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 Nov. 4, 2020
VIOLATION: IC PROFESSIONAL DOCUMENTATION Tag No: A0773
Based on observation, interviews with staff and review of documentation the facility failed to monitor the negative pressure air flow in the Covid-19 units. There was no documentation available for the surveyor to review that the negative air flow cycles pressures in the Covid-19 unit had been performed.

Findings
Review of policy Negative Pressure. Effective Date 6/17/2020. Policy Statement; To separate patients who are presumptively positive or confirmed COVID infectious disease from other patients. Procedure; All monitoring of the air flow cycles per hour and any maintenance of RA HEPA Air scrubber will be managed by environmental services (EVS).

An interview was conducted with staff #10 on 11/2/2020 2:35 pm. The surveyor asked staff #10, do you have documentation for the negative pressure air flow rooms? How do you verify the airflow is working correctly and what is the procedure? Staff #10 said, he uses a smoke pencil, which emits a string of smoke or tissue paper to see if the paper is suck into the room. The surveyor asked staff #10 for verification of the procedures being performed. Staff#10 said, "I did not document the procedures."
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
Based on review of documents and staff interview, the facility failed to ensure that verbal or telephone orders were signed by a practitioner within 48 hours in accordance with facility policy.

Findings included:

The medical record for patient #2 was reviewed by the survey team the afternoon of 11/3/2020 in the facility conference room. As of 11/3/2020, telephone orders were not signed or authenticated by the provider from the following dates/times:
7/15/2020 at 2236, admitting orders
7/15/2020 at 2236, admitting orders, medication reconciliation
7/16/2020 at 0847, medication orders
7/16/2020 at 2320, emergency medication order
7/18/2020 at 0735, emergency medication order
7/19/2020 at 1131, DC neuro-checks
7/19/2020 at 0250, emergency medication order
7/19/2020 at 0235, medication order
7/20/2020 at 0730, 1:1 order
7/20/2020 at 1900, DC 1:1
7/21/2020 at 0420, emergency medication order
7/21/2020 at 0435, emergency medication order
7/21/2020 at 1235. emergency medication order
7/22/2020 at 0310, emergency medication order
7/22/2020 at 2240, emergency medication order
7/23/2020 at 1327, observation 1:1 and emergency medication order
7/23/2020 at 1327, personal restraint
7/23/2020 at 1345, med consult
7/24/2020 at 1000 medication order
7/24/2020 at 1655, med consults.
7/26/2020 at 0630, precautions order
7/26/2020 at 0830, med consult

As of 11/3/2020, telephone orders for Patient #2 were not signed or authenticated by the provider within 48 hours of the time the order was originally issued:
7/21/2020 at 0423, telephone order for emergency medications not signed by the provider until 7/27/2020 at 1425.

The medical record for patient #5 was reviewed by the survey team the afternoon of 11/3/2020 in the facility conference room. As of 11/3/2020, telephone orders were not signed or authenticated by the provider on the following dates/times:
7/12/2020 at 1320, admitting orders
7/12/2020 at 1320, admitting orders, medication reconciliation7/13/2020 at 2230, discharge orders.
The discharge note on 7/13/2020 for Patient #5 was not signed, dated, or timed by the provider.

Facility policy, Read Back of Telephone Orders and Critical laboratory Values/Tests, Policy Number NPSG-2, provided to the survey team, stated, in part, "A. Telephone Orders ...5. A physician will review and authenticate any telephone or verbal medication order within 48 hours."

The above findings were reviewed and confirmed with Staff #4 on 11/4/2020 at 11:30 am in the facility conference room.
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on interviews with the staff, and review of documentation the facility failed to have an infection control (IC) nurse trained in education, experience or certification. There was no documented infection control training for the IC nurse.

Findings

Review of staff #3 infection control nurse personnel file did not have an infection control job description. There was no documentation of education or training in infection control.

Staff Position Description-Addendum. Rev. 5/25/2016. Infection Control Nurse. Qualifications: Education: Required; Documented evidence of Infection Control Training.

In an interview with staff #4 risk manager in the administrative conference room 11/4/20 11:50 am, the findings were confirmed.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on review of documentation, and interviews the facility failed to ensure the patient's right to be free from neglect. There was no documentation of re-assessments of patient #1 blood pressure.

Findings
Review of the patient #1 medical record 9/10/20 9:40 am, B/P 178/93 on admission. Adult Daily Nursing Assessment/progress 9/10/20. Blood pressure 146/107, 9/11/20 at 0015 after patient #1 complain of not feeling good. Physician was notified Vistaril and Motrin was given. 0200 Patient resting comfortably in bed. There was no documentation the blood pressure had been rechecked.

Physician Orders 9/10/20 1200p. Labetalol 100mg po BID. (1st dose now). An interview was conducted with staff#11 at the facility on 11/3/20, 12:00 pm in the conference room. Staff #11 reviewed the medical record said the physician may have gotten the dates mixed up when the order was written. Labetalol was given on 9/11/20 at 1330. There was no documentation of blood pressure being reassessed. Hydralazine 10 mg po every 2 hours if SBP>160 was order. There was no documentation the blood pressure had been recheck in two hours.

History and Physical. 9/11/20, 20:28 B/P 145/101.

Medication Administration Record (MAR) stated, Labetalol 100mg po BID-1st dose give now 9/11/2020 at 13:30. Hydralazine 10 mg every two hours SBP >160. There was no documentation available for the surveyor to review that patient #1 blood pressure had been re-assessed after medication was given. Review of discharge note 9/11/20 1545 stated physical complete. There was no other blood pressure assessment documentation available for the surveyor to review for pt#1.

Review of Nursing Assessments policy. Effective Date 6/10/13 stated, "Inpatient Procedures. 2. A nursing reassessment shall be conducted on every shift thereafter; any time a significant change of condition takes place or more frequently as patient needs determine."

Review of medical record did not reveal nursing assessment/progress note for the time and condition of patient #1 at discharge. An email was sent to staff #4 risk manager on 11/12/20. 5:07 pm requesting copy of 9/11/20 Nurse assessment/progress note. Progress note received by email, 11/13/20. The nursing assessment note did not state any reassessment of patient #1 blood pressure.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on review of documentation and staff interview, the facility failed to ensure that telephone orders for restraint were signed and dated by the ordering physician within 48 hours of the time the order was originally issued.

Findings included:

The medical record for patient #2 was reviewed by the survey team the afternoon of 11/3/2020 in the facility conference room. As of 11/3/2020, telephone orders were not signed or authenticated by the provider on the following dates/times:

7/23/2020 at 1327, telephone order for personal restraint and emergency medication order was not signed by provider.

Telephone orders were not signed or authenticated by the provider within 48 hours of the time the order was originally issued:
7/21/2020 at 0423, telephone order for personal restraint and seclusion and emergency medications was not signed by the provider until 7/27/2020 at 1425.
7/21/2020 at 0423, telephone order for personal restraint and seclusion and emergency medications was not signed by the provider until 7/27/2020 at 1425.
7/22/2020 at 1640, telephone order for personal restraint and emergency medications was not signed by the provider until 7/27/2020 at 1425.

Facility policy, Seclusion/Restraint/Emergency Medications, Policy Number PC-C-3, provided to the survey team, stated, in part, "3.1.4 Telephone/verbal orders for restraint/seclusion may be received and recorded by an RN or LVN. 3.1.5 The physician/LIP shall authenticate the telephone/verbal order within 48 hours."

The above findings were reviewed and confirmed with Staff #4 on 11/4/2020 at 11:30 am in the facility conference room.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on review of documentation the nursing staff failed to reassess patient's blood pressure. This causes potential for patients' condition to deteriorate.

Findings
Review of the patient #1 medical record 9/10/20 9:40 am, B/P 178/93 on admission. Adult Daily Nursing Assessment/progress 9/10/20. Blood pressure 146/107, 9/11/20 at 0015 after patient #1 complain of not feeling good. Physician was notified Vistaril and Motrin was given. 0200 Patient resting comfortably in bed. There was no documentation the blood pressure had been rechecked.

Physician Orders 9/10/20 1200p. Labetalol 100mg po BID. (1st dose now). An interview was conducted with staff#11 at the facility on 11/3/20, 12:00 pm in the conference room. Staff #11 reviewed the medical record said the physician may have gotten the dates mixed up when the order was written. Labetalol was given on 9/11/20 at 1330. There was no documentation of blood pressure being reassessed. Hydralazine 10 mg po every 2 hours if SBP>160 was order. There was no documentation the blood pressure had been recheck in two hours. History and Physical. 9/11/20, 20:28 B/P 145/101.

Medication Administration Record (MAR) stated, Labetalol 100mg po BID-1st dose give now 9/11/2020 at 13:30. Hydralazine 10 mg every two hours SBP >160. There was no documentation available for the surveyor to review that patient #1 blood pressure had been re-assessed after medication was given. Review of discharge note 9/11/20 1545 stated physical complete. There was no other blood pressure assessment documentation available for the surveyor to review for pt#1.

Review of Nursing Assessments policy. Effective Date 6/10/13 stated, "Inpatient Procedures. 2. A nursing reassessment shall be conducted on every shift thereafter; any time a significant change of condition takes place or more frequently as patient needs determine."

Review of medical record did not reveal nursing assessment/progress note for the time and condition of patient #1 at discharge. An email was sent to staff #4 risk manager on 11/12/20. 5:07 pm requesting copy of 9/11/20 Nurse assessment/progress note. Progress note received by email, 11/13/20. The nursing assessment note did not state any reassessment of patient #1 blood pressure.