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WELLBRIDGE HEALTHCARE OF PLANO 4301 MAPLESHADE LANE PLANO, TX 75093 March 18, 2019
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
Based on a review of facility documentation and staff interviews, the facility failed to include patients in the development and implementation of her or her plan of care for 9 of 10 patients (Patients #1-4 and #6-10). Updates to the treatment plan were not signed by 10 of 10 patients (Patients #1-10).

Findings were:

Facility policy entitled "Patient Rights," effective date 2/1/2017, included the following:
" ... PURPOSE:
To assure that the dignity and rights of all patients are respected and protected, and that patients and/or their representatives have the information necessary to exercise their rights.
PROCEDURE:
1. Patient Rights according to federal guidelines include the following at a minimum:
a. The right to participate in the development and implementation of his or her plan of care ...
c. The right to make informed decisions regarding his or her care, including being informed of their health status, being involved in care planning and treatment, and being able to request or refuse treatment ...
l. The right to participate actively in the development and review of an individualized treatment plan ..."

Facility policy entitled "Interdisciplinary Treatment Planning," effective date 2/1/2017, included the following:
"Policy:
It is the policy of the Wellbridge Hospital of Plano that each patient is provided with individualized, planned, and appropriate interventions that are designed to meet the patient's need for treatment. Patient response to care is regularly monitored and treatment reassessed to determine effectiveness and to enable the individual to feel a sense of achievement about treatment progress.
Procedure:
I. Initial Treatment Plan
a. Treatment planning begins at the time of initial screening, where preliminary plans are developed to address any emergent or risk issues identified during the assessment phase and prior to the initiation of the comprehensive treatment plan ...
II. The comprehensive interdisciplinary treatment plan (ITP)
2. Signatures also include the patient, and guardian when applicable, by means of the team reviewing and discussing the plan with the patient ..."

A review of patient medical records revealed only one patient (Patient #5) had signed his initial treatment plan. Thus the facility had no documented evidence that Patients #1-4 and #6-10 were allowed to participate in developing their own plans of care. In addition, Patient #5 had not signed subsequent updates to his treatment plan, nor had the other patients in the records reviewed. There was no reason documented for the patients not having signed the treatment plans despite an area provided on the plan form for doing this.

The above findings were confirmed with the facility chief executive officer and other administrative staff on the afternoon of 3/18/19 in the hospital conference room.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of facility documentation and staff interview, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for 2 of 10 patients (Patients #2 and #9) as medical monitoring and treatment was not carried out in accordance with physician orders. In addition, for 10 of 10 patients, there was little or no documented evidence of hygiene care, especially patient baths, provided to the patients.

Findings were:

Facility policy entitled "Vital Signs," effective date 2/1/2017, included the following:
"Policy:
It is the policy of the facility to obtain vital signs at regular intervals and to report vital signs that are out of normal range to the appropriate clinician ...
Procedure: ...
3. Vital signs will be measured at the interval ordered by the physician and more frequently, if required to prior to a particular medication or intervention, or if the RN is concerned that the patient's medical condition has changed ...
5. The following are normal vital ranges and vital sign measurements that require additional interventions: ...
Pulse - 60-100 beats per minutes (BPM) ...Alert, tell RN within thirty minutes [if] <60 BPM or >100 BPM ...
Blood Pressure - 90/60 mm/Hg to 120/80mm/Hg ...Alert, tell RN within thirty minutes [if] <90/60 mm/Hg or >140/90 mm/Hg ...
If B/P (blood pressure) reaches Hypertensive Crisis, which the AHA (American Heart Association) indicates as Systolic mm/Hg 180 or higher of [sic] Diastolic mm/Hg of 110 or higher, an immediate recheck in both arms and notify the Doctor." ... [facility policy bold]

Facility policy entitled "The Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar), guidelines for performing," included the following:
" ...Policy: It is the policy of the facility to define appropriate processes for recognition and early treatment of Alcohol Withdrawal Syndrome ...
Purpose:
There are significant clinical advantages to quantifying the alcohol withdrawal syndrome. Quantification is key to preventing excess morbidity and mortality in a group of patients who are at risk for alcohol withdrawal. Such instruments help clinical personnel recognize the process of withdrawal before it progresses to more advanced stages, such as delirium tremens. By intervening with appropriate pharmacotherapy in those patients who require it, while sparing the majority of patients whose syndromes do not progress to that point, the clinician can prevent over and under treatment of the alcohol withdrawal syndrome.

The best known and most extensively studied scale is the Clinical Institute Withdrawal Assessment - Alcohol (CIWA-A) and a shortened version, the CIWA-A revised (CIWA-Ar) ...
Guidelines: ...
3. CIWA to be completed on admission; alert physician immediately if score is greater than or equal to 35. Transportation to an ED should be considered ...
6. Notify Attending Physician if BP > 160/100 mmHg or Heart Rate 110 bpm or above ..."


A review of the medical record of Patient #2 revealed he was admitted to the facility on [DATE]. Medical issues identified in the psychiatric evaluation and history and physical examination included insomnia, chronic pain, alcohol abuse and hypertension. These issues were not included on the patient's master treatment plan, nor on subsequent updates.

Physician orders for the patient included the following:
2/27/19 at 1:59 p.m. -- "V/S (vital signs) Q 6 hours... CIWA (Clinical Institute Withdrawal Assessment for Alcohol) rating Q 4 hrs ..."

Vital signs were recorded from this patient as follows:
2/27/19 at 7:00 p.m.
2/28/19 at 7:00 a.m. -- Pulse 110
2/28/19 at 7:00 p.m. -- BP 142/101
3/1/19 at 7:00 p.m. -- BP 143/109
3/2/19 7p - 7a shift, no time -- "refused"
3/2/19 7p - 7a shift, no time -- BP 140/102
3/3/19 7a-7p shift, no time

No other documented vital signs could be located in the patient record despite the physician order on 2/17/19 that they be conducted every 6 hours. In addition, the pulse and blood pressure readings included above required notification of either the registered nurse or physician. The record of Patient #2 included no documented evidence that these notifications occurred.

Assessments of Patient #2 with the CIWA rating were recorded as follows:
2/28/19 at 9:00 p.m.
3/1/19 at 10:00 p.m.

No other documented CIWA assessments could be located in the patient record, despite the physician order of 2/27/19 that they be conducted every 4 hours.

A discharge summary for Patient #2 dictated on 3/4/19 at 12:56 p.m. included the following psychiatric diagnoses:
"... d. Alcohol use disorder, severe, with withdrawal.
e. Sedative use disorder, severe, with withdrawal..."

A review of the medical record of Patient #9 revealed multiple medical issues. A history and physical assessment on 3/4/19 at 8:11 a.m. included the following diagnoses: hypertension, COPD (chronic obstructive pulmonary disease), hepatitis C, bilateral otitis media, and chronic joint pain. These issues were not included on the patient's master treatment plan, nor on subsequent updates. Her pulse on 3/10/19 at 7:00 p.m. was noted as 108. The patient record included no documented evidence that a registered nurse of physician had been notified of the reading.

Review of Daily Care Monitoring Flow Sheets for Patients #1-10 revealed either no or infrequent documentation of patient hygiene care. According to the flow sheet, the grooming section was to include the time provided and the initials of staff involved in the bathing care of each patient. None of the sheets included a time or staff initials of when the patient bathed. The section included only an occasional "X" marked by the word "independent" for each of these patients, whether the patient was independent or needed assistance with bathing.

In an interview with Staff #3, Director of Quality/Risk, on the afternoon of 3/18/19 in the facility conference room, she confirmed the above findings. The findings were again reviewed with the hospital chief executive officer and other administrative staff later on the afternoon of 3/18/19 in the facility conference room. No additional evidence of compliance was brought forth by the hospital.