The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

OCEANS BEHAVIORAL HOSPITAL OF PLANO 4301 MAPLESHADE LANE PLANO, TX March 20, 2018
VIOLATION: GOVERNING BODY Tag No: A0043
Based on record review and interview, the hospital failed to ensure that the governing body discharged its oversight responsbilities for the operations of the hospital effectively. On 01/04/18, 2 male patients were discharged to a homeless shelter. Patient #1 only had slipper-socks on his feet and with his Foley Catheter in place. The temperature in Dallas, TX was 47 degrees at 1500 on 01/04/18. The patients were dropped off at approximate 1530 and the shelter that does not open to allow intake until 1600. The patients were placed in line under an awning and left unattended. The patients wondered down the street to a meat packing company and were brought back to the shelter by an employee of the meat packing company. On 01/05/18, Patient #1 wandered away from the shelter and a Silver Alert was issued for his return. Patient #1 and Patient #2's Discharge Summary reflected both patient would need assistance with activities of daily living.

Cross Refer A0049
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to ensure the discharge planning evaluation included the patient's capacity for self-care in that 2 of 2 patients (Patient #1 and #2) were discharged to a homeless shelter after being identified by the physician as needing assistance with activities of daily living.


Findings included:


Patient #1's Interdisciplinary Treatment Plan dated 11/08/17 at 2000 reflected..."Placement...Nursing home, refer...Homeless shelter, refer...Aftercare...Substance abuse treatment with, refer...Medication management with, refer..."


Patient #1's Physicians Discharge Order and Instructions dated 01/04/18 reflected..." Discharge...to Austin Street Shelter.


Patient #1's Discharge Summary dated 01/05/18 at 1005 reflected..." The patient was able to walk and ambulate, but needed assistance with activities of daily living..."


Patient #1's chart did not reflect any referrals made to nursing homes for possible placement. Patient #1's chart did not reflect the patient's refusal to be placed in a nursing home.



Patient #2's Interdisciplinary Treatment Plan dated 11/30/18 at 1830 reflected..."Placement...Nursing home..."


Patient #2's Physicians Discharge Order and Instructions dated 01/04/18 reflected..." Discharge...to Austin Street Shelter.


Patient #2's Discharge Summary dated 01/05/18 at 1016 reflected..." The Patient needed assistance with activities of daily living..."


The temperature in the Dallas area on [DATE] was 47 at noon (https://www.timeanddate.com/weather/usa/dallas/historic?month=1&year=2018)


During an interview on 03/13/18 at 1145 Personnel #2 verified that Patient #1 and Patient #2 were discharged to a homeless shelter. Personnel #2 verified there was no documentation the hospital attempted to place Patients #1 and #2 in any nursing home, nor was there any documentation of the patients refusing to be placed in a nursing home.
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to ensure the initial implementation of the patients discharge plan in that 2 of 2 patients (Patient #1 and #2) were discharged to a homeless shelter on 01/04/18 with no documentation the shelter had been contacted to verify they had the capacity for and could meet the needs of the patient. Patient #1 and #2 were discharged without medications. Patient #2 was discharged with a Foley Catheter in place, wearing slipper-socks with no shoes in 47 degree weather. Patient #1 and #2 were left outside the shelter in line for entrance approximately 30 minutes before the shelter opened unattended. On 01/05/18 Patient #1 wandered away from the shelter and a Silver Alert was issued for his return. There is no documentation Patient #1 and #2 had the needed identification to be allowed entrance to the homeless shelter.


Findings included:


Patient #1's Interdisciplinary Treatment Plan dated 11/08/17 at 2000 reflected..."Placement...Nursing home, refer...Homeless shelter, refer...Aftercare...Substance abuse treatment with, refer...Medication management with, refer..."


Patient #1's Discharge Summary dated 01/05/18 at 1005 reflected..." The patient was able to walk and ambulate, but needed assistance with activities of daily living..."


Patient #1's Physicians Discharge Order and Instructions dated 01/04/18 reflected..." Discharge...to Austin Street Shelter...Discharge Medications...Clonazepam...Lactobacillus Acidophilus...Levofloxacin...Ensure nutritional supplement...Seroquel..."


Patients #1's Patient Belongings Inventory reflected..."Admission...date 11/13/17 at 1400...Driver's license TX license...Discharge...signature of Patient and Staff, date, and time are blank..." The Patient Belongings Inventory did not reflected the patient's belongings were returned to them upon discharge.


Patient #2's Interdisciplinary Treatment Plan dated 11/30/18 at 1830 reflected..."Placement...Nursing home..."


Patient #2's Physicians Discharge Order and Instructions dated 01/04/18 reflected..." Discharge...to Austin Street Shelter...Discharge Medications...Aspirin...Cyclobenzaprine...Divalproex Sodium DRT...Docusate Sodium...Dutasteride...Gemfibrozil...Lactulose...Levothyroxine...Medroxyprogesterone...Nitrofurantoin Macrocrystals, Risperidone...Tamsulosin..."


Patient #2's Discharge Summary dated 01/05/18 at 1016 reflected..." The Patient needed assistance with activities of daily living..."


Patients #2's Patient Belongings Inventory reflected..."Admission...undated and unsigned...Driver's license: none listed...Discharge...signature of Patient and Staff, date, and time are blank..." The Patient Belongings Inventory did not reflected the patient's belongings were returned to them upon discharge.


The temperature in the Dallas area on [DATE] was 47 at noon (https://www.timeanddate.com/weather/usa/dallas/historic?month=1&year=2018)


During an interview on 03/13/18 at 1145 Personnel #2 verified that Patient #1 and Patient #2 were discharged to a homeless shelter. Personnel #2 verified there was no documentation the hospital had made any referrals for Patient #1 and #2 to be placed in a nursing home. Personnel #2 verified there was no documentation the hospital contacted the homeless shelter to see if they could accommodate the patients. Personnel #2 stated when the patients are discharged they call their medications into the pharmacy of their choice. Personnel #2 confirmed there was no documentation the medications for Patient #1 and #2 were called to any pharmacy. Personnel #2 verified there is no signatures on the Patient Belongings Inventory reflecting the patients received their belongings on discharge.


During an interview on 03/13/18 at 1615 Personnel #5 verified he dropped Patient #1 and #2 at the Austin Street Center approximately 30 minutes before the shelter opened. Personnel #5 stated he recalled Patient #2 was not wearing any shoes and was wearing slipper socks because he had to help him across the street with his walker. Personnel #5 recalled Patient #2 had a Foley Catheter in place when he was discharged from the hospital. Personnel #5 stated he placed Patient #1 and #2 in the front of the line under an awning and told them not to get out of line. Personnel #5 then left the patients unattended.


During an interview on 03/14/18 at 0945 via telephone Personnel #6 stated she recalled getting a call from the shelter on 01/05/18 regarding Patient #1 because he had wandered away from the shelter.


During an interview with a representative from the Austin Street Center on 03/20/18 at 1230 via telephone, the representative stated you must have a state issued identification to be allowed entrance to the center. The center opens at 1600 for intake of male guest.
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based on interview and record review, the governing body failed to ensure that the medical staff is accountable to governing body for the quality of care provided to patients in that, 2 of 2 patients (Patient #1 and Patient #2) werenot provided a safe and appropriate discharge. Patient #1 and #2 were discharged to a homeless shelter when their discharge summaries indicated the patients needed help with activities of daily living.


Findings Included:


Patient #1's Interdisciplinary Treatment Plan dated 11/08/17 at 2000 reflected..."Placement...Nursing home, refer...Homeless shelter, refer...Aftercare...Substance abuse treatment with, refer...Medication management with, refer..."


Patient #1's Physicians Discharge Order and Instructions dated 01/04/18 and untimed reflected..." Discharge...to Austin Street Shelter.


Patient #1's Discharge Summary dated 01/05/18 at 1005 reflected..." The patient was able to walk and ambulate, but needed assistance with activities of daily living..."



Patient #2's Interdisciplinary Treatment Plan dated 11/30/18 at 1830 reflected..."Placement...Nursing home..."


Patient #2's Physicians Discharge Order and Instructions dated 01/04/18 and untimed reflected..." Discharge...to Austin Street Shelter.


Patient #2's Discharge Summary dated 01/05/18 at 1016 reflected..." The Patient needed assistance with activities of daily living..."



During an interview on 03/13/18 at 1145 Personnel #2 verified that Patient #1 and Patient #2 were discharged to a homeless shelter.
VIOLATION: CONTRACTED SERVICES Tag No: A0083
The hospital's governing body failed to ensure that appropriate discharge planning was provided for 2 of 2 patients (Patient #1 and Patient #2). There was no documented evidence of referrals for proper placement of patients #1 and #2 after discharge resulting in the patients being discharged to a homeless shelter. The patients required assistance in the performance of activities of daily living.


Findings included:


Patient #1's Interdisciplinary Treatment Plan dated 11/08/17 at 2000 reflected..."Placement...Nursing home, refer...Homeless shelter, refer...Aftercare...Substance abuse treatment with, refer...Medication management with, refer..."


Patient #2's Interdisciplinary Treatment Plan dated 11/30/18 at 1830 reflected..."Placement...Nursing home..."


Patient #2's Progress Note dated 12/26/17 at 1147 reflected..."spoke with pt's son, pt. came from Heritage Gardens in Carrollton, may or may not be allowed to return. Pt's son asked for update on placement when possible..."


During an interview on 03/13/18 at 1145 Personnel #2 and Personnel #3 were asked to provide documentation for the discharge planning of Patient #1 and #2. Personnel #2 stated she could not find any documentation that any facilities were contacted for the placement of Patients #1 and #2. Personnel #3 verified there was no documentation in the charts for further discharge planning.
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to ensure the patient's discharge plans were reassessed for the appropriateness of the discharge plan in that, 2 of 2 patients (Patient #1 and #2) discharge plans were not reassessed for the appropriateness of the discharge plan.


Findings included:


Patient #1, a [AGE] year old male, was admitted on [DATE]. Patient #1's Interdisciplinary Treatment Plan dated 11/08/17 at 2000 reflected..."Placement...Nursing home, refer...Homeless shelter, refer...Aftercare...Substance abuse treatment with, refer...Medication management with, refer..." There was no documentation that the discharge portion of the treatment plan was updated prior to Patient #1's discharge.


Patient #1's Discharge Summary dated 01/05/18 at 1005 reflected..." The patient was able to walk and ambulate, but needed assistance with activities of daily living..."


Patient #2 a [AGE] year old male was admitted on [DATE]. Patient #2's Interdisciplinary Treatment Plan dated 11/30/18 at 1830 reflected..."Placement...Nursing home..." There was no documentation that the discharge portion of the treatment plan was updated prior to Patient #2's discharge.


Patient #2's Discharge Summary dated 01/05/18 at 1016 reflected..." The Patient needed assistance with activities of daily living..."


During an interview on 03/13/18 at 1145 Personnel #2 verified there was no documentation the Patient #1's or #2's discharge plans had been reassessed prior to discharge.
VIOLATION: PATIENT RIGHTS: GRIEVANCE PROCEDURES Tag No: A0121
Based on record review and interview, the hospital failed to follow their grievance process in that a call concerning the inappropriate discharge of 2 of 2 patients (Patients #1 and #2) was not addressed as a grievance.


Findings included:


On 01/04/18 the hospital received 2 calls regarding the appropriateness of a discharge of 2 male patients to a homeless shelter.


During a review of the Grievance and Complaint log there was no evidence of the above grievance.


During an interview on 03/12/18 at 1140 with Personnel #1 in the Conference Room, Personnel #1 stated she was unaware of a grievance regarding the discharge of Patients #1 and #2. Personnel #1 stated the employees are aware of the grievance process.


During an interview on 03/14/18 at 0940 with Personnel #6 via telephone, Personnel #6 stated she received more than 1 phone call regarding the discharge of Patients #1 and #2. Personnel #6 stated she also receive a call the day after the patients were discharge stating that Patient #1 was missing. Personnel #6 stated she tried to call the shelter back a couple of times and even emailed them with no response. Personnel #6 stated she notified the DON, CEO and the Patient Advocate. Personnel #6 stated she charted the above information. During a review of the charts for Patient #1 and Patient #2 the above stated information was not found.


During an interview on 03/20/18 at 0945 with Personnel #7 via telephone, Personnel #7 stated she received a call regarding the shelters ability to take care of the needs of Patients #1 and #2. Personnel #7 stated she referred the call back to Personnel #6.


The policy titled Patient Complaints and Grievances effective 02/01/17 reflected ..." 5 ...Any complaint or issue not resolved with the initial staff person addressing the issue will be treated as a grievance ..."
VIOLATION: NURSING SERVICES Tag No: A0385
Based on interview and record review, the hospital failed to have an organized nursing service.

1. Nursing failed to reassess and evaluate 6 of 7 patients (Patients #1, #3, #5, #6 and #7) after administering emergency medications for aggressive behavior.

2. Nursing failed to reassess and evaluate 2 of 2 patients (Patient #2 and #5) after administering pain medication.

3. Nursing failed to administer sliding scale insulin to 2 of 2 patients (Patient#4 and #7) when blood glucose readings were elevated.

4. Nursing failed to recognize and treat 2 of 2 patients (Patient #1 and #2) for hypertension.

Cross Refer: A0395


Nursing failed to update and address physical and/or emotional needs of 3 of 3 patients care plans (Patients #1, #2, and #7) for their mental and physical well-being.

1. Patient #1's for aggression with interventions/goals.

2. Patient #2's for pain with interventions/goals.

3. Patient #1, #2, and #7 with short term goals met, revised or discontinued.

Cross Refer: A0396.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to ensure nursing staff reassessed and evaluated 6 of 7 patients (Patients #1, #2, #3, #5, #6 and #7) after administering emergency medications for aggressive behavior. The hospital failed to ensure nursing reassessed and evaluated 2 of 2 patients (Patient #2 and #5) after administering pain medication. The hospital failed to ensure nursing administered sliding scale insulin to 2 of 2 patients (Patient#4 and #7) when blood glucose readings were elevated. The hospital failed to ensure nursing recognized and treated 2 of 2 patients (Patient #1 and #2) for hypertension.


Findings included:


1. Patient #1 was admitted on [DATE] for altered mental status. Patient #1's Daily Nursing Assessment and Progress note dated 11/20/17 at 2255 reflected ..." Patient confused, aggressive towards staff trying to elope, trying to open doors. Patient received emergency injection per MD (doctor) order before change of shift ...Patient able to be redirected, sleeping at this time ..." The shift began at 1900. The assessment is 3 hours and 55 minutes after change of shift. There is not a Medication Administration Record (MAR) available for 11/20/17.


Patient #1's Daily Nursing Assessment and Progress note dated 11/22/17 at 0650 reflected ..." Patient aggressive at beginning of shift. Received emergency injection per MD order. Patient calmed down after receiving medication ..." The shift began at 1900 on 11/21/17. The assessment was 11 hours and 50 minutes after change of shift. There was not a MAR available for 11/21/17 or 11/22/17.


Patient #1's MAR dated 12/28/17 reflected ..." Ativan 1 mg Intramuscular every 6 hours as needed ...Admin. Time 2025 ..." The Daily Nursing Assessment and Progress note dated 12/28/17 does not reflect any aggressive behavior.


Patient #1's MAR dated 12/29/17 reflected ..." Ativan 1 mg Intramuscular every 6 hours as needed ...Admin. Time 1945 ..." The Daily Nursing Assessment and Progress note dated 12/29/17 does not reflect a reassessment of Patient #1 during the shift.


Patient #1's blood pressure (BP) was elevated on multiple occasions. On 11/13/17 his BP was 157/105, on 11/30/17 his BP was 149/101, on 12/01/17 his BP was 134/100 and on 12/09/17 his BP was 153/105. There was no evidence this was reported to the MD until 12/24/17 when the MAR reflected a new order for Clonidine 0.1 mg PO (per mouth) Q6HRS (every 6 hours) PRN. The MAR does not reflect the medication was administered.



2. Patient #2 was admitted on [DATE] for hypersexual behavior. Patient #2's Inpatient Nursing assessment dated [DATE] at 1820 reflected ..." Elimination ...Urinary ...Prostate Problems. Pt. (patient) has a Foley, Amber urine in Foley ..." There was no documented Foley care in Patient #2's chart for his entire stay in the hospital. The Progress Note dated 01/04/18 reflected ..." Pt. discharged to Austin Street Shelter ...SW (social worker) notified of Foley and advised Pt. cleared for d/c (discharge). Pt. d/c at 1530 ..." Patient #2 was discharged to a homeless shelter with the Foley catheter still in place.


Patient #2's BP was elevated on multiple occasions. Patient #'2 BP on 12/05/17 was 131/94, on 12/06/17 his BP was 122/96, on 12/09/17 his BP was 132/102, on 12/10/17 his BP was 130/95, on 12/13/17 his BP was 140/99, and on 12/22/17 his BP was 138/104. There is no documentation that Patient #2's elevated BP was reported to the physician and Patient #2 was never medicated for his elevated BP.


Patient #2's MAR dated 01/02/18 reflected ..." Tramadol 50 mg PO given at 0950 and 2100..." The Daily Nurse Assessment and Progress Note dated 01/02/18 and untimed reflected ..." Pt. utilized w/c (wheelchair) this day due to increased pain, PRN pain meds given ..." There was no evidence Patient #2 was reassessed for pain after the pain medication was administered.


Patient #2's MAR dated 01/03/18 reflected ..." Tramadol 50 mg oral every 6 hours as needed ...Admin. Time 1830 ..." Patient #2's Daily Nurse Assessment and Progress Note dated 01/03/18 does not reflect a complaint of pain nor a reassessment for effectiveness of pain medication.


Patient #2's MAR dated 01/04/18 reflected ..." Tramadol 50 mg oral every 6 hours as needed ...Admin. Time 0610 ..." Patient #2's Daily Nurse Assessment and Progress Note dated 01/04/18 at 0630 reflected ..." Pt. reported pain to back, administered meds per MAR ..." There was no documented reassessment for effectiveness of the pain medication.


3. Patient #3 was admitted on [DATE] for increasingly aggressive behavior. Patient #3's MAR dated 12/25/17 reflected ..." Haldol 2 mg IM (Intramuscular) now x1 ...admin. time 0945 ..." The Daily Nurse Assessment and Progress Note dated 12/25/17 does not reflect aggressive behavior nor does it reflect a reassessment after emergency medications were given.


4. Patient #4 was admitted on [DATE] for Schizoaffective disorder. The Capillary Blood Glucose Monitoring Log reflected on 01/30/18 at bedtime Patient #4's BS (blood sugar) was 179. The MAR dated 01/30/18 reflected ..." insulin regular human (Regular) Subcutaneous as Directed PRN to give 2 units use 0.02mL of 100 units/mL for Blood Glucose 151-200 ..." There was no documentation the insulin was given to Patient #4.


The Capillary Blood Glucose Monitoring Log dated 02/01/18 reflected at bedtime Patient #4's BS was 290. The MAR dated 02/01/18 reflected Patient #4's BS was 160 at 1130 and 167 at 1630. The MAR dated 02/01/18 reflected ..." insulin regular human (Regular) Subcutaneous as Directed PRN to give 2 units use 0.02mL of 100 units/mL for Blood Glucose 151-200 ...insulin regular human (Regular) Subcutaneous as Directed PRN to give 6 units use 0.06mL of 100 units/mL for Blood Glucose 251-300 ... There was no documentation the insulin was given.

The Capillary Blood Glucose Monitoring Log reflected on 02/02/18 at lunch Patient #4's BS was 232. The MAR dated 020/02/18 reflected ..." insulin regular human (Regular) Subcutaneous as Directed PRN to give 4 units use 0.04mL of 100 units/mL for Blood Glucose 201-250 ..." There was no documentation the insulin was given to Patient #4.


5. Patient #5 was admitted on [DATE] for aggression. The MAR dated 12/07/17 and untimed reflected ..." Haldol 2.5 mg IM ..." The Daily Nurse Assessment and Progress Note for 12/06/17 does not reflect any aggressive behavior nor does the note reflect a reassessment after medications were given.


Patient#5's Progress Note dated 12/15/17 at 1000 reflected ..."at 1000 pt. noted with increased agitation and aggression, IM Ativan 1 mg given with good effect. No further agitation, will continue to monitor ..." The MAR dated 12/15/17 reflected ..." 1123 1 mg Ativan IM ..." The medication was administered 1 hour and 23 minutes after being charted as given and effective.


6. Patient #6 was admitted on [DATE]. Patient #6's MAR dated 12/05/17 reflected ..." Haldol 2.5 mg IM and Ativan 1 mg IM now ...Admin. Time 1245 ..." The Progress Note dated 12/05/17 at 1300 reflected ..." Pt. struck this nurse on face ...shaking door handles ...pt. tried to attack and choke another female patient ..." There was no evidence of a reassessment after emergency medications were given.


Patient #6's MAR dated 12/06/17 reflected ..." Haldol 2.5 mg IM stat x1 dose admin. time 1900. Ativan 1 mg IM state x1 dose admin. time 1900. .The Daily Nurse Assessment and Progress Note for 12/06/17 does not reflected aggressive behavior or a reassessment after emergency medications were given.


7. Patient #7 was admitted on [DATE] for agitated, disruptive and violent behavior. Patient #7's MAR dated 11/24/17 page 3 reflected ..." Haldol 2.5 mg IM now ...Ativan 2 mg IM now ..." The MAR reflected initials, but no admin. time. Page 8 of the MAR reflected ..." Ativan 2 mg IM x1 now for agitation aggression. Admin. time. 2300. The Progress Notes dated 11/24/17 at 2248 reflected ..." 2 mg IM Ativan x1 now for aggression/agitation. Emergency injection administered to right deltoid at 2257...11/25/17 at 0000 ...patient calmer, falling asleep. Behavior improved ..." The Progress Note did not reflect any earlier aggression nor a reassessment for the Haldol injection.


Patient #7's MAR dated 01/19/18 reflected ..." Blood Glucose test ...2030 BS 178 ...insulin lispor (HumaLOG) 2 units Subcutaneous as directed PRN. To give 2 units use 0.02 mL of 100 units/mL for Blood Glucose 151-200 ..." There was no documentation that the insulin was given.


During a chart review on 03/13/18 ending at 1530 Personnel #4 was asked to review the chart of Patient #1, #2, #3, #4, #5, #6, and #7. Personnel #4 verified the above findings.


During an interview on 03/13/18 ending at 1600 Personnel #1 was asked for a policy on administration of emergency medications. Personnel #1 stated there was not a policy for the administration of emergency medications.


The policy titled Medication Administration effective 02/01/17 reflected ..." Policy:2. e. An indication for medication must be documented in the medical record ...Procedure: 9. Administration of PRN Medications: a ...Chart medication and time given on the MAR ...b. Chart reason for and patient's response to PRN medications in the Nurses Notes ..."


The policy titled Pain effective 02/01/17 reflected ..." Procedure: 3. The following pain intensity scale (0-10) will be used: a. 0: No Pain; b. 1-3: Mild Pain; c. 4-6: Moderate Pain; d. 7-10: Severe ...4. Patients will be asked to rate their pain levels using the 0-10 scale ...9. Documentation of pain assessments after the initial inpatient assessment is completed on the daily nursing assessment and through an additional progress note, if appropriate ...Documentation includes: a. intensity, location and duration of pain. b. Pain management method utilized. c. Pharmacological management. e. Effectiveness of management intervention. f. Patient and family teaching. 10. The RN will also document the patient's perceived effectiveness of the pain intervention using the 1-10 numeric scale within one hour of the intervention ..."


The policy titled Urinary Catheters effective 02/01/17 reflected ..." Procedure: 1. Foley (indwelling) catheters ...b. Routine care and cleaning: i. Trained registered nurses (RNs) and mental health technicians (MHTs) may complete routine care and cleaning of Foley catheters. ii. Occurs at least once a day, or more frequently if soiled or dirty ..."


The Texas Board of Nursing (2017) noted "Professional nursing involves the observation, assessment, intervention, evaluation, rehabilitation, care and counsel, or health teachings of a person who is ill, injured, infirm or experiencing a change in normal health process..." (http://www.bon.texas.gov/practice_scope_of_practice_rn.asp).
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to ensure that 3 of 3 patients' (Patient #1, #2, and #7) care plan were updated and/or addressed

1. Patient #1's aggressive behavior with interventions/goals and short term goals met, revised or discontinued.

2. Patient #2's pain with interventions/goals and short term goals met, revised or discontinued.

3. Patient #3's short term goals met, revised or discontinued.


Findings included:


1. Patient #1's Daily Nursing Assessment and Progress note dated 11/20/17 at 2255 reflected ..." Patient confused, aggressive towards staff trying to elope, trying to open doors. Patient received emergency injection per MD (doctor) order before change of shift ...


Patient #1's Discharge Summary dated 01/05/18 at 1005 reflected ..." The patient was noticed aggressive and violent. On November 18, 2017, the patient refused p.o. medications. The patient was given Ativan 1 mg IM for agitation. The patient became aggressive on November 20, 2017, refused p.o. medications ..."


Patient #1's Interdisciplinary Treatment Plan Master Plan dated 11/08/17 at 2000 reflected ..." Problem: 1. Thought disorder ...2. Substance use disorder ...3. HTN (hypertension) ...4. Hx. (history) of Prostate CA (cancer) ...5. Hx. of falls ...The Interdisciplinary Treatment Plan problem page reflected ...#1 Thought disorder ...#2 Substance Use Disorder ...#3 HTN ...#5. Fall Risk ...Short term goals ...Date established 11/08/17 ...By Target Date 11/21/17 ...Date Met, Revised or Discontinued ...is blank." There was no evidence the Treatment Plan was updated for aggression.


2. Patient #2's Inpatient Nursing assessment dated [DATE] at 1820 reflected ..." Elimination ...Urinary ...Prostate Problems. Pt. (patient) has a Foley, Amber urine in Foley ..."
Patient #2's MAR dated 01/02/18 reflected ..." Tramadol 50mg PO given at 0950 and 2100..." The Daily Nurse Assessment and Progress Note dated 01/02/18 and untimed reflected ..." Pt. utilized w/c (wheelchair) this day due to increased pain, PRN pain meds given ..."


Patient #2's Discharge Summary dated 01/05/18 at 1016 reflected ..." The patient was also given Tylenol for lower back pain ...The patient continued to complain of pain. The patient was given tramadol for lower back pain ...


Patient #2's Interdisciplinary Treatment Plan dated 11/30/17 at 1830 reflected ..." Problem:1. Sexually inappropriate Behavior ...2. Depression ...3. Fall Risk ...4. BPH (benign prostatic hyperplasia) ...5. CAD (coronary artery disease) ...6. HLD ([DIAGNOSES REDACTED]) ...The Interdisciplinary Treatment Plan Problem Page #1 Sexually Acting Out Behavior ...2. Depression ...3. Fall Risk ...Date Established 11/30/17. By Target Date 12/07/17 ...Date Met, Revised or Discontinue ...is blank" There was no evidence the Treatment Plan was updated for pain.


3. Patient #7's Interdisciplinary Treatment Plan Master Plan dated 11/15/17 at 1600 reflected ..." Problem ...2. Altered Thought Process ...The Interdisciplinary Treatment Plan Problem Page #2 the title is cut off reflected ...Date Established 11/19/17, By Target Date is blank, Date Met, Revised or Discontinued is blank ..."


During a chart review on 03/13/18 ending at 1530 Personnel #4 verified the above findings.
VIOLATION: DISCHARGE PLANNING Tag No: A0799
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the hospital failed to ensure an effective discharge planning process that applies to all patients.


The Discharge Planning staff failed to refer 2 male patients (Patient #1 and #2) for proper placement after discharge. Patient #1, a [AGE] year old male, was discharged to a homeless shelter on 01/04/18 after being identified as needing assistance with activities of daily living. Patient #2, a [AGE] year old male, was discharged to a homeless shelter on 01/04/18 with a Foley Catheter still in place, wearing slipper-socks and having been identified as needing assistance with activities of daily living.


Patient #1 and #2 were dropped off approximate 30 minutes before the shelter was open for intake, placed in line and told not to move. Patient #1 and #2 were then left unattended to wait for the shelter to open in 47 degree weather.


Cross Refer A 0820