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Based on interviews and review of documentation the facility failed to protect patient #1 from neglect. Patient #1 complained of abdomen pain level 10, on a scale of 1-10. Staff #4, RN informed staff #11 FNP of the patient continue pain with no relief after medications were administered. Patient was not assessed by staff #11 FNP for 5 hours. Patient #1 condition deteriorated, patient #1 was transferred to Methodist Emergency Department. Emergency surgery was performed for rupture appendix.

This practice has cause harm to a patient and presents the threat of continued harm to the remaining patients.

The facility was made aware of the Immediate Jeopardy on 12/14/2020 and was instructed to put measures in place to abate the situation.

The facility was able to enact plan of correction which included the immediate education of physician/nurse practitioner.

The facility abated the immediate jeopardy on 12/15/20 however, the condition level finding remained.

Cross refer to A145

Based on interviews and review of documentation the facility failed to protect patient #1 from neglect. Patient #1 complained of abdomen pain level 10, on a scale of 1-10. Staff #4 RN informed staff #11 FNP of the patient continue pain with no relief after medications were administered. Patient was not assessed by staff #11 FNP for 5 hours. Patient's condition deteriorated, patient #1 was transferred to Methodist Emergency Department. Emergency surgery was performed for rupture appendix. This practice has cause harm to a patient and presented the threat of continued harm to the remaining patients.

Findings
Review of patient #1 medical record revealed the listed medications were given to patient #1 with no relief from pain.
12/6/2020 0648 am Tramadol Hcl 50 mg
12/6/2020 0822 am Tylenol 650 mg pain scale 10
12/6/2020 0900 am Neurontin 600mg pain scale 10
12/6/2020 0943 am Baclofen 10mg not helpful, NP and MD aware. pain scale 10
12/6/2020 0947 am Ibuprofen 600mg, 10mg not helpful, NP and MD aware. pain scale 10
12/6/2020 1100 am Hydrocodone/Apap 325 pain scale 10

In an interview conducted with the staff #11 FNP 12/15/20 2:50 pm in the conference room at the facility. Staff #11FNP was on call December 6, 2020 7A-7P. The surveyor asked staff#11 FNP, what is the procedure for patients who continue to complain of pain without relief after medication? staff#11 FNP said the nurse should notify the supervisor, who will notify me, if the patient needs to be sent out.

An interview was conducted with staff#3 CNO and staff#2 Risk Manager at the facility on the afternoon of 12/15/2020 3:55pm. The surveyor asked what is done for patients who continue to complain of pain? staff #3 CNO said the nurse notifies the physician first for orders. The supervisor is notified if the nurse is unable to reach the physician.

Interviews with facility staff and facility documentation confirmed patient #1 was given multiple pain medications without relief and was not assess by #2 FNP for 5 hours.

Patient #2
Based on review of documentation and interviews the facility failed to provide a safe environment to protect patient #2 from abuse. Patient #2 was punched by patient #10 while sleeping.

Findings

Review of documentation revealed, 11/23/19.12:15 pm Patient parents were upset due to lack of communication regarding medications, not speaking with patient. and not being informed of pt being assaulted by his roommate. Review of nursing assessment note 11/23/2019, 12:15 pm stated, parent requested discharge AMA because they had not received report of their son being hit by peers.

Rights of Persons with Mental Illness. Policy Stat ID: 8823632. 25 TAC 404.160 (1) Rights: Assure the rights of all patient admitted to SUN Behavioral Houston inpatient services are protected. Room assignments and Responsibilities. Policy Stat ID:7455389. Purpose: To provide a safe and comfortable environment for patients. To provide safety and security for all individuals. There was no documentation or assessment of the incident or of the roommates being transferred to another room.

In an interview at the facility on 12/15/2020 at 4:10 pm with staff #2 and staff #3, the surveyor asked to review the report for 11/23/2019. Staff #2 said they did not have a report of the incident. The surveyor asked staff #2 and #3 did the nurse called the family to report the incident. Staff #3 said the therapists will consult the families about social issues and the nurses will report medical issues to the family. Documentation revealed the therapist spoke to the parents after they brought the incident to the attention of the therapist.