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Based on record review and interviews, the Governing Body failed to:


1.) follow its own Governing Body Bylaws for appointment of Governing Board Members (GBM).


Review of the Governing Body Bylaws under Article III Board of Directors stated, "Appointment and Term. Directors shall be elected by the affirmative vote of a majority of the other Directors of the Company and shall serve a term of 2 years."


Review of the list for Governing Board Members (GBM) revealed there were four GBM's. GBM's staff#18, #19, and #20 should have been re-elected in 2016. GBM staff #21 should be re-elected in 2017. Review of the Governing Board Minutes for 2016 revealed there was no found election, re-appointment or mention of election of GBM for the year of 2016.


An interview with staff #1 on 2/13/17 confirmed there was no evidence of GBM appointment, election, or re-election found in the GB minutes.


An interview with staff #4 on 2/15/17 revealed staff #4 transcribed all of the GB meeting minutes since 8/2016. Staff #4 reviewed all of the meeting minutes for 2016 and stated, "It's not here. I can't find where it was written about any elections for the GB." Staff #4 confirmed there was no appointments, re-elections, or elections mentioned in the GB meeting minutes for 2016.




2.) A. to have an addendum to the medical staff rules and regulations approving the use of telemedicine and include the required elements concerning credentialing and privileging of the telemedicine physicians and practitioners.


B. to grant privileges to telemedicine physicians before providing telemedicine services.


Review of the current Governing Body Bylaws dated 12/11/2012 and the current Medical Staff Rules and Regulations dated 12/11/2012 revealed there was no found documentation of provisions or approval of Telemedicine.


Refer to Tag A0052



3.) recognize a Medical Director or physician responsible for the organization and conduct of the medical staff.

Refer to Tag A0053

Based on record reviews and interviews, the facility failed to:

1. ) A. provide the first and second notice of the "Important Message from Medicare" (IM) in 1(#14) of 3(#2, 6, and 14) charts reviewed.

B. provide the second notice of the "Important Message from Medicare" (IM) in 1(#2) of 3(#2, 6, and 14) charts reviewed.

C. ensure the patient was able to understand the information on the IM before signing in 1(#6) of 3(#2, 6, and 14) patients charts reviewed.

Refer to Tag A0117


2.) A. have a complaint log.

B. ensure a documented and active Grievance Committee.

C ensure 3 (#21, #22, and #25) of 3 complaints were recognized as a grievance.

D. ensure 1 (#22) of 3 (#21, #22, and #25) patient reports were identified as a concern, complaint, or grievance.

E. ensure 3 (#21, #22, and #25) out of 3 patients or families were instructed on how to lodge a grievance if she/he was not happy with the outcome of her complaint.

F. identify problems with complaints, concerns, and grievances for the last two quarters of 2016 and first quarter of 2017. There was no identification of problems nor was there any performance improvements in place.

Refer to Tag A0118


3.) ensure correct information in the policy and procedure on how and where to appeal patient Medicare concerns to the QIO (Quality Improvement Organization).

Refer to Tag A0120


4.) A. provide the patient with information on patient rights and consent for treatment on 3 (#2, 21, and 6) of 3 charts reviewed.

B. educate staff on patient rights, or signed consents used during the admission process.

Refer to Tag A0131


5.) document in a prominent part of the patient's medical record whether or not the patient had executed an advance directive in 3(#21, 14, and 2)of 4(#21, 14, 6, and 2) charts reviewed.

Refer to Tag A0132


6.) A.) have a safe environment in 15 of 15 patient rooms.

B.) have staff with adequate training in competencies and SAMA in 15 of 15 (#2,3,4,6,14,15,16,17,25,28,30,31,33,37,and 38) employee files reviewed.

C). appropriately monitor and protect patients from harm, in 2 (patient #8 and #9) of 2 (patients #8 and #9) patient records reviewed. The facility also failed to ensure patients received the appropriate and recommended follow up care after an injury in 1 (#9) of 2 (#8, #9) patient records reviewed.

Refer to Tag A0144



7.) A. protect the patient from corporal punishment and intimidation in 1(#6) of 3( #6, #2, and #3) charts reviewed.

B. assess and monitor the patient's condition on an ongoing basis to ensure that the patient is released from restraint or seclusion at the earliest possible time.1(#6) of 3( #6, #2, and #3) charts reviewed.

C. educate the staff and create a culture that supports patient rights and ensure policies and processes were developed to eliminate the inappropriate use of restraint or seclusion. 1(#6) of 3( #6, #2, and #3) charts reviewed.

Refer to Tag A0154

Based on rexcord review and interview, the Governing Body failed to:

1.) take actions aimed at performance improvement in high risk, high volume, or problem prone areas.

Refer to Tag A0283


2.) document quality improvement projects or make a comparable effort for 2016.

Refer to Tag A0297


3.) A. implement an effective, ongoing , hospital wide, quality assessment and performance improvement program that reflected the facility's services and departments.

B. focus on indicators related to health outcomes and prevention of medical errors.

C. have a qualified Quality Director.


Review of the the QAPI data for 2016 revealed the facility was not collecting data nor had addressed certain departments in the QAPI process as follows;

Laboratory
Radiology
Emergency Services
Respiratory Department
Contracted Services


Review of the QAPI given for 2016 revealed the information was data. The only departments with action plans were medical records and environmental. There was no performance improvement documented concerning falls, medication errors, restraints, incident reports with injuries, or grievances. Staff #4 reported that the departments were followed if there was a problem. Staff #4 was asked how did she know if there was a problem if she didn't follow it. Staff #4 stated, " We are all aware of what needs to be done. We just know."

An interview was conducted with the staff #4 (Quality Director) on 2/15/17. Staff #4 reported that she collects the data and reports to the corporate quality director. Staff #4 reported she went to a conference for a week on QAPI but has had no formal training. Staff #4 was asked how new projects were started or ended in the process. Staff #4 reported that the data is followed for a year and was resolved yearly. Staff #4 reported that she has never done a Root Cause Analysis since her employment of 8/2016.

Review of staff #4's job description revealed the QAPI director must be a Associate Degree Nurse (ADN RN) or higher. Staff #4 was a Licensed Vocational Nurse (LVN) and does not qualify for the position. Staff #4 was unaware of the qualifications of the facility.

There was no QAPI offered upon 3 requests for 2017. Staff #4 reported its being gathered.

Based on observation, record review, and interview, Nursing Services failed to:

A) develop, review, and approve nursing policies for 2 of 2 units (Acute Care Unit and Behavioral Health Unit).
See Tag A0386

B) provide an adequate numbers of qualified and/or trained nursing staff to meet the needs of patients in 3 out of 3 units reviewed [Acute Care Unit, Behavioral Health Unit, and Intensive Outpatient Unit (IOP)].
See Tag A0392

C) assess the patients on an ongoing basis and when a change in condition occurred in 7 (Patient #s, 1, 8, 9, 10, 12, 18, and 19) out of 7 patients reviewed.
See Tag A0395

D) update the Treatment Plan and Problem List with medical problems identified throughout the patients' stay in 4 (Patient #s, 1, 10, 12, and 19) out of 5 patients reviewed(Patient #s, 1, 10, 12, 18, and 19).
See Tag A0396

E) assign qualified staff to patient assignments on 2 (12-8-2016 and 2-14-2017) out of 10 days reviewed.
See Tag A0397

Based on observation, record review, and interview, Medical Records Services failed to:

A. store patient records in a manner that protected them from water damage in 4 out of 4 (3 separate room on the first floor across from Medical Records Office and in the attic) storage areas toured.

See Tag A0438



B. protect patient records from unauthorized access in 2 out of 4 (1 storage room on the first floor across from Medical Records Office and in the attic) storage areas toured.

See Tag A0441


C. ensure entries into the medical records were complete with patient identifying information, signatures, dates and times, and legible in 5 out 5 charts reviewed (Patient #s, 1, 10, 12, 18, and 19).

See Tag A0450


D. ensure the physician authenticated telephone orders within 48 hours of dictating the telephone order in 4 (Patient #s, 1, 10, 12, and 19) out 5 charts reviewed (Patient #s, 1, 10, 12, 18, and 19).

See Tag A0454


E. ensure the History and Physical (H&P) or H&P addendum was completed within 24 hours of admission in 2 (Patient #s 18 and 19) out 5 charts reviewed (Patient #s 1, 10, 12, 18, and 19).

See Tag A0458


F. ensure that consultative records were documented and placed in the records for 20 out of 20 patients reviewed (Patient #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21).

See Tag A0464

Based on document review and interview, the facility failed to ensure a current Utilization Review Plan was in place.

A review of the facility's documents revealed a Utilization Performance Management Plan that had not been reviewed or updated since October 2012.

An interview conducted on 2/16/17, with staff #6, confirmed the facility did not have a current Utilization Review Plan.

Based on observation, document review, and interview, the facility failed to:

A. maintain a sanitary environment.

These deficiencies had the likelihood to cause harm to patients, employees, and/or visitors.

During a tour of the facility's Behavioral Health Unit on 2/13/17, the following unsanitary conditions were observed:

1. Visible debris was observed on a handrail in the unit's patient shower room.
2. A wheelchair found in patient #9's room was visibly dirty with torn vinyl and foam on both arm supports.
3. The inside of a under sink cabinet in a patient bathroom/shower area had cracked, stained and molded laminate/wood and 2 large holes in the cabinet walls.
4. A shower/toilet chair made of PVC pipe was visibly dirty, worn and rusted.
5. A floor drain in the unit's soiled utility room was covered with dirt and debris.
6. A dirty linen cart in the unit's soiled utility room had yellowed dirty tape stuck to the lid.
7. A pill cutter in the unit's medication room had white residue in the pill placement area.
8. A med cart in the nurse's station had multiple drawers that contained debris, the outer part of the patient medication drawers had old tape and tape residue on them, and the lower part of the cart was visibly dirty and rusty.


B. maintain a active Infection Control Program that included prevention, control and investigation of infections.

A review of the facility's Infection Control (IC) Manual revealed the IC Manual had not been reviewed and approved by the Governing Board since 10/29/12.

A review of data collection provided by staff #4 (IC Officer) revealed a list, dated December 2016, of patients that had positive urine cultures. There was NO documentation indicating the IC Committee or Officer investigated and/or developed a plan to prevent and/or control future infections.

An interview conducted on 2/15/17, with staff #4, confirmed the above findings.


C. ensure the IC Committee was conducting meetings with recorded minutes.

There were no IC Committee meeting minutes provided.

An interview conducted on 2/15/17, with staff #4, confirmed there were no IC Committee meeting recorded minutes.

Based on record review and interviews, the Governing Body failed to:


A.) have an addendum to the medical staff rules and regulations approving the use of telemedicine and include the required elements concerning credentialing and privileging of the telemedicine physicians and practitioners.


B.) grant privileges to telemedicine physicians before providing telemedicine services.


Review of the current Governing Body Bylaws dated 12/11/2012 and the current Medical Staff Rules and Regulations dated 12/11/2012 revealed there was no found documentation of the approval or use of Telemedicine.


An interview with staff #3 was conducted on 2/14/16 revealed the psychiatrist, staff #22, was only coming into the facility on Fridays to see patients. Staff #3 confirmed the psychiatrist lived and worked approximately two in a half hours away and was seeing patients via telemedicine when patients were admitted.


An interview was conducted with staff #22 on 2/23/17 at 1:13PM. Staff #22 confirmed the use of telemedicine. Staff #22 stated, "I was not aware the use of telemedicine was not in the bylaws." Staff #22 reported that telemedicine was used and the nurses were to put in the notes that the patients were seen by staff #22 via telemedicine. Staff #22 confirmed she did not write the progress notes when using telemedicine.


Review of staff#22's credentialing file revealed there was no mention of telemedicine in the "delineation of privileges" section in the credential file or as an addendum.


An interview was conducted with staff #1 and #2 on 2/16/17 concerning telemedicine. Staff #1 and #2 confirmed staff #22 was seeing patients via telemedicine. Staff #1 confirmed the bylaws for Governing Body, Medical Staff Bylaws and Rules and regulations were the most current and no addendums were offered upon request.

Based on record review and interview, the Governing Board failed to appoint a Medical Director or physician responsible for the organization and conduct of the medical staff.


Review of the Governing Body Meeting Minutes(GB) and The Medical Executive Meeting Minutes (MEC) revealed there a MEC meeting on 4/21/16. The minutes stated, "XXX (staff #22) appointed to Medical Staff in Psychiatry for both the Tyler and Kilgore IOP programs as well as inpatient BHU."


Governing Body Minutes dated 4/29/16 stated, " XXX (staff #22) appointed to Medical Staff in Psychiatry for both the Tyler and Kilgore IOP programs as well as inpatient BHU." There was no documentation that staff #22 was also appointed as the facility's Medical Director in the GB or MEC minutes for 2016-2017.


An interview was conducted with staff #22 on 2/23/17. Staff #22 confirmed she was practicing as the current Medical Director.


Review of staff #22's credentialing file revealed there was no documentation of staff #22's appointment of Medical Director.

Based on record reviews and interviews, the facility failed to:

A.) provide the first and second notice of the "Important Message from Medicare" (IM) in 2 (#2,#14) of 3 (#2, 6, and 14) charts reviewed.

B.) ensure the patient was able to understand the information on the IM before signing in 1(#6) of 3(#2, 6, and 14) patients charts reviewed.




A.) Review of patient #14's chart revealed the patient was admitted on 1/2/2017 and discharged on 2/2/2017. There was no "An Important Message from Medicare" (IM) found on patient #14's chart.

Review of "An Important Message from Medicare" revealed Patients must be provided the standardized notice, "An Important Message from Medicare" (IM), within 2 days of admission and the second IM letter 2 days before discharge.

Review of patient #2's chart revealed the patient was admitted voluntarily, on 1/11/17 with diagnosis of Dementia with self-harm. Patient #2 had an IM in the chart dated 1/11/17. The IM was not signed. The RN had documented on the form, "verbal consent from POA(Power of Attorney)/son." There was no second IM noted in the chart before discharge. Patient was discharged on 1/25/17.


B.) Review of patient #6's chart revealed the patient was admitted on 1/30/17. The nurse practitioner had written the patient was involuntary on the psychiatric exam on 1-31-17. The physician admission order did not have a voluntary or involuntary status upon admission; nor was there an order to hold the patient as involuntary. There was no Emergency Detention Warrant (EDW) or Peace Officers Warrant (POW) on the chart to hold the patient as involuntary. A telephone order was found given by staff #26, Nurse Practitioner (NP) on 2/1/17. The order read, "Begin court commitment process due to very aggressive behavior and confusion- unable to make informed decision."

Review of the Nursing Admission Assessment dated 1/30/17 revealed the RN documented the patient was confused. Patient #6 was allowed to sign the IM document.


An interview was conducted with staff#25 (staff RN) on 2/16/17 concerning consents, patient rights and the admission process. Staff #25 stated, "If they have a medical POA I just call them and get permission on consents. I get all the patients to sign the consents if they are voluntary." Staff #25 was not aware that there was a difference between a medical POA and a mental health POA. Staff #25 confirmed that she had allowed confused patients to sign consents.

Based on record review and interviews, the facility failed to

A.) have a complaint log.

B.) a documented and active Grievance Committee.

C.) ensure 3 (#21, #22, and #25) of 3 complaints were recognized as a grievance.

D.) ensure 1 (#22) of 3 (#21, #22, and #25) patient reports were identified as a concern, complaint, or grievance.

E.) ensure 3 (#21, #22, and #25) out of 3 patients or families were instructed on how to lodge a grievance if she/he was not happy with the outcome of her complaint.

F.) identify problems with complaints, concerns, and grievances for the last two quarters of 2016 and first quarter of 2017. There was no identification of problems nor was there any performance improvements in place.


Review of the policy and procedure Concern/Complaint/Grievance Policy revealed the policy directs the patient to call the Texas Department of State Health Services to make a complaint at 512-834-6646. This is a wrong number. The number goes to licensing section and not the complaint line. The patient is then directed to call another number if they feel they are being discharged too early. The patient is to call the QIO (TMF) by calling 1-800-725-8315. This number was also incorrect. The number when called is a retail promotions number for a credit card.


The policy stated, "Governing Board Commitment I Grievance Committee: The Governing Board is responsible for the effective operation of the grievance process and has delegated the responsibility of grievance review and resolution to the Grievance Committee.

A suggested list of members for the Grievance Committee consists of:
1. Department Director where the concern occurred.
2. Director of Clinical Services
3. Physician involved as appropriate
4. CEO

Patient Complaints/Grievances will be reviewed and action taken on each occurrence by the grievance committee. A system analysis approach will be utilized when investigating and analyzing complaint/grievances. The reviews and resolutions will be forwarded to the Director of Clinical Service for appropriate placement in the Complaint log for the facility."


An interview with staff#3 was conducted on 2/14/16. Staff #3 stated "well ...there is really not a grievance committee." Staff #3 reported that staff #4 would review the complaints and after staff #4 investigated, staff #3 would follow up. Staff #3 stated that the complaints were taken to the governing body but there was no notes from a Grievance Committee. Staff #3 confirmed there was no log. Staff #3 stated, "I just brought you what was in my book for the last six months." Staff #3 confirmed she was the Risk Manager and in charge of all Grievances and Complaints.


Review of the policy and procedure Concern/Complaint/Grievance under explanations stated,

"A "patient concern" is defined as a complaint given verbally by a patient, family member/visitor, or staff that can be readily solved in a timely manner. An example of a concern is the temperature in the room being too hot. Adjustment of the thermometer and subsequent validation with the complainant that the concern has been resolved is all that is required for a concern. No written documentation of follow up is required.


A "patient complaint" can be issued verbally or in writing, and cannot be easily rectified at the time received, and requires some further investigation and intervention. When the verbal complaint about patient care is not resolved at the time of the complaint by staff present then a written document of investigation steps and actions taken is required. A follow up letter to the complainant is required and the incident of complaint is documented in the complaint log. A complaint is considered resolved when the patient is satisfied with the actions taken on their behalf.


A "patient grievance" is defined as a serious allegation by a patient, or the patient's representative, regarding the patient's care, including issues of abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (COP), or a Medicare beneficiary billing complaint related to tights and limitations provided by 42 CFR §489, All such allegations will be handled by removing any patient for harm immediately and with prompt reporting to administration for detailed investigation and plan of correction.


All written complaints are carefully screened by the grievance committee and are considered grievances until full investigation occurs and "complaint status" has been verified. For the purposes of this requirement an e-mail or fax is considered "written".


Patient complaints that are ruled as grievances also include situations where a patient or a patient's representative telephones the hospital with a complaint regarding their care or with an allegation of abuse or neglect, or failure of the hospital to comply with one or more COPs, or other CMS requirements. Those post hospital verbal communications regarding patient care that would routinely have been handled by staff present if the communication had occurred during the stay/visit are not required to be defined as a grievance.


All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS requirements, are to be considered a grievance for the purposes of these requirements.


Data collected regarding patient grievances, as well as some other complaints that are not defined as grievances (as determined by the hospital) must be incorporated in the hospital's Quality Assessment and Performance Improvement Program (QAPI) to identify opportunities for program or system improvement."



An interview with staff#3 and staff #4 was conducted on 2/14/16. Staff #3 was unable to correctly identify when a complaint became a grievance. Staff #3 stated, "A complaint was something that you can handle right away. A grievance is when it has gotten real complicated and needs a lot of time to investigate." Staff #3 reported a written complaint was not always considered a grievance. Staff #3 stated when they have a grievance, a letter is sent out by certified mail to the complainant. Staff #3 reported the facility has not had a grievance in 6 months. Staff #4 was also unable to correctly identify the difference between a complaint and grievance. Staff #4 reported that he investigates all complaints and reports his findings back to staff #3. Staff #4 was not aware of the definitions of a complaint or grievance.


Review of a Customer Complaint Record dated 9/20/16 revealed patient #25's wife made a complaint over the phone 7 days after his discharge on 10/11/16. Patient #25's wife reported that the patient died on 10/9/16 and was upset. The wife stated on the report, "Y'all didn't take good care of him. You just let him fall." Further review revealed the social worker apologized to the wife and offered medical staff consultation. She declined the offer, stated "that's all I have to say" and ended the call.


The complaint was referred to staff #4 on 10/11/16. Staff #4 wrote that this was considered a concern and did not require a letter. Staff #4 wrote, "Pt's wife expressed concern that husband was not taken care of while hospitalized here. Called pt.'s with social worker.(sic) Pts wife verbalized same concern as above and did not want anything else done. Resolved on 10/17/16." There was no evidence that the patient's wife was contacted by phone or sent a letter concerning her grievance.



Review of a Customer Complaint Record revealed Patient #21 made a complaint concerning care. Patient #21 voiced his complaint to social worker on 12/21/16. The patient complained of being left wet and dirty in the bed for long periods of time. Pt said, "I call to be changed and tech tells me will be right back then I fall asleep and wake up still in my poop. Then they come and change me." Patient complaint was written as a concern and resolved the same day.



Patient #22's family called after the patient was discharged. Review of the Customer Complaint Record revealed the date was blank when the complaint was taken. The patient had returned to the nursing home without her dentures and wanted them replaced and was referred to staff #3 on 11/18/16. The form was blank for concern, complaint, or grievance. On 12-15-16 the daughter was told the facility would pay for the dentures. There was no letters sent.


Review of the Quality Assurance and Performance Improvement (QAPI) meeting minutes for the last two quarters of 2016 revealed the facility was collecting only numbers on how many concerns, complaints, or grievances were being done each month. There was no identification of problems nor was there any performance improvements in place.

Based on record review and interview, the facility failed to provide the correct information to patients on how and where to appeal patient's Medicare concerns to the QIO(Quality Improvement Organization).


Review of the policy and procedure titled "Concern/Complaint/Grievance Policy" revealed the policy directs the patient to call the Texas Department of State Health Services to make a complaint at 512-834-6646. This was a wrong number. The number goes to licensing section and not the complaint line. The patient is then directed to call another number if they feel they are being discharged too early. The patient was to call the QIO (TMF) by calling 1-800-725-8315. This number was also incorrect. The number when called was a retail promotions number for a credit card.


Interview with staff #4 and #3 on 2/14/16 revealed both staff members were not aware of the Medicare appeal process. Staff #4 and staff #3 was unable to state who the QIO was for the facility.

Based on record review and interviews, the facility failed to:

a.) provide the patient with information on patient rights and consent for treatment on 3 (#2, 21, and 6) of 3 charts reviewed.

b.) educate staff on patient rights, or signed consents used during the admission process.



1.) Review of patient #2's chart revealed the patient was admitted, voluntarily, on 1/11/16 with diagnosis of Dementia with self-harm. Patient #2 did not sign her consents for treatment, medication administration, or patient rights. The nurse had documented that a verbal consent was given by her power of attorney (POA).

Review of patient's POA document revealed under Information Concerning the Medical Power of Attorney, "Your agent may not consent to voluntary inpatient mental health services." The patient was allowed to sign a request for voluntary admission on 1/11/17. The form allows the patient to agree to abide by the rules and regulations and understands the provisions of the State Mental Health Code. The nurse had documented the patient was too confused to sign the consents but was allowed to sign a voluntary admission request.


2.) Review of patient #6's chart revealed the patient was admitted on 1/30/17. The nurse practitioner had written the patient was involuntary on the psychiatric exam on 1-31-17. The physician admission order did not have a voluntary or involuntary status upon admission; nor was there an order to hold the patient as involuntary. There was no Emergency Detention Warrant (EDW) or Peace Officers Warrant (POW) on the chart to hold the patient as involuntary. A telephone order was found given by staff #26 Nurse Practitioner (NP) on 2/1/17. The order read, "Begin court commitment process due to very aggressive behavior and confusion- unable to make informed decision."

Review of the Nursing Admission Assessment dated 1/30/17 revealed the RN documented the patient was confused. Patient #6 was allowed to sign all of his consents for treatment, patient rights, and psychoactive medication consents in a confused state.


3.) Review of patient #21's chart revealed the patient was admitted to the facility on 10/13/16. The patient did not sign any of his consents. The Consent to treatment stated at the signature line, "Pt unable to sign d/t confusion." The form stated, "I have received and have read a copy of the Patient Rights and Responsibilities Form." The form was checked, "yes."


An interview was conducted on2/16/17 with staff#25 (staff RN) concerning consents, patient rights and the admission process. Staff #25 stated, "If they have a medical POA I just call them and get permission on consents. I get all the patients to sign the consents if they are voluntary." Staff #25 was not aware that there was a difference between a medical POA and a mental health POA. Staff #25 confirmed that she had allowed confused patients to sign in voluntarily.


An interview with staff #15 (staff RN) was conducted on 2/16/17 concerning consents, patient rights and the admission process. Staff #15 stated, "If the patients can't sign we just call family members. We just get a verbal from the family. I also call the family when I have to get consent for psycho active medications." Staff #15 was asked if she allows confused patients to sign consents and do they understand what they are signing. Staff #15 stated, "I really can't tell you if they understand what they are signing."

Based on record review, the facility failed to document in a prominent part of the patient's medical record whether or not the patient had executed an advance directive in 3(#21, 14, and 2)of 4(#21, 14, 6, and 2) charts reviewed.


Review of patient #21's chart revealed the patient was admitted to the facility on 10/13/16. The patient did not sign any of his consents. The Consent to treatment,stated at the signature line, "Pt unable to sign d/t confusion." In the "Advanced Directive Acknowledgement Statement" there is a statement that said, "I understand that my Advanced Directive will not be honored until I have given the appropriate documents to my physicians and/or the Hospital." The box was checked, "yes". There was no further information on an advanced directive.


Review of patient #14's chart revealed the patient was admitted on 1/2/17 with a diagnosis of dementia. Patient #14 was unable to sign consents due to confusion. There was no information found of patients Do Not Resuscitate (DNR) status.


Review of patient #2's chart revealed the patient was unable to sign consents. Nurse had documented on the advanced directive "unknown" on advance directive statement. There was no further documentation found on advanced directives.

Based on record review and interviews, the facility failed to:

A.) have a safe environment in 15 of 15 patient rooms.

B.) have staff with adequate training in competencies and SAMA in 15 of 15 (#2,3,4,6,14,15,16,17,25,28,30,31,33,37,and 38) employee files reviewed.

C). appropriately monitor and protect patients from harm, in 2 (patient #8 and #9) of 2 (patients #8 and #9) patient records reviewed. The facility also failed to ensure patients received the appropriate and recommended follow up care after an injury in 1 (#9) of 2 (#8, #9) patient records reviewed.



This deficient practice was determined to pose Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.



A. During a tour of the hospital on 2/13/17 the following conditions were found:


1.) The patient bedrooms and bathrooms had drop down ceilings. The ceiling was not hard. The drop down ceilings are easily accessible by standing on a bed or chair. The tiles can be lifted allowing medications or contraband to be stored. The metal railings can be removed from the ceiling and used as a weapon to harm themselves or others. The railing could also be used by the patient to hang themselves. There were 5 private rooms and 10 semiprivate rooms; 25 patient beds in all.


2.) All of the patient beds were hospital beds with railing and headboards that had slots to use as a hanging device.


3.) The cabinet doors to the bathroom sinks were open and accessible to the pipes underneath that would allow for hanging device.


4.) The toilet paper and soap holders in the bathrooms were not solid and allowed for a sheet to be tied around it. The soap holder was mounted inside the wall. The holders could be used as a hanging device.


5.) The wall thermostats in the patient rooms were accessible to the patient. The thermostats were not in a tamper proof box. The thermostats had metal in the covers that could be removed to cause harm to the patient or others.


6.) The patient rooms had a closet for each bed. Room 115 was semi private room that was considered terminally cleaned and waiting for a new patient. Inside the wardrobe was a shelf with a metal track. The track was deep and a patients earrings were found in the track. In the other wardrobe used plastic dental pics were found in the track hidden from sight.


7. A broken plastic electrical socket plate cover with sharp jagged edges was observed in a patient room (#115) on the Behavioral Health Unit.


8. Multiple patient beds were observed with broken plastic footboards in the Behavioral Health Unit.


9. A wheelchair being used by a patient (patient #9) on the Behavioral Health Unit was observed to have torn vinyl and foam on both arm supports exposing metal with sharp edges.


An interview conducted on 2/13/17, with staff #7, confirmed the above findings.



B. Review of the employee files revealed the employees did not have any training for aggressive patients. There was no de-escalation or physical training to prevent injury in 15 employee files reviewed. There was also missing competencies, no abuse and neglect training, patient rights/Confidentiality training, or age appropriate training. Staff #1 reported that several employees did not have training or had expired training for SAMA (Satori Alternatives to Managing Aggression SAMA is a 16-hour training program that focuses on risk management of aggressive behavior for individuals in schools, police departments, foster care services, residential institutions, offices, hospitals and elsewhere.)


Staff #1 reported on 2/13/17 that she would be putting the staff through the de-escalation training process for SAMA. Staff #1 was instructed that the staff needed all the training and not just de-escalation. Staff #1 reported that staff #1, #2 and #3 had decided not to teach all of the SAMA training just the de-escalation and to avoid kicks and blocks. Staff #1 stated she did not teach the staff all of the appropriate holds due to "I don't trust my staff." Staff #1 reported she shouldn't have to teach the holds due to "Nurses should have learned that in school."




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2.) A review of the facility's Incident Log revealed patient #8 had sustained a fall on 1/16/17. The log contained the following statement: "PT ROOMATE ALARMED NURSE THAT PATIENT WAS IN BATHTUB. PT WAS FOUND LYING IN BATHTUB. PT SENT TO ER FOR CT SCAN DUE TO UNWITNESSED FALL. PT HAD NO CHANGE IN LEVEL OF CONSCIOUSNESS."


A review of patient #8's record revealed the following information, Patient #8 was a 79 year old male admitted to the facility on 1/9/17, with a diagnosis of impulse control disorder.


The patient's fall on 1/16/17, was documented in the record as follows:

On 1/17/17 at 1304, the RN's computerized narrative note documentation stated, "Late entry for 1/16/17 at 1620: Staff was alerted to patient by patient's roommate who stated patient had fallen. When this nurse and the Director of Clinical Services arrived in the room, patient was lying in the bathtub with his pants pulled down. Patient stated he had hit his head. Vital signs and neuro checks begun. Calls placed to the appropriate people. Patient sent to ER for CT of his head to rule out intracranial hemorrhage. When report called from ER, the nurse stated that the CT scan was negative but the Dilantin level was elevated. Will continue to monitor for any change in condition ...".


On 1/17/17, at 1300, the Registered Nurse's (RN) computerized Post Fall Assessment documentation stated, "1/17/2017 1300 ....Location of Patient at Time of Fall ... Patient Room ... Witnesses to Fall ...Patient's roommate ...Actual Level of Monitoring at time of fall ...Level II (constant monitoring within 20 feet distance) ...Activities at Time of Fall ...Going to or from Bathroom ....Vitals ... In Progress ..."


A review of the MHT (Mental Health Tech) Care and Observation Flowsheet reflected every 15 minutes observations of patient #8. The MHT documented patient #8 was located in the Dining Room from 1400 until 1830 on 1/16//17. There was no documentation of the patient's fall by the MHT. Patient #8's staff monitoring level was documented as a "Level II". According to facility's policy, Level II is defined as, "constant monitoring within 20 feet distance". The patient fell while in his room with NO staff monitoring him. The MHT that was assigned to monitoring the patient, documented he was in the Dining Room during the time of the fall.



A review of the facility's Incident Log revealed patient #9 had sustained falls on 2/3, 2/5, 2/6 and 2/7. The Incident Log revealed the following statement related to patient #9's fall on 2/3/17: "PT STOOD UP AND LOST BALANCE AND LANDED ONTO THE LAP OF ANOTHER PATIENT. FALL WAS WITNESSED AND NO INJURY OCCURRED."


A review of patient #9's record revealed the following information: Patient #9 was a 74 year old male admitted to the facility on 1/25/17, with a diagnosis of dementia and homicidal ideations.


The patient's fall on 2/3/17, was NOT documented in the patient's record.


The Incident Log revealed the following statement related to patient #9's fall on 2/5/17: "PT STOOD UP FROM W/C (wheelchair), LOST BALANCE AND FELL FROM W/C".


The patient's fall on 2/5/17, was documented in the record as follows: On 2/5/17, at 2257, the Registered Nurse's (RN) computerized Post Fall Assessment documentation stated, "2/5/2017 2257 ....Location of Patient at Time of Fall ... Dining Room ... Actual Level of Monitoring at time of fall ...Level II (constant monitoring within 20 feet distance) ...Activities at Time of Fall ...In Dining Room having meal or snack ....Other Activity ...Watching TV sitting in wheelchair, with chair alarm on, happened at shift change ...Vitals ... BP (blood pressure) 98/72, Resp (respirations) 20, HR (heart rate) 66 ..."


On 2/5/17, a handwritten Post Fall Assessment form completed by the RN contained the following information: " ...Pt (patient) fell @ 1900 in DR (Dining Room), witnessed, stood up from wheelchair lost balance, No injury ..."


A review of the MHT (Mental Health Tech) Care and Observation Flowsheet reflected every 15 minutes observations of patient #9. The MHT documented patient #9 was awake and in the Dining Room from 1715 until 2100 on 2/5/17. There was no documentation of the patient's fall by the MHT.


Patient #9's staff monitoring level was documented as a "Level II". According to facility's policy, Level II is defined as, "constant monitoring within 20 feet distance". The patient fell while in the Dining Room at 1900. The MHT that was assigned to monitoring the patient, did NOT document the patient's fall.


The Incident Log revealed the following statement related to patient #9's fall on 2/6/17: "PT GOT UP OUT OF W/C AND FELL ON HIS LEFT SIDE. NO INJURIES".


The patient's fall on 2/6/17, was documented in the record as follows: On 2/6/17, at 1615, the RN's computerized Post Fall Assessment documentation stated, "2/6/2017 1615 ...Location of Patient at Time of Fall ...Dining Room ... Actual Level of Monitoring at time of fall ...Level II (constant monitoring within 20 feet distance) ... Activities at Time of Fall ...Sitting in a chair ...Vitals ...(BP) 117/51, HR 52, R (respirations) 20 ..."


On 2/6/17, a handwritten Post Fall Assessment form completed by the RN did NOT contain any information about how patient #9 fell from the chair or if the patient sustained any injuries.


A review of the MHT (Mental Health Tech) Care and Observation Flowsheet reflected every 15 minutes observations of patient #9. The MHT documented patient #9 was awake and in the Dining Room from 1245 until 1630 on 2/6/17. There was no documentation of the patient's fall by the MHT.


Patient #9's staff monitoring level was documented as a "Level II". According to facility's policy, Level II is defined as, "constant monitoring within 20 feet distance". The patient fell while in the Dining Room. The MHT that was assigned to monitoring the patient, did NOT document the patient's fall. In addition, patient #9 had sustained 3 falls in 3 days, while standing up from a sitting position and the facility did not seek alternative measures to protect patient #9 from future falls.


The Incident Log revealed the following statement related to patient #9's fall on 2/7/17: "PT FOUND ON FLOOR SATURATED IN URINE, SENT TO ER FOR EVAL PER MD ORDERS".


The patient's fall on 2/7/17, was documented in the record as follows: On 2/7/17 at 0656, the Registered Nurse's (RN) computerized Post Fall Assessment documentation stated, "2/7/2017 0656 ....Location of Patient at Time of Fall ... Patient Room ...Ordered Level of Monitoring ...Level IV (monitoring on a routine basis every 15 minutes) ...Activities at Time of Fall ...(blank) ....Other Activity ...(blank) ...Vitals ... (blank) ...Cardiovascular ...Tachycardia, Hypotensive ...Other skin conditions ...abrasion left shoulder and elbow ..."


On 2/7/17, a handwritten Post Fall Assessment form completed by the RN did NOT contain any information about how patient #9 fell.


On 2/7/17 at 0504, the RN's computerized narrative note documentation stated, "Patient found in floor in room by PCT (Patient Care Tech) BP 96/54, HR 120. Patient noted to have two bumps on back of head. Dr. (staff #24) notified by charge nurse."


A review of the MHT (Mental Health Tech) Care and Observation Flowsheet reflected every 15 minutes observations of patient #9. The MHT documented on 2/7/17 at 0500, patient #9 was "awake" located in his "room" and the intervention of "hygiene/toileting help" took place. In addition, the MHT documented patient #9 was "sleeping" and located in his "room", from 0515 until 0600.


Patient #9's staff monitoring level was documented as a "Level IV". According to facility's policy, Level IV is defined as, "monitoring on a routine basis every 15 minutes". The patient fell while in his room with NO staff monitoring him. The MHT that was assigned to monitoring the patient, documented he was "awake" located in his "room" and the intervention of "hygiene/toileting help" took place.


In addition, patient #9 had sustained 4 falls in 4 days, and staff decreased the patient's monitoring level from a Level II to a Level IV after his 3rd fall.


Patient #9 was sent to the Emergency Room (ER) operated by another facility located in the same building, after the 2/7/17 fall, per staff #24's order.


A review of patient #9's ER record for 2/7/17, revealed the following information: The ER Physician's documentation stated the patient arrived to the ER at 0448 with complaint of head pain. The ER Physician's exam revealed ..."SMALL CONTUSION TO POSTERIOR SCALP" ....


Following diagnostic testing, the ER Physician documented: "Response to Treatment: ...CT (computerized tomography) HEAD NEG (negative) FOR ACUTE BLEEDING. CT C-SPINE (cervical spine) SHOWS T1-T2 (thoracic spine level 1-2) SUPERIOR ENDPLATE FRACTURE W/10% HEIGHT LOSS. UNCLEAR IF THIS IS NEW OR CHRONIC. NO NEURO (neurological) DEFICIT. PT HAS NO TENDERNESS. CALLED DR. XXX (neurosurgeon) W/SPINE AND HE STATED THAT PT SHOULD BE PUT IN COLLAR AND F/U (follow up) IN CLINIC. WILL DC (discharge) BACK TO ALLEGIANCE."


The ER nurse's documentation stated, " ...Follow up: XXX,MD; When 1 - 2 days; Reason: Recheck today's complaints ....Notes: PATIENT IS TO WEAR CERVICAL COLLAR AT ALL TIMES UNTIL FOLLOW UP W/ DR XXX IN CLINIC .....Instructions were given to caretaker, ... follow up and referral plans ... USE OF C COLLAR Demonstrated understanding of instructions ...09:08 REPORT GIVEN TO (staff #16) RN ALLEGIANCE BEHAVIOR HEALTH."


Further review of patient #9's record revealed NO documentation of a follow up visit with the neurosurgeon 1-2 days after the 2/7/17 ER visit.


An interview and record review conducted on 2/14/17, with staff #3, confirmed the above findings. Staff #3 was unaware that patient #9 was supposed to follow up with the neurosurgeon after the 2/7/17 post fall ER visit.


An interview was conducted on 2/14/17, with patient #9's nurse at the patient's bedside. Patient #9 was observed wearing a cervical collar. The surveyor asked the nurse why the patient had been wearing the collar for so long (since 2/7/17), and she stated, "I'm not sure. I know he fell about a week ago and has a fracture." The patient's skin on left side below the collar was observed with 2 reddened areas where the collar contacted the skin.



Further review of patient #9's record revealed the following information: On 2/10/17 at 1736, staff #6's computerized narrative note documentation stated, "Continues to be confused. Irritable. Easily agitated. Aggressive at times. Fell this morning and was sent to ER for CT scan of head."
A review of the Physician's Orders revealed an order dated 2/10/17, stated, " ...Transfer Pt to ER for evaluation for fall related injuries ...".


A review of the MHT Care and Observation Flowsheet reflected every 15 minute observations of patient #9. The MHT documented on 2/10/17, from 0945 until 1200, patient #9 was in the ER. There was NO further documentation found in the record related to patient #9's fall on 2/10/17.


Patient #9 was sent to the Emergency Room (ER) operated by another facility located in the same building, after the 2/10/17 fall, per staff #24's order.


A review of patient #9's ER record for 2/10/17, revealed the following information: The ER Physician's documentation stated the patient arrived to the ER at 1013 with complaint of fall injury. The ER physician's documentation stated, "PT IS A PATIENT AT ALLEGIANCE SPECIALTY HOSPITAL. HIS CAREGIVER STATES HE FELL OUT OF HIS WHEELCHAIR FACE FIRST. HE MIGHT HAVE HIT HIS HEAD. PT WAS HERE IN ED 3 DAYS AGO FOR A FALL AND THEY PLACED A C COLLAR ....ED course PT IS A 74 YO (year old) MALE FROM ALLEGIANCE FOR GROUND LEVEL FALL. THIS WAS WITNESSED HE WAS IN HIS WHEELCHAIR AND PITCHED FORWARD. UNSURE IF HE HIT HIS HEAD. NO BLOOD THINNERS ON HIS LIST. CT HEAD AND C SPINE WITH CHRONIC CHANGES. NOTHING ACUTE. DC (discharge) BACK TO ALLEGIANCE."


The facility's Incident Log did not include patient #9's, fall on 2/10/17.


A review of the facility's policy number 605.1, titled, "Patient Monitoring and Precautions", revealed the following information:


"PROCEDURE

1. In order to provide protection to patients, three levels of staff monitoring are provided.

A. Level I: constant monitoring within arms-length distance.

B. Level II: constant monitoring within 20 feet distance.

C. Level III: close monitoring every 15 minutes, visual observation at a distance of 40 feet or less.

D. Level IV: monitoring on a routine basis every 15 minutes.


2. Special Precautions will be initiated for suicidal risk, agitation, elopement risk, aggression, fall risk or for a change in a medical condition and will continue until orders are received from the attending physician to discontinue.

A. A RN will assign a Special Precaution Level based on assessments, observation and history of the patient at the time of admission.

B. A RN may change the level of monitoring based on changes in the patient's behavior or condition. All changes must be documented to include the level of monitoring and the reasons for the monitoring level.

C. A RN must contact the attending physician to get a physician's order for a Level I Special Precaution. The order will document the reason for the increased level of monitoring.

D. The patient is told why the staff monitoring has been instituted and the procedure is explained to the patient.

E. In all cases, the least restrictive clinically appropriate intervention will be made.

F. The patient is placed in a room as close to the nursing station as possible for continuous contact.

G. The patient's behavior is documented on the Close Observation Sheet ...."

Based on record review and interviews, the facility failed to:

1.) protect the patient from corporal punishment and intimidation in 1(#6) of 3( #6, #2, and #3) charts reviewed.

2.) assess and monitor the patient's condition on an ongoing basis to ensure that the patient was released from restraint or seclusion at the earliest possible time. Citing 1(#6) of 3( #6, #2, and #3) charts reviewed.

3.) educate the staff and create a culture that supports patient rights and ensure policies and processes were developed to eliminate the inappropriate use of restraint or seclusion. Citing 1(#6) of 3( #6, #2, and #3) charts reviewed.


This deficient practice was determined to pose Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.



Review of patient #6's chart revealed the patient was a 73 year old male, admitted on 1/30/17, with a diagnosis of psychosis. There were no orders found upon admission that stated if the patient was voluntary or involuntary. There was an emergency detention warrant found on the patients chart for 1/29/17.


Patient #6's patient chart revealed nursing reported on 1/31/17 patient was calm and cooperative throughout the day. At 21:56 (9:56PM) the nurse documented, "Patient in room awake and very confused this HS. Does not want a roommate he thinks he is in a trailer he has had reserved for over a month. Pt. redirected be staff. Cooperative with HS medications. No c/o pain or discomfort at this time."(sic)


Review of the Mental Health Care Technician (MHT) Care and Observation Flowsheet notes dated 1/31/17 revealed the patient was awake ambulating in his room from 9:15PM until 1:15AM where he is found aggressive in the hallway. There were no interventions documented on the flowsheet during 1/31/17 at 9:15 PM - 2/1/17 at 1:15AM. Patient #6 was documented on the flowsheet to be in seclusion from 2:45AM -6:45AM. At 7:00AM on 2/1/17 a new flowsheet was started and patient #6 was documented as sleeping in seclusion until 8:00AM.


Review of patient #6's clinical nursing notes dated 2/1/17 at 1:15AM revealed the RN documented, "Called down the hallway by MHT, stating she needed assistance with this patient-noted patient in the hallway fully dressed and yelling out at staff that "No one is gonna come in my house, I can leave whenever I want to and no one is gonna stop me." Patient entered room 105, attempting to calmly request patient to come out of room 105, patient refused and began slamming the door of the room 105 (4-5) times. Patient came out of the room and started walking down the hallway yelling and swinging at staff. Patient struck nurse in the face multiple times with a closed fist. Patient kicked MHT in her right leg. Patient going into different patient rooms and when called, he became increasingly agitated and began chasing staff, patient kicked both doors to nurses station and finally breaking a door and gained entry into nurses station, grabbed a chart and started swinging it and threw it at staff. 911 & upper management called."


Nurse documented on 2/1/17 at 1:30AM Police here and patient in day room calmly talking to police. XXX (staff #26 NP Nurse Practitioner) called and N/O obtained for Benadryl 12.5mg, Ativan 1mg & Haldol 2 mg IM x1."


Nurse documented on 2/1/17 at 1:45AM, "Benadryl 12.5mg, Ativan 1mg & Haldol 2 mg IM given into patient's right buttock."


Patient had been documented as calm and talking to police but was still administered a chemical restraint ordered by the nurse practitioner.


Nurse documented on 2/1/17 at 2:55AM, "Police escorted patient into seclusion room- MHT assisted patient into a gown. The nurse called the patients daughter at 3:00AM and informed her of the situation.


There was no further nursing documentation found on the patient concerning an assessment, vital signs or nursing care after the chemical restraint or seclusion.


There was not a psychiatrist progress note found until 2/3/17. The nurse practitioner documented visits on 2/1/17, 2/2/17 and 2/6/17. There was no other psychiatrist notes found from the psychiatrist or nurse practitioner.


There was an order found on 2/1/17 by the nurse practitioner to begin court commitment process due to aggressive behavior at 2:40PM. The nurse practitioner does not have the authority to write court commitment orders per the facility medical by-laws or governing board bylaws. The NP orders were never co-signed by the psychiatrist. In the medical by-laws under "Behavioral Health Inpatient F. Patients shall be cared for by on staff physicians except as otherwise provided for in the Medical Staff ByLaws and Rules and Regulations." There was no further information found on the use of a Physician Assistant or Nurse Practitioner in the Medical By-laws.


Review of the Medical Staff Bylaws revealed the following:

"Behavioral Health Inpatient

F. Patients shall be cared for by on-staff physicians except as otherwise provided for in the Medical Staff Bylaws, Rules and Regulations".

There was no provisions found in the Bylaws that Physician Assistants or Nurse Practitioners were included as members of the Medical Staff.


Review of the patient #6's chart revealed a physician order form that stated the patient could be placed in seclusion for violent behavior. The order stated, "Check vital signs every 15 minutes." The nurse checked a box on the form that stated, "Medical condition present which increases physical risk HTN (hypertension)." Denial rights section was left blank and unsigned by author of the order. The nurse documented on the order that the psychiatrist gave the order for seclusion on 2/1/17 at 3:30AM. The psychiatrist signed the order but did not date or time the signature. There was no note found for the psychiatrist. During a phone interview with the medical director and psychiatrist on 2/23/17 at 1:00PM, the psychiatrist revealed she thought the nurse practitioner wrote the note about her visit. The psychiatrist reported she does not always write a note.


The Psychiatrist was not aware the medical staff by-laws and Governing by-laws did not recognize the nurse practitioner to see the patients and write orders.


Review of the restraint and seclusion review completed by the RN on 2/1/17 revealed;

1.) Patient #6 was placed in seclusion at 3:05AM. The MHT note stated that patient #6 was placed in seclusion at 2:45. There was a 20 minute difference.

2.) The only alternatives attempted was verbal de-escalation.

3.) Patient education was provided but did not state what education.

4.) Leadership was notified but there was no documentation on who was notified and response.

5.) Psychiatrist saw the patient on 2/1/17 at 10:00AM for a face to face. The physician or authorized practitioner was to do the face to face within one hour of the seclusion and chemical restraint. The documentation revealed the psychiatrist saw the patient 7 hours later. There was no physician notes found that the psychiatrist had seen the patient on 2/1/17. The nurse checked that a trial release was documented. There was no documented evidence that a trial release was attempted. The nurse checked that a response to release was documented.

There was no evidence documented that the patient gave a response to release. There was a time of release on the seclusion log of 6:30AM. The patient was in seclusion for 3 hours and 25 minutes with no assessment documented. There was no documentation of a chemical restraint in the nurse's notes, on the restraint order, or on the restraint log. This was the only patient documented on the restraint log. There was no one documented on the restraint log for January 2017 for restraint or seclusion.


A telephone interview with staff #25 (RN) was conducted on 2/16/17 at 4:45PM. Staff #25 was questioned about the restraint and seclusion of patient #6 on 2/1/17. Staff #25 reported patient #6 had sundowners and he would become more difficult during the night.


Staff #25 reported Patient #6 came out of his room fully dressed and was agitated and wanted to leave. Staff #25 tried to talk to patient #6 and get him to watch TV but he just became more agitated, patient #6 then began to slam another patient's door to their room over and over. Patient #6 was inside the other patient's room. The other two patients in room 105 were trying to sleep. "We were trying to get him to come out of that room while I was trying to get XXX (staff #26 NP) on the phone." While staff #25 was on the phone with staff #26, staff #25 stated, "all of my staff was running down the hallway and he was chasing them. He punched the LVN in the face three times and kicked one of my MHT's. I called XXX (staff #3 RN administration) and he instructed me that we needed to get him out of here".


Staff #25 stated she was instructed by staff #3 to call the police. Staff #25 reported the patient came into the nurse's station and started to "chunk charts at me. I got the chart cart out of reach and informed my staff to lock themselves into the breakroom." Staff #25 reported, she went out to look for patient #6 on the unit. Staff #25 stated, "He could tear up the unit as long as nobody got hurt. I ran off the unit to go get the security guard from XXX (another facility in the building) and they said they could not come and help. They had their own issues that night. Finally, the police came and took the patient to the activity room. The patient calmed down and the policemen took him to the seclusion room. The policeman asked patient #6 if he would let us give him a shot and he said, yes. The police held him while staff #38 gave him the shot and closed the seclusion room door. XXX (Patient #6) just paced for 2 hours." Staff #25 was asked if she thought the patient was intimidated by the police and she stated, "Sure, I guess, I would be," we wanted them to take him to jail.


Staff #25 stated, "The police would not take him to jail. They stated that this was the safest place for him. They said the jail was full of patients that needed care and they were not going to do that." Staff #25 reported that no supervisor came to the facility till the next morning. There was no physician present.


Staff #25 reported that she had not had SAMA training at this facility. Staff #25 stated she had not been trained that behavioral emergency medications needed to be documented as a restraint. Staff #25 stated she did not know a face to face had to be done for meds or seclusion. Staff #25 stated she felt like they handled the situation the best that they knew how. Staff #25 agreed they could use more training in handling the patients that become violent.


An interview with staff #15 (RN) was conducted on 2/16/17 concerning chemical and behavioral restraints. Staff #15 stated, "If I needed to give a behavioral medication I would look to see if they have a PRN (as needed). Sometimes they order PRN's IM. If not I would just call and get an order. We just call the nurse practitioner for all the orders. Then we just give it. We don't do any restraint paperwork. We don't chart the medications as a chemical restraint. We don't usually take vital signs. We just let them sleep."


An interview was conducted with staff #3 concerning patient #6 on the night of 2/1/17. Staff #3 reported that he was called by the RN of the unit and told what was going on. Staff #3 confirmed that he instructed the nurse to have the police come and arrest the patient for his behavior. Staff #3 stated, "We just cannot deal with that kind of patient. He needed to go to jail." Staff #3 confirmed he never came to the unit to assist with the situation.


An interview was conducted with staff #1 on 2/16/17. Staff #1 reported that she had been training the staff in SAMA for the last 2 days to be eligible to sit with the patient's one on one. Staff #1 confirmed the staff had been in a 4 hour session and had been taught verbal de-escalation. The surveyor pointed out to staff #1 the incident with patient #6. Staff #1 was questioned why the staff would not be receiving the entire training. Staff #1 stated that she felt this was all they needed to know. Staff #1 reported that herself, staff #2, and #3 had decided that de-escalation and learn to block kicks would be the best method.


When Staff #1 was asked how staff were supposed to hold an aggressive patient, Staff #1 stated, "They know how to do that. Nurses are taught in nursing school how to hold a patient." Surveyor asked staff #1 if the staff knew how to handle patient #6 and why were the police called? Staff #1 responded, "I know about the police coming. They could not handle the patient so the police had to be called. They needed to come and get him. He needed to be removed from the facility. He needed to go to jail. We can't handle patients like that?" The surveyor asked staff #1 where she thought patients like patient #6 should go? Staff #1 stated, "It would have to be a forensic psych with bars on the windows and the patient secluded in their own space."


A review of the incident logs showed from 9-2-2016 to 2-8-2017 there were 20 incidents involving physical aggression that nursing staff were not able to manage using SAMA Assisting (Verbal De-escalation) Process. Staff #1 confirmed the findings but continued to insist that the staff would not be taught appropriate holds. Staff #1 stated, "I just don't trust them to do that."


Review of The Satori Alternative to Managing Aggression (SAMA) revealed the Assisting Process course was a one-day course. Participants who demonstrate competency in all areas were certified in the SAMA Assisting (Verbal De-escalation) Process. Staff #1 stated this was all that was taught to the staff.


Full SAMA training was a two-day, 16 hour program that included 4 areas for managing aggressive patients. Those areas were:

Principles and Assisting Process
Protection of Self and Others
Containment
Object Retrieval


Review of annual training records revealed that annual training had not been completed hospital-wide since December 2015. This included annual nursing training in Abuse/Neglect, Infection Control, Patient Rights/Confidentiality, and Age Appropriate Care training and SAMA. This was confirmed by Staff #2 and Staff #14.


Review of the policy and procedure for restraints was dated as last updated 2012. The policy did not address behavioral restraints, seclusion, or time outs. An interview with staff #2 on 2/13/17 revealed a current policy was written but had not been approved by the governing body and was not on the floor accessible to the nursing staff. Staff #2 confirmed there had not been a restraint log in place until 1/17. Staff #2 was writing the policies but was not aware of the state regulations and what they required. Staff #2 confirmed she had not had any previous psychiatric training other than in nursing school.


The policy and procedure for restraints dated 2/2012 was as follows:


"PURPOSE AND USE:
Restraint is a high-risk, potentially harmful procedure that is intended to be used only when less restrictive methods have not succeeded or clearly are not likely to succeed in preventing injury to a patient or others.


CRITERIA FOR RESTRAINTS:
1. Self-injurious behavior such as pulling/interfering with treatments, catheters, tubes, lines, dressings, and is unable to follow or retain instructions.
2. Unsteady gait/balance, attempts ambulating or climbing out of bed against advise and is unable to follow or retain instructions.


TYPES OF RESTRAINTS:

1. PHYSICAL - The use of a physical or mechanical device to involuntarily restrain the movement of the whole or a portion of a patient's body as a means of controlling physical activities to protect the patient or others from injury.

2. CHEMICAL - use of medications that alter mood or behavior, for the purpose of controlling the patient's physical activity to protect the patient from harming self or others.


USE OF ORDERS TO INITIATE RESTRAINT USE:
Any independent licensed practitioner (physician) of the active medical staff may issue an order for restraint. Orders must state a specific length of time for which the restraints may apply - up to and including 24 hours (orders may not exceed 24 hours). A physician must personally complete a direct patient assessment to initiate a restraint order or renew an order after 24 hours. Orders or accompanying progress notes must:

state date and time of entry for order
state the justification for restraint
state the type of restraint; and
state the time limit for restraint."


There was no policy found that addressed Seclusion. Review of the Medical By-laws under restraints stated, "The use of restraints or seclusion shall comply with Facility policy and Texas Administrative Code chapter 405, subchapter F, and be employed only when other methods of control are deemed inadequate to assure the safety of the patient or others. The physician must justify the use of restraints or seclusion in the medical record, at the time of the order. The verbal or written order from a physician shall be obtained within one hour of initial use and reviewed and countersigned by the physician within 12 hours."


An interview with staff #2 on 2/13/17 confirmed there was no found seclusion policy but a new policy had been written. The policy on Seclusion had not gone through governing body or accessible to the nursing staff.

Based on record review of the Quality Assessment Performance Improvement data and interviews, the facility failed to:

A.) take actions aimed at performance improvement in high risk, high volume, or problem prone areas.

Review of the QAPI given for 2016 revealed the information was data. The only departments with action plans were medical records and environmental. There was no performance improvement documented concerning falls, medication errors, restraints, incident reports with injuries, or grievances.

An interview was conducted with the staff #4 (Quality Director) on 2/15/17. Staff #4 reported that she collects the data and reports to the cooperate quality director. Staff #4 reported she went to a conference for a week on QAPI but has had no formal training.

Review of staff #4's job description revealed the QAPI director must be a Associate Degree Nurse (ADN RN) or higher. Staff #4 was a Licensed Vocational Nurse (LVN) and does not qualify for the position. Staff #4 was unaware of the qualifications of the facility.

Based on record review of the Quality Assessment Performance Improvement data and interviews the facility failed to:


A.) document quality improvement projects or make a comparable effort for 2016.


Review of the QAPI given for 2016 revealed the information was data. The only departments with action plans were medical records and environmental. There was no performance improvement documented concerning falls, medication errors, restraints, incident reports with injuries, or grievances.


An interview was conducted with staff #4 (Quality Director) on 2/15/17. Staff #4 reported that she collects the data and reports to the cooperate quality director. Staff #4 reported she went to a conference for a week on QAPI but has had no formal training.


Review of staff #4's job description revealed the QAPI director must be a Associate Degree Nurse (ADN RN) or higher. Staff #4 was a Licensed Vocational Nurse (LVN) and does not qualify for the position. Staff #4 was unaware of the qualifications of the facility.

Based on observation, review of records, and interview, the Chief Nursing Officer (CNO) failed to develop, review, and approve nursing policies for 2 of 2 units (Acute Care Unit and Behavioral Health Unit).


In a review of the organizational chart on 2-14-2017, it was discovered that there was an Acute Medical Unit within the hospital. Staff #1 was asked who the director of that unit was. Staff #1 stated the unit was on the second floor, but had been closed for "quite a while" so there wasn't a director. When Staff #1 was asked when the last time a patient had been admitted to the unit, Staff #1 replied, "It's been a long time since we had a patient up there." When asked for a specific date, a patient had been on the unit two months prior, 12-7-2016.


Interview with Staff #3 was conducted. Staff #3 stated that he was the Program Director for that unit and reported directly to Staff #2. He stated the unit was available for admissions of psychiatric patients who had medical problems, such as pneumonia, that could be treated at their facility. While not being used at the time, Staff #3 confirmed that the unit was not closed as previously stated by Staff #1.


A tour of the Acute Unit on the 2nd floor was conducted with Staff #3 and Staff #20. A policy binder was found in the nursing area of the unit. The form at the front of the policy manual contained "Allegiance Specialty Hospital of Kilgore, Clinical Services Manual, This Manual was Reviewed and Approved by:" The page contained signatures of the CNO, CEO, Medical Director and Governing Board. The CNO and Medical Director's signatures were dated in 2012. There was no date for the CEO and Governing Board signatures. When asked why the manual hadn't been updated, Staff #3 stated the signature sheet for the 2016 review and approval was downstairs and that the content had not changed. When asked if he was sure nothing had changed since 2012, Staff #20 stated, "They have been updated. It was an oversight on our part and we'll replace the manual with a current one."


Further review of the hospital-wide nursing policy manual provided by the facility for the survey showed that it also had the same signature page from 2012. Inside the front pocket of the binder was a new signature page that had been signed by Staff #1, Staff #2, and Staff #22 on 12-16-16. The Governing Board signature was missing. It also contained the statement, "This Manual was Reviewed and Approved by:"


An interview was conducted with Staff #2. Staff #2 was asked if she had reviewed and approved all of the nursing policies. Staff #2 stated she had been made aware in November of 2016 that the policy manuals had not been updated since 2012. When asked if she had actually reviewed and updated the policies, since they were at least 4 years old, she stated she had not. She said, "We try to review policies every week, but there are just too many policies to review them this quickly." When asked if she had a strategic plan such as prioritizing the policies with timelines and target dates for completion, Staff #2 stated she did not. Staff #2 confirmed that none of the policies reviewed or updated since November 2016 had been completed with printable, usable policies with Governing Board approval.


Review of Allegiance Specialty Hospital Clinical Services Manual Policy titles "Policy Development and Revision", Policy: CS6-1 was completed as follows:


"Purpose:
To establish a consistent approach for policy development and approval for hospital policies, and a consistent method of review to current policies.


Policy:
All policies at the hospital will follow the steps outlined below while being developed, approved, and distributed to the appropriate policy manuals. Review of existing policies will be completed by the leadership team on an annual basis and revisions made as appropriate. Policy manual approval will be completed annually through the Quality Safety Survey Readiness Committee, Medical Executive Committee and Governing Board."

Based on review of records and interview, Nursing Services failed to provide adequate numbers of qualified and/or trained nursing staff to meet the needs of patients in 3 out of 3 units reviewed [Acute Care Unit, Behavioral Health Unit, and Intensive Outpatient Unit (IOP)].


Review of annual training records revealed that annual training had not been completed hospital-wide since December 2015. This included annual nursing training in Abuse/Neglect, Infection Control, Patient Rights/Confidentiality, and Age Appropriate Care training. This was confirmed by Staff #2 and Staff #14.


An interview was conducted with Staff #1. The Satori Alternative to Managing Aggression (SAMA) Assisting Process course was a one-day course. Participants who demonstrate competency in all areas were certified in the SAMA Assisting (Verbal De-escalation) Process. Staff #1 stated this was all that was taught to the staff. Staff #1 stated she did not trust the staff to properly use the full SAMA training.


Full SAMA training was a two-day, 16 hour program that included 4 areas for managing aggressive patients. Those areas were:

o Principles and Assisting Process
o Protection of Self and Others
o Containment
o Object Retrieval


When Staff #1 was asked how staff were supposed to hold an aggressive patient, Staff #1 stated, "They know how to do that. Nurses are taught in nursing school how to hold a patient." When asked how staff are supposed to get a weapon away from a patient, Staff #1 stated, "We don't allow weapons. Patients can't get weapons in here. We search everyone thoroughly upon admission."


A review of the incident logs showed from 9-2-2016 to 2-8-2017 there were 20 incidents involving physical aggression that nursing staff were not able to manage using SAMA Assisting (Verbal De-escalation) Process. These incidents included a patient breaking into the nurse's station, retrieving a pair of scissors, stabbing at the staff and stabbing himself in the abdomen. Staff #28 was interviewed about the incident. Staff #28 stated, "It all happened so fast, I didn't know what to do." Staff #28 stated she had been taught the full SAMA course "years ago", but didn't remember much of it.


Another incident resulted in multiple staff being struck and the police being called. Review of this incident showed that police held the patient for the staff to be able to administer emergency medications and removed the patient to the seclusion room for the staff so the patient could be contained.


Review of Patient #11's chart showed that he was an Intensive Outpatient Program (IOP) patient who became unresponsive on 12-14-2017 in the IOP. A Code Blue (emergency situation requiring immediate medical attention) was called overhead. The nurse charted "Staff called code blue to IOP. ER & BHC staff arrived. Pt continue to have pulse & resp. BHC staff obtained gurney. Pt lifted to gurney and at that time became responsive slightly to verbal stimuli. Pt transferred to (a separately licensed hospital's emergency room) for higher level of care."


Staff #3 was interviewed about this incident. Staff #3 stated, the staff from (emergency room staff from a separately licensed hospital's emergency room in the same building as the IOP and behavioral hospital) can hear the overhead paging system and come over to assist in the IOP and on the behavioral unit whenever a code is called. Staff #3 stated, "They come over here to help us out during a code." Staff #2 was interviewed about the incident. Staff #2 was not aware of, nor able to provide copies of, any contract, agreement, or training for non-employed staff from another hospital to come into the behavioral hospital and provide emergency care for their patients.


A Review of Policy # CS3A-01, titled "Code Blue", was completed. The policy stated:

"PROCEDURE:

1. Call the Code internally but using the overhead paging system. Dial 444 and announce clearly three times, "Code Blue, Room #___ / location (Noisy Activity)". (sic)

2. Establish unresponsiveness and attain emergency assistance via calling "CODE SHEPHERD" and if needing help to transport "CODE SHEPHERD, ASSISTANCE NEEDED" and give the location.

8. Once the (name of separately licensed facility) staff, on-call physician or any physician has arrived, they assume responsibility for running code. Nursing staff at this point will provide care under ordered by the available physician. Traffic control of extra personnel/visitors should be initiated."


This procedure is not permissible under the CMS regulations. The regulation requires that each independently certified facility must be able to demonstrate independent compliance with all applicable regulations. This hospital must not rely on other independent certified to assume the provision of care to this hospital's patients.


A review of admissions to the Acute Care unit showed that one patient was admitted in December. Staff #37 was one of the nurses assigned to care for the patient during that stay. Review of Staff #37's file showed that she did not have SAMA training and there was no documentation of orientation for the Acute Care Unit to include location of supplies and the admission process. Staff #37 was a PRN (as needed) employee and did not work full time. She was left with one mental health technician on the second floor alone to admit a psychiatric patient and no orientation to the floor or the admission process for the Acute Care Unit. Staff #3 was interviewed. Staff #3 confirmed that Staff #37 was left on the Acute Care Unit with one MHT. Staff #3 stated he showed her where everything was and told her what she needed to do to complete the admission process to the Acute Care Unit. Review of the Allegiance Specialty Hospital Clinical Services Manual policy titled "Nurse Staffing", Policy # CS8-03, last reviewed 10-2012 was completed. The policy contained the "Behavioral Health Staffing Matrix" that was noted "UPDATE April 2012". Per the Acute Care Staffing portion of the Matrix, minimum staffing for 1 patient on the Acute Care Unit required, 1 Registered Nurse, 1 Licensed Vocational Nurse, and 1 Certified Nurses Aid.


During observations of the Behavioral Unit on 2-14-2017, Patient #20 was observed to be pacing around the nursing station with Staff #29 following behind her. Staff #29 was observed to come back to the nursing station without the patient. Staff #29 was asked what had been happening with the patient. Staff #29 explained that she was a nursing student doing her clinical rotations for nursing school. She explained that Staff #30 was the assigned Mental Health Technician (MHT) assigned to the patient. Staff #29 stated Staff #30 had to go somewhere so left Staff #29 to monitor the patient. Staff #29 stated she had been alone with the patient for about 20 minutes. Staff #29 was asked if she had any training to deal with aggressive patients. Staff #29 denied receiving any training. Review of Patient #20's MHT Care and Observation Flowsheet showed that the patient was on "Fall Precautions and Aggression Precautions". Staff #30 was interviewed about the incident. Staff #30 stated she did not tell the Charge Nurse that she was leaving or that she had delegated her assignment to a nursing student. Staff #30 stated that she was not aware that she had done anything wrong. Staff #2 and Staff #3 were interviewed about the incident. Staff #2 and Staff #3 confirmed that the nursing student did not have the appropriate training to monitor a patient and should not have been left responsible for monitoring the patient.


Review of the Allegiance Specialty Hospital Clinical Services Manual policy titled "Nurse Staffing", Policy # CS8-03, last reviewed 10-2012 was completed. The policy contained the "Behavioral Health Staffing Matrix" that was noted "UPDATE April 2012". Staff #3 was asked to provide the Staffing Matrix that was being used during scheduling. Staff #3 provided a Matrix that did not match the policy. The matrix did not have any dates of approval. Staff #3 was asked to provide the date this matrix had been approved through committee. Staff #3 was not able to provide this information. Staff #3 stated, "I don't know. This was here when I started so that's what I've been using." The unapproved staffing grid reduces staffing by one nurse when the census is high, above 17, on day shift. The unapproved staffing grid reduces staffing by one MHT when the census is high, above 19, on night shift.


Review of Staffing for day shift on 2-1-2017 show that the census was 20. Per the approved staffing grid in the policy, 4 nurses should have been scheduled. Only 3 nurses worked that day. Per the approved staffing grid in the policy, 4 MHTs should have been scheduled. Five (5) MHT's were scheduled, but 2 of them were assigned to patients on a 1:1 (one MHT to stay with the patient at all times) removing 2 MHT's from the staffing matrix minimum. This left them short 1 MHT.


Review of Staffing for day shift on 1-30-2017 show that the census was 20. Per the approved staffing grid in the policy, 4 nurses should have been scheduled. Only 3 nurses worked that day. Per the approved staffing grid in the policy, 4 MHTs should have been scheduled. Five (5) MHT's were scheduled, but 2 of them were assigned to patients on a 1:1 (one MHT to stay with the patient at all times) removing 2 MHT's from the staffing matrix minimum. This left them short 1 MHT.


Review of Staffing for day shift on 1-28-2017 show that the census was 20. Per the approved staffing grid in the policy, 4 nurses should have been scheduled. Only 3 nurses worked that day.


Review of Staffing for night shift on 1-28-2017 show that the census was 21. Per the approved staffing grid in the policy, 4 MHTs should have been scheduled. Five (5) MHT's were scheduled, but 2 of them were assigned to patients on a 1:1 (one MHT to stay with the patient at all times) removing 2 MHT's from the staffing matrix minimum. This left them short 1 MHT.


Review of Staffing for night shift on 1-27-2017 show that the census was 21. Per the approved staffing grid in the policy, 4 MHTs should have been scheduled. Five (5) MHT's were scheduled, but 2 of them were assigned to patients on a 1:1 (one MHT to stay with the patient at all times) removing 2 MHT's from the staffing matrix minimum. This left them short 1 MHT.


Review of Staffing for day shift on 1-26-2017 show that the census was 21. Per the approved staffing grid in the policy, 4 nurses should have been scheduled. Only 3 nurses worked that day.


Review of Staffing for night shift on 1-25-2017 show that the census was 21. Per the approved staffing grid in the policy, 4 MHTs should have been scheduled. Five (5) MHT's were scheduled, but 2 of them were assigned to patients on a 1:1 (one MHT to stay with the patient at all times) removing 2 MHT's from the staffing matrix minimum. This left them short 1 MHT.


Review of Staffing for day shift on 1-22-2017 show that the census was 18. Per the approved staffing grid in the policy, 4 nurses should have been scheduled. Only 3 nurses worked that day.


Interview was conducted with Staff #28 on 2-14-2017. Staff #28 was attempting to schedule staffing due to increased need for staff. SAMA training was not completed by all staff. Staff #28 had a list of staff with their dates of SAMA training. The list showed that some people had Part One of the training, SAMA Assisting (Verbal De-escalation) Process. No one on the list had Part Two which included Containment and Object Retrieval. Staff #28 was using this list to determine who was qualified to work. Staff #2 was asked to provide a copy of that list. Staff #2 provided a list that was different. The list provided by Staff #2 had only one column that said "S.A.M.A" instead of Part One and Part Two. When asked why he had given me a different list, he said the nurse that was scheduling staff to work did not have the most current list.

Based on review of records and interview, registered nursing (RN) staff failed to assess the patients on an ongoing basis and when a change in condition occurred in 7 (Patient #s, 1, 8, 9, 10, 12, 18, and 19) of 7 patients reviewed.


A review of Patient #1's chart was conducted. Patient #1 chart revealed on 2-28-2016 at 1:20 PM, "Pt continues to threaten staff, contacting MD." The nurse charted at 1:25 PM, "Dr. Jacobson Notified of Pt's behavior, new orders: 1 time dose-Combine Ativan 2mg (milligram) inj. (injection) Haldol 10mg inj. and Benadryl 50 mg inj to be given IM (in a muscle) NOW for combative behavior." The nurse charted that the injection was given at 1:40 PM. At 2:00 PM, the Mental Health Technician (MHT) charted that the patient was in their room sleeping until 10:15 PM. The MHT charted that the patient was back to sleep at 10:30 PM and woke up intermittently. The next nursing note was at 12:50 AM on the morning of 2-29-2016, the nurse charted, "Pt restless and agitated - attempting to climb out of bed. PRN Klonipin 1 mg po (by mouth) administered. Pt scuffing arms on bed mattress and reopening skin tears. Unable to keep dressings in place." The patient slept a total of 12.75 hours out of the 17 hours between receiving the injection on 2-28-2016 at 1:40 PM and 7:00 AM the next morning. On 2-29-2016 at 12:10 PM, the nurse charted a change in the patient's condition. The patient had decreased responsiveness. The nurse charted, "1210 - New order for Narcan 0.4 mg IM one time order. Patient leaning right in wheelchair, sedated, slurred speech and delayed answer when asked question."


There was no documentation of interventions attempted to avoid having to medicate the patient with sedating medications. There was no documentation of a nursing follow-up assessment of the patient to include vital signs before medication administration or after medication administration. Vital signs were assessed on 2-29-2016 at 7:12 AM and were within normal parameters. Vital signs were reassessed at 7:15 PM (approximately 7 hours after patient was identified as having decreased responsiveness). The patient was found to have a temperature of 101.6 degrees Fahrenheit and an oxygen saturation level of 88% on room air. A posting of normal vital sign range in the nurse's station showed that the normal range for oxygen saturation level was 94% to 100%. The patient was transferred to a medical hospital in another city and did not return to the specialty hospital.


Patient #10's chart was reviewed. Patient #10 was admitted on 11-29-2016 to the acute care unit. The patient transferred to the Behavioral Unit on 11-30-2016. Patient number 10 discharged on 12-13-2016. Patient number 10 had an interrupted stay. The patient was transferred to another hospital on 12-8-2016. There was no documentation found stating when the patient returned. The last shift assessment prior to transfer to another hospital was on 12-7-2016 at 8:08 PM. The next shift assessment was completed on 12-10-2016 at 11:40 AM. Staff #24 charted a physician's medical assessment occurred on 12-10-2016 at 6:25 AM. The actual date and time of return from the other facility was not documented in the chart with an RN assessment.


The patient required a nursing shift assessment each shift. The nursing shift assessment was a comprehensive assessment of multiple body systems and risk assessments. The shift assessment was not a focused nursing assessment. The patient arrived on the Behavioral Unit on 11-30-2016. Between 12-1-2016 and patient transfer on 12-8-2016, 15 RN shift assessments should have been documented. Nine (9) of the assessments were documented and signed by Licensed Vocational Nurses (LVN). One (1) RN shift assessment was not found in the chart at all. Only 5 shift assessments were signed by an RN. Between 12-10-2016 and discharge on 12-13-2016, 7 RN shift assessments were due. Five (5) out of 7 were charted and signed by an LVN. Two (2) were signed by an RN.


Patient #12's chart was reviewed. On 1-29-2017 the nurse charted at 10:00 PM, "Pt. isolating in room and remains delusional. States that nurse call button to bed is not working and that is a federal violation for call button not to be working and that all of the nurses were going to jail. Compliant with HS medications. Will continue to monitor. Pt remains agitated about call button on bed not working. Yelling out and difficult to redirect. Refusing to take PRN Ativan 0.5 mg. Pt assisted to WC and moved for closer monitoring near nurses station. Norco 10/325 mg administered at 21:40 for bilateral leg pain. Will continue to monitor."


At 10:40 PM, the nurse charted, "Follow up PRN Norco 10/325 mg: Pt states that he continues to have pain and pain level is 6/10. Pt continues to be agitated and threw laundry hamper over nurses station counter attempting to hit nurses sitting in the area."


At 10:50 PM, the nurse charted, "Pt. remains loud and disruptive and continues to refuse PRN Ativan 0.5 mg po. (Nurse Practitioner's Name) notified by Charge Nurse and new order noted. Zyprexa 5mg IM administered to Rt deltoid site and Benadryl 12.5 mg IM administered to Lt. deltoid site. Will continue to monitor."


At 11:05 PM, the nurse charted, "Follow-up Zyprexa 5 mg IM and Benadryl 12.5 mg IM one time only dose. Pt drowsy and assisted to bed by staff." There was no documentation of a nursing follow-up assessment of the patient to include vital signs before medication administration or after medication administration.


Review of the physician orders and medication administration record for 2-1-2017, Patient #12 was conducted. The physician orders do not contain an order for Zyprexa on 2-1-2017. An order written on 2-1-2017 at 9:30 PM was found for "Give Haldol 1 mg, Ativan 1 mg, and Benadryl 12.5 mg IM x 1 dose - If ineffective after 1 hr give Haldol 1 mg IM." The Medication Administration Record (MAR) was documented that those medications were given on 2-1-2017 at 9:30 pm.


The Nursing Rounding Documentation for 2-1-2017 at 9:00 PM showed, "No evidence of pain observed, Offered emotion support/active listening, Being observed per orders." The chart for Patient #12 did not contain documentation of interventions attempted to avoid having to medicate the patient with sedating medications. The last nursing note for 2-1-2017 was at 12:30 pm. The next nursing note was 2-2-2017 at 2:40 pm.


Review of Patient #18's chart was conducted. Patient #18 was admitted on 2-12-2017 and was still a patient at the time of chart review on 2-14-2017. Patient #18 should have had an admission assessment and 4 shift assessments completed by an RN. On 2-13-2017, both shift assessments were charted and signed by an LVN.


Review of Patient #19's chart was conducted. Patient #19 was admitted on 2-5-2017 and was still a patient at the time of chart review on 2-14-2017. Patient #19 should have had an admission assessment and 18 shift assessments completed by an RN. On 2-11-2017 an LVN charted and signed the shift assessment for the day shift. The night shift assessment was missing. The night shift assessment on 2-13-2017 and day shift assessment on 2-14-2017 were both charted and signed by an LVN.


An interview was conducted with Staff #15 on 2-15-2017 in the conference room. Staff #15 stated that when patients are aggressive, nursing staff will call and get a medication order if needed. Staff #15 stated the Emergency Behavioral Medication order is not treated as a restraint. Staff #15 stated a face-to-face assessment with the patient is not documented. After medication administration, Staff #15 said, "We don't wake them up for vital sign checks. We just let them sleep."



Review of Assessment and Reassessment of Patient policy number CS2-01 was as follows:

"Page 2 of 2

6. Reassessment

i. Reassessment of the patient shall occur PRN and each time there is a change in the patient's condition.

ii. Nursing shall reassess the patient on a per shift basis.


7. Reassessment by all disciplines caring for the patient will occur on an ongoing basis throughout the patient stay. Changes in condition and progress in recovery will be documented in the patient medical record. Changes in the plan of care and treatment will be documented accordingly."


The policy did not address the shift assessments.


A review of Allegiance Specialty Hospital policy titled "Transfer Policy"; Policy: CS5-07, was conducted. The policy reads as follows:

"PROCEDURE:

Patients may be scheduled for temporary placement within an acute care facility for treatment or procedure. A Memorandum of Transfer will be completed for non-emergent patient transfers. A physician assessment of patient's stability of condition for transfer will be completed for non-emergent transfers, A patient / family consent for transfer will be completed for non-emergent transfers.


Report on the patient's status should be documented prior to and upon return to ALLEGIANCE SPECIALTY HOSPITAL OF KILGORE.

Utilize the Appropriate Documentation tools to record the patient's status.

Upon return to the facility, nursing staff should evaluate the patient through reassessment and document findings in the nursing notes. A reassessment will be completed to determine need for frequent monitoring of the patient.

Upon return of the patient to the facility vital signs are to be recorded.

Frequent monitoring includes, but is no limited to, the following:

Changes in vital signs i.e. significant drop or elevation of blood pressure
Changes in mental status and/or motor activity
Changes in pulmonary status
Changes in wound status
Changes in urinary output
Increase in pain

Changes in condition and or unusual findings are to be reported to the physician.

Physician notification of return to the hospital will be completed and continuing care orders obtained."



Review of the Texas Board of Nursing Board Rule 217.11(2)(A) showed:

"(2) Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and:
(A) Shall utilize a systematic approach to provide individualized, goal-directed nursing care by:
(i) collecting data and performing focused nursing assessments;"




35515

A review of the facility's Incident Log revealed patient #8 had sustained a fall on 1/16/17. The log contained the following statement: "PT ROOMATE ALARMED NURSE THAT PATIENT WAS IN BATHTUB. PT WAS FOUND LYING IN BATHTUB. PT SENT TO ER FOR CT SCAN DUE TO UNWITNESSED FALL. PT HAD NO CHANGE IN LEVEL OF CONSCIOUSNESS."

A review of patient #8's record revealed the following information:

Patient #8 was a 79 year old male admitted to the facility on 1/9/17, with a diagnosis of impulse control disorder. The patient's fall on 1/16/17, was documented in the record as follows:

On 1/17/17 at 1304, the RN's computerized narrative note documentation stated, "Late entry for 1/16/17 at 1620: Staff was alerted to patient by patient's roommate who stated patient had fallen. When this nurse and the Director of Clinical Services arrived in the room, patient was lying in the bathtub with his pants pulled down. Patient stated he had hit his head. Vital signs and neuro checks begun. Calls placed to the appropriate people. Patient sent to ER for CT of his head to rule out intracranial hemorrhage. When report called from ER, the nurse stated that the CT scan was negative but the Dilantin level was elevated. Will continue to monitor for any change in condition ...".

On 1/17/17 at 1300, the Registered Nurse's (RN) computerized Post Fall Assessment documentation stated, "1/17/2017 1300 ....Location of Patient at Time of Fall ... Patient Room ... Witnesses to Fall ...Patient's roommate ...Actual Level of Monitoring at time of fall ...Level II (constant monitoring within 20 feet distance) ...Activities at Time of Fall ...Going to or from Bathroom ....Vitals ... In Progress ..."


There was no documentation in the record of patient #8's fall on the date it occurred (1/16/17).



A review of the facility's Incident Log revealed patient #9 sustained a fall on 2/3/17.

The Incident Log revealed the following statement related to patient #9's fall on 2/3/17:

"PT STOOD UP AND LOST BALANCE AND LANDED ONTO THE LAP OF ANOTHER PATIENT. FALL WAS WITNESSED AND NO INJURY OCCURRED."

A review of patient #9's record revealed the following information:

Patient #9 was a 74 year old male admitted to the facility on 1/25/17, with a diagnosis of dementia and homicidal ideations.

There was NO documentation in the record of patient #9's fall on 2/3/17.

The Incident Log revealed the following statement related to patient #9's fall on 2/7/17:
"PT FOUND ON FLOOR SATURATED IN URINE, SENT TO ER FOR EVAL PER MD ORDERS".

The patient's fall on 2/7/17, was documented in the record as follows:
On 2/7/17 at 0656, the Registered Nurse's (RN) computerized Post Fall Assessment documentation stated, "2/7/2017 0656 ....Location of Patient at Time of Fall ... Patient Room ...Ordered Level of Monitoring ...Level IV (monitoring on a routine basis every 15 minutes) ...Activities at Time of Fall ...(blank) ....Other Activity ...(blank) ...Vitals ... (blank) ...Cardiovascular ...Tachycardia, Hypotensive ...Other skin conditions ...abrasion left shoulder and elbow ..."

On 2/7/17, a handwritten Post Fall Assessment form completed by the RN did NOT contain any information about how patient #9 fell.

On 2/7/17 at 0504, the RN's computerized narrative note documentation stated, "Patient found in floor in room by PCT (Patient Care Tech) BP 96/54, HR 120. Patient noted to have two bumps on back of head. Dr. (staff #24) notified by charge nurse."

A review of the MHT (Mental Health Tech) Care and Observation Flowsheet reflected every 15 minutes observations of patient #9. The MHT documented on 2/7/17 at 0500, patient #9 was "awake" located in his "room" and the intervention of "hygiene/toileting help" took place. In addition, the MHT documented patient #9 was "sleeping" and located in his "room", from 0515 until 0600.

Patient #9's staff monitoring level was documented as a "Level IV". According to facility's policy, Level IV is defined as, "monitoring on a routine basis every 15 minutes". The patient fell while in his room with NO staff monitoring him. The MHT that was assigned to monitoring the patient, documented he was "awake" located in his "room" and the intervention of "hygiene/toileting help" took place. The RN failed to appropriately oversee and monitor the MHT's care of the patient.

In addition, patient #9 had sustained 4 falls in 4 days, and staff decreased the patient's monitoring level from a Level II to a Level IV after his 3rd fall. The RN failed to appropriately assess the patient's need for constant supervision to prevent further falls and injury.

Patient #9 was sent to the Emergency Room (ER) operated by another facility located in the same building, after the 2/7/17 fall, per staff #24's order.

A review of patient #9's ER record for 2/7/17, revealed the following information:

The ER Physician's documentation stated the patient arrived to the ER at 0448 with complaint of head pain. The ER Physician's exam revealed ..."SMALL CONTUSION TO POSTERIOR SCALP" ....
Following diagnostic testing, the ER Physician documented: "Response to Treatment: ...CT (computerized tomography) HEAD NEG (negative) FOR ACUTE BLEEDING. CT C-SPINE (cervical spine) SHOWS T1-T2 (thoracic spine level 1-2) SUPERIOR ENDPLATE FRACTURE W/10% HEIGHT LOSS. UNCLEAR IF THIS IS NEW OR CHRONIC. NO NEURO (neurological) DEFICIT. PT HAS NO TENDERNESS. CALLED DR. XXX(neurosurgeon) W/SPINE AND HE STATED THAT PT SHOULD BE PUT IN COLLAR AND F/U (follow up) IN CLINIC. WILL DC (discharge) BACK TO ALLEGIANCE."
The ER nurse's documentation stated, " ...Follow up: XXX MD; When 1 - 2 days; Reason: Recheck today's complaints ....Notes: PATIENT IS TO WEAR CERVICAL COLLAR AT ALL TIMES UNTIL FOLLOW UP W/ DR. XXX IN CLINIC .....Instructions were given to caretaker, ... follow up and referral plans ... USE OF C COLLAR Demonstrated understanding of instructions ...09:08 REPORT GIVEN TO (staff #16) RN ALLEGIANCE BEHAVIOR HEALTH."

Further review of patient #9's record revealed NO documentation of a follow up visit with the neurosurgeon 1-2 days after the 2/7/17 ER visit. The RN failed to assess the patient's need for follow up care post fall and spinal fracture which, resulted in discomfort for the patient due to the cervical collar remaining on him for over 7 days.

An interview and record review conducted on 2/14/17, with staff #3, confirmed the above findings. Staff #3 was unaware that patient #9 was supposed to follow up with the neurosurgeon after the 2/7/17 post fall ER visit.

An interview was conducted on 2/14/17, with patient #9's nurse at the patient's bedside. Patient #9 was observed wearing a cervical collar. The surveyor asked the nurse why the patient had been wearing the collar for so long (since 2/7/17), and she stated, "I'm not sure. I know he fell about a week ago and has a fracture." The patient's skin on left side below the collar was observed with 2 reddened areas where the collar contacted the skin.


A review of the facility's policy titled, "RISK MANAGEMENT PROGRAM", revealed the following information:

" ...DEFINITIONS: ...
B. Incidents include but are not limited to, the following:
...1. Physical harm to patients, visitors, staff, students, etc.
...14. Falls ...

PROCEDURE:
A. Any person who discovers or observes an incident/variance, is to direct the completion of an incident report. This must be completed by the end of the shift on which the event takes place.
This report must be forwarded to the appropriate Department Director for recommendations and actions to be taken. Once the report is completed by the appropriate department manager, the report is forwarded to the Director of Risk Management within 24 hours of the incident/variance ...."

Based on record review and interview, nursing staff failed to update the Treatment Plan and Problem List with medical problems identified throughout the patients' stay in 4 (Patient #s, 1, 10, 12, and 19) of 5 patients reviewed(Patient #s, 1, 10, 12, 18, and 19).


Review of Patient #1's chart revealed the patient had fallen twice. The patient had skin tears. Review of the Treatment Plan and Problem List show that the only medical problem listed was "3a: Gate Disturbance as Evidenced by Unsteady Gate." The problem list did not identify Skin Integrity or Risk of Infection due to skin tears as a problem.


Review of Patient #10's chart revealed the patient had elevated lab findings related to kidney function requiring intravenous (IV) fluids. The patient had syncope (loss of consciousness), nausea, vomiting, and liquid bowel movements. The patient had a urinary tract infection (UTI) and was on antibiotics. The only two medical problems listed on the Treatment Plan Problem List in the chart were 3a: Gait Disturbance as Evidenced by Unsteady Gate; and 3i: Dysuria, altered LOC (level of consciousness) a/w (associated with) UTI as evidenced by UTI." The Treatment Plan Problem List did not address nausea, vomiting, or diarrhea or the need for IV fluids due to abnormal labs in the treatment plan.


Review of Patient #12's chart revealed the patient had multiple cuts to both feet. Patient #12 had made the cuts himself in a suicide attempt. The patient had stitches in his feet. The wounds required bandages be changed regularly. The wounds became infected and required antibiotics. The patient had difficulty managing the pain from the wounds. The patient was diabetic and had elevated blood sugar levels during his stay. Review of the Treatment Plan and Problem List show that the only medical problem listed was "3a: Gate Disturbance as Evidenced by Unsteady Gate." The Treatment Plan Problem List did not address Wounds, Wound Care or the Wound Infection.


Review of Patient #19's chart revealed the patient had abnormal lab values for the potassium level and hemoglobin A1C (an indicator of blood sugar control) that resulted in new orders for medication and monitoring. The patient had a nutrition assessment with specific interventions recommended. The only two medical problems listed on the Treatment Plan Problem List in the chart were 3a: Gait Disturbance as Evidenced by Unsteady Gate; and 3i: Dysuria, altered LOC (level of consciousness) a/w (associated with) UTI as evidenced by UTI Upon Admission." The Treatment Plan Problem List did not include the Electrolyte Imbalance (low potassium), Diabetes, or Dietary needs.


An interview was conducted with Staff #3. Staff #3 confirmed that the nursing plan of care is integrated with the interdisciplinary plan of care.


An interview was conducted with Staff #28. Staff #28 stated the nursing plan of care is found with the master treatment plan and new problems are updated for treatment team.


Review of "Assessment and Reassessment of Patient" policy number CS2-01 was as follows:

"Page 2 of 2
6. Reassessment
i. Reassessment of the patient shall occur PRN and each time there is a change in the patient's condition.
ii. Nursing shall reassess the patient on a per shift basis.

7. Reassessment by all disciplines caring for the patient will occur on an ongoing basis throughout the patient stay. Changes in condition and progress in recovery will be documented in the patient medical record. Changes in the plan of care and treatment will be documented accordingly."


Review of Standards of Patient Care Policy #CS1-3 was as follow:

"CARE MANAGEMENT PROCESS
Standard of Care I: A systematic collection of data regarding his/her health status will be performed. This data collection will be performed on admission and daily throughout the hospital stay. The data collection will be documented and communicated to the interdisciplinary care team.

1. An appropriate head to toe assessment will be completed upon admission.

2. Data elements are obtained from family/patient interview, observation, patient assessment, examination and review of previous medical record.

3. Reassessments will be performed daily.

4. Data collection includes:
(a) Biophysical
(b) Psychosocial
(c) Environmental
(d) Self care needs
(e) Educational needs
(f) Discharge planning

5. Ongoing health status data is collected daily and includes:
(a) Status of physiologic parameters
(b) Emotional status
(c) Response to medical and nursing interventions
(d) Educational needs and responses
(e) Performance of activities of daily living
(f) Patient's perception of his health status
(g) Patient's health goals
(h) Patterns of coping
(I) Environment (physical, social, emotional)
(j) Relationship with family as it relates to health status

6. New health status data is incorporated into the interdisciplinary plan of care.

7. Deviations from the patient's norm are brought to the physician's attention.


Standards of Patient Care II: Patient problems/needs will be identified based on the data collected. A plan of care will be established from these identified needs.

1. An appropriate plan of care will be initiated upon admission.

2. Expected outcome/goals are established based on problems/needs identified.

3. Expected outcome/goals are realistic and are stated in observable, measurable terms.

4. The expected outcomes/goals are achievable within an identified time frame.

5. Goals are established with the patient and/or significant others.

6. Problems/needs and goals are congruent with the medical plan of care.

7. Reassessment of problems/needs and goals are performed daily and whenever warranted by a change in the patient's condition.


Standard of Care III: An appropriate plan of care with prescribed interventions to achieve the expected outcome/goals and to maximize health capabilities will be initiated for each patient.

1. The plan of care includes relevant physiological and psychological measures specific to the patient's current problems/needs and goals.

2. The plan of care specifies appropriate interventions.

3. The plan of care will be reassessed daily and whenever warranted by a change in patient's condition.

4. Interventions are based on current scientific knowledge.

5. The plan of care is developed in collaboration with the patient and/or significant others, and all pertinent members of the interdisciplinary team.


Standards of Patient Care IV: The prescribed plan of care will be implemented and documented along with the patient's response to the care."

Based on record review, observation, and interview, Nursing Services failed to assign qualified staff to patient assignments on 2 (12-8-2016 and 2-14-2017) out of 10 days reviewed.


A review of staffing on the Acute Unit for the 12-8-2016 revealed that one employee was assigned to the unit. The employee training file for the nurse assigned (Staff #37) revealed she had not been oriented to the unit and did not have Satori Alternative to Managing Aggression (SAMA) training.


A telephone interview was conducted with Staff #37 was conducted. Staff #37 stated she had not been oriented to the floor or the paperwork required for admission of a patient to the Acute Unit. Staff #37 confirmed she had not had SAMA training.


An Interview was conducted with Staff #3. Staff #3 stated he showed her where everything was when they went to the floor together. Staff #3 stated he explained the paperwork to her. Staff #3 confirmed that Staff #37 had never worked that floor before and had only worked PRN (as needed) on the Behavioral Unit. Staff #3 confirmed that Staff #37 was left as the only nurse on the floor with one Mental Health Technician (MHT) and one patient.


On 2-14-2017, a nursing student (Staff #29) was observed following a patient (Patient #20) in the hallway. Patient #20 appeared to be agitated. When the nursing student returned, she was without the patient. When asked what had happened, the student stated that the MHT (Staff #30) had left her (Staff #29) with the patient. Staff #29 stated Staff #30 had to leave the floor, but had just returned and took over care of the patient. Staff #29 stated she was a nursing student performing clinicals for her nursing class. When asked if she was allowed to chart her observations and care of the patient, Staff #29 stated, "No, I can't write in the patient chart." When asked how long she had been alone with the patient, Staff #29 stated, "No more than 20 minutes.


Interview was conducted with Staff #28, the Charge Nurse. Staff #28 stated she had no idea that Staff #30 had left the floor and delegated her assignment to a student.

Interview was conducted with Staff #30. Staff #30 confirmed that she had left the student with the patient and had not notified the Charge Nurse. Staff #30 stated she was only gone for about 15 minutes.

Review of the Patient #20's chart revealed the physician had ordered special precautions for being aggressive. Staff #29 stated she had not had training to manage aggressive patients.

Based on observation and interview, Medical Record Services failed to store patient records in a manner that protected them from water damage in 4 out of 4 (3 separate room on the first floor across from Medical Records Office and in the attic) storage areas toured.


On 2-13-2017, a tour of medical records storage areas was conducted with Staff #2, Staff #7, and Staff #12. The medical records observed in all four areas were stored on open shelving, and on the floor or pallets in cardboard boxes. The building was protected with sprinkler system. There were approximately 398 boxes of records with approximately 12 records per box in one section of the attic. Three boxes close to the attic door were found to have water damage that had seeped into the records.


An interview was conducted with Staff #12. Staff #12 was asked why boxes were stored on the floor and unprotected from water. Staff #12 stated, "Because I don't have anything to put them on or anywhere else to put them."

Based on observation, interview, and record review, Medical Record Services failed to protect patient records from unauthorized access in 2 out of 4 (1 storage room on the first floor across from Medical Records Office and in the attic) storage areas toured.


On 2-13-2017, a tour of medical records storage areas was conducted with Staff #2, Staff #7, and Staff #12. In the room across from the Medical Records office, 8 boxes of records with approximately 15 charts per box were found. In the bathroom area, patient records of charges from January through May 2015, January through May 2014, and June through December 2014 were found. This room was also being used to store equipment used by the nursing department for Basic Life Support training. Staff #2 and Staff #7 had keys to the room. Nursing Staff and Maintenance Staff had keys to the room. Medical records staff did not. This was confirmed by interview with Staff #2, Staff #7, and Staff #12.


There were approximately 398 boxes of records with approximately 12 records per box in one section of the attic. The storage area in the attic was also a maintenance work area. Medical records were accessible to all maintenance staff. This was confirmed by interview with Staff #7.


Review of General Policies, Policy: CS9-08 was completed as follows:


"POLICY:
The Health Information Management Department shall he responsible for maintaining an accurate and complete health record in accordance with state and federal laws and licensing and accrediting agency regulations For every patient admitted to ALLEGIANCE SPECIALTY HOSPITAL OF KILGORE.


CONFIDENTIALITY:
All health records and the information contained therein shall be protected against unauthorized access or use.

1. ONLY authorized individuals shall be permitted access to the health record.

2. Health information shall be released ONLY on written authorization of the patient or his/her legal representative.

3. Health records should NOT be removed from the hospital premises except upon receipt of a court order, subpoena duces tecum or statute."



Review of Security of Medical Records, Policy CS9-14 was completed as follows:


"POLICY:

The Health Information Management Department in conjunction with Hospital Administration shall set up policies to safeguard the health record and its informational content against loss, defacement and tampering or review by unauthorized individuals.


PROCEDURE:

...
5. HIM personnel shall be the only employees permitted access to the permanent file area."

Based on record review and interview, Medical Records Services failed to ensure entries into the medical records were complete with patient identifying information, signatures, dates and times, and legible in 5 out 5 charts reviewed (Patient #s 1, 10, 12, 18, and 19).


Review of Patient #1's chart was conducted. A Consent to Treat with Psychoactive Medication signed on 2-15-2016 was found without a patient label. The only patient identifier on the page was the patient's last name. The MHT Care and Observation Flowsheet for 2-25-2016 had information written over in the "Every 15 Minute Direct Observation of Patient Clinical and Location Status" section, making it illegible


Review of Patient #10's chart was conducted. A form titled Imminent Danger Risk Assessment was completed on 11-30-2016. Page 2 and 3 of the form did not have patient labels. The only patient identifier on these pages was the patient's last name and first name initial. The Pre-Admission Screening form, Page 4 of 4 was signed and dated, but not timed. A Consent to Treat with Psychoactive Medication dated 12-7-2016 did not have a patient label. The only patient identifier on this form was the patient's last name. A Consent to Treat with Psychoactive Medication was found in the chart without a date or time for the Patient or Nurse's signature block. The physician's signature block was dated 11/30/2016 at 1130. The Psychiatric Evaluation, Pages 2 and 3 did not have patient labels or any patient identifiers on them.


Review of Patient #12's chart was conducted. Allegiance Specialty Hospital of Kilgore Statement That You Have Received "Handbook of Consumer Rights for Mental Health Services" did not have a patient label or any patient identifying information on it. In the patient signature block, it read, "pt refused to sign d/t confusion" and was dated 1/30/2017. Form titled, "Patient gives permission for these significant others to have information during the patient stay." did not have a patient label or any patient identifying information on it. In the patient signature block, it read, "pt refused to sign d/t confusion" and was dated 1/30/2017.Form titled Consent for Use of Telemedicine did not have a patient label or any patient identifying information on it. In the patient signature block, it read, "pt refused to sign d/t confusion" and was dated 1/30/2017. Physician Progress Notes from 2-7-2017, 2-8-2017, and 2-9-2017 did not have labels. The only patient identifier on each form was the patient's last name. A Consent to Treat with Psychoactive Medication dated 2-3-2017 did not contain the signature, date, and time of the treating physician at the time the chart was reviewed on 2-14-2017. Three Consents to Treat with Psychoactive Medication dated 2-2-2017 did not contain the signature, date, and time of the treating physician at the time the chart was reviewed on 2-14-2017. The MHT Care and Observation Flowsheet for 2-9-2017 and 2-10-2017 had information written over in the "Every 15 Minute Direct Observation of Patient Clinical and Location Status" section, making it illegible.



Review of Patient #18's chart was conducted. The Psychiatric Progress Note Page 2 of 2 was dated 2-14-2017, but not timed.


Review of Patient #19's chart was conducted. The Psychiatric Progress Note Page 2 of 2 was dated 2-13-2017, but not timed. Physician Progress Notes dated 2-8-2017 and 2-9-2017 did not have labels on them. The only patient identifier was the patient's last name. The Psychiatric Evaluation dated 2/6/2017, pages 1 through 6, did not have a label or any patient identifying information on any of the pages. Two Consents to Treat with Psychoactive Medication dated 2-5-2017 did not contain the signature, date, and time of the treating physician at the time the chart was reviewed on 2-14-2017. Two Consents to Treat with Psychoactive Medication dated 2-9-2017 were signed and dated in the treating physician's box, but not timed.


A review of the instruction on the Consents to Treat with Psychoactive Medication showed that "Signature of Treating Physician (required within 2 working days of RN / LVN explanation)"


A review of Allegiance Specialty Hospital Authentication of Records, Policy: CS9-02 was completed as follows:

"All entries in the health record shall be dated and when necessary (i.e. evaluations, assessments, progress notes, etc.) shall be authenticated promptly by the person who is responsible for ordering, providing or evaluating the service furnished. The individual shall be identified by name and discipline. Indications of authentication may include written signatures or initials, rubber stamps or computer key/entry."


A review of Allegiance Specialty Hospital Documentation Guidelines, Policy: CS9-07 was completed as follows:

"CORRECTIONS:
To make a proper correction, utilize the following procedure:
1. Draw a single line through the error
2. Make the necessary correction.
3. Initial and date the correction.

...

LEGIBILITY:
The health record is considered a legal document, therefore, it is important that you document legibly for medicolegal purposes, for compliance with JCAHO and DHH standards and for effective continuity of patient care. "

Interview was completed with Staff #28. Staff # 28 stated that records needing signatures, dates and times are flagged, "But, it's hard to catch everyone. Especially when the Psychiatrist only comes once a week."

Based on record review and interview, Medical Records Services failed to ensure the physician authenticated telephone orders within 48 hours of dictating the telephone order in 4 (Patient #s, 1, 10, 12, and 19) out 5 charts reviewed (Patient #s, 1, 10, 12, 18, and 19).


Review of Patient #1's chart was conducted. Findings were as follows:


On 2-11-2026 at 11:00 AM, a telephone order was written by the nursing staff for medication. The order was dictated by Staff #39 and authenticated on 2-16-2016 at 11:30 AM.


On 2-27-2016 at 9:27 AM, a telephone order was written by the nursing staff for medication. The order was dictated by Staff #24 and never authenticated.


On 2-29-2026 at 1:59 PM, a telephone order was written by the nursing staff for medication. The order was dictated by Staff #38 and authenticated on 3/30/2016 at 9:00 AM.



A review of Patient #10's chart was conducted. Findings were as follows:


On 12-1-2016 at 4:30 PM, a telephone order was written by the nursing staff for court commitment. The order was dictated by Staff #8. Staff #8 signed the order, but did not date or time it.


On 11-29-2016 at 4:00 PM, a telephone order was written by the nursing staff for medications. The order was dictated by Staff #8. Staff #8 signed the order, but did not date or time it.


On 11-29-2016 at 3:20 PM, a telephone order was written by the nursing staff for medications. The order was dictated by Staff #8. Staff #8 signed the order, but did not date or time it.


On 11-29-2016 (was not timed), a telephone order was written by the nursing staff for medications. The order was dictated by Staff #24. Staff #24 signed and dated the order, but did not time it.



A review of Patient #12's chart was conducted. Findings were as follows:

On 2-1-2017 at 9:30 PM, a telephone order was written by the nursing staff for medications. The order was dictated by Staff #26. Staff #26 never authenticated the order.


On 2-3-2017 at 4:00 PM, a telephone order was written by the nursing staff for wound care. The order was dictated by Staff #26. Staff #26 never authenticated the order.


On 2-8-2017 at 3:57 PM, a telephone order was written by the nursing staff for medications. The order was dictated by Staff #24. Staff #24 never authenticated the order.


On 2-11-2017 at 5:10 PM, a telephone order was written by the nursing staff for medications and contact isolation precautions. The order was dictated by Staff #23. Staff #23 signed the order, but did not date or time it.



A review of Patient #19's chart was conducted. Findings were as follows:

On 2-5-2017 at 10:50 AM, a telephone order was written by the nursing staff for patient admission. The order was dictated by Staff #22. Staff #22 never authenticated the order.


On 2-9-2017 at 2:26 PM, a telephone order was written by the nursing staff for medications. The order was dictated by Staff #8. Staff #8 signed the order, but did not date or time it.



Review of the Allegiance Specialty Hospital of Kilgore Medical Staff Rules and Regulations was completed as follows:

"k. All orders for treatment shall be in writing, timed, and dated and then signed by the physician. Verbal orders shall be considered to be in writing if dictated to a registered nurse, pharmacist, respiratory therapist, and dietician. The person to whom dictated and the name of the physician giving the orders documented shall sign such orders. The physician that gave the verbal order shall authenticate such orders at the next visit, within forty-eight (48) hours, by dated and timed signature. Verbal orders should be used sparingly.


Interview was conducted with Staff # 28. Staff #28 stated that charts are flagged for the physicians and nurse practitioners to sign their telephone orders. When asked why some orders in the open charts were authenticated and some not authenticated, Staff #28 stated, "I don't know why. Sometimes it's hard to get the psychiatrist (Staff #22) to sign her orders because she only comes in on Fridays. I don't know about the rest of them."

Based on record review, Medical Records Services failed to ensure the History and Physical (H&P) or H&P addendum was completed within 24 hours of admission in 2 (Patient #s 18 and 19) of 5 charts reviewed (Patient #s 1, 10, 12, 18, and 19).



A review of Patient #18's chart was completed on 2-14-2017 as follows:


Patient #18 was admitted on 2-12-2017. The chart contained an H&P that had been dictated by Staff #24 on 1-21-2017 from a previous admission to the hospital. The dictated copy had blanks where the transcriptionist was not able to understand the dictation. These blanks had not been filled in with corrections. The dictated copy of the H&P was not authenticated with Staff #24's signature date and time. There was not an addendum to the H&P found in the chart showing that a physician had reviewed the H&P.


A review of Patient #19's chart was completed on 2-14-2017. Patient #19 was admitted on 2-5-2017. No H&P was found on the chart.


Review of the Allegiance Specialty Hospital of Kilgore Medical Staff Rules and Regulations was completed as follows:


"d. Within sixty (60) hours of admission, the admitting physician must complete a psychiatric evaluation in the patient's medical record, justifying admission criteria. Within twenty-four (24) hours of admission, a history and physical must be completed, documented and in the medical record; however if a history and physical was completed within the last 30 days of admission, the physician may review it and document an addendum within the first 24 hours of admission. "

Based on record review and interview, Medical Records Services failed to ensure that consultative records were documented and placed in the records for 20 out of 20 patients reviewed (Patient #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21).


Review of the medical charts listed above was completed. No documentation of telemedicine notes were found.


Interview was conducted with Staff #2. When asked why the psychiatrist only sees patients once a week, Staff #2 explained that the psychiatrist sees the patients several times during the week via telemedicine (the physician assesses the patient remotely by camera on the computer or other electronic means). When asked why there weren't any telemedicine notes in the chart, Staff #2 stated, "I don't know."


32143


Interview was conducted with Staff #8. Staff #8 was questioned as why she was admitting patients without the psychiatrist seeing and evaluating the patients except on Fridays. Staff #8 stated she did consult with the psychiatrist via telemedicine with the patient present. Staff #8 reported that it was in her scope of practice to diagnosis and see the patients. Staff #8 stated, " I did not know that the medical by-laws did not address telemedicine. The psychiatrist is called about the admissions and gives approval to admit. I know she has seen patients by telemedicine but I am not writing the physicians reports."


An interview was conducted with staff #22 on 2/23/17 at 1:13PM. Staff #22 confirmed the use of telemedicine. Staff #22 stated, "I was not aware the use of telemedicine was not in the bylaws." Staff #22 reported that telemedicine was used and the nurses were to put in the notes that the patients were seen by staff #22 via telemedicine. Staff #22 confirmed she did not write the consultative notes when using telemedicine.


Review of staff #22's credentialing file revealed there was no mention of telemedicine in the "delineation of privileges" section in the credential file or as an addendum.


An interview was conducted with staff #1 and #2 on 2/16/17 concerning telemedicine. Staff #1 and #2 confirmed staff #22 was seeing patients via telemedicine. Staff #1 confirmed the bylaws for Governing Body, Medical Staff Bylaws and Rules and regulations were the most current and no addendums were offered upon request.


Review the "Allegiance Specialty Hospital of Kilgore Medical Staff Rules and Regulations" was completed. Nothing was found that authorizes or addresses telemedicine.

Based on document review and interview, the facility failed to ensure the Utilization Review Committee included at least two physicians.


A review of the facility's "Utilization Review/Case Management/RAC Committee" meeting minutes dated 1/20/17 and 1/27/17, revealed the committee did not include two physicians. The only physician on the committee was the Utilization Review Medical Director, staff #22.


An interview conducted on 2/16/17, with staff #6, confirmed the Utilization Review Committee did not include two physicians.

Based on observation and interview, the facility failed to maintain the physical environment to ensure the safety of patients, staff and visitors.


During a tour of the facility on 2/13/17, the following observations were made:


The inside of a under sink cabinet in a patient bathroom/shower area on the Behavioral Health Unit was observed to have cracked, stained and molded laminate/wood and 2 large holes in the cabinet walls.


Flooring in a hallway on the first floor had multiple tears that appeared to have been waxed over.


A broken plastic electrical socket plate cover with sharp jagged edges was observed in a patient room on the Behavioral Health Unit.


Multiple patient beds were observed with broken plastic footboards in the Behavioral Health Unit.


A wheelchair being used by a patient on the Behavioral Health Unit was observed to have torn vinyl and foam on both arm supports.


An interview conducted on 2/13/17, with staff #7, confirmed the above findings. Staff #7 also confirmed, the facility's Environment of Care Committee members had conducted environmental rounds periodically but, had not observed the above findings.

Based on record review and interview, the facility failed to ensure the Infection Control Officer received the appropriate training to oversee the Infection Control Program.


A review of the employee record for the Infection Control Officer, staff #4, revealed staff #4 had NOT received any Infection Control (IC) training/education.


An interview conducted on 2/15/17, with staff #4, confirmed the above findings. Staff #4 informed surveyors she was a Licensed Vocational Nurse (LVN) and started working at the facility in August 2016. Staff #4 was questioned if she had obtained any IC experience from her previous nursing employement, she had not. Staff #4 informed surveyors she planned to receive education/training in IC once the facility's Administration approved for her to do so.

Based on review of records and interview, the hospital failed to keep current and implement policies and procedures related to Organ Procurement responsibilities in 1 of 1 policies reviewed.

A review of hospital policy table of contents revealed only one policy related to Organ and Tissue Procurement, Policy Number CS6-07. The policy was as follows:

"PURPOSE
1. To establish guidelines for identification and referral of potential organ and tissue donors.
2. To inform the appropriate family member(s) or other person (so) of the option to donate.
3. To comply with federal and state laws that have been established for organ and tissue donation.

DEFINITIONS

"Organ" includes human heart, lungs, liver, kidneys, pancreas, and small bowel. These organs are recovered from cadaver donors where brain death has occurred and when physiologic support (respiration and circulation) is maintained.

'Tissue" includes human eyes, corneas, skin, heart valves, saphenous veins, connective tissue, and bone. Tissue is recovered following the cessation of cardiopulmonary function.

"Imminent Death" for organ donation referral is defined as: A patient with acute brain injury and (1) who requires mechanical ventilation; and (2) is in an Intensive Care Unit (ICU)or Emergency Department (ED) and (3) has clinical findings consistent with a Glascow Coma Score of 4 or less; or (a) for whom physicians are evaluating a diagnosis of brain death; or (b) for whom a physician has ordered that the sustaining procedures be withdrawn, pursuant to the family's decision, Imminent death also includes the initial evaluation of brain death.

POLICY

1. Allegiance Specialty Hospital (ASH) documents and honors the wishes of patients concerning organ donation within the limits of the law and hospital capacity.
2. ASH endorses organ, eye, and tissue donation for transplantation a) and Southwest Transplant Alliance is notified in a timely manner of individuals whose death is imminent or who have died.
3. The hospital works with STA in educating staff on donation on donation issues.
4. ASH works with STA in reviewing death records to improve identification of potential donors.

IDENTIFICATION AND REFERRAL OF POTENTIAL ORGAN/TISSUE DONORS

NOTE: Organ donation requires pronouncement of brain death as well as oxygenation and perfusion of all vital organs up to the time of actual recovery. If tissue donation is occurring without organ donation, oxygenation and perfusion of organs are not required. All individuals who are pronounced dead (including stillborns>20 weeks gestation), either by cessation of cardiopulmonary function or by brain death criteria, are referred to STA's.

If the patient is deemed medically unsuitable for donation following initial screening by referral line coordinators, the family will not be provided the option of tissue.
A. Referrals for potential organ donation will occur in a timely manner, at or near the time of brain death, regardless of age or medical history.
a. Medical suitability for organ donation is determined, by the referral line coordinators after consultation with transplant physicians.
B. Referrals regarding potential tissue only donation will occur at or near the time of cessation of cardiopulmonary function, regardless of age or medical history, by calling the referral lines.

NOTE: Initial contact should be made prior to death, if at all possible, in order to facilitate evaluation and request for donation.

C. The referral call may be placed by the Charge Nurse on the unit in cooperation with the House Supervisor, or the Chief Nursing Officer as applicable. When calling a referral, refer to the Routine Death Notification Guide in order to have appropriate information available. All referrals will be noted on the routine Death Report/Authorization for Release.

PROVIDING THE OPTION OF ORGAN AND TISSUE DONATION

ASH ensures, in collaboration with STA, that the family of each potential donor is informed of its option to donate organs, tissues, or eyes. The individual designated by the hospital to initiate the request to the family must be an organ procurement representative or a designated requester.
NOTE: (1) A designated requester is an individual who has completed a course offered or approved by the OPO and designed in conjunction with the tissue and eye bank community in the methodology of approaching potential donor families and requesting organ or tissue donation.
(2) House Supervisors will be designated requesters at ASH for tissue and organ donation. All requests for organ donation will be made by a STA representative.

A. ORGAN DONATION

B. TISSUE DONATION"


Staff #1 and 3 were interviewed on 2-16-2017 about the Organ Procurement policy.

Staff #3 was asked who the contracted Organ Procurement Organization (OPO) was and how a referral was made. Staff #3 stated he did not know; and "I would have to refer to the policy." When asked what number to call, Staff #3 stated, "I would have to refer to the policy." Staff #3 was advised that the policy stated the OPO was Southwest Transplant Alliance (STA), but that was not who the hospital was contracted with. Staff #1 stated that STA was their current OPO.

The date of the last review of the policy was 10/2012. A contract was reviewed that showed in 2014 a contract for organ and tissue procurement was executed with The University of Texas Southwestern Medical Center Transplant Services Center (UT Southwestern TSC).

Staff #1 or #3 were unable to provide any protocols for referring or contacting UT Southwestern TSC. Staff #1 stated, "We don't have anyone ever die here so we haven't needed it."

Based on review of records and interview, the hospital failed to conduct training, in conjunction with the contracted Organ Procurement Organization (OPO) related to Organ Procurement, with all hospital staff.


A review of hospital policy table of contents revealed only one policy related to Organ and Tissue Procurement, Policy Number CS6-07. The policy was as follows:

"PURPOSE
1. To establish guidelines for identification and referral of potential organ and tissue donors.
2. To inform the appropriate family member(s) or other person (so) of the option to donate.
3. To comply with federal and state laws that have been established for organ and tissue donation.

DEFINITIONS

"Organ" includes human heart, lungs, liver, kidneys, pancreas, and small bowel. These organs are recovered from cadaver donors where brain death has occurred and when physiologic support (respiration and circulation) is maintained.

'Tissue" includes human eyes, corneas, skin, heart valves, saphenous veins, connective tissue, and bone. Tissue is recovered following the cessation of cardiopulmonary function.

"Imminent Death" for organ donation referral is defined as: A patient with acute brain injury and (1) who requires mechanical ventilation; and (2) is in an Intensive Care Unit (ICU)or Emergency Department (ED) and (3) has clinical findings consistent with a Glascow Coma Score of 4 or less; or (a) for whom physicians are evaluating a diagnosis of brain death; or (b) for whom a physician has ordered that the sustaining procedures be withdrawn, pursuant to the family's decision, Imminent death also includes the initial evaluation of brain death.

POLICY

1. Allegiance Specialty Hospital (ASH) documents and honors the wishes of patients concerning organ donation within the limits of the law and hospital capacity.
2. ASH endorses organ, eye, and tissue donation for transplantation a) and Southwest Transplant Alliance is notified in a timely manner of individuals whose death is imminent or who have died.
3. The hospital works with STA in educating staff on donation on donation issues.
4. ASH works with STA in reviewing death records to improve identification of potential donors.

IDENTIFICATION AND REFERRAL OF POTENTIAL ORGAN/TISSUE DONORS

NOTE: Organ donation requires pronouncement of brain death as well as oxygenation and perfusion of all vital organs up to the time of actual recovery. If tissue donation is occurring without organ donation, oxygenation and perfusion of organs are not required. All individuals who are pronounced dead (including stillborns>20 weeks gestation), either by cessation of cardiopulmonary function or by brain death criteria, are referred to STA's.

If the patient is deemed medically unsuitable for donation following initial screening by referral line coordinators, the family will not be provided the option of tissue.
A. Referrals for potential organ donation will occur in a timely manner, at or near the time of brain death, regardless of age or medical history.
a. Medical suitability for organ donation is determined, by the referral line coordinators after consultation with transplant physicians.
B. Referrals regarding potential tissue only donation will occur at or near the time of cessation of cardiopulmonary function, regardless of age or medical history, by calling the referral lines.

NOTE: Initial contact should be made prior to death, if at all possible, in order to facilitate evaluation and request for donation.

C. The referral call may be placed by the Charge Nurse on the unit in cooperation with the House Supervisor, or the Chief Nursing Officer as applicable. When calling a referral, refer to the Routine Death Notification Guide in order to have appropriate information available. All referrals will be noted on the routine Death Report/Authorization for Release.

PROVIDING THE OPTION OF ORGAN AND TISSUE DONATION

ASH ensures, in collaboration with STA, that the family of each potential donor is informed of its option to donate organs, tissues, or eyes. The individual designated by the hospital to initiate the request to the family must be an organ procurement representative or a designated requester.
NOTE: (1) A designated requester is an individual who has completed a course offered or approved by the OPO and designed in conjunction with the tissue and eye bank community in the methodology of approaching potential donor families and requesting organ or tissue donation.
(2) House Supervisors will be designated requesters at ASH for tissue and organ donation. All requests for organ donation will be made by a STA representative.

A. ORGAN DONATION

B. TISSUE DONATION"

Review of the Policy did not address the OPO providing regularly scheduled training.

Staff #1 and 3 were interviewed on 2-16-2017 about the Organ Procurement policy.

Staff #3 was asked who the contracted Organ Procurement Organization (OPO) was and how a referral was made. Staff #3 state he did not know; and "I would have to refer to the policy." When asked what number to call, Staff #3 stated, "I would have to refer to the policy." Staff #3 was advised that the policy stated the OPO was Southwest Transplant Alliance (STA), but that was not who the hospital was contracted with. Staff #1 stated that STA was their current OPO.

The date of the last review of the policy was 10/2012. A contract was reviewed that showed in 2014 a contract for organ and tissue procurement was executed with The University of Texas Southwestern Medical Center Transplant Services Center (UT Southwestern TSC).

When asked if the OPO ever provided training to the staff, Staff #3 replied, "No." Staff #3 confirmed that the hospital did not provide training on organ and tissue donation.

Based on document review and interview, the facility failed to appoint a physician to serve as the Director of Respiratory Services.


A review of the facility's organizational chart revealed the facility did not have a documented Director of Respiratory Services.


An interview conducted on 2/16/17, with staff #2, confirmed the facility did provide respiratory services but, did not have a Director of Respiratory Services.