HospitalInspections.org

Based on observations, interviews, and records review, the hospital failed to ensure a safe environment was provided for 1 of 12 patients (Patient #1). (Patient #1's) every fifteen minute observation round record was left incomplete and (Patient #1's) location and behavior was not monitored.

Findings Included:

1) (Patient #1's) 12/05/14 physician's preadmission examination orders dated 12/05/14 timed at 1820 reflected, "Precautions Assaultive..."

The Integrated Psychosocial Assessment dated 12/05/14 timed at 1600 reflected, "Patients behavior has become more aggressive...patient hits his sister, verbalizes he wants to stab his brother, throws chairs, hits kicks walls...on 12/01/14 stabbed his left forearm with pencil for no reason...for five minutes banged head against the chair lightly...parents insist the medication regimen has drastically worsened his behavior..."

The 12/05/14 observation round record reflected, "Every 15 minutes for aggression....the 1815, 1830 and 1915 rounds was blank." No documentation was found which indicated monitoring of (Patient #1's) location and behavior.

The 12/22/14 observation round record reflected, "Every 15 minutes for aggression...the 1700, 1715, 1730, 1745,1800,1815,1830 and 1945 rounds were blank." No documentation was found which indicated monitoring of (Patient #1's) location and behavior.

On 03/12/15 at 1008 Staff #13 was interviewed. Staff #13 was asked to review (Patient #1's) medical record. Staff #13 stated the observation rounds records should not have been incomplete.

The policy and procedure entitled, "Level of Observation/Hand-Off Communication with a review date of 08/14 reflected, "Staff will complete the patient observation record as rounds are made...will observe the patient and note his or her behavior and location...the purpose of observations is to provide a system of progressive intensity of patient observation, precaution and oversight based on patient acuity, severity and type of symptoms and overall needs."

Based on interview and record review the hospital failed to ensure 1 of 12 patient medical records (Patient #1's) were complete, accurate, dated and/or authenticated.

Findings Included:

Patient #1's Integrated Psychosocial Assessment dated 12/05/14 timed at 1600 reflected, "Patients behavior has become more aggressive...patient hits his sister, verbalizes he wants to stab his brother, throws chairs, hits kicks walls...on 12/01/14 stabbed his left forearm with a pencil for no reason...for five minutes banged head against the chair lightly...parents insist the medication regimen has drastically worsened his behavior..."

The History and Physical with a dictate date of 12/06/14 timed at 0503 was not signed and/or dated by the physician.

The physician psychiatric progress notes dated 12/06/14 through 12/29/14 revealed the following:

The 12/06/14 physician psychiatric progress note timed at 1200 reflected, "Patient seen...phoned foster mother..." The note was not signed by the physician.

The 12/11/14 physician psychiatric progress note timed at 1240 reflected, "Patient seen, chart reviewed...doing better today..." The risk assessment/rationale for continued inpatient stay was left blank and no physician signature was found on the document.

The 12/14/14 physician psychiatric progress note timed at 0830 reflected, "Patient seen, chart reviewed..." The assessment on page 2 was left blank which included the physician signature section.

The 12/16/14 physician psychiatric progress note timed at 1115 reflected, "Patient seen, chart reviewed..." The assessment on page 2 was left blank which included the physician signature section.

The 12/21/14 physician psychiatric progress note timed at 0927 reflected, "Patient seen, chart reviewed..." The assessment on page 2 was left blank which included the physician signature section.

The Group notes dated 12/07/14 through 12/21/14 revealed the following:

The Skills Group note dated 12/07/14 start time at 1100 with an end time of 1130 revealed the patient attended and Staff #12 charted the group note at 1020 on 12/07/14 prior to the group occurring.

The Skills Group note dated 12/12/14 start time of 1430 to 1520 revealed the patient attended and Staff #11 charted the group note at 1425 on 12/12/14 prior to the group occurring.

The Process Group note dated 12/13/14 start time of 1300 to 1330 revealed the patient attended the group and Staff #12 charted the group note at 0849 on 12/13/14 prior to the group occurring.

The Skills Group note dated 12/13/14 timed at 1330 to 1400 revealed the patient attended the group and Staff #12 charted the skills group at 0910 on 12/13/14 prior to the group occurring.

The Process Group note dated 12/21/14 timed at 0900 to 0930 revealed the patient attended the group and Staff #12 charted the process group at 0818 on 12/21/14 prior to the group happening.

On 03/12/15 at 1015 Staff #13 was interviewed. Staff #13 was asked to review (Patient #1's) medical record. Staff #13 verified the above group notes were not accurate charted on prior to the group occurring and the physician notes were either incomplete and/or not signed.

Based on interview and record review the hospital failed to ensure informed consent was obtained prior to the administration of psychoactive medication for 2 of 12 patients (Patient #1 and Patient #2).

Findings Included:

1) (Patient #1's) 12/05/14 physician's preadmission examination orders dated 12/05/14 timed at 1820 reflected, "Precautions Assaultive...Divalproex 250 mg (milligrams) po (by mouth) one tablet in the morning and two at hour of sleep...Trazodone 50 mg (milligrams) po at hour of sleep."

The 12/14/14 physician orders timed at 0830 reflected, "Vistaril (Anxiolytics) 50 mg po TID (three times a day)...get consent."

The Consent to Treatment with Psychoactive Medication records was reviewed. No medication consent was found for Divalproex (Depakote) mood stabilizer, Trazodone (antidepressant) and Vistaril 50 mg po TID..."

The MAR (medication administration Record) for Depakote 250 mg po one AM (in the morning) was administered 12/05/14 through 12/30/14 without psychoactive medication consent. Depakote 250 mg po two tabs at 2000 was administered 12/05/14 through 12/28/14 without a psychoactive medication consent. Trazodone 50 mg po at hour of sleep was administered 12/05/14 through 12/28/14 without a psychoactive medication consent. Vistaril 50 mg po TID was administered 12/14/14 through 12/29/14 without a psychoactive medication consent.

On 03/12/15 at 1025 Staff #13 was interviewed. Staff #13 reviewed the medical record. Staff #13 verified no psychoactive medication consents were obtained for Depakote, Trazodone and or Vistaril. Staff #13 verified the medications were administered with no medication consent.

2) (Patient #2's) Integrated Psychosocial Assessment dated 01/15/15 timed at 1240 reflected, "High blood pressure, high cholesterol, eating disorder, mother died last year...medications...Viibryd and Xanax."

The physician's orders and medication administration records (MAR's) dated 01/16/15 through 01/20/15 revealed the following:

The 01/16/15 order reflected, "Viibryd 20 mg (milligrams) po (by mouth daily..."

The MAR reflected, (Patient #2) received "Viibryd 20 mg on 01/17/15." No psychoactive medication consent was found in the medical record.

The 01/16/15 order reflected, "Vistaril 25 mg po every six hours prn (as needed) for anxiety..."

The MAR reflected, (Patient #2) was administered "Vistaril 25 mg for anxiety at 2240 on 01/17/15." No psychoactive medication consent was found in the medical record.

The 01/17/15 order reflected, "Viibryd 40 mg po every day..."

The MAR reflected, (Patient #2) was administered "Viibryd 40 mg po on 01/18/15 and 01/19/15." No psychoactive medication consent was found for the Viibryd.

On 03/12/15 at 1228 Staff #13 was interviewed. Staff #13 was asked to review (Patient #2's) medical record. Staff #13 stated she could not find signed psychoactive medication consent for Vistaril and Viibryd.

The policy and procedure entitled, "Informed Consent for Medication Administration" with a review date of 11/14 reflected, "Informed consent for the administration of psychoactive medication shall be required for all patients, voluntary or involuntary...informed consent must be given by the legally authorized representative of a patient under the age of 18 admitted under the voluntary, emergency or OPC (order of protective custody) provisions of Texas Statutes, or by the patient himself..."

Based on interview and record review the hospital failed to ensure 1 of 12 patients (Patient #2) had an individualized treatment plan which addressed binge eating, high blood pressure and high cholesterol.

Findings Included:

(Patient #2's) Integrated Psychosocial Assessment dated 01/15/15 timed at 1240 reflected, "High blood pressure, high cholesterol, eating disorder, mother died last year..."

The Initial Nursing Assessment treatment plan dated 01/15/15 at 1735 reflected, "Binge eating...dietician notified...problem...depressed." No documentation was found which indicated binge eating was addressed in the initial treatment plan.

The Interdisciplinary Individualized Treatment Plan dated 01/16/15 signed by (Patient #2) reflected, "Problem alteration in mood depressed." No further problems were identified on the treatment plan.

The Psychiatric Evaluation dated 01/16/15 timed at 1000 reflected, "Admitted voluntarily...depressed and wants to die...history of binge eating disorder...suicidal thoughts since 14 years old...high cholesterol, hypertension...major depressive disorder."

On 03/12/15 at 1228 Staff #13 was interviewed. Staff #13 was asked to review (Patient #2's) medical record. Staff #13 reviewed (Patient #2's) treatment plan and verified (Patient #2's) hypertension, cholesterol, and binge eating were not addressed on the treatment plan. Staff #13 stated the above problems should have been addressed on the treatment plan.

The policy and procedure entitled, "Master Treatment Plan" with a review date of 11/2014 reflected, "The treatment team will in collaboration with the patient and identified family members develop a master treatment plan that addresses the problems identified...admitting nurse will complete problem/goal sheet for Axis III diagnosis...treatment team will review and discuss with each discipline...adding additional goals and objectives..."