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.

ABILENE BEHAVIORAL HEALTH LLC 4225 WOODS PLACE ABILENE, TX Aug. 14, 2013
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of patient records, facility policies, and staff interviews, the facility failed to ensure a safe setting for patients as the " Observation Record " form did not reflect the correct patient ' s observation level or precautions as ordered by the patient ' s practitioner. Documentation of observation levels were incorrect or left blank on the observation form; there were also observation levels documented which were not ordered by the patient ' s practitioner. Nursing assessment forms did not indicate which of the following observation level the physician had ordered for the patient, including Close, LOS [Line of Sight] Continuous, LOS while awake, 1:1 continuous, or 1:1 while awake. This deficient practice had the potential to affect all patients as there was no way to confirm that the mental health techs responsible for observing the patients knew the ordered observation level for each patient. These deficient practices had the potential to affect all patients as all patients were required to have an order for their observation status.

Findings were:

A review of patient medical records revealed that for 6 of 20 patients [patients #1, 3, 12, 14, 15, and 16] the facility failed to follow patient precaution and observation levels according to facility policy.

Facility policy #PC.22 entitled Observation Levels, last reviewed 3/13, stated in part, "A Level of Observation is defined as an intensified level of staff awareness and attention to patient safety/security needs requiring the initiation of specific protocols and supplemental documentation ... Note: This guideline is in addition to but does not replace special precautions procedures for Suicidal patients, Elopement Precautions, Fall Precautions, Seizure Precautions, Assault Precautions, etc ...
2.0 An order for the appropriate level of observation and precautions should be documented in the physician ' s order section of the medical record, and the Observation Flow Sheets should be initiated by the charge nurse or designee. The physician should be contacted within 1 hour to obtain verbal order for observation or special precaution. Initiation of precautions should be documented in the physician orders specifying date, time and level of observation.
A licensed nurse or designee should ensure that all patient orders for special precautions are recorded and posted per facility policies and procedures.
3.0 Reassessment by a physician should be completed and documented every 24 hours (or as noted in specified policy) with clinical justification for renewal, modification, or discontinuation of orders for special precautions.
4.0 The registered nurse should address the status of the patient on special precautions in the progress notes as outlined below for the level of observation and precaution initiated ...
6.0 A physician order is required to increase, continue, decrease or discontinue a level of observation and special precaution level. [Facility's bold] This order should not be a telephone or verbal order and should be accompanied by a progress note by the physician, within 24 hours of the order, with the rationale regarding the order for the observation or special precaution.
7.0 Prior to the patient ' s discharge, the physician must substantiate in the medical record that the potential for high risk behavior no longer exists, or exists at a level that can be safely managed at a lower level of care."

Facility policy #PC.67 entitled Precautions, stated in part, "A precautionary measure and/or level that determine [sic] the minimum frequency of nursing observation and degree of independent activity within the behavioral milieu will be ordered for each patient ...The physician documents the initiation, termination, and reason for all precautions ...
1. Aggressive Behavior Precautions - Patients that present themselves as a danger to others, either by threats or physical actions, will be placed on aggressive behavior precautions: ...Patients on aggressive behavior precautions will be placed on unit restriction. This will be documented in the multidisciplinary notes and will be discontinued by physician ' s order only ...The Treatment Team will review the precautions as well as any restriction and bed assignment concerns for the patient at least weekly. The patient ' s precaution status shall be communicated to all staff responsible for the care of the patient...
2. ...
3. Suicide Precautions: Patients at risk of harming themselves will be monitored to the degree that is clinically appropriate: ...Suicide observations ...will not be discontinued without a physician's order..."


Review of patient #1's clinical record revealed the following inconsistencies regarding precaution and observation levels among staff and among shifts:
Daily Nursing Assessments for the patient from 5/5/13 through his discharge date of [DATE] on 7a-3p and 3p-11p shifts had "No" checked by the phrase "Special Precautions" indicating no precautions for the patient.
Night Shift Nursing Assessments (11p-7a shift) for the patient indicated the following special precautions:
? 5/6 SP [Suicide Precautions], HI [Homicidal Ideation], Agg [Aggression]
? 5/7 SP, AAO [Aggressive Acting Out], HI, Self-Harm
? 5/8 SP, AAO, Self Inj, HI
? 5/9 SP, AAO, Self-Harming, HI
? 5/10 - 5/23 SP, Self Harm, HI
Mental Health Technician Observation Records for patient #1 for all shifts revealed the following precautions checked:
? 5/5 Agg, HI
? 5/6 Suicide, Agg, HI
? 5/7 none
? 5/8 Suicide, Agg
? 5/9-5/11 none
? 5/12 Suicide, Agg, HI
? 5/13 Suicide, HI
? 5/14-5/15 Suicide, Agg, HI
? 5/16-5/19 Suicide, Agg
? 5/20-5/23 Suicide, Agg, HI
There were no Physician's Orders regarding patient #1's precaution levels at Acadia Abilene between the dates of 5/9/13 and 5/20/13. There were no nursing notes reflecting changes in precaution levels. There was no evidence in patient #1's chart that the physician documented that the patient's high risk behaviors no longer existed prior to discharge.

Review of the medical chart for patient #14 revealed the following precautions noted on the Observation Records for the mental health technicians (MHTs):
8/5/13-8/9/13 no precautions, though there was a MHT note on 8/9/13 stating
patient was trying to choke himself
8/10/13-8/12/13 AAO [Aggressive Acting Out] checked
8/13/13 no precautions, but Line of Sight [LOS] while awake observation
level checked
Daily Nursing Assessments for 7a-7p shifts and 7p-7a shifts indicated the following:
8/6/13 special precautions "no" checked
8/7/13 7a-7p shift: blank 7p-7a: special precautions "no" checked
8/8/13-8/11/13 special precautions "no" checked
8/12/13 7a-7p shift: blank 7p-7a: special precautions "no" checked
8/13/13 7a-7p shift: LOS checked 7p-7a: special precautions "no" checked
Reason: SI [Suicidal Ideation]
(there is no other nursing note regarding this)
A Physician's Order on 8/12/13 at 7:30 a.m. stated, in part "LOS w/a [while awake] for SI/Self harm." This was the only order addressing precautions or observation levels.
A Physician's Note on 8/12/13 for patient #14 at 5:20 p.m. stated, in part "expressed SI this weekend and today; attempted to choke himself this weekend several times..."

A review of patient #15's medical chart revealed the following from the MHT Observation Records:
7/19/13-8/9/13 no precautions
8/10/13 AAO
8/11/13 no precautions
8/12/13 AAO
8/13/13 no precautions
Daily Nursing Assessments for patient #15 showed the following:
Special precautions "no" checked for both the 7a-7p and 7p-7a shifts with the following exceptions:
7/23/13 7p-7a shift: no assessment sheet at all; form completely blank
7/25/13 7a-7p shift: blank
7/30/13 7a-7p shift: LOS for falls
7/31/13 7a-7p shift: blank
8/3/13 7a-7p shift: blank
8/7/13 7a-7p shift: blank
8/9/13 7p-7a shift: blank
8/12/13 7a-7p shift: blank
8/13/13 7a-7p shift: blank
There were no precaution or observation level orders for patient #15 available in the patient record.

Review of patient chart #16 revealed the following:
MHT Observation Records with the following special precautions checked:
7/11/13-7/12/13 SAO [Sexually Acting Out] and LOS w/a [Line of Sight while awake]
7/13/13-7/18/13 SAO, AAO, LOS w/a
7/19/13 SAO, AAO
7/20/13-7/21/13 SAO, AAO, LOS w/a
Note on 7/21/13 at 12:18 p.m.: "punched [peer] in jaw ..."
Note on 7/21/13 at 5:49 p.m.: "outside on patio patient fell ..."
7/22/13-7/23/13 No precautions checked
7/24/13 Note at 7:00 a.m.: "LOS w/a by Dr. Parrott" signed by MHT
No other precautions checked
7/25/13 SAO, LOS w/a
7/26/13 SAO, LOS and close observation checked [conflicting]
7/27/13-8/1/13 SAO, AAO, LOS w/a
8/2/13-8/7/13 SAO, LOS w/a
8/8/13-8/9/13 SAO, LOS w/a, UR [Unit Restrictions]
8/10/13 SAO, AAO, LOS w/a, UR
8/11/13 SAO, AAO, UR
8/12/13 SAO, AAO, LOS w/a, UR
8/13/13 blank
Daily Nursing Assessments showed the following by the phrase "special precaution" on the form:
7/14/13 7a-7p shift: SAO
7/15/13 7a-7p shift: "no" checked
7/16/13 7a-7p shift: "yes" checked with reason: "behavior"; no type
7p-7a shift: "yes" checked with reason: "past behavior"; no type
7/17/13 7a-7p shift: "no" checked
7p-7a shift: SAO as type and written reason: "inappropriate comments"
7/18/13 7a-7p shift: SAO as type and written reason: "accusations at home"
7p-7a shift: SAO as type and written reason: "poor behavior"
7/19/13-7/23/13 "no" box checked on special precautions on both shifts
7/24/13 7a-7p shift: SAO and LOS w/a
7p-7a shift: "no" box checked on special precautions
7/25/13 both shifts: SAO and LOS
7/26/13 both shifts: LOS w/a
7/27/13 7a-7p shift: SAO and LOS w/a
7p-7a shift: SAO, Agg, LOS w/a
7/28/13 both shifts: SAO and LOS w/a
7/29/13 7a-7p shift: SAO, Agg, LOS w/a
7p-7a shift: form completely blank
7/30/13 7a-7p shift: LOS w/a
7p-7a shift: SAO, Agg, LOS w/a
7/31/13 both shifts: LOS
8/1/13 both shifts: LOS, SAO
8/2/13 both shifts: LOS w/a
8/3/13 7a-7p shift: SAO, AAO
7p-7a shift: SAO, Agg, LOS w/a
8/4/13 7a-7p shift: SAO, LOS w/a
7p-7a shift: LOS w/a, Aggression
8/5/13 7a-7p shift: SAO/AAO
7p-7a shift: LOS w/a, Aggression
8/6/13-8/7/13 No Nursing Assessment sheets found
8/8/13 7a-7p shift: LOS
7p-7a shift: LOS w/a, SAO
8/9/13 both shifts: LOS w/a, SAO
Physician's Orders regarding precautions and observation levels for patient #16 during his stay at Acadia Abilene were as follows:
7/12/13 1030 "LOS w/a for 24 hours (SAO); blocked room (SAO)"
7/15/13 1100 "Renew blocked room
Renew LOS w/a for SAO"
7/20/13 1000 "Discontinue unit restrictions"
7/22/13 1500 "Blocked bed due to SAO/aggression
Discontinue LOS; close obs status"
7/24/13 1310 "LOS w/a for aggression"
1500 "Discontinue blocked bed - no overt SAO in house
Continue LOS w/a for aggression as above"
7/29/13 "Continue LOS while awake; aggression"
8/8/13 1440 "Unit restriction for bullying behavior"
8/9/13 1645 "Renew unit restriction with cafeteria privileges"
8/12/13 no time "Take patient off unit restriction"
No other physician orders were available in the patient chart regarding precautions or observation levels.

In an interview with the LVN of the children's Miller Unit and the adolescent Focus Unit [staff #5] on the afternoon of 8/14/13 on the adolescent unit, when asked if she felt precaution/observations levels were communicated well, she said, "No. Honestly, I don't feel like levels are communicated. The next shift comes in and it's all new."

The above findings were confirmed in an interview with the facility CEO and other administrative staff the evening of 8/14/14 in the facility conference room.






Review of the medical record for Patient #13 revealed an admission observation level order for " Close Observation " on 7/22/13. There was no documented order for precautions for Patient #13. Review of the record for Patient #13 revealed the following incorrect and inconsistence documentation of observation monitoring:
7/22/13 from 2210 until 2345, the " Observation Record " form had no Observation Level or Precautions indicated. There was no check mark in any of the following observation levels, Close, LOS [Line of Sight] Continuous, LOS while awake, 1:1 continuous, or 1:1 while awake, to inform the staff monitoring the patient the level of observation for the patient who was admitted for suicide ideation and severe depression.

Review of the record for Patient #3 revealed an admission observation level order for " Close Observation " on 5/23/13. There was no documented order for precautions for Patient #3 throughout the admission. There was no documentation on the Observation Record form to inform the staff monitoring the patient which observation levels the patient was on: Close, LOS [Line of Sight] Continuous, LOS while awake, 1:1 continuous, or 1:1 while awake. The patient was admitted for suicide ideation and severe depression. Review of the record for Patient #3 revealed the following incorrect and inconsistence documentation of observation monitoring:

5/23/13 - Patient admitted at 2035.
There was no Observation Record form for 5/23/13 in the medical record. There were 2 Observation Record forms in the medical record dated 5/24/13.
Night Nursing Assessment 11-7 form stated, Level of Observation: 15 min; Precaution: SP [suicide precautions], SI [suicidal ideation], Dep mood [depressed mood]. There was no documented order for the above precautions of SP, SI, Dep mood.

5/24/13 -
Observation Record form had no Observation level indicated.
Nursing Shift note for 7-3 had no Special Precautions indicated.
Nursing Shift note for 3-11 had no Special Precautions indicated.
Night Nursing Assessment 11-7 form stated, Level of Observation: 15 min; Precaution: SI, Dep mood, Sub abuse [substance abuse]. There was no documented order for the above precautions of SI, Dep mood, Sub abuse.

5/25/13 -
Nursing Shift note for 7-3 had no Special Precautions indicated.
Nursing Shift note for 3-11 had no Special Precautions indicated.
Night Nursing Assessment 11-7 form stated, Level of Observation: 15 min; Precaution: SI, Dep mood, Sub abuse.
There was no documented order for the above precautions of SI, Dep mood, Sub abuse.
5/26/13 -
Observation Record form had no Observation level indicated.
Nursing Shift note for 7-3 had Special Precautions indicated and " EDO " [Emergency Detention Order] incorrectly documented as the patient was on voluntary status.
Nursing Shift note for 3-11 had no Special Precautions indicated.
Night Nursing Assessment 11-7 form stated, Level of Observation: 15 min; Precaution: SI, Dep mood, Sub abuse. There was no documented order for the above precautions of SI, Dep mood, Sub abuse.

5/27/13 -
Observation Record form had no Observation level indicated.
Nursing Shift note for 7-3 had Special Precautions indicated and " EDO " [Emergency Detention Order] incorrectly documented as the patient was on voluntary status.
Nursing Shift note for 3-11 had Special Precautions indicated and " EDO " [Emergency Detention Order] incorrectly documented as the patient was on voluntary status.
Night Nursing Assessment 11-7 form stated, Level of observation: not checked; Precaution: SI, Dep mood, Sub abuse.

5/28/13 -
Observation Record form had no Observation level indicated.
Nursing Shift note for 7-3 had Special Precautions indicated and " EDO " [Emergency Detention Order] incorrectly documented as the patient was on voluntary status.
Patient discharged at 1505.

Review of facility policy # PR.5, Court Ordered Mental Health Services, last revised 02/13, stated, in part, " e. NOTE: On Admission, a physician must write a unit restriction order for all involuntary patients. The charge nurse should notify all staff of the unit restriction order. "

Review of the medical record for Patient #3 correctly revealed no unit restriction order, as Patient #3 was a voluntary patient; however the documentation reflected that for 4 shifts, the nurse incorrectly documented that Patient #3 was under court ordered mental health services, " EDO " , which is a stricter observation level, thereby potentially restricting the patient ' s rights without an order.

Review of facility policy #PC.22, Observation Levels, last revised 6/13, stated, in part, " 2.0 An order for the appropriate level of observation and precautions should be documented in the physician ' s order section of the medical record, and the Observation Flow Sheets should be initiated by the charge nurse or designee ....6.0 A physician order is required to increase, continue, decrease or discontinue a level of observation and special precaution level. This order should not be a telephone or verbal order and should be accompanied by a progress note by the physician, within 24 hours of the order, with the rationale regarding the order for the observation or special precaution ...13.2.2 A Physician's order is necessary for the initiation, continuation and discontinuation of unit restriction. "

The above findings were confirmed in an interview with the facility Director of Nursing the afternoon of 8/14/13 in the facility conference room.
VIOLATION: CONTENT OF RECORD - INFORMED CONSENT Tag No: A0466
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of documentation and interview it was determined the facility failed to consistently obtain informed consent for psychoactive medications.

Findings were:

Facility based policy entitled, "Patient Constant for Psychoactive Medication-Typical, Emergency, & Court Ordered Procedure" stated in part, "Legally Authorized Representative: The parent, managing conservator or guardian of a minor; the guardian of the person of an adult, or the person to whom authority to make health care decisions is delegated under a durable power of attorney for health care provided by Ch. 135 of the Texas Civil Practices and Remedies ....
Minor: A person under the age of 16 years who is not and has not been married or who has not had his/her disabilities of minority removed for general purposes ...
Procedure:..
9. If a patient lacks the capacity to give informed consent, or refuses to sign the documentation following explanations of informed consent, psychoactive medications will not be administered until such time as the patient gains capacity to make an informed decisions, agrees to sign the consent documentation, a legally authorized representative gives informed consent, or the hospital is in receipt of a court order to authorize administration of psychoactive medications (see section on Order ro Authorize Psychoactive Medication)."

The Texas Administrative Code, Title 25 ? 414.403 defines a minor as follows, "(7) Minor--A person under 18 years of age who is not and has not been married or who has not had his or her disabilities of minority removed for general purposes."

In an interview on, 08/14/13, staff members # 1 and 2 confirmed that in the case of minors, under the age of 18, the facility practice is for parents to give consent for psychoactive medication. Staff member # 2 added that in the case of Patient # 8 "there was discussion of getting court ordered medication" but the facility ended up obtaining the consents from the patient's mother.

A review of the medical record for patient # 8 (a [AGE] year old minor) revealed the following psychoactive medication consents:
? Patient # 8 signed 3 consents for psychoactive medications (Klonopin, Depakote, and Cogentin).
? Patient # 8's mother signed 4 consents for psychoactive medications (Cymbalta, Risperdal, Abilify, and Hydroxyzine).
Patient # 8 received all of the above listed psychoactive medications during her inpatient stay. Per the facility practice and Texas Administrative Code only the patient's mother should have provided consent for these medications.

This inconsistency in the obtaining consent to administer psychoactive medication for this minor indicates a risk for all minor patients that informed consent for psychoactive medication may not properly by obtained.

In an interview on 08/14/13, staff member #1 confirmed that the medication consents for psychoactive were not properly obtained for patient # 8.
VIOLATION: DISCHARGE PLANNING Tag No: A0799
Based on a review of facility meeting minutes and policies and procedures, patient records, and staff interviews, the facility failed to ensure that the discharge planning process applied to all patients to ensure a smooth and safe transition from the hospital to the discharge destination as patients were discharged without access to or information regarding medications which had been prescribed for their health and safety during their inpatient hospitalization .This deficient practice has the potential to affect all voluntary patients requesting release from the hospital.

Findings were:

Review of 4 out of 4 records for patient on voluntary status which were discharged "AMA" (against medical advice - psychiatric) revealed that were not provided with medication prescriptions for their behavioral/psychiatric and medical conditions. While hospitalized , Patients #3, 7, 12, and 13 were prescribed medications that prevented them from being in a condition that could potentially lead to harm for themselves or others. The patients were discharged without any access or information regarding these medications; therefore it was not a "smooth and safe transition from the hospital." 3 out of the 4 patients (Patients #3, 12, and 13) had consented to and had been taking their medications while they were in voluntary inpatient status up to the point the patient requested to be discharged . The documented reason for not giving the patients in the survey sample prescriptions of the medications they had been prescribed was merely, "AMA discharge." There was no documented evidence by the physician or other practitioner of any specific clinical justification for not providing the patient with prescriptions at their discharge.Consequently the discharge planning process did not apply to all patients, including those patients that requested discharge while on voluntary status.

Review of the record for Patient #3 revealed that Buspar, Cymbalta, and Atarax had been ordered for the patient's mood instability, aggression, and anxiety while an inpatient. The Discharge Summary for Patient #3 dated 5/28/13 stated "Discharge Medications & Prescriptions: There were no medications given as she left AMA." The "Medications Prescribed Upon Discharge" form had "Left AMA" and AMA" handwritten across the "Current Medications" table on the form where the "name of medication, dosage, route, frequency, reason" were to be documented for the patient.

Review of the record for Patient #7 revealed that Risperdal and Valproic Acid had been ordered for the patient's psychosis and aggression. The Discharge Summary for Patient #7 stated "Discharge Medications & Prescriptions: Were not given, he left AMA." The "Medications Prescribed Upon Discharge" form listed Risperdal M Tab and Valproic Acid Syrup as the patients current medications. There was no documented evidence of a clinical justification by the practitioner for not providing medication prescriptions on discharge.

Review of the record for Patient #12 revealed that Lexapro and Trazadone had been ordered for the patient's depression and insomnia. The Discharge Note for Patient #12 stated, "Discharge Medications and Prescriptions: No scripts written (patient left AMA)." The Integrative Discharge Plan form for Patient #12 stated the reason prescriptions and medication reconciliation list was not given and explained to patient/family was "AMA Discharge." The "Medications Prescribed Upon Discharge" form had "AMA Discharge" handwritten in large letters across the form. There was no documented evidence of a clinical justification by the practitioner for not providing medication prescriptions on discharge.

Review of the record for Patient #13 revealed that Seroquel, Klonopin, and Cymbalta had been ordered for the patient's mood irritability and volatility, depression, and anxiety. The Discharge Summary for Patient #13 stated, "Discharge Medications & Prescriptions: Were not given as she left AMA." The "Medications Prescribed Upon Discharge" form had the names of 9 medications listed, however " AMA " was handwritten in large letters across the list of medications. There was no documented evidence of a clinical justification by the practitioner for not providing medication prescriptions on discharge.

An "Acknowledgements" form was signed and in the medical records for Patients #3, 7, 12, and 13 at admission which stated, in part, "Abilene Behavioral Health Hospital Discharge Policy Information ...Patients that are discharged AMA (Against Medical Advice) may not be given prescriptions or follow-up appointments made based on decisions made by their physician and treatment team." There was no documented evidence of a clinical justification or decision by the practitioner for not providing medication prescriptions on discharge for Patients #3, 7, 12, and 13.

Review of facility policy #PC69 AMA Discharge Policy, issued 7/2013 stated, in part, "7.0 Discharge Procedure
7.1 An appropriate discharge plan should be completed prior to discharge of the patient requesting early discharge or AMA ...The Discharge Plan should be completed and should include: ...
7.1.2 Medication recommendations"

The "Discharge Checklist" form provided by the facility the afternoon of 8/12/13 included a checklist for "Physician" with the following 4 items:

* Discharge order completed
* Discharge note dictated - include amount of meds needed until next doctor visit
* Discharge Med Reconciliation signed
* Script completed

Review of facility policy #PC.10 entitled "Discharge Planning Procedure", last revised 06/13, stated, in part, "9. Prior to discharge, the patient is referred to Nursing staff to receive instructions concerning the specific medications that the (sic) he or she may have been prescribed ...13. A Discharge Medication Reconciliation form will be completed listing the routine medications the patient is taking on discharge and instruction on when and how often to take these medications. This will be explained to the patient, the patient's family member(s) or legal representative, or other appropriate individual chosen by the patient by nursing staff ...17. The RN/LVN document a discharge progress note in the medical record. The note includes, but is not limited to, the following: a) date and time of discharge, b) prescriptions given to the patient"

Review of the Abilene Behavioral Health Medical Executive Committee Meeting Minutes dated June 26, 2013, May Review, stated, in part, "20. Miscellaneous/Other Business ...Discharge Summary ...When documenting medications and scripts at discharge, if not listing, indicate that you have acknowledged the medication reconciliation form with a signature."

In an interview with the facility administrator the afternoon of 8/14/13 in the facility conference room, he confirmed the above findings and that "AMA", or a patient's request to leave the facility, is not a clinical justification for withholding prescriptions for patients for medications they were currently prescribed. The facility administrator agreed that if there was a valid clinical justification for not providing prescriptions to a patient, the physician should document the clinical justification for not providing prescriptions in the patient's medical record. When asked, the facility administrator confirmed that some medications cannot be stopped abruptly for medical or behavioral indications and to withhold prescriptions without a clinical justification is not safe. The facility administrator stated that this was a problem that needed to be addressed with the physicians.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of patient records, facility policies, and staff interview, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient as,
(1) medications were not administered as ordered for a patient with multiple medical and behavioral diagnoses, despite the patient informing nursing staff and the patient ' s practitioner;
(2) a patient making suicidal statements was not assessed by theand the practitioner was not notified; and
(3) the Patient " Observation Record " forms were incomplete as the correct observation levels as ordered by the patient ' s practitioner were missing and observation levels were documented that were not ordered by the practitioner. There was no way to confirm that the mental health techs knew the observation level for their assigned patients.
These deficient practices had the potential to affect all patients.

Findings were:

Review of the record for Patient #13 revealed that she was admitted on [DATE] at 2128 on voluntary status for depressed mood, mood instability, anxiety, and suicidal ideation.

Review of the Admission Assessment for Patient #13 on 7/22/13 at 22:10 revealed the typed question, " Is patient compliant with taking medications as ordered? " and the box for " Yes " is indicated by handwritten mark. Review of the list of the patient ' s current medications revealed the last dose the patient had taken as of 7/22/13 at 22:10 for the following medications:
Trazodone (antidepressant)- last dose was " last night "
Clonazepam (anxiety medication)- last dose " last night "
Hydroxyzine (anxiety medication)- last dose " AM today "
Metformin (diabetic medication)- last dose " AM today "
Proventil Inhaler (asthma medication)- last dose " AM today "
Vesicare (urinary incontinence medication)- last dose " Last night "
Pantoprazole (gastroesophageal reflux disease medication)- last dose " Last night "
Cosartan Potassium (high blood pressure)- last dose " AM today "
Glipizide ER (diabetic medication)- last dose " AM today "
Lyrica (nerve pain medication)- last dose " AM today "
Quetiapine (antipsychotic medication)- last dose " Last night "
Cymbalta (antidepressant medication)- last dose " 3 or 4 days ago "
The nurse documented " Pt has been compliant with medications. However, ran out of Cymbalta " 3 or 4 days ago " & ran out of gas & therefore unable to refill prescription. "

The physician ordered Advair, Protonix, Cozaar, Vesicare, Glipizide, Aspirin, Seroquel, Metformin, Klonopin, and Cymbalta for asthma, hypertension, neuropathy, diabetes, gastroesophageal reflux disease, urinary urge incontinence, depression, mood irritability, and anxiety. Patient #13 signed medication consents for psychoactive medications, including Cymbalta, Ativan, Atarax, Haldol, Benadryl, Clonazepam, Seroquel, and Trazadone.

Review of the Medication Administration Record for Patient #13 revealed the following medications and treatments were not initialed for the 0900 dose on 7/23/13 indicating the medications were not administered as ordered:
Advair 1 puff BID 100/50
Protonix 40 mg PO Q am
Cozaar 25 mg PO daily
Vesicare 10 mg PO daily
Glipizide ER 5 mg PO TID with meals
Aspirin 81 mg PO daily
Metformin 850 mg PO BID
Klonopin 0.5 mg po BID Anxiety
Cymbalta 60 mg PO Daily
Seroquel 100 mg PO Q am
Accucheck AC & HS (blood sugar check before meals and at bedtime)
There was no documented evidence that the above medical and psychoactive medications were administered as ordered. There was no documented evidence that the practitioner for Patient #13 was notified that the patient did not receive the above medications.

Review of Multidisciplinary Progress Notes for Patient #13 dated 7/23 (untimed), stated, in part, " Pt requested to leave. CM [Case Management] spoke with pt and asked her what was wrong. Pt stated that she hadn ' t had any of her medications since she was admitted . CM checked on her medications, they had not been processed yet. The pt was given medication within the hour. Pt calmed down and stated she would stay after talking with CN and CM. "

Review of Daily Nursing Assessment for Patient #13 for the 7-3 shift on 7/23/13 revealed it was written at 1700. The assessment stated, in part, " Medication Compliance: pt states she is not getting her medication ...The patient is upset she is not getting the right medications. She requests AMA and is referred to CM ... " The handwritten documentation continues for 4 more lines, but is illegible. In an interview with the writer of the note, Staff #9, an RN, the afternoon of 8/14/13, he read aloud the illegible note. There was no mention by Staff #9 of the patient receiving her ordered medications at 0900 on 7/23/13. There was no assessment by Staff #9, an RN, of the patient ' s request for discharge related to not getting her medications, no evidence that the patient ' s medications were reviewed with her. The practitioner for Patient #13 was not notified that patient #13 did not receive her medications as ordered. This was confirmed during the interview with Staff #9.

Review of the Psychiatric Evaluation for Patient #13 dictated at 13:46 on 7/23/2013 stated, in part, " She claims to have been compliant with her medications as an outpatient; however, it is shown that she has been off of her Cymbalta at least recently ...She is quite agitated at this time ...At this point, she basically tells me that all of her problems are our fault and that she is upset with us and does not understand why we would not just let her go. "

Review of the MHT Daily Note for Patient #13 at 1400 at 7/23/13 stated, in part, Pt became upset and said she was leaving and going to go home and die since no one cared. Charge nurse is aware. "

Review of the Medication Administration Record for Patient #13 on 7/24/13 revealed that she was to receive Glipizide XL 5 mg and Metformin 850 mg at 0700. Patient #13 was to receive Omeprazole 20 mg, Vesicare 10 mg, Losartan Potassium 25 mg, Cymbalta 60 mg, Seroquel 100 mg, Advair inhaler, and Clonazepam 0.5 mg at 0900. All the above medications are initialed as having been given.

However, review of Multidisciplinary Progress Notes for Patient #13 dated 7/24 at 930 stated, in part, " Pt requested to leave again this morning. CM spoke to pt about why she wanted to leave. Pt reports not getting her medication. CM checked her medication records and saw she received (sic) 3 medications. CM confronted pt and pt stated that there was one she wanted that she didn ' t get. CM did not see that medication on the list. CM explained to pt and pt became upset and started to raise her voice. Pt stated she wanted to leave so get her the ' damn paperwork now. ' "

The documentation by the case manager reflected that at 0930, the patient had not received her 0900 medications on 7/24/13, despite the initials for the 0900 medications on the MAR.

Review of the " Request for Release " form signed by Patient #13 on 7/24/13 at 10:00 am revealed the patient had handwritten, " I have not been treated with respect or giving (sic) my right meds since I got here this 2nd time. "

Review of the Physician ' s Daily Progress Note for Patient #13 on 7/24/13 at 1300 stated, " Pt is irritable, denies SHI
c/o having to wait one day for medications
Pt requests AMA discharge
Pt not direct threat to self/others
Pt may D/C AMA today. "

Review of the Discharge Summary for Patient #13 dictated 7/24/13 at 13:20 stated, in part, " The patient was admitted to the unit and exposed to therapeutic milieu. We have reinstated her medication ...She was not willing to cooperate with treatment. She was stating that we were incompetent and unable to handle her problems. She asked to be discharged last evening as an AMA discharge ...There is no evidence of overt psychosis. "

Review of facility policy #PC69 AMA Discharge Policy, issued 7/2013 stated, in part, " A well-informed patient who is treated with dignity and respect will gain trust in the hospital staff and may be less likely to request early discharge against medical advice ...
4.0 After a Request for Early or AMA discharge
4.1 If patient requests discharge verbally, staff should explain the facility ' s procedure for early discharge request. If the patient is on formal voluntary status, he/she may complete a Request for Release form. This form should also be signed, and the date and time noted, by the staff person receiving the request. Staff receiving the request for discharge should document the request and reason for the request in the medical record ...
4.3 Interventions that may be utilized to assist the patient in completing the recommended course of inpatient treatment include, but are not limited to the following: ...
4.3.1 Meet individually with the patient to discuss the reason for the discharge request and work collaboratively with the patient to address issues that may be presented ... "

In an interview with Staff #1, the Director of Nursing, and Staff #9, Assistant Director of Nursing, at 5:20 pm on 8/14/13 in the conference room, the record for Patient #13 was reviewed. When the surveyor pointed out that there was no documented evidence in the Medication Administration Record or the nurses notes that Patient #13 received her 0900 medications on 7/23/13, Staff #1 stated, " we didn ' t have those medications in stock. "
In reviewing the list, the surveyor questioned whether specific medications ordered, such as aspirin and Seroquel were truly not available at the hospital; Staff #1 stated that those medications were available.
Staff #1 confirmed that the patient had signed consents and that there was no documentation by nursing staff in the Medication Administration Record or Daily Nursing Assessment that the patient received her 0900 medications as ordered.
When asked by the surveyor about the practice and expectation of a nurse at the facility when medications were not available, Staff #1 and Staff #9 confirmed that the nurse should have contacted the practitioner to make them aware when medications were not available and see if substitutions should be ordered, especially for high blood pressure, diabetes, and other medical conditions. Staff #9 stated, " That sounds bad; it says the case manager confronted her when we didn ' t give her [Patient #13] her meds like she said. "

Staff #1 and Staff #9 confirmed the above findings for Patient #13 the afternoon of 8/14/13 in the facility conference room.

Review of the MHT Daily Note for Patient #13 at 1400 at 7/23/13 stated, in part, " Pt became upset and said she was leaving and going to go home and die since no one cared. Charge nurse is aware. " There is no documented evidence of a nursing assessment for this patient related to this reported comment. The 7-3 shift nursing assessment for Patient #13 was documented on 7/23/13 at 1700 on the Daily Nursing Assessment. Staff #9, the RN, documented for Treatment Plan Problem Review, Problem: " Self-harm (SI) - None observed. " In the narrative portion of the note, Staff #9 documented " The patient is upset she is not getting the right medications. She requests AMA and is referred to CM. " The remainder of the note is predominantly illegible. In an interview with the writer of the note, Staff #9 the afternoon of 8/14/13, Staff #9 read aloud the note and there was no mention of an assessment related to the documented comment that the patient stated she was " going to go home and die. " There was no documented assessment by Staff #9, an RN, of the patient ' s request for discharge, no evidence that the patient ' s medications were reviewed with her, or an offer for the patient to complete the " Request for Release " form. There was no documentation that the practitioner for Patient #13 was notified of the patient ' s statement.

The above findings were confirmed in an interview with Staff #1 and Staff #9 the afternoon of 8/14/13 in the facility conference room.

Review of the medical record for Patient #13 revealed an admission observation level order for " Close Observation " on 7/22/13. There was no documented order for precautions for Patient #13. Review of the record for Patient #13 revealed the following incorrect and inconsistence documentation of observation monitoring:
7/22/13 from 2210 until 2345, the " Observation Record " form had no Observation Level or Precautions indicated. There was no check mark in any of the following observation levels, Close, LOS [Line of Sight] Continuous, LOS while awake, 1:1 continuous, or 1:1 while awake, to inform the staff monitoring the patient the level of observation for the patient who was admitted for suicide ideation and severe depression.

Review of the record for Patient #3 revealed an admission observation level order for " Close Observation " on 5/23/13. There was no documented order for precautions for Patient #3 throughout the admission. There was no documentation on the Observation Record form to inform the staff monitoring the patient which observation levels the patient was on: Close, LOS [Line of Sight] Continuous, LOS while awake, 1:1 continuous, or 1:1 while awake. The patient was admitted for suicide ideation and severe depression. Review of the record for Patient #3 revealed the following incorrect and inconsistence documentation of observation monitoring:

5/23/13 - Patient admitted at 2035.
There was no Observation Record form for 5/23/13 in the medical record. There were 2 Observation Record forms in the medical record dated 5/24/13.
Night Nursing Assessment 11-7 form stated, Level of Observation: 15 min; Precaution: SP [suicide precautions], SI [suicidal ideation], Dep mood [depressed mood]. There was no documented order for the above precautions of SP, SI, Dep mood.

5/24/13 -
Observation Record form had no Observation level indicated.
Nursing Shift note for 7-3 had no Special Precautions indicated.
Nursing Shift note for 3-11 had no Special Precautions indicated.
Night Nursing Assessment 11-7 form stated, Level of Observation: 15 min; Precaution: SI, Dep mood, Sub abuse [substance abuse]. There was no documented order for the above precautions of SI, Dep mood, Sub abuse.

5/25/13 -
Nursing Shift note for 7-3 had no Special Precautions indicated.
Nursing Shift note for 3-11 had no Special Precautions indicated.
Night Nursing Assessment 11-7 form stated, Level of Observation: 15 min; Precaution: SI, Dep mood, Sub abuse.
There was no documented order for the above precautions of SI, Dep mood, Sub abuse.
5/26/13 -
Observation Record form had no Observation level indicated.
Nursing Shift note for 7-3 had Special Precautions indicated and " EDO " [Emergency Detention Order] incorrectly documented as the patient was on voluntary status.
Nursing Shift note for 3-11 had no Special Precautions indicated.
Night Nursing Assessment 11-7 form stated, Level of Observation: 15 min; Precaution: SI, Dep mood, Sub abuse. There was no documented order for the above precautions of SI, Dep mood, Sub abuse.

5/27/13 -
Observation Record form had no Observation level indicated.
Nursing Shift note for 7-3 had Special Precautions indicated and " EDO " [Emergency Detention Order] incorrectly documented as the patient was on voluntary status.
Nursing Shift note for 3-11 had Special Precautions indicated and " EDO " [Emergency Detention Order] incorrectly documented as the patient was on voluntary status.
Night Nursing Assessment 11-7 form stated, Level of observation: not checked; Precaution: SI, Dep mood, Sub abuse.

5/28/13 -
Observation Record form had no Observation level indicated.
Nursing Shift note for 7-3 had Special Precautions indicated and " EDO " [Emergency Detention Order] incorrectly documented as the patient was on voluntary status.
Patient discharged at 1505.

Review of facility policy # PR.5, Court Ordered Mental Health Services, last revised 02/13, stated, in part, " e. NOTE: On Admission, a physician must write a unit restriction order for all involuntary patients. The charge nurse should notify all staff of the unit restriction order. "

Review of the medical record for Patient #3 correctly revealed no unit restriction order, as Patient #3 was a voluntary patient; however the documentation reflected that for 4 shifts, the nurse incorrectly documented that Patient #3 was under court ordered mental health services, " EDO " , which is a stricter observation level, thereby potentially restricting the patient ' s rights without an order.

Review of facility policy #PC.22, Observation Levels, last revised 6/13, stated, in part, " 2.0 An order for the appropriate level of observation and precautions should be documented in the physician ' s order section of the medical record, and the Observation Flow Sheets should be initiated by the charge nurse or designee ....6.0 A physician order is required to increase, continue, decrease or discontinue a level of observation and special precaution level. This order should not be a telephone or verbal order and should be accompanied by a progress note by the physician, within 24 hours of the order, with the rationale regarding the order for the observation or special precaution ...13.2.2 A Physician's order is necessary for the initiation, continuation and discontinuation of unit restriction. "

The above findings were confirmed in an interview with the facility Director of Nursing the afternoon of 8/14/13 in the facility conference room.





A review of patient medical records revealed that for 6 of 20 patients [patients #1, 3, 12, 14, 15, and 16] the facility failed to follow patient precaution and observation levels according to facility policy.

Facility policy #PC.22 entitled Observation Levels, last reviewed 3/13, stated in part, "A Level of Observation is defined as an intensified level of staff awareness and attention to patient safety/security needs requiring the initiation of specific protocols and supplemental documentation ... Note: This guideline is in addition to but does not replace special precautions procedures for Suicidal patients, Elopement Precautions, Fall Precautions, Seizure Precautions, Assault Precautions, etc ...
2.0 An order for the appropriate level of observation and precautions should be documented in the physician ' s order section of the medical record, and the Observation Flow Sheets should be initiated by the charge nurse or designee. The physician should be contacted within 1 hour to obtain verbal order for observation or special precaution. Initiation of precautions should be documented in the physician orders specifying date, time and level of observation.
A licensed nurse or designee should ensure that all patient orders for special precautions are recorded and posted per facility policies and procedures.
3.0 Reassessment by a physician should be completed and documented every 24 hours (or as noted in specified policy) with clinical justification for renewal, modification, or discontinuation of orders for special precautions.
4.0 The registered nurse should address the status of the patient on special precautions in the progress notes as outlined below for the level of observation and precaution initiated ...
6.0 A physician order is required to increase, continue, decrease or discontinue a level of observation and special precaution level. [Facility's bold] This order should not be a telephone or verbal order and should be accompanied by a progress note by the physician, within 24 hours of the order, with the rationale regarding the order for the observation or special precaution.
7.0 Prior to the patient ' s discharge, the physician must substantiate in the medical record that the potential for high risk behavior no longer exists, or exists at a level that can be safely managed at a lower level of care."

Facility policy #PC.67 entitled Precautions, stated in part, "A precautionary measure and/or level that determine [sic] the minimum frequency of nursing observation and degree of independent activity within the behavioral milieu will be ordered for each patient ...The physician documents the initiation, termination, and reason for all precautions ...
1. Aggressive Behavior Precautions - Patients that present themselves as a danger to others, either by threats or physical actions, will be placed on aggressive behavior precautions: ...Patients on aggressive behavior precautions will be placed on unit restriction. This will be documented in the multidisciplinary notes and will be discontinued by physician ' s order only ...The Treatment Team will review the precautions as well as any restriction and bed assignment concerns for the patient at least weekly. The patient ' s precaution status shall be communicated to all staff responsible for the care of the patient...
2. ...
3. Suicide Precautions: Patients at risk of harming themselves will be monitored to the degree that is clinically appropriate: ...Suicide observations ...will not be discontinued without a physician's order..."


Review of patient #1's clinical record revealed the following inconsistencies regarding precaution and observation levels among staff and among shifts:
Daily Nursing Assessments for the patient from 5/5/13 through his discharge date of [DATE] on 7a-3p and 3p-11p shifts had "No" checked by the phrase "Special Precautions" indicating no precautions for the patient.
Night Shift Nursing Assessments (11p-7a shift) for the patient indicated the following special precautions:
? 5/6 SP [Suicide Precautions], HI [Homicidal Ideation], Agg [Aggression]
? 5/7 SP, AAO [Aggressive Acting Out], HI, Self-Harm
? 5/8 SP, AAO, Self Inj, HI
? 5/9 SP, AAO, Self-Harming, HI
? 5/10 - 5/23 SP, Self Harm, HI
Mental Health Technician Observation Records for patient #1 for all shifts revealed the following precautions checked:
? 5/5 Agg, HI
? 5/6 Suicide, Agg, HI
? 5/7 none
? 5/8 Suicide, Agg
? 5/9-5/11 none
? 5/12 Suicide, Agg, HI
? 5/13 Suicide, HI
? 5/14-5/15 Suicide, Agg, HI
? 5/16-5/19 Suicide, Agg
? 5/20-5/23 Suicide, Agg, HI
There were no Physician's Orders regarding patient #1's precaution levels at Acadia Abilene between the dates of 5/9/13 and 5/20/13. There were no nursing notes reflecting changes in precaution levels. There was no evidence in patient #1's chart that the physician documented that the patient's high risk behaviors no longer existed prior to discharge.

Review of the medical chart for patient #14 revealed the following precautions noted on the Observation Records for the mental health technicians (MHTs):
8/5/13-8/9/13 no precautions, though there was a MHT note on 8/9/13 stating
patient was trying to choke himself
8/10/13-8/12/13 AAO [Aggressive Acting Out] checked
8/13/13 no precautions, but Line of Sight [LOS] while awake observation
level checked
Daily Nursing Assessments for 7a-7p shifts and 7p-7a shifts indicated the following:
8/6/13 special precautions "no" checked
8/7/13 7a-7p shift: blank 7p-7a: special precautions "no" checked
8/8/13-8/11/13 special precautions "no" checked
8/12/13 7a-7p shift: blank 7p-7a: special precautions "no" checked
8/13/13 7a-7p shift: LOS checked 7p-7a: special precautions "no" checked
Reason: SI [Suicidal Ideation]
(there is no other nursing note regarding this)
A Physician's Order on 8/12/13 at 7:30 a.m. stated, in part "LOS w/a [while awake] for SI/Self harm." This was the only order addressing precautions or observation levels.
A Physician's Note on 8/12/13 for patient #14 at 5:20 p.m. stated, in part "expressed SI this weekend and today; attempted to choke himself this weekend several times..."

A review of patient #15's medical chart revealed the following from the MHT Observation Records:
7/19/13-8/9/13 no precautions
8/10/13 AAO
8/11/13 no precautions
8/12/13 AAO
8/13/13 no precautions
Daily Nursing Assessments for patient #15 showed the following:
Special precautions "no" checked for both the 7a-7p and 7p-7a shifts with the following exceptions:
7/23/13 7p-7a shift: no assessment sheet at all; form completely blank
7/25/13 7a-7p shift: blank
7/30/13 7a-7p shift: LOS for falls
7/31/13 7a-7p shift: blank
8/3/13 7a-7p shift: blank
8/7/13 7a-7p shift: blank
8/9/13 7p-7a shift: blank
8/12/13 7a-7p shift: blank
8/13/13 7a-7p shift: blank
There were no precaution or observation level orders for patient #15 available in the patient record.

Review of patient chart #16 revealed the following:
MHT Observation Records with the following special precautions checked:
7/11/13-7/12/13 SAO [Sexually Acting Out] and LOS w/a [Line of Sight while awake]
7/13/13-7/18/13 SAO, AAO, LOS w/a
7/19/13 SAO, AAO
7/20/13-7/21/13 SAO, AAO, LOS w/a
Note on 7/21/13 at 12:18 p.m.: "punched [peer] in jaw ..."
Note on 7/21/13 at 5:49 p.m.: "outside on patio patient fell ..."
7/22/13-7/23/13 No precautions checked
7/24/13 Note at 7:00 a.m.: "LOS w/a by Dr. Parrott" signed by MHT
No other precautions checked
7/25/13 SAO, LOS w/a
7/26/13 SAO, LOS and close observation checked [conflicting]
7/27/13-8/1/13 SAO, AAO, LOS w/a
8/2/13-8/7/13 SAO, LOS w/a
8/8/13-8/9/13 SAO, LOS w/a, UR [Unit Restrictions]
8/10/13 SAO, AAO, LOS w/a, UR
8/11/13 SAO, AAO, UR
8/12/13 SAO, AAO, LOS w/a, UR
8/13/13 blank
Daily Nursing Assessments showed the following by the phrase "special precaution" on the form:
7/14/13 7a-7p shift: SAO
7/15/13 7a-7p shift: "no" checked
7/16/13 7a-7p shift: "yes" checked with reason: "behavior"; no type
7p-7a shift: "yes" checked with reason: "past behavior"; no type
7/17/13 7a-7p shift: "no" checked
7p-7a shift: SAO as type and written reason: "inappropriate comments"
7/18/13 7a-7p shift: SAO as type and written reason: "accusations at home"
7p-7a shift: SAO as type and written reason: "poor behavior"
7/19/13-7/23/13 "no" box checked on special precautions on both shifts
7/24/13 7a-7p shift: SAO and LOS w/a
7p-7a shift: "no" box checked on special precautions
7/25/13 both shifts: SAO and LOS
7/26/13 both shifts: LOS w/a
7/27/13 7a-7p shift: SAO and LOS w/a
7p-7a shift: SAO, Agg, LOS w/a
7/28/13 both shifts: SAO and LOS w/a
7/29/13 7a-7p shift: SAO, Agg, LOS w/a
7p-7a shift: form completely blank
7/30/13 7a-7p shift: LOS w/a
7p-7a shift: SAO, Agg, LOS w/a
7/31/13 both shifts: LOS
8/1/13 both shifts: LOS, SAO
8/2/13 both shifts: LOS w/a
8/3/13 7a-7p shift: SAO, AAO
7p-7a shift: SAO, Agg, LOS w/a
8/4/13 7a-7p shift: SAO, LOS w/a
7p-7a shift: LOS w/a, Aggression
8/5/13 7a-7p shift: SAO/AAO
7p-7a shift: LOS w/a, Aggression
8/6/13-8/7/13 No Nursing Assessment sheets found
8/8/13 7a-7p shift: LOS
7p-7a shift: LOS w/a, SAO
8/9/13 both shifts: LOS w/a, SAO
Physician's Orders regarding precautions and observation levels for patient #16 during his stay at Acadia Abilene were as follows:
7/12/13 1030 "LOS w/a for 24 hours (SAO); blocked room (SAO)"
7/15/13 1100 "Renew blocked room
Renew LOS w/a for SAO"
7/20/13 1000 "Discontinue unit restrictions"
7/22/13 1500 "Blocked bed due to SAO/aggression
Discontinue LOS; close obs status"
7/24/13 1310 "LOS w/a for aggression"
1500 "Discontinue blocked bed - no overt SAO in house
Continue LOS w/a for aggression as above"
7/29/13 "Continue LOS while awake; aggression"
8/8/13 1440 "Unit restriction for bullying behavior"
8/9/13 1645 "Renew unit restriction with cafeteria privileges"
8/12/13 no time "Take patient off unit restriction"
No other physician orders were available in the patient chart regarding precautions or observation levels.

In an interview with the LVN of the children's Miller Unit and the adolescent Focus Unit [staff #5] on the afternoon of 8/14/13 on the adolescent unit, when asked if she felt precaution/observations levels were communicated well, she said, "No. Honestly, I don't feel like levels are communicated. The next shift comes in and it's all new."

The above findings were confirmed in an interview with the facility CEO and other administrative staff the evening of 8/14/14 in the facility conference room.