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.
|ALLEGIANCE BEHAVIORAL HEALTH CENTER OF PLAINVIEW||2601 DIMMITT ROAD, SUITE 400 PLAINVIEW, TX 79072||Jan. 13, 2015|
|VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION||Tag No: A0160|
|Based on record review and staff interview the facility utilized restraint defined as, "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." The facility failed to ensure treatment of the patient with psychoactive medication in the manner consistent with clinically appropriate medical care and with no documentation of less intrusive forms of treatment being evaluated or utilized, for 1 of 10 patient records reviewed (Patient #5).
Review of the patient medical record for Patient #5 on 1/14/15 revealed orders for intramuscular injections of psychoactive medications for extreme agitation as follows:
* 9/10/14 10:50pm Ativan 2 mg IM extreme agitation
* 9/13/14 10:10pm Zyprexa 10 mg IM extreme agitation
* 9/18/14 6:40pm Ativan 2 mg IM extreme agitation
Review of nursing notes and monitoring records for Patient #5 for the dates of 9/10/14, 9/13/14, and 9/18/14 revealed no documentation in the notes that the patient was exhibiting extreme agitation or aggressive behavior. There was no documentation in the medical record for any other forms of redirection of the patient prior to using the emergency medications.
In an interview with the CEO on 1/14/15 she confirmed there was no documentation in the patient medical record to indicate extreme agitation or aggressive behavior prior to the administration of the medication.
|VIOLATION: PATIENT RIGHTS||Tag No: A0115|
|Based on a review of documentation and interview, the facility failed to protect and promote each patient's rights.
1. The facility failed to ensure that informed consent for psychoactive medication was properly executed. Cross refer to A0131.
2. The facility failed to ensure care in a safe setting, by failing to identify and investigate a severe injury to a patient. Cross refer to A0144.
3. The facility failed to ensure that patients were free from abuse, as evidence by failing to follow up/report patient allegations of physical abuse to the authorities. Cross refer to A0145.
4.The facility utilized restraint defined as, "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." The facility failed to ensure treatment of the patient with psychoactive medication in the manner consistent with clinically appropriate medical care and with no documentation of less intrusive forms of treatment being evaluated or utilized. Cross refer to A0160.
5. The facility failed to ensure patient rights were protected regarding the use of restraint. A patient was restrained without a physician order. Cross refer to A0168.
|VIOLATION: PATIENT RIGHTS: INFORMED CONSENT||Tag No: A0131|
|Based on review of documentation and interview, it was determined the facility failed to obtain properly executed informed consent for psychoactive medications, for 2 of 10 patient records reviewed (patient #1 and #6).
Facility based policy (# 453) entitled, "Informed Consent" stated in part,
"In accordance with state law and accreditation standard, a written dated, signed informed consent is obtained from the patient or the patient's legal guardian (when applicable) for participation in or for the use or performance of the following: ...
5. Psychoactive medication; and ...
4. In the case of emergency, the physician or charge nurse will document the reason why consent was not obtained prior to the treatment or release of information. In an emergency, consent may be given by the legally authorized person by telephone. Emergency consent will be witnessed by two staff members, and the time, name of person giving consent, and an explanation will be documented in the medical record."
Review of medical records revealed that Patients # 1 and 6 had Psychoactive Medication Consent forms that were not completed appropriately.
Patient #1 had consent forms completed for 6 psychoactive medications. These consents were obtained from a legally authorized person via telephone; however the consent was not witnessed by two staff members per policy when obtained.
Patient #6 had consent forms completed for 3 psychoactive medications. The patient signed these consent forms under the section for "withdrawal of consent for medication", thus making these consents not valid for the administration of those psychotropic medications. Record review revealed that all three psychotropic medications were administered to this patient while at the facility without properly executed informed consent.
In an interview on 01/13/15, staff member # 1 (CEO) confirmed the above findings.
|VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING||Tag No: A0144|
|Based on a review of documentation and interview the facility failed to ensure that patients received care in a safe setting for 1 of 10 patient records reviewed.
- Patient # 1:
? Patient # 1 was admitted to this facility on on 11/03/14 at approximately 4:40pm related to dementia. Admitting diagnoses included: Behavior problems and dementia.
? The Admission Assessment completed on 11/03/14 for Patient #1 stated "no s/s of pain" and no respiratory problems identified. The only integumentary issue noted was a bruise to the left back of the hand and a scratch to the left cheek.
? A nursing note on 11/03/14 at 8:40pm stated the patient was confused and "wandering up and down the hallway", remained on every 15 minute observations. No pain or injuries were documented.
? Nursing notes on 11/04/14 at 11:45am stated, "B. Pt confused, one to one monitoring r/t unpredictable aggression. Grabbing et hitting at staff noted this am X 4. Shuffled unsteady gait with leaned forward posture noted. MD here for H & P. Pt. c/o left rib pain. See N.O. I. Administer meds per order ..." At 2:30pm, "Xray results received, faxed to Dr. May." At 3:30pm, "N.O. per Dr. May r/t rib fx's et tiny pneumothorax, see RTBO, Lane, daughter, notified of fx's et tx." At 6:00pm. "O2 sat rechecked, 92 % on RA." At 9:00pm, " Pt. combative striking out at staff, multiple attempts to redirect and unsuccessful. Ativan 1 mg PO given."
? The radiology report (Upright view of the chest and AP and oblique views of the ribs) on 11/04/14 stated, "Moderate subcutaneous gas is noted outside the ribcage in the upper chest with evidence of left third through fifth rib fractures and a tiny pneumothorax noted." The radiology report (Chest AP) on 11/6/14 stated, "Subcentimeter tiny pneumothorax suggested in the left apex. However there is moderate additional air noted over the soft tissues in the left chest and this would be consistent with a small pneumothorax which is slowly leaking into the thoracic soft tissues."
? The patient was transferred to another facility on 11/08/14 at approximately 12:15pm. According to the discharge summary, due to "Due to persistent pneumothorax" the patient was "subsequently transferred to [another facility]. Prognosis is poor."
Patient # 1 was diagnosed with 3 rib fractures less than 24 hours after admission to the facility. Initial admitting assessment for this patient noted no injury or pain to the patient's ribs. There was no documentation in the patient record that indicated that between 11/03/14 and 11/04/14 the patient sustained a fall or required any physical restraint.
This patient having such a serious injury, that was not noted/identified at the time of admission, with no documented cause, indicates the facility did not ensure care in a safe setting.
In an interview on 01/13/15, Staff member # 1 (CEO) and 3 (CNO) confirmed the facility was not able to determine the origin of the 3 fractured ribs this patient sustained. The facility also did not investigate this unusual injury.
|VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT||Tag No: A0145|
|Based on a review of documentation and interview the facility failed to ensure that patients were free from all forms of abuse and/or harassment, as evidence by failing to address a patient's complaints of abuse, for 1 of 10 patient records reviewed (Patient #6).
Facility based policy (#109) entitled, "Patient Rights" stated in part, "4. The right to be free from mistreatment, abuse, neglect, and exploitation".
Facility based policy (#101) entitled, "Abuse, Neglect, and Exploitation" stated in part,
"[Facility] staff will be aware of the signs of abuse, neglect and exploitation. Staff has the responsibility of protecting patients and reporting such suspicious to administrative staff...
4) Staff are to be aware of comments or 'hints' that patients may give in the course of regular conversation that might imply abuse, neglect, exploitation...
6) Staff is to report suspicions to immediate supervisor who will initiate investigation. Social Services personnel may be involved in the investigation.
7) If at any time, there is reason to believe that a patient has been abused, neglected, or exploited; authorities (Police Department, Adult Protective Services) will be contacted by management."
Based on a review of the medical record, Patient # 6 made documented verbal allegations of abuse to three different staff members on 04/21/14 with no documented follow up or investigation of these allegations.
On 04/21/14 a therapy session note stated in part, "...Said she is being abused by the staff. Admonished to let the psychiatrist know..."
On 04/21/14 at 6:25pm, a physician progress note stated in part, "Patient complained of being mistreated by 'day-staff'. 'Someone pulled me from there (pointing@ the [2 illegible words] her room).' Noted healing hematomas on both knees..."
Nursing progress notes 04/21/14 stated the following:
At 6:35pm stated "[Physician] has stated to CN and LVN pt. making grievous complaints how she is being treated. RN gave MHT form and pen so pt. could fill form out. MHT could answer quest. pt might have".
At 7:30pm"1-2 B Assessed pt with nurse [name] r/t allegations that staff physically abused her. Pt. has named 3 staff members. One of which did not work today when this episode occurred. We took pictures of her bil ?extremities and her back. Pt was given a Zyprexa inj on day shift. She is calm and cooperative at this time. Able to move all extremities. No injuries notes. Pt. states 'I did wrestle with them.'...@ first acted like she was afraid of nurse [name] then hugged her. P. Continue with POC."
The PM nursing assessment at 7:15pm on 04/21/14 noted the following injuries: "Dull pink bruising to bil arm. Scratch to [illegible word] upper arm superficial".
The medical record for Patient # 6 did not contain the photographs noted in the nursing progress note on 04/21/14 at 6:35pm.
The medical record for Patient # 6 also contained no documented notification of the supervisor regarding this pateint's injuries and allegations of abuse. There was no documented notification of Adult Protective Service of these allegations. The was no documented investigation or follow up to this patient's allegation of physical abuse.
In an interview on 01/13/15, Staff member #1 (CEO) confirmed the above findings.
|VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION||Tag No: A0168|
|Based on review of documentation and interview, it was determined that the facility restrained patient #6 without a physician order, for 1 of 10 patient records reviewed. The use of force in order to medicate a patient, as with other restraint, must have a physician's order prior to the application of the restraint (use of force).
Facility based policy (#CS1-10) entitled, "Restraint/Seclusion" stated in part,
"Restraints: Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of the patient to move his or her arms, legs, body, or head freely ...
Behavioral restraint/seclusion: Used for violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or others....
? The LIP primarily responsible for the patient's ongoing care must order the use of a restrain/seclusion. However, a qualified nurse may apply a restraint/institute seclusion in response to an unanticipated event prior to obtaining a physician order. The physician must then be consulted as soon as possible, if he/she did not order the restraint or seclusion."
A review of the medical record for Patient # 6 revealed the following documentation:
A nursing note on 04/19/14 at 4:30pm stated , "Placed a call to [physician] d/t pt's behavior escalating. Pt ordered Zyprexa IM now. While LVN et CN leaving nurse's office to carry on Dr's order, Pt attempted to jump over half door et tried to grab injection off LVN's hand. Pt. scratched LVN's R wrist. Pt. explained about Zyprexa PRN et pt. became agitated. Pt. lifted a chair on hallway pt attempted to throw it against CNs. While trying to hold pt, she scratch CN on L wrist et slightly bit CN on R wrist. Pt scratched CNA on R wrist. Pt. layed [sic]to floor by staff X 4 et injection given to R buttocks by [name] LVN. Staff to monitor pts safety."
This note indicated two holds of this patient. The first hold occurred after they attempted to throw a chair. The second hold occurred after the patient scratched and bit staff members. The notation that the patient was "layed [sic] to floor by staff X 4" indicated that the patient's extremities (legs and arms) were manually immobilized by staff members, meeting the definition of a behavioral restraint. The description of the patient's behavior prior to the physical hold indicates physical force was required by the 4 staff involved in the restraint. Holding a patient in a manner that restricts the patient's movement against the patient's will is considered restraint.
There were no orders for restraint of this patient, per facility based policy and regulation.
In an interview on 01/13/15, staff member # 1 (CEO) confirmed the above note described the physical restraint of the patient related to aggressive behavior. The staff member confirmed an order should have been present for this restraint episode.