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Based on reviews and interviews the facility failed to:

A. Discharge the patient or initiate a commitment warrant after a discharge request was initiated.
B. Properly fill out the four hour discharge notice, notify the physician within four hours of signing the four hour discharge notice, have a plan in place to file for court ordered care, and a physician order to hold the patient to complete the court ordered paperwork in 2 (#1 and 9) of 2 charts reviewed.

Refer to Tag A0131


B. provide safety grab bars in the shower area in 17 (room #109, 110, 111, 112, 113, 114, 115, 117, 118, 119, 120, 121, 122, 123, 124, 126 and 127) out of 19 adult patient rooms to protect patients from falling who were identified as being at risk for fall.

Refer to Tag A0144


C. Based on the Quality Assessment Performance Improvement (QAPI) data the facility failed to follow the written plan. The facility failed to develop a performance improvement team and re-train employees on fall risk identifiers.

Refer to Tag A0286

Based on chart reviews the facility failed to{
A. Discharge the patient or initiate a commitment warrant after a discharge request was initiated.
B. Properly fill out the four hour discharge notice, notify the physician within four hours of signing the four hour discharge notice, have a plan in place to file for court ordered care, and a physician order to hold the patient to complete the court ordered paperwork in 2 (#1 and 9) of 2 charts reviewed.
Review of patient #1's physician order reveals the patient was admitted on 9/26/16 at 1645. There was no physician order to state if the patient was voluntary or involuntary. Review of the patient consents revealed the patient came into the facility voluntarily.
Review of patient #1's physician progress notes revealed the psychiatrist had seen the patient on 9/29/16 at 13:11 (1:11PM). The psychiatrist describes the patient as "angry" and "endorsing suicidal ruminations." Patient #1 had "stormed out" of the psychiatrist office after demanding to be discharged. The psychiatrist felt the patient was not ready for discharge and advised the patient that he was "very clear cut risk for suicide and will hold off on discharge and file for court order and then try to establish a more firmer therapeutic alliance." (SIC)
Review of patient #1's chart revealed a four hour discharge notice was filled out on 9/29/16 at 1358 (1:58). It was filled out after the patient had seen the psychiatrist. The patient had requested to leave to be with his father during surgery. In the section for the nurses signature (staff nurse accepting request), it was signed by staff #39 a Mental Health Technician (MHT). There was a signature line under the MHT's signature that stated, "Notification made to: ___, at (Time) ___, on: (Date) ____by (Name & Title) ___. " The information was left blank. There was no notification documented on the form that a nurse or physician was notified. On the bottom of the form was a place where the patient can cancel their request for immediate discharge. The patient wrote, "My father having surgery 9/30/16 need to be there." Then above that in different ink it said "continue treatment" The patient signed it on 9/29/16 at 2:15PM. The staff signature, date and time were blank.
Review of the psychiatrist progress note on 9/30/16 at 11:12AM stated, "Patient is irritable and angry. Refused medication last night, very focused on discharge and put in a request for discharge yesterday. Advised him given his recent overdose and short stay is obvious significant risk factors with no stable home environment, substance abuse. I did not feel comfortable with his discharge without a better treatment plan. Discharge plan in place and for now we will file for court ordered care." There was no found evidence that court ordered care was ever started.
Review of patient #1's chart revealed there was no documentation of a court order in process or that the physician or RN was aware he signed the four hour discharge notice until 9/30/16 at 11:12AM. There was no physician order to hold the patient for a court commitment. Review of the RN notes revealed the patient told the RN he wanted to leave the facility but there was no documentation that the physician was notified and what time he told the nurse he wanted to leave.
Review of the policy and procedure FOUR HOUR REQUEST FOR DISCHARGE stated, "4.2 Requests for discharge may be verbal or in writing. Upon the patient making the request for discharge to any employee or contractor of Glen Oaks with authority for charting progress notes in the medical record, such person shall immediately notify a Registered Nurse, who will then assist the patient with completion of request of discharge form. 4.2.1.1 The Registered Nurse will also document in the Progress Note the circumstances of the request, including the manner of request, the time of the request and the presentation of the request for discharge form. 4.2.2. The Registered Nurse will immediately notify the attending physician or the first available physician of the patient's request for discharge and document in the medical record that the physician has been notified and the time the physician was notified."
Review of Patient #9's chart revealed the patient was admitted as a voluntary patient on 10/12/16 with a diagnosis of schizophrenia. Review of the chart revealed the patient had signed a Request for Discharge form on 10/15/16 at 6:00AM. The patient stated she wanted to be discharged because "The rules and regulations are prohibiting my religious and smoking preferences." The DPN staff #4 documented on the form that the physician was notified at 5:30AM on 10/15/16. An order was found to detain the patient for a face to face with physician within 24 hours. Review of the chart revealed there was no nursing documentation about the request for discharge. There was no mention found of why the patient was upset or if any nursing interventions were done.
Review of physician progress note dated 10/15/16 at 1:30PM revealed the physician did not fill out the progress form that a mental status exam was performed. The change in medications section was left blank and the section "patient has capacity to make an informed decision regarding admission status Yes__ or No__" was left blank. There was no documentation found concerning the request for discharge. There was no orders or documentation to detain the patient for court ordered commitment. The patient was not discharged from the facility nor did the patient rescind the discharge request.
Review of patient #9's chart revealed another Request for Discharge dated 10/18/16 at 11:25PM. The patient documented, "I am being rattled teased ignored and defied by all staff members even the MD's PhD's and CEO." The patient signed in the patient signature to cancel the request but there was no documentation that the patient was aware that was to cancel the request. There was no nursing documentation concerning the discharge request. A physician order to hold the patient for 24 hours to see physician was found on 10/18/16 at 2329 (11:29PM).
Review of the physician progress note dated 10/19/16 at 9:07AM revealed there was no documentation concerning the patients discharge request. The physician documented, "Patient remains intrusive, inappropriate, and very mechanically elevated at this point. She is not responding well to medications and refusing all medications significant worsening motor activity today. For now I would characterize her level of mania at catatonically agitated and we will try to intervene with Ativan and started her on fairly substantial dose at 2mg t.i.d. and we will assess response to that. Failing that, we will need to apply for court order meds with patient refusing basically all medication strategies." There was no documentation in the patient's chart that any paperwork was initiated for court commitment. There was no physician order to hold the patient or change the status to involuntary. The patient was not discharged.

Based on observation and interview, the hospital failed to provide safety grab bars in the shower area in 17 (room #109, 110, 111, 112, 113, 114, 115, 117, 118, 119, 120, 121, 122, 123, 124, 126 and 127) out of 19 adult patient rooms to protect patients from falling who were identified as being at risk for fall.

Findings include:

On the morning of 11-18-2016 a tour with Staff # 1 was conducted of the patient room's bathrooms on the adult unit (rooms 109 through 127). The tour revealed that only two rooms (room #116 and room #125) had grab bars in the shower area to protect patients who were at risk of falling. The two rooms could house two patients each for a total of four patients having access to the protective equipment.

An interview was conducted following the tour in the nursing station on the adult unit with Staff #36. Staff #36 confirmed, based on the census board and falling leaf markers on patient doorways, there were eight patients who were identified as at risk to fall. Staff #36 confirmed the patient in room #126 was identified as at risk to fall and the patient in room #125 was not identified at risk to fall. When it was pointed out that the patient in room #126 was in need of the additional safety equipment, Staff #36 could not explain how the rooms were assigned.

Based on review of the Quality Assessment Performance Improvement (QAPI) data the facility failed to follow the written plan. The facility failed to develop a performance improvement team and re-train employees on fall risk identifiers.

Review of the Quality Assessment Performance Improvement (QAPI) presented to the Hospital Quality Council Meeting dated October 20th 2016 revealed the facility had reported falls for the last quarter. However there was no current data for October-December 2016.

Review of the QAPI council meeting notes revealed the facility had logged 7 falls for September 2016. It was an increase from 6 patient falls reported in August 2016. Staff #2 reported there had been more than 7 falls in October. The plan was to have a post -fall conference completed for all patient falls and Yellow "fall" leaves will be placed on the patients door along with yellow bracelets and non-slip socks. Staff would be retrained to the risk identifiers.

Review of the Topic for Discussion stated, "A task force has been organized at this time. If there is no marked improvement in the next couple of months, this will become a PI Team." Staff #2 reported that they are closely looking at falls but there was no PI team in place at this time.

Review of staff employee files and staff training revealed there had been no staff re-training to falls.

Review of patient #1's chart revealed the patient had a near fall and a Green leaf was put on the patients door not yellow.

Based on record review and interviews, nursing failed to:
A. ensure all patients received a physical assessment by a Registered Nurse (RN) at least every 12 hours after the initial comprehensive admission nursing assessment in 14 (patients #1 and #10- #22) of 14 (patients #1 and #10- #22) patient records reviewed.
B. Nursing failed to assess patient with changes in condition in elevated blood sugars or elevated blood pressures. Failed to document correct times and dates in the patients medical record.
C. ensure there was nursing documentation on how the patient tolerated the insulin, vital signs, if there were s/sx of hyperglycemia, duration of pain, or if any interventions were given to relieve the pain.
D. ensure the patients was given safety equipment in the shower to prevent falls.


Refer to Tag A0395

Based on record review and interviews, nursing failed to;
A. ensure all patients received a physical assessment by a Registered Nurse (RN) at least every 12 hours after the initial comprehensive admission nursing assessment in 14 (patients #1 and #10- #22) of 14 (patients #1 and #10- #22) patient records reviewed.
B. Nursing failed to assess patient with changes in condition in elevated blood sugars or elevated blood pressures. Failed to document correct times and dates in the patients medical record.
C. ensure there was nursing documentation on how the patient tolerated the insulin, vital signs, if there were s/sx of hyperglycemia, duration of pain, or if any interventions were given to relieve the pain.
D. ensure the patients was given safety equipment in the shower to prevent falls.

A review of the records of patients #10 through #22 revealed, multiple forms titled, "Daily Nursing Flow Sheet". The forms contained multiple assessment check boxes related to the patient's psychosocial state. The form contained a small area for documentation of the patient's physical/medical issues that covered wound care and elimination assessment only. The bottom of the form contained an area for pain assessment but, did not cover any nursing interventions or patient response.
A review of the Texas Nurse Practice Act revealed the following statement:
"The RN takes responsibility and accepts accountability for practicing within the legal scope of practice and is prepared to work in all health care settings, and may engage in independent nursing practice without supervision by another health care provider. The RN, with a focus on patient safety, is required to function within the parameters of the legal scope of practice and in accordance with the federal, state, and local laws; rules and regulations; and policies, procedures and guidelines of the employing health care institution or practice setting. The RN is responsible for providing safe, compassionate, and comprehensive nursing care to patients and their families with complex healthcare needs."
A review of the facility's policy titled, "Assessment and Reassessment of Patients" revealed the following information:
"SCOPE: All RNs on all nursing units.
PURPOSE: To utilize the Nursing Process and assess all patient at a minimum of every shift and document findings.
DEFINITION: The Admission Nursing Assessment is done to discover medical problems, psychosocial problems, and functional levels from which to gauge improvement and progression toward a healthier state, or to gauge a decline in health. Reassessments are performed frequently, at a minimum of once every nursing shift in order to determine progress or decline in a given patient."
An interview was conducted on 11/15/2016, with staff #32, the charge RN on the Youth Care Unit (YCU). At the time of the interview, the YCU patient census was 13 and was staffed with 2 RNs and 1 Mental Health Tech (MHT). During the interview, staff #32 revealed the patient assessments and overall care was the charge RN's responsibility and medication administration was assigned to the 2nd nurse, which could be an RN or LVN. Staff #32 was asked to explain how she was able to perform physical assessments and document on 13 patients during a 12 hour shift. Staff #32 stated, "I don't do a full assessment on them. I just talk to them and I can usually tell if there is anything going on with them." Staff #32 further explained that in order to complete her nursing documentation on each patient, she frequently works several hours past her shift end time. Staff #32 was questioned if she was scheduled as the only nurse for the YCU unit at times. Staff #32 responded, "yes, I usually am the only nurse here", (on the YCU unit).




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1.) Patient #1 was admitted to the facility on 9/26/16 with a diagnosis of depression, Hypertension, and insulin dependent Diabetes. Review of the Initial Nursing Assessment dated 9/26/16 revealed the patient was admitted but there is no time documented on the nursing assessment. Review of the admitting physician order dated 9/26/16 revealed a time of 1645 (4:45PM) as official admission time.

Review of the narrative nursing admission note revealed a date of 9/27/16 with no time. The nursing assessment revealed patient #1 was given insulin during the admission at 10:50PM. However the patient was admitted on 9/26/16. Review of the Admissions 15 Minute Safety Check Sheet revealed the patient was monitored in admissions from 1645- 2345. Review of patient #1's chart revealed there was no clarification of when the patient arrived on the unit or why the patient was in admissions for 7 hours.

Review of the nursing admission note dated 9/27/16 (no time documented) revealed the patient had an elevated blood sugar of "415" in admissions and was given 8 units of regular insulin. There was no nursing documentation that the physician was notified. A telephone physician order was found dated 9/26 at 2250 (10:50PM) to administer Humulin R 8 units x1 now for BS greater than 400. Review of the MAR revealed the patient received 8 units of Humulin R on 9/26/16 at 2310 (11:10PM) for a blood sugar of "417." There was no further information on how the patient tolerated the insulin, vital signs, if there were s/sx of hyperglycemia, or any nursing interventions.

Review of the Nursing Admission note dated 9/27/16 (no time documented) revealed once on the unit patient #1 had a blood sugar of 351 and was given 5 units of regular insulin. Review of the physician orders revealed a telephone order for Humulin R 5 units now for BS of 315 and before meals. The MAR revealed patient #1 received 5 units sq. now on 9/27/16 at 2:00AM. There was no further documentation on the patient until 9/27/16 at 7:50AM. There was no assessment or blood sugar documented after the 2:00AM dose; 6 hours later.

Review of patient #1's Nursing Flow Sheet dated 9/27/16 at 7:50AM that the patient was having "back pain 8/10 due to herniated disk. HTN monitored with v/s 99% 02 sat. 192/91, 97.9, 71, 18 medications as ordered. 0950 blood pressure rechecked with reading of 152/69. Will continue to monitor." There was no documentation that the physician was made aware of the elevated blood pressure of 192/91 or his pain level of 8 out of 10 (10 being the worst pain.) Review of the MAR for 9/27/16 revealed the patient was not given any PRN medication for pain. Patient #1 was not administered his blood pressure medications until 9:00AM; one hour after elevated blood pressure noted. There was no further documentation on pain or blood pressure until 9/28/16 at 8:00AM.

Review of the patients daily nursing flow sheet on 9/29/16 7:00AM-7:00PM revealed the nurse never signed the note. The nurse put in the narrative note that the patient's pain level was 8 out of 10 on the pain scale. The pain scale on the flow sheet was left blank. There was no further information documented on the duration of pain or if any interventions were given to relieve the pain.

Review of patient #1's chart revealed he had complained to the nursing staff on 9/30/16 of a fall in the shower and increased back pain. On 9/30/16 1615 (4:15PM) the nurse documented, "Pt reports he told staff all day he had fallen in shower went to room to examine. When questioned why he had not informed me or med nurse he stated he had. When I explained he had not reported to me he explained, "he had told somebody and the state too!" he told me he had hurt his back trying not to fall. Upon assessment, no bruising, swelling, or abrasion is noted. Pt ambulated to room and meals without a limp or (eligible word), or painful gait. Pt is demanding to go to ER. MD contacted and report given. MD recommended med consult in AM. Pt informed and became angry stating his needs were not being met."(SIC) MD was called and the patient was sent to ER for further care on 9/30/16 at 1745 (5:45PM).

Patient #1 was seen in the ER and returned to the facility on 9/30/16 at with a diagnosis of lumbar strain. There was no nursing documentation of any nursing interventions to prevent falls in shower or in the facility until 10/2/16, 2 days after the accident. Review of the nursing flow sheet dated 10/2/16 at 8:00AM patient was "prescribed green leaf fall risk on door, nonskid foot wear." There was no documentation that the patient was given safety equipment in the shower where he was injured initially.

An interview with staff #2 on 11/17/16 revealed an incident report was found on the patients near fall and injury in the shower. Staff #2 stated only a few of the rooms were equipped with safety bars in the showers. Staff #2 stated that she was sure he was in one of those rooms. When asked what room he was in staff #2 was unable to give us the room number. There was no documented proof of what room the patient was in. Staff #1 and #2 confirmed the facility never documents what room the patients are in.