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Based on interview and record review, the facility failed to follow the Corporate Compliance Policy when it did not provide a written response to a patient's grievance/complaint.

Findings Include:

During a telephone interview on 1/31/16 at 5:50 p.m. Patient #1 stated he contacted the Corporate Compliance Hotline number provided by the facility on 10/6/15. Patient #1 stated the Corporate Compliance personnel took his complaint concerning erroneous laboratory results. Patient #1 stated the Corporate Compliance and/or the Facility did not contact him with the results of complaint.

Review of Corporate Compliance complaint (dated 10/6/15) reflected Patient #1's complaint.
Issue Summary:
Patient #1 stated Staff #15 obtained false positive results on Patient #1's urinalysis. In addition, Staff #15 mentioned Patient #1's medical information in an unprofessional manner.
The facility self-investigation was completed on 10/19/15.
Case Action Disposition Summary: Staff #10 spoke with Staff #15. Staff #15 had stated that explained to the patient that the drug results were due to previous detox protocol for Benzo regimen. There is a progress note documenting this event. Secondly, Staff #15 stated that she did not discuss any lab results in public. i.e. the "hallway".

Review of the facility provided policy (undated) PROCESS FOR HANDLING THE COMPLIANCE HOTLINE AND WEB REPORTING PROGRAM reflected:
Purpose: To establish protocols for how UHS Compliance Hotline and Web Reporting cases are received, documented, investigated and ultimately resolved.
Procedure: Appropriate action will be taken in response to each call and/or report. In most cases, appropriate action will include an investigation into the allegations of the complaint or concerns, and action plan to resolve the issues, and communication back to the caller, if applicable. Complaints that do not raise a potential compliance issue will be referred to the appropriate department (e.g. risk management, Human Resources, facility management, or other departments as appropriate).

During an interview on 2/1/16 at 2:00 a.m., in the conference room, Staff #2, Risk Manager, stated Corporate Compliance Reporting Program does not provide the facility with information regarding complaints coming into the Compliance Hotline and the interaction between the Corporate Compliance Program and the complainant.

During an interview on 2/2/16 at 3:15 p.m., in the conference room, Staff #3, Director of Clinical Services stated the Corporate Compliance Program and the facility had not contacted the patient regarding the resolution of the complaint.

Based on interview and record review the facility failed to counsel and obtain consent from two (2) of six (6) patient's (Patient #1 and #14) for psychoactive medication, its intended effects, and the potential side-effects.

Findings include:

Review of Patient #1's Medication Administration Record dated 10/28/15 at 9:00 p.m. reflected the administration of Zyprexa 10 mg (milligram) p.o.(by mouth).

Review of Patient #1's Consent for Medication Administration reflected that no consent or medication teaching for the Zyprexa had been obtained prior to the administration of the medication.

Review of Patient # 14's Physician Telephone Orders dated 11/30/15 reflected: Vistaril 50 mg (milligrams) p.o. (by mouth) now for anxiety.

Review of Patient#14's Medication Administration Record dated 11/30/15 at 10:15 p.m. reflected the administration of Vistaril 50 mg.

Review of Patient #14's Consent for Medication Administration reflected that no consent or medication teaching for Vistaril had been obtained prior to the administration of the medication.

Review of the facility provided policy Informed Consent for Medication Administration (dated 11/2015) reflected:
POLICY: In accordance with State Licensing Standards of the Texas Department of State Health Services, ...Health System shall comply with the established guidelines for Prescribing Medications.
INFORMED CONSENT:
INFORMATION REQUIRED TO BE GIVEN:
Before administering psychoactive medication to any patient the treating physician shall explain to the patient and/or the patient's legally authorized representative, the following in a simple, non-technical language (this information may be given by the nurse if the treating physician cannot be present, but the treating physician must confirm the explanation with the patient and/or his legally authorized representative within two (2) working days:
DOCUMENTATION OF INFORMED CONSENT:
Informed consent for the administration of psychoactive medication will be evidenced by a copy of the Consent for Treatment with Psychoactive Medication form executed by the patient admitted under the voluntary, emergency, or OPC provisions of Texas statues or his legal authorized representative. This executed form will establish a rebuttal presumption of valid consent and will be retained in the medical record. Any time the medication regimen is altered in a way which would result a significant change in the risks for benefits for the patient, an explanation of the change must be provide to the patient.
If a patient or his legally authorized representative consents to the administration of psychoactive medication, but refused or is unable to execute the form, the treatment physician may document the consent the consent in the patient's record.

During an interview, on 02/02/16 at 3:00 p.m.Staff#3, Director of Clinical Services, confirmed the findings.