HospitalInspections.org

Based on record review and staff interview, the facility failed to ensure the patients right to safe implementation of restraint or seclusion by trained staff.

Findings include:

In review of facility policy titled, Plan for the Delivery of Patient Care, Treatment and Services stated in part, " ...Purpose: This policy establishes guidelines for intervention with early warning signs of potential escalating behaviors through the use of crisis prevention procedures established by the Crisis Prevention Institute (CPI) or a similar system designed to recognize and respond to such behaviors in a safe and effective manner to assist the patient with regaining behavioral control while respecting the dignity of the individual.

6. All staff will receive initial CPI training upon hire or will demonstrate documentation of current CPI certification.

7. Ongoing training will occur every 6-12 months ..."

In an interview with staff #2, it was confirmed that staff #7 was delinquent with her CPI training; training expired 8/2020.

Based on record review and staff interview, the facility failed to ensure that medical records were accurately written when a long acting injectable antipsychotic medication was administered at the hospital but was not documented on the patients' discharge paperwork.

Findings include:

In a review of patient #1 medical records, a Brief Psychiatric Note, dated 12/14/ 2020 stated in part, " ...Pt. is showing significant improvement. Pt. denies any SI/HI. Pt's. Aggression is resolved. Pt. finally agreeable to take Invega Sustenna yesterday. Pt. is doing well with the shot. Pt. denies any side affects from it. His hygiene is improving ..."

Discharge Plan and Tx Recommendations, dated 12/15/2020 stated in part, " ...[Patient #1] will follow up aftercare with Pecan Valley MHMR-Mineral Wells for psychiatric and
case management. [Patient #1] has appointment scheduled for 12/18/20 @ 1pm with PV-Mineral Wells with his case manager... Clinical paperwork will need to be faxed...

Is the Patient on a Long Lasting Psychotropic Medication: No
Medication Reconciliation Discharge Form has all medications, dosages, frequencies,
reason listed: Yes
Did the Patient Receive a Copy of the Medication Reconciliation Discharge Form: Yes
Psychiatric Diagnoses:
schizophrenia
General Anxiety Disorder
Medical Diagnoses:
Diabetes ..."

In an interview with staff #10 on 02/10/2021, staff #10 stated, "Staff #10 am the Clinical Program Therapist of Well Bridge Healthcare Fort-Worth regarding patient #1. He was inpatient 12/01/2020-12/17/2020. I attempted to meet with [Patient #1]on 12/15/2020 to complete his discharge paperwork between 1-1:30 pm. However, [Patient #1] was uncooperative and refused to comply. Met with patient #1 again between 3-3:30pm he was cooperative in the completion of his discharge at this time. I received a call from MHMR days later (uncertain exact date or time) regarding whether or not patient #1 had received the Invega Sustena Injection. I informed the MHMR I would need to do some research and get back to them regarding this matter. I diligently inquired whether or not patient #1 had received the injection. I was informed patient #1 had received the injection. Unfortunately, I was notified due to patient #1 discharging, the documentation was no longer available. However, I was unfamiliar with how to locate the documentation of said injection. I wasn't trained or familiar with eMar. I did not witness patient #1 receive said injection. I followed up with MHMR that I had been informed patient #1 received the injection. However, I was informed the documentation of said injection was no longer available in the database due to patient #1 already discharging."

In an interview with staff #2, it was confirmed that an injection of Invega Sustenna 156 mg, administered at the hospital was not documented on patient #1's Discharge Summary nor was the due date for the patients next scheduled injection.