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Based on document review and interview, nursing services failed to notify a change in the patient's condition to a provider in 1 out 13 patient (Patient 4) medical record reviewed; failed to document medications administered in 1 out of 10 patient (Patient 1) medical records reviewed; failed to obtain discharge orders in 2 out of 10 patient (Patients 3 and 5) medical records reviewed; and failed to notify providers of patient weight loss in 3 out of 10 patient (Patients 4, 11, and 13).

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

Based on document review and interview, the facility failed to obtain consents for treatment in 1 out of 13 (Patient 13) patient medical records reviewed.

Findings include:

1. Facility policy titled, Emergency Detention Order (EDO), PolicyStat ID 12197144, last approved 08/2024, indicated under PROCEDURE: Emergency Detainment Order (EDO), After the 14 days have expired the Report Following Emergency Detainment must be completed and signed by the attending physician. This document will be faxed back to the Superior Court Probate Division. Within this report, the attending physician must complete one of three paragraphs outlining the current status of the patient (paragraph 3, 4, or 5). Paragraph 3 states that the attending physician still believes that the patient still requires attention and treatment and the patient is not willing to voluntarily sign themselves into the facility. If the attending physician completes this paragraph the temporary commitment process will begin which will include a court hearing. Paragraph 4 states that a patient no longer meets criteria for involuntary commitment and has been discharged from the hospital. Paragraph 5 states the patient has voluntarily signed themselves into a hospital for treatment.

2. Review of Patient 13's medical record indicated the patient was admitted on 12/03/2024 with a 14-day Emergency Detention Order which ended on 12/17/2024. Medical record lacked documentation of a temporary commitment or patient informed consents for voluntary admission. Patient was discharged on 01/01/2025.

3. Interview with A1 (Chief Executive Officer) on 01/162/2025 at approximately 3:48 p.m. confirmed the facility failed to obtain a temporary commitment or obtain consents from Patient 13 for voluntary admission.

Based on document review and interview, nursing services failed to document medications administered in 1 out of 10 patient (Patient 1) medical records reviewed; failed to obtain discharge orders in 2 out of 10 patient (Patients 3 and 5) medical records reviewed; and failed to notify providers of patient weight loss in 3 out of 10 patient (Patients 4, 11, and 13).

Findings include:

1. Facility policy titled, General Medication Administration, PolicyStat ID 12386373, last approved 09/2022, indicated under Process, Each dose of medication administered must be properly recorded in the patient's medical record. "PRN" medications administered will be documented on the patient's MAR along with the times of administration and monitoring parameters if ordered (i.e., patient's blood sugar, blood pressure). Medications administered as PRN require follow up of patients' response to medication within one (1) hour after administration. The nurse shall document the date and time administered, medication name, dose, rationale, patients' response to medication (effective or ineffective) and follow up date and time.

2. Facility policy titled, Patient Discharge - AMA, PolicyStat ID: 13916075, last approved 06/2023, indicated under POLICY: Patients will be discharged only upon orders of the attending licensed practitioner.

3. Facility policy titled, Vital Signs and Weight, PolicyStat ID 12386461, last approved 09/2022, indicated under PROCEDURE: Nurses will notify the provider of findings outside patient's normal range.

4. Review of Patient 1's medical record indicated on 11/15/2024, the provider ordered Ativan 1 milligram (mg) tablet every 6 hours as needed (PRN) by mouth (PO) for anxiety; on 11/20/2024, medication administration record (MAR) lacked documentation that the patient was administered Ativan 1 mg tablet.

5. Review of medDISPENSE Station report indicated that on 11/20/2024 at 8:33 a.m. Ativan 1 mg tablet was pulled from the station for patient 1.

6. Review of Patient 3's medical record indicated patient was admitted on 12/1/2024. On 12/3/2024, the patient's power of attorney (POA) requested the patient be discharged; medical record indicated the provider granted patient to be discharged against medical advice (AMA). Medical record lacked documentation of provider order to discharge patient AMA and patient was discharged at approximately 1:00 p.m. on 12/03/2024.

7. Review of Patient 4's medical record indicated the following:
a. Upon admission, patient 4's home medication reconciliation indicated the patient took Zenpep three times a day by mouth; P2 (Nurse Practitioner) signed to hold medication during hospital stay on 12/06/2024 at 1:00 p.m. On 12/09/2024, medical record indicated the patient requested Zenpep; patient began to experience diarrhea. On 12/12/2024 nursing note indicated the patient's family reached out to indicate the patient needed their medication and had sent the medication to the facility for the patient. On 12/13/2024 nursing note indicated the patient complained of abdominal pain and bloody stools; patient was transferred to an acute care facility for further evaluation. Medical record lacked documentation of nurse follow up or provider notification regarding patient's pain and request for medication.
b. Patient's admission weight was 110 pounds (lbs.). On 12/11/2024, patient's weight was 104.4 lbs., a loss of 5.6 lbs. in 5 days. Medical record lacked documentation that provider was notified of patient's weight loss during hospitalization.

8. Review of Patient 5's medical record indicated patient was admitted on 12/11/2024. On 12/13/2024, medical record indicated that the patient requested to be discharged AMA and AMA paperwork was initiated. Provider discharge summary indicated patient was psychiatrically at baseline. Medical record lacked documentation of provider order to discharge the patient; nursing note indicated patient was discharged AMA at approximately 2:45 p.m. on 12/13/2024.

9. Review of Patient 11's medical record indicated the patient's admission weight on 12/17/2024 was 163 lbs., on 12/18/2024 patient's weight was 162.9 lbs., and on 12/25/2024 the patient's weight was 151.6 lbs.; a loss of 11.3 lbs. in 8 hospitalization days. Medical record lacked documentation that provider was notified of patient's weight loss during hospitalization.

10. Review of Patient 12's medical record indicated the following:
a. Provider order dated 01/01/2025 to transfer patient to an acute care facility for further evaluation.
b. Medical record lacked documentation of nurse-to-nurse report in nursing notes and lacked fully complete documentation on the Patient Transfer/Transport Order form per facility policy on 01/01/2025.

11. Review of Patient 13's medical record indicated patient's admission weight was 197.9 lbs. On 12/11/2024 patient's weight was 191.9 lbs. On 12/18/2024 patient's weight was 190.0 lbs. On 12/25/2024 patient's weight was 186.0 lbs. On 01/01/2025 patient's weight was 178.1 lbs., for a total loss of 19.8 lbs. in 29 hospitalization days. Medical record lacked documentation that provider was notified of patient's weight loss during hospitalization.

12. Interview with A2 (Director of Risk/Quality) on 01/08/2024 at approximately 3:50 p.m. confirmed the pharmacy report indicated Ativan was pulled from the medication dispensing system for patient 1 and patient 1 medical record lacked documentation of administration. A2 confirmed patient 3 and patient 5's medical records lacked documentation of provider order for discharge and that nursing should receive order before patient is discharged.

13. Interview with A1 (Chief Executive Officer) and A2 on 01/16/2025 at approximately 3:48 p.m. confirmed the following:
a. Patient 4 did not receive medication, and patient had requested multiple times for need of medication. Patient 4 lost 5.6 lbs. during hospitalization per MD documentation.
b. Patient 13 lost 19.8 lbs. during hospitalization per MR documentation. Patient 13 was admitted on an Emergency Detention Order (EDO) which expired on 12/17/2024 and the facility failed to obtain a temporary commitment or a voluntary admission.

Based on document review and interview, the facility failed to ensure that the patient's discharge planning included prescriptive medications at the time of discharge in 1 out of 13 (Patient 5) medical records reviewed.

Findings include:

1. Facility policy titled, Evaluation Treatment and Discharge General Procedure, PolicyStat ID 12197169, last approved 08/2022, indicated under POLICY, The patient care protocol shall include, but not limited to: vi. Continuity of Care/Discharge planning, c. Medication regimen.

2. Review of Patient 5's medical record indicated the following:
a. Patient's discharge medication list included Remeron 7.5 milligrams by mouth at bedtime daily
b. Patient was discharged to home on 12/13/2024.
c. Review of the patient's prescription summary indicated the patient's prescription for Remeron was not ordered until 12/15/2024 to the patient's preferred pharmacy.

3. Interview with P1 (Clinical Nurse Specialist) on 01/08/2024 at approximately 2:10 p.m. confirmed Patient 5 was discharged on 12/13/2024 and the patient's prescriptions were not ordered from the patient's preferred pharmacy until 12/15/2024.