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Based on document review and interview the Governing Body failed to ensure that a physician assessed voluntary patients, either in person or through the hospital's telemedicine services prior to being admitted in 3 (Patient # 15, #21, and #31) of 3 medical records reviewed.

This deficient practice had the likelihood to cause harm to all patients that were admitted on a voluntary basis. Without a physician assessing the patient the physician could not determine the ability of the patient to make informed decisions, observe the patient's behavior to determine safe observation levels, or speak to the patients or their LAR (Legally Authorized Representative) to determine the mental health needs at the time of admission.

Findings:

Patient #15
Patient #15 was a 12-year-old female transferred to the hospital and admitted due to a Suicide Attempt on 12/12/2022.

A review of the pre-admission evaluation & medical clearance screening was conducted by Telemedicine Physician #15.

A review of the document was as follows:

" ...Consult Type: MOT review
Presenting Legal Status: Voluntary
Chief Complaint: Suicide Attempt
Per Staff: Patient reports that she attempted suicide via OD on ibuprofen. Pt has a history of self-harm via cutting. Pt is nonchalant about suicide attempt/self-harm. Patient laughing asking if her IV will kill her and is infatuated with the IV/her blood draw.
Recent Overdose: unknown. Ibuprofen 12/12 Per transferring facility.
Suicidality: Per report: Positive for thoughts, plan, attempt, and self-injury behavior.
MOT ACCEPTED BY Telemedicine Physician #15 on 12/12/2022 at 2:50 PM.
Patient may be accepted based on clinical review. Above per staff noted. Reviewed ..."

Staff #8 confirmed Telemedicine Physician #15 did not see the patient through the telemedicine services or speak directly to the patient's LAR (Legally Authorized Representative). Staff #8 confirmed the decision to accept the patient was based on the Memorandum of Transfer (MOT) review provided to him by the hospital.


Patient #22
Patient #22 was a 13-year-old male admitted to the hospital with a preliminary diagnosis of Bipolar current mixed severe, Disruptive mood dysregulation disorder on 6/01/2023.

A review of the Preadmission Evaluation & Medical Clearance Screening was conducted by Telemedicine Physician #12.

A review of the document was as follows:

" ...Presenting legal status per staff: Voluntary
Vitals: Per nursing assessment, the patient is in no acute clinical distress.

HPI: History per intake staff: Pt was discharged from PHP (partial hospital program) and set to go to RTC. Pt had a fight with mom at home and runs away. When patient was found by police he was weaving through traffic on foot. Patient has a history of aggressive behavior and has been aggressive with hospital staff ...
Per Provider: The clinical information provided by intake staff has been reviewed.
Review of Systems: Information per intake staff
Recommendations: Based on available information presented to me at this time: I certify that inpatient psychiatric hospital services furnished are necessary for either treatment which could reasonably be expected to improve the patient's condition or diagnostic study ..."

Staff #8 was asked if Telemedicine Physician #12 saw the patient through telemedicine and discussed the immediate care with the patient or the patient's mother. Staff #8 confirmed Patient #22 was not seen through telemedicine services by Physician #12 prior to admission. Telemedicine Physician #12 was given the clinical information and gave admission orders based on the information provided to him.


Patient #31
Patient #31 was a 22-year-old female admitted to the hospital on 6/02/2023 for a suicide attempt.

A review of the preadmission evaluation & medical clearance screening was conducted by Telemedicine Staff #15.

A review of the document was as follows:

" ...Consult Type: MOT Review
Presenting Legal Status: Voluntary
Present History: Per Staff: Patient reports taking 10 tabs of both Trazadone and Vraylar in attempt to kill herself.
Recent Overdose: Trazadone and Vraylar Per transferring facility
Suicidality: Per report-thoughts, plan, attempt
MOT ACCEPTED BY Telemedicine Physician #15 on 6/02/2023 at 9:00 PM ..."

A review of the MOT with Staff #1 confirmed no documentation that Telemedicine Physician #15 received a report from the transferring physician.

Staff #8 confirmed Patient #31 was not seen by Telemedicine Physician #15. The decision to admit the patient was based on a review of the MOT and information entered by the Intake Department.

An interview was conducted with Staff #8 on 6/14/2023 at 2:00 PM. Staff #8 was asked if all patients that come through the intake department were assessed by a Physician. Staff # 8 replied, if the patient is involuntary, the telemedicine doctors see them. If the patient is voluntary, the telemedicine doctors do not see them. We enter all the clinical information into the system, and they decide on admission. If the patient is admitted, then we get the orders. Staff #8 confirmed there are standing orders on the intake template that is sent to the physicians. Staff #8 was asked who determined the patient's legal admission status. Staff #8 replied, "They depend on our information that we put into their clinicals so if the patients are here voluntarily then they are admitted as a voluntary patient." Staff #8 was asked if the Intake Department Staff decided if the patient was competent to make informed decisions about their care. She confirmed the information was entered as voluntary because they presented themselves to the hospital or were transferred here at their request. Staff #8 was asked if the information entered in the system was based on the intake person's assessment of the patient. Staff #8 stated, "There is a template that is used depending on the arrival mode of the patient. If they are transferred by another hospital, it is one form and if they present any other way it is a different form, but they are very similar. Both templates have a place for us to check their present legal status. Staff #8 was asked if Registered Nurses (RN) completed the assessments on patients in the intake department prior to admission. Staff #8 reported that there are nurses that work in the intake department but there are times the therapists do it.

During an interview on 6/14/2023 with Staff #1, it was confirmed the telemedicine physicians were not seeing the voluntary patients admitted through the telehealth services. Staff #1 stated, "The patients have 24 hours to see a psychiatrist once they are admitted." Staff #1 was asked if the physician was not seeing the patients, who was determining their legal status, giving admission orders, medication orders, precautions, and observation levels for safety. Staff #1 confirmed the physicians were provided with the patient's clinical information from the Intake Department to determine if the patients met the criteria for admission. If they did, the telemedicine physician would give those orders based on the information he was given.
Staff #1 was asked if the telemedicine physicians contacted the hospital transferring physicians prior to accepting the patient. Staff #1 stated they should be doing that. A review of 3 (Patient #29, #30, and #31) MOTs and MOT admission orders did not reveal any communication was done between the physicians. Staff #1 confirmed the patient was accepted based on the MOT review and information provided by the Intake Department.
On 6/15/2023 Staff #1 presented a contract for review. The document reviewed was for Telemedicine Services, and it was titled, "Second Amendment to The Physician Services Agreement." The contract was effective September 1, 2014. There was no expiration date and no auto-renewal date in the contract. The contract gave no clear direction or expectation for Telehealth Services. The contract presented for review was financial only. The contract read in part,
" ...Section II. A. shall be amended and restated as of the Effective Date as follows:

A. For services rendered pursuant to this Agreement, Hospital shall provide Group with compensation as follows: (i) ******** Dollars per face-to-face evaluation per telemedicine and (ii) ******* dollars per MOT (memorandum of transfer) without a face-to-face evaluation telemedicine....

Staff #1 confirmed that the contract presented for review read that the telemedicine physicians were being paid for MOT reviews without a face-to-face evaluation per telemedicine. No further contract was presented for review.


An interview was conducted with Staff #16 on June 15, 2023, after 12:00 PM. Staff #16 asked if he knew that the Telemedicine Physicians were not seeing voluntary patients. Staff #16 stated, "No I was not aware of that. They must see the patients regardless of their voluntary or involuntary status. It is a requirement of their license. How hard is it to see someone over Zoom? This will be taken care of today."


Staff #1 and Staff #8 confirmed voluntary patients admitted for inpatient services were not seen by the telemedicine providers. The patients were admitted based on review of clinicals or MOTs submitted to them through their clinical system by the Intake Department.

Based on document review and interview the hospital failed to ensure a properly executed informed consent was completed in 2 (Patient #21 and #22) of 2 patient records reviewed before psychoactive medications were administered. Also, the hospital failed to follow their own policy, "Consent to Administer Psychoactive Drugs", and have the physician sign and date the informed consent.

Medical record reviews were conducted with Staff #7 RN on 6/13/2023 at 10:00 AM.

Findings:

Patient #21
Patient #21 was admitted to the hospital on 5/27/2023 with a diagnosis of DMDD (Disruptive Mood Dysregulation Disorder).

A review of the informed consents for treatment with Psychoactive medications was as follows:

"...Zyprexa (antipsychotic). The dosage was documented as "all doses". There was no route of administration documented on the informed consent. The CPS caseworker gave verbal consent on 5/30/2023 at 10:30 AM.

Seroquel (antipsychotic). The dosage was documented as "all doses". There was no route of administration documented on the informed consent. The CPS caseworker gave verbal consent on 5/30/2023 at 10:30 AM..."

As of survey exit date on 6/15/2023, the physician failed to sign and date the informed consent.



Patient #22
Patient #22 was admitted on 5/31/2023 with a diagnosis of Bipolar and DMDD.

A review of the informed consents for treatment with Psychoactive medications was as follows:

"...Latuda (antipsychotic). There was no dosage or route for the medication documented on the informed consent. A signature by the LAR (Legally authorized representative) was confirmed but illegible. There was no relationship to the patient, date, or time documented on the consent. The nurse witnessed the signature on 6/01/2023.

Depakote-There was no dosage or route for the medication documented on the informed consent. A signature by the LAR was confirmed but illegible. There was no relationship to the patient, date, or time documented on the consent. The nurse witnessed the signature on 6/01/2023.

Thorazine (antipsychotic) There was no dosage or route for the medication documented on the informed consent. A telephone consent was obtained with the moms first name only on 6/06/2023 at 1546 (3:46 PM). The consent was witnessed by 2 nurses on 6/06/2023..."

As of survey exit date on 6/15/2023, the physician failed to sign and date the informed consents.


Review of the hospital policy titled, "Consent to Administer Psychoactive Drugs" Policy Stat ID 9884298, with a last approval date of 12/2021 was as follows:

" ...POLICY STATEMENT:
It shall be the policy of the Millwood Hospital that a patient shall be treated with psychoactive medications only after the patient and/or the patient's parent, guardian, or legally authorized responsible person has been informed of the right to accept or refuse such medications and has consented to the administration of such medications. If consent was given, may be withdrawn at any time by stating such intention to any member of the treating staff. It is the purpose of this policy to protect the right of the patient (or minor patient's parent, guardian, or legally authorized responsible person) to make informed decision to accept or refuse treatment with psychoactive drugs.

DEFINITIONS:
Informed Consent:
informed consent must be given by the legally authorized representative of a patient under the age of 18 admitted under the voluntary, emergency or OPC provisions of Texas statutes, or by the patient himself if the patient meets the following criteria:
...
Responsibility - Physician or Designee
A. Sign and date consent form and acknowledge the interaction in the progress note ..."


An interview was conducted with Staff #7 RN on 6/13/2023 at 10:30 AM. Staff #7 was asked why the physician had not signed the informed consents for the medications. Staff #7 RN stated she was not aware that the consents were not signed but she would get them signed.

An interview was conducted with Staff #6 on 6/13/2023 after 10:30 AM. Staff #6 was asked if she compared the medication order to the informed consent. Staff #6 confirmed the nurses look at the consents, but they do not really focus on the dose. Staff #6 stated, "As long as there is a consent, we give the medication. I was not aware the dose or change in doses had to be on the consent."


Staff #6 and #7 confirmed 5 of 5 medication consents reviewed were not signed by the Physician and did not have the dose or route of administration documented.

Based on observation of records and interview the facility failed to have a process to ensure the patient's identity was placed on each page of a multiple page document (Memorandum of Transfer) considered part of a patient's medical record for te six month period of January 1, 2023 through June 12, 2023.


On June 12, 2023 a request was made to review the medical record of MOT's (Memorandum of Transportation) from January 1, 2023 through June 12, 2023. Each month was bound together in a single file. Each month's MOT's were observed having multiple page forms. If the first page had been removed to send with the emergency services crew, the remaining pages were kept as evidence of the completion of the MOT. Upon observation, the remaining pages did not contain the full identification of the patient. Some of the pages had the patient's name which was transferred by the carbon copy material. Some pages had no information for identification of the patient. No patient identifier had been affixed to the remaining forms. The review of all six months of MOT's identified copies of forms but no identifiable patient names or IDs for these transfers.

On 6/13/2023 a carbon copy with no information was taken to staff RN #6. Staff #6 stated, "There is no way I can tell you who that patient was".

Based on observation, review of documentation, and interview with facility staff, the facility failed to maintain the physical plant and environment in such a manner that the safety and well-being of patients are assured as evidenced by multiple patient care areas that had chipped or peeling paint, crumbling drywall, damaged wood, water-stained ceilings, torn chairs or bed mattresses, and inadequately functioning bathroom sinks.

The findings were:

The facility policy titled, "Cleaning Environment/Patient Equipment and Medical Devices," states, "All staff are responsible for ensuring high standards of cleanliness with regard to patient care equipment, medical devices and the environment of care. Standards of cleanliness: At a minimum, the standard of cleanliness is that all parts of equipment should be visibly clean with no blood or body fluids, dirt, debris, dust, tape, stains or spillage; the environment of care including, but not limited to, furniture, fixtures, floors and windows should be visibly clean with no blood or body fluids, dirt, debris, dust, tape, stains or spillages."

During a tour of the facility on 6/12/23 with the Director of Risk Management (Staff #1), the COO (Staff #2), and the CNO (Staff #3), it was observed:
- Room 241 (Consult Room): chair with multiple tears on covering exposing the foam underneath
- Room 196 (Day Room): multiple chairs with unknown dried residue and food particles; floor and doorway caked with dark dirt-like substance
- Room 181 (Clean Linen): linen cart uncovered and the clean linen exposed; dirty packing boxes stored above clean linen
- Room 129 (Consult Room): light fixture water-stained with red/pink residue
- Room 85 (Consult Room): water-stained ceiling around air vent
- Room 77 (Clean Linen): approximately 9-inch chip on wood countertop; approximately 9-inch chipped/crumbling dry wall; dirty packing boxes stored above clean linen; multiple areas with paint peeling on walls
- Room 218 (Patient Room): ½ inch tear on bed mattress
- Room 211 (Patient Room): peeling paint and crumbling drywall in bathroom; low water pressure in sink faucet that would be difficult for patient to wash their hands
- Room 201 (Patient Room): black substance on shower tiles/grout; bathroom light fixture water-stained; drywall around toilet warped and crumbling; ceiling by fire alarm warped and split; and both bed mattresses had multiple tears approximately 6-18 inches long
- Hallways: multiple areas with peeling paint, chipped wood, crumbling/split drywall, and dark brown/black residue stains on walls

Staff #1, #2, and #3 acknowledged the findings during the tour.

During a tour of the facility on 6/13/23 with the Director of Risk Management (Staff #1) and the Director of Plant Operations (Staff #5), it was observed:
- Room 102: multiple areas with paint chipped or peeling
- Room 110: low water pressure in sink faucet that would be difficult for patient to wash their hands
- Room 113: paint peeling in multiple areas of bathroom
- Room 114: paint peeling in multiple areas
- Room 201: approximately 9-inch laminate floor board missing by room entrance
- Room 210: low water pressure in sink faucet that would be difficult for patient to wash their hands
- Near Adolescent Boys nurse's station, the Exit sign is missing from the ceiling

In an interview with Staff #5, on the morning of 6/12/23, Staff #5 stated, "A contractor comes by every Friday to touch up paint. There is another contractor for the drywall patching as needed."

Based on review, observation, and interview the facility failed to ensure all nursing disciplines were addressed on the staffing grid, all staff were covered for meals and breaks, and all units were staffed accordingly when using the minimum staffing levels. Failure to staff according to the staffing matrix and staffing plan placed patients and staff at risk in the child and adolescent units.

A tour of the child and adolescent unit was conducted on 6/14/23 at 9:00 AM with staff #3. 2 RNs (Registered Nurses) and 1 LVN (Licensed Vocational Nurse) were working on the unit. A review of the child and adolescent units revealed there were two separate units that shared a nurse's station. Upon interviews and observation, the nurses were sharing the units, and the two units were being staffed as 1 unit. Each unit must be staffed appropriately according to the staffing matrix and staffing plan. Staff #3 confirmed the nurses were being shared between the two units instead of staffing each unit to the matrix. The child and adolescent unit was short on all shifts according to the matrix.

The Staffing Matrix is a tool to help leadership determine what levels of each staff group are needed based on the census. This matrix is used as a guideline, Adjustments are made that take into consideration patient needs and acuity.

The facility had a house supervisor, and on the day shift, the units have a nurse manager. An interview was conducted with the Staff #7 nurse manager on 6/14/23. Staff #7 stated that the RN's are covered by the house supervisor for lunch breaks, but the LVN is not covered.

A review of the staffing matrix revealed there were Registered Nurses (RN's), Mental Health Technicians (MHT's), and unit clerks listed on the matrix but not Licensed Vocational Nurses (LVN's). The matrix just stated nurse and did not distinguish between the RN and LVN. An LVN must be always supervised by the RN. Staff #3 stated that she was not aware the LVN was not covered for lunch. Staff #3 confirmed if the schedule was being filled at the minimal level and a staff member took lunch without a replacement then the floor was understaffed to the minimum grid.

An interview with Staff #3 CNO was conducted on 6-14-23. Staff #3 stated she had only been working at the facility for 3 weeks. She stated that she was aware of some issues with the staffing process and was trying to make some changes to the staffing plan and the grid. Staff #3 stated she had not had the opportunity to take the new matrix up until she can have a staffing advisory meeting and solidify the process. Staff #3 confirmed the grid did not address the LVN.