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Based on record review and interview, the hospital failed to ensure less restrictive interventions were determined to be ineffective prior to the use of chemical restraints for 3 of 8 sampled patients (#1, #3, #8). Findings:

Patient #1

Review of Patient #1's medical record revealed she was admitted on 02/14/10 with diagnoses of chronic paranoid schizophrenia, mental retardation, anemia, and seizure disorder. Review of Patient #1's "Doctor's Order Sheet" revealed a telephone order was received from Psychiatrist S19 by RN (registered nurse) S11 on 02/21/10 at 1315 (1:15 p.m.) and on 02/22/10 at 0920 (9:20 a.m.) for Ativan 2 mg (milligrams), Benadryl 25 mg, and Haldol 5 mg to be administered as a one-time dose intramuscularly.

Review of Patient #1's medical record revealed no documented evidence of less restrictive interventions that were attempted prior to the administration of a chemical restraint.

In a face-to-face interview on 02/24/10 at 10:40 a.m., S11 RN indicated she would usually administer intramuscular medication to a patient with increased agitation to prevent the patient from injuring himself/herself. She further indicated she couldn't remember what behavior Patient #1 was exhibiting that warranted the chemical restraint or what other interventions she had first attempted. S11 RN confirmed Patient #1's medical record had no documented evidence of her (S11's) assessment of Patient #1's behavior as well as the less restrictive interventions she had attempted.

Patient #3

Review of the physician ' s orders for 11/20/09 at 1030 (10:30 a.m.) revealed a telephone order from S20MD for #3 to be administered Ativan 2 mg, Haldol 5 mg and Benadryl 25 mg X 1 IM now. Review of the Observation Flowsheet dated 11/20/09 for #3 revealed that at 0930 (9:30 a.m.), 0945 (9:45 a.m.), and 1000 (10:00 a.m.) #3 was in the Day Room participating in Group activity. Documentation for 1015 (10:15 a.m.) revealed #3 was outside smoking. Documentation for 1030 (10:30 a.m.) revealed #3 was in his room lying/sitting.

Review of the nurses notes documented by S12RN for 11/20/09 at 1030 (10:30 a.m.) read: " Pt. inappropriately touched staff on back. Pt. redirected to room. Ativan 2 mg, Haldol 5 mg, and Benadryl 25 mg IM X1 given per med nurse. "

In an interview on 02/25/10 at 10:50 a.m. S12RN indicated that #3 was seated on his bed in his room when S12RN assessed him about the inappropriate touching of the staff member. S12RN indicated that #3 was separated from staff and that neither the staff nor patient #3 were in immediate danger. S12RN further indicated that #3 would not " guarantee " that he would not inappropriately touch staff or patients so " the medication was administered anyway. "

In an interview on 02/25/10 with S2DON she indicated she would expect the Charge Nurse to make all staff aware of the inappropriate sexual behavior of #3 and have the MHT ' s monitor the patient closely.

Patient #8

Review of Patient #8's medical record revealed the patient was admitted to the hospital on 2/22/2010 with diagnoses that included Chronic Paranoid Schizophrenia and Mental Retardation. Further review revealed the patient was administered Ativan 2 milligrams and Benadryl 25 milligrams Intramuscularly as per a verbal "now" order received on 2/22/2010 at 11:10 a.m. and administered at 11:20 a.m.

Review of the entire medical record revealed no documented evidence describing the behaviors warranting the administration of Ativan and Benadryl or less restrictive behavior interventions attempted prior to the administration of the "now" dosage of Ativan and Benadryl.

This finding was confirmed by the Director of Nursing (DON S2) on 2/25/2010 at 2:00 p.m. who further indicated there should be documentation in the patient's medical record describing the patient's behavior and therapeutic interventions utilized in response to the patient's behavior prior to the administration of Ativan and Benadryl. The Director of Nursing indicated the Nurse should have used the hospital's "Unscheduled Medication Intervention Form" which would have covered this needed documentation.

Review of the hospital policy titled "Seclusion And/Or Restraint", last revised 02/08 and submitted by S2 Director of Nursing as the hospital's current policy for the use of restraints, revealed, in part, "...Prior to the use of seclusion/restraint, alternative techniques must be attempted which are reflected in the medical record along with the patient's response to each intervention. Alternative techniques include but are not limited to the following interventions: Time out, Verbal de-escalation, Increased observational status, Frequent contact/reassurance, Modification of environment, Attempts at re-direction such as providing activities, distraction...".

Based on record review and interview, the hospital failed to ensure the medical record included a description of the patient's behavior with each administration of a chemical restraint by failing to have the RN (registered nurse) assess and document the patient's behavior prior to administering a chemical restraint for 3 of 8 sampled patients (#1, #3, #8). Findings:

Patient #1

Review of Patient #1's medical record revealed she was admitted on 02/14/10 with diagnoses of chronic paranoid schizophrenia, mental retardation, anemia, and seizure disorder. Review of the "Unscheduled Medication Intervention Form" for 02/21/10 at 1949 (7:49 p.m.) revealed the entry by RN S15, in part, "...Description of Patient Complaint or Behaviors: Patient anxious and easily agitated. Patient require frequent redirection...". Further review revealed no documented evidence of the behaviors Patient #1 was exhibiting that warranted the use of a chemical restraint. Further review revealed Patient #1 received a chemical restraint on 02/21/10 at 1:15 p.m. administered by RN S11 with no documented evidence of the behaviors Patient #1 was exhibiting that warranted the use of a chemical restraint.

Review of Patient #1's "Unscheduled Medication Intervention Form" for 02/22/10 at 1615 (4:15 p.m.) revealed the entry by RN S11 of the behavior as increased agitation. Further review revealed no documented evidence of the behaviors Patient #1 was exhibiting that warranted the use of a chemical restraint. Further review revealed Patient #1 received a chemical restraint on 02/22/10 at 9:20 a.m. administered by RN S11 with no documented evidence of the behaviors Patient #1 was exhibiting that warranted the use of a chemical restraint.

In a face-to-face interview on 02/24/10 at 10:40 a.m., S11 RN indicated she would usually administer intramuscular medication to a patient with increased agitation to prevent the patient from injuring himself/herself. She further indicated she couldn't remember what behavior Patient #1 was exhibiting that warranted the chemical restraint or what other interventions she had first attempted. S11 RN confirmed Patient #1's medical record had no documented evidence of her (S11's) assessment of Patient #1's behavior on 02/21/10 and 02/22/10 as well as the description of the behaviors on 02/22/10 at 3:15 p.m..

In a face-to-face interview on 02/25/10 at 11:10 a.m., S15 RN indicated she wasn't sure what behavior Patient #1 was exhibiting when she administered the chemical restraint on 02/21/10 at 7:49 p.m.. She confirmed her documentation did not include a description of Patient #1's behaviors at the time she administered the chemical restraint.

Patient #3

Review of the physician ' s orders for 11/20/09 at 1030 (10:30 a.m.) revealed a telephone order from S20MD for #3 to be administered Ativan 2 mg, Haldol 5 mg and Benadryl 25 mg X 1 IM now. Review of the Observation Flowsheet dated 11/20/09 for #3 revealed that at 0930 (9:30 a.m.), 0945 (9:45 a.m.), and 1000 (10:00 a.m.) #3 was in the Day Room participating in Group activity. Documentation for 1015 (10:15 a.m.) revealed #3 was outside smoking. Documentation for 1030 (10:30 a.m.) revealed #3 was in his room lying/sitting.

Review of the nurses notes documented by S12RN for 11/20/09 at 1030 (10:30 a.m.) read: " Pt. inappropriately touched staff on back. Pt. redirected to room. Ativan 2 mg, Haldol 5 mg, and Benadryl 25 mg IM X1 given per med nurse. "

In an interview on 02/25/10 at 10:50 a.m. S12RN indicated that #3 was seated on his bed in his room when S12RN assessed him about the inappropriate touching of the staff member. S12RN indicated that #3 was separated from staff and that neither the staff nor patient #3 were in immediate danger. S12RN further indicated that #3 would not " guarantee " that he would not inappropriately touch staff or patients so " the medication was administered anyway. "

In an interview on 02/25/10 with S2DON she indicated she would expect the Charge Nurse to make all staff aware of the inappropriate sexual behavior of #3 and have the MHT ' s monitor the patient closely.

Patient #8

Review of Patient #8's medical record revealed the patient was admitted to the hospital on 2/22/2010 with diagnoses that included Chronic Paranoid Schizophrenia and Mental Retardation. Further review revealed the patient was administered Ativan 2 milligrams and Benadryl 25 milligrams Intramuscularly as per a verbal "now" order received on 2/22/2010 at 11:10 a.m. and administered at 11:20 a.m.

Review of the entire medical record revealed no documented evidence describing the patient's behavior or behavior interventions prior to the administration of the "now" dosage of Ativan and Benadryl.

This finding was confirmed by the Director of Nursing (DON S2) on 2/25/2010 at 2:00 p.m. who further indicated there should be documentation in the patient's medical record describing the patient's behavior and therapeutic interventions utilized in response to the patient's behavior prior to the administration of Ativan and Benadryl. The Director of Nursing indicated the Nurse should have used the hospital's "Unscheduled Medication Intervention Form" which would have covered this needed documentation.

Review of the form titled, "Unscheduled Medication Intervention Form" presented by DON S2 as the current form revealed comment sections under the headings of: 1) Description of Patient Complaint or Behaviors, Alternative interventions attempted, Type of medication, Mental Status, Patient's Response, Vital Signs, and (Follow up) Mental Status.

Review of the hospital handout titled, "Unscheduled Medication Intervention Form" presented by the hospital as current revealed in part, "Unscheduled Medication Intervention Form is to be completed every time a patient is ordered to receive a one-time or now medication for the purpose of a medical or behavioral intervention."
Review of the hospital policy titled "Seclusion And/Or Restraint", last revised 02/08 and submitted by S2 Director of Nursing as the hospital's current policy for the use of restraints, revealed no documented evidence of a requirement that the RN must document patient behaviors that require the use of a chemical restraint.

In a face-to-face interview on 02/25/10 at 10:25 a.m., S2 Director of Nursing (DON) indicated she had "inherited" the position of DON approximately one year ago, and she was still trying to review and revise policies and procedures. She could offer no explanation for the restraint policy not requiring that documentation of the patient behavior be included prior to the administration of a chemical restraint.

Based on record review and interview, the hospital failed to ensure the medical record included documentation that alternatives or other less restrictive interventions were attempted prior to administering chemical restraints by failing to have attempts at less restrictive interventions documented for 3 of 8 sampled patients (#1, #3, #8). Findings:

Patient #1

Review of Patient #1's medical record revealed she was admitted on 02/14/10 with diagnoses of chronic paranoid schizophrenia, mental retardation, anemia, and seizure disorder. Further review revealed Ativan 2 mg (milligrams), Benadryl 25 mg, and Haldol 5 mg were administered on 02/21/10 at 1345 (1:45 p.m.) and on 02/22/10 at 9:30 a.m.. Further review of Patient #1's medical record revealed no documented evidence of less restrictive interventions that were attempted prior to the administration of a chemical restraint.

In a face-to-face interview on 02/24/10 at 10:40 a.m., S11 RN indicated she would usually administer intramuscular medication to a patient with increased agitation to prevent the patient from injuring himself/herself. She further indicated she couldn't remember what other interventions she had first attempted. S11 RN confirmed Patient #1's medical record had no documented evidence of her (S11's) assessment of Patient #1's behavior as well as the less restrictive interventions she had attempted.

Patient #3

Review of the physician ' s orders for 11/20/09 at 1030 (10:30 a.m.) revealed a telephone order from S20MD for #3 to be administered Ativan 2 mg, Haldol 5 mg and Benadryl 25 mg X 1 IM now. Review of the Observation Flowsheet dated 11/20/09 for #3 revealed that at 0930 (9:30 a.m.), 0945 (9:45 a.m.), and 1000 (10:00 a.m.) #3 was in the Day Room participating in Group activity. Documentation for 1015 (10:15 a.m.) revealed #3 was outside smoking. Documentation for 1030 (10:30 a.m.) revealed #3 was in his room lying/sitting.

Review of the nurses notes documented by S12RN for 11/20/09 at 1030 (10:30 a.m.) read: " Pt. inappropriately touched staff on back. Pt. redirected to room. Ativan 2 mg, Haldol 5 mg, and Benadryl 25 mg IM X1 given per med nurse. "

In an interview on 02/25/10 at 10:50 a.m. S12RN indicated that #3 was seated on his bed in his room when S12RN assessed him about the inappropriate touching of the staff member. S12RN indicated that #3 was separated from staff and that neither the staff nor patient #3 were in immediate danger. S12RN further indicated that #3 would not " guarantee " that he would not inappropriately touch staff or patients so " the medication was administered anyway. "

In an interview on 02/25/10 with S2DON she indicated she would expect the Charge Nurse to make all staff aware of the inappropriate sexual behavior of #3 and have the MHT ' s monitor the patient closely.


Patient #8

Review of Patient #8's medical record revealed the patient was admitted to the hospital on 2/22/2010 with diagnoses that included Chronic Paranoid Schizophrenia and Mental Retardation. Further review revealed the patient was administered Ativan 2 milligrams and Benadryl 25 milligrams Intramuscularly as per a verbal "now" order received on 2/22/2010 at 11:10 a.m. and administered at 11:20 a.m.

Review of the entire medical record revealed no documented evidence describing less restrictive behavior interventions attempted prior to the administration of the "now" dosage of Ativan and Benadryl.

This finding was confirmed by the Director of Nursing (DON S2) on 2/25/2010 at 2:00 p.m. who further indicated there should be documentation in the patient's medical record describing the patient's behavior and therapeutic interventions utilized in response to the patient's behavior prior to the administration of Ativan and Benadryl. The Director of Nursing indicated the Nurse should have used the hospital's "Unscheduled Medication Intervention Form" which would have covered this needed documentation.

Review of the hospital policy titled "Seclusion And/Or Restraint", last revised 02/08 and submitted by S2 Director of Nursing as the hospital's current policy for the use of restraints, revealed, in part, "...Prior to the use of seclusion/restraint, alternative techniques must be attempted which are reflected in the medical record along with the patient's response to each intervention. Alternative techniques include but are not limited to the following interventions: Time out, Verbal de-escalation, Increased observational status, Frequent contact/reassurance, Modification of environment, Attempts at re-direction such as providing activities, distraction...".

Review of the form titled, "Unscheduled Medication Intervention Form" presented by DON S2 as the current form revealed comment sections under the headings of: 1) Description of Patient Complaint or Behaviors, Alternative interventions attempted, Type of medication, Mental Status, Patient's Response, Vital Signs, and (Follow up) Mental Status. Further review revealed in part, "Unscheduled Medication Intervention Form is to be completed every time a patient is ordered to receive a one-time or now medication for the purpose of a medical or behavioral intervention."




25065

Based on record review and interview, the hospital failed to develop and implement a policy for the amount of time in which a patient's response to the administration of a chemical restraint should be assessed by the RN (registered nurse) by having the RN assess a patient's response to a chemical restraint 1 hour and 55 minutes after administration for 1 of 8 sampled patients (#1). Findings:

Review of Patient #1's medical record revealed she was admitted on 02/14/10 with diagnoses of chronic paranoid schizophrenia, mental retardation, anemia, and seizure disorder. Further review revealed Patient #1 received Haldol 5 mg (milligrams), Benadryl 25 mg, and Ativan 2 mg intramuscularly (IM) on 02/20/10 at 2:35 p.m.. Further review revealed RN S12 assessed Patient #1 for the effectiveness of the IM medication at 4:30 p.m., 1 hour and 55 minutes after the medication had been administered.

In a face-to-face interview on 02/25/10 at 9:05 a.m., S12 indicated he usually checked for the effectiveness of medication that he administered 30 minutes to 1 hour after the administration. After reviewing Patient #1's medical record, RN S12 confirmed he didn't assess her for almost 2 hours, and he should have done his assessment within 1 hour of the administration.

In a face-to-face interview on 02/25/10 at 10:25 a.m., S2 Director of Nursing (DON) indicated she had "inherited" the position of DON approximately 1 year ago, and she was still reviewing and revising policies and procedures. She could offer no explanation for the medication administration policy not including the time interval for the reassessment of a patient for medication effectiveness.

Review of the hospital policy titled "Medication Administration Record Completion of", adopted June 2007 and submitted by S2 DON as their current policy for medication administration, revealed, in part, "...If a PRN (as needed) medication is given, the additional documentation MUST be on the back of the MAR (medication administration record); the date, time, medication and dosage, reason, results/response, time noted, and your signature, the appropriate Key Codes are to be utilized for instance in the case of a medication given IM (intramuscular)...".

Review of the "Guidelines For Therapeutic Use of Psychotropic PRN", submitted by S2 DON, revealed, in part, "...Nursing assessments and interventions conducted in conjunction with use of prn must be identified...". Further review revealed no documented evidence of the time interval that was required for the reassessment of the patient's response to the medication that was administered.

Based on record review and interview the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient by failing to:
1) ensure hospital protocol was followed for the administration of Digoxin in 1 of 1 patients surveyed on Digoxin out of a total sample of 8 (# 2); 2) ensure hospital policy was followed regarding abnormal vital signs for 2 of 8 sampled patients (#1, #4); 3) ensure policies and procedures were developed and implemented for the assessment of a patient by the RN after a fall that resulted in a laceration to the scalp for 1 of 1 patient reviewed with a fall from a total of 8 sampled patients (#1); 4) ensure the RN assessed a patient's behavior prior to administering a chemical restraint for 2 of 8 sampled patients (#1, #3); 5) ensure CBG's (capillary blood glucose checks) were done as ordered, that the insulin sliding scale was administered as ordered and that the physician was notified of any missed CBG's, doses of insulin and/or abnormal findings on the CBG's (#3). Findings:

1) Ensure hospital protocol was followed for administration of Digoxin:

Review of patient #2's medical record revealed the patient was admitted to the hospital on 2/15/2010 with diagnoses that included Major Depression, Anorexia, Bulimia, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Seizure Disorder, Hemophilia, and Cerebral Vascular Accident. Further review revealed a physician's order dated 2/15/2010 at 1805 (6:05 p.m.) for "Digoxin 0.25 PO (by mouth) q (every) AM (morning)."

Review of Patient #2's Medication Administration Record revealed the patient was administered Digoxin 0.25 milligrams at 9:00 a.m. on 2/16/2010, 2/17/2010, 2/18/2010, 2/19/2010, 2/20/2010, 2/21/2010, 2/22/2010, and 2/23/2010. Further review revealed documentation revealing the pulse was taken on 2/23/2010 at the time of administration and recorded as a rate of "65". There was no documentation as to how the pulse was taken (radial versus apical). Review of the entire medical record revealed no documented evidence of assessment of Patient #2's pulse prior to the administration of Digoxin at 9:00 a.m. from 2/16/2010 through 2/22/2010 (7 occasions of administering Digoxin without documented monitoring of the patient's pulse prior to administration). This finding was confirmed by the Director of Nursing (S2) on 2/23/2010 at 2:10 p.m. S2 further indicated she would expect nursing staff to take an Apical pulse for one full minute immediately before administering the medication on any patient receiving Digoxin. S2 indicated she would also expect the nursing staff to hold the medication and inform the patient's physician if the patient's heart rate was less than 60.

During a face to face interview on 2/24/2010 at 9:15 a.m., Licensed Practical Nurse (LPN)S4 indicated she was one of the nurses that had administered Digoxin to Patient #2 without documenting the patient's pulse prior to administration. LPN S4 indicated that although she was sure she had taken the apical pulse prior to administration, she had failed to document it and knew that she should not only assess the pulse but should document it in the patient's medical record.

Review of a medication handout presented by the Director of Nursing (S2) as the hospital's protocol for administering Digoxin in the facility revealed in part, "Before giving drug, take apical-radial pulse for 1 full minute. Record and notify prescriber of significant changes -sudden increase or decrease in pulse rate, pulse deficit, irregular beats and particularly regularization of previously irregular rhythm."

2) Ensure hospital policy was followed regarding abnormal vital signs:

Patient #1
Review of Patient #1's medical record revealed she was admitted on 02/14/10 with diagnoses of chronic paranoid schizophrenia, mental retardation, anemia, and seizure disorder.
Review of the "7A-7P Nursing Assessment" for 02/21/10 at 0800 (8:00 a.m.) by RN S11 revealed the blood pressure was 153/72. Further review of the section labeled "Vital Signs" revealed RN S11 had Patient #1's vital signs assessed as a Level 1, which was blood pressure of 120/80 to 90/60. Further review revealed Level 2 included systolic blood pressure greater than 150 or less than 85, diastolic blood pressure less than 59 or greater than 100, and to recheck and/or monitor.
Review of the nurses notes and the "Vital Signs Record" for 02/21/10 revealed no documented evidence the blood pressure was rechecked as per policy until 8 hours later.
In a face-to-face interview on 02/24/10 at 10:40 a.m., S11 RN indicated she couldn't remember if she documented the level of vital signs at the start of the shift or in the evening and could not remember if she repeated the blood pressure reading at the time it was noted to be 153/72.

Review of the policy titled "Physical Status Monitoring", last revised May 2007 and submitted on 02/23/10 by S2 Director of Nursing (DON) as the hospital's current policy for vital sign monitoring, revealed, in part, "...Vital signs, height and weight are obtained on all patients upon admission. ...Level 0 Vital Sign Range falls within the following parameters: B/P (blood pressure) 90/60 - 120/80 ... Level 1 Vital Signs: B/P: Systolic (top number) greater than 150 or less than 85 or Diastolic (bottom number) less than 59 or greater than 100... Level 2 Vital Signs: B/P: Systolic (top number) greater than 160 or less than 80, or Diastolic (bottom number) less than 50 or greater than 110... Level Vital Signs - Re-check, monitor, or report to physician as indicated. Level 2 Vital Signs - Intervention needed which may include but is not limited to the following: Contact the physician immediately especially if patient is symptomatic ... Continue to monitor and obtain order to increase frequency of vital signs".

When S2 DON was asked about the "7A-7P Nursing Assessment" having vital sign levels of 1, 2, and 3 and the "Physical Status Monitoring" policy having levels of 0, 1, and 2, S2 DON presented another policy titled "Physical Status Monitoring" with the same revision date and all information identical to the original policy presented other than the vital sign levels. The second policy S2 DON presented had the vital sign levels as level 1, level 2, and level 3. Further review revealed Level 2 required vital signs to be re-checked, monitored, or reported to the physician as indicated, and Level 3 required intervention of contacting the physician immediately if the patient was symptomatic, administer ordered prn (as needed) or scheduled anti-hypertensive or anti-anxiety medications as appropriate, re-check vital signs and contact the physician, and/or continue to monitor and obtain an order to increase the frequency of vital sign checks.

Patient #4

Review of Patient #4's medical record revealed the patient was admitted to the hospital on 12/28/2009 with diagnoses that included Major Depression Recurrent.
Further review of Patient #4's medical record revealed the following:
12/30 (09): 0500 (5:00 a.m.) B/P (blood pressure) 80/52. (Vital Signs Record)
12/30/2009 (no documented time): B/P 80/52, MD made aware. B/P meds (Lisinopril/HCTZ 20/12.5 milligrams) held (Nursing Assessment).
12/30/09 at 0730 (7:30 a.m.): Hold Lisinopril today only. (check) B/P tid (three times per day) (Doctor's order sheet).
12/30 (09): 1600 (4:00 p.m.) B/P 82/50. (Vital Signs Record)
12/31 (09): 1600 B/P 73/40 (Vital Signs Record)
12/31/2009 (no documented time): B/P 73/40. will notify MD (medical doctor) in a.m. (morning).
12/31/09: 2100 (9:00 p.m./5 hours after patient was documented as having a blood pressure of 73/40) B/P 112/54 (Vital Signs Record)
1/01/10: 0500 B/P 82/55 (Vital Signs Record)
1/01/10: 0900 B/P 82/64 recheck (Vital Signs Record)
1/01/09 (2010): 0915 (9:15 a.m.) D/C (Discontinue) Lisinopril/HCTZ. (Doctor's order sheet).
1/01/10: 1600 B/P 74/44 (Vital Signs Record)
1/01/10: 1700 (5:00 p.m.) B/P 80/58 (Vital Signs Record)
1/01/10: (no documented time) Patient vital signs low. Patient B/P rechecked B/P 114/71. (Nursing Assessment).
Review of pre-printed check list found on the front page of form entitled "nursing assessment" revealed in part, "Level 2. . B/P (blood pressure): systolic. . < (less than) 85. . . Recheck and/or Monitor. Level 3. . . B/P: systolic. . . < (less than) 80. . . Need Intervention, refer to policy."
During a face to face interview on 2/24/2010 at 9:00 a.m., Director of Nursing S2 indicated the nurse that failed to call the patient's physician on 12/31/09 at 1600 (4:00 p.m.) when the patient's blood pressure was documented as 73/40 and the nurse wrote "will notify MD in a.m.". was out of the country doing volunteer work and could not be reached. S2 further indicated the nurse should have followed hospital policy and called the physician. Further she indicated the nurse also should have monitored the patient's vital signs more frequently after discovering the low blood pressure.

Review of the hospital policy titled, "Physical Status Monitoring, last revised May 2007" presented by the hospital as their current policy revealed in part, "Level 1 Vital Signs: B/P: systolic (top number) greater than 150 or less than 85. . . Level 2 Vital Signs: B/P: Systolic greater than 160 ore less than 80. . .Level 1 Vital Signs - Recheck, monitor, or report to physician as indicated. Level 2 Vital signs- Intervention needed which may include but is not limited to the following: Contact the physician immediately especially if patient is symptomatic. . . . Continue to monitor and obtain order to increase frequency of vital signs."

3) Ensure policies and procedures were developed and implemented for assessment of a patient after a fall:

Review of Patient #1's medical record revealed she was admitted on 02/14/10 with diagnoses of chronic paranoid schizophrenia, mental retardation, anemia, and seizure disorder. Further review revealed Patient #1 was found by RN S12 on 02/18/10 at 2:15 p.m. sitting on her bed bleeding from the head. Further review revealed a laceration to the "right posterior side of the head" was noted by RN S12. Patient #1 was transferred to the emergency room on 02/18/10 at 3:45 p.m..

Review of the "Nursing Re-Assessment" of 02/18/10 at 2105 (9:05 p.m.) documented by S15 RN revealed blood pressure 124/64, pulse 66, respirations 18, and temperature 97.9 degrees Fahrenheit. Further review revealed the following was assessed by S15 RN: fall risk; pain; mental status; review of systems; skin assessment; behavior; and physical assessment. The skin assessment revealed a laceration located over the posterior occipital scalp 4 centimeters in length and 0.8 centimeters in width with 3 staples present. Further review of the entire medical record revealed no documented evidence of a reassessment by S15 RN of the vital signs, stapled laceration, level of consciousness, and pain throughout the remainder of the shift which covered a 10 hour span of time.

In a face-to-face interview on 02/25/10 at 11:10 a.m., S15 RN confirmed she was the nurse who received Patient #1 upon her return from the hospital emergency room for treatment of a laceration to the scalp. She indicated she took Patient #1's vital signs and notified Psychiatrist S19 and Physician S20 of Patent #1's return. She further indicated she received no orders for monitoring Patient #1. S15 RN indicated she woke Patient #1 every hour through the night to assess her level of consciousness but confirmed that she did not document the reassessments. She further confirmed that she did not check Patient #1's vital signs after the initial vital signs taken upon return from the emergency room.

In a face-to-face interview on 02/25/10 at 1:25 p.m., S2 DON indicated she would expect the following to be done by the RN after a fall or injury to the head: initiate a re-assessment form; initiate a wound assessment form; assess the wound; incorporate the treatment in the patient's treatment plan; increase the fall precautions; monitor for head trauma which would include assessing the level of consciousness and vital signs at least hourly throughout the night; assess for nausea and vomiting; and place the bed/mattress on the floor. When asked by the surveyor if the hospital had a policy and procedure for assessment and treatment of a patient after a fall or head injury, S2 DON indicated the nurses would be expected to follow the guidelines in Perry and Potter's "Clinical Nursing Skills & (and) Techniques" which was what the hospital policy required them to follow. After S2 DON reviewed the Perry and Potter's "Clinical Nursing Skills & Techniques", she confirmed that she could not find the treatment/assessment for head injury in the book.

Review of the hospital policy titled "Medical Assessment, Intervention/Treatment", adopted March 2004 and submitted by S2 DON as their current policy for intervention and treatment of patients for situations not covered in hospital policy, revealed, in part, "...Nursing staff will refer to Perry and Potter's Clinical Nursing Skills & Techniques for clinical direction not covered in the hospital's Policy and Procedure Manual...".

4) Assess patient's behavior and use of less restrictive measures prior to chemical restraints:

Patient #1

Review of Patient #1's medical record revealed she was admitted on 02/14/10 with diagnoses of chronic paranoid schizophrenia, mental retardation, anemia, and seizure disorder. Further review revealed Ativan 2 mg (milligrams), Benadryl 25 mg, and Haldol 5 mg were administered on 02/21/10 at 1345 (1:45 p.m.) and on 02/22/10 at 9:30 a.m.. Further review of Patient #1's medical record revealed no documented evidence of less restrictive interventions that were attempted prior to the administration of a chemical restraint.

Review of Patient #1's "Unscheduled Medication Intervention Form" for 02/21/10 at 1949 (7:49 p.m.) revealed the entry by RN S15, in part, "...Description of Patient Complaint or Behaviors: Patient anxious and easily agitated. Patient require frequent redirection...". Further review revealed no documented evidence of the behaviors Patient #1 was exhibiting that warranted the use of a chemical restraint. Further review revealed Patient #1 received a chemical restraint on 02/21/10 at 1:15 p.m. administered by RN S11 with no documented evidence of the behaviors Patient #1 was exhibiting that warranted the use of a chemical restraint.

Review of Patient #1's "Unscheduled Medication Intervention Form" for 02/22/10 at 1615 (4:15 p.m.) revealed the entry by RN S11 of the behavior as increased agitation. Further review revealed no documented evidence of the behaviors Patient #1 was exhibiting that warranted the use of a chemical restraint. Further review revealed Patient #1 received a chemical restraint on 02/22/10 at 9:20 a.m. administered by RN S11 with no documented evidence of the behaviors Patient #1 was exhibiting that warranted the use of a chemical restraint.

In a face-to-face interview on 02/24/10 at 10:40 a.m., S11 RN indicated she would usually administer intramuscular medication to a patient with increased agitation to prevent the patient from injuring himself/herself. She further indicated she couldn't remember what behavior Patient #1 was exhibiting that warranted the chemical restraint or what other interventions she had first attempted. S11 RN confirmed Patient #1's medical record had no documented evidence of her (S11's) assessment of Patient #1's behavior on 02/21/10 and 02/22/10 as well as the description of the behaviors on 02/22/10 at 3:15 p.m..

In a face-to-face interview on 02/25/10 at 11:10 a.m., S15 RN indicated she wasn't sure what behavior Patient #1 was exhibiting when she administered the chemical restraint on 02/21/10 at 7:49 p.m.. She confirmed her documentation did not include a description of Patient #1's behaviors at the time she administered the chemical restraint.

Patient #3

Review of the physician ' s orders for 11/20/09 at 1030 (10:30 a.m.) revealed a telephone order from S20MD for #3 to be administered Ativan 2 mg, Haldol 5 mg and Benadryl 25 mg X 1 IM now. Review of the Observation Flowsheet dated 11/20/09 for #3 revealed that at 0930 (9:30 a.m.), 0945 (9:45 a.m.), and 1000 (10:00 a.m.) #3 was in the Day Room participating in Group activity. Documentation for 1015 (10:15 a.m.) revealed #3 was outside smoking. Documentation for 1030 (10:30 a.m.) revealed #3 was in his room lying/sitting.

Review of the nurses notes documented by S12RN for 11/20/09 at 1030 (10:30 a.m.) read: " Pt. inappropriately touched staff on back. Pt. redirected to room. Ativan 2 mg, Haldol 5 mg, and Benadryl 25 mg IM X1 given per med nurse. "

In an interview on 02/25/10 at 10:50 a.m. S12RN indicated that #3 was seated on his bed in his room when S12RN assessed him about the inappropriate touching of the staff member. S12RN indicated that #3 was separated from staff and that neither the staff nor patient #3 were in immediate danger. S12RN further indicated that #3 would not " guarantee " that he would not inappropriately touch staff or patients so " the medication was administered anyway. "

In an interview on 02/25/10 with S2DON she indicated she would expect the Charge Nurse to make all staff aware of the inappropriate sexual behavior of #3 and have the MHT ' s monitor the patient closely.

Patient #8

Review of Patient #8's medical record revealed the patient was admitted to the hospital on 2/22/2010 with diagnoses that included Chronic Paranoid Schizophrenia and Mental Retardation. Further review revealed the patient was administered Ativan 2 milligrams and Benadryl 25 milligrams Intramuscularly as per a verbal "now" order received on 2/22/2010 at 11:10 a.m. and administered at 11:20 a.m.

Review of the entire medical record revealed no documented evidence describing the patient's behavior or behavior interventions prior to the administration of the "now" dosage of Ativan and Benadryl.

This finding was confirmed by the Director of Nursing (DON S2) on 2/25/2010 at 2:00 p.m. who further indicated there should be documentation in the patient's medical record describing the patient's behavior and therapeutic interventions utilized in response to the patient's behavior prior to the administration of Ativan and Benadryl. The Director of Nursing indicated the Nurse should have used the hospital's "Unscheduled Medication Intervention Form" which would have covered this needed documentation.

Review of the form titled, "Unscheduled Medication Intervention Form" presented by DON S2 as the current form revealed comment sections under the headings of: 1) Description of Patient Complaint or Behaviors, Alternative interventions attempted, Type of medication, Mental Status, Patient's Response, Vital Signs, and (Follow up) Mental Status.

Review of the hospital handout titled, "Unscheduled Medication Intervention Form" presented by the hospital as current revealed in part, "Unscheduled Medication Intervention Form is to be completed every time a patient is ordered to receive a one-time or now medication for the purpose of a medical or behavioral intervention."
Review of the hospital policy titled "Seclusion And/Or Restraint", last revised 02/08 and submitted by S2 Director of Nursing as the hospital's current policy for the use of restraints, revealed no documented evidence of a requirement that the RN must document patient behaviors that require the use of a chemical restraint. Further review revealed, in part, "...Prior to the use of seclusion/restraint, alternative techniques must be attempted which are reflected in the medical record along with the patient's response to each intervention. Alternative techniques include but are not limited to the following interventions: Time out, Verbal de-escalation, Increased observational status, Frequent contact/reassurance, Modification of environment, Attempts at re-direction such as providing activities, distraction...".

In a face-to-face interview on 02/25/10 at 10:25 a.m., S2 Director of Nursing (DON) indicated she had "inherited" the position of DON approximately one year ago, and she was still trying to review and revise policies and procedures. She could offer no explanation for the restraint policy not requiring that documentation of the patient behavior be included prior to the administration of a chemical restraint.

5) Ensure CBG's (capillary blood glucose checks) were done as ordered, that the insulin sliding scale was administered as ordered and that the physician was notified of any missed CBG's, doses of insulin and/or abnormal findings on the CBG's (#3).

Patient #3

Review of the physicians orders revealed S21MD added Regular Insulin on a sliding scale to the medication therapy of #3 on 11/20/09 at 2000 (8:00 p.m.) for three days. The admission orders written by S20MD on 11/13/09 contained an order for CBG ' s (capillary blood glucose checks) to be done ac (before meals) and hs (hour of sleep).

Review of the Diabetic Flowsheet for #3 revealed the following after 11/20/09 at 2000 (8:00 p.m.): (the CBG ' s were to be performed at 0630 (6:30 a.m.), 1100 (11:00 a.m.), 1630 (4:30 p.m.) and 2100 (9:00 p.m.))

11/21/09 at 11:00 a.m.: No documentation that the CBG was performed as ordered or notification that the physician was informed of the missed CBG.

11/22/09 at 2000 (8:00 p.m.) CBG documented as 199 (mg/dl - milligrams per deciliter). Review of the Regular Insulin sliding scale ordered for #3 revealed the patient should have been administered 2 units of Regular Insulin SQ (subcutaneously). Review of the MAR revealed no documented evidence of #3 being administered the insulin per the physician ' s order or notification of the physician of the missed dose of insulin.

11/23/09 at 1630 (4:30 p.m.) CBG documented as 187 (mg/dl). Review of the Regular Insulin sliding scale ordered for #3 revealed the patient should have been administered 2 units of Regular Insulin SQ (subcutaneously). Review of the MAR revealed no documented evidence of #3 being administered the insulin per the physician ' s order or notification of the physician of the missed dose of insulin.

11/24/09 at 1630 (4:30 p.m.) CBG documented as 160 (mg/dl). The order for Regular Insulin sliding scale was expired as it was only written for three days. There is no documentation of notification of the physician of the elevated blood glucose of patient #3.

11/24/09 at 2100 (9:00 p.m.) CBG documented as 198 (mg/dl). The order for Regular Insulin sliding scale was expired as it was only written for three days. There is no documentation of notification of the physician of the elevated blood glucose of patient #3.







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26458

Based on record review and interview, the hospital failed to ensure: 1) the nursing staff followed the patient's care plan by failing to ensure a) patient weights were taken as ordered by the physician for 1 of 8 sampled patients (#1) and b) medications were administered as ordered by the physician for 1 of 8 sampled patients (#1) and 2) the patient's care plan was kept current by failing to add changes in a patient's condition (use of chemical restraints, patient injury) to the care plan for 1 of 8 sampled patients (#1). Findings:

1) Nurses followed the plan of care:
a) Weights:
Review of Patient #1's medical record revealed she was admitted on 02/14/10 with diagnoses of chronic paranoid schizophrenia, mental retardation, anemia, and seizure disorder. Review of the "Medical Initial Doctors Order Set" dated 02/14/10 at 0155 (1:55 a.m.) revealed an order to weigh the patient upon admit and weekly.
Review of the "Adult Admission Data Base" completed by the S15, the admitting RN (registered nurse) on 02/14/10 at 1:55 a.m., revealed a notation of "unable to obtain weight". Further review revealed no documented evidence of the reason the weight could not be obtained.
Review of the "Vital Signs Record" for Patient #1 revealed a hand-written note (with no documented evidence of the author of the note) at the top of the page of "unable to obtain weight". Further review revealed no documented evidence of Patient #1's weight from 02/14/10 through 02/23/10.
In a face-to-face interview on 02/25/10 at 11:10 a.m., S15 RN indicated she was unable to obtain a weight for Patient #1 upon admit, because Patient #1 was too sedated. She could offer no explanation for a weight not being taken for 10 days when it was ordered to be taken upon admit and weekly thereafter.
Review of the hospital policy titled "Standards of Care - Nursing", last revised June 2007 and submitted by S2 DON (Director of Nursing) as their current policy regarding patient weights, revealed, in part, "...Weight will be assessed upon admission then weekly thereafter or as needed...".

b) Medications as ordered by the physician:
Review of Patient #1's medical record revealed she was admitted on 02/14/10 with diagnoses of chronic paranoid schizophrenia, mental retardation, anemia, and seizure disorder.
Review of Patient #1's MAR (medication administration record) revealed Klonopin 1 mg (milligram), Depakote ER 500 mg, and Geodon 40 mg were held on 02/14/10 at 9:00 a.m., because the patient was sedated. Further review revealed no documented evidence the physician was notified of the medications being held.
Review of Patient #1's "7A-7P Nursing Assessment" dated 02/14/10 at 7:45 a.m. of "Documentation Related To Risk" revealed, in part, "Sedated, can't stand, mumbled, incoherent speech ... AM meds held".
In a telephone interview on 02/24/10 at 2:40 p.m., S17 RN indicated she had instructed the medication nurse to hold Patient #1's medications, because Patient #1 was so sedated. When asked by the surveyor if she had notified the physician, S17 RN indicated she informed the medical doctor by placing paperwork in his box, and an entry was made on the paper census report of the medication that was held. She confirmed that she did not call either the psychiatrist or the medical doctor to notify them that Patient #1's medications had to be held due to being sedated. She further indicated there's so many things happening, and she used her nursing judgement to hold the medications; "I'm not going to round everybody up", which she said meant calling the physicians.
In a face-to-face interview on 02/24/10 at 2:50 p.m., S2 DON confirmed there was no documented evidence in Patient #1's medical record that a physician had been notified that the morning medications had been held on 02/14/10. When asked by the surveyor if the hospital had a policy for holding medications, S2 DON indicated held medications was addressed in the medication error policy.
Review of the hospital policy titled "Medication Error/Occurrence Reporting", last revised September 2009, revealed, in part, "...Medication Error/Occurrence - Any error/occurrence that occurs in the dispensing or administration of medications in which the patient receives the wrong medication, wrong dose, wrong route, or wrong frequency...". Further review revealed no documented evidence of medications held being addressed in the policy.

2) Patient's care plan kept current:
Chemical restraints:
Review of Patient #1's medical record revealed she was admitted on 02/14/10 with diagnoses of chronic paranoid schizophrenia, mental retardation, anemia, and seizure disorder.
Further review revealed Patient # 1 received a chemical restraint of Ativan 2 mg, Haldol 5 mg, and Benadryl 5 mg intramuscularly on 02/20/10 at 10:50 a.m. and 2:35 p.m., 02/21/10 at 1:45 p.m. and 7:55 p.m., 02/22/10 at 9:30 a.m. and 4:15 p.m., and on 02/23/10 at 12:55 p.m..
Review of Patient #1's "Nursing Plan of Care" for safety revealed the statement "frequent use of unscheduled medications to manage agitation/anxiety and/or psychotic episodes" had no documented evidence that it was checked by the nurse. Further review revealed no documented evidence that Patient #1's care plan had been updated to include the use of chemical restraints and the less restrictive measures that had been attempted without success prior to the use of the chemical restraint.
In a face-to-face interview on 02/24/10 at 2:00 p.m., S3 RN indicated he updates patients' treatment plans on Monday and Thursday, and the charge nurse was supposed to update the plans with any changes that occur after/before those days. He further indicated that unscheduled medications, such as chemical restraints, were not part of a patient's treatment plan; only scheduled medications were included a patient's treatment plan. He further indicated the use of prn (as needed) medications was put on a sheet that was reviewed by Psychiatrist S19.
Review of the hospital policy titled "Seclusion And/Or Restraint", last revised 02/08 and submitted by S2 Director of Nursing as the hospital's current policy for the use of restraints, revealed, in part, "...The use of restraint or seclusion must be: In accordance with a written modification to the patient's plan of care for each episode of seclusion or restraint...".

Patient injury:
Review of Patient #1's medical record revealed she was admitted on 02/14/10 with diagnoses of chronic paranoid schizophrenia, mental retardation, anemia, and seizure disorder. Further review revealed Patient #1 was found by RN S12 on 02/18/10 at 2:15 p.m. sitting on her bed bleeding from the head. Further review revealed a laceration to the "right posterior side of the head" was noted by RN S12. Patient #1 was transferred to the emergency room on 02/18/10 at 3:45 p.m. and returned to the original hospital on 02/18/10 at 9:05 p.m..
Review of the "Multidisciplinary Administration of the Master Treatment Plan" and the "Medical Nursing Plan of Care" revealed an entry on 02/18/10, with no documented evidence of the time the entry was written, by S3 RN of, in part, "...No falls noted...".
In a face-to-face interview on 02/24/10 at 2:00 p.m., S3 RN indicated his documentation was usually done in the morning, but he confirmed there was no documented evidence of the time that he wrote the entry on 02/18/10. He further confirmed there was no documented evidence of Patient #1's fall in his care plan and that a review of the fall precautions had taken place to ensure that all measures were taken to avoid a future fall.
In a face-to-face interview on 02/25/10 at 1:25 p.m., S2 DON indicated the RN should incorporate the treatment for a patient after an injury into the patient's plan of care.

Review of the hospital policy titled "Standards of Care - Nursing", revised June 2007 and submitted by S2 DON as one of their current policies on care plans, revealed, in part, "...Treatment Plan Reviews/Updates The registered nurse as part of the multi-disciplinary treatment team participates in staffing to review Treatment Plans at least every 5 days. Treatment plans are reviewed to determine status of goals and any revisions needed...".

Based on record review and interview, the hospital failed to ensure non-employee contract registered nurses (RN) were supervised by a RN who is a regular employee of the hospital by having a non-employee contract RN as the only RN on duty (S17) on 1 of 14 days reviewed for staffing. Findings:

Review of the staffing pattern for 02/14/10 presented by S2 Director of Nursing (DON) revealed there was 1 RN on each shift.

Review of the "Contract Nurse Agreement" signed by S17 RN on 02/07/10 and Administrator S1 revealed, in part, "...The contract nurse shall provide nursing services consistent with established company policy and procedure. ... It is understood this agreement is a contract between independent parties and shall not be construed to create any relationship other than that of independent contractors. Each party will act and perform as an independent contractor with respect to the other party...".

During a telephone conference on 02/24/10 at 2:40 p.m., S17 RN indicated she was employed for about 2 years as an agency nurse, but recently she had begun to work at the hospital as a prn (as needed) contract nurse.

In a face-to-face interview on 02/24/10 at 2:50 p.m., S2 DON indicated she thought a RN who was contracted by the hospital could work in a charge nurse position. She confirmed S17 RN was the only RN working on 02/14/10 on the 7A-7P shift.