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Based on review of medical records, review of facility documents, and staff interview, the facility failed to protect and promote each patient's rights when the facility failed to:

A. appropriately and effectively address voluntary requests for discharge at the facility when Patient #1 requested to be discharged and was detained beyond four hours without the right to be examined in person by a physician and assessed for discharge readiness within 24 hours of filing the request for release and an application for court-ordered mental health services was not filed or obtained by 4 pm on the next succeeding business day (11/01/24). Cross-refer A0129.

B. appropriately file an application for court-ordered mental health services for 1 of 3 patients reviewed for involuntary status when Patient #6 presented to the hospital on emergency detention on 09/19/24 but the facility neither released Patient #6 nor filed for court-ordered mental health services within 24 hours. Cross-refer A0129.

C. notify 2 of 2 patients (Patient #1 and #9) of intent to detain nor document the reasons for the decision to detain when the facility decided to file for court-ordered mental health services. Cross-refer A0131

D. ensure each patient or his or her representative had the right to make informed decisions regarding his or her care when it is not specifically disclosed there are no physicians on-site at any time. Physicians only see patients via telemedicine services. Cross-refer A0131.

E. ensure patients received care in a safe setting for 3 out of 14 inpatients reviewed when Patient #3, 5, and 7's "Close Observation" sheets did not accurately reflect the physician's current observation order. Cross-refer A0144.

Based review of documentation and interviews, the facility is not in substantial compliance with the Condition of Participation of QAPI (Quality Assurance Performance Improvement) CFR 482.21 as evidence by failing to:

1. To take actions aimed at performance improvement, as evidence by failing to monitor 2 of 4 self-identified Performance Improvement Projects. The facility also failed after implementing other actions, to measure its success, and track performance to ensure that improvements are sustained. Cross-refer to A0283.

Based on a review of clinical records, facility documentation, credentialing files and an interview with staff, the facility failed to ensure that the medical staff operate under bylaws approved by the governing body, as evidenced by:

*6 of 6 Medical Staff members did not live within the 60 minute distance specified in the bylaws.
*3 of 3 patients did not receive a psychiatric evaluation within 24 hours, as specified in the bylaws.
*2 of 4 active-staff physicians did not carry the required amount of liability coverage specified in the bylaws.

Cross-refer to A0353

Based review of documentation and interviews, the facility is not in substantial compliance with the Condition of Participation of Infection Prevention Control Abx Stewardship CFR 482.42, to have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, as evidence by failing to:

1. Ensure an individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, was appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention. Cross-refer to A0748.

2. Use of antibiotics were optimized through an antibiotic stewardship program with appointed leadership of the antibiotic stewardship program. Cross-refer to A0760 and A0761.

3. Infection prevention and control problems were not being addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. Cross-refer to A0774.

4. Maintain a clean and sanitary environment when infection control issues were observed during tours of the facility. Cross-refer to A0750.

Based on review of facility documents and staff interview, the facility failed to have adequate numbers of qualified professional and supportive staff when:

A. the facility failed to ensure the number of doctors of medicine and osteopathy were adequate to provide essential psychiatric services when no physician is on-site. (Cross refer A1691)

B. the facility failed to provide adequate numbers of staff necessary under each patient's active treatment program staffing is not based on acuity and there is only 1 RN available on nightshift. (Cross refer A1704)

Based on review of medical records, review of facility documents, and staff interview, the facility failed ensure each patient were able to exercise their rights as evidenced by failing to:
A. appropriately and effectively address voluntary requests for discharge at the facility when Patient #1 requested to be discharged and was detained beyond four hours without the right to be examined in person by a physician and assessed for discharge readiness within 24 hours of filing the request for release and an application for court-ordered mental health services was not filed or obtained by 4 pm on the next succeeding business day (11/01/24).; and
B. appropriately file an application for court-ordered mental health services for 1 of 3 patients reviewed for involuntary status when Patient #6 presented to the hospital on emergency detention on 09/19/24 but the facility neither released Patient #6 nor filed for court-ordered mental health services within 24 hours.

Findings were:

A. Review of the medical record for Patient #1 revealed they were admitted to the facility voluntarily on 10/30/24 at 7:40 pm. Patient #1 submitted a formal request to discharge on 10/30/24 at 10:53 pm. The nurse notified the psychiatrist of the request to discharge on 10/30/24 at 10:55 pm. The psychiatrist did not respond until 10/31/24 at 6:37 am, over 7 hours after the request for discharge, and reported to "change patient to involuntary status."

Although Patient #1's application for court-ordered mental health services titled "Physician's Certificate of Medical Examination for Mental Illness" stated it was signed on 11/01/24, this was not signed by the physician until 11/06/24 at 8:00 am and was not filed with the court until 11/06/24, 2 business days after the deadline of 4 pm on the next succeeding business day (11/01/24).

In an interview on the morning of 11/06/24, Staff #2, CNO, reported there continues to be no physician on-site at their facility, everything is via telemedicine services. Staff #2 verified Patient #1 requested to be discharged, but the physician did not respond within 4 hours of the request and although the psychiatrist completed the psychiatric evaluation on 10/31/24 at 3:32 pm, the facility had no ability for a physician to see a patient in-person for an examination.

In an interview on the afternoon of 11/06/24, Staff #1, CEO, reviewed the paperwork for Patient #1 and clarified the physician signed the "Physician's Certificate of Medical Examination for Mental Illness" on 11/06/24 at 8:00 am. Staff #1, CEO, confirmed the physician did not respond to the request for discharge within 4-hours nor was an application for court-ordered mental health services filed nor obtained by 4 pm on the next succeeding business day (11/01/24).

The facility held Patient #1 beyond the 4-hour right to be discharged, did not allow them the right to be seen in-person by a physician within 24 hours of request to be discharged, and held them for several days without filing the appropriate paperwork for court-ordered mental health services.

Review of the facility-based policy titled "Patient Leaving Facility Against Medical Advice [AMA]" with an effective date of 07/01/2022 stated in part, "Procedure: ...If the request takes place when the attending psychiatrist is not present and available:
-If present and available, the medical director or his/her designee shall be informed and shall evaluate the patient.
-All means to convince the patient to stay until his/her attending psychiatrist is available shall be attempted.

*If this is unsuccessful:
-The mental status of the patient shall first be evaluated. If he/she is considered to be immediately dangerous to self, imminently dangerous to others or gravely disabled, the procedure for institution of 72-hour detention shall begin immediately.
-If the patient is not considered any of the above, the attending psychiatrist or medical doctor (if the attending psychiatrist cannot be reached) shall be informed by telephone."

B. Review of the medical record for Patient #6 revealed they arrived to the facility on 09/19/24 at 6:50 pm on a warrant of apprehension and detention dated 09/19/24 at 1:33 pm that stated in part, "You are hereby commanded to take into custody [Patient #6] ... and immediately transport to [Facility] for a preliminary examination, as provided in the Texas Mental Health Code, SEC. 573.012 ..."

Patient #6's psychiatric evaluation completed 09/20/24 at 1:39 pm indicated admission status of "Voluntary" but stated in part, "Justification for 24-hour care - Patient has a psychiatric diagnosis indicated by the DSM-V diagnosis AND Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24 hr medical supervision due to acute decompensation. Treatment at a lower level of care would place the patient 'AT RISK': Yes
Patient is gravely disabled due to inability to care for self, hallucinations, delusions, agitation, anxiety, depression, or other factors resulting in severe loss of functioning: Yes
...This patient requires hospitalization.
This patient could not be adequately and appropriately treated in a less restrictive environment. I have based my decision on the above information ..."

Patient #6's medical record was reviewed with Staff #2, CNO, who reported the facility should have filed for court-ordered mental health services within 24-hours, on 09/20/24 by 1:33 pm, however, the facility did not file until 09/27/24, 5 business days after the original 24-hour warrant of apprehension and detention.

Patient #6 was held at the facility without the appropriate paperwork from 09/20/24 at 1:33 pm until the facility filed on 09/27/24 at an unknown time, almost a full week.

Based on review of documents and staff interview, the facility failed to:

A. notify 2 of 2 patients (Patient #1 and #9) of intent to detain nor document the reasons for the decision to detain when the facility decided to file for court-ordered mental health services.

B. ensure each patient or his or her representative had the right to make informed decisions regarding his or her care when it is not specifically disclosed there are no physicians on-site at any time. Physicians only see patients via telemedicine services.

Findings were:

A. Review of the medical record for Patient #1 revealed they were admitted to the facility voluntarily on 10/30/24 at 7:40 pm. Patient #1 submitted a formal request to discharge on 10/30/24 at 10:53 pm. Patient #1's application for court-ordered mental health services was filed 11/06/24. There was no notification by physician of intent to detain nor documentation of the reasons for the decision to detain Patient #1.

Review of the medical record for Patient #9 revealed they were admitted to the facility voluntarily on 10/30/24 at 4:45 pm. Patient #9's application for court-ordered mental health services was filed 11/06/24. There was no notification by physician of intent to detain nor documentation of the reasons for the decision to detain Patient #9.

In an interview on the afternoon of 11/06/24, Staff #2, CNO, confirmed there was no notification nor documentation of the reasons for the decision of intent to obtain a court order for further detention for Patients #1 and #9.

B. Review of facility patient's initial admission packet revealed two documents:
-Document titled "Telemedicine Informed Consent" stated in part, "Telemedicine services involved the use of secure interactive
videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites.
...2. I understand that I will not be physically in the same room as my health care providers. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room."

-Document titled "Informed Consent, Notice of Privacy Policy, and Notice Regarding complaints for Telemedicine Services" stated in part, "Telemedicine Physician Disclosures: I have been disclosed required disclosures about my provider whom shall provide telemedicine services: 1) I will be seeing [Physician #16] ... 2) the physician's specialty is in Psychiatry ..."

There is no written disclosure or signed acknowledgement by patients that a MD/DO [Doctor of Medicine or Osteopathy] is not present in the facility.

In an interview the morning of 11/05/24, Staff #2, CNO, reported there have been no updates to the telemedicine disclosure statements.

Based on review of medical records and staff interview, the facility failed to ensure patients received care in a safe setting for 3 out of 14 inpatients reviewed when Patient #3, 5, and 7's "Close Observation" sheets did not accurately reflect the physician's current observation order.

Findings were:

Review of the medical record for Patient #3 revealed they were placed on fall precautions on 10/25/24 and bleeding precautions on 10/27/24. Patient #3's Close Observation sheets for the day shift of 11/05/24 revealed no bleeding precautions marked. The Close Observation sheet for the day shift of 11/06/24 revealed fall and bleeding precautions were not checked. Suicide precautions were marked on Patient #3's Close Observation sheet on the dayshift of 11/06/24, but were not ordered.

Review of the medical record for Patient #5 revealed they were placed on risk for sexually acting out precautions [SAO] on 10/26/24 at 7:49 pm through the current survey. Patient #5's Close Observation sheets for the day shifts of 11/05/24 and 11/06/24 revealed SAO was not marked as a precaution.

Review of the medical record for Patient #7 revealed they were placed on suicide precautions on 10/27/24 through 11/01/24. Patient #7's Close Observation sheets for the day shifts of 11/05/24 and 11/06/24 revealed suicide precautions were marked as a precaution, but were not ordered.

The above was verified in an in interview on the afternoon of 11/06/24 with Staff #2, CNO, who reported they were monitoring these Close Observation sheets.

Based on a review of documentation and interview, the facility failed to take actions aimed at performance improvement, as evidence by failing to monitor 2 of 4 self-identified Performance Improvement Projects. The facility also failed after implementing other actions, to measure its success, and track performance to ensure that improvements are sustained.

Findings were:

Facility Quality Program stated in part, "2.4 PLAN-DO-CHECK-ACT (POCA) APPROACH TO PROCESS IMPROVEMENT
The Plan, Do, Check, Act (POCA) cycle developed by Shewhart is the most familiar quality assurance approach to process improvement and is the methodology used by the BTQM system and its Committee.

The POCA model has two (2) parts:
A. Three (3) fundamental questions, which can be addressed in any order.
B. The Plan-Do-Check-Act (POCA) cycle to test process revisions in actual hospital environment. The POCA cycle guides the test of a process revision to determine if the revision is an improvement.

The two (2) parts of the POCA Model are combined to give a consistent workflow as shown below:
1) Setting the Target Expectation (PLAN - What Needs to Happen?)
To improve anything, a target expectation must be set. The target expectation should be time-specific and measurable. It should also define whom it will include and what other processes it will affect.
2) Establishing Measures (PLAN - What is an Acceptable Score Range?)
Develop a quantitative measure for the target expectation so that it can be determined
if the process revision produces and improvement.
3) Selecting Process Revisions (DO - What are the Right Indicators?)
Indicators represent the revised actions to be performed to reach the target expectation. These will be monitored in the form of questions that will be scored for compliance. Indicator ideas may come from experience of coworkers, from change concepts initiated by regulatory agencies, or by other creative critical thinking techniques.
4) Monitors are testing tools that are made up of indicators and are used to evaluate a process.
Indicators are steps in a standing or revised process that are measured for compliance or improvement. The monitoring tool collect the necessary data needed to analyze the measures compared to the target expectation.
5) Implement and Update (ACT by Implementing Process Revisions & Updating the Policy)
After the successful outcome of the monitoring activity of a process revision, the hospital can implement the new process and update the policy to the more successful procedure ....

IV. QUALITY - Pl PROJECT
5.1 I&O - WITH A HYDRATION FOCUS ON GERIATRIC PATIENTS
o Based on previous Pl project on THLOC - trend observed of the pts that were transferred out having decreased hydration.
o What could have been done on the front end to minimize this?
o Proper documentation/monitoring of intake/output?
o Proper interventions implemented to prevent decline?
o Establish, implement, and monitor processes and effects of focused efforts.
5.2 FALLS- WITH/WITHOUT INJURY
o Monitor the number of staff on each shift
o Monitor with the assistance of the DON that each Charge Nurse knows what is going on, on the unit always
o Monitor Fall Program is being utilized
o Monitor that all MHT/Nursing groups are being completed
5.3 PERSONAL BELONGINGS
o Deep dive focus/look into patient belonging processes for needed modifications and/or compliance due to continued issues with some items not being logged on admission and/or patients not leaving with all belongings at discharge.
5.4 MED VARIANCES
o Consistent Staffing
o Monitor and review Psych Consents
o Monitor and review Pharmacy
o Monitor and review MAR
o Monitor and review refill orders"

Review of facility Quality Meeting Minutes for June 2024-October 2024 revealed the only of the 2 identified facility Performance Improvements Projects were being tracked. Only Medication Variance and Falls were currently being tracked and reported at Quality Meetings. Personal Belongings and Hydration were not being tracked and reported at the Quality Meetings.
Review of facility Quality Meeting Minutes for June 2024-October 2024 also revealed that only employee health issues and the following health issues: UTIs, pneumonia, and skin issues were being tracked reported. In interview on 11/05/24, staff member #2 (Infection Control Coordinator) verified that they tracked urinalysis after antibiotic administration to ensure infections clear before discharge, and also complete culture and sensitivity testing on patients. However, the facility was unable to produce evidence that this information was coordinated with the QAPI program and pharmacy services.

Staff member #2 was also asked if any Environment of Care Round were conducted to ensure the facility was cleaned effectively. Staff member #2 "Once a week, we enter what we find in a form, we check if housekeeping cleans the rooms and disinfect. Staff are required to disinfect the unit twice a day." Staff member #2 verified this information was not being presented to quality in meetings.
In interview with staff members #1 and 2 on 11/ 05/24, they verified that all infection control surveillance and data is not currently reported during QAPI meetings. The staff members also verified that currently the collected information has no measurable metric set to monitor the effectiveness of the surveillance date that is conducted, to evaluate if there need to be adjustments to ensure performance improvement. The facility The Plan, Do, Check, Act (POCA) Cycle includes, "4) Monitors are testing tools that are made up of indicators and are used to evaluate a process. Indicators are steps in a standing or revised process that are measured for compliance or improvement. The monitoring tool collect the necessary data needed to analyze the measures compared to the target expectation."

By failing to collect all data to QAPI, particularly related to Infection Control, the facility cannot effectively identify and set actions aimed at performance improvement. By failing to monitor 2 of 4 Performance Improvement Projects, they are unable to measure success for these projects and/or track performance to ensure that improvements are sustained.

Based on a review of clinical records, facility documentation, credentialing files and an interview with staff, the medical staff failed to enforce the bylaws to carry out its responsibilities:

Findings were:

Facility Medical Staff Bylaws state, in part (page 11):
"4.2 ACTIVE STAFF
4.2 (a) Qualifications
he Active Staff shall consist of practitioners, each of whom shall:
(1) Meet the basic qualifications set forth in Section 3.2 (a);
(2) Have his/her primary office and residence located within sixty (60) minutes response distance to the Hospital in order to provide continuous care to his/her patients.

In an interview with staff #1 on 11-5-24, staff #1 stated that staff #16 and #21 have their primary office in a city 334 miles (5.5 hours) away, staff #17, #18 and #20 have their primary office 310 miles (5.25 hours) away and staff #19 has a primary office in a city 599 miles (9-10 hours) away. Staff #1 furnished the surveyor with written documentation of the primary office addresses.

Facility Medical Staff Bylaws state, in part (beginning page 5):
"Medical Records
...
2. A complete history and physical examination, as well as a complete Psychiatric Evaluation shall be dictated or recorded within twenty-four (24) hours of admission. If a complete history has been recorded and a physical examination performed by a member of the Medical Staff at Allegiance Behavioral Health Center of Plainview, L.L.C. or his designee within seven (7) days prior to the patient's admission, a durable, legible copy may be used in the medical record. In such instances, an interval admission note, which includes all additions to the history and any subsequent changes in the physical findings, must be recorded."

A review of 3 clinical records was conducted (patients #2 - #4).
*Patient #2 was admitted on 10-25-24 at 5:05 pm. The psychiatric evaluation was not performed until 10-28-24 at 11:33 pm.
*Patient #3 was admitted on 10-25-24 at 5:39 pm. The psychiatric evaluation was not performed until 10-28-24 at 11:33 pm.
*Patient #4 was admitted on 10-26-24 at 5:30 am. The psychiatric evaluation was not performed until 10-28-24 at 10:11 am.

Facility Medical Staff Bylaws state, in part (beginning page 6):
"3.2 BASIC QUALIFICATIONS FOR MEMBERSHIP
3.2 (a) Basic Qualifications
The only people who shall qualify for membership on the Medical Staff are those practitioners legally licensed in the State of Texas; who:
...
(4) Maintain professional liability insurance of at least 1,000,000/3,000,000 aggregate, through a company who is licensed to provide insurance in the State of Texas."

A review of credentialing files for 4 active-staff physicians (staff #16 - #19) was conducted. Staff #17 & #18 only carried liability insurance in the amounts of $500,000/$1,000,000 aggregate.

The above was confirmed in an interview with staff #1 on 11-5-24

Based on a review of documentation and interviews, the facility failed to ensure an individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, was appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention.

Findings were:

The facility identified staff member #3 as the current Infection Control Coordinator as of November 2024. Prior to November 2024, staff member #2 was the facility Infection Control Coordinator prior to November 2024. Staff member # 2 stated she had taken online training for infection control, including passing a test, however staff #2 was unable to produce evidence they had education, training, experience, or certification in infection prevention and control to ensure they were qualified for the role of Infection Coordinator, prior to the survey exit date of 11/07/24.

Based on observation and staff interview, the facility failed to maintain a clean and sanitary environment when infection control issues were observed during tours of the facility.

Findings were:

The following was observed during a tour of the facility with Staff #1, CEO, on the morning of 11/05/24:

*Missing tile and chipping paint throughout

*Conference room: several ceiling tile with water damage

*Laundry Room:
-weather stripping missing between hallway and room leaving a residue and making it impossible to clean
-Chips in floor tile
-build-up of dust/lint on high horizontal surfaces including washing machine, dryer, hand sanitizer dispenser
-mop, detergent, and other items stored on the floor
-visible dirt in washing machine

*Dining room:
-ceiling tile not flush allowing a hole where pests could enter room
-trays delivered on a dining cart with visible dirt along outside crease, indicating this was inappropriately cleaned

The following was observed during a tour of the Intensive Outpatient Program with Staff #1, CEO, on the morning of 11/07/24:
-Chipping paint and visible dirt/discoloration of walls and floors throughout
-Fire extinguisher that had not been checked since 02/19/2022
-Discolored wood TV tray
-Room with access to the attic exposed and not covered, allowing access by pests and other organisms
-Back door with frame chipping from wall

Staff #1, CEO, accompanied during the tours on 11/05/24 and 11/07/24 and verified the above findings.

Based on a review of documentation and interviews, the facility to ensure that the infection preventionist/infection control professional had effective communication and collaboration with the hospital's QAPI program on infection prevention and control issues.

Findings were:

Facility based, "INFECTION CONTROL AND PREVENTION IC - 8010 PREVENTION CONTROL AND MONITORING" stated in part,
"PROCEDURE
Infection Prevention and Control activities include the following:
o Monitoring and evaluation of key performance aspects of infection control surveillance, prevention and management:
o Healthcare acquired/Community acquired infections
o Respiratory potentials
o Medical equipment device-related infections
o Antibiotic-resistant organisms (MORO) / wound infections
o HCA1: TB
o Other communicable diseases, particularly preventable vaccine proven to be infectious
o Employee health trends including increasing hand hygiene compliance.
o Disinfecting of needed equipment, devises and supplies.
o Facilitating a multidisciplinary approach to the prevention and control of infections.
o Collaborating with all organizational ...

Monthly Quality data collection reports:
o Monitoring
o Review of positive culture, infectious cases, clusters and outbreaks."

Review of facility Quality Meeting Minutes for June 2024-October 2024 revealed that only employee health issues and the following health issues: UTIs, pneumonia, and skin issues were being reported. In interview on 11/05/24, staff member #2 (Infection Control Coordinator) verified that they tracked urinalysis after antibiotic administration to ensure infections clear before discharge, and also complete culture and sensitivity testing on patients. However, the facility was unable to produce evidence that this information was coordinated with the QAPI program and pharmacy services.

Staff member #2 was also asked if any Environment of Care Round were conducted to ensure the facility was cleaned effectively. Staff member #2 "Once a week, we enter what we find in a form, we check if housekeeping cleans the rooms and disinfect. Staff are required to disinfect the unit twice a day." Staff member #2 verified this information was not being presented to quality in meetings.
In interview with staff members #1 and 2 on 11/ 05/verified that all infection control surveillance and data is not currently reported during QAPI meetings. The staff members also verified that currently the collected information has no measurable metric to met to monitor the effectiveness of the surveillance date that is conducted, to evaluate if there need to be adjustments to ensure performance improvement.

Based on review of facility documentation and staff interview, the facility failed to the facility failed to provide adequate numbers of staff necessary under each patient's active treatment program when and staffing is not based on acuity and there is only 1 RN available on nightshift.

Findings were:

Review of the facility staffing plan revealed a grid based on the number of patients only and stated in part:
*# of patients 1-6: 1 RN, 0 LVN/LPN, 1 Tech (MHT)
*# of patients 7-12: 1 RN, 1 LPN, 2 Tech
*# of patients 13-16: 1 RN, 1 LPN, 3 Tech
*# of patients 17-18: 1 RN, 2 LPN, 3 Tech
*# of patients 19-20: 1 RN, 2 LPN, 4 Tech

In an interview on the morning of 11/04/24, Staff #2, CNO, reported there remained mostly only 1 RN on nightshift and reported that RN does not get breaks unless there is another RN scheduled, which is not often, as there always has to be an RN on the unit. In a follow-up interview on the morning of 11/05/24, Staff #2, CNO, reported staffing was still in accordance with the provided staffing grid and the facility has not yet developed an acuity tool. Staff #2 reported they were not "flexing" staff off and updated the staffing sheets to accurately reflect their staffing. Staff #2 reported the "Patient Information Sheet" was developed to monitor observation and precaution levels of each patient but did not factor into the staffing.

Review of the "Patient Information Sheet" for 11/05/24 revealed a census of 13 patients, 7 of which were on high fall precautions (Patients #1, 2, 6, 9, 10, 11, and 21) while the other 6 (Patients #4, 3, 5, 7, 8, and 12) were on fall precautions. Other precautions included: 12 patients on Assault (Patients # 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, and 21), 4 on Elopement (Patients #6, 9, 10, 12), 3 on Bleeding (Patients #3, 6 and 9), 2 on Seizure (Patients #3 and 11), 2 on SAO (Patients 5 and 9) and one on Diabetic (Patient #7).

Review of the "Patient Information Sheet" for 11/06/24 revealed a census of 13 patients, 8 of which were on high fall precautions (Patients #1, 2, 6, 9, 10, 11, 13, and 21) while the other 6 (Patients #4, 3, 5, 7, 8, and 12) were on fall precautions. Other precautions included: 13 patients on Assault (Patients # 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 13, and 21), 4 on Elopement (Patients #6, 9, 10, 12), 3 on Bleeding (Patients #3, 6 and 9), 2 on Seizure (Patients #3 and 11), 2 on SAO (Patients 5 and 9) and one on Diabetic (Patient #7).

In a telephone interview on the evening of 11/05/24, Staff #11, nightshift RN verified they do not get breaks unless another RN is scheduled as there always has to be an RN on the unit and reported RNs are technically never relieved of their duties. Staff #11 reported if an admission or transfer happens during their shift, the LVN or MHT will leave the unit to pick up or accompany a patient, the RN will be on the unit at all times.

With only 1 RN scheduled, especially at nights, there is no RN back-up available to monitor patients or relieve the one scheduled RN for breaks or lunch. If there is a restraint, there is no other RN to monitor patients or complete the 1 hour face-to-face.

Facility-policy titled "General Staffing" effective 07/01/22 stated in part, "Each unit or area where patient care is provided will have a staffing plan to
provide a sufficient number of professional nursing staff (RNs, LPNs/LVNs, CNAs) and professional ancillary staff (registered physical therapists, registered respiratory therapists, etc.) to carry out at least the following activities:
-Prescription of care, treatment and services care for patients based on:
*Assessment data and other relevant information
*Identified patient needs/problems
*Appropriate healthcare interventions as specified in standards, policies, and procedures, protocols or as determined by professional judgment
*The patient's response to healthcare interventions
...Clinical and service indicators will be utilized in combination with human resource screening indicators to assess staffing effectiveness ..."

Based on a review of documentation and interviews, the facility failed to demonstrate that an individual (or individuals), who is qualified through education, training, or experience in infectious diseases and/or antibiotic stewardship, is appointed by the governing body as the leader(s) of the antibiotic stewardship program.

Findings were:

The tab in the survey readiness binder for the antibiotic stewardship program was empty. In interview on 11/05/24, staff members #2 verified there currently was no antibiotic stewardship program and that the contracted pharmacist/pharmacy provider was designated by the facility as the leader of the antibiotic stewardship program but was not providing for any antibiotic stewardship program. The appointed the leaders of the antibiotic stewardship program (the contracted pharmacist/pharmacy provider) has not provided any form of antibiotic stewardship program for any of the calendar year 2024.

Based on a review of documentation and interviews, the facility failed to demonstrate coordination among all components of the hospital responsible for antibiotic use and resistance, including, but not limited to, the infection prevention and control program, the QAPI program, the medical staff, nursing services, and pharmacy services.

Findings were:

In interview on 11/05/24, staff member #2 (Infection Control Coordinator) verified that they tracked urinalysis after antibiotic administration to ensure infections clear before discharge, and also complete culture and sensitivity testing on patients. However, the facility was unable to produce evidence that this information was coordinated with the QAPI program and pharmacy services. The facility was unable to coordinate with pharmacy service regarding antibiotic use and resistance, due to the fact the contracted pharmacist/pharmacy provider had not developed/implemented an antibiotic stewardship program or participated in quality meetings for the 2024 calendar year. Review of Quality Meeting minutes from June 2024-September 2024 supported that the contracted pharmacist/pharmacy provider did not participate in the meetings.

The above findings were verified with staff member #2 on 11/05/24.

Based on review of facility documents and staff interview, the facility failed to ensure the number of doctors of medicine and osteopathy were adequate to provide essential psychiatric services when no physician is on-site.

Findings were:

Texas Administrative Code 404.157(b)(1) states, "(b) All persons voluntarily admitted to inpatient services for treatment of mental illness or chemical dependency have the right to be discharged within four hours of a request for release unless the individual's treating physician (or another physician if the treating physician is not available) determines that there is cause to believe that the individual might meet the criteria for court-ordered mental health services or emergency detention.
(1) Each such person detained beyond four hours has the right to be examined in person by a physician and assessed for discharge readiness
within 24 hours of the filing of a request for release, with results of the assessment and recommendation resulting documented in the medical record and disclosed to the individual. All such persons have the right not to be detained beyond the completion of the in-person examination..."

Review of the medical record for Patient #1 revealed they were admitted to the facility voluntarily on 10/30/24 at 7:40 pm. Patient #1 submitted a formal request to discharge on 10/30/24 at 10:53 pm. The nurse notified the psychiatrist of the request to discharge on 10/30/24 at 10:55 pm. The psychiatrist did not respond until 10/31/24 at 6:37 am, over 7 hours after the request for discharge, and reported to "change patient to involuntary status."

In an interview on the morning of 11/06/24, Staff #2, CNO, reported there continues to be no physician on-site at their facility, everything is via telemedicine services. Staff #2 verified Patient #1 requested to be discharged, but the physician did not respond within 4 hours of the request and although the psychiatrist completed the psychiatric evaluation on 10/31/24 at 3:32 pm, the facility had no ability for a physician to see a patient for an in-person examination.

In an interview on the morning of 11/05/24, Staff #10, RN, reported they make rounds with the physician via telemedicine which could take about an hour to an hour and a half and up to 5 hours.

In an interview on the afternoon of 11/05/24, Staff #1, CEO, reported physicians are 100% telemedicine and they have been actively trying to obtain staff. She verified an RN was not on the unit while doing rounds with the physician.