HospitalInspections.org

Based on interview, record review, the hospital failed its hospital patients by protecting and promoting each patient's rights, by employing a graduate nurse as an RN whom has failed to pass the state Nursing Board.

Interview
Through interview with the Hospital Staff #2, it was reported that (Unlicensed Staff "RN") was hired on 07/22/2019 as a graduate nurse and was signing charts as an RN. Unlicensed Staff RN was hired as a graduate nurse with a plan to complete his certification prior to his September 30, 2019 expiration date. The hiring paperwork was never presented to CEO and has never been signed off on. Mrs. Fouch reports was interviewed by former Acting DON and hired by former Interim HR Director. Review of shift round, facility
Per hospital Staff #9, there was a note written on Staff #8's interview evaluation form that says, "NCLEX scheduled August 1."
On 08/19/2019, hosptial Staff #1 was hired as the new Director of Nursing. Staff #7 was still the acting HR Director and Staff #6 was still the acting DON that Staff #1 was not aware that Staff #8 not a registered nurse.

On 11/20/2019, Staff #8 was called into HR at which time he was interviewed by Staff #9 and Staff #1. It was discovered that per Staff #8 had been hired as a GN, had taken the Registered Nurse boards exam, and failed the boards, but never took them again. A copy of the graduate nurse permit was found to have expired on 09/30/2019 per Texas Board of Nursing. Evidently when failed the nursing board. This placed the GN permit expired by default.

Record Review
In review of the hospital Nursing Scheduling software Staff #8 was scheduled as a Nurse from July through November working the units providing direct care to patients as a nurse.
Per nursing scheduling and assignment sheets Staff #8 was labeled an RN and working as an RN. On 08/29/2019, Staff #8 via text notified Staff #7 that he failed to pass his RN boards.
On 11/20/2019, Staff #8 gave Staff #9 a copy of the ACLS certificate, (Note Staff #8 is also an EMT). When the new Staff #9 pulled Staff #8's HR file Staff #9 was not able to find RN licensure verification. He then noted via Texas Board of Nursing verification system that Staff #8 did not have a valid RN license. However, per the Mayhill/ UHS HR system he had been classified and paid as an RN per Staff #9.
On 11/22/2019, Staff #8 was terminated at Mayhill Hospital via telephone during a call with Staff #9 and Staff #1.
In accordance to The hospital SAWYERP (hours accumulated while working 10/05/2019 without any licensure Staff #8 accumulated a total of 220.73 hours from 10/05/2019 through 11/20/19. This allowing Staff #8 to assess 180 patients. Some of these same patients are included within the 180 patients with multiple assessments on the same patient. (ex. Patient #11 assessed 5 times 10/13/2019 through 10/21/2019 by Staff #8.)

The hospital failed 2 of 2 Patient's (Patient #15, and Patient #16) the right to reeive care in a safe setting.

Based on Record Review, Interview, and Observation Patient #15 and Pateint #16 were able to engage in sexual acting out activities during their hospital stay.

Interview
Staff #3 reported Patient #15 now on Gero unit was interviewed in assigned bedroom. Patient #15 was alert and oriented, willing to be interviewed. Patient #15 reported on 11/28/2019 having consensual sex with Patient #16 in the CSU dayroom kitchenette. Indicating it was vaginal intercourse, sustaining no injury. Patient #15 stated Patient #16 then entered into Patient #15's room wanting more sex. Patient #15 indicated it occurred in the bathroom, Patient #16 came in there and stood behind Patient #15 pushed her over, putting his hands on her back and he threatened to beat her up if she told anyone. She further stated she blamed staff that it happened. She indicated that there wasn't enough staff and they were not doing their job. They were at the nurse's station laughing and not watching the patients. Patient #15 reported no injuries, but the hospital could tell she had rough sex. (Not noted, in clinical record from Medical City Denton).

On 11/29/2019 at 0825, Patient #16 was interviewed in his bedroom. Patient #16 was alert and oriented. Patient #16 was smiling and laughing over the incident. Patient #16 acknowledged having sex with Patient #15 on 11/28/2019 twice. Patient #16 reported no injury to self or Patient #15. Reported each incident was consensual. Patient #16 denied forcing or raping Patient #15. Patient #16 stated one incident occurred in the dayroom kitchenette and the other in Patient #15's room. Patient #16 said Patient #15 stated to hurry up, because Patient #15 was afraid they would get caught by staff. Patient #16 indicated Patient #15 provided a telephone number and wanted Patient #16 to call when discharged so they could be together again. Patient #16is provided no further details.

Staff #4 reported, immediately once finding out about the incident Patient #15, was referred to Medical City of Denton for evaluation/SANE exam. Due to Patient #15 reporting that a raped occurred. Patient #15 was interviewed by the police, and they reported there would be no follow - up investigation. There were no charges pressed against Patient #16.
Hospital Staff #5 reported on 11/28/2019, interviewed Patient #16 and informed they had consensual sex in the dayroom. Patient #16's denied having sex with Patient #15 after entering her room. "No, we didn't have sex in Patient #15's room, because Patient #15 was too worried and kept asking if someone was walking by. Then Patient #16 left the room."

The Staff #10 on duty on 11/28/2019 was interviewed and reported, "At 1706 Patient #15 told staff that she 'fucked' Patient #16. Patient #15 was in dayroom speaking about switching food within food trays. Due to Patient #15 giving Patient #16 some meat off of sandwich. Patient #15 then sat in Patient #16's lap bouncing up and down saying, 'give me some more of that dick.' Staff #10 told Patient #15 to get up. Patient #15 then told the staff that she had 'fucked that black dick, earlier today.' Patient #15 got a bible and swore on that she 'fucked Patient #16 twice and wanted some more of that black dick.' Staff #10 asked Patient #15 where was the staff and she reported they waited between staffing rounds were being conducted and looked around and fucked him. Staff #10 asked about the second time and she told staff she fucked Patient #16 in the room bathroom and that she bent over for him again. Patient #15 indicated she liked the 'Big Black Dick' and wanted some more of it. Staff #10 left the dayroom and informed the Staff #1.

Observation
The hospital video footage reflected Patient #15 and Patient #16 engage in sexual conduct. There is a timeline associated with the video footage.

The time line of the camera reflected the following:
This incident took place on 11/28/2019 between Patient #15 and Patient #16.
3:10 PM Hallway cam - Patient #16 disappears in front of alcove by Patient #15's room. Unable to tell if he enters the room

3:12 PM hallway cam - Patient #16 seen in alcove outside of Patient #15's room. Unable to tell if he enters the room.

Shift Change with staff hand off is occurring during this time

Dayroom Cam-

At 3:11 PM Staff #12 entered day room but stopped near the trashcan and could only see the day room not kitchenette.

At 3:11 PM Patient #15 and Patient #16 were seen hugging and physically embracing one another while in kitchenette alcove out of view of staff.

At 3:13 PM Patient #15 slides her pants down to her knees and bend forward, Patient #16 slides his pants down and approached her from behind. He was behind her for 40 seconds.

At 3:14 PM Staff #11walked in dayroom standing in the doorway near the trashcan.
At 3:38 PM Patient #15 approached Patient #16 in dayroom from behind and appeared to be playing with his hair.

Hallway cam 3:54 PM Patient #15 seen in hallway speaking to Staff #1 and Staff #5.

Hallway cam 4:53 PM while Patient #16 was in his room Patient #15 was observed entering his room, but only staying about 6 seconds.

Dayroom cam - 5:07 PM while eating dinner Patient #15 got up from the table, walked over to Patient #16 and sat on his lap. Patient #11 was present in the Kitchenette alcove an overhears the comment by Patient #15 to Patient #16.

Dayroom Cam - 5:47 PM Staff #1, Staff #11 observed speaking privately with Patient #15 in day room. Afterwards Staff #1 walked down and checked/looked into Cordreals room.

6:43 PM last female patient on CSU was moved to another unit away from Patient #16 during investigation.

Hallway Cam - 6:57 pm EMT arrive with gurney and take Patient #15 off of the unit to ER for exam.

11/28/19 both patients were placed on SAO precautions

Patient #16 remained on CSU.


Policy:
The hospital Policy on Abuse and Neglect dated 05/2019 reflected, "Mayhill Hospital will maintain an environment free of Abuse and Neglect. All potential new employees will be screened for a history of abuse, neglect or mistreatment of patients ...It is the policy ...to report alleged and suspect abuse and neglect to the Texas Department of Health and appropriate authorities in accordance with state and federal statutes. The staff member who conducts the screening and has cause to suspect abuse has occurred is legally responsible for reporting ...All staff provided with education on identification of abuse and neglect, including sexual abuse of a minor ...Prevention of abuse will be communicated to families and staff. There are encouraged to report concerns of incidents, and grievances without fear of retribution."

The hospital Policy on Levels of Observation dated 10/2017 reflected, "All patients will be routinely observed in compliance with physician orders and prescribed protocols."

The hospital Patient Rights dated 06/2016 reflected, "It is the policy of this hospital to ensure that all patients receive a copy of the Patient's Bill of Rights form, as well as an oral explanation of those rights, both in their primary language and in simple non-technical terms. We will strive to abide by and respect all patient rights without regard to race, religion, creed, ethnicity, gender, age, sexual orientation, or handicap shall support and protect the fundamental human, civil constitutional and statutory rights of the individual patient and recognize and respect personal dignity of the patient at all times."

The hospital Policy on Abuse and Neglect dated 05/2019 reflected, "Mayhill Hospital will maintain an environment free of Abuse and Neglect. All potential new employees will be screened for a history of abuse, neglect or mistreatment of patients ...It is the policy ...to report alleged and suspect abuse and neglect to the Texas Department of Health and appropriate authorities in accordance with state and federal statutes. The staff member who conducts the screening and has cause to suspect abuse has occurred is legally responsible for reporting ...All staff provided with education on identification of abuse and neglect, including sexual abuse of a minor ...Prevention of abuse will be communicated to families and staff. There are encouraged to report concerns of incidents, and grievances without fear of retribution."

Based on interview, record review, the hospital failed its hospital patients by protecting and promoting each patient's rights, by employing a graduate nurse as an RN whom has failed to pass the state Nursing Board.

Interview
Through interview with the Hospital Staff #2, it was reported that (Unlicensed Staff "RN") was hired on 07/22/2019 as a graduate nurse and was signing charts as an RN. Unlicensed Staff RN was hired as a graduate nurse with a plan to complete his certification prior to his September 30, 2019 expiration date. The hiring paperwork was never presented to CEO and has never been signed off on. Mrs. Fouch reports was interviewed by former Acting DON and hired by former Interim HR Director. Review of shift round, facility
Per hospital Staff #9, there was a note written on Staff #8's interview evaluation form that says, "NCLEX scheduled August 1."
On 08/19/2019, hosptial Staff #1 was hired as the new Director of Nursing. Staff #7 was still the acting HR Director and Staff #6 was still the acting DON that Staff #1 was not aware that Staff #8 not a registered nurse.

On 11/20/2019, Staff #8 was called into HR at which time he was interviewed by Staff #9 and Staff #1. It was discovered that per Staff #8 had been hired as a GN, had taken the Registered Nurse boards exam, and failed the boards, but never took them again. A copy of the graduate nurse permit was found to have expired on 09/30/2019 per Texas Board of Nursing. Evidently when failed the nursing board. This placed the GN permit expired by default.

Record Review
In review of the hospital Nursing Scheduling software Staff #8 was scheduled as a Nurse from July through November working the units providing direct care to patients as a nurse.
Per nursing scheduling and assignment sheets Staff #8 was labeled an RN and working as an RN. On 08/29/2019, Staff #8 via text notified Staff #7 that he failed to pass his RN boards.
On 11/20/2019, Staff #8 gave Staff #9 a copy of the ACLS certificate, (Note Staff #8 is also an EMT). When the new Staff #9 pulled Staff #8's HR file Staff #9 was not able to find RN licensure verification. He then noted via Texas Board of Nursing verification system that Staff #8 did not have a valid RN license. However, per the Mayhill/ UHS HR system he had been classified and paid as an RN per Staff #9.
On 11/22/2019, Staff #8 was terminated at Mayhill Hospital via telephone during a call with Staff #9 and Staff #1.
In accordance to The hospital SAWYERP (hours accumulated while working 10/05/2019 without any licensure Staff #8 accumulated a total of 220.73 hours from 10/05/2019 through 11/20/19. This allowing Staff #8 to assess 180 patients. Some of these same patients are included within the 180 patients with multiple assessments on the same patient. (ex. Patient #11 assessed 5 times 10/13/2019 through 10/21/2019 by Staff #8.)

Policy

The hospital Policy on Rules and Regulations dated 01/2019 are as follows:
"15. Member Information/Licensure/Malpractice Insurance;
2. Each Member is responsible for informing the Medical Staff Office immediately of any change in status of his:
1. Licensure status ...
20. Standards of Practice
1. In general, the standards of the practice of psychiatry and clinical psychology in the Facility shall be governed by the standards of practice prevailing within the community. The Medical Director is accountable for the quality of practice within the Facility and may ask a Member to alter temporarily aspects of the treatment to a patient when, in judgment of the Medical Director"

The hospital Patient Rights dated 06/2016 reflected, "It is the policy of this hospital to ensure that all patients receive a copy of the Patient's Bill of Rights form, as well as an oral explanation of those rights, both in their primary language and in simple non-technical terms. We will strive to abide by and respect all patient rights without regard to race, religion, creed, ethnicity, gender, age, sexual orientation, or handicap shall support and protect the fundamental human, civil constitutional and statutory rights of the individual patient and recognize and respect personal dignity of the patient at all times."