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Based on review of records, interview, and observation, the facility failed to ensure the Governing Body followed its processes that protected the rights of patients as shown by:


1. Allowing improper consenting of patients for:

a. admission to the facility, and
b. psychotropic medications;

2. Not addressing and processing grievances for one year;

3. Allowing improper restraint practices, including:

a. patients not being monitored for restraints,
b. patients not being assessed within one hour post restraint,
c. non-physicians ordering restraints;

4. Not ensuring the hospital's QA program monitored, tracked, and
analyzed:

a. Restraint & Seclusions for three quarters;
b. Grievances for three quarters.


More specifically, this failure was evidenced by the following:

(1a). Admission consents: 2 of 4 Patients who were considered voluntary (Patient #
9 & 12) and had either refused to sign, or were unable to sign admission
consent forms due to being only oriented to self, were admitted and treated at
the facility.

Cross reference tag #A0131


(1b). Psychotropic medication consents: 4 of 4 voluntary patients that were
prescribed and given multiple psychotropic drugs were improperly consented
(Patient #1, 3, 9, & 12). These patients had documentation on their
psychoactive medication consent forms that either they were cognitively
impaired and unable to sign (Patient #1, 3, & 9), or, the patient's legally
authorized representative did not consent for the medication (Patient #12).
These patients were still administered these medications.


Cross reference tag #A0131


(2). Grievances were not addressed for approximately one year-from August of 2021
to July of 2022, and, the facility's Governing Body did not take responsibility. It
was unknown how many complaints were involved.


Cross reference tag #A0118 and tag #A0119


(3a). Restraints-Not monitoring patients: Emergency Medication administration used
to control patient behavior in behavioral emergency situations were not treated
as restraints, which require patients to be monitored during the process by
trained staff. This monitoring was not performed for 5 of 5 patients (Patient #
9, 13, 14, 15, 16, & 17).

Cross reference tag #A0175 (and see tag A0160 for federal definition of restraint)


(3b). Restraints-Not performing required Face-to-Face assessment of patient within
one hour of the intervention: Emergency Medication administration used to
control patient behavior in emergency situations were not treated as restraints,
which require face-to-face post restraint assessments within one hour of the
intervention. These assessments were not completed for 6 of 6 patients after
they were restrained (Patient #9, 13, 14, 15, 16, & 17).

Cross reference tag #A0179


(3c). Restraints not ordered by physicians: Emergency medication administrations
were ordered by four Nurse Practitioners (Staff #F, J, H, & I), not physicians,
for 3 of 5 patients (Patient #15, 16, & 17). This was not in accordance with
State law which allows only physicians to order restraints.

Cross reference tag #A0168 (and refer to Texas Administrative Code- Emergency Requirement ST-Y1942-Initiation of R/S in Behavioral Emergency 415.260 (b)(1)(A-(D)(2)-(3)(b) Physician's order. Only a physician member of the facility's medical staff may order restraint or seclusion).


(4). Quality Assurance meeting records for the second quarter of 2022 dated
8/2/22, the third quarter of 2022 dated 10/25/22, and the fourth quarter of 2022
dated 1/19/23, did not show any information about tracking, trending, or
analyzing restraints/seclusions, or, grievances.

Cross reference tag #A0283

Based on review of records, interview, and observation, the facility failed to ensure processes were developed with effective implementation of those processes that protected the rights of patients as shown by:

1. Improper consenting of patients for:

a. admission to the facility, and;
b. psychotropic medications;

2. Not addressing and processing grievances for one year;

3. Improper restraint practices, including:

a. patients not being monitored for restraints,
b. patients not being assessed within one hour post restraint, and;
c. non-physicians ordering restraints.


More specifically, this failure was evidenced by the following:

(1a). Admission consents: 2 of 4 Patients who were considered voluntary (Patient #
9 & 12) and had either refused to sign, or were unable to sign admission
consent forms due to being only oriented to self, were admitted and treated at
the facility.

Cross reference tag #A0131


(1b). Psychotropic medication consents: 4 of 4 voluntary patients that were
prescribed and given multiple psychotropic drugs were improperly consented
(Patient #1, 3, 9, & 12). These patients had documentation on their
psychoactive medication consent forms that either they were cognitively
impaired and unable to sign (Patient #1, 3, & 9), or, the patient's legally
authorized representative did not consent for the medication (Patient #12).
These patients were still administered the medications.

Cross reference tag #A0131


(2). Grievances were not addressed for approximately one year-from August of 2021
to July of 2022, and, the facility's Governing Body did not take responsibility. It
was unknown how many complaints were involved.

Cross reference tag #A0118 and tag #A0119

The following two deficient practices identified in (3a) and (3b) were determined to pose an Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death:

(3a). Restraints-Not monitoring patients: Administration of Emergency Medication
administration used to control patient behavior in behavioral emergency
situations were not treated as restraints, which require patients to be
monitored during the process by trained staff. This monitoring was not
performed for 5 of 5 patients (Patient #9, 13, 14, 15, 16, & 17).

Cross reference tag #A0175 (and see tag A0160 for federal definition of restraint).


(3b). Restraints-Not performing required Face-to-Face assessment of patient within
one hour of the intervention: Emergency Medication administration used to
control patient behavior in emergency situations were not treated as
restraints, which require face-to-face post restraint assessments within one
hour of the intervention. These assessments were not completed for 6 of 6
patients after they were restrained (Patient #9, 13, 14, 15, 16, & 17).

Cross reference tag #A0179


(3c). Restraints not ordered by physicians: Emergency Medication administrations
were ordered by four Nurse Practitioners (Staff #F, J, H, & I), not physicians,
for 3 of 5 patients (Patient #15, 16, & 17). This was not in accordance with
State law which allows only physicians to order restraints.

Cross reference tag #A0168 (and refer to Texas Administrative Code- Emergency Requirement ST-Y1942-Initiation of R/S in Behavioral Emergency 415.260 (b)(1)(A-(D)(2)-(3)(b) Physician's order. Only a physician member of the facility's medical staff may order restraint or seclusion).

Based on record review and interview, the facility failed to ensure they followed a process for prompt resolution of grievances as evidenced by facility not addressing grievances for 12 of 12 months-August 2021 through July 2022.

Findings included:

Record review of facility policy titled "PATIENT GRIEVANCE PROCESS", #RTS-04, last revised 2/1/23, showed that the facility follows federal regulation Title 42 CFR, §482.13 with regards to addressing grievances. The policy also showed that the Patient Advocate maintains a grievance log, opens an investigation of grievances within 48 hours, sends written notice to complainants within seven days, and reports the findings to their Quality Assurance Performance Improvement program.

Record review on 2/8/23 of facility's Grievance log revealed there was an absence of complaints from August 2021 through July of 2022.

In an interview on 2/8/23, Staff #A (Quality/Infection Control/Director Of Nursing) stated that grievances had not been addressed for a while because the Patient Advocate had not been doing her job and had left employment, and, nobody else in the facility had been addressing grievances either. Staff #A stated that this had gone on for about a year, from August of 2021 until July of 2022, and added that this was should not have been allowed to occur.

Based on record review and interview, the facility's Governing Body failed to be responsible for the effective operation of the grievance process as evidenced by facility not addressing grievances for 12 of 12 months; August 2021 through July 2022.

Findings included:

Record review of facility policy titled "PATIENT GRIEVANCE PROCESS", #RTS-04, last revised 2/1/23, showed that the facility follows federal regulation Title 42 CFR, §482.13 with regards to addressing grievances. The policy also showed that the Patient Advocate maintains a grievance log, opens an investigation of grievances within 48 hours, sends written notice to complainant within seven days, and reports the findings to the Quality Assurance Performance Improvement committee. The Governing Body then addresses appeals.

Record review on 2/8/23 of facility's Grievance log revealed there was an absence of complaints from August 2021 through July of 2022.

In an interview on 2/8/23, Staff #A (Quality/Infection Control/Director Of Nursing) stated that grievances had not been addressed for a while because the Patient Advocate had not been doing her job and had left employment, and, nobody else in the facility had been addressing grievances either. Staff #A stated that this had gone on for about a year, from August of 2021 until July of 2022, and added that this was should not have been allowed to occur.

Based on record review, observation, and interview, the facility failed to:

A. Ensure the rights of 2 of 4 patients to make an informed consent for admission and treatment (Patient #9 & 12), as evidenced by these patients not having the mental faculties to make an informed decision on their own volition, and;

B. Not properly obtaining consent for psychoactive medications for 4 of 4 patients (Patient # 1, 3, 9, & 12), as evidenced by these patients being cognitively impaired per documentation at the time of consent process (Patient #3, 9, & 12), or, not obtaining consent from the patient's legally authorized representative (Patient #1).


A. Findings for admission consent included:

Review of facility policy titled "ADMISSIONS VOLUNTARY AND INVOLUNTARY TEXAS", #PC-06, last revised 3/1/21, showed that for voluntary patient admissions to facility, the Intake Coordinator ascertains the patient's ability to understand that he/she is in a treatment facility and wishes to be admitted. The Intake coordinator determines the appropriateness of voluntary admission status based on the patient's capacity to make a knowing and voluntary consent for treatment. "Knowing and voluntary consent is determined by the patient's ability to understand". The policy also states that a request for voluntary admission will be in writing and signed by the patient making the request.


Patient #9

During observation of facility and patients on 2/8/23 at 10:30 am, Patient #9 was observed seated in facility's common dayroom. She was yelling loudly and talking to herself. When a surveyor approached her to ask her a question, patient yelled "I'm not pregnant". Staff #D (Mental Health Technician) who had observed the interaction, stated to the surveyor that she was familiar with the patient. Staff #D went on to say that the patient was very confused, did not understand what was happening or where she was, and had been that way since being admitted to facility.

Record review of Patient #9's medical chart showed the following: 66 year old female voluntarily admitted from Park Manor, a nursing home, on 2/7/23 under attending physician Staff #Z. There was no legally authorized representative identified such as a guardian, nobody identified as having Power of Attorney, and no court order to for the facility to treat the patient.

In an interview on 2/8/23 at 2:30 pm, Staff #A (Quality/Infection Control/Director of Nursing) confirmed the patient was voluntary and added that all patients' legal status documentation are contained in their medical charts.

Further chart review showed a form titled "INTAKE SCREENING & ASSESSMENT" dated 2/7/23 at 2:08 pm, with assessment performed by Staff #U (LCSW-therapist). It contained the following information: Patient's presenting problems were exhibiting outbursts, throwing things, aggression, inappropriate sexual comments, delusional, yelling and screaming, not easy to re-direct. Current Psychiatric diagnosis was Schizophrenia. Medical problems were Alzheimers disease, Dementia, Depression. There was also this following entry: "Verified Signed Legal Status ... Formal Voluntary".

Further review of the form showed a question which read "Willing to be treated in a locked setting (Psych Hospital) for treatment? Yes/No" (Yes/No was left blank and not circled). There was another entry on the form showing "Realizes he/she has a problem?" Answer was circled "No".

Other entries on the form showed "Guardian: Yes/No (must have a copy, patient can not give consent) Guardian contacted? Yes/No Explain_______" These two questions were left unanswered.

More entries on the form showed "Medical Power of Attorney: Yes/No (need copy if yes) Patient/Caregiver given a copy of Patient Information? Yes/No"
These two questions were also unanswered.

On a form titled "ADMIT NURSING ASSESSMENT", dated 2/7/23 at 2:45 pm, it did not indicate who performed the assessment; Page 1 of 8 had a blank entry where the nurse was supposed to print her/his name and another blank entry on page 8 of 8 where the nurse was supposed to sign his/her name. However, an assessment was documented, which showed the following: an entry labeled "Cognition/Orientation" showed patient was only oriented to Person and not to place, time, or situation. Another entry labeled "Insight/Judgement" showed Impaired Judgement.

Further chart review revealed a progress note dated 2/9/23 written by Staff #J (NP-nurse practitioner) and cosigned by Staff #Z (MD-patient's attending physician). It showed the following: "..we are unable to complete psychiatric assessment at this time due to disorganized thought, confusion, and anger. Per the nursing staff, the patient had been refusing her medication therapy as prescribed".

"NURSING SHIFT ASSESSMENT" form for 2/7/23, Night shift (7p-7a) showed: Orientation to person only, not to place, time, or situation. Thought processes were illogical.

Admission consent forms all dated 2/7/23 at 2:40 pm signed by Staff #T (Admit Tech) showed the following (Note: "SAO" means Sexually Acting Out):

"ADMISSION CONSENT FORM INPATIENT": "Refused to sign (SA0)"
"INFORMED CONSENT FOR TELEHEALTH SERVICES": "Refused to sign (SA0)".
"INPATIENT COMMUNITY AGREEMENT": "Refused to sign (SAO)".
"An Important Message From Medicare About Your Rights": "Refused to sign (SAO)".
"ADVANCE DIRECTIVE ACKNOWLEDGEMENT": "Refused to sign (SAO)".
PATIENT HEALTH QUESTIONNAIRE": "Refused/SAO".
"Financial Responsibility: Authorization and Assignments": "Refused to sign (SA0)".


Patient #12:

Record review of Patient #12's medical records showed the following: 82- year-old male admitted to facility on 12/30/22 from Spring Branch Transitional Care nursing care home, under attending physician Staff #Z, and discharged on 1/9/23.

Review of facility form titled "INTAKE SCREENING & ASSESSMENT" authored by Staff #K (Intake RN) showed these entries: "Guardian: Yes/No". The answer "No" was circled. "Guardian contacted? Yes/No Explain______" (this was left blank/unanswered). Medical Power of Attorney Yes/No" "No" was circled. "Patient/caregiver given a copy of Patient Information? Yes/No". This was left blank/unanswered. "Primary Family Contact" (Name of patient's brother was listed). "Phone/Cell ?" (unknown, not listed). Permission to contact family? Yes/No" This was left blank/unanswered. "Family supportive of admission? Yes/No". This also was left unanswered/blank. "Verified Signed Legal Status ...Formal Voluntary".

Record review of form titled "ADMIT NURSING ASSESSMENT", performed by Staff #K on 12/30/22 at 9:15 pm, showed reason for admission: " per report, pt is Combative, Refusing care, Non-Compliant, Refused to Eat.." An entry labeled "Cognition/Orientation" showed patient was oriented to person only, and not to place, time, or situation, with impaired judgement.

Initial Psychiatric Evaluation performed on 1/1/23 by attending physician Staff #Z showed the following: "Upon evaluation today ...He is alert and oriented to self only. No behavioral disturbance is noted at this time .... He does not know where he is or why he was brought to Oceans Behavioral Hospital ...Due to his confusion, the patient did not answer most of the assessment questions asked".

Initial History and Physical Exam dated 12/31/22 at 11:20 (provider unknown) showed: Chief Complaint in patient's words "I don't know", and doctor wrote "confused @ baseline" and " ...awake & alert oriented x 1"

Review of facility's Multidisciplinary Treatment Plan documents showed that where the patient was supposed to sign and acknowledge his treatment plan, it was written "pt was too low [sic] cognitive function".

Admission Consent form for admission process (signed by Staff #K) dated 12/30/22:

"VOLUNTARY REQUEST FOR ADMISSION" dated 12/30/22 at 5:00 pm, witnessed by Staff #K (RN Intake), showed a very long, scribbled, signature presumably from the patient.

Admission consent forms (signed by Staff #AA) all dated 12/30/22:

"ADMISSION CONSENT FORM Inpatient": "Refused to sign (Agitated)".
"ADVANCE DIRECTIVE ACKNOWLEDGEMENT": Signature space blank.
"INFORMED CONSENT FOR TELEHEALTH SERVICES": "Refused to sign (Agitated)".
"STATEMENT OF PATIENT ACKNOWLEDGEMENT": "Ref. to sign (Agitated)"
"CONSENT FOR INVOLVEMENT IN TREATMENT-Authorization for Disclosure and Family/Significant Other Consent & Authorization of Treatment" (Brother is listed but not the phone number ("?"): "pt unable to sign (Confused/Agitated)".
"INPATIENT COMMUNITY AGREEMENT": "Refused to sign (Agitated)".
"Financial Responsibility: Authorization and Assignments": "Refused to sign (Agitated)".
"AN IMPORTANT MESSAGE FROM MEDICARE ABOUT YOUR RIGHTS": "Ref. to Sign (Agitated)".


In an interview on 2/14/23 at 3:00 pm, Staff #L (RN intake coordinator) stated that voluntary patients, with regards to being consented for admission and treatment, need to understand the process and " know what's going on, or else the facility isn't allowed to treat them because they can't consent". Staff #L stated, when presented with the example of Patient #9's current cognitive status, that the patient should not have been admitted for treatment.





B. Findings for Psychoactive Medication Consent included:

Review of facility policy titled "PSYCHOACTIVE MEDICATION ADMINISTRATION/CONSENT-TEXAS", #MM-02, last updated 2/1/21, showed that if psychoactive medications are prescribed, a written informed consent must be obtained from the patient or legally authorized representative.

Record review of current Patient #3's medical records showed the following: 74-year-old male admitted 2/1/23 voluntarily with no guardian, due to agitation, aggression, and combativeness. Diagnoses were Psychosis unspecified, Dementia with behavioral disturbance.

The following consent documents for psychoactive medications showed that the facility did not obtain consent from the patient for taking several psychoactive medications.

Medication Consent forms:

Haldol 5mg ... ..."Pt unable to sign D/T cognition" (Patient unable to sign due to cognition) dated 2/3/23 at 9:00m pm.

Depakote 250 mg ..."Pt unable to sign D/T cognition" dated 2/3/23 at 9:00 pm.

Trazadone 50 mg ..."Pt unabe [sic] to sign D/T cognition" dated 2/3/23 at 9:00 pm.

Risperdal 1 mg ...."Pt unable to sign D/T cognition" dated 2/3/23 at 8:30 pm.

Ativan (no dosage listed) ..."Pt unable to sign D/T cognition" dated 2/3/23 at 8:30 pm.

In an interview on 2/9/23 at 10:30 am, Staff #A (Quality/Infection Control/Director of Nursing) and #C (Regional DON) stated that with regards to the nurse's documentation for the medication consents, the patient was verbally consented. However, review of the patient's medical records failed to show documentation which supported this.


Record review of Patient #1's medical records showed the following: 86-year-old female admitted 10/12/21 and discharged 10/15/21, under the care of attending physician Staff #BB, with the diagnoses of Bipolar disorder, mixed, severe, with psychosis, Dementia with behavioral disturbance.

Records showed that the legally authorized representative was the patient's wife. Review of all the following psychoactive medication consent forms and/or patient progress notes, failed to show the patient consented or the patient's wife consented for these following medications:

Medication Consent forms:

Temazepam 15 mg ..."Pt unable to sign d/t cognitive impairment" dated 10/12/21.

Clonazepam 0.5 mg ..."Pt unable to sign d/t cognitive impairment" dated 10/12/21.

Risperdal 0.5 mg ...."Pt unable to sign d/t cognitive impairment" dated 10/12/21.

Trileptal 75 mg ..."Pt. unable to sign d/t cognitive impairment" dated 10/12/21.

Zyprexa 2.5 mg ..."Pt. unable to sign d/t cognitive impairment".


Record review of Patient #9's medical records showed the following (See above for information regarding Patient #9's admission documentation and legal status. Note: Nursing shift assessment for 2/7/23 night shift 7a-7p showed that the patient was oriented to self only and not to place, time, or situation, and thought processes were illogical):

Medication consent forms:

Risperdal 3 mg ...."Patient unable to sign" dated 2/7/23 at 11:00 pm.

Depakote 125 mg ....."Patient unable to sign" dated 2/7/23 at 11:00 pm.

Nuedexta 10-20 mg ... ....."Patient unable to sign" dated 2/7/23 (not timed).

Trazadone 100 mg ...."Patient unable to sign" dated 2/7/23 at 9:00 pm.

Zoloft 100 mg ..."Patient unable to sign" dated 2/7/23 at 9:00 pm.

Zyprexa 5 mg ... ..."Patient unable to sign" dated 2/7/23 at 9:00 pm.


Record review of Patient #12's medical records showed the following (See above for information regarding Patient #12's admission, assessments, and legal status; per these records, patient was oriented to self-only):

Medication consent forms:

Trazadone 50 mg...."Pt unable to sign document" dated 12/31/22 at 9:00 am

Zyprexa 2.5 mg/5 mg...."Patient unable to sign due to cognitive impairment" dated 1/6/23.


Review of all four above patients' Medication Administration Records showed that all of them had received these medications.

(Note: review of drug manufacturer's prescribing information for Haldol and Risperdal showed they have important 'Black Box' warnings for elderly patients with Dementia).

Based on record review and interview, the facility failed to ensure restraints were safely implemented for 6 of 6 patients who were given emergency medication (Patient #9, 13, 14, 15, 16, & 17), as evidenced by staff not monitoring these patients after they were administered the restraints.


Findings included:

Federal definition of restraint: A0160-PATIENT RIGHTS: RESTRAINT OR SECLUSION 482.13(e)(1)(i)(B). Regulation Definition: [A restraint is-](B) A drug or medication when it is used as a restriction to 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.

Review of facility policy titled "SECLUSION AND RESTRAINT", #NSG-71, last revised 8/1/21, shows that one of the definitions of restraint is a drug or medication when it is used as a restriction to manage the patient's behavior and is not a standard treatment dosage for the patient's condition. The policy also showed that the administration of emergency psychotropic medication to a patient is a restraint.

In an interview on 2/8/23 at 4:40 pm, Staff #A (Quality/Infection Control/DON) stated that the only time monitoring of a patient for restraint/seclusion is performed was only if there had been a physical hold restraint, and there was no monitoring done for Patient #9, 13, 14, 15, 16 & 17, who had received emergency behavioral medications.


Record review of facility incident reports and patient charts showed the following:


Patient #9:

On 2/8/23 at 11:49 am, it was documented in the patient's physician's orders to give the emergency medications Ativan 1 mg and Benadryl 25 mg IM (intramuscular injection) x 1 stat (one-time, now). There was no indication why this medication was ordered and no documentation of patient monitoring for the medication administration restraint.


Patient #13:

Facility's incident report showed that on 11/21/22 at 10:15 pm, Patient #13 was screaming and yelling, banging on windows, and threatening staff. The patient was given the emergency medications Haldol 2.5 mg and Ativan 1 mg IM, one time, now. The incident report generated had restraint/seclusion monitoring paperwork forms attached which had a 'slashes' on them, indicating they were not done.

Patient #14:

On 11/18/22 at 11:45 am, Patient #14 was aggressive and hitting & kicking staff per facility incident report. The patient was given the emergency medications Haldol 1 mg and Ativan 1 mg IM, one time, now. There was no documentation that the patient was monitored after the administration of the restraint medication.

Patient #15:

On 10/4/21 at 2:20 pm, Patient #15 had an incident report generated. It showed that the patient was agitated and punching doors and windows. He was given Haldol 5 mg, Ativan 1 mg, and Benadryl 25 mg IM, one time, now. There was no documentation that the patient was monitored after administration of the restraint medication.

Patient #16:

On 11/22/22 at 9:90 am, Patient #15 was yelling, hyperverbal, and sexually explicit. She was given the emergency medications Haldol 5 mg and Ativan 1 mg IM, one time, now. There was no documentation that the patient was monitored after administration of the restraint medication.

Patient #17:

On 9/3/21 at 4:35 pm, per facility incident report, patient was agitated and scratching his face. He was given Ativan 1 mg and Benadryl 25 mg IM, one time, now. There was no documentation that the patient was monitored after administration of the restraint medication.

Based on record review and interview, the facility failed to ensure they were practicing in accordance with state law that allows only physicians to order restraints, as evidenced by four Nurse Practitioners (Staff #F, J, H, & I) ordering restraints for 3 of 5 patients (Patient #15, 16, & 17).

(Cross reference Texas Administrative Code- Emergency Requirement ST-Y1942-Initiation of R/S in Behavioral Emergency 415.260 (b)(1)(A-(D)(2)-(3)(b) Physician's order. Only a physician member of the facility's medical staff may order restraint or seclusion).

Findings included:

Review of facility policy titled "SECLUSION AND RESTRAINT", #NSG-71, last revised 8/1/21, shows that one of the definitions of restraint is a drug or medication when it is used as a restriction to manage the patient's behavior and is not a standard treatment dosage for the patient's condition. The policy also showed that the administration of emergency psychotropic medication is a restraint.

During a group interview and discussion on 2/14/23 at 4:00, administration Staff #A, Staff #B, and Staff #C expressed they were unaware that state law in Texas only allows physicians to order restraints.


Record review of facility incident reports and patient charts showed the following:

Patient #15:

On 10/3/21 at 8:45 am, facility incident report showed Patient #15 was combative and aggressive. He received the emergency medications Haldol 5 mg, Ativan 1 mg, Benadryl 25 mg IM (intramuscular injection) one time, now. The restraint was ordered by Staff #H, a nurse practitioner.

On 10/4/21 at 2:20 pm, Patient #15 had an incident report generated. It showed that patient was agitated and punching doors and windows. He was given the emergency medications Haldol 5 mg, Ativan 1 mg, and Benadryl 25 mg, IM, one time, now. The restraint was ordered by Staff #I, a nurse practitioner.


Patient #16:

On 11/22/22 at 9:90 am, Patient #15 was yelling, hyperverbal, sexually explicit. She was given the emergency medications Haldol 5 mg and Ativan 1 mg IM, one time, now. The order was made by Staff #J, a nurse practitioner.


Patient #17:

On 9/3/21 at 4:35 pm, an incident report showed patient was agitated and was scratching his face. He was given the emergency medications Ativan 1 mg and Benadryl 25 mg IM, one time, now. The restraint was ordered by Staff #I, a nurse practitioner.

Based on record review and interview, the facility failed to ensure restraints were safely implemented for 6 of 6 patients given emergency medication (Patient #9, 13, 14, 15, 16, & 17), as evidenced by staff not performing required Face-to-Face assessments within 1 hour after initiation of the restraint.


Findings included:

(Federal definition of restraint: A0160-PATIENT RIGHTS: RESTRAINT OR SECLUSION 482.13(e)(1)(i)(B). Regulation Definition: [A restraint is-](B) A drug or medication when it is used as a restriction to 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).

Review of facility policy titled "SECLUSION AND RESTRAINT", #NSG-71, last revised 8/1/21, shows that one of the definitions of restraint is a drug or medication when it is used as a restriction to manage the patient's behavior and is not a standard treatment dosage for the patient's condition. The policy also showed that the administration of emergency psychotropic medication to a patient is a restraint. In addition, the policy shows that a face-to-face evaluation must be conducted within one hour of restraint by a qualified staff member.


In an interview on 2/8/23 at 4:40 pm, Staff #A (Quality/Infection Control/Director of Nursing) stated that the only time a face-to-face 1-hour post intervention assessment is performed, was only if a person was physically restrained. Staff #A confirmed there had not been the required face-to-face assessments done for Patient #9, 13, 14, 15, 16, & 17 after they received emergency medication restraints.


Record review of facility incident reports and patient charts showed the following:

Patient #9:

On 2/8/23 at 11:49 am, it was documented in the patient's physician's orders to give the emergency medications Ativan 1 mg and Benadryl 25 mg IM (intramuscular injection) x 1 stat (one-time, now). There was no indication why this medication was ordered, no monitoring, and no documentation of a 1-hour post restraint face-to-face assessment performed.

Patient #13:

On 11/21/22 at 10:15 PM, Patient #13 had was screaming and yelling, banging on windows, threatening staff, and was given the emergency medications Haldol 2.5 mg and Ativan 1 mg IM, one time, now. There was no documentation of a 1-hour post restraint face-to-face assessment performed.


Patient #14:

On 11/18/22 at 11:45 am, Patient #14 was aggressive and hitting & kicking staff per incident report. Patient was given the emergency medications Haldol 1 mg and Ativan 1 mg IM one time, now. There was no documentation of a 1-hour post restraint face-to-face assessment performed.



Patient #15:

On 10/4/21 at 2:20 pm, incident report showed that Patient #15 was agitated and punching doors and windows. He was given the emergency medications Haldol 5 mg, Ativan 1 mg, and Benadryl 25 mg IM, one time, now. There was no documentation of a 1-hour post restraint face-to-face assessment performed.


Patient #16:

On 11/22/22 at 9:90 am, incident report showed Patient #15 was yelling, hyperverbal, sexually explicit. She was given the emergency medications Haldol 5 mg and Ativan 1 mg IM, one time, now. There was no documentation of a 1-hour post restraint face-to-face assessment performed.


Patient #17:

On 9/3/21 at 4:35 pm, an incident was generated because patient was agitated and was scratching his face. He was given the emergency medications Ativan 1 mg and Benadryl 25 mg IM, one time, now. There was no documentation of a 1-hour post restraint face-to-face assessment performed.

Based on record review and interview, the facility failed to ensure they implemented and maintained an effective ongoing performance improvement program, as shown by:

a. Not addressing, monitoring and analyzing patient restraints & seclusions for three quarters in 2022, and;

b. Not tracking, investigating and responding to grievances for three quarters in 2022.

Cross refer to tag #A-0283

Based on record review and interview, the facility failed to ensure their QAPI program:

a. Addressed, monitored, and analyzed patient restraints & seclusions for three quarters in 2022, or;

b. Tracked, investigated, and responded to grievances for three quarters in 2022.



Findings included:


Record review of facility's quality assurance program's meeting minutes for three quarters of 2022 revealed that Quarter #2 meeting held 8/5/22, Quarter #3 meeting held 10/25/22, and Quarter #4 held 2/29/23, failed to show any information regarding restraints/seclusions, or, grievances.

In an interview on 2/8/23 at 2:45 pm, Staff #A (Quality/Infection Control/Director Of Nursing) stated these items were not addressed by the program during those quarters.

Based on observation and interview, the hospital failed to be maintained to ensure the safety of their patients, as shown by:

A. 17 patient bedrooms' bathrooms had sharp, rusty toilet-screws with bolts in the patient bathrooms, exposing 18 patients to risk of injury and/or self-harm (Patient #5, 6, 9, 18, 19, 20, 21, 22, 23, 24, 25, 26, 28, 29, 30, 31, 32 & 33).

Cross reference tag #A701

B. 28 patient bedrooms had plastic 'Lexan' glass covers over the light fixtures which were able to be removed and potentially be used as weapons and/or for self-harm, placing all of the facility's 34 patients at risk (Patient #1-34).


Cross reference tag #A701

Based on observation and interview, the facility failed to ensure the physical plant was maintained safely to protect patient's from harm, as shown by the presence of exposed sharp rusty toilet-screws with bolts in the patient bathrooms, putting 18 of 34 patients at risk of injury (Patient #5, 6, 9, 18, 19, 20, 21, 22, 23, 24, 25, 26, 28, 29, 30, 31, 32 & 33).


Findings included:


Observation on 2/8/23 at 10:15 am of the patient bathrooms located inside the patient bedrooms, showed the toilets were bolted to the floor with two bolts; one bolt with screw on each side of the toilets, securing them to the floors. These exposed screws with bolts were sharp and rusty. They protruded upwards approximately one inch.

The screws with bolts were observed to be in the following patient bedroom bathrooms: 1602, 1603, 1604, 1605, 1607, 1608, 1610, 1612, 1613, 1615, 1702, 1705, 1707, 1710, 1712, 1713, & 1714 housing the following patients, putting them at risk for injury: Patient #5, 6, 9, 18, 19, 20, 21, 22, 23, 24, 25, 26, 28, 29, 30, 31, 32 & 33.

In an interview on 2/8/23 at the time of the sharp, rusty screws with bolts findings, Staff #E (Plant Operations) acknowledged these bolts could potentially cause harm to patients if they used the restroom and inadvertently stepped on the bolts, or, if the patient tried to cut themselves intentionally. Staff #E added that the exposed bolts would be fixed as soon as possible.


43549

During a tour 02/08/2023 at 12:15 pm with Staff C, Regional DON, the following was noted:
B. 28 patient bedrooms had plastic 'Lexan' glass covers over the light fixtures which were able to be removed and potentially be used as weapons or for self-harm, placing all of the facility's 34 patients at risk (Patient #5, 6, 9, 18, 19, 20, 21, 22, 23, 24, 25, 26, 28, 29, 30, 31, 32 & 33).

Staff E, EOC/Plant Operations joined the tour at 12:30 pm and stood on an empty bed to check the light fixtures with the surveyor and Staff C present.

When interviewed at 12:37 pm Staff E stated the fixtures could be reached and broken by patients. He stated the Lexan is sharp when broken. During the same interview Staff C agreed the fixtures could be reached ans stated she had been unaware of the danger.