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Based on review of documentation and interview it was determined that the hospital failed to ensure that nursing staff documented the reason(s) that a minor patient was that administered prn (as needed) medications that had been ordered for aggression.

Findings were:
Patient #1 who was hospitalized at Kingwood Pines Hospital received prn (as needed) medication for aggression. Review of the narrative nursing notes for several dates revealed that nursing staff did not document what aggressive behaviors on the part of patient #1 required the administration of the prn medications that had been ordered for aggression.

Review of Kingwood Pines Hospital Medication Administration Record for patient #1 for dates 11/7/2018 19:30 to 11/20/2018 23:59 revealed an order for 5mg of "Olanzapine (*Zydis) Three Times A Day PRN for aggression". Continued review revealed that patient #1 received prn Olanzapine on 12 separate occasions to include: 17:04 hours on 11/11/18, 7:51 hours on 11/12/18, 8:12 hours on 11/13/18, 9:02 hours on 11/14/18, 13:32 hours on 11/14/18, 12:01 hours on 11/15/18, 18:08 hours on 11/16/18, 14:51 hours on 11/17/18, 19:41 hours on 11/17/18, 19:34 hours on 11/18/18, 7:59 hours on 11/19/18 and 19:53 hours on 11/19/18.

Further review of the Kingwood Pines Hospital Medication Administration Record for patient #1 for dates 11/7/2018 19:30 - 11/20/2018 23:59 revealed an order for 25 mg "diphenhydramine (*Benadryl) Oral Three Times A DAY PRN for aggression". Continued review revealed that patient #1 received prn diphenhydramine on 11 separate occasions to include: 17:04 hours on 11/11/18, 8:11 hours on 11/13/18, 19:41 hours on 11/13/18, 9:02 hours on 11/14/18, 18:32 hours on 11/14/18, 12:01 hours on 11/15/18, 19:44 hours on 11/15/18, 18:08 hours on 11/16/18, 8:05 hours 11/17/18, 14:51 hours on 11/17/18 and 19:41 hours on 11/17/18.

Review of the medication administration record for patient #1 documented patient #1 as receiving a prn medication of 5mg of Olanzapine (*Zydis) at 17:04 hours on 11/11/2018. Also documented as being administered was diphenhydramine 25mg at 17:04 hours. Review of Kingwood Pines Hospital Observation Rounds/Precautions sheets revealed that on 11/11/18, patient #1 was documented as being 4 (Cooperative) from 0800 hours until 2045 hours. Review of the Kingwood Pines Hospital Nursing Notes for 11/11/18 at 1220 hours stated: "Patient is visible in unit A/A/Ox3. Patient appearance is appropriate. Patient is cooperative, complaint with his medications. Patient noted interacting with peers, no inappropriate or aggressive behaviors noted at this time. Patient encourage to utilize positive coping skills throughout the day and also to seek staff if he has any issues or concerns. Will continue to monitor patient Q 15 minutes for patient safety."

Review of the Kingwood Pines Hospital Nursing Progress Notes for 11-11-18 at 22:53 hours stated: "Patient is AAO x3, denies any SI/HI or AVH at this time. He is calm and cooperative. He has appropriate mood and affect with good insight." "Therapeutic milieu provided, given ordered meds." "Sleeping during HS Rounds. Continue to do safety checks q 15 mins." No documentation was found in the nursing progress note or the Observation Rounds/Precautions Sheet indicating the behaviors or describing the situation(s) or behaviors that required patient #1 to require receiving a prn medication for aggression.

On 11/12/2018 patient #1 is documented per the Medication Administration record as receiving a prn medication of 5mg of Olanzapine (*Zydis) at 7:51 hours on 11/12/2018. Review of Kingwood Pines Hospital Observation Rounds/Precautions sheets revealed that on 11/12/18, patient #1 was documented as 7 (Sleeping) from 0500 to 0730 and being 4 (Cooperative) from 0745 hours until 0915 hours. Review of the Kingwood Pines Hospital Nursing Progress Notes for 11-12-18 for 7A-7P stated: "Presents with irritable mood and blunt affect." "Denies SI, HI, or AVH @ present time. Will redirect as needed and assist patient to identify triggers. SN educated on positive coping skills to help improve mood and decrease aggression. Encouraged to attend groups ..." No documentation was found in the nursing progress note or the Observation Rounds/Precautions Sheet indicating the behaviors or describing the situation(s) or behaviors that required patient #1 to require receiving a prn medication for aggression.

On 11/13/2018 patient #1 is documented per the Medication Administration record as receiving a prn medication of 5mg of Olanzapine (*Zydis) at 8:12 hours on 11/13/2018. Also documented as being administered was diphenhydramine 25mg at 8:11 hours. Review of Kingwood Pines Hospital Observation Rounds/Precautions sheets revealed that on 11/13/18, patient #1 was documented as 7 (Sleeping) from 0500 to 0730 and being 4 (Cooperative) at 0745. From 0800 until 1300 hours 11 (Calm). Review of the Kingwood Pines Hospital Nursing Progress Notes for 11-13-18 for 7A-7P stated: "Pt awake and visible on unit; presents with irritable mood and labile affect. Denies SI, HI or AVH at @ present time. Pt. wrote wishing to work on his "anger" for his daily goal. RN educated on positive coping skills such as slow deep breathing to help to improve mood by by releasing the body's natural endorphins - Also to attend (illegible word) groups + follow medical (illegible) for optimal health + wellness. Pt needs encouragement to follow though + attend groups, Caseworker to be notified by therapist to obtain more clothing for pt. Q15 min monitoring remains in progress for safety." No documentation was found in the nursing progress note or the Observation Rounds/Precautions Sheet indicating the behaviors or describing the situation(s) or the behaviors that required patient #1 to require receiving a prn medication for aggression.

On 11/13/2018 patient #1 is documented per the Medication Administration record as receiving a prn medication of 25 mg of diphenhydramine at 19:41 hours. Review of Kingwood Pines Hospital Observation Rounds/Precautions sheets revealed that on 11/13/18, patient #1 was documented as 4 (cooperative) from 1800 hours until 2015 hours. Review of the Kingwood Pines Hospital Nursing Progress Notes for 11-13-18 at 2127 hours stated: "Pt visible in bed, resting with eyes closed. Pt. observed earlier on unit, denied SI/HI, denied AVH. Pt had appropriate affect, mood appeared happy. Provide therapeutic milieu. Medicate per Drs. Orders encourage use of coping skills, Q15 minute checks." No documentation was found in the nursing progress note or the Observation Rounds/Precautions Sheet indicating the behaviors or describing the situation(s) or the behaviors that required patient #1 to require receiving a prn medication for aggression.

On 11/14/2018 patient #1 is documented per the Medication Administration record as receiving a prn medication of 25 mg of diphenhydramine at 18:32 hours. Patient #1 also received a prn medication of 5mg of Olanzapine (*Zydis) at 18:32 hours on 11/14/2018. Review of Kingwood Pines Hospital Observation Rounds/Precautions sheets revealed that on 11/14/18, patient #1 was documented as 11(calm) from 1600 hours until 1945 hours. Review of the Kingwood Pines Hospital Nursing Progress Notes for 11-14-18 revealed no documentation regarding the 1832 hours administration of the prn diphenhydramine and olanzapine. No other documentation was found in the nursing progress note or the Observation Rounds/Precautions Sheet indicating the behaviors or describing the situation(s) or the behaviors that required patient #1 to require receiving a prn medication for aggression.

On 11/15/2018 patient #1 is documented per the Medication Administration record as receiving a prn medication of 5mg of Olanzapine (*Zydis) at 12:01 hours on 11/15/2018. Also documented as being administered was diphenhydramine 25mg at 12:01 hours. Review of Kingwood Pines Hospital Observation Rounds/Precautions sheets revealed that on 11/15/18, patient #1 was documented as 4 (Cooperative) from 0800 until 1215 hours. At 1230 hours staff made what appears to be an illegible entry which possibly resembles a U or a 4. Review of the Kingwood Pines Hospital Nursing Progress Notes for 11-15-18 at 1015 hours stated: "Patient is A/A/Ox3. Patient is cooperative. Affect is flat. Patient stated that he is in a good mood today not feel down or depress. Patient denies any SI/HI/AVH. Patient is complaint with medications, tolerated well. Attends group sessions and also participates in group activities. Will continue to monitor patient Q15 minutes to ensure safety." No documentation was found in the nursing progress note or the Observation Rounds/Precautions Sheet indicating the behaviors or describing the situation(s) or the behaviors that required patient #1 to require receiving a prn medication for aggression.

On 11/15/2018 patient #1 is documented per the Medication Administration record as receiving a prn medication of 25 mg of diphenhydramine at 19:44 hours. Review of Kingwood Pines Hospital Observation Rounds/Precautions sheets revealed that on 11/15/18, patient #1 was documented as 11(cooperative) from 1915 hours until 2000 hours. At 2015 hours until 2030 hours patient #1 is 2 (awake/in bed) and at 2045 hours until 2215 hours 7 (asleep). Review of the Kingwood Pines Hospital Nursing Progress Notes for 11-15-18 revealed no documentation regarding the 19:44 hour administration of the prn diphenhydramine. No other documentation was found in the nursing progress note or the Observation Rounds/Precautions Sheet indicating the behaviors or describing the situation(s) or the behaviors that required patient #1 to require receiving a prn medication for aggression.

On 11/16/2018 patient #1 is documented per the Medication Administration record as receiving a prn medication of 5mg of Olanzapine (*Zydis) at 18:08 hours on 11/16/2018. Also documented as being administered was diphenhydramine 25mg at 18:08 hours. Review of Kingwood Pines Hospital Observation Rounds/Precautions sheets revealed that on 11/16/18, patient #1 was documented as 11 (Calm) from 1515 until 1800 hours. At 1815 hours patient #1 is 5/9 (5 is hyperactive, 9 is uncooperative). At 1830, patient #1 is 2 (awake/in bed) and from 1845 until 2000 hours patient #1 is 5 (hyperactive) and 2 (awake/in bed). Review of the Kingwood Pines Hospital Nursing Progress Notes for 11-16-18 at 1000 hours revealed no documentation of aggressive behaviors. The next nursing note is dated and timed 11/16/2018 at 2230. No other nursing documentation was found by or provided to the survey team describing what situation(s) or the behaviors that required patient #1 to require receiving a prn medication for aggression at 18:08 hours.

On 11/17/2018 patient #1 is documented per the Medication Administration record as receiving a prn medication of 5mg of Olanzapine (*Zydis) at 19:41 hours on 11/17/2018. Also documented as being administered was diphenhydramine 25mg at 19:41 hours. Review of Kingwood Pines Hospital Observation Rounds/Precautions sheets revealed that on 11/17/18, patient #1 was documented as 9 (uncooperative) at 1900 hours. At 1915, patient #1 is 11 (calm). At 1930, 4 (cooperative). At 1945 to 2015 patient #1 is 2 (awake/in bed). From 2030 to 2245 patient #1 is 7 (sleeping). Review of the Kingwood Pines Hospital Nursing Progress Notes for 11-17-18 at 2045 hours revealed no documentation of any aggressive behaviors. The nursing note stated: "Alert and oriented. Denies audio or visual hallucinations. Denies thoughts of harm to self or others. Hyperactive at times. Agitates easily but only minor incidents this evening. Now resting quietly in bed. Being monitored closely and q15 minutes." No other nursing documentation was found by or provided to the survey team describing what situation(s) or the behaviors that required patient #1 to require receiving prn medication for aggression at 1941 hours.

On 11/18/2018 patient #1 is documented per the Medication Administration record as receiving a prn medication of 5mg of Olanzapine (*Zydis) at 19:34 hours on 11/18/2018. Review of Kingwood Pines Hospital Observation Rounds/Precautions sheets revealed that on 11/18/18, patient #1 was documented as 5 (hyperactive) from 1830 to 2000 hours. At 2015 until 2045, patient #1 is 2 (awake/in bed). At 2100, 7 (sleeping). Review of the Kingwood Pines Hospital Nursing Progress Notes for 11-18-18 at 1400 hours stated: " ...Pt is easily agitated but no aggression at this time ..." No other nursing documentation was found by or provided to the survey team describing what situation(s) or the behaviors that required patient #1 to require receiving a prn medication for aggression at 1934 hours.

On 11/19/2018 patient #1 is documented per the Medication Administration record as receiving a prn medication of 5mg of Olanzapine (*Zydis) at 7:59 hours on 11/18/2018. Patient #1 was also documented as receiving 5mg of Olanzapine (*Zydis) at 19:53 hours.
Review of Kingwood Pines Hospital Observation Rounds/Precautions sheets revealed that on 11/19/18, patient #1 was documented as 7 (sleeping) from 0500 to 730 hours. At 0745 until 1130, patient #1 is 11 (calm). Review of the Kingwood Pines Hospital Nursing Progress Notes for 11-19-18 at 0900 hours revealed no documentation of aggression. The nursing note stated: "Pt visible in unit A/A/Ox3. Patient is clam, cooperative; interacting with peers. Denies any SI HI AVH. Patient stated that is in a happy mood affect is appropriate. Patient is compliant with medications. Attends group session and participates in activities. Encourage to seek staff if he has any issues or concerns. Will continue to monitor Q 15 minutes for safety." No other nursing documentation was found by or provided to the survey team describing what situation(s) or the behaviors that required patient #1 to require receiving a prn medication for aggression at 759 hours.

Review of Kingwood Pines Hospital Observation Rounds/Precautions sheets revealed that on 11/19/18, patient #1 was documented as 5 (hyperactive) from 1915 until 2000. 2015 hours, patient #1 is 5, 9 (hyperactive and uncooperative). Continued review of the Kingwood Pines Hospital Nursing Progress Notes for 11-19-18 revealed no additional documentation of any situation(s) or the behaviors that required patient #1 to require receiving a prn medication (Olanzapine) for aggression at 19:53 hours.

In an interview on the afternoon of 12/11/2018 it was confirmed by staff members #3 and #4 that hosptial nursing staff failed to document behavior(s) that required the administration of prn medications for aggression. It was also confirmed in the same interview that nursing staff should doucment the need for adminstration of prn medications for aggression.

Based on review of documentation and interview it was determined that the hospital failed to ensure that consents for medications had been signed by the treating physician.

Findings were:
Consents for medications were not signed by the treating physician. Review of medication consent for olanzapine (Zyperxa, Zydis), an antipsychotic medication revealed that an RN had (Registered Nurse) had obtained consent for the medication from a CPS (Child Protective Services) caseworker on 11/11/18 at 0925. The area on the consent form where the treating physician was to sign was found to be blank. The area directly underneath where the physician was to sign contained the comment: "required within two-working days of P.A., R,N. or L.VN. giving explanation."

Review of medication consent for diphenhydramine (Benadryl), a sedative/hypnotic medication revealed that an RN had (Registered Nurse) had obtained consent for the medication from a CPS (Child Protective Services) caseworker on 11/11/18 at 0925. The area on the consent form where the treating physician was to sign was found to be blank. The area directly underneath where the physician was to sign contained the comment: "required within two-working days of P.A., R,N. or L.VN. giving explanation."

Review of hospital policy: PR-18, entitled: "Patient's Consent for Psychoactive Medications" stated on page one: "5. Consent to the administration of psychoactive medication given by a patient or by a person authorized by law to consent on behalf of the patient is valid only if: a. The consent if given voluntarily and without coercive or undue influence; b. The treating physician, licensed nurse, or physician's assistant provided the following information to the patient and, if applicable, to the patient's representative authorized by law to consent on behalf of the patient in simple, non-technical language in the person's primary language:".

Continued review of the policy revealed on page two of policy stated: "6. If a person other than the treating physician provides the information under 5b, then not later than two working days after that person provides the information, excluding weekends and legal holidays, the physician shall meet with the patient and, if appropriate, the patient's representative who provided the consent, to review the information and answer any questions. The physician must document confirmation of the the consent in the patient's medical record."

Review of hospital policy: IM 107, entitled: "Mental Health Record of Content" stated on page one: "Consents: As necessary, the patient mental health record shall contain documentation of the consent given by the patient or legal representative for admission, treatment, evaluation or after-care. Consent to "Treatment with Psychoactive Medications" must be signed by the attending physician."

In an interview with staff member #3 on the afternoon of 12/11/2018 it was confirmed that the physician had not signed the medication consent forms referenced above.

Based on review of documentation and interview it was determined that the hospital failed to ensure that nursing staff documented the reason(s) that a minor patient was that administered prn (as needed) medications that had been ordered for aggression.

Findings were:
Patient #1 who was hospitalized at Kingwood Pines Hospital received prn (as needed) medication for aggression. Review of the narrative nursing notes for several dates revealed that nursing staff did not document what aggressive behaviors on the part of patient #1 required the administration of the prn medications that had been ordered for aggression.

Review of Kingwood Pines Hospital Medication Administration Record for patient #1 for dates 11/7/2018 19:30 to 11/20/2018 23:59 revealed an order for 5mg of "Olanzapine (*Zydis) Three Times A Day PRN for aggression". Continued review revealed that patient #1 received prn Olanzapine on 12 separate occasions to include: 17:04 hours on 11/11/18, 7:51 hours on 11/12/18, 8:12 hours on 11/13/18, 9:02 hours on 11/14/18, 13:32 hours on 11/14/18, 12:01 hours on 11/15/18, 18:08 hours on 11/16/18, 14:51 hours on 11/17/18, 19:41 hours on 11/17/18, 19:34 hours on 11/18/18, 7:59 hours on 11/19/18 and 19:53 hours on 11/19/18.

Further review of the Kingwood Pines Hospital Medication Administration Record for patient #1 for dates 11/7/2018 19:30 - 11/20/2018 23:59 revealed an order for 25 mg "diphenhydramine (*Benadryl) Oral Three Times A DAY PRN for aggression". Continued review revealed that patient #1 received prn diphenhydramine on 11 separate occasions to include: 17:04 hours on 11/11/18, 8:11 hours on 11/13/18, 19:41 hours on 11/13/18, 9:02 hours on 11/14/18, 18:32 hours on 11/14/18, 12:01 hours on 11/15/18, 19:44 hours on 11/15/18, 18:08 hours on 11/16/18, 8:05 hours 11/17/18, 14:51 hours on 11/17/18 and 19:41 hours on 11/17/18.

Review of the medication administration record for patient #1 documented patient #1 as receiving a prn medication of 5mg of Olanzapine (*Zydis) at 17:04 hours on 11/11/2018. Also documented as being administered was diphenhydramine 25mg at 17:04 hours. Review of Kingwood Pines Hospital Observation Rounds/Precautions sheets revealed that on 11/11/18, patient #1 was documented as being 4 (Cooperative) from 0800 hours until 2045 hours. Review of the Kingwood Pines Hospital Nursing Notes for 11/11/18 at 1220 hours stated: "Patient is visible in unit A/A/Ox3. Patient appearance is appropriate. Patient is cooperative, complaint with his medications. Patient noted interacting with peers, no inappropriate or aggressive behaviors noted at this time. Patient encourage to utilize positive coping skills throughout the day and also to seek staff if he has any issues or concerns. Will continue to monitor patient Q 15 minutes for patient safety."

Review of the Kingwood Pines Hospital Nursing Progress Notes for 11-11-18 at 22:53 hours stated: "Patient is AAO x3, denies any SI/HI or AVH at this time. He is calm and cooperative. He has appropriate mood and affect with good insight." "Therapeutic milieu provided, given ordered meds." "Sleeping during HS Rounds. Continue to do safety checks q 15 mins." No documentation was found in the nursing progress note or the Observation Rounds/Precautions Sheet indicating the behaviors or describing the situation(s) or behaviors that required patient #1 to require receiving a prn medication for aggression.

On 11/12/2018 patient #1 is documented per the Medication Administration record as receiving a prn medication of 5mg of Olanzapine (*Zydis) at 7:51 hours on 11/12/2018. Review of Kingwood Pines Hospital Observation Rounds/Precautions sheets revealed that on 11/12/18, patient #1 was documented as 7 (Sleeping) from 0500 to 0730 and being 4 (Cooperative) from 0745 hours until 0915 hours. Review of the Kingwood Pines Hospital Nursing Progress Notes for 11-12-18 for 7A-7P stated: "Presents with irritable mood and blunt affect." "Denies SI, HI, or AVH @ present time. Will redirect as needed and assist patient to identify triggers. SN educated on positive coping skills to help improve mood and decrease aggression. Encouraged to attend groups ..." No documentation was found in the nursing progress note or the Observation Rounds/Precautions Sheet indicating the behaviors or describing the situation(s) or behaviors that required patient #1 to require receiving a prn medication for aggression.

On 11/13/2018 patient #1 is documented per the Medication Administration record as receiving a prn medication of 5mg of Olanzapine (*Zydis) at 8:12 hours on 11/13/2018. Also documented as being administered was diphenhydramine 25mg at 8:11 hours. Review of Kingwood Pines Hospital Observation Rounds/Precautions sheets revealed that on 11/13/18, patient #1 was documented as 7 (Sleeping) from 0500 to 0730 and being 4 (Cooperative) at 0745. From 0800 until 1300 hours 11 (Calm). Review of the Kingwood Pines Hospital Nursing Progress Notes for 11-13-18 for 7A-7P stated: "Pt awake and visible on unit; presents with irritable mood and labile affect. Denies SI, HI or AVH at @ present time. Pt. wrote wishing to work on his "anger" for his daily goal. RN educated on positive coping skills such as slow deep breathing to help to improve mood by by releasing the body's natural endorphins - Also to attend (illegible word) groups + follow medical (illegible) for optimal health + wellness. Pt needs encouragement to follow though + attend groups, Caseworker to be notified by therapist to obtain more clothing for pt. Q15 min monitoring remains in progress for safety." No documentation was found in the nursing progress note or the Observation Rounds/Precautions Sheet indicating the behaviors or describing the situation(s) or the behaviors that required patient #1 to require receiving a prn medication for aggression.

On 11/13/2018 patient #1 is documented per the Medication Administration record as receiving a prn medication of 25 mg of diphenhydramine at 19:41 hours. Review of Kingwood Pines Hospital Observation Rounds/Precautions sheets revealed that on 11/13/18, patient #1 was documented as 4 (cooperative) from 1800 hours until 2015 hours. Review of the Kingwood Pines Hospital Nursing Progress Notes for 11-13-18 at 2127 hours stated: "Pt visible in bed, resting with eyes closed. Pt. observed earlier on unit, denied SI/HI, denied AVH. Pt had appropriate affect, mood appeared happy. Provide therapeutic milieu. Medicate per Drs. Orders encourage use of coping skills, Q15 minute checks." No documentation was found in the nursing progress note or the Observation Rounds/Precautions Sheet indicating the behaviors or describing the situation(s) or the behaviors that required patient #1 to require receiving a prn medication for aggression.

On 11/14/2018 patient #1 is documented per the Medication Administration record as receiving a prn medication of 25 mg of diphenhydramine at 18:32 hours. Patient #1 also received a prn medication of 5mg of Olanzapine (*Zydis) at 18:32 hours on 11/14/2018. Review of Kingwood Pines Hospital Observation Rounds/Precautions sheets revealed that on 11/14/18, patient #1 was documented as 11(calm) from 1600 hours until 1945 hours. Review of the Kingwood Pines Hospital Nursing Progress Notes for 11-14-18 revealed no documentation regarding the 1832 hours administration of the prn diphenhydramine and olanzapine. No other documentation was found in the nursing progress note or the Observation Rounds/Precautions Sheet indicating the behaviors or describing the situation(s) or the behaviors that required patient #1 to require receiving a prn medication for aggression.

On 11/15/2018 patient #1 is documented per the Medication Administration record as receiving a prn medication of 5mg of Olanzapine (*Zydis) at 12:01 hours on 11/15/2018. Also documented as being administered was diphenhydramine 25mg at 12:01 hours. Review of Kingwood Pines Hospital Observation Rounds/Precautions sheets revealed that on 11/15/18, patient #1 was documented as 4 (Cooperative) from 0800 until 1215 hours. At 1230 hours staff made what appears to be an illegible entry which possibly resembles a U or a 4. Review of the Kingwood Pines Hospital Nursing Progress Notes for 11-15-18 at 1015 hours stated: "Patient is A/A/Ox3. Patient is cooperative. Affect is flat. Patient stated that he is in a good mood today not feel down or depress. Patient denies any SI/HI/AVH. Patient is complaint with medications, tolerated well. Attends group sessions and also participates in group activities. Will continue to monitor patient Q15 minutes to ensure safety." No documentation was found in the nursing progress note or the Observation Rounds/Precautions Sheet indicating the behaviors or describing the situation(s) or the behaviors that required patient #1 to require receiving a prn medication for aggression.

On 11/15/2018 patient #1 is documented per the Medication Administration record as receiving a prn medication of 25 mg of diphenhydramine at 19:44 hours. Review of Kingwood Pines Hospital Observation Rounds/Precautions sheets revealed that on 11/15/18, patient #1 was documented as 11(cooperative) from 1915 hours until 2000 hours. At 2015 hours until 2030 hours patient #1 is 2 (awake/in bed) and at 2045 hours until 2215 hours 7 (asleep). Review of the Kingwood Pines Hospital Nursing Progress Notes for 11-15-18 revealed no documentation regarding the 19:44 hour administration of the prn diphenhydramine. No other documentation was found in the nursing progress note or the Observation Rounds/Precautions Sheet indicating the behaviors or describing the situation(s) or the behaviors that required patient #1 to require receiving a prn medication for aggression.

On 11/16/2018 patient #1 is documented per the Medication Administration record as receiving a prn medication of 5mg of Olanzapine (*Zydis) at 18:08 hours on 11/16/2018. Also documented as being administered was diphenhydramine 25mg at 18:08 hours. Review of Kingwood Pines Hospital Observation Rounds/Precautions sheets revealed that on 11/16/18, patient #1 was documented as 11 (Calm) from 1515 until 1800 hours. At 1815 hours patient #1 is 5/9 (5 is hyperactive, 9 is uncooperative). At 1830, patient #1 is 2 (awake/in bed) and from 1845 until 2000 hours patient #1 is 5 (hyperactive) and 2 (awake/in bed). Review of the Kingwood Pines Hospital Nursing Progress Notes for 11-16-18 at 1000 hours revealed no documentation of aggressive behaviors. The next nursing note is dated and timed 11/16/2018 at 2230. No other nursing documentation was found by or provided to the survey team describing what situation(s) or the behaviors that required patient #1 to require receiving a prn medication for aggression at 18:08 hours.

On 11/17/2018 patient #1 is documented per the Medication Administration record as receiving a prn medication of 5mg of Olanzapine (*Zydis) at 19:41 hours on 11/17/2018. Also documented as being administered was diphenhydramine 25mg at 19:41 hours. Review of Kingwood Pines Hospital Observation Rounds/Precautions sheets revealed that on 11/17/18, patient #1 was documented as 9 (uncooperative) at 1900 hours. At 1915, patient #1 is 11 (calm). At 1930, 4 (cooperative). At 1945 to 2015 patient #1 is 2 (awake/in bed). From 2030 to 2245 patient #1 is 7 (sleeping). Review of the Kingwood Pines Hospital Nursing Progress Notes for 11-17-18 at 2045 hours revealed no documentation of any aggressive behaviors. The nursing note stated: "Alert and oriented. Denies audio or visual hallucinations. Denies thoughts of harm to self or others. Hyperactive at times. Agitates easily but only minor incidents this evening. Now resting quietly in bed. Being monitored closely and q15 minutes." No other nursing documentation was found by or provided to the survey team describing what situation(s) or the behaviors that required patient #1 to require receiving prn medication for aggression at 1941 hours.

On 11/18/2018 patient #1 is documented per the Medication Administration record as receiving a prn medication of 5mg of Olanzapine (*Zydis) at 19:34 hours on 11/18/2018. Review of Kingwood Pines Hospital Observation Rounds/Precautions sheets revealed that on 11/18/18, patient #1 was documented as 5 (hyperactive) from 1830 to 2000 hours. At 2015 until 2045, patient #1 is 2 (awake/in bed). At 2100, 7 (sleeping). Review of the Kingwood Pines Hospital Nursing Progress Notes for 11-18-18 at 1400 hours stated: " ...Pt is easily agitated but no aggression at this time ..." No other nursing documentation was found by or provided to the survey team describing what situation(s) or the behaviors that required patient #1 to require receiving a prn medication for aggression at 1934 hours.

On 11/19/2018 patient #1 is documented per the Medication Administration record as receiving a prn medication of 5mg of Olanzapine (*Zydis) at 7:59 hours on 11/18/2018. Patient #1 was also documented as receiving 5mg of Olanzapine (*Zydis) at 19:53 hours.
Review of Kingwood Pines Hospital Observation Rounds/Precautions sheets revealed that on 11/19/18, patient #1 was documented as 7 (sleeping) from 0500 to 730 hours. At 0745 until 1130, patient #1 is 11 (calm). Review of the Kingwood Pines Hospital Nursing Progress Notes for 11-19-18 at 0900 hours revealed no documentation of aggression. The nursing note stated: "Pt visible in unit A/A/Ox3. Patient is clam, cooperative; interacting with peers. Denies any SI HI AVH. Patient stated that is in a happy mood affect is appropriate. Patient is compliant with medications. Attends group session and participates in activities. Encourage to seek staff if he has any issues or concerns. Will continue to monitor Q 15 minutes for safety." No other nursing documentation was found by or provided to the survey team describing what situation(s) or the behaviors that required patient #1 to require receiving a prn medication for aggression at 759 hours.

Review of Kingwood Pines Hospital Observation Rounds/Precautions sheets revealed that on 11/19/18, patient #1 was documented as 5 (hyperactive) from 1915 until 2000. 2015 hours, patient #1 is 5, 9 (hyperactive and uncooperative). Continued review of the Kingwood Pines Hospital Nursing Progress Notes for 11-19-18 revealed no additional documentation of any situation(s) or the behaviors that required patient #1 to require receiving a prn medication (Olanzapine) for aggression at 19:53 hours.

In an interview on the afternoon of 12/11/2018 it was confirmed by staff members #3 and #4 that hosptial nursing staff failed to document behavior(s) that required the administration of prn medications for aggression. It was also confirmed in the same interview that nursing staff should doucment the need for adminstration of prn medications for aggression.