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.

STRATEGIC BEHAVORIAL CENTER-GARNER 3200 WATERFIELD DRIVE GARNER, NC 27529 Feb. 8, 2019
VIOLATION: GOVERNING BODY Tag No: A0043
Based on policy review, medical record review, and staff interview, the hospital's Governing Body failed to provide oversight and have systems in place to ensure an organized nursing service to provide the protection of patients' rights and safe delivery of care to adolescent behavioral health patients.

The findings included:

1. The facility failed to protect and promote patients' rights by failing to ensure a safe environment for the delivery of care to an adolescent behavioral health patient with a known history of suicide risk that attempted self harm by strangulation; and failing to include an adolescent patient's guardian in a decision to shave the patient's hair.

~cross refer to 482.13 Patient Rights' Condition: Tag 0115

2. The hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations by failing to ensure a newly admitted adolescent behavioral health patient with known plans to harm herself was assessed, evaluated and protected from self harm by strangulation. Nursing staff failed to ensure safe administration of medications for 2 of 5 observed medications administered and failed to reconcile medications at admission and discharge.

~cross refer to 482.23 Nursing Services Condition: Tag 0385.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on policy review, medical record review and staff interview, the facility failed to protect and promote patients' rights by failing to ensure a safe environment for the delivery of care to an adolescent behavioral health patient with a known history of suicide risk that attempted self harm by strangulation for 1 of 1 sampled patients that had a suicide gesture during admission (#17); and failing to include an adolescent patient's guardian in a decision to shave the patient's hair for 1 of 1 sampled patients that received a hair cut (#6).

The findings include:

1. Facility staff failed to provide a safe environment for the delivery of care to a newly admitted adolescent behavioral health patient with known suicide plans and to prevent self harm by strangulation.

~cross refer to 482.13(c)(2) Patient Rights' Standard: Tag A0144

2. Facility staff failed to include the patient's legal guardian in a decision to shave the adolescent patient's hair.

~cross refer to 482.13(b)(1) Patient Rights' Standard: Tag A0130
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, and staff interviews, facility staff failed to include legal guardian in the decision to shave Patient #6's hair.

Review of closed medical record for Patient #6 (Pt #6) revealed he was a [AGE] year old male involuntarily committed to facility on 11/22/2018 with Disruptive Mood Dysregulation Disorder. Review of Pt #5's medical history revealed a diagnosis of Conduct Disorder and Attention-Deficit Hyperactivity Disorder. Review of a Therapy Group Note signed by Therapist #8 on 12/22/2018 at 1234 revealed "Patient was getting his hair cut prior to group. Patient kept making comments about his hair, which was preventing group from starting. For example, "I can't believe I'm bald" and "I can't believe how short it is." Thus, therapist redirected patient to stop talking as he's preventing group from beginning..."

Telephone interview with Therapist #8 on 02/06/2019 at 1500 revealed she observed Mental Health Technician (MHT) #9 giving a haircut to Pt #5 using electric clippers when she entered the unit on 12/22/2018. Therapist #8 reported informing MHT #9 that she should not be cutting Pt #5's hair, and MHT #9 replied "It's okay, I have approval." Therapist #8 reported she left the unit and notified the House Supervisor of the incident. Therapist #8 reported she then returned to the unit with the House Supervisor and observed MHT #9 cutting a different patient's hair with electric clippers. Therapist #8 reported the House Supervisor spoke to MHT #9 and the Registered Nurse (RN) assigned to the unit. Therapist #8 reported this was the first time she observed a staff member cutting a patient's hair in the facility. Therapist #8 reported she observed MHT #9 cut two patient's hair with electric clippers.

An interview was requested with MHT #9, but she was not available for interview.

Interview with House Supervisor 02/06/2019 at 1600 revealed she was notified on 12/22/2018 by Therapist #8, that MHT #9 was cutting Pt #5's hair with clippers. The House Supervisor reported once notified of the incident, she walked to the unit and "immediately shut it (hair cutting) down." The House Supervisor reported she then educated the RN and MHT of the safety concerns related to cutting a patient's hair. The House Supervisor reported she did not complete an incident report because Pt #5 was not injured. The House Supervisor revealed she realizes that she should have filed an incident report and notified Pt #5's parent or guardian. The House Supervisor reported she notified the Chief Executive Officer (CEO) of the incident on 12/22/2018.

Interview with CEO on 02/07/2019 at 1615 revealed CEO did not recall being notified of the incident on 12/22/2018, but that it is not ok for a staff member to cut a patient's hair. The CEO reported she was made aware of the incident during the survey on 02/08/2019. The CEO reported staff will be re-trained on boundaries and she will work with the Director of Nursing and human resources to roll-out computer based training for staff.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review and staff interview, facility staff failed to provide a safe environment for the delivery of care to a newly admitted adolescent behavioral health patient with known suicide plans and to prevent self harm by strangulation for 1 of 1 sampled patients that had a suicide gesture during admission (#17).

The findings include:

Review of the "Suicide Risk Assessment" policy revised 05/24/2015 revealed "Each resident admitted to (named facility) shall be assessed for suicide risk upon admission ... If the nurse deems appropriate, the resident will be supervised as one to one observation until the MD (physician) is contacted and a decision is made at the level observation required. The SRA (Suicide Risk Assessment) score aids in identification of a high risk resident, however the score is not the requirement that mandates the physician's order. ..."

Review of the "Initial Nursing Assessment" policy revised 12/2016 revealed "All clients admitted to (named facility) will receive a comprehensive nursing assessment that will be utilized to help formulate the individualized plan of care. 1. A Registered Nurse will initiate the nursing portion of the Integrated Assessment upon the client's arrival at (the facility). The nursing assessment must be completed by a registered nurse within 8 hours of the client's admission. ... 5. Assessment of the client's nursing care needs will include: (a) Past and current medical psychiatric history ... (b) Mental status exam ...6. The nursing assessment includes a note documenting that the physician was notified of the client's arrival and any pertinent medical/psychiatric history."

Review of the "Level of Patient Observation" policy revised 07/29/2017 revealed "To provide the appropriate level of observation for those residents considered dangerous or at risk to themselves or others. (Named facility) has a primary responsibility to ensure the safety and well being of individuals within our care. ... Nursing personnel implements these levels of observation throughout the 24 hour period. Each resident is assigned to a staff member and staff must have relief present before leaving their assigned residents. Any staff member who becomes aware that a resident is in imminent danger of harming themselves or others will immediately ensure that the resident is under constant eye view of a staff member until the RN (registered nurse) and/or Psychiatrist is notified and present to assess the resident. ... Fifteen minute observation is required for all residents. ... Close observation (Line of sight observation). The assigned staff maintains a full, unobstructed view of the resident at all times ... One to one observation ... The staff member assigned is in constant visual range of the resident and is within arms's length of the resident at all times ... The RN may initiate a higher level of observation based on a resident's status, but can never decrease the observation level without a psychiatrist's order. ... Upon identifying that a resident is in need of a higher level of observation, the RN will ... contact the Milieu Manager who will ensure adequate staffing is available to provide the increased level of observation. ... Upon admission to the facility, an initial risk assessment should be completed by the RN ...While maintaining the resident's privacy and dignity, two staff members will conduct a room and body search for any potentially dangerous items such as shoelaces, hairpins ... Any potentially hazardous items are to be removed from the resident's possession. ..."

Review of the "Contraband Safety Check" policy revised 06/06/2017 revealed "(Name of facility) maintains a safe environment for residents and staff by ensuring that potentially harmful items are prevented from the facility. ... 1. Contraband is defined as any item, which may be potentially hazardous, considering the unique nature of a residential treatment facility and the resident's unique treatment issues. 2. A list of items considered contraband is included in both the Resident and Parent Handbooks, is revised periodically, and includes a statement of understanding, signed by residents. Contraband may also include items not specifically listed, but which at the discretion of staff members, could be considered potentially harmful. ..."

Review of the "Adult Child and Adolescent Handbook" (not dated), presented as currently used revealed "... Prohibited/Contraband Items - Staff reserves the right to remove items from you or your room that he/she feels are dangerous to you or others. Below is a list of some of the items that you should leave behind. This is NOT a complete list of prohibited items. ..." Review of the list revealed 22 listed items. Review of the list revealed hairbands were not on the list of prohibited items.

Medical record review on 02/06/2019 of Patient #17 revealed a [AGE] year-old female admitted on [DATE] at 1237 under involuntary commitment status with a diagnosis of Disruptive Mood Dysregulation Disorder (DMDD). Review of a "Safety Search Form" dated 02/05/2019 revealed Assessor #1 and another staff member conducted a safety search at 1305 that included a search of hair, tongue, underarms, fingers, toes, belongings, and clothing including belts and strings. Review of a "Comprehensive Psychosocial Assessment Tool" completed by Assessor #1 on 02/05/2019 at 1340 recorded the patient was at the facility for "running away for undisclosed reasons. Recently wrote a suicide note with plan to die at the lake. ... visible cut marks on face, history of OD (overdose) on assigned meds, history of cutting on self ..." Review of a "Suicide Risk Monitoring Tool" dated 02/05/2019 (not timed) by Assessor #1 revealed the patient was identified as a "Medium Risk", which indicated "Place on 15 minute checks or close observation depending on the degree of lethality involved with the patient and as specified by the physician's order." Review of another "Evaluation of Risk" tool dated as completed by Assessor #1 on 02/05/2019 (not timed) revealed the patient was identified as "Moderate Risk" and "Moderate Vulnerability". Review of the tool recorded the patient had suicide ideations (thoughts) with a note to kill herself by drowning in a lake. Review of the assessment tool documented that the patient had repetitive thoughts with a plan that involved serious, lethal intent. Review of the record revealed a "High Risk/High Alert HANDOFF" form signed by Assessor #1 and RN #5 on 02/05/2019 at 1300 that documented the patient was a "High Risk" for "Suicidal" and "Elopement". Review of the form revealed the patient had a history of overdose, cutting, running away and suicide ideations with a plan to drown herself in a lake. Review of the form revealed the patient reported she was tired of living and that she refused to talk with the Assessor. Review of a nursing progress note dated 02/05/2019 at 2142 revealed the nurse heard a "Code White" (medical emergency) page and responded at 2142. Review of the note revealed Patient #17 was found at 2142 in bed with an abrasion and redness to the left side of her neck due to a string around her neck. Review revealed the patient was assessed and vital signs recorded. Review revealed the patient was coughing, able to talk and complained of throat pain. Review of the note revealed the patient was placed on one to one observation for safety after the incident. Review of the record revealed the nursing note recording the incident at 2142 was the first nursing documentation of the patient since arrival at 1237. Review of the record revealed an initial nursing assessment was documented at 2245 (10 hours and 8 minutes after arrival). Review of the nursing assessment recorded the patient had a red mark at her neck area related to "patient tried to choke" herself. Review of the admit note recorded by RN #6 at 2340 revealed the patient was "... very quiet, vague, and did not want to talk about why she is here. ... Before assessment tonight pt (patient) attempted to choke herself with a shoestring. Pt reports her only coping skill is to harm herself. Pt allowed to go back to bed and has 1:1 supervision at all times." Review of an "Evaluation of Risk" tool dated 02/05/2019 at 2300 revealed the patient was identified as "Imminent Risk" of suicide. Review of the tool recorded the patient had suicide ideations (thoughts) and recorded that the patient "wanted/attempted to tie a string around her neck to strangle herself." Review of the assessment tool documented that the patient had repetitive thoughts with a plan that involved serious, lethal intent. Review of physician's orders revealed a telephone order dated 02/05/2019 at 2300 to place the patient on 1:1 (observation) for SIB (self injurious behavior). Review revealed no physicians order for level of observation written prior to 2300 (10 hours and 23 minutes after the patient's arrival). Review of a nursing progress note dated 02/05/2019 at 2345 documented by LPN #1 recorded "Patient is a new admit. Spent the afternoon in bed resting. Later in shift, peer called stating that something was wrong with patient, and that she could hardly breathe. On arrival, it was noted that patient had tied a string and sock totally around her neck leaving an abrasion to right side of neck with redness around neck. Patient was assessed and noted to be breathing without any problems. Patient refused to talk, but did state 'This is what I do'. Mother also stated that she has done this before. Order obtained for 1:1 observation for safety. ..." Review of an observation Sheet dated 02/05/2019 revealed the patient was documented as observed every 15 minutes from 1300 through 2345. Review of the observation sheet recorded the patient was located in the assessment office and gym areas from 1300 through 1730. Review of the observation sheet revealed the patient was located on the nursing unit from 1800 through 2345.

Interview on 02/08/2019 at 0930 with Assessor #1 revealed he worked in the admissions and referral center and his role was to conduct a psychosocial assessment and evaluate risks of newly admitted patients. He stated he gathers information on new admissions and reports off to a nurse after his assessment is completed. The staff member stated he remembered Patient #17. He reported that the patient had suicide ideations with a plan to kill herself when she came in and was identified as a risk for self harm with his assessment tools. The staff member stated the patient refused to talk with him and he felt that was a "red flag". Interview revealed the staff member saw visible cut marks on the patient's face and she had a history of suicide attempts in the past. Assessor #1 stated "Her (suicide) notes were very thorough. She attempted to carry out her plan. She was unwilling to discuss. I was concerned she was going to carry out her plan. I talked with the male nurse day shift day of admission around 1230 or 1245 and provided the Handoff Alert at 1300. I advised him of my concerns. I didn't feel comfortable with every 15 minute observations. I felt like she needed a higher level of observations. Staff needed to be with her at all times. I was thinking one to one. I told the nurse and (Director of Nursing) that. I stayed with her until (MHT #5) arrived." The assessor stated the patient remained in the admissions area while he was assessing her and she had one to one staff with her during this time. Interview revealed the assessor talked with the Director of Nursing (DON) and relayed his concerns for safety and need for increased observations for Patient #17. The staff member stated he did not talk with the physician regarding his assessment of the patient. The staff member stated "We don't get any orders on admission. Orders are obtained through nursing staff." Interview revealed he had assisted with a search for contraband upon admission of the patient and that "hairbands are allowed unless they stretch very large. She had a faded gray small hair band in her hair that was not able to stretch much. She was allowed to keep it."

Interview on 02/08/2019 at 1350 with MHT #5 revealed she was pulled from her current position as an administrative assistant to provide one to one observation with Patient #17 on 02/05/2019. The staff member stated the DON and CEO had asked her to assist. The staff member stated "We always keep an eye on new admits in the admission area until they get to the unit. The nurse has to get an order for precautions when they get to the unit." Interview revealed MHT #5 remained with the patient until 1715 when she switched off with two admission and referral technicians to monitor the patient one to one in the admissions area.

Telephone interview on 02/08/2019 at 1310 with RN #5 revealed he was working day shift on the 200 hall when Patient #17 arrived on the unit. Interview revealed the staff member was an agency nurse that had worked at the facility around six weeks. The nurse stated this was his first time working on the 200 hall. The nurse stated Patient #17 was the third admission that he had that day and when Assessor #1 had brought the paperwork for Patient #17's admission to him around 1330, there was no bed available for her. He stated he let the assessor know there was no bed at that time and the assessor and the patient left the area. Interview revealed the patient and a female staff member returned to the unit around 1815 and he accepted the patient to the unit at that time. The nurse stated the patient had to wait in the day room while her room was being cleaned. The nurse stated there was "high acuity" on the unit that day and a "Code Purple (psychiatric emergency) occurred around 1830 on the unit. The nurse stated "All I did with (Patient #17) was told her to have a seat in the chair in the day room and that someone would be with her." The nurse stated he didn't do anything with the patient because he was involved in the code. RN #5 stated "all patients are on close observation for the first 24 hours after admission." The nurse stated "I was not told I could increase (level of observation) to one to one when I felt it was necessary." The nurse stated he did not take report on Patient #17 and that the House Supervisor took report on Patient #17 while he was at lunch. The nurse stated that normally the nurse has to call the physician for admission orders and stated "I had not been trained on the admission process." The nurse stated the House Supervisor told him what forms to complete with the new admissions. Interview with RN #5 revealed his shift ended and he reported to the oncoming shift that Patient #17 was on the unit and he had not assessed her. When asked if he assigned a staff member to observe Patient #17, the nurse stated "I don't know what happened, what the night nurse did. I do not know who was assigned to watch her. I gave report at 7:00 PM." The nurse stated "I got no report from (Assessor #1). I signed the patient in at 1830 and got the sheet (High Risk/High Alert HANDOFF sheet). I did not look at it."

Telephone interview on 02/08/2019 at 1020 with MHT #3 revealed the staff member was assigned to do close observation on a patient in bed B who was the roommate of Patient #17 on 02/05/2019. The staff member stated Patient #17 had the blanket pulled up around her neck, but her face was visible. She stated the room was dark. MHT #3 stated "I was at the doorway (of the room). I heard A bed (Patient #17) breathing funny." The staff member stated she asked MHT #4 to go with her to check on Patient #17. Interview revealed MHT #4 turned on the lights and saw the patient's face was discolored. The staff member stated she turned the patient toward her and removed a sock and two ponytail holders that were tied together and were around the patients neck. The staff member stated "She was breathing, abnormal breathing. I thought it was asthma." Interview revealed two patients ran to get the nurse who came and assessed the patient.

Interview on 02/07/2019 at 1540 with MHT #4 revealed she was called to come to the room because Patient #17 was breathing funny. The staff member stated "It was dark in the room. I saw something was not right. I have been a CNA (certified nursing assistant) for 29 years. I turned on the light. Her face was blue gray. I got the covers off and saw a yellow sock and ties around her neck. I removed them and turned her to the side and told her to breathe. She started to cough. The nurse arrived and took over."

An interview was attempted with RN #6 and LPN #1. (nurses working the 100/200 hall on 02/05/2019 nights). Neither was available for interview.

Interview on 02/07/2019 at 1630 with the CEO revealed the patient arrived to the facility at 1237 and Assessor #1 evaluated the patient. The CEO stated Assessor #1 and the Director of Nursing (DON) had approached her around 1330 with concerns about Patient #17. Interview revealed there had been multiple admissions on the 200 hall that day and Assessor #1 was concerned about the risk level of the patient with multiple admissions on the unit. Interview revealed there was no one to one level of observation ordered. The CEO stated "We decided a one to one would be an appropriate way to manage the patient." Interview revealed MHT #5 was placed with the patient one to one until she was handed off to the nurse at 1815. The CEO stated "The RN can, and is expected to evaluate and ensure the appropriate level of observation. If there was not staff available (RN #5) should have contacted the House Supervisor and staffing coordinator."

In summary, facility staff failed to provide a safe environment for the delivery of care to a newly admitted adolescent behavioral health patient identified with suicidal ideations. Findings revealed the patient was admitted at 1237 and had a known, identified risk of suicide thoughts with a plan. The patient was found at 2142 with hair ties and a sock tied around her neck. Findings revealed no nursing assessment of the patient was conducted until the time of the incident at 2142 and no orders for safety level of precautions were obtained from the physician until after the incident at 2300 when the patient was ordered on one to one monitoring.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of policy, medical records review, and staff interviews, the facility failed to identify and record an unusual patient occurrence for 2 of 20 sampled patients (Patient #5 and #6).

The findings include:

Review of the policy titled "Incident Reporting Policy" with a revised date of 05/24/2016 revealed "POLICY: Quality of care can always be improved and risks can always be minimized...Procedure: A. Employees who witness or are aware of an incident are responsible for completing an Incident Report at the time they become aware of the incident or as soon as the situation is under control."

Review of the policy titled "Risk Management/Incident Reporting" with a revised date of 05/24/2016 revealed, "Definition: Incidents - Any unusual or unexpected occurrence that results in injury or potential injury to patients ...Procedure: A. Employees who witness or are aware of an incident are responsible for completing an Incident Report at the time they become aware of the incident ..."

1. Review of the closed medical record for Patient #5 revealed he was a [AGE] year old male who had been admitted on [DATE] from an outside emergency department (ED) under involuntary commitment (IVC) orders after aggression toward family members, and attempted self-harm with a knife. Review of a "Physician Progress Note" by MD #2 dated 09/30/2018 at 1438 revealed "C/O (complains of) being dizzy-consult ordered (with) IM (Internal Medicine) team, ongoing concern for safety of self/others; recent att (? attack) ..." Review of a "Therapy Group Note" dated 10/01/2018 at 1300 by Therapist #1 revealed, "Patient processed the events from the weekend regarding his alteration with his roommate. Patient stated the roommate was throwing his hygiene items around the room: patient stated he accidentally stepped on his foot which caused a fight ..." Review of a "Medical Consult Form" signed by RN #1 (date and time not entered), and consultant notification (date and time not completed on the form) revealed a "STAT" (without delay) consult form which indicated "pt (patient) states he was hit on head C/O slight nausea." Review of the completed consult form listed the consult reason as headache after trauma, and plan as hourly neurologic checks, reporting of any nausea, vomiting, worsening headache, or vision changes, and "send to ER (emergency room ) if no better." Continued review revealed the consult was completed 10/02/2018 at 1514. Review revealed Patient #5 was discharged home on 10/02/2018 at 1515. Review of the chart revealed no documented aggression associated with Patient #5, notation of an altercation with a peer, alteration in levels of observation during the stay, notification to the parents of an aggression incident, or rationale for Patient #5's internal medicine consult.

Interview with the Utilization Review Director (URD) on 02/06/2019 at 1320 revealed there were no incident reports related to Patient #5's stay between 09/27/2018 and 10/02/2018.

Request to interview the registered nurse (RN) #1 who signed the consult sheet and provided care on the 800 hall revealed she was not available for interview.

Interview on 02/06/2019 at 1325 with Therapist #1 revealed she recalled Patient #5 and his dietary allergies, but did not remember "anything about an altercation with one of the other patients" although she had reviewed her 10/01/2018 note. Therapist #1 stated that if there was an altercation between patients, it would be normally "on shift report or on the back of their (patients) fifteen minute checks." Interview confirmed absence of altercation documentation.

Interview with the Nurse Practitioner (NP #1) on 02/07/2019 at 1400 who completed the medical consult for Patient #5 on 10/02/2018 revealed she did not know why the consult had not been completed on the weekend or on Monday 10/01/2018 since it was marked STAT. Interview revealed NP #1 typically worked days from Monday through Friday while other staff covered needs on nights and weekends. Interview revealed Patient #5 "had a little tenderness on the right" side of his face, but had no nausea, dizziness, or vomiting, and his vision was normal. Interview revealed NP #1 believed he was stable but if he had worsening symptoms he was to be sent to an emergency department for evaluation.

Interview with the Director of Nursing (DON) on 02/07/2019 at 1435 revealed that any time there was an aggression incident between patients, and especially if there was an allegation of injury, she expected an incident report to be entered for each of the individuals, and the administrator on call (AOC) to be notified as soon as reasonably possible. Interview revealed incidents from the previous day are reviewed in a morning meeting with the AOC to look for issues of concern, and try to prevent recurrence. Interview revealed an incident report was not written on the incident with Patient #5 and one should have been done.





2. Review of a closed medical record for Patient #6 (Pt #6) revealed a [AGE] year old male involuntarily committed to the facility on [DATE] with Disruptive Mood Dysregulation Disorder. Review of Pt #6's medical history revealed Conduct Disorder and Attention-Deficit Hyperactivity Disorder. Review of a Therapy Group Note signed by Therapist #8 on 12/22/2018 at 1234 revealed "Patient was getting his hair cut prior to group. Patient kept making comments about his hair, which was preventing group from starting." Review of the notes recorded the patient stated, "I can't believe I'm bald" and "I can't believe how short it is." Review of the note revealed the therapist redirected the patient to stop talking because he was preventing the group from beginning.

Telephone interview with Therapist #8 on 02/06/2019 at 1500 revealed upon entering the unit on 12/22/2018, she observed Mental Health Technician (MHT) #9 giving a haircut to Pt #6 using electric clippers. Therapist #8 reported informing MHT #9 that she should not be cutting Pt #6's hair to which MHT #9 replied "It's okay, I have approval." Therapist #8 reported she left the unit and notified the House Supervisor of the incident. Therapist #8 reported she returned to the unit with the House Supervisor and observed MHT #9 cutting a different patient's hair with electric clippers. Therapist #8 reported the House Supervisor spoke to MHT #9 and the Registered Nurse (RN) assigned to the unit. Therapist #8 reported this was the first time she observed a staff member cutting a patient's hair in the facility. Therapist #8 reported she observed MHT #9 cut two patient's hair with electric clippers.

An interview was attempted with MHT #9 who was not available for interview.

Interview with the House Supervisor (RN #8) on 02/06/2019 at 1600 revealed she was notified on 12/22/2018 by Therapist #8, that MHT #9 was cutting Pt #6's hair with clippers. The House Supervisor reported once notified of the incident, she walked to the unit and "immediately shut it (hair cutting) down." The House Supervisor reported she did not complete an incident report because Pt #6 was not injured. The House Supervisor revealed she realizes that she should have filed an incident report and notified Pt #6''s parent or guardian.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on policy review, medical record review, observation, and staff interview, the hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations by failing to ensure a newly admitted adolescent behavioral health patient with known plans to harm herself was assessed, evaluated and protected from a self harm by strangulation for 1 of 1 sampled patients that had a suicide gesture during admission (#17). Nursing staff failed to ensure safe administration of medications for 2 of 5 observed medications administered (#7 and #12) and failed to reconcile medications at admission and discharge for 1 of 9 sampled closed medical records (#5).

The findings include:

1. Nursing staff failed to assess, evaluate and protect an adolescent patient with known plans to harm herself from self harm by strangulation.

~cross refer to 482.23 (b)(3) Nursing Services Standard: Tag A0395

2. Nursing staff failed to provide safe administration of medications by allowing self administration of eye drops without a physician order; failing to document administration and refusal of medication on the MAR (medication administration records); and failing to accurately reconcile long term medications at admission and discharge.

~cross refer to 482.23 (c)(1) Nursing Services Standard: Tag A0406
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review and staff interview, nursing staff failed to assess, evaluate and protect an adolescent behavioral health patient with known plans to harm herself from self harm by strangulation for 1 of 1 sampled patients that had a suicide gesture during admission (#17).

The findings include:

Review of the "Suicide Risk Assessment" policy revised 05/24/2015 revealed "Each resident admitted to (named facility) shall be assessed for suicide risk upon admission ... If the nurse deems appropriate, the resident will be supervised as one to one observation until the MD (physician) is contacted and a decision is made at the level observation required. The SRA (Suicide Risk Assessment) score aids in identification of a high risk resident, however the score is not the requirement that mandates the physician's order. ..."

Review of the "Initial Nursing Assessment" policy revised 12/2016 revealed "All clients admitted to (named facility) will receive a comprehensive nursing assessment that will be utilized to help formulate the individualized plan of care. 1. A Registered Nurse will initiate the nursing portion of the Integrated Assessment upon the client's arrival at (the facility). The nursing assessment must be completed by a registered nurse within 8 hours of the client's admission. ... 5. Assessment of the client's nursing care needs will include: (a) Past and current medical psychiatric history ... (b) Mental status exam ...6. The nursing assessment includes a note documenting that the physician was notified of the client's arrival and any pertinent medical/psychiatric history."

Review of the "Level of Patient Observation" policy revised 07/29/2017 revealed "To provide the appropriate level of observation for those residents considered dangerous or at risk to themselves or others. (Named facility) has a primary responsibility to ensure the safety and well being of individuals within our care. ... Nursing personnel implements these levels of observation throughout the 24 hour period. Each resident is assigned to a staff member and staff must have relief present before leaving their assigned residents. Any staff member who becomes aware that a resident is in imminent danger of harming themselves or others will immediately ensure that the resident is under constant eye view of a staff member until the RN (registered nurse) and/or Psychiatrist is notified and present to assess the resident. ... Fifteen minute observation is required for all residents. ... Close observation (Line of sight observation). The assigned staff maintains a full, unobstructed view of the resident at all times ... One to one observation ... The staff member assigned is in constant visual range of the resident and is within arms's length of the resident at all times ... The RN may initiate a higher level of observation based on a resident's status, but can never decrease the observation level without a psychiatrist's order. ... Upon identifying that a resident is in need of a higher level of observation, the RN will ... contact the Milieu Manager who will ensure adequate staffing is available to provide the increased level of observation. ... Upon admission to the facility, an initial risk assessment should be completed by the RN ...While maintaining the resident's privacy and dignity, two staff members will conduct a room and body search for any potentially dangerous items such as shoelaces, hairpins ... Any potentially hazardous items are to be removed from the resident's possession. ..."

Medical record review on 02/06/2019 of Patient #17 revealed a [AGE] year-old female admitted on [DATE] at 1237 under involuntary commitment status with a diagnosis of Disruptive Mood Dysregulation Disorder (DMDD).
Review of a "Safety Search Form" dated 02/05/2019 revealed Assessor #1 and another staff member conducted a safety search at 1305 that included a search of hair, tongue, underarms, fingers, toes, belongings, and clothing including belts and strings. Review of a "Comprehensive Psychosocial Assessment Tool" completed by Assessor #1 on 02/05/2019 at 1340 recorded the patient was at the facility for "running away for undisclosed reasons. Recently wrote a suicide note with plan to die at the lake. ... visible cut marks on face, history of OD (overdose) on assigned meds, history of cutting on self ..." Review of a "Suicide Risk Monitoring Tool" dated 02/05/2019 (not timed) by Assessor #1 revealed the patient was identified as a "Medium Risk", which indicated "Place on 15 minute checks or close observation depending on the degree of lethality involved with the patient and as specified by the physician's order." Review of another "Evaluation of Risk" tool dated as completed by Assessor #1 on 02/05/2019 (not timed) revealed the patient was identified as "Moderate Risk" and "Moderate Vulnerability". Review of the tool recorded the patient had suicide ideations (thoughts) with a note to kill herself by drowning in a lake. Review of the assessment tool documented that the patient had repetitive thoughts with a plan that involved serious, lethal intent. Review of the record revealed a "High Risk/High Alert HANDOFF" form signed by Assessor #1 and RN #5 on 02/05/2019 at 1300 that documented the patient was a "High Risk" for "Suicidal" and "Elopement". Review of the form revealed the patient had a history of overdose, cutting, running away and suicide ideations with a plan to drown herself in a lake. Review of the form revealed the patient reported she was tired of living and that she refused to talk with the Assessor. Review of a nursing progress note dated 02/05/2019 at 2142 revealed the nurse heard a "Code White" (medical emergency) page and responded at 2142. Review of the note revealed Patient #17 was found at 2142 in bed with an abrasion and redness to the left side of her neck due to a string around her neck. Review revealed the patient was assessed and vital signs recorded. Review revealed the patient was coughing, able to talk and complained of throat pain. Review of the note revealed the patient was placed on one to one observation for safety after the incident. Review of the record revealed the nursing note recording the incident at 2142 was the first nursing documentation of the patient since arrival at 1237. Review of the record revealed an initial nursing assessment was documented at 2245 (10 hours and 8 minutes after arrival). Review of the nursing assessment recorded the patient had a red mark at her neck area related to "patient tried to choke" herself. Review of the admit note recorded by RN #6 at 2340 revealed the patient was "... very quiet, vague, and did not want to talk about why she is here. ... Before assessment tonight pt (patient) attempted to choke herself with a shoestring. Pt reports her only coping skill is to harm herself. Pt allowed to go back to bed and has 1:1 supervision at all times." Review of an "Evaluation of Risk" tool dated 02/05/2019 at 2300 revealed the patient was identified as "Imminent Risk" of suicide. Review of the tool recorded the patient had suicide ideations (thoughts) and recorded that the patient "wanted/attempted to tie a string around her neck to strangle herself." Review of the assessment tool documented that the patient had repetitive thoughts with a plan that involved serious, lethal intent. Review of physician's orders revealed a telephone order dated 02/05/2019 at 2300 to place the patient on 1:1 (observation) for SIB (self injurious behavior). Review revealed no physicians order for level of observation written prior to 2300 (10 hours and 23 minutes after the patient's arrival). Review of a nursing progress note dated 02/05/2019 at 2345 documented by LPN #1 recorded "Patient is a new admit. Spent the afternoon in bed resting. Later in shift, peer called stating that something was wrong with patient, and that she could hardly breathe. On arrival, it was noted that patient had tied a string and sock totally around her neck leaving an abrasion to right side of neck with redness around neck. Patient was assessed and noted to be breathing without any problems. Patient refused to talk, but did state 'This is what I do'. Mother also stated that she has done this before. Order obtained for 1:1 observation for safety. ..." Review of an observation Sheet dated 02/05/2019 revealed the patient was documented as observed every 15 minutes from 1300 through 2345. Review of the observation sheet recorded the patient was located in the assessment office and gym areas from 1300 through 1730. Review of the observation sheet revealed the patient was located on the nursing unit from 1800 through 2345.

Interview on 02/08/2019 at 0930 with Assessor #1 revealed he worked in the admissions and referral center and his role was to conduct a psychosocial assessment and evaluate risks of newly admitted patients. He stated he gathers information on new admissions and reports off to a nurse after his assessment is completed. The staff member stated he remembered Patient #17. He reported that the patient had suicide ideations with a plan to kill herself when she came in and was identified as a risk for self harm with his assessment tools. The staff member stated the patient refused to talk with him and he felt that was a "red flag". Interview revealed the staff member saw visible cut marks on the patient's face and she had a history of suicide attempts in the past. Assessor #1 stated "Her (suicide) notes were very thorough. She attempted to carry out her plan. She was unwilling to discuss. I was concerned she was going to carry out her plan. I talked with the male nurse day shift day of admission around 1230 or 1245 and provided the Handoff Alert at 1300. I advised him of my concerns. I didn't feel comfortable with every 15 minute observations. I felt like she needed a higher level of observations. Staff needed to be with her at all times. I was thinking one to one. I told the nurse and (Director of Nursing) that. I stayed with her until (MHT #5) arrived." The assessor stated the patient remained in the admissions area while he was assessing her and she had one to one staff with her during this time. Interview revealed the assessor talked with the Director of Nursing (DON) and relayed his concerns for safety and need for increased observations for Patient #17. The staff member stated he did not talk with the physician regarding his assessment of the patient. The staff member stated "We don't get any orders on admission. Orders are obtained through nursing staff." Interview revealed he had assisted with a search for contraband upon admission of the patient and that "hairbands are allowed unless they stretch very large. She had a faded gray small hair band in her hair that was not able to stretch much. She was allowed to keep it."

Interview on 02/08/2019 at 1350 with MHT #5 revealed she was pulled from her current position as an administrative assistant to provide one to one observation with Patient #17 on 02/05/2019. The staff member stated the DON and CEO had asked her to assist. The staff member stated "We always keep an eye on new admits in the admission area until they get to the unit. The nurse has to get an order for precautions when they get to the unit." Interview revealed MHT #5 remained with the patient until 1715 when she switched off with two admission and referral technicians to monitor the patient one to one in the admissions area.

Telephone interview on 02/08/2019 at 1310 with RN #5 revealed he was working day shift on the 200 hall when Patient #17 arrived on the unit. Interview revealed the staff member was an agency nurse that had worked at the facility around six weeks. The nurse stated this was his first time working on the 200 hall. The nurse stated Patient #17 was the third admission that he had that day and when Assessor #1 had brought the paperwork for Patient #17's admission to him around 1330, there was no bed available for her. He stated he let the assessor know there was no bed at that time and the assessor and the patient left the area. Interview revealed the patient and a female staff member returned to the unit around 1815 and he accepted the patient to the unit at that time. The nurse stated the patient had to wait in the day room while her room was being cleaned. The nurse stated there was "high acuity" on the unit that day and a "Code Purple (psychiatric emergency) occurred around 1830 on the unit. The nurse stated "All I did with (Patient #17) was told her to have a seat in the chair in the day room and that someone would be with her." The nurse stated he didn't do anything with the patient because he was involved in the code. RN #5 stated "all patients are on close observation for the first 24 hours after admission." The nurse stated "I was not told I could increase (level of observation) to one to one when I felt it was necessary." The nurse stated he did not take report on Patient #17 and that the House Supervisor took report on Patient #17 while he was at lunch. The nurse stated that normally the nurse has to call the physician for admission orders and stated "I had not been trained on the admission process." The nurse stated the House Supervisor told him what forms to complete with the new admissions. Interview with RN #5 revealed his shift ended and he reported to the oncoming shift that the patient was on the unit and he had not assessed her. When asked if he assigned a staff member to observe Patient #17, the nurse stated "I don't know what happened, what the night nurse did. I do not know who was assigned to watch her. I gave report at 7:00 PM." The nurse stated "I got no report from (Assessor #1). I signed the patient in at 1830 and got the sheet (High Risk/High Alert HANDOFF sheet). I did not look at it."

Telephone interview on 02/08/2019 at 1020 with MHT #3 revealed the staff member was assigned to do close observation on a patient in bed B who was the roommate of Patient #17 on 02/05/2019. The staff member stated Patient #17 had the blanket pulled up around her neck, but her face was visible. She stated the room was dark. MHT #3 stated "I was at the doorway (of the room). I heard A bed (Patient #17) breathing funny." The staff member stated she asked MHT #4 to go with her to check on Patient #17. Interview revealed MHT #4 turned on the lights and saw the patient's face was discolored. The staff member stated she turned the patient toward her and removed a sock and two ponytail holders that were tied together and were around the patients neck. The staff member stated "She was breathing, abnormal breathing. I thought it was asthma." Interview revealed two patients ran to get the nurse who came and assessed the patient.

Interview on 02/07/2019 at 1540 with MHT #4 revealed she was called to come to the room because Patient #17 was breathing funny. The staff member stated "It was dark in the room. I saw something was not right. I have been a CNA (certified nursing assistant) for 29 years. I turned on the light. Her face was blue gray. I got the covers off and saw a yellow sock and ties around her neck. I removed them and turned her to the side and told her to breathe. She started to cough. The nurse arrived and took over."

An interview was attempted with RN #6 and LPN #1 (nurses working the 100/200 hall on 02/05/2019 nights). Neither was available for interview.

Interview on 02/07/2019 at 1600 with the DON revealed Patient #17 was admitted and assessed by Assessor #1 who provided a "Handoff report" to nursing. Interview revealed nursing staff should notify the physician of the admission and obtain orders including level of observations. Interview revealed the patient arrived on the nursing unit around 1815 and the nurse should have started the admission process. The DON stated she had talked with the nurse and he had failed to notify the House Supervisor or the DON of the increased acuity and need for help.

Interview on 02/07/2019 at 1630 with the CEO revealed the patient arrived at 1237 and Assessor #1 evaluated the patient. The CEO stated Assessor #1 and the DON had approached her around 1330 with concerns about Patient #17. Interview revealed there had been multiple admissions on the 200 hall that day and Assessor #1 was concerned about the risk level of the patient with multiple admissions on the unit. Interview revealed there was no one to one level of observation ordered. The CEO stated "We decided a one to one would be appropriate way to manage the patient." Interview revealed MHT #5 was placed with the patient one to one until she was handed off to the nurse at 1815. The CEO stated "The RN can, and is expected to evaluate and ensure the appropriate level of observation. If there was not staff available (RN #5) should have contacted the House Supervisor and staffing coordinator."

In summary, facility nursing staff failed to ensure assessment and supervision of a adolescent behavioral health patient that was admitted with identified suicide risks. Nursing staff failed to evaluate and assess the patient's needs and failed to obtain physician admitting orders for a level of observation upon arrival to the nursing unit. The patient was found with hair ties and a sock around her neck nine hours and five minutes after arriving and prior to a nursing assessment being conducted.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of policies, observations, review of medical records, and interviews with staff, nursing staff failed to provide safe administration of medications by allowing a patient to self administer eye drops without a physician order for 1 of 5 medication observations (Patient #7); failing to document administration and refusal of medication on the MAR (medication administration records) for 2 of 5 observed medications administered (Patient #7 and #12); and failing to accurately reconcile long term medications at admission and discharge for 1 of 9 sampled closed medical records (Patient #5).

The findings include:

1. Review of policy titled "Self-Administration of Medications by Residents" with revised date of 01/23/2018 revealed "Policy: Residents shall be allowed to self-administer medications if permitted to do so by the prescribing physician..."

Observation on 02/05/2019 at 1400 of medication administration revealed RN #1 gave the eye drop bottle to Patient #7 to self administer the eye drops. The patient attempted to instill an eye drop into the right eye, then asked for help with administration, saying "I need some help."

Review of open medical record of Patient #7 revealed a [AGE] year old female admitted on [DATE] for Mood Dysregulation Disorder. Review of a physician's order written and signed on 01/24/2019 at 2005 revealed "Artificial Tears...Instill 1 drop in each eye PRN (as needed)." Review revealed no physician order for the patient to self administer the eye drops.

Interview on 02/05/2019 at 1405 with RN #7 revealed the patient had self administered eye drops in the past.

Interview on 02/05/2019 at 1445 with the CNO (Certified Nursing Officer) revealed an order was needed for patients to self administer medications. Interview revealed no order was found in the medical record for Patient #7 to self administer the eye drops. Interview revealed the patient should not have been allowed to self administer the eye drops.

2. Review of a policy titled Medication Administration--General Guidelines with a revision date of 01/23/2018 revealed "...7. When PRN (as needed) medications shall be administered, the following documentation is provided: a. Date and time of administration, dose, route of administration (if other than oral)....b. Complaints or symptoms for which the medications were given. c. Results achieved from giving the dose and the time results were noted...."

Observation on 02/05/2019 at 1400 of medication administration revealed RN #7 administered one drop of Artificial Tears eye drops in each eye.

Review of an open medical record for Patient #7 revealed a [AGE] year old female admitted on [DATE] for Mood Dysregulation Disorder. Review of a physician order written on 01/25/2019 for "Artificial Tears OPTH (Ophthalmic-eye)--Instill one drop into both eyes as needed for dry eyes." Review on 02/06/2019 at 1000 of a MAR for Patient #7 revealed no documentation entry for eye drops administered by RN #7 on 02/05/2019 at 1400. Review revealed no date, time or initials to indicate administration of eye drops. Review revealed no documentation entry on back of MAR under Nurse's Medication Notes. "Date/Hour, Medication/Dosage, Reason, Results/Response and Hour/Initials" sections were not completed. RN #7 had not written an entry documenting the administration of the PRN eye drops upon review on 02/06/2019 at 1000 (10 hours after the medication was administered).

Interview on 02/06/2019 at 1000 with the CNO revealed the nurse is expected to document on the MAR when medications are administered. Interview revealed RN #1 failed to document administration of medication and failed to follow the hospital medication administration policy.

3. Review of policy titled "Medication Administration--General Guidelines" with a revision date of 01/23/2019 revealed "...8. If a dose of regularly scheduled medication is withheld or refused, documentation of the reason for this missed dose is provided in the MAR..."

Observation on 02/05/2019 at 1400 of medication administration revealed RN #7 placed Fish Oil (Vitamin) 1000 mg (milligrams) in a medication cup. Patient #12 refused the capsule.

Review of the open medical record of Patient #12 revealed a [AGE] year old female admitted on [DATE] for Mood Dysregulation Disorder. Review of a physician's order written on 02/02/2019 revealed "Fish Oil 1000 mg capsule: Give 1 capsule by mouth three times daily." Review on 02/06/2019 at 1000 of MAR revealed no documentation on the MAR of refusal of the Fish Oil medication attempted on 02/05/2019 at 1400 by RN #7. Review revealed the time of the medication was blank. Review revealed no documentation of a reason for refusal of medication.

Interview on 02/06/2019 at 1000 with the CNO revealed nurses are expected to complete documentation of medication administration or refusal. Interview revealed documentation should reflect the refusal of the medications.





4. Review of the policy titled "Medication Reconciliation" with a revised date of 12/2016 revealed "Policy: (Named facility) ensures that a complete list of medications is documented at the time of the patient's admission and a current list of medications is shared with providers at the time of transitions in care to outside hospitals and to aftercare providers. Procedure: 1. Upon admission the Registered Nurse (RN) documents a complete list of all medications the patient is currently prescribed or taking on the Medication Reconciliation Form... 4. The medication information that the patient brought to the facility will be compared to the medications ordered for the patient by the physician, PA/NP (Physician Assistant/Nurse Practitioner) or RN in order to identify and resolve discrepancies ...6. At the time of discharge, the nurse will list the patient's current medications as noted on the physician's discharge orders on the Discharge Plan ..."

Review of the closed medical record for Patient #5 revealed he was a [AGE] year old male who had been admitted to the facility on [DATE] from an outside emergency department (ED) under involuntary commitment (IVC) orders after aggression toward family members, and attempted self-harm with a knife. Review of an initial "History and Physical Evaluation" dated 09/27/2018 at 1615 noted " ...mod (moderate) persistent asthma, Bipolar, anxiety, ADHD...(and) Current Prescription Medications ...Flovent ...Albuterol ..." Review of the current medication list from the transferring ED indicated Patient #5 used fluticasone 44 mcg (micrograms)/activation, two inhalations BID (twice a day), and had received doses at the outside ED from 09/25/2018 to 09/27/2018. Review revealed his latest dose was on 09/27/2018 at 0801. Review revealed Patient #5 used albuterol 90 mcg/actuation, two inhalations every six hours as needed, and had received the latest dose on 09/26/2018 at 1642. Review of the Medication Reconciliation Form transcribed by a RN on 09/27/2018 at 1251 and cosigned by a physician (MD) #1 on 09/28/2018 at 0906 listed "Flovent (fluticasone) INH (inhaled) 2 puffs BID (twice a day), (and) Albuterol INH 2 puffs q6 prn (every 6 hours as needed). Review of telephone medication orders received from MD #2 on 09/27/2018 at 1600 revealed "110 Flovent inhaler 2 puffs BID PRN (and) Albuterol inhaler 2 puffs q6 PRN..." Review of an amended telephone medication order for Flovent on 09/30/2018 revealed the previous order was changed to "Flovent 44 mcg Inhaler 2 puffs BID PRN." Review of the medical record revealed orders for Flovent and albuterol were unchanged for the remainder of the admission. Review of the Medication Record revealed Flovent was administered once on 10/02/2018 and albuterol was administered twice during the six day admission. Review of the Continuing Care/Discharge Summary 10/02/2018 at 1250 revealed Flovent and albuterol were not included on the discharge medication list, and prescriptions for them had not been provided by MD #1.

Interview with RN #4 on 02/06/2019 at 1050 revealed she had transcribed Patient #5's medications onto the Medication Reconciliation Sheet for physician review. RN#4 confirmed she had transcribed medications onto the reconciliation sheet and had transcribed Flovent as a twice a day medication. Interview revealed it had been RN #4's first day at the facility, and another nurse had contacted a facility physician to review the medications, and transcribe the verbal medication orders.

A telephone interview with RN #2 was conducted on 02/06/2019 at 1540. Interview revealed RN #2 did not recall the patient and could not provide information on the orders.

Request for interview with RN #1 who entered amended telephone verbal medication orders on 09/30/2018 revealed she was unavailable for interview.

Telephone interview with MD #2 on 02/07/2019 at 1010 revealed he had been the psychiatric physician on call the week of 09/24/2018. Interview revealed MD #2 did not remember Patient #5, and did not have access to the medical record.

Interview with MD #1 on 02/07/2019 at 1320 revealed he had been the discharging physician for Patient #5, and later, confirmed his signature on the medication reconciliation form. During interview, MD #1 stated "I deal with psychiatric problems and not with the medical side. We have a medical team that deals with it." Interview revealed MD #1 did not recall the details regarding Flovent and albuterol orders and did not "remember in this case why the Flovent was not prescribed at discharge but there was no need to prescribe it."

Interview with NP #1 on 02/07/2019 at 1400 revealed she worked for the facility's medical consult service. Interview revealed she had done Patient #5's admission history and physical and noted his use of Flovent and albuterol in the record. NP #1 revealed that if a psychiatrist wanted input on a non-psychiatric medication, a "pink" consultation sheet would be left "flagged" on the chart for the medical service, indicating a requesting for their input. Interview revealed no consult request was evident from her review of the closed record. NP #1 noted the initial medical reconciliation sheet was correct except, since Flovent came in different strengths, the dose per inhalation was "missing." Interview with NP #1 revealed she knew of no reason to prescribe Flovent on an as needed (PRN) basis since it was prescribed to reduce the likelihood of asthma attacks, and was not an asthma rescue medication. "There's no reason to change Flovent from BID to BID PRN," she stated.

Interview with a hospital pharmacist, on 02/06/2019 at 1026, revealed the pharmacist was not involved with medication reconciliation. Interview revealed nurses were responsible for medication reconciliation, and "confirm it with the MD on-call."

NC ; NC 673; NC 117; NC 042; NC 5; NC 313