HospitalInspections.org

Based on interview and record review, the facility failed to uphold the right of 4 of 10 sampled patients to receive care in a safe setting ( Patient # 2, 3, 6, 8).The facility failed to ensure:

1. A medical or forensic exam was conducted following an allegation of sexual assault by Patient # 6.

2. Identification / implementation of appropriate precaution levels based upon patient assessment & history ( Patients# 2 , 3 , 6)

3. Timely implementation of change in precaution levels:(Patient # 8, 3)

Findings include:

TX 00292234
TX 00292167

1. Medical/Forensic Exam Patient # 6:

Record review of Patient # 6's psychiatrist progress note, dated 07-22-18 ( 1 p.m.), read: "...alleged that staff beat him up...and sexually assaulted by staff..."

During an interview on 08-16-18 at 1:45 p.m. with Chief Nursing Officer (CNO) # 2 he was unable to locate documentation of an order for / or documentation of a medical consult or forensic exam for Patient # 6. CNO said "if patient alleged sexual assault, we send them to an ER to be evaluated."

During an interview on 08-16-18 at 11:00 a.m. with facility Risk Manager # 9 she stated on 07-21-18, Patient # 6 alleged that a staff member physically assaulted him on Unit 6 but did not say anything about sexual assault. This incident was investigated and included suspension of the tech involved during the investigation; witness interviews; and viewing of the camera footage for the timeframe involved. The facility conducted an "intensive analysis" which included the psychiatrist who made the progress note entry dated 07-22-18 of "alleged sexual assault." The facility found the physical assault allegation was unfounded.

The Risk Manager said the psychiatrist was unaware of the Patient # 6's allegation the day before of a physical assault only. She went on to say the video footage showed the tech was in Patient # 6's room less than 12 seconds. The tech followed the patient into the room because it was thought the patient had possibly taken a pen from the nurses's station.

Risk Manager # 9 went on to say the psychiatrist should have been informed of the patient's allegation of physical assault on 07-21-18. She further stated that if a patient alleged sexual assault, a medical or forensics exam was usually indicated; documentation should indicate reason not to obtain / extenuating circumstances.

Review of facility "Basic Rights for All Patients," read: "...16. You have the right to receive treatment of any physical problems which affect your treatment.."

2. Identification /Implementation of Appropriate Precaution Levels:

Patient # 3:

Record review of Patient #3's clinical record revealed he was a 17 year old male admitted involuntarily to the facility on 08-08-18 for suicidal ideation and behavioral emergencies. Further review revealed the following:

a. "High Risk Notification Alert", dated on 08-08-18, read" Sexual-Victimization "(indicated by check mark); handwritten notation next to this: "molested at age 7 years old."

b. "Psychiatric Evaluation", dated 08-08-18, read:"...patient reports history of sexual trauma by Mom's previous lovers..."

Review of Patient # 3's admission orders, dated 08-08-18, failed to reveal he was placed on "sexual-victimization" precautions.

Review of Patient # 3's physician orders revealed he was not placed on SAO (sexually acting out) precautions until 08-14-18.

Patient # 2:

Record review of Patient #2's clinical record revealed he was a 16 year old male admitted to the facility on 07-24-18 for suicidal ideation.

Review of "Intake Assessment", dated 7-24-18, read: "patient brought in by cps (child protective services) staff from RTC (residential treatment center) with report of SI (suicidal ideation) with a plan to OD (overdose) on pills..to kill self...pt. ran away form RTC today for about 4 hours..."

Review of this same intake assessment, dated 07-24-18, revealed a section titled "Elopement Risk". One of the screening risk indicators was: "Prior elopement attempts within 7 days"; this indicator was not checked. Under the title "ELOPEMENT RISK", staff had checked "No Risk".

During an interview on 08-15-18 at 12:30 p.m. with Quality Director # 3 she stated because this patient had just eloped from the RTC before admission; the "prior elopement within 7 days" indicator should have been checked. This would have triggered Patient # 2 to be placed on Elopement Precautions on admission.

Review of Patient #2's admission orders, dated 7-26-18, revealed he was not placed on Elopement Precautions.

Patient # 6:

Record review of Patient # 6's clinical record revealed he was a 20 year old male admitted to the facility on 07-21-18 for suicidal ideation.

Review of Licensed Professional Counselor (LPC) progress notes dated 7-23-18, read :"... pt reports history of sexual and physical...no history of emotional abuse..."

Review of all physician orders for for Patient # 6 failed to reveal he was placed on sexual victimization precautions.."

During an interview on 08-15-18 at 12:30 p.m. with Quality Director # 3 she stated if the LPC had communicated this new information; it likely would have triggered SAO precautions.

Review of facility policy titled "Levels of Observation", dated 6/18, read:"...Policy Statement: All patients will be routinely observed in compliance with physician orders and prescribed protocols...Special Precautions: E. Sexual Victim. 1. patients who have history of being sexually abused/assaulted will be placed on this precaution. These patients may be at risk to be victimized again, or to act out sexually..."

3. Timely Implementation of Orders for Change in Precaution Levels:

Patient # 8

Record review of Patient # 8's clinical record revealed he was a 16 year old male admitted to the facility on 04-10-18 for suicidal ideation and major depressive disorder.

Review of physician orders for Patient #8 revealed the following:

1. Physician order dated 4-29-18 (time 10:29 a.m.):"Place on unit restriction (UR)"
Review of "Observation Rounds/Precautions" sheets for Patient # 8 revealed this order was not implemented until 4-30-18.

2. Physician order dated 5-13-18 ( 7 p.m.):"Place on UR and Elopement Precautions(EP)"Review of "Observation Rounds/Precautions" sheets for Patient # 8 revealed this order was not implemented until 5-14-18.

3. Physician order dated 6-08-18 (5:15 p.m.):"Place on UR and EP"
Review of "Observation Rounds/Precautions" sheets for Patient # 8 revealed this order was not implemented until 6-09-18.

Patient # 3

Record review of Patient #3's clinical record revealed he was a 17 year old male admitted involuntarily to the facility on 08-08-18 for suicidal ideation and behavioral emergencies.

Review of nursing notes, dated 8-11-18 (1548) , read: "Patient was seen wrapped both hands around another patient's neck (sic). Staff had to get him off. He was angry and threatening..."

Review of physician orders for Patient #3 revealed the following:

1. Physician order dated 8-11-18 (1600)"Place on Assaultive Precautions (AP)/ UR"
Review of "Observation Rounds/Precautions" sheets for Patient # 3 revealed this order was not implemented until 8-12-18.

During an interview on 08-16-18 at 1:45 p.m. with CNO # 2 he said that orders for changes in precaution levels "should be implemented immediately if possible; or for sure on the same day."

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) documented a patient assessment following an allegation of physical assault by a staff member. [citing Patient # 6]

Findings include:

TX 00292234

Patient # 6:

Record review of Patient # 6's clinical record revealed he was a 20 year old male admitted to the facility on 07-21-18 for suicidal ideation.

During an interview on 08-16-18 at 11:00 a.m. with facility Risk Manager # 9 she stated on 07-21-18, Patient # 6 alleged that a staff member physically assaulted him on Unit 6.

During an interview on 08-16-18 at 1:45 p.m. with the Chief Nursing Officer (CNO) # 2 he was unable to locate a nursing assessment for Patient # 6 following his allegation of physical assault on 07-21-18. He said he felt certain the supervisor assessed this patient after the allegation but she must not have documented it in his medical record.

Record review of facility policy titled "Nursing Documentation", dated 2/18, read: ".. Nursing documentation shall include: Patient data obtained through assessment...C, Daily reassessment:...* Any change in the patient's status (to include...physical ...variances in care or outcomes..)

Record review of facility policy titled "Incident Reporting", dated 5/17, read: "..Responsibility: ...Procedure...C. Completing the Healthcare Peer Review (HPR) Reporting (Occurrence Reporting) ..g. The Nurse Charge of Shift (sic) ensured the following information is obtained prior to forwarding the completed HPR to the Risk Manager:...patient was examined and received immediate medical attention as needed, medical record documentation is appropriate..."

Based on observation, interview, and record review, the facility failed to ensure three (3) of 10 sampled patients' master treatment plans were kept current and individualized based on assessed needs and significant occurrences (Patient # 7, 8, 9).

Findings include:

TX 00292167

Patient # 7:

Record review of the clinical record of Patient # 7 revealed he was a 17 year old male admitted involuntarily on 08-03-18 for "increased aggression."

Review of Patient # 7's "Psychosocial Assessment," dated 08-03-18, read:"..he is being treated for aggression and alteration in thinking processes. Patient is mute and unable to communicate verbally and has barriers to cognitive understanding..."

Review of "Initial Nursing Treatment Plan," dated 08-03-18 , read: Under the heading "Problems/Goals:

"Alteration in Thinking" a box next to this problem was checked as "NONE."

"Communication Barriers": the box to identify this as a problem was not checked.

During an interview on 08-16-18 at 1:45 p.m. with Chief Nursing Officer (CNO) # 2 he stated the nursing care plan should not have documentation that Patient # 7 had no "alteration in thinking"; because he had severe intellectual disabilities. CNO # 2 went on to say nursing should have identified "communication barriers" as a problem for Patient # 7, as he was mute.
~~~~~~
Review of Patient # 7's psychiatrist progress note, dated 08-06-18, read: "..patient continues to wander the unit..poor boundaries and poor impulse control...He becomes aggressive when it comes to food. He will try to take his peers snacks. He will eat food out of the trash bags.."

Observation on 08-15-18 at 9:45 a.m. revealed Patient # 7 taking food from a trash can in the common area on Unit 7. Staff redirected Patient # 7 twice for this behavior.

Record review of Patient # 7's "Interdisciplinary Master Treatment Plan," dated 08-06-18, failed to identify this patient's specific issues related to "aggression with food; taking food from peers and trash" as individual problems.

During an interview on 08-15-18 at 11:45 a.m. with the Quality Director # 3, she stated Patient # 7's "issues with food" should have been addressed on his care plan.

Patient # 8:

Record review of the clinical record of Patient # 8 revealed he was a 16 year old male admitted involuntarily on 04-10-18 for "suicide attempt."

Review of facility self-reported incident revealed Patient # 8 eloped from the hospital cafeteria on 07-03-18 at 4:11 p.m. with another female patient. Patient # 8 was returned to the facility by staff and police approximately 25 minutes later.

Review of Patient # 8's "Master Treatment Plan/ Update" , dated 07-10-18 , revealed a section that read:"Any significant incidents/ behavioral changes...". There were designated sections / headings to document the following information: "Date; Type of Incident; RN initial; and Brief Description." These sections were left blank; there was no documentation on Patient #8's treatment plan that he had actually eloped on 07-03-18.

During an interview on 08-16-18 at 1:45 p.m. with CNO # 2 he stated Patient # 8's treatment plan should have been updated to include the actual elopement incident.

Patient # 9:

Record review of the clinical record of Patient # 9 revealed she was a 17 year old female admitted involuntarily on 05-01-18 for increased aggression and homicidal behavior.

Review of facility self-reported incident revealed Patient # 9 eloped from the hospital cafeteria on 07-03-18 at 4:11 p.m. with another male patient. Patient # 9 was returned to the facility by staff approximately 1 hour later.

Review of Patient # 9's "Master Treatment Plan/ Update" , dated 07-10-18; 07-12-18; and 07-23-18, revealed a section that read: "Any significant incidents/ behavioral changes...". There were designated sections / headings to document the following information: "Date; Type of Incident; RN initial; and Brief Description." These sections were left blank on all 3 treatment plan updates following the incident. There was no documentation on Patient #9's treatment plan that she had actually eloped on 07-03-18.

During an interview on 08-16-18 at 1:45 p.m. with CNO # 2 he stated Patient # 9's treatment plan should have been updated to include the information she had actually eloped.

Record review of facility policy titled "Initial Nursing Treatment Plan, Master Treatment Plan and Reassessment,"dated 6/18, read:"...Policy:...3... Problems for ( sic) shall have individualized plans of care to meet the patient's needs...12. The Master Treatment Plan shall be reviewed by the interdisciplinary team, at 72 hours; by the 7th day, by the 14th day...and every 7 subsequent days. The review may also occur more frequently...if behavior changes....14. A reassessment will be made...for any issues identified that impede the patient's progress towards meeting discharge criteria..."