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||March 22, 2017|
|VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY||Tag No: A0143|
|Based on a review of facility documentation and staff interview, the facility failed to ensure that each patient had the right to personal privacy as one-to-one patient observations were conducted without physician orders and without clear assignment for 3 of 3 patients (Patients #1, #4 and #6) on such precautions. In addition, the facility had no clear and specific policy to address one-to-one patient observation.
Facility policy #605.1 entitled Patient Monitoring and Precautions, last reviewed 4/14, included the following:
"C. An RN must contact the attending physician to get a physician's order for a one to one monitoring for Special Precaution. The order will document the reason for the increased level of monitoring. The physician reviews the level of monitoring and signs the order for each 24 hour period ..."
A review of the clinical record of Patient #1 included the following nursing note: 12/19/16 at 1:30 a.m.
" ...Requires MHT x2 for 1:1 monitoring ..." The record also included the following physician order: 12/19/16 at 8:40 p.m. - "1:1 Close Observation." Thus, the patient was placed on one-to-one observation prior to receiving a physician's order. The record contained no other orders regarding continuing this level of observation nor an order to discontinue it.
The clinical record for Patient #4 included nursing documentation that she had been on a one-to-one observation status. The record included no physician order for such observation.
The clinical record for Patient #6 included a physician's order for "1:1 monitoring" on 2/28/17 at 6:45 a.m. The next order related to the monitoring was on 3/7/17 at 3:30 p.m. which stated, "Discontinue 1:1." Nursing documentation reflected that Patient #6 had continued to be observed on a one-to-one status during the interim.
In an interview with Staff #2, the Chief Nursing Officer, on the afternoon of 3/22/17 in a facility meeting room she was asked about the documentation required by the facility for one-to-one patient monitoring. She stated, "It doesn't really say anything in our policy. I know a lot of places have special forms and usually they're required to document on the person more often than every 15 minutes." When asked how the facility knew exactly which staff was assigned to a one-to-one observation, she stated, "We can't really go back. It would just be what's on the regular observation sheet. There would have been breaks for the staff member with an assignment like that, so the sheets don't accurately show who was with the patient ...We don't have any special instructions in our policy about one-to-ones. All we have is that sentence or two in that patient monitoring policy. We need to re-write that."
|VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING||Tag No: A0144|
|Based on staff interviews and observation, the facility failed to ensure the safety of each patient by having light fixtures in patient rooms which were not tamper-proof.
A tour of the 20-bed GeriPsych Unit of Allegiance Behavioral Health was conducted on the afternoon of 3/22/17 with Staff #2, CNO. Patient rooms included plastic and metal fluorescent light fixtures affixed at shoulder height in each room. The fixtures posed a possible danger to patient safety as the hard plastic was within easy reach and could potentially be broken by patients, allowing for access to the fixture's light bulb and hard edges. The CNO concurred that the light fixtures needed removal. She stated, "We can fix these immediately."