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Note: The CMS-2567 is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. If information is inadvertently changed by the provider, you should notify the state Survey Agency. If the SA notices any discrepancy in the information related to scope and severity assigned or the deficiency citation (s), the SA will report this occurrence to the Dallas Regional Office. The Regional Office will make a referral of possible fraud to the Office of the Inspector General (OIG).
An unannounced complaint survey was conducted in accordance with the relevant sections of the State Operations Manual (SOM). Appendix A-Survey Protocol, Regulations and Interpretive Guidelines for Hospitals was utilized to determined hospital's compliance with 42 CFR 482 Conditions of Participation (CoP) for Hospitals regarding: Governing Body, Patient Rights, Quality Assessment/Performance Improvement, Nursing Services and Infection Control.
An entrance conference was held on the morning of 4/11/19 with key administrative personnel. The purpose, scope, and process of the complaint survey was explained and an opportunity for questions and discussion was provided.
An exit conference was held on the afternoon of 4/16/19 with key administrative personnel. Preliminary findings of the investigation were discussed and again, an opportunity for questions and discussion was provided.
Complaint #TX00309578 was substantiated with deficiencies cited
Complaint #TX00306375 was substantiated with deficiencies cited
The facility's noncompliance has placed the health and safety of patients in its care at risk for serious injury, serious harm, serious impairment, or death. The deficient practices were determined to pose Immediate Jeopardy under the following Conditions of Participation:
42 CFR 482.13, Patient Rights
42 CFR 482.21, QAPI
The facility failed to provide care in a safe setting. This failure resulted in:
A. Patients on suicide precautions being placed in bedrooms and on a psychiatric unit that had multiple observable ligature risks. These ligature points could be used to attach material for the purpose of hanging or strangulation.
B. Patients being assessed for suicide risk with two different suicide risk assessment tools during the admission process in the Intake Department. This resulted in contradictory suicide risk assessment findings. Such contradictory findings created confusion as to the actual suicidal risk of the patient.
C. A patient being assessed as a "high" risk for suicide on the SADPERSONS assessment tool and not being placed on a 1:1 as is delineated in the facility's policies. Such actions can compromise the safety of suicidal patients and have the likelihood to cause serious injury, impairment, or death.
D. A patient being in bed with the bedroom door closed during a scheduled group time. Such actions do not follow the facility's observation policies by allowing patients in unobserved areas.
E. Patients in bedrooms and on a psychiatric unit with numerous screws that were not tamper resistant. Fifty percent of these patients were on suicide precautions. Such hardware has the potential to be used for serious self-harm by patients.
Cross reference: A-0144
The facility was notified of the Immediate Jeopardy findings on the afternoon of 04/16/2019. The facility provided an acceptable plan to remove the Immediate Jeopardy. This plan included:
1. Regular 15-minute rounds will continue to be done by CNAs (Certified Nursing Assistants) and Psychiatric Technicians.
2. Real-time surveillance monitoring allowing a single clinician from the nursing station to have visibility to all areas simultaneously will also continue. This includes visibility of all bedroom doors and door handles. The station is manned 24/7 by a staff member, indicated on the assignment sheet for each shift, dedicated solely to the purpose of monitoring the environment. Policy has been created to govern this process. Staff have been in-serviced on the new policy and process.
3. A new paper-based, and evidence based, suicidal assessment and reassessment will be implemented in admissions and on the behavioral unit by Friday, 04/19/2019.
4. Patients identified as high suicide risk will be placed immediately on 1:1.
5. Patients identified as moderate suicide risk will be placed immediately on close observation.
6. All other ligature risks in patient rooms 100, 101, 102, 202, 203, 204, and 205 (beds to be bolted to the floor, access to toilet piping, shelves installed next to skins, and soap dispensers) will be remedied by 04/22/2019 and will be dedicated first to acutely suicidal patients.
7. All other rooms (same issues) will be remedied by 04/26/2019.
The Chief Executive Officer, Chief Operating Officer, and Director of Quality and Risk were provided a copy of the written CMS IJ template on 04/17/2019 at 12:11 PM.
Glossary.
ADHD - Attention Deficit Hyperactivity Disorder. ADHD is a disorder that makes it difficult for a person to pay attention and control impulsive behaviors. He or she may also be restless and almost constantly active. ADHD is not just a childhood disorder. Although the symptoms of ADHD begin in childhood, ADHD can continue through adolescence and adulthood.
Auditory hallucinations. Auditory hallucinations are most commonly experienced by people with schizophrenia and may include hearing voices-sometimes multiple voices - or other sounds like whispering or murmuring. Voices may seem angry or urgent and often make demands on the hallucinating person.
Benzodiazepines - a class of drugs primarily used for treating anxiety.
Bipolar I Disorder - A form of mental illness also known as manic depressive disorder. It is characterized by episodes of abnormally elevated mood and high energy known as manic episodes. Most people with bipolar I disorder also suffer from episodes of depression.
Generalized Anxiety Disorder. Generalized Anxiety Disorder is characterized by six months or more of chronic, exaggerated worry and tension that is unfounded or much more severe than the normal anxiety most people experience.
Major Depressive Disorder. Depression (major depressive disorder or clinical depression) is a common but serious mood disorder. It causes severe symptoms that affect how you feel, think, and handle daily activities, such as sleeping, eating, or working. To be diagnosed with depression, the symptoms must be present for at least two weeks.
Odontoid fracture - break in the peg-like part of the second bone in the neck
Psychosis - used to describe conditions that affect the mind, where there has been some loss of contact with reality.
SADPERSONS - screening tool for suicide risk in those who have self-harmed.
Subarachnoid hemorrhage - a life threatening bleeding into the space surrounding the brain.
Schizoaffective Disorder - a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression.
Schizophrenia - a serious mental disorder in which people interpret reality abnormally. Schizophrenia may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning, and can be disabling.
Subdural hematoma - collection of blood over the surface of the brain.
Status post. It basically means the condition (or status) after (or post) an event. For example, status post overdose refers to a patient's condition following an overdose.
Suicide Precautions - measures taken in advance to prevent an individual from taking their own life.
Visual hallucinations. Visual hallucinations involve seeing objects, people, lights, or patterns that are not actually present.
Xanax - a benzodiazepine that is indicated for management of anxiety disorders.
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