HospitalInspections.org

Based on observation, record review, and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by: 1) having electric beds with cords as long as 5 feet that could be a means of strangulation or cause falls for elderly patients, 2) having a telephone jack in room "e" with exposed wiring, and 3) failure to have tamper proof screws used in patient rooms. Findings:

1) Having electric beds with cords as long as 5 feet that could be a means of strangulation or cause falls for elderly patients:
Review of the response from DHH (Department of Health and Hospitals) to the waiver request for the use of electric beds in the Geri-Psych Unit dated 11/24/10 revealed, in part, "...Power cords have been secured to the beds with tamper proof tie wraps and the cords are not accessible to patients. The length of the unsecured section of the cord (that extends from the bed to the wall outlet) will be less than 20 inches...".

Observation of the patients' beds in rooms "a", "b", "c", "d", "e", and "f" revealed the beds were electric beds with varying lengths of electric cords that were greater than 20 inches as allowed by the waiver.

In a face-to-face interview on 12/09/11 at 9:40am, Maintenance Engineer S9 measured the cord to each electrical bed while observed by the surveyor. S9 confirmed the following measurements:
Room "a" - the bed nearest the door had an electrical cord that was 60 inches long; the bed nearest the window had an electrical cord that was 52 inches long;
Room "b" - the bed nearest the door had an electrical cord that was 60 inches long; the bed nearest the window had an electrical cord that was 36 inches long;
Room "c" - the bed nearest the door had an electrical cord that was 55 inches long; the bed nearest the window had an electrical cord that was 55 inches long;
Room "d" - the only bed in the room had an electrical cord that was 55 inches long;
Room "e" - the bed nearest the door had an electrical cord that was 30 inches long;
Room "f" - the bed nearest the door had an electrical cord that was 48 inches long; the bed nearest the window had an electrical cord that was 48 inches long; observation revealed a patient was in bed, alone in the room, with the door closed.
S9 confirmed the electric cords from the bed to the wall were all longer than 20 inches except the bed nearest the window in Room "e".

2) Having a telephone jack in room "e" with exposed wiring:
Observation on 12/08/11 at 10:20am revealed the telephone jack in Room "e" had the covering off the jack with exposed wires. This observation was confirmed by Geri-Psych Unit Manager S3.

3) Failure to have tamper proof screws used in patient rooms:
Observation of Rooms "a", "b", "c", "d", "e", and "f" on 12/08/11 at 10:20am revealed the screws used on the windows were not tamper proof. These observations were confirmed by Geri-Psych Unit Manager S3.

Based on record review and interviews, the hospital failed to ensure the RN (registered nurse) supervised and evaluated the nursing care of each patient as evidenced by: 1) failure of the RN to timely assess a patient with a change in condition related to abnormal blood glucose results that included an assessment for the effectiveness of the intervention for 2 of 2 patients with a change in condition from a total of 8 sampled patients (#1, #3); 2) the RN delegating the performance of capillary blood glucose to CNAs/MHTs when the hospital policy required this task to be done only by trained nurses for 2 of 2 patients reviewed with orders for accuchecks from a total of 8 sampled patients (#1, #3); 3)failure of the RN to assess a patient's blood pressure prior to administration of blood pressure medications as required by policy and to assess a patient's apical pulse prior to the administration of Metoprolol (standard of care) for 5 of 8 sampled patients (#1, #2, #3, #5, #8); 4) failure of the RN to ensure the observations delegated to the CNAs (certified nursing assistant) or MHTs (mental health tech) were performed and documented according to hospital policy for 7 of 8 sampled patients (#1, #2, #3, #4, #5, #6, #8); and 5) failure of the RN to ensure a nurse was present on the Geri-Psych Unit at all times by leaving the Unit without a nurse for 13 minutes on 12/08/11. Findings:

1) Failure of the RN to timely assess a patient with a change in condition related to abnormal blood glucose results that included an assessment for the effectiveness of the intervention:
Patient #1
Review of Patient #1's medical record revealed she was admitted on 11/23/11 with an admit diagnosis of Schizoaffective Disorder. Further review revealed she had a history of diabetes, hypertension, and coronary artery disease.

Review of Patient #1's "Behavioral Health Physician Admission Orders" dated 11/23/11 at 2200 (10:00pm) revealed an order for "AC & HS" (meaning accuchecks before meals and at bedtime). Review of the "Physician Order" dated 11/27/11 at 1145 (11:45am) revealed an order "for CBG (capillary blood glucose) between 400-450 give 13 units Aspart Insulin ac & hs per sliding scale; notify MD (physician) if > (greater than) 450". Further review revealed no documented evidence of a clarification order to indicate whether the previous sliding scale order was the same for other levels of blood glucose results.

Review of Patient #1's "Fingerstick Flowsheets" revealed her blood sugar was tested by MHT S6 on 11/26/11 at 11:34am with the result of > 400. Review of the nurses' notes revealed RN S8 administered 13 units Aspart Insulin as ordered per sliding scale at 11:38am. Further review revealed the next assessment of the blood glucose to determine the effectiveness of the intervention was performed by MHT S12 on 11/26/11 at 1714 (5:14pm), more than 5 hours after the insulin was administered.

Review of Patient #1's "Fingerstick Flowsheets" revealed her blood sugar was tested by CNA S20 on 12/02/11 at 2101 (9:01pm) with the result of > 400. Review of the nurses' notes revealed RN S21 verified the blood glucose result of 404 and administered 13 units Aspart Insulin as ordered per sliding scale at 22:51 (10:51pm), one hour and 50 minutes after the initial reading of > 400. Further review revealed the next documented blood sugar assessment was performed by RN S11 on 12/03/11 at 1452 (2:52pm), more than 15 hours after the insulin was administered.

Patient #3
Review of Patient #3's medical record revealed she was admitted on 11/17/11 with the diagnoses of Depression and Anxiety. Review of Patient #3's H&P revealed she had a history of diabetes, hypertension, dementia, degenerative joint disease, hyperlipidemia, and depression.

Review of Patient #3's "Behavioral Health Physician Admission Orders" dated 11/17/11 at 1956 (7:56pm) revealed an order for accuchecks ac & hs. Further review revealed no documented evidence of an order with parameters of blood glucose results to be reported to the physician.

Review of Patient #3's "Fingerstick Flowsheets" revealed her blood glucose was tested on 11/20/11 at 7:59am by CNA S15 with a result of < (less than) 40. Review of the nurses' note revealed Agency RN S22 assessed the blood glucose to be 37, notified the physician, and implemented the treatment as ordered. Further review revealed the response to the treatment was documented by S22 as "CBG (capillary blood glucose) increased to 125 with no documented evidence of the time the reassessment was performed. Review of the "Fingerstick Flowsheet" revealed the blood glucose was 125 at 9:22am on 11/20/11 as tested by MHT S12, 1 hour and 23 minutes after the intervention was implemented.

Review of Patient #3's "Fingerstick Flowsheet" revealed MHT S6 tested her blood glucose on 11/22/11 at 7:31am with a result obtained of < 40. Further review revealed S6 retested the blood glucose at 7:34am and obtained the result of 60. There was no documented evidence that a nurse assessed Patient #3's blood sugar when a reading of < 40 was obtained at 7:31am.

Review of the "Fingerstick Flowsheet" revealed CNA S15 documented Patient #3's blood glucose result of 40 at 7:42am and < 40 at 7:44am on 11/23/11. Review of the nurses' notes revealed RN S4 notified the physician of the blood glucose result, and treatment was ordered (no documented evidence of the time). Further review revealed no documented evidence of a RN's assessment for the effectiveness of the intervention until the blood glucose was checked by CNA S15 at 11:56am with a result of 51, more than 4 hours after the intervention (this was the test done prior to the noon meal).

Review of the "Fingerstick Flowsheet" revealed CNA S15 performed an accucheck on 12/04/11 at 5:15pm with a result of 50, and MHT S6 performed an accucheck with a result of 59 on 12/06/11 at 5:29pm. Review of the nurses' notes for 12/04/11 and 12/06/11 revealed no documented evidence of an assessment by the RN of Patient #3's blood glucose and the patient's condition at these times.

In a face-to-face interview on 12/13/11 at 11:20am, CCO (Chief Clinical Officer) S1 indicated a patient's change of condition, such as a low capillary blood glucose, should have an assessment by the RN, and after any intervention was implemented, there should be a reassessment of the effectiveness of the intervention that was implemented.

Review of the hospital policy titled "Assessment / Reassessment - Interdisciplinary Patient", policy number H-PC 04-009, revised 11/10, and submitted by CCO S1 as the current policy for assessment and reassessment, revealed, in part, "...Patients are reassessed based on but not limited to the following: To evaluate his or her response to care, treatment, and services To respond to a significant change in status and / or diagnosis or condition ...Notification Responsibilities When an Assessment Reveals a Change or Suspected Change in Condition. 1. The nurse assigned to the patient or supervising the care of the patient is responsible for notification of and communication to the patient's primary physician... Document change of condition, notification and interventions in the medical record...".

Review of the hospital policy titled "Admission Assessment and Reassessment - Nursing Services", policy number PE-2, revised 03/07/01, and submitted by CCO S1 as the current policy for nursing assessment and reassessment, revealed, in part, "... An Registered Nurse will perform nursing re-assessment under the following conditions: 1. At the beginning of the shift. 2. When there has been a significant change in the patient's condition. 3. To determine the patient's response to treatment. 4. When a significant change occurs in the patient's diagnosis...".

2) RN delegating the performance of capillary blood glucose to CNAs/MHTs when the hospital policy required this task to be done only by trained nurses:
Review of Patient #1's and Patient #3's medical records revealed they had physician orders for accuchecks ac & hs. Further review revealed the accuchecks were performed by CNAs and MHTs, while hospital policy required the tests to be performed only by trained nurses.

In a face-to-face interview on 12/13/11 at 3:00pm, CCO (Chief Clinical Officer) S1 indicated that around September or October of this year they began to have the CNAs and MHTs perform the accuchecks on the Geri-Psych Unit. S1 confirmed the hospital policy was not revised and approved by the Medical Staff or Governing Body.

Review of the hospital policy titled "Blood Glucose Testing Protocol", policy number LM-02.003, revised 11/09, and submitted by CCO S1 as the current policy for blood glucose testing, revealed, in part, "... Only trained nurses are authorized to perform blood glucose tests...".

3) Failure of the RN to assess a patient's blood pressure prior to administration of blood pressure medications as required by policy and to assess a patient's apical pulse prior to the administration of Metoprolol:
Patient #1
Review of Patient #1's medical record revealed she was admitted on 11/23/11 with an admit diagnosis of Schizoaffective Disorder. Further review revealed she had a history of diabetes, hypertension, and coronary artery disease.

Review of Patient #1's admission physician orders revealed orders for the following medications: Lisinopril 10 mg (milligrams) by mouth daily; Metoprolol Tartrate 25 mg by mouth BID (twice a day). Further review revealed an order on 11/24/11 at 1355 (1:55pm) for Norvasc 2.5 mg daily.

Review of the nurses' medication administration records revealed no documented evidence of the RN's assessment of Patient #1's blood pressure prior to administering Lisinopril and Norvasc (both used to treat blood pressure) as required by hospital policy. Further review revealed no documented evidence of the RN's assessment of Patient #1's apical pulse prior to administering Metoprolol (this was a standard of care listed in the drug book used as a resource on the Geri-Psych Unit).

Patient #2
Review of Patient #2's medical record revealed he was admitted on 11/20/11 with diagnoses of Altered Mental Status, Depression, and Dementia. Review of his H&P (history and physical) revealed he had a history of hypertension, colon cancer with a colostomy, benign prostatic hypertrophy (BPH), and dementia, possibly of the Alzheimer's type.

Review of Patient #2's admission orders revealed an order for Propanolol (used to treat hypertension) 80 mg by mouth at bedtime. Review of the medication administration record revealed no documented evidence Patient #2's blood pressure was assessed by the RN prior to the administration of Propanolol on 11/23/11 at 9:10pm, on 11/24/11 at 9:00pm, on 11/28/11 at 8:56pm, on 11/29/11 at 8:38pm, on 12/02/11 at 9:12pm, and on 12/03/11 at 9:18pm as required by hospital policy.

Patient #3
Review of Patient #3's medical record revealed she was admitted on 11/17/11 with the diagnoses of Depression and Anxiety. Review of Patient #3's H&P revealed she had a history of diabetes, hypertension, dementia, degenerative joint disease, hyperlipidemia, and depression.

Review of Patient #3's physician orders revealed an order at admit for Amlodipine Besylate (to treat hypertension) 5 mg by mouth daily with Olmesartan Medoxomil (Benicar) (to treat hypertension) 20 mg.

Review of Patient #3's medication administration record revealed no documented evidence her blood pressure was assessed by the RN prior to administering Amlodipine and Benicar on 11/19/11 at 11:00am, 11/20/11 at 9:00am, 11/23/11 at 10:19am, 11/24/11 at 9:00am, 11/25/11 at 9:46am, 11/26/11 at 9:04am, 11/29/11 at 9:00am, 11/30/11 at 9:09am, 12/01/11 at 9:23am, 12/02/11 at 9:00am, 12/03/11 at 9:00am, 12/05/11 at 9:06am, and 12/06/11 at 9:24am. Further review revealed both medications were not administered on 11/27/11, 12/07/11, and 12/08/11 due to blood pressure results, but there was no documented evidence of the blood pressure results.

In a face-to-face interview on 12/08/11 at 3:10pm, RN S4 confirmed she did not document the blood pressure for Patient #3 on the medication administration record on 12/07/11 and 12/08/11.

Patient #5
Review of Patient #5's medical record revealed she was admitted on 08/31/11 at 0100 (1:00pm) with the diagnosis of Altered Mental Status.

Review of Patient #5's physician orders revealed orders for Metoprolol 25 mg by mouth daily and Benicar 20 mg by mouth daily. Further review revealed the Benicar was to be held for a systolic blood pressure less than or equal to 100.

Review of Patient #5's medication administration record revealed no documented evidence that her apical pulse was assessed by the RN prior to the administration of Metoprolol (noted as the standard of practice in the drug resource book used by the nurses) or her blood pressure as required by hospital policy on 09/01/11 at 9:57am, 09/03/11 at 8:53am, and 09/04/11 at 9:00am. Further review revealed no documented evidence of the blood pressure or apical pulse result when the medication was held on 09/05/11 at 11:18am and 09/05/11 at 5:39pm. Further review revealed no documented evidence of an assessment of the blood pressure by the RN prior to the administration of Benicar on 09/01/11 at 9:57am, 09/03/11 at 8:51am, 09/04/11 at 9:00am, and 09/06/11 at 8:58am.

Patient #8
Review of Patient #8's medical record revealed she was admitted on 11/17/11 with the diagnosis of depression.

Review of Patient #8's physician's orders revealed an order on 11/17/11 at 2345 (11:45pm) for Lisinopril 10 mg by mouth daily.

Review of Patient #8's medication administration record revealed Lisinopril was held on 11/19/11 at 11:24am, 11/20/11 at 9:49am, and 11/21/11 at 8:55am with no documented evidence of the blood pressure results assessed by the RN to justify holding the medication.

In a face-to-face interview on 12/13/11 at 4:05pm, CCO S1 confirmed the audit she was in the process of compiling revealed a problem with the nurses' not assessing the blood pressure prior to the administration of blood pressure medications and the apical pulse prior to the administration of Metoprolol.

Review of the "Nursing 2008 Drug Handbook", presented by Geri-Psych Unit Manager S3 as the resource book used by the nurses for medication administration revealed on pages 310, 311, and 312 the information on Metoprolol. Further review of the "Nursing Considerations" revealed to "always check patient's apical pulse rate before giving drug. If it's slower than 60 beats/ (per) minute, withhold drug and call prescriber immediately".

Review of the hospital policy titled "Administration of Medications", policy number H-MM 50-001, revised 11/09, and submitted by CCO (Chief Clinical Officer) S1 as their current policy for medication security, revealed, in part, "... Clinical assessment necessary before dose must be documented on the medication administration record (MAR) e.g. (for example), Pulse before Digoxin, B/P (blood pressure) before antihypertensive...".

4) Failure of the RN to ensure the observations delegated to the CNAs or MHTs were performed and documented according to hospital policy:
Patient #1
Review of Patient #1's medical record revealed she was admitted on 11/23/11 at 2200 (10:00pm) with an admit diagnosis of Schizoaffective Disorder. Further review revealed she had a history of diabetes, hypertension, and coronary artery disease.

Review of Patient #1's physician admit orders revealed she was ordered to be on unit observation every 30 minutes.

Review of the CNA/MHT "Observation Record" for Patient #1 revealed no documented evidence of a record for 11/23/11 from admit at 10:00pm, 11/24/11, 11/28/11, 12/02/11, 12/03/11, and 12/04/11. Further review of Patient #1's "Observation Record" revealed no documented evidence of the type of behavior exhibited at the 15 minute checks, the type of observation level ordered for Patient #1, and a signature by the RN verifying "observations completed by staff member and unusual behaviors reported to nurse".

Patient #2
Review of Patient #2's medical record revealed he was admitted on 11/20/11 with diagnoses of Altered Mental Status, Depression, and Dementia. Review of his H&P (history and physical) revealed he had a history of hypertension, colon cancer with a colostomy, benign prostatic hypertrophy (BPH), and dementia, possibly of the Alzheimer's type.

Review of Patient #2's physician admission orders revealed no documented evidence that the observation was ordered.

Review of the CNA/MHT "Observation Record" for Patient #2 revealed no documented evidence of the type of behavior exhibited at the 15 minute checks, the type of observation level ordered for Patient #2, and a signature by the RN verifying "observations completed by staff member and unusual behaviors reported to nurse".

Patient #3
Review of Patient #3's medical record revealed she was admitted on 11/17/11 with the diagnoses of Depression and Anxiety. Review of Patient #3's H&P revealed she had a history of diabetes, hypertension, dementia, degenerative joint disease, hyperlipidemia, and depression.

Review of Patient #3's physician admission orders revealed no documented evidence that the observation was ordered.

Review of the CNA/MHT "Observation Record" for Patient #3 revealed no documented evidence of the type of behavior exhibited at the 15 minute checks, the type of observation level ordered for Patient #2, and a signature by the RN verifying "observations completed by staff member and unusual behaviors reported to nurse". Further review revealed no documented evidence of an observation record for 11/28/11.

Patient #4
Review of Patient #4's medical record revealed she was admitted on 10/04/11 with the diagnosis of Depression. Review of her H&P revealed she had a history of hypertension, congestive heart failure, and degenerative joint disease.

Review of Patient #4's physician admit orders revealed she was ordered to be on close observation every 15 minutes.

Review of the CNA/MHT "Observation Record" for Patient #4 revealed no documented evidence of the type of behavior exhibited at the 15 minute checks, the type of observation level ordered for Patient #4, and a signature by the RN verifying "observations completed by staff member and unusual behaviors reported to nurse".

Patient #5
Review of Patient #5's medical record revealed she was admitted on 08/31/11 at 0100 (1:00pm) with the diagnosis of Altered Mental Status.

Review of Patient #5's physician's admit orders revealed she was ordered to be on unit observations every 30 minutes.

Review of the CNA/MHT "Observation Record" for Patient #5 revealed no documented evidence of the type of behavior exhibited at the 15 minute checks, the type of observation level ordered for Patient #5, and a signature by the RN verifying "observations completed by staff member and unusual behaviors reported to nurse". Further review of the record for 09/05/11 revealed no documented evidence of observations by CNA S14 from 2:30am (morning of 09/06/11) through 6:45am.

Patient #6
Review of Patient #6's medical record revealed he was admitted on 08/30/11 with the diagnoses of Altered Mental Status and Dementia with Mood Disorder. Review of his H&P revealed Patient #6 had a history of chronic obstructive pulmonary disease, hypertension, valvular heart disease with bioprosthetic mitral valve replacement, dementia, diverticulitis, cardiomyopathy, and coronary artery disease.

Review of Patient #6's physician admit orders revealed he was ordered to be on close observations every 15 minutes.

Review of the CNA/MHT "Observation Record" for Patient #5 revealed no documented evidence of the type of behavior exhibited at the 15 minute checks, the type of observation level ordered for Patient #6, and a signature by the RN verifying "observations completed by staff member and unusual behaviors reported to nurse".

Patient #8
Review of Patient #8's medical record revealed she was admitted on 11/17/11 with the diagnosis of depression.

Review of Patient #8's physician admit orders revealed she was ordered to be on close observation every 15 minutes.

Review of the CNA/MHT "Observation Record" for Patient #8 revealed no documented evidence of the type of behavior exhibited at the 15 minute checks, the type of observation level ordered for Patient #8, and a signature by the RN verifying "observations completed by staff member and unusual behaviors reported to nurse".

In a face-to-face interview on 12/09/11 at 9:25am, Geri-Psych Unit Manager S3 confirmed the observation records completed by the CNAs or MHTs did not have dates, behaviors exhibited by the patient, the type of observation ordered and to be performed by the CNA or MHT, and the signature of the RN designating that she had reviewed the record. S3 indicated the policy for unit restriction was incorrect, and one-to-one observation would be the only ordered observation that would require constant visual observation of the patient by the CNA or MHT.

Review of the hospital policy titled "Close Observation/Special Precautions Behavioral Health", policy number TX-39, approved 06/14/04, and submitted by CCO S1 as the current policy for observation levels, revealed, in part, "...three levels of staff monitoring are provided: A. Unit Observation / Routine (watch monitoring every 30 minutes) B. Close Observation (close monitoring every 15 minutes) C. Suicide Precautions 1:1 (monitoring on a constant basis) ... The Attending Physician is always contacted to give a specific order for the level of monitoring. ... C. The physician's order shall include the level of the monitoring (watch, close, constant) and the type of monitoring (suicidal risk, agitation, elopement risk). ... 3. The order for staff monitoring is communicated to all staff, on all shifts. ... 5. A nursing staff member is assigned the responsibility of the observation and the documentation of the observation times on the monitoring log...".

5) Failure of the RN to ensure a nurse was present on the Geri-Psych Unit at all times by leaving the Unit without a nurse for 13 minutes on 12/08/11:
Observation on 12/08/11 at 3:52pm revealed RN S4, the only nurse on the unit, left the unit at 3:25pm with the door to the medication room open. Further observation revealed RN S4 returned to the unit 13 minutes later at 3:38pm. During the absence of RN S4 there was no nurse present on the Geri-Psych Unit with a census of 3 inpatients.

In a face-to-face interview on 12/08/11 at 3:42pm, RN S4 confirmed she left the unit with no nurse present.

Based on record review and interviews, the hospital failed to ensure the nursing staff kept a current nursing care plan for each patient on the Geri-Psych Unit as evidenced by: 1) failing to have patient-specific care plans that included measurable goals, was updated with changes in the patient's condition, included the medical diagnoses of the patient, and goals were noted to be resolved, continued, or revised by the target date for 5 of 8 sampled patients (#1, #2, #3, #4, #6) and 2) failing to implement the physician's orders for weights, accuchecks, and labs for 3 of 8 sampled patients (#2, #3, #4). Findings:

1) Failing to have patient-specific care plans that included measurable goals, was updated with changes in the patient's condition, included the medical diagnoses of the patient, and goals were noted to be resolved, continued, or revised by the target date:
Patient #1
Review of Patient #1's medical record revealed she was admitted on 11/23/11 with an admit diagnosis of Schizoaffective Disorder. Further review revealed she had a history of diabetes, hypertension, and coronary artery disease.

Review of Patient #1's "Master Problem List" revealed the identified patient problems were agitation and combative behavior and altered thought process. Further review revealed no documented evidence Patient #1's medical conditions of diabetes, hypertension, and coronary artery disease was incorporated in the care plan.

Review of the "Problem Statement" for agitated combative behavior revealed the plan was initiated on 11/23/11, and the target date was 12/07/11. Further review revealed the long-term goal was (arrow down meaning decreased) agitation and combative behavior by discharge. There was no documented evidence of the measure to be used to determine when this goal would be met.
Review of the "Problem Statement" for altered thought process revealed the plan was initiated on 11/23/11, and the target date was 12/07/11. Further review revealed the long-term goal was (arrow up meaning increased) reality orientation by discharge. There was no documented evidence of the measure to be used to determine when this goal would be met.
Review of the "Master Treatment Plan Update" completed on 11/29/11 no documented evidence whether the two patient problems had deteriorated, had no change, had some improvement, had significant improvement, or were resolved. Further review revealed the target dates for the goals and objectives were reviewed and were not revised. Review of the "Master Treatment Plan Update" dated 12/06/11 revealed the problem of agitation had deteriorated, and the revised target date was 12/01/11 to 12/15/11. Further review revealed the problem of altered thought process had some improvement, the target date for goals and objectives was reviewed, and there was no revised target date. Further review of the "Problem Statement" for altered thought process revealed no documented evidence whether the problem was resolved or had to be continued as of the initial target of 12/07/11.

Patient #2
Review of Patient #2's medical record revealed he was admitted on 11/20/11 with diagnoses of Altered Mental Status, Depression, and Dementia. Review of his H&P (history and physical) revealed he had a history of hypertension, colon cancer with a colostomy, benign prostatic hypertrophy (BPH), and dementia, possibly of the Alzheimer's type.

Review of Patient #2's "Master Problem List" revealed the identified patient problems were agitation and altered thought process. Further review revealed no documented evidence Patient #2's medical conditions of hypertension, colostomy, BPH, and dementia were incorporated in the care plan.

Review of the "Problem Statement" for agitation revealed the plan was initiated on 11/20/11, and the target date was 12/04/11. Further review revealed the long-term goal was (arrow down meaning decreased) agitation by discharge. There was no documented evidence of the measure to be used to determine when this goal would be met.
Review of the "Problem Statement" for altered thought process revealed the plan was initiated on 11/20/11, and the target date was 12/04/11. Further review revealed the long-term goal was (arrow up meaning increased) reality orientation by discharge. There was no documented evidence of the measure to be used to determine when this goal would be met.

Patient #3
Review of Patient #3's medical record revealed she was admitted on 11/17/11 with the diagnoses of Depression and Anxiety. Review of Patient #3's H&P revealed she had a history of diabetes, hypertension, dementia, degenerative joint disease, hyperlipidemia, and depression.

Review of Patient #3's "Master Problem List" revealed the identified patient problems were anxiety and altered thought process. Further review revealed the care plan did not include the problem of depression which was the reason for Patient #3 was admitted. Further review revealed no documented evidence Patient #3's medical conditions of diabetes, hypertension, dementia, and hyperlipidemia were incorporated in the care plan.

Review of the "Problem Statement" for anxiety revealed the plan was initiated on 11/17/11, and the target date was 12/01/11. Further review revealed the long-term goal was (arrow down meaning decreased) anxiety by discharge. There was no documented evidence of the measure to be used to determine when this goal would be met.
Review of the "Problem Statement" for altered thought process revealed the plan was initiated on 11/18/11, and the target date was 12/02/11. Further review revealed the long-term goal was (arrow up meaning increased) reality orientation by discharge. There was no documented evidence of the measure to be used to determine when this goal would be met.

Review of the "Master Treatment Plan Update" dated 11/22/11 revealed the problem with anxiety and altered thought process had no change, the target dates for goals and objectives were reviewed, and the treatment plan was not revised. Review of the "Master Treatment Plan Update" dated 11/29/11 revealed there was some improvement to both identified problems, the target dates for goals and objectives were reviewed, and the treatment plan was not revised. Review of the "Master Treatment Plan Update" dated 12/06/11, which was after the initial target dates for both identified problems, revealed no documented evidence whether the two patient problems had deteriorated, had no change, had some improvement, had significant improvement, or were resolved. Further review revealed the target dates for the goals and objectives were reviewed, and the treatment plan was not revised.

Patient #4
Review of Patient #4's medical record revealed she was admitted on 10/04/11 with the diagnosis of Depression. Review of her H&P revealed she had a history of hypertension, congestive heart failure, and degenerative joint disease.

Review of Patient #4's "Master Problem List" revealed the identified patient problems were depression and noncompliance with ADLs (activities of daily living) and treatment. Further review revealed the care plan did not include the medical conditions of hypertension and congestive heart failure.

Review of the "Problem Statement" for depression revealed the plan was initiated on 10/04/11, and the target date was 10/11/11. Further review revealed the long-term goal was to alleviate the signs and symptoms of depression by discharge. There was no documented evidence of the measure to be used to determine when this goal would be met.
Review of the "Problem Statement" for noncompliance with ADLs and treatment revealed the plan was initiated on 10/04/11, and the target date was 10/11/11. Further review revealed the long-term goal was to (arrow up meaning increased) compliance with care and treatment by discharge. There was no documented evidence of the measure to be used to determine when this goal would be met.

Patient #6
Review of Patient #6's medical record revealed he was admitted on 08/30/11 with the diagnoses of Altered Mental Status and Dementia with Mood Disorder. Review of his H&P revealed Patient #6 had a history of chronic obstructive pulmonary disease, hypertension, valvular heart disease with bioprosthetic mitral valve replacement, dementia, diverticulitis, cardiomyopathy, and coronary artery disease.

Review of Patient #6's "Master Problem List" revealed the identified patient problems were aggression and labile mood. Further review revealed the care plan did not include Patient #6's medical conditions of chronic obstructive pulmonary disease, hypertension, valvular heart disease with bioprosthetic mitral valve replacement, dementia, diverticulitis, cardiomyopathy, and coronary artery disease.

Review of the "Problem Statement" for aggression revealed the plan was initiated on 08/31/11, and the target date was 09/13/11. Further review revealed the long-term goal was to (arrow down meaning to decrease) aggression. There was no documented evidence of the measure to be used to determine when this goal would be met.
Review of the "Problem Statement" for labile mood revealed the plan was initiated on 08/31/11, and the target date was 09/13/11. Further review revealed the long-term goal was to stabilize mood. There was no documented evidence of the measure to be used to determine when this goal would be met.

Patient #8
Review of Patient #8's medical record revealed she was admitted on 11/17/11 with the diagnosis of depression.

Review of Patient #8's "Master Problem List" revealed the identified patient problem was depression. Review of the "Problem Statement" for depression revealed the plan was initiated on 11/17/11, and the target date was 12/01/11. Further review revealed the long-term goal was to (arrow down meaning to decrease) the signs and symptoms of depression by discharge. There was no documented evidence of the measure to be used to determine when this goal would be met.

In a face-to-face interview on 12/09/11 at 11:20am, Geri-Psych Unit Manager S3 confirmed the long-term goals were not measurable, and the target dates were not addressed to indicate whether the goal had been met or if the plan needed to be revised. S3 further indicated the patients' medical problems were not included in the treatment plan.

Review of the hospital policy titled "Nursing Care Plan Policy", policy number CC-18, revised 03/07/01, and submitted by CCO (Chief Clinical Officer) S1 as the current policy for nursing care plans, revealed, in part, "... All patients will have a Plan of Care developed by the admitting RN (registered nurse) and/or Charge Nurse in conjunction with other appropriate healthcare team members within 24 hours of admission. ... Initiation of the Plan of Care: 1. Nursing will interview and assess the new patient upon admission. 2. Nursing will help analyze the health care data and identify all the patients problems at this point in time for all disciplines. ... 3. Nursing will write the identified problems according to priority on the Patient Care Plan: a. Establish appropriate standard of care for each identified problem. b. Establish time frame for achieving long/short-term goals. ... g. Update care plan as goals are achieved and/or new problems are identified. ... 6. Goals must be realistic, measurable and achievable in specified time frame. ...".

Review of the hospital policy titled "Treatment Plan-Initial, Master and Review", policy number BH 0275, with no documented evidence of the date of implementation or revision, and submitted by CCO S1 as the current policy for the master treatment plan, revealed, in part, "... 2. The Master Treatment Plan will include: the identification of the patient's problem areas/needs; ... diagnosis; a corresponding determination of the treatment goals; an assignment of specific responsibilities to staff to meet these goals; patient-specific interventions; ... a clear description of criteria anticipated prior to discharge; a continuing care plan... 3. The specific treatments ordered, including the type, amount, frequency, and duration of the services to be furnished will be clearly documented;;; 4. The expected outcome for each problem addressed will be included ... by listing the criteria for termination of treatment. ... 7. The long-term and short-term goals must be stated in patient terms, time-framed, measurable, realistic, and directly related to the cause of the patient's admission. ... 10. Use the Master Treatment Plan review form to document treatment plan reviews for any changes and updates, for patient's progress towards goals, for level of functioning, and discharge plans. ... 5. If the patient is not making expected progress, a revision of the goals or interventions should be considered...".

2) Failing to implement the physician's orders for weights, accuchecks, and labs:
Patient #2
Review of Patient #2's medical record revealed he was admitted on 11/20/11 with diagnoses of Altered Mental Status, Depression, and Dementia. Review of his H&P (history and physical) revealed he had a history of hypertension, colon cancer with a colostomy, benign prostatic hypertrophy, and dementia, possibly of the Alzheimer's type.

Review of Patient #2's "Behavioral Health Physician Admission Orders" dated 11/20/11 at 2200 (10:00pm) revealed an order for a RPR (rapid plasma reagin). Review of the lab results for Patient #2 revealed no documented evidence of a RPR result.

In a face-to-face interview on 12/09/11 at 11:20am, Geri-Psych Unit Manager S3 indicated the RPR was not ordered, and there was no result.

Patient #3
Review of Patient #3's medical record revealed she was admitted on 11/17/11 with the diagnoses of Depression and Anxiety.

Review of Patient #3's "Behavioral Health Physician Admission Orders" dated 11/17/11 at 1956 (7:56pm) revealed an order for accuchecks (blood glucose testing) before meals and at bedtime. Review of the "Fingerstick Glucose" results revealed no documented evidence the blood glucose was checked before breakfast on 12/02/11 and before lunch on 12/05/11 as ordered.

Review of Patient #3's "Physician Order" dated 11/19/11 at 12:40pm revealed an order to perform standing weights daily. Review of the documented weights presented by CCO (Chief Clinical Officer) S1 revealed no documented evidence that Patient #3 was weighed on 11/19/11, 11/20/11, 11/22/11, and 12/05/11 as ordered by the physician.

In a face-to-face interview on 12/13/11 at 11:20am, CCO S1 presented documentation of the accuchecks and standing weights performed for Patient #3 and confirmed the above listed accuchecks and standing weights were not performed as ordered by the physician.

Patient #4
Review of Patient #4's medical record revealed she was admitted on 10/04/11 with the diagnosis of Depression. Review of her H&P revealed she had a history of hypertension, congestive heart failure, and degenerative joint disease.

Review of Patient #4's "Behavioral Health Physician Admission Orders" dated 10/04/11 at 0200 (2:00am) revealed an order for a Vitamin D level to be drawn. Review of the lab results for Patient #4 revealed no documented evidence that Vitamin D had been drawn and results included in the medical record.

In a face-to-face interview on 12/13/11 at 11:20am, CCO S1 could offer no explanation for the Vitamin D level not being drawn as ordered.

Based on record review and interview, the hospital failed to ensure the nursing care of each patient on the Geri-Psych Unit was assigned to nursing personnel who were oriented to the unit and were assessed for competency prior to providing patient care as evidenced by: 1) failure to orient and assess the competency to provide care to patients on the Geri-Psych Unit for 1 of 6 RN's (registered nurse) personnel files reviewed (S11), for 3 of 3 LPN's (licensed practical nurse) personnel files reviewed (S13, S16, S17), for 2 of 4 CNA's (certified nursing assistant) / MHT's (mental health tech) personnel files reviewed (S14, S15), and for 1 of 1 agency CNA's personnel file reviewed from Company A (S7); 2) failure to ensure an agency CNA and LPNs assigned to the Geri-Psych Unit had successfully completed CPI (crisis prevention intervention) certification prior to being assigned to the Unit for 1 of 1 agency CNA's (from Company A) personnel file reviewed (S7) and 3 of 3 LPNs' personnel files reviewed (S13, S16, S17); and 3) failure to ensure the staff assigned to the Geri-Psych Unit were currently certified in CPI by having staff work the Unit while their CPI certification was expired for 3 of 6 RNs' personnel files reviewed (S4, S8, S11) and 3 of 4 CNA's / MHTs' personnel files reviewed (S6, S12, S15). Findings:

1) Failure to orient and assess the competency to provide care to patients on the Geri-Psych Unit for 1 of 6 RN's (registered nurse) personnel files reviewed (S11), for 3 of 3 LPN's personnel files reviewed (S13, S16, S17), for 2 of 4 CNA's / MHT's personnel files reviewed (S14, S15), and for 1 of 1 agency CNA's personnel file reviewed from Company A (S7):
RN S11
Review of RN S11's personnel file revealed she was hired in June 2000. Further review revealed had been oriented to and assessed for competency for the Intensive Care Unit and the Medical Surgical Department. There was no documented evidence of orientation to and assessment of competency for the Geri-Psych Unit for RN S11.
Review of the "Nursing Assignment Sheet" revealed RN S11 worked the Geri-Psych Unit on the following dates: the 7A to 7P shift (7:00am to 7:00pm) on 09/10/11, 09/15/11, 09/29/11, 10/03/11, 10/04/11, 10/12/11, 11/17/11, 11/19/11, 12/04/11 and the 7P to 7A shift (7:00pm to 7:00am) on 09/01/11 and 11/15/11.

LPN S13
Review of LPN S13's personnel file revealed her date of hire was 07/11/11. Further review revealed no documented evidence of prior work experience in the geriatric psych setting, no orientation to the Geri-Psych Unit, and no assessment of competency for providing care to patients on the geri-Pscy Unit.
Review of the "Nursing Assignment Sheet" revealed LPN S13 worked the Geri-Psych Unit on the 7P to 7A shifts on 10/26/11 and 11/20/11.

LPN S16
Review of LPN S16's personnel file revealed her date of hire was 12/06/07. Further review revealed no documented evidence of prior work experience in the geriatric psych setting, no orientation to the Geri-Psych Unit, and no assessment of competency for providing care to patients on the geri-Pscy Unit.
Review of the "Nursing Assignment Sheet" revealed LPN S16 worked the Geri-Psych Unit on the 7A to 7P shifts of 09/01/11, 09/05/11, and 09/19/11.

LPN S17
Review of LPN S17's personnel file revealed her date of hire was 05/11/07. Further review revealed no documented evidence of prior work experience in the geriatric psych setting, no orientation to the Geri-Psych Unit, and no assessment of competency for providing care to patients on the geri-Pscy Unit.
Review of the "Nursing Assignment Sheet" revealed LPN S17 worked the Geri-Psych Unit on the 7A to 7P shift on 09/18/11.

CNA S14
Review of CNA S14's personnel file revealed she was hired on 05/02/11. Further review revealed no documented evidence of orientation to the Geri-Psych Unit and no assessment of competency for providing care to patients on the geri-Pscy Unit.
Review of the "Nursing Assignment Sheet" revealed CNA S14 worked the Geri-Psych Unit on the following dates: the 7A to 7P shift on 09/22/11 and the 7P to 7A shift on 09/01/11, 09/03/11, 09/04/11, 09/05/11, 09/06/11, 09/14/11, 09/15/11, 09/20/11, 09/21/11, 09/23/11, 10/04/11, 10/07/11, 10/19/11, 10/26/11, 11/07/11, 11/08/11, 11/14/11, 11/16/11, 11/21/11, 11/25/11, 11/30/11, 12/01/11, 12/02/11, 12/3/11, and 12/04/11.

CNA S15
Review of CNA S15's personnel file revealed her date of hire was 04/05/01. Further review revealed no documented evidence of an assessment of competency for providing care to patients on the Geri-Psych Unit.
Review of the "Nursing Assignment Sheet" revealed CNA S15 worked the Geri-Psych Unit on the 7A to 7P shifts on 09/05/11, 09/10/11, 09/15/11, 09/19/11, 09/20/11, 09/29/11, 10/03/11, 10/04/11, 10/12/11, 10/13/11, 11/19/11, 12/03/11, and 12/04/11 and the 7P to 7A shift on 11/15/11.

Agency CNA S7
Review of Agency CNA S7's personnel file revealed she was contracted through Company A. Further review revealed no documented evidence of hospital wide orientation as required by policy, orientation to the Geri-Psych Unit, and an assessment of competency to provide care to patients on the Geri-Psych Unit.
Observation on 12/08/11 at 3:25pm revealed Agency CNA S7 was performing observations of patients on the Geri-Psych Unit.

In a face-to-face interview on 12/13/11 at 2:00pm, Director of Quality S2 indicated she could not find the competency assessment for CNA S15.

In a face-to-face interview on 12/13/11 at 2:05pm, CCO (Chief Clinical Officer) S1 confirmed RN S11, LPNs S13, S16, and S17, CNAs S14 and S15, and Agency CNA S7 did not have orientation to the Geri-Psych Unit and an assessment of competency to provide care for patients on the Geri-Psych Unit.

In a face-to-face interview on 12/13/11 at 2:30pm, CCO S1 indicated while the hospital was between unit managers for the Geri-Psych Unit, either she or the house supervisor would give the Geri-Psych Unit staff permission to pull staff from other hospital units, and it was usually from ICU (Intensive care Unit).

Review of the hospital policy titled "Hospital Wide Education Plan", policy number H-ML 11-001, revised 11/10, and submitted by COO S1 as the current policy for department orientation, revealed, in part, "...Department Directors/Managers: 1. Are responsible for the implementation and documentation of department-specific orientation, education activities, competency testing, program evaluation, department needs assessment and follow-up monitoring of educational activities. 2. Ensure completion of sign-in sheet, skills checklist, and program evaluations, which are forwarded to the Educator. 3. Facilitate and support ongoing competence of department staff. ... Hospital Wide Orientation ... 3. All new employees will attend General Orientation within the first 30 days of their employment. 4. Hospital wide orientation includes but is not limited to organizational structure, general hospital policies, Human Resource policies, infection control, risk management, patient rights, and confidentiality, hazardous communications, emergency preparedness, fire safety, sexual harassment, cultural diversity and sensitivity training and code of business conduct. ... Department Specific Orientation 1. Each employee will receive individual job description from Department Director/designee at the time of hire. 2. In collaboration with the Educator, the Department Director/Manager or designee coordinates department specific orientation. 3. This orientation is based on individual needs, assessment of knowledge skills, level of competence and standards relating to service or care provided and requirements of various regulatory agencies. 4. Department specific orientation will include the following key elements: a. Department Specific skills b. Environment of Care components c. Policies and Procedures d. Communications e. Quality improvement activities f. Core competencies role specific... Competency Assessment ... 2. Competency is part of the performance appraisal system and is assessed upon hire, transfer to a new role, prior to assignment to a new unit, when there is a change in either job performance or job requirements and thereafter on an annual basis... Agency/Contract Staff All personnel will complete a hospital-wide orientation, which includes all the essential items listed above under general orientation with the exception of Employee Benefits and Payroll, and Department specific orientation which includes computer training, clinical competencies, equipment usage competence, and chain of command reporting. ... D. Documentation of current clinical competence in the assigned responsibilities of patient care, will be documented by the agency. The Department Manager/designee is responsible to ensure that this documentation is present and accessible...".

2) Failure to ensure an agency CNA and LPNs assigned to the Geri-Psych Unit had successfully completed CPI certification prior to being assigned to the Unit for 1 of 1 agency CNA's (from Company A) personnel file reviewed (S7) and 3 of 3 LPNs' personnel files reviewed (S13, S16, S17):
Agency CNA S7
Review of Agency CNA S7's personnel file revealed she was contracted through Company A. Further review revealed no documented evidence that S7 had successfully completed certification in CPI as required for the CNAs employed by the hospital.
Observation on 12/08/11 at 3:25pm revealed Agency CNA S7 was performing observations of patients on the Geri-Psych Unit.

LPN S13
Review of LPN S13's personnel file revealed her date of hire was 07/11/11. Further review revealed no documented evidence that LPN S13 had successfully completed certification in CPI.
Review of the "Nursing Assignment Sheet" revealed LPN S13 worked the Geri-Psych Unit on the 7P to 7A shifts on 10/26/11 and 11/20/11.

LPN S16
Review of LPN S16's personnel file revealed her date of hire was 12/06/07. Further review revealed no documented evidence that LPN S16 had successfully completed certification in CPI.
Review of the "Nursing Assignment Sheet" revealed LPN S16 worked the Geri-Psych Unit on the 7A to 7P shifts of 09/01/11, 09/05/11, and 09/19/11.

LPN S17
Review of LPN S17's personnel file revealed her date of hire was 05/11/07. Further review revealed no documented evidence that LPN S17 had successfully completed certification in CPI.
Review of the "Nursing Assignment Sheet" revealed LPN S17 worked the Geri-Psych Unit on the 7A to 7P shift on 09/18/11.

In a face-to-face interview on 12/13/11 at 2:05pm, CCO S1 indicated the LPNs were pulled to the unit from other hospital units. S1 confirmed the LPNs and Agency CNA S7 did not have CPI certification when they worked the Geri-Psych Unit. S1 further indicated CPI certification was required of all staff working the Geri-Psych Unit.

Review of the job description of the MHT or CNA for the Behavioral Health Department revealed successful completion of CPI was required.

3) Failure to ensure the staff assigned to the Geri-Psych Unit were currently certified in CPI by having staff work the Unit while their CPI certification was expired for 3 of 6 RNs' personnel files reviewed (S4, S8, S11) and 3 of 4 CNA's / MHTs' personnel files reviewed (S6, S12, S15):
RN S4
Review of RN S4's personnel file revealed her date of hire was 04/01/11. Further review revealed her CPI certification expired on 06/30/11, and she had not attended a class for certification in CPI until 10/25/11.
Review of the "Nursing Assignment Sheet" revealed RN S4 worked the Geri-Psych Unit on the 7A to 7P shift on 09/01/11, 09/05/11, 09/10/11, 09/15/11, 09/29/11, 10/03/11, 10/04/11, 10/12/11, and 10/13/11.

RN S8
Review of RN S8's personnel file revealed her date of hire was 01/29/04. Further review revealed her CPI certification expired 06/30/11, and she had not attended a class to recertify in CPI as of 12/13/11.
Observation on 12/09/11 revealed RN S8 was assigned as the RN on the Geri-Psych Unit.
Review of the "Nursing Assignment Sheet" revealed RN S8 worked the Geri-Psych Unit on the 7A to 7P shift on 09/03/11, 09/18/11, 09/22/11, and 11/17/11.

RN S11
Review of RN S11's personnel file revealed she was hired in June 2000. Further review revealed RN S11's CPI certification had expired 06/11, and she had not attended a class for certification in CPI until 12/09/11.
Review of the "Nursing Assignment Sheet" revealed RN S11 worked the Geri-Psych Unit on the following dates while her CPI certification was expired: the 7A to 7P shift on 09/10/11, 09/15/11, 09/29/11, 10/03/11, 10/04/11, 10/12/11, 11/17/11, 11/19/11, 12/04/11 and the 7P to 7A shift on 09/01/11 and 11/15/11.

CNA S6
Review of CNA S6's personnel file revealed her CPI certification expired on 05/11, and she had not attended a class to recertify in CPI as of 12/13/11.
Observation on 12/08/11 at 3:25pm revealed CNA S6 was one of the CNAs assigned to the Geri-Psych Unit on the 7A to 7P shift.
Review of the "Nursing Assignment Sheet" revealed CNA S6 worked the Geri-Psych Unit on the 7A to 7P shift on 09/03/11, 09/15/11, 09/18/11, and 11/17/11.

CNA S12
Review of CNA S12's personnel file revealed he was hired on 06/07/10. Further review revealed his CPI certification expired on 06/30/11, and he had not attended a class for certification in CPI as of 12/13/11.
Observation on 12/09/11 at 9:40am revealed CNA S12 was performing one-to-one observation of a patient on the Geri-Psych Unit.

CNA S15
Review of CNA S15's personnel file revealed her date of hire was 04/05/01. Further review revealed her CPI certification expired on 09/30/11, and she had not attended a class for certification in CPI until 10/25/11.
Review of the "Nursing Assignment Sheet" revealed CNA S15 worked the Geri-Psych Unit on the following dates while her CPI certification was expired: the 7A to 7P shifts on 10/03/11, 10/04/11, 10/12/11, and 10/13/11.

In a face-to-face interview on 12/13/11 at 2:05pm, CCO S1 indicated the Geri-Psych Unit opened around 10/26/10. She further indicated the Education Department was responsible for the system that notified supervisors of the expiration dates of CPI for staff. S1 confirmed the above listed Geri-Psych staff worked the Unit while their CPI certification was expired.

Review of the RN job description for the Behavioral Health Department revealed, in part, "...Additional Requirements: Complete knowledge of crisis intervention techniques. CPR (cardiopulmonary resuscitation) certification and successful completion of Crisis Prevention Intervention (CPI) including restraint and seclusion policies, within 90 days of employment, and prior to assisting in restraining procedures...".

Review of the job description of the MHT or CNA for the Behavioral Health Department revealed successful completion of CPI was required.

Based on record review and interview, the hospital failed to ensure patients' medications were administered according to hospital policy and as ordered by the physician for 4 of 8 sampled patients (#1, #2, #3, #6). Findings:

Patient #1
Review of Patient #1's medical record revealed she was admitted on 11/23/11 with an admit diagnosis of Schizoaffective Disorder. Further review revealed she had a history of diabetes, hypertension, and coronary artery disease.

Review of the physician admit orders revealed the following medications were ordered: Amiodarone HCL 200 mg (milligrams) by mouth daily; Diltiazem 60 mg by mouth daily; Furosemide 40 mg by mouth BID (twice a day); Oxcarbazepine 300 mg by mouth BID.

Review of the medication administration record revealed Amiodarone HCL was to be administered at 9:00am. Further review revealed it was administered on 11/25/11 at 12:15pm, on 11/28/11 at 9:46am (not within 30 minutes of the scheduled time as required by policy), on 12/01/11 at 1:40pm, on 12/02/11 at 10:30am, on 12/03/11 at 1:00pm, and on 12/04/11 at 10:09am. Further review revealed Diltiazem was to be administered at 9:00am. Further review revealed it was administered on 11/24/11 at 9:56am, on 11/25/11 at 12:15pm, on 11/28/11 at 9:46am, on 11/29/11 at 10:02am, on 12/02/11 at 10:30am, and on 12/03/11 at 3:30pm. Review of the medication administration record revealed Furosemide was to be administered at 9:00am and 6:00pm. Further review revealed it was administered on 11/25/11 at 12:15pm and 5:31pm, 5 hours and 16 minutes between doses. Further review revealed it was administered on 12/02/11 at 10:30am, 1 hour and 30 minutes after the scheduled time. Further review revealed Oxcarbazepine was to be administered at 9:00am and 6:00pm. Further review revealed it was administered on 11/25/11 at 12:15pm (3 hours and 15 minutes after the scheduled time), on 11/29/11 at 10:02am, on 12/02/11 at 10:30am, and on 12/03/11 at 3:30pm. There was no documented evidence the physician was notified that the medications were not administered as ordered.

Patient #2
Review of Patient #2's medical record revealed he was admitted on 11/20/11 with diagnoses of Altered Mental Status, Depression, and Dementia. Review of his H&P (history and physical) revealed he had a history of hypertension, colon cancer with a colostomy, benign prostatic hypertrophy (BPH), and dementia, possibly of the Alzheimer's type.

Review of Patient #2's physician orders revealed an order for CO Q 400 mg by mouth daily. Review of the medication administration record revealed on 11/23/11, 11/25/11, and 12/02/11 the medication was administered more than 30 minutes after the scheduled time.

Patient #3
Review of Patient #3's medical record revealed she was admitted on 11/17/11 with the diagnoses of Depression and Anxiety. Review of Patient #3's H&P revealed she had a history of diabetes, hypertension, dementia, degenerative joint disease, hyperlipidemia, and depression.

Review of Patient #3's physician orders revealed an order at admit for Amlodipine Besylate (to treat hypertension) 5 mg by mouth daily with Olmesartan Medoxomil (Benicar) (to treat hypertension) 20 mg and Aspirin 81 mg by mouth daily.

Review of Patient #3's medication administration record revealed Benicar was scheduled to be administered at 9:00am. Further review revealed Benicar was administered on 11/19/11 at 11:00am (documented that medication to be given with Norvasc which was not available at 10:37am, more than 30 minutes after the scheduled time), on 11/23/11 at 10:19am (more than 30 minutes after the scheduled time), and on 12/04/11 at 9:54am (more than 30 minutes after the scheduled time). Further review revealed Aspirin was administered on 11/18/11 at 10:05, 1 hour and 5 minutes after the scheduled time, and on 11/23/11 at 10:19am, 1 hour and 19 minutes after the scheduled time.

Patient #6
Review of Patient #6's medical record revealed he was admitted on 08/30/11 with the diagnoses of Altered Mental Status and Dementia with Mood Disorder. Review of his H&P revealed Patient #6 had a history of chronic obstructive pulmonary disease, hypertension, valvular heart disease with bioprosthetic mitral valve replacement, dementia, diverticulitis, cardiomyopathy, and coronary artery disease.

Review of Patient #6's physician admit orders revealed an order for Ciprofloxacin (Cipro) 500 mg (milligrams) by mouth every 12 hours.

Review of Patient #6's medication administration record revealed the scheduled times for the administration of Cipro were 9:00am and 9:00pm. Further review revealed Cipro was administered on 09/02/11 at 2:06pm and 9:00pm, 6 hours and 54 minutes between the doses. Further review revealed Cipro was administered on 09/03/11 at 1:30pm and 9:30pm, 8 hours between the doses. Further review revealed Cipro was administered on 09/05/11 at 3:40pm and 9:10pm, 5 hours and 30 minutes between the doses. Further review revealed no documented evidence the physician was notified for an order to address whether the second dose should be held, since the first dose was given later than scheduled.

In a face-to-face interview on 12/09/11 at 9:30am, RN S8 indicated that some of the late times for administration may be due to the patient refusing the medication earlier. S8 confirmed the documentation didn't revealed that an earlier attempt was made or that the physician was notified.

In a face-to-face interview on 12/13/11 at 4:05pm, CCO S1 indicated an audit had begun of nursing documentation that revealed some of the above findings initially, but compilation of the data and a resultant action plan had not been implemented yet.

Review of the hospital policy titled "Administration of Medications", policy number H-MM 50-001, revised 11/09, and submitted by CCO (Chief Clinical Officer) S1 as their current policy for medication security, revealed, in part, "... S. Medications will be administered within 30 minutes before or after the scheduled time...".

Review of the hospital policy titled "Standard Times of Administration", policy number KPS-MM-50.01, revised 09/11, and submitted by CCO S1 as the current medication administration time policy, revealed, in part, "...Twice day 9am - 6 p.m. (0900 - 1800) ... Every day 9 a.m. (0900) ... Hour of sleep 9p.m. (2100)... Every 8 hours 6a.m.-2p.m.-10p.m. (0600-1400-2200) Every 12 hours 9a.m.-9p.m. (0900-2100)...".

Based on observation, record review, and interview, the hospital failed to ensure all drugs and biologicals were kept secured and in a locked area by having the door to the medication room on the Geri-Psych Unit left open and unsupervised by a nurse with unauthorized staff present in the nursing station on 12/08/11. Findings:

Observation on 12/08/11 at 3:52pm revealed the door to the medication room on the Geri-Psych Unit was accessible from inside the nursing station. Further observation revealed the nursing station was open to the dayroom and separated by a half-wall with a swing-door (part of the half-wall) to enter the nursing station approximately four feet from the door to the medication room. Further observation revealed RN (registered nurse) S4, the only nurse on the unit, left the unit at 3:25pm with the door to the medication room open. Further observation revealed RN S4 returned to the unit 13 minutes later at 3:38pm. During the absence of RN S4, the medication room door remained open with Psychiatrist S19 seated at the nursing station with his back to the medication room, LCSW (licensed clinical social worker) Case Manager S5 standing in the nursing station, and CNA (certified nursing assistant) S6, CNA S7 with Company A, and one patient seated in the dayroom near the nursing station.

In a face-to-face interview on 12/08/11 at 3:42pm, RN S4 confirmed she left the unit with no nurse present with the medication room door open while staff was present who had no authorization to enter the medication room.

Review of the hospital policy titled "Administration of Medications", policy number H-MM 50-001, revised 11/09, and submitted by CCO (Chief Clinical Officer) S1 as their current policy for medication security, revealed, in part, "...C. All medications must be properly stored / secured at all times prior to administration...".

Based on observation, record review, and interview, the hospital failed to ensure expired drugs were not available for patient use by having 5 syringes of Diazepam 10 mg (milligrams) / 2 ml (milliliter) (2 ml contained in each) contained in the locked narcotic cabinet on the Geri-Psych Unit with an expiration date of 11/01/11 and available for patient use. Findings:

Observation of the medications locked in the narcotic cabinet in the medication room of the Geri-Psych Unit on 12/08/11 at 10:10am revealed 5 syringes of Diazepam 10 mg / 2 ml, 2 ml each, with an expiration date of 11/01/11.

In a face-to-face interview on 12/08/11 at 10:20am, Geri-Psych Unit Manager S3 confirmed the above findings. S3 indicated it was the responsibility of the pharmacy department to remove expired medications, and the nurses were supposed to check for expired medications before administering any medication.

Review of the hospital policy titled "Controlled Substances: Security, Ordering and Inventory Procedures", policy number H-MM 20-006 A, revised 11/10, and submitted by CCO (Chief Clinical Officer) S1 as the current policy related to expired medications, revealed, in part, "... 1. The Pharmacy Department is responsible for the direct control and management of all controlled substances. ... L. Controlled Drug Destruction 1. Controlled drugs approaching the expiration date will be removed from stock by a pharmacy technician or pharmacist in the presence of a licensed nurse. They will be returned to the pharmacy for appropriate documentation. ... a. Controlled drugs approaching expiration: will be pulled from the narcotic cabinet on any nursing unit will be signed out on the CSAR (controlled substance administration record) by a nurse and a pharmacist/pharmacy technician with the note "Returned to Pharmacy."...".