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 9, 2019|
|VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION||Tag No: A0123|
|Based on staff interview and record review of closed grievances, the facility failed to ensure that the patient advocate provided the patient with a written notice (response) that contained all of the required elements. This failure resulted in 3 of 3 patients (patient #2, #3, and patient #4) receiving a letter that did not contain a legible signature of the patient advocate, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.
Record review of the written response to patient #2, #3, and patient #4 by the Patient Advocate, Staff F, revealed a form letter that was sent to all three patients. It stated, "This letter is in response to a complaint made by you: it is our expectation that our patients are treated with kindness ... Please contact me at your convenience if I may be of any further assistance ... Sincerely, Patient Advocate ..." Staff F did not provide a phone number to contact her. The letter did not outline the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, or the date of completion. Staff F's signature was illegible.
Record review of the policy 65, "Complaint and Grievance Procedures," revised 8/2018, showed that the patient will be provided with a written notice of the name of the Patient Rights Advocate, the steps taken to investigate and resolve the grievance, the result of the complaint and grievance process, and the date of completion of the complaint and grievance process.
In an interview with the Patient Rights Advocate, Staff F, on 5/9/2019 at 2:15 PM, she stated patients receive the same form letter. She also stated the form letter does not include all the elements outlined in the regulation.
|VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION||Tag No: A0184|
|Based on interview with administrative nursing staff and medical record review, the facility failed to ensure that a 1-hour face-to-face was documented in the patient's medical record following the administration of medications that were used as a restriction to manage a patient's behavior. This failure resulted in 1 of 3 instances in which a 1-hour face-to-face was not documented in the medical record of Patient #1.
Record review of policy 42, Seclusion and Restraint, revised 4/2019 stated: "Required Documentation ... 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 ... restraint."
Record review of a Nursing Assessment Note for Patient #1, dated 4/12/2019 at 8:15 PM, showed impulsive, paranoid, delusional, disruptive, agitated behavior. The patient attempted to pull down the TV that was mounted to the wall and turned over chairs in the day room. Attempts were made to verbally deescalate the patient and oral medication was offered, but "the situation remained the same." Patient #1 was administered an injection of Benadryl 50 mg, Ativan 2 mg, and Haldol 5 mg. A face-to-face evaluation was not performed by a registered nurse or other licensed independent practitioner within 1-hour.
In an interview with Staff A, B, C, and D on 5/9/2019 at 2:30 PM, Staff C stated that a face-to-face evaluation for Patient #1 was not performed by a registered nurse within 1-hour of the injection of Benadryl, Ativan, and Haldol.
|VIOLATION: PROGRAM SCOPE, PROGRAM DATA||Tag No: A0273|
|Based on record review of QAPI data and interview, the facility failed to analyze restraint and seclusion data for 13 of 13 months (all of 2018 and January, 2019). Failure to measure, analyze, and track this high-risk, problem-prone area resulted in 360 incidents of restraint and 147 incidents of seclusion not being analyzed for appropriateness, safety, and proper implementation through the facility's Quality Improvement Organization.
Record review of the policy 42, Seclusion and Restraint, revised 4/2019, showed: "IX. Quality Assurance. A. The Quality Committee will monitor and evaluate the use of restraints and seclusions as a performance indicator, and report trends quarterly to the Governing Board. B. Senior leaders of the hospital will review daily all use of restraints and seclusions."
Record review of the restraint and seclusion data for 2018 and January of 2019 showed 360 incidents of restraint and 147 incidents of seclusion was reported to QAPI. Of note was the increase in restraints:
1. January 2018 = 18. February 2018 = 44
2. November 2018 = 14. December 2018 = 34.
Also of note was the increase in seclusion: June 2018 = 8. July 2018 = 25. There was no analysis or interpretation of the data to reduce the large amount of raw data to a manageable aggregate.
In an interview with Staff B on 5/9/2019 at 1:50 PM, he stated that the reason for the increases in restraint and seclusion was "population mix." No further analysis or explanation of the increases has been identified. Staff B also stated:
1. Staff completes a staff debriefing on all restraints and seclusions.
2. The staff debriefing is captured on a Staff Debriefing form.
3. The Staff Debriefing form remains in the patient's chart.
4. The data on the Staff Debriefing form is not used in monitoring the effectiveness and safety of restraint/seclusion by the Risk Manager.
5. He thought it would be a good idea to start reviewing the Staff Debriefing form as part of the monitoring of restraints and seclusions.
|VIOLATION: TRANSFER OR REFERRAL||Tag No: A0837|
|Based on record review of aftercare discharge instructions and interview with clinical services, the facility failed to ensure that necessary medical information was forwarded to the next level of care providers for continuity of care. This failure resulted in the discharge plan and instructions form not being sent to the psychiatrist providing medication management in outpatient services for 1 of 3 patients (Patient #1).
Record review of the policy 72, Discharge Planning, revised 4/2019 showed: "The discharge planner will ensure that the patient has appropriate continuity of care by maintaining ongoing contact with outside providers ... The discharge planner will send the Discharge Plan and Instructions form to the next level of care providers, for continuity of services and treatment. This will be sent at discharge within 24 hours of discharge."
Record review of the Aftercare Discharge Patient Instructions form dated 4/22/2019 showed that a counseling and psychiatric appointment had been made for Patient #1 for 4/23/2019 at 9:00 AM. Patient #1 was to "walk in" and "reestablish services." The address and phone number of Gulf Coast - Galveston were provided to the patient. There was no documentation that the discharge plan and instructions form had been faxed to the psychiatrist providing medication management in outpatient services. There is additional documentation, "No fax number. Not faxed. 4/23/2019." The author of this additional entry is not identified on the form.
In an interview with Staff H on 5/9/2019 at 12:20 PM, she stated they are to call the receiving outpatient service and "fax over clinical [information]." She also stated that these interventions are to be documented.
In a phone interview with Staff R on 5/9/2019 at 8:30 AM at Gulf Coast - Galveston, she provided a fax number.