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.

OCEANS BEHAVIORAL HOSPITAL OF SAN MARCOS 1106 N IH 35 SAN MARCOS, TX 78666 Jan. 17, 2018
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of medical records and interview, the facility failed to ensure patients received care in a safe setting.

Findings included:

Review of the medical record for patient #1 revealed patient #1 had a fall on 12/16/17 at 2:30 pm. An order dated 12/16/17 at 5:50 pm for an x-ray was documented.

There was no documentation by the behavioral health nursing staff indicating:
*Date and time of the fall
*Circumstance of the fall
*Vital signs and the results of any other assessments taken following the fall
*The patient's pain level after the fall
*An assessment of injuries after the fall
*The patient's pain level after administration of medication at 7:50 pm

The nursing shift working on 12/16/17 from 7pm-7am did not re-evaluate the patient after administering medication for pain and did not follow-up with the ordered x-ray.

At 8:10 am on 12/17/17, the nursing staff called the x-ray contract company who stated a technician came on 12/16/17 at 9:31 pm, attempted to contact the facility, then left after two minutes of no answer. There were 14 hours after the x-ray was ordered that no staff attempted to contact the x-ray company to ensure the order was received and would be completed.

On 12/17/17 at 11:10 am, the nurse called the doctor for an order to transfer the patient to the emergency room because of pain rated 10/10 [the highest pain on the pain scale]. The patient was transferred to the emergency room at 12:45 pm, 22 hours after the fall.

The above was confirmed in an interview with staff #2 on the afternoon of 1/17/18.
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
Based on review of facility policy, review of medical records and staff interview, the facility failed to ensure records contained all information necessary to monitor the patient's condition.

Findings included:

Facility policy titled "Pain" stated in part, "Policy: It is the policy of the WellBridge Hospital of San Marcos to effectively manage the patient's pain ...
Procedure:
...2. Pain is also assessed every shift and whenever a patient complaints [sic] of pain or appears to be uncomfortable, in pain, or experiencing an unexplained behavioral change.
...9. Documentation of pain assessments after the initial ... is completed on the daily nursing assessment and through an additional progress note, if appropriate. Actions taken regarding pain and other related comments are also documented. Documentation includes:
A. Intensity, location and duration of pain
b. Pain management method(s) utilized
c. Pharmacological management: medication given, amount, route
...e. Effectiveness of management intervention
...10. The RN will also document the patient's perceived effectiveness of the pain intervention using the 1-10 numeric scale within ONE hour of the intervention ..."

Facility policy titled "Medical Record Documentation" stated in part, "Policy: It is the policy of the facility that medical records are adequately maintained in order to provide documentary evidence of the course of the patient's medical evaluation, treatment and change in condition.
Procedures:
...5. Progress notes
a. Each discipline ... will be responsible for writing progress notes at intervals defined as such:
...c. Nursing ...
...4. Shift progress notes must include any observations related to care, treatment, and services, and the patient's response ... and a precise assessment of the patient's progress in treatment."

Facility policy titled "Post Falls" stated in part, "Policy: It is the policy of the facility to provide staff with guidance on treating a patient following a fall in order to reduce injury and foster overall recovery.
Procedure:
...5. The RN will assess the patient and obtain, or delegate to a MHT to obtain, a set of vital signs.
6. The RN will assess for bleeding and/or other injury.
...14. Documentation of the fall occurs in the progress notes of the patient's chart and should address all of the following:
A. Date and time of the fall
B. Circumstance of the fall
...D. Vital signs and the results of any other assessments taken following the fall
E. Interventions implemented as a result of the fall."

Review of the medical record for patient #1 revealed patient #1 had a fall on 12/16/17 at 2:30 pm. The patient was administered Tylenol at 7:50 pm.

There was no documentation by the behavioral health nursing staff indicating:
*Date and time of the fall
*Circumstance of the fall
*Vital signs and the results of any other assessments taken following the fall
*The patient's pain level after the fall
*An assessment of injuries after the fall
*The patient's pain level after administration of medication at 7:50 pm

The above was confirmed in an interview with staff #2 on the afternoon of 1/17/18.