HospitalInspections.org

Based upon observation, record review and interview, the governing body failed to:


A.) ensure the patients signed a consent for treatment. The facility failed to ensure the patient was able to understand their patient rights before signing an informed consent in 6 (# 1, 6, 11, 12, 13, and 14) of 6 charts reviewed.

Refer to Tag A0117


B.) allow the patient or family members participate in the development and implementation of patient plan of care in 2 (#1 and # 11) of 3 ( #1, #11, and #13) charts reviewed.

Refer to Tag A0130


C.) ensure the patients and patient representatives were provided information about the patients health status, diagnosis, and prognosis. The facility failed to ensure the patient and patients representatives were allowed to participate in the development of his/her plan of care, including providing consent to, or refusal of, medical or surgical interventions, and in planning for care after discharge from the hospital in 2 (#1 and #11) of 3 (#1, #11, and #13) charts reviewed.

Refer to Tag A0131


D.) follow its own policy and procedures to ensure the patients were safe from falls. The facility failed to have working bed alarms on all the patient beds and staff failed to provide monitoring of patients on special precautions for 11( #7, 11, 14, 15, 16, 17, 20, 21, 22, 23, and 25) of 11 patients reviewed.

Refer to Tag A0144


E.) ensure Nursing obtained physician's orders for emergency psychoactive medications, refrain from using prohibited "as needed" psychoactive medications for restraint, conduct a comprehensive patient assessment to determine the need for other types of interventions, and prevent use of psychoactive medication for staff convenience in 2 (#1, 11) of 2 patients reviewed.

Refer to Tag A0160


F.) follow its own policy and procedures to have RN supervision on each shift during break time, failed to have adequate staffing of licensed personnel, and failed to have a Director of Nursing for a two month period. This deficient practice had the likelihood to cause harm to all presenting and in-patients in the hospital.
Refer to Tag A0392

G.) ensure nursing provided ongoing assessment of patient's medical condition throughout the hospitalization for 2 (#1, #11)of 6 patients review. Nursing failed to provide assessment and notify physician when a change of condition occurred for 6 (#1, #3, #5, #7, #9, #11) of 6 patients reviewed. Nursing failed to obtain physician's orders for emergency psychoactive medications that were given to 2 (#1, #11) of 6 patients reviewed.
Refer to Tag A0395

H.) ensure the patient or family members were allowed to participate in the development and implementation of patient plan of care in 1(#1) of 3(#1, #11, #13) charts reviewed.
Refer to Tag A0396

Based upon observation, record review and interview, the facility failed to:

A.) ensure the patients were signed an informed consent for treatment. The facility failed to ensure the patient was able to understand their patient rights before signing an informed consent in 6 (# 1, 6, 11, 12, 13, and 14) of 6 charts reviewed.

Refer to Tag A0117


B.) allow the patient or family members participate in the development and implementation of patient plan of care in 2 (#1 and # 11) of 3 ( #1, #11, and #13) charts reviewed.

Refer to Tag A0130


C.) ensure the patients and patient representatives were provided information about the patients health status, diagnosis, and prognosis. The facility failed to ensure the patient and patients representatives were allowed to participate in the development of his/her plan of care, including providing consent to, or refusal of, medical or surgical interventions, and in planning for care after discharge from the hospital in 2 (#1 and #11) of 3 (#1, #11, and #13) charts reviewed.

Refer to Tag A0131


D.) follow its own policy and procedures to ensure the patients were safe from falls. The facility failed to have working bed alarms on all the patient beds and staff failed to provide safety monitoring of patients on special precautions for 11 ( #7, 11, 14, 15, 16, 17, 20, 21, 22, 23, and 25) of 11 patients reviewed.

Refer to Tag A0144


These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.




E.) obtain physician's orders for emergency psychoactive medications, refrain from using prohibited "as needed" psychoactive medications for restraint, conduct a comprehensive patient assessment to determine the need for other types of interventions, and prevent use of psychoactive medication for staff convenience in 2 (#1, 11) of 2 patients reviewed.

Refer to Tag A0160


These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.

Based on chart reviews and interview the facility failed to ensure the patients were oriented to sign a consent for treatment. The facility failed to ensure the patient was able to understand their patient rights before signing a legal consent in 6 (# 1, 6, 11, 12, 13, and 14) of 6 charts reviewed.


Review of the following patient charts revealed the patients were allowed to sign consents for voluntary inpatient psychiatric treatment and receive explanation of their patient rights when the patients were in a confused or disoriented mental state:


1.) Review of patient #14's chart revealed she was admitted to the facility on 9/11/15. Patient #14 signed all consents including voluntary treatment and patient rights. Review of the physician history and physical dated 9/11/15 revealed, "Current mental status- altered. Judgement and insight- poor."


2.) Review of patient #1's chart revealed he was admitted to the facility on 6/15/15. Patient #1 signed all consents including voluntary treatment and patient rights. Review of the physician history and physical dated 6/17/15 at 6:20AM stated, "Chief Complaint- Dementia. Mental/Emotional Status; Pleasant Confused."


3.) Review of patient #11's chart revealed he was admitted to the facility on 5/13/15, with a diagnosis of Neurocognitive Disorder. Review patient #11's consents including Patient Rights consent was blank in the signature line and had no comments. The two witness signatures were staff #10 (RN) and an unidentifiable signature. Patient #11's Consent for Treatment was signed by two employees the next morning on 5/14/15 at 7:50AM stating, "verbal consent given." Patient states, "yes."


Review of patient #11's physician history and physical dated 5/14/15, at 6:00AM, stated," mental status - confused" Review of patient #11's notes from the Mental Health Authority dated 5/13/2015(one day prior) revealed the patient had been interviewed due to mental status and placement. The interviewer stated, "Client did not appear oriented. Did not feel it was appropriate to have client sign a voluntary paper in which he did not understand what the paper was."


4.) Review of patient #12's chart revealed he was admitted to the facility on 6/18/15. Review patient #12's consents including Patient Rights consent was blank in the signature line and had no comments. There was two employee signatures stating patient gave verbal consent but no reason why the patient was unable to sign. One employee signature is unidentifiable and the other signature is not on the official employee roster given to the surveyor for this time period. Review of the patient's physician history and physical dated 6/20/15 stated, "mental status-Confused."



5.) Review of patient #13's chart revealed the patient was admitted on 7/24/15. Patient #13 signed all consents except Patient Rights. Patient #13 signed the voluntary treatment consent. Review of the physician history and physical dated 7/25/15, at 12:00PM, stated, "Patient not assessed verbally abusive. Near physically abusive. Did not approach patient. Pt urinated on the floor and clothes." Review of the intake screening dated 7/24/15, revealed the patient has dementia and has been having an increase in confusion, combativeness and increase cognitive impairment."



6.) Review of patient #6's chart revealed patient was admitted to the facility on 5/11/15. Patient #6 signed all consents including voluntary treatment and patient rights. Review of the physician history and physical dated 5/12/15, at 6:00AM. stated, "Confused tried to fix heater."


Interview with staff #3 confirmed the findings and stated, "Its not really clear to me when they can and cannot sign themselves in."

Based on chart reviews and interviews, the facility failed to allow the patient or family members participate in the development and implementation of patient plan of care in 2 (#1 and # 11) of 3 ( #1, #11, and #13) charts reviewed.


Review of patient #1's chart revealed an admission on 6/15/2015, with a diagnosis of Neurocognitive Disorder with behavioral disturbances. ( Neurocognitive disorder was previously known as dementia and the primary feature of all neurocognitive disorders (NCDs) is an acquired cognitive decline in one or more cognitive domains.)


Review of patient #1's treatment plan revealed the multidisciplinary treatment team met on 6/24/2015, at 8:30AM. There was no found documentation of the patient participation during the treatment team meeting or documentation of the family notification to participate. The team consisted of the physician and two social workers.


An interview with patient #1's daughter on 9/21/15, reported she had requested multiple times to the DPN, social worker, and charge nurses to speak with the psychiatrist concerning her father's care and treatment. The daughter reported, what she got were excuses from the staff. Patient #1's daughter reported the Social Worker (SW) explained to her that patient #1 would be discharged back to the nursing home when the psychiatrist felt he was ready.


2.) Review of patient #11's chart revealed an admission on 5/13/2015, at 5:50PM, with a diagnosis of Neurocognitive Disorder with behavioral disturbances, Aggression. Patient #11's chart revealed he was escorted to the facility on a Peace Officers Warrant (OPC) from the Sheriff's Department.


Review of the treatment plan revealed the patient nor family was involved in treatment team planning.


An interview with patient #11's "significant other" and power of attorney (POA) reported she asked multiple times to speak to the social worker and psychiatrist concerning his care and was told they did not have consent to speak with her. A consent was found at admission with significant others name and contact information.



An interview with staff #1 confirmed the above findings. Staff #1 reported that the psychiatrist did not like families in treatment team. They could make an appointment with him for a family sessions if needed.

Based on chart reviews and interviews, the facility failed to ensure the patients and patient representatives were provided information about the patients health status, diagnosis, and prognosis. The facility failed to ensure the patient and patients representatives were allowed to participate in the development of his/her plan of care, including providing consent to, or refusal of, medical or surgical interventions, and in planning for care after discharge from the hospital in 2 (#1 and #11) of 3 (#1, #11, and #13) charts reviewed.


1.) Review of patient #1's chart revealed an admission on 6/15/2015, with a diagnosis of Neurocognitive Disorder with behavioral disturbances. ( Neurocognitive disorder was previously known as dementia and the primary feature of all neurocognitive disorders (NCDs) is an acquired cognitive decline in one or more cognitive domains.)


Review of patient #1's chart revealed he was admitted as a voluntary patient to the facility. Patient #1 signed all consents including voluntary treatment and patient rights. Review of the physician history and physical dated 6/17/15, at 6:20AM, stated, "Chief Complaint- Dementia. Mental/Emotional Status; Pleasant Confused."


Review of the Nurses notes revealed, "On 6/16/15 pt remains confused and delusional, 6/17/2015 pt. confused, 6/18/15 continues to be confused."


Review of patient #1's treatment plan revealed the multidisciplinary treatment team met on 6/24/2015, at 8:30AM. There was no documentation of the patient participation during the treatment team meeting or documentation of the family notification to participate. The team consisted of the physician and two social workers.


A telephone interview was conducted with patient #1's daughter on 9/21/15. The daughter revealed she was with patient #1 on admission and watched him sign all the consents. The daughter reported she asked why he was signing all the consents when he was confused, the admissions nurse reported patient #1 had to or could not be admitted. Patient #1's daughter denied receiving any patient rights.


Patient #1's daughter reported that she was at the facility to check on the patient at each visitation time. The daughter reported that she noted patient #1 was declining and looking "sick." Patient #1 was alert but confused and was able to propel the wheelchair upon admission. As patient #1 was there for several days the family noticed a change in his condition. Patient #1 was now less verbal and unable to move the wheelchair. Patient #1's daughter was advised of the medications administered to the patient. Patient #1's daughter felt that was an excessive amount and requested to discuss with the psychiatrist. Patient #1's daughter reported they would let the psychiatrist know and get back with her. Patient #1's daughter stated, "They always had an excuse on why I couldn't speak with the doctor."


Patient #1's daughter requested for patient #1 to be discharged back to the Nursing Home due to her concern of her patient #1's health and well being. Patient #1's daughter reported, she was told by the SW and DON that the psychiatrist did not feel patient #1 was ready for discharge but was given no reasons why or when patient #1 would be ready. Patient #1's daughter reported she was denied an interview with the psychiatrist by the charge nurse, DON, and SW.


Patient #1's daughter reported, she called the Director of Nursing (DON) at the nursing home and the patients primary care doctor about the problems she was having with getting information from the facility concerning patient #1. She asked if they could assist getting patient #1 discharged and sent back to the Nursing home.


An interview was conducted with staff #2 concerning patient #1's daughter requesting the patient's discharge and information on patients condition. Staff #2 reported, she remembered patient #1's PCP's office calling to discharge the patient. Staff #2 reported, she explained to the PCP's office that he had no privileges at the facility and it would be up to the psychiatrist to determine discharge for the patient. Staff #2 reported, she did remember the DON of the nursing home calling and just checking on the patients progress. Staff #2 reported, she did not remember speaking to the patients daughter about discharge.


Review of the Complaint and Grievance log revealed no documented complaint from patient #1's daughter. There was no documentation found in the chart of the daughter requesting an appointment with the psychiatrist, or that the PCP and DON of the patients nursing home called, and requested information about discharge and patient status.



2.) Review of patient #11's chart revealed an admission on 5/13/2015, at 5:50PM, with a diagnosis of Neurocognitive Disorder with behavioral disturbances, Aggression. Patient #11's chart revealed he was escorted to the facility on a Peace Officers Warrant (OPC) from Brazos County Sheriff's Department.


Review of patient #11's "Multi-Disciplinary Note" dated 5/13/15, at 5:50PM, revealed patient #11 was brought to the facility by ambulance in four point restraints. Patient #11 was combative and agitated on arrival. Nurse stated, "Order obtained for injection for severe agitation. Note new orders."


Review of a verbal physician orders for 5/13/15, at 6:10PM, stated, "Give Ativan 2mg IM, Haldol 10mg IM, and Benadryl 50mg IM now 1 time dose for sever agitation." Medication was administered on 5/13/2015 at 6:10PM.


Review of the Authorization and Informed Consent Form dated 5/13/2015, at 5:30PM, revealed the patient had given verbal consent and two nurses had signed as witnesses. Patient #11 was not documented as arriving to the unit until 5:50PM a span of 20 minutes later.


Review of the verbal physician orders on 5/14/15, at 7:45AM, stated, "Admit to voluntary status."


Review of the consent for treatment dated 5/14/15, at 7:50AM, revealed in the patient signature line, "verbal consent given. Patient states, "yes". Staff #9 and staff #14, social workers, signed the consent as witnesses.


Review of the psychiatrist evaluation on 5/14/15, at 10:35AM, stated," Patient #11 was initially referred to the facility on an emergency order of detention secondary to his continued deterioration in the community as well as his persistent risk of harm to others. He arrived to this facility in 4 point restraints. This morning, he was able to sign in as a voluntary patient. He presents with a history of Bipolar Disorder now with an acute exacerbation of his chronic mental illness characterized by severe mood swings, profound irritability, threats of suicide, as well as combative behaviors requiring 4 point restraint and chemical restraint for his safety as well as the safety of others.


EXAM: Patient #11 appears flat following chemical restrain upon admission last evening. His speech cannot be tested. Mood cannot be assessed. It is not possible to determine if underlying psychotic symptoms are present. Patient's condition today does not allow cognition to be formally tested. Insight into problems appears to be poor.
Judgment appears to be poor. A short attention span is evident. Mr. Albin is restless."


An interview with patient #11's significant other and POA stated, "The facility was about two in a half hour drive from our home so I tried to stay in contact with patient #11 by phone and through the nursing staff until our daughter and I could arrive the next day on 5/16/15. When we arrived they had his name incorrect on his chart. The nurse reported she could not call me because the patient had not yet given permission to speak to me. The nurse in charge then showed me patient #11's chart and and made a list of his medications without verifying who I was."


On the dates 5/17-5/20/15, I called the facility at least one time a day usually in the evenings. The nurses would talk to me and give me some type of update. Each day, I would ask to speak to the psychiatrist or request to have him call me back. I never received a call about the care plan or was invited to participate in his care. The social worker called patient #11's brother and discussed discharge planning. Patient #11's brother told the social worker that they needed to contact me due to I was the significant other and POA. I was called on 5/21/15 and told he was sent to the ER due to breathing difficulties. Patient #11 died from breathing complications on 5/31/15. "


Review of the "Consent To Treatment" dated 5/14/2015, at 7:50AM, revealed a statement documented on the back of the consent. Staff #9 (SW) had written a late entry note dated, "6/1/2015 10:30AM (Late entry and clarification for 5/14/15 at 10:10AM) Met with patient to get consent to involve family in his treatment. asked patient if social worker could contact his significant other to be involved in his treatment and patient stated, "No I haven't talked to her in months." To clarify, social worker stated so you don't want us speaking to her at all and patient stated, "no." Patient did give consent to speak with his brother.


Review of the "Consent for Involvement in Treatment" had patient #11's significant other as the first contact, his daughter as the second, and his brother as the third. Patient #11 had not signed the consent. The consent stated, "Verbal consent." Two staff members signed the consent; a RN and staff #9 (SW). Staff #9 dated and timed the consent 5/14/15 at 10:10 AM. The consent stated, "I have read and understand the above statement. I understand I may revoke any or all of these consents at any time via written notice or post discharge via written notice sent certified mail."


An interview with staff #9 on 9/23/15, confirmed she had written the statement on the back of the "Consent to Treatment." Staff #9 was questioned by the surveyor why she signed a consent stating she heard the patient agree to contacting his significant other on 5/14/15 at 10:10AM and then documented on "Consent to Treatment" on 6/1/2015 at 10:30AM as a "late entry" that patient did not want significant other and daughter contacted on 5/14/15? Staff #9 confirmed the patient was confused and was changing his mind. Staff #9 confirmed that the patient should not be signing consents in a confused state.


Staff #9 and staff #1 confirmed patient #11's significant other and daughter were not involved in patient #11's care or discharge planning.

Based on chart reviews, interview, and policy and procedure review, the facility failed to follow its own policy and procedures to ensure the patients were safe from falls. The facility failed to have working bed alarms in on all the patient beds and staff failed to document at appropriate times for 11 ( #7, 11, 14, 15, 16, 17, 20, 21, 22, 23, and 25) out of 11 patients reviewed.

1.) Review of patient #11's chart revealed an admission on 5/13/2015, at 5:50PM, with a diagnosis of Neurocognitive Disorder with behavioral disturbances, Aggression. Patient #11's chart revealed, he was escorted to the facility on a Peace Officers Warrant (OPC) from The County Sheriff's Department.

Review of the MHT observation check sheet on 5/18/15, at 1:15AM, revealed, patient #11 was allowed to lay in a bed in his room to rest from 1:15AM till 3:30AM, then again from 5:15AM-6:00AM. Patient #11 was documented to be in chair in dining room or dayroom from 5/13/15 (date of admission) until discharge on 5/21/15 except for these 3 hours documented on 5/18/15.

Review of patient #11's chart revealed from 5/13/15 through 5/16/15, revealed, the patient had received a chemical restraint of Haldol 10mg, Ativan 2mg, and Benadryl 50mg IM, a total of 6 times in a span of 3 days. Review of the daily nurses notes for 5/19/2015, at 8:00AM, stated, "Pt is sedated. Will open his mouth to eat and take meds but will not open his eyes to look at nurse or speak. Re-evaluated med regime per Dr. Johnson. Pt remains lethargic and non- communicative. "RN documented the patients thought content was unable to be assessed. Neurological status was "sedated" and the patients breath sounds were diminished.

Review of the MHT observation check sheet on 5/18/15, at 1:15AM, revealed patient #11 was allowed to lay in a bed in his room to rest from 1:15AM till 3:30AM and again from 5:15AM-6:00AM. Patient #11 was documented to be in a Geri- chair in dining room or dayroom at all other times during his stay at the facility. Review of the nurses notes from 5/16-5/21 revealed patient #11 had a bed alarm on his bed but not in the Geri-chair.

An interview was conducted on 9/23/15, with Staff #13. Staff #13 reported, when a patient is medicated for behavior issues the RN should stay with the patient. Staff #13 stated, "Since there is only one RN and the LVN is passing medications I have to put the patient in the recliner or chair and sit them by the desk so I can monitor everybody else." Staff #13 confirmed the patients have to stay the entire shift, in the dayroom, and not allowed to lie down in the bedroom due to staffing shortages. Staff #13 reported that administration did not encourage 1:1's (1 staff member to 1 patient within arm's length.)

Review of the policy and procedure "Fall Assessment/Re-Assessment and Precautions" stated,

"Policy:
All patients will be assessed and identified for the potential of being at risk for falls upon admission and every 7 days and/or immediately after a fall if identified as moderate or high risk. In the event of a fall occurrence, patients will be re-assessed every day, moved to a higher fall risk, and secondary fall prevention interventions will be implemented. The RN utilizing the Fall Risk criteria score sheet, will assess/re-assess and determine the risk of all patients with regard to falls and implement fall precautions
if so indicated."

The Admitting RN:
Assessment:

At the time of patient's admission, evaluates patient's ambulatory status and completes Fall Risk criteria. If a score of 6 or greater is obtained, initiates fall precautions.

Patients will be scored as follows: 0-6: Low Risk (Reassess as needed)
7-16: Moderate Risk (Initiate Fall Precautions) Greater than 17: High Risk (Add Secondary Interventions) If fall precautions are identified, High Risk for Falls Treatment Plan is initiated by RN.


Fall precautions - Interventions for High Risk:

All of Moderate Risk Interventions Bed alarm highly recommended for night time use (nursing decision is based on patient variables) Non- skid footwear"





Surveyor: Tucker, Susan A.

Review of the facility's "Performance Improvement Program - Quality Monitoring...RISK MANAGEMENT INCIDENT REPORT" monthly reports revealed the following information:


For the month of May 2015, there were 13 incidents reported. 12 of the incidents were patient falls and 1 was an incident that involved an employee and a patient in which the patient received a hand injury. Of the 13 incidents reported, 5 of them occurred in the patient's room or bathroom.


For the month of June 2015, there were 7 incidents reported. 4 of the incidents were patient falls, 1 was a violent episode by a patient that resulted in the patient slapping an employee in the face, and 2 were patient decline in physical condition warranting transfer to the Emergency Room for evaluation. Of the 7 incidents reported, 5 of them occurred in the patient's room or bathroom.


For the month of July 2015, there were 8 incidents reported. 5 of the incidents were patient falls, 2 were medication errors, and 1 was a patient suicide attempt. Of the 8 incidents reported, 2 of them occurred in the patient's room or bathroom.


For the month of August 2015, there were 14 incidents reported. 5 of the incidents were patient falls, 2 were listed as "employee incident" with no further explanation, 1 was listed only as "VIOLENCE", and 8 were listed only as "SECLUSION/RESTRAINT". Of the 14 incidents reported, 6 of them occurred in the patient's room or bathroom.


An interview with staff #5 (the facility's Safety Officer) revealed the following information:
For the month of March 2015, there were 16 fall incidents reported.
For the month of April 2015, there were 7 fall incidents reported.


On 9/23/2015, at approximately 3:30 p.m., a tour of the patient rooms was conducted by the surveyors and administrative staff. Surveyors discovered that the facility had 13 patients (patient #7, #14 through #25) at the time of the tour. Out of the 13 patients in the facility, 10 patients (patient #7, #14, #15, #16, #17, #20, #21, #22, #23, and #25) were documented by the nursing staff as having a bed alarm installed on their bed. The surveyors toured each patient room and tested each bed alarm found. The bed alarms being used were mounted on the wall approximately 2 feet above the head of the patient beds. The system had a sensor that was operated by battery power and when turned on was supposed to alarm if any motion was detected. All rooms assigned to patients with documented bed alarms did not have functioning bed alarms. 6 patient's beds (patient #7, #14, #16, #17, #20, #22) bed alarms did not alarm at the appropriate signal (motion) when tested. 4 patient's beds (patient #15, #21, #23 and #25) with documented bed alarms did not have an alarm installed in their rooms.


A review of the facility's policy, "NSG-30 Fall Alarm" revealed the following information:

"Nursing Surveillance & Response:.....

The alarm will be checked to verify proper mechanical functioning at least every shift.....

Purpose:
The fall alarm is an electronic monitoring system which may be used as part of the fall prevention program in situations where continuous surveillance is not necessary. The system consists of a control unit and a sensor pad. As weight is lifted off the sensor or movement occurs the alarm is activated."


An interview with staff #1 on 9/23/2015, at approximately 4:00 p.m., confirmed the findings that the facility's bed alarms were not working properly. Staff #1 stated, "I hate those bed alarms anyway. I have ordered 5 new ones but, haven't received them yet. I have to order a small amount each month because they are expensive."



A review of the facility's policy "TX-SPEC-05: Level of Observations/Monitoring" revealed the following information:

"Observation Levels:

Every 15 minutes - the staff member should visually observe the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression, and unsafe activities....

Close Observation Form:
The staff member utilizes the close observation form to document the location of the patient....

Procedure:
Every 15 Minute Observation:...
Assigned Nursing Staff (MHT):
· Circles/writes the type of specialty observation on the form (fall, suicide, etc.)....
· Physically walks to find each patient on q (every) 15 minute observation....
· Documents the location on the close observation form. Documents the activity when indicated (water offered, etc.)
· Initials the form every 15 minutes."


On 9/22/2015, at 2:30 p.m., a review of the facility's "Observation Notebook" containing a "Close Observation Check Sheet" for each patient with orders for every 15 minute observation revealed the following information:


There were 4 patient observation sheets (patient #15, #18, #22 and #26) dated 9/22/15 that had not been documented on since 9:15 a.m.


An interview conducted with staff #8 (MHT) confirmed that staff is not documenting the visual observations of each patient every 15 minutes. Staff #8 was asked how she could remember where and what each patient was doing 5 hours later when she documents on the observation sheets, she stated, "I just kinda know where they all have been most of the time." When staff #8 was asked if she made written notes to help her remember all the different patient's whereabouts, she stated, "No I don't write it down. I just kinda know what they were doing."










35515

Based upon record review and interview, Nursing staff failed to obtain physician's orders for emergency psychoactive medications, refrain from using prohibited "as needed" psychoactive medications for restraint, conduct a comprehensive patient assessment to determine the need for other types of interventions, and prevent use of psychoactive medication for staff convenience in 2 (#1, 11) of 2 patients reviewed.

These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, potential for harm, serious injury, impairment and/or subsequent death.



Review of the facility's policy and procedure "Psychiatric Emergencies:

Policy:
Psychoactive medications will not be administered to patients committed to a mental
health facility under an order for temporary or extended mental health services if the
patient or the patient's legally authorized representative refuses the medication.
Procedure:


Attending Physician Commitments:
Determines if an exclusion to the policy exists prior to prescribing medications. To order
that psychoactive medications be administered to a refusing patien,t one of the following
must exist. The patient:


Is in a psychiatric emergency and medication is administered as provided in
§414.410 of this title (relating to Psychiatric Emergencies):


Does not have a legally authorized representative and the administration of the
medication, regardless of the patient's refusal, is authorized by an order as
outlined in THSC §574.101 -574.110; or


Is a ward who is 18 years of age or older and the guardian of the person of the
ward consents to the administration of psychoactive medications regardless of the
ward's expressed preferences regarding treatment with psychoactive medication.



B. If a physician issues an order to administer psychoactive medication to a
patient without the patient's consent because of a psychiatric emergency,
then the physician will document in the patient ' s clinical record in specific
medical or behavioral terms:

Why the order is necessary;

Other generally accepted, less intrusive forms of treatment, if any,
that the physician has evaluated but rejected; and

The reasons those treatments were rejected.


C. Treatment of the patient with the psychoactive medication will be provided
in the manner, consistent with clinically appropriate medical care, least
restrictive of the patient's personal liberty."



1.) Review of patient #1's chart revealed an admission on 6/15/2015, with a diagnosis of Neurocognitive Disorder (Dementia) with behavioral disturbances. Patient #1 was 87 years old, 5'10", and 130 lbs at admission. Patient #1 had episodes of aggression and had hit another patient at the nursing home. Patient #1 was admitted as a voluntary patient to the facility. Review of the physician history and physical dated 6/17/15, at 6:20AM, stated, "Chief Complaint- Dementia. Mental/Emotional Status; Pleasant Confused."

Review of patient #1's physician orders for 6/15/2015, revealed, patient #1 was placed on seizure, assault and fall precautions.

Review of patient #1's daily nursing notes for 6/16/2015, 7AM-7PM, revealed, patient #1 was mobile in his wheelchair but remained confused and delusional. In the section for precautions, the nurse only checked fall precautions. Review of the vital sign record revealed, the patients oxygen saturation (O2 sat) was 95 at room air. Review of the chart revealed, there was no nursing documentation found for 6/16/15, for the 7PM-7AM shift or for 6/17/15, 7AM-7PM. The next nursing documentation was on 6/17/15, at 7PM-7AM, a lapse of 36 hours.

Review of patient #1's daily nursing notes dated 6/17/2015, 7PM-7AM, revealed, patient #1 has had increased confusion and had kicked a Mental Health technician (MHT) on that shift. Patient #1's O2 sat was 94% on room air but lung sounds were clear. There was no documentation of MD notification of decreasing O2 sat. RN stated, "Remains cooperative and easily re-directed." Nurse only checked falls for safety precautions observed.

Review of patient #1's daily nurse's notes revealed there was no nursing documentation or assessments found for 6/18/2015. No nursing documentation for 36 hours.

Review of the Nutrition assessment completed by the Dietician on 6/19/15, revealed, patient #1 had a history of a Cardiovascular Accident (CVA) but had no issues with swallowing. Patient #1 had consumed 75% of his meal and drank a supplement. Dietician's plan stated, Glucerna 1 can twice a day, monitor weight, and monitor for s/s of choking.

Review of patient #1's daily nurse's notes for 6/19/2015, revealed the patient was now on choking precautions. There was no documentation found of physician notification.

Review of patient #1's chart revealed there was no nursing documentation for 24 hours from 6/21/15, at 10:25PM until 6/22/15 at 10:15PM.

Review of patient #1's daily nurses notes for 6/24/15, revealed, there was no found nursing documentation for 6/24/15, 7AM-7PM. Review of the nurses note for 6/24/15, 7PM-7AM, revealed, the patient was pacing in wheelchair. "Easily redirected."

Review of patient #1's chart revealed a "Physician's Order for Emergency Administration for Psychoactive Medication" dated 6/25/15 at 7:00AM.
The order read,"Haldol 5mg IM now, Benadryl 50mg IM now, and Ativan 2mg IM now for severe agitation."

Review of patient #1's chart revealed a "Multi-Disciplinary Note" dated 6/25/2015, at 6:55AM. The RN documented, "Patient was physically and verbally aggressive with one of the techs. Patient stated, "You bitch leave me alone I'm going to piss on the floor." Patient was swinging at staff. Patient #1's daughter was notified of medication administration."

There was no documentation of a comprehensive patient assessment to determine the need for other types of interventions before using a drug or medication as a restraint. There was no documentation found of what interventions were attempted, how the patient responded, or what provoked the behavior.

Review of the daily nurse's notes on 6/25/15, revealed there was no found documentation on patient #1 for the 7AM-7PM shift. There was no further documentation found of any patient assessment until 8:15PM, on 6/25/2015. There was no found documentation if the patient tolerated the medication or effectiveness. RN documented, "Patient asleep at start of shift no behavior."

Review of the physician orders on 6/26/15, at 10:50AM, revealed, a verbal order, "Benadryl 50 mg IM now EPS."

EPS (extrapyramidal symptoms) are serious side effects associated with the administration of antipsychotic medications. Examples of EPS include rigidity, akathisia (restlessness), and acute dystonic reactions such as tightening of muscles in neck or throat.

Review of patient #1's chart revealed there was no daily nurse's note for 6/26/15, on the 7AM-7PM shift. Review of the 6/26/15, 7PM-7AM, daily nurse's note revealed, there was no documentation of EPS symptoms. The RN had documented under Neurological/L.O.C. "Unimpaired."

Review of the physician progress notes for 6/26/15, revealed, no reason for the Benadryl IM order. The medication and EPS was not documented in the physician progress note.

Review of the physician orders on 6/27/2015, at 10:20AM, revealed, a verbal telephone order to discontinue Zoloft and "start Valium 5mg at 6am and 6pm for anxiety and agitation daily and Trazadone 50mg po QHS for insomnia."

Review of the daily nurse's notes for 6/27/15, at 7AM-7PM shif,t revealed, patient #1 was agitated and anxious. The RN documented, "Patient is confused. Pt was sitting at nurse's desk and reached out to hit a tech that was standing beside him. Pt was redirected to drink his coffee. Pt complied. I will continue to redirect as needed." There was no documentation found of new medication ordered, administered, or effectiveness of new psychotropic medication.

Review of the daily nurse's notes on 6/28/15, at 8:00AM, revealed, the patient is now hallucinating and picking at the floor. There is no documentation that the physician was contacted about the change in condition. Review of the physician progress note on 6/28/15 does not mention the hallucinations or EPS.

Review of the physician orders on 7/2/2015, at 8:30AM, revealed, patient #1 had new orders to discontinue the Invega and to start on Risperdal 0.5mg twice a day. Increase Valium to 10 mg twice a day.


Review of Risperdal use, dosage, and side effects revealed the following:

" WARNING - INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA RELATED PSYCHOSIS

Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. RISPERDAL® (risperidone) is not approved for the treatment of patients with dementia-related psychosis. [See WARNINGS AND PRECAUTIONS] "

Review of the daily nurse's notes for 7/2/2015, at 8:15AM, stated, "Easily agitated. Refuses asst from staff. Irritable. Isolates to self. Withdrawn. Redirection and verbal support provided. Pt not easily receptive but will calm himself if given quiet time. Will continue to follow closely and assist his care as needed." There was no nursing documentation concerning the medication changes and evaluation of changes for 7/2/2015.

Review of a Physician Progress Note dated 7/2/2015, at 1:10PM, revealed, the Nurse Practitioner (NP) saw patient#1. The NP stated, "Pt seen: Health status exam: Up via w/c, very quiet, staff report pt barely able to eat lunch, and returning him to bed. Barely responds to inquiry ...states he is tired and wants to go to bed ...discussed holding meds Staff report pt. is usually verbally aggressive and easily agitated. Vital signs Temperature (T) 96.7, Pulse (P) 78, Blood Pressure (BP) 102/58, Respirations (R) 16, and Oxygen Saturation (SAT): 94 %" ( did not indicate whether its on room air or oxygen). There was no further documentation of who was to hold medications or if medications were held.

Review of patient #1's medication record for 7/2/15, revealed, the patients Lopressor (antihypertensive) 50 mgs was held at 6:00AM due to a decrease in blood pressure 102/58 and again at 6:00PM, B/P was 112/70. There was no documentation in the nurse's notes that MD was notified. Patient #1 was administered Trazadone 50mg and Valium 10mg at 6:00PM. No further evaluation of blood pressure.

Review of the physician orders for Friday 7/3/15, at 10:30AM, revealed an order to increase the Risperdal to 1 mg twice a day.

Review of the nurse's multi-disciplinary notes on 7/3/15, at 11:15AM, revealed a note documented by the LVN, "Patient sitting in w/c at dining room table, sleeping, very difficult to arouse. V/S 122/75, 61, T96, R-16, 98% on room air. Sternal rub done by charge nurse. Patient moaned and tried to get nurse to stop. Patient moved to recliner to rest. Patient woke during transfer. V/S WNL nurse practitioner notified and Psychiatrist to be notified."

There was no documentation of decreased LOC, sternal rub, or close observation documented by the RN. Review of the RN assessment for 7/3/2015, 7AM-7PM, revealed all systems were normal. In the section on number hours of sleep RN documented, "all day asleep." No other information was documented on holding the patients medications, patient assessments, psychiatrist notification, or if patient required closer observation.

Review of the multi-disciplinary note dated 7/4/15, at 5:30PM, revealed patient #1 was sent to the ER for Bradycardia and unresponsive to sternal rub. The RN also wrote a verbal physicians order, given by the NP, to transfer the patient to the ER on 7/4/2015, at 5:30PM. However, the patient ER note stated, he was sent on 7/3/15, at 5:42PM. The RN had written the wrong date on the order and the nurse's note.

Review of the multi-disciplinary note dated 7/4/15, at 1:30AM, revealed patient #1 returned from the ER. RN documented patients daughter notified. Will continue to monitor closely. There was no other nursing assessment documented. There were no vital signs or a head to toe assessment to document any changes.

There was no daily nurse note found for the evening shift of 7/3/2015. There was no patient assessment documented from 7/3/2015, at 2:00PM, until 7/4/2015 at 12:00PM, a 22 hour span. There was only documentation of the patient leaving the facility and returning from the ER.

Review of the ER notes on 7/3/2015-7/4/2015 by the hospital ER physician stated,

"Additional Notes: Resume nursing home medications and orders. However, it is probably not the best idea to give Valium, Risperdal. Cogentin, Dilantin, and Depakote all at 18:00 (6:00PM), and then follow it up with Trazodone at 21:00 (9:00PM). Any one of those medications can be sedating, so it is not surprising that all of them given together would cause him to be unresponsive, Therefore, please have his physician reconsider his nighttime medications to avoid having this happen again."

Review of the physician progress note on 7/4/2015, at 11:40AM, revealed the NP saw the patient again and stated, "Up and out to meal...doing well ...staff report sent out to ER last PM and returned w/recommendations for med chg ...this to be referred ...Responds well to inquiry ...denies C/O ...staff report no px management today either behavioral or medical. V/S T97.6, P: 62, B/P: 143/59 R: 17 Sat: 97%."

Review of the nurse's daily notes dated 7/4/15, at 12:00PM, revealed the RN documented all systems were normal and wrote "sedated" under behavior column. RN documented, "pt slowed medication held/MD notified. Pt stimulated and reports no complaint. Will continue to monitor closely." There was no further nursing documentation.

Review of patient #1's medication record (MAR) on 7/4/15. revealed Lopressor was held at 6:00AM due to B/P 100/67, Valium 10 mgs at 6:00PM, and Trazodone 50mg at 9:00PM. Nurse documented on MAR "pt already sleepy. Hard to wake."

Review of the physician orders for 7/5/15, at 6:00PM, revealed a verbal order to decrease the Valium to 10 mg once daily at 6:00PM, decrease Risperdal to 1mg at 6:00PM. Another verbal order was taken at 8:20PM to administer Benadryl 50mg IM now and every 2 hours for EPS.

Review of patient #1's MAR for 7/5/2015 revealed patient #1 received the following medications:
1. Benadryl 50mg IM at 9:00PM and 11:00PM.

2. Lopressor 50mg by mouth at 6:00AM and 6:00PM

3. Risperdal 1mg by mouth at 6:00AM and at 6:00PM

4. Cogentin 1mg by mouth at 6:00AM and 6:00PM

5. Valium 10mg by mouth at 6:00PM.

6. Trazadone "refused Trazadone tonight." There were no vital signs documented for 7/5/2015.

Review of the nursing assessment for 7AM-7PM shift on 7/5/15, revealed the nurse did not fill out the patient systems assessment. There was no documentation of any EPS symptoms documented for the 7AM-7PM and 7PM-7AM shift. Review of the physician progress notes for 7/5/15 revealed no documentation of EPS symptom to justify Benadryl injections.

Review of daily nurse's notes dated 7/7/15, at 9:00AM, revealed the nurse documented under hours of sleep, "slept on and off today. Pt did not sleep during night shift as reported by nurse." Under the Neurological/LOC section the RN documented, "+ confusion, tremors, and seizures v/s T-95.5, P-78, R-15, B/P 157/96. Temp f/u -97.2." There was no further documentation found of a seizure, assessment afterwards, if the physician was called, or when this follow up temperature was taken. There was no physician documentation on 7/5/15 of tremors, seizure, or EPS symptoms.

Review of patient #1's physician orders on 7/10/15, at 11:30AM, revealed a verbal order to increase Risperdal to 2mg by mouth twice a day for psychosis. There was no nursing documentation found of increased psychosis, or EPS symptoms in nursing or physician documentation. There was no teaching provided to patient or consent from patient for increase in psychotropic medication. Review of the daily nursing notes revealed there was no notes for the day shift 7AM-7PM on 7/10/15 -7/14/2015.

Review of the multi-disciplinary note for 7/14/15, at 4:00AM, revealed the RN documented, "During medication pass (AM), pts medication was given with pudding. Pts swallowing appeared slowed and insufficient. Pt began allowing medication to drool from mouth. (Note: medication was crushed and combined with pudding for affective pallibility.) " There was no daily nursing note found for this shift. There was no further nursing assessment or evaluation of LOC. Patient #1 had no medications ordered for 4:00AM.

Review of the multi-disciplinary note for 7/14/15, at 4:30PM, revealed, "oral temp 89.9. Pt assessed and rectal temp was 90.1. On taking rectal temp impaction noted. Notified Dr. Todd re findings. Note new orders. Orders implemented. Temp evaluated in the room and blankets applied. To f/u per results."

Review of patient #1's chart revealed patient#1 had three bowel movements from 6/15/15-7/13/15. Review of the chart revealed the only bowel movements were on 6/16, 6/23, and 7/10/15. There was no documentation of nursing assessment of bowel movements or possible impactions.

Review of patient #1's physician orders for 7/14/15, at 4:40PM, revealed a verbal order to check for an impaction and administered a fleets enema if impacted. If patient had no results to administer a Ducolax suppository x1.

Review of patient #1's chart revealed no daily nurses note on 7/14/15 or systems assessment. There was no documentation found of impaction removal, patient neurological status, vital signs, or if the physician orders were followed.

Review of patient #1's physician orders for 7/14/15, at 7:00PM, revealed a verbal order that stated, "Send to hospital ER for Hypothermia and R/O GI bleeding. (rectal temp =90.1; large black tarry stool s/p enema."

Review of the physician's History and Physical from the receiving acute care hospital stated the patient was admitted for the following;

1. Encephalopathy (Disease, damage, or malfunction of the brain).

2. Dehydration (occurs when your body does not have as much water and fluids as it should).

3. Dementia (is a general term for a decline in mental ability severe enough to interfere with daily life).

4. Dysphagia (difficulty swallowing).

Patient #1 was hypothermic and was admitted into ICU for IV antibiotics and received a PEG tube (Percutaneous endoscopic gastrostomy involves placement of a tube involving a surgical procedure for placing a tube for feeding.) The GI bleed was ruled out. After 8 days in the acute care hospital patient #1 returned to his nursing home."

Review of the policy and procedure "Nursing NSG-02: Documentation" stated,
"Documentation: Inpatient:
RN/LVN documents on the Daily Nurse's Note a minimum of once per shift or at the time any pertinent event occurs (may utilize integrated progress notes if additional space is needed). "
Review of patient #1's chart revealed the nurse documented only once in a 24 hour period for the following dates;
a.) 6/16/2015- 6/19/15
b.) no daily nursing notes found for 6/18/15
c.) 6/20/15, 6/22/15
d.) 6/24/15- 6/26/15
e.) 7/1/15 and 7/3/15
f.) 7/4/15- 7/13/15
g.) no notes for 7/14/15

Review of the "Vital Signs- Intake and Output" documentation revealed there was no found vital signs, intake of meals, fluids, output of urine and bowels, or weights on 6/26/15, or 7/4/15- 7/9/15.

An interview was conducted with staff #1 and staff #2 concerning nursing documentation. Staff #2 reported she was aware of the poor documentation but was working on "strengthening the documentation process." Staff #1 confirmed the documentation was poor or absent. Staff #1 was asked who was monitoring and auditing the charts and staff #1 reported the nurses documenting were to do audits. Staff #1 and #2 confirmed that was not an effective plan.





2.) Review of patient #11's chart revealed an admission on 5/13/2015, at 5:50PM, with a diagnosis of Neurocognitive Disorder with behavioral disturbances, Aggression. Patient #11's chart revealed he was escorted to the facility on a Peace Officers Warrant (OPC) from Brazos County Sheriff's Department.

Review of patient #11's "Multi-Disciplinary Note" dated 5/13/15, at 5:50PM, revealed patient #11 was brought to the facility by ambulance in four point restraints. Restraints were removed upon arrival to facility. Patient #11 was combative and agitated on arrival. Nurse stated, " Order obtained for injection for severe agitation. Note new orders."

Review of the verbal physician orders for 5/13/15, at 6:10PM, stated, "Give Ativan 2mg IM, Haldol 10mg IM, and Benadryl 50mg IM now 1 time dose for severe agitation." Review of the medication administration record (MAR) revealed medication was administered on 5/13/2015, at 6:10PM. There was no documentation found of injection site.

Review of the chart revealed there was no interventions documented before the administration of psychoactive medications on 5/13/15, at 6:10PM. There was no "face to face" done by the physician for a chemical restraint. There was no assessment of patient's v/s or physical/mental status, or medication effectiveness after the administration of medication.

Review of the Multi- Disciplinary Note dated 5/13/15, at 9:00PM, stated, "Received in report at shift change, information for new admission, pt. is awake, eyes closed up at nurses station in Geri-chair moving legs and arms, removing lap covering and gown, responds to verbal and physical stimuli, does not answer questions, occasionally swats at air, mumbling words, 1:1 staff supervision. S/P sedation no pain or discomfort noted, agitation continues no combativeness at this time." Review of patient #11's chart revealed there was no order found for use of the Geri-chair from 5/13-5/21/2015. A Geri chair, short for geriatric chair, is an upholstered recliner on wheels that can be pushed around like a wheel chair. It usually has a removable tray.

An interview with staff #1 on 9/22/15, confirmed the Geri chairs are not used that often because they have to obtain a physician's order to use it. A Geri- chair can be used as a restraint.

Review of the policy and procedure "Levels of Observation and Monitoring" stated the following:
One-to-One Observation:
Physician/LIP:
Provides order for one-to-one observation based on assessed risk and individual needs.
The physician/LIP must give the order to discontinue a one-to-one level of observation once it is begun.

Registered Nurse:
1.) Explains procedure to the patient. Provides for the respect of the patient.
2.) Shall implement one-to-one order when received.
3.) May invoke a one-to-one observation with approval of the DON or Administrator based on identified risk of patient pending notification of LIP for an order.
4.) Assesses patient's condition regarding danger to self, others, fall risk, psychological factors, elopement and psychosis which places the patient at risk.
5.) Reports assessment findings to physician/LIP and DON.
6.) Assigns a nursing staff to perform one-to-one and relief staff for all breaks.
7.) Documents the reason for the observation by circling on close observation form, precautions type, suicide, fall, etc. If precautions are for fall risk includes a fall risk sticker on the close observation form.
8.) Documents in the patient's chart and nurse report sheet and kardex the level of observation ordered and implemented.
9.) Assigns member(s) of nursing staff to conduct a thorough search of the patient's room and belongings and remove any object that can be harmful to the patient. Monitors belonging per belongings policy."

Review of patient #11's chart revealed there was no order for a 1:1. Review of the staffing schedule 5/13/2015 revealed no documentation of a staff member assigned as a 1:1. There was no documentation of vital signs before or after medication administration.

Review of the MHT's close observation sheet for 5/13/15, revealed patient #11 was to be monitored and charted on every 15 minutes. The documentation reported patient #11 in the dayroom (nurse's station is in the dayroom) from 6:00PM to 6:15AM on 5/14/2015. The next "every 15 minute observation" starts on the next sheet at 7:30AM on 5/14/15. There was no found documentation for 1 hour and 45 minutes.

Review of patient #11's verbal physician orders dated 5/14/15, at 4:00PM, stated, " Give Ativan 2 mg, Haldol 10mg, Benadryl 50mg IM now 1 time dose for severe agitation. A nurses note was found for 5/14/15, 7AM-7PM. The nurse documented on the daily nurse's note at 6:55PM. There was no nursing documentation found for behaviors requiring chemical restraint, interventions performed, condition of the patient, or effectiveness of the medication. There was no documentation of injection site.

Review of the daily nurses notes dated 5/14/15, at 10:35PM, stated, "Pt is confused, is irritable and increase anxiousness with agitation, yells out loud, cursing staff, striking staff, After multiple redirections and attempts to reorient, order received Ativan, Benadryl, Haldol injection to be given."

Review of patient #11's MAR dated 5/14/15, revealed patient #11 received Ativan 2 mg, Haldol 10mg, and Benadryl 50mg IM at 10:35PM.

Review of patient #11's chart revealed there was no order found for the administration of psychoactive medications on 5/14/2015, at 10:35PM. There was no found documentation of a face to face done before or after the medication administration. There was no assessment or vital signs documented after the administration of psychotropic medications. There was no found documentation of injection site.

Review of the MHT's close observation sheet for 5/13/15- 5/14/2015, revealed patient #11 was in the dayroom area or at nurse's station. There was no documentation found that patient #11 was taken to his room to rest in a bed away from stimulation. There was no documentation of patient consuming any fluids or food. There is no documentation of any out-put of urine or bowels for 5/13/15 or 5/14/15.

Review of patient #11's MAR revealed patient #11 received an injection of Ativan 2mg, Haldol 10mg, and Benadryl 50mg IM now dose on 5/15/2015, at 10:30AM. There was no documentation of the injection site. There was no physician's order documented for the IM medications.

Review of patient #11's daily nurse's note revealed the RN did not document until 4:10PM a span of 5 hours and 20 minutes later. RN documented, "increased agitation and aggressive behavior as evidence by pt. hitting and kicking and cursing nursing staff. Redirection and verbal support provided."

A one hour face to face was found dated 5/15/, at 11:30AM. There was no signature of discipline on who performed the face to face. The document stated, "Pt combative with hospital staff- spitting and hitting MHT's, yelling- attempting to climb over Geri-chair increased aggression/agitation. The following interventions were checked:
1.) Verbal support
2.) Offer food
3.) Offer one to one support
4.) Make environmental changes
5.) Redirection
6.) Offer fluids
7.) Verbal de-escalation
8.) Utilize pharmacotherapies as ordered.

A one hour face to face dated 5/15/15, at 11:30AM, under "patient's response to interventions stated, " decreased aggression, agitation- pt. still attempted to hit at staff but became calmer. Ate and drank ensure soon after decreased anxiousness."

Review of the nursing notes and MHT observation record on 5/15/15, revealed the patient was never taken out of the dining room or Geri-chair. There is no documentation on the "vital sign/intake and out put record" that patient consumed any fluids or food. There was no assessment before the restraint or afterwards documented by the RN.

Review of the daily nurse's notes dated 5/15/15, for the 7PM-7AM, shift RN documented, "Aggression/sleeplessness: Pt aggressive and swatted at staff members in dayroom. Minimal sleep noted. Redirect/ reorient behavior.

Review of the Multi-Discipline Note for 5/15/15, at 8:30PM, revealed RN documented, "Psychiatrist contacted for pt. aggression and combativeness towards staff. Ordered medication initiated by nursing staff to calm aggression. Drug IM given in (r) arm."

A verbal physician order dated 5/15/15, at 8:30PM, stated, "Haldol 10mg, Benadryl 50mg, and Ativan 2mg IM now, and Q 4 hours PRN for severe agitation, aggression." Review of the MAR revealed there was no documentation of medication administration for the IM medications or injection site on 5/15/15, at 8:30PM. Drugs used as a chemical restraint may not be ordered as PRN (as needed).

Review of the one hour face to face Evaluation form dated 5/15/15, at 9:35PM, stated, "Severely agitated and swinging and an attempt to hit staff, hollering".

The following interventions were checked;
1.) Verbal support
2.) Encourage appropriate expression
3.) Offer one to one support
4.) Diversional techniques
5.) Redirection
6.) Offer fluids
7.) Verbal de-escalation
8.) Utilize pharmacotherapies as ordered.

Vital signs were documented as B/P -103/70, P- 68, R-18, and O2 Sat: 95%. RR documented, "findings from the evaluation were reviewed with the psychiatrist on 5/15/15, at 9:35PM. There was no documentation found from the RN on 5/15/15, at 8:45PM, if food or fluids were offered. The RN documented at 9:00PM, 9:15PM, and 9:30PM "N/A" for snacks or fluids offered.

Review of the MHT's close observation sheet for 5/15/15, from 12:00AM until 12:00PM, revealed patient #11 was in the dayroom area or at nurse's station. There was no documentation that patient #11 was taken to his room to sleep and rest in a bed with no stimulation. There was no documentation that patient was given IM medications in a private area.

Review of patient #11's Multi-Discipline Note for 5/16/15, at 12:25PM, RN documented, "Pt began hitting himself in the head and hitting both of his upper thighs w/ his fists, crying, cursing, screaming, hitting at staff. Pt was a danger to himself and others. Pt was administered an injection per Dr.'s "PRN" order. Pt. restraint and seclusion packet done, Administrator, Dr notified, family not notified d/t pt has not consented. V/s taken. 1 hour face to face completed by RN. 12:25PM Pt. still hitting himself at this time pt has one on one feeding him."

Review of patient #11's MAR for 5/16/2015, at 12:25PM, revealed there was no documentation of IM medications given or site of injections.

Review of the one hour face to face form dated 5/16/15, at 12:25, revealed there was no second page with the evaluators name or discipline. The first page stated, "Pt hitting himself on his head and both thighs with his fist. Hitting at self, cursing, hollering. "

Review of the Seclusion/Restraint/Emergency Administration of Psychotropic Medications dated 5/16/2015, at 12:20PM, revealed the patient was given "Emergency Administration of a PRN order." Pt was given "redirection and reorientation." The patient's family was not notified of the administration of psychoactive medications due to "Pt has not consented to notifying family." RN documented the patient was on a 1:1 with staff. There was no order noted for the 1:1. There were no documented vital signs due to " pt refused. " No further interventions or assessments were documented.

Review of the Seclusion/Restraint/Emergency Administration of Psychotropic Medications dated 5/16/2015, at 12:20PM the section under "Debriefing with Patient/LAR (contact and document) stated, "Date: 5/17/15 at 2:00PM Pt. confused unable to understand." Below that comment a hand written note was found with an asterisk sign. The comment stated, "Family notified during visitation about the chemical restraints and consent rcvd." The hand written note was in different hand writing and had no name of the author, date, or time. There was no documentation of what family member was notified.

Review of Patient #11's "significant others" written complaint stated, "On May 16 patient (#11) & my daughter & his fulltime caregiver from Oct. 2009-March 2015, drove to Lufkin to see patient at the facility & found him angry, scared, & agitated in a Geri-Chair with feet up head down & all of his weight on his bottom. He had no straps or ties on but he was clearly restrained, unable to get out of the Geri-Chair. He complained of discomfort & of his bottom hurting. He squirmed constantly & was unable to get comfortable. We ask if he could go to his bed & were told that he would not stay there. The staff called him the wrong name & when I talked to the nurse she told me that his name on his chart was: first name and last name were backwards. She explained to me that they had been unable to call me to inform me of his condition because he had not given consent

Based upon observation, record review and interview, nursing failed to


A.) have a responsible DON present for the operation of the services provided, including determining the types and numbers of nursing personnel, and staff necessary to provide nursing care for all areas of the hospital from 3/22/15-5/26/15.

Refer to Tag A0386



B.) follow its own policy and procedures to have RN supervision on each shift during break time, failed to have adequate staffing of licensed personnel, and failed to have a Director of Nursing for a two month period. This deficient practice had the likelihood to cause harm to all presenting and in-patients in the hospital.
Refer to Tag A0392


These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.



C.) provide ongoing assessment of patient's medical condition throughout the hospitalization for 2 (#1, #11) of 6 patients review. Nursing failed to provide assessment and notify physician when a change of condition occurred for 6 (#1, #3, #5, #7, #9, #11) of 6 patients reviewed. Nursing failed to obtain physician's orders for emergency psychoactive medications that were given to 2 (#1, #11) of 6 patients reviewed.
Refer to Tag A0395


These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients causing harm to 2 patients, the likelihood to cause harm, serious injury, impairment and/or subsequent death.



D.) allow the patient or family members participate in the development and implementation of patient plan of care in 1 (#1) of 3 (#1, #11, #13) charts reviewed.

Refer to Tag A0396

Based on review of employee files and interview, the facility failed to have a responsible Director of Nursing present for the operation of the services provided, including determining the types and numbers of nursing personnel, and staff necessary to provide nursing care for all areas of the hospital from 3/22/15-5/26/15.

Review of the Director of Nursing (DON) employee file revealed she was hired on 5/26/2015. Review of the previous DON employee file revealed the DON resigned from the position and took a RN patient care position on 3/22/2015.

An interview was conducted with staff #1 on 9/22/15. Staff #1 reported the facility did not have a DON from 3/22/15- 5/26/15. Staff #1 reported the corporate DON had been down for a week during that time but he was not onsite. Staff #1 reported during that time she was responsible for staffing.

Based on chart reviews, interviews, and policy and procedures review, the facility failed to follow its own policy and procedures to have RN supervision on each shift during break time, failed to have adequate staffing of licensed personnel, and failed to have a Director of Nursing for a two month period. This deficient practice had the likelihood to cause harm to all presenting and in-patients in the hospital.

These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.


Review of the facility's policy and procedure "Nursing Staffing Plan" policy stated, "The facility is staffed utilizing a core staffing pattern with increase in nursing census utilized for acuity with a minimal staffing of 7.0 NHPPD and maximum hours based on the DON judgment and approval.

Staffing hours are adjusted based on the clinical decision of the DON regarding the needs of the unit. The staffing will be flexed up or down depending on the acuity, level of skills of staff, and other variables deemed appropriate by the DON."

Review of the patient census and staff scheduling revealed 25 patients is the maximum census. The grid revealed the following staffing pattern:

1.) 1 RN, 1LVN, and 1 MHT per shift up to 5 patients.
2.) 1 RN, 1LVN, 2MHT's for 6-10 patients.
3.) 1 RN, 1 LVN, 3MHT's for 11-15 patients.
4.) 1 RN, 1 LVN, 4MHT's for 16-20 patients.
5.) 1 RN, 1 LVN, 5MHT's for 20-25 patients.

During an interview on 9/23/15, staff #2 confirmed the grid was used currently for staffing. The grid also included a mid shift LVN and Staff #2 reported the facility is currently not utilizing the mid shift LVN.

Review of the staffing schedules and the "daily staffing and census" sheets revealed 20 out of 62 shifts with no licensed personnel (RN's and LVN's) scheduled in August 2015.

Review of the staffing schedules and the "daily staffing and census" sheets revealed 30 out of 34 shifts with no licensed personnel scheduled from 9/1-17/2015.

August 2015;
13th- No LVN documented for 7AM-7PM. No RN or LVN 7PM-7AM.
14th- No LVN documented for 7AM-7PM. No RN or LVN 7PM-7AM.
15th- No RN or LVN documented for 7PM-7AM shift.
16th- No RN or LVN documented for 7PM-7AM shift.
18th- No LVN documented for 7PM-7AM shift.
27th- No RN or LVN documented for 7AM-7PM or 7PM-7AM.
28th- No RN or LVN documented for 7AM-7PM.
29th- No RN or LVN documented for 7AM-7PM
30th- No RN or LVN documented for 7PM-7AM shift.
31st- No LVN documented for 7AM-7PM.

September 2015;
1st- No LVN documented for 7AM-7PM.
2nd- No LVN documented for 7PM-7AM.
3rd- No RN or LVN documented for 7PM-7AM shift.
4th- No LVN documented for 7AM-7PM. No RN or LVN documented for 7PM-7AM shift.
6th- No LVN documented for 7AM-7PM.
7th- No LVN documented for 7AM-7PM.
9th- No RN or LVN documented for 7AM-7PM or 7PM-7AM.
11th- No RN or LVN documented for 7PM-7AM shift.
9/12, 13, and 14th- No RN or LVN documented for 7AM-7PM or 7PM-7AM.
15th- No LVN documented for 7AM-7PM.
17th- No RN or LVN documented for 7AM-7PM or 7PM-7AM.

An interview with staff #2 was conducted on 9/23/15. Staff #2 confirmed there were blanks in the staffing schedule. Staff #2 reported the facility was short staffed and they were trying to get nurses. Staff #2 denied using agency nurses even though the facility had a contract with staffing agencies to assist in staffing shortages. Staff #2 reported she had come in to cover when there were no nurses. Staff #2 stated, "I am salary so I never clocked in or put my name on the schedule." Staff #2 confirmed she could not prove she worked as a staff nurse.

On 9/22/15, at 10:00AM, the surveyor saw the RN(Staff #10) assigned for the unit, off of the unit in the administrative offices. This was the only RN scheduled on the floor to supervise the staff and patients. Staff #10 (RN) was seen leaving the unit with no RN supervision two more times that day for up to 20 minutes.

An interview was conducted with staff #1 and #2 concerning the patient unit with no RN supervision. Staff # 1 reported she talked to the RN about leaving the unit and reported the RN did this frequently and they were planning on terminating her. Staff #1 reported she had already instructed staff # 10 that she was not to leave the unit uncovered.

The following morning on 9/23/15, staff #10 was found off the unit again at 9:30AM. Staff #10 was in the administrative offices leaving the floor uncovered. Staff #1 stated, "I am calling right now to get someone to come in and replace her and I am sending her home." Staff #1 was not able to get another RN to cover until 3:00PM. Staff #13 came in but staff #10 was not sent home.

Staff #1 was questioned on how and when the RN took breaks and who was supervising the unit during those times? Staff #1 reported they took their breaks at the desk or on the unit. Staff #1 stated, "They are not supposed to leave the unit and the facility was not required to give them a break". Staff #1 reported the RNs in the administrative office can go to the unit to relieve the RN as needed. Staff #1 was asked by the surveyor about the RN coverage on weekends and nights. Staff #1 reported the nurses didn't take lunch breaks. Staff #1 confirmed the employees were not getting paid for the lunch breaks they were not taking.

Staff #14 (RN) worked the night shift, on 9/22/15, 7PM-7AM. Staff #1 was asked if this RN took a lunch break. Staff #1 stated, "No I don't think she did." Staff #14's time sheet was pulled and revealed the RN was docked 30 minutes for a lunch break.

Review of Policy and Procedure "Rest /Meal Periods" stated,

"POLICY
The hospital recognizes that short rest periods and relaxing meal periods during the course of the workday enhance employee morale and productivity. All rest and meal periods must be in strict compliance with applicable state and federal laws. Neither state nor federal law requires that employees 18 years or older be given a break (including lunch). The failure to give a break is, therefore, not a violation of law. Minors must take a documented break of not less than 30 minutes if they work any period in excess of five (5) hours. For any meal period to be unpaid, it must be at least 30 minutes in duration and uninterrupted,

REST PERIODS
The facility may allow each employee a rest period, not to exceed 15 minutes, for each continuous four hours worked in a work shift. These breaks are to be taken as permitted by schedules and workloads, and as approved by the employee's supervisor and/or department head If circumstances do not allow such a break or if an employee chooses not to take a break, the time cannot be used to lengthen a lunch break, to shorten a shift or to accumulate for future use.

MEAL PERIODS
Employees who work six or more continuous hours are eligible to receive an unpaid meal period of 30 minutes. Meal periods will be scheduled by appropriate supervisory personnel at times that do not interfere with patient care or departmental operations. Although there are times and circumstances that may prevent the granting of a meal period, every reasonable effort will be made to do so. If it becomes necessary for employees to remain on duty during their meal periods or to be called back to work due to an emergency, employees will be paid for the entire meal period or granted another meal period during the shift.
A lunch/dinner break of thirty minutes will automatically be deducted from each 6- hour shift worked unless the employee's supervisor notes otherwise on his/her timesheet.

USE OF MEAL PERIODS
Employees who are on their meal periods are not permitted to interfere with fellow employees who are continuing to work.

LOCATION OF MEAL PERIODS
Rest or meal periods must be taken in the employee lounge areas, appropriately designated smoking areas or in other similarly designated non-work areas. Patient care areas, lobbies and other public areas are not to be used as rest areas."


An interview was conducted with staff #12 (LVN) on 9/23/15, at 3:45PM. Staff #12 stated the RN was responsible for assessing the patients during the shift. The LVN assists but spends most of the work time passing medications. Staff #12 confirmed they have worked shorthanded frequently and when the facility is full it's difficult to take a break.

Staff #12 took the surveyor to the break room assigned for the nurses. Surveyor was taken off the unit, through a door, down a hallway, and through another door to the break room. It was confirmed the licensed staff leave the unit to take a break in the break room. The surveyor was unable to hear anything on the unit from that distance.

Staff #12 confirmed that she was afraid something might happen due to the level of severity of some of the patient's mental and physical status. Staff #12 stated, "It's just too much sometimes. These patients are really sick and take a lot of time. We do the best we can but it gets scary sometimes."

An interview with staff #10 (RN) on 9/23/15, confirmed she had not taken a lunch break today. Staff #10 stated, "It causes me more stress to take a break. I just can't keep up with all the patient assessments and paperwork. Staff #10 did confirm she gets docked for the lunch break whether she takes it or not. Staff #10 stated, "There are times I do need a break and I take it." Staff #10 reported she goes to the assigned break room off of the nursing unit. Staff #10 confirmed having only one RN with this many patients was not safe. Staff #10 confirmed she has voiced her opinions concerning patient safety to administration but they are still shorthanded.

An interview with staff # 13 (RN) revealed she takes her lunch breaks in the assigned break room located off of the patient unit. Staff #13 also confirmed there have been shifts she did not get a break due to patient load or severity of the patients on the unit.

Staff #13 reported when a patient is medicated for behavior issues the RN should stay with the patient. Staff #13 stated, "Since there is only one RN and the LVN is passing medications I have to put the patient in the recliner or chair and sit them by the desk so I can monitor everybody else." Staff #13 confirmed the patients have to stay the entire shift, in the dayroom, and not allowed to lie down in the bedroom due to staffing shortages. Staff #13 reported that administration did not encourage 1:1's (1 staff member to 1 patient within arm's length.)

Staff #13 stated, "I feel they need more staff to cover. I can't keep up sometimes. It scares me. I have always been one to speak up and ask for help. Sometimes I get it and sometimes they just can't find anybody."

Review of the facility's policy and procedure "Nursing Staffing Plan" policy stated, "Advisory Committee: Any RN/LVN may report concerns regarding staffing to the advisory committee without any retaliation."

There was no found documentation that a nursing advisory committee meeting had been held for 2015.

Staff #1 reported the facility did not have a DON from 3/22/15- 5/26/15. Staff #1 reported the corporate DON had been down for a week during that time but he was not onsite. Staff #1 reported during that time she was responsible for staffing.

Based upon record review and interview, Nursing staff failed to provide ongoing assessment of patient's medical condition throughout the hospitalization for 2 (#1, #11) of 6 patients review. Nursing failed to provide assessment and notify physician when a change of condition occurred for 6 (#1, #3, #5, #7, #9, #11) of 6 patients reviewed. Nursing failed to obtain physician's orders for emergency psychoactive medications that were given to 2 (#1, #11) of 6 patients reviewed.

These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients causing harm to 2 patients, the likelihood to cause harm, serious injury, impairment and/or subsequent death.


1.) Review of patient #1's chart revealed an admission on 6/15/2015 with a diagnosis of Neurocognitive Disorder (Dementia) with behavioral disturbances. Patient #1 was 87 years old, 5'10", and weighed 130 lbs at admission. Patient #1 had episodes of aggression and had hit another patient at the nursing home. Patient #1 was admitted as a voluntary patient to the facility. Review of the physician history and physical dated 6/17/15, at 6:20AM, stated, "Chief Complaint- Dementia. Mental/Emotional Status; Pleasant Confused."

Review of patient #1's physician orders for 6/15/2015, revealed patient 31 was placed on seizure, assault and fall precautions.

Review of patient #1's daily nursing notes for 6/16/2015, 7AM-7PM revealed patient #1 was mobile in his wheelchair but remained confused and delusional. In the section for precautions the nurse only checked fall precautions. Review of the vital sign record revealed the patients oxygen saturation (O2 sat) was 95 at room air. Review of the chart revealed there was no nursing documentation found for 6/16/15 for the 7PM-7AM shift or for 6/17/15, 7AM-7PM. The next nursing documentation was on 6/17/15, at 7PM-7AM, a lapse of 36 hours.

Review of patient #1's daily nursing notes dated 6/17/2015, 7PM-7AM, revealed patient #1 has had increased confusion and had kicked a Mental Health technician (MHT) on that shift. Patient #1's O2 sat was 94% on room air but lung sounds were clear. There was no further documentation of MD notification of decreasing O2 sat. RN stated, "Remains cooperative and easily re-directed." Nurse only checked falls for safety precautions observed.

Review of patient #1's daily nurse's notes revealed there was no nursing documentation or assessments found for 6/18/2015. No nursing documentation for 36 hours.

Review of the Nutrition assessment completed by the Dietician on 6/19/15, revealed patient #1 had a history of a Cardiovascular Accident (CVA) but had no issues with swallowing. Patient #1 had consumed 75% of his meal and drank a supplement. Dietician's plan stated, Glucerna 1 can twice a day, monitor weight, and monitor for s/s of choking.

Review of patient #1's daily nurse's notes for 6/19/2015, revealed the patient was now on choking precautions. There was no documentation found of physician notification.

Review of patient #1's chart revealed there was no nursing documentation for 24 hours from 6/21/15, at 10:25PM, until 6/22/15, at 10:15PM.

Review of patient #1's daily nurses notes for 6/24/15, revealed there was no found nursing documentation for 6/24/15, 7AM-7PM. Review of the nurses note for 6/24/15, 7PM-7AM revealed the patient was pacing in wheelchair. "Easily redirected."

Review of patient #1's chart revealed a "Physician's Order for Emergency Administration for Psychoactive Medication" dated 6/25/15, at 7:00AM.

The order read," Haldol 5mg IM now, Benadryl 50mg IM now, and Ativan 2mg IM now for severe agitation."

Review of patient #1's chart revealed a "Multi-Disciplinary Note" dated 6/25/2015, at 6:55AM. The RN documented, "Patient was physically and verbally aggressive with one of the techs. Pt stated, "You bitch leave me alone I'm going to piss on the floor." Patient was swinging at staff. Patient #1's daughter was notified of medication administration."

There was no documentation of a comprehensive patient assessment to determine the need for other types of interventions before using a drug or medication as a restraint. There was no documentation found of what interventions were attempted, how the patient responded, or what provoked the behavior.

Review of the daily nurse's notes on 6/25/15, revealed there was no found documentation on patient #1 for the 7AM-7PM shift. There was no further documentation found of any patient assessment until 8:15PM, on 6/25/2015. There was no found documentation if the patient tolerated the medication or effectiveness. RN documented, "Patient asleep at start of shift no behavior."

Review of the physician orders on 6/26/15, at 10:50AM revealed a verbal order, "Benadryl 50 mg IM now EPS."

EPS (extrapyramidal symptoms) are serious side effects associated with the administration of antipsychotic medications. Examples of EPS include rigidity, akathisia (restlessness), and acute dystonic reactions such as tightening of muscles in neck or throat.

Review of patient #1's chart revealed there was no daily nurse's note for 6/26/15, on the 7AM-7PM shift. Review of the 6/26/15, 7PM-7AM daily nurse's note revealed there was no found documentation of EPS symptoms. The RN had documented under Neurological/L.O.C. "Unimpaired."

Review of the physician progress notes for 6/26/15, revealed no reason for the Benadryl IM order. The medication and EPS was not documented in the physician progress note.

Review of the physician orders on 6/27/2015, at 10:20AM, revealed a verbal telephone order to discontinue Zoloft and "start Valium 5mg at 6am and 6pm for anxiety and agitation daily and Trazadone 50mg po QHS for insomnia."

Review of the daily nurse's notes for 6/27/15, at 7AM-7PM shift, revealed patient #1 was agitated and anxious. The RN documented, "Patient is confused. Pt was sitting at nurse's desk and reached out to hit a tech that was standing beside him. Pt was redirected to drink his coffee. Pt complied. I will continue to redirect as needed." There was no documentation found of new medication ordered, administered, or effectiveness of new psychotropic medication.

Review of the daily nurse's notes on 6/28/15, at 8:00AM, revealed the patient is now hallucinating and picking at the floor. There is no documentation that the physician was contacted about the change in condition. Review of the physician progress note on 6/28/15 does not mention the hallucinations or EPS.

Review of the physician orders on 7/2/2015 at 8:30AM revealed patient #1 had new orders to discontinue the Invega and to start on Risperdal 0.5mg twice a day. Increase Valium to 10 mg twice a day.

Review of Risperdal use, dosage, and side effects revealed the following:
" WARNING
INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA RELATED PSYCHOSIS

Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. RISPERDAL® (risperidone) is not approved for the treatment of patients with dementia-related psychosis. [See WARNINGS AND PRECAUTIONS] "

Review of the daily nurse's notes for 7/2/2015, at 8:15AM, stated, "Easily agitated. Refuses asst from staff. Irritable. Isolates to self. Withdrawn. Redirection and verbal support provided. Pt not easily receptive but will calm himself if given quiet time. Will continue to follow closely and assist his care as needed." There was no nursing documentation concerning the medication changes and evaluation of changes for 7/2/2015.

Review of a Physician Progress Note dated 7/2/2015, at 1:10PM, revealed the Nurse Practitioner (NP) saw patient#1. The NP stated, "Pt seen: Health status exam: Up via w/c, very quiet, staff report pt barely able to eat lunch, and returning him to bed. Barely responds to inquiry ...states he is tired and wants to go to bed ...discussed holding meds Staff report pt. is usually verbally aggressive and easily agitated. Vital signs Temperature (T) 96.7, Pulse (P)78, Blood Pressure (BP) 102/58, Respirations (R) 16, and Oxygen Saturation (SAT): 94 %" ( did not indicate on room air or oxygen.) There was no further documentation of who was to hold medications or if medications were held.

Review of patient #1's medication record for 7/2/15, revealed the patients Lopressor (antihypertensive) 50 mgs was held at 6:00AM due to a decrease in blood pressure 102/58 and again at 6:00PM B/P was 112/70. There was no documentation in the nurse's notes that MD was notified. Patient #1 was administered Trazadone 50mg and Valium 10mg at 6:00PM. No further evaluation of blood pressure.

Review of the physician orders for Friday 7/3/15 at 10:30AM revealed an order to increase the Risperdal to 1 mg twice a day.

Review of the nurse's multi-disciplinary notes on 7/3/15 at 11:15AM revealed a note documented by the LVN, "Patient sitting in w/c at dining room table, sleeping, very difficult to arouse. V/S 122/75, 61, T96, R-16, 98% on room air. Sternal rub done by charge nurse. Patient moaned and tried to get nurse to stop. Patient moved to recliner to rest. Patient woke during transfer. V/S WNL nurse practitioner notified and Psychiatrist to be notified."

There was no documentation of decreased LOC, sternal rub, or close observation documented by the RN. Review of the RN assessment for 7/3/2015, "all day asleep." No other information was documented on holding the patients medications, patient assessments, psychiatrist notification, or if patient required closer observation.

Review of the multi-disciplinary note dated 7/4/15, at 5:30PM, revealed patient #1 was sent to the ER for Bradycardia and unresponsive to sternal rub. The RN also wrote a verbal physicians order, given by the NP, to transfer the patient to the ER on 7/4/2015, at 5:30PM. However, the patient ER note states he was sent on 7/3/15 at 5:42PM. The RN had written the wrong date on the order and the nurse's note.

Review of the multi-disciplinary note dated 7/4/15, at 1:30AM, revealed patient #1 returned from the ER. RN documented patients daughter notified. Will continue to monitor closely. There was no other nursing assessment documented. There were no vital signs or a head to toe assessment to document any changes.

There was no daily nurse note found for the evening shift of 7/3/2015. There was no patient assessment documented from 7/3/2015, at 2:00PM, until 7/4/2015, at 12:00PM, a 22 hour span. There was only documentation of the patient leaving the facility and returning from the ER.

Review of the ER notes on 7/3/2015-7/4/2015 by the hospital ER physician stated,

"Additional Notes: Resume nursing home medications and orders. However, it is probably not the best idea to give Valium, Risperdal. Cogentin, Dilantin, and Depakote all at 18:00 (6:00PM), and then follow it up with Trazodone at 21:00 (9:00PM). Any one of those medications can be sedating, so it is not surprising that all of them given together would cause him to be unresponsive, Therefore, please have his physician reconsider his nighttime medications to avoid having this happen again."

Review of the physician progress note on 7/4/2015, at 11:40AM, revealed the NP saw the patient again and stated, "Up and out to meal...doing well ...staff report sent out to ER last PM and returned w/recommendations for med chg ...this to be referred ...Responds well to inquiry ...denies C/O ...staff report no px management today either behavioral or medical. V/S T97.6, P: 62, B/P: 143/59 R: 17 Sat: 97%."

Review of the nurse's daily notes dated 7/4/15, at 12:00PM, revealed the RN documented all systems were normal and wrote "sedated" under behavior column. RN documented, "pt slowed medication held/MD notified. Pt stimulated and reports no complaint. Will continue to monitor closely." There was no further nursing documentation.

Review of patient #1's medication record (MAR) on 7/4/15, revealed Lopressor was held at 6:00AM due to B/P 100/67, Valium 10 mgs at 6:00PM, and Trazodone 50mg at 9:00PM. Nurse documented on MAR "pt already sleepy. Hard to wake."

Review of the physician orders for 7/5/15, at 6:00PM, revealed a verbal order to decrease the Valium to 10 mg once daily at 6:00PM, decrease Risperdal to 1mg at 6:00PM. Another verbal order was taken at 8:20PM to administer Benadryl 50mg IM now and every 2 hours for EPS.

Review of patient #1's MAR for 7/5/2015 revealed patient #1 received the following medications:
1. Benadryl 50mg IM at 9:00PM and 11:00PM.
2. Lopressor 50mg by mouth at 6:00AM and 6:00PM
3. Risperdal 1mg by mouth at 6:00AM and at 6:00PM
4. Cogentin 1mg by mouth at 6:00AM and 6:00PM
5. Valium 10mg by mouth at 6:00PM.
6. Trazadone "refused Trazadone tonight." There were no vital signs documented for 7/5/2015.

Review of the nursing assessment for 7AM-7PM shift on 7/5/15 revealed the nurse did not fill out the patient systems assessment. There was no documentation of any EPS symptoms documented for the 7AM-7PM and 7PM-7AM shift. Review of the physician progress notes for 7/5/15 revealed no documentation of EPS symptom to justify Benadryl injections.

Review of daily nurse's notes dated 7/7/15 at 9:00AM revealed the nurse documented under hours of sleep, "slept on and off today. Pt did not sleep during night shift as reported by nurse." Under the Neurological/LOC section the RN documented, " + confusion, tremors, and seizures v/s T-95.5, P-78, R-15, B/P 157/96. Temp f/u -97.2." There was no further documentation found of a seizure, assessment afterwards, if the physician was called, or when this follow up temperature was taken. There was no physician documentation on 7/5/15 of tremors, seizure, or EPS symptoms.

Review of patient #1's physician orders on 7/10/15, at 11:30AM, revealed a verbal order to increase Risperdal to 2mg by mouth twice a day for psychosis. There was no nursing documentation found of increased psychosis, or EPS symptoms in nursing or physician documentation. There was no teaching provided to patient or consent from patient for increase in psychotropic medication. Review of the daily nursing notes revealed there was no notes for the day shift 7AM-7PM on 7/10/15 -7/14/2015.

Review of the multi-disciplinary note for 7/14/15, at 4:00AM, revealed the RN documented, "During medication pass (AM), pts medication was given with pudding. Pts swallowing appeared slowed and insufficient. Pt began allowing medication to drool from mouth. (Note: medication was crushed and combined with pudding for affective pallibility.) " There was no daily nursing note found for this shift. There was no further nursing assessment or evaluation of LOC. Patient #1 had no medications ordered for 4:00AM.

Review of the multi-disciplinary note for 7/14/15, at 4:30PM, revealed , "oral temp 89.9. Pt assessed and rectal temp was 90.1. On taking rectal temp impaction noted. Notified Dr. Todd re findings. Note new orders. Orders implemented. Temp evaluated in the room and blankets applied. To f/u per results."

Review of patient #1's chart revealed patient#1 had three bowel movements from 6/15/15-7/13/15. Review of the chart revealed the only bowel movements were on 6/16, 6/23, and 7/10/15. There was no documentation of nursing assessment of bowel movements or possible impactions.

Review of patient #1's physician orders for 7/14/15, at 4:40PM, revealed a verbal order to check for an impaction and administered a fleets enema if impacted. If patient had no results to administer a Ducolax suppository x1.

Review of patient #1's chart revealed no found daily nurses note on 7/14/15 or systems assessment. There was no documentation found of impaction removal, patient neurological status, vital signs, or if the physician orders were followed.

Review of patient #1's physician orders for 7/14/15, at 7:00PM, revealed a verbal order that stated, "Send to hospital ER for Hypothermia and R/O GI bleeding. (rectal temp =90.1; large black tarry stool s/p enema."

Review of the physician's History and Physical from the receiving acute care hospital stated the patient was admitted for the following;
1. Encephalopathy (Disease, damage, or malfunction of the brain).
2. Dehydration (occurs when your body does not have as much water and fluids as it should).
3. Dementia (is a general term for a decline in mental ability severe enough to interfere with daily life).
4. Dysphagia (difficulty swallowing).

Patient #1 was hypothermic and was admitted into ICU for IV antibiotics and received a PEG tube (Percutaneous endoscopic gastrostomy involves placement of a tube involving a surgical procedure for placing a tube for feeding.) The GI bleed was ruled out. After 8 days in the acute care hospital patient #1 returned to his nursing home."

Review of the policy and procedure "Nursing NSG-02: Documentation" stated,

"Documentation:
Inpatient:
RN/LVN documents on the Daily Nurse's Note a minimum of once per shift or at the time any pertinent event occurs (may utilize integrated progress notes if additional space is needed). "

Review of patient #1's chart revealed the nurse documented only once in a 24 hour period for the following dates;

a.) 6/16/2015- 6/19/15
b.) no daily nursing notes found for 6/18/15
c.) 6/20/15, 6/22/15
d.) 6/24/15- 6/26/15
e.) 7/1/15 and 7/3/15
f.) 7/4/15- 7/13/15
g.) no notes for 7/14/15

Review of the "Vital Signs- Intake and Output" documentation revealed there was no found vital signs, intake of meals, fluids, output of urine and bowels, or weights on 6/26/15, or 7/4/15- 7/9/15.

An interview was conducted with staff #1 and staff #2 concerning nursing documentation. Staff #2 reported she was aware of the poor documentation but was working on "strengthening the documentation process." Staff #1 confirmed the documentation was poor or absent. Staff #1 was asked who was monitoring and auditing the charts and staff #1 reported the nurses documenting were to do audits. Staff #1 and #2 confirmed that was not an effective plan.

2.) Review of patient #11's chart revealed an admission on 5/13/2015, at 5:50PM, with a diagnosis of Neurocognitive Disorder with behavioral disturbances, Aggression. Patient #11's chart revealed he was escorted to the facility on a Peace Officers Warrant (OPC) from Brazos County Sheriff's Department.

Review of patient #11's "Multi-Disciplinary Note" dated 5/13/15, at 5:50PM revealed patient #11 was brought to the facility by ambulance in four point restraints. Restraints were removed upon arrival to facility. Patient #11 was combative and agitated on arrival. Nurse stated, " Order obtained for injection for severe agitation. Note new orders."

Review of the verbal physician orders for 5/13/15, at 6:10PM, stated, "Give Ativan 2mg IM, Haldol 10mg IM, and Benadryl 50mg IM now 1 time dose for severe agitation." Review of the medication administration record (MAR) revealed medication was administered on 5/13/2015, at 6:10PM. There was no documentation found of injection site.

Review of the chart revealed there was no interventions documented before the administration of psychoactive medications 0n 5/13/15, at 6:10PM. There was no "face to face" done by the physician for a chemical restraint. There was no assessment of patient's v/s or physical/mental status, or medication effectiveness after the administration of medication.

Review of the Multi- Disciplinary Note dated 5/13/15, at 9:00PM, stated, "Received in report at shift change, information for new admission, pt. is awake, eyes closed up at nurses station in Geri-chair moving legs and arms, removing lap covering and gown, responds to verbal and physical stimuli, does not answer questions, occasionally swats at air, mumbling words, 1:1 staff supervision. S/P sedation no pain or discomfort noted, agitation continues no combativeness at this time." A Geri chair, short for geriatric chair, is an upholstered recliner on wheels that can be pushed around like a wheel chair. It usually has a removable tray. Review of patient #11's chart revealed there was no order found for use of the Geri-chair from 5/13-5/21/2015.

An interview with staff #1 on 9/22/15, confirmed the Geri chairs are not used that often because they have to obtain a physician's order to use it. A Geri- chair can be used as a restraint.

Review of the policy and procedure "Levels of Observation and Monitoring" stated the following:
One-to-One Observation:
Physician/LIP:
Provides order for one-to-one observation based on assessed risk and individual needs.
The physician/LIP must give the order to discontinue a one-to-one level of observation once it is begun.

Registered Nurse:
1.) Explains procedure to the patient. Provides for the respect of the patient.
2.) Shall implement one-to-one order when received.
3.) May invoke a one-to-one observation with approval of the DON or Administrator based on identified risk of patient pending notification of LIP for an order.
4.) Assesses patient's condition regarding danger to self, others, fall risk, psychological factors, elopement and psychosis which places the patient at risk.
5.) Reports assessment findings to physician/LIP and DON.
6.) Assigns a nursing staff to perform one-to-one and relief staff for all breaks.
7.) Documents the reason for the observation by circling on close observation form, precautions type, suicide, fall, etc. If precautions are for fall risk includes a fall risk sticker on the close observation form.
8.) Documents in the patient's chart and nurse report sheet and kardex the level of observation ordered and implemented.
9.) Assigns member(s) of nursing staff to conduct a thorough search of the patient's room and belongings and remove any object that can be harmful to the patient. Monitors belonging per belongings policy."

Review of patient #11's chart revealed there was no order for a 1:1. Review of the staffing schedule 5/13/2015 revealed no documentation of a staff member assigned as a 1:1. There was no documentation of vital signs before or after medication administration.

Review of the MHT's close observation sheet for 5/13/15, revealed patient #11 was to be monitored and charted on every 15 minutes. The documentation reported patient #11 in the dayroom (nurse's station is in the dayroom) from 6:00PM to 6:15AM on 5/14/2015. The next "every 15 minute observation" starts on the next sheet at 7:30AM on 5/14/15. There was no found documentation for 1 hour and 45 minutes.

Review of patient #11's verbal physician orders dated 5/14/15, at 4:00PM stated, " Give Ativan 2 mg, Haldol 10mg, Benadryl 50mg IM now 1 time dose for severe agitation. A nurses note was found for 5/14/15, 7AM-7PM. The nurse documented on the daily nurse's note at 6:55PM. There was no nursing documentation found for behaviors requiring chemical restraint, interventions performed, condition of the patient, or effectiveness of the medication. There was no documentation of injection site.

Review of the daily nurses notes dated 5/14/15, at 10:35PM, stated, "Pt is confused, is irritable and increase anxiousness with agitation, yells out loud, cursing staff, striking staff, After multiple redirections and attempts to reorient, order received Ativan, Benadryl, Haldol injection to be given."

Review of patient #11's MAR dated 5/14/15, revealed patient #11 received Ativan 2 mg, Haldol 10mg, and Benadryl 50mg IM at 10:35PM.

Review of patient #11's chart revealed there was no order found for the administration of psychoactive medications on 5/14/2015, at 10:35PM. There was no found documentation of a face to face done before or after the medication administration. There was no assessment or vital signs documented after the administration of psychotropic medications. There was no found documentation of injection site.

Review of the MHT's close observation sheet for 5/13/15- 5/14/2015, revealed patient #11 was in the dayroom area or at nurse's station. There was no documentation found that patient #11 was taken to his room to rest in a bed away from stimulation. There was no documentation of patient consuming any fluids or food. There is no documentation of any out-put of urine or bowels for 5/13/15 or 5/14/15.

Review of patient #11's MAR revealed patient #11 received an injection of Ativan 2mg, Haldol 10mg, and Benadryl 50mg IM now dose on 5/15/2015, at 10:30AM. There was no documentation of the injection site. There was no physician's order documented for the IM medications.

Review of patient #11's daily nurse's note revealed the RN did not document until 4:10PM a span of 5 hours and 20 minutes later. RN documented, "increased agitation and aggressive behavior as evidence by pt. hitting and kicking and cursing nursing staff. Redirection and verbal support provided."

A one hour face to face was found dated 5/15/15, at 11:30AM. There was no signature of discipline on who performed the face to face. The document stated, " Pt combative with hospital staff- spitting and hitting MHT's, yelling- attempting to climb over Geri-chair increased aggression/agitation. The following interventions were checked:

1.) Verbal support
2.) Offer food
3.) Offer one to one support
4.) Make environmental changes
5.) Redirection
6.) Offer fluids
7.) Verbal de-escalation
8.) Utilize pharmacotherapies as ordered.

A one hour face to face dated 5/15/15, at 11:30AM, under "patient's response to interventions stated, " decreased aggression, agitation- pt. still attempted to hit at staff but became calmer. Ate and drank ensure soon after decreased anxiousness."

Review of the nursing notes and MHT observation record on 5/15/15, revealed the patient was never taken out of the dining room or Geri-chair. There is no documentation on the "vital sign/intake and out put record" that patient consumed any fluids or food. There was no assessment before the restraint or afterwards documented by the RN.

Review of the daily nurse's notes dated 5/15/15, for the 7PM-7AM shift RN documented, "Aggression/sleeplessness: Pt aggressive and swatted at staff members in dayroom. Minimal sleep noted. Redirect/ reorient behavior.

Review of the Multi-Discipline Note for 5/15/15, at 8:30PM, revealed RN documented, "Psychiatrist contacted for pt. aggression and combativeness towards staff. Ordered medication initiated by nursing staff to calm aggression. Drug IM given in (r) arm."

A verbal physician order dated 5/15/15, at 8:30PM, stated, "Haldol 10mg, Benadryl 50mg, and Ativan 2mg IM now, and Q 4 hours PRN for severe agitation, aggression." Review of the MAR revealed there was no documentation of medication administration for the IM medications or injection site on 5/15/15, at 8:30PM. Drugs used as a chemical restraint may not be ordered as PRN (as needed).

Review of the one hour face to face Evaluation form dated 5/15/15, at 9:35PM, stated, "Severely agitated and swinging and an attempt to hit staff, hollering".

The following interventions were checked;
1.) Verbal support
2.) Encourage appropriate expression
3.) Offer one to one support
4.) Diversional techniques
5.) Redirection
6.) Offer fluids
7.) Verbal de-escalation
8.) Utilize pharmacotherapies as ordered.

Vital signs were documented as B/P -103/70, P- 68, R-18, and O2 Sat: 95%. RR documented, "findings from the evaluation were reviewed with the psychiatrist on 5/15/15, at 9:35PM. There was no documentation found from the RN on 5/15/15, at 8:45PM if food or fluids were offered. The RN documented at 9:00PM, 9:15PM, and 9:30PM "N/A" for snacks or fluids offered.

Review of the MHT's close observation sheet for 5/15/15, from 12:00AM until 12:00PM, revealed patient #11 was in the dayroom area or at nurse's station. There was no documentation that patient #11 was taken to his room to sleep and rest in a bed with no stimulation. There was no documentation that patient was given IM medications in a private area.

Review of patient #11's Multi-Discipline Note for 5/16/15, at 12:25PM RN documented, "Pt began hitting himself in the head and hitting both of his upper thighs w/ his fists, crying, cursing, screaming, hitting at staff. Pt was a danger to himself and others. Pt was administered an injection per Dr.'s "PRN" order. Pt. restraint and seclusion packet done, Administrator, Dr notified, family not notified d/t pt has not consented. V/s taken. 1 hour face to face completed by RN. 12:25PM Pt. still hitting himself at this time pt has one on one feeding him."

Review of patient #11's MAR for 5/16/2015, at 12:25PM revealed there was no documentation of IM medications given or site of injections.

Review of the One hour face to face form dated 5/16/15, at 12:25, revealed there was no second page with the evaluators name or discipline. The first page stated, "Pt hitting himself on his head and both thighs with his fist. Hitting at self, cursing, hollering. "

Review of the Seclusion/Restraint/Emergency Administration of Psychotropic Medications dated 5/16/2015, at 12:20PM, revealed the patient was given "Emergency Administration of a PRN order." Pt was given "redirection and reorientation." The patient's family was not notified of the administration of psychoactive medications due to "Pt has not consented to notifying family." RN documented the patient was on a 1:1 with staff. There was no order noted for the 1:1. There were no documented vital signs due to " pt refused. " No further interventions or assessments were documented.

Review of the Seclusion/Restraint/Emergency Administration of Psychotropic Medications dated 5/16/2015, at 12:20PM ,the section under "Debriefing with Patient/LAR (contact and document) stated, "Date: 5/17/15 at 2:00PM Pt. confused unable to understand." Below that comment a hand written note was found with an asterisk sign. The comment stated, "Family notified during visitation about the chemical restraints and consent rcvd." The hand written note was in different hand writing and had no name of the author, date, or time. There was no documentation of what family member was notified.

Review of Patient #11's "significant others" written complaint stated, "On May 16 patient (#11) & my daughter & his fulltime caregiver from Oct. 2009-March 2015, drove to Lufkin to see patient at the facility & found him angry, scared, & agitated in a Geri-Chair with feet up head down & all of his weight on his bottom. He had no straps or ties on but he was clearly restrained, unable to get out of the Geri-Chair. He complained of discomfort & of his bottom hurting.

He squirmed constantly & was unable to get comfortable. We ask if he could go to his bed & were told that he would not stay there. The staff called him the wrong name & when I talked to the nurse she told me that his name on his chart was: first name and last name were backwards. She explained to me that they had been unable to call me to inform me of his condition because he had not given consent to release his info to me. They said they had attempted to call his brother & he had told them that I was the POA & Responsible Party The nurse in charge showed me patient's chart and made a list of his meds for me without asking for any documentation or ID.

During our visit on 5/16/15, both of us noticed that patient #11's eyes were sunken, he was gaunt, & his skin was extremely dry. We asked the nurse if he was being watched for dehydration & she assured us that he was offered fluids every 2 hours but often was too agitated to drink. While we were there he motioned with his hand cupped & his mouth in a sucking position that he was thirsty & we got water & helped him drink two full glasses (appox. 12 oz.) during our visit. The nurse assured me that if he showed signs of dehydration they would start IV fluids.

On the dates 5/17/15- 5/20/15, I called the facility at least one time usually in the evening, asked for the nurse and inquired about his condition and was told each day he was doing better, much quieter, and one nurse said they just let him sleep in the Geri-chair right by the nurses station so they could keep an eye on him."

Review of the vital signs and intake/output form dated 5/16/2015, revealed the patient had consumed only 25% of breakfast, lunch, and dinner. Patient #11 had consumed 480cc of fluids.

Review of the nurse's notes for 5/17/2015, 7PM-7AM, revealed patient #11 was still agitated and hitting. The daily nursing note is blank for observation of patient thought content. The RN documented, "Pt. does not speak to me." RN documented that patient #11 was on a 1:1 but there was no physician order found for a 1:1. Review of the vital signs/intake and output record for 5/17/2015 revealed patient #11 had consumed a 1000cc of fluids, urinated x2, and consumed 100% of all three meals.

Review of patient #11's chart revealed there was no nursing documentat

Based on chart reviews and interviews the facility failed to allow the patient or family members participate in the development and implementation of patient plan of care in 1 (#1) of 3 (#1, #11, #13) charts reviewed.


Review of patient #1's chart revealed an admission on 6/15/2015, with a diagnosis of Neurocognitive Disorder with behavioral disturbances. ( neurocognitive disorder was previously known as dementia and the primary feature of all neurocognitive disorders (NCDs) is an acquired cognitive decline in one or more cognitive domains.)


Review of patient #1's treatment plan revealed the multidiscinplinary treatment team met on 6/24/2015, at 8:30AM. There was no found documentation of the patient present during the treatment team meeting or documentation of the family notification to participate. The team consisted of the physician and two social workers.


There was no nursing care plan to address the patients condition during hospitalization. Patient #1 was transported to the ER for Bradycardia and oversedation on 7/3/15 and 7/14/15, for constipation, hypothermia, and unresponsiveness. Patient #1 experienced hypotention on 7/2/15-7/5/15 and was being treated for EPS(Extrapyramidal Symptoms).


Staff #2 confirmed there was no nursing care plan for patient #1's medical issues.


An interview with staff #1 confirmed the above findings. Staff #1 reported that the psychiatrist did not like families in treatment team. They could make an appointment with him for a family sessions if needed.