HospitalInspections.org

Based on record review of the Quality Indicator Report and Quality Assurance (QA) Plan and staff interviews with the Director of Quality Assurance and Director of Risk Management, the hospital failed to meet the requirements of the Condition of Participation for Quality Assurance/Improvement / Performance Improvement on the Senior Behavioral Unit as evidenced by:

1. Failed to have documentation for monitoring the effectiveness of the services on the Senior Behavioral Unit, and failing to identify opportunities through the QA process that could lead to improvements and changes by not identifying and reporting the following through the QA department of the hospital: delays in consultations to the Medical Executive Committee; nursing assessments failed to identify, evaluate and address a patient's decline in weight and hydration status and report these findings to the attending physician for 1 of 11 sampled patients (Patient #4) resulting in the patient's transfer to the acute care setting with a diagnosis of Altered Mental Status, Acute renal failure, Rhabdomyolysis, Hypernatremic Dehydration; nurses working on the psychiatric unit not knowing the side effects of psychotropic medication and the failure of the documented nursing assessments to identify the patient's signs and symptoms as possible side effects of the psychotropic medications being administered to the patient (evidence of the patient experiencing increased lethargy and elevated temperature likely secondary to Neuroleptic Malignant Syndrome); the failure to identify that the weights obtained on patients were considered accurate; failure to identify through the nursing assessments patients' weight loss; failure of the nursing staff to keep current the medical nursing care plan on all patients; the failure to provide all nursing personnel education and training on psychotropic medication and the side effects and determine nursing staff were competent on medication administration of psychotropic medications; and ensure adverse drug reactions were immediately reported to the physician and to its hospital wide QA/PI program. (Deficiency Cited at 276)

2.. Failed to ensure departmental indicators were implemented on the Senior Behavioral Unit to identify and trend problems through the QA process which included a) nurse's lack of knowledge/training on monitoring and evaluating side effects of psychotropic medications and implementing education of staff for neuroleptic malignant syndrome b) identifying and tracking patient weight loss and/or scale problems c) implementing a plan for identifying and monitoring dehydration/malnutrition d) identifying and monitoring obtaining orders for physical therapy consults for Stage II decubitus ulcers e) identifying and monitoring nursing assessments and notifying physicians for patients with significant changes in condition.(Deficiency cited at A267)

Based on record review (medical records, policy and procedure) and interview the hospital failed to meet the Condition of Participation for Nursing Services as evidence by:


1. Failed to assess and evaluate Patient #4's decline for drastic weight loss, dehydration and malnutrition which resulted in the transfer of the patient to the emergency room with a resulting diagnosis of Altered Mental Status, Acute Renal Failure, Rhabdomyolysis, Hypernatremic Dehydration for 1 of 11 sampled patients (Patient #4) (Deficiency cited at A395)

2. Failed to recognize and assess psychotropic medication side effects of elevated temperature and lethargy as exhibited by Patient #11 as being possible life threatening symptoms of Neuroleptic Malignant syndrome (NMS) and report these findings to the psychiatrist. (Patient #11) (Deficiency cited at A395)

3. Failed to ensure accurate weights were obtained and documented and that nursing assessments for weight loss were documented. (Patient #2) (Deficiency cited at A395)

4. Failed to ensure the nursing staff kept current the nursing care plan by 1) failing to identify and update the plan of care for a patient's decline when the patient began experiencing a change in behavior, decreased appetite with extreme weight loss, and decrease in fluid intake with a potential for dehydration, and the development of skin breakdown with a Stage II Decubitus (Patient #4). The care plan was not updated for patient #11 who developed Neuroleptic Malignant Syndrome and a Stage II decubitus. (Deficiency cited at A396)

5. The psychiatric nurse manager failed to provide evidence that any nursing education on Neuroleptic Malignant Syndrome and the signs and symptoms exhibited by patients who may be experiencing this syndrome as well as other side effects of psychotropic medications had been provided to the RN's and LPN's working on the psychiatric unit. (Deficiency cited at A397)

6. Failed to ensure routine accuchecks were performed for a patient with a diagnosis of Non Insulin Dependent Diabetes, failed to monitor and assess the patient for not having a bowel movement for 7 days and failed to ensure a physical therapy consult was obtained for treatment of a Stage II Decubitus. (Patient #4) (Deficiency cited at A395)

An immediate jeopardy situation was identified on 5/19/10 10:15 AM. and reported to the hospital's chief Nursing Officer and the Director of Risk Management. The immediate jeopardy was a result of the nursing staff failure to recognize and assess psychotropic side effects exhibited by Patient #11 having life threatening symptoms of NMS. The results of this failure to recognize the patient's symptoms of elevated temperatures, rigidity of muscles, drooling and drastic weight loss resulted in a delay for treatment for a diagnosis of Neuroleptic Malignant Syndrome. Patient #11 continued to decline and was transferred to the hospital's emergency room 11/11/09 and later discharged to in patient hospice services. Psychiatric Nurses were not aware of the immediacy of the life threatening signs and symptoms of NMS. The staff failed to immediately alert the psychiatrist and to obtain immediate medical attention for the patient. The psychiatric nurse manager failed to provide evidence that any nursing education on this syndrome or other side effects of psychotropic medications had been provided to the RN's and LPN's working on the psychiatric unit. Nursing staff also failed to assess Patient #4's decline with drastic weight loss, dehydration and malnutrition which resulted in the transfer of the patient to the emergency room where he was hospitalized for acute care for hypernatremic dehydration, rhabdomyolysis and acute renal failure. There was no documented evidence the physician was notified of the patient's not eating for 2 days and drinking minimally with decreased urine output.


A corrective action plan was submitted by the hospital on 5/20/10 to address the immediate jeopardy situation which revealed the hospital had called in all staff on 5/19/10 and had addressed the following: 1)Signs and symptoms of side effects of psychotropic medication and neuroleptic malignant syndrome and revealed all staff providing care to patients, including OT, PT, ST and recreation therapy will be a immediately in serviced. Facilitator led presentations on the unit by content experts in the various areas. Competency will be assessed by a written exam for the nursing staff with a passing score of 90% today. Added competency assessment will be added to the individual job description. 2) Signs and symptoms of dehydration and malnutrition revealed all nursing staff including RN's, LPN's, MHT's and dietary recreation therapy, OT's will be able to assess patients and recognize signs and symptoms of dehydration and malnutrition. An in service on the signs and symptoms of dehydration and malnutrition will be provided for the identified staff immediately. Facilitator led presentation on the unit by content experts in the various areas. Competency will be assessed by written exam for the nursing stuff with a passing score of 90% today. The added competency assessment will be added to the individual job description. 3) All staff will recognize that a weight loss of >/= 5 pounds is evidence of the either dehydration and/or malnutrition. A weight loss of >/= 5 pounds will be: communicated to the charge nurse, notify Medical Physician, addressed at each team meeting by the treatment team for multidisciplinary approach for improvement. 4) Nurses, PCT's and MHT's will be able to identify changes in patient weights. The computer documentation system time scale was changed for the staff from eight days to 2 months to enable staff to be able to see patient weights from admission to current. Clinical manager will educate the staffed today, 5/19/10 on changes on computer documentation system. 5) All staff will recognize that a patient's continued to decrease consumption of meals (50% or less) is evidence of either dehydration and/or a malnutrition. A decrease in the consumption of meals for more than two meals (50% or less) will be communicated to the charge nurse. RN will notify Medical Physician and will be addressed at each team meeting by the treatment team for multidisciplinary approach for improvement. 6) Accuracy of weighing devices will be validated. The hospital will validate the calibration of all scales 5/19/10 by a Bio medical technician. Staff will document the scale used to weigh patients for accuracy of patient weights. The character unit was changed on the computer documentation systems screen to allow for the type of scaled to be visualized. 7) All staff will be able to verbalize how the chain of command is activated. All staff will review the policy and procedure on how to escalate concerns through the chain of command. There was a discussion of how changes in patient conditions will be documented. A patient progress form was created by the treatment team to document the discussion of patients for transfer to a higher level of care for a retrospective review.
Staff were called in 5/19/10 to complete education. Any staff that is unable to come in today will receive one on one education by their supervisor. No staff will be permitted to work until this is completed. As a result of the hospital's action plan, the Immediate Jeopardy situation was removed on 5/20/10 at 10:00 AM.

Non-compliance remained at the condition level.

Based on observation and interview the hospital failed to ensure a patient's right to privacy by having a patient sitting in the dining and group area with her breast and diaper area exposed (Patient #1) and another patient with her clothing at the perineal area saturated with urine. (Patient #3) for 2 of 11 sampled patients. Findings:

On 05/12/10 at 8:10am Patient #1 was observed slouched in a geri-chair in the dining area sitting at the table with her gown pulled up over her breasts and diaper area. A female and male patient were sitting on the opposite side of the table and staring at the patient. The Mental Health Technician (MHT) was sitting in a chair observing the patient. She then noted the patient's exposure and lowered the patient's gown. Patient #1 was again observed on 05/19/10 at 9:15 am in the group room with her gown pulled up above her waist with diaper exposed. Other patients were in the room ..The MHT covered her with a sheet. Patient #3 was observed in a gerichair in the dining area with her pants at the perineal area saturated with urine. The Nurse Manager entered the dining area and 2 MHTs took the patient to her room.

S12, MHT was interviewed on 05/12/10 at 9:35am. She indicated Patient #1 is always pulling her gown up over her breasts and staff usually keep a blanket over her. Further she indicated Patient #3 is usually continent and was not wearing briefs.

Based on record reviews and interviews the hospital failed to ensure Medical Staff Rules and Regulations, with a revision date of 01/06/2010, were implemented by failing to ensure the attending physician, when the Patient's acute medical changes exceeded capabilities, obtained a medical consultation for Patient #4. This failure to ensure a patient's decline in weight loss and hydration status was discussed with a consulting physician, as soon as the need for a consult was determined, resulted in further decline and resulted in the patient's transfer to the acute care setting with a diagnosis of Altered Mental Status, Acute renal failure, Rhabdomyolysis, Hypernatremic Dehydration (Patient #4) and failed to ensure a consult for a patient was responded to within 24 hours which resulted in the patient's continued elevated BUN and creatinine and the patient's transfer to the acute care setting in guarded condition (Patient #8) for dehydration following repeated documented attempts to contact a physician for the patient's decline for 2 of 2 patients requiring consults out of a total of 11 sampled patients.:

Patient #4
The Medical Record for Patient #4 was reviewed. Documentation revealed Patient #4 was admitted to the Senior Behavioral Health Unit of Lakeview Regional Medical center on 02/08/10.

The Psychiatric Evaluation dated 02/09/10 revealed in part, "Reason for admission:
1. Potential danger to self, others, or property
2. Inability to maintain ordinary habits of daily living
3. Bizarre or socially inappropriate behavior
4. Failure or unavailability of outpatient treatment

History of Present Illness:
The patient is a 76 year old, white male with a history of dementia of unknown duration. He lives in an assisted living facility in Mississippi. He presents with the above symptoms. He is in need of medication adjustment for stabilization to allow him to continue to live safely in a structured environment.
Past Psychiatric History: Know only for dementia, the course and duration of his illness are unknown.
Mental status Examination:
The patient is a well developed, well nourished, white male.
He is reasonably well kept. He is cooperative and friendly during the examination although his cognition is severely impaired. He is oriented to person only.
Diagnosis:
1. Dementia with behavioral disturbance
2. Hypertension
3. Noninsulin dependent diabetes mellitus
4. Chronic progressive mental illness.
Estimated length of stay: 12 to 14 days.

Review of the Consultation Report for the History and Physical Examination dated 02/09/10 revealed in part, "...History of Present Illness: This is a 76 year old man who is admitted under non-contested admission to the Senior Behavioral Health Unit at the request of his daughter for medication adjustment due to his increased confusion and combativeness at his adult daycare. He apparently had been doing well in his assisted living center until approximately a month ago, when he began wandering at night and missing medications. He was very agitated last night and so he required Ativan for sedation and currently he is sleeping fairly soundly so I am not able to get any information from him. I am therefore relying on the medical records data mainly provided by his family ... "

PAST MEDICAL HISTORY:
1. Hypertension
2. Type II Diabetes
3. Coronary artery disease
4. Decreased auditory acuity on the left.

Medications:
1. Paxil 20 milligrams p.o. daily
2. Exelon 3 milligrams p.o. daily
3. Namenda 10 milligrams p.o. daily
4. Atenolol 25 mg milligrams p.o. daily
5. Trazodone 100 milligrams p.o. daily
6. Triamcinolone 0.1% to facial rash twice daily
7. Lotrimin cream to rash twice daily
8. Several routine p.r.n. medications.

Physical Examination: Vital Signs: Temperature 98.5, pulse 76, respirations 18 blood pressure 120/72, weight 142 pounds.
IMPRESSION AND RECOMMENDATIONS:
1. Diabetes: Will continue to follow sliding scale coverage and monitor as he is not currently on any medication and his glucose is normal at 112.
2. Hypertension and Coronary Artery disease: Continue current blood pressure medicine and monitor
3. Deafness: This will need to be taken into account when interacting with the patient
4. Increased Confusion: His Depakote level is elevated and his dose is being held.
Will continue to make further recommendations as his case progresses.

Review of documented weights in the electronic record for Patient #4 revealed the following;
02/08/10; 142 lbs
02/14/10; 136 lbs
02/20/10; 135 lbs
02/28/10; 119 lbs Loss of 23 pounds

Review of Intake and Output Worksheets revealed Patient #4's fluid and nutritional intake continued to decline through his admit.

Review of the Physician/Psychiatric Nurse Practitioner Daily Progress Notes by Psychiatric Services revealed
02/19/10 1900 (7pm) Poor appetite, 280cc liquid intake
02/20/10 (no time) Quiet but alert; becomes combative only with ADLs; CBG (capillary blood glucose199)
02/27/10 (no time) Cont to have poor appetite; lethargic. Pt is lethargic so will wait before ordering any meds since this may increase sedation. Due to 0 stool for several days in spite of increased fluid & MOM will order mineral oil enema now and repeat in am if ineffective.

There was no documented evidence a medical consult was obtained from 02/19/10 through 02/28/10 for the patient ' s decline with decreased nutritional and fluid intake, lethargy, increased glucose of 192, no BM in several days.

On 2/28/10 (no time) the Psychiatric Nurse Practitioner documented, " Staff reports increase lethargy; refused to eat, No BM after fleets x 2. Pt. in room in bed supine with eyes closed-responds with thrashing when touched but doesn't open eyes or speak; alternating jerking of extremities; abd soft with bowel signs; digital Rectal exam with lg amt stool palpated that is soft, small amt removed; normal color. Will order CMP, CPK, Troponin for today. Pt ' s psychotropic meds have been held x approx 4 days. Continue to monitor.

Review of the Patient Notes/Reassessment revealed Patient #4 was admitted on 02/08/10 at 1245, (12:45pm) form an assisted living facility. The patient was ambulatory with an unsteady gait assisted by his daughters on unit. The patient was well groomed with a flat affect. Documentation revealed the patient ate a hamburger and drank a soft drink brought to unit by his daughters. Further review of the nursing Patient Notes/Reassessments, from 2/09/10 through 02/26/10, revealed documented evidence of nursing assessments of lethargy, not eating and drinking due to decreased level of consciousness and increased level of sedation. Further documentation revealed shuffling gait, bilateral lower extremity weakness, shivering, body tremors, rigidness, not responding verbally, no BM for 7 days, and development of a Stage II decubitus.

Further review of the Patient Notes/Reassessment revealed in part the following dates of occurrence:

02/27/10 1600 (4pm) LOC (level of consciousness) Drowsy, Generalized weakness
02/28/10 0416 (4:16am) Pt. mostly non-verbal, will grunt. PRN Ativan admin.IM at 0200, (2am) Pt cont. with body twitching /jerking from time to time. Will cont. to monitor.
2/28/10 1123 (11:23am) MOM and Prune juice given last 2 days, Fleets enema last night No results. MOM and prune juice given again this am. Will repeat enema if has not worked by after lunch time. Pt. continues to be drowsy keeping eyes closed most of time, Not verbalizing, just grunting, Resistive to care, Hits out, Movements are stiff and jerky. Will continue to monitor.
02/28/10 1900 (7pm) New orders from (Name of S18 Psychiatric Nurse Practitioner) after talking to (name of S4) Psychiatrist) to send pt to radiology for CT and labs for CMP and CK and troponin done. Ambulance called to transport for CT, reported off to night shift. Ambulance pickup arrived. Family called asking about pt. Informed he was going for test at main hospital and we would be able to tell them more after the tests were done. Pt expected to return after CT. Abnormal reports to be called to (name of S4 or name of S18
02/28/10 2000 (8pm) Pt. received from day shift with orders to transport to Lakeview for CT of head without contrast from S18 NP for mental status changes, stiff and jerky body movements. Had CPK, and Troponin labs drawn prior to change of shift and awaiting results. Pt. resisting staff trying to transfer pt to stretcher and Ativan 1 mg IM given left thigh for transport and for pt to cooperate with CT Scan@ 2015 (8:15pm) and pt. left unit. After pt. left, lab called with abnormal values of Sodium 166, Glucose 734. Abnormal values called to S18 Richard, NP at 2029. (8:29pm) Orders received from S18 to have pt. evaluated in ER and not have CT done if procedure not started. RN in ER called and orders given to eval and treat in ER. At 2320 (11:20pm) admitting called to notify us that pt would be admitted to ICU.

There was no documented evidence in the record the patient's medical physician was notified and consulted for the decline in the patient's condition from 02/08/10 through 02/28/10. There was no documented evidence the medical physician was notified of the patient's rigidity, tremors, twitching, fidgeting, drowsiness, poor appetite with less than 50% intake and extreme weight loss and lack of fluid intake. Further there was no documented evidence the medical physician was notified of Patient #4's skin breakdown with a Stage II Decubitus.

The History and Physical, dictated 02/28/10 (the date Patient #4 was transferred to Lakeview Medical Center for acute care) per S17, MD Internal Medicine, was reviewed. Documentation revealed in part,
"History of present illness: This is a 76 year old man with a past history of Alzheimer's dementia, hypertension, diabetes and coronary artery disease that was previously being treated for increased aggression at Lakeview's Geri-psych Facility.

They noted that he had some mental status changes last night and were in the process of transferring him to the Emergency Room for evaluation and at that time his accu-chek was 775 as I recall, so they proceed to the Emergency Room. Once in the Emergency Room they also found out that his sodium was high at 166 and creatinine high at 4.5 so he was admitted to the intensive care unit with the diagnosis of hypernatremic dehydration and hyposmolar state. Over the night he received intravenous fluids and an insulin drip. Currently his glucose is somewhat normal; however his sodium had increased to 177. His creatinine has also increased slightly to 4.3. F
Review of systems: Is unobtainable from the patient at this time, as he is somnolent and is easily agitated when aroused. I did speak with his stepdaughter, and she said that he has declined in his clinical status over the past month, becoming increasingly unable to perform his activities of daily living; specifically, he is not able to feed himself or drink very much. I believe this further exacerbated his dehydration. They deny that he had complained of any chest pain, or shortness of breath, fever, chills, nausea, vomiting, diarrhea, constipation hematuria, dysuria, hematochezia, or melena. He has been treated for scabies back on February 24, with Elamite cream times one and it will be repeated on March 4.

Physical Examination: Vital signs: Currently blood pressure of 157/77, pulse 94, respirations 24, saturation of 95% room air. Temperature 98.8. His intake and output since admission are: 1090 in and looks like 50 milliliters urine output. HEENT: Mucus membranes are quite dry. Skin: There is decreased sin turgor globally. There are no lesions of scabies that I can tell.
Laboratory Data: Currently, Sodium of 177, potassium 3.6, chloride 138, bicarb is 24, BUN 124, creatinine 4.3, glucose 86, calcium 8.8, white count of 19.7, hemoglobin and hematocrit of 16.5 and 45.3, platelets of 191. Troponin lst nigh of 0.24, MB of 2.5, creatine phosphokinase (CPK) of 1293.

Review of the Discharge Summary with a discharge date of 03/09/10 revealed in part, Final Diagnosis:
1. Altered Mental status
2. Acute renal failure
3. Type II diabetes Mellitus.
4. Rhabdomyolysis
5. Hypernatremic dehydration
6. Coronary artery disease
Treatment Rendered/Procedures Performed:
The patient was treated prophylactically for scabies, placed on intravenous fluids and antibiotics. It was felt that his acute renal failure was related to his rhabdomyolysis all related to dehydration and this was treated aggressively. He did not respond well to the very aggressive care that he was given, and the decision was made by family to have the patient be admitted to hospice. He was therefore transferred to the care of hospice on March 8."

An interview was held with S10 MD, Internal Medicine/Pediatrics 5/13/10 at 8:35 AM. After review of the medical record for Patient #4, he indicated he only did the initial History and Physical on 2/9/10 then saw the patient at the main campus when he was in the Intensive Care Unit. S10 MD indicated the documented assessment by his associate, revealed Patient #4 labs on transfer to the acute unit the creatinine was 1.2 which was a little high, his urine was a little concentrated; it was borderline but nothing terrible. Further Patient #4 went 12 days without lab work being performed while a patient on the geri-psych unit. S10 MD further indicated a sodium level of 166 was reported on 02/28/10 and added that with abnormal labs the staff should notify him or the Nurse Practitioner. S10 MD further indicated he did see things in the progress notes of Patient #4's decline and change in status that may have been as issue and he should have been consulted. He indicated he did not see anything in the notes that staff had communicated with him about the change in the patient's status.

An interview was held with S4, MD Psychiatrist on 5/13/10 at 1:15 PM. He indicated that he was familiar with Patient #4. He indicated the patient was admitted to the unit with advanced dementia, combative and resistant to care. He further indicated the patient was medically stable at admit, was not eating well but his fluid intake was good. S4, MD Psychiatrist reported Patient #4 began to show signs of over sedation and was sent to the emergency room. He indicated it could have been some of the medications that caused problems for Patient#4 and added that he was approaching this situation from a psychiatric viewpoint. S4, MD Psychiatrist further indicated that a CPK of 1293 was not always indicative of neuroleptic malignant syndrome and added that this level was also associated with dehydration. Further S4, indicated there was a problem getting timely responses with medical problems from medical doctors and he had brought this to the attention in a MECHE meeting in 9/28/09 about the problems he had getting consults. Further the hospital had changed the bylaws to reflect that the referring physician would discuss the patient and the situation with the consulting doctor; doctor to doctor contact for all consults. S4, MD Psychiatrist indicated he had instructed all of the nurses to call him with any abnormal problems then if it is a medical problem for them to call the attending internal medicine physician on call as he does not treat acute medical problems. He indicated sometimes he has to wait hours for a response from a medical doctor or is not until the next day. He added that psychiatric sick patients should receive the same level of care as all patients in the hospital. S4, MD Psychiatrist indicated faxed information had been sent to internal medicine many times that resulted in a no response. S4, MD Psychiatrist indicated the unit does not have routine rounding by internal medicine doctors.

An interview was held with S17 MD Internal Medicine/Pediatrics on 5/14/9 at 10:20 AM. He indicated his specialty was internal medicine/pediatrics and he had seen Patient #4 initially in the Emergency Department of Lakeview Medical Center. He indicated he did remember Patient #4 and added this patient ' s sodium level was the highest he had ever seen. He indicated his first interaction with the patient and the family was at the emergency room of the hospital. This Physician indicated he had not been called from the Senior Behavioral Unit prior to his admission to the ED and added he would have expected a call from the staff if a patient is not eating or drinking for just one day. S17 MD indicated he could have ordered an IV for hydration if he been notified of the patient not eating and drinking. He added he had met with the family in the Emergency Department, the day he was transferred from the Senior Behavioral Health Unit, and they were aware that Patient #4 was not eating and drinking and had also reported this patient was not on a diuretic. He indicated that a CPK of 1293 was high and added he felt this level was from the patient not drinking. S17 MD indicated Patient #4 was hydrated with normal saline, free water, as well as a nasal gastric tube in the hospital. Further Patient #4 ' s mental status never came back. He added the family elected for hospice care. S17 MD reported he did not feel that the staff recognized side effects of antipsychotic medication. A second interview was held with S17 MD on 5/19/10 at 1:10 PM. He indicated that he wished the staff would have called him earlier about Patient #4 ' s decline in medical status and added he wished he would have seen Patient #4 3 hours earlier. He further indicated that he tells the staff to always call him with any concerns and that he also tells them to wake him in the night if he is needed.

An interview was held with S19 MD, and Medical Director on 5/14/10 at 11:40 AM. He indicated he did not remember Patient #4 or the details surrounding this case. He further indicated he was not a part of the investigation nor was this situation brought to his attention by the Quality Assurance Department. S19 MD, Medical Director indicated he would think that internal medicine would make rounds on patients on the unit on a regular basis at least 2 to 3 times a week and he was not aware that they were not doing this. He further indicated he recalled an issue several months ago getting consulting physicians to come to the Senior Behavioral Health unit. He added the bylaws had been changed to reflect the Psychiatrist should call the internal medicine physician and have direct communication when a medical consult is needed. He added S4, MD Psychiatrist is a physician and should be checking the patient ' s medical needs. He added that he expects medical doctors to provide continuous care and that all patient needs are addressed.

.Review of the Medicine on-call list revealed medical coverage for Lakeview Medical center from 02/01/10 through 02/28/10.

The Lakeview Regional Medical Center Medical Staff Rules and Regulations with a revision date of 01/06/2010 were reviewed. Documentation reveled in part, " F. Consultation
1. An attending Physician is responsible for the care of his/her patient to the limit of their training and clinical privileges. When the patient need exceed the capabilities of the Attending Physician, a consultation is required with a qualified Active and Consulting medical staff practitioner possessing the appropriate training and clinical privileges in the interest of providing optimal patient care.
2. Emergent or complex consultations are best initiated by the Attending Physician verbally discussing the patient ' s clinical condition with the consulting physician as soon as the need to consult is determined. Even routine consultations are expedited by the practice of physician to physician discussion improving the delivery of patient care.
3. All consultations should be ordered by the Attending Practitioner and not by other specialists attending the patient without his/her specific knowledge and approval. All elective consultations must be performed within 24 hours of consultation or sooner when emergent..Any disagreements about the appropriateness of a consult by a consultant should be personally discussed with the patient ' s attending Practitioner.
4. If a nurse has any reason to doubt or question the care provided any patient or believes that appropriate consultation is needed, the nurse shall call this to the attention of her supervisor who may refer the matter to the Medical Director and Chief Nursing Officer. If warranted, the Director will bring the matter to the attention of the chairman of the department which the practitioner has clinical privileges. The chairman of the division or department may request a consultation where circumstances justify such action.

Patient #8
Review of the history and physical and the medical record revealed Patient #8 was admitted to the unit on 2/22/10 for increased confusion and hallucinations by S10 MD. Further documentation by S10 MD revealed he would check on the patient's labs when they became available, and would be able to assist with any changes in the patient's medical condition that might arise during her stay.
Review of the nurse's notes on 2/23/10 revealed the patient had a strong urine odor. A urinalysis was collected and a culture and sensitivity was ordered.
Review of the Physician orders on 2/25/10 revealed an order for Bactrim 1 PO (by mouth) BID (twice a day) for UTI (urinary tract infection). Further review revealed orders to encourage fluids and to get Basic Metabolic Profile (BMP) on 2/26/10, 3/1/10, 3/2/10, 3/4/10, 3/5/10 and 3/8/10. Review of the BMP's revealed :
2/26/10: BUN- 49H (reference units 7-18mg/dl)
CREA - 2.0H (reference units 0.6-1.0mg/dl)
3/1/10: BUN- 63H (reference units 7-18mg/dl)
CREA - 2.8H (reference units 0.6-1.0mg/dl)
3/2/10: BUN- 54H (reference units 7-18mg/dl)
CREA - 2.8H (reference units 0.6-1.0mg/dl)
3/4/10: BUN- 58H (reference units 7-18mg/dl)
CREA - 2.7H (reference units 0.6-1.0mg/dl)
3/5/10: BUN- 60H (reference units 7-18mg/dl)
CREA - 2.7H (reference units 0.6-1.0mg/dl)
3/8/10: BUN- 65H (reference units 7-18mg/dl)
CREA - 2.7H (reference units 0.6-1.0mg/dl)

Review of documentation of reveals on 2/26/10 the nurse practitioner for S10 MD was notified of the BMP and orders were written to encourage fluids, BMP on Monday. 3/1/10 S10 MD was notified of the BMP results with orders to push fluids and recheck in AM. 3/2/10 S10 MD was faxed the BMP results at 11:30 AM with documentation from a faxed cover sheet that indicated he was notified yesterday (3/1/10) of BUN 63 and Creatinine 2.8, orders had been received for repeat today (3/2/10) which is attached, please advise. 3/5/10 revealed documentation S4 MD encouraged fluids. 3/8/10 documentation revealed a faxed cover sheet to A10 MD that indicated stuff were sending laboratory results, they were encouraging fluids and that the patient was getting approximately 2000 cc's qd (every day). Further review of the nurse's notes on 3/8/10 repealed documentation lab work had been faxed to S10 MD and that his office had been called about Patient #8. Record review revealed S4 MD was on the unit and wrote orders to send Patient #8 to the emergency room to evaluate and treat. The documentation revealed S10 MD's office was notified. The patient left the by ambulance for transport to the emergency room. There is no documentation in the medical record that S10 MD responded to the faxed reports or telephone calls about Patient #8. Record review further revealed on 2/8/10 the patient was admitted to the medical surgical floor of the hospital.

An interview was held with S4 MD on 5/13/10 at 1:15 PM. He indicated the patient was admitted to the hospital for mild dehydration. He further indicated with the patient's elevated BUN and internal medicine not responding to the elevated BUN that the patient needed care in an acute care setting and was tired of waiting for a consult.

The discharge summery dictated by S4, MD on 3/8/10 revealed that the patient was discharged to the hospital's emergency room in guarded condition, with activity and medications to be re evaluated at the receiving facility.
An interview was held with S3 RN Risk Management on 5/17/10 at 2:00 PM. After a view of the medical executive committee meeting minutes for October 2009 and November 2009 she indicated there was no documentation of a follow-up on the failure to obtain a neurology consults in a timely manner from the 9/28/09 meeting.
An interview was held with S26 RN Quality in the presence of S2 RN Clinical Manager and S16, CNO on 5/18/10 at 2:45 PM. She indicated the quality report failed to identify the delay in consultations reported to the medical executive committee by S4, MD in September 2009.
An interview was held with 2 RN on 5/13/10 at 11:15 AM. She indicated there are patients on the unit only receiving hydration and added they were ready to go back to the nursing home. She added they do not meet the criteria for acute care. She further indicated the unit has a difficult time getting a medical physician to come to the senior behavioral unit. She further indicated when patients declines we call the medical doctor and added they do not treat us like we are a part of the hospital.

An interview was held with S2 RN on 5/13/10 at 2:05 PM. She indicated that most of the neurologist will not come to the unit to see patients for consultation. She further indicated the neurologist tell us to send the patient's to an out patient clinic once they are discharged. She reported this situation was brought to the attention of S4 MD and S19 MD Medical Director. An additional interview was held with S2 RN Clinical Manager on 5/14/10 at 9:30 AM. She indicated that an occurrence report should be written if/when a physician does not respond to a call from the unit about one of their patients. She further indicated they do not do a good job of documenting these occurrences but added that the unit would then call S1 Assistant Administrator/Director. S2 RN Clinical Manager indicated that the hospital did not have data on the physicians who fail to respond to calls from the unit nor were this data being tracked. .

An interview was held with S16, CNO on 5/15/10 at 9:45 AM. She indicated that S4 MD had addressed the medical executive committee on 9/28/09 about the problems he had getting consults. She indicated the hospital had changed the bylaws to reflect that the referring physician would discuss the patient and the situation with the consulting doctor; doctor to doctor contact for all consults. She also indicated the hospital was tracking physicians who did not respond to the nurses concerns.

Review of the Medical Staff By-Laws for 2010 under section 4.4 consulting Staff, Section 4.4.3 Obligations of Consulting staff revealed that each member of the Consulting Staff shall discharge the basic obligations of staff members as required in these Bylaws; maintain sufficient levels of clinical activity at the hospital or provide supplemental data to assess clinical competency, provide continuos care and supervision of his/her patients in the hospital or arrange a suitable alternative; and perform such further duties as may be required of him/her under these Bylaws of Rules and Regulations.

Based on record review (medical records, policy and procedure) and interview the registered nurse failed to supervise and evaluate the nursing care for each patient by 1) failing to ensure nursing assessments for a patient's decline in weight and hydration status were evaluated and identified and reported to the attending physician for 1 of 11 sampled patients resulting in the patient's transfer to the acute care setting with a diagnosis of Altered Mental Status, Acute Renal failure, Rhabdomyolysis, Hypernatremic Dehydration and failing to ensure routine accuchecks were performed for a patient with a diagnosis of Non Insulin Dependent Diabetes, failing to monitor and assess the patient for not having a bowel movement for 7 days and failing to ensure a physical therapy consult was obtained for treatment of a Stage II Decubitus. (Patient #4) 2) failing to have a system in place for the monitoring of side effects of psychotropic medication to ensure that nursing assessments documented were evaluated and identified as side effects of the psychotropic medications being administered to the patient as evidenced by the patients' increased drowsiness, lethargy, rigidity, and tremors (Patient #4 and Patient #11) and elevated temperature 2nd to Neuroleptic Malignant Syndrome (Patient
#11) 3) failing to ensure accurate weights were obtained for Patient #2 and documented and that nursing assessments for weight loss were documented for Patient #2, #4 and #11 for 3 of 11 sampled patients. Findings:

1) failing to ensure nursing assessments for a patient's decline in weight and hydration status were evaluated and identified and reported to the attending physician.

Patient #4
The Medical Record for Patient #4 was reviewed. Documentation revealed Patient #4 was admitted to the Senior Behavioral Health Unit of Lakeview Regional Medical center on 02/08/10.

The Psychiatric Evaluation dated 02/09/10 revealed in part, "Reason for admission:
1. Potential danger to self, others, or property
2. Inability to maintain ordinary habits of daily living
3. Bizarre or socially inappropriate behavior
4. Failure or unavailability of outpatient treatment

History of Present Illness:
The patient is a 76 year old, white male with a history of dementia of unknown duration. He lives in an assisted living facility in Mississippi. He presents with the above symptoms. He is in need of medication adjustment for stabilization to allow him to continue to live safely in a structured environment.
Past Psychiatric History: Know only for dementia, the course and duration of his illness are unknown.
Mental status Examination:
The patient is a well developed, well nourished, white male.
He is reasonably well kept. He is cooperative and friendly during the examination although his cognition is severely impaired. He is oriented to person only.
Diagnosis:
1. Dementia with behavioral disturbance
2. Hypertension
3. Noninsulin dependent diabetes mellitus
4. Chronic progressive mental illness.
Estimated length of stay: 12 to 14 days.

Review of the Consultation Report for the History and Physical Examination dated 02/09/10 revealed in part, "...History of Present Illness: This is a 76 year old man who is admitted under non-contested admission to the Senior Behavioral Health Unit at the request of his daughter for medication adjustment due to his increased confusion and combativeness at his adult daycare. He apparently had been doing well in his assisted living center until approximately a month ago, when he began wandering at night and missing medications. He was very agitated last night and so he required Ativan for sedation and currently he is sleeping fairly soundly so I am not able to get any information from him. I am therefore relying on the medical records data mainly provided by his family ... "

PAST MEDICAL HISTORY:
1. Hypertension
2. Type II Diabetes
3. Coronary artery disease
4. Decreased auditory acuity on the left.

Medications:
1. Paxil 20 milligrams p.o. daily
2. Exelon 3 milligrams p.o. daily
3. Namenda 10 milligrams p.o. daily
4. Atenolol 25 mg milligrams p.o. daily
5. Trazodone 100 milligrams p.o. daily
6. Triamcinolone 0.1% to facial rash twice daily
7. Lotrimin cream to rash twice daily
8. Several routine p.r.n. medications.

Physical Examination: Vital Signs: Temperature 98.5, pulse 76, respirations 18 blood pressure 120/72, weight 142 pounds.
IMPRESSION AND RECOMMENDATIONS:
1. Diabetes: Will continue to follow sliding scale coverage and monitor as he is not currently on any medication and his glucose is normal at 112.
2. Hypertension and Coronary Artery disease: Continue current blood pressure medicine and monitor
3. Deafness: This will need to be taken into account when interacting with the patient
4. Increased Confusion: His Depakote level is elevated and his dose is being held.
Will continue to make further recommendations as his case progresses.

Review of documented weights in the electronic record for Patient #4 revealed the following;
02/08/10; 142 lbs
02/14/10; 136 lbs
02/20/10; 135 lbs
02/28/10; 119 lbs (Loss of 23 pounds)

Review of Intake and Output Worksheets revealed the following:
02/08/10 Admit Day Dinner 10% , Oral fluid Intake 840cc. Voided x3 (nurses notes indicate patient #4 ate a hamburger and dank soft drink on arrival to unit at 4:04pm)
02/09/10 Breakfast 0; Lunch 0; Dinner 0; HS Snack 100%; Oral Fluid 240cc, Voided x 2
02/10/10 Breakfast 40%; Lunch 0%; Dinner 0%, Oral Fluid 480cc, Voided x 4
02/11/10 Breakfast 10%, Lunch 10, Dinner 0%, Oral Fluid 240cc, Voided x3
02/12/10 Breakfast 0%, Lunch 0%, Dinner 0% Oral Fluid 0%, Voided x 1
02/13/10 Breakfast 0%, Lunch 50%, Dinner 25%, Oral Fluid 720cc, Voided x 4
02/14/10 Breakfast 0%, Lunch 0%, Dinner 20%, Oral Fluid 570cc Voided x 2
02/15/10 Breakfast 10% Lunch 0 %, Dinner 0%, Oral Fluid 750cc, Voided x 4
02/16/10 Breakfast 0%, Lunch 0%, Dinner 0%, Oral Fluid 750cc, Voided X 4
02/17/10 Breakfast 0%, Lunch 0%, Dinner 25%, Oral Fluid 440cc, Voided x 4
02/18/10 Breakfast 40%, Lunch 5%, Dinner 10%, Oral Fluid 960cc, Voided x 5
02/19/10 Breakfast 5%, Lunch 5%, Dinner 10%, Oral Fluid 2800cc, Voided x 4
02/20/10 Breakfast 0%, Lunch 0%, Dinner 25%, Oral Fluid 540cc, Voided x 3
02/21/10 Breakfast couple of bites, Lunch 25%, Dinner 25%, Oral Fluid 1430cc, Voided x 4
02/22/10 Breakfast 20%, Lunch couple of bites, Dinner couple of bites, Oral Fluid 1300cc, Voided x 4
02/23/10 Breakfast 10%, Lunch 20%, Dinner 10%, Oral Fluid 1460cc, Voided x 5
02/24/10 Breakfast 0%, Lunch 0%, Dinner 50%, Oral Fluid 840cc, Voided x 4
02/25/10 Breakfast 0%, Lunch 0%, Dinner 0%, Oral Fluid 780cc, Voided x 5
02/26/10 Breakfast 5%, Lunch 0%, Dinner 0%, Oral Fluid 490cc, Voided x 5
02/27/10 Breakfast Refused, Lunch 2 bites, Dinner refused, Oral Fluid 840cc, Voided x 4
02/28/10 Breakfast 0%, Lunch 0%, Dinner 0%, Oral Fluid 340cc, Voided x 2

Review of the Physician Order Sheet revealed orders dated 02/08/10 for Trazodone HCL 100mg daily, 02/09/10 for Depakote Liquid 500mg BID (twice daily) and 02/13/10 for Seroquel 25 mg po (by mouth) every am and 02/18/10 Seroquel 25 mg po q am and 50mg at bedtime. Further documentation revealed the Seroquel, Depakote and Trazodone were discontinued on 02/25/10.

Review of the Physician/Psychiatric Nurse Practitioner Daily Progress Notes by Psychiatric Services revealed
02/19/10 1900 (7pm) Poor appetite, 280cc liquid intake
02/20/10 (no time) Quiet but alert; becomes combative only with ADLs; CBG (capillary blood glucose199)
02/27/10 (no time) Cont to have poor appetite; lethargic. Pt is lethargic so will wait before ordering any meds since this may increase sedation. Due to 0 stool for several days in spite of increased fluid & MOM will order mineral oil enema now and repeat in am if ineffective.

There was no documented evidence a medical consult was obtained from 02/19/10 through 02/28/10 for the patient ' s decline with decreased nutritional and fluid intake, lethargy, increased glucose of 192, no BM in several days.

On 2/28/10 (no time) the Psychiatric Nurse Practitioner documented, "Staff reports increase lethargy; refused to eat, No BM after fleets x 2. Pt. in room in bed supine with eyes closed-responds with thrashing when touched but doesn't open eyes or speak; alternating jerking of extremities; abd soft with bowel signs; digital Rectal exam with lg amt stool palpated that is soft, small amt removed; normal color. Will order CMP, CPK, Troponin for today. Pt ' s psychotropic meds have been held x approx 4 days. Continue to monitor.

Review of the Patient Notes/Reassessment revealed Patient #4 was admitted on 02/08/10 at 1245, (12:45pm) form an assisted living facility. The patient was ambulatory with an unsteady gait assisted by his daughters on unit. The patient was well groomed with a flat affect. Documentation revealed the patient ate a hamburger and drank a soft drink brought to unit by his daughters. Further review of the nursing Patient Notes/Reassessments, from 2/09/10 through 02/26/10, revealed documented evidence of nursing assessments of lethargy, not eating and drinking due to decreased level of consciousness and increased level of sedation. Further documentation revealed shuffling gait, bilateral lower extremity weakness, shivering, body tremors, rigidness, not responding verbally, no BM for 7 days, and development of a Stage II decubitus.

Physical Therapy and Occupational Notes revealed Patient #4 was receiving PT for gait training and OT for ADL self care.

Further review of the Patient Notes/Reassessemnts revealed in part the following:
02/27/10 0750 (7:50am) Pt. cont. to twitch/jerk various body parts from time to time. Will cont. To monitor
02/27/10 1513 (3:33pm) Has sacral breakdown about ? inch red excoriated area between cheeks, no bowel movement since the 20th documented pt not eating does drink the supplement, MOM given yesterday and today, also prune juice, not eating at all except a little Jello or pudding, drinks supplements,.on Megace, fed by staff, seldom opens eyes. Will cont. to monitor.
02/27/10 1600 (4pm) LOC (level of consciousness) Drowsy, Generalized weakness
02/28/10 0416 (4:16am) Pt. mostly non-verbal, will grunt. PRN Ativan admin.IM at 0200, (2am) Pt cont. with body twitching /jerking from time to time. Will cont. to monitor.
2/28/10 1123 (11:23am) MOM and Prune juice given last 2 days, Fleets enema last night No results. MOM and prune juice given again this am. Will repeat enema if has not worked by after lunch time. Pt. continues to be drowsy keeping eyes closed most of time, Not verbalizing, just grunting, Resistive to care, Hits out, Movements are stiff and jerky. Will continue to monitor.
02/28/10 1900 (7pm) New orders from (Name of S18 Psychiatric Nurse Practitioner) after talking to (name of S4) Psychiatrist) to send pt to radiology for CT and labs for CMP and CK and troponin done. Ambulance called to transport for CT, reported off to night shift. Ambulance pickup arrived. Family called asking about pt. Informed he was going for test at main hospital and we would be able to tell them more after the tests were done. Pt expected to return after CT. Abnormal reports to be called to (name of S4 or name of S18
02/28/10 2000 (8pm) Pt. received from day shift with orders to transport to Lakeview for CT of head without contrast from S18 NP for mental status changes, stiff and jerky body movements. Had CPK, and Troponin labs drawn prior to change of shift and awaiting results. Pt. resisting staff trying to transfer pt to stretcher and Ativan 1 mg IM given left thigh for transport and for pt to cooperate with CT Scan@ 2015 (8:15pm) and pt. left unit. After pt. left, lab called with abnormal values of Sodium 166, Glucose 734. Abnormal values called to S18 Richard, NP at 2029. (8:29pm) Orders received from S18 to have pt. evaluated in ER and not have CT done if procedure not started. RN in ER called and orders given to eval and treat in ER. At 2320 (11:20pm) admitting called to notify us that pt would be admitted to ICU.

The Patient Plan of Care for Patient # 4, initiated 02/08/10, was reviewed. There was no documented evidence the Patient ' s history of Diabetes was addressed and accucheks were implemented.

The Interdisciplinary Treatment Plan Update on 02/18/10 and 02/25/10 revealed no documented evidence of the Patient ' s potential for side effects and monitoring for side effects of psychotropic medications were addressed. There was no documented evidence the patient rigidity, tremors, twitching, fidgeting, drowsiness, poor appetite with less than 50% intake and extreme weight loss and decrease in fluid intake with a potential for dehydration were addressed. Further there was no documented evidence the Patient ' s skin breakdown with a Stage II Decubitus was addressed or treated. There was no documented evidence of the patient ' s failure to have a BM since 02/20/10.

There was no documented evidence in the record the patient's medical physician was notified and consulted for the decline in the patient's condition. There was no documented evidence the medical physician was notified of the patient's rigidity, tremors, twitching, fidgeting, drowsiness, poor appetite with less than 50% intake and extreme weight loss and lack of fluid intake. Further there was no documented evidence the medical physician was notified of Patient #4's skin breakdown with a Stage II Decubitus.

The History and Physical, dictated 02/28/10 (the date Patient #4 was transferred to Lakeview Medical Center for acute care) per S17, MD Internal Medicine, was reviewed. Documentation revealed in part,
"History of present illness: This is a 76 year old man with a past history of Alzheimer's dementia, hypertension, diabetes and coronary artery disease that was previously being treated for increased aggression at Lakeview's Geri-psych Facility.

They noted that he had some mental status changes last night and were in the process of transferring him to the Emergency Room for evaluation and at that time his accu-chek was 775 as I recall, so they proceed to the Emergency Room. Once in the Emergency Room they also found out that his sodium was high at 166 and creatinine high at 4.5 so he was admitted to the intensive care unit with the diagnosis of hypernatremic dehydration and hyposmolar state. Over the night he received intravenous fluids and an insulin drip. Currently his glucose is somewhat normal; however his sodium had increased to 177. His creatinine has also increased slightly to 4.3. F
Review of systems: Is unobtainable from the patient at this time, as he is somnolent and is easily agitated when aroused. I did speak with his stepdaughter, and she said that he has declined in his clinical status over the past month, becoming increasingly unable to perform his activities of daily living; specifically, he is not able to feed himself or drink very much. I believe this further exacerbated his dehydration. They deny that he had complained of any chest pain, or shortness of breath, fever, chills, nausea, vomiting, diarrhea, constipation hematuria, dysuria, hematochezia, or melena. He has been treated for scabies back on February 24, with Elamite cream times one and it will be repeated on March 4.

Physical Examination: Vital signs: Currently blood pressure of 157/77, pulse 94, respirations 24, saturation of 95% room air. Temperature 98.8. His intake and output since admission are: 1090 in and looks like 50 milliliters urine output. HEENT: Mucus membranes are quite dry. Skin: There is decreased sin turgor globally. There are no lesions of scabies that I can tell.
Laboratory Data: Currently, Sodium of 177, potassium 3.6, chloride 138, bicarb is 24, BUN 124, creatinine 4.3, glucose 86, calcium 8.8, white count of 19.7, hemoglobin and hematocrit of 16.5 and 45.3, platelets of 191. Troponin lst nigh of 0.24, MB of 2.5, creatine phosphokinase (CPK) of 1293.

Review of the Discharge Summary with a discharge date of 03/09/10 revealed in part, Final Diagnosis:
1. Altered Mental status
2. Acute renal failure
3. Type II diabetes Mellitus.
4. Rhabdomyolysis
5. Hypernatremic dehydration
6. Coronary artery disease
Treatment Rendered/Procedures Performed:
The patient was treated prophylactically for scabies, placed on intravenous fluids and antibiotics. It was felt that his acute renal failure was related to his rhabdomyolysis all related to dehydration and this was treated aggressively. He did not respond well to the very aggressive care that he was given, and the decision was made by family to have the patient be admitted to hospice. He was therefore transferred to the care of hospice on March 8."

An interview was held with S10 MD, Internal Medicine/Pediatrics 5/13/10 at 8:35 AM. After review of the medical record for Patient #4, he indicated he only did the initial History and Physical on 2/9/10 then saw the patient at the main campus when he was in the Intensive Care Unit. S10 MD indicated the documented assessment by his associate, revealed Patient #4 labs on transfer to the acute unit the creatinine was 1.2 which was a little high, his urine was a little concentrated; it was borderline but nothing terrible. Further Patient #4 went 12 days without lab work being performed while a patient on the geri-psych unit. S10 MD further indicated a sodium level of 166 was reported on 02/28/10 and added that with abnormal labs the staff should notify him or the Nurse Practitioner.S10 MD further indicated he did see things in the progress notes of Patient #4 ' s decline and change in status the that may have been as issue and he should have been consulted. He indicated he did not see anything in the notes that staff had communicated with him about the change in the patient ' s status.

An interview was held with S4, MD Psychiatrist on 5/13/10 at 1:15 PM. He indicated that he was familiar with Patient #4. He indicated the patient was admitted to the unit with advanced dementia, combative and resistant to care. He further indicated the patient was medically stable at admit, was not eating well but his fluid intake was good. S4, MD Psychiatrist reported Patient #4 began to show signs of over sedation and was sent to the emergency room. He indicated it could have been some of the medications that caused problems for Patient#4 and added that he was approaching this situation from a psychiatric viewpoint. S4, MD Psychiatrist further indicated that a CPK of 1293 was not always indicative of neuroleptic malignant syndrome and added that this level was also associated with dehydration.

An interview was held with S17 MD Internal Medicine/Pediatrics on 5/14/9 at 10:20 AM. He indicated his specialty was internal medicine/pediatrics and he had seen Patient #4 initially in the Emergency Department of Lakeview Medical Center. He indicated he did remember Patient #4 and added this patient ' s sodium level was the highest he had ever seen. He indicated his first interaction with the patient and the family was at the emergency room of the hospital. This Physician indicated he had not been called from the Senior Behavioral Unit prior to his admission to the ED and added he would have expected a call from the staff if a patient is not eating or drinking for just one day. S17 MD indicated he could have ordered an IV for hydration if he been notified of the patient not eating and drinking. He added he had met with the family in the Emergency Department, the day he was transferred from the Senior Behavioral Health Unit, and they were aware that Patient #4 was not eating and drinking and had also reported this patient was not on a diuretic. He indicated that a CPK of 1293 was high and added he felt this level was from the patient not drinking. S17 MD indicated Patient #4 was hydrated with normal saline, free water, as well as a nasal gastric tube in the hospital. Further Patient #4 ' s mental status never came back. He added the family elected for hospice care. S17 MD reported he did not feel that the staff recognized side effects of antipsychotic medication. A second interview was held S17 MD on 5/19/10 at 1:10 PM. He indicated that he wished the staff would have called him earlier about Patient #4 ' s decline in medical status and added he wished he would have seen Patient #4 3 hours earlier. He further indicated that he tells the staff to always call him with any concerns and that he also tells them to wake him in the night if he is needed.

An interview was held with S18, and Psychiatric Nurse Practitioner on 5/14/10 at 11:20 AM. She indicated that she did not remember Patient #4. Documentation revealed she had visited the patient 9 days on the unit. After a review of the medical record she indicated she had been told by a Mental Health Tech on 02/28/10 the patient had not had a bowel movement. She further indicated she checked the patient for a fecal impaction and he did not have an impaction. She reported the patient was confused and added that she could not remember why she had ordered lab work. She added the patient had an elevated white blood count on 2/23/10 and she would have thought internal medicine had been involved with the patient. S18, Psychiatric Nurse Practitioner also reported that the documentation reflected on 2/26/09 the patient was escalating in aggression. She indicated she had discussed the possibility of Neuroleptic Malignant Syndrome with S4, MD Psychiatrist but that Patient #4 had been off of psychotropic medications for four days. A second interview was held with S18, Psychiatric Nurse Practitioner on 5/14/10 at 12:10 P M. She indicated documentation of the lab work on 2/23/10 for Patient #4 was not very significant and added that he did have an elevated white blood count. She added that she looked at the medical record to see if the lab work had been repeated. She further indicated her note on 2/27/10 that the patient was lethargic. She added that on 2/28/10 patient had an increase in lethargy, had no bowel movement, and involuntary jerking.

An interview was held with S3 RN Risk Manager on 5/17/10 at 2:10 PM. She indicated she was familiar with Patient #4's file. She further indicated she had received a telephone call from the patient's granddaughter on 3/11/10. S3 RN Risk Manager reported she were shocked at the amount of weight loss this patient had experienced and also that the staff had not identified this situation. She further indicated she had notified S1 Assistant Administrator that the patient had no intake for several days. In another interview on 5/13/10 at 1:00 PM S3 further indicated "we failed this patient" Further she also reported Patient #4's chart was very disappointing to her and could not find documentation that staff had spoken to the physician. In another interview 5/13/10 at 4:10 PM S3 indicated after review of the medical record Patient #4 had a Stage II Decubitus. She further indicated hospital protocol is to call the attending physician and to obtain a Physical Therapy consult. She added the physician order for the referral to physical therapy was never obtained.

An interview was held with S22 RD on 5/17/10 at 12:00 PM. After a view of the medical record she indicated that Patient #4 had a normal BMI. (Body Mass Index) She indicated on 2/11/10 the record reflect that the patient had been offered a supplement, and that the attending Physician had ordered Megace. She further indicated his labs , dated 02/09/10 reflected an albumin of 3.5 (reference range 3.4-5) and a glucose of 112. (reference range 70-110) She further indicated on 2/16/10 the patient ' s lab report reflected an albumin was 3.6 and his glucose was 192. She reported that if a patient is eating 50% or more of their food she was comfortable with that unless there albumin goes down. Further S22 indicated there was a weight loss of 7 lbs with a documented weight of 135 pounds on 02/25/10 and she had not noted the weight in her assessment note probably because she reviewed the patient ' s record before the weight was recorded Further she stated that was not good and could mean muscle or fluid loss. Further Patient #4 should have been triggered for a dietary evaluation at that point and that was not done.

An interview was held with S15 RN on 5/14/10 at 8:45 AM. S15 indicated she worked 7p to 7a and had worked on the geri-psych unit for 1 ? years. She indicated she did remember Patient #4 who was nonverbal, mumbled, was incontinent, slept a lot and would refuse his 9:00 PM medications. She added that Patient #4 kept his mouth clamped and they could not get him to take oral medications. Further she had not reported this to the physician but would pass it on during shift report to the 7a/7pm nurse. She further indicated his medications would be crushed in an attempt to get him to take the medications and this information was given to the day nurses. S15 RN reported she observed the patient shivering one night and that he did not feel cold to the touch nor did he feel feverish. She did not take vital signs and did not inform the physician as she thought he was having a dream so she just patted his arm. She added that Patient #4 had fine body tremors and that his hands would shake. S15 indicated that the side effects of Seroquel are that it can cause drowsiness as well as interacting with other medications. She further indicated that an AIMS (Abnormal Involuntary Movement Scale) assessment is done only on admission. She indicated she has not had a specific in service related to identifying the side effects of psychotropic medications nor was this done during orientation.

An interview was held with S8 LPN on 5/12/10 at 3:10 PM. She indicated she did not remember Patient #4. After review of the medical record and the note from 2/14/10, she reported she documented the patient had a poor appetite and had refused the Megace that was ordered. She added that she had given report to the on-coming evening shift that Patient #4 had not eaten and indicated if she had called the physician, she would have documented that conversation and this was not documented. She also indicated that if a patient is not eating a nutritional consult would be obtained but she had not requested a dietary consult. Further a 5 pound weight loss should be reported to the physician. After review of the notes on 2/16/10 she indicated there was a small reddened area on the patient ' s buttocks and that barrier cream had been applied. S8 LPN further indicated the physician had not been notified of the reddened area but added she reported the area to the RN. There was no documentation of an assessment of the reddened area by the RN. S8 LPN added that she should have notified the physician. S8 LPN indicated the side effects for Seroquel are that it " kind of " makes you drowsy, is an anti-anxiety medication, (Seroquel is an antipsychotic) can cause hypotension and make a patient weak. She further indicated there was no documentation of monitoring medication side effects for Patient #4. She added that, " We just watch them. "

An interview was held with S11 PCT (Patient Care technician) on 5/13/10 at 9:20 AM. She indicated that she did remember Patient #4. She further indicated she was working as the recreational therapist at the time of his admission. S11 PCT added that he participated with the music group but was very quiet. She indicated that he was aggressive, would resist and hit at staff, with his activities of daily living and added that he was a very private man. She reported the staff had trouble walking Patient #4 and that he had refused to eat. She also reported that Patient #4 would clinch his mouth shut and turn his head away when trying to be fed.

An interview was held with S9 RN, on 5/13/10 at 10:45 AM. after review of the medical record, S10 RN indicated the RN staged the wound on 2/24/10 as a Stage II ulcer. She indicated it was the hospital protocol to consult physical therapy for a stage II ulcer. Further it was not documented this was done.

An interview was held with S29 LPN, on 5/13/10 at 10:45 AM. After a view of the medical record she indicated when Patient #4 was approached he would get rigid. She also indicated he had redness on his buttocks that was not broken down and barrier cream was used to prevent further sheering.
An interview was held with S21 RN on 5/17/10 at 9:45 AM. After a view of the entire medical record he indicated that he vaguely remembered Patient #4. He indicated that the patient was preoccupied with his pants, was easily directed, had no agitation/or aggression, and that he took his medication with fluids. S21 RN added that the patient ' s legs were stiff on 2/22/10 after he had been sitting in a geri-chair. He indicated the patient would scream when he was moved. He further indicated that on 2/23/10 at 8:05 PM Patient #4 had rigid extremities and his legs were stiff. He indicated the documentation revealed the patient was lethargic, mumbled words and again was able to be directed. S21 RN reported he did not call the physician and the patient was declining. He added physical therapy had probably overworked him that day and the patient ' s muscles were sore. He indicated side effects of psychotropic medications are restlessness and the patients become quiet. He further indicated that side effects would be documented in the nurse ' s notes. S21 RN reported he had heard of neuroleptic malignant syndrome but could not explain any details about the syndrome at this time.

Review of the Medicine on-call list revealed medical coverage for Lakeview Medical center from 02/01/10 through 02/28/10.

The Lakeview Regional Medical Center Medical Staff Rules and Regulations with a revision date of 01/06/2010 were reviewed. Documentation reveled in part, " F. Consultation
1. An attending Physician is responsible for the care of his/her patient to the limit of their training and clinical privileges. When the patient need exceed the capabilities of the Attending Physician, a consultation is required with a qualified Active and Consulting medical staff practitioner possessing the appropriate training and clinical privileges in the interest of providing optimal patient care.
2. Emergent or complex consultations are best initiated by the Attending Physician verbally discussing the patient ' s clinical condition with the consulting physician as soon as the need to consult is determined. Even routine consultations are expedited by the practice of physician to physician discussion improving the delivery of patient care.
3. All consultations should be ordered by the Attending Practitioner and not by other specialists attending the patient without his/her specific knowledge and approval. All elective consultations must be performed within 24 hours of consultation or sooner when emergent..Any disagreements about the appropriateness of a consult by a consultant should be personally discussed with the patient ' s attending Practitioner.
4. If a nurse has any reason to doubt or question the care provided any patient or believes that appropriate consultation is needed, the nurse shall call this to the attention of her supervisor who may refer the matter to the Medical Director and Chief Nursing Officer. If warranted, the Director will bring the matter to the attention of the chairman of the department which the practitioner has clinical privileges. The chairman of the division or department may request a consultation where circumstances justify such action.

Lakeview Policies:

The policy entitled Reassessment of Patients #002.05 presented as the hospital ' s current policy was reviewed. Documentation revealed in part, " Interdisciplinary Involvement in Reassessment: The nursing staff collaborates with interdisciplinary team members such as social workers, case managers, physical therapists, etc.. The purpose of this collaboration is to review certain patient's personal progress based on biophysical, psychosocial, environmental, self care, educational and discharger planning needs.
Data provided by each discipline is available to assist the nurse in revising the patient's plan of care.
In addition, the patient will be reassessed:
1. To determine the patient's response to treatment.
2. When a significant change occurs in the patient's condition
3. When a significant change occurs in the patient's diagnosis
4. According to the specified time frames as defined by nursing and approved by the Medical Staff.
Reassessment will

Based on record review (medical record and hospital policy)and interviews the hospital failed to ensure the nursing staff keep current the medical nursing care plan by 1)failing to identify and update the plan of care for a patient's symptoms of rigidity, tremors, twitching, fidgeting, drowsiness, poor appetite with consumption of less than 50% intake and extreme weight loss and decrease in fluid intake with a potential for dehydration and the development of skin breakdown with a Stage II Decubitus (Patient #4) and for updating the care plan for a patient who developed Neuroleptic Malignant Hypertension and Stage II decubitus for (Patient #11) for 2 of 11 sampled patients. Findings:

Patient #4
The Medical Record for Patient #4 was reviewed. Documentation revealed Patient #4 was admitted to the Senior Behavioral Health Unit of Lakeview Regional Medical center on 02/08/10.

The Psychiatric Evaluation dated 02/09/10 revealed in part, "Reason for admission:
1. Potential danger to self, others, or property
2. Inability to maintain ordinary habits of daily living
3. Bizarre or socially inappropriate behavior
4. Failure or unavailability of outpatient treatment

History of Present Illness:
The patient is a 76 year old, white male with a history of dementia of unknown duration. He lives in an assisted living facility in Mississippi. He presents with the above symptoms. He is in need of medication adjustment for stabilization to allow him to continue to live safely in a structured environment.
Past Psychiatric History: Know only for dementia, the course and duration of his illness are unknown.
Mental status Examination:
The patient is a well developed, well nourished, white male.
He is reasonably well kept. He is cooperative and friendly during the examination although his cognition is severely impaired. He is oriented to person only.
Diagnosis:
1. Dementia with behavioral disturbance
2. Hypertension
3. Noninsulin dependent diabetes mellitus
4. Chronic progressive mental illness.
Estimated length of stay: 12 to 14 days.

Review of the Consultation Report for the History and Physical Examination dated 02/09/10 revealed in part, "...History of Present Illness: This is a 76 year old man who is admitted under non-contested admission to the Senior Behavioral Health Unit at the request of his daughter for medication adjustment due to his increased confusion and combativeness at his adult daycare. He apparently had been doing well in his assisted living center until approximately a month ago, when he began wandering at night and missing medications. He was very agitated last night and so he required Ativan for sedation and currently he is sleeping fairly soundly so I am not able to get any information from him. I am therefore relying on the medical records data mainly provided by his family ... "

PAST MEDICAL HISTORY:
1. Hypertension
2. Type II Diabetes
3. Coronary artery disease
4. Decreased auditory acuity on the left.

Medications:
1. Paxil 20 milligrams p.o. daily
2. Exelon 3 milligrams p.o. daily
3. Namenda 10 milligrams p.o. daily
4. Atenolol 25 mg milligrams p.o. daily
5. Trazodone 100 milligrams p.o. daily
6. Triamcinolone 0.1% to facial rash twice daily
7. Lotrimin cream to rash twice daily
8. Several routine p.r.n. medications.

Physical Examination: Vital Signs: Temperature 98.5, pulse 76, respirations 18 blood pressure 120/72, weight 142 pounds.
IMPRESSION AND RECOMMENDATIONS:
1. Diabetes: Will continue to follow sliding scale coverage and monitor as he is not currently on any medication and his glucose is normal at 112.
2. Hypertension and Coronary Artery disease: Continue current blood pressure medicine and monitor
3. Deafness: This will need to be taken into account when interacting with the patient
4. Increased Confusion: His Depakote level is elevated and his dose is being held.
Will continue to make further recommendations as his case progresses.

Review of documented weights in the electronic record for Patient #4 revealed the following;
02/08/10; 142 lbs
02/14/10; 136 lbs
02/20/10; 135 lbs
02/28/10; 119 lbs (loss of 23 pounds)

Review of Intake and Output Worksheets revealed the following:
02/08/10 Admit Day Dinner 10% , Oral fluid Intake 840cc. Voided x3 (nurses notes indicate patient #4 ate a hamburger and dank soft drink on arrival to unit at 4:04pm)
02/09/10 Breakfast 0; Lunch 0; Dinner 0; HS Snack 100%; Oral Fluid 240cc, Voided x 2
02/10/10 Breakfast 40%; Lunch 0%; Dinner 0%, Oral Fluid 480cc, Voided x 4
02/11/10 Breakfast 10%, Lunch 10, Dinner 0%, Oral Fluid 240cc, Voided x3
02/12/10 Breakfast 0%, Lunch 0%, Dinner 0% Oral Fluid 0%, Voided x 1
02/13/10 Breakfast 0%, Lunch 50%, Dinner 25%, Oral Fluid 720cc, Voided x 4
02/14/10 Breakfast 0%, Lunch 0%, Dinner 20%, Oral Fluid 570cc Voided x 2
02/15/10 Breakfast 10% Lunch 0 %, Dinner 0%, Oral Fluid 750cc, Voided x 4
02/16/10 Breakfast 0%, Lunch 0%, Dinner 0%, Oral Fluid 750cc, Voided X 4
02/17/10 Breakfast 0%, Lunch 0%, Dinner 25%, Oral Fluid 440cc, Voided x 4
02/18/10 Breakfast 40%, Lunch 5%, Dinner 10%, Oral Fluid 960cc, Voided x 5
02/19/10 Breakfast 5%, Lunch 5%, Dinner 10%, Oral Fluid 2800cc, Voided x 4
02/20/10 Breakfast 0%, Lunch 0%, Dinner 25%, Oral Fluid 540cc, Voided x 3
02/21/10 Breakfast couple of bites, Lunch 25%, Dinner 25%, Oral Fluid 1430cc, Voided x 4
02/22/10 Breakfast 20%, Lunch couple of bites, Dinner couple of bites, Oral Fluid 1300cc, Voided x 4
02/23/10 Breakfast 10%, Lunch 20%, Dinner 10%, Oral Fluid 1460cc, Voided x 5
02/24/10 Breakfast 0%, Lunch 0%, Dinner 50%, Oral Fluid 840cc, Voided x 4
02/25/10 Breakfast 0%, Lunch 0%, Dinner 0%, Oral Fluid 780cc, Voided x 5
02/26/10 Breakfast 5%, Lunch 0%, Dinner 0%, Oral Fluid 490cc, Voided x 5
02/27/10 Breakfast Refused, Lunch 2 bites, Dinner refused, Oral Fluid 840cc, Voided x 4
02/28/10 Breakfast 0%, Lunch 0%, Dinner 0%, Oral Fluid 340cc, Voided x 2

Review of the Physician Order Sheet revealed orders dated 02/08/10 for Trazodone HCL 100mg daily, 02/09/10 for Depakote Liquid 500mg BID (twice daily) and 02/13/10 for Seroquel 25 mg po (by mouth) every am and 02/18/10 Seroquel 25 mg po q am and 50mg at bedtime. Further documentation revealed the Seroquel, Depakote and Tranzodone were discontinued on 02/25/10.

Review of the Physician/Psychiatric Nurse Practitioner Daily Progress Notes by Psychiatric Services revealed
02/19/10 1900 (7pm) Poor appetite, 280cc liquid intake
02/20/10 (no time) Quiet but alert; becomes combative only with ADLs; CBG (capillary blood glucose199)
02/27/10 (no time) Cont to have poor appetite; lethargic. Pt is lethargic so will wait before ordering any meds since this may increase sedation. Due to 0 stool for several days in spite of increased fluid & MOM will order mineral oil enema now and repeat in am if ineffective.

On 2/28/10 (no time) the Psychiatric Nurse Practitioner documented, "Staff reports increase lethargy; refused to eat, No BM after fleets x 2. Pt. in room in bed supine with eyes closed-responds with thrashing when touched but doesn't open eyes or speak; alternating jerking of extremities; abd soft with bowel signs; digital Rectal exam with lg amt stool palpated that is soft, small amt removed; normal color. Will order CMP, CPK, Troponin for today. Pt ' s psychotropic meds have been held x approx 4 days. Continue to monitor.

Review of the Patient Notes/Reassessment revealed Patient #4 was admitted on 02/08/10 at 1245, (12:45pm) form an assisted living facility. The patient was ambulatory with an unsteady gait assisted by his daughters on unit. The patient was well groomed with a flat affect. Documentation revealed the patient ate a hamburger and drank a soft drink brought to unit by his daughters. Further review of the nursing Patient Notes/Reassessments, from 2/09/10 through 02/26/10, revealed documented evidence of nursing assessments of lethargy, not eating and drinking due to decreased level of consciousness and increased level of sedation. Further documentation revealed shuffling gait, bilateral lower extremity weakness, shivering, body tremors, rigidness, not responding verbally, no BM for 7 days, and development of a Stage II decubitus.

The Patient Plan of Care for Patient #4, initiated 02/08/10, was reviewed. There was no documented evidence the Patient ' s history of Diabetes was addressed and accucheks were implemented.

The Interdisciplinary Treatment Plan Update on 02/18/10 and 02/25/10 revealed no documented evidence of the Patient ' s potential for side effects and monitoring for side effects of psychotropic medications were addressed. There was no documented evidence the patient rigidity, tremors, twitching, fidgeting, drowsiness, poor appetite with less than 50% intake and extreme weight loss and decrease in fluid intake with a potential for dehydration were addressed. Further there was no documented evidence the Patient ' s skin breakdown with a Stage II Decubitus was addressed or treated. There was no documented evidence of the patient ' s failure to have a BM since 02/20/10.

The Interdisciplinary Treatment Plan Update on 02/18/10 and 02/25/10 revealed no documented evidence of the Patient's potential for side effects and monitoring for side effects of psychotropics were addressed. There was no documented evidence the patient rigidity, tremors, twitching, fidgeting, drowsiness, poor appetite with less than 50% intake and extreme weight loss and decrease in fluid intake with a potential for dehydration were addressed. Further there was no documented evidence the Patient's skin breakdown with a Stage II Decubitus was addressed.

An interview was held with S2 RN Clinical Manager on 5/18/10 at 9:20 AM. S2 indicated she had reviewed the record for Patient #4. Further the treatment team had met twice on 02/18/10 and 02/25/10 for Patient #4 and the Care Plan had not been updated for his rigidity, tremors, twitching, fidgeting, drowsiness, poor appetite with consumption of less than 50% intake and extreme weight loss and decrease in fluid intake with a potential for dehydration and the development of skin breakdown with a Stage II Decubitus.

Patient #11
The medical record for Patient #11 was reviewed. Patient #11 was admitted to the Senior Behavioral Health Unit of Lakeview Regional Medical center on 10/08/09 with a diagnosis of Dementia with Hallucinations and past medical history of prostatitis, ENT problems and GI problems.
Review of documented weights for Patient #11 revealed the following;
10/08/09 168 lbs
10/20/09 166 lbs
11/07/09 144 lbs
11/29/09 134 lbs
12/13/09 138 lbs. (loss of 30 pounds)

Review of the Patient Notes revealed in part the following dates of occurrence:
10/11/09 1622 (4:22pm) All meds held due to sedation this shift
10/14/09 0800 (8am) Refused meals--too drowsy
10/15/09 1834 (6:34pm) Needs to be fed R/T twitching like motion in the arms
10/22/09 1821 (6:21pm) Notified by MHT hat pt has not urinated all day. when pt does urinated is usually a large amt.
10/30/09 2030 (8:30pm) Patient received Zyprexa 10mg Patient was not give Klonopin because although he refused bedtime meds, he was assessed to be too sedated to attempt to administer Klonopin
11/01/09 1827 Encouraged foods and fluids without success
11/06/09 1730 (5:30pm) Refused meals/Fluid
11/08/09 1800 (6pm) Haldol 5 mg IM
11/08/09 1309 (1:09pm) Arousable but mostly sleepy appetite poor, took a few bites
11/09/089 0532 (5:32am) Appeared to sleep 10 hours last night. Sedated . Stage I noted on buttock
11/09/09 1346 (1:46pm) Pt drowsy but does not respond to verbal communication easily
11/09/09 1805 (6:05pm) Pt. low grade temp 99.8 (axilla)
11/09/09 2000 (8pm) Temperature 100.2 oral medicated with Tylenol. Very difficult to give to pt secondary to over sedation/lethargic state. All 2100 (9pm ) meds held (There was no documented evidence the physician was notified of the patient's elevated temperature; the lethargic state and the holding of the 9pm medications)
11/11/09 0516 (5:16am) Pt is having these jerking involuntary movements. Reported to (Name of S4, MD Psychiatrist)
11/11/09 0800 (8am) (Name of S17, MD Internal Medicine) vs; Noted to have involuntary movements to arms

Review of the Physician Progress Note dated 11/10/09 1330 (1:30pm) revealed in part, "pt lethargic today notes reviewed... 65 yo male with Progressive Neurodegenerative Paraplegia... could new lethargic today be natural h/o disease or 2nd to other etiology? Lethargy..check CBC, CMP, CXR, KUB, U/A Temp 100.2 last pm..." Further review of the physician progress notes dated 11/11/09 1430 (2:30pm) revealed in part, " Lethargy likely 2nd to Neuroleptic Malignant Syndrome as evidence by elevated CPK, positive blood in U/A and elevated LFT's and increased creatinine. Would treat with Bactrim DS BID , x 3 days..Would also D/C Haldol as most likely culprit. Cont IV fluids for now. give Ensure 6 cans /day po..." Review of the Physician Progress Notes dated 11/18/09 revealed in part, "F/U for Neuroleptic Malignant Syndrome. Pt clinically getting better after med change...Violent still. IMP (Neuroleptic Malignant Syndrome Improving..

Review of the Patient Plan of Care dated 10/08/09 through 12/03/09 revealed no documented evidence Patient #11's Plan of Care was updated for the Neuroleptic Malignant Syndrome and the potential of developing further serious side effects of psychotropics and for continued monitoring for serious side effects of psychotropics.

On 12/18/09 1940 7:40pm the following was documented: "Presents at beginning of shift with decreased vocalizations compared to this norm, confused. VS are 98.1.. Axillary; HR 93; R. 17; BP 96/56
2100 9pm Drowsy, Responds to tactile stimuli
0040 12:40am V/S are 101 oral; HR 102; RR 20; BP 84/52; Pulse OX 88% on room air. O2 at 5l/min per mask
0050 12:50am Dr. (name of) contacted. Apprised of pt status. Orders given to sen Pt to ER to eval and treat.

Patient #11 was evaluated in the emergency department of Lakeview Hospital. Review of the emergency room visit note revealed in part, "I discussed the case with the patient's wife she reports that she actually wants to make the patient a DNR and she would acutely like to arrange to have him placed on hospice as she reports the patient is not even eating anymore. She reports she does not want the patient intubated. She wants no PEG tube. No IV fluids or IV antibiotics. She is aware that the patient's death will likely be imminent given this treatment strategy. Patient #11 was admitted to the inpatient hospice and expired on 12/26/09.

Based on record reviews and interviews the hospital failed to ensure nursing personnel received education and were competent on administering psychotropic medications, and/or how to monitor and report the side effects of these medications before they were assigned to provide nursing care for each patient on the senior behavioral unit take took psychotropic medications. Findings

Review of the personnel files and in-service training for S14 RN, S15 RN and S8 LPN revealed no documentation they had been trained by the hospital on psychotropic medications and/or how to monitor the side effects of these medications. S14 RN was hired at the hospital on 12/7/09, S15 RN was hired 6/23/08, and S8 LPN was hired 1/7/02.
An interview was held with S14 RN, on 5/14/10 at 8:10 AM. She further indicated that side effects of Seroquel which is an antipsychotic could cause an increased level of sedation, could cause them not to eat or function. S14 RN indicated that she not had an inservice on medication side affects since she was employed on the unit. She further indicated that she did not know about neuroleptic malignant syndrome.

An interview was held with S15 RN, on 5/14/10 at 8:45 AM. She indicated that the side effects of Seroquel is that it can cause drowsiness as well as interacting with other medications. She indicated she has not had a specific in service related to identifying the side effects of psych atrophic medications nor was this done during orientation.

An interview was held with S8 LPN on 5/12/10 at 3:10 PM. She indicated the side effects for Seroquel are that it "kind of" makes you drowsy, is an anti-anxiety medication, can cause hypotension and make a patient weak. She further indicated that she could not remember if she had been trained on neuroleptic malignant syndrome.

A telephone interview was held with S27 RN on 5/18/10 at 820 AM. She indicated she was a preceptor for new nurses hired on the senior behavioral unit of the hospital. She further indicated she reviews the nurse's expectations, assessments and reassessments of patients and assists them in their orientation to the unit. S27 RN added she instructs new nurses to watch for drastic changes in their patients when they perform , patients on antipsychotic medications that exhibit parkinson's signs and symptoms such as involuntary muscle movement and dystonia. She reported she instructs nurses on neuroleptic malignant syndrome and added that she informs them that this situation can be fatal and to watch for fever and changes in a patient's blood pressure. S27 RN indicated she had no documentation to support this training as a preceptor to new staff. She added she was not aware that side affects to antipsychotic medications was not on the competency check off for new staff on the unit senior behavioral unit.
An interview was held with S28 RN Education on 5/19/10 at 830 AM. She indicated that all new employees receive the general hospital orientation, as well as department and job specific training. She further indicated new staff received the core competencies for the patient population they care for during their shift. S28 RN reported that antipsychotic medication was and not part of the core competency at the senior behavioral center. She indicated neuroleptic malignant syndrome was in not identified as a competency for the patient population on the senior behavioral unit.
An interview was held with S17 MD on 5/14/9 at 10:20 AM. He reported he did not feel that the staff recognized side effects of antipsychotic medication.

An interview was held with S2 RN Clinical Manager on 5/17/10 at 10:45 AM. She indicated there was no documentation of in services for staff related to the side effects of psychotropic medications or neuroleptic malignant syndrome.
An interview was held with S3 RN Risk Management on 5/18/10 at 10:30 AM. She indicated there were two medication side affects reported in the last six months from senior behavioral health. She indicated an occurrence report should be generated if the wrong medication, wrong drug, a delay in medication administration or adverse drug reactions should be triggered through the pharmacy. She further indicated there was no occurrence report related to neuroleptic malignant syndrome. She added that all staff are trained on the completion of occurrence reports upon hire and again annually at the job fair.
Review of the hospital policy titled Competency Assessment Plan revealed in part " ... The competence of all staff members is assessed, demonstrated, maintained, and improved continually. The hospital uses a combination of ongoing competence assessment and educational activities to maintain and improve staff competence. The termination of competence occurs prior to providing patient care, treatment, and services. Competencies are delineated and evaluated as follows: Prior to performing a procedure/task that is higher risk, problem prone patient care processes or when we have data indicating a problem..."

Based on record review (hospital medical record, policy and procedure,medication occurrence reports) the hospital failed to ensure adverse drug reactions were immediately reported to the physician and to its hospital wide QAPI program. for 2 of 11 sampled patients. (Patient #4 and Patient #11) Findings:

The policy entitled Medication Variances #003.41 presented as the hospital ' s current policy was reviewed. Documentation revealed in part, " Adverse Drug Reactions are a detrimental response to medication, undesired, unintended or unexpected in doses recognized in accepted medical practices. ADS may or may not result from a variance in the selection, ordering, administration or monitoring process. This could result in one or more of the following:
1. Hospital admission\
2. Change in drug dose
3. Discontinuance of the drug
4. Prolongation of hospital stay
5. An effect complicating the diagnosed state
6. Additional treatment for side effects or reaction symptoms.

Medication variances, including actual errors, adverse drug reactions and near misses (errors that are intercepted prior to reaching the patient) are to be reported immediately to via the hospital occurrence reporting system in Meditech.. Adverse Drug Reactions are communicated via the ADR hotline. The patient's condition will be monitored and the medication discrepancy and notification of the physician will be documented in the patient's medical record. An occurrence report will be completed. Reporting medication variances will be encouraged and follow-up process will be non-punitive.

Review of the Performance Improvement Averse Drug Reactions revealed documented evidence of 2 adverse drug reactions reported from 08//2009 through 04/2010. (9 month period)

Review of the Medication Administration Record for Patient #4 revealed he was administered Seroquel (class-antipsychotic drug) 25 mg daily and 50mg at bedtime from 02/14/10 until 02/25/10 at which time it was discontinued.

There were no documented medication variances/occurrence reports including adverse drug reactions for the following occurrences documented for Patient #4. There was no documented evidence the physician, pharmacist and hospital-wide quality assurance program were notified of the occurrences.

02/10/10 0515 (5:15am) LOC (level of consciousness) Drowsy shuffle Gait
02/11/10 0400 (4am) Generalized weakness, chair bound, unsteady gait
02/11/10 1500 (3pm) Generalized Weakness
02/12/10 1400 (2pm) LOC Drowsy Unsteady gait at times.
02/13/10 1538 (3:38pm) Generalized weakness
02/14/10 1803 (6:03pm) Poor appetite this shift. Ate as little as 10%; Drank approx 350ml
02/15/10 1746 (5:46pm) Bilateral Lower extremity weakness
02/16/10 1621 (4:21pm) Pt is more drowsy than awake
02/17/10 1430 (2:30pm) Closed lips a mealtime to avoid eating meal..tol some fluids. Ensure offered.
02/18/10 1538 (2:38pm) Appetite cont to be poor
02/19/10 0454 (4:54am) This RN observed pt. with an episode of severe shivering..enough to shake his bed..pt.
02/19/10 1927 (7:27pm) shaky at vs (vital sign) time around 1600 (4pm) b/p (blood pressure) 82/67 will retake later pt asymptomatic.
02/20/10 0800 (8am) Fidgety at times, slight body tremors noted at times.
02/20/10 1412 (2:12pm) Appetite poor
02/21/10 0445 (4:45am) Fine body tremors noted from time to time.
02/21/10 1954 (7:54pm) Remains non -verbal at this time. Pt will open his eyes with contact and verbal stimuli, offered pt. juice, no response at this time.
02/22/10 1308 (1:08pm) Rigid towards staff when attempting to change or transfer him, appetite fair.
02/23/10 0203 (2:03am) Pt becomes rigid with extrem, screams out at times.
02/23/10 1154 (11:54am) Last BM so far on the 20th.
02/24/10 0800 (8am) Appetite poor.
02/24/10 1528 (3:28pm) Pt. becomes very rigid with moving, very weak
02/24/10 1602 (4:02pm) Appetite poor
02/25/10 1514 (3:14pm) Poor appetite and poor fluid intake so far this shift. Anxious at times; fidgeting, Has not ambulated this shift.
02/26/10 1354 (1:54pm) Not eating, on Megace.
02/27/10 0750 (7:50am) Pt. cont. to twitch/jerk various body parts from time to time.
02/27/10 1600 (4pm) LOC (level of consciousness) Drowsy, Generalized weakness
02/28/10 0416 (4:16am) Pt. mostly non-verbal, will grunt. (2am) Pt cont. with body twitching /jerking from time to time.
2/28/10 1123 (11:23am) Pt. continues to be drowsy keeping eyes closed most of time, Not verbalizing, just grunting, Resistive to care, Hits out, Movements are stiff and jerky.

Patient #11
Review of the Medication Administration Record for Patient #11 revealed he was administered Klonopin po hs, from 10/08/09 through 10/12/09, Haldol bid po, from 11/05/09 through 11/11/09, Haldol IM PRN from 10/24/09 through 11/12/09, Zyprexa 10mg po hs, 10/08/09 through 10/26/09 and Geodan IM prn from 11/1/09 through/18/09. (drug class antipsychotics)
There were no documented medication variances/occurrence reports including adverse drug reactions for the following occurrences documented for Patient #11. There was no documented evidence the physician, pharmacist and hospital-wide quality assurance program were notified of the occurrences. Review of the Patient Notes revealed in part the following dates of occurrence:

10/11/09 1622 (4:22pm) All meds held due to sedation this shift
10/14/09 0800 (8am) Refused meals--too drowsy
10/15/09 1834 (6:34pm) Needs to be fed R/T twitching like motion in the arms
10/22/09 1821 (6:21pm) Notified by MHT hat pt has not urinated all day. when pt does urinated is usually a large amt.
10/30/09 2030 (8:30pm) Patient received Zyprexa 10mg Patient was not give Klonopin because although he refused bedtime meds, he was assessed to be too sedated to attempt to administer Klonopin
11/01/09 1827 Encouraged foods and fluids without success
11/06/09 1730 (5:30pm) Refused meals/Fluid
11/08/09 1800 (6pm) Haldol 5 mg IM
11/08/09 1309 (1:09pm) Arousable but mostly sleepy appetite poor, took a few bites
11/09/089 0532 (5:32am) Appeared to sleep 10 hours last night. Sedated . Stage I noted on buttock
11/09/09 1346 (1:46pm) Pt drowsy but does not respond to verbal communication easily
11/09/09 1805 (6:05pm) Pt. low grade temp 99.8 (axilla)
11/09/09 2000 (8pm) Temperature 100.2 oral medicated with Tylenol. Very difficult to give to pt secondary to over sedation/lethargic state. All 2100 (9pm ) meds held (There was no documented evidence the physician was notified of the patient's elevated temperature; the lethargic state and the holding of the 9pm medications)
11/11/09 0516 (5:16am) Pt is having these jerking involuntary movements. Reported to (Name of S4, MD Psychiatrist)
11/11/09 0800 (8am) (Name of S17, MD Internal Medicine) vs; Noted to have involuntary movements to arms

Review of the Physician Progress Note dated 11/10/09 1330 (1:30pm) revealed in part, "pt lethargic today notes reviewed... 65 yo male with Progressive Neurodegenerative Paraplegia... could new lethargic today be natural h/o disease or 2nd to other etiology? Lethargy..check CBC, CMP, CXR, KUB, U/A Temp 100.2 last pm..." Further review of the physician progress notes dated 11/11/09 1430 (2:30pm) revealed in part, " Lethargy likely 2nd to Neuroleptic Malignant Syndrome as evidence by elevated CPK, positive blood in U/A and elevated LFT's and increased creatinine. Would treat with Bactrim DS BID , x 3 days..Would also D/C Haldol as most likely culprit. Cont IV fluids for now. give Ensure 6 cans /day po..." Review of the Physician Progress Notes dated 11/18/09 revealed in part, "F/U for Neuroleptic Malignant Syndrome. Pt clinically getting better after med change...Violent still. IMP (Neuroleptic Malignant Syndrome Improving..

An interview was held with S3 RN Risk Management on 5/18/10 at 10:30 AM. She indicated there were two medication side affects reported in the last six months from Senior Behavioral Health. She indicated an occurrence report should be generated if the wrong medication, wrong drug, a delay in medication administration or adverse drug reactions should be triggered through the pharmacy. She further indicated there was no occurrence report related to neuroleptic malignant syndrome. She added that all staff are trained on the completion of occurrence reports upon hire and again annually at the job fair.

An interview was held with S2 RN Clinical Manager on 5/18/10 at 9:20 AM about QA/PI on the Senior Behavioral Health Unit. She reported adverse medication reactions should be called to the pharmacy and/or added in medi -tech as an occurrence report. She indicated there were two medication side affects reported in the last six months from this unit and neither were for Patient #4 or Patient #11. She also added that the unit does not track or trend declines in their patient care population.

An interview was held with S25 RPh on 5/18/10 at 2:00 PM. He added that all occurrence reports should go to the main hospital. S25 RPh indicated that it was a challenge to differentiate between illness, specifically with the geri-psych patients, vs. medication and added that if there are any questions an occurrence report should be generated so pharmacy can track the data. He further indicated that he does receive adverse drug events by hospital unit and severity but added that he does not get many adverse drug events from Senior Behavioral Health.

Based on observation, record reviews and interviews the hospital failed to have documentation of an ongoing quality assurance/performance improvement program that demonstrated measurable improvement in patient health outcomes, analyzed, and tracked quality indicators, and adverse patient events on the senior behavioral unit. Findings:

Review of the QA/PI data from January 2009 through April 2010 revealed no documentation the hospital had identified nurse's lack of knowledge/training on psychotropic medications, neuroleptic malignant syndrome, did not identify patient weight loss and/or scale problems, did not identify or implement a plan for dehydration/malnutrition, did not identify electronic charting times were inaccurate and did not obtain orders for physical therapy consults for Stage II decubitus ulcers, did not have measurable improvement in patient health outcomes, analyzed, nor tracked quality indicators, and adverse patient events on the senior behavioral unit.
An interview was held with S2 RN Clinical Manager on 5/18/10 at 9:20 AM about QA/PI on the behavioral health unit. She indicated that the quality assurance data from this unit included tracking to ensure that the doors remained locked to the unit, there were chart audits, critical laboratory results, suicide precautions, medications, discharge teachings, pain assessments, and medication reconciliation. She further indicated there had been no quality assurance measures implemented related to neuroleptic malignant syndrome. She further indicated that falls are the most critical area the unit would track and trend. She reported adverse medication reaction should be called to the pharmacy and/or added in medi -tech as an occurrence report. She indicated there were two medication side affects reported in the last six months from this unit. She added that the unit does not track or trend declines in their patient care population.

S26 RN Quality indicated quality assurance does track all of the items S2 RN Clinical Manager reported earlier and added the hospital also tracks environment of care, infection control with urinary tract infections. She further indicated that no staff members from the behavioral health unit had reported any occurrences to the quality assurance department. She added that quality assurance had failed to identify nurses lack of knowledge/training on psychotropic medications, did not identify patient weight loss and/or scale problems, did not identify or implement a plan for dehydration/malnutrition, did not identify electronic charting times were inaccurate or obtaining orders for physical therapy consults for Stage II decubitus ulcers.
Review of the hospital policy titled " Patient Grievance and Complaint Management Policy " revealed " ...Data collected regarding patient grievance and complaints is incorporated in the quality assessment and performance improvement program with a quarterly report forwarded to the Board for review ... " " ...Reporting of individual cases deemed to be serious grievances, as defined by the hospital )e.g., potential for causing harm, serious breech of policy, etc.), and any root cause analysis that might have been done in response, if necessary ... "
Review of the hospital policy titled " Performance Improvement Plan " revealed in part " ... The scope of this plan encompasses the entire organization, community, medical staff, hospital administration, ancillary employees, all nursing and clinical departments. A. Encourages reporting of quality issues and events that have or have the potential to adversely affect patient care without punitive actions. B. Focuses on the process/systems and in effect to identify how the event occurred. C. Initiates actions to decrease the risk/likelihood of the event reoccurring. Uses information surrounding the event in a proactive incident reduction process. D. Patients and their family's along with the hospital leaders and staff participate as a team and or responsible for a quality centered patient care environment ... "

Based on record reviews and interviews the hospital failed to identify through the QA process problems that could lead to improvements and changes in the senior behavioral unit as evidence by having, Findings:

1. Failed to identify and report delays in consultations to the Medical Executive Committee. (Deficiency cited at A 267)

2. Failed to ensure nursing assessments for a patient's decline in weight and hydration status were evaluated and identified and reported to the attending physician for 1 of 11 sampled patients (Patient #4) resulting in the patient's transfer to the acute care setting with a diagnosis of Altered Mental Status, Acute renal failure, Rhabdomyolysis, Hypernatremic Dehydration (Deficiency cited at A395)

3. Failed to ensure nurses knew the side effects of psychotropic medication and that the nursing assessments documented were identified as side effects of the psychotropic medications being administered to the patient as evidenced by the patient's lethargy and elevated temperature likely 2nd to Neuroleptic Malignant Syndrome (Patient #11) (Deficiency cited at A395)

4. Failed to ensure accurate weights were obtained and documented and that nursing assessments for weight loss were documented. (Patient #2) (Deficiency cited at A395)

5. Failed to ensure the nursing staff keep current the medical nursing care plan by 1)failing to identify and update the plan of care for a patient's symptoms of rigidity, tremors, twitching, fidgeting, drowsiness, poor appetite with consumption of less than 50% intake and extreme weight loss and decrease in fluid intake with a potential for dehydration and the development of skin breakdown with a Stage II Decubitus (Patient #4) and for updating the care plan for a patient who developed Neuroleptic Malignant Hypertension and Stage II decubitus for (Patient #11) (Deficiency cited at A396)

6. Failed to ensure nursing personnel received education and were competent on administering psychotropic medications and/or how to monitor and report the side effects of these medications before they were assigned to provide nursing care for each patient on the senior behavioral unit take took psychotropic medications.(Deficiency cited at A397)

7. Failed to ensure adverse drug reactions were immediately reported to the physician and to its hospital wide QA/PI program or 2 of 11 sampled patients. (Patient #4 and Patient #11).(Deficiency cited at A508)