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Based on a review of facility documentation, observation and staff interview, the facility failed to ensure each patient received accurate and complete information regarding his or her psychoactive medications from the treating physician, including the reason for the medication, desired effects and potential side effects, for 5 of 10 patients [Patients #1, #5, #7-8 and #10].

Findings were:

Facility policy #MM-02 entitled "Psychoactive Medication Administration/Consent - Texas," last revised 02/01/2017, included the following:
"PURPOSE:
To ensure the safe, appropriate, and accurate administration and handling of medications. To provide a process for ensuring patients and/or families are involved in decisions about care, treatment and services.
POLICY: Medications are administered to patients by qualified licensed personnel in compliance with regulatory bodies after verbal informed consent has been provided by the patient ...If psychoactive medications are prescribed by a LIP (Licensed Independent Practitioner), a written informed consent must be obtained from the patient or legally authorized representative ...
Only licensed prescribers are allowed to provide orders for medications. All medications require an order which is written on the physician/LIP order form ...
3. The prescriber and nurse provide education to the patient and the patient's legally authorized representative in nontechnical language in the patient's primary language.
If the information is not provided by the treating physician, the physician must confirm the explanation with the patient and the patient's legally authorized representative within two working days ..."

As an example, Patient #1 signed consents to be administered the psychoactive medications of clonazepam (anti-anxiety medication) and two consents for Cymbalta (anti-depressant medications) at different dosage levels. The consent to be administered clonazepam was signed by the patient on 5/26/18 at 10:00 a.m. The physician signed that he/she had reviewed the medication information provided Patient #1 regarding expected beneficial effects, side effects, alternative forms of treatment and medications risks on 6/22/18 at 1:40 p.m. The consents for Cymbalta had been signed by the patient on 5/24/18 at 6:10 p.m. The physician signed that he/she had ensured accurate information regarding this medication was provided to the patient on 6/20/18 at 11 p.m. Patient #1 was discharged from the facility on 5/28/18.

The above findings were confirmed in an interview with the facility Program Director and other administrative staff on the afternoon of 9/18/18 in the facility meeting room.

Based on a review of facility documentation and staff interview, the facility failed to ensure each patient's individualized treatment plan, which directed the treatment of and care provided to a patient, included a substantiated diagnosis for 1 of 10 patients [Patient #1].

Findings were:

Facility policy #CS-02 entitled "Treatment Planning: Integrated/Multidisciplinary," last revised 05/01/2017, included the following:
"POLICY:
The multi-disciplinary treatment team, under the direction and supervision of the attending physician, shall develop an integrated written, comprehensive Treatment Plan with specific goals and objectives necessary to address deficits identified in the assessment process. The Treatment Plan shall be initiated as a component of the admission process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient's involvement, throughout the course of treatment ...
PROCEDURE:
1. The admitting physician is responsible for providing the following:
o Prescribing treatment modalities for the initial plan of care.
o Documenting the assessment and physician's orders in medical record.
o Providing direction to the multi-disciplinary team in the formulation of treatment planning goals, objectives and clinical interventions ..."

Review of the medical record of Patient #1 revealed a multidisciplinary treatment plan which directed the treatment of and care provided to Patient #1. The treatment plan included no listing of diagnoses for Axis I or II. It did include the following for Axis III: "HTN (hypertension), DM II (diabetes mellitus, type 2), Hx Pacemaker, neuropathy." However, the treatment plan problem list included no problems addressing the patient's medical status. No such problem was added to the plan during her admission despite poor control of the patient's blood glucose levels and blood pressure.

The above findings were confirmed in an interview with the hospital Program Director and other administrative staff on the afternoon of 9/18/18.

Based on a review of facility documentation, observation and staff interview, the facility failed to ensure each patient had an individualized treatment plan developed according to facility policy as for 5 of 10 patients [Patients #1-3, #8 and #10] the treatment plan appeared to be devised without physician direction.

Findings were:

Facility policy #CS-02 entitled "Treatment Planning: Integrated/Multidisciplinary," last revised 05/01/2017, included the following:
"POLICY:
The multi-disciplinary treatment team, under the direction and supervision of the attending physician, shall develop an integrated written, comprehensive Treatment Plan with specific goals and objectives necessary to address deficits identified in the assessment process. The Treatment Plan shall be initiated as a component of the admission process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient's involvement, throughout the course of treatment ...
PROCEDURE:
1. The admitting physician is responsible for providing the following:
o Prescribing treatment modalities for the initial plan of care.
o Documenting the assessment and physician's orders in medical record.
o Providing direction to the multi-disciplinary team in the formulation of treatment planning goals, objectives and clinical interventions ...
4. The treatment plan shall be signed by all members of the IDT-interdisciplinary team. If the patient is usable and/or unwilling to sign the treatment plan, the reason or circumstances of such inability or unwillingness shall be documented in the patient's medical record ..."

For example, a review of the medical record of Patient #8 revealed a treatment plan initiated by a registered nurse upon the patient's admission to the hospital on 9/6/18. Patient #8 was discharged on 9/17/18. The treatment plan was never signed by a physician.

The treatment plan of Patient #2 was initiated upon his admission to the facility on 8/15/18 by a registered nurse. Patient #2 was discharged from the facility on 8/23/18. A physician signed the patient's treatment plan on 8/24/18.

The above findings were confirmed in an interview with the facility Program Director and other administrative staff on the afternoon of 9/18/18. No additional evidence of compliance was offered by facility staff at that time.

Based on a review of facility documentation, observation and staff interviews, the facility failed to document implementation of therapeutic efforts to comply with facility policies and procedures which addressed patient informed consent and rights of voluntary patients for discharge. As a result, the hospital failed to ensure:

1) each voluntarily admitted individual who informed a staff person of his or her desire to leave, was either discharged or a facility physician pursued court-ordered mental health services according to facility policy and regulatory requirements, for 1 of 2 such patients requesting discharge [Patient #1]. This deficient practice had the potential for the facility to keep voluntarily admitted patients against their wishes.

2) each patient received accurate and complete information regarding his or her psychoactive medications, including the reason for the medication, desired effects and potential side effects for 5 of 10 patients [Patients #1, #5, #7-8 and #10].

Findings were:

1) The facility failed to ensure each voluntarily admitted individual who informed a staff person of his or her desire to leave, was either discharged or a facility physician pursued court-ordered mental health services according to facility policy and regulatory requirements, for 1 of 2 such patients requesting discharge [Patient #1]. This deficient practice had the potential for the facility to keep voluntarily admitted patients against their wishes.

Facility policy #PC-09 entitled "Unfavorable Discharges," last revised 10/1/17, included the following:
"2. TEXAS FACILITIES: ...
If patient signs a 4-hour notice of intent to leave treatment: ...
At expiration of 4 hours, if patient has not revoked notice, physician either voices desire to examine the patient for potential commitment of [sic] writes discharge order to discharge patient AMA. If the physician does not have reasonable cause to believe that the patient may meet the criteria for court-ordered inpatient mental health services or emergency detention, a facility shall discharge the patient within the four-hour time frame ...
If the physician conducting the examination determines that the patient meets the criteria for court-ordered inpatient mental health services or emergency detention, the facility shall by 4:00 p.m. on the next business day file an application for court-ordered inpatient mental health services or emergency detention and obtain a court order for further detention of the patient, or discharge the patient ..."

Patient #1 was admitted voluntarily to Oceans Behavioral Hospital - Permian Basin on 5/23/18. She signed a request for discharge, entitled "Four-Hour Discharge Notice," on 5/27/18 at 5:39 p.m. The request for discharge was never revoked by the patient.

A nursing progress notes on 5/27/18 at 8:00 p.m. read as follows:
"Bx (behavior) 4º (4-hour) letter. On administrative hold. BG (blood glucose) ranges are high. Orders for fast acting insulin. Pt non-compliant [with] diet ..."

An additional Physician's Order read as follows:
5/27/18 at 10:30 p.m. - "Late note: Pt placed on administrative hold @ 1740 on 5/27/18."
No additional information was included with the final order.

The physician ordered discharge of Patient #1 on 5/28/18 at 12:20 p.m.

The medical record of Patient #1 included no documented evidence that the treating physician intended to petition for court-ordered mental health services for the patient.

A Discharge Summary for Patient #1 dictated on 5/30/18 at 2:17 p.m. included the following:
"Date of Discharge: 05/28/2018 ...
COURSE OF TREATMENT: ...When I evaluated the patient on May 27, 2018, I did not see any evidence of depression whatsoever...In fact, the patient reports "I am doing good" ...She then signed a 4-hour letter and demanded to be released from out facility. She continued to deny thoughts of wanting to harm herself. We did not have anything appropriate to take her to court so I discharged the patient against medical advice ..."

In an interview with Staff #1, Program Director, on the afternoon of 9/18/18 in the facility meeting room, he agreed either Patient #1 should have been discharged within 4 hours, or the physician should have documented a valid reason for not doing so.

The above findings were confirmed in an additional interview with hospital administrative staff on the afternoon of 9/18/18 in the hospital meeting room. No additional evidence of compliance was supplied by the facility at that time.


2) The hospital failed to ensure each patient received accurate and complete information regarding his or her psychoactive medications, including the reason for the medication, desired effects and potential side effects for 5 of 10 patients [Patients #1, #5, #7-8 and #10].

Facility policy #MM-02 entitled "Psychoactive Medication Administration/Consent - Texas," last revised 02/01/2017, included the following:
"PURPOSE:
To ensure the safe, appropriate, and accurate administration and handling of medications. To provide a process for ensuring patients and/or families are involved in decisions about care, treatment and services.
POLICY: Medications are administered to patients by qualified licensed personnel in compliance with regulatory bodies after verbal informed consent has been provided by the patient ...If psychoactive medications are prescribed by a LIP (Licensed Independent Practitioner), a written informed consent must be obtained from the patient or legally authorized representative ...
Only licensed prescribers are allowed to provide orders for medications. All medications require an order which is written on the physician/LIP order form ...
3. The prescriber and nurse provide education to the patient and the patient's legally authorized representative in nontechnical language in the patient's primary language.
If the information is not provided by the treating physician, the physician must confirm the explanation with the patient and the patient's legally authorized representative within two working days ..."

As an example, Patient #1 signed consents to be administered the psychoactive medications of clonazepam (anti-anxiety medication) and two consents for Cymbalta (anti-depressant medications) at different dosage levels. The consent to be administered clonazepam was signed by the patient on 5/26/18 at 10:00 a.m. The physician signed that he/she had reviewed the medication information provided Patient #1 regarding expected beneficial effects, side effects, alternative forms of treatment and medications risks on 6/22/18 at 1:40 p.m. The consents for Cymbalta had been signed by the patient on 5/24/18 at 6:10 p.m. The physician signed that he/she had ensured accurate information regarding this medication was provided to the patient on 6/20/18 at 11 p.m. Patient #1 was discharged from the facility on 5/28/18.

The above findings were confirmed in an interview with the facility Program Director and other administrative staff on the afternoon of 9/18/18 in the facility meeting room.

Based on a review of facility documentation, observation and staff interview, the facility failed to ensure each patient, upon discharge, received a description of his/her discharge medication regimen, including a listing and dosage for each medication for 3 of 10 patients [Patient #1, #4 and #7].

Findings were:

Facility policy #MM-14 entitled "Reconciled Medications," last revised 9/1/17, included the following:
"PURPOSE:
Medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten ...
POLICY:
Medication reconciliation applies across the continuum of care, this includes inpatients and outpatients. Medication reconciliation is a multidisciplinary process between Nursing, the Pharmacist and the physician/LIP (licensed independent practitioner) with patient/family involvement ...
Upon Discharge:
5. All variances must be corrected before the patient is discharged.
6. All discharge medications and instructions are documented in the medical record and a copy is given to the patient/family, and the original placed in the patient's medical record.

Patient instructions include how to take the medication prescribed, the time for the next dose and how long to take any new medications that may be prescribed ...Patients and families shall be reminded to throw away old lists of medications, and to give all of their physicians and pharmacies the updated list of medications ..."

A review of the medical record of Patient #1 revealed Physician's Discharge Orders on 5/28/18 at 12:20 p.m. which included the following:
"DC (discharge) TO: home with family ...
Medications:
X Documented on Discharge Medication Reconciliation Order Sheet ..."

A review of the Discharge Medication Reconciliation Order/Transition Record revealed 11 medications, including psychoactive medications, for the patient to continue at home with instructions for taking them. The form included lines for the patient and/or the patient's representative to sign for receipt of the listing. The lines were blank.

The medical records of Patients #4 and #7 also included discharge medication reconciliation forms which were unsigned by the patient or a patient representative.

The above findings were confirmed in an interview with the facility Program Director and other administrative staff on the afternoon of 9/18/18. No other evidence of compliance was offered by the facility at that time.