient Name,
- Drug Name,
- Route of Administration,
- Dose,
- Frequency.

The policy also stated "Order Clarification, The nurse is ultimately responsible to clarify unclear/incomplete medication orders with the physician. The pharmacist may assist in this process as needed. The nurse taking a telephone order must repeat the order back to the physician to ensure the accurate order was taken."

This policy was not followed. Examples include:

a. Patient #7 was a [AGE] year old male admitted to the facility on [DATE] for dementia, unspecified psychosis, and hypertension.

His record documented he was transferred from Mountain View Center for Geriatric Psychiatry to an acute care hospital on [DATE] until 4/08/14, as a result of an inadvertent dose of Thorazine.

A nursing note, dated 4/06/14 at 4:00 PM, was the first nursing entry for the day shift (7:00 AM to 7:00 PM). The note documented Patient #7 received Thorazine 200 mg at 11:30 AM. The RN wrote she held all of Patient #7's 8:00 AM and 12:00 PM medications due to his sleeping and combative behavior. The RN did not indicate the route of administration.

In a nursing note at 6:00 PM on 4/06/14, the same RN described Patient #7's agitated behaviors of spitting, biting, and hitting at staff. The RN documented at that time the psychiatrist was notified and "Thorazine & Ativan IM ordered." The nurse wrote "...these were given in the R [right] dorso gluteal, Ativan given in the L [left] dorso gluteal. Pt [patient] continues [with] physical & verbal aggression." The nurse did not document in her notes what time the medications were administered, or the doses delivered.

In a nursing note at 7:00 PM on 4/06/14, the same RN wrote "Pt [patient] transferred out of facility for further monitoring." It did not include further details of why Patient #7 was transferred. Patient #7's record did not include documentation for hospital transfer, or physician orders for the transfer.

A form titled "DOCTOR'S ORDERS AND PROGRESS NOTES," included an entry by Patient #7's psychiatrist on 4/06/14 at 6:30 PM: "[Patient Name] became more & more agitated & refused oral meds X 2, and started hitting & trying to bite staff. I ordered Haldol 10 mg IM & Ativan 2 mg IM. The nurse gave it and the Team Control Positioning was required for less than 30 seconds for both injections. When I arrived to evaluate him he was sitting quietly on the bedside & did not require more physical restraints." Patient #7's record did not include a verbal order or written order for Haldol, Thorazine, or Ativan. The record did not include a physician's order for Patient #7's transfer or notes written by his physician indicating why a transfer would be indicated.

Review of Patient #7's medication administration records did not include documentation Thorazine, Haldol, or Ativan were administered that evening.

An admission History and Physical from the hospital where Patient #7 was transferred to, dated 4/06/14, noted he received the Thorazine and Ativan dose at 6:25 PM.

Patient #7's Discharge Summary from Mountain View Center for Geriatric Psychiatry, dictated 6/06/14, dictated by his Psychiatrist, documented that on 4/06/14, Patient #7 received Haldol 10 mg and Ativan 2 mg IM, then was transported to the hospital for evaluation and returned 4/08/14. The discharge summary was not accurate as it indicated Haldol was administered, although Patient #7 received Thorazine. The discharge summary did not include the reason for the hospital transfer, and did not reference the medication adverse event.

The DON was reported to have conducted an investigation regarding the medication error, but was unavailable during the survey. During an interview on 8/08/14 beginning at 11:15 AM, the Admissions Coordinator reviewed Patient #7's record and stated she was familiar with the incident. She stated she was covering for the DON during her absence, and provided a packet of papers she described as the DON's investigation of the incident.

The investigation packet included Progress notes and Nursing notes, however, they were undated and/or unsigned, as follows:

i. An undated and unsigned Progress note, timed 7:55 PM, indicated a phone order was obtained from the psychiatrist. The writer of the progress note documented administration of Thorazine and Ativan. The progress note stated a phone order was obtained from the psychiatrist for Patient #7's transport to the acute care hospital.

ii. A dated and timed, but unsigned, Nurse's notes with Patient #7's name, date and time, however the notes did not have a signature to indicate the authors. Dated and timed, but unsigned, Nurse's notes with Patient #7's name on them, were written by 2 different individuals. This was evidenced by the use two different writing instruments and two different handwriting styles. These included:

- A Nurse's note, dated 4/06/14 at 7:30 PM, was a three page description of the medication administration, written as a narrative of how the individual (an RN,) assisted Patient #7's nurse. The writer of the Nursing note stated she drew up two 5 ml syringes of Thorazine, (which would be a total dose of 500 mg). She wrote that the other nurse drew up the Ativan 2 ml, (which would be a dose of 4 mg). The writer documented the Ativan and 5 ml of Thorazine was administered into Patient #7's left gluteal region by the other nurse, and she administered Thorazine 5 ml into his right gluteal region. She documented the injections were administered at 6:40 PM. Additionally, the RN documented Patient #7's physician came in to see him and wrote orders at 6:30 PM.

- A Nurse's note dated 4/06/14 at 7:40 PM, was a three page description of the events surrounding the medication administration and transfer of Patient #7. The note appeared to have been written by the nurse who took care of Patient #7 on 4/06/14, however, the note was not signed. The writer stated Patient #7 was combative on 4/06/14 shortly after 11:00 AM, and Thorazine 200 mg was administered orally. The nurse documented that Patient #7 got up at 5:45 PM, was belligerent, and difficult to redirect. She wrote that she attempted to call the psychiatrist twice, then he called back and "...gave order for Thorazine 10 ml IM and Ativan 2 ml." The writer stated another nurse offered assistance, and she delegated the nurse to draw up the Thorazine. The writer stated she was questioned by the other nurse regarding the volume, and they decided to divide the medication into two syringes of 5 ml each. The writer documented the injections were administered at 6:45 PM, and vital signs were taken at 6:40 and 6:50 PM, and were within normal limits.

During an interview on 8/08/14 beginning at 11:15 AM, the Admission Coordinator (an RN who was covering in the DON's absence) reviewed Patient #7's record and confirmed the times of the medication administration differed in ea[DIAGNOSES REDACTED]erent document. The administration times ranged from 6:25-6:45 PM. She also confirmed there was no order for Haldol, Thorazine, or Ativan written the evening of 4/06/14, by either the psychiatrist, or the nurse who received the orders. Additionally, the medication administration was not documented on Patient #7's Medication Administration Records. The Admission Coordinator confirmed the Discharge Summary and Physician's notes included information Patient #7 received Haldol and Ativan, although he was documented by the nurse as receiving Thorazine and Ativan. She confirmed the discrepancy in documentation.

During an interview on 8/08/14 at 9:00 AM, the RN who was the charge nurse who provided care to Patient #7, and who administered the Thorazine/Ativan injections, reviewed her process for obtaining medications from the pharmacy. She stated the charge nurse had access to the key for the pharmacy. The RN unlocked the door of the pharmacy and demonstrated where the medication was stored, and stated the only dose of Thorazine the facility carried was in 2 ml glass ampules of 50 mg Thorazine. She stated 10 ml would mean 5 of the ampules would be used.

During an interview on 8/08/14 at 1:40 PM, the facility Pharmacist reviewed Patient #7's record and confirmed it was Thorazine 10 ml (500 mg total dose), and Ativan 2 ml (4 mg total dose) that Patient #7 received. He confirmed there were no written orders for either medication. The Pharmacist stated he did not perform an analysis of the incident, as he felt it was a nursing incident and not related to pharmacy. He was questioned about monitoring of inventory, and how he reconciled counts of medications if the orders did not match what was used. He stated the Thorazine and Ativan was not ordered, and it was not on the medication administration records, so it would not be possible to track where it went. The Pharmacist stated he did not review Patient #7's record during the monthly medication audits that he performed.

During a phone interview on 8/11/14 beginning at 12:40 PM, the DON stated the nurse who administered the Thorazine and Ativan was an experienced nurse with the hospital. She stated she reviewed the nurse's competencies and annual performance evaluations. The DON stated the nurse was counseled after the incident, she had been assigned "Homework," and had to complete a PowerPoint and med-pass audit before she was able to return to patient care. The DON stated the incident was reviewed with the hospital physicians and the administrator.

b. Patient #4 was a [AGE] year old male admitted to the facility on [DATE], for dementia and aggression. Additional diagnoses included [DIAGNOSES REDACTED].

Patient #4's medical record included a signed verbal order dated 10/24/13 at 10:35 PM, for blood to be drawn for labwork and to start antibiotics. Rocephin 2 gm IM was ordered "now," as the initial dose, and was to be followed by 1 gm every 24 hours for the next 5 days. The order did not include a time when the physician authenticated the order, or when the nurse noted the order.

A Medication Administration Record included documentation Patient #4 received the first dose of Rocephin 2 gm on 10/25/13. The medication sheet did not include a time of administration.

A nursing note dated 10/26/13 at 4:00 AM, was unclear, as multiple events were described, but no time was provided when they occurred. The note lacked clarity of what time the first dose of Rocephin was administered, and if he received an additional dose as follows: "Rocephin 2 gm IM initial dose, then Rocephin 1 gm IM q [every] 24 hours X 5 d [days]. Pt breathing labored, noted Rhonci." The nursing note, also under the 4:00 AM entry, included "Pt VS [vital signs] recheck after Rocephin given @ approx (sic) 2300 [11:00 PM]." The nurse documented Patient #4's blood pressure was 100/52.

In a nursing note on 10/26/13 at 4:55 AM, the nurse documented Patient #4 was transferred to an acute care hospital.

During an interview on 8/08/14 beginning at 11:15 AM, the Admission Coordinator, (an RN who was covering in the DON's absence,) reviewed Patient #4's record and confirmed the medication order was written on 10/24/13. She verified the MAR documented Patient #4 received the first dose of Rocephin on 10/25/13, and the time was not noted on the MAR. She confirmed the RN documented she gave the IM Rocephin injection to Patient #4 at 11:00 PM on 10/25/14.

During an interview on 8/08/14 beginning at 1:40 PM, the facility Pharmacist reviewed Patient #4's record and confirmed the medication administration record indicated his first dose of Rocephin 2 gms was administered on 10/25/13. He was asked about medication errors, and if this was identified as a medication error. The Pharmacist stated he did not think Patient #4's record was reviewed for medication errors. He stated that most medication errors are self disclosed, meaning the nursing staff identifies an error and will complete an incident report. The Pharmacist stated he chooses 3 random records for medication review each month. From the review of the 3 records, he stated, he then is able to determine the percentage of medication errors for the facility each month.

Antibiotics for Patient #4 were ordered to be given "Now," on 10/24/13 at 10:35 PM. The facility failed to administer his first dose until 24 hours later, on 10/25/13 at 11:00 PM. Five hours later he was transferred to a higher level of care facility where he later died .

The facility failed to fully investigate medication errors, failed to ensure accuracy of documentation by the physician and nursing staff, and failed to ensure verbal orders for medications were written and authenticated as per the facility's policy and commonly understood nursing standards of practice.

2. Patient #1 was a [AGE] year old male admitted on [DATE] for Schizoaffective Disorder.

A form titled "Medication Sheet" indicated Patient #1 had an elevated temperature of 102 on 5/6/14 at 7:00 PM. At 7:30 PM on 5/6/14 a verbal order was received to give him Tylenol "now" and recheck Patient #1's temperature along with vital signs in one hour, then to call the NP back to inform them of the results. However, this order was not followed. One and a half hours later at 9:00 PM on 5/6/14, on a form titled "Patient Vitals Data," the nurse documented Patient #1's temperature as 101. One hour later, at 10:00 PM on 5/6/14, the nurse documented contacting the NP and Patient #1's temperature was 102. A temperature of 101 and administration of Tylenol was documented on the "Medication Sheet" at 1:30 AM on 5/7/14, three and half hours later. Patient #1's temperature was not documented again until 5:00 AM on 5/7/14, three and half hours after the Tylenol was given. His tempature at that time was 101.2.

Vital signs were not documented in a consistent location in Patient #1's record for monitoring of changes in his condition and effectiveness of medications administered. Elevated temperatures were not rechecked in a timely manner after medications were given.

Patient #1 was, subsequently, transferred to an acute care hospital on [DATE].

The facility did not have a policy related to vital signs, and this was confirmed by the Director of Medical Records and Health Information on 8/08/14 at 10:00 AM.


During an interview on 8/08/14 at 11:15 AM, the Admission Coordinator reviewed Patient #1's record and confirmed his temperature was elevated, and the documentation of vital signs was in multiple locations in his record. She stated the frequency of his vital signs should have been increased, and his temperature monitored more closely. The Admission Coordinator stated she was not aware of the lack of a policy related to vital signs.


3. Patient #2 was a [AGE] year old female admitted to the facility on [DATE] for care related to dementia, aggressive behavior, HTN, and irregular heart rhythm. A fall risk assessment was performed on 5/01/14, with a score of 9. The worksheet used by the facility noted "TOTAL SCORES ABOVE 10 REPRESENTS A HIGH RISK."

An incident report documented Patient #2 fell out of her wheelchair on 5/06/14, at approximately 6:13 PM. The report indicated there were no witnesses to the fall. It stated the recording was reviewed, and Patient #2 was observed attempting to stand up from the wheelchair and reaching for the dining room table. The incident report documented the review of the recording showed Patient #2 falling backwards, landing on her buttocks, back, and head. Additionally, the report documented her wheelchair was not locked. On 5/07/14, Patient #2's fall risk assessment was re-evaluated, and the score was 16. A care plan related to falls was implemented on 5/06/14.

During an interview on 8/08/14 beginning at 11:30 AM, an RN who identified herself as an Admissions Coordinator, and was covering for the DON, reviewed Patient #2's record. She stated Patient #2 was considered a risk for falls, although her score on admission was less than 10. She stated the wheelchair should have been locked, and was not able to explain why the fall was unwitnessed as it was during mealtime.

Patient #2 experienced a fall when she attempted to stand up from an unlocked wheelchair.

The facility did not ensure patients received care in a safe setting.





4. Falls:

The minutes of 4 Medical Executive Committee meetings were documented between 8/01/13 and 8/7/01. Medical Executive Committee meeting minutes, dated 8/27/13, stated "There have been 15 falls during the 2nd quarter, of which (1) was addressed as being preventable. Goal not met." The 15 falls were not specifically addressed.

Medical Executive Committee meeting minutes, dated 12/10/13, stated "There have been 22 falls during the 3rd quarter, of which (0) were addressed as being preventable. Goal met." The 22 falls were not specifically addressed.

Medical Executive Committee meeting minutes, dated 2/25/14, stated "There have been 34 falls during the 4th quarter [of 2013], of which (3) were addressed as being preventable. There was a annual total of 84 falls, of which 4, (5%) were addressed as being preventable. The annual goal was not met."

Medical Executive Committee meeting minutes, dated 5/20/14, stated "There have been 62 falls during the 1st quarter [of 2014] of which 10 were addressed as being preventable. The 1st quarter rate is 5.3%, so the quarterly goal is not met." The meeting minutes stated the hospital had a "Goal of 2% or < fall rate." This was the first mention of a 2% fall rate. The rationale for this change was not documented. No specific actions or recommendations to reduce the fall rate were documented.

The Administrator was interviewed on 8/08/14 at 9:25 AM. He confirmed the data for 2013 and 2014.

The Administrator was interviewed again on 8/15/14 at 2:25 PM. He stated changes to the hospital's fall prevention program had been implemented but were not documented for the year prior to survey. The Administrator stated the hospital had not analyzed fall data beyond the total number or percentage of falls. He stated the hospital's QAPI program had not measured the effects of efforts to reduce falls.

The hospital did not take actions to prevent falls and protect patients from harm.

5. Medication Errors:

The "QAPI REPORT FOR THE YEAR OF 2013," not dated, stated the medication error rate for 2013 was 4.51%. The document stated this was higher than the hospital's goal of 3.5%. Medical Executive Committee meeting minutes, dated 2/25/14, stated the medication error rate for the fourth quarter of 2013 was 7.35% which did not meet the 3.5% goal. The FORM "QAPI MEDICATION ERRORS FOR APRIL 2014" stated the error percentage rate was 1.2%. The FORM "QAPI MEDICATION ERRORS FOR MAY 2014" stated the error percentage rate was 4.1%. The FORM "QAPI MEDICATION ERRORS FOR JUNE 2014" stated the error percentage rate was 6.1%.

Raw data showed the medication error rate was determined based on the pharmacist's review of 3 randomly chosen medical records per month. This brought into question the accuracy of the data as it was solely dependent on which records were chosen for review. The severity of medication errors was not tracked. Also, causal analysis of the errors was not done. No review of systems for prescribing, transcribing, and administering medications had been conducted.

Medical Executive Committee meeting minutes from 8/01/14 to 8/07/14 documented the hospital's QAPI actions. The only actions documented to reduce medication errors were to "educate" staff who passed medications.

The pharmacist was interviewed on 8/08/14 beginning at 1:40 PM. He stated the medication error rate was determined by his review of 3 randomly chosen medical records per month. He stated incident reports were not completed for the medication errors that were identified.

The pharmacist stated the error rate was determined by the number of errors identified divided by the number of doses ordered. He stated the data used to determine the error rate was not broken down into sub-categories such as the severity of the errors or the type of errors identified, i.e. prescription errors, transcription errors, etc. He stated causal analyses of medication errors was not conducted.

The administrator was interviewed on 8/08/14 at 9:25 AM. He confirmed the data for 2013 and the first quarter of 2014. He stated other than educating staff to be more careful, the hospital had not taken specific measures to reduce the medication error rate for at least one year prior to the survey.

The hospital did not take action to reduce the number of medication errors and
protect patients from harm.

6. Refer to A283 as it relates to the failure of the facility ensure its QAPI program effectively monitored falls and medication errors by implementing quality improvement processes, tracking progress, analyzing results, and revising ineffective processes.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, staff interview, and policy review, it was determined the hospital failed to ensure drugs were administered in accordance with accepted standards of practice for 2 of 8 patients (Patient #4 and #7 ) whose records were reviewed. The negative practices had the potential to affect all patients in the facility. This resulted in patients receiving medications that were not ordered and adverse patient outcomes resulting in transfer to an acute care hospital. Findings include:

A facility policy, "ADMINISTRATION OF MEDICATIONS," revised 2/2013, stated

Medication orders must include:

- Date and Time,
- Patient Name,
- Drug Name,
- Route of Administration,
- Dose,
- Frequency.

The policy also stated "Order Clarification, The nurse is ultimately responsible to clarify unclear/incomplete medication orders with the physician. The pharmacist may assist in this process as needed. The nurse taking a telephone order must repeat the order back to the physician to ensure the accurate order was taken."

The following examples include errors related to a failure to document written medication orders, a failure to ensure the correct medication, and dose was administered, and recorded as given, and inaccurate documentation of the medication as it related to timing and related activities:

a. Patient #7 was a [AGE] year old male admitted to the facility on [DATE] for dementia, unspecified psychosis, and hypertension.

His record documented he was transferred from Mountain View Center for Geriatric Psychiatry to an acute care hospital on [DATE] until 4/08/14, as a result of an inadvertent dose of Thorazine.

A nursing note, dated 4/06/14 at 4:00 PM, was the first nursing entry for the day shift (7:00 AM to 7:00 PM). The note documented Patient #7 received Thorazine 200 mg at 11:30 AM. The RN wrote she held all of Patient #7's 8:00 AM and 12:00 PM medications due to his sleeping and combative behavior. The RN did not indicate the route of administration.

In a nursing note at 6:00 PM on 4/06/14, the same RN described Patient #7's agitated behaviors of spitting, biting, and hitting at staff. The RN documented at that time the psychiatrist was notified and "Thorazine & Ativan IM ordered." The nurse wrote "...these were given in the R [right] dorso gluteal, Ativan given in the L [left] dorso gluteal. Pt [patient] continues [with] physical & verbal aggression." The nurse did not document in her notes what time the medications were administered, or the doses delivered.

In a nursing note at 7:00 PM on 4/06/14, the same RN wrote "Pt [patient] transferred out of facility for further monitoring." It did not include further details of why Patient #7 was transferred. Patient #7's record did not include documentation for hospital transfer, or physician orders for the transfer.

A form titled "DOCTOR'S ORDERS AND PROGRESS NOTES," included an entry by Patient #7's psychiatrist on 4/06/14 at 6:30 PM: "[Patient Name] became more & more agitated & refused oral meds X 2, and started hitting & trying to bite staff. I ordered Haldol 10 mg IM & Ativan 2 mg IM. The nurse gave it and the Team Control Positioning was required for less than 30 seconds for both injections. When I arrived to evaluate him he was sitting quietly on the bedside & did not require more physical restraints." Patient #7's record did not include a verbal order or written order for Haldol, Thorazine, or Ativan. The record did not include a physician's order for Patient #7's transfer or notes written by his physician indicating why a transfer would be indicated.

Review of Patient #7's medication administration records did not include documentation Thorazine, Haldol, or Ativan were administered that evening.

An admission History and Physical from the hospital where Patient #7 was transferred to, dated 4/06/14, noted he received the Thorazine and Ativan dose at 6:25 PM.

Patient #7's Discharge Summary from Mountain View Center for Geriatric Psychiatry, dictated 6/06/14, dictated by his Psychiatrist, documented that on 4/06/14, Patient #7 received Haldol 10 mg and Ativan 2 mg IM, then was transported to the hospital for evaluation and returned 4/08/14. The discharge summary was not accurate as it indicated Haldol was administered, although Patient #7 received Thorazine. The discharge summary did not include the reason for the hospital transfer, and did not reference the medication adverse event.

The DON was reported to have conducted an investigation regarding the medication error, but was unavailable during the survey. During an interview on 8/08/14 beginning at 11:15 AM, the Admissions Coordinator reviewed Patient #7's record and stated she was familiar with the incident. She stated she was covering for the DON during her absence, and provided a packet of papers she described as the DON's investigation of the incident.

The investigation packet included Progress notes and Nursing notes, however, they were undated and/or unsigned, as follows:

i. An undated and unsigned Progress note, timed 7:55 PM, indicated a phone order was obtained from the psychiatrist. The writer of the progress note documented administration of Thorazine and Ativan. The progress note stated a phone order was obtained from the psychiatrist for Patient #7's transport to the acute care hospital.

ii. A dated and timed, but unsigned, Nurse's notes with Patient #7's name, date and time, however the notes did not have a signature to indicate the authors. Dated and timed, but unsigned, Nurse's notes with Patient #7's name on them, were written by 2 different individuals. This was evidenced by the use two different writing instruments and two different handwriting styles.

- A Nurse's note, dated 4/06/14 at 7:30 PM, was a three page description of the medication administration, written as a narrative of how the individual (an RN,) assisted Patient #7's nurse. The writer of the Nursing note stated she drew up two 5 ml syringes of Thorazine, (which would be a total dose of 500 mg). She wrote that the other nurse drew up the Ativan 2 ml, (which would be a dose of 4 mg). The writer documented the Ativan and 5 ml of Thorazine was administered into Patient #7's left gluteal region by the other nurse, and she administered Thorazine 5 ml into his right gluteal region. She documented the injections were administered at 6:40 PM. Additionally, the RN documented Patient #7's physician came in to see him and wrote orders at 6:30 PM.

- A Nurse's note dated 4/06/14 at 7:40 PM, was a three page description of the events surrounding the medication administration and transfer of Patient #7. The note appeared to have been written by the nurse who took care of Patient #7 on 4/06/14, however, the note was not signed. The writer stated Patient #7 was combative on 4/06/14 shortly after 11:00 AM, and Thorazine 200 mg was administered orally. The nurse documented that Patient #7 got up at 5:45 PM, was belligerent, and difficult to redirect. She wrote that she attempted to call the psychiatrist twice, then he called back and "...gave order for Thorazine 10 ml IM and Ativan 2 ml." The writer stated another nurse offered assistance, and she delegated the nurse to draw up the Thorazine. The writer stated she was questioned by the other nurse regarding the volume, and they decided to divide the medication into two syringes of 5 ml each. The writer documented the injections were administered at 6:45 PM, and vital signs were taken at 6:40 and 6:50 PM, and were within normal limits.

During an interview on 8/08/14 beginning at 11:15 AM, the Admission Coordinator, (an RN who was covering in the DON's absence,) reviewed Patient #7's record and confirmed the times of the medication administration differed in ea[DIAGNOSES REDACTED]erent document. The administration times ranging from 6:25-6:45 PM. She also confirmed there was no order for Haldol, Thorazine, or Ativan written the evening of 4/06/14, by either the psychiatrist, or the nurse who received the orders. Additionally, the medication administration was not documented on any of Patient #7's Medication Administration Records. The Admission Coordinator confirmed the Discharge Summary and Physician's notes included information Patient #7 received Haldol and Ativan, although he was documented by the nurse as receiving Thorazine and Ativan. She confirmed the discrepancy in documentation.

During an interview on 8/08/14 at 9:00 AM, the RN who was the charge nurse who provided care to Patient #7, and who administered the Thorazine/Ativan injections, reviewed her process for obtaining medications from the pharmacy. She stated the charge nurse had access to the key for the pharmacy. The RN unlocked the door of the pharmacy and demonstrated where the medication was stored, and stated the only dose of Thorazine the facility carried was in 2 ml glass ampules of 50 mg Thorazine. She stated 10 ml would mean 5 of the ampules would be used.

During an interview on 8/08/14 at 1:40 PM, the facility Pharmacist reviewed Patient #7's record and confirmed it was Thorazine 10 ml (500 mg total dose), and Ativan 2 ml (4 mg total dose) that Patient #7 received. He confirmed there were no written orders for either medication. The Pharmacist stated he did not perform an analysis of the incident, as he felt it was a nursing incident and not related to pharmacy. He was questioned about monitoring of inventory, and how he reconciled counts of medications if the orders did not match what was used. He stated the Thorazine and Ativan was not ordered, and it was not on the medication administration records, so it would not be possible to track where it went. The Pharmacist stated he did not review Patient #7's record during the monthly medication audits that he performed.

During a phone interview on 8/11/14 beginning at 12:40 PM, the DON stated the nurse who administered the Thorazine and Ativan was an experienced nurse with the hospital. She stated she reviewed the nurse's competencies and annual performance evaluations. The DON stated the nurse was counseled after the incident, she had been assigned "Homework," and had to complete a PowerPoint and med-pass audit before she was able to return to patient care. The DON stated the incident was reviewed with the hospital physicians and the administrator.

b. Patient #4 was a [AGE] year old male admitted to the facility on [DATE], for dementia and aggression. Additional diagnoses included [DIAGNOSES REDACTED].

Patient #4's medical record included a signed verbal order dated 10/24/13 at 10:35 PM, for blood to be drawn for labwork and to start antibiotics. Rocephin 2 gm IM was ordered "now," as the initial dose, and was to be followed by 1 gm every 24 hours for the next 5 days. The order did not include a time when the physician authenticated the order, or when the nurse noted the order.

A Medication Administration Record included documentation Patient #4 received the first dose of Rocephin 2 gm on 10/25/13. The medication sheet did not include a time of administration.

A nursing note dated 10/26/13 at 4:00 AM, was unclear, as multiple events were described, but no time was provided when they occurred. The note lacked clarity of what time the first dose of Rocephin was administered, and if he received an additional dose as follows: "Rocephin 2 gm IM initial dose, then Rocephin 1 gm IM q [every] 24 hours X 5 d [days]. Pt breathing labored, noted Rhonci." The nursing note, also under the 4:00 AM entry, included "Pt VS [vital signs] recheck after Rocephin given @ approx (sic) 2300 [11:00 PM]." The nurse documented Patient #4's blood pressure was 100/52.

In a nursing note on 10/26/13 at 4:55 AM, the nurse documented Patient #4 was transferred to an acute care hospital.

During an interview on 8/08/14 beginning at 11:15 AM, the Admission Coordinator, (an RN who was covering in the DON's absence,) reviewed Patient #4's record and confirmed the medication order was written on 10/24/13. She verified the MAR documented Patient #4 received the first dose of Rocephin on 10/25/13, and the time was not noted on the MAR. She confirmed the RN documented she gave the IM Rocephin injection to Patient #4 at 11:00 PM on 10/25/14.

During an interview on 8/08/14 beginning at 1:40 PM, the facility Pharmacist reviewed Patient #4's record and confirmed the medication administration record indicated his first dose of Rocephin 2 gms was administered on 10/25/13. He was asked about medication errors, and if this was identified as a medication error. The Pharmacist stated he did not think Patient #4's record was reviewed for medication errors. He stated that most medication errors are self disclosed, meaning the nursing staff identifies an error and will complete an incident report. The Pharmacist stated he chooses 3 random records for medication review each month. From the review of the 3 records, he stated, he then is able to determine the percentage of medication errors for the facility each month.

Antibiotics for Patient #4 were ordered to be given "Now," on 10/24/13 at 10:35 PM. The facility failed to administer his first dose until 24 hours later, on 10/25/13 at 11:00 PM. Five hours later he was transferred to a higher level of care facility where he later died .

The facility failed to fully investigate medication errors, failed to ensure accuracy of documentation by the physician and nursing staff, and failed to ensure verbal orders for medications were written and authenticated as per the facility's policy and commonly understood nursing standards of practice.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on staff interview and review of meeting minutes and QAPI documents, it was determined the hospital failed to take actions aimed at performance improvement when it failed to meet quality goals. This affected the care of 1 of 2 sample patient who sustained a fall and whose record was reviewed (Patient #7) and had the potential to affect all patients at the hospital. This prevented the hospital from reaching those quality goals and decreasing adverse patient outcomes. Findings include:

1. Falls:

The Administrator was interviewed on 8/08/14 at 9:25 AM. He stated the Medical Executive Committee was also the hospital's QAPI Committee. He stated the Medical Executive Committee minutes served for both committees.

The minutes of 4 Medical Executive Committee meetings were documented between 8/01/13 and 8/7/01. Medical Executive Committee meeting minutes, dated 8/27/13, stated the "Objective" for the hospital was "No avoidable or preventable patient fall incidents, ensuring that all appropriate fall precautions are implemented and adhered to." The minutes stated "There have been 15 falls during the 2nd quarter, of which (1) was addressed as being preventable. Goal not met." The 15 falls were not specifically addressed. The Action column stated "Preventable fall assessment form is to be completed on all fall incidents and reported at the monthly QAPI meeting, break down time and complete trending. Assess the root cause of what the patient was trying to accomplish before the fall. Individualize care plan and educate staff to follow care plan."

Medical Executive Committee meeting minutes, dated 12/10/13, stated the "Objective" of for the hospital was "No avoidable or preventable patient fall incidents, ensuring that all appropriate fall precautions are implemented and adhered to." The minutes stated "There have been 22 falls during the 3rd quarter, of which (0) were addressed as being preventable. Goal met." The 22 falls were not specifically addressed. The Action column stated "Preventable fall assessment form is to be completed on all fall incidents and reported at the monthly QAPI meeting, break down time and complete trending. Assess the root cause of what the patient was trying to accomplish before the fall. Individualize care plan and educate staff to follow care plan."

Medical Executive Committee meeting minutes, dated 2/25/14, stated the "Objective" of for the hospital was "No avoidable or preventable patient fall incidents, ensuring that all appropriate fall precautions are implemented and adhered to." The minutes stated "There have been 34 falls during the 4th quarter [of 2013], of which (3) were addressed as being preventable. There was a annual total of 84 falls, of which 4, (5%) were addressed as being preventable. The annual goal was not met." The Action column stated "Preventable fall assessment form is to be completed on all fall incidents and reported at the monthly QAPI meeting, break down time and complete trending. Assess the root cause of what the patient was trying to accomplish before the fall. Individualize care plan and educate staff to follow care plan."

Medical Executive Committee meeting minutes, dated 5/20/14, stated the "Objective" of for the hospital was "No avoidable or preventable patient fall incidents, ensuring that all appropriate fall precautions are implemented and adhered to. Goal of 2% or < fall rate." This was the first mention of a 2% fall rate. The rationale for this change was not documented. This was the last documented meeting by the Medical Executive Committee.

The 5/20/14 minutes stated "There have been 62 falls during the 1st quarter [of 2014] of which 10 were addressed as being preventable. The 1st quarter rate is 5.3%, so the quarterly goal is not met." The "Action" listed was "Preventable fall assessment form is to be completed on all fall incidents and reported at the monthly QAPI meeting, break down time and complete trending. Assess the root cause of what the patient was trying to accomplish before the fall. Individualize care plan and educate staff to follow care plan. Therapy to screen for any patients with greater than 2 falls. Establish a fall rate goal of 2% or less based on monthly census."

The Administrator was interviewed on 8/08/14 at 9:25 AM. He stated data regarding falls had not been presented for the 2nd quarter of 2014. He confirmed the data for 2013 and the first quarter of 2014.

Medical Executive Committee meeting minutes stated the total number of falls and then told how many of those falls were "preventable." The minutes stated one objective was to have "No avoidable or preventable patient fall incidents."

The Administrator was interviewed on 8/15/14 at 10:20 AM. He stated the hospital did not have a definition of preventable falls. The Administrator was not able to state how the number of preventable falls was determined .

All of the Medical Executive Committee meeting minutes mentioned above stated one of the actions to prevent falls was to "Assess the root cause of what the patient was trying to accomplish before the fall." However, the incident reports used to record falls did not include a section to assess the root cause of patients' behavior before falls. For example, Patient #7 had an incident report for a fall on 5/31/14. The incident report contained identifying information, a description of the incident, and corrective action taken. The form did not ask for or include information regarding what Patient #7 was trying to accomplish prior to his fall.

The Administrator was interviewed on 8/15/14 at 2:25 PM. He stated for at least 1 year prior to the survey on 8/11/14, the incident reports had not changed. He stated they did not request information regarding the root cause of what the patient was trying to accomplish before the fall.

During the same interview, the Administrator stated actions had been taken to prevent falls such as using specific colors to identify patients at high risk for falls. He stated these actions had not been included in the QAPI program and no data had been gathered to determine if the actions had been successful. The administrator stated staff had always utilized measures to prevent falls such as low bed positions and bed alarms. He stated, other than measures to allow staff to easily identify patients at risk for falls, no new actions had been implemented to prevent falls in the past year.

The hospital did not take actions when it failed to meet goals for fall prevention.

2. Medication Errors:

The "QAPI REPORT FOR THE YEAR OF 2013" document, not dated, stated the medication error rate for 2013 was 4.51%. The document stated this was higher than the hospital's goal of 3.5%. The report stated "we will continue to educate everyone who passes meds so that they can become familiar and confident when passing meds."

Medical Executive Committee meeting minutes, dated 2/25/14, stated the medication error rate for the fourth quarter of calendar year 2013 was 7.35% which did not meet the 3.5% goal. The "Recommendations" section of the minutes stated "Continue to encourage everyone to explain anything out of the ordinary on the back of the MAR. Ensure that all drugs are pulled and recorded as given on the MARs. Continue to alert those who pass meds on how to improve. Include known medication errors in the QAPI process. Use PCC [a type of software] as EHR for immediate real time communication when it goes live."

Medical Executive Committee meeting minutes, dated 5/20/14, stated the medication error rate for the first quarter of 2014 was 4.3% which was higher than the goal. The recommendations were "Continue to encourage everyone to explain anything out of the ordinary on the back of the MAR. Ensure that all drugs are pulled and recorded as given on the MARs. Continue to alert those who pass meds on how to improve. Include known medication errors in the QAPI process. Use PCC [a type of software] as EHR for immediate real time communication when it goes live."

The FORM "QAPI MEDICATION ERRORS FOR APRIL 2014" stated the error percentage rate was 1.2%. The FORM "QAPI MEDICATION ERRORS FOR MAY 2014" stated the error percentage rate was 4.1%. The FORM "QAPI MEDICATION ERRORS FOR JUNE 2014" stated the error percentage rate was 6.1%.

The Pharmacist was interviewed on 8/08/14 beginning at 1:40 PM. He stated the medication error rate was determined by his review of 3 randomly chosen medical records per month. The pharmacist stated the error rate was determined by number of errors identified by the number of doses ordered. He stated the data used to determine the error rate was not broken down into sub-categories such as the severity of the errors or the type of errors identified, i.e. prescription error, transcription error, etc. He stated he did not use incident reports to identify a medication error rate. He stated causal analyses of medication errors was not conducted.

The Administrator was interviewed on 8/08/14 at 9:25 AM. He confirmed the data for 2013 and the first quarter of 2014. He stated the hospital had not reviewed the way the medication error rate was determined or the way data was used in the past year. He stated other than educating staff to be more careful, the hospital had not taken specific measures to reduce the medication error rate for at least one year prior to the survey.

The hospital did not take action when it failed to meet goals for medication errors.
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview, it was determined the facility failed to ensure all orders were dated, timed, and authenticated for 1 of 8 patients (#7) whose records were reviewed. This resulted in orders that were not transcribed, medications administered without a physician order, lack of authentication of physician orders, medication and treatment errors, as well as lack of clarity about the course of patient care. Findings include:

1. Patient #7 was a [AGE] year old male admitted to the facility on [DATE] for dementia, unspecified psychosis, and hypertension.

His record documented he was transferred to an acute care hospital, where he was on observation for 2 days as a result of an inadvertent dose of Thorazine.

In a nursing note dated 4/06/14 at 6:00 PM, the RN described Patient #7's agitated behaviors of spitting, biting, and hitting at staff. The RN documented at that time the Psychiatrist was notified by phone and "Thorazine & Ativan IM ordered." The nurse wrote "...these were given in the R [right] dorso gluteal, Ativan given in the L [left] dorso gluteal. Pt [patient] continues [with] physical & verbal aggression."

In a nursing note on 4/06/14 at 7:00 PM, the same RN wrote "Pt [patient] transferred out of facility for further monitoring." It did not include further details of why Patient #7 was transferred. Patient #7's record did not include a physician order for the transfer.

A form titled "DOCTOR'S ORDERS AND PROGRESS NOTES," included an entry by Patient #7's psychiatrist on 4/06/14 at 6:30 PM: "[Patient Name] became more & more agitated & refused oral meds X 2, and started hitting & trying to bite staff. I ordered Haldol 10 mg IM & Ativan 2 mg IM. The nurse gave it and the Team Control Positioning was required for less than 30 seconds for both injections. When I arrived to evaluate him he was sitting quietly on the bedside & did not require more physical restraints."

Patient #7's record did not include a verbal order or written order for Haldol, Thorazine, or Ativan. The record did not include a physician's order for Patient #7's transfer or notes written by his physician indicating why a transfer would be indicated.

During an interview on 8/08/14 beginning at 11:15 AM, the Admissions Coordinator reviewed Patient #7's record and stated she was familiar with the patient and the event that occurred on 4/06/14. She confirmed the record did not include either verbal or written orders for Thorazine, Haldol, or Ativan. She confirmed the record did not include either verbal or written orders for Patient #7's transfer to another facility.

The facility did not ensure verbal orders were written and authenticated.
VIOLATION: CONTENT OF RECORD: COMPLICATIONS Tag No: A0465
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policies, record review, and staff interview, it was determined the facility failed to ensure medical records included documentation of complications, hospital acquired infections and unfavorable reactions to drugs for 1 of 8 patients (#7 ) whose records were reviewed. This had the potential for patients to have an inaccurate health care record of their hospitalization . Findings include:

1. Patient #7 was a [AGE] year old male admitted to the facility on [DATE] for dementia, unspecified psychosis, and hypertension.

In a nursing note at 6:00 PM on 4/06/14, an RN described Patient #7's agitated behaviors of spitting, biting, and hitting at staff. The RN documented the Psychiatrist was contacted by phone and "Thorazine & Ativan IM ordered." The nurse wrote "...these were given in the R [right] dorso gluteal, Ativan given in the L [left] dorso gluteal. Pt [patient] continues [with] physical & verbal aggression." The nurse did not document in her notes what the doses of the medications were that were administered.

In a nursing note at 7:00 PM on 4/06/14, the same RN wrote "Pt [patient] transferred out of facility for further monitoring."

His record included an admission note from an acute care hospital dated 4/06/14. It noted he was transferred from Mountain View Center for Geriatric Psychiatry as a result of an inadvertent dose of Thorazine on 4/06/14. He remained at the hospital until 4/08/14, when he was returned to Mountain View Center for Geriatric Psychiatry.

In Patient #7's discharge summary, dictated 6/06/14, his Psychiatrist documented that on 4/06/14, Patient #7 received Haldol 10 mg and Ativan 2 mg IM, then was transported to an acute care hospital for evaluation and returned 4/08/14. The discharge summary was not accurate as it indicated Haldol was administered, although Patient #7 received Thorazine. The discharge summary did not include the reason for the hospital transfer, and did not include the complication related to a medication error.

During an interview on 8/08/14 beginning at 11:15 AM, the Admission Coordinator, (an RN who was covering in the DON's absence,) reviewed Patient #7's record and confirmed the discharge summary did not include documentation of the medication error and complication which required additional hospitalization at another facility.

The facility did not include critical medical patient information in Patient #7's discharge summary.