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Based on documentation review and interview, the hospital failed to ensure that all Psychoactive Medication Consents were signed by the patient, the legally authorized representative or had a court order signed by the County Judge to administer Psychoactive medications in 1 (Patient #13) of 3 (Patient #4, #7, and #13). Additionally, the hospital failed to follow the hospital policy titled "Informed Consent for Psychoactive Medications".

Findings:

Patient #13

Patient #13 was a 35-year-old female who was admitted involuntarily to the hospital on 3/27/2025 at 11:19 AM with a diagnosis of Bipolar Disorder, Current Manic Severe with psychotic features, Cannabis Disorder with psychotic features, and General Anxiety Disorder.

Patient #13 was transferred from the Gregg County jail by a peace officer and arrived at the hospital on 3/27/2025 at 11:17 AM. A review of the Emergency Detention Warrant (EDW) revealed that a Gregg County Judge signed the EDW on 3/26/2025. According to the Health and Safety Code Section 573.021(b), the EDW was valid until 3/29/2025 at 11:17 AM. There was no forced medication order from the county judge that allowed the hospital to administer psychoactive medications without the informed consent of Patient #13. Patient #13 had been held involuntarily for 36 days without an appropriate order.

A review of the documents titled, "Consent for Treatment with Psychoactive Medications" signed and dated by Patient #13 was as follows:

" ...Seroquel (antipsychotic medication) 300 milligrams (mg) orally (PO) Q (every) night (HS). Patient consented to 200mg po qhs. Patient #13 signed the informed consent on 3/27/2025 at 2:15 PM. The witnessing nurse's signature was illegible.

Gabapentin (anticonvulsant medication used to treat symptoms of Bipolar Mania) 100 mg PO 3 times a day (TID). Patient #13 signed the informed consent on 3/27/2025 at 2:15 PM. The witnessing nurse signature was illegible.

Lithium (Mood stabilizer) 600 mg PO twice a day (BID). Patient #13 signed the informed consent on 3/27/2025 at 2:15 PM. The witnessing nurse signature was illegible.

Zyprexa (antipsychotic) 5 mg PO BID then increase to 15mg po qhs. Patient #13 signed the informed consent on 3/29/2025 at (time is illegible). The witnessing nurse signature was illegible. Patient #13 wrote a statement on the consent form. The handwritten statement was incoherent.

Atarax (antihistamine medication used to treat anxiety) 50 mg PO BID as needed (PRN). Patient consented to 25 mg. Patient #13 signed the informed consent on 3/29/2025 at 10:30 AM. The witnessing nurse signature was illegible. Patient #13 wrote a statement on the consent form. The handwritten statement was incoherent.

Gabapentin 300 mg po TID. Patient #13 signed the informed consent. There was no date or time when the patient signed the consent. The witnessing nurse signature, dated 4/04/2025 at 12:00 PM was illegible. Patient #13 wrote a statement on the consent form. The handwritten statement was incoherent.

Gabapentin 600 mg PO BID-mood. Patient #13 signed the informed consent on 4/14/2025 at 1525 (3:25 PM). The witnessing nurse signature was illegible.

Haldol (antipsychotic) 5mg PO BID x 3 days, then increase to 5mg PO TID. Patient #13 gave verbal consent on 4/15/2025 at 2250 (10:50 PM). Both nurses' signatures on 4/15/2025 at 2250 (12:50 PM) were illegible. There was no documentation explaining why Patient #13 did not sign the consent and only gave verbal consent.

Clozapine 25mg PO QHS, then increase 25mg PO BID on 4/29/2025. Patient #13 signed the informed consent on 4/26/2025 at 1940 (7:40 PM). The witnessing nurse signature was illegible.

Clozapine 25mg PO BID then on 4/30/2025 PO Q AM and 50mg PO Q HS. Patient #13 signed the informed consent on 4/28/2025 at 1340 (1:40 PM). The witnessing nurse signature was illegible. Patient #13 wrote a statement on the consent form. The handwritten statement was incoherent.

Clozapine 50mg PO BID on 5/02/2025 then increase to 100mg PO QHS and 50mg PO QAM on 5/04/2025. Patient #13 signed the informed consent on 4/30/2025 at 1820 (6:20 PM). The witnessing nurse signature was illegible..."

A review of the physician's emergency admission for mental health services documented 3/27/2025 at 11:48 AM revealed the patient presented with psychosis, mood swings, suicidal and homicidal ideations, audio and visual hallucinations, paranoia, delusional, disorganized, internally preoccupied, she was guarded and using marijuana. Patient #13 signed 3 psychoactive medication consents on this day.

A review of Nurse Practitioner (NP) #13's progress note dated 3/29/2025 revealed Patient #13 was responding to internal stimuli and believed her food was being poisoned, had paranoid delusions, and continued to have auditory and visual hallucinations. Patient #13's judgment was impaired, and her insight was poor however Patient #13 signed 2 consents for treatment with psychoactive medications on this day.

A review of Physician #11's progress note dated 4/04/2025 revealed the patient was delusional and continued having auditory and visual hallucinations, she had poor judgment, and poor insight however Patient #13 signed psychoactive medication consents on this day.

An interview was conducted with Physician #14 on 5/07/2025 after 9:00 AM. Physician #14 was asked if the patient had the capacity to understand the risks and benefits of treatment with psychoactive medications before the informed consent was signed. Physician #14 confirmed that Patient #13 did not have the capacity to understand the treatment. Physician #14 was asked if the physicians obtained informed consent for medications from the patient.

An interview was conducted with Registered Nurse (RN) #10 on 5/06/2025 after 10:00 AM. RN #10 was asked if Patient #13 had the capacity to understand the risks and benefits of treatment with psychoactive medications. RN #10 stated, "She was not capable of understanding any treatment with medications and especially not when she first arrived. She probably should not have signed the consents". RN Staff #10 confirmed that Patient #13 was receiving all medications that were prescribed.

Physician #14 confirmed that the nursing staff were responsible for getting the patients to sign the informed consents for the medications. Physician #14 confirmed that they do discuss the medications with the patients as part of their daily visits, but Patient #13 did not have the capacity to understand.

A review of the facility policy titled, "Informed Consent for Psychoactive Medications" was as follows:

"POLICY:
Psychoactive medications are administered with the patient's informed consent and/or the informed consent of the patient's legally authorized representative (LAR). Psychoactive medication may only be administered with the patient's informed consent when the patient meets emergency criteria, has a legal guardian or legal authorized representative who consents for the administration of medication, and/or is under specific court order. Provisions applicable state states and regulations are followed to protect patient rights ..."

An interview was conducted with Chief Nursing Officer (CNO) Staff #2 and Staff #3 on 5/06/2025 after 11:00 AM. Staff #2 was asked if Patient #13 had a court order for medications. Staff #2 confirmed that Patient #13 did not have a court order for psychoactive medications. CNO Staff #2 confirmed Patient #13 did not have an Order of Protective Custody with an order from the court to administer psychoactive medications. Staff #2 confirmed Patient #13 should not have been administered psychoactive medications without an order from the court due to her capacity to understand and give informed consent.

Based on review of records, observation, and interview, the facility failed to ensure patient monitoring was performed at the established time intervals ordered by medical staff to ensure patient safety on 1 (Adult Unit) of 2 units observed.

On the morning of 05/07/25, unit observations were made with Staff #2 present for observations. The Unit had 18 patients. One patient was on a one staff member to one patient level of monitoring. That left 17 patients with two Mental Health Techs (MHT) to monitor them. Nine patients were assigned a level of monitoring of Q10 (every 10 minutes an MHT had to lay eyes on the patient and document the patient location and what they were doing). Eight patients were assigned a level of monitoring Q15 (every 15 minutes an MHT had to lay eyes on the patient and document the patient location and what they were doing). These time frames were assigned by the medical staff to ensure patient safety.

On the Adult Unit, Staff #15, MHT was observed interacting with patients. Patient rooms were kept locked during the day. Staff #15 was observed unlocking a door for a patient to access his room. Two other patients were observed exiting their rooms on a different hallway. No other MHT was observed on the unit.

Staff #15 was asked to show his observation sheets where he was documenting Q10 and Q15 minutes checks. He had two clipboards with observation sheets for all 17 patients. At 9:46 AM it was noted that the last checks for patients on Q10 minute checks had last been done at 9:30 AM. When asked why checks hadn't been done Q10 as ordered by the medical staff, Staff #15 explained that the second MHT had to leave the floor to deliver a food tray. He had been doing patient laundry and opening doors for patients to use their restrooms, providing direct patient care. Because of this situation, it had made it logistically impossible for him to do both tasks, direct patient care and safety checks.

Staff #2 confirmed the observations.

Failure to perform safety checks as ordered could result in patients being unaccounted for with the potential for them to harm themselves or other patients on the unit and potentially creating an unsafe treatment environment for all patients.

Based on observation and interview, the facility failed to ensure confidential medical record information could not be accessed by unauthorized individuals in one of one treatment rooms observed.

On the morning of 05/05/25 a tour of the hospital was conducted with Staff #1 and Staff #4. Staff #5 was present during the tour of the admission area. A room between the admission area and the hospital units was observed. This room was identified as a patient examination room used by both admission staff and the nursing staff for patient skin assessments. A form, commonly referred to as a face sheet, for Patient #6 was observed laying on the countertop. This form contained a picture of the patient, name, address, birthdate, date of admission, diagnosis, legal status of admission, and other confidential patient information. The form was from the patient admission date of 04/12/25 and could have been in the room for potentially 23 days allowing unauthorized staff and patients access to confidential patient information.

Based on observation of the environment, the facility failed to comply with providing a sanitary environment to avoid sources and transmission of infections and communicable diseases, creating an environment that could promote the spread of nosocomial (hospital acquired) infections and communicable diseases between patients and personnel in 3 out of 3 hospital areas toured.

On the morning of 05/05/25, a tour of the Admissions area, Adult Unit, and Adolescent Girl's Unit was made with Staff #1 and Staff #3. The following observations were made:

Admissions Area
The admissions waiting area had vinyl covered seating. The vinyl was observed to be cracked and peeling on 7 of the seats. Cracked and peeling vinyl allows for bacteria, germs, mold, and moisture to be trapped and prevents proper sanitation.

The television in the admissions waiting area was secured behind plexiglass in a wooden frame. The wood was gouged, revealing unfinished wood. Porous wood allows for bacteria, germs, and moisture to be trapped and prevents proper sanitation.

Adult Unit
The medication room was observed. There were paper bags of donated items stored on the floor. A cardboard box with donated items was stored on the floor. Water bottles were stored on the floor. Items stored on the floor allow for dirt, dust, debris, and moisture to collect on items, promoting growth of bacteria, mold, and germs.

The medication room lower cabinet was opened and observed to have a dried spill on the top shelf that appeared to have run out the bottom of the cabinet and was dried on the floor. In the back of the shelf with the dried spill was observed a personal drinking cup on it's side, a Medline Aeromist Colors Nebulizer Compressor Kit in the box (used to provide breathing treatments to patients) and four decks of playing cards in their boxes. The cabinet to the right of this was opened. The shelves were observed to be heavily soiled with dirt/debris and had a box of gloves stored on that shelf.

The door to the medication room had leftover pieces of clear tape where papers had been taped to the door. The tape and residue was observed to be dark with dirt stuck to the tape residue. Tape and tape residue allowed for bacteria, germs, and moisture to be trapped and prevents proper sanitation.

The laundry area for patient laundry was observed. Patients were allowed to wear personal clothing and the clothing was laundered on site. The laundry equipment cleaning log for April was found to be incomplete for 17 of the 31 days without cleaning being logged. As of 05/05/2025, the log for May had not been started. The dryers were observed to have a heavy buildup of lint around the edges of the doors. The dryer on the right side had condensation built up on the door edge that was running down the door and to the floor. The vent screen was moist and rusted. Both washers had a build up of dirt and soap residue on the bottom and around the tub.

The room for lab sample collections was observed. The sharps container for disposing of glass and sharp items (used needles) contaminated with biohazardous material such as blood and bodily fluids was observed to have the sealed lid removed. The sealed lid allows sharps to be placed in the container while protecting the staff from being punctured/injured, thereby preventing staff from contracting serious infections such as HIV, Hepatitis and other infections spread by contact with bodily fluids. Sharps containers have a line on them to mark when the container is full and should be replaced. The container was observed to be filled past the full-line and overflowing with contaminated sharps. This presented a serious risk for spread of infection to staff by accidental puncture with a contaminated sharp item.

The biohazard disposal container for the lab room was observed to have a red topped glass specimen tube partially filled with blood. The container was lined with a red plastic biohazard disposal bag. Glass tubes, if broken during removal and disposal of the bag, could puncture the bag and skin of the person removing/disposing of the bag. This presented a serious risk for spread of infection to staff by accidental puncture with a contaminated sharp item.

A urine specimen container with yellow liquid in it was observed on the counter of the patient examination room. The specimen container did not have a patient label so there was no way of knowing who the specimen belonged to or how long it had been sitting there. The specimen was unsecured in an area where psychiatric patients could handle it, presenting a risk of spread of infection from contact with bodily fluids.

The sharps container in the patient exam room was filled past the full line, posing a potential risk of accidental skin puncture to staff when disposing of contaminated sharp items. This presented a risk for spread of infection to staff by accidental puncture with a contaminated sharp item.

A styrofoam cup with water and what appeared to be a used band aid was observed to be sitting on the counter of the patient exam room. This was next to a box of crayons, a container of cleaning wipes, gallon container of shampoo/body wash and an unopened container of Vanilla Snack Pack pudding. Food products and crayons for children were at risk of contamination.

Children's Unit
Upon entering the Children's Unit, the floors were observed to be heavily soiled with dirt buildup. Hair and sand were observed on the floor. A deck of "Exploding Kittens the Rules" playing cards was observed to be laid out in an arrangement on the floor as if children had been playing with the cards. No children were present on the unit. A styrofoam cup was observed next to the cards. The cup had been partially broken apart with styrofoam pieces scattered on the floor. The floor presented an unsanitary location for children to be crawling around, playing, and eating/drinking.

Based on record review and interview, the hospital failed to ensure that changes in the admitting legal status in 1 (Patient #13) of 3 (Patient #4, #7, and #13) patient medical records reviewed were correct and had supporting legal documentation in the medical record to hold an involuntary patient for 38 days.

The hospital failed to follow the Texas Administrative Code (TAC) 568.23(d)(5) and obtain an Order of Protective Custody (OPC) from the county judge at the end of 48 hours when holding a patient for admission with an Emergency Detention Warrant in accordance with the Texas Health and Safety Code 573.021(b) that states, "A person accepted for a preliminary examination may be detained in custody for not longer than 48 hours after the person was presented to the facility, unless a written order for protective custody is obtained. If the 48-hour period ends on a Saturday, Sunday, legal holiday, or before 4:00 PM on the first succeeding business day, the person may be detained until 4:00 PM on the first succeeding business day. If the 48-hour period ends at a different time, the person may be detained only until 4:00 PM on the day the 48-hour period ends. If extremely hazardous weather conditions exist or a disaster occurs, the presiding judge or magistrate may, by written order made each day, extend by an additional 24 hours the period during which the person may be detained. The written order must declare that an emergency exists because of the weather or the occurrence of a disaster".

Refer to Tag 1622

Based on record review and interview, the hospital failed to ensure that changes in the admitting legal status in 1 (Patient #13) of 3 (Patient #4, #7, and #13) patient medical records reviewed were correct and had supporting legal documentation in the medical record to hold an involuntary patient for 38 days.

The hospital failed to follow the Texas Administrative Code (TAC) 568.23(d)(5) and obtain an Order of Protective Custody (OPC) from the county judge at the end of 48 hours when holding a patient for admission with an Emergency Detention Warrant in accordance with the Texas Health and Safety Code 573.021(b) that states, "A person accepted for a preliminary examination may be detained in custody for not longer than 48 hours after the person was presented to the facility, unless a written order for protective custody is obtained. If the 48-hour period ends on a Saturday, Sunday, legal holiday, or before 4:00 PM on the first succeeding business day, the person may be detained until 4:00 PM on the first succeeding business day. If the 48-hour period ends at a different time, the person may be detained only until 4:00 PM on the day the 48-hour period ends. If extremely hazardous weather conditions exist or a disaster occurs, the presiding judge or magistrate may, by written order made each day, extend by an additional 24 hours the period during which the person may be detained. The written order must declare that an emergency exists because of the weather or the occurrence of a disaster".


Findings:

Patient #13

Patient #13 was a 35-year-old female who was admitted involuntarily to the hospital on 3/27/2025 at 11:19 AM with a diagnosis of Bipolar Disorder, Current Manic Severe with psychotic features, Cannabis Disorder with psychotic features, and General Anxiety Disorder.

Patient #13 was transferred from the Gregg County jail by a peace officer and arrived at the hospital on 3/27/2025 at 11:17 AM. A review of the Emergency Detention Warrant (EDW) revealed that a Gregg County Judge signed the EDW on 3/26/2025. According to the Health and Safety Code Section 573.021(b), the EDW was valid until 3/29/2025 at 11:17 AM.

A review of the document titled, "Physicians Preadmission Examination Orders and Preliminary Plan of Care" was as follows:

" ... Physician Evaluation Date and Time: 3/27/2025 11:48 AM.
Admit Recommendations: Inpatient psychiatric unit, notify attending physician for admission.
Present Legal Status: Involuntary. Physician Statement for Emergency Admission (with CME when applicable). May hold patient for involuntary admission while pending involuntary commitment filing with the court, as long as the hospital is compliant with the Texas Administrative Code.
Admitting Legal Status: Involuntary ..."

The hospital's telehealth contracted service completed the pre-admission examination.

A review of Patient #13's medical record was conducted on 5/06/2025 with Registered Nurse (RN) #2 and Staff #9. The Initial Psychiatric Evaluation was completed by Physician #14 on 3/28/2025 at 11:23 AM. The mental status exam revealed that Patient #13 was anxious, had poor concentration, a disorganized thought process, delusional thought content with paranoid hallucinations, oriented to person only, short-term memory was not intact, poor insight, poor judgment, and poor reasoning.

A review of the physician orders dated 3/28/2025-5/06/2025 did not show a written, verbal, or telephone order to hold Patient #13 for an Order of Protective Custody (OPC). An Order of Protective Custody is an order issued by a Probate Court after an Application for Court-Ordered Mental Health Services has been filed. Once the OPC is issued, an attorney is appointed to the case. The patient will go before the judge to determine if he/ she requires further inpatient psychiatric treatment and medications. The patient may waive their right to appear before the court after the attorney has counseled the patient.

An interview was conducted with Staff #9 on 5/06/2025 after 11:00 AM. Staff #9 was asked if Patient #13 was a voluntary or involuntary patient. Staff #9 stated Patient #13 was admitted on an EDW and was still an involuntary patient. Staff #9 was asked to provide the OPC for Patient #13. Staff #9 stated, "We have been trying to get the judge in Gregg County to sign an OPC on the patient and we have not been able to get that done." Staff #9 was asked to provide the completed OPC sent to the Gregg County judge and all communication showing the dates and times attempted to contact the judge. Staff #9 confirmed there were no documented notes or an OPC completed on this patient. Staff #9 confirmed the hospital did not have any documented proof that an OPC had been filed with the court once the EDW expired.

An interview was conducted with Nurse Practitioner (NP) #13 on 5/06/2025 after 11:00 AM. NP #13 was asked if Patient #13 had the capacity to consent to voluntary treatment and psychoactive medication administration. NP #13 replied, "She is starting to respond to some treatment, but she does not have the capacity to understand the risks and benefits of the psychoactive medications, and she was not ready to consent for voluntary admission". NP #13 confirmed there was no OPC on the medical record and there had been no order received by the attending physician for the hospital to obtain an OPC.

An interview was conducted with Chief Executive Officer (CEO) #1, Chief Nursing Officer (CNO) #2 and the Director of Quality Staff #9 on 5/06/2025 after 11:30 AM. CEO Staff #1 confirmed Patient #13 was being held as an involuntary patient in the hospital without the legal documentation of an OPC for 38 days. CEO Staff #1 stopped all admissions to the hospital on 5/06/2025 at 12:00 PM for a comprehensive review of all involuntary patients' medical records to ensure legal admission status was obtained and on the medical records of all patients affected.

An interview was conducted with Physician #14 on 5/07/2025 after 9:00 AM. Physician #14 confirmed Patient #13's admission status was changed from involuntary to voluntary on 5/06/2025, and Patient #13 signed the voluntary consent for treatment and admission on 5/06/2025.