Mount Carmel Behavioral Health

“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: 32088 Based on record review, interview and policy review, the facility failed to ensure medications were administered as ordered, failed to ensure daily weights were obtained as ordered, and failed to ensure a patient was properly assessed/reassessed with appropriate interventions implemented prior to and after falls. This affected one (Patient #3) of three patients reviewed for nursing care. The census was 52. Findings include: Review of Patient #3’s medical record revealed on 05/25/25 at 3:27 PM the patient was pink slipped by Mount Carmel East Psychiatry. The pink slip stated patient had a prior history of depression and recent psychiatric hospitalization for suicidal ideations presented to the hospital after placing a drill to his head. The wife expressed safety concerns as the patient is exhibiting mood lability and unpredictable behaviors. The provider noted the patient would benefit from further stabilization with inpatient hospitalization. Review of the intake assessment dated 05/27/25 at 2:12 PM revealed the patient was admitted from a neighboring medical facility. His wife was listed as his emergency contact. The patient had a history of congestive heart failure (CHF), stage 3 kidney disease, diabetes, neuropathy and leg edema. The patient was noted to use a walker and wheelchair for mobility. The patient was noted to be a high fall risk and stated he was having weakness. The patient presented with a history of depression and anxiety. The patient reported he recently lost a friend, brother in law and sister in law and these losses triggered the depression and suicidal ideations. The short term memory issues started one month ago. The patient frequently discussed the edema to his legs and is concerned about this. He was diagnosed with major depressive disorder (MDD). His speech was noted as talkative, not slurred. a. Review of Patient #3’s orders revealed on 05/28/25 the provider ordered Lasix 20 milligrams (mg) by mouth daily as needed for weight gain, increased shortness of breath or increased swelling. Lasix 20 mg remained on the order set until the patient discharged. On 05/29/25 at 12:38 AM there was an order placed for daily weights and for the nurse to notify the provider of weight gain of two pounds in a day and/or five pounds in a week. Review of the medication administration record (MAR) revealed the patient received as needed (prn) Lasix 20 mg on 05/29/25, 05/30/25, 05/31/25, 06/02/25, 06/05/25 and 06/06/25. There was no indication as to why the medication was administered. The Lasix medication was not administered on 06/01/25, 06/03/25 and 06/04/25. The patient weighed 195 pounds on 05/30/25 at 10:41 AM. Review of the MAR and weight flow sheet revealed on 05/27/25 at 4:24 PM, Patient #3 weighed 207 pounds; on 05/28/25 at 12:30 PM, the patient weighed 207 pounds; on 05/29/25 at 12:19 PM, 199.4 pounds; on 05/30/25 at 10:41 AM, 195 pounds; and on 06/05/25 at 9:00 AM, 210 pounds. There were no daily weights obtained on 05/31/25, 06/01/25, 06/02/25, 06/03/25, and 06/04/25. Review of the day shift note dated 06/05/25 revealed the patient had fluid retention and the provider was notified. There were no nursing notes for night shift on 06/03/25, 06/04/25 and 06/06/25 or day shift on 06/06/25. Review of Patient #3’s orders revealed on 06/05/25 at 12:54 PM there was an order to transport the patient to the hospital due to a 15-pound weight gain in five days. Review of the incident report dated 06/05/25 at 3:09 PM revealed the patient had heart and kidney failure and had been gaining weight. The patient was had daily weights and the last documented weight was 195 pounds on 05/30/25. The nurse noted on this day (06/05/25) the patient’s weight was 210 pounds. The provider ordered for the patient to be sent out to the hospital. Review of the ED visit discharge notes for the 06/05/25 visit revealed the provider noted the patient was being seen for a 15 pound weight gain over the last several days. The provider noted the patient’s potassium was mildly elevated but was ordering Lasix to try to help that. He noted the patient had an enlarged prostate that he was ordering Tamulosin (alpha blocker that relaxes muscle in the prostate and bladder) for it. The patient was discharged back to the mental health hospital with follow up appointments scheduled. The ED provider noted the patient had been seen on 06/01/25 for weakness and low blood pressure. He noted the patient was getting 60 mg of Lasix and this was more that he should have been taking. The patient was cut back to 20 mg and was discharged. The provider noted for this visit that the patients left bicep was torn and there is no acute treatment. The patient would need to follow up with outpatient therapy. b. Review of Patient #3’s MAR revealed the patient was ordered Coreg 12.5 mg by mouth (po) twice a day (bid) and hold if the blood pressure (BP) is less than 110/60 or heart rate less than 60. On 05/30/25 was given Coreg at 9:00 PM but the patient’s BP was 99/60 at 6:38 PM and at 9:26 PM. On 06/01/25 the patient’s BP was 106/62 at 7:23 AM and 109/68 at 6:39 PM, but was given Coreg at 9:00 AM and 9:00 PM. Review of the incident report dated 06/01/25 completed by Staff O revealed at 10:35 AM the patient had an episode of dizziness, light headedness, weakness and left shoulder pain. The nurse noted a series of vitals from 10:30 AM to 10:35 AM ranging from 70/41 to 76/47. The provider was called and the patient was sent to the hospital. Review of Patient #3’s orders revealed on 06/01/25 at 10:48 AM there was an order to transport the patient to the hospital due to decreased blood pressure. Review of the Emergency Department (ED) visit discharge notes for 06/01/25 revealed the patient was seen for hypotension. The discharge notes stated if the systolic BP is under 90 do not take the Coreg and if that continues to happen to notify the primary care provider (PCP). c. Review of the Initial Nursing Assessment dated 05/27/25 at 5:25 PM revealed the patient arrived on the unit at 5:00 PM. The nurse noted the patient was independent with walking, eating, dressing, bathing, toileting, cooking and cleaning. The patient needed supervision with errands, and bill paying. The nurse noted the patient had a walker as an assistive device. The patient did not have urinary incontinence. He was identified as a high fall risk with a score of 65 (high risk 45+). His speech was normal. The patient was noted as ambulatory with a rollator. An additional Initial Nursing Assessment dated 05/27/25 revealed the patient arrived on the unit at 4:42 PM and was identified as a low fall risk, contradicting the high fall risk on the other nursing assessment. This assessment stated the patient did not use an ambulatory aid, had normal gait and no history of falls. The anticipated discharge plan was home with his spouse. Review of the care plan revealed on 05/28/25 the patient was identified as a moderate fall risk. The plan stated nursing would implement fall precautions and educate the patient on the importance of compliance and the bed will be in the low position. There were no other interventions noted nor was the plan updated after the patient fell. Review of the Nursing Notes revealed on 05/28/25, 05/29/25, 05/30/25, 05/31/25 for the 7:00 PM to 7:00 AM shift there were no fall precautions identified for Patient #3. Review of the Nursing Note dated 06/02/25 for 7:00 PM to 7:00 AM shift revealed the patient had a “fall in room.” Review of the Incident report dated 06/02/25 at 9:30 PM revealed in the 400 hall phone room the patient attempted to self-transfer from the wheelchair and was found on the floor, sitting. There were no injuries or pain noted. The patient was assessed and educated to call for help. The provider and wife were notified. Review of Patient #3’s fall risk assessment on 06/02/25 revealed the patient was re-assessed for falls and was high risk. A post fall assessment was conducted on 06/02/25 at 9:30 PM after the patient fell and indicated the patient remained a high risk for falls. Review of Patient #3’s care plan revealed it was not updated with additional fall interventions after the fall. Review of the 06/03/25 day shift note revealed the patient had active medical problems and a left elbow skin tear, bruising to bilateral upper extremities and edema bilaterally to lower extremities. The note also stated the patient was “very slow to answer or talk this morning”. His skin color was noted as pale, his lips slightly pale. His speech was slurred and the patient reported it was hard to get his words out. The nurse noted the patient drifts off and his eyes are closed. The nurse noted the patient had cardiovascular issues, peripheral edema, was using a wheelchair and stated the patient was talking better and perked up by the late afternoon. The nurse noted the patient needed assistance with toileting, showering and dressing. Review of the 06/04/25 day shift note revealed the patient needed help showering and had no fall precautions. Interview on 12/30/25 at 11:20 AM with Staff A confirmed there were no nursing notes for night shift on 06/03/25, 06/04/25 and 06/06/25 nor day shift 06/06/25. He also verified the DC summary listed two falls one in the shower and one in the wheelchair but there was one incident report for the fall from the wheelchair and none of the nursing notes mention the shower fall. He stated when a patient falls, the nurse writes it in the nursing notes and completes an incident report. In addition, he verified there were no fall precautions listed for Patient #3 post fall on 06/04/25 day shift and Patient #3’s plan of care has the patient as a moderate risk for falls throughout the stay. Staff A verified the patient was not getting daily weights, nor was the Coreg and Lasix being administered as ordered. Interview on 12/30/25 at 11:30 AM with Staff L revealed she was the APRN who wrote the DC Summary for Patient #3 on 06/06/25. She verified she noted the patient had two falls while at the facility but states she cannot remember how she knew of the two falls. She stated usually staff informs them or they see it in a note. She stated she remembers Patient #3 because he was medication sensitive. She stated, “I remember after increasing a medication his words were slurred.” Staff L revealed the patient’s wife was not happy with the falls and blood pressure issues that happened here at the facility. She stated his blood pressure was low and they had to send him to the hospital although she did not remember why it was low. Staff L stated, “the wife had valid concerns with the care her husband received here.” Review of the hospital policy titled “Fall Prevention”, undated, revealed all patients will be assessed for falls using the MORSE Falls Assessment as part of the nursing assessment. Each patient will be placed in risk category (Standard, Low 0-24, Medium 25-44 and High 45+). Standard prevention interventions include orient the patient to their surroundings, keep the room free from clutter, ensure the patient has proper non-skid footwear, provide the patient with the ability to contact nursing staff at night, routine checks. If the patient is a medium risk staff should implement the following: all standard and low risk intervention, perform a gait assessment, review the medications, monitor the patients gait after sedating medications, ensure appropriate assistive devices, adequate lighting and consult therapy if appropriate. For high risk patients staff should implement all standard, low, and medium risk precautions. In addition, staff should educate the patient to change positions slowly, monitor the patient for fatigue and encourage rest, assist and encourage the patient to use the bathroom every two hours and monitor for incontinence, use safety mats and alarms at night, do not leave the patient in the bathroom unattended, place the patient on 1:1 if indicated by a provider order or nursing judgement. After a fall and incident report will be completed and submitted to the Director of Risk Management. The medical practitioner will be contacted by the charge nurse to determine the course of treatment after a patient has fallen. The patient will be identified as a fall risk if not done on admission. The patient’s fall risk status will be reassessed and appropriate interventions will be implemented. Any changes in interventions will be indicated in the Interdisciplinary Treatment Plan.”