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AUSTIN OAKS HOSPITAL
FORM AND RETENTION OF RECORDS
Tag No.: A0438
Based on review of medical records and staff interview the facility failed to ensure that their Treating Physician dated and signed four patients (#3, 5,18 and 19) Consent to Treat with Psychoactive Medication Form, confirming the explanation for each medication had been given to the patient's by PA, CNC, R.PH., RN or LVN.
Findings were:
During a review of patient records on the morning of 02/14/2022 and 02/15/2022, it was observed that patients #3, #5, #18, and #19 did not have a Physician signature or date signed on their Consent to Treat with Psychoactive Medication confirming within 2 working days the explanation for each medication had been given to the patient by PA, CNC, R.PH., RN or LVN.
In an interview with facility COO and CNO on the afternoon of 02/15/2022, the above findings were confirmed.
Document Therapeutic Efforts
Tag No.: A1650
Based on review of documentation, staff interviews, and complaint review the facility failed to ensure the treatment received by the patient was documented in such a way to assure that all active therapeutic effort are included.
Findings were:
Patient #2 stated in part, "...Patient reported the incident to staff about patients' space being invaded by male patient, so male patient was placed on a "10-foot rule" where he could no longer physically come near patient. The 10-foot rule was not enforced at all, and male patient continuously invaded patients' space by sitting next to her and putting his arm around patient..."
The facility failed to provide policy/procedure, in-service or any type of documentation about referenced ten-foot rule noted in complaint.
In an interview with Staff #5 on 2/15/2022 staff #5 stated, "There is no physician's order for this rule, we don't currently have anyone on this rule and we haven't had anyone on the rule for a long time."
Clinical Director
Tag No.: A1690
Based on review of staff personnel files and staff interview the facility failed to ensure that staff job descriptions were signed by the CEO and the HR Director.
Findings were:
In review of personnel files, 3 out of 8 personnel files (staff # 8, 11, and 12) contained staff job description's that were not signed by the CEO and the HR Director.
The above information was confirmed with the CNO and the Director of Risk Management/PI on February 15, 2022.