Georgetown Behavioral Health Institute

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 30250 Based on a review of documentation and interview, the facility failed to ensure that drugs were administered in accordance with hospital policies. Findings included: Facility based policy number PHR-175 entitled, “USE OF PRN MEDICATIONS” stated in part, “1.0 STATEMENT OF PURPOSE: Orders for PRN medications must be clear and concise to ensure patients are effectively and accurately treated for the desired condition. 2.0 STATEMENT OF POLICY: The Pharmacy in conjunction with the facility’s Medical Staff and Administration will advocate the use of ·PRN medications provided certain guidelines are followed ... 4.0 PROCEDURE: ... 4.2 The nurse who administers the “PRN” medication will document in the appropriate section of the patient record. the purpose for which the medication was given and whether the patients outcome was effective or ineffective in response to the medication.” Review of Child and Adolescent medication administration records revealed the following: * Patient #1 had Haldol 10 mg PO PRN [pro re nata which means as the need arises] TID ordered for agitation and severe anxiety on 10/12/24 at 1730. Haldol 10 mg was administered on the following dates and times: 10/12: Haldol 10 mg at 1730 (PRN) and 10/13 Haldol 10 mg at 0445 (PRN). The effectiveness of these PRN doses was not documented, and there was no documented purpose or rationale related “agitation and severe anxiety” for administering this medication in the medical record. A note on 10/13/24 at 0445 stated, “Pt came out into hallway with pants halfway down. Pt re-directed to her room. PRN Haldol given. Staff will monitor.” This notes does not describe agitation and severe anxiety behaviors. * Patient #19 received PRN doses of a psychotropic medication of Thorazine 100 mg PO ordered to address agitation and aggression on 10/21/24 at 1050 and 10/22/24 at 1530. The effectiveness of these PRN doses was documented, however there was no documented purpose or rationale related to “agitation and aggression” for administering the medication in the medical record. * Patient #20 received PRN doses of a psychotropic medication Zydis 5 mg PO ordered to address agitation on 10/22/24 at 1040 and 1415. The effectiveness of these PRN doses was documented, however there was no documented purpose or rationale related to “aggression” for administering the medication in the medical record. The only documentation as to rationale was a nurse note on 10/22 at 0900 stating the patient was agitated and the patient took the PRN (this was documentation over an hour and half prior to the actual administration of the Zydis). Due to the lack of documentation, to reflect the purpose or rationale for administered PRN psychoactive medications in the medical record, it cannot be established that the PRN medications were being administered to address the indicated behaviors/symptoms in the original physician order (such as agitation, anxiety, and/or aggression) or that the medications were effective in addressing those symptoms/behaviors. The above findings were verfied with staff member #2 on 10/23/24.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 30250 Based on a review of documentation and interview, the facility failed to ensure the right to care in a safe setting, by failing to assess patients post fall, per facility policy. Findings included: Facility policy PC.3.07 entitled, “FALL RISK MANAGEMENT” stated in part, “PROCEUDRE: [sic] ... 11. Patients who are on fall precuations [sic] will have a fall risk assessment completed once every shift using the Edmonsons Fall Risk Assessment Tool for adults or the Humpty Dumpty Fall Risk Assessment for child and adolescent patients.” Review of the medical record for Patient #1 revealed the patient sustained a fall without injury on 07/17/24, that resulted in the patient being placed on “Q5 level of observation fall precautions” on 07/117/24 at 1401. Review of Patient #1’s medical record revealed no Edmonsons Fall Risk Assessment Tool assessments were present after this patient was placed on fall precautions on 07/17/24. The above findings were verfied on 08/27/24 with staff members #1 and 3.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(ii) [there must be documentation in the patient’s medical record of the following:] A description of the patient’s behavior and the intervention used. This Standard is not met as evidenced by: 30250 Based on a review of documents and interviews, the facility failed to ensure the medical record for patients included a description of the patient’s behavior requiring interventions such as restraint or seclusion. Findings included: Facility policy PC.4.02 entitled, “RESTRAINT AND SECLUSION” stated in part, “POLICY Restraint or seclusion shall be only be utilized in a psychiatric emergency, where a patient’s behavior presents imminent danger to self or others, as an intervention of last resort and after less restrictive measures have been attempted without success. (Policy is based on requirements set forth by the Texas Administrative Code (25 TAC §415.251-415.257) DEFINITIONS Psychiatric Emergency-A situation involving an individual who is behaving in a violent or self-destructive manner and in which preventive or verbal de-escalation techniques have been determined to be ineffective and restraint or seclusion is immediately necessary to prevent imminent probable death or substantial bodily harm to the individual or others as a result of acts or behavior in which the individual is engaged ... PROCEDURE: ... 4. Physician’s order - restraint and seclusion require an order from a physician that must be obtained as soon as possible during or immediately after the event ... a. The initial physician’s order shall: ... 2) Describe the specific behaviors which resulted in the intervention ... Review of 10 Medical Records for patients restrained or secluded at the facility revealed that 4 of 10 patients did not have documentation to describe the specific behaviors which resulted in the intervention or that met the definition of a psychiatric emergency. * Patient #1 had a physical hold episode on 07/10/24 from 1459-1508 and a seclusion episode on the same date from 1508-1530. Review of the Seclusion/Restraint Physician Order and Record form revealed the clinical justification had “imminent danger to others” with the check box indicated. The area to describe the specific behaviors displayed stated, “threatens staff”. Patient #1 also had a seclusion episode on 08/02/24 from 1326-1415. Review of the Seclusion/Restraint Physician Order and Record form revealed the clinical justification had “imminent danger to others” with the check box indicated. The area to describe the specific behaviors displayed stated, “Pt very disruptive on the milieu. Intrusive at desk, loud & disruptive on unit. Pt refused staff vernal prompts several times to comply”. These two events did not have descriptions of behavior that would support the definition of a “Psychiatric Emergency-A situation involving an individual who is behaving in a violent or self-destructive manner per facility policy and regulations. * Patient #5 had a seclusion episode on 08/07/24 from 1601-1645. Review of the Seclusion/Restraint Physician Order and Record form revealed the clinical justification for the intervention had “imminent danger to others” with the check box indicated, the physician order did not describe specific behaviors displayed. * Patient #7 had a physical hold on 08/17/24 from 1211-1212. Review of the Seclusion/Restraint Physician Order and Record form revealed the clinical justification for the intervention had “imminent danger to self” and “imminent danger to others” with check boxes indicated, the physician order did not describe specific behaviors displayed. * Patient #8 had a physical hold on 08/17/24 from 1210-1220. Review of the Seclusion/Restraint Physician Order and Record form revealed the clinical justification for the intervention had “imminent danger to others” with the check box indicated, the physician order did not describe specific behaviors displayed. The above findings were verified with staff members #1 and 3 on 08/27/24.”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 47893 Based on interviews, record review and review of facility policy, the facility failed to ensure the exercise of rights for 1of 10 patients (Patient #1) for whom client rights were reviewed. Upon admission to the facility, patient #1 was denied access to a folder containing homework assignments, which were removed from the patient and placed in storage. Additionally, patient #1 was not provided someone to come in to teach him so he did not fall behind in his schoolwork. These failures placed patient #1 at risk for not being allowed to exercise basic rights, for which patients are entitled. Findings were: During an interview in a facility conference room at approximately 10:00 AM on 3/21/24, Staff #8 stated, “... They don’t have teachers here. Family should be told that. (Patients are) encouraged to bring in coursework. (Staff) try to encourage patients to do homework ...” Review of patient #1’s clinical record documented an inventory list of items brought into the facility on the day of admission. The inventory list documented items, including a folder containing homework, were placed in storage. Review of written documents presented to patient/parent/guardian/caregiver at the time of admission to the facility, included: “Basic Rights”, undated, which states in part, “ ... 6. You have the right to keep and use any personal possessions you brought with you, like games or books or clothes ... 11. The hospital has to have someone come in to teach you so you don’t fall behind in your schoolwork. [Editor’s note: As required by Texas Education Agency (TEA) guidelines ... “ During an interview in a facility conference room at approximately 10:30 AM on 3/21/24, Performance Improvement & Risk Director (Staff #1) stated, “ ... we focus on getting them (patients) stabilized, getting better. When they (patients) come here, they (patients) are usually in crisis, unable to focus on homework. We have many people that could help with homework.” In further interview on 3/21/24 at 11:10 AM, Staff #1 confirmed that inventory sheet reflected homework was placed in storage. During an interview in a facility conference room at approximately 1:30 PM on 3/21/24, Director of Outpatient Services (Staff #10) stated, “... Teacher available in contract to help with inpatient.””