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. 10, 2013
VIOLATION: GOVERNING BODY Tag No: A0043
Based on a review of facility policies, facility documentation, clinical records, interviews with staff and a tour of the facility, the facility failed to have an effective governing body responsible for the conduct of the hospital.

Findings were:

Facility policy #PC.26 titled Patient Assessments states, in part, "Admission Assessment ...The Admission Assessment is completed by a Registered Nurse, Licensed Professional Counselor, a practitioner's assistant, a licensed psychologist, a psychologist associate, a licensed social worker, or a licensed marriage and family therapist when the proposed patient presents for treatment."

An electronic search (www.bon.state.tx.us) on the Texas Board of Nursing website revealed that Staff #5 had been issued a Licensed Vocational Nurse license on 2-6-07, a Graduate Nurse permit on 6-15-12 and a Registered Nurse license on 10-9-12. A review of 8 clinical records for patients admitted during the time period of 7-12 through 10-12 revealed that 7 of the 8 patients admitted had admission assessments performed by Staff #5 prior to her being licensed as a Registered Nurse.

Facility policy #PC.28 titled Patient Care Staffing states, in part, "The Department of Nursing Services at Acadia Abilene strives to provide quality patient care and maintain a safe and therapeutic environment. Staffing decisions are based upon the following:
1. Number of patients.
2. Characteristics of the patients, including the intensity of the patient's emotional, mental and medical needs.
3. The anticipated admissions, discharges and transfers.
8. The amount of time required by the nursing staff to perform administrative activities.
9. The recommendations of the advisory committee regarding the adequacy of the staffing plan."

Facility staffing grid, facility census and staff assignment sheets for the time period of 10-1-12 through 1-7-13 revealed no indication that hospital staffing took into account patient acuity, anticipated admissions, discharges or transfers or the amount of time required by nursing staff to perform administrative duties.

The tour of the Geriatric/Focus/Crisis Stabilization Unit (one of the three separate units) revealed a bed-bound patient (patient #13) with the following comorbidities:
? Foley urinary catheter
? Continuous oxygen per nasal cannula
? Prior left above-the-knee amputation
? Morbid obesity (patient ' s wt was >349 pounds)
? Line-of-sight observation level
? Prior hernia repair 10-12 with an abdominal dressing requiring daily changes
? Anti-fungal powder twice daily to the groin folds for Candida
? Blood glucose checks 4 times daily with sliding scale insulin coverage
? Turning/repositioning every 2 hours

At the time of the tour, the unit was staffed with 1 Registered Nurse, 1 Licensed Vocational Nurse and 3 Mental Health Technicians. In an additional interview (conducted privately on the unit) with Staff #10, the nurse stated that she was overwhelmed by the medical needs of patient #13 and that most of her shift was spent tending to the medical needs of patient #13.

A review of Governing Body meeting minutes for 2011 and 2012 revealed no input by, reference to or discussion of the Nursing Staffing Committee or any staffing recommendations made by the committee.

Review of facility policy entitled, "Patient Consent for Psychoactive Medication-Typical, Emergency, & Court Ordered Procedure" stated in part, "5. When the legally authorized representative is not present, telephone or faxed consent may be obtained providing:
a. Two staff members, one of whom must be a licensed nurse, documents the telephone conversation with the legally authorized representative which includes all aspects of the informed consent mentioned above, on the Consent to Psychoactive Medication Form ...
8. Nursing staff are to assure that the informed consent process, and all relevant documentation for each class of psychoactive medication prescribed, have been completed prior to administration of the first dose of psychoactive medication."

A review of 6 adolescent and child medical records reveal 5 of the 6 had verbal consents to psychoactive medication with no witness signature present. No witness signatures were present, making these consents not valid per policy.

Patient # 11 had a signed consent for Prozac dated 09/29/12. A review of the medication administration record revealed that Patient # 11 received the initial dose of Prozac on 09/28/12 prior to signing consent.

Facility policy #PC.26 titled Patient Assessments states, in part: "Admission Assessment ...The Admission Assessment is completed by a Registered Nurse, Licensed Professional Counselor, a practitioner's assistant, a licensed psychologist, a psychologist associate, a licensed social worker, or a licensed marriage and family therapist when the proposed patient presents for treatment."

In a sample of 8 patients admitted from 07/10/12 to 10/8/12, 7 of the 8 Initial Nursing Assessments were perfumed by Staff member # 5. Staff # 5 was a licensed vocational nurse, not a registered nurse at the time these assessments were performed.

Facility Based Policy entitled "Patient Belongings" stated in part, "1. On admission, nursing staff members document all personal belongings and the disposition on patient belongings inventory form. The patient and staff member sign the form, which is then filed in the patient's medical record. "This policy did not address how to maintain accountability for patient belongings or the steps to return personal property at discharge."

Facility Based Document entitled "Patient Rights and Acknowledgements" under the section titled "Basic Rights for All Patients" stated in part, "10. You have the right to keep and use your personal possessions including the right to wear your own clothing ..."

A review of Patient #1's medical record revealed that he was admitted with several items of clothing. The Patient Belongings Record indicated the following items: shirt (1), pants (1), socks (1), shoes (1), underwear (1), and hat (1). This form was signed on admission by Patient # 1.The certificate of receipt portion for "on discharge" was left blank. The Reception Belonging Sheet listed the following items: underwear (3), socks (3), tank top (10), pants (3), shirts (5), slippers (1 pair), and jacket (1). This form indicated "MHT put in storage" for all items, no items were left in patient's possession. This form was dated and time on 11/19/12 at 07:47 PM.

In an interview, Staff Members # 4 and 6 confirmed that the facility was unable to locate several items belonging to Patient #1 after his discharge. Documentation was provided that the facility had to reimburse the Patient's family to replace the missing items.

The above findings were discussed and verified in a meeting with the Risk Manager, the Director of Social Services, the Regional CEO, the Facility CEO, the Director of Nursing and the Chief of Psychiatric Services on the afternoon of 1-10-13 in the facility administrative conference room.
VIOLATION: QAPI Tag No: A0263
Based on a review of facility documentation, the hospital failed to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven QAPI program that involved all hospital departments.

Findings were:

A review of QAPI meeting minutes for 2011 and 2012 revealed no input by, reference to or discussion of the Nurse Staffing Committee or any staffing recommendations made by the committee.

The above findings were discussed and verified in a meeting with the Risk Manager, the Director of Social Services, the Regional CEO, the Facility CEO, the Director of Nursing and the Chief of Psychiatric Services on the afternoon of 1-10-13 in the facility administrative conference room.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on a review of facility documentation, interviews with staff, a review of clinical records and a tour of the facility, the nursing services were not adequately supervised by a registered nurse.
Findings were:

A review of Nurse Staffing Committee meeting minutes for 2011 and 2012 revealed that, although meeting rosters were present for the dates of 5-27-11, 1-9-12 and 12-14-12, no formal minutes existed. The rosters revealed that the committee was composed of RNs, LVNs and mental health technicians, falling short of the minimum requirement of 60% Registered Nurses who provide direct patient care at least 50% of their time.

Facility policy #PC.26 titled Patient Assessments states, in part: "Admission Assessment ...The Admission Assessment is completed by a Registered Nurse, Licensed Professional Counselor, a practitioner's assistant, a licensed psychologist, a psychologist associate, a licensed social worker, or a licensed marriage and family therapist when the proposed patient presents for treatment."

An electronic search (www.bon.state.tx.us) on the Texas Board of Nursing website revealed that Staff #5 had been issued a Licensed Vocational Nurse license on 2-6-07, a Graduate Nurse permit on 6-15-12 and a Registered Nurse license on 10-9-12. A review of 8 clinical records for patients admitted during the time period of 7-12 through 10-12 revealed that 7 of the 8 patients admitted had admission assessments performed by Staff #5 prior to her being licensed as a Registered Nurse.

Facility policy #PC.28 titled Patient Care Staffing states, in part, "The Department of Nursing Services at Acadia Abilene strives to provide quality patient care and maintain a safe and therapeutic environment. Staffing decisions are based upon the following:
1. Number of patients.
2. Characteristics of the patients, including the intensity of the patient's emotional, mental and medical needs.
3. The anticipated admissions, discharges and transfers.
8. The amount of time required by the nursing staff to perform administrative activities.
9. The recommendations of the advisory committee regarding the adequacy of the staffing plan."

Facility staffing grid, facility census and staff assignment sheets for the time period of 10-1-12 through 1-7-13 revealed no indication that hospital staffing took into account patient acuity, anticipated admissions, discharges or transfers or the amount of time required by nursing staff to perform administrative duties.

The tour of the Geriatric/Focus/Crisis Stabilization Unit (one of the three separate units) revealed a bed-bound patient (patient #13) with the following comorbidities:

? Foley urinary catheter
? Continuous oxygen per nasal cannula
? Prior left above-the-knee amputation
? Morbid obesity (patient's wt was >349 pounds)
? Line-of-sight observation level
? Prior hernia repair 10-12 with an abdominal dressing requiring daily changes
? Anti-fungal powder twice daily to the groin folds for Candida
? Blood glucose checks 4 times daily with sliding scale insulin coverage
? Turning/repositioning every 2 hours

At the time of the tour, the unit was staffed with 1 Registered Nurse, 1 Licensed Vocational Nurse and 3 Mental Health Technicians. In an additional interview (conducted privately on the unit) with Staff #10, the nurse stated that she was overwhelmed by the medical needs of patient #13 and that most of her shift was spent tending to the medical needs of patient #13.

Review of facility policy entitled, "Patient Consent for Psychoactive Medication-Typical, Emergency, & Court Ordered Procedure" stated in part, "5. When the legally authorized representative is not present, telephone or faxed consent may be obtained providing:
a. Two staff members, one of whom must be a licensed nurse, documents the telephone conversation with the legally authorized representative which includes all aspects of the informed consent mentioned above, on the Consent to Psychoactive Medication Form ...
8. Nursing staff are to assure that the informed consent process, and all relevant documentation for each class of psychoactive medication prescribed, have been completed prior to administration of the first dose of psychoactive medication."

A review of 6 adolescent and child medical records reveal 5 of the 6 had verbal consents to psychoactive medication with no witness signature present. No witness signatures were present, making these consents not valid per policy.

Patient # 11 had a signed consent for Prozac dated 09/29/12. A review of the medication administration record revealed that Patient # 11 received the initial dose of Prozac on 09/28/12, prior to signing consent.

Facility Based Policy entitled "Patient Belongings" stated in part, "1. On admission, nursing staff members document all personal belongings and the disposition on patient belongings inventory form. The patient and staff member sign the form, which is then filed in the patient's medical record." This policy did not address how to maintain accountability for patient belongings or the steps to return personal property at discharge.

Facility Based Document entitled "Patient Rights and Acknowledgements "under the section titled "Basic Rights for All Patients" stated in part, "10. You have the right to keep and use your personal possessions including the right to wear your own clothing ... "

A review of Patient #1's medical record revealed that he was admitted with several items of clothing. The Patient Belongings Record indicated the following items: shirt (1), pants (1), socks (1), shoes (1), underwear (1), and hat (1). This form was signed on admission by Patient # 1. The certificate of receipt portion for "on discharge" was left blank. The Reception Belonging Sheet listed the following items: underwear (3), socks (3), tank top (10), pants (3), shirts (5), slippers (1 pair), and jacket (1). This form indicated "MHT put in storage" for all items, no items were left in patient 's possession. This form was dated and time on 11/19/12 at 07:47 PM.

In an interview, Staff Members # 4 and 6 confirmed that the facility was unable to locate several items belonging to Patient #1 after his discharge. Documentation was provided that the facility had to reimburse the Patient's family to replace the missing items.

The above findings were discussed and verified in a meeting with the Risk Manager, the Director of Social Services, the Regional CEO, the Facility CEO, the Director of Nursing and the Chief of Psychiatric Services on the afternoon of 1-10-13 in the facility administrative conference room.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on a review of facility documentation, interviews with staff and a tour of the facility, there was not an adequate number of registered nurses, licensed vocational nurses or other personnel to provide nursing care fo all patients as needed.


Findings were:

Facility policy #PC.28 titled Patient Care Staffing states, in part, "The Department of Nursing Services at Acadia Abilene strives to provide quality patient care and maintain a safe and therapeutic environment.
Staffing decisions are based upon the following:
1. Number of patients.
2. Characteristics of the patients, including the intensity of the patient's emotional, mental and medical needs.
3. The anticipated admissions, discharges and transfers.
8. The amount of time required by the nursing staff to perform administrative activities.
9. The recommendations of the advisory committee regarding the adequacy of the staffing plan."

Facility staffing grid, facility census and staff assignment sheets for the time period of 10-1-12 through 1-7-13 revealed no indication that hospital staffing took into account patient acuity, anticipated admissions, discharges or transfers or the amount of time required by nursing staff to perform administrative duties.

In an interview with Staff #3 on 1-8-13 at 1155, the nurse stated that they felt staffing was very unsafe, as the hospital staffing was calculated on the total number of patients in the hospital, despite the fact that the hospital has 3 separate units. When this person was asked if they had ever declared Safe Harbor, they stated that they had not because they was scared they would lose their job. When asked if they could recount a specific situation or shift where they felt they did not have adequate staffing, the staff member stated that on 1-7-12 (the previous day) they had had (during this staff member's shift) 2 patient admissions, 4 patient discharges and had charted on 31 patients, all while staffed only with a licensed vocational nurse and 2 mental health technicians.

Additional interviews conducted with staff members #7, #8, #9, #10 & #11 (both telephonic and face-to-face) revealed concerns from each staff member interviewed regarding the minimal staffing of each unit and safety concerns regarding patient care.

The tour of the Geriatric/Focus/Crisis Stabilization Unit (one of the three separate units) revealed a bed-bound patient (patient #13) with the following comorbidities:
? Foley urinary catheter
? Continuous oxygen per nasal cannula
? Prior left above-the-knee amputation
? Morbid obesity (patient ' s wt was >349 pounds)
? Line-of-sight observation level
? Prior hernia repair 10-12 with an abdominal dressing requiring daily changes
? Anti-fungal powder twice daily to the groin folds for Candida
? Blood glucose checks 4 times daily with sliding scale insulin coverage
? Turning/repositioning every 2 hours

At the time of the tour, the unit was staffed with 1 Registered Nurse, 1 Licensed Vocational Nurse and 3 Mental Health Technicians. In an additional interview (conducted privately on the unit) with Staff #10, the staff member stated that they were overwhelmed by the medical needs of patient #13 and that most of their shift was spent tending to the medical needs of patient #13.

The above findings were discussed and verified in a meeting with the Risk Manager, the Director of Social Services, the Regional CEO, the Facility CEO, the Director of Nursing and the Chief of Psychiatric Services on the afternoon of 1-10-13 in the facility administrative conference room.