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.

GEORGETOWN BEHAVIORAL HEALTH INSTITUTE 3101 S AUSTIN AVENUE GEORGETOWN, TX Dec. 11, 2017
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of documentation and the clinical record, the facility failed to protect the patient's right to receive care in a safe setting.

Findings were:

Patient #1 was admitted to the facility on on [DATE] and placed on suicide precautions.

A review of the "Patient Observation Record" for each day of patient #1's stay indicated that the patient was not observed on suicide precautions for 4 of the 8 days of his stay (9-5-17, 9-8-17, 9-9-17 and 9-12-17).

Facility policy 1000.01 titled "Patient Rights and Responsibilities" states, in part:
"II. Policy
...
C. The Patient's Bill of Rights shall include, but is not limited to, the patient's right to:
...
3. Expect considerate, dignified and respectful care, provided in a safe environment, free from all forms of abuse, neglect, harassment and/or exploitation."

Facility policy 200.39 titled "Levels of Observation" states, in part:
"Policy:
All patients shall be assessed for safety risks and assigned the appropriate level of observation. Patients assessed as having safety risks will be managed in such a way to minimize the threat of injury or harm. Safety risks include but are not limited to ideation, impulses, or behavior indicating that they are a danger to themselves or others. Medically compromised patients may also be identified as higher risk. In addition, other risks may be identified that warrant an increased level of observation."

The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 12-11-17.
VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY Tag No: A0468
Based on a review of the clinical record, the patient's treating physician failed to prepare a written discharge summary with outcome of hospitalization , disposition of care and provisions for follow-up care.

Findings were:

Patient #1 was admitted to the facility 9-5-17 and was discharged from the facility on 9-12-17. A review of the clinical record of patient #1 on 12-11-17 revealed no discharge summary.

Facility policy 900.02 titled "Documentation Overview" states, in part:
" ...
4.0 Procedure
...
L. Discharge Documentation
" The Discharge and Aftercare Plan includes appointments and any instructions given to the patient and/or family/significant other(s).
" The Provider Discharge Summary is completed by the physician and includes:
a) The provisional diagnosis (the principal and additional or associated diagnoses)
b) Complete mental status exam
c) Reason for hospitalization with the significant findings
d) Treatments rendered
e) Procedures and diagnostic studies performed
f) Condition of the patient on discharge which is stated in terms that permit a specific measurable comparison with the condition on admission, avoiding the use of vague relative terminology
g) Specific instructions given to the patient and/or family, as pertinent. Consideration is given to instructions relating to physical activity, medication, diet, and follow-up care.
h) If authorized in writing by the patient or his legally qualified representative, a copy of the discharge summary is sent to any known medical practitioner and/or medical organization responsible for the subsequent medical care of the patient.
M. Completion of Medical Record
" The records of discharged patients are completed, signed and in the chart with 15-30 days following discharge (or per hospital medical staff rules and regulations).
" A medical record is ordinarily considered complete when the required contents have been completed and all entries and/or dictation have been authenticated (e.g. signed) by responsible author."

The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 12-11-17.