The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ALLEGIANCE SPECIALTY HOSPITAL OF KILGORE 1612 SOUTH HENDERSON BLVD KILGORE, TX 75662 Dec. 16, 2014
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on chart review and interviews the facility failed to ensure the patient was informed of his/her health status, being involved in care planning, treatment, and ability to request or refuse treatment of psychoactive medications administered in 1 (#1) out of 5 (#1-5) charts reviewed.

Review of patient #3's chart revealed the patient was admitted on [DATE]. Patient #3 had refused to sign his admission consents.

Review of the Psychiatric Evaluation on 12/10/2014 revealed the patient was admitted with Dementia of the Alzheimer's type with behavioral disturbances. Patient #3 was only oriented to person. Patient #3 is 81 but thought he was [AGE] years old. He was essentially non-conversant and his judgement was poor. Attention and concentration was impaired.

Review of patient #3's chart revealed a statement made by the nurse on 10/9/2014 upon admission. The statement revealed patient #3 was admitted on a Order of Protective Custody (OPC) warrant. There was no evidence of the warrant in the chart. There is no physician order for involuntary or voluntary admission.

Review of the "Consent To Treat With Psychoactive Medication" sheet revealed patient #3's son verbally consented on patient #3's consents. There was no evidence found of patient #3's son as the LAR.

Review of the "Consent To Treat With Psychoactive Medication" sheets revealed patient #3 was administered the following medications with verbal consent from patient #3's son, no evidence found of a patient consent, patient education, how the medications were explained to the son, or what signs and symptoms to report of adverse reactions. The medications were as follows;

1. Xanax (alprazolam) is a benzodiazepine medication used to treat anxiety and panic disorders.
2. Zoloft (sertraline) is used to treat depression, obsessive-compulsive disorder and panic and anxiety disorders
3. Depakote (divalproex sodium) as an add-on treatment for epilepsy, or bipolar mania.

Staff #1 and #2 confirmed the above findings. Staff #2 reported they would do further training with the staff and physicians.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on chart review and interview the facility failed to instruct the patient in his or her rights to formulate Advance Directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives in 1(#3) of 5 (#1-5) patient charts reviewed.

Review of patient #3's chart revealed the patient was admitted on [DATE]. Patient #3 had refused to sign his admission consents that include advanced directives. The consents were blank. There was no Medical Power of Attorney (MPOA) found on the chart.

Review of the Psychiatric Evaluation on 12/10/2014 revealed the patient was admitted with Dementia of the Alzheimer's type with behavioral disturbances. Patient #3 was only oriented to person. Patient #3 is 81 but thought he was [AGE] years old. He was essentially non-conversant and his judgement was poor. Attention and concentration was impaired.

Review of the patient chart report dated 12/9/2014 revealed demographic information " Alternate Code Status Information." In a box to the right of " Alternate Code Status Information." staff # 9 documented, "Request for order for Do Not Resuscitate (DNR) pending." There was no evidence found of who requested the DNR status. There was no evidence found of a previous DNR status.

Review of patient # 3's chart a revealed on 12/10/2014 the physician had written an order for DNR but there was no advanced directive on the chart. No further documentation found on advance directives, or the attempt to instruct patient of his rights.

Interview with staff #1 on 12/17/2014 confirmed the above findings.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based upon record review and interview, the facility failed to ensure 1 of 5 patients reviewed received a complete nursing assessment on admission and as condition changed.

Review of the medical record for patient #1 revealed patient was admitted to the facility from an acute care facility after undergoing a percutaneous transluminal angioplasty/stenting of the right distal superficial femoral artery and of the right tibioperoneal trunk without complication. Prior to the acute care hospitalization , patient had been diagnosed with a vascular dementia which family had reported had caused patient to have a change in behavior and had become combative at home. Family had made previous arrangements for patient to be evaluated and treated at this facility prior to her emergency admission at the acute care facility.

Review of the pre-admission screening revealed patient's chief complaint was "I had surgery and I had pain because I let it go." The screening further revealed patient was depressed, had fleeting thoughts of suicide, and was oriented to person and date with some confusion when asked multiple questions. The psychiatric assessment section of the nursing assessment revealed patient was oriented only to person. The patient's daughter reported patient is irritable, anxious, agitated, verbally and physically aggressive which worsens around 6:00pm. Patient was admitted at approximately 6 pm. Patient signed a consent for voluntary admission and her consent to treatment.

Review of the hand written admission nursing assessment revealed the chief complaint was confusion, depressed (not in patient's own words). The patient reported pain in her left upper leg (surgical site) that was rated "6" on a verbal scale of 1-10. Patient reported pain on moving around and standing. The nursing assessment revealed the sections for musculoskeletal, respiratory, social history, psychomotor assessment, thought content, escalating behavior triggers and strategies, and monitoring level was left blank. The section for integumentary (skin) revealed "scars" was the only problem identified and the only scar marked on the diagram of the human body was on the right buttocks. The section for surgeries revealed patient had 4 abdominal surgeries and the recent stent placement with access site in the left groin but none of these were noted on the diagram. Review of the electronic admission assessment section for integumentary revealed "scars, bruising throughout. Pt. had IVs that left bruising. Bruises in different stages of healing.

Review of electronic nurses notes on 12/2/14 at 2030 (8:30 pm) revealed "Patient had completed shower and stated that she was "feeling tingling all over." States that she is not feeling well. Vital sign = 83, pulse 90/42, bp,and O2 sat - 98%RA (room air). Hardness noted around Lt. groin catheterization site covering a large area. Area marked. Will continue to monitor."

2130 (9:30pm) - "Size of hematoma to groin site decreasing in size. Patient anxious and Valium 5 mg. po administered.

21:45 "Patient had small amount of emesis. Food particles noted."

22:10 "Patient assisted to and from BR and had soft formed BM."

00:00 "Patient remains restless. Continues to moan at this time."

01:00 "Patient incontinent of soft formed stool. Patient sat on floor by bed refusing to cooperate with staff. Staff assisted patient in standing position. Patient "went limp" when staff attempted to stand. Hygiene care provided by staff and bed linens changed. Patient assisted to bed."

01:30 "Patient asleep at this time. Respirations regular and unlabored."

There was no documentation of reassessing vital signs (BP 90/42 at 2030), no documentation of a hematoma to groin site or description of size, color, or associated pain, no reassessment of the effectiveness of the Valium given at 2130, and no assessment of vital signs when patient "went limp" at 01:00.

The next documentation was dated 12/3/14 at 07:24: "At or about 06:20, I went to patient's room to assess her. Upon entering her room, Patient stated she could not breathe. I retrieved the O2 monitor and returned to her room. Her O2 saturation was at 93% with a HR (heart rate) of 50. She had no s/s of SOB (shortness of breath) her respirations were even and unlabored. The PCT asked me if I wanted her to get up and go in the dining room. I informed the PCT that all she was going to do is sit in bed, so I told them to get her dressed and up. At or about 06:30, the PCT brought the patient to the nurses station in a wheelchair and stated she is not responding. I did an assessment, tried to get a BP and O2, I was unable. Patient blood sugar was 272. Patient was given a hard sternum rub with little response. Patient had shallow breathing, pulse was weak, pupils were unresponsive. I immediately took her to the ER."

There was no documentation of a complete assessment when the RN went to the room to assess the patient and before telling the PCT to get patient up and dressed for the day. The patient's heart rate had been 83 at 20:30 on 12/2/14 which was the last time vital signs were assessed. The patient BP at that time was 90/42 but it was not reassessed and BP was not assessed when patient experienced a change in condition 12/3/14 at 06:20am.

Further review of record reveal patient was transferred to an acute care facility for higher level of care.

Review of the policy #CS2-01 titled "Assessment and Reassessment of Patients" revealed the following:

4. "The admission assessment will include, but not be limited to the following areas:

Biophysical needs may include as appropriate, a review of the patient's major body systems;
Physiological parameters ...(vital signs, lab values, respiratory capacity, etc.)
Psycho-social factors (prior history and meds, behavioral issues, support systems, etc.)
Environmental considerations
Self care and educational needs
Assessment of patient's educational or teaching needs.

6. Reassessment - Reassessment of the patient shall occur PRN and each time there is a change in the patient's condition.