HospitalInspections.org

Based on record review and interview, the governing body failed to:

A. consult directly to the medical staff and medical staff director concerning the last survey conducted by HHSC on 4/14/20 concerning the allegations in the 2567.

B. include the medical staff and medical staff director in a potential patient and staff exposure to a positive COVID 19 employee.

C. ensure the partial hospitalization program was closed appropriately with the recommendations of the medical director and psychiatric staff.


A. An interview was conducted with Staff #2 on 5-14-20 in the afternoon. Staff #2 reported that he was not being included by the administration and governing board in clinical decisions regarding patient care since the last administrator was terminated on 4/24/20. Staff #2 reported that he was not given access to the 2567 from the 4/14/20 visit. Staff #2 reported that all the clinical changes, policy and procedure changes involving clinical care, and processes have not included the medical staff. Staff #2 stated, "the whole action plan has been directed from corporate administration without including medical staff. I have been asking administration to allow me to be involved with the process changes. I don't even have a copy of the 2567. I have no idea what it even says. I asked ____ (Staff #3) to send me her copy and she told me she was not allowed to email it to anyone. The 2567 is due tomorrow and I haven't even read it, nor do I know what changes are being made clinically."

B. Staff #2 reported that he was not notified of an employee testing positive for COVID 19 and potential exposure to the patients for 5 days. Staff #2 was texted by staff from the floor that an employee had tested positive for COVID 19 and had been around patients, staff, and himself in late April/ early May. The employee had symptoms on the 5th of May, tested positive on the 6th of May, and he was never informed by administration. Staff #2 stated he called Staff #1 on May 8th concerning the positive employee and Staff #1 confirmed it. The staff and patients had been exposed for 5 days and no one knew it including myself. Staff #2 stated when he found out he called all medical and psychiatry staff to inform them of the exposure. Staff #2 stated, "I asked them to wear mask and if they had symptoms to please stay home." Staff #2 stated, "The facility put a notice up to the staff on paper and that was it." Staff #2 stated he was also on the governing board and no meeting has been held with the governing board. Staff #2 stated the corporate CNO, interim CEO and the DPN had a meeting with the health department on 5/8/20 concerning the positive employee and he was not notified.

Staff #2 reported that there was now a patient and his roommate placed on unit 2 with possible COVID 19. The two patients were isolated from the other patients. Staff #2 reported he was not consulted as the medical director concerning the patient care, testing for the patients, or any process and changes they have implemented.



C. The facility had an Intensive Outpatient Program (IOP) and a Partial Hospitalization Program (PHP). Review of the facility's website stated,
"OUTPATIENT PROGRAMS
Rock Prairie's Outpatient Programs (both Partial Hospitalization and Intensive Outpatient Program) address the needs of adolescents and adults with general challenges including anxiety, depression, bipolar disorder and psychiatric disorders. Clients may be enrolled directly into the program from the initial point of assessment and referral, or they can be "stepped down" from the inpatient setting. Outpatient is designed for individuals who would benefit from a structured day program to assist with the development of more adaptive coping skills.

PARTIAL HOSPITALIZATION PROGRAM (PHP)
The Outpatient Programs help individuals struggling with behavioral health challenges who would benefit from a structured day program. Rock Prairie offers a Partial Hospitalization Program (PHP) for adults and seniors. The Partial Hospitalization Program is designed for individuals with primary psychiatric disorders who require intensive support and structure but not 24-hour inpatient care. Clients attend PHP five days per week for six hours a day. They can return home in the evening and attend treatment at our facility during the day.

The PHP program runs Monday through Friday, 8:30am to 3:00pm with lunch provided. The PHP programs offers intensive group therapy (psychoeducational and process groups), recreational therapy, and sessions with a psychiatrist.

NEW - Adolescent IOP Program - Ages 12-17."

Staff #2 stated that on May 6th, 2020 Staff #1 instructed Staff #2 to immediately discharge patients from the PHP. Staff #1 had informed Staff #2 that he did not have a nurse to work in the day program and they would have to be discharged immediately. Staff #2 reported that he tried to give the administration staff some other ideas and that he did not feel comfortable in discharging patients from the program. Staff #2 stated that he did discharge the patients but against his medical advice. Staff #2 stated the administrator opened the program back up the following Monday on 5/11/20.

An interview was conducted with Staff #1, #4, and #6 on 5/14/20 in the afternoon. Staff #6 reported that Staff #2 was included in the morning meetings and knew about the COVID related issues and plans for the staff and patients. Staff #4 reported that Staff #2 was in the flash meetings concerning the COVID issues. Staff #1 and #6 insisted that they had conversations with the medical director. Staff #6 was asked if they had an official Ad hoc (a meeting for a specific problem or event) Medical Executive meeting to discuss with the medical staff. Staff #6 confirmed they had not had an Ad hoc meeting. Staff #6 stated, "we discussed all this with him, but I didn't realize we need to write it all down." Staff #1, #4 and #6 was unable to provide the surveyors with any medical executive meetings or governing board meeting minutes discussing the COVID 19 exposures or the closing of the partial hospitalization program.
Staff #1 confirmed he was not sure if Staff #2 had a copy of the 2567 but he would get him a copy.
Staff #4 reported they had a table-top disaster drill on 5/6/20 to help prepare for an outbreak of COVID 19 in the facility however, the medical staff and patient care staff were not involved in the disaster drill. Only administrative staff signed in to the event.

On the day of the survey completion, 5/15/2020, an email was forwarded to the surveyor of an email between Staff #2 and Staff #3 dated the same date, 5/15/2020 at 3:35 pm. The email stated,

"Dr. _____ (Staff #2),
We appreciate your desire to participate and provide input into the Action Plan. However, given the urgency of the matter and the deadline imposed by CMS, we are unable to delay a response to them until Monday. If you are available for review today by 4:00, we are more than happy to review your suggestions. If not, the current plan has been reviewed by all members of the Governing Board and approved by a majority. It should also be noted, there are no substantial changes to referenced clinical policies that would dictate an approval by MEC as required by JC and CMS. The plan is also not imposing any additional duties on the Medical Staff beyond the Medical Staff Bylaws, Rules and Regulations that would require a vote of MEC. If you are unable to review the plan prior to the 4:00 deadline, please feel free to delay your review until Monday, and we could potentially request CMS to amend the response if your recommendations are considered substantive. Thank you, ____ (Staff #3)." According to the email, Staff #2 was going to be allowed only 25 minutes to review a 92-page document involving the infection control program before submitting to CMS.

Staff #2 responded to Staff #3 via email on Friday, May 15, 2020 4:30 PM. The email stated,

"______(Staff #3),

Again, I have been shut out of this process. I was not included in the creation of this plan, it was not vetted through any physician or medical staff and is not going through the proper channels as we have done in the past. MEC, according to our bylaws, recommends anything that affects patient care to the Governing Board. I disagree completely that the Governing Board should accept this plan without any feedback from the medical staff or the medical director. I requested _____ (Staff #4) send this to staff today to get their input from an Ad-Hoc MEC meeting. The current vote from the medical staff is for more time to review this plan, as they too are overwhelmed by the size of this plan and the last minute, rubber-stamp that has been asked of them. The very nature of these IJ's are clinical and DO affect patient care and health. It is imperative that Strategic and Rock Prairie include physicians and medical staff in this process. Approving a plan without their input is a detriment to our employees and patients. You also state that this does not change clinical policies-however, this plan demands the medical staff to be "trained" when they are the content experts on this subject matter. You are imposing more duties in the form of these trainings-of which the medical staff should be educating you on, not the other way around. This plan was sent at 1pm on the due date-I was given 3 hours to attempt to get through the plan (some odd 90 pages) and present any changes. That's unreasonable as administrators have been working on this since state left weeks ago.

As a physician, a medical director, and someone who uses common sense, not involving the medical staff, including myself, is setting us up for more failure. We have several safety issues, including staffing, public health, and an overall culture that is leading us down a road of failure and may end in causing significant harm to our employees or patients. I became a doctor to help people and am an expert in mental health, education/training, and caring for these patients. I have been retaliated against for calling out staffing and various safety concerns in this facility that has led to my exclusion from aiding in creation of this plan addressing major issues that are occurring in this hospital today. As you have noted in our brief conversations, I have the ear of the staff, am a good clinician, and a valued member of this facility; as I read this email from you, I am shocked and disappointed that administrators are leading the efforts on clinical care."