HospitalInspections.org

Based on review of records, observations, and interview, the facility failed to ensure processes were developed with effective implementation of those processes that:
" provided services free of neglect,
" restricted the use of PRN emergency medications, and
" guaranteed the one-hour face-to-face was provided.

More specifically:
1) The facility failed to ensure that a proactive approach was maintained to identify occurrences that constituted or contributed to the progression of symptoms of Patient #1 over a ten-day period in which the patient went from complaining of pain with ambulation to crawling on the floor to being a "total care patient," unable to move his legs.
2) The facility failed to ensure that Patient #1 was provided a walker during his ten-day inpatient stay. Neither his walker nor a hospital-owned walker was procured for him.
3) The facility failed to ensure that the policy for fall precautions was followed for Patient #1.

Refer to FED - A0145 - PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT
CFR 482.13(c)(3)


4) The facility failed to ensure that medications being used for emergency situations were never written or administered as a standing order or on an as needed basis (PRN) for 1 of 1 patients (Patient #1).

Refer to FED - A0169 - PATIENT RIGHTS: RESTRAINT OR SECLUSION
CFR 482.13(e)(6)


5) The facility failed to ensure that 15 of 15 patients (Patients 1-5 and Patients 7-16) were seen face-to-face within 1-hour after the initiation of a medication used for the management of violent or self-destructive behavior. In addition, the facility failed to ensure that the policy on emergency medications was revised to include the need for the face-to-face by a trained professional.

Refer to FED - A0178 - PATIENT RIGHTS: RESTRAINT OR SECLUSION
CFR 482.13(e)(12)

Based on record review and interview, the facility failed to ensure that the right to be free from abuse and neglect for 1 of 1 patients (Patient #1) was maintained. More specifically,
a) The facility failed to ensure that a proactive approach was maintained to identify occurrences that constituted or contributed to the progression of symptoms of Patient #1 over a ten-day period in which the patient went from complaining of pain with ambulation to crawling on the floor to being a "total care patient," unable to move his legs.
b) The facility failed to ensure that Patient #1 was provided a walker during his ten-day inpatient stay. Neither his walker nor a hospital-owned walker was procured for him.
c) The facility failed to ensure that the policy for fall precautions was followed for Patient #1.

Findings included:

a) The facility neglected to take a proactive approach to the progression of symptoms.
b) The facility neglected to ensure that Patient #1 was provided a walker

Record review of policy, "Patient Abuse, Neglect, Exploitation Investigation and Reporting," effective date 7/2013 [no review date], showed: "Policy ... A major physical injury may be defined as any injury determined to be serious by appropriate medical personnel who examine the patient. Examples of major physical injury include ... fracture ... NEGLECT means the negligence of an employee, affiliate, or agent, which causes or may have caused any physical or emotional injury to a patient."

Record review of policy, "Reporting Suspected Abuse, Neglect, and Exploitation," revised 5/202021, showed: "Policy ... all patients are assessed for signs and symptoms of abuse, neglect, assault, and exploitation during their initial admission or visit and reassessment."

In an interview with Staff D (DON) on 2/23/2021 at 1225, she stated had worked as a nurse for 38 years, which included the operating room, rehabilitation, and long-term acute care settings, and, for the past 17-18 years, behavioral health facilities. She stated the Patient #1 developed "hip pain" that "got bad." She also stated that Patient #1 was transferred to a medical surgical facility and underwent surgery for a hip fracture.

In an interview with Staff W (RN) on 2/24/2021 at 1505, she stated that Patient #1 decompensated "overall" with a decline in mental status. She also stated he had been using a wheelchair and was found "crawling on the floor," adding she did not know if he had fallen. She went on to say that she noted "muscle rigidity of his leg" but did not recall which leg. The patient told her he "hurt" but he did not state what part of his body hurt. She concluded by saying she thought Patient #1 was experiencing neuroleptic malignant syndrome (NMS), adding that she had seen it once in a medical surgical setting.

The Medical Record of Patient #1.

Record review of "Admit Nursing Assessment" for Patient #1 by Staff M (RN) dated 9/1/2021 at 1746 showed "Neurological - no problems. Surgeries - previous hip. No pain. Functional ability and ambulation - independent."

Record review of ZOOM "Multidisciplinary Psychiatric Evaluation" for Patient #1 by Staff B (MD) dated 9/2/2021 at 1120 showed a 61 y/o male, threatening people with physical harm, auditory hallucinations, history of schizophrenia, paranoid. Gait normal.

Day 1: 9/1/2021
Review of MAR
At 2100, meds given to Patient #1 by Staff U (RN)
" Thorazine 200mg PO
" Depakote ER 1000mg PO

Day 2: 9/2/2021
Review of MAR
At 0900, meds given to Patient #1 by Staff O (RN)
" Thorazine 100mg PO
" Zyprexa 10mg PO
" Depakote ER 500mg PO
" Trileptal 300mg PO
" Lamictal 25mg PO
At 1200, given by Staff O (RN)
" Zyprexa 15mg IM PRN
" Ativan 2mg IM PRN
" Benadryl 25mg IM PRN
At 2100, given by Staff U (RN)
" Thorazine 200mg PO
" Zyprexa 25mg at PO
" Depakote ER 1000mg PO
" Trileptal 300mg PO
" Doxepin 100mg PO

Record Review of Shift 1 Nursing Daily Assessment by Staff O (RN) dated 9/2/2021 at 0857 showed: Patient #1 with normal motor activity. "Patient became very paranoid this morning and Dr. Baron ordered IM medications."

Record review of ZOOM Multidisciplinary Psychiatric Evaluation by Staff B (MD) dated 9/2/2021 at 1120 showed: Patient #1 with a normal gait.

Record review of History and Physical Exam by Staff S (AGNP) dated 9/2/2021 at 1530 showed: Patient #1 had a history of a right hip fracture from a fall and replacement 2020. Skin - multiple scars on arms.

Day 3: 9/3/2021
Review of MAR
At 0900, meds given to Patient #1 by Staff O (RN)
" Thorazine 200mg PO
" Zyprexa 10mg at PO
" Depakote ER 500mg PO
" Trileptal 300mg PO
" Lamictal 25mg PO
At 2100, given by Staff Y (RN)
" Thorazine 200mg PO
" Zyprexa 25mg at PO
" Depakote ER 1000mg PO
" Trileptal 300mg PO
" Doxepin 100mg PO

Record review of Physician's Progress Note by Staff B (MD) dated 9/3/2021 at 1310 showed: Patient #1 can be difficult to understand. Seems drowsy.

Day 4: 9/4/2021
Review of MAR
At 0815, meds given to Patient #1 by Staff W (RN)
" Atarax 50mg PO PRN
At 0845 by Staff W (RN)
" Zyprexa 15mg PO PRN
" Ativan 2mg PO PRN
" Benadryl 25mg PO PRN
At 0900 given by Staff W (RN)
" Thorazine 200mg PO
" Zyprexa 10mg at PO
" Depakote ER 500mg PO
" Trileptal 300mg PO
" Lamictal 25mg PO
At 2100 given by Staff Y (RN)
" Thorazine 200mg PO
" Zyprexa 25mg at PO
" Depakote ER 1000mg PO
" Trileptal 300mg PO
" Doxepin 100mg PO
At 2200 given by Staff Y (RN)
" Doxepin 100mg PO PRN
" Atarax 50mg PO PRN

Record review of Physician Progress Note by Staff X (NP) dated 9/4/2021 at 0910 showed: Patient #1 states his right leg hurts and that he will need a walker. [Gait not documented.] Pain assessment: current pain level (0-10) - 7 - right leg.

Day 5: 9/5/2021
Review of MAR
At 0800 meds given to Patient #1 by Staff W (RN)
" Atarax 50mg PO PRN
" Ativan 1mg PO PRN
At 0900 given by Staff W (RN)
" Thorazine 200mg PO
" Zyprexa 10mg at PO
" Depakote ER 500mg PO
" Trileptal 300mg PO
" Lamictal 25mg PO
At 1830 given by Staff W (RN)
" Ativan 1mg PO PRN
At 2100 given by Staff Y (RN)
" Thorazine 200mg PO
" Zyprexa 25mg at PO
" Depakote ER 1000mg PO
" Trileptal 300mg PO
" Doxepin 100mg PO

Record review of Shift 2 Nursing Daily Assessment by Staff Y (RN) dated 9/5/2021 at 2200 showed: Patient #1 speech was slurred but thought process was relevant. He reported concerns regarding his treatment particularly his medications. "Why am I getting all this medication?"

Day 6: 9/6/2021
Review of MAR
At 0900 meds given to Patient #1 by Staff W (RN)
" Trileptal 300mg PO
" Thorazine, Zyprexa, Depakote ER, and Lamictal ON HOLD
At 1210 given by Staff W (RN)
" Ativan 1mg PO PRN
At 2100 given by Staff Q (RN)
" Zyprexa 25mg PO
" Trileptal 150mg PO
" Doxepin 100mg PO
" Thorazine, Depakote ER, and Lamictal ON HOLD

Record review of ZOOM: Physician Progress Note by Staff B (MD) dated 9/6/2021 at 1203 showed: Patient #1 "had to be given Ativan because of agitation. Also TeleMed [physician] had him on Thorazine 200mg twice a day - sedated. Also, Depakote ER 500/1000, Lamictal 25mg every day, Zyprexa 10/25, Trileptal 300mg twice a day. Hold Thorazine 200 twice a day. Decrease Trileptal to 150mg twice a day. Barking words out, but not sensical to me."

Record review of Shift 2 Nursing Daily Assessment by Staff Q (RN) dated 9/6/2021 at 2115 showed: Patient #1 had activity deficits. Speech rambling, slurred. "Need clarification regarding his meds. Detailed information given regarding his all [sic] medications. Patient is on [sic] wheelchair."

Day 7: 9/7/2021
Review of MAR
At 0900 meds given to Patient #1 by Staff W (RN)
" Zyprexa 10mg PO
" Trileptal 150mg PO
At 2100 given by Staff Q (RN)
" Zyprexa 25mg PO
" Trileptal 150mg PO
" Doxepin 100mg PO

Record review of Shift 1 Nursing Daily Assessment by Staff O (RN) dated 9/7/2021 at 0836 showed: Patient #1 had "gait problems. Patient complains of pain when walking." Notified group home to get walker for patient. Patient "currently using a wheelchair for mobility, but often gets himself out and is sitting on the floor." Complaints of pain to both knees.

Record review of ZOOM Physician Progress Note by Staff B (MD) dated 9/7/2021 at 1233 showed: Patient #1 is "very hard to understand. Staff is having a hard time understanding what he is trying to say. He has Thorazine, Lamictal, and Depakote being held. He is clearer today, although hard to understand. They are bringing his walker from his personal care home." Gait normal.

Record review of Shift 2 Nursing Daily Assessment by Staff U (RN) dated 9/7/2021 at 2110 showed: Patient #1 had gait problems. Staff observed patient sitting on the floor in his room. He began crawling on the floor. Patient encouraged to use his wheelchair for ambulation.

Day 8: 9/8/2021
Review of MAR
At 0900 meds given to Patient #1 by Staff O (RN)
" Zyprexa 10mg PO
" Trileptal 150mg PO
At 2100 given by Staff Y (RN)
" Zyprexa 25mg PO
" Trileptal 150mg PO
" Doxepin 100mg PO
At 2200 given by Staff Y (RN)
" Doxepin 100mg PO PRN

Record review of Shift 2 Nursing Daily Assessment by Staff U (RN) dated 9/8/2021 at 0500 showed: Patient #1 "lying on the floor on the hallway. Staff encouraged patient to ambulate in his room, but he refused and continued crawling on the floor. Staff B (MD) notified with orders for Ativan and Benadryl one time now for severe agitation. Patient sat on his wheelchair and was also able to ambulate."

Record review of Physician's Orders (telephone order) for Patient #1 by Staff B (MD) dated 9/8/2021 at 1214 showed: Discontinue Depakote, Lamictal, and Thorazine.

Record review of Shift 2 Nursing Daily Assessment by Staff Y (RN) dated 9/8/2021 at 2100 showed: Patient #1 - Skin integrity - abrasion, bruises, and scratches on the arms. Patient crawls and slides himself to somebody else's room at night. Restless. Speech slurred. Confusion. Patient confused, hostile, and not directable at bedtime. Needed to give as needed medication for hostile/anxiety behavior and mood. Abrasions, scratches may be due to his behavior. He refused to get up and must be carried to his room like he is a total care patient."

Day 9: 9/9/2021
Review of MAR
At 0235 meds given to Patient #1 by Staff Y (RN)
" Atarax 50mg PO PRN
" Ativan 1mg PO PRN
At 0900 given by Staff W (RN)
" Zyprexa 10mg PO
" Trileptal 150mg PO
At 2100 given by Staff Y (RN)
" Zyprexa 25mg PO
" Trileptal 150mg PO
" Doxepin 100mg PO
At 2200 given by Staff Y (RN)
" Doxepin 100mg PO PRN
At 2230 given by Staff Y (RN)
" Atarax 50mg PO PRN

Record review of Shift 1 Nursing Daily Assessment by Staff W (RN) dated 9/9/2021 at 0840 showed: Patient #1 - Skin integrity: bruises, cuts/abrasions. Agitated. Activity deficits. Gait problems. Speech rambling. Auditory hallucinations. Preoccupied, easily distracted, poor concentration. Patient requires assistance to get in wheelchair and for ADLs. Requires redirection, but redirectable.

Record review of Shift 2 Nursing Daily Assessment by Staff Y (RN) dated 9/9/2021 at 2130 showed: Patient #1 - Skin integrity - abrasion, bruises, and scratches. Cut on left elbow. Scratches in right and left forearms. Patient unable to get up from bed. Patient reported inability to move legs. Mood hostile/angry.

Day 10: 9/10/2021
Review of MAR
At 0900 meds given to Patient #1 by Staff W (RN)
" Zyprexa 10mg PO
" Trileptal 150mg PO

Record review of Shift 1 Nursing Daily Assessment by Staff W (RN) dated 9/10/2021 at 0845 showed: Patient #1 incontinent of urine. Activity deficits. Gait problems. Pressured speech. Thought processes: bizarre, Unable to stand on his own. Requires assistance with ADLs. Observed crawling on floor in room. Muscle rigidity noted. MD notified of patient's decompensation. Order received to send to Emergency Room (ER) for medical evaluation of altered mental status and to rule out neuroleptic malignant syndrome. Patient sent to ER at 1307.

Record review of ZOOM Physician Progress Note by Staff B (MD) dated 9/10/2021 [not timed] showed: Patient #1 "complained of left upper thigh pain. Incontinent. More alert. Speech is not as bizarre as before. Will send out for clearance/treatment - rule out NMS [neuroleptic malignant syndrome]." Gait normal.

Record review of [Psychosocial] Discharge Summary by Staff V (LMSW) dated 9/10/2021 at 1315 - 1330 showed: At discharge, Patient #1 with "limited mobility ... slurred speech ... rambling."

Record review of Memorandum of Transfer dated 9/10/2021 at 1200 showed Patient #1 was transferred to HCA Hospital North Houston - Cypress with "limited mobility."


Medical records from HCA Hospital North Houston.

Record review of the HCA Hospital North Houston MAR dated 9/10/2021 at 2131 showed that Patient #1 was given morphine sulfate 2mg IV for severe pain - 7 (scale of 1-10).

Record review of the HCA Hospital North Houston x-ray of pelvis and hips dated 9/10/2021 at 1802 reported and signed by Staff HH (MD) showed that Patient #1 had a mildly displaced intertrochanteric fracture of the proximal left femur.

Record review of the HCA Hospital North Houston Discharge Summary by Staff GG (DO) dated 9/13/2021 at 1420 showed Patient #1 presented to the emergency department with a two-day history of left leg pain. He was found to have a left intertrochanteric femur fracture and underwent intramedullary nailing.
Alert and oriented to time and person, accelerated speech, difficult to understand Discharged back to group home.
Discharge Medications (psychiatric):
Benztropine 1mg PO twice a day
Doxepin 100mg PO at bedtime
Zyprexa 10mg daily and 20mg at bedtime


c) The facility failed to identify a fall as defined by the facility and neglected to ensure that fall precautions were initiated.

Record review of policy, "Fall Prevention Plan and Precautions," revised 5/2014, showed: "POLICY ...
To establish a mechanism to identify those adult patients with potential risk for falling.
To establish a proactive fall prevention program for adult patients determined to be at risk.
DEFINITION: A fall is defined as any event witnessed or un-witness ... in which the patient is found on the floor, regardless of how they got there. This includes patients assisted to the floor.
PROCEDURE ...
Patients will be assessed at the time of admission for potential risk of falling and evaluated periodically throughout their continued or changing fall risk ...
Upon completion of the Nursing Admission Assessment, the nurse will utilize the following risk factors to determine whether the patient demonstrates fall potential:
" Generalized unsteady gait at time of admission or during course of hospital stay ...
" Presently uses a wheelchair or other orthotic devices ...
" History of previous falls prior to admission ...
The hospital has identified the following patients to be at risk for falls at Lone Star Behavioral Hospital:
" History of falls
" Limited mobility or requiring the use of adaptive equipment such as wheelchairs, walkers, and canes.
" History of confusion ...
" Taking medication which causes sedation ...
If fall potential exists, the patient shall be classified as "High Risk for Falling" and placed on "Fall Precautions." The following shall occur:
This shall be documented on the Nursing Admission Assessment and in the Treatment Plan.
The patient shall be identified on "Fall Precautions" ...
Fall Precautions shall be instituted immediately if criteria is established:
Notify the physician for an order for Fall Precautions.
The RN may place a patient on Fall Precautions based on clinical judgment ...
Interventions ... Intrinsic - Personal Factors
" Evaluate for polypharmacy for patients ...
" Adaptive equipment, use of wheelchair when out of bed
If a patient does fall, the Nurse shall assess the patient for injuries and notify physician of any noted injuries to obtain further orders for evaluation ...
If a patient does fall (according to hospital definition) a fall report must be completed and sent to the DON within 24 hours.
[A form titled "Fall Report" was attached to the policy.]

In an interview with Staff D (DON) on 2/23/2021 at 1225, she stated she could not say that Patient #1 fell because "there was no witnessed fall" but was found on the floor. She stated there was no fall report. She also stated prior to admission, there was a history of fall with resultant fracture of a hip and surgical repair. She stated the patient had a change in physical condition, adding he was not placed on fall precautions.

In an interview with Staff C on 2/25/2022 at 1145, she stated Patient #1 was found in the floor but did not fall, adding there was no witnessed fall.

In an interview with Staff W (RN) on 2/24/2021 at 1420, she stated Patient #1 decompensated and was found on the floor crawling. She also stated that there was no witnessed fall.

Based on record review and interview, the facility failed to ensure that medications being used for emergency situations were never written or administered as a standing order or on an as needed basis (PRN) for 1 of 1 patients (Patient #1).

Findings included:

Record review of Nursing Policy "Emergency Medications," effective date 12/2011, showed, "Patients shall receive emergency medication on the direction of a physician ... The order for emergency medication may not be given in a PRN format. The medication order shall only be given as a one-time NOW order."

In an interview with Staff D (DON) on 2/24/2022 at 1420, she stated that emergency medications cannot be written or administered as PRN medications.

Patient #1.
Record review of Physician's Orders for Patient #1 dated 9/2/2021 at 1143 showed that Staff O (RN) received a telephone order from Staff B (MD) for:
Zyprexa 15mg, Ativan 2mg, and Benadryl 25mg IM NOW.
May give [Zyprexa 15mg, Ativan 2mg, and Benadryl 25mg] by mouth every 8 (eight) hours PRN.

Record review of the Medication Administration Record for Patient #1 showed that on 9/4/2021 at 0845 Staff W (RN) administered Zyprexa 15mg, Ativan 2mg, and Benadryl 25mg by mouth to the patient.

Record review of the "Shift 1 Nursing Daily Assessment for Patient #1 dated 9/4/2021 at 0810 by Staff W (RN) showed:
"Mood - calm.
Affect - congruent.
Thought patterns bizarre, delusional, preoccupation, tangential, phobias, paranoid.
Perception - auditory hallucinations.
Insight/Judgment - impaired.
Attention/Concentration - preoccupied, easily distracted, poor concentration, unable to remain [sic], over-stimulated.
Nursing Interventions from Treatment Plan implemented this shift: Redirect and set limits on inappropriate behavior, encourage meds.
Behavior: patient labile, threatening other patients, asks questions and talks while information is being provided.
Response to intervention: Patient requires redirection, PRN sedative, med compliant after two attempts.
Additional Comments: No problems."
Further review of the assessment showed that Staff W (RN) did not document any communication with a physician prior to administering Zyprexa 15mg, Ativan 2mg, and Benadryl 25mg orally to the patient.

Based on interview and record review, the facility failed to ensure that 15 of 15 patients (Patients 1-5 and Patients 7-16) were seen face-to-face within 1-hour after the initiation of a medication used for the management of violent or self-destructive behavior. In addition, the facility failed to ensure that the policy on emergency medications was revised to include the need for the face-to-face by a trained professional.

Findings included:

CFR 482.13(e)(1)(i)(B) defines a restraint is as "A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition."

Record review of Nursing Policy "Emergency Medications," effective date 12/2011, showed, "Patients shall receive emergency medication on the direction of a physician ... The medication shall be documented on the medication administration record ... Vital signs shall be taken as soon as is safe to do so following administration of the emergency medication ... The monitoring of the patient shall be documented on the Progress Notes ..." The policy does not state that the
patient must be seen face-to-face within 1-hour after the initiation of the intervention by a physician or other licensed practitioner or a Registered Nurse who has been trained in accordance with the requirements to evaluate the patient's immediate situation, the patient's reaction to the intervention, and the patient's medical and behavioral condition.

Review of the policy, "Seclusion and Restraint," last revised 4/2018, showed: "A physician, physician's assistant, nurse practitioner, or RN shall conduct a face-to-face evaluation of the patient within (1) hour following the initiation of seclusion and/or restraint to verify the need for the seclusion and/or restraint ... All face-to-face documentation must be completed and include all of the required components: An evaluation of the patient's immediate situation ... The patient's reaction to the intervention ... The patient's medical and behavioral condition ... The need to continue or terminate the restraint or seclusion ..."

In an interview with Staff D (DON) on 2/24/2022 at 1420, she stated that there should be "a packet for each emergency medication given." She also stated that the current form, "Emergency Medication Administration," does not prompt the RN to complete a face-to-face within 1-hour after the initiation of the intervention to evaluate the patient's immediate situation, the patient's reaction to the intervention, and the patient's medical and behavioral condition.

FIFTEEN (15) PATIENTS REFERENCED ABOVE.

Patient #1.
Record review of Telephone Physician Orders by Staff B (MD) dated 9/2/2021 at 1143 showed that Staff O received an order for Ativan 2mg IM, Zyprexa 15mg IM, and Benadryl 25mg IM.

Record review of the Medication Administration Record showed that the Ativan 2mg IM, Zyprexa 15mg IM, and Benadryl 25mg IM was administered by Staff O (RN) at 1200. Further review of the documentation showed that a one-hour face-to-face form was not completed.

Patient #2.
Record review of Nursing Documentation Progress Note by Staff D (DON) dated 6/12/2021 at 1200 showed Patient #2 was hitting walls. He could not be redirected. He complained of auditory hallucinations. Ativan 2mg IM, Zyprexa 20mg IM, and Benadryl 25mg IM was administered at that time. Further review of the documentation showed that a one-hour face-to-face form was not completed.

Patient #3.
Record review of Nursing Documentation Progress Note by Staff P (RN) dated 5/10/2021 at 1150 showed Patient #3 was threatening to staff and the physician. He started screaming and could not be redirected. Ativan 2mg IM, Haldol 10mg IM, and Benadryl 25mg IM was administered at that time. Further review of the documentation showed that a one-hour face-to-face form was not completed.

Patient #4.
Record review of Nursing Documentation Progress Note by Staff D (DON) dated 1/21/2021 at 1435 showed Patient #4 was agitated, anxious, and tearful with persecutory delusions bout being killed. Ativan 2mg IM, Zyprexa 10mg IM, and Benadryl 25mg IM was administered at that time. Further review of the documentation showed that a one-hour face-to-face form was not completed.

Patient #5.
Record review of Nursing Documentation Progress Note by Staff P (RN) dated 5/24/2021 at 1002 showed Patient #5 was incontinent of urine. She refused to get up off the floor to shower and change clothes. She went into another patient's room and tried to take razors from a psychiatric technician. She also charged at a nurse. Ativan 2mg IM, Haldol 10mg IM, and Benadryl 50mg IM was administered at that time. Further review of the documentation showed that a one-hour face-to-face form was not completed.

Patient #7.
Record review of Nursing Documentation Progress Note by Staff Q (RN) dated 8/16/2021 at 2230 showed Patient #7 was agitated and aggressive. He hit a staff member. Ativan 2mg IM, Zyprexa 15mg IM, and Benadryl 50mg IM was administered at that time. Further review of the documentation showed that a one-hour face-to-face form was not completed.

Patient #8.
Record review of Nursing Documentation Progress Note by Staff P (RN) dated 3/19/2021 at 1708 showed Patient #8 was yelling and using profanity. She kicked and punched a staff member. Ativan 2mg IM, Haldol 10mg IM, and Benadryl 50mg IM was administered at that time. Further review of the documentation showed that a one-hour face-to-face form was not completed.

Patient #9.
Record review of Nursing Documentation Progress Note by Staff D (DON) dated 8/21/2021 at 0340 showed Patient #9 was agitated and screaming. She was having auditory hallucinations and nightmares. Ativan 2mg IM, Zyprexa 10mg IM, and Benadryl 25mg IM was administered at that time. Further review of the documentation showed that a one-hour face-to-face form was not completed.

Patient #10.
Record review of Nursing Documentation Progress Note by Staff P (RN) dated 9/25/2021 at 1645 showed Patient #10 knocked on the door to the intake department, demanding her insurance information. She yelled and threatened a peer. Ativan 2mg IM, Haldol 10mg IM, and Benadryl 25mg IM was administered at that time. Further review of the documentation showed that a one-hour face-to-face form was not completed.

Patient #11.
Record review of Nursing Documentation Progress Note by Staff O (RN) dated 9/30/2021 at 0933 showed Patient #11 was "banging on" nurse's station window. She was also yelling, cursing, and spitting. She had become agitated because she wanted to smoke. Ativan 2mg IM, Haldol 10mg IM, and Benadryl 50mg IM was administered at that time. Further review of the documentation showed that a one-hour face-to-face form was not completed.

Patient #12.
Record review of the Nursing Daily Assessment by Staff O (RN) dated 9/22/202 at 0841 showed Patient #12 was paranoid with auditory hallucinations. He was pacing and shouting out at Staff B (MD).

Record review of Nursing Documentation Progress Note by Staff O (RN)dated 9/22/2021 at 1200 showed Patient #12 stated, "I'm going out of my head." Haldol 10mg IM and Benadryl 25mg IM was administered at that time. Further review of the documentation showed that a one-hour face-to-face form was not completed.

Patient #13.
Record review of Nursing Documentation Progress Note by Staff N (RN) dated 4/18/2021 at 0155 showed Patient #13 was "swinging his fists at" Staff N (RN) and Staff EE. Ativan 2mg IM, Haldol 10mg IM, and Benadryl 25mg IM was administered at that time. Further review of the documentation showed that a one-hour face-to-face form was not completed.

Patient #14.
Record review of Nursing Documentation Progress Note by Staff M (RN) dated 4/18/2021 at 0155 showed Patient #14 was "swinging his fists at Patient #18 and Patient #19." Ativan 2mg IM, Haldol 10mg IM, and Benadryl 25mg IM was administered at that time. Further review of the documentation showed that a one-hour face-to-face form was not completed.

Patient #15.
Record review of Nursing Documentation Progress Note by Staff D (DON) dated 1/27/2021 at 1730 showed Patient #15 was "verbally threatening to staff and other patients." Ativan 2mg IM, Thorazine 50mg IM, and Benadryl 25mg IM was administered at that time. Further review of the documentation showed that a one-hour face-to-face form was not completed.

Patient #16.
Record review of Nursing Documentation Progress Note by Staff D (DON) dated 6/20/2021 at 1245 showed Patient #16 was "verbally threatening to staff and other patients." Ativan 2mg IM, Haldol 10mg IM, and Benadryl 50mg IM was administered at that time. Further review of the documentation showed that a one-hour face-to-face form was not completed.

Based on record review and interview, the facility failed to ensure processes were developed with effective implementation of those processes to identify and reduce medical errors. More specifically, an investigation of an adverse patient event, a hip fracture of 1 of 1 patients (Patient #1), was not conducted so that causes could be identified and analyzed, and preventive actions and mechanisms could be implemented if needed. There was no investigation to analyze:

1) The potential role of antipsychotic polypharmacy as a risk factor for the occurrence of the adverse patient event
2) The administration of Ativan and Atarax, both written as separate PRN medications, and given simultaneously
3) The administration of an emergency medication written as a PRN order
4) No one-hour face-to-face by a qualified RN following the administration of an emergency medication
5) The applicability of fall precautions
6) Discrepancies between disciplines in the description of the patient's gait

Findings included:

Record review of policy, "Patient Abuse, Neglect, Exploitation Investigation and Reporting," effective date 7/2013 [no review date], showed: "Policy ... A major physical injury may be defined as any injury determined to be serious by appropriate medical personnel who examine the patient. Examples of major physical injury include ... fracture ... NEGLECT means the negligence of an employee, affiliate, or agent, which causes or may have caused any physical or emotional injury to a patient ...
PROCEDURE ... Any ... suspected negligence ... is to be immediately reported to the Director of Nursing and/or Administrator on Call ... An incident/occurrence report shall immediately be completed ... A complete investigation of the alleged incident is to occur ..."

Record review of policy, "Reporting Suspected Abuse, Neglect, and Exploitation," revised 5/202021, showed: "Policy ... all patients are assessed for signs and symptoms of abuse, neglect, assault, and exploitation during their initial admission or visit and reassessment."

In an interview with Staff D (DON) on 2/23/2021 at 1225, she stated Patient #1 was transferred to a medical surgical facility with "hip pain" that "got bad," adding that the patient was admitted and treated for a hip fracture. She also stated that an incident report was not completed, and an investigation was not conducted into this adverse patient event.

In an interview with Staff JJ (MD Administrator) on 3/8/2022 at 0950, he stated an investigation and a root cause analysis should have been conducted on Patient #1.

In an interview with Staff W (RN) on 2/24/2021 at 1505, she stated that Patient #1 decompensated "overall" with a decline in mental status. She also stated he had been using a wheelchair and was found on "crawling on the floor," adding she did not know if he had fallen. She went on to say that she noted "muscle rigidity of his leg" but did not recall which leg. The patient told her he "hurt" but he did not state what part of his body hurt. She concluded by saying she thought Patient #1 was experiencing neuroleptic malignant syndrome (NMS), adding that she had seen it once in a medical surgical setting.

In an interview with Staff S (AGNP) on 3/8/2022 at 0950, she stated she gets a report on patients when arrives to the inpatient unit, usually in the afternoon. She went on to say that if the nurse does not bring up an issue with a patient, she may not see that patient. She stated she saw Patient #1 for a gastrointestinal problem. a root cause analysis should have been conducted on Patient #1. She also stated that the fractured hip needed to be investigated.


1) The role of antipsychotic polypharmacy as a risk factor for the occurrence of an adverse patient event
2) The administration of Ativan and Atarax, both written as separate PRN

In an interview with Staff S (AGNP) on 3/8/2022 at 0950, she reviewed the MAR of Patient #1 and stated that the patient had been receiving a lot of medication. She concluded by saying she believed some patients received an increase in medications "too quickly." She did not know why Ativan and Atarax would be given at the same time as PRN medications.

Record review of the MAR days 1 through 10 for Patient #1 showed:

Day 1: 9/1/2021
At 2100, meds given to Patient #1 by Staff U (RN)
" Thorazine 200mg PO
" Depakote ER 1000mg PO

Day 2: 9/2/2021
At 0900, meds given to Patient #1 by Staff O (RN)
" Thorazine 100mg PO
" Zyprexa 10mg PO
" Depakote ER 500mg PO
" Trileptal 300mg PO
" Lamictal 25mg PO
At 1200, given by Staff O (RN)
" Zyprexa 15mg IM PRN
" Ativan 2mg IM PRN
" Benadryl 25mg IM PRN
At 2100, given by Staff U (RN)
" Thorazine 200mg PO
" Zyprexa 25mg at PO
" Depakote ER 1000mg PO
" Trileptal 300mg PO
" Doxepin 100mg PO

Day 3: 9/3/2021
At 0900, meds given to Patient #1 by Staff O (RN)
" Thorazine 200mg PO
" Zyprexa 10mg at PO
" Depakote ER 500mg PO
" Trileptal 300mg PO
" Lamictal 25mg PO
At 2100, given by Staff Y (RN)
" Thorazine 200mg PO
" Zyprexa 25mg at PO
" Depakote ER 1000mg PO
" Trileptal 300mg PO
" Doxepin 100mg PO

Day 4: 9/4/2021
At 0815, meds given to Patient #1 by Staff W (RN)
" Atarax 50mg PO PRN
At 0845 by Staff W (RN)
" Zyprexa 15mg PO PRN
" Ativan 2mg PO PRN
" Benadryl 25mg PO PRN
At 0900 given by Staff W (RN)
" Thorazine 200mg PO
" Zyprexa 10mg at PO
" Depakote ER 500mg PO
" Trileptal 300mg PO
" Lamictal 25mg PO
At 2100 given by Staff Y (RN)
" Thorazine 200mg PO
" Zyprexa 25mg at PO
" Depakote ER 1000mg PO
" Trileptal 300mg PO
" Doxepin 100mg PO
At 2200 given by Staff Y (RN)
" Doxepin 100mg PO PRN
" Atarax 50mg PO PRN

Day 5: 9/5/2021
At 0800 meds given to Patient #1 by Staff W (RN)
" Atarax 50mg PO PRN
" Ativan 1mg PO PRN
At 0900 given by Staff W (RN)
" Thorazine 200mg PO
" Zyprexa 10mg at PO
" Depakote ER 500mg PO
" Trileptal 300mg PO
" Lamictal 25mg PO
At 1830 given by Staff W (RN)
" Ativan 1mg PO PRN
At 2100 given by Staff Y (RN)
" Thorazine 200mg PO
" Zyprexa 25mg at PO
" Depakote ER 1000mg PO
" Trileptal 300mg PO
" Doxepin 100mg PO

Day 6: 9/6/2021
At 0900 meds given to Patient #1 by Staff W (RN)
" Trileptal 300mg PO
" Thorazine, Zyprexa, Depakote ER, and Lamictal ON HOLD
At 1210 given by Staff W (RN)
" Ativan 1mg PO PRN
At 2100 given by Staff Q (RN)
" Zyprexa 25mg PO
" Trileptal 150mg PO
" Doxepin 100mg PO
" Thorazine, Depakote ER, and Lamictal ON HOLD

Day 7: 9/7/2021
At 0900 meds given to Patient #1 by Staff W (RN)
" Zyprexa 10mg PO
" Trileptal 150mg PO
At 2100 given by Staff Q (RN)
" Zyprexa 25mg PO
" Trileptal 150mg PO
" Doxepin 100mg PO

Day 8: 9/8/2021
At 0900 meds given to Patient #1 by Staff O (RN)
" Zyprexa 10mg PO
" Trileptal 150mg PO
At 2100 given by Staff Y (RN)
" Zyprexa 25mg PO
" Trileptal 150mg PO
" Doxepin 100mg PO
At 2200 given by Staff Y (RN)
" Doxepin 100mg PO PRN

Day 9: 9/9/2021
At 0235 meds given to Patient #1 by Staff Y (RN)
" Atarax 50mg PO PRN
" Ativan 1mg PO PRN
At 0900 given by Staff W (RN)
" Zyprexa 10mg PO
" Trileptal 150mg PO
At 2100 given by Staff Y (RN)
" Zyprexa 25mg PO
" Trileptal 150mg PO
" Doxepin 100mg PO
At 2200 given by Staff Y (RN)
" Doxepin 100mg PO PRN
At 2230 given by Staff Y (RN)
" Atarax 50mg PO PRN

Day 10: 9/10/2021
At 0900 meds given to Patient #1 by Staff W (RN)
" Zyprexa 10mg PO
" Trileptal 150mg PO


3) The administration of an emergency medication written as a PRN order

Record review of Physician (Telephone) Orders by Staff B (MD) dated 9/2/2021 at 1143 showed
Zyprexa 15mg with Ativan 2mg with Benadryl 25mg intramuscularly [IM] was ordered as a now dose for Patient #1. The order also stated: May give orally every 8 hours PRN.

Record review of Shift 1 Nursing Daily Assessment by Staff W (RN) dated 9/4/2021 at 0810 showed: Patient #1 labile, threatening other patients. PRN sedative [administered].

Record review of Medication Administration Record by Staff W (RN) dated 9/4/2021 at 0845 showed Zyprexa 15mg, Ativan 2mg, Benadryl 25mg given orally to Patient #1.


4) No one-hour face-to-face by a qualified RN following the administration of an emergency medication

Record review of Telephone Physician Orders by Staff B (MD) dated 9/2/2021 at 1143 showed that Staff O received an order for Ativan 2mg IM, Zyprexa 15mg IM, and Benadryl 25mg IM for Patient #1.

Record review of the Medication Administration Record showed that the Ativan 2mg IM, Zyprexa 15mg IM, and Benadryl 25mg IM was administered by Staff O (RN) at 1200 to Patient #1. Further review of the documentation showed that a one-hour face-to-face form was not completed.


5) The applicability of fall precautions

Record review of policy, "Fall Prevention Plan and Precautions," revised 5/2014, showed: "POLICY ...
To establish a mechanism to identify those adult patients with potential risk for falling.
To establish a proactive fall prevention program for adult patients determined to be at risk.
DEFINITION: A fall is defined as any event witnessed or un-witness ... in which the patient is found on the floor, regardless of how they got there. This includes patients assisted to the floor.
PROCEDURE ...
Patients will be assessed at the time of admission for potential risk of falling and evaluated periodically throughout their continued or changing fall risk ...
Upon completion of the Nursing Admission Assessment, the nurse will utilize the following risk factors to determine whether the patient demonstrates fall potential:
" Generalized unsteady gait at time of admission or during course of hospital stay ...
" Presently uses a wheelchair or other orthotic devices ...
" History of previous falls prior to admission ...
The hospital has identified the following patients to be at risk for falls at Lone Star Behavioral Hospital:
" History of falls
" Limited mobility or requiring the use of adaptive equipment such as wheelchairs, walkers, and canes.
" History of confusion ...
" Taking medication which causes sedation ...
If fall potential exists, the patient shall be classified as "High Risk for Falling" and placed on "Fall Precautions." The following shall occur:
This shall be documented on the Nursing Admission Assessment and in the Treatment Plan.
The patient shall be identified on "Fall Precautions" ...
Fall Precautions shall be instituted immediately if criteria is established:
Notify the physician for an order for Fall Precautions.
The RN may place a patient on Fall Precautions based on clinical judgment ...
Interventions ... Intrinsic - Personal Factors
" Evaluate for polypharmacy for patients ...
" Adaptive equipment, use of wheelchair when out of bed
If a patient does fall, the Nurse shall assess the patient for injuries and notify physician of any noted injuries to obtain further orders for evaluation ...
If a patient does fall (according to hospital definition) a fall report must be completed and sent to the DON within 24 hours.
[A form titled "Fall Report" was attached to the policy.]

Record review of the telemedicine "Preadmission Evaluation & Medical Clearance Screening" by Staff T (MD) dated 9/1/2021 at 1746 showed Patient #1 to be in "good physical health." He had bizarre behavior with abnormal movements. Fall precautions were not ordered.

Record review of "Admit Nursing Assessment" for Patient #1 by Staff M (RN) dated 9/1/2021 at 1746 showed "Neurological - no problems. Surgeries - previous hip. No pain. Functional ability and ambulation - independent."

Record review of ZOOM "Multidisciplinary Psychiatric Evaluation" for Patient #1 by Staff B (MD) dated 9/2/2021 at 1120 showed gait normal.

Record review of History and Physical Exam by Staff S (AGNP) dated 9/2/2021 at 1530 showed: Patient #1 had a history of a right hip fracture from a fall and replacement 2020. Skin - multiple scars on arms.

Record review of Physician Progress Note by Staff X (NP) dated 9/4/2021 at 0910 showed: Patient #1 states his right leg hurts and that he will need a walker. Gait not documented. Pain assessment: current pain level (0-10) - 7 - right leg.

Record review of Shift 2 Nursing Daily Assessment by Staff Q (RN) dated 9/6/2021 at 2115 showed: Patient #1 had activity deficits. "Patient is on [sic] wheelchair."

Record review of Shift 1 Nursing Daily Assessment by Staff O (RN) dated 9/7/2021 at 0836 showed: Patient #1 had "gait problems. Patient complains of pain when walking." Notified group home to get walker for patient. Patient "currently using a wheelchair for mobility, but often gets himself out and is sitting on the floor." Complaints of pain to both knees.

Record review of Shift 2 Nursing Daily Assessment by Staff U (RN) dated 9/7/2021 at 2110 showed: Patient #1 had gait problems. Staff observed patient sitting on the floor from his room and began crawling on the floor. "Patient encouraged to use his wheelchair for ambulation."

Record review of Shift 2 Nursing Daily Assessment by Staff U (RN) dated 9/8/2021 at 0500 showed: Patient #1 "lying on the floor on the hallway. Staff encouraged patient to ambulate in his room, but he refused and continued crawling on the floor ... Patient sat on his wheelchair and was also able to ambulate."

Record review of Shift 2 Nursing Daily Assessment by Staff Y (RN) dated 9/8/2021 at 2100 showed: Patient #1 - Skin integrity - abrasion, bruises, and scratches on the arms. Patient crawls and slides himself to somebody else's room at night. directable at bedtime. "He refused to get up and must be carried to his room like he is a total care patient."

Record review of Shift 1 Nursing Daily Assessment by Staff W (RN) dated 9/9/2021 at 0840 showed: Patient #1 - Skin integrity: bruises, cuts/abrasions. Agitated. Activity deficits. Gait problems. Patient requires assistance to get in wheelchair and for ADLs. Requires redirection, but redirectable.

Record review of Shift 2 Nursing Daily Assessment by Staff Y (RN) dated 9/9/2021 at 2130 showed: Patient #1 - Skin integrity - abrasion, bruises, and scratches. Cut on left elbow. Scratches in right and left forearms. Patient unable to get up from bed. Patient reported inability to move legs.

Record review of Shift 1 Nursing Daily Assessment by Staff W (RN) dated 9/10/2021 at 0845 showed: Patient #1 incontinent of urine. Activity deficits. Gait problems. Unable to stand on his own. Requires assistance with ADLs. Observed crawling on floor in room. Muscle rigidity noted. Patient sent to ER at 1307.

Record review of [Psychosocial] Discharge Summary by Staff V (LMSW) dated 9/10/2021 at 1315 - 1330 showed: At discharge, Patient #1 with "limited mobility."

Record review of the HCA Hospital North Houston x-ray of pelvis and hips dated 9/10/2021 at 1802 reported and signed by Staff HH (MD) showed that Patient #1 had a mildly displaced intertrochanteric fracture of the proximal left femur.

Review of the Physician Orders for Patient #1 dated 9/1 through 9/10 showed no fall precautions ordered.


6) Discrepancies between disciplines in the description of the patient's gait

Record review of ZOOM: Physician Progress Note by Staff B (MD) dated 9/6/2021 at 1203 showed: Patient #1 - gait normal.

Record review of Shift 2 Nursing Daily Assessment by Staff Q (RN) dated 9/6/2021 at 2115 showed: Patient #1 had "activity deficits." "Patient is on [sic] wheelchair."

Record review of Shift 1 Nursing Daily Assessment by Staff O (RN) dated 9/7/2021 at 0836 showed: Patient #1 had "gait problems. Patient complains of pain when walking." Notified group home to get walker for patient. Patient "currently using a wheelchair for mobility, but often gets himself out and is sitting on the floor." Complaints of pain to both knees.

Record review of ZOOM: Physician Progress Note by Staff B (MD) dated 9/7/2021 at 1233 showed: Patient #1 "They are bringing his walker from his personal care home." Gait normal.

Record review of Shift 2 Nursing Daily Assessment by Staff U (RN) dated 9/7/2021 at 2110 showed: Patient #1 had gait problems. Staff observed patient sitting on the floor from his room and began crawling on the floor. Patient encouraged to use his wheelchair for ambulation.

Record review of Shift 2 Nursing Daily Assessment by Staff U (RN) dated 9/8/2021 at 0500 showed: Patient #1 "lying on the floor on the hallway. Staff encouraged patient to ambulate in his room, but he refused and continued crawling on the floor. Dr. Baron notified with orders for Ativan and Benadryl one time now for severe agitation. Patient sat on his wheelchair and was also able to ambulate."

Record review of Shift 2 Nursing Daily Assessment by Staff Y (RN) dated 9/8/2021 at 2100 showed: Patient #1 - Skin integrity - abrasion, bruises, and scratches on the arms. Patient crawls and slides himself to somebody else's room at night. "He refused to get up and must be carried to his room like he is a total care patient."

Record review of Shift 1 Nursing Daily Assessment by Staff W (RN) dated 9/9/2021 at 0840 showed: Patient #1 - Skin integrity: bruises, cuts/abrasions. Agitated. Activity deficits. Gait problems. Patient requires assistance to get in wheelchair and for ADLs.

Record review of Shift 2 Nursing Daily Assessment by Staff Y (RN) dated 9/9/2021 at 2130 showed: Patient #1 - Skin integrity - abrasion, bruises, and scratches. Cut on left elbow. Scratches in right and left forearms. Patient unable to get up from bed. Patient reported inability to move legs.

Record review of Shift 1 Nursing Daily Assessment by Staff W (RN) dated 9/10/2021 at 0845 showed: Patient #1 incontinent of urine. Activity deficits. Gait problems. Unable to stand on his own. Requires assistance with ADLs. Observed crawling on floor in room. Muscle rigidity noted. MD notified of patient's decompensation. Order received to send to ER for medical evaluation of altered mental status and to rule out neuroleptic malignant syndrome. Patient sent to ER at 1307.

Record review of ZOOM: Physician Progress Note by Staff B (MD) dated 9/10/2021 [not timed] showed: Patient #1 "complained of left upper thigh pain. Incontinent. More alert. Speech is not as bizarre as before. Will send out for clearance/treatment - rule out NMS [neuroleptic malignant syndrome]." Gait normal.

Record review of Memorandum of Transfer dated 9/10/2021 at 1200 showed Patient #1 was transferred to HCA Hospital North Houston - Cypress with "limited mobility."

Record review of Physician's Orders (telephone order) by Staff B (MD) dated 9/10/2021 at 1859.
Discharge patient to hospital for altered mental status.

Record review of the HCA Hospital North Houston Discharge Summary by Staff GG (DO) dated 9/13/2021 at 1420 showed Patient #1 presented to the emergency department with left leg pain. He was found to have a left intertrochanteric femur fracture and underwent intramedullary nailing.

Based on record review and interview, the facility failed to adhere to the policies and procedures that reflect accepted professional pharmacy principles in the documentation of medication orders. Failure to do so resulted in 2 of 2 patients (Patient #2 and Patient #16) with PRN medication orders that did not include an indication.

Findings included:

Record review of the policy, "Medication Administration," reviewed and revised 04/2021, showed:
"A complete medication order includes date, time, medication name, dose, frequency of administration, and route. PRN orders must contain the target symptoms or the reason for their use, and the minimum interval allowed between doses."

Review of the Institute for Safe Medication Practices website, January 12, 2010, shows guidelines for medication orders that reflect best practices and clear communication. "Medication orders include:
Drug name ... Dose / Strength ... frequency ... route of administration ... indication ..."
See:
https://www.ismp.org/guidelines/standard-order-sets

Review of the National Coordinating Council for Medication Error Reporting and Prevention website shows the following recommendations to reduce confusion pertaining to verbal orders:
"Information that should be given in a verbal order include the following:
... Drug name, Dosage form ... Exact strength, dose, or concentration ... Dose, frequency, and route ... Quantity ... Purpose or indication ..."
See:
https://www.nccmerp.org/recommendations-reduce-medication-errors-associated-verbal-medication-orders-and-prescriptions

TWO (2) PATIENTS REFERENCED ABOVE.

Patient #2.
Record review of the Physician's Orders for Patient #2 dated 6/11/2021 at 2130 showed that Staff M (RN) received a telephone order from Staff B (MD) for:
Thorazine 100mg by mouth at bedtime, may repeat one time.
Further review showed that there was no indication for the repeat [as needed] dose of Thorazine.

Patient #16.
Record review of the Physician's Orders for Patient #16 dated 6/20/2021 at 0738 showed that Staff P (RN) received a telephone order from Staff FF (NP) for:
Zydis 10mg sublingual twice a day PRN

Based in record review and interview, the facility failed to ensure the treatment team developed an individualized, comprehensive treatment plan that included the initiation of Fall Precautions following a fall (according to hospital definition) for 1 of 1 patients (Patient #1).

Findings included:

Record review of policy, "Fall Prevention Plan and Precautions," revised 5/2014, showed: "POLICY ...
To establish a mechanism to identify those adult patients with potential risk for falling.
To establish a proactive fall prevention program for adult patients determined to be at risk.
DEFINITION: A fall is defined as any event witnessed or un-witness ... in which the patient is found on the floor, regardless of how they got there. This includes patients assisted to the floor.
PROCEDURE ...
Patients will be assessed at the time of admission for potential risk of falling and evaluated periodically throughout their continued or changing fall risk ...
Upon completion of the Nursing Admission Assessment, the nurse will utilize the following risk factors to determine whether the patient demonstrates fall potential:
" Generalized unsteady gait at time of admission or during course of hospital stay ...
" Presently uses a wheelchair or other orthotic devices ...
" History of previous falls prior to admission ...
The hospital has identified the following patients to be at risk for falls at Lone Star Behavioral Hospital:
" History of falls
" Limited mobility or requiring the use of adaptive equipment such as wheelchairs, walkers, and canes.
" History of confusion ...
" Taking medication which causes sedation ...
If fall potential exists, the patient shall be classified as "High Risk for Falling" and placed on "Fall Precautions." The following shall occur:
This shall be documented on the Nursing Admission Assessment and in the Treatment Plan.

Record review of the Treatment Plan for Patient #1 showed that "Falls" was not listed as a problem.

In an interview with Staff D (DON) on 2/23/2021 at 1225, she stated there was a change in Patient #1's condition and he was not placed on fall precautions. She also stated that Patient #1 was found on the floor out of his chair but there was no "witnessed fall."