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.

ASPIRE HOSPITAL 2006 SOUTH LOOP 336 WEST, SUITE 500 CONROE, TX 77304 Dec. 10, 2015
VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY Tag No: A0468
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure that 2 of 2 Discharge Summaries dictated by MD #56 accurately and completely documented the outcome of Patient #1 ' s hospitalization .

Findings included:

TX 597

Patient #1 ' s admission on 08/22/2015 and discharge on 08/29/2015.

Record review of Registration Admission face sheet for Patient #1 revealed the patient was admitted on [DATE] and discharged on [DATE] at 0437.

Record review of an Incident Report by RN #60 dated 08/28/2015 at 1136 revealed that Patient #1 was transferred from the facility to a medical surgical hospital for evaluation of chest pain radiating to the left arm.

Record review of Discharge Summary for Patient #1 by MD #56 dated 09/25/2015 at 1623 revealed discharge on 08/29/2015. " Condition on discharge: improved (level of depression decreased, reduced anxiety, reduced psychosis, compliant with treatment plan and medication management.) Follow up with medical - routine. Psychiatric follow-up in 2 weeks with psychiatrist. " There was no mention of the transfer to a medical surgical hospital for evaluation of chest pain. The reason for admission, a suicide risk assessment, prognosis, dietary and/or activity restrictions, and name of individual providing aftercare were not included.


Patient #1 ' s admission on 08/29/2015 and discharge on 09/04/2015.

Record review of Registration Admission face sheet for Patient #1 revealed the patient was admitted on [DATE] and discharged on [DATE].

Record review of Cardiology Consultation by MD #62 on 08/29/15 at 1310 for Patient #1 revealed chest pain, renal disease, chronic pulmonary embolism and chronic diastolic heart failure. MD #62 stated the patient needed better blood pressure control, follow-up with a cardiologist as an outpatient and " better stabilization on her multiple antipsychotic medications prior to further aggressive workup from cardiac standpoint. "

Record review of Discharge Summary for Patient #1 by MD #56 dated 09/105/2015 at 1812 revealed discharge on 09/04/2015. " Improved condition. Follow up with medical - routine. Psychiatric follow-up in two weeks with psychiatrist. " The reason for admission, suicide risk assessment, prognosis, dietary and/or activity restrictions, special procedures, consultation findings and recommendations, and name of individual providing aftercare were not included.

In an interview with Personnel #53 on 12/04/2015 at 1315, he stated there had been some problems with completion of medical records by physicians.

Record review of Policy & Procedure: Psychiatric Discharge Summary dated 12/08/2014 revealed that the format should include: reason for admission, suicide risk assessment, prognosis, dietary and/or activity restrictions, special procedures, consultation findings and recommendations, and name of individual providing aftercare.
VIOLATION: GOVERNING BODY Tag No: A0043
The Governing Body of the facility failed to ensure:

The facility's policies and procedures were enforced;

A safe, ligature proof environment was provided;

Medical records were complete;

Environment of Care Safety Rounds were documented;

Discharge Summaries were complete;

Yearly competencies for staff that provide patient care were completed;

Staff had CPI (Crisis Prevention Institute) training prior to working with patients;

An updated copy of the Bill of Rights was given to patients;

Rounds were made on patients every 15 minutes;

RN assigned 15 minute round intervals to staff;

Patient's rooms were free of ligature contraband;

RN provided oversight of the Unit Round Worksheet;

Each patient had a Patient Observation Rounds sheet;

Staff could identify patients on suicide precautions; and

Suicide Risk Assessments were done.



The Governing Body failed to ensure that patients received care in a safe environment. The environment was not non-ligature proof resulting in the suicide of a patient. The RN was not providing oversight for the 15 minute rounds nor was there consistency in the RN's responsibility for making rounds. Staff could not identify patients on suicide precautions. There was not a checklist for staff to identify environmental hazards. Cross reference A-0115 Patient Rights.



The Governing Body failed to ensure that the medical record department provided executive accountability for the patient's medical records. Medical records were incomplete and inconsistencies were found in the records. Instead of each patient having an individualized Observation Rounds Sheet for 15 minute rounds, all of the rounds were documented on the Unit Round Worksheet. The Unit Round Worksheet was not part of the medical record. The Patient Observation Rounds policy stated that each patient was to have an observation flow sheet. There were inconsistencies in the timeframes for Suicide Risk Assessments by the RN. Patients did not receive a current copy of the Bill of Rights during the admission process; nor was a copy of the signed Bill of Rights kept as part of the permanent chart. Cross reference A-0431 Medical Records.



The Governing Body failed to ensure that there was an organized nursing service that provided safe nursing care. A staff member stated she had not made 15 minute rounds but charted she had made the rounds. Another staff member documented assessments on a patient. Video surveillance didn't support the claim. Nursing staff members were unable to identify patients on suicidal precautions. A patient hung himself using what was described as a pajama string or a shoe lace, which were contraband items. RN Suicide Risk Assessments were not documented according to policy guidelines. Techs and RNs were not using Patient Observation Rounds Sheets to document the 15 minute rounds. RNs were not providing oversight of the Unit Round Worksheet. Techs and RNs were not using a checklist to identify environmental hazards. Staff in the admissions department were not providing patients with a current copy of the Bill of Rights and a copy of the signed Bill of Rights was not part of the permanent record. Nursing staff were functioning with an incomplete orientation and no annual competency assessments. Cross reference A-0385 Nursing Services.
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review, and interview, the hospital failed to ensure that services were provided in compliance with all applicable rules and standards as evidenced by:


1. Failure to provide a safe non-ligature proof environment In 16 of 16 patient rooms (rooms 100, 101, 102, 103, 105, 106, 107, 108, 202, 203, 204, 205, 206, 207, 208 and 209) creating suicide risk and widespread endangerment to 21 of 21 patients (Patient #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, and Patient #23).

2. Suicide of Patient #2 due to unsafe non-ligature proof environment and failure of staff to perform 15 minute rounds per policy.

3. Environment of care safety rounds were not documented.

4. Medical records were incomplete and/or inconsistent on 26 of 26 patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #25, #26 and Patient #27).

5. Incomplete orientation and/or competency assessments for 6 of 6 Nursing Services personnel (LVN #55, RN #58, RN #81, Tech #70, RN #86 and Tech #72) providing patient care.

6. 26 of 26 patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #25, #26 and Patient #27) did not have a signed copy of the Bill of Rights in their charts.


Findings included:


1. Non-ligature Proof Environment.


Observation of the adult psychiatric unit on 12/03/2015, at 1000, revealed 16 of 16 patient rooms (rooms 100, 101, 102, 103, 105, 106, 107, 108, 202, 203, 204, 205, 206, 207, 208 and 209) had hinges on the bathroom and bedroom doors that were not ligature proof.


Record review of Unit Round Worksheet dated 12/03/2015, revealed 21 of 21 patients in 15 of the 16 patient rooms (rooms 100, 101, 102, 103, 105, 106, 107, 108, 202, 203, 204, 205, 206, 208 and 209) that had hinges on the bathroom and bedroom doors that were not ligature proof.


In an interview with Personnel #53 on 12/03/2015, at 1000, he stated that the hinges on the doors had been identified as a suicide risk.



2. Suicide of Patient #2.


Record review of Nursing 12 Hour Assessment by RN #81 dated 11/26/2015 at 2020 revealed that Patient #2 was "observed hanging on the door hinges with a string around his neck..... "


In a phone interview with RN #81 on 12/07/2015, at 0800, he stated he was the charge nurse on the night of 11/26/2015. He got out of report at 1935 and began checking physician's orders. He stated rounds were made on time by the techs. LVN #55 discovered that Patient #2 had hung himself. He went to the room and untied a "black string" from the door hinge that was around Patient #2's neck. It looked like a "shoe lace." He also stated, "The RN makes rounds from time to time if not busy with admissions ... sometimes I have to make rounds ... If we have four admissions, I make rounds when I get caught up ... Sometimes there's 3 to 4 admissions waiting for us ... There's lots of calls on the phone."


In an interview with Tech #72 on 12/03/2015, at 1210, she stated that on 11/26/2015, she was busy helping Tech #76 with a total care patient until 2035 but was supposed to be making rounds. She stated she did not do the 15 minute rounds at 0815 but documented she had done them and later crossed out the 2015 and 2030 entries she had made on the Unit Round Worksheet for Patient #2. She stated she did not know if Patient #2 was on suicide precautions the night he hung himself. She stated that suicidal patients are to have "no strings ... every now and then we will find contraband in the patient rooms." She stated she has found draw strings in pajamas in the patient rooms in the past.


Record review of Psychiatric Evaluation by MD #67 dated 11/23/2015, at 1935, revealed Patient #2 was an [AGE] year old male, admitted status post two failed suicide attempts, carbon monoxide poisoning and a gun, just prior to admission.


Record review of [Physician's] Orders by MD #67 dated 11/23/2015, at 0937, revealed Patient #2 was on Suicide Precautions. Further review of all physician's orders revealed the Suicide Precautions were not discontinued during his hospital stay.


Record review of Social Worker Note by Licensed Professional Counselor (LPC) #68 dated 11/24/2015, at 1045, revealed: Patient #2 stated he was upset due to health problems and did not want to be a burden his family.


Record review of the Psych Safety Rounds Assessment for Patient #2 by LVN #75 dated 11/26/2015, at 0952, revealed Patient #2 was monitored every 15 minutes by staff with "visual inspection of the patient and environment, and a completed search ...No items removed."


Record review of Group Progress Note by Therapist #65 dated 11/23/2015, at 1230, revealed: Patient #2 stated he met his second wife on Thanksgiving. He became tearful "as he still misses his second wife."



3. Patient #2 had Ligature Contraband.


In an interview with LVN # 55 on 12/03/2015, at 1420, stated that on 11/26/2015, (Thanksgiving Day) she found Patient #2 dead in his room. She also stated that Patient #2 died when he hung himself with a "navy blue, maybe black string." He used the middle hinge of the door leading into his room from the hallway. She stated, "Usually techs inventory and remove contraband material ... Strings are cut from clothing if the patient opts to keep it." Patients are not allowed "shoe strings or belts." Patient #2 was on "suicide precautions."


In an interview with RN #60 on 12/04/2015, at 1000, she stated that an investigating officer told her the string around Patient #2's neck looked like a string from pajama pants.


Record review of Policy & Procedure: Contraband Search Guidelines dated 12/08/2014 revealed: "1.0 Belongings Search. All Patients' belongings will be searched for potentially hazardous items by behavioral health staff on admission ... 1.4 ... look for belts or drawstrings and remove from clothing ... 1.6.13 Belts, cords, straps, ties, and shoelaces....... "



4. RN Responsibility in Providing Oversight of the Unit Round Worksheet.


In an interview with RN #58 on 12/03/2015, at 1030, she stated she makes rounds every 4 hours and documents this on the Unit Round Worksheet. She stated this is the policy.


In an interview with DON #51 on 12/10/2015, at 1600, she stated that the Charge RN is supposed to review the Unit Rounds Worksheet and make rounds on the patients every four hours. She stated this is the policy.


In an interview with Tech #70 on 12/03/2015, at 1040, he stated he takes the board to the RN for the RN to make rounds every four hours.


In an interview with Tech #85 on 12/03/2015, at 1100, she stated the RN does not always check patients when they do the four hour documentation on the rounds sheet.


In an interview with RN #60 on 12/04/2015, at 1000, she stated, "Every few hours" the RN makes sure the rounds are being done. "We make sure the board is complete every four hours. The RN initials it ... and returns the board to the tech after signing it." She makes rounds on patient "when I have time ... there is no specific time to make rounds, usually at group and meal times."


Record review of Policy & Procedure: Patient Observation Rounds dated 12/08/2014, revealed:

"11.0 ... The Charge RN will review the patient observation rounds flow sheet at the end of each shift to ensure completion of rounds as assigned and sign....... "


Record review of Policy & Procedure: Clinical Hand-Off Communication dated 12/08/2014, revealed: " A 5. After listening to shift report the outgoing RN will round with the incoming RN ... "



5. No Staff Assignments for 15 Minute Round Intervals.


Record review of 7P-7A Patient Care and Supervisory Report Sheet [assignment sheet] dated 11/26/2015, revealed four staff members: RN #81, RN #82, Tech #72 and Tech #76. Techs #72 and #76 were assigned to do "rounds." Designated round intervals had not been assigned to the techs. Staff had not been assigned to monitor hallways.


Record review of 7A-7P Patient Care and Supervisory Report Sheet [assignment sheet] dated 12/03/2015, revealed six staff members: RN #58, RN #87, LVN #84, Tech #70, Tech #83 and Tech #85. Techs #70, #83 and #85 were assigned to do "rounds." Designated round intervals had not been assigned to the techs. Staff had not been assigned to monitor hallways.


In an interview with Tech #72 on 12/03/2015, at 1210, she stated, "Rounds are not assigned by the RN. Usually who gets the rounds board first does the first two hours of rounds."


Record review of Policy & Procedure: Patient Observation Rounds dated 12/08/2014, revealed:

"Patient observation rounds are to be performed on all patients by the assigned nursing staff at a frequency of every 15 minutes ...

1.0 ... The Charge Nurse will assign staff responsibility for round intervals on patients each shift and document on the shift assignment sheet ...

3.0 ... Staff are to be assigned to monitor hallways at all times......"



6. Identification of Patients on Suicide Precautions.


In an interview with Tech #83 on 12/03/2015, at 1010, she stated she was not able to name the patients on suicide precautions.


In an interview with RN #58 on 12/03/2015, at 1030, she stated, "There were too many patients on suicide precautions to name...... I need to look at the report sheet."


In an interview with Tech #70 on 12/03/2015, at 1040, he stated he was unable to name the patients on suicide precautions.


In an interview with LVN #84 on 12/03/2015, at 1120, she stated she didn't look to see what patients were on suicidal precautions. "I know we have some." She stated she was unable to name the patients on suicide precautions.


Record review of Policy & Procedure: Patient Observation Rounds dated 12/08/2014, revealed:

"1.0 Patient observation rounds...... All staff assigned will update the flow sheets during their shift to reflect any changes in precaution level......."


Record review of the Policy & Procedure: Suicide Risk Assessment and Precautions dated 12/08/2014 revealed: " ... 10.0 The observation flow sheet will clearly indicate patients on suicide precautions ... "



7. Environment of Care Safety Rounds.


Record review of the Unit Round Worksheet dated 11/26/2015, revealed that there was not a checklist for staff to identify environmental hazards on the form.


In an interview with DON #51 on 12/03/2015, at 1315, she stated there was not a check list for staff to use to identify environmental hazards.


Record review of Policy & Procedure, Environment of Care Safety Rounds dated 12/08/2014, revealed: "..... A systematic approach will be operational to proactively identify environment risks and minimize the harm risk to patients or others. Staff will actively participate in this approach by identifying and reducing environmental risks ... 1.0 Once a day, Environment of Care Safety rounds will be conducted by assigned staff and documented on checklist ... "
VIOLATION: NURSING SERVICES Tag No: A0385
Based on record review and interview, the facility failed to ensure that nursing services provided and documented safe nursing care and practice for 26 of 26 patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #25, #26 and Patient #27) as evidenced by:


1. 2 of 2 staff members (Tech #72 and RN #81) inconsistency in the documentation on Patient #2.

2. 4 of 4 staff members (Tech #83, RN #58, Tech #70, and LVN #84) were unable to identify patients on suicide precautions.

3. 1 of 10 patients (Patient #2) had ligature contraband on 11/26/2015.

4. 1 of 1 patients (Patient #2) did not have suicide risk assessments as outlined in the policy.

5. 21 of 21 patients (Patient #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, and Patient #23) did not have Patient Observation Rounds Sheets.

6. RN was not providing oversight of the Unit Round Worksheet affecting 26 of 26 patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #25, #26 and Patient #27).

7. No check list for staff to identify environmental hazards.

8. 6 of 6 nursing staff (LVN #55, RN #58, RN #81, Tech #70, RN #86 and Tech #72) had incomplete orientation and/or competency assessments for 5 of 5 nursing staff members.


1. Inconsistencies in the Documentation on Patient #2.


Record review of Nursing 12 Hour Assessment by RN #81 dated 11/26/2015, at 2100, revealed that Patient #2 was alert and oriented to person, place, time and situation, speech within normal limits, goal directed thought processes, no hallucinations, willing to contract for safety, adequate appetite and sleep and a full physical examination. RN #81 documented pain management of lower back pain with a score of 3 on the pain scale.


Record review of surveillance video for 11/26/2015, with Personnel #52 and #53 revealed a non-audio video. The following events were noted:

At 1912, RN #81 arrived to the nurse's station.

At 1930, RN #81 went to a side room to get report.

At 1940, Patient #2 came to the nurse's station to get a cookie.

At 1941, RN #81 returned to the nurse's station. He did not interact with Patient #2.

At 1946, Patient #2 left the nurse's station.

At 1947, Patient #2 went to his room.

At 1948, Patient #2 exited his room and sat on a couch in the hallway across from his room.

At 2004, Patient #2 returned to his room.

At 2011, the door to Patient #2's room opened slightly for about 20 seconds then shut quickly.

At 2027, LVN #55 entered Patient #2's room, immediately exited the room and ran toward the nurse ' s station.


In an interview with Personnel #52 and #53 on 12/10/2015, at 1355, they both stated that there was no evidence on the surveillance video that RN #81 verbally interacted with Patient #2. As they viewed the video they stated that RN #81 could not have completed the evaluations on Patient #2 that he documented in the medical record.


In an interview with Tech #72 on 12/03/2015, at 1210, she stated that on 11/26/2015, she did not do the 15 minute rounds on 10 of 10 patients (Patient #2, #5, #8, #14, #16, #19, #20, #25, #26, and Patient #27) at 0815 but "falsely documented" on the Unit Round Worksheet she had done them. She also stated she later crossed out the entries on Patient #2 rounds for 2015 and 2030 after Patient #2 was found dead.


Record review of a Disciplinary / Counseling Form for Tech #72 dated 11/30/2015, [not timed] revealed that Tech #72 was suspended for five days because of "falsifying documentation on 15 minute rounds" and "pre-charting of every 15 minute rounds" on 11/26/2015, at 2000. The report further stated that the "sentinel event occurred during time that rounds should have occurred." It was signed by Tech #72, DON #51 and Human Resources Director #88.


In an interview with RN #60 on 12/04/2015, at 1000, she stated, . "There's a problem at night with techs not making rounds." She went on to say that she has seen techs at night not do the rounds but document the rounds as having been done


Record review of Policy & Procedure: Patient Observation Rounds dated 12/08/2014, revealed:

"Patient observation rounds are to be performed on all patients by the assigned nursing staff at a frequency of every 15 minutes or more frequently as ordered by the physician for each 24-hour period ...

1.0 Patient observation rounds are recorded on the observation flow sheet for each patient by the assigned staff member ...

10.0 Documentation of the 15 minute patient observation rounds occurs at the assigned time and not in advance ... "


Record review of Nursing 12 Hour Assessment by RN #81 dated 11/26/2015, at 2020, revealed that Patient #2 was "observed hanging on the door hinges with a string around his neck ... 911 was called ... Hospital administration, attending MD and patient relatives was [sic] notified of patient's current status." RN #81 did not document time of death, doctor pronouncing death, disposition of patient's body, clothes, and valuables, and any specific circumstances or instructions as given by the Medical Examiner or next of kin.


Record review of Policy & Procedure: Patient Death dated 12/08/2014 revealed: ".....4.0 Nursing staff will document in the progress notes recorded time of death, doctor pronouncing death, disposition of patient ' s body, clothes, and valuables, and any specific circumstances or instructions as given by the Medical Examiner or next of kin ..."



2. Identification of Patients on Suicide Precautions.


In an interview with Tech #83 on 12/03/2015, at 1010, she stated she was not able to name the patients on suicide precautions.


In an interview with RN #58 on 12/03/2015, at 1030, she stated, "There were too many patients on suicide precautions to name ... I need to look at the report sheet."


In an interview with Tech #70 on 12/03/2015, at 1040, he stated he was unable to name the patients on suicide precautions.


In an interview with LVN #84 on 12/03/2015, at 1120, she stated she didn't look to see what patients were on suicidal precautions. "I know we have some." She stated she was unable to name the patients on suicide precautions.


Record review of Policy & Procedure: Patient Observation Rounds dated 12/08/2014, revealed:

"1.0 Patient observation rounds ... All staff assigned will update the flow sheets during their shift to reflect any changes in precaution level ..."


Record review of the Policy & Procedure: Suicide Risk Assessment and Precautions dated 12/08/2014 revealed: " ... 10.0 The observation flow sheet will clearly indicate patients on suicide precautions ... "



3. Patient #2 had Ligature Contraband.


In an interview with LVN # 55 on 12/03/2015, at 1420, stated that on 11/26/2015, (Thanksgiving Day) she found Patient #2 dead in his room. She also stated that Patient #2 died when he hung himself with a "navy blue, maybe black string." He used the middle hinge of the door leading into his room from the hallway. She stated, "Usually techs inventory and remove contraband material ... Strings are cut from clothing if the patient opts to keep it." Patients are not allowed "shoe strings or belts." Patient #2 was on "suicide precautions."


In an interview with RN #60 on 12/04/2015, at 1000, she stated that an investigating officer told her the string around Patient #2 ' s neck looked like a string from pajama pants.


Record review of Policy & Procedure: Contraband Search Guidelines dated 12/08/2014 revealed: "1.0 Belongings Search. All Patients' belongings will be searched for potentially hazardous items by behavioral health staff on admission ... 1.4 ... look for belts or drawstrings and remove from clothing ... 1.6.13 Belts, cords, straps, ties, and shoelaces ... "



4. Suicide Risk Assessments and Progress Note Documentation.


In an interview with DON #51 on 12/03/2015, at 1315, she stated that the RNs document their assessments, including suicide assessment, every 12 hours.


Record review of Patient #2's medical record revealed a nursing assessment every 12 hours.


Record review of the Policy & Procedure, Progress Record Documentation, dated 12/18/2014, revealed: "3.2 The Registered Nurse reassesses the patient and documents in the progress notes every shift not to exceed 8 hours ... "


Record review of the Policy & Procedure, Suicide Risk Assessment and Precautions, dated 12/08/2014 revealed:

" 6.0 Patients on suicide precautions will be reassessed [by the] RN every 8 hours ...

8.0 The reassessments will be documented in the progress notes of the medical record...

9.0 All nursing staff are responsible to observe patients on suicide precautions and will be assigned specific intervals on the staff assignment sheet ... "



5. No Patient Observation Rounds Sheets.


Record review of the Unit Round Worksheet dated 12/03/2015, revealed a one page document with 21 of 21 patients (Patient #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, and Patient #23) listed on the form. Documentation of the whereabouts of each patient was documented every 15 minutes.


In an interview with RN #58 on 12/03/2015, at 1030, she stated the Unit Round Worksheet is not part of the permanent chart. The worksheets "are kept indefinitely, I think." She also stated there is one Unit Round Worksheet per shift and that the 15 minute checks are documented on this form for all patients. She also stated that each patient does not have an individual observation rounds sheet.


Record review of Policy & Procedure: Patient Observation Rounds dated 12/08/2014 revealed:

"1.0 Patient observation rounds are recorded on the observation flow sheet for each patient by the assigned staff member ...

11.0 All rounds must be maintained as part of the medical record ... "



6. RN Responsibility in Providing Oversight of the Unit Round Worksheet.


In an interview with RN #58 on 12/03/2015 at 1030, she stated she makes rounds every 4 hours and documents this on the Unit Round Worksheet. She stated this is the policy.


In an interview with DON #51 on 12/10/2015, at 1600, she stated that the Charge RN is supposed to review the Unit Rounds Worksheet and make rounds on the patients every four hours. She stated this is the policy.


In an interview with Tech #70 on 12/03/2015, at 1040, he stated he takes the board to the RN for the RN to make rounds every four hours.


In an interview with Tech #85 on 12/03/2015, at 1100, she stated the RN does not always check patients when they do the four hour documentation on the rounds sheet.


In an interview with RN #60 on 12/04/2015 at 1000, she stated, "Every few hours" the RN makes sure the rounds are being done. "We make sure the board is complete every four hours. The RN initials it ... and returns the board to the tech after signing it." She makes rounds on patient "when I have time ... there is no specific time to make rounds, usually at group and meal times."


Record review of 7P-7A Patient Care and Supervisory Report Sheet [assignment sheet] dated 11/26/2015 revealed four staff members: RN #81, RN #82, Tech #72 and Tech #76. Techs #72 and #76 were assigned to do "rounds." Designated round intervals had not been assigned to the techs. Staff had not been assigned to monitor hallways.


Record review of 7A-7P Patient Care and Supervisory Report Sheet [assignment sheet] dated 12/03/2015 revealed six staff members: RN #58, RN #87, LVN #84, Tech #70, Tech #83 and Tech #85. Techs #70, #83 and #85 were assigned to do "rounds." Designated round intervals had not been assigned to the techs. Staff had not been assigned to monitor hallways.


In an interview with Tech #72 on 12/03/2015, at 1210, she stated, "Rounds are not assigned by the RN. Usually who gets the rounds board first does the first two hours of rounds."


Record review of Policy & Procedure: Patient Observation Rounds dated 12/08/2014, revealed:

" Patient observation rounds are to be performed on all patients by the assigned nursing staff at a frequency of every 15 minutes ...

1.0 ... The Charge Nurse will assign staff responsibility for round intervals on patients each shift and document on the shift assignment sheet ...

3.0 ... Staff are to be assigned to monitor hallways at all times ...

11.0 ... The Charge RN will review the patient observation rounds flow sheet at the end of each shift to ensure completion of rounds as assigned and sign ... "


Record review of Policy & Procedure: Clinical Hand-Off Communication dated 12/08/2014 revealed: "A 5. After listening to shift report the outgoing RN will round with the incoming RN ... "



7. Environment of Care Safety Rounds.


Record review of the Unit Round Worksheet dated 11/26/2015, revealed that there was not a checklist for staff to identify environmental hazards on the form.


In an interview with DON #51 on 12/03/2015, at 1315, she stated there was not a check list for staff to use to identify environmental hazards.


Record review of Policy & Procedure, Environment of Care Safety Rounds dated 12/08/2014, revealed: " ... A systematic approach will be operational to proactively identify environment risks and minimize the harm risk to patients or others. Staff will actively participate in this approach by identifying and reducing environmental risks ... 1.0 Once a day, Environment of Care Safety rounds will be conducted by assigned staff and documented on checklist ... "



8. Incomplete orientation and/or competency assessments.


In an interview with Tech #70 on 12/03/2015, at 1040, he stated 15 minute rounds were not covered in orientation.


Record review of four personnel files (LVN #55, RN #58, RN #81 and Tech #72) revealed that none of them had received annual and training with competencies in for 2014 and 2015. RN #82 was hired on 11/11/2015. RN #82's personnel file did not contain certification of Crisis Prevention Institute (CPI) training.


In an interview with Human Resources Director #88 on 12/10/2015, at 1555, she stated (when asked about annual competencies), "Competencies are done once every three years." She went on to say that yearly competencies stopped in 2013. She stated CPI training was mandatory and that RN #82 was working the unit and had not had CPI training.


Record review of the Policy & Procedure, Suicide Risk Assessment and Precautions, dated 12/08/2014 revealed: " 19.0 All new employees responsible for patient care will receive orientation regarding Management of Suicidal Patients. All staff will successfully complete the Suicide Prevention competency annually. "
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on record review and interview, the facility failed to ensure that nursing services provided supervision and evaluation of safe nursing care and practice for 26 of 26 patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #25, #26 and Patient #27) as evidenced by:


1. 1 of 1 patients (Patient #2) had ligature contraband.

2. 1 of 1 patients (Patient #2) did not have suicide risk assessments as outlined in the policy.

3. 21 of 21 patients (Patient #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, and Patient #23) did not have Patient Observation Rounds Sheets.

4. RN was not providing oversight of the Unit Round Worksheet affecting 26 of 26 patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #25, #26 and Patient #27).

5. No check list for staff to identify environmental hazards.


Findings included:



1. Patient #2 had Ligature Contraband.


In an interview with LVN # 55 on 12/03/2015, at 1420, stated that on 11/26/2015, (Thanksgiving Day) she found Patient #2 dead in his room. She also stated that Patient #2 died when he hung himself with a "navy blue, maybe black string." He used the middle hinge of the door leading into his room from the hallway. She stated, "Usually techs inventory and remove contraband material ... Strings are cut from clothing if the patient opts to keep it." Patients are not allowed "shoe strings or belts." Patient #2 was on "suicide precautions."


In an interview with RN #60 on 12/04/2015, at 1000, she stated that an investigating officer told her the string around Patient #2's neck looked like a string from pajama pants.


Record review of Policy & Procedure: Contraband Search Guidelines dated 12/08/2014 revealed: "1.0 Belongings Search. All Patients' belongings will be searched for potentially hazardous items by behavioral health staff on admission ... 1.4 ... look for belts or drawstrings and remove from clothing ... 1.6.13 Belts, cords, straps, ties, and shoelaces ... "



2. Suicide Risk Assessments and Progress Note Documentation.


In an interview with DON #51 on 12/03/2015, at 1315, she stated that the RNs document their assessments, including suicide assessment, every 12 hours.


Record review of Patient #2's medical record revealed a nursing assessment every 12 hours.


Record review of the Policy & Procedure, Progress Record Documentation, dated 12/18/2014, revealed: "3.2 The Registered Nurse reassesses the patient and documents in the progress notes every shift not to exceed 8 hours ... "


Record review of the Policy & Procedure, Suicide Risk Assessment and Precautions, dated 12/08/2014 revealed:

" 6.0 Patients on suicide precautions will be reassessed [by the] RN every 8 hours ...

8.0 The reassessments will be documented in the progress notes of the medical record.

9.0 All nursing staff are responsible to observe patients on suicide precautions and will be assigned specific intervals on the staff assignment sheet ... "



3. No Patient Observation Rounds Sheets.


Record review of the Unit Round Worksheet dated 12/03/2015, revealed a one page document with 21 of 21 patients (Patient #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, and Patient #23) listed on the form. Documentation of the whereabouts of each patient was documented every 15 minutes.


In an interview with RN #58 on 12/03/2015, at 1030, she stated the Unit Round Worksheet is not part of the permanent chart. The worksheets "are kept indefinitely, I think." She also stated there is one Unit Round Worksheet per shift and that the 15 minute checks are documented on this form for all patients. She also stated that each patient does not have an individual observation rounds sheet.


Record review of Policy & Procedure: Patient Observation Rounds dated 12/08/2014 revealed:

" 1.0 Patient observation rounds are recorded on the observation flow sheet for each patient by the assigned staff member ...

11.0 All rounds must be maintained as part of the medical record ... "



4. RN Responsibility in Providing Oversight of the Unit Round Worksheet.


In an interview with RN #58 on 12/03/2015, at 1030, she stated she makes rounds every 4 hours and documents this on the Unit Round Worksheet. She stated this is the policy.


In an interview with DON #51 on 12/10/2015, at 1600, she stated that the Charge RN is supposed to review the Unit Rounds Worksheet and make rounds on the patients every four hours. She stated this is the policy.


In an interview with Tech #70 on 12/03/2015, at 1040, he stated he takes the board to the RN for the RN to make rounds every four hours.


In an interview with Tech #85 on 12/03/2015, at 1100, she stated the RN does not always check patients when they do the four hour documentation on the rounds sheet.


In an interview with RN #60 on 12/04/2015, at 1000, she stated, "Every few hours" the RN makes sure the rounds are being done. "We make sure the board is complete every four hours. The RN initials it ... and returns the board to the tech after signing it." She makes rounds on patient "when I have time ... there is no specific time to make rounds, usually at group and meal times."


Record review of 7P-7A Patient Care and Supervisory Report Sheet [assignment sheet] dated 11/26/2015, revealed four staff members: RN #81, RN #82, Tech #72 and Tech #76. Techs #72 and #76 were assigned to do "rounds." Designated round intervals had not been assigned to the techs. Staff had not been assigned to monitor hallways.


Record review of 7A-7P Patient Care and Supervisory Report Sheet [assignment sheet] dated 12/03/2015, revealed six staff members: RN #58, RN #87, LVN #84, Tech #70, Tech #83 and Tech #85. Techs #70, #83 and #85 were assigned to do "rounds." Designated round intervals had not been assigned to the techs. Staff had not been assigned to monitor hallways.


In an interview with Tech #72 on 12/03/2015, at 1210, she stated, "Rounds are not assigned by the RN. Usually who gets the rounds board first does the first two hours of rounds."


Record review of Policy & Procedure: Patient Observation Rounds dated 12/08/2014 revealed:

" Patient observation rounds are to be performed on all patients by the assigned nursing staff at a frequency of every 15 minutes ...

1.0 ... The Charge Nurse will assign staff responsibility for round intervals on patients each shift and document on the shift assignment sheet ...

3.0 ... Staff are to be assigned to monitor hallways at all times ...

11.0 ... The Charge RN will review the patient observation rounds flow sheet at the end of each shift to ensure completion of rounds as assigned and sign ... "


Record review of Policy & Procedure: Clinical Hand-Off Communication dated 12/08/2014, revealed: "A 5. After listening to shift report the outgoing RN will round with the incoming RN ... "



5. Environment of Care Safety Rounds.


Record review of the Unit Round Worksheet dated 11/26/2015, revealed that there was not a checklist for staff to identify environmental hazards on the form.


In an interview with DON #51 on 12/03/2015, at 1315, she stated there was not a check list for staff to use to identify environmental hazards.


Record review of Policy & Procedure, Environment of Care Safety Rounds dated 12/08/2014 revealed: " ... A systematic approach will be operational to proactively identify environment risks and minimize the harm risk to patients or others. Staff will actively participate in this approach by identifying and reducing environmental risks ... 1.0 Once a day, Environment of Care Safety rounds will be conducted by assigned staff and documented on checklist ... "
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on record review and interview, the facility failed to ensure staff had been properly trained provided annual training and competencies for 6 of 6 nursing staff members as evidenced by:

1. 2 of 2 staff members (Tech #72 and RN #81) inconsistency in the documentation on Patient #2.

2. 4 of 4 staff members (Tech #83, RN #58, Tech #70, and LVN #84) were unable to identify patients on suicide precautions.

3. 6 of 6 nursing staff (LVN #55, RN #58, RN #81, Tech #70, RN #86 and Tech #72) had incomplete orientation and/or competency assessments for 5 of 5 nursing staff members.


Findings included:


1. Inconsistencies in the Documentation on Patient #2.


Record review of Nursing 12 Hour Assessment by RN #81 dated 11/26/2015, at 2100, revealed that Patient #2 was alert and oriented to person, place, time and situation, speech within normal limits, goal directed thought processes, no hallucinations, willing to contract for safety, adequate appetite and sleep and a full physical examination. RN #81 documented pain management of lower back pain with a score of 3 on the pain scale.


Record review of surveillance video for 11/26/2015, with Personnel #52 and #53 revealed a non-audio video. The following events were noted:

At 1912, RN #81 arrived to the nurse's station.

At 1930, RN #81 went to a side room to get report.

At 1940, Patient #2 came to the nurse's station to get a cookie.

At 1941, RN #81 returned to the nurse's station. He did not interact with Patient #2.

At 1946, Patient #2 left the nurse's station.

At 1947, Patient #2 went to his room.

At 1948, Patient #2 exited his room and sat on a couch in the hallway across from his room.

At 2004, Patient #2 returned to his room.

At 2011, the door to Patient #2's room opened slightly for about 20 seconds then shut quickly.

At 2027, LVN #55 entered Patient #2's room, immediately exited the room and ran toward the nurse's station.


In an interview with Personnel #52 and #53 on 12/10/2015, at 1355, they both stated that there was no evidence on the surveillance video that RN #81 verbally interacted with Patient #2. As they viewed the video they stated that RN #81 could not have completed the evaluations on Patient #2 that he documented in the medical record.


In an interview with Tech #72 on 12/03/2015, at 1210, she stated that on 11/26/2015, she did not do the 15 minute rounds on 10 of 10 patients (Patient #2, #5, #8, #14, #16, #19, #20, #25, #26, and Patient #27) at 0815 but "falsely documented" on the Unit Round Worksheet she had done them. She also stated she later crossed out the entries on Patient #2 rounds for 2015 and 2030 after Patient #2 was found dead.


Record review of a Disciplinary / Counseling Form for Tech #72 dated 11/30/2015, [not timed] revealed that Tech #72 was suspended for five days because of "falsifying documentation on 15 minute rounds" and "pre-charting of every 15 minute rounds" on 11/26/2015 at 2000. The report further stated that the "sentinel event occurred during time that rounds should have occurred." It was signed by Tech #72, DON #51 and Human Resources Director #88.


In an interview with RN #60 on 12/04/2015, at 1000, she stated, . "There's a problem at night with techs not making rounds." She went on to say that she has seen techs at night not do the rounds but document the rounds as having been done


Record review of Policy & Procedure: Patient Observation Rounds dated 12/08/2014, revealed:

" Patient observation rounds are to be performed on all patients by the assigned nursing staff at a frequency of every 15 minutes or more frequently as ordered by the physician for each 24-hour period ...

1.0 Patient observation rounds are recorded on the observation flow sheet for each patient by the assigned staff member ...

10.0 Documentation of the 15 minute patient observation rounds occurs at the assigned time and not in advance ... "


Record review of Nursing 12 Hour Assessment by RN #81 dated 11/26/2015, at 2020 revealed that Patient #2 was "observed hanging on the door hinges with a string around his neck ... 911 was called ... Hospital administration, attending MD and patient relatives was [sic] notified of patient ' s current status." RN #81 did not document time of death, doctor pronouncing death, disposition of patient's body, clothes, and valuables, and any specific circumstances or instructions as given by the Medical Examiner or next of kin.


Record review of Policy & Procedure: Patient Death dated 12/08/2014 revealed: "...4.0 Nursing staff will document in the progress notes recorded time of death, doctor pronouncing death, disposition of patient ' s body, clothes, and valuables, and any specific circumstances or instructions as given by the Medical Examiner or next of kin... "



2. Identification of Patients on Suicide Precautions.


In an interview with Tech #83 on 12/03/2015, at 1010, she stated she was not able to name the patients on suicide precautions.


In an interview with RN #58 on 12/03/2015, at 1030, she stated, "There were too many patients on suicide precautions to name ... I need to look at the report sheet."


In an interview with Tech #70 on 12/03/2015, at 1040, he stated he was unable to name the patients on suicide precautions.


In an interview with LVN #84 on 12/03/2015, at 1120, she stated she didn't look to see what patients were on suicidal precautions. "I know we have some." She stated she was unable to name the patients on suicide precautions.


Record review of Policy & Procedure: Patient Observation Rounds dated 12/08/2014, revealed:

"1.0 Patient observation rounds ... All staff assigned will update the flow sheets during their shift to reflect any changes in precaution level ... "


Record review of the Policy & Procedure: Suicide Risk Assessment and Precautions dated 12/08/2014, revealed: " ... 10.0 The observation flow sheet will clearly indicate patients on suicide precautions ... "



3. Incomplete orientation and/or competency assessments.


In an interview with Tech #70 on 12/03/2015, at 1040, he stated 15 minute rounds were not covered in orientation.


In an interview with RN #86 on 12/03/2015, at 1115, she stated she was on day two of on the job training. The process of rounding every 15 minutes had not been explained to her. She did not know the patients on suicide precautions.


Record review of four personnel files (LVN #55, RN #58, RN #81 and Tech #72) revealed that none of them had received annual and training with competencies in for 2014 and 2015. RN #82 was hired on 11/11/2015. RN #82 ' s personnel file did not contain certification of Crisis Prevention Institute (CPI) training.


In an interview with Human Resources Director #88 on 12/10/2015, at 1555, she stated (when asked about annual competencies), "Competencies are done once every three years." She went on to say that yearly competencies stopped in 2013. She stated CPI training was mandatory and that RN #82 was working the unit and had not had CPI training.


Record review of the Policy & Procedure, Suicide Risk Assessment and Precautions, dated 12/08/2014 revealed: "19.0 All new employees responsible for patient care will receive orientation regarding Management of Suicidal Patients. All staff will successfully complete the Suicide Prevention competency annually."
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to ensure that medical records were complete and/or free of inconsistencies on 26 of 26 patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #25, #26 and Patient #27) as evidenced by:


1 RN #81's documentation in Patient #2's chart on 11/26/2015, inconsistent with video surveillance.

2 Tech #72's documentation on Unit Round Worksheet of 10 out of 10 patients (Patient #2, #5, #8, #14, #16, #19, #20, #25, #26, and Patient #27) on 11/26/2015, inconsistent with her interview.

3 15 minute rounds not documented on an individual observation rounds sheet on 26 of 26 patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #25, #26 and Patient #27).

4 Inconsistency in the timeframes in which suicide risk assessments and progress notes are documented.

5 A signed copy of the Bill of Rights was not a part of the medical records of 26 of 26 patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #25, #26 and Patient #27).

6 In 1 of 1 medical records the documentation of the death of Patient #2 was incomplete.

7 In 1 of 1 medical records the documentation of Patient #2's request for discharge was incomplete.

8 2 of 2 Discharge Summaries dictated by MD #56 accurately and completely documented the outcome of Patient #1 ' s hospitalization .


Findings included:



1. Inconsistency in Patient #2 ' s Chart and Video Surveillance.

Record review of Nursing 12 Hour Assessment by RN #81 dated 11/26/2015, at 2100 revealed that Patient #2 was alert and oriented to person, place, time and situation, speech within normal limits, goal directed thought processes, no hallucinations, willing to contract for safety, adequate appetite and sleep and a full physical examination. RN #81 documented pain management of lower back pain with a score of 3 on the pain scale.


Record review of surveillance video for 11/26/2015 with Personnel #52 and #53 revealed a non-audio video. The following events were noted:

At 1912, RN #81 arrived to the nurse's station.

At 1930, RN #81 went to a side room to get report.

At 1940, Patient #2 came to the nurse's station to get a cookie.

At 1941, RN #81 returned to the nurse's station. He did not interact with Patient #2.

At 1946, Patient #2 left the nurse's station.

At 1947, Patient #2 went to his room.

At 1948, Patient #2 exited his room and sat on a couch in the hallway across from his room.

At 2004, Patient #2 returned to his room.

At 2011, the door to Patient #2's room opened slightly for about 20 seconds then shut quickly.

At 2027, LVN #55 entered Patient #2's room, immediately exited the room and ran toward the nurse's station.


In an interview with Personnel #52 and #53 on 12/10/2015, at 1355, they both stated that there was no evidence on the surveillance video that RN #81 verbally interacted with Patient #2. As they viewed the video they stated that RN #81 could not have completed the evaluations on Patient #2 that he documented in the medical record.



2. Inconsistency in Tech #72's Unit Round Worksheet Documentation and Her Interview.


In an interview with Tech #72 on 12/03/2015, at 1210, she stated that on 11/26/2015, she did not do the 15 minute rounds on 10 of 10 patients (Patient #2, #5, #8, #14, #16, #19, #20, #25, #26, and Patient #27) at 0815 but " falsely documented " on the Unit Round Worksheet she had done them. She also stated she later crossed out the entries on Patient #2 rounds for 2015 and 2030 after Patient #2 was found dead.


Record review of a Disciplinary / Counseling Form for Tech #72 dated 11/30/2015, [not timed] revealed that Tech #72 was suspended for five days because of "falsifying documentation on 15 minute rounds" and "pre-charting of every 15 minute rounds " on 11/26/2015 at 2000. The report further stated that the "sentinel event occurred during time that rounds should have occurred." It was signed by Tech #72, DON #51 and Human Resources Director #88.


In an interview with RN #60 on 12/04/2015, at 1000, she stated, . "There's a problem at night with techs not making rounds." She went on to say that she has seen techs at night not do the rounds but document the rounds as having been done.


Record review of Policy & Procedure: Patient Observation Rounds dated 12/08/2014, revealed:

"Patient observation rounds are to be performed on all patients by the assigned nursing staff at a frequency of every 15 minutes or more frequently as ordered by the physician for each 24-hour period ...

1.0 Patient observation rounds are recorded on the observation flow sheet for each patient by the assigned staff member ...

10.0 Documentation of the 15 minute patient observation rounds occurs at the assigned time and not in advance ... "



3. No Patient Observation Rounds Sheets.


Record review of the Unit Round Worksheet dated 12/03/2015m revealed a one page document with 21 of 21 patients (Patient #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, and Patient #23) listed on the form. Documentation of the whereabouts of each patient was documented every 15 minutes.


In an interview with RN #58 on 12/03/2015, at 1030, she stated the Unit Round Worksheet is not part of the permanent chart. The worksheets "are kept indefinitely, I think." She also stated there is one Unit Round Worksheet per shift and that the 15 minute checks are documented on this form for all patients. She also stated that each patient does not have an individual observation rounds sheet.


Record review of Policy & Procedure: Patient Observation Rounds dated 12/08/2014, revealed:

"1.0 Patient observation rounds are recorded on the observation flow sheet for each patient by the assigned staff member ...

11.0 All rounds must be maintained as part of the medical record ... "



4. Suicide Risk Assessments and Progress Note Documentation.


In an interview with DON #51 on 12/03/2015, at 1315, she stated that the RNs document their assessments, including suicide assessment, every 12 hours.


Record review of Patient #2's medical record revealed a nursing assessment every 12 hours.


Record review of the Policy & Procedure, Progress Record Documentation, dated 12/18/2014, revealed: "3.2 The Registered Nurse reassesses the patient and documents in the progress notes every shift not to exceed 8 hours ... "


Record review of the Policy & Procedure, Suicide Risk Assessment and Precautions, dated 12/08/2014, revealed:

"6.0 Patients on suicide precautions will be reassessed [by the] RN every 8 hours ...

8.0 The reassessments will be documented in the progress notes of the medical record.

9.0 All nursing staff are responsible to observe patients on suicide precautions and will be assigned specific intervals on the staff assignment sheet ... "



5. Bill of Rights.


Record review of the medical records of 26 patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #25, #26 and Patient #27) revealed that 26 of 26 charts did not have a signed copy of the Bill of Rights as part of the permanent medical record.


Record review of Admission Packet revealed Patient's Bill of Rights was missing the last page. It was also an outdated version.


In an interview with DON #51 on 12/10/2015, at 1400, she presented another version of the Patient's Bill of Rights. It was also an outdated version. She stated patients received a copy of the admission paperwork found in the Admission Packet. A current version was found on line at the Texas DSHS website.


Record review of Policy & Procedure, Admission to Behavioral Health Service, dated 12/08/2014, revealed: " ... Patients will receive appropriate patient rights ... prior to admission ... The facility or the administrator ' s authorized designee may admit a person for whom a proper request for voluntary inpatient services is filed if they determine: ... The person has been informed of the person ' s rights as a voluntary patient. "



6. Incomplete Documentation of Patient #2's Death.


Record review of Nursing 12 Hour Assessment by RN #81 dated 11/26/2015, at 2020, revealed that Patient #2 was " observed hanging on the door hinges with a string around his neck ... 911 was called ... Hospital administration, attending MD and patient relatives was [sic] notified of patient ' s current status. " RN #81 did not document time of death, doctor pronouncing death, disposition of patient ' s body, clothes, and valuables, and any specific circumstances or instructions as given by the Medical Examiner or next of kin.


Record review of Policy & Procedure: Patient Death dated 12/08/2014 revealed: ".....4.0 Nursing staff will document in the progress notes recorded time of death, doctor pronouncing death, disposition of patient ' s body, clothes, and valuables, and any specific circumstances or instructions as given by the Medical Examiner or next of kin ... "



7. Patient #2's Request for Discharge on 11/25/2015.


In an interview with RN #58 on 12/10/2015, at 1220, she stated that Patient #2 ' s son requested to be discharged . RN #58 and RN #69 (Charge Nurse) had Patient #2 sign a Request for Release from Voluntary Admission.


Record review of Request for Release from Voluntary admitted d 11/25/2015, at 1520, revealed Patient #2 signed a request to be released from the facility. RN #58 and RN #69 witnessed the request.


Record review of Patient #2 ' s Medical Record dated 11/25/2015, did not reveal any documentation by RN #69 of Patient #2's request and reason he requested to be released from the hospital. There was no documentation of an assessment of the patient's legal, physical, and mental health status including the potential for the risk of harm of self or others.


In an interview with RN #58 on 12/10/2015, at 1220, she stated she could not find documentation by RN #69 of the Patient #2's legal, physical, and mental health status including the potential for the risk of harm of self or others. She further stated it was her expectation as a nurse supervisor that Nurse #69 document the request for release from voluntary admission in the medical record. "When you're too busy, this can happen. RN #69 was too busy."


Record review of Policy & Procedure, AMA [Against Medical Advice] Discharge Prevention Guidelines, dated 12/08/2014, revealed: "4.0 ... The patient must request early or AMA discharge in writing ... Staff receiving the request for discharge should document the request and reason for the request in the medical record ... "


Record review of Policy & Procedure, AMA discharge date d 11/20/2013, revealed: "If a patient requests discharge ... a 4-hour letter will be completed by the patient. A Registered Nurse will assess the patient ' s legal, physical, and mental health status including the potential for the risk of harm to self or others. The RN will notify the patient ' s attending physician."



8. Discharge Summaries: Patient #1 - Two Admissions.


Patient #1's admission on 08/22/2015 and discharge on 08/29/2015.


Record review of Registration Admission face sheet for Patient #1 revealed the patient was admitted on [DATE], and discharged on [DATE], at 0437.


Record review of an Incident Report by RN #60 dated 08/28/2015, at 1136, revealed that Patient #1 was transferred from the facility to a medical surgical hospital for evaluation of chest pain radiating to the left arm.


Record review of Discharge Summary for Patient #1 by MD #56 dated 09/25/2015, at 1623 revealed discharge on 08/29/2015. "Condition on discharge: improved (level of depression decreased, reduced anxiety, reduced psychosis, compliant with treatment plan and medication management.) Follow up with medical - routine. Psychiatric follow-up in 2 weeks with psychiatrist." There was no mention of the transfer to a medical surgical hospital for evaluation of chest pain. The reason for admission, a suicide risk assessment, prognosis, dietary and/or activity restrictions, and name of individual providing aftercare were not included.


Patient #1's admission on 08/29/2015 and discharge on 09/04/2015.


Record review of Registration Admission face sheet for Patient #1 revealed the patient was admitted on [DATE] and discharged on [DATE].


Record review of Cardiology Consultation by MD #62 on 08/29/15, at 1310, for Patient #1 revealed chest pain, renal disease, chronic pulmonary embolism and chronic diastolic heart failure. MD #62 stated the patient needed better blood pressure control, follow-up with a cardiologist as an outpatient and " better stabilization on her multiple antipsychotic medications prior to further aggressive workup from cardiac standpoint."


Record review of Discharge Summary for Patient #1 by MD #56 dated 09/105/2015, at 1812, revealed discharge on 09/04/2015. "Improved condition. Follow up with medical - routine. Psychiatric follow-up in two weeks with psychiatrist." The reason for admission, suicide risk assessment, prognosis, dietary and/or activity restrictions, special procedures, consultation findings and recommendations, and name of individual providing aftercare were not included.


In an interview with Personnel #53 on 12/04/2015, at 1315, he stated there had been some problems with completion of medical records by physicians.


Record review of Policy & Procedure: Psychiatric Discharge Summary dated 12/08/2014 revealed that the format should include: reason for admission, suicide risk assessment, prognosis, dietary and/or activity restrictions, special procedures, consultation findings and recommendations, and name of individual providing aftercare.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on record review and interview, the facility failed to ensure that the medical records of 21 of 21 patients (Patient #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, and Patient #23) were accurate and complete as evidenced by:

1. In 21 of 21 medical records (Patient #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, and Patient #23) there were no Patient Observation Rounds.
2. In 1 of 1 medical records the documentation of the death of Patient #2 was incomplete.
3. In 1 of 1 medical records the documentation of Patient #2 ' s request for discharge was incomplete.

Findings included:

TX 597

1. Patient Observation Rounds.

Record review of the Unit Round Worksheet dated 12/03/2015 revealed a one page document with 21 of 21 patients (Patient #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, and Patient #23) listed on the form. Documentation of the whereabouts of each patient was documented every 15 minutes.

In an interview with RN #58 on 12/03/2015 at 1030, she stated the Unit Round Worksheet is not part of the permanent chart. The worksheets " are kept indefinitely, I think. " She also stated there is one Unit Round Worksheet per shift and that the 15 minute checks are documented on this form for all patients. She also stated that each patient does not have an individual observation rounds sheet.

Record review of Policy & Procedure: Patient Observation Rounds dated 12/08/2014 revealed:
" 1.0 Patient observation rounds are recorded on the observation flow sheet for each patient by the assigned staff member ...
" 11.0 All rounds must be maintained as part of the medical record ... "


2. Incomplete Documentation of Patient #2 ' s Death.

Record review of Nursing 12 Hour Assessment by RN #81 dated 11/26/2015 at 2020 revealed that Patient #2 was " observed hanging on the door hinges with a string around his neck ... 911 was called ... Hospital administration, attending MD and patient relatives was [sic] notified of patient ' s current status. " RN #81 did not document time of death, doctor pronouncing death, disposition of patient ' s body, clothes, and valuables, and any specific circumstances or instructions as given by the Medical Examiner or next of kin.

Record review of Policy & Procedure: Patient Death dated 12/08/2014 revealed: " ... 4.0 Nursing staff will document in the progress notes recorded time of death, doctor pronouncing death, disposition of patient ' s body, clothes, and valuables, and any specific circumstances or instructions as given by the Medical Examiner or next of kin ... "


3. Patient #2 ' s Request for Discharge on 11/25/2015.

In an interview with RN #58 on 12/10/2015 at 1220, she stated that Patient #2 ' s son requested to be discharged . RN #58 and RN #69 (Charge Nurse) had Patient #2 sign a Request for Release from Voluntary Admission.

Record review of Request for Release from Voluntary admitted d 11/25/2015 at 1520 revealed Patient #2 signed a request to be released from the facility. RN #58 and RN #69 witnessed the request.

Record review of Patient #2 ' s Medical Record dated 11/25/2015 did not reveal any documentation by RN #69 of Patient #2 ' s request and reason he requested to be released from the hospital. There was no documentation of an assessment of the patient ' s legal, physical, and mental health status including the potential for the risk of harm of self or others.

In an interview with RN #58 on 12/10/2015 at 1220, she stated she could not find documentation by RN #69 of the Patient #2 ' s legal, physical, and mental health status including the potential for the risk of harm of self or others. She further stated it was her expectation as a nurse supervisor that Nurse #69 document the request for release from voluntary admission in the medical record. " When you ' re too busy, this can happen. RN #69 was too busy. "

Record review of Policy & Procedure, AMA [Against Medical Advice] Discharge Prevention Guidelines, dated 12/08/2014, revealed: " 4.0 ... The patient must request early or AMA discharge in writing ... Staff receiving the request for discharge should document the request and reason for the request in the medical record ... "

Record review of Policy & Procedure, AMA discharge date d 11/20/2013, revealed: " If a patient requests discharge ... a 4-hour letter will be completed by the patient. A Registered Nurse will assess the patient ' s legal, physical, and mental health status including the potential for the risk of harm to self or others. The RN will notify the patient ' s attending physician. "