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Based on Interview, Record Review the hospital failed 1 of 1 Patient #3 by failing to ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs. The nursing care plan may be part of an interdisciplinary care plan. The hospital Patient #3 was intermently taking his medications Zoloft, Seroquel and Trileptal.

Findings Include.

During interview with hospital Staff #8, LVN reporting while Patient #3 was intermittently taking his medication he complained about a headache. Staff #8 reported documenting only that the patient refused the medication.

During interview with hospital Staff #8, LVN reported that there was no medical consult established to improve Patient #3's goals and care.

During Interview with hospital Staff #10, DON it was reported the physicians were aware Patient #3 was internmently taking their medication, but nothing was done to ensure the Patient's goals were met or education the patient that headache's may be a side affect. The DON was informed Patients Care Plan was not updated by nursing staff.

During Record Review Patient #3, Medication Administration Record on 09/25 at 1:06PM, "Patient #3, refused to take Zoloft."

During Record Review Patient #3, Medication Administration Record reflected on 09/19/2024, at 9:32 AM. Patient #3 refused to take Catapres."

During Record Review Patient #3, Medical Administration Record reflected on 09/19/2024 at 9:29PM. Patient #3 refused to take Zoloft."

During Record Review Patient #3, Medical Administration Record reflected on 09/20/2024 at 8:56 AM, Patient #3 refused to take Trileptal.

During Record Review Patient #3, Medical Administration Record on 09/20/25 8:56 AM. Patient #3 refused Seroquel."

Policy:
The hospital Policy on Patient Rights 10/2022, "University Behavioral Health of Denton shall protect the rights of patients as per the Patient Bill of Rights and Texas Law. The staff shall be trained on the 'Patient Bill of Rights' and upon admission, patients will be fully informed of their rights as outlined below. Restriction of patient rights is done only in those situations where the safety, security and welfare of the patient mandates such restriction."

The hospital Policy on Neglect, 12/2022, "To establish a uniform policy and procedures for reporting and responding to all allegations of abuse and neglect. To comply with Texas law the requires professionals to make a report within 48 hours of first suspecting abuse, neglect or exploitation of a child or person 65 years or older or an adult with disabilities."

The hospital Policy on Coordination of Services 08/2023, "Individualized treatment is based on the findings of the completed assessments and is provided by a multi-disciplinary team and professional staff. This team includes but is not limited to, the psychiatrist, nursing staff, social services staff, dietitian, and recreational therapist. The primary object of the treatment team is the assessment, treatment, and rehabilitation of the patient in an environment that promotes positive behavioral changes.

The hospital Policy on Clinical Records "Medical Record Completion, 01/2023," 'It is the Policy of University Behavioral Health of Denton that the medical records shall contain sufficient information to identify the Patient; support Patient Diagnosis, to justify admission and continued hospitalization and describe the patient's progress and response to medical services accurately."

The hospital Policy on Pharmaceutical Services 07/2024, "Medication Administration and Management.' The administration of medications shall conform with local and state Pharmacy regulations as well as meeting The Joint Commission guidelines of Pharmaceutical Services."