HospitalInspections.org

Based on review and interview the facility failed to,

1.
provide and have signed the Important Message from Medicare not more than two calendar days before the patient's discharge in 2 of 2(patient #II, and D) discharged patient charts.

Review of patient chart #II and #D revealed the patient's received the initial IMM letters but did not receive the letters before discharge.

An interview was conducted with staff #13 and staff #33 on 5/22/23. Staff #13 and staff #33 confirmed they have never given a medicare patient an IMM letter at discharge. Both staff #13 and #33 was unaware of the process.

Refer to Tag A0117


2.
follow the policy and procedures for prompt resolutions of complaints and grievances, incomplete investigations, failure to report a patient request for a the patient advocate, failure to compile, analysis, monitor, and report the data on grievances and complaints to medical staff and governing body in 6 out of 6 (Dec. 2022-May 2023) months reviewed.

Refer to Tag A0118

3.
ensure the patient has the right to participate in the development and implementation of his or her plan of care
Refer to Tag A0130

4.

A. ensure the patients were instructed on their involuntary status, and warrants were filed in a timely manner with results available to the patient and surveyor. Failed to have written documentation that the patient was aware of their rights, court hearing dates, and awareness of the judge's decision on their legal status after the court hearings, and failed to release the patient without the proper warrants in place in 3 of 3(#F, AA, and II) charts reviewed.

B. ensure a signed Order of Protective Custody with a forced medication order granted by the county judge was on the medical record before administering psychotropic medications to patients with the inability to consent or refused medications and treatment in 1 of 1(#II) patient medical records reviewed.

C. ensure the patient had the capacity to consent to the administration of psychotropic medications, the beneficial effects on the patient's mental illness, or the condition expected as a result of treatment with psychotropic medication in 5 of 5 (#AA, BB, JJ, II, and LL) charts reviewed.

D. ensure psychoactive medications were administered to 1 of 2 patients (Patient #E) without first obtaining properly, informed consent from the patient or the patient's legally authorized representative.

The deficient practices were identified under the following Condition of Participation, CFR 482.13 Patient Rights, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death.
Refer to Tag A0131

5.
protect the patient's right to care in a safe setting, as 2 of 2 patients (Patients D & E) were not observed at the appropriately precaution or observation levels during their stay.
Refer to Tag A0144

6.
ensure that a patient with an eating disorder #N, was given the proper assessments, monitoring, and nursing care for diagnosis.
Refer to Tag A0145

7.
provide a process to safely use seclusion as an approved restraint within the facility, failed to provide a key or a written process on how to properly access the key for seclusion, failed to educate the staff on least restrictive methods of restraints, and failed to review the policy and procedures to remove restraint information not approved for use to direct staff in 2 of 2(unit #1 and #4) patient units.
Refer to Tag A0159

8.
A. ensure only a physician ordered a chemical/emergency behavioral medication (EBM) restraint.

B. ensure a process was in place for continuous monitoring after administering a chemical restraint/emergency behavioral medication for side effects, respiratory or cardiac distress, and assessment of medication effectiveness and safety after administration in 2 of 2(Patients #MM and #W) patient charts reviewed.

C. follow their own policy and procedures to ensure the restraint packet was filled out appropriately and completely, a face-to-face was conducted by a trained individual that was not part of the restraint process, and patient/ staff debriefing was completed and appropriate in 2 of 2 (# MM and #W) charts reviewed.

D. ensure staff was educated on the administration of the chemical/emergency behavioral medication (EBM) restraint for appropriate assessment, reassessment, and black box warnings for psychotropic medications.

E. ensure chemical restraints were added to the restraint log and were monitored through Risk and Quality in 2 of 2(#MM and #W) charts reviewed.

The deficient practices were identified under the following Condition of Participation, CFR 482.13 Patient Rights, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death.

Refer to Tag A0160

9.
ensure that two different RN's complete the initiation of restraint and the one hour face-to face evaluation as directed by the Texas state regulation in 1 of 1 charts (# JJ) restraint charts reviewed, and shown in their policy and procedure of Restraint/seclusion.
Refer to Tag A0180

Based on review and interview the facility failed to provide and have signed the Important Message from Medicare not more than two calendar days before the patient's discharge in 2 of 2(patient #II, and D) discharged patient charts.

Review of patient chart #II and #D revealed the patient's received the initial IMM letters but did not receive the letters before discharge.

An interview was conducted with staff #13 and staff #33 on 5/22/23. Staff #13 and staff #33 confirmed they have never given a medicare patient an IMM letter at discharge. Both staff #13 and #33 was unaware of the process.

Based on review and interview the facility failed to follow the policy and procedures for prompt resolutions of complaints and grievances, incomplete investigations, failure to report a patient request for a the patient advocate, failure to compile, analysis, monitor, and report the data on grievances and complaints to medical staff and governing body in 6 out of 6 (Dec. 2022-May 2023) months reviewed.

A review of the facility grievance log revealed there were three grievances for December 2022.

Patient #CC had a complaint dated 12/15/22 on "unfair tx- and racism" staff #1 (Patient Advocate) documented that the complaint was resolved on 12/20/22, 5 days later. Staff #1 did not change the complaint over into a grievance. There was no documentation of the allegations or if the patient was interviewed concerning his complaint. The patient was not sent any follow-up letter.

A review of the policy and procedure Patient Grievance Procedure- policy ID 13517667 stated, " A patient grievance is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present and or CEO) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoP) or Joint Commission.

Staff present includes any hospital staff present at the time of the complaint or who can quickly be at the patient's location (i.e., nursing, administration, nursing supervisors, and patient advocates) to resolve the patient's complaint.

A written complaint is always considered a grievance, whether from an inpatient, released/discharged patient, or his/ her representative regarding the patient care provided, abuse or neglect, or the hospital's policies and procedures."

A review of patient #DD's entry stated the complaint was filed on 12/9/23 and resolved on 12/9/23. A review of the Staff #1's note stated, " 1577- pt requested to speak with a patient advocate. Pt reports feeling unsafe d/t peer on unit. Pt was educated on voluntary legal status and discharge process. Pt was given support and encouragement. Nurse advised to provide AMA letter and notify MD info passed onto treatment team. 1805- Pt wife (ROI in chart) in lobby requesting to speak with patient advocate. Wife voiced frustration with admission process and other complaints. Wife was educated on pt signing AMA letter and legal process. Wife also given info on hospital policies for visitation. Wife gave collateral info on pt- states that he took approx.. (illegible) Remeron while she walking dog (sic). Info passed along to treatment team. "

The advocate did not provide any detailed information about the patient's complaints, if he was in danger or being threatened by another patient, if the patient received a 4-hour discharge notice, and what the outcome was. There was no evidence the complaint was resolved.

Patient #EE also complained on 12/9/22 that he felt unsafe on the unit. The patient asked to speak to the advocate. The note written by Staff #1 on 12/9/22 stated, " ...Pt expressed multiple complaints, mainly feels he's not getting proper tx and feels unsafe on unit. Pt. requesting to discharge ...pt was allowed to vent frustrations, given encouragement, and support. Pt was educated on discharge process ..." There was no found documentation on patient EE's "multiple complaints". There was no information if the patient's accusations about feeling unsafe on the unit were verified or what was done to ensure the patient's safety. There no was documentation if the patient was discharged or what the outcome was.

A review of the complaint log for March revealed patient #FF complained of lost dentures on 3/1/23. The log stated it was listed as a "complaint." The log stated under "status" that the complaint was substantiated. There was no grievance letter sent to the patient. The date resolved was 3/24/23 by staff #1. There was no documentation found or provided on whether the dentures were found, if the patient was provided new dentures, nor any other documented outcomes.

A review of the April grievance log revealed patient #GG's made a complaint of stolen property on 4/14/23. The complaint was turned over as a grievance and was not documented on the log as resolved until 4/25/23, 11 days later. There was no grievance letter sent to the patient. A note was attached dated 4/27/23. The note stated, "Re: Reimbursement for ____ (patient #GG)
When ____ (patient #GG) discharged on April 14, 2023 it was discovered that he was missing $1019.00 in cash. An investigation was done by ____( staff #2), CEO. Staff were interviewed and camera playback was reviewed. It was discovered that the cash was in a sealed security bag and was placed in the patient's belongings in the storage room instead of being placed in the valuables safe. A staff member was observed on camera on April 8, 2023 taking the security bag from the patient's belongings in the storage room. The staff member placed the security bag in his pocket then went to the bathroom. The staff member has been terminated."

There was no information documented if the patient received a letter concerning the incident, or if the money was paid back to the patient, there was no receipt attached, and there was no information if charges were placed upon the terminated employee.

A review of patient #F's chart revealed she was admitted on 5/10/23. A review of the log revealed patient #F had made a complaint concerning her legal status. A note was found from staff #1 that was dated 5/18/23 at 1430. The note stated, " Pt requested to speak to patient advocate. Pt has complaints about legal status, "I'm not f-ing paranoid" Attempted to educate pt. on legal stays but pt is screaming and cursing. Attempted to educate pt. on use of court-appointed attorney but is difficult to redirect."

A review of patient #F's written complaint revealed there were many topics that were not addressed. Patient #F stated it took 4 days to get psych and pain medications prescribed, no clean linens or towels were available, threats by staff, no way to shower, no therapy, and patient complained of falls. There was no evidence that patient #F's complaints were addressed or resolved. There was no documentation of a grievance. Staff #1 had documented on the log as unsubstantiated.

5/15/23 at 1600- Staff #37 documented, " pt keeps asking to talk to pt advocate or DON all day with no legitimate complaint." There was no documentation that Staff #37 ever notified the patient advocate on behalf of the patient.

A review of patient #F's chart revealed a note on 5/16/23 from the patient advocate at 10:15 AM. Staff #1 documented the patient was "paranoid with rambling speech. Focused on discharge with poor insight." The advocate explained her involuntary status and gave her the number to her court-appointed attorney at 1630. There was no documentation of what the patient's complaints were concerning the legal status and if the patient was able to contact her attorney. The complaint /grievance was not documented on the log.

An interview was conducted with staff #1 on 5/25 at 9:48 AM. Staff #1 was asked if she knew when a complaint would turn into a grievance. Staff #1 stated, "It becomes a grievance when it's written or if it concerns monetary value." Staff #1 confirmed she was not aware of the policy and procedure definition of a complaint vs grievance. Staff #1 stated that she had not been vigilant in keeping up with the grievances due to all the changes and responsibilities she had been given. During the review time frame staff #1 had been the interim Director of Nurses, Patient Advocate, Quality Director, Patient Safety Officer, Infection Control Nurse, and Staff Nurse when needed. Staff #1 stated that she had not been able to aggregate data for Quality concerning complaints and grievances and had no additional information to provide us.

Based on review of documentation and interviews, the facility failed to ensure the patient has the right to participate in the development and implementation of his or her plan of care.

Findings included:

Facility policy "Patient Treatment Plan" (PolicyStat ID 12386362) stated in part,
"POLICY:

Each patient shall have a written, comprehensive, individualized treatment plan that is based on assessment of his/ her medical, clinical and nursing needs. Individualized treatment planning shall be based on patient need.

A. Patients have the right to ongoing participation in their treatment plan ...

K. Treatment plans will be provided to the patient or the guardian ...

PROCEDURE:

Preliminary Treatment Plan:

Upon admission, the nurse shall initiate the Interdisciplinary Treatment Plan for the patient's identified nursing care needs as part of the admission assessment. This plan will be based on the patient assessment and an evaluation of the patient's presenting problems, physical health, emotional status and behavior and provider input. An initial discharge plan will be completed along with the admission assessment.

Once the treatment plan has been developed, a staff person shall review the treatment plan with the patient. This participation shall be noted by the staff's signature on the treatment plan."

Facility policy, "Plan of Care-Protocol for the Use of the Interdisciplinary Format" (PolicyStat ID 12197123) stated in part,
"Phase II: Formulating the Interdisciplinary Treatment Plan (Initial Session)
Prior to the initial Interdisciplinary Treatment Plan session for the patient, the social worker will incorporate the information gathered from the history and physical, psychiatric evaluation, social service meetings, nursing, and therapy services assessments into the initial Interdisciplinary Treatment Plan. This integration will reflect all assessed strengths and limitations.
The Interdisciplinary Treatment Team will meet on a weekly basis to ensure the preparation, review, and update of each patient's individualized problem, goals, and approaches through an interdisciplinary approach. The Interdisciplinary Treatment Team meetings will be attended by at least the Psychiatrist or designee, Director of Nursing or designee, Social Worker, Psychology, Therapy Services, Medical Provider (or designee), Utilization Review, Dietary, and Pharmacy.
Family, caretakers, guardians and/or significant members of the patient's support system may be included by patient permission. When this occurs, the Social Worker will contact the significant person to arrange for their inclusion. The individual's Interdisciplinary Treatment plan will be adjusted as necessary to accommodate family input and wishes ...

Each team member will provide their signature to signify their agreement with the plan ...

Phase Ill: Ongoing Treatment Review (Subsequent Sessions) ...
The Interdisciplinary treatment team will sign the patient's updated Interdisciplinary Treatment Plan."


Review of treatment planning documentation for 7 Patients revealed that only Nurse Practitioners and Social Workers were typically present for and actively participating in Treatment Plan Meetings at the facility. Also that patient's and family members did not consistently have opportunities to participate in treatment planning:

Regarding Patient #F:
* On the initial Interdisciplinary Treatment Plan dated 05/11/23 the boxes to indication the patient or the patient representative participated in planning were not checked.
* The Weekly Interdisciplinary Treatment Plans dated 05/12/23 and 05/19/23 under "DISCHARGE PLAN/NEEDS" indicated "Communication will be completed weekly with:" the "Family/Guardian/POA:" Only representatives from Clinical Services and Psychiatry signed this form to indicate participation. Only one social worker note indicated discussing the care plan with Patient #F. There was no documentation that the patient and/or family members participated in the development and implementation of their plan of care.

Regarding Patient #G:
* The Weekly Interdisciplinary Treatment Plan dated 05/16/23, only representatives from Clinical Services and Psychiatry signed this form to indicate participation. There was no documentation that the patient participated in the development and implementation of their plan of care at this meeting.

Regarding Patient #H:
* The Weekly Interdisciplinary Treatment Plan dated 05/15/23, only representatives from Clinical Services and Psychiatry signed this form to indicate participation. There was no documentation that the patient's family members participated in the development and implementation of their plan of care, despite indicating weekly communication.

Regarding Patient #K
* On the initial Interdisciplinary Treatment Plan dated 05/15/23 the boxes to indication the patient or the patient representative participated in planning were not checked.
* The Weekly Interdisciplinary Treatment Plan dated 05/15/23, only representatives from Clinical Services and Psychiatry signed this form to indicate participation. There was no documentation that the patient or the patient's family members participated in the development and implementation of their plan of care.

Regarding Patient #L:
* On the initial Interdisciplinary Treatment Plan dated 05/17/23 the boxes to indication the patient or the patient representative participated in planning were not checked.
* The Weekly Interdisciplinary Treatment Plans dated 05/17/23 under "DISCHARGE PLAN/NEEDS" indicated "Communication will be completed weekly with:" the "Family/Guardian/POA:" Only representatives from Clinical Services and Psychiatry signed this form to indicate participation. There was no documentation that the patient and/or family members participated in the development and implementation of their plan of care.

Regarding Patient #M
The Weekly Interdisciplinary Treatment Plans dated 05/12/23 under "DISCHARGE PLAN/NEEDS" indicated "Communication will be completed weekly with:" the "Family/Guardian/POA:" Only representatives from Clinical Services and Psychiatry signed this form to indicate participation. Two social worker notes on 05/12/23 and 05/17/23 indicated discussing the care plan with Patient #M and a family member. There was no documentation that the patient and/or family members participated in the development and implementation of their plan of care.

Regarding Patient #Q:
* On the initial Interdisciplinary Treatment Plan dated 05/15/23 indicated involvement of Patient #Q. The boxes to indication patient representative participated in planning was not checked.
* The Weekly Interdisciplinary Treatment Plan dated 05/15/23 under "DISCHARGE PLAN/NEEDS" indicated "Communication will be completed weekly with:" the "Family/Guardian/POA: mother [name]" and "Community Mental Health: [name]". Only representatives from Clinical Services and Psychiatry signed this form to indicate participation. There was no documentation that the patient's family members participated in the development and implementation of their plan of care, despite indicating weekly communication.

In an interview with staff member #3, the Director of Nursing (DON), on 05/23/23 at 11:00 AM, they were asked when treatment team meetings occurred? Staff member #3 replied, "I don't know. Afternoons, maybe Wednesdays?" On 05/23/23 at 11:05 AM, a staff nurse, staff member #13, was asked if they ever participated in treatment planning. Staff member #3 replied, "No. We start the initial treatment plan only."

In interview on 05/23/23 at 11:30 AM, staff member #11, a social worker was asked when treatment team meetings occurred. Staff member # 11 replied, "Monday, Wednesday, and Friday a 1100, based on nurse practitioner availability." Staff member #11 was asked if any other staff members attend treatment team planning? Staff member #11 replied, "It's just us, the nurse practitioner and me." Staff member #11 was asked if patients or family members participate in treatment team. Staff member #11 replied, "The patient isn't there. Since I've been here the patient is never there. With the previous psych team the entire medical team, including UR (utilization review) was present at treatment planning." Regarding treatment planning staff member #11 stated, "There is no standardized or systemic way to do it. I usually go over it with them on the phone, we talk about goals, discharge, and continuum of aftercare."

In an interview with staff member #13, Director of Clinical Services, on 05/25/23 at 9:30 AM, they verified that typically treatment plan meetings only have the nurse practitioner and social worker present. Staff member #15 added, "It's not that patient and family aren't invited, it's that processes here have changed, before the physician and family and nursing would have been involved."

Based on the above findings the facility failed to provide opportunities for patient and their family or LAR to exercise their right to participate in the development and implementation of his or her plan of care.

Based on record review and interview the facility failed to;

A. ensure psychoactive medications were administered to 1 of 2 patients (Patient E) without first obtaining properly, informed consent from the patient or the patient's legally authorized representative.

B. ensure the patients were instructed on their involuntary status, and warrants were filed in a timely manner with results available to the patient and surveyor. Failed to have written documentation that the patient was aware of their rights, court hearing dates, and awareness of the judge's decision on their legal status after the court hearings, and failed to release the patient without the proper warrants in place in 3 of 3(#F, AA, and II) charts reviewed.

C. ensure a signed Order of Protective Custody with a forced medication order granted by the county judge was on the medical record before administering psychotropic medications to patients with the inability to consent or refused medications and treatment in 1 of 1(#II) patient medical records reviewed.

D. ensure the patient had the capacity to consent to the administration of psychotropic medications, the beneficial effects on the patient's mental illness, or the condition expected as a result of treatment with psychotropic medication in 5 of 5 (#AA, BB, JJ, II, and LL) charts reviewed.

The deficient practices were identified under the following Condition of Participation, CFR 482.13 Patient Rights, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death.

Findings were:

A.
Patient E was admitted on 2-28-23 and discharged on 3-8-23. He was prescribed and administered the following psychoactive medications during his stay:
* Haldol - 1 dose
* Risperdone - 10 doses
* Vistaril/Atarax - 11 doses
* Buspar - 11 doses
* Depakote - 14 doses
* Lexapro - 7 doses

The clinical record contained no documentation that the facility had obtained informed consent from the patient for any of the above-listed medications.

Facility policy 10041880 titled "Informed Consent Process" states, in part:
"Policy:
All patient medical records shall contain evidence of informed consent for medical care and psychiatric treatment specified by state or federal laws/regulations. This is to include consents for psychotropic medications.
The Hospital's informed consent process assures patients or their legal representatives are given the information and disclosures needed to make an informed decision about whether to consent to medical care and psychiatric treatment, and psychotropic medications.
(a) Informed medication consent must be obtained for each individual medication, not by medication class.
(b) Informed consent for the administration of each psychoactive medication will be evidenced by a completed copy of NPH's Informed Consent for the Use of Psychotropic Medications.

The above was confirmed in an interview with staff #1 during the complaint investigation.

B.
Patient #F requested to talk to the surveyor on 5/22/23 in the afternoon. Patient #F stated that she had been in the facility for a couple of weeks, and no one will explain to her why she cannot leave. Patient #F stated that she volunteered to come in for depression. Patient #F stated, "I am bipolar, and I have been medicated for a long time. I know I was having issues and suffering from depression, but I wanted to get help. I have not seen a psychiatrist since I have been here, and I have asked to speak to the patient advocate several times. She had spoken to me a couple of times but will not listen to me and she cannot tell me why I am being held here." Patient #F stated that they told her that she had a warrant against her. Patient #F stated that the advocate told her she had an attorney and gave her the number. Patient #F stated that she had attempted to call the attorney numerous times but received no callback. Patient #F stated that she had not been before a judge or given any information concerning her detainment.

A review of patient #F's chart revealed she was admitted on 5/10/23. A review of the log revealed patient #F had made a complaint concerning her legal status. A note was found from staff #1 that was dated 5/18/23 at 1430. The note stated, " Pt requested to speak to patient advocate. Pt has complaints about legal status, "I'm not f-ing paranoid" Attempted to educate pt. on legal stays but pt is screaming and cursing. Attempted to educate pt. on use of court-appointed attorney but is difficult to redirect."

A review of patient #F's written complaint revealed there were many topics that were not addressed. Patient #F stated it took 4 days to get psych and pain medications prescribed, no clean linens or towels were available, threats by staff, no way to shower, no therapy, and the patient complained of falls. There was no evidence that patient #F's complaints were addressed or resolved. There was no documentation of a grievance. Staff #1 had documented on the log as unsubstantiated.

5/15/23 at 1600- Staff #37 documented, " pt keeps asking to talk to pt advocate or DON all day with no legitimate complaint." There was no documentation that Staff #37 ever notified the patient advocate on behalf of the patient.
A review of patient #F's chart revealed a note on 5/16/23 from the patient advocate at 10:15 AM. Staff #1 documented the patient was "paranoid with rambling speech. Focused on discharge with poor insight." The advocate explained her involuntary status and gave her the number to her court-appointed attorney at 1630. There was no documentation of what the patient's complaints were concerning the legal status and if the patient was able to contact her attorney. The complaint /grievance was not documented on the log.

A review of patient #F's chart revealed the physician admission order dated 5/10/23 at 1730 stated the patient was admitted voluntarily. A review of the physician orders dated 5/11/23 at 1635 revealed staff #47 Nurse Practitioner (NP) wrote an order to start the court commitment process.

A review of the psychiatric evaluation revealed the NP performed the evaluation however the physician documented he also saw the patient on 5/11/23 at 8:30 AM but there was no other documentation that the psychiatrist saw the patient again. In the body of the evaluation, patient #F asked when she was going to see the physician. A review of patient #F's chart revealed the patient was seen every day from 5/12/23 -5/22/23(excluding 5/19/23) only by the nurse practitioner for her psychiatric care.

A review of patient #F's chart revealed a request to the court for an Order of Protective Custody (OPC) on 5/11/23. Staff #14 Court Liaison made an application on behalf of the hospital to court-commit patient #F on 5/12/23.

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

An order of protective custody and notice of hearing form was in the chart. A hearing was set for 5/15/23 at 12:00 PM for the probable cause hearing. The hearing for the application for OPC was set for 5/22/23 at 9:00 AM. There was no found evidence that the hearing was performed and what the results of the hearing were. There was no documentation that the patient had an opportunity to speak at her court appointment hearing, that she was informed of the dates and times of her hearings, and was aware of the final judgment. There was no evidence the patient was being held lawfully.

A review of patient # AA's chart revealed she was admitted to the facility on 5/11/23 as a voluntary patient. A review of the chart signed by the justice on 5/12/23 revealed she had an order of protective custody and notice of hearing. There was no physician order to change the patient status to involuntary. The date for the probable cause hearing was set for 5/15/23 and the hearing for the application for OPC was on 5/19/23. There was no found evidence that the hearing was performed and what the results of the hearing were. There was no documentation that the patient had an opportunity to speak at her court appointment hearing, that she was informed of the dates and times of her hearings and was aware of the final judgment. There was no evidence the patient was being held lawfully.

C.
A review of patient #II's chart revealed he was admitted as a voluntary patient by nurse practitioner staff #27 on 5/12/23. There was no psychiatric evaluation or any psychiatric notes on the patient's chart. A review of the nurse's notes dated 5/12/23 (no time) stated, " pt a/o only to self. Pt is with a history of autism and appears to be non-verbal. Pt was seen in his room and appeared to be masturbating. Pt was humming in his room and throughout the day as well as other noises but no words unable to assess with for SI/HI/AVH or pain due to patient's limitations ..."
A review of patient #II's chart revealed he was allowed to sign in as a voluntary patient even though the patient did not have the capacity to consent. The patient's signature was just circles and a line. A motion for an OPC was started in Henderson County and an order to transport the patient to the facility was signed by the judge. There were no further court orders found that were filed on the patient's behalf for Harris County for court commitment.

Review of patient #II's chart revealed he was administered psychotropic medication without the capacity to consent and did not have an OPC with forced medication order.

Review of the Consent for Admission and Treatment stated, "POLICY:
Patients can be admitted to the facility on a voluntary or involuntary basis. Only the patient is able to sign him/herself in for voluntary treatment. If a patient is a danger to self, danger to others, and/ or gravely disabled and refuses to sign in voluntarily; a physician will assess the patient to determine if an Emergency Detention Order (EDO) should be initiated."

A review of patient #II's medication administration record (MAR) revealed patient II was administered Invega (psychotropic) from 5/16/22 through 5/22/23 and Risperdal (psychotropic) from 5/12/23 through 5/14/23.

An interview was conducted with staff #14 court liaison on 5/23/23. Staff # 14 stated that she does not assist the patients with speaking with their attorneys or court appearances. Staff #14 stated," I don't know who helps out the patients, I'm not the advocate." Staff #14 stated that she looks in well sky(computer program) for new admissions and sees if they need to have the paperwork completed for the courts. Staff #14 stated, " I just fill out the paperwork and take it to the courts." Staff #14 was unable to give the surveyor a court decision or time frame on how long the patients are committed through the court system. Staff #14 stated that she just gets emails through a court link when the court hearings are and "we do the process through tele court."

Staff #14 was unable to give the surveyor any final court hearings on patients #F and #AA. Staff #14 confirmed patient #II was voluntary and did not have an OPC in place for Harris County.


D.
Record review of the facility's policy titled, "Informed Consent," dated 07/21, showed the following:

"Written authorization for medical care and psychiatric treatment including changes in medication therapy or addition of new medication both psychotropic and non-psychotropic shall be on the patient's medical record prior to initiation of care, treatment, or services."

"Written authorization will not be obtained when a patient admission is court ordered under emergency detainment terms."

"Texas Administrative Code 414.405; notes the consent by mentally incompetent patients. This section applies to a patient who is deemed incompetent shall provide consent for treatment through the informed consent of the following:"

"The patient's legal guardian or other court appointed representative."

Patient #BB

Review of patient #BB medical record (Emergency Apprehension and Detention Warrant [EDO]) showed the patient #BB was admitted via an EDO from Harris County on 05/13/23 at 15:37.

Review of Patient #BB medical record (Order of protective custody) from Harris County Texas was approved on 5/15/23 at 1:25 PM.

Review of Patient #BB medical record showed an authorization for medical care and psychiatric treatment was signed by the patient on 5/13/23 at 17:00. The patient was deemed incompetent to by the EDO.

Review of Patient #BB medical record (Medication Administration Record) for 5/14/23 showed Prozac 30mg was given at 0900. An informed consent for the use of psychotropic medication dated 05/17/23 showed patient #BB signature, indicating that the patient who was deemed incompetent on an EDO had signed the informed consent.

Review of Patient #BB medical record showed no clearance from a doctor that the patient was now competent to sign consents.

Review of Patient #BB medical record showed that a court order to give Psychotropic Medication was not requested for by the facility at the time of admission nor before the administration of the medication by the nurse.

Review of Patient #BB medical record showed that Psychotropic medication was administered without consent.

Patient AA

Review of patient #AA medical record (Emergency Apprehension and Detention Warrant [EDO]) showed the patient #AA was admitted via an EDO from another hospital on 5/11/23. An Order for Protective Custody was requested by MBHCL and granted on 5/15/23.

Review of Patient #AA medical record showed a Certificate of Medical Examination completed on 05/11/23 by MD from another hospital, Harris Health Lyndon B. Johnson Hospital. The medical exam indicated the patient needed to be hospitalized and was not able to make this decision. "Likely to cause harm to self and likely to cause harm to others".

Review of Patient #AA medical record (Order of protective custody) from Harris County Texas was approved on 5/15/23 at 11:25 PM.

Review of Patient #AA medical record showed an authorization for medical care and psychiatric treatment was signed by the patient on 05/11/23.

Review of Patient #AA medical record (Medication Administration Record) showed that Patient received psychotropic medications (Depakote and Seroquel) without a consent 33 times from 05/11/23 to 05/22/23.

PATIENT #JJ

Review of patient #JJ medical record (Emergency Apprehension and Detention Warrant [EDO]) showed the patient #JJ was admitted via an EDO from another hospital on 5/12/23. An Order for Protective Custody and transfer to MBHCL no further documentation was provided it is unknown if it was approved.

Review of Patient #JJ medical record showed a Certificate of Medical Examination completed on 05/14/23 by MD from HCA . The medical exam indicated the patient needed to be hospitalized and was not able to make this decision. "Likely to cause harm to self and likely to cause harm to others".

Review of Patient #JJ medical record (Order of protective custody) from Montgomery County Texas was approved on 5/15/23 at 11:25 PM.

Review of Patient #JJ medical record showed the patient had no consents for any Psychotropic medication to be given by the court.

Review of Patient #JJ medical record (Medication Administration Record) showed that Patient received psychotropic medications (Depakote, Haldol, Ativan, and Trazadone) without a consent 63 times from 05/15/23 to 05/23/23.

Patient #LL

Review of patient #LL medical record (Emergency Apprehension and Detention Warrant [EDO]) showed the patient #LL was admitted via an EDO from Harris County on 05/12/23 at 15:30.

Review of Patient #LL medical record (Medication Administration Record) From 05/12/23 to 05/22/23 showed the patient received psychotropic medication(Depakote and Zyprexa) without a legal consent 25 times.

Review of Patient #LL medical record an informed consent for the use of psychotropic medication dated 05/12/23 showed patient #LL signature, indicating that the patient who was deemed incompetent on an EDO had signed the consent.

Based on a review of clinical records and facility documentation, the facility failed to protect the patient's right to care in a safe setting, as 2 of 2 patients (Patients D & E) were not observed at the appropriately precaution or observation levels during their stay.

Findings were:

Patient D was admitted to the facility on 11-23-22 at approximately 9:30 pm. The patient was admitted on q 5 minute checks as well as elopement, assault and fall precautions.

A review of observation/precaution sheets completed during the patient's stay revealed the following:
* 11-23-22 - q 5 minute observation level as well as elopement, assault and fall precautions not noted
* 11-24-22 - elopement, assault and fall precautions not noted
* 11-25-22 - q 15 minute observation level is noted, although patient was on q 5 minute observation level
* 11-26-22 - elopement precaution not noted
* 11-27-22 - elopement precaution not noted
* 11-28-22 - fall precaution not noted
* 11-29-22 - sheet completed correctly
* 11-30-22 - fall precaution not noted
* 12-1-22 - elopement precaution not noted
* 12-2-22 - elopement precaution not noted

Patient E was admitted to MBH on 2-28-23 at 10:45 am. The patient was admitted to the adult unit and placed on q 15 minute checks as well as precautions for suicide and elopement.

A review of observation/precaution sheets completed during the patient's stay revealed the following:
* 2-28-23 - sheet contained no indication of observation level or precaution levels
* 3-1-23 - sheet incorrectly stated that the patient was on a q 5 minute monitoring level and did not indicate his precaution levels
* 3-2-23 - no observation sheet found in clinical record for this date
* 3-3-23 - time blanks were labeled "LOA" from 12:00 pm until 4:35 pm and no observations were made at all from 4:40 pm through 6:55 am on 3-4-23.
* 3-4-23 - time blanks were labeled "LOA" from 7:00 am through 10:45 am, when documentation of q 15 minute checks resumed (although nursing notes state that the patient returned to the facility at 9:45 am, an hour prior to the resumption of his q 15 checks)
* 3-5-23 - sheet was properly completed
* 3-6-23 - sheet was properly completed
* 3-7-23 - sheet contained no documentation of the suicide precaution
* 3-8-23 - no observation sheet found in clinical record for this date, although the patient did not discharge from the facility until 2:14 pm

Facility policy 12385972 titled "Patient Observation" states, in part:
"POLICY:
On admission, patients shall be assigned an observation level. An order indicating the observation level shall be based on an assessment of the patient's emotional, physical, cognitive, and behavioral status as determined by the nursing personnel assessing the patient for admission with specific consideration as to the risk posed to themselves or others. Patients will continue to be assessed and monitored during their treatment to ensure observation levels are appropriate.
PROCEDURE:
1. On admission, the patients will be assessed for the level of observation. The provider will order the one of three observation levels. All patients will be admitted to the patient care unit with a minimum of "every 15 minutes" (Q 15) observation level.
2. Observation levels can be increased or decreased by a provider's order.

A. Provider Orders: Providers will order specific precautions for any patient(s) who requires a level of monitoring other than routine, including but not limited to:
1. Assault
2. Aspiration
3. Elopement
4. Fall
5. Self-Harm
6. Seizure
7. Sexually acting out
8. Suicide

B. Observation Levels: A frequency or intensity of observation assigned to a patient during which a health care professional, or their designee, will observe a patient. The approved observation levels assigned are:
1. Q 15 Minute Observation
a. All patients on this level are on every 15 minute observation, at a minimum.
b. This is the minimum acceptable level for all patients; for patients at a lower risk
c. The location of the patient should be known to staff at all times but they are not necessarily within sight.
2. Q 5 Minute Observation
a. All patients on this level are on every 5 minute observation, at a minimum.
b. This is an increased level of observation for patients that are determined to be higher risk and require more frequent monitoring.
c. The location of the patient should be known to staff at all times but they are not necessarily within sight.
3. 1:1 Observation
a. The patient is to be under constant visual observation by an assigned staff member, regardless of other unit activities.
b. Staff member must remain in close proximity to the patient, to include patient bathing and toileting activities. Under these conditions, the patient's safety and protection outweighs his/her right to privacy. For bathing and toileting activities, staff of the same sex may be utilized if available.
c. Staff will continuously monitor the patient's behavior and immediately report any changes in conditions of circumstances to the nurse.
d. Q 5 minute documentation is to be completed when patients are on 1:1 observation.
e. Staff is not to engage in personal activities such as reading, eating, phone use, or similar activity that could distract or otherwise interfere with the continuous observation of the patient.
3. All patients on a 1:1 should be re-evaluated each shift. A provider order to continue or discontinue 1:1 observation is to be documented daily.
4. 1:1 is to be discontinued at the earliest possible time.
5. Documentation:
A. Documentation of all observations will be completed in the patient's record at least once per 15 minute increment.
B. Staff will complete the patient observation record using a coding system described on the Patient Observation Rounds form."

The above was confirmed in an interview with staff #1 during the complaint investigation.

Based on Observation, record review and interview the facility failed to ensure that a patient with an eating disorder #N, was given the proper assessments, monitoring, and nursing care for diagnosis.

Observation: This surveyor (37492) observed Patient #N on unit 300 in the milieu area. Patient was emaciated and frail in appearance, with dry skin and hair. She was wearing several layers of clothing.

Review of Patient #N medical record nursing admission assessment dated 05/12/23 at 00:15 showed the Patient #N was admitted with a weight of 66.4 pounds at 4 feet 9 inches her Body Mass Index (BMI) was at 14.4 indicating she was underweight. The question for eating disorder was left blank. The question for Malnutrition was answered, yes, by the RN (signature was illegible).

Record of Patient #N medical record (History and Physical Exam), dated 05/12/23, by Staff Doctor #47. The review of symptoms for Nausea/vomiting was left blank, but the history of present illness indicates the patient denies nausea and vomiting. The patient's weight and appearance were not addressed.

Review of Patient #N medical record showed an Internal Medicine Progress Note written by Staff FNP #48, dated 05/16/23, written under the title, "Assessment/Plan" Patient has an eating disorder and throws up food.

Review of Patient #N medical record showed an admitting Psychiatric Evaluation, dated 05/12/23, written by Staff Nurse Practitioner #47, under the Admitting Diagnosis lists Body Dysmorphic disorder (F45.22).

Review of Patient #N medical record showed a doctor's order, dated 05/12/23 at 16:00, written by Staff Nurse Practitioner #47, monitor during meals, daily weights, calorie count, and monitor patient in bathroom after meals.

Review of Patient #N medical record showed a doctor's order, dated 05/16/23 at 15:00, written by Staff Nurse Practitioner #47, the order calls for 1:1 monitoring for one hour post meals and a nutritional consult.

Review of Patient #N medical record (Nutritional Consult), dated 05/18/23, written by Staff Dietician #24, listed under other problems the Dietician wrote Nausea and Vomiting and Eating Disorder.

Review of Patient #N medical record (Nutritional Consult), dated 05/18/23, written by Staff Dietician #24, altered labs related to intake and medical condition as evidenced by patient presenting with diagnosis of Irritable Bowel Disease (IBS) and symptoms of bulimia. Nutritional Diagnosis: inadequate fluid intake, underweight. Nutritional interventions: Monitor weight, signs and symptoms of dehydration, and nutritional intake.

Review of Patient #N medical record (Nursing Notes) from 05/12/23 till 05/20/23 showed the no documentation of monitoring the patient after meals, calorie counts, daily weight are not listed in the chart.

Interview with Staff RN #36 on 05/22/23 at 14:30 showed the following:
There is no place to write a patient's intake of food "I guess we can put in the nursing notes".
We do not do one to one monitoring for food intake.
We do not weight the patient at the same time every day. It depends on how many staff are on.
When asked about caloric intake documentation no response was given.

Interview with staff CEO #2 on 05/22/23 about Patient #N and the fact that no documentation was found on the patient's chart to indicate monitoring was done. The CEO stated, "You can't prove we didn't do it."

Interview with the Staff Medical Director #04 on 05/23/23 showed that the facility doesn't treat eating disorders and the patient was admitted with depression. There are no facilities in the Houston area that do.

Based on review and interview the facility failed to provide a process to safely use seclusion as an approved restraint within the facility, failed to provide a key or a written process on how to properly access the key for seclusion, failed to educate the staff on least restrictive methods of restraints, and failed to review the policy and procedures to remove restraint information not approved for use to direct staff in 2 of 2(unit #1 and #4) patient units.

On 5/22/23 an observation was made in unit 4 (acute adult unit) of patient #MM. Patient #MM had been placed on a 1:1 observation due to her behavioral outbursts and self-inflicting harm. Patient #MM had an open wound on her forehead. Staff #19 stated patient #MM had injured herself the night before by banging her head on the wall.

An interview was conducted with Staff #13 on 5/22/23 at 11:00 AM. Staff #13 was asked about restraints and what would be appropriate for Patient #MM when she was having behavioral outbursts or inflicting self-harm. Staff #13 stated that she would try to de-escalate the patient by talking to her or trying to meet her needs. Staff #13 stated that if she was unable to de-escalate the patient, she would call the nurse practitioner or physician for a chemical restraint/emergency behavioral medication (EBM). Staff #13 was asked what other types of restraints the facility use and staff #13 stated, "We just usually give them a shot." Staff #13 confirmed the facility did not use or have any mechanical restraints. Staff #13 stated that staff uses physical holds on the patients if needed and they do have a seclusion room, but they never use it. Staff #13 stated, "We don't have a key to the seclusion room." Staff #13 stated that she was not aware of why they did not have a key for the seclusion room but if they needed to use the room, she would have to call a house supervisor. Staff #13 was asked what restraint would be least restrictive a hold, seclusion, or an intramuscularly injection (IM) chemical restraint/EBM? Staff #13 stated, "A shot." It was confirmed by staff #1 on 5/22/23 that there were no house supervisors available for an interview. Both house supervisors were out due to vacation and illness.

Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior.
Staff #13 confirmed that she was not aware that there was no antidote for psychotropic medications that are administered IM for behavioral emergencies. Staff #13 was not aware of the black box warnings for Haldol or Geodon.

A review of the policy and procedure "Restraints and/or Seclusion use" stated,
"Restraint - any method (physical or chemical) of restricting a patient's freedom of movement, physical activity, or normal access to his or her body that is not a customary part of a medical diagnostic or treatment procedure to which the patient or his/her representative has consented; is not indicated to treat the patient's condition or symptoms and/or cannot be easily removed by the patient in the same manner that it was applied.
.
Emergency Medication - a medication, when used, to manage the patient's behavior or restrict and is NOT a standard treatment or dosage for the patient's condition. Emergency Medications cannot be ordered as a PRN or as needed medication. (Medications which are part of the patient's regular medical regimen, even if PRN, are not considered emergency medications, even if their purpose is to control ongoing behavior).

Seclusion - the confinement of a person alone in a room or an area where the person is physically prevented from leaving.

DISCONTINUATION OF RESTRAINT/
SECLUSION:
Restraints/seclusion must be discontinued as soon as safely possible, regardless of the length of time identified in the order.

A nurse may discontinue the restraint/seclusion as soon as the unsafe situation ends, or a less restrictive measure can be used. The criteria for early release of restraint/seclusion is documented on the physician order such as the patient is no longer a danger to self or others and the staff /patient is able to construct a safety plan."

Physical holds, seclusion, and mechanical restraints can be released immediately ending the restraint process. However, a psychotropic medication such as Geodon, Haldol, or Zyprexa, given as a chemical restraint or EBM has no antidote. The patient must metabolize the medications or in case of overdose may require hospitalization and respiratory ventilation support.

An interview was conducted with Staff #16 on 5/23/23. Staff #16 stated that the unit did not have a key to the seclusion room for months and she had not used it due to no key. Staff #16 confirmed the DON placed the key there the day before. Staff #16 got the key and off the ring in the nurse's station and showed it to the surveyors. Staff #16 confirmed the facility does not use mechanical restraints. Staff #16 stated, "We can hold them and give them a shot. I guess now since we have a key we can use the seclusion room." Staff #16 confirmed that she was not aware that psychotropic medications given for behavioral emergencies IM or IV did not have an antidote. Staff #16 was not aware of the black box warnings for Haldol or Geodon.

A review of the policy and procedure "Restraints and/or Seclusion use" revealed the policy does not list approved restraints. The policy had multiple areas of direction for the staff for mechanical restraints. The policy stated,

"INITIATION OF RESTRAINT & SECLUSION
Any staff member trained in CPI techniques may initiate a CPI hold in an emergency. A mechanical restraint may only be initiated by a trained Nurse, Physician, or LP ...Patients will have range of motion movement to any restrained extremity at least every 2 hours. Each restrained extremity will be released for range of motion for at least 2 minutes each 2 hours. As appropriate to the situations, only one extremity need be released at a time ...

REMOVAL OF RESTRAINTS: Restraint removal may take place when: Two staff members must be present to remove restraints, Patient must have exhibited criteria for release, Patient is sleeping while in restraints, Patient is exhibiting physiological symptoms that indicate restraints may be harmful, Patient is exhibiting psychological trauma that indicates restraints may be harmful."

An interview was conducted with Staff #3 on 5/23/23. Staff #3 stated that he had not been at the facility long and was still learning. Staff #3 stated that the staff should attempt to de-escalate the patients to avoid behavioral restraint. Staff #3 stated that he believed a chemical restraint/ EBM would be the least restrictive restraint and then seclusion if needed. Staff #3 was not aware of the policy and procedure for seclusion and restraints and spoke about the use of mechanical restraints. Staff #3 stated he was not aware that the nurses did not have a key to the seclusion rooms and had not been using them due to having no key or control of the room. Staff #3 was unable to tell me the process for placing a patient in seclusion.

Based on record review and interview the facility failed to,
A. ensure only a physician ordered a chemical/emergency behavioral medication (EBM) restraint.

B. ensure a process was in place for continuous monitoring after administering a chemical restraint/emergency behavioral medication for side effects, respiratory or cardiac distress, and assessment of medication effectiveness and safety after administration in 2 of 2(Patients #MM and #W) patient charts reviewed.

C. follow their own policy and procedures to ensure the restraint packet was filled out appropriately and completely, a face-to-face was conducted by a trained individual that was not part of the restraint process, and patient/ staff debriefing was completed and appropriate in 2 of 2(# MM and #W) charts reviewed.

D. ensure staff was educated on the administration of the chemical/EBM restraint for appropriate assessment, reassessment, and black box warnings for psychotropic medications.

E. ensure chemical restraints were added to the restraint log and were monitored through Risk and Quality in 2 of 2(#MM and #W) charts reviewed.

The deficient practices were identified under the following Condition of Participation, CFR 482.13 Patient Rights, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death.

Findings:
Patient #MM

A review of patient #MM's file revealed she was admitted to the facility on 5/17/23 at 04:00 AM.
A review of the admission order dated 5/17/23 revealed the patient was admitted by staff #27 (nurse practitioner NP) and given a legal status of voluntary. The reason for admission was blank. There was no diagnosis for the admission, The initial treatment plan problems section was left blank, and the nurse signed the order on 5/17/23 at 5:30 AM. The nurse practitioner signed and dated the order on 5/17/23 but failed to document the time the order was signed. The patient was placed on seizure precautions. The physician failed to write an admission order.

According to Texas Administrative Code TITLE 26, PART 1, CHAPTER 568, SUBCHAPTER B, RULE §568.22 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS, ADMISSION, Voluntary Admission
(h) Admission examination.
(1) The admission examination referenced in subsection (d)(2)(A) of this section shall be conducted by a physician in accordance with Texas Health and Safety Code Chapter 572 and include a physical and psychiatric examination conducted in the physical presence of the patient or by using audiovisual telecommunications.
(2) The physical examination may consist of an assessment for medical stability.
(3) The physician may not delegate conducting the admission examination to a non-physician.
(i) Documentation of admission order. In accordance with Texas Health and Safety Code §572.0025(f) (l), the order described in subsection (f)(2)(B) of this section shall:
(1) be issued in writing and signed by the issuing physician; or
(2) be issued orally or electronically if, within 24 hours after its issuance, the hospital has a written order signed by the issuing physician."

A review of the nurse notes dated 5/17/23 at 4:10 AM stated, "Pt arrived via EMS from___ (hospital) for pseudo seizures. Pt A, O x3. Pt denies SI/HI/AVH at this time. Consents signed. Pt checked for contraband. Pt. walked with nurse to unit 100 RM 107 B. 5:00 AM Pt shaking on floor. Does not respond to verbal stimuli. V/S 97.9, B/P 162/94, P 89, RR 16 O2 sat 97.6. 5:10 AM. Pt sitting up and talking to nurse. Pt escorted to rm 107. 5:30 AM Pt sitting on floor beating head against the wall, blood on wall, pt c/o feeling dizzy. Pt refuses blood draw and refuses to set (sic) in bed. Call placed to Dr. ____ waiting call back. 5:45 AM no call back from MD will send out to ____ (ER) for eval of head. 5:55 AM Report called to ___ (ER) 6:00 AM calling (illegible) ambulance for transport, spoke with ___, ETA 30-40 min."

A review of patient #MM's chart revealed there was no information on what time she left the facility and if she was escorted by the staff.

A review of the nurse's note dated 5/17/23 at 12:30 PM revealed patient #MM returned to the facility. The nurse documented, "Pt returned via EMS and was having pseudo seizures, so they took her back to the ER and ER said they can't do anything for pseudo seizures and told EMS to take her back to us. She immediately started head banging and having pseudo seizures upon return here. ____ (staff #27) NP wrote order to transfer to 400 as soon as bed available." There was no further documentation on what the staff did to protect the patient from injury, if there were de-escalation attempts, or if the patient was placed on a 1:1. There was no documentation found that the physician was aware of patient #MM's ER visit, return from the ER, or that the patient continued to self-harm.
A review of the physician notes revealed staff #27 NP documented on 5/18/23 at 5:51 AM Patient presented on unit 400 for assessment. She was transferred to a more acute unit due to her impulsive, aggressive and self-harming behavior. Per staff reports, the patient started banging her head on the wall causing a hematoma and abrasion to her forehead. When staff intervened she became verbally and physically aggressive. Started to attempt to strike and spit at staff. She had to be restrained for safety and emergency medication was administered (Zyprexa 10mg IM, Ativan 1 mg IM, Benadryl 50mg IM). The patient verbally requested discharge. A 4-hour letter was completed and administration, supervising psychiatrist and Court liaison was notified. Due to her continued self-harming behaviors and aggression. Her request for release was denied and the commitment process was started. After administration the patient was evaluated by Internal Medicine. It was decided that she be sent out to the ER for a CT scan. Neuro Check was performed by provider. Later she decided to engage in assessment. Reports that she started engaging in self-harming behaviors because she wanted to leave. I am just tired of being here. "She later apologized for verbal aggression. Reports no side effects to medication. Reports that she continues to have mood instability. Irritability, racing thoughts. Command auditory hallucinations to harm herself and SI.".

No further documentation was found that a physician or an NP saw the patient after 5/18/23. There was no documentation found in the chart that a psychiatrist had evaluated the patient from 5/17/23 to 5/24/23.

5/18/23

A review of patient #MM's nurse notes dated 5/18/23 at 9:30 AM stated, "pt A,O x3 able to verbalize needs (4 illegible words) Administered emergency meds per provider orders due to combative and impulsive aggressive behavior. Continue to monitor during the (illegible.) There was no documentation on the medication administration record that the medication was administered or by whom. There was no order written for emergency medications until 5/18/23 at 11:00 AM. There was no further assessment or reassessment found in the nursing notes until 22:35 (10:35 PM), 11.5 hours later.

A review of patient #MM's physician orders dated 5/18/23 at 6:47 AM revealed staff #27 wrote an order to change the level of observation to every 5 minutes. "place on self-harm precautions."
10:57 AM "send to ER CT of Head"
11:02 AM "Start commitment process." No further orders were noted for patient #MM on 5/18/23.
A review of the patient observation round sheet revealed patient #MM was on q 15-minute observations until 11:50 AM. Pt #MM was not placed on q 5-minute observation for 6 hours after the order was written. There was no found documentation that justified the delay in care and safety.

A review of patient #MM's chart revealed a restraint packet dated 5/18/2023 at 11:00 AM. Review of the order written by Staff #36, RN read, "Zyprexa 10 mg, Lorazepam 1 mg IM and Benadryl 50mg IM... for "aggression, combative with nursing staff." The orders stated verbal de-escalation as an alternative to restraint/ seclusion attempted and indication for the order was "hematoma forehead bang head on the wall ...combative with staff." There was no documentation from the RN that this was a verbal order. Staff #27 NP signed the order on 5/18/23 at 11:00 AM for a chemical/EBM restraint.

A review of patient #MM's restraint packet dated 5/18/23 at 11:00 AM revealed the same nurse, staff #36 RN initiated the restraint and documented the face-to-face. The nurse documented on the face-to-face form that the intervention (medication administration) was initiated on 5/18/23 at 11:00 AM and the initial face-to-face was initiated at 11:00 AM. Staff #36 RN was completing both tasks. Staff #36 documented the patient's response to the intervention was "patient sleeping." Staff #36 documented that patient #MM had denied pain, had no aggression, was cooperative and thought process was clear, speech wnl, and alert to person, place, and situation, even though patient #MM was just given a chemical/EBM restraint for aggressive and combative behavior.

A review of the second page of the face-to-face form dated 5/18/23 at 12:00 PM revealed staff #36 documented the patient's vital signs. Staff #36 also documented, "Pt lying in bed resting in supine position. No distress noted. No behaviors noted at this time. Pt calm. Respirations even and unlabored. Open area to the forehead area, pt apologized to nursing staffing (sic). Continue to monitor during shift." A review of the patient observation round sheet revealed patient #MM was not in her room at 12:00 PM but was in the dining room alert and cooperative. The mental health technician documented that patient #MM was in the dining room from 11:30 AM - 12:20 PM.

A review of the staff debriefing sheet dated 5/18/23 at 12:30 PM revealed there was no staff listed that was involved in the debriefing.

A review of patient #MM's treatment plan revealed there was no documentation of the chemical restraint/ EBM administration that was administered on 5/18/23.

5/19/23

A review of the nurses' notes dated 5/19/23 revealed patient #MM was banging her head on the wall. The nurse documented patient #MM was able to be redirected. On 5/19/23 at 10:00 AM the nurse documented the patient fell in the shower and was still on a 1:1 observation level. 2:00 PM- patient was spitting on the staff. 2:40 PM staff #27 NP was called and an order for po Zydis was ordered but patient refused. A review of the MAR revealed the nurse signed out on the po Zydis as given to the patient.

A review of patient #MM's chart revealed a medication order was written on 5/19/23 at 1550 (3:50 PM) by staff #27 NP to administer Ativan 1 mg IM x 1 dose "now agitation" and Benadryl 50mg IM x 1 dose "now agitation."
There was no nursing documentation found on patient # MM's chart from 2:40 PM until 9:00 PM. There was no documentation found of the patient's behavior, what attempts were made to de-escalate the patient, or what other options were used before the administration of a chemical/EBM restraint. A review of the MAR revealed the medication was given at 4:04 PM. There was no assessment or reassessment of the patient after the medication administration.

Upon reviewing patient #MM's chart, it was discovered that the restraint packet was incomplete. The packet only contained a 1-hour face-to-face form and a blank debriefing sheet for the patient. The face-to-face session took place on 5/19/23 at 4:50 PM, where the nurse indicated that the intervention was for "emergency medications." The patient's response to the intervention was noted as "patient sleeping." Additionally, the nurse documented that the patient refused vital signs, denied pain, and was cooperative with a normal mood and orientation to person, place, time, and situation. There was no documentation of any vital signs, how the patient reacted to the medication, if any side effects were noted, or the effectiveness of the medication. The patient had been sent to the emergency room two days in a row for head injuries. There was no mention of neuro checks or neurological assessments after the administration of psychotropic medications and sedatives.

A review of the patient observation rounds revealed the patient was on a 1:1 observation level. The mental health technician's documentation was to be done every 5 minutes. The technician documentation should show the patient's location and behaviors. A review of the 5/19/23 observation round sheets revealed there was no documentation on patient #MM from 7:00 AM until 1:05 PM and from 8:05 PM until 10:25 PM. There was no documentation of why the mental health technician failed to document the patients' observations or if there was a 1:1 assigned as ordered.
A review of the treatment plan revealed there was no mention of the chemical restraint/EBM administered on 5/19/23.

5/21/23

A review of patient #MM's nurse notes revealed on 5/21/23 at 10:45 AM the RN documented, "Pt continues on 1:1 at bedside. Pt started spitting on staff and hit staff. Pt kept swinging at staff being physical and verbally aggressive. NP ____ (staff #47) on unit. New order for Benadryl 50 IM and Ativan 1 mg IM. Nurse administered shot to each deltoid. Pt took shot with no resistance. Pt tolerated well. Pt. med complaint with po meds as well. VSS (vital signs stable)." The nurse stated that the patient was medication complaint however, there was no documentation that the patient was offered any po meds at the time of her behavioral emergency. There was no documentation of any de-escalation techniques used or any other options before the administration of a chemical restraint/ EBM.

A review of patient #MM's chart revealed there was an incomplete restraint packet. A face-to-face was documented for 5/21/23 at 12:00 PM. The patient was given "emergency medication." The patient had improved behavior and vital signs were taken. On the bottom of the face-to-face form was a line for the name of the physician that was notified of the findings of the face-to-face. The form stated, "Physician notification of evaluation (if evaluated by RN/NP/PA). The nurse documented that NP staff #47 was notified and not the physician.

Patient #W

A review of patient #W's chart revealed he was admitted to the facility on 5/15/23. A review of patient #W's psychiatric evaluation revealed it was performed by Staff #27 NP on 5/18/23 at 5:51 AM. Staff #27 had also documented that she was on another unit assessing patient #MM on 5/18/23 at 5:51 AM.

A review of patient #W's psychiatric evaluation stated, "Patient is a 78-year-old, who was admitted from Spindletop Center Service. However, due to the patient's diminished cognitive function collateral information was obtain from the patient's wife and daughter. According to patient's wife the patient was diagnosed with dementia two and a half years ago, and his behavior has started to get progressively worst(sic) every day. She reports that the patient has been verbally and physically abusive towards her ..."

A review of patient #W's nurse notes dated 5/21/23 at 4:16 PM revealed the patient was being verbally aggressive towards staff and patients. A review of the chart revealed a restraint packet dated 5/21/23 at 5:00 PM. The verbal order stated to give the patient Benadryl 25 mg IM x 1 now and Haldol 2.5mg IM x 1 now. Staff #47 NP gave the order for restraint.

A review of the face-to-face revealed the nurse initiated it on 5/21/23 at 6:30 PM. Vital signs were taken, and the nurse documented the patient had improved. The nurse failed to report the face-to-face to the physician but reported the findings to the nurse practitioner.

There was no further documented time of assessment or reassessment until 5/22/23 at 5:20 AM.
According to the Texas Administrative Code TITLE 25 HEALTH SERVICES PART 1, CHAPTER 415, SUBCHAPTER F, RULE §415.260 Initiation of Restraint or Seclusion in a Behavioral Emergency stated, "(b) Physician's order. Only a physician member of the facility's medical staff may order restraint or seclusion. (2) If restraint or seclusion was ordered by telephone, the ordering physician shall personally sign and date the telephone order, including the time of the order, within 48 hours of the time the order was originally issued."

An interview was conducted with Staff #13 on 5/22/23 at 11:00 AM. Staff #13 was asked about restraints and what would be appropriate for Patient #MM when she was having behavioral outbursts or inflicting self-harm. Staff #13 stated that she would try to de-escalate the patient by talking to her or trying to meet her needs. Staff #13 stated that if she was unable to de-escalate the patient, she would call the nurse practitioner or physician for a chemical restraint/emergency behavioral medication (EBM). Staff #13 was asked what other types of restraints the facility used and staff #13 stated, "We just usually give them a shot." Staff #13 confirmed the facility did not use or have any mechanical restraints. Staff #13 stated that staff uses physical holds on the patients if needed and they do have a seclusion room, but they never use it. Staff #13 stated, "We don't have a key to the seclusion room." Staff #13 stated that she was not aware of why they did not have a key for the seclusion room but if they needed to use the room, she would have to call a house supervisor. Staff #13 was asked what restraint would be least restrictive, a hold, seclusion, or an intermuscular injection (IM) chemical restraint/EBM? Staff #13 stated, "A shot." It was confirmed by staff #1 on 5/22/23 that there were no house supervisors available for an interview. Both house supervisors were out due to vacation and illness.

Staff #13 confirmed that she was not aware there was no antidote for psychotropic medications that are administered IM for behavioral emergencies. Staff #13 was not aware of the black box warnings for Zyprexa, Haldol or Geodon. Staff #13 was asked how the patient was supposed to be reassessed, how frequently, and for how long after the patient received a chemical restraint/EBM. Staff #13 stated, "I try to keep an eye on them but confirmed she was unaware.

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

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

An interview was conducted with Staff #16 on 5/23/23. Staff #16 stated that the unit did not have a key to the seclusion room for months and she had not used it due to no key. Staff #16 confirmed the DON placed the key there the day before. Staff #16 got the key off the ring in the nurse's station and showed it to the surveyors. Staff #16 confirmed the facility does not use mechanical restraints. Staff #16 stated, "We can hold them and give them a shot. I guess now since we have a key, we can use the seclusion room." Staff #16 confirmed that she was not aware that psychotropic medications given for behavioral emergencies IM or IV did not have an antidote. Staff #16 was not aware of the black box warnings for Zyprexa, Haldol, or Geodon. Staff #16 was asked how the patient was supposed to be reassessed, how frequently, and for how long after the patient received a chemical restraint/EBM. Staff #16 stated, "We do a face-to-face within 1 hour and that's when we get the vital signs." Staff #16 stated she was not sure what the time frames were.

An interview was conducted with Staff #3 on 5/23/23. Staff #3 stated that he had not been at the facility long and was still learning. Staff #3 stated that the staff should attempt to de-escalate the patients to avoid behavioral restraint. Staff #3 stated that he believed a chemical restraint/ EBM would be the least restrictive restraint and then seclusion if needed. Staff #3 was not aware of the policy and procedure for seclusion and restraints. Staff #3 stated he was not aware that the nurses did not have a key to the seclusion rooms and had not been using them due to having no key or control of the room. Staff #3 was unable to tell me the process for placing a patient in seclusion. Staff #3 was asked about the process for evaluating a patient after the administration of a chemical restraint/EBM. Staff # 3 stated they should be checking on them frequently and doing a 1-hour face to face to check vital signs. Staff #3 confirmed he was unaware of how frequently and for how long the nurse should assess the patient after the administration of an IM chemical restraint/EBM.

A review of the policy and procedure Restraint and/or Seclusion Use revealed there was no process for how the nurse was to monitor the patient after a chemical/EBM restraint. The policy stated, "EVALUATION DURING RESTRAINT/SECLUSION:
Patients in simultaneous restraint and seclusion will be directly observed by one-to-one staff observation
A nurse shall observe and assess patients in restraint or seclusion approximately every 60 minutes including respiratory and circulatory status, skin integrity, and vital signs.In some circumstances, approaching the patient may be dangerous and may increase patient agitation. Visual checks may be performed if the patient is too agitated to approach. but at a minimum, the patient must be assessed for safety and signs of injury, as well as readiness for discontinuation of restraint or seclusion.

The patient's response to the intervention or interventions used shall be documented every fifteen (15) minutes throughout the duration of the restraint or seclusion. The fifteen (15) minute monitoring must include the monitoring of the patient's physical and psychological condition including, but not limited to:
Respiratory and circulatory status;
Skin integrity;
Vital signs:" The policy stated the patient shall be observed every 15 minutes throughout the duration of the restraint or seclusion. There was no documented information on how the nurse was to determine the ending of a chemical/ EBM restraint.

An interview was conducted with Staff #1 on 5/24/23 at 10:21 AM. Staff #1 stated that she did have a restraint log, but it was not complete. Staff #1 stated that the administration including the physician had discussed changing the restraint packets and putting in "every 15-minute' observation for the patients after a chemical/EBM restraint but that had not been completed or changed at this time. Staff #1 confirmed the staff was still using the same restraint packets. Staff #1 stated the face-to-face training was done upon hire in the orientation process but staff #1 was unable to provide the surveyor with specific face-to-face training. Staff #1 supplied the surveyor with clinical orientation training on seclusion and restraint and stated that this was what was used for the face-to-face training. One slide was in the training stating the regulation of face-to-face. There was no specific training information found. Staff #1 confirmed that she did not have any QAPI she could provide at this time for restraints and no data to report.

Based on record review and interview the facility failed to ensure that two different RN's complete the initiation of restraint and the one hour face-to face evaluation as directed by the Texas state regulation in 1 of 1 charts (# JJ) restraint charts reviewed, and shown in their policy and procedure of Restraint/seclusion.

415.260[c][1] Face-to-face evaluation. A physician, physician assistant as provided in paragraph (3) of this subsection, or a registered nurse who is trained and has demonstrated competence in assessing medical and psychiatric stability, other than the registered nurse who initiated the use of restraint or seclusion, shall conduct a face-to-face evaluation of the individual within one hour following the initiation of restraint or seclusion to personally verify the need for restraint or seclusion.

1. Review of the facility's current policy titled, Restraint and or Seclusion, Policy ID #10854266, last revised 12/2021, Approved 12/2021, revealed the following information: It failed to contain the additional provision that the state requires for 2 different RN's to complete the initial then the face to face.

Review of Patient #JJ medical record (Restraint, Seclusion, and Emergency Medication), dated 05/16/23 at 17:00, showed that RN (illegible signature [no signature key provided]) completed the initial face to face evaluation was completed at 17:00. The one hour face to face evaluation was completed by the same RN with an illegible signature at time of 18:00.

Based on a review of 2 clinical records, the facility failed to maintain an accurately-written for 1 of the 2 records, as the clinical record for patient E contained no documentation that a certain physician's order was carried out.

Findings were:

Paitent # E male, revealed that the patient was admitted to MBH on 2-28-23 at 10:45. The patient's medical history included Type II diabetes mellitus.On 3-2-23, an order was written to check the patient's blood sugar twice daily, at 7:30 am and again at 4:30 pm. The record contained documentation of only one check, which was performed at 4:30 pm on 3-4-27 and never again during the patient's stay. The patient discharged from the facility on 3-8-23.

Facility policy 12507952 titled "Content of the Medical Record" states, in part:
"POLICY:
The medical record contains sufficient information to identify the patient, support the diagnosis, justify the treatment, and document the course and results accurately and facilitate continuity of care among health care providers. Each medical record contains at least the following:
1. The patient's name, address, date of birth, legal status and the name of any legally authorized representative: Organizations generally develop a cover sheet containing relevant admissions related information and whatever other third-party payers, the name of the responsible family member and attending physician, and procedures. In addition, the patient's race and ethnicity will be recorded. The admitting and discharge diagnosis will be present on the cover sheet after the patient has been discharged.
2. MEDICAL CONSULTATIONS
3. A medical consultation will be provided to the psychiatric patient within 24 hours after admission. If the physician providing the medical consultation recommends a specialist to see the patient, the psychiatrist will be notified to identify and order further consultation. Consultation reports are to be written or dictated within 72 hours of consultant's examination.
4. History and Physical
5. A medical history and physical examination shall in all cases be completed within 24 hours following admission of the patient.
6. The history and physical shall include a current physical assessment of pertinent systems of the body and must also include the impression or reason for hospitalization, as well as the plan for treatment based on the needs of the patient. Treatment plans should define the treatment modalities, include long-range and short-term goals and be individualized based on an inventory of the patient's strengths and disabilities.
7. The elements of the History and Physical include: Age, chief complaint, history of present illness, past medical and surgical history, family and social history, allergies, review of systems, medications, physical exam, neurological exam including testing of cranial nerves I through XII, impression and plan.
8. If a history and physical has been obtained within 30 days prior to admission by an external practitioner or through a transferring hospital, then a durable, legible copy of this report may be used in the patient's hospital medical record, provided that a qualified member of the Medical Staff reviews the H&P that was completed before admission and conducts their own assessment within 24 hours following admission to determine if there have been any changes since the H&P was completed. If there are no changes, the practitioner must indicate so then sign and date the updated (interval) note. If there are changes, the interval note should include language such as concurrence with the H&P conducted on the specified date by a specific practitioner from a specific hospital "with the following additions and/or exceptions". Example: Please see Dr Smith's H&P dated 00/00/00 from Hospital "with the following additions and/or exceptions".
9. When a patient is readmitted within 30 days for the same medical problem, an interval history and physical reflecting any subsequent changes and the reason for readmission may be used in the medical record.
10. Communication Needs: Documentation of the patient's preferred language, both spoken and written, will be recorded. If the patient is incapacitated, or has a designated advocate, the communication needs of the parent or legal guardian, surrogate decision-maker, or legally authorized representative is documented in the medical record.
11. Care provided to the patient before arrival, if any: If patients have been undergoing treatment in a hospital or other health care facility, a discharge form and a discharge summary along with other pertinent information should accompany the patient. This provides information to ensure ongoing continuity of care. When patients are admitted from their homes, information is forwarded to the hospital by the patients' primary physician.
12. The record and findings of the patient's assessment: Medical assessments are performed on patients by the provider within specified time frames based on the patients' conditions.
13. Conclusions or impressions drawn from the medical history and physical examination: The history and physical (H&P) includes a past health history along with a current physical examination. Upon admission the patient should receive a thorough history and physical examination with all indicated laboratory examinations. These investigations must be sufficient to discover all structural, functional, systemic and metabolic disorders. A thorough history of the patient's past physical disorders, head trauma, accidents, substance dependence/abuse, exposure to toxic agents, tumor, infections, seizures or temporary loss of consciousness, and headaches, will alert the provider to look for the presence of continuing pathology or possible sequelae of any of which may turn out to be significant and pertinent to the present mental illness. Equally important is a thorough physical examination to look for signs of any current illness since psychotic symptoms may be due to a general medical condition or substance related disorder.
As part of the physical examination, the provider will perform a "Screening" neurological examination in medical practice such examination is expected to assess gross function of the various divisions of the central nervous system as opposite to detailed, fine testing of each division. Gross testing of Cranial Nerves II through XII should be included. Statements such as "Cranial Nerves II to XII intact" are not acceptable. These areas may be found in various parts of the physical examination and not just grouped specifically under the neurological.
In any case where a system review indicates positive neurological symptomatology, a more detailed examination would be necessary, with neurological work-up or consultation ordered as appropriate after the screening neurological examination was completed.
...
21. All diagnostic and therapeutic procedures and tests results: The results of any relevant diagnostic tests or procedures performed on a patient prior to being or admitted to an organization are noted in the admission procedure and become a part of the patient's medical record. Any diagnostic tests or procedures after admission are ordered by the physician and the results become a part of the medical record. Documentation of the reporting of diagnostic test results and appropriate follow-up is also included."

The above was confirmed in an interview with staff #1 during the complaint investigation.