HospitalInspections.org

Based on a review of documentation, the Nursing Services Director failed to demonstrate responsibility for the operaton of the nursing service.

Findings were:

Patient #1 stated that he was currently taking the following medications:
" Lexapro
" Seroquel
" Adderall
" Xanax
" Methadone
" Prazosin
Patient #1 stated allergies to penicillin, prednisone and olanzapine. Medication reconciliation forms were completed by the nursing staff on 9-24-17 and 9-27-17 but gave no indication as to whether or not the listed medications were to be continued.

Patient #1 brought in the following home medications: Lexapro, Prazosin, Alprazolam (schedule IV controlled substance), Quetiapine, Methadone (schedule I controlled substance), Gabapentin, Metoprolol and Dronabinol (schedule I controlled substance). The Alprazolam, Methadone and Dronabinol were counted and documented on facility form "Home Medication Control Count Sheet". Although the initial counts for the Alprazolam (quantity of 5) and Dronabinol (quantity of 42) were verified by the signatures of 2 nurses, the initial count for the Methadone (quantity of 32) was only verified by the signature of 1 nurse. The same control count sheets had been completed each shift throughout the patient's stay and the word "sealed" and arrows pointing to the right was listed under the columns marked "start amount", "amount given" and "end amount". On the date of the patient's discharge, the end count was again listed as "sealed".

Facility policy PHR-118 titled "Medications Brought in with Patients" states, in part:
"4.0 Procedure:
...
4.6 At the time of admissions, if the use of the medication is not warranted, then the following procedure should be used:
...
4.6.3 Controlled substances that are taken into custody will be counted and the quantity noted on the inventory sheet. The patient and staff member receiving medications will sign the form. If the patient/caregiver cannot sign, then a second hospital witness is required."

Facility policy PHR-201 titled "Medication Inventory/Reconciliation" states, in part:
"4.0 Procedure
...
4.2 The information will be recorded in the Medication Reconciliation section of admitting paperwork and will include:
...
4.2.4 Medications will be checked Yes or No to continue at the hospital. This section constitutes as a doctor's order.
...
4.2.10 If a patient has controlled substances being returned at discharge, the nurse and a witness will count the medication and note the amount on the medication inventory form that is attached to the bag of medications. Unless the home control drug was used during hospitalization, the amount taken into custody should match the amount being returned. The patient/care giver will sign the inventory form verifying the return of all home medications is correct and the count of control substances is accurate."

During patient #1's stay, he was prescribed the following psychoactive medications:
" Geodon
" Ativan
" Thorazine
" Risperdal
" Seroquel
" Vistaril
" Invega Sustenna (court-ordered medication; patient's consent not required)
Signed, psychoactive medication consents were found in the clinical record for all psychoactive medications except Vistaril. Review of the MAR [medication administration record] revealed that patient #1 received Vistaril during his stay.

Facility policy 1000.07 titled "Informed Consent for Psychoactive Medications - Texas" states, in part:
"Procedure:
Consents:
...
2. 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) executed by the patient or his/her Legal Advocate Representative (LAR)."

Facility policy PHR-154 titled "Authorization for Psychotropic Medications" states, in part:
"2.0 Statement of Policy:
...
2.1.4 Ensure that the patient has signed the Consent for Psychotropic Medications form prior to the administration of medication(s) to the patient."

A review of the clinical record for patient #1 revealed no documentation of nursing assessments on either 10-6-17 (night shift) or 10-9-17 (night shift).

Although patient #1 was admitted on 9-24-17, the nursing admission assessment for patient #1 was not performed until 9-27-17. Nursing documentation revealed no indication that the assessment was attempted on either the day shift or the night shift on
9-25-17.

Facility policy 200.03 titled "Nursing Documentation Standards" states, in part:
"II. Procedure:
...
A. Assessment/Data Collection
...
3a. The Nursing Admission Assessment shall be started in the first 8 hours of admission, and completed in 24 hours on cooperative patients. If the patient is uncooperative, the assessment shall be completed as soon as possible, and daily attempts to complete data should be made. A progress note entry is needed with current status of the assessment.
...
3e. Each patient is reassessed by the nurse every 12 hours. The reassessments are completed on the Nursing Shift Assessment."

The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 2-21-18.

Based on a review of documentation, the Nursing Services Director failed to demonstrate competence to participate in interdisciplinary formulation of individual treatment plans; to give skilled nursing care and therapy or to direct, monitor, and evaluate the nursing care furnished.

Findings were:

Patient #1 stated that he was currently taking the following medications:
" Lexapro
" Seroquel
" Adderall
" Xanax
" Methadone
" Prazosin
Patient #1 stated allergies to penicillin, prednisone and olanzapine. Medication reconciliation forms were completed by the nursing staff on 9-24-17 and 9-27-17 but gave no indication as to whether or not the listed medications were to be continued.

Patient #1 brought in the following home medications: Lexapro, Prazosin, Alprazolam (schedule IV controlled substance), Quetiapine, Methadone (schedule I controlled substance), Gabapentin, Metoprolol and Dronabinol (schedule I controlled substance). The Alprazolam, Methadone and Dronabinol were counted and documented on facility form "Home Medication Control Count Sheet". Although the initial counts for the Alprazolam (quantity of 5) and Dronabinol (quantity of 42) were verified by the signatures of 2 nurses, the initial count for the Methadone (quantity of 32) was only verified by the signature of 1 nurse. The same control count sheets had been completed each shift throughout the patient's stay and the word "sealed" and arrows pointing to the right was listed under the columns marked "start amount", "amount given" and "end amount". On the date of the patient's discharge, the end count was again listed as "sealed".

Facility policy PHR-118 titled "Medications Brought in with Patients" states, in part:
"4.0 Procedure:
...
4.6 At the time of admissions, if the use of the medication is not warranted, then the following procedure should be used:
...
4.6.3 Controlled substances that are taken into custody will be counted and the quantity noted on the inventory sheet. The patient and staff member receiving medications will sign the form. If the patient/caregiver cannot sign, then a second hospital witness is required."

Facility policy PHR-201 titled "Medication Inventory/Reconciliation" states, in part:
"4.0 Procedure
...
4.2 The information will be recorded in the Medication Reconciliation section of admitting paperwork and will include:
...
4.2.4 Medications will be checked Yes or No to continue at the hospital. This section constitutes as a doctor's order.
...
4.2.10 If a patient has controlled substances being returned at discharge, the nurse and a witness will count the medication and note the amount on the medication inventory form that is attached to the bag of medications. Unless the home control drug was used during hospitalization, the amount taken into custody should match the amount being returned. The patient/care giver will sign the inventory form verifying the return of all home medications is correct and the count of control substances is accurate."

During patient #1's stay, he was prescribed the following psychoactive medications:
" Geodon
" Ativan
" Thorazine
" Risperdal
" Seroquel
" Vistaril
" Invega Sustenna (court-ordered medication; patient's consent not required)
Signed, psychoactive medication consents were found in the clinical record for all psychoactive medications except Vistaril. Review of the MAR [medication administration record] revealed that patient #1 received Vistaril during his stay.

Facility policy 1000.07 titled "Informed Consent for Psychoactive Medications - Texas" states, in part:
"Procedure:
Consents:
...
2. 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) executed by the patient or his/her Legal Advocate Representative (LAR)."

Facility policy PHR-154 titled "Authorization for Psychotropic Medications" states, in part:
"2.0 Statement of Policy:
...
2.1.4 Ensure that the patient has signed the Consent for Psychotropic Medications form prior to the administration of medication(s) to the patient."

A review of the clinical record for patient #1 revealed no documentation of nursing assessments on either 10-6-17 (night shift) or 10-9-17 (night shift).

Although patient #1 was admitted on 9-24-17, the nursing admission assessment for patient #1 was not performed until 9-27-17. Nursing documentation revealed no indication that the assessment was attempted on either the day shift or the night shift on
9-25-17.

Facility policy 200.03 titled "Nursing Documentation Standards" states, in part:
"II. Procedure:
...
A. Assessment/Data Collection
...
3a. The Nursing Admission Assessment shall be started in the first 8 hours of admission, and completed in 24 hours on cooperative patients. If the patient is uncooperative, the assessment shall be completed as soon as possible, and daily attempts to complete data should be made. A progress note entry is needed with current status of the assessment.
...
3e. Each patient is reassessed by the nurse every 12 hours. The reassessments are completed on the Nursing Shift Assessment."

The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 2-21-18.