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.

CHRISTUS MOTHER FRANCES HOSPITAL 800 EAST DAWSON TYLER, TX 75701 July 11, 2019
VIOLATION: GOVERNING BODY Tag No: A0043
Based on record review and interview,The Governing Body (GB) failed to:

A. ensure a suicidal patient, with a plan, was observed and interviewed by the physician to ensure a safe discharge with a discharge order in 1(10) of 1 patient charts reviewed.

B. ensure that a suicidal patient that eloped from the ED had a new chart and documented re-assessment to ensure no substances were consumed while out of the ED observation in 1(10) of 1 patient charts reviewed.

C. ensure that staff conducted and documented a comprehensive patient assessment to determine the need for other types of interventions before using a drug or medication as a restraint in 1(10) of 1 patient charts reviewed.

D. ensure nursing documented and reported to the physician patient changes in condition and increased agitation in 1(10) of 1 patient charts reviewed in 1(10) of 1 patient charts reviewed.

E. to have a physician order to hold a suicidal patient involuntarily for safety and placement. Failed to have documentation of an Emergency Detention Warrant (EDW) or Order of Protective Custody (OPC) in place after the initial physician examination was completed in 1(10) of 1 patient charts reviewed.

The deficient practices identified above 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.

Refer to Tag A0144


F. objectively investigate an allegation of abuse and harassment in a through manner. The Patient Advocate failed to provide a patient with information of reporting to the medical board, the deemed agency, or The State of Texas complaint line in 1(#2) of 1 patient charts reviewed.

Refer to Tag A0145


G. recognize the prohibited use of "as needed" (PRN) chemical restraints in 6 (3,4,5,7,8, and 9) out of 6 patient charts reviewed.


H. follow the of use chemical restraints in Quality Assurance Performance Improvement (QAPI). QAPI failed to recognize the prohibited use of "as needed" (PRN) chemical restraints and failed to recognize the restraint policy and procedure does not address the monitoring, assessment, and face to face requirement before administering a chemical restraint.

The deficient practices identified above 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.

Refer to Tag A0160


I. have a minimal nurse staffing grid for 3 out of 3 (Orthopedic 6th floor and Telemetry floors 1 and 4) units reviewed.

J. have the Licensed Vocational Nurse (LVN) integrated into the nurse schedule matrix in 1(Ortho 6th floor) of 3(Orthopedic 6th floor and Telemetry floors 1 and 4) units reviewed.

Refer to Tag A0392


K. ensure nursing monitored, assessed, reassessed, and documented on patients receiving conscious sedation medications by Emergency Medical Services (EMS) or in the Emergency Department (ED) in 1(9) of 1 (9) patient charts reviewed.

L. ensure nursing had training and competencies for the Registered Nurse (RN) in the ED for monitoring conscious sedation in 7(17, 20, 21, 22, 23, 24, 25) of 7 employee charts reviewed.

M. ensure the patient was alert, competent, and not under sedation medications before asking questions of abuse and neglect and medical history before documenting a response in 1(9) of 1(9) patient charts reviewed.

N. ensure nursing did not subjectively administer as needed (PRN) psychotropic medications without physician notification or a scale to determine the levels of agitation in 2 (3 and 9) of 2 charts reviewed.

The deficient practices identified above 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.


Refer to Tag A0395
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review and interview the facility failed to:

A. ensure a suicidal patient, with a plan, was observed and interviewed by the physician to ensure a safe discharge with a discharge order in 1(10) of 1 patient charts reviewed.

B. ensure that a suicidal patient that eloped from the ED had a new chart and documented re-assessment to ensure no substances were consumed while out of the ED observation in 1(10) of 1 patient charts reviewed.

C. ensure that staff conducted and documented a comprehensive patient assessment to determine the need for other types of interventions before using a drug or medication as a restraint in 1(10) of 1 patient charts reviewed.

D. ensure nursing documented and reported to the physician patient changes in condition and increased agitation in 1(10) of 1 patient charts reviewed in 1(10) of 1 patient charts reviewed.

E. to have a physician order to hold a suicidal patient involuntarily for safety and placement. Failed to have documentation of an Emergency Detention Warrant (EDW) or Order of Protective Custody (OPC) in place after the initial physician examination was completed in 1(10) of 1 patient charts reviewed.

The deficient practices identified above 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.

Refer to Tag A0144


F. objectively investigate an allegation of abuse and harassment in a through manner. The Patient Advocate failed to provide a patient with information of reporting to the medical board, the deemed agency, or The State of Texas complaint line in 1(#2) of 1 patient charts reviewed.

Refer to Tag A0145


G. recognize the prohibited use of "as needed" (PRN) chemical restraints in 6 (3, 4, 5, 7, 8, and 9) out of 6 patient charts reviewed.

H. follow the of use chemical restraints in Quality Assurance Performance Improvement (QAPI). QAPI failed to recognize the prohibited use of "as needed" (PRN) chemical restraints and failed to recognize the restraint policy and procedure does not address the monitoring, assessment, and face to face requirement before administering a chemical restraint.

The deficient practices identified above 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.

Refer to Tag A0160
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on review and interview, Nursing failed to:

A. have a minimal nurse staffing grid for 3 out of 3 (Orthopedic 6th floor and Telemetry floors 1 and 4) units reviewed.

B. have the Licensed Vocational Nurse (LVN) integrated into the nurse schedule matrix in 1(Ortho 6th floor) of 3(Orthopedic 6th floor and Telemetry floors 1 and 4) units reviewed.


Review of the nursing schedule for Orthopedic 6th floor failed to have a matrix that addressed the minimum staffing grid. The floor uses a LVN. There was no LVN integrated into the matrix. An LVN cannot be substituted as a RN. An LVN must have supervision by an RN and cannot be scheduled as a Registered Nurse (RN). The nursing staff grid should show what was the minimum nursing staff used compared to the patient census and patient needs.


An interview with staff #11 on 7/10/19 stated she was not aware her staffing grid or matrix needed to show the minimum staffing required compared to the census. Staff #11 confirmed there was no LVN on the grid and was using the LVN in the staffing mix.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on record review and interviews, Nursing failed to:

A. monitor, assess, reassess, and document on patients receiving conscious sedation medications by Emergency Medical Services (EMS) or in the Emergency Department (ED) in 1 (9) of 1 (9) patient charts reviewed.

B. nursing failed to have training and competencies for the Registered Nurse (RN) in the ED for monitoring conscious sedation in 7(17, 20, 21, 22, 23, 24, and 25) of 7 employee charts reviewed.

C. ensure the patient was alert, competent, and not under sedation medications before asking questions of abuse and neglect and medical history before documenting a response in 1 (9) of 1 (9) patient charts reviewed.

D. subjectively administered as needed (PRN) psychotropic medications without physician notification or a scale to determine the levels of agitation in 2 (3 and 9) of 2 charts reviewed.


The deficient practices identified above 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.


Review of Patient #9's chart revealed he was brought to the facility by Emergency Medical Services (EMS) on 7/2/19. Review of the EMS "Patient Care Report" chief complaint stated, "Called due to pt. not acting himself. Pt. does not respond to his name and just yells out uncontrollably. Spouse stated that he had smoked "weed" last evening but does not no (sic) that he has taken anything else. Last seen normal around noon today."


Review of the Patient Care Report revealed Patient #9 was administered Versed and Ketamine for agitation and combative behavior as follows:

7/2/19 at 22:46 Midazolam (Versed) 2.5mg intranasal- administered

7/2/19 at 23:18 Midazolam (Versed) 5.0mg Intravenous- administered

7/2/19 at 23:26 Midazolam (Versed) 2.5mg Intravenous- administered

7/2/19 at 23:46 Midazolam (Versed) 5.0mg Intravenous- administered

7/2/19 at 00:01 Ketamine (Ketalar) 50mg IV infusion- administered.


Review of PDR.net Midazolam (Versed) is an Anxiolytics, Benzodiazepines Benzodiazepine Sedative/Hypnotics Other General Anesthetics. Midazolam has black box warnings as follows:

"Intravenous administration, requires a specialized care setting, requires an experienced clinician, respiratory depression, respiratory insufficiency. Administration of midazolam requires an experienced clinician trained in the use of resuscitative equipment and skilled in airway management. Midazolam administration also requires a specialized care setting that can provide continuous monitoring of respiratory and cardiac functioning; oral midazolam should not be administered at home or outside of the care setting in which procedures will be performed. Midazolam has been associated with respiratory depression and respiratory arrest, especially when given via intravenous administration for procedural sedation. Death or hypoxic [DIAGNOSES REDACTED] has resulted in some instances where these symptoms were not recognized or properly treated. Individualize the midazolam dose based on the patient's age, weight, indication, concomitant medications, and disease history. High risk surgical and debilitated patients, patients undergoing upper airway procedures (i.e., endoscopy), and those with hemodynamic compromise may need lower dosages of midazolam with close monitoring. Many of these patients may be vulnerable to hypoventilation or reduced elimination of midazolam. Prior to administration, ensure the immediate availability of oxygen, resuscitative drugs, and age- and size-appropriate ventilation and intubation equipment. Monitor patients for early signs of respiratory insufficiency, respiratory depression, hypoventilation, airway obstruction, or apnea (i.e., via pulse oximetry), which may lead to hypoxia and/or cardiac arrest. Have flumazenil available for immediate use. For deeply sedated patients receiving midazolam for procedural sedation, a dedicated individual, other than the person performing the procedure, should monitor the patient. When used for sedation/anxiolysis/amnesia, infuse IV midazolam over at least 2 minutes and wait an additional 2 minutes to assess sedation before administering an additional dose."


Ketamine (Ketalar) classification- General Anesthetic. Contraindications for Ketamine included Psychosis, schizophrenia:

"Because ketamine can cause psychosis and exacerbate symptoms of [DIAGNOSES REDACTED]"


Review of Patient #9's Emergency Department (ED) record revealed the patient arrives in the ED on 7/3/19 at 00:08. Review of the ED Provider exam dated 7/3/19 at 12:10AM revealed the patient was agitated and alert. Under Psychiatric: "He has a normal mood and affect. His behavior is normal."


Review of the ED Care timeline dated 7/3/19 at 00:23 (12:23AM) the RN documented, "Chief Complaints Updated+ Altered Mental Status (pt presents to ED with MAS, onset yesterday, patient is combative, VSS, Pupils are fixed and dilated at 7mm. MD at bedside.) The patient has been sedated with general anesthesia and review of the consents revealed that Patient #9 was "unable to sign" however the nurse was able to ask the patient questions about abuse and neglect. The question on the chart was "Do you feel safe returning to home? Patient #9 responded with "no". The nurse continued to document that the patient was able to answer if he had been out of the country and or if he had heart failure. Under head to toe assessment the RN documented, "Best Verbal Response- Inappropriate words. Best motor response: Withdraws from pain." 00:25 "Task Completed: Gowned; Side rails up x 2; Connected to NIBP; Connected to EKG; Family at bedside; Connected to Pulse Ox."


Review of Patient #9's chart revealed the patient was not being monitored for conscious sedation due to the general anesthetic medications administered by EMS when patient arrived at the ED.


Review of the policy and procedure "Adult Sedation/Analgesia" stated,

"A. Minimal Sedation:

1. Minimal sedation (anxiolysis is a drug induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.

6. Minimal sedation/anxiolysis is limited to a maximum of 2 mg midazolam only, titrated to the desired level of minimal sedation. This dosage may be repeated if so determined by the physician up to a maximum of 4 mg midazolam in divided doses.

7. Minimal sedation/anxiolysis may occur in holding or preparatory areas and may also occur in a procedure room without the attendance of the licensed physician, who should be readily available within the department. Nothing herein shall be interpreted to relieve the physician of being present in the procedure room at the time that the level of sedation/ anxiolysis is advanced to moderate sedation/analgesia with administration of higher doses of anxiolytic or any doses of a parenteral analgesic.

B. Moderate Sedation:

1. Moderate sedation/analgesia (formerly "conscious sedation") is the use of drug/drugs defined herein for an inpatient or outpatient invasive or non-invasive procedure, inducing depression of consciousness during which the patient can respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

2. During moderate sedation/analgesia, the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide unless precluded or invalidated by the nature of the patient, procedure or equipment."


There was no direction found, in the P&P of Adult Sedation/ Analgesia on how the nurse would monitor or document on a patient that was given conscious sedation outside of the facility. Patient #9 had received 15mg of midazolam within an hour when he arrived in the ED.


An interview with Staff #2 and #9 on the morning of 7/11/19. Staff #2 confirmed that the nurse would follow the policy and procedure of conscious sedation when a patient had been administered Midazolam (Versed) or Ketamine (Ketalar) before entering the ED. Staff #2 confirmed the RN caring for the sedated patient should be competent and had a competency "check off" for conscious sedation. Staff #9 stated that the nurses that do procedural sedations such as catherization lab and surgery would have competencies but there were no competencies that Staff #9 was able to provide for the ED nursing staff.


Review of Patient #9's chart revealed the following medication were ordered and administered within an hour and a half upon arrival to the ED:

7/3/19 at 00:33- Lorazepam (ATIVAN) antianxiety agent- injection 1 mg - Dose: 1 mg; Route: Intravenous. There was no reason on the order for the injection.

7/3/19 at 00:43 haloperidol lactate (HALDOL) butyrophenone antipsychotic - injection 5 mg IV once. There was no reason documented on the order for the psychotropic medication.

7/3/19 at 0206 ziprasidone (GEODON) butyrophenone antipsychotic - 20 mg in sterile water PF 1 mL (20 mg/mL) injection once. There was no reason documented on the order for the psychotropic medication.


Review of the nurse's documentation revealed there was no documentation on Patient #9's behavior, sedation level or neurological status, effectiveness of the medication, or why he was administered psychotropic medications.


Review of the Haldol insert, Haldol IV administration is not FDA-approved, is associated with an increased risk of QT prolongation and torsade de pointes. Review of the Geodon insert stated, "GEODON use should be avoided in patients with bradycardia, hypokalemia or [DIAGNOSES REDACTED], congenital prolongation of the QT interval, or in combination with other drugs that have demonstrated QT prolongation." Patients should be carefully monitored and assessed by the RN for QT prolongation and any complications of multiple administration of psychotropic medications.


Review of Patient #9's ED notes revealed, "7/3/19 01:50 ED Notes Mittens placed on pt due to attempts to pulling ivs out, other measures unsuccessful in keeping pt from reaching for iv lines." Review of the chart revealed there was no order for the mittens. There was no further documentation concerning the mittens use or removal.


Review of the ED physician orders revealed Patient #3 had an order for Haldol 2mg IM ordered once "as needed" on 7/5/19 at 2358 (11:58PM). There was no reason documented on the physician order for the administration of the psychotropic medication. Review of the chart revealed the Haldol 2mg was given on 07/06/19 at 0005 (12:05AM). Review of the nurse's notes revealed the medication was not documented as a chemical restraint or was monitored as a restraint. There was no found nursing documentation on the patient's behaviors, de-escalation techniques applied, or effectiveness of the medications.


Review of the chart revealed Patient #3 received a physician order for haloperidol lactate (HALDOL) injection 2 mg, IV, Q6H PRN 7/6/19 at 10:34AM. There was no reason documented for administering the psychotropic drug in the physician order. Patient #3 received the medication PRN on the following dates and times:

7/6/19 at 1126 (11:26AM)

7/6/19 at 1846 (6:46PM)

7/9/19 at 1:28AM. There was no found nursing documentation on the patient's behaviors, de-escalation techniques applied, or effectiveness of the medications.


An interview was conducted with Staff #8 RN and # 9 RN on 7/10/19 in the afternoon. Staff #8 and #9 confirmed that PRN orders are written for the administration of psychoactive medications to control a patient's behaviors.
Interview with Staff #1 and#2 on 7/11/19 confirmed the policy for restraints failed to direct the nursing staff in safe use, monitoring, and documentation for the use of chemical restraints.


An interview was conducted on 7/10/19 with Staff #7. Staff #7 confirmed chemical restraints (emergency behavioral medications) were not being monitored in the Quality Assurance Performance Improvement Process.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review and interview the facility failed to:

A. ensure a suicidal patient, with a plan, was observed and interviewed by the physician to ensure a safe discharge with a discharge order in 1(10) of 1 patient charts reviewed.

B. ensure that a suicidal patient that eloped from the ED had a new chart and documented re-assessment to ensure no substances were consumed while out of the ED observation in 1(10) of 1 patient charts reviewed.

C. ensure that staff conducted and documented a comprehensive patient assessment to determine the need for other types of interventions before using a drug or medication as a restraint in 1(10) of 1 patient charts reviewed.

D. ensure nursing documented and reported to the physician patient changes in condition and increased agitation in 1(10) of 1 patient charts reviewed in 1(10) of 1 patient charts reviewed.

E. to have a physician order to hold a suicidal patient involuntarily for safety and placement. Failed to have documentation of an Emergency Detention Warrant (EDW) or Order of Protective Custody (OPC) in place after the initial physician examination was completed in 1(10) of 1 patient charts reviewed.

The deficient practices identified above 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.


Review of Patient #10's chart revealed the patient came into the Emergency Department (ED) on 7/3/2019 2:18 PM with Suicidal Ideation.

Review of the physician's notes dated 7/3/2019 at 2:46 PM, "Context: Pt presents to the ED with SI that have worsened over the past six months. Hx of depression. Reports that he took 30 pills of Ambien over the course of Saturday and Sunday. Stopped taking ambien on Monday. States that he "does not deserve help" and "does not want to be here anymore." Reports that he "put a gun to his mouth" when he was [AGE] years old. Has been taking wellbutrin "for years." Recently stopped taking venlafaxine due to the cost of medication. States that he recently became unemployed and ended a romantic relationship, leaving him "time alone with his thoughts." Hx of hypertension. Is currently taking BP medications. Denies drinking alcohol or recreational drug use.

Psychiatric/Behavioral: Positive for suicidal ideas. Psychiatric: His behavior is normal. He exhibits a depressed mood. He expresses suicidal ideation. He expresses suicidal plans."

Review of the Nurses flowsheet revealed the RN documented, "Behavioral Monitoring - Wed July 03, 2019 at 1600 (4:00PM) and 1637 (4:37PM) Belongings removed; Sitter at bedside Room safety check performed by Nurse and all potential hazards removed. Patient checked for contraband."

Review of the physician orders revealed there was no order for suicide precautions, to hold the patient for evaluation, or for a sitter. Review of nursing flowsheet revealed the patient's wife was with the patient.

Review of the physician orders revealed an order for Lorazepam (Ativan) sedative injection 1 mg on 7/3/19 at 1756 (5:56PM). The order did not state for what reason. There was no documentation from the physician for the Ativan or the patient's behavior or state of mind.

The nurse administered the medication at 1807 (6:07PM). The nurse documented that Patient #10 was anxious at 1506 (3:06PM), 1600 (4:00PM), and 1637(4:37PM). At 1754 (5:54PM) the nurse documented the patient was calm and cooperative. The nurse documented the patient was calm at 1942(7:42PM). There was no documentation describing the patient's anxiety and what the nurse did to alleviate the anxiety before administration of a sedative. There was no found nursing documentation on the patient's behavior or effectiveness of the medication.

Patient #10 received another injection of Ativan 1 mg IV on 7/3/19 at 2347 (11:47PM). There was no nursing or physician documentation of the patient's behavior or why the patient was administered the medication. There was no documentation on the effectiveness of the medication or any de-escalation measures performed.

Review of Patient #10's ED Notes by Staff #26 RN at 7/4/2019 1:30 AM stated, "Pt c/o pain at IV site, while assessing site pt became increasingly agitated. Suggested replacing dressing to site as there was no redness or swelling noted, pt grabbed IV tubing and pulled out IV. Pt stated he was leaving; that he was here voluntarily. Pt put on pants and walked out of ED. Pt does not have a POW. 1:40 AM _____ ED Doctor and ED charge RN informed of pt elopement. Call placed to Tyler PD to report pt elopement. Hospital security notified of pt elopement. 2:20 AM Tyler PD and Hospital security have not been able to locate pt. 2:40 AM Security reports pt returned to main hospital entrance where he saw his ex-wife told security not to talk to him and left with ex-wife. 3:00 AM (continued) Call to Tyler PD to request Welfare Check, Tyler PD referred to Smith County SD d/t pt resides in Arp."

Review of the Patient #10's ED Provider notes revealed the physician documented,

"1:37 AM-The pt became angry at the nurse and fled the ED. Security was notified; however, the pt had already left the campus and they could not obtain him. Tyler PD has been contacted. They will attempt to return pt. Pt's spouse is still in the ED.

2:53 AM-The pt reportedly returned to the hospital lobby where security confronted him. The pt cursed at security and left the hospital with wife. Tyler PD contacted for a welfare check.

3:33 AM-Confirmed authorities were made aware about the welfare check.

4:38 AM-Pt has returned to the ED and requests to not be placed in the Annex. Pt will be roomed in room 2.

5:04 AM-Pt is adamant that he will kill himself the moment he is free. Pt has been with wife since he eloped; therefore, I am not concerned for ingestion of drugs or alcohol. Wife was with him until she was able to get him to come back

6:10 AM-Tyler PD at bedside."


Review of Patient #10's chart revealed there was no new chart opened when the patient returned to the ED after 3 hours of leaving the ED as an elopement. There was no documentation that Patient #10 was re-evaluated, and the physician documented "Pt has been with wife since he eloped; therefore, I am not concerned for ingestion of drugs or alcohol. Wife was with him until she was able to get him to come back."


An interview with Staff #9 on 7/11/19 confirmed that Patient #10 should have been readmitted to the ED and a new chart and evaluation should have been completed on the patient. The ED did not follow the facility's process. Staff #9 reported that she was not aware that the POW was voided after the patient had been seen by the physician and evaluated. Staff #9 confirmed there was no process in place.


Review of Patient #10's chart revealed there was no physician order to hold the patient involuntarily for safety and placement to a psychiatric facility. The physician indicated the Police were at the patient's bedside. There was no found documentation that Patient #10 was in police custody.


Review of the social workers notes on 7/7/2019 9:58 AM stated the patient was on a Police Officers Warrant (POW). There was no found copy of any warrant or order to hold the patient. Chapter 573 of the Texas Health and Safety Code stated,

"(c) A physician shall examine the person as soon as possible within 12 hours after the time the person is apprehended by the peace officer or transported for emergency detention by the person's guardian.

A person accepted for preliminary examination may be detained in custody for not longer than 48 hours after the time the person is presented to the facility, unless a written order for protective custody is obtained. The 48-hour period includes any time the patient spends waiting in the facility for medical care before the person receives the preliminary examination. Section 573.021 (b) Health and Safety Code.


Sec. 573.023. RELEASE FROM EMERGENCY DETENTION. (a) A person apprehended by a peace officer or transported for emergency detention under Subchapter A or detained under Subchapter B shall be released on completion of the preliminary examination unless the person is admitted to a facility under Section 573.022."


Review of the chart revealed the facility had no documentation that the patient was released after his medical exam or if a physician order and/or Emergency Detention Warrant (EDW) was started to hold the patient.


Review of Staff #27's Progress Notes on 7/4/2019 at 10:03 AM stated, "SW met with pt at bedside. Pt reported that he got "pissed off at the nurse" last night and that is why he left. Pt stated that he asked the nurse to do something with his IV, when she told him that she couldn't he decided to rip it out, throw it at her and leave. Pt came back to ER approximately one hour later. SW asked him what made him decide to return and he stated, "his wife". She has gone home to get some rest but will be back up here today.


Pt is very restless and cannot be still. He stated that he feels like there are things crawling all over his skin and that he has restless leg syndrome. He stated that the nurse told him he could not have anything to help this but was not told why. SW asked nurse about this, so that pt could be given a reason why he could not have anything.
Nurse informed SW that pt had indeed been given medication and it was not time for more."


There was no documentation found that nurse attempted any other techniques to help calm the patient or reported the patient's complaints to the physician.


Patient #10 was ordered Ziprasidone (Geodon)IM 20 mg once on 7/4/19 at 7:31AM. The nurse administered the medication to the right deltoid at 7:46AM. There was no reason for the medication on the physician's order. There was no de-escalation or response to the effectiveness of the medication from the nurse or physician.


Patient #10 was ordered Ziprasidone (Geodon)IM 20 mg once on 7/4/19 at 12:29PM. The nurse administered the medication to the right deltoid at 12:55PM. There was no reason for the medication on the physician's order. There was no de-escalation or response to the effectiveness of the medication from the nurse or physician.


Review of Staff #27's Progress Notes on 7/8/2019 at 4:17PM stated, "SW met with pt for f/u assessment per pt request. Pt tells SW that he is no longer experiencing SI and would like to d/c home. Pt's POW expired at 1600 today. Per Brianna with UTNE no beds today but pt is #2 on wait-list. Pt's spouse (_____) at bedside states she is willing to monitor pt 24/7 until he receives outpt f/u care at Andrews Center tomorrow. Established safety plan with pt and spouse and both are agreeable to return to ER if thoughts/behaviors worsen. SW notified MD of pt's request for d/c."


Review of the physician notes on 7/8/19 at 5:00AM revealed he saw Patient #10 at 5:00AM. The physician documented he had a face to face visit with the patient and the patient was suicidal. The documented physicians expected disposition was "transfer." There was no found physician documentation that the patient was reevaluated and found the patient safe to be discharged and why. There was no safety plan on the patient's chart. There was no found physician order to discharge the patient to home.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review and interviews, the facility failed to:

A. objectively investigate an allegation of abuse and harassment in a thorough manner. The Patient Advocate failed to provide a patient with information of reporting to the medical board, the accreditation organization, or The State of Texas complaint line in 1 (#2) of 1 patient charts reviewed.

B. follow its own process to involve Risk Management to investigate and monitor allegations of abuse and potential harm in 1(#2) of 1 patient charts reviewed.


Review of Patient #2's chart revealed that he was a [AGE]-year-old male admitted on [DATE] for typical atrial flutter. Review of the physician's history and physical (H&P) dated 3/26/19 at 8:21PM revealed the patient was admitted for "urgent ablation, improve rates with digoxin load."

Further review of the H&P revealed, "HPI: Very pleasant 61 y.o. white male with a history of Aflutter ablation presents to Christus Trinity Mother Health System with complaint of increasing SOB, weakness and fatigue. Seen at Titus regional med center and noted to be back in Aflutter. Pt transferred here and set up for Aflutter ablation in AM /c Dr. Tran. Pt denies any recent injury or illness. No medication changes. No fever, night sweats, chills, productive cough, or significant bowel habit changes. No intermittent claudication or tibial edema. Psychiatric/Behavioral: The patient is nervous/anxious." There was no found documentation from the physician that the patient was having any verbal or emotional outburst.

Review of the nurses procedure assessment notes revealed at 8:16AM on 3/26/19 the nurse documented, "Alert, Oriented x4, Appropriate Judgement; Appropriate for Developmental Age; Appropriate Safety Awareness; Appropriate Attention/Concentration Follows Commands."

Review of the nursing flowsheet dated 3/26/19 at 1311 revealed staff #14 documented the patients pain scale was a "9" out of 10 with 10 being worst pain, his pain orientation "mid", pain location was "chest", Pain onset "awakened from sleep." There was no further documentation of Patient #2's mental status, orientation, or neurological status found.

Review of the Medication Administration Record (MAR) revealed Patient #2 was medicated with a pain medication "fentaNYL (SUBLIMAZE) injection 50 mcg once" was administered on 3/26/19 at 1305. There was no further documentation on the effectiveness of the medication or any adverse reactions from the medications.

Review of the Anesthesia Record dated 3/26/19 @1324 revealed Staff (CRNA)#13 documented, "This assessment was performed by me immediately prior to Discharge from the PACU. Patient evaluated and has returned to baseline cardiopulmonary and mental status.

Review of the nursing flowsheet on 3/26/19 at 1436 ( approximately 1 hour after CRNA entry) revealed Staff #15 RN documented, "pt back from OPCU, very combative, non-cooperative, complaining of pain in his right chest muscle like cramping." Staff #14 documented Alert, Oriented- Yes, Pt is verbally abusive with foul language usage." There was no further documentation found on what de-escalation techniques were used, how the staff assisted the patient, no pain evaluation was performed. There was no found documentation that the patient's physician was called and informed on Patient #2's change in condition.

Review of Patient #2's chart revealed on 3/26/19 at 1540 the nurse documented, "Provider at bedside; Provider updating patient; Provider updating family/ significant other(s)." There was no documentation found that the physician was aware of the patient's outburst or when the patient calmed down.


A phone interview was conducted with Patient #2 in the morning of 7/8/19. Patient #2 stated his memory was a little fuzzy, but he remembered having a lot of pain after his procedure. He remembers getting something for pain. He stated the medication made him feel very agitated and stated he felt like he was sitting on the ceiling looking at everyone in the room. He stated he could not remember if it happened in surgery or in his room, but some nurses came in and tried to move him to another bed. He stated he thought they were trying to hurt him. Patient #2 stated he remembers them holding his arms down and when he got lose from the staff he began to swing his arms around. He said the staff threatened to press charges against him. Patient #2 stated when he woke up enough he called to speak with the patient advocate.


A phone interview was conducted with Patient #2's wife in the morning of 7/8/19. Patient #2's wife reported that after her husband came out of his procedure she came back to the holding area. She stated her husband was in pain and was given pain medication. She stated Patient #2 became belligerent and was cursing and swinging his arms. She stated that she was sent out of the room and was told they would bring him to his room on the floor and she could go there. She stated the patient came up on a stretcher and was cursing and acting bizarre. She stated she has never seen her husband act like that. The nurses were trying to move him over in the bed from the stretcher, but one male nurse was holding him down and threatened to call security to press charges on him. "Once he was moved into the bed and the nurses left the room he calmed down. I was afraid to say anything else. I was afraid they were going to call the police and file charges against him." The surveyor asked Patient#2's wife if the nurse said that they were pressing charges against him? Patient #2's wife stated, "no, they didn't say they were pressing charges but why else would you call security?"


Review of Patient #2's chart revealed he was discharged on [DATE] at 11:35AM.

Review of the nurse's notes revealed on 3/27/19 at 11:48AM Patient #2 called back to the facility. The RN stated, "Pt called & states he had a reaction to a medication yesterday in a procedure. He would like to know what medication it was. States you can e-mail it so he has the spelling. At 3:02PM a Licensed Vocational Nurse (LVN) documented, "Emailed the pt and gave him the 3 medications administered during his procedure, sevoflurane, fentanyl, and Propofol. Requested the pt contact me back with any questions or concerns." There was no found documentation that the nursing staff asked the patient if there was a problem, if he was having any issues after discharge, or if he needed to speak with a supervisor. There was no documentation that the complaints or grievance coordinator, physician, or supervisor was notified that a recently discharged patient was complaining of a drug reaction.


Review of the complaints and grievance log revealed a complaint was taken from Patient #2 on 3/27/19 at 9:16 AM. Staff #16 Patient Advocate documented, "Notes from conversation with ______ Patient #2 During conversation with ______ Patient #2, he was verbally attacking, demanding, rude and very hard to deal with on a rational level. I explained to ______ Patient #2 that I would open an investigation, he would receive a letter from me when the investigation was completed. His response was "so you will do nothing.' "I have read all of the online reviews about you. You never get back with anyone." "Your hospital is horrible." I shared with ______ Patient #2 that I did not appreciate being called a liar, he no longer had the excuse of medication to explain his rude behavior and if he wished to continue the conversation, I suggested he conduct himself in a respectful manner. I asked him if there was anything else I could do for him. He stated, "I guess not". I told him we would be back in touch and wished him a good day. A female companion was sitting on the couch by the window and never said a word." Review of the investigation revealed the patient advocate never asked the patient if that was his wife and if she had any information to share concerning the incident.

Review of the grievance revealed Staff #16 had resolved the grievance in one day. Staff #16 documented,

"Priority: Routine
Created on: 03/27/2019 08:50 AM By: ____ (Staff #16)

Primary Information
Page 1 of 6
Owner: _____ (Staff #16) Status: Resolved
Source Subject Topic _____ (Patient #2) (Patient) ______ (Patient #2)A (Patient) Quality of Care Summary: Quality of Care - LPOHH 4 Received a call from the patient on 03/26/2019 at 1619 stating he had been "mistreated" by staff during a seizure he experienced while coming out from under anesthesia. He was totally offended by the treatment by "___ (Staff #17)". Staff could have waited 10 more minutes before taking him out of recovery and putting him back in his room. "He did not want his wife to see him like that." Stated "____ (Staff #17) threatened to have him arrested. Demanded someone come to his room in the morning to resolve these issues "if you care about how patients are treated in this hospital."

03/27/2019 @ 0807 I went to visit the patient per his request. He immediately stated he wanted three people fired, I told him that was outside of my decision-making process. He then stated, fine I will sue the hospital. I told the patient that was his right if he chose that path. He then demanded the names of all the people who were in the room yesterday, so he can name them in his law suite.(sic) I explained due to HR laws, I was unable to do so. I asked if there was anything else I could do for him, he thought a moment and started talking: While coming out from under anesthesia, his arms were flailing (sic) and he was "out of control". States he was told "we are taking you back to your wife, so she can deal with your crazy act." "Why was I not given medication to count act (sic) the drugs that caused my reaction?" I have checked on line and spoken with nurse friends and have been told there are drugs that could have helped me but you did not give them to me." Stated he felt something "stabbing me in the butt last night." when I looked, I found this: Showed me a picture of a needle on a bedside table. "____ (nurse) came in and freaked out and took the needle''. "I don't understand why I was abandoned and no one cared for in the recovery room yesterday. ____ (nurse) told me the reason I needed to go back to my room so quickly was so the recovery room staff could have the bed back and go home on time." Patient stated he was told I had forms in my office that he could report the MD to the board. I shared with him that was not the case. He asked me where I could get the forms, I told him I would suggest he check on line. He then stated, you mean to tell me you are a professional and you don't have the forms or know where to find the forms. I said, that is correct. He stated "I suggest you go back to your office and find them, print them and bring them to me. I don't have access to a printer and I would have to spend $5.00 to go have them printed." I asked if there was anything else I could do for him. He said no."


There was no further information that the Patient Advocate assisted the patient with information to report a physician to the board of Medicine. The advocate did not document that Patient #2 was given any information on how to make a complaint with the deemed agency or the State of Texas complaint line.


Staff #16 interviewed three physicians concerning the Patient #2's complaint.

"Physician #12, 03/29/2019 08:56 AM "I saw the patient in the pre-cath area prior to his procedure. We had a professional conversation and he reported no previous complications with anesthesia. I saw him again in the cath lab as the case was starting and there were no problems. His case eventually converted from a sedation case to a general anesthetic. The CRNA informed me of this. I came by the room shortly after that and the CRNA again reported no problems. I had no further contact with the patient, nor was I informed of any issues after the procedure."

Physician #18, 03/28/2019 08:16 PM "I came to round on the patient in the afternoon and was made aware that the patient had "seizures" or "myoclonic" actions after the fact after discussing with pt's beside nurse. I asked the patient what happened, and he informed me he felt he was being mistreated. I apologized that he felt that way and stated I would discuss with ____ (Staff #17) who explained to me later that the patient was being verbally combative and threatening physical harm to the ancillary staff. The following morning, I made rounds and patient informed me in the middle of the night, he felt something behind him in bed and showed me a picture of his glasses and a needle he found. I discussed with him I would discuss with our staff and informed ____ (Staff #17) of the findings and how that we needed to address this."

Physician #19, 03/28/2019 07:53 AM "I reviewed this patients anesthetic record. A. Fib. Ablation in OPCU. No problems with anesthetic or his recovery to my knowledge. This event description does not sound like a seizure to me. I think the patient was confused maybe a little agitated. Cath lab recovery nurses are very vigilant to keep the patients legs straight following arterial and venous cannulation sights in the groin. Hematoma prevention. I do not know anyone that is named Kent in Cath Lab. This is not an anesthesia issue."


There was no found documentation in Patient #2's chart that Staff #17 had discussed Patient #2's behaviors with Physician #18 or the complaint Patient #2 made against Staff #17.


Staff #17 was on vacation and was not available to talk with the surveyor. Staff # 17 was interviewed by the patient Advocate on 3/28/19 at 9:05AM. The interview of Staff #17 stated, "_____ (Staff #17 )03/28/2019 09:05 AM When the patient arrived from his procedure, he was using extreme profanity with ____ (Staff #14), to the point where I was able to hear his expressions from my office. I immediately responded to assist ____( Staff #14) in resolving the situation. The patient was using profanity very loudly and claiming " I am having a seizure" I informed him, based off of my assessment he was not having a seizure since he was able to communicate with me. I attempted to restrain his hand so we could move him onto his hospital bed to prevent injury to himself. At which point he informed me that "He would (expletive) punch me if I touched him again. I promptly and sternly informed him that I would not be spoken to in that manner and if he was unable to cooperate I would involve our security department and allow them to handle the situation in whatever means they felt necessary. At this point he began to calm down and did not need any further intervention. I was informed the following morning regarding the needle in his bed, according to the picture I was shown, it was not a needle that we keep on the telemetry department as it was not a safety type needle. We only keep safety needles in our areas, so I simply cannot explain this piece?"


An interview was conducted with Staff #20 RN on 7/10/19 at 10:16AM. Staff #20 stated she was on the floor when Patient #2 came up to his room. Staff #20 stated the patient was cursing loudly and seemed very agitated. I asked why he was cursing and yelling and he started cursing me and stated he could not control his arms. Staff # 17 held patient #2's arms down and then Patient #2 started threatening Staff #17. After Staff #17 told him to stop he quit cursing and flailing his arms. He became complaint. I left the room." Staff #20 was asked why she did not document any of her assessment of the patient or the situation. Staff #20 stated she was not the primary nurse and in hind sight she should have.


Review of the grievance had no mention of any bruising on the patients arms. Patient #2 and his wife stated that Patient #2 had bruises on both arms where staff #17 had grabbed the patient when holding his arms. Patient #2 stated he informed the patient Advocate of the bruising.


An interview was conducted with Staff #3 Director of Risk Management on 7/10/19 at 3:11PM. Staff #3 stated the Patient Advocate did not report this incident up to Risk Management. Staff #3 stated if she had been aware of the allegation a formal investigation would have been opened. Staff #3 reported that there was a process problem and would need to be assessed.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0160
Based on review and interview, the facility failed to:

A. recognize the prohibited use of "as needed" (PRN) chemical restraints in 6 (3, 4, 5, 7, 8, and 9) out of 6 patient charts reviewed.

B. follow the of use chemical restraints in Quality Assurance Performance Improvement (QAPI). QAPI failed to recognize the prohibited use of "as needed" (PRN) chemical restraints and failed to recognize the restraint policy and procedure does not address the monitoring, assessment, and face to face requirement before administering a chemical restraint.


The deficient practices identified above 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.


Review of the facility's restraint log revealed there was no seclusions, holds, or chemical restraints documented. Review of patient charts revealed psychotropic medications were ordered "as needed" (PRN) for agitation and aggressive behaviors.


Review of the facility's policy and procedure "Restraints and Seclusions" stated, "Procedure: A. Restraints or Seclusion Orders: 4. Standing Orders or PRN ("as needed") are not used."


Review of the ED physician orders revealed Patient #3 had an order for Haldol 2 mg IM ordered once "as needed" on 7/5/19 at 2358 (11:58 PM). There was no reason documented on the physician order for the administration of the psychotropic medication. Review of the pharmacy order sheet revealed it was ordered for severe agitation. Review of the chart revealed the Haldol 2 mg was given on 07/06/19 at 0005 (12:05 AM).


Review of the chart revealed Patient #3 received a physician order for haloperidol lactate (HALDOL) injection 2 mg, IV, Q6H PRN 7/6/19 at 10:34 AM. There was no reason documented for administering the psychotropic drug in the physician order. Review of the pharmacy order sheet revealed it was ordered for severe agitation. Patient #3 received the medication PRN on the following dates and times:

7/6/19 at 1126 (11:26 AM)

7/6/19 at 1846 (6:46 PM)

7/9/19 at 1:28 AM.


Review of Patient # 5's chart revealed an order on 7/7/19 at 2:00 PM for haloperidol lactate (HALDOL) injection 5 mg PRN every 6 hours for severe agitation.


Review of Patient # 8's chart revealed an order on 6/27/19 at 4:17 PM for haloperidol lactate (HALDOL) injection 5 mg PRN every 4 hours for severe agitation.


Review of Patient # 7's chart revealed an order for haloperidol lactate (HALDOL) injection 5 mg every 1-hour PRN for severe agitation.


Review of Patient # 9's chart revealed an order for haloperidol lactate (HALDOL) injection 5 mg PRN every 2 hours for severe agitation.


Review of Patient # 4's chart revealed an order for haloperidol lactate (HALDOL) injection 2 mg PRN every 1 hour for severe agitation.


An interview was conducted with Staff #8 RN and # 9 RN on 7/10/19 in the afternoon. Staff #8 and #9 confirmed that PRN orders are written for the administration of psychoactive medications to control a patient's behaviors.


An interview was conducted on 7/10/19 with Staff # 7. Staff #7 confirmed chemical restraints (emergency behavioral medications) were not being monitored in the Quality Assurance Performance Improvement Process.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on review and interview, the facility failed to maintain an effective quality assessment and performance improvement that focused on all restraints applied within the hospital.

A restraint log was offered to the surveyor. The log had patients with soft wrist restraints only. There were no chemical restraints listed. The Pharmacy supplied a list of chemical restraints given to patients in the hospital. There was no identifiers in place to monitor chemical restraints.

An interview was conducted on 7/10/19 in the afternoon with staff # 7 Director of Quality concerning restraints and seclusions. Staff #7 stated there was no data or monitors in place for restraints at this time. Staff #7 stated Directors pull up their quality indicators and performance improvement projects at the unit levels. No one from any of the departments have reported any issues to Quality concerning restraints. Staff # 7 stated, " we are just not following chemical restraints at this time."
VIOLATION: NURSING SERVICES Tag No: A0385
Based on review and interview, Nursing failed to:

1.
A. have a minimal nurse staffing grid for 3 out of 3 (Orthopedic 6th floor and Telemetry floors 1 and 4) units reviewed.

B. have the Licensed Vocational Nurse (LVN) integrated into the nurse schedule matrix in 1(Ortho 6th floor) of 3(Orthopedic 6th floor and Telemetry floors 1 and 4) units reviewed.

Refer to Tag A0392


2.
A. monitor, assess, reassess, and document on patients receiving conscious sedation medications by Emergency Medical Services (EMS) or in the Emergency Department (ED) in 1 (9) of 1 (9) patient charts reviewed.

B. nursing failed to have training and competencies for the Registered Nurse (RN) in the ED for monitoring conscious sedation in 7(17, 20, 21, 22, 23, 24, and 25) of 7 employee charts reviewed.

C. ensure the patient was alert, competent, and not under sedation medications before asking questions of abuse and neglect and medical history before documenting a response in 1 (9) of 1 (9) patient charts reviewed.

D. subjectively administered as needed (PRN) psychotropic medications without physician notification or a scale to determine the levels of agitation in 2 (3 and 9) of 2 charts reviewed.

The deficient practices identified above 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.


Refer to Tag A0395