HospitalInspections.org

Based on observation, record review and interview the facility failed to provide patient rights information in advance of furnishing care as evidenced by one of one involuntary minor admission reviewed.
Policy:
Admission of Patient to Unit Origin 01/2016 Last Review 11/21
Purpose:
To ensure a safe and appropriate admission process occurs.
All patients refer to, or who request that mission, will be evaluated utilizing establish criteria. When criteria for admission are met and a Physician order is given, the patient will be admitted to the hospital. All patients or Guardians must sign the patient admission forms which includes the consent for inpatient treatment and this document, as well as all the admission paperwork must be completed thoroughly. All consent for treatments must be co-signed/witnessed by a hospital employee. For those hospitals using the EMR, the consents will be completed in the EMR and electronically signed.
Procedure:
The on-call psychiatrist will be notified of the potential admission by the intake department. The intake coordinator will provide the on-call psychiatrist with the clinical information obtained during the intake assessment. The on-call psychiatrist will determine the level of care that the patient requires based on the assessment. The on-call psychiatrist will determine if the patient meets medical necessity for inpatient, partial hospitalization, or outpatient. This determination will be communicated to the Intake Coordinator, who will proceed with admission or referral to the appropriate outpatient level of care.
Policy:
Voluntary Admission Last Review 12/2000. Next Review due 12/2021
Purpose: To assure patients admitted for services are accommodated in accordance with Texas administrative code 25 404.157
Policy:
B. All persons voluntarily admitted to inpatient services for treatment of mental illness or chemical dependency or the person who requested admission on the individual's behalf have the right to request discharge. Any such person expressing a request for release shall be given an explanation of the process for requesting release and afforded the opportunity to request the release in writing.
H. Fifth of all persons voluntarily admitted to inpatient services for treatment of mental illness or chemical dependency to have the right not to have an application for court ordered mental health or chemical dependency services filed while receiving voluntary services on last, in the opinion of the Physician responsible for the individual's treatment, the individual meets the criteria for court ordered services as outlined in the hall and safety code and either
1. Request discharge
2. Is absent without authorization
3. Is unable to consent to appropriate and necessary psychiatric and chemical dependency treatment or
Refuses to consent to necessary and appropriate treatment recommended by the Physician responsible for the individual's treatment and the Physician completes a certificate of medical examination for mental illness that in addition to the information required by the Texas Health and safety code includes the opinion of the Physician that:
A. There is no reasonable alternative to the treatment recommended by the Physician; and:
B. The individual will not benefit from continued in patient care without the recommended treatment.
Patient was a walk in accompanied by her mother on 03/01/21.
Certificate of Preliminary Medical Examination by Dr. #48, Tele-visit Psychiatrist; Major depression without psychosis.
A substantial risk of serious harm to herself.
The risk of harm is imminent unless the proposed patient is immediately restrained.
That emergency detention is the least restrictive means by which the necessity restraint may be effective.
That the facts which forms the basis for my medical opinion as to the mental illness, risk of harm, and need for immediate restraint are:
The patient form to a suicide pact with a friend and this was confirmed by mom be a text message.
No detailed documentation of this evaluation was present in the record
Emergency Apprehension and Detention Warrant, Harris County, 3/1/21 at 1603.
Conditions of Admission/Consent to Treatment and Information Disclosure:
The undersigned certifies that he/she has read the foregoing, received a copy, it is the patient/legal guardian if the patient is a minor is otherwise not legally able to complete this consent on his/her behalf. If this document has been executed by a parent/legal guardian of the patient, all references to the patient above shall be deemed to have been made by the parent/legal guardian on behalf of the patient.

Form was signed by an RN admissions staff #47 on 3/31/21. The signature space at for the legal guardian to sign was left blank. There was no consent in writing or documentation that verbal consent was obtained or that the parent refused to sign.
The patient, age 16, was brought to the facility by her mother who was her legal guardian. The patient was admitted however there was no documentation in the record that the patient or her legal guardian received any information on patient rights.
When interviewed 2/2/22 at 1255 Staff #19, Registered Nurse, Admissions stated the form should have been signed as received upon admission.

Based on interview and record review the facility failed to uphold the rights of 1 of 1 adult patients (ID#C) to receive care in a safe setting. Therapeutic boundaries were not maintained by staff and patient (ID#C) was taken to a blocked room by a MHT (ID# 12) without notifying other staff members, putting the patient at risk.

Findings Include:

Record review of the facility policy Therapeutic Boundaries (no date), stated staff should notify other staff members when you need to enter a patient's a room. Ensure that other staff members can monitor you when you must enter a private area with a patient.

Interview on 02/01/2022 at 1340 with the CNO, (ID#6) who stated, she interviewed the patient (ID# C), staff, the MHT (ID#12) in question, stated she watched the video tape, and concluded that something happened but could not prove it. She also stated the MHT (ID# 12) violated the hospital policy by taking the patient into a blocked room.

Interview on 02/01/2022 at 1400 with the Human Relations Director (ID# 18) who stated, "we terminated the MHT (ID#12) because he violated hospital policy, by taking patient (ID# C) to a blocked room". During his interview with the MHT (ID#13) who stated the patient (ID # C) wanted to use the restroom and he decided to take her to a locked room, it was a blocked room to avoid confrontation.

Record review of the documentation of the events documented by the Patient Advocate (ID#48) and by patient (ID# C) revealed MHT (ID#12) did not maintain a therapeutic boundary, by taking a patient in a blocked room by himself, while the registered nurses was off the unit. The patient claimed the MHT (ID# 12) sexually abused her.



43549

Based on observation, record review and interview the facility failed to provide care in safe setting for a total of 31 of 31 patients on two adult units, as evidenced by pencils and nickel size plastic disk game pieces in the dayroom with unsupervised patients.
Policy:
Contraband and Restricted Articles Last Revised 09/21
Purpose: To ensure a safe environment.
To provide a monitoring system for present with sharps or items designated as contraband and to record patient belongings.
Policy: Items, which are considered a danger or potential danger to patients and others, I will be locked in a secure location and administered to the patients on request and understaffed supervision. An instance when patient families are present at the time of admission, in a contraband will be sent home at the time of admission.
Patient will be provided an explanation of the contraband procedure and the rationale.
Items that are not allowed:
3. Anything that may jeopardize patients' mental, emotional, or physical safety.
4. Binders, Spiral notebooks, writing pens, sharpeners
21. Weapons, Wood, Metal, hard plastic, Cans, Kes, Firearms, Guns, Knives, Plastic bags, Cellophane, Balloons, or anything that may be used as a weapon.
Observations:
During the initial tour 1/31/22 at 1210 Adult Dual Diagnosis unit, Pathways
Staffing included one RN, and two mental health technique (MHT), were present for 14 patients
Most of the patients were in the dayroom and interacting with staff or talking to each other. One patient was playing solitaire at a table in the dayroom. Sitting across from her another female patient was coloring with crayons and colored pencils. Approximately 4 feet from the table was a counter with various games and books on top. One of the game boxes was without a lid and contained numerous nickel sized plastic blue chips. It also contained small triangular multicolored game pieces. There was also a small box of approximately 25 gulf pencils. The CEO confirmed to the pencils and game pieces should not have been sitting out unattended and could pose a risk.
No technicians were in the area. The nurse was behind the desk and although the table was in her view, she was busy with her tasks and other patients speaking to her and needing her attention. She was not observing the table.
Second floor Connections was a unit with males on one wing and females on the other. Total 17 patients
Staffing included 2 registered nurse, and three MHTs, who were interacting with the patients.
All patients were in group therapy sessions except one who was laying on a sofa in the dayroom with a MHT who stated the patient was his 1:1.
There was a box of colored markers and colored pencils open and unattended on the dayroom table. Staff #3, PA, confirmed the box contained potential sharps/pencils and took the box to the nurse.

During an interview 1/31/22 at 1305 Staff #3, Patient Advocate, confirmed the boxes contained potential sharps/pencils and took the box from the second floor Connections unit to the nurse.

Based on record review and interview, the facility failed to ensure restraint was imposed to ensure the immediate physical safety of the patient, a staff member, or others. This failure was evidenced by a staff member administering a psychotropic medication as an emergency medication to 1 of 5 patients (Patient T) for the convenience of staff.

Findings included:

Record review of policy # 10938268, "Medicating Patients in Emergencies," revised 3/2017 and last approved 1/2022, showed:
"Both voluntary and involuntary patients can be given psychotropic medication over their objection if an emergency exists.
DEFINITION:
Emergency is defined as a situation in which action to impose treatment over the persons' objection is immediately necessary for the preservation of life or the preservation of serious bodily harm to the patient or others, and it is impracticable to first obtain consent ...
Emergencies are not indefinite. An emergency situation allows for administration of medication only to the degree and duration needed to address the emergency. If at any point the behavior justifying the emergency ends or it becomes practicable to obtain informed consent, the justification for the emergency administration of medication no longer exists."

Record review of the Emergency Administration of Psychotropic Medication for Patient T dated 2/1/2022 at 11:58 am showed Haldol 10mg IM, Ativan 2mg IM, and Benadryl 50mg IM were ordered by Staff #38 (MD) and administered by Staff #36 (RN). Justification for the administration of these medications were danger to self (self-mutilation), danger to others, and acute psychosis and impaired judgement as evidenced by "increased psychosis as evidenced by screaming, yelling, violating personal boundaries of peers, attempts to attack people, combative, and threatening physical violence unless he is discharged from the hospital."

Record review of the Emergency Administration of Psychotropic Medication for Patient T dated 2/2/2022 at 11:38 am showed Haldol 10mg IM, Ativan 2mg IM, and Benadryl 50mg IM were ordered by Staff #38 (MD) and administered by Staff #21 (RN). Justification for the administration of these medications were danger to self (self-mutilation) and danger to others as evidenced by "increased psychosis as evidenced by screaming, yelling, violating personal boundaries of peers, attempts to attack people, combative, and threatening physical violence unless he is discharged from the hospital." Note: The 'as evidenced by" statement on 2/2/2022 is verbatim to the "as evidenced by" statement on 2/1/2022.

In an interview with Staff #21 (RN) on 2/2/2022 at 1:10pm, he stated that Patient T had been angry and yelling he wanted to go home. He stated the patient had slammed the patient phone receiver down several times. He stated he documented the patient was disruptive to the group therapy because he thought group members could hear Patient T yelling in the hall, not because Patient T had done anything in group. When Staff #21 (RN) was asked about the phrase "violating personal boundaries of peers," he stated Patient T had softly bumped a peer's shoulder when he approached the desk. When asked if Patient T had been removed from group therapy to receive an emergency medication, he said, "Yes." Staff #21 (RN) added that Patient T was calm and quiet in group but because he had already called the doctor and gotten the order for the emergency medication, he was going to administer it. When asked if the patient was having an emergency by sitting calmly in group, he hesitated and answered, "No."

In further interview with Staff #21 (RN), he was quired about what interventions were taken to calm the patient. He said he told the patient to lay down and take a nap and felt that was a de-escalation technique. Staff #21 (RN) concluded by saying that:
" Patient T had not attempted to attack anyone;
" Patient T's combativeness was slamming the phone;
" Patient T yelled a couple times that he felt like hitting someone if he could not go home but no one was near him (all the patients were in group); and
" Patient T went to group on his own.

Based on record review and interview, the facility failed to ensure that a description of the patient's behavior was documented on 4 of 6 patients (Patients H, U, V, and W) that justified the administration of emergency psychotropic medications.

Findings included:

Record review of policy # 976868, "Seclusion and Restraint," revised and approved 5/2021 showed:
"The use of restraint and seclusion will be avoided whenever possible and used safely when necessary.
DEFINITIONS ...
E. A drug or medication is a restraint when it is used to restrict or manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition ... The type of restraint or seclusion used must be the least restrictive technique that will be effective to protect the patient, a staff member, or others from harm ...
V. EMERGENCY USE OF RESTRAINTS / SECLUSION ...
An emergency is a situation in which it is necessary to restrain or seclude a patient to prevent:
" Imminent injury to the patient
" Imminent physical or the emotional harm to the patient or others, because of threats to harm, attempts to harm, or inappropriate acts ...
Required Documentation: ... The RN or LVN / LPN will document behaviors, triggers, pathways, de-escalation methods attempted prior to restraint or seclusion ... "

Record review of policy # 10938268, "Medicating Patients in Emergencies," revised 3/2017 and last approved 1/2022, showed:
"Both voluntary and involuntary patients can be given psychotropic medication over their objection if an emergency exists.
DEFINITION:
Emergency is defined as a situation in which action to impose treatment over the persons' objection is immediately necessary for the preservation of life or the preservation of serous bodily harm to the patient or others, and it is impracticable to first obtain consent ...
DOCUMENTATION:
Proper documentation is the best way to demonstrate that the standard for an emergency situation was met; it is needed for the protection of the facility as well as the patient. Good documentation should state what the patient said and did to indicate that medication was immediately necessary to preserve life or prevent serious bodily harm to him/her or others. Generalized descriptions such as 'dangerous,' 'threatening,' and 'combative' do not adequately convey the nature of the emergency. Documentation should also indicate why it was 'impracticable to first obtain consent' as the definition states.
Inadequate Documentation
[1] 'prevention of serious bodily harm to others'
[2] 'emergency situation'
[3] 'unpredictable; combative suddenly'
[4] 'delusional, threatening behavior'
Adequate Documentation
[1] 'Patient was choking another patient'
[2] 'Patient threw herself to the ground and began banging her head against the floor causing her mouth and nose to bleed'
[3] Patient was pacing in circles and began pounding his fist against the lockers'
[4] 'Patient stood inches away from staff with shaking, clenched fists yelling, 'I am the avenging angel. You must die, Satan.'"

4 of 6 patients (Patients H, U, V, and W):

Patient H.
Record review of the Emergency Administration of Psychotropic Medication for Patient H dated 2/15/2022 at 10:14 am showed Ativan 2mg IM, Benadryl 25mg IM, and Haldol 5mg IM were ordered by Staff #47 (MD) and administered by Staff #29 (RN). Justification for the administration of these medications: "Patient getting agitated, verbally and disruptive, paranoid."


Patient U.
Record review of the Emergency Administration of Psychotropic Medication for Patient U dated 2/1/2022 at 7:10 pm showed Benadryl 50mg IM and Haldol 10mg IM were ordered by Staff #25 (MD) and administered by Staff #26 (RN). Justification for the administration of these medications were danger to self (self-mutilation), danger to others, and acute psychosis and impaired judgement as evidenced by "aggressive, psychosis, delusional, paranoid, patient throw [sic] her clothes physically threating [sic] the staff."


Patient V.
Record review of the Emergency Administration of Psychotropic Medication for Patient V dated 1/29/2022 at 12:30 pm showed Haldol 10mg IM, Ativan 2mg IM, and Benadryl 50mg IM were ordered by Staff #28 (MD) and administered by Staff #29 (RN). Justification for the administration of these medications was acute psychosis and impaired judgement as evidenced by "patient severely psychotic, verbally aggressive, yelling and arguing, demanding to see the doctor, does not understand that he already saw the doctor today, believes that it was yesterday, unwilling to listen to redirection and orientation to reality."

Record review of the Observation Times form dated 1/29/2022 showed that Staff #31 (MHT) documented:
The 11:45 am round was documented at 11:47 am, the patient was "calm."
The 12:00 pm round was documented at 12:09 pm, the patient was "confused."
The 12:15 pm round was documented at 12:16 pm, the patient was "calm."
The 12:30 pm round was documented at 12:35 pm, the patient was "calm."


Patient W.
Record review of the Emergency Administration of Psychotropic Medication for Patient W dated 1/30/2022 at 7:43 pm showed Haldol 10mg IM, Ativan 2mg IM, and Benadryl 50mg IM were ordered by Staff #25 (MD) and administered by Staff #32 (RN). Justification for the administration of these medications was danger to others and acute psychosis and impaired judgement as evidenced by "patient was severely psychotic and agitated. He was verbally and physically threatening peers. He became a danger to other. He was difficult to redirect."

Record review of Nursing Note for Patient W dated 1/30/2022 at 11:20 pm by Staff #32 (RN) showed: "Patient is alert and oriented. Was noted in the day room screaming and shouting at other patients and staff and trying to fight. Notified Staff #25 (MD) and got order for order for Benadryl 50mg, Ativan 2mg, and Haldol 10mg. Patient was guided to the patient's room and IM was administered."

Record review of the Observation Times form for Patient W dated 1/29/2022 showed that Staff #35 (MHT) documented: The 6:15 pm, 6:30 pm, 6:45 pm, 7:00 pm, 7:15 pm, 7:30 pm, and 7:45 pm rounds were documented at 7:58 pm. Except for the 7:45 pm round, Staff #35 (MHT) documented that the patient was "calm." For the 7:45 pm round, he documented the patient was "disruptive, agitated, verbally aggressive, threatening."