HospitalInspections.org

The Governing body failed to:


A. fully implement continuous monitoring for all Medicare patients when in their rooms as outlined in their corrective action plan for previously cited defeciency. The facility failed to secure light fixtures and drop down ceilings which placed all patients in that unit at risk for the likelihood of harm, injury, or subsequent death.

Refer to tag A0144



B. provide adequate number of trained staff to ensure that patients are placed in restraints safely and exceeded the safe maximum time for use of restraints without following established hospital policy for renewing an order.

Refer to tag A0167


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The facility failed to:


A. fully implement continuous monitoring for all Medicare patients when in their rooms as outlined in their submitted corrective action plan for previously cited deficiency. The facility failed to secure light fixtures and drop down ceilings which placed all patients in that unit at risk for the likelihood of harm, injury, or subsequent death.

Refer to tag A0144



B. provide adequate number of trained staff to ensure that patients are placed in restraints safely and exceeded the safe maximum time for use of restraints without following established hospital policy for renewing an order.

Refer to tag A0167


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Based on review of records, the hospital failed to establish a process to ensure patient were provided the standardized notice, "An Important Message from Medicare" (IMM), within 2 days of admission.


Findings include:


Review of 5 charts (patient #1, #2, #3, #4 and #5) showed that the IMM for 1 (patient #1) out of 5 was not dated. Five out of five IMM were not timed. Patient #3 does not contain a patient signature on the IMM. In the patient signature block is a note that reads, "Refused to Sign" but does not contain the name/signature of person making the note or a witness to the refusal.

Based on observation and interview, the facility failed to fully implment continuous monitoring for all Medicare patients when in their rooms as outlined in the corrective action plan submitted for previously cited deficiency. The facility failed to secure light fixtures and drop down ceilings which placed all patients in that unit at risk for the likelihood of harm, injury, or subsequent death.

A tour of the Angelina Unit #1 (AU1) and Angelina Unit #3 (AU3), in buildings 514 and 515, was conducted on 3/14/16 with Administrative staff #1, #2, and #3. The AU1 and AU3 was designated for Medicare patients. During the tour the following observations were found:

1. Patients were in their rooms with no visible supervision.

2. Drop down ceilings were located in patient care areas and patient rooms. This ceiling was easily accessible to patients.

In the psychiatric setting, this provides a place for psychiatric patients to hide medications, weapons, or other contraband. The metal supports for the drop down ceilings can be easily pulled down and used by psychiatric patients to harm themselves or others.

4. Light fixtures in patient rooms were not securely contained. The lens to the fixture was easily opened with two tabs securing it. Once open, the glass fluorescent tubes were exposed and easily accessible to patients. The glass tubes can be removed by a patient and used to harm themselves or others.

Staff #3 confirmed during the tour on 3/14/16, that the patients were on an every 15 minute checks and not continuous observations, while in patient rooms, per the plan of correction on the previous visit.

Staff #1 stated, "We have not made any changes on this unit because we were concentrating on the San Jacinto Unit. We didn't know that you were going to look at these units."Staff #3 confirmed AU1 and AU3 was a designated for Medicare patients.

On 3/14/16, a tour of the New San Jacinto Unit in building 514 was conducted with staff #1, #2, and #3.

An interview with maintenance during the tour 3/14/16, revealed there was no secured light fixtures on AU1 or AU3. Maintenance stated the only unit they have worked on to secure light fixtures was on San Jacinto Unit in building 514.



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Based on review of policy and patient records, the facility failed to follow their own policy by not providing adequate number of trained staff to place patients in restraints safely and exceeded the safe maximum time for use of restraints without following established hospital policy for renewing an order for 2 (#1, #3) of 5 (#1-#5) patients reviewed.


Findings include:


Review of policy titled "RHS OM Policy No: 04-12-05 Section: Patient Care, Treatment and Services Title: Behavioral Emergencies Subtitle: Mechanical Restraint Devices" provided the guidelines for using a Mechanical Restraint Chair. This device is used to keep a patient in a seated position when a patient's "behavior is too dangerous to allow the patient to be safely escorted or personally restrained by staff." Per the established hospital policy, "A minimum of four competently trained staff members are needed to place a patient in a restriction chair. The patient will be placed and restrained in the chair following FCTD training guidelines."


Per the established hospital policy, "The maximum length of time for a patient to be placed in a mechanical restraint chair is 2 hours due to possible DVT risks. If a patient continues to exhibit behaviors which necessitate continuation of the restraint chair at the end of 2 hours, the physician must see the patient and write an order containing justification of the continuation. The order must state the reason(s) that the benefit of continuation outweighs the risks associated with releasing the patient."


Review of policy titled "RHS OM Policy No: 04-12-09 Section Patient Care, Treatment and Services Title: Behavioral Emergencies Subtitle: Time Limitation on Restraint/Seclusion orders" provided the guidelines for renewing restraint orders. "If the original order has not yet expired and the clinically competent registered nurse has evaluated the individual face-to-face and determined the continuing existence of a behavioral emergency, the registered nurse must contact the physician. The physician shall conduct a face-to face (sic) evaluation before issuing an order that continues the use of restraint or seclusion." "The physician shall document the clinical justification for continuing the restraint or seclusion before issuing or renewing an order that continues the use of restraint or seclusion.


Two (Patient #1 and Patient #3) of five (Patient #1, #2, #3, #4, and #5) medical reords reviewed showed that the Mechanical Restraint Chair was used.


Review of Patient # 1 medical record showed that the patient had been placed in the Mechanical Restraint Chair 6 times: 2-5-2016, 2-6-2016, 2-8-2016, 2-11-2016, 2-14-2016, and 3-6-2016. Further review of the medical record revealed that on 3 of the 6 occasions, staff failed to use the minimum number of required staff. On 2-6-16 and 2-15-16, only 3 staff members were used. On 3-6-16, only 2 staff members were used.


Review of 2-14-16, use of Mechanical Restraint Chair shows that the patient was first placed in the restraint at 6:45 AM. "At 08:39 AM physician contacted because the two hour time limit on the mechanical restraint was approaching and patient continued to be agitated. New order received per physician for Ativan 2mg IM Stat for aggressive and threatening. Physician gave order to continue mechanical restraint chair for another 2 hours or until patient is less aggressive and threatening. Physician came to the ward at 09:20 AM to assess the patient."


The physician did not see the patient until 41 minutes after the new order to extend the restraints was obtained by nursing staff. The new order entered at 8:44 AM and does not state the reason(s) that the benefit of continuation outweighs the risks associated with releasing the patient. The order placed states "Relative contraindication include: None" and "Justification/rationale for over-riding contraindication: N/A". The physician did not document clinical justification for continuing restraint until 2-14-16 at 06:40 PM.


Review of Patient #3 medical record showed that the patient had been placed in the Mechanical Restraint Chair 6 times: 2-24-16, 2-25-16, 2-26-16, 3-3-16, 3-4-16, and 3-12-16. Further review of the medical record revealed that on 5 of the 6 occasions, staff failed to use the minimum number of required staff. On 2-24-16, 2-26-16, 3-4-16, and 3-12-16, only three staff members were used to place the patient in restraints. On 3-3-16, only 1 staff member was used to place the patient in restraints.

Based on review of medical records, hospital policy, and interview, the hospital failed to develop policies and/or processes to ensure the entry is authenticated by the person responsible for providing or evaluating services provided. Staff failed to document forms completely.


Findings include:


Review of policy titled "RSH OM Policy No: 08-06-05 Section: Information Management Title: Patient Record Information Subtitle: Documentation in the Record" covered "Authentication in the Electronic Medical Record". This process only describes the process of the EMR tracking the login and password of the user making entries. The policy detailed the Computer Use Agreement and the need to secure login information. It does not include a process for the staff who provided the services to authenticate the information entered by and/or finalized by another staff member.


Under Procedures for Documentation it says, "2. A designated staff member is assigned to each trainee while on RSH assignment as her/her supervisor. Entries that require countersigning are warranted by discipline license. Countersigning is demonstrated in the hospital's electronic medical record by the assessment/document being finalized by the person countersigning and the progress note being filed by the person countersigning. Each supervisor is ultimately responsible for the care and treatment of the patient at all time."


When the medical record entries were examined, there was no way to distinguish between an entry that required a countersignature or an entry that one staff member had charted for another staff member's assessment or care.


Review of policy titled: "RSH OM Policy No: 08-06-05 Section: Information Management Title: Patient Record Information Subtitle: Documentation in the Record" provided instructions for documenting in the written record. "When documenting the written record: a. Use ink b. write neatly and legible c. include the date and time of entries. Use a.m. and p.m. notation on all entries when designating time of day. Do not use military time in documenting. e. Sign or print name and title as applicable."


Review of Patient # 1 showed:


1. Social Assessment MH lists the Assessment Date as 2/4/2016, the Assessment Time as 04:32PM and Draft/Final as Final. The Assessing Clinician is listed as Staff #6.


The Data Entry By is listed as Staff #7 on 2-5-2016.


Interview via phone on 3-18-16, with Staff #3 and Staff #4 revealed that Staff #6 was being supervised by Staff #7 and due to licensure, required a countersignature.


There was no authenticating signature (electronic or written) for Staff #6 to indicate that the data listed on the final report is her true and accurate assessment with nothing altered by Staff #7 prior to being filed as a completed document.


2. Progress Note entry on 2-3-2016, at 11:04 AM, Written By: Staff #8, Note Type: Other (Inpatient Progress Note (Diagnosis Entry)), Assessing Clinician: Staff #9, Progress Note: "Patient had EKG done on 2/3/16. JL"


There was no authenticating signature (electronic or written) for Staff #9 indicating that he had assessed the EKG (electrocardiogram is used to assess the heart functioning and abnormalities with the heart rhythm) on 2/3/2016.


3. Medical Observations Note dated 3-5-2016 at 08:49 PM, Data Entry By: Staff #10, Assessing Clinician: Staff #11.


There was no authenticating signature (electronic or written) for Staff #11 to indicate that the data listed is his true and accurate assessment with nothing altered.


4. Medical Observations Note dated 2-23-2016 at 05:21 AM, Data Entry By: Staff #12, Assessing Clinician: Staff #13.


There was no authenticating signature (electronic or written) for Staff #13 to indicate that the data listed is his true and accurate assessment with nothing altered.


5. Medical Observations Note dated 2-17-2016 at 09:07 PM, Data Entry By: Staff #10, Assessing Clinician: Staff #14.


There was no authenticating signature (electronic or written) for Staff #14 to indicate that the data listed is her true and accurate assessment with nothing altered.


6. Medical Observations Note dated 2-9-2016 at 09:43 PM, Data Entry By: #10, Assessing Clinician: Staff #15.


There was no authenticating signature (electronic or written) for Staff #15 to indicate that the data listed is his true and accurate assessment with nothing altered.


7. Medical Observations Note dated 2-5-2016 at 08:51 PM, Data Entry By: Staff #16, Assessing Clinician: Staff #17.


There was no authenticating signature (electronic or written) for Staff #17 to indicate that the data listed is her true and accurate assessment with nothing altered.


8. The chart contained a form titled "Anatomy Form" The signature of "Staff completing form:" was illegible and did not contain the title of the staff member. The form was not timed.


9. The chart contained a form titled "Dental Record Initial Examination Report" The physician's signature was illegible and the form was not timed.


10. The chart contained a form titled "Dental Progress/Treatment Record Work Completed. This form contains entries dated 2-9-16, 2-16-16, and 3-14-16. All signatures were illegible and did not contain the title of the staff member. All entries on the form were not timed.


11. The chart contained a form titled "Vital Sign Worksheet". One set of vital signs was listed, including blood pressure, temperature, pulse, respiration rate, and oxygen saturation level. There was no date, time, or staff signature to include title on this form.


12. The chart contained a form titled "Consent to Treatment - Therapy-Surgical Procedure". The patient's signature did not include the time the patient signed. The physician's signature was illegible and did not contain the time the physician signed.


13. The chart contained a form titled "Authorization to Disclose Protected Health Information (or other confidential information)" The patient's signature did not include the date and time of the signature. The witness signature did not contain a title and was not timed.


14. The chart contained a form titled "Rusk State Hospital Receipt of Articles. It contained Staff Initials and Staff Signature, but no title, date or time with the signature. It contained Witness Initials, but no witness name/signature or title. There was a Date Received on the form, but it was not timed. The patient signed the form, but the signature was not dated or timed.


15. The chart contained three forms titled Rusk State Hospital Clothing Record. On the first form, the first date listed was 2-1-16 with staff initial that matched staff signature. There was a second date of 2/2/16 with staff initials and no staff signature. Staff signature did not contain a title. Patient signature was not dated. There were no times on the form. On the second form, there was a dat4e of 2/2/16, but did not contain any staff signature with title, patient signature was absent, and no time was listed. The third form was a copy of the first form with the 2-1-16 entry on it. The 2-2-16 entry was missing. It had a 2-11-16 entry. The staff initials for 2-11-16 entry did not have a signature to identify the staff. None of the signatures were dated or timed.


16. The chart contained a form titled Trust Fund Account Authorization. The signature of staff did not contain a title. Signatures were dated but not timed.


17. The chart contained a form titled Personal Medication Inventory. The form was not dated or timed. The Admission Staff Signature did not contain a title.


Review of Patient #2 showed:


1. Progress Note entry on 3-9-2016 at 03:19 PM, Written By: Staff #8, Note Type: Other (Inpatient Progress Note (Diagnosis Entry)), Assessing Clinician: Staff #18 Progress Note: "Patient had EKG done on 3/9/16. JL"


There was no authenticating signature (electronic or written) for Staff #18 indicating that she had assessed the EKG (electrocardiogram is used to assess the heart functioning and abnormalities with the heart rhythm) on 3/9/2016.


2. Medical Observations Note dated 3-14-2016 at 05:10 AM, Data Entry By: Staff #19, Assessing Clinician: Staff #13.


There was no authenticating signature (electronic or written) for Staff #13 to indicate that the data listed is his true and accurate assessment with nothing altered.


3. The chart contained a form titled Rusk State Hospital - Diet History. The form was dated but not timed. The form was incomplete. Staff signature did not include title.

4. The chart contained a form titled "Authorization to Disclose Protected Health Information (or other confidential information)" The patient's signature did not include the time of the signature. The witness signature did not contain a title and was not timed.

5. The chart contained a form titled "Rusk State Hospital Receipt of Articles. It contained Staff Initials and Staff Signature, but no title, date or time with the signature. It did not contain Witness Initials. There was a Date Received on the form, but it was not timed. The patient signed the form, but the signature was not dated or timed.

6. The chart contained a form titled "Rusk State Hospital Clothing Record" The staff signature did not contain a title, date, or time. The Patient's Signature did not contain a date or time.

7. The chart contained a form titled Trust Fund Account Authorization. The signature of staff did not contain a title. Signatures were dated but not timed.

8. The chart contained a form titled Personal Medication Inventory. The form was not dated or timed. The Admission Staff Signature did not contain a title.

Review of Patient #4 chart was completed.


1. Social Assessment MH lists the Assessment Date as 1/15/2016, the Assessment Time as 10:32 AM and Draft/Final as Final. The Assessing Clinician is listed as Staff # 22.


The Data Entry By is listed as Staff #23 on 1-15-16.


There was no authenticating signature (electronic or written) for Staff #22 to indicate that the data listed on the final report is her true and accurate assessment with nothing altered by Staff #23 prior to being filed as a completed document.


2. Psychiatric Nursing Assistant (Inpatient Progress Notes (Diagnosis (sic) dated 1-24-16. Written by Staff #24. Assessing Clinician Staff #25. Weekly PNA Documentation/Safety Check.


There was no authenticating signature (electronic or written) for Staff #25 to indicate that the data listed is his true and accurate assessment with nothing altered.


3. Progress Note entry on 2-3-2016 at 11:04 AM, Written By: Staff #8, Note Type: Other (Inpatient Progress Note (Diagnosis Entry)), Assessing Clinician: Staff #26, Progress Note: "Patient had EKG done on 1/14/16. JL"


There was no authenticating signature (electronic or written) for Staff #26 indicating that she had assessed the EKG (electrocardiogram is used to assess the heart functioning and abnormalities with the heart rhythm) on 1/14/2016.


4. Psychiatric Nursing Assistant (Inpatient Progress Notes (Diagnosis (sic) dated 2-7-16. Written by Staff #27. Assessing Clinician Staff #25. Weekly PNA Documentation/Safety Check.


There was no authenticating signature (electronic or written) for Staff #25 to indicate that the data listed is his true and accurate assessment with nothing altered.


5. Psychiatric Nursing Assistant (Inpatient Progress Notes (Diagnosis (sic) dated 3-5-16. Written by Staff #27. Assessing Clinician Staff #25. Weekly PNA Documentation/Safety Check.


There was no authenticating signature (electronic or written) for Staff #25 to indicate that the data listed is his true and accurate assessment with nothing altered.


6. Medical Observations Note dated 3-14-2016 at 05:18 AM, Data Entry By: Staff #19, Assessing Clinician: Staff #13.


There was no authenticating signature (electronic or written) for Staff #13 to indicate that the data listed is his true and accurate assessment with nothing altered.


7. Medical Observations Note dated 3-12-2016 at 08:20 AM, Data Entry By: Staff #24, Assessing Clinician: Staff #28.


There was no authenticating signature (electronic or written) for Staff #28 to indicate that the data listed is his true and accurate assessment with nothing altered.


8. Medical Observations Note dated 3-11-2016 at 09:29 PM, Data Entry By: Staff #27, Assessing Clinician: Staff #24.


There was no authenticating signature (electronic or written) for Staff #24 to indicate that the data listed is his true and accurate assessment with nothing altered.


9. Medical Observations Note dated 3-16-2016 at 04:33 AM, Data Entry By: Staff #29, Assessing Clinician: Staff #13.


There was no authenticating signature (electronic or written) for Staff #13 to indicate that the data listed is his true and accurate assessment with nothing altered.


10. Medical Observations Note dated 2-26-2016 at 08:21 AM, Data Entry By: Staff #29, Assessing Clinician: Staff #13.


There was no authenticating signature (electronic or written) for Staff #13 to indicate that the data listed is his true and accurate assessment with nothing altered.


11. Medical Observations Note dated 2-21-2016 at 08:15 PM, Data Entry By: Staff #27, Assessing Clinician: Staff #24.


There was no authenticating signature (electronic or written) for Staff #24 to indicate that the data listed is his true and accurate assessment with nothing altered.

Based on review of record, review of policy, and interview, nursing staff failed to follow established policy for documentation of emergency medication administration.

A review of policy titled, "RSH OM Policy No: 04-12-17 Section: Patient Care, Treatment and Services Subtitle: Emergency Medication" established that "The nurse, once aware of symptoms/conditions that are indicators for emergency medication use, will conduct a face-to-face assessment of the patient." Specific elements of the assessment were identified and include: "a. The patient's condition, specific exacerbation of symptoms or other conditions triggering the request for emergency medication. b. What alternatives to medication have been attempted, and the effectiveness of those interventions. c. Whether or not the patient is willing to accept a medication and the patient's preferred route (PO vs. IM)." The policy further established "If the nurse's assessment is that emergency medications might be indicated, the nurse will then call the physician, report assessment findings, and seek orders." "The nurse will document this assessment and outcome in an intervention progress note (IPN)."

A review of five (Patient #1, #2, #3, #4, and #5) showed that three of the patients (Patient #1, #3, and #4) received Emergency Medication Administrations.

Review of Patient #1 chart showed that the patient had received Emergency Medication Administration once on each of the dates 2-3-16, 2-4-16, 2-5-16, 2-9-16, 2-15-16, 2-17-16, 2-28-16, and 3-06-16. The patient received Emergency Medication Administration twice on 2-8-16 and 2-11-16. The patient received Emergency Medication Administration three times on 2-6-16 and 2-14-16. This was a total of 18 events. There was no clearly documented Emergency Medication Administration face-to-face documented on any of the 18 events.

Review of Patient #3 Chart showed that the patient had received Emergency Medication Administration once on each day of 2-25-16 and 2-15-16. The patient received Emergency Medication Administration twice on 2-26-16 and 2-24-16. This was a total of 6 events. There was no clearly documented Emergency Medication Administration face-to-face documented on any of the 6 events.

Review of Patient #4 chart showed that the patient had received Emergency Medication Administration once on 1-16-16. There was no clearly documented Emergency Medication Administration face-to-face documented for this event.

Staff # 2was interviewed on the afternoon of 3-14-16 in the conference room. When asked about the lack of face-to-face documentation in the IPN, Staff #2 replied, "The face-to-face is implied in the nurse's documentation."

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