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.

AUSTIN OAKS HOSPITAL 1407 WEST STASSNEY LANE AUSTIN, TX 78745 Feb. 13, 2019
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on a review of documentation and interview the facility failed to ensure that medical records were accurate and complete, containing information to describe the patient's progress.

Findings included:

A review of the facility policy Documentation Guidelines, Review Date 1/16/2019 stated, in part:
"Mental Health Technicians ...
b. A progress note is documented on the back of the Patient Observation form in the designated section on each shift"

Review of documentation for Patient #1 revealed the following:
* Patient #1 was found in a shower with another patient on 01/25/19.
* A review of the Q15 Patient Observation/MHT Progress Notes on 01/25/19 revealed this incident and discovery of Patient #1in the shower was not documented by the mental health technician per policy.

In an interview on 02/13/19 staff member #6 confirmed that there was no progress note documented by the mental health technician regarding this incident. Per facility policy a progress note is to be made on each shift.