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Based on document review and interview, facility staff failed to complete admission lab draw, failed to notify provider of change in patient weight, failed to notify provider of patient refusal of medications, failed to complete a nursing care plan to evaluate/address patient's nutritional needs for 1 in 10 patients (Patient 6).

The cumulative effect of these systemic problems resulted in the facility's inability to provide nursing care in a safe manner.

Based on document review and interview facility staff failed to complete admission lab draw, failed to notify MD (Medical Doctor) of change in patient weight, and failed to notify MD of patient refusal of medications in 1 of 10 patient MRs (Medical Records) reviewed (Patient 6).

Findings include:
1. Facility policy titled, Medication Administration And Documentation, No Policy Number, originated 12/2022, indicated under Procedure: 3. Administration. y. Document all refused drugs on the patient's MAR. Notification of the practitioner is also to be documented in the progress note.

2. P6's MR indicated patient refused Paliperidone (Invega ER [Emergency Release]), 3 mg (milligrams), by mouth, daily on March 20, 22, 24, and 30, 2025. The MR indicated P6 refused Divalproex Sodium, 500 mg, by mouth, twice daily on March 20, 22, 24, and 28, 2025. P6's MR indicated patient refused Lisinopril, 5 mg, by mouth, daily on March 30, 2025. P6's MR lacked documentation of provider notification of patient's refusal of scheduled medications on these dates, per policy. P6's MR indicated lab draws were ordered on 3/19/25 which included (but not limited to), Lithium Level, Valproic Acid, TSH (thyroid stimulating hormone), and CBC (complete blood count). P6's MR lacked documentation of Lithium Level, Valproic Acid, TSH and/or CBC labs drawn, as ordered. MR lacked nursing staff's documentation of attempts to obtain labs or patient's refusal of labs. Review of patient 6's MR indicated patient weight on 3/18/25 and 3/19/25 was 174 lb., and on 3/30/25 was 154 lb. MR lacked documentation of patient's weight on 3/26/25, as ordered and lacked documentation of MD notification of weight loss.

3. In interview on 4/21/25 at approximately 4:15 pm to 4:30 pm, A1 (Director Risk & Performance Improvement) confirmed staff did not follow policy/orders regarding lab draw, weekly patient weight, and/or provider notification with missed medications regarding P6.

4. Facility Incident Report, dated 3/30/25 and initiated by A1 (Director Risk & Performance Improvement) regarding P6 indicated on patient's admission (3/18/25) a reported history of chronic kidney disease, psychiatric treatment, hypertension, functioning deterioration, and decreased food intake was noted in patient's MR. Facility Incident Report indicated admitting labs were ordered on 3/18/25 which included (but not limited to), lithium level, CBC (complete blood count), CMP (complete metabolic panel), and U/A (urine analysis). No indication/documentation of lab attempts/why not completed, or physician notification orders were not completed. Facility Incident Report indicated P6 with fair to good appetite throughout facility stay, but lacked intake/output of food/liquid, or percentage of meals eaten and/or skipped. Patient had a documented 20-pound weight loss from 3/18/25 to 3/30/24 with no provider/or dietician notification and no weight recorded for P6 on 3/26/25, per order. On 3/28/25, P6 with a noted decline by staff in patient's ADL's (activities of daily living) function despite prompting and poor food intake. Facility Incident Report indicated P6 was transported to F2 (Acute Care Facility) on 3/30/25 where patient was determined to be dehydrated, had an elevated lithium level. P6's lithium level, while at F2, indicated 1.4 outside of the therapeutic range (therapeutic = 0.6 - 1.2, mild toxicity = 1.5 - 2.5). Facility Incident Report indicated investigative results regarding P6's lack of care during facility stay included lack of nursing staff communication regarding patient's change in condition, lack of meal intake/fluids/weight documentation, lack or labs drawn, as ordered, and lack of timely labs/notification to the provider.

Based on document review and interview facility staff failed to add a nursing care plan to evaluate/address patient's nutritional needs after patient refused to eat or drink for 1 in 10 patients (Patient 6).

1. Facility policy titled, Dietary Services, No Policy Number, last revised 3/2024, indicated under Policy: The hospital will ensure provision of patient specific nutritional services through dietary services for meal planning and assessments, processes that address diet orders and meal delivery, staff training for all processes and contract with a food service provider. Patients will receive three meals a day along with snacks and beverages to meet nutritional and hydration needs as calculated by the dietician and ordered by the practitioner. Procedure: 1. A Diet Order - will be obtained based on information provided at time of admission. 3. A Nutritional Screen will be conducted on all admitted patients. A Dietary Consult (Nutritional Assessment) is triggered if any items on the screen are positive. Staff Training: All Registered Nurses and Behavioral Health Technicians shall receive training related to the Dietary Services processes, include assessment, ordering diets, completion of dietary forms, meal/snack delivery and patient observations.

2. P6's MR (Medical Record) lacked Dietary Consult after patient reported refusal to eat related to paranoia of food being poisoned. P6's MR lacked documentation of meal and/or liquid intake. P6's MR lacked documentation of weekly weight, as ordered. P6's MR lacked documentation of provider notification of patient's 20 pound weight loss within 12 days. P6's MR lacked Nursing Care Plan of Insufficient Nutrition/Hydration. P6's MR from F2 on 3/30/25 at approximately 11:39, indicated patient presented to ED (Emergency Department) from F1 (Psychiatric Hospital) for weight loss, failure to thrive, and dehydrated.,

3. In interview on 4/21/25 at approximately 4:15 pm to 4:30 pm, A1 (Director Risk & Performance Improvement) confirmed missed opportunity for dietary consult with patient reported food paranoia, no measured food/fluid intake, and no weekly weight was documented in P6's MR.