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.

HAVEN BEHAVIORAL HOSPITAL OF FRISCO 5680 FRISCO SQUARE BLVD, SUITE 3000 FRISCO, TX 75034 Feb. 1, 2018
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0116
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of records and interview the hospital failed to ensure 1 of 1 Patient's Right's were met (Patient #7) with appropriate treatment by failing to provide medication as written in the doctors orders. Patient #7 did not receive the medication 5 out of 5 days as orders were written.

Findings Include:

In the hospital review of records the Practitioner Order dated 09/24/17 at 2050 reflected, Nystatin Powder 500,000 units apply every 8 hours topically to the buttocks and groin areas for rashes x5days.

In the hospital review of records they revealed, the hospital Medication Administration Record dated 09/24/17 at 0700 reflected Nystatin Powder, 500,000 units applied every 8 hours to the buttocks and groin areas for rashes every for 5 days. The hospital nursing reassessment on evening shift on 09/26/17 revealed the medication was administered at 1600. The hospital Medication Administration Record on 09/26/17 reflected, 2200 the patient received nystatin topical. The hospital Medication Administration Record on 09/27/17 at 0600, 1400, and 2200 the patient received the nystatin topical for rash to the buttocks and groin areas. There is no record that the patient received any medication on 09/25/17. The patient only received the medication once on 09/24/17. The patient did not receive all treatments on 09/26/17.

During an Interview with Personnel #7, it was reported that Patient #7 did not receive all medications as the order was written. Personnel
#7 verified that documentation was properly completed during their shift. Personnel #7 reported that medication had been passed to the Behavioral Health Tech to apply medication if it was a male patient for a male tech.

Policy

The hospital Policy on Abuse Reporting dated 08/2018, reflected, "Patients have the rights to be free from, mental, physical, sexual and verbal abuse, neglect and exploitation. It is the policy of this hospital to protect patients from real or perceived abuse, neglect or exploitation from anyone ...All allegation, observations, or suspected cases of abuse, neglect or exploitation that occur in the hospital will be investigated by the hospital."

The hospital Policy on Assessment/Reassessment dated ,d+[DATE] reflected, "All patients admitted to the hospital will receive a thorough assessment and evaluation. Results assessments are reviewed and integrated by the multidisciplinary team to prioritize identified problems within the interdisciplinary Treatment Plan."

The hospital Policy on Patient Rights dated 10/2018 reflected, "It is the Policy of the hospital to ensure the patient's rights are protected and maintained. All patients are informed of their rights verbally and in writing upon admission. Any limitation of the patient's rights shall be made in accordance with applicable statues and rules and only if the exercise of those rights would constitute harm to the patient or others."