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.

ABILENE BEHAVIORAL HEALTH LLC 4225 WOODS PLACE ABILENE, TX Jan. 11, 2012
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on a review of facility documents and staff interviews, the facility did not ensure that Patient #2 received care in a safe setting.

Findings were:

Review of the medical record for Patient #2 revealed a Case Management Progress Note dated 12/7/11 (untimed) completed by a social worker which stated " B - Pt appeared anxious and was pacing back/forth in front of nurses station I - Pt. then came up to CM [case manager] and asked to speak with her R- Pt. informed CM she felt uncomfortable with a certain staff member; stated the staff member (male) had come up and given her a frontal hug; that she felt violated. P - Informed C.N. and clinical director and allegations will be investigation [sic]. " There was no documentation that the physician was notified per hospital policy of the incident or the patient ' s comments related to the alleged or suspected abuse by the social worker

Review of Incident Report Form Brief Summary of Event(s) dated 12/8/11 revealed that Patient #2 stated that a staff member went into the room of Patient #2, gave her a hug and " touched her booty. " Staff #2 and her roommate also stated that Patient #2 and her roommate also stated that Staff #2 smelled like alcohol. "

Review of the personnel record for Staff #2 revealed that he was employed by Acadia Abilene on 10/25/11 as a mental health associate. On 12/7/11, Staff #2 was brought to the Human Resources Director for reasonable suspicion for alcohol and was taken for a drug alcohol screen. Review of Alcohol Testing Form dated 12/7/11 for Staff #2 at 10:24 revealed the result for alcohol breath test of .199. Review of Drug & Alcohol Policy states " Under the Influence of Alcohol shall be determined by using the same standard relied upon by the state. The State of Texas defines legal intoxification as a blood alcohol level of .08 or higher. " Review of facility Personnel Action Form dated 12/14/11 documented that Staff #2 was officially terminated (involuntary separation) on 12/14/11 and was ineligible for rehire.

The above was confirmed in interview on 1/10/12 with the chief executive officer, clinical director, and risk manager.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on a review of available documents, medical record, and staff interviews, the facility failed to ensure that Patient #2 was free from all forms of abuse and harassment as staff did not report alleged abuse.

Findings were:

Review of the medical record for Patient #2 revealed that in the Initial Nursing Assessment, completed on 11/28/11 at 2025, the nurse documented scratches on the patient ' s face and right arm, and bruises on the patient ' s right and left arms. The Observation Record dated 11/28/11 (untimed entry) completed by the mental health tech stated " Pt came on to unit with bruises on arms, red in her eyeball and scratch on her head. Stated it came from [Patient #2 ' s previous facility] " The Observation Record completed on 11/30/11 (untimed entry) by a mental health tech stated the patient " wants to press charges against staff at [Patient #2 ' s previous facility]. " There was no documentation to reflect that this was reported to the nurse or physician. Multidisciplinary Progress Note dated 12/11/11 at 2100 completed by a licensed vocational nurse stated " Pt was found in bathroom with lights off in the corner with cover over her head crying ...pt stated that she did not want to go back to [Patient #2 ' s previous facility] ...Pt then stated that the reason she didn ' t want to go back was because she was " inappropriately touched " by male staff members. Pt ...said that it happened during the last restraint she was in while at [Patient #2 ' s previous facility]. " A note dated 12/11/11 at 2130 stated that " Pt stating that she was going to cause a big scene tonight after 3-11 shift left because she did not want to and was not going to go back to [Patient #2 ' s previous facility]. " There was no documentation in any of the above notes to indicate that the physician was notified per hospital policy of the patient ' s comments or requests related to alleged or suspected abuse or that the patient ' s concerns were assessed or addressed.

Review of facility policy entitled " Patient Rights Abuse & Neglect " policy # PR.1 stated " An employee who has received information or has observed evidence that would reasonably cause him/her to believe that a patient has been, or will be adversely affected by abuse, neglect, or exploitation from any person will immediately report the information to the Hospital Administrator and the Attending Physician ...The RN and/or the therapist is responsible for documenting all relevant information in the medical record. "

The above was confirmed on 12/10/11 in interview with the risk manager and clinical director in the administrative conference room.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on a review of the medical record for Patient #2, facility documents, and staff interviews, the facility failed to ensure that the use of restraint was in accordance with the order of a physician.

Findings were:

Review of the medical record for Patient #2 revealed that documentation in the Observation Record dated 12/5/11 (untimed entry) completed by the mental health tech stated " [Patient #2] attacked pt # 3-901 from behind when she was standing at the nurse ' s station. Staff separated the pts. CN [charge nurse] witnessed. " The Case Management Progress Note dated 12/5/11 (untimed entry) completed by a social worker stated " B-[Patient #2] attacked another peer; was pulling out the peers hair and attempting to hit peer in the face I- C.N. [charge nurse] & MHT [mental health tech] observing and pt. was pulled away from the other pt. " at 1035 There was no mention in the Daily Nursing Assessment notes by a nurse dated 12/5/11 of the fight or the personal restraint of the patient. There was no documentation that the physician was notified within an hour of the fight and no documentation of an order for the personal restraint of Patient #2 on 12/5/11.

Review of the medical record for Patient #2 revealed that the Multidisciplinary Progress Note for 12/8/11 at 0840 completed by a registered nurse documented " [Patient #2] was laying in bed today, feeling ill. A peer came into her room screaming at her ...[Patient #2] hit the peer and knocked her down on the floor and punched the peer in the face repeatly [sic] until pulled off by staff. " Case Management Note dated 12/8/11 (untimed entry) completed by a social worker stated " Another peer had gone in pt. room and began instigating pt. Pt. got up from her bed and began hitting the peer in the face. Pt had to be re-directed and the fight was broken up. " Observation record dated 12/8/11 (untimed entry) completed by the mental health tech stated " Pt had a peer come into [Patient #2 ' s] room yelling & was up in her face. [Patient #2] then started punching peer in her face ...Staff was able to break up fight & redirect " . There was no documentation by a nurse that the physician was notified by the registered nurse of the personal hold/restraint. There was no order for a personal restraint or hold for Patient #2 on 12/8/11.

Review of facility policy entitled, " Seclusion and Restraint " policy #PC.38 states that " Definition of terms ...Restraint: Any manual method, physical or mechanical device, material , or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or heat freely; or a drug or medication when it is used as a restriction to manage the patient ' s behavior or restrict the patient ' s freedom of movement and is not a standard treatment or dosage for the patient ' s condition ...Physical holding of a patient ...Holding a patient in a manner that restricts the patient ' s movement against the patient ' s will is considered a restraint ...The MD will write an order for restraint or seclusion after personally observing the patient. In an emergency, a registered nurse may write an order for seclusion/restraint. Must notify the treating physician within 1 hour and obtain confirmation of the order ...A physician must see and evaluate the need for restraint or seclusion within 1 hour after initiation of intervention, even if the patient is no longer in restraint or seclusion ...Registered nurse may initiate the personal hold in the absence of a physician if he/she is satisfied, after direct observation, that the use of personal hold is clinically indicated. A written, verbal or telephone order from the physician is then obtained within 1 hour by the RN. "

The above was confirmed on 12/10/11 in interview with the risk manager and clinical director in the administrative conference room.
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on review of the clinical record for Patient #2, the director of nursing failed to supervise and evaluate the nursing care rendered for Patient #2, as the nurse did not document or report allegations of abuse, and failed to document or obtain an order for two incidents of personal restraint.

Findings were:

Review of the medical record for Patient #2 revealed that a social worker documented on 12/7/11 that a staff member hugged Patient #2 and that the social worker notified the nurse. There was no nursing documentation of the incident which occurred around 10 am. There was also no documentation to indicate that the nurse notified the physician per hospital policy.

Review of the medical record for Patient #2 revealed that on 11/28/11 at 2025 a nurse documented in the Initial Nursing Assessment that Patient #2 had scratches on her face and right arm, and bruises on her right and left arms. The Observation Record dated 11/28/11 (untimed entry) completed by the mental health tech stated " [Patient #2] came on to unit with bruises on arms, red in her eyeball and scratch on her head. Stated it came from [Patient #2 ' s previous facility]. " The Observation Record completed on 11/30/11 (untimed entry) by a mental health tech stated Patient #2 " wants to press charges against staff at [Patient #2 ' s previous facility]. " There was no documentation that the mental health tech reported this to the nurse or physician. Multidisciplinary Progress Note dated 12/11/11 at 2100 completed by a licensed vocational nurse stated " [Patient #2] was found in bathroom with lights off in the corner with cover over her head crying ....[Patient #2] stated that she did not want to go back to [Patient #2 ' s previous facility] ...[Patient #2] then stated that the reason she didn ' t want to go back was because she was " inappropriately touched " by male staff members. Pt wouldn ' t give names but said that it happened during the last restraint she was in while at [Patient #2 ' s previous facility]... " A note dated 12/11/11 at 2130 stated that " Pt ...did not want to and was not going to go back to [Patient #2 ' s previous facility]. " There was no documentation in any of the nursing notes to indicate that the physician was notified per hospital policy of the patient ' s comments or requests related to alleged or suspected abuse or that the patient ' s concerns were addressed.

Review of facility policy entitled " Documentation Procedure/Error Correction/Authorized Personnel " , policy #HIM.14 stated " Relevant, objective information should be documented. " Review of facility policy entitled " Patient Rights Abuse & Neglect " policy # PR.1 stated " An employee who has received information or has observed evidence that would reasonably cause him/her to believe that a patient has been, or will be adversely affected by abuse, neglect, or exploitation from any person will immediately report the information to the Hospital Administrator and the Attending Physician ...The RN and/or the therapist is responsible for documenting all relevant information in the medical record. "

Review of the medical record for Patient #2 revealed that she was restrained in a personal hold on two separate incidents, yet the nurse did not document these incidents nor did the nurse obtain an order for the two incidents of restraint.
Cross refer: CFR 482.13(e)(5)

The above was confirmed in interview on 1/10/12 with the risk manager and clinical director in the administrative conference room.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on a review of available documentation, medical record, and staff interview, the facility failed to ensure that medical records were complete, as entries were not timed, one night shift nursing note was omitted, and errors were incorrectly noted.

Findings were:

Review of the record for Patient #2 revealed that 9 out of 12 case Management Progress Notes had no time documented on following notes in space for the time provided on preprinted form:
11/29/11, 11/30/11, 12/1/11, 12/2/11, 12/3/11, 12/5/11, 12/7/11, 12/8/11, and
12/10/11.

Review of the record for Patient #2 revealed that 21 out of 22 narrative MHT notes/entries documenting patient behavior were not timed on the following dates: 11/28/11 (2 entries), 11/29/11 (2 entries), 11/30/11 (2 entries), 12/1/11 (2 entries), 12/3/11 (1 entry), 12/5/11 (2 entries), 12/6/11 (1 entry), 12/8/11 (2 entries), 12/10/11 (3 entries), 12/11/11 (2 entries), and 12/12/11 (2 entries).

Review of the record for Patient #2 revealed that 12 out of 44 nursing assessment notes were not timed, including 11 Night Nursing Assessment times which were not entered in the space labeled " DATE TIME " on the preprinted form on the following dates: 11/29/11, 11/30/11, 12/1/11, 12/2/11 12/3/11, 12/4/11, 12/6/11 12/8/11, 12/9/11, 12/10/11, 12/11/11; and 1 Daily Nursing Assessment form dated 12/10/11 did not have the time in the space labeled " Time " .

There was no Night Nursing Assessment note for the 11-7 shift on 12/7/11.

Review of the medical record for Patient #2 revealed that on the Daily Nursing Assessment note for 11/30/11 on the 7-3 shift, 4 lines of nursing documentation had been lined through without date or initials; on 12/2/11 on the 3-11 shift, 2 lines of nursing documentation had been obliterated and scratched through without date or initials.

Review of facility policy entitled " Documentation Procedure/Error Correction/Authorized Personnel " , policy #HIM.14 stated " Fill in all spaces when entering data on a form, even if an item is not applicable (N/A). If a form cannot be completed, document why and sign ...Relevant, objective information should be documented ...All medical record entries must be signed, dated and timed by the author ...Complete obliteration of any documentation is not permitted ...Strike through errors with a single line, make correction and initial. If the error includes several lines, there can be an " X " put through the lines and dated and initialed. "

The above was confirmed on 12/10/11 in interview with the risk manager and clinical director in the administrative conference room.