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Based on facility document review, medical record review and staff interview, the facility failed to ensure patients had the right to make informed decisions regarding his or her care.

Findings included:

Facility policy titled "Protective Hold/Seclusion" stated in part, "Definitions: ...E. Emergency: An emergency is an instance in which there is imminent risk of an individual harming him/herself or others.
F. Less Restrictive Interventions: Measures which modify the environment, enhance interpersonal interaction, or provide treatment so as to minimize or eliminate the problems/behaviors which place the patient at risk, Examples of less restrictive measures include, but are not limited to:
1. Verbal interventions such as talking quietly with the patient
2. Reduction of stimuli causing irritation
3. Relaxation techniques
4. Physical activity
5. Psychoactive medications
6. Reality orientation
7. Quiet time
8. Time out/time away."

Facility policy titled "Informed consent for psychoactive medications - Texas" stated in part, "Policy: It is the policy of Georgetown Behavioral Health Institute that patients (and/or the patient's guardian/legal representative) be involved in the process of the patient's care. Prior to initiation of Psychoactive Agents, the person being treated (and /or legal guardian/legal representative) shall be informed of the potential benefits and risk of prescribed medications."

Facility policy titled "Rights and responsibilities of the individual" stated in parted, "The Patient's Bill of Rights shall include, but is not limited to, the patient's right to:
...11. Receive information about any proposed treatment or procedure he/she may need in order to participate in the development of the plan of care, give informed consent or to refuse the course of treatment and to participate in planning for care after discharge.
a. Except in emergencies, this information shall include a description of the procedure or treatment, the medically significant risks involved in the treatment, alternate courses of treatment or non-treatment and the risks involved in each and the name of the person who will carry out the procedure or treatment."

Review of patient #7's medical record revealed they were admitted on 6/14/17 for Bipolar I disorder, mixed, without psychotic features. Physician orders dated 6/14/17 at 7:45 pm stated in part, "Ativan [an anti-anxiety medication] 1 mg [milligram] IM [intramuscular], Benadryl [a sedating antihistamine medication] 25 mg IM, Haldol [an antipsychotic medication] 5 mg IM: X 1 now severe agitation.

Nursing note dated 6/14/17 at 9:00 pm stated in part, "Behavior: Pt [patient] demanding and yelling at staff, peers, slamming down the phone over and over, labile, angry, and agitated.
Intervention: Pt was offered assistance with the phone but began yelling at staff and other patients slamming the phone down. On call was notified and orders for 1 mg Ativan IM, Haldol 5 mg IM, and 25 mg Benadryl IM to be given.
Response: Pt took medications willingly after de-escalation. Pt did come to writer later and thanked nurse that the medication was very helpful and helped calm her down.
Plan: Pt was asked to please try to calm down before demanding things and try to treat others the way she wished to be treated. Pt agreed."

There was no documentation stating other generally accepted, least restrictive forms of treatment, if any, that the physician has evaluated but rejected and the reasons those treatments were rejected. There was a psychoactive medication consent for Benadryl on 6/14/17 without a specified route or dosage. There were no psychoactive medication consents signed for Ativan or Haldol.

In an interview with staff #2 regarding patient #7, when asked what interventions were attempted before IM medications were given, they stated, "I don't know. It's not documented well." When asked about the documented line "Pt took medications willingly after de-escalation," she stated, "Yes, it sounds like she's calm at that time. But I can guarantee, that's probably not what happened." When asked if an emergency still existed at the time patient #1 received the IM medications, staff #2 stated, "It's not documented well."

Review patient #9's medical record revealed patient #9 was admitted to the facility on 6/13/17 for schizophrenia, undifferentiated. Physician orders stated in part: "Date: 6/13/17 Time: 4:05 pm Zyprexa [an antipsychotic medication] 10 mg PO [by mouth] X [times] 1 dose now for agitation
Ativan 2 mg PO X 1 dose now for agitation
Date: 6/14/17 Time: 2:05 pm Zyprexa 10 mg PO and Ativan 2 mg PO X 1 dose now for aggression/agitation.
Date: 6/14/17 Time: 2:35 pm Zyprexa 10 mg IM and Ativan 2 mg IM X 1 dose now for agitation."

Nursing note dated 6/14/17 at 2:00 pm stated in part, "Pt became suddenly angry and flipped a table. Pt then calmly walked down the hallway then into the quiet room. Pt unable to identify or tell staff what caused his outburst. Dr [name omitted] notified. Ativan 2 mg and Zyprexa 10 mg given PO. Will continue to monitor for safety."

Nursing note dated 6/14/17 at 2:14 pm stated in part, "Pt vomiting at this time. Pt spinning in circles attempting to make himself fall down. Dr [name omitted] notified."

In an interview with staff #1 regarding patient #9, they stated, "The nurse didn't document why the second dose was given. It says he continued 'out of control behavior' when the provider saw him the next day. He was transferred after that, too [to a more acute unite]."

There was no documentation found stating other generally accepted, least restrictive forms of treatment, if any, that the physician has evaluated but rejected and the reasons those treatments were rejected. There was not a psychoactive medication consent signed for Ativan or Zyprexa until 6/16/17 at 3:00 am and there were no dosages or routes listed for either medication.

The above was verified in an interview with staff #1 on the afternoon of 8/29/17.







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Patient #1 was voluntarily admitted to Georgetown Behavioral Health Institute on 3/7/16. A review of her clinical record revealed the following physician's order:
3/10/16 at 7:00 p.m.: "Thorazine 50mg/ml IM x 1 dose now for acute agitation."

Patient #1 received the injection at 7:15 p.m. The patient's record included no consent to receive Thorazine, an anti-psychotic medication. The nursing note most immediately prior to the injection was at 4:30 p.m. The next nursing note discussed the patient passing out at 8:00 p.m. No further documentation was found regarding the IM injection of Thorazine either in nursing or physician documentation.

In an interview with Staff #1, Risk Manager/Compliance Officer, on the afternoon of 8/29/17 in the facility conference room, the requirement of a voluntary patient to consent to receive psychoactive medication was discussed. The required documentation for administration of psychoactive medication to a patient in a psychiatric emergency was also discussed. Staff #1 stated, "There's no documentation here [in record] that this woman wasn't willing to receive this medication. It sounds like she consented to receive it since she wasn't fighting." It was pointed out there was no documentation regarding the injection at all, thus the record was incomplete. As the medication was not prescribed on a regular basis, was ordered for acute agitation and was administered IM, it appeared to be a one-time order for a psychiatric emergency. There was no consent for treatment with the psychoactive medication Thorazine available for surveyor review in the record of Patient #1.

Based on observations and interview the facility failed to provide appropriate safeguards to protect medical record information when patient's medical records where left within view and accessible to other patients, visitors and staffs not involved with the care.

Findings Include:

An observation made during a tour of the Geriatric patient behavioral unit observation made on the morning of 8/29/17 revealed several patient's medical record information left unattended sitting on the nurse's station; the information was visible and accessible to other patients, visitors and staffs not caring for the patient.

Further observation on the morning of 8/29/17 on the facility's Adult unit revealed multiple patient's records sitting on the nursing station counter, the files were visible to anyone standing at the counter.

During the tour Staff #8, CEO confirmed the findings and stated, "We need to keep the records secure ...."

Review of the facility provided policy Patient Rights (dated 5/19/17) revealed "...Full consideration of privacy concerning his/her medical care program. Case discussion, consultation, examination and treatment are confidential and should be conducted discreetly.... Confidential treatment of all communications and records pertaining to his/her care and his/her stay in the hospital. His/her written permission will be obtained before his/her medical records can be made available to anyone not directly concerned with his/her care."
Review of the Staff Personnel Files, Patient Rights Documents and Nursing Training records did not reflect any areas of concern.

Based on a review of facility documentation and staff interviews, the facility failed to ensure appropriate nursing care was provided for 2 of 2 patients [Patients #2-3] for which a hypertension protocol was ordered. These two patients were each tranferred to a local emergency room during their inpatient stay at Georgetown Behavioral Health.

Cross refer Organization of Nursing Services, 482.23(a).

Based on a review of facility documentation and staff interviews, the facility failed to ensure appropriate nursing care was provided for 2 of 2 patients [Patients #2-3] for which a hypertension protocol was ordered.

Findings were:

Patient #3 was placed on a Hypertension Protocol on 8/23/17 at 1:00 a.m. Instructions for this protocol read as follows:
"For a manual Blood Pressure of Systolic > 190 or Diastolic > 100:
1. Give Clonidine 0.2 mg PO NOW.
2. Recheck Blood Pressure in 30 minutes ...
For a manual Blood Pressure of Systolic > 170 or Diastolic > 90:
1. Give Clonidine 0.1 mg PO NOW.
2. Recheck Blood Pressure in 30 minutes ..."
On 8/24/17, Patient #3's blood pressure was 155/108 at 1:03 p.m. Per the Hypertension Protocol, he should have received 0.2 mg Clonidine at that time. He was administered 0.1 mg Clonidine. It is unknown if his blood pressure was re-checked in 30 minutes, as the subsequent reading included no time.

His blood pressure on 8/26/17 at 9:00 p.m. was 130/97. He received no medication at that time and no further action was documented. There was no documentation that his blood pressure was re-checked in 30 minutes. At 11:50 p.m. his blood pressure was 158/100. At that time, he received Clonidine 0.1 mg. A later reading of his blood pressure was 139/89. There was no time noted for this reading and thus, it is unclear if the patient's blood pressure was rechecked in 30 minutes.

On 8/27/17, Patient #3 was transferred to an emergency room with complaints of chest pain. When he returned to the hospital, he continued on his Hypertension Protocol. The Memorandum of Transfer completed by Georgetown Behavioral Health included no documentation of contact with the receiving hospital administration or physician. There was no documentation of the accepting hospital having been secured by the transferring hospital. No diagnosis was on the form. There was no signature of a physician to attest to the following statement: "based upon the information available at the time of the transfer the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks of the transfer ..." There was no physician signature on the form at all.

On 8/29/17, Patient #3's blood pressure was 145/109 at 2:30 a.m. According to the Hypertension Protocol instructions, he should have received 0.2 mg Clonidine at that time. He was given 0.1 mg Clonidine. His blood pressure was re-checked later (time undocumented) and was 145/94. At that point, according to the protocol, he should have received additional medication. No medication was administered to Patient #3 at that time. At 9:16 a.m. that same day, his blood pressure read 140/97. The record included no documentation of Clonidine having been administered to the patient and no additional nursing documentation regarding these values.

On 8/12/17 at 8:45 a.m., Patient #2 was placed on a Hypertension Protocol per physician order. Instructions for this protocol read as follows:
"For a manual Blood Pressure of Systolic > 190 or Diastolic > 100:
1. Give Clonidine 0.2 mg PO NOW.
2. Recheck Blood Pressure in 30 minutes ...
For a manual Blood Pressure of Systolic > 170 or Diastolic > 90:
1. Give Clonidine 0.1 mg PO NOW.
2. Recheck Blood Pressure in 30 minutes ..."

On 8/13/17 at 2:00 p.m. a Vitals Chart Sheet had the patient's blood pressure at 167/124. A Hypertension Flow Sheet listed her blood pressure on 8/13/17 at that same time as 160/100. She was given 0.1 mg Clonidine. The Vitals Chart Sheet then noted her blood pressure at 2:10 p.m. as 160/100. A re-check of her blood pressure at an undocumented time on the Hypertension Flow Sheet showed her blood pressure at 160/130. That same form had an additional entry at 2:45 p.m. noting her blood pressure at 160/100. The form showed she was then given 0.2 mg Clonidine. A re-check of her blood pressure at an undocumented time noted it at 160/116. The only notation on the patient Medication Administration Record of Clonidine being administered to Patient #2 on 8/13/17 was 0.1 mg at 2:15 p.m.

On 8/18/17 at 6:40 p.m., the patient's blood pressure was 160/110. She was given 0.2 mg Clonidine and a re-check of her blood pressure (time unknown) showed it at 160/116. At 7:10 p.m., she was given an additional 0.1mg Clonidine, then sent to the ER. There was no evidence of a physician's order to give the additional 0.1 mg Clonidine.

Additional physician's orders read as follows:
8/18/17 at 10:20 p.m.: "Hold current order for Labetalol. Send pt to ER for eval - r/o (rule out) stroke."

Patient #2 was transferred to an emergency room on 8/18/17 per the physician's order made at 8:20 p.m. The undated Memorandum of Transfer was incomplete and included: no documentation that the accepting hospital had been secured by the transferring hospital and no diagnosis. There was no signature of a physician to attest to the following statement: "based upon the information available at the time of the transfer the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks of the transfer ..." There was no physician signature on the form at all. Her blood pressure at time of transfer was 138/106. Reason for transfer was documented as: "C/o right sided weakness, dizziness, headache an hour after blood pressure medication administration (Clonidine x 2 to decrease elevated blood pressure) ..."

There patient record included no documented evidence that Clonidine had been administered to Patient #2 other than what was noted on the Memorandum of Transfer.

Additional physician's order read as follows:
8/19/17 at 4:25 p.m.: "BP [check] Q4 hrs."

Only three blood pressures values were documented in the patient record on 8/20/17. Four values were found documented on 8/21/17. At 9:00 p.m. on that date, her blood pressure was 178/94. She was given 0.1 mg Clonidine. It was unclear when her blood pressure was re-checked, but it was listed as 154/85 at some later time. On 8/24/17 at 9:51 a.m., her blood pressure was 152/118. The Hypertension Flow Sheet showed she was administered 0.1 mg Clonidine. At an unknown time, her blood pressure was re-checked and was 158/102. No further action was noted. At 11:06 a.m., her blood pressure was noted as 158/102. She was then given an additional 0.1 mg Clonidine.

A Detox Nursing Shift Assessment on 8/24/17, 7am-7pm shift, included the following note:
"Pt's BP continues to be elevated. Doses of Clonidine administered per HTN (hypertension) protocol ...Medical consult established due to risk to pregnancy ...Plan: Ensure safety. Monitor pregnancy ..."

The only doses of Clonidine documented on the patient's Medication Administration Record were on 8/12/17 at 9:25 a.m. - 0.2 mg Clonidine, and on 8/13/17 at 2:15 p.m. - 0.1 mg Clonidine.

These findings were all discussed and confirmed with Staff #2, the Assistant Director of Nursing, during several interviews on the afternoon of 8/29/17 in the facility conference room. No additional evidence was provided by the facility to address these findings.