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Based on medical record review and interview, the facility failed to follow advance directives for one patient (#1) and failed to ensure a surrogate was appointed for one patient (#4) with psychiatric illness of five patients reviewed.

The findings included:

Patient #1 was admitted to the facility from August 16 through 20, 2009, and was discharged with diagnoses of Dementia with psychosis, Diabetes, Orthostasis, and Alzheimer's Dementia.

Patient #1 was re-admitted to the facility on August 25, 2009, with a diagnosis of Altered Mental Status, Alzheimer's Dementia, Dementia with Behavior Disturbance, Psychosis, UTI (urinary tract infection), Epilepsy, Asthma, Atrial Fibrillation, Diabetes, and Orthostatic Hypotension.

Medical record review revealed the patient had an Advance Care Plan/POST (Physician Orders for Scope of Treatment) supplied by the patient's spouse and Power of Attorney (POA) on admission August 16 and 25, 2009, which indicated the patient's wishes were to have CPR (cardiopulmonary resuscitation) and treatment of new conditions, but no life support.

Medical record review of a physician's progress note dated September 8, 2009, at 8:04 a.m., revealed, "Pt (patient) is confused this AM...was combative over the weekend & refused meds @ (medications at) times. Pt refuses to keep O2 (oxygen) on much of the time & O2 sats (saturations) were (decreased) over the weekend..."

Medical record review of a nurse's note dated September 8, 2009, at 3:00 p.m., revealed "Continued sleeping in bed - intermittent remove O2/NC (oxygen per nasal cannula). Let staff reapply - minimal withdrawal. Vitals 98.3 (temperature), 28 (respirations), 108/49 (blood pressure), 111 (pulse). Pt c/ (with) frothy sputum - MD called - orders to transfer to ER."

Medical record review of a telephone physician's order dated September 8, 2009, at 3:00 p.m., revealed, "Send pt to ER (secondary to) dyspnea (difficulty breathing)/coarse breath sounds."

Medical record review of a nurse's note dated September 8, 2009, at 3:10 p.m., revealed, "Transferred pt to ER via pt bed..."

Medical record review of the Emergency Nursing Record dated September 8, 2009, at 3:40 p.m. revealed, "...SOB (shortness of breath) - agitation...Hypoxic very combative...Thick yellow secretion suction from throat...Respiratory...severe distress..." and the patient was intubated at 4:02 p.m., and placed on a ventilator at 4:10 p.m.

Medical record review of the Emergency Room physician's notes revealed the patient was combative, had 4+ congestion, had respiratory failure, and Pneumonia.

Review of the Addendum to Physician Records completed by the emergency room physician September 9, 2009, at 5:45 p.m., revealed, "...Pt was combative - SOB...Placed on 100% NRB (non-rebreather) O2 Sat 84%...Ambu bag valve mask...pt intubated..."

Medical record review of a telephone physician's order dated September 8, 2009, at 6:00 p.m., revealed, "D/C (discharge) to ICU..."

Medical record review of the H&P (history and physical) by the critical care physician dated September 8, 2009, revealed, "...seen in the emergency room...found to be in respiratory distress...oxygen saturation was low in the 80% range...struggling and they had to restrain (patient). In view of...respiratory distress and worsening blood gases...intubated...signs of respiratory distress...respiratory failure. Left lower lobe pneumonia...sepsis syndrome will be taken into consideration..."

Medical record review of a nurse's note dated September 8, 2009, at 9:05 p.m., revealed, "...spoke c/ wife and (POA) re: code status. States 'do nothing, no CPR (cardiopulmonary resuscitation) or anything'..."

Telephone interview with the Director of Quality Assurance and Risk Management on July 15, 2010, at 2:25 p.m., confirmed the patient had advance directives and a POST (Physician Orders for Scope of Treatment) signed by the patient and the patient's Power of Attorney which indicated the patient was not to be intubated or placed on a ventilator, and the facility intubated the patient and placed the patient on a ventilator when in the Emergency Room.

Patient #4 was admitted to the facility on July 8, 2010, with diagnoses of Dementia with Behavior Disturbance.

Medical record review of the Appointment of Surrogate revealed, "I, (designated physician not completed) made the decision to appoint (named individual) as surrogate for (patient #2)..." Continued review revealed the reason for appointing a surrogate had not been completed. Continued review revealed the physician signed the documents July 13, 2010. Continued review revealed the Acceptance for Surrogate Selection section had not been signed by the surrogate but was dated July 8, 2010, at 5:45 p.m.

Interview with the Director of Senior Care Unit on July 13, 2010, at 11:20 a.m., on the Senior Care Unit confirmed the Appointment of Surrogate form was not complete.

Based on medical record review, observation, and interview, the facility failed to ensure after-hours access to medications for one patient (#1) of five patients reviewed.

The findings included:

Patient #1 was re-admitted to the facility on August 25, 2009, with a diagnosis of Altered Mental Status, Alzheimer's Dementia, Dementia with Behavior Disturbance, Psychosis, UTI (urinary tract infection), Epilepsy, Asthma, Atrial Fibrillation, Diabetes, and Orthostatic Hypotension.

Medical record review of a physician progress note dated September 1, 2009, revealed the patient had become aggressive, struck a staff member, and required two PRN (as needed) medications to calm the patient.

Medical record review of a physician's progress note dated September 4, 2009, revealed the patient required multiple prn medications the previous day, due to aggressive behaviors.

Medical record review of a nurse's note dated September 7, 2009, at 8:00 p.m., revealed, "...Hollering periodically, warning staff & peers that 'they're down there starting a fire.' Refuses to wear...N/C (nasal cannula) or to take...HS (bedtime) medication or for staff to take...B/P (blood pressure), becomes verbally threatening at times stating 'Get the (expletive) away from me' & 'I'll hit you' & has swung at peers who get too close at times...Notified (physician). N.O. (new orders) received et (and) noted..."

Medical record review of a physician's telephone order dated September 7, 2009, at 8:00 p.m., revealed, "Abilify 9.75 mg (milligrams) IM (intramuscular) x 1. Ativan 1 mg IM x 1..."

Medical record review of a physician's telephone order dated September 7, 2009, at 8:20 p.m., revealed, "Haldol 5 mg IM x 1. Ativan 1 mg IM x 1. Cancel Abilify order above..."

Medical record review of a nurse's note dated September 7, 2009, at 8:20 p.m., revealed, "...IM Abilify not available d/t (due to) pharmacy being closed. (Physician) notified. N.O. received et noted...will monitor effectiveness..."

Review of the Senior Care Night Cabinet list of medications available for emergency administration revealed Abilify 9.75 mg was stocked by pharmacy and available for nurses to use after hours when the pharmacy was closed.

Observation and interview with the medication nurse (LPN #1 - licensed practical nurse) of the afterhours stock on the Senior Care unit on July 13, 2010, at 10:05 a.m., confirmed Abilify injection was available in the stocked drawer. Continued interview confirmed LPN #1 had been employed on the unit for two years and not had problems with obtaining a medication when ordered by a physician.

Interviews with the pharmacist on July 13, 2010, at 9:40 a.m., in the pharmacy, and at 4:35 p.m., in the Board Room, revealed each unit had medications stocked for use after hours when the pharmacy was closed to ensure each unit had access to medications most frequently used by the unit. Continued interviews confirmed Abilify was a frequently used medication on the Senior Care Unit and the night supply for Senior Care was stocked daily or when nursing requested re-stock due to low supply. Continued interviews confirmed the nursing supervisor had access to the pharmacy to obtain any medications needed and not available after hours on the units. Continued interviews revealed the pharmacist was not aware of any issues with departments obtaining needed medications after hours, because they are stocked in the night supply or the supervisor could obtain medications from the pharmacy. Continued interview confirmed, "I can't imagine they could not get it (Abilify)."

Telephone interview with the admitting Psychiatrist on July 15, 2009, at 9:05 a.m., revealed the patient was possibly exhibiting early signs of akisthesia (a possible side effect of Haldol) and was weaned from Haldol to decrease the risk of side effects. Continued interview confirmed the physician ordered the Abilify injection on September 7, 2009, for aggression, and it was the preferred drug to administer, but was told by staff they could not obtain Abilify, so Haldol was ordered with Ativan added to decrease the risk of side effects. Continued interview confirmed the physician would have preferred the patient received the Abilify injection because it was the best choice for the patient.