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.

CROSS CREEK HOSPITAL 8402 CROSS PARK DRIVE AUSTIN, TX 78754 Dec. 28, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on interview, observation, and document review, the facility failed to ensure that a patient or legally authorized representative had the right to participate actively in the development and periodic review of an individualized treatment plan.


The facility failed to ensure that the treatment plan for Patient #1 was fully appropriate to the needs and interests of the patient as it contained an incomplete goal to restore and maintain an optimal level of physical and psychological functioning.


The facility failed to ensure that a treatment plan was reviewed when there was a significant change in a patient's condition or when clinically indicated or per facility policy.


The facility failed to ensure that the treatment plan was reviewed and effectiveness evaluated in accordance with the time frames and measures described in the treatment plan.


The facility failed to ensure that a patient was provided therapeutic activities as ordered by the physician and in the treatment plan.


The facility failed to ensure that medication consent forms were complete and the facility failed to ensure that an individual's legally authorized representative or family member was notified of each episode of restraint of a minor under [AGE] who is not or has not been married.


The facility failed to ensure a safe setting for patients that ensures protection from harm as the written staffing plan was not implemented.


The facility failed to ensure the treatment plan contained identification of the level of monitoring assigned to the patient, failed to ensure that a patient injuries and pain level were reassessed, and failed to ensure that patients on suicide and assault precautions were observed as ordered.


The facility failed to ensure documentation reflected a physician or other licensed independent practitioner or registered nurse or physician assistant who has been trained conducted a face to face evaluation within an hour of a patient that had been restrained as there was no signature time or date on the entry for the face to face in the medical record.


The facility failed to ensure that staff members who initiate involuntary interventions were current in training and demonstrated ongoing competence in CPI training. The facility failed to have a specific policy regarding CPI staff training and competency assessment, the frequency and personnel records requirements for training. The facility failed to ensure documentation in staff personnel records that the training and demonstration of competency for the restraint/seclusion training course were successfully completed.


Refer to Tags:

A0130 Patient Rights: Participation in Care Planning CFR 482.13(b)(1)

A0131 Patient Rights: Informed Consent CFR 482.13(b)(2)

A0144 Patient Rights: Care in Safe Setting CFR 482.13(c)(2)

A0178 Patient Rights: Restraint Seclusion Face-to-Face CFR 482.13(e)(12)

A0196 Patient Rights: Restraint or Seclusion CFR 482.13(f)(1)

A0208 Patient Rights: Restraint or Seclusion CFR 482.13(f)(4)
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on a review of documentation and interviews, the facility failed to ensure that a patient or legally authorized representative had the right to participate actively in the development and periodic review of an individualized treatment plan. Review of the available documentation of the dates and times of attendance of the members of the treatment team revealed that a patient and/or legally authorized representative were not provided the opportunity to participate in meetings with their multidisciplinary team to provide input into the development of the comprehensive interdisciplinary treatment plan. The documentation reflected that the members of the treatment team signed the form indicating attendance, hours to days apart, thereby indicating the patient did not actually have the benefit of providing input to the multidisciplinary treatment team, consisting of medical, nursing, social work, activity therapy, and any other disciplines as indicated. This could cause potential inadequate identification and care of patient's needs.

The facility failed to ensure that the treatment plan for Patient #1 was fully appropriate to the needs and interests of the patient as it contained an incomplete goal to restore and maintain an optimal level of physical and psychological functioning.

The facility failed to ensure that a treatment plan was reviewed when there was a significant change in a patient's condition or when clinically indicated or per facility policy. The facility failed to ensure that the treatment plan was reviewed and effectiveness evaluated in accordance with the time frames and measures described in the treatment plan. The facility failed to ensure that a patient was provided therapeutic activities as ordered by the physician and in the treatment plan.

Findings included:

Review of the treatment plan for Patient #1 revealed no documented evidence that the patient was involved in his own treatment planning. The space on the treatment plan form for "Patient's Goal in the Patient's Own Words (Quoted):" was left blank. The entire section of the treatment plan form for "Patient/Legal Representative Involvement" was left completely blank. There was no patient signature in the space provided and the options for "Refused to participate" and "Unable to participate (reason)" were left blank. There was no signature in the space for "Legal Rep. Signature (as applicable)" and options for "Refused to participate" and "Unable to participate (reason)" and "Legal representative is unable to review in person. Staff (name/cred.) ____ on (date) ____ (time) ____" were all left completely blank. There was no documented evidence that the patient or the patient's family/legally authorized representative were involved in his treatment planning as the form was left incomplete.

Review of the medical record for Patient #1 revealed that the initial treatment plan for Patient #1 was completed on 12/5/16 at 2300. The Interdisciplinary Treatment Plan was completed on 12/6/16 at 1548 by Social Services, with a nursing signature on 12/7/16 at 0657, activity therapy on 12/7/16 at 1500, and the physician signature on 12/8/16 at (what appears to be) 8:00 am. The History and Physical was conducted on 12/6/16 at 6:48 pm, and the Psychosocial Assessment was conducted on 12/7/16 at 1230. There was no documented evidence in the medical record for Patient #1 that the interdisciplinary treatment team met to discuss and plan Patient #1's treatment plan or that Patient #1 and/or his legally authorized representative were involved. The interdisciplinary treatment plan was completed before the History and Physical and the Psychosocial Assessment were conducted, therefore the information from those assessments was not available for inclusion in the Interdisciplinary Treatment Plan.

Review of the medical record for Patient #1 also revealed the treatment plan contained a goal that was not complete and directed toward restoring and maintaining optimal levels of psychological functioning. In the treatment plan, goal #2 was simply for the patient to "Verbalize specific suicidal thoughts, feelings, plans." There was no documentation or goal related to a response or behavior for Patient #1 after he verbalized suicidal thoughts, feelings, or plan; no action to take or response to take when he was suicidal. The treatment plan goals were incomplete, as the goals do not address and Patient #1 may not understand what he should do after verbalizing that he has suicidal thoughts, feelings or plans.

The above findings were confirmed in an interview with Staff #2 the afternoon of 12/28/16 in the conference room.

Patient #1 experienced a fall and hit his head after being pushed by a staff member during an aggressive incident between several patients. There was no update to the treatment plan to include interventions related to the fall and the injury to his head. Review of the Medical Record for Patient #1 revealed a nursing progress note on 12/9/16 at 1917 which stated, "Pt had altercation [with] peers in gym, he verbally expressed racial slur to other peers, who became upset and started approaching pt. Staff stepped in to prevent physical altercation, in which pt fell & his L posterior aspect of parietal region. RN assessed and found edema to area [with] superficial abrasion. Vital signs WNL BP 136/63, HR 109, RR 20, T98.9F. Neurocheck, WNL. RN gave ice pack. Pt reported 9/10 pain to back of head and L jaw. Cont. RN notified Dr., supervisor & mother of pt. Dr. ordered neurochecks Q1hr until 2100 12/9/16. Will continue to monitor for safety and head injury."

Review of the medical record revealed that Patient #1 was restrained on 12/6/16 at 1947 for attacking staff after an aggressive incident with another patient. Patient #1 experienced a restraint; there was no documented evidence that the restraint episode was addressed on the treatment plan.

Facility policy "Restraint" Number PC-043 stated, in part, "6. A practitioner or trained registered nurse shall conduct an in-person evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status ...10. The treatment plan shall be reviewed and revised following the first episode of restraint to include measures to prevent recurrence.

Review of the medical record for Patient #1 revealed the following:
The treatment plan was not updated during Patient #1's stay between 12/5/16 and 12/14/16. There were two short term goals, initiated on 12/6/16. Goal #1 was to "Create a personal safety plan". Goal #1 had a target date of 12/12. There was no documentation in the "Updated date" or "Date Resolved" area for Goal #1.

Goal #2 was to "Verbalize specific suicidal thoughts, feelings, plans." Goal #2 had a target date of 12/13. There was no documentation in the "Updated date" or "Date Resolved" area for Goal #2. Patient #1 was not discharged until 12/14/16, yet his treatment plan was not updated.

The above findings were confirmed in an interview with Staff #2 the afternoon of 12/28/16.

Review of the treatment plan in the medical record for Patient #1 revealed a treatment intervention dated 12/6/16 which stated, "AT/RT [Activity Therapist/Recreation Therapist] will facilitate groups to increase social skills, leisure education, coping skills, and leisure time." An intervention dated 12/7 for Patient #1 stated "Therapist will ... provide process groups". Per the treatment plan, treatment for Patient #1 included attending various types of group therapy.

Review of the admission orders for Patient #1 on 12/6/16 stated, in part, "Group Activity: Group Activity as tolerated and per treatment plan."

However, on 12/10/16 at 0911, Staff #8, RN, documented in the medical record for Patient #1, "pt was not allowed to participate in group this morning because of his behavior towards peers yesterday. Patient was getting frustrated that he could not go and began knocking chairs over in the dayroom. We made an agreement that if he could behave appropriately for 5 minutes then I would turn the TV on. I mentioned to him that if he behaves today, he may be able to go to groups tomorrow ... " Per this documentation, Patient #1 exhibited behaviors related to the diagnoses for which he was hospitalized , yet was penalized by the Staff #8, RN, who prevented him from participating in the very treatment (group therapy) the treatment team determined he needed for those behaviors. Instead, the RN negotiated with Patient #1 to allow him to watch TV, which was not an intervention on his treatment plan. There was no other treatment option provided for Patient #1, despite his demonstrated frustration.


In an interview with Staff #2, LPC, PI/RM the afternoon of 12/18/16 in the conference room, she confirmed that attending group therapy is one of the primary treatment modalities for patients generally at Cross Creek Hospital, and specifically for Patient #1. Staff #2 stated that the actions by the RN, Staff #8 in restricting Patient #1 from attending his group therapy, i.e., his treatment, should not have happened, or at least another form of treatment should have been provided, not watching TV. Staff #8, RN, was not available for an interview during the survey.

Review of facility Interdisciplinary Treatment Plan for Patient #5 revealed on page one of the plan that the area where the presenting psychiatric diagnosis and the medical diagnosis are to be documented was blank. Page two of the plan contained an area where the treatment team members were to sign and date the plan; this area was incomplete as the form required that treatment team members were to include the date and time when signing the master treatment plan. The area where the physician had signed on 11/28/16 had no time documented and the area where nursing and social services/therapists sign contained no date or time next to the signatures.

Review of Treatment Plan Problem Sheet for patient #5 revealed that the short term goals area was incomplete. The target date for the two short term goals which had been selected was documented as 11/28. The status and date resolved area were blank. Patient #5 had been admitted on [DATE] and discharged on 11/29/2016.

Facility policy, "Assessment/Reassessment" Number PC-008, stated, in part, Psychiatric Evaluation/Mental Status Exam Within the first twenty-four (24) hours of the patient's admission, a physician will complete the Admission Note and dictate the Psychiatric Evaluation. History and Physical. Within the first twenty-four (24) hours of the patient's admission, a practitioner will complete a history and physical examination. Nursing Assessment. A comprehensive nursing assessment is performed by a Registered Nurse within 24 hours of admission ...Psycho-Social Evaluation. The psycho-social history is obtained from the patient, family, and/or significant others by a licensed therapist and is in the patient's record within seventy-two (72) hours of the patient's admission...All admission/initial assessments will be completed prior to the development of the initial treatment plan which must be completed within 72 hours."

Facility policy "Treatment Planning" Number PC-047 stated, in part, "4.3.3 Treatment plan goals shall be modified and resolved as treatment progresses ...4.4.4 Interventions shall be modified by responsible staff throughout the course of treatment ....5.0 Treatment plan updates shall be documented at least weekly, as the physician and treatment team asses (sic) the patient's current clinical status, review progress toward treatment plan goals, and make necessary modifications ...6.0 The Treatment Plan shall be reviewed in the Multidisciplinary Treatment Team meeting. The treatment team includes the physician, unit nurse, and clinical staff ...8.0 The patient (or guardian) shall be given the opportunity to have input in the development of the Treatment Plan. This shall be accomplished by the therapist meeting with the patient and/or family member to review the recommendations of the treatment team. The therapist shall be responsible for obtaining the signature of the patient or guardian to document acknowledgement of the Treatment Plan."

Facility policy, "Documentation Protocol" Number HIM-012 stated, in part, "1. All patient medical record entries are to be: legible, completed, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, and consistent with facility policies and procedures."

The above findings were confirmed in an interview with Staff #1 the afternoon of 12/28/16 in the conference room.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of documentation and interview it was determined that the facility failed to ensure that medication consent forms were complete. The facility failed to ensure that an individual's legally authorized representative or family member was notified of each episode of restraint of a minor under [AGE] who is not or has not been married. This was not in accordance with facility policy and presents a risk for patient rights violations.

Findings were:

Facility medication consents were found to be incomplete. Review of the medical records of patient #1, #3, #4, #5, #8 and #9 revealed that medication consents were incomplete as evidenced by:

Review of the medication consents for Patient #1 revealed consent forms which were incomplete. Consent forms for Vistaril, Melatonin, and Trazadone, psychotropic medications, were dated 12/8/16 at 2100. Review of these medication consent forms revealed that consent had been obtained verbally. On the back of the consent form where the patient or the legally authorized representative was to sign, there was a handwritten "VC [name] Mom" In the area of the form where a "Physician, R.PH, Advanced Practice Professional, RN or LVN" giving explanation was to sign there was a signature from a staff member. The area below this signature contained an area where another staff member was to sign as a witness if the patient was unable or unwilling to sign or when a verbal consent is obtained. This witness area was blank on the consent, with no signature from a witness from a verbal consent.

Review of the medication administration record for Patient #1 revealed documentation that he was administered Vistaril 50 mg po PRN at 2100 on 12/7/2016, Melatonin 3 mg po PRN at 2100 on 12/7/16, and Trazodone 50 mg 1/2 tab po QHS PRN at 2100 on 12/7/16. There was no consent or education documented for Vistaril, Melatonin, and Trazodone signed for Patient #1 until 12/8/16 at 2100, the following day, consequently these psychotropic medications were administered without consent or education, including:
1) The nature of his/her mental and physical condition.
2) The expected beneficial effects on his/her condition as a result of treatment with the medication(s).
3) The probable health and mental health consequences of not taking medication, including the occurrence, increase or reoccurrence, increase of symptoms of mental illness.
4) The existence of generally accepted alternative forms of treatment, if any, that could reasonably be expected to achieve the same benefits as the medication(s) and why the physician rejects the alternative treatment.
5) A description of the proposed course of treatment with the medication(s).
6) The fact that side effects of varying degrees of severity are a risk of all medications.
7) The relevant side effects of the medication(s) being prescribed are explained, Including: (A) any side effects which are known to frequently occur in most individuals; (B) any side effects to which the individual may be predisposed; and (C) the nature and possible occurrence of the potentially irreversible symptoms of tardive dyskinesia in some individuals taking neuroleptic medication in large dosages and/or over long periods of time.
8) The need to advise staff immediately if any of these side occur.

Patient #3 had a medication consent for Seroquel; a psychiatric medication. This consent was dated: 11/24/16 at 1845 hours. Review of this medication consent form revealed that consent had been obtained verbally. On the back of the consent form where the patient or the legally authorized representative was to sign there was a handwritten "Verbal phone consent Adoptive Mom" and the name of the adoptive mother had been written in area where the legally authorized representative is documented. In the area of the form where a "Physician, R.PH, Advanced Practice Professional, RN or LVN" giving explanation was to sign there was a signature from an individual who was identified as an LVN. The area below this signature contained an area where another staff member was to sign as a witness if the patient was unable or unwilling to sign or when a verbal consent is obtained. This area was blank on the consent, with no signature from a witness although some had written in the date 11/24/2016 and the time of 1900.

Patient #4 had medication consents for three separate psychiatric medications to include: Melatonin, Trazadone and Zyprexa. All of these consents were dated: 11/25/16. No time was documented although the form contained an area for recording the time that consent was given. The front of the consent form contained 11 separate areas where: "The explanation was given to the individual in simple, non-technical language. These included:
"1) The nature of his/her mental and physical condition.
2) The expected beneficial effects on his/her condition as a result of treatment with the medication(s).
3) The probable health and mental health consequences of not taking medication, including the occurrence, increase or reoccurrence, increase of symptoms of mental illness.
4) The existence of generally accepted alternative forms of treatment, if any, that could reasonably be expected to achieve the same benefits as the medication(s) and why the physician rejects the alternative treatment.
5) A description of the proposed course of treatment with the medication(s).
6) The fact that side effects of varying degrees of severity are a risk of all medications.
7) The relevant side effects of the medication(s) being prescribed are explained, Including: (A) any side effects which are known to frequently occur in most individuals; (B) any side effects to which the individual may be predisposed; and (C) the nature and possible occurrence of the potentially irreversible symptoms of tardive dyskinesia in some individuals taking neuroleptic medication in large dosages and/or over long periods of time.
8) The need to advise staff immediately if any of these side occur.
9) Not on Court-Ordered Medications: Individual may withdraw consent at any time without negative action on part of the staff. On Court-Ordered Medications: Individual may not withdraw consent or refuse medications.
10) A review of Patient's Right's Under the Consent to Treatment with Psychoactive Medication rule (See MHRS 9-7.1).
11) An offer to answer any questions concerning this treatment." To the right of these items was an area which contained the statement: "Indicate Accomplishment by a check mark". Items 1-11 on all three of these medication consents were found to be blank with no check mark indicating that the patient or their legally authorized representative had been informed of any items. Additionally the bottom of each of the three consent forms contained the statement: I have received a complete explanation of the psychoactive medications(s) by means of: (Circle those appropriate) oral explanation, video presentation, printed material, other_____________ (specify). This area was found to be blank as none of the response choices had been selected on any of three consent forms.

Patient #5 had a medication consents for Prozac and Risperidone; psychiatric medications. These consents were dated: 11/30/16 at 1150 hours. Review of this medication consent form revealed that consent had been obtained verbally. On the back of the consent form where the patient or the legally authorized representative was to sign there was a handwritten "VC" and the name of the patient's mother had been written in area where the legally authorized representative is documented. In the area of the form where a "Physician, R.PH, Advanced Practice Professional, RN or LVN" giving explanation was to sign there was a signature from an individual which was not legible and no credential was documented as to whether the signature belonged to an RN or LVN. The area below this signature contained an area where another staff member was to sign as a witness if the patient was unable or unwilling to sign or when a verbal consent is obtained. This area was blank on the consent, with no signature from a witness.

Patient #8 had medication consent for seven separate psychiatric medications to include: Vistaril, Melatonin, Trazodone, Concerta, Depakote, Seroquel, and Trileptal. All of these consents were dated: 12/22/2016 at 2000 hours. The front of the consent form contained 11 separate areas where: "The explanation was given to the individual in simple, non-technical language. The first five of these areas were:
"1) The nature of his/her mental and physical condition.
2) The expected beneficial effects on his/her condition as a result of treatment with the medication(s).
3) The probable health and mental health consequences of not taking medication, including the occurrence, increase or reoccurrence, increase of symptoms of mental illness.
4) The existence of generally accepted alternative forms of treatment, if any, that could reasonably be expected to achieve the same benefits as the medication(s) and why the physician rejects the alternative treatment.
5) A description of the proposed course of treatment with the medication(s)." To the right of these items was an area which contained the statement: "Indicate Accomplishment by a check mark". Items 1-5 on all of these medication consents were found to be blank with no check mark indicating that the patient or their legally authorized representative had been informed of these of these items.

Review of these seven medication consent forms for Patient #8 revealed that consent had been obtained verbally. On the back of each consent form where the patient or the legally authorized representative was to sign there was a handwritten "VC" and the mother of the patient was listed as the legally authorized representative. In the area of the form where a "Physician, R.PH, Advanced Practice Professional, RN or LVN" giving explanation was to sign there was a signature from an individual who was identified as an RN. The area below this signature contained an area where another staff member was to sign as a witness if the patient was unable or unwilling to sign or when a verbal consent is obtained. This area was blank on each of the seven medication consents, with no signature from a witness. Below the witness area was another area where a confirmation signature of the treating physician was to be documented. This area stated: "Confirmation Signature of Treating Physician to confirm explanation given by R.Ph, Advanced Practice Professional, RN or LVN (is required within two working days of R.PH, Advanced Practice Professional, RN or LVN giving explanation)." On each of these seven consent forms this area was blank with no signature of a treating physician.

Patient #9 had medication consent for multiple psychiatric medications to include: Ativan, Haldol, Trileptal, Clonidine, Geodon, Trazodone, and Ambien. The consents for Clonidine, Geodon, Trazodone, Ambien and Vistaril dated 11/24/2016 at 11:24. Review of these medication consent forms revealed that consent had been obtained telephonically. On the back of each consent form where the patient or the legally authorized representative was to sign there was a handwritten "telephone consent" and the name of a legally authorized representative had been written in. The area of the form where a "Physician, R.PH, Advanced Practice Professional, RN or LVN" giving explanation was to sign did not contain a signature but there was a signature documented in the area below where the witness was to sign in case of a verbal consent. Additionally medication consent forms were found for Ativan and Haldol, both psychiatric medications. The date/time on these consents was 12/8/2016 at 1400 hours. On the back of the consent forms was the name of an individual identified as "caseworker" and next to this individuals name was the abbreviation: "TO". A staff member identified as an RN had signed in the area of the form where a "Physician, R.PH, Advanced Practice Professional, RN or LVN" giving explanation was to sign. The area below this signature contained an area where another staff member was to sign as a witness if the patient was unable or unwilling to sign or when a verbal consent is obtained. This area was blank on each of the seven medication consents, with no signature from a witness.

Review of facility policy, "Documentation Protocol" Number HIM-012 stated, in part, "1. All patient medical record entries are to be: legible, completed, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, and consistent with facility policies and procedures."

Facility policy, "Informed Consent, Medication" Number MM 1205 stated, in part, "Informed consent will be secured prior to the initial dose of medication except in an emergency situation. It is the responsibility of the ordering practitioner to obtain the signed informed consent of the patient and/or legal representative using the MHRS 9-7 form ...Informed consent will be documented on the Medication Consent form."

In an interviews with staff member #2, the facility Process Improvement/Risk Manager at various times on the afternoon of 12/28/2016 it was confirmed that medication consent forms were incomplete.

Facility policy "Restraint" Number PC-043 stated, in part, "9. The legal representative or an immediate family member as requested by the patient shall be promptly notified of the restraint."

Review of the medical record revealed that Patient #1, a [AGE] year old male was restrained on 12/6/16 at 1947 for attacking staff after an aggressive incident with another patient. There was no documentation in the medical record that the mother or legally authorized representative of Patient #1 was notified.

Review of the medical record revealed that Patient #9, a [AGE] year old female was restrained on 12/3/16 at 1848 after an aggressive incident with another patient. There was no documentation in the medical record that the parent or legally authorized representative of Patient #9 was notified.

The above findings were confirmed in an interview with Staff #2 the afternoon of 12/28/16 in the conference room.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of documentation and interview, the facility failed to ensure a safe setting for patients that ensures protection from harm as the written staffing plan was not implemented.


There were 12-15 adolescent patients with one staff member in the gym when a patient was injured. The staffing was not incompliance with the facility staffing plan. A staff member was not current in CPI training and used an unapproved technique of pushing a patient which resulted in an injury to the head. The staff member worked 16 shifts with patients even though his training was not current. Patients on suicide and assault precautions were not monitored at the level ordered by the physician. A patient was not reassessed after sustaining an injury to the head and jaw.


The facility failed to ensure the treatment plan contained identification of the level of monitoring assigned to the patient, and failed to ensure that a patient injuries and pain level were reassessed.


Findings included:


Staff #3, TCS (therapeutic care specialist), was interviewed on the afternoon of 12/28/2016. He stated that he was working with a female tech for approximately 12-15 adolescent boys and girls and they were all in the gym on 12/9/16. Staff #3 stated that he left the 12-15 patients with the tech in the gym alone while he went to the restroom. After he left the gym, Staff #3 stated that he was called back to the gym by his coworker. Upon arrival to the gym, there were 12-15 adolescent patients and still only the one other staff member present. Staff #3 recalled that other patients were going after Patient #1 who had verbalized racial slurs and was antagonizing his peers. Staff #3 commented that at one point there were 6 patients charging and he had to use "proximity" to separate them from Patient #1. Staff #3 also described that after that, Patient #1 had fallen backwards and hit his head and as a result had a little knot on his head and that the nurse did vital signs and iced the bump.


Review of the Medical Record for Patient #1 revealed a nursing progress note on 12/9/16 at 1917 which stated, "Pt had altercation [with] peers in gym, he verbally expressed racial slur to other peers, who became upset and started approaching pt. Staff stepped in to prevent physical altercation, in which pt fell & his L posterior aspect of parietal region. One RN assessed and found edema to area [with] superficial abrasion. Vital signs WNL BP 136/63, HR 109, RR 20, T98.9F. Neurocheck, WNL. RN gave ice pack. Pt reported 9/10 pain to back of head and L jaw. Cont. RN notified Dr., supervisor & mother of pt. Dr. ordered neurochecks Q1hr until 2100 12/9/16. Will continue to monitor for safety and head injury."


Review of facility internal report dated 9 December, 2016 which was provided to the survey team for review stated: "On the day of December 9, 2016 patient [Patient #1] was in the gym doing recreation [Patient #1] began to hit his peers with a paddle in the gym swinging the paddle and cursing at them calling them [racial slur] I'll kill you to all his male peers. When I arrived in the gym [Patient #1] was calling his peers racial slurs and swinging paddle. [Patient #1] peer was chasing him I then get in the middle of [Patient #1] and 4 of his peers, trying to keep them from assaulting one another I pushed his peers and [Patient #1] from making contact patient [Patient #1] slipped and fell and bumped his head on the floor." This statement had been hand written and signed by Staff #3, whose title was listed as: "Lead Tech". Review of page two of this document revealed that Patient #1 had sustained an injury (abrasion to head) as a result of the fall, documented as "Abrasion to L [left] posterior parietal region of head, surface blood; slight edema [with] bump."


There was no documentation in the medical record for Patient #1 that the jaw pain or the head pain, rated at a level of 9/10 was monitored or further assessed. There was no further documentation of a re-assessment of the jaw pain, head abrasion, bleeding, edema or "bump" on the head or the client's pain level in the progress notes by the nurse. Review of the nursing documentation for the following day, 12/10/16 revealed no assessment of Patient #1's jaw pain, head pain, head abrasion, edema or "bump" on his head.


Review of the nurse staffing plan revealed that for 12-15 patients, there should be two techs or Therapeutic Care Specialists. During the time that Staff #3 was absent on 12/9/16 and when the patients' behavior began to escalate, there were no other techs present for the 12-15 patients. That the gym was not staffed appropriately with at least 2 techs for 12-15 patients was confirmed in an interview with Staff #1 and Staff #2 the afternoon of 12/28/16.


Facility document, "Nurse Staffing Plan" stated in part, "Policy 1. For a census of 1-9, there will be one licensed nurse and two Therapeutic Care Specialist assigned. When the census reaches 15, one licensed nurse will be added." indicating that for a census of 15, there would be two licensed nurses and two Therapeutic care Specialists. Facility document entitled, "Staffing Matrix (Adult Unit)" was provided to the surveyors with the Nurse Staffing Plan. Staff #1, CNO stated that the Adult unit staffing matrix was the same for the adolescent unit and wrote and signed on the document, "Ratio is the same for Adolescent Staff #1, [name] CNO." The matrix revealed that for a census of 10-14 patients, two Therapeutic Care Specialists were required.


Facility policy, "Assignment of Nursing Staff" Number NU-001 stated, in part, "To assure quality nursing care and a safe patient environment, nursing personnel staffing and assignments are based on at least the following: A registered nurse plans, supervises and evaluates the nursing care of each patient ...Patient care assignment is based on acuity and equally distributed among staff."


In an interview with Staff #4, therapeutic care specialist/facility CPI instructor, on the afternoon of 12/28/2016 the survey team was informed that there are no approved CPI techniques which involve pushing a patient. Staff #4 also commented that hands on techniques are a last resort and that pushing of a patient is not condoned in any way by the hospital. Staff #4 also added that staff are not supposed to be working after CPI certification expires.


In an interview with Staff #1, the facility Chief Nursing Officer on the afternoon of 12/28/2016 the survey team was informed that Staff #3 had worked on dates other than just 12/27/2016.


Review of facility staffing schedules for December, 2016 revealed that Staff #3 was listed on the schedule for the following dates:

Monday, December 5 on Unit B from 7a-3p.
Tuesday, December 6 on Unit B from 7a-3p.
Wednesday, December 7 on unit B from 3p-11p.
Thursday, December 8 on Unit B from 3p-11p
Friday, December 9 on Unit B from 3p-11p
Monday, December 12 on Unit B from 7a-3p
Tuesday, December 13 on Unit B from 3p-11p
Wednesday, December 14 on Unit B from 3p-11p
Thursday, December 15 on Unit B from 3p-11p
Monday, December 19 on Unit B from 3p-11p
Tuesday, December 20 on Unit B from 3p-11p
Wednesday, December 21 on Unit B from 3p-11p
Thursday, December 22 on Unit B from 7a-3p
Friday, December 23 on Unit B from 3p-11p
Monday, December 26 on Unit B from 3p-11p


Additionally Staff #3 had also been scheduled to work on Wednesday, 28 December 2016 (the day of the complaint survey) but was sent home by the facility and did not work. Staff #1 confirmed that Staff #3 worked the above dates, despite having expired CPI certification.


In an interview with Staff #2, the facility process improvement/risk manager on the afternoon of 12/28/2016 the survey team was informed that facility staff should not be working on a unit if CPI is expired.


Review of the personnel folder for Staff #3, Therapeutic Care Specialist, was found to have expired training related to nonviolent crisis intervention techniques. Staff #3 was also found to have worked on a patient unit on multiple occasions as direct care staff even after training had expired. Staff #3 was also found to have engaged in an unapproved physical intervention technique on December 9, 2016 which resulted in injury to Patient #1.


Review of the "CPI blue card" (nonviolent crisis intervention) completion card found in the personnel file for Staff #3, revealed that this individual had completed 8 hours of training in the nonviolent crisis intervention program. The card was issued on 12/2/15 and expired on [DATE]. Review of a "CPI" Participant Workbook used by the facility and provided to the survey team for review; revealed on page 1: "Throughout the course, you will learn a range of preventative strategies, de-escalation skills, and communication techniques. You will also learn psychological and psychological responses that minimize the potential harm of disruptive and aggressive behavior."


Review of facility staff roster for "Cert NonvCrisis Intervent" time stamped 1:17:31PM which was provided to the survey team revealed that Staff #3 had received Nonviolent Crisis Intervention training on 12/02/2015. The renewal date was listed as 12/02/2016.


Review of facility "Orientation Checklist - New Employee Orientation" found in the personnel file of Staff #3 revealed that there were no documented dates for current training on: "Age -Specific Competencies, Safety Training, CPI training, Treatment Models" or "Customer Service".


Facility policy, "Assignment of Nursing Staff" Number NU-001 stated, in part, "To assure quality nursing care and a safe patient environment, nursing personnel staffing and assignments are based on at least the following: A registered nurse plans, supervises and evaluates the nursing care of each patient ...Patient care assignment is based on acuity and equally distributed among staff."


Facility policy, "Fall Prevention and Monitoring" Number PC-027 stated, in part, "3. In the event of a patient fall, nursing staff will: ...d. Document the clinically pertinent information in the patient's medical record, including a description of the fall, the patient status/vital signs/injuries, and the follow-up."


Facility policy, "Licensure & Certification Policy" Number HR910.20 stated, in part, "It is the policy of Cross Creek Hospital that no staff member, including contract staff, shall be allowed to work without evidence of current licensure and / or certification, if such is required for the position ....3.3 At the beginning of each month, Human Resources will send a notice to the supervisor, and to the affected employee, of licenses / certifications that are due to expire the following month. 3.3.1 If an employee's licensure / certification is expired, Human Resources shall notify the supervisor the day following expiration. The supervisor shall then be responsible for placing the employee of Administrative Leave without pay until such time as renewal is obtained."


The above findings were confirmed in an interview the afternoon of 12/28/16 with Staff #2 in the conference room.


Review of the "Patient Observations" sheet for Patient #1 revealed that he had observation checks ordered for every 15 minutes for suicide and assault precautions. However, on 12/9/16, there was documentation that he was observed/checked at 0615, but no documentation that he was observed/checked again until 0700. That he was not observed for 45 minutes presents a safety risk for Patient #1 and for other patients and staff in the unit due to his suicidality and aggressiveness.


Review of the medical record for Patient #9 "Patient Observations" sheet revealed that she had observation checks ordered for every 15 minutes for assault precautions. However, on 12/9/16, there was documentation that she was observed/checked at 0615, but no documentation that he was observed/checked again until 0700. That she was not observed for 45 minutes presents a safety risk for Patient #9 and for other patients and staff in the unit due to her aggressiveness.


Facility policy, "Observations, Patient" Number PC-032 stated, in part, "Documentation of Observations. Staff documents all levels of observation on each patient's observation form which becomes a part of the patient record. Each entry is to include the following ...Level of observation, Precaution, Location, Behavior, Activity, Time, Staff Initial and Signature ...Documentation of Line of Sigh of 1:1 observation occurs q 15 minutes even though the patient is being observed continuously ...All patients are monitored at minimum once in every 15 minutes block of time."


The above findings were confirmed in an interview with Staff #1 the afternoon of 12/28/16 in the conference room.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
Based on review of documentation and interview, the facility failed to ensure documentation reflected a physician or other licensed independent practitioner or registered nurse or physician assistant who has been trained conduct a face to face evaluation within an hour of a patient that had been restrained as there was no signature, time or date on the entry for the face-to-face in the medical record.


Findings included:


Review of the medical record revealed that Patient #1 was restrained on 12/6/16 at 1947 for attacking staff after an aggressive incident with another patient. There was no practitioner signature, date, or time for the "In-Person Evaluation By Practitioner/RN" after the "evaluation of the patient's immediate situation."


Facility policy "Restraint" Number PC-043 stated, in part, "6. A practitioner or trained registered nurse shall conduct an in-person evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status."


Facility policy, "Documentation Protocol" Number HIM-012 stated, in part, "1. All patient medical record entries are to be: legible, completed, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, and consistent with facility policies and procedures."


The above findings were confirmed in an interview with Staff #1 the afternoon of 12/28/16 in the conference room.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of documentation and interviews, the facility failed to ensure that staff members who initiate involuntary interventions were current in training and demonstrate ongoing competence in CPI training, the facility's approved course for applying knowledge and effective use of communication strategies and a range of early intervention, de-escalation, mediation, problem-solving, and other non-physical interventions, such as clinical timeout and quiet time. The facility failed to have a specific policy regarding CPI staff training and competency assessment, the training intervals and personnel records requirements for training.


Findings included:


Review of the personnel folder for Staff #3, Therapeutic Care Specialist, was found to have expired training related to nonviolent crisis intervention techniques, including the application of personal restraint. Staff #3 was also found to have worked on a patient unit on multiple occasions as direct care staff even after training had expired. Staff #3 was also found to have engaged in an unapproved physical intervention technique on December 9, 2016 which resulted in injury to Patient #1.


Review of the "CPI blue card" (nonviolent crisis intervention) completion card found in the personnel file for Staff #3, revealed that this individual had completed 8 hours of training in the nonviolent crisis intervention program. The card was issued on 12/2/15 and expired on [DATE]. Review of a "CPI" Participant Workbook used by the facility and provided to the survey team for review; revealed on page 1: "Throughout the course, you will learn a range of preventative strategies, de-escalation skills, and communication techniques. You will also learn psychological and psychological responses that minimize the potential harm of disruptive and aggressive behavior."


Review of facility staff roster for "Cert NonvCrisis Intervent" time stamped 1:17:31PM which was provided to the survey team revealed that Staff #3 had received Nonviolent Crisis Intervention training on 12/02/2015. The renewal date was listed as 12/02/2016.


Review of facility "Orientation Checklist - New Employee Orientation" found in the personnel file of Staff #3 revealed that there was no documented dates for current training on: "Age -Specific Competencies, Safety Training, CPI training, Treatment Models".


Staff #3, TCS (therapeutic care specialist), was interviewed on the afternoon of 12/28/2016. Staff #3 informed the survey team that he was aware his CPI had expired. When asked if he had worked with expired CPI, he stated that he had only worked yesterday (12/27/2016) since the CPI expired. Staff #3 was involved in an involuntary intervention with a patient the afternoon of 12/9/16, however instead of using approved CPI techniques to intervene, Staff #3 documented that he "pushed" a patient, which resulted in the patient falling to the floor and sustaining an injury to the head.


In an interview with Staff #4, TCS (therapeutic care specialist), and the facility CPI instructor on the afternoon of 12/28/2016, the survey team was informed that there are no approved CPI techniques which involve pushing a patient. Staff #4 also commented that hands on techniques are a last resort and that pushing of a patient is not condoned in any way by the hospital. Staff #4 also added that staff are not supposed to be working after CPI certification expires.


In an interview with Staff #1, the facility Chief Nursing Officer on the afternoon of 12/28/2016 the survey team was informed that Staff #3 had worked on dates other than just 12/27/2016.


Review of facility staffing schedules for December, 2016 revealed that Staff #3 was listed on the schedule for the following dates:

Monday, December 5 on Unit B from 7a-3p.
Tuesday, December 6 on Unit B from 7a-3p.
Wednesday, December 7 on unit B from 3p-11p.
Thursday, December 8 on Unit B from 3p-11p
Friday, December 9 on Unit B from 3p-11p
Monday, December 12 on Unit B from 7a-3p
Tuesday, December 13 on Unit B from 3p-11p
Wednesday, December 14 on Unit B from 3p-11p
Thursday, December 15 on Unit B from 3p-11p
Monday, December 19 on Unit B from 3p-11p
Tuesday, December 20 on Unit B from 3p-11p
Wednesday, December 21 on Unit B from 3p-11p
Thursday, December 22 on Unit B from 7a-3p
Friday, December 23 on Unit B from 3p-11p
Monday, December 26 on Unit B from 3p-11p


Additionally Staff #3 had also been scheduled to work on Wednesday, 28 December 2016 (the day of the complaint survey) but was sent home by the facility and did not work. Staff #1 confirmed that Staff #3 worked the above dates, despite having expired CPI certification.


Facility policy, "Licensure & Certification Policy" Number HR910.20 stated, in part, "It is the policy of Cross Creek Hospital that no staff member, including contract staff, shall be allowed to work without evidence of current licensure and / or certification, if such is required for the position ....3.3 At the beginning of each month, Human Resources will send a notice to the supervisor, and to the affected employee, of licenses / certifications that are due to expire the following month. 3.3.1 If an employee's licensure / certification is expired, Human Resources shall notify the supervisor the day following expiration. The supervisor shall then be responsible for placing the employee of Administrative Leave without pay until such time as renewal is obtained."


The survey team requested a policy regarding CPI from four separate people the afternoon of 12/28/16, including the HR Director, the Chief Nursing Officer, the CPI Instructor and the PI/RM Director, but was told by Staff #7, #1, #2, and #4 that the facility did not have a specific policy regarding CPI staff training, competency assessment and training intervals requirement for training. No policy was found by or provided to the survey team.


In an interview with Staff #2, the facility process improvement/risk manager on the afternoon of 12/28/2016 the survey team was informed that facility staff should not be working on a unit if CPI is expired.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0208
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of documentation and interviews, the facility failed to ensure documentation in staff personnel records that the training and demonstration of competency for the restraint/seclusion training course, CPI, were successfully completed. The facility failed to have a specific policy regarding CPI staff training and competency assessment, the frequency and personnel records requirements for training.


Findings included:


Review of the personnel folder for Staff #3, Therapeutic Care Specialist, contained an expired training related to nonviolent crisis intervention techniques, including the application of personal restraint. Staff #3 was also found to have worked on a patient unit on multiple occasions as direct care staff even after training had expired.


Review of the "CPI blue card" (nonviolent crisis intervention) completion card found in the personnel file for Staff #3, revealed that this individual had completed 8 hours of training in the nonviolent crisis intervention program. The card was issued on 12/2/15 and expired on [DATE].


Review of a "CPI" Participant Workbook used by the facility and provided to the survey team for review; revealed on page 1: "Throughout the course, you will learn a range of preventative strategies, de-escalation skills, and communication techniques. You will also learn psychological and psychological responses that minimize the potential harm of disruptive and aggressive behavior."


Review of facility staff roster for "Cert NonvCrisis Intervent" time stamped 1:17:31 PM which was provided to the survey team revealed that Staff #3 had received Nonviolent Crisis Intervention training on 12/02/2015. The renewal date was listed as 12/02/2016.


Review of facility "Orientation Checklist - New Employee Orientation" found in the personnel file of Staff #3 revealed that there was no documented dates for current training on: "Age -Specific Competencies, Safety Training, CPI training, Treatment Models".


Staff #3, TCS (therapeutic care specialist), was interviewd on the afternoon of 12/28/2016. Staff #3 informed the survey team that he was aware his CPI had expired. When asked if he had worked with expired CPI, he stated that he had only worked yesterday (12/27/2016) since the CPI expired.


Facility policy, "Licensure & Certification Policy" Number HR910.20 stated, in part, "It is the policy of Cross Creek Hospital that no staff member, including contract staff, shall be allowed to work without evidence of current licensure and / or certification, if such is required for the position ....3.3 At the beginning of each month, Human Resources will send a notice to the supervisor, and to the affected employee, of licenses / certifications that are due to expire the following month. 3.3.1 If an employee's licensure / certification is expired, Human Resources shall notify the supervisor the day following expiration. The supervisor shall then be responsible for placing the employee of Administrative Leave without pay until such time as renewal is obtained."


The survey team requested a policy regarding CPI from four separate people on the afternoon of 12/28/16, including the HR Director, the Chief Nursing Officer, the CPI Instructor and the PI/RM Director, but was told by Staff #7, #1, #2, and #4 that the facility did not have a specific policy regarding CPI staff training and competency assessment, the frequency and personnel records requirements for training. No policy was found by or provided to the survey team.


In an interview with Staff #2, the facility process improvement/risk manager, on the afternoon of 12/28/2016, the survey team was informed that facility staff should not be working on a unit if CPI is expired.
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review, the facility failed to include relevant patient safety issues in the Quality Assessment Process Improvement. The facility failed to ensure that staff members who initiate involuntary interventions were current in training and demonstrate ongoing competence in applying knowledge and effective use of communication strategies and a range of early intervention, de-escalation, mediation, problem-solving, and other non-physical interventions.


One staff member, providing direct patient care, was delinquent in required training of the facility's designated course, CPI, and engaged in an unapproved physical intervention technique and the patient was injured. The Human Resource Department confirmed that the staff member was known to be delinquent in CPI training. The facility failed to have a specific policy regarding CPI staff training and competency assessment, the frequency and personnel records requirements for training.


Findings included:


Review of the personnel folder for Staff #3, Therapeutic Care Specialist, contained an expired CPI training related to nonviolent crisis intervention techniques, including the application of personal restraint. Staff #3 was also found to have worked on a patient unit on multiple occasions as direct care staff even after training had expired. Staff #3 was also found to have engaged in an unapproved physical intervention technique on December 9, 2016 which resulted in injury to Patient #1.


In an interview with Staff #7, Human Resources Director, on the afternoon of 12/28/16, she confirmed that Staff #3 was delinquent in CPI training, that he should have taken it on or by 12/2/16. Staff #7 stated that she maintains a list of staff training due and provided it to the departments. The staff then take the training with the next class.


Review of the "CPI blue card" (nonviolent crisis intervention) completion card found in the personnel file for Staff #3, revealed that this individual had completed 8 hours of training in the nonviolent crisis intervention program. The card was issued on 12/2/15 and expired on [DATE]. Review of a "CPI" Participant Workbook used by the facility and provided to the survey team for review; revealed on page 1: "Throughout the course, you will learn a range of preventative strategies, de-escalation skills, and communication techniques. You will also learn psychological and psychological responses that minimize the potential harm of disruptive and aggressive behavior."


Review of facility staff roster for "Cert NonvCrisis Intervent" time stamped 1:17:31PM which was provided to the survey team revealed that Staff #3 had received Nonviolent Crisis Intervention training on 12/02/2015. The renewal date was listed as 12/02/2016.


Review of facility "Orientation Checklist - New Employee Orientation" found in the personnel file of Staff #3 revealed that there was no documented dates for current training on: "Age -Specific Competencies, Safety Training, CPI training, Treatment Models".


In an interview with Staff #3, TCS (therapeutic care specialist) on the afternoon of 12/28/2016, Staff #3 informed the survey team that he was aware his CPI had expired. When asked if he had worked with expired CPI, he stated that he had only worked yesterday (12/27/2016) since the CPI expired. Staff #3 was involved in an involuntary intervention with a patient the afternoon of 12/9/16, however instead of using approved CPI techniques to intervene, Staff #3 documented that he "pushed" a patient, which resulted in the patient falling to the floor and sustaining an injury to the head.


In an interview with Staff #4, TCS (therapeutic care specialist), and the facility CPI instructor on the afternoon of 12/28/2016 the survey team was informed that there are no approved CPI techniques which involve pushing a patient. Staff #4 also commented that hands on techniques are a last resort and that pushing of a patient is not condoned in any way by the hospital. Staff #4 also added that staff are not supposed to be working after CPI certification expires.


In an interview with Staff #1, the facility Chief Nursing Officer, on the afternoon of 12/28/2016 the survey team was informed that Staff #3 had worked on dates other than just 12/27/2016.


Review of facility staffing schedules for December, 2016 revealed that Staff #3 was listed on the schedule for the following dates:

Monday, December 5 on Unit B from 7a-3p.
Tuesday, December 6 on Unit B from 7a-3p.
Wednesday, December 7 on unit B from 3p-11p.
Thursday, December 8 on Unit B from 3p-11p
Friday, December 9 on Unit B from 3p-11p
Monday, December 12 on Unit B from 7a-3p
Tuesday, December 13 on Unit B from 3p-11p
Wednesday, December 14 on Unit B from 3p-11p
Thursday, December 15 on Unit B from 3p-11p
Monday, December 19 on Unit B from 3p-11p
Tuesday, December 20 on Unit B from 3p-11p
Wednesday, December 21 on Unit B from 3p-11p
Thursday, December 22 on Unit B from 7a-3p
Friday, December 23 on Unit B from 3p-11p
Monday, December 26 on Unit B from 3p-11p


Additionally, Staff #3 had also been scheduled to work on Wednesday, 28 December 2016 (the day of the complaint survey) but was sent home by the facility and did not work. Staff #1 confirmed that Staff #3 worked the above dates, despite having expired CPI certification.


Facility policy, "Licensure & Certification Policy" Number HR910.20 stated, in part, "It is the policy of Cross Creek Hospital that no staff member, including contract staff, shall be allowed to work without evidence of current licensure and / or certification, if such is required for the position ....3.3 At the beginning of each month, Human Resources will send a notice to the supervisor, and to the affected employee, of licenses / certifications that are due to expire the following month. 3.3.1 If an employee's licensure / certification is expired, Human Resources shall notify the supervisor the day following expiration. The supervisor shall then be responsible for placing the employee of Administrative Leave without pay until such time as renewal is obtained."


The survey team requested a policy regarding CPI from four separate people the afternoon of 12/28/16, including the HR Director, the Chief Nursing Officer, the CPI Instructor and the PI/RM Director, but was told by Staff #7, #1, #2, and #4 that the facility did not have a specific policy regarding CPI staff training, competency assessment and frequency requirement for training. No policy was found by or provided to the survey team.


Cross Creek Hospital Perfomance (sic) Improvement Committee meeting minutes were reviewed for 10/27/16, 11/22/16, and 12/27/16. The meetings included review of safety indicators, such as falls, seclusions, and restraints, and quality indicators, such as treatment planning. There was no review of delinquent CPI training in the minutes reviewed for Staff #3.


In an interview with Staff #2, the facility process improvement/risk manager, on the afternoon of 12/28/2016, the survey team was informed that facility staff should not be working on a unit if CPI is expired.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on a review of documentation, observation, and interview, the hospital failed to:

1. ensure that current standards of nursing were followed;

2. failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient as patients on suicide and assault precautions were protected by nursing staff monitoring the patient at the level of monitoring most recently specified in the patient's medical record;

3. reassess a patient based on the patient's needs and acuity by an RN;

4. ensure that a patient was provided therapeutic activities as ordered by the physician and determined in the treatment plan;

5. ensure that vital signs were monitored and documented as ordered;

6. ensure that the written staffing plan was implemented;

7. ensure that documentation reflected current standards of practice in medication administration.


Cross refer to Tags:

A0386 Organization of Nursing Services CFR 482.23(a)
A0392 Staffing and Delivery of Care CFR 482.23(b)
A0395 RN Supervision of Nursing Care CFR 482.23(b)(3)
A0405 Administration of Drugs CFR 482.23(c)(1), (c)(1)(i) & (c)(2)
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on record review and interview, the facility failed to ensure that patients on suicide and assault precautions were not protected by nursing staff because patients were not monitored at the level specified in the patient's medical record.


Findings included:


Review of the medical record for Patient #1 "Patient Observations" sheet revealed that he had observation checks ordered for every 15 minutes for suicide and assault precautions. However, on 12/9/16, there was documentation that he was observed/checked at 0615, but no documentation that he was observed/checked again until 0700. That he was not observed for 45 minutes presents a safety risk for Patient #1 and for other patients and staff in the unit due to his suicidality and aggressiveness.


Review of the medical record for Patient #9 "Patient Observations" sheet revealed that she had observation checks ordered for every 15 minutes for assault precautions. However, on 12/9/16, there was documentation that she was observed/checked at 0615, but no documentation that he was observed/checked again until 0700. That she was not observed for 45 minutes presents a safety risk for Patient #9 and for other patients and staff in the unit due to her aggressiveness.


The above findings were confirmed in an interview with Staff #2 on the afternoon of 12/28/16 in the conference room.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on review of documentation and interview, the facility failed to ensure that the written staffing plan was implemented. ON 12/28/2016, there were 12-15 adolescent patients with one staff member in the gym which was not incompliance with the facility staffing plan, a patient was injured.


Findings included:


In an interview with Staff #3, TCS (therapeutic care specialist), on the afternoon of 12/28/2016, he stated that he was working with a female tech for approximately 12-15 adolescent boys and girls and they were all in the gym, the patients and the two techs. Staff #3 stated that he left the 12-15 patients with the tech in the gym alone while he went to the restroom. After he left the gym, Staff #3 stated that he was called back to the gym by his coworker. Upon arrival to the gym, there were 12-15 adolescent patients and still only the one other staff member present. Staff #3 recalled that other patients were going after Patient #1 who had verbalized racial slurs and was antagonizing his peers. Staff #3 commented that at one point there were 6 patients charging and he had to use "proximity" to separate them from Patient #1. Staff #3 also described that after that, Patient #1 had then fallen backwards and hit his head and as a result had a little knot on his head and that the nurse did vital signs and iced the bump.


Review of the Medical Record for Patient #1 revealed a nursing progress note on 12/9/16 at 1917 which stated, "Pt had altercation [with] peers in gym, he verbally expressed racial slur to other peers, who became upset and started approaching pt. Staff stepped in to prevent physical altercation, in which pt fell & his po L posterior aspect of parietal region."


Review of the nurse staffing plan (see below) revealed that for 12-15 patients, there should be two techs or Therapeutic Care Specialists. During the time that Staff #3 was absent and when the patients' behavior began to escalate, there were no other techs present for the 12-15 patients. The gym was not staffed appropriately for 12-15 patients was confirmed in an interview with Staff #1 and Staff #2 the afternoon of 12/28/16.


Facility document, "Nurse Staffing Plan" stated in part, "Policy 1. For a census of 1-9, there will be one licensed nurse and two Therapeutic Care Specialist assigned. When the census reaches 15, one licensed nurse will be added." Indicating that for a census of 15, there would be two licensed nurses and two Therapeutic care Specialists. Facility document entitled, "Staffing Matrix (Adult Unit)" was provided to the surveyors with the Nurse Staffing Plan. Staff #1, CNO stated that the Adult unit staffing matrix was the same for the adolescent unit and wrote on the document, "Ratio is the same for Adolescent Staff #1, CNO." The matrix revealed that for a census of 10-14 patients, two Therapeutic Care Specialists were required.


Facility policy, "Assignment of Nursing Staff" Number NU-001 stated, in part, "To assure quality nursing care and a safe patient environment, nursing personnel staffing and assignments are based on at least the following: A registered nurse plans, supervises and evaluates the nursing care of each patient ...Patient care assignment is based on acuity and equally distributed among staff."


The above findings were confirmed in an interview with Staff #1 the afternoon of 12/28/16 in the conference room.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on record review and interview, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient in accordance with current standards of practice. An RN failed to reassess a patient based on the patient's needs and acuity, failed to ensure that a patient was provided therapeutic activities as ordered by the physician and determined in the treatment plan, and failed to ensure that vital signs were monitored and documented as ordered.


Findings included:


Facility policy, "Assignment of Nursing Staff" Number NU-001 stated, in part, "To assure quality nursing care and a safe patient environment, nursing personnel staffing and assignments are based on at least the following: A registered nurse plans, supervises and evaluates the nursing care of each patient ...Patient care assignment is based on acuity and equally distributed among staff."


Review of the Medical Record for Patient #1 revealed a nursing progress note on 12/9/16 at 1917 which stated, "Pt had altercation [with] peers in gym, he verbally expressed racial slur to other peers, who became upset and started approaching pt. Staff stepped in to prevent physical altercation, in which pt fell & his L posterior aspect of parietal region. On RN assessed and found edema to area [with] superficial abrasion. Vital signs WNL BP 136/63, HR 109, RR 20, T98.9F. Neurocheck, WNL. RN gave ice pack. Pt reported 9/10 pain to back of head and L jaw. Cont. RN notified Dr., supervisor & mother of pt. Dr. ordered neurochecks Q1hr until 2100 12/9/16. Will continue to monitor for safety and head injury."


There was no documentation in the medical record for Patient #1 that the jaw pain or the head pain, rated at a level of 9/10 was monitored or further assessed. There was no further documentation of a re-assessment of the jaw pain, head abrasion, bleeding, edema or "bump" on the head or the client's pain level in the progress notes by the nurse. Review of the nursing documentation for the following day, 12/10/16 revealed no assessment of Patient #1's jaw pain, head pain, head abrasion, edema or "bump" on his head.


Facility policy, "Fall Prevention and Monitoring" Number PC-027 stated, in part, "3. In the event of a patient fall, nursing staff will: ...d. Document the clinically pertinent information in the patient's medical record, including a description of the fall, the patient status/vital signs/injuries, and the follow-up."


Review of the treatment plan in the medical record for Patient #1 revealed a treatment intervention dated 12/6/16 which stated, "AT/RT [Activity Therapist/Recreation Therapist] will facilitate groups to increase social skills, leisure education, coping skills, and leisure time." An intervention dated 12/7 for Patient #1 stated "Therapist will ... provide process groups". Per the treatment plan, treatment for Patient #1 included attending various types of group therapy.


Review of the admission orders for Patient #1 on 12/6/16 stated, in part, "Group Activity: Group Activity as tolerated and per treatment plan."


However, on 12/10/16 at 0911, Staff #8, RN, documented in the record for Patient #1, "pt was not allowed to participate in group this morning because of his behavior towards peers yesterday. Patient was getting frustrated that he could not go and began knocking chairs over in the dayroom. We made an agreement that if he could behave appropriately for 5 minutes then I would turn the TV on. I mentioned to him that if he behaves today, he may be able to go to groups tomorrow ... "Per this documentation, Patient #1 exhibited behaviors related to the diagnoses for which he was hospitalized , yet was penalized by the Staff #8, RN, who prevented him from participating in the very treatment (group therapy) the treatment team determined he needed for those behaviors. Instead, the RN negotiated with Patient #1 to allow him to watch TV, which was not an intervention on his treatment plan. There was no other treatment option provided for Patient #1, despite his demonstrated frustration.


In an interview with Staff #2, LPC, PI/RM the afternoon of 12/18/16 in the conference room, she confirmed that attending group therapy is one of the primary treatment modalities for patients generally at Cross Creek Hospital, and specifically for Patient #1. Staff #2 stated that the actions by the RN, Staff #8 in restricting Patient #1 from attending his group therapy, i.e., his treatment, should not have happened, or at least another form of treatment should have been provided, not watching TV. Staff #8, RN, was not available for an interview during the survey.


Review of the medical record for Patient #1 "Graphic Sheet" log for vital signs, stated, "VS obtained 0600 and 2000 unless otherwise ordered by Physician." There were no vital signs documented for Patient #1 at 2000 on 12/10/16; on 12/11/16, there were vital signs documented which were untimed with no means to determine when the vital signs were obtained.


Review of the medical record for Patient #2 "Graphic Sheet" log for vital signs, stated, "VS obtained 0600 and 2000 unless otherwise ordered by Physician." There were no vital signs documented for Patient #1 for 0600 or 2000 on 11/23/16; there were vital signs documented which were untimed with no means to determine when the vital signs were obtained.


Review of the medical record for Patient #9 "Graphic Sheet" log for vital signs, stated, "VS obtained 0600 and 2000 unless otherwise ordered by Physician." There were no vital signs documented for Patient #9 for 2000 on 12/10/16. On 12/11/16 and 12/16/16, there were vital signs documented which were untimed with no means to determine when the vital signs were obtained.


The Graphic Sheet did not provide the normal or expected ranges for vital signs for the techs obtaining the vital signs, which presents a risk that a tech might not be aware of and report abnormal or dangerous vital signs in a timely manner to the nurse.


In an interview with Staff #5, Therapeutic Care Specialist, on the patient care unit the afternoon of 12/28/16, the surveyor asked how vital signs are taken. The staff member responded by commenting that vital signs are done twice a day unless they have been ordered to be taken more often. Staff #5 described the vital signs as being blood pressure, O2, respirations, pulse and temperature. She also added that the staff always notify the nurse on duty of the vital signs.


The surveyor asked what a "normal blood pressure" reading would likely be and the staff member responded: 120-125/80. She again emphasized that staff always let the nursing staff know what the patient vital signs are.


In a separate interview with Staff #6, RN (Registered Nurse), who was sitting at the nurses station, informed the surveyor that staff (techs) always notify nursing staff about patient vitals.


In a separate interview on the afternoon of 12/28/2016 with Staff #2, it was confirmed that there was no documentation regarding vital sign parameters on either the Patient Observation sheets or the Graphic Sheet where vital signs are recorded. Later upon request by the surveyor, Staff #2 provided a blank copy of both the Patient Observation Sheet and Graphic Sheet. A review of both of these documents revealed no vital sign parameters listed. Staff #2 agreed that the expected and/or abnormal ranges of vital signs should be included on the graphic sheet so that techs would recognize abnormal vital signs and report abnormal vital signs immediately to the nurse.


Review of the Texas Nurse Practice Act 217.11, Standards of Nursing Practice, states, in part,

"(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall:

(D) Accurately and completely report and document:

(i) the client's status including signs and symptoms;
(ii) nursing care rendered; ...
(v) client response(s); and
(vi) contacts with other health care team members concerning significant events regarding client's status;"


The above findings were confirmed in an interview with Staff #1 the afternoon of 12/28/16 in the conference room.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on review of documentation and interview, the facility failed to ensure that medication administration reflects current standards of practice . The route of medication was not documented for 2 medications administered to ensure that the method of administration - orally, intramuscular, intravenous, etc., was the appropriate one for that particular medication and patient.


Findings included:


Review of the medication administration record for Patient #1 revealed that he was administered Benadryl 50 mg 1 dose STAT on 12/6 at 2005 and Zyprexa 10 mg 1 dose STAT on 12/6 at 2005. There was no documentation of the route of administration for these two medications.

Review of the Texas Nurse Practice Act 217.11, Standards of Nursing Practice, states, in part,

"(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: ...(C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document: ...
(iv) administration of medications and treatments."


The above findings were confirmed in an interview with Staff #2 the afternoon of 12/28/16 in the conference room.