HospitalInspections.org

Based on review and interview the facility failed to:

1.
provide the second Important Message from Medicare (IMM) letter at discharge for 1 of 1(#1) patient charts reviewed. The facility failed to have a signed document or documentation that the patient's rights were explained or offered in 5 of 5 (#1,4,5,6, and 7) patient charts reviewed.

Refer to A117

2.
follow its own policy and procedure for complaints and grievances. The facility failed to provide written documentation that the patients received patient rights, how to make a complaint or grievance, and failed to provide the patient with phone numbers for the state or the deemed entity to make a complaint in 5 of 5 (#1,4,5,6, and 7) patient charts reviewed.

Refer to A118


3.

A. recognize that medications administered to restrain a patient's behavior, resulting in restricting the patient's freedom of movement, was a Chemical Restraint/Emergency Behavioral Medication (EBM) administration.

B. recognize that psychotropic medications administered were chemical restraints and not therapeutic treatments in 2 of 2 (#4 and 5) patient charts reviewed.

C. ensure staff conducted comprehensive patient assessments with the escalation of behavior to determine patient needs and interventions prior to the administration of chemical restraints/emergency behavioral medication, and continuous monitoring after administering a chemical restraint/emergency behavioral medication for side effects, respiratory or cardiac distress, and assessment of medication effectiveness and safety after administration in 2 of 2 (#4 and 5) patient charts reviewed.

Refer to A160

Based on review and interview the facility failed to provide the second "Important Message from Medicare" (IMM) letter at discharge in 1 of 1 (#1) patient charts reviewed. The facility failed to have a signed document or documentation that the patient's rights were explained or offered in 5 of 5 (#1,4,5,6, and 7) patient charts reviewed.

A review of patient #1's chart revealed the patient was given his first IMM letter on admission dated 10/19/22. A review of the chart revealed there was no second IMM letter in the chart for his discharge. There was no documentation that the patient was informed of the IMM process.

A review of patient charts #1,4,5,6, and 7 revealed there was no signed document or documentation that the patient's rights were explained or offered.

On 3/24/23 Staff #2 provided an email that stated, "We have reviewed the process with our registration staff related to patient rights, Privacy Practice, HIPAA, and general consents. All are to be signed electronically at the time of registration by a competent patient and then populate to the medical record. In the charts we reviewed during survey, we are unable to evidence that this process was followed, so we are working with the teams now to ensure they understand the process and complete the process every time."

Based on review and interview the facility failed to follow its own policy and procedure for complaints and grievances. The facility failed to provide written documentation that the patients received patient rights, how to make a complaint or grievance, and failed to provide the patient numbers for the state or the deemed entity to make a complaint in 5 of 5 (#1,4,5,6, and 7) patient charts reviewed.

A review of patient #1's chart revealed he was admitted to the facility on 10/19/22 for acute chronic hypoxemia and hypercarbia respiratory failure, Spiculated left upper lobe lung mass and COPD exacerbation.

A review of the nurse's notes revealed staff #18 documented on 10/28/2022 at 10:30PM. "Family member asked me to step out of room. Proceeded to inform me that I had been disrespectful for calling pt "darlin". Immediately apologized but family member was very upset and proceeded to state she was also upset with asking her questions about patients care. Again apologized and explained I was trying to involve her and make sure she was comfortable with the care he was receiving and particular timing of care. Family requests at this time to "just do our job when its time and dont ask her questions", also to "always address the patient as only ____ (pts. name)". Daughter also stated she would be notifying _____ (Staff #5) and filing a complaint. Charge nurse _____ present for conversation."A review of the complaint log revealed there were no complaints or grievances from patient #1 or his family documented.

An interview with Staff #5, #2, #7, and #3 was conducted on 3/20/23 in the afternoon. Staff #3 stated the facility had a Risk Manager that was also the patient advocate but had quit in December 2022. The facility "system" administrators felt that there was no need for that position and chose not to replace the Risk Manager/Patient Advocate. Staff #3 stated that the Tyler system hospital was to take on that responsibility. (The facility and Tyler facility are in the same hospital system but are separately licensed and deemed facilities.) Staff #3 stated that the staff should put a complaint or grievance into the computer "TRIDEO" system. This was then followed by the Risk Manager located in Tyler. The reporting facility (UT Carthage) staff would have to get an email from the Tyler risk manager because they did not get alerts from TRIDEO. After receiving an email from the Risk manager in Tyler, the staff directors investigated and would send an email back. The staff of the facility did not address the issue in TRIDEO. Staff #3 and #2 confirmed there was no designated person at the facility that was a patient advocate and responsible for addressing the complaints and grievance process. Staff #3 confirmed patients had not been given their patient rights, appropriate information on how to file a complaint or grievance, or numbers for the State of Texas or deeming entity to file a complaint.

Staff #5 stated the family of patient #1 made multiple complaints during the hospitalization and were difficult to deal with. Staff #5 confirmed that the complaints made by the family were not resolved immediately. Staff #5 was asked why a complaint or grievance was not logged. Staff #5 stated that she had talked to the family the next day and didn't think it needed to be written up. Staff #7 confirmed the RT staff had experienced complaints and noncompliance from the family and had documented it in the chart. Staff #7 stated that she had to talk with the family several times. Staff #7 confirmed that she had not logged a complaint or grievance into the system. Staff #5 and #7 confirmed that they did not know the difference between a complaint and a grievance and were not able to speak to the policy and procedure.

An interview was conducted with staff #11 RN on 3/21/23 at 10:20 AM. Staff #11 stated that she would just report a complaint to her supervisor. Staff # 11 stated that she thought the TRIDEO system was just for incident reports and not for complaints or grievances.

A review of the policy and procedure, "Complaint/Grievance Policy" stated,
"Purpose: To establish a process to address, respond, resolve, and track patient complaints and grievances.
Definitions: 1) Complaint means an oral or written expression of displeasure or dissatisfaction with service received that can be immediately resolved by the staff present. 2) Grievance means written or verbal complaint by a patient, or the patient's representative, regarding the patient's care (when the complaint has not been resolved at that time by staff present), abuse or neglect, or the hospital's compliance with the CMS Hospital Conditions of Participation (CoP) ...
Complaint & Grievance Process
1) Processing a Grievance
a) All formal and informal grievances will be investigated to determine if opportunities exist to improve processes and systems related to the issues reported. The following are the steps used to process a grievance within the determined timeframes: i) The grievance will be dated using the date of receipt.
ii) The grievance will be placed on a patient grievance tracking log.
iii) Assignments for investigation and/or action will be made.
iv) The patient and or patient's representative, in accordance with the HIPAA Process for Release of Protected Health Information policy, will receive written communication from the organization within 7 days of the receipt of the grievance.
This written communication shall outline the results of the investigation and actions taken therein.
b) Note: When a grievance will not be resolved or the investigation is not or will not be completed within the 7-day timeframe, the patient or patient's representative will be informed, in writing, of the status of their grievance and inform them that they will receive follow up in the form of a written response within 45 days.
c) The final written response will include: i) Date of receipt of grievance ii) Name of the Hospital contact person for the patient to follow up with if needed iii) Steps taken to investigate iv) Results of investigation v) Completion date
d) Note: A grievance is considered resolved when the patient is satisfied with the actions taken on their behalf. In situations where the organization has taken appropriate and reasonable actions on the patient's behalf in order to resolve the grievance and the patient or the patient's representative remains unsatisfied with the actions taken, the organization will consider the grievance closed.
2) Processing a Complaint
a) Complaints given to staff members by patients, or their representatives should be addressed in a timely manner and an attempt to resolve the issue, by staff present, should be made. If resolution is achieved, then no further action is required, the complaint and actions taken to resolve should be entered into the complaint tracking system, however, if resolution is not achieved after attempts have been made to resolve the complaint it should be forwarded to the Patient Advocate or Quality Representative. Unresolved complaints or those requiring additional investigation or intervention should be listed on the Patient grievance tracking log as a grievance for reporting purposes ..."

Based on review and interview the facility failed to:

A. recognize that medications administered to restrain a patient's behavior, resulting in restricting the patient's freedom of movement, was a Chemical Restraint/Emergency Behavioral Medication (EBM) administration.

B. recognize that psychotropic medications administered were chemical restraints and not therapeutic treatments in 2 of 2 (#4 and 5) patient charts reviewed.

C. ensure staff conducted comprehensive patient assessments with the escalation of behavior to determine patient needs and interventions prior to the administration of chemical restraints/emergency behavioral medication, and continuous monitoring after administering a chemical restraint/emergency behavioral medication for side effects, respiratory or cardiac distress, and assessment of medication effectiveness and safety after administration in 2 of 2 (#4 and 5) patient charts reviewed.

Patient #4
A review of patient #4's chart revealed he came into the Emergency Room (ER) on 03/18/2023 7:20PM via ambulance for a Psychiatric Evaluation Visit. A review of the physician progress note dated 3/18/23 at 7:20PM stated, "diagnoses: Schizophrenia, unspecified type (HCC) (primary), Methamphetamine use, and History of medication noncompliance.

47-year-old male with a past medical history of schizophrenia and previous history of methamphetamine abuse presents to the emergency department via EMS for a mental health evaluation. The patient's sitter called EMS due to the patient's recent history of being confused, talking to himself, and experiencing visual hallucinations. The patient apparently has not been taking his medication appropriately for schizophrenia for approximately 1 month. The patient also admits to recent use of methamphetamines. Admits also to have the visual hallucinations of seeing "demons that crawled inside of him". Positive for hallucinations.
Neurological:
Mental Status: He is alert. He is disoriented.
Psychiatric:
Attention and Perception: He perceives auditory and visual hallucinations.
Mood and Affect: Affect is labile.
Speech: Speech is slurred and tangential.
Behavior: Behavior is agitated and slowed. Behavior is cooperative.
Thought Content: Thought content does not include homicidal or suicidal plan.
Judgment: Judgment is inappropriate."

A review of the nurse's notes dated 3/18/23 at 8:13 PM stated, "PT is a 47yo male brought in by EMS with c/c of psychiatric evaluation. Per EMS they state the pts sitter called due to the patient being confused, talking to himself and seeing things. PT has a history of schizophrenia and has not taken his medication in approximately 1 month. PT states that he has used methamphetamines recently. PT is confused, unable to make formed sentences with tardive dis kinetic facial movements. PT states that the "demons crawled inside of him". PT is oriented to person only. PT VSS and in NAD. ERP aware of pts arrival. 3/18/23 at 1946-EMS reported pt was punching and slapping self, also pulling his own hair.

Patient #4's chart revealed vital signs were documented on 3/18/23 at 7:22 PM. The temperature was (96.5 °F), pulse 57, respirations 20, Blood pressure 171/109 (elevated).

A review of the physician documentation on 3/18/23 at 8:35 PM stated, "Awaiting MHMR evaluation. The patient began to exhibit increased agitation and yelling and attempted to walk out of the room. I have decided to administer Geodon 20 mg IM and Ativan 2 mg IM as we wait on placement acceptance and transportation."

There was no documentation from the nurse on the patient's behavior, or any de-escalation or crisis interventions performed at the time of medication administration. There was no physician order found to hold the patient for a psychiatric evaluation.

A physician order was found for the administration of ziprasidone (GEODON) 20 mg in water for injection IM syringe 20 mg/mL and Lorazepam (ATIVAN) injection 2 mg on 03/18/23 10:35PM. There was no route of administration documented on the physician's order.

A review of the chart revealed there was no nursing documentation of patient reassessment after medication administration.

Patient #5

A review of patient #5's chart revealed he came into the ER complaining of chest pain. A review of the physician notes dated 2/19/23 stated, " ...Complains of chest pain for 2 days and pain going to left shoulder. Also has a headache and swelling to left cheek for several years but getting worse. Is also has altered mental status very agitated constantly moving and talking about what happened many years ago. No suicidal or homicidal ideations.
Psychiatric/Behavioral: Positive for agitation and behavioral problems. The patient is hyperactive ... Mental Status: He is alert and oriented to person, place, and time.
Psychiatric:
Mood and Affect: Mood normal.
Behavior: Behavior normal.
Thought Content: Thought content normal.
Judgment: Judgment normal.
Alcohol abuse with intoxication, uncomplicated
Cutaneous abscess of face
Unspecified psychosis not due to a substance or known
physiological condition (HCC) ..."

Review of the physician orders revealed Patient #5 was ordered and administered morphine injection 4 mg IV for pain on 02/19/23 6:11PM

A review of the physician orders on 02/19/23 at 7:04PM stated, " ziprasidone (GEODON) 20mg in water for injection IM ziprasidone (GEODON) 20 mg in water for injection IM syringe 20 mg/mL. Frequency: Once 02/19/23 1855 - 1 occurrence."

A review of patient #5's MAR revealed he was administered the Geodon IM on 02/19/23 at 7:04 PM.
There was no nursing documentation found of the patient's behaviors, any de-escalation techniques used, or any assessment of the medication's effectiveness after the medication was administered. A review of the nursing flowsheet dated 2/19/23 at 7:30PM revealed the patient had vital signs taken but no further nursing assessment.

A review of the physician documentation on 02/19/23 9:25PM stated, " ...He also has a high alcohol level. Initially, he was very agitated and given 20 mg IM Geodon since then he has been calm down and sleeping." The physician had no documentation that the patient was a known mental health patient or was on any psychotropic medications. The only physician-documented reason for the administration of the chemical restraint/emergency behavioral medication was "intoxicated and agitation." There was no documentation by the physician or nurse that any attempt was made to de-escalate the patient before administering a chemical restraint/emergency behavioral medication.

According to www.geodon.com "GEODON is a type of prescription medicine called a psychotropic, also known as an atypical antipsychotic. GEODON can be used to treat symptoms of schizophrenia and acute manic or mixed episodes associated with bipolar disorder. GEODON can also be used as a maintenance treatment for bipolar disorder when added to lithium or valproate. Patients need to be monitored due to possible side effects of Atrioventricular Block, A Type of Slow Heart Rhythm Disorder
Bundle Branch Block
Torsades De Pointes, A Type of Abnormal Heart Rhythm
Atrial Fibrillation
Slow Heartbeat
Prolonged QT Interval On EKG."

A review of the policy and procedure "Restraint Policy, Policy Number 40039.3" revealed there was no instruction to the nurse on when to monitor the patient, how frequently to monitor the patient, or for how long after administering the medication. Review of attachment A, algorithm stated, " ...If behavior requires an EBM (emergency behavioral medication), physician must place an order. Medication given for a behavioral emergency is not considered a restraint ..." The policy did not have instructions for EBM but had the definition of chemical restraint.

"Chemical Restraints: 1) The use of chemical restraints is expressly prohibited in the State of Texas. 25 TAC §415.255(a)(2). 2) Under Texas rules, a chemical restraint is: "The use of any chemical, including pharmaceuticals, through topical administration, oral administration, injection or other means, for purposes of restraining an individual and which is not a standard treatment for the individual's medical or psychiatric condition." 25 TAC 415.253(a)(3). 3) CMS's definition of a chemical restraint is: "A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition." 41 CFR 482.13(e)(1)(i)(B). 4) The regulation does not permit a drug or medication to be used to restrain the patient for staff convenience, to coerce or discipline the patient, or as a method of retaliation. 5) It is this facility's policy and practice that chemical restraints are not used in any area of the hospital. Hospital staff will not order or administer drugs or (1) for the purpose of restraining or restricting a patient's behavior or movement that is (2) not a standard treatment and dose for the individual's condition."

An interview was conducted on 3/21/23 in the afternoon with staff #2 concerning the restraint policy and procedure and emergency behavioral medications. Staff #2 stated that the patient was being treated appropriately and that the medications were not a restraint but given to treat the patient's clinical condition. Staff #2 confirmed that the medications were not placed on the restraint log and monitored due to the medication administration not being considered a restraint.

The physician did not document that he was treating a psychiatric disease process nor assisting the patient to a therapeutic level. Instead, the ER physician documented it was for agitation and intoxication (agitation is subjective and can have many different interpretations). The physician documented that patient #5 was not suicidal or homicidal. There was no documentation of harmful or destructive behaviors toward himself or others. The physician documented that patient #5 "has altered mental status very agitated constantly moving and talking about what happened many years ago." However, the physician continued to document that patient #5 had normal mood, behavior, thought content, and judgment.

Based on review and interview the facility failed to obtain a physician's order before administering Oxygen therapy in 1 of 1 (#1) chart reviewed.

A review of patient #1's chart revealed he came into the Emergency Room (ER) for an exacerbation of chronic obstructive pulmonary disease (COPD) and was having difficulties breathing. A review of the chart revealed on 10/19/22 and 10/20/22 the patient was administered oxygen by nasal cannula and a venti mask without an order for O2. The physician's order for Oxygen was not written until 10/21/22 at 7:49 AM. The order read, "Oxygen Therapy - Nasal Cannula; 3 lpm; 92%."

According to https://pubmed.ncbi.nlm.nih.gov/19377391/ ...oxygen is normally present in the air; higher concentrations are required to treat many disease processes. Oxygen is therefore considered to be a drug requiring a medical prescription and is subject to any law that covers its use and prescription. The administration is typically authorized by a physician following legal written instructions to a qualified nurse. This standard procedure helps prevent the incidence of misuse or oxygen deprivation which could worsen the patient's hypoxia and ultimate outcome."
An interview was conducted with Staff #7 Respiratory Therapist (RT) on 3/20/23 at 2:25 PM. Staff #7 confirmed the patient did not have an order for O2 until 10/21/22 at 7:49 AM. Staff #7 stated the patient came into the emergency room with the O2 on and had been on O2 at home for his respiratory condition. Staff #7 stated the order was just missed.