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CROSS CREEK HOSPITAL 8402 CROSS PARK DRIVE AUSTIN, TX 78754 May 15, 2018
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review the facility failed to provide appropriate treatment for a female patient when her previous admission was not reviewed and her claims of a sexual encounter were not addressed in the treatment plan.

Findings include:

Review of Patient #13's medical records reflected a 27-year-old-female admitted on [DATE] with a diagnosis of Psychosis and deteriorations.

Review of the nurse's progress notes dated 11/13/16 at 12:25 pm reflected "...Patient is impulsive going into other people rooms. Patient was found in a male patient's room. Patient reported to RN that this male patient put his "penis in my mouth." Patient reported that she "consented" to this activity ....

Patient #13 was readmitted on [DATE] under an emergency detention with a diagnosis of Bipolar Disorder. Review of the Discharge Summary dated 3/13/18 reflected, "The patient presented to Cross Creek Hospital on an involuntary basis with Austin Police Department, handcuffed, highly manic, and being sexually suggestive with staff and officers ..."
Review of the initial treatment plan dated 3/2/18 did not include Patient #13's past and current history of sexually acting out.
Review of physician's orders dated 3/10/18 reflected 1:1 eyesight while awake at night check when asleep female staff only due to allegation of rape at PICU 2016.

Review of the updated treatment plan dated 3/12/18 reflected Psychiatric Problems -Updates/Comments: Patient is still dealing with delusions of being raped. The Physician had placed Patient #13 on line of sight and SAO level of observation. The patient did not attend or participate in the updated treatment plan and sexually acting out was not added to the treatment plan.
Review of the facility provided policy Sexual Acting Out Precautions NO: PC-055 (dated 7/2017) reflected, "This policy establishes the guidelines for staff to follow when treating a patient who may have a history of sexual acting out behaviors or exhibits sexual behavior during the course of treatment.

Procedure:
A. SAO identified prior to and at admission
1. The history of SAO is identified by the Admissions Staff according to the referring clinical information and/or in the interview with the patient, and or parent(s)/ guardian(s) ....
3. The attending physician determines if the patient should be placed on SAO precautions ...
C. Ongoing SAO Management ...
1. For patients identified as SAO at the time of admission, when the Master Treatment Plan is completed, the attending physician and Treatment team will assess the continuing need for SAO status based on one or more of the following:
a. Information obtained from all assessment ...and any previous clinical information ...."

During an interview on the morning of 5/15/18, in the facility conference room, Staff #1, Risk Manager confirmed Patient #13's past sexual encounter in the facility was not included in the current treatment plan, in spite of the patient making repeated claims, and stated, " ...The previous records need to be reviewed ...."
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility's Nursing staff failed to assign the appropriate care for (3) three patient's when the physician ordered level of observations were not implemented. (Patients #1, 8 and 13)

Findings Include:

Review of Patient #13's medical records reflected a 27-year-old-female admitted on [DATE] with a diagnosis of Psychosis and deteriorations and on 3/2/18 under an emergency detention with a diagnosis of Bipolar Disorder.

Review of the Discharge Summary dated 3/13/18 reflected, "The patient presented to Cross Creek Hospital on an involuntary basis with Austin Police Department, handcuffed, highly manic, and being sexually suggestive with staff and officers ...."

Review of physician's orders dated 3/7/18 reflected SAO precautions, Block room- sexually inappropriate.
Review of the Patient #13's Observation rounding logs dated 3/7/18 to 3/12/18 reflected only suicide precautions were checked. The Physician's order for Sexual Acting Out and the female only checks at night had not been implemented.

Review of Patient #1's medical record reflected a 30-year-old-male admitted on [DATE] for postictal psychosis. The psychologist progress note reflected, a History of Grand Mal Seizures, has grand mal seizures every 3-4 days, Tonic-clonic epilepsy. On 3/11/18 the Psychiatric progress note reflected, " ...reports roommate observed 2 seizure episodes last night."

Review of the Patient #1's physician's orders reflected an order for assault and seizure precautions.

Review of the Patient #1's observations rounding logs dated 3/9/18 to 3/12/18 reflected only Assault precautions had been implemented.

Review of Patient #8's medical records reflected a 29-year-old-female admitted on [DATE] for Schizoaffective disorder. The physician orders reflected Precautions: none.

Review of the Patient #8's Observation rounding logs dated 3/8/18 to 3/16/18 reflected Suicide and Assault Precautions had been implemented without a physician's order. The patient's medical history did not reflect a reason for the increased level of precautions.

Review of the facility provided policy Observations, Patient NO: PC-032 (dated 2/2015) reflected, "In order to maintain patient safety the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN .... The RN may increase the level of observation if the patient's condition changes. The psychiatric practitioner will be contacted soon as possible for notification of the change in condition and to obtain an order for the observation level ..."

During an interview on the afternoon of 5/15/18, in the administrative conference room, Staff #1, Risk Manager confirmed the findings.