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WEST OAKS HOSPITAL 6500 HORNWOOD HOUSTON, TX 77074 Feb. 26, 2016
VIOLATION: COMPLIANCE WITH LAWS Tag No: A0021
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


TX 599

Based on observation, record review and interview, the facility failed to ensure that:
1 of 9 patients (Patient #2) had the right to keep and use personal possessions, and
20 of 20 (Patient #2, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, and Patient #26) had the right to have an opportunity for going outdoors.

Findings included:

The right to keep and use personal possessions.

Record review of Psychosocial Assessment by LMSW #69 dated 11/08/2014 at 1035 revealed that Patient #2 was dressed in scrubs

Record review of Physician Orders for Patient #2 revealed:
On 1/05/2014 at 1020 by MD #60: Admission Orders ... admit to [Unit] 2. Search [to] rule out contraband ... Unit Restrictions; Suicide, Assault and Elopement Precautions.
On 11/06/2014 at 1100 by MD #60: Unit Restrictions; Suicide, Assault and Elopement Precautions renewed. Transfer to Unit 1 [Psychiatric Intensive Care Unit].
On 11/07/2014 at 1200 by MD #60: Unit Restrictions; Suicide, Assault and Elopement Precautions renewed.
On 11/08/2014 at 1100 by MD #60: Suicide, Assault and Elopement Precautions renewed. [Unit restrictions were not renewed.]
On 11/09/2014 at 1100; 11/10/2014 at 1400; 11/11/2014 at 0900; 11/12/2014, 1700; and 11/13/2014 at 1100 by MD #60: Suicide, Assault and Elopement Precautions renewed.
On 11/14/2014 at 1500 by MD #60: Assault and Elopement Precautions renewed. Suicide Precautions discontinued.
On 11/15/2014 at 1500 and 11/16/2014 at 1300 by MD #60: Assault and Elopement Precautions renewed.
On 11/17/2014 at 1000 by MD #60: Assault Precautions renewed. Elopement Precautions were discontinued.
11/18/2014 at 1200 by MD #60: Assault Precautions renewed. Patient discharged .

Observation of Unit 1, the Psychiatric Intensive Care Unit, on 02/25/2016 at 0930 revealed 8 patients of 19 patients (Patient #8, #10, #11, #12, #15, #24, #27, and Patient #28) were on elopement precautions. Patient #8 and Patient #28 were asleep in bed and could not be assessed. Patient #11, #12, #24 and Patient #27 had on shoes. Patient #12 had on no-skid socks - his choice. Patient #15 did not have any socks or shoes on - her choice. She was agitated and very psychotic.

In an interview with PICU RN # 68 on 02/24/2016 at 1100, she stated that patients placed on elopement precautions do not automatically have their shoes taken. She also stated that shoes were removed from a patient if there ' s a threat that they can be used as a weapon.

In an interview with PICU RN #72 on 02/24/2016 at 1110, she stated that all 19 patients on PICU were on unit restrictions. She also stated that shoes were not taken from patients on elopement precautions and only shoe strings were taken as a safety precaution.

In an interview with PICU MHT #73 on 02/24/2016 at 1120, he stated that patients on elopement precautions do not have their shoes taken away from them.

In an interview with PICU MHT #74 on 02/24/2016 at 1130, he stated that patient ' s shoes were taken only if there ' s a threat to use them as a weapon.

In interviews with Unit 2 RN #76 and Unit 2 MHT #77, they stated shoes are taken if the patient is placed on elopement precautions.

Record review of Policy POC-N149, Levels of Observation, dated 12/2015 revealed:
" Policy Statement: All patients will be routinely observed in compliance with physician orders and prescribed protocols. Patients exhibiting a high risk potential for suicide , assault, sexual acting out, falls, or elopement will be placed on closer observation per physician order ...
" D. Elopement Precautions ... 1. Patient should be unit restricted ... Patient ' s shoes should be replaced with slippers. "

Record review of Policy POC-N114, Elopement Precautions, dated 12/2014 revealed:
" Policy: ... Patients on elopement precautions are on unit restriction ...
" Protective Measures ... Confiscate shoes and provide slippers. Coats may be confiscated at discretion of charge nurse ...
" Contraband: Patients on Elopement Precautions may wear personal clothing, with the exception of shoes. Patient may be placed in hospital gown or scrubs at the discretion of the charge nurse if elopement attempts are persistent. If the patient refuses, the physician should be contacted for an order. Coats may be kept by staff and issued only when needed. "


The right to have an opportunity for going outdoors.

Findings included:

Record review of the Initial Psychiatric Evaluation by MD #60 dated 11/05/2014 at 1100 revealed Patient ##2 was a [AGE]-year-old female admitted involuntary into the Psychiatric Intensive Care Unit with a schizoaffective disorder.

Record review of Physician Orders for Patient #2 revealed:
On 1/05/2014 at 1020 by MD #60: Admission Orders ... admit to [Unit] 2. Search [to] rule out contraband ... Unit Restrictions; Suicide, Assault and Elopement Precautions.
On 11/06/2014 at 1100 by MD #60: Unit Restrictions; Suicide, Assault and Elopement Precautions renewed. Transfer to Unit 1 [Psychiatric Intensive Care Unit].
On 11/07/2014 at 1200 by MD #60: Unit Restrictions; Suicide, Assault and Elopement Precautions renewed.
On 11/08/2014 at 1100 by MD #60: Suicide, Assault and Elopement Precautions renewed. [Unit restrictions were not renewed.]
On 11/09/2014 at 1100; 11/10/2014 at 1400; 11/11/2014 at 0900; 11/12/2014, 1700; and 11/13/2014 at 1100 by MD #60: Suicide, Assault and Elopement Precautions renewed.
On 11/14/2014 at 1500 by MD #60: Assault and Elopement Precautions renewed. Suicide Precautions discontinued.
On 11/15/2014 at 1500 and 11/16/2014 at 1300 by MD #60: Assault and Elopement Precautions renewed.
On 11/17/2014 at 1000 by MD #60: Assault Precautions renewed. Elopement Precautions were discontinued.
11/18/2014 at 1200 by MD #60: Assault Precautions renewed. Patient discharged .

Observation of Unit 1, the Psychiatric Intensive Care Unit, on 02/24/2016 at 0930 revealed 19 patients (Patient #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, and Patient #26) on the unit. At the end of the hallway was a door leading outside. On the other side of the door was an enclosed courtyard with wooden walls approximately 10 feet high. Locked doors lead from the courtyard to the outside. Patients did not have access to the courtyard.

In an interview with CNO #51 on 02/24/2016 at 1135, he stated that patients on PICU were not allowed to go outside because they were on unit restrictions. He also stated patients were taken to the courtyard at one time but the courtyard was not currently being used and he was unsure when or why staff stopped using the courtyard. He also stated Patient #2 would not have been allowed to go outside when she was a patient on PICU in November 2014.

In an interview with PICU RN #68 on 02/24/2016 at 1100, she stated:
There were 19 patients (Patient #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, and Patient #26) on PICU.
19 of 19 patients (Patient #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, and Patient #26) on PICU were on unit restriction.
19 of 19 patients (Patient #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, and Patient #26) on PICU were not allowed to go outside.
An order was needed to limit a patient ' s right to go outside. " That ' s why patients are on unit restriction - they can ' t go outside. "

In an interview with PICU RN #72 on 02/24/2016 at 1110, she stated that 19 of 19 patients (Patient #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, and Patient #26) on PICU were on unit restrictions and were not allowed to go outside. " Every patient is on unit restrictions. "

In an interview with PICU MHT #73 on 02/24/2016 at 1120, he stated that patients on PICU are not allowed to go outside. " They did [get to go outside] about 3 years ago. " He also stated he was unsure why this practice was stopped.

In an interview with PICU MHT #74 on 02/24/2016 at 1130, he stated that PICU patients are not allowed to go outside.

In an interview with QM #53 on 02/24/2016 at 1300, she stated there was no policy on Unit Restriction. She stated the policy, Levels of Observation, covered precautions.
VIOLATION: DELIVERY OF DRUGS Tag No: A0500
TX 135

Based on interview and record review, the facility failed to ensure that pharmaceutical services were provided to 1 of 1 patients (Patient #1) as evidenced by methadone, a non-formulary medication, being ordered, dispensed and administered without prior approval of the Medical Director (MD #55).

Findings included:

Record review of Physician Orders by MD #56 dated 01/27/2016, [no time] for Patient # 1 revealed: Methadone 10mg 0700 and 1800 daily.

Record review of Medication Administration Record for Patient #1 dated 01/29/2016 at 0700 revealed Methadone 10mg administered.

In an interview with MD #56 on 02/25/2016 at 0940, he stated he placed Patient #1 on methadone to stabilize his pain.

In an interview with Pharmacy Director #65 on 02/24/2016 at 1245, he stated:
There is no methadone protocol or policy.
The Medical Executive Committee Meeting was on 01/27/2016, 0830-1030. It was during this meeting that the decision was made to remove methadone from the formulary.
MD Jorge Raichman wrote the order for methadone on 01/27/2016 at 0930.
He did not get approval from the Medical Director (MD #55) prior to supplying the methadone to the unit for Patient #1.
He should have emailed MD #55 about the methadone.

In an interview with Medical Director MD #55 on 02/25/2016 at 1045, he stated:
During the January 2016 Medical Executive Committee Meeting, methadone was removed from the hospital formulary.
MD #56 missed the January 2016 Medical Executive Committee Meeting. MD #56 was rounding on his patients while the Medical Executive Committee Meeting was happening. It was at this time that MD #56 wrote an order for methadone for Patient #1.
The decision to allow the methadone to be dispensed was made by MD #56 and Pharmacy Director #65.
He was not notified of the decision to use the methadone.
He did not know that Patient #1 was on methadone until the death of Patient #1.
He should have been notified of the use of methadone.

Record review of Policy #39, Obtaining Non-Formulary Medications, [no date], revealed: " When a non-formulary drug is requested via physician ' s order, the pharmacist will contact the physician at the soonest possible moment to ascertain if a formulary drug may be substituted. If a formulary drug is not acceptable to the physician, a written request for non-formulary item(s) will then be made by the physician on a Non-Formulary Drug Request Form(s) and forwarded to the Medical Director for approval. The Medical Director must sign the Non-Formulary Drug Request Form indicating approval before pharmacy is to procure the medication. Medication for non-formulary items will not be procured until pharmacy is in receipt of a signed Non-Formulary Drug Request form from the Medical Director. "