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 Aug. 19, 2015
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based upon observation, record review and interview, the facility failed to:
A). ensure the patient's right to make informed decisions regarding his or her care and to ensure the patient was mentally competent to sign admission consents, patient rights information, and voluntary admission status in 4 (#1,2,3,and 11) out of 11 patients reviewed.
Refer to TAG A0131

B.) ensure documented nursing interventions, increased observation/monitoring, management of violent and aggressive behaviors before chemical restraints to ensure safety of the patient and protection of others in 1(#1) of 10 charts reviewed.
Refer to TAG A0144

C. document patient interventions before administration of psychotropic medications. Nursing failed to document ongoing assessments, monitoring, interventions, and care that are appropriate for that patient's needs before and after administration of psychotropic medication and failed to provide a court order to administer these medications against the wishes of the patient in 1(#1) of 10 charts reviewed.
Refer to TAG A160
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on chart reviews, interviews and policy and procedures, the facility failed to ensure the patient's right to make informed decisions regarding his or her care and to ensure the patient was mentally competent to sign admission consents, patient rights information, and voluntary admission status in 4 (#1, 2, 3, and 11) out of 11 patients reviewed.

1.) Review of patient #1's chart revealed he was admitted from a local hospital. Patient #1 had been treated for a Gastrointestinal (GI) bleed. Patient #1 had received 2 units of blood due to anemia while in the hospital.

Patient #1 was brought to the facility on [DATE], with a diagnosis of psychosis and schizophrenia. The patient was brought to the facility on an Emergency Detention Warrant (EDW). Review of the nurse's assessment for 7/21/2015, revealed the patient was confused and agitated. The nurse documented, "IS HOMELESS HAS IMPAIRED JUDGEMENT." Patient #1 signed a "Request for Voluntary Admission" upon arrival on 7/21/2015. Patient #1 had signed all of his consents including patient rights and for psychotropic medications.

Patient #1 was seen by Staff #3 (psychiatrist) on 7/22/2015. Staff #3 wrote on the psychiatric evaluation note dated 7/22/2015, at 12:00PM, "EDW agrees to sign in." There was no documentation found of a physician order changing the patient from involuntary to voluntary.

During an interview with staff #3 on 8/18/2015, staff #3 was asked why patient #1 was admitted as a voluntary patient if he was confused, agitated, and impaired judgement. Staff #3 stated, just because a patient has schizophrenia and psychosis does not mean he didn't understand what he's signing or what's going on around him." Staff #3 reported she was not aware that the psychiatrist would have to write an order to change the patient from involuntary to voluntary status.

Review of the nurse's notes dated 7/23/2015, at 9:13PM, the RN documented, "Received call from the GI physician's office. The office person requesting an appointment with patient #1 ASAP today or no later than Tuesday. The office will fax a copy of report from EGD that shows ulcer at base of esophagus".

8:15AM, GI physician's office called, stating pt. needed to be seen urgently today at 2:30 or 2:45PM. Notified staff #2 (RN) and staff #5 (DPN).

8:45AM, Received ok from adm. That pt to be discharged to go to appointment. Pt. to be discharged , see GI physician, then will be re-evaluated to be readmitted . Staff #6 (intake coordinator) to contact pts family.

9:00AM, called Staff #7 (MD) and notified him of the above. No new orders at this time.

9:10AM, Received report that pts. brother requested to speak to the GI physician and that pt. dc be held at this time.

9:45AM, Received report, that pt's brother, had spoken with the GI doctor. Pt to remain in hospital at this time, and follow up with GI physician once he is discharged .

10:30AM, Staff #7 (MD) notified that pt. will not be discharged at this time, but will follow up with GI doctor once discharged , and that his brother is aware of the plan."

Review of patient #1's chart revealed there was no information that the nursing staff contacted the GI physician's office and clarified the brother's statement. Review of the chart revealed the patient did not have a guardian or MPOA. There was no documentation found that patient #1 was informed of his medical issues or was allowed to make medical decision for himself.

2.) Patient #3 was brought to the facility on [DATE], with a diagnosis of Psychosis NOS. The patient was brought to the facility on an Emergency Detention Warrant (EDW). Review of the nurse's assessment for 8/17/2015 revealed the patient cognitive status was "disorientation and confusion." Patient #3 signed a "Request for Voluntary Admission" upon arrival on 8/17/2015.

Review of patient #3's chart revealed, he had signed his consents for Patient Rights, Request for voluntary admission, medicare rights, consent to treatment and admission, medicaid acknowledgement statement, and a consent for psychoactive medication, Trazadone 150mg, on admission 8/17/2015, at 3:30PM.

Review of patient #3's admission physician orders on 8/17/15, at 6:45PM, revealed the patient status section was blank. There was no order for involuntary or voluntary legal status documented. There was no documentation found in the nurses notes for legal status.

An interview was conducted with staff #6 RN on 8/18/15, at 11:15AM., Staff #6 reported that she allowed the patient to sign the consents and voluntary consent before admission on 8/18/2015, while she was conducting the pre-screening. Staff #6 stated she thought he was confused at first but then she realized he was hard of hearing. Patient #3's wife was giving information to staff #6. Staff #6 stated, "I felt he was able to sign in as alert and oriented due to the interview I had with him."

Review of the Physician Notes dated from the medical clearance dated 8/17/15, reported "acute confusion."

Review of the Community Group Note filled out by the MHT for 8/17/15, stated "Very confused."

An interview with patient #3 on 8/18/2015, revealed he was hard of hearing. During the interview, he was able to read what I wrote and read the questions out loud but was unable to give a coherent answer. Patient stated, "I don't know why I am here at this hotel but I'm ready to go home. Patient #3 could not give me his wife's name, date, year, where he was at, or his birthdate. Patient #3 was not able to follow simple instructions. Patient #3 asked to go home twice and was referred to the nurse to notify the physician by the surveyor.

Review of the nurse's assessment for 8/17/2015, revealed the patient cognitive status was "disorientation and confusion." There was no documentation that patient #3 was cognitively able to understand his patient rights or able to sign a consent for treatment at the facility.

3.) Patient #2 was brought to the facility on [DATE], with a diagnosis of Dementia with psych disturbances and Depression. Patient #2 also had a diagnosis of a Urinary Tract Infection (UTI) upon admission. Patient #2 was reported by family as being aggressive, confused, paranoid, drank disinfectant thinking it was Koolaid, threatening spouse, and difficult to redirect.

Review of the physician history and physical revealed the patient #3 was only oriented to person. Patient #2 was allowed to sign all consents including patient rights and voluntary status. There was no documentation that patient #3 was cognitively able to understand his patient rights or able to sign a consent for treatment at the facility.

4.) Review of patient #11's chart revealed the patient was brought to the facility on an EDW on 2/20/2015, with the diagnosis of psychosis not otherwise specified likely schizophrenia paranoid type, acute exacerbation. Review of the admission assessment nurses notes for 2/20/15 revealed the patient was confused. Review of patient #11's chart revealed the patient was allowed to sign all of her consents including consent to treatment and patients' rights in a confused mental state. There was no documentation that patient #3 was cognitively able to understand his patient rights or able to sign a consent for treatment at the facility.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on chart reviews and interviews, the facility failed to ensure documnetations of nursing interventions, increased observation/monitoring, management of violent and aggressive behaviors before chemical restraints were administered to ensure safety of the patient and protection of others in 1 (#1) of 10 charts reviewed.

There was no nursing documentation of any nursing interventions, increased observation, or who was assessing or observing the patient in his room behind a closed door for 35 minutes after a violent and aggressive episode.

Review of patient #1's chart revealed he was admitted to the facility on [DATE], with a diagnosis of psychosis and schizophrenia.

Review of the nursing admission assessment note stated, "PATIENT REFERRED TO THE FACILITY DUE TO PSYCHOSIS. PATIENT WAS FOUND ON THE STREET LAYING FACE DOWN. PATIENT IS HOMELESS AND HAS NOT BEEN TAKING HIS MEDICATIONS. HISTORY OF SCHIZOPHRENIA. PATIENT IS CURRENTLY A DANGER TO HIMSELF DUE TO NOT TAKING PSYCHOACTIVE MEDS, IS HOMELESS HAS IMPAIRED JUDGEMENT. PATIENT IS ALSO A DANGER TO OTHERS DUE TO LACK OF INSIGHT INTO DISEASE PROCESS. HOMELESS AND DOES NOT TAKE MEDS PATIENT ALSO SUFFERS FROM AGITATION, AGGRESSION AND OTHER FACTORS THAT REQUIRE TREATMENT, CLOSE MONITORING AND OBSERVATION. PSYCHIATRIC CONDITION COULD NOT BE TREATED A LESS RESTRICTIVE LEVEL OF CARE AND INPATIENT TREATMENT IS APPROPRIATE. PATIENT CAN REASONABLY BE EXPECTED TO BENEFIT FROM THE INPATIENT PROGRAM OFFERED AT THE HOSPITAL."

Review of Patient #1's admission physician orders dated 7/21/15, at 12:46PM, revealed the patients ordered observation status. The order read, "Level II -Monitoring close observation within eyesight at all times, 20 feet."

Review of the policy and procedure Patient Monitoring and Precautions stated, "1. In order to provide protection to patients, three levels of staff monitoring are provided.
A. Level I: constant monitoring within arm's length distance
B. Level II: Constant monitoring within 20 feet distance.
C. Level III: close monitoring every 15 minutes, visual observation at a distance of 40 feet or less.
D. Level IV: monitoring on a routine basis every 15 minutes.

2. Special precautions will be initiated for suicidal risk, agitation, elopement risk, aggression, fall risk, or for a change in a medical condition and will continue until orders are received from the attending physician to discontinue.

B. An RN may change the level of monitoring based on changes in the patients behavior or condition. All changes must be documented to include the level of monitoring and the reasons for the monitoring level."

Review of patient #1's MHT CARE AND OBSERVATION FLOWSHEET dated 7/21/2015, revealed a section on the flowsheet titled Observation. In the observation block was a check box and the statement,
" Monitor less than 40 ft, Q15min checks,
Or
one to one monitoring, ordered by physician, requiring one of the following criteria: suicide risk, elopement precautions, violent aggression, change in medical condition. " There was no observation levels checked or documented on 7 out of 28 observation flowsheets.

Review of the following MHT notes and nurses notes revealed patient #1 was allowed to be out of the range of sight, to be aggressive to others, be destructive to property, allowed to be behind closed doors with no supervision, and no documentation of an increase or decrease in observation level to ensure safety for the patient or others:

Review of patient #1's MHT CARE AND OBSERVATION FLOWSHEET on 7/25/2015, revealed the Observation level was checked and stated,"Monitor less than 40 ft, Q15min checks." The observation sheet was filled out every 15 minutes. Documentation on the sheet stated, "Pt. peeled paint off of walls. Pt. talking loud racist comments. Ripped B/P cuff off refused at 7:45PM."

Review of the patient #1's nurse's notes chart revealed on 7/25/2015, patient #1 was sitting in his room at 7:27PM. Patient #1 was writing on paper "some rather delusional thoughts." He was calm but agitated.

On 7/25/2015, at 7:43PM, "Pt has increased his agitation to the point that he is at danger to both himself and staff as well as other patients. He is yelling cussing and has swung at staff. As a result he has been given Ativan 2mg and Benadryl 50mg IM as ordered for agitation to right deltoid. No restraints were used yet extra staff was present for pt protection during the injection which he took albiet (albeit means although) cussing during the process. He is yelling and saying staff was hurting him which is not the case. Pictures were taken of the room destruction he did earlier today see pictures in assessment section of the chart. Will continue to monitor the effect of med on his behavior. Also his brother was contacted and advised of what transpired. "

Review of the nurses note on 7/28/15, at 7:20AM, Pt is extremely agitated yelling out, cursing and making derogatory remarks, slamming his door frequently. Ativan 2mg, Benadryl 50mg, and Zyprexa 10mg given IM in right hip. Pt did not resist shot but repeatedly kept yelling at staff. "

Review of the nurse's note on 7/28/15, at 3:10PM, stated, "Pt extremely agitated at nurse's station yelling and trying to yank computers and phone off of the counter. Pt has been coming up to the nurse's station frequently yelling about various things and slamming doors. Charge nurse called the physician to inform him of pts continued and increased agitation even though pt is taking meds and prn IM injection given this am with only slight improvement in agitation and only for a couple of hours. Physician stated to keep giving IM injection of Ativan2mg, Zyprexa 10mg and Benadryl 50 mg every 6 hrs as needed and eventually it would help. No new orders at this time. "There was no documentation of any other nursing interventions performed.

Review of the nurses note on 7/28/15, at 5:50PM, pt was agitated and yelling no documentation of nursing intervention. Goes into his room and slams the door.

Review of the nurse's notes for 7/29/2015 at 4:22AM stated,

"0355 Pt came out of his room after being in his room for 30 minutes yelling. Pt is stating that the tech in the hall took 5 million dollars worth of books and information out of his room. Pt called tech a whore and was yelling at tech (Very Loudly). Pt was getting dirty cups out of trash and filling them up with water. Pt then placed them on a table in day room and went back to his room and slammed the door. Pt continues to yell at staff calling all names and stating we have stolen his 5 million worth in information and his 5 billion dollars in cash."

"0410 Pt came out of his room (106) and went to room 107 turned light on and closed the door. Nurse went to room and found pt going threw night stands and closets stating his stuff was here and we took it. I informed pt several times that he is in a hospital and no one has taken his belongings. Pt again became aggressive in his body gestures and tone of voice. He was yelling at the top of his voice calling female staff whores and calling all thiefs. Pt stated the next person to come at him with an injection he was going to pick up a table and smash their fucking head and murder them. Pt stated he would rather be in jail for murder then be in this place. Pt then went back to his room and slammed the door."

"0415 Pt again came out of his room yelling at staff, he went to the day room and by the time the CN and other staff arrived, Pt had taken a fire extinguisher off the wall and was walking around with it stating he was going to shove it up his ass. CN then got the extinguisher and Pt returned to his room yelling and slammed the door."

0440 Pt approached nurse station in calm manner and asked for a couple sheets of paper. Nurse informed Pt that he really needs to remain calm and quiet as others are trying to sleep. Pt then asked nurse for something to help him sleep and his agitation, PRN orders for 10mg of Zyprexa, 50mg Benadryl, and 2mg of Ativan was administered PO at 0445. Pt then went down to day room and sat down at table and began to write on the paper he was given."

"0520 Pt in his room, no outburst in last 35 minutes, medication effective in controling anxiety, and insomnia. "

Review of the MHT CARE AND OBSERVATION FLOWSHEET Q 15 minute check dated 7/29/2015 stated the patient was awake and in his room from 4:00AM - 6:15AM. No further information.

There was no nursing documentation of any nursing interventions, increased observation, or who was assessing or observing the patient in his room behind a closed door for 35 minutes after a violent and aggressive episode.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0160
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on chart reviews, interviews and policy and procedures, the facility failed to document patient interventions before administration of psychotropic medications. Nursing failed to document ongoing assessments, monitoring, interventions, and care that are appropriate for that patient's needs before and after administration of psychotrpic medication and failed to provide a court order to administer these medications against the wishes of the patient in 1(#1) of 10 charts reviewed.

Patient #1 was admitted to the facility on [DATE], with a diagnosis of psychosis and schizophrenia. The patient was brought to the facility on an Emergency Detention Warrant (EDW). Patient #1 signed a "Request for Voluntary Admission" upon arrival on 7/21/2015. Patient #1 was seen by Staff #3 (psychiatrist) on 7/22/2015. Staff #3 wrote on the psychiatric evaluation dated 7/22/2015, at 12:00PM, "EDW agrees to sign in." There was no documentation found of a physician order changing the patient from involuntary to voluntary.

Review of the chart revealed a physician telephone order dated 7/25/2015, at 9:05AM, for Zyprexa 10mg po or IM, Benadryl 50mg po or IM, Ativan 2mg po or IM PRN every 6 hours for agitation psychosis.

1.) Review of the patient #1's nurse's notes chart revealed on 7/25/2015, patient #1 was sitting in his room at 7:27PM. Patient #1 was writing on paper "some rather delusional thoughts." He was calm but agitated.

On 7/25/2015, at 7:43PM, "Pt has increased his agitation to the point that he is at danger to both himself and staff as well as other patients. He is yelling cussing and has swung at staff. As a result he has been given Ativan 2mg and Benadryl 50mg IM as ordered for agitation to right deltoid. No restraints were used yet extra staff was present for pt protection during the injection which he took albiet (albeit means although) cussing during the process. He is yelling and saying staff was hurting him which is not the case. Pictures were taken of the room destruction he did earlier today see pictures in assessment section of the chart. Will continue to monitor the effect of med on his behavior. Also his brother was contacted and advised of what transpired."

On 7/25/15, at 8:36PM, stated, "At present time pt is asleep and is snoring with even rise and fall of chest wall, no distress is noted, will continue to follow."

Review of the nurse's notes revealed no neurological/physical assessments, close monitoring, interventions, or care that was appropriate for that patient's needs on or after emergency medications administered. There was no documentation found if a hold was used to administer the medication, how long the hold was, or how many people were holding the patient. ("He is yelling and saying staff was hurting him which is not the case." )

There was no documentation found that a physician or practitioner saw the patient after the emergency medication administration until 7/27/2015, at 12:30PM, by the Nurse Practitioner (NP). Staff #8 NP's note was reviewed. There was no documentation of the patients outburst and need for emergency medication on 7/25/2015 noted.

2.) Review of patient #1's nurses notes on 7/27/2015, at 6:38AM, stated "Pt was awakened in a highly agitated and psychotic state is yelling loudly, speaking very delusional and slamming door to room, attempts at verbal de-escalation have not been effective, as has attempts to get am blood drawn as scheduled. Have attempted to explain need for blood draw yet pt. is not listening and keeps yelling. He has gotten up suddenly and has walked out of the dining room and into another empty room yelling. Another staff is drawing up PRN medication as ordered for this behavior. With addition staff present he has been given Ativan 2 mg. Benadryl 50mg and Zyprexa 10 mg IM to the left gluteal, afterwards pt. walked out of room and down hallway towards his room. Will relay to next shift to continue to monitor effect of meds on behavior. Pt took medication with no injuries noted and no restraints were needed to give med. "

Review of patient #1's nurse's notes on 7/27/2015, at 5:17PM, stated, "Pt extremely agitated coming up to nurse's station frequently and going in and out of day room yelling and cursing. Pt took computer off of counter in nurse's station and put on floor in front of counter in the hallway and then ambulated to his room. RN called NP to inform her of pts extreme agitation and; NP stated to go ahead and give the IM injection that pt. previously had wanted and then refused. 5:30PM, Ativan 1mg, Zyprexa 10mg, and Benadryl 50mg given IM in right hip. Pt took shot willingly without resistance. "There was no nursing documentation found of medication effectiveness for 7/27/2015, 5:30AM dosage.

Review of the physician progress notes dated 7/28/2015, at 2:01 PM, revealed the NP documented, "difficult to redirect last night became volatile gave emergency injection."

Patient #1 was voluntary status and had no Order of Protective Custody (OPC) to force psychotropic medications. There was no documentation of patient consent to give medication. There were no consents signed for the administration of Ativan 2mg IM, Benadryl 50mg IM, or Zyprexa 10mg IM.