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.
|UNIVERSITY BEHAVIORAL HEALTH OF DENTON||2026 WEST UNIVERSITY DRIVE DENTON, TX 76201||Feb. 22, 2013|
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the hospital failed to ensure RN's (Registered Nurses) supervised and evaluated the nursing care for 1 of 10 patients (Patient #1's) medical needs. (Patient #1's) B/P (blood pressure), HR (heart rate) and change of condition was either not documented and/or (Patient #1's) vital signs were not re-evaluated by hospital RN's assigned to care for (Patient #1).
(Patient #1's) Clinical assessment dated [DATE] timed at 03:25 PM reflected, "Haven't been sleeping...try not to be on drugs...smoking a lot of synthetic stuff...not been bathing...not been rational lately...paranoid laughs inappropriately...B/P (blood pressure) 148/92...pulse 101...substance abuse history...marijuana daily...synthetic marijuana almost daily...periods of sobriety months ago..."
The Patient Rounds Progress Note/15 Minute Patient Rounds document for B/P (blood pressure) and heart rate from 01/18/13 through 01/29/13 reflected the following:
The 01/18/13 progress note timed at 09:02 AM reflected, "B/P 143/99, HR (Heart Rate) 109." No follow-up documentation was found which indicated (Patient #1's) heart rate and blood pressure were re-checked.
The 01/22/13 progress note timed at 08:29 AM reflected, "B/P 80/57, HR 119." No B/P re-check was completed for the above and no documentation was found which indicated the nurse provided intervention and/or (Patient #1's) vital signs were re-checked.
The 01/23/13 progress note timed at 09:00 AM reflected, "B/P 143/100, HR 110." No follow-up and/or re-check was completed for the above and no documentation was found which indicated the nurse provided intervention and/or (Patient #1's) vital signs were re-checked.
The 01/25/13 progress note timed at 09:16 AM reflected, "B/P 140/103, HR 119." No follow-up and/or re-check was documented for (Patient #1's) elevated B/P or elevated heart rate.
The 01/28/13 progress note reflected no documentation which indicated (Patient #1's) vital signs were obtained.
The 01/29/13 progress note timed at 17:00 PM reflected, "Patient outside smoking, became dizzy, dropped cigarette...nurse notified." No nursing assessment and/or documentation was found which indicated the above event was addressed and/or evidence (Patient #1's) vital signs were obtained.
The Patient Data/Assessment/Treatment Process document dated 01/30/13 through 02/01/13 reflected the following:
The 01/30/13 Patient Data document timed at 16:40 PM reflected under the section entitled, "Gastrointestinal...vomited times one during smoke break...no food content, encouraged to eat..." No further documentation intervention/assessment of vital signs was completed.
The 02/01/13 Patient Data document timed at 07:00 AM reflected, "Complained of being drowsy majority of shift and stayed in bed..." No further assessment/documentation was found for the above event.
The Patient Rounds/progress note reflected, "Document significant behavior events and/or unusual incidents for patient...normal ranges B/P 100/80-140/90...pulse...60-100...notify nurse if any vitals are out of normal range..."
On 02/22/13 at approximately 10:45 AM Personnel #6 was interviewed. Personnel #6 reviewed the Patient Data Documents and the Patient Rounds Progress Note/15 Minute Patient Rounds document from 01/18/13 through 02/01/13. Personnel #6 stated nursing did not document and/or reassess (Patient #1) for the above out of range vital signs and events.
|VIOLATION: ADMINISTRATION OF DRUGS||Tag No: A0405|
|Based on interview and record review the hospital failed to ensure one of one patient (Patient #1) received medication in accordance with physician orders in that nursing staff administered Ibuprofen without a physician order on 02/02/13.
(Patient #1's) discharge summary dated 02/05/13 and signed by Personnel #8 noted (Patient #1's) final diagnoses included Bipolar disorder with Psychotic Features, K2 and Marijuana Abuse, Hypertension, Possible Seizure or Respiratory Failure.
The Medication Administration Record (MAR) dated 02/02/13 at 12 AM through 02/02/13 at 11:59 PM reflected, "Ibuprofen 600 milligrams (mg) by mouth every six hours when necessary for pain." Ibuprofen 600 milligrams was documented as administered on 02/02/13 at 10:30 AM.
The Physician Orders dated 01/16/13 through 02/02/13 did not reflect an order for Ibuprofen 600 mg by mouth every six hours when necessary for pain.
During an interview on 02/22/13 at 1:35 PM Personnel #6 stated there was no order for Ibuprofen written for (Patient #1).