Medical City Mental Health and Wellness Center

“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: 37325 Based on record review and interview the facility failed to administer medication in accordance with federal and state laws, and the approved medical staff policies and procedures for 1 of 10 (Patient #1) patients. Findings included: Patient #1 was administered Zyprexa 2.5 mg IM (intramuscularly) on 08/06/24 at 01:35 AM. The medical record did not evidence why the order was necessary, What less intrusive forms of treatment were tried or rejected. What was the patients response to the medications. During an interview on 09/26/24 at 12:20 PM Personnel #1 and Personnel #2 verified the above findings. 25 Texas Administrative Code Chapter 414, Rule 414.410 reflected b) If a physician issues an order to administer psychoactive medication to a patient without the patient’s consent because of a psychiatric emergency, then the physician will document in the patient’s clinical record in specific medical or behavioral terms: (1) why the order is necessary: (2) other generally accepted, less intrusive forms of treatment, if any, that the physician has evaluated but rejected; and (3) the reasons those treatments were rejected. The policy titled Medication Administration Revised 02/2024 reflected...”PRN (as needed) Medication Administration Guidelines...Effect of PRN medication must be documented within one hour of medication administration...””

“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: 39057 Based on record reviews, and interviews, the facility failed to protect patients from other known aggressive patients. One (1) out of two (2) patient’s, reviewed for having been identified as being assaulted by another patient with known aggression. The failure of the facility to maintain safe boundaries, places all the patients in the facility at risk for injury, pain, and affective dysregulation (the ability to control one’s emotions). Findings included: Review of facility’s policy for Levels of Observation and Special Precautions revised 04/2020, Policy Statement: “It is the policy of the hospital to maintain safety and provide care to patients while maintaining their dignity and respect.” Definition: Dangerous to others: “Within the recent past, the individual has inflicted or attempted to inflict or threatened to inflict serious bodily harm on another, or has acted in such a way as to create a substantial risk of serious bodily harm to another, or has engaged in extreme destruction of property; and that there is a reasonable probability that this conduct will be repeated.” One-to-One Observation (1:1): - A specified and dedicated staff member will stay within approximately one arm’s length of the patient on 1:1 observation. This continuous direct visual observation will continue even when patients shower, change clothes, or use the bathroom ... - The RN will complete a reassessment and documents the findings in the medical record. The findings of the reassessment will be communicated to the attending provider related to whether or not the patient still requires this level of observation. - Note: This level of observation is best used in situations in which it is determined that staff would not be able to successfully intervene in time using constant line of sight observation level. Review of facility’s policy for Patient Rights- Texas revised 07/2020, Basic Rights for All Patients: 3. You have the right to a clean and humane environment in which you are protected from harm, have privacy with regards to personal needs, and are treated with respect and dignity. 5. You have the right to be free from mistreatment, abuse, neglect, and exploitation. Review of Patient #1’s admission records reflected, admitted voluntarily on 03/09/2024 recent history of aggressive, threatening and physically assaultive behaviors. Patient #1 was placed under suicide, elopement, aggression, fall and sexual acting out precaution while in the facility. Review of Incident Report dated 03/27/2024 at 23:35 revealed patient #1 was found in a female patient’s room hiding behind a door. Both patients in room were in their own beds. Patient #K stated she did not know he was in the room. Director of Nursing (DON), Shift supervisor and practitioner notified. New physician order dated on 3/28/2024 at 13:02 for Level of Observation One to One due to SAO (Sexually Acting Out) and poor boundaries. Review of Patient #2’s admission records reflected, admitted voluntarily on 03/26/2024 with a diagnosis of disruptive mood dysregulation. Per Psychiatric Evaluation dated 03/26/2024, patient has history of running away from home and suicidal ideation. Patient was placed under aggression and elopement precaution while in the facility. Patient #2 was discharged on 04/02/2024. Review of the facility provided Incident Report dated 03/28/2024 at 20:30 revealed, staff heard screaming in hallway, observed patient #1 hitting patient #2 continuously. Staff intervened and separated both patients. Patient #1 had a laceration on right side of scalp and bleeding. One-to-One observation order for patient #1 was still in effect at the time of the incident. Interview with facility’s Director of Quality on 06/25/2024 at 9:50 AM revealed she was unable to provide any documentation showing Patient #2 was provided One to One observation as per order. She confirmed patient #2 was supposed to be on One-to-One Observation at the time of the incident with patient #1. Director of Quality stated facility’s videos are recorded over every 10 days unless purposely saved for future documentation. She stated there was no video available for the incident on 03/28/2024 and for patient #2’s elopement on 03/29/2024. Record review of Narrative Note dated 03/29/2024 at 02:45 showed patient #2 returned from care facility after being evaluated. Later that day at 19:43 note revealed: at 1720 patient #2 was in dining room and burst through the double doors and eloped from the hospital. Code Green was activated, and search initiated. Police report was made and description of patient at time of elopement was provided. Provider and mother notified. Patient #2 was gone for several hours. Interview on 06/24/2024 with mother on of patient #2 stated that the patient told her he did not want to be at the facility any longer after being assaulted.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 39057 Based on record review and interview the facility failed to maintain written Level of Observation report for one of one (Patient #1) patient. Medical records did not have evidence of Level One-to-One Observation. This failure places all the patients in the facility at risk for injury. Findings included: Review of facility’s policy for Levels of Observation and Special Precautions revised 04/2020, Policy Statement: “It is the policy of the hospital to maintain safety and provide care to patients while maintaining their dignity and respect.” Definition: Dangerous to others: “Within the recent past, the individual has inflicted or attempted to inflict or threatened to inflict serious bodily harm on another, or has acted in such a way as to create a substantial risk of serious bodily harm to another, or has engaged in extreme destruction of property; and that there is a reasonable probability that this conduct will be repeated.” Procedure Level of Observation: “The RN may increase the level of observation if the patient’s condition changes. The physician will be notified as soon as possible of the change in condition.” A. The RN may not decrease the level of observation ... B. Staff will complete the patient observation record as rounds are made, using the coding system described on the record. C. Staff documentations will be complete, timely and accurate. D. In addition to recording the whereabouts pf patients at ordered intervals, the purpose of observation is to provide a system of progressive intensity of patient observation, precaution and oversight based on patient acuity, severity and type of symptoms and overall needs. One-to-One Observation (1:1): - A specified and dedicated staff member will stay within approximately one arm’s length of the patient on 1:1 observation. This continuous direct visual observation will continue even when patients shower, change clothes, or use the bathroom ... - The RN will complete a reassessment and documents the findings in the medical record. The findings of the reassessment will be communicated to the attending provider related to whether or not the patient still requires this level of observation. - Note: This level of observation is best used in situations in which it is determined that staff would not be able to successfully intervene in time using constant line of sight observation level. Patient #1 admitted voluntarily on 03/09/2024 with recent history of aggressive, threatening and physically assaultive behaviors. Patient #1 was placed under suicide, elopement, aggression, fall and sexual acting out precaution while in the facility. Physician order dated on 3/28/2024 at 13:02 for Level of Observation One to One due to SAO (Sexually Acting Out) and poor boundaries. Review of the medical records for Patient #1 did not reveal any observation forms or documentation showing patient #1 was receiving One-to-One observation. Incident Report dated 03/28/2024 at 20:30 revealed staff heard screaming in hallway, observed patient #1 hitting patient #2 continuously. Staff intervened and separated both patients. Patient #2 had a laceration on right side of scalp and bleeding. One-to-One observation ordered for patient #1 was still in effect at the time of the incident. Interview with facility’s Director of Quality on 06/25/2024 at 9:50 AM revealed she was unable to provide any documentation showing Patient #1 was provided One to One observation as ordered. She confirmed patient #1 was supposed to be on One-to-One Observation at the time of the incident with patient #2.”