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 | May 16, 2013 |
| VIOLATION: GOVERNING BODY | Tag No: A0043 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility unit monitoring videos, patient records, incident reports, facility policies, and staff interviews, the governing body failed to ensure that services were rendered in a safe and effective manner as evidenced by: 1. a patient was not assessed after falls which resulted in injuries, 2. minor patients were assigned to rooms with patients known to act out sexually, 3. a patient was discharged without a physician or practitioner physical assessment after two falls and two blows to the head which resulted in a subdural hematoma, 4. abnormal blood pressures were not assessed, evaluated, or reported, and 5. incident reporting was not conducted per the facility's Patient Safety Program. Findings were: Review of facility policies and patient records, tour of the facility, and staff interviews on 5/13/13 through 5/16/13 revealed that the facility failed to ensure that abnormal vital signs were assessed and reported; failed to ensure that patients were provided a safe environment; failed to assess a patient's physical condition and vital signs after two separate falls and blows to the head which resulted in a subdural hematoma; and failed to complete incident reports after patient falls. Cross refer: A0385 Review of the unit observation video in the conference room on 5/14/13 with Staff #1 revealed that on 4/11/13 at 8:24 am, Patient #1, was standing in the crisis stabilization unit, experienced a blow to the head and a fall. The fall was initiated by another patient, Patient #4, who lunged at Patient #1, hitting Patient #1 forcibly in the head and neck area causing her head to snap back and her body to fall. Approximately 6 staff members responded to the event. The two patients were separated, after which, the staff do not appear in the room on the video. On 4/11/13 at 8:28 am , in a separate incident, Patient #1 was standing in the unit on the other side of the room and Patient #4 again approached Patient #1 with raised arms. Patient #4 lunged at Patient #1's head causing Patient #1 to fall back forcibly, landing on the floor. The kinetic force of the blow from Patient #4's body weight thrust into Patient #1 caused Patient #1 to slide approximately 20 inches (almost the width of the patient room door) after she landed on the floor. Patient #1 was observed hitting her head on the floor as she fell . Staff members returned to the unit. Patient #1 was left on the floor alone until 8:32 am, until she was able to get up from the floor with the assistance of a chair. After Patient #1 got up, she walked across the room, pointing and gesturing repeatedly to her head. Further review of the video revealed that Patient #1 did not receive an assessment by a registered nurse or other practitioner before she was moved after the first blow to the head and subsequent fall at 8:24 am. Patient #1 was not assessed by a registered nurse or other practitioner before she was moved after the second blow to the head and subsequent fall at 8:28 am. Patient #1 did not have vital signs taken after the first blow to the head and resulting fall. Patient #1 did not have vital signs taken after the second blow to the head and resulting fall. During review of the above video in the conference room on 5/14/13, Staff #1, Director of Performance Improvement/Risk Management stated, "Now in the second fall, she does actually hit her head." Review of the medical record for Patient #1 on the afternoon of 4/14/13 in the conference room revealed the following: 4/11/13 Progress note by Staff #3 Director of Nursing: "0830 event, 1030 documentation time. Responded to incident in patient's pod to find her [Patient #1] sitting on the floor. Staff in pod stated observed peer push pt to ground after altercation ... Handed patient off to [Staff #10 nurse practitioner] for further evaluation. .. Met [Staff #5 physician assistant] in hall & went into office to speak with him. [Staff #5] was informed of patient having taken her AM meds." 4/11/13 at 0930 Progress note by charge nurse: "Pt is demanding to leave c [with] pressured speech - she has been assaulted by another pt @ 0830. She was removed from CSU & given PRN meds to help her calm down - notified [Staff #5 physician assistant], therapist, DON about pt request to leave & AMA form completed. [Staff #6, RN]" 4/11/13 7-3 shift report by charge nurse. Entry for the shift was documented at 10:00 am. "Medical symptoms reported by patient: intermittent HA's [headaches] B/P was 161/108 before meds" [per the Medication Administration Record for 4/11/13, medications were scheduled to be given at 0800. The block next to 0800 is initialed as given for Norvasc, Trileptal, and Zyprexa. As documented, the medications were administered at 0800.] Complaints of pain: "Headache." Assessment of Current Status/Response to Treatment Plan: "Pt would c/o of HA & then suddenly not have a HA & would trail off to other subjects ...no change noted since admission on 4-6-13 x [except] for c/o HA." 4/11/13 at 9:15 am, "D/C AMA" Order by Staff #5, physician assistant. In an interview with Staff #6, Charge Nurse, RN in the conference room at 2:02 pm on 5/14/2013, when discussing the care of Patient #1, she stated, " I do remember her complaining about a headache. " In an interview with Staff #5, physician assistant, the afternoon of 5/14/13, regarding the two blows to the head and resulting falls of Patient #1 the morning of 4/11/13, Staff #5 stated "I didn't see her for the incident, I saw her for my rounds. I came in that day probably 8:35ish. I believe it happened around 8:15 something, like that. They had told me that she had an altercation in the CSU unit. Now I just talked to her and she said she was assaulted. She just said she was mad and wanted out. What I do with most people if they want leave I just talk to them." When Staff #5 was asked by the surveyors if he assessed Patient #1 before she was discharged , Staff #5 stated, " I did not lay hands on her, no. I reviewed her symptoms: she said wasn't suicidal or homicidal. With her, I had no ability to medicate her. She wasn't taking her medications. I had no recourse but to let her go AMA [Against Medical Advice]. She did not complain to me of any pain - I wish she had - she was lucid so I said ok you can go." When asked about a physical assessment for the falls, Staff #5 stated, "I believe the other practitioner saw her for that. [Staff 10, nurse practitioner] saw her for that. It was all quelled by that time. I was just starting my day on rounds. I just assumed all this was done. " Review of the record for Patient #1 after the two blows to the head and falls, Staff #10, nurse practitioner at 4/11/13 at 1600 documented "At 8:30A responding to a call to the adult unit to assist with patient altercations. The patient approach (sic) me pointing to her head and yelling obscenities (sic) to me. She reported headache. She then became aggressive & backed into the room." Review of the medical record for one of one patients (Patient #1) discharged against medical advice (psychiatric) revealed the following: The document entitled, "Request for Release" completed by Patient #1 on 4/11/13 stated that the patient's reason for the request was "assault by patient ...tattoo." The case manager signed the form on 4/11/13 at 9:15 am. The "Administrator" signed the form on 4/11/13, though the time was written over and is illegible. The space provided for "Physician's Name" is signed by Staff #5, a physician assistant; the physician assistant signed the form on 4/11/13, between 9 am and 10 am. However, the time the physician assistant signed the form was written over and is illegible except for the hour, which is documented as "9". There was no physician signature on the Request for Release form. There was no documented evidence that Patient #1 was evaluated by a physician or psychiatrist within the last 24 hours before discharge. Review of the document entitled, "Integrative Discharge Plan" in the space for "Psychiatric" were the handwritten words, "Pt leaving AMA" . Discharge diagnosis was "schizoaffective disorder"; the form was signed by the physician assistant on 4/11/13; the hand written time appeared to be 9:15 am, but is handwritten over. Review of facility policy entitled "Request for Release," last revised 2/13, stated, in part, "1. If an adult patient requests to be released ...the Charge RN asks the requestor to complete the form titled Request for Release ...In addition the risk assessment form must be completed. 2. The case manager, admissions counselor, or charge RN talks with the patient ...to explore the reasons for the request and encourages the requestor to remain until the planned discharge date . 3. If the patient ...continues to request the release, the case manager, admissions counselor, and/or charge RN notifies the significant team members. A treatment team meeting is called to allow all parties to discuss the issues and attempt to plan a mutually agreed upon discharge date . The treatment team should consist of all available and pertinent staff members including: a. Charge RN B. Director of Clinical Services C. Case Manager D. Patient ' s attending physician or on-call physician ... 4. At the conclusion of the treatment team meeting, the findings are discussed with the patient, and assuming the treatment team believes the patient should remain in treatment, another attempt is made via the treatment team to convince the patient to continue his/her treatment course. 5. If the requestor continues to insist on leaving, the attending physician (or on-call physician if the request is made after hours/weekends/holidays) is contacted. The physician has four hours from the initial request for discharge to make one of the following decisions: ... b. If the physician does not believe that the patient meets criteria for court ordered mental health services, he/she gives an order to: i. Discharge the patient outright; or ii. Discharge the patient against medical advice (AMA). iii. NOTE: The patient must have been seen by a psychiatrist within the last 24 hours before discharge. The attending or on-call psychiatrist must evaluate the patient prior to discharge if there has not been a documented visit within that time frame." Review of the "Collaborative Practice Agreement" signed on 1/9/13 between Staff # 5 physician assistant, and Staff #9, physician, stated in part, "Consultation will occur: For any uncommon, unfamiliar, or unstable patient condition ...For all emergency situations after initial stabilizing care has been initiated." Review of the credentialing folder for Staff #5, physician assistant, revealed current privileges that included "The scope of privileges also allow for routine non-life threatening general medical assessment and treatment." In an interview with Staff #1 Risk Manager the afternoon of 5/15/13, she confirmed that the facility policy requires a psychiatrist and/or physician to evaluate the patient within 24 hours before discharge and that patient #1 was not evaluated by a psychiatrist or physician within 24 hours of her discharge. The Discharge Summary for Patient #1, dictated at 4/11/13 at 9:21 am by Staff #5, physician assistant, stated the following: "admitted the patient to the unit, exposed her to therapeutic milieu. We initially admitted und EDO status. Attempted to stabilize the patient with medications. However, she refused to comply with the medication. We presented this case to the court as patient was continuously psychotic; however, the ADA felt that the patient was not in need of a court-committed stay. She felt like the criteria for admission was not met. However, the patient was actively aggressive during the hospitalization . We were left without recourse. We attempted to allow the patient to stay in treatment under voluntary status. However, the patient was noncompliant with medication, continued to be erratic and the decision was made to continue to try the treatment but patient refused and asked for an AMA discharge. At this point with the request for against-medical-advice discharge and inability for the ADA to take this case to court, we have no recourse but to allow the patient to be discharged . She is not actively suicidal or homicidal at this time. Certainly is psychotic and hypomanic but is not a danger to herself or others so we will allow her to be discharged ." Per the Discharge Summary, discharge diagnoses for Patient #1 included: ? Axis I Schizoaffective Disorder ? Axis II None ? Axis III None ? Axis IV Moderately severe ? GAF: 20. At discharge is 30. There was no documentation in the discharge summary for Patient #1 of the two assaults resulting in two falls with head injuries the morning of the discharge. There was no documentation of the headache the patient reported prior to her discharge. There was no documentation of the hypertension the patient was being treated for. There was no documented evidence that Patient #1 was assessed or seen by a physician or psychiatrist within 24 hours prior to her discharge. Interview with Staff #1, Director of Performance Improvement and Risk Management, and Staff #3, Director of Nursing on 5/15/2013 was at approximately 10:20 a.m in the conference room. When asked about the communication between the nursing staff and the physician assistant and the nurse practitioner, Staff #3 stated, "I really don't think I even got a chance to communicate to [Staff #10, nurse practitioner]. I communicated with [Staff #5, Physician Assistant]. He had asked what had happened - that there was an altercation ...He knew. He knew they had an altercation and that she had fallen. He had been told by Staff #6 [Charge RN], but he didn't know that she'd hit her head. But really nobody knew that. I would assume [Staff #10 Nurse Practitioner] knew, but what I understood from [Staff #10 ' s] report afterwards, it was "she pushed me, she pushed me" but no real c/o pain. I don't know what [Staff #10] said to [Staff #5]" Staff #1 stated, "I didn ' t hear anyone say they saw her hit her head. It was more complaining about the headaches." When Staff #3 was asked how long it was before an RN assessed Patient #1 after the two separate falls, Staff #3 stated, "15-20 minutes." The following are documents from general hospital records: Review of medical records for Patient #1 from Abilene Regional Medical Center for 4/11/2013 at 1244 revealed that the Patient #1 "states she was pushed down twice while pt at Acadia pt states she fell on her head both times pt has to be agitated to respond to questions otherwise she falls back to sleep ...Pt is obtunded but easy to arouse. Pt states she left Acadia because she was assaulted twice by another pt. She further states the staff did nothing to keep her sage (sic). Pt neighbor called EMS. The friend at bedside states that pt is not normally hard to arouse. Review of CT Scan of Head without contrast, ordered at 1320 on 4/11/13, reported, "History: Altered mental status. Possible assault. Impression: Large Left subdural hematoma causing some left-to-right midline shift." Patient #1 was transferred from Abilene Regional Medical Center to Hendrick Medical Center at 1440 on 4/11/13. Review of medical records for Patient #1 from Hendrick Medical Center revealed that the patient was taken into surgery on 4/11/13 for "left frontoparietal craniotomy with evacuation of subdural hematoma and placement of Jackson-Pratt drain. " Pre- and Postoperative diagnoses were "Left frontoparietal subdural hematoma with mass effect." Consultation note on 4/12/13 stated, "This patient is a [AGE]-year-old white female who was admitted yesterday after all (sic) fall at Acadia, suffering a subdural hematoma on the left. She has since undergone surgery and evacuation of this hematoma." Review of the Acadia Incident Report Form dated 4/11/13 at 0830 am revealed that an incident report was completed for the "AMA Discharge" for Patient #1, as follows: Staff completing form was Staff #6, RN on 4/11/13. Date of incident 4/11/13; time of incident 0830 AM. "AMA/Discharge" was circled for "circle the type of incident below" . Review of the Acadia Incident Report Form dated 4/11/13 at 8:40 am revealed that an incident report was completed for "Patient Attacked Other Patient" for Patients #1 and #4 as follows: Staff completing form was Staff #4, MHA on 4/11/13 Date of incident: 4/11/13; time of incident: 8:40 AM. "Patient Attacked Other Patient" was circled for "circle the type of incident below." For the section entitled, "Facts Summary of Event" the following was handwritten: "[Patient #4] hit [Patient #1] with both fists and pushed her to floor kept advancing on her till MHT stepped inbetween (sic)." Review of the incident report revealed that the two falls experienced by Patient #1 were not reported or identified on the incident report when completed on 4/11/13. The words "[Patient #1] fell during altercation x2 investigation pending" were added by the Risk Manager on 4/12/13; thus no incident report was completed by the staff for Patient #1 ' s fall at 8:24 am and Patient #1 ' s fall at 8:28 am on 4/11/13. Review of the facility "Patient Safety Program" issued 3/13, stated in part, "Internal Reporting - In order to have an effective patient safety improvement and management program, there must be an emphasis on reporting all types of events that may have or have harmed patients ....All staff are required to report incidents, events or occurrences through the Incident Reporting System ...An Incident Report is completed when an unusual even with the potentially harmful outcome occurs, which is not consistent with the routine care of a patient and/or the desired operation of the facility." Review of facility policy entitled, "Incident Reporting/Severity Level" , last reviewed 3/13, stated in part, "1.0 Procedure: ...1.1 Supervisor will review the Incident Report for legibility, completion, sign and date ... 2.0 Definitions on Incident Report Form: ... 01q. AMA Discharge- Unplanned discharge documented by the physician ' s order as being against medical advice ... 11. Falls- Unintentionally coming to rest on the ground, floor or other lower level. 11a. Observed Fall ? Patient ? Visitor 11b. Unobserved Fall ? Patient ? Visitor" Review of facility policy entitled, "Fall Assessment & Precautions" last review date 3/13, stated in part, "IV. Management of Falls. Initiate the following for: A. Patient Fall: ... 4. The charge nurse will complete or delegate the completion of an Incident Report. The incident report is forwarded to the Risk Manager." Review of incident reports provided to the surveyors on request between 5/13/13 and 5/16/13 revealed no documented evidence of an incident report for the fall of Patient #1 on 4/11/13 at 8:24 am; there was no documented evidence of an incident report for the fall of Patient #1 on 4/11/13 at 8:28 am, a separate incident. Interview with Staff #1 Risk Manager on the afternoon of 5/15/13 was done in the conference room. When asked for an incident report for the two patient falls that Patient #1 experienced, Staff #1 stated that there was no incident report for the falls; that there was one incident report for an AMA discharge and one for the patient to patient altercation that included a fall. Staff #1 stated, "but we wouldn't have done a separate incident report for a fall. If a patient falls of their own accord, or slips on water, that's a fall. That incident would have been a patient to patient incident. A patient attacked another patient causing her to fall. That's just from a risk management perspective ...Because if we took every incident and dissected it ...we just don't do it. That's just our policy. It should be reflected in there. What we do with our incident reports - that is our notification to the administration that there was an incident. They were never designed to report the entire story." The above findings were confirmed in an interview with the Chief Executive Officer, PI/RM, Director of HIM in the conference room the afternoon of 5/16/13. |
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| VIOLATION: PATIENT RIGHTS | Tag No: A0115 | |
| Based on a review of facility policies and documents, 10 patient medical records, and staff interviews, the facility failed to properly respond to a patient report of abuse for 1 of 10 patients. Findings were: The facility staff neglected to ensure a safe environment for a 7-year-old male patient, after he had made an allegation that his roommate exposed his penis to him. Cross refer A0145. |
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| VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT | Tag No: A0145 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policies and documents, 10 patient medical records, and staff interviews, the facility failed to properly respond to a patient report of abuse for 1 of 10 patients. Findings were: Medical records of Acadia Abilene were reviewed on May 14, 2013 in the facility conference room. Facility staff failed to ensure a safe environment for patient #2, a 7-year-old male patient, after he had made an allegation on 1/23/13 that his roommate (patient #3) exposed his penis to patient #2. Patient #3 was a [AGE]-year-old male patient who had been placed on precautions for Sexual Acting Out (SAO) upon his admission on 12/28/12 and per MD on 12/29/12 for SAO precautions "due to report of public masturbation, sexually acting out." The precautions had not been stopped for patient #3 and Sexual Acting Out remained listed as a treatment plan problem on patient #3's Daily and Night Nursing Assessments as of 1/23/13. Facility Policy entitled "Sexual Acting Out (SAO) Precautions" last revised date 1/13, stated in part, "to provide guidelines for the observation of patients with a known history of sexual perpetration, and/or those patients who have a high probability of demonstrating such behavior. Patients determined to be a danger to other patients due to sexual perpetration will be placed on "Sexual Acting Out (SAO) precautions ...The Treatment Team shall review the "SAO Precautions" for the patient at least weekly. The patient's precaution status shall be communicated to all staff responsible for the care of the patient ...The physician's order is transcribed to the Treatment Plan, the Nursing Communication Sheet and the Observation Record by the RN ...Observation Record-Identified SAO Risk is to be noted on this record." Facility document entitled "Miller Census" for dates of 1/23/2013 through 1/25/2013 revealed a listing of patients on the Miller Unit of Acadia Abilene which included each patient's room number. It showed patient #3 assigned to 150A and patient #2 to 150B for these dates. The listing for Friday, January 25, 2013 indicated that patient #3 was discharged at 2:15p.m. "NS" [Nursing Services] Progress Note of 1/23/2013, 8:30p.m. stated, "Patient's roommate came out of room stating [patient #3] had pulled down his pants and exposed his penis. I counseled with [patient #3], explaining the seriousness of the offense. AOC notified and his parents notified." Review of the patient medical record for patient #2 revealed a multidisciplinary progress note of 1/24/2013 at 1105 which stated, "Pt's grandmother notified that roommate ...exposed his genitals to [patient #2]. Reassured her of [patient #2] safety and observation. Asked ? questions. " This was the only documentation of this incident in patient #2's chart. There is no documentation indicating a room change or an increased level of observation. In an interview with staff #1, Performance Improvement/Risk Manager (PI/RM) on 5/13/13 at 3:21p.m., in response to the question of how room assignments were handled, she said there is no facility policy specifically addressing room assignments and that when the alleged incident occurred on 1/23/13, the unit census was very high. She stated "We had 31 patients on the unit and the unit only holds 32 patients. We had no way to separate [roommates] until the other person was discharged ... It was an exposure. You know, sometimes with little boys... There was no penetration, no harm. The parents were notified. We didn't go any further with it. The first we knew of it was in April when we heard from the corporate office and knew there was a complaint." An interview with staff #1, PI/RM and staff #3, Director of Nursing (DON) was conducted on the morning of 5/15/2013 at approximately 10:20a.m.. When asked to provide a facility policy on how patient rooms are assigned, especially regarding children and adolescents, staff #3 replied, "It's not a policy really, it's more of a procedure for our adolescents. It goes by gender/age. And our adolescents are 13-17. For the children, [room assignment is made according to] the same gender and age. We try to keep to no more than a 3 year difference. With a 5 year old, we're not going to put a [AGE] year old in the same room with them." Staff #1 added, "It was the rule at all times." When asked to provide the facility's written procedure pertaining to how patient rooms are assigned, both individuals confirmed there was no such document. Facility Incident Report Form with date of 1/23/13 for patient #2 with Type of Incident circled as "Body Exposure/Misconduct ...Patient/Patient." Facts Summary of Event were handwritten as follows: "[Patient #3]'s roommate reported to staff that [Patient #3] had exposed his penis. AOC [Administrator on Call] was notified, parents notified, and youth counseled about incident." In the Nursing Evaluation & Intervention section of the same form is handwritten, in total, "patient exposed his penis to peer in room. Pt was given instruction not to exposed [sic] himself. AOC and parents notified." The Incident Report Form was signed by a registered nurse no longer employed by Acadia Abilene, and staff #1, PI/RM. A facility document entitled "INCIDENT INVESTIGATION REPORT FORMAT, ABILENE BEHAVIORAL HEALTH, ATTORNEY/CLIENT PRIVILEGED DOCUMENTATION, PREPARED IN ANTICIPATION OF LITIGATION" was also attached to the Incident Report Form with the following typewritten at the bottom of page 2 at the end of the document: "Risk Manager: [typed name of staff #1], Risk Manager Date: 5/13/2013." [note: date of complaint investigation; surveyors on site] This document stated, in part, "I reviewed both charts and interviewed staff. [Patient #2] admitted on [DATE] at 1530. At that time there were 31 patients on a 32-bed unit. As a result, the bed availability was limited so patient was placed with Patient #3, [AGE] year old male who is autistic." An interview was held on the afternoon of 5/15/2013 in the facility Conference Room with staff #9, the treating psychiatrist of both patients #2 and #3. He said that typically a patient making a complaint of sexual misconduct against a roommate would be removed from that room. The above was confirmed in an interview on the morning of 5/15/13 with staff #1, PI/RM and staff #3, DON in the facility conference room. |
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| VIOLATION: NURSING SERVICES | Tag No: A0385 | |
| Based on a review of facility policies and patient records, tour of the facility, and staff interviews, the facility failed to: 1. ensure that abnormal vital signs were assessed and reported; 2. failed to ensure that patients were provided a safe environment; 3. failed to assess patient's physical condition and vital signs after two separate falls and blows to the head which resulted in a subdural hematoma; and 4. failed to ensure that incident reports were completed after patient falls. Findings: Review of the unit observation video in the conference room on 5/14/13 with Staff #1 revealed that on 4/11/13 at 8:24 am, Patient #1, was standing in the unit. Patient #4 lunged at Patient #1, hitting Patient #1 forcibly in the head and neck area causing her head to snap back and her body to fall. Approximately 6 staff members responded to the event and the two patients were separated, after which, the staff do not appear in the room on the video. On 4/11/13 at 8:28 am , Patient #1 was standing in the unit on the other side of the room. Patient #4 again approached Patient #1 with raised arms, lunged at Patient #1's head causing Patient #1 to fall back forcibly, landing on the floor. The kinetic force of the blow from Patient #4's body weight thrust into Patient #1 caused Patient #1 to slide approximately 20 inches (almost the width of the patient room door) after she landed on the floor. Patient #1 was observed hitting her head on the floor as she fell . Staff members returned to the unit. Patient #1 was left on the floor alone until 8:32 am, until she was able to get up from the floor. After Patient #1 got up, she walked across the room, pointing and gesturing repeatedly to her head. Further review of the video revealed that Patient #1 did not receive an assessment before she was moved after the first blow to the head and subsequent fall at 8:24 am. Patient #1 was not assessed before she was moved after the second blow to the head and subsequent fall at 8:28 am. Patient #1 did not have vital signs taken after the first blow to the head and resulting fall; Patient #1 did not have vital signs taken after the second blow to the head and resulting fall. In an interview with Staff #4, mental health tech at approximately 2:30 p.m. on 5/14/2013 in the patient care unit, he stated, "Basically the confrontation I witnessed was that Patient #1 got too close to Patient #4. Patient #4 said "she got in my face and I pushed her out of it." And a code was called. They responded. The view that I remember was that she [Patient #1] fell to the floor. That was the code then. There was a lot of people [staff] there for a while. The charge nurse assumed leadership of the code. The 2 patients were separated and the code was cleared. Everybody left. Staff #4 raised his arms and shook his head and stated, "WAIT A MINUTE! I'm alone." When asked if all the staff left the room after Patient #1's fall, Staff #4 stated that the staff all left the room. Staff #4 stated, "It was pretty doggone quick that it happened again after everyone left. It was pretty quick that I looked back and she [Patient #1] was on the floor again. When I saw her [Patient #1] that first instance and she was on the floor, I reported it to the charge nurse." Review of the medical record for Patient #1 revealed a progress note for 4/11/13 at 0840 by Staff #4, mental health tech : "Late entry: On April 11, 2013 at approx. 8:40 am I saw patient get pushed down to floor twice by female peer." Review of the medical record for Patient #1 revealed no documented evidence on 4/11/13 that Patient #1 received an assessment before she was moved after the first fall at 8:24 am. There was no documented evidence in the medical record that Patient #1 had vital signs taken after the first fall at 8:24 am. There was no documented evidence that Patient #1 had vital signs taken after the second fall at 8:28 am. In an interview with Staff #4, mental health tech at approximately 2:30 p.m. on 5/14/2013 in the patient care unit, when asked if vital signs were taken after Patient #1 fell , he stated, "I can't swear vital signs were taken." An interview with Staff #1, Director of Performance Improvement and Risk Management, and Staff #3, Director of Nursing on 5/15/2013 at approximately 10:20 am was conducted in the conference room. When Staff #3 was asked how long it was before an RN assessed Patient #1 after Patient #1 experienced the two separate falls, Staff #3 stated, "15-20 minutes." Review of facility policy entitled, "Fall Assessment & Precautions" last review date 3/13, stated, in part, "IV. Management of Falls. Initiate the following for: A. Patient Fall: 1. Ensure an assessment is completed by a nurse before the patient is moved. Obtain vital signs and have an RN perform a patient assessment as soon as possible after the fall. Vital signs and assessment information is documented in the medical record. Interventions and the patient's response to the interventions are documented in the progress note section of the medical record ..." Review of facility policy entitled, "Assignment of Patient Care Responsibilities - 24 Hour Nursing Report" , last reviewed 3/13, stated in part, "Patient care assignments at Abilene Behavioral Health will conform to the standards and intent set by the Nurse Practice Act for the State of Texas, as well as all other licensing, regulatory, and accrediting bodies to which the Hospital submits ...The Registered Nurse (RN) is responsible for the nature and quality of all nursing care that patient receives under his/her direction. Assessment of the nursing needs of a patient, the plan of nursing care, implementation of the plan, and evaluation are essential components of professional nursing practice and are function of the RN, Charge Nurse, assigned to each unit." Review of the Texas Nurse Practice Act ?217.11. Standards of Nursing Practice, states in part, "(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: ... (D) Accurately and completely report and document: (i) the client ' s status including signs and symptoms; (ii) nursing care rendered; ... (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client ' s status ... (3) Standards Specific to Registered Nurses. The registered nurse shall assist in the determination of healthcare needs of clients and shall: (A) Utilize a systematic approach to provide individualized, goal-directed, nursing care by: (i) performing comprehensive nursing assessments regarding the health status of the client" Review of facility policy entitled, "Patient Assessments" , last revised 2/13, stated, in part, "The Nursing Assessment is completed by a Registered Nurse within 8 hours of admission ...To identify additional or alternate patient needs, elements of the Nursing Assessment are re-assessed as indicated throughout the hospitalization ...Vital Signs ...Abnormal vital signs are to be assessed by the RN and reported to the practitioner if necessary ...Vital signs are documented on the Patient Flow Sheet." Review of the handout entitled, "Vital Signs Table" provided by Staff #3, Director of Nursing on 5/15/2013 in the conference room, revealed that normal blood pressure range for an adult is 90 to 140 mmHg for systolic pressure and 60 to 90 mm Hg for diastolic pressure. Review of the medical record for Patient #1 revealed that she had abnormal elevated blood pressures throughout her stay. Nursing assessment of the abnormal, elevated blood pressures was inconsistent or did not occur, and abnormal, elevated blood pressures were not reported to the attending physician or practitioner as follows: 4/6/13 at 0147, BP was 226/155 on Admission Assessment. No documented assessment of abnormal blood pressure of 226/155 at admission or documented evidence of physician/practitioner notification. 4/6/13 at 0700, BP: 206/129 Documented by MHT. Box checked "CN notified" No documented nursing assessment of abnormal blood pressure of 206/129 by the charge nurse; no documented evidence of physician/practitioner notification. 4/6/13 Psych evaluation Axis III - No diagnosis of hypertension or abnormal elevated blood pressure. 4/6/13 at 1045, RN 7-3 shift note BP left blank. No documented assessment of earlier abnormal blood pressure of 206/129; no documented evidence of physician/practitioner notification. 4/6/13 at 1131, History and Physical; "Assessment ...2. Hypertension. Blood pressure is elevated. She does not have a history of essential hypertension." 4/6/13 at 2210, BP: 160/92 RN 3-11 shift note. No documented assessment of abnormal blood pressure of 160/92; no documented evidence of physician/practitioner notification. 4/7/13 at 0900, BP: 177/127 MHT documented. Box checked CN notified 4/7/13 at 0910 ORDER: Clonidine 0.1 mg po q now. Recheck one hour. 4/7/13 No documented evidence of a blood pressure recheck in one hour as ordered; no documented evidence of physician/practitioner notification; and no documented evidence of physician/practitioner follow-up. 4/7/13 at 1900, BP: 143/98 RN documentation. No documented assessment of abnormal blood pressure of 143/98; no documented evidence of physician/practitioner notification. 4/7/13 at 2230, RN 3-11 shift assessment. BP left blank/not documented or assessed. 4/8/13 at 0930, BP: 156/110 by MHT. Box CN notified. 4/8/13 at 1200, RN 7-3 shift assessment. BP left blank. No documentation of abnormal blood pressure of 156/110; no documented evidence of physician/practitioner notification. 4/8/13 ORDER Amlodipine 5 mg one po qday (HTN), Continue Clonidine as before, (Noted by nurse at 1910) 4/8/13 at 2215, RN 3-11 shift assessment. BP left blank. No documented assessment of blood pressure or assessment of abnormal elevated blood pressure on previous shift. 4/9/13 at 0735, BP: 182/124. MHT documented- box checked CN notified. 4/9/13 No documented assessment of abnormal elevated blood pressure of 182/124 reported at 0735; no documented evidence of physician/practitioner notification. 4/9/13 at 1600, BP: 202/123. Nurse documented "Pt BP taken. 202/123 HR 124, R-20. No distress noted. Pt given clonidine 0.1 mg. po Will continue to monitor the pt and recheck her BP in 1 hr." 4/9/13, No documented evidence of blood pressure taken in 1 hour. No documented evidence of an assessment for abnormal blood pressure of 202/123; no documented evidence of physician/practitioner notification. 4/9/13 at 2210, RN 3-11 shift note. Space for BP left blank; No documented evidence of blood pressure assessed. 4/10/13, BP: 157/108 MHT note. Box CN notified left blank. No documented evidence of assessment of abnormal blood pressure of 157/108; no documented evidence of physician/practitioner notification. 4/10/13 BP: 157/108, RN 7-3 shift assessment documented at 1100. No documented evidence of assessment of abnormal blood pressure of 157/108; no documented evidence of physician/practitioner notification. 4/10/13 at 2300 RN 3-11 shift assessment. No documented assessment of blood pressure. 4/11/13 BP: 161/108. RN 7-3 shift assessment. Documented: "B/P was 161/108 before meds." No documented assessment of abnormal blood pressure of 161/108; no documentation of physician/practitioner notification of abnormal blood pressure. Review of the medication administration form for Patient #1 revealed that medications on 4/11/13 were initialed on the medication administration record as given at 0800. No vital signs, including blood pressure, or other assessment was documented after patient experienced a blow to the head and resulting fall at 8:24 am. There were no vital signs, including blood pressure documented after Patient #1 experienced a blow to the head and resulting fall at 8:28 am. Review of facility policy entitled, "Incident Reporting/Severity Level" , last reviewed 3/13, stated in part, "1.0 Procedure: ...1.1 Supervisor will review the Incident Report for legibility, completion, sign and date ... 2.0 Definitions on Incident Report Form: ... 01q. AMA Discharge- Unplanned discharge documented by the physician ' s order as being against medical advice ... 11. Falls- Unintentionally coming to rest on the ground, floor or other lower level. 11a. Observed Fall ? Patient ? Visitor 11b. Unobserved Fall ? Patient ? Visitor" Review of facility policy entitled, "Fall Assessment & Precautions" last review date 3/13, stated in part, "IV. Management of Falls. Initiate the following for: A. Patient Fall: ... 4. The charge nurse will complete or delegate the completion of an Incident Report. The incident report is forwarded to the Risk Manager." Review of Incident Report Form on 4/11/13 at 0830 am revealed that an incident report was completed for the "AMA Discharge" for Patient #1, as follows: Staff completing form was Staff #6, RN on 4/11/13. Date of incident 4/11/13; time of incident 0830 AM. "AMA/Discharge" was circled for "circle the type of incident below" . Review of Incident Report Form on 4/11/13 at 8:40 am, revealed that an incident report was completed for "Patient Attacked Other Patient" for Patients #1 and #4 as follows: Staff completing form was Staff #4, MHA [mental health assistant] on 4/11/13 Date of incident: 4/11/13; time of incident: 8:40 AM. "Patient Attacked Other Patient" was circled for "circle the type of incident below." For the section entitled, "Facts Summary of Event" the following was handwritten: "[Patient #4] hit [Patient #1] with both fists and pushed her to floor kept advancing on her till MHT stepped inbetween" (sic). Review of the incident report revealed that the two falls experienced by Patient #1 were not reported on the incident report when completed on 4/11/13. The words "[Patient #1] feel during altercation x2 investigation pending" were added by the Risk Manager on 4/12/13; thus no incident report was completed by the staff for Patient #1's fall at 8:24 am and Patient #1's fall at 8:28 am on 4/11/13. Review of incident reports provided to the surveyors on request between 5/13/13 and 5/16/13 revealed no documented evidence of an incident report for the fall of Patient #1 on 4/11/13 at 8:24 am; there was no documented evidence of an incident report for the fall of Patient #1 on 4/11/13 at 8:28 am, a separate incident. The above findings were confirmed in an interview in the conference room the morning of 5/16/13 with Staff #1. |
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