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.

BEHAVIORAL HOSPITAL OF LONGVIEW 22 BERMUDA LANE LONGVIEW, TX Aug. 4, 2015
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Observe, monitor, and protect the patients from harm resulting in the death of 1 (#1) of 10 patients reviewed. The nurse's notes and 15 minute observation status records had multiple discrepancies on where and what the patients were doing. There were minimal or no nursing interventions documented to alleviate potential volatile situations, resulting in injury to 1 (#2) of 10 patients reviewed. Review of 2 (#1, #4) of 10 patients revealed the staff allowed patients to have volatile outbursts and go into a closed door room and remain there without observation or intervention.

1. Review of the patient #1's medical record revealed she was a [AGE] year old white female that was a voluntary admission on 7/9/2015. Patient #1 was admitted with a diagnosis of major depressive disorder, recurrent episode, and unspecified anxiety disorder. Patient #1 had a history of prior suicide attempts and was placed on suicidal precautions with an every 15 minute observation level. Patient #1 was placed in the high risk room next to the nurse's station.

Review of the Suicide/Harm Risk Assessment sheet was blank.

Review of Patient #1's chart revealed she had a session with the nurse practitioner (NP) on 7/20/2015 at 4:20PM. The NP documented "Pt reports" mood up and down "and irritable and" had my first outburst here." Trilepal to increase per physician. AIOx4 and ambulatory. Denies any suicidal or homicidal ideation. Denies Auditory or visual hallucinations."

Review of the physician progress notes revealed she was seen by a psychiatrist two days later on 7/23/2015 at 6:30 PM. The psychiatrist documented patient #1 was tearful and taking medication without side effects.

Review of the Q (EVERY)15 minute observation status sheet the Mental Health Technician (MHT) had documented at 6:00PM the patient #1 was eating in the lounge, at 6:15PM the patient was on a smoke break, 6:30PM outside on the patio, and from 6:45PM- 10:15PM patient was in her room. The observation sheets have a large discrepancy of the patients where bouts according to the psychiatrist and nursing notes.

Review of the nurse's and MHT notes on 7/23/2015 revealed the following;

1.) 8:05PM the nurse's note revealed the patient was calm and pleasant. Patient #1 denied any suicidal or homicidal ideation's and daily nursing assessment was completed.

Review of the Q (EVERY) 15 minute observation status sheet revealed from 8:00pm- 8:45PM that the patient was in her room lying down with eyes open.

2.) 8:20PM staff #10 documented, "Pt. in day area. This nurse heard pt. yell "fuck this place!" Pt ambulated to room and slammed the door shut. This nurse attempted to engage with pt. Pt states, "leave me alone! I don't want to deal with anyone right now!" this nurse offered emotional support when patient felt ready to talk. Pt voiced understanding. Will continue monitor."

Review of the "Q (EVERY) 15 minute observation status sheet" revealed from 8:00PM- 8:45PM Patient #1 was in her room lying down with eyes open. There was no documentation from the MHT of Patient #1 leaving her room or the described outburst documented by the nurse.

Review of the Medication Administration Record in Patient #1's chart revealed on 7/23/2015 at 8:00PM medications had an "R" circled next to them. There was no documentation the medications were ever administered or why the patient #1 refused.

3.) 8:27PM staff #10 (RN) documented, "Pt at coffee table in day area, throwing coffee on wall and table. This nurse inquired as to what caused pts brief outbursts. Pt. walked away from this nurse stating, "Don't you talk to me right now! I just want to be left alone" this nurse respected pt. boundaries. Pt walked to her room and slammed the door. Will continue to monitor." There was no further documentation found of interventions or close observation with this significant behavioral change.

Review of the "Q (EVERY) 15 minute observation status sheet " revealed from 8:00PM- 8:45PM Patient #1 was in her room lying down with eyes open. There was no documentation from the MHT of Patient #1 leaving her room or the described outburst documented by the nurse.

4.) 9:05PM Staff #10 (RN) documented, "Pt. in day area, helping this nurse clean coffee from floor. This nurse attempted to engage pt., asking if she wanted to talk to about what was bothering her. Pt. shook her head and continued to help organize coffee table. This nurse offered emotional support when pat felt ready to talk. Pt. voiced understanding will continue to monitor."

Review of the "Q (EVERY) 15 minute observation status sheet" revealed from 9:00-9:15PM the patient was in her room using the bathroom.

5.) 9:25PM staff #10 (RN) documented, "Pt. standing at nurse's station. Pt. initiated conversation with this nurse. Pt states, "I just want to go home. I thought I was going home this week. I don't belong here. It's so noisy. I just want to go home and see my son." This nurse offered emotional support and active listening. Pt. at times smiled and laughed during conversation. No intention of self-harm indicated. Pt states, "I'll be fine." Will continue to monitor.

Review of the "Q (EVERY) 15 minute observation status sheet" revealed from 9:30PM - 10:00PM patient #1 was in her room yelling/screaming/verbal threats.

Patient #1 had requested to go home and a four hour discharge notice was not found in the chart. There was documentation that the physician was ever called concerning a voluntary patient requesting to leave. There was no order found to hold the patient for psychiatric evaluation.

6.) 9:40PM staff #10(RN) documented, "Pt sitting in day area watching TV by herself. This nurse attempted to engage the patient. Pt stated, "I just want to sit here right now. I don't want anyone messing with me. I'm fine I just want to be left alone." Pt. is currently calm and somewhat tearful. This nurse urged pt. to notify staff of any SI/HI or thoughts of self-harm. Pt states,"ok" will continue to monitor.

Review of the "Q (EVERY) 15 minute observation status sheet" revealed from 9:30PM - 10:00PM patient #1 was in her room yelling/screaming/verbal threats.

7.) 10:00PM staff #10 was asked by Patient #1 to unlock her room so she could go to bed.

An interview with the staff RN on 8/4/2015 stated, " The patient rooms lock from automatically when the door is completely closed. The staff have to go unlock the doors to let them in their rooms."

8.) 10:15 PM The med nurse, staff #6 (LVN), entered the patient's room to dispense nighttime medications. Staff #10 (RN) documented, "Med nurse could not see pt. in her room without entering by himself. Med nurse notified MHT's."

Review of the "Q (EVERY) 15 minute observation status sheet" revealed the patient was in her room lying down at 10:15PM.

9.) 10:20PM Staff #10 (RN) documented, "MHT's and med nurse notified this nurse that pt. had "hung herself " in her room. This nurse observed pt. facing the wall, kneeling between two wardrobe armoires with a twisted bed sheet wrapped around her neck. This nurse immediately unwrapped pt. and began CPR."

CPR was started, the house supervisor was contacted and an AED was applied. At 10:24PM 911 was called. At 10:30 EMS arrived and took over. The patient was taken to Longview Regional Hospital and died on [DATE].

An interview was conducted with Staff #10 (RN) on 8/4/2015. Staff #10 reported that Patient #1 had gone in to talk to the psychiatrist a during shift change. When Patient #1 came out of the session she started yelling and cursing. Staff #10 reported the others went out to smoke but patient #1 stayed in. Patient #1 then threw hot coffee on the wall and started cursing. Staff #10 reported Patient #1 went to her room and slammed the door. Staff #10 reported she tried talking to the patient but denied any other interventions were attempted. Staff #10 reported the patient was allowed to leave the dayroom and close the bedroom door during these emotional outbursts.

Staff #10 reported when she saw the patient hanging from the bed sheet it took some time to get her down. Staff #10 stated, "I have never seen any cut down shears until this incident. Now we have them in the locked medicine cabinet." Patient #1 had wrapped her neck around in a sheet and tied it in-between two armoires in the room. The patient was kneeling into the sheet. When they untied patient #1 from the sheet she thought she heard the patient moan. There was no pulse or respirations. CPR was started.

Staff #10 was asked how often the 15 minute checks were done at night and she stated, "We go through a few times at night to check on them but not every 15 minutes."

An interview was conducted on 8/4/2015 with Staff #6 (LVN). Staff #6 confirmed he was the medication nurse for Patient #1 on 7/23/2015.

Staff #6 reported that he was in the medication room around 10:00PM setting up some night time medications. Patient #1 came to the desk requesting her 8:00PM medications. Staff #6 reported he told Patient #1 he would get them together and bring them to her. Staff #6 reported he went to Patient #1's room and he did not see her. He could see into the bathroom and patient #1 was not there. Staff #6 reported he called out Patient #1's name and she did not answer. Staff #6 stated he did not go into the room without another female. Staff #6 stated he walked back up to the nurse's station and had a MHT go in the room to look with him. Staff #6 reported when he walked in the room he found the patient hanging from a sheet. Patient #1 had twisted the ends of the sheets and tied them to metal brackets holding the armoires flush to the wall. The patient had wrapped the sheet around her neck and had kneeled into the sheet. Staff #6 and staff #7 (MHT) worked on getting the patient down while the female MHT went to get the RN. Staff #6 and the RN started CPR.





2.) Review of patient #4's chart revealed the patient was a [AGE] year old white female, admitted to the facility on [DATE], with a diagnosis of Bipolar I disorder. Patient #4 came in on an Emergency Detention Warrant (EDW). Patient #4 was suicidal and stated she had a plan to overdose on prescription medication. Review of the Nursing Admission Assessment under Reason for Admission patient #4 stated, "Had a fight with my brother in law. I threw some things and we began to fight. I became depressed and said I would take 10 sleeping pills."
Review of patient #2 chart revealed a [AGE] year old female admitted for Bipolar, Depression, and alcohol withdrawl.
Review of patient #4's chart revealed on 5/19/2015 patient #4 had a behavioral outburst with psychiatrist and mother on a conference call. Review of the nurses notes dated 5/19/2015 at 2:45PM stated, "pt. became agitated left office, throwing things, cursing, Dr. M_____ on unit. Pt agrees needs something to calm her. Pt stated, "upset with mother." New order Haldol 10mg IM/ Ativan 2 mg IM given."
Review of the physician orders on 5/19/2015 at 2:40PM stated, "Haldol 10mg IM Now and Ativan 2 mg IM Now." There was no documentation found of any nursing interventions to redirect or calm the patient before medication administration.
Review of the "PRN ASSESSMENT AND NARRATIVE" sheet dated 5/19/2015 at 3:30PM stated, "Pt continues to have loud outbursts when talking to peers will continue to monitor. 4:30PM Pt. in dayroom, med effective."
Review of the "Q (EVERY) 15 minute observation status" sheet the Mental Health Technician (MHT) had documented on patient #4 on 5/19/2015. The following statements are as follows;
1.) 2:00PM In recreational therapy.
2.) 2:15PM yelling, screaming, verbal threats- Treatment Team.
3.) 2:30PM yelling, screaming, verbal threats.
4.) 2:45PM Patient in the Solarium
5.) 3:00PM Recreational Therapy
6.) 7:00PM the patient was in the lounge
7.) 7:15PM yelling, screaming, verbal threats. Angry. Aggressive.
There was no documentation found of patient intervention at 7:15PM on 5/19/2015.
Review of patient #4's nurses notes dated 5/19/2015 at 7:20PM stated, "Informed by male MHT that pt. #4 lunged at another pt.(#2) and hit her on R side of forehead. Patient #4 put in safety hold and separated from other patient. Patient #4 is agitated and cursing loudly. At 7:25PM pt. #4 offered Ativan 1mg po prn as ordered for anxiety/agitation. Pt. consented to take medication. Will continue to monitor."
7:27PMPt. #4 placed on 1:1 observation (one employee to one patient at arm's length) for safety. Pt redirected to sit next to nurses station will continue to monitor.
Review of patient #4's nurses notes revealed at 7:27PM patient #4 was placed on 1:1 observation (one employee to one patient at arm's length) for safety. Pt redirected to sit next to nurses station will continue to monitor. There was no documentation found of the patient's guardian notified of the 1:1 observation or physical altercation with another patient, any nursing interventions before offering more medication, or a physical assessment for any injuries after a hold or altercation.
Review patient #2's physician orders on 5/19/2015 revealed the patient was sent to the ER. The order stated, "Transport pt. to ER due to trauma to head further evaluation of injury." Patient #2 was transported to the ER on 5/19/2015 at 8:32PM.
Review of patient #2's chart revealed she returned from the ER with a diagnosis of a closed head injury. Patient #2 was brought back to the same unit with patient #4. Patient #2 was discharged the next day on 5/20/2015. Patient #4 was released from the 1:1 status on 5/20/2015.
Review of the incident report concerning the altercation between patient #2 and patient #4 revealed the following:
- Staff #13 (MHT) documented, "I witnessed patient #4 and patient #2 have a verbal altercation near the med room. Patient #4 told patient #2 to shut the f--- up singing. Patient #2 continued. At that time patient #4 took her jacket off and attempted to go after patient #2. This staff and staff #7 (MHT) redirected both patients before physical contact occurred. Several times I witnessed both patients making remarks towards one another and were redirected. "
-Staff #14 (LVN) documented, "On or about 5/19/2015 patient #4 was at med room getting meds when patient #2 walked up singing. Patient #4 rudely said why you don't shut the f--- up. She was verbally redirected when patient #2 starts to ask her what would happen if she didn't. Patient #4 turned as to strike patient #2, when two MHT's intervened and walked patient #4 away. From then on, the two ladies appeared not to care for each other. Patient #4 would be verbally aggressive while patient #4 while patient #2 would mumble just enough to aggravate patient #4."
Review of the incident report from the RN on 5/19/2015 revealed the patients #2 and #4 had an altercation. When trying to separate the patients staff #4 came back to the scene with a wet floor sign and tried to hit patient #2 with it but the RN intervened the sign. The RN stated, "I ran over once again to intervene by stepping between and grabbing the wet floor sign out of pats hand and lowering patient to the floor to keep her from harming herself, charge nurse was immediately notified and patient #4 was placed on a 1:1 by doctor orders, to keep both herself and others safe."
Interview with Staff #3 (RN/QAPI Director) on 8/4/2015 revealed the altercation between patient #2 was with patient #4. Staff #3 reported that patient #2 had difficulties with boundaries and personal space. Staff #3 reported that patient #2 was singing in patient #4's face. Patient #4 had warned patient #2 to back off. Patient #2 continued to antagonize patient #4. Patient #4 hit patient #2 with a closed fist.

The deficient practices were identified under the following Conditions of Participation and were determined to pose Immediate Jeopardy to patient health and safety, resulting in the death of patient #1, injury to patient #2, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death. The facility implemented corrective action as a result of the patient death to ensure patient safety. The corrective action was sufficient to abate the Immediate Jeopardy.
VIOLATION: THERAPEUTIC DIETS Tag No: A0629
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on chart reviews, policy and procedures the facility failed to assess, observe, and recognize the need for a therapeutic diet for 1(#2) out of 10(#1-10) patients reviewed.

Review of patient #1's chart revealed the patient was admitted to the facility on [DATE]. The patient has had a pacemaker with defibrillator place in the past and is on a medication called Coumadin a blood thinner. Patient #2 was placed on a detox protocol for alcohol withdrawal.

Review of patient #2 chart revealed the patient was admitted on Coumadin (an anticoagulant medication) due to a pacemaker and defibrillator. On 5/5/15 the physician ordered the patient to have a PT/INR blood test to determine if the patients Coumadin level was therapeutic.
Review of physician notes revealed Internal medicine (IM) was consulted and ordered to have "stat" labs done on 5/9/2015 to recheck the patients PT/INR. Reviewed lab results on 5/9/15 and the results were 16.2 H (range 9.9-14.9).
Review of the physician orders on 5/10/15 at 4:5PM read, "Lovenox (anticoagulant) to be 90mg SQ daily for anticoagulation. Increase Coumadin to 4mg po daily at 5:00PM for anticoagulation.
Review of the policy and procedure "Anticoagulation Guidelines" revealed the following;
A.) Staff responsibilities include monitoring patients for signs of adverse events such as bleeding, skin necrosis, purple toe syndrome, [DIAGNOSES REDACTED] and others.
D.) The nurse alerts the dietician to a patient on coagulant therapy.
E.) Dietary evaluates and determines any dietary restrictions.
F.) The treatment team adds the patient's diagnosis that meets the indication for anticoagulation therapy to the Treatment Plan and updates according to Treatment Plan reviews.
J.) There is ongoing assessment of the patient's response. Identification of any problem is evaluated by the physician, Nursing, Pharmacy and dietary using the following criteria:
1. Signs and symptoms of [DIAGNOSES REDACTED]
2. Change in condition requiring Warfarin therapy
3. Recent alterations in diet or medication.
4. Changes in other medical condition or illness
5. Compliance"
Review of the chart revealed there was no dietary consult ordered or addressed in the patients chart. Patient had been ordered a regular diet with no documentation of observation or teaching to the patient regarding foods to avoid on a Coumadin Diet.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Review of patient charts, interviews, and policy and procedures the facility failed to follow its own policy and procedures to monitor ongoing patient assessments regarding changes in medical conditions, and medications that could possibly be life threatening in 1(#2) out of 10 (1-10) charts reviewed.


Review of patient #2 chart revealed the patient was admitted on Coumadin (an anticoagulant medication) due to a pacemaker and defibrillator. On 5/5/15 the physician ordered the patient to have a PT/INR blood test to determine if the patients Coumadin level was therapeutic.

According to the National Library of Medicine, Warfarin (Coumadin) is used to prevent heart attacks, strokes, and blood clots in veins and arteries. It is important to monitor the therapeutic range of the medication through laboratory testing. Patients should be observed and evaluated due to this medication may affect blood clotting. The patient should avoid activities that may cause an increase in bleeding or injury.

Review of patient #2's lab results revealed the PT was 16.2 H (range 9.9-14.9). A physician order on 5/6/2015 at 1835 stated, "Coumadin 6 mg po q now x1. IM consult 5/7/2015."

Review of the nursing notes on 5/6/2015 revealed there was no documentation found concerning patient #2's increase in Coumadin or patient instruction of medication adjustment.

Review of physician notes revealed Internal medicine (IM) was consulted and ordered to have "stat" labs done on 5/9/2015 to recheck the patients PT/INR. Reviewed lab results on 5/9/15 and the results were 16.2 H (range 9.9-14.9).

Review of the physician orders on 5/10/15 at 4:5PM read, "Lovenox (anticoagulant) to be 90mg SQ daily for anticoagulation. Increase Coumadin to 4mg po daily at 5:00PM for anticoagulation.

Review of the policy and procedure "Anticoagulation Guidelines" revealed the following;
A.) Staff responsibilities include monitoring patients for signs of adverse events such as bleeding, skin necrosis, purple toe syndrome, [DIAGNOSES REDACTED] and others.
D.) The nurse alerts the dietician to a patient on coagulant therapy.
E.) Dietary evaluates and determines any dietary restrictions.
F.) The treatment team adds the patient's diagnosis that meets the indication for anticoagulation therapy to the Treatment Plan and updates according to Treatment Plan reviews.
J.) There is ongoing assessment of the patient's response. Identification of any problem is evaluated by the physician, Nursing, Pharmacy and dietary using the following criteria:
1. Signs and symptoms of [DIAGNOSES REDACTED]
2. Change in condition requiring Warfarin therapy
3. Recent alterations in diet or medication.
4. Changes in other medical condition or illness
5. Compliance"

Review of the nursing notes revealed there was no documentation found of nursing assessment for adverse reactions of the Coumadin or Lovenox. There was no nursing documentation found of patient instruction, dietary consult, or any assessments of possible hemorrhage. There was no documentation found of patient response to anticoagulation therapy.

Review of the nurse's notes on 5/15/2015 at 9:12PM stated, "Pt walked up to nurse and said she was coughing up blood. Assessment completed. Pt is A&O x4. Respirations even and unlabored. Pt c/o of chest pain. Physician called and new orders noted to send pt to the ER."

Review of the nurse's notes on 5/15/2015 at 9:12PM revealed the nurse checked a box under lung sounds, "crackles." There was no documentation found of what lobe had crackles or the patient's respirations. The nurse documented "bloody sputum." There was no documentation found describing bloody sputum, amount, if the nurse actually saw it, or just stated by patient #2.

Review of the ER discharge papers on 5/16/2015 revealed the patient was diagnosed with [DIAGNOSES REDACTED].

Review of the nurses notes for 5/17/2015 revealed patient #2 had clear lung sounds and there was no mention of antibiotic therapy or new diagnosis of [DIAGNOSES REDACTED]

Review of the physician consultation report revealed patient #2 was seen by the staff #15 nurse practitioner (FNP-C) on 5/19/2015 at 3:00PM.

Staff #15 stated, "The pt c/o bleeding from rectum. The pt reported small amount and just started today and worse with walking and movement. The pt reported previous coughing was "infection and not blood." states may be hemorrhoid and denies irritation. PT/INR pending at this time."

Review of the nurses notes for 5/19/2015 and 5/20/2015 revealed no documentation of rectal bleeding, assessment of rectal bleeding, and no discharge instructions of rectal bleeding on 5/20/2015.

Review of the nurse's notes for 5/19/2015 at 7:25PM stated, "MHT informed this nurse that pt. was struck on right side of forehead by peer. This nurse observed a red, raised area approximately 1-1/2 inches in diameter. Pt c/o pain and slight dizziness and nausea. Pt. assisted to feet and escorted to room for rest and safety. House Supervisor and MD notified. Will continue to monitor. 7:30PM Order received to transfer pt. to ER due to trauma to head and further evaluation of injury. HS notified. Will continue to monitor."

Review patient #2's physician orders on 5/19/2015 revealed the patient was sent to the ER. The order stated, "Transport pt. to ER due to trauma to head further evaluation of injury."

Patient #2 was transported to the ER on 5/19/2015 at 8:32PM.

Review of patient #2's chart revealed she returned from the ER on 5/19/15 with a diagnosis of [DIAGNOSES REDACTED]#2 was discharged the next day on 5/20/2015.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on patient charts, interviews, and policy and procedures, nursing failed to keep a current and ongoing treatment plan for new onset diagnosis, new medications, patient teaching, responses, interventions, and ongoing assessments to re-enforce an integrated, multi-faceted approach to the patients care in 1 (#2) out of 10 (1-10) charts reviewed.


Review of patient #2 chart revealed the patient was admitted on Coumadin (an anticoagulant medication) due to a pacemaker and defibrillator. On 5/5/15 the physician ordered the patient to have a PT/INR blood test to determine if the patients Coumadin level was therapeutic.

Review of patient #2's lab results revealed the PT was 16.2 H (range 9.9-14.9). A physician order on 5/6/2015 at 1835 stated, "Coumadin 6 mg po q now x1. IM consult 5/7/2015."

Review of the nursing notes on 5/6/2015 revealed there was no documentation found concerning patient #2's increase in Coumadin or patient instruction of medication adjustment.

Review of physician notes revealed Internal medicine (IM) was consulted and ordered to have "stat" labs done on 5/9/2015 to recheck the patients PT/INR. Reviewed lab results on 5/9/15 and the results were 16.2 H (range 9.9-14.9).

Review of the physician orders on 5/10/15 at 4:5PM read, "Lovenox (anticoagulant) to be 90mg SQ daily for anticoagulation. Increase Coumadin to 4mg po daily at 5:00PM for anticoagulation.

Review of the policy and procedure "Anticoagulation Guidelines" revealed the following;
A.) Staff responsibilities include monitoring patients for signs of adverse events such as bleeding, skin necrosis, purple toe syndrome, [DIAGNOSES REDACTED] and others.
D.) The nurse alerts the dietician to a patient on coagulant therapy.
E.) Dietary evaluates and determines any dietary restrictions.
F.) The treatment team adds the patient's diagnosis that meets the indication for anticoagulation therapy to the Treatment Plan and updates according to Treatment Plan reviews.
J.) There is ongoing assessment of the patient's response. Identification of any problem is evaluated by the physician, Nursing, Pharmacy and dietary using the following criteria:
1. Signs and symptoms of [DIAGNOSES REDACTED]
2. Change in condition requiring Warfarin therapy
3. Recent alterations in diet or medication.
4. Changes in other medical condition or illness
5. Compliance"

Review of the nursing notes and "Treatment Care Plan" revealed there was no documentation found of nursing assessment for adverse reactions of the Coumadin or Lovenox. There was no nursing documentation found of patient instruction, dietary consult, or any assessments of possible hemorrhage. There was no documentation found of patient response to anticoagulation therapy.

Review of the physician orders dated 5/15/2015 at 9:15PM patient #2 was sent to the emergency room for evaluation. Review of the nurse's notes on 5/15/2015 at 9:12PM revealed the nurse checked a box under lung sounds, "crackles." There was no documentation found of what lobe had crackles or the patient's respirations. The nurse documented "bloody sputum."

Review of the nurse's notes on 5/15/2015 at 9:12PM stated, "Pt walked up to nurse and said she was coughing up blood. Assessment completed. Pt is A&O x4. Respirations even and unlabored. Pt c/o of chest pain. Physician called and new orders noted to send pt to the ER."

Review of the hospital discharge papers on 5/16/2015 revealed the patient was diagnosed with [DIAGNOSES REDACTED].

Review of the Treatment Care Plan revealed no found documentation of the new diagnosis Hemoptysis-Bronchitis or the new antibiotic.

Review of the nurse's notes for 5/19/2015 at 7:25PM stated, "MHT informed this nurse that pt. was struck on right side of forehead by peer. This nurse observed a red, raised area approximately 1 1/2 inches in diameter. Pt c/o pain and slight dizziness and nausea. Pt. assisted to feet and escorted to room for rest and safety. House Supervisor and MD notified. Will continue to monitor. 7:30PM Order received to transfer pt. to ER due to trauma to head and further evaluation of injury. HS notified. Will continue to monitor."

Review patient #2's physician orders on 5/19/2015 revealed the patient was sent to the ER. The order stated, "Transport pt. to ER due to trauma to head further evaluation of injury." Patient #2 was transported to the ER on 5/19/2015 at 8:32PM.

Review of patient #2's chart revealed she returned from the ER on 5/19/15 with a diagnosis of [DIAGNOSES REDACTED]
VIOLATION: NURSING SERVICES Tag No: A0385
Based upon observation, record review and interview, the Governing Body (GB) failed to;


A. follow its own policy and procedures, nursing failed to monitor ongoing patient assessments regarding changes in medical conditions, and medications that could possibly be life threatening in 1(#2) out of 10 (#1-10) charts reviewed.



Refer to Tag A392


B. keep a current and ongoing treatment plan for new onset diagnosis, new medications, patient teaching, responses, interventions, and ongoing assessments to re-enforce an integrated, multi-faceted approach to the patients care in 1 (#2) out of 10 (1-10) charts reviewed.


Refer to Tag A396
VIOLATION: GOVERNING BODY Tag No: A0043
Based upon observation, record review and interview, the Governing Body (GB) failed to;


A. Observe, monitor, and protect the patients from harm resulting in the death of 1(#1) of 10 patients reviewed. The nurse's notes and 15 minute observation status records had multiple discrepancies on where and what the patients were doing. There were minimal or no nursing interventions documented to alleviate potential volatile situations, resulting in injury to 1 (#2) of 10 patients reviewed. Review of 2 (#1, #4) of 10 patients revealed the staff allowed patients to have volatile outbursts and go into a closed door room and remain there without observation or intervention.


Refer to Tag A144


B. ensure nursing kept a current and ongoing treatment plan for new onset diagnosis, new medications, patient teaching, responses, interventions, and ongoing assessments to reinforce an integrated, multi-faceted approach to the patients care in 1 (#2) out of 10 (1-10) charts reviewed.


Refer to Tag A396


C. To ensure the dietician and nursing assessed, observed, and recognized the need for a therapeutic diet for 1(#2) out of 10(#1-10) patients reviewed.


Refer to Tag A629


D. follow its own policy and procedures, nursing failed to monitor ongoing patient assessments regarding changes in medical conditions, and medications that could possibly be life threatening in 1(#2) out of 10 (1-10) charts reviewed.

Refer to Tag A392





.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based upon observation, record review and interview, the facility failed to


A. Observe, monitor, and protect the patients from harm resulting in the death of 1 (#1) of 10 patients reviewed. The nurse's notes and 15 minute observation status records had multiple discrepancies on where and what the patients were doing. There were minimal or no nursing interventions documented to alleviate potential volatile situations, resulting in injury to 1 (#2) of 10 patients reviewed. Review of 2 (#1, #4) of 10 patients revealed the staff allowed patients to have volatile outbursts and go into a closed door room and remain there without observation or intervention.

Refer to Tag A144


The deficient practices were identified under the following Conditions of Participation and were determined to pose Immediate Jeopardy to patient health and safety, resulting in the death of patient #1, injury to patient #2, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death. The facility implemented corrective action as a result of the patient death to ensure patient safety. The corrective action was sufficient to abate the Immediate Jeopardy.