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.

CEDAR CREST HOSPITAL & RTC 3500 SOUTH IH-35 BELTON, TX Jan. 13, 2014
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of clinical records and facility documentation, the facility failed to protect and promote each patient's rights.

The patient's right to participate in the development and implementation of their plan of care was not ensured. Cross refer to Tag A0130.

The facility failed to protect the rights of patients to receive care in a safe setting. Cross refer to Tag A0144.

The facility failed to protect the patient's right to not be restrained except by order of a physician. Cross refer to Tag A0168.

The facility failed to protect the patient's right to receive a face-to-face evaluation within 1 hour after the initiation of the intervention (physical restraint). Cross refer to Tag A0179.


The above findings were confirmed in an interview with the Director of Nursing, the Director of Quality and Risk Management and the Medical Director on the afternoon of 1-13-14, in the administrative office.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
Based on review of clinical records, the facility failed to protect the patient's right to receive a face-to-face evaluation within 1 hour after the initiation of the intervention (physical restraint) for 1 of 12 patients(patient #10).

Findings were:

A review of facility policy #1000.44 titled Physical Restraint (Acute Care) reveals the following:

"All physical restraints require a physician's order to be obtained by the clinically competent Registered Nurse (RN) as soon as possible following the initiation of a physical restraint.

PROCEDURE:

6. Physician's Responsibilities
6.6 The physician or nurse must conduct a face-to-face evaluation within 1 hour following the initiation of the restraint with subsequent documentation in the patient's medical record."

Review of 1 of 12 clinical records on 1-13-14, involving a personal restraint (patient #10), revealed that no face-to-face evaluation was conducted on the patient following application of the restraint.

The above finding was confirmed in an interview with the Director of Nursing, the Director of Quality and Risk Management and the Medical Director on the afternoon of 1-13-14, in the administrative office.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on a review of documentation, the facility failed to ensure adequate number of nursing staff to meet the care needs of patients.

Findings were:

The nursing service did not supply adequate numbers of licensed registered nurses and other personnel to provide nursing care to all patients as needed. Cross refer to A0392

The above finding was confirmed in an interview with the Director of Nursing, the Director of Quality and Risk Management and the Medical Director on the afternoon of 1-13-14, in the administrative office.
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
Based on review of clinical records, the patient's right to participate in the development and implementation of their plan of care was not ensured for 9 of 12 patients (patients #1, #2, #4, #5, #6, #7, #8, #9 and #10).

Findings were:

A review of facility policy #1000.77 titled Treatment Planning reveals the following:

"POLICY: An individualized interdisciplinary Treatment Plan will be developed for each patient admitted to Cedar Crest. The Treatment Plan will be reviewed and updated to the interdisciplinary Treatment Team with patient and parent/guardian/family member participation on a regular basis during the course of treatment.

DEFINITIONS:

Initial Treatment Plan: is formulated by the admitting Nurse and found in the Nursing Assessment portion of the initial comprehensive Bio-psycho-social assessment. It is good for the initial 3, 7 or 30 days of treatment (see below), at which time the Interdisciplinary Master Treatment Plan is developed.

Master Treatment Plan (MTP) - Is interdisciplinary in nature and shall be completed for the different levels of care as follow (sic):

Acute Care: 3 days
RTC (Medical Model): 7 days
RTC (Social Model): 30 days
PHP: 3 days

PROCEDURE:

2. By the (as previously described) day following admission, a Treatment Team meeting is held, and the MTP is developed. The MTP is based upon the findings of assessments completed by each provider, as well as documentation received from outside providers. The MTP for guides each team member/discipline to document their input into the individualized treatment plan."

A review of 12 clinical records on 1-13-14, revealed that 9 of 12 records (patients #1, #2, #4, #5, #6, #7, #8, #9 and #10) contained treatment plans that had not been updated after the initial treatment plan initiated by the admitting nurse as required in the above facility policy.

The above finding was confirmed in an interview with the Director of Nursing, the Director of Quality and Risk Management and the Medical Director on the afternoon of 1-13-14, in the administrative office.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on a review of clinical records and facility documentation, the governing body failed to exercise its oversight responsibilities to ensure that staff followed approved policies and procedures established to ensure safe patient care.

Findings were:

A review of facility policy #HR.49 titled Reporting Abuse & Neglect reveals the following:

"No patient will be allowed to suffer abuse, neglect or violations of rights. Appropriate actions will be taken as allowed below. For the purpose of this policy abuse and neglect will be defined as follows:

? NEGLECT Shall be defined as any act involving dereliction of duty which threatens the physical or emotional well-being of a resident/patient.
? 2. Failure to perform
? d. Failure to supervise patient activities as directed
? e. Leaving resident/patients unattended, per level."

A review of facility policy #1000.17 titled Observation/Precaution Levels reveals the following:

"Moderate (Line-of-sight)

? The unit staff will provide constant visual observation of the patient at all times. The unit staff may perform line-of-sight observations within a group of patient or milieu group activities. The unit staff documents the observation every 15 minutes in the Patient Observation Monitoring Form."

Review of patient #1's record on 1-13-14, revealed that on the evening of 11-10-13, patient #1 was to be monitored on line-of-sight precautions. Despite this monitoring level, the patient was able to cross the hallway and was later found in the shower of patient #2. Both patients admitted to staff that they had sexual intercourse.

A review of 12 other clinical records on 1-13-14, revealed that 6 of 12 patients (patients #1, #2, #4, #5, #9 and #10) were not monitored at the appropriate level ordered by the physician throughout their admission.

A review of facility policy #1000.24 titled Suspected Cases of Patient Sexual Activity reveals the following:

"PROCEDURE:

1. Staff Member first learning of a case of suspected sexual activity between patients is to immediately report this to: 1.1 Supervisor, Charge RN, 1.2 Attending Physician, 1.3 Administrator/on Call".

A review of facility documentation on 1-13-14, regarding a self-investigation of the incident revealed that the nurse on the unit was notified of the incident immediately after it occurred but that the physician was not notified until 12:30 pm the following day (Monday). There was no documentation to indicate that the Administrator on call was notified.

A review of facility policy #1000.77 titled Treatment Planning reveals the following:

"POLICY: An individualized interdisciplinary Treatment Plan will be developed for each patient admitted to Cedar Crest. The Treatment Plan will be reviewed and updated to the interdisciplinary Treatment Team with patient and parent/guardian/family member participation on a regular basis during the course of treatment.

DEFINITIONS:

Initial Treatment Plan is formulated by the admitting Nurse and found in the Nursing Assessment portion of the initial comprehensive Bio-psycho-social assessment. It is good for the initial 3, 7 or 30 days of treatment (see below), at which time the Interdisciplinary Master Treatment Plan is developed.

Master Treatment Plan (MTP) is interdisciplinary in nature and shall be completed for the different levels of care as follow (sic):

Acute Care: 3 days
RTC (Medical Model): 7 days
RTC (Social Model): 30 days
PHP: 3 days

PROCEDURE:

2. By the (as previously described) day following admission, a Treatment Team meeting is held, and the MTP is developed. The MTP is based upon the findings of assessments completed by each provider, as well as documentation received from outside providers. The MTP for guides each team member/discipline to document their input into the individualized treatment plan."

A review of 12 clinical records on 1-13-14 revealed that 9 of 12 records (patients #1, #2, #4, #5, #6, #7, #8, #9 and #10) contained treatment plans that had not been updated after the initial treatment plan initiated by the admitting nurse as required in the above facility policy.

A review of facility policy #1000.44 titled Physical Restraint (Acute Care) reveals the following:

"All physical restraints require a physician's order to be obtained by the clinically competent Registered Nurse (RN) as soon as possible following the initiation of a physical restraint.

PROCEDURE:

6. Physician's Responsibilities
6.6 The physician or nurse must conduct a face-to-face evaluation within 1 hour following the initiation of the restraint with subsequent documentation in the patient's medical record."

A review of 1 clinical record on 1-13-14 involving a personal restraint (patient #10), revealed that the order for the restraint had not been obtained by a physician as required in the above facility policy. Additionally, the record revealed that no face-to-face evaluation had been conducted on the patient following release from the restraint as required in the above facility policy.

A review of facility policy #1300.0 titled Nursing Staffing Plan reveals the following:

"There will be adequate numbers of Registered Nurses (RNs), Licensed Vocational Nurses
(LVNs), and Mental Health Associate (MHA) personnel to provide safe and quality care
to all patients.

B. The Hospital and RTC shall adopt, implement and enforce a written staffing plan."

A review of unit census, staffing assignment & staffing grid for 11-10-13, revealed a total of 20 patients on the Generations Unit. Per the facility staffing grid, staffing on the evening shift for 20 patients should have been a minimum of 2 Registered Nurses and 3 Mental Health Associates. A review of the staffing assignment sheet revealed that the actual staffing for the evening shift was only 1 Registered Nurse and 2 Mental Health Associates, only 60% of the minimum staff required.

A review of the staffing and census sheets for the time period of 11-5-13, at 7:00 am, until 11-15-13, at 11:00 pm, (a total of 33 shifts) revealed that 29 of the 33 shifts were staffed below the minimum staffing standards established by the facility.

The above finding was confirmed in an interview with the Director of Nursing, the Director of Quality and Risk Management and the Medical Director on the afternoon of 1-13-14, in the administrative office.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of clinical records and facility documentation, the facility failed to protect the rights of patients to receive care in a safe setting for 6 of 12 patients (patients #1, #2, #4, #5, #9 and #10).

Findings were:

A review of facility policy #1000.17 titled Observation/Precaution Levels reveals the following:

"Moderate (Line-of-sight)

? The unit staff will provide constant visual observation of the patient at all times. The unit staff may perform line-of-sight observations within a group of patient or milieu group activities. The unit staff documents the observation every 15 minutes in the Patient Observation Monitoring Form."

Review of patient #1's record on 1-13-14, revealed that on the evening of 11-10-13, patient #1 was to be monitored on line-of-sight precautions. Despite this monitoring level, the patient was able to cross the hallway and was later found in the shower of patient #2. Both patients admitted to staff that they had sexual intercourse.

A review of 12 other clinical records on 1-13-14 revealed that 6 of 12 patients (patients #1, #2, #4, #5, #9 and #10) were not monitored at the appropriate level ordered by the physician throughout their admission.

The above finding was confirmed in an interview with the Director of Nursing, the Director of Quality and Risk Management and the Medical Director on the afternoon of 1-13-14, in the administrative office.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on review of clinical records, the facility failed to protect the patient's right to not be restrained except by order of a physician for 1 of 12 patients (patient #10).

Findings were:

A review of facility policy #1000.44 titled Physical Restraint (Acute Care) reveals the following:

"All physical restraints require a physician's order to be obtained by the clinically competent Registered Nurse (RN) as soon as possible following the initiation of a physical restraint.

PROCEDURE:

6. Physician's Responsibilities
6.6 The physician or nurse must conduct a face-to-face evaluation within 1 hour following the initiation of the restraint with subsequent documentation in the patient's medical record."

A review of 1 of 12 clinical records on 1-13-14 involving a personal restraint (patient #10), revealed that there was no physician's order for the restraint used.

The above finding was confirmed in an interview with the Director of Nursing, the Director of Quality and Risk Management and the Medical Director on the afternoon of 1-13-14, in the administrative office.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on a review of documentation, the nursing service failed to have adequate number of licensed registered nurses and other personnel to provide nursing care to all patients as needed.

Findings were:

A review of facility policy #1000.17 titled Observation/Precaution Levels reveals the following:

"Moderate (Line-of-sight)

? The unit staff will provide constant visual observation of the patient at all times. The unit staff may perform line-of-sight observations within a group of patient or milieu group activities. The unit staff documents the observation every 15 minutes in the Patient Observation Monitoring Form."

A review of facility policy #1300.0 titled Nursing Staffing Plan reveals the following:

"There will be adequate number of Registered Nurses (RNs), Licensed Vocational Nurses
(LVNs), and Mental Health Associate (MHA) personnel to provide safe and quality care
to all patients.

B. The Hospital and RTC shall adopt, implement and enforce a written staffing plan."

While on Line-of-Sight observation level, patient #1 was assigned to be monitored by staff #2. Staff #2 was also assigned the care of 9 other patients on the unit. While on Line-of-Sight observation level on 11-10-13, patient #1 walked across the hallway to the room of patient #2 and was found in patient #2's shower. Although the census on 11-10-13, called for 2 Registered Nurses and 3 Mental Health Associates (per the facility's staffing plan), only 1 Registered Nurse and 2 Mental Health Associates were working on the unit.

A review of census and staffing sheets on 1-13-14, for the time period of 7:00 am on 11-5-13, to 11:00 pm on 11-15-13, (a total of 33 shifts) revealed that 29 of the 33 shifts were staffed below the minimum staffing standard established by the facility.

A review of facility policy #1000.24 titled Suspected Cases of Patient Sexual Activity reveals the following:

"PROCEDURE:

1. Staff Member first learning of a case of suspected sexual activity between patients is to immediately report this to: 1.1 Supervisor, Charge RN 1.2 Attending Physician 1.3 Administrator/on Call".

A review of facility documentation regarding self-investigation of the incident revealed that the nurse on the unit was notified of the incident immediately after it occurred but that the physician was not notified until 12:30 pm the following day (Monday). There was no documentation to indicate that the Administrator on call was notified.

The above finding was confirmed in an interview with the Director of Nursing, the Director of Quality and Risk Management and the Medical Director on the afternoon of 1-13-14, in the administrative office.
VIOLATION: CONTENT OF RECORD Tag No: A0449
Based on review of clinical records, the clinical records did not contain information to justify continued hospitalization of patients or to describe the patient's progress and response to medications and services provided.

Findings were:

A review of 12 clinical records on 1-13-14 revealed that 9 of 12 records (patients #1, #2, #4, #5, #6, #7, #8, #9 and #10) contained treatment plans that had not been updated after the initial treatment plan initiated by the admitting nurse.

The above finding was confirmed in an interview with the Director of Nursing, the Director of Quality and Risk Management and the Medical Director on the afternoon of 1-13-14, in the administrative office.