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 March 21, 2013
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
Based on a review of facility policies, patient records, and staff interviews, the facility failed to ensure that patient ' s right to participate in the multidisciplinary treatment team planning was maintained.

Findings were:

Review of facility policy entitled "Multidisciplinary Treatment Planning" stated, in part, "The treatment plan is individualized and based on the needs, liabilities and strengths of the patient. The patient has the opportunity to take part of have other people of his/her choice take part in the treatment planning process. Care is planned and provided in an interdisciplinary, collaborative manner by qualified staff members ...Within 72 hours of the patient's admission, the Initial Treatment Plan is reviewed by the patient ' s multidisciplinary treatment team. The patient is encouraged to participate in the review process....If the patient is unable or unwilling to sign the review or revision, the reason for or circumstances of such inability or unwillingness is documented in the patient's medical record."

Review of the records for 10 out of 10 patients with treatment plans revealed the following:
The dates and times of attendance of the members of the treatment team revealed that patients were not provided the opportunity to participate in meetings with their multidisciplinary team to provide input into the development of a "multi-disciplinary treatment plan." The documentation reflected that the patient and other members of the treatment team signed the form indicating attendance, hours to days apart, thereby indicating the patient did not actually have the benefit of providing input to the multidisciplinary treatment team, consisting of medicine, nursing, social work, activity/therapy, and any other disciplines as indicated.

Multidisciplinary treatment plan for patient #1:
Physician: 1/18/13 at 9:00 AM
Nursing: 1/18/13 at 2:00 AM
Social work/case manager: 1/18/13 at 9:00 AM
Activities staff: 1/19/13 at 5:00 PM
Patient: signed, not timed or dated.

Multidisciplinary treatment plan for patient #5:
Physician: 5/15/12 at 9:00 AM
Nursing: 5/14/12 at 9:00 PM
Social work/case manager: 5/17/12 at 5:00 PM
Activities staff: 5/18/12 at 7:00
Patient: not signed, not timed or dated. No documentation why the patient didn ' t sign.

Multidisciplinary treatment plan for patient #8:
Physician: 2/17/13 at 12:30 PM
Nursing: 2/17/13 at 1:40 AM
Social work/case manager: 2/18/13 at 1:30 PM
Activities staff: 2/17/13 at 5:00 PM
Patient: signed, not timed or dated.

Subsequent multidisciplinary treatment plan update for patient #8:
Physician: 2/25/13 11:00 AM
Nursing: 2/25/13 at 11:00 PM
Social work/case manager: 2/25/13 at 11:10
Activities staff: 2/22/13 at 5:00
Patient: not signed, not timed or dated. No documentation why the patient didn ' t sign.

Subsequent multidisciplinary treatment plan update for patient #8:
Physician: 3/8/13 11:30 AM
Nursing: 3/8/13 at 11:30 AM
Social work/case manager: 3/8/13 at 11:00 AM
Activities staff: 3/8//13 at 5:00
Patient: signed, not timed or dated.

Multidisciplinary treatment plan for patient #9:
Physician: 3/6/13 at 11:15 AM
Nursing: 3/3/13 at 5:00 AM
Social work/case manager: 3/4/13 at 5:00 PM
Activities staff: 3/3/13 at 5:00 PM
Patient: 3/14/13, untimed

Subsequent multidisciplinary treatment plan update for patient #9:
Medical: 3/13/13 at 11:00 AM
Nursing: 3/11/13 at 11:15 AM
Social work/case manager: 3/11/13 at 11:00 AM
Activity Therapy: 3/11/13 5:00
Patient: 3/14/13, untimed

Multidisciplinary treatment plan for patient #10:
Physician: 1/18/13 at 9:00 AM
Nursing: 1/17/13 at 12:00
Social work/case manager: 1/18/13 at 9:00 AM
Activities staff: 1/19/13 at 5:00 PM
Patient: 1/18/13 at 10:15.

Multidisciplinary treatment plan for patient #12:
Physician: 1/7/13 at 10:00 AM
Nursing: 1/4/13 at 2:40 AM
Social work/case manager: 1/4/13 at 6:30
Activities staff: 1/5/13 at 5:00 pm
Patient: signed, not timed or dated.

Subsequent multidisciplinary treatment plan update for patient #12:
Physician: 1/10/13 at 9:30 AM
Nursing: 1/9/13 at 9:00 AM
Social work/case manager: 1/9/13 at 9:30 AM
Activities staff: 1/25/13 at 9:00 AM
Patient: 1/9/13 at 1:30 pm.

Multidisciplinary treatment plan for patient #15:
Physician: 11/27/12 at 9:20 AM
Nursing: 11/26/12 at 8:20 PM
Social work/case manager: 11/27/12 at 11:21
Activities staff: unsigned.
Patient: signed, not timed or dated.

Multidisciplinary treatment plan for patient #17:
Physician: 3/6/13 at 2:00 PM
Nursing: 3/6/13, untimed
Social work/case manager: 3/6/13 at 11:00 AM
Activities staff: not signed
Patient: 3/6/13 at 7:07 PM

Multidisciplinary treatment plan for patient #18:
Physician: 2/11/13 at 1:05 PM
Nursing: 2/9/13 at 2:00 AM
Social work/case manager: 2/11/13 at 9:30
Activities staff: 2/11/13 at 1:35
Patient: signed, not timed or dated.

Subsequent multidisciplinary treatment plan update for patient #18:
Physician: 2/13/13 at 1:25 PM
Nursing: 2/15/13 at 1:00 PM
Social work/case manager: 2/15/13 at 12:40 PM
Activities staff: 2/20/13 at 3:30 PM
Patient: 2/15/13, not timed or dated.

Multidisciplinary treatment plan for patient #19:
Physician: 12/3/12 at 9 AM
Nursing: 12/1/12 at 6:00 PM
Social work/case manager: 12/4/12, untimed
Activities staff: 12/1/12 at 5:00
Patient: signed, not timed or dated.

Subsequent multidisciplinary treatment plan update for patient #19:
Physician: 12/7/12, not timed
Nursing: 12/10/12 3:25 PM
Social work/case manager: 12/7/12 at 9:20
Activities staff: 12/8/12 at 2:00
Patient: signed, not timed or dated.

The above findings indicate that the patient was not able to have a "multidisciplinary treatment team" meeting with all members in the development of an individualized treatment plan including input from the patient.

The above was confirmed in an interview on 3/21/13 in the conference room with the Director of Nursing.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on review of Clinical records and interview with the DON on the afternoon of 03/21/13, it was determined that the facility failed to follow the Hospital's policy regarding informed consent.
Findings were:
Review of the Medication Administration Record (MAR) for patient # 3 on 03/21/13 revealed the following:
Zyprexa Zidis was increased to10 mg by mouth at bed time for mood/aggression on 08/22/12. No documentation to support that the client's mother received notification of this change. Furthermore, Depakote ER was increased to 750 mg by mouth at bed time on 08/20/12, and Abilify was discontinued due to lack of efficacy (as per doctor's order) on 08/13/12. No documentation to support that the client' s mother received notification of this changes.
Acadia Abilene policy # PR. 8 states the following on page 3 and paragraph 13: "Any time the medication regimen is altered in such a way as to significantly change the risks or benefits for the patient, an explanation of the change will be provided to the patient and /or his/her legally authorized representative.This explanation will include notification of the right to withdraw consent at any time."
VIOLATION: CONTENT OF RECORD - INFORMED CONSENT Tag No: A0466
Based on a review of facility policy, patient records, and staff interviews, the facility failed to ensure that properly executed informed consent for the administration of psychoactive medication was completed as all required components were not included on the consent form and forms were missing information such as dates and witness signatures.

Findings were:

Review of facility policy entitled, " Patient Consent for Psychoactive Medication - Typical, Emergency, & Court Ordered Procedure " Policy #PR.8, last revised 2/12, stated, in part, " Legally Authorized Representative: The parent, managing conservator or guardian of a minor; the guardian of the person of an adult; or the person to whom the authority to make health care decisions is delegated under a durable power of attorney for health care provided by Ch. 135 of the Texas Civil Practices and Remedies ...
1. Before administration of psychoactive medication to a patient, the treating physician must assure that an explanation has been given to the patient or the patient ' s legally authorized representative, for each class of psychoactive medication that is ordered.
2 ...This explanation may be given by the registered nurse or licensed vocational nurse but the treating physician must confirm that the explanation has been given to the patient or the patient ' s legally authorized representative, within two working days, not including weekends or legal holidays. The explanation should contain the following information:
a. The nature of the patient ' s mental illness and condition;
b. The beneficial effects on the patient ' s mental illness and/or condition expected as a result of treatment with the medication;
c. The probably health and mental health consequences to the patient of not taking the medication, including the occurrence, increase or re-occurrence of symptoms of mental illness;
d. The existence of generally accepted alternative forms of treatment if any, that could reasonably be expected to achieve the same benefits as the medication and why the physician rejects the alternative treatments.
e. A description of the proposed course of treatment with medication.
f. The fact that side effects of varying degrees of severity are a risk factor for all medications.
g. The relevant side effects of the medication including:
ii. Any side effects which are known to frequently occur in most persons;
iii. Any side effects to which the particular patient may be predisposed;
iv. The nature and possible occurrence of the potentially irreversible symptoms of tardive dyskinesia.
v. The need to advise Abilene Behavioral Health staff immediately if any of these side effects occur;
h. An instruction that the patient may withdraw consent at any time without negative actions on the part of the staff;
i. The patient ' s rights with regard to the administration of psychoactive medication.
3. The above referenced explanation of the psychoactive medication(s) may be given by means of one or more of the following, as appropriate:
a. Orally;
b. Video presentation; and/or
c. Printed material.
4.The patient and/or his/her legally authorized representative must be provided with a summary of this information, in writing, along with an offer to answer any questions concerning the treatment ....
7. No psychoactive medication will be administered at Abilene Behavioral Health without completion of the informed consent process with the exception of administration of psychoactive medication in the event of an emergency situation ... "

Review of facility policy, " Informed Consent " , Policy# PR.7, last reviewed 3/10, stated, in part, " In accordance with state law and accreditation standards, a written, dated, and signed informed consent is obtained from the patient of the patient ' s legal guardian (when applicable) for participation in or for the use of performance of the following: ...
Psychoactive Medication ...
4. The patient or legal guardian will sign the consent form and the staff member will sign as the witness. "

Review of 13 out of 20 patient records revealed that the Psychoactive Med Consent Forms did not include all the information required by policy. Review of the consent forms revealed the following information was not included:
? The existence of generally accepted alternative forms of treatment if any, that could reasonably be expected to achieve the same benefits as the medication and why the physician rejects the alternative treatments.
? A description of the proposed course of treatment with medication.
? The fact that side effects of varying degrees of severity are a risk factor for all medications.
? The relevant side effects of the medication including:
? ii. Any side effects which are known to frequently occur in most persons;
? iii. Any side effects to which the particular patient may be predisposed;
? iv. The nature and possible occurrence of the potentially irreversible symptoms of tardive dyskinesia.
? v. The need to advise Abilene Behavioral Health staff immediately if any of these side effects occur;
? An instruction that the patient may withdraw consent at any time without negative actions on the part of the staff;
? The patient ' s rights with regard to the administration of psychoactive medication.
? The patient and/or his/her legally authorized representative must be provided with a summary of this information, in writing, along with an offer to answer any questions concerning the treatment.

The following 13 out of 20 patients signed psychoactive consent forms without all required components documented; 2 of 13 patient forms had no witness signature, and 2 of 13 patient consents were undated, as follows:
? Patient #1 signed consents for Ativan (1/18/13), Loxapine (1/18/13) Alprazolam (1/18/13), Perphanzine (1/18/13) Hydroxyzine (1/13/13), Trazodone (1/18/13), Doxepin (1/18/13), Lamictal (1/18/13)
? Patient #5 signed consents for Lorazepam (5/18/12), Wellbutrin (5/15/12) without a witness signature, Doxepin (5/14/12), Klonopin (5/14/12), Valium (5/14/12), Ataraz (5/14/12).
? Patient #6 signed consents for Depakote (3/14/13), Hydroxyzine (3/14/13), Wellbutrin (3/14/13)
? Patient #8 signed consents for Risperdal (2/22/13), Klonopin (2/22/13), Restoril (consent form was undated), Seroquel (2/17/13), Divalprex (2/17/13),
? Patient #9 signed consents for Zoloft (3/4/13), Valproic Acid (3/4/13), Trazodone (3/4/13), Zyprexa (3/4/13), and Buspar (3/4/13)
? Patient 10 signed consents for Remeron (1/18/13), Nefazadone (1/18/13), Temazepam (1/17/13), Fluoxetine (1/17/13), Seroquel (1/17/13), Lorazepam (1/17/13).
? Patient #12 signed consents for Temazepam (consent form was undated), Trazadone (1/9/13), Restoril (1/3/13), Clonazepam (1/5/13), Abilify (1/4/13), Cymbalta (1/4/13), Ambien (1/4/13). None of the consent forms contained a witness signature.
? Patient #13 signed consents for Zyprexa Zydis (1/15/13), Depakote (1/16/13), Ativan (1/16/13), Restoril (1/20/13).
? Patient #15 signed consents for Lexapro (11/27/12), Seroquel (11/27/12), Ativan (11/27/12), Gabapentin (11/27/12).
? Patient #16 signed consents for hydroxyzine (12/18/12)
? Patient #17 signed consents for Risperdal (3/8/13), Klonopin (3/6/13), Cymbalta (3/6/13), Trazadone (3/6/13), Ambien (3/5/13).
? Patient #18 signed consents for Ativan (2/15/13), Klonopin (2/13/13), Depakote (2/9/13), Paxil (2/9/13), Zyprexa Zydis (2/9/13), perphenazine (2/9/13), and temazepam (2/9/13).
? Patient #19 signed consents for Klonopin (12/3/12), Effexor (12/3/12), Doxepin (21/1/12), Atarax (12/1/13), Ativan (12/1/12), Pristiq (12/1/12), Zyprexa (12/1/12).

The above was confirmed in an interview with the Director of Nursing and the PI/Risk Manager the afternoon of 3/20/2103 in the conference room.
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
Based on review of clinical records and interview with the DON, it was determined that the facility failed to provide Medical records that are accuratly written and promply completed.

Findings were:

Review of the Seclusion/Therapeutic Hold Package on 03/21/13 indicated that the patient was restrained and placed on seclusion on 08/22/12 at 2100. No Daily Nursing Assessment could be located in the patient's clinical record for the dates of 08/20/12 and 08/22/12. In an interview with the DON, on 03/20/13 in the facility conference room at approximately 1500, she confirmed that nurses' notes (routine assessments) for those dates were not present in this closed record. No nursing assessment or reassessment could be evaluated regarding the incident.
Review of the facility policy # PC. 26 revealed that "The following generally identifies various routine assessments conducted throughout a patient's course of treatment. They include:" Admission Assessment; Nursing Assessment; Psychiatric Evaluation; Vital Signs; Weights; History and Physical; Biopsychosocial History; Chemical Dependency Assessment; Diagnostic Testing and Nutritional Assessment.