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Based on Record Review, Interview and Observation the hospital failed Patient #1 and Patient #12 by failing to ensure the Patient was kept in a safe setting.


Findings Include:

During Record Review the hospital Admission Nursing Assessment, 02/15/2024 at 0402AM, "Patient is Lactose Intolerant." Patient #1 had no record of follow up in the medical record indicating the patient was cared for or treated.

During Interview the hospital Staff #1 and Staff #2 was unaware that Patient #1 was Lactose Intolerant.

During Interview with hospital Staff #4 and Record Review 03/13/2024 at 3:30 PM provided the cafeteria menu's during the time Patient #1 was admitted into the hospital. There was an opportunity at each meal for Patient #1 to have non-dairy products. Patient #1 was noted to be on the Lactose Intolerant meal plan, but Staff #1 reported Patient #1 was on a regular diet and could not control what Patient #1 did once on the table.

During Observation Patient #1 was observered seated in the milieu with peers. Patient #12 was down the hallway with Staff #3. Patient #1 appears to hear Patient #2 kicking doors and yelling in the hallway. Patient #1 stood up and ran down the hallwayand tackled Patient #12. There is no documentation in Patient #1 or Patient #2's medical record addressing this situation. The patients were quickly separated, and there were no visible injuries noted on this observation. The incident occured on 02/20/2023 at 6:35PM.

Policy
The hospital policy on Abuse, Neglect, Exploitation, Unethical or Unprofessional Conduct, dated 07/17/2019 reflected, "Perimeter Healthcare promotes and requires professional, ethical and legal conduct of staff. The advocacy role of health care is maximized when addressing issues of conduct of staff. Perimeter Healthcare assesses the conditions of illegal, unethical and/or unprofessional conduct of staff. All health care services providers will immediately report to the appropriate supervisors, manager, or department head any suspected illegal, unethical and/or unprofessional conduct by another individual.

The hospital Policy on Patient Rights dated 07/17/2019, reflected, "The rights, benefits, responsibilities, and privileges guaranteed by the constitutions and laws of the United States of Texas unless they have been restricted by specific provisions of law. The rights include, but are not limited to, the right to impartial access to and provision of treatment, regardless of race, nationality, religion, sex, ethnicity, sexual orientation, age, or disability; the right to petition for habeas corpus; the right to register and vote at elections, the right to acquire use, and dispose of property including contractual licenses, permits, privileges and benefits under law, the right to religious freedom and rights concerning domestic relations."

The hospital Policy on Nursing Services 07/17/2019 reflected, "An accurate record of the patient's condition, care, and treatment is provided throughout the hospital visit. Screening and admission assessment and histories are completed upon arrival to the hospital and during the admission process on the inpatient units. Reassessments are documented when there is a significant change in patient status. Post procedure, etc. Patient information obtained, during reassessments will be post procedure, etc. Patient information obtained during reassessments will be documented in the patient's medical record.