HospitalInspections.org

Based on observation and interview, the hospital failed to ensure that the rights of 50 of 50 patients were met. It failed to ensure that

1. Patients #1, 3, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 24, 25, 26, 27, 39, 42, 44, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 76, 77, 78, 79, 80, 81 had the opportunity for daily outdoor activity as set forth under Texas Title 25 Chapter 404 Rule 404.15,

2. Patient #18 received care in a therapeutic environment. Patient #18 was exposed to violent visual material during the lunch meal on 03/31/22. This failure had the potential to affect all 12 patients identified as Hall 200 census as of 03/31/22 and included Patients #18, 19, 39, 62, 63, 64, 65, 66, 67, 69, 81, and 82,

3. Patient #16, who needed nutritional support for adequate pressure ulcer wound healing, received a diet appropriate for the patient's lack of dentition. On 03/31/22, Patient #16 was unable to eat her lunch meal of pork chops and potatoes which sat untouched for approximately 3.5 hours on a table in the patient's room.



Findings included:


1. A hospital tour was conducted on the hospital's 100 and 200 unit on 03/31/22 between 1125 and 1220. Hospital Personnel#5 accompanied the surveyor at that time and was surveyor asked about patient rights to daily access outside space. Hospital Personnel #5 denied and stated there was no patient access to the outside.

Observation in the hospital's 200 Hall dayroom on 03/31/22 at 1210 and on 04/02/22 at 1130 reflected multiple patients were in the day room. None was outside.

A hospital tour was conducted on the hospital's 300 and 400 unit on 04/02/22 between 1130 and 1205. None of the patients was outside. Hospital Personnel #7 and #8 accompanied the surveyor and stated the patients did "not go outside because we don't have a courtyard."

Record review of Texas Title 25 Chapter 404 Rule 404.15 (Rights of Persons Receiving Residential Mental Health Services) reflected that the patient's personal rights included the "right to have an opportunity for physical exercise and for going outdoors, with or without supervision, as clinically indicated, at least daily ...a physician's order limiting this right must be reviewed and renewed ...at intervals no longer than every three days ..." (https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=T&app=9&p_dir=N&p_rloc=115419&p_tloc=&p_ploc=14831&pg=3&p_tac=&ti=25&pt=1&ch=404&rl=154)


2. Observations on the 200 Hall Day Room on 03/31/22 at 1210 reflected multiple patients, including Patient #18, were eating their lunch meal that consisted of pork chops, potatoes, and spinach.

The 12-noon news show was observable to all patients and displayed on a big TV. The news reported a story of an Uber passenger threatening the driver. Graphic video footage showed the masked passenger holding a gun to the driver's head whose most terrified expression was visible.

Hospital Personnel #5 witnessed that the patients were exposed to the violence on the show and stated it was "reality orientation." The surveyor asked how the news story added value to the unit's therapeutic treatment environment. Hospital Personnel #5 acknowledged that there was none.


3. Record review of Patient #16's Preadmission Assessment dated 03/30/22 at 1103 reflected the patient's Psychosis with Paranoia and Hallucinations. The patient had made a suicidal threat and "everything...[was] removed from pt ...[Patient #16] per staff."

Nursing Admission Assessment dated 03/30/22 at 1805 reflected the patient arrived on a stretcher. The space for the patient's weight documentation was left blank. Patient #16's skin assessment reflected "Issue #1- a pressure ulcer" in the sacral area.

Patient #16's Interdisciplinary Care Plan dated 03/30/22 at 1855 reflected the patient's nutritional concern and set as goal to "maintain" the patient's body weight. In addition, the care plan set out to "observe daily for new area of ...[skin] breakdown."


Observation in the hospital's 200 Hall dayroom on 03/31/22 at 1210 reflected seven patients eating their lunch meal of pork chops, potatoes and spinach.


Patient #16 was observed in 03/31/22 at 1530 in her room. A covered meal with pork chop, potatoes and spinach was observed on the patient's table. Patient #16 pointed to the meal and stated," I have no teeth ...now it's cold and I don't want it."


Hospital Personnel #4 acknowledged the findings during an interview on 04/01/22 at 1030.

The facility failed to ensure the patients' privacy for 16 of 50 patients on 04/02/22. The semi-private rooms shared by Patients #57 and #25, #60 and #61, #65 and #66, #19 and #67, #39 and #68, #12 and #9, #11 and #10, #72 and #73 on that day did not have protection from direct visualization during patient shower activity. This failure potentially affected all patients in case of room reassignment.


Findings included:
Observations on the Hospital's 100 Unit on 03/31/22 at approximately 1125 reflected there was no shower curtain in Room 101. The bathroom door had a slanted top which provided a view onto the uncovered shower area.

Hospital Personnel #5 accompanied the surveyor at that time and acknowledged the finding. Hospital Personnel stated at that time that there was "no shower curtain in any room" in the hospital.

Hospital Personnel #9 was interviewed on 04/02/22 at approximately 1205 and acknowledged the finding as a patient privacy concern.

Record review of the hospital's Patient Handbook provided to the surveyor on 04/02/22 at approximately 1200, undated, reflected on Page 16 of 26 that the patient has the right "to receive privacy in treatment and care for personal needs."