HospitalInspections.org

The hospital failed 1 of 1 Patient (Patient #1) the right to receive care in a safe setting.

Findings include

During interview with hospital Staff #1, Staff #3, and Staff #4, Patient #1 was touched inappropriately by Patient #2 in their assigned room.

During interview with hospital Staff #3, Patient #2 was observed touching other Patients inappropriately. Staff #3 reported she documented the event, Pateitn #2 was placed on unit restriction, and she was already in a blocked room and on SAO (sexually acting out) Behavior Precautions.

During record review Patient #1 was observed being physically assaulted by Patient #2 and was found with blood in her nostril, and scratches to the right side of face.

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 Sexual Aggressor and Sexual victimization dated 07/17/2019 reflected, "As a provision of care Perimeter Healthcare strives to prevent sexual aggression and victimization occurrences ...The Assessment & Referral Clinician shall assess patient for variables of sexual behavior groups: history of sexually acting out, sexual abuse, and those at risk for sexual victimization ...Patients at risk for sexual acting out behavior are placed on SAO precautions upon physician order."

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 dated 07/17/2019 reflected, "It is the policy of the Perimeter Healthcare Nursing Services Department to provide the highest attain able quality of nursing care to all patients consistent with the mission, values, vision and goals."

The hospital Policy on Administration/Personnel dated 07/17/20219 reflected, "Perimeter Healthcare provides patient centered care and working to understand each individual's needs to supply excellent, differentiated treatment plans. We strive to employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives ...Leadership Responsibility; The leaders of the Facility have defined responsibilities. These responsibilities are intended to further facilitate our ability to develop an environment that contributes to a quality system and patient safety ...Planning, formulation of specific goals, structure, and functions to assure achievement of the Mission. The process includes information gathered from both internal and external customers. Management, the process of organizing, directing, and coordinating the functions of the systems to achieve its goals ...Improvement, the process of regulating service activities to ensure achievement of goals through a continuous performance improvement process."

The hospital Policy on Incident Reporting dated 07/17/2019, reflected, "The Incident Report is a mechanism for informing administration of 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/or 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 ... Only the employee who is directly involved in the occurrence or incident, either through witnessing the event or being told by a visitor that an event has occurred, should initiate and comment on the Incident Report Form. This should be done immediately after the incident occurs (if a witness) or as soon as one becomes aware of such an occurrence (receiving information form another person)."

The hospital failed 2 of 2 Pateints (Patient #1 and Pateint #2) (3) Clear expectations for safety are established.

Findings Include

During Record Review the hospital Incident report indicated over 30 Patient to Patient Phyiscal Altercations.

During Record Review the hospital identifed areas of failed hospital activity in these occurences, but failed to identify completion dates of trainings and new process to ensure patient safety.
1.) Crisis Prevention Institute (CPI Training) techniques to de-escalate the actions of the patients involved.
2.) Training for long stay behavior plans,
3.) Lack of private spaces for telephone time,
4.) Consistency hospital-wide planning to establish structures and process that focus on safety and quality.
5.) The hospital not utilizing its organization-wide, integrated patient safety program within its performance improvements 6.) The lack of use of Root Cause Anaylsis, to address hospital failures
7.) Training to conduct with the staff to review when to initiate a call to the local police for assistance.

During Interview hospital Staff #1 indicated that there has been a lot of turnover in the hospital. The hospital staff are going through all approved training, but Staff #6 failed to practice their training in a real life situation. Staff #6 responded by calling the local Police Department. The hospital staff identified Staff #6 to be restrained in the hospital processes.

POLICY

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 dated 07/17/2019 reflected, "It is the policy of the Perimeter Healthcare Nursing Services Department to provide the highest attain able quality of nursing care to all patients consistent with the mission, values, vision and goals."

The hospital Policy on Administration/Personnel dated 07/17/20219 reflected, "Perimeter Healthcare provides patient centered care and working to understand each individual's needs to supply excellent, differentiated treatment plans. We strive to employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives ...Leadership Responsibility; The leaders of the Facility have defined responsibilities. These responsibilities are intended to further facilitate our ability to develop an environment that contributes to a quality system and patient safety ...Planning, formulation of specific goals, structure, and functions to assure achievement of the Mission. The process includes information gathered from both internal and external customers. Management, the process of organizing, directing, and coordinating the functions of the systems to achieve its goals ...Improvement, the process of regulating service activities to ensure achievement of goals through a continuous performance improvement process."

The hospital Policy on Incident Reporting dated 07/17/2019, reflected, "The Incident Report is a mechanism for informing administration of 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/or 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 ... Only the employee who is directly involved in the occurrence or incident, either through witnessing the event or being told by a visitor that an event has occurred, should initiate and comment on the Incident Report Form. This should be done immediately after the incident occurs (if a witness) or as soon as one becomes aware of such an occurrence (receiving information form another person)."