HospitalInspections.org

Based on a on a review of facility documentation and staff interview, the facility failed to obtain and implement physician orders for medications to address medical issues for 2 of 11 patients (Patients #1 and #11).

Findings were:

Facility policy #100.03 entitled Rights of Persons Receiving Mental Health Services, last reviewed 6/15/16, included the following:
"25 TAC 404.155(b)(6) Rights: Residential Treatment.
(6) The right to receive appropriate treatment of any physical ailments essential to the treatment of a mental disorder and for a physical disorder arising in the course of an individual's inpatient psychiatric care ..."

Facility policy #900.06 entitled Legibility of Medical Record Documentation, effective date 7/7/14, included the following:
"The hospital shall set legibility standards for medical record documentation and to monitor compliance with these standards as part of our performance improvement and medical error reduction activities ...
D. If a healthcare professional writes an order that is not legible, the order must be clarified by licensed nursing staff with the ordering physician prior to implementation ..."

A review of the Admission Medication Reconciliation form included the following:
"Imuran 50 mg p.o. daily. Indication: Crohn's." Boxes to indicate whether or not to continue the medication were left blank. However, a review of handwritten physician orders included an order on 11/18/16 at 10:45 a.m. for "Imuran 50mg daily for Crohn's," as well as three other medications. The three other medications were transcribed by Staff #11, to the medication administration record on 11/18/16. The patient received doses of each of these medications at 2100. The Imuran was not added to the medication administration record until 11/19/16 at which time it was noted as "unavailable." The patient did not receive a dose of Imuran while at Georgetown Behavioral Health.

In an interview with Staff #11, on the morning of 1/31/17 in the facility conference room, he was asked about Imuran, the Crohn's medication Patient #1 did not receive while at the facility. He stated "It could be that I couldn't read the doctor's writing. [The physician] had exceptionally hard handwriting to read. Either I couldn't read it, or it was a home med. I don't know. But it's obvious she didn't get it and she probably should have."

The Admission Medication Reconciliation - Medical form for Patient #11 included a medication, Savella, for which the indication was noted as fibromyalgia. There was no check mark by a physician indicating whether or not to continue the medication upon admission. There was no handwritten order addressing the medication. The medication was not addressed in any manner.

The above findings were confirmed in an interview with the CNO and Nurse Manager on the afternoon of 1/31/17 in the facility conference room. They agreed the medications had in some way been missed for the above two patients.