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AUSTIN OAKS HOSPITAL 1407 WEST STASSNEY LANE AUSTIN, TX 78745 Sept. 10, 2014
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on a review of facility documentation and staff interview, the facility failed to ensure that information specific to individual psychoactive medications was provided to each patient so that he/she could make an informed decision regarding treatment in 10 of 10 patient charts reviewed.

Findings were:

A review of patient clinical records revealed the facility Medication Consent forms were titled by class of medication. Side effects of the class of medication were listed, but no information regarding side effects of the specific medication were supplied to the patient. This was found in the records of Patients #1-10.

For example, Patient #6 signed a Medication Consent for "Antipsychotics" on 8/25/14 at 22:00. The consent was for "Thorazine" as indicated by a check mark next to that medication under the list of possible medications included in that class. Side effects of "Antipsychotics" were listed on the form. She also signed another Medication Consent for "Antipsychotics" on 8/25/14 at 22:00. This consent was for "Risperdal" as indicated by a check mark next to that medication under the list of possible medications included in that class. The form was exactly the same as that used for Thorazine and included the exact same list of side effects.

In an interview with Director of Performance Improvement/Risk Management on the afternoon of 9/10/14 in the facility conference room, she was asked if information regarding side effects specific to Thorazine or Risperdal was supplied to the patient. She stated, "We don't have anything but the consent that we give the patient. We didn't realize you needed to give information that was just for a specific drug."

Facility policy #RI-27, entitled Consent for Psychotropic Medication, effective date 6/19/14, stated in part:
"All patients or Legally Authorized Representatives (LAR) shall be provided with specific information regarding the benefits and risks associated with antipsychotic medications, to enable him/her to make an informed decision.
Procedure:
1. In order to make an informed decision and provide consent, the patient or LAR is provided with information about the prescribed psychoactive medication, by the physician prescribing the medication, or the nurse ...
3. Prior to the administration of the medication, the specific [underline and italics by facility] consent for psychotropic medication form must be signed by the patient or LAR. Each psychotropic medication requires a separate authorization form..."
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of facility documentation and staff interviews, the facility failed to provide supervised care to each patient as needed as vital signs and/or accucheck results were not documented as ordered by the physician in 8 of 10 patient charts reviewed.

Findings were:

A review of patient clinical records revealed that for 8 of 10 patients [Patients #1-4, #6-8 and #10] vital signs were not monitored as ordered by the physician and/or blood glucose values, or accuchecks, were not monitored as ordered by the physician.

The clinical record of Patient #1 revealed the following:
Admitting Orders on 7/15/14 at 6:35 p.m. stated in part, " Vital Signs: Upon admissions and once daily ..." The Vital Signs Flow Sheet revealed the following entries for the entire hospitalization of Patient #1 as follows:
7-20 7:25 Temp: 98.2; Pulse 95; Resp 17; BP 131/85; Pulse Ox 95...
7/22 8:00 Refused-----------------------------------------------------
His admission lab included a Serum Glucose level of 103 which was slightly elevated. He was prescribed Seroquel which can elevate blood sugar levels. The level was never re-checked.

Admitting Orders for Patient #2 on 8/26/14 at 7:55 a.m. included "Vital Signs: Upon admissions and once daily..." The Physician's Order Sheet included the following order on 8/26/14 at 8:00 a.m.: "Check blood glucose level via fingerstick AC & HS..." The Vital Signs Flow Sheet included a listing of vital signs for Patient #2 which included a blood pressure value of 154/90. According to the "Abnormal Vital Sign Parameters" listed at the top of the form, if blood pressure was above 140/90, the nurse was to be notified. There was no documented evidence on the Flow Sheet that the nurse had been notified of the value. Nursing Progress Notes included no documentation of the abnormal value. There was no evidence that the patient's blood glucose level had been checked for the evening of 8/26/14, nor for the morning of 8/27/14. The patient was discharged on the afternoon of 8/27/14.

Patient #3 had diagnoses which included Diabetes Uncomp. - Type II Controlled and Long-Term (current) Use of Insulin. The patient was admitted on [DATE] at 12:50 p.m. Physician's Preadmission Examination Orders at that time included the following:
"Insulin Sliding Scale:
Fingerstick blood glucose: qAC, qHS,
Sliding scale regular insulin subcutaneously..."
A scale followed which indicated the amount of insulin to provide based on the blood glucose values. The first blood glucose value entered on the Diabetic Flow Sheet was on 8/28/14. The facility could provide no evidence that the patient's blood glucose levels had been checked prior to that date.

Patient #4 had diagnoses which included Diabetes Uncomp. - Type II Controlled and Long-Term (current) Use of Insulin. The patient was admitted on [DATE]. The Physician's Order Sheet on 8/25/14 at 11:15 a.m. included the following: "Glipizide 2.5 mg p.o. daily...Lantus 13 units sub Q in AM...Accu [check] AC & HS..." There was no Diabetic Flow Sheet available for review for Patient #4. Thus, the facility could provide no evidence that his blood glucose values had ever been checked. In addition, A Physician's Order on 8/28/14 at 12:45 stated in part, "VS (Vital Signs) BID x 3 days..." The Vital Signs Flow Sheet included a large handwritten note at the top of the page, "VS BID x 3 Day." Vital signs recorded on the sheet for 8/28/14, 8/29/14, and 8/30/14 included only one entry each day.

The clinical record of Patient #6 included Admitting Orders on 8/25/14 at 3:29 a.m. for "Vital Signs Upon admissions and once daily..." There was no Vital Signs Flow Sheet in the patient record, and thus no evidence that the patient's vital signs had ever been checked.

Patient #7 had a diagnosis of Diabetes Uncomp. - Type II Controlled. The patient was admitted on [DATE]. The Physician's Order Sheet on 8/23/14 at 11:05 a.m. included the following: "Accu [check] BS, AC & HS..." The Diabetic Flow Sheet had a total of five blood glucose values missing during the patient's hospitalization . There was no documented evidence that the patient had refused these tests, including no mention of possible refusals in the nursing progress notes.

Patient #8 had been admitted on [DATE] at 11:00 a.m. and discharged on [DATE]. Admitting Orders on 8/1/14 at 11:00 a.m. included, "Vital Signs Upon admissions and once daily..." The Vital Signs Flow Sheet included entries on 8/6/14, 8/13/14 and 8/15/14. The entry on 8/7/14 had "Refused" handwritten across the line for values. Other than vital signs taken upon admission, these were the only values recorded during the patient's entire hospitalization . There was no documentation of refused vital signs other than the entry on 8/7/14.

Patient #10 was admitted on [DATE] and discharged on [DATE]. Admitting Order on 8/17/14 included, "Vital Signs Upon admissions and once daily..." There was no entry recording vital signs on 8/20/14 and no documentation available in the chart which indicated the patient's refusal of vital signs.

Upon surveyor request, there was no facility policy available for review which included discussion of obtaining daily vital signs or vital signs as ordered by the physician. There was no policy available for review which included discussion of obtaining blood glucose levels as ordered by the physician.

The above clinical charts were each thoroughly discussed with the Director of Performance Improvement/Risk Management and the Director of Nursing in an interview on the afternoon of 9/10/14 in the facility conference room. They reviewed the findings, searched each chart to validate them, and agreed to each finding as noted.