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Based on review of records, observation, and interview, the facility failed to:

A) protect the patients from sexual predators and to identify predators and victims of sexual abuse in 2(45 and 33) of 2 charts reviewed.

B) provide timely staff education, an approved policy and procedure, or any plan of monitoring of room assignments for patient safety.

C) provide a plan of quality assurance performance improvement (QAPI) for sustainability of education of staff, data collection through chart audits, or tracking method to prevent a patient from being a victim of sexual abuse.


D) ensure medications given in a psychiatric emergency were ordered, administered, and monitored to make sure they were appropriate and safe in 6 out of 6 (Patient #21, #22, #27, #28, #20, and #33) patients reviewed.

E) ensure, when medications were ordered by physicians, they were documented by the physicians with the required elements per the Texas Administrative Code.

F) ensure Medical Staff managed the process of ensuring safety and appropriateness of medication administrations in a behavioral emergency through the peer review process per hospital policy. Medications given in a behavioral emergency were not analyzed and evaluated through hospital processes or programs to ensure safety and appropriate usage per the Texas Administrative Code. Medications administered were not always monitored as behavioral restraints to ensure patient safety and appropriate usage. Psychotropic medications (medication capable of affecting the mind, emotions, and behavior) were observed to be given for staff convenience in 1 (Patient #33) out of 2 patients (Patient #32 and #33) for emergency behavioral medication administrations.

Medications given without proper oversight and review of the Medical Staff and hospital administration, and given for staff convenience, have the potential for these medications to be abused by staff causing psychological harm to patients, physical harm during forced administration of medications, or for patients to become over sedated, resulting in the potential for death.

G) develop policies and procedures that prevent the exchange of patient care information via text messaging unless it is on a secured platform. Patient care decisions were made via unsecured text messaging by limiting patient identifying information. Without the use of appropriate patient identifiers, the potential existed for errors in patient care decisions.

H) provide a safe setting for the psychiatric patients. Ligature risks were observed and identified during the tour of the hospital on the afternoon of 10/15/2018 accompanied by the administrative staff and on the afternoon of 10/16/2018 accompanied by the environmental staff. The presence of ligature risks in the physical environment of a psychiatric patient, including any setting where psychiatric patients may be present, even for a short period of time, compromises their right to receive care in a safe setting.

These deficient practices identified above were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Findings for A), B), and C) were as follows:

Review of the facility's previous plan of correction revealed they had addressed the safe monitoring of individuals who were being held under emergency detention while awaiting assessment and admission. Review of the facility's correction plan for sexual abuse only addressed the following:

1. failure to ensure that patient's guardians and Child Protective Services (CPS) were notified of patient sexual abuse.
2. address, in the treatment plan, the patient's behavior that could result in risk of harm to self or others.

There was no documentation found on how the patient was to be protected from sexual predators, how to identify predators and victims of sexual abuse, any staff education, an approved policy and procedure, or any tracking and monitoring of sexual predators who were admitted to the facility in order to prevent other patients from becoming a victim of sexual abuse while admitted to the facility for care.

An interview was conducted with Staff #1 and Staff #2 in the morning of 10-15-2018 at 3:45PM. Staff #2 stated there had been no staff training for sexual contact between patients. Staff #2 reported the facility had not developed the training module. The administrative staff had not involved the medical staff and had not taken the training to Governing Body (GB) for approval as of 10-15-2018. Staff #2 reported the GB was to meet the night of 10-15-2018. Staff #2 reported he could have the training module done the morning of 10-16-2018.

Staff #1 reported the facility had worked so hard on the first part of the deficiencies in relating to the intake process of the hospital, that they had not completed all the training needed to protect patients from sexual predators. Staff #1 stated they would provide the training information in the morning of 10-16-2018 for review.

An interview was conducted on 10-16-2018 with Staff #1 and Staff #2. Staff #2 reported they had developed training for the staff. The administrative staff was instructed by the surveyor to train the staff and to make sure all staff was trained before working with patients. Staff #2 stated, "I will make sure everybody is trained before they start work." Staff #2 reported that he had training sessions starting "today" (10-16-2018) and would catch everybody before their shifts start.

Review of Patient #45's chart revealed she was admitted to the facility on 10/11/2018. Patient #45 was a 27-year-old female brought in on an Order of Protective Custody warrant for psychosis.

Review of the Patient #45's chart revealed the patient was seen by a psychiatrist via telemedicine on 10-11-2018 at 15:33 (3:33PM) in the intake area. The physician wrote the following:

"27y/o CM with h/o polysubstance use DO, and schizoaffective DO was found in an ally, passed out. Pt then climbed firetruck and wouldn't come down, she reported that people were after her and she was trying to get away from them." Physician reported the patient was, "actively psychotic, delusions, disorientation, disorganized, hyper sexuality, hallucination." The psychiatrist did not write an order for an SAO precaution.

Review of the nurse's notes dated 10-12-2018 revealed Patient #45 was "touching others." There was no further documentation on how the patient was touching others.

On 10-13-2018 at 9:05AM, nurse's notes stated, "Inappropriate sexual behavior with staff tried to kiss employees." A physician order was found on 10-13-2018 at 11:45AM, "please add SAO to patient's precautions." (sexually acting out precautions)

Review of the Patient Observation Round Sheet on 10-13-2018 through 10-17-2018 revealed there was no documentation that the Mental Health Technician (MHT) was aware the patient was on SAO precautions. There is a check box on the sheet that stated, "Observation level and precautions." The only things checked on the observation sheet was "every 15 minutes" for observation level and "S/P danger to self (suicide precautions)" for precautions. Observation Round Sheet found for 10-14-2018 did show the patient was on a SAO.

Review of Patient #45's nurse's notes for 10-14-2018 at 8:00AM revealed the nurse had checked a box under Sexual Behavior Assessment as a "sexual predator."

Review of Patient #45's nurse's notes for 10-15-2018 at 7:48AM revealed under the section Sexual Behavior Assessment a "N/A" was written. There was no documentation that the physician was called to reassess the patient; to see if she was no longer appropriate to be on SAO precautions. There was no order to discontinue the precautions. There was no further documentation of the patient's behaviors under the SAO physician orders.

On 10-18-2018 in the afternoon, the surveyor found Patient #45 had a roommate. Patient #46 had been admitted to the facility on 10-17-2018 and was placed in Patient #45's room. There was no documentation that Patient #45 was on a 1:1 during the nighttime hours, or under constant supervision by a nurse, or that a physician order was written to remove the patient from SAO precautions.

Review of the policy and procedure "Sexually Acting Out Precautions" revised on 10/16/2018 revealed:

"PROCEDURE: 3. The RN will assess each patient for potential for sexually inappropriate behavior during the admission nursing assessment. The high risk areas are marked with an asterisk on the assessment, if any of these sections are checked, then place on SAO precautions. Any patient who has demonstrated sexually inappropriate behavior during hospitalization will be placed on SAO and remain on SAO precautions for the remainder of the hospitalization.

a. The RN or MD may place a patient on SAO precautions. The MD is the only staff who can remove a patient from SAO precautions. b. The Treatment Team at weekly conferences will review the SAO precautions and behaviors necessitating the precautions. c. All personnel caring for the patient shall be sufficiently informed of the patient's status.

4. SAO precautions will be addressed on the Treatment Plan, and will be noted on the Precautions Sheets and Report Sheets to denote the appropriate concerns.

a. Treatment Plan Entry made and dated documenting the patient's sexually acting out status, with a description (brief) of the behavior that prompted the patient being placed on SAO precautions as well as if the patient has been a victim or perpetrator. b. Appropriate documentation will also be entered in the multidisciplinary notes. c. SAO precautions will be documented on the Patient Data and Assessment form.

6. Patient is to be housed in a private room when available. If a private room is unavailable, the patient on SAO's will sleep in the room across from the Nurse's station for close observation. If a room across from the Nurse's station is not available, the patient will be placed on a COHS "Continuous Observation at Night" observational level.

7. General Safety Procedures to be enforced:
a. Report and record all sexual remark and gestures. b. Never leave patient unattended with other patients. c. Perpetrators will be redirected from situations that might stimulate negative behaviors. d. Victims will be observed closely and staff will maintain a safe environment avoiding potential threats."

An interview was conducted in the afternoon on 10-18-2018 with Staff #41 (RN). Staff #41 reported to surveyor that Patient #45 was in room 105 and had a roommate. Staff #41 reported the roommate had come the night before. Staff #41 was not aware Patient #45 was on a SAO. Staff #41 stated, "I guess they forgot to tell me in report." Staff #41 stated, "I don't know why she is on a SAO precaution. She has not been acting out. Only took her pants down a couple of times." Staff #41 confirmed she had not called the doctor to reevaluate the patient because the Staff #41 was not aware the patient was on precautions. Staff #41 confirmed for the MHT to know about the precautions the nurse would have to instruct them at the beginning of the shift. Staff #41 reported that she had not been to any of the training on SAO but planned to go after she got off work today. Staff #41 had been allowed to work without being provided the necessary training.

Review of the treatment plan for Patient #45 revealed there was no problem addressed for the SAO.

An interview was conducted with staff #4 on the morning of 10/17/2018. Staff #4 was asked about performance improvement projects and what type of projects are going on at the present. Staff #4 was unable to provide any documentation of current or ongoing performance improvement projects concerning the ongoing deficiencies the facility received on 8/31/2018. Staff #4 reported that he did not have any current projects written or reported at this time. Staff #4 was unable to provide any monitoring data or chart reviews of SAO's or patient safety since 8-31-2018.

An interview was conducted in the afternoon on 10-18-2018 with Staff #2 and #1. Staff #2 confirmed Staff #41 had not had the SAO training and was allowed to work. Staff #2 reported that he thought he had until the end of the CMS survey to complete the training of staff. Staff #2 was reminded by the surveyor that he had agreed to have all staff trained before they worked with the patient population. Staff #1 and #2 was unable to tell the survey team how many patients in the facility were identified as sexual perpetrators, what units those patients had been assigned, and if those patients had been placed on SAO precautions while in the facility. There was no tracking in place to monitor, assess, or identify who was on SAO precautions, who was a sexual predator, and if patients were safe in the facility.

In the afternoon on 10-19-2018 an interview was conducted with Staff #1, #2, #3 and #4. Staff #1 submitted an Abatement Plan for "Sexual Acting Out." This plan was submitted after the surveyors made the administrative staff aware of the failure to address this as part of the Immediate Jeopardy on 8-31-2018.


Findings for D)and F) were as follows:

Review of patient #50's chart revealed she was a 13-year-old female admitted on 10/29/17. Patient #50 was admitted with a diagnosis of Bipolar disorder, current episode mixed, severe without psychotic features.

Review of the physician orders revealed the patient was ordered "seclusion, Zyprexa 5 mg IM, and Benadryl 25 mg IM now for sever agitation and aggression." Review of the Restraint /Seclusion record dated 10-30-18 at 2145 (9:45PM) revealed the patient was "hitting, yelling, scratching staff." Review of the chart revealed there was no documentation that patient #50's mother or any legal guardian was notified of the seclusion or emergency medication administration.

Review of the nurse's notes dated 11/3/17 at 2130 (9:30PM) revealed the nurse documented, "Pt has been given HS meds and instructed to go to bed multiple times by multiple staff. Pt refuses, sitting out in dayroom. Pt began hitting walls, windows and counters with hands. Pt started bouncing paper towels off walls and began to upset other peers. Pt continued to increase verbally yelling at staff and continues to refuse to go simply lay down in room. Will notify MD. 2138 (9:38PM) phoned on call MD ____ (staff #45) and orders received for IM injections. Consents for IM meds on chart from previous Monday. 2149 (9:49PM) House supervisor____ notified of injection given.2157 (9:57PM) Attempt to notify parents, left voice msg at (phone number) to update on meds given.2218 (10:18PM) pt asleep in bed w/o further concern or distress. Continue to maintain safety w/q 15 minute checks."

Review of patient #50's chart revealed a physician order written on 11/3/17 at 2138 (9:38PM). The physician order stated, "Give IM injection x1 Now of Benadryl 25 mg IM and Zyprexa 5 mg IM for severe agitation."

Review of patient #50's chart revealed there was no Restraint /Seclusion record documented for the emergency behavioral medication administered on 11/3/18. There was no documentation found of the patient receiving any therapeutic interventions before giving a chemical restraint, face to face, nursing assessments, vital signs, or continuing nursing interventions. There was no further attempt documented to contact the legal guardian regarding the medication administration.


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Findings for D), E), and F) were as follows:

A review was made of psychotropic medications (medication capable of affecting the mind, emotions, and behavior) that were given in the Intramuscular (IM) route. Haldol injections, Geodon injections, Thorazine injections and Zyprexa injections were reviewed for a 6-month period of 4-15-2018 to 10-15-2018.

A total of 985 doses were identified as requiring an override for "Emergency Use" or "Other". Medications that did not require an override or were identified as requiring an override for "Initial Dose" were not counted.

Review of Texas Administrative Code, Title 25 Health Services, Part 1 Department of State Health Services, Chapter 133 Hospital Licensing, Psych Meds-Psychiatric Emergencies, 414.410(b)-(c) was as follows:

"(b) If a physician issues an order to administer psychoactive medication to a patient without the patient's consent because of a psychiatric emergency, then the physician will document in the patient's clinical record in specific medical or behavioral terms:
(1) why the order is necessary,
(2) other generally accepted, less intrusive forms of treatment, if any, that the physician has evaluated but rejected; and
(3) the reasons those treatments were rejected.
(c) Treatment of the patient with the psychoactive medication will be provided in the manner, consistent with clinically appropriate medical care, least restrictive of the patient's personal liberty."

Review of medical records for Patient #21, #22, #27, #28, #20, and #33 did not contain the required documentation.

Review of Policy #801.00, Peer Review and Performance Monitoring, Effective 12-2-2013 was as follows:

"PURPOSE

To provide a mechanism whereby the Medical Staff ensures that the Medical Staff approved Peer Review Criteria are effectively monitored for all members of the Medical Staff in an organized and fair manner, and that a process for performing an ongoing evaluation of each practitioner's professional practice and abilities to perform requested clinical privileges has been defined to include at a minimum, requests for initial appointment and at reappointment.

...

PEER REVIEW CRITERIA

Criteria for review will be developed and approved by the Medical Staff. Peer Review cases are identified by, but not limited to, the following Peer Review Criteria. Cases are identified by direct knowledge of the case, incident reports, patient complaints, and regulatory agency review or routine case review. Reviews may include:
Cardiac or Respiratory Arrest
Death in Facility
Restraint/Seclusion Review
Inadequate Medical Record Documentation
Significant Adverse Drug Reaction
Medical Management / Miscellaneous
Significant Complaint
Other as deemed reviewable

Peer review cases will be reviewed and scored as a "1" through "6" by the initial reviewer/screener and results will be forwarded to the Medical Executive Committee for the review and final determination of the variation code, if necessary.

..."


An interview was conducted with Staff #37 on the morning of 10-19-2018. Staff #37 stated Peer Review was conducted 90 days after medical staff was hired and when reappointed at the 2-year reappointment. Staff #37 stated she was not aware of a peer review committee or a mechanism/process for other issues to go before peer review.

An interview was conducted with Staff #35, Medical Director. Staff #35 stated there was not a peer review committee. Staff #35 stated the Medical Executive Committee looks at cases but there was not a formal process. Staff #35 was not familiar with the process for an initial reviewer/screener to review cases, score them, and forward to the Medical Executive Committee for review and final determination, per policy.

Because of the failure to follow the policy, this prevented psychotropic medications administered during a behavioral emergency, and being monitored as a restraint, from being screened and reviewed by the Medical Staff and facility for potential overuse or misuse.

Review of Texas Administrative Code, Title 25 Health Services, Part 1 Department of State Health Services, Chapter 133 Hospital Licensing, Psych Meds: Monitoring Compliance, 414.413(a)-(d) was as follows:


"(a) Each service setting will implement policies and procedures in accordance with this subchapter.
(b) Self-monitoring of compliance will include the following components:
(1) procedures to audit records for compliance;
(2) procedures to analyze and report audit results to staff responsible for the informed consent process; and
(3) procedures to improve the performance of individual employees, contractors, and agents, and to improve overall facility performance.
(c) Each service setting will collect information related to obtaining consent to treatment with psychoactive medication and the use of psychoactive medication in psychiatric emergencies as may be required by the medical director of TDMHMR.
(d) Each service setting will maintain a record of self-monitoring of compliance and may present these records to licensing or oversight authorities when requested."

Review of Quality / Process Improvement (QAPI) reporting provided by Staff #4 revealed there was no mechanism for audit or analysis of psychotropic medications given during a psychiatric emergency to ensure that a true psychiatric emergency existed and that the medication was appropriate. No Process Improvement (PI) initiatives were identified to improve the overall facility performance in the use of psychotropic medications in a behavioral emergency.

An interview was conducted with Staff #2 on 10-16-2018. Staff #2 stated that if the patient accepted the shot willingly and signed a consent, staff did not monitor the shot as behavioral restraint used in an emergency situation. However, if the patient refused to consent, they were given the shot anyway because it was a behavioral emergency. No mechanism was in place to ensure patients didn't sign consents and accept medication injections to prevent multiple staff from holding them down and being forced to receive a shot. No mechanism was in place to evaluate if the patient was calm enough to sign a consent and agree to a shot, was the shot actually needed for a behavioral emergency where a patient was a danger to themselves or others.


Review of Patient #21's chart

Patient #21 was an 11-year-old boy admitted to the facility on 10-5-2018 with an admitting diagnosis of Major Depressive Disorder, recurrent severe without psychotic features. The patient was discharged on 10-11-2018.

On 10-5-2018 at 7:50 PM, an order was written for IM (a shot to be given in a muscle) Zyprexa 5 mg (milligram) x 1 dose and IM Benadryl 25 mg x 1 dose. The order did not include the reason for the medication being ordered. The medication was given. A restraint and seclusion package was initiated. Per nursing documentation on Nursing Assessment form and Narrative, the patient was first placed in seclusion. Because the patient continued to hit the wall and the door while in seclusion, "causing lots of noise and disturbance" he was administered IM Zyprexa and Benadryl. Nothing was documented about what type of danger the patient presented to himself or others.

On 10-6-2018 at 8:40 PM, an order was written for IM Zyprexa 5 mg x 1 dose and IM Benadryl 25 mg x 1 dose. The reason given was for aggression / agitation. The medication was given. This was a telephone order written by the nurse. No physician signature was found for the order. A restraint and seclusion package was initiated but not signed by the physician.

On 10-8-2018 at 12:35 PM, an order was written for Haldol 5 mg, Benadryl 25 mg, and Ativan 1 mg to be given IM for increased agitation and increased aggression. The medication was given. A restraint and seclusion package was initiated.

On 10-8-2018 at 5:40 PM, an order was written for Haldol 5mg and Benadryl 25 mg to be given IM for severe agitation and increased aggression. The medication was given. No restraint and seclusion package was found.

Review of psychiatric progress notes from 10-6-2018 through 10-10-2018 did not contain mention of the need to give Patient #21 repeated doses of psychotropic medications in emergency behavioral situations.

Review of Patient #22's chart

Patient #22 was a 10-year-old girl admitted to the facility on 11-15-2017 with an admitting diagnosis of Disruptive Mood Dysregulation Disorder.

On 11-19-2017 at 8:37 PM, an order was written for Zyprexa 5 mg IM and Benadryl 25 mg IM to be given for Aggression. The medication was given. No restraint and seclusion package was found. Per nursing documentation on Nursing Assessment form and Narrative, the patient was "intrusive, disruptive, agitated, aggressive, rec'd IM Benadryl 25mg x 1 Zyprexa 5mg x 1. Pt went to quiet room still agitated. Pt in bed asleep at this time." The note was not timed, so unable to tell what time the note "Pt in bed asleep at this time" was made.

Review of psychiatric progress notes from 11-20-2017 showed a note that said, "Received emergency meds yesterday." The note did not contain information in specific medical or behavioral terms as to why the order was necessary, other generally accepted, less intrusive forms of treatment, if any, that were evaluated and rejected, and why they were rejected.

Review of Patient #27's chart

Patient #27 was a 9-year-old boy admitted to the facility on 9-21-2018 with an admitting diagnosis of Disruptive Mood Dysregulation Disorder.

On 9-27-2018 at 6:20 PM, an order was written for Haldol 5 mg, Benadryl 25 mg, and Ativan 1 mg to be given IM for increased agitation. The medication was given. No restraint package was found. An incident report was completed that confirmed emergency medications were given because the patient was a danger to self or others.

On 9-28-2018, the psychiatric progress note documented the patient was instigating others, was not following directions, and needed frequent staff interventions to reduce aggression towards others. Psychiatrist notes did not address the need for emergency behavioral medication administrations.

On 10-8-2018 at 12:35 PM, an order was written for Haldol 5 mg, Benadryl 25 mg, and Ativan 1 mg to be given IM for increased agitation and increased aggression. A restraint package was initiated for medication and a hold. The box for the patient being placed in seclusion and the start/stop times were blank. The Multidisciplinary Progress Note contained an entry on 10-8-2018 at 2:13 PM, "Patient was in seclusion during class today." No other information about the seclusion was charted on the Multidisciplinary Progress Note.

On 10-8-2018, the psychiatric progress note documented the patient was "Defiant, agitated easily, aggressive towards peers and staff; received emergency meds today." Psychiatrist notes did not address the need for emergency behavioral medication administrations. Psychiatrist notes did not address other generally accepted, less intrusive forms of treatment, if any, that the physician has evaluated but rejected; and the reasons those treatments were rejected.

Review of Patient #28's chart

Patient #28 was a 53-year-old female admitted to the facility on 6-17-2018 with an admitting diagnosis of Schizophrenia.

On 6-21-2018 at 6:10 PM, the nurse wrote a telephone order for Geodon 20 mg and Ativan 2 mg to be given IM for agitation / aggression. The medication was given per the Medication Administration Record (MAR). No restraint and seclusion package was found. Psychiatrist notes did not address the need for emergency behavioral medication administrations.

On 6-29-2018 at 7:27 AM, the nurse wrote a telephone order for Zyprexa 10 mg and Benadryl 50 mg IM for agitation. This order was not signed by the physician. The medication was given per the MAR. No restraint and seclusion package was found. Psychiatrist notes addressed the need for emergency behavioral medication administrations; but, did not address other generally accepted, less intrusive forms of treatment, if any, that the physician has evaluated but rejected; and the reasons those treatments were rejected.

On 6-29-2018 at 3:15 PM, the nurse wrote a telephone order for Geodon, 20 mg IM and Ativan 2 mg IM for agitation. This order was not signed by the physician. The medication was given per the MAR. No restraint and seclusion package was found. Psychiatrist notes addressed the need for emergency behavioral medication administrations; but, did not address other generally accepted, less intrusive forms of treatment, if any, that the physician has evaluated but rejected; and the reasons those treatments were rejected.

On 6-30-2018 at 3:25 PM, the nurse wrote a telephone order for Zyprexa 10 mg and Benadryl 50 mg IM for agitation. The medication was given per the MAR. No restraint and seclusion package was found. Psychiatrist notes addressed the need for emergency behavioral medication administrations; but, did not address other generally accepted, less intrusive forms of treatment, if any, that the physician has evaluated but rejected; and the reasons those treatments were rejected.

On 7-4-2018 at 11:15 AM, the nurse wrote an order for Geodon 20 MG and Ativan 2 mg IM for increased agitation and psychosis. This order was not signed by the physician. The medication was given per the MAR. No restraint and seclusion package was found. Psychiatrist notes did not address the need for emergency behavioral medication administrations.

Review of Patient #20's chart

Patient #20 was a 15-year-old admitted on 9/16/2018 with a diagnosis of auditory hallucinations, flights of ideas, impaired thinking, hyperactive, suicidal, patient running across streets in traffic. Patient #20 was a current patient as of 10/19/2018. Twelve emergency IM injections were ordered. Nine injections were given from 9/16/2018 through 10/19/2018 end of survey. Two injections (9/28/18 and 10/05/18) did not have restraint/seclusion orders and 3 injections were refused per patient.

On 9/16/2018 5:30 PM, the nurse charted, "encourage to take anxiety medication, pt refuse injection Haldol 5mg, Ativan 2mg, Benadryl 50mg. Seclusion criteria for release calm and aggressive for 15 minutes, pt agree, release 1830."

9/17/2018 0840 encourage to take anxiety medication, pt refuse injection Haldol 5mg, Benadryl 50mg for agitation, calm in dayroom, refuse vital signs.

9/21/2018 1220 Zyprexa 5mg, Benadryl 25mg order not given. Seclusion no PRN

9/24/2018 1335 Haldol 5mg, Ativan 1mg, Benadryl 25mg IM severe aggression, seclusion 1158-1240

On 9/28/2018 at 9:20 AM, a physician order was found for Zyprexa 5mg and Benadryl 25mg IM for severe aggression.

10/01/2018 0910 Zyprexa 5mg Benadryl 25mg IM severe aggression, seclusion end 0935

10/02/2018 1155 Haldol 5mg, Ativan 1mg, Benadryl 25mg IM severe aggression, seclusion 1158-1240

10/04/2018 0955 Haldol 5mg, Ativan 1mg, Benadryl 25mg IM severe aggression, seclusion 0850-0955

Review of nursing progress note from 10/05/2018 stated 1632 Pt in dayroom with other patients watching TV. No complaints noted at this time. Late entry 1530, patient stumping feet yelling screaming. Provider order injection to be given to patient. 1530 shot given.

10/06/2018 1400 Zyprexa 10mg Benadryl 50mg IM severe agitation, seclusion 1415-1500

10/08/2018 0845 Haldol 5mg, Ativan 1mg, Benadryl 25mg IM severe aggression, seclusion 0845-1000

10/11/2018 0930 Haldol 5mg, Ativan 1mg, Benadryl 25mg IM severe aggression, seclusion 0930-1130


Review of Patient #33's chart

Review of the medical record for Patient #33 on the morning of 10/18/2018 revealed Patient #33 was a 12-year-old boy admitted to the facility on 09/21/2018 with an admitting diagnosis of Disruptive Mood Dysregulation Disorder (Adolescent). The patient was a current inpatient on Unit 5 at the time of the survey.

Review of a Daily Nursing Assessment note, dated 9/27/2018, read in part "1720 (5:20 PM) Patient alert, oriented X3, very hyperactive, easily irritated. Acting out, running up and down the unit. Refused to follow unit instruction. Send to his room for time out continuous re-directing but still pt didn't want to follow instruction." "1820 (6:20 PM) - ______ (Staff #23, physician) ordered emergency medication Haldol 5mg/IM (in muscle), Ativan 1 mg/IM and Benadryl 25mg/IM for agitation - and administered to the patient." The nurse narrative also stated "1900 (7:00 PM) - Patient in his bed sleep and no distress observed. Will continue to monitor q15 mins for safety." The review revealed there was no restraint and seclusion package initiated. There were no documented vital signs for 09/27/2018 after the administration of the emergency medication injection.

Review of the "Medication Administration Record" dated 09/27/2018 read in part "Haldol 5mg/IM, Benadryl 25mg/IM, Ativan 1 mg/IM X1 for agitation" was given at "1825" (6:25 PM).

Review of the "Patient Observation Rounds" dated 9/27/2018 documented that from 1715 - 1815, (5:15 PM - 6:15 PM) Patient #33 was in the dayroom interacting with peers; 1830 (6:30 PM) he was in dayroom watching TV; 1845 (6:45 PM) he was in the dayroom lying down; 1900-1945 (7:00 PM - 7:45 PM) he was in the dayroom and appears s

Based on review and interview the facility failed to:
1.) protect patient #1 and #49 from further harm by investigating to see if the children had been injured and needed further examination, if the physician had all the information to make an appropriate plan of care and potential examination, that the patient received appropriate counseling concerning the sexual abuse, and if the patients CPS worker was informed of the full extent of the sexual abuse in 2 of 2(#1 and #49) charts reviewed.

2.) identify events and occurrences by investigating, monitoring, tracking, and analyzing all incident reports to protect all patients from sexual abuse and harm.


Review of patient #1's chart revealed the patient was admitted on 7/16/18. He was a 11-year-old Hispanic male that was placed on the children's unit. Patient #1 was brought in by his case worker with Child Protective Services (CPS).

Review of patient #1's psychosocial assessment dated 7/18/18 at 5:00PM revealed the patient was having fights, becoming more aggressive, and running away from the shelter he lives at. "patient reported to therapist that that he felt that he wanted to kill himself by chocking himself but currently reports no SI." Review of the section on abuse or self-harm the patient denied any sexual abuse as a victim or predator.

Review of the physician psychiatric evaluation completed on 7-17-18 revealed the patient was feeling "helpless and hopeless". The physician documented, "In foster care- sibling was abused in bio-home. Children removed 7 weeks ago." There was no documentation on what type of abuse in the home. The psychiatrist did not document any questioning of sexual abuse with the child.

Review of the physician orders for admission on 7/17/18 at 0020(12:20AM) revealed the patient was placed on suicidal precautions-moderate and every 15 minute checks.

Review of the nurse's notes dated 7/25/18 at 1330 (1:30PM) revealed the nurse documented, "Pt. was found engaging in sexually inappropriate behavior with roommate. No acute distress noted. 1345 (1:45PM) Dr. (____staff #23) notified. 1424 (2:24PM) CNO notified/ House Sup (1435) notified. 1357 (1:57PM) Attempted to contact CPS______ (name of worker) voicemail left. 1707 (5:07PM) _____ (CPS worker) notified; thankful for call."
There was no further information documented from the nurse concerning the incident, what happened, the physical or emotional condition of patient #1 or #49, or how the nurse protected the patients from further harm.

Review of the physician orders revealed a telephone order was written on 7/25/18 at 1345 (1:45PM). The order stated, "ADD SAO PRECAUTION 1:1 observation due to SAO with roommate."

A physician order was found on 7/25/18 at 1530 (2:30PM) BLOCK ROOM (SAO behavior) pt. to have 1:1 observation if he gets a roommate."

Review of the nurse's notes dated 7/25/17 at 1755 (5:55PM) stated, "Patient was placed on 1:1 at the beginning of the shift for SAO behavior until his room was blocked. Roommate _____ (illegible word) removed to another room for safety. Will continue to monitor closely." There was no further documentation found concerning the patient sexual abuse in the nurse's notes.

Review of the Patient Observation Rounds sheet revealed there was no documentation that the patient was on a 1:1. The Mental Health Technician (MHT) documented the patient was in his room from 1:30PM-2:00PM and back in his room from 3:00PM -4:30.

Review of the psychiatric progress note dated 7/26/18 8;20PM revealed there was no documentation concerning the sexual abuse. The physician documented "awaiting placement." There was no documentation of a medical exam found concerning the sexual abuse. Review of the physician discharge summary dated 8/7/18 revealed there was no found documentation of the sexual abuse, SAO precautions or any therapy to help the child cope with the incident.
Review of the progress notes on 7/25/18 at 5:07PM revealed staff #25 (social worker) documented, "called the patients caseworker ______ (name of CPS worker) to make her aware of the incident that happened with another patient. I did make her aware that him and another male patient were having poor boundaries with one another and touching each other inappropriately. I made the case worker aware that the patient was placed on a 1:1; and SAO precautions. The case worker said thank you for making her aware and she had no further questions nor concerns at this time. (sic)"

An interview was conducted with staff #25 in the afternoon on 10/16/18. Staff #25 reported that she did remember the incident and patient #1. Staff #25 confirmed that she had not interviewed the child and was repeating what she was told by the nurse, Staff #25 stated, "I didn't know there was penetration. I was told it was just inappropriate touching."

Review of the incident reports revealed there was a report filed on 7/25/18 at 1330 (1:30PM) for patient #1. Staff #38 RN filed the report. The report stated the patient was on unit 6 and it happened in the patient's room. The incident type was checked, "boundary violation with peer." In the description is stated, "see attached sheet." There was no attached sheets or information found. A witness was documented to be staff #39 MHT. The back side of the report had a section for "additional findings and outcomes, was the patient sent out for additional evaluation? and follow up action taken." There was no information in these sections. They were left blank. The director of nursing signed the form and dated the form 7/26/18. The risk manager also signed and dated the form on 7/26/18 with no further evaluation. The other child involved in this incident, patient #49, had the same incident report with no follow up.

An interview was conducted with staff #39 on 10/16/18 in the afternoon. Staff #39 reported that she witnessed the sexual encounter between the two 11-year-old boys on 7/25/18. Staff #39 reported during her 15 minute rounds she walked into the boy's room and found patient #49 with his penis in patient #1's anus. Staff #39 stated, "I told them to stop that. They both pulled up their pants and I separated them." Staff #39 reported that she took the boys to the nurse's station and reported to the nurse that patient #49 was on top of patient #1 and they were having sex. The surveyor asked staff #39 if there was penetration and if she conveyed that to the nurse? Staff #39 stated, "yes, there was penetration and I told the nurse exactly what I saw." Staff #39 reported the nurse separated the boys and talked to them. Patient #1 went back to his room and didn't want to come back out. Staff #39 stated, "he was ashamed and embarrassed and didn't want anybody to ask him questions." Staff #39 was asked if she was ever interviewed or asked to write a written statement about the incident and she stated, "no."

An interview with staff #2 and #4 was conducted on 10/16/18 in the afternoon. Staff # 2 and #4 was asked about the incident report written on patient #1 and #49 on 7/25/18. Staff #2 reported that he was not sure why the incidents were not completed. Staff #4 reported that he was sure something was written on the issue but he was unable to provide any documentation. Staff #4 was unable to explain to the surveyor how the incidents were managed, investigated, or analyzed for reporting to medical staff and governing board. Staff #2 and #4 failed to protect patient #1 from further harm by investigating to see if the child had been injured and needed further examination, if the physician had all the information to make an appropriate plan of care and potential examination, that the patient received appropriate counseling concerning the sexual abuse, if the patients CPS worker was informed of the full extent of the sexual abuse, monitor, track and analyze other incidents to protect all patients from sexual abuse and harm.

Based on review of documentation and interviews the facility failed to identify hospitalized patients who would likely suffer re-admissions for inadequate discharge planning. Patient #38 and #39 had multiple re-admissions for the same diagnosis. The discharge plans did not address anticipated problems after discharge.

Findings were;
Review of medical records reveal patient #38 had six admissions from 2/15/18 through 6/9/18. Patient #39 had five admissions 4/10/17-10/9/17.

In an interview with staff #20 director of social services on the afternoon of 10/17/18 at the facility. Staff #20 said previously they did not have a functioning discharge procedure. Staff #20 said staff changes were made and new forms have been created. Staff is being trained on the correct discharge procedure. Staff #20 gave the surveyor copies of the forms the facility is currently using. The surveyor asked staff #20 when did the forms become effective as there was no revision or effective date on the forms. Staff #20 said they are in the process of training the staff at this time.

An interview was conducted on 10/17/18 at 4:40pm at the hospital with staff #30 (MHT) mental health tech concerning the discharge of patient #39. The surveyor asked staff #30 did she remember patient #39, staff #30 said yes, she was here several times; when it was time for her to be discharge she would become angry. It got so bad that staff would not tell her when it was time for her discharge.

An interview was conducted with staff # 4 the risk manager at 10:05 am on 10/17/18 at the facility. The surveyor asked staff # 4 about discharge planning, staff #4 said that is handle by social services. Staff #4 said he did a summary of events for patient #38 after being notified by Parkland the patient was taken by Dallas Police to Parkland on the eve of discharge from DBH. Staff #4 said the doctor said she was safe to go home and she had to go.

An interview was conducted with staff #2 CNO on the morning of 10/17/18. Staff #2 was asked if he was aware of the multiple readmissions for patient 38 and 39. Staff #2 said they are in the process of re-training for discharge planning.
Staff #4 said they consulted with patient #38's mother about her discharge. Staff #2 said the mother was instructed to pick up her child or they would start a case with CPS for abandonment.

Based on review of records and interview, the facility failed to ensure discharge planning was completed in time to make arrangements before discharge as 6 of 6 (Patient #2, 3, 33, 41, 47, 48) medical records reviewed did not contain complete updated discharge planning in the comprehensive treatment plan which could result in possible inadequate aftercare for discharged patients.

Findings were:

Review of medical records for Patients #2, 33, 47, 48 revealed no documented active discharge plans in the comprehensive treatment plans. Review of medical records for Patient #3 and 41 revealed no documentation of updated complete discharge plans in the master treatment plan until the date of discharge.

An interview was conducted with the Chief Nursing Officer (CNO) Staff #2 on the morning of 10/18/2018. Staff #2 was asked if he could find specific discharge plans in the master treatment plan for Patients #2, 33, 47 and #48. Staff #2 stated "No. There are no specific discharge plans."

Review of facility policy titled "Master Treatment Plan" with a revised date of "02-15-17" stated in part "F. The Master Treatment Plan includes:
1. Long Tern Goals (Discharge Criteria):
a. Builds on the patient's strengths
b. Supports the transition to re-integration into the community when identified as a need
c. Barriers that may need to be considered include co-occurring illnesses, cognitive and communicative disorders, developmental disabilities, vision or hearing disabilities, physical disabilities, and social and environmental factors.