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.

FULTON MEDICAL CENTER LLC 10 SOUTH HOSPITAL DRIVE FULTON, MO 65251 Aug. 23, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview, record review, policy review, and video review the facility failed to:
- Ensure nursing staff adequately performed 15 minute observations for seven patients (#1, #3, #8, #9, #18, #27 and #28) of seven reviewed. (refer to A144)
- Ensure nursing staff adequately performed patient safety rounds every two hours for eight patients (#2, #4, #5, #13, #14, #15, #16 and #17) of eight reviewed. (refer to A144)
- Ensure a safe environment for the Geropsychiatric seclusion room. (refer to A144)
- Ensure staff followed policy for appropriate care and management of one psychiatric patient (#19) of one psychiatric patient reviewed, who presented for admission to the Geropsychiatric Unit with documented suicidal ideations (thoughts of killing self). (refer to A144)
- Ensure they provided written notice with the name of the facility contact person, the steps taken to investigate a grievance and the date of completion for two discharged patient grievances (#21 and #24) of four discharged patient grievances reviewed. (refer to A123)

These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Patient's Rights. The facility census was 16.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on interview, record review, and policy review, the facility failed to provide written notice with the name of the facility contact person, the steps taken to investigate a grievance and the date of completion for two discharged patient grievances (#21 and #24) of four discharged patient grievances reviewed. This failure affects all patients and/or patient's representatives who filed a grievance, by denying them necessary information related to their grievance outcome. The facility census was 16.

Findings included:

1. Review of the facility's policy titled, "Grievance Procedure - Patient Complaints & Grievance Process," dated 04/2016, showed:
- A grievance was formal or informal, written or verbal, made by a patient or patient's representative regarding the patient care.
- If a patient complaint cannot be resolved by the involved employee or staff member at the time of the complaint, then it should be escalated to a grievance for resolution.
- Written, emailed or faxed complaints were considered a written grievance.
- Grievance Timeline - The Chief Executive Officer (CEO) shall be responsible for oversight so that a full investigation with action plan, resolution and written communication back to the patient is completed no later than seven calendar days from the date the grievance was received.
- All patient communication shall be in accordance with the timelines for grievance resolution noted in the grievance timeline.
- Communication and response to the patient shall include the steps taken to investigate, staff involved in the investigation, initiation and completion dates of the investigation, results/findings of the investigation, action plan and resolution (if indicated) and the CEO name and contact information for further information.

Review of Patient #21's grievance dated 02/21/18, showed that Patient #21 and another patient, complained that a nurse became frustrated in speech and actions after one of the patients questioned whether her medications were correct. The patients also complained the the nurse used liquid corrector on a medical record, and that a patient fell the night before and was not assessed for injuries. Hospital response to the patients was, "I told both of them that I would look into their concerns." Actions taken were review of the patient's medications and medication administration record, and interviews conducted with the nurse's leader and nurse involved. On 02/23/18, a follow-up with the patients occurred, but there was no documentation that a written notice was provided to the patients, with the name of the facility contact person, the steps taken to investigate the grievance and the date of completion.

Review of Patient #24's grievance dated 04/20/18, showed that the patient complained in writing, that a technician was rude, yelled at him, and grabbed and jerked his arm. Actions taken were interviews with all staff, and review of video surveillance. There was no documentation that a written notice was provided to the patients, with the name of the facility contact person, the steps taken to investigate the grievance and the date of completion.

During an interview on 08/22/18 at 4:00 PM, Staff U, Risk Manager, stated that she did not provide written notice to the patient grievances because the patients continued as inpatients at the conclusion of the investigation.

During an interview on 08/23/18 at 1:40 PM, Staff U stated that because resolution was reached at the time the complaints were made, they would not be considered a grievance and therefore did not require a written notice.

Both Patient #21 and Patient #24's complaints met the definition of a grievance. Patient #21's grievance resolution was postponed when the patient was told the hospital would look into her concerns, and it required an investigation. Patient #24's grievance was received in writing, and required an investigation.

During an interview on 04/23/18 at 1:26 PM, Staff V, Chief Executive Officer, stated "I don't know regulatory," when questioned about grievances and written notice requirements, and added that he relied on Staff U's knowledge for that.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review, policy review and review of recorded video surveillance, the facility failed to:
- Ensure nursing staff adequately performed 15 minute observation rounds for seven patients (#1, #3, #8, #9, #18, #27 and #28) of seven reviewed.
- Ensure nursing staff adequately performed patient safety rounds every two hours for eight patients (#2, #4, #5, #13, #14, #15, #16 and #17) of eight reviewed.
- Ensure a safe environment for the Geropsychiatric seclusion room when mats were placed on the floor which posed a risk to geriatric patients.
- Ensure staff followed policy for the appropriate care and management of one psychiatric patient (#19) of one psychiatric patient reviewed, who presented for admission to the Geropsychiatric Unit with documented suicidal ideations (thoughts of killing self).
These failures placed all patients at risk for an unsafe environment and had the potential to lead to injury and death. The facility census was 16, with all 16 patients in the Geropsychiatric Unit.

Findings included:

1. Review of the facility's policy titled, "Patient Observation Categories, Special Precautions," dated 07/2018, showed the directives for nursing to round on patients and chart every two hours for safety and staff assigned (PCT, Patient Care Technician) to perform 15 minute observations and documentation.

Review of the facility's policy titled, "Special Precautions Patient Observation Record," dated 04/2015, showed that:
- Patients should be monitored and observed Face to Face on 15 minute timeframes.
- Staff should make Face to Face contact on each encounter observing the patient's location, behavior and level of alertness.
- Documentation of Face to Face rounding should be written in real-time.

Observation on 08/20/18 at 1:18 PM, on the 300 hall of the Geropsychiatric Unit, showed that the patient room doors had a hinged door in the middle of the full sized-door, with a key lock, known as an anti-barricade door (an emergency door, that can be opened outward to allow access to a patient room if the patient barricades the door).

During an interview on 08/20/18 at 1:30 PM, Staff C, Patient Care Technician (PCT), stated that the anti-barricade doors were opened at night to observe the patients on rounds.

Video review of 08/18/18 night shift, 300 hall (Patient #1, #3, #8, #9, #18, #27 and #28's rooms) of the Geropsychiatric Unit, showed that at:
- 9:55 PM, Staff S, PCT, opened the anti-barricade door of each room, performed the 15 minute observation rounds, and left the doors open.
- 10:11 PM, Staff S, PCT, briefly looked into the anti-barricade doors during 15 minute observation rounds.
- 10:28 PM, Staff Q, PCT, briefly looked into the anti-barricade doors during 15 minute observation rounds.
- 10:42 PM, Staff Q, PCT, briefly looked into the anti-barricade doors during 15 minute observation rounds. After the 15 minute observation rounds, Staff Q sat in a chair outside of the nurses' station with her feet up, and focused on her cell phone.
- 11:10 PM, Staff Q, PCT, briefly looked into the anti-barricade doors during 15 minute observation rounds. After the 15 minute observation rounds, Staff Q sat in a chair outside of the nurses' station with her feet up, and focused on her cell phone.
- 11:51 PM, Staff S, PCT, briefly looked into the anti-barricade doors during 15 minute observation rounds.

These real-time observation rounds were not performed every 15 minutes with time lapses between 10:42 PM and 11:10 PM, and 11:10 PM and 11:51 PM.

Record review of 08/18/18 of the Behavioral Health Unit Special Precautions Patient Observation Record for Patients #1, #3, #8, #9, #18, #27 and #28, showed that documentation for the observation rounds for the entire night shift was every 15 minutes. (This contradicted what was reviewed on video).

2. Video review of 08/18/18 night shift, 200 hall (Patient #2, #4, #5, #13, #14, #15, #16 and #17's rooms) of the Geropsychiatric Unit, showed Staff R, Licensed Practical Nurse (LPN) performed her two hour safety rounds. Staff R looked in the anti-barricade doors at 10:10 PM and then at 11:58 PM, she looked in the anti-barricade doors with a flashlight.

Observation on 08/23/18 at 9:53 AM, showed an estimated 13 feet between the patient's bed to their door, for all rooms on the 200 and 300 hall. These observations through the anti-barricade doors were inadequate (not being able to see the patient clearly from the door to assess their breathing) and created an unsafe environment for the geropsychiatric patients at night.

During an interview on 08/27/18 at 5:25 PM, Staff R, LPN, stated that some of the patient rooms were set up so you could see the whole bed from the door. She stated that she shined her flashlight through the anti-barricade door and listened for patient breathing, during her two hour safety rounds.

During an interview on 08/27/18 at 5:40 PM, Staff T, PCT, stated that until this past week she was trained to open the anti-barricade doors, and look into the room through the door, for her 15 minute rounds.

During an interview on 08/27/18 at 6:24 PM, Staff S, PCT, stated that he was told to use the anti-barricade doors for the 15 minute observation rounds.

During an interview on 08/21/18 at 12:40 PM, Staff G, Geropsychiatric Unit Manager, stated that the anti-barricade doors should not be used, except in emergencies. He stated nursing staff were expected to enter the room for Face to Face, to check for breathing and signs of life.

During an interview on 08/23/18 at 12:50 PM, Staff D, Chief Nursing Officer (CNO), stated that the anti-barricade doors were to be opened only for emergencies. She also stated that she expected the PCTs to put their eyes on the patients during their 15 minute observation rounds, and for nurses to perform a Face to Face for their two hour safety rounds.

3. Review of the facility's policy titled, "Safety Overview," dated 04/2015, showed that geriatric patients' physical care should be as high a priority as their psychiatric care.

Observation on 08/23/18 at 10:00 AM, in the Geropsychiatric seclusion room, showed three mats on the floor. The patients on the unit were elderly and had difficulty walking and bending, and all were documented as a fall risk.

These physical difficulties would make it difficult for the patients to lay on mats on the floor, and increased the risk of falls, if a patient was placed in seclusion.

During an interview on 08/23/18 at 12:50 PM, Staff D, CNO, stated that she understood the risk by having the mats on the floor.

4. Review of the facility's policy titled, "Admission Process to Unit," dated 04/2015, showed:
- If a patient met criteria for voluntary admission and refused to sign the form or be admitted , the physician must refuse admission, initiate procedures for emergency certificate (application for involuntary detention/96 hour hold) or refer to another mental health treatment facility.
- An RN will assess each new patient upon arrival on the unit.
- An RN will enter admission notes in the electronic medical record of the exact time of admission, mode of admission, narrative description of the patient's psychiatric symptoms, present behavior and reasons for hospitalization .

Review of the facility's policy titled, "Against Medical Advice," dated 04/2015, showed:
- It is the policy of the organization to provide the patient with all of the information needed that will allow them to make an informed decision, regarding leaving without completion of treatment.
- When the patient requests to leave AMA, staff were to notify the psychiatrist, the psychiatrist or treatment team would talk with the patient to discuss the need for treatment, the staff would follow psychiatrist orders, and document the request and all interactions with the patient.
- Staff would encourage the patient to stay, and explain to the patient the reasons, importance and benefits for continuing treatment.
- If the patient is competent and a voluntary admission who is requesting to leave AMA, after being explained the consequences of potential risk, then request they sign the AMA form, sign below that line with the date, exact time and brief description of patient comments and what transpired, and document the patient's decision and the events of AMA in the patient's chart, and include any actions take to ensure the patient's safety.
- If the patient is a danger to self, appropriate steps to ensure safety and placement in a more restrictive environment are required.

Review of Patient #19's medical record from Hospital B (nearby hospital) showed:
- The patient was admitted to Hospital B on 07/06/18 for suicidal ideations.
- The patient had a history of suicide attempts.
- The patient signed the voluntary admission, consent for authorization and medical treatment, patient statement of rights and other forms for admission to Fulton Medical Center.
- The signed forms were faxed to the facility on [DATE].

During an interview on 08/21/18 at 12:14 PM, Hospital B Social Worker (SW) X, stated that Patient #19 had a psychiatric history, and stated that she was suicidal, so Hospital B staff contacted Fulton medical Center on 07/06/18, and arranged for admission to Fulton Medical Center's Geropsychiatric Unit. Fulton Medical Center accepted the patient, and paperwork from Hospital B was faxed to Fulton Medical Center, which included an affidavit (legal written statement) that documented the patient was suicidal. On 07/07/18, the patient was discharged from Hospital B, and transferred to Fulton Medical Center by ambulance. A copy of the paperwork also accompanied the patient on the ambulance. SW X also stated that Fulton Medical Center contacted her on 07/07/18 at 10:00 AM, and demanded that they (Hospital B staff) complete a 96 hour court-ordered hold (court-ordered detention for psychiatric evaluation) for Patient #19.

Review of an ambulance report dated 07/07/18, showed that Patient #19 was transported from Hospital B to Fulton Medical Center for suicidal ideations.

Although requests were made to Staff U, Risk management, Staff Y, Health Information Management, Staff F, Geropsychiatric RN and Staff Z, Social Worker (SW), Patient #19's medical record for arrival to the Geropsychiatric Unit on 07/07/18, was unable to be found.

During an interview on 08/21/18 at 1:20 PM, Staff Y stated that Patient #19 had never been to the hospital, and likely planned to come for admission to the Geropsychiatric Unit, but never made it.

During an interview, with concurrent record review on 08/23/18 at 9:45 AM, Staff Z, SW, stated that she was unable to locate any paperwork for Patient #19 on or around 07/07/18. Approximately 15 minutes later, Staff Z produced Patient #19's paperwork titled, "Psychiatric Intake/Referral Assessment Worksheet - Patient Identification Information," dated 07/06/18 at 8:30 PM. Included in the paperwork was:
- The reason for admission was that the patient actively had suicidal ideations (SI).
- Immediate risk for potential danger to others or self, listed as "suicide (attempt W/I [within] 72 hours).
- The intake was completed by Staff F, Geropsychiatric RN, with a reason for admission "SI."
- "Packet sent" at 8:00 PM, "Faxed" to the ED Physician, "approved" at 6:30 AM by ED Physician.

During an interview on 08/21/18 at 11:40 AM, Patient #19 stated that when she presented to Fulton Medical Center for admission to the Geropsychiatric Unit, the hospital was dirty, made her feel "icky" and because staff didn't pay attention to her, she wanted to leave. Staff took her vital signs (temperature and blood pressure), did not attempt to make her stay, she called her husband to pick her up, and left the facility.

During an interview on 08/21/18 at 3:04 PM, Staff AA, Geropsychiatric RN, stated that when Patient #19 arrived on 07/07/18, she wanted to leave. Staff BB, ED Physician Assistant (PA), was contacted, came to the Geropsychiatric Unit, and he asked the patient if she had suicidal ideations. Staff AA stated that she also asked the patient if she had suicidal ideations, when the patient confirmed she was, but did not understand that she was coming for admission. The patient stated that she preferred to go to outpatient treatment, and was advised to contact her psychiatrist for arrangements. The patient called her husband, and when he arrived, the patient was escorted out by a PCT (name unknown) and left. Staff AA stated that she did not have the patient sign Against Medical Advice (AMA, signed statement that patient is aware of the risks associated with leaving) paperwork because she was informed by Staff CC, House Supervisor, that because the patient wasn't a patient, it was not necessary.

During an interview on 08/22/18 at 4:20 PM, Staff F, Geropsychiatric RN, stated that when Patient #19 arrived to the Geropsychiatric Unit, she wanted to leave. Staff BB, ED PA, was contacted, came to the unit and spoke with her, and the patient informed staff that she knew her rights and that she could not be kept against her will, and the patient was allowed to leave. Staff F stated that she did not document anything about the patient and did not complete an AMA form, because the patient was not registered as a patient. Staff F stated that staff did not attempt to obtain a 96 hour court-ordered hold on the patient because the patient did not say she was suicidal.

During an interview on 08/22/18 at 10:45 AM, Staff BB, ED PA, stated that if Patient #19 was suicidal at Hospital B, they should have obtained a 96 hour court-ordered hold. Staff BB stated that he was informed by a nurse (name unknown) on the Geropsychiatric Unit, that Patient #19 had arrived, was no longer suicidal, and wanted to leave. Staff BB stated that he did not remember if he spoke with the patient, and believed that she had left by the time he arrived to the Geropsychiatric Unit.

During an telephone interview on 08/29/18 at 3:25 PM, Staff DD, Psychiatrist stated:
- If a patient arrived by ambulance for admission to the Geropsychiatric unit and wanted to leave, the patient would not be released because they cannot be trusted (not to harm themselves).
- Staff were trained to determine if a patient was suicidal, and "just because they say they are not suicidal is not valid."
- Staff did not find anything that showed the patient would be dangerous to herself.
- Staff did not contact her when Patient #19 arrived for admission by ambulance and wanted to leave, "they contacted me after it happened and told me about it."
- She was the person who made the final decision to release a patient.
- If a patient insisted on leaving, she would talk with the patient on the phone, and sometimes talk to the family, but because Staff BB, PA was at the hospital and available, he was contacted instead instead of Staff DD.
- Staff BB, PA, spoke with the patient and the patient "did not give anything positive (indicate that she was suicidal)," so we didn't have enough to hold her on a 96 hour court-ordered hold (prevents psychiatric patients from leaving a hospital, so they can be evaluated for necessary psychiatric care), based on her information.

During an interview on 08/21/18 at 12:14 PM, Hospital B SW X, stated that on 07/07/18, after Patient #19 left Fulton Medical Center, she contacted Hospital B three times and asked to be admitted for continued suicidal ideations.

This showed that a patient with documented suicidal ideations, presented to Fulton Medical Center for psychiatric admission, and left the facility without any documentation that the patient presented, if she was still suicidal, of a provider's examination or nursing assessment, or the patient's disposition.

These accumulative failures placed the Geropsychiatric Unit patients in an an unsafe environment.
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on interview and policy review, the facility failed to ensure that policies were reviewed in a timely manner. This failure had the potential to affect all patients admitted to the facility as staff may not have the most current and accurate information to care for patients. The facility census was 16.

Findings included:

1. Policy titled, "Maintenance of Policy and Procedure Manuals," dated 03/2015, showed that all policies were to be reviewed at least every three years and annually for certain areas. The following policies were found to be out of date:
- Maintenance of Policy and Procedure Manuals dated 03/2015;
- Care Planning dated 04/2015;
- IC Isolation Plan dated 04/2015;
- Handwashing dated 05/2015;
- Nursing Process and Procedures dated 04/2015;
- Use Orientation of Agency Personnel dated 04/2015;
- Abusive Patient or Visitor dated 03/2015;
- Restraint and Seclusion Use dated 06/2015;
- Disruptive Visitor dated 04/2015; and
- Visitors in the Facility dated 03/2015.

During an interview on 08/24/17 at 1:15 PM, Staff U, Risk Manager, stated that policies were reviewed annually or every three years, depending on what type of policy it was.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview, record review and policy review, the facility failed to ensure that nursing staff adequately assessed, documented and treated patient's output (bowel movements) for one discharged patient (#7) and two current patients (#13 and #16) of three patients reviewed, and failed to date, time and initial a wound dressing for one patient (#1) of one dressing change observed. These failed practices had the potential to affect all patients and placed them at risk for serious injury or death. The facility census was 16.

Findings included:

1. Although requested, the facility failed to provide a policy for input and output procedures.

Review of Patient #7's "Bowel Movement Record," handwritten by Patient Care Technicians (PCTs), showed the patient had bowel movements on:
- 05/22;
- 05/24 (two);
- 05/29; and
- 06/04.

Review of Patient #7's electronic medical record (EMR) showed there were no bowel movements documented by Registered Nurses (RNs) in the EMR between 05/16/18 and 06/26/18 (The PCT documentation of bowel movements, were not included in the EMR).

Review of Patient #7's physician orders, showed that throughout her inpatient stay between 05/16/18 and 06/26/18, there were medication orders for the following:
- Docusate Sodium (stool softener) 100 milligram capsules twice daily as needed;
- Biscolax Suppository for constipation 10 milligrams daily as needed; and
- Milk of Magnesium for constipation daily as needed.

Review of Patient #7's medication administration record showed that no medications were given for constipation between 05/16/18 and 06/26/18.

These failures show that Patient #7 had only four bowel movements between 05/16/18 and 06/26/18. The bowel movements were not documented in the EMR, and medications were not administered as ordered, which placed the patient at great risk for injury and possibly death.

Review of Patient #13's (admitted on [DATE]) "Bowel Movement Record," handwritten by PCTs, showed the patient had bowel movements on:
- 08/02/18;
- 08/09/18; and
- 08/16/18.

Review of Patient #13's EMR showed there were no bowel movements documented by RNs in the EMR between 08/01/18 and 08/22/18

Review of Patient #16's (admitted on [DATE]) "Bowel Movement Record," handwritten by PCTs, showed the patient had one bowel movement on 08/22/18.

Review of Patient #16's EMR, showed there were no bowel movements documented by RNs in the EMR between 08/04/18 and 08/22/18.

During an interview on 08/22/18 at 10:08 AM, Staff K, Licensed Practical Nurse (LPN), stated that they logged every patient's bowel movements, and if they had not had a bowel movement in three days, they called the physician.

During an interview on 08/22/18 at 4:16 PM, Staff G, Manager of the Geropsychiatric Unit, stated that the PCTs documented the patient's bowel movements on the Bowel Movement Record, and nightshift was expected to document the bowel movements from the Bowel Movement Record in the EMR.

During an interview on 08/23/18 at 12:50 PM, Staff D, Chief Nursing Officer (CNO), stated that her expectation was for the nurses to document the bowel movements from the Bowel Movement Record in the EMR.

2. Although requested, the facility failed to provide a policy for dressing change procedure.

Observation and concurrent interview on 08/21/18 at 7:00 AM, Staff H, RN, performed a dressing change on Patient #1. Staff H removed the old dressing, which showed no date, time or initials, and upon completion of her dressing change, she failed to date, time and initial the new dressing. Staff H stated that she forgot to label the dressing.

During an interview on 08/22/18 at 10:08 AM, Staff K, LPN, stated that they were expected to date, time and initial all dressings.

During an interview on 08/22/18 at 2:22 PM, Staff N, RN, stated that their policy directed staff to date, time and initial all dressings.

During an interview on 08/23/18 at 12:50 PM, Staff D, CNO, stated that she expected all staff to date, time and initial dressings.

These failures had the potential for negative outcomes to include injury or death of patients that were already compromised.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on observation, interview, record review and policy review, the facility failed to ensure staff administered medication according the facility's medication administration policy for six patients (#2, #3, #4, #6, #13 and #14) of six patients observed. These practices failed to provide a safe and effective medication administration process, and placed all patients admitted to the facility at risk for medication errors. The facility census was 16.

Findings included:

1. Review of the facility's policy titled, "Medication Administration," dated 03/2017, showed the directive for staff to scan the patient's wristband, then scan the medication barcode, before administering medications.

Observation on 08/21/18 at 2:00 PM showed Staff O, Registered Nurse (RN) performed the following for Patient #13's medication administration:
- Removed a tray, from a small cabinet with multiple drawers, that had the patient's barcode label on the end of the tray;
- Scanned the patient's barcode;
- Removed the patient's medications from the automated medication dispensing system;
- Scanned each medication barcode;
- Placed the medications into the tray;
- Took the tray out to Patient #13, verified the patient's identity at bedside with the patient's name and date of birth; and
- Administered the medication.
This process did not follow facility policy, when Staff O failed to scan the patient's armband at bedside prior to medication administration.

Observation on 08/21/18 at 5:00 PM, showed Staff K Licensed Practical Nurse (LPN), scanned the barcode label on each of Patient #3's medications while she sat at a computer in the nurses station. Staff K then took the medications to the patient, failed to scan the patient's armband, and administered the medications.

Observation on 08/22/18 at 4:16 PM, showed Staff G, RN, failed to scan Patient #3's armband before he administered the patient's medications.

Observation 08/21/18 at 5:15 PM, showed Staff K, scanned the barcode label on each of Patient #6's medications while she sat at a computer in the nurses station. Staff K then took the medications to the patient, failed to scan the patient's armband, and administered the medications.

Observation on 08/21/18 at 5:00 PM, showed Staff G, RN, scanned the barcode label on each of Patient #4's medications while he sat at the computer in the nurses station. Staff G then took the medications to the patient, failed to scan the patient's armband, and administered the medications.

Observation on 08/21/18 at 5:13 PM, showed Staff G, RN scanned the barcode label on each of Patient #2's medications while he sat at a computer in the nurses' station. Staff G then took the medications to the patient, failed to scan the patient's armband, and administered the medications.

Observation on 08/21/18 at 5:24 PM, showed Staff G, RN scanned the barcode label on each of Patient #14's medications while he sat at a computer in the nurses' station. Staff G then took the medications to the patient, failed to scan the patient's armband, and administered the medications.

During an interview on 08/21/18 at 5:20 PM, Staff G, RN, stated that his process was to scan the barcode in the nurses' station and then bring the medications to the patients.

During an interview on 08/21/18 at 10:30 AM, Staff F, RN, stated that their process was to scan the barcode in the nurse's station and then bring the medications to the patient.

During an interview on 08/23/18 at 12:50 PM, Staff D, Chief Nursing Officer (CNO), stated that her expectation was that all nurses scanned the patient's armband, and then pulled the medications (removed the medications from the automated medication dispensing system).

During an interview on 08/22/18 at 9:45 AM, Staff I, Director of Pharmacy, stated that their goal was to scan the patient's armband at the bedside. He encouraged the facility to use the workstations on wheels (mobile cart with a computer and barcode scanner mounted on top), and was informed there were no funds for this.