HospitalInspections.org

The facility failed to protect and promote each patients rights, as evidenced by:

* A patient was denied the right to receive care in a safe setting, as he was allowed to leave the facility with no additional assessment or interventions after stating on his discharge paperwork that he was still suicidal. As a result, this patient was at a high risk for harming himself. Refer to A0144

Based on a review of documentation, the clinical record and interview with staff, a patient was denied the right to receive care in a safe setting, as the patient was allowed to leave without any additional assessment or intervention following his written statement that he was still suicidal.


Findings were:


Review of the clinical record for patient #1 revealed that the patient, a 31-year-old male, was admitted to the psychiatric unit of BSW (through the emergency department) on an emergency detention order at approximately 2:18 am on 10-25-18. Patient #1 stated that he had been having suicidal thoughts for 3 days and had recently attempted to jump into traffic but was stopped by his girlfriend. He stated that he had recently been released from jail (3 months prior) after a man 'put his hands' on him and the patient physically attacked him in response. Patient #1 had a history of methamphetamine use disorder, substance-induced psychotic disorder, delusional disorder and antisocial personality disorder. The patient reported a history of seizures, for which he stated medication compliance with Tegretol. He stated that he had visual hallucinations of a person in the room watching everyone, but denied any auditory hallucinations. His urine drug screen was positive for amphetamines and THC (tetrahydrocannabinol). He was admitted with suicidal and assaultive thoughts.


During his admission to the unit, patient #1 again stated suicidal ideations but denied any homicidal ideations.


Patient #1 was prescribed no psychoactive medications during his stay. He was seen by staff #6 (attending physician) on the morning of 10-26-18 at approximately 11:00 am. Staff #6 stated, "[Patient #1] has no specific complaints. He denies any thoughts of plans of harming himself or anyone else. He is not reporting any psychotic symptoms. He asked about being released. We did explain to him that his notification of emergency detention expires today. He'll be discharged [to] outpatient treatment. He continues to be somewhat sarcastic in his interactions." Patient #1 was discharged with the diagnoses of substance induced mood disorder, stimulant use disorder (severe, methamphetamines & cocaine), stimulant withdrawal, history of delusional disorder, history of substance induced psychotic disorder, cannabis use disorder and tobacco use disorder.


The discharge summary for patient #1 revealed a follow-up appointment at a local mental health clinic for 11-5-18 and referral to MHMR for medication management and continuation of care.


Patient #1 was provided with an after visit summary, which included his discharge instructions. He was given the date, time, and address of his follow-up appointment on 11-5-18 as well as additional instructions on safety planning.


The signature page for the after visit summary contained patient #1's signature but no corresponding nurse signature in the blank marked for the same. Written on the signature sheet for patient #1 was the following: "I left still feeling like I want to kill myself."


A progress note written by staff #7 on 10-26-18 at 11:54 am stated the following:

"Discharged with personal belongings, escorted to pt [patient] relations by staff member due to pt stating he is missing some items that were not listed on property sheets, all belongs (sic) from safe returned including 2 cell phones, a game system and 3 games and white cigarette lighter." The progress note contained no mention of the written statement on the patient's after visit summary.


During the review of the electronic record with staff #8 (nursing supervisor), staff #8's attention was called to the missing nurse's signature on the after visit summary. When asked by the surveyor why the discharging nurse did not sign the after visit summary, staff #8 stated that [staff #7] (the nurse that discharged the patient) "did not feel comfortable" signing the after visit summary after the written statement by patient #1 that he was leaving despite still feeling suicidal. Staff #8's answer indicated that [staff #8] was aware of patient #1's statement prior to the surveyor's visit to the facility.


In an interview with staff #7 at 12:28 pm on 11-1-18, staff #7 was asked if she remembered discharging patient #1 and staff #7 stated that she remembered the event. When asked to speak about the events surrounding patient #1's discharge, staff #7 stated that patient #1 wanted to leave and did not like the hospital. Staff #7 said that the patient had denied any suicidal or homicidal ideations. She stated that the patient needed transportation and that the facility social worker worked with the patient to find transportation. She said that the patient was upset and said that he hadn't gotten all of his belongings back, even though his belongings were all inventoried at admission and again at discharge and the patient wanted to speak with someone in patient relations about it. Staff #7 stated that she walked patient #1 to patient relations to speak to someone about his belongings.


When asked about the statement that patient #1 had written on his "after visit summary" (discharge paperwork), staff #7 stated that it was not her practice to sign the paperwork at the same time as the patient and that she didn't see the message until she opened up the paperwork later. Staff #7 stated that she handed the paperwork (containing the patient's written message) to staff #8 (nursing supervisor). When asked if she documented anything in the medical record or notified the treating physician regarding the statement the patient had written on the paperwork, staff #7 stated that she had not. When asked if she had taken any additional action at all regarding the statement (contacting law enforcement to check on the patient's welfare etc), staff #7 stated that she had not. When asked if staff #8 had taken any action regarding the statement the patient had written, staff #7 stated that she was not sure. When asked if she knew the current status or whereabouts of patient #1, staff #7 stated that she did not.


In an interview with staff #8, at 12:35 pm, on 11-1-18, staff #8 was asked if she had been made aware of patient #1's written statement on his after visit summary and staff #8 stated that she had been, although she was unable to remember when she had become aware of it. When asked if she (staff #8) had documented anything in the medical record or notified the treating physician regarding the statement patient #1 had written on the paperwork, she stated that she had not. When asked if she had taken any additional action at all regarding the statement (contacting law enforcement to check on the patient's welfare etc), staff #8 stated that she had not. When asked if she knew the current status or whereabouts of the patient, staff #8 stated that she did not.


In an interview with staff #6 (treating physician) on 11-1-18, staff #6 was asked if he remembered patient #1's stay and he stated that he did. Staff #6 that patient #1 suffered from antisocial personality disorder and methamphetamine-induced psychosis and that [patient #1] had been admitted involuntarily.


Staff #6 stated that he met with patient #1 shortly before his discharge and that the patient denied any suicidal or homicidal ideations and he deemed patient #1 appropriate to be discharged and wrote the necessary discharge orders. When asked if he had been made aware of the statement patient #1 wrote on his after visit summary (at the time it was discovered by nursing staff), staff #6 stated that he had not been made aware and had only been made aware of it by administration a few minutes prior to our interview.


Staff #6 was asked what his expectations would have been for the situation (patient #1 writing that he was still suicidal on his discharge paperwork). Staff #6 stated that he would have expected to be contacted by the nursing staff immediately upon discovery of the statement.


Review of facility document titled "Patient's Bill of Rights" revealed the following:

"Basic Rights for All Patients:
...
3. You have the right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs and are treated with respect and dignity."


Facility policy BSWH.CLN.006.P titled "Self- Harm (Suicide) Screening - Inpatient" states, in part:

"Policy

BSWH screens inpatients for imminent risk of harm to self (i.e., suicidal thoughts).

Screening is completed on patients when admitted to the hospital with initial patient assessment(s) (either in the ED or upon admission to inpatient unit), or when a change in the patient's behavior that indicates that the patient may be at imminent risk of harm to self."


Review of facility document titled "Patient's Bill of Rights" revealed the following:

"Basic Rights for All Patients:
...
3. You have the right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs and are treated with respect and dignity."

The above was confirmed in an interview with the Chief Nursing Officer and other administrative staff on the evening of 11-1-18.

The facility failed to provide an organized nursing service supervised by a registered nurse, as evidenced by:

* Two registered nurses violated facility policies and procedures as well as their job descriptions and standards of professional practice, as they knowingly allowed a patient to leave the facility with no additional assessment or interventions after stating on his discharge paperwork that he was still suicidal. As a result, this patient was at a high risk for harming himself. Refer to A0386

Based on a review of documentations, the clinical records review, and interview with staff, the director of nursing services failed toprovide an effective oversight of the nursing service, as two Registered Nurses failed to follow the facility policies & procedures as well as their job descriptions when providing patient care.


Findings:


Review of the clinical record for patient #1 revealed that the patient, a 31-year-old male, was admitted to the psychiatric unit of thehospital (through the emergency department) on an emergency detention order at approximately 2:18 am on 10-25-18. Patient #1 stated that he had been having suicidal thoughts for 3 days and had recently attempted to jump into traffic but was stopped by his girlfriend. He stated that he had recently been released from jail (3 months prior) after a man 'put his hands' on him and the patient physically attacked him in response. Patient #1 had a history of methamphetamine use disorder, substance-induced psychotic disorder, delusional disorder and antisocial personality disorder. The patient reported a history of seizures, for which he stated medication compliance with Tegretol. He stated that he had visual hallucinations of a person in the room watching everyone, but denied any auditory hallucinations. His urine drug screen was positive for amphetamines and THC (tetrahydrocannabinol). He was admitted with suicidal and assaultive thoughts.


During his admission to the unit, patient #1 again stated suicidal ideations but denied any homicidal ideations.


Patient #1 was prescribed no psychoactive medications during his stay. He was seen by staff #6 (attending physician) on the morning of 10-26-18 at approximately 11:00 am. Staff #6 stated, "[Patient #1] has no specific complaints. He denies any thoughts of plans of harming himself or anyone else. He is not reporting any psychotic symptoms. He asked about being released. We did explain to him that his notification of emergency detention expires today. He'll be discharged [to] outpatient treatment. He continues to be somewhat sarcastic in his interactions." Patient #1 was discharged with the diagnoses of substance induced mood disorder, stimulant use disorder (severe, methamphetamines & cocaine), stimulant withdrawal, history of delusional disorder, history of substance induced psychotic disorder, cannabis use disorder and tobacco use disorder.


The discharge summary for patient #1 revealed a follow-up appointment at a local mental health clinic for 11-5-18 and referral to MHMR for medication management and continuation of care.


Patient #1 was provided with an after visit summary, which included his discharge instructions. He was given the date, time and address of his follow-up appointment on 11-5-18 as well as additional instructions on safety planning.


The signature page for the after visit summary contained patient #1's signature but no nurse's signature in the blank marked for the same. Written on the signature sheet for patient #1 was the following: "I left still feeling like I want to kill myself."


A progress note written by staff #7 on 10-26-18 at 11:54 am stated the following:

"Discharged with personal belongings, escorted to pt [patient] relations by staff member due to pt stating he is missing some items that were not listed on property sheets, all belongs(sic) from safe returned including 2 cell phones, a game system and 3 games and white cigarette lighter." The progress note contained no mention of the written statement on the patient's after visit summary.


During the review of the electronic record with staff #8 (nursing supervisor), staff #8's attention was called to the missing nurse signature on the after visit summary. When asked by the surveyor why the discharging nurse did not sign the after visit summary, staff #8 stated that [staff #7] (the nurse that discharged the patient) "did not feel comfortable" signing the after visit summary after the written statement by patient #1 that he was leaving despite still feeling suicidal. Staff #8's answer indicated that [staff #8] was aware of patient #1's statement prior to the surveyor's visit to the facility.


In an interview with staff #7 at 12:28 pm on 11-1-18, staff #7 was asked if she remembered discharging patient #1 and staff #7 stated that she remembered the event. When asked to speak about the events surrounding patient #1's discharge, staff #7 stated that patient #1 wanted to leave and did not like the hospital. Staff #7 said that the patient had denied any suicidal or homicidal ideations. She stated that the patient needed transportation and that the facility social worker worked with the patient to find transportation. She said that the patient was upset and said that he hadn't gotten all of his belongings back, even though his belongings were all inventoried at admission and again at discharge and the patient wanted to speak with someone in patient relations about it. Staff #7 stated that she walked patient #1 to patient relations to speak to someone about his belongings.


When asked about the statement patient #1 had written on his "after visit summary" (discharge paperwork), staff #7 stated that it was not her practice to sign the paperwork at the same time as the patient and that she didn't see the message until she opened up the paperwork later. Staff #7 stated that she handed the paperwork (containing the patient's written message) to staff #8 (nursing supervisor). When asked if she documented anything in the medical record or notified the treating physician regarding the statement the patient had written on the paperwork, staff #7 stated that she had not. When asked if she had taken any additional action at all regarding the statement (contacting law enforcement to check on the patient's welfare etc), staff #7 stated that she had not. When asked if staff #8 had taken any action regarding the statement the patient had written, staff #7 stated that she was not sure. When asked if she knew the current status or whereabouts of patient #1, staff #7 stated that she did not.


In an interview with staff #8 at 12:35 pm on 11-1-18, staff #8 was asked if she had been made aware of patient #1's written statement on his after visit summary and staff #8 stated that she had been, although she was unable to remember when she had become aware of it. When asked if she (staff #8) had documented anything in the medical record or notified the treating physician regarding the statement patient #1 had written on the paperwork, she stated that she had not. When asked if she had taken any additional action at all regarding the statement (contacting law enforcement to check on the patient's welfare etc), staff #8 stated that she had not. When asked if she knew the current status or whereabouts of the patient, staff #8 stated that she did not.


In an interview with staff #6 (treating physician) on 11-1-18, staff #6 was asked if he remembered patient #1's stay and he stated that he did. Staff #6 that patient #1 suffered from antisocial personality disorder and methamphetamine-induced psychosis and that [patient #1] had been admitted involuntarily.


Staff #6 stated that he met with patient #1 shortly before his discharge and that the patient denied any suicidal or homicidal ideations and he deemed patient #1 appropriate to be discharged and wrote the necessary discharge orders. When asked if he had been made aware of the statement patient #1 wrote on his after visit summary (at the time it was discovered by nursing staff), staff #6 stated that he had not been made aware and had only been made aware of it by administration a few minutes prior to our interview.


Staff #6 was asked what his expectations would have been for the situation (patient #1 writing that he was still suicidal on his discharge paperwork). Staff #6 stated that he would have expected to be contacted by the nursing staff immediately upon discovery of the statement.


Facility policy BSWH.CLN.006.P titled "Self- Harm (Suicide) Screening - Inpatient" states, in part:

"Policy

BSWH screens inpatients for imminent risk of harm to self (i.e., suicidal thoughts).


Screening is completed on patients when admitted to the hospital with initial patient assessment(s) (either in the ED or upon admission to inpatient unit), or when a change in the patient's behavior that indicates that the patient may be at imminent risk of harm to self."


Facility policy 632.005 titled "Charting/Nursing Documentation - Psychiatric Unit STC 1" states, in part:

"III. Procedure(s)

1. The Patient Care Documentation (PCD) is the primary location for nursing to ensure ongoing documentation.

2. Considerations for documentation of the patient in the inpatient psychiatric setting include mood, affect and behavior ...Detailed documentation of suicidal or homicidal ideation, psychotic behavior or thought, and change in status is vital. Therapeutic interventions and the nurse's evaluation of those interventions will be reflected in the narrative notes."


Facility document titled "Job Description, Registered Nurse" stated, in part:

"Job Summary

Coordinates and provides nursing care including the assessment, education, counseling and treatment of patients and delegating nursing care to others as appropriate. Works cooperatively with ancillary nursing staff and other patient team personnel and maintains standards for professional nursing practice in the clinical setting.

...
Makes accurate multi-system assessments and clearly documents in patient records on a continuous basis.

...
Clearly communicates in a timely manner data obtained during nursing assessments, reports and interdisciplinary rounds and serves as an advocate for patients and families when communicating with other health team members."


Review of the personnel file for staff #7 revealed a signed job description, indicating that staff #7 had read and was aware of the requirements for her position.


Facility document titled "Job Description, Supv Nursing" stated, in part:

"Provides supervision to all nursing and unit-based personnel on a designated shift in the provision of professional patient-centered care in accordance with physician orders, established policies and procedures, Texas Board of Nursing scope of practice and regulatory requirements.
...

2. Supervises staff and provides professional nursing care for patients in accordance with physician orders and established policies and procedures to include performing assessments, implementing and evaluating treatments and developing and documenting nursing care plans.
...

8. Implements and interprets organization policies and procedures, and nursing standards and regulations. Participates in ongoing quality improvement activities to enhance the delivery of patient care. Ensures the safety of patients."


Review of the personnel file for staff #8 revealed a signed job description, indicating that staff #8 had read and was aware of the requirements for her position.

The above was confirmed in an interview with the Chief Nursing Officer and other administrative staff on the evening of 11-1-18.