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Based on record reviews and interviews, the Governing Body failed to ensure a pharmacist was in charge of all services provided by the pharmacy as evidenced by 2 different Pharmacy Contracts (A and B) without either contract clearly defining responsibilities of the pharmacist in charge of pharmacy services to make sure the hospital remained in compliance with all Pharmacy Services. Findings:

Review of Pharmacy Contract A and B revealed various pharmacy services, such as supplying medications/drugs, chart audits, checking for out of date medications, and so on; however, there failed to be documentation that indicated the responsibilities of the pharmacist in charge of pharmacy services.

Review of pharmacy policies/procedures and Pharmacy contracts (A and B) revealed there failed to be evidence a pharmacist was to perform a first dose evaluation prior to a patient taking a new medication/s. Continued review of the pharmacy policies/procedures revealed a statement to the effect that a pharmacist and/or registered nurse (RN), would make the decision if a medication could be changed from a pill form to liquid form.

Interviews, 04/30/14 at 9:30am, with S1 Administrator and S2 Director of Nurses (DON) confirmed that they did not know which Pharmacy Contract (A and B) supplied the pharmacist in charge of pharmacy services. S1 Administrator and S2 DON confirmed that a pharmacist and/or an RN could not make the decision to change a medication from a pill form to liquid form, only the physician could make such a change.

S1 Administrator confirmed a pharmacist must be in charge of pharmacy services in order for the hospital to remain in compliance with all Pharmacy Services. S1 Administrator agreed in order to ensure that pharmacy services were supplied in a safe and effective manner, a pharmacist must supervise, develop, and coordinate all aspects of pharmacy services.

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Based on record reviews and interview, the hospital failed to ensure: (1) that each patient or their representative was provided the address and telephone number for lodging a grievance with the State agency as evidenced by having the incorrect address and telephone number for the State agency listed on the form provided to patients or their representative and (2) that provisions for lodging a grievance after hours and on weekends were available to the patients or representative. Findings:

Review of the hospital's Grievance Policy revealed that S1Administrator serves as the patient advocate and was available from 8:00 a.m.- 4:30 p.m. Monday-Friday.

Review of the patients medical records revealed a form titled "Complaint/Grievance Process Patient Representative/Advocacy Program". Continued review of the form revealed an incorrect address and telephone number was listed for reporting grievances to the State agency.

An interview, on 04/30/14 at 11:00 a.m, with S1Administrator confirmed the number listed on the form (provided to patients and their representatives and located in the patients' medical records) did not have the correct address and telephone number for the State agency.

In a subsequent interview on 05/01/14 at 10:00 a.m., S1Administrator confirmed that the hospital had no provision for patients or their representative/s to contact another hospital member after hours or on weekends.

Based upon observations, policy review, and staff interview, the hospital failed to ensure patient's received care in a safe setting as evidenced by the hospital having 20 out of 20 beds with upper beds rails and hand cranks located at the end of each of the 20 beds. Review of hospital policies revealed the policy for monitoring the psychiatric patient was for suicidal patients only and did not identify the ligature hazards for the remainder of the patient population. Findings:

Observations made during the environmental tour on 4/28/14 at 8:40 a.m. revealed 20 of the 20 beds in the hospital had upper side rails. The beds also had hand cranks located at the end of each bed.

Interview with S1 Administrator and S2 RN/Director of Nursing on 4/29/14 at 1:30 p.m. revealed there was a patient safety policy related to the bed rails and hand cranks; however, review of policy, "TX-SPEC-05: Level of Observations", revealed it only identified the monitoring of suicidal patients. The policy failed to identify the ligature hazard to remaining patient population.

Based on review of 6 of 6 credentialing files (S#s 13-18) and interview, the Medical Staff and Governing Body failed to ensure physicians/psychologists/Allied Health Personnel (who made application/reapplication for appointment and were approved for privileges) supplied the references required by the Medical Staff Bylaws. Findings:

Reviews of S13, S14 Psychiatrists, S15, S16 Medical Physicians, S17 Physician Assistant, and S18 Contract Radiologist's credentialing files revealed a lack documented evidence of the required 3 references required for the initial appointment and the 1 reference required for subsequent reappointments.

Review of the Medical Staff Bylaws revealed the following: " ...SECTION 5: SUBMISSION OF APPLICATION...B. Specific Information Required ...11. Peer references: Recommendations three (3) from persons other than family or affiliated by marriage for initial appointment one (1) for re-appointment, (appropriate practitioner in the same professional discipline as the applicant who have personal knowledge of the applicant) reflects a basis for recommending the granting of privileges. Peer recommendations must include the following: Medical/Clinical knowledge, technical and clinical skills, clinical judgement interpersonal skills, communication skills and professionalism...SECTION 7: REVIEW AND RECOMMENDATION PROCEDURES A. Review and Recommendation by the Committee of the Whole ...The recommendation shall be based on the review of all available information and will include information provided by peer/peers of the applicant..."

Interview, 04/30/14 at 2:30pm, with S1 Administrator confirmed the medical staff members (S13-S18) failed to have the required references and should have had the references checked prior to appointment/reappointment.

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Based on record reviews and interviews, the hospital failed to ensure that the RN (registered nurse) supervised and evaluated the nursing care of each patient as evidenced by: 1) failure of the Mental Health Technicians (MHT) to observe/monitor 1 of 1 patients (#6) according to physician's order for line of sight (#6) and 1of 1 patients (#7) with physician's orders for suicidal precaution; 2) failure of the RN to ensure that the patient observation levels documented by the MHTs were accurate and indicated what activities the patient/s were actually doing (#s1, 2, 3, 8) and to assess patients for bowel movements (#2, 3) . Findings:

Patient # 6
Review of Patient #6's medical record revealed: a 70 year old male admitted on 01/29/14, under a PEC (physician emergency certificate) for Suicidal Ideation.

Review of Physician's orders, dated 01/30/14 at 11:45am, revealed S13 Psychiatrist documented an order for "Line of sight for 48 hrs.(hours) from admission."

Review of Daily Nurse Notes and Close Observation Check Sheets, both dated 01/30/14 through 02/02/14, failed to indicate that patient #6 was observed, Line of Sight, per physician's order. The RN failed to ensure patient #6's safety by ensuring Line of Sight was carried out for the 48 hours following the admission.

In an interview on 04/30/14 at 3:20 p.m., S2DON indicated that the observation level ordered by the physician was not followed and should have been.

Patient #7
Review of the closed medical record for Patient #7 revealed he was a 96 year old male admitted to the hospital (under a PEC) on 01/14/14 with diagnosis of Suicidal Ideation.

Review of the physician admitting orders, dated 01/14/14, revealed an order for suicidal precaution and close observation Q 15. Review of Close Observation Check Sheets revealed a lack of documented evidence patient #7 was actually placed on suicidal precautions per physician's orders. There failed to be documentation that indicated hospital staff monitored/observed patient #7 per policy.

In an interview on 04/30/14 at 3:20 p.m., S2DON indicated that Patient #7 was ordered suicidal precaution and his level of observation was no different than every 15 minutes as for all patients admitted to the hospital. S2 DON stated staff did not follow physician's orders and keep patient on suicidal precautions, which meant patient #7 would have been 1:1 observation.

Patient #8

Review of the closed medical record for Patient #8 revealed he was an 83 year old male admitted to the hospital (under a PEC) on 01/13/14 with the diagnosis of Suicidal Ideation and Recurrent Depression with Psychosis.

Review of the physician admitting orders, dated 01/13/14, revealed an order for close observation Q 15 and fall precaution.
Review of Nurses notes, dated 01/18/14 at 2330 (11:30 p.m.), indicated patient informed nurse that he fell out of bed.

Review of the Close Observation Check Sheet, dated 01/18/14 at 8:00pm, revealed the MHT documented, Patient #8 was observed to be in his room; and at 11:30pm patient #8 was observed in his room (no indication of a fall) and on 01/21/14 at 6:45 p.m. patient was with visitor. Continued review of Patient #8's observation level revealed a lack of documented evidence that patient #8 was monitored/observed for fall precautions.

Patient #1
Review of a Daily Nurse Note, dated 04/27/14 for 7P-7A shift, revealed S22 RN documented, "Irritable, intrusive, restless, at nurses' station several times-needy, demanding, difficult to redirect at times." Review of "Close Observation Check Sheet, dated 04/27/14, revealed the MHT documented the patient was in his room from 8:30pm until the morning at 6:15am. There failed to be documentation by MHTs that patient #1 had been at the nurses' station.

Patient #2
Review of a Daily Nurse Note, dated 04/22/14 at 0015 hrs, revealed S23 RN documented, "Called to pt's (patient's) room by tech (MHT) Pt in bed and stated 'I wanted to go outside'. Swelling noted above Rt. (right) eye and abrasion noted to Rt. cheek. Tech stated 'she fell'. Abrasions cleaned. Ice pack applied to Rt eye...closely monitoring..." Review of the Close Observation Check Sheet, dated 04/22/14, revealed the MHTs documented, from 10pm until midnight patient #2 was in the hallway; then from 12:15am until 6:30am in her room. There failed to be documentation by the MHTs as to what patient #2 was doing or what had happened in relation to the fall documented by S23 RN.

Review of physician's orders revealed an order, dated 04/17/14, documented by S13 Psychiatrist for the patient to be on "Fall Precautions". There failed to be documented evidence the RN had instructed the MHTs that patient #2 was on Fall Precautions.

Review of Incident/Accidents reports, dated 04/30/14, revealed Patient #2 had fallen again on the night of 04/29/14 with a resultant bruise to her left hip. S13 Psychiatrist ordered, on 04/30/14, "X-Ray hip today". Interview, 05/01/14 at 9:45am, with S2 Director of Nursing revealed patient #2 did not receive her hip x-ray per physician's order until the morning of 05/01/14. No reason was documented by RNs.

Continued review of Patient #2's medical record revealed a form titled "Vital Signs and I&O" revealed sections labeled "BM" (bowel movement) and "Bathing". There failed to be documentation in these areas on 04/18/14 for the evening shift. Continued review of the form revealed: 04/22/14, 04/26/14 and 04/27/14 no documentation of BM or Bathing for any shift; and on 04/28/14 no documentation for day and evening shifts.

Patient #3
Review of Patient #3's Vital Signs and I&O forms revealed: on 04/12/14 and 04/13/14 no documentation relative to Bathing; on 04/11/14, 04/12/14 and 04/13/14 no documentation relative to a BM. Review of Close Observation Check Sheets for the same dates revealed the MHTs failed to document on the form if patient #3 had a shower or was toileted. Continued review of the Vital Signs and I&O form revealed a lack of documentation relative to patient #3 having a BM on 04/21/14, 04/22/14, 04/24/14 through 04/30/14. There failed to documentation by an RN that patient #3 had been assessed for a BM for 7 days consecutively (04/24/14 through 04/30/14).

In an interview on 04/30/14 at 3:00 p.m., S1Administrator indicated that the hospital had two level of observation: Close observation every 15 minutes and and 1:1 observation. According to S1Administrator the Hosptial did not have a policy for line of sight observation or suicidal precaution; however, if the patient was suicidal they would be on 1:1 observation.

In an interview on 04/30/14 at 3:20 p.m,. S2DON indicated that the RN is responsible for the supervision, monitoring and documenting performed by the MHTs. According to S2DON the documented observation of the patient should be reflected and mirrored in the nurses notes.

S2 DON agreed the RNs did not document reassessments that may have been performed on patients; and this made it difficult to have knowledge if patients were being monitored for bowel movements.

Based on review of the pharmacy contracts and interview, the hospital failed to ensure the contract defined the responsibilities of the contracted pharmacist to include the development, supervision and coordination of all activities of pharmacy services. Findings:

Review of Pharmacy Contract A and Pharmacy Contract B revealed there failed to be documentation relative to the pharmacist's responsibilities that included the development, supervision and coordination of all the activities of pharmacy services.

Interview, 04/30/14 at 3:40pm, with S1 Administrator confirmed the pharmacy contracts failed to define the pharmacist's responsibilities which included the supervision, development, and coordination of all activities of the pharmacy service.

Based on record review and interview, the hospital failed to ensure the Medical Staff determined the specific qualifications for respiratory therapy technicians and other personnel performing respiratory therapy treatments and that the Governing Body had approved the qualifications. Findings:

Review of the Medical Staff Bylaws revealed there failed to be specified qualifications for respiratory technicians and other personnel performing respiratory therapy treatments. Continued review of the Medical Staff Bylaws revealed there failed to be documentation relative to any respiratory therapy service/s.

Interviews, 04/30/14 at 10:45am, with S1 Administrator and S2 Director of Nursing confirmed the respiratory therapist was a hospital employee. Further interview confirmed the Medical Staff Bylaws did not have the qualifications specified relative to respiratory technicians and other personnel who performed respiratory therapy treatments.

Based on record reviews and interview, the hospital failed to ensure the psychiatrist documented a psychiatric evaluation that included description/s of the patients' insight and judgement for 8 of 8 patients (#s 1-3, 5-8, 10) reviewed out of a sample of 11. Findings:

Review of Patient #1's medical record revealed a Psychiatric Evaluation, dated 04/19/2014, which S13 Psychiatrist documented. Under a section, titled "MENTAL STATUS EXAM" on the Psychiatric Evaluation, was "INSIGHT" and "JUDGEMENT", both areas were left blank, no information documented.

Review of Patient #s 3, 2, and 5's Psychiatric Evaluation, dated 04/11/14, 04/18/14, and 03/21/14 respectively, revealed S13 Psychiatrist documented for "Insight:" a check mark was placed next to "gravely impaired"; under "Judgement" a check mark was placed next to "gravely impaired".

Review of Patient #6's Psychiatric Evaluation, dated 01/30/14, revealed S13 Psychiatrist documented "Insight and judgement are currently impaired."

Review of Patient #7's Psychiatric Evaluation, dated 01/15/14, revealed S13 Psychiatrist documented "Insight: limited" and "Judgement: fair".

Review of Patient #8's Psychiatric Evaluation, dated 01/14/14, revealed S13 Psychiatrist documented "Insight: poor" and "Judgement: gravely impaired".

Review of Patient #10's Psychiatric Evaluation, dated 04/19/14, revealed S13 Psychiatrist documented "Insight: poor" and "Judgement: poor".

Interview, 05/01/14 at 12:15pm, with S13 Psychiatrist agreed the documentation needed to be more specific and that the description was appropriate to the patients' condition .

Based upon review of 11 of 11 medical records (patients 1-11) for Treatment Plans, and staff interview, the hospital failed to ensure the Multidisciplinary Integrated Treatment Plan identified specific treatment modalities related to active treatment approaches. This was evidenced by: 1) failure to identify clinical interventions for patients #9 and #6 related to alteration in Health Maintenance; and 2) failure to identify clinical interventions for patient #s 1-5, 7, 8, 10 and 11 related to alterations in perception. Findings:

1) Review of patient #9's Multidisciplinary Integrated Treatment Plan revealed Problem #2 was identified as "Alteration in Health Maintenance" related to the patient's fluid intake. The long term and short term goals identified the patient was to "have a p.o. (by mouth) fluid intake of greater than or equal to one liter per day". Review of the clinical interventions revealed no interventions were listed. For problem #3, it was identified the patient was at an increase risk for falls. Review of the clinical interventions revealed no interventions were identified.


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Review of patient #6's Multidisciplinary Integrated Treatment Plan revealed Problem #2 was identified as "Alteration in Health Maintenance" related to recent foot surgery. The long and short term goals identified the patient was to "have pain < (less than) 5/10 scale for 5 consecutive days within 14 days". Review of the clinical interventions revealed, "Monitor disease process parameters daily and implement interventions as indicated." There failed to be interventions indicated.

2) Review of patient #1's Multidisciplinary Integrated Treatment Plan (MITP) revealed Problem # 1 was identified as "Alteration in Perception" related to "Disease process" as evidenced by grandiose delusions.

Review of patient #2's MITP revealed Problem #1 was identified as "Alteration in Perception" related to confusion, restlessness and wandering. The long and short term goals identified the patient was to "sleep at least 6 hours nightly for 3 consecutive nights within 10 days; respond to verbal cues spontaneously within 7 days... Upon review of the clinical interventions there failed to be interventions indicated.

Review of patient #3's MITP revealed Problem #1 was identified as "Alterations in Perception" related to disease process as evidenced by paranoia, aggressive behaviors, confusion. The long and short term goals identified the patient would "verbalize why driving is an unsafe behavior for him within 7 days...sleep at least 8 hours nightly for 5 consecutive nights within 14 days. Review of the clinical interventions failed to have interventions indicated for these behaviors.

Review of patient #4's MITP revealed the same as above for Problem #1. The long and short term goals were identified as "sleep at least 6 hours nightly for 3 consecutive nights...". There failed to be interventions listed.

Review of patient #5's MITP revealed basically the same as for patient #s 2, 3, and 4 with the exception of the sleeping hours and consecutive nights. There failed to be interventions indicated.

Review of patient #7's MITP revealed Problem #1 was identified as "Potential for Self Harm" related to "Pain and numbness in legs" as evidenced by "Suicidal ideation and/or behavior, 'I am suicidal' ". Goals were for patient #7 to "deny suicidal thoughts daily for at least 3 consecutive days within 5 days"; "openly express feelings of self-harm within 7 days"; and "Openly discuss positive aspects of his/her life within 7 days"... There failed to be interventions documented.

Review of patient #8's MITP revealed Problem #3 was identified as "Alteration in Perception" related to dementia. There failed to be interventions indicated.

Review of patient #10's MITP revealed Problem #1 was identified as "Alteration in Perception" related to Disease process as evidenced by threatening and aggressive behaviors. Goals were listed as "sleep at least 8 hours nightly for 5 consecutive nights within 14 days..." There failed to be interventions indicated directed toward the threatening and aggressive behaviors.

Review of patient #11's MITP revealed Problem #1 was identified as "Alterations in Perception" related to disease process as evidenced by paranoia, threatening and aggressive behaviors. Goals identified were the same as Patient #10's goals. There failed to be documented interventions.

Interview, 04/30/14 at 1:40pm, with S2 Director of Nursing confirmed the interventions were non-existent for the identified problems for patient #s 1-11.