HospitalInspections.org

Based on a review of patient records, facility policies, and staff interviews, the facility failed to ensure a safe setting for patients.

Findings were:

Review of the clinical records of Patient # 1 and # 2 revealed that Patient # 1 was involved in an incident with Patient # 2 on 08/17/12. According to documentation Patient # 2 entered the open seclusion room when Patient # 1 was sleeping. Per Patient # 1, Patient # 2 grabbed her breast and exposed his genitals to her.

According to a facility based incident report, "Patient (# 1) was in open seclusion room due to agitation and requiring a less stimulus in milieu. Patient (# 2) went into the next seclusion and told a female patient (# 2) he wanted to have sex with her. She (Patient # 1) informed staff member... While the two staff were talking female patient (# 1) came running out of the open seclusion room with male patient (# 2) following her with his penis in his hand. Male patient (# 2) stated ' she ' s lying on me she ' s lying on me ' even before staff members had asked what happened. Female patient (# 1) reported that male (Patient # 2) came into the open seclusion touched her breast and has his penis out of his pants."

Review of the record for Patient #1, a female patient, revealed a male patient exposed himself to her and " grabbed her breasts " based on the following social worker notes:
8/16/12 Patient #1 " tried to hurt herself by putting a pillow on her face around 11 am today. She then stated she was assaulted by another patient who walked into room in the afternoon. "
8/16/12 " MSW was to see patient but she was sexually assaulted by a male patient who touched her/exposed himself. She agreed to press charges. Patient is seeing the sexual assault team which includes police officer + female volunteer. "
8/17/12 " She put a cloth around her neck in a suicide attempt. She feels hopeless + distress with the sexual assault. "
8/21/12 " Upon this hospitalization 8/14/12 - patient was sexually assaulted in the Shoal Creek by another patient 8/16/12. She was suicidal after this incident, and was on a one to one - took a cloth and put it around her neck. "

Review of the record for Patient #1 revealed the following nursing notes:
Nursing notes documented the following:
8/16/12 at 1330 stated, " Emerged from open seclusion followed by male peer with genitals exposed - reports male peer came into room requesting sex, exposing himself & grabbed her breasts. "
8/16/12 at 1500 " late note ...RN was asked to be with pt during [illegible]. Pt told RN that male pt had come into her rm on 8-15 & asked her for oral sex. Pt said she did not tell anyone today male pt came into her rm 2 times asking for oral sx & showed pt his penis. Emotional support given & pt was told staff would keep her safe. "

Review of facility policy, " Coordination of Care Treatment/Discharge Plan " stated, in part, " The Master Treatment Plan shall address each problem that is identified as a priority to address in treatment during the current hospitalization ....PURPOSE I. To provide a working document for current treatment during inpatient hospitalization ...As indicated thereafter, add objectives to goals already set, or identify new problems and goals ...Subsequent to the initial staffing conference,..
B. Add new problems to Master Treatment Plan based on assessment data documented according to discipline-standards. C. Update prioritized problem list on first page of Master Treatment Plan. "

Review of facility policy, " Assessing/Reassessing a Patient " stated, in part, Plan of Care.
1. After completing the initial assessment, the RN will develop a nursing plan of care.
2. As appropriate, members of the healthcare team, based on the patient needs and problems as identified in the various screenings and assessments , will establish and prioritize an interdisciplinary plan of care and update the plan of care when the patients ' needs and priorities change. "

Review of the treatment plan for Patient #1 revealed that the Interdisciplinary Master Treatment Plan was initiated on 8/14/12 and last signed on 8/16/12. There was no documented evidence that the Interdisciplinary Master Treatment Plan was ever updated to reflect the patient ' s reported suicide attempt, the incident involving another patient grabbing her breasts and exposing himself to her, or the increase to 1:1 observation status.

Facility Based Policy entitled Abuse & Neglect: Elderly and Disabled stated in part, " Abuse means sexual abuse or the negligent or willful infliction of injury, unreasonable confinement, intimidation, or cruel punishment with resulting physical or emotional harm or pain to an elderly or disabled person by the person ' s caretaker, family member or other individual who has an ongoing relationship with the patient.
Sexual Abuse includes any involuntary or nonconsensual sexual conduct that would constitute an offense under the Penal Code, Section 21.08 (indecent exposure) or Penal Code, Chapter 22, (assaultive offenses) committed by the person ' s caretaker, family member, or other individual who has an ongoing relationship with the elderly or disabled person ...
B. Allegations Against A Seton Employee or Seton Patient
When any Seton associate or contracted person suspects abuse, neglect, or exploitation perpetrated by an employee or a patient at a Seton facility, that person shall immediately report it to the Texas Department of State Health Services ...
Safeguarding those involved (alleged victim & alleged perpetrator) and securing any evidence;
Taking necessary action to provide immediate medical and psychological attention to the victim and alleged perpetrator. "

Patient # 2, a male patient, continued to harass other patients sexually after this incident on 08/17/12. A review of Patient # 2's medical record reveled the following nursing notes:

Nursing Note dated 08/17/12 at 1830 stated, " Pt. was sitting next to a female patient and asked her for sex and touched patient. Patient became angry. Patient told to go to open seclusion and informed again not to talk to or touch female patients. Patient standing up against nurses station window and had zipper unzipped and fingers fondling himself. Pt. redirected to open seclusion. "

Nursing Note on 08/18/12 at 1130 stated in part, " ...advised to have staff monitor patient closely when near other patients and listen to pt ' s conversations r/t frequent request for sexual favors and exposing himself to peers previous days. "

Based on a review of documentation and interviews, the facility failed to ensure that clients receiving mental health services were free from mistreatment, abuse, neglect, and exploitation.

Findings were:

Facility Based Policy entitled Abuse & Neglect: Elderly and Disabled stated in part, " Abuse means sexual abuse or the negligent or willful infliction of injury, unreasonable confinement, intimidation, or cruel punishment with resulting physical or emotional harm or pain to an elderly or disabled person by the person ' s caretaker, family member or other individual who has an ongoing relationship with the patient.
Sexual Abuse includes any involuntary or nonconsensual sexual conduct that would constitute an offense under the Penal Code, Section 21.08 (indecent exposure) or Penal Code, Chapter 22, (assaultive offenses) committed by the person ' s caretaker, family member, or other individual who has an ongoing relationship with the elderly or disabled person ...
B. Allegations Against A Seton Employee or Seton Patient
When any Seton associate or contracted person suspects abuse, neglect, or exploitation perpetrated by an employee or a patient at a Seton facility, that person shall immediately report it to the Texas Department of State Health Services ...
Safeguarding those involved (alleged victim & alleged perpetrator) and securing any evidence;
Taking necessary action to provide immediate medical and psychological attention to the victim and alleged perpetrator. "

Review of the clinical records of Patient # 1 and # 2 revealed that Patient # 1 was involved in an incident with Patient # 2 on 08/17/12. According to documentation Patient # 2 entered the open seclusion room when Patient # 1 was sleeping. Per Patient # 1, Patient # 2 grabbed her breast and exposed his genitals to her.

According to a facility based incident report, "Patient (# 1) was in open seclusion room due to agitation and requiring a less stimulus in milieu. Patient (# 2) went into the next seclusion and told a female patient (# 2) he wanted to have sex with her. She (Patient # 1) informed staff member... While the two staff were talking female patient (# 1) came running out of the open seclusion room with male patient (# 2) following her with his penis in his hand. Male patient (# 2) stated ' she ' s lying on me she ' s lying on me ' even before staff members had asked what happened. Female patient (# 1) reported that male (Patient # 2) came into the open seclusion touched her breast and has his penis out of his pants."

Review of the record for Patient #1, a female, revealed that she was on Precautions for Suicide and Self-Injurious Behavior.

Nursing notes documented the following:
8/15/12 at 0940 and 1200 documented that the patient was on " line-of-sight monitoring. "
8/16/12 at 0845 stated " Will cont close monitor, assess safe environment. "
8/16/12 at 1215 stated, " Reported to group leader that she wrapped linen around neck in attempt to hang herself ...Placed on total line-of-sight monitor. Will sleep in open seclusion room absent of linen. "
8/16/ at 1330 stated, " will cont line of sight monitor. "

Despite the " line of sight monitoring " and the Suicide and Self-Injurious Behavior Precautions monitoring, a male patient was able to enter the open seclusion room where the patient was and expose himself to her and grab her breasts.

Nursing notes documented the following:
8/16/12 at 1330 stated Patient #1 " Emerged from open seclusion followed by male peer with genitals exposed - reports male peer came into room requesting sex, exposing himself & grabbed her breasts. "
8/16/12 at 1500 " late note ...RN was asked to be with pt during [illegible]. Pt told RN that male pt had come into her rm on 8-15 & asked her for oral sex. Pt said she did not tell anyone today male pt came into her rm 2 times asking for oral sx & showed pt his penis. Emotional support given & pt was told staff would keep her safe. "

Review of the record for Patient #1, a female patient, revealed a male patient exposed himself to her and " grabbed her breasts " based on the following social worker notes:
8/16/12 Patient #1 " tried to hurt herself by putting a pillow on her face around 11 am today. She then stated she was assaulted by another patient who walked into room in the afternoon. "
8/16/12 " MSW was to see patient but she was sexually assaulted by a male patient who touched her/exposed himself. She agreed to press charges. Patient is seeing the sexual assault team which includes police officer + female volunteer. "
8/17/12 " She put a cloth around her neck in a suicide attempt. She feels hopeless + distress with the sexual assault. "
8/21/12 " Upon this hospitalization 8/14/12 - patient was sexually assaulted in the Shoal Creek by another patient 8/16/12. She was suicidal after this incident, and was on a one to one - took a cloth and put it around her neck. "

Patient # 2, a male patient, continued to harass other patients sexually after this incident on 08/17/12. A review of Patient # 2's medical record reveled the following nursing notes:

Nursing Note dated 08/17/12 at 1830 stated, " Pt. was sitting next to a female patient and asked her for sex and touched patient. Patient became angry. Patient told to go to open seclusion and informed again not to talk to or touch female patients. Patient standing up against nurses station window and had zipper unzipped and fingers fondling himself. Pt. redirected to open seclusion. "

Nursing Note on 08/18/12 at 1130 stated in part, " ...advised to have staff monitor patient closely when near other patients and listen to pt ' s conversations r/t frequent request for sexual favors and exposing himself to peers previous days. "

Based on review of the medical record, the facility failed to protect patient # 1 and other patinets from abuse, neglect, and harassment by Patient # 2. The above was confirmed in an interview with Staff #1 the afternoon of 10/9/12 in the conference room.

Based on a review of clinical record and facility based policy, the facility failed to ensure that a physician order was present for a documented episode of restraint.

Findings were:

Facility Based Policy entitled Behavioral Restraint & Seclusion at Seton Shoal Creek stated in part, " 1. A physician must order each use of restrain/seclusion to manage violent or aggressive behavior according to policy and procedure guidelines. "
Review of the clinical record for Patient # 2, revealed documentation of the patient being placed in the restraint chair on 08/14/12. According to the Nursing Admission Assessment completed on 08/14/12 at 2103 , " Pt. arrived to unit by APD with (physician). Pt. given Zyprexa and PO Ativan. Pt. calm and cooperative after release at 2045 from restraint chair. Denies SI/HI/AVH after release. Pt. states he grows 3 " every three weeks. "

A review of Patient # 2's medical record revealed no physician order present for the episode of restrain documented on 08/14/12.

Based on review of clinical records, hospital policies, and staff interviews, the hospital failed to ensure that a registered nurse properly supervised and evaluated the nursing care for each patient, as there was no documented evidence that patients were consistently monitored per physician order, and the treatment plan was not updated following a patient incident.

Findings were:

Facility Based Policy entitled Assessing Patients for Suicide Risk and Implementing Suicide Precautions stated in part, " b) Suicide Risk Assessment Levels and Interventions ...
(2) Moderate ...
(b)Observation/Monitoring: Monitoring is every 15 minute suicide precautions unless continuous observation or 1:1 arm ' s length observation is specified by the admitting physician ...
(3) High Risk
(a) 15 minute precautions ...
2. Suicide Precaution Procedures ...
b) Staff performing Suicide Precaution Monitoring ...
ii) Ensure that visual checks of patient are made by assigned staff at least every 15 minutes and documented on the Precautions Checklist, to be permanent part of the medical record. "

Review of the clinical record for Patient #1 revealed that she was admitted to 3N (PICU) on Suicide and Self-Injurious Precautions on 8/14/12 at 1150 per physician order.

Review of the form " Suicide Precautions " for Patient #1 revealed a Risk Level of " H " [High] requiring q 15 minute monitoring and documentation. On 8/15/12, there was documentation of monitoring at 1645, but no documentation at 1700 and 1715. There was no documented evidence that the patient was monitored per order and policy between 1645 and 1730.

Review of facility policy entitled, " Coordination of Care One-to-One " stated, in part, " 1. 1:1 monitoring is instituted when patient safety cannot be maintained using less restrictive interventions ...
Registered Nurse: ...
4. Ensures that 1:1 is occurring as assigned and per procedure ...
Staff assigned to 1:1
1. Maintain constant visual observation within arm ' s length of patient during toilet, showering, or hygienic functions.
2. Documents patient status on precaution checklist every 15minutes (sic). "

In an interview with Staff #1, RN Manager, she stated that 1:1 monitoring is documented on the Suicide Precautions checklist.

Review of the clinical record for Patient #1 revealed she was placed on 1:1 monitoring at 2209 on 8/16/12 for " patient safety. " The order for 1:1 monitoring was discontinued on 8/20/12 at 0940.

Review of the Suicide Precautions Checklist for Patient #1 revealed no documented evidence of every 15 minute checks for the following:
? 8/16/12 - no documentation of 1:1 monitoring every 15 minutes between 2209 and 2345.
? 8/17/12 - no documentation of 1:1 monitoring every 15 minutes
? 8/18/12 - no documentation of 1:1 monitoring every 15 minutes between 2400 and 1545. Documentation of 1:1 monitoring on the Suicide Precautions Checklist began at 1600 through 2345.
? 8/19/12 - no documentation of 1:1 monitoring at 0530, 0545, 0600, 0615, 0630, 0630, 0645, 0700, and 0715.
? 8/20/12 - no documentation of 1:1 monitoring at 0645, 0700, 0715, 0730, 0745, 0800, 0815, 0830, 0845, 0900, 0915, 0930. Order for 1:1 monitoring discontinued at 0940.

The above was confirmed in an interview with Staff #1 the afternoon of 10/9/12 in the conference room.

Based on a review of documentation, patient record review, and interviews the facility failed to ensure that medical record entries were complete.

Findings were:

Review of the clinical record for Patient # 2, revealed documentation of the patient being placed in the restraint chair on 08/14/12. According to the Nursing Admission Assessment completed on 08/14/12 at 2103 , " Pt. arrived to unit by APD with (physician). Pt. given Zyprexa and PO Ativan. Pt. calm and cooperative after release at 2045 from restraint chair. Denies SI/HI/AVH after release. Pt. states he grows 3 " every three weeks. "

A review of Patient # 2's medical record revealed no physician order for this restraint present or any documented monitoring of this restraint.

Based on a review of clinical records, facility policies, and staff interviews, the facility failed to ensure that medical records were complete, as 1:1 monitoring, precautions, and physician orders were not documented.

Findings were:

Review of facility policy entitled Assessing Patients for Suicide Risk and Implementing Suicide Precautions stated in part, " b) Suicide Risk Assessment Levels and Interventions ...
(2) Moderate ...
(b)Observation/Monitoring: Monitoring is every 15 minute suicide precautions unless continuous observation or 1:1 arm ' s length observation is specified by the admitting physician ...
(3) High Risk
(a) 15 minute precautions
(b) Consider higher level of observation
(i) Continuous eyesight
(ii) If does not cooperate with continuous eyesight consider 1:1 ...
2. Suicide Precaution Procedures ...
b) Staff performing Suicide Precaution Monitoring ...
ii) Ensure that visual checks of patient are made by assigned staff at least every 15 minutes and documented on the Precautions Checklist, to be permanent part of the medical record. "

Review of the clinical record for Patient #1 revealed that she was admitted to 3N (PICU) on Suicide and Self-Injurious Precautions on 8/14/12 at 1150 per physician order.

Review of the form " Suicide Precautions " for Patient #1 revealed a Risk Level of " H " requiring q 15 minute monitoring and documentation. On 8/15/12, there was documentation of monitoring at 1645, but no documentation at 1700 and 1715. There was no documented evidence that the patient was monitored per order and policy between 1645 and 1730.

Review of the clinical record for Patient #1 revealed an order for " 1:1 for patient safety " on 8/16/12 at 2209.

Review of facility policy entitled, " Coordination of Care One-to-One " stated, in part, " 1. 1:1 monitoring is instituted when patient safety cannot be maintained using less restrictive interventions ...
Registered Nurse: ...
4. Ensures that 1:1 is occurring as assigned and per procedure ...
Staff assigned to 1:1
1. Maintain constant visual observation within arm ' s length of patient during toilet, showering, or hygienic functions.
2. Documents patient status on precaution checklist every 15minutes (sic). "

In an interview with Staff #1, RN Manager, she stated that 1:1 monitoring is documented on the Suicide Precautions checklist.

Review of the Suicide Precautions Checklist for Patient #1 revealed no documented evidence of every 15 minute checks for the following:
8/16/12 - no documentation of 1:1 monitoring every 15 minutes between 2209 and 2345.
8/17/12 - no documentation of 1:1 monitoring every 15 minutes
8/18/12 - no documentation of 1:1 monitoring every 15 minutes between 2400 and 1545. 1:1 monitoring on the Suicide Precautions Checklist began at 1600 through 2345.
8/19/12 - no documentation of 1:1 monitoring at 0530, 0545, 0600, 0615, 0630, 0630, 0645, 0700, and 0715.
8/20/12 - no documentation of 1:1 monitoring at 0645, 0700, 0715, 0730, 0745, 0800, 0815, 0830, 0845, 0900, 0915, 0930. Order for 1:1 monitoring discontinued at 0940.

Review of facility policy entitled, " Coordination of Care One-to-One " stated, in part, " 1. 1:1 monitoring is instituted when patient safety cannot be maintained using less restrictive interventions ...
Physician:
1. Gives order for 1:1 and documents reason in order.
2. Assess patient need to 1:1 and renews 1:1 every 24 hours.
3. Writes order to discontinue.

Review of the clinical record for Patient #1 revealed an order for 1:1 monitoring on 8/17/12 at 1200 and the next order for 1:1 monitoring on 8/19/12 at 1700. There was no order to discontinue 1:1 monitoring or to continue the order for 1:1 monitoring after 24 hours. The order was not renewed for 53 hours.