HospitalInspections.org

Based on observation, document review, and interview the facility failed to ensure a safe environment was provided to all patients and staff on 1 (Changes Unit, Restore Unit, and Square One Unit) of 3 patient care units.


Findings include:


A tour of the facility was conducted on 4/20/2021 at 3:47 PM with Staff #1 and Staff #2. The following observations were made.

Changes Unit

A large window in the Common Area was noted to have two separate large pieces of plywood replacing 2 windowpanes. The plywood was secured to the metal window frame with screws.

An interview was conducted with Staff #1 on 4/20/2021 at 4:40 PM. Staff #1 was asked why plywood was placed in the windowpanes. Staff #1 stated, "We had an aggressive patient, Patient #6 kicked the window out in February. Then we had another patient, Patient #7 kicked out the plywood in April." Staff #1 was then asked how the facility ensured the plywood was not going to be kicked out again to keep the patients safe until the needed repairs were made. Staff #1 said, "We have pushed the chairs in front of the plywood, secured the plywood with more screws, and when the patients go outside there is always a Mental Health Tech with them."

A review of the daily staffing for the Changes Unit on 4/2/2021 was conducted with Staff #1 on 4/21/2021 after 10:00 AM. The Nurse and Mental Health Tech staff to patient ratio was adequate to ensure patient safety and staffed according to the facility staffing plan.


A review of the incident report dated 2/19/2021 at 4:17 PM regarding Patient #6 was as follows:

" ...Patient intrusive, agitated, verbally aggressive and disrupting unit. Orders for Zyprexa, Zydis 10mg received and patient refused. Pt then kicked dayroom window down-area immediately secured and patient removed from window. At this time MD was called again and new orders received for Haldol 10mg and Benadryl 50mg IM. Injections given at 1535 ..."


An interview was conducted with Staff #1 on 4/20/2021 after 4:00 PM. Staff #1 was asked if Patient #6 sustained any injuries at the time of the incident. Staff #1 stated, "No."



A review of the incident report dated 4/2/2021 at 1:37 PM regarding Patient #7 was as follows:

" ...Patient received court ordered IM injection. Four minutes after injection patient became angry and upset due to having to receive court ordered medication. Patient began banging the window and knocked down dayroom window with foot. Window immediately removed. Patient suffered no injuries ..."

A review of the medical record for Patient #7 was as follows:

" ...@10:15 patient became increasingly agitated and began banging dayroom window and took out dayroom window by kicking it out. Window was immediately removed from patients possession-no injury involved ..."



An interview was conducted with Staff #7 on 4/21/2021 after 10:00 AM. Staff #7 was asked if he replaced the plywood in the window. Staff #7 stated, "The plywood was replaced and secured with screws as soon as the incident happened. We are still waiting for the regular window to come in that was ordered. Right now all we can do is put more screws in the wood to make sure that it holds in place better." Staff # 4 confirmed the findings.


An interview was conducted on 4/21/2021 at 8:30 AM with Staff #4. Staff #4 was asked why the windows had not been repaired. Staff #4 stated, "We ordered the material in February, but we have not been able to get the replacements yet."

A review of the document titled "Purchase Order No. 039-1811282" 2/22/2021 revealed "2 Lexan (an impact resistant polycarbonate sheeting used in place of glass windows) for Changes" had been ordered to replace the existing plywood being used in the window space on the Changes Unit.

A review of an email dated 4/21/2021 at 10:41 AM addressed to Staff #4 from ********** was as follows:

" ...Greetings,

We have the estimated delivery for the door on 4/27 with the Lexan arriving around 5/6. Appologies (sic) for the Lexan delay, there was a manufacturing delay which caused a push back from our original date of 3/10.

Please let us know if you have any other questions or concerns ..."



An interview was conducted with Staff #1 and Staff #2 on 4/21/2021 after 10:00 AM. Staff #1 and #2 was asked if there was any documentation of the plywood in the Common Area on the Changes Unit. Staff #2 replied, "We do not have any documentation regarding the plywood on the Changes Unit other than the purchase order or email that was provided." Staff #1 was asked if the staff monitored the plywood to ensure there was no missing or broken pieces to ensure all patients were safe. Staff #1 confirmed the plywood was not monitored by staff for any damage. Without proper monitoring of the plywood in the patient care area, the facility cannot ensure the wood was not damaged. Small pieces of wood can be used by patients as weapons to harm themselves or others.

Staff #1, #2, and #4 confirmed the above findings.

Based on observation, document review, and interview the facility failed to provide a clean and sanitary environment on 2 (Restore Unit, Square One Unit, and Changes Unit) of 3 patients care units to prevent the transmission of infectious diseases and hospital acquired infections.



Findings include:

Square One Unit

The floor throughout the unit, outside patient rooms, was covered with dirt, dust, and trash.

In the hallway, directly beneath the room #125 sign, the rubber baseboard was peeling away from the wall exposing the sheetrock. The paint was peeling away from the sheetrock. The porous surface cannot be properly sanitized to prevent the spread of infectious diseases.


Changes Unit

The floor throughout the unit, outside patient rooms, was covered with dirt, dust, and trash.

In the common area are two large pieces of plywood replacing windowpanes that were destroyed by a patient. The porous surface cannot be properly sanitized to prevent the spread of infectious diseases.


Outside the patient nutrition room, a wall hanging hand sanitizer dispenser unit had been removed leaving 6 small holes and one plastic anchor exposed. Loose sheetrock was visible. The holes were unfilled and the surface was unpainted. The porous surface cannot be properly sanitized to prevent the spread of infectious diseases. This surveyor tried to remove the plastic anchor and was unable to do so.

Inside the Patient Nutrition Room was a metal sink that was noted to have a brown colored stain in and around sink. On the countertop, next to the sink was a large coffee maker. The metal coffee maker had a dried liquid visibly noted down the side. Around the base of the coffee maker was a dried brown liquid that outlined the shape of the coffee maker. The cabinet doors directly under the sink were noted to have a dried brown color on the face of the doors. Inside the unlocked cabinets beneath the sink was hand tools, several napkins heavily soiled with a brown color directly under the plumbing fixture, a dried sponge, and the floor of the cabinet was covered with a dried brown liquid, dirt, dust, and debris.

The inside of the lower cabinets, under the countertop to the right of the sink was covered with dirt and dust. The cabinets were being used for storage of patient supplies such as syringes, needles, and plastic eating utensils.


A refrigerator labeled "PATIENT FOOD ONLY" was in the Patient Nutrition Room. Inside the refrigerator was a plastic bin storing approximately 15 four-ounce boxed cartons of apple juice and approximately 13 four-ounce boxed cartons of orange juice. No expiration date could be located on any carton of the orange juice or apple juice. All items were readily available for patients to consume. Staff #1 and Staff #2 were unable to determine how long the items had been in the refrigerator and when they expired.

The wall inside the laundry room was noted to have chipped and peeling paint exposing the sheetrock beneath. The porous surface cannot be sanitized to prevent the spread of infectious diseases.

An interview was conducted on 4/21/2021 at 8:30 AM with Staff #4. Staff #4 was asked how often housekeeping cleaned each unit and patient rooms. Staff #4 stated the units and patient rooms are cleaned daily. We only have one full-time housekeeper that works Sunday-Thursday. We let one housekeeper go yesterday. Staff #7 also does housekeeping and some minor maintenance repairs. We did hire another housekeeper and she will start in orientation on 4/26/2021. Right now, we have a contract with a cleaning company that comes once a week and I have asked for them to come daily and we are waiting for approval from corporate. The MHT's will also clean when needed to."

An interview was conducted with Staff #7 on 4/21/2021 at 11:36 AM. Staff #7 was asked how often housekeeping was cleaning the facility. Staff #7 stated, "We only have one housekeeper right now because the other one was let go yesterday. I help with housekeeping when I can, but I also do maintenance in the facility. Somedays there is no housekeeping staff in the building and we all just have to help when we can. We are doing some repairs in some patient rooms so the dust can get bad at times."

Staff #2 confirmed the contracted company also comes on an "as needed basis." Staff #2 also said, "We have been trying to hire for housekeeping staff, but we have not had any luck with filling the positions. We did hire a new housekeeper and they will start in orientation on 4/26."

A review of the document titled, "Team North Texas Glen Oaks work list report 3/9/21" was as follows:
" ...11. Provided deep clean of all (3) patient units ..."


A review of the Visitor Screening logs dated 4/11/2021 and 4/18/2021 revealed Team North Texas was in the building for contract work. Staff #4 confirmed they were in the building for cleaning.

A review of the document titled, "Team North Texas Invoice" dated 4/21/2021 was as follows:

" ...Provided deep clean of all patient units at ******* on 4/11/21 and 4/18/21 ..."

Staff #1, #2, #4 confirmed the above findings