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.

BEHAVIORAL HOSPITAL OF LONGVIEW 22 BERMUDA LANE LONGVIEW, TX March 12, 2014
VIOLATION: GOVERNING BODY Tag No: A0043
Based on review of the Governing Board (GB) minutes, and interviews the GB failed to monitor the care, treatment, and safety of patients receiving nursing care in 2 (#1 and #4) out of 3(#1, #4, and #5) charts reviewed.

Refer to Tag A0395

Based on chart reviews, interviews, and policy/procedures the GB failed to ensure nursing provided appropriate pain assessments and pain management in 1(#1) out of 3(#1, #4 and #5) patient charts reviewed.

Refer to Tag A0144

Based on medical record review and interviews the GB failed to protect the patients from abuse and neglect. The facility failed to communicate, intervene, and assess the patient during a behavioral emergency in 1(#1) out of 3(#1, #4, and #5) charts reviewed.

Refer to Tag A0145
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on chart reviews, interviews, and policy/procedures the facility failed to provide appropriate pain assessments and pain management in 1(#1) out of 6(#1-6)) patient charts reviewed.

Refer to Tag A0144

Based on medical record review and interviews the facility failed to protect the patients from abuse and neglect. The facility failed to communicate, intervene, and assess the patient during a behavioral emergency in 1 (#1) out of 6(#1-6) charts reviewed.

Refer to Tag A0145
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on chart reviews, interviews, and policy/ procedures the facility failed to provide appropriate pain assessments and pain management in 1 (#1) of 6 (#1-6) patient charts reviewed.
Review of the nurse's notes for 1/17/14 reveals the patient #1 was having a 9/10 pain level at 2:00PM. There was no documentation of nursing assessment, pain location, medications administered, or the times medications were administered on the nurse's notes.
Review of patient #1's medication administration record (MAR) revealed Tramadol 100 mg was given as a prn, at 3:00 PM, for a 5/10 pain level, with "eff " in the response box. No follow up time on the nurse's note or MAR documenting the effectiveness of the medication. At 5:50 PM the MAR revealed administration of a Lidoderm patch. The reason was for "pain" and a response of "eff." There was no documentation in the nurse's notes on nursing assessment, pain level, medication administration, or the time the patient was re-assessed for pain control.
On 1/17/14 a daily nursing assessment sheet was written at 8:40 PM. In the pain assessment box the nurse documented patient #1 was having an 8/10 pain level. There was no documentation of location or description of the pain. The nurse had checked a box stating medication given but no documentation on what medication. The MAR revealed Tramadol 100 mg was administered as a prn medication. Response box was marked "eff" no time or pain level was documented for response.
On 1/18/14 patient #1's MAR had a prn entry for Tramadol 100mg and Vistaril 25 mg (anxiety) administration at 5:25 AM. The MAR revealed a 7/10 pain level. There was no response for effectiveness. There was no documentation or RN assessment after 11:00 PM on 1/17/14.
On 1/18/14 a daily nursing assessment sheet was written at 8:30 AM. In the pain assessment box the nurse documented patient #1 was having a 5/10 pain level. There was no documentation of location or description of the pain. The MAR had the following prn medications administered. There was no nursing documentation on the need for the prn medication or effectiveness;
1/18/14- 10:30 AM Naproxen (pain) 500 mg "back pain" "eff"
1/18/14 - 7:26 PM Tramadol 100 mg "pain" "eff"
1/18/14 - 8:53 PM Vistaril 25 mg "anx" "eff"
On 1/19/14 a daily nursing assessment sheet was written at 8:30 PM. In the pain assessment box the nurse documented patient #1 was having a 6/10 pain level. There was no documentation of location or description of the pain. The nurse had checked a box stating medication given but no documentation on what medication. There was no nursing assessment or documentation on the need for the prn medication or effectiveness. The MAR had the following prn medications administered;
1/19/14- 5:00 PM Klonopin(anti- anxiety) 1mg "anx "calm" no time documented for pain re-assessment.
1/19/14- 8:28 PM Tramadol 100 mg "pain" "eff" no time documented for pain re-assessment.
1/19/14- 8:27PM Ambien (sleep) 10 mg "sleep" no response or time documented for nursing re-assessment.
On 1/20/14 a daily nursing assessment sheet was written at 7:35 AM. In the pain assessment box the nurse documented patient #1 was having a 7/10 pain level. There was no documentation of location or description of the pain. The nurse had checked a box stating medication given but no documentation on what medication. There was no nursing assessment or documentation on the need for the prn medication or effectiveness. The MAR had Tramadol 100 mg prn medications administered.
On 1/21/14 a daily nursing assessment sheet was written at 8:00 AM. In the pain assessment box the nurse documented patient #1 was having a 6/10 pain level "back" . There was no documentation that any medication or intervention was administered. Patient #1 was not reassessed until 1:00 PM. Pain reassessment was documented at 4/10 pin level. No documentation that any medication or intervention was administered. The MAR had the following prn medications administered;
1/21/14- 10:30 AM Bentyl 20 mg "cramps abd" "eff 12:00pm denies"
1/21/14- 1:45 PM Naproxen 500 mg "7/10" "3/10"
1/21/14- 2:45 PM Tramadol 100 mg "7/10" "eff 3/10"

2. Review of patient #1's chart revealed a physician order on 1/17/14 at 6:05 PM to initiate an Opiate Detox Protocol.
Review of the policy and procedure titled "Detoxifications from opiates" approved on 10/13 states, "All clients on detoxification from opiates shall be assessed for the following withdrawal signs and symptoms;
Abdominal cramps, Diaphoresis, Irritability, Piloerection, agitation, Diarrhea, Insomnia, Rhinorrhea, Anorexia, Dilated pupils, Lacrimation, Tachycardia, Muscle spasms, Fever, Arthralgias, Tachypnea, Myalgias, Hypertension, Yawning.
In the management of opiate withdrawal, the goal is to minimize discomfort, avoid adverse effects of withdrawal medications, and facilitate engagement in ongoing treatment."
Review of the Opiate Withdrawal Protocol states, "Obtain vital signs every four hours and complete Opiate Withdrawal Symptom Scale and enter findings under date and time column.
Score 5 or greater = Administer clonidine per physician PRN order. If physician has not ordered PRN clonidine notify physician of patient's current condition immediately."
The Detox flowsheet has 12 boxes at the top of the page. Each box has a withdrawal symptom with a numbered scale for resting pulse rate, sweating over 30 minutes, restlessness, pupil size, bone or joint aches, runny nose or tearing, GI upset, tremor, yawning, anxiety or irritability, and gooseflesh skin.
Review of the Opiate Detoxification Flowsheet on 1/17/2014 revealed vital signs were taken only once. There was no time documented and the symptom scale was blank. The order for Opiate detoxification was ordered at 6:05 PM. The patient was not assessed from 1/17/14 at 6:05 PM until 1/18/14 at 5:00 AM. Patient #1 had no documentation of assessment for symptoms of detox for 11 hours on the flowsheet or nurses notes.
Review of the Opiate Detoxification Flowsheet on 1/18/2014 revealed vital signs were taken at 5:00AM, 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM. Vital signs were taken at each time period. There was no documentation on the symptom scale for 9:00 AM, 1:00 PM, and 5:00 PM.
There was no further documentation or vital signs from 1/18/14 at 9:00 PM- 1/19/14 at 5:00 AM. The patient was not assessed for 8 hours.
Review of the Opiate Detoxification Flowsheet on 1/19/2014 revealed vital signs were taken at 5:00 AM, 9:00 AM, 1:00 PM, and 9:00 PM. There was no assessment or vital signs documented for 5:00 PM nor documentation on the symptom scale for 9:00 AM or 1:00 PM. The symptom scale for 9:00 PM revealed the total score was an "11". There is no documentation that the physician was notified.
Review of patient #1's MAR on 1/19/2014 revealed Vistaril 25mg (for anxiety) was administered at 7:26 PM and 8:53 PM. There was no documentation of anxiety on the flowsheet or in the nurse's notes.
Review of patient #1 ' s MAR on 1/20/2014 revealed Phenergan 25 mg (for nausea) was administered at 8:00 AM and 2:40 PM. The symptom scale had "0" in the GI upset column for both times. There was no documentation on the nurse's notes concerning patient #1's nausea.
Review of the Opiate Detoxification Flowsheet on 1/21/2014 revealed vital signs were taken at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM. Vital signs were the only documentation on the flow sheet. There was no documentation for symptom scale.
Review of patient #1's MARS on 1/21/2014 revealed Bentyl 20 mg (abdominal cramps) and Phenergan 25 mg (nausea) was administered at 10:30 AM, Imodium AD 4 mg (anti-diarrheal) was administered at 2:40 PM, and Bentyl 20 mg (abdominal cramps) and Phenergan 25 mg (nausea) was administered at 10:00PM. There was no documentation on the symptom scale in the nurses notes, concerning medications administered, or gastric upset.
Review of the Opiate Detoxification Flowsheet on 1/22/2014 revealed only two times 1:00 AM and 5:00 AM. Under each column was "refused." No documentation in the nursing notes of refusal. There were no physician orders to discontinue the detox protocol. The patient was discharged on [DATE] at 11:10 AM.
An interview was conducted on 3/19/14 at 2:30 pm with staff #3 and #2. Staff #2 and #3 confirmed patient #1 was not assessed per physician orders and nursing documentation was not present.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on medical record review and interviews the facility failed to protect the patients from abuse and neglect. The facility failed to communicate, intervene, and assess the patient during a behavioral emergency in 1 (#1) out of 6(#1-6) charts reviewed.
Review of patient #1's nurse's notes for 1/20/14 at 4:15 PM revealed that patient #1 requested to move to another unit. Patient #1 was not comfortable on the Christian Faith Based unit.
At 5:00 PM the patient was transferred to unit one.
Nurses notes dated 1/20/14 at 6:15 stated, "patient admitted to unit one at this time. Patient asked for against medical advise (AMA) form because she said she missed her smoke break. Throwing objects at staff, pushing, screaming. Explained to patient we would not talk to her so as not to encourage her loud threatening outburst. Threatened to harm staff and peers. Did throw things and hit this nurse. Pushed a male staff MHT. Gave patient a AMA form. Dr. Moomaw on call MD. Orders received."
A 'four hour discharge notice' was signed by patient #1 at 6:00 PM. Patient documented on the AMA form, "will not give smoke break missed one on unit four cause was busy getting ready." There was no witness signature, date, or time.
Physician orders for 1/20/14 at 6:30 PM stated "Hold for face to face with MD."
No further documentation of communication, interventions, or medical assessment was offered or performed on patient #1. No documentation that patient #1 was informed of her rights and that an MD order had been obtained to hold her for a face to face with physician.
Patient #1 revoked the four hour discharge notice on 1/20/14 at 7:50 PM. No witness signature, time or date noted on the revocation. There was no documentation of why the patient revoked the discharge notice. There was no documentation that the physician was notified.
An Interview with staff #1, 2, and 3 was conducted on 3/13/14. Staff #1, 2, and 3 confirmed that staff #5 had documented, "Explained to patient we would not talk to her so as not to encourage her loud threatening outburst." Staff #1, 2, and 3 confirmed that patient #1 was not offered appropriate interventions, communication, and nursing assessment for behavioral emergencies.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on chart reviews, interviews, policy, and procedures nursing failed to follow physician orders, document medication errors, provide adequate RN supervision, and appropriatly assess the patients in a medical detox condition in 2 (#1 and #4) out of 6(#1-6) charts reviewed. Failure to assess the patients in detox, and providing basic nursing assessment has the potential to place all detoxification patients at risk for seziures, cardiac arrest, and possible death.

Refer to Tag A0395

Based on chart reviews, interviews, and policy/procedures, the facility failed to provide appropriate pain assessments and pain management in 1(#1) of 6 (#1-6) patient charts reviewed.

Refer to Tag A0144
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on chart reviews, interviews, policy, and procedures nursing failed to follow physician orders, document medication errors, provide adequate RN supervision, and appropriately assess the patients in a medical detox condition in 2 (#1 and #4) out of 6 (#1-6) charts reviewed. Failure to assess the patients in detox, and providing basic nursing assessment can leave the patient at risk for seziures, cardiac arrest, and possible death.

Review of patient #1's chart revealed a physician order on 1/17/14 at 6:05 PM to initiate an Opiate Detox Protocol.
Review of the policy and procedure "Detoxifications from Opiates" revealed, "All clients on detoxification from opiates shall be assessed for the following withdrawal signs and symptoms:
Abdominal cramps, Diaphoresis, Irritability, Piloerection, agitation, Diarrhea, Insomnia, Rhinorrhea, Anorexia, Dilated pupils, Lacrimation, Tachycardia, Muscle spasms, Fever, Arthralgias, Tachypnea, Myalgias, Hypertension, Yawning.
In the management of opiate withdrawal, the goal is to minimize discomfort, avoid adverse effects of withdrawal medications, and facilitate engagement in ongoing treatment."
Review of the "Opiate Withdrawal Protocol" revealed, "Obtain vital signs every four hours and complete Opiate Withdrawal Symptom Scale and enter findings under date and time column.
Score 5 or greater = Administer clonidine per physician PRN order. If physician has not ordered PRN clonidine notify physician of patient's current condition immediately. "
Review of the "Detoxification Flowsheet" revealed the flowsheet had 12 boxes at the top of the page. Each box had a withdrawal symptom with a numbered scale for resting pulse rate, sweating over 30 minutes, restlessness, pupil size, bone or joint aches, runny nose or tearing, GI upset, tremor, yawning, anxiety or irritability, and gooseflesh skin.
Review of the Opiate Detoxification Flowsheet dated 1/17/2014 revealed vital signs were taken only once. There was no time documented and the symptom scale was blank. The order for Opiate detoxification was ordered at 6:05 PM. The patient was not assessed from 1/17/14 at 6:05 PM until 1/18/14 at 5:00 AM. Patient #1 had no documentation of assessment for symptoms of detox for 11 hours on the flowsheet or nurses notes.
Review of the Opiate Detoxification Flowsheet on 1/18/2014 revealed vital signs were taken at 5:00 AM, 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM. There was no documentation on the symptom scale for 9:00 AM, 1:00 PM, and 5:00 PM.
There was no further documentation or vital signs from 1/18/14 at 9:00 PM- 1/19/14 at 5:00 AM. The patient was not assessed for 8 hours.
Review of the Opiate Detoxification Flowsheet on 1/19/2014 revealed vital signs were taken at 5:00 AM, 9:00 AM, 1:00 PM, and 9:00 PM. There was no assessment or vital signs documented for 5:00 PM nor documentation on the symptom scale for 9:00 AM or 1:00 PM. The symptom scale for 9:00 PM revealed the total score was an "11" There was no documentation that the physician was notified.
Review of patient #1's MAR on 1/19/2014 revealed Vistaril 25mg (for anxiety) was administered at 7:26 PM and 8:53 PM. There was no documentation of anxiety on the flowsheet or in the nurse's notes.
Review of patient #1's MAR on 1/20/2014 revealed Phenergan 25 mg (for nausea) was administered at 8:00 AM and 2:40 PM. The symptom scale had "0" in the GI upset column for both times. There was no documentation on the nurse's notes concerning patient #1's nausea.
Review of the Opiate Detoxification Flowsheet on 1/21/2014 revealed vital signs were taken at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM. Vital signs were the only documentation on the flow sheet. There was no documentation for symptom scale.
Review of patient #1's MARS on 1/21/2014 revealed Bentyl 20 mg (abdominal cramps) and Phenergan 25 mg (nausea) was administered at 10:30 AM, Imodium AD 4 mg (anti-diarrheal) was administered at 2:40 PM, and Bentyl 20 mg (abdominal cramps) and Phenergan 25 mg (nausea) was administered at 10:00PM. There was no documentation on the symptom scale or in the nurses notes concerning medications administered or GI upset.
Review of the Opiate Detoxification Flowsheet on 1/22/2014 revealed only two times 1:00 AM and 5:00 AM. Under each column was "refused". No documentation in the nursing notes of refusal. There were no physician orders to discontinue the detox protocol. The patient was discharged on [DATE] at 11:10 AM.

Review of patient #4's chart revealed the patient was admitted on [DATE] at 2:05 PM. Patient #4 was admitted for suicidal ideation, unstable mood, and polysubstance abuse. Review of the psychiatric evaluation performed on 1/26/14 revealed the patient had been abusing Xanax (Benzodiazepine), Vicodin (opioid analgesic), and Marijuana.
Patient #4's chart revealed a physician order to on 1/25/14 at 5:00 PM to admit the patient to unit one and "start Benzo Detox Protocol".
Review of the Benzodiazepine- Detox Admission order revealed patient #4 was ordered "detox for 5 days, medical consult for history and physical, vital signs every 4 hours x72 hours, then daily if stable (Note: Take vital signs before medicating with detox meds.) Routine diet,
Ativan .5mg by mouth every 4 hours prn (as needed) scale 1-10 for detox.
Ativan 1mg by mouth every 4 hours prn (as needed) scale 11-20 for detox.
Ativan 2mg by mouth every 4 hours prn (as needed) scale 21-30 for detox. Call MD if scale 20 or greater."
Review of patient #4's chart revealed an Alcohol Withdrawal Flow sheet was used instead of a Benzodiazepine- Detox flowsheet. The Alcohol Withdrawal Flow sheet was in patient #4's chart and had no patient sticker or identifier. The assessment scale for 1/26/14 at 4:30 PM and 1/27/14 at 4:30 AM were blank. Nurses failed to use the correct flow sheet that caused an error in medication dosage.
Review of patient #4's MAR revealed the following PRN medications were given:
1/25/14 at 5:40PM -Ativan 1 mg by mouth for agitation. The score on the Alcohol Withdrawal Flow sheet for this time period was not present. The patient had no order for the Ativan administration. There was no follow up response for effectiveness of medication documented. The nurse's notes have no documentation of medication administration.
1/25/14 at 9:50PM- Ativan 1 mg by mouth for anxiety. The total score on the Alcohol Withdrawal Flow sheet for this time period was 1. The response for effectiveness of medication documented was "asleep". There was no time documented. The nurse's notes have no documentation of medication administration. The nurse failed to administer the correct dose of Ativan 0.5 mgs.
1/26/14 at 4:16 PM a medication was given as a prn but was illegible. There was no nursing documentation of prn administration in nursing notes.
1/26/14- at 8:30PM - Ativan 1 mg by mouth for anxiety. The total score on the Alcohol Withdrawal Flow sheet for this time period was 2. The response for effectiveness of medication documented was "asleep". A Licensed Vocational Nurse (LVN) assessed and medicated the patient. No RN documentation. The nurse failed to administer the correct dose of Ativan 0.5 mgs.
1/26/14- 9:50PM- Benadryl 50 mg administered by mouth for a headache. It was a "prn as needed" medication. The LVN assessed and medicated the patient.
1/27/14 at 1:35AM - Ativan 1mg by mouth for anxiety. The Alcohol Withdrawal Flow sheet for this time period was a 0. The nurse's notes for 1:35AM revealed patient #4 complained of anxiety and a headache. The LVN assessed and medicated the patient. The nurse failed to administer the correct dose of Ativan 0.5 mgs.
1/27/14 at 2:30AM - LVN documented patient #4 was asleep and will continue to monitor. The patient was medicated 3 times by the LVN with no RN supervision or assessment documented. There was no incident report or physician notification of medication errors.
Interview with staff # 3 on 3/13/14 confirmed nursing was not performing appropriate assessments.

A phone interview on 3/21/14 with staff #2 revealed that the Opiate Detoxification Order set did not have a flowsheet to go with it. Staff #2 reported that staff #3 was working on a flowsheet. Staff #2 provided the surveyor with a vital sign sheet. There was no flowsheet for Opiates provided.