HospitalInspections.org

Based on record reviews and interviews, the facility failed protect and promote each patient's rights when,

- 4 out of 4 patients, (Patients #2, 3, 4, and 5) were placed in seclusion for over 2 hours and their hygiene, hydration, nutrition, elimination needs were not provided for, placing these patients at risk for pain, dehydration, and at risk for urinatry tract infections.

- patients placed in seclusion were not reassessed by licensed professionals to determine the need for continuation in seclusion, placing these patients at risk of emotional and physical harm. (Patients # 2,3,4,5)

Cross refer: A0154

Based on record reviews, and interviews, the facility's nursing staff failed to ensure the immediate physical safety of patient placed in seclusion were released at the earliest possible time when (4) out of (4) patients placed in seclusionpatients placed in seclusion comply with the requirements set forth by State law and hospital policy when the use of restraint or seclusion is necessary;

- were not reassessed by licensed professionals to determine the need for continuation in seclusion, placing these patients at risk of emotional and physical harm. (Patients # 2,3,4,5) and

- were placed in seclusion for over 2 hours and their hygiene, hydration, nutrition, elimination needs were not provided every two hours as the Texas Administrative Code Title 25 Chapter 415.266 (c)(1) and (2) requires.


Findings include:

Review of the facility provided policy "RESTRAINT AND SECLUSION" (last reviewed 8/17/23) reflected,
"Definitions: 2. Seclusion is the involuntary confinement of a person alone in a room or an area from which the patient is physically prevented from leaving.
1. Indications:
a. Restraint or seclusion may be used when less restrictive means are not sufficient to protect the
physical safety of patients, staff members or others.
b. Seclusion may only be used for the management of violent or self-destructive behavior that
jeopardizes the immediate safety of the patient, a staff member, or others ...

7. Assessment and Monitoring of Restraint Seclusion:
Assessment: Assessments by a registered nurse or physician assistant or evaluations completed by a responsible Licensed Independent Practitioner shall occur as often as indicated by the patient's condition, behavior, and environmental considerations and at least once every 60 minutes.

8. Documentation of Monitoring:
Episodes of restraint shall be documented as indicated on currently approved assessments,
monitoring and ordering forms. The annotation of actual real time continuous monitoring is not
required to be documented concurrently but is encouraged.
Discontinuation: Restraint or seclusion shall be discontinued:
a. Once the behaviors or situations that prompted the use of restraint are no longer evident; or
b. When it is determined that less restrictive means will be effective in protecting the patient /
others.

Review of the facility provided medical records of patients Patients # 2,3,4,5, reflected the patients were placed in seclusion for over 2 hours and did not receive the required reassessments every 60 minutes.

During an interview on the morning of 9/10/24, in the administrative office, Staff #1, Risk Manager confirmed the medical records did not have the required hourly reassessments documented, either in the nursing notes or on the reassessment form; the patient's on-going need for seclusion was not indicated.

The following seclusion records were reviewed for start and stop times, bathroom and fluids were requested or offered to the patients and reassessments:

Patient #2
- 8/31/24 in seclusion for 3.57 hours, start time 12:20 pm released at 4:05 pm, reassessed by a nurse at 1:07pm. There were no further reassessments available. There was no recorded bathroom or fluids request or provisions.
- 9/1/24 in seclusion for 3.17 hours, start time 5:55 pm released at 9:12 pm, reassessed by a nurse at 6:32 pm. There were no further reassessments available. There was no recorded bathroom or fluids request or provisions.
- 9/1/24 in seclusion for 3.40 hours, start time 9:59 pm released at 1:45 am. There were no further assessments available. There was no recorded bathroom or fluids request or provisions.
- 9/2/24 in seclusion for 3.45 hours, start time 7:17 pm released at 11:15 pm, reassessed by a nurse at 7:51 pm. There were no further reassessments available. There was no recorded bathroom or fluids request or provisions.

Patient #3
- 7/28/24 in seclusion for 2.47 hours start time 8:28 am released at 11:15 am, reassessed by a nurse 9:00 am. There were no further reassessments available. There was no recorded bathroom or fluids request or provisions.

Patient #4
- 8/23/24 in seclusion for 3.07 hours start time 9:40 am released at 12:47 pm, reassessed by a nurse 10:11 pm. There were no further assessments available. There was no recorded bathroom or fluids request or provisions.
- 8/24/24 in seclusion for 4.0 hours start time 12:00 pm released at 4:00 pm, reassessed by a nurse 12:31 pm. There were no further reassessments available. There was no recorded bathroom or fluids request or provisions.

Patient #5
- 8/25/24 in seclusion for 3.50 hours start time 3:10 am released at 7:00 am, reassessed by a nurse 4:10 am. There were no further reassessments available. There was no recorded bathroom or fluids request or provisions.
- 8/36/24 in seclusion for 3.50 hours start time 12:43 am released at 3:50 am, reassessed by a nurse 1:20 am. There were no further assessments available. There was no recorded bathroom or fluids request or provisions.

During an interview on the morning of 9/10/24, in the administrative office, when asked how the monitoring staffs document if the patients are provided bathroom breaks or something to drink, Staff #3, CEO stated in part that the facility could not open the doors of the seclusion room, it would require them to start new orders for seclusion. The facility was unable to provide evidence that the patients were being offered or the patients had asked for bathroom breaks and fluids.

Based on record reviews, and interviews, the facility failed to provide an organized nursing services when

- the facility failed to restrict or define 'today' orders resulting in 2 out of 2 patients, with an order for an EKG (electrocardiogram, measures the hearts rhythm and rate) today order, having to wait 24-48 hours for diagnostic testing, the delay in treatment placed the patients at risk of a negative cardiac event. (Patients #6 and #11)

- the facility failed to implement a policy and procedure for the assessing and monitoring of patient wounds to ensure proper healing resulting in Patient #1's knee and left antecubital wound worsening without the physician's notification or interventions.

Cross refer: A0386

Based on record review and interview, the facility failed provide a well-organized nursing services when it failed to develop and enforce policies to ensure patient care, the facility

1. failed to restrict or define 'today' orders resulting in 2 out of 2 patients, with an order for an EKG (electrocardiogram, measures the hearts rhythm and rate) today order, having to wait 24-48 hours for diagnostic testing, the delay in treatment placed the patients at risk of a negative cardiac event. (Patients #6 and #11)

2. failed to implement a policy and procedure for the assessing and monitoring of patient wounds to ensure proper healing resulting in Patient #1's knee and left antecubital wound worsening without the physician's notification or interventions.

Findings:

Review of Patient #6's physician's order dated 8/31/24 at 11:00 am reflected, "EKG today - chest pain."
Review of Patient #6's physician's order, dated 9/2/24 at 11:45 am reflected, "Please follow up on EKG orders 8/31/24. Pt reported nobody did the EKG."
Review of Patient #6's EKG dated 9/2/24 reflected abnormal EKG and was initialed by the physician as having been read.

Review of Patient #11's physician's orders dated 8/23/24 at 1:00 pm reflected, "EKG today - bradycardia (slow heart rate)"
Review of Patient #11's EKG dated 8/24/24 at 10:35 am reflected A-fib (atrial fibrillation, an abnormal heart rhythm with an increased risk of stroke) and initialed by the physician as having been read and interpreted.

During an interview on the morning of 9/10/24, when asked about the orders for EKGs, Staff #5, NP (Nurse Practitioner) stated, "Patient #6 came from the hospital, he had gotten an EKG while he was there. He was reporting a lot of pain, all over. He had an EKG before he came here, I wanted to see if there were any changes; I ordered the EKG to be done that day. When I came back in, (two days later) patient #6 reported no one had done the EKG, so I wrote the second order. After we got Patient #11's EKG we placed her on anticoagulants. (Blood thinners)"

During an interview on the afternoon of 9/9/24, Staff #2, CNO (Chief Nursing Officer), stated, "We contract our Radiology services. We have 24 hours to get an EKG, if it is on the weekends, we have till Monday."

During an interview on the afternoon of 9/9/24, Staff #3, CEO (Chief Executive Officer) when asked what the time for completion for a today order stated in part, the today order is not a term used at the facility. We have STAT orders, done immediately and routine orders, can be done the next day. Staff #3 confirmed the facility did not have a policy for the use of today orders and the nursing staff had not clarified the order with the physician.

2.)1. Review of the facility provided policy "Record of Care, Treatment and Services", (last reviewed 8/10/2022) reflected, "It is the policy of Dallas Behavioral Healthcare Hospital to assure that the maximum possible information about a patient is available to the professional staff providing care, subsequent caregivers, regulatory/accrediting bodies and utilization review ...Progress Notes 3. Notes should include a brief and concise description of the patient's condition ..."

Review of the facility provided policy, "Wound Care" (last review date 8/1/23) reflected, "Purpose: To provide clear guidelines for the treatment and management of wounds, including those acquire by patients during their stay, ensuring medical intervention and adherence to discharge care plans ...Any wounds or bruises that develop will be promptly assessed by a Registered Nurse (RN), who will consult with our medical team. Necessary treatment will be provided based on the assessment, and the patient's condition will be closely monitored to ensure proper healing."

Review of the facility provided policy, "Assessment and Re-Assessment of Patients" (last reviewed 8/17/23) reflected, " ...each patient is reassessed as necessary based on the patients plan for care or change in their condition ..."

Review of the facility provided policy "Record of Care, Treatment and Services", (last reviewed 8/10/2022) reflected, "It is the policy of Dallas Behavioral Healthcare Hospital to assure that the maximum possible information about a patient is available to the professional staff providing care, subsequent caregivers, regulatory/accrediting bodies and utilization review ...Progress Notes 3. Notes should include a brief and concise description of the patient's condition ..."

Review of Patient #1's Nursing Admission Assessment dated 8/27/24 reflected bruises, to the back of patients #1's arms and a spider bite to the abdomen; there were no other indications of injuries or wounds.

Review of Patient #1's Skin Assessment Sheet dated 8/28/24 at 6:10 pm reflected, bruises to both knees and a laceration to the nose. A note reflected, "pt started to run and trip over her foot an [sic]felled [sic]and hit her face to the floor. RN came and met pt on the floor crying with a laceration on the top of her nose bleeding, and bruises bil (bilateral, both) knee ...Pt sent out via 911 to ER."

Review of Patient #1's Acute Care Hospital's emergency room discharge instructions dated 8/28/24 reflected, "Diagnosis: Open fracture of nasal bone."

Review of Patient #1's pictures, taken 9/3/24 by the ISS (Individual Socialization Skills) facility staff and sent to this surveyor reflected the following:
- Picture #1 had an approximately 5cm x 2 cm opened wound to the AC (left antecubital, inside elbow) with a dark pink inside and reddened edges; the wound was open to air.
- Picture #2 reflected an approximately 10 cm x 6 cm open wound to the left knee, the edges had healing scabs with the inside showing reddened/dark pink inside the wound.
- Picture#3 showed an approximately 4 cm x .5 cm healing laceration across the bridge of the nose; the wound was already healing leaving a thick scab. The edges were slightly reddened.

During an interview, on the afternoon of 9/9/24, when asked for the policy for wound care documentation and patient #1's skin assessment sheets, showing the measurements and description of the wounds upon her return from the ER, Saff #2, Chief Nursing Officer stated, "We don't do that here, we aren't going to be doing measurements in this environment ...They (nurses) should be documenting the wounds in their notes, there isn't a specific form." Staff #2, CNO confirmed there were no documented measurements of patient #1's wounds.

During an interview on the morning of 9/10/24, when asked about patient #1's wounds Staff #5, Nurse Practioner stated, "I saw her (patient #1) when she returned from the hospital, there was a cut on her nose. I don't see her every day. I expect the nurse to clean and observe the wound and call me if needed. I know she had a nasal fracture and a very superficial cut to the left AC."
Staff #5, NP was shown the pictures (taken after discharge) of patient #1 and stated, "When she left here it was a small linear line (the nose laceration). I wasn't aware of the wound to the knee; it was a bruise when she came back from the ER. I ordered treatments for the left AC wound, it didn't look like that, it was still superficial." Staff #5 reported, she had not reassessed patient #1's left arm prior to discharge.

During an interview, on the afternoon of 9/9/24, Staff #1, Risk Manager, confirmed there was no available documentation of the left knee opening or of the worsening wound to the left AC."