HospitalInspections.org

Based on documentation review and interview, the facility failed to ensure that 3 of 5 involuntary patients were made aware of their rights

Findings included:

Review of the medical record revealed Patient #2 was admitted on 11/16/16 as a transfer from a local acute hospital psychiatric emergency department on an emergency detention. The admitting orders dated 11/16/16 at 16:13 revealed admission type was involuntary. The admission forms dated 11/16/16 did not contain Patient #2 initials for Item -1 Application for Voluntary Admission and Item -2 Consent for Treatment. The record revealed that Patient #2 had not initialed the Application for Voluntary Admission and Consent for Treatment items as of 11/21/16 requesting admission on a voluntary basis. In an interview with the risk manager, Staff #2 on 11/21/16 at approximately 12:25 pm in the conference room, Staff #2 agreed the above listed patient admission items were not initialed by Patient #2 and she was held at the facility after the emergency detention expired without a court order or signing in voluntarily.

Review of the medical record revealed that Patient #5 was admitted on 11/12/16 on an emergency detention. The admission forms dated 11/12/16 did not contain Patient #5 initials for Item -1 Application for Voluntary Admission and Item -2 Consent for Treatment. The record revealed that Patient #5 had not initialed the Application for Voluntary Admission and Consent for Treatment items as of the date of discharge on 11/18/16 requesting admission on a voluntary basis. In an interview with the risk manager, Staff #2 on 11/21/16 at approximately 12:55 pm in the conference room, Staff #2 agreed the above listed patient admission items were not signed by Patient #5 and he was held at the facility after the emergency detention expired without a court order or signing in voluntarily.

Review of the medical record revealed that Patient #7 was admitted on 11/8/16 on an emergency detention. The record revealed that Patient #7 had not initialed the Application for Voluntary Admission Item-1 or the Consent for Treatment Item-2 as of the date of discharge on 11/19/16 requesting admission on a voluntary basis. In an interview with the risk manager, Staff #2 on 11/21/16 at approximately 1:05 pm in the conference room, Staff #2 agreed the above listed patient admission items were not signed by Patient #7 and she was held at the facility after the emergency detention expired without a court order or signing in voluntarily.

Facility policy, "Patient Rights" policy number PR-012 stated, in part, "Emergency Detention-Special Rights for People Brought to the Hospital Against Their Will 1. You have all the right to be seen by a doctor. You will not be allowed to leave if the doctor believes that:
· You may seriously harm yourself or others;
· The risk of this happening is likely unless you are restrained; and
· Emergency detention is the least restrictive means of restraint.
If the doctor decides you don't meet all of these criteria, you must be allowed to leave. A decision concerning whether you must stay must be made within 24 hours, except that on weekends and legal holidays, the decision may be delayed until 4:00 in the afternoon on the first regular workday ..."

The above findings were confirmed in an interview with Staff #2 and Staff #3 the afternoon of 11/21/16 in the facility conference room.

Based on a review of documentation, interview, and observation, the facility failed to ensure that consent to treatment with psychoactive medication was obtained and executed by a patient or his or her legally authorized representative as medications were administered to patients without a signed or executed consent form.

Findings included:

Review of the medical record for Patient #3 on 11/21/16 revealed that psychotropic medications had been administered without documented evidence of informed consent as required by facility policy and state regulation.

Patient #3 refused Risperdal, as documented on the " Education Acknowledgement/Consent to Treatment with Psychoactive Medication " form. A handwritten note was documented on the bottom of the form in the space entitled, " Physician or nurse comments " which stated, " 5-19-16 [Patient #3] refused to sign consent for Risperdal stating he does not want to take it. " This note was signed with an illegible staff signature. The form had 2 staff signatures dated 5/19/16, and a physician signature on 5/23/16. There was no other documented consent for Risperdal for Patient #3 in the medical record. Review of the Medication Administration Record for Patient #3 revealed that the " Consent " check box for Risperdal was checked, despite his not having consented for Risperdal. The MAR reveals that Patient #3 refused Risperdal on 5/18/16, took Risperdal on 5/19/16 (at 2100), took Risperdal on 5/20/16 (0800 and 2100), took Risperdal on 5/21/16 (at 2100), refused on 5/22/16, took Risperdal on 5/21/16 (at 0615 and 2010) and took Risperdal on 5/24/16 (at 2100). The doses taken by Patient #3 were taken without consent, and actually administered after Patient #3 had expressly stated he did not want to take Risperdal.

Facility policy, " Informed Consent, Medication " stated, in part, " All patients, or their legal guardians or legal representatives, shall be informed of the right to consent or to refuse treatment with psychoactive medications ...Informed consent will be secured prior to the initial dose of medication except in an emergency situation. "

25 Texas Administrative Code 414.405(b)(1)-(2), states, in part, "(b) Informed consent for the administration of each psychoactive medication will be evidenced by a completed copy of the department's form, Consent to Treatment with Psychoactive Medication (MHRS 9-7 form (or other format including the same information)) executed by the patient or his or her LAR...
(1) Any time the medication regimen is altered in a way that would result in a significant change in the risks or benefits for the patient, an explanation of the change will be provided to the patient and the patient's legally authorized representative. The explanation will include notification of the right to withdraw consent at any time.
(2) A new consent will be obtained if a change to a different medication is prescribed."

These findings were confirmed in an interview with Staff #3, CNO, in the facility conference room the afternoon of 11/21/16.

Based on review of documentation and interview, the facility failed to ensure that medical records were completed as the percentage of meal intake for each patient and review of vital signs was not consistently documented and was not reviewed by a registered nurse. This presents a risk that a patient assessment or identification of a patient problem may be delayed or missed.

Findings included:

Review of the medical records for 10 out of 10 patients (Patients # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) revealed incomplete and inconsistent documentation of percentage of meal intake. The form entitled, "Graphic" included patient vital signs, percentage of meal intake, and hours slept. The space for the RN to document review of each patient's vital signs, meal intake and hours slept was not completed consistently for each patient.

The " Graphic " form for patient #3, where meal intake is to be documented for each day (breakfast, lunch and dinner) was incomplete or left totally blank for 24 out of 25 days. There was no means to determine whether or not Patient #3 had any meal intake for most of the days he was a patient at Cross Creek Hospital. In addition, the space for the RN to initial for each meal and/or shift was sporadically left blank; as such, there was no means to determine whether the RN was assessing the meal intake and nutritional status or vital signs for Patient #3.
 
Review of the form entitled "Graphic" for Patient #3 revealed the following missing documentation for percent of meal intake:
5/4/16 - no documentation dinner
5/5/16 - no documentation breakfast, lunch, dinner; no RN initials
5/6/16 - no documentation breakfast, lunch, dinner
5/7/16 - no documentation breakfast, lunch, dinner
5/8/16 - no documentation breakfast, lunch, dinner; no RN initials
5/9/16 - no documentation breakfast, lunch, dinner
5/10/16 - no documentation breakfast, lunch, dinner
5/11/16 - no documentation breakfast, lunch, dinner
5/12/16 - no documentation breakfast, lunch, dinner; no RN initials
5/13/16 - no documentation breakfast, lunch
5/14/16 - no documentation breakfast, lunch, dinner; no RN initials
5/15/16 - no documentation breakfast, lunch, dinner
5/16/16 - no documentation lunch
5/18/16 - no documentation breakfast, lunch
5/19/16 - no documentation breakfast, lunch, dinner; no RN initials
5/20/16 - no documentation breakfast, lunch, dinner; no RN initials
5/21/16 - no documentation breakfast, lunch, dinner
5/22/16 - no documentation breakfast, lunch, dinner
5/23/16 - no documentation breakfast, lunch, dinner
5/24/16 - no documentation breakfast, lunch, dinner
5/25/16 - no documentation breakfast, lunch, dinner; no RN initials

The " Graphic " form for patient #1, where meal intake is to be documented for each day (breakfast, lunch and dinner) was incomplete or left totally blank for 6 out of 7 days. There was no means to determine whether or not Patient #1 had any meal intake on his meals for most of the days he was a patient at Cross Creek Hospital. In addition, the space for the RN to initial for each meal and/or shift was left blank; as such, there was no means to determine whether the RN was assessing the meal intake and nutritional status or vital signs for Patient #1.

Review of the form entitled "Graphic" for Patient #1 revealed the following missing documentation for percent of meal intake:
11/14/16 - no documentation breakfast, lunch, dinner
11/15/16 - no documentation lunch, dinner
11/16/16 - no documentation breakfast, lunch, dinner, no RN initials
11/17/16 - no documentation dinner, no RN initials
11/18/16 - no RN initials
11/20/16 - no documentation breakfast, lunch, dinner, no RN initials

All medical records reviewed (Patients #1-10) had omissions in meal intake percentage documentation and RN nutritional status assessment and documentation similar to the above.

Facility policy, " Assignment of Nursing Staff " stated, in part, " A registered nurse plans, supervises and evaluates the nursing care of each patient. "
 
Facility policy, " Early Response to Change in Condition " stated, in part, " Registered Nurse will provide assessment data to the attending physician/covering practitioner who will give orders for treatment or additional assessment ...
Elevated temperature ...
Pulse-above 110/below 50
BP Diastolic above 100
BP Systolic less than 90 and/or greater than 180
Respirations that are labored and above 30 or below 10 ...
Refusal (less than 25%) to eat or drink longer than 24 hours. "

Review of the Texas Nurse Practice Act 217.11, Standards of Nursing Practice, states, in part,
" (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: ...(D) Accurately and completely report and document: (i) the client's status including signs and symptoms; ...(v) client response(s); "

The above findings were confirmed in an interview the afternoon of 11/21/16 in the facility conference room with the CNO, Staff #3.

Based on review of documentation and interview, the facility failed to ensure that medical records were completed as each patient discharged from the facility did not have a completed or legible discharge summary in accordance with the facility medical staff bylaws.

Findings included:

Review of the record for Patient #3, discharged on 5/26/16, revealed a form entitled, "Cross Creek Hospital Discharge Summary". The Discharge Summary form contained primarily partially illegible notes jotted down on the form and the form had not been completed. The following areas to complete were left blank or were illegible:
Chief Complain and Reason for Hospitalization, Course of Treatment, History of Present Illness, Evaluations, Clinical Findings, Procedures, Treatment rendered, Patient/Family Response to Treatment Interventions. The Discharge Diagnoses (Five Axis Diagnosis) were not completed, and the Brief Summary of Patient's Condition at Discharge was incomplete.

The above findings were reviewed and discussed with the CNO, Staff #3, who confirmed the above findings. The CNO did check to see if there was a dictated Discharge Summary, which perhaps hadn ' t been added to the paper medical record, however the CNO confirmed that there was no dictated Discharge Summary for Patient #3, and the notes that were on the Discharge Summary form were partially illegible. The physician, Staff #8 was not available for interview as he was no longer associated with the facility.

Review of the Medical Staff Rules and Regulations, dated 3/15, stated, in part, " 7.12 Discharge Documentation - Patients shall be discharged only on a written order of the Attending Physician/designee ...The record of each discharged patient must have a discharge summary, signed by the Attending Physician, off the patient ' s hospitalization and recommendations concerning follow-up or aftercare ...as well as a brief summary of the patient ' s condition on discharge. The discharge summary must also include the reason for hospitalization, significant findings, procedures performed and treatments rendered, progress in meeting treatment goals, the name, dosage, frequency of any medications ordered for the patient at the time of discharge and the DSM Five Axis discharge diagnosis.

The above findings were confirmed in an interview the afternoon of 11/21/16 in the facility conference room with the CNO, Staff #3.