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The hospital failed 1 of 1 Patient (Patient #1) the rights to care inasafe seetting. Patient #1 was able to use materials from clothing initially Patient #1's personal clothing then hospital provided clothing without Patient # 1 being placed on further precautions until the third attempt to commit suicide in the hospital.


Findings Include:

During interview with hospital Patient #1, Patient #1 indicated that tearing up own clothing is not an option. Patient #1 requested that hospital staff return the clothing and hospital refused and placed the patient in hospital paper scrubs. Patient #1 reported that the elastic from the waist was taken out of the pants and used to tie around the neck. Patient #1 denied using the elastic out of the shorts initially worn in the hospital on the first attempt to committ suicide.

During interview with hospital Staff #3, reported the Patient discussed not having a will to live and did not have any real family indicated father was in prison and mother was a drug addict. Staff #3 indicated that the Patient used the elastic from the paper scrubs to choke self. Staff #3 reported not being a 1:1 with patient until 04/14/2022.

During interivew with hospital Staff #4, reported Patient #1 was having a seizure. Staff # 4 indicated immediately responded to Patient #1's room. Upon entering the room witnessed Patient #1 kicking both legs and saw Patients' arms shaking. Noted Patient was unresponsive then, felt for a pulse immediately delegated another staff to to call a Code Blue. The other staff came and before then Staff #4 had started CPR. Patient #1 was on stomach and was turned over and that's when it was observed a string tied around Patient #1's neck. It was cut off and removed from the neck. CPR lasted about 3 minutes. Patient #1 was put in a sitting position, but not able to talk. Doctor on site. Approximately an hour later Patient #1 informed Staff #4 that having a lot going on in her life and feels life is worthless and wanted to kill self. Staff #4 identified that Patient #1 was not placed on 1:1 status prior to these events. The order for 1:1 status was given after this final attempt while Patient #1 was in the hospital.

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. Illegal, unethical and/or unprofessional conduct by any health care services providers are prohibited behaviors and will be grounds for disciplinary action and reporting to local and or state regulatory and/or legal authorities as mandated by statue, hospital policy and/or regulation(s). It is the responsibility of all staff members and health care professionals of Perimeter Healthcare to report concerns regarding illegal, unethical and/or unprofessional conduct to hospital administration."

The hospital Policy on Patient Rights dated 01/2021, reflected, "It is the policy of Perimeter Behavioral Hospital of Dallas, to treat all patient information confidentially. This includes patient records and conversations. We will investigate any reported violation of this policy. If you have any questions, ask a front desk representative for information. Perimeter Behavioral Hospital of Dallas makes every effort to provide our patients with an environment, which is safe, private, and respectful of our patient's needs. IF you have a complaint about our services, facilities, or staff, we want to hear from you. We will do everything we can to see that your experience with us is professional in every way. The maintenance of confidentiality and protection of person health information is dictated by Perimeter Healthcare, and is subsidiaries', most current HIPPA Privacy Rule Policies and Procedures."

The hospital Policy on Nursing Services dated 11/17/2019 reflected, "It is the policy to adhere to the overall hospital mission statement, values, and goals of Perimeter Healthcare and various State/Federal regulatory agencies. The focus of nursing services is providing patient-centered care that is safe and reflects current, evidence-based practice, using the milieu to its maximum therapeutic potential that available human, technical and financial resources permit ...It is the policy ...to provide the highest attainable quality of nursing care to all patients consistent with the mission, values, vision and goals."

The hospital Policy on Administration dated 03/2022 reflected "The direction for the leadership of this facility is established y our mission, , values and strategic plan ...Perimeter Healthcare is dedicated to providing patient-centered care and working to understand each individual's needs in order to supply excellent, differentiated treatment plans. We strive employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives."

The hospital failed 1 of 1 Patient (Patient #1) by medical staff and administrative officials ensuring that clear expections for safety are established. Patient #1 attempted to choke self on 3 attempts with mimimal precautions set in place for safety, and by using hospital approved paper scrubs elastic found in the waist of the pants.



Findings Include:

During interview with hospital Patient #1, Patient #1 indicated that tearing up own clothing is not an option. Patient #1 requested that hospital staff return the clothing and hospital refused and placed the patient in hospital paper scrubs. Patient #1 reported that the elastic from the waist was taken out of the pants and used to tie around the neck. Patient #1 denied using the elastic out of the shorts initially worn in the hospital on the first attempt to committ suicide.

During interview with hospital Staff #3, reported the Patient discussed not having a will to live and did not have any real family indicated father was in prison and mother was a drug addict. Staff #3 indicated that the Patient used the elastic from the paper scrubs to choke self. Staff #3 reported not being a 1:1 with patient until 04/14/2022.

During interivew with hospital Staff #4, reported Patient #1 was having a seizure. Staff # 4 indicated immediately responded to Patient #1's room. Upon entering the room witnessed Patient #1 kicking both legs and saw Patients' arms shaking. Noted Patient was unresponsive then, felt for a pulse immediately delegated another staff to to call a Code Blue. The other staff came and before then Staff #4 had started CPR. Patient #1 was on stomach and was turned over and that's when it was observed a string tied around Patient #1's neck. It was cut off and removed from the neck. CPR lasted about 3 minutes. Patient #1 was put in a sitting position, but not able to talk. Doctor on site. Approximately an hour later Patient #1 informed Staff #4 that having a lot going on in her life and feels life is worthless and wanted to kill self. Staff #4 identified that Patient #1 was not placed on 1:1 status prior to these events. The order for 1:1 status was given after this final attempt while Patient #1 was in the hospital.

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. Illegal, unethical and/or unprofessional conduct by any health care services providers are prohibited behaviors and will be grounds for disciplinary action and reporting to local and or state regulatory and/or legal authorities as mandated by statue, hospital policy and/or regulation(s). It is the responsibility of all staff members and health care professionals of Perimeter Healthcare to report concerns regarding illegal, unethical and/or unprofessional conduct to hospital administration."

The hospital Policy on Patient Rights dated 01/2021, reflected, "It is the policy of Perimeter Behavioral Hospital of Dallas, to treat all patient information confidentially. This includes patient records and conversations. We will investigate any reported violation of this policy. If you have any questions, ask a front desk representative for information. Perimeter Behavioral Hospital of Dallas makes every effort to provide our patients with an environment, which is safe, private, and respectful of our patient's needs. IF you have a complaint about our services, facilities, or staff, we want to hear from you. We will do everything we can to see that your experience with us is professional in every way. The maintenance of confidentiality and protection of person health information is dictated by Perimeter Healthcare, and is subsidiaries', most current HIPPA Privacy Rule Policies and Procedures."

The hospital Policy on Nursing Services dated 11/17/2019 reflected, "It is the policy to adhere to the overall hospital mission statement, values, and goals of Perimeter Healthcare and various State/Federal regulatory agencies. The focus of nursing services is providing patient-centered care that is safe and reflects current, evidence-based practice, using the milieu to its maximum therapeutic potential that available human, technical and financial resources permit ...It is the policy ...to provide the highest attainable quality of nursing care to all patients consistent with the mission, values, vision and goals."

The hospital Policy on Administration dated 03/2022 reflected "The direction for the leadership of this facility is established y our mission, , values and strategic plan ...Perimeter Healthcare is dedicated to providing patient-centered care and working to understand each individual's needs in order to supply excellent, differentiated treatment plans. We strive employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives."

The hospital failed 1 of 1 Patient (Patient #1) by not administering medication in accordance with the Federal and State laws. the orders of the practiioner or practitioners responsible for the patietn's care as specified under 482.12(c), and accepted standards of practice.

Findings Include:


During interview with Patient #1 it was reported that during morning medication pass Patient #1 was wearing facecovering (mask). Patient #1 reported cheeking the medications, by just dropping them in the mask. When the nurse left the room Patient #1 reported turning to the 1:1, Staff #3, and said see how easy that was to cheek the meds, Pulled the face mask out and medications all fell into hand.

During interview with Staff #3 it was reported, that Patient #1 has informed 1:1 Staff #3 of feeling as if there was no purpose to live. Thats why Patient #1 was making attempts to self-harm. Staff #3 verified Patient #1 did drop morning medications out of the mask and hand gave them up. Staff #3 indicates the medications were then taken to nurses station and turned and stating Patient #1 refused. Staff #3 indicated that the nurse says, 'No, she took them. I watched Patient #1. Medication were turned into this nurse.

During record review the medication administration record reflected Patient #1 took the medication at 8:35AM. The medication administration record reveals being marked through at 1854 by nursing staff on 04/14/2022.

During record review the hospital Shift Progress Note dated 04/14/2022 at 1500, reflected, "Patient #1 attempted suicide yesterday and has been on 1:1 precaution. New order getting all belongs out of room was issued. Patient refused all our medications."

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. Illegal, unethical and/or unprofessional conduct by any health care services providers are prohibited behaviors and will be grounds for disciplinary action and reporting to local and or state regulatory and/or legal authorities as mandated by statue, hospital policy and/or regulation(s). It is the responsibility of all staff members and health care professionals of Perimeter Healthcare to report concerns regarding illegal, unethical and/or unprofessional conduct to hospital administration."

The hospital Policy on Patient Rights dated 01/2021, reflected, "It is the policy of Perimeter Behavioral Hospital of Dallas, to treat all patient information confidentially. This includes patient records and conversations. We will investigate any reported violation of this policy. If you have any questions, ask a front desk representative for information. Perimeter Behavioral Hospital of Dallas makes every effort to provide our patients with an environment, which is safe, private, and respectful of our patient's needs. IF you have a complaint about our services, facilities, or staff, we want to hear from you. We will do everything we can to see that your experience with us is professional in every way. The maintenance of confidentiality and protection of person health information is dictated by Perimeter Healthcare, and is subsidiaries', most current HIPPA Privacy Rule Policies and Procedures."

The hospital Policy on Nursing Services dated 11/17/2019 reflected, "It is the policy to adhere to the overall hospital mission statement, values, and goals of Perimeter Healthcare and various State/Federal regulatory agencies. The focus of nursing services is providing patient-centered care that is safe and reflects current, evidence-based practice, using the milieu to its maximum therapeutic potential that available human, technical and financial resources permit ...It is the policy ...to provide the highest attainable quality of nursing care to all patients consistent with the mission, values, vision and goals."

The hospital Policy on Administration dated 03/2022 reflected "The direction for the leadership of this facility is established y our mission, , values and strategic plan ...Perimeter Healthcare is dedicated to providing patient-centered care and working to understand each individual's needs in order to supply excellent, differentiated treatment plans. We strive employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives."

The hospital Policy on Medication Ordering, Dispensing and Administration reflected, "It is the policy of Perimeter Behavioral Hospital that all medications dispensed to nursing units will conform to all State and Federal Laws, Joint Commission Standards, and standards of good patient care ...Each dose of medication administered must be properly recorded in the patient's medical record (MAR)."