HospitalInspections.org

The hospital governing body has failed to ensure 6 of 6 Patients (Patient's #1, #2,#3#4,#5, and #6) that the medical staff is accountable to the governing body for the quality of care provided to patients.

Findings Include

During Interview with hospital Staff #2, Patient's #1, #2,#3, #4,#5, and #6 have eloped from the hospital.

During Interview with hosptial Staff #2, It was reported that the staff did not follow the procedures that were put in place two weeks ago prior to additional elopements from the hospital.

During Interview with hospital Staff #6 it was reported that hospital Staff #7 allowed Patients #3, Patient #4, and Patient #5 to go outside for fresh air break during the 2nd shift. During that time Patients #3, #4, and #5 pulled the fire alarm and eloped through the wood fence in courtyard.

During Interview the hospital Staff #2 reported Staff #8 struck Patient #4 in the face after Patient #4 punched her. Patient #4 was then separated from the scene.

During Record Review, there are no Incident Report's of the elopements that were provided to the surveyor as request for the hospital physical confrontation Patient to Staff.

During Interview and Record Review with hospital Staff #3 the hospital failed to reprimand or educate hospital Staff #7 for taking Patients outside for a fresh air break at shift change to 2nd shift.

During record review the hospital failed to report these incidents to the department.

During Record Review there are no doctors orders that address Patient Assessment, Level of Observation and Care upon their return into the hospital.

Policy
The hospital policy on Neglect Abuse 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 07/17/2019, reflected, "The rights, benefits, responsibilities, and privileges guaranteed by the constitutions and laws of the United States of Texas unless they have been restricted by specific provisions of law. The rights include, but are not limited to, the right to impartial access to and provision of treatment, regardless of race, nationality, religion, sex, ethnicity, sexual orientation, age, or disability; the right to petition for habeas corpus; the right to register and vote at elections, the right to acquire use, and dispose of property including contractual licenses, permits, privileges and benefits under law, the right to religious freedom and rights concerning domestic relations."

The hospital Policy on Nursing Services 07/17/2019 reflected, "In order to protect the safety of patients and employees, immediate response shall be initiated for any violence by visitors and or prospective patients. All program staff are responsible for recognizing and observing the signs of potentially violent behavior, reporting it to the appropriate staff and acting within the limits of their position descriptions to protect, with the least restrictive method, any prospective patient visitors and all patients. The staff will respect and maintain the rights of patients at all times as defined in hospital policies and regulatory statues. A Code ten (10) may be called for assaultive/aggressive management of visitors and or prospective patients."

The hospital Policy on Incident Reporting dated 07/17/2019 reflected, "is a mechanism for administration of the occurrence of circumstances surrounding individual problematic events. An 'Incident' is defined as any happening that is not consistent with the normal or usual operations of the hospital and/or department. Injury does not have to occur. The potential for injury and/r property damage is sufficient for an event to be considered an incident. Incidents are reviewed by the Perimeter Healthcare Performance Improvement Committee and referred to other committees as indicated by hospital policy or legal, regulatory or accreditation requirements."

The hospital Policy on Abuse 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 service providers will immediately report to the appropriate supervisor, 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 service 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 statute, 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 failed to protect and promote each patient's rights to treatment in a safe enviornment.

Findings Include

The hospital governing body has failed to ensure 6 of 6 Patients (Patient's #1, #2,#3#4,#5, and #6) that the medical staff is accountable to the governing body for the quality of care provided to patients.

Findings Include

During Interview with hospital Staff #2, Patient's #1, #2,#3, #4,#5, and #6 have eloped from the hospital.

During Interview with hosptial Staff #2, It was reported that the staff did not follow the procedures that were put in place two weeks ago prior to additional elopements from the hospital.

During Interview with hospital Staff #6 it was reported that hospital Staff #7 allowed Patients #3, Patient #4, and Patient #5 to go outside for fresh air break during the 2nd shift. During that time Patients #3, #4, and #5 pulled the fire alarm and eloped through the wood fence in courtyard.

During Interview the hospital Staff #2 reported Staff #8 struck Patient #4 in the face after Patient #4 punched her. Patient #4 was then separated from the scene.

During Record Review, there are no Incident Report's of the elopements that were provided to the surveyor as request for the hospital physical confrontation Patient to Staff.

During Interview and Record Review with hospital Staff #3 the hospital failed to reprimand or educate hospital Staff #7 for taking Patients outside for a fresh air break at shift change to 2nd shift. Staff #7 has been allowed back to work without being educated on inappropriate actions of supervisor.

During record review the hospital failed to report these incidents to the department.

During Record Review there are no doctors orders that address Patient Assessment, Level of Observation and Care upon their return into the hospital.

Policy
The hospital policy on Neglect Abuse 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 07/17/2019, reflected, "The rights, benefits, responsibilities, and privileges guaranteed by the constitutions and laws of the United States of Texas unless they have been restricted by specific provisions of law. The rights include, but are not limited to, the right to impartial access to and provision of treatment, regardless of race, nationality, religion, sex, ethnicity, sexual orientation, age, or disability; the right to petition for habeas corpus; the right to register and vote at elections, the right to acquire use, and dispose of property including contractual licenses, permits, privileges and benefits under law, the right to religious freedom and rights concerning domestic relations."

The hospital Policy on Nursing Services 07/17/2019 reflected, "In order to protect the safety of patients and employees, immediate response shall be initiated for any violence by visitors and or prospective patients. All program staff are responsible for recognizing and observing the signs of potentially violent behavior, reporting it to the appropriate staff and acting within the limits of their position descriptions to protect, with the least restrictive method, any prospective patient visitors and all patients. The staff will respect and maintain the rights of patients at all times as defined in hospital policies and regulatory statues. A Code ten (10) may be called for assaultive/aggressive management of visitors and or prospective patients."

The hospital Policy on Incident Reporting dated 07/17/2019 reflected, "is a mechanism for administration of the occurrence of circumstances surrounding individual problematic events. An 'Incident' is defined as any happening that is not consistent with the normal or usual operations of the hospital and/or department. Injury does not have to occur. The potential for injury and/r property damage is sufficient for an event to be considered an incident. Incidents are reviewed by the Perimeter Healthcare Performance Improvement Committee and referred to other committees as indicated by hospital policy or legal, regulatory or accreditation requirements."

The hospital Policy on Abuse 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 service providers will immediately report to the appropriate supervisor, 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 service 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 statute, 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 failed ensure 6 of 6 Patients (Patient's #1, #2,#3#4,#5, and #6) by failing to implement an enviornmental risk strategy.
The hospital must implemtent enviornmental risk assessmments stratigies appropriate to the specific care enviornment and patient popluation. The hospital has multiple Patient's #1, #2,#3, #4,#5, and #6 have eloped from the hospital. The hospital has failed to properly hire and train the staff according to the patient population. The hospital has Patient's fighting staff and staff retaliate in fighting. The hospital failed to reprimand/retrain employees after incidents and allows the employee to return to regular duty.

Findings Include

During Interview with hosptial Staff #2, It was reported that the staff did not follow the procedures that were put in place two weeks ago prior to additional elopements from the hospital.

During Interview with hospital Staff #6 it was reported that hospital Staff #7 allowed Patients #3, Patient #4, and Patient #5 to go outside for fresh air break during the 2nd shift. During that time Patients #3, #4, and #5 pulled the fire alarm and eloped through the wood fence in courtyard.

During Interview the hospital Staff #2 reported Staff #8 struck Patient #4 in the face after Patient #4 punched her. Patient #4 was then separated from the scene.

During Record Review, there are no Incident Report's of the elopements that were provided to the surveyor as request for the hospital physical confrontation Patient to Staff.

During Interview and Record Review with hospital Staff #3 the hospital failed to reprimand or educate hospital Staff #7 for taking Patients outside for a fresh air break at shift change to 2nd shift.

During record review the hospital failed to report these incidents to the department.

During Record Review there are no doctors orders that address Patient Assessment, Level of Observation and Care upon their return into the hospital.

Policy
The hospital policy on Neglect Abuse 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 07/17/2019, reflected, "The rights, benefits, responsibilities, and privileges guaranteed by the constitutions and laws of the United States of Texas unless they have been restricted by specific provisions of law. The rights include, but are not limited to, the right to impartial access to and provision of treatment, regardless of race, nationality, religion, sex, ethnicity, sexual orientation, age, or disability; the right to petition for habeas corpus; the right to register and vote at elections, the right to acquire use, and dispose of property including contractual licenses, permits, privileges and benefits under law, the right to religious freedom and rights concerning domestic relations."

The hospital Policy on Nursing Services 07/17/2019 reflected, "In order to protect the safety of patients and employees, immediate response shall be initiated for any violence by visitors and or prospective patients. All program staff are responsible for recognizing and observing the signs of potentially violent behavior, reporting it to the appropriate staff and acting within the limits of their position descriptions to protect, with the least restrictive method, any prospective patient visitors and all patients. The staff will respect and maintain the rights of patients at all times as defined in hospital policies and regulatory statues. A Code ten (10) may be called for assaultive/aggressive management of visitors and or prospective patients."

The hospital Policy on Incident Reporting dated 07/17/2019 reflected, "is a mechanism for administration of the occurrence of circumstances surrounding individual problematic events. An 'Incident' is defined as any happening that is not consistent with the normal or usual operations of the hospital and/or department. Injury does not have to occur. The potential for injury and/r property damage is sufficient for an event to be considered an incident. Incidents are reviewed by the Perimeter Healthcare Performance Improvement Committee and referred to other committees as indicated by hospital policy or legal, regulatory or accreditation requirements."

The hospital Policy on Abuse 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 service providers will immediately report to the appropriate supervisor, 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 service 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 statute, 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.

Perimeter Hospital has failed Executive Responsiblities by the governing body, medical staff, and administrative officals who are responsible and accountable for ensuring clear expectations for safety are established.

Findings Include


During an Interview with hospital Staff #2, it was reported, that the patients were informed by their caseworkers they can have what they wanted and brought multiple items (hairspray, perfume, piercings) into the hospital. These patients also felt it was not necessary for programming while in the program and they were just to sit there until long term placement was found for them.
Staff #2 indicated that Patients did use hairspray or perfume to dislodge the fire alarm system. Staff #2 reported that the hospital had purchased more apporpriate supplies for these patients after the fact that the safety measures had been breached.

During Interview with hospital Staff #2, Patient's #1, #2,#3, #4,#5, and #6 have eloped from the hospital.

During Interview with hosptial Staff #2, It was reported that the staff did not follow the procedures that were put in place two weeks ago prior to additional elopements from the hospital.

During Interview with hospital Staff #6 it was reported that hospital Staff #7 allowed Patients #3, Patient #4, and Patient #5 to go outside for fresh air break during the 2nd shift. During that time Patients #3, #4, and #5 pulled the fire alarm and eloped through the wood fence in courtyard.

During Interview the hospital Staff #2 reported Staff #8 struck Patient #4 in the face after Patient #4 punched her. Patient #4 was then separated from the scene.

During Record Review, there are no Incident Report's of the elopements that were provided to the surveyor as request for the hospital physical confrontation Patient to Staff.

During Interview and Record Review with hospital Staff #3 the hospital failed to reprimand or educate hospital Staff #7 for taking Patients outside for a fresh air break at shift change to 2nd shift.

During record review the hospital failed to report these incidents to the department.

During Record Review there are no doctors orders that address Patient Assessment, Level of Observation and Care upon their return into the hospital.

Policy
The hospital policy on Neglect Abuse 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 07/17/2019, reflected, "The rights, benefits, responsibilities, and privileges guaranteed by the constitutions and laws of the United States of Texas unless they have been restricted by specific provisions of law. The rights include, but are not limited to, the right to impartial access to and provision of treatment, regardless of race, nationality, religion, sex, ethnicity, sexual orientation, age, or disability; the right to petition for habeas corpus; the right to register and vote at elections, the right to acquire use, and dispose of property including contractual licenses, permits, privileges and benefits under law, the right to religious freedom and rights concerning domestic relations."

The hospital Policy on Nursing Services 07/17/2019 reflected, "In order to protect the safety of patients and employees, immediate response shall be initiated for any violence by visitors and or prospective patients. All program staff are responsible for recognizing and observing the signs of potentially violent behavior, reporting it to the appropriate staff and acting within the limits of their position descriptions to protect, with the least restrictive method, any prospective patient visitors and all patients. The staff will respect and maintain the rights of patients at all times as defined in hospital policies and regulatory statues. A Code ten (10) may be called for assaultive/aggressive management of visitors and or prospective patients."

The hospital Policy on Incident Reporting dated 07/17/2019 reflected, "is a mechanism for administration of the occurrence of circumstances surrounding individual problematic events. An 'Incident' is defined as any happening that is not consistent with the normal or usual operations of the hospital and/or department. Injury does not have to occur. The potential for injury and/r property damage is sufficient for an event to be considered an incident. Incidents are reviewed by the Perimeter Healthcare Performance Improvement Committee and referred to other committees as indicated by hospital policy or legal, regulatory or accreditation requirements."

The hospital Policy on Abuse 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 service providers will immediately report to the appropriate supervisor, 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 service 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 statute, 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.