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Based on interview, document and record review, the hospital failed to ensure that a nursing assessment at the time of one patient's (Patient 10) transfer from the Emergency Psychiatric Unit, contained all of the elements of the hospital's newly revised policy and procedure, related to writing a final progress note prior to a patient's admission to an inpatient unit.

Findings:

Patient 10 presented to the hospital's Emergency Psychiatric Unit (EPU) on 4/8/12, for treatment of depression and suicidal ideation, according to the Admission Face Sheet. A review of Patient 10's medical record was conducted on 4/13/12 at 8:35 A.M. Patient 10 was admitted to one of the hospital's inpatient units CRU (Crisis Restabilization Unit), on 4/9/12 at 9:30 A.M. Prior to Patient 10's transfer to a CRU, Registered Nurse (RN 10) assessed Patient 10 and documented her assessment in the Progress Notes. The nursing note written at 9:30 A.M. on 4/9/12 indicated that, "Pt. (patient) walked to CRU after [name of nurse] re-eval (re-evaluated) pt. Pt. calm and derectable."

According to the hospital's policy and procedure entitled, "Admission to Inpatient Units" dated 2/22/12, "Assigned license nurse will write a final Progress Note on EPU record indicating time of discharge/transfer. The transfer note shall include patient V/S (vital signs), ambulatory status, suicidal/homicidal ideation, sensorium status, patient's own medications and items being transferred, and patient's understanding of admission to the CRU."

An interview was conducted with the Assistant Director of Nursing (ADON) on 4/13/12 at 8:50 A.M. The ADON stated that RN 10's nursing note, documenting the assessment of Patient 10 prior to her transfer, was not adequate because it did not contain all the elements listed in the hospital's policy and procedure. The ADON further stated that the nursing note only documented that Patient 10 walked to the unit but the nursing note did not even specify who the patient walked with.

On 4/13/12 at 9:10 A.M., an interview was conducted with the hospital's Director of Nursing (DON). The DON acknowledged that, RN 10 was not following the hospital's policy and procedure related to a final progress note prior to a patient's admission to an inpatient unit.

Based on interview and record review, the hospital failed to ensure that it's pain management policy and procedure was implemented by licensed nurse staff. Pain assessments and reassessments were not performed by licensed nurses for Patients 13 and 14, per hospital policy and procedure. When Patient 13's back pain was unrelieved, there was no evidence that licensed nurses implemented other non-pharmaceutical treatment options, per the nursing care plan. When Patient 14 complained of abdominal pain there was no evidence of any intervention by the Registered Nurse (RN) to manage the patient's pain.

Findings:

1. A record review of Patient 13 was initiated on 4/12/12 at 9:00 A.M. Patient 13 was admitted to the hospital via the Emergency Psychiatric Unit (EPU) on 4/10/12 at 3:25 P.M., per the Client Assignment and Service Record. Per a Psychiatric Evaluation dated 4/10/11, Patient 13 was brought to the hospital because she was "gravely disabled and a danger to others."

A review of the Patient 13's Physician's Orders revealed that, on 4/11/12 at 1:00 P.M., Gabapentin (nerve pain medication) 300 milligram (mg), 1 capsule three times a day (TID) orally, was ordered for the patient's chronic back pain. The hospital's TID medication administration times were 9:00 A.M., 1:00 P.M., and 5:00 P.M. In addition, a prn (as needed) order for Motrin 600 mg. orally every six hours for pain, was ordered.

A pain management plan of care dated 4/11/12, revealed that other non-pharmaceutical treatment options for the patient's pain included heat and relaxation.

A review of Patient 13's Medication Administration Record (MAR) revealed that, Patient 13 received 300 mg. of Gabapentin on 4/11/12, at 1:00 P.M. There was no documented pain assessment or reassessment of the patient's pain level before or after she was administered the medication.

On 4/11/12 at 4:35 P.M., Patient 13 was administered another 300 mg. of Gabapentin, and at 4:45 P.M., 600 mg. of Motrin was also administered. There was no documented pain assessment or pain level by licensed nurses prior to the administration of Patient 13's pain medications.

On 4/11/12 at 5:21 P.M., RN 13 documented that Patient 13's pain level was 6 out of 10. According to RN 13's assessment, her plan was "pain medication as ordered." However, according to physician's orders, the patient would not be due for more routine pain medication until 9:00 A.M. the next morning or prn pain medication until 10:45 P.M. that night. There was no documented evidence that RN 13 implemented other treatment options per the plan of care, to relieve the patient's continued complaint of pain. Continued review of the record revealed that Patient 13's level of pain was not reassessed until the following morning, on 4/12/12, at 6:34 A.M.

On 4/12/12 at 9:30 A.M., an interview was conducted with the Assistant Director of Nursing (ADON). Per the ADON, a patient's pain level should be reassessed within 1 hour following the administration of oral pain medication.

A review of the hospital's policy entitled "Pain Management," dated 7/14/09, was reviewed on 4/12/12. Per the policy, nursing staff were to assess all patients for pain whenever pain medication was given. The licensed nurse was to document a patient's report of pain, the patient's pain rating scale numbers, and the patient's response to interventions. In addition, "non-medication" techniques to relieve pain were to be considered.

2. A record review of Patient 14's record was initiated on 4/12/12, at 10:00 A.M. Patient 14 was admitted to the hospital via the Emergency Psychiatric Unit (EPU) on 4/11/12 at 1:15 P.M. Per the EPU Psychiatric Evaluation, dated 4/11/12, Patient 14's diagnoses included chronic paranoia and auditory hallucinations. Per that same document, Patient 14 had right upper quadrant and mid-abdominal pain, at times.

Per a nursing plan of care for pain, dated 4/11/12, the patient's pain rating intensity would be within the patient's comfort zone and at a satisfactory level for comfort and function. However, there was no documentation on the plan of care as to what level of pain was considered satisfactory to the patient.

A review of physician's orders revealed that nothing had been ordered for Patient 14's complaints of pain.

On 4/11/12 at 7:40 P.M., Registered Nurse (RN) 14 documented that Patient 14 had a pain level of 7 out of 10. There was no documented evidence in the record that RN 14 implemented any interventions, including calling a physician, to treat the patient's pain.

A review of the hospital's policy entitled "Pain Management," dated 7/14/09, was reviewed on 4/12/12. Per the policy, nursing staff were to evaluate a patient's report of pain. Effective pain management interventions were to be established. If an intervention was ineffective the nurse was responsible for notifying the physician for further treatment orders.

On 4/12/12 at 2:20 P.M., an interview was conducted with the Assistant Director of Nursing (ADON). Per the ADON, RN 14 failed to implement the hospital's pain management policy and procedure, and should have followed through with an intervention or further assessment to manage the patient's pain level of 7.

Based on interview and record review, the hospital failed to ensure that its policy and procedure pertaining to physician duties was implemented. A medical History and Physical (H&P) examination was not completed, documented, and in the medical record within 24 hours of Patient 11's admission.

Findings:

A record review was initiated on 4/11/12, at 11:00 A.M. Patient 11 was admitted to the hospital on 4/5/12, with diagnoses that included acute paranoia and agitation, per a psychiatric evaluation dated 4/5/12.

A medical H&P was in found in Patient 11's record that was dictated by MD 11 on 4/11/12 at 9:22 A.M., 6 days after the patient's admission, which was also the day of the patient's discharge.

Per the H&P, Patient 11 complained of pain at a level of 7 out of 10, in her left upper molar tooth, due to a cracked tooth. Further review of the record revealed no plan, by nursing or dietary staff, to address the patient's tooth pain, as it had just been identified in the patient's H&P that was 6 days late.

On 4/11/12 at 11:30 A.M., an interview was conducted with MD 11. MD 11 stated that medical H&Ps were supposed to be completed within 24 hours of the patient's admission. MD 11 stated, "This one was missed. I don't know why."

The hospital's policy and procedure entitled, "Physicians: General duties, days, weekend, and holidays," dated 6/10/10, was reviewed. Per the hospital's policy, physicians were to ensure that a physical examination and medical history was performed within 24 hours, after a patient's admission to the Crisis Recovery Unit, for each patient.

Based on interview and document review, the hospital failed to ensure that their Tuberculosis (TB - is a potentially fatal contagious disease that can affect almost any part of the body but is mainly an infection of the lungs), clearance protocol was implemented, for 1 of 5 personnel files reviewed. There was no documented evidence to show that a current Registered Nurse's (RN 21) annual TB clearance, was obtained.

Findings:

On 4/13/12 at 7:41 A.M., a review of RN 21's personnel file was conducted. RN 21 was a psychiatric nurse who was hired on 1/12/01. According to the hospital's "Clearance Status," dated 4/12/12, RN 21 had a TB clearance date of 2/18/11. There was no documented evidence to show that an annual TB clearance had been obtained for RN 21.

A telephone interview with the human resources analyst (HRA) was conducted on 4/13/12 at 1:45 P.M. The HRA stated that RN 21 had a negative chest x-ray on file dated in 2006. Per this interview, the HRA was unable to provide documented evidence to show that, a current Symptom Questionnaire had been completed by RN 21, and if the hospital's current TB clearance protocol had been implemented. The HRA explained that a new TB clearance protocol was implemented in 2008 or 2009 that required the following:

1. For staff who had a past positive PPD (purified protein derivative) skin test (a method used to diagnose TB), the staff were responsible for providing the human resources department with a copy of their positive test result.

2. A negative chest x-ray dated after the positive PPD skin test result.

3. A Symptom Questionnaire completed annually.

4. A medical clearance will be obtained from the Medical Evaluator.

A review of the hospital's document which included their "Tuberculosis Skin Testing Table," was conducted. The document indicated that "Pre-employment/in-service and surveillance tuberculosis testing shall be performed using the following protocols." Per the document, it stipulated that employees with past positive PPD test results were required to complete a Symptom Questionnaire, provide documentation of their past positive skin test with the MM (millimeter) reading and a negative chest x-ray dated after the positive skin test reading.

An interview with the Assistant Administrator was conducted on 4/13/12 at 2:20 P.M. The Assistant Administrator confirmed that there was no documented evidence to show that a completed annual questionnaire was obtained from RN 21. The Assistant Administrator acknowledged that the hospital's TB clearance protocol was not implemented.

Based on observation, interview and document review the hospital failed to ensure that a medication was administered to Patient 12 by Licensed Vocational Nurse (LVN) 12, per hospital standards of practice. In addition, the hospital failed to ensure that its medication administration policy and procedure provided guidelines and expectations to licensed staff concerning a process called "med watch," where a licensed nurse must check a patient's oral cavity to ensure that the patient swallowed all oral medications.

Findings:

On 4/10/12 at 1:50 P.M. a tour and observations were conducted on Crisis
Recovery Unit (CRU) "C" with the Director of Nursing (DON). The unit's medication room was observed with the DON. Per the DON, patients came to the window for medication administration. According to the DON, a licensed staff member stood outside of the medication room with the patients and inspected the patients' oral cavities to make sure that medications weren't "pocketed" (saved) and were swallowed, for safety purposes. This process was referred to as a "med watch." The goal of the "med watch" process was to ensure that patients took their own medications for stabilization purposes, and did not give them to other patients. In addition, the hospital did not want patients to hoard their medications and possibly take them all at once and harm themselves.

Patient 12 was observed at the unit's medication room window. LVN 12 was assigned to administer medications. Patient 12 complained to LVN 12 that he had a headache. LVN 12 administered a 600 milligram (mg) Motrin (pain medication) tablet to Patient 12. Another licensed staff member was not observed on the other side of the medication window for the "med watch" process.

On 4/10/12 at 1:55 P.M., LVN 12 was interviewed. LVN 12 stated "normally I do make sure that someone was outside watching." LVN 12 acknowledged that she had not followed the hospital's process.

According to the DON, LVN 12 should not have administered the Motrin to Patient 12 without ensuring that another licensed staff member was present for the "med watch."

On 4/11/12, the hospital's policy and procedure entitled "Medication Administration," dated 3/24/11, was reviewed. The policy did not contain guidelines and expectations for the licensed staff regarding the "med watch" process. On 4/11/12, the Assistant Administrator (AA) was informed that the policy failed to contain all of the guidelines for staff pertaining to medication administration.