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Based on documents review and interviews, the facility failed to:

A. follow their own policy to provide written documentation of patient rights to 4 (#2, 3, 4, 12) of 12 patients reviewed.

Refer to Tag A 0117

B. establish a prompt process and resolution for patient grievances that was approved by the Governing Body. The Governing Body did not ensure the effectiveness of a grievance process.

Refer to Tag A 0118, A119

C. provide documentation of patient/family involvement and development of treatment plans for 3(#2, #3, #4) of 12 patients reviewed.

Refer to Tag A 0130

D. ensure 5 (Patient #12, #2, #3, #4, and #1) of 12 patients were allowed to give informed consent for their care.

Refer to Tag A 0131

E. provide ongoing nursing assessment to 5 (#1, #2, #4, #6, and #12) of 12 patient (#1-#12) reviewed. The nursing staff failed to provide nursing assessment each shift per facility policy, fall risk assessments, skin assessments, assessment of the effectiveness of psychotropic medication, and assessment of patient injuries. Nursing staff also failed to protect patients #2 and #12 from injury related to falls due to lack of nursing assessment and nursing intervention.

Refer to Tag A 0144

Based on documents review, interviews and observations, the facility failed to:

A. ensure Registered Nurse (RN) coverage for 8 hours during the night which caused the Director of Nurses to provide RN coverage leaving the facility with no guidance for the nursing staff during normal business hours for 6/9 days reviewed. The facility also failed to provide adequate Registered Nurse (RN) coverage and ensure a Registered Nurse was physically present on the patient care unit at all times.

Refer to tag A0386

B. provide ongoing nursing assessment to 5 (#1, #2, #4, #6, and #12) of 12 patient (#1-#12) reviewed. The nursing staff failed to provide nursing assessment each shift per facility policy, fall risk assessments, skin assessments, assessment of the effectiveness of psychotropic medication, and assessment of patient injuries. Nursing staff also failed to protect patients #2 and #12 from injury related to falls due to lack of nursing assessment and nursing intervention.

Refer to tag A0395

C. The facility failed to create and maintain a current care plan for 3 (patient #12, #1, and #2) of 12 patients (#1-#12) reviewed.

Refer to tag A 0396

Based on charts and policy/procedures review, and interviews, the facility failed to provide patient rights in writing to 4 (#2, 3, 4, and 12) out of 12 (#1- #12) charts reviewed.

Review of policy "Patient Rights NO: RTS-01" dated 9/30/2011 states, "Every client shall receive a written copy of the Patient Bill of Rights. The patient will sign the 'Acknowledgement of Rights' form stating they reviewed and understand their rights. The patient rights form will be available in Spanish, as well as English."

Review of patient charts #2,#3, #4, and #12 revealed that there were no forms for Acknowledgement of Rights or documentation where the patient was given and understands their rights.

An interview on 10/16/2013, with staff #3 revealed that she was not aware that the consents for patient #12 were blank. Staff #3 stated that the admission forms should have been signed and an admission book given to the patients upon arrival.

Based on review of charts, policy and procedures, and interviews the Governing Body (GB) failed to ensure a prompt process and resolution for patient grievances.

Review of the policy "Patient Grievance/Resolution No: RTS-04" revealed that the facility shall give each patient/family members a copy of the procedure with 24 hours of admission and explain it in a clear and simple term that the client understands. Administration will document all patient grievances and appropriate resolution on the Patient Concern Response Form.

Interview with staff #2 confirmed there was no active complaint log or grievance log. No patient Concern Response Forms were provided.

Based on review of charts, policy and procedures, and interviews, the Governing Body (GB) failed to ensure a process and prompt resolution for patient grievances.

Review of the policy "Patient Grievance/Resolution No: RTS-04" revealed that the facility shall give each patient/family members a copy of the procedure within 24 hours of admission and explain it in a clear and simple term that the client understands. Administration will document all patient grievances and appropriate resolution on the Patient Concern Response Form.

Review of the GB minutes for 2011-2013 revealed there was no documentation of current or resolved grievances.

Interview with staff #2 confirmed there was no active complaint log or grievance log. Staff #2 confirmed that there had been some patient complaints but they had been resolved. No documentation was provided. Staff #2 stated, "that the facility did not have a grievance committee or gievance employee in place."

On 10/14/2013 at 10:00 AM pt #12's sister was interviewed by phone. She indicated she was not satisfied that her concerns(complaints) with the facility had been resolved.

The facility failed to provide documentation of patient/family involvement and development of treatment plans for 3 (#2, #3, #4) out of 12 (#1- #12) patients.

Review of treatment plan for patient #2 reveals a treatment plan for 9/27/2013. The back page states, "patient participated but having acting delusions." There is no patient, family or clinician signature. Review of treatment plan for 9/30/2013 reveals the team meeting was held on 10/2/2013. No patient or family involvement. No further treatment plan meeting or documentation found.

Review of treatment plans for patient #4 reveals no patient or family participation on the initial plan 8/10/2013, 8/12/2013, or 8/20/2013.

Review of treatment plans for patient #3 reveals the patient nor the family were involved in the treatment plan. Treatment plan meeting on 1/27/2013 in patient signature line, "Patient too confused to sign does not understand where he is."

Based on documents review and interview, the facility failed to provide documentation of consents or signed consents for 5 (Patient #12, #2, #3, #4, and #1) of 12 (#1-#12) patients reviewed.

On 10/16/2013, in the conference room, the medical record (MR) for Patient (pt) #12 was reviewed and revealed the following: Pt #12 signed herself in as a voluntary admission for inpatient psychiatric treatment. Review of the multiple consents found in the MR for pt #12 revealed not one consent was signed. The following blank consents forms were found in the MR for pt #12:

Consent for admission and treatment, was blank with no patient signature.

Consent to photograph, was blank with no patient signature.

Consent to participate in tele-medicine consultation,was blank with no patient signature.

The single consent for Psychotropic Medications, was not completed by a nurse and no patient signature was on the form. The 8/22/2013, medication list included the following psychotropic medications: Lunesta for sleep, Exelon for depression, Trazadone for Psychosis, Phenobarbital for Seizures, Ativan for anxiety were ordered routinely and Geodon for psychosis, Respirdol for psychosis, and Haldol for psychosis were ordered as PRN (as needed) medications.

On 10/17/2013 at 1:00 PM in the conference room, an interview with the Administrator, staff #2, confirmed "the consents were not getting signed".



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Review of patient charts #2,#3,#4 revealed there were no consents for treatment, no consents for patient rights, assignment of benefits, consent for photograph, or privacy notice. Consents were not obtained for all psychotropic medications administered at the facility.

Review of patient chart #1 revealed admission consent forms incomplete.

1.) "Assignment of Benefits" was signed by the patient and a RN. Signature of the RN is illegible. There is no patient identification on the page and no responsible party signature.

2.) "Contract for safety" was signed by patient and RN but no patient identification, date, or plan for patient if she feels suicidal or homicidal. The page is blank except for signatures.

3.) "Authorization for DNR (Do Not Resuscitate) Consent" was blank except for patient and RN signature. The consent did not address her wishes for or if she had a DNR.

4.) "Documentation of Good Faith Efforts to Obtain Signature of receipt of Notice of Privacy Practices" had the patient's name at the top of the form. The rest of the form was blank with no signature of the employee or patient.

5.) "Therapeutic Medication Contract" The benefits for continuing my medications section was blank. At the bottom of the form where it says, "copy given to patient" was blank.

Review of patient #3's chart revealed no psychoactive medication consents were provided or signed by patient/family for Namenda or Celexa.

Review of patient #2's chart revealed no psychoactive medication consents were provided or signed by patient/family for Haldol, Ativan, Zyprexa, or Benadryl.

Review of patient #4's chart revealed no psychoactive medication consents were provided or signed by patient/family for Risperadol.

Review of patient #1's chart revealed no psychoactive medication consents were provided or signed by patient/family for Klonopin, Pristiq, and Trazodone.

An interview with staff #22 on 10/17/2013, reported that the charts were completed charts. Interview with staff #2 confirmed the psychactive medications consents were not complete or filled out on the charts. Staff #2 confirmed that the patients charts did not have signed consents for treatment.

Based on document review and interview the facility failed to provide ongoing nursing assessment to 5 (#1, #2, #4, #6, and #12) of 12 patient (#1-#12) reviewed.

The nursing staff failed to perform nursing assessment each shift per facility policy, fall risk assessments, skin assessments, assessment of the effectiveness of psychotropic medication, and assessment of patient injuries. Nursing staff also failed to protect patients #2 and #12 from injury related to falls due to lack of nursing assessment and nursing intervention.

This deficient practice had the likelihood to affect all patients admitted to the facility.

On 10/17/2013, in the conference room, review of the MR for pt #12 revealed the following:

Pt #12 was a 91 year old female who was admitted for inpatient psychiatric treatment on 8/22/2013. She was admitted with medical diagnosis that included hypertension, hyperthyroidism, and insomnia. Home medications were continued. This information was found on the Medical Clearance Admission form for the inpatient psychiatric facility. Identified in the MR, was a previously dictated outpatient office visit that indicated Pt #12 also had a diagnosis of dementia with Alzheimer's disease. Pt #12 demonstrated agitation, depression and paranoid behavior. She was co-managed by a neurologist, who had placed her on Phenobarbital for suspected seizures. The physician dictated in his note the family felt the Phenobarbital had increased Pt #12's confusion and interrupted her sleep. On admission the Phenobarbital was still ordered for Pt #12.

Review of the initial nursing evaluation found in the MR, pt #12 was mobile in a wheeled chair and also used a rolling walker at times for ambulation. The MR for pt #12 also revealed the facility Medical Director had ordered the following admission medications: Restoril 15-30 mg (Milligrams) at H.S. (Nightly) for PRN (As needed) sleep, Ativan 1-2 mg by mouth (PO) OR IM (Intra muscular) every (Q) 4-6 hours PRN anxiety, Haldol 5-10 mg po or IM 4-6 hrs (Hours) PRN psychosis, and Geodon 10 mg IM q 4 hrs PRN severe agitation or psychosis not to exceed 40 mg in 24 hours. The supporting diagnosis was listed as dementia, paranoia and agitation.

Further review of the MR also revealed the Current Medications as listed on the medication reconciliation form, were not limited to but included the following medications: Lunesta 3 mg po QHS for sleep, Exelon 3 mg po QAM (every morning) the treatment of Dementia, Trazadone 50 mg po TID (three times a day) antidepressant, Ativan 0.5 mg BID (twice a day) for anti-anxiety and Phenobarbital for seizures.

Further review revealed Pt #12 first fall was reported as follows: "Pt #12 reported ( to the nurse) she fell while returning from the bathroom on 8/22/2013 at 0952 hours. Pt #12 second fall was documented on 8/25/2013 at 1845 hours (military time) hours by the Mental Health Tech (MHT) as follows: pt #12 "...got up to walk around and the pt fell on her right side."

Review of the MR identified, there was no nursing documentation for assessment of patient #12 after the fall of 8/25/2013, no documentation of notification of the family or the physician for the fall which was documented by the MHT on 8/25/2013.

On 10/15/2013 in the conference room, the Fall Risk Assessment was reviewed. Pt #12 MR revealed documentation of the Fall Risk Assessment begins on 8/28/2013, 4 days after admission and the day after the second recorded fall pt #12 suffered.

The initial score for the Fall Risk Assessment on 8/28/2013, was 22. The instructions for the Fall Risk Assessment indicates that the physician should be notified of a score higher than 10. There was no nursing documentation that either the medical physician or the psychiatric physician was notified of pt #12's high score of 22. It was also noted that the score of Pt #2's Fall Risk Assessment did not change from 22 even when she stopped ambulating. In fact, the initial score reflected that Pt #12 who was admitted on 8/22/2013 as an assisted ambulatory patient who used both a wheel chair and a rolling walker and was later, on 8/28/2013, assessed as "chair bound requiring restraints and assistance with elimination."

On 8/11/2013, a telephone interview was conducted at 10:00 AM with Pt #12's sister. During the telephone interview the patient's sister indicated that she had requested an x-ray of her sister (pt #12's) hip after the second fall. She indicated she had been told her sister took a "Pretty hard fall". She indicated she had observed pt #12's decreased mobility, decreased appetite and increased pain. She reported no x-ray was done. She reported a soft tissue sonogram was done in place of an x-ray. She was told by a nurse it was negative for a hip fracture. Per the family, "patient #12 was admitted with a fractured right hip."Review of the admission record from the acute hospital, pt #12 was admitted with a fracture with dislocation of her right hip confirmed by radiology report.

On 10/17/2013, in the conference room, an interview with the Medical Director, staff #1, was conducted. During the interview staff #1 confirmed that he was not notified of the Pt #12's fall on 8/25/2013, but felt the physician over seeing medical issues had been notified. He was aware that a soft tissue sonogram was completed. It was not until after he had a face to face conference with the patient's family that he ordered the x-ray and transferred pt #12 to the acute hospital, at the families request, the same day.

On 10/17/2013, in the conference room, the Braden scale for Predicting Pressure Sore Risk was found in Pt #12 MR and was reviewed. On admission, 8/22/2013, the total score for risk was measured at 16. A score of 16 reflects a mild risk of pressure breakdown. Notably, the Braden Score did not change during the entire admission from 8/22/2013 - 9/10/2013.

Review of documentation by MHT beginning 8/23/2013 reflected that pt #12 spent approximately 10 or 12 hours every day seated in a geri-chair.

Further review of MR documentation beginning 8/23/2013, revealed the dietician's note reflected an admission weight (wt) of 167.5, 115% above her ideal body wt (IBW). Pt #12 began refusing meals after her fall on 8/25/2013. She refused to eat supper that night. Documentation reflected the following: Pt #12 refused 40 of 58 meals, ate less that 25% of 9 meals, ate 50% of 3 meals, ate 75% of 4 meals and ate 100% of 2 and received boost or ensure 4 times. No other wt. was recorded after the admission wt. of 167.5 pounds. Pt #12 was transferred on 9/10/2013 to an acute hospital. Upon admission to the acute hospital Pt #12's diagnosis was fractured right trochanter, and visible pressure damage to bilateral heels and sacrum.

Nursing documentation reflected no awareness of, or intervention for Pt #12 lack of nutritional intake. There was no documentation notifying the family, dietician or physician for the lack of nutritional intake that the MHT documented for Pt #12. Pt #12 spent approximately 10 or 12 hours each day reclined in a geri-chair, after the fall documented on 8/25/2013. There was no nursing skin assessment documented after the admission skin assessment of 8/22/2013. The admission skin assessment, nursing staff documentation for pt #12 consisted of "Pt has strong pulses, warm temperature to skin". Documentation reflected pt #12 was admitted with a hematoma to the right inner thigh but otherwise her skin was intact. No skin break down was recorded throughout the patient's stay.

Review of policy and procedure on Fall Assessments and Precautions NO: AS-09 states,"All patients will be assessed and identified for the potential of being at risk for falls, upon admissions, every 7 days thereafter, and/or after any fall. The RN utilizing the Fall Risk Assessment score sheet will assess and determine the risk of all patients with regard to falls and implement fall precautions if so indicated. A patient put on fall precautions will be observed every 15 minutes, with special attention paid to possible behaviors that may indicate an increased danger of falls."

Review of policy and procedure on Assessment of Pain Management NO:AS-16 states, "For patients that can communicate, nurses will assess pain characteristics, which will be assessed UPON ADMIT, every shift, weekly, and PRN for active pain levels. 1.) Character, 2.) Location, 3.) Type/quality, 4.) Duration, 5.) Onset, 6.) Frequency, 7.) Precipitating/relieving factors, 8.) Exacerbating alleviating factors, 9.) Intensity, using 0-10 Pain Scale (verbal or non-verbal) or faces Pain Scale for adults with limited mental capacity. Reassess pain level every shift if pain is an active problem and patient is receiving continuous treatment."

Review of patient #2's chart revealed that she was admitted on 9/27/2013 with a diagnosis of Hallucinations, Asthma, Hypertension, and ?Chronic Obstructive Pulmonary Disease. Patient #2 was assessed by an RN on 9/27/2013, for initial admission evaluation. Staff #22 documented that the patient was anxious, having hallucinations, and paranoid ideas. Patient #2 denied suicidal or homicidal ideation's. Patient#2 had a normal gait. Patient #2 was able to answer questions appropriately. Under fall assessment staff #22 reported that the patient #2 received 1 point for altered mental status and 1 point for impaired vision. No explanation for point system or if patient was low risk or high risk for falls. Nurse documented that the patient had "abnormality noted" to the skin to right hand due to a skin disorder. No other problems were documented.

No nursing assessment was documented for 9/28/13. On 9/29/2013, there was no nursing documentationm until 9:27 PM. Staff #25 failed to document a head to to assessment, fall assessment, or vital signs. Staff #25 reported that the patient had a diminished food and fluid intake. Patient #2 was "coaxed" to eat and drink but no intake or output was documented.

There was no RN assessment documented from 9/29/13 at 9:27 PM until 9/30/13 at 2:14 PM (17 hours). On 9/30/2013 at 2:14 PM staff #15 documented, "While MHTs were assisting patient from the bathroom, notice a 0.5 x 0.5 skin tear to left forearm. Cleansed and non adhesive dressing with Keri." There was no documentation that MD or family was notified. No head to toe assessment,vital signs, incident report, or orders to dress the wound was documented.

On 9/30/2013 at 9:56 PM, Staff #15 documented "vital signs-blood pressure (B/P)126/69, heart rate (HR) 76, respirations (R) 18 per minute, Oxygen saturation 95% and a temperature of 98.5. Weight is 109 pounds." Staff #15 also documented, "PRNs are used about once or twice a week and are described as effective." There was no documentation of medications given and no medication sheets are in the chart. Staff #15 reported that the patient #2 was a 7 on the fall risk assessment and high risk for falls.

Documentation on 10/01/2013 at 1:10 AM, revealed that patient #2 was given Tylenol 500 mg po at 9:45 PM on 9/30/13. No pain assessment for headache or follow up pain assessment for med effectiveness was documented. Further documentation on 10/01/2013 revealed Patient #2 sleeping only three hours. Patient #2 was confused and hallucinating. Vital signs - B/P-142/68, HR-93, R-18, Temperature 98.5. There was no documentation that B/P and HR were elevated compared to several hours earlier.

On 10/3/2013 at 1:30 AM, staff #26 documented that Patient #2 fell at 12:20 AM in her room and hit her head. Patient #2 was going to the bathroom. Staff #18(Physician) was notified at 12:23 AM and gave orders to transfer patient #2 to the Emergency Room (ER). Family was notified. Staff #26 documented, "Patient #2's vital signs were stable but she was hallucinating." No nursing assessment or vital signs were documented. Staff #26 documented, "A prn was used today and was described as effective." No documentation noted on what was given, time given, why it was given and there were no medication sheets in the medical record to review. Medication sheets were requested a number of times but were never made available. Staff # 26 further documented "DON (Director of Nurses) was called at 12:43 to be notified of the patient sent to the Emergency Room due to fall no answer message center full." Staff #26 documented that hospital sent patient #2 back to the facility "around 3 am" with a negative CT scan. There was no nursing assessment documented on return from the Emergency Room.

Documentation on 10/4/2013, revealed Patient #2 was trying to go to the bathroom and fell again at 2:40 AM. Patient #2 was found on the floor with a raised area to the back of her head that was tender to the touch. There was no documentation of call to physician, administration, or family. Nurse documented, "patient #2 is rambling and hallucinating." There was no documentation that patient had fall assessment or head to toe assessment conducted or interventions to prevent further falls or injuries. At 7:00 AM, nurse documentation revealed that the patient had fallen again. No assessment or vital signs were done at time of incident. Staff #18 gave orders to send to hospital for Cat Scan of the head at 8:18 AM. There was no documentation when and how the patient was. Nursing documentation revealed patient returned at 12:15 PM with a diagnosis of Urinary Tract Infection (UTI). She had an order to start Cipro 500 mg (antibiotic). Patient #2 received her first dose at hospital. Documentation revealed on 10/4/2013, at 8:22 PM patient #2 had increased heart rate of 109. There was no documentation that HR was reassessed or physician was notified. Patient #2 was reported to have a temperature of 101.2 at 10:30 PM. Tylenol 500 mg was given. Nurse documented physician was notified but did not specify which one. Nurse documented, "Orders given to alternate Tylenol 500 mg with Ibuprofen 400 mg every 3-4 hours as needed." This order was not documented in the physician orders of the medical record.

On 10/5/2013, at 1:30 AM, staff #15 documented that patient#2 was lying in the bed pointing and interacting as if someone was in the room. Nurse asked patient who she was waving at? Patient #2 stated, "God." There was no assessment of elevated vital signs and no documentation of effectiveness of prn medication given. At 8:15 AM, patient #2's B/P is 140/90 but no other vital signs were documented. At 3:45 PM, nursing documentation revealed that patient #2 keeps trying to throw herself out of the wheel chair and refusing to eat. Nurse documented, "patient #2 having jerky movements reported to the RN." Physician was notified. The patient #2 was put on a mat in her room to prevent injury. Patient #2 was sweating. Staff sitting with her to prevent injury. Nurse documented at 6:50 PM, patient was administered "Ativan 2 mg IM, Haldol 10 mg IM, and Benadryl 50 mg IM per physician's orders." Patient continues to stay on the floor. At 9:06 PM, nurse documented that staff #17 was making rounds. Nurse documented, "Upon arrival, patient was observed in room lying on mat mumbling to herself. The patient was able to answer few questions nurse asked but most of what patient is saying is not understood. Pt is sweating and scratching at her arms and chest area. Noted spasms to upper body. Staff # 17 gave orders to transfer pt to ER. Patient wastransferred at 9:25 PM. No documentation of family notification, nurse to nurse report, or administration notified.


On 10/9/2013, at 1:45 PM, staff #15 documented, "Patient is at WHMC stepdown, Ativan IV q8hr, still lethargic, can carry coherent conversation when awake. Getting Vanc and Miram IV. Patient has been out of facility for 72 hours." No discharge orders documented. No Physician Discharge Summary dictated in chart.


Review of patient #1 chart revealed an admission to the facility on 9/11/2013, on a Emergency Detention Warrant but was admitted as a voluntary patient. Patient #1 was admitted with a diagnosis of Schizoaffective disorder, Bipolar Type. Patient #1 had been involved in the outpatient program of the facility.

On the Initial Psychiatric Evaluation dated 9/12/2013, the presenting problems for which the patient is seeking admission states, "Suicide attempt with phone cord stated 'I just want to get it over', drug seeking behavior, suicidal. Prior diagnosis of suicidal Ideation." Upon admission patient #1 signed a Contract for Safety on 9/11/2013. The form had a line for patient name and date that was blank. A statement that reads, "I will not intentionally or unintentionally harm myself or others. If the anxiety, depression, anger or fears return, I will commit to do the following: the three lines under this statement are blank. The next statement on the form states,"If the thought to harm myself or others returns, I will contact the following people:" The three lines below this statement is blank. Only patient #1's signature and a signature from a RN that is not legible is on the form.

On 10/15/2013, during an interview, Staff #2 was asked if there had been any sentinel events or available logs for incidents concerning any attempted suicides . Staff #2 denied any logs or sentinel events. An interview with staff #2 on 10/17/2013, revealed that patient #1 had tried to commit suicide by hanging on 9/28/2013. Staff #2 provided a typed timeline dated 9/30/2013. Staff #2 stated that it was written due to a personnel issue with two social workers.

The report reads,"9/28/2013 received call from the charge nurse that approximately 8:30 PM Patient #1 attempted suicide in her bedroom.

Scenario: As reported by charge nurse: Nurses were discussing group topic 'How do you feel about yourself ' with various patients in the dayroom area. Patient #1 overheard a conversation between the charge nurse and another patient. The charge nurse stated that Patient #1 began to make statements that she did not like herself and that she hated herself. Patient #1 went to her room and the charge nurse followed her.

The charge nurse and the patient began talking about the statements that Patient #1 made earlier. Patient #1 again repeated the same statements of 'hating' herself and 'not liking anything' about herself. The charge nurse advised the patient that it was medicine time and informed the patient that she was going to speak to the medicine nurse to give her medications first. The patient verbalized understanding and the nurse exited the room.

The charge nurse spoke to the medicine nurse to give patient #1 her medication first and then re-entered patient #1's room to follow up on a plan. When the charge nurse re-entered the room, the patient was facing the window in a "praying position." The charge nurse kneeled down in front of patient #1 and noticed a torn pillow case looped around her neck and tied to the lower part of the foot of the bed. The nurse called for help and 2 MHTs and the LVN came in the room to assist. The charge nurse removed the loop and the instrument from patient #1 neck. Patient #1 began to cry and began telling the charge nurse why she "hated" herself. She made allegations of incest and rape as a young child and regrets that family members never came to help her. Patient #1 also stated that she believed that her mother was aware of the incest. The charge nurse reported that family and staff #1 were notified. An order of 1:1 was initiated and followed through at that time. Patient #1 was assessed, denied pain, no apparent bruising or skin tears to neck area. An apparent skin tear and bruising was noted to the wrists areas. No bleeding reported however."

Review of nurses notes for patient #1 dated 9/28/2013, at 12:08 AM revealed staff #8 documented that the patient had been in the day room and became loud and upset. The patient was crying and stated, "Everyone thinks its easy to like yourself but it's not." Patient #1 began to walk back to her room and commented she needed time to herself. The nurse followed. Staff #8 asked patient #1 why she was crying? The patient kept saying she needed time to herself.

Staff #8 documented, "At approximately I stepped out to tell the LVN to get patient #1 her night medications first. When I went back to the room, patient #1 was on her knees, looking as if she was praying. When I investigated further patient #1 had ripped the hem of a pillow case and wrapped it around her neck and on the bed post in an attempt to kill herself.

Staff #8 reported that she notified staff # 1 and staff #15 of the incident. The patients linen was removed from the room. Patient #1 had tried to cut her wrist with a pen earlier in the day but it was to dull. The patient's room was searched and items removed that may cause injury. Staff #8 reported that she informed the MHT to stay with the patient.

No further documentation from nursing for 9/28/2013. No documentation that skin lacerations to wrist were addressed and treated. There was no documentation that the patients family was notified. The chart had no documented medication sheets in it. No documentation of what medications were given.

Review of nursing notes dated 10/2/2013, at 9:57 PM, staff #25 documented, "Mental health technician was assigned to patient #1 at the time. She was reminded that she must visualize the patient at all times for her safety." No other nursing documentation found on 1:1 observation up to patient #1's discharge date of 10/9/2013.

A telephone physician order was documented in the physician orders on 9/29/2013, at 9:00 PM, by staff #8. The order read, 1:1 observation read back and verified per staff #1. As of 10/17/2013, this order was never signed by a physician. Physician progress note dated 9/30/2013, at 5:31 AM, revealed patient was experiencing confusion and anxiety but no mention of attempted suicide, skin lacerations to wrist, or safety precautions or measures documented.

Review of the Mental Health Technician (MHT) notes revealed there was no documentation on 9/28/2013. Review of the MHT notes from 9/29/2013 - 10/9/2013 have no documentation that the patient is on a 1:1 or that any safety precautions have been in place. MHT is documenting every 15 minute checks.

An interview was conducted with staff #1 and #2 on 10/17/2013 concerning the suicide attempt of patient #1 confirmed that the patient had tried to hang herself with a sheet on 9/28/2013.


On 10/15/2013, at 2:00 PM, the medical record (MR) for patient #6 revealed that she was an 86 year old female admitted on 7/16/2013 with Alzheimer's disease, depression and anxiety. She was given a "1X (time) dose of Hadol 5 mg (milligrams) with Benadryl 25 mg for severe anxiety. The physician's order contained no criteria for sever anxiety. No nursing assessment of behavior of severe anxiety was identified in the nurses notes or reflected in the MHT (Mental Health Tech) notes. No follow-up nursing observations, documenting effectiveness of the PRN medication was identified for this pt. No medication administration record was identified for this patient.

On 10/16/2013, in the conference room the MR for Pt #4 was reviewed and revealed that pt #4 was an 84 year old female patient admitted on 8/10/2013, and discharged on 8/23/2013. She was ambulatory under her own power. However, the nursing staff failed to complete the Fall Risk assessment on days 8/11,12,18,19 and 23. The Anxiety scale was not completed on admission. Documentation reflected pt #4 refused. No other attempts were documented to complete anxiety scale. The Suicide/homicide assessment was not completed and the depression assessment was not completed on admission. Documentation did not reflect another attempt to complete these assessments. There was no nursing entries found in the MR for pt #4. No medication administration record was identified in the MR for pt #4.



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Based on interviews, observations, and documents review, the facility failed to provide adequate Registered Nurse (RN) coverage and ensure a Registered Nurse was physically present on the patient care unit at all times. The facility failed to ensure Registered Nurse (RN) coverage for 8 hours during the night which caused the Director of Nurses to provide RN coverage leaving the facility with no guidance for the nursing staff during normal business hours for 6/9 days reviewed.

On 10/15/2013, at 9:30 AM, during the entrance conference, the Administrator confirmed that the facility have a Director of Nurses (DON) but she had worked the night shift the preceding night and was unable to work her normally scheduled hours. The Administrator further confirmed that there was no current Assistant Director of Nurses. The Administrator confirmed that the facility had been without a night nurse for about a week and the shift had been covered by the DON. The Administrator further reported the UR was the other RN in the building to support or relieve the RN on the locked unit with the patients.

Further interview with the Administrator revealed that the facility was unable to hire qualified RN staff to work and there was very little relief staff to help on dayswhen the census were high. The Administrator went on to explain new patient admission assessments were conducted by the RN charge nurse (RN supervisor in the patient care unit) or the UR nurse in the examination room provided in the administration (Outside of the secure unit) area prior to placement behind a locked entrance. This would leave the LVN (Licensed Vocational Nurse) with no nursing support in a locked psychiatric unit.

On 10/16/2013, in the afternoon, the RN who worked in the secure unit was observed outside the unit visiting with administrative staff. This left 1 LVN in the unit with 12 patients. The LVN would have to phone for assistance if a patient situation required RN skills. This was confirmed by the Administrator.

On 10/16/2013, the DON provided the 30 day staffing schedule and one RN was scheduled for each shift, with the DON working the unit to provide RN coverage for the night shift. She also confirmed that there were times when the RN charge nurse would leave the patient care unit to conduct a new patient assessment leaving the unit with one LVN.

Based on documents review and interviews, the facility failed to provide ongoing nursing assessment to 5 (#1, #2, #4, #6, and #12) of 12 patient (#1-#12) reviewed.

The nursing staff failed to provide nursing assessment each shift per facility policy, fall risk assessments, skin assessments, assessment of the effectiveness of psychotropic medication, and assessment of patient injuries.

Nursing staff also failed to protect patients #2 and #12 from injury related to falls due to lack of nursing assessment and nursing intervention.

This deficient practice had the likelihood to effect all patients admitted to the facility.

On 10/17/2013, in the conference room, review of the MR for pt #12 revealed the following:

Pt #12 was a 91 year old female who was admitted for inpatient psychiatric treatment on 8/22/2013. She was admitted with medical diagnosis that included hypertension, hyperthyroidism, and insomnia. Home medications were continued. This information was found on the Medical Clearance Admission form for the inpatient psychiatric facility. A dictated outpatient office visit found in the MR indicated that Pt #12 also had a diagnosis of dementia with Alzheimer's disease. Pt #12 demonstrated agitation, depression and paranoid behavior. She was co-managed by a neurologist, who had placed her on Phenobarbital for suspected seizures. The physician dictated in his note that the family felt the Phenobarbital had increased Pt #12's confusion and interrupted her sleep. On admission the Phenobarbital was still ordered for Pt #12.

Review of the initial nursing evaluation found in the MR revealed that pt #12 was mobile in a wheeled chair and also used a rolling walker at times for ambulation.

The MR for pt #12 also revealed that the facility Medical Director had ordered the following medications on admission: Restoril 15-30 mg (Milligrams) at H.S. (Nightly) for PRN (As needed) sleep, Ativan 1-2 mg by mouth (PO) OR IM (Intra muscular) every (Q) 4-6 hours PRN anxiety, Haldol 5-10 mg po or IM 4-6 hrs (Hours) PRN psychosis, and Geodon 10 mg IM q 4 hrs PRN severe agitation or psychosis not to exceed 40 mg in 24 hours. The supporting diagnosis was listed as dementia, paranoia and agitation.

The MR also revealed that the Current Medications as listed on the medication reconciliation form, included the following medications: Lunesta 3 mg po QHS for sleep, Exelon 3 mg po QAM (every morning) the treatment of Dementia, Trazadone 50 mg po TID (three times a day) antidepressant, Ativan 0.5 mg BID (twice a day) for anti-anxiety and Phenobarbital for seizures.

Further review of the MR revealed that Pt #12 first fall was reported as follows: "Pt #12 reported ( to the nurse) that she fell while returning from the bathroom on 8/22/2013 at 0952 hours. Pt #12's second fall was documented on 8/25/2013 at 1845 hours (military time) hours by the Mental Health Tech (MHT) as follows: pt #12 "...got up to walk around and the pt fell on her right side."

There was no nursing documentation for assessment of patient #12 after the fall of 8/25/2013, no documentation of notification of the family or the physician for the fall which was documented by the MHT on 8/25/2013.

On 10/15/2013, in the conference room, the Fall Risk Assessment was reviewed. Pt #12 MR revealed documentation of the Fall Risk Assessment began on 8/28/2013, 4 days after admission and the day after the second recorded fall of pt #12. The initial score for the Fall Risk Assessment on 8/28/2013, was 22.

The instructions for the Fall Risk Assessment indicated that the physician should be notified of a score higher than 10. There was no nursing documentation that either the medical physician or the psychiatric physician was notified of pt #12's high score of 22. It was also noted that the score of Pt #12's Fall Risk Assessment did not change from 22 even when she stopped ambulating. In fact, the initial score reflected that Pt #12 who was admitted on 8/22/2013, as an assisted ambulatory patient who used both a wheel chair and a rolling walker and was later, on 8/28/2013, assessed as "chair bound requiring restraints and assistance with elimination."

On 8/11/2013, a telephone interview was conducted at 10:00 AM with Pt #12's sister. During the telephone interview the patient's sister indicated she had requested an x-ray of her sister (pt #12's) hip after the second fall. She indicated she had been told her sister took a "Pretty hard fall". She indicated she had observed pt #12's decrease in mobility, decrease in appetite and increase in pain. She reported no x-ray was done. She reported a soft tissue sonogram was done in place of an x-ray. She was told by a nurse it was negative for a hip fracture. Per the family, "patient #12 was admitted with a fractured right hip." Review of the admission record from the acute hospital, pt #12 was admitted with a fracture with dislocation of her right hip confirmed by radiology report.

On 10/17/2013, in the conference room, an interview with the Medical Director, staff #1, was conducted. During the interview staff #1 confirmed that he was not notified of the Pt #12's fall, on 8/25/2013, but felt that the Physician overseeing medical issues at the time was notified. He was aware that a soft tissue sonogram was completed. It was not until after he had a face to face conference with the patient's family, that he ordered the x-ray and transferred pt #12 to the acute hospital the same day, at the families request.

On 10/17/2013, in the conference room, the Braden scale for Predicting Pressure Sore Risk was found in Pt #12 MR and was reviewed. On admission, 8/22/2013, the total score for risk was measured at 16. A score of 16 correlated to a mild risk of skin breakdown. Notably the Braden Score did not change during the entire admission from 8/22/2013-9/10/2013. Review of documentation by MHT from 8/23/2013 reflected that pt #12 spent approximately 10 or 12 hours every day seated in a geri-chair.

Review of the dietician's note showed an admission weight (wt) of 167.5 115% above her ideal body wt (IBW). Pt #12 began refusing meals after her fall on 8/25/2013. She refused to eat supper that night.

Documentation reflected the following: Pt #12 Refused 40 of 58 meals, ate less that 25% of 9 meals, ate 50% of 3 meals, ate 75% of 4 meals and ate 100% of 2 and received boost or ensure 4 times. No other wt. was recorded after the admission wt. of 167.5 pounds. Pt #12 was transferred on 9/10/2013 to an acute hospital. Upon admission to the acute hospital Pt #12's diagnosis was fractured right trochanter, and visible pressure damage to bilateral heels and sacrum.

Nursing documentation showed no awareness of or intervention for Pt #12 lack of nutritional intake. There was no documentation notifying the family, dietician or physician for the lack of nutritional intake that the MHT documented for Pt #12.

Pt #12 spent approximately 10 or 12 hours each day reclined in a geri-chair, after the fall documented on 8/25/2013. There was no nursing skin assessment documented after the admission skin assessment of 8/22/2013. The admission skin assessment, nursing staff documentation for pt #12 consisted of "Pt has strong pulses, warm temperature to skin". Documentation revealed that pt #12 was admitted with a hematoma to the right inner thigh but otherwise her skin was intact. No skin break down was recorded throughout the patient's stay.

Review of policy and procedure on Fall Assessments and Precautions NO: AS-09 states,"All patients will be assessed and identified for the potential of being at risk for falls, upon admissions, every 7 days thereafter, and/or after any fall. The RN utilizing the Fall Risk Assessment score sheet will assess and determine the risk of all patients with regard to falls and implement fall precautions if so indicated. A patient put on fall precautions will be observed every 15 minutes, with special attention paid to possible behaviors that may indicate an increased danger of falls."

Review of policy and procedure oon Assessment of Pain Management NO:AS-16 states, "For patients that can communicate, nurses will assess pain characteristics, which will be assessed UPON ADMIT, every shift, weekly, and PRN for active pain levels. 1.) Character, 2.) Location, 3.) Type/quality, 4.) Duration, 5.) Onset, 6.) Frequency, 7.) Precipitating/relieving factors, 8.) Exacerbating alleviating factors, 9.) Intensity, using 0-10 Pain Scale (verbal or non-verbal) or faces Pain Scale for adults with limited mental capacity. Reassess pain level every shift if pain is an active problem and patient is receiving continuous treatment."

Review of patient #2's chart revealed that she was admitted on 9/27/2013 with a diagnosis of Hallucinations, Asthma, Hypertension, and ?Chronic Obstructive Pulmonary Disease.
Patient #2 was assessed by an RN on 9/27/2013, for initial admission evaluation. Staff #22 documented that the patient was anxious, having hallucinations, and paranoid ideas. Patient #2 denied suicidal or homicidal ideation's. Patient#2 had a normal gait. Patient #2 was able to answer questions appropriately. Under fall assessment, staff #22 reported that the patient #2 received 1 point for altered mental status and 1 point for impaired vision. No explanation for point system or if patient was low risk or high risk for falls. Nurse documented that the patient had "abnormality noted" to the skin to right hand due to a skin disorder. No other problems were documented.

No nursing assessment was documented for 9/28/13.

On 9/29/2013, there was no nursing documentationm until 9:27 PM. Staff #25 failed to document a head to toe assessment, fall assessment, or vital signs. Staff #25 reported that the patient had a diminished food and fluid intake. Patient #2 was "coaxed" to eat and drink but no intake or output was documented.

There was no RN assessment documented from 9/29/13 at 9:27 PM until 9/30/13 at 2:14 PM (17 hours).

On 9/30/2013, at 2:14 PM staff #15 documented, "While MHTs were assisting patient from the bathroom, notice a 0.5 x 0.5 skin tear to left forearm. Cleansed and non adhesive dressing with Keri." There was no documentation that MD or family was notified. No head to toe assessment,vital signs, incident report, or orders to dress the wound was documented.

On 9/30/2013, at 9:56 PM, Staff #15 documented "vital signs-blood pressure (B/P)126/69, heart rate (HR) 76, respirations (R) 18 per minute, Oxygen saturation 95% and a temperature of 98.5. Weight is 109 pounds." Staff #15 also documented, "PRNs are used about once or twice a week and are described as effective." There was no documentation of medications given and no medication sheets are in the chart. Staff #15 reported that the patient #2 was a 7 on the fall risk assessment and high risk for falls.

Documentation on 10/01/2013, at 1:10 AM, revealed that patient #2 was given Tylenol 500 mg orally at 9:45 PM on 9/30/13. No pain assessment for headache or follow up pain assessment for medication effectiveness was documented.

Further documentation on 10/01/2013, revealed Patient #2 sleeping only three hours. Patient #2 was confused and hallucinating. Vital signs - B/P-142/68, HR-93, R-18, Temperature 98.5. There was no documentation that B/P and HR were elevated compared to several hours earlier.

On 10/3/2013, at 1:30 AM, staff #26 documented that Patient #2 fell at 12:20 AM in her room and hit her head. Patient #2 was going to the bathroom. Staff #18(Physician) was notified at 12:23 AM and gave orders to transfer patient #2 to the Emergency Room (ER). Family was notified. Staff #26 documented, "Patient #2's vital signs were stable but she was hallucinating." No nursing assessment or vital signs were documented. Staff #26 documented, "A prn was used today and was described as effective." No documentation noted on what was given, time given, why it was given and there were no medication sheets in the medical record to review. Medication sheets were requested a number of times but were never made available.

Staff # 26 further documented "DON (Director of Nurses) was called at 12:43 to be notified of the patient sent to the Emergency Room due to fall no answer message center full." Staff #26 documented that hospital sent patient #2 back to the facility "around 3 am" with a negative CT scan. There was no nursing assessment documented on return from the Emergency Room.

Documentation on 10/4/2013, revealed that Patient #2 was trying to go to the bathroom and fell again at 2:40 AM. Patient #2 was found on the floor with a raised area to the back of her head that was tender to the touch. There was no documentation of call to physician, administration, or family. Nurse documented, "patient #2 is rambling and hallucinating."

There was no documentation that patient had fall assessment or head to toe assessment conducted or interventions to prevent further falls or injuries. At 7:00 AM nurse documentation revealed that the patient had fallen again. No assessment or vital signs were done at time of incident.

Staff #18 gave orders to send to hospital for CT scan of the head at 8:18 AM. There was no documentation when and how the patient was. Nursing documentation revealed patient returned at 12:15 PM with a diagnosis of Urinary Tract Infection (UTI). She had an order to start Cipro 500 mg (antibiotic). Patient #2 received her first dose at hospital.

Documentation revealed on 10/4/2013, at 8:22 PM, that patient #2 had increased heart rate of 109. There was no documentation that HR was reassessed or physician was notified. Patient #2 was reported to have a temperature of 101.2 at 10:30 PM. Tylenol 500 mg was given. Nurse documented physician was notified but did not specify which one. Nurse documented, "Orders given to alternate Tylenol 500 mg with Ibuprofen 400 mg every 3-4 hours as needed." This order was not documented in the physician orders of the medical record.

On 10/5/2013, at 1:30 AM, staff #15 documented that patient#2 was lying in the bed pointing and interacting as if someone was in the room. Nurse asked patient who she was waving at? Patient #2 stated, "God."


There was no assessment of elevated vital signs and no documentation of effectiveness of prn medication given. At 8:15 AM, patient #2's B/P is 140/90 but no other vital signs were documented. At 3:45 PM, nursing documentation revealed that patient #2 keeps trying to throw herself out of the wheel chair and refusing to eat. Nurse documented, "patient #2 having jerky movements reported to the RN." Physician was notified. The patient #2 was put on a mat in her room to prevent injury. Patient #2 is sweating. Staff sitting with her to prevent injury.


Nurse documented at 6:50 PM, patient was administered "Ativan 2 mg IM, Haldol 10 mg IM, and Benadryl 50 mg IM per physician's orders". Patient continues to stay on the floor. At 9:06 PM nurse documented that staff #17 was making rounds. Nurse documented, "Upon arrival, patient was observed in room lying on mat mumbling to herself. The patient was able to answer few questions nurse asked but most of what patient is saying is not understood. Pt is sweating and scratching at her arms and chest area. Noted spasms to upper body. Staff # 17 gave orders to transfer pt to ER. Patient wastransferred at 9:25 PM. No documentation of family notification, nurse to nurse report, or administration notified.


On 10/9/2013, at 1:45, staff #15 documented "Patient is at WHMC stepdown, Ativan IV q 8 hr, still lethargic, can carry coherent conversation when awake. Getting Vanc and Miram IV. Patient has been out of facility for 72 hours." No discharge orders documented. No Physician Discharge Summary dictated in chart.


Review of patient #1 chart revealed an admission to the facility on 9/11/2013 on a Emergency Detention Warrant but was admitted as a voluntary patient. Patient #1 was admitted with a diagnosis of Schizoaffective disorder, Bipolar Type. Patient #1 had been involved in the outpatient program of the facility.

On the Initial Psychiatric Evaluation dated 9/12/2013, the presenting problems for which the patient is seeking admission states, "Suicide attempt with phone cord stated 'I just want to get it over', drug seeking behavior, suicidal. Prior diagnosis of suicidal Ideation."


Upon admission patient #1 signed a Contract for Safety on 9/11/2013. The form had a line for patient name and date that was blank. A statement that reads, "I will not intentionally or unintentionally harm myself or others. If the anxiety, depression, anger or fears return, I will commit to do the following: the three lines under this statement are blank. The next statement on the form states," If the thought to harm myself or others returns, I will contact the following people:" The three lines below this statement is blank. Only patient #1's signature and a signature from a RN that is not legible is on the form.

On 10/15/2013, during an interview, Staff #2 was asked if there had been any sentinel events or available logs for incidents concerning any attempted suicides . Staff #2 denied any logs or sentinel events.


An interview with staff #2 on 10/17/2013, revealed that patient #1 had tried to commit suicide by hanging on 9/28/2013. Staff #2 provided a typed timeline dated 9/30/2013. Staff #2 stated that it was written due to a personnel issue with two social workers.

The report reads,"9/28/2013, received call from the charge nurse that approximately 8:30 PM Patient #1 attempted suicide in her bedroom. Scenario: As reported by charge nurse: Nurses were discussing group topic 'How do you feel about yourself ' with various patients in the dayroom area. Patient #1 overheard a conversation between the charge nurse and another patient. The charge nurse stated that Patient #1 began to make statements that she did not like herself and that she hated herself. Patient #1 went to her room and the charge nurse followed her. The charge nurse and the patient began talking about the statements that Patient #1 made earlier. Patient #1 again repeated the same statements of 'hating' herself and 'not liking anything' about herself. The charge nurse advised the patient that it was medicine time and informed the patient that she was going to speak to the medicine nurse to give her medications first. The patient verbalized understanding and the nurse exited the room.


The charge nurse spoke to the medicine nurse to give patient #1 her medication first and then re-entered patient #1's room to follow up on a plan. When the charge nurse re-entered the room, the patient was facing the window in a "praying position." The charge nurse kneeled down in front of patient #1 and noticed a torn pillow case looped around her neck and tied to the lower part of the foot of the bed. The nurse called for help and 2 MHTs and the LVN came in the room to assist. The charge nurse removed the loop and the instrument from patient #1 neck. Patient #1 began to cry and began telling the charge nurse why she "hated" herself. She made allegations of incest and rape as a young child and regrets that family members never came to help her. Patient #1 also stated that she believed that her mother was aware of the incest. The charge nurse reported that family and staff #1 were notified. An order of 1:1 was initiated and followed through at that time. Patient #1 was assessed, denied pain, no apparent bruising or skin tears to neck area. An apparent skin tear and bruising was noted to the wrists areas. No bleeding reported however."

Review of nurses notes for patient #1 dated 9/28/2013 at 12:08 AM revealed staff #8 documented that the patient had been in the day room and became loud and upset.


The patient was crying and stated, "Everyone thinks its easy to like yourself but it's not." Patient #1 began to walk back to her room and commented she needed time to herself. The nurse followed. Staff #8 asked patient #1 why she was crying? The patient kept saying she needed time to herself. Staff #8 documented, "At approximately I stepped out to tell the LVN to get patient #1 her night medications first. When I went back to the room , patient #1 was on her knees, looking as if she was praying. When I investigated further patient #1 had ripped the hem of a pillow case and wrapped it around her neck and on the bed post in an attempt to kill herself. Staff #8 reported that she notified staff # 1 and staff #15 of the incident. The patients linen was removed from the room. Patient #1 had tried to cut her wrist with a pen earlier in the day but it was to dull. The patient's room was searched and items removed that may cause injury. Staff #8 reported that she informed the MHT to stay with the patient. No further documentation from nursing for 9/28/2013. No documentation that skin lacerations to wrist were addressed and treated. There was no documentation that the patients family was notified. The chart had no documented medication sheets in it. No documentation of what medications were given.

Review of nusing notes dated 10/2/2013 at 9:57 PM staff #25 documented, "Mental health technician was assigned to patient #1 at the time. She was reminded that she must visualize the patient at all times for her safety." No other nursing documentation found on 1:1 observation up to patient #1's discharge date of 10/9/2013.

A telephone physician's order was documented in the physician orders on 9/29/2013, at 9:00 PM by staff #8. The order read, 1:1 observation read back and verified per staff #1. As of 10/17/2013 this order was never signed by a physician. Physician progress note dated 9/30/2013, at 5:31 AM revealed patient was experiencing confusion and anxiety but no mention of attempted suicide, skin lacerations to wrist, or safety precautions or measures documented.

Review of the Mental Health Technician (MHT) notes revealed there was no documentation on 9/28/2013. Review of the MHT notes from 9/29/2013 to 10/9/2013, have no documentation that the patient is on a 1:1 or that any safety precautions have been in place. MHT is documenting every 15 minute checks.

An interview was conducted with staff #1 and #2 on 10/17/2013, concerning the suicide attempt of patient #1 confirmed that the patient had tried to hang herself with a sheet on 9/28/2013.


On 10/15/2013, at 2:00 PM the medical record (MR) for patient #6 revealed that she was an 86 year old female admitted on 7/16/2013, with Alzheimer's disease, depression and anxiety. She was given a "1X (time) dose of Hadol 5 mg (milligrams) with Benadryl 25 mg for severe anxiety. The physician's order contained no criteria for sever anxiety. No nursing assessment of behavior of severe anxiety was identified in the nurses notes or reflected in the MHT (Mental Health Tech) notes. No follow-up nursing observations, documenting effectiveness of the PRN medication was identified for this pt. No medication administration record was identified for this patient.

On 10/16/2013, in the conference room, the MR for Pt #4 was reviewed and revealed that pt #4 was an 84 year old female patient admitted on 8/10/2013, and discharged on 8/23/2013. She was ambulatory under her own power. However, the nursing staff failed to complete the Fall Risk assessment on days 8/11,12,18,19 and 23. The Anxiety scale was not completed on admission. Documentation reflected pt #4 refused. No other attempts were documented to complete anxiety scale. The Suicide/homicide assessment was not completed and the depression assessment was not completed on admission. Documentation did not reflect another attempt to complete these assessments.


There was no nursing entries found in the MR for pt #4. No medication administration record was identified in the MR for pt #4.to the family, dietician or physician for the lack of nutritional intake the MHT documented for Pt #12. Pt #12 spent 10-12 hours each day reclined in a geri-chair after the fall documented on 8/25/2013. There was no nursing skin assessment documented after the admission skin assessment where nursing staff documented that pt #12 had strong pulses, warm temperature to skin. Pt #12 was admitted with a hematoma to the R inner thigh but otherwise her skin was intact. No skin break down was recorded.

The lack of nursing documentation reflected a lack of nursing assessment and evaluation. The lack of nursing documentation reflected a lack of nursing care and a lack of nursing supervision.

Based on documents review and interviews, the facility failed to create and maintain a current care plan for 3 (patient #12, #1, and #2) of 12 patients (#1-#12)reviewed.

On 8/17/2013, at 3:00 PM in the conference room, the MR of patient #12 (Pt) was reviewed and revealed the following:

Pt #12 was a 91 year old female admitted on 8/22/2013. Documentation showed that pt #12 refused 40 of 58 meals offered. Review of Mental Health Tech (MHT) documentation showed that liquid supplement was offered and accepted 4 times for the 40 meals refused. Further review of the MR also revealed that the registered Dietician (RD) consulted on pt #12 8/23/2013 and documented pt #12 weighed (wt) 167.5 pounds and was 115% above her Ideal Body Weight . Pt #12 was not weighed again. Pt #12 was not consulted again by the RD. She was discharge on 9/10/2013.

Further review of the MR revealed that pt #12 was admitted mobile and ambulatory via a wheel chair and rolling walker. Pt #12 reported an unwitnessed fall to the nurse on 8/22/2013, and a witnessed fall on 8/25/2013. After 8/25/2013, MHT documentation reflected Pt #12 was no longer ambulatory and spent 10-12 hours each day seated in a geri-chair or her wheel chair.

On 9/10/2013, pt #12 was discharged to an acute care hospital for a "higher level of care" and she was diagnosed with a fractured right hip and bilateral pressure ulcer on her heels and sacrum. Review of the MR for pt #12 did not reflect skin assessment after the initial admission skin assessment which documented normal skin for a 91 year old female on 8/22/2013.

Further review of Pt #12 initial treatment plan created on 8/23/2013, revealed the following:

Problem #1 Cognitive impairment, problem #2 Anger management, and Problem #3 Diabetes. The facility never identified nutritional needs (refusal to eat and secondary wt. loss), mobility needs or skin breakdown in the care planning process.

Further review of the care planning process revealed the care planning documentation did not include the family who reported via phone interview they had requested medical assessment and an x-ray of pt #12 hip.


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Review of the treatment plans for patient (#1) revealed that the patient had made a suicide attempt on 9/28/2013. This attempt and implementation of a safety plan was not documented in the treatment plan.

Review of treatment plans for patient #2 revealed that patient #2 had two serious falls requiring Emergency Room transfer and a Cat Scan. No safety assessments, no documentation on falls, or prevention plans were addressed on the treatment plan.

Based on observation, document review and interview the facility failed to maintain proper records for discontinued drugs (Too numerous to count) and drugs awaiting destruction (Too numerous to count).

On 10/15/2013, during a tour of the building at 10:00 AM the following was observed:

The tour was conducted with the Environment of Care Director (EOC). This employee was asked to open the door to the Director of Nurses office (DON), who was not present for the tour. Upon opening the door, multiple large boxes filled with drugs that had been dispensed in blister packs, too numerous to count, was observed. When asked what they were doing stored in the DON office on the floor, the EOC Director reported he thought they were being prepared for destruction. Found among the boxes of drugs in blister packs, was a plastic container with a lid. This container was full, holding multiple colors and shapes of loose medications, not in blister packs. The container would hold approximately 1 gallon of content. During this observation the Administrator approached the EOC Director and told him he should not open that door without a nurse present. However, it had already been observed that the DON's office had containers of discontinued patient drugs. The DON office opened into the common patient day area.

The tour of the building was stopped and a phone interview was conducted with the consulting pharmacist, staff #26. The pharmacist reported he was aware that drugs were stored in the DON's office and they were scheduled for destruction. The delay occurred when the DON began working the night shift and was not available to destroy medication. Staff #26 confirmed that he was aware of the 1 gallon plastic container of medications that had been removed from the blister packs but not yet destroyed. He voiced that the nursing staff told him everything in the plastic container had been written down and logged for destruction, however he had not seen the list. He confirmed there was no way to identify what was in the container, if all of the content had been accounted for or how long the container had been there.

On 10/15/2013, in the conference room, an attempt to review the policy for access to medication storage was made. No policy was found reflecting who could and could not enter the locked area where controlled medication was stored. Furthermore, there was no policy for where discontinued medication could be kept while awaiting destruction. There was no policy for securing dispensed medication in the original container until the time of destruction.