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Based on record review and interview, the facility failed to provide a copy of the "Important Message from Medicare" (IMM) Form in advance of the patient's discharge, but not more than two calendar days before the patient's discharge in 7 (Patients #2, #3, #4, #5, #6, #7, and #8) of 7 records reviewed.

Review of Patient #3, 2, and 4's chart revealed she was not provided a copy of her IMM letter before discharge.

An interview was conducted with Staff #4 on 6/14/22. Staff #4 stated that she was not aware that the patients had to recieve a second IMM letter before discharge. Staff #4 stated, " we have not been doing that."




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Record reviews and interviews completed June 13-15, 2022 revealed the following:

Review of Patient #5's chart revealed she was not provided a copy of her IMM letter before discharge.
Review of Patient #6's chart revealed she was not provided a copy of her IMM letter before discharge.
Review of Patient #7's chart revealed she was not provided a copy of her IMM letter before discharge.
Review of Patient #8's chart revealed she was not provided a copy of her IMM letter before discharge.

During an interview with Staff #1 on 6/14/2022, the findings were confirmed.

Based on record review and interview the facility failed to:

A. ensure the informed consent to treat, for a voluntary admission, was signed, and understood by a competent adult that had the capacity to consent in 1 (#4) of 2 (#1 and #4 ) charts reviewed.

B. ensure the patients consented and received an explanation by the nurse or physician the name of administered psychotropic medications, the beneficial effects on the patient's mental illness, or condition expected as a result of treatment with psychotropic medication in 2 (#4, #7) of 3 (#1, #4 and #7) chart reviewed.

Review of patient #4's chart revealed she was brought to the facility by ambulance on 1/25/22. Patient #4 was brought to the facility on an Emergency Detention Without a Warrant (Police Officers Warrant) for detainment until she was seen by a physician to determine further care or release to home.

Review of the physician orders dated 1/26/22 stated the patient was to be admitted as voluntary.

Review of the psychiatric evaluation dated 1/26/22 stated in the patient admit status was "voluntary." The physician documented, "Patient presents after being on a prolonged one on one supervision at her nursing home. The patient has had altercations with multiple residents. The patient has been yelling and cursing at staff posturing having homicidal ideations towards both staff and other residents. The patient repeatedly was awakening another male resident thinking he was her husband the patient then would go into a paranoid delusional state and scream "help me" over and over again the patient clearly was under distress the patient also was paranoid and believe "people are trying to kill me." patient was unable to be redirected the patient was dropping her pants and putting herself and others in danger. The patient was not caring for her ADLs was confused, agitated and aggressive. The patient is bizarre and disorganized. The patient is tangential and circumstantial. The patient is on edge and internally preoccupied. The patient is responding to internal stimuli. The patient can questionably not care for themselves as they have poor reality testing, they need prompting in order to adjust to the milieu, and they are extremely bizarre. The patient is easily agitated. The patient is restless. The patient is volatile and labile. The patient lacks insight and has poor judgment."

Review of the chart revealed there was no documentation from the physician that Patient #4 had a capacity to consent. There was no evidence found that the patient was able to understand where she was, her patient rights, or was mentally competent to understand she was in the facility to receive treatment for mental health care or receive psychotropic medications. The physician upon examination could have applied for an Order of Protective Custody (OPC) through the court system to hold the patient for mental health care. There was no evidence that Patient #4's rights were honored and an OPC was filed to allow the patient to go before a judge to determine if she could be detained against her will for treatment.

Review of the facility's policy and procedure "Voluntary and Involuntary Texas" stated, " ...POLICY: The inpatient program accepts both voluntary and involuntary admissions. Voluntary admissions include formal voluntary admissions), while involuntary admissions include: Protective Custody Order (OPC), Emergency Peace Officer's Warrant (EPOW), Emergency Detention Warrant (EDW), and a Guardian Emergency Detention Order (GDO). An involuntarily admitted person who understands that he/she is in a facility which treats psychiatric and addictive diseases and desires to be admitted for such treatment can have his/her status changed to voluntary by signing the required documents at any time.

...Voluntary Admissions:
Intake Coordinator: Ascertains the patient's ability to understand that he/she is in a treatment facility, that he/she wishes to be admitted, and that a four (4) hour written notice must be given of intent to leave treatment.
Gives both written and verbal notice of patient rights and ability to sign under Voluntary Status.
Determines the appropriateness of voluntary admission status based on the patient's capacity to make a knowing and voluntary consent for treatment. Knowing and voluntary consent is determined by the patient's ability to understand:
The facility is for mentally ill persons or persons requiring some type of intervention. That he/she is making an application for admission; and the nature of his/her status and the provisions governing discharge (4-hour notice) or conversion to an involuntary status (i.e. OPC, EDW, etc.).

...Capacity to consent: If a prospective patient does not have the capacity to consent to diagnosis, observation, care and treatment, as determined by a physician, then the facility may not admit the prospective patient on a voluntary basis. When appropriate, the facility may initiate an emergency detention proceeding, or file an application for court-ordered in-patient mental health services in accordance with Texas Health and Safety Code, Chapter 574."

Review of Patient #4's chart revealed an Education Acknowledgement & Consent to Treatment with Psychotropic Medication form for Depakote 500mg for mood disturbance. The form stated Patient #4 was given an oral explanation of the medication by the nurse. On the patient signature line it stated, "unable to sign/patient on warrant." Review of the Medication Administration Record (MAR) the medication was given to the patient on 1/26/22 at 9:00am.

Review of the policy and procedure "Patient Rights Texas" revealed, " ... You have the right to be free from unnecessary or excessive medication, which includes the right to give or withhold informed consent to treatment with psychoactive medications, unless the right has been limited by court order or in an emergency ..." There was no documented evidence that Patient #4 was able to give consent due to confusion, lack of insight, and poor judgment. The patient did not have an OPC with medication order. An emergency detention by a police officer does not cover forced medications.

Review of Patient #4's chart revealed two Education Acknowledgement & Consent to Treatment with Psychotropic Medication form for Haldol by mouth for psychosis on 1/27/22 at 1800 and Trileptal 75mg for mood. The nurse wrote "verbal consent" on the patient's signature and two nurses signed. The form stated Patient #4 was given an oral explanation of the medication by the nurse. Review of the Medication Administration Record (MAR)revealed the Haldol and Trileptal was given to the patient on 1/27/22 at 2100. Review of the nurse's notes dated 1/27/22 stated, "thought content, confused. Thought process, confused." There was no documentation that the patient had the capacity to consent.

An interview was conducted with Staff #1,4,3, and 8 on 6/15/22. Staff #4 stated she felt the physicians were confused about the documentation needed to change a patient to voluntary status or when a patient needs to be involuntary vs voluntary. Staff #1 stated that she felt the physicians were documenting the condition of the patients but was not documenting if the patient had times of lucidity and were able to understand their rights and had a capacity to consent. Staff #8 requested a meeting with surveyors via computer to discuss the involuntary vs voluntary. Staff #8 stated that if a patient was admitted as voluntary but was not a candidate for voluntary services when she did her psychiatric evaluation then she would OPC the patient. A conversation was had on the facility's police and regulatory on the responsibility of the screener and communication with the physician on voluntary vs involuntary status. During the admission process the physician should not give an order for voluntary admission if the patient does not have a capacity to consent. After review of the regulatory Staff #8 stated that she understood and was clear on voluntary vs involuntary status and need for clearer documentation. Staff #3 stated that she was involved in all the admissions and would be more aware of the process. Staff #3 stated that she had spoke with Staff #10 and he also had a clearer picture of the capacity consent and need for clear documentation.


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Findings Include:


Patient #7

A review of Patient #7's medical record with Staff #2 on 6/13/2022 revealed Patient #7 was admitted on 7/28/2021 involuntary under an Emergency Detention Warrant. Patient #7 was placed under an Order of Protective Custody on 7/29/2021.

Patient #7 was admitted with a diagnosis of Dementia, with Behavioral Disturbances. Patient #7 was not on any Psychotropic medications prior to admission.

A review of the document titled, "Consent to Treatment with Psychotropic Medication" was as follows:

" ...Start Depakote Sprinkles 125mg 1 PO (by mouth) BID (twice a day) for mood/agitation. 1st dose now ..."

Further review revealed Patient #7 was given an oral explanation. On the Patient or Guardian Signature line "Verbal Consent" was written on 7/28/2021 at 6:00 PM. The consent was witnessed by Staff #12 and the second witness signature was illegible. There was no matching signature on the printed name/signature page in the medical record.


A review of the Psychiatric Evaluation by Staff #8 was as follows:

" ...Justification for 24-hour care: She suffers from anxiety, agitation, and confusion.

History of present illness: In the last few weeks, she has been anxious, restless, confused, irritable, agitated and combative. During exam, the patient is unable to sit still, constantly pacing, easily agitated and attempted to assault staff members.

Mental Status Exam: She is not cooperative. She exhibits psychomotor agitation. Mood: Irritable Anxious. Speech and rest of the mental status examination is to perform as the patient is combative, unable to sit still and stormed out of the office ..." There was no documentation found that the patient had the capacity to consent.

A review of the Daily nurses notes on 7/28/2021 Day (7A-7P) by Staff # 14 at 11:15 AM revealed the patient was confused.

A review of the Daily nurses notes on 7/28/2021 Night (7P-7A) by Staff # 13 at 10:00 PM revealed the patient was confused.


Staff #2 confirmed the findings.

The facility failed to have problematic conditions, treatments, and goals for new and current conditions that require staff interventions in 3 (#2, #4, and #8) of 6 (#1, #2, #4, #6, #7, and #8) patient charts reviewed.

Patient #2
Review of the Patient #2's chart revealed she was admitted on 2/2/22 for dementia with increased aggression and wandering. The patient came to the facility on a Emergency Detention Warrant (EDW) and the patient was committed to the facility with a Order of Protective (OPC) custody.

Review of Patient #2's chart revealed she had swelling in the dorsal part of her right foot. Review of the History and Physical dated 2/3/22 at 12:02PM stated, " The patient did not know how she injured her foot. The patient was sent out to the ER on 2/2/22 and had xrays to foot which showed fractures. Patient was to stay off her foot and was placed in wheelchair to avoid weightbearing. "

Review of her Treatment Plan revealed there was no information or mention of the patients fractured foot, pain management or interventions required to ensure care and healing.


Patient #4

Review of Patient #4's chart revealed she was admitted to the facility involuntarily for Alzheimer's with behavioral disturbances. Patient #4's chart revealed on 1/29/22 at 2115 the nurse documented, "Pt urinated on herself. Nurse and MHT directed pt. to her room. Upon attempting to provide care, pt. became physically aggressive; hitting, kicking and attempting to bite staff. MHT attempted to redirect pt. to bed and pt. swung arm back, hitting arm on the closet. MHT stated she heard a popping noise and pt. is guarding left wrist and complaining of pain.1/30/22 at 0100 pt. arrived back on unit at 0100 via Acadian EMS. Dx: forearm fracture..."

Review of her Treatment Plan revealed there was no information or mention of the patient's fractured arm, pain management, or interventions required to ensure care and healing.


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Patient #8

Review of the Patient #8's medical record revealed she was a voluntary admit on 7/01/2021 for Bipolar with Psychotic Features.

Review of Patient #8's medical record revealed she had an unwitnessed fall on 7/06/2021 causing a large hematoma and black left eye. Patient #8 was transferred to the Emergency Department on 7/06/2021 for further evaluation. The results of the Cat Scan showed a left periorbital fracture and contusion to the left forehead.

Review of her Treatment Plan revealed there was no documentation of the injury or how the team would ensure that she received the proper interventions, medical management, and pain management for the injuries to ensure no further complications and proper healing of the injuries.