HospitalInspections.org

Based on interview, and record review, nursing failed to supervise the care of each patient per facility policy and professional nursing standards of practice for 8 of 8 patients (Patient #'s 1, 2, 3, 4, 5, 8, 9, & 10) as shown by failure of nursing staff to document and implement physician orders for patient precaution levels.

Findings included:

Record review of Texas Administrative Code (TAC) Title 22; Part 11 Texas Board of Nursing; Chapter 217; Rule §217.11 "Standards of Nursing Practice" showed:
(1) Standards Applicable to All Nurses. All vocational nurses, registered
nurses and registered nurses with advanced practice authorization shall:

(B) Implement measures to promote a safe environment for clients and
others;
(D) Accurately and completely report and document:
(ii) nursing care rendered;
(iii) physician, dentist or podiatrist orders;

Review of facility policy titled "Documentation", Policy #NSG-02, last revised 2/1/22 stated that the nurse will document the implementation and execution of physician orders. In addition, documentation is to provide concise and comprehensive information about the care of the patient.

Review of facility form located in patient clinical charts (which contained physician admit orders), titled "Admit Orders/Initial Plan of Care Texas" showed the following choices listed for physician orders for patient precaution levels: "8). Precautions: Suicide; Violence/Homicide; falls; CIWA/Detox; IC (infection control); Seizure; Bleeding; Choking; Elopement"

In an interview on 10/18/22 at 10:15 am with RN-Staff #I, she was asked to show daily implementation of physician orders for precaution levels in the records of Patient #1. Staff #I stated that on the Admit Order form, it was item #19, "Initial Treatment Plan Problem". When asked how precautions were implemented, she was unable to answer, but stated that usually during morning meetings, clinical staff discuss patients and these staff will remember what to be on the lookout for.

In an interview on 10/18/22 at 10:20 am with Charge Nurse-Staff #F, she was asked how patient precaution levels orders were implemented by nursing. Staff #F stated that all patient locations and behaviors were monitored and documented every 15 minutes and that staff keep a close eye on patients. During this same time, five patient records were reviewed with surveyor (Patients #1, 2, 3, 4, & 5). When Staff #F was asked to show daily implementation of physician orders for precaution levels, review of records showed the following:

Patient #1: no daily documentation of nursing implementation of "Falls" precautions as ordered;

Patient #2; no daily documentation of nursing implementation of "Falls" precautions as ordered;

Patient #3; no daily documentation of nursing implementation of "Suicide, Falls, Violence/Homicide" precautions as ordered;

Patient #4; no daily documentation of nursing implementation of "Falls" precautions as ordered;

Patient #5; no daily documentation of nursing implementation of "Violence/Homicide, Falls" precautions as ordered.

Further record review on 10/18/22 at 3:00 pm of three more patient charts (Patient #'s 8, 9 & 10) showed the following:

Patient #8; no daily documentation of nursing implementation of "Violence/Homicide, Falls, Bleeding, Elopement precautions";

Patient #9; no daily documentation of nursing implementation of "Falls" precautions;

Patient #10; no daily documentation of nursing implementation of "Suicide, Falls" precautions.


23032

Based on observation, interview and record review, RN staff failed to supervise the care of patients to ensure their needs were met.

- Two of two current patients were observed in need of bathing, grooming, and attention to basic hygiene activities ( Patient # 6, 7).

Findings included:

TX00431768

Review of facility policy titled: "Activities of Daily Living,"dated 12/01/2019, showed:
-RN is responsible for assessing the patient's level of performing activities of daily living (ADL) that includes showering/bathing; hair grooming; changes of underwear.
-Nursing personnel will clean and or bathe incontinent patients immediately upon voiding or soiling.

Review of facility policy titled: "Infection Control For Behavioral Health,"dated 11/01/2019, showed:
-Daily bath or shower to be taken.
-Assist patient as needed with their personal hygiene and grooming activities.

During an interview on 10/19/2022 at 1:45 PM with Staff-F, RN , she said all patients should be showered or bathed every day- unless they refused. Staff-F said if a patient refused, this should be documented.

Patient ID # 7 :

Observation on 10/18/2022 at 9:30 AM showed Patient ID # 7 walking in the common dayroom area. He approached the surveyor and Staff -H, mental health tech (MHT). He addressed Staff-H and said: "When are you going to change me? I still have crap running down my leg." Patient # 7 was observed to be unkempt and unshaven. His hair was oily and uncombed. He was wearing dirty, stained scrubs and had a very foul odor.

Record review on 10/18/2022 of ADL documentation for Patient # 7 showed he was admitted on 10/10/2022. There was no documentation of a bath/shower or refusal for his entire admission ( 8 days). At time of review, this information was verified and acknowledged by Staff-F, RN.

Patient ID # 6:

Observation on 10/18/2022 at 1:20 PM showed Patient ID # 6 sitting in a chair in the common area. Her hair was unkempt and uncombed. She was scratching furiously and repeatedly all over her head. Patient # 6 was moving in the chair, making motions as if her back might be itching. During an interview at the time of observation with Staff -H, MHT, she said "when people are around, these are her behaviors."

During an interview on 10/19/2022 at 1:30 PM with Staff-F, RN , she was unaware if anyone had checked Patient # 6 for head lice . At surveyor's request, Patient # 6 was briefly checked for head lice. Staff-F, RN stated the patient was not very co-operative, but " we tried."

Record review on 10/18/2022 of ADL documentation for Patient # 7 showed there was no documentation of a bath/shower or refusal for the last 8 days (October 10-17, 2022). At time of review, this information was verified and acknowledged by Staff-F, RN.

Based on observation, interview, and record review, the facility failed to implement an effective program to prevent and control infections and to avoid sources and transmission of infection. The facility failed to:

a. store multi-patient use equipment per policy to ensure equipment disinfection maintained between patients.

b. to handle and store patient clothing per policy in the laundry; to keep clean and dirty clothes separate.

Findings included:

TX00431768

a. Equipment storage:

Record review of facility policy titled : "Separation of Clean and Dirty Supplies,"dated 09/01/2022, showed: ...the clean and dirty utility areas are separated into two different rooms.

Observation on 10/18/2022 at 10:30 AM in the facility "Biohazard Room" showed three (3) wheelchairs stored inside. This room was located directly off of the common day area on the patient unit.

During an interview at the time of observation with Staff -G, MHT, she said the wheelchairs did not belong in the Biohazard Room. She said this was a dirty room and verified a staff member could easily obtain a dirty wheelchair for patient use.

Staff-G went on to say the wheelchairs were to be cleaned and stored in the "Medical Maintenance "room.

b. Laundry room clothing issues:

Record review of facility policy titled : "Laundry and Linen Service, "dated 08/01/2022, showed:

-Each individual patient's clothes will be stored separately, away from other patient's soiled clothes.
-Each patient's soiled clothes will be stored separate from their clean clothes.
-Each patient's clothes will be washed and dried separately from other patient's clothes.

Observation on 10/18/2022 at 10:15 AM in the facility laundry room showed the following:

- a pile of unfolded, loose clothes located on one end of of a counter; a dirty sheet on the other end of the same counter.

- a large pile of clothing was located on the top of a dryer; the clothes were not in a basket.

During an interview at the time of observation with Staff -G, MHT, she said she did not know who the clothes in the counter belonged to; they may have been donated. She said they should not be placed there; unknown if clean or dirty. She also said the dirty sheet should not be on the counter.

Staff-G went on to say the loose pile of clothes on top of the dyer was not per policy. She said every patient had a numbered laundry basket. The process was to put the numbered basket on top of machine when a patient clothes were placed inside . When the clothes were finished, they are placed back into the numbered basket.