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Based on document review and interview, the facility failed to follow its policy/procedures and ensure all patients and/or their representatives were kept informed about the patient's health status for 1 (Patient #4) of 10 medical records (MR) reviewed.

Findings include:

1. Review of the policy/procedure Patient Rights and Responsibilities, reviewed 6-17, indicated the following: "A designated spokesperson will be identified for discussion of the patient's condition."

2. Review of the policy/procedure Incident Reports, revised 3-17, indicated the following: "The completed incident report reflects documentation that the following actions have occurred ... Family/significant other of patient notified of incident/injury after physician is notified."

3. Review of the MR entry for Patient #4 on 7-22-17 at 2120 hours indicated the patient was found on the floor and the MR lacked documentation indicating a family member was notified at any time following the event.

4. Review of the facility incident report associated with the unobserved fall event indicated above lacked documentation indicating a family member or patient representative was contacted and notified of the event.

5. On 8-18-17 at 0930 hours, the Chief Clinical Officer, staff A5 confirmed the facility lacked documentation indicating a family member or patient representative was contacted and informed of the patient's fall on 7-22-17.

Based upon document review and interview, the nurse executive failed to ensure that the policy/procedures Patient Rounding and Fall Prevention Protocol were followed for 2 of 10 medical records (MR) reviewed (Patient #s 2 & 4).

Findings include:

1. Review of the policy/procedure Patient Rounding, revised 2-17, indicated the following: "Rounds are to be made on the unit on all patients by the assigned nursing staff at a minimum of every fifteen minutes or more frequently as ordered for each 24-hour period ... The purpose of rounds is to check all aspects of safety and security while monitoring patient behavior and location."

2. Review of the policy/procedure Fall Prevention Protocol, revised 1-17, indicated the following: "All patients admitted to [the facility] will be placed on fall prevention protocol ... Every 15-minute safety checks [will be] conducted by MHT's (Mental Health Techs), CNA's (Certified Nursing Assistants)."

3. Review of the MR on 7-21-17 for Patient #4 lacked documentation indicating every 15 minute monitoring checks were performed from 2000 hours to 2230 hours.

4. On 8-18-17 at 0930 hours, the Chief Clinical Officer, staff A4 confirmed the MR for Patient #4 lacked documentation on 7-21-17 indicating every 15 minute checks were performed between 2000 hours and 2230 hours.

5. Review of the MR on 7-23-17 for Patient #2 lacked documentation indicating every 15 minute monitoring checks were performed from 1500 hours to 1900 hours.

6. On 8-18-17 at 1345 hours, the Chief Clinical Officer, staff A4 confirmed the MR for Patient #2 lacked documentation on 7-23-17 indicating every 15 minute checks were performed between 1500 hours and 1900 hours.

Based on document review and interview, the facility failed to follow its policy/procedures and ensure a Registered Nurse (RN) supervised and evaluated the care of all patients for 4 of 10 medical records (MR) reviewed (Patient #s 1, 4, 6, & 8).

Findings include:

1. Review of the policy/procedure Nursing Assessments, reviewed 7-17, indicated the following: "Each patient's needs shall be assessed by an RN at the time of admission and documentation completed within the first 24 hours upon admission by an RN ...The assessment includes information regarding the patient's ...integumentary (skin) ... Nursing assessments will be completed each shift and PRN (as needed)."

2. Review of the policy/procedure Content of the Medical Record, reviewed 5-17, indicated the following: "Each medical record contains at least the following ...Reassessments are conducted at predetermined and regular intervals or whenever a change in the patient's condition requires his or her re-evaluation."

3. Review of the MR on 7-13-17 for Patient #1 indicated no skin breakdown or bruising was present at the time of admission and lacked documentation indicating a RN completed or staffed the admission assessment. Review of the 7-20-17 Discharge Skin Assessment indicated a 45mm by 15 mm bruise was present on the patient's right wrist and the MR lacked documentation indicating the area of bruising was identified and monitored during daily nursing assessments prior to discharge.

4. On 8-18-17 at 1245 hours, the Chief Clinical Officer, staff A4 confirmed the MR for Patient #1 lacked documentation indicating a RN completed or staffed the admission assessment or indicating the bruise on the patient's right wrist was identified and monitored during daily nursing assessments prior to discharge.

5. Review of the MR on 7-15-17 for Patient #4 indicated no skin breakdown or bruising was present at the time of admission and on 7-30-17 the Discharge Skin Assessment indicated three scabbed 3 mm (millimeter) lacerations across the nose bridge, a 27 mm by 15 mm bruise on the right wrist, and a 70 mm by 32 mm bruise on the left hand were present. The MR lacked documentation indicating the areas of healing skin lacerations and bruising were identified and monitored during daily nursing assessments between 7-15-17 and 7-30-17.

6. On 8-18-17 at 0930 hours, the Chief Clinical Officer, staff A4 confirmed the MR for Patient #4 lacked documentation indicating the skin lacerations and bruising were identified and monitored during daily nursing assessments prior to 7-30-17.

7. Review of the MR on 7-17-17 for Patient #6 indicated no skin breakdown or bruising was present at the time of admission and on 7-23-17 the Discharge Skin Assessment indicated a 21 mm by 40 mm bruise on the right posterior shoulder, a 50 mm by 40 mm bruise on the right hand, a 25 mm by 20 mm bruise on the right upper extremity, a 21 mm by 20 mm bruise involving the right antecubital space, a 35 mm by 40 mm bruise involving the left antecubital space, and a 40 mm by 20 mm bruise on the right forearm were present. The MR lacked documentation indicating the areas of bruising were identified and monitored during daily nursing assessments between 7-17-17 and 7-23-17.

8. On 8-18-17 at 1450 hours, the Chief Clinical Officer, staff A4 confirmed the MR for Patient #6 lacked documentation indicating the areas of bruising were identified and monitored during daily nursing assessments prior to 7-23-17.

9. Review of the MR for Patient #8 on 7-6-17 indicated no skin breakdown or bruising was present and on 7-25-17 the Weekly Skin Assessment indicated a 15 mm by 20 mm area of bruising to the left antecubital space and a 36 mm by 40 mm area of bruising to the right antecubital space. The MR lacked documentation indicating the areas of bruising were identified and monitored during daily nursing assessments between 7-6-17 and 7-25-17. On 7-31-17 the Discharge Skin Assessment indicated new areas of soft tissue injury were described as a 30 mm by 40 mm area of bruising to the left wrist and a 120 mm by 100 mm area of green/yellow bruising to the right side of the patient's abdomen and the MR lacked documentation indicating the new areas of bruising were identified and monitored during daily nursing assessments prior to 7-31-17.

10. On 8-18-17 at 1550 hours, the Chief Clinical Officer, staff A4 confirmed the MR for Patient #8 lacked documentation that the indicated areas of bruising were identified and monitored during daily nursing assessments prior to 7-25-17 and 7-31-17.

Based on document review and interview, the facility failed to follow its policy/procedures and ensure patient care plans were developed and maintained for 3 of 10 medical records (MR) reviewed (Patient #s 2, 4 & 7).

Findings include:

1. Review of the policy/procedure Treatment Plan, reviewed 5-17, indicated the following: "Every patient shall have an individualized comprehensive Master Treatment Plan ... Within twenty-four (24) hours of admission, the Registered Nurse (RN) will initiate the treatment plan ... Within 72 hours of admission, members of the treatment team shall further develop the treatment plan ...The team will consist of the Physician, Licensed Independent Practitioners, the RN, Social Worker, Activity Therapist and other members, as appropriate. All members of the treatment team must sign the treatment plan ... at a minimum, the treatment plan is to be reviewed by 7 days after the Plan of Care [first full team approval], and 7 days thereafter. All members of the treatment team must sign the treatment plan update."

2. Review of the treatment plan for Patient #2 lacked documentation indicating it was updated by the Registered Nurse, staff N15, a Social Worker, staff A7, staff A8 or staff A10, the Activities Director, staff A9, or the Psychiatrist, Physician MD12 within 7 days of the initial treatment plan review on 7-14-17 until the plan review conducted on 7-25-17.

3. On 8-18-17 at 1345 hours, the Chief Clinical Officer, staff A5 confirmed the treatment plan for Patient #2 lacked documentation indicating the treatment plan was reviewed within 7 days of the initial plan review conducted on 7-14-17.

4. Review of the treatment plan for Patient #4 lacked documentation indicating it was initiated and/or staffed by a RN within 24 hours of admission or indicating a plan review was completed by the Registered Nurse, staff N15, a Social Worker, staff A7, staff A8 or staff A10, the Activities Director, staff A9, or the Psychiatrist, Physician MD12 within 7 days of the plan review on 7-20-17 at any time up to and including patient discharge on 7-31-17.

5. On 8-18-17 at 0930 hours, the Chief Clinical Officer, staff A5 confirmed the MR for Patient #4 lacked documentation indicating a RN initiated or staffed the initial treatment plan within 24 hours of admission or indicating the treatment plan was reviewed within 7 days of the plan review conducted on 7-20-17 before and/or including discharge on 7-31-17.

6. Review of the treatment plan for Patient #7 lacked documentation indicating a RN initiated or staffed the initial treatment plan within 24 hours of admission and lacked documentation indicating the Registered Nurse, staff N15, a Social Worker, staff A7, staff A8 or staff A10, the Activities Director, staff A9, or the Psychiatrist, Physician MD12 reviewed the treatment plan within 7 days of the plan review conducted on 6-27-17 or within 7 days of the plan review conducted on 7-13-17.

7. On 8-18-17 at 1525 hours, the Chief Clinical Officer, staff A5 confirmed the MR for Patient #7 lacked documentation indicating a RN initiated or staffed the initial treatment plan within 24 hours of admission and confirmed the treatment plan lacked documentation indicating the treatment plan was reviewed within 7 days of the plan review conducted on 6-27-17 or within 7 days of the plan review conducted on 7-13-17.