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Based on a review of facility documentation and staff interviews, the facility failed to ensure that each patient had the right to make informed decisions regarding his or her care or treatment as psychoactive medications were administered prior to informed consent being given by the patient.

Findings were:

A review of facility patient clinical records revealed that for 5 of 10 patients prescribed psychoactive medications [Patients #1, 4, 6, 9 and 10], consent for treatment with that medication was either signed after the first dose was given to the patient, or was not available at all.

A review of the clinical record for Patient #1 revealed a verbal order received on 4/22/14 at 0415 for "Ativan 2mg IM x 1 for agitation...Use personal restraint to give Zyprexa and Ativan IM injection." The Medication Administration Record included an entry that Patient #1 received "Ativan 2mg x 1 IM" on 4/22/14 at 0425. The record also included an entry that Patient #1 received "Zyprexa 10mg IM Q6hrs PRN agitation (Do Not exceed 30 mg per day)" administered on 4/22/14 at 0406. Patient #1 signed consent for these 2 medications on 4/22/14 at 1905.

Patient #4 received a dose of Buspar on the evening of 7/11/14 at 10:00 p.m. as noted on the Medication Administration Record (MAR). A Consent to Treat with Psychoactive Medication for Buspar was signed by the patient on 7/12/14 at 6:15 a.m.

Patient #6 received a dose of Ativan on 7/11/14 at 5:48 a.m.as noted on the MAR. A Consent to Treat with Psychoactive Medication for Ativan was signed by the patient on 7/11/14 at 6:29 a.m.

Patient #9 received a dose of Ativan on 7/22/14 at 4:15p.m. and on 7/23/14 at 6:40 a.m. A Consent to Treat with Psychoactive Medication for Ativan was unavailable for review in the patient clinical record.

An admission order for Patient #10 on 6/28/14 at 8:05 p.m. read as follows: "Haldol 5mg IM and Benadryl 50mg IM q 6 hrs prn severe agitation." He received an IM injection of Haldol on 7/6/14 at 7:21 a.m. and on 7/16/14 at 11:50 a.m. A Consent to Treat with Psychoactive Medication for Haldol was unavailable for review in the patient clinical record. He also received an IM injection of Benadryl on 7/6/14 at 7:21 a.m. and on 7/7/14 at 12:10 p.m. A Consent to Treat with Psychoactive Medication for Benadryl was signed by Patient #10 on 7/17/14 at 5:10 p.m. An Order for Protective Custody was noted in the patient's clinical record, but no documentation was available which indicated he was on Court Ordered Medication.

A review of Facility policy entitled Consent to Treatment With Psychoactive Medication, last reviewed May 2012, stated, in part:
"Informed consent is required for each psychoactive medication ordered ...Psychoactive medications may be ordered and administered to individuals without their consent ONLY in an emergency ...
Definition: An emergency situation is one in which imminent probable death or substantial bodily harm to the person or others or imminent physical or emotional harm to others is likely to occur due of [sic] overt threats or attempts made by the person.
Program Policy
Psychoactive medications are not administered to persons admitted to Sunrise Canyon Hospital under the Voluntary, Emergency, or Order of Protective Custody, (OPC), provisions of Texas statutes without informed consent, except in an emergency to ensure appropriate treatment while protecting the rights of patients.
Procedure
Prior to administration of psychoactive medication, staff obtains the patient signature on the "Consent to Treatment with Psychoactive Medication ..."
III. Documentation of Informed Consent
A) Consent is documented on the Consent to Treatment with Psychoactive Medications form.
1) The patient and/or the patient's representatives signs the Consent to Treatment with Psychoactive Medications form ...
V. Persons Admitted Under Texas Statutes
For persons on a Voluntary, Emergency, and OPC admission;
1) No medication is administered without informed consent unless deemed an "emergency" by the physician ..."

Facility policy entitled Involuntary Administration of Medication, last reviewed May 2012, stated, in part:
"Program Policy
Sunrise Canyon Hospital conducts involuntary administration of medications to patients only in accordance with the provisions of the Texas Administrative Code, Chapter 405, Subchapter FF, and "Consent to Treatment with Psychoactive Medication."
Procedure
Admitting, on-call, and physicians/physician-extenders and nurses comply with all procedures described in the "Consent to Treatment with Psychoactive Medication," of this manual."

In an interview with staff #15 on the afternoon of 7/22/14, he stated there had been no emergency medication administered during July 2014.

In an exit conference with the hospital administrator and other administrative staff on the afternoon of 7/23/14 in the facility conference room, these findings were discussed.

Based on a review of facility documentation and staff interviews, the facility failed to ensure a safe patient environment by failing to accurately report incidents of patient restraints and seclusions to the administrator so that correct quality assurance data was maintained by the facility and problematic patterns identified.

In an interview with Staff #3, Quality Assurance, on the afternoon of 7/23/14 in the facility lobby, she stated all incidents of restraint and seclusion are entered on the Seclusion and Restraint Log. These are then entered into the facility's electronic system where the Director of Nursing then reviews the reports. These are then also reviewed by the hospital Administrator who then reports to the Quality Assurance/Performance Improvement Committee.

A review of the facility Seclusion and Restraint Log revealed from January, 2014 through July, 2014 revealed only the following two entries:
? January 17, 2014 at 1342 - Patient 72091; and,
? July 7, 2014 at 1620 - Patient 49718

A review of the clinical record for Patient #10 revealed a Physician Order for Seclusion on 7/16/14 at 1142. This event was not listed on the Seclusion and Restraint Log. There was no Incident Report available for review regarding this event Thus, at a minimum, one incident requiring patient seclusion was not reported to administrative staff, and proper channeling through that staff could not have occurred which would have resulted in review of the incident in the Quality Assurance/Performance Improvement Committee.

Facility policy entitled Incident Reporting, last review date May 2012, stated, in part:
"II. Procedure
A. Staff is required to complete an incident report when an incident or event involves consumers, staff, volunteers and guests within 48 hours of the incident ..."

In an interview with the facility Administrator in the presence of Staff #3, Quality Assurance, on the afternoon of 7/23/14 in the facility conference room, the Administrator was asked if the manner she obtained information and data regarding episodes of patient restraint and seclusion was by review of incident reports in the facility's electronic system. She stated this was the source of her information regarding these events, and the basis of her reports to the Quality Assurance/Performance Improvement Committee.

Based on a review of facility documentation and staff interview, the facility failed to ensure that drugs were administered to patients on the orders of the practitioner responsible for the patients' care.

Findings were:

A review of the clinical record for Patient #1 revealed a verbal telephone order received on 4/22/14 at 0415 for "Ativan 2mg IM x 1 for agitation...Use personal restraint to give Zyprexa and Ativan IM injection." The Medication Administration Record included an entry that Patient #1 received "Zyprexa 10mg IM Q6hrs PRN agitation (Do Not exceed 30 mg per day)" on 4/22/14 at 0406. The physician telephone order for Zyprexa included no route, no dose, and no reason for the IM medication. The order was signed by the physician on 4/23/14 at 0800.

Facility policy entitled Medication Administration, last reviewed 4/17/14, stated, in part:
"Medication management follows the accepted standard of care for medical, nursing, and pharmacy practice and is performed in accordance with state and federal regulations.
Procedure
Established controls for safety in medication administration ensure no patient is given a drug or food to which there is a history of a dangerous allergic reaction.
A) Medications are administered only upon written or verbal orders by those physician/physician extenders approved by the Medical Staff Committee in accordance with hospital bylaws, to practice medicine at Sunrise Canyon Hospital ...
Administration: ...
2) A nurse ...will conduct a secondary review of all new orders given during the shift for correct transcription, allergies, doses, times, etc. and (pharmacy contacted immediately with any questions) before new medications are administered ...
3) Each dose administered is recorded on the Medication Administration Record which becomes part of the medical record ..."

Facility policy entitled Medication Ordering, last reviewed October 25, 2012, state, in part:
"Administrative Policy
Prescription drugs or devices are ordered and administered only with an order from a licensed physician/physician extender ...
PRN Orders
Each physician/physician extender must give intervals and indications for administration of medication, if it is to be given as a "prn." For example, an order may read "Tylenol 325 mg tabs 1-2 po q4 to 6H prn pain." However, "Tylenol tabs po prn" is not acceptable and must be further qualified by the physician/physician extender ..."

The above findings were confirmed with Staff #7, the patient's treating psychiatrist, on the morning of 7/23/14 in the facility conference room. They were again discussed in an interview with the hospital administrator and other administrative staff on the afternoon of 4/23/14 in the facility conference room.

Based on a review of facility documentation and staff interview, the facility failed to ensure that all patient medical record entries were complete, dated, timed and timely, consistent with hospital policies and procedures and standards of practice.

Findings were:

A review of the clinical record for Patient #1 revealed a late entry by Staff #12, RN. The entry was dated 5/20/14 at 11:30 p.m. and was entered 27 days after Patient #1 had been discharged. The late entry did not not indicate the time, shift or even the date referred to in the entry.

Facility policy entitled Medical Records Forms, Order and General Procedures, last reviewed May 15, 2014, stated, in part:
"All entries contain the date and the time...Documentation that is not completed during the shift is labeled, "Late Entry." When a late entry is necessary, the words "Late Entry" is written on the top line of the entry, Enter the current date and time with signature. An addendum is another type of "Late Entry" that is used to provide additional information in conjunction with a previous entry. Document the date and time and signature on which the addendum was made. Write "addendum" and state the reason for creating the addendum, referring back to the original entry. When writing an addendum, complete it as soon as possible after the original note ...
6) Documentation standards for medical records follow The Joint Commission, (CMS) Centers for Medicaid and Medicare Services, and Texas Administrative Codes compliance requirements. These address the following:
- Presence of information on completed forms;
- Timeliness of the information following requirements of each discipline; ...
- Quality of the documentation ..."

Facility policy entitled Supervision and Monitoring Patients, last reviewed May 2012, stated, in part:
"Center nursing staff provides leadership to ensure continuous and timely availability of nursing services to patients according to standards of patient care and practice.
Administrative Policy
Clients are supervised and monitored based on client need and services outlined in the individual treatment plan ..."

In an interview with Staff #7 on the morning of 7/23/14 in the facility conference room, he stated "That's a very late entry. She [that nurse] was pretty new at the time...She's no longer here anymore. Wow, that's a pretty late entry, isn't it? That would have been important to be documented at the time. Unfortunately that happens too often."

The above findings were again confirmed in an interview with the hospital Administrator and other administrative staff on the afternoon of 7/23/14 in the facility conference room.