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.

RED RIVER BEHAVIORAL HEALTH SYSTEM 1451 44TH AVENUE S GRAND FORKS, ND April 28, 2016
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on policy and procedure review, record review, and staff interview, the Hospital failed to obtain consent for administration of medications for 1 of 1 minor patient's (Patient #18) closed record reviewed. Failure to obtain consent for medication administration limited the guardian's right to be informed and make decisions regarding the patient's care.

Findings include:

Review of the facility policy "Notification and Facilitation of Patient Rights" occurred on 04/28/16. This policy, dated 12/14/15, stated, ". . . A patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care . . . The patient or patient representative is provided information, needed in order to make informed decisions regarding his/her care, including the development of the patient's plan of care, medical interventions . . ."

Review of Patient #18's closed medical record occurred on 04/28/16 and identified the Hospital admitted the patient, a minor, on 01/08/16 due to a medication overdose. Other diagnoses on admission included depression and attention-deficit/hyperactivity disorder (ADHD).

Review of Patient #18's medical record identified the Hospital failed to obtain consent from the patient's guardian for the following physician's orders:
*Cymbalta (used for depression) 30 milligrams (mg) daily, ordered 01/18/16
*Concerta (used for ADHD) 27 mg daily, ordered 01/21/16
*Concerta 54 mg daily, increased on 01/24/16
The patient received these medications as ordered without the Hospital obtaining consent from the guardian.

During an interview on the afternoon of 04/28/16, an administrative nurse (#1) stated Patient #18's medical record lacked evidence staff obtained consent from the patient's guardian prior to administering the above medications. The nurse (#1) stated she expected staff to obtain consent from a patient's guardian before administering medications.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
THIS IS A REPEAT DEFICIENCY FROM THE COMPLAINT SURVEY COMPLETED ON 07/09/15.

Based on observation and review of Hospital policy, the Hospital failed to provide privacy during personal cares and confidentiality when speaking about patients for 4 of 9 active patients (Patient #3, #4, #5, and #8) observed. Failure to provide privacy and confidentiality infringed on the rights of these patients and all patients in the Hospital.

Findings include:

Review of the Hospital policy titled "Notification and Facilitation of Patient Rights" occurred on 04/28/16. This policy, dated 12/14/15, stated, "Purpose: To promote and protect each patient's rights. . . . A patient has the right to personal privacy. Patients have privacy during personal hygiene activities (e.g. toileting, bathing, and dressing), during medical/nursing treatments, and when requested as appropriate. . . ."

Observations on April 26-27, 2016 showed the following:
* 04/26/16 at 10:45 a.m. - The nurse (#5) and the Behavioral Health Technician (BHT) (#9) in Patient #4's room providing personal cares. Another BHT (#7) entered the room without knocking or asking permission to enter.
* 04/26/16 at 10:53 a.m. - Two BHTs (#7 and #9) yelled down the hall to another BHT (#8) and asked if Patient #8 needed to toilet. The BHT (#8) stated Patient #8 had an accident in her pants and she changed her already. The BHTs used the patient's name during this observation and other patients were present in the TV lounge area and in the hall.
* 04/26/16 at 10:55 a.m. - Two BHTs (#7 and #9) in Patient #3's room providing personal cares. The nurse (#4) entered the room without knocking or asking permission to enter.
* 04/26/16 at 3:45 p.m. - Patient #2, #5, and #6 seated in the TV lounge area. Patient #5 hit a BHT (#6) with a stuffed animal. The BHT stated to the nurse (#5), "I'm outta [out of] here in 45 minutes. She kicked me!" The nurse (#5) stated he/she would check Patient #5's record to see if she could have a PRN [as needed] medication.
* 04/26/16 at 5:40 p.m. - Patient #3 and two unidentified patients seated in the dining room. The nurse (#4) stood in the hall outside the dining room and stated to Patient #3, "Your blood sugar was high. I'm glad you left your corn." The nurse then stated to the surveyor, "I know her well [Patient #3] and she's a drug seeker."
* 04/27/16 at 8:30 a.m. - Two unidentified BHTs assisting Patient #4 with personal cares. Another BHT (#6) entered the room without knocking or waiting for permission to enter.
* 04/27/16 at 9:08 a.m. - Two BHTs (#6 and #10) in the dining room with 9 patients. Patient #4 could be heard yelling loudly in the hall outside the dining room. The BHT (#6) stated to the other BHT (#10), "Does she [Patient #4] naturally have a very loud voice?" The BHT (#10) stated, "She has dementia." The BHT (#6) stated, "Well, duh!"
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, record review, review of Hospital policy, and staff interview, the Hospital failed to provide a safe environment free from both physical and emotional harm for 7 of 9 active patient records (Patient #3, #4, #5, #6, #7, #8, and #9) reviewed. Failure to provide a safe environment resulted in agitation, crying, yelling, and altercations among the patients.

Findings include:

Review of the Hospital policy titled "Notification and Facilitation of Patient Rights" occurred on 04/28/16. This policy, dated, 12/14/15, stated, "Purpose: To promote and protect each patient's rights. . . . g. A patient has the right to receive care in a safe setting. . . . *Staff is educated on policies and procedures regarding abuse prevention, aggressive behavior prevention, suicide/self-harm prevention, . . . and incident response and reporting. *Incidents are logged and trended . . . A Root Cause Analysis is performed for incidents resulting in significant injury, those identified as a trend, and sentinel events to identify contributing causes and implement corrective action measures promptly. . . ."

Review of the facility policy titled "Aggressive Behavior Prevention" occurred on 04/28/16. This policy, dated 09/28/15, stated, "Purpose: To prevent patient-to-patient aggression. . . . Policy: It is the policy of RPSPC [Richard P. Stadter Psychiatric Center] to take all necessary actions to prevent patient-to-patient aggression in order to protect patient rights and assure patient safety and dignity and maintain a therapeutic environment for all patients. . . . STAFF INTERVENTION FOR 24-HOUR PATIENT CARE: . . . 2. Staff will adhere to the following processes for observing patient behaviors, monitoring patient aggression, and intervening proactively before the patient becomes aggressive with another patient: *Assess triggers and environmental stimuli that are agitating or will agitate patient . . . *Utilize proactive de-escalation techniques learned in required training to respond to patients consistently by noting behavior(s) and/or negative statement(s) and attempt to redirect. . . . *If verbal redirection and other calming techniques do not work, separate patient from group population, in order to minimize risk to self and other patients, . . ."

Review of Patient #3, #4, #5, #6, #7, #8, and #9's medical records occurred on April 26-28, 2016. The patients were admitted to the Hospital for the following reasons:
*Patient #3 - suicidal ideation
*Patient #4 - suicidal ideation and increased confusion
*Patient #5 - agitation and aggression
*Patient #6 - aggression, hitting, kicking, biting, and scratching
*Patient #7 - aggression and physical violence towards staff
*Patient #8 - striking out at staff/residents
*Patient #9 - agitation, paranoid behavior, and threatening to staff/residents

- Observation on 04/27/16 from 5:33 p.m. to 5:55 p.m. showed Patient #3, #4, #5, #6, and #7 seated in the TV lounge area. Patient #7 and #8 walked back and forth from the lounge area to their rooms. Two unidentified Behavioral Health Technicians (BHTs), BHT (#11), and a nurse (#12) were also present in the lounge. Patient #4 spoke/yelled loudly and made statements such as, "Where do you go to the bathroom in this house. Somebody please help me. Come and help me," while Patient #5 cried. Patient #6 sat in a reclined geriatric chair and the BHT (#11) stated numerous times, "[Patient name]! Sit back. You're fine. Sit down [Patient name]!" The nurse (#12) stated, "too much stimuli, too much." Patient #9 left the lounge area and stated, "It's so loud around here," and covered her ears.

Failure to maintain a therapeutic environment, assess and address triggers for each patient, address patients' in a dignified manner, and attempt to de-escalate each patient's behavior, may have created behaviors and placed patients at risk of patient to patient altercations/abuse.

- Review of Patient #7's progress note, dated 04/15/16 at 8:30 p.m., stated, "Pt [patient] sitting in chair when another pt approached her and hit her on the forehead with a lotion bottle. Immediately removed aggressive pt & [and] implemented 1:1's [1 to 1 observation]."

During an interview on 04/28/16 at 12:25 p.m., an administrative nurse (#3) stated the nurse working when the incident involving Patient #7 occurred failed to compete an incident report and failed to notify the administrative staff.

Failure to report the incident and complete an incident report does not allow the Hospital to trend patient to patient altercations and implement appropriate interventions to assure the safety of patients.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on observation, record review, and Hospital policy, the Hospital failed to obtain a physician's order for 1 of 1 active patient record (Patient #6) reviewed placed in a geriatric reclining chair. Failure to obtain a physician's order does not allow the physician to determine the best treatment option for the patient.

Findings include:

Review of the Hospital policy titled "Notification and Facilitation of Patient Rights" occurred on 04/28/16. This policy, dated 12/14/15, stated, ". . . A patient has the right to be free from . . . restraints, of any form that are not medically necessary or are used as a means of coercion, discipline, convenience, or retaliation by staff. . . ."

Review of the Hospital policy titled "Restraint and Seclusion" occurred on 04/28/16. This policy, dated 10/21/15, stated, ". . . Policy: . . . All patients have the right to be free from any physical/chemical restraint and seclusion, . . . physical/chemical restraint are allowed to be used in an emergency situation in which there is imminent danger to the patient causing injury to self or others and after non-restrictive measures have been proven to [be] ineffective or assessed to be inappropriate. . . . Restraint Devices: Only restraint devices approved for use in the hospital shall be used. Those approved for use . . . Geriatric chair with tray . . . Definitions: A restraint is any manual method, physical or mechanical device, . . . or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely;. . . Initiating and Ordering Restraint . . . As soon as possible, but no longer than one hour after the initiation of restraint or seclusion, a trained RN . . . Notifies and obtains an order (verbal or written) from the attending . . ."

- Review of Patient #6's medical record occurred on April 26-28, 2016 and identified the Hospital admitted the patient on 03/02/16 for aggressive behaviors. Medical diagnoses included depression and Alzheimer's disease with behavioral disturbances. A physician's order, dated 03/03/16, stated, "May use geri [geriatric] chair for comfort and positioning - use only if needed."

A progress note, dated 04/19/16 at 1:15 p.m., stated Hospital staff utilized the geri chair related to, "hitting staff, getting up and down."

Observation throughout the survey showed Patient #6 walking with the assistance of one staff member, a gait belt, and an occasional walker. The patient would sit in a chair for a few minutes at a time and then would begin walking again. Observation on 04/27/16 at 1:20 p.m., 4:40 p.m., and 5:33 p.m. showed Patient #6 seated in a reclined geri chair, with the foot rest elevated as high as her head, and unable to stand up out of the chair unless she rolled over the side. At 5:45 p.m., at behavioral health technician (BHT) (#11) stated to Patient #6, "[Patient name]! Sit back. You're fine. Sit down [Patient name]," as the patient attempted to crawl out of the chair.

The medical record showed the Hospital failed to obtain a physician's order for the geri chair on 04/19/16 and on 04/27/16.

Review of the "Geriatric Shift Review" forms which are completed by the BHTs each shift, from April 05-27, 2016, identified the following:
*04/05/16 - "Pt was antsy and kept trying to get up and walk . . . "
*04/08/16 - "Pt was hitting staff when told she needs to sit down . . ."
*04/16/16 - "Pt repetitively stood up out of her chair and attempted to ambulate throughout the main room . . ."
*04/18/16 - "Pt attempted to climb out of chair multiple times during shift . . . Staff should monitor pt for falls due to climbing/crawling out of her chair."
*04/20/16 - "pt constant motion [up] et [and] [down] in chair. aggitated [sic] when ask to sit. Ambulate pt [with] gait belt and walker. Notify RN [registered nurse]. Pt still anxious. PRN given, geri chair ordered . . ."
*04/27/16 - "pt was restless and kept getting up from her chair . . ."

The above Geriatric Shift Review forms failed to identify the reason staff members tried to refrain Patient #6 from getting up from the chair and walking and failed to identify if the chair used was a geri chair.

The Hospital failed to obtain a physician's order each time staff members utilized the geri chair. This failure infringes upon Patient #6's right to be free from restraints.

Refer to A143 and A144 regarding staff failure to address resident behaviors in relation to environmental factors, patient treatment, and patient dignity.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, record review, policy and procedure review, professional literature/reference review, and staff interview, the Hospital failed to assess and implement timely interventions to aid in the healing of pressure ulcers, failed to implement timely interventions for weight loss, failed to ensure the completion of physician's orders, failed to obtain physician's orders, failed to notify the provider related to high glucose, failed to attempt non-pharmacological interventions prior to as needed medications (Refer to A395); and failed to ensure the development and revision of the nursing care plan to provide direction for individualized patient care based on the assessment of the patient's behavioral/nursing care needs (Refer to A396). Failure of nursing staff to adequately take care of the needs of the patients places all patients at risk of pain, harm, and injury and may decrease their quality of life.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
PRESSURE ULCERS

THIS IS A REPEAT DEFICIENCY FROM THE COMPLAINT SURVEY COMPLETED ON 07/09/15.

1. Based on observation, record review, policy review, review of a professional, and staff interview, the Hospital failed to assess and implement timely interventions to aid in the healing of pressure ulcers for 1 of 1 active patient (Patient #7) and 1 of 1 closed patient record (Patient #17) reviewed with a pressure ulcer. Failure to adequately assess skin breakdown, coordinate with nutritional services, and provide pressure-relieving devices in a timely manner may have contributed to Patient #17's worsened pressure ulcer and placed Resident #7 at risk for additional skin breakdown and delayed wound healing.

Findings include:

Kozier and Erb's "Fundamentals of Nursing, Concepts, Process, and Practice," 2016, 10th edition, Pearson Education, Inc., New Jersey, page 829, stated, "SAFETY ALERT! . . . PREVENT HEALTH CARE-ASSOCIATED PRESSURE ULCERS (DECUBITUS ULCERS). Assess and periodically reassess each resident's risk for developing a pressure ulcer and take action to address any identified risks. . . ." Page 838 stated, ". . . When a pressure ulcer is present, the nurse notes the following: *Location of the ulcer . . . *Size of ulcer in centimeters. . . ."

Review of the facility policy titled "Pressure Ulcer Prevention and Managing Skin Integrity" occurred on 04/28/16. This policy, dated 09/11/15, stated, ". . . It is the policy of Richard P. Stadter Psychiatric Center (RPSPC) to assess and manage skin integrity for all patients throughout their hospital stay . . . Responsibilities . . . Geriatric BHT [behavioral health technicians]: Notify RN [registered nurse] of any areas of concern identified when providing care/assistance to patients, RN: Assess area of concern and report to appropriate provider (i.e. Medical Staff, dietician), Medical Staff: Assess and provide treatment recommendations, Dieticians: Assess and recommend nutritional supplements . . . Admission Skin Assessment . . . Skin inspections will be completed on admission and daily for all hospital patients . . . Findings will be documented on the Nursing Admission Assessment form. If an area of concern is noted, a weekly pressure ulcer progress report is completed along with documentation in nursing notes . . . Communication to the provider, dietician and other care givers of a skin breakdown is completed at first detection of skin breakdown and weekly upon inspection . . . Routine skin monitoring is completed at the time ADLs [activities of daily living] are performed. Notification to RN is done immediately when skin breakdown is suspected/discovered. RN to complete a skin assessment and initiate appropriate measures following their assessment as necessary . . . RPSPC aims to have prompt evaluation and interventions of any skin changes upon admission and throughout the course of one's treatment at RPSPC. The care and intervention for any identified skin breakdown or wound will be aimed at the prevention of any further advancement of the wound, or additional skin breakdown . . ."

Review of the facility policy titled "Nutritional Supplements" occurred on 04/28/16. This policy, dated 08/13/14, stated, ". . . the Registered Dietitian if deems appropriate can recommend nutritional supplements i.e. Ensure, Boost, Enlive, Propass and/or Magic Cup. Risk factors to include but not limited to . . . pressure ulcers . . . are identified on the Dietary Screening that warrant such nutritional supplements to be ordered . . . Dietician to complete Dietary Screening and Nutritional Consult. RN to complete the Dietary Screening in absence of the Dietitian. Medical staff order recommended supplements and/or dietary needs of the patient as per Dietitian recommendations . . . A dietary consult may be ordered at anytime throughout a patient's stay when a dietary concern has been identified."

- Review of Patient #17's closed medical record occurred on April 27-28, 2016 and identified the Hospital admitted the patient on 02/16/16 for increased aggression and impulsivity.

Review of nursing progress notes identified the following:
*03/06/16 at 10:30 a.m.,". . . . Noted pressure area on buttocks noted 0.5 X [by] 0.5 cm [centimeters] skin red in color, shallow base . . . wound, maceration noted. Will leave a note for family practice."
*03/12/16 at 11:00 p.m., ". . . redened [sic] area above anus. Assessment done and stage II pressure ulcer noted, with dimensions of 0.25 X 0.25 X 0.1 [cm] . . . Family practice notified, dietary consult ordered, duoderm placed on open area above anus . . ."
*03/19/16 at 5:51 a.m., " . . . Staff reported to nurse that patient's ulcer on coccyx was looking worse . . . Nurse did an assessment, cleansed area and duoderm was applied. Estimated size of ulcer was 2 cm X 2 cm X 1 cm, was yellow and had slough on it . . ."

Review of physician's orders, including dietary interventions, identified the following:
*03/13/16, "Duoderm to buttocks topical check daily, change weekly and as needed . . ."
*03/14/16, "Calmoseptine Cream topical to peri area and buttock b.i.d. [twice daily] . . ."
*03/14/16, "Out of bed into chair - assist with transfer (may use mechanical lift) . . ."
*03/16/16, "Clean coccyx ulcer with sterile water or wound cleanser pack with . . . dressing . . . change every 72 hours . . ."
*03/16/16, "Propass protein powder 2 scoops mixed in liquid by mouth t.i.d. [three times daily] . . ."
*03/17/16, "Gel cushion in chair."
*03/19/16, "Dietary consult, OT [occupational therapy] consult coccygeal decubitus ulcer. Weight off loading for coccyx."
*03/20/16, "Silver Alginate to coccyx . . ."
*03/20/16, "Give 500 ml [milliliters] of fluids [with] meals . . ."

Dietary progress notes identified the following:
*03/15/16, ". . . Does have a pressure ulcer on buttocks. Will add 2 scoops propass 3x [times]/[per] day for pressure ulcer . . ."
*03/19/16, ". . . Does now receive 2 scoops propass 3x/day . . . Dietary consult ordered for ulcer. Visited [with] pt [patient] and his wife over lunch . . . discussed the importance of protein foods for wound healing. Informed wife that pt is receiving propass for wound . . ."

An OT progress note, dated 03/21/16, stated, ". . . OT consult received on 03/19/16 due to coccygeal ulcer. Unable to assess due to pt discharging . . ."

The medical record identified the patient as ambulatory upon admission and experienced a steady decline in mobility and ambulation during his stay at the Hospital.

Nursing staff first observed Patient #17's pressure ulcer on 03/06/16. A nurse applied a Duoderm dressing on the night of 03/12/16 (actual physician's order received on 03/13/16), almost one week after the pressure ulcer developed. A physician ordered Propass protein powder on 03/16/16, ten days after the pressure ulcer developed; and a gel cushion for the patient's chair on 03/17/16, eleven days after the pressure ulcer developed. The facility failed to implement interventions in a timely manner to aid in the healing of the patient's pressure ulcer and failed to consider pressure-reducing interventions for the patient's bed due to the patient's decline and increased time spent in bed.

- Review of Patient #7's active medical record occurred on April 26-28, 2016 and identified the Hospital admitted the patient on 03/14/16 for aggressiveness and physical violence. The Hospital identified a pressure ulcer to the patient's coccyx.

Patient #7's physician's orders identified the following:
*04/26/16 - ". . . wounds cares . . . Please reposition q [every] 2 [hours] chair or bed."
*04/27/16 - "DC [discontinue] calmoseptine to [left] buttock wound. Apply duoderm to [left] buttock wound."

Review of the nursing progress notes failed to identify a skin assessment, including size, color, and location of the pressure ulcer, and failed to notify the dietician of Patient #7's pressure ulcer.

On 04/28/16 at 10:20 a.m., a nurse (#4) removed a dressing from Patient #7's coccyx. Observation showed a pressure ulcer, about the size of an eraser of a pencil, and some redness around the ulcer. The nurse applied calmoseptine and a duoderm dressing to the pressure ulcer, contrary to the physician's order. The application of a duoderm dressing over an ointment may limit the ability to adhere to the skin and affect the healing of the wound.

During an interview on 04/28/16 at 10:30 a.m. the nurse (#4) stated she notified the charge nurse when she first discovered Patient #7's pressure ulcer on 04/26/16 and assumed the charge nurse completed the assessment and documented the findings in the patient's medical record. The nurse (#4) stated she does not chart the measurement of a pressure ulcer unless it is 2.2 cm in size or greater.

During an interview on the morning of 04/28/16, an administrative nurse (#1) stated if a nurse discovers a pressure ulcer, she/he is expected to inform the dietician about a pressure ulcer by placing a note in the department's inbox.

The Hospital's process of not documenting pressure ulcers unless staff identify them at a size of 2.2 cm limits the identification of pressure ulcers at an early stage of development and initiation of prompt treatment.

WEIGHT LOSS

2. Based on record review, review of facility policy, and staff interview, the Hospital failed to provide nutritional interventions in a timely manner for 1 of 1 closed patient record (Patient #17) reviewed with weight loss. Failure to provide timely interventions may have contributed to Patient #17's weight loss and placed all patients at risk for avoidable weight loss.

Findings include:

Review of the facility policy titled "Weights" occurred on 04/28/16. This policy, dated 08/13/14, stated, ". . . 1. Each patient will be weighed upon admission and weekly thereafter. 2. . . . Geris [geriatric patients] are weighed two times weekly . . . 4. The attending physician will be notified of any weight gain or loss of five pounds or greater. Dietary consults will be ordered according to physician assessment . . ."

Review of the facility policy titled "Nutritional Supplements" occurred on 04/28/16. This policy, dated 08/13/14, stated, ". . . the Registered Dietitian if deems appropriate can recommend nutritional supplements i.e. Ensure, Boost, Enlive, Propass and/or Magic Cup. Risk factors to include but not limited to . . . pressure ulcers . . . failure to thrive . . . are identified on the Dietary Screening that warrant such nutritional supplements to be ordered . . . Dietician to complete Dietary Screening and Nutritional Consult. RN [registered nurse] to complete the Dietary Screening in absence of the Dietitian. Medical staff order recommended supplements and/or dietary needs of the patient as per Dietitian recommendations . . . A dietary consult may be ordered at anytime throughout a patient's stay when a dietary concern has been identified."

Review of Patient #17's closed medical record occurred on April 27-28, 2016 and identified the Hospital admitted the patient on 02/16/16 for increased aggression and impulsivity.

Review of Patient #17's weights identified the following:
*02/16/16 - 169 pounds (lbs) on admission
*02/22/16 - 162.6 lbs
*02/25/16 - 158.2 lbs
*02/29/16 - 153.6 lbs
*03/03/16 - 150.4 lbs
*03/07/16 - 141.8 lbs
*03/14/16 - 148.8 lbs
*03/17/16 - 146.3 lbs
*03/21/16 - 159.1 lbs upon discharge from the facility

Physician's orders identified the following weight loss interventions:
*02/16/16 (admission), Ensure one can daily
*03/11/16, Ensure increased to one can twice daily
*03/11/16, Magic cups three times daily
*03/11/16, Nectar thick liquids
*03/16/16, Propass protein powder, two scoops, three times daily

Additional interventions included continual intravenous (IV) fluids ordered March 07-11, 2016 and ordered again March 19th until discharge on March 21st.

Review of dietary progress notes identified the following:
*02/17/16 - ". . . male admitted to center for dementia [with] behavioral disturbance, alzheimers. Pt [patient] not oriented to place, time, or person. Does have orders for 8 oz [ounces] Ensure qd [every day] . . . Pt is (estimated) 5'6" [5 feet, six inches], 200# [lbs], BMI [body mass index] 32.3. Pt has dentures, no chewing or swallowing problems . . . PO [oral] intakes 5-75% meals/snacks . . . I recommend a regular diet . . ." The nursing admission assessment identified Patient #17 weighed 169 lbs, not 200 lbs as estimated by the dietician.
*02/25/16 - ". . . Pt wt [weight] of 162.6# on 02/22/16 . . . Pt is eating [approximately] 50-70% of meals [and] snacks. Pt on Ensure 8 oz daily. Continue [with] supplements . . ."
*03/06/16 - ". . . Pt wt 150# on 3-3-16, wt 158# on 2-25-16. Pt wt decreased by . . . 8# over past week. Notified by nursing that pt has no upper teeth [and] poor fitting dentures. Nursing tried mech [mechanical] soft textures of which he ate everything. Will [change] diet order to mech soft textures for difficulty chewing r/t [related to] poor fitting dentures. Pt does receive 8 oz Ensure qd. Hope to see wt stabilize [with] diet texture change . . ."
*03/10/16 - ". . . Pt wt 142# on 3-7-16, wt 150# on 3-3-16. Per nursing pt is doing better on mech soft textures. Nursing informed writer that pt does better [with] nectar thick liquids. PO intakes 0-25% [with] multiple meal/snack refusals. Does receive 8 oz Ensure qd. Will add magic cups tid [three times daily] [and] 1 can thickened Ensure bid [twice daily] for wt management/wt loss. I recommend nectar thick liquids for swallowing difficulties . . ."
*03/15/16 - ". . . Pt wt . . . 149# on 3-14-16, wt 142# on 3-7-16. Wt increased by [approximately] 7# over past week which is considered beneficial at this time. Does receive 1 can Ensure qd, magic cups tid, intakes [approximately] 50-100% over past couple days . . . Will add 2 scoops propass 3x/day [three times daily] for pressure ulcer . . ."
*03/19/16 - ". . . Pt wt [approximately] 146# on 3-17-16, wt [approximately] 142# on 3-7-16. Wt increased by [approximately] 4#. Does now receive 2 scoops propass 3x/day, [and] receives Ensure qd, magic cups tid . . . Wife is coming for meals to feed pt. Pt eating 75-100% meals over past week. Will leave pt on current mech soft textures . . ."

Patient #17 lost approximately 28 lbs over a four week period prior to the addition of magic cups three times daily and an increase in Ensure to twice daily on 03/11/16.

During an interview on the morning of 04/28/16, an administrative nurse (#1) concluded Patient #17's weight on the day of discharge (159.1 lbs accurate. The nurse (#1) accounted this as an improvement in appetite initiation of IV fluids on March 19th through the time of discharge. The nurse (#1) verified the dietician estimated Patient #17's weight when completing the admission nutritional assessment.

COMPLETING PHYSICIAN'S ORDERS

3. Based on record review and staff interview, the Hospital failed to ensure the completion of physician's orders for 1 of 1 closed patient record (Patient #17) reviewed with orders for a physical therapy consult. Failure of nursing staff to carry through a physician's order resulted in a patient not receiving physical therapy services. This failure may have contributed to Patient #17's decline and placed all patients at risk for declines in mobility and ambulation.

Findings include:

Review of Patient #17's closed medical record occurred on April 27-28, 2016 and identified the Hospital admitted the patient on 02/16/16 for aggression and impulsivity.

The medical record identified the patient as ambulatory upon admission and experienced a steady decline in mobility and ambulation during his stay at the Hospital.

A physician's order, dated 02/28/16, stated "PT [physical therapy]/OT [occupational therapy] consults, Dx: [diagnosis] declining status."

The medical record lacked evidence a Physical Therapist evaluated Patient #17.

During an interview on the morning of 04/28/16, an administrative nurse (#1) stated when a physician ordered a PT consult, nursing staff faxed the physical therapy company contracted by the Hospital to provide services. The nurse confirmed the medical record lacked evidence nursing staff faxed/consulted Physical Therapy.





OBTAINING PHYSICIAN'S ORDER

4. Based on observation, record review, and Hospital policy, the Hospital failed to obtain a physician's order for 1 of 2 active patient records (Patient #5) reviewed who were placed in the low stimulation area and 1 of 1 active patient record (Patient #6) reviewed placed in a geriatric reclining chair. Failure to obtain a physician's order does not allow the physician to determine the best treatment option for the patient.

Findings include:

Review of the Hospital policy titled "Intensive Care Unit [ICU]/Low Stimulation [Stim]" occurred on 04/28/16. This policy, dated 09/17/15, stated, "Purpose: To identify the need for a patient to utilize the ICU/Low Stim Area . . . Procedures: 1. Patients are admitted to the ICU/Low Stim patient care unit by the physician for any of the following criteria: . . . d. Harmful aggression towards others . . . 2. A physician order is required to utilize/initiate ICU/low stim programming. Low stim PRN orders are prohibited. . . . 5. The use of the ICU/Low stim Unit is discontinued as soon as the provider, with feedback from staff, has determined that it is no longer medically necessary for the patient to be in the ICU/Low Stim Unit. . . . A physician order is required to discontinue ICU/low stim programming. . . . 8. A nursing note is completed by the registered nurse at a minimum of once per shift with justification for the use of ICU/low stim programming. 9. The Registered Nurse will provide physician updates on a routine basis. The RN is required to keep the physician informed of changes with the patient."

Review of the Hospital policy titled "Restraint and Seclusion" occurred on 04/28/16. This policy, dated 10/21/15, stated, ". . . Policy: . . . All patients have the right to be free from any physical/chemical restraint and seclusion, . . . Restraint Devices: Only restraint devices approved for use in the hospital shall be used. Those approved for use . . . Geriatric chair with tray . . . Definitions: A restraint is any manual method, physical or mechanical device, . . . or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely;. . . Initiating and Ordering Restraint . . . As soon as possible, but no longer than one hour after the initiation of restraint or seclusion, a trained RN . . . Notifies and obtains an order (verbal or written) from the attending . . ."

- Review of Patient #5's medical record occurred on April 26-28, 2016 and identified the Hospital admitted the patient on 02/26/16 for agitation and aggression. Diagnoses included major depression and Alzheimer's disease with behavioral disturbances.

Patient #5's progress notes identified the following:
* 03/01/16 at 7:40 p.m. - "Pt [patient] was taken to low stim"
* 03/02/16 at 8:30 p.m. - "Resident aggressive behavior to staff & [and] other res. [residents]. Place in 4S [low stim]."

Review of Patient #5's physician's orders identified an order, dated 02/29/16 at 10:45 p.m., which stated, "low stim programming due to increased agitation and aggression related to psychosis." The physician's orders failed to include an order for low stim on 03/01/16 and 03/02/16 and failed to include an order to discontinue low stim.

- Review of Patient #6's medical record occurred on April 26-28, 2016 and identified the Hospital admitted the patient on 03/02/16 for aggressive behaviors. Medical diagnoses included depression and Alzheimer's disease with behavioral disturbances. A physician's order, dated 03/03/16, stated, "May use geri [geriatric] chair for comfort and positioning - use only if needed."

A progress note, dated 04/19/16 at 1:15 p.m., stated Hospital staff utilized the geri chair related to, "hitting staff, getting up and down."

Observation throughout the survey showed Patient #6 walking with the assistance of one staff member, a gait belt, and an occasional walker. The patient would sit in a chair for a few minutes at a time and then would begin walking again. Observation on 04/27/16 at 1:20 p.m., 4:40 p.m., and 5:33 p.m. showed Patient #6 seated in a reclined geri chair, with the foot rest elevated as high as her head, and unable to stand up out of the chair unless she rolled over the side. At 5:45 p.m., at behavioral health technician (BHT) (#11) stated to Patient #6, "[Patient name]! Sit back. You're fine. Sit down [Patient name]," as the patient attempted to crawl out of the chair.

The medical record showed the Hospital failed to obtain a physician's order for the geri chair on 04/19/16 and on 04/27/16.

Review of the "Geriatric Shift Review" forms which are completed by the BHTs each shift, from April 05-27, 2016, identified the following:
*04/05/16 - "Pt was antsy and kept trying to get up and walk . . . "
*04/08/16 - "Pt was hitting staff when told she needs to sit down . . ."
*04/16/16 - "Pt repetitively stood up out of her chair and attempted to ambulate throughout the main room . . ."
*04/18/16 - "Pt attempted to climb out of chair multiple times during shift . . . Staff should monitor pt for falls due to climbing/crawling out of her chair."
*04/20/16 - "pt constant motion [up] et [and] [down] in chair. aggitated [sic] when ask to sit. Ambulate pt [with] gait belt and walker. Notify RN [registered nurse]. Pt still anxious. PRN given, geri chair ordered . . ."
*04/27/16 - "pt was restless and kept getting up from her chair . . ."

The above Geriatric Shift Review forms failed to identify the reason staff members tried to refrain Patient #6 from getting up from the chair and walking and failed to identify if the chair used was a geri chair.

The Hospital failed to obtain a physician's order each time staff members utilized the geri chair. This failure infringes upon Patient #6's right to be free from restraints.

Refer to A143 and A144 regarding staff failure to address resident behaviors in relation to environmental factors, patient treatment, and patient dignity.

HIGH BLOOD SUGAR

5. Based on record review, the Hospital failed to follow physician's orders related to high blood glucose readings for 1 of 2 active patients (Patient #2) reviewed on insulin. Failure to notify the physician about high blood glucose readings may result in adverse consequences such as ketoacidosis, a life-threatening condition which requires immediate treatment.

Findings include:

Review of Patient #2's medical record occurred on April 26-28, 2016 and identified the Hospital admitted the patient on 02/16/16 for suicidal ideation.

Review of Patient #2's Physician's orders, dated 03/31/16, included Lantus insulin 10 units at bedtime and Novolog insulin (sliding scale). The Novolog sliding scale orders stated:
* Blood sugar 0 to 150 - no insulin
* Blood sugar 151 to 200 - 2 units
* Blood sugar 201 to 250 - 6 units
* Blood sugar 251 to 300 - 8 units
* Blood sugar 301 to 350 - 12 units
* Blood sugar greater that 350 - 16 units and call the provider

Review of Patient #2's nursing progress notes and medication administration records (MARs) for March and April identified the following:
* 03/31/16 at 4:30 p.m. - The blood sugar measured 588. The nurse called the provider and received orders to administer Novolog 20 units now and recheck the blood sugar in 20 minutes. At 5:00 p.m., the nurse checked the patient's blood sugar and it registered 426. The nurse failed to inform the provider about the reading of 426.
* 04/04/16 at 9:00 p.m. - The MAR identified a blood sugar of 595 and Novolog 16 units administered. A progress note, dated 04/04/16 at 10:30 p.m. stated, Resident BS [blood sugar] 595. Informed Charge [nurse] Gave 16 units Novolog [plus] 10 units Lantus at 1800 [6:00 p.m. (scheduled for bedtime)] Rechecked BS @ [at] 1930 [6:30 p.m.] was 328. Recheck @ 0200 [2:00 a.m.] on 4/5 [04/05/16] 198 BS. Will monitor and report." The nurse failed to inform the provider about the patient's high blood sugar readings and the early administration of the Lantus insulin.
* 04/05/16 at 12:00 p.m. - The MAR identified a blood sugar of 442 and Novolog 16 units administered. The nurse failed to notify the provider about the patient's high blood sugar.

PHARMACOTHERAPY

6. Based on record review, review of Hospital policy, and staff interview, the Hospital failed to provide/attempt non-pharmacological interventions prior to the initiation of an as needed (PRN) medication for 3 of 9 active patient records (Patient #5, #6, and #7) reviewed. Failure to assess the patients' environment, assess for care needs, and utilize de-escalation techniques prior to the administration of PRN mediations does not allow the Hospital to determine the best treatment plan for their behaviors.

Findings include:

Review of the facility policy titled "Aggressive Behavior Prevention" occurred on 04/28/16. This policy, dated 09/28/15, stated, "Purpose: To prevent patient-to-patient aggression. . . . STAFF INTERVENTION FOR 24-HOUR PATIENT CARE: . . . 2. Staff will adhere to the following processes for observing patient behaviors, monitoring patient aggression, and intervening proactively before the patient becomes aggressive with another patient: *Assess triggers and environmental stimuli that are agitating or will agitate patient . . . *Utilize proactive de-escalation techniques learned in required training to respond to patients consistently by noting behavior(s) and/or negative statement(s) and attempt to redirect. . . . *Observe patient response and assess need for further intervention (continued redirection, nurse assesses need for pharmacotherapy, calming techniques) . . ."

Review of Patient #5's medial record occurred on April 26-28, 2016 and identified the Hospital admitted the patient on 02/26/16 for agitation and aggression. As needed (PRN) medications included Ativan (an anxiolytic) 1 milligram (mg) orally, Haldol (antipsychotic) 5 mg injection, and Seroquel (antipsychotic) 50 mg orally.

Patient #5's "Master Treatment Plan" stated, "Short Term Goal: [less] aggression. As evidenced by: [less] Hitting out, and yelling out . . . Intervention: MD [medical doctor] will meet [with] pt daily to assess effectiveness of medications and monitor for possible side effects . . ." The treatment plan lacked individualized approaches for staff to attempt prior to the initiation of medications.

Review of Patient #5's medication administration record (MAR), dated February 26, 2016 through April 26, 2016, identified the following:
*02/26/16 at 9:43 p.m. - Haldol administered
*02/29/16 at 10:30 p.m. - Seroquel administered and Haldol administered at 11:00 p.m. for increased agitation
*03/01/16 at 11:30 p.m. - Ativan administered for anxiety/aggression
*03/03/16 at 1:10 p.m. - Seroquel administered for increase anxiety
*03/06/16 at 9:47 p.m. - Ativan administered for agitation
*03/12/16 at 10:16 p.m. - Ativan administered for increased anxiety
*04/10/16 at 4:15 p.m. - Haldol administered for increased agitation
*04/16/16 at 5:45 p.m. - Haldol administered for hitting and aggression
*04/18/16 at 9:15 a.m. and again at 2:30 p.m. - Ativan administered for agitation and crawling on the floor
*04/19/16 at 9:30 a.m. - Ativan administered for agitation
*04/26/16 at 1:15 p.m. - Ativan administered for anxiety/aggression

The nursing staff failed to identify the interventions/techniques utilized before administering Patient #5 PRN medications.

Review of Patient #5's "Geriatric Shift Review" forms, completed by the behavioral health technicians (BHTs) or certified nursing assistants (CNAs) every 12 hours, failed to identify interventions/techniques utilized prior the administration of a PRN medication by the nurse.

- Review of Patient #6's medical record occurred on April 26-28, 2016 and identified the Hospital admitted the patient on 03/02/16 for aggression. PRN medications included Seroquel 25 mg orally or topically (increased to 50 mg on 04/27/16), Ativan 1 mg orally or injected, and Xanax (anxiolytic) 0.25 mg orally.

Patient #6's "Master Treatment Plan" stated, "Short Term Goal: [decrease mood sx [symptoms] As evidenced by: [no] hitting, normal sleep/wake cycle. Intervention: MD will met [sic] [with] pt daily to assess for effectiveness of medications and monitor for any side effects of medication . . ." The treatment plan lacked individualized approaches for staff to attempt prior to the initiation of medications.

Review of Patient #6's MAR, dated April 05-26, 2016 identified the following:
*04/05/16 at 2:45 p.m. - Ativan administered for hitting staff and Xanax administered at 8:00 p.m. for anxiety/restlessness
*04/07/16 at 4:30 p.m. - Xanax administered for anxiety
*04/08/16 at 4:30 a.m. - Xanax administered for restlessness/anxiety, and Ativan administered 4:10 p.m.
*04/10/16 at 6:00 a.m. - Ativan administered for agitation
*04/14/16 at 3:00 p.m. - Xanax administered for anxiety, and Xanax administered at 9:00 p.m. for constant motion
*04/15/16 at 2:30 p.m. - Ativan administered for agitation towards staff
*04/16/16 at 4:45 p.m. - Ativan administered for hitting staff
*04/18/16 at 10:00 a.m. - Ativan administered for agitation, and Xanax administered at 11:00 a.m. for "won't stay seated"
*04/19/16 at 11:50 a.m. - Xanax administered for "can't stop getting up and down," and Ativan administered at 1:15 p.m. for hitting staff
*04/20/16 at 4:00 p.m. - Seroquel administered for agitation
*04/22/16 at 8:30 a.m. - Seroquel administered for agitation
*04/23/16 at 11:15 a.m. - Seroquel administered for agitation
*04/25/16 at 11:50 a.m. - Seroquel administered for combativeness and hitting
*04/26/16 at 6:30 p.m. - Seroquel administered for aggression and agitation

The nursing staff failed to identify the interventions/techniques utilized before administering Patient #6 PRN medications.

Review of Patient #6's "Geriatric Shift Review" forms, completed by the BHTs or CNAs every 12 hours, failed to identify interventions/techniques utilized prior the administration of a PRN medication by the nurse.

- Review of Patient #7's medical record occurred on April 26-28, 2016 and identified the Hospital admitted the patient on 03/14/16 for aggression and physical violence towards others. PRN medications included Seroquel 25 mg orally, Zyprexa (antipsychotic) 5 mg injection, Ativan 0.5 mg orally, and Haldol 2 mg injection.

Patient #7's "Master Treatment Plan" stated, "Short Term Goal: Pt will stabilize mood As evidenced by: Cooperating [with] cares and following group structure. Intervention: Dr [doctor] will meet [with] pt daily to assess medication effectiveness and monitor for any side affects . . . Short Term Goal: Continue to [decrease] aggression & confusion As evidenced by: [no] hitting out during OT [occupational therapy] groups & cooperating with group process [with] prompts . . . Long Term Goal: Pt will [decrease] aggression in order to successfully transition to an appropriate skilled nursing facility . . ."

Review of Patient #7's MAR, dated 03/14/16 through 04/25/16, identified the following:
*03/14/16 at 6:37 p.m. - Haldol and Ativan administered for severe agitation, extreme aggression, threatening staff
*03/21/16 - Ativan administered at 5:33 a.m. and at 9:00 p.m. and Seroquel administered at 5:30 a.m. and at 9:00 p.m. for increased agitation, anxiety, hitting, and kicking
*03/22/16 at 8:40 p.m. - Haldol administered for physical aggression
*03/23/16 at 9:40 p.m. - Haldol administered for physical aggression
*03/25/16 - Seroquel administered at 7:00 a.m. for agitation and Ativan administered at 8:00 p.m. for increased anxiety and agitation
*03/27/16 - Ativan administered at 8:00 p.m. for agitation and Seroquel administered at 8:18 p.m. for agitation and refusing oral medications
*03/29/16 - Seroquel administered at 1:21 a.m. for increased agitation and Haldol administered at 1:44 a.m. for aggression, hitting, and kicking
*04/13/16 at 7:00 a.m. - Seroquel administered for agitation
*04/16/16 - Seroquel administered at 8:45 a.m. for yelling and swinging and again at 9:30 p.m. for yelling and hitting
*04/17/16 at 1:45 p.m. - Seroquel administered for hitting/yelling at staff
*04/18/16 at 1:30 p.m. - Seroquel administered for swinging and agitation
*04/20/16 at 3:45 p.m. - Seroquel administered for hitting staff
*04/23/16 at 12:40 p.m. - Seroquel administered for agitation and aggression
*04/24/16 - Ativan administered at 10:15 a.m. for agitation and Se
VIOLATION: NURSING CARE PLAN Tag No: A0396
THIS IS A REPEAT DEFICIENCY FROM THE COMPLAINT SURVEY COMPLETED ON 07/09/15.

Based on record review, the Hospital failed to ensure the development of a treatment plan/care plan for 3 of 9 active patient records (Patient #5, #6, and #7) reviewed who received as needed (PRN) medications for behaviors. Failure to assess each patient's specific behavior, develop an individualized plan of care, review the plan, and revise the patient's care in response to those assessments may result in the Hospital not meeting the behavioral needs of each patient.

Findings include:

- Review of Patient #5's medical record occurred on April 26-28, 2016 and identified the Hospital admitted the patient on 02/26/16 for agitation and aggression. Medical diagnoses included depression and Alzheimer's disease with behavioral disturbances. As needed (PRN) medications included Ativan (an anxiolytic) 1 milligram (mg) orally, Haldol (antipsychotic) 5 mg intramuscular (IM), and Seroquel (antipsychotic) 50 mg orally.

Review of Patient #5's medication administration record (MAR), dated February 26, 2016 through April 26, 2016, identified the patient received PRN medication 13 times for aggression, anxiety, agitation, hitting, or crawling on the floor, and placed in the low stimulation unit three times.

Review of the nursing progress notes, dated February 26, 2016 through April 26, 2016, identified Patient #5 had altercations with other patients on six occasions.

Patient #5's "Master Treatment Plan" stated, "Short Term Goal: [less] aggression. As evidenced by: [less] Hitting out, and yelling out . . . Intervention: MD [medical doctor] will meet [with] pt daily to assess effectiveness of medications and monitor for possible side effects . . . Goal: [increased] mood stability As evidenced by: [decreased] aggression, tearfulness [with] normal sleep wake cycle. Intervention: RN [registered nurse] reminisce [with] pt, provide comfort [with] stuffed animals. Pt will be 100% med [medication] compliant . . . Goal: [decreased] impulsivity As evidenced by [no] hitting out behaviors during group. Intervention: During OT [occupational therapy] groups pt will be prompted to participate in exercise/therapy/and other meaningful activities; utilize weighted lap pad to help [with] concentration/impulsivity . . ." The treatment plan narrative stated, "Pt was admitted to RPSPC [Richard P. Stadter Psychiatric Center] on 2/26/16 and continues to program on the geri [geriatric] unit. Pt is still presenting with aggression and is not being compliant with taking medication. . . ."

- Review of Patient #6's medical record occurred on April 26-28, 2016 and identified the Hospital admitted the patient on 03/02/16 for aggression. PRN medications included Seroquel 25 mg orally or topically (increased to 50 mg on 04/27/16), Ativan 1 mg orally or IM, and Xanax (anxiolytic) 0.25 mg orally.

Review of Patient #6's MAR, dated April 05-26, 2016, identified the patient received PRN medications 19 times for behaviors of aggression, agitation, combativeness, hitting getting up and down from a chair, anxiety, or restlessness, and staff placed the patient in a geriatric reclined chair.

Patient #6's "Master Treatment Plan" stated, "Short Term Goal: [decrease mood sx [symptoms] As evidenced by: [no] hitting, normal sleep/wake cycle. Intervention: MD will met [sic] [with] pt daily to assess for effectiveness of medications and monitor for any side effects of medication . . . Goal: [decrease] impulsivity As evidenced by: engaging in meaningful activity [with] less than 2-3 attempts to impulsively stand [sic] up. Intervention: During OT groups, pt will be encouraged to engage in movement activities, assist ambulating pt [with] gait belt when she stands up. Use weighted lap pad or diversional activities to help [with] restlessness. Provide reassurance when anxious - hand holding . . ."

- Review of Patient #7's medical record occurred on April 26-28, 2016 and identified the Hospital admitted the patient on 03/14/16 for aggression and physical violence towards others. PRN medications included Seroquel 25 mg orally, Zyprexa (antipsychotic) 5 mg IM, Ativan 0.5 mg orally, and Haldol 2 mg IM.

Review of Patient #7's MAR, dated 03/14/16 through 04/25/16, identified the patient received PRN medications 25 times for behaviors of mood change, anxiety, agitation, yelling, hitting, aggression, or kicking.

Patient #7's "Master Treatment Plan" stated, "Short Term Goal: Pt will stabilize mood As evidenced by: Cooperating [with] cares and following group structure. Intervention: Dr [doctor] will meet [with] pt daily to assess medication effectiveness and monitor for any side affects . . . Goal: Remain mood stable As evidenced by: completing ADL's [activities of daily living] Intervention: Staff will encourage pt verbally & assist as needed & complete ADLs - staff will also encourage pt to attend groups . . . Goal: Continue to [decrease] aggression & confusion As evidenced by: [no] hitting out during OT groups & cooperating with group process [with] prompts . . . Long Term Goal: Pt will [decrease] aggression in order to successfully transition to an appropriate skilled nursing facility . . ."

Failure to assess each patient's behaviors on an ongoing basis, develop an individualized treatment/care plan related to those behaviors other than interventions by the MD (medication management) and group therapies, and evaluate the effectiveness of the interventions limits the staff's ability to provide consistent care for the patients.