HospitalInspections.org

Based on a review of the clinical record and facility documentation, the director of the nursing service failed to be responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital.

Findings were:

Patient #1 fell on the following dates:
* 8-16-18
* 8-20-18
* 8-21-18
No post-fall assessment was performed by the nursing staff following the fall on 8-16-18 or the fall on 8-21-18.

Facility policy AS-12 titled "Fall Assessment/Re-Assessment and Precautions" states, in part:
"Policy:
Inpatient:
All patients will be assessed and identified for the potential of being at risk for falls within the first 8 hours of admission at the time of their initial nursing assessment, immediately after a fall and every 7 days if identified as moderate or high risk."

The above was confirmed in an interview with the DON and Director of Quality on 9-7-18.

Based on a review of documentation and a clinical record, the facility failed to ensure that informed consent was obtained prior to the administration of psychoactive medications.

Findings were:

Patient #1 was prescribed the following psychoactive medications during his stay:
* Risperdal
* Seroquel
No psychoactive medication consents were found for either medication. In an interview with staff #1, staff #1 confirmed that no psychoactive medication consents were present in the clinical record. The medication administration record provided documentation that patient #1 had been administered the above-listed medications during his stay.

Facility policy MM-02 titled "Psychoactive Medication Administration/Consent-Texas" states, in part:
"Policy:
" ...If psychoactive medications are prescribed by a LIP [licensed independent practitioner], a written informed consent must be obtained from the patient or legally authorized representative."

The above was confirmed in an interview with the DON and Director of Quality on 9-7-18.

Based on a review of documentation, the facility failed to make sure that each patient had a comprehensive treatment plan.

Findings were:

A review of the clinical record for patient #1 revealed that a master treatment plan had been initiated by the Registered Nurse on 8-15-18. The treatment plan was not completed by all necessary disciplines and was not reviewed or signed by the physician until 8-24-18, the day after the patient's discharge.

Facility policy CS-02 titled "Treatment Planning; Integrated/Multidisciplinary" states, in part:
"Purpose:
To document and implement treatment objectives/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of patient's treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided.
...
Procedure:
...
4. The treatment plan shall be signed by all members of the IDT-interdisciplinary team."

The above was confirmed in an interview with the DON and the Director of Quality on 9-7-18.

Based on a review of documentation, progress notes were not recorded by the physician responsible for the care of the patient as specified in §482.12(c).

Findings were:

Patient #1 was admitted to the facility on 8-15-18. A psychiatric evaluation was performed on 8-16-18. The physician recorded progress notes on the following dates:
* 8-17-18
* 8-20-18
* 8-21-18
The patient was subsequently discharged on 8-23-18.

Facility Medical Staff Rules & Regulations LBAW-03, page 5 states in part:
"6 ...Nevertheless, during an inpatient's stay, the inpatient must be seen by a physician/LIP [licensed independent practitioner] at least five (5) out of the seven (7) days after the date on which the psychiatric evaluation took place."

The above was confirmed in an interview with the DON and Director of Quality on 9-7-18.

Based on a review of the clinical record and facility documentation, the director of the nursing service failed to direct, monitor, and evaluate the nursing care furnished.

Findings were:

Patient #1 fell on the following dates:
* 8-16-18
* 8-20-18
* 8-21-18
No post-fall assessment was performed by the nursing staff following the fall on 8-16-18 or the fall on 8-21-18.

Facility policy AS-12 titled "Fall Assessment/Re-Assessment and Precautions" states, in part:
"Policy:
Inpatient:
All patients will be assessed and identified for the potential of being at risk for falls within the first 8 hours of admission at the time of their initial nursing assessment, immediately after a fall and every 7 days if identified as moderate or high risk."

The above was confirmed in an interview with the DON and Director of Quality on 9-7-18.