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8550 HUEBNER ROAD

SAN ANTONIO, TX 78240

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

Based on review of records and interviews, the facility's staff failed to ensure patient's rights to receive care in a safe setting for 1 of 1 Patient (Patient #1) reviewed with allegations in the area of Patient Rights.

Specifically, facility nursing staff failed to assess and/or document a physical assessment for Patient #1 to evaluate potential injuries following an assaultive incident on 3/14/21; and in accordance with their policy.

As a result, Patient #1 reported abuse allegations against the staff following an assaultive incident against staff on 3/14/21; causing injuries.

Findings included:

Review of Complaint Intake TX00376552 reported on behalf of Patient #1 on 3/16/21; alleged Patient #1 reported four people restrained her arms and that Mental Health Tech (MHT) A came after her causing marks (injury) to her neck. Patient #1 also complained that her tongue hurt to move.

Review of the Facility Self-Reported incident, "Psychiatric Hospital Incident Report," TX00376889 revealed on 3/18/21 the facility reported an incident dated 3/14/21 for Patient #1 where she walked down the hall and attacked MHT-A from behind, who was on a 1:1 with another patient. Patient had to be separated from the MHT (A), as she was holding onto the MHT and would not let go. Patient claimed to have scratches on chest from the incident via staff assaulting her. Further review of the Psychiatric Hospital Incident Report documented, "No" for the question, "Did the patient sustain any injuries."

Review of the facility's internal Incident Report dated 3/14/21 at 21:31 completed by Registered Nurse (RN)-A; regarding Patient #1, revealed the following:

Description of the incident- "Patient came out of her room to the day area at about 21:25 saying she needed her room light on. Patient was told it was sleep time. Patient went back to her room angry. Patient then left her room and ran down the hallway and assaulted staff [MHT- A]. Patient was taken to quiet room before finally going to bed."

Further review of the Incident report documented the Clinical Intervention by RN -A; that "RN assessed" and, "No injury involved." RN-A signed the report 3/14/21 at 22:30.

Risk Management Review documented "will review camera footage and fact find."
Reported incident to Child Protective Services (CPS) on 3/15/21 for "fight with staff."

Review of Patient #1's Progress Notes revealed the following:
On 3/15/21 at 14:26 her Therapist, Licensed Master Social Worker (LMSW-A) documented that Patient #1's CPS Caseworker expressed concerns that Patient #1 made statements of facility staff "attacking" her. LMSW-A documented, Patient #1 had multiple scratches on her face, neck and chest. LMSW-A alerted nursing supervisor and patient advocate.

On 3/20/21 at 20:32 RN-A documented an "Addendum. In addition to the incident reported on 3/15/21. Patient was checked by the Med Nurse [Medication Nurse-A] on duty and she told me she had some scrate on her chest."

On 3/17/21 (3 days following the incident), RN-B documented a "Skin Assessment" on the Daily Nursing Assessment/Progress Note in the presence of another MHT-B. Documentation included multiple (single) scratches to the following areas; left breast area (1 scratch and bruise), mid sternal area (1 scratch), left side lower ear (1 scratch), left side of lower neck (1 scratch), right side of jaw (1 scratch), right side of neck (1 scratch).

Interview on 3/22/21 at 6:15 PM with RN-A stated the following regarding the Incident dated 3/14/21 for Patient #1 at 21:31:
Patient #1 came out of her room, charged at MHT-A and assaulted her. RN-A stated he and two other staff were trying to get Patient #1's hands off MHT-A because she had a hold of MHT-A. RN A was asked if he assessed Patient #1 after the Incident in which he responded, "No." He said he didn't assess Patient #1 because he was a male and he was the Charge Nurse. RN-A said he had a female Med Nurse - A check on her and "she had scratches on her chest." RN-A was asked if there was documentation by the Med Nurse-A of the scratches to Patient #1's chest observed on 3/14/21, and he said there was not.

Interview on 3/25/21 at 3:00 PM with Licensed Vocational Nurse (LVN) A stated she assisted during the incident on 3/14/21 where Patient #1 went towards MHT-A; attacked her, grabbed her shirt and badge. LVN-A said that MHT-A was being pulled from Patient #1 and she assisted with getting Patient #1 hands off MHT-A's shirt. LVN-A stated that Patient #1 did say she was scratched during the incident while in the day area afterwards. LVN-A stated it was the RN's who were the ones to assess the patient after the incident and she was not sure if there were any scratches documented for Patient #1.

Review of the facility's policy for Incident Reports, Policy #RI.1.05, last revised 1/25/2017 revealed the following in part; an Incident Report is to be completed by the employee(s) who witnessed the event or discovered the event. The categories included, but not limited to: Assaultive behavior to staff. In the case of a patient incident, facts related to the treatment rendered should be documented in the patient's record. The incident report form includes an area to be completed by the nurse including; clinical intervention and documentation of any injury to the patient.