HospitalInspections.org

Based on observation, interview, and record review, the facility failed to meet hospital Conditions of Participation for CFR 481.13(c)(2)- Patient Rights: Care in a Safe Setting (Tag A0144) for 1 of 1 patients (Patient #5) as shown by facility's failure to:

a. Ensure a secured window inside a second story suicidal patient's bedroom
(Patient #5) could not breached by the patient to prevent patient from jumping
out;

b. Ensure staff were accurately closely monitoring a patient (Patient #5) per doctor's
orders, and;

c. Ensure a patient (Patient #5) received pharmacotherapy treatment in a timely
manner.

Findings included:

Review of facility policy titled "Levels of Observation and Precaution Levels", ID# 11887705, last revised 06/2022 showed that staff will complete Patient Observations (close patient monitoring as ordered by the physician) at a minimum of every 15 minutes and using an electronic device, document the patient's whereabouts and demeanor as the rounds are made. In addition, it stated that staff will make visual contact with the patient during these rounds to ensure the patient is not in danger or distress, and, staff will be vigilant for potential risk factors identified for specific patents.

Review of facility policy titled "Medical Staff Rules and Regulations", policy ID# 12085695, last revised 07/2022 showed that the Psychiatric Evaluation and Mental Status Examination shall, in all cases, be completed within 24 hours after patient admission and an admission note from the physician will be entered in the progress notes at the time of evaluation.

Review of facility self-reported incident showed that on 10/28/22 at approximately 3:58 pm, a Mental Health Technician (MHT) heard a noise coming from a patient's room (Patient #5, Room #212). Upon entering the room, the MHT found that the patient had apparently hit the window, breaking it, resulting in the patient, along with the entire glass window with frame coming out and landing on the ground outside. A registered nurse (RN) called 911 while another RN ran to the location of the patient outside. Paramedics later arrived and transported the patient to Ben Taub Hospital (county hospital).

In an interview on 10/31/22 at 10:30 am with CEO-Staff #A and Risk Manager (RM)-Staff #B, they both stated that at around 3:55 pm on 10/28/22, Patient #5 was able to somehow break the window frame in her bedroom on the facility's second floor adult "Connections" unit and jump out. Both the patient and the window frame with glass fell out to the outside ground below. Staff #A and #B both stated they were unsure how the patient was able to accomplish this and added that the window should not have been able to have been breached, as this was a secured facility.

Patient #5 was then brought via EMS ambulance to the county hospital (Ben Taub) where she was diagnosed with three vertebrae (spinal bone) fractures and a calcaneus (heel) fracture. She underwent surgery the following day which took 11 hours per Staff #B.

Observation on 10/31/22 at 11:30 am of facility's "Connections" adult unit revealed that bedroom #212 was locked, vacant, and blocked to patients. The window where the patient had broken through was covered with plywood. Review of pictures submitted by Staff #B showed a cracked window inside it's entire metal frame laying on the ground.

Record review of patient #5's clinical chart showed the following:

The patient was a 38-year-old female admitted to facility involuntarily from HCA Houston Healthcare Mainland hospital's emergency room on 10/27/22 at 11:24 am under the care of Dr.-Staff #F. Reason for admittance was suicidal ideation and homicidal ideation towards her six-week-old newborn.

Review of attending doctor Staff #F's Initial Psychiatric Examination signed on 10/28/22 at 5:01 pm, showed the patient appeared to be psychotic and was exhibiting bizarre behavior, and, there was no prior psychiatric history noted as patient was selectively mute. A Psychosocial Assessment conducted by LSW-Staff #N on 10/28/22 signed at 2:05 pm documented that the patient had three prior psychiatric hospitalizations, a history of three prior suicide attempts, and history of self-harm.

A daily nursing assessment done on 10/27/22 signed at 3:43 pm, 7 am-7 pm shift by RN-Staff #K, showed that the patient had thought about killing herself by jumping out a window.

Patient's Plan of Care dated 10/27/22 authored by RN-Staff #K showed "Problem #1.. Danger to self ...Provide safe and supportive environment...suicidal...ideation... TO JUMP FROM WINDOW..."

A narrative document titled Pre-admission Evaluation and Medical Screening at Admission, authored by Dr.-Staff #G dated 10/27/22, signed 12:29 pm showed: Suicidal-Yes, with intent. Judgement-Poor. Thought- Psychotic. Problem-Psychotic Symptoms, Suicidal Thinking or Behavior. Intervention Goal (Long and Short Term treatment plan): Antipsychotic, anxiolytic, or other sedating medications to reduce patient anxiety, agitation, and; Antipsychotic medication to reduce psychotic symptoms with aggressive or self-injurious behavior associated with psychotic disorder.

An Initial Psychiatric Exam performed by Dr.-Staff #F signed on 10/28/22 at 5:01 pm also showed the patient's short-term goal was to be stabilized on medication, and plan was to initiate pharmacotherapy.

The Medication Administration Record (MAR) failed to show any ordered and/or administered medications indicated for psychosis or depression for entirety of hospital stay.

Nursing notes from RN-Staff #L dated 10/28/2022 signed at 7:17 pm showed: "AT 3:58 RN was on telephone on hold for Medicaid transportation for a pt who is being discharged to check on their arrival. MHT tech yelled to RN that Pt had broken a window and jumped out of it. RN and [first name and last initial of RN-Staff#M] ran to the pt room and found pt on her back on the ground below with eyes open. RN called 911, and Code blue. [First name and last initial of RN-Staff #M] and MHT ran to the downstairs yard where pt was on the ground. Dr. [name of Dr.-Staff #F] was notified and the pt sister, [name of patient's sister] was were notified of the incident".

Orders from Dr.-Staff #F showed the patient was placed on Close Observation monitoring every 15 minutes. Close Observation rounds documentation showed the following:


Mental Health Technician (MHT)-Staff #H''s documentation:

10/28/22 for 3:45 pm observation, signed 3:50 pm; patient calm in dayroom.

10/28/22 for another 3:45 pm observation (same time of 3:45 as above), signed 4:21 pm; patient calm in patient room.

10/28/22 for 4:00 pm observation, signed 4:02 pm; patient calm in dayroom.

10/28/22 for another 4:00 pm (same time of 4:00 pm above), signed 4:21 pm; patient calm in dayroom;


RN-Staff #J's documentation:

10/28/22 observation for 7:45 pm, signed 8:01 pm; patient calm in dayroom.

10/28/22 observation for 8:00 pm, signed 8:02 pm; patient calm in dayroom.


(Per RN-Staff #L's progress note and facility incident report, the patient was found lying on the ground in the facility's yard, next to a broken window on 10/28/22 at 3:58 pm, after she had apparently jumped out of her bedroom window. The was then taken to the emergency room via EMS ambulance).