HospitalInspections.org

Based on a review of documents and interview with staff, the governing body failed to appoint a chief executive officer who was responsible for managing the hospital.

Findings were:

During a review of hospital policy entitled, " Nursing Staffing Policy and Plan " according to the staffing grid for the child and adolescent unit located in the Nursing Staffing Policy and Plan, the facility staffing did not meet the required staffing needs:

Date: 7-22-11, Shift: 3p-11p, Census: 16, Required: 2 nurses; 3 MHTs, Actual: 1 nurse, 3 MHTs
Date: 7-25-11, Shift: 11p-7a, Census: 13, Required: 2 nurses; 1 MHT, Actual: 1 nurse, 2 MHTs
Date: 7-26-11, Shift: 7a-3p, Census: 18, Required: 3 nurses; 3 MHTs, Actual: 2 nurses, 2 MHTs
Date: 7-28-11, Shift: 7a-3p, Census: 18, Required: 3 nurses; 3 MHTs, Actual: 2 nurses, 3 MHTs

A review of hospital policy entitled, " Transfer of Patients to Other Facilities " states, in part, on page 5 of 6, " NHCS will provide a memorandum of transfer, as prescribed by the Texas Department of Health, to be completed for every patient who is transferred. "

During a review of clinical record for Patient #1 and an interview with staff, no memorandum of transfer could be located within the clinical record or in another file for the transfer of Patient #1 to Methodist Hospital ER on 7-26-11.

The above was confirmed in an interview with the Chief Operating Officer and other administrative staff on the afternoon of 9/6/11 in the facility conference room.

Based on a review of facility documentation, the hospital's medical record service did not ensure that the patient's medical record contained properly executed consent forms.

Findings were:

Four of five consent forms for psychoactive medications did not contain properly executed consent from the minor patient's legal guardian.

The above was confirmed in an interview with the Chief Operating Officer and other administrative staff on the afternoon of 9/6/11 in the facility conference room.