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Based on review of facility policies, random review of patient charts from 2023 and confirmed in interview, the facility failed to protect and promote each patient's rights.

A. The facility failed to ensure a properly executed informed consent per TAC 133.41(I)(3)(D) were completed before psychoactive medication were administered for two of four (Patient #A, #I) patient charts reviewed. Refer to A0131

B. The hospital failed to ensure an order of protective custody (OPC) per TAC 131.41(I)(3)(B) were updated in a timely manner for one of ten patient records (Patient #A) reviewed. Refer to A0131

C. The facility failed to ensure staff identified the use of a emergency behavioral medication as a restraint for two of four charts (Patient #I, and A) reviewed. Refer to A0160

D. The facility failed to ensure a face-to-face evaluation to include the physical and behavioral assessment were conducted in person by a physician, licensed practitioner (LP), or trained RN after the administration of an emergency behavioral medication used as a chemical restraint in two of four charts reviewed (Patient #I, and A). Refer to A0179

I. Based on review of facility policy, a random review of the medical records from 2023 and confirmed in interview, the facility failed to ensure a properly executed informed consent per TAC 133.41(I)(3)(D) were completed before psychoactive medication were administered for two of four (Patient #A, #I) patient charts reviewed.

Findings included:

In review of the facility policy Administration of Psychoactive Medication (Policy No. 7.26, effective 03/01/2011), it stated "Psychoactive Medication that is ordered as a maintenance medication, to a patient to treat symptoms of psychosis or another mental or emotional disorder if Harris Health obtains the patient's or the patient's LARs [legal authorized representative] Informed Consent for the administration prior to the administration of the Psychoactive Medication. Informed Consent must be obtained using [facility] form No. 281464, Consent for Treatment with Psychoactive Medication."

Patient #A
Review of Patient #A's MAR (Medication Administration Record) revealed she was provided Depakote tablet 500/500/1000 mg daily [500mg by mouth every morning, 500mg by mouth 1:00 PM daily, and 1000mg by mouth daily at bedtime starting on 08/05/2023 until day of discharge on 08/15/2023.

Review of physician notes from 08/05/2023 (staff #1) "As previously discussed (and given severity of outbursts yesterday): 1) Added Depakote DR 500mg PO QAM [by mouth every morning], 500mg PO Q1300 [by mouth 1:00 PM daily], and 1000mg PO QHS [daily at bedtime]"

Review of physician notes (staff #8) it stated "Over the weekend Depakote was added to regimen due to behavioral outbursts and destroying property. Today pt [patient] calm and resting in bed, staff denied any behavioral problems recently. Staff continue to provide structure, activities, and consistent schedule to minimize behavioral outbursts."

Review of physician notes (staff #8) from 08/11/2023, it stated "Depakote was added for mood stabilization. Since then has had minimal outbursts. Would recommend she remain on this medication for mood stabilization, irritability associated with autism, behavioral dysregulation. She does not meet criteria for inpatient psychiatric hospitalization currently. Her diagnoses are chronic and pt will require more wrap around support after discharge. She can follow up with her outpatient psychiatrist after discharge."

Patient #I
A review of Patient #I's chart revealed he came into the ER on 03/18/2023 at 3:43 PM via a police EDO with chief complaints of behavioral problem (singing songs, spitting out on people/ambulatory) and homeless. A review of the physician notes (Staff #4) under psychiatric stated " ...Delusions stating "I am secret agent Elvis. I'm here to protect others, kanye and kanye's daughter." Denies SI, HI, auditory or visual hallucinations."
Review of the nurse's note (Staff #10), it stated "Awake, up, sing and talking loud, and try to use urinal not able to urinate, bed low and lock, officer at bedside, ask to be calm, he talking to officer then laying back, consulting with attending will order medication"

Review of Patient #I's MAR revealed he was given Risperdal on 03/20/2023.

Further documentation of the nurse's notes (staff #10) it stated, "Wake up med given take med well, drink ginger ale smile, cooperative now."

Review of the above medical charts revealed no informed consent for Depakote or Risperdal for the above two patients prior to administration of the psychoactive medication.

An interview with staff #2 on 10/13/2023 at 2:05 PM in the conference room confirmed the above findings.


II. Based on review of the facility policy, record review, and confirmed in interview the hospital failed to inform patients their rights, court hearing dates, and awareness of their legal status. The hospital failed to ensure an order of protective custody (OPC) per TAC 131.41(I)(3)(B) were updated in a timely manner for one of ten patient records (Patient #A) reviewed.


Findings included:

In review of the facility policy Emergency Detention and Orders for Protective Custody (Policy No 3.68, effective 09/08/2020) under Protective Custody, it stated "A judge will order the release of a patient under a Protective Custody Order if the judge determines after the probable-cause hearing that probable cause does not exist to believe that the patient presents a substantial risk of harm to himself or herself or others.

Harris Health must release a person under a Protective Custody Order if:
Harris Health does not receive notice that the patient's continued detention under the Protective Custody Order was authorized after a probable cause hearing, or a final order for court-ordered mental health services is not entered within 14 days (or 30 days if a continuance is granted); or Harris Health determines that the patient no longer meets the criteria for Protective Custody.

Initiation of Applications for Protective Custody: All Applications for Protective custody are initiated by Clinical Case Management or by a Nurse Case Manager. le documents to be submitted to the court are the following:

1. Application for Temporary Mental Health Services (B29);

2. Affidavit of Applicant (B31);

3. Patient Information Sheet;

4. Informant Information Sheet;

5. Civil Case Information Sheet;

6. A Certificate of Medical Examination (F25), which is attached as Appendix C.

Clinical Case Management or a Nurse Case Manager is responsible for faxing the forms to the court, completing the patient/informant information sheets, civil case information sheet, contacting the court to advise it of the transmission, and notifying staff of the Court's return of signed documents.

Submission of Certificate of Medical Examination: After a patient is subject to Protective Custody, Clinical Case Management or a Nurse Case Manager must submit a second Certificate of Medical Examination (F25) and a signed pychosocial assessment completed by a psychiatrist to the Court."

A review of patient #A's chart revealed she came into the ER on 06/19/2023 at 12:38 AM via a police EDO (Emergency Detention order) with chief complaints of aggressive behavior and psychiatric problem. The facility applied for an Order of Protective Custody (OPC) on 06/20/2023. The county judged granted the OPC on 06/20/2023.

An OPC is an order issued by a Texas county judge that allows the facility to hold the patient and provide treatment. The judge had determined that the proposed patient presents a substantial risk of serious harm may be demonstrated by the proposed patient's behavior or by evidence that the proposed patient cannot remain at liberty.

A review of patient #A's chart revealed she had a probable cause hearing on 06/30/2023. The facility failed to submit another certificate of examination and signed pychosocial assessment to extend the OPC on 06/30/2023 per requirements of TAC 133.41(I)(3)(B); thus, the OPC expired on 06/30/2023.

No documentation was available of the facility providing information about her probable cause hearing or her legal status.

Further review of Patient #A's chart revealed another EDO was filed on 08/15/2023. No OPC was in place from 06/30/2023 to 08/15/2023.

An interview with the Staff #2 on 10/13/2023 at 1020 AM in the conference room confirmed the above findings. She acknowledged that the facility failed to update her OPC while she remained an inpatient for the above time period.

Based on review of facility policies, record review from 2023, and confirmed in interview, the facility failed to ensure emergency behavioral medication that were administered IM or IV for behavioral emergencies were identified and monitored as chemical restraints in two of four (Patient #I, A) patient charts reviewed.

Findings included:

In review of the facility policy Restraint and Seclusion (Policy No 7.02, effective 09/28/2007), it stated "BEHAVIORAL EMERGENCY: 1 A situation involving an individual who is behaving in a violent (e.g., using or involving physical force that is intended to hurt, damage, or cause probable death or substantial bodily harm to self, someone else, or something) or self-destructive manner and in which preventive, de-escalate, or verbal techniques have been determined to be ineffective and it is immediately necessary to restrain or seclude the individual to prevent:
1. Probable death or substantial bodily harm to the individual because the individual is attempting to commit suicide or inflict serious bodily harm that is imminent (about to happen at any moment);
2. Physical harm to others because of acts the individual commits that is imminent (about to happen at any moment).
3. Note: Both psychiatric (e.g., schizophrenia) and medical (e.g., delirium) conditions can cause a behavioral emergency necessitating the use of either mechanical or personal restraints and/or seclusion

CHEMICAL RESTRAINT: The use of any Psychoactive Medication or other chemical-through topical application, oral administration, injection, or other means-for purposes of restraining an individual and which is not standard treatment for the individual's medical or psychiatric condition. The use of Chemical Restraints is strictly prohibited at [facility]."

Random review of patient charts revealed two of four patients (Patient #I and A) who had behavioral emergencies that required drugs given IM (intramuscular) and/or IV (intravenous) used as restraints to control extreme behaviors during an emergency. Drugs provided were not a standard of treatment for the patient's medical or psychiatric condition.

Patient #I
A review of Patient #I's chart revealed he came into the EC (emergency center) on 03/18/2023 at 3:43 PM via a police EDO (Emergency Detention order) with chief complaints of behavioral problem (singing songs, spitting out on people/ambulatory) and homeless.

3/18/2023
In review of the physician notes (Staff #4) under psychiatric, it stated " ...Delusions stating "I am secret agent Elvis. I'm here to protect others, kanye and kanye's daughter." Denies SI, HI, auditory or visual hallucinations."

In review of the EC nursing notes (Staff #5) it stated "Pt [patient] very aggressive grabbing hand of RN trying to inflict pain by squeezing and gouging his thumb into RN's hand. Pt to remove spit mask and start spitting at security in room. Spit mask replaced. MD notified of need for more medications. [Staff #26] states to give 2 of Ativan."

Review of the MAR on 03/18/2023 at 4:53 PM, Patient #I was given Haldol IV. On 03/18/2023 at 5:15 PM, Ativan and Benadryl IV were given.

The physician (Staff #4) who ordered the above emergency medication did not document that he was treating a psychiatric disease process nor assisting the patient to a therapeutic level. Instead, the physician documented it was for "paranoia/delusion; harm to others (verbal/physical acts of threatening, attempting, or committing acts that will cause physical or emotional harm); agitation, shouting at staff."

3/19/2023
In review of the pysch consult (Staff # 7) on 3/19/2023, it stated "hx [history] of poor adherence to treatment, hx of Bipolar Disorder with reported hx of bouts of psychosis, aggressive and belligerent behaviors with multiple psych hospitalizations presenting to the LBJ ED with symptoms of mood instability and psychosis. In the ED the pt has required two emergency medications for aggressive behaviors in the context of mood elevation symptoms. The pt has been loud, euphoric, has been singing, but also acting offensive and aggressive. The pt has been confrontational leading up to his emergency medications hx of poor adherence to treatment, hx of bipolar disorder with reported hx of bouts of psychosis, aggressive and belligerent behaviors with multiple psych hospitalizations presenting to the [EC] with symptoms of mood instability and psychosis. The pt features symptoms of acute psychosis with aggressive behaviors tied to his mood elevation symptoms."

In review of the EC nursing notes (staff #6) at 3:00 PM, it stated "[staff #24] notified of patient's maniac behavior, pt making loud outburst, attempting to leave room, pt having flights of thoughts and making inappropriate remarks towards staff. Provider came to assess pt, pt became belligerent, aggressive towards provider and was making threats; pt stated "I will beat you ass!" To provider. Security called to patient's bedside, medications ordered, security assisted this RN in holding patient to prevent any harm to staff or patient. Pt given IM injection and is currently lying in bed, continues to make rude statements to staff."

In review of nursing (staff #10) notes on 03/19/2023 at 7:26 PM, it stated "More aggressive toward staff and security crisis intervention call, security, house supervisor, and care provider arrive, verbal order haldol5mg, versed 5mg, benadryl 50, also psychiatrist also present ,witness by [staff #23], read order back to attending, agree, verify PT VERY AGITATE,AGGRESSIVE SEVERE,TRY TO HIT SECURITY AND STAFF,CRISIS INTERVENTION PAGE OVER HEAD BY OPERATOR, CARE PROVIDER,SECURITY OFFICERS,HOUSE SUPERVISOR CHARGE NURSE ARRIVE AT BEDSIDE, MED PLAN TO ORDER BY PROVIDER."

In review of the EC provider's notes (staff #33) on 03/19/2023 at 10:11 PM, it stated "Chemical sedation given for agitation
Per Psych, consider thorazine if additional meds needs."

Review of the MAR patient #I was given Haldol, Versed, and Benadryl IV at 3:03 PM and again at 7:35 PM

The physician (Staff #24) who ordered the above emergency medication did not document that he was treating a psychiatric disease process nor assisting the patient to a therapeutic level. Instead, the physician documented it was for "agitation."

Patient #A
A review of patient #A's chart revealed she came into the EC on 06/19/2023 at 12:38 AM via a police EDO with chief complaints of aggressive behavior and psychiatric problem. A review of the physician notes (Staff #3) dated 06/19/2023 under psychiatric stated " ...cooperative, nonverbal"

07/18/2023
In review of the physician (staff #27) notes, it stated "Crisis intervention called at approximately 1200 today for agitation, sitting in nursing station and refusing to return to her room, yelling/crying/throwing objects. On psychiatry team arrival, patient not receptive to verbal de-escalation and was given ativan 4mg emergency medications for agitation given. Psychiatry team will continue to follow ...Crisis intervention called at approximately 13:00 today for agitation. Pt had finished lunch and walked out of her room back to the nursing station, refusing to return to her room. On psychiatry team arrival, patient not receptive to verbal de-escalation and began to damage the computer. Police Officers had to transition pt back to her room. Emergency medication of haldol 10mg and benadryl 25mg was given to patient. Psychiatry team will continue to follow."

In review of the physician (Staff #28) notes, it stated "Hospital stay has been complicated by multiple aggressive outbursts that have put the patient and staff at risk for harm..Has required intermittant PRN meds due to agitation, banging on windows, damaging property. Can be difficult to redirect, multiple crisis interventions have been called ... Agitated and difficult to redirect overnight requiring Ativan 4mg x 1. Had multiple crisis interventions called throughout the day today due to patient refusing to go back into her room, thrashing around, destroying property, and being aggressive towards staff who are trying to redirect her. Required Haldol 10mg IM x 1, Thorazine 50mg IM x 1, Benadryl 25mg IM x 2, and Ativan 4mg IM x 1. Also additionally required violent physical restraints for a short period of time."

Review of the MAR, Patient #A received Benadryl, Haldol, and Ativan IM on 07/18/2023 at 1:13 PM 12:48 PM and 5:00 PM.

The physician (Staff #28) who ordered the above emergency medication did not document that she was treating a psychiatric disease process nor assisting the patient to a therapeutic level. Instead, the physician documented it was for emotional lability; threat to hurt self or others; throwing things, hurting self/others.

08/04/2023
In review of physician (staff #1) notes, it stated "present for crisis intervention at 1530 - pt yelling, and moaning. Assaulted staff few hours ago. (s/p huddle with team members, admin this afternoon). -Ordered Haldol 10mg IM and Benadryl 25mg IM x 1."
Pt s/p several rounds of emergency medication. Received Haldol 10mg and Benadryl 25mg IM recently during a crisis intervention. Pt subsequently tore superficial coating off of wall... seen wailing, yelling, and banging."

Review of the MAR, Patient #A received Haldol, Benadryl IM on 08/04/2023 at 3:42 PM.

The physician (Staff #1) who ordered the above emergency medication did not document that he was treating a psychiatric disease process nor assisting the patient to a therapeutic level. Instead, the physician documented it was for emotional lability; threat to hurt self or others.

8/14/2023
In review of the physician (staff #30) notes, it stated "crisis intervention called around 1:45 pm, she became frustrated at nursing station and knocked over items that were on the nursing station, no one was injured, she was redirected to her room, still agitated in room, thorazine 50 mg was given, then haldol 5 mg was given, slowly became calmer. Psychiatry has been on board.

Review of the MAR, Patient #A received Haldol IM on 08/14/2023 at 1:51 PM.

The physician (Staff #29) who ordered the above emergency medication did not document that he was treating a psychiatric disease process nor assisting the patient to a therapeutic level. Instead, the physician documented it was for "agitation."

An interview with Staff #31 on 10/13/2023 at 2:35 PM in the conference confirmed the above findings. She was unaware that emergency behavioral medication could be considered as restraints but acknowledged that it should be safely monitored once given.

Based on record review and interview, the facility failed to ensure a face-to-face evaluation that included the physical and behavioral assessment were conducted in person by a physician, licensed practitioner (LP), or trained RN after the administration of an emergency behavioral medication used as a chemical restraint in two of four charts reviewed (Patient #I,and A).

Findings included:

In review of the facility policy Restraint and Seclusion (Policy No 7.02, effective 09/28/2007), it stated "Monitoring and Documentation Requirements:

a. Patients in Restraint or Seclusion will have the following statuses monitored in accordance with the duration and documentation requirements set forth in the Texas Administrative Code:
i. Respiratory status; ii. Circulation iii. Skin integrity iv. Change in condition v. Continued need/justification for use; vi. Mental status vii. Range of motion/position; and viii. Other vital signs.
b. Respiratory status, circulation, and skin integrity must be continuously monitored and documented every fifteen (15) minutes."

Random review of patient charts (Patient #I, A) revealed two of four patients who had behavioral emergencies that required drugs given IM (intramuscular) and/or IV (intravenous) used as restraints to control extreme behaviors during an emergency. Drugs provided were not a standard of treatment for the patient's medical or psychiatric condition. Cross refer to A0160

Patient #I
Review of the MAR on 03/19/2023 at 08:06AM, Patient #I were given the following emergency behavioral medication: Haldol IM, Versed IM.

Patient #A

Review of the MAR, Patient #A received Benadryl, Haldol, and Ativan IM on 07/18/2023 at 1:13 PM 12:48 PM and 5:00 PM in response to an emergency behavioral incident.

Review of the MAR, Patient #A received Haldol, Benadryl IM on 08/04/2023 at 3:42 PM in response to an emergency behavioral incident.

Review of the MAR, Patient #A received Haldol IM on 08/14/2023 at 1:51 PM in response to an emergency behavioral incident.

Review of records revealed no face to face by a physician, LP, or RN within an hour after administration of the above emergency behavioral medication/chemical restraint. No documentation of the Respiratory status, circulation, and skin integrity every fifteen (15) minutes per the facility policy.

An interview with Staff #31 on 10/13/2023 at 2:35 PM in the conference confirmed the above findings. She was unaware that emergency behavioral medication could be considered as restraints but acknowledged that it should be safely monitored once given.