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.

DALLAS BEHAVIORAL HEALTHCARE HOSPITAL LLC 800 KIRNWOOD DRIVE DE SOTO, TX Aug. 31, 2018
VIOLATION: DIETS Tag No: A0630
Based on record review, the facility failed to ensure the patients had orders for therapeutic diets when needed in 1(5) of 1 patient charts reviewed.

Review of patient #5's chart revealed she was pregnant and had complained that she did not receive the diet she had ordered. Review of the physician order dated 1-3-18 at 1:00AM revealed the patient was ordered a regular diet or per patient preference.

Review of the chart revealed that patient #5 received a visit from the dietician on 1-3-18 at 9:00PM. There was no order for a dietician and no mention in the nurses notes that a dietician was requested. The dietician documented that she was there for a "vegetarian and pregnant consult 1/3/18 received today."

The dietician documented that the patient received education for a vegetarian diet and management during pregnancy. The dietician documented to "continue diet/ Rx". There was no order noted for a vegetarian diet.
VIOLATION: SCOPE AND FREQUENCY OF REVIEW Tag No: A0655
Based on review of records and interview, the facility failed develop a Utilization Review Plan that defined cases they reasonably assumed to be Extended Stay Outliers and/or High Cost Outliers and include a process for reviewing those cases.

Findings included:

The Utilization Review Plan (URP) was reviewed on 8-30-2018. The plan stated that "The Utilization Management Committee will maintain written records of all its activities. Minutes of each committee meeting shall be documented and will include

" ...
A description of its activities in the following areas:
A summary of reviews of admissions, continued stays and all subsequent reviews which will include:
Number in each category
Committee action for cases not approved
Copies of written notification letters sent
Cases discussed (identified by hospital number)
Worksheets used for Committee review function
Review of LOS less than 72 hours
Review of AMA discharges
Problematic disposition issues
Recommendations of the Committee"

Extended Length of Stay was not a category mentioned. Review of the minutes for the first and second quarter of 2018 revealed 3 charts were reviewed for medical necessity in the first quarter and no charts were reviewed in the second quarter.

The Utilization Review Director (URD) was asked about the medical necessity review of the 3 charts. She stated they were patients that had been denied by the insurance company and were reviewed to determine if they could have presented information in a different manner to have days approved for payment.

The Utilization Review Committee (URC) reviewed "underutilized days". Those were day that were approved by third party payers but were not used. When asked, the URD stated they were reviewed to see if the patient could have benefited from more days and how they could improve the use of approved days.

Review of the 2018 Inpatient Quality Dashboard showed that discharges within 24 and 72 hours and 30-day readmissions are tracked. However, the numbers were only tracked and reported. Per the URD and review of the URC meeting minutes, these records were not discussed or reviewed for quality of care and appropriate utilization of services.

Further review of the URP revealed that there was no definition of an extended stay outlier. The plan provided no mechanism for the URC to review extended stay outliers for quality of care and appropriate utilization of services.

Per the 2018 Inpatient Quality Dashboard, the Average Length of Stay (ALOS) for the first quarter of 2018 was 7.91 days. The ALOS for the second quarter was 7.99. This is an ALOS of 1 week and 1 day.

During the first quarter of 2018, 48 patients were discharged with a Length of Stay (LOS) of 21 days (3 weeks) or longer. The longest LOS was 70 days (10 weeks). None of these charts were reviewed by the URC as extended stay outliers.

During the second quarter of 2018, 36 patients were discharged with a Length of Stay (LOS) of 21 days (3 weeks) or longer. The longest LOS was 63 days (8 weeks and 6 days). None of these charts were reviewed by the URC as extended stay outliers.

Review of the URP did not include a methodology for identifying high cost outliers or a process for the URC to review high cost outliers in order to improve quality of care or evaluate appropriate utilization of services. The URP states "The Utilization Management Committee shall identify cases that are associated with unusually high costs or excessive services ..." Review of the URC minutes, Inpatient Quality Dashboard, along with interview of the URD, revealed that these cases were not identified, tracked, trended, or reviewed.

An interview was conducted with Staff #21 on 8-30-2018. Staff #21 confirmed the hospital was paid under the Prospective Pay System (PPS). Staff #21 confirmed that the Utilization Review Committee did not review cases of patients who were discharged after an extended period of time or had unusually high costs associated. Staff #21 confirmed that the UR Plan did not include a definition of Extended Stay Outliers and/or High Cost Outliers. Staff #21 confirmed that patient cases of readmission within 30 days are not reviewed by the URC.
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observation and interview, the facility failed to ensure the environment was sanitary to prevent infection sources or the spread of infection in 9 out of 9 areas toured (Patient Intake, Courtyard, Unit 3, Unit 4, Cafeteria Dining Area, Kitchen, Unit 1, Unit 2, and Unit 6)


A facility tour was conducted with Staff #1 and Staff #2 on the afternoon of 8-29-2018. Findings included:


A. Patient Intake Area.


In the staff office area of Patient Intake, a portable monitor for telemedicine was observed to be stored in between copier and shredding box. The base of monitor heavily soiled with dust and had trash sitting on top of it. The dust was thick enough to write readable lettering on it. A trashcan was observed to be overflowing with trash under a table. Used gloves were observed to be on the floor next to the trash can. Directly next to this, was observed to be a stack of patient blankets in plastic wrapping stored on the carpeted floor next to the trash. The carpeted floor was observed to soiled with stains and debris.


B. Courtyard


During the tour, a courtyard with a water feature could be observed from a hallway window. Water in the water feature was observed to be stagnant and a dark greenish/brown color. Upon entering the courtyard for closer observation, small unidentified flying insects could be seen on the surface of the water.


Interview with Staff #1 revealed, the pump for the waterfall and fountain had been out for a period of time and was not scheduled to be repaired soon. Staff #1 stated, the water was not treated or monitored for bacterial growth or mosquitos. Staff #1 confirmed that patients were taken to the courtyard to participate in groups.


C. Units 3 and 4


The patient nutrition room for Units 3 and 4 was observed to have a tray with six individually packaged cups of pudding on it. These had been prepared and packaged in the hospital kitchen. The cups of pudding were on a tray with other commercially packaged snacks. The cups of pudding did not have a date they were prepared or a date when they should be used by on them.


Staff #1 confirmed there was no way to know how old each individual cup was to determine if they were safe for patients to eat.


The refrigerator for patient nutrition had a buildup of dirt and debris in the refrigerator door seal. The bottom of the inside of the refrigerator was observed to have what appeared to be a large food particle on the bottom shelf. The door area by the bottom shelf was observed to be soiled. The exterior top of the freezer door was observed to be soiled with dried matter.


The patient medication room for Unit 3/4 was observed to have a small patient medication refrigerator sitting directly on the floor. Because of the small size, there was no barrier to prevent dust and dirt from being swept into the patient medication refrigerator when the door was opened or closed. When opened, the refrigerator was observed to have dirt, debris, and hair in it. The door of the refrigerator had a tattered paper sign taped to the front. This prevented the exterior of the refrigerator door from being properly sanitized. Syringes for use with patients were observed to be on a shelf in an open bin above the sink area. Twenty-seven (27) out of 37 of the packaged syringes had an expiration date of January 2018. One unpackaged syringe was observed in the bin. The bin was observed to be soiled in the bottom with dust and debris. Staff #1 confirmed the findings.


A tour of Patient Room 122 was made. The bathroom was observed to have a buildup of soiled matter along the base of the wall where the tile met the wall. The bed in Room 122 was observed to have a gap between the bottom platform that the mattress rests on the footboard. This gap had not been sealed. The gap had dirt and debris collected in it. There were bugs in the gap and on the bottom platform by the right side corner at the foot of the bed. Staff #2 confirmed the findings. All beds observed throughout the tour had similar construction with unsealed gaps collecting dirt and debris.


D. Units 1 and 2


The bathroom in room 104 was a cleaned room. The toilet was observed to have a visible buildup of matter along the seam where the toilet met the wall. There was heavy buildup of matter on the grout between floor tiles, on the floor where the floors meet the walls and in the corners. The chairs in the dayroom for Unit 1 were observed to trash, dirt, and dried spills between the chair seat cushions and the wooden arms of the chairs.


Unit 2 seclusion rooms were observed to have dirt and trash on the floors. The transition between the concrete floors in the seclusion room and the laminate flooring in the staff observation area was missing transition strips in both seclusion rooms. The height difference allowed dirt and debris to collect along the transition point.


A treatment room for labs was observed to contain a red metal biohazard waste can. The can did not contain any type of liner. Biohazard waste was observed to be in the can. This presented an unsafe situation where biohazard material had to be transferred from the biohazard container to another container, increasing the risk of staff coming into contact with biohazardous material and the potential spread of infection.


E. Unit 6


Unit 6 seclusion rooms were observed to have dirt and debris on the floors. The transition between the concrete floors in the seclusion room and the laminate flooring in the staff observation area was missing transition strips in both seclusion rooms. The height difference allowed dirt and debris to collect along the transition point.


Patient room 214 was observed to have a heavy buildup of dirt at the transition of bathroom floor to shower, bathroom floor corners, and seams of flooring material. The shower floor was observed to be cracked from side-to-side, across drain area of shower. This would allow for water to seep into the crack and potentially provide for the growth of fungus such as mold and athletes foot, viruses such as warts, and bacteria that could spread infections.


The chairs in the dayroom for Unit 6 were observed with trash, dirt, and dried substances between the chair seat cushions and the wooden arms of the chairs. All chairs in the dayroom on Unit 6 had damaged cushions preventing the appropriate sanitation of chair cushions.


The wall across from the nurses' station was observed to have a dried substance down the wall. The wall baseboard was observed to be pulling away from the wall in the same area with a buildup of dirt and debris. The nursing station on the patient's side of the station where children sit to speak with staff was observed to have chipped and missing laminate, preventing proper sanitation of the area.


F. Cafeteria Dining Area and Kitchen


Interview with Staff #7 was conducted during the tour of the dining area and kitchen. Staff #7 stated, the dining area had been recently cleaned after lunch and was ready for patient for the upcoming dinner meal.


Tables were observed to have food crumbs on them and dried food substances along the table edges. Chairs were observed to be soiled with dirt and debris.


The serving line was observed to have self-serve stations for drinks to include ice, water, coffee, and latte. The nozzle dispense areas for each machine were found to have heavy buildup of deposits from the liquids that were dispensed and splashed. Staff #7 stated that the machines are cleaned every two weeks per manufacturer recommendations. They are not inspected for being dirty or cleaned in between.


Inside the kitchen area, an ice and water dispense machine was observed. Directly next to the machine and touching the water and ice dispense drain pan (the pan directly under the dispense area to catch spills while dispensing) was a trashcan with dried matter and dirt on the lid. The machine was heavily soiled and had dried deposits in the drain pan. The metal table it was sitting on was heavily soiled on the bottom shelf, as well as the floor area around and the wall behind the ice and water machine.


Staff #7 was asked if the machine was used by kitchen staff. Staff #7 denied that it was used. Staff #2 stated it was the back up for patient water and ice on the units.


Upon entering the walk-in refrigerator in the kitchen, an undated pitcher of orange colored drink was observed. The drink appeared to be separated into two different layers. The serving dispensers of Koolaide were observed on the shelf with the date of 8/27/18 on them. When asked if that was the preparation date or use by date, Staff #7 replied, it didn't matter because Koolaide doesn't go bad. A container of thawed raw shrimp was observed on the shelf. The container was not dated as to when it was placed in the refrigerator or the use-by date. This was confirmed by Staff #1 and Staff #7.


Staff #1 was interviewed as to the findings. Staff #1 stated the Infection Control staff member was not available at the time. Staff #1 stated that the Infection Control staff member conducts regular surveillance rounds and had previously identified some of the findings but did not know why they were continuing.






28 patient trays and 12 cooking pans were stacked wet.


Opened Styrofoam plates with lids were found stacked, face down, on top of the serving line metal top. The surface was soiled with grease and dust. Styrofoam plates were also stacked 2 inches from the soiled floor uncovered. The floor and vent on the serving line were heavily soiled with dirt, hair and old food particles.


The large trash cans were being pushed out of the kitchen, down the hall, out onto the parking lot to the dumpster. The same trash cans were being brought back into the kitchens preparation area from the parking lot. The trash cans were heavily soiled.


Shipping boxes were found in the refrigerator, freezer, dry goods, and food preparation areas. There were no clean or dirty areas identified in the kitchen to unload supplies or boxes to prevent contamination.


5 baking pans were found heavily coated in carbon and unable to be cleaned properly.


A floor drain under the food preparation area was found to be partially blocked and growing a slimy, green wet substance. There was no schedule or process to clean the drains.


The shelving holding the pots and pans was heavily soiled with grease, dirt, and food particles.


A mixing bowl and pans found for immediate use was soiled on the inside, with an identifiable food product, and coated on the outside of the pans with grease and food particles.


Two ovens were heavily coated in carbon and baked food particles.


The warming ovens were soiled on the outside with dust, hair, and grease. The inside of the warming ovens was soiled with carbon, spilled and dried liquids.


The sink to wash your hands in the kitchen was soiled with dirt and a black unidentifiable substance.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on review of records, observation, and interview, the Governing Body failed to ensure that the facility:


A. perform a preliminary examination, that included an assessment of medical stability, of individuals to determine if the individual met the criteria for admission for emergency detention. The facility failed to ensure that individuals who arrived under an emergency detention warrants were provided with the notice of their rights while under emergency detention warrant. The facility failed to ensure the appropriate assessment and safe monitoring of individuals who were being held under emergency detention warrant while awaiting physician's preliminary assessment and admission. The facility failed to ensure individuals received appropriate diets and basic health needs while awaiting assessment and admission.


B. protect minor patients from physical harm in 2 (#17 and #32) of 2 charts reviewed. The facility failed to follow its own policy to ensure that patients were being monitored per physician orders for safety in 2 (#17 and #32) of 2 charts reviewed. The facility failed to ensure that patients guardians and child protective services were notified of patient sexual abuse in 2 (#17 and #32) of 2 charts reviewed. The facility failed to address patient's behavior in the treatment plan in 2 (#17 and #32) of 2 charts reviewed.


The condition and deficient practices were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

See Tag A0144




C. provide the patients with clean clothes. The facility failed to provide needed clothes to promote patient dignity and avoid mental anguish in the milieu in 3 (5, 7, 25) of 8 patient charts reviewed.


D. provide a place for patients to sit down or lie down while being secluded. Patients had no choice but to sit or lie down on the floor in 3 (Unit 2, Unit 3, and Unit 6) out of 3 seclusion rooms.

See Tag A0145



E. ensure all Medicare and Medicare Advantage patients were provided with the appropriate notice of rights (Important Message from Medicare) within 2 days prior to discharge as required. Patients were only given the Important Message from Medicare upon admission.

See Tag A0117



F. provide the necessary information for informed consent and/or provide it in manner that the patient was able to understand for 5 (Patient #15, #19, #20, #22, and #23) out of 5 patients. Patients were asked to sign blank and incomplete consents. Information was not always provided in the patient's primary language.

See Tag A0131



G. provide the patient privacy when clinical care issues were discussed between the patient and physician in 1 of 7 patient care areas observed. Patients were interviewed at the nurse's station in front of staff and with other patients in the area.

See Tag A0143



H. ensure the environment was sanitary to prevent infection sources or the spread of infection in 9 out of 9 areas toured (Patient Intake, Courtyard, Unit 3, Unit 4, Cafeteria Dining Area, Kitchen, Unit 1, Unit 2, and Unit 6).

See Tag A0747
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of records, observation, and interview, the facility failed to:


A. perform a preliminary examination, that included an assessment of medical stability, of individuals to determine if the individual met the criteria for admission for emergency detention. The facility failed to ensure that individuals who arrived under emergency detention warrants were provided with notice of their rights while under emergency detention warrant. The facility failed to ensure the appropriate assessment and safe monitoring of individuals who were being held under emergency detention warrant while awaiting physician's preliminary assessment and admission. The facility failed to ensure individuals received appropriate diets and basic health needs while awaiting assessment and admission.


B. protect minor patients from physical harm in 2 (#17 and #32) of 2 charts reviewed. The facility failed to follow its own policy to ensure that patients were being monitored per physician orders for safety in 2 (#17 and #32) of 2 charts reviewed. The facility failed to ensure that patients guardians and child protective services were notified of patient sexual abuse in 2 (#17 and #32) of 2 charts reviewed. The facility failed to address patient's behavior in the treatment plan in 2 (#17 and #32) of 2 charts reviewed.


The condition and deficient practices were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

See Tag A0144




C. provide the patients with clean clothes. The facility failed to provide needed clothes to promote patient dignity and avoid mental anguish in the milieu in 3 (5, 7, 25) of 8 patient charts reviewed.


D. provide a place for patients to sit down or lie down while being secluded. Patients had no choice but to sit or lie down on the floor in 3 (Unit 2, Unit 3, and Unit 6) out of 3 seclusion rooms.

See Tag A0145



E. ensure all Medicare and Medicare Advantage patients were provided with the appropriate notice of rights (Important Message from Medicare) within 2 days prior to discharge as required. Patients were only given the Important Message from Medicare upon admission.

See Tag A0117



F. provide the necessary information for informed consent and/or provide it in manner that the patient was able to understand for 5 (Patient #15, #19, #20, #22, and #23) out of 5 patients. Patients were asked to sign blank and incomplete consents. Information was not always provided in the patient's primary language.

See Tag A0131



G. provide the patient privacy when clinical care issues were discussed between the patient and physician in 1 of 7 patient care areas observed. Patients were interviewed at the nurse's station in front of staff and with other patients in the area.

See Tag A0143
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on review of records and interview, the facility failed to ensure all Medicare and Medicare Advantage patients were provided with the appropriate notice of rights (Important Message from Medicare) within 2 days prior to discharge as required.


Findings included:


During a review of hospital policies, it was noted there was no readily identifiable policy on providing Medicare and Medicare Advantage patients with a copy of the Important Message from Medicare (IM). The IM provides patients or their appointed representative with the information necessary to file a complaint concerning quality of care or to appeal a discharge when they believe it to be too soon.


Staff #21 stated she didn't know of a separate policy, but that patients who required the notice were given the notice upon admission. Staff #21 stated that was the only time the patients received the notice. Patients did not receive a follow-up copy of the IM


Review of Centers for Medicare and Medicaid (CMS) guidelines for the delivery of the IM in the Medicare Claims Processing Manual, Chapter 30 - Financial Liability Protections was as follows:


"200.3.2 - The Follow-Up Copy of the Signed Important Message from Medicare.
(Rev. 1257, Issued: 05-25-07; Effective: 07-01-07; Implementation: 07-02-07)


A "follow-up" copy of the signed IM must be delivered to the beneficiary using the following guidelines:


Delivery Timeframe. The follow-up copy must be delivered as far in advance of discharge as possible, but no more than 2 calendar days before the planned date of discharge. Thus, when discharge seems likely within 1- 2 calendar days, hospitals should make arrangements to deliver the follow-up copy of the notice, so that the beneficiary has a meaningful opportunity to act on it. However, when discharge cannot be predicted in advance, the follow-up copy may be delivered as late as the day of discharge, if necessary. If the follow-up copy of the notice must be delivered on the day of discharge, hospitals must give beneficiaries who need it at least 4 hours to consider their right to request a QIO review. Beneficiaries may choose to leave prior to that time, however, hospitals must not pressure a beneficiary to leave during that time period. If the hospital delivers the follow-up copy, and the beneficiary status subsequently changes, so that the discharge is beyond the 2-day timeframe, hospitals must deliver another copy of the signed notice again within 2 calendar days of the new planned discharge date . Hospitals may not develop procedures for delivery of the follow up copy routinely on the day of discharge.


Alternative to Delivery of the Signed Copy. A hospital may choose to deliver a new copy of the IM (not a copy of the signed IM) during the required timeframes; however, the hospital must obtain the beneficiary's or representative's signature and date on the notice again at that time.


Exception to Delivery of the Follow-Up Copy. If delivery of the original IM is within 2 calendar days of the date of discharge, no follow-up notice is required. For example, if a beneficiary is admitted on Monday, the IM is delivered on Wednesday and the beneficiary is discharged on Friday, no follow-up notice is required.


If a beneficiary receives and signs the initial copy of the IM as part of the preadmission process, the follow-up copy of the notice must be delivered if delivery of the initial copy occurred more than 2 calendar days prior.


Documentation. Hospitals must document timely delivery of the follow-up copy of the IM in the patient records, when applicable. Hospitals are responsible for demonstrating compliance with this requirement. If hospitals have processes in place to document delivery of other information related to discharge that includes a beneficiary signature and date, hospitals may include the follow-up copy of the notice in those documents. If there are no other existing processes in place, hospitals may use the "Additional Information" section of the IM to document delivery of the follow-up copy, for example, by adding a line for the beneficiary's or representative's initials and date."
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**




Based on review of records and interview, the facility failed to provide the necessary information for informed consent and/or provide it in manner that the patient was able to understand for 5 (Patient #15, #19, #20, #22, and #23) out of 5 patients.


Findings were as follows:


Review of medication consents showed the initial statement to be "The individual _ (blank for written in name) _ has received a complete explanation of the listed medication in their preferred mode of communication: (blank for Specify Language to be filled in)


At the bottom of the page was a statement, "I have received a complete explanation of the psychoactive medication(s) by means of: (Circle those appropriate) oral explanation video presentation printed material other (specify)_________"


The back of the consent form contained the following statements:


"I have received the Consent to Treatment with Psychoactive Medication Information Sheet (9-7.1 Or 9-7.2) and the printed material which summarizes specific information regarding the psychoactive medication(s) for which I have given my consent or for which there is an existing court order for medications.


Based upon this explanation, I hereby consent to treatment with a specific psychoactive medication as indicated on the front of this form. I understand that I may withdraw this consent at any time, however a probate court may decide that I lack the capacity to make the decisions whether or not to take the medication(s) and decide that I must continue taking the psychoactive medication prescribed by the physician. If, however, there is an existing court order for psychoactive medication, my signature indicates only that I have received information and education regarding this medication."



Patient #15


Patient #15's chart was reviewed. The nursing assessment completed on 3-23-2018, at 9:10 AM, states the patient "needs an interpreter". On 3-24-2018, at 4:55 PM, the nurse charted the patient "Mostly speaks Spanish, but seems to understand English." On 3-25-2018, nursing group notes indicated "unable to process Spanish speaking".


The forms on 3-23-2018 for the medications Lexapro 5mg (milligrams) PO (by mouth) and Risperdal 2 mg PO were in English. The space to fill in the patient's preferred language was blank. The method of presentation of information had not been circled. No legible patient signature was present. An unreadable signature was on the "Legally Authorized Representative" signature line. The "Relationship to Patient" was left blank. The signature was dated, but not timed. The blank for the person giving the explanation for informed consent was blank.


Consents were found for the medications Vistaril and Trazadone dated 3-24-2018. The consents were in English. No dosage of medication or route for medication to be given was listed on the consent. The space to fill in the patient's preferred language was blank. The method of presentation of information had not been circled. The patient signature block indicated the patient refused to sign.


The physician did not sign any of the medication consents confirming the explanation provided by someone other than his-self/her-self until 4-9-2019. The patient discharged on 3-25-2018.



Patient #19


Review of Patient #19's chart included 3 psychotropic medication consents. None of the three consents contained the dosage of the medication to be given. The consent for Risperdal did not contain the form or route. The Risperdal consent was signed by the patient. No nursing staff or medical staff signatures were present on the consent. The patient had received 0.5 mg of Risperdal by mouth at bedtime on 8-22/23/24-2018. The dosage was doubled to 1 mg by mouth at bedtime on 8-25-2018. No documentation was made that the patient was advised of the new dosage or was given any information regarding the nature or effect the change may have. The patient was given the new dosage on 8 -25/26/27/28/29/30 - 2018.



Patient #20


Review of Patient #20's chart on 8-31-2018 included 3 psychotropic medication consents. None of the three consents contained the dosage of the medication to be given.


The consent for Vistaril PO had "unable to sign/shaky" on the patient signature line and was dated 8-27-2018. Two staff signatures were on the Staff Witness line and dated 8-27-2018. No signature was found on the line for the person who explained the consent form to the patient. No physician signature was found on the form to verify the correct explanation of consent was given, more than two days from obtaining the consent. Vistaril was given to the patient on 8-28-2018 at 9:40 AM per the Medication Administration Record.


The consent for Seroquel PO had "unable to sign/shaky" on the patient signature line and was not dated. Two staff signatures were on the Staff Witness line and was not dated. No signature was found on the line for the person who explained the consent form to the patient. No physician signature was found on the form to verify the correct explanation of consent was given. Seroquel was given to the patient on 8-27/28/29-2018.


The consent for Tegretol was signed by the patient and the nurse on 8-28-2018. No physician signature was found on the form to verify the correct explanation of consent was given, more than two days after the consent was initiated. The patient received Tegretol on 8-28/29/30-2018.


Patient #22


A review of Patient #22's chart was made on 8-31-2018. A blank consent was found in the chart. All parts of the consent were blank except the patient signature. The patient had signed but not dated the form. The physician, Staff #28, had signed the consent on the line as "Confirmation Signature of Treating Physician to confirm explanation given by P.A., CNC, R.PH., Rn or LVN" The purpose of this signature line is for the physician to confirm that another staff member had given an appropriate explanation of medication information required for informed consent. No medication was listed or staff signature present to indicate that the patient had been given an explanation of any medication. On 8-30-2018, at 11:50 AM, the physician wrote an order to start Haldol 2.5mg PO BID (twice a day). The MAR was documented that the patient was given Haldol at 9:00 PM. No consent for Haldol was found in the patient record.


Patient #23


A review of Patient #23's chart was made on 8-31-2018. An order had been written on 8-30-2018 at 3:38 PM for Haldol 5mg PO BID to be given. This medication was given at 9:00 PM on 8-30-2018 and at 9:00 AM on 8-31-2018. An incomplete consent for Haldol PO was found in the chart. It did not contain any signatures for patient, staff, or physician.


Review of Texas Administrative Code, Title 25, Part 1, Chapter 144, Subchapter I, Rule 414.405 states:

"(d) If the RN, LVN, PA, or RPh (Registered Nurse, Licensed Vocational Nurse, Physician Assistant, or Registered Pharmacist) gives the initial explanation of the consent information to the patient, then the treating physician must confirm the explanation and the consent and sign the MHRS 9-7 form (or other format including the same information) within two working days, not including weekends or legal holidays."



Review of hospital policy, Subject: Consent to Psychotropic Medication, Section 10: Rights and Responsibilities of the Individual, Policy #1000.07, Effective: 01-10-2014 was as follows:


"II. POLICY:

A. The State of Texas has adopted regulations which set forth the right of Voluntary and Involuntary Psychiatric Patients to refuse treatment with Psychotropic Medications (except in emergency situations).

1. To comply with state regulations.

2. To ensure that the patient's right to refuse medications (except in emergency) have been explained to the patient.

3. To ensure that the patient has received specific information regarding the nature and effect of psychotropic medications, to enable him/her to make an informed decision.

4. To ensure that the patient has signed the Consent to Treatment with Psychoactive Medication Form prior to administering the medication(s) to the patient.


III.PROCEDURE:

A. Written documentation of the patient's decision to consent must be maintained and the patient may withdraw consent at anytime.(sic)

B. When the patient is conserved and the conservator has been given the right to consent for medication, a copy is in the medical record.

C. The patient must be provided with sufficient information by the physician prescribing the medication, in order to make an informed consent. This includes the following information:

1. Nature of the patient's mental condition

2. Reasons for taking the medication, including the likelihood of improving or not improving without such medication, and that the patient has the right to withdraw consent at anytime

3. Reasonable alternative treatments available, if any

4. Type, range of frequency and amount (including use of PRN orders), method (oral or injection) and duration of taking the medications

5. Probable side effects of these drugs known to commonly occur, and any particular side effects likely to occur

a. Possible additional side effects which may occur, i.e., persistent involuntary movement of the face or mouth, and at times which may include similar movement of the hands and feet, and that these symptoms of [DIAGNOSES REDACTED]

b. Other possible side effects include [DIAGNOSES REDACTED], agranulocytosis, hypertensive crisis, [DIAGNOSES REDACTED], elevated glucose, lithium toxicity.

D. Prior to the administration of the medication, the Consent to Treatment with Psychoactive Medication Form must be signed by the patient. No nurse may administer the prescribed medication(s) until this form is completed. If the patient has been informed, but refused to sign the consent, the unsigned form should be placed on the patient's medical record. The nurse is responsible for making this notation in the patient's medical record and notifying the physician of the refusal.

E. When the informed consent has been signed by the patient, the nurse should make a notation on the Medication Administration Record (MAR) and notify the Pharmacy Department. ..."


Review of hospital policy, Title: Medication Administration and Records, Policy Number - PHR-159, Effective: 11/2015 was as follows:

"4.0 PROCEDURE:

4 1 CONSENT PROCEDURE:

4.1.1 All patients who are able to provide expressed and informed consent for psychotropic medications will do so prior to the initial dose.

4.1.2 Patients who are able to provide expressed and informed consent will do so; otherwise consent will be obtained from the guardian/parent/guardian advocate; or an Emergency Treatment Order by the attending licensed practitioner will be necessary...."
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on observation and interviews, the facility failed to provide the patient privacy when clinical care issues were discussed between the patient and physician in 1 of 7 patient care areas observed.


A tour of the facility was performed on 8-29-18 at 2:00PM. Upon entering unit 3, staff #31 (MD) was observed interviewing a patient about their medical information and needs at the nurses desk. There were other patients standing around and was able to hear the conversation between the MD and the patient.


An interview with staff #1 and #2 on 8-29-18 was asked if the physicians normally interview and examine patients at the nurse's desk. Staff #1 revealed the physicians do have a private place to interview the patients and examine them but the physicians also talk with the patients at the nurse's station. Staff #2 confirmed the physicians talk with the patients at the nurses station concerning their care and treatment.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on record review, observation, and interviews, the facility failed to:


A. Perform a preliminary examination, that included an assessment of medical stability, of individuals to determine if the individual met the criteria for admission for emergency detention warrant. The facility failed to ensure that individuals who arrived under an emergency detention warrant were provided with notice of their rights while under emergency detention. The facility failed to ensure the appropriate assessment and safe monitoring of individuals who were being held under emergency detention warrants while awaiting physician's preliminary assessment and admission. The facility failed to ensure individuals received appropriate diets and basic health needs while awaiting assessment and admission.


B.Protect minor patients from physical harm in 2 (#17 and #32) of 2 charts reviewed. The facility failed to follow its own policy to ensure the patients were being monitored per physician orders for safety in 2 (#17 and #32) of 2 charts reviewed. The facility failed to ensure the patients guardians and child protective services were notified of patient sexual abuse in 2 (#17 and #32) of 2 charts reviewed. The facility failed to address patient's behavior in the treatment plan in 2 (#17 and #32) of 2 charts reviewed.


The condition and deficient practices were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.


A.
A tour of the patient intake area was conducted on 8/29/18 with staff #1 and #2. This is an area where potential patients come for an assessment to determine whether potential patients meet admission criteria. This was a locked area that requires the facility staff to open the doors for potential patients to enter or leave.


Upon entering the intake area, a waiting room was found on the right hand side. There were windows for viewing into the room from the hallway. Chairs were pushed together end-to-end to create beds. Two people were found lying in chairs with blankets and one person was sitting in a chair. One of the individuals was a man and two were women. There was no facility employee in the room with these individuals or in the hallway monitoring them thru the glass windows. Within 30 seconds, a male Mental Health Technician (MHT) came out of a closed door room next to the waiting room. When the surveyor asked who was watching these potential patients, the MHT, staff #11 stated, "I am." The surveyor stated, "you were not here when I walked up and they were alone." The MHT stated, "I was just getting something out of there and we have monitors on them in the next room. Somebody was watching them."


Inside the second room on the right, behind a closed door, was a room with 3 facility staff. One of the staff members was watching the cameras for the waiting rooms. There were several views of the rooms in the intake area. There was also an intake room for children and their parents. Staff #2 confirmed that the child and adolescent patients were put together with their families supervising them.


Review of the patient chart revealed, she was a [AGE]-year-old female that was suicidal. Patient #26 was brought to the facility by police with a "Notification of Emergency Detention, dated 8/29/18 at 9:13 (did not specify am or pm). Review of the emergency detention written for patient #26 stated, "2. I have reason to believe and do believe that the above named person evidences a substantial risk of serious harm to himself/herself or others based upon the following:

She stated that she told mother/father she wanted to hurt herself and that she wanted to jump in front of a car to end it all."


The Notification of Emergency Detention according to the SUBTITLE C. TEXAS MENTAL HEALTH CODE CHAPTER 573. EMERGENCY DETENTION stated, "
Sec. 573.001. APPREHENSION BY PEACE OFFICER WITHOUT WARRANT. (a) A peace officer, without a warrant, may take a person into custody if the officer:

(1) has reason to believe and does believe that:

(A) the person is a person with mental illness; and

(B) because of that mental illness there is a substantial risk of serious harm to the person or to others unless the person is immediately restrained."


Review of the facility "EMTALA Log" revealed patient #26 had arrived in the intake area on 8/29/18 at 21:35 (9:35PM). There was no documented evidence that this patient had been medically screened by a physician before she was brought to the facility. There was no documentation that the patient was put on suicidal precautions while in the intake area. Review of the intake checklist on the front of the patient's chart revealed she was on a q-15-minute observation and a rounding sheet was initiated with a picture.


The patient was seen by the Registered Nurse (RN) on 8/29/18 at 2138 (9:38PM). Review of the Medical Screening Triage note revealed the form had a check off section asking "Are you pregnant or lactating?" The nurse marked "no" on both. There was no documentation of a pregnancy test performed or the date of her last menstrual period. The vital signs were documented at 2145 (9:45PM). The nurse did not obtain a temperature on the patient. All other v/s were within normal limits.


Under current medical problems, the nurse documented "Epilepsy" (Epilepsy is a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain). The nurse documented, patient #26 had a fall from a seizure on 8/27/18. There was no evidence documented that the patient had been treated for the fall or if she had a head injury, if she was symptomatic, or a nursing neurological check performed. Review of the current medication section revealed, patient #26 was taking "Capra"(sic) 500mg BID last dose 8/28/18. [Keppra (levetiracetam) is an anti-epileptic drug, also called an anticonvulsant. Keppra is used as adjunctive therapy to treat partial onset seizures in adults and children 1 month of age and older with epilepsy.] There was no further nursing documentation found.


Review of the Intake Assessment form for patient #26, dated 8/30/18 at 4:44AM, staff #29 (Licensed Intake Counselor) documented, "Epilepsy - diagnosed two days ago -Monday night my boyfriend said I had a seizure and when I woke up I was in the hospital ...when I came back from it I don't remember anything." (sic) There was no documentation that staff #29 informed the RN that this was a new diagnosis for this patient. Staff #29 documented, "pt. denies SI, HI and AVH." (suicidal ideations, homicidal ideations, auditory/visual hallucinations.)


On 8/30/18, the survey team went back to the intake area at 10:20AM and found 5 people in the adult waiting room. A male patient and patient #26 were lying in separate chairs with a blanket. Three females were sitting up in the chairs. There was no bathroom facilities in the waiting area. There was no available water or food in the waiting area. There were no patient rights posted in the waiting area. One (1) male MHT was watching the patients by standing in the doorway. The MHT left the room to take a patient down the hall. The patients in the waiting room were left alone. The surveyor walked into the intake office where the cameras were located. There were four staff members including 1 RN in the room. Three computers were on but there was no video monitoring of the waiting area on the computer screens. Staff #2 confirmed there was no one video monitoring the waiting area. Staff #30 (RN) reported that she was monitoring the patients. Staff #30 was asked about the status of the patients in the waiting room. Staff #30 stated, "I haven't seen them yet this morning. This was my first day back so I really don't know any of these patients except ______ (patient #26). She has been here before." Staff #30 was asked what time she reported to work. Staff #30 stated 7:00AM. Staff #30 had been at work for 3.5 hours and had not assessed any of her patients. There had been no nursing documentation on patient #26 since 8/29/18 at 9:38PM (a total of 13 hours) with a new diagnosis of epilepsy, a recent fall, and no medications for her epilepsy since sometime on 8/28/18. Review of the nursing policy and procedures "Assessment and Reassessment of Patients" stated, "Procedure: 2. The registered nurse will assess each patient at a minimum every 8 hours and more often as deemed necessary."


Review of patient #26's chart on 8/30/18 at 10:30AM revealed she had not seen a physician since her arrival on 8/29/18 at 21:35 (9:35PM).


Review of patient #26, #27, #29, and #30's intake charts revealed no documentation of the patient's diet, activities of daily living (ADL) also called self-help or self-care activities. These activities can include everyday tasks such as dressing, self-feeding, bathing, laundry, and / or meals. There were no physician orders for diets. This could be detrimental to a patient that requires a special diet due to a current disease process. Staff #2 reported on 8/30/18 that the patients were fed while waiting in intake. Staff #2 confirmed that there was no physician order for a diet and the RN provides the oversight for the patient's diet. There was no documentation found of the patients receiving meals or how the patients tolerated the meal.


An interview with staff #2 on 8/30/18, at 1:28PM, revealed the nursing policies are for inpatients that are admitted into the facility. Staff #2 was asked if there were any nursing policy and procedures for the direction of the intake nurse. Staff #2 stated, they had just placed nurses in the intake area sometime in June. Staff #5, Intake Coordinator and Human Services Director, confirmed the RNs were put in the intake area on 7/9/18. Staff #2 confirmed the facility had not developed any policy and procedures for the nurses in the intake area.


Staff #2 reported that the patients did not see a doctor until the facility had a bed available and they were able to admit the patient. Staff #2 stated, if the patient was unstable, had a change in condition, or was better and could leave the facility, the RN would call the doctor to get further instruction. Staff #2 confirmed that patients could be in the intake area for up to 3-4 days. Staff #1 and #2 confirmed the patients were being detained by the facility on a peace officer's emergency detention with no physician oversight.


On 8/30/18, Staff #1 and #2 were asked by the surveyor why the patients were accepted to the facility if there were no beds available. Staff #1 stated that they go on divert and notify the Dallas County Hospital and the Dallas police with a phone call. Staff #1 reported, the police bring the patients straight to their facility instead of an acute care ER knowing they are on divert and have no beds. Staff #2 reported that some of the patients have to be immediately transferred out to an acute care setting due to medical conditions. The surveyor asked staff #1 and #2 why the police continue to bring patients to the facility, that have not had medical clearance, when there is no bed available, and the facility has gone on divert. Staff #2 reported that they had tried to work on getting a better relationship with the local police so they would bring the patients to their facility. Staff #1 and #2 confirmed they had not instructed the police to divert the patients to a facility that can meet the patients need or medically clear the patients until a bed becomes available for an admission.


According to the "State of Texas Psychiatric Hospital Licensing Rules" 404.158(1)(F),


"Each person apprehended or detained, but not yet admitted , has the following rights.

(F) The right to a preliminary examination by a physician conducted immediately upon arrival at the department facility, community center, or psychiatric hospital following apprehension to determine whether the person meets the criteria for admission for emergency detention. If a physician is not available to conduct the examination, steps shall immediately be taken to arrange for the examination as soon as possible, but in no case more than 24 hours after apprehension." Staff #2 stated on 8/30/18 that the facility used a contracted telemedicine service for physician services. The service is available 24 hours a day, 7 days a week. The facility has the capabilities for a psychiatrist to see the patient as soon as the patient arrives.


According to the "State of Texas Psychiatric Hospital Licensing Rules" 411.462(b)(2)(A)-(B) "Preliminary Examination:

(2) The preliminary examination shall include:

(A) an assessment for medical stability; and

(B) a psychiatric examination to determine if the individual meets the criteria described in subsection (c)(1) of this section." (emergency detention admission criteria)


According to "State of Texas Psychiatric Hospital Licensing Rules" 411.461(f)(3) "Admission Examination. (3) The physician may not delegate conducting the admission examination to a non-physician."


Review of patient # 27's chart revealed, he was a 6-year-old male brought in by his mother due to behavioral issues. The nursing assessment revealed the RN assessed patient #27 on 8/29/18 at 1350 (1:50PM). The vital sign section was blank. The "current medical problems" listed were ADHD (Attention Deficit Disorder), DMDD (disruptive mood dysregulation disorder) and Depression. Patient was not currently taking any medications. There was no further nursing documentation after the initial assessment found.


Review of patient # 27's chart revealed an intake assessment was performed by the social worker on 8/29/18 at 14:36 (2:36PM). The chief complaint stated, "ADHD, DMDD, Aggression, flipping table and chairs. Throwing things, being physical towards others and himself." A safety plan was found that the mother would agree to keep the patient safe but there was no date or time. The patient did not receive a physician evaluation. Review of the EMTALA log dated 8/29/18 at 1820 (6:20PM) revealed the patient was discharged without a physician evaluation. The comment section stated, "Will return in the morning for a bed."


Review of patient #29's chart revealed, the patient was a [AGE]-year-old male brought in on a peace officer's emergency detention warrant on 8/29/18 at 2:30PM. Staff #1 confirmed the facility was on divert at this time due to no beds available. The emergency detention warrant stated, "He was lying in the grass next to the street screaming. He believed the sky was falling on him. He may have rolled into the street." The patient was brought into the facility handcuffed.


Review of the EMTALA LOG revealed patient #29 arrived in the facility at 16:00 (4:00PM). A nursing assessment was performed at 1620 (4:20PM). The RN had documented that the patient was "Confused/Disoriented." The nurse had documented that the patient was not presenting for detox. Under the current medical problems, the nurse documented "no." The nurse had documented that the patient has had no falls in the past three months and has not had any communicable disease exposure. The nurse documented that the patient was on no medications. There was no documentation that the patient had a medical clearance or had been seen by a physician to rule out any medical issues or diagnostic test to rule out alcohol or drug use.


Review of the clinical intake screening form dated 8/29/18 at 2140 (9:40PM) stated, the patient #29 was actively endorsing psychosis, manic, screaming and confused. The patient was unable to articulate thought content and was having auditory and visual hallucinations. The licensed professional counselor was unable to do the evaluation of risk due to "UTA" (unable to answer). There was no further documentation found. Review of the EMTALA LOG revealed the patient was admitted on [DATE] at 12:30PM. The patient was left in a waiting room with other patients in a psychotic state for 15 hours and 50 minutes. There was no documentation that the patient's basic needs were met. There was no documentation that the patient was being monitored and by whom.


Review of patient #30's intake chart revealed, she was a [AGE]-year-old female brought into the facility, on 8/29/18 at 9:48AM, on a peace officer's emergency detention warrant. Patient #30 had hit her roommate and made threatening acts towards her roommates at the boarding house. Review of the nursing assessment dated [DATE] at 9:55AM revealed, there were no vital signs obtained. The patient had refused to answer any questions of current medical problems, or communicable disease exposure. The nurse marked that the patient was on medications but were unknown. There was no documentation that the patient had been seen by a physician or had any diagnostic tests performed to rule out any medical condition or substance abuse. The EMTALA LOG revealed, the patient was admitted [DATE] at 15:35 (3:35PM). There was no further documentation that a nurse assessed the patient. There were no documented vital signs and no documentation on why there was no nursing assessment/ reassessment performed. The patient was in the waiting area without seeing a physician or nurse assessment for at least 25 hours and 40 minutes.



B.

Review of patient #17's chart revealed, he was a [AGE]-year-old male, admitted to the facility on [DATE] at 6:55AM for Suicidal Ideation (SI), Homicidal Ideation (HI), and Aggression. The patient was medically cleared by an ER and was transferred by parents to the facility.


Review of the Intake assessment dated on 2/6/18 at 6:25AM revealed, the patient was seen by a Licensed Intake Counselor. Under the abuse/neglect/trauma section of the Intake Assessment revealed patient #17 was sexually abused in 2016 by an older sister. CPS was involved. There was no further documentation of the physician or nursing staff being notified of the patient being a sexual victim.


Review of the policy and procedure "Sexually Acting Out Precautions" revealed:

"PROCEDURE:

1. Patients will be assessed during the Initial Evaluation for any history of sexually acting out behavior or abuse history.

2. If the Admission staff identify that a patient is a risk for sexually acting out, they will then notify the admitting doctor and also pass on this information to the Nursing staff on the Intake to Unit handoff form. They will also inform the staff if a patient has been a perpetrator or victim."


Review of the Physician "Preadmission Evaluation/Management" revealed, the physician saw the patient via telemedicine on 2/6/18 at 2:29AM. The physician documented, "PHYSICIAN NOTE Per staff: Pt. presents to ED d/t deteriorating behavior. He is verbally aggressive towards family and physically aggress: towards mother. Over the weekend, mother reports, she woke up to him holding a full cup of hot coffee over her and made the statement " I wasn't trying to kill you." His caregiver also reports him saying "I'm going to make myself disappear, going to die." He also reported to his therapist yesterday that he wanted to kill himself by banging his head up against the wall until he die. (sic) He also made threats to kill both his mother and his [AGE] year old nephew. Per MD: Above per staff noted. Patient has been medically evaluated and cleared per transferring provider. _____(NP) Medical Clearance: Yes." The physician did not include documentation of the patient having been sexually abused.


An interview was conducted with staff #2 on 8/31/18 concerning patient assignments and how to determine predator and victim room assignments. Staff #2 reported that the patients would have on their intake screening if they were a predator or a victim. The staff would not put a victim and predator together. Staff #2 confirmed that the staff would follow the "Sexually Acting Out Precautions (SAO)."


Review of the policy and procedure "Sexually Acting Out Precautions" revealed:

"PROCEDURE:

4. The RN will assess each patient for potential of sexually inappropriate behavior during the admission nursing assessment. Any patient who has demonstrated sexually inappropriate behavior during hospitalization will be placed on SAO and remain on SAO precautions for the remainder of the hospitalization .

a. The RN or MD may place a patient on SAO precautions. The MD is the only staff who can remove a patient from SAO precautions.

b. The Treatment Team at weekly conferences will review the SAO precautions and behaviors necessitating the precautions.

c. All personnel caring for the patient shall be sufficiently informed of the patient's status."


Review of the nursing assessment dated [DATE] at 7:55AM revealed no assessment found concerning the patient's potential for inappropriate sexual behavior or patient's history of sexual abuse as a victim.


Review of patient #17's nurses notes for 2/6/18 revealed, "11:40AM Pt. was choked by roommate; assessed no visible injury. Pt room re-assigned. Will continue to monitor.


2/6/18 12:15PM _____mother notified; thankful for call. Asked "did we do anything to provoke the child?"

2/6/18 12:18PM House supervisor notified.

2/6/18 13:00 (1:00PM) ______MD notified."


There was no further information documented on how the staff was going to protect the child from another roommate, what room changes were made, how the patient was coping from the incident, or if an incident report was filed.


The Patient Observation Record is a log of the patient's location and behaviors that are observed every 15 minutes by the Mental Health Technician (MHT) or other staff as required. Review of patient #17's Patient Observation Record dated 2/6/18 revealed the patient was in his room at 11:30AM talking with peers. At 11:45AM to 12:00PM, pt was in his room sitting quietly, 12:15PM pt was talking to peers. Patient #17 was documented being in his room until 2:00PM when he went to the gym. There was no documentation that the patient was with the nurse or had changed rooms.


Review of the psychiatrist evaluation dated 2-6-18 at 1735 (5:35PM) revealed there was no documentation of the patient's past sexual abuse or the patient's physical altercation that was reported at 11:40AM.


Review of the Daily Nursing assessment dated [DATE] revealed, "11:50AM- Pt(#17) in room, MHT walked in pt on floor with pants unzipped, roommate (#32) on top of patient attempting to put penis in buttock. Per patient they had just started nothing had happened he asked roommate to do it to him, but they got caught by staff before it happened, Per patient (#32) it was what was done to him when he was younger. Pt (#17) place on LOS (line of sight) by doctor. Pt continues to be monitored LOS on all safety. 1230 - pt reassessed pt upset now afraid he will not be able to go home because of situation. Pt encouraged to used coping skills and remember his boundaries with others and make positive choices. Pt (#17) continues to be monitored on LOS at all times per doctor."


Review of the nurses notes on 2/13/18 revealed, the nurse was performing a nursing group with the patients from 12:30PM until 1:30PM. The nurse documented that patient #17 was attending the group during this time. There was inconsistency in the documentation of where and what the patient was doing between 12:30PM and 1:30 PM. There was no documentation that the parents were notified by the nurse of the sexual encounter. There was no documentation that the patient was placed in the room by himself or if the predator was still in the room. There was no documentation that the child was assessed medically for any injuries.


Review of patient #32's chart revealed, he was a [AGE]-year-old male sharing the room with patient #17. Patient #32 was involved in the sexual acting out behavior. Review of patient #32's chart revealed there was no documentation that the patient was a sexual victim or predator. Review of patient #32's nurse's notes dated 2/13/18 at 11:50AM revealed, "pt in room during quiet time. MHT walked in pt was on top of roommate with his penis in hand attempting to put in roommate buttocks. Pt jumped up, removed from room. Pt continues to be monitored q 15 minutes for safety. 1330 (1:30PM) pt reassessed for situation encouraged not to do that again. Patient (#32) stated roommate asked him to do it. Pt continues to be monitored q 15 minutes and in LOS (line of sight)."


Review of patient #32's chart revealed, the patient was in custody of CPS. There was no documentation that CPS worker was ever notified of the patient sexual acting out behavior.


Review of patient #32's physician orders revealed, "block pts room due to SAO if pt gets a roommate will need 1:1 at HS. Add SAO to precautions." The sexual encounter happened during the day and not at night. There was no order that specified that the patient be on 1:1 during the day if he receives a roommate. This would allow the patient to have another opportunity to be "sexually acting out" with another patient. Review of patient #32's nurse's notes dated 2/13/18 at 1435 (2:45) revealed, "Pt moved to a different room." The nurse had also documented the patient was in a nursing group from 12:30PM until 1:30PM. The MHT documented the patient was in other areas between 12:30PM and 1:30PM.


Review of the MHT patient observation record for patient #32 dated 6/13/18 revealed the following:

1145AM the patient was in his room lying down.

12:00PM patient was in the dayroom sitting quietly until 12:30PM.

12:30PM patient was in room and sitting quietly.

12:45PM The patient was in the dayroom watching TV.

1:00PM In day room. pt talking with nurse.

1:15PM till 1:30PM In dayroom watching TV.


Review of the MHT patient observation record for patient #17 dated 6/13/18 revealed the following:

1145AM the patient was in his room lying down.

12:00PM patient was in his room then marked over and documented the patient was in the dayroom sitting quietly until 12:30PM.

12:30PM patient was in room and lying down.

12:45PM The patient was in the dayroom watching TV.

1:00PM In day room. pt talking with nurse.

1:15PM till 1:30PM In dayroom watching TV.


The MHT documented that patient #17 and #32 were in pt room alone at 12:30PM. There was no documentation that patient #32 was removed to another room until 2:35PM. There was no documentation from the MHT that the patients were on a LOS or a 1:1. The patients had an opportunity to sexually act out at 12:30PM.


Review of the policy and procedure "Sexually Acting Out Precautions" revealed:

"PROCEDURE:

5. SAO precautions will be addressed on the Treatment Plan, and will be noted on the Precautions Sheets and Report Sheets to denote the appropriate concerns.

a. Treatment Plan Entry made and dated documenting the patient's sexually acting out status, with a description (brief) of the behavior that prompted the patient being placed on SAO precautions as well as if the patient has been a victim or perpetrator. b. Appropriate documentation will also be entered in the multidisciplinary notes. c. SAO precautions will be documented on the Patient Data and Assessment form.


Review of the treatment plan revealed no documentation of the patient's sexually acting out status for patient #17 or 32. There was no interventions or goals for the patient's precautions or safety.


Review of patient #17's social workers notes (SW) dated 2/13/18 at 3:15PM revealed, "Spoke to mom in-person when she came to pick up pt. for discharge but discharge was canceled due to SAO behavior that occurred an hour before mother arrived. Pt to discharge for another week till early next week. Treatment team to discuss situation w/pt. reevaluate medication and treatment resources." There was no documentation that the mother was told what happened to the patient until she arrived to pick up the patient for discharge on 2/13/18 at 3:15PM.


Review of patient #17's physician order dated 2/13/18 at 1540 (3:40PM), "cancel discharge for today per parent's request."


Review of patient #17's physician order dated 2/13/18 at 1615 "(4:15PM) SAO precaution 1:1 for safety." There was no physician order or direction documented from the physician from 11:40AM until 4:15PM. There was no documented orders or direction from the physician on SAO precautions or an order for safety for 4.5 hours.


Review of patient #17's physician orders revealed a telephone order that stated, "LOS during day/block room. If get a roommate pt will need to be 1:1 at qhs. DC 1:1 order from 2/13/18." There was no documentation that the patient was in a room alone or if the patient had a roommate. There was no clear documentation that the patient was on a 1:1 at night or LOS.


Review of patient #17's progress notes dated 02/16/18 at 12:04PM revealed, the SW documented, "spoke with patient mom about coming to p/u patient. Mom began talking about did we report the "incident" to CPS. I explained to the mom due to the act not happening, we are not mandated to report to CPS, but to the legal guardians. Mom began stating that she did not feel safe with the patient coming home and that she would call CPS herself to get more recommendations and call us back." The facility chose not to call Child Protective Services (CPS) concerning the sexual behavior of the patient. The patient's mother contacted CPS to discuss the potential danger of the other children in the home.


Review of patient #17's nurse's notes dated 2/19/18 at 1430 (2:30PM), Pt is discharged home with parents. Pt given all personal items. Copies of all D/C documents are given to guardian. Pt is discharged ." There was no further discharge information documented.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on review of records, observation, and interviews, the facility failed to:


A.) prevent neglect by providing the patients with clean clothes. Provide needed clothes to promote patient dignity and avoid mental anguish in the milieu in 3(5, 7, 25) of 8 patient charts reviewed.


B.) provide a place for patients to sit down or lie down while being secluded. Patients were forced to sit or lie down on the floor in 3 (Unit 2, Unit 3, and Unit 6) out of 3 seclusion rooms.


Findings included:


A.) During a tour of the children's unit on 8/29/18, patient #7, a 9-year-old boy, was found sitting alone in the common area. Patient #7 was sitting in paper scrubs, socks and flip flops. Patient #7 had lint in his hair and had not been groomed. Patient #7 stated, he did not have any clothes except the underwear he was wearing and a pair of pants. Patient #7 stated he has been in the same underwear since he came to the facility on [DATE] (7 days). Patient #7 stated that his underwear had not been washed since he had been there. Staff #1 and #2 were aware of the conversation and did not deny the patients accusations. Staff #4 stated that patient #7's Child Protective Services (CPS) worker was made aware but had no clothes to bring to the patient. The patient's foster mother had refused to bring the patient any clothes. The foster mother was punishing him by not giving him clothes, according to the charge nurse and staff #4.






B.) A tour of the facility was conducted on 8-29-2018 with Staff #1 and Staff #2. Three (3) of 3 seclusion rooms toured on the units were found to have visibly dirty floors with trash/dirt/or debris on them. The rooms were completely empty and did not have psychiatric safe chairs or beds. No provisions were observed for patients who may have been medicated prior to being placed in the seclusion room during a psychiatric emergency to sit or lie down other than on the dirty floor.


Staff #2 was asked where the patient was supposed to sit if they wanted to or needed to sit down. Staff #2 stated patients who were being secluded would be given a blanket and required to sit on the floor, if needed.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of records and interview, the facility failed to ensure nursing staff carried out and documented medication administration per policy and as ordered by the physicians in 2 (Patient #15, #20, and #5) of 6 patient charts reviewed.

Findings were as follows:

Patient #15

A review of Patient #15's chart revealed regularly scheduled medications were not given with no documentation as to why.

An order written on 3-23-2018 for Risperdal 2mg (milligrams) PO (by mouth) QHS (at bedtime) and Lexapro 5mg PO daily was written.

On 3-23-2018 at 9:00 pm, the nurse documented on the Medication Administration Record that an attempt to administer Risperdal was made; however, the patient refused. This was the only attempt documented during her stay.

No documentation of any attempt to administer Lexapro was found in the patient chart. The MAR was not documented per policy or a note made as to why the medication was not given.

Instead, she was given Emergency Behavioral Medication Administrations of Haldol, Benadryl, and Ativan (HBA); one time on 3-23-2018, three times on 3-24-2018, and once on 3-25-2018. A second dose of medication was ordered for 3-25-2018 just prior patient falling, sustaining a head injury, and having to be transferred to a medical hospital Intensive Care Unit.

Patient was given HBA on 3-25-3018 at 0840 per nursing notes. This was not documented on the Medication Administration Record (MAR). Nursing staff failed to document the administration of HBA on the MAR on 3-25-2018 at 8:40 AM. This administration was found documented in the daily nursing narrative notes.


Patient #20

A review of Patient #20's chart was made on the morning of 8-31-2018. An order was found to be written upon patient admission to the facility on [DATE] for the medication Seroquel to be given at bedtime. This medication was scheduled for 9:00 PM. Review of the MAR did not show that the medication was not given on 8-30-2018 at 9:00 pm with no documented explanation of why the medication was not given.

An order was given on 8-28-2018 for the nurse to check the patient's blood sugar prior to meals and at bedtime. The bedtime check was scheduled for 9:00 pm. The patient was to receive insulin based on what the blood sugar reading was. The MAR did not reflect that the blood sugar check was accomplished or that the patient received insulin based on the blood sugar level.


No documentation of missed dose rescheduling was found on either patient's chart.



An interview was conducted with staff #3 on 8-30-2018 in regards to Patient #15's chart. Staff #3 stated that he had reviewed the chart and that all Emergency Behavioral Medication Administrations had been appropriately documented with all required monitoring paperwork completed. When it was pointed out that medication administrations had not been documented on the MAR and did not have monitoring paperwork for each administration, Staff #3 confirmed that he was not aware that the nurses had not documented the medication administrations and monitoring paperwork.



Review of hospital policy, Title: Medication Administration and Records, Policy Number - PHR-159, Effective: 11/2015 was as follows:

" ...

4.2.5 "Stat" and Missed Doses:
4.2.5.1 When a "STAT" initial medication dose is ordered, the dose will be administered (within 15 minutes).
4.2.5.2 "NOW" orders will be given within 60 minutes.
4.2.5.3 If a medication dose has been missed for any reason, the nurse will decide whether the missing dose should be rescheduled. The decision will be based on the type of drug that is involved, how it is being used, and the patient's
condition. The nurse may consult with the pharmacist and/or licensed practitioner in reaching a decision.

...

4.3.1.16 "One Time" or "STAT" orders are transcribed onto the next available space on
the routine order MAR page.

...

4.3.1.18 To indicate the administration of a scheduled medication, the nurse will cross out the time the medication was administered and initial directly to the right of the medication with time.
4.3.1.19 If a scheduled medication is refused or not given, then the medication time is circled; and the nurse's initials are written directly to the right of the refused time. In addition, the nurse will place the appropriate note in the chart.

..."






Patient #5

Review of Patient #5's complaint revealed on the morning of 1-3-18 she asked about her antibiotics and prenatal vitamins. She was told by staff that they were not aware of any medications or her pregnancy.

Review of the physician admission orders on 1-3- 18 at 1:00AM revealed an order for Amoxicillin (antibiotic) 500 mg q8hr x 5 days for UTI/strep.

A physician order was written on 1-3-18 at 12:30PM. The order read, "Macrobid 100mg po BID x 5 days for UTI and prenatal vitamins 1 po daily."

A "PRN & 1st Dose Medication Documentation" form dated 1-3-18 at 1315 (1:15PM) revealed the patient received her first dose of Amoxicillin, Macrobid and prenatal vitamin. There was no documentation on why the patient's Amoxicillin was not administered until 12 hours later. Nursing failed to administer the patients medication at the appropriate time as ordered. Nursing failed to identify and document any reasons for the delayed medication administration.
VIOLATION: TIMELY DISCHARGE PLANNING EVALUATIONS Tag No: A0810
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review the facility failed to initiate and and develop a timely discharge plan for 1(5) of 2 (5&7) charts reviewed.

Review of patient #5's chart revealed she was admitted to the facility on [DATE]. She had reported that she was homeless, pregnant and did not have a job or a place to stay.

Review of patient #5's chart revealed an entry, by the case manager (CM), in the progress notes with no date or time. The note stated, " CM (case manager) met with pt to discuss d/c planning/care coordination. Pt states that she is working with a lady at her church who is helping her find housing and other resources. CM tried to contact the church who is helping her find housing and other resources. CM tried to contact the church members_____ (name and number) but was unable to reach her; left a msg. CM did contact pts friend_____ (name and number) to inquire about pt d/c and her home. ______(friend) stated pt could d/c to her home if needed."

Review of the social worker progress notes dated 1-6-18 at 1342 (1:42PM), "Pt was discharged , pt. refused to accept taxi voucher to location. Pt was discharged after completing treatment pt. stated that she did not have access to any items /weapons nor did she express any suicidal thoughts/plans. Pt was able to identify alternative methods to SI/identify triggers." There was no other documentation found of SW involvement or discharge planning. There was no clear documentation if the patient received the taxi ride and made it to her destination.

Review of patient #5's written complaint revealed she was seen by her primary physician "via skype and asked numerous times when would I be discharged . On each occasion I asked a date, his (psychiatrist) words verbatim was he wasn't going to release me homeless and pregnant, so he wanted me to work with the social worker to establish placement. I had only met the social worker once on 1-5-18 and she said she was going to work with my church therapist to find placement. On the morning of 1-6-18 staff _____(SW) says you're going home today. I said couldn't be haven't talked to anyone."

Patient #5 had not seen a social worker until 1-6-18 at 10:39AM, The day of discharge. There was a case manager's note found in the chart but had no date or time. The Social Worker (SW) documented that they tried to locate and phone the patients church members with no success. Pt was to be discharged to "The Bridge" in Dallas. There was no documentation of what "The Bridge " was or if they could assist the patient with her current issues.