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Based on review and interview the facility failed to have policies and procedures that were specific to the facility.

The facility's corporate company has multiple locations in Texas, Mississippi, Oklahoma, and Louisiana. A review of the policy and procedures revealed they all stated: "This policy applies to all Oceans Healthcare Facilities." There was no indication in the policy that it was specific to the hospital.

Review of the policy and procedure Psychotropic Medications: Emergencies stated, "This policy applies to all Oceans Healthcare Facilities." The policy describes psychiatric emergencies and procedures for both Texas and Louisiana. The two states have very different rules, and the policy goes back and forth between the Texas rule and the Louisiana rule.
An interview was conducted with Staff # 15 concerning the policy's and lack of clarity on which facility the policy was for. Staff #15 stated that she was aware that the policy and procedures had not been corrected and that the facility would be working on each policy. Staff #15 confirmed the findings.

Based on review and interviews the facility failed to;

1. provide the second IMM (Important Message from Medicare) letter prior to discharge in 3 (Patient #12, #13, and #14) of 3 patient records reviewed.

Refer to Tag A0117

2.
A. patients had the capacity to consent as voluntary patients upon admission in 1 of 1 (#10) patient charts reviewed.

B. patients failed to have the capacity to sign for the administration of psychotropic medications in 1 of 1 (#10) patient charts reviewed.

Refer to Tag A0131

3.
patient's receiving chemical restraints for a behavioral emergency was recognized as a restraint and received monitoring to prevent injury or possible death in 1 of 1 (#10) patient charts reviewed.

Refer to Tag A0160

4.
make sure that orders for chemical restraints were written by physicians in 1 of 1 (#7) patient chart reviewed.

Refer to Tag A0168

5.
make sure that orders for chemical restraints were not written to be carried out on a PRN (as-needed) basis in 1 of 1 (#7) patient chart reviewed.

Refer to Tag A0169

Based on document review and interview the facility failed to provide the second IMM (Important Message from Medicare) letter prior to discharge in 3 (Patient #12, #13, and #14) of 3 patient records reviewed.

Findings:

A review of Patient #12's medical record revealed the IMM letter was signed and dated on the admission date of 7/19/2023 at 1:35 AM. A copy was not presented to the patient #12 prior to the discharge date of 7/28/2023.


A review of Patient #13's medical record revealed the IMM letter was signed and dated on the admission date of 7/12/2023 at 6:05 PM. A copy was not presented to the patient #13 prior to the discharge date of 08/01/2023.


A review of Patient #14's medical record revealed the IMM letter was signed and dated on the admission date of 07/17/2023 at 9:20 AM. Further review revealed that Patient #14 also signed the IMM letter for discharge at the same time. A copy was not presented to the patient #14 prior to the discharge date of 7/26/2023.


An interview was conducted with Staff #8 on 8/3/2023 after 10:00 AM. Staff #8 was asked who had the IMM letters signed on discharge? Staff #8 replied, "The case manager or the nurses can have them signed but I am not sure that we are doing that. We did find that we were having some problems getting them signed on admission and we completed some re-education to all the staff."

A review of the document titled, "Important Message from Medicare" was presented for review by Staff #8. A review of the document revealed the education was directed at the intake personnel on admission and did not give education or direction on when to present the IMM letter to the discharging patient. There was no employee sign in sheet and this Surveyor could not determine which employees received the training. Staff #8 was asked why Patient #14 signed the IMM letter in both places confirming she received the letter on admission and prior to discharge on the date of admission. Staff #8 replied that the computer placed a hard stop on the admission process because it showed "missing information" so the staff just had the patient sign in both places,

Staff #15 confirmed the IMM letter was not being presented to the patient within 2 days of discharge.

Based on review and interviews the facility failed to ensure;
A. patients had the capacity to consent as voluntary patients upon admission in 1 of 1 (#10) patient charts reviewed.
B. patients failed to have the capacity to sign for the administration of psychotropic medications in 1 of 1 (#10) patient charts reviewed.

Patient #10

A review of patient #10's chart revealed he was admitted under an Emergency Detention Warrant (EDO) as involuntary. The facility moved forward to submit an Order of Protective Custody (OPC) to the court but before the OPC was approved the patient was changed to voluntary. To be voluntary in a psychiatric hospital the patient must have the mental capacity to consent to treatment, administration of psychotropic medications, understand how to request discharge, patient rights, and financial responsibilities.

A review of the admission nurse notes dated 7/15/23 stated, " Assessment completed. Patient disoriented to day, time, and place. Can state name appropriately. Patient believes he is at Tradewind airport. Patient very hard of hearing. Asking why he is here. Unable to answer questions appropriately regarding anxiety and depression. States "yes" when asked if he's eating good. Also states "yes" when asked if he is sleeping. Needs constant redirection. Will attempt to stand up out of wheelchair by himself however patient has very unsteady gait. Needs assistance with ADL's Will continue to monitor."

A review of the physician orders dated 7/27/23 at 9:00 AM revealed the Nurse Practitioner (NP) wrote an order to change the patient's status from involuntary to voluntary.

A review of staff #16 (NP) note for 7/27/23 at 3:15 PM stated, "Orientation -Not Oriented Attention/Concentration- Impaired." There was no documentation found that patient #10 had the capacity to consent as a voluntary patient. There was no documentation that she was changing the patient's status, that the psychiatrist was aware, or that the patient had any understanding of his legal status.

A review of the chart revealed the patient had signed a voluntary request for admission on 7-26-23 at 2:11 PM, 5 hours after the order was placed. The witness's signature was illegible, and the surveyor could not determine the witness's discipline. No other admission forms were signed by the patient such as patient rights, financial responsibilities, consent for treatment, etc.

A review of the nurse notes for 7/27/23 at 1820 (6:20PM) revealed that patient #10 was disoriented and only oriented to person, the nurse documented, "Patient in day room. AOx1. Angry and difficult to redirect. Denies SI, HI, or A/V hallucinations. Wanders during therapy sessions. Interactive with peers/staff ..."

A request was made several times to speak with Staff #16 NP. Staff #16 was not made available for the surveyor.
An interview was conducted with Staff #2 MD on 8/2/23 at 11:21 AM. Staff #2 stated that he was not aware that the psychiatrist was required to make the determination of legal status and not the nurse practitioner. Staff #2 stated that he was from Missouri and was not familiar with all the Texas regulations for involuntary patients.

A review of the chart revealed patient #10 was given 22 doses of psychotropic medication, Zyprexa 10mg by mouth, from 7/16/23 through 8/1/23 without the capacity to consent or an Order of Protective Custody with the right to force medications.

Based on review and interview the facility failed to ensure the patient's receiving chemical restraints for a behavioral emergency was recognized as a restraint and received monitoring to prevent injury or possible death in 1 of 1 (#10) patient charts reviewed.

A review of patient #10's chart revealed he was admitted on 7/14/23 for Admitting Diagnosis: Major Depressive Disorder (MDD). The patient was admitted involuntarily upon admission.

A review of the physician orders dated 07/17/2023 10:40 AM stated, "OLANZapine (Zyprexa) 10 MG, 5 mg (0.5 Given vial(s)) intramuscularly One Time Only.- Medication Indication: Aggressive Behavior."

A review of the Medication Administration Record (MAR) revealed the medication was not given until 07/17/2023 at 11:40 AM, 1 hour after the order was received.

A review of the nurse notes dated 7/17/23 7am-7pm stated, "Patient is confused and disoriented, is only able to answer to his name only, is irritable, agitated due to having a foley in place, pt was resting this AM and this writer was able to drain blood tinged urine 500mls with 2 small clots noted, foleys is emptied. Patient did awaken and was upset and attempted to pull on foley, pt was not able to be redirected easily, continued to state, " I almost have it out, Let me get it out", then will yell out "Marie", pt is unable to be redirected at this time, staff is having to stay with him 1:1 to keep him from pulling his foley out, then the patient was becoming irritated, started to become combative from the redirection, ______ Staff #16 NP came to assess the patient. Patient is noted to be restless and agitated, unable to complete further assessment at this time due to agitation." There was no time when the nursing statement was written. There was no restraint packet completed on the patient and there was no documentation on why the emergency medication was ordered, or why it took the nurse 1 hour to administer a medication for a behavioral emergency. A review of the nurse's note revealed there was no assessment of the patient after the restraint was given, no documentation of effectiveness, no vital signs, and no indication if the patient was medically stable or continued to have aggressive behaviors while attempting to pull out his Foley catheter.

A review of patient #10's chart revealed a physician order written on 07/19/2023 at 09:38 PM, "diphenhydrAMINE HCL (Benadryl) 50 MG/MLF 50 mg (1 mL) intramuscularly One Time Only - Medication Pt agitated and aggressive toward staff. He is confused and disoriented and is in danger of hurting himself. Indication: insomnia"
07/19/2023 09:39 PM haloperidoL LACTATE (Haloperidol Lactate) 5 MG/ML, 5 mg (1 mL) intramuscularly One Time Only - Medication Pt agitated and aggressive toward staff. He is confused and disoriented and is in danger of hurting himself. Indication: psychotic disorder."

A review of patient #10's MAR revealed he was administered the medication on 07/19/2023 at 10:15 PM for both Haldol and Benadryl. There was no reason documented why the nurse delayed the injection for 37 minutes. There was no restraint or seclusion packet done for the chemical restraint.

A review of the progress notes dated 7/20/23 revealed Staff #16 documented, "7/20....He was sitting in the TV room today and was sleeping. He would wake up but then go back to sleep and would not answer any of the questions that were asked. Last night the patient fell and hit his head and the staff started neuro checks. He was agitated when he fell and continued to be agitated and combative. He received an IM injection. He is eating and drinking only a minimal amount. The staff reported that he only slept 4 hours last night. He is not going to groups. He has been med-compliant. Social services are going to talk with the patient's family about Hospice or Palliative Care." There was no documentation that a physician was ever aware of the patient's decline.

A review of the nurse's notes dated 7/19/23 7pm-7am revealed there was no documentation found about the chemical restraint, why it was given, if it was effective, if an assessment was performed after the medication was administered, and no face to face performed.

An interview was conducted with Staff # 20 on 8/2/23. Staff #20 confirmed there were no specific instructions on monitoring a chemical restraint in the restraint and seclusion policy, but the Mental Health Tech (MHT) takes vital signs every 15 minutes for an hour. There was no policy that instructed the nurse on when to assess the patient after a chemical restraint, how often, or for how long. There was no documentation that the MHT took vital signs or that the RN who was the clinician observed the patient at any time after the administration of the chemical restraint. There was no evidence that the RN that administered the medication realized it was a chemical restraint.

A review of patient #10's treatment plan revealed there was no mention of the chemical restraint, a monitoring plan, goals, or outcomes.

Based on a review of the clinical record and facility documentation, the facility allowed a mid-level provider to order a chemical restraint for 1 of 1 patient (patient #7) reviewed, in violation of State law. According to the Texas Health and Safety Code title 25, Part 1, Chapter 415, Subchapter F:
(b) Physician's order. Only a physician member of the facility's medical staff may order restraint or seclusion.

Findings were:

Patient #7 was admitted to the facility on 7-18-23 and was still inpatient at the conclusion of the survey on 8-3-23. The patient's medication orders were reviewed for the time period of 7-18-23 through 8-1-23. The following chemical restraint orders were found:

*7-23-23 at 11:13 pm, 11:14 pm and 11:15 pm - Benadryl 50 mg IM, Haldol 5 mg IM, Ativan 2 MG IM; given as a single injection. Orders state "medicatio confirmed with [staff #33], NP.

*7-28-23 at 8:13 pm - Thorazine 50 mg IM "medication ordered by [staff #5, MD] via [staff #33, NP].

*7-29-23 at 1:49 am - Thorazine 25 mg IM every hour PRN "medication ordered by [staff #5, MD] via [staff #33, NP].

*8-1-23 at 12:27 pm - Thorazine 50 mg IM every hour PRN; max 2 doses for this order. The ordering clinician was staff #5, NP.

The above was confirmed in an interview with the CEO and other administrative staff on 8-3-23.

Based on a review of clinical records, the facility failed to ensure that orders for restraint or seclusion were not writton on an as-needed (PRN) basis

Findings were:

Patient #7 was admitted to the facility on 7-18-23 and was still inpatient at the conclusion of the survey on 8-3-23. The patient's medication orders were reviewed for the time period of 7-18-23 through 8-1-23. The following chemical restraint orders, written as PRN (as-needed) were found:

*7-29-23 at 1:45 am - Thorazine 50 mg IM every hour PRN for mania associated with bipolar disorder.

*7-29-23 at 1:49 am - Thorazine 25 mg IM every hour PRN for mania associated with bipolar disorder.

*8-1-23 at 12:10 pm - Thorazine 50 mg IM every hour PRN for agitation/aggression; max 2 doses.

The above was confirmed in an interview with the CEO and administrative staff on 8-3-23.

Based on review and interview the facility failed to ensure;

1.
nursing was following physician orders, reporting missed medications to the providers, assessing the patient's vital signs as ordered, monitoring and documenting changes in the patient's condition, and documenting the transportation of a patient to the emergency department or the return in 1 of 1(#10) patient charts reviewed.

Refer to Tag A0395

Based on review and interview the facility failed to ensure nursing was following physician orders, reporting missed medications to the providers, assessing the patient's vital signs as ordered, monitoring and documenting changes in the patient's condition, and documenting the transportation of a patient to the emergency department or the return in 1 of 1(#10) patient charts reviewed.

A review of patient #10's chart revealed the Nurse Practitioner (NP) wrote an order on 7/24/23 to start patient #10 on Metformin 850mg by mouth daily for type 2 diabetes. A second order was placed on 7/24/23 at 7:00 AM for Fingerstick Blood Glucose Before Meals and Bedtime.

A review of the admitting physician orders revealed on 7/15/23 patient #10 had a dietary order for "Type: Routine, Diet: Regular, Diet Consistency." A review of the physician's orders revealed there was no alteration to the regular diet. Patient #10 was not placed on a diabetic or NCS diet. There was no order found for a dietician consult.

A review of staff #16 NP progress note dated 7/24/23 at 1745 (5:45 PM) revealed there was no mention of the patient being placed on metformin or the need for blood sugar checks. There was no documentation that the patient was made aware of the new diagnosis, or medical condition change. There was no written evidence that any family was notified. There was no documented evidence that the nurse practioner reported any of these findings to a medical physician or the psychiatrist assigned to the patient. There was no evidence that any physician saw patient #10 from admission on 7/14/23 until current (8/1/23).

A review of the nurse's notes and Medication Administration Record (MAR) revealed from 7/24/23 to 8/1/23 the nurses failed to follow the provider's orders to check the patient's blood sugars by glucometer before every meal and at bedtime, a total of 4 times a day. Failure to check the patient's blood sugar can result in hyperglycemia or hypoglycemia and be life-threatening.

According to https://www.mayoclinic.org/diseases-conditions/hyperglycemia/symptoms-causes/syc-20373631

Hyperglycemia
Hyperglycemia is the technical term for high blood glucose (blood sugar). In people who have diabetes, glucose tends to build up in the bloodstream. This condition is called hyperglycemia. It may reach dangerously high levels if it is not treated properly. Insulin and other drugs are used to lower blood sugar levels.

Illness or stress can trigger hyperglycemia. That's because hormones your body makes to fight illness or stress can also cause blood sugar to rise. You may need to take extra diabetes medication to keep blood glucose in your target range during illness or stress.

Emergency complications
If blood sugar rises very high or if high blood sugar levels are not treated, it can lead to two serious conditions. Diabetic ketoacidosis. This condition develops when you don't have enough insulin in your body. When this happens, glucose can't enter your cells for energy. Your blood sugar level rises, and your body begins to break down fat for energy. When fat is broken down for energy in the body, it produces toxic acids called ketones. Ketones accumulate in the blood and eventually spill into the urine. If it isn't treated, diabetic ketoacidosis can lead to a diabetic coma that can be life-threatening.

Hypoglycemia-
Hypoglycemia is a condition in which your blood sugar (glucose) level is lower than the standard range. Glucose is your body's main energy source.
As hypoglycemia worsens, signs and symptoms can include:
Confusion, unusual behavior or both, such as the inability to complete routine tasks
Loss of coordination
Slurred speech
Blurry vision or tunnel vision
Nightmares, if asleep
Severe hypoglycemia may cause:
Unresponsiveness (loss of consciousness)
Seizures."

A review of the MAR revealed the nurse's documentation for blood sugar checks and results below.

07/24/2023 07/24/2023 12:17 PM -163
07/24/2023 05:36 PM- Refused/Unable-
The nurse failed to take the patient's blood sugars 4 x a day. There was no documentation that the provider was aware of the patient's refusal or if the nurse ever attempted to recheck the blood sugars.

07/25/2023 11:51 AM-Refused/Unable
07/25/2023 05:06 PM -Refused/Unable
The nurse failed to take the patient's blood sugars 4 x a day. There was no documentation that the provider was aware of the patient's refusal or if the nurse ever attempted to recheck the blood sugars.

07/26/2023 10:59 AM-225
07/26/2023 04:21 PM- Refused/Unable
The nurse failed to take the patient's blood sugars 4 x a day. There was no documentation that the provider was aware of the patient's refusal or if the nurse ever attempted to recheck the blood sugars.

07/27/2023 11:14 AM Refused/Unable Refused
07/27/2023 04:30 PM 168
The nurse failed to take the patient's blood sugars 4 x a day. There was no documentation that the provider was aware of the patient's refusal or if the nurse ever attempted to recheck the blood sugars.

07/28/2023 05:05 PM -Refused/Unable
07/28/2023 09:51 PM -Refused/Unable
The nurse failed to take the patient's blood sugars 4 x a day. There was no documentation that the provider was aware of the patient's refusal or if the nurse ever attempted to recheck the blood sugars.

07/29/2023 12:27 PM -Refused/Unable
07/29/2023 05:20 PM- Refused/Unable
The nurse failed to take the patient's blood sugars 4 x a day. There was no documentation that the provider was aware of the patient's refusal or if the nurse ever attempted to recheck the blood sugars.

07/30/2023 06:00 AM -122
07/30/2023 10:38 AM -134
07/30/2023 05:03 PM- 137
07/30/2023 08:10 PM -Refused/Unable
There was no documentation that the provider was aware of the patient's refusal or if the nurse ever attempted to recheck the blood sugars.

07/31/2023 06:16 AM -123
07/31/2023 10:23 AM -Refused/Unable
07/31/2023 04:03 PM -Refused/Unable
The nurse failed to take the patient's blood sugars 4 x a day. There was no documentation that the provider was aware of the patient's refusal or if the nurse ever attempted to recheck the blood sugars.

A review of patient #10's chart revealed he was transferred to the Emergency Department on 7/16/2023 at 11:09 PM. When the patient returned, he had a Foley catheter for urinary retention. There was no nursing documentation found when the patient returned, what time he returned, and by what means, if a full head-to-toe assessment was performed, if there were new orders, or if the physician was notified. There were no documented vital signs documented by the nurse and no documentation of a Foley catheter.

A review of the nurse notes dated 7/17/23 for the 7 AM-7 PM shift revealed there was no documentation of the patient's Foley catheter. The nurse checked "GU/Renal: Reports no problems or burning during urination. Reports clear yellow to amber urine." There was no documentation of catheter care, no vital signs, and there was no added problem of urinary issues, diagnosis, or foley catheter in the nursing care plan.

A review of the NP note dated 7/17/23 stated, "7/17....He was sent to BSA d/t failure to void and was sent back after being medically cleared and a foley placed. He was agitated today and was trying to pull his foley out. He was trying to hit staff when they attempted to redirect him. An IM injection was given by the staff after orders were obtained. He is baseline confused and was unable to appropriately answer any questions that were asked. His responses were all nonsensical. He is eating some and the staff reported that he slept 6 hours last night. He took his meds this morning." There was no documentation of the patient's diagnosis or any orders on how to care for the patient's Foley catheter.

A review of patient #10's chart revealed he was ordered "cefTRIAXone SODIUM (cefTRIAXone) 1 G, 1 gram vial(s)) intramuscularly Daily Indication: klebsiella 7/28/2023 11:43." cefTRIAXone (Rocephin) is an antibiotic for bacterial infections. The physician's order stated it was for Klebsiella which is bacteria. The bacteria live in your intestines and feces, but they can be dangerous when they enter other parts of your body. Klebsiella can cause severe infections in your lungs, bladder, brain, liver, eyes, blood, and wounds. Your symptoms depend on your type of infection.

A review of the progress notes revealed there was no mention of patient #10's infection, where it was located, or that the antibiotic was ordered. An interview was conducted with Staff #13 RN on 8/1/23. Staff # 13 stated that patient #10 was diagnosed with pneumonia.

The Rocephin was administered on 07/28/2023 at 01:38 PM, 07/29/2023 at 09:22 AM, and 07/30/2023 at 09:01 AM, but was not administered on 07/31/2023 at 09:45 AM. The MAR stated, "Patient refused." There was no nursing documentation that the patient refused the medication or why. There was no documentation that the physician was notified or that the nurse tried again at a later time. Staff #13 stated that the patient refused on 7/31/23 and that she was going to give him his injection today 8/1/23. Staff #13 stated she did not attempt to give him the injection at a later time on 7/31/23. Staff #13 stated that the NP was aware of the patient's behaviors.

A review of the treatment team nursing care plan revealed there was no documentation of the patient's infection, treatment, goals, or outcomes.

Based on interviews and observation, the facility failed to:

1.
make sure all staff involved in food service practiced proper hand hygiene between duties that were "clean" and "dirty" (such as delivering trays and emptying the garbage)

2.
make sure that the hand-washing sink in the dining area was operational

3.
make sure that food procured from a contract provider was served to inpatients and outpatients without first ensuring required food temperatures were maintained.

4.
make sure that all staff involved in food service were provided thermometers and that food temperatures were checked prior to meals served

Refer to Tag A0750

Based on review of facility policies, observations and interviews, the facility failed to provide and maintain a clean and sanitary environment to avoid sources and transmission of infections and communicable diseases, when: a) proper hand hygiene practices were not implemented to limit exposure to pathogens; and b) food procured from a contract provider was served to inpatients and outpatients without first ensuring required food temperatures were maintained.

Findings were:

Review of a facility policy, last revised 11/1/2022, and entitled: "Hand Hygiene in a Healthcare Setting" documented in part: " ... Procedure: Indications for Hand Washing and Hand Antisepsis: When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with soap and water. If hands are not visibly soiled, hand sanitizer may be used for routinely decontaminating hands. Wash hands or decontaminate hands as follows: ... After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. After removing gloves ... In addition, food service employees shall wash their hands and exposed portions of their arms with soap and water (hand sanitizer should not be used in place of hand washing in the kitchen): ... b. After touching bare human body parts other than clean hands or arms ... g. Following contact with any unsanitary surfaces (e.g., touching trash cans, hair, opening doors) ... j. Before putting on disposable gloves. k. Before distributing trays/meals to residents. l. Before serving food to patients. m. After collecting soiled plates and food waste ..."

Further review of the facility's "Hand Hygiene in a Healthcare Setting" documented: "Other Aspects of Hand Hygiene: ... Do not wear the same pair of gloves for the care of more than one patient ... Disposable gloves shall not be substituted for proper hand washing. Hand hygiene technique: When decontaminating hands with an antiseptic hand rub: Wet hands and thoroughly spread solution over both hands, particularly around nail beds, vigorously rub until dry. Allow hands to dry ... When washing hands with soap and water: Remove jewelry (rings, bracelets) and watches. Thoroughly wet hands with warm - never hot - running water. Apply soap and lather up. Vigorously rub lathered hands together for at least 20 seconds, including all parts of hands and wrists. Minimize splashes and do not touch the sink. Rinse thoroughly under a stream of running water to flush away dirt and debris. Point hands and fingers downward so dirty water runs into the sink. Pat hands completely dry with a clean, disposable towel. Use a clean dry towel to turn off the faucet to avoid hand contamination ..."

Observation of the lunch service on 8/1/2023 at 11:45 AM, in the facility dining area, revealed Staff #23 was observed to don gloves, without first washing or decontaminating hands, before removing Styrofoam containers of food from a rolling, metal cart. Staff #23 was then observed to touch patient arms and hands, to read patient name bands, before placing the containers of food on the table in front of the patients. Staff #23 carried a personal size bottle of hand sanitizer but was not observed to use it at any time during the lunch service.

Patients were observed to take empty containers and containers with uneaten food to a counter containing a sink, in the dining area; however, the sink was not observed to be used for handwashing during the lunch service.

Observation on 8/2/2023 at 9:50 AM, in the facility dining/training area, revealed Staff #32 carrying trash to a rolling garbage receptacle. After touching both the trash and the rolling trashcan, Staff #32 was not observed to wash or decontaminate hands. Staff #32 removed gloves from her pocket, put one glove on and walked to the soiled utility room. Staff #32 returned immediately from the utility room, donning a glove to her ungloved hand. Using the same gloved hands, Staff #32 walked to the enclosed nurse's station, opened the door, retrieved an oxygen concentrator, and immediately returned to the training area. Without first removing gloves, and washing or decontaminating hands, Staff #32 handed Patient #1 the tubing containing a nasal cannula for Patient #1 to place in her nose.

During interview in a facility meeting room on 8/1/2023 at 2:00 PM, Staff #29 was asked about hand sanitation and glove use. Staff #29 stated: "We have gloves in our pockets. We wear (personal-sized) hand sanitizers. There is a hand sanitizer in the nurse's station. I try to change gloves after passing food out."

During interview in a facility meeting room on 8/2/2023 at 1:45 PM, Staff #32 stated: "We wash our hands before putting gloves on. We use gloves for everything. After we take off gloves, we wash our hands. We wear hand sanitizer on our badge. The sink in the dining area does not work ..."

During interview in a facility meeting room on 8/1/2023 at 4:00 PM, Dietary Manager, Staff #25 was asked about facility policy regarding handwashing, hand sanitizer and glove use. Staff #25 stated: "Wash hands before donning gloves. Change gloves if soiled or ripped; wash hands between glove changes." At 4:07 PM, Staff #25 confirmed that the sink in the dining area was not operational. Staff #25 stated, "I will let (Staff #26) know."

b) Review of a facility policy, last revised 11/1/2022, and entitled: "Nutrition Services" documented in part: " ... 1. INPATIENT ... Test Trays - RD (Registered Dietician), dietary manager or designated staff will perform inpatient and outpatient (as appropriate) meal test tray audits at least once weekly. In order to ensure accuracy and temperature quality, the test tray will alternate between breakfast, lunch and dinner trays as well as trays with altered consistencies (e.g., chopped, pureed). Test tray will be ordered on day of the check. Thermometers are calibrated and sanitized according to manufacturer's instructions prior to utilization and each time it is dropped or mishandled. Guidelines for temperatures of all foods and liquids as follows: Hot foods leaving production kitchen or steam table are to be greater than or equal to 140 (degrees Fahrenheit) and cold items less than or equal to 41 (degrees Fahrenheit). Hot items should be greater than or equal to 120 (degrees Fahrenheit) when served. Cold items should be less than or equal to 50 (degrees Fahrenheit) when served. Milk should be less than or equal to 41(degrees Fahrenheit) when served ... 2. OUTPATIENT - A snack and a lunch meal may be served to patients participating in the intensive outpatient program (IOP). If a lunch meal is served, it will be provided through a contracted service or an in-house kitchen. Meals shall be transported to the IOP in a manner that protects it from contamination, while maintaining required temperatures."

Observation of the lunch service on 8/1/2023 at 11:45 AM, in the dining area, revealed Staff #23 opened the doors to the rolling, metal cart and removed Styrofoam containers, placing the containers on top of the cart. The Styrofoam containers removed from the cart held both cold and hot foods including, but not limited to, sandwiches, beans, corn, and hot dogs. Staff #23 was not observed to check food temperatures before placing the containers in front of the patients to eat.

During interview in a facility meeting room on 8/1/2023 at 1:45 PM, Staff #23 stated: "We have computerized training on infection control. We are trained on food temperatures ... (Food) is in a big cooler that is heat-controlled when it arrives from (the restaurant contractor). Once it gets here, we transfer it to a steel cart. (The restaurant contractor) does a temperature check when they leave (the restaurant contractor), and then I check it (the food temperature). Everyone has a food thermometer. They (the patients) can have up to an hour to eat the food ..."

During interview in a facility meeting room on 8/1/2023 at 2:00 PM, Staff #29 stated: "I take a metal cart downstairs to meet the driver from (the restaurant contractor). I transfer trays from (the restaurant contractor bags) into the food cart. The (restaurant contractor) checks temperatures at the restaurant. We don't have thermometers. We used to check (food temperatures). I don't know why they stopped. If group (held in the dining area) runs a little late, we heat up food in the microwave."

During interview in a facility meeting room on 8/2/2023 at 11:00 AM, Staff #32 stated: " ... We transfer food from (the restaurant contractor) coolers/bags to a rolling cart. We used to check temperatures. There used to be a log kept in the nurse's station. Food temperatures were checked downstairs. The (restaurant contractor) would log the time and food temperature, and we would log the time and food temperature. About a month ago, we were told that we no longer have to check temperatures."

During interview in the IOP building on 8/2/2023 at 10:20 AM, Staff #28 stated: "(The restaurant contractor) delivers the food to the IOP. Food temperatures are checked at the restaurant ... I don't have a food thermometer."

During interview in a facility meeting room on 8/1/2023 at 4:00 PM, Dietary Manager, Staff #25 stated: " ... (the restaurant contractor) marks food containers for special diets, allergies. Food temperatures are supposed to be 140 (degrees Fahrenheit) or higher. The food is placed in temperature-safe containers. Once the food arrives here, we are also 'temping' to make sure. The MHTs should be taking the temperatures. I do spot checks every week."

Based on review and interview the facility failed to ensure the psychiatrist was performing the initial psychiatric evaluation in 2 of 2 (#7 and #10) charts reviewed.

A review of patient #7's chart revealed the initial psychiatric exam was completed by the nurse practitioner. The nurse practitioner stated the eval was done and signed on 07/19/2023 at 11:40 however, the psychiatrist did not sign the evaluation until the next day on 07/20/2023 at 07:49 AM. Staff # 20 confirmed that the nurse practitioner performed the initial psychiatric evaluation.

The State of Texas requirements are as follows. "(f) Psychiatric evaluation. A physician shall conduct an initial psychiatric evaluation of a patient." Per RULE §568.62-Medical Services of the Texas Administrative Code. The rule does not allow the task to be delegated.

A review of patient #10's chart revealed the patient's had a medical history and physical done by a Physician Assistant (PA) on 07/15/2023 at 08:29 AM. There was no initial psychiatric evaluation found on the chart.

An interview was conducted with Staff #2 MD on 8/2/23 at 11:21 AM. Staff #2 stated that he was not aware that the psychiatrist was required to make the determination of legal status and not the nurse practitioner. Staff #2 stated that he was from Missouri and was not familiar with all the Texas regulations for involuntary patients. Staff #2 stated that the nurse practitioners were doing the initial psychiatric evaluations. Staff #2 stated he was not aware that the initial psychiatric evaluation was required to be performed by the psychiatrist.