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Based on record review and interview, the facility failed to ensure their policies and procedures protected patient's rights to be free from all forms of abuse or harassment while a patient in the facility. Specifically, the facility's procedures for; how to report abuse/neglect/exploitation were not specific and did not include the reporting requirements regarding allegations of abuse/neglect against the facility and/or facility employees to the appropriate state health care regulatory agency that has authority and licenses the facility; Department of State Health Services (DSHS) at (888) 973-0022; and in accordance with the Health and Safety Code §161.132(b).


Findings included:

Review of the facility's Policy and Procedures titled, Abuse and Neglect, last reviewed April 2017 revealed the following: reports, observed, or suspected patient abuse, neglect, mistreatment and/or exploitation were to be reported to the facility's Chief Executive Officer (CEO) or designee immediately. The CEO, Director of Quality Management (DQM), or their designee would review the federal reporting requirements.

Further review revealed the facility's Abuse and Neglect policy did not have any further information regarding the specific state health care regulatory agency (Department of State Health Services) that has authority over allegations of abuse/neglect against the facility and/or facility employees was provided within the policy; or a phone number to the DSHS agency (888-973-0022) was provided within the policy.


During an interview on 12/21/17 at 05:15 PM with the Facility's DQM confirmed after review of the facility's policy for reporting Abuse and Neglect (last reviewed 4/2017) did not contain the specific information for reporting abuse and neglect to the appropriate agency that licensed the facility [DSHS] or the appropriate state health care regulatory agency [DSHS] for allegations of abuse associated with the facility or an employee of the facility. The DQM further stated upon an allegation of abuse and/or neglect an investigation would be conducted and if there was evidence; or a threat, then corporate legal would be notified for further advisement.


Health and Safety Code §161.132(b) indicates: b) An employee of or other person associated with an inpatient mental health facility, a treatment facility, or a hospital that provides comprehensive medical rehabilitation services, including a health care professional, who reasonably believes or who knows of information that would reasonably cause a person to believe that the facility or an employee of or health care professional associated with the facility has, is, or will be engaged in conduct that is or might be illegal, unprofessional, or unethical and that relates to the operation of the facility or mental health, chemical dependency, or rehabilitation services provided in the facility shall as soon as possible report the information supporting the belief to the agency that licenses the facility [DSHS] or to the appropriate state health care regulatory agency [DSHS].

Based on record review of patient records and staff interviews, the hospital failed to ensure the nursing staff developed an accurate nursing plan of care; kept the plan of care current, and implemented the nursing care plan consistent with the patient's nursing care needs and documented nursing interventions related to the patient's assessments for 1 of 1 patient reviewed (Patient #1) following complaint allegations in the area of nursing services.

Specifically the nursing staff failed to:

1. Implement a Plan of Care (POC) for Patient's #1's Seizure Disorder to include goals, interventions, and treatment. Patient #1 had a Vagus Nerve Stimulator implant to assist in the control of seizures, routine medications ordered, and prn medications ordered for seizure activity that was not implemented in the nursing POC.

2. Implement goals and interventions for Impaired Skin Integrity (Wound Care) that was transferred to Nursing on 1/10/17. The POC was blank and; in addition was not updated on 1/19/17 once Patient #1 was noted to have acquired multiple bruising documented which resulted in a diagnosed fracture after discharge.

3. Implement a POC for impaired bed mobility and; implement Physician Orders dated 1/11/17 that ordered Patient #1 up in a wheelchair twice daily from his bed.

Findings included:

1. Record review of Patient (Pt.) #1's History and Physical (H&P) dated 1/10/17 revealed patient was admitted to the facility because of cough and fever. Patient with pneumonia and positive for streptococcus. Review of Past Medical History included; "seizure disorder, cerebral palsy (CP), noncommunicating" (Intellectual Disabled). Impression and plan included Seizure Disorder; Keppra and Vimpat medications for seizure disorder.

Nurse assessment on 1/15/17 at 07:45 revealed Patient #1 had a VNS (Vagus Nerve Stimulator) anti-seizure implant to right chest with device [magnet] at bedside. (Note: The magnet device is used to help stop a seizure or lessen the severity or length of a seizure if the magnet is applied at the time of the seizure).

Review of Patient #1's Nurses Flow Sheets revealed seizures documented as follows:
a. 1/12/17 at 13:25 Patient #1 noted by sitter that his eyes rolled back, patient having a seizure. Physician called.
At 13:31 medicated with Ativan 2 milligrams due to seizure.
b. 1/14/17 at 22:30 Seizure activity noted. Dissipated with repositioning.
c. 1/19/17 at 08:15 Patient #1's sitter reported that pt. had a seizure that lasted 30 seconds.
d. 1/20/17 at 23:54 Pt. had a 30 second seizure. Vital signs obtained. Was in a daze, eye movement. Upon assessing, pt. calm.
e. 1/22/17 at 10:23 sitter called and stated patient had a seizure for 1 minute. Sitter applied magnet [VNS magnet]. Physician called and made aware. No new orders.
f. 1/22/17 at 21:00 sitter stated pt. had a 1 minute seizure. Non-witnessed [by facility staff]. Pt calm.
g. 1/25/17 at 02:38 bedside sitter came to nurse's station to report a 35 second seizure. Sitter reports seizure dissipated on its own without intervention.

Record review of Patient #1's Interdisciplinary (IDT) Plan of Care (POC) initiated on 1/10/17 and updated as needed; revealed in the area of Seizures was blank for Goals and Interventions, and the area was checked for: "No related issues at this time." There were no nursing care plan interventions documented regarding Patient #1's seizure disorder; which would include routine medications ordered (Keppra and Vimpat), prn medications ordered (Ativan), repositioning, and the use of the VNS magnet at the time of seizure activity.

2. Review of the IDT POC initiated 1/10/17 revealed the area for Wound Care, Impaired Skin-Integrity was blank with no Goals and Interventions documented or updated.

A. Review of the Wound care evaluation and management consultation report dated 1/10/17 revealed patient severely contracted all extremities. Assessment and plan as follows:
1. Bilateral heel pressure injury stage 1. Heels will be offloaded with offloading boots at all times while in bed.
2. Moisture-associated dermatitis bilateral buttocks. Calazime Cream will be applied 3 times daily and prn for soiling. He will be on a low air loss mattress and repositioned every 2 hours prophylactically.
3. Functional quadriplegia.
4. Pneumonia. Intravenous antibiotics will be managed by physician.

Review of the Wound Care Transfer of Service Notification dated 1/10/17 revealed Patient #1 has been transferred from Wound Care to Nursing Care with the following skin issues documented:
-Moisture wound on bilateral buttocks recommendation for antifungal powder.
-Stage one on bilateral heels recommendation for offload with pillows or boots.

There were no further Wound Care assessments or consultations noted during Patient #1's inpatient stay at this facility. The nursing POC was not updated to include these recommendations and treatment interventions transferred to nursing by the Wound Care.

B. Review of the complaint intake TX00273524 revealed patient #1 acquired injuries of unknown origin during his inpatient care at this facility from 1/10/17 to 1/25/17. Patient #1 was noted to have a bruise on his left outer thigh measuring 11 centimeters (cm) by 16 cm, and a bruise on his left knee measuring 6.5 cm by 6.5 cm. There was no explanation as to what happened; or how Patient #1 attained the large bruises.

Review of Nursing Daily Flowsheets revealed the following documentation in the area of "Surgical Wounds/Lesions/Tube Sites" documentation was to include; "Location, Description, Treatment."
On 1/19/17 at 20:00 documented "bruising to l [left] hip/thigh area." There was no description of the bruising or size indicated.
On 1/20/17 documentation of bruise, left flank, left thigh, and left knee. There was no description of the bruising or sizes of bruises.
On 1/21/17 documentation left flank small bruise fading. Left knee and left thigh bruising fading.
On 1/22/17 documentation that bruising; left flank, left knee and left thigh fading.
On 1/23/27 documentation was blank. No documentation of bruising noted.
On 1/24/17 documented Reddened buttocks, Reddened groin-antifungal powder. "Large Bruise, hematoma. Purple. L outer thigh, skin intact."
On 1/25/17 documentation of left outer thigh- reddish/purple areas.

There were no further Wound Care assessments or consults completed following these new identified bruises to Patient #1 on 1/19/17. The nursing POC was not updated to include treatment or interventions; and/or an explanation as to how Patient #1 may have acquired the bruising.

Review of the facility's Complaint and Grievance log revealed on 2/24/17 the facility's Director of Quality Management (DQM) met with the Medical Director of Patient #1's long-term placement facility (state school). The Medical Director of the long-term placement facility stated that a State Representative had been to see Patient #1 while he was at this acute care facility; the night prior to transfer (1/24/17) and questioned facility staff as to why Patient #1 had a "reddened area to Left thigh and inner aspect of lower leg." When Patient #1 transferred back to the State School (long-term placement facility) they noticed the reddened area was worse, so they took an X-Ray of the area and discovered the patient had a fracture.

During an interview on 12/21/17 at 4:00 PM with the DQM indicated the facility was not able to determine an explanation as to how Patient #1 attained the documented bruising to his left flank, thigh, and knee area that was initially documented on 1/19/17.

3. Review of Patient #1's Admission Orders dated 1/10/17 at 00:05 revealed orders for W/C [wheelchair] Evaluate and Treat, PT [Physical Therapy] Evaluate and Treat, OT [Occupational Therapy] Evaluate and Treat.

Review of the IDT POC initiated on 1/10/17 revealed the area for Impaired Mobility was checked for: "No mobility issues at this time." Further review revealed it was documented, "Not appropriate for Rehab."

Review of the Registered Nurse's / Case Manager (RN CM) Admission documentation on 1/10/17 at 14:00 revealed the RN CM met with staff from the state school (Patient #1's long term care placement). CM was informed that Patient #1 was "total care, he gets up to a chair at least twice daily; using a lift." Patient #1 is on "temporary HD [hemodialysis], with the plan to discontinue." CM will monitor closely in case permanent HD is needed.

Review of Patient #1's Physician Orders (PO) revealed a telephone PO dated 1/11/7 at 17:50 taken by nursing staff that ordered patient "up in wheelchair twice daily."

Review of the Patient Care Records completed by nursing staff dated 1/11/17 through 1/25/17 for Activity: Wheelchair/Chair revealed the only documentation by nursing staff that patient was in in a Wheelchair/Chair was on 1/14/17 at 17:00 and on 1/18/17 at 14:00 and 15:00 was initialed.

Review of the Nursing Daily Flowsheets from 1/11/17 through 1/25/17 revealed the only documentation by nursing staff that documented patient was out of his bed and into a wheelchair/chair was on 1/14/17 at 15:30 that documented Patient up in chair until 17:35 when Pt was in bed and; on 1/18/17 at 16:00 that documented Patient "resting up to chair." The nursing notes correlated with the patient care records that documented Patient #1 was up in a wheelchair/chair only on 1/14/17 and 1/18/17. There was no further documentation that the PO were followed for Patient #1 to be "up in wheelchair twice daily."

Review of the Nursing Daily Flowsheet on 1/25/17 revealed at 16:60 CNA and Physical Therapist tech stated pt. "hasn't been up" and due to safety for pt. and unable to transfer pt. due to his contractures up to his personal school chair. Case Manager was informed, stated to re-call state school regarding transportation; which was done. Spoke with nursing and stated she would notify her supervisor regarding transportation and would recall (sic). Further review at 17:00 revealed Pt. transferred back to state school via EMS ambulance.

During an interview on 12/21/17 at 4:10 PM with the Director of Rehabilitation stated that Patient #1 did not qualify for rehabilitation services in this acute care facility because he was receiving long term rehabilitation at his permanent long-term care placement facility. The Director of Rehab stated that any bed mobility transfers from Patient #1's bed into a wheelchair/chair would have been completed by the nursing staff based on the physician's orders. The Director of Rehab indicated that Patient #1 had CP, was a quadriplegic; and would require transfer from his bed into his wheelchair using a [Hoyer] lift.

Review of the staff training; in part dated 1/25/17 regarding Staff Roles and Administration Expectations revealed Patient Care Plans (aka, POC) "must be updated daily."

During an interview on 12/21/17 at 5:00 PM with the Director of Quality Management (DQM) and RN Manager confirmed the above findings during document review. The RN Manager confirmed that Patient #1's IDT POC initiated on 1/10/17 was not accurately and thoroughly completed upon admission, and did not contain updated needs/treatments as they were identified. The DQM confirmed there was not documentation in Patient #1's records that indicated nursing staff followed the PO to get Patient #1 up in wheelchair twice daily other than the two days on 1/14/17 and 1/18/17. No additional evidence was provided at that time to refute these findings.

Based on a record review and interview, the facility failed to provide rehabilitation services in accordance with the admission practitioner orders for 1 of 1 patient reviewed (Patient #1) for rehabilitation services following complaint allegations.

Specifically, Patient #1 had Cerebral Palsy with all extremities contracted and noted to be "bedbound". Admission orders on 1/10/17 ordered therapy services for evaluation and treat for; Wheelchair, Physical Therapy, and Occupational Therapy. There was no evidence in Patient #1's records that these specific rehabilitation services were evaluated and/or provided.

Findings included:

Review of Patient #1's Admission Orders dated 1/10/17 at 00:05 revealed orders for W/C [wheelchair] Evaluate and Treat, PT [Physical Therapy] Evaluate and Treat, OT [Occupational Therapy] Evaluate and Treat.

Record review of Patient (Pt.) #1's History and Physical (H&P) dated 1/10/17 revealed patient was admitted to the facility because of cough and fever. Patient with pneumonia and positive for streptococcus. Review of Past Medical History included; Seizure disorder, Cerebral palsy (CP), noncommunicating" (Intellectual Disabled), Macrocytic anemia, Hypothyroidism, and Moderate protein malnutrition. Patient bedbound, contracted all extremities, and tube feeding.

Review of the Interdisciplinary (IDT) Plan of Care (POC) initiated on 1/10/17 revealed the area for Impaired Mobility was checked for: "No mobility issues at this time." Further review revealed it was documented, "Not appropriate for Rehab."

Review of the Registered Nurse's / Case Manager (RN CM) Admission documentation on 1/10/17 at 14:00 revealed the RN CM met with staff from the state school (Patient #1's long term care placement). CM was informed that Patient #1 was "total care, he gets up to a chair at least twice daily; using a lift." Patient #1 is on "temporary HD [hemodialysis], with the plan to discontinue." CM will monitor closely in case permanent HD is needed.

Review of Patient #1's Physician Orders (PO) revealed a telephone PO dated 1/11/7 at 17:50 taken by nursing staff that ordered patient "up in wheelchair twice daily."

Review of the Patient Care Records completed by nursing staff dated 1/11/17 through 1/25/17 for Activity: Wheelchair/Chair revealed the only documentation by nursing staff that patient was in in a Wheelchair/Chair was on 1/14/17 at 17:00 and on 1/18/17 at 14:00 and 15:00 was initialed.

Review of the Nursing Daily Flowsheets from 1/11/17 through 1/25/17 revealed the only documentation by nursing staff that documented patient was out of his bed and into a wheelchair/chair was on 1/14/17 at 15:30 that documented Patient up in chair until 17:35 when Pt was in bed and; on 1/18/17 at 16:00 that documented Patient "resting up to chair." The nursing notes correlated with the patient care records that documented Patient #1 was up in a wheelchair/chair only on 1/14/17 and 1/18/17. There was no further documentation that the PO were followed for Patient #1 to be "up in wheelchair twice daily."

Review of the Nursing Daily Flowsheet on 1/25/17 revealed at 16:60 CNA and Physical Therapist tech stated pt. "hasn't been up" and due to safety for pt. and unable to transfer pt. due to his contractures up to his personal school chair. Case Manager was informed, stated to re-call state school regarding transportation; which was done. Spoke with nursing and stated she would notify her supervisor regarding transportation and would recall (sic). Further review at 17:00 revealed Pt. transferred back to state school via EMS ambulance.

Review of Patient #1's medical record revealed there was not an assessment or consultation completed by Rehabilitation/Therapy Services for Patient #1 as ordered on the Admission Orders dated 1/10/17 for W/C, PT, and OT evaluation with treatment recommendations.

During an interview on 12/21/17 at 4:10 PM with the Director of Rehabilitation stated that Patient #1 did not qualify for rehabilitation services in this acute care facility because he was receiving long term rehabilitation at his permanent long-term care placement facility. The Director of Rehab stated that any bed mobility transfers from Patient #1's bed into a wheelchair/chair would have been completed by the nursing staff based on the physician's orders. The Director of Rehab indicated that Patient #1 had CP, was a quadriplegic; and would require transfer from his bed into his wheelchair using a [Hoyer] lift.

During an interview on 12/21/17 at 5:00 PM with the Director of Quality Management (DQM) and RN Manager confirmed the above findings during document review. The RN Manager confirmed that Patient #1's IDT POC initiated on 1/10/17 was not accurately and thoroughly completed upon admission, and did not contain updated needs/treatments as they were identified. The DQM confirmed there was not documentation in Patient #1's records that indicated nursing staff followed the PO to get Patient #1 up in wheelchair twice daily other than the two days on 1/14/17 and 1/18/17. No additional evidence was provided at that time to refute these findings.