HospitalInspections.org

Based on record review and interview, the facility failed to ensure adolescent patients were provided a safe setting for receiving medications for 2 of 6 patients (#1 and #6 ) reviewed as evidenced by:

-Patient #1 had two incidents in two admissions of stating she had overdosed on medications she and other adolescents had cheeked during medication administration. Neither of these incidents were investigated and nothing had been put in place to ensure adolescents were swallowing their medications.

-Patient #6 was a current patient who had been found to be cheeking medications on 3/17/15 and had them in her pocket. No incident report or investigation had been initiated by 3/19/15 for the occurrence within the time frame established by the facility's Policy and Procedure (P&P).

Complaint #TX00211163

Findings include:

Patient #1

Record review of Patient #1's closed medical record revealed she was a 16 year old female admitted on 11/16/14 to the adolescent unit for Major Depressive Disorder (MDD) without psychotic behavior. The patient had run away from a Residential Treatment Center (RTC) and was sexually assaulted several times while under the influence of drugs and alcohol.

Record review of Patient #1's Discharge Summary dated 11/28/14 revealed the patient had been discharged to a medical/surgical hospital because of a drug overdose while at the facility.

Record review of the patient's Occurrence Report Form dated 11/27/14 at 3:05 a.m. revealed the category of the occurrence was Medication - Drug reaction or toxic effect. The patient was transferred to the ER (Emergency Room). Under Corrective Actions Taken, nothing was checked. Under Comments in that section was a hand written reiteration of what the patient did. The handwriting appeared to be by the RN who filled out the form, RN (Registered Nurse) #21.

Interview on 3/18/15 at 3:05 p.m. with Director of Risk Management #4 revealed on 11/27/14 the patient told staff she had been hiding and hoarding her own and other patients' medications. She said she had 15 pills. The patient said she crushed some of the pills and snorted them and ingested the rest. When asked if there was an investigation into the incident, she said the incident happened at the time she started working at the facility. She said there was no investigation that she knew of. She said RN #21 was not an active employee anymore.

Record review of Patient #1's closed medical record revealed she was re-admitted on 11/29/14 to the adolescent unit for Major Depressive Disorder (MDD) without psychotic behavior.

Record review of Patient #1's Mode of Transportation (MOT) Physician Note dated 11/29/14 revealed her chief complaint was suicidal attempt (SA) and suicidal ideation (SI). Her past psychiatric history revealed she had SA/SI 14 times by overdosing, self mutilation and self injury behaviors (tried to set self on fire) with multiple inpatient psychiatric hospitalizations.

Record review of Patient #1's Physician's Orders dated 12/1/14 revealed an order to observe the patient swallow medications.

Record review of Patient #1's Occurrence Report Form dated 12/5/14 at 2:00 p.m. revealed the patient stated that she overdosed on her medication. Under Corrective Actions Taken a check mark was in the box for In-service education. Under Comments there was a hand written note the patient was transferred to (Hospital #1) ER for evaluation. It was signed by Director of Risk Management #4.

Record review of a hand written statement by LVN (Licensed Vocational Nurse) #25, attached to the Occurrence form, revealed the patient told her she had overdosed on her night medications. She told the LVN the medication was Tylenol. When the LVN told Patient #1 that her night medication had been Risperdal, the patient stated she had taken about 18 pills that she got from offering sexual favors and money once she was discharged. The patient would not reveal who she got medications from. The patient was sent out to the hospital.

Interview on 3/19/15 at 8:45 a.m. with Director of Risk Management #4, she was asked if any investigation had been done for either of Patient #1's allegations of overdosing on saved medications from the facility. She said she did not know of any investigations. She was asked if any in-services had been done. She said she did not know. At 9:20 a.m. she was asked for the Policy and Procedure (P&P) for Investigating Occurrences and Medication Administration.

Patient #6

Record review of Patient #6's active medical record revealed she was a 13 year old female admitted to the adolescent unit on 3/15/15 with diagnoses of Depression and Bipolar disorder. She was admitted for assaulting her mother and anger management.

Record review on 3/18/15 of Patient #6's Nurses' Note dated 3/17/15 revealed the patient was found to be "cheeking her meds by sucking her thumb & sliding her meds into other hand. Pt had med in her pocket they fell out while she was rolling on floor. pt says she doen't (sic) need any meds. pt destroying her room, not following staff direction, pulling mattresses in hallway, argumentative, agitated defiant." Her physician was called and he ordered Benadryl and Thorazine to be given IM (intramuscular) now at 10:20 p.m. The patient was asleep by 11:30 p.m.

Record review of Patient #6's MAR (Medication Administration Record) revealed on 3/17/15 her medications for 9:00 p.m. were fish oil and Depakote 500 mg, two tablets by mouth.

During an interview on 3/19/15 at 2:00 p.m. with Director Risk Management #4, she was asked if she had received an Occurrence Report form for Patient #6. She said she had not received any form. When she was informed the patient had cheeked medications and they were found fall out of her pocket, she said there was no place on the occurrence form for medications not being taken. She said she guessed they could put it under "Other".

Record review of the Occurrence Report Form for designated category revealed a check box for Medication and under that a check box for "Dispensing Error."

Further interview with Risk Manager #4, when she was shown "Dispensing Error" said that would be used if the patient was given the wrong medication. When she was asked if staff were not ensuring medications were being swallowed, could be part of dispensing error, she said that was a "nursing thing." She said an occurrence form should have been initiated.

Record review of the facility's P&P for Medication Administration dated 9/17/12 (without any revision date) revealed nothing about ensuring the patient had ingested the medication or how to look in the patient's mouth to ensure medications had been swallowed.

Record review of the facility's P&P for Incident/Occurrence Reporting dated 6/23/14 and revised on 2/21/15 revealed the procedure was for the Occurrence Report form was to be completed by the person witnessing the event prior to the end of that person's shift. The Charge RN should review the report for interventions necessary to handle the occurrence and co-sign the form. the completed form should be forwarded to the Nursing supervisor prior to the end of the shift. The Nursing Supervisor was to review the form for completeness. The Nursing Supervisor was to immediately inform the Administrator, Chief Nursing Officer (CNO) and risk Manager of any serious incidents....such as...serious patient injury... patient suicide attempt or other serious incident. The report was to be sent to the CNO by the next day to be reviewed, signed, and forward to Risk Manager "for investigation as necessary, review with leadership, and trending." There was no information on how the Occurrence was to be investigated.

Interview on 3/19/15 at 3:45 p.m. with Director of Risk Management #4 she said since she had begun working at the facility, she recognized the old Incident/Occurrence Reporting form was difficult to understand and use so she developed a new form. She said the P&P was updated, because she found that incident forms were being held for a long time and not getting to where they needed to be. She said she could see that a P&P needed to be written on how to conduct an investigation. She said there might be an incident report form for Patient #6's incident that had not been turned when it should have been.

Based on interview and record review, the facility failed to ensure that 6 of the 8 sampled patients (Patients #3, #9, #10, #12, #13, #14) had an individualized and comprehensive treatment plan that included medical conditions as evidenced by:
? Medical conditions identified in the Psychiatric Assessment and History & Physical Examination were not transcribed to the Master Treatment Plan (MTP) Problem List, and/or
? A plan of care for each of the medical conditions identified on the Master Treatment Plan (MTP) Problem List was not developed.

Findings include:

Patient #3

Record review of Patient #3's Psychiatric Assessment dated 01/12/15 revealed a seizure disorder listed under Impressions.

Further review showed that on 01/11/15 Nursing documented the seizure disorder on the MTP Problem List but did not develop a treatment plan for the seizure disorder.

Patient #9

Record review of Patient #9's Psychiatric Assessment dated 03/07/15 revealed a seizure disorder listed under Impressions.

Record review of Patient #9's History & Physical Examination dated 03/07/15 revealed hypertension, migraine headaches and seizure disorder listed under Impressions.

Further review showed that on 03/06/15 Nursing documented only the seizure disorder on the MTP Problem List. A treatment plan had not been developed for any of the medical conditions.

Patient #10

Record review of Patient #10's History & Physical Examination dated 02/28/15 revealed hypertension listed under Impressions.

Further review showed that on 02/28/15 Nursing documented hypertension on the MTP Problem List but did not develop a treatment plan for hypertension.

Patient #11

Record review of Patient #11's History & Physical Examination dated 03/07/15 revealed chronic right shoulder pain listed under Impressions.

Further review showed that Nursing neither documented chronic pain on the MTP Problem List nor developed a treatment plan for chronic pain.

Patient #13

Record review of Patient #13's Psychiatric Assessment dated 02/26/15 revealed hypertension, HIV positive and hyperlipidemia listed under Axis III diagnosis.

Further review showed that on 02/25/15 Nursing documented hypertension and HIV positive on the MTP Problem List but failed to list hyperlipidemia. Nursing did not develop a treatment plan for any of the medical conditions.

Patient #14

Record review of Patient #14's Psychiatric Assessment dated 03/15/15 revealed elevated cholesterol and HIV positive under Medical History.

Further review showed that on 03/14/15 Nursing documented HIV positive on the MTP Problem List but failed to list the elevated cholesterol. Nursing did not develop a treatment plan for any of the medical conditions.

Interviews with the Director of Risk Management (#4) and RN #18 on 03/19/15 at 2:20 PM and 2:25 PM respectively both stated that the nurses are responsible for developing the Master Treatment Plan Problem List. RN #18 stated that nurses are responsible for developing the care plans for the medical diagnoses.

Record review of the Policy & Procedure, "Comprehensive Individualized Treatment Plan," dated 9/17/12 revealed: "The Registered Nurse, or any other member of the treatment team, identifies the patient's active and inactive problems and medical needs/interventions based on his/her assessment and will list Axis I, II and III problems on the Master Treatment Plan Problem List ... the Nurse will complete a Diagnosis Problem sheet for each problem noted on the Master Treatment Plan Problem List."

Based on interview and record review, the facility failed to ensure the treatment plan included the responsibilities of the psychiatrist as a member of the treatment team for 3 of 3 psychiatrists (#'s 22, 23, and 26) for 8 of 12 patients reviewed (#'s 9, 10, 11, 13, 14, 5, 6, 7) and the Nurse and Therapist did not note who wrote the Treatment Update form as evidenced by:

? The psychiatrists did not document their interventions on the Master Treatment Plan;
? The psychiatrists did not approve the Master Treatment Plan with their signature;
? The psychiatrists did not direct the staff in reaching consensus on the problems addressed; and/or
? The treatment team did not meet weekly to discuss, review and update the Master Treatment Plan or document who wrote the note on the Treatment Update form per the facility's Policy and Procedure (P&P).

Findings include:

Patient #9

Record review of Patient #9's Master Treatment Plan revealed an admission date of 03/06/15. Further review revealed no interventions by Psychiatrist #23 for the problem of Mood Disorder and no signature by the psychiatrist indicating that the treatment plan had been reviewed. The Treatment Plan Review/Update form was blank. On 03/18/15, 12 days after admission, a therapy and nursing signed the Treatment Team Meeting Notes form but did not document a note on Patient #9. There was no signature by Psychiatrist #23 to show she was present.

Patient #10

Record review of Patient #10's Master Treatment Plan revealed an admission date of 02/28/15. Further review revealed no signature by Psychiatrist #23 indicating that the treatment plan had been reviewed. On 03/06/15 a treatment team update note was recorded on the Treatment Plan Review/Update form but no indication as to who wrote the note. On 03/18/15, 18 days after admission, a note was documented on the Treatment Team Meeting Notes form by therapy and nursing on Patient #10. There was no signature by Psychiatrist #23 to show she was present.

Patient #11

Record review of Patient #11's Master Treatment Plan revealed an admission date of 03/07/15. Further review revealed that the Treatment Plan Review Update form was blank. On 03/18/15, 11 days after admission, therapy and nursing signed the Treatment Team Meeting Notes form but did not document a note on Patient #11. There was no signature by Psychiatrist #22 to show he was present.

Patient #13

Record review of Patient #13's Master Treatment Plan revealed an admission date of 02/25/15. On 03/03/15 a treatment team update note was recorded on the Treatment Plan Review/Update form but no indication as to who wrote the note.

Patient #14
Record review of Patient #14's Master Treatment Plan revealed no interventions by Psychiatrist #26. Further review revealed no signature by the psychiatrist indicating that the treatment plan had been reviewed by the psychiatrist. On 03/18/15, 21 days after admission, therapy and nursing signed the Treatment Team Meeting Notes form but did not document a note on Patient #14. There was no signature by Psychiatrist #26 to show he was present.


16838


Patient #5

Record review of Patient #5's active medical record revealed he was a 15 year old male admitted to the adolescent unit on 3/9/15 for Major Depressive Disorder.

Record review of the patient's Master Treatment Plan dated 3/10/15 revealed the MD section of the modalities and interventions section was blank. The signature page was blank for Psychiatrist #26's signature. The only Treatment Team Meeting note dated 3/16/15 did not have the Psychiatrist's signature.

Patient #6

Record review of Patient #6's active medical record revealed she was a 13 year old female admitted to the adolescent unit on 3/15/15 for Bipolar Disorder and Depression.

Record review of the patient's Master Treatment Plan dated 3/17/15 revealed the MD section of the modalities and interventions section was blank. The signature page was blank for Psychiatrist #26's signature.

Patient #7

Record review of Patient #7's active medical record revealed she was a 14 year old female admitted to the adolescent unit on 3/10/15 for Bipolar Disorder and Depression.

Record review of the patient's Master Treatment Plan dated 3/12/15 revealed the MD section of the modalities and interventions section was blank. The signature page was blank for Psychiatrist #26's signature. The only Treatment Team Meeting note dated 3/16/15 did not have the Psychiatrist's signature.

Psychiatrist #26 was not at the Master Treatment Plan meeting to direct the team in reaching a consensus on the problems to be addressed during the current admission as per the facility's P&P. There was no signature by the physician to show approval of the entire plan.

Interview on 3/18/15 at 1:10 p.m. with RN (Registered Nurse) #11, she said the Treatment team met daily and the psychiatrists did not attend.

Interview with RN #18 on 03/19/15 at 10:35 AM, she stated that Psychiatrist #23 "came early this morning. The therapist was not there ... there are no set days and times for the doctors to do their staffings ."

Interview on 3/19/15 at 11:10 a.m. with Therapist #10 revealed the psychiatrists did not attend any Treatment Plan meetings. She said the Therapist were the case managers also. She said the Treatment Team met for the initial Master Treatment Plan meeting, if there was a crisis that needed to be addressed and for the Patient's pending discharge.

Interview with Director of Clinical Services #8, on 03/19/15 at 12:30 PM, he stated the psychiatrists do not attend treatment plan meetings.

Record review of the facility's Policy & Procedure, "Treatment Plan - Protocol for the use of the Multidisciplinary Format," effective 9/17/12 revealed: "Signature sheets [include] ... team signatures indicating approval of entire plan by the physician and treatment team members ... Treatment team meetings will be attended by the psychiatrist or designee, the Charge Nurse, Social Worker, Recreational Therapist and Director of Psychiatric Nursing...The documentarist or designee will record...These recordings will reflect the input of the psychiatrist, the team and the patient.... The psychiatrist will direct the staff in reaching consensus on the problems to be addressed during the current admission ... The representatives from each discipline ... will meet weekly to discuss, review and update the plan."