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.

SUN BEHAVIORAL HOUSTON 7601 FANNIN STREET HOUSTON, TX 77054 Sept. 27, 2018
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review, the facility failed to uphold the rights of 1 of 6 sampled patients, admitted involuntarily, to participate in decision-making regarding their care (Patient # 34).

The facility failed to follow the the Emergency Detention Warrant (EDW) process and support Patient # 34's legal rights. Patient # 34 was held without voluntary consent or an EDW for 13 days.

Findings include:

TX 263

Review of intake # TX 263 alleged Patient #34 was brought to the facility involuntarily on an EDW issued on 03-13-18. The patient's case was dismissed on 03-23-18 but he was not released from the facility until 04-05-18.

Interview on 09-26-18 at :30 a.m. with Court Liaison # 4 he stated the general process for a patient admitted on an EDW was the warrant was "good" for 48 hours. The physician must perform the first medical examination (F-25) within 24 hours: this exam, along with an affidavit of application must be notarized and then filed with the court. The court then issued an Order of Protective Custody (OPC). He went on to say the court then scheduled a probable cause hearing, usually within 72 hours; followed by a final hearing. Prior to the final hearing, a second medical exam was required, along with a psychosocial exam.

Review of the clinical record of Patient #34 showed he was a [AGE] year old male admitted involuntarily to the facility on [DATE] for altered mental status and possible history of bipolar disorder. He was not oriented to place, time, or situation.

Further review of Patient # 34's clinical record showed the following documents related to involuntary admission :

1. EDW signed 03-13-18
2. First medical exam , dated 03-13-18
3. Second medical exam, dated 03-14-18
4. Affidavit of Application, dated 03-14-18
5. "Order of Protective Custody"-dated 03-14-18
6. "Order of Dismissal"-signed by the probate court judge on 03-23-18.

Further record review showed a physician order dated 04-05-18 (1300) that read "discharge patient today to a nursing home."

During a second interview with Court Liaison # 4 on 09-27-18 at 9:30 a.m., he reviewed Patient #34's record and said he "thought there had been an issue with placement." He went on to say he spoke with the court attorney and determined the patient's attorney "waived" the final hearing that had been scheduled for 3-23-18 because the patient was due to be discharged . The Court Liaison said the patient was not discharged as planned on 03-23-18 but was discharged on [DATE].

Court Liaison # 4 stated Patient #34 would have been unable to consent for voluntary admission on 03-23-18. He said the facility should have discharged this patient and readmitted him; and filed for another OPC. The Court Liaison acknowledged Patient # 34 was held on the facility for 13 days neither voluntarily or legally involuntary.

Review of facility policy titled "Emergency Detention Process," dated 02/2018, read:" Purpose: To assure all rights are afforded to... patients admitted under Emergency Extension as outlines in Chapter 573... Texas Health & Safety Code: Title 7, Chapter 573: Emergency Detention :...Sec. 573.025. RIGHTS OF PERSONS APPREHENDED, DETAINED, OR TRANSPORTED FOR EMERGENCY DETENTION. (a) A person apprehended, detained, or transported for emergency detention under this chapter has the right:...(2) to a reasonable opportunity to communicate with and retain an attorney...(4) to be released from a facility as provided by Section 573.023..."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0160
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review, the facility failed to ensure the appropriate use of restraint for Patient # 1.

Patient # 1 was inappropriately administered a medication to control his behavior which is not consistent with hospital policy.

Findings included:

TX 787

Review of facility policy titled "Seclusion and Restraint,"dated 07/2018, read:":...1. Definitions:...E. A drug or a medication is a RESTRAINT (facility capitalization) when it is used to restrict or manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. This type of restraint is not approved for use at the hospital (facility bolding)..."

Record review on 09-27-18 of Patient #1's clinical record revealed he was a 9 year old male admitted to the facility on [DATE] for escalating aggressive episodes and suicidal threats.

Continued review of this patient's records revealed the following:

Nurses's Notes, dated 05-19-18 :

*Time (7:00 p.m.):" ...patient has been agitated since the beginning of the shift...has been redirected a few times..patient has been talked to numerous times on the need to stop yelling and shouting on the unit..."

The next nurse's note in sequence on 05-19-18 was :

*Time (9:00 p.m.):Patient given 25 milligram of Benadryl and 25 mg of Thorazine IM..."

Record review of Patient # 1's "Patient Safety Observation Round Sheet (Nursing):, dated 05-19-18, revealed the following:

*Between 7 p.m. and 8:00 p.m. "awake, in dayroom watching TV."

*Between 8:15 p.m. and 9:30 p.m: "awake, in room lying on bed quietly."

Review of written physician order, dated 05-19-18, read: "25 mg Thorazine and 25 mg Benadryl IM..TORB..". The order was not timed and did not contain required documentation for "indication" for drugs ordered.

On 09-27-18 at 11:30 a.m., Patient # 1's record was reviewed with Interim CNO# 2. Upon review, CNO # 2 stated there was no documentation that Patient # 1 was at risk of harming himself or others. She went on to day a patient should not be medicated for control of behaviors of "yelling, shouting." Interim CNO # 2 said this medication was used as a restraint, which was not approved at this facility.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the facility failed to monitor and perform ongoing assessments for 1 of 1 restrained and secluded patients (Patient #6) to prevent patient injury or death.

Findings included:

TX 787

Record review at time of survey revealed that Patient #6 was a [AGE]-year-old male, admitted to facility on 3/27/18. The admitting diagnoses were Schizophrenia, disorganized type, later changed to Major Depressive Disorder, single episode, severe, without psychotic symptoms. Patient was discharged on [DATE].

Record review at time of survey of facility's Incident Report log revealed Patient #6 was restrained and secluded on 3/29/18.

Further record review failed to show documentation for the 3/29/18 restraint and seclusion. There was no 'one-hour face-to-face evaluation' and no evidence of monitoring documentation and/or patient's response to the intervention.

In an interview on 9/25/18 at 3:00 pm, CNO Staff#2 stated Patient # 6's restraint and seclusion intervention should have been monitored per facility policy and the documentation should have been present in the patient's chart, but were not present.

Record review at time of survey of facility's policy titled "Seclusion and Restraint" policy ID# 84, stated " .....B. The one-hour face to face evaluation by a physician or qualified RN will be documented with a progress note that includes an evaluation of the patient's immediate situation, the medical and behavioral status of the patient, any injury, the patient's reaction to the technique, and whether there is a continuing need for the use of seclusion or restraint .... The medical record will include within 24 hours the following documentation: ...The patient's response to the the techniques, Observations, including 5 (five) minute checks, Attention given for personal needs (nutrition, hydration, elimination, circulation, comfort) ....Observation every 15 minutes after the conclusion of the event ... ....."