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Based on record review and interview, the facility failed to have a well-organized medical staff accountable to the governing body for the quality of the medical care provided to one of one patients (Patient #1). Patient #1 had been admitted to the facility on 10/31/2023 for DMDD (disruptive mood dysregulation disorder) and PTSD (post-traumatic stress disorder). Patient #1's medical condition required the administration of three controlled substances for seizure disorder-Lacosamide, Clonazepam, and Phenobarbital. The patient was discharged on 11/13/2023 with the controlled medications to be continued. There was no evidence that the medical bylaws addressed the process of electronic discharge prescription of controlled medicinal substances for a patient's medical condition. The medically necessary prescriptions were not electronically communicated to a pharmacy for at least 4 days. Patient #1 suffered multiple seizures after discharge and required inpatient hospitalization for her condition at a local acute pediatric medical hospital on 11/16/2023.

Findings Included:

The "Discharge Medication Summary for Patient" form that was provided to the case worker upon discharge listed the following medications to be taken after discharge: Clonidine for impulsivity, Lacosamide for seizures, MiraLax for constipation, Clonazepam for seizures, and Phenobarbital for seizures.

A review of the medical record revealed a copy of a paper prescription completed on 11/13/2023 by Personnel #6 for the following controlled medications: Lacosamide, Phenobarbital, and Clonazepam.

During a personal interview on 11/28/2023 at 11:00 AM, Personnel #1 stated "The problem was her discharge prescriptions were controlled substances and were written on a paper prescription. Controlled substances cannot be written on paper, they must be sent in electronically. Personnel #5 told me she is not set up for e-scribe (electronic prescriptions) and does not have the capability to order medications electronically. It's not that she wasn't willing, but that she just was not able. Unfortunately, it looks like it fell through the cracks since no one called the psychiatrist to ask them to send in the patient's controlled substance medications electronically."

During a personal interview on 11/28/2023 at 11:18 AM, Personnel #5 stated "I received a Tiger Text (text messaging in a HIPAA [Health Insurance Portability and Accountability Act] compliant manner) from our team that this patient was on seizure medications and asked if we could call them in. I remember I specifically stated in the text that they are controlled substances, and they cannot be called in. I do not have access to electronic scripts so I asked if one of the psychiatric doctors could order the medications since they can all send prescriptions electronically. I never heard anything back, so I assumed it was taken care of. I don't know if anyone followed up with psych for the e-scripts."

During a telephone interview on 11/28/2023 at 2:00 PM, Personnel #6 stated she had written the three controlled medications for seizure disorder on a paper prescription to go home with the patient. Personnel #6 stated she was not aware that a paper prescription could not be used for controlled substances.

During a personal interview on 11/28/2023 at 2:50 PM, Personnel #2 stated "Our medical staff does have a formal organized structure with bylaws, rules, and regulations. The MEC (medical executive committee) is made up of internal medicine physicians and psychiatrists. The medical staff is held accountable to the governing body for the quality of medical care provided to the patients by reviewing performance improvement data, peer review done by physicians and nurse practitioners, feedback analysis from patient complaints, discharge chart audit process, and physician score cards. We do a discharge chart audit process quarterly that includes a full chart review. We don't audit 100% of the charts, but hopefully if someone had picked this patient's chart, they would have identified that three controlled substances were ordered on a paper prescription and a corrective action plan would have been developed. We had an MEC meeting today, and the issue has been discussed and addressed. Our Medical Director and Personnel #5 were both present. Personnel #5 is getting e-scribe privileges today. We will also provide education with attestations to our nurse practitioners regarding the use of paper prescriptions for controlled substances."

Medical Staff Bylaws approved by the Medical Staff on 3/24/2020 reflected the following, " ...Medical Executive Committee (MEC) ...11.2.2 The duties of the MEC shall be to ...account to the Board and to the Staff for the overall quality, uniformity, and efficiency of medical care rendered to patients ...11.4.5 Bylaws, Rules and Regulations ...The duties involved in this function are to ...recommend any changes deemed necessary or desirable in the Bylaws, the Rules and Regulations, and the procedures and forms; and develop and implement the Rules and Regulations to establish standards of patient care and ensure that these Rules and Regulations are consistent with Medical Staff Bylaws and with Facility Policy and Procedure ..."

Per the Texas Medical Board website, "Controlled Substance Electronic Prescribing Requirement Effective January 1, 2021, Texas Health and Safety Code, §§481.0755 requires that prescriptions for controlled substances to be issued electronically, except in limited circumstances, or unless a waiver has been granted by the appropriate agency."