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.

SOUTHERN NEVADA ADULT MENTAL HEALTH SERVICES 6161 W CHARLESTON BLVD LAS VEGAS, NV Nov. 3, 2011
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and document review the facility failed to follow patient grievance policies and procedures to ensure a prompt investigation and resolution of a patient's grievance concerning physical abuse by staff members (Patient #1).

Findings include:

Patient #1 was admitted to the facility on [DATE] on a legal 2000 (72 hour hold for psychiatric evaluation) after exhibiting aggressive and hostile behavior at a group home.

The patient had a history of bipolar disease and had become increasingly aggressive and agitated on the psychiatric observation unit and had refused to leave the bathroom on the unit. The patient was reported to be delusional and offensive to staff and other patients on the floor.

The patient was deemed a potential threat to staff and other patients on the floor secondary to aggressive behavior. A show of force was unsuccessful in de-escalating the situation and the patient refused oral medication.

The patient was physically restrained and was given an intramuscular injection of Zyprexa (Antipsychotic Medication) for severe agitation. The patient was then brought to a seclusion room by staff.

On 11/02/11 at 1:30 PM, an interview was conducted with Patient #1 who reported being placed on a legal hold by police on 10/21/11 after being involved in an altercation at a group home she resided at. The patient reported she was medically cleared at an acute care hospital and transported to the facility. Patient #1 reported she was using the bathroom in the psychiatric observation unit when a male staff member entered the bathroom when she had her pants down and was seated on the toilet. The staff member informed her a physician was here to see her. Patient #1 reported she was not finished in the bathroom and refused to leave the bathroom. Several male MHT (Mental Health Technicians) entered the bathroom and physically grabbed her by the arms and forced her out of the bathroom. The patient reported several male MHTs punched her in the right arm, right side and kicked her on the left knee forcing her to the floor outside the bathroom area. The patient reported injuries to the right arm, right abdominal area and left knee.

The patient had visible bruising to the right elbow, right abdomen and swelling and bruising to the left knee area. The patient reported she was administered an injection of Zyprexa by nursing staff which she had an allergy to and was also administered Benadryl and Geodon medication by nursing staff which she was allergic to. Patient #1 reportedly developed a rash on her neck as a result of an allergic reaction to the medication.

Patient #1 completed a written complaint grievance incident report about the physical assault and abuse allegations by staff members and handed the report to Employee #4 (Director of Performance Improvement) on 10/21/11. Patient #1 reported photographs were taken of her bruises by nursing staff two days later. Patient #1 reported no representatives from the facility had interviewed her about the abuse allegations and no members of the police department had contacted her to take a police report. Patient #1 reported no representatives of the facility had provided any information regarding an investigation or a decision regarding the physical abuse grievance and did not know if an investigation had been conducted by the facility.

An incident report/grievance dated 11/21/11 (10/21/11) filled out by Patient #1 documented the patient reported being physically assaulted by several male staff members on the psychiatric observation unit and forcibly removed from the bathroom. The patient reported injuries were sustained during the assault by staff.

On 11/02/11 at 10:00 AM, an interview was conducted with Employee # 4 (Director of Performance Improvement) who reported on 10/21/11 at 3:00 PM she was handed a written incident report/grievance filled out by Patient #1 who reported being physically assaulted by several male staff members on the psychiatric observation unit who dragged her out of the bathroom and placed her in a locked room. Employee #4 reported Patient #1 informed her several male staff on the observation unit attacked and struck her causing injuries to her left arm, left abdomen and left knee. Employee #4 reported the patients hand written incident report was given to an Administrative Assistant and the abuse allegation was verbally reported to the facility's Administrator and Director of Nursing on 10/21/11 at 3:00 PM.

Employee #4 acknowledged no internal incident report was completed and no internal investigation was initiated or completed by staff concerning the patient's allegation of physical abuse by staff members. Employee #4 confirmed law enforcement was not notified and no police report was taken. Employee #4 acknowledged the patient had not been provided with any response to the grievance by facility staff. Employee #4 acknowledged the facility staff failed to follow established abuse investigation/reporting and patient grievance policies and procedures.

A Nursing Note dated 10/23/11 included the following:"Patient was very paranoid about bruises on both inner arms. The patient stated,"I was beat up by five staff members in the psychiatric observation unit and ended up with all these bruises. It had been 2 days and no one took pictures." Charge Nurse informed. "Pictures were taken, but she kept insisting they weren't."

On 11/02/11 at 11:00 AM, an interview was conducted with Employee #5 (Administrator) who confirmed on 10/21/11 he was informed of Patient #1's allegations regarding physical assault by staff on the observation unit. Employee #5 reported the patient was reported to be in a manic phase and had to be removed from a bathroom and placed in seclusion on the observation unit. Employee #5 reported he felt due to the patients delusional state the patients allegations of physical assault by staff members on the psychiatric observation unit were not credible.

Employee #5 acknowledged there was no evidence an internal incident report was completed or an internal investigation into the physical assault allegations was assigned or completed by facility staff. Employee #5 acknowledged law enforcement was not notified of the abuse allegations and no police report was taken. Employee #5 acknowledged the facility failed to follow the facility's Prohibition of Abuse and Neglect policy and procedure and the facility's Patient Grievance policy and procedure.

The facility could not provide any documented evidence of any action regarding the patient's complaint grievance that had been taken by the facility as of the date of the survey completion on 11/03/11.

On 11/02/11 at 11:30 AM, an interview was conducted with Employee #2 (Director of Nursing)) who acknowledged on 10/21/11 she was made aware of Patient #1's allegations of abuse by Employee #4 while in a meeting with the Administrator. Employee #2 reported the facility's abuse reporting policy and procedure required an incident report be filled out on any suspected physical and sexual abuse and report was to be given to an administrative assistance and entered into the system. The incident report would then be pulled by the Administrator and assigned to the appropriate unit nurse manager to conduct an investigation.

Law enforcement and Adult Protective Services were to be called and notified of the abuse allegations. Employee #2 confirmed no internal incident report was completed regarding the patients allegations of physical abuse. Employee #2 acknowledged no internal investigation was conducted regarding the abuse allegations and law enforcement and Adult Protective Services were not notified of the patient's physical abuse allegations. Employee #2 acknowledged the facility failed to follow the facility's Prohibition of Abuse and Neglect policy and procedure and the Patient Grievance policy and procedure.

A review of the facility's Division of Mental Health and Development Services Prohibition of Abuse or Neglect of Consumers and Reporting Requirements last revised 09/08/10 documented the following:

All allegations of abuse and/or neglect shall be reported by the following requirements, Reporting Serious Incidents and denial of Rights:

a. Any staff, upon observing, hearing of, or suspecting abuse and/neglect of a person served by the Division will:

1. Make a verbal report to a supervisor immediately and in all instances within a maximum of (1) hour from becoming aware of the suspected abuse and/or neglect. The report must be made through person to person contact; voice messages do not meet the reporting requirements;

2. Complete an incident report to their supervisor, or designee, detailing the information as soon as possible following the verbal report, and in all instances by the end of the staffs work day, or if off duty within 16 hours;

3. Make all verbal and written reports to the supervisor's supervisor if the direct supervisor is suspected of abuse or neglect.

4. Notify other applicable entities as appropriate or required (Child Protective Services, Aging Protective Services, and Law Enforcement) within 24 hours.

5. The supervisor on receiving the report will take immediate action to ensure the victim has received appropriate medical treatment and follow-up as applicable, and take prompt action to provide for the persons welfare and safety.

6. Make a verbal report to the MHDS agency or director, or designee, immediately, and in all instances within a maximum of one (1) hour from becoming aware of the suspected abuse and/or neglect, and within 24 hours of being apprised of the suspected abuse and/or neglect ensure that a serious incident report is submitted to the MHDS agency director or designee.

The facility's Consumer/Family Complaints and Grievance Policy and Procedure effective 11/2010 included the following:

1. All complaints shall be reviewed by the recovery services Coordinator within two business days of receipt to determine level of severity.

2 Incidents identified as Severity Level 1 shall be reported to the Appointing Authority and turned into an incident report. Tracking, reporting and confidentiality shall be turned into the incident tracking process and the complaint form shall be so noted. Consumers involved with these complaints shall be referred to the Appointing Authority for resolution. Examples of Severity Level 1 include but are not limited content alleging abuse, neglect, or immediate safety concerns.

3. Individuals making complaints shall have the opportunity to participate in the entire complaint and grievance process. Consumers making complaints shall be informed of the steps taken on behalf of the complainant to investigate the complaint during the process and shall know the results within 10 business days of submitting the complaint.

The patient's complaint grievance was submitted to the facility on [DATE]. As of 11/02/11 there was no documentation of any communication with patient regarding any investigation results or resolution of the patient's complaint grievance.

Complaint # NV 697
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and document review the facility's governing body failed to be responsible and ensure the effective operation of the grievance process by failing to ensure a review and prompt investigation and resolution of a patient's grievance concerning physical abuse by staff members (Patient #1).

Findings include:

Patient #1 was admitted to the facility on [DATE] on a legal 2000 (72 hour hold for psychiatric evaluation) after exhibiting aggressive and hostile behavior at a group home.

The patient had a history of bipolar disease and had become increasingly aggressive and agitated on the psychiatric observation unit and had refused to leave the bathroom on the unit. The patient was reported to be delusional and offensive to staff and other patients on the floor.

The patient was deemed a potential threat to staff and other patients on the floor secondary to aggressive behavior. A show of force was unsuccessful in de-escalating the situation and the patient refused oral medication.

The patient was physically restrained and was given an intramuscular injection of Zyprexa (Antipsychotic Medication) for severe agitation. The patient was then brought to a seclusion room by staff.

On 11/02/11 at 1:30 PM, an interview was conducted with Patient #1 who reported being placed on a legal hold by police on 10/21/11 after being involved in an altercation at a group home she resided at. The patient reported she was medically cleared at an acute care hospital and transported to the facility. Patient #1 reported she was using the bathroom in the psychiatric observation unit when a male staff member entered the bathroom when she had her pants down and was seated on the toilet. The staff member informed her a physician was here to see her. Patient #1 reported she was not finished in the bathroom and refused to leave the bathroom. Several male MHT (Mental Health Technicians) entered the bathroom and physically grabbed her by the arms and forced her out of the bathroom. The patient reported several male MHTs punched her in the right arm, right side and kicked her on the left knee forcing her to the floor outside the bathroom area. The patient reported injuries to the right arm, right abdominal area and left knee.

The patient had visible bruising to the right elbow, right abdomen and swelling and bruising to the left knee area. The patient reported she was administered an injection of Zyprexa by nursing staff which she had an allergy to and was also administered Benadryl and Geodon medication by nursing staff which she was allergic to. Patient #1 reported she developed a rash on her neck as a result of an allergic reaction to the medication.

Patient #1 completed a written complaint grievance incident report about the physical assault and abuse allegations by staff members and handed the report to Employee #4 (Director of Performance Improvement) on 10/21/11. Patient #1 reported photographs were taken of her bruises by nursing staff two days later. Patient #1 reported no representatives from the facility had interviewed her about the abuse allegations and no members of the police department had contacted her to take a police report. Patient #1 reported no representatives of the facility had provided any information regarding an investigation or a decision regarding the physical abuse grievance and did not know if an investigation had been conducted by the facility.

An incident report/grievance dated 11/21/11 (10/21/11) filled out by Patient #1 documented the patient reported being physically assaulted by several male staff members on the psychiatric observation unit and forcibly removed from the bathroom. The patient reported injuries were sustained during the assault by staff.

On 11/02/11 at 10:00 AM, an interview was conducted with Employee # 4 (Director of Performance Improvement) who reported on 10/21/11 at 3:00 PM she was handed a written incident report/grievance filled out by Patient #1 who reported being physically assaulted by several male staff members on the psychiatric observation unit who dragged her out of the bathroom and placed her in a locked room. Employee #4 reported Patient #1 informed her several male staff on the observation unit attacked and struck her causing injuries to her left arm, left abdomen and left knee. Employee #4 reported the patients hand written incident report was given to an Administrative Assistant and the abuse allegation was reported to the facility's Administrator and Director of Nursing on 10/21/11 at 3:00 PM.

Employee #4 acknowledged no internal incident report was completed and no internal investigation was initiated or completed by staff concerning the patient's allegation of physical abuse by staff members. Employee #4 confirmed law enforcement was not notified and no police report was taken. Employee #4 acknowledged the patient had not been provided with any response to the grievance by facility staff. Employee #4 acknowledged the facility staff failed to follow established abuse investigation/reporting and patient grievance policies and procedures.

On 11/02/11 at 11:00 AM an interview was conducted with Employee #5 (Administrator) who confirmed on 10/21/11 he was informed of Patient #1's allegations regarding physical assault by staff on the observation unit. Employee #5 reported the patient was reported to be in a manic phase and had to be removed from a bathroom and placed in seclusion on the observation unit. Employee #5 reported he felt due to the patients delusional state the patients allegations of physical assault by staff members on the psychiatric observation unit were not credible.

Employee #5 acknowledged there was no evidence an internal incident report was completed or an internal investigation into the physical assault allegations was assigned or completed by facility staff. Employee #5 acknowledged law enforcement was not notified of the abuse allegations and no police report was taken. Employee #5 acknowledged the facility failed to follow the facility's Prohibition of Abuse and Neglect policy and procedure and the facility's Patient Grievance policy and procedure.

The facility could not provide any documented evidence of any action regarding the patient's complaint grievance that had been taken by the facility as of the date of the survey completion on 11/03/11.

On 11/02/11 at 11:30 AM, an interview was conducted with Employee #2 (Director of Nursing)) who acknowledged on 10/21/11 she was made aware of Patient #1's allegations of abuse by Employee #4 while in a meeting with the Administrator. Employee #2 reported the facility's abuse reporting policy and procedure required an incident report be filled out on any suspected physical and sexual abuse and a report was to be given to an administrative assistance and entered into the system. The incident report would then be pulled by the Administrator and assigned to the appropriate unit nurse manager to conduct an investigation.

Law enforcement and Adult Protective Services were to be called and notified of the abuse allegations. Employee #2 confirmed no internal incident report was completed regarding the patients allegations of physical and sexual abuse. Employee #2 acknowledged no internal investigation was conducted regarding the abuse allegations and law enforcement and Adult Protective Services were not notified of the patient's physical abuse allegations. Employee #2 acknowledged the facility failed to follow the facility's Prohibition of Abuse and Neglect policy and procedure and the Patient Grievance policy and procedure.

A review of the facility's Division of Mental Health and Development Services Prohibition of Abuse or Neglect of Consumers and Reporting Requirements last revised 09/08/10 documented the following:

All allegations of abuse and /or neglect shall be reported by the following requirements, Reporting Serious Incidents and denial of Rights:

a. Any staff, upon observing, hearing of, or suspecting abuse and/neglect of a person served by the Division will:

1. Make a verbal report to a supervisor immediately and in all instances within a maximum of (1) hour from becoming aware of the suspected abuse and/or neglect. The report must be made through person to person contact; voice messages do not meet the reporting requirements;

2. Complete an incident report to their supervisor, or designee, detailing the information as soon as possible following the verbal report, and in all instances by the end of the staffs work day, or if off duty within 16 hours;

3. Make all verbal and written reports to the supervisor's supervisor if the direct supervisor is suspected of abuse or neglect.

4. Notify other applicable entities as appropriate or required (Child Protective Services, Aging Protective Services, and Law Enforcement) within 24 hours.

5. The supervisor on receiving the report will take immediate action to ensure the victim has received appropriate medical treatment and follow-up as applicable, and take prompt action to provide for the persons welfare and safety.

6. Make a verbal report to the MHDS agency or director, or designee, immediately, and in all instances within a maximum of one (1) hour from becoming aware of the suspected abuse and/or neglect, and within 24 hours of being apprised of the suspected abuse and/or neglect ensure that a serious incident report is submitted to the MHDS agency director or designee.

The facility's Consumer/Family Complaints and Grievance Policy and Procedure effective 11/2010 included the following:

1. All complaints shall be reviewed by the recovery services Coordinator within two business days of receipt to determine level of severity.

2 Incidents identified as Severity Level 1 shall be reported to the Appointing Authority and turned into an incident report. Tracking, reporting and confidentiality shall be turned into the incident tracking process and the complaint form shall be so noted. Consumers involved with these complaints shall be referred to the Appointing Authority for resolution. Examples of Severity Level 1 include but are not limited content alleging abuse, neglect, or immediate safety concerns.

3. Individuals making complaints shall have the opportunity to participate in the entire complaint and grievance process. Consumers making complaints shall be informed of the steps taken on behalf of the complainant to investigate the complaint during the process and shall know the results within 10 business days of submitting the complaint.

The patient's complaint grievance was submitted to the facility on [DATE]. As of 11/02/11 there was no documentation of any communication with patient regarding any investigation results or resolution of the patient's complaint grievance.

Complaint # NV 697
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and document review the facility failed to follow state mandated abuse reporting laws and the facility's patient abuse policy and procedure by failing to conduct an investigation into a patients allegation of physical abuse by staff members and failing to report the allegation of physical abuse to law enforcement(Patient #1).


Findings include:


Patient #1 was admitted to the facility on [DATE] on a legal 2000 (72 hour hold for psychiatric evaluation) after exhibiting aggressive and hostile behavior at a group home.

The patient had a history of bipolar disease and had become increasingly aggressive and agitated on the psychiatric observation unit and had refused to leave the bathroom on the unit. The patient was reported to be delusional and offensive to staff and other patients on the floor.

The patient was deemed a potential threat to staff and other patients on the floor secondary to aggressive behavior. A show of force was unsuccessful in de-escalating the situation and the patient refused oral medication.

The patient was physically restrained and was given an intramuscular injection of Zyprexa (Antipsychotic Medication) for severe agitation. The patient was then brought to a seclusion room by staff.

On 11/02/11 at 1:30 PM, an interview was conducted with Patient #1 who reported being placed on a legal hold by police on 10/21/11 after being involved in an altercation at a group home she resided at. The patient reported she was medically cleared at an acute care hospital and transported to the facility. Patient #1 reported she was using the bathroom in the psychiatric observation unit when a male staff member entered the bathroom when she had her pants down and was seated on the toilet. The staff member informed her a physician was here to see her. Patient #1 reported she was not finished in the bathroom and refused to leave the bathroom. Several male MHT (Mental Health Technicians) entered the bathroom and physically grabbed her by the arms and forced her out of the bathroom. The patient reported several male MHTs punched her in the right arm, right side and kicked her on the left knee forcing her to the floor outside the bathroom area. The patient reported injuries to the right arm, right abdominal area and left knee.

The patient had visible bruising to the right elbow, right abdomen and swelling and bruising to the left knee area. The patient reported she was administered an injection of Zyprexa by nursing staff which she had an allergy to and was also administered Benadryl and Geodon medication by nursing staff which she was allergic to. Patient #1 reported she developed a rash on her neck as a result of an allergic reaction to the medication.

Patient #1 completed a written complaint grievance incident report about the physical assault and abuse allegations by staff members and handed the report to Employee #4 (Director of Performance Improvement) on 10/21/11. Patient #1 reported photographs were taken of her bruises by nursing staff two days later. Patient #1 reported no representatives from the facility had interviewed her about the abuse allegations and no members of the police department had contacted her to take a police report. Patient #1 reported no representatives of the facility had provided any information regarding an investigation or a decision regarding the physical abuse grievance and did not know if an investigation had been conducted by the facility.

An incident report/grievance dated 11/21/11 (10/21/11) filled out by Patient #1 documented the patient reported being physically assaulted by several male staff members on the psychiatric observation unit and forcibly removed from the bathroom. The patient reported injuries were sustained during the assault by staff.

A review of the facility's Division of Mental Health and Development Services Prohibition of Abuse or Neglect of Consumers and Reporting Requirements last revised 09/08/10 documented the following:

All allegations of abuse and /or neglect shall be reported by the following requirements, Reporting Serious Incidents and denial of Rights:

a. Any staff, upon observing, hearing of, or suspecting abuse and/neglect of a person served by the Division will:

1. Make a verbal report to a supervisor immediately and in all instances within a maximum of (1) hour from becoming aware of the suspected abuse and/or neglect. The report must be made through person to person contact; voice messages do not meet the reporting requirements;

2. Complete an incident report to their supervisor, or designee, detailing the information as soon as possible following the verbal report, and in all instances by the end of the staffs work day, or if off duty within 16 hours;

3. Make all verbal and written reports to the supervisor's supervisor if the direct supervisor is suspected of abuse or neglect.

4. Notify other applicable entities as appropriate or required (Child Protective Services, Aging Protective Services, and Law Enforcement) within 24 hours.

5. The supervisor on receiving the report will take immediate action to ensure the victim has received appropriate medical treatment and follow-up as applicable, and take prompt action to provide for the persons welfare and safety.

6. Make a verbal report to the MHDS agency or director, or designee, immediately, and in all instances within a maximum of one (1) hour from becoming aware of the suspected abuse and/or neglect, and within 24 hours of being apprised of the suspected abuse and/or neglect ensure that a serious incident report is submitted to the MHDS agency director or designee.

NRS 200.5093 Report of abuse, neglect, exploitation or isolation of older person; voluntary and mandatory reports; investigation; penalty: included the following:

1. Any person who is described in subsection 4 (includes professional or practical nurse, any personnel of a hospital or similar institution engaged in the admission, examination, care or treatment of persons or an administrator, manager or other person in charge of a hospital) and who in his professional or occupational capacity, knows or has reasonable cause to believe that an older person has been abused, neglected, exploited or isolated shall: report the abuse, neglect, exploitation or isolation of the older person to:

1. The local office of the Aging Services Division of the Department of Health and Human Services.
2. A police department or sheriff's office.
3. The county's office for protective services.
4. A toll free telephone service designated by the Aging Services Division of the Department of Health and Human services.

On 11/02/11 at 10:00 AM, an interview was conducted with Employee # 4 (Director of Performance Improvement) who reported on 10/21/11 at 3:00 PM she was handed a written incident report/grievance filled out by Patient #1 who reported being physically assaulted by several male staff members on the psychiatric observation unit who dragged her out of the bathroom and placed her in a locked room. Employee #4 reported Patient #1 informed her several male staff on the observation unit attacked and struck her causing injuries to her left arm, left abdomen and left knee. Employee #4 reported the patients hand written incident report was given to an Administrative Assistant and the abuse allegation was reported to the facility's Administrator and Director of Nursing on 10/21/11 at 3:00 PM.

Employee #4 acknowledged no internal incident report was completed and no internal investigation was initiated or completed by staff concerning the patient's allegation of physical abuse by staff members. Employee #4 confirmed law enforcement was not notified and no police report was taken. Employee #4 acknowledged the patient had not been provided with any response to the grievance by facility staff. Employee #4 acknowledged the facility staff failed to follow established abuse investigation/reporting and patient grievance policies and procedures.

On 11/02/11 at 11:00 AM, an interview was conducted with Employee #5 (Administrator) who confirmed on 10/21/11 he was informed of Patient #1's allegations regarding physical assault by staff on the observation unit. Employee #5 reported the patient was reported to be in a manic phase and had to be removed from a bathroom and placed in seclusion on the observation unit. Employee #5 reported he felt due to the patients delusional state the patients allegations of physical assault by staff members on the psychiatric observation unit was not credible.

Employee #5 acknowledged there was no evidence an internal incident report was completed or an internal investigation into the physical assault allegations was assigned or completed by facility staff. Employee #5 acknowledged law enforcement was not notified of the abuse allegations and no police report was taken. Employee #5 acknowledged the facility failed to follow the facility's Prohibition of Abuse and Neglect policy and procedure and the facility's Patient Grievance policy and procedure.

On 11/02/11 at 11:30 AM, an interview was conducted with Employee #2 (Director of Nursing)) who acknowledged on 10/21/11 she was made aware of Patient #1's allegations of abuse by Employee #4 while in a meeting with the Administrator. Employee #2 reported the facility's abuse reporting policy and procedure required an incident report be filled out on any suspected physical and sexual abuse and report was to be given to an administrative assistance and entered into the system. The incident report would then be pulled by the Administrator and assigned to the appropriate unit nurse manager to conduct an investigation.

Law enforcement and Adult Protective Services were to be called and notified of the abuse allegations. Employee #2 confirmed no internal incident report was completed regarding the patients allegations of physical and sexual abuse. Employee #2 acknowledged no internal investigation was conducted regarding the abuse allegations and law enforcement and Adult Protective Services were not notified of the patient's physical abuse allegations. Employee #2 acknowledged the facility failed to follow the facility's Prohibition of Abuse and Neglect policy and procedure and the Patient Grievance policy and procedure.

Complaint # NV 697
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on interview, record review and document review the facility's nursing staff failed to ensure a patient did not receive medications the patient had a documented allergy to (Patient #1).

Findings include:

On 10/21/11 Patient #1 reported the facility nursing staff had administered Geodon medication which she had a documented allergy to. Patient #1 reported physicians had ordered the administration of Benadryl medication which she had a documented allergy to. The patient reportedly developed a rash to the neck as a result of being administered medication she had an allergy to.

A Psychiatric Evaluation dated 10/21/11 documented the patient was allergic to the following medications.

1. Depakote
2. Haldol
3. Sulfa.
4. Lithium
5. Benadryl
6. Cogentin
7. Topamax
8. Seroquel

A Medical Examination History and Physical dated 10/21/11 at 2:00 PM documented the patient was allergic to the following medications.

Depakote, Haldol, Lithium, Sulfa and Geodon

An Allergy sticker in red on the front of the patients chart indicated the patient was allergic to Depakote, Haldol, Lithium, Sulfa, Benadryl, Cogentin, Topamax and Seroquel.

A Physician Admit order dated 10/20/11 at 11:10 PM included the following:

1. Geodon 40 milligrams (mg) and Benadryl 50 mg by mouth every 6 hours as needed (PRN) severe agitation.

A review of Physician Orders dated 10/21/11 at 11:30 AM documented an order for Geodon 20 mg IM (intramuscular injection) x1 and Benadryl 50 mg IM x1 for agitation.

A Physicians order dated 10/21/11 at 5:10 PM included the order for Benadryl 50 mg by mouth every 6 hours PRN psychotic agitation.

A Nursing Note dated 10/21/11 indicated the patient complained of rashes to both sides of her neck.

A review of Patient #1s Medication Administration Record indicated the patient received Geodon 20 mg and Ativan 1 mg IM on 10/21/11 at 12:25 PM for agitation. (Patient had documented allergy to Geodon)

A review of the facility's Patient Allergy Policy and Procedure effective 03/10 included the following:

"It shall be the policy of (facility) to ensure patient allergies are documented, reconciled and available to all individuals involved with the patient's care. (Facility) clinicians involved with patient care and safety shall recognize and use the following locations for the documentation of patient allergies:

1. On the hard copy record.

2. In the electronic medical record (AVATAR) in the allergy assessment section of the clinical work station.

3. In the electronic medical record (WORx) for the patient profile.

Nursing Services shall be responsible to reconcile the electronic medical record of AVATAR and WORx as is necessary, but at least every 90 days when treatment plans are updated.

Members of the medical staff shall add, delete or clarify patient allergies via an order. The change shall be justified in written documentation.

Pharmacy services shall ensure the "footprint" of all patient allergies is maintained..."

Complaint # NV 697