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 Oct. 20, 2017
VIOLATION: PATIENT RIGHTS Tag No: A0115
The hospital did not protect and promote each patient's rights as it failed to:

A. Ensure that each patient or his/her parents or guardians were allowed to actively participate in the patient's plan of care or treatment plan. Cross refer Patient Rights: Participation in Care Planning 482.13(b)(1).

B. Obtain a signed consent for psychoactive medication prior to the administration of such medication. Cross refer Patient Rights: Informed Consent 482.13(b)(2).

C. Ensure the right of each patient to be free from neglect as it failed to safeguard the safety of legally incompetent patients from access to medications at discharge. Cross refer Patient Rights: Care In a Safe Setting 482.13(c)(2).
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 facility documentation and staff interview, the facility failed to ensure that each patient or his/her guardians were allowed to actively participate in the patient's plan of care or treatment plan for 1 of 4 patients (Patient #12).

Findings were:

Facility document titled "CCH Admissions: guardianship" states in part " Emergency Detention: Per Lambra: An individual with a legal guardian cannot be signed into a psychiatric facility by their guardian, nor can they sign themselves in voluntarily for treatment. A person with a known guardian MUST be on emergency detention or an OPC. We can of course call for an ED if they come in with family/guardian & appear they would benefit from inpatient treatment. We need to do all that we can to 1) identify if a patient has a legal guardian, 2) If so, obtain the legal guardian paperwork for the chart."

Facility policy #PC-047 titled Treatment Planning, last reviewed 8/2016, states in part:
"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.
9.0 The overall responsibility for the Treatment Plan is assigned to the attending physician who must indicate approval by signature ..."

Review of the medical record of Patient #12, a [AGE]-year-old female, who had documentation in the patient medical record of a legal guardian, revealed an Interdisciplinary Treatment Plan completed on 7/23/17. The plan included a section entitled "Patient/Family/Legal Representative Involvement." The section was blank. The patient signed their own Treatment Plan with no indication the legal guardian was involved in the Treatment Plan development process. The patient was discharged on [DATE] to the group home.

In an interview with the legal guardian of patient #12 she stated she was not informed when the patient was admitted to the hospital and was not called until 7/24/17 to inform her of the admission of patient #12. She stated she was never asked for paperwork as to her guardian status for patient #12. She staed patient #12 had been a patient in the facility before this admission and the facility was familiar with how to get in touch with her for consents and paperwork. She stated she had been the legal guardian since appointed by the courts in November 2009 due to patient #12 being declared incompetent to care for herself.

In an interview with the Risk Manager on 10/16/17 and 10/17/17 she stated there was no official policy on legal guardianship when an adult had been declared incompetent by the courts for the facility to follow in their care.

These findings were confirmed in an interview with the hospital CEO and Director of Performance Improvement/Risk Management on the morning of 10/17/17 in the facility conference room.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on a review of facility documentation and staff interview, the facility failed to ensure informed patient consent as it failed to obtain a signed consent for psychoactive medication prior to the administration of such medication for 1 of 4 patients (Patient #12).

Findings were:

Facility policy #MM 002, titled Informed Consent, Medication, last reviewed 8/16, states in part:
"PURPOSE
To establish a mechanism for obtaining and documenting education and informed consent for psychotropic medications ordered during hospitalization .
PROCEDURE
The requirement for informed consent applies to psychoactive medications, consent must be obtained for each individual medication, not by medication class.
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 ..."

A review of the medical record of Patient #12 revealed the [AGE]-year-old patient admitted under emergency detention on 7/21/17 at 6:03 pm was administered , Ambien 5mgm, an antipsychotic medication, orally on 7/21/17 at 8:30 pm, 7/22/17 at 9:30 pm, 7/23/17 at 9:15 pm and Vistaril 50mgm, an antipsychotic medication, orally on 7/21/17 at 8:30 pm for anxiety. Seroquel 100 mgm 8:00 am and 12:00 pm and Seroquel 400 mgm at 9:00 pm was administered to patient #12 on 7/22/17 and 7/23/17 with no consent for administration of the psychoactive medication from the patient's guardian. Seroquel 200 mgm at 8:00 am and 12:00 pm was administered to patient #12 on 7/24/17. The record included no consent for treatment with these psychoactive medications from the patient's legal guardian. Consent forms for the above medications was not signed by the legal guardian until 7/24/17 at 2:00 pm when telephone consent was obtained from the legal guardian.

In an interview with the legal guardian of patient #12 she stated she was not informed when the patient was admitted to the hospital and was not called until 7/24/17 to inform her of the admission of patient #12. She further stated she was never asked to provide guardianship papers for patient #12, even though the patient was known to the facility and she was known to be the guardian of the patient.

The above findings were confirmed in an interview with the CEO, Nursing Supervisor, and Director of Performance Improvement/Risk Management on the afternoon of 10/16/17 in the facility conference room.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on document rreview, policy review, and staff interview the facility failed to ensure medication administered to a patient was not returned to a patient upon discharge who was identified in her psychosocial intake assessment as a person who has "Lethality" if she has access to her medications.

Findings were:

Review of form titled "Psychosocial Intake Assessment" for patient #12 States in part:
"Suicide Risk Assessment: Presenting Problem: Lethality: Patient does not have access to her medications and she has to be watched while taking them."

Document titled "Nursing Assessment: Medication Inventory/Reconciliation" indicates no medication was brought into the hospital with patient #12.

Document titled "Discharge Order" does not indicate medication Verapamil on the discharge medications. This form is signed by the physician and the nursing supervisor. There is no documentation on the form the patietn was given a bottle of Verapamil at the time of discharge from the facility. A bottle of Verapamil is not listed on the form as current medications/discharge medications. The patient signed the discharge paperwork.

Facility policy titled "Discharges", policy # PC-019, reviewed 09/2017, states in part "D. Nursing staff will document the discharge time, return of prescriptions, valuables, etc. E. Nursing staff members have the responsibility of obtaining patient's own medication and patient valuables in advance of the discharge time."

Facility policy titled "Medication Management: Medications Brought in With Patients" states in part:
"4.9 When the patient is discharged , the medications will be returned as ordered by the licensed practitioner."

In an interview with the pharmacist in the morning of 10/16/17 in the facility conference room she stated a bottle of Verrapamil was ordered for the patient to take during her hospitalization and obtained from a local pharmacy since the medication was not on their formulary. She stated the medication was kept at the nurses station medication room under double lock from the patients. She stated the medication should have been returned to the pharmacy when the patient was discharged as this medication was not a home medication brought into the hospital by the patient.

In an interview with the nursing supervisor in the facility conference room on the afternoon of 10/16/17 she stated the bottle of medications was handed to the patient at the time of discharge. She acknowledged there was not a physician order for the medication bottle to be given to the patient.

In an interview with the Risk Manager and the CEO on the afternoon of 10/16/17 both acknowledged a root cause analysis and a performance improvement plan had not been done regarding the incident of medications released to a patient upon discharge. The Risk Manager stated the corporate office said the incident with the patient taking a large number of the medicine supplied to the patient upon discharge occurred outside the hospital and the case was closed and did not need to be reviewed.