HospitalInspections.org

Based on record review and interview, the facility failed to ensure written policies and procedures regarding the visitation rights of patients included those settings with restrictions and/or limitations for visitation in which the hospital placed on such rights, and reasons for the clinical restriction or limitations.

Specifically, the facility restricted Patient #3's in-person visitation rights without a written policy or justified restriction which was a violation of Patient #3's rights.

Findings included:

Review of the Complaint Intake Information for Complaint Number TX00464162 from Patient #3's parent/guardian indicated on 7/19/23 she had to call to see how her daughter was doing since the facility did not allow in-person visitations. During this phone call, she heard staff "being rude and verbally aggressive" with her daughter.

Patient #3's record did not include documentation that the facility informed Patient #3 or her parent/guardian of her visitation rights which included a restriction of in-person visitation. Patient #3's records also did not inform her or parent/guardian of optional Zoom visitation.

During an interview on 9/7/23 at 12:25 PM with the Director of Quality and Risk Management (QRM) confirmed there was not a policy in place during 7/19/23 for any justification to restrict in person visitation since the federal COVID-19 Public Health Emergency declaration ended on May 11, 2023. He stated the facility now has an updated policy dated 8/24/23 for visitation which includes in person, telephonic and Zoom. The Director of QRM further stated that once the public pandemic was removed (May 11, 2023) the facility had to update their policies, schedules and staffing to accommodate in person visitation which took some time to complete and coordinate.

Based on record review and interviews, the facility's nursing services failed to supervise and evaluate the nursing care for each patient in accordance with the patient's treatment plan and the facility's policy for 2 of 2 patient's reviewed for supervision monitoring (Patient #1, Patient #2). Specifically,

RN's (Registered Nurses) delegated the performance of the physician/provider ordered 15-minute observation safety checks of patients to the Mental Health Technicians (MHT's). As a result, the supervision and monitoring for Patient's #1, and #2, with ordered observations to be conducted every 15 minutes for patient safety and in accordance with the facility policies were not completed according to the physician and/or provider orders.

A.) Patient #1's records for 8/4/23 through 8/14/23 and for the 7:00 PM to 07:00 AM shift times; documented at least 12 occurrences where observations exceeded 15 minutes (16 minutes up to 28 between observations).

B.) Patient #2's records for 8/4/23 through 8/14/23 and for the 7:00 PM to 07:00 AM shift times; documented at least 16 occurrences where his observations exceeded 15 minutes (16 minutes up to 43 minutes between observations).

Findings:

1.) Patient #1

Review of the Initial Psychiatric Evaluation dated 8/3/23 documented by Medical Doctor -A indicated Patient #1 has been placed on suicide precautions and 15 minute checks. Level of Observation: Q 15 (every 15 minutes). Patient Diagnosis (DX): Major depressive disorder, suicidal ideation.

Review of Patient #1's Treatment Plan dated 8/2/23 documented in part, a risk for sexually acting out and a risk for suicide.

Review of Patient #1's Final Ancillary Orders for non-med dated 8/12/23 revealed at 11:00 AM Level of observations were ordered "every 5 minutes" start time 8/12/23 11:00 AM and Stop Time: 8/13/23 at 8:59AM.

Review of Patient #1's Final Ancillary Orders for non-med dated 8/14/23 revealed at 11:00 AM Level of observations were ordered "every 5 minutes" start time 8/14/23 11:00 AM and Stop Time: 8/16/23 at 11:16 AM.

Review of Patient #1's Patient Observations (Q 15-minute monitoring checks) for 8/4/23 through 8/14/23 conducted by the facility's Mental Health Technicians (MHT's) revealed the following breaches in the physician ordered supervision for the 7:00 PM to 07:00 AM shift times; (Note: all times in military time format):

a.) 08/4/23 at 20:19 with the next check at 20:39 (20 minutes)
b.) 8/5/23 at 03:37 with the next check at 03:54 (17 minutes)
c.) 8/6/23 at 04:46 with the next check at 05:06 (20 minutes)
d.) 8/6/23 at 05:21 with the next check at 05:39 (18 minutes)
e.) 8/6/23 at 06:22 with the next check at 06:38 (16 minutes)
f.) 8/7/23 at 18:51 with the next check at 19:10 (19 minutes)
g.) 8/7/23 at 19:21 with the next check at 19:39 (18 minutes)
h.) 8/7/23 at 21:34 with the next check at 21:50 (16 minutes)
i.) 8/7/23 at 21:50 with the next check at 22:16 (26 minutes)
j.) 8/11/23 at 03:59 with the next check at 04:16 (17 minutes)
k.) 8/14/23 at 02:46 with the next check at 03:14 (28 minutes)
l.) 8/14/23 at 06:32 with the next check at 06:49 (17 minutes)

2.) Patient #2

Review of Patient #2's Final Ancillary Orders non-med dated 8/4/23 by the physician ordered Level of Observation: Q 15 minutes. Precautions: Suicide Precautions

Review of Patient #2's Initial Psychiatric Evaluation dated 8/5/23 by the physician ordered Level of Observation: Q 15 minutes for suicide precaution.

Review of Patient #2's Observations (Q 15-minute monitoring checks) for 8/5/23 through 8/14/23 conducted by the facility's MHT's revealed the following breaches in the physician ordered supervision for the 7:00 PM to 07:00 AM shift times; (Note: all times in military time format):

a.) 8/5/23 at 03:37 with the next check at 03:53 (16 minutes)
b.) 8/6/23 at 00:09 with the next check at 00:25 (16 minutes)
c.) 8/6/23 at 05:21 with the next check at 05:38 (17 minutes)
d.) 8/6/23 at 22:40 with the next check at 22:57 (17 minutes)
e.) 8/7/23 at 18:51 with the next check at 19:10 (19 minutes)
f.) 8/7/23 at 19:20 with the next check at 19:38 (18 minutes)
g.) 8/9/23 at 18:46 with the next check at 19:29 (43 minutes)
h.) 8/9/23 at 19:29 with the next check at 19:45 (16 minutes)
i.) 8/9/23 at 20:34 with the next check at 20:50 (16 minutes)
j.) 8/11/23 at 18:29 with the next check at 19:02 (33 minutes)
k.) 8/11/23 at 21:10 with the next check at 21:34 (24 minutes)
l.) 8/12/23 at 03:28 with the next check at 03:46 (18 minutes)
m.) 8/13/23 at 02:25 with the next check at 2:51 (26 minutes)
n.) 8/13/23 at 05:29 with the next check at 05:46 (17 minutes)
o.) 8/13/23 at 21:49 with the next check at 22:06 (17 minutes)
p.) 8/14/23 at 05:28 with the next check at 05:45 (17 minutes)

Review of Patient #2's RN Daily Shift Assessments for 8/5/23 through 8/14/23 documents the following: "Nurse has reviewed patient observations. This Shift:" and they are all are documented as Yes; without any further documentation or concern noted.

Interview with the facility's Quality Director (QD) on 9/11/23 at 12:30 PM stated the observation cues are delegated to the MHT's with the RN's checking the observation checks for compliance every shift and documenting on their nursing assessment for completion. The QD stated the facility's Quality department monitors the overall compliance rate of the observation checks monthly with a rate of 97% reported for last month. The QD reviewed with this surveyor the above patients (#1 and #2) documentation for the breach in observation checks not being conducting as ordered. The QD further stated the facility has had some technical difficulties with the IPAD's that are used to conduct and document the Q observation checks such as buffering issues, broken antennas, cracked screens, etc. that have resulted in some of the noncompliance with the observation checks.

Review of the hospital policy entitled, "Levels of Observation," last reviewed/revised 03/7/23 stated the following, in part:
PURPOSE: To provide a consistent, therapeutic approach to ensure a safe environment for the patients within the facility.

PROCEDURES included;

A. The following levels of observation are approved for utilization when clinically indicated:

1. 15 minute Observations

-Minimum level of observation for all patients.

-The patient is observed with visual checks every 15 minutes.

-All patients admitted to the inpatient acute units are on 15 minute observations unless otherwise ordered by the physician/provider.

-15 minute observations will occur at random intervals no longer than 15 minutes.

B. The physician must order a level of observation with the reason i.e. due to Suicide Precautions, etc.

G. The RN is to assure the ObservSmart Tablets or Patient Observations Sheets reflect 1:1, Q5, Q10, or status with 15-minute Observations. Documentation in the progress note should include level of observation.

Based on record review of patient records and staff interview, the hospital failed to ensure the nursing staff documented nursing interventions and the patient's assessments related and to the nursing care plan consistent with the patient's nursing care needs for 1 of 1 patient reviewed (Patient #3) following a complaint in the area of nursing services.

Specifically, the nursing staff failed to document the assessment and interventions for Wound Care for Patient #3 in accordance with their treatment plan.

Findings included:

Review of the Complaint Intake Information for Complaint Number TX00464162 from Patient #3's parent/guardian indicated when Patient #3 returned home from the facility she had injuries; a "bruise on her left thigh and some on her upper extremities."

Record review of Patient (Pt.) #3's History and Physical (H&P) dated 7/17/23 documented lacerations to left forearm-keep area clean and dry, avoid picking at area. Report any redness, swelling or heat to area.

Record review of Patient #3's Treatment Plan dated 7/17/23 indicated the RN will assess the wounds daily every shift for signs of infection and document for drainage, redness, edema, and tissue granulation and report any abnormalities to the physician.

Review of the RN Daily Shift Assessment for Patient #3 dated 7/18/23 to 7/19/23 did not include documentation of Patient #3's assessment of wounds to include treatment provided and/or signs of infection with documentation for drainage, redness, edema, and tissue granulation.

During an interview on 9/7/23 at 12:07 PM with the Director of Nursing and Director of Quality, Compliance, and Risk Management (DQCRM) confirmed Patient #3's RN Nursing assessments did not include documentation of Patient #3's wound care in accordance with the treatment plan. The DQCRM stated he would put a ticket in for their electronic health record (EHR) to ensure this gets added into their EHR for the nurses to document.

Based on a review of documentation and interviews, the facility failed to ensure documentation that individual patient nutritional needs were met in accordance with recognized dietary practices for 1 of 1 patient reviewed (Patient #3) for dietary complaints.

Findings included:

Review of complaint TX00464162 intake information revealed the following: Patient #3 reported that during her time at the facility (7/17/23 at 12:44 PM to 7/19/23 9:59 PM) she had not eaten; since she did not like the food served. Patient #3 was offered a supplement option, however, the staff forgot to provider her with that option.

Review of Patient #3's records revealed the following: Final Ancillary Orders non-med dated 7/17/23 at 14:00 for Regular Diet ordered by Physician-A.

It was determined during the complaint survey; the facility did not have a policy to ensure patient's nutritional needs were met to include monitoring or documentation. This was confirmed during an email dated 9/15/23 by the Director of Quality, Compliance, and Risk Management (DQCRM) in which he indicated the facility was in the process of developing an intake and output policy.

Review of the RN Daily Shift Assessment for Patient #3 dated 7/18/23 to 7/19/23 in the area of "Meals" indicated only: "Eating On/Off unit." There is no description or information if patient ate her meal provided, refused, or a percentage of food consumed.

Review of the Psychiatric Progress Note dated 7/19/23 at 09:40 AM indicated Patient #3 stated that she does not like the food and did request Ensure.

During an interview on 9/7/23 at 12:14 PM with the Director of Nursing and DQCRM present stated that meal documentation was completed in the RN Daily Shift Assessment for Meals. Further interview, the DQCRM confirmed after review of the RN Daily Shift Assessment where Meals was documented confirmed that there was no information to determine if Patient #3 ate her meals, refused, or if she consumed a percentage of food. The DQCRM further stated he would put in a ticket for their Electronic Health Record with a hard stop in Meals to provide additional information.