HospitalInspections.org

Based on document review and interview, it was determined that the facility failed to comply with the Texas Administrative Code, Title 25, 414.404 (a)(2) regarding patient and/or legally authorized representatives participating in treatment planning.

Findings were:

Facility policy entitled "Treatment Planning" stated in part:

"The nursing staff is responsible for developing the Initial Treatment Plan within twenty-four (24) hours of admission (TAC 411.47).

The Treatment Plan shall be completed no later than seventy-two (72) hours after admission ...

Patients (and/or their guardians when appropriate) will be invited to participate in treatment team meetings. The patient (or guardian/legally authorized representative) shall be given the opportunity to have input in the development of the Treatment Plan. This shall be accomplished by the clinical staff meeting with the patient to review the recommendations of the treatment team."

Review of the medical record of patient # 1 revealed no completed treatment plan within the designated 72 hour period. No parental involvement was noted. This was confirmed in an interview with the Director of Nurses on 10/28/24.

Based on document review and interview, it was determined that the facility failed to comply with the Texas Administrative Code, Title 26, 568.61 (c) (2) regarding informed consent for medications.

Findings were:

Facility policy entitled "Informed Consent" stated in part:

"In accordance with state law and accreditation standards, a written, dated, and signed informed consent is obtained from the patient or the patient's legal guardian (when applicable) for participation in or for the use or performance of the following:

1. Release of information
2. Authorization for admission, including, but not limited to:
a. consent to treatment
b. emergency medical and dental treatment
c. disclosure of required HIV/AIDS testing
d. consent to photograph
3. Use of audio-visual equipment
4. Medication which has potential for abuse (usually considered Schedule II medication)
5. Psychoactive Medication
6. Research medication and therapy (Cross Creek Hospital does not use research medication and/or therapy)"

Review of the medication administration record dated 9/13/24 through 9/16/24 of patient # 1, revealed no documented consent for hydroxyzine (vistaril). This medication was given all three days. This finding was confirmed by the DON on 10/28/24.