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.

ROCK PRAIRIE BEHAVIORAL HEALTH 3550 NORMAND DRIVE COLLEGE STATION, TX April 12, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of records and interview, the facility failed to:

A. protect 1 patient (Patient #6) out of 8 patients reviewed from improper restriction of rights. The patient had privileges restricted without obtaining physician orders or modifying the patient's treatment plan.


See Tag A0154 for further information.


B. identify by policy when medications are used as behavioral restraints, and to monitor medications given to patients as a behavioral restraint during a psychiatric behavioral emergency (when the patient's behavior is determined by staff to be a danger to self or others without the patient's informed consent) in 1 (Patient #6) of 8 patients.


Patient #6 was given multiple medications injected into large muscles without prior informed consent during psychiatric behavioral emergencies during her stay in order to control her behavior. The hospital did not have policies to identify or manage these instances as behavioral restraints.


See Tag A0160 for further information.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on review of records, the facility failed follow their own policy to protect 1 (Patient #6) of 8 patients reviewed from improper restriction of rights. The patient had privileges restricted without obtaining physician orders or modifying the patient's treatment plan.


Findings included:


Review of Patient #6's chart showed that her telephone privileges were restricted from 2-23-2018 to 2-27-2018 without a physician order or modification of the interdisciplinary treatment plan.

Nursing notes on 2-23-2018 showed that the patient had been using the phone to call 911 multiple times. At 10:00 PM, the patient "was instructed not to use the phone any because it was time to close"


Patient Observation sheets were documented as follows:

2/23/2018 "No more phone calls tonight"
2/24/2018 "Phone Restriction"
2/25/2018 "Monitor Phone Calls Likes to call Police"
2/26/2018 "Monitor Phone Calls Likes to call Police"
2/27/2018 "Monitor Phone Calls Likes to call 911"


Review of Policy 1800.1, Patient Rights, Reviewed/Revised 03/17 was as follows:


"POLICY:

It is the policy of Rock Prairie to comply with patient rights as defined by state and federal laws and Texas Mental Health Code. The facility shall furnish all persons receiving evaluation, care or treatment under any provisions of 25 TAC 404 with a written copy of the following rights (translated into language that the person understands) upon admission, if the person is not able to read the rights, the person shall be read the rights in a language that s/he understands. These rules shall be interpreted by the Texas Department of State Health Services in accordance with a standard of reasonableness. ...


4. TELEPHONES; You have the right to have reasonable and frequent access to telephones, both to make and receive calls in privacy


19. RESTRICTIONS: A patient's rights may be limited or denied for good cause by the professional person providing treatment as follows:
A physician providing treatment may deny only the rights enumerated in Tex. HS Code ANN 576.006 only to the extent that the restriction is necessary to the patient's welfare or to protect another person but may not restrict the right to communicate with legal counsel, the department, the courts, or the state attorney general.


1. The reason for denying the right shall be documented in the medical record signed, and dated by the physician and shall be available, upon request, to the person or his/her attorney.


2. Restrictions on the rights shall be reviewed for at least every seven (7) calendar days and if renewed, renewed in writing. A person's rights may be limited or denied under court order by an imposition of legal disability or deprivation of right. Any restriction or denial of rights must be written as a time limited physician's order and the Physician's progress note must support the order."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0160
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on review of records and interview, the facility failed to identify by policy when medications are used as behavioral restraints, and to monitor medications given to patients as a behavioral restraint during a psychiatric behavioral emergency (when the patient's behavior is determined by staff to be a danger to self or others without the patient's informed consent) in 1 (Patient #6) of 8 patients.


Findings include:


Patient #6 was admitted on [DATE] under a Peace Officer Emergency Commitment. She was determined to have homicidal ideation, was manic, and aggressive. She had not been taking her home medications.

A telephone order was written on 2-23-2018 at 1:35 PM that read, "Ativan 2mg, Benadryl 50mg IM x 1 Now for Agitation." On 2-23-2018 at 1:40 PM, it was documented on the Medication Administration Record (MAR) that she was given a one-time dose of Ativan 2 milligrams (mg) by injection in a muscle (IM) and Benadryl 50 mg IM for agitation. No signed patient consent for this medication administration was found. Earlier in the day, at 1:00 PM, the nursing staff documented, "Pt requesting shot to calm her down. Called (physician) + ordered Benadryl + Ativan. She took willingly + went to sleep."

On 2-24-2018, the physician ordered Ativan 1mg by mouth to be given 3 times a day for anxiety.

In addition to the scheduled Ativan for anxiety, on 2-26-2018, the patient was given Ativan 1mg IM for agitation at 10:45 AM. She was then given 2mg IM for agitation at 4:12 PM. These were telephone orders initiated by the nurse because of the patient's behavior. No signed patient consents for these medication administrations was found.


Nursing notes were as follows:

10:00 AM 'D: Altered thought process. (patient) is loud with pressured speech, demanding and intrusive at the nurse's station and with staff. She states "I'm going to call the nursing board and have your license." She states "I'm going to call the licensing board and have this place shut down." "I cannot be sober here. Just give me a shot." She denies SI/HI and states "absolutely not and don't ask me again." A: Monitor Q15, med compliance and group participation.'

4:00 PM 'R: (patient) again is irritable and agitating patients making racial comments to other patients. She states "they won't give me my meds because I'm black: she tells patients, "you better watch out for staff." She requests baby aspirin added back "because I've had a stroke" See MAR for medical needs and topical given for pain. She continues to raise her voice to staff and knock on nurse's window continuously.'

5:00 PM "See MAR for 1X dose of medication for agitation which she willingly takes and is somewhat affective (sic) as patient is not as loud, though still at nurse's window often."


On 2-27-2018 at 12:30, nursing documentation indicated, "Pt received to unit screaming, cussing, shouting inappropriate racial slangs at other clients. Within 2 minutes, 2 physical fights about to break out and staff had to break up these patients. Pt given 2mg IM NOW with little to no results." No other nursing documentation of patient behavior and assessment was noted until 11:00 PM. The MAR and the physician telephone order did not list the reason for the medication being given. In addition to the scheduled Ativan and the 12:30 PM emergency medication administration, she was given Ativan 1mg IM, Geodon 20mg IM, and Cogentin 1mg IM at 2:00 PM per the MAR. The MAR did not list the reason for the medication being given. The physician order was incomplete. It was not dated, timed, physician signature, or telephone order signature. No signed patient consent for these medication administrations was found.


Nursing notes on 2-28-2018 at 12:20 PM state, "pt continues to need constant redirection. She is selective with medication and is demanding and very abusive to staff/peers. Screaming, threatening at staff/peers." In addition to the scheduled medication, on 2-28-2018 at 12:35 PM, the patient was given Ativan 2mg IM and Benadryl 50mg IM Now. The MAR and the physician telephone order did not list the reason for the medication being given. No signed patient consent for this medication administration was found.


Review of Physician Progress Notes and Nursing Notes did not list other interventions that were considered and why they were rejected prior to using medication to control the patient's behavior in a psychiatric behavioral emergency.


Review of the Texas Administrative Code (TAC) Title 25 Health Services; Part 1 Department of State Health Services; Chapter 414 Rights and Protections of Persons Receiving Mental Health Services; Subchapter I - Consent to Treatment with Psychoactive Medication--Mental Health Services;


RULE 414.403 Definitions

(9) Psychiatric emergency--A situation in which, in the opinion of the physician, it is immediately necessary to administer medication to ameliorate the signs and symptoms of a patient's mental illness and to prevent:

(A) imminent probable death or substantial bodily harm to the patient because the patient:

(i) is threatening or attempting to commit suicide or serious bodily harm; or

(ii) is behaving in a manner that indicates that the patient is unable to satisfy the patient's need for nourishment, essential medical care, or self-protection; or

(B) imminent physical or emotional harm to others because of threats, attempts, or other acts the patient makes or commits.


Rule 414.410 Psychiatric Emergencies was as follows:


"(a) Nothing in this subchapter is intended to preclude the administration of psychoactive medication to any patient in a psychiatric emergency.


(b) If a physician issues an order to administer psychoactive medication to a patient without the patient's consent because of a psychiatric emergency, then the physician will document in the patient's clinical record in specific medical or behavioral terms:

(1) why the order is necessary:

(2) other generally accepted, less intrusive forms of treatment, if any, that the physician has evaluated but rejected; and

(3) the reasons those treatments were rejected.


(c) Treatment of the patient with the psychoactive medication will be provided in the manner, consistent with clinically appropriate medical care, least restrictive of the patient's personal liberty.


(d) A brief physical hold is not considered restraint for purposes of this subchapter provided that:

(1) the individual currently exhibits behavior that meets the definition of psychiatric emergency as defined in this subchapter, or the individual is currently under a court order allowing the facility to administer medication without consent of the individual, the individual is refusing medication, and the medication ordered is permitted by the court order;

(2) the purpose of administering medication is active treatment to reduce symptoms of a diagnosed mental illness;

(3) using medication to reduce specified symptoms of a diagnosed mental illness is standard clinical practice;

(4) the specific medication and dosage ordered can be clinically justified as in keeping with standard clinical practice and are appropriate for reduction of specified target symptoms; and

(5) the physical hold is terminated as soon as the medication is administered.


(e) When the psychiatric emergency is no longer imminent or present, medication prescribed without consent on an emergency basis must be safely discontinued. If continued use of medication is recommended on a regular basis, the physician must comply with provisions outlined in 414.406 of this title (relating to Patients admitted Under Texas Statutes), 414.407 of this title (relating to Patients Committed to Mental Health Facilities Under Provisions of the Texas Health and Safety Code), or 414.408 of this title (relating to Patients Committed to Mental Health Facilities under Provisions Other than Those Found in the Texas Health and Safety Code (i.e., Code of Criminal Procedure, Family Code)), as appropriate.


(f) In no case may inappropriate designation of a situation as a psychiatric emergency be used to circumvent the process of obtaining consent or applying to the court for an order authorizing administration of psychoactive medication.


On the afternoon of 4-11-2018, an interview was conducted with Staff #1 and Staff #6. Staff #6 stated that a "purple package" (restraint package) was completed for emergency behavioral medication administration. When asked where the package was for Patient #6, Staff #6 was not sure why it had not been completed. Upon reviewing the quality reporting and incident reports, Staff #1 and Staff #6 determined that a purple package would only be initiated if a Code Purple had been called and patient had been physically restrained or secluded. Medications given and monitored vital signs were documented on the purple package. Otherwise, the emergency behavioral medication administrations were not captured, monitored, analyzed, and reviewed by Quality, Medical Staff, or Governing Body.


On 4-12-2018 at 8:17, an interview was conducted with Staff #11. Staff #11 was the nurse for Patient #6 on 2-27-2018. Staff #11 stated she wrote both telephone orders for emergency behavioral medications on the 27th. She was not sure why she did not complete the second order with the required information. She confirmed that it was a behavioral emergency. "(patient) was extremely manic. She was all up on people. There was no talking to her, no redirecting." Staff #11 confirmed that this was an emergency situation in which the patient's behavior needed to be controlled immediately. Staff #11 stated she did not obtain consents from the patient because it was an emergency situation. Staff #11 stated she would not initiate a restraint package unless staff had to hold the patient to give the medication. Then, they would initiate a restraint package for the hold, but not the medication. Staff #11 confirmed that she did not initiate an incident report for medication administration either.


Review of Policy 1000.49 Emergency Non-Emergency Administration of Medication; Reviewed/Revised 4/2017 was as follows:


"PURPOSE

To define guidelines for emergency and non-emergency medication administration.


PROCEDURE

EMERGENCY ADMINISTRATION OF MEDICATIONS

Medications may be administered to a patient suffering from mental illness or substance abuse or intoxication without his consent and against his wishes when he engages in behavior judged by a physician to be a psychiatric or a behavioral emergency. The patient's behavior is such that it places him or others at risk of damage to life or to limb. This is applicable to patients that are on voluntary, emergency certificate, or judicially
committed status.

A. Physician must be observing the patient during the emergency.

B. Emergency administration of medication can continue until emergency subsides, but not more than 48 hours. On weekends and holidays the time may be extended an additional 24 hours.

C. The physician shall make a reasonable effort to consult with the primary physician outside the facility that has previously treated the patient for his/her mental condition no later than 48 hours after the emergency administration of medication has begun. On weekends and holidays the time may be extended an additional 24 hours.

D. The physician shall record the date, time, and summary of the consultation or the date and time the consult was attempted.


Review of the patient's chart did not show that the physician was observing the patient during the emergency or that the physician attempted to contact the primary physician outside of the facility.


Review of Policy 1000.57 Seclusion and Physical Restraint Hold, Reviewed/Revised 10/2015, page 4 of 20, has adopted the definition of a Chemical Restraint as "A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment for the patient's condition."

The definition for Physical Holding for Forced Medications was "The application of force to physically hold a patient, in order to administer a medication against the patient's wishes, is considered a restraint."

The physical hold was identified as requiring additional monitoring as a restraint, but the injection with multiple drugs at once during a behavioral emergency without patient consent was not.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on review of records and interview, the facility failed to track, analyze, and report psychoactive medication use during psychiatric behavioral emergencies in order to improve hospital and staff performance. The facilitiy failed to identify the administratiion of psychoactive medications without patient consent during a psychiatric behavioral emergency as a high risk area that affected patient safety and quality of outcomes.


Findings included:


On 4-11-2018, an interview was conducted with Staff #1. Staff #1 stated that Emergency Behavioral Medication Administrations were tracked in the facility's incident reporting system.


The incident report from February 1, 2018 to April 10, 2018 was reviewed. Categories of incidents on the report were as follows:


Admission/Discharge/Transfer/AMA
Behavioral (Patient)
Complaint
Contraband
Facilities / Life Safety
Laboratory
Medication
Medication Reaction / Allergy (ADR)
Patient Care Management
Patient Injury
Restraint
Seclusion
Sexual Behavior


When asked where the information on Emergency Behavioral Medication Administrations was, Staff #1 stated it would be included with the restraints and seclusions. The information about the medications given was not on the report presented. Staff #1 stated he would have to get with the corporate office to figure out how to run a report, "pivot table", that would provide the information on Emergency Behavioral Medication Administrations. Staff #1 stated he did not know how to run the reports.


When the report was printed later in the day, the report did not contain any information on Patient #6. Patient #6 had been admitted in February and had received several Emergency Behavioral Medication Administrations during her stay. An interview was conducted with Staff #6. Staff #6 confirmed that the patient had received multiple Emergency Behavioral Medication Administrations. Upon further investigation, the report that had been produced only captured psychoactive medications administered during a seclusion or if the staff had to hold the patient in order to give the medication. When presented with the fact that they were going to receive the shot willingly or be held and the patient chose not to fight and accept the shot, the Emergency Behavioral Medication Administration was not tracked, analyzed, or reported in order to improve hospital processes and patient safety.


Review of quality reporting data revealed that restraints and seclusions were reported in hours per patient days. Information on the use of Emergency Behavioral Medication Administrations given with or without a physical hold or seclusion was not found in the quality reporting. Staff #1 confirmed that he did not track, analyze, or report on psychoactive medication use during psychiatric behavioral emergencies in order to improve hospital and staff performance
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on record review and interview, the Registered Nurse (RN) nursing staff failed to properly complete ongoing assessments of patients or evaluate patients' physical and behavioral response after medications were given in psychiatric emergency in 4 (Patient #1, #2, #5, and #6) out of 8 patients reviewed.


Findings include:


Patient #1

Patient #1 was admitted involuntary after a failed suicide attempt. The patient was identified as a suicide risk and required a Suicide Risk Assessment each shift. Nursing staff failed to complete the Suicide Risk Assessment and/or failed to assign a risk level on the following dates:


3-25-2018 - Both shifts failed to assign a risk level.

3-26-2018 - No form found for night shift. Day shift failed to assign a risk level.

3-27-2018 - Two assessment forms for night shift were found. Night shift failed to assign a risk level on both forms.

3-28-2018 - Night shift failed to assign a risk level.

3-29-2018 - No form found for night shift.

4-1-2018 - Both shifts failed to assign a risk level.

4-2-2018 - No form found for night shift. Day shift failed to assign a risk level.


Patient #2

Patient #2 was admitted involuntary after threatening to kill her husband. The Suicide risk assessment was being completed once each shift if the suicide risk was determined to be low. The assessment was required more often if the assessment determined the risk to be higher. Nursing staff failed to complete the Suicide Risk Assessment and/or failed to assign a risk level on the following dates:

3-26-2018 - Both shifts failed to assign a risk level.

3-29-2018 - Night shift failed to assign a risk level.

3-31-2018 - Day shift failed to assign a risk level. No form found for night shift.

4-1-2018 - Night shift failed to assign a risk level


Patient #5

Review of Patient #5's chart showed that the patient was involuntarily admitted on [DATE] after attempting suicide by walking into traffic. Patient admitted suicidal ideation. The patient was receiving Suicide Risk Assessments each shift. Nursing staff failed to complete the Suicide Risk Assessment and/or failed to assign a risk level on the following dates:

3-24-2018 - No form found for night shift.

3-25-2018 - Day shift failed to assign a risk level.

3-26-2018 - Both shifts failed to assign a risk level.

3-27-2018 - Night shift failed to assign a risk level.

3-28-2018 - No form found for day shift. Night shift failed to assign a risk level.

3-29-2018 - Day shift failed to assign a risk level.

3-30-2018 - Night shift failed to assign a risk level.

3-31-2018 - Both shifts failed to assign a risk level.


A review of the instructions on the Suicide Risk Monitoring Tool were as follows:

"PLEASE CIRCLE THE RISK FOR THE ASSESSED PATIENT. Total all responses in each column. The degree of risk should be determined by the highest numerical value within any ONE column. Note: The numerical value should not override any direct assessment performed by the skilled clinician." ...

"Rationale: If you are assigning a risk level other than as assessed, please comment:"

The form requires the assessor to select Low, Medium, or High risk for self-harm by choosing to use the totals in the appropriate column or selecting a risk level based off of independent assessment. Risk precautions required to keep the patient safe were based off of the staff assignment of Low, Medium, or High risk for self-harm.


Patient #6

Review of Patient #6's chart showed that the patient had an order written on 2-23-2018 for vital signs to be recorded 3 times a day.

Review of "Vitals Form" showed that vital signs were documented twice on 2-28-2018 and once on 3-1-2018. The RN on duty initialed the block titled "Initials of Nurse Reviewing Vitals" on 3-1-2018 only. No other vital sign form was found.

The Medication Administration Record (MAR) for patient #6 had a daily block for "Vitals" and was timed for 9:00 AM, 3:00 PM, and 9:00 PM.

On 2-23-2018 the nurse signed that it was done at 9:00 PM. No vital signs were found documented.

On 2-24-2018 the nurse signed that it was done at 9:00 AM, 3:00 PM, and 9:00 PM. No vital signs were found documented.

On 2-25-2018 the MAR was signed for the 9:00 PM and 3:00 PM vital signs. No vital signs were found documented.

On 2-26-2018 the MAR was signed for the 9:00 PM and 3:00 PM vital signs. No vital signs were found documented.

On 2-27-2018 the nurse signed that it was done at 9:00 AM, 3:00 PM, and 9:00 PM. No vital signs were found documented.

On 2-23-2018 at 10:00 PM, the patient received medication for a psychiatric behavioral emergency. No nursing assessment or patient response to medication was found to be documented. No modification to the patient plan of care was made.

On 2-26-2018 at 12:45 PM and 4:15 PM, the patient received medication for a psychiatric behavioral emergency. No nursing assessment or patient response to medication was found to be documented. No modification to the patient plan of care was made.

On 2-27-2018 at 12:34 PM and 2:00 PM, the patient received medication for a psychiatric behavioral emergency. No nursing assessment or patient response to medication was found to be documented. No modification to the patient plan of care was made.
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
Based on review of records and interview, the facility failed to ensure that all telephone orders were dated, timed, and authenticated by the ordering practitioner in 4 (Patients #1, #2, #5, #6) out of 4 patient charts reviewed.

Findings included:


Patient #1

Review of physician orders on Patient #1 revealed that telephone orders were received by the nurse from the Nurse Practitioner (NP) on 3-26-2018 at 6:00 PM and 6:25 PM for medications to treat the patient for withdrawal symptoms. These orders were not authenticated (signed, dated and timed) by the practitioner.


Patient #2

Review of physician orders on Patient #2 revealed that telephone orders were received by the nurse from the physician on 3-30-2018 to "DC order to give today + instead give Invega IM 1.56 mg X1 Monday (April 2)". This order was not authenticated (signed, dated and timed) by the practitioner.

On 3-29-2018 at 10:00 PM a telephone order was received by the nurse from a practitioner for chapstick and artificial tears to be used every two hours as needed. The practitioner's credentials were not listed. This order was not authenticated (signed, dated and timed) by the practitioner.

On 3-28-2018 the nurse received an order from the physician for Vistaril 25 milligrams by mouth times one dose for agitation. This order was not authenticated (signed, dated and timed) by the practitioner.

On 3-27-2018 the nurse received an order from the physician to transfer the patient to another unit. This order was not authenticated (signed, dated and timed) by the practitioner.


Patient #5

Review of physician orders on Patient #5 revealed that telephone orders were received by the nurse from the physician on 3-21-2018 for Cogentin 1mg by mouth twice a day and Risperdal 1 mg by mouth twice a day. This order was not authenticated (signed, dated and timed) by the practitioner.


Patient #6

Review of physician orders on Patient #6 revealed that telephone orders were received by the nurse from an unidentified practitioner (name only - no credentials listed) at 2:13 PM on 2-26-2018. The order was "May have 1st dose of Lidocaine Patch and prenatal vitamin when available." Telephone orders were received by the nurse from an unidentified practitioner (name only - no credentials listed) at 3:50 PM on 2-26-2018. The order was for aspirin and chapstick. These orders were not authenticated (signed, dated and timed) by the practitioner.

An entry was made on the physician order for Geodon, Cogentin, and Ativan to be given as an injection into the patient's muscle for a one-time dose "now". The order did not contain a date, time, or signature of the person issuing or receiving the order. Review of the Medication Administration Record (MAR) showed that the medications were given to the patient on 2-27-2018 at 2:00 PM. These orders were not authenticated (signed, dated and timed) by the practitioner.

Interview was conducted with Staff #11 who confirmed she had written the entry. Staff #11 stated she had called the physician for the order and was not sure why she had left off the date, time, ordering physician's name and her signature.