HospitalInspections.org

Based on document review and interview, the facility failed to follow their policy related to complaint/grievances by not initiating a complaint/grievance for 1 of 10 medical records reviewed. (Patient #2) (see tag 118), failed to ensure family/power of attorney notification of restraint application for 9 of 9 patients (patients #1, 2, 3, 4, 5, 6, 7, 8 and 9). (see tag 131), failed to follow their policy related to patient privacy, data protection and handling of personally identifiable information for 1 Unit. (Locked Psychiatric Unit) (see tag 143) and failed to follow physician orders for the type of restraints to be applied and facility policy for restraints for 7 of 9 patients (patients #1, 2, 3, 4, 6, 8 and 9).
(see tag 168).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that Patients Rights were promoted.

Based on document review and interview, the facility failed to follow their policy related to complaint/grievances by not initiating a complaint/grievance for 1 of 10 medical records reviewed. (Patient #2)

Findings include:

1. Facility policy titled "Complaint Grievance Process" last reviewed/revised 1/2018 indicated the following: "...Policy: Patients have the right to express concerns and expect resolution in a timely manner. ...Patient complaints that are considered grievances also include situations where a patient or a patient's representative telephones the hospital with a complaint regarding the patient's care ... Provide a process to review, investigate, and resolve a patient's/patient representative's complaint/grievance within a reasonable time frame. ...Procedure: 1. In the event a patient or the patient's family or representative have a comment, complaint, or grievance he/she is encouraged to do one or more of the following: Inform or ask any staff member ...PROCEDURES FOR USING THE EVENT REPORT - COMPLAINTS AND GRIEVANCES FORM OR ONLINE REPORTING IN THE EVENT REPORTING SYSTEM ("ERS'): 2. When a complaint/grievance is initiated, the Event Report - Complaints and Grievances (RM-3306), is utilized by staff receiving a complaint/grievance. The form is initiated by the person receiving the complaint/grievance and is then forwarded to Risk Manager or enters the reported information into the ERS, as with any other event type. ...5. The person documenting receipt of the complaint/grievance describes/summarizes the complaint in the patient/patient representative's words as best as possible, places the date, the time, and the signature of the person completing the form as indicated. The same person then forwards to Risk Manager for reporting. 6. The complaint or grievance report is forwarded to the applicable Department Manager immediately for review and action ...."

2. A review of patient #2's medical record indicated the following: " ...07/29/18 12:06 [hours] Nurses Notes...: Pts [Patient's] [family member #4] is here to visit. Upset with how pt [patient] is walking. Pt has been walking all morning and when [family member #4] came on the unit pt could barely walk to room. [Family member #4] asked for a wheelchair and has been wheeling pt around. Informed family of the report given to this writer. [Family member #4] still upset. Will continue to monitor, educate, and inform as necessary ... ...07/29/18 17:09 [hours] Nurses Notes...: [Facility #2's] case management called and wanted to speak to a case worker about the care that we are giving to the pt. The pts family had called them to complain about the care that is being given to [him/her]...."

3. A review of the grievance/complaint log, on 11/26/18 at 2:30 p.m. for the time period of 7/1/8 through 11/26/18, indicated a lack of a complaint/grievance event documented in relation to patient #2.

4. An interview on 11/27/18 at 5:30 p.m. with A#2 (Director of Psychiatric Services) and A#12 (Manager of Behavioral Health), they both indicated that they were unaware of Facility #2's case management staff sharing a complaint via the telephone with one of the nurses about care concerns voiced to them from patient #2's family.

5. An interview on 11/28/18 at 4:40 p.m. with A#12, he/she indicated that A#1 (Chief Nursing Officer), A#2 and himself/herself were not aware of the complaint/grievance related to patient #2 from Facility #2 and that the complaint/grievance lacked follow-up documentation.

Based on document review and interview, the Registered Nurse failed to ensure family/power of attorney notification of restraint application for 9 of 9 patients (patients #1, 2, 3, 4, 5, 6, 7, 8 and 9).

Findings include:

1. Facility policy titled "PATIENT RIGHTS AND RESPONSIBILITES" last reviewed/approved 1/2017 indicated the following: PROCEDURE: ...7. The patient or surrogate has the right to information necessary to make treatment decisions that reflect his/her wishes, to be obtained from the practitioner responsible for coordinating care. Complete and current information will be given ...Treatment and any known prognosis should be communicated in terms patient can reasonably be expected to understand. When not medically advisable to share with the patient, the information should be made available to a legally-authorized individual...."

2. Facility policy titled "RESTRAINT & SECLUSION" last reviewed/approved 6/2016 indicated the following: " ...PURPOSE STATEMENT: To define the use and monitoring of restraint ... I. PURPOSE: ...to preserve the patient's ...rights... IV. PROCEDURES: D. Notification Of The Patient's Family 1) Efforts are made to discuss the issue of restraint, when practical, with the patient and family around the time of restraint ...is applied.
2) In cases in which the patient, or surrogate decision maker, has consented to have the family kept informed regarding his or her care and the family has agreed to be notified, staff attempts to contact the family promptly to inform them of the restraint ...episode and document in the medical record of the notification ...I. Documentation Guidelines: Document with Every Order/Episode (Under Restraint Indication): ...c. Notification of the patient's family, when appropriate...."

3. Review of patient #1's medical record indicated the following:
(A) The patient was admitted on 6/27/18 and discharged on 7/26/18.
(B) On 6/28/18 at 2240 hours and 6/30/18 at 0030 hours a pelvic restraint was applied. The patient's flowsheet indicated the family was not notified on 6/30/18 related to a pelvic restraint being applied to the patient.

4. Review of patient #2's medical record indicated the following:
(A) The patient was admitted on 7/16/18 at 1730 hours and discharged on 7/31/18 at 1345 hours.
(B) The patient was placed in a waist restraint per physician orders on the following dates and times:
On 7/19/18 at 1418 hours and removed/discontinued at 1553 hours.
On 7/20/18 at 1130 hours and removed/ discontinued at 1900 hours.
The medical record lacked documentation of family/POA (power of attorney) notification of restraint applications.
(D) On 7/21/18 at 0845 hours, a pelvic restraint was applied and removed/discontinued at 1045 hours.
The medical record lacked a family/POA notification of restraint application.

5. Review of patient #3's medical record indicated the following:
(A) The patient was admitted on 7/24/18 and discharged on 8/3/18.
(B) The patient was placed in a waist restraint per physician orders on 7/30/18 at 0944 hours and removed/discontinued at 1941 hours. The medical record lacked documentation of family/POA (power of attorney) notification of restraint applications.

6. Review of patient #4's medical record indicated the following:
(A) The patient was admitted on 10/27/18 and a current patient.
(B) On 11/26/18 at 1200 hours, a pelvic restraint was applied. The medical record lacked family/POA notification of restraint being applied.

7. Review of patient #5's medical record indicated the following:
(A) The patient was admitted on 11/15/18 and a current patient.
(B) The patient was placed in a waist restraint per physician orders on the following dates and times:
On 11/15/18 at 2030 hours and removed/discontinued at 2230 hours.
On 11/17/18 at 1421 hours and removed/ discontinued at 2054 hours.
On 11/18/18 at 0920 hours and lacked documentation of removal/discontinuation date and time.
On 11/20/18 at 1030 hours and lacked documentation of removal/discontinuation date and time.
On 11/25/18 at 1030 hours and removed/discontinued at 2110 hours.
The medical record lacked documentation of family/POA (power of attorney) notification of restraint applications.

8. Review of patient #6's medical record indicated the following:
(A) The patient was admitted on 11/20/18 and a current patient.
(B) On 11/20/18 at 2031 hours, a waist restraint was applied and removed/discontinued on 11/21/18 at 0800 hours. The medical record lacked documentation of family/POA notification of restraint being applied. On 11/23/18 at 1230 hours, mitts with ties was applied and removed/discontinued at 1500 hours. The medical record lacked documentation of family/POA notification of restraint being applied.

9. Review of patient #7's medical record indicated the following:
(A) The patient was admitted on 11/8/18 and a current patient.
(B) On 11/10/18 at 0620 hours, a waist belt restraint was applied and indicated no family notified. On 11/19/18 at 1519 hours, a waist belt restraint was applied. The medical record lacked family/POA notification of restraints being applied on 11/10/18 and 11/19/18.

10. Review of patient #8's medical record indicated the following:
(A) The patient was admitted on 7/23/18 and discharged on 8/3/18.
(B) On 7/27/18 at 0300 hours, a pelvic restraint was applied and discontinued at 0808 hours. The patient's flowsheet indicated the family was not notified. On 7/27/18 at 2300 hours, a pelvic restraint was applied and discontinued on 7/28/18 at 0630 hours. The medical record lacked family/POA notification of restraint being applied.

11. Review of patient #9's medical record indicated the following:
(A) The patient was admitted on 6/20/18 and discharged on 7/25/18.
(B) On 7/22/18 at 1210 hours, a pelvic restraint was applied and discontinued at 2300 hours.
The medical record lacked family/POA notification of restraint being applied.

12. Staff member A#4 (Director of Clinical Outcomes/Infection Control Preventionist) verified the medical record information for patients #1, 2, 3, 4, 5, 6, 7, 8 and 9 at approximately 4:20 p.m. on 11/28/18.

Based on observation, document review and interview, the facility failed to follow their policy related to patient privacy, data protection and handling of personally identifiable information for 1 Unit. (Locked Psychiatric Unit)

Findings include:

1. Facility policy titled "PATIENT RIGHTS AND RESPONSIBILTIES" last reviewed/approved 1/2017 indicated the following: "...POLICY STATEMENT: ...ensure rights are protected. PROCEDURE: ...11. The patient has a right to privacy and confidentiality ...."

2. Facility policy titled "Sanctions for Violations of Data Protection and Handling Policies, Standards, and Procedures Policy" last reviewed/revised 10/8/18 indicated the following: "...POLICY STATEMENT: This model policy is in keeping with the requirements of various state, federal, and sector regulations that govern the use, disclosure and maintenance of Data... DEFINITIONS: ...4. Personally Identifiable Information (PII) means information which can be used to distinguish or trace an individual's identity, such as their name ...alone, or when combined with other personal or identifying information which is linked or linkable to a specific individual...."

3. During a facility tour on 11/26/18 at 10:55 a.m. with A#2 (Director of Psychiatric Services) and A#6 (Quality Manager) of a public hallway and a visitor room with lockers located directly outside of the locked psychiatric unit, a visitor log was observed laying on the counter top in an unlocked room accessible to staff, the general public including those not visiting patients on the locked unit. The visitor log included completed sign-in sheets for the time period of 8/30/18 through 11/25/18. The sign in sheets titled "[Psychiatric] VISITORS SIGN-IN SHEET" included the date, visitor name, patient name, time in and time out. It also included an non-disclosure statement at the top of the sign in sheet that indicated the following: " ...ALL VISITORS SIGN IN ON ARRIVAL AND OUT ON DEPARTURE AND AGREE TO KEEP CONFIDENTIAL THE NAMES AND SITUATIONS OF OTHER PATIENTS ON THE UNIT." A#2 removed the visitor log from the room that is accessible to the public including those not visiting patients on the locked unit during tour.

4. An interview on 11/28/18 at 4:45 p.m. with A#1 (Chief Nursing Officer), he/she verified that the visitor sign in log for the locked psychiatric unit should not be accessible to the public.

Based on document review and interview, the Registered Nurse failed to follow physician orders for the type of restraints to be applied and facility policy for restraints for 7 of 9 patients (patients #1, 2, 3, 4, 6, 8 and 9).

Findings include:

1.. Facility policy titled "RESTRAINT & SECLUSION" last reviewed/approved 6/2016 indicated the following: " ...E. Orders For Restraint: 1) The physician or Licensed Independent Practitioner (LIP) responsible for the care of the patient is authorized to order a restraint ...a) Orders should be for each use of the restraints and related to a specific episode of the patient's behavior and not for an unspecified future time or episode. ...3) Orders for restraints may never been written as standing orders or PRN orders. Each episode of restraint ...must be initiated in accordance with an order by a physician or other LIP. If a patient was recently released from restraint..., and exhibits behavior that can only be handled through the reapplication of restraint ...as a trial and then re-start it under the same order ...I. Documentation Guidelines: Document with Every Order/Episode (Under Restraint Indication): ...3. Order Present (check box - yes) ...1) Each episode of restraint is documented in the patient's medical record, consistent with policies and procedures ...d. Orders for use ...."

3. Review of patient #1's medical record indicated the following:
(A) The patient was admitted on 6/27/18 and discharged on 7/26/18.
(B) On 6/28/18 at 2240 hours and 6/30/18 at 0030 hours a pelvic restraint was applied. The physician order on 6/28/18 at 2240 hours indicated "...RESTRAINT ORDERS FOR NON-VIOLENT BEHAVIOR ...APPLY RESTRAINT TO PREVENT: INJURY TO SELF; TYPE OF LEAST RESTRICTIVE RESTRAINT: WAIST BELT...." The medical record lacked a physician order for a restraint on 6/30/18 at 0030 hours and physician orders for pelvic restraints to be applied on 6/28/18 and 6/30/18.

4. Review of patient #2's medical record indicated the following:
(A) The patient was admitted on 7/16/18 at 1730 hours and discharged on 7/31/18 at 1345 hours.
(B) On 7/21/18 at 0845 hours, a pelvic restraint was applied and removed/discontinued at 1045 hours.
The physician order on 7/21/18 at 0845 hours indicated " ...RESTRAINT ORDERS FOR NON-VIOLENT BEHAVIOR ...APPLY RESTRAINT TO PREVENT: INJURY TO SELF; TYPE OF LEAST RESTRICTIVE RESTRAINT: WAIST BELT...." The medical record lacked a physician order for a pelvic restraint to be applied.

5. Review of patient #3's medical record indicated the following:
(A) The patient was admitted on 7/24/18 and discharged on 8/3/18.
(B) On 7/29/18 at 1827 hours, a pelvic restraint was applied and removed/discontinued at 2030 hours. The physician order on 7/29/18 at 1828 hours indicated " ...RESTRAINT ORDERS FOR NON-VIOLENT BEHAVIOR ...APPLY RESTRAINT TO PREVENT: INJURY TO SELF; TYPE OF LEAST RESTRICTIVE RESTRAINT: WAIST BELT ...." The medical record lacked a physician order for a pelvic restraint to be applied.

6. Review of patient #4's medical record indicated the following:
(A) The patient was admitted on 10/27/18 and a current patient.
(B) On 11/26/18 at 1200 hours, a pelvic restraint was applied. The physician order on 11/26/18 at 1159 hours indicated " ...RESTRAINT ORDERS FOR NON-VIOLENT BEHAVIOR ...APPLY RESTRAINT TO PREVENT: INJURY TO SELF; TYPE OF LEAST RESTRICTIVE RESTRAINT: WAIST BELT ...." The medical record lacked a physician order for a pelvic restraint to be applied.
(C) An update to the patient's treatment plan dated 11/27/18 indicated the following: " ...Pt has been [in] pelvic restraint since 11/26/18...."

7. Review of patient #6's medical record indicated the following:
(A) The patient was admitted on 11/20/18 and a current patient.
(B) On 11/20/18 at 2031 hours, a waist restraint was applied and removed/discontinued on 11/21/18 at 0800 hours. The medical record lacked a physician order for a waist restraint to be applied on 11/20/18. On 11/23/18 at 1230 hours, mitts with ties was applied and removed/discontinued at 1500 hours. The medical record lacked a physician order for mitts with ties to be applied.

8. Review of patient #8's medical record indicated the following:
(A) The patient was admitted on 7/23/18 and discharged on 8/3/18.
(B) On 7/27/18 at 0300 hours, a pelvic restraint was applied and discontinued at 0808 hours. On 7/27/18 at 2300 hours, a pelvic restraint was applied and discontinued on 7/28/18 at 0630 hours. The physician order on 7/27/18 at 2300 hours indicated " ...RESTRAINT ORDERS FOR NON-VIOLENT BEHAVIOR ...APPLY RESTRAINT TO PREVENT: INJURY TO SELF; TYPE OF LEAST RESTRICTIVE RESTRAINT: WAIST BELT ...." The medical record lacked a physician order for a pelvic restraint to be applied.

9. Review of patient #9's medical record indicated the following:
(A) The patient was admitted on 6/20/18 and discharged on 7/25/18.
(B) On 7/22/18 at 1210 hours, a pelvic restraint was applied and discontinued at 2300 hours.
The physician order on 7/22/18 at 1208 hours indicated " ...RESTRAINT ORDERS FOR NON-VIOLENT BEHAVIOR ...APPLY RESTRAINT TO PREVENT: INJURY TO SELF; TYPE OF LEAST RESTRICTIVE RESTRAINT: WAIST BELT ...." The medical record lacked a physician order for a pelvic restraint to be applied.

10. Staff member A#4 (Director of Clinical Outcomes/Infection Control Preventionist) verified the medical record information for patients #1, 2, 3, 4, 5, 6, 7, 8 and 9 at approximately 4:20 p.m. on 11/28/18.

11. During an interview on 11/28/18 at 4:52 p.m., staff member A#1 indicated it was a nursing standard to follow physician orders.

Based on document review and interview, the Registered Nurse failed to supervise the care of providing patient baths/showers and mouth care of patients for 10 of 10 medical records (MR) reviewed (patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10). The facility failed to ensure patient meal intakes were documented for 9 of 10 medical records reviewed (patient #1, 2, 3, 4, 6, 7, 8, 9 and 10). The facility failed to ensure nursing staff followed physician orders for weekly weights for 8 of 10 patients (patients #1, 2, 3, 4, 5, 7, 8, and 10).

Findings include:

1. Facility policy titled "NURSING DOCUMENTATION PROCEDURE" last reviewed/approved 3/2015 indicated the following: "...I. The following is charted on the flow sheet ...by the nurse or nursing personnel: ...2. Status of patient's condition ...7. Any...change noted in the patient condition. ...J. Graphic Sheet, record the following: ...5. Amount consumed at meals ...."

2. Review of patient #1's medical record indicated the following:
(A) The patient was admitted on 6/27/18 and discharged on 7/26/18.
(B) The patient's initial treatment plan dated 6/27/18 indicated the following: " ...Objectives: Maintain good personal hygiene: ...Assist patient to perform ADLs daily ...Facilitate daily and PRN oral hygiene ...Maintain personal safety: ...Assess Nutritional needs and dietary intake monitor...."
(C) The medical record lacked documentation of baths or patient refusing baths for 28 out of 28 days for the following dates: 6/28/18, 6/29/18, 6/30/18, 7/1/18, 7/2/18, 7/3/18, 7/4/18, 7/5/18, 7/6/18, 7/7/18, 7/8/18, 7/9/18, 7/10/18, 7/11/18, 7/12/18, 7/13/18, 7/14/18, 7/15/18, 7/16/18, 7/17/18, 7/18/18, 7/19/18, 7/20/18, 7/21/18, 7/22/18, 7/23/18, 7/24/18 and 7/25/18.
(D) The medical record lacked documentation of mouth care or patient refusing mouth care for out 28 of 28 days for the following dates: 6/28/18, 6/29/18, 6/30/18, 7/1/18, 7/2/18, 7/3/18, 7/4/18, 7/5/18, 7/6/18, 7/7/18, 7/8/18, 7/9/18, 7/10/18, 7/11/18, 7/12/18, 7/13/18, 7/14/18, 7/15/18, 7/16/18, 7/17/18, 7/18/18, 7/19/18, 7/20/18, 7/21/18, 7/22/18, 7/23/18, 7/24/18 and 7/25/18.
(E) The medical record lacked documentation of meal intakes or the patient refusing meals for 37 of 84 meals on the following dates:
On 6/28/18, lack of lunch meal intake or patient refusal.
On 6/29/18, lack of breakfast meal intake or patient refusal.
On 6/30/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 7/1/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 7/5/18, lack of breakfast, lunch meal intake or patient refusal.
On 7/6/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 7/9/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 7/12/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 7/13/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 7/14/18, lack of breakfast meal intake or patient refusal.
On 7/15/18, lack of dinner meal intake or patient refusal.
On 7/18/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 7/21/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 7/22/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 7/23/18, lack of dinner meal intake or patient refusal.
On 7/24/18, lack of breakfast, lunch meal intake or patient refusal.
On 7/25/18, lack of dinner meal intake or patient refusal.
(F) The patient had a physician order for weekly weights ordered on 6/29/18. Weights were documented on 6/27/18 of 62.14 kilograms, 7/16/18 of 62.14 kilograms and on 7/26/18 of 62.14 kilograms. The medical record lacked documentation of weekly weights.

3. Review of patient #2's medical record indicated the following:
(A) The patient was admitted on 7/16/18 at 1730 hours and discharged on 7/31/18 at 1345 hours.
(B) The patient's initial treatment plan dated 7/16/18 indicated the following: " ...Objectives: Maintain good personal hygiene ...Encourage daily shower minimum of every other day ...Assist patient with ADLs [activities of daily living] daily ...Facilitate daily and PRN [as needed] oral hygiene ...Maintain personal safety: ...Assess Nutritional needs and dietary intake monitor...."
(C) The medical record lacked documentation of baths or patient refusing baths for 15 out of 15
days for the following dates: 7/17/18, 7/18/18, 7/19/18, 7/20/18, 7/21/18, 7/22/18, 7/23/18, 7/24/18, 7/25/18, 7/26/18, 7/27/18, 7/28/18, 7/29/18, 7/30/18 and 7/31/18.
(D) The medical record lacked documentation of mouth care or patient refusing mouth care for 15 out of 15 days for the following dates: 7/17/18, 7/18/18, 7/19/18, 7/20/18, 7/21/18, 7/22/18, 7/23/18, 7/24/18, 7/25/18, 7/26/18, 7/27/18, 7/28/18, 7/29/18, 7/30/18 and 7/31/18.
(E) The medical record lacked documentation of meal intakes or the patient refusing meals for 26 of 44 meals on the following dates:
On 7/17/18, lack of lunch meal intake or patient refusal.
On 7/18/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 7/19/18, lack of lunch meal intake or patient refusal.
On 7/20/18, lack of lunch meal intake or patient refusal.
On 7/21/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 7/22/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 7/24/18, lack of breakfast, lunch meal intake or patient refusal.
On 7/25/18, lack of dinner meal intake or patient refusal.
On 7/26/18, lack of breakfast, lunch meal intake or patient refusal.
On 7/27/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 7/28/18, lack of lunch, dinner meal intake or patient refusal.
On 7/29/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 7/31/18, lack of lunch meal intake or patient refusal.
(E) The patient had a physician order for weekly weights ordered on 7/17/18. The medical record indicated documentation of weights on the following dates:
On 7/16/18 at 1510 hours, a weight of 83.01 kilograms.
On 7/18/18 at 1036 hours, a weight of 83 kilograms.
On 7/27/18 at 1013 hours, a weight of 73.9355 kilograms. A weight loss difference of approximately 9 kilograms or 20 pounds in nine days from 7/18/18 to 7/27/18. The medical record lacked documentation of a reassessment of the patient's weight or an acknowledgement of the difference in the patient's weights.

4. Review of patient #3's medical record indicated the following:
(A) The patient was admitted on 7/24/18 and discharged on 8/3/18.
(B) The medical record lacked documentation of baths or patient refusing baths for 10 out of 10 days for the following dates: 7/25/18, 7/26/18, 7/27/18, 7/28/18, 7/29/18, 7/30/18, 7/31/18, 8/1/18, 8/2/18 and 8/3/18.
(C) The medical record lacked documentation of mouth care or patient refusing mouth care for 10 out of 10 days for the following dates: 7/25/18, 7/26/18, 7/27/18, 7/28/18 7/29/18, 7/30/18, 7/31/18, 8/1/18, 8/2/18 and 8/3/18.
(D) The medical record lacked documentation of meal intakes or the patient refusing meals for 11 of 27 meals on the following dates:
On 7/25/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 7/27/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 7/30/18, lack of dinner meal intake or patient refusal.
On 7/31/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 8/1/18, lack of lunch meal intake or patient refusal.
(E) The patient had a physician order for weekly weights ordered on 7/25/18. The medical record lacked documentation of weekly weights. One weight was documented on 7/27/18 of 123.377 kilograms.

5. Review of patient #4's medical record indicated the following:
(A) The patient was admitted on 10/27/18 and a current patient.
(B) The patient's initial treatment plan dated 10/27/18 indicated the following: "...Objectives: Maintain good personal hygiene: Assist patient to perform ADLs daily...."
(C) The medical record lacked documentation of baths or patient refusing baths for 12 out of 12 days for the following dates: 11/15/18, 11/16/18, 11/17/18, 11/18/18, 11/19/18, 11/20/18, 11/21/18, 11/22/18, 11/23/18, 11/24/18, 11/25/18 and 11/26/18.
(D) The medical record lacked documentation of mouth care or patient refusing mouth care for 12 out of 12 days for the following dates: 11/15/18, 11/16/18, 11/17/18, 11/18/18, 11/19/18, 11/20/18, 11/21/18, 11/22/18, 11/23/18, 11/24/18, 11/25/18 and 11/26/18.
(E) The medical record lacked documentation of meal intakes or the patient refusing meals for 7 of 33 meals on the following dates:
On 11/15/18, lack of dinner meal intake or patient refusal.
On 11/18/18 lack of lunch meal intake or patient refusal.
On 11/19/18, lack of lunch meal intake or patient refusal.
On 11/21/18, lack of breakfast meal intake or patient refusal.
On 11/23/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
(F) The patient had a physician order for weekly weights ordered on 10/28/18. The medical record lacked documentation of weekly weights. One weight was documented on 10/27/18 of 117.94 kilograms.

6. Review of patient #5's medical record indicated the following:
(A) The patient was admitted on 11/15/18 and a current patient.
(B) The patient's initial treatment plan dated 11/15/18 indicated the following: " ...Objectives: Maintain good personal hygiene ...Pt is dependent [with] care/staff completes all aspects of care...."
(C) The medical record lacked documentation of baths or patient refusing baths for 10 out of 10
days for the following dates: 11/16/18, 11/17/18, 11/18/18, 11/19/18, 11/20/18, 11/21/18, 11/22/18, 11/23/18, 11/24/18 and 11/25/18.
(D) The medical record lacked documentation of mouth care or patient refusing mouth care for 10 out of 10 days for the following dates: 11/16/18, 11/17/18, 11/18/18, 11/19/18, 11/20/18, 11/21/18, 11/22/18, 11/23/18, 11/24/18 and 11/25/18.
(E) The patient had a physician order for weekly weights ordered on 11/16/18. The medical record lacked documentation of weekly weights. One weight was documented on 11/15/18 of 89.81 kilograms.

7. Review of patient #6's medical record indicated the following:
(A) The patient was admitted on 11/20/18 and a current patient.
(B) The patient's initial treatment plan dated 11/21/18 indicated the following: " ...Objectives: Maintain good personal hygiene: ...Assist patient to perform ADLs daily ...Maintain personal safety: ...Facilitate daily and PRN oral hygiene ...Assess Nutritional needs and dietary intake monitor...."
(C) The medical record lacked documentation of baths or patient refusing baths for 6 out of 6 days for the following dates: 11/21/18, 11/22/18, 11/23/18, 11/24/18, 11/25/18 and 11/26/18.
(D) The medical record lacked documentation of mouth care or patient refusing mouth care for 6 out of 6 days for the following dates: 11/21/18, 11/22/18, 11/23/18, 11/24/18, 11/25/18 and 11/26/18.
(E) The medical record lacked documentation of meal intakes or the patient refusing meals for 6 of 18 meals on the following dates:
On 11/22/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 11/24/18, lack of breakfast, lunch, dinner meal intake or patient refusal.

8. Review of patient #7's medical record indicated the following:
(A) The patient was admitted on 11/8/18 and a current patient.
(B) The patient's initial treatment plan dated 11/9/18 indicated the following: "...Objectives: Maintain good personal hygiene: Encourage daily shower minimum of every other day ...Assist patient to perform ADLs daily ...Facilitate daily and PRN oral hygiene ...Maintain personal safety ...Assess Nutritional needs and dietary intake monitor...."
(C) The medical record lacked documentation of baths or patient refusing baths for 18 out of 18 days for the following dates: 11/9/18, 11/10/18, 11/11/18, 11/12/18, 11/13/18 , 11/14/18, 11/15/18, 11/16/18, 11/17/18, 11/18/18, 11/19/18, 11/20/18, 11/21/18, 11/22/18, 11/23/18, 11/24/18, 11/25/18 and 11/26/18.
(D) The medical record lacked documentation of mouth care or patient refusing mouth care for 16 out of 18 days for the following dates: 11/9/18, 11/10/18, 11/13/18, 11/14/18 11/15/18, 11/16/18, 11/17/18, 11/18/18, 11/19/18, 11/20/18, 11/21/18, 11/22/18, 11/23/18, 11/24/18, 11/25/18 and 11/26/18.
(E) The medical record lacked documentation of meal intakes or the patient refusing meals for 16 of 27 meals on the following dates:
On 11/12/18, lack of breakfast, lunch meal intake or patient refusal.
On 11/13/18 lack of lunch meal intake or patient refusal.
On 11/14/18, lack of lunch, dinner meal intake or patient refusal.
On 11/15/18, lack of dinner meal intake or patient refusal.
On 11/16/18, lack of lunch, dinner meal intake or patient refusal.
On 11/17/18, lack of lunch, dinner meal intake or patient refusal.
On 11/20/18, lack of dinner meal intake or patient refusal.
On 11/24/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 11/26/18, lack of breakfast, lunch meal intake or patient refusal.
(F) The patient had a physician order for weekly weights ordered on 11/10/18. The medical record lacked documentation of weekly weights.

9. Review of patient #8's medical record indicated the following:
(A) The patient was admitted on 7/23/18 and discharged on 8/3/18.
(B) The patient's initial treatment plan dated 7/23/18 indicated the following: " ...Objectives: Maintain good personal hygiene: Encourage daily shower minimum of every other day ...Assist patient to perform ADLs daily ...Facilitate daily and PRN oral hygiene ...Maintain personal safety ...Assess Nutritional needs and dietary intake monitor...."
(C) The medical record lacked documentation of baths or patient refusing baths for 8 out of 10 days for the following dates: 7/24/18, 7/25/18, 7/26/18, 7/27/18, 7/28/18, 7/29/18, 7/30/18 and 8/2/18.
(D) The medical record lacked documentation of mouth care or patient refusing mouth care for 10 out of 10 days for the following dates: 7/24/18, 7/25/18, 7/26/18, 7/27/18, 7/28/18, 7/29/18, 7/30/18, 7/31/18, 8/1/18 and 8/2/18.
(E) The medical record lacked documentation of meal intakes or the patient refusing meals for 11 of 30 meals on the following dates:
On 7/25/18, lack of breakfast, lunch meal intake or patient refusal.
On 7/27/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 7/30/18, lack of lunch, dinner meal intake or patient refusal.
On 7/31/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 8/1/18, lack of lunch meal intake or patient refusal.
(F) The patient had a physician order for weekly weights ordered on 7/24/18. The medical record lacked documentation of weekly weights. One weight was documented on 7/27/18 of 66.2244 kilograms.

10. Review of patient #9's medical record indicated the following:
(A) The patient was admitted on 6/20/18 and discharged on 7/25/18.
(B) The patient's initial treatment plan dated 7/23/18 indicated the following: " ...Objectives: Maintain good personal hygiene: Encourage daily shower minimum of every other day ...Assist patient to perform ADLs daily ...Maintain personal safety ...Assess Nutritional needs and dietary intake monitor...."
(C) The medical record lacked documentation of baths or patient refusing baths for 32 out of 34 days for the following dates: 6/21/18, 6/22/18, 6/23/18, 6/24/18, 6/25/18, 6/26/18, 6/27/18, 6/28/18, 6/29/18, 6/30/18, 7/2/18, 7/3/18, 7/4/18, 7/5/18, 7/6/18, 7/7/18, 7/8/18, 7/9/18. 7/10/18, 7/11/18, 7/12/18, 7/13/18, 7/14/18, 7/15/18, 7/16/18, 7/17/18, 7/18/18, 7/19/18, 7/20/18, 7/21/18, 7/22/18 and 7/24/18.
(D) The medical record lacked documentation of mouth care or patient refusing mouth care for 34 out of 34 days for the following dates: 6/21/18, 6/22/18, 6/23/18, 6/24/18, 6/25/18, 6/26/18, 6/27/18, 6/28/18, 6/29/18, 6/30/18, 7/1/18, 7/2/18, 7/3/18, 7/4/18, 7/5/18, 7/6/18, 7/7/18, 7/8/18, 7/9/18. 7/10/18, 7/11/18, 7/12/18, 7/13/18, 7/14/18, 7/15/18, 7/16/18, 7/17/18, 7/18/18, 7/19/18, 7/20/18, 7/21/18, 7/22/18, 7/23/18 and 7/24/18.
(E) The medical record lacked documentation of meal intakes or the patient refusing meals for 35 of 102 meals on the following dates:
On 6/21/18, lack of lunch meal intake or patient refusal.
On 6/25/18, lack of lunch meal intake or patient refusal.
On 6/26/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 6/27/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 6/30/18 lack of breakfast, lunch, dinner meal intake or patient refusal.
On 7/1/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 7/6/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 7/9/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 7/2/18, lack of breakfast meal intake or patient refusal.
On 7/12/18, lack of lunch meal intake or patient refusal.
On 7/13/18, lack of dinner or patient refusal.
On 7/18/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 7/21/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 7/5/18, lack of breakfast, lunch meal intake or patient refusal.
On 7/11/18, lack of breakfast, lunch meal intake or patient refusal.
On 7/20/18, lack of breakfast and lunch or patient refusal.

11. Review of patient #10's medical record indicated the following:
(A) The patient was admitted on 7/17/18 and discharged on 8/17/18.
(B) The patient's initial treatment plan dated 7/17/18 indicated the following: " ...Objectives: Maintain good personal hygiene: Independent with ADLs ...Assist patient to perform ADLs daily ...Maintain personal safety ...Assess Nutritional needs and dietary intake monitor...."
(C) The medical record lacked documentation of baths or patient refusing baths for 24 out of 31 days for the following dates: 7/18/18, 7/19/18, 7/20/18, 7/21/18, 7/22/18, 7/24/18, 7/27/18, 7/29/18, 7/30/18, 7/31/18, 8/2/18, 8/3/18, 8/5/18, 8/6/18, 8/7/18, 8/8/18, 8/9/18, 8/10/18, 8/11/18, 8/12/18, 8/14/18, 8/15/18, 8/16/18 and 8/17/18.
(D) The medical record lacked documentation of mouth care or patient refusing mouth care for 31 out of 31 days for the following dates: 7/18/18, 7/19/18, 7/20/18, 7/21/18, 7/22/18, 7/23/18, 7/24/18, 7/25/18, 7/26/18, 7/27/18, 7/28/18, 7/29/18, 7/30/18, 7/31/18, 8/1/18, 8/2/18, 8/3/18, 8/4/18, 8/5/18, 8/6/18, 8/7/18, 8/8/18, 8/9/18, 8/10/18, 8/11/18, 8/12/18, 8/13/18, 8/14/18, 8/15/18, 8/16/18 and 8/17/18.
(E) The medical record lacked documentation of meal intakes or the patient refusing meals for 10 of 93 meals on the following dates:
On 7/23/18, lack of dinner meal intake or patient refusal.
On 7/26/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 8/6/18, lack of lunch meal intake or patient refusal.
On 8/16/18, lack of breakfast, lunch, dinner meal intake or patient refusal.
On 8/17/18, lack of breakfast, lunch meal intake or patient refusal.
(F) The patient had a physician order for weekly weights ordered on 7/18/18. Weights were documented on 7/17/18 of 110.68 kilograms, 7/19/18 of 110.7 kilograms and 7/27/18 of 112.0372 kilograms. The medical record lacked documentation of weekly weights.

12. During an interview on 11/27/18 at 6:00 p.m., staff member A#1 (Chief Nursing Officer) indicated it was a standard to bathe patients on the locked psychiatric unit at least daily, either by bed bath or shower.

13. During a tour of the psychiatric locked unit on 11/28/18 beginning at 10:35 a.m., staff member A#15 (Patient Care Associate) and A#14 (Patient Care Associate) indicated that a patient's meal intake is gathered by the patient care associates or certified nurse aides and given to the nurses to chart in the patients' electronic medical records. They also indicated that a patient can either be weighed in their bed or standing on a scale. A#14 and A#15 indicated that a patient is weighed upon admission to the unit, then every Sunday and document the weights in the patients' medical record. They further indicated that they offer patients a bath/shower, mouth care daily and document those in the patients' medical record along with any patient refusals.

14. Staff member A#4 (Director of Clinical Outcomes/Infection Control Preventionist) verified the medical record information for patients #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 at approximately 4:20 p.m. on 11/28/18.

15. During an interview on 11/28/18 at 4:52 p.m., staff member A#1 indicated it was a nursing standard to follow physician orders.