HospitalInspections.org

Based on record review and interview, the facility failed to uphold the right to receive care in a safe setting as evidenced by 1 of 10 discharged patients having inaccurate Observation Rounds (Patient #1), indicating the patient was not monitored properly.

Findings included:

TX00308231

Record review during survey of facility policy titled "Q-15 Minute Patient Rounds", dated 4/18, showed that unit staff shall conduct visual rounds observing patients every 15-20 minutes. Nursing staff shall document rounds on patient's Observation sheets which include the patients' whereabouts and behavior, using numeric codes.

Further record review of Patient #1's progress notes showed that on 1/29/19 just prior to 8:00 pm, there was a "Code White" (patient out of control, aggressive, assaultive, combative) called on Patient #1 due to the patient trying to jump over nursing station in an attempt to get into the boy's side of the unit. She was subsequently restrained and secluded from 8:00 pm to 8:45 pm, then returned to her room. While in her room, she had lit her bed and blanket on fire with a cigarette lighter (facility's investigation failed to definitively determine how and where Patient #1 obtained the lighter). The fire department was called and patients on the entire unit (second floor) were moved to the third floor while the fire department was present. After it was determined to be safe, the adolescent girls were then moved back to the unit (after approximately 45 minutes). However, Patient #1 was arrested at approximately 10:00-10:15 PM and brought to a juvenile detention center.

Record review of Patient #1's Q-15 Minute Patient Rounds sheet, authored by Staff Mental Health Technician (MHT) #56, indicated that on 1/29/19, from 7:15 PM until 9:45 PM, the patient was in the "2nd room", using the code "33", with no indication of the patient's behavior.

Per these rounding sheets, there was no indication the patient was on the unit having an altercation with staff prior to being secluded, no indication the patient was restrained and secluded, no indication the patient was moved to the third floor, and no indication the patient was moved back to the second floor.

In an interview on 3/6/19 at 11:00 AM with Staff Program Manager #54, he stated that Staff # 56 should not have written "33" on the Rounding sheets from 7:15 PM to 9:45 PM. Staff #54 further stated that "33", meant "second room", which was a common day room on the Adolescent Girl's unit.

In an interview on 3/6/19 at 11:15 with Staff DON #51, she stated that MHT #56 should not have written "33" the entire length of time from 7:15 PM to 9:45 PM, which was inaccurate. She also added that MHT #56 was no longer employed by the facility.

Based on record review and interview, the facility nursing staff failed to supervise and evaluate the care of 1 of 1 current patient (Patient #1) as evidenced by inaccurate Observation Rounds (Patient #1), indicating the patient was not monitored properly.

Findings included:

TX00308231

Record review during survey of facility policy titled "Q-15 Minute Patient Rounds", dated 4/18, showed that unit staff shall conduct visual rounds observing patients every 15-20 minutes. Nursing staff shall document rounds on patient's Observation sheets which include the patients' whereabouts and behavior, using numeric codes.

Further record review of Patient #1's progress notes showed that on 1/29/19 just prior to 8:00 PM, there was a "Code White" (patient out of control, aggressive, assaultive, combative) called on Patient #1 due to the patient trying to jump over nursing station in an attempt to get into the boy's side of the unit. She was subsequently restrained and secluded from 8:00 PM to 8:45 PM, then returned to her room. While in her room, she had lit her bed and blanket on fire with a cigarette lighter (facility's investigation failed to definitively determine how and where Patient #1 obtained the lighter). The fire department was called and patients on the entire unit (second floor) were moved to the third floor while the fire department was present. After it was determined to be safe, the adolescent girls were then moved back to the unit (after approximately 45 minutes). However, Patient #1 was arrested at approximately 10:00-10:15 PM and brought to a juvenile detention center.

Record review of Patient #1's Q-15 Minute Patient Rounds sheet, authored by Staff Mental Health Technician (MHT) #56, indicated that on 1/29/19, from 7:15 PM until 9:45 PM, the patient was in the "2nd room", using the code "33", with no indication of the patient's behavior.

Per these rounding sheets, there was no indication the patient was on the unit having an altercation with staff prior to being secluded, no indication the patient was restrained and secluded, no indication the patient was moved to the third floor, and no indication the patient was moved back to the second floor.

In an interview on 3/6/19 at 11:00 AM with Staff Program Manager #54, he stated that Staff # 56 should not have written "33" on the Rounding sheets from 7:15 PM to 9:45 PM. Staff #54 further stated that "33", meant "second room", which was a common day room on the Adolescent Girl's unit.

In an interview on 3/6/19 at 11:15 with Staff DON #51, she stated that MHT #56 should not have written "33" the entire length of time from 7:15 PM to 9:45 PM, which was inaccurate. She also added that MHT #56 was no longer employed by the facility.

In addition, nursing failed to identify the inaccurate Rounding documentation and record review of facility's own investigation failed to identify the inaccurate Q-15 Minute Patient Rounds.