HospitalInspections.org

Based on video review, review of facility incident reports and patient record review, and confirmed in interview, the facility failed to promote each patient's rights when the facility failed to:

A. ensure staff followed provider's order for patient monitoring for one of three patients reviewed (Patient #A) refer to A0144-C
B. ensure each patient had the right to be free from all forms of abuse or harassment as the facility did not follow their policy related to the investigation of actual events of sexual allegations; placing all patients at risk of delayed investigations. refer to A0145

The deficient practices were identified under the following Condition of Participation §482.13 Patient's Rights, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk
for the likelihood of harm, serious injury, and possible death.

Review of records and updated policy confirmed IJ abated on 02/20/2025 at 10:10 AM.

Based on observation, interview, and record review, the facility failed to provide care in a safe setting for 2 of 5 patients (Patient A, Patient B). This was evidenced by the facility's failure to ensure that:
a. 1 of 3 patients (Patient B), a 15-year-old adolescent with an emergency medical condition, was transferred as quickly as possible to a medical facility for treatment of nonstop nausea, vomiting, and severe abdominal pain following a Tylenol overdose. Additionally, the facility failed to ensure that an accurate On-Call Schedule that outlined medical coverage was available to the nurses.
b. 2 of 4 staff members, Staff #3 (Intake Assessor) and Staff #9 (Unit RN on the Adolescent Unit), were able to describe the side effects of Tylenol overdose.
c. 1 of 3 patients (Patient A) were monitored per provider's order for patient monitoring

Findings were:

a. Transfer of Patient B.

Record review of policy 16488078, "Transfer to Another Facility (Texas Only)," last reviewed by Staff #6 (VP of Nursing) on 09/2024, showed:
Transfer of Patients Who Have Emergency Medical Conditions. A. If a patient at the Hospital has an emergency medical condition that has not been stabilized ... because the Hospital does not have the appropriate equipment or personnel to correct the underlying process ..., evaluation and treatment shall be performed, and transfer shall be carried out as quickly as possible.

Record review of policy 17374043, "On-Call Policy," last reviewed by Staff #6 (VP of Nursing) on 01/2025, showed:
Purpose ... To establish a process of notifying the ... Physician on Call ...
Each Hospital will create a Physician On-Call Schedule. A physician will be available for consultation 24 hours per day ... to determine if presenting patients have an emergency medical condition (EMC) ... that exceeds the facility's capacity to treat ... will be transferred via safe transport to a facility that can provide definitive treat for their EMC.

Record review of the Consultation/Management and Medical Clearance for Patient B, dated 01/08/2025 at 6:48 PM by Staff #14 (DO) showed:
MOT. Voluntary.
Blood Pressure 115/68, Pulse 70, Respirations 16, Temperature 98.2.
Recent overdose with Tylenol 20 tablets at 3:00 AM. Patient may be accepted based on clinical review.
Medical clearance - Yes

Record review of the Physician's MOT Orders and Preliminary Plan of Care for Patient B, dated 01/08/2025 at 6:48 PM by Staff #14 (DO) showed:
Medical consult for physical exam within 24 hours of admission.
Psychiatric consult for complete admission psychiatric exam within 24 hours of admission.

Record review of the Screening Assessment for Patient B, dated 01/08/2025 at 8:19 PM by Staff #3 (Intake Assessor), showed an "impulsive" suicide attempt "last night" with Tylenol and a previous suicide attempt in 2020.

Record review of Nursing Admission Assessment for Patient B, dated 01/08/2025 at 9:50 PM by Staff #17 (RN-adolescent unit) showed:
Pain Assessment with pain level at 7 (scale of 0-10). Constant. Abdomen. Cramping. "It's nonstop." "Vomiting due to OD on Tylenol."
Pain at its best = 4; at worst = 9.
Nausea/vomiting.

Record review of the Inpatient Therapy Note for Patient B dated 01/09/2025 at 12:32 PM by Staff #15 showed: Patient nauseous.

Record review of the Inpatient Comprehensive Psychiatric Evaluation for Patient B, conducted on 01/09/2025 at 12:59 PM by Staff #8 [MD-attending], showed a 15-year-old adolescent female admitted per MOT for treatment of a Tylenol overdose. She complained of abdominal pain and nausea. She was placed on suicide precautions and line of sight observations.
Diagnoses: Major depressive disorder, recurrent, severe, without psychotic features and Cannabis use disorder, mild.
Problems: Chronic illness with SEVERE exacerbation, progression, or side effects of treatment.
Risk: Drug therapy requiring intensive monitoring for toxicity.

Record review of Medication Administration Record for Patient B showed Zofran 4mg given as a PRN by Staff 16 (RN) on 01/09/2025 at 2:34 PM.

Record review of the January 2025 On-Call Schedule showed the following medical coverage:
01/08/2025, 7p-7a Staff #10 (MD)
01/09/2025, 7a-7p Staff #11 (NP)
01/09/2025. 7p-7a Staff #12 (DO)

Record review of the Nursing Shift Progress Note for Patient B, dated 01/09/2025 at 3:25 PM by Staff #9 (RN - adolescent unit), showed:
Patient was admitted last night after being medically cleared after a Tylenol overdose. It was reported that patient was having nauseated [sic], vomiting, and right lower abdominal pain that comes and goes. Night shift reported that they called the on-call provider, and the provider did not answer. Throughout the day, the patient continued to vomit, and have nausea and the right lower abdominal pain. Day shift nurses continued to try and call the listed on-call provider. It was then discovered that the scheduled on-call provider (Staff #11, NP) was being covered for by Staff #12, DO. Staff #12 was then notified about the situation. Patient received Zofran ordered by Staff #8 (MD) which was somewhat helpful. Patient reported increased right lower abdominal pain radiating to her back. Notified Staff #12 of the worsening of the situation. Staff #12 ordered for patient to be transferred out for medical clearance. Notified nursing supervisor Staff #13, Staff 8 (MD-attending), and [patient's] mother.
Vital Signs - Blood pressure 110/55, Heart rate 101 [Note: heart rate increased from 70 on admission to 101], Respirations 20, Temperature 100.2 [Temperature was 98.2 on admission], SpO2 98% room air ...
Ambulance arrived at 5:15 PM.

In an interview with Staff #9 (RN) on 02/19/2025 at 1:54 PM, she stated, after reviewing her documentation in the Nursing Shift Progress Note for Patient B dated 01/09/2025 at 3:25 PM, the following.
" She did not know how many times the night shift had attempted to call the on-call provider and not get an answer.
" She did not know when the calls were made.
" She did not know if anyone tried to reach the Administrator on Call.
" She could not remember the times that the day shift nurses tried to call the on-call provider.
" She did not know when the patient reported increased right lower abdominal pain radiating to her back.
" She should have provided the time frames within her narrative note for clarification and accuracy.

Record review of the Nursing Shift Progress Note for 7pm-7 am on 01/08/2025 (beginning 7 PM on 01/08/2025 and ending at 7 AM 01/09/2025) did not document any phone calls to the on-call provider or the Administrator on-call.

Record review of Physician Orders for Patient B ordered by Staff #12 (DO) on 1/9/2025 at 3:45 PM showed: Medical transfer to emergency department/hospital.
Pain, nausea/vomiting (PER PARENTAL REQUEST)


b. Staff's knowledge of Tylenol overdose.

Record review of "Acetaminophen Overdose" from the National Library of Medicine - MedlinePlus, updated 01/02/2023, showed:
Acetaminophen (most common brand name Tylenol) is a pain medicine. Acetaminophen overdose occurs when someone takes more than the recommended amount of this medicine. Acetaminophen overdose is one of the most common poisonings. People often think that this medicine is very safe. However, it can be deadly if taken in large doses ... Taking ... 7,000 mg or more, can lead to a severe overdose problem ...
Symptoms may include: Abdominal pain, upset stomach, appetite loss, coma, seizures, diarrhea, irritability, jaundice (yellow skin and whites of the eyes), nausea/vomiting, and sweating.
https://medlineplus.gov/ency/article/002598.htm

Record review of the "Screening Assessment" for Patient B dated 01/08/2025 at 8:19 PM by Staff #3, an Intake Assessor, showed: Suicide attempt by Tylenol "last night." The patient denied pain. Neither the amount of Tylenol taken, nor the time of the overdose were documented.

In an interview with Staff #3, an Intake Assessor, on 02/19/2025 at 11:57 AM, she stated she saw Patient B in the Intake Department. She also stated Patient B had overdosed on Tylenol. When asked if she knew what the symptoms of Tylenol overdose were, she replied she was unsure.

In an interview with Staff #9, an RN on the adolescent unit, on 02/19/2025 at 1:54 PM, she stated she worked the day shift on the adolescent unit on 01/09/2025, the day Patient B was transferred to Texas Children's Hospital. She reviewed her documentation on Patient B dated 01/09/2025 at 3:25 PM. When asked if she knew what the symptoms of Tylenol overdose were, she replied, "I really don't know."

In an interview with Staff #4 (Medical Director) on 02/19/2025 at 1:20 PM, he stated that staff's lack of knowledge of Tylenol overdose needed to be addressed.





38387

c. line of sight monitoring

Review of the facility policy Levels of Observation and Precautions (PolicyStat ID 14807112, effective 03/2024) it stated under Line of Sight (LOS) observation: "this level of observation is very restrictive and involves continuous visual monitoring at all times. Documention should reflect the need for continued line of sight or improvement in behaviors. Staff must be within visual contact of the patient at all times. A staff member may observe more than one patient on line of sight observation only while those patients remain in an area for scheduled activity. If a staff member is observing more than one patient and one or more of the patients go to separate areas, the staff must transfer responsibility for line of sight to other staff members so that there is continuouse observation of all patients on line of sight preautions."

Review of Patient A chart revealed she is a 51 year old female with a longstanding history of schizophrenia brought in on an emergency detainment order. She stated she was having command thoughts and would hear voices internally expressing to harm herself. Review of the chart orders revealed a LOS was ordered at her date of admission (02/09/2025).

Review of the staffing sheet for 02/12/2025 revealed 2 nurses (and 1 nurse training) and three techs with a census of 23 patients. Staff #21 was assigned LOS observation for Patient A and Patient M along with Q15 rounds for six other patients.

Review of the 2/12/2025 video incident with Staff #2 on 02/19/2025 at 10:40 AM revealed no tech observing Patient #A per facility policy for LOS. Patient A in room 9 also had her door closed from 9:00 PM to 9:30 PM.

An interview with Staff #2 on 02/20/2025 at 1:40 PM in the conference room confirmed the above findings. She stated that there were discussions to downgrade her observation levels but nothing was documented nor ordered.

Based on review of facility policy, review of facility incident reports and patient record review, and confirmed in interview, the facility failed to ensure patients are free from all forms of abuse or neglect by failure of staff not following their policy related to the investigation of actual events of sexual allegations; placing all patients at risk of delayed investigations for one of three patients (Patient A) reviewed.

Findings included:

Review of the facility policy Incident Report Protocol and Patient Safety Events (PolicyStat ID 15693888, effective 04/2024) it stated "it is the responsibility of all staff to report all patient safety incidents, accidents, or injuries involving patients or visitors and to report such occurrences using the Incident Reporting System along with notifying their supervisor immediately."

Review of facility incident reports revealed an incident occurred on 2/12/25 around 9:00-09:30 PM when Patient C entered Patient A's room (room 9) to sexually assault her in the bathroom. Patient A and Patient C were alone in the room for eleven minutes (09:16 PM to 9:27 PM). Patient D notified Staff #21 that Patient A and Patient C were in the bathroom at about 9:30 PM. After the notification, Staff #21 entered the room and found Patient C in the bathroom getting dressed and Patient A in the bedroom dressed.

Review of the incident report above revealed it was reported on 2/13/25 by the Patient D, the roommate of Patient A. Patient D made the outcry to the nursing staff the following morning on 02/13/2025 at 08:30 AM. No report was made by Staff #21, who witnessed the two patients in the room. Patient A was not assessed for injuries, nor was Patient C placed in a blocked room after the incident on 2/12/2025.

The facility did not follow their policy related to the investigation of actual events of sexual allegations, placing all patients at risk of delayed investigations.

In an interview with Staff # 2 on 02/19/2025 at 10:50 AM in the CEO office confirmed the above findings. She stated that after the notification the following day, the facility sent Patient A for a sane exam and Patient C was placed in a room in an opposite hallway away from Patient A.