HospitalInspections.org

Based on review of records and staff interview, the facility failed to protect and promote each patient's rights or provide care in a safe setting when:

A. the facility failed to monitor each patient at the level of monitoring most recently specified in the patient's medical record for 3 of 5 patients (Patients B, C, and H) reviewed for observation levels when each patient's "Close Observation" sheets did not accurately reflect the physician's observation order and failed to have a policy guiding the observation levels. (Cross refer A0144)

B. patients were not reassessed for pain relief after receiving pain medications for 4 of 5 patients reviewed (Patients A, D, E, G). (Cross refer A0144)

D. emergency behavioral medication administered IM (intramuscular) for behavioral emergencies were not identified nor monitored as chemical restraints in one of one patient charts reviewed (Patient A) for emergency medication administration. (Cross refer A0160)

E. the facility failed to ensure a process was in place for continuous monitoring after administering a chemical restraint/emergency behavioral medication for side effects, respiratory or cardiac distress, and assessment of medication effectiveness and safety after administration in 1 of 1 patient charts reviewed (Patient A). (Cross refer A0160)

F. the facility failed to ensure chemical restraints were added to the restraint log nor were monitored through Risk and Quality in 1 of 1 patient charts reviewed (Patient A). (Cross refer A0160)

G. the facility failed to ensure each patient or his or her representative had the right to make informed decisions regarding his or her care as it is not specifically disclosed there are no physicians on-site at any time; physicians only see patients via telemedicine services. (Cross refer A0131)

Based on review of documents and staff interview, the facility failed to ensure each patient or his or her representative had the right to make informed decisions regarding his or her care as it is not specifically disclosed there are no physicians on-site at any time. Physicians only see patients via telemedicine services.

Findings were:

Review of facility patient's initial admission packet revealed two documents:
-Document titled "Telemedicine Informed Consent" stated in part, "Telemedicine services involved the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites.
...2. I understand that I will not be physically in the same room as my health care providers. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room."
-Document titled "Informed Consent, Notice of Privacy Policy, and Notice Regarding complaints for Telemedicine Services" stated in part, "Telemedicine Physician Disclosures: I have been disclosed required disclosures about my provider whom shall provide telemedicine services: 1) I will be seeing [Physician #10] ... 2) the physician's specialty is in Psychiatry ..."

There is no written disclosure or signed acknowledgement by patients that a MD/DO [Doctor of Medicine or Osteopathy] is not present in the facility.

In an interview on the morning of 09/11/24, Staff #2, CNO, reported there was one document for the medical doctor's telemedicine agreement and one document for the psychiatrist's services, but nothing specifically that notifies a patient there is not a MD/DO present in the facility. She reported there is no physician on-site at their facility, everything is via telemedicine services.

In an interview on the afternoon of 09/11/24, Staff #1, CEO, reported the physicians are 100% telemedicine for about a year now, due to COVID and being a rural area. She reported they've been having difficulty getting someone full-time, but they have been working on it.

Based on review of medical records, review of facility documents, and staff interview, the facility failed to ensure patients received care in a safe setting when:
A. the facility failed to monitor each patient at the level of monitoring most recently specified in the patient's medical record for 3 of 5 patients (Patients B, C, and H) reviewed for observation levels when each patient's "Close Observation" sheets did not accurately reflect the physician's observation order and failed to have a policy guiding the observation levels.

B. patients were not reassessed for pain relief after receiving pain medications for 4 of 5 patients reviewed (Patients A, D, E, G).

Findings were:

A. Review of the medical record for Patient B revealed they were placed on Line-of-Sight [LOS] observation level on 09/06/24 at 6:25 pm. Patient's B's Close Observation sheets for the evening shifts of 09/06/24 and 09/08/24 and both shifts of 09/07/24 and 09/09/24 had "Level I - Observation every 15 minutes" checked as the level of precaution. The morning shift of 09/08/24 was unable to found and was not provided.

Review of the medical record for Patient C revealed they were placed on 1:1 observation on 09/01/24 for hitting staff and poor impulse control. Patient C's Close Observation sheets were not consistently documented as 1:1. 09/04/24 through 09/09/24 day and night shifts, either "Level I - Observation every 15 minutes" or "Level II - Line of Sight" was checked. On 09/08/24, "Level I - Observation every 15 minutes" was checked and "1:1" was written on the top of the sheet and circled.

Review of the medical record for Patient H revealed they were placed on LOS observation on 08/31/24 at 6:08 pm until 09/08/24 at 11:28 am. Patient H's Close Observation sheets for the evening shift of 08/31/24 and both shifts of 09/01/24 through 09/03/24 had "Level I - Observation every 15 minutes" checked as the level of precaution.

In an interview on the morning of 09/11/24, Staff #2, Chief Nursing Officer, verified there were no policies guiding level of precautions including LOS, 1:1, aggressive, or high fall risk precautions. Staff #2 provided the policy titled "Safety Precautions / Rounds" with an effective date of 07/01/22 and reported this was the only policy guiding observation levels.

Facility policy titled "Safety Precautions / Rounds" effective date 07/01/22 stated in part, "Purpose: -To have established rules and guidelines regarding safety concerns and incidents
-To ensure a safe and secure environment of care...

Procedure:
-All safety concerns regarding patients and their treatment will be documented and communicated during nursing shift reports.
...Patient rounds will include the following identifications:
*Potential for assaultive behavior
...*Fall risks
...*Medical conditions that require close observation"

In an interview on the afternoon of 09/11/24, Staff #1 and #2 verified facility policy titled "Safety Precautions / Rounds" effective date 07/01/22, was the only policy guiding observation levels.

B. Review of the medical record for Patient A revealed they received Acetaminophen-codeine #3 tablet every 6 hours PRN [as needed] pain on 09/08/24 at 9:38 am and 09/10/24 at 11:30 pm with no assessment of pain prior to or after administration. Staff #2, CNO stated, "They should have assessed the pain prior to and after administration."

Review of the medical record for Patient D revealed no reassessment of pain after administration of hydrocodone-acetaminophen 5-325 mg tab on:
-09/07/24 at 3:44 am for pain level 6
-09/08/24 at 9:33 am for pain level 7
-09/08/24 at 11:23 pm for pain level 5.

Review of the medical record for Patient E revealed they received a dose of acetaminophen 650 mg 8 hour extended release on 09/02/24 at 1:04 am for a pain of 6 with no reassessment.

Review of the medical record for Patient G revealed they received a dose of Acetaminophen 500 mg on 09/11/24 at 12:42 pm for a pain level of 3 and was not reassessed.

In an interview on the afternoon of 9/11/24, Staff #2, CNO reported pain should be assessed prior to administration of medications, reassessed after administration, and documented.

Facility policy titled "Pain Assessment and Pain Scale" effective date 07/01/22 stated in part, "Policy: The facility shall respect and support the patient's right to optimal pain assessment and management. Pain shall be assessed in all patients in the organization. The organization shall also address the appropriateness and effectiveness of pain management.
Procedure:
...The patient shall undergo reassessment of pain at least once per shift and after every pain control mechanism employed by patient care providers.
*Any patient care provider, from any department, who has implemented a pain control mechanism shall reassess the patient within one-half (1/2) hour to determine amount of pain control or relief achieved.
-Pain control mechanisms shall include, but are not limited to:
*Medications administered for the control or relief of pain ...
Ongoing Reassessment:
-As part of the reassessment, the multidisciplinary team shall assess and document the pain in terms of its duration, characteristics and intensity as well as the time of the pain, the pain rating and any use of analgesics.
...-This ongoing reassessment shall be performed at least every shift and more often if the patient's pain has not been controlled."

Facility policy titled "Patient Rights and Responsibilities" effective date 07/01/22 stated in part, "Rights of Persons Suffering from Mental Illness and Substance Abuse
...You have the right to:
...Appropriate education, assessment, and management of pain."

Based on review of medical records, review of facility policies, and confirmed in staff interview, the facility failed to ensure:
A. emergency behavioral medication administered IM for behavioral emergencies were identified and monitored as chemical restraints in one of one patient charts reviewed (Patient A) for emergency medication administration.

B. ensure a process was in place for continuous monitoring after administering a chemical restraint/emergency behavioral medication for side effects, respiratory or cardiac distress, and assessment of medication effectiveness and safety after administration in 1 of 1 patient charts reviewed (Patient A).

C. ensure chemical restraints were added to the restraint log and were monitored through Risk and Quality in 1 of 1 patient charts reviewed (Patient A).


Findings were:

Review of the medical record for Patient A revealed 2 (two) orders for Emergency Administration of Psychoactive Medication:
*08/29/24 at 7:45 pm for Haldol 5 mg [milligrams] IM [intramuscular] X 1 [times one] [Haldol is an antipsychotic medication] (it was documented family was not informed of this administration of medication)
*09/05/24 at 2:15 pm for Zyprexa 5 mg IM once [an atypical antipsychotic]
The Seclusion/Restraint/Emergency Administration of Psychoactive Medication form stated in part, "Emergency administration of psychoactive medication must be assessed/monitored every 15 minutes X 4 (1 hour) at minimal and documented."

The physician (Staff #10) who ordered the above emergency medications did not document the medication was treating a psychiatric disease process nor assisting the patient to a therapeutic level. The patient's behavior necessitating use of intervention was documented as "Immediate & Serious Danger to Others."

During review of the medical record on the afternoon of 09/11/24, Staff #2, CNO verified there was no assessment or reassessment of Patient A after medication administration and there was no 1 hour face-to-face. She was unaware that emergency behavioral medication could be considered as restraints but acknowledged that it should be safely monitored once given. She confirmed these were not added to the restraint log nor were monitored through Risk and Quality.


According to the FDA.gov Black Box Warning
Zyprexa is not approved for older adults with dementia-related psychosis as the drug can increase the risk of death in this population by 60% to 70%. The FDA placed a black box warning on all antipsychotics (atypical and typical) due to this increased mortality risk.

Black Box warnings for psychotropic medications revealed causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug, as opposed to some characteristic(s) of the patients, is not clear.

Facility policy titled "CMS Regulation of Use" section "Restraint & Seclusion" effective 07/01/22 stated in part, "Definitions:
A restraint is also defined as: A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.
...Policy: ...Note: A medication or chemical restraint may NEVER be administered without the prior order of an authorized licensed prescriber.
...Continuous observation is maintained on any patient in Restraint or Seclusion. The staff member monitoring the patient has been trained in observation of the patient in Restraint or Seclusion. The staff member is able to identify potential problems and/or signs and complaints of symptoms that may occur, and actions to be taken in response to ensure the safety and security of the patient.
The monitoring staff member will observe the patient continuously and document the patient's condition every 15 minutes on the Restraint or Seclusion Observation Flowsheet.
Procedure:
...4. The registered nurse enters the occurrence in the Restraint or Seclusion log
5. A qualified staff member is assigned to provide continuous monitoring ...
6. If the patient permits, the patient's family member or designated representative will be notified of the intervention and of the precipitating event ...
7. Within one hour of initiation, the patient will undergo a face-to-face assessment by a registered nurse, a physician assistant, an advanced practice registered nurse or a physician." This policy goes on to describe debriefing of the patient and staff members.

Based on review of documents and staff interview, the facility failed to have adequate numbers of qualified professional and supportive staff when:

A. the facility failed to ensure the number of doctors of medicine and osteopathy were adequate to provide essential psychiatric services when no physician is on-site. (Cross refer A1691)

B. the facility failed to provide adequate numbers of staff necessary under each patient's active treatment program when three of three staffing sheets (09/06/24, 09/09/24, and 09/11/24) reviewed revealed inadequate staff that did not reflect the accurate staffing for that day and staffing is not based on acuity. (Cross refer A1704)

Based on review of documents and staff interview, the facility failed to ensure the number of doctors of medicine and osteopathy were adequate to provide essential psychiatric services when no physician is on-site.

Findings were:

Texas Administrative Code 404.157(b)(1) states, "(b) All persons voluntarily admitted to inpatient services for treatment of mental illness or chemical dependency have the right to be discharged within four hours of a request for release unless the individual's treating physician (or another physician if the treating physician is not available) determines that there is cause to believe that the individual might meet the criteria for court-ordered mental health services or emergency detention.
(1) Each such person detained beyond four hours has the right to be examined in person by a physician and assessed for discharge readiness within 24 hours of the filing of a request for release, with results of the assessment and recommendation resulting documented in the medical record and disclosed to the individual. All such persons have the right not to be detained beyond the completion of the in-person examination..."

Review of facility patient's initial admission packet revealed two documents:

-Document titled "Telemedicine Informed Consent" stated in part, "Telemedicine services involved the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites.
...2. I understand that I will not be physically in the same room as my health care providers. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room."

-Document titled "Informed Consent, Notice of Privacy Policy, and Notice Regarding complaints for Telemedicine Services" stated in part, "Telemedicine Physician Disclosures: I have been disclosed required disclosures about my provider whom shall provide telemedicine services: 1) I will be seeing [Physician #10] ... 2) the physician's specialty is in Psychiatry ..."

In an interview on the morning of 09/11/24, Staff #2, CNO, reported there was one document for the medical doctor's telemedicine agreement and one document for the psychiatrist's services. She reported there is no physician on-site at their facility, everything is via telemedicine services. She reported at times, they do get voluntary patients who request to be discharged, but that is not something that quality tracks and no list of patients who have requested to be discharged could be provided. Staff #2 confirmed, if a voluntary patient were to request discharge, there would be no physician to complete an in-person examination within 24 hours of filing a request for release as all physicians were telemedicine only. She stated the examination would be via "telemedicine."

In an interview on the afternoon of 9/11/24, Staff # 1, CEO, reported the physicians are 100% telemedicine for about a year now, due to COVID and being a rural area. She reported they've been having difficulty getting someone full-time, but they have been working on it. She reported she has been requesting for more staff for about a year and verified an RN was not on the unit while doing rounds with the physician. She reported RN nightshift do not get a break as they cannot leave the unit. She verified the facility only had one policy related to observations titled "Safety Precautions/Rounds."

Based on review of facility documentation and staff interviews, the facility failed to provide adequate numbers of staff necessary under each patient's active treatment program when three of three staffing sheets (09/06/24, 09/09/24, and 09/11/24) reviewed revealed inadequate staff that did not reflect the accurate staffing for that day and staffing is not based on acuity.

Findings were:

Review of the facility staffing plan revealed a grid based on the number of patients only and stated in part:
*# of patients 1-6: 1 RN, 0 LVN/LPN, 1 Tech (MHT)
*# of patients 7-12: 1 RN, 1 LPN, 2 Tech
*# of patients 13-16: 1 RN, 1 LPN, 3 Tech
*# of patients 17-18: 1 RN, 2 LPN, 3 Tech
*# of patients 19-20: 1 RN, 2 LPN, 4 Tech

Review of the staffing sheet for dayshift 09/06/24 revealed 2 RNs (one on orientation), 1 LVN, and 4 MHTs with a census of 19 patients with one 1:1 (Patient C). According to the staffing grid, the staffing was short by 1 LVN.

There was an incident between two patients on 9/6/24 at approximately 2:00 pm. Patient A had to be transferred to the ER and was off the unit with one MHT from 2:00 pm until 4:30 pm, leaving the unit with 3 MHTs, one of which was assigned as 1:1 with Patient C. According to the staffing grid, the staffing was short by 1 LVN and 1 MHT from 2:00 pm until 4:30 pm.

In interview on the morning of 09/11/24, Staff #2, CNO, reported the census on 09/09/24 was 19 with one 1:1 (Patient C). According to the staffing grid for 19 patients, there should be 1 RN, 2 LVNs, and 4 MHTs. Staff #2 reported there were two RNs present that day, but one was on orientation and did not count toward the staffing and reported she worked the unit and the unit clerk worked as an MHT to cover staffing; this was not reflected on the staffing sheet.

Review of the sheet for nightshift 09/06/24 revealed 1 RN, 1 LVN, and 4 MHTs with a census of 19 patients with one 1:1 (Patient C). According to the staffing grid, the staffing was short by 1 LVN.

Review of the staffing sheet for dayshift 09/09/24 revealed 1 RN, 1 LVN, and 4 MHTs with a census of 18 patients with one 1:1 (Patient C). According to the staffing grid, the staffing was short by 1 LVN.

Review of the staffing sheet for nightshift 09/09/24 revealed one RN, one LVN, and 3 MHTs; the census was 18 with one 1:1 (Patient C). According to the staffing grid, the staffing was short by 1 LVN.

Review of the staffing sheet for dayshift 09/11/24 revealed 1 RN, 1 LVN, and 4 MHTs with a census of 19 patients with one 1:1 (Patient C). According to the staffing grid, the staffing was short by 1 LVN.

In an interview on the morning of 09/11/24, Staff #2, CNO reported staffing was in accordance with the provided staffing grid with the number of patients and no acuity, characteristics of patients, or administrative activities were used to determine staffing. When asked if there was a certain number of LOS patients a MHT could have at one time, she reported there was not. When asked if there was an acuity tool used with the facility staffing grid, she stated, "I talk to the doctors, and we discuss it. If needed, I, or transportation, is the extra person, if we have a lot of acuity on the unit." She reported there was no acuity taken into account when staffing and stated, "I just go help, if that makes sense. There's a lot of confused and restless patients and they wander ... And everyone's a fall risk. So I assist out there [on the unit]." She stated, "Usually, there's only 1 RN and she's not on the unit if she's making doctor rounds, she's with the patients."

In an interview on the morning of 09/11/24, Staff #3, RN reported if she needed help, the CNO was available, and she always had an LVN. She reported during doctor rounds, she was in the room with the patients and the LVN has to watch the unit without her and stated it "takes about 2 hours when there aren't any new patients" but has taken 3-5 hours at times.

In a follow-up interview on the afternoon of 09/11/24, Staff #2, CNO, reported she does help out on nightshifts at times and had to work a nightshift last week because the RN called in sick. She reported RNs on nightshift do not get breaks unless there is another RN scheduled, which is not often, as there always has to be an RN on the unit. She stated, "She doesn't get a lunch and the time doesn't get taken out ... For the most part, they can't get a break because they can't leave." She reported, in the last few months, they've had more aggressive male patients than usual.

With only 1 RN scheduled, especially at nights, there is no RN back-up available to monitor patients or relieve the one scheduled RN for breaks or lunch. If there is a restraint, there is no other RN to monitor patients or complete the 1 hour face-to-face

Facility-policy titled "General Staffing" effective 07/01/22 stated in part, "Each unit or area where patient care is provided will have a staffing plan to provide a sufficient number of professional nursing staff (RNs, LPNs/LVNs, CNAs) and professional ancillary staff (registered physical therapists, registered respiratory therapists, etc.) to carry out at least the following activities:
-Prescription of care, treatment and services care for patients based on:
*Assessment data and other relevant information
*Identified patient needs/problems
*Appropriate healthcare interventions as specified in standards, policies, and procedures, protocols or as determined by
professional judgment
*The patient's response to healthcare interventions
...Clinical and service indicators will be utilized in combination with human resource screening indicators to assess staffing effectiveness ..."