HospitalInspections.org

Based on a review of facility documentation and staff interview, the hospital failed to ensure each patient had the right to a timely comprehensive treatment plan according to facility policy, and that each patient had the right to participate in his/her own plan of care for 1 of 5 patients (Patient #4).

Findings were:

Facility policy #2642647 entitled Treatment Planning - Philosophy and Purpose, approved 9/2016, included the following:
"The hospital believes that the Interdisciplinary Treatment Plan can be an effective therapeutic tool, which is productive and helpful to staff as well as to patients ...The success of the plan depends upon the following components: ...
In TX the initial treatment plan will be formulated within 24 hours of admission and completed within 72 hours of admission ...
6. A Treatment Plan review/update that evaluates patient response to goals and interventions will be revised based on changes in the patient's condition, problems, needs and responses to care, treatment and services. If there is no appreciable change in the patient's condition, goals and objectives will be reevaluated and revised on a weekly basis at a minimum for inpatient ..."

A review of the treatment plan for Patient #4 revealed he was admitted to the hospital on 7/8/17. His comprehensive treatment plan was signed by the medical provider on 7/13/17 and an activity therapist on 7/12/17. The only other signatures were two RNs who initiated the treatment plan upon the patient's admission. There was no patient signature on the treatment plan and no documentation on the plan as to why he had not be allowed to participate. Patient #4 was discharged from the hospital on 7/18/17. The above treatment plan was the only one available in the patient record for surveyor review. No updates to the treatment plan were found in the clinical record of Patient #4.

The above findings were confirmed in an interview with the Director of Nursing and the Director of Quality on the afternoon of 7/31/17 in the facility meeting room. No further evidence to refute these findings was provided by the facility.

Based on a review of facility documentation and staff interviews, the hospital failed to ensure each patient had the right to make informed decisions regarding his or her care as psychoactive medications were administered to 3 of 10 patients (Patients #1, #3 and #5) receiving such medications without a signed consent. Thus the facility could supply no documented evidence that these patients received information about benefits, risks, side effects and alternative treatment possibilities related to these medications. In addition, for 2 of 10 patients (Patients #1 and #9) receiving psychotropic medications, the treating physician did not confirm information that was provided to the patient according to facility policy and regulatory requirements.

Findings were:

Facility policy #3166529 entitled Informed Consent for Psychotropic Medications, last revised 7/2017, included the following:
"Procedure:
1. The treating physician or designee must present this information about psychotropic medication in simple, non-technical language, and in the person's primary language, to the patient or legal guardian:
1. The nature of the patient's mental illness
2. The beneficial effects expected as a result of treatment with the medication
3. The probable health and mental consequences to the patient of not taking the medication
4. Alternative forms of treatment, if any
5. A description of the proposed course of treatment with medication
6. That side effects of varying degrees of severity are a risk of all medications
7. The relevant side effects ...
8. Instruct the patient and/or legal representative that he/she may withdraw consent at any time without negative actions on the part of the staff
9. The patient and his/her legal representative must also be provided a summary of this information in writing also with an offer to answer any questions concerning the treatment ...
2. Documentation of the Informed Consent - Informed consent for the administration of psychotropic medication will be evidenced by a completed copy of the consent form ...
4. If the patient or legally authorized person consents to the administration of a psychoactive medication but refuses or is unable to execute the form, documentation of the verbal consent is required.
5. A patient's refusal or attempt to refuse, whether verbally or indicated, will be documented in the patient's clinical record, in the progress notes, and on the consent form ..."

A review of the clinical record for Patient #1 included a physician progress note on 4/2/17 at 8:20 a.m.: "Medication changes: ...DC (discontinue) Ambien, + Restoril 15mg p.o. QHS, rationale: insomnia ..." A nursing shift assessment on 4/2/17 signed on 4/3/17 at 6:45 a.m. noted the patient received Restoril 15 mg p.o. Likewise, a nursing shift assessment on 4/3/17 signed on 4/4/17 at 7:00 a.m. included the following: "Pt received Norco x 2 for pain, Restoril for sleep & Imitrex for migraine. Pt reports not feeling the Restoril work but encouraged to try it again ..." There was no consent for treatment with Restoril, a sedative used for sleep, available for surveyor review in the record of Patient #1.

Patient #4 received Zyprexa, an anti-psychotic medication, and trazodone, a tetracyclic antidepressant medication often used for sleep, several times during his inpatient stay. The clinical record for Patient #4 revealed no consents signed by the patient for treatment with these psychoactive medications, and no court order to administer such medications.

Patient #5 received Lexapro, an anti-depressant medication, during her inpatient stay at the hospital. The clinical record for Patient #5 included no consent for treatment with this medication which had been signed by the patient.

In addition, the facility consent to treatment with psychoactive medication included an area for the treatment physician to sign. Below the signature line was the following statement: "Signature of treating Physician to confirm explanation given (If the explanation is not provided by the treating physician, he or she must confirm the explanation with the patient and the patient's legally authorized representative, within two working days.)"

The consent form for Restoril, unsigned by Patient #1, had been signed by the treating physician as confirming he had ensured she obtained accurate information about the medication. However, he signed it on 4/19/17. Patient #1 was discharged on 4/4/17. Patient #1 had signed consents to receive trazodone and Vistaril, on 3/29/17. However, again the treating physician signed his verification of the medication information she received on 4/19/17.

Patient #9 signed consents to receive Vistaril and trazodone on 5/31/17. He signed consent to receive Lexapro on 6/2/17. Patient #9 was discharged on 6/8/17. The treating physician validated the medication information Patient #9 received on 6/22/17.

The above findings were all confirmed in an interview with the hospital Director of Nursing and Director of Quality on the afternoon of 7/31/17 in the facility meeting room.

Based on a review of facility documentation and staff interview, the facility failed to ensure nursing reassessment of each patient per each shift according to facility policy and regulatory requirements for 1 of 10 patients (Patient #1). In addition, pain assessments were incompletely documented for 2 of 6 patients complaining of pain issues (Patients #1 and #5). Finally, falls were not documented according to facility policy for 1 of 1 patients sustaining falls while hospitalized (Patient #1).

Findings were:

Facility policy #3820031 entitled Shift Nursing Assessment/Reassessment, effective 1/2012, included the following:
"Policy
The Shift Nursing Assessment will be completed on all patients for each shift of stay ...
B. The RN will complete the required assessment each shift ...
D. The pain assessment must be done at minimum once every shift ...It should also be completed prior to administration of pain medication and when completing the pain medication followup evaluation ..."

Facility policy #3662506 entitled Assessment - Fall, approved 7/2017, included the following:
"6. A patient Incident Report will be completed and submitted to the Nursing Supervisor if the patient experiences a fall.
7. The attending physician will be contacted by the Charge Nurse to determine the course of treatment if a fall occurs.
8. A re-assessment will be completed after each patient's incident report of a fall ..."

A review of the clinical record of Patient #1 revealed missing nursing documentation for a period prior to which the patient was documented to have been in severe pain and during which a mental health technician documented the patient suffered a fall. Review of a shift nursing assessment for Patient #1 on 3/29/17 - 7am to 7pm shift, signed at 7:00 p.m., revealed the following: "Patient complained of severe pain throughout morning until MD ordered hydrocodone..." Pain was assessed as a "9" by the RN with cause of pain noted as "fractured L foot." Interventions were noted as "cold, relaxation, medication." There was no post-intervention pain assessment.

No nursing shift assessment form could be located by the facility for the 3/29/17 shift for 7pm to 7am.

A close observation record completed by a mental health technician on 3/30/17 included a note signed at 6:00 a.m.: "Pt slept in [seclusion room] all night once she fell out of bed ..." The patient had a history of seizures. Patient #1 was documented to have sustained three falls while at the hospital. Only a fall on 4/3/17 included documentation as required and noted in the hospital's fall policy. However, the post-fall form included no signature.

On the 7pm to 7am shift on 7/23/17, Patient #5 was noted to have "acute pain" (a checked box indicated). No interventions were documented, no pain score was assigned and no re-evaluation of Patient #5's pain level was documented. On the 7pm to 7am shift on 7/24/17, Patient #5 was noted to have a pain score of "6." There were no nursing interventions documented and thus no post-intervention re-assessment of the patient's pain level.

The above findings were confirmed in an interview with the facility Director of Nursing and the Director of Quality on the afternoon of 7/31/17 in the facility meeting room. No evidence to refute these findings was provided.

Based on a review of facility documentation and staff interview, the hospital failed to ensure each patient had the right to a timely comprehensive treatment plan according to facility policy, and that each patient had the right to participate in his/her own plan of care for 1 of 5 patients (Patient #4).

Findings were:

Facility policy #2642647 entitled Treatment Planning - Philosophy and Purpose, approved 9/2016, included the following:
"The hospital believes that the Interdisciplinary Treatment Plan can be an effective therapeutic tool, which is productive and helpful to staff as well as to patients ...The success of the plan depends upon the following components: ...
In TX the initial treatment plan will be formulated within 24 hours of admission and completed within 72 hours of admission ...
6. A Treatment Plan review/update that evaluates patient response to goals and interventions will be revised based on changes in the patient's condition, problems, needs and responses to care, treatment and services. If there is no appreciable change in the patient's condition, goals and objectives will be reevaluated and revised on a weekly basis at a minimum for inpatient ..."

A review of the treatment plan for Patient #4 revealed he was admitted to the hospital on 7/8/17. His comprehensive treatment plan was signed by the medical provider on 7/13/17 and an activity therapist on 7/12/17. The only other signatures were two RNs who initiated the treatment plan upon the patient's admission. There was no patient signature on the treatment plan and no documentation on the plan as to why he had not be allowed to participate. Patient #4 was discharged from the hospital on 7/18/17. The above treatment plan was the only one available in the patient record for surveyor review. No updates to the treatment plan were found in the clinical record of Patient #4.

The above findings were confirmed in an interview with the Director of Nursing and the Director of Quality on the afternoon of 7/31/17 in the facility meeting room. No further evidence to refute these findings was provided by the facility.