HospitalInspections.org

The facility failed to protect and promote each patient's rights. As evidence by:

* The facility failed to ensure that each patient was informed of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible. The facility also failed to provide this information in the patient's primary language. Cross refer to A0117.
* The facility failed to ensure that patients were able to exercise their rights, as evidence by failing to properly address a request for discharge from a patient on a voluntary status. Cross refer to A0129.
* The facility failed to ensure the right to care in a safe setting for patients. Cross refer to A0144.

Based on a review of documentation and interview, the facility failed to ensure each patient was informed of the patient's rights in advance of furnishing or discontinuing patient care whenever possible.

Findings included:

Facility based "Patients' Bill of Rights for Mental Health Services" stated in part, "You also have the right to have these rights explained to you aloud in simple terms in a way you can understand within 24 hours of being admitted to the hospital to receive services (e.g., in your language if you are not English-speaking ..."

Review of the the medical record for Patient # 1 revealed the following:
* The RN Admission Assessment dated 12/27/14 stated in part, " Preferred Language : English. Preferred language to receive health care information: Spanish ...Communication barriers include preferred language different than interviewer. Primary Language: Spanish. Preferred language to receive health care information: Spanish. Patient does not speak English. Interpreter needed."
* Patient # 1 signed the facility based form which stated in part, "Statement that you have received the pamphlet titled 'Patient's Bill of Rights for Mental Health' and it has been explained to you" on 12/27/14 at 5:30 PM. The portion which stated, "I certify that I have received a copy of this six-page document" was not marked. The portion which stated, "I certify that staff has explained its content to me in a language I understand" was not marked.

In an interview on 06/03/15, staff member # 1 and 2 confirmed due to the incomplete nature of this form, it cannot be determined if this patient was informed of their rights in a language they could understand (Spanish) or if they received a copy of their Patient Rights.

Based on review of documentation and interview, it was determined that the facility failed to ensure that patients were able to exercise their rights, by failing to properly address a voluntary patient's request for discharge.

Findings included:

Facility based "Patients' Bill of Rights for Mental Health Services" stated in part, "You also have the right to have these rights explained to you aloud in simple terms in a way you can understand within 24 hours of being admitted to the hospital to receive services (e.g., in your language if you are not English-speaking ...
4. You have the right to appropriate treatment in the least restrictive setting available. This is a setting that provides you with the highest likelihood for improvement ... and for protection against any dangers which you might pose to yourself or others....

Voluntary Patients- Special Rights
1. You have the right to request discharge from the hospital. If you want to leave, you need to say so in writing or tell a staff person. If you tell a staff person you want to leave, the staff person must write it down for you.
2. You have the right to be discharged from the hospital with [sic] four hours of requesting discharge."

Facility based policy and procedure entitled, "Discharge, Request for" #2.026, stated in part,
"1. All persons voluntarily admitted to inpatient services for treatment of mental illness or the person who requested admission on the individual's behalf have the right to request a discharge ...
b. If a patient informs any employee of the patient's desire to leave, the employee shall, as soon, as possible, assist the patient in creating the written request and present it to the patient to sign, date, and time.
i. Without regard to whether the patient agrees to sign the paperwork requesting discharge, the request will be documented and processed by staff ....
d. The facility shall, within four hours after request for discharge is filed, notify the psychiatrist responsible for the patient's well-being. If the psychiatrist is not available, the facility should notify any available physician.

2. The notified physician shall discharge patient within four hour period unless the physician has reasonable cause to believe the patient might meet criteria for court-ordered mental health services or emergency detention."

Review of the medical record for patient # 1 revealed the following:
* The patient was admitted to the facility on a voluntary status on 12/26/15 and signed a "Request for Voluntary Admission" on 12/27/14 at 1125.
* A provider note on 01/05/15 at 23:03 stated in part, "Restless; trying to get out of alarmed W/C. ... served as interpreter. He reported patient was agitated and stated that he wanted to go home. Staff reported that he has been agitated today and threw drink on floor."
* A nursing note on 1/05/15 at 12:33, "MEDICATED FOR AGITATION, HITTING AT STAFF AND ATTEMPTING TO GET OUT OF CHAIR AND REPEATING THAT HE WANTS TO LEAVE. MEDICATED WITH PRN ATIVAN 1 MG IM. SEE MAR."

A review of the patient's chart revealed there was no documented follow up to the patient's request to leave on 01/05/15 (documented in a nurse and provider notes). The patient was not assisted in completing a request for discharge per facility based policy and regulations.

In an interview on 06/03/15, staff member's # 1 and 2 confirmed the documented notes in Patient's # 1 chart requesting to leave when on voluntary status, should have been followed up with a request to discharge and subsequent assessment from the physician according to policy and regulations.

Based on a review of documentation and interview, it was determined the facility failed to ensure the patient's rights for care in a safe setting.

Findings included:

Facility based "Patients' Bill of Rights for Mental Health Services" stated in part, "4. You have the right to appropriate treatment in the least restrictive setting available. This is a setting that provides you with the highest likelihood for improvement ... and for protection against any dangers which you might pose to yourself or others. "


Facility based policy and procedure entitled, "Fall Prevention" #11.235 stated in part,
"POST FALL INTERVENTION..
3. Initiate Neuro-checks Q15 minutes for 1 hour ...
9. Reassess patient using Fall Risk Assessment.
10. Review and revise care plan as appropriate."
Facility based policy and procedure entitled, "Assessment, Patient" #11.205 stated in part,

"2. A patient assessment will be performed by the RN or LVN every 12 hours (each shift). An RN must perform an assessment:..
c. Behavioral Health-every 12 hours ...

5. The patient assessment will include, but not be limited to: ...
j. Safety assessment including:
i. Fall Risk

7. The plan of care will be revised with each assessment."

Review of Patient # 1's medical record revealed patient sustained documented falls on the following dates:
* On 01/03/15 at 01:40 a nursing note stated in part, "CNA heard pt roll off bed onto floor. Pt lying on right side on floor. Side rails up x 2. No sign of injury. Vital signs taken: T 97.1, BP 127/57, P 80, R 17, and O2 94% on room air."
* On 01/06/15 at 04:30 a nursing note stated in part, "This nurse was informed that pt. had fallen in the bathroom and when this nurse got to his room the pt. was resting in his bed assess the pt. as found a small bump to the pt's left side of his head and pt. states that it does not heard [sic] and no injures [sic] found on pt. at this time. Bed alarm was not on when pt. got up out of bed to go to the bathroom."
* On 01/12/15 at 12:30 a nursing note stated in part, "PATIENT WAS IN THE HALLWAY AND UNDID HIS BELT AND GOT UP AND FELL. CNA'S RAN TO HIM TO TRY AND CATCH HIM BUT DID NOT MAKE IT. CHARGE NURSE INFORMED.VSS."
* On 01/13/15 at 05:45 at nursing note stated, "Aide reports patient was found on floor of room next to bed. Patient laying on floor with head propped on lower shelf of bedside table. Patient makes continuous attempts to sit up. New approximately one centimeter abrasion noted on right mid-forehead. Repeated attempts to retrieve vital signs were unsuccessful while patient laid on the floor, so he was transferred back to his bed. Vital signs taken BP 152/54, P 52, R 20, SaO2 95%. Patient was attempting to remove his clothing, but no other signs of agitation observed at this time. Bed in low position, wheels locked, siderails up x 3, bed alarm on, and call light within reach. Other staff members notified of fall on current and oncoming shifts."
* Another nursing note On 01/13/15 at 0600 stated, "[name], CNA reports found on floor at 0600. four siderails up and no alarm going off. Old scratch noted to the left forehead with small scab. rt forehead with approx 1cm scratches x 2 and bleeding noted. cleaned with water. pressure bandage applied. CNA with pt at all times for the next 2 hours for safety." At 06:15, "152/54,52,95%. rt eye nonreactive, lt eye sluggish. removed bandage. 0 new bleeding noted at this time. drowsy, but does awaken to touch."

Patient # 1 was subsequently transferred to another facility on 01/13/15 at approximately 0742 related to this fall. Per the discharge summary, "[pt] fell multiple times over the past 2 days. This am he fell striking his head. HR was found to be in the 30s. Mental status was altered."

"Fall Risk Assessments" completed by facility nursing staff from 12/27/14 (admission date) through 1/13/15 documented, "Patient does not have a history of falling during this admission or within the last 3 months". However medical record review documented falls on 1/3/2015; 1/6/2015; 1/12/2015 and 1/13/2015.
On 01/13/15 the Fall Risk Assessment increased, indicating a higher risk for falls, with the statement "Patient has fallen since admission or within the last 3 months".The Nursing Plan of Care was not adjusted to address the patient ' s falls after its initiation on 12/27/2014 when a check mark indicated the patient as a potential fall risk. Neither the fall risk assessment nor plan of care were updated after the falls per the facility ' s policy.


Neuro checks were not initiated following the patient ' s falls on 01/03, 01/06 and 01/12 according to facility policy. Nero checks were clinically indicated because the patient struck his head and sustained " a small bump " to the side of his head and abrasion to his forehead. After his fall on 1/13/2015, neuro checks were not documented every 15 minutes for an hour per policy.

After these 4 falls, the patient was transferred to another facility where he was diagnosed with a subdural hematoma.

Facility based policy and procedure entitled, "Patient Monitoring" #2.013 stated in part,
"3. Levels of Monitoring include:
a. Standard patient monitoring
i. All patients are monitored a minimum of once every fifteen (15) minutes upon admission and until discharge ...

8. Document patient monitoring
a. From the time of admission to the unit, a staff member will note and document on the Patient Monitoring Form the location of the patient at a minimum of fifteen (15) minute intervals."

Review of the "Q 15 Minute Checklist" revealed incomplete documentation for 3 of 10 patient records reviewed:
* Patient # 1's checklist on 01/13/15 from 6:45 to 8:00 was not completed.
* Patient # 4's checklist on 05/26/15 from 17:00 to 17:45 was not completed.
* Patient # 5's checklist on 05/20/15 from 23:45 to 0:15 was not completed.

In an interview on 06/03/15, staff members # 1 and 2 confirmed the above findings.

The facility failed ensure properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent were obtained.

Findings were:

The Texas Administrative Code Title 25 Chapter 414, Subchapter I of this title (relating to Consent to Treatment with Psychoactive Medication--Mental Health Services) which states in part,

"§414.404. Information Required To Be Given.

(a) The treating physician, registered nurse (RN), licensed vocational nurse (LVN), physician's assistant (PA), or registered pharmacist (RPh) will explain to the patient and to the patient's legally authorized representative, the information in paragraphs (1) - (10) of this subsection in simple, nontechnical language in the person's primary language, if possible. If the explanation is not provided by the treating physician, he or she must confirm the explanation with the patient and the patient's legally authorized representative, within two working days, not including weekends or legal holidays:...

§414.405. Documentation of Informed Consent.

(a) Informed medication consent must be obtained for each individual medication, not by medication class.
(b) Informed consent for the administration of each psychoactive medication will be evidenced by a completed copy of the department's form, Consent to Treatment with Psychoactive Medication (MHRS 9-7 form (or other format including the same information)) executed by the patient or his or her LAR. A copy of which may be obtained by contacting TDMHMR, Office of Policy Development, P.O. Box 12668, Austin, TX 78711-2668...

(d) If the RN, LVN, PA, or RPh gives the initial explanation of the consent information to the patient, then the treating physician must confirm the explanation and the consent and sign the MHRS 9-7 form (or other format including the same information) within two working days, not including weekends or legal holidays."

Review of medical records revealed issues with Consents to Treatment with Psychoactive Medication in 5 of 10 records reviewed:

* Patient # 1 was on voluntary status during the hospitalization, yet the patient's daughter signed a consent for Xanax.
* 2 consents (Xanax and Ativan) did not have a method of explanation indicated on the MHRS 9-7 form (oral explanation, video presentation, printed material, other). Without a method indicated it is unknown how the patient received this information.
* Patient # 1's medication administration record (MAR) revealed they received medication prior to the Consent to Treatment with Psychoactive medications being obtained. Tegretol was administered on 12/31/14, consent was not obtained until 01/02/15. Klonopin and Zoloft were administered on 01/01/15, consent was not obtained until 01/02/15.
* Patient # 3 had 4 consents that did not have treating physician confirming the explanation and the consent, by signing the MHRS 9-7 form (or other format including the same information) within two working days, not including weekends or legal holidays. The consents for Remeron, Klonopin, and Xanax were obtained on 05/23/15, as of 06/03/15 the consents had not been signed by the physician.
* Patient # 4 had 2 consents (Ativan and Lexapro) that did not have method of explanation indicated on the MHRS 9-7 form (oral explanation, video presentation, printed material, other). Without a method indicated it is unknown how the patient received this information.
* Patient # 5 had 4 consents that did not have treating physician confirming the explanation and the consent, by signing the MHRS 9-7 form (or other format including the same information) within two working days, not including weekends or legal holidays. The consents for Haldol, Klonopin, Seroquel, and Prozac were obtained on 05/18/15, as of 06/03/15 the consents had not been signed by the physician.
* Patient # 10 had 5 consents (Topiramate, Phenobarbital, Valium, Lunesta, and Cymbalta) that did not have method of explanation indicated on the MHRS 9-7 form (oral explanation, video presentation, printed material, other). Without a method indicated it is unknown how the patient received this information.

The above findings were confirmed in an interview with staff members # 1 and 2 on 06/03/15.