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WELLBRIDGE HEALTHCARE OF PLANO 4301 MAPLESHADE LANE PLANO, TX 75093 Aug. 19, 2016
VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure its medical staff was accountable to the governing body for the quality of the medical care provided to one of one patient (Patient #2). Although aware of Patient #2's critically high blood level of her psychotropic medication, Physician Personnel #9 did not change the medication dose for sixteen hours and Patient #2 received two additional doses of the medication. The incident was not reviewed by the hospital administrative personnel.


Findings included:

Patient #2's Preadmission Exam and Certification dated 10/12/15 at 1643 reflected the patient was delusional and had auditory hallucinations.

Physician Personnel #9's Physician Orders dated 10/13/15 at 0930 reflected Patient #2 was to take Depakote Sprinkles 250 mg (milligram) by mouth for agitation. Personnel #9 increased the medication dose on 10/15/17 at 1015 to Depakote Sprinkles 375 mg by mouth three times daily.

Clinical laboratory results dated [DATE] at 0800 reflected Patient #2's Valproic Acid blood level as test for her Depakote (mood stabilizing) medication level was "high" and recorded as 102.4 ug/ml (microgram per milliliter) with a reference of 50 to 100 ug/ml. Two days later, on 10/17/15 at 1010, the laboratory report reflected a "critical" level of 133.1 ug/ml for Patient #2.

Nursing Note dated 10/17/15 at 1730 reflected nursing staff notified Physician Personnel #9. Nursing did not receive new orders.

Daily Nurse Note dated 10/17/15 at 1315 reflected that Patient #2 was "disoriented" and experienced "psychomotor retardation."

Medication Administration Records dated 10/17/15 at 1800 and 10/18/15 at 0700 reflected Patient #2 received her (unchanged) dose of Depakote Sprinkles 375 mg.

Physician Personnel #9's Orders dated 10/18/15 at 1034 reflected to decrease Depakote Sprinkles 375 mg from three times daily to two times per day.

Personnel # 3 acknowledged the above findings during an interview on 08/19/16 at 1330.


During a telephone interview on 08/30/15 at 1400 Personnel #3 denied that the incident had been reviewed by the hospital's medical staff. Personnel #3 denied that administration was aware of the incident until the survey.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, interview, and observation, the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for five of 12 patients (Patients #2, #7, #8, #3, #1) according to patient needs.

1) Patient #2 experienced a critically high blood level of her psychotropic medication, was disoriented, and experienced psychomotor retardation. Nursing administered two additional doses of the medication after becoming aware of the laboratory result.

2) Patient #7 had oral canker sores which were not assessed or documented by nursing staff.

3) Patient #8 was surveyor observed with a bruise on top of his left hand. There was no evidence of nursing assessment of the patient wound.

4) Patient #3 was surveyor observed with a quarter size wound on the back of his head which he had acquired the day prior to survey. Two out of four subsequent nursing shifts failed to assess the patient's head wound.

5) Patient #2 was admitted with intact skin. On nine days out of the patient's fourteen-day hospital stay, nursing documented the patient had bruises without additional assessments as to origin, location, size, and coloration of the skin changes.

6) Although Patient #1 had expressed severe pain during her admission, nursing failed to assess the patient's pain level on at least two days during the patient's hospital stay.


Findings included

1) Patient #2's Preadmission Examination orders dated 10/12/15 at 1730 reflected admitting diagnoses that included Bipolar Disorder.

Patient #2's Physician Orders dated 10/15/17 at 1015 reflected Patient #2 was to receive Depakote Sprinkles 375 mg (a mood stabilizer) by mouth three times daily.

Clinical laboratory results dated [DATE] at 0800 reflected Patient #2's Valproic Acid blood level as test for her Depakote medication level was "high." Two days later, on 10/17/15 at 1010, the laboratory report reflected Patient #2's Valproic Acid level was "critical" at 133.1 ug/ml (microgram per milliliter).

Daily Nurse Note dated 10/17/15 at 1315 reflected that Patient #2 was "disoriented" and experienced "psychomotor retardation."

Medication Administration Records dated 10/17/15 at 1800 and 10/18/15 at 0700 reflected Patient #2 received her (unchanged) dose of Depakote Sprinkles 375 mg.

Personnel # 3 acknowledged the above findings during an interview on 08/19/16 at 1330.


2) During observations on the hospital unit on 08/17/19 at 1450, Patient #7 spontaneously opened her mouth and showed the surveyor her lower lip with a blister. The patient complained of pain in her mouth.

Personnel #3 witnessed the event and acknowledged that Patient #7 had two canker sores in her mouth. After reviewing Patient #7's chart Personnel #3 denied documentation of the patient's oral sores.

Record review of Patient #7's Nursing Admission assessment dated [DATE] at 2030 reflected "no significant findings" during the dental screen. There was no documented evidence of oral sores.

Daily Nurse Notes dated 08/16/16 (day shift and night shift) did not reflect a skin or wound assessment was completed on Patient #7.

3) During observations on the hospital's patient unit on 08/17/16 at 1515 the surveyor noted Patient #8 with a bruise on top of his left hand. The bruise was the size of a quarter.

Personnel #3 witnessed the bruise and reviewed Patient #8's chart. Personnel #3 denied nursing documentation of the patient's bruise.

Record review of Patient #8's Admission Nursing assessment dated [DATE] at 1656 reflected that nursing staff completed the patient's skin assessment. There was no documentation of a bruise or other skin changes.

Daily Nurse Notes dated 08/16/16 (day shift and night shift) did not reflect a skin assessment was completed. There was no documentation of Patient #8's left hand bruise.

4) Patient #3 was observed with a quarter-size wound on the back of his head during unit observations on 08/19/16 at 1355.

Personnel #3 acknowledged the wound at that time and stated the laceration was due to a fall the patient had experienced at the hospital on [DATE].

Record review of Patient #3's nursing notes dated 08/16/16 at 1930 reflected that the patient " ...lost [his] balance and fell ...lying on his right side ...had a laceration to the back ...of his head ..." Patient #3 was transferred to an emergency department (ED) and returned to the unit on 08/16/16 at 2245.

Daily Nurse Notes dated 08/17/16 (night shift) and 08/18/16 (night shift) reflected the skin assessment was "N/A [not applicable]."

5) Patient #2's Nursing Admission assessment dated [DATE] at 1730 reflected the patient had intact skin.

Patient #2's Nursing Notes dated 10/15/15 (day shift), 10/16/15 (day and night shifts), 10/18/15 (day and night shifts), 10/20/15 (day and night shifts), 10/21/15 (day shift), 10/22/15 (day shift), 10/23/15 (day and night shifts), 10/24/15 (day and night shifts), and 10/25/15 (day shift) reflected that Patient #2 had bruises. There was no evidence of nursing assessment as to origin, location, size, and coloration of the bruises.

Personnel # 3 acknowledged the above findings during an interview on 08/19/16 at 1330.

6) Patient #1's physician admission orders dated 01/21/16 at 2330 reflected the patient's admitting diagnosis of Depression.

Admission Nursing assessment dated [DATE] at 0831 reflected Patient #1 experienced generalized burning pain rated as a "10" and as the highest rating on a 1 to 10 severity scale. The patient had a medical history that included gastric ulcers and hip replacement.

The daily nurses' notes dated 01/25/16 (day shift) and 01/26/16 (night shift) did not reflect documented evidence that nursing assessed Patient #1's pain level.