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 | Dec. 8, 2015 |
| VIOLATION: PATIENT RIGHTS: GRIEVANCES | Tag No: A0118 | |
| Based on a review of facility documentation and staff interview, the facility failed to implement its process for resolution of patient grievances for 1 of 1 patient grievances reviewed [Patient #1]. Findings were: Paperwork from the screening crisis assessment center for Patient #1 included the following line highlighted in green: "Legal Status: Adult w/Guardian ..." Admissions paperwork for Abilene Behavioral Health included a form entitled "Patient Provided Information" which was completed by the patient, though not signed, and included a section entitled "Guardian/Legal Representative." Patient #1 had written in the name of his mother and her address. He identified the relationship as "mother." A review of an email from Staff #9, Director of Health Information Management, to Staff #2, Director of Risk Management/Performance Improvement on 9/18/15 at 9:39 a.m. revealed the following: "FYI. I pulled [Patient #1] chart to review. He was brought in on an EDO from [town name] ...According to ...crisis assessment he is an adult with a guardian HOWEVER, we do not have copies of guardianship paperwork in the chart. " Attached to the email was an earlier email from the mother of Patient #1 with her email address and phone number included. The email contained complaints regarding the handling of the discharge of Patient #1. A handwritten note on the bottom of the printed email stated, "No Phone Message." Staff #2 identified this as her handwriting. In an interview with Staff #2, the Director of Risk Management/Performance Improvement, on the morning of 12/8/15 in a facility administrative office, she stated, "I couldn't follow up on this complaint. I had to be very careful. We had no guardianship papers, so I couldn't leave any kind of message on the phone. I had no idea whether this patient had a guardian or who it might have been." When asked if there had been any further follow-up regarding this matter, she stated there had not. In an interview with Staff #3, Director of Clinical Services, on the afternoon of 12/8/15 in a facility office, she stated, "This was definitely an oversight on this patient. Admissions will usually call me and tell me that there's at least some indication that a patient has a guardian. I usually wouldn't go back to look through the admissions paperwork. Either we have the papers, or somehow admissions would follow up on a guardian..." Facility policy #PR.6, entitled Patient Grievance Procedure, last revised 3/14, included the following: "All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements are considered to be a grievance ... 6.0 When grievances are received, the Patient Advocate will review, investigate, and resolve grievances and determine the appropriate response to the complaint. If the grievance involves a confidentiality or privacy concern, it is referred to the HIPPA Compliance Officer. The HIPPA Compliance Officer will direct an investigation and will respond in the same time frame as described below ...The Patient Advocate will attempt to respond in writing to all grievances within seven (7) calendar days of receipt of the grievance ...Written response may be made to an individual filing a grievance on the patient's behalf if responding directly to the patient could potentially be detrimental to the patient's welfare or if the complainant requests that the response be sent to him/her, provided that the patient's protected health information is not shared with the individual ... 8.0 The grievance and problem resolution/follow-up should be documented ... 17.0 Any grievance received after a patient is no longer in the facility's system should be documented by the staff member receiving the complaint and forwarded to the Patient Advocate. The Patient Advocate and/or designee should ensure that the Patient Advocate follows up on the grievance consistent with the procedures above ... " The above findings were confirmed in an interview with the facility Chief Executive Officer, the Director of Risk Management/Performance Improvement and the Director of Nursing on the afternoon of 12/8/15 in the facility conference room. |
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| VIOLATION: PATIENT RIGHTS: INFORMED CONSENT | Tag No: A0131 | |
| Based on a review of facility documentation and staff interviews, the facility failed to ensure that each patient received information about psychoactive medications used in his/her treatment as 4 of 10 patient charts reviewed [Patients #1, #4, #7 and #9] contained either no patient consent to receive the medication, or contained consent for psychoactive medication signed by the patient after the medication had already been initiated. Findings were: A review of patient clinical records revealed that Patient #4 signed a consent for Cymbalta, an antidepressant medication, on 11/28/15 at 1:00 p.m. He received the initial dose on 11/28/15 at 9:00 a.m. In addition, he signed a consent for Ambien, a hypnotic, on 11/28/15 at 1:00 p.m. He received the initial dose on 11/28/15 at 3:52 a.m. Patient #9 signed a consent to receive Ativan, an antianxiety medication, on 11/18/15 at 12:15 p.m. He received a dose of Ativan on 11/17/15 at 10:00 p.m. Patient #1 received Depakote, a mood stabilizer, at 9:00 a.m. on 9/10/15 and 9/11/15. There was no consent signed by Patient #1 to receive this psychoactive medication available for surveyor review. In addition, he received both oral Haldol and long-acting injectable Haldol. Only one consent for the medication Haldol signed on 9/11/15 by the patient was included in the record of Patient #1, and no route was specified. Side effects and impact of the two forms of the medication differ significantly. The patient received both forms of Haldol. He received the first dose of oral Haldol on 9/10/15 at 9:00 a.m., prior to signing the consent. Patient #7 received doses of Abilify, an antipsychotic medication, on 11/30/15 and 12/1/15. There was no consent signed by Patient #7 agreeing to receive Abilify available for surveyor review in the patient ' s clinical record. Facility policy #PR.8, entitled Patient Consent for Psychoactive Medication - Typical, Emergency, & Court ordered Procedure, last revised 9/13, included the following: "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 ... 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 psychoactive medication ..." In an interview with Staff #4, Director of Nursing, on the afternoon of 12/8/15 in a facility administrative office, she reviewed the problems with the consents for psychoactive medications and confirmed the findings. She stated, "I just started at the beginning of October. I am real aware we've got some things we're needing to fix." The above findings were again confirmed in an interview with the Chief Executive Officer, Director of Risk Management/Performance Improvement and Director of Nursing on the afternoon of 12/8/15 in the facility conference room. |
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| VIOLATION: ADMINISTRATION OF DRUGS | Tag No: A0405 | |
| Based on a review of facility documentation and staff interviews, the facility failed to ensure that drugs were administered in accordance with the orders of the treating physician in 1 of 10 patient charts reviewed [Patient #1]. Findings were: Patient #1 was ordered to receive Depakote 500 mg twice daily. He received the medication at 9:00 a.m. on 9/10/15 and 9/11/15. There was no documentation of a second dose being administered either day or of the patient's refusal of the second dose. He was also ordered to receive Haldol 10 mg twice daily. He received a dose at 9:00 a.m. on 9/10/15 and on 9/11/15. There was no documentation of a second dose being administered either day or of the patient's refusal of the second dose. In an interview with Staff #4, Director of Nursing, on the afternoon of 12/8/15 in a facility administrative office, she reviewed these issues and confirmed the findings. The above findings were again confirmed in an interview with the Chief Executive Officer, Director of Risk Management/Performance Improvement and Director of Nursing on the afternoon of 12/8/15 in the facility conference room. |
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| VIOLATION: DISCHARGE PLANNING | Tag No: A0812 | |
| Based on a review of facility documentation and staff interview, the facility failed to ensure an accurately completed discharge evaluation and plan for 2 of 10 recently discharged patient charts reviewed [Patient #1 and #6]. Findings were: The Integrative Discharge Plan for Patient #1 included no information as to where the patient was being discharged . The information regarding his form of transportation from the facility was inaccurate. A review of the Integrative Discharge Plan for Patient #1 revealed the following: "Type of Discharge: ...AMA ... Discharge arrangements (transport, etc.): pt will arrange (handwritten in space) ... " A line titled "discharged to:" included options to check for home, CPS placement, police, hospital, nursing home, or other. "Other" had been checked with the single word "jail" written in, then crossed out. Thus there was no indication of where the patient was going. A line titled "Discharge Transportation:"had "Personal Vehicle" checked, though the patient had been brought to the facility by the police and had no personal vehicle available. A review of the Integrative Discharge Plan for Patient #6 revealed no information, despite blanks provided, for "Medication Ordered at Discharge", "Status at Time of Discharge," where the patient was discharged to, discharge transportation, whether appropriate releases had been signed, whether the patient was ambulatory and/or needed special assistive devices, or dietary changes. In an interview with Staff #3, Director of Clinical Services, on the afternoon of 12/8/15 in a facility office, she discussed the discharge plan of Patient #1. She stated, "I remember this person ...I know this discharge plan has some problems. I remember there was some confusion about whether he actually was going back to jail or somewhere else. And I remember I was training another person when this was going on ...We tried to get this man a cab, but he refused it. I know it says there he has a car. It was kind of a mess." When it was pointed out there was no documentation of an attempt made to provide transportation to the patient and/or his subsequent refusal, Staff #3 agreed and again stated there were issues with the discharge plans. A review of facility policy #PC 69, entitled AMA Discharge Policy, last revised 10/15, revealed the following: "It is not uncommon for patients, for various reasons, to request discharge before the physician and treatment team determine he or she is ready for discharge. This premature discharge may put the patient at greater risk for relapse in mood and acting out behaviors ...The physician and staff should meet with the patient and family ...If the provider determines that this discharge is not contraindicated, appropriate discharge plans should be made and the patient should be discharged ..." These findings were again confirmed in an interview with the facility Chief Executive Officer, the Director of Risk Management/Performance Improvement and the Director of Nursing in an interview on the afternoon of 12/8/15 in the facility conference room. |
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