HospitalInspections.org

Based on record review and interview, the facility failed to ensure specific patient rights were protected and promoted, and implement their written policy and procedures that protect and promote each patient's rights for 3 of 3 patients (Patient #1, #2, and #3) reviewed with complaints of rights violations. Specifically, the facility failed to ensure:

1.) Supervision and monitoring for Patient #1, #2, and #3 with ordered observations to be conducted every 15 minutes for patient safety and in accordance with the facility policies.

A.) Patient #1's records documented at least 38 occurrences where his observations exceeded 15 minutes (18 minutes up to 2 hours and 3 minutes between observations) from 11/6/20 to 11/9/20;

B.) Patient #2's records documented at least 26 occurrences where his observations exceeded 15 minutes (18 minutes up to 1 hour and 53 minutes between observations) from 10/18/20 to 11/14/20.

C.) Patient #3's records documented at least 16 occurrences where his observations exceeded 15 minutes (18 minutes up to 50 minutes between observations) from 7/2/20 to 7/8/20.

Refer to A 0144 for evidence of specific findings and,


2.) Patient's rights to be free from all forms of abuse or harassment by failing to protect, investigate, and respond to multiple allegations of abuse and mistreatment in accordance with their policy for Patient #2 with multiple allegations against facility staff of abuse or harassment documented in his records. As a result, these allegations were not thoroughly investigated by the facility for the possible identification of physical abuse or mistreatment

Refer to A 0145 for evidence of specific findings.

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Patient Rights.

Based on review of records and interviews, the facility's staff failed to ensure patient(s) rights to receive care in a safe setting.

Specifically, the facility failed to provide adequate supervision and monitoring for 3 of 3 Patient's reviewed (Patient #1, #2 and #3) with ordered observations to be conducted every 15 minutes for patient safety; and in accordance with the facility policies.

As a result, Patient #1, Patient #2, and Patient #3 reported abuse allegations while in the facility receiving treatment services.

1.) Patient #1's records documented at least 38 occurrences where his observations exceeded 15 minutes (18 minutes up to 2 hours and 3 minutes between observations) from 11/6/20 to 11/9/20;

2.) Patient #2's records documented at least 26 occurrences where his observations exceeded 15 minutes (18 minutes up to 1 hour and 53 minutes between observations) from 10/18/20 to 11/14/20.

3.) Patient #3's records documented at least 16 occurrences where his observations exceeded 15 minutes (18 minutes up to 50 minutes between observations) from 7/2/20 to 7/8/20.

These deficient practices identified placed patient health and safety at risk and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death due to insufficient supervision and monitoring.


Findings:

A.) Patient #1

Review of the complaint TX00366360 intake information, revealed an allegation that Patient #1 was sexually assaulted by an unknown male while in the facility receiving treatment services between 11/5/2020 and 11/9/2020.

Review of the New Intake Screening Assessment dated 11/5/20 for Patient #1 documented that he was a 62-year-old male on Emergency Detention for Suicidal Ideation with a plan/intent to crash the car with his wife in the car.

Review of the Ancillary Orders dated 11/5/20 completed by the Nurse Practitioner (NP #6) ordered "Level of Observation: Every (Q) 15 minutes."

Review of the Initial Psychiatric Evaluation dated 11/6/20 by the NP #6 documented Patient #1 was a "Dangerous to self, other, or property with need for controlled environment" and legally mandated admission. Level of Observation: Q 15 as evidenced by: low Columbia score. Patient Diagnosis (DX): bipolar and Differential DX: schizoaffective.

Review of Patient #1's Observations (Q 15-minute monitoring checks) conducted by the facility's Mental Health Technicians (MHT's) revealed the following breaches in the ordered supervision (Note all times in military time format):

a.) 11/6/20 at 0:07 Patient's Room

11/6/20 at 0:25 Patient's Room (18 minutes between observations)

b.) 11/6/20 at 7:00 Hall

11/6/20 at 7:21 Lobby (21 minutes between observations)

11/6/20 at 7:41 Lobby (20 minutes between observations)

11/6/20 at 8:01 Hall (20 minutes between observations)

11/6/20 at 8:45 Nurses Station (44 minutes between observations)

c.) 11/6/20 at 14:05 Dayroom

11/6/20 at 14:23 Dayroom (18 minutes between observations)

11/6/20 at 14:41 Dayroom (18 minutes between observations)

11/6/20 at 15:29 Dayroom (48 minutes between observations)

d.) 11/6/20 at 15:43 Dayroom

11/6/20 at 16:03 Dayroom (20 minutes between observations)

e.) 11/6/20 at 16:14 Dayroom

11/6/20 at 18:17 Hall (2 hours 3 minutes between observations)

f.) 11/7/20 at 4:56 Patient's Room

11/7/20 at 5:14 Dayroom (18 minutes between observations)

g.) 11/7/20 at 6:25 Lobby

11/7/20 at 6:50 Lobby (25 minutes between observations)

11/7/20 at 8:14 Dayroom (1 hour 24 minutes between observations)

h.) 11/7/20 at 8:22 Dayroom

11/7/20 at 8:55 Dayroom (33 minutes between observations)

11/7/20 at 9:14 Dayroom (19 minutes between observations)

11/7/20 at 9:33 Dayroom (19 minutes between observations)

i.) 11/7/20 at 10:00 Dayroom

11/7/20 at 11:19 Dayroom (1 hour 19 minutes)

j.) 11/7/20 at 11:33 Lobby

11/7/20 at 12:22 Nurses Station (49 minutes between observations)

k.) 11/7/20 at 14:23 Lobby and with Therapist

11/7/20 at 14:40 Dayroom (17 minutes between observations)

l.) 11/7/20 at 15:16 Dayroom

11/7/20 at 15:37 Dayroom (21 minutes between observations)

m.) 11/7/20 at 15:59 Dayroom

11/7/20 at 17:46 Lobby (1 hour 47 minutes between observations)

11/7/20 at 18:03 Hall (17 minutes between observations)

n.) 11/7/20 at 20:32 Dayroom

11/7/20 at 21:04 Dayroom (32 minutes between observations)

o.) 11/8/20 at 5:15 Dayroom

11/8/20 at 5:33 Dayroom (18 minutes between observations)

p.) 11/8/20 at 6:34 Dayroom

11/8/20 at 6:56 Dayroom (22 minutes between observations)

11/8/20 at 7:19 Dayroom (23 minutes between observations)

11/8/20 at 7:36 Dayroom (17 minutes between observations)

11/8/20 at 8:14 Dayroom (38 minutes between observations)
11/8/20 at 8:47 Dayroom (33 minutes between observations)


q.) 11/8/20 at 9:35 Dayroom

11/8/20 at 10:54 Nurses Station (1 hour 19 minutes between observations)

11/8/20 at 11:13 Patient's Room (19 minutes between observations)

11/8/20 at 11:46 Dayroom (33 minutes between observations)

r.) 11/8/20 at 16:34 Dayroom

11/8/20 at 17:03 Courtyard (29 minutes between observations)

s.) 11/8/20 at 17:14 Dayroom

11/8/20 at 17:32 Hall (18 minutes between observations)

t.) 11/9/20 at 9:52 Dayroom

11/9/20 at 10:10 Patient's Room (18 minutes between observations)

u.)11/9/20 at 10:34 Dayroom

11/9/20 at 10:57 Patient's Room (23 minutes between observations)

v.) 11/9/20 at 18:14 Dayroom

11/9/20 at 18:35 Dayroom (31 minutes between observations)

w.) 11/9/20 at 20:09 Hall

11/9/20 at 20:35 Dayroom (26 minutes between observations)



2.) Patient #2

Review of the complaint TX00365967 intake information revealed, Patient #2 alleged a named person dragged him back to his room and several staff persons hit him in the face a few times.

Review of the New Intake Screening Assessment dated 10/17/20 for Patient #2 documented, he was a 56-year-old male being assessed due to attempting to walk into traffic and delusional thoughts.

Review of Patient #2's Direct Admission Orders dated 10/18/20 by the physician ordered Level of Observation: Q 15 minutes for suicide precaution.

Review of Patient #2's Final Ancillary Orders dated 10/18/20 by the physician ordered Level of Observation: Q 15 minutes. Precautions: Elopement Precautions and Self Harm.

Review of Patient #2's incident report dated 10/29/20 at 1255 stated in part, "pt [patient] attacked by fellow male pt, physical confrontation. Location: Dayroom.

Review of Patient #2's incident report dated 11/14/20 with a time listed as AM unknown; stated in part, "patient reported another male peer ...hit him on the R side while standing in front of nurses station. This event was not witnessed by anyone (right upper hip).

Review of Patient #2's Observations (Q 15-minute monitoring checks) conducted by the facility's MHT's revealed the following breaches in the ordered supervision:

a.) 10/18/20 at 6:16 Patient's Room

10/18/20 at 7:04 Patient's Room (48 minutes between observations)

b.) 10/18/20 at 8:35 Dayroom

10/18/20 at 9:03 Dayroom (28 minutes between observations)

c.) 10/18/20 at 9:26 Dayroom

10/18/20 at 9:44 Dayroom (18 minutes between observations)

d.) 10/18/20 at 9:55 Dayroom

10/18/20 at 10:12 Dayroom (17 minutes between observations)

e.) 10/18/20 at 11:22 Nurses Station

10/18/20 at 11:41 Attending Group (19 minutes between observations)

f.) 10/18/20 at 12:06 Dayroom

10/18/20 at 12:23 Lobby (17 minutes between observations)

g.) 10/18/20 at 12:34 Hall

10/18/20 at 12:51 Hall (17 minutes between observations)

h.) 10/18/20 at 16:42 Attending Group

10/18/20 at 17:02 Dayroom (20 minutes between observations)

i.) 10/18/20 at 17:11 Nurses Station

10/18/20 at 17:32 Dayroom (21 minutes between observations)

j.) 10/18/20 at 18:45 Nurses Station and With Nurse

10/18/20 at 19:19 Patient's Room (34 minutes between observations)

k.) 10/18/20 at 19:56 Patient's Room

10/18/20 at 20:16 Patient's Room (20 minutes between observations)

l.) 10/19/20 at 4:27 Patient's Room

10/19/20 at 4:51 Patient's Room (24 minutes between observations)

10/19/20 at 5:08 Patient's Room (17 minutes between observations)

m.) 10/19/20 at 11:38 Lobby

10/19/20 at 12:05 Nurses Station (27 minutes between observations)

n.) 10/20/20 at 15:14 Nurses Station

10/20/20 at 15:37 Dayroom (23 minutes between observations)

o.) 10/20/20 at 16:30 Nurses Station

10/20/20 at 16:52 Cafeteria (22 minutes between observations)

10/20/20 at 17:26 Dayroom (34 minutes between observations)

p.) 10/21/20 at 5:20 Lobby

10/21/20 at 6:08 Patient's Room (38 minutes between observations)

10/21/20 at 6:33 Dayroom (25 minutes between observations)

q.) 10/22/20 at 5:38 Lobby

10/22/20 at 5:58 Lobby (20 minutes between observations)

r.) 10/22/20 at 6:13 Dayroom

10/22/20 at 6:41 Patient's Room and Shower (28 minutes between observations)

s.) 10/22/20 at 7:25 Hall

10/22/20 at 7:52 Lobby (27 minutes between observations)

t.) 10/22/20 at 10:59 Lobby

10/22/20 at 11:32 Lobby (33 minutes between observations)

u.) 10/22/20 at 16:56 Dayroom

10/22/20 at 17:42 Patient's Room (46 minutes between observations)

v.) 10/29/20 at 12:39 Dayroom

10/29/20 at 13:12 Dayroom (33 minutes between observations)

w.) 11/14/20 at 8:12 Nurses Station

11/14/20 at 10:05 Quiet Room (1 hour 53 minutes between observations)


Further review of Patient #2's incident report dated 10/29/20 at 1255 that stated in part, "pt [patient] attacked by fellow male pt, physical confrontation revealed there was a breach in supervision documented this date (10/29/20) at 12:39 to 13:12 (33 minutes). The incident report documented a time of occurrence of 1255 or 16 minutes from 12:39 or the last observation documented. The next observation was made at 13:13 or 17 minutes after the time of occurrence on the incident report.

Further review of Patient #2's incident report dated 11/14/20 with a time listed as AM unknown; stated in part, "patient reported another male peer ...hit him on the R side while standing in front of nurses station. This event was not witness by anyone (right upper hip). There was a breach in supervision documented this date (11/14/20). There was an observation made at the nurses station on 11/14/20 at 8:12 and the next observation was not documented until at 10:05 (1 hour and 53 minutes later) with the location identified as the quiet room.



3.) Patient #3

Review of the complaint TX00366342 intake information revealed, Patient #3 said he was physically assaulted by three employees while a patient in the facility between 7/2/20 and 7/9/20. Patient #3 alleged he was "choked out" and received two bruises on his abdomen.

Review of Patient #3's Admission Telephone Order dated 7/2/20 completed by the NP #6 ordered Level of Observation: Every (Q) 15 minutes. Precautions: Suicide Assault.

Review of Patient #3's Observations (Q 15-minute monitoring checks) conducted by the facility's MHT's revealed the following breaches in the ordered supervision:

a.) 7/2/20 at 16:31 Dayroom Lying/sitting

7/2/20 at 16:52 Dayroom and With Nurse (21 minutes between observations)

b.) 7/3/20 at 7:04 Dayroom

7/3/20 at 7:26 Courtyard Smoking (22 minutes between observations)

c.) 7/4/20 at 9:54 Dayroom

7/4/20 at 10:16 Patient's Room, Resting quietly (22 minutes between observations)

d.) 7/4/20 at 14:52 Dayroom, Socializing

7/4/20 at 15:21 Patient's Room (29 minutes between observations)

e.) 7/5/20 at 10:59 Patient's Room

7/5/20 at 11:29 Dayroom (30 minutes between observations)

f.) 7/6/20 at 1:29 Patient's Room

7/6/20 at 1:50 Patient's Room (21 minutes between observations)

g.) 7/7/20 at 6:11 Patient's Room

7/7/20 at 6:31 Hall Walking/pacing (20 minutes between observations)

h.) 7/7/20 at 11:47 Cafeteria

7/7/20 at 12:10 Dayroom (23 minutes between observations)

i.) 7/7/20 at 13:04 Courtyard

7/7/20 at 13:25 Dayroom (21 minutes between observations)

j.) 7/8/20 at 2:31 Patient's Room

7/8/20 at 2:51 Patient's Room (20 minutes between observations)

k.) 7/8/20 at 9:02 Cafeteria

7/8/20 at 9:31 Courtyard (29 minutes between observations)

l.) 7/8/20 at 11:07 Courtyard Smoking

7/8/20 at 11:57 Patient's Room (50 minutes between observations)

7/8/20 at 12:20 Patient's Room (23 minutes between observations)

m.) 7/8/20 at 14:42 Hall

7/8/20 at 15:01 Patient's Room (19 minutes between observations)

n.) 7/8/20 at 16:40 Cafeteria

7/8/20 at 17:20 Dayroom (40 minutes between observations)

o.) 7/8/20 at 18:02 Dayroom

7/8/20 at 18:20 Dayroom (18 minutes between observations)


Interview with the facility's Quality Director (QD) on 12/29/20 at 3:55 PM stated the facility's administration became aware "last week" that the 15-minute observation checks (also known as; "cues") were not always being completed by the facility staff. The QD confirmed this deficient practice had not been identified before the onsite complaint visit on 12/08/20 and 12/09/20. The QD stated that if the MHT's could not do the 15-minute observation checks then the nursing staff were supposed to conduct the observation cues. The QD stated the facility RN's were responsible for the observation cues but they delegate them to the MHT's.

Interview on 12/29/20 at 4:28 PM with the Director of Nursing (DON) confirmed nursing oversight of the MHT's was not occurring related to the 15-minute patient observations that were delegated to the MHT's by nursing. The DON stated there was a breakdown of communication between nursing and the Mental Health Technicians.


POLICES REVIEWED, in part:

1.) Review of the hospital policy entitled, "Patient Abuse and Neglect," last reviewed/revised 1/23/2019 stated the following definition for Neglect; "is a form of abuse in which there is failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness."

2.) Review of the hospital policy entitled, "Levels of Observation," last reviewed/revised 01/23/19 stated the following, in part:

PURPOSE: To provide a consistent, therapeutic approach to ensure a safe environment for the patients within the facility.

PROCEDURES included;

A. The following levels of observation are approved for utilization when clinically indicated:

1. 15 minute Observations

-Minimum level of observation for all patients.

-The patient is observed with visual checks every 15 minutes.

-All patients admitted to the inpatient acute units are on 15 minute observations unless on another indicated level.

-Staff will observe patient and document on the patient observation for every 15 minutes.

-15 minute observations will occur at random intervals no longer than 15 minutes.


B. The following precautions are approved for utilization when clinically indicated:

1. Suicide Precautions

Used when a patient communicates or gives evidence an attempt is possible.

C. The physician must order a level of observation with the reason i.e. due to Suicide Precautions, etc.

H. The RN assures levels of observation are placed on the patient's treatment plan and report sheet and notifies the Director of Nursing for adequate staffing.

I. A physician's order must be received to discontinue the precaution.

J. In general, a patient will have ongoing observations by Mental Health Techs and Nursing Staff. If and/or when a Mental Health Tech has to leave the floor, the MHT will notify nursing staff and another MHT or the Nurse will replace them on the floor for patient observation until the staff member returns.

3.) Review of the hospital policy entitled, "Locator Rounds Procedure," last reviewed/revised 02/2019 stated the following, in part:
Policy:

It is the policy of Palms Behavioral Health all patients are supervised, at a minimum, every 15 minutes through the rounds/milieu Locator process.

Procedures:

II. Roles and Responsibilities

1. General

c. Observe each patient, a minimum of every 15 minutes and document on IPad (electronic documentation)

2. Charge Nurse/Nursing Supervisor/Team Leader

a. Assigns responsibility for completion of patient Locator and environmental safety rounds at the beginning of each shift.

c. Ensures the Patient Electronic documentation are occurring as ordered, 24 hours per day, seven days a week.

d. Nurse/Unit Supervisor oversight of patient Locator rounds is evident per review/signature on Patient electronic documentation at a minimum of twice per shift as evidenced by initials on locator form for those times.

3. MHT:

c. Observe each patient, a minimum of every 15 minutes and/or according to LOCATOR Level of Observation and document on the patient electronic IPad

j. When other staff assumes responsibility for the patient, (i.e. admissions follow up, individual therapy, session with physician, etc.) the patients Locator electronic documentation should accompany them, or the person assigned to checks should document who accompanied the patient, the time the patient left and returned to the unit.

k. Hand off assigned patient electronic documentation rounds to another staff member before leaving the patient treatment area (meals, breaks, emergencies)

4.) The hospital policy entitled, "Patient Bill of Rights," last reviewed/revised 01/23/20 stated the following, in part:

Basic Rights for All Patients

5. You have the right to be free from mistreatment, abuse, neglect, and exploitation.

Based on record review and interviews, the facility failed to ensure patient's rights to be free from all forms of abuse or harassment by failing to protect, investigate, and respond to multiple allegations of abuse and mistreatment in accordance with their policy for 1 of 3 patients reviewed (Patient #2) with multiple allegations against facility staff of abuse or harassment documented in his records. As a result, these allegations were not thoroughly investigated by the facility for the possible identification of physical abuse or mistreatment

This deficient practice could affect the prevention of possible unidentified abuse, neglect, or mistreatment for all patients in the facility; by compromising their safety.


Findings:

Review of the complaint TX00365967 intake information revealed the following allegations alleged by Patient #2: A staff person named "Bruce" said he was going to tear up the patient's face. Bruce dragged Patient #2 back to his room and hit him in the face a few times. Several unnamed staff persons hit the patient in the face, then the staff persons held him down and pushed their elbows into his body. Patient #2 additionally alleged that male staff speak horrible to him. They say they are going to call someone to "take care of it." They walk fast behind him on purpose in order to intimidate him and call him, "IT."

Review of the hospital policy entitled, "Patient Abuse and Neglect," last reviewed/revised 1/23/2019 stated the following, in part:

III. Procedure

1. Anyone who receives or witnesses an incident of patient abuse or neglect must report the incident to his/her immediate supervisor or to the Patient Advocate.

b. The complaint must be described in writing ...

c. The employee is to inform the patient of the availability of the Patient Advocate ...who will be contacting him/her.

d. The employee is to inform their respective supervisor of any patient allegations related to abuse and/or neglect inflicted by staff.

7. The Patient Advocate will:

a. Maintain a Rights Complaints Log, documenting ...every 24 hour period.

b. ...investigate all complaints within two working days of receipt.

c. Ascertain all substantial allegations in a complaint shall remain open until adequate remedial action has been provided.

d. ...track all complaints, noting any similarities or trends which need to be addressed ...


Review of Patient #2's incident reports revealed there was not any incidents identified or reported regarding allegations of abuse or mistreatment alleged against facility staff.

Review of Patient #2 records in part revealed the following abuse and mistreatment allegations documented within the record:

1.) 10/20/20 Psychiatric Progress Note at 12:59, "paranoid believes someone in the unit is threatening him and cursing him."

2.) 10/21/20 RN Mental Status Assessment at 08:37, "he believes others are talking about him wanting to kill him. He believed that others on the unit were talking about him and he was inferring that they were planning imminent harm to him."

3.) 10/21/20 Psychiatric Progress Note at 15:05, "believes Diego is in unit trying to kill him."

4.) 10/22/20 Psychiatric Progress Note at 15:29, "believes someone in the unit wants to kill him."

5.) 10/26/20 RN Mental Status Assessment at 23:46, states "people here are going to hurt me."

6.) 10/28/20 RN Mental Status Assessment at 11:00, thoughts that the techs want "to kill me" "I heard them last night saying that."

7.) 10/29/20 Psychiatric Progress Note at 13:12, he is paranoid believes staff wants to hurt him, calls them demons and Satan.

8.) 10/30/20 Psychiatric Progress Note at 11:39, he is paranoid believes male staff is plotting against him.

9.) 11/4/20 Nursing Progress Note at 07:31, he has multiple complaints this am-telling me he was accosted (sic) by male tech staff days ago because "He does not like me."

10.) 11/4/20 Psychiatric Progress Note at 13:14, he states that an "MHT punched him on the eye."

11.) 11/4/20 RN Mental Status Assessment at 13:14, believes that male staff want "to kill me."

12.) 11/7/20 Psychiatric Progress Note at 10:32, believes staff is injecting him with poison. He is aggressive and hostile towards male staff and he states "they want to ripped my face off."

13.) 11/8/20 Therapy Group Note by Licensed Masters Social Worker at 12:15, stated that staff member "Bruce" was an atheist and had been rude to him.

14.) 11/9/20 RN Mental Status Assessment at 00:32 stating, "I fear for my life, someone is gonna hurt me, I am in danger" Patient was noted to call 911.

15.) 11/9/20 Psychiatric Progress Note at 12:21 Chief Complaint: "Bruce said he would pull my face off." Reports Bruce the MHT went to his room last night and threaten to "torn his face off."

16.) 11/10/20 Psychiatric Progress Note at 12:06 "Bruce is giving me the wrong meds." He is paranoid believes Bruce the MHT is giving him the wrong medication and is threatening him very night with "ripping" his face.

17.) 11/12/20 Therapy Group Note by Licensed Professional Counselor at 14:30, stating MHT are hitting him, trying to hurt him and kill him.

18.) 11/13/20 Nursing Progress Note at 16:16 He believed that there was a staff member carrying a gun and will shoot him. He was talking on the phone then yanked the phone (sic) out - cutting the cord from the phone.

19.) 11/14/20 Nursing Physical Assessment at 11:14 he started with his delusions that someone is going to kill him. ...demanding to use the phone to call Patient Advocacy. He calmed down for fifteen minutes but then he resumed his delusionary thinking (sic) believing that demons/devils are in the building and that his daughter is embezzling his money from his account and that his sister is conspiring with his daughter.

20.) 11/16/20 Psychiatric Progress Note at 10:54 "requesting for the detention of Bruce the MHT as he believes he followed him to his room and threaten to kill him." Delusions: paranoid, believes the devil is out to get him, believes Bruce wants to kill him.


Review of Patient #2's Direct Admission Orders dated 10/18/20 by the physician ordered Level of Observation: Q 15 minutes for suicide precaution.

Review of Patient #2's Observations (Q 15-minute monitoring checks) conducted by the facility's Mental Health Technicians (MHT's) documented at least 26 breaches in the ordered supervision where his observations exceeded 15 minutes (18 minutes up to 1 hour and 53 minutes between observations) from 10/18/20 to 11/14/20 (Cross Reference A0144 for specific evidence of dates and times).

Interview on 12/08/20 at 1:00 PM with the Quality Director confirmed the facility had multiple staff members with the specified name that Patient #2 was making abuse and mistreatment allegations against.

Further interview on 1/19/21 at 1:28 PM with the Quality Director (QD) confirmed there were not any allegations of abuse or mistreatment reported on behalf of Patient #2 to the Quality Director for investigation and there was not any follow up on the allegations documented in Patient #2's record. The QD stated that Patient #2 had called the Patient Advocate hotline with several concerns about "other patients". The QD stated Patient #2 "had delusions and hallucinations; there was no Diego. No staff or patients named Diego." The Quality Director was asked if there were any patient interventions regarding the continuous allegations of abuse and mistreatment documented; in which he responded they conduct "safety checks" every 15 minutes and that these allegations were due to the "symptomology of the patient."

Based on record review and interviews, the facility's nursing services failed to supervise and evaluate the nursing care for each patient in accordance with the patient's treatment plan and the facility's policies for 3 of 3 patient's reviewed (Patient #1, Patient #2, and Patient #3). Specifically,

1.) RN's delegated the performance of the physician/provider ordered 15-minute observation safety checks of patients to the Mental Health Technicians (MHT's). As a result, the supervision and monitoring for Patient #1, #2, and #3 with ordered observations to be conducted every 15 minutes for patient safety and in accordance with the facility policies were not completed according to the physician and/or provider orders.

A.) Patient #1's records documented at least 38 occurrences where his observations exceeded 15 minutes (18 minutes up to 2 hours and 3 minutes between observations) from 11/6/20 to 11/9/20;

B.) Patient #2's records documented at least 26 occurrences where his observations exceeded 15 minutes (18 minutes up to 1 hour and 53 minutes between observations) from 10/18/20 to 11/14/20.

C.) Patient #3's records documented at least 16 occurrences where his observations exceeded 15 minutes (18 minutes up to 50 minutes between observations) from 7/2/20 to 7/8/20. And,

2.) On 11/2/20 Patient #2 was given intramuscular (IM) emergency medications which included Haldol, Ativan and Benadryl without a nursing (RN) assessment or evaluation completed after the administration of the emergency medications.


Findings:

1.) A.) Patient #1

Review of the Ancillary Orders dated 11/5/20 completed by the Nurse Practitioner (NP #6) ordered "Level of Observation: Every (Q) 15 minutes."

Review of the Initial Psychiatric Evaluation dated 11/6/20 by the NP #6 documented Patient #1 was a "Dangerous to self, other, or property with need for controlled environment" and legally mandated admission. Level of Observation: Q 15 as evidenced by: low Columbia score. Patient Diagnosis (DX): bipolar and Differential DX: schizoaffective.

Review of Patient #1's Observations (Q 15-minute monitoring checks) conducted by the facility's Mental Health Technicians (MHT's) revealed the following breaches in the ordered supervision (Note all times in military time format):

a.) 11/6/20 at 0:07 Patient's Room

11/6/20 at 0:25 Patient's Room (18 minutes between observations)

b.) 11/6/20 at 7:00 Hall

11/6/20 at 7:21 Lobby (21 minutes between observations)

11/6/20 at 7:41 Lobby (20 minutes between observations)

11/6/20 at 8:01 Hall (20 minutes between observations)

11/6/20 at 8:45 Nurses Station (44 minutes between observations)

c.) 11/6/20 at 14:05 Dayroom

11/6/20 at 14:23 Dayroom (18 minutes between observations)

11/6/20 at 14:41 Dayroom (18 minutes between observations)

11/6/20 at 15:29 Dayroom (48 minutes between observations)

d.) 11/6/20 at 15:43 Dayroom
11/6/20 at 16:03 Dayroom (20 minutes between observations)

e.) 11/6/20 at 16:14 Dayroom

11/6/20 at 18:17 Hall (2 hours 3 minutes between observations)

f.) 11/7/20 at 4:56 Patient's Room

11/7/20 at 5:14 Dayroom (18 minutes between observations)

g.) 11/7/20 at 6:25 Lobby

11/7/20 at 6:50 Lobby (25 minutes between observations)

11/7/20 at 8:14 Dayroom (1 hour 24 minutes between observations)

h.) 11/7/20 at 8:22 Dayroom

11/7/20 at 8:55 Dayroom (33 minutes between observations)

11/7/20 at 9:14 Dayroom (19 minutes between observations)

11/7/20 at 9:33 Dayroom (19 minutes between observations)

i.) 11/7/20 at 10:00 Dayroom

11/7/20 at 11:19 Dayroom (1 hour 19 minutes)

j.) 11/7/20 at 11:33 Lobby

11/7/20 at 12:22 Nurses Station (49 minutes between observations)

k.) 11/7/20 at 14:23 Lobby and with Therapist

11/7/20 at 14:40 Dayroom (17 minutes between observations)

l.) 11/7/20 at 15:16 Dayroom

11/7/20 at 15:37 Dayroom (21 minutes between observations)

m.) 11/7/20 at 15:59 Dayroom

11/7/20 at 17:46 Lobby (1 hour 47 minutes between observations)

11/7/20 at 18:03 Hall (17 minutes between observations)

n.) 11/7/20 at 20:32 Dayroom

11/7/20 at 21:04 Dayroom (32 minutes between observations)

o.) 11/8/20 at 5:15 Dayroom

11/8/20 at 5:33 Dayroom (18 minutes between observations)

p.) 11/8/20 at 6:34 Dayroom
11/8/20 at 6:56 Dayroom (22 minutes between observations)

11/8/20 at 7:19 Dayroom (23 minutes between observations)

11/8/20 at 7:36 Dayroom (17 minutes between observations)

11/8/20 at 8:14 Dayroom (38 minutes between observations)

11/8/20 at 8:47 Dayroom (33 minutes between observations)

q.) 11/8/20 at 9:35 Dayroom

11/8/20 at 10:54 Nurses Station (1 hour 19 minutes between observations)

11/8/20 at 11:13 Patient's Room (19 minutes between observations)

11/8/20 at 11:46 Dayroom (33 minutes between observations)

r.) 11/8/20 at 16:34 Dayroom

11/8/20 at 17:03 Courtyard (29 minutes between observations)

s.) 11/8/20 at 17:14 Dayroom

11/8/20 at 17:32 Hall (18 minutes between observations)

t.) 11/9/20 at 9:52 Dayroom

11/9/20 at 10:10 Patient's Room (18 minutes between observations)

u.)11/9/20 at 10:34 Dayroom

11/9/20 at 10:57 Patient's Room (23 minutes between observations)

v.) 11/9/20 at 18:14 Dayroom

11/9/20 at 18:35 Dayroom (31 minutes between observations)

w.) 11/9/20 at 20:09 Hall

11/9/20 at 20:35 Dayroom (26 minutes between observations)



B.) Patient #2

Review of Patient #2's Direct Admission Orders dated 10/18/20 by the physician ordered Level of Observation: Q 15 minutes for suicide precaution.

Review of Patient #2's Final Ancillary Orders dated 10/18/20 by the physician ordered Level of Observation: Q 15 minutes. Precautions: Elopement Precautions and Self Harm.

Review of Patient #2's Observations (Q 15-minute monitoring checks) conducted by the facility's MHT's revealed the following breaches in the ordered supervision:

a.) 10/18/20 at 6:16 Patient's Room

10/18/20 at 7:04 Patient's Room (48 minutes between observations)

b.) 10/18/20 at 8:35 Dayroom

10/18/20 at 9:03 Dayroom (28 minutes between observations)

c.) 10/18/20 at 9:26 Dayroom

10/18/20 at 9:44 Dayroom (18 minutes between observations)

d.) 10/18/20 at 9:55 Dayroom

10/18/20 at 10:12 Dayroom (17 minutes between observations)

e.) 10/18/20 at 11:22 Nurses Station

10/18/20 at 11:41 Attending Group (19 minutes between observations)

f.) 10/18/20 at 12:06 Dayroom

10/18/20 at 12:23 Lobby (17 minutes between observations)

g.) 10/18/20 at 12:34 Hall

10/18/20 at 12:51 Hall (17 minutes between observations)

h.) 10/18/20 at 16:42 Attending Group

10/18/20 at 17:02 Dayroom (20 minutes between observations)

i.) 10/18/20 at 17:11 Nurses Station

10/18/20 at 17:32 Dayroom (21 minutes between observations)

j.) 10/18/20 at 18:45 Nurses Station and With Nurse

10/18/20 at 19:19 Patient's Room (34 minutes between observations)

k.) 10/18/20 at 19:56 Patient's Room

10/18/20 at 20:16 Patient's Room (20 minutes between observations)

l.) 10/19/20 at 4:27 Patient's Room

10/19/20 at 4:51 Patient's Room (24 minutes between observations)

10/19/20 at 5:08 Patient's Room (17 minutes between observations)

m.) 10/19/20 at 11:38 Lobby

10/19/20 at 12:05 Nurses Station (27 minutes between observations)

n.) 10/20/20 at 15:14 Nurses Station

10/20/20 at 15:37 Dayroom (23 minutes between observations)

o.) 10/20/20 at 16:30 Nurses Station

10/20/20 at 16:52 Cafeteria (22 minutes between observations)

10/20/20 at 17:26 Dayroom (34 minutes between observations)

p.) 10/21/20 at 5:20 Lobby

10/21/20 at 6:08 Patient's Room (38 minutes between observations)

10/21/20 at 6:33 Dayroom (25 minutes between observations)

q.) 10/22/20 at 5:38 Lobby

10/22/20 at 5:58 Lobby (20 minutes between observations)

r.) 10/22/20 at 6:13 Dayroom

10/22/20 at 6:41 Patient's Room and Shower (28 minutes between observations)

s.) 10/22/20 at 7:25 Hall

10/22/20 at 7:52 Lobby (27 minutes between observations)

t.) 10/22/20 at 10:59 Lobby

10/22/20 at 11:32 Lobby (33 minutes between observations)

u.) 10/22/20 at 16:56 Dayroom

10/22/20 at 17:42 Patient's Room (46 minutes between observations)

v.) 10/29/20 at 12:39 Dayroom

10/29/20 at 13:12 Dayroom (33 minutes between observations)

w.) 11/14/20 at 8:12 Nurses Station

11/14/20 at 10:05 Quiet Room (1 hour 53 minutes between observations)


C.) Patient #3

Review of Patient #3's Admission Telephone Order dated 7/2/20 completed by the NP #6 ordered Level of Observation: Every (Q) 15 minutes. Precautions: Suicide Assault.

Review of Patient #3's Observations (Q 15-minute monitoring checks) conducted by the facility's MHT's revealed the following breaches in the ordered supervision:

a.) 7/2/20 at 16:31 Dayroom Lying/sitting

7/2/20 at 16:52 Dayroom and With Nurse (21 minutes between observations)

b.) 7/3/20 at 7:04 Dayroom

7/3/20 at 7:26 Courtyard Smoking (22 minutes between observations)

c.) 7/4/20 at 9:54 Dayroom

7/4/20 at 10:16 Patient's Room Resting quietly (22 minutes between observations)

d.) 7/4/20 at 14:52 Dayroom Socializing

7/4/20 at 15:21 Patient's Room (29 minutes between observations)

e.) 7/5/20 at 10:59 Patient's Room

7/5/20 at 11:29 Dayroom (30 minutes between observations)

f.) 7/6/20 at 1:29 Patient's Room

7/6/20 at 1:50 Patient's Room (21 minutes between observations)

g.) 7/7/20 at 6:11 Patient's Room

7/7/20 at 6:31 Hall Walking/pacing (20 minutes between observations)

h.) 7/7/20 at 11:47 Cafeteria

7/7/20 at 12:10 Dayroom (23 minutes between observations)

i.) 7/7/20 at 13:04 Courtyard

7/7/20 at 13:25 Dayroom (21 minutes between observations)

j.) 7/8/20 at 2:31 Patient's Room

7/8/20 at 2:51 Patient's Room (20 minutes between observations)

k.) 7/8/20 at 9:02 Cafeteria

7/8/20 at 9:31 Courtyard (29 minutes between observations)

l.) 7/8/20 at 11:07 Courtyard Smoking

7/8/20 at 11:57 Patient's Room (50 minutes between observations)

7/8/20 at 12:20 Patient's Room (23 minutes between observations)

m.) 7/8/20 at 14:42 Hall

7/8/20 at 15:01 Patient's Room (19 minutes between observations)

n.) 7/8/20 at 16:40 Cafeteria

7/8/20 at 17:20 Dayroom (40 minutes between observations)

o.) 7/8/20 at 18:02 Dayroom

7/8/20 at 18:20 Dayroom (18 minutes between observations)


Interview with the facility's Quality Director (QD) on 12/29/20 at 3:55 PM stated the facility's administration became aware "last week" that the 15-minute observation checks (also known as; "cues") were not always being completed by the facility staff. The QD confirmed this deficient practice had not been identified before the onsite complaint visit on 12/08/20 and 12/09/20. The QD stated that if the MHT's could not do the 15-minute observation checks then the nursing staff were supposed to conduct the observation cues. The QD stated the facility RN's were responsible for the observation cues but they delegate them to the MHT's.

Interview on 12/29/20 at 4:28 PM with the Director of Nursing (DON) confirmed nursing oversight of the MHT's was not occurring related to the 15-minute patient observations that were delegated to the MHT's by nursing. The DON stated there was a breakdown of communication between nursing and the Mental Health Technicians.


2.) Review of an incident report for Patient #2 dated 11/02/20 at 1400 - patient agitated removed AED from wall posturing trying to elope. Assisted to room. Emergency meds given.

Review of the Physician Medication Orders (PO) dated 11/2/20 at 14:02 for Patient #2 revealed Haloperidol Injectable (Haldol) 5 mg/ml SOLN 10 mg IM NOW, Lorazepam (Ativan) Oral 1mg TAB 2 mg PO NOW and at 14:03 Diphenhydramine (Benadryl) oral 50 mg CAP 50 mg PO Once were ordered due to the patients Agitation.

Review of the medication administration records dated 11/2/20 at 14:13 revealed RN (staff# 12) administered the PO for Haloperidol Solution Intramuscular, Diphenhydramine capsule and Lorazepam tablet as ordered.

Review of Patient #2's medical records revealed there was not any type of Nursing (RN) assessment or progress note completed for 11/2/20. There was not a nursing assessment completed after the administration of the emergency medications on 11/2/20.

Interview on 12/29/20 at 12:15 PM with the Quality Director (QD) confirmed the following:
He reviewed the patient's record and did not see a nursing progress note for 11/02/20. He did not see an RN mental status assessment or an RN physical assessment for 11/02/20. The QD indicated that there should have been a nursing progress note or nursing assessment of the patient on 11/02/20 on the day an incident report was completed that noted the patient was given emergency medications.


POLICES REVIEWED:

Review of the hospital policy entitled, "Levels of Observation," last reviewed/revised 01/23/19 stated the following, in part:

PURPOSE: To provide a consistent, therapeutic approach to ensure a safe environment for the patients within the facility.

PROCEDURES included;

A. The following levels of observation are approved for utilization when clinically indicated:

1. 15 minute Observations

-Minimum level of observation for all patients.

-The patient is observed with visual checks every 15 minutes.

-All patients admitted to the inpatient acute units are on 15 minute observations unless on another indicated level.

-Staff will observe patient and document on the patient observation for every 15 minutes.

-15 minute observations will occur at random intervals no longer than 15 minutes.

C. The physician must order a level of observation with the reason i.e. due to Suicide Precautions, etc.

H. The RN assures levels of observation are placed on the patient's treatment plan and report sheet and notifies the Director of Nursing for adequate staffing.

I. A physician's order must be received to discontinue the precaution.

J. In general, a patient will have ongoing observations by Mental Health Techs and Nursing Staff. If and/or when a Mental Health Tech has to leave the floor, the MHT will notify nursing staff and another MHT or the Nurse will replace them on the floor for patient observation until the staff member returns.


3.) Review of the hospital policy entitled, "Locator Rounds Procedure," last reviewed/revised 02/2019 stated the following, in part:
Policy: It is the policy of Palms Behavioral Health all patients are supervised, at a minimum, every 15 minutes through the rounds/milieu Locator process.

Procedures:

II. Roles and Responsibilities

1. General

c. Observe each patient, a minimum of every 15 minutes and document on IPad (electronic documentation)

2. Charge Nurse/Nursing Supervisor/Team Leader

a. Assigns responsibility for completion of patient Locator and environmental safety rounds at the beginning of each shift.

c. Ensures the Patient Electronic documentation are occurring as ordered, 24 hours per day, seven days a week.

d. Nurse/Unit Supervisor oversight of patient Locator rounds is evident per review/signature on Patient electronic documentation at a minimum of twice per shift as evidenced by initials on locator form for those times.


Review of the facility's policy for clinical services titled, Assessment and Reassessment of the Patient, effective 06/2016 revealed the following in part: Reassessment of patient is
;
1. Reassessed daily, every shift, and as the patient's condition/needs warrant by an RN (Registered Nurse).

2. Done to determine the patient's response to treatment.

3. Completed by the RN on the need or change of patient condition.

Based on record review and interview, the facility's nursing staff failed to follow the facility's policy on Medication Administration in order to ensure physician orders were implemented.

Specifically, nursing staff failed to ensure the patient swallowed the prescribed medication (Divalproex sodium) during administration for 1 of 1 patient reviewed (Patient #2) with a medication complaint.

As a result, 3 Divalproex sodium (Depakote) pills were found at a later date in the dayroom's couch accessible to other patients in the unit.


Findings:

Review of the complaint TX00365967 intake information, revealed Patient #2 stated that they try to give him Zyprexa or Depakote. Patient cannot take Zyprexa or Depakote because the medication makes him scream and run.

Review of the Medication Orders by Nurse Practitioner (NP) staff (#11) dated 10/18/20 at 17:49 included Divalproex sodium ERT (Depakote ER) 750 milligrams (mg) PO BID (by mouth twice daily).

Review of the Medication Administration Record dated 10/18/20 at 20:00 by RN (staff #9) documented the administration of Divalproex Sodium ERT tablet, extended release (Depakote ER) oral twice daily. To give 750 mg use 3 each of 250 mg for Seizures.

Review of an incident report for Patient #2 dated 11/2/20 revealed 3 - 250 mg pills of Depakote were found in the Dayroom couch crevice- "appeared to have been cheeked and discarded there." Patient agitated, anxious. Treatment: Refused. The incident report did not include measures or follow up to prevent this patient or other patients from not taking a medication and placing the medication(s) where the patient or other patients may have future access.

Review of the Nursing Progress Note by RN (staff #10) dated 11/3/20 at 08:51 documented that Mental Health Tech's (MHT's) found 3, 250mg Depakote in couch yesterday. Pills belong to Patient #2 and he was confronted about the meds. Pt at first denied, but then asked that I no tell anyone.


Review of the hospital policy entitled, "Medication Administration," reviewed/revised 01/23/20 was reviewed on 01/18/21 and stated, in part:

Policy: Palms Behavioral Health administers medications in an efficient and safe manner according to hospital policy.

Procedure

31. The Nurse will assist the patient as necessary and check to make sure the patient has swallowed the medication.


Interview on 1/13/21 at 2:00 PM with the Quality Director was asked what interventions or follow-up was done after this incident for Patient #2; where his Depakote medication appeared to have been "cheeked" and placed in the couch. The QD's response was that he "spoke with the nurse." The QD stated the patient admitted to "cheeking" the medication. The QD stated they disposed of the medication through their pharmacy and the physician was notified. The QD stated he would need to follow up with the facility's Director of Nursing (DON) for any other resolutions or follow-up; further stating the DON just started her position less than a month ago in December.