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 March 11, 2021
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0160
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of policy and procedures, medical records, and staff and physician interviews, the facility staff failed to identify a chemical restraint for 2 of 4 chemically restrained patients sampled (Patient #6 and #1).

Findings included:

1. Review on 3/11/2021 of the facility policy titled "Seclusion and Physical or Chemical Restraints," revised 04/28/2020, revealed "A chemical restraint means the administration of a medication(s) which is neither a part of the client`s daily medicine regimen or a treatment for the client`s medical or psychiatric condition and is used for the primary purpose of restricting a client`s freedom of movement, or for the primary purpose of controlling a client`s behavior ... Appendix A ... The following Chemical Restraint Criteria Distinction from the Centers for Medicare and Medicaid services (CMS) provides questions which shall be used to evaluate if a medication meets the definition for Chemical Restraint based upon the LCA [unknown] and CMS` definitions. 1. Is medication a standard treatment for the client`s psychiatric condition? 2. Is the medication a part of their daily medication regime? 3. Is the medication used primarily to control the client`s behavior? 4. Is the medication being given to restrict the client`s freedom of movement? If the response to 1 or 2 is "No" and "Yes" to 3 or 4 it is a Chemical Restraint ..."

Closed medical record review on 03/11/2021 of Patient #6 revealed a [AGE] year old male patient admitted on [DATE] involuntarily for suicidal and homicidal ideations. Review of a nurse practitioner`s order dated 01/22/2021 at 1340 revealed " ...continue LOS [line of sight] c [with] blocked room [no roommate] at all times. Thorazine [medication used to reduce aggression and behavioral problems] 150 mg [milligrams] x (times) 1 IM [intramuscular] now Ativan [medication used to treat anxiety] 2 mg x 1 IM now. Review of a nursing summary note dated 01/22/2021 at 1645 revealed " ... [patient name] became upset again later that day, when writer called him to the med [medicine] window to take meds. He stated he doesn`t take any med + [and] that he wasn`t taking them. Writer informed him that it was a scheduled medication + that he has a right to refuse but to not get upset about it. He started yelling + began kicking the unit door. He kicked off the unit + refused to go back on the hall. Staff was able to talk to him + redirect behavior. [Patient name] agreed to take the scheduled medication + prn [as needed] meds by mouth..." Review of a nurse practitioner`s order dated 01/22/2021 at 1730 revealed "order for Thorazine and Ativan IM written at 1340 today may be given: Thorazine 150 mg IM or PO [oral] X1 Ativan 2 mg IM or PO x 1 (Both given PO @ 1444 this order is complete." Review of the medical record revealed no available documentation of a physician order for chemical restraints.

Interview on 03/11/2021 at 0950 with RN #9, revealed "If he was not in a hold, I would not do a restraint packet and not consider it a chemical restraint. Interview revealed the medications given would have the same desired effect just slower and the outcome [side effects] the same regardless of orally or IM. Interview revealed after review of the facility policy RN #9 stated, "I would call that a chemical restraint from the perspective of the meds given regardless of route." Interview revealed the medications were not identified as a chemical restraint per the facility policy.

Interview on 03/11/2021 at 1435 with Nurse Practitioner (NP) #12, whom cared for Patient #6, revealed the nurse on the unit on 01/22/2021 voiced to her that she may be able to get Patient #6 to take the Thorazine and Ativan orally and if so, could she. The NP gave a verbal order that the nurse could give orally if able. The NP then wrote a clarification order to reflect the change in route. Interview revealed the NP was on the unit and observed Patient #6 "busting up the place" and considered it an "emergency situation because of his behavior." Interview revealed "the need was there for a chemical restraint." Interview revealed the medications were "sedating and a high dose because he was that bad."

2. Review on 3/11/2021 of the facility policy titled "Seclusion and Physical or Chemical Restraints," revised 07/2019 revealed "A chemical restraint means the administration of a medication(s) which is neither a part of the client`s daily medicine regimen or a treatment for the client`s medical or psychiatric condition and is used for the primary purpose of restricting a client`s freedom of movement, or for the primary purpose of controlling a client`s behavior ... Appendix A ...The following Chemical Restraint Criteria Distinction from the Centers for Medicare and Medicaid services (CMS) provides questions which shall be used to evaluate if a medication meets the definition for Chemical Restraint based upon the LCA [unknown] and CMS` definitions. 1. Is medication a standard treatment for the client`s psychiatric condition? 2. Is the medication a part of their daily medication regime? 3. Is the medication used primarily to control the client`s behavior? 4. Is the medication being given to restrict the client`s freedom of movement? If the response to 1 or 2 is "No" and "Yes" to 3 or 4 it is a Chemical Restraint ..."

Closed medical record review on 03/11/2021 of Patient #1 revealed a [AGE] year old male admitted on [DATE] for major depressive disorder involuntarily for threatening to kill himself and his mother. Patient #1`s history included Obsessive Compulsive Disorder, Anxiety, Attention Deficit Disorder, and Self-injurious Behavior, Suicidal Ideations and increased conflict with family. Patient #1`s home medications included Clonidine (medication used for Attention Deficit Disorder and anxiety) 0.3 milligrams daily. Review of a nursing assessment dated [DATE] at 1155, revealed "Mom, dad, and Patient very anxious & agitated. Pt [Patient] did a low volume scream, clenched his fists, & then scratch [sic] the sides of his face ...Obvious tension & conflict between parents." Review of a physician order dated 11/17/2019 at 1222 revealed "...Seroquel [antipsychotic medication used to treat depression] 100mg [milligrams] po [oral] once- agitation; Benadryl [medication used to prevent unwarranted side effects of psychiatric drugs] 50 mg po once- EPS ppx [sic] [extrapyramidal symptoms prophylaxis-prevent involuntary movements of psychiatric medications]; and Ativan [medication used to treat anxiety] 1 mg po once-anxiety." Review revealed the 3 medications were taken by Patient #1 voluntarily by mouth at 1235. Review revealed no available documentation of prior use of Ativan, Seroquel, and Benadryl by Patient #1. Review of the medical record revealed no available documentation of a physician order for chemical restraints.

Interview on 03/11/2021 at 0950 with RN #9, revealed "If he was not in a hold, I would not do a restraint packet and not consider it a chemical restraint. Interview revealed the medications given would have the same desired effect just slower and the outcome [side effects] the same regardless of orally or IM. Interview revealed after review of the facility policy RN #9 stated, "I would call that a chemical restraint from the perspective of the meds given regardless of route." Interview revealed the medications were not identified as a chemical restraint per the facility policy.

Interview on 03/10/2021 at 1006 with Pharmacist #10 revealed the combination of the three medications were not commonly ordered at the facility. Interview revealed Seroquel`s side effects included sleepiness and fatigue, and/or lack of energy with a slow onset; Benadryl`s side effects included sleepiness and fatigue, and/or lack of energy and dry mouth.; Ativan`s side effects included sleepiness. Interview revealed the expected outcome of all 3 medications given would have been sleepiness and tiredness. Interview revealed the combination of the three medications would restrict the patient`s freedom of movement. Interview revealed Seroquel, Ativan and Benadryl given together orally would have "fit the definition of a chemical restraint."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, and staff interview facility staff failed to monitor patients after administration of a chemical restraint according to the facility's policy for 4 of 4 sampled patients who received a chemical restraint (Patients #7, #5, #6, and #1).

The findings include:

Review 03/11/2021 of the facility policy titled "Seclusion and Physical or Chemical Restraints," revised 04/28/2020, revealed " ... Assessment will include evaluation of patient`s immediate situation; reaction to the intervention; current psychological status and need to continue or terminate the emergency intervention; physical assessment including skin integrity, respiratory/circulatory status, nutrition/hydration, pain, and review of medications; and lab results. This Seclusion/Restraint Hourly Flow Sheet shall be continued whereby the above parameters are documented for the patient every 15 minutes for physical restraints or episodes of seclusion for the duration of the event and, for chemical restraints, for one consecutive hour ... Implementation of Order ... C. ... For incidents of chemical restraints, patients are observed and findings of same documented every 15 minutes times four, or one hour ... d. An RN (registered nurse) assesses the patient in physical restraint or seclusion or who has received a chemical restraint and documents the assessment at least every hour (or more frequently as warranted by the patient's condition by unstable vital sign findings) during the restraint or seclusion episode. For chemical restraints, the RN assesses the patient hourly times two hours then resumes her regular schedule of assessment of the patient that routinely occurs during his/her shift ... Full vital signs (Blood pressure, pulse, respirations [and encompassing the patient's temperature unless unable to obtain due to the patients level of agitation]) are taken at the frequency determined by the RN assessment ... every 30 minutes times two for episodes of chemical restraint ... f. Nursing staff/direct care staff monitors the physical and psychological status of the patient for a minimum of one hour following release from seclusion or restraint or after having received a chemical restraint ..."

1. Review of open medical record conducted on 03/10/2021 0925 revealed Patient #7 was a [AGE]-year-old male IVC (involuntary committed) on 12/30/2020. Review of Initial Psychiatric Evaluation completed by Physician Assistant #16 on 12/31/2020 (no time indicated) revealed " ...He held a knife to his throat and threatened to kill himself. He physically attacked his mother using a taser gun on her twice grabbing her around the throat leaving marks on her arm and neck. He has bipolar disorder and other mental health conditions but refuses to take meds. He needs placement and is a danger to himself and others. Pt (patient) reports that his actions were all in order to get mom out of his room as he doesn't like people 'touching my stuff' (sic) and if he could go back he would stab/kill/tase my mom more.' While in intake pt threw hand sanitizer on staff ..." Review of a PHYSICIAN ORDER SHEET dated 02/15/2021 at 1050 completed by LPN #17 (Licensed Practical Nurse) revealed "Administer Haldol (medication used to treat mental disorders) 5mg (milligram), Benadryl (medication used to induce drowsiness) 50mg, Ativan (medication used to treat mental disorders) 1mg IM (intramuscular) injection for unsafe behaviors now. One-time dose TO (telephone order): NP #12 (Nurse Practitioner)/LPN #17." Review of Medication Administration Record February 11, 2021 - February 17, 2021 revealed Haldol 5mg IM now, Ativan 1mg IM now, Benadryl 50mg IM now were administered by LPN #17 on 02/15/2021 at 1104. Review of SECLUSION AND/OR RESTRAINT CHECKLIST FOR EMERGENCY BEHAVIOR MANAGEMENT dated 02/15/2021 1052 completed by RN #9 (registered nurse) revealed face-to-face evaluation was completed by RN #9 on 02/15/2021 at 1109. Review of 24-HOUR REGISTERED NURSE DAILY MENTAL STATUS ASSESSMENT completed by LPN #17 on 02/15/2021 at 1608 revealed "...Patient #7 became upset & (and) refused to program. He got upset & began banging his head on the door & punching the door. Staff tried to redirect behavior (sic) he became more agitated. He spit at staff, kicked staff, & punched a staff (sic). He was placed into a therapeutic hold and escorted to the quiet room. IM injections were administered 50mg Benadryl, 5mg Haldol, 1mg Ativan per MD order ...Patient #7 showed no adverse reactions & has since been programming well and interacting appropriately ..." Review of Patient Observation Rounds completed by MHT #18 (Mental Health Technician) on 02/15/2021 (no time indicated) revealed " ...Resident refused to participate in Rec (recreational) therapy & Demanded (sic) to be let into his room. Became aggressive towards staff & Punched (sic) 2 different Members (sic) of Staff (sic). Was escorted to Quiet (sic) room & Given PRN (as needed). SPatt (sic) & threw water on the floor ..." Review revealed no evidence of an hourly assessment completed post chemical restraint administration nor a second set of vital signs recorded 30 minutes times two. Record review revealed Patient #7 is still currently a patient at facility.

Interview with RN #6 conducted on 03/10/2021 at 1540 revealed when she administers a chemical restraint she documents the initial assessment and vital signs on the packet then in one hour she documents the effectiveness of the chemical restraint on the back of the MAR (Medication Administration Record).

Interview with LPN #17 conducted on 03/10/2021 at 1602 revealed as an LPN she can not administer chemical restraints or complete the packet associated with a restraint. Interview further revealed she contacts the RN supervisor when a restraint is required. LPN revealed, "I contact the patient's family, the doctor and the AOC (administrator on call).

Interview with RN #9 House Supervisor conducted on 03/11/2021 at 1008 revealed she recalled Patient #7 and the incident that occurred on 02/15/2021. She reviewed the physician's order, MAR, nurses' notes, restraint documentation, incident report and policy and procedure titled "Seclusion and Physical or Chemical Restraint" and verified the administration of a chemical restraint. Interview revealed "I can't remember this policy regarding the two hours." Interview and review of said documents revealed there was not a second nursing assessment and second set of vital signs documented for the chemical restraint administered on 02/15/2021 at 1104. Interview revealed "I go back in 30 minutes to observe patient ...Effective or is he sleeping. Checking vital signs. Make sure pt (patient) is safe." Interview revealed "we are supposed to do another face-to face" in an hour. I don't necessarily get two sets of vital signs. I document the effectiveness." Interview further revealed "there is not a place to document the second face-to-face assessment so if it was completed it would be in a nurse's note." RN House Supervisor stated a face-to-face assessment is completed within an hour of chemical restraint administration and includes physically seeing patient, assessing vital signs, checking for injuries, performing a full body assessment, and checking for pain.

Interview and review of open medical record for Patient #7 conducted on 03/10/2021 at 1400 with CNO #4 (Chief Nursing Officer) revealed there was not a second nursing assessment and second set of vital signs documented for the chemical restraint administered on 02/15/2021 at 1104.





2. Closed medical record review revealed Patient #5 was a [AGE]-year-old male admitted to the facility on [DATE] with diagnoses of Major Depressive Disorder and Post Traumatic Stress Disorder. Review revealed Patient #5 received Zyprexa and Ativan (psychiatric medications) on 01/06/2021 at 1904 for escalating aggressive behavior. Review revealed a RN performed a face to face assessment on Patient #5 on 01/06/2021 at 1905. Review revealed no evidence an hourly assessment times two of the patient's physical and psychological status was documented after administration of the chemical restraint. Review of the record revealed no evidence of vital signs documented every 30 minutes times two after the administration of the chemical restraint.

Interview on 03/11/2021 at 0950 with RN #9 revealed after a chemical restraint was implemented monitoring included a nursing assessment hourly times two hours and vital signs every 30 minutes times two. Interview revealed the chemical restraint for Patient #5 was not monitored per facility policy.





3. Closed medical record review on 03/11/2021 of Patient #6 revealed a [AGE] year old male patient admitted on [DATE] involuntarily for suicidal and homicidal ideations. Review of a nurse practitioner`s order dated 01/22/2021 at 1340 revealed " ...continue LOS [line of sight] c [with] blocked room [no roommate] at all times. Thorazine [medication used to reduce aggression and behavioral problems] 150 mg [milligrams] x 1 IM [intramuscular] now Ativan [medication used to treat anxiety] 2 mg x 1 IM now. Review of a nursing summary note dated 01/22/2021 at 1645 revealed " ... [patient name] became upset again later that day, when writer called him to the med [medicine] window to take meds. He stated he doesn`t take any med + [and] that he wasn`t taking them. Writer informed him that it was a scheduled medication + that he has a right to refuse but to not get upset about it. He started yelling + began kicking the unit door. He kicked off the unit + refused to go back on the hall. Staff was able to talk to him + redirect behavior. [Patient name] agreed to take the scheduled medication + prn [as needed] meds by mouth. He is currently sitting quietly on the unit..." Review of a nurse practitioner`s order dated 01/22/2021 at 1730 revealed "order for Thorazine and Ativan IM written at 1340 today may be given: Thorazine 150 mg IM or PO [oral] X1 Ativan 2 mg IM or PO x 1 (Both given PO @ 1444 this order is complete." Review of the Patient Observation Rounds sheet revealed Patient #6 was monitored every 15 minutes by a staff member. Review revealed no documentation of vital signs, patient`s response to the medications or assessments by the nursing staff after the administration of Thorazine and Ativan.

Interview on 03/11/2021 at 0950 with RN #9 revealed after a chemical restraint was implemented monitoring included a nursing assessment hourly times two hours and vital signs every 30 minutes times two. Interview revealed the chemical restraint for Patient #1 was not monitored per facility policy.

4. Review on 03/11/2021 of facility policy titled "Seclusion and Physical or Chemical Restraint" reviewed/revised 07/2019 revealed " ...Once a physical/chemical restraint or seclusion has been implemented the qualified RN [Registered Nurse] shall conduct a face to face assessment using the Seclusion/Restraint Hourly Flow sheet. Assessment will include evaluation of patient`s immediate situation; reaction to the intervention; current psychological status and need to continue or terminate the emergency intervention; physical assessment including skin integrity, respiratory/circulatory status, nutrition/hydration, pain, and review of medications; and lab results. This Seclusion/Restraint Hourly Flow Sheet shall be continued whereby the above parameters are documented for the patient every 15 minutes for physical restraints or episodes of seclusion for the duration of the event and, for chemical restraints, for one consecutive hour ... Implementation of Order ... 5 ...b ...Patients receiving chemical restraints are (unless specified by their psychiatrist for a more frequent interval of observation or who are concomitantly in physical restraint or seclusion) observed every 15 minutes for one hour after the medication administration by trained and competent staff in order that they can best respond to the medication. C. For incidents of physical restraint or seclusion, continuous observations are documented at least every 15 minutes. For incidents of chemical restraints, patients are observed and findings of same documented every 15 minutes times four, or one hour ... ...d. An RN (registered nurse) assesses the patient in physical restraint or seclusion or who has received a chemical restraint and documents the assessment at least every hour (or more frequently as warranted by the patient's condition by unstable vital sign findings) during the restraint or seclusion episode. For chemical restraints, the RN assesses the patient hourly times two hours then resumes her regular schedule of assessment of the patient that routinely occurs during his/her shift ...Full vital signs (Blood pressure, pulse, respirations [and encompassing the patient's temperature unless unable to obtain due to the patients level of agitation]) are taken at the frequency determined by the RN assessment ...and every 30 minutes times two for episodes of chemical restraint ...f. Nursing staff/direct care staff monitors the physical and psychological status of the patient for a minimum of one hour following release from seclusion or restraint or after having received a chemical restraint ..."

Closed medical record review on 03/11/2021 of Patient #1 revealed a [AGE] year old male admitted on [DATE] for major depressive disorder involuntarily for threatening to kill himself and his mother. Patient #1`s history included Obsessive Compulsive Disorder, Anxiety, Attention Deficit Disorder, and Self-injurious Behavior, Suicidal Ideations and increased conflict with family. Review of a nursing assessment dated [DATE] at 1155, revealed "Mom, dad, and Patient very anxious & agitated. Pt [Patient] did a low volume scream, clenched his fists, & then scratch [sic] the sides of his face ...Obvious tension & conflict between parents. Review of a physician order dated 11/17/2019 at 1222 revealed "...Seroquel [antipsychotic medication used to treat depression] 100mg [milligrams] po [oral] once- agitation; Benadryl [medication used to prevent unwarranted side effects of psychiatric drugs] 50 mg po once- EPS ppx [sic] [extrapyramidal symptoms prophylaxis-prevent involuntary movements of psychiatric medications]; and Ativan [medication used to treat anxiety] 1 mg po once-anxiety." Review revealed the three mediations were given at 1235. Review of the Patient Observation Rounds sheet revealed Patient #1 was monitored every 15 minutes by a staff member. Review revealed no documentation of vital signs, patient`s response to the medications or assessments by the nursing staff after the administration of Seroquel, Benadryl and Ativan.

Interview on 03/11/2021 at 0950 with RN #9 revealed after a chemical restraint was implemented monitoring included a nursing assessment hourly times two hours and vital signs every 30 minutes times two. Interview revealed the chemical restraint for Patient #1 was not monitored per facility policy. Interview on 03/11/2021 at 0950 with RN #9 revealed "If he was not in a hold, I would not consider it a chemical restraint." Interview revealed after review of the facility policy RN #9 stated, "I would call that a chemical restraint from the perspective of the meds given regardless of route." Interview revealed after a chemical restraint monitoring included a nursing assessment hourly times two hours and vital signs every 30 minutes times two. Interview revealed the chemical restraint for Patient #1 was not monitored per facility policy.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review and staff interview, the facility failed to identify and investigate a medication administration error in 1 of 2 medical records in which a medication error was identified (Patient #5).

The findings included:

Review of policy titled "Medication Preparation and Administration" last revised 02/2018 revealed, "...Before administration, the nurse administering the medication verifies that the medication selected matches the medication order..."

Review of policy titled "Pharmacy Department" last revised 01/23/2018 revealed, ...Medication variances shall be investigated, discussed and reported ... Definitions ... Wrong Drug - the administration to a patient of any medication different from that ordered for the patient..."

Closed medical record review revealed Patient #5 was a [AGE]-year-old male admitted to the facility on [DATE] with diagnoses of Major Depressive Disorder and Post Traumatic Stress Disorder. Review of an order written by Psychiatrist #11 revealed, "1/9/21 1325 1-Zyprexa Zydis (a psychiatric medication) 10 mg PO NOW (if refused, give 10 mg (Zyprexa) IM) 2- Benadryl (a medication with sedative side effects) 50 mg PO Now (if refused, give 50 mg (Benadryl) IM)" Review revealed no evidence of an order for Vistaril (a psychiatric medication) in medical record. Review of a Nursing note written by LPN (Licensed Practical Nurse) #13 revealed, "Pt A&O x 3 (alert and oriented) able to verbalize needs, denies SI/HI/AH/VH (Suicidal Ideation/Homicidal Ideation/Auditory Hallucinations/Visual Hallucinations), behaviors reported, pt showed his ... left arm with scratches, stated he did it last night, asked why he did not report ... to night staff he reported he was scared, pt stated he was nervous about transport to TN (Tennessee), talked about coping skills, pt stated he liked to color, then suggested he write a letter to his therapist about his concerns, resident stated he isn't writing it, compliant with morning medications, later in the afternoon resident went to room, was asked to sit in the common area so staff can keep an eye on him cause his previous night behaviors, resident did not comply and began to ... not comply and began to ... start scratching himself with a comb and covering himself with his blanket, spoke with doctor shots order, level of observation changed to 1:1, resident did leave his room, then proceeded to continue the behavior in the dayroom, start trying to take comb from him, eventually patient complied gave comb and took oral PRN (as needed) medication, Vistaril and Zyprexa given..."

Review of the medication administration record revealed Vistaril 50 mg PO and Zyprexa 10 mg PO was administered to Patient #5 on 01/09/2021 at 1340.

Staff interview was conducted with LPN #13 on 03/10/2021 at 1440. Interview confirmed there was no provider order for Vistaril for Patient #5. Interview revealed when LPN #13 called the provider to report Patient #5's escalating behaviors, a Registered Nurse (RN) came to assist. Interview revealed the RN called the provider for medication orders. LPN #13 stated in the facility Zyprexa and Vistaril is normally what is prescribed for escalating so that is what LPN #13 administered. Interview revealed "(RN Named) called for the order and didn't tell me about the Benadryl order."

Interview conducted on 03/11/2021 at 0919 with the facility's Interim Chief Executive Officer (CEO) #3 revealed there was no medication error report or investigation for Patient #5's medication error.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policies and procedures, medical record review, Root Cause Analysis (RCA) review, and staff interviews facility staff failed to implement measures or actions to prevent a medication error for 1 of 2 medication errors reviewed (Patient #2).

The findings included:

Review of facility Policy titled "PI Plan" effective 0910/2018 " ... Quality / Performance Improvement Plan Overview of the Program 2021.. Measure Once a system has been designed or modified, performance indicators are established to measure the effectiveness or status of the new or modified system. These performance indicators as well as their associated expectations are created to monitor new, modified, or key processes in order to ensure reliability in such processes ... The performance of new, key and modified processes will be measured ... Control After a change has been made, the Hospital monitors the change by collecting and analyzing data to make sure the desired improvement is achieved and sustained ..."

Review of (Patient # 2) revealed a [AGE] year-old-female admitted on [DATE] through 01/16/2021 for a diagnosis of major depressive disorder with psychotic features. Review of a History and Physical by FNP #1 revealed " ...Current Medications (prescription/OTC (over the counter)/herbal): No Meds ..." Review of Medication administration record Scheduled New Orders revealed " ...Abilify (behavioral medication) 7.5mg (milligrams) 1 tab PO (by mouth) BID (twice a day) mood consent. Clonidine 0.1mg 1 tab PO QHS (every night) ADHD (attention deficit hyperactive disorder) ..." Both medications were documented as given on 01/06/2021 at 2000. Review of physician orders for 01/06/2021 revealed no orders for Abilify or Clonidine. Review of a Nursing note by RN #1 on 01/07/2021 at 0313 revealed "While this nurse was doing MAR (medication administration record) change and 25 hours (sic) chart check I noticed that (named patient) received meds that belongs (sic) to another patient. The nurse who did the admission had (another) pt (patient) meds on (named patient) MAR with (named patient's) label. Checked VS ...Pt breathing unlabored ... She denies any concerns, no signs of distress noted." Review of Nursing Note dated 01/07/2021 at 0736 revealed PA #2 was notified.

Review of the facility's Med Error Investigation/Report revealed " ...Findings: Upon investigation it was determined that the MAR (medication administration record) was indeed labelled incorrectly during the admission process. Both charts were audited, and the medications was (sic) on the physician's order sheet ...Med administering nurse failed to verify by comparing the new MAR to the physician orders which is standard practice of doing a med pass to a new admit ..."

Review of the facility's RCA Framework revealed the event occurred on 01/06/2021 at 0837. RCA revealed 5 Action Items to implement as a Risk Reduction Strategy. " ...Action Item #1: Reeducation to nursing staff with using 2 patient identifiers, paying attention to detail Action Item #2: Education and reviewing policies 1700.38 Medication Variances; 1300.23 Medication Preparation and Administration; 1700.43 Administration-General Guidelines Action Item #3: Implementing wristband systems Action Item #4: Restablishing (sic) Agency contract for emergency Action Item #5: Random medication audits and monitoiring (sic) process for all the nurses ..." Review revealed the Position/Title of the responsible Party for each of the action items listed was the Interim CNO.

Staff interview on 03/10/2021 at 1040 with the Interim CEO #3 revealed that there was a transition of the CNO (chief nursing officer) and the action items from the RCA were not followed through.

Interview on 03/10/2021 at 1048 with CNO #4 revealed that as a result of the RCA, the only action item that was implemented was adding wristbands for patient identification. Interview revealed there was no monitoring. Interview revealed that action items identified would not have addressed root cause of medication error. Interview revealed that CNO #4 started in that role on 02/01/2021 and that there was no hand-off of RCA action items to be implemented and monitored.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, and staff interview the facility failed to ensure there was a medical provider order for a medication administered to a patient in 1 of 13 sampled records reviewed for medication administration (Patient #5).

The findings include:

Review of policy titled "Medication Preparation and Administration" last revised 02/2018 revealed, "...Before administration, the nurse administering the medication verifies that the medication selected matches the medication order.."

Closed medical record review revealed Patient #5 was a [AGE]-year-old male admitted to the facility on [DATE] with diagnoses of Major Depressive Disorder and Post Traumatic Stress Disorder. Review of an order written by Psychiatrist #11 revealed, "1/9/21 1325 1-Zyprexa Zydis (a psychiatric medication) 10 mg PO NOW (if refused, give 10 mg (Zyprexa) IM) 2- Benadryl (a medication with sedative side effects) 50 mg PO Now (if refused, give 50 mg (Benadryl) IM)" Review revealed no evidence of an order for Vistaril (a psychiatric medication) in medical record. Review of a Nursing note written by LPN (Licensed Practical Nurse) #13 revealed, "Pt A&O x 3 (alert and oriented) able to verbalize needs, denies SI/HI/AH/VH (Suicidal Ideation/Homicidal Ideation/Auditory Hallucinations/Visual Hallucinations), behaviors reported, pt showed his ... left arm with scratches, stated he did it last night, asked why he did not report ... to night staff he reported he was scared, pt stated he was nervous about transport to TN (Tennessee), talked about coping skills, pt stated he liked to color, then suggested he write a letter to his therapist about his concerns, resident stated he isn't writing it, compliant with morning medications, later in the afternoon resident went to room, was asked to sit in the common area so staff can keep an eye on him cause his previous night behaviors, resident did not comply and began to ... not comply and began to ... start scratching himself with a comb and covering himself with his blanket, spoke with doctor shots order, level of observation changed to 1:1, resident did leave his room, then proceeded to continue the behavior in the dayroom, start trying to take comb from him, eventually patient complied gave comb and took oral PRN (as needed) medication, Vistaril and Zyprexa given..."

Review of the medication administration record revealed Vistaril 50 mg PO and Zyprexa 10 mg PO was administered to Patient #5 on 01/09/2021 at 1340.

Staff interview was conducted with LPN #13 on 03/10/2021 at 1440. Interview confirmed there was no provider order for Vistaril for Patient #5. Interview revealed when LPN #13 called the provider to report Patient #5's escalating behaviors, a Registered Nurse (RN) came to assist. Interview revealed the RN called the provider for medication orders. LPN #13 stated in the facility Zyprexa and Vistaril is normally what is prescribed for escalating so that is what LPN #13 administered. Interview revealed "(RN Named) called for the order and didn't tell me about the Benadryl order."

NC 667; NC 765; NC 982; NC 190; NC 235