Bhc Alhambra Hospital

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48186 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by: 1. The facility failed to ensure that a 1:1 sitter (a staff member who provides continuous observation of a patient in a hospital to prevent patient harm by alerting nurses or other healthcare personnel when needed) did not delay notifying the Registered Nurse (RN), when one of 30 sampled patients (Patient 1) was having shallow breathing indicating a change in condition (a deterioration in a patient’s physical or mental health status), in accordance with the facility’s policy and procedure regarding “Medical Emergencies and Acute (severe and sudden in onset) Change/Deterioration in Condition.” This deficient practice resulted in Patient 1 receiving delayed life-saving cardio-pulmonary resuscitation (CPR, a lifesaving technique that is useful in many emergencies in which someone’s breathing or heartbeat has stopped), when Patient 1 was found not breathing and pulseless (having no pulse). (Refer to A-0395) 2. The facility failed to conduct a nursing assessment (process of collecting, analyzing, and interpreting data to evaluate a patient’s health) or reassessment (process of reanalyzing and interpreting data to evaluate a patient’s health) regarding ongoing and increased confusion for one of 30 sampled patients (Patient 1) who was experiencing sundowning (a state of confusion that occurs in the late afternoon and lasts into the night), in accordance with the facility’s policy and procedure regarding patient assessment. This deficient practice had the potential for Patient 1’s care needs not to be addressed in a timely manner causing a delay in the notification of the physician thus resulting in a delay for Patient 1 to receive appropriate medical care and treatment which can result in worsening of condition for Patient 1. (Refer to A-0395) 3. The facility failed to communicate with physician to coordinate medication treatment plan when medication consent (informed consent [a collaborative process allowing patients and healthcare providers to make decisions together] for psychotropic medication [medications that affect the mind, emotions, and behavior] to ensure patient understand and agree with the treatment) for Depakote (medication for mood stabilizer) was not obtained for one of 30 sampled patients (Patient 16), in accordance with the facility’s policy and procedure regarding consent for psychotropic medications. This deficient practice resulted in Patient 16 not receiving Depakote per physician order which had the potential for Patient 16’s condition to worsen and prolong recovery. (Refer to A-0395) 4. The facility failed to assess/reassess one of 30 sampled patient’s (Patient 21) vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) and notify physician when Patient 21’s blood pressure was below set parameter (adult systolic [first number of blood pressure when the heart contracts and pushes out blood] blood pressure parameter (range) less than 85 millimeters of mercury [mmHg, unit of measure]), in accordance with the facility’s policy and procedure regarding assessment and physician notification. Patient 21 had a blood pressure of 80/50 (low; normal blood pressure is 120/80) millimeters of mercury (mmHg, a unit of measurement). This deficient practice had the potential to put Patient 21 at risk for delay of care and treatment due to unstable vital signs, which may result in worsening of Patient’s 21’s condition or death. (Refer to A-0395) 5. The facility failed to reassess and evaluate one of 30 sampled patient’s (Patient 24) blood pressure after Clonidine (medication to control high blood pressure) was given for an initial blood pressure of 174/77 (high; normal blood pressure is 120/80) mmHg (millimeters of mercury, a unit of measurement), in accordance with the facility’s policy and procedure regarding Medication administration. This deficient practice had the potential for Patient 24’s response to Clonidine medication to remain undetected and the blood pressure to remain uncontrolled which may result in complications such as heart attack, stroke (when the blood supply to the brain is blocked or reduced), etc. (Refer to A-0395) 6. The facility failed to reassess and evaluate one of 30 sampled patient’s (Patient 30) vital signs to determine possible over sedation (a state of calmness, relaxation, or sleepiness caused by certain drugs) after Ativan (medication to treat agitation [feeling of irritability or severe restlessness] and anxiety [feeling of fear or dread]) Intramuscular (IM, injection given into muscle) was given to Patient 30, in accordance with the facility’s policy and procedure regarding assessment of patients following medication administration. This deficient practice had the potential for Patient 30 to not be monitored properly for possible over sedation which may result in adverse outcomes such as respiratory depression (when breathing becomes shallow or slow) and/or death. (Refer to A-0395) 7. The facility failed to notify the physician after a patient-to-patient physical altercation (a confrontation, tussle or physical aggression that may or may not result in injury) for one of 30 sampled patients (Patient 1), when Patient 1 was slapped in the back of the head by another patient, in accordance with the facility’s policy and procedure regarding reassessment of patients and physician notification as well as assault (physical harm) precautions and occurrence. This deficient practice had the potential for delayed implementation of appropriate interventions which may result in Patient 1 to have neurological deficits (altered function is due to injury of the brain, spinal cord [tube-like structure that runs from the brain to the lower back], muscles, or nerves that feed the affected area) related to head trauma (results from a violent blow or jolt to the head) and/or death. (Refer to A-0398) 8. The facility failed to ensure that all sections of the admission nursing assessment (process of collecting, analyzing, and interpreting data to evaluate a patient’s health) form was completed by Registered Nursing staff for one of 30 sampled patients (Patient 1), when Patient 1 was admitted to the facility, in accordance with the facility’s policy and procedure regarding admission assessments and documentation. This deficient practice had the potential for Patient 1’s needs and risks not to be identified which may result in a delay in implementation of appropriate medical treatment. (Refer to A-0398) 9. The facility failed to ensure one of two sampled multi-dose (used multiple times) Ativan (medication to treat anxiety [feeling of fear or dread]) vial (Vial 1) was labeled with open and expiration dates after opening, in accordance with the facility’s policy and procedure regarding medication labeling. This deficient practice had the potential to put patients at risk for receiving expired or contaminated (dirty) Ativan dose which are less effective and may lead to more serious illnesses for patients. (Refer to A-0398) 10. The facility failed to ensure the completion of “Notice of Certification for Intensive Treatment - 5250 (5250-hold form, allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment)” form for three of 30 sampled patients (Patients 19, 23, and 24), in accordance with the facility’s policy and procedure regarding 5250 form completion. Patients 19, 23 and 24’s 5250 forms either had missing hold begin date, inconsistent hold serving date and/or missing psychiatrist signature. This deficient practice had the potential to result in an invalid 14- day hold for Patients 19, 23 and 24 due to incomplete 5250-hold form, which may result in a delay of implementation of necessary treatment plan to address the patients’ (Patient 19, 23 and 24) psychiatric conditions. This deficient practice also had the potential for Patients 19, 23 and 24’s right to be violated for placing them (Patients 19, 23 and 24) on hold (involuntary detention) without a valid hold form. (Refer to A-0398) 11. The facility failed to ensure there was an accurate controlled substance count (“narcotic count,” a count of controlled medications [a drug or chemical whose manufacture, possession, or use is regulated by a government]) when medication names and medication doses were not verified by Licensed Psychiatric Technician 1 (LPT 1) and Licensed Psychiatric Technician 2 (LPT 2), during an observed narcotic count in one of three medication rooms (medication room 2 [in Adult Unit 2]), in accordance with the facility’s policy and procedure regarding controlled substance count. This deficient practice had the potential to result in controlled medication diversion (when a medication is taken for use by someone other than whom it is prescribed). This deficient practice also had the potential to result in medication error when the narcotic name and dose are not verified during the count, which may result in patient harm and or death when administered to patients. (Refer to A-0398) 12. The facility failed to ensure one of 30 sampled patients (Patient 1) was included in the development of the treatment plan of care (provides a framework for evaluating and providing patient care needs related to the nursing process), in accordance with the facility’s policy and procedure regarding patient centered care planning. This deficient practice had the potential to result in Patient 1’s lack of awareness and understanding regarding his (Patient 1) treatment plan, which may result in lack of compliance or adherence with treatment regimen, thus resulting in prolonged hospitalization and recovery from psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional and behavioral disorders) condition. (Refer to A-0398) 13. The facility failed to ensure nursing staff administered medication (Clonidine, medication to control blood pressure) for one of 30 sampled patients (Patient 24), in accordance with the physician order and with the facility’s policy and procedure regarding medication administration. This deficient practice had resulted in Patient 24’s blood pressure to be out of control with systolic (first number of blood pressure when the heart contracts and pushes out blood) blood pressure above 150 millimeters of mercury (mmHg, unit of measure) and put Patient 24 at risk for complications such as severe headache, vision problems, pounding in the chest and irregular heartbeat, heart attack, and or death. (Refer to A-0405) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48186 Based on interview and record review, the facility failed to ensure the following: 1.a. The facility failed to ensure that a 1:1 sitter (a staff member who provides continuous observation of a patient in a hospital to prevent patient harm by alerting nurses or other healthcare personnel when needed) did not delay notifying the Registered Nurse (RN) 1, when one of 30 sampled patients (Patient 1) was having shallow breathing indicating a change in condition (a deterioration in a patient’s physical or mental health status), in accordance with the facility’s policy and procedure regarding “Medical Emergencies and Acute (Severe and sudden in onset) Change/Deterioration in Condition.” This deficient practice resulted in Patient 1 receiving delayed life-saving cardio-pulmonary resuscitation (CPR, a lifesaving technique that is useful in many emergencies in which someone’s breathing or heartbeat has stopped), when Patient 1 was found not breathing and pulseless (having no pulse). 1.b. The facility failed to conduct a nursing assessment (process of collecting, analyzing, and interpreting data to evaluate a patient’s health) or reassessment (process of reanalyzing and interpreting data to evaluate a patient’s health) regarding ongoing and increased confusion for one of 30 sampled patients (Patient 1) who was experiencing sundowning (a state of confusion that occurs in the late afternoon and lasts into the night), in accordance with the facility’s policy and procedure regarding patient assessment. This deficient practice had the potential for Patient 1’s care needs not to be addressed in a timely manner causing a delay in the notification of the physician thus resulting in a delay for Patient 1 to receive appropriate medical care and treatment which can result in worsening of condition for Patient 1. 2. The facility failed to communicate with physician to coordinate medication treatment plan when medication consent (informed consent [a collaborative process allowing patients and healthcare providers to make decisions together] for psychotropic medication [medications that affect the mind, emotions, and behavior] to ensure patient understand and agree with the treatment) for Depakote (medication for mood stabilizer) was not obtained for one of 30 sampled patients (Patient 16), in accordance with the facility’s policy and procedure regarding consent for psychotropic medications. This deficient practice resulted in Patient 16 not receiving Depakote per physician order which had the potential for Patient 16’s condition to worsen and prolong recovery. 3. The facility failed to assess/reassess one of 30 sampled patient’s (Patient 21) vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) and notify physician when Patient 21’s blood pressure was below set parameter (adult systolic [first number of blood pressure when the heart contracts and pushes out blood] blood pressure parameter (range) less than 85 millimeters of mercury [mmHg, unit of measure]), in accordance with the facility’s policy and procedure regarding assessment and physician notification. Patient 21 had a blood pressure of 80/50 (low; normal blood pressure is 120/80) millimeters of mercury (mmHg, a unit of measurement), This deficient practice had the potential to put Patient 21 at risk for delay of care and treatment due to unstable vital signs, which may result in worsening of Patient 21’s condition or death. 4. The facility failed to reassess and evaluate one of 30 sampled patient’s (Patient 24) blood pressure after Clonidine (medication to control high blood pressure) was given for an initial blood pressure of 174/77 (high; normal blood pressure is 120/80) mmHg (millimeters of mercury, a unit of measurement), in accordance with the facility’s policy and procedure regarding Medication administration. This deficient practice had the potential for Patient 24’s response to Clonidine medication to remain undetected and the blood pressure to remain uncontrolled which may result in complications such as heart attack, stroke (when the blood supply to the brain is blocked or reduced), etc. 5. The facility failed to reassess and evaluate one of 30 sampled patient’s (Patient 30) vital signs to determine possible over sedation (a state of calmness, relaxation, or sleepiness caused by certain drugs) after Ativan (medication to treat agitation [feeling of irritability or severe restlessness] and anxiety [feeling of fear or dread]) Intramuscular (IM, injection given into muscle) was given to Patient 30, in accordance with the facility’s policy and procedure regarding Assessment of patients following medication administration. This deficient practice had the potential for Patient 30 to not be monitored properly for possible over sedation which may result in adverse outcomes such as respiratory depression (when breathing becomes shallow or slow) and/or death. Findings: 1.a. During a concurrent interview and record review on 5/29/2024 at 9:30 a.m. with the Assistant Chief Nursing Officer (ACNO), while reviewing Patient 1’s Face Sheet (a document that gives a patient’s information at a quick glance), the ACNO stated that Patient 1 was admitted to the facility on 1/25/2024 at 4:15 a.m. with a diagnosis of bipolar disorder (a mental health condition that causes extreme mood swings). In addition, during a review of Patient 1’s “Application for Assessment, Evaluation and Crisis Intervention or Placement for Evaluation and Treatment (5150, the law, which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional and behavioral disorders] hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled [a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter]),” the ACNO stated Patient 1 was also admitted on a 5150 as a danger to others and gravely disabled. During an interview on 5/29/2024 at 9:30 a.m. with the ACNO, the ACNO stated the following: on 2/7/2024, Patient 1 had a 1:1 sitter (a staff member who provides continuous observation of a patient in a hospital to prevent patient harm by alerting nurses or other healthcare personnel when needed) at night, starting at 8:45 p.m., for increased confusion, possible sundowners (increased confusion that people with dementia [a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life] may experience from dusk through night) and increased risk for fall (an unintentional event that results in the person coming to rest on the ground or another lower level). During the same interview with the ACNO, the ACNO said that on 2/8/2024 at 5:45 a.m., the sitter noted Patient 1 had shallow respirations (breathing). The sitter attempted to obtain vital signs (include temperature, respiratory rate, heart rate, blood pressure and pain level), and then the Registered Nurse (RN) was notified at 5:50 a.m. At 5:50 a.m., Registered Nurse 1 (RN 1) responded and found Patient 1 without a pulse, without respirations (not breathing), and unresponsive to sternal rubs (applying painful stimuli [something that elicits a response] to the sternum [a flat, vertical bone at the center of your chest that protects your organs and muscles]). At 5:54 a.m., a code blue (patient with unexpected cardiac or respiratory arrest requiring resuscitation [methods used to restart the heart and lungs when they stop working]) was initiated, compressions (the act of applying pressure to someone’s chest to help blood flow through the heart in an emergency situation) were initiated and 911 was called. At 6:03 a.m., the paramedics arrived and took over CPR (Cardiopulmonary Resuscitation, a lifesaving technique that is useful in many emergencies in which someone’s breathing or heartbeat has stopped). At 6:25 a.m., Patient 1 expired (died). During a review of Patient 1’s “Physician’s Order (instructions for a patient’s care written by a Medical Doctor) Sheet,” dated 2/7/2024 at 10:30 a.m., the Physician’s Order indicated the following: “1:1 [sitter] monitor for safety while asleep.” During a review of Patient 1’s “Interdisciplinary Notes,” dated 2/8/2024 at 5:50 a.m., documented by Registered Nurse 1 (RN 1), the Interdisciplinary notes indicated the following: “Hallway monitor Program Specialist 1 (PS1, unlicensed staff that monitors mental health patients in psychiatric units of hospitals) brought to my attention that 1:1 staff needed assistance with patient (Patient 1). Upon entering the room, 1:1 staff brought to my (RN 1) attention patient (Patient 1) felt cool. Temperature was measured 96 degrees Fahrenheit (a unit measurement for temperature). Then 1:1 staff alerted me that pulse felt weak. Radial (the pulse between the wrist bone and the thumb side of the wrist) pulse was assessed and unable to palpate (examine by touch). At the same time, no chest rise was noted. During further review of Patient 1’s Interdisciplinary Notes, dated 2/8/2024, the Interdisciplinary Notes indicated the following: At this point a sternal shake (applying painful stimuli to the sternum [a flat, vertical bone at the center of your chest that protects your organs and muscles]) was assessed (the process to collect and evaluate a patient information), and no response was noted, carotid pulse (pulse obtained in the front of the neck) was assessed, unable to palpate (to feel and evaluate a part of the body). From the bedroom door, called for help, other RN (Registered Nurse 6 [RN 6]) on unit responded immediately ... At this point, she (RN 6) stated call the code (code blue, patient with unexpected cardiac or respiratory arrest requiring resuscitation [methods used to restart the heart and lungs when they stop working]), and started compressions (helps restore blood flow to the brain and other vital organs, including the lungs and the heart itself, until the heart can be shocked [a medical procedure that uses low energy shock to restore a regular heart rythm]). In addition, the Interdisciplinary Notes, dated 2/8/2024, also indicated the following: At approximately 5:54 a.m., I (RN 1) shouted to call code blue from the doorway ... code blue team arrived, 911 was called ... At approximately 6:03 a.m. paramedics (a person trained to give emergency medical care to people who are injured or ill) arrived and shortly took over ... I heard paramedics call time of expiration at 6:25 a.m.” During a review of Patient 1’s “Interdisciplinary Notes,” dated 2/8/2024 at 6:15 a.m., documented by Program Specialist 1 (PS 1), the note indicated the following: “At 5:15 a.m., patient (Patient 1) went into deeper sleep, was no longer moving around as much. At 5:45 a.m., patient’s oxygen (O2) saturations (the amount of oxygen circulating in blood) and temp (Temperature) were taken due to patient (Patient 1) not snoring and slower respirations. Temperature 96 degrees Fahrenheit and unable to obtain O2 saturations. Nurse notified at approximately 5:50 a.m.” During an interview on 5/31/2024 at 8:06 a.m. with Program Specialist 1 (PS 1), PS 1 stated the following: On 2/7/2024 at 11:15 p.m., hand-off report (the transfer of essential information and the responsibility for care of the patient from one health care staff to another) for Patient 1 was received from the prior shift’s sitter. At the hand-off report, no medical issues, including breathing issues, were noted for Patient 1. Patient 1 had been increasingly confused over the course of one week, requiring a patient 1:1 sitter. PS 1’s 1:1 sitter duties included monitoring Patient 1’s breathing (counting 3 respirations every 15 minutes), movement, position, and behavior. Throughout the night, while Patient 1 was sleeping, Patient 1 snored and stopped snoring off and on. Patient 1 stopped snoring and it was noticed Patient 1’s sleeping pattern was abnormal. Patient 1’s breaths were shallow, and vital signs were obtained (temperature and oxygen saturations). After vital signs were obtained and were abnormal, the RN was made aware, then a code blue was called. During the same interview on 5/31/2024 at 8:06 a.m. with the Program Specialist (PS) 1, PSI stated the following: the RN should have been notified immediately when Patient 1’s breathing was shallow, prior to obtaining vital signs. Training received by the facility included letting the RN know immediately when a patient has a change of condition (a deterioration in a patient’s physical or mental health status), and this should be prior to performing interventions for the patient. It is important to notify the RN immediately when there is a patient change of condition because the nurse is responsible for the medical care of the patient. If the RN is not notified when there is a patient change of condition, there is a potential for delayed medical care for the patient. During an interview on 5/31/2024 at 10:45 a.m. with the Staff Development Manager (SDM), the SDM confirmed that PS 1 was CPR certified. However, the SDM stated that PS 1 did not initiate CPR for Patient 1. The SDM also stated the following: If a patient has a change of condition, unlicensed staff [e.g., Program Specialists] should notify a Registered Nurse immediately with any change. If a patient has a change of breathing, such as shallow breathing, vital signs should not be taken before the RN is notified because this can cause a delay in response and care for the patient. During a review of the facility’s policy and procedure (P&P) titled, “Medical Emergencies and Acute (severe and sudden in onset) Change/Deterioration in Condition,” dated 12/2023, the P&P indicated the following: “Airway and Breathing Problems: Observing patients for the presence of respirations is an important part of monitoring. Normally a person breathes 16-20 times per minute (respiration rate). Increase or decrease in this rate could indicate signs of distress (symptoms indicating the need for medical attention) and should be reported immediately to the RN ...” During a review of the facility’s policy and procedure (P&P) titled, “Level of Observation/Rounds (best practice intervention of checking in on patients to meet patient care needs),” dated 4/2024, the P&P indicated the following: “ ... Assessment/Referral staff will begin the q (every) 15-minute observation in compliance with physician orders and prescribed protocols ... 3. Licensed Vocational Nurse (LVN)/Licensed Psychiatric Technician (LPT)/Program Specialist 1 (PS1): ...13. Observe patients on bed rest or when sleeping by: Looking for the rise and fall of the chest, Counting at least three respirations ...” 1.b. During a concurrent interview and record review on 5/29/2024 at 9:30 a.m. with the Assistant Chief Nursing Officer (ACNO), Patient 1’s Daily Nursing Flowsheet (a tool to help clinicians document patient data in a grid-like format), was reviewed. The ACNO stated the following: After the initial admission assessment is completed, the “Daily Nursing Flowsheet” (RN assessment [process of collecting, analyzing, and interpreting data to evaluate a patient’s health]) is completed twice per day (24-hour period) for each patient, 7:00 a.m. - 7:30 p.m. and 7:00 p.m. - 7:30 p.m., by licensed staff. If the nursing flowsheet containing the nursing assessment is completed by Licensed Vocational Nurse (LVN) or Licensed Psychiatric Technician (LPT) staff, the RN must sign off since they oversee the LVN and the LPT staff. The RN staff are the only staff permitted to write a narrative for the assessment of the patient. The RNs are responsible for the care of the patient. During further interview on 5/29/2024 at 9:30 a.m. with the ACNO, the ACNO verified that Patient 1’s nursing admission assessment, dated 1/25/2024, and daily nursing assessments, dated 1/24/2024 at 7:00 p.m. through 2/7/2024 7:30 a.m., did not indicate that Patient 1 was assessed or reassessed (process of reanalyzing and interpreting data to evaluate a patient’s health) by RN staff with initial or on-going confusion, or that confusion or sundowning (a state of confusion that occurs in the late afternoon and lasts into the night) was reported to the Physician (Medical Doctor). In the same interview on 5/29/2024 at 9:30 a.m., the ACNO also verified that Patient 1’s medical record did not indicate that there was assessment or reassessment documentation by RN staff that Patient 1 had initial or on-going confusion or sundowning, and that the Physician was notified. Documentation of Patient 1’s increased confusion at nighttime was documented by RN staff on 2/8/2024 at 10:30 a.m., after Patient 1 expired (died) on 2/7/2024 at 6:25 a.m. The ACNO said that if a patient is confused or experiencing sundowning, this should be documented by RN staff in the narrative on the nursing flowsheet, progress note or interdisciplinary (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) progress note. The ACNO stated that any patient change of condition, including confusion, should be reported to the Medical Doctor (MD). The ACNO further stated that the MD should be notified immediately by the RN with any patient change of condition so physician’s orders (instructions for a patient’s care written by a Medical Doctor) given can be carried out and the patient can be properly assessed and treated. During a review of Patient 1’s “Nursing Admission Assessment,” dated 1/25/2024 at 7:05 a.m., the nursing assessment indicated the following: The “Review of Systems- Neurological (a part of the body that includes the spine, brain, and nerves),” the Registered Nurse assessment indicated identified issues as “ataxic (the loss of full control of bodily movements) extremities upon awakening, no evidence of head injury, and pupils constricted (narrowed), fixed (pupil is dilated and doesn’t respond to light) and equal.” During a review of Patient 1’s “RN Nursing Admission Narrative Summary,” dated 1/25/2024, the notes indicated “ ...patient (Patient 1) responds appropriately with one-word answers. Sometimes disorganized (when someone’s speech is filled with run-on sentences, jumbled or incoherent words, words or concepts that do not go together, or awkward phrasing), incoherent (lacking normal clarity or intelligibility in speech or thought), loud, hysterical (uncontrolled extreme emotion). Cooperative ...” The RN nursing assessment did not indicate Patient 1 was confused or experiencing sundowning on admission. During a review of Patient 1’s “Medicine Progress Note,” dated 2/7/2024 at 9:15 a.m., the Medicine Progress Note indicated the following: “According to staff, they noticed patient (Patient 1) gets confused at night. Patient responded to all of the questions well. Denies any nausea (uneasiness in the stomach) and vomiting (emptying stomach contents through the mouth), no abdominal pain, no shortness of breath, no chest pain, patient eating well ... Assessment/Recommendation: ...possible sundowners, asymptomatic (no symptoms) this morning ...” During a review of Patient 1’s “Nursing Progress Note,” dated 2/8/2024 at 10:30 a.m., the nursing progress note indicated the following: “Following discussion with Medical Doctor (MD), will place patient on 1:1 [sitter] monitoring while asleep and throughout the night shift related to increased confusion during the nighttime due to possible sundowning. Patient has been presenting irritable with others and increased fall (an unintentional event that results in the person coming to rest on the ground or another lower level) risk during the night.” During a review of the facility’s policy and procedure (P&P) titled, “Reassessment of Patients,” dated 12/2020, the P&P indicated the following: “ ...Procedure: ... 2. An RN admission assessment is completed upon admission ... 3. Reassessment is conducted by a Registered Nurse each shift 4. Reassessment is conducted by a Registered Nurse, in the following circumstances: Change in patient condition ... 1. RN findings from reassessment activities will be documented in the medical record and reported to the physician ...” 2. During a review of Patient 16’s “Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional and behavioral disorders) Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health]),” dated 9/27/2023, the Psych Eval indicated, Patient 16 was admitted to the facility from another facility with diagnoses of major depression (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), recurrent, severe with psychotic (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) features (delusions [something that is believed to be true or real but that is actually false or unreal] and hallucinations [false perception of objects or events involving the senses of sight, smell, etc.]), rule out bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration) with psychotic features, and history of attention deficit hyperactivity disorder (ADHD, a chronic condition including attention difficulty, hyperactivity [excess movement that is not fitting to the setting], and impulsivity [hasty acts that occur in the moment without thought]). The Psych Eval also indicated, Patient 16 was taking Risperdal (medication to treat bipolar disorder), BuSpar (medication to treat anxiety [feeling of fear or dread]) and Strattera (medication to treat ADHD), with family member (FM1) agreeing to an increase in Risperdal as well as additional of Depakote (medication for mood stabilizer) according to transfer facility documentation. During a review of Patient 16’s “Doctor’s Order Sheet (physician order, orders written by physicians to direct care and treatment),” dated 9/27/2023, the physician order indicated to give Patient 16 Risperdal 0.5 milligrams (mg, unit of measure) by mouth at bedtime, Depakote ER (extended release, last longer in the body) 250 mg by mouth in the morning and at bedtime, and Strattera 25 mg by mouth daily. During a concurrent interview and record review on 5/29/2024 at 10:25 a.m. with the Chief Nursing Office (CNO), Patient 16’s “Medication Consent” for Depakote, undated, was reviewed. The section for patient/guardian signature on the medication consent was blank. CNO stated FM 1 needed to give consent for Patient 16 to take Depakote because FM 1 was Patient 16’s guardian. CNO stated FM 1 did not sign consent due to unknown reason. CNO stated Depakote was not given due to lack of FM1’s consent. At the same time, the nursing staff did not notify the psychiatrist that the consent for Depakote was not signed by FM1. During a concurrent interview and record review on 5/29/2024 at 10:30 a.m. with CNO, Patient 16’s “Medication Administration Record (MAR, record of medications given to patients),” dated from 9/27/2023 to 10/4/2023, was reviewed. The MAR indicated Depakote was not given to Patient 16 from 9/27/2023 to 10/4/2023. CNO stated Depakote was not given from 9/27/2023 to 10/4/2023 due to no consent. During an interview on 5/31/2024 at 10:42 a.m. with the Staff Development Manager (SDM), SDM stated if a medication consent was not signed by the guardian, nurse should notify physician so that the physician could determine if change of medication regimen was needed and speak with the guardian. During an interview on 5/31/2024 at 11:58 a.m. with CNO, CNO stated there was a breakdown in communication between nursing staff and the psychiatrist regarding the medication consent. CNO stated nursing staff should have communicated with the psychiatrist regarding the medication consent not being signed by FM 1. During a review of the facility’s policy and procedure (P&P) titled, “Consents Informed,” dated 12/2023, the P&P indicated, “It is the policy of [name of the facility] to ensure that each patient has a right to clear, concise, understandable information concerning a procedure, treatment or release of information ... written consent is mandatory for: voluntary admission, psychotropic medications [medications to treat mental illnesses, emotions and behavior], and release of information. Prior to ordering the medication, the physician will meet with the patient to discuss the mediation to be prescribed ... the physician will complete all areas on the Informed Consent form and obtain the patient’s or patient’s legal guardian’s/conservator’s consent for the medication. The consent form will be dated and timed at the time the consent is obtained.” 3. During a review of Patient 21’s “Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional and behavioral disorders) Evaluation (Psych Eval),” dated 5/25/2024, the Psych Eval indicated, Patient 21 was admitted to the facility with diagnoses of psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality). The Psych Eval also indicated Patient 21 had no other medical problem. During a concurrent interview and record review on 5/30/2024 at 11:11 a.m. with the Chief Nursing Officer (CNO), Patient 21’s “Vital Signs Flow Sheet (the VS flowsheet, record of vital signs [measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level]),” dated from 5/24/2024 to 5/29/2024, was reviewed. The VS flowsheet indicated for “adult systolic (first number of blood pressure when the heart contracts and pushes out blood) blood pressure parameter (range) less than 85 millimeters of mercury (mmHg, unit of measure) or above 170 mmHg with the following instructions: 1. You must immediately notify the Charge Nurse (Registered Nurse who is in charge of the unit) if the patient’s vital signs fall outside the above parameters. 2. Unless otherwise ordered, the physician/nurse practitioner (NP) shall be notified of any values outside the above parameters. 3. Vital signs shall be rechecked on patients that fall outside the above parameters every hour until values are within parameters or unless ordered otherwise by physician/NP.” The VS flowsheet also indicated on 5/26/2024 at 8 a.m. with vital signs: Blood pressure 80/50 mmHg (low; normal blood pressure is 120/80), temperature 98.2, pulse 111, respiration 18, pain 0/10 (means zero pain level). CNO stated the BP of 80/50mmgHg would require nursing staff to notify the charge nurse and physician, and to recheck vital signs every hour per VS flowsheet instruction. During an interview on 5/30/2024 at 11:20 a.m. with CNO, CNO stated there was no nursing documentation that charge nurse was notified for the BP 80/50mmHg, no assessment documented on Patient 21 addressing the low blood pressure, no nursing documentation on physician notification with regards to BP 80/50mmHg and no documentation on rechecking Patient 21’s blood pressure on 5/26/2024. CNO stated there was potential risk that Patient 21’s condition could deteriorate due to lack of monitoring. During an interview on 5/31/2024 at 11:09 a.m. with the Staff Development Manager (SDM), SDM stated nursing staff should notify the medical physician (physician who manages patient’s medical aspect of care) for BP 80/50mmHg so that the physician could give treatment order for Patient 21. During a review of the facility’s policy and procedure (P&P) titled, “Vital Signs,” dated 12/2023, the P&P stated, “It is the policy of [the facility] to assess and reassess the physical status of all patients at the time of admission, throughout hospitalization and at the time of discharge ... unless otherwise ordered, the physician shall be notified of any values outside of these parameters: Adult Systolic blood pressure below 85 mmHg or above 170mmHg.” During a review of the facility’s policy and procedure (P&P) titled, “Reassessment of Patients,” dated 12/2020, the P&P indicated, reassessment if conducted by a Registered Nurse in the following circumstances ... change in patient condition.” 4. During a review of Patient 24’s “Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional and behavioral disorders) Evaluation (Psych Eval),” dated 5/18/2024, the Psych Eval indicated, Patient 24 was admitted to the facility with diagnoses of schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations [false perception of objects or events involving the senses of sight, smell, etc.]), and/or delusions [something that is believed to be true or real but that is actually false or unreal]), obesity (overweight) and hypertension (high blood pressure). During a review of Patient 24’s “Doctor’s Order Sheet (physician order),” dated 5/17/2024, the physician order indicated Clonidine (blood pressure medication) 0.1 milligrams (mg, unit of measurement) by mouth every 8 hours as needed (prn) to be given for blood pressure (BP) systolic (first number of blood pressure when the heart contracts and pushes out blood) at or above 150 mmHg (millimeters of mercury, a unit of measurement) and/or diastolic (second number of blood pressure when the heart relaxes and fills with blood) blood pressure at or above 90 mmHg. During a review of Patient 24’s “Vital Signs Flow Sheet,” dated from 5/17/2024 to 5/29/2024, the “Vital Signs Flow Sheet” indicated, on 5/27/2024 at 8 a.m., Patient 24’s BP was 174/77 mmHg. The “Vital Signs Flow Sheet” also indicated next BP was taken on 5/28/2024 at 8 a.m. with BP 177/104 mmHg. During a concurrent interview and record review on 5/30/2024 at 2:25pm with CNO, Patient 24’s “Medication Administration Record (MAR, record of medications given to patients),” from 5/17/2024 to 5/30/2024 was reviewed. The MAR indicated Clonidine 0.1 mg by mouth was given on 5/27/2024 at 6:40 a.m. for BP 174/77mmHg. CNO stated there should be a reassessment of blood pressure after Clonidine was given to Patient 24 however it was not documented as done. CNO stated without rechecking the blood pressure, nurse would not know the effectiveness of Clonidine and would not know if Patient 24’s blood pressure was controlled or not. During an interview on 5/31/2024 at 10:04 a.m. with the Staff Development Manager (SDM), SDM stated nurse should reassess patient by rechecking patient’s blood pressure after a prn (as needed) blood pressure medication was given in order to evaluate the effectiveness of the medication. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated 12/2023, the P&P indicated, “The medication effectiveness is documented on PRN (as needed) form and includes the drug name, dose, route, time of administration, indications for and response to the administered medication and is signed by the licensed staff administering the medication. The licensed nursing staff is responsible for assessing how often and how much PRN medication a patient is receiving before administering an additional dose.” 5. During a review of Patient 30’s “Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional and behavioral disorders) Evaluation (Psych Eval),” dated 9/21/2023, the Psych Eval indicated, Patient 30 was admitted to the facility with diagnoses of major depression (a mood disorder that causes persistent feeling of sadness and loss of interest and can interfere with daily activities). During an interview on 5/28/2024 at 2:26 p.m. with Licensed Vocation Nurse (LVN) 1, LVN 1 stated the following: nurse would call physician for an emergency medication (example is Ativan [medication to treat agitation] to manage a patient’s agitated [feeling of irritability or severe restlessness]) behavior. The medication would be a one-time order given by mouth or by injection. A licensed nurse would reassess the patient after administering an emergency medication. LVN 1 stated the licensed nurse should check patient’s vital signs and check if patient was arousable (awaken from sleep) in an hour after medication administration to evaluate patient’s response to the medication. During a review of Patient 30’s “Emergency Medication Communication Tool (documentation filled out by registered nurse when communicating with the physician and received a one-time order for the emergency medication),” dated 10/4/2023, the “Emergency Medication Communication Tool” indicated physician ordered Ativan 2 mg IM (intramuscular, administered through the muscle) one time now for agitation. During a review of Patient 30’s “Medication Administration Record (MAR) from 10/1/2023 to 10/10/2023, the MAR indicated Ativan 2mg IM was given on 10/4/2023 at 9:28 a.m. by Licensed Vocational Nurse (LVN) 3. During a concurrent interview and record review on 5/30/2024 at 10:54 a.m. with the Chief Nursing Officer (CNO), Patient 30’s “24-Hour Medication Progress Note (documentation for licensed nursing staff to document reassessment and patient’s response after one time for as needed medications are given),” dated 10/4/2023, was reviewed. The medication progress note indicated Ativan 2mg intramuscular (IM, injection given into muscle) was given at 9:28 a.m. with response “effective” noted at 10:28 a.m. The medication progress note also indicated instruction of all psychotropic IM medication and one time PO (per orem, via the mouth) orders required vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) monitoring. CNO stated there should be vital signs taken in an hour after Ativan IM was given to ensure Patient 30’s vital signs were stable (within normal limits). CNO confirmed LVN 3 did not document any vital signs after Ativan was given to Patient 30. During a review of the facility’s policy and procedure (P&P) titled, “Emergency Use of Medication,” dated 12/2023, the P&P indicated, “Patient will receive emergency medication on the direction of a physician ... the physician may choose to order medication as they determine appropriate for the patient’s clinical presentation. They will indicate it the emergency medication is a standard medication and dosage for the patient’s condition ... if the physician indicates the emergency medication is a non-restraint (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) medication, the nurse will monitor medication efficacy as standard on the PRN (Pro re nata, as needed) form ... the patient’s response to the medication is to be documented by a licensed member of the nursing staff in the medical record.” During a review of the facility’s policy and procedure (P&P) titled, “Reassessment of Patients,” dated 12/2020, the P&P indicated, “reassessment if conducted by a Registered Nurse in the following circumstances: PRN and emergency medication administration.””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to ensure the following: 1.a. The facility failed to notify the physician after a patient-to-patient physical altercation (a confrontation, tussle or physical aggression that may or may not result in injury) for one of 30 sampled patients (Patient 1), when Patient 1 was slapped in the back of the head by another Patient, in accordance with the facility’s policy and procedure regarding reassessment of patients and physician notification as well as assault (physical harm) precautions and occurrence. This deficient practice had the potential for delayed implementation of appropriate interventions which may result in Patient 1 to have neurological deficits (altered function is due to injury of the brain, spinal cord, muscles, or nerves that feed the affected area) related to head trauma (results from a violent blow or jolt to the head) and/or death. 1.b. The facility failed to ensure that all sections of the admission nursing assessment (process of collecting, analyzing, and interpreting data to evaluate a patient’s health) were completed by Registered Nursing staff for one of 30 sampled patients (Patient 1), when Patient 1 was admitted to the facility, in accordance with the facility’s policy and procedure regarding admission assessments and documentation. This deficient practice had the potential for Patient 30’s needs and risks not to be identified which may result in a delay in implementation of appropriate medical treatment. 2. The facility failed to ensure one of two sampled multi-dose (used multiple times) Ativan (medication to treat anxiety [feeling of fear or dread]) vial (Vial 1) was labeled with open and expiration date after opening, in accordance with the facility’s policy and procedure regarding medication labeling. This deficient practice had the potential to put patients at risk for receiving expired or contaminated (dirty) Ativan dose which are less effective and may lead to more serious illnesses for patients. 3. The facility failed to ensure the completion of “Notice of Certification for Intensive Treatment - 5250 (5250-hold form, allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment)” form for three of 30 sampled patients (Patients 19, 23, and 24), in accordance with the facility’s policy and procedure regarding 5250 form completion. Patients 19, 23 and 24’s 5250 forms either had missing hold begin date, inconsistent hold serving date and/or missing psychiatrist signature. This deficient practice had the potential to result in an invalid 14-hold for Patients 19, 23 and 24 due to incomplete 5250-hold form, which may result in a delay of implementation of necessary treatment plan to address the patients’ (Patient 19, 23 and 24) psychiatric conditions. This deficient practice also had the potential for Patients 19, 23 and 24’s right to be violated for placing them (Patients 19, 23 and 24) on hold (involuntary detention) without a valid hold form. 4. The facility failed to ensure there was an accurate controlled substance count (“narcotic count,” a count of controlled medications [a drug or chemical whose manufacture, possession, or use is regulated by a government]) when medication names and medication doses were not verified by Licensed Psychiatric Technician 1 (LPT 1) and Licensed Psychiatric Technician 2 (LPT 2), during an observed narcotic count in one of three medication rooms (medication room 2 [in Adult Unit 2]), in accordance with the facility’s policy and procedure regarding controlled substance count. This deficient practice had the potential to result in controlled medication diversion (when a medication is taken for use by someone other than whom it is prescribed). This deficient practice also had the potential to result in medication error when the narcotic name and dose are not verified during the count, which may result in patient harm and or death when administered to patients. 5. The facility failed to ensure one of 30 sampled patients (Patient 1) was included in the development of the treatment plan of care (provides a framework for evaluating and providing patient care needs related to the nursing process), in accordance with the facility’s policy and procedure regarding patient centered care planning. This deficient practice had the potential to result in Patient 1’s lack of awareness and understanding regarding his (Patient 1) treatment plan, which may result in lack of compliance or adherence thus resulting in prolonged hospitalization and recovery from psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional and behavioral disorders) condition. Findings: 1.a. During a concurrent interview and record review on 5/29/2024 at 9:30 a.m. with the Assistant Chief Nursing Officer (ACNO), while reviewing Patient 1’s Face Sheet (a document that gives a patient’s information at a quick glance), the ACNO stated that Patient 1 was admitted to the facility on 1/25/2024 at 4:15 a.m. with a diagnosis of bipolar disorder (a mental health condition that causes extreme mood swings). During a review of Patient 1’s “Application for Assessment, Evaluation and Crisis Intervention or Placement for Evaluation and Treatment (5150, the law , which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional and behavioral disorders] hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled [a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter]),” the ACNO also stated Patient 1 was also admitted on a 5150 as a danger to others and gravely disabled. During a concurrent interview and record review on 5/29/2024 at 9:30 a.m. withe ACNO, Patient 1’s “Daily Nursing Flowsheet (a tool to help clinicians document patient data in a grid-like format),” dated 2/7/2024 at 3:10 a.m., was reviewed. The ACNO said Patient 1 was slapped on the back of the head by another patient (Patient 31). The ACNO also stated the following: The MD should be notified by RN staff, per policy, anytime there is a patient-to-patient physical altercation (a confrontation, tussle or physical aggression that may or may not result in injury), and a patient is physically assaulted (intentional use of force or violence against another). The MD should be notified so that any physician’s orders (instructions for a patient’s care written by a Medical Doctor) given can be implemented and to further assess the patient. If the MD is not notified, there may be patient harm. The ACNO verified the medical record did not indicate that the Medical Doctor (MD) was notified by RN staff that the patient (Patient 1) was slapped. During a review of Patient 1’s “Daily Nursing Flowsheet,” dated 2/7/2024 at 3:10 a.m., the “additional nursing notes” indicated the following: “Patient (Patient 1) slapped on back of head by roommate (Patient 31) ...” The nursing flowsheet did not indicate the MD was notified after Patient 1 was slapped. During a review of Patient 1’s “Interdisciplinary Notes,” dated 2/8/2024 at 6:45 p.m., the “nursing notes” indicated the following: “Addendum/late entry: Patient (Patient 1) was slapped in the back of the head by roommate (Patient 31). Slap was observed by staff present on a 1:1 (sitter, staff that are immediately available to help prevent a fall [an unintentional event that results in the person coming to rest on the ground or another lower level] or redirect a patient from engaging in a harmful act) observation of patient’s (referring to Patient 1) roommate (Patient 31) ...” The nursing notes did not indicate the MD was notified after Patient 1 was slapped. During a review of the facility’s policy and procedure (P&P) titled, “Assault (physical harm) Precautions and Occurrence,” dated 12/2023, the P&P indicated the following: “Assault Occurrence: 1. In the event of a patient to patient - assault staff will: c ... If injury is present immediately notify MD for appropriate orders and follow up d. RN, or designee, will collect data on details of event by talking to involved patients. ... 2. Charge Nurse to notify: a. Attending MD ...” During a review of the facility’s policy and procedure (P&P) titled, “Reassessment (process of reanalyzing and interpreting data to evaluate a patient’s health) of Patients,” dated 12/2020, the P&P indicated the following: “ ...Procedure: ... 4. Reassessment is conducted by a Registered Nurse, in the following circumstances: ... Following any physical altercations ... 1. RN findings from reassessment activities will be documented in the medical record and reported to the physician ...” 1.b. During a concurrent interview and record review on 5/29/2024 at 9:30 a.m. with the Assistant Chief Nursing Officer (ACNO), Patient 1’s nursing admission assessment record was reviewed. The ACNO had stated the following: When patients were admitted to the facility, Registered Nursing (RN) staff should ensure the admission nursing assessment (process of collecting, analyzing, and interpreting data to evaluate a patient’s health) was completed immediately, and no later than prior to the end of their shift. If there was a section or sections of the admission nursing assessment that were unable to be completed, they should be endorsed to RN staff on the next shift. For any section(s) of the nursing admission assessment marked as “unable to assess (UTA, unable to evaluate),” the RN should endorse the section(s) to the next shift to be completed. The admission nursing assessment can be endorsed up to three times and attempts should be documented on the admission nursing assessment or within the patient chart. During further concurrent interview and record review on 5/29/2024 at 9:30 a.m. with the ACNO, the ACNO verified that the following sections on Patient 1’s “Admission Nursing Assessment,” dated 1/25/2024 at 7:05 a.m., were marked “UTA” and were incomplete: 1. Admitting Vital Signs (clinical measurements that indicate the state of a patient’s essential body functions): Height and Weight 2. Berlin questionnaire (a tool to identify patients at high risk for sleep apnea) to screen for obstructive sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts) 3. Tobacco use screening 4. Substance abuse (overindulgence in or dependence on an addictive substance, especially alcohol or drugs) assessment During the same interview and record review with the ACNO, the ACNO stated that Patient 1’s admission assessment should have been completed by nursing staff or attempts to complete the sections marked as “UTA” should have been endorsed to the next shift for completion. The ACNO stated the documented efforts to complete Patient 1’s admission nursing assessment attempts should have included the date, time, reason unable to complete and RN initials. The ACNO verified that there were no attempts documented to complete Patient 1’s admission nursing assessment. The ACNO further verified Patient 1’s height and weight were not recorded in the medical record. During an interview on 5/31/2024 at 10:45 a.m. with the Staff Development Manager (SDM), the SDM stated the following: The admission nursing assessment should be completed within 8 hours of admission. If and any sections of the nursing admission assessment were incomplete or marked “UTA,” there should be three documented attempts to complete the assessment noting the date, time, reason the assessment was incomplete and initialed. The admission nursing assessment needed to be completed so that facility staff understands the medical and psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional and behavioral disorders) needs of the patient. The admission assessment was used to assess what treatments were needed for the patient. It was the responsibility of the RN staff completing the assessment to notify the physician with the any abnormal findings from the admission nursing assessment. During a review of the facility’s policy and procedure (P&P) titled, “Integrated Interdisciplinary Admission Assessments,” dated 12/2023, the P&P indicated the following: “III. 1. The Nursing Assessment will be completed for all persons admitted [to the facility] within eight (8) hours of admission. a. Upon arrival to the unit, the patient will be escorted into a consult room with his/her belongings (in sight of nursing staff at all times), until the nursing assessment is completed ... 2. The Nursing Assessment must be completed by a registered nurse (RN); however, other nursing personnel may assist in collecting data to contribute to the Nursing Assessment ... 4. The Nursing Assessment will include, but are not limited to, the following: ...b. Admitting Vital Signs ...k. Berlin Questionnaire for Obstructive Sleep Apnea ... l. Tobacco Use Screening ... q. Substance Abuse Assessment ... Upon completion of the Nursing Assessment, the nurse will contact the admitting psychiatrist, or designee, to inform him/her of any/all information obtained which requires immediate physician involvement/follow-up.” 2. During a concurrent observation and interview on 5/28/2024 at 3:29 p.m. with Licensed Psychiatric Technician (LPT) 2 in facility’s Adult 2 Unit (adult inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) medication room, the medication refrigerator was left unlocked with two vials of Ativan (medication to treat anxiety (feeling of fear or dread]) with strength of 20mg (milligram, a unit of measurement)/10ml (milliliter, a unit of measurement) inside. One of Ativan vial (Vial 1) was open and unlabeled with the date when it was opened including the expiration date. LPT 2 stated the following: licensed nursing staff should label Vial 1 with date opened and expiration date. Without the label, she (LPT2) would not know when Vial 1 would expire. During an interview on 5/30/2024 at 9:51 a.m. with the Director of Pharmacy (DIRP), DIRP stated the following: Multi-dose Ativan was stocked for Adult 2 Unit due to national shortage. The expectation was that licensed nursing staff must write open and expiration date when opening the vial. The vial was good for 28 days once opened. Licensed nursing staff should not use an unlabeled multi-dose vial due to possible contamination (dirty) as the open date and expiration date were unknown. The unlabeled vial should be removed and discarded. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated 12/2023, the P&P indicated, “It is the policy of [the facility] to administer all medications in a safe and efficient manner in compliance with regulatory guidelines ... All vials are to be labeled with “date of opening” and expiration date [28 days from date of opening] ... Questionable medications are to be returned to the pharmacy and not be administered: mislabeled.” 3.a. During a review of Patient 19’s “Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional and behavioral disorders) Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 5/23/2024, the Psych Eval indicated, Patient 19 was admitted to the facility with diagnoses of Bipolar Disorder (a mental illness that causes unusual shifts in mood, energy, and concentration), Manic (a state of mind characterized by high energy or excitement) with psychotic (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) features (delusions [something that is believed to be true or real but that is actually false or unreal] and hallucinations [false perception of objects or events involving the senses of sight, smell, etc.]), rule out Schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations and/or delusions), Bipolar Type (a mental health condition that causes extreme mood swings). During an interview on 5/28/2024 at 1:53 p.m. with the Chief Nursing Officer (CNO), CNO stated the following: a psychiatrist might place a patient on a 5250-hold (allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric evaluation and treatment) if he or she felt the patient needed longer inpatient psychiatrist treatment after the 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric evaluation and treatment) expired. The psychiatrist would complete the “Notice of Certification for Intensive Treatment - 5250 (5250-hold form)” indicating the reason for the extension of inpatient psychiatrist treatment and location of the treatment, date and sign the 5250-hold form. The Registered Nurse (RN) would sign and date as witness and then sign and date again when serving (notifying patient is being put on a involuntary 14-day hold) the 5250-hold form to the patient. CNO stated all dates should be same as the start date of the 5250-hold form. During an interview on 5/29/2024 at 2:24 p.m. with the Manager of Adult 1 and 2 Unit (UM), UM stated Patient 19 was placed on a 5150-hold on 5/22/2024 for danger to self (harming self) and gravely disabled (a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter). During a concurrent interview and record review on 5/29/2024 at 2:24 p.m. with UM, Patient 19’s “Notice of Certification for Intensive Treatment - 5250,” dated 4/28/2024, was reviewed. The 5250-hold form indicated, “We, therefore, certify the above-named person to receive intensive treatment related to the mental disorder or impairment by chronic alcoholism (alcohol addiction) beginning 5/25/2024 in the intensive treatment facility,” and the name of the facility, psychiatrist signature and date section were blank on the 5250-hold form.The 5250-hold also indicated a Registered Nurse (RN) 2 signature with date of 4/28/2024. UM stated the 5250-hold form was incomplete and incorrect because the psychiatrist should have filled out the 5250-hold form with signature and date to certify the need for the 14-day hold. Likewise, RN 2 should have dated with the same date when the 14-day hold began. UM stated, “the dates were not matching.” During an interview on 5/28/2024 at 11:04 a.m. with the Staff Development Manager (SDM), SDM stated the RN serving the 5250-hold was responsible to ensure the completion of the form and dated before serving to the patient. SDM further stated the 5250-hold was considered invalid if the 5250-hold form was not filled out correctly. During a review of the facility’s policy and procedure (P&P) titled, “LPS [Lanterman-Petris-Short, authorizes involuntary psychiatric treatment in very limited circumstances] - Certification for Intensive Treatment - 5250 (14-day hold) & Probable Cause Hearing (court trial),” dated 12/2022, the P&P indicated the following: “a. if during the 72-hour treatment and evaluation period, the attending psychiatrist and the professional person in charge of the facility determine that a mental disordered patient has not recovered sufficiently for release into the community and that the patient is still a danger to themselves or others or gravely disable due to a mental disorder and the patient is unwilling to accept voluntary treatment, the attending psychiatrist, Medical Director or other psychiatrist may certify the patient for a period not to exceed 14 days including holidays and weekends ... c. the “Notice of Certification” form will be completely legible and signed by the attending psychiatrist and the Medical Director or designated authorized staff member after evaluating the patient and concurring with the certification application. The notice of certification will include the date. In addition, the psychiatrist must state the reason(s) for validity of the criteria the certification is based upon. It is incumbent upon the psychiatrist initiating the certification to arrange the second signature. The “Notice of Certification” must be cosigned by one of the following licensed staff members: Psychiatrist, Psychologist, Registered Nurse, or Social Worker ... d. The certification for Intensive Treatment will not be considered valid until it has been appropriately completed and co-signed and all the required documentation on the certification has been completed legibly prior to the expiration of the 72-hour hold. e. Upon appropriate completion of the Notice of Certification, it is the responsibility of the Charge Nurse, or other designated RN, to complete the following procedure: i. Personally deliver a copy of the “Notice of Certification” to the patient. ii. Explain to the patient that his/her psychiatrist has place him/her on an involuntary hold for up to 14 days to treat him/her for a mental disorder ... Note: if the “Notice of Certification” is incomplete, illegible or not signed, it is not considered valid and should not be served.” 3.b. During a review of Patient 23’s “Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional and behavioral disorders) Evaluation (Psych Eval),” dated 5/16/2024, the Psych Eval indicated, Patient 23 was admitted to the facility with diagnoses of Major Depression (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) with psychotic (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) features (delusions [something that is believed to be true or real but that is actually false or unreal] and hallucinations [false perception of objects or events involving the senses of sight, smell, etc.]). During an interview on 5/28/2024 at 1:53 p.m. with the Chief Nursing Officer (CNO), CNO stated the following: a psychiatrist might place a patient on a 5250-hold (allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric evaluation and treatment) if he or she felt the patient needed longer inpatient psychiatrist treatment after the 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric evaluation and treatment) expired. The psychiatrist would complete the “Notice of Certification for Intensive Treatment - 5250 (5250-hold form)” indicating the reason for the extension of inpatient psychiatrist treatment and location of the treatment, date and sign the 5250-hold form. The Registered Nurse (RN) would sign and date as witness and then sign and date again when serving the 5250-hold form to the patient. CNO stated all dates should be same as the start date of the 5250-hold form. During an interview on 5/30/2024 at 2:03 p.m. with CNO, CNO stated Patient 23 was placed on 5150-hold on 5/15/2024 due to danger to self and gravely disabled (a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter). During a concurrent interview and record on 5/30/2024 at 2:05pm with CNO, Patient 23’s “Notice of Certification for Intensive Treatment - 5250,” dated 5/18/2024, was reviewed. The 5250-hold form indicated Patient 23 was placed on 5250-hold with begin date of 5/18/2024 signed by psychiatrist. The 5250-hold form also indicated RN 5 signed and dated on 5/19/2024 as witness and serving the 5250-form to Patient 23. CNO stated based on the documentation, RN 5 did not witness when the psychiatrist placed Patient 23 on 5250-hold on 5/18/2024 and RN 5 did not serve the 5250-hold form to Patient 23 on the same day when hold was started on 5/18/2024. During an interview on 5/28/2024 at 11:04 a.m. with the Staff Development Manager (SDM), SDM stated the RN serving the 5250-hold was responsible to ensure the completion of the form and dated before serving to the patient. SDM further stated the 5250-hold was considered invalid if the 5250-hold form was not filled out correctly. During a review of the facility’s policy and procedure (P&P) titled, “LPS [Lanterman-Petris-Short] - Certification for Intensive Treatment - 5250 (14-day hold) & Probable Cause Hearing,” dated 12/2022, the P&P indicated the following: “a. if during the 72-hour treatment and evaluation period, the attending psychiatrist and the professional person in charge of the facility determine that a mental disordered patient has not recovered sufficiently for release into the community and that the patient is still a danger to themselves or others or gravely disable due to a mental disorder and the patient is unwilling to accept voluntary treatment, the attending psychiatrist, Medical Director or other psychiatrist may certify the patient for a period not to exceed 14 days including holidays and weekends ... c. the “Notice of Certification” form will be completely legible and signed by the attending psychiatrist and the Medical Director or designated authorized staff member after evaluating the patient and concurring with the certification application. The notice of certification will include the date. In addition, the psychiatrist must state the reason(s) for validity of the criteria the certification is based upon. It is incumbent upon the psychiatrist initiating the certification to arrange the second signature. The “Notice of Certification” must be cosigned by one of the following licensed staff members: Psychiatrist, Psychologist, Registered Nurse, or Social Worker ... d. The certification for Intensive Treatment will not be considered valid until it has been appropriately completed and co-signed and all the required documentation on the certification has been completed legibly prior to the expiration of the 72-hour hold. e. Upon appropriate completion of the Notice of Certification, it is the responsibility of the Charge Nurse, or other designated RN, to complete the following procedure: i. Personally deliver a copy of the “Notice of Certification” to the patient. ii. Explain to the patient that his/her psychiatrist has place him/her on an involuntary hold for up to 14 days to treat him/her for a mental disorder ... Note: if the “Notice of Certification” is incomplete, illegible or not signed, it is not considered valid and should not be served.” 3.c. During a review of Patient 24’s “Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional and behavioral disorders) Evaluation (Psych Eval),” dated 5/18/2024, the Psych Eval indicated, Patient 24 was admitted to the facility with diagnoses of schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations [false perception of objects or events involving the senses of sight, smell, etc.]) and/or delusions [something that is believed to be true or real but that is actually false or unreal]), obesity (overweight) and hypertension (high blood pressure). During an interview on 5/28/2024 at 1:53 p.m. with the Chief Nursing Officer (CNO), CNO stated the following: a psychiatrist might place a patient on a 5250-hold (allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric evaluation and treatment) if he or she felt the patient needed longer inpatient psychiatrist treatment after the 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric evaluation and treatment) expired. The psychiatrist would complete the “Notice of Certification for Intensive Treatment - 5250” indicating the reason for the extension of inpatient psychiatrist treatment and location of the treatment, date and sign the 5250-hold form. The RN would sign and date as witness and then sign and date again when serving the 5250-hold form to the patient. CNO stated all dates should be same as the start date of the 5250-hold form. During an interview on 5/30/2024 at 2:18 p.m. with CNO, CNO stated Patient 24 was placed on 5150-hold on 5/17/2024 due to being gravely disabled (a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter). During a concurrent interview and record review on 5/30/2024 at 2:20 p.m. with CNO, Patient 24’s “Notice of Certification for Intensive Treatment - 5250,” dated 5/19/2024, was reviewed. The 5250-hold form indicated Patient 24 was placed on 5250-hold with no begin date documented and with a psychiatrist signature without date. The 5250-hold form also indicated RN 5’s signature with date 5/19/2024. CNO stated the 5150-hold form was incomplete and invalid without the begin date. CNO further stated it could be a violation of Patient 24’s rights for putting Patient 24 on hold without proper paperwork. During an interview on 5/28/2024 at 11:04 a.m. with the Staff Development Manager (SDM), SDM stated the RN serving the 5250-hold was responsible to ensure the completion of the 5250-hold form and dated before serving to the patient. SDM further stated the 5250-hold was considered invalid if the 5250-hold form was not filled out correctly. During a review of the facility’s policy and procedure (P&P) titled, “LPS [Lanterman-Petris-Short] - Certification for Intensive Treatment - 5250 (14-day hold) & Probable Cause Hearing,” dated 12/2022, the P&P indicated the following: “a. if during the 72-hour treatment and evaluation period, the attending psychiatrist and the professional person in charge of the facility determine that a mental disordered patient has not recovered sufficiently for release into the community and that the patient is still a danger to themselves or others or gravely disable due to a mental disorder and the patient is unwilling to accept voluntary treatment, the attending psychiatrist, Medical Director or other psychiatrist may certify the patient for a period not to exceed 14 days including holidays and weekends ... c. the “Notice of Certification” form will be completely legible and signed by the attending psychiatrist and the Medical Director or designated authorized staff member after evaluating the patient and concurring with the certification application. The notice of certification will include the date. In addition, the psychiatrist must state the reason(s) for validity of the criteria the certification is based upon. It is incumbent upon the psychiatrist initiating the certification to arrange the second signature. The “Notice of Certification” must be cosigned by one of the following licensed staff members: Psychiatrist, Psychologist, Registered Nurse, or Social Worker ... d. The certification for Intensive Treatment will not be considered valid until it has been appropriately completed and co-signed and all the required documentation on the certification has been completed legibly prior to the expiration of the 72-hour hold. e. Upon appropriate completion of the Notice of Certification, it is the responsibility of the Charge Nurse, or other designated RN, to complete the following procedure: i. Personally deliver a copy of the “Notice of Certification” to the patient. ii. Explain to the patient that his/her psychiatrist has place him/her on an involuntary hold for up to 14 days to treat him/her for a mental disorder ... Note: if the “Notice of Certification” is incomplete, illegible or not signed, it is not considered valid and should not be served.” 4. During an observation and interview on 5/28/2024 at 3:15 p.m. with Licensed Psychiatric Technician 1 (LPT 1) and Licensed Psychiatric Technician 2 (LPT 2), LPT 1 and LPT 2 were observed performing the controlled medications count (“narcotic count,” a count of controlled medications [a drug or chemical whose manufacture, possession, or use is regulated by a government]) in medication room 1 (in the Adult 2 Unit). LPT 2 was observed with a clipboard containing the narcotic sheets used to verify the narcotic count. LPT 2 was observed verbally stating numbers from the narcotic count sheet, without verifying the medication name and medication dose with LPT 1. LPT 1 was observed looking at the medications and verifying the count, without verifying the medication name and medication dose with LPT 2. LPT 1 and LPT 2 acknowledged they were performing the required narcotic count for their shift change. During the same interview, LPT 1 and LPT 2 stated the following: LPT 1 was the on-coming medication nurse and LPT 2 was the off-going medication nurse. The narcotic count is performed between two licensed staff during every change of shift with the off-going and on-coming assigned medication nurse. For this narcotic count, the medications were arranged in the order of the narcotic sheet by LPT 2, prior to LPT 1’s arrival and the narcotic count. Because the medications were arranged ahead of the narcotic count, LPT 2 was able to know they were in the correct order, which is why only the number was verbally stated during the count. LPT 1 did not verify the order of the medications prior to the narcotic count. During the same observation and interview, LPT 2 stated the following: During the narcotic count, the medication names and medication doses should have been verbally stated while counting so it is known which medication is being counted. Without verbally verifying the medication name and medication dose, the medications could have been out of order, the count could have been off and there could have been a medication error. During an interview on 5/30/2024 at 9:45 a.m. with the Director of Pharmacy (DIRP), the DIRP stated the following: The narcotic count is performed to count controlled substances. The narcotic count is performed for each change of shift, 3 times per day, with two licensed staff. During the narcotic count, the licensed staff should verbally verify the name, dose, and quantity of each controlled medication. If the medication name, dose, and quantity are not verified, there can be a medication error, and this could reach the patient causing harm. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated 12/2023, the P&P indicated the following: “Policy: It is the policy of [the facility] to administer all medications in a safe and efficient manner in compliance with regulatory guidelines ... Medication Administration: ...4. All controlled substances will be ‘counted’ at the start of each shift with off-going medication nurse and the on-coming medication nurse ...” 5. During a concurrent interview and record review on 5/29/2024 at 9:30 a.m. with the Assistant Chief Nursing Officer (ACNO), the ACNO stated the following: Patient 1 was admitted to the facility on 1/25/2024 at 4:15 a.m. with a diagnosis of bipolar disorder (a mental health condition that causes extreme mood swings). Patient 1 was also admitted on a 5150 (the law , which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional and behavioral disorders] hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled [a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter]), as a danger to others and gravely disabled. During the same interview with the ACNO, the ACNO stated that the interdisciplinary team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) consisted of the Psychiatrist (a medical doctor that specializes in mental health), Registered Nurse, Case Manager, and Therapists. The initial IDT Treatment Plan (provides a framework for evaluating and providing patient care needs related to the nursing process) was completed within 72 hours of admission during the IDT meeting with the patient. The Interdisciplinary (IDT) Master Treatment Plan was revised 7 days after the Initial IDT Treatment Plan. The IDT Master Treatment Plan was updated weekly by the IDT, during the IDT meeting, in discussion with the patient. The IDT Master Treatment Plan included identified problems such as psychiatric problems, medical problems, patient strengths, and patient limitations. The IDT Master Treatment Plan was discussed weekly with the patient, then the IDT signs and the patient signs indicating if the patient participated in their treatment plan. During a review of Patient 1’s “Interdisciplinary Master Treatment Plan,” the ACNO verified the following treatment plans were unsigned by Patient 1 on the following dates: 1/28/2024 and 2/4/2024. During the same interview and record review, The ACNO stated that the IDT Master Treatment Plan should have had documentation of Patient 1’s refusal or inability to participate. The ACNO confirmed the IDT Master Treatment Plans, dated 1/28/2024 and 2/4/2024, did not indicate that Patient 1 participated in their treatment plan, or if the patient refused to participate. The ACNO said that Patient 1 should have been included in the IDT Master Treatment Plan because the patient (Patient 1) needed to be aware of his (Patient 1) care and goals so the treatment plan could have been adjusted to meet the needs of the patient (Patient 1). During a review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Patient-Centered Care Planning,” dated 12/2022, the P&P indicated the following: “ ...4. Within 72 hours of admission, the multidisciplinary team shall meet to develop the treatment plan. Whenever possible, the patient and family /responsible party will be included in the treatment team meeting ... 5. The patient/family and/or representative is to sign the treatment plan to indicate their agreement with and participation in development of the plan ... Interdisciplinary Treatment Plan Update 1. Treatment Plan Review: The treatment team, including the patient/family/representative will complete a review of the treatment plan as clinically indicated, or at a minimum every (7) seven days ...””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure nursing staff administered medication (Clonidine, medication to control blood pressure) for one of 30 sampled patients (Patient 24), in accordance with the physician order and with the facility’s policy and procedure regarding medication administration. This deficient practice had resulted in Patient 24’s blood pressure to be out of control with systolic (first number of blood pressure when the heart contracts and pushes out blood) blood pressure above 150 millimeters of mercury (mmHg, unit of measure) and put Patient 24 at risk for having severe headache, vision problems, pounding in the chest and irregular heartbeat, heart attack, and or death. Findings: During a review of Patient 24’s “Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional and behavioral disorders) Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health]),” dated 5/18/2024, the Psych Eval indicated, Patient 24 was admitted to the facility with diagnoses of schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations [false perception of objects or events involving the senses of sight, smell, etc.] and/or delusions [something that is believed to be true or real but that is actually false or unreal]), obesity (overweight) and hypertension (high blood pressure). During a review of Patient 24’s “Doctor’s Order Sheet (physician order, orders written by physicians to direct care and treatment),” dated 5/17/2024, the physician order indicated Clonidine 0.1 milligrams (mg, unit of measurement) by mouth every eight (8) hours as needed (PRN) to be given for blood pressure systolic at or above 150 mmHg (millimeters of mercury, a unit of measurement) and/or diastolic (second number of blood pressure when the heart relaxes and fills with blood) blood pressure at or above 90 mmHg. During a concurrent interview and record review on 5/30/2024 at 2:18 p.m. with the Chief Nursing Officer (CNO), Patient 24’s “Vital Signs Flow Sheet (record of vital signs [measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level]),” dated from 5/17/2024 to 5/29/2024, was reviewed. The “Vital Signs Flow Sheet” indicated the following blood pressure (BP): 5/17/2024 at 4:40 p.m. BP 155/92 mmHg (high, normal BP is 120/80) 5/18/2024 at 8 a.m. BP 176/106 mmHg 5/19/2024 at 8 a.m. BP 161/88 mmHg 5/20/2024 at 8 a.m. BP 162/96 mmHg 5/21/2024 at 8 a.m. BP 145/91 mmHg 5/22/2024 at 8 a.m. BP 132/89 mmHg 5/23/2024 at 8 a.m. BP 152/102 mmHg 5/24/2024 at 8 a.m. BP 160/106 mmHg 5/25/2024 at 8 a.m. BP 163/97 mmHg 5/26/2024 at 8 a.m. BP 172/110 mmHg 5/26/2024 at 9 a.m. BP 164/104 mmHg 5/27/2024 at 8 a.m. BP 174/77 mmHg 5/28/2024 at 8 a.m. BP 177/104 mmHg 5/29/2024 at 8 a.m. BP 173/102 mmHg CNO stated all the listed days except 5/21/2024 and 5/22/2024 would meet the physician ordered criteria for Clonidine administration because the systolic BP was above 150 mmHg. CNO further stated Patient 24’s blood pressure was not controlled. During a concurrent interview and record review on 5/30/2024 at 2:25 p.m. with CNO, Patient 24’s “Medication Administration Record (MAR, record of medications given to patients),” from 5/17/2024 to 5/30/2024 was reviewed. The MAR indicated Clonidine 0.1 mg by mouth was given on 5/27/2024 at 6:40 a.m. for BP 174/77mmHg. CNO stated nursing staff did not give Clonidine to Patient 24 per physician order from 5/17/2024 to 5/30/2024. During a review of Patient 24’s care plan (provides a framework for evaluating and providing patient care needs related to the nursing process), dated 5/20/2024, the care plan indicated short-term goals for hypertension including but not limited to patient will report no signs of symptoms of high blood pressure including: severe headache, vision problems, pounding in the chest, neck or ears and irregular heartbeat. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated 12/2023, the P&P indicated, “It is the policy of [the facility] to administer all medications in a safe and efficient manner in compliance with regulatory guidelines ... Only medications needed to treat the patient’s condition shall be administered and then only after they have been ordered ... the licensed nursing staff is responsible for assessing how often and how much PRN (as needed) medication a patient is receiving before administering an additional dose. PRN medications may only be administered for the indication specified on the order.””

“CONTROLLED DRUGS KEPT LOCKED CFR(s): 482.25(b)(2)(ii) Drugs listed in Schedules II, III, IV, and V of the Comprehensive Drug Abuse Prevention and Control Act of 1970 must be kept locked within a secure area. This Standard is not met as evidenced by: 48186 Based on observation, interview, and record review, the facility failed to: 1. Keep Ativan (medication classified as controlled substances [drug that is tightly controlled by the government because it may be abused or cause addiction] Schedule IV [controlled substances schedule range from Schedule I most potential for addiction to Schedule V least potential for addiction] to treat anxiety [feeling of fear or dread]) vials locked in a secure area for three of three medication refrigerators (Fridge 1, 2 and 3) when all three medication refrigerators were observed unlocked, in accordance with the facility’s policy and procedure regarding placing controlled substances in a locked drawer or medication refrigerator. This deficient practice had the potential for unauthorized personnel to gain access to Ativan and risk for drug diversion (occurs when prescription medicines are obtained or used illegally by healthcare providers). 2. Lock one of three (narcotic [a class of drugs used to treat moderate to severe pain] drawer 1) narcotic drawers, containing controlled substances (a drug or chemical whose manufacture, possession, or use is regulated by a government), in one of three medication rooms (medication room 1 [in Adult Unit 1]), in accordance with the facility’s policy and procedure regarding placing controlled substances in a locked drawer or medication refrigerator.. This deficient practice had the potential for unauthorized patients and facility staff to gain access to the narcotic drawers resulting in patient or staff harm or death. Findings: 1. During a concurrent observation and interview on 5/28/2024 at 2:50 p.m. with Licensed Vocational Nurse (LVN) 1 in facility’s Adult 1 Unit (adult inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) medication room, the medication refrigerator (Fridge 1) was observed left unlocked with 26 vials of Ativan (medication to treat anxiety [feeling of fear or dread]) in strength of 2 milligrams per milliliter (mg/ml, unit of measurement) inside. LVN 1 stated Fridge 1 should be locked. During a concurrent observation and interview on 5/28/2024 at 3:13 p.m. with Licensed Psychiatric Technician (LPT) 2 in facility’s Adult 2 Unit medication room, the medication refrigerator (Fridge 2) was left unlocked with two vials of Ativan in strength of 20 mg/10ml inside. LPT 2 stated the lock for Fridge 2 had been broken for a while and Fridge 2 remained unlocked. LPT 2 stated Fridge 2 should be locked at all times because Ativan was inside Fridge 2. During a concurrent observation and interview on 5/28/2024 at 3:39 p.m. with LVN 2 in facility’s Youth Unit (adolescent inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) medication room, LVN 2 was able to open the medication refrigerator (Fridge 3) door without a key. LVN 2 stated there were 19 vials of Ativan in strength of 2mg/ml inside. LVN 2 stated Fridge 3 should be locked otherwise someone could access the Ativan. During an interview on 5/30/2024 at 9:46 a.m. with the Director of Pharmacy (DIRP), DIRP stated the following: all narcotics (drugs that affect mood or behavior, relieved moderate to severe pain) were controlled substances (drug or chemical whose manufacture, possession, or use is regulated by the government) under Schedule II to V (refers to the placement of controlled substances under the Federal law based upon the substances’ medical use, potential for abuse, and safety or dependence liability. Schedule II refer to drugs with high potential for abuse and Schedule V refers to drugs with lower potential for abuse). They were required to be double locked per facility’s policy and procedure. All narcotics should be kept in a locked medication room and locked inside a drawer or the medication refrigerator. Ativan was under schedule II classification and should be kept locked inside the medication refrigerator. Lock for Fridge 2 had been broken over a year and waiting for replacement. Ativan in Fridge 2 was removed and returned to pharmacy department on 5/29/2024. There was potential risk for diversions when narcotics were not locked in secure area. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated 12/2023, the P&P indicated, “It is the policy of [name of the facility] to administer all medications in a safe and efficient manner in compliance with regulatory guidelines ... To assure safety and security, all medication rooms on the inpatient units will adhere to the following: all controlled substances will be housed in an identified locked drawer within the locked medication room (Double lock). This controlled substance drawer is to remain locked whenever not in use. The same is applicable if any narcotics are housed in the medication refrigerator.” 2. During a concurrent observation and interview on 5/28/2024 at 2:43 p.m. with Licensed Vocational Nurse 1 (LVN 1) in medication room 1, narcotic [a class of drugs used to treat moderate to severe pain] drawer 1 was observed unlocked. LVN 1 verified narcotic drawer 1 contained controlled substances (a drug or chemical whose manufacture, possession, or use is regulated by a government) for patient use to be administered with a physician’s order (a doctor’s written instructions for a patient’s care). LVN 1 was able to pull narcotic drawer 1 open without using the assigned narcotic drawer 1 key. During an interview on 5/28/2024 at 2:43 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the following information: There was one assigned medication nurse on each unit for each shift. LVN 1 was the assigned medication nurse for medication room 1. There was one key for the narcotic drawer 1 in medication room 1. Only licensed staff had access to the narcotic drawer 1. LVN 1 was the assigned medication nurse with the narcotic drawer 1 key and was the only staff with access to the narcotic drawer 1 for medication room 1. The narcotic drawer 1 should have been locked. If the narcotic drawer 1 was accessed for patient use or narcotic counts (a count of controlled medications [a drug or chemical whose manufacture, possession, or use is regulated by a government]), the drawer should have been locked after each use. During an interview on 5/30/2024 at 9:45 a.m. with the Director of Pharmacy (DIRP), the DIRP stated the following: Only licensed staff, such as Pharmacists, Registered Nurses, Licensed Psychiatric Technicians, and Licensed Vocational Nurses, were allowed in the medication rooms and have access to narcotic drawers. The narcotic drawers contained controlled substances (a drug or chemical whose manufacture, possession, or use is regulated by a government), and medication drawers containing controlled substances should always be locked. During an interview on 5/30/2024 at 9:45 a.m. with the Director of Pharmacy (DIRP), the DIRP stated the following: If a medication was pulled out of a narcotic drawer, the drawers should be locked after each use. All keys to each narcotic drawer were different and there was only one master key per drawer. The narcotic drawer key was always assigned to one licensed staff. There should be a double lock for all narcotics, a lock on the door and a lock on the drawer containing the narcotics. The narcotic drawers should always be locked to ensure controlled medications were not diverted (when a medication is taken for use by someone other than whom it is prescribed). During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated 12/2023, the P&P indicated the following: “Policy: It is the policy of [name of the facility] to administer all medications in a safe and efficient manner in compliance with regulatory guidelines ... Medication Administration: ... Controlled Medications are stored in locked drawers on the medication carts or in the controlled medications drawer ... Safety and Security of Medication Rooms: To assure safety and security, all medication rooms on the inpatient units will adhere to the following: The medication room is restricted to authorized personnel only; only licensed nursing staff (LVN, LPT and/or RN) may enter the medication room; at no time can unlicensed staff be present in and/or enter into the medication room ... All controlled substances will be housed in an identified locked controlled substance drawer to remain locked whenever not in use ...””