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Based on record review and interview, the facility failed to ensure Patient #1's medical record documented the information necessary to monitor the patient's condition.
Specifically, patient #1's record did not contain the following:
1.) Documentation of the meal intake for each meal; in accordance with the Physician Orders (PO's).
2.) Documentation of the Individual Observation records (15 minute documented checks); in accordance with the PO's.
3.) Completion/documentation on the Personal Belongings Inventory record of Patient #1's listed personal belongings to include the disposition; date returned and time.

Findings included:

Review of the Texas Health and Human Services Commission (HHSC) Complaint Form, Intake #TX00294831 revealed Patient #1's family member reported complaints against the facility indicated the following on behalf of Patient #1:

A.) Prior to admission to the facility; on 3/26/18, patient was eating at a cognitive/normal level. By the third day (3/29/18) from admission, Patient #1 "was so disoriented from her medication that it induced a loss of appetite and she had to be spoon fed." On 3/29/18 during Patient #1's family visitation during lunch, she was refusing to eat.

B.) On 3/26/18 Patient #1 fell resulting in bruising on the back of her head and forehead. Patient #1 was sent to the hospital for a Computed Tomography (CT) scan of the head on 3/27/18 due to the fall. Family does not know all the details of the fall.

C.) The family requested discharge for Patient #1 on 3/29/18 and upon discharge; staff had "misplaced the clothes" that had been previously requested to bring to the facility, and Patient #1 was "found in someone else's clothes."

Review of Patient #1's record revealed the following:

A.) History and Physical dated 3/27/18 indicated Patient #1 was a 79-year old admitted to the behavioral health center with a history of dementia decompensations, history of diabetes and hypertension; blood sugars are severely uncontrolled.

B.) 1.) Review of the Physician Orders dated 3/26/18 for Patient #1 included;
a.) "3 main Meals, 1 snack."
b.) "CareMobile Intake and Output" - Patient care monitoring
c.) "CareMobile Individual Observation Record" Patient care monitoring

2.) Review of the Meal Intakes/Nutritional documentation indicated the following from the Certified Nursing Assistant's (CNA's):
a.) 3/27/18 - Lunch- No documentation of percentages of meal intake.
b.) 3/28/18 - Breakfast- 0% Percentage of intake documented.
c.) 3/28/18 - Lunch- 0% Percentage of intake documented.
d.) 3/28/18 - Dinner- No documentation of percentage of meal intake.
d.) 3/29/18 - Breakfast 0% Percentage of intake documented.

3.) Review of Patient #1's permanent medical record, MRN #00102406 revealed the Individual Observation Record- (15 minute documented checks) for the Patient care monitoring was not available.

C.) Review of the Personal Belongings Inventory Forms dated 3/26/18, 3/27/18, and 3/29/18 documented specific items of clothing received. The "Date Returned and Time" were blank for the Inventory Forms dated 3/27/18 and 3/29/18.

Review of facility Standard Operation Procedure (SOP) for Inventory Process of clothing and objects, effective 6/29/18 indicated an inventory of clothing and objects were to be completed for items being dropped off for the patient admitted to the Behavioral Hospital. An inventory sheet will be completed documenting the patient belongings on the inventory sheet. Further review revealed there was no further discussion for the disposition or documentation of the patient's belongings upon return to the patient and/or discharge of the patient from the facility.

During an interview on 11/28/18 at 10:00 AM with Charge Registered Nurse (RN)- A stated the nursing staff were to monitor the patient's meal intake during meals and the CNA's would document in the computer for I and O (input and output). RN-A also stated the CNA's would document on a form that was kept in the dining room. RN-A further indicated that when patients were discharged from the facility, the techs were to get the inventory sheet; complete it, and have the patient and/or family sign when receiving the belongings back.

During an interview on 11/28/18 at 11:30 AM with the Behavioral Health Director (BHD) stated the Individual Observation records (15 minute documented checks) for Patient #1 were not available and were not made part of the record because the documented checks were combined on one page/form with multiple patients listed on that one form. The BHD confirmed the meal intake record for Patient #1 was incomplete and not documented for two meals; on 3/27/18 and 3/28/18. The BHD also confirmed the clothing record inventory for Patient #1 was incomplete upon discharge to include the disposition of her belongings for forms dated 3/27/18 and 3/29/18.