HospitalInspections.org

Based on record review and interview, the facility failed to ensure the rights of nine of ten patients (Patients #10, #4, #6, #8, #9, #16, #17, #18. #19) and/or their legal representatives to be involved in their plan of care and/or make informed decisions regarding their care and treatment.


1) Patient #10 was admitted with Psychosis. The patient's surgical history included a recent shoulder surgery that staff members did not include in treatment planning. Patient #10 and/or her legal representative did not participate in her treatment plan and/or contribute to the patient's care decisions.

2) Patient #4, a minor, was admitted diagnoses that included Severe Major Depressive Disorder. The patient was tearful, depressed, and had thoughts of suicide. Patient #4's legal representative did not participate in planning care and treatment for the patient.

3) Patient #6, a minor, was admitted with diagnoses that included Major Depression. The patient had a history of self-injurious behavior including burning and cutting herself. The patient's responsible party did not actively participate in or agreed to the patient's treatment plan. Five days into her hospitalization, Patient #6 attempted suicide.

4) Patient #8 was admitted with suicidal thoughts and required emergency medication administration on at least three occasions during her hospitalization. Patient #8 did not contribute to or participate in her treatment planning or agreed to the plan.

5) Patient #9, a minor, was admitted with anger and behavior problems and required emergency medication intervention. Patient #9's responsible party did not contribute to an effective treatment plan or was involved in planning interventions for Patient #9. The treatment plan was left blank.

6) Patient #16, a minor, required hospitalization for active suicidal thoughts. Neither the patient or the legal representative were actively involved in the treatment plan.

7) Patient #17's admission diagnoses included Major Depression. The patient told staff that she was suicidal and had formulated a plan to kill herself. Patient #17 did not have the opportunity to ask questions about her treatment plan or contribute information.

8) Patient #18 was hospital admitted with Schizoaffective Disorder. The patient was depressed, paranoid, and delusional. Patient #18 and/or her legal representative were not involved in effective treatment planning or contribute information to the team.

9) Patient #19 was severely depressed on admission, was crying uncontrollably, and had frequent thoughts of suicide. The patient did not actively participate in her treatment plan or was able to request or refuse treatment.



Findings included:

1) Patient #10's Psychiatric Evaluation dated 01/24/18 at 1000 reflected admitting diagnoses that included Psychosis, Diabetes Mellitus, and Sleep Apnea. The patient presented with rambling speech, impaired abstract ability, and compromised insight and judgment.

Patient #10's History and Physical Exam dated 01/24/18 at 0800 reflected the patient had a left shoulder replacement surgery. The document did not specify the date of surgery.

The Initial Treatment plan dated 01/27/18 at 1900 did not reflect the patient's shoulder surgery. The space for Patient #10 and/or her legal representative to sign the treatment plan was left blank.

The Interdisciplinary Treatment Plan Master, undated, untimed, reflected the patient had "chronic pain."

Hospital Personnel #7 stated during an interview on 02/01/18 at 1150 that she had been informed of Patient #10's surgery and had "told staff to be careful not to re-injure [Patient #10's] shoulder" during the patient's restraint incident on 01/24/18.

Hospital Personnel #24 acknowledged that Patient #10's shoulder surgery was not addressed in the treatment plan during an interview on 02/01/18 at 1205.


2) Patient #4' Summary Sheet reflected the patient was admitted on 01/21/18 at 0556. Patient #4 stated that he was thinking about suicide.

Patient #4's Physician Psychiatric Evaluation dated 01/22/18 at 0610 reflected the patient was depressed and had periods of uncontrollable crying. Admitting diagnoses included Major Depressive Disorder, Severe.

Patient #4's Interdisciplinary Treatment Plan Master Sheet dated 01/23/18 at 1730 did not reflect the signature of the patient's legal representative and the signature line was left blank. There was no evidence that the treatment plan was reviewed by phone.

Hospital Personnel #23 acknowledged the above findings during an interview on 02/02/18 at approximately 1200.

3) Patient #6's Psychiatric Evaluation dated 01/20/18 at 1538 reflected admitting diagnoses that included Major Depression. Patient #6 had a history of self-mutilation by burning and cutting on herself and planned to commit suicide by overdosing.

Patient #6's Interdisciplinary Treatment Plan Master dated 01/21/18 at 1725 was signed by the patient only. There was no evidence that Patient #6's responsible party actively participated in the treatment planning and agreed to the it. The line for minor Patient #6's responsible party's signature was left blank.

Patient #6's Physician Orders dated 01/26/18 at 2110 reflected the patient had made a suicide attempt.

Hospital Personnel #27 was interviewed on 02/01/18 at 1435 and acknowledged that Patient #6's legal representative had not been evidenced to be actively involved in the patient's treatment planning.

4) Patient #8 Psychiatric Evaluation dated 01/08/18 at 0907 reflected the patient had been admitted with suicidal thoughts on 01/05/18.

The Interdisciplinary Treatment Plan Master dated 01/09/18 at 0830 did not provide evidence that Patient #8 had actively participated in her treatment planning and agreed to the plan. The line for the patient's signature was blank.

Patient #8's Physician Orders dated 01/06/18 at 2035, 01/06/18 at 1010, 01/08/18 at 1600 reflected the patient received one-time doses of Haldol 10 milligram(mg), Ativan 2 mg, and Benadryl 50 mg.

Hospital Personnel #27 acknowledged the above findings during an interview on 02/01/18 at 1445.

5) Patient #9's Psychiatric Evaluation dated 01/05/18 at 0656 reflected the patient was admitted on 01/04/18 to the hospital's child and adolescent patient care unit with "recurring behavior problems due to anger and impulsivity."

Patient #9's Physician Orders dated 01/09/18 at 0005 reflected the administration of an emergency medication.

Patient #9's Interdisciplinary Treatment Plan Master dated 01/05/18 at 0900 reflected blank active psychiatric and medical problem lists. There was no evidence of active treatment planning and participation by minor Patient #9's responsible party, and the signature line was left blank.

Hospital Personnel #23 acknowledged the above findings during an interview on 02/02/18 at approximately 1200.

6) Patient #16's Physician Psychiatric Evaluation dated 11/28/17 reflected the patient was admitted to the hospital's child and adolescent care unit with continuous thoughts of killing herself. Patient #16 was placed under close monitoring staff supervision.

Patient #16's Interdisciplinary Treatment Plan Master dated 11/30/18 did not reflect evidence that the patient and/or the legal representative were actively involved and participated in treatment planning and agreed to the plan. The signature lines were left blank.

Hospital Personnel #27 acknowledged the above findings during an interview on 02/01/18 at approximately 1445.


7) Patient #17's Physician Psychiatric Evaluation dated 12/05/17 at 0817 reflected the patient's admission date of 12/04/17. Patient #17's admission diagnoses included Major Depressive Disorder, Hypertension (high blood pressure), and Neuropathy (pain) in her left leg.

The Interdisciplinary Treatment Plan Master did not reflect evidence that the patient was involved in her treatment plan and had the opportunity to ask questions and make suggestions. The lines provided for the patient and/or legal representative were left blank.

Nursing Daily Shift Note dated 12/05/17 at 1215 reported Patient #17 stated the wanted to overdose. Nursing staff noted that Patient #17 was suicidal.

Nursing Daily Shift Note dated 12/05/17 at 2150 reflected Patient #17 was suicidal, had formulated a plan and stated, "I know if I try, I will succeed...I knew I needed help."

Hospital Personnel #27 acknowledged the above findings during an interview on 02/01/18 at approximately 1450.


8) Patient #18's Psychiatric Evaluation dated 12/11/17 at 1103 reflected the patient's admission date of 12/08/17. The patient's admission diagnoses included Schizoaffective Disorder. The patient was depressed, paranoid, delusional, and responded to internal stimuli. The patient had poor insight and judgement.

Patient #18's Interdisciplinary Treatment Master Plan dated 12/11/17 did not reflect any psychiatric problems. The document did not reflect evidence that Patient #18 actively participated in and contributed to her treatment plan. The lines for the patient's and/or her legal representative's signatures were left blank.

Hospital Personnel #27 acknowledged the above findings during an interview on 02/01/18 at approximately 1450.


9) Patient #19's Psychiatric Evaluation dated 12/20/17 at 0651 reflected the patient's statement that she wanted to kill herself. The physician noted that Patient #19 was severely depressed with "periods of uncontrollable crying, poor energy, motivation, no enjoyment of activities...frequent thoughts of suicide by hanging or cutting herself..."

Patient #19's Interdisciplinary Treatment Plan Master dated 12/21/17 at 1045 did not reflect that the patient actively participated in her treatment planning. The line for the patient signature was left blank.

During an interview on 02/01/18 at approximately 1435, Hospital Personnel #27 reviewed clinical files of Patient #10, Patient #6, Patient #8, Patient #9, Patient #16, Patient #17, Patient #18, and Patient #19 and acknowledged the above findings.

The hospital's Patients' Rights Policy (POC 139) dated 03/2013 reflected the policy that "the patient and family, when appropriate, have the right to be involved in all aspects of the patient's care...to take part in the development of an individualized treatment plan for his/her hospitalization and discharge...the right extends to the parent or conservator of a minor or the legal guardian, when applicable."

Based on record review and interview, the hospital failed to ensure the right to personal privacy for one of one patient (Patient #4). For 34.5 hours following his hospital admission, Patient #4 did not have a patient room to sleep in or access to private shower or bathroom facilities.


Findings included:

Patient #4's Summary Sheet reflected the male patient was admitted on 01/21/18 at 0556 to Room 305 Bed 2.

Preliminary Census Report dated 01/21/18 at 0848 reflected Patient #14, a female patient, was assigned to Room 305, Bed 1.

Hospital Personnel #27 stated during an interview on 02/01/18 at 1230 that male Patient #4 was admitted to a room occupied by a female patient "but he was not in her room."


Hospital Personnel #14 stated during an interview on 02/01/18 at approximately 0945 that parents of prospective minor patients signed permission that the patients "sleep on the sofa, and the unit will have a bed for them for sure in the morning." Hospital Personnel #14 was surveyor asked where patients who slept in common areas completed their hygiene and used the restroom. Hospital Personnel did not provide an answer.

Hospital Personnel #26 was interviewed on 01/31/18 at 2120 and asked about patients sleeping in the common area/day room. Hospital Personnel #26 stated that it happened "occasionally when we have a discharge the next day [and the bed becomes available]." Hospital Personnel #26 pointed to the wall underneath the TV and stated that was the place that staff "would usually put the mattresses because it is darker there."

Nursing Daily Shift Notes dated 01/22/18 at 0907 reflected Patient #4's statement that, "I guess it's ok, I mean sleeping in here isn't the best (regarding group room)."


Patient #4's Behavioral Health Technician Flow Sheets dated 01/21/18 at 0600 through 01/22/18 at 1615 did not reflect Patient #4 had access to a private shower or bathroom facilities. Flow Sheets dated 01/21/18 between 0600 and 2100 reflected Patient #4 was awake in the day room, at the nurses' station or hallway (in close proximity to the day room), and /or attended group. Flow Sheets dated 01/21/18 between 2130 and 2345 and 01/22/18 between 0000 and 0515 reflected Patient #4 was asleep in the day room. According to Flow Sheets dated 01/22/18 between 0530 and 1615, Patient #4's activities included school and groups. The patient was noted to be in the hallway, patio, gym, and nurses' station. There was no mention of Patient #4 completing his hygiene.

During observational rounds on the hospital's pediatric (CAPS) unit on 01/31/18 at 2120, Patient #4 was observed on 01/31/18 at 2120 close to the nurses' station. Upon surveyor inquiry, Patient #4 stated he had slept on a mattress in the common area for the first two nights of his hospitalization.

The hospital's Patients' Rights Policy (POC 139) dated 03/2013 reflected Patients' basic rights that included "the rights ...guaranteed by the constitution and laws of the United States and the state of Texas ..."

The State of Texas Patient's Bill of Rights reflected that basic rights for all patients included the rights to an environment where the patient has "privacy with regard to personal needs ..." (www.dshs.texas.gov/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=10177).

Based on record review and interview, the hospital failed to ensure that six out of ten patients (Patients #10, #6, #8, #9, #16, #18) had an individual comprehensive treatment plan.

1) Patient #10 had a left should replacement surgery prior to her hospital admission. The treatment plan did not reflect the patient's shoulder surgery as preexisting condition that could place the patient at risk with restraints. The patient needed to be emergently restrained within 24 hours after admission.

2) Patient #6 had a history of self-mutilation prior to her hospital admission. Patient #6 displayed self-harm behavior, attempted suicide during her hospitalization and required one-to-one staff supervision. Staff failed to update Patient #6's care plan to reflect the self-harming and attempted suicide events.

3) Patient #8 was hospital admitted with suicidal thoughts. On her first day of hospitalization, Patient #8 attempted twice to barricade herself on the unit and received emergently administered medication. The patient required emergency medication management on two additional occasions during the following 72 hours. The events were not reflected in the patient's treatment plan update. Nursing staff did not participate in the patient's treatment planning.

4) Patient #9 was admitted for recurrent behavior and anger problems. The master treatment plan did not have any psychiatric and/or medical problems to be addressed and nursing staff did not participate. Four days into his hospitalization, Patient #9 was physically aggressive to other patients and property, received emergently administered medication, and was placed in seclusion. An updated treatment plan was left blank and did not reflect the patient's seclusion incident and emergency medicine administration.

5) Patient #16 was admitted with thoughts of suicide. After five days of hospitalization, the patient used a plastic fork for self-harm. Her wounds required nursing interventions. Staff failed to update the patient's care plan with the patient's self-harming behavior.

6) Patient #18 was admitted depressed, paranoid and actively hallucinating. The patient's behavior required emergently administered medications. Her room was blocked due to the patient's aggression. Patient #18's master treatment plan did not reflect any psychiatric problems and lacked long- and short-term goals for her hospitalization. Medical staff and therapists did not contribute to the patient's plan of care.



Findings included:

1) Patient #10's Psychiatric Evaluation dated 01/24/18 at 1000 reflected admitting diagnoses that included Psychosis, Diabetes Mellitus, and Sleep Apnea. The patient presented with rambling speech, impaired abstract ability, and compromised insight and judgment.

Patient #10's History and Physical Exam dated 01/24/18 at 0800 reflected the patient had a left shoulder replacement surgery. The document did not specify the date of surgery.

The Initial Treatment plan dated 01/27/18 at 1900 and the Interdisciplinary Treatment Plan Master Sheets, undated, untimed, did not reflect the patient's shoulder surgery.

Hospital Personnel #7 stated during an interview on 02/01/18 at 1150 that she had been informed of Patient #10's recent surgery and had "told staff to be careful not to re-injure [Patient #10's] shoulder" during a patient restraint incident the morning of 01/24/18.


Hospital Personnel #24 acknowledged that Patient #10's shoulder surgery was not addressed in the treatment plan during an interview on 02/01/18 at 1205.


2) Patient #6's Psychiatric Evaluation dated 01/20/18 at 1538 reflected admitting diagnoses that included Major Depression. Patient #6 had a history of self-mutilation by burning and cutting on herself and planned to commit suicide by overdosing.

Nursing Daily Shift Note dated 01/23/18 at 0749 reflected the patient had cut on herself the previous night. Nursing Notes dated 01/23/18 at 1629 reflected "...confirmed that superficial lacerations to LFA (left forearm) were from last night."

Physician Progress Notes dated 01/24/18 at 2212 reflected the patient remained "at risk for self-harm." Physician Progress Notes dated 01/25/18 at 2200 reflected Patient #6 was "significantly dysphoric...insists that self-harm is still in her repertoire..."

Nursing Daily Shift Note dated 01/26/18 at 0818 reflected Patient #6 was "angry...attempted to choke herself."

Physician Orders dated 01/26/18 at 2110 reflected an order for one-to-one staff supervision "due to suicide attempt..."

Patient #6's Interdisciplinary Treatment Plan Master Sheets was dated 01/21/18. There was no evidence that the plan was updated to reflect the patient's in-hospital attempts for self-harm.

3) Patient #8 Psychiatric Evaluation dated 01/08/18 at 0907 reflected the patient had been admitted with suicidal thoughts on 01/05/18.

Nursing Daily Shift Note dated 01/06/18 at 0940 reflected Patient #8 was "anxious and very aggressive...tried to barricade herself in an empty dayroom...began [to] threaten staff...tried to barricade herself in the restroom...started punching...was put in a hold and given emergency medication..."

Physician Orders dated 01/06/18 at 1010, 01/06/18 at 2035 and 01/08/18 at 1600 reflected the patient received one-time doses of Haldol 10 mg, Ativan 2 mg, and Benadryl 50 mg.

Interdisciplinary Treatment Plan Master Sheets dated by social service staff on 01/09/18 at 0830 did not reflect that nursing and/or medical staff participation. Interdisciplinary Treatment Plan Update dated 01/10/18 at 0800 did not reflect emergency medication administration or the patient's attempts to barricade self on the unit. Nursing staff did not participate in the update.

Hospital Personnel #23 acknowledged the above findings during an interview on 02/02/18 at approximately 1200.

4) Patient #9's Psychiatric Evaluation dated 01/05/18 at 0656 reflected the patient was admitted on 01/04/18 to the hospital's child and adolescent patient care unit with "recurring behavior problems due to anger and impulsivity."

Nursing Daily Shift Note dated 01/08/18 at 2300 reflected Patient #9 was "irritable and easily agitated...angry...yelling, cursing and running around unit...picking up plastic chairs and throwing them...able to...open locked doors...throwing cards at...[peer], then slapped peer...order received for Zyprexa 5 mg IM [intramuscular]...patient again became aggressive and was placed in seclusion at 2105...patient asleep at 2135..."

Patient #9's Physician Orders dated 01/09/18 at 0005 reflected to emergently administer Zyprexa 5 mg intramuscular.

Patient #9's Interdisciplinary Treatment Plan Master dated 01/05/18 at 0900 reflected blank active psychiatric and medical problem lists. There was no evidence that nursing staff contributed to the interdisciplinary treatment plan. The Interdisciplinary Treatment Plan Update, signed by medical staff only on 01/12/18, time not legible, was left blank without updated clinical data of Patient #9's behavior, administration of emergency medication, and/or seclusion. There was no evidence of nurse, social services, and/or therapy staff participation.

Hospital Personnel #23 acknowledged the above findings during an interview on 02/02/18 at approximately 1200.

5) Patient #16's Physician Psychiatric Evaluation dated 11/28/17 reflected the patient was admitted to the hospital's child and adolescent care unit with continuous thoughts of killing herself. Patient #16 was placed under close monitoring staff supervision.

Nursing Daily Shift Note dated 12/02/17 reflected Patient #16 approached staff and "gave them a plastic fork which ...[Patient #16] had used to scratch her inner left forearm. Nursing noted the patient had an open area on her outer left wrist and scratches on both arms.

Physician Orders dated 12/02/17 at "0845" [not specified AM or PM] reflected an order for nursing to cleanse a would on the patient's left wrist.

Patient #16's Interdisciplinary Treatment Plan Update dated 12/08/17 reflected Patient #16 "has attempted to control her anger throughout the week..." The update did not reflect the patient's new wounds on her arms and left wrist.

Hospital Personnel #27 acknowledged the above findings during an interview on 02/01/18 at approximately 1445.

6) Patient #18's Psychiatric Evaluation dated 12/11/17 at 1103 reflected the patient's admission date of 12/08/17. The patient's admission diagnoses included Schizoaffective Disorder. The patient was depressed, paranoid, delusional, and responded to internal stimuli. The patient had poor insight and judgement.

Patient #18's Physician Orders dated 12/10/17 at 2300 reflected to block the patient's room due to aggressive behavior. Orders dated 12/11/17 at 0210 reflected the patient was to receive emergency intramuscular medications that included Haldol 10 mg, Ativan 2 mg, and Benadryl 50 mg for severe agitation.

Patient #18's Interdisciplinary Treatment Master Plan dated 12/11/17 at 1300 did not reflect any psychiatric problems. The blank psychiatric problem list was signed by nursing only. The document did not reflect any long-term or short-term goals.

Hospital Personnel #27 acknowledged the above findings during an interview on 02/01/18 at approximately 1450.