Perimeter Behavioral Hospital of New Orleans

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 48051 Based on record review, observation and interview, the hospital failed to ensure the personal privacy of 2 (#R1, #R2) of 2 patients was maintained and consent for video surveillance was obtained prior to assigning the patient to a bedroom that was under constant video surveillance. Findings: A review of hospital policy titled, “Patient Rights,” PolicyStat ID: 17246869, last revised and approved: 01/2025 and effective as of 01/2025, revealed in part, “POLICY All Patients receiving mental health services at Perimeter Healthcare will be granted the following rights: 18. The right to give or withhold informed consent for the use or performance of any of the following (exceptions to this right must be in accordance with applicable laws, and/or standards, and must be fully explained to the individual and the person authorized to give consent, if applicable): f. Audiovisual equipment.” A review of a hospital document titled, “Conditions of Admission and Consent for Treatment” revealed in part: “Video Surveillance: It is understood and agreed that the hospital utilizes video monitoring of the facility grounds, parking area, building entrances and internal hallways, [Room “b”], [Room “c”] and common areas for safety and security purposes.” A review of the hospital’s final self-report to Louisiana Department Health Standards Section (LDH HSS), completed by S3DQ and dated 01/15/2026, revealed in part, video review conducted by the facility included recorded video of Patient #1 in Room “b” and indicated, “camera monitored room.” In an interview on 02/23/2026 at 8:25 a.m., S3DQ confirmed patient Rooms “a” - “d” had a video camera mounted to the ceiling and were video monitored. A review of an untitled hospital document provided by S3DQ on 02/23/2026 at 8:25 a.m. revealed in part, the daily staffing assignments and the room assignments of each patient. The document revealed Patient #R1 was assigned to Room “a” and Patient #R2 was assigned to Room “d.” A review of Patient #R1’s medical record revealed the previously mentioned document, “Conditions of Admission and Consent for Treatment.” The document was signed by Patient #R1, however the document failed to include Room “a” (currently assigned) under the section related to “Video Surveillance.” A review of Patient #R2’s medical record revealed the previously mentioned document, “Conditions of Admission and Consent for Treatment.” The document was signed by Patient #R2, however the document failed to include Room “d” (currently assigned) under the section related to “Video Surveillance.” In an interview on 02/23/2026 at 8:25 a.m., S3DQ confirmed the above-mentioned findings. Observations during a walk-through of the hospital on 02/23/2026 from 12:50 p.m. to 1:00 p.m. revealed a video surveillance camera mounted to the ceiling in each of the following rooms: Room “a,” Room “b,” Room “c” and Room “d.” In an interview on 02/23/2026 and present during this walk-through, S1CEO confirmed the presence of the video surveillance cameras in Rooms “a” - “d.””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48051 Based on observation, record review and interview, the hospital failed to ensure the patient’s right to care in a safe setting as evidenced by: 1) Failure to ensure the EvenCare G3 Blood Glucose Test Strips vial was dated with an opening date upon the first opening of the test strip vial; 2) Failure to ensure pre-employment, criminal background check screening was performed through a Louisiana State Police approved vendor in 3 (S5MHT, S6MHT, S7MHT) of 3 sampled personnel files reviewed; 3) Failure to ensure the documentation of the performance of a registry query on each unlicensed direct care staff member on the Louisiana Department of Health’s Adverse Action’s List Search website every 6 months in 1 (S7MHT) of 3 personnel files reviewed; and 4) Failure to ensure patient care supplies were stored separately from soiled, dirty and/or contaminated patient care items, janitorial items and/or trash. Findings: 1) Failure to ensure the EvenCare G3 Blood Glucose Test Strips vial was dated with an opening date upon the first opening of the test strip vial A review of hospital policy titled, “Care of Patients with Diabetes,” PolicyStat ID: 17314457, last revised and approved: 01/2025 and effective as of 01/2025, revealed in part, “POLICY Point-of-care (POC) glucose monitoring should be performed before meals, in those not eating, glucose monitoring is advised every 4-6 h. (1) See Waived Testing policy for Glucometer use and training.” A review of a hospital document titled, “Waive Testing Reference,” revealed in part, “PROCDURES - follow manufacturer’s instructions - the following are highlighted items to be followed: 8. EvenCare G3 Blood Glucose testing: c. Test Strips: Test strips are light sensitive. Close the bottle immediately after removing the test strip. Record the “date opened” on the bottle label. Discard the bottle and any remaining test strips after 6 months from date of opening.” Observations during a walk-through of the hospital on 02/18/2026 from 10:25 a.m. to 12:05 p.m. revealed the EvenCare G3 Blood Glucose Test Strips open and in use, failing to have a first opening date marked on the vial or documented on any other hospital records. The use of blood glucose test strips that are potentially out of date can create a safety risk to the patient resulting in injury and/or harm related to the accuracy of the blood glucose results and the subsequent therapeutic measures performed based on these blood glucose results. In an interview on 02/18/2026 and present during this walk-through, S2DON confirmed the above-mentioned findings, confirmed a first opening date should be marked on the vial and confirmed she was not sure when the test strip vial was open. 2) Failure to ensure pre-employment, criminal background check screening was performed through a Louisiana State Police approved vendor in 3 (S5MHT, S6MHT, S7MHT) of 3 sampled personnel files reviewed Pursuant La RS 40:1203.1-2 requiring that licensed health care providers shall request that a criminal history and security check be conducted on the non-licensed person, prior to any employer making an offer to employ or to contract with a non-licensed person or any licensed ambulance personnel to provide nursing care, health-related services, medic services, or supportive assistance to any individual and in accordance with La RS 40:1203.1-5. Pursuant to the laws cited La. R.S. 15:575 et seq. The Louisiana Office of State Police, Bureau of Criminal Identification and Information (Bureau), is the State’s designated repository for criminal history information. Any criminal event that is documented by the submission of fingerprints to the State is stored in the Louisiana Computerized Criminal History (LACCH) database. The Bureau is authorized to release criminal history information stored in LACCH to those employers and Authorized Agencies defined in La. R.S. 40:1203.1 as required by La. R.S. 40:1203.2. Employers may request criminal history information stored in LACCH in one of three ways: (1) use of the Bureau’s Internet Background Check (IBC) website, (2) via Authorized Agents, and (3) submission of applicants’ fingerprints. Pursuant to La. R.S. 40:1203.7, Authorized Agencies must be domiciled in the state of Louisiana and must be certified by the La. Secretary of State’s office. Authorized Agents must also be certified by the Bureau. Companies that perform background check services that are not domiciled in Louisiana nor certified through the Secretary of State’s office and the Bureau are not authorized to request or receive criminal history information stored in LACCH. Additionally, Authorized Agents are not authorized to request criminal history information on behalf of national background check companies. La. R.S. 15:579 mandates the Bureau to issue rules and regulations consistent with the U.S. Dept. of Justice governing the privacy and security of criminal history records. To meet this requirement, the Bureau has adopted rules and regulations including those described in 28 Code of Federal Regulations (CFR) 20.21 which limits the release of criminal history information to only those agencies authorized by statutes. Employers may contact LDH or the Bureau for a current list of Authorized Agencies. A review of personnel files revealed the following: --S6MHT personnel file review revealed a date of hire as 07/28/2022 and a criminal background check completed on 07/16/2021. However, the criminal background check failed to reveal the source of the information received; --S7MHT personnel file review revealed a date of hire as 10/03/2019 and a criminal background check completed on 10/02/2019. However, the criminal background check was completed by a Company A, which did not appear on the Louisiana State Police Aurhtorized Agencies list; and --S8MHT personnel file review revealed a date of hire as 09/17/2024 and a criminal background check completed on 08/21/2024. However, the criminal background check was completed by a Company B, which did not appear on the Louisiana State Police Aurhtorized Agencies list. In an interview on 02/23/2026 at 11:50 a.m., S9MHR confirmed the above-mentioned findings. 3) Failure to ensure the documentation of the performance of a registry query on each unlicensed direct care staff member on the Louisiana Department of Health’s Adverse Action’s List Search website every 6 months in 1 (S7MHT) of 3 personnel files reviewed A review of LAC: Title 48, Chapter 92, Direct Service Worker Registry, revealed in part, the following: “§9202. C. Licensed and/or certified health care providers shall access the registry to determine if there is a finding that a prospective hire, or currently employed or contracted DSW, has been determined to have committed exploitation, extortion, abuse or neglect of an individual being supported, or misappropriated the individual’s property or funds. If there is such a finding on the registry, the prospective employee shall not be hired as a DSW nor shall a current employee have continued employment as a DSW with the licensed and/or certified health care provider. §9231. Health Care Provider Responsibilities, A. Prior to hiring any DSW or trainee, the licensed and/or certified health care provider shall: 3. Access the registry in accordance with the provisions of §9202.C-C.1. B. The health care provider shall: have a written policy/process to check the DSW registry on the department’s designated database at least every six months to determine if any currently employed or contracted DSW or trainee has been placed on the registry with a finding that he/she has been determined to have committed abuse or neglect of an individual being supported or misappropriated the individual’s property or funds or committed exploitation or extortion of an individual being supported. 2. If there is such a finding on the registry, the employee shall not have continued employment as a DSW with the licensed and/or certified health care provider in accordance with the provisions of §9202.C.” A review of the Louisiana State Adverse Actions List Search website revealed in part: “Employers must use the DSW registry to determine if there is a finding that a prospective hire has abused or neglected an individual being supported, or misappropriated the individual’s property or funds. If there is such a finding on the registry, the prospective employee shall not be hired. The provider shall check the registry every six months to determine if any currently employed direct service worker or trainee has been placed on the registry with a finding that he/she has abused or neglected an individual being supported or misappropriated the individual’s property or funds.” A review of S7MHT’s personnel file failed to reveal the performance of a registry query on the Louisiana Department of Health’s Adverse Action’s List Search website. A review of a spreadsheet presented by S9MHR revealed a list of all staff members. This spreadsheet included in part, a column labeled “Adverse Actions.” This column had a date on each unlicensed direct care staff member’s associated row. S7MHT’s row included a date under the column labeled “Adverse Actions” as 04/10/2025, which was greater than 6 months ago. This spreadsheet failed to reveal where the documentation was obtained. In an interview on 02/23/2026 at 11:50 a.m., S9MHR confirmed the above-mentioned findings. S9MHR confirmed the dates associated with the column labeled “Adverse Actions” would have been associated with the last performance of the registry query on the Louisiana Department of Health’s Adverse Action’s List Search website for each employee. S9MHR confirmed she could not produce documentation related to the performance of this registry query on 04/10/2025 and confirmed the registry query results would need to be saved for proof of this performance. 4) Failure to ensure patient care supplies were stored separately from soiled, dirty and/or contaminated patient care items, janitorial items and/or trash. Observations during a walk-through of the hospital on 02/18/2026 from 10:25 a.m. to 12:05 p.m. revealed Rooms “e” and “f” having patient care supplies stored with soiled, dirty and/or contaminated patient care items, janitorial items and/or trash. These rooms contained the following: Room “e:” Observations of this Room “e” included a mop sink, damaged patient equipment that was confirmed as not being used and needed to be removed from the hospital, a large grey storage contained dirty linen and a large grey storage bin contained trash, clean lab supplies, a refrigerator labeled for lab specimens, a lab centrifuge, and sharps container attached to the wall. The following lab supplies were stored in this area: A mobile cart included: -4 Tourniquets -6 BD Safety-Lok Blood Collection Kits 25 G -12 Muti-Sample Needles with an expiration of 05/15/2025; -1 21 G 1 ¼” Multi-Sample Needle open; -2 22 G 1 ¼” Multi/Sample Needle open; an -10 clear specimen tubes; -18 BD Vacutainer SST collection tubes (8.5 ml capacity); -5 Vacutainer Purple top collection tubes (4ml capacity); and -10 BD Vacutainer Serum blood collection tubes (10 ml capacity); and A floor chest included: -31 BD Vacutainer Safety-Loc Blood Collection Kit; -Multi-Specimen Collection Tubs in a bag labeled as contained 100, this bag was approximately 25% empty; -5 Vacutainer Purple top collection tubes (4ml capacity); -19 Alinity Multi-Collect Specimen Collection Kit; and -10 vacutainer collection device holders; and A wall cabinet contained: -2 boxes of 50 each BD vacutainer C&S Transfer Straw Kits; -75 Vacutainer Purple top collection tubes (4ml capacity); -125 BD Vacutainer SST collection tubes (8.5 ml capacity); -100 BD Vacutainer Serum blood collection tubes (10 ml capacity); -Box of 50 BD Safety-Lok Blood Collection Kits 25 G; -Full box (no quantity indicated on box) of BD Vacutainer Eclipse Blood Collection Needle 21 G, 1 ¼”; - Full box (no quantity indicated on box) of BD Vacutainer Eclipse Blood Collection Needle 22 G, 1 ¼”; -2 boxes of 200 count Cardinal Health Alcohol Pads; -2 boxes of 100 count Medline Alcohol Pads; and -3 packs of 200 count McKesson Woven Gauze Sponges. Room “f:” Observations of Room “f” included a wall shelving storing patient toiletry items, a rolling cart with uncovered clean linen stored, a red biohazard bin with a labeled which indicated dirty linen and a red biohazard bin with a label which indicated trash. The following toiletry items and linen were stored in this area: -pencil box style storage boxes containing toiletry items and labeled by patient room numbers; Blue storage bins containing: -20 Medline Antiperspirants 1.5-ounce container; -8 Remedy Essentials Cleanse Shower and Body Wash 2-ounce container; -9 Remedy Baby Moisturize Lotion 2-ounce container; -25 Medline Sparkle Fluoride Toothpaste 1.5-ounce container; -50 Toothbrushes; and - 25 Medicine Cups - 30 ml capacity; and A rolling cart containing approximately 10 bath towels and 10 wash clothes. The storage of clean patient care supplies with soiled, dirty and/or contaminated patient care items, janitorial items and/or trash in the same room presented a safety risk to the current Patients (#2, #R3 - #R33). This safety risk included the potential for harm and/or injury related to the transfer of infectious disease between clean, patient care items and dirty and/or contaminated items while in storage. In an interview on 02/18/2026 and present during the walk-through of the hospital, S1CEO and S2DON confirmed the above-mentioned findings and confirmed these items should not be stored together.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure the patient’s right to be free from all forms of abuse and harassment as evidenced by the failure to report instances of potential abuse/neglect to the Louisiana Department of Health, Health Standards Section (LDH HSS). Findings: Pursuant to La. R.S. 40:2009.20 facilities/health care workers shall report allegations abuse/neglect within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Louisiana Department of Health (LDH). A review of hospital’s incident log revealed an incident related to an elopement. A request was initiated 02/18/2026 at 2:30 p.m., with S1CEO and S3DQ for additional information and for documentation of a self-report being submitted to the LDH HSS. The following information was received: A review of the incident log revealed an incident on 01/13/2026 at 6:15 p.m. involving Patient #R3 and revealed in part, “Pt was on patio with others. MHT stepped inside. Pt jumped wall onto the roof. He walked the roof for several minutes stating “I want my phone so that I can call my friend to pick me up.” Staff made several attempts to talk pt down. Pt got down on his own, escorted back into building by staff. No injuries involved. Pt crying hysterically asking to be discharged. Stating that the doctor told him that he would be able to use his phone.” An elopement would constitute a potential allegation of neglect and the need to report to LDH HSS within 24 hours. In an interview on 02/18/2026 at 2:40 p.m., S3DQ confirmed the incident on 01/13/2026. She further confirmed the hospital determined this incident did not meet the criteria of a need to report to LDH HSS because the patient did not leave the facility’s premises. S3DQ did confirm the patient did not remain in the secured confinements of the facility’s patient care area.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 48051 Based on record reviews and interviews, the hospital failed to recognize opportunities for improvement and initiate changes to ensure compliance with patient care in a safe setting as evidenced by improper quality control and functionality of the blood glucose meters. Findings: A review of the Quality Assurance Performance Improvement (QAPI) Indicators 2025 and 2026 year to date failed to reveal an indicator related to the performance and monitoring of the hospital’s blood glucose meters. Observations during a walk-through of the hospital on 02/18/2026 from 10:25 a.m. to 12:05 p.m. revealed the EvenCare G3 Blood Glucose Test Strips open and in use, failing to have a first opening date marked on the vial or documented on any other hospital records. The use of blood glucose test strips that are potentially out of date can create a safety risk for the patient resulting in injury and/or harm related to the accuracy of the blood glucose results and the subsequent therapeutic measures performed based on these blood glucose results. In an interview on 02/18/2026 and present during this walk-through, S2DON confirmed the above-mentioned findings. In an interview on 02/23/2026 at 11:30 a.m. S3DQ confirmed QAPI had not been monitoring the hospital’s blood glucose meter for quality control and performance.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure the documentation of the performance of daily temperature checks on the lab specimen refrigerator. Findings: A request was initiated on 02/23/2026 at 8:25 a.m. for a hospital policy related to the performance of refrigerator temperature checks. A review of the lab specimen refrigerator log during the walk-through of the facility on 02/18/2026 from 10:25 a.m. to 12:05 p.m. revealed the associated log being labeled as: “Location: LAB ROOM” and “Month/Year FEBRUARY 2026.” The log included a statement under the daily graph as follows, “Directions: Please initial daily at the bottom of the graph in the space provided and graph the daily temp in the block.” The log failed to reveal the documentation of the performance of daily temperature checks on 02/08/2026 - 02/10/2026, 02/16/2026 and 02/17/2026. In an interview on 02/23/2026 at 1:00 p.m., S3DQ confirmed the above-mentioned findings, confirmed the hospital did not have a policy related to the performance of refrigerator checks and confirmed the refrigerators should be checked daily and this performance documented accordingly.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 44495 Based on record review and interview, the psychiatric hospital failed to provide care in a safe setting. The deficient practice is evidenced by failure to monitor the patient according to the ordered level of observation in 1 (#3) of 3 (#1-#3) reviewed medical records. Findings: Review of the medical record for Patient #3 revealed admission on 04/28/2024 with a diagnosis of bipolar disorder. Review of the nursing notes from 04/29/2024 at 11:40 a.m. revealed “Patient grabbed housekeeping penis while mopping. S4MD wants to give PRN.” Further review revealed an additional nursing note at 11:46 a.m., “Room was changed and placed on 1 to 1. Review of the evening shift notes and observation sheets failed to reveal documentation the patient was on one to one observation. Review of the physician’s orders revealed a verbal order initiated on 04/29/2024 at 12:05 p.m. for 1 to 1 observation. Review of the psychiatrist note from 04/29/2024 at 1:29 p.m. revealed in part, “The staff has reported that the patient is sexually inappropriate. He was touching people on the unit. He was placed on 1 on 1 due to sexually inappropriate behavior.” Review of the Nursing Assignment Sheets for 04/29/2024 for the day and evening shift revealed the patient was on line of sight observation. In interview on 05/08/2024 at 2:02 p.m., S3RN verified there was no documentation Patient #3 was observed 1 to 1 on the evening of 04/29/2024 as ordered by the physician.”

“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: 44495 Based on record review and interview, the nursing staff failed to assess the care needs and health status of each patient on admission. The deficient practice is evidenced by failure to complete the Nursing Admission Assessment in 1 (#2) of 3 (#1-#3) reviewed medical records. Findings: Review of Policy PC81, “Plan of Care- Protocol for the Use of Multidisciplinary Format,” reviewed 08/2023, revealed in part, “Nursing will complete an admission Assessment within eight (8) hours of admission . . . . The Charge Nurse or designee will update the Master Problem List by adding new problems, closing resolved problems and entering the appropriate status code. . . . All unit staff should be apprised of revisions and review the plan of care prior to making a care intervention with the patient.” Review of the Nursing Admission Assessment initiated on 04/05/2024 at 5:40 p.m. revealed the nurse documented in several places “refuses-sleepy,” and “too sleepy assess.” Further review revealed the assessment was never completed and never signed and dated by the nurse attempting the assessment. In interview on 05/08/2024 at 2:25 p.m., S2RN verified the assessment was started but not completed because the patient could not cooperate. S2RN verified the nurse failed to complete the assessment at a later time when the patient was more cooperative.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 44495 Based on record review and interview, the nursing staff failed to update the plan of care after a significant event. The deficient practice is evidenced by failure to update the nursing plan of care after sexually inappropriate behavior was noted for 1 (#3) for 3 (#1-#3) reviewed medical records. Findings: Review of Policy PC81, “Plan of Care- Protocol for the Use of Multidisciplinary Format,” reviewed 08/2023, revealed in part, “Nursing will complete an admission Assessment within eight (8) hours of admission . . . . The Charge Nurse of designee will update the Master Problem List by adding new problems, closing resolved problems and entering the appropriate status code. . . . All unit staff should be apprised of revisions and review the plan of care prior to making a care intervention with the patient.” Review of the medical record for Patient #3 revealed admission on 04/28/2024 with a diagnosis of bipolar disorder. Review of the nursing notes from 04/29/2024 at 11:40 a.m., revealed the patient had inappropriately grabbed housekeeping. Review of the psychiatrist note from 04/29/2024 at 1:29 p.m. revealed in part, “The staff has reported that the patient is sexually inappropriate. He was touching people on the unit. He was placed on 1 on 1 due to sexually inappropriate behavior.” Review of the plan of care revealed the plan was not updated to include sexually inappropriate behavior. In interview on 05/08/2024 at 2:19 p.m., S2RN verified the plan of care was not updated to address the sexually inappropriate behavior.”

“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: 44495 Based on record review and interview, the nursing staff failed to follow hospital policy and standard of care for medication administration. The deficient practice is evidenced by failure to follow up after administration of PRN medication for effectiveness in 2 (#2, #3) of 3 (#1-#3) reviewed medical records. Findings: Review of Policy MM24, “Medication Administration,” reviewed 08/2023. revealed in part, “’PRN’ medications administered are qualified by designating the times of administration and parameters, i.e. patient’s blood sugar, blood pressure. . . . Each dose of medication administered is properly recorded in the patient’s medical record on the Medication Administration Record. The nurse marks through the medication and initial the block next to the appropriate date and time on the MAR when medication is given. The nurse circles the time block if the patient refuses the medication or if it is not given. The nurse documents refusals and all relevant information on the back of the MAR.” Patient #2 Review of the physician orders for Patient #2 revealed an order initiated on 04/05/2024 at 6:00 p.m. for Zofran 4 milligrams by mouth every 6 hours as needed for nausea and/or vomiting. Review of the Medication Administration Record revealed the medication was administered on 04/09/2024 at 8:25 p.m. Further review of the medication administration record and the nurses notes failed to reveal the nurse followed up for effectiveness. In interview on 05/08/2024 at 2:26 p.m., S2RN verified the nursing staff did not follow up after administering the PRN medication. S2RN verified the nursing staff should have documented the reason it was given and the follow-up for effectiveness on the back of the medication administration sheet. Patient #3 Review of the physician orders for Patient #3 revealed an order initiated on 04/28/2024 at 1:55 p.m. for Haldol 5 milligrams PO/IM PRN every 6 hours as needed for psychosis, Ativan 2 milligrams PO/IM PRN every 6 hours as needed for anxiety, and Benadryl 50 milligrams PO/IM PRN every 6 hours as needed for anxiety. Review of the nursing notes for 04/29/2024 at 11:40 a.m. revealed an incident where the patient inappropriately grabbed housekeeping and the psychiatrist “wants to give PRN.” Review of the psychiatrist note from 04/29/2024 at 1:29 p.m., revealed in part, “He was given a B52.” Review of the MAR for 04/29/2024 revealed no documentation the medication was given. Further review of the MAR revealed the three medications were given by injection on 04/28/2024 at 2:55 p.m., 05/01/2024 at 6:55 p.m. 05/03/2024 at 11:20 a.m. and 5:34 p.m. with no documentation of the site or if the medication was effective. In interview on 05/08/2024 at 2:19 p.m., S2RN verified the nursing failed to document the medication administration on the medication administration record when given on 04/29/2024 and did not document a follow-up for effectiveness on 04/28/2024, 05/01/2024, and 05/03/2024.”