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CYPRESS CREEK HOSPITAL 17750 CALI DRIVE HOUSTON, TX 77090 July 27, 2017
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
Based on record review and interview the facility failed to implement a safe discharge plan to ensure a patient's Guardian was informed the patient had sedation less than two (2) hours prior to his discharge.

This failed practice had the potential for inadequate monitoring of the patient after discharge. Citing one patient named in a complaint. Patient # 1

Findings:

Review of complaint narrative revealed allegations that Patient # 1 was in and out of consciousness and had slurred speech, hallucinations and babbling throughout his trip from the hospital to the treatment center on the day of his discharge.

It was alleged the patient's condition was due to "strong" sedating medication he was given prior to discharge.

It was alleged the medication was administered without consent by the Patient's legal guardians.

Review of nurses notes dated 5/3/2017 at 10:08 am revealed documentation patient was administered 20 milligrams of Zyprexia (Psychoactive medication) and 50 milligrams of Benadryl by mouth for agitation.

The patient became more agitated attempting to jump into nurses station, hitting the Plexiglas at the nurses station multiple times. The patient would not stop at which time he was restrained.

The patient attempted to bite, kick, and head-butt staff. Thorazine 75 milligrams injection was administered at 10:18 am. He calmed down slowly then fell asleep.

Review of nurses notes dated 5/3/2017 at 11:45 am revealed documentation the patient was escorted out of the unit on a wheel chair with Case worker with all his belongings. Patient to go to RTC (Residential Treatment Center).(The patient left the hospital less than two(2) hours after he was sedated).

Review of discharge Summary dated 5/3/2017 revealed discharge instructions were as follows:
"Patient will follow up with "P" Residential Treatment Center, post discharge.

Patient requires continued structured care to prevent relapse and control residual symptomatology. Patient also educated to call 911 immediately in the event of an emergency".

The discharge instructions were signed by the Case Worker at 11:25 am (5/3/2017).

The instructions did not include information the patient required monitoring for his recent sedation.

There was no documentation the Case Worker or the Treatment Center was informed of the patient's recent aggressive behavior that necessitated sedating medication , and what medications he was given.

Review of the facility's Discharge Policy/Protocol (not dated) presented at the time of the survey revealed the following information:

"The patient and his/her legally authorized representative, if applicable will receive written copy of the Discharge instructions, the patient safety plan, Post discharge wellness check and depression/suicide information, and information regarding concerns at the time of discharge."

During an interview on 7/27/2017 at 10:40 am with Staff D 54 Registered Nurse who discharged Patient # 1, she stated the patient was agitated and was displaying aggressive behavior and could not be talked into calming himself, because he did not want to go to the treatment center. She stated the patient was awake and oriented when he left the facility.

According to Staff D 54 she did have concerns the patient might not get to the center, that he might jump out of the car.

According to Staff D 54 the Director at the Treatment Center later called her to find out why the patient arrived at the treatment center asleep and in the condition he was in. She stated she explained about the patient's behavior and what medication he was given prior to his discharge.