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Based on observation, interview, and record review, the Governing Body failed to:

A. 1. provide patients and/or their representatives with the appropriate patient rights in the form of the State of Texas required posting of the patient bill of rights in 4 areas (Lobby, Visitation Room, Exam Room, and Recreation Room) out of 5 areas frequented by persons receiving services.

2. notify the patient or patient's representative of the patients rights contained in the Important Message from Medicare about "Your Rights" form prior to discharge in 4 (Patient #3, #5, #6, and #8) of 4 charts reviewed.

Cross refer to Tag A0117



B. 1. properly identify a grievance from a complaint and follow the grievance process in 3 (Patient #14, #16, and #18) of 3 complaints reviewed.

2. failed to follow the Quality Improvement Plan Policy QAPI-00 to track, analyze, aggregate the data collected quarterly, and report to the Governing Board.

Cross refer to Tag A0119



C. 1. sign consensual contracts for admission, financial, medical treatment, and administration of psychotropic medications with impaired judgement in 2 (Patient #3 and #19) of 3 (Patient #3, #6, and #19) charts reviewed.

2. follow procedures for involuntary detention when a patient was unable to consent for treatment and after Apprehension by a Peace Officer without a Warrant as established in the Texas Administrative Code and Texas Health and Safety Code, preventing patients from being able to exercise their right to consent to or refuse treatment in 3 (Patient #3, #6, and #19) of 3 patient charts reviewed.

Cross refer to Tag A0131



D. ensure that patients did not have access to hazardous items in the nursing station when the station was left unattended. Items that could have been potentially hazardous to psychiatric patients were found to be within arm's reach of 2 of 2 window openings that provided access to the nursing station. This deficient practice had the potential for harm to all patients.

Cross refer to Tag A0144



E. 1. ensure that allegations of abuse were identified as a grievance and thoroughly investigated following the policy and procedures of the facility in 2 (Patient #14 and #16) of 2 complaints reviewed.

2. ensure that all contracted employees giving patient care, or had potential patient contact, had an employee file and appropriate training in abuse and neglect.

3. ensure the facility had appropriate information on how and where to "self-report" an incident of abuse or neglect. There was no information on how to self-report a case of abuse or neglect to the State of Texas. The policy only addressed Louisiana.

4. ensure staff training and/or education concerning any allegations of abuse and/or neglect were documented.

Cross refer to Tag A0145



F. follow its policy and procedure allowing an Licensed Vocational Nurse (LVN) to administer a chemical restraint on 1 (Patient #3) out of 3 (Patient #3, #6, and #8).

Cross refer to Tag A0160



G. 1. ensure the patient was seen within 1 hour for a face-to-face evaluation after an intervention in 1 (Patient #6) of 2 (Patient #3 and #6) charts reviewed.

2. ensure the RN performing the face to face was not involved in the initiation/administration of the restraint in 1 (Patient #3) of 2 (Patient #3 and #6) charts reviewed.

Cross refer to Tag A0178



H. ensure that the data collected was accurate, analyzed, and monitored to ensure effectiveness of safety, services provided, and quality of care.

Cross refer to Tag A0273



I. ensure the staffing available for the number and acuity of patients met the minimum number of staffing necessary per the staffing matrix identified by the facility as being used for 9 (December 1, 5, 6, 7, 8, 9, 10, 11, and 12) of the first 12 days of December 2019.

Cross Refer to Tag A0392



J. 1. follow its own policy and procedures allowing a Licensed Vocational Nurse (LVN) to administer a chemical restraint in 1 Patient #3) of 3 (Patient #3, #6 and #8) patient charts reviewed.

2. assess and monitor a patient every 15 minutes for 1 hour after a chemical restraint administration in 2 (Patient #2 and #6) of 3 (Patient #2, #6, and #8) charts reviewed.

3. administered wound care to a patient with no physician orders in 1(Patient #3) of 3 (Patient #3, #6 and #8) charts reviewed.

Cross refer to Tag A0395



K. ensure that contract nursing staff had completed the hospital approved training required to initiate or assist with patient restraint and/or seclusion for 3 of 3 contracted nursing staff personnel files reviewed (Staff #22, #23, and #24). Since contract nursing staff worked directly with patients, this deficient practice had the potential to result in harm to all patients the contract nursing staff came in contact with during their shifts.

Cross Refer to Tag A0398



L. ensure that a functioning Utilization Review (UR) plan was in effect for the review of services provided. No evidence of physician oversight and involvement in the UR function was found.


M. have an organized respiratory services department to offer the services according to the acceptable standards of practice.

Cross refer to Tag 1152



N. ensure a physician was appointed as director of respiratory care services to ensure services provided were appropriate to the scope of patients served and were administered properly.

Cross refer to Tag A1153

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


A. provide patients and/or their representatives with the appropriate patient rights in the form of the State of Texas required posting of the patient bill of rights in 4 areas (Lobby, Visitation Room, Exam Room, and Recreation Room) out 5 areas frequented by persons receiving services.

B. notify the patient or patient's representative of the patients rights contained in the "Important Message from Medicare" about "Your Rights" form prior to discharge in 4(#3,5,6,and 8) of 4 charts reviewed.

Refer to Tag A0117


C. properly identify a grievance from a complaint and follow the grievance process in 3(#14,16, and 18) of 3 complaints reviewed.

D. failed to follow the Quality Improvement Plan Policy QAPI-00 to track, analyze, aggregate the data collected quarterly, and report to the Governing Board.

Refer to Tag A0119


E. sign consensual contracts for admission, financial, medical treatment, and administration of psychotropic medications with impaired judgement in 2 (3 and 19) of 3(#3,6 and 19) charts reviewed.

F. follow procedures for involuntary detention when a patient was unable to consent for treatment and after Apprehension by a Peace Officer without a Warrant as established in the Texas Administrative Code and Texas Health and Safety Code, preventing patients from being able to exercise their right to consent to or refuse treatment in 3 of 3(#3,6, and 19) patient charts reviewed.

Refer to Tag A0131


G. ensure that patients did not have access to hazardous items in the nursing station when the station was left unattended. Items that could have been potentially hazardous to psychiatric patients were found to be within arm's reach of 2 of 2 window openings that provided access to the nursing station. This deficient practice had the potential for harm to all patients.

Refer to Tag A0144


H. ensure that allegations of abuse were identified as a grievance and thoroughly investigated following the policy and procedures of the facility in 2 (#14 and #16) of 2 complaints reviewed.

I. ensure that all contracted employees giving patient care, or had potential patient contact, had an employee file and appropriate training in abuse and neglect.

J. ensure the facility had appropriate information on how and where to "self-report" an incident of abuse or neglect. There was no information on how to self-report a case of abuse or neglect to the State of Texas. The policy only addressed Louisiana.

K. ensure staff training and/or education concerning any allegations of abuse and/or neglect were documented.

Refer to Tag A0145


L. follow its policy and procedure allowing an Licensed Vocational Nurse (LVN) to administer a chemical restraint on 1(#3) out of 3(#3,6,and 8).

Refer to Tag A0160



L. ensure the patient was seen within 1 hour for a face to face evaluation after an intervention in 1(6) of 2(3 and 6) charts reviewed.

M. ensure the RN performing the face to face was not involved in the initiation/administration of the restraint in 1(3) of 2 (3 and 6) charts reviewed.

Refer to Tag A0178

Based on observation and interview, the facility failed to:

A. provide patients and/or their representatives with the appropriate patient rights in the form of the State of Texas required posting of the patient bill of rights in 4 areas (Lobby, Visitation Room, Exam Room, and Recreation Room) out 5 areas frequented by persons receiving services.

B. notify the patient or patient's representative of the patients rights contained in the Important Message from Medicare about "Your Rights" form prior to discharge in 4(#3,5,6,and 8) of 4 charts reviewed.


Findings:

A. On 12-9-2019, a tour of the facility was made with Staff #4 and #5 present. During the tour, it was observed that the patient bill of rights was only posted in the patient day-room area, across from the nursing station. No postings of the patient bill of rights were found in the Lobby, Visitation Room, Exam Room, and Recreation Room.

Interview was conducted with Staff #4 during the tour. Staff #4 confirmed that they were missing and stated she did not know why the postings were not there as they had been previously displayed.


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B. The regulation at 42 CFR 489.27(a) requires that each Medicare beneficiary who is an inpatient or his/her representative must be provided the standard notice, "An Important Message from Medicare," within 2 days of admission and not more than 2 colander days in advance of patient discharge.

Review of patient charts #3, 5, 6, and 8 revealed that the patients received only one "An Important Message from Medicare" form on admission. There was no second one provided prior to discharge.

An interview was conducted with Staff # 4 in the morning of 12/11/19. Staff #4 confirmed the second notice had not been given to the patients reviewed.

Based on review and interview, the facility failed to:

A. properly identify a grievance from a complaint resulting and follow the grievance process in 3 (#14, 16, and 18) of 3 complaints reviewed.

B. failed to follow the Quality Improvement Plan Policy QAPI-00 to track, analyze, aggregate the data collected quarterly, and report to the Governing Board.


A. Findings:

Review of the complaints and grievance log revealed that Patient #18 made a complaint, after discharge, on 4/1/19 at 11:00 AM. The complaint was logged as a complaint and stated on 11/15/19 it was resolved, verbal complaint, no letter."

Review of the complaint revealed, Staff #6 documented the complaint investigation. The complaint stated, "____ (Patient #18) called the facility 4/1/19 to report he was missing some of his belongings. States he had them when he was admitted but did not receive them back when he discharged. Missing items: Norelco (black) electric razor, life alert items (4 or 5) different items (black), Black bag. Wants his belongings found and returned to him or reimbursed missing items. Medical record pulled, and patients inventory log and Patient Valuables reviewed. Items listed as missing are not documented on the patient inventory or Patient Valuables log. Items not found in patient storage room. Items located in the med room in the storage cabinet. Items given to ____ (unknown person) for return to ____ (Patient #18) at his home." The patient was contacted on 4/4/19 at 11:26 AM.

There was no documentation found of staff education on appropriate inventory and storage of patient items or if the patient received his items. Staff #6 failed to document the complaint as a grievance and failed to send any documentation out to the patient addressing the grievance procedure. Staff #6 failed to appropriately document the grievance process and was not reported as a grievance to QAPI or governing board.


Review of the complaints and grievance log revealed that Patient #16 made a complaint on 11/13/19 at 12:30 PM. The complaint was logged as a complaint and stated on 11/15/19 it was resolved, verbal complaint, no letter."

Review of the complaint revealed, Staff #6 documented the complaint investigation. Staff #6 documented, "____ (Patient #16) made complaint re 'Staff ___ (#33)' was 'uncaring' and 'judgmental' towards patients. Reported he used inappropriate language in the smoking area reported staff 'grabbed my arm when I reached in the smoke box.' Sts 'I am not prejudiced against him .... I have biracial children with a Mexican woman.' Wants staff to be counseled and be more caring with patient care. Reassigned ____ (Staff #33) to the hallway while investigating the incident.

Results of the investigation: Spoke with ____ (Patient #16) and other witnesses- Rec'd several versions of the event. Met with ____ (Staff #33) 11-15-19 (two days later) ____ (Staff #33) denies ever touching ____ (Patient #16) although he did repeat back the statements made by____ (Patient #16). Meeting with witnesses to investigate this complaint.

Actions Taken: Spoke with all staff including ____ (Staff #33) to review customer service and patient perceptions of events. Apologies made by ____ (Patient #16) ____ (Patient #17) ____ and ____ (Staff #33) All parties agreed to move on and get past this incident." Staff #6 failed to appropriately document the grievance process and was not reported as a grievance to QAPI or governing board.

An interview was conducted with Staff #6 on 12/12/19 at 2:00 PM. Staff #6 stated that she felt this was not a grievance since it was resolved. Staff #6 failed to follow the facility's policy and procedure for grievances. Staff #6 was unable to provide any documentation on what training or instruction the staff was given staff to deal with these types of incidents nor any clarification if the staff inappropriately touched a patient.


Review of the complaints and grievance log revealed that Patient # 14 made a complaint on 3/22/19 at 1600 (4:00 PM). The complaint was logged as a complaint and stated on 3/23/19 it was resolved, verbal complaint, no letter."

Review of the complaint revealed Staff #6 documented the complaint investigation. Staff #6 documented, "Rec'd verbal complaint from ____ (Patient #14) who stated 'the tech was rough with me when I was getting my x-ray. They were talking in another language ... I was afraid I would fall again the way they were rolling me around. I want you to do something about it."

Review of the complaint investigation under "Results of investigation" stated, "Discussed with the MHT's who stated, '____ (Patient #14) was hollering and hitting them as they tried to assist Mobilex with the x-ray procedure. She was afraid she was going to fall again so she was very resistant to having the procedure done.' Patient had orders for x-ray of (L) shoulder (L) elbow and (L) forearm results are all normal-no fracture or skeletal injury noted.

Actions Taken: Discussed with staff. Contacted Mobilex to inform them of patient perception that the tech was rough." There was no documentation found on what was discussed with staff, who the tech was at Mobilex, or if the tech or staff had appropriate training. Staff #6 completed the investigation on 3/23/19 with no time documented. There was no evidence that the complaint was resolved at the time of the complaint by staff present.

An interview was conducted with Staff #6 on 12/12/19 at 2:00 PM. Staff #6 stated that she did talk with the staff concerning the incident but had no documentation. Staff #6 confirmed both staff members were from the Philippines and were talking in their native language (other than English). Staff #6 stated that she talked to the staff about speaking English around English speaking patients but has no documentation of education. There was no documentation in how to handle a patient with fears of falling, manhandling a patient, or forcing a patient to perform a medical procedure when the patient no longer consents.

Staff #6 was asked why Patient #14,16, and 18 was logged as a complaint instead of a grievance? Staff #6 confirmed that she was not aware that the complaints should have been logged as a grievance. Staff #6 stated she was not fully aware of what made the complaint a grievance. Staff #6 was asked if she was familiar with the Centers for Medicare/Medicaid Services (CMS) regulations or the facility's policy and procedure? Staff #6 stated, "I would have to look at it again but apparently I have been doing it incorrectly."


B. Review of the QAPI reporting revealed there was reported data concerning "Grievance Appropriateness" There was no data reported for the first quarter of 2019, 100% reported for the second quarter and nothing reported for the third quarter of 2019. There was no evidence of analyzation of the data or how the data assist the facility in monitoring the effectiveness, safety, or quality of care. Review of the Governing Board minutes for 2019 revealed there was no found reporting of the Grievance/Complaint data or outcomes.

Review of the "Quality Assessment and Performance Improvement Plan Policy # QAPI-00" Stated, "The frequency and detail of data shall be specified by the Governing Board through the QAPI Committee. Data must be tracked, aggregated, analyzed at least quarterly."

An interview was conducted with Staff #7 on 12/11/19 in the afternoon. Staff # 7 stated that she had recently taken the position of Quality Director. Staff #7 confirmed that Staff #6 was collecting the data and the data was sent to the corporate level. Staff #7 was unable to articulate the process in how the data was aggregated or reported.


Review of the facility's policy and procedure "Grievance Procedure Patient and Family Texas policy number RTS-04" stated, "COMPLAINT: An expression of dissatisfaction however made, about the standard of service, actions or lack of action by staff or regarding the facility and is resolved by staff at the time the complaint is made requiring no further resolution.

GRIEVANCE: An allegation, however made, of a violation of a patient's rights, quality of care, premature discharge, and/or a complaint that is not resolved at the time the complaint is made and requires further action for resolution.

PROCEDURE: All Employees: Will be alert to any patient or family problems which might be present and report them to the Department Director and Administration for completion of a Patient Concern Response Form. Employees are expected to resolve the concern within their ability at the time the concern is reported. Concerns that can be resolved at the time are not considered formal grievances, and do not require the facility to follow the formal grievance resolution process.

Patient: May surface issue in a.m. treatment planning and goals group for resolution. If issues resolution requires interdepartmental resources or community RN is unable to enact resolution, or community is an inappropriate format for resolution of issue or a satisfactory resolution was not forthcoming, the patient or patient's family may verbally (or in writing) bring issues to the primary therapist/RN.

Administration, QA/Risk Mgmt., or Department Director: Will be available to interpret facility policy and procedure to patients and their family when appropriate. Staff listens to patients' concerns/grievances, organizes relevant facts, and initiates action when necessary.

Depending on the nature and severity of grievance and/or inability of the therapist/RN to resolve issue, will forward to Clinical Director/DON as soon as feasible.

For grievances alleging abuse, neglect, and/or exploitation, will notify the state hotline and document this immediately.
For complaints alleging discrimination against the handicapped, written complaint includes name and address of person filing the complaint, and a brief description of the action alleged to be prohibited by state laws.

Clinical Director/DON/Administrator: The employee receiving the grievance will discuss verbally or in writing the formal grievance with Administration and the appropriate Department Director within 24 hours of the grievance. All grievances received on satisfaction surveys requesting Administrative follow-up will be documented on a Patient Concern Response Form.

Investigation of the grievance will begin within 48 hours of Administration or Department Director receiving the grievance. A final written response will be provided to the complainant within 1 week and will include: 1) The facility's decision, 2) The name of the facility contact person, 3) The steps taken on behalf of the person reporting to investigate the grievance, 4) The results of the grievance process and 5) The date of completion.

Administration: Documents all patient grievances and appropriate resolution on the Patient Concern Response Form. These forms are maintained in the Risk Management Department.

Responsible for reporting all grievance investigation findings and attempts resolution to QAPI committee hierarchy.
Rights Protection Officer: Duties of the Rights Protection Officer must include the following: Maintains complete grievance log along with files and results of all resolved grievances.

Receiving complaints/allegations of violations of rights, allegations of inadequate provision of services, and requests for advocacy from service recipients, their families, their friends, service providers, other facility or center personnel, other agencies, the general public, and the Office of Consumer Services and Rights Protection.

Thoroughly investigating each such complaint received and representing the expressed desires of the individuals served and advocating for the resolution of their grievances.

Reporting the results of investigations and advocacy to service recipients and the complainants, consistent with the protection of the service recipients' right to have any identifying information remain confidential.

Based on observation, review of records, and interview, the facility failed to:

A. ensure patients were not allowed to sign consensual contracts for admission, financial, medical treatment, and administration of psychotropic medications with impaired judgement in 2 (3 and 19) of 3 (#3, 6, and 19) charts reviewed.

B. follow procedures for involuntary detention when a patient was unable to consent for treatment and after Apprehension by a Peace Officer without a Warrant as established in the Texas Administrative Code and Texas Health and Safety Code, preventing patients from being able to exercise their right to consent to or refuse treatment in 3 of 3 (#3, 6, and 19) patient charts reviewed.


Patient #3

Review of Patient #3's chart revealed, he was a 78-year-old male, admitted to the facility on 6/10/19, with a diagnosis of Dementia with behavioral occurrences. Patient #3 had been living in an assisted living facility. He had become agitated with the assisted living staff and tried to choke a staff member.

Review of Patient #3's chart revealed, a telephone physician "admit order" dated 6/10/19 at 16:00 (4:00 PM). The order stated for the patient to be admitted "voluntary" to the facility. The patient was allowed to sign consents for treatment, financial responsibilities, telemedicine treatment, consent for involuntary treatment even though he was signed in as voluntary, complaint and grievance process, HIPAA notice, IMM letter, and Patient Bill of Rights. Patient #3's signature was scribbled onto the pages and never on the signature lines. The patient wrote his name up the pages, down the pages, and in the middle of the pages.

Review of Patient #3's Admit Nursing Assessment dated 6/10/19 at 1545 (3:45 PM). The note stated the Patient #3 was brought to the facility on 6/10/19 via the facility's van service. The nurse documented the patient was "only oriented to person, restless/agitated, impaired judgment, disorganized thought process, and suspicious." Patient #3 was allowed to sign consensual contracts for admission, financial, medical treatment, and consents for psychotropic medications with impaired judgement.

Review of the physician orders dated 6/11/19 at 5:45 PM stated, "Start OPC process." The physician was requesting the facility to start involuntary court proceedings with an Order of Protective Custody (OPC). There was no documentation found that the patient had any type of warrant or court order to hold him in the facility. The Patient attempted to leave the facility on 6/22/19 and was medicated with a chemical restraint. Patient #3 was never given a 4-hour discharge notice since no OPC was in the chart to hold the patient.

An interview was held with Staff #4 on 12/11/19 concerning the patients OPC or documentation following the physicians order. Staff #4 confirmed the OPC was missing from the chart and they were unable to locate it. There was no evidence that the patient was legally held within the facility.


Patient #6

Review of Patient #6's chart revealed, she was a 56-year-old female admitted to the facility on 8/28/19. Patient #6 was admitted for Bipolar disorder with psychotic features. The patient had received medical clearance at a local hospital and was transferred to the unit by a police officer's warrant. The patient had already been seen by a physician and was medically cleared at the local hospital.

Patient #6 was sent to the facility with an Emergency Police Officers Warrant (EPOW) dated 8/28/19 at 1518 (3:18 PM). The EPOW stated, "Subject is in a manic state and stated that killing people and herself didn't seem like a bad idea." The patient arrived at the facility and refused to sign any consents.

Review of the Admit Nursing Assessment dated 8/28/19 stated, Patient #6 was assessed and admitted at 1600 (4:00 PM). However, the Physician order to admit was written 8/28/19 at 1800 (6:00 PM) 2 hours after the patient was admitted.

Review of Patient #6's Psychiatric Evaluation performed on 8/28/19 at 1825 (6:25 PM) revealed, she was involuntary, however, the EPOW was no longer valid. There was no order to hold the patient and initiate an Emergency Detention Warrant (EDW) or OPC. There was no documented evidence that Patient #6 was instructed of her rights and that she was no longer involuntary.

Review of patient #6's chart revealed, she requested a discharge. A four-hour discharge Notice was found dated 8/29/19 at 1145. The Patient had stated, "Additional hospital stay is not necessary or wanted. Take Paxil 40 mg (antidepressant since 1998)." Physician order dated 8/30/19 at 9:40 AM, " DC to Sunny Pines in Lufkin, Texas AMA (against medical advice.)"

An interview was conducted with Staff #4 and #5 on 12/10/19. Staff #4 stated that she was not aware the EPOW was invalid after the patient had seen the physician and thought they had 72 hours. Staff #5 stated that she had been the DON for 7 months. Staff #5 confirmed she did not understand the difference or time frames of the EPOW or EDW. Staff #4 and 5 confirmed Patient #6 did not have a EDW or OPC.


Patient #19

Review of Staff #19's chart revealed, he was admitted as a voluntary patient to the facility on 12/6/19 at 1830 (6:30 PM). The patient had a diagnosis of psychosis unspecified. Review of the preadmission evaluation clearance screening on 12/6/19 at 6:27 PM. The MD stated the patient had "poor judgement and poor insight". Review of the admission nurses notes on 12/6/19 at 1830 (6:30 PM), " Patient arrived via private vehicle with his sister. AA&O x 1 (awake, alert and oriented times one) person....Patient is a voluntary admit he signed all consents." Patient #19 was allowed to sign consents for treatment with poor judgement, poor insight, and disoriented to place and time as documented by the physician and nurse. There was no order on the chart to hold for commitment.


Review of the Texas Health and Safety Code, Subtitle B. Alcohol and Substance Abuse Programs, Subchapter C. Emergency Detention revealed the following:

"Sec. 462.041. APPREHENSION BY PEACE OFFICER WITHOUT WARRANT.

(a) A peace officer, without a warrant, may take a person into custody if the officer:

(1) has reason to believe and does believe that:

(A) the person is chemically dependent; and

(B) because of that chemical dependency there is a substantial risk of harm to the person or to others unless the person is immediately restrained; and

(2) believes that there is not sufficient time to obtain a warrant before taking the person into custody.

(b) A substantial risk of serious harm to the person or others under Subsection (a)(1)(B) may be demonstrated by:

(1) the person's behavior; or

(2) evidence of severe emotional distress and deterioration in the person's mental or physical condition to the extent that the person cannot remain at liberty."


"Sec. 462.044. PRELIMINARY EXAMINATION. (a) A physician shall conduct a preliminary examination of the apprehended person as soon as possible within 24 hours after the time the person is apprehended under Section 462.041 or 462.043.
(b) The person shall be released on completion of the preliminary examination unless the examining physician or the physician's designee provides a written opinion that the person meets the criteria specified by Section 462.043(b)."

Criteria specified by Section 462.043(b) was as follows:

"(1) the person who is the subject of the application is a person with a chemical dependency;

(2) the person evidences a substantial risk of serious harm to the person or others;

(3) the risk of harm is imminent unless the person is immediately restrained; and

(4) the necessary restraint cannot be accomplished without emergency detention."



Review of the Texas Health and Safety Code, Subtitle C. Texas Mental Health Code, Subchapter C. Emergency Detention, Release, and Rights revealed the following:

"Sec. 573.001. APPREHENSION BY PEACE OFFICER WITHOUT WARRANT.

(a) A peace officer, without a warrant, may take a person into custody if the officer:

(1) has reason to believe and does believe that:

(A) the person is a person with mental illness; and

(B) because of that mental illness there is a substantial risk of serious harm to the person or to others unless the person is immediately restrained; and

(2) believes that there is not sufficient time to obtain a warrant before taking the person into custody.

(b) A substantial risk of serious harm to the person or other under Subsection (a)(1)(B) may be demonstrated by:

(1) the person's behavior; or

(2) evidence of severe emotional distress and deterioration in the person's mental condition to the extent that the person cannot remain at liberty.

(c) The peace officer may form the belief that the person meets the criteria for apprehension:

(1) from a representation of a credible person; or

(2) on the basis of the conduct of the apprehended person or the circumstances under which the apprehended person is found.

(d) A peace officer who takes a person into custody under Subsection (a) shall immediately:

(1) transport the apprehended person to:

(A) the nearest appropriate inpatient mental health facility; or

(B) a mental health facility deemed suitable by the local mental health authority, if an appropriate inpatient mental health facility is not available; or

(2) transfer the apprehended person to emergency medical services personnel of an emergency medical services provider in accordance with a memorandum of understanding executed under Section 573.005 for transport to a facility described by Subdivision (1)(A) or (B).


"Sec. 573.021. PRELIMINARY EXAMINATION.
(a) A facility shall temporarily accept a person for whom an application for detention is filed or for whom a peace officer or emergency medical services personnel of an emergency medical services provider transporting the person in accordance with a memorandum of understanding executed under Section 573.005 files a notification of detention completed by the peace officer under Section 573.002(a).

(b) A person accepted for a preliminary examination may be detained in custody for not longer than 48 hours after the time the person is presented to the facility unless a written order for protective custody is obtained. The 48-hour period allowed by this section includes any time the patient spends waiting in the facility for medical care before the person receives the preliminary examination."


"Sec. 573.022. EMERGENCY ADMISSION AND DETENTION.

(a) A person may be admitted to a facility for emergency detention only if the physician who conducted the preliminary examination of the person makes a written statement that:

(1) is acceptable to the facility;

(2) states that after a preliminary examination it is the physician's opinion that:

(A) the person is a person with mental illness;

(B) the person evidences a substantial risk of serious harm to the person or to others;

(C) the described risk of harm is imminent unless the person is immediately restrained; and

(D) emergency detention is the least restrictive means by which the necessary restraint may be accomplished; and

(3) includes:

(A) a description of the nature of the person's mental illness;

(B) a specific description of the risk of harm the person evidences that may be demonstrated either by the person's behavior or by evidence of severe emotional distress and deterioration in the person's mental condition to the extent that the person cannot remain at liberty; and

(C) the specific detailed information from which the physician formed the opinion in Subdivision (2)."


Review of the Texas Administrative Code showed the time-frame that an involuntary patient could be detained by a facility after Apprehension by a Peace Officer without a Warrant was strictly limited to 24-hours with the exception of weekends and holidays unless a further court order was obtained.

Review of Texas Administrative Code, Title 25 Health Services; Part 1 Department of State Health Services; Chapter 411 State Mental Health Authority Responsibilities;

Subchapter J Standards of Care and Treatment in Psychiatric Hospitals; was as follows:

"411.485 Discharge of an Involuntary Patient

(a) Discharge from emergency detention.

(1) Except as provided by 411.465 of this title (relating to Voluntary Treatment Following Involuntary Admission) and in accordance with Texas Health and Safety Code, 573.023(b) and 573.021(b), a hospital shall immediately discharge a patient under emergency detention if either of the following occurs:

(A) the administrator or the administrator's designee determines, based on a physician's determination, that the patient no longer meets the criteria described in subsection 411.462(c)(1) of this title (relating to Emergency Detention); or

(B) except as provided in paragraphs (2) and (3) of this subsection, 24 hours elapse from the time the patient was presented to the hospital and the hospital has not obtained a court order for further detention of the patient.

(2) In accordance with Texas Health and Safety Code, 573.021(b), if the 24-hour period described in paragraph (1)(B) of this subsection ends on a Saturday, Sunday, or legal holiday, or before 4:00 p.m. on the next business day after the patient was presented to the hospital, the patient may be detained until 4:00 p.m. on such business day.

(3) In accordance with Texas Health and Safety Code, 573.021(b), the 24-hour period described in paragraph (1)(B) of this subsection does not include any time during which the patient is receiving necessary non-psychiatric medical care in the hospital's emergency room or non-psychiatric emergency care in another area of the hospital."

Based on observation, interview, and review of records, the facility failed to ensure that patients did not have access to hazardous items in the nursing station when the station was left unattended. Items that could have been potentially hazardous to psychiatric patients were found to be within arm's reach of 2 of 2 window openings that provided access to the nursing station. This deficient practice had the potential for harm to all patients.

Findings:

On the morning of 12-11-2019, the surveyors observed that the nursing station was unattended by nursing staff. The nursing station was observed to be completely enclosed with the exception of two window openings where patients could easily communicate with nursing staff and items could be passed through the window if necessary.

A cell phone, a cordless phone, three-ring binders with metal parts, and packets of paperwork clipped together with metal paperclips were observed to have been left close to the window openings. Surveyors were able to reach into the window opening and retrieve the items.

An interview was conducted on 12-11-2019, at approximately 10:30 AM, with Staff #30. Staff #30 stated that patients could not retrieve the items identified because they were always being observed by staff. Upon further review of the events, Staff #30 confirmed that all nursing staff had been tied up with patient care at the time of surveyors retrieving the identified items from the nursing station. Staff #30 confirmed, staff had not witnessed the surveyors retrieve the identified items and that it was possible for a patient who was not the focus of patient care at the time to retrieve those items without being observed. When asked who conducted safety rounds to ensure there were not hazards in the environment, Staff #30 stated, the mental health technicians made safety rounds every shift and documented them on a rounding form.


Review of Policy Number: EOC-28, titled Safety Inspection of All Areas was as follows:

"Purpose:
To monitor physical environment to ensure compliance with standards.

Policy:
Areas of the facility shall be inspected on a monthly basis to ensure that safety standards are being met, that when deficiencies are found corrective action is taken.

Procedure:
EOC Safety Coordinator


Nursing Staff:
Performs safety walk through every shift.
Documents on the Safety Round Form.
Removes unsafe items and reports issues to charge nurse.
Nurse will notify the EOC coordinator of all unsafe situations identified."


Staff #30 provided the binder used to keep the documented rounding sheets. The form being used by the mental health technicians was not titled, "Safety Round Form". It was titled, "Security Rounds". The checklist required staff to check 16 areas. Of the 16 areas, the form asked staff to check the following areas for safety:

"Courtyard is checked for safety risks?
...
Dining area is checked for safety?
Dayroom is checked for safety?
Tub room is checked for safety?
...
Patient rooms are checked for safety risks?"

The checklist did not require staff to observe the nursing station for potential safety hazards that patients may be able to access.

Based on review and interview, the facility failed to:

A. ensure that allegations of abuse were identified as a grievance and thoroughly investigated following the policy and procedures of the facility in 2 (#14 and #16) of 2 complaints reviewed.

B. ensure that all contracted employees giving patient care or had potential patient contact, had an employee file and appropriate training in abuse and neglect.

C. ensure the facility had appropriate information on how and where to "self-report" an incident of abuse or neglect. There was no information on how to self-report a case of abuse or neglect to the State of Texas. The policy only addressed Louisiana.

D. ensure staff training and/or education concerning any allegations of abuse and/or neglect were documented.


Patient #16
Review of the complaints and grievance log revealed that Patient #16 made a complaint on 11/13/19 at 12:30 PM. The complaint was logged as a complaint and stated on 11/15/19 it was resolved, verbal complaint, no letter."
Review of the complaint revealed Staff #6 documented the complaint investigation. Staff #6 documented, "____ (Patient #16) made complaint re' 'Staff ___ (#33)' was 'uncaring' and 'judgmental' towards patients. Reported he used inappropriate language in the smoking area reported David 'grabbed my arm when I reached in the smoke box.' Sts 'I am not prejudiced against him .... I have biracial children with a Mexican woman.' Wants staff to be counseled and be more caring with patient care. Reassigned ____ (Staff #33) to the hallway while investigating the incident.

Results of the investigation: Spoke with ____ (Patient #16) and other witnesses- Rec'd several versions of the event. Met with ____ (Staff #33) 11-15-19 (two days later) ____ (Staff #33) denies ever touching ____ (Patient #16) although he did repeat back the statements made by____ (Patient #16). Meeting with witnesses to investigate this complaint.

Actions Taken: Spoke with all staff including ____ (Staff #33) to review customer service and patient perceptions of events. Apologies made by ____ (Patient #16) ____ (Patient #17) ____ and ____ (Staff #33) All parties agreed to move on and get past this incident."


Staff #6 failed to appropriately document the grievance process and was not reported as a grievance to QAPI or governing board.

An interview was conducted with Staff #6 on 12/12/19 at 2:00 PM. Staff #6 stated that she felt this was not a grievance since it was resolved. Staff #6 failed to follow the facility's policy and procedure for grievances. Staff #6 was unable to provide any documentation on what training or instruction the staff was given staff to deal with these types of incidents nor any clarification if the staff inappropriately touched a patient. There was no evidence that allegations of abuse and neglect were thoroughly investigated.


Patient #14
Review of the complaints and grievance log revealed that Patient #14 made a complaint on 3/22/19 at 1600 (4:00 PM). The complaint was logged as a complaint and stated on 3/23/19 it was resolved, verbal complaint, no letter."

Review of the complaint revealed Staff #6 documented the complaint investigation. Staff #6 documented, "Rec'd verbal complaint from ____ (Patient #14) who stated 'the tech was rough with me when I was getting my x-ray. They were talking in another language ... I was afraid I would fall again the way they were rolling me around. I want you to do something about it."

Review of the complaint investigation under "Results of investigation" stated, "Discussed with the MHT's who stated, '____ (Patient #14) was hollering and hitting them as they tried to assist Mobilex with the x-ray procedure. She was afraid she was going to fall again so she was very resistant to having the procedure done.' Patient had orders for x-ray of (L) shoulder (L) elbow and (L) forearm results are all normal-no fracture or skeletal injury noted.

Actions Taken: Discussed with staff. Contacted Mobilex to inform them of patient perception that the tech was rough."

There was no documentation found on what was discussed with staff, who the Technician was at Mobilex, or if the Technician or staff had appropriate training. Staff #6 completed the investigation on 3/23/19 with no time documented.

There was no documentation in how to handle a patient with fears of falling, manhandling a patient, or forcing a patient to perform a medical procedure when the patient no longer consents. There was no documented information on who the x-ray technician was that performed the procedure from Mobilex. The administrator was unable to provide a staff folder for the Mobilex technician's and no facility training found for contracted employees of Mobilex. Staff #6 confirmed she did not write the contracted person's name on the report but notified Mobilex of the patients "perception that the tech was rough."

An interview was conducted with Staff #6 on 12/12/19 at 2:00 PM. Staff #6 stated that she did talk with the staff concerning the incident but had no documentation. Staff #6 confirmed both staff members were from the Philippines and were talking in their native language (other than English). Staff #6 stated that she talked to the staff about speaking English around English speaking patients but has no documentation of education.


Review of the facility's policy and procedure "Grievance Procedure Patient and Family Texas policy number RTS-04" stated, "For grievances alleging abuse, neglect, and/or exploitation, will notify the state hotline and document this immediately."


Review of policy and procedure Abuse and/or Neglect of Patients by Staff Members, Students, Interns Policy Number RTS-10 stated, "No employee or student will mistreat and/or neglect a patient. Examples of actions/inactions which could be considered mistreatment/abuse include:

Causing pain or suffering;

Using inappropriate or excessive physical restraint techniques;

Direct physical aggressive behavior toward a patient;

Any engagement in sexual behavior;

Using his/her position for sexual gratification or exploitation;

Dating or engaging in any business dealings or more than platonic relationships with former or current patients;

Directing to a patient any derogatory, threatening, belittling, humiliating, profane or obscene language, whether in writing, orally or with gestures;

Failing to or refusing to attend to the necessary care and treatment;

Implementing actions contrary to the prescribed treatment of the program;

Unauthorized restriction of patients' rights;

Failing to intervene to protect a patient form abuse and/or mistreatment.

Therapeutic intervention warranted by the treatment team and ordered by the physician (i.e., seclusion, restraints, CD group confrontation, restriction of mail and/or phone) are not considered abuse and/or neglect.

Any staff or student suspected of any of the above infractions will be investigated under this policy. If it is determined that the staff member physically, sexually, or verbally abused the patient in question or willfully neglected the patient(s), disciplinary actions will be enacted against him/her, up to and including termination of employment. Employees are educated on the policy.


PROCEDURE: Refer to Assessment and Reporting of Abuse, Neglect, Exploitation and/or Extortion of Youth and Adults Policy for reporting procedure."

Review of the policy and procedure "Assessment and Reporting of Abuse, Neglect, Exploitation, and/or Extortion of Youth and Adults" revealed there was no information on how to self-report a case of abuse or neglect to the State of Texas. The policy only addressed Louisiana.

Based on record review and interviews, nursing staff failed to follow its policy and procedure allowing an Licensed Vocational Nurse (LVN) to administer a chemical restraint on 1 (#3) out of 3 (#3,6,and 8).

Patient #3
Review of Patient #3's chart revealed, he was a 78-year-old male with a diagnosis of Dementia with behavioral disturbances. The patient was admitted to the facility on 6/10/19. Review of the Nurses notes dated 6/22/19, at 10:05 AM, revealed the RN documented that the patient was "pacing and trying to open door near nurse's station. He kept demanding that the door be unlocked so he could leave." The nurse continued to document that the patient was "pushing, hitting, and kicking staff." Staff continued to attempt to deescalate the patient but was unsuccessful and received an order for a chemical restraint from the physician. The physician telephone order dated 6/22/19 at 10:05 AM stated, "Give Ativan 1 mg IM x 1 now and Haldol 5 mg IM x 1 now for agitation and aggression." The order was documented by Staff #32 Licensed Vocational Nurse (LVN).


Review of the Seclusion/Restraint/Emergency Administration of Psychoactive Medication sheet was filled out by Staff #34 Registered Nurse (RN). The RN had documented and initialed that she obtained the order at 6/22/19 at 10:05 AM and administered the chemical restraint at 10:10 AM. The face to face was also administered by Staff #34 RN.


Review of the nurse's notes dated 6/23/19 at 8:40 AM, "Late Entry for 6/22/19 1010: Ativan 1 mg given IM in the Lt deltoid and Haldol 5 mg IM given in Lt deltoid by LVN ____ (Staff #32 LVN) for agitation and aggression. Medications were effective. At 1110, patient was lying down asleep. Vital signs attempted, but patient resisted. unable to get vital signs at 1010,1025,1040 due to patient refusal. Unable to get vitals at 1055."


Review of the patient's medication administration record (MAR) revealed Staff #32 LVN administered the chemical restraint.


Review of the facility's policy and procedure Seclusion and Restraint Texas stated, "Procedure Initiation: RN (Registered Nurse) Initiate emergency restraint and/ or seclusion in absence of physician post determination that alternative interventions were not effective or would not deter harm to self or others.

Notify physician as soon as possible and no greater than one hour.

Document contact and physician order on Physician Order for Seclusion and/or Restraint Form."


Review of the chart revealed the RN documented that she had taken the physician order and administered the chemical restraint on the Physician Order for Seclusion and/or Restraint Form. However, a telephone order was found on the patient's chart with the same date and time by the LVN. The LVN documented on the MAR that she administered the medication.

The RN documented the next day a late entry nurses note. Staff #34 RN documented the LVN administered the chemical restraint. It is not in an LVN's scope of practice to initiate a restraint.

An interview was conducted with Staff #4 on 12/10/19. Staff #4 stated, she was not aware the LVN could not administer the medication. Staff #4 was asked if the LVN could apply a physical restraint? Staff #4 stated, "no." Staff #4 was shown the policy and procedure. Staff #4 stated, " I guess I just thought about it being medication administered and not necessarily a restraint." Staff #4 and #5 confirmed the LVN administered the chemical restraint.

Based on record review and interview. the facility failed to:

A. ensure the patient was seen within 1 hour for a face-to-face evaluation after an intervention in 1(6) of 2 (3 and 6) charts reviewed.

B. ensure the RN performing the face-to-face was not involved in the initiation/administration of the restraint in 1(3) of 2 (3 and 6) charts reviewed.


Patient #3

Review of Patient #3's chart revealed, he was a 78-year-old male with a diagnosis of Dementia with behavioral disturbances. The patient was admitted to the facility on 6/10/19. Review of the Nurses notes dated 6/22/19, at 10:05 AM, revealed, the RN documented that the patient was "pacing and trying to open door near nurse's station. He kept demanding that the door be unlocked so he could leave." The nurse continued to document that the patient was "pushing, hitting, and kicking staff." Staff continued to attempt to deescalate the patient but was unsuccessful and received an order for a chemical restraint from the physician. The physician telephone order dated 6/22/19, at 10:05 AM, stated, "Give Ativan 1 mg IM x 1 now and Haldol 5 mg IM x 1 now for agitation and aggression." The order was documented by Staff #32 Licensed Vocational Nurse (LVN).

Review of the Seclusion/Restraint/Emergency Administration of Psychoactive Medication sheet was filled out by Staff #34 Registered Nurse (RN). The RN had documented and initialed that she obtained the order at 6/22/19 at 10:05 AM and administered the chemical restraint at 10:10 AM. The face-to-face was also administered by Staff #34 RN.

Review of the nurse's notes dated 6/23/19 at 8:40 AM, "Late Entry for 6/22/19 1010: Ativan 1 mg given IM in the Lt deltoid and Haldol 5 mg IM given in Lt deltoid by LVN ____ (Staff #32 LVN) for agitation and aggression. Medications were effective. At 1110, patient was lying down asleep. Vital signs attempted, but patient resisted. unable to get vital signs at 1010,1025,1040 due to patient refusal. Unable to get vitals at 1055." Review of the patient's medication administration record revealed Staff #32 LVN administered the chemical restraint.

Review of the facility's policy and procedure Seclusion and Restraint Texas stated, "Procedure Initiation: RN (Registered Nurse) Initiate emergency restraint and/ or seclusion in absence of physician post determination that alternative interventions were not effective or would not deter harm to self or others.

Notify physician as soon as possible and no greater than one hour.

Document contact and physician order on Physician Order for Seclusion and/or Restraint Form.

RN/MHT: Monitoring: Provide monitoring as indicated on Seclusion/Restraint Flow Sheet every 15 minutes:
Provide care for patient as indicated in Seclusion/Restraint Flow Sheets in time(s) indicated.

Psychoactive medication follows the same protocol and procedure: every 15 minutes an assessment and vital signs must be conducted and the one hour RN assessment is performed. All patients receiving intramuscular psychoactive medication will be assessed at a minimum of every 15 minutes for one hour for vital signs, nutritional needs and safety.

A complete RN assessment will be performed at one hour and documented on the flow sheet.
Current physical, emotional and behavioral condition status
Medication(s) administration
Type of care needed.

Review of the chart revealed the RN documented, that she had taken the physician order and administered the chemical restraint on the Physician Order for Seclusion and/or Restraint Form. However, a telephone order was found on the patient's chart with the same date and time by the LVN. The LVN documented on the MAR that she administered the medication. The RN documented the next day a late entry nurses note. Staff #34 RN documented the LVN administered the chemical restraint. It is not in an LVN's scope of practice to initiate a restraint.

Review of the Seclusion/Restraint/Emergency Administration of Psychoactive Medication dated 6/22/19 at 1010 (10:10 AM) revealed there was an assessment done of Patient #3 by Staff #34 RN. Staff #34 documented Patient #3 had endured injuries from the initiation of seclusion and/or restraint. Staff #34 documented, "Superficial skin tears on both forearms. Given Ativan 1 mg and Haldol 5 mg IM for agitation and aggression. Too combative. Will not wound care at this time. (SIC) 1025- Skin tear on both forearms cleansed with skin integrity, covered with non-adhering dressing, kling and tape continues too combative." (SIC)

There was no physician order for the wound care or dressing. There was no nursing documentation that the physician was notified of the injuries or if the next shift was notified of the injury. There was no incident report completed concerning the injuries or any description on size, bleeding, swelling or pain. The RN only documented on the patient for 45 minutes.


Patient #6

Review of Patient #6's chart revealed, she was a 56-year-old female admitted to the facility on 8/28/19. Patient #6 was admitted for Bipolar disorder with psychotic features. The patient had received medical clearance at a local hospital and was transferred to the unit by a police officer's warrant. The patient had already been seen by a physician and was medically cleared at the local hospital.

Patient #6 was sent to the facility with an Emergency Police Officers Warrant (EPOW) dated 8/28/19 at 1518 (3:18 PM). The EPOW stated, "Subject is in a manic state and stated that killing people and herself didn't seem like a bad idea." The patient arrived at the facility and refused to sign any consents.

Review of the Admit Nursing Assessment dated 8/28/19 stated Patient #6 was assessed and admitted at 1600 (4:00 PM). However, the Physician order to admit was written 8/28/19 at 1800 (6:00 PM) 2 hours after the patient was admitted.

Review of Patient #6's Psychiatric Evaluation performed on 8/28/19 at 1825 (6:25 PM) revealed she was involuntary however, the EPOW was no longer valid. There was no order to hold the patient and initiate an Emergency Detention Warrant (EDW) or OPC. There was no documented evidence that Patient #6 was instructed of her rights and that she was no longer involuntary.

Review of Patient #6's physician orders revealed a telephone order for "Emergency Administration for Psychoactive Medications" dated 8/28/19 at 1715 (5:17 PM). The physician order stated, "1) DC Zyprexa Zydis 10 mg now and Ativan 2 mg po now agitation. 2) Give Haldol 5 mg IM now agitation. Nurse had documented 8/28/19 at 1715 (5:17 PM), "Patient is having increased agitation rolling on the floor, cursing, kicking, at staff. ____ (psychiatrist) notified. Now order for Zyprexa Zydis 10 mg po and Ativan 2 mg po now. 'I'm not taking that (expletive) medicine, I don't know what it is." Explained it is for mood disorder. 'No, I'm not taking it.' ____ (psychiatrist) notified. Now order to DC Zyprexa Zydis 10 mg po and Ativan 2 mg po now. Give Haldol 5 mg IM now, given in left hip at 1725 physical hold times one minute. No injuries noted. Will monitor patient until she is calm and will transport to the unit.

Review of the chart revealed a face to face evaluation form. The face to face was performed at 1825 (6:25 PM) 8 minutes past the 1-hour administration. There was no name or signature on who performed the face to face.

Review of the nurse's notes dated 8/29/19 1755 "Pt is calmer talking to the nurse eating jello 'I'm hungry I need something soft cause my teeth hurt.' Patient non-aggressive siting in wheelchair awake alert." SIC Nurse documented the patient was taken to the unit at 1800 and vital signs were documented. Nurse documented, "head to toe assessment done." Nurse documented at 1825(6:25 PM), "One-hour face to face evaluation by ____ (Staff #30). Patient is calm cooperative, eating/drinking. VS 97.9, p 113, r 16 b/p 118/78 O2 Sat 98% R/A.

Review the chart revealed there was no vital signs or nursing assessments performed for 45 minutes after the initial injection.

Review of the policy and procedure Seclusion and Restraint Texas stated,
"Face-to-Face: Evaluation: Conduct face-to-face within one hour after initiation of intervention even if patient is no longer in restraint or seclusion. (trained RN may be delegated to do so).

Document on Face-to-Face Evaluation Form:
Date/time
Behaviors
Alternative interventions to prevent restraint/seclusion
Medical review of patient's status post-intervention
Release patient from restraint and seclusion when patient no longer is in danger to self and others."

Based on record review and interview, the facility failed to:

A. ensure that the data collected was accurate, analyzed, and monitored to ensure effectiveness of safety, services provided, and quality of care.

Refer to Tag A0273

Based on review and interview, the facility failed to ensure that the data collected was accurate, analyzed, and monitored to ensure effectiveness of safety, services provided, and quality of care.

Review of the facility's Quality Assurance Performance Improvement revealed a "Facility Scoring Sheet." The sheet only revealed data. The data was broken down into category as follows:

Responsible Party
Measure
Indicator name
Goal
Months of 2019.

Review of the data sheet revealed, there was 1 physical restraint in June of 2019. The measure was "Physical Restraint Use and Documentation Completed." In the Indicator name it stated, "Was restraint documentation completed per policy?" The result was 100%. Staff #7 was unable to give the surveyor the names of the patients used in the data.

Review of Patient #3's chart revealed, he was a 78-year-old male with a diagnosis of Dementia with behavioral disturbances. He received a physical hold and chemical restraint on 6/22/19. There was no incident report on this patient and no documentation on the restraint and seclusion log. Patient #3's seclusion and restraint paperwork were incomplete on the chart. Staff #7 was unable to confirm if patient #3 was the patient referred to on the data of the QAPI reporting.


Review of the facility's Quality Assurance Performance Improvement (QAPI) revealed the facility did not have any data for chemical restraints. The facility did have data listed for Emergency Medication Orders. Staff #4 confirmed that was for chemical restraints/ Emergency Behavioral Medication (EBM) orders. Review of the numerator /denominator for EBM 2019 was as follows:

July 0/584
August 1/542
September 0/615
October 0/579

Staff #5 was asked if this was the numbers for the EBM and Staff #5 stated, "yes." Staff #5 was asked what the numerator and denominator represented and how did they get these numbers? Staff #5 was unable to confirm where these numbers came from. Staff #5 stated she just puts in her data she has to the computer system and reports that to Staff #7 (QAPI Director). Staff #7 stated she had not been in this job long and was not sure how the data was calculated. She stated that she sends the information they have to a corporate person who plugs in the data and shares with the corporate governing body.


Review of the restraint and seclusion log revealed the log was blank for October, November, and December of 2019. Staff #5 stated, "I didn't know I was supposed to be keeping a log." Staff #5 had been in the Director of Nursing position for 7 months. Staff #5 was unable to ensure the accuracy of the data reported.


An interview was conducted with Staff #7 QAPI Director, Staff #31 Texas Regional Corporate Director, #35 Texas Regional Corporate CNO on 12/12/19.

Staff #7 was asked how she collects the data for QAPI and how is the data aggregated, analyzed, and monitored. Staff #7 stated that she is new in the role and is learning about the QAPI process. Staff #7 presented the Facility Scoring Report (data) and 5 Performance Improvement Actions. Staff #7 was unable to speak on how the data was analyzed or how to read the "Facility Scoring Sheet." Staff #7 stated at this point she was sending data to the corporate QAPI department and they completed the Scoring Report.

Staff #35 and #31 confirmed that they were not able to speak to the QAPI process and was unable to clarify to the surveyor how data was collected, analyzed, aggregated, how and what indicators are chosen for the QAPI Scoring Report, what data was mandated reporting for reimbursement, and what data was specialized for that specific facility.

Based on interview and document review, the facility failed to ensure periodic appraisals were completed on each Medical Staff member on a regular basis. The facility also failed to follow their own policy and the Medical Staff Bylaws.


Findings:

An interview was conducted on 12/11/2019, at 1:20 PM, with Staff #4 and #12. Staff #4 and #12 were asked how the peer review was completed on the medical staff. Staff #4 said, "We have not reported any Ongoing Performance Practice Evaluations (OPPE) on the medical staff to the Medical Executive Committee in the last year. It is hard because we don't have that many providers with the same medical experience to complete a peer review." Staff #12 stated, "We have decided that the provider in Longview will complete the OPPE on myself and I will complete the OPPE on the provider in Longview." Staff #4 said, "We did do a Focused Professional Practice Evaluation (FPPE) on one of our medical staff members and reported it to the Medical Executive Meeting on 10/29/2019. We know we have to correct this problem and we are working on this now."



A review of the MEDICAL STAFF BYLAWS revealed the following:


" ...SECTION 2.1: MEC CREDENTIALS FUNCTION

The MEC is responsible for reviewing the credentials of Physicians and NPP's in connection with initial, renewal and modification requests for Medical Staff Membership and Clinical Responsibilities and for reporting to and making recommendations to the Board regarding same. When an NPP is being reviewed for Medical Staff Membership or Clinical Responsibilities, The MEC may, in its sole discretion, request a peer representative of the non-Physician to consult with the MEC regarding the requested Membership or Clinical Responsibilities. The quality assessment and performance improvement activities including Practitioners Profiles and Peer Review data shall be a standing agenda item for the MEC ..."


Staff #4 and #12 confirmed no peer review data had been reported to the Medical Executive Committee in the last year.



A review of the Policy titled, "FOCUSED PROFESSIONAL PRACTICE EVALUATION (FPPE)/ONGOING PROFESSIONAL PRACTICE EVALUATION(OPPE)" revealed the following:

" ...POLICY:
A Focused Professional Practice Evaluation will be conducted when the Medical Staff Executive Committee evaluates the privilege-specific competence of a practitioner who does not have documented evidence of competently performing the requested privilege within the organization. The process will also be used when a question arises regarding privileged practitioners ability to provide safe, high quality patient care or for a process of managing a breach of ethical or professional conduct. A focused professional practice evaluation is a time limited period during which the organization evaluates and determines the practitioners professional performance. The decision to assign a period of performance monitoring is to further assess current competence is bases on the evaluation of a practitioner's current clinical competence, practice behavior and ability to perform the request the privilege(s). Other existing privileges in good standing will be conducted to allow for identification of professional practice trends, that may require intervention by the organized Medical Staff and will be factored into the decision to maintain, refuse or revoke an existing prior to or at the time of renewal. Ongoing profession practice evaluation may be utilized on a "for cause" concern basis or in the case of reporting behaviors which undermine the culture of safety ..."



A review of the MEC meeting minutes for the 3rd quarter dated 10/29/2019 revealed:

" ...Closed Session-Administrator and Physicians

Specifically discussed some of the findings from JC and how we are going to correct them.

OPPE/FPPE policy/process-reviewed deficiency we received in this area. Training will occur on 11/12 by corporate to ensure we are following our policy and adequately looking at the performance of our physicians ..."



After multiple requests to Staff #4 no further documentation was provided for review.


Staff #4 and Staff #12 confirmed the above findings.

Based on review of documents and interview, the facility and Nursing Services failed to:

A. 1. follow its own policy and procedures allowing a Licensed Vocational Nurse (LVN) to administer a chemical restraint in 1 (Patient #3) of 3 (Patient #3, #6, and #8) patient charts reviewed.

2. assess and monitor a patient every 15 minutes for 1 hour after a chemical restraint administration in 2 (Patient #2 and #6) of 3 (Patient #2, #6, and #8) patient charts reviewed.

3. ensure wound care was administered to a patient with required physician orders in 1 (Patient #3) of 3 (Patient #3, #6 and #8) patient charts reviewed.

Cross Refer to Tag A0395


B. ensure that contract nursing staff had completed the hospital approved training required to initiate or assist with patient restraint and/or seclusion for 3 of 3 contracted nursing staff personnel files reviewed (Staff #22, #23, and #24). Since contract nursing staff worked directly with patients, this deficient practice had the potential to result in harm to all patients the contract nursing staff came in contact with during their shifts.

Cross Refer to Tag A0398


C. ensure the staffing available for the number and acuity of patients met the minimum number of staffing necessary per the staffing matrix identified by the facility as being used for 9 (December 1, 5, 6, 7, 8, 9, 10, 11, and 12) of the first 12 days of December 2019.

Cross Refer to Tag A0392



32143

Based on review of records and interview, the facility failed to ensure the staffing available for the number and acuity of patients met the minimum number of staffing necessary per the staffing matrix identified by the facility as being used for 9 (December 1, 5, 6, 7, 8, 9, 10, 11, and 12) of the first 12 days of December 2019.

Findings included:

Staffing for December was reviewed with Staff #5 on 11-12-2019. Staff #5 provided a policy titled Staffing Plan; Policy Number NSG-06, Revised: 07-01-2019. The "Scope" of the policy was defined as, "This policy applies to all Oceans Healthcare facilities".

Staff #5 confirmed that there was not a staffing policy specific to Oceans Behavioral Hospital of Lufkin.

Staff #5 provided a staffing matrix (table that lists the minimum staff necessary based on number of patients) with the title "Staffing Matrix for Fort Worth, Plano, and Katy". Staff #5 was asked to provide a staffing matrix that had been approved for the facility in Lufkin. During interview, Staff #5 explained that staffing was determined by the corporate office and the form Staff #5 had provided to surveyors was the form that was provided to her for use in scheduling staff. Staff #5 was not able to provide a staffing plan or matrix that identified specific needs of the Lufkin population or location.

When reviewed, 11 shifts during the first 12 days of December were found to be short one or more Mental Health Technicians necessary to monitor patients based on number of patients and acuity of patients. This was confirmed during interview by Staff #5.

Based on reviews and interviews, the Nursing failed to:

A. follow its own policy and procedures by allowing a Licensed Vocational Nurse (LVN) to administer a chemical restraint in 1 (3) of 3 (3, 6 and 8) patient charts reviewed.

B. assess and monitor a patient every 15 minutes for 1 hour after a chemical restraint administration in 2 (2 and 6) of 3 (2,6,and 8) charts reviewed.

C. administered wound care to a patient with no physician orders in 1(3) of 3(3, 6 and 8) charts reviewed.


Patient #3
Review of Patient #3's chart revealed, he was a 78-year-old male with a diagnosis of Dementia with behavioral disturbances. The patient was admitted to the facility on 6/10/19. Review of the Nurses notes dated 6/22/19, at 10:05 AM, revealed, the RN documented that the patient was "pacing and trying to open door near nurse's station. He kept demanding that the door be unlocked so he could leave." The nurse continued to document that the patient was "pushing, hitting, and kicking staff." Staff continued to attempt to deescalate the patient but was unsuccessful and received an order for a chemical restraint from the physician. The physician telephone order dated 6/22/19 at 10:05 AM stated, "Give Ativan 1 mg IM x 1 now and Haldol 5 mg IM x 1 now for agitation and aggression." The order was documented by Staff #32 Licensed Vocational Nurse (LVN).

Review of the Seclusion/Restraint/Emergency Administration of Psychoactive Medication sheet was filled out by Staff #34 Registered Nurse (RN). The RN had documented and initialed that she obtained the order at 6/22/19, at 10:05 AM, and administered the chemical restraint at 10:10 AM. The face to face was also administered by Staff #34 RN.

Review of the nurse's notes dated 6/23/19, at 8:40 AM, "Late Entry for 6/22/19 1010: Ativan 1 mg given IM in the Lt deltoid and Haldol 5 mg IM given in Lt deltoid by LVN ____ (Staff #32 LVN) for agitation and aggression. Medications were effective. At 1110, patient was lying down asleep. Vital signs attempted, but patient resisted. unable to get vital signs at 1010, 1025, 1040 due to patient refusal. Unable to get vitals at 1055."Review of the patient's medication administration record revealed Staff #32 LVN administered the chemical restraint.


Review of the facility's policy and procedure Seclusion and Restraint Texas stated, "Procedure Initiation: RN (Registered Nurse) Initiate emergency restraint and/ or seclusion in absence of physician post determination that alternative interventions were not effective or would not deter harm to self or others.

Notify physician as soon as possible and no greater than one hour.

Document contact and physician order on Physician Order for Seclusion and/or Restraint Form.

RN/MHT: Monitoring: Provide monitoring as indicated on Seclusion/Restraint Flow Sheet every 15 minutes:
Provide care for patient as indicated in Seclusion/Restraint Flow Sheets in time(s) indicated.

Psychoactive medication follows the same protocol and procedure: every 15 minutes an assessment and vital signs must be conducted and the one hour RN assessment is performed. All patients receiving intramuscular psychoactive medication will be assessed at a minimum of every 15 minutes for one hour for vital signs, nutritional needs and safety. A complete RN assessment will be performed at one hour and documented on the flow sheet.
Current physical, emotional and behavioral condition status Medication(s) administration Type of care needed."


Review of the chart revealed the RN documented that she had taken the physician order and administered the chemical restraint on the Physician Order for Seclusion and/or Restraint Form. However, a telephone order was found on the patient's chart with the same date and time by the LVN. The LVN documented on the MAR that she administered the medication. The RN documented the next day a late entry nurses note. Staff #34 RN documented the LVN administered the chemical restraint. It is not in an LVN's scope of practice to initiate a restraint.


Review of the Seclusion/Restraint/Emergency Administration of Psychoactive Medication dated 6/22/19, at 1010 (10:10 AM), revealed there was an assessment done of Patient #3 by Staff #34 RN. Staff #34 documented Patient #3 had endured injuries from the initiation of seclusion and/or restraint. Staff #34 documented, "Superficial skin tears on both forearms. Given Ativan 1 mg and Haldol 5 mg IM for agitation and aggression. Too combative. Will not wound care at this time. (SIC) 1025- Skin tear on both forearms cleansed with skin integrity, covered with non-adhering dressing, kling and tape continues too combative." (SIC)

There was no physician order for the wound care or dressing. There was no nursing documentation that the physician was notified of the injuries or if the next shift was notified of the injury. There was no incident report completed concerning the injuries or any description on size, bleeding, swelling or pain. The RN only documented on the patient for 45 minutes.


Patient #6

Review of Patient #6's chart revealed, she was a 56-year-old female admitted to the facility on 8/28/19. Patient #6 was admitted for Bipolar disorder with psychotic features. The patient had received medical clearance at a local hospital and was transferred to the unit by a police officer's warrant. The patient had already been seen by a physician and was medically cleared at the local hospital.

Patient #6 was sent to the facility with an Emergency Police Officers Warrant (EPOW) dated 8/28/19, at 1518 (3:18 PM). The EPOW stated, "Subject is in a manic state and stated that killing people and herself didn't seem like a bad idea." The patient arrived at the facility and refused to sign any consents.

Review of the Admit Nursing Assessment dated 8/28/19 stated, Patient #6 was assessed and admitted at 1600 (4:00 PM). However, the Physician order to admit was written 8/28/19 at 1800 (6:00 PM) 2 hours after the patient was admitted.

Review of Patient #6's Psychiatric Evaluation performed on 8/28/19, at 1825 (6:25 PM), revealed, she was involuntary, however, the EPOW was no longer valid. There was no order to hold the patient and initiate an Emergency Detention Warrant (EDW) or OPC. There was no documented evidence that Patient #6 was instructed of her rights and that she was no longer involuntary.

Review of Patient #6's physician orders revealed a telephone order for "Emergency Administration for Psychoactive Medications" dated 8/28/19 at 1715 (5:17 PM). The physician order stated, "1) DC Zyprexa Zydis 10 mg now and Ativan 2 mg po now agitation. 2) Give Haldol 5 mg IM now agitation. Nurse had documented 8/28/19 at 1715 (5:17 PM), "Patient is having increased agitation rolling on the floor, cursing, kicking, at staff. ____ (psychiatrist) notified. Now order for Zyprexa Zydis 10 mg po and Ativan 2 mg po now. 'I'm not taking that (expletive) medicine, I don't know what it is." Explained it is for mood disorder. 'No, I'm not taking it.' ____ (psychiatrist) notified. Now order to DC Zyprexa Zydis 10 mg po and Ativan 2 mg po now. Give Haldol 5 mg IM now, given in left hip at 1725 physical hold times one minute. No injuries noted. Will monitor patient until she is calm and will transport to the unit.

Review of the chart revealed a face to face evaluation form. The face-to-face was performed at 1825 (6:25 PM) 8 minutes past the 1-hour administration. There was no name or signature on who performed the face to face.

Review of the nurse's notes dated 8/29/19 1755 "Pt is calmer talking to the nurse eating jello 'I'm hungry I need something soft cause my teeth hurt.' Patient non-aggressive siting in wheelchair awake alert." SIC Nurse documented the patient was taken to the unit at 1800 and vital signs were documented. Nurse documented, "head to toe assessment done." Nurse documented at 1825(6:25 PM), "One-hour face to face evaluation by ____ (Staff#30). Patient is calm cooperative, eating/drinking. VS 97.9, p 113, r 16 b/p 118/78 O2 Sat 98% R/A.
Review the chart revealed there was no vital signs or nursing assessments performed for 45 minutes after the initial injection.

Based on review of records and interview, the facility failed to ensure that contract nursing staff had completed the hospital approved training required to initiate or assist with patient restraint and/or seclusion for 3 of 3 contracted nursing staff personnel files reviewed (Staff #22, #23, and #24). Since contract nursing staff worked directly with patients, this deficient practice had the potential to result in harm to all patients the contract nursing staff came in contact with during their shifts.

Findings:

Contract nursing staff personnel files were reviewed on the morning of 12-13-2019. Review of new employee orientation and training revealed that contracted nursing staff (Staff #22, #23, and #24) did not contain evidence that they had the appropriate training to initiate or assist with restraints and seclusion. The files contained a statement that they had "reviewed Tx-Spec-07: Seclusion and Restraints, the MD Orders for Seclusion or Restraints, the S/R Flow Sheet, and the Code Green Debriefing Form."

No training was found for a hospital approved program such as Satori Alternatives to Managing Aggression (SAMA) or Nonviolent Crisis Intervention Training from the Crisis Prevention Institute (CPI). These programs ensured that staff had the training and competencies to safely protect patients and staff when a patient became aggressive.

Interview was conducted with Staff #5. Staff #5 confirmed that this requirement had not been completed with contracted nursing staff. All contracted nursing staff were working with patients without evidence of proper training for initiating or assisting in a restraint or seclusion. Staff #5 confirmed that all contract staff were working with patients and had the potential to be involved in a restraint or seclusion.

Review of the Contract Agency Staff usage for September, October, and November of 2019 showed that contract nursing staff had been used 33 times during that period.

Based on document review and interview, the facility failed to ensure verbal orders were legible and complete in 5 (Patient #1, #2, #4, #9, and #10) of 7 records reviewed. The facility also failed to follow their own policy regarding verbal orders.


This deficient practice had the likelihood to cause harm to all patients. Medication orders not legible and/or not authenticated with a date and time could result in the wrong dose of medication or the wrong medication being given to patients, ultimately resulting in a severe allergic reaction that could possibly lead to death of a patient.


Findings:


PATIENT #1

A review of Patient #1's medical record revealed an order was written on 12/06/2019 at 6:00 AM by Staff #11.

An interview was conducted with Staff #30 on 12/11/2019, after 9:00 AM., Staff #30 was asked to clarify the written order and identify the provider who wrote the order. Staff #30 stated, "It is for Metropolol, but I can't read the dosage. I would have to call the provider to clarify the order." Staff #30 was asked again who wrote and signed the order. Staff #30 stated, "It looks like it is Staff #11 and he signed on top of the nurses signature, so it really isn't clear who wrote the order, but I know who's handwriting it is."

Further review of the document revealed no clearly defined physician signature for the medication order.

Staff #30 confirmed the above findings.


PATIENT #2

A review of Patient #2's medical record revealed a verbal order given by Staff #11 was written by Staff #32 on 12/04/2019 at 2:30 PM. Further review of Patient #2's medical record revealed Staff #11 had not authenticated the verbal order as of 12/11/2019. That is 3 days late per the facility policy for verbal orders.

Additional review of Patient #2's medical record revealed a verbal order given by Staff #11 was written by Staff #30 on 12/04/2019 at 11:15 AM. Patient #2's medical record revealed Staff #11 had not authenticated the verbal order as of 12/11/2019. That is 4 days late per facility policy for verbal orders.

Staff #30 and #5 confirmed the above findings.



PATIENT #4

A review of Patient #4's medical record revealed a verbal order was given by Staff #3 to Staff #32 on 11/29/2019 at 4:20 PM. Staff #5 was asked to review the verbal order and confirm when the provider authenticated the order. Staff #5 stated, "That is Staff #3 that signed the order, but he did not date or time it."

A verbal order was given by Staff #3 to Staff #32 on 11/30/2019 at 11:20 AM. Staff #3 authenticated the verbal order on 12/10/2019 at 5:11 AM. This is 6 days late according to the facility policy.

An order was written on 12/02/2019 at 6:00 AM. Staff #8 was asked if the order was signed by the provider. Staff #8 stated, "It looks like he signed in the nurses name but there is no date or time that he signed it. He has trouble with his handwriting and you can't read what he writes most of the time. We have brought this to the attention of Staff #4 and Staff #5."


Staff #5 and #8 confirmed the above findings.



PATIENT #9

A review of Patient #9's medical record revealed a verbal order was given by Staff #3 to the nursing staff on 8/6/2019 at 4:30 PM for Preparation H (a cream used to treat hemorrhoids).

Staff #8 was asked when the order was authenticated. Staff #8 said, "The provider did not date or time his signature, so I have no way of knowing when the order was signed."



PATIENT #10

A review of Patient #10's medical record revealed a verbal order was given by Staff #3 to the nursing staff on 9/01/2019 at 11:15 AM. Further review revealed a verbal order from Staff #3 was also given to the nursing staff on 8/27/2019 at 6:20 PM.

An interview was conducted with Staff #8 on 12/10/2019 after 9:00 AM. Staff #8 was asked when the verbal order was authenticated. Staff #8 stated, "The provider did not write a date or time on the day he signed the verbal order." Staff #8 was asked how the facility monitors verbal orders and ensure they are being signed according to the facility policy. Staff #8 stated, "There really is no tracking of this. Most of the time I don't know they are delinquent on signing orders until I receive the chart when the patient has been discharged. When I get them, I look through the medical record for completeness and I will flag anything outstanding and notify the provider."

Staff #5 and #8 confirmed the above findings.



A review of the Policy titled, "VERBAL ORDERS POLICY NUMBER: HIM-01.11" was as follows:

" ...PROCEDURE:

4. Verbal orders should be authenticated by the prescriber within the timeframes specific to the state in which the order is executed.

Texas=within 96 hours of date order is given; with the exception of the admit order which if given verbally must be authenticated within 24 hours ..."

Staff #4 and #5 confirmed the above findings.

Based on observation, review of documents, and interview, the facility failed to ensure that approved Pharmacy Policies pertaining to the hospital's Pharmaceutical Services were readily available to hospital staff, including Medical Staff and Administrative Staff. This deficient practice had the potential for harm to all patients in the hospital. Incomplete, outdated, and/or unapproved policies have the potential to create a condition where serious medication errors could occur.

Findings:

During the entrance conference on 12-9-2019, Staff #5 and Staff #6 were provided with a document request list that included a request for the Table of Contents for approved Pharmacy Services Policies and Procedures. A table of contents for approved Pharmacy Services Policies and Procedures was never provided during the survey.

On 12-10-2019, provided copies of Policy Number: MM-01 titled Medications, Policy Number: MM-07 titled Multiple and Single Dose Medication Vials, Policy Number: MM-09 titled Adverse Drug Reactions/Incompatibilities/Events, and Policy Number: MM-30 Antimicrobial Stewardship. Staff #31, a corporate director was interviewed about the inability of hospital staff to provide a table of contents and/or polices. Staff #31 stated that a table of contents could be provided. A document was provided that was titled "Table of Contents for Oceans Policy Manual". The section titled Medication Management listed 19 policies related to Pharmaceutical Services, but did not list all Pharmacy Policies.

Review of the contract for Pharmacy Services revealed that the contractor was to provide policies for the contracted hospital services. Staff #31 contacted the contracted Pharmacist and copies of policies were provided. The policies were numbered PH.1 through PH.105. All policies had an effective date of 11/2019. All policies showed that they were "Approved By: Pharmacy and Therapeutics." None of the policies contained information that the policies were approved for use at Oceans Behavioral Hospital of Lufkin. Review of the policies showed that where hospital names should be, the policy stated, "INSERT NAME HERE". Several policies were shown to have the name of a Critical Access Hospital from another part of Texas in it.

On 12-11-2019, Staff #4 and Staff #31 were notified that the policies provided were incomplete and without evidence that the policies were for Oceans Behavioral Hospital of Lufkin. Staff #4 and Staff #31 were asked to provide evidence that the policies had been approved by the governing body for use in Oceans Behavioral Hospital of Lufkin. Staff #4 provided a binder of Pharmacy Policies and stated that these were the original set of Pharmacy Policies that had been approved for Oceans Behavioral Hospital of Lufkin.

The binder did not contain a Table of Contents. Review of the policies showed that the headers of the policies were for "OBH Lufkin Luker Pharmacy Management". Policies were numbered as follows:
PH074 through PH078
PH080 through PH087
PH090 through PH091
PH093 through PH103
PH200 through PH202
PH300 through PH302
PH400 through PH402
PH405 through PH407
PH410
PH500 through PH502
PH600 through PH601
PH700 through PH701
un-numbered policy "Subject: Safety: Equipment and Devices"
PH704 through PH707

The policies all had an "Originated Date" of 1/2015. The "Current Reviewed/Revised Date:" was left blank. The policies did not include information on who approved the policies for use or a date of approval for use. The numbering of policies did not match the numbering of previous policies provided that only went to PH105. The effective dates of 11-2019 on the previous policies superseded the 1/2015 dates of the policies in the binder.

Two policies numbered TX-MED-11 Monitoring of High Risk/High Alert Medication and TX-MED-12 Look-Alike Sound-Alike Medications were found in the binder with an Oceans review date of 9/2013. Review of the Table of Contents for Oceans Policy Manual indicated these policies were replaced by MM-11 Monitoring of High Risk/High Alert Medication and MM-12 Handling of Look-Alike Medications but had not been removed and replaced in the binder.

On 12/13/2019, Staff #4 provided a stack of policies and stated that they were all of the Pharmaceutical Services Policies that were currently approved for Oceans Behavioral Hospital of Lufkin. The "Policy Number:" line on the header was blank on all of the policies. The header had a picture logo that said, "Oceans Behavioral Hospital." Oceans Behavioral Hospitals had many facilities across Texas. The header of the policies did not contain information on who approved the policies for use at Oceans Behavioral Hospital of Lufkin. The policies were as identified as follows:

Formulary Revision; Origination Date: Jan 2014; Effective Date: Jan 2014; Review Date: Jan 2018

Adverse Drug Reactions and Medication Errors; Origination Date: Jan 2014; Effective Date: Jan 2014; Review Date: Jan 2018.

Automatic Stop Orders; Origination Date: Jan 2014; Effective Date: Jan 2014; Review Date: Jan 2018

Clozapine REMS; Origination Date: Jan 2016; Effective Date: Jan 2016; Review Date: Jan 2019

Definition of Terms; Origination Date: Jan 2014; Effective Date: Jan 2014; Review Date: July 2016

Disaster Preparedness; Origination Date: Jan 2014; Effective Date: Jan 2014; Review Date: July 2016

Downtime Procedures; Origination Date: Jan 2014; Effective Date: Jan 2014; Review Date: July 2019

Equipment, Devices, & Supplies; Origination Date: Jan 2014; Effective Date: Jan 2014; Review Date: July 2016

Glossary; Origination Date: Jan 2014; Effective Date: Jan 2014; Review Date: July 2016

Hazardous Drugs; Origination Date: Jan 2014; Effective Date: Jan 2014; Review Date: December 2017

Home Medication Use; Origination Date: Jan 2014; Effective Date: Jan 2014; Review Date: July 2016

Licenses; Origination Date: Jan 2014; Effective Date: Jan 2014; Review Date: July 2016

Pharmacist in Charge; Origination Date: Jan 2014; Effective Date: Jan 2014; Review Date: July 2016

Pharmacy & Therapeutics Committee; Origination Date: Jan 2014; Effective Date: Jan 2014; Review Date: July 2016

Pharmacy Security; Origination Date: Jan 2014; Effective Date: Jan 2014; Review Date: January 2018

Reference Materials; Origination Date: Jan 2014; Effective Date: Jan 2014; Review Date: Jan 2018

Sanitation - Environment; Origination Date: Jan 2014; Effective Date: Jan 2014; Review Date: July 2016

Scope of Services; Origination Date: Jan 2014; Effective Date: Jan 2014; Review Date: July 2016

Security of Medication Storage & Preparation Areas; Origination Date: Jan 2014; Effective Date: Jan 2014; Review Date: July 2016

Unusable Medication Stock; Origination Date: Jan 2014; Effective Date: Jan 2014; Review Date: July 2016

The last set of policies provided, as listed above, were found to be incomplete for the management of Pharmaceutical Services. Some of the areas not addressed were as follows:

Policies did not address the record keeping, dispensing, and control of scheduled medications to include the destruction/wasting of scheduled medications or process for return of scheduled medications.

Policies did not address the standardization of prescribing and communication practices such dangerous abbreviations, elements of the order (dose, strength, units, route, frequency, rate) or the process for pharmacy to clarify orders.

Policies did not address monitoring and managing drug alerts and recalls.

Policies did not address the Automated Medication Dispense system to include removing of medication, returning medications, and documenting the waste of medications.

Policies did not address the use of floor stock medications, to include a list of medications that could be used as floor stock, levels of floor stock allowed to be kept on hand, or record keeping for the removal and use of floor stock.

Policies did not address establishing beyond use dates when floor stock medications were opened for multiple patient use.

Based on observation, review of documents, and interview, the facility failed to ensure that:

A) outdated and improperly labeled drugs were removed from stock in 1 of 1 drug storage area (nursing station medication room)

B) policy and procedures were developed and used to manage the labeling of time-frame for use for bottles of medication to be used for more than one patient, along with records for the management/dispensing/administration of those medications commonly referred to as Floor Stock medications. (Floor Stock is typically defined as prescription or over-the-counter medications or devices maintained in a part of the hospital other than pharmacy and not labeled for a specific patient use)

Findings:

On 12-11-2019, the following observations were made in the nursing station medication room with Staff #32 present.

A tube of Zinc Oxide Ointment was found in the medication room. The tube had been opened and used. The tube did not have a label indicating it was for a specific patient or a date opened so that it could be used as a multi-dose medication for different patients.

Two bottles of 81 milligram strength aspirin were found opened in the medication room. The bottles did not have a label indicating they were for a specific patient or a date opened so that they could be used as a multi-dose medication for different patients.

One bottle of Bausch+Lomb PreserVision Eye Vitamin & Mineral Supplement was found to be opened in the medication room. The bottle did not have a label indicating it was for a specific patient or a date opened so that it could be used as a multi-dose medication for different patients.

A bottle of the sleep supplement, Melatonin, was found to be opened in the medication room. The bottle did not have a label indicating it was for a specific patient or a date opened so that it could be used as a multi-dose medication for different patients.

Three bottles of Magnesium Citrate Saline Laxative were found in the medication room with an expiration date of 11-2019.

Staff #32 was interviewed during the observations. Staff #32 was asked if there was a list of medications that had been approved to be used for multiple patients (typically referred to as Floor Stock). Staff #32 was not able to provide a list of approved Floor Stock inventory or any forms that accounted for the inventory dispensing such as documenting who removed the medication; for which patient the medications was removed; etc.

A review was made of Oceans Healthcare policy titled Medications; Revised Date: 10/01/2018; Policy Number: MM-01 was made. The Purpose was as follows:

"To establish protocols for inpatient medications related to:
Ordering
Dispensing
Labeling
Storage
Transcription
Administration
Documentation"

During the review, no protocol or process was found for the management of Floor Stock. Review of the contract for Pharmacy Services revealed that the contractor was to provide policies for the contracted hospital services. Staff #31 was asked to provide the contractor's policies that had been approved for use at the hospital. Three sets of contractor policies were provided. The hospital was not able to provide evidence that policies from the contractor had been approved or which set was being used. (Cross refer to TAG A0491 for detailed findings on Pharmacy Policies)

An interview was conducted with the consulting pharmacist, Staff #28 on 12-12-2019. Staff #28 stated he was not aware that there was Floor Stock medications in the cabinets of the nursing medication room and had not been managing them.

Based on a review of documents and interview, the facility failed to ensure that a functioning Utilization Review (UR) plan was in effect for the review of services provided. No evidence of physician oversight and involvement in the UR function was found.

Findings:

Review of the past 5 Utilization Review Committee meeting minutes was made. The UR Committee met on the following dates:

October 29, 2018
January 30, 2019
April 30, 2019
August 6, 2019
October 8, 2019

During that time-frame, no physician had ever been present at any of the meetings. No evidence was presented of physician oversight and review of appropriateness of admissions, length of stay, patient care provided for quality of care, over-utilization of services, under-utilization of services, or other UR functions. Review of meeting minutes showed that only one physician was assigned to the UR Committee, Staff #12.

During interview with Staff #12 on the morning of 12-12-2019, Staff #12 confirmed that charts had not been reviewed during the time frame of October 29, 2018 to current for the quality of care, over-utilization of services, under-utilization of services, or other UR functions. Staff #12 confirmed that she was the only physician assigned to the committee. Staff #12 explained that due to the small size of the hospital's medical staff, no other physician was available to review psychiatric care.

Interview with Staff #4 confirmed that the UR function had not been delegated to any outside group for review due to the small size of the hospital's medical staff.

Review of Oceans Behavioral Hospital Medical Staff Bylaws, Article IV Committees and Functions, Section 3: Utilization Review Committee on page 17 of 80 was as follows:

"A. Composition: The Utilization Review Committee shall be composed of the Medical Director (who will serve as the chairman), on additional MEC committee member, Quality Director, Infection Control Coordinator, Director of Nursing, Administrator, Health Information Director, Clinical/Program Director, and any other individuals the chairman deems appropriate.

B. Responsibilities: The Utilization Review Committee shall:

(1) Comply with all requirements of the utilization review plan recommended by the Medical Staff and approved by the Board;

(2) Require documentation that utilization review is applied regardless of payment source;

(3) Monitor and evaluate objective clinical data regarding practice patterns and prepare such reports as may be required;

(4) Require that focused reviews be emphasized; and

(5) Determine whether under-utilization and, when appropriate, over-utilization on practice impact adversely on the quality of patient care and recommend the appropriate action to be taken.


C. Meetings: The Utilization Review Committee shall meet quarterly or as often as necessary to accomplish its functions as agreed to by the Chairman and Administrator."

Review of the "Plan for Utilization Review", Policy Number PC-00.01, Revised Date: 02/01/2017, was provided by the facility. This policy contradicted the Medical Staff Bylaws by assigning the responsibility of Utilization Review Committee Chairman to the Utilization Review Coordinator.

Based on observation, review of records, and interview, the facility failed to:

A) ensure that policies and procedures were developed and implemented to ensure equipment on 1 of 2 emergency carts (Cart in Admission Examination Room) were plugged into an electrical outlet supplied by emergency power source. This deficient practice had the potential to prevent emergency equipment necessary for patient care from operating properly in an emergency situation if power were interrupted.

B) ensure 3 out 4 call bells located at patient bedsides in 2 of the patient rooms (Rooms 6 and 8) were in working order. This deficient practice had the potential to harm patients by depriving them of a means to call for help from nursing staff if needed.

Findings for A):

On the afternoon of 12-9-2019, a tour of the Admissions Examination Room was made with Staff #5 present. An emergency equipment and supply cart (Crash Cart) was observed with equipment plugged into a standard electrical outlet. Review of the equipment and supply cart checklist log book included an instruction sheet that said:

"Notice to Staff:

Effective immediately the Crash Cart will be checked and signed off jointly every night by the Charge Nurse RN (registered nurse) and the LVN (licensed vocational nurse).

The nightly Crash Cart Check must include checking to make sure the equipment is plugged into a red plug and the completion of the check-off list."


Staff #5 was interviewed at the time of the observation. Staff #5 confirmed that emergency equipment on the cart was supposed to be plugged into a red plug.

Neither the hospital policy, procedures, or form to be checked off by the staff addressed the need for equipment to be plugged into a red outlet. Red outlets with red covers indicated that the outlet was connected to an emergency power source and would continue to power equipment in the event of a power outage.

Review of the Policy Number: CS-28, titled Emergency Cart, was as follows:

"Purpose:

To provide access to life support medical equipment, the facility has made available an emergency cart to house needed supplies.


Procedure:

Charge Nurse is responsible for restocking the emergency chart (sic) for any used items immediately after use during an emergency.

Nursing Staff (Night Shift)
Inspect the emergency cart daily and document findings on Ready for Use checklist.

Checks, stocks, and cleans the emergency cart.

Notifies the DON (director of nursing) and supply clerk for missing or expired items to be restocked."


Review of the check-off list for the month of December contained the following instructions:

"Nightly check each item in block and sign signature line. Check for expiration date and replace expired items."

The items listed in the blocks did not include a spot for staff to document that the equipment on the cart was plugged into a red plug.


Findings for B):

On the afternoon of 12-9-2019, a tour of patient rooms was made with Staff #5 and #9 present. During the tour, call bells were observed to be fixed to the nightstands next to patient beds. When the call bells were checked for operation in rooms #6 and #8, three of the four call bells checked did not make any sound to alert staff that a patient needed assistance. This was confirmed by Staff #5.

Review of Policy Number: AS-24, titled Use of Nurse Call System, was as follows:

"Purpose:
To ensure safe and therapeutic environment for all patients by providing a mechanism for patients to alert staff for assistance.

Policy:
It is the policy to provide call bells in rooms for patients to utilize as a means to contact staff.

Procedures:

Maintenance:

1. Secure call bell to designated bedside tables.

2. Ensure all call systems are intact and working properly.

Nursing Staff:

1. Educate patients regarding use of call bells or call system.

2. Instructs patient on how to use call bell or alter staff for assistance when assistance is needed in the event the patient becomes weak, dizzy, lightheaded, or distressed in any way.

3. Performs rounds to ensure that the call bells are within reach of patients who have physical circumstances that require greater assistance.

4. Reinforces use of the call bell for Fall Risk Patients."

Based on observation and interview, the facility failed to maintain a sanitary environment in 12 of 12 areas of the hospital observed (Day Room, Patient Bathrooms, Patient Bedrooms, Admission Exam Room, Hallway Housekeeping/Maintenance Closets, Dining Area/Group Room, Nutrition Room, Emergency Exam Room, Clean Medical Supply Room, Kitchen, Supply Room, and Seclusion Room Toilet area)


Findings:

A tour of the facility was made on 12-9-2019 with Staff #4, Staff #5, and Staff #9 present during the tour. The following unsanitary conditions were observed.

Day Room

A wooden piano was observed in the patient day room The finish on the wood was observed to be deteriorated, leaving a porous surface. The surface was observed to have moisture stains. The piano keys were observed to be visibly dirty. Porous wood surfaces could absorb and hold moisture which could promote the growth and spread of harmful bacteria, mold, mildew, and viruses.


Patient Bathrooms and Bedrooms

A tour of patient bathrooms in rooms #6 and #8 revealed that the metal finishes inside of the shower stalls on handrails, faucet handles, and shower heads were corroded and had heavy buildup of dirt and mineral deposits. These surfaces left in this condition, along with the moisture from the shower, could provide an environment for the growth and spread of harmful bacteria, mold, mildew, and viruses. Ceiling air vents in the patient bedrooms and bathrooms were observed to be visibly soiled with what appeared to be mold growth (circular clusters of dark matter) on them.

During interview with Staff #4, Staff #4 confirmed that the air-conditioning system had been found to have moisture problems. Purchase orders had been placed and the hospital was waiting on the contractor to make necessary repairs. However, steps had not been taken to ensure the vents were cleaned regularly to prevent the build-up of dark matter on the vents with potential for it to become airborne.


32143


Admissions Exam Room

The metal handles on the cabinets were rusted and corroded.

The floor lamp was soiled with dust and dirt. The floor under the lamp was soiled with dust and dirt.

The reclining chair in the exam room was soiled with dust, dirt, paper clips and trash on the top and underneath.

The air vent in the ceiling was mildewed.


Hallway Housekeeping/Maintenance Closets

In the housekeeping closet multiple items were found. A metal shelf was found with bagged up linen and rags, trash was found on the floor. Liquid cleaning products were found on the floor. Card board boxes, a vacuum cleaner, a Christmas tree box and cloth bags sitting next to a heavily soiled mop pan.

The electrical/ heating unit maintenance closets had multiple items stored in the closets. Dry erase boards. Boxes and linen were found.


Dining Area/Group Room

A vinyl chair in the dining room was found torn.


Nutrition Room

An ice chest was found filled with ice. The cooler was soiled on the inside and outside.

The ice scoop container was attached to a metal cart underneath the soiled cooler. The scoop was removed, and the bottom was soiled with mildew and mold.

The trash can was heavily soiled on the outside with dried liquids, dirt, and dust.

The coffee pot holder was found heavily stained and soiled on the inside.


Emergency Exam Room

Two rolling blood pressure machines were found heavily soiled with dust, dirt, old tape, Rusted and missing paint.

The metal trash can was found to be soiled on the outside with rust, dirt, and dust. The inside had trash that had not been emptied.


Patient Bedrooms

In all the patient rooms, plastic clocks were found on the wall. The surveyor removed the clocks and the batteries were exposed.


Clean Medical Supply Room

A heavily soiled plastic caddy was found. The caddy had blood draw supplies on the inside. Under the supplies was dust, dirt, hair, trash, and rubber bands. The outside of the caddy was soiled with dirt and old stickers and tape residue.

Plastic containers with drawers were found. The containers were soiled with dust and hair.


Kitchen

The refrigerator and freezer had corrugated shipping boxes found sitting next to unboxed food causing the food to be exposed to any contaminates on the boxes.

The 3-sink basin dishwashing system was used to clean, rinse, and sanitize in kitchens. Automatic dispensing systems accurately deliver correct levels of sanitizer ensuring health code compliance. Test strips & sanitizer test are used to confirm sanitizer concentration levels and regulatory compliance. The test strips in the kitchen were expired since 8-2019. The kitchen staff were unable to ensure the right amount of sanitizer had been used.

The metal base of the small cooler had a grated base. The grated base was heavily soiled with clumps of dust and dirt.


40989

Supply Closet

Metal shelves were observed in the supply closet with no protective bottom barrier. On these shelves was patient equipment. There was no way to identify the clean from the dirty equipment. The floor was covered with dirt, dust, and trash.. Without a bottom barrier, contaminated water can splash on to patient equipment increasing the risk of spreading infectious diseases between patients. In the corner nearest the door, there was an old tongue depressor and a dead bug on the floor.


Seclusion Room Toilet Area

Behind the toilet, on the wall above the metal plate, paint was missing and exposing the sheetrock. The porous surface could not be properly sanitized. On the floor behind the toilet was a dead bug, dirt, and dust.


Staff #9, #4, and #5 confirmed the above findings.

Based on document review and interview, the facility failed to:


1. ensure Respiratory Care Services was integrated into the Quality Assessment Process Improvement (QAPI) program.


2. have an organized Respiratory Service Department to meet the needs of patients who require respiratory care.


3. appoint a qualified respiratory services director to have oversight and administer the services properly.



Cross refer to Tag A1152 and A1153

Based on interview the facility failed to have an organized respiratory services department to offer the services according to the acceptable standards of practice.


Findings:


An interview was conducted on 12/10/2019, after 12:00 PM, with Staff #4 and #5. Staff #5 was asked if the facility had a respiratory services department. Staff #4 replied, "No, we do not have a Respiratory Department, but our physicians do have privileges to order the services if the patients need them. We call one of the doctors if there are any problems. Most of the time it is just breathing treatments that the patients are getting and occasionally we will have a patient that requires oxygen but only by nasal cannula." Staff #4 was asked if the facility contracted with a respiratory therapist. Staff #4 said, "No we do not have a contract with a respiratory therapist."


Staff #4 and #5 confirmed the above.

Based on document review and interview, the facility failed to ensure a physician was appointed as director of respiratory care services to ensure services provided were appropriate to the scope of patients served and were administered properly


Findings:


A review of the physician staff roster did not reveal an identifiable director of respiratory care.


An interview was conducted on 12/11/2019 at 3:30 PM with Staff #4. Staff #4 was asked who was appointed by the Medical Staff as the Respiratory Director. Staff #4 stated "We have not appointed a physician to oversee the respiratory services and I know we need to do that. Staff #12 does oversee the respiratory services but there has not been an appointment by the medical staff."


A review of Staff #12's credentialing file was completed on 12/12/2019 after 9:00 AM. No documentation was located within the credential file or provided for review stating Staff #12 had been appointed as the Respirator Services Director.


A review of the policy titled, PROVISION OF CARE FOR RESPIRATORY SERVICES, POLICY NUMBER: NSG-50, revealed the following:

" ...PROCEDURE:

1. Respiratory Care Services provided at the facility are directed by the consulting medical physician, who is a doctor of medicine or osteopathy.

2. The consulting medical physician is a member of Medical Staff at the Facility and has experience, knowledge, and capabilities related to supervision and delivery of the services provided ..."


Staff #4 confirmed the above findings.