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 Feb. 22, 2017
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on reviews and interviews, the facility failed to:

1.)

a.) provide the patient with information on patient rights and consent for treatment on 3 (#2, 21, and 6) of 3 charts reviewed.

b.) educate staff on patient rights, or signed consents used during the admission process.

Refer to Tag A0131



2.)

A.) have a safe environment in 15 of 15 patient rooms.

B.) have staff with adequate training in competencies and SAMA in 15 of 15 (#2,3,4,6,14,15,16,17,25,28,30,31,33,37,and 38) employee files reviewed.

C). appropriately monitor and protect patients from harm, in 2 (patient #8 and #9) of 2 (patients #8 and #9) patient records reviewed. The facility also failed to ensure patients received the appropriate and recommended follow up care after an injury in 1 (#9) of 2 (#8, #9) patient records reviewed.


This deficient practice was 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.

Refer to Tag A0144



3.)

1.) protect the patient from corporal punishment and intimidation in 1(#6) of 3( #6, #2, and #3) charts reviewed.

2.) assess and monitor the patient's condition on an ongoing basis to ensure that the patient was released from restraint or seclusion at the earliest possible time. Citing 1(#6) of 3( #6, #2, and #3) charts reviewed.

3.) educate the staff and create a culture that supports patient rights and ensure policies and processes were developed to eliminate the inappropriate use of restraint or seclusion. Citing 1(#6) of 3( #6, #2, and #3) charts reviewed.


This deficient practice was 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.

Refer to Tag A0154
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the facility failed to:

A.) have a safe environment in 15 of 15 patient rooms.

B.) have staff with adequate training in competencies and SAMA in 15 of 15 (#2,3,4,6,14,15,16,17,25,28,30,31,33,37,and 38) employee files reviewed.

C). appropriately monitor and protect patients from harm, in 2 (patient #8 and #9) of 2 (patients #8 and #9) patient records reviewed. The facility also failed to ensure patients received the appropriate and recommended follow up care after an injury in 1 (#9) of 2 (#8, #9) patient records reviewed.



This deficient practice was 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.



A. During a tour of the hospital on [DATE] the following conditions were found:


1.) The patient bedrooms and bathrooms had drop down ceilings. The ceiling was not hard. The drop down ceilings are easily accessible by standing on a bed or chair. The tiles can be lifted allowing medications or contraband to be stored. The metal railings can be removed from the ceiling and used as a weapon to harm themselves or others. The railing could also be used by the patient to hang themselves. There were 5 private rooms and 10 semiprivate rooms; 25 patient beds in all.

2.) All of the patient beds were hospital beds with railing and headboards that had slots to use as a hanging device.

3.) The cabinet doors to the bathroom sinks were open and accessible to the pipes underneath that would allow for hanging device.

4.) The toilet paper and soap holders in the bathrooms were not solid and allowed for a sheet to be tied around it. The soap holder was mounted inside the wall. The holders could be used as a hanging device.

5.) The wall thermostats in the patient rooms were accessible to the patient. The thermostats were not in a tamper proof box. The thermostats had metal in the covers that could be removed to cause harm to the patient or others.

6.) The patient rooms had a closet for each bed. Room 115 was semi private room that was considered terminally cleaned and waiting for a new patient. Inside the wardrobe was a shelf with a metal track. The track was deep and a patients earrings were found in the track. In the other wardrobe used plastic dental pics were found in the track hidden from sight.

7. A broken plastic electrical socket plate cover with sharp jagged edges was observed in a patient room
(#115) on the Behavioral Health Unit.

8. Multiple patient beds were observed with broken plastic footboards in the Behavioral Health Unit.

9. A wheelchair being used by a patient (patient #9) on the Behavioral Health Unit was observed to have torn vinyl and foam on both arm supports exposing metal with sharp edges.

An interview conducted on 2/13/17, with staff #7, confirmed the above findings.



B. Review of the employee files revealed the employees did not have any training for aggressive patients. There was no de-escalation or physical training to prevent injury in 15 employee files reviewed. There was also missing competencies, no abuse and neglect training, patient rights/Confidentiality training, or age appropriate training. Staff #1 reported that several employees did not have training or had expired training for SAMA (Satori Alternatives to Managing Aggression SAMA is a 16-hour training program that focuses on risk management of aggressive behavior for individuals in schools, police departments, foster care services, residential institutions, offices, hospitals and elsewhere.)

Staff #1 reported on 2/13/17 that she would be putting the staff through the de-escalation training process for SAMA. Staff #1 was instructed that the staff needed all the training and not just de-escalation. Staff #1 reported that staff #1, #2 and #3 had decided not to teach all of the SAMA training just the de-escalation and to avoid kicks and blocks. Staff #1 stated she did not teach the staff all of the appropriate holds due to "I don't trust my staff." Staff #1 reported she shouldn't have to teach the holds due to "Nurses should have learned that in school."




2.) A review of the facility's Incident Log revealed patient #8 had sustained a fall on 1/16/17. The log contained the following statement: "PT ROOMATE ALARMED NURSE THAT PATIENT WAS IN BATHTUB. PT WAS FOUND LYING IN BATHTUB. PT SENT TO ER FOR CT SCAN DUE TO UNWITNESSED FALL. PT HAD NO CHANGE IN LEVEL OF CONSCIOUSNESS."

A review of patient #8's record revealed the following information:
Patient #8 was a [AGE] year old male admitted to the facility on [DATE], with a diagnosis of impulse control disorder.

The patient's fall on 1/16/17, was documented in the record as follows:
On 1/17/17 at 1304, the RN's computerized narrative note documentation stated, "Late entry for 1/16/17 at 1620: Staff was alerted to patient by patient's roommate who stated patient had fallen. When this nurse and the Director of Clinical Services arrived in the room, patient was lying in the bathtub with his pants pulled down. Patient stated he had hit his head. Vital signs and neuro checks begun. Calls placed to the appropriate people. Patient sent to ER for CT of his head to rule out intracranial hemorrhage. When report called from ER, the nurse stated that the CT scan was negative but the Dilantin level was elevated. Will continue to monitor for any change in condition ...".
On 1/17/17, at 1300, the Registered Nurse's (RN) computerized Post Fall Assessment documentation stated, "1/17/2017 1300 ....Location of Patient at Time of Fall ... Patient Room ... Witnesses to Fall ...Patient's roommate ...Actual Level of Monitoring at time of fall ...Level II (constant monitoring within 20 feet distance) ...Activities at Time of Fall ...Going to or from Bathroom ....Vitals ... In Progress ..."

A review of the MHT (Mental Health Tech) Care and Observation Flowsheet reflected every 15 minutes observations of patient #8. The MHT documented patient #8 was located in the Dining Room from 1400 until 1830 on 1/16//17. There was no documentation of the patient's fall by the MHT.
Patient #8's staff monitoring level was documented as a "Level II". According to facility's policy, Level II is defined as, "constant monitoring within 20 feet distance". The patient fell while in his room with NO staff monitoring him. The MHT that was assigned to monitoring the patient, documented he was in the Dining Room during the time of the fall.


A review of the facility's Incident Log revealed patient #9 had sustained falls on 2/3, 2/5, 2/6 and 2/7.
The Incident Log revealed the following statement related to patient #9's fall on 2/3/17:
"PT STOOD UP AND LOST BALANCE AND LANDED ONTO THE LAP OF ANOTHER PATIENT. FALL WAS WITNESSED AND NO INJURY OCCURRED."

A review of patient #9's record revealed the following information:
Patient #9 was a [AGE] year old male admitted to the facility on [DATE], with a diagnosis of dementia and homicidal ideations.

The patient's fall on 2/3/17, was NOT documented in the patient's record.

The Incident Log revealed the following statement related to patient #9's fall on 2/5/17:
"PT STOOD UP FROM W/C (wheelchair), LOST BALANCE AND fell FROM W/C".

The patient's fall on 2/5/17, was documented in the record as follows:
On 2/5/17, at 2257, the Registered Nurse's (RN) computerized Post Fall Assessment documentation stated, "2/5/2017 2257 ....Location of Patient at Time of Fall ... Dining Room ... Actual Level of Monitoring at time of fall ...Level II (constant monitoring within 20 feet distance) ...Activities at Time of Fall ...In Dining Room having meal or snack ....Other Activity ...Watching TV sitting in wheelchair, with chair alarm on, happened at shift change ...Vitals ... BP (blood pressure) 98/72, Resp (respirations) 20, HR (heart rate) 66 ..."

On 2/5/17, a handwritten Post Fall Assessment form completed by the RN contained the following information:
" ...Pt (patient) fell @ 1900 in DR (Dining Room), witnessed, stood up from wheelchair lost balance, No injury ..."
A review of the MHT (Mental Health Tech) Care and Observation Flowsheet reflected every 15 minutes observations of patient #9. The MHT documented patient #9 was awake and in the Dining Room from 1715 until 2100 on 2/5/17. There was no documentation of the patient's fall by the MHT.

Patient #9's staff monitoring level was documented as a "Level II". According to facility's policy, Level II is defined as, "constant monitoring within 20 feet distance". The patient fell while in the Dining Room at 1900. The MHT that was assigned to monitoring the patient, did NOT document the patient's fall.


The Incident Log revealed the following statement related to patient #9's fall on 2/6/17:
"PT GOT UP OUT OF W/C AND fell on HIS LEFT SIDE. NO INJURIES".
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the facility failed to:

1.) protect the patient from corporal punishment and intimidation in 1(#6) of 3( #6, #2, and #3) charts reviewed.

2.) assess and monitor the patient's condition on an ongoing basis to ensure that the patient was released from restraint or seclusion at the earliest possible time. Citing 1(#6) of 3( #6, #2, and #3) charts reviewed.

3.) educate the staff and create a culture that supports patient rights and ensure policies and processes were developed to eliminate the inappropriate use of restraint or seclusion. Citing 1(#6) of 3( #6, #2, and #3) charts reviewed.


This deficient practice was 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.



Review of patient #6's chart revealed the patient was a [AGE] year old male, admitted on [DATE], with a diagnosis of psychosis. There were no orders found upon admission that stated if the patient was voluntary or involuntary. There was an emergency detention warrant found on the patients chart for 1/29/17.


Patient #6's patient chart revealed nursing reported on 1/31/17 patient was calm and cooperative throughout the day. At 21:56 (9:56PM) the nurse documented, "Patient in room awake and very confused this HS. Does not want a roommate he thinks he is in a trailer he has had reserved for over a month. Pt. redirected be staff. Cooperative with HS medications. No c/o pain or discomfort at this time."(sic)

Review of the Mental Health Care Technician (MHT) Care and Observation Flowsheet notes dated 1/31/17 revealed the patient was awake ambulating in his room from 9:15PM until 1:15AM where he is found aggressive in the hallway. There were no interventions documented on the flowsheet during 1/31/17 at 9:15 PM - 2/1/17 at 1:15AM. Patient #6 was documented on the flowsheet to be in seclusion from 2:45AM -6:45AM. At 7:00AM on 2/1/17 a new flowsheet was started and patient #6 was documented as sleeping in seclusion until 8:00AM.

Review of patient #6's clinical nursing notes dated 2/1/17 at 1:15AM revealed the RN documented, "Called down the hallway by MHT, stating she needed assistance with this patient-noted patient in the hallway fully dressed and yelling out at staff that "No one is gonna come in my house, I can leave whenever I want to and no one is gonna stop me." Patient entered room 105, attempting to calmly request patient to come out of room 105, patient refused and began slamming the door of the room 105 (4-5) times. Patient came out of the room and started walking down the hallway yelling and swinging at staff. Patient struck nurse in the face multiple times with a closed fist. Patient kicked MHT in her right leg. Patient going into different patient rooms and when called, he became increasingly agitated and began chasing staff, patient kicked both doors to nurses station and finally breaking a door and gained entry into nurses station, grabbed a chart and started swinging it and threw it at staff. 911 & upper management called."

Nurse documented on 2/1/17 at 1:30AM Police here and patient in day room calmly talking to police. XXX (staff #26 NP Nurse Practitioner) called and N/O obtained for Benadryl 12.5mg, Ativan 1mg & Haldol 2 mg IM x1."

Nurse documented on 2/1/17 at 1:45AM, "Benadryl 12.5mg, Ativan 1mg & Haldol 2 mg IM given into patient's right buttock." Patient had been documented as calm and talking to police but was still administered a chemical restraint ordered by the nurse practitioner.

Nurse documented on 2/1/17 at 2:55AM, "Police escorted patient into seclusion room- MHT assisted patient into a gown. The nurse called the patients daughter at 3:00AM and informed her of the situation.

There was no further nursing documentation found on the patient concerning an assessment, vital signs or nursing care after the chemical restraint or seclusion.

There was not a psychiatrist progress note found until 2/3/17. The nurse practitioner documented visits on 2/1/17, 2/2/17 and 2/6/17. There was no other psychiatrist notes found from the psychiatrist or nurse practitioner.

There was an order found on 2/1/17 by the nurse practitioner to begin court commitment process due to aggressive behavior at 2:40PM. The nurse practitioner does not have the authority to write court commitment orders per the facility medical by-laws or governing board bylaws. The NP orders were never co-signed by the psychiatrist. In the medical by-laws under "Behavioral Health Inpatient F. Patients shall be cared for by on staff physicians except as otherwise provided for in the Medical Staff ByLaws and Rules and Regulations." There was no further information found on the use of a Physician Assistant or Nurse Practitioner in the Medical By-laws.
Review of the Medical Staff Bylaws revealed the following:

"Behavioral Health Inpatient

F. Patients shall be cared for by on-staff physicians except as otherwise provided for in the Medical Staff Bylaws, Rules and Regulations".

There was no provisions found in the Bylaws that Physician Assistants or Nurse Practitioners were included as members of the Medical Staff.


Review of the patient #6's chart revealed a physician order form that stated the patient could be placed in seclusion for violent behavior. The order stated, "Check vital signs every 15 minutes." The nurse checked a box on the form that stated, "Medical condition present which increases physical risk HTN (hypertension)." Denial rights section was left blank and unsigned by author of the order. The nurse documented on the order that the psychiatrist gave the order for seclusion on 2/1/17 at 3:30AM. The psychiatrist signed the order but did not date or time the signature. There was no note found for the psychiatrist. During a phone interview with the medical director and psychiatrist on 2/23/17 at 1:00PM, the psychiatrist revealed she thought the nurse practitioner wrote the note about her visit. The psychiatrist reported she does not always write a note. The Psychiatrist was not aware the medical staff by-laws and Governing by-laws did not recognize the nurse practitioner to see the patients and write orders.

Review of the restraint and seclusion review completed by the RN on 2/1/17 revealed;

1.) Patient #6 was placed in seclusion at 3:05AM. The MHT note stated that patient #6 was placed in seclusion at 2:45. There was a 20 minute difference.

2.) The only alternatives attempted was verbal de-escalation.

3.) Patient education was provided but did not state what education.

4.) Leadership was notified but there was no documentation on who was notified and response.

5.) Psychiatrist saw the patient on 2/1/17 at 10:00AM for a face to face. The physician or authorized practitioner was to do the face to face within one hour of the seclusion and chemical restraint. The documentation revealed the psychiatrist saw the patient 7 hours later. There was no physician notes found that the psychiatrist had seen the patient on 2/1/17. The nurse checked that a trial release was documented. There was no documented evidence that a trial release was attempted. The nurse checked that a response to release was documented. There was no evidence documented that the patient gave a response to release. There was a time of release on the seclusion log of 6:30AM. The patient was in seclusion for 3 hours and 25 minutes with no assessment documented. There was no documentation of a chemical restraint in the nurse's notes, on the restraint order, or on the restraint log. This was the only patient documented on the restraint log. There was no one documented on the restraint log for January 2017 for restraint or seclusion.

A telephone interview with staff #25 (RN) was conducted on 2/16/17 at 4:45PM. Staff #25 was questioned about the restraint and seclusion of patient #6 on 2/1/17. Staff #25 reported patient #6 had sundowners and he would become more difficult during the night.

Staff #25 reported Patient #6 came out of his room fully dressed and was agitated and wanted to leave. Staff #25 tried to talk to patient #6 and get him to watch TV but he just became more agitated, patient #6 then began to slam another patient's door to their room over and over. Patient #6 was inside the other patient's room. The other two patients in room 105 were trying to sleep. "We were trying to get him to come out of that room while I was trying to get XXX (staff #26 NP) on the phone." While staff #25 was on the phone with staff #26, staff #25 stated, "all of my staff was running down the hallway and he was chasing them. He punched the LVN in the face three times and kicked one of my MHT's. I called XXX (staff #3 RN administration) and he instructed me that we needed to get him out of here".

Staff #25 stated she was instructed by staff #3 to call the police. Staff #25 reported the patient came into the nurse's station and started to "chunk charts at me. I got the chart cart out of reach and informed my staff to lock themselves into the breakroom." Staff #25 reported she went out to look for patient #6 on the unit. Staff #25 stated, "He could tear up the unit as long as nobody got hurt. I ran off the unit to go get the security guard from XXX (another facility in the building) and they said they could not come and help. They had their own issues that night. Finally, the police came and took the patient to the activity room. The patient calmed down and the policemen took him to the seclusion room. The policeman asked patient #6 if he would let us give him a shot and he said, yes. The police held him while staff #38 gave him the shot and closed the seclusion room door. XXX (Patient #6) just paced for 2 hours." Staff #25 was asked if she thought the patient was intimidated by the police and she stated, "Sure, I guess, I would be," we wanted them to take him to jail.
Staff #25 stated, "The police would not take him to jail. They stated that this was the safest place for him. They said the jail was full of patients that needed care and they were not going to do that." Staff #25 reported that no supervisor came to the facility till the next morning. There was no physician present.

Staff #25 reported that she had not had SAMA training at this facility. Staff #25 stated she had not been trained that behavioral emergency medications needed to be documented as a restraint. Staff #25 stated she did not know a face to face had to be done for meds or seclusion. Staff #25 stated she felt like they handled the situation the best that they knew how. Staff #25 agreed they could use more training in handling the patients that become violent.

An interview with staff #15 (RN) was conducted on 2/16/17 concerning chemical and behavioral restraints. Staff #15 stated, "If I needed to give a behavioral medication I would look to see if they have a PRN (as needed). Sometimes they order PRN's IM. If not I would just call and get an order. We just call the nurse practitioner for all the orders. Then we just give it. We don't do any restraint paperwork. We don't chart the medications as a chemical restraint. We don't usually take vital signs. We just let them sleep."

An interview was conducted with staff #3 concerning patient #6 on the night of 2/1/17. Staff #3 reported that he was called by the RN of the unit and told what was going on. Staff #3 confirmed that he instructed the nurse to have the police come and arrest the patient for his behavior. Staff #3 stated, "We just cannot deal with that kind of patient. He needed to go to jail." Staff #3 confirmed he never came to the unit to assist with the situation.
An interview was conducted with staff #1 on 2/16/17. Staff #1 reported that she had been training the staff in SAMA for the last 2 days to be eligible to sit with the patient's one on one. Staff #1 confirmed the staff had been in a 4 hour session and had been taught verbal de-escalation. The surveyor pointed out to staff #1 the incident with patient #6. Staff #1 was questioned why the staff would not be receiving the entire training. Staff #1 stated that she felt this was all they needed to know. Staff #1 reported that herself, staff #2, and #3 had decided that de-escalation and learn to block kicks would be the best method.
When Staff #1 was asked how staff were supposed to hold an aggressive patient, Staff #1 stated, "They know how to do that. Nurses are taught in nursing school how to hold a patient." Surveyor asked staff #1 if the staff knew how to handle patient #6 and why were the police called? Staff #1 responded, "I know about the police coming. They could not handle the patient so the police had to be called. They needed to come and get him. He needed to be removed from the facility. He needed to go to jail. We can't handle patients like that?" The surveyor asked staff #1 where she thought patients like patient #6 should go? Staff #1 stated, "It would have to be a forensic psych with bars on the windows and the patient secluded in their own space."

A review of the incident logs showed from 9-2-2016 to 2-8-2017 there were 20 incidents involving physical aggression that nursing staff were not able to manage using SAMA Assisting (Verbal De-escalation) Process. Staff #1 confirmed the findings but continued to insist that the staff would not be taught appropriate holds. Staff #1 stated, "I just don't trust them to do that."

Review of The Satori Alternative to Managing Aggression (SAMA) revealed the Assisting Process course was a one-day course. Participants who demonstrate competency in all areas were certified in the SAMA Assisting (Verbal De-escalation) Process. Staff #1 stated this was all that was taught to the staff.

Full SAMA training was a two-day, 16 hour program that included 4 areas for managing aggressive patients. Those areas were:

Principles and Assisting Process
Protection of Self and Others
Containment
Object Retrieval

Review of annual training records revealed that annual training had not been completed hospital-wide since December 2015. This included annual nursing training in Abuse/Neglect, Infection Control, Patient Rights/Confidentiality, and Age Appropriate Care training and SAMA. This was confirmed by Staff #2 and Staff #14.

Review of the policy and procedure for restraints was dated as last updated 2012. The policy did not address behavioral restraints, seclusion, or time outs. An interview with staff #2 on 2/13/17 revealed a current policy was written but had not been approved by the governing body and was not on the floor accessible to the nursing staff. Staff #2 confirmed there had not been a restraint log in place until 1/17. Staff #2 was writing the policies but was not aware of the state regulations and what they required. Staff #2 confirmed she had not had any previous psychiatric training other than in nursing school.

The policy and procedure for restraints dated 2/2012 was as follows:

"PURPOSE AND USE:
Restraint is a high-risk, potentially harmful procedure that is intended to be used only when less restrictive methods have not succeeded or clearly are not likely to succeed in preventing injury to a patient or others.

CRITERIA FOR RESTRAINTS:
1. Self-injurious behavior such as pulling/interfering with treatments, catheters, tubes, lines, dressings, and is unable to follow or retain instructions.
2. Unsteady gait/balance, attempts ambulating or climbing out of bed against advise and is unable to follow or retain instructions.

TYPES OF RESTRAINTS:

1. PHYSICAL - The use of a physical or mechanical device to involuntarily restrain the movement of the whole or a portion of a patient's body as a means of controlling physical activities to protect the patient or others from injury.

2. CHEMICAL - use of medications that alter mood or behavior, for the purpose of controlling the patient's physical activity to protect the patient from harming self or others.

USE OF ORDERS TO INITIATE RESTRAINT USE:
Any independent licensed practitioner (physician) of the active medical staff may issue an order for restraint. Orders must state a specific length of time for which the restraints may apply - up to and including 24 hours (orders may not exceed 24 hours). A physician must personally complete a direct patient assessment to initiate a restraint order or renew an order after 24 hours. Orders or accompanying progress notes must:
state date and time of entry for order
state the justification for restraint
state the type of restraint; and
state the time limit for restraint."

There was no policy found that addressed Seclusion. Review of the Medical By-laws under restraints stated, "The use of restraints or seclusion shall comply with Facility policy and Texas Administrative Code chapter 405, subchapter F, and be employed only when other methods of control are deemed inadequate to assure the safety of the patient or others. The physician must justify the use of restraints or seclusion in the medical record, at the time of the order. The verbal or written order from a physician shall be obtained within one hour of initial use and reviewed and countersigned by the physician within 12 hours."

An interview with staff #2 on 2/13/17 confirmed there was no found seclusion policy but a new policy had been written. The policy on Seclusion had not gone through governing body or accessible to the nursing staff.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of records and interview, registered nursing (RN) staff failed to assess the patients on an ongoing basis and when a change in condition occurred in 7 (Patient #s, 1, 8, 9, 10, 12, 18, and 19) of 7 patients reviewed.

A review of Patient #1's chart was conducted. Patient #1 chart revealed on 2-28-2016 at 1:20 PM, "Pt continues to threaten staff, contacting MD." The nurse charted at 1:25 PM, "Dr. Jacobson Notified of Pt's behavior, new orders: 1 time dose-Combine Ativan 2mg (milligram) inj. (injection) Haldol 10mg inj. and Benadryl 50 mg inj to be given IM (in a muscle) NOW for combative behavior." The nurse charted that the injection was given at 1:40 PM. At 2:00 PM, the Mental Health Technician (MHT) charted that the patient was in their room sleeping until 10:15 PM. The MHT charted that the patient was back to sleep at 10:30 PM and woke up intermittently. The next nursing note was at 12:50 AM on the morning of 2-29-2016, the nurse charted, "Pt restless and agitated - attempting to climb out of bed. PRN Klonipin 1 mg po (by mouth) administered. Pt scuffing arms on bed mattress and reopening skin tears. Unable to keep dressings in place." The patient slept a total of 12.75 hours out of the 17 hours between receiving the injection on 2-28-2016 at 1:40 PM and 7:00 AM the next morning. On 2-29-2016 at 12:10 PM, the nurse charted a change in the patient's condition. The patient had decreased responsiveness. The nurse charted, "1210 - New order for Narcan 0.4 mg IM one time order. Patient leaning right in wheelchair, sedated, slurred speech and delayed answer when asked question."

The chart did not contain documentation of interventions attempted to avoid having to medicate the patient with sedating medications. The chart did not contain any documentation of a nursing follow-up assessment of the patient to include vital signs before medication administration or after medication administration. Vital signs were assessed on 2-29-2016 at 7:12 AM and were within normal parameters. Vital signs were reassessed at 7:15 PM (approximately 7 hours after patient was identified as having decreased responsiveness). The patient was found to have a temperature of 101.6 degrees Fahrenheit and an oxygen saturation level of 88% on room air. A posting of normal vital sign range in the nurse's station showed that the normal range for oxygen saturation level was 94% to 100%. The patient was transferred to a medical hospital in another city and did not return to the specialty hospital.

Patient #10's chart was reviewed. Patient #10 was admitted on [DATE] to the acute care unit. The patient transferred to the Behavioral Unit on 11-30-2016. Patient number 10 discharged on [DATE]. Patient number 10 had an interrupted stay. The patient was transferred to another hospital on 12-8-2016. There was no note documentation found stating when the patient returned. The last shift assessment prior to transfer to another hospital was on 12-7-2016 at 8:08 PM. The next shift assessment was completed on 12-10-2016 at 11:40 AM. Staff #24 charted a physician's medical assessment occurred on 12-10-2016 at 6:25 AM. The actual date and time of return from the other facility was not documented in the chart with an RN assessment.

The patient was required a nursing shift assessment each shift. The nursing shift assessment was a comprehensive assessment of multiple body systems and risk assessments. The shift assessment was not a focused nursing assessment. The patient arrived on the Behavioral Unit on 11-30-2016. Between 12-1-2016 and patient transfer on 12-8-2016, 15 RN shift assessments should have been documented. Nine (9) of the assessments were documented and signed by Licensed Vocational Nurses (LVN). One (1) RN shift assessment was not found in the chart at all. Only 5 shift assessments were signed by an RN. Between 12-10-2016 and discharge on 12-13-2016, 7 RN shift assessments were due. Five (5) out of 7 were charted and signed by an LVN. Two (2) were signed by an RN.

Patient #12's chart was reviewed. On 1-29-2017 the nurse charted at 10:00 PM, "Pt. isolating in room and remains delusional. States that nurse call button to bed is not working and that is a federal violation for call button not to be working and that all of the nurses were going to jail. Compliant with HS medications. Will continue to monitor. Pt remains agitated about call button on bed not working. Yelling out and difficult to redirect. Refusing to take PRN Ativan 0.5 mg. Pt assisted to WC and moved for closer monitoring near nurses station. Norco 10/325 mg administered at 21:40 for bilateral leg pain. Will continue to monitor."

At 10:40 PM the nurse charted, "Follow up PRN Norco 10/325 mg: Pt states that he continues to have pain and pain level is 6/10. Pt continues to be agitated and threw laundry hamper over nurses station counter attempting to hit nurses sitting in the area."

At 10:50 PM the nurse charted, "Pt. remains loud and disruptive and continues to refuse PRN Ativan 0.5 mg po. (Nurse Practitioner's Name) notified by Charge Nurse and new order noted. Zyprexa 5mg IM administered to Rt deltoid site and Benadryl 12.5 mg IM administered to Lt. deltoid site. Will continue to monitor."

At 11:05 PM the nurse charted, "Follow-up Zyprexa 5 mg IM and Benadryl 12.5 mg IM one time only dose. Pt drowsy and assisted to bed by staff." The chart did not contain any documentation of a nursing follow-up assessment of the patient to include vital signs before medication administration or after medication administration.

Review of the physician orders and medication administration record for 2-1-2017, Patient #12 was conducted. The physician orders do not contain an order for Zyprexa on 2-1-2017. An order written on 2-1-2017 at 9:30 PM was found for "Give Haldol 1 mg, Ativan 1 mg, and Benadryl 12.5 mg IM x 1 dose - If ineffective after 1 hr give Haldol 1 mg IM." The Medication Administration Record (MAR) was documented that those medications were given on 2-1-2017 at 9:30 pm.

The Nursing Rounding Documentation for 2-1-2017 at 9:00 PM showed, "No evidence of pain observed, Offered emotion support/active listening, Being observed per orders." The chart for Patient #12 did not contain documentation of interventions attempted to avoid having to medicate the patient with sedating medications. The last nursing note for 2-1-2017 was at 12:30 pm. The next nursing note was 2-2-2017 at 2:40 pm.

Review of Patient #18's chart was conducted. Patient #18 was admitted on [DATE] and was still a patient at the time of chart review on 2-14-2017. Patient #18 should have had an admission assessment and 4 shift assessments completed by an RN. On 2-13-2017, both shift assessments were charted and signed by an LVN.

Review of Patient #19's chart was conducted. Patient #19 was admitted on [DATE] and was still a patient at the time of chart review on 2-14-2017. Patient #19 should have had an admission assessment and 18 shift assessments completed by an RN. On 2-11-2017 an LVN charted and signed the shift assessment for the day shift. The night shift assessment was missing. The night shift assessment on 2-13-2017 and day shift assessment on 2-14-2017 were both charted and signed by an LVN.

An interview was conducted with Staff #15 on 2-15-2017 in the conference room. Staff #15 stated that when patients are aggressive, nursing staff will call and get a medication order if needed. Staff #15 stated the Emergency Behavioral Medication order is not treated as a restraint. Staff #15 stated a face-to-face assessment with the patient is not documented. After medication administration, Staff #15 said, "We don't wake them up for vital sign checks. We just let them sleep."


Review of Assessment and Reassessment of Patient policy number CS2-01 was as follows:
"Page 2 of 2
6. Reassessment
i. Reassessment of the patient shall occur PRN and each time there is a change in the patient's condition.
ii. Nursing shall reassess the patient on a per shift basis.

7. Reassessment by all disciplines caring for the patient will occur on an ongoing basis throughout the patient stay. Changes in condition and progress in recovery will be documented in the patient medical record. Changes in the plan of care and treatment will be documented accordingly."

The policy did not address the shift assessments.


A review of Allegiance Specialty Hospital policy titled "Transfer Policy"; Policy: CS5-07, was conducted. The policy reads as follows:
"PROCEDURE:
Patients may be scheduled for temporary placement within an acute care facility for treatment or procedure. A Memorandum of Transfer will be completed for non-emergent patient transfers. A physician assessment of patient's stability of condition for transfer will be completed for non-emergent transfers, A patient / family consent for transfer will be completed for non-emergent transfers.

Report on the patient's status should be documented prior to and upon return to ALLEGIANCE SPECIALTY HOSPITAL OF KILGORE.

Utilize the Appropriate Documentation tools to record the patient's status.

Upon return to the facility, nursing staff should evaluate the patient through reassessment and document findings in the nursing notes. A reassessment will be completed to determine need for frequent monitoring of the patient.

Upon return of the patient to the facility vital signs are to be recorded.

Frequent monitoring includes, but is no limited to, the following:
Changes in vital signs i.e. significant drop or elevation of blood pressure
Changes in mental status and/or motor activity
Changes in pulmonary status
Changes in wound status
Changes in urinary output
Increase in pain

Changes in condition and or unusual findings are to be reported to the physician.

Physician notification of return to the hospital will be completed and continuing care orders obtained."



Review of the Texas Board of Nursing Board Rule 217.11(2)(A) showed:

"(2) Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and:
(A) Shall utilize a systematic approach to provide individualized, goal-directed nursing care by:
(i) collecting data and performing focused nursing assessments;"





A review of the facility's Incident Log revealed patient #8 had sustained a fall on 1/16/17.
The log contained the following statement: "PT ROOMATE ALARMED NURSE THAT PATIENT WAS IN BATHTUB. PT WAS FOUND LYING IN BATHTUB. PT SENT TO ER FOR CT SCAN DUE TO UNWITNESSED FALL. PT HAD NO CHANGE IN LEVEL OF CONSCIOUSNESS."

A review of patient #8's record revealed the following information:

Patient #8 was a [AGE] year old male admitted to the facility on [DATE], with a diagnosis of impulse control disorder.
The patient's fall on 1/16/17, was documented in the record as follows:
On 1/17/17 at 1304, the RN's computerized narrative note documentation stated, "Late entry for 1/16/17 at 1620: Staff was alerted to patient by patient's roommate who stated patient had fallen. When this nurse and the Director of Clinical Services arrived in the room, patient was lying in the bathtub with his pants pulled down. Patient stated he had hit his head. Vital signs and neuro checks begun. Calls placed to the appropriate people. Patient sent to ER for CT of his head to rule out intracranial hemorrhage. When report called from ER, the nurse stated that the CT scan was negative but the Dilantin level was elevated. Will continue to monitor for any change in condition ...".

On 1/17/17, at 1300, the Registered Nurse's (RN) computerized Post Fall Assessment documentation stated, "1/17/2017 1300 ....Location of Patient at Time of Fall ... Patient Room ... Witnesses to Fall ...Patient's roommate ...Actual Level of Monitoring at time of fall ...Level II (constant monitoring within 20 feet distance) ...Activities at Time of Fall ...Going to or from Bathroom ....Vitals ... In Progress ..."

There was no documentation in the record of patient #8's fall on the date it occurred (1/16/17).



A review of the facility's Incident Log revealed patient #9 sustained a fall on 2/3/17.

The Incident Log revealed the following statement related to patient #9's fall on 2/3/17:

"PT STOOD UP AND LOST BALANCE AND LANDED ONTO THE LAP OF ANOTHER PATIENT. FALL WAS WITNESSED AND NO INJURY OCCURRED."

A review of patient #9's record revealed the following information:

Patient #9 was a [AGE] year old male admitted to the facility on [DATE], with a diagnosis of dementia and homicidal ideations.

There was NO documentation in the record of patient #9's fall on 2/3/17.

The Incident Log revealed the following statement related to patient #9's fall on 2/7/17:
"PT FOUND ON FLOOR SATURATED IN URINE, SENT TO ER FOR EVAL PER MD ORDERS".

The patient's fall on 2/7/17, was documented in the record as follows:
On 2/7/17 at 0656, the Registered Nurse's (RN) computerized Post Fall Assessment documentation stated, "2/7/2017 0656 ....Location of Patient at Time of Fall ... Patient Room ...Ordered Level of Monitoring ...Level IV (monitoring on a routine basis every 15 minutes) ...Activities at Time of Fall ...(blank) ....Other Activity ...(blank) ...Vitals ... (blank) ...Cardiovascular ...Tachycardia, Hypotensive ...Other skin conditions ...abrasion left shoulder and elbow ..."
On 2/7/17, a handwritten Post Fall Assessment form completed by the RN did NOT contain any information about how patient #9 fell .

On 2/7/17 at 0504, the RN's computerized narrative note documentation stated, "Patient found in floor in room by PCT (Patient Care Tech) BP 96/54, HR 120. Patient noted to have two bumps on back of head. Dr. (staff #24) notified by charge nurse."

A review of the MHT (Mental Health Tech) Care and Observation Flowsheet reflected every 15 minutes observations of patient #9. The MHT documented on 2/7/17 at 0500, patient #9 was "awake" located in his "room" and the intervention of "hygiene/toileting help" took place. In addition, the MHT documented patient #9 was "sleeping" and located in his "room", from 0515 until 0600.

Patient #9's staff monitoring level was documented as a "Level IV". According to facility's policy, Level IV is defined as, "monitoring on a routine basis every 15 minutes". The patient fell while in his room with NO staff monitoring him. The MHT that was assigned to monitoring the patient, documented he was "awake" located in his "room" and the intervention of "hygiene/toileting help" took place. The RN failed to appropriately oversee and monitor the MHT's care of the patient.

In addition, patient #9 had sustained 4 falls in 4 days, and staff decreased the patient's monitoring level from a Level II to a Level IV after his 3rd fall. The RN failed to appropriately assess the patient's need for constant supervision to prevent further falls and injury.

Patient #9 was sent to the emergency room (ER) operated by another facility located in the same building, after the 2/7/17 fall, per staff #24's order.

A review of patient #9's ER record for 2/7/17, revealed the following information:
The ER Physician's documentation stated the patient arrived to the ER at 0448 with complaint of head pain. The ER Physician's exam revealed ..."SMALL CONTUSION TO POSTERIOR SCALP" ....
Following diagnostic testing, the ER Physician documented: "Response to Treatment: ...CT (computerized tomography) HEAD NEG (negative) FOR ACUTE BLEEDING. CT C-SPINE (cervical spine) SHOWS T1-T2 (thoracic spine level 1-2) SUPERIOR ENDPLATE FRACTURE W/10% HEIGHT LOSS. UNCLEAR IF THIS IS NEW OR CHRONIC. NO NEURO (neurological) DEFICIT. PT HAS NO TENDERNESS. CALLED DR. XXX(neurosurgeon) W/SPINE AND HE STATED THAT PT SHOULD BE PUT IN COLLAR AND F/U (follow up) IN CLINIC. WILL DC (discharge) BACK TO ALLEGIANCE."
The ER nurse's documentation stated, " ...Follow up: XXX MD; When 1 - 2 days; Reason: Recheck today's complaints ....Notes: PATIENT IS TO WEAR CERVICAL COLLAR AT ALL TIMES UNTIL FOLLOW UP W/ DR. XXX IN CLINIC .....Instructions were given to caretaker, ... follow up and referral plans ... USE OF C COLLAR Demonstrated understanding of instructions ...09:08 REPORT GIVEN TO (staff #16) RN ALLEGIANCE BEHAVIOR HEALTH."

Further review of patient #9's record revealed NO documentation of a follow up visit with the neurosurgeon 1-2 days after the 2/7/17 ER visit. The RN failed to assess the patient's need for follow up care post fall and spinal fracture which, resulted in discomfort for the patient due to the cervical collar remaining on him for over 7 days.

An interview and record review conducted on 2/14/17, with staff #3, confirmed the above findings. Staff #3 was unaware that patient #9 was supposed to follow up with the neurosurgeon after the 2/7/17 post fall ER visit.

An interview was conducted on 2/14/17, with patient #9's nurse at the patient's bedside. Patient #9 was observed wearing a cervical collar. The surveyor asked the nurse why the patient had been wearing the collar for so long (since 2/7/17), and she stated, "I'm not sure. I know he fell about a week ago and has a fracture." The patient's skin on left side below the collar was observed with 2 reddened areas where the collar contacted the skin.

A review of the facility's policy titled, "RISK MANAGEMENT PROGRAM", revealed the following information:

" ...DEFINITIONS: ...
B. Incidents include but are not limited to, the following:
...1. Physical harm to patients, visitors, staff, students, etc.
...14. Falls ...
PROCEDURE:
A. Any person who discovers or observes an incident/variance, is to direct the completion of an incident report. This must be completed by the end of the shift on which the event takes place.
This report must be forwarded to the appropriate Department Director for recommendations and actions to be taken. Once the report is completed by the appropriate department manager, the report is forwarded to the Director of Risk Management within 24 hours of the incident/variance ...."
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on reviews and interviews, the facility failed to:

a.) provide the patient with information on patient rights and consent for treatment on 3 (#2, 21, and 6) of 3 charts reviewed.

b.) educate staff on patient rights, or signed consents used during the admission process.


1.) Review of patient #2's chart revealed the patient was admitted , voluntarily, on 1/11/16 with diagnosis of Dementia with self-harm. Patient #2 did not sign her consents for treatment, medication administration, or patient rights. The nurse had documented that a verbal consent was given by her power of attorney (POA).

Review of patient's POA document revealed under Information Concerning the Medical Power of Attorney, "Your agent may not consent to voluntary inpatient mental health services." The patient was allowed to sign a request for voluntary admission on 1/11/17. The form allows the patient to agree to abide by the rules and regulations and understands the provisions of the State Mental Health Code. The nurse had documented the patient was too confused to sign the consents but was allowed to sign a voluntary admission request.


2.) Review of patient #6's chart revealed the patient was admitted on [DATE]. The nurse practitioner had written the patient was involuntary on the psychiatric exam on 1-31-17. The physician admission order did not have a voluntary or involuntary status upon admission; nor was there an order to hold the patient as involuntary. There was no Emergency Detention Warrant (EDW) or Peace Officers Warrant (POW) on the chart to hold the patient as involuntary. A telephone order was found given by staff #26 Nurse Practitioner (NP) on 2/1/17. The order read, "Begin court commitment process due to very aggressive behavior and confusion- unable to make informed decision."

Review of the Nursing Admission assessment dated [DATE] revealed the RN documented the patient was confused. Patient #6 was allowed to sign all of his consents for treatment, patient rights, and psychoactive medication consents in a confused state.


3.) Review of patient #21's chart revealed the patient was admitted to the facility on [DATE]. The patient did not sign any of his consents. The Consent to treatment stated at the signature line, "Pt unable to sign d/t confusion." The form stated, "I have received and have read a copy of the Patient Rights and Responsibilities Form." The form was checked, "yes."

An interview was conducted on2/16/17 with staff#25 (staff RN) concerning consents, patient rights and the admission process. Staff #25 stated, "If they have a medical POA I just call them and get permission on consents. I get all the patients to sign the consents if they are voluntary." Staff #25 was not aware that there was a difference between a medical POA and a mental health POA. Staff #25 confirmed that she had allowed confused patients to sign in voluntarily.

An interview with staff #15 (staff RN) was conducted on 2/16/17 concerning consents, patient rights and the admission process. Staff #15 stated, "If the patients can't sign we just call family members. We just get a verbal from the family. I also call the family when I have to get consent for psycho active medications." Staff #15 was asked if she allows confused patients to sign consents and do they understand what they are signing. Staff #15 stated, "I really can't tell you if they understand what they are signing."
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on observation, review of records, and interview, the Chief Nursing Officer (CNO) failed to develop, review, and approve nursing policies for 2 of 2 units (Acute Care Unit and Behavioral Health Unit).

In a review of the organizational chart on 2-14-2017, it was discovered that there was an Acute Medical Unit within the hospital. Staff #1 was asked who the director of that unit was. Staff #1 stated the unit was on the second floor, but had been closed for "quite a while" so there wasn't a director. When Staff #1 was asked when the last time a patient had been admitted to the unit, Staff #1 replied, "It's been a long time since we had a patient up there." When asked for a specific date, a patient had been on the unit two months prior, 12-7-2016.

Interview with Staff #3 was conducted. Staff #3 stated that he was the Program Director for that unit and reported directly to Staff #2. He stated the unit was available for admissions of psychiatric patients who had medical problems, such as pneumonia, that could be treated at their facility. While not being used at the time, Staff #3 confirmed that the unit was not closed as previously stated by Staff #1.

A tour of the Acute Unit on the 2nd floor was conducted with Staff #3 and Staff #20. A policy binder was found in the nursing area of the unit. The form at the front of the policy manual contained "Allegiance Specialty Hospital of Kilgore, Clinical Services Manual, This Manual was Reviewed and Approved by:" The page contained signatures of the CNO, CEO, Medical Director and Governing Board. The CNO and Medical Director's signatures were dated in 2012. There was no date for the CEO and Governing Board signatures. When asked why the manual hadn't been updated, Staff #3 stated the signature sheet for the 2016 review and approval was downstairs and that the content had not changed. When asked if he was sure nothing had changed since 2012, Staff #20 stated, "They have been updated. It was an oversight on our part and we'll replace the manual with a current one."

Further review of the hospital-wide nursing policy manual provided by the facility for the survey showed that it also had the same signature page from 2012. Inside the front pocket of the binder was a new signature page that had been signed by Staff #1, Staff #2, and Staff #22 on 12-16-16. The Governing Board signature was missing. It also contained the statement, "This Manual was Reviewed and Approved by:"

An interview was conducted with Staff #2. Staff #2 was asked if she had reviewed and approved all of the nursing policies. Staff #2 stated she had been made aware in November of 2016 that the policy manuals had not been updated since 2012. When asked if she had actually reviewed and updated the policies, since they were at least 4 years old, she stated she had not. She said, "We try to review policies every week, but there are just too many policies to review them this quickly." When asked if she had a strategic plan such as prioritizing the policies with timelines and target dates for completion, Staff #2 stated she did not. Staff #2 confirmed that none of the policies reviewed or updated since November 2016 had been completed with printable, usable policies with Governing Board approval.

Review of Allegiance Specialty Hospital Clinical Services Manual Policy titles "Policy Development and Revision", Policy: CS6-1 was completed as follows:

"Purpose:
To establish a consistent approach for policy development and approval for hospital policies, and a consistent method of review to current policies.

Policy:
All policies at the hospital will follow the steps outlined below while being developed, approved, and distributed to the appropriate policy manuals. Review of existing policies will be completed by the leadership team on an annual basis and revisions made as appropriate. Policy manual approval will be completed annually through the Quality Safety Survey Readiness Committee, Medical Executive Committee and Governing Board."
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on review of records and interview, Nursing Services failed to provide an adequate numbers of qualified and/or trained nursing staff to meet the needs of patients in 3 out of 3 units reviewed [Acute Care Unit, Behavioral Health Unit, and Intensive Outpatient Unit (IOP)].


Review of annual training records revealed that annual training had not been completed hospital-wide since December 2015. This included annual nursing training in Abuse/Neglect, Infection Control, Patient Rights/Confidentiality, and Age Appropriate Care training. This was confirmed by Staff #2 and Staff #14.

An interview was conducted with Staff #1. The Satori Alternative to Managing Aggression (SAMA) Assisting Process course was a one-day course. Participants who demonstrate competency in all areas were certified in the SAMA Assisting (Verbal De-escalation) Process. Staff #1 stated this was all that was taught to the staff. Staff #1 stated she did not trust the staff to properly use the full SAMA training.

Full SAMA training was a two-day, 16 hour program that included 4 areas for managing aggressive patients. Those areas were:

o Principles and Assisting Process
o Protection of Self and Others
o Containment
o Object Retrieval

When Staff #1 was asked how staff were supposed to hold an aggressive patient, Staff #1 stated, "They know how to do that. Nurses are taught in nursing school how to hold a patient." When asked how staff are supposed to get a weapon away from a patient, Staff #1 stated, "We don't allow weapons. Patients can't get weapons in here. We search everyone thoroughly upon admission."

A review of the incident logs showed from 9-2-2016 to 2-8-2017 there were 20 incidents involving physical aggression that nursing staff were not able to manage using SAMA Assisting (Verbal De-escalation) Process. These incidents included a patient breaking into the nurse's station, retrieving a pair of scissors, stabbing at the staff and stabbing himself in the abdomen. Staff #28 was interviewed about the incident. Staff #28 stated, "It all happened so fast, I didn't know what to do." Staff #28 stated she had been taught the full SAMA course "years ago", but didn't remember much of it.

Another incident resulted in multiple staff being struck and the police being called. Review of this incident showed that police held the patient for the staff to be able to administer emergency medications and removed the patient to the seclusion room for the staff so the patient could be contained.

Review of Patient #11's chart showed that he was an Intensive Outpatient Program (IOP) patient who became unresponsive on 12-14-2017 in the IOP. A Code Blue (emergency situation requiring immediate medical attention) was called overhead. The nurse charted "Staff called code blue to IOP. ER & BHC staff arrived. Pt continue to have pulse & resp. BHC staff obtained gurney. Pt lifted to gurney and at that time became responsive slightly to verbal stimuli. Pt transferred to (a separately licensed hospital's emergency room ) for higher level of care."

Staff #3 was interviewed about this incident. Staff #3 stated the staff from (emergency room staff from a separately licensed hospital's emergency room in the same building as the IOP and behavioral hospital) can hear the overhead paging system and come over to assist in the IOP and on the behavioral unit whenever a code is called. Staff #3 stated, "They come over here to help us out during a code." Staff #2 was interviewed about the incident. Staff #2 was not aware of, nor able to provide copies of, any contract, agreement, or training for non-employed staff from another hospital to come into the behavioral hospital and provide emergency care for their patients.

A Review of Policy # CS3A-01, titled "Code Blue", was completed. The policy stated:

"PROCEDURE:

1. Call the Code internally but using the overhead paging system. Dial 444 and announce clearly three times, "Code Blue, Room #___ / location (Noisy Activity)". (sic)

2. Establish unresponsiveness and attain emergency assistance via calling "CODE SHEPHERD" and if needing help to transport "CODE SHEPHERD, ASSISTANCE NEEDED" and give the location.

...

8. Once the (name of separately licensed facility) staff, on-call physician or any physician has arrived, they assume responsibility for running code. Nursing staff at this point will provide care under ordered by the available physician. Traffic control of extra personnel/visitors should be initiated."


A review of admissions to the Acute Care unit showed that one patient was admitted in December. Staff #37 was one of the nurses assigned to care for the patient during that stay. Review of Staff #37's file showed that she did not have SAMA training and there was no documentation of orientation for the Acute Care Unit to include location of supplies and the admission process. Staff #37 was a PRN (as needed) employee and did not work full time. She was left with one mental health technician on the second floor alone to admit a psychiatric patient and no orientation to the floor or the admission process for the Acute Care Unit. Staff #3 was interviewed. Staff #3 confirmed that Staff #37 was left on the Acute Care Unit with one MHT. Staff #3 stated he showed her where everything was and told her what she needed to do to complete the admission process to the Acute Care Unit. Review of the Allegiance Specialty Hospital Clinical Services Manual policy titled "Nurse Staffing", Policy # CS8-03, last reviewed 10-2012 was completed. The policy contained the "Behavioral Health Staffing Matrix" that was noted "UPDATE April 2012". Per the Acute Care Staffing portion of the Matrix, minimum staffing for 1 patient on the Acute Care Unit required, 1 Registered Nurse, 1 Licensed Vocational Nurse, and 1 Certified Nurses Aid.

During observations of the Behavioral Unit on 2-14-2017, Patient #20 was observed to be pacing around the nursing station with Staff #29 following behind her. Staff #29 was observed to come back to the nursing station without the patient. Staff #29 was asked what had been happening with the patient. Staff #29 explained that she was a nursing student doing her clinical rotations for nursing school. She explained that Staff #30 was the assigned Mental Health Technician (MHT) assigned to the patient. Staff #29 stated Staff #30 had to go somewhere so left Staff #29 to monitor the patient. Staff #29 stated she had been alone with the patient for about 20 minutes. Staff #29 was asked if she had any training to deal with aggressive patients. Staff #29 denied receiving any training. Review of Patient #20's MHT Care and Observation Flowsheet showed that the patient was on "Fall Precautions and Aggression Precautions". Staff #30 was interviewed about the incident. Staff #30 stated she did not tell the Charge Nurse that she was leaving or that she had delegated her assignment to a nursing student. Staff #30 stated that she was not aware that she had done anything wrong. Staff #2 and Staff #3 were interviewed about the incident. Staff #2 and Staff #3 confirmed that the nursing student did not have the appropriate training to monitor a patient and should not have been left responsible for monitoring the patient.

Review of the Allegiance Specialty Hospital Clinical Services Manual policy titled "Nurse Staffing", Policy # CS8-03, last reviewed 10-2012 was completed. The policy contained the "Behavioral Health Staffing Matrix" that was noted "UPDATE April 2012". Staff #3 was asked to provide the Staffing Matrix that was being used during scheduling. Staff #3 provided a Matrix that did not match the policy. The matrix did not have any dates of approval. Staff #3 was asked to provide the date this matrix had been approved through committee. Staff #3 was not able to provide this information. Staff #3 stated, "I don't know. This was here when I started so that's what I've been using." The unapproved staffing grid reduces staffing by one nurse when the census is high, above 17, on day shift. The unapproved staffing grid reduces staffing by one MHT when the census is high, above 19, on night shift.

Review of Staffing for day shift on 2-1-2017 show that the census was 20. Per the approved staffing grid in the policy, 4 nurses should have been scheduled. Only 3 nurses worked that day. Per the approved staffing grid in the policy, 4 MHTs should have been scheduled. Five (5) MHT's were scheduled, but 2 of them were assigned to patients on a 1:1 (one MHT to stay with the patient at all times) removing 2 MHT's from the staffing matrix minimum. This left them short 1 MHT.

Review of Staffing for day shift on 1-30-2017 show that the census was 20. Per the approved staffing grid in the policy, 4 nurses should have been scheduled. Only 3 nurses worked that day. Per the approved staffing grid in the policy, 4 MHTs should have been scheduled. Five (5) MHT's were scheduled, but 2 of them were assigned to patients on a 1:1 (one MHT to stay with the patient at all times) removing 2 MHT's from the staffing matrix minimum. This left them short 1 MHT.

Review of Staffing for day shift on 1-28-2017 show that the census was 20. Per the approved staffing grid in the policy, 4 nurses should have been scheduled. Only 3 nurses worked that day.

Review of Staffing for night shift on 1-28-2017 show that the census was 21. Per the approved staffing grid in the policy, 4 MHTs should have been scheduled. Five (5) MHT's were scheduled, but 2 of them were assigned to patients on a 1:1 (one MHT to stay with the patient at all times) removing 2 MHT's from the staffing matrix minimum. This left them short 1 MHT.

Review of Staffing for night shift on 1-27-2017 show that the census was 21. Per the approved staffing grid in the policy, 4 MHTs should have been scheduled. Five (5) MHT's were scheduled, but 2 of them were assigned to patients on a 1:1 (one MHT to stay with the patient at all times) removing 2 MHT's from the staffing matrix minimum. This left them short 1 MHT.

Review of Staffing for day shift on 1-26-2017 show that the census was 21. Per the approved staffing grid in the policy, 4 nurses should have been scheduled. Only 3 nurses worked that day.

Review of Staffing for night shift on 1-25-2017 show that the census was 21. Per the approved staffing grid in the policy, 4 MHTs should have been scheduled. Five (5) MHT's were scheduled, but 2 of them were assigned to patients on a 1:1 (one MHT to stay with the patient at all times) removing 2 MHT's from the staffing matrix minimum. This left them short 1 MHT.

Review of Staffing for day shift on 1-22-2017 show that the census was 18. Per the approved staffing grid in the policy, 4 nurses should have been scheduled. Only 3 nurses worked that day.

Interview was conducted with Staff #28 on 2-14-2017. Staff #28 was attempting to schedule staffing due to increased need for staff. SAMA training was not completed by all staff. Staff #28 had a list of staff with their dates of SAMA training. The list showed that some people had Part One of the training, SAMA Assisting (Verbal De-escalation) Process. No one on the list had Part Two which included Containment and Object Retrieval. Staff #28 was using this list to determine who was qualified to work. Staff #2 was asked to provide a copy of that list. Staff #2 provided a list that was different. The list provided by Staff #2 had only one column that said "S.A.M.A" instead of Part One and Part Two. When asked why he had given me a different list, he said the nurse that was scheduling staff to work did not have the most current list.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of records and interview, registered nursing (RN) staff failed to assess the patients on an ongoing basis and when a change in condition occurred in 7 (Patient #s, 1, 8, 9, 10, 12, 18, and 19) of 7 patients reviewed.

A review of Patient #1's chart was conducted. Patient #1 chart revealed on 2-28-2016 at 1:20 PM, "Pt continues to threaten staff, contacting MD." The nurse charted at 1:25 PM, "Dr. Jacobson Notified of Pt's behavior, new orders: 1 time dose-Combine Ativan 2mg (milligram) inj. (injection) Haldol 10mg inj. and Benadryl 50 mg inj to be given IM (in a muscle) NOW for combative behavior." The nurse charted that the injection was given at 1:40 PM. At 2:00 PM, the Mental Health Technician (MHT) charted that the patient was in their room sleeping until 10:15 PM. The MHT charted that the patient was back to sleep at 10:30 PM and woke up intermittently. The next nursing note was at 12:50 AM on the morning of 2-29-2016, the nurse charted, "Pt restless and agitated - attempting to climb out of bed. PRN Klonipin 1 mg po (by mouth) administered. Pt scuffing arms on bed mattress and reopening skin tears. Unable to keep dressings in place." The patient slept a total of 12.75 hours out of the 17 hours between receiving the injection on 2-28-2016 at 1:40 PM and 7:00 AM the next morning. On 2-29-2016 at 12:10 PM, the nurse charted a change in the patient's condition. The patient had decreased responsiveness. The nurse charted, "1210 - New order for Narcan 0.4 mg IM one time order. Patient leaning right in wheelchair, sedated, slurred speech and delayed answer when asked question."

The chart did not contain documentation of interventions attempted to avoid having to medicate the patient with sedating medications. The chart did not contain any documentation of a nursing follow-up assessment of the patient to include vital signs before medication administration or after medication administration. Vital signs were assessed on 2-29-2016 at 7:12 AM and were within normal parameters. Vital signs were reassessed at 7:15 PM (approximately 7 hours after patient was identified as having decreased responsiveness). The patient was found to have a temperature of 101.6 degrees Fahrenheit and an oxygen saturation level of 88% on room air. A posting of normal vital sign range in the nurse's station showed that the normal range for oxygen saturation level was 94% to 100%. The patient was transferred to a medical hospital in another city and did not return to the specialty hospital.

Patient #10's chart was reviewed. Patient #10 was admitted on [DATE] to the acute care unit. The patient transferred to the Behavioral Unit on 11-30-2016. Patient number 10 discharged on [DATE]. Patient number 10 had an interrupted stay. The patient was transferred to another hospital on 12-8-2016. There was no note documentation found stating when the patient returned. The last shift assessment prior to transfer to another hospital was on 12-7-2016 at 8:08 PM. The next shift assessment was completed on 12-10-2016 at 11:40 AM. Staff #24 charted a physician's medical assessment occurred on 12-10-2016 at 6:25 AM. The actual date and time of return from the other facility was not documented in the chart with an RN assessment.

The patient was required a nursing shift assessment each shift. The nursing shift assessment was a comprehensive assessment of multiple body systems and risk assessments. The shift assessment was not a focused nursing assessment. The patient arrived on the Behavioral Unit on 11-30-2016. Between 12-1-2016 and patient transfer on 12-8-2016, 15 RN shift assessments should have been documented. Nine (9) of the assessments were documented and signed by Licensed Vocational Nurses (LVN). One (1) RN shift assessment was not found in the chart at all. Only 5 shift assessments were signed by an RN. Between 12-10-2016 and discharge on 12-13-2016, 7 RN shift assessments were due. Five (5) out of 7 were charted and signed by an LVN. Two (2) were signed by an RN.

Patient #12's chart was reviewed. On 1-29-2017 the nurse charted at 10:00 PM, "Pt. isolating in room and remains delusional. States that nurse call button to bed is not working and that is a federal violation for call button not to be working and that all of the nurses were going to jail. Compliant with HS medications. Will continue to monitor. Pt remains agitated about call button on bed not working. Yelling out and difficult to redirect. Refusing to take PRN Ativan 0.5 mg. Pt assisted to WC and moved for closer monitoring near nurses station. Norco 10/325 mg administered at 21:40 for bilateral leg pain. Will continue to monitor."

At 10:40 PM the nurse charted, "Follow up PRN Norco 10/325 mg: Pt states that he continues to have pain and pain level is 6/10. Pt continues to be agitated and threw laundry hamper over nurses station counter attempting to hit nurses sitting in the area."

At 10:50 PM the nurse charted, "Pt. remains loud and disruptive and continues to refuse PRN Ativan 0.5 mg po. (Nurse Practitioner's Name) notified by Charge Nurse and new order noted. Zyprexa 5mg IM administered to Rt deltoid site and Benadryl 12.5 mg IM administered to Lt. deltoid site. Will continue to monitor."

At 11:05 PM the nurse charted, "Follow-up Zyprexa 5 mg IM and Benadryl 12.5 mg IM one time only dose. Pt drowsy and assisted to bed by staff." The chart did not contain any documentation of a nursing follow-up assessment of the patient to include vital signs before medication administration or after medication administration.

Review of the physician orders and medication administration record for 2-1-2017, Patient #12 was conducted. The physician orders do not contain an order for Zyprexa on 2-1-2017. An order written on 2-1-2017 at 9:30 PM was found for "Give Haldol 1 mg, Ativan 1 mg, and Benadryl 12.5 mg IM x 1 dose - If ineffective after 1 hr give Haldol 1 mg IM." The Medication Administration Record (MAR) was documented that those medications were given on 2-1-2017 at 9:30 pm.

The Nursing Rounding Documentation for 2-1-2017 at 9:00 PM showed, "No evidence of pain observed, Offered emotion support/active listening, Being observed per orders." The chart for Patient #12 did not contain documentation of interventions attempted to avoid having to medicate the patient with sedating medications. The last nursing note for 2-1-2017 was at 12:30 pm. The next nursing note was 2-2-2017 at 2:40 pm.

Review of Patient #18's chart was conducted. Patient #18 was admitted on [DATE] and was still a patient at the time of chart review on 2-14-2017. Patient #18 should have had an admission assessment and 4 shift assessments completed by an RN. On 2-13-2017, both shift assessments were charted and signed by an LVN.

Review of Patient #19's chart was conducted. Patient #19 was admitted on [DATE] and was still a patient at the time of chart review on 2-14-2017. Patient #19 should have had an admission assessment and 18 shift assessments completed by an RN. On 2-11-2017 an LVN charted and signed the shift assessment for the day shift. The night shift assessment was missing. The night shift assessment on 2-13-2017 and day shift assessment on 2-14-2017 were both charted and signed by an LVN.

An interview was conducted with Staff #15 on 2-15-2017 in the conference room. Staff #15 stated that when patients are aggressive, nursing staff will call and get a medication order if needed. Staff #15 stated the Emergency Behavioral Medication order is not treated as a restraint. Staff #15 stated a face-to-face assessment with the patient is not documented. After medication administration, Staff #15 said, "We don't wake them up for vital sign checks. We just let them sleep."


Review of Assessment and Reassessment of Patient policy number CS2-01 was as follows:
"Page 2 of 2
6. Reassessment
i. Reassessment of the patient shall occur PRN and each time there is a change in the patient's condition.
ii. Nursing shall reassess the patient on a per shift basis.

7. Reassessment by all disciplines caring for the patient will occur on an ongoing basis throughout the patient stay. Changes in condition and progress in recovery will be documented in the patient medical record. Changes in the plan of care and treatment will be documented accordingly."

The policy did not address the shift assessments.


A review of Allegiance Specialty Hospital policy titled "Transfer Policy"; Policy: CS5-07, was conducted. The policy reads as follows:
"PROCEDURE:
Patients may be scheduled for temporary placement within an acute care facility for treatment or procedure. A Memorandum of Transfer will be completed for non-emergent patient transfers. A physician assessment of patient's stability of condition for transfer will be completed for non-emergent transfers, A patient / family consent for transfer will be completed for non-emergent transfers.

Report on the patient's status should be documented prior to and upon return to ALLEGIANCE SPECIALTY HOSPITAL OF KILGORE.

Utilize the Appropriate Documentation tools to record the patient's status.

Upon return to the facility, nursing staff should evaluate the patient through reassessment and document findings in the nursing notes. A reassessment will be completed to determine need for frequent monitoring of the patient.

Upon return of the patient to the facility vital signs are to be recorded.

Frequent monitoring includes, but is no limited to, the following:
Changes in vital signs i.e. significant drop or elevation of blood pressure
Changes in mental status and/or motor activity
Changes in pulmonary status
Changes in wound status
Changes in urinary output
Increase in pain

Changes in condition and or unusual findings are to be reported to the physician.

Physician notification of return to the hospital will be completed and continuing care orders obtained."



Review of the Texas Board of Nursing Board Rule 217.11(2)(A) showed:

"(2) Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and:
(A) Shall utilize a systematic approach to provide individualized, goal-directed nursing care by:
(i) collecting data and performing focused nursing assessments;"