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RUSK STATE HOSP 805 N DICKINSON DR RUSK, TX Aug. 22, 2012
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based upon record review and interview, the facility failed to ensure that an RN was evaluating the care needs and health status of 1 of 1 (#1) patients reviewed.

Review of the medical record of patient #1 revealed patient was a [AGE] year old female patient admitted to the facility with diagnoses of Mood Disorder and Borderline Personality Disorder. Patient was admitted on a protective order due to the patient isolating herself in her room, not eating or drinking for approximately 2 weeks prior to admission. The patient reportedly had tried to jump out of a moving vehicle. Review of admission labs revealed a slightly low Potassium level - 3.1 (Reference range 3.5 - 5.5) but that was the only abnormal result.

Further review of the medical record revealed physician's notes and social worker notes indicating patient continued to refuse food, fluids, and meals throughout hospitalization . Review of progress notes revealed documentation by nursing staff of patient refusing food, fluids or meals from 5/14/12 - 5/29/12 was documented 15 times out of a minimum of 45 opportunities to document mealtimes (3 meals x 15 days). Review of progress notes revealed documentation by nursing staff of patient's intake of food or drink from 5/14/12 - 5/29/12 was 3 times out of a minimum of 45 nursing shifts ( 3 nursing shifts x 15 days). Nursing failed to consistently document patient's refusal or intake of meals, snacks, or fluids.

Review of physician's orders revealed an order dated 5/14/12 to weigh patient weekly. Patient weighed 151 lbs. on admission. Nursing notes revealed that patient was weighed on 5/20/12 and weighed 142 lbs. Physician's order revealed a referral to medical clinic on 5/24/12 related to patient's weight loss of 9 lbs in one week but patient's weight was not obtained while in medical clinic. No other weights were documented in the medical record. The physician's progress note for medical clinic visit on 5/24/12 revealed the following: "The patient did attend Medical Clinic, and sat on the exam table as requested, but did not respond verbally to any questions, nor to even acknowledge why she was referred. She would not give consent for any aspect of physical examination, but apparently allowed vital signs to be checked in the waiting area. Chart review reveals no medications suspicious for appetite suppression, and in the current context I doubt the type of food being offered to the patient is relevant. That context includes the absence of any overt manifestations of electrolyte imbalance; I suspecty this patient finds ways to take in just enough calories to avoid unpleasant symptoms, as she likely did in the weeks before admission. Nonetheless, if her fluid intake is largely in the form of free water, problems could arise. Short of force feeding, I would recommend fluids with electrolytes, like Pedialyte or Gatorade; even adding a pinch of table salt or baking soday to orange juice could suffice." Review of the medical record revealed none of these interventions were written in a physician's order or implemented by nursing.

Review of treatment team meetings titled "Client Recovery Plan" revealed an initial plan formulated by nursing dated 5/14/12 that identified an initial problem of "Mood". "Patient has a long history of mental illness and substance abuse. Indications are she has been noncompliant, not eating or attending to hygiene and health, and become isolative." The "Goal" to address this problem stated "Patient will experience a sufficient reduction of symptoms to return to a less restrictive environment." The "Objective" stated "Patient will participate in treatment formulation and display socially acceptable behaviors and interactions for seven days prior to discharge." The "Interventions" identified were as follows: "1.) Direct Care Interventions: Monitor Behavior and interactions for indications of escalating target symptoms ( labile; depressed; evasive; resistant; withdrawn; inadequate self care/neglect; unpredictable; displayed or expressed intent for self harm or suicide). Provide prompt de-escalation techniques such as redirection, reorienting, distraction, supportive counseling, alternate activity when escalating. Notify nurse when ineffective or frequent de-escalation is required. RN(Registered Nurse), LVN (Licensed Vocational Nurse, PNA(Psychiatric Nurse Assistant. Daily 2.)Engage in therapeutic interactions and activities daily by providing diversionary and/or educational pursuits to enhance skills needed for appropriate social interactions. RN. LVN, PNA. Daily. 3.) Administer medications as indicated and ordered. RN, LVN. Daily. 4.)Medication education weekly at medication pass by LVNon specific current medication indications, side effects, and compliance." Further review of the treatment plan revealed on 5/18/12 the treatment plan was formulated and the problem identified as "Mood" had been changed to "Danger to self, Danger of Deterioration. Patient was sent to facility from the Mental Health Authority (MHA) on an Order of Protective Custody. This is the patient's fourth admission to this facility. She has not eaten or drank much for the past several weeks. She is not currently on medications. She attempted to jump out of a moving van. She states that she hears"mumbling" voices of no distinct content. The "Goal" had also changed to "Patient will express increased energy and hope." The "Objective" and "Interventions" remained the same for nursing as the initial plan. The objectives and interventiions did not address nursing montioring the patient's intake, weights or health needs. Further review of the interdisciplinary team progress notes revealed no efforts by nursing to implement intake and output monitoring, monitoring of patient's weight weekly as ordered or more frequently than once a week, and no frequent RN assessment of patient's care needs or medical status.

An interview was conducted on 8/22/12 at 2:30pm with the Unit Nursing Administrator. The Nursing Administrator reviewed the medical record and reported the documentation is sketchy but staff did ongoing monitoring and assessment. of patient.

An interview was conducted with the Quality Director on 8/22/12 at 11:00 am. The Qualtiy Director reported the focus was on the psychiatric issues and not the possibility of medical issues. Director further reported that patient's weight was slightly over the weight range for her age and height and there were no visible signs that patient was not eating or drinking. The Director also reported it is not uncommon for psychiatric patients to refuse food and medications.