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 May 23, 2019
VIOLATION: PHARMACEUTICAL SERVICES Tag No: A0490
Based on interview and record review the facility failed to ensure that "hard stops" were built into the electronic medication administration record system for obtaining a consent prior to the administration of medications. Failure to do so resulted in 1 of 1 patients (patient #1) receiving Ability with no prior consent to administer the medication.

Findings included:

Record review of the policy, "Medication Consent," last revised 1/2019, showed: "It is the policy of the Hospital to obtain consent for treatment with psychoactive medication ... The treating physician or designee must present this information about psychoactive medication ... to patient or legal guardian: ... beneficial effects ..., course of treatment with medication ..., the relevant side effects ..., and the nature and possible occurrence of irreversible symptoms ... Documentation of Informed Consent - Informed consent for the administration of psychoactive medication will be evidenced by a completed coy of the consent form."

In an interview with Staff G on 5/23/2019 at 9:00 AM, he stated that here has been "an issue with consent in the chart," adding that this information cannot be viewed in the electronic medical record.

In an interview with Staff B on 5/23/2019 at 10:05, she stated the facility is transitioning to an electronic medical record, adding, "We currently have a hybrid system." The two systems will be blended by 2020.

In an interview with Staff H on 5/23/2019 at 10:15 AM, he stated:
1) The medication nurse can denote "REFUSED CONSENT" in the electronic medical record.
2) When administrating a medication, one of the "hard stops" involves a drop down that prompts documentation of a consent.
3) The nurse must click yes or no to the consent prompt before moving forward; however, if there is no consent, the nurse can bypass the system and administer the medication.

Record review of the "Consent to Treatment with Psychoactive Medication" dated 3/11/2019 [not timed] showed that Patient #1's mother declined the administration of Ability 5mg at bedtime and wanted to speak with the physician before consenting. The consent was signed by Staff F (MD) on 3/12/2019 at 3:00 PM.
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to provide the necessary medical information to the receiving facility at the time of discharge. Failure to do so resulted in 1 of 1 patients (Patient #3) being discharged from the adolescent unit back into a Juvenile Detention Center with no documentation in the follow-up aftercare plan of noncompliance with treatment for a sexually transmitted disease.

Findings included:

Record review of Initial Psychiatric Evaluation for Patient #3 by Staff R (MD) dated 5/10/2019 at 12:00 PM showed a [AGE]-year-old female with suicidal thoughts. She was sexually abused at age 8 years old and raped at [AGE] years old. She had recently run away from home and was living with a [AGE]-year-old man. Primary diagnoses: bipolar I disorder, post-traumatic stress disorder, amphetamine use disorder, alcohol use disorder, and cannabis use disorder.

Record review of the History and Physical for Patient #3 by Staff S (MD) dated 5/10/2019 at 10:15 AM showed no acute or active medical diagnosis.

Record review of the Psychosocial Assessment for Patient #3 by Staff T dated 5/10/2019 at 11:35 AM showed a history of sex trafficking at [AGE] years old. She identified herself as bisexual. She was sexually active and used condoms.

Record review of Daily 7a to 7p Nursing Assessment Note for Patient #3 by Staff W dated 5/15/2019 at 10:00 AM showed, "Refuses meds ... found out had been treated for STD [sexually transmitted disease] - Chlamydia and gonorrhea in emergency department. Tearful."

Record review of Multidisciplinary Notes for Patient #3 by Staff Y (Nurse Practitioner) dated 5/15/2019 at 10:40 AM showed: Prior to admission patient tested positive for gonorrhea in the throat and chlamydia. She was treated with Flagyl 2 grams, Rocephin 50mg and Azithromycin 1 gram. "Patient needs to be retested at SUN ... Repeat test urine G/C [gonorrhea / chlamydia] throat swab."

Record review of Physician's Orders for Patient #3 showed:
5/9/2019 [not timed] - Urinalysis Culture and Specimen; Urine HCG; Urine Drug Screen; and RPR, Reflex Titer
5/15/2019 [not timed] - Urine GG [gonorrhea] / Chlamydia
5/16/2019 [not timed] - HIV

Record review of LabCorp log dated 5/17/2019 [not timed] by Staff U showed that Patient #3 refused to have blood work done for gonorrhea, chlamydia, and HIV.

Record review of Discharge Summary for Patient #3 by Staff R (MD) dated 5/17/2019 at 11:57 AM showed diagnoses at discharge had not changed from the admission diagnoses. Physical Findings: Physical examination is within normal limits. Diagnostic Laboratory Findings: no labs in the chart.

Record review of the "Aftercare Discharge Patient Instructions" form by Staff W for Patient #3 showed:
1. Counseling, psychiatric, and primary care physician appointments were made for 5/17/2019 a 2:00 PM at Fort Bend Juvenile Detention Center.
2. A note was written by an unidentified person: "Not faxed. No fax #. 5/20/19.
3. Discharge medication reconciliation: Depakote ER and Seroquel.

Record review of "Patient Personal Home Medications" form for Patient #3 dated 5/14/2019 at 9:30 PM showed that Patient #3's mother left a "new bottle" of Doxycycline 100mg at the reception desk. The form was signed by Patient #3's mother and Staff W.

Record review of "Patient Personal Home Medications" form for Patient #3, dated 5/17/2019 [not timed] showed Doxycycline 100mg. The form was signed at discharge by Patient #3's mother and Staff W.

Record review of Daily 7a to 7p Nursing Assessment Note by Staff W dated 5/17/2019 at 2:00 PM showed that Patient #3 was discharged to a juvenile detention center. The juvenile detention officer received discharge instructions, script, copy of labs, and home medications of Lexapro, Abilify and doxycycline.

In a phone interview with Staff V at the receiving juvenile detention center on 6/1/2019 at 9:05 AM, she stated that she had not received any information from the transferring facility about the antibiotic that accompanied Patient #3 to the detention center. Staff V also stated that they did not receive any information from the facility that Patient #3 had refused to have repeat lab work done to test for HIV and gonorrhea, Staff V asked Patient #3 why she was on an oral antibiotic. Staff V concluded by giving the surveyor the facility's fax number.

Record review of the website for the juvenile detention center on 6/1/2019 at 9:00 showed a fax number. It was the same fax number that Staff V relayed to the surveyor.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review, the facility failed to thoroughly investigate, and resolve each patient's grievance. Failure to do so resulted in allegations of abuse by 1 of 1 patients (Patient #2) against Staff I and Staff J were not thoroughly investigated and resolved.

Findings included:

Record review of the "Initial Psychiatric Evaluation" by Staff Q (MD) dated 3/3/2019 at 11:11 AM showed that Patient #2 was a [AGE] year old female admitted Bipolar Disorder and Post-Traumatic Stress Disorder. Her mood was euphoric and grandiose and her affect was labile.

Observation of the Connections Unit on 5/23/2019 from 9:00 AM - 11 AM showed 17 patients. The patients were engaged in various activities. There were two (2) RNs and three (3) Mental Health Technicians [MHT] on the unit. One of the MHTs was conducting the observation rounds. There were no altercations between patients and staff noted.

In an interview with Patient #7 on 5/23/2019 at 10:40 AM, she stated she had an issue with Staff J, an RN. Patient #7 described Staff J as "rude and racial." She did not believe that Staff J understood that patients are sometimes "sensitive and emotional."

In an interview with Staff K (Unit RN) on 5/23/2019 at 10:55 AM, she stated that she hears complaints from patients about staff being "rude" and "I don't like that nurse." Staff K would not disclose any staff member names, adding that one of the nurses named was no longer working at the facility.

Record review of a "Patient Advocate Report and Follow-Up" dated 3/6/2019 [not timed] showed a complaint by Patient #2. Patient #2 alleged:
1. Staff I was "rude and unprofessional" and 'heartless."
2. Staff I had "fussed" about the MHT letting Patient #2 into the employee's restroom.
3. Staff I referred to her as "ghetto."
4. The nurse supervisor spoke with Patient #2.

In an interview with Staff J (the nurse named by Patients #2 and #7) on 5/23/2019 at 10:45 AM, she stated that a complaint was made against her by a patient, adding that the patient accused her of being "rude."

In an interview with Staff I on 5/23/2019 at 11:55 AM, she stated:
1) Patient #2 was on the Connections Unit.
2) Staff I encountered Patient #2 on the Connections Unit.
3) Patient #2 got "extremely angry" with Staff I.
4) Two MHTs overheard the altercation between Staff I and Patient #2.
5) Patient #2's toilet clogged in the middle of the night.
6) The altercation resulted over Staff I's misunderstanding of where the MHTs were going to take the patient for toileting.
7) Staff I questioned the MHTs about their choice of bathrooms, thinking the MHTs were going to take Patient #2 into one of the staff bathrooms.
8) Patient #2 "thought I was saying that she was not good enough to use that bathroom. I didn't mean that. This was a cash-paying patient."
9) Patient #2 stated she was going to report Staff I to the Texas Board of Nursing.
10) Administration removed Staff I from the Connections Unit.
11) Patient #2 wrote a "long letter" to the Patient Advocate.
12) Someone other than Patient #2 wrote the letter to the Patient Advocate.
13) Administration told her (Staff I) to "change your approach" and "instructed me to bring it down a bit."
14) "I didn't get a promotion to the nurse educator position because of the letter Patient #2 wrote [to the Patient Advocate]."
15) "My standards are so much higher than those of other people."
16) "I get targeted as the bitch."

In an interview with Staff L on 5/23/2019 at 3:00 PM, she stated that Staff I referred to Patient #2 as "ghetto."

In an interview with Staff L on 5/23/2019 at 2:10 PM, she stated that Staff I was on a performance improvement plan and that Staff AA was responsible for following up with Staff L on the performance improvement plan by having periodic meetings with Staff L. She also stated that the MHTs that witnessed the altercation between Staff I and Patient #2 were not interviewed.

In an interview with Staff AA on 5/23/2019 at 2:45 PM, she stated that she had been assigned to meet with Staff I to discuss the performance improvement plan and assess performance, but had not followed through in scheduling meetings with Staff I.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review:

A. The facility failed to obtain a consent from a parent or legal guardian for the administration of a psychoactive medication to an adolescent patient prior to the administration of the medication. Failure to do so resulted in 1 of 1 patients (Patient #1) receiving Ability with no prior consent to administer the medication.
B. The facility failed to obtain consents that were both dated and timed for the administration of psychoactive medications to adolescent patients prior to the administration of the medications. Failure to do so resulted in 2 of 2 patients (patient #4 and #5) receiving medications with no documentation of the time the consent was signed by the parent or legal guardian.
C. The facility failed to follow through with administration of an antibiotic for 1 of 1 patients (Patient #3), diagnosed with a sexually transmitted disease.

Findings included:

A. Patient #1 - no consent for Abilify.

Record review of the policy, "Medication Consent," last revised 1/2019, showed: "It is the policy of the Hospital to obtain consent for treatment with psychoactive medication ... The treating physician or designee must present this information about psychoactive medication ... to patient or legal guardian: ... beneficial effects ..., course of treatment with medication ..., the relevant side effects ..., and the nature and possible occurrence of irreversible symptoms ... Documentation of Informed Consent - Informed consent for the administration of psychoactive medication will be evidenced by a completed coy of the consent form."

Record review of the "Initial Psychiatric Evaluation" by Staff F (MD) dated 3/10/2019 at 1:00 PM showed a [AGE]-year-old female with suicidal ideation. Psychiatric diagnosis: Major Depressive Disorder and Post-Traumatic Stress Disorder.

Record review of the "Physician's Order" showed Ability 5mg was ordered by Staff F (MD) on 3/11/2019 at 3:37 PM with a start date and time of 3/11/2019 at 9:00 PM.

Record review of the "Consent to Treatment with Psychoactive Medication" dated 3/11/2019 [not timed] showed that Patient #1's mother declined the administration of Ability 5mg at bedtime and wanted to speak with the physician before consenting. The consent was signed by Staff F (MD) on 3/12/2019 at 3:00 PM.

Record review of Medication Administration Record [MAR] dated 3/11/2019 at 9:00 PM, showed Abilify 5mg was given by mouth at bedtime with NO CONSENT by Staff E. ["NO CONSENT" was in all capitals on the MAR.]

Record review of the "Daily 7a to 7p Nursing Assessment Note" by Staff O. dated 3/12/2019 at 8:20 AM, showed that Patient #1 complained of feeling dizzy upon awakening. Staff O documented, "Upon reviewing MAR, patient was given Abilify 5mg on 3/11/2019 at 8:55 PM with no consent."

Record review of the "Patient Initiated Discharge/AMA [Against Medical Advice] Intervention Protocol" by Patient #1's mother, dated 3/12/2019 at 11:34 AM, showed that the guardian was "unhappy with care, desiring to seek outside treatment." Reason for Leaving: "Given medication without consent." RN Signature: Staff O. Witness Signature: Staff P.

Record review of the Discharge Summary by Staff F (MD) dated 3/12/2019 at 1:00 PM showed that Patient #1's mother refused a mood stabilizer for her daughter. The discharge was AMA.

Record review of an article, "Practice Parameter on the Use of Psychotropic Medication in Children and Adolescents" in the Journal of the American Academy of Child Adolescent Psychiatry, 2009; 48:961-973, showed: "Parents and guardians and the youth must be informed about the potential risks as well as the benefits when giving consent and assent for initiation of a trial of psychotropic medications."


B. Patient #4 and #5 - Medication Consents.

Patient #4.

Record review of Physician's Order by Staff F dated 5/15/2019 at 4:31 PM showed that Buspar 5mg three times a day was ordered for Patient #4.

Record review of the "Consent to Treatment with Psychoactive Medication" showed consent given by the legal guardian of Patient #4 on 5/16/2019 for the Buspar. The consent is not timed.

Record review of MAR showed that Buspar 5 mg was given to Patient #4 on 5/16/2019 at 9:00 AM.

Patient #5.

Record review of Physician's Order by Staff F dated 5/16/2019 at 3:14 PM showed that Strattera 80mg daily, Lexapro 20mg daily, Buspar 15mg twice a day, Abilify 30mg every evening, and Benadryl 25mg at bedtime as needed for sleep was ordered for Patient #5.

Record review of the "Consent to Treatment with Psychoactive Medication" showed consent given by the legal guardian of Patient #5 on 5/16/2019 for Strattera, Lexapro, Buspar, Abilify, and Benadryl. The consent is not timed.

Record review of MAR showed the following medications were given to Patient #5:
Strattera 80mg, Lexapro 20mg, and Buspar 15mg on 5/16/2019 at 9:00 AM;
Ability 30mg on 5/16/2019 at 5:00 PM; and Benadryl 25mg at bedtime on 5/16/2019 at 8:30 PM.


C. No follow through in the administration of an antibiotic for a sexually transmitted disease.

Record review of Daily 7a to 7p Nursing Assessment Note for Patient #3 by Staff W dated 5/15/2019 at 10:00 AM showed, "Refuses meds ... found out had been treated for STD [sexually transmitted disease] - Chlamydia and gonorrhea in emergency department. Tearful."

Record review of Multidisciplinary Notes for Patient #3 by Staff Y (Nurse Practitioner) dated 5/15/2019 at 10:40 AM showed: Prior to admission patient tested positive for gonorrhea in the throat and chlamydia. She was treated with Flagyl 2 grams, Rocephin 50mg and Azithromycin 1 gram. "Patient needs to be retested at SUN ... Repeat test urine G/C [gonorrhea / chlamydia] throat swab."

Record review of "Patient Personal Home Medications" form for Patient #3 dated 5/14/2019 at 9:30 PM showed that Patient #3's mother left a "new bottle" of Doxycycline 100mg at the reception desk. The form was signed by Patient #3's mother and Staff W.

Record review of "Patient Personal Home Medications" form for Patient #3, dated 5/17/2019 [not timed] showed Doxycycline 100mg. The form was signed at discharge by Patient #3's mother and Staff W.

Record review of Daily 7a to 7p Nursing Assessment Note by Staff W dated 5/17/2019 at 2:00 PM showed that Patient #3 was discharged to the juvenile detention center. The juvenile detention officer received discharge instructions, script, copy of labs, and home medications of Lexapro, Abilify and doxycycline.

Record review of the Medication Administration Record for Patient #3, dated 5/9/2017 through 5/17/2019 showed no administration of doxycycline.

In an interview with Staff B on 5/23/2019 at 1425, she stated she did not know why the doxycycline was not considered in the treatment of Patient #3's sexually transmitted disease.