Rio Vista Behavioral Health

“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: 30468 Based on review of facility documents, interview and patient records, the facility failed to ensure Patient #3’s right to care in a safe setting when the facility failed to obtain legal consent for admission and treatment for voluntary inpatient services for mental illness of a minor on April 16, 2025, through May 8, 2025. The facility accepted consent from a nonparent without documented legal documents. Findings: 1. Patient #3, age 16 years, was admitted April 16, 2025 voluntarily as an inpatient and remained until May 8, 2025. 2. Consent for admission and treatment was given by patient’s adult sister who presented as guardian (POA) with verification by CPS. No written documentation was provided. 3. Written statement provided 3/17/26, Director of Risk Management reads as follows “[Patient #3] DOB 7/2/2008, admitted to Rio Vista on 4/14/2025, under an Emergency Detention Order filed by EHN CIT [local mental health authority crisis intervention team]. At the time of admission, the patient was accompanied by her biological sister... Per the EHN CIT Assessment and [POC], [Patient #3] was under the guardianship of [POA] after being removed from her mother’s home due to allegations of molestation by the mother’s boyfriend and exposure to drugs and alcohol. [POA] signed all admission documents and provided verbal phone consents for psychotropic medication administration. When conservatorship or guardianship concerns are identified upon admission, parents/patients/guardians are asked to provide supporting legal documentation to verify status. Due to the emergency crisis [Patient #3] was experiencing at the time of admission, we accepted [POA]’s signature for consents for inpatient treatment. The CPS caseworker was notified of the admission and verified the accuracy of the information provided at the time of admission; however, she did not provide written documentation.” 4. Texas Health and Safety Code 572.001 Request for Admission - (a-2) Except as provided by Subsection (c-1), an inpatient mental health facility may admit or provide services to a person 16 years of age or older and younger than 18 years of age if the person’s parent, managing conservator, or guardian consents to the admission or services, even if the person does not consent to the admission or services. 5. The facility did not obtain legal consent for patient’s admission on April 16, 2025.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 28421 Based on review of documentation and interview, it was determined that the facility failed to adequately protect patient privacy for all of its patients. Findings were: Facility policy entitled “Patient Rights” stated in part “The following rights shall be afforded to all patients and are not subject to modification: ... Patients have the right to voice grievances to staff of the hospital, and to outside representatives of their choice with freedom from restraint, interference, coercion, discrimination or reprisal. Patients have the right to be treated with consideration, respect and full recognition of their dignity and individuality. Patients have the right to be protected by the Hospital from neglect; from physical, verbal and emotional abuse (including corporal punishment); and from all forms of misappropriation and/or exploitation. Patients have the right to be assisted by the Hospital in the exercise of their civil rights. Patients have the right to be free of any requirement by the Hospital that they preform services which are ordinarily performed by hospital staff. Patients have the right to privacy while receiving services.” On November 8th, 2023, while Patient # 2 was being admitted, the mother of Patient # 2 was given a medication consent form with another patient’s name on it. The mother felt that this was a clear violation of HIPPA. In an interview with the CEO on 1/16/24, it was indicated that the facility could not determine if a HIPPA violation occurred at admission when Patient # 2’s mother claimed to have been given another child’s medication consent form to sign. The CEO said that admission staff denied that the incident occurred. However, the CEO confirmed that Patient # 2’s mother knew the other child’s name who was being admitted at the same time as her child. She admitted that this knowledge could have come from being presented with the wrong medication consent form.”

“PHARMACY DRUG RECORDS CFR(s): 482.25(a)(3) Current and accurate records must be kept of the receipt and distribution of all scheduled drugs. This Standard is not met as evidenced by: 47893 Based on review of facility documentation and interview, the facility failed to maintain current and accurate records of the receipt and distribution of all scheduled drugs. Facility procedures to trace the movement of scheduled drugs from the point of entry into the facility to the point of disposition were not implemented. Documentation to confirm the quantity of oxycodone hydrochloride (oxycontin), a Schedule II drug, tablets released to Patient #1 at the time of discharge was not maintained. A complaint received by HHSC alleged Patient #1’s scheduled, narcotic medication was ‘stolen’. The facility’s failure to implement policy to maintain documentation regarding disposition of medications in its custody, to include medications ordered to be returned to the patient upon discharge, failed to minimize the risk for drug diversion. Findings include: Review of policy and procedure titled, “Medications Brought in with Patients”, annual review 01/2023, documented in part: “... Controlled substances that are taken into custody will be counted and the quantity noted on the inventory sheet. The patient and staff member receiving medication will sign the form. If the patient/caregiver cannot sign, then a second hospital witness is required... All medication documentation regarding disposition of medications must be clearly marked and maintained for a period of two years.” Review of a Patient’s Own Medication, “(POM) - Controlled Drug Administration” record, for Patient #1, indicated the following: - “oxycontin (oxycodone hyrochloride) 15 milligram extended release tablets, 7 boxes of 20 (sealed) and 1 box of 13 (opened), total quantity of 153” was received by facility nursing staff on 9/12/2023 at 2:00 AM. - between 9/12/2023 and 9/14/2023, 13 tablets were administered, and “quantity remaining” reflected 140 tablets. - a notation on 9/14/2023 at 4:20 PM, “discharged” and quantity remaining 140. Further review of Patient #1’s “(POM) - Controlled Drug Administration” record included the following instruction: “Two witnesses must be present to verify count and sign when returning to patient,” and “Note: MAINTAIN IN MAR (Medication Administration Record)”. The section of the form, including space for documentation of “date’, “quantity”, “describe in detail”, “signature 1”, and “signature 2” was blank. Review of a Progress Note, dated 9/14/2023 at 4:55 PM documented in part: “... All personal belongings including home medications with person at time of discharge...” During an interview on the afternoon of 11/14/2023, in the facility conference room, Staff #1, Director of Nursing, stated, “... We’ve asked for a copy (of documents to verify Patient #1’s receipt of home medications at time of discharge, including oxycontin) as the police were here. As of today we have not been able to obtain one, and we have not heard anything further from the police or the patient.””