HospitalInspections.org

The hospital failed 1 of 1 Patient (Patient #1) by failing this patient to receive care in a safe setting . The nurse failed ti fikkiw current standards of practice for patient environment safety. This standard is intended to provide protection for the patient's emothioal health and safety as well as their phyiscal safety.

Findings Include:

During observation of hospital video footage Staff #7 failed to search the patient for contraband (ie., belt, shoelaces, empty pockets, cell phone) at the front desk, while in the presence of delivering Police Officer before allowing patient to enter into the Care Center.. During.observation of video footage while Patient #1 is seated in the Care Center lobby Patient #1 pulls out a cell phone from his pocket.
During obersvation of video footage Staff #7 exited the Care Center without informing remaining staff Patients still seated in the Care Center Lobby.
During Observation of video footage Staff #7 never physically examines Patient #1 for injury or scars or bruising during assessment period.
During Observation of Video Footage Staff #7 never takes Patient #1's vital signs.
During Observation of Video Footage Staff #7 left Patient #1 in the Assessment room alone, and upon her return Patient #1 had fallen and struck himself in the head.

During Interview Staff #2 stated Staff had failed to properly complete a nursing assessment and document Patient #1's record.
During Interview Staff #2 stated Staff #7 failed to excute Nursing duties. in assessing the patient after the fall. Staff #7 failed to notify the House Supervisor or Administrator on Call after the incident. Staff #7 failed report this incident to the next shift and or complete an Incident Report.
During nterview with Hospital Staff #2 it was reported that Staff #7 was reported to The Nursing Board.

During Interview with Hospital Staff #3 it was reported that Staff #7 failed to follow hospital protocols that are set in place.
During Interview with Hosptial Staff #3 it was reported that Staff #7 failed the Paitent by not reported the incident to the physican and Administrator on Call.
During Interview with Hosptial Staff #3 it was reported that Staff #7 failed Patient #1 by not completing an Incident Report.
During Interview with Hosptial Staff #3 it was reported that Staff #7 has been suspended pending an investigation.
During Interview with Hosptial Staff #3 it was reported that Staff #7 wanted the Police to return to the hospital to obtain Emergency Order to have Patient #1 admitted Involuntary rather than Voluntary. When Staff #7 left Patient #1 alone in the assessment room, she exited the unit to answer the front door and allow the Police officers to reenter the facility.

During Record Review Patient #1 did not have vital signs documented.

Policy
The hospital policy Patient Rights dated 11/2022 reflected, "It is the hospital policy to strictly observe patient rights as per the Patient Bill of Rights and Texas Law. Restriction of patient rights is done only in those situations where the safety, security and welfare of the patient mandates such restrictions."

The hospital Policy for Patient Neglect 12/2022 reflected, "To establish a uniform policy and procedures for reporting and responding to all allegations of neglect. To comply with Texas law that requires professionals to make a report within 48 hours first suspecting neglect. Neglect-is a negligent act or omission by any individual responsible for providing services in a facility rendering care or treatment which caused or may have caused injury or death to an individual with mental illness or which placed an individual with mental illness at risk of injury or death, and includes an act or omission such as the failure to establish or carry out an appropriate individual program plan or treatment plan for an individual with mental illness, the failure to provide adequate nutrition, clothing, or health care to an individual with mental illness, or the failure to provide a safe environment for an individual with mental illness, including the failure to maintain adequate numbers of appropriate trained staff."

The hospital Policy for the Assignment of Patient Care 01/2023, "It is the responsibility of Nursing Administration to provide an adequate number of nursing personnel to prove safe, therapeutic quality care to all patients. With input from the facility CEO and Medical Staff, staffing ratios are defined for each patient unit and an established patient acuity classification system is utilized in order to ensure adequate ratios that factor in acuity, census, etc. At least one RN will be assigned to all units on all shifts and a sufficient number of nursing personnel will be assigned to each unit. "

The hospital Policy 'Admission and Exclusionary Criteria, 01/2023, "This policy is to identify a process for recognizing the limitations of the facility's ability to treat patients with certain conditions. Staff shall contact the medical physician based on the established criteria. Treatment is offered without regard to race, color, religion, orientation, nationality, age or handicap."

The hospital Policy on Nursing Services dated 04/2017 reflected, "The delivery of nursing care at University Behavioral Health of Denton Shall be understood as the purposeful and perpetual application of diversified talents with the common goal of positively impacting the health status of those entrusted to our care. Therapeutic use of self shall be the central treatment modality with specialized cognitive experiential and managerial capabilities as the practice foundation."

The hospital Policy Assessment of Patients 02/2023, "All patients admitted to University Behavioral Health of Denton will receive a thorough assessment and evaluation. Results of assessments are reviewed and integrated by the multidisciplinary treatment team to prioritize identified problems within the interdisciplinary Treatment Plan. If the patient is unable to participate and/or provide information for an assessment, the reason will be documented with the date and time. Reattempts to complete an assessment will be made and documented. The documentation will include date and time of reattempt and if necessary, reason for inability to complete."

The hospital Policy on Incident Report-IR/Incident Reporting Process 11/2021, "The incident Report-IR/Incident Reporting Process I the reporting methodology used to track incidents outcomes or issues that potentially represent patient safety concerns or questionable clinical practices. The reporting process supports each facility's patient safety efforts and multi-disciplinary peer review Process."

The hospital Policy on Reporting Allegations of Abuse and Neglect 12/2022, "To establish a uniform policy and procedures for reporting and responding to all allegations of abuse and neglect. To comply with Texas law that requires professionals to make a report within 48 hours of first suspecting abuse, neglect or exploitation of a child or person 65 years or older or an adult with disabilities."

The hospital Policy on Patient Falls: Prevention and Management10/2022, "During their inpatient stay, patients are continually assessed/reassessed throughout their admission to identify fall risk factors that prompt initiation of/or change in fall precaution/levels of monitoring, using an evidence based tool that is approved by the medical staff. Patients are continually/assessed/reassessed throughout their admission to identify fall risk factors that prompt initiation of/or change in fall precautions/levels of monitoring."

The hospital failed 1 of 1 Patient (Patient #1) by failing to provide medical records, including current medical records upon an oral or written request.

Findings Include

During Interview with Hospital Staff #3, reported that to their knowledge they do not know if there has been any records provided to requesting hospital.
During Interview with Hosptial Staff #3, reported that to their knowledge they do not know if current medical records were provided upon oral or written request.

Policy

The hospital policy Patient Rights dated 11/2022 reflected, "It is the hospital policy to strictly observe patient rights as per the Patient Bill of Rights and Texas Law. Restriction of patient rights is done only in those situations where the safety, security and welfare of the patient mandates such restrictions."

The hospital Policy for Patient Neglect 12/2022 reflected, "To establish a uniform policy and procedures for reporting and responding to all allegations of neglect. To comply with Texas law that requires professionals to make a report within 48 hours first suspecting neglect. Neglect-is a negligent act or omission by any individual responsible for providing services in a facility rendering care or treatment which caused or may have caused injury or death to an individual with mental illness or which placed an individual with mental illness at risk of injury or death, and includes an act or omission such as the failure to establish or carry out an appropriate individual program plan or treatment plan for an individual with mental illness, the failure to provide adequate nutrition, clothing, or health care to an individual with mental illness, or the failure to provide a safe environment for an individual with mental illness, including the failure to maintain adequate numbers of appropriate trained staff."

The hospital Policy for the Assignment of Patient Care 01/2023, "It is the responsibility of Nursing Administration to provide an adequate number of nursing personnel to prove safe, therapeutic quality care to all patients. With input from the facility CEO and Medical Staff, staffing ratios are defined for each patient unit and an established patient acuity classification system is utilized in order to ensure adequate ratios that factor in acuity, census, etc. At least one RN will be assigned to all units on all shifts and a sufficient number of nursing personnel will be assigned to each unit. "

The hospital Policy 'Admission and Exclusionary Criteria, 01/2023, "This policy is to identify a process for recognizing the limitations of the facility's ability to treat patients with certain conditions. Staff shall contact the medical physician based on the established criteria. Treatment is offered without regard to race, color, religion, orientation, nationality, age or handicap."

The hospital failed 1 of 1 Patient (Patient #1) by failing to complete the Nursing Care Plan, which is based on assessing the Patients nursing care needs. The assessment considers the patients treatment goals and as appropropriate physiological and psychosocal factors and patient discharge planning.

Findings Include:

During Interview with Hospital Staff #2 it was reported hosptial Staff #7 failed to properly complete a nursing assessment and document the Patient Assessment thoroughly.

During Interview with Hospital Staff #3 it was reported hospital Staff #7 failed to properly assess the Patient for contraband at the front door.

During observation Hospital Staff #7 failed to assess Patient #1 after the fall and reassess Patient #1. The Police Officer assessed the Patient checking for pulse, and the Patient #1 responding turning over. Nurse #7 was observed handing guaze to the Police officer for the patient instead of taking medical responsibility of Patient #1.

During Observation the Police Officer notifed his dispatch for 911 to arrive and transport Patient #1, not Nurse #7.

Policy
The hospital policy Patient Rights dated 11/2022 reflected, "It is the hospital policy to strictly observe patient rights as per the Patient Bill of Rights and Texas Law. Restriction of patient rights is done only in those situations where the safety, security and welfare of the patient mandates such restrictions."

The hospital Policy for Patient Neglect 12/2022 reflected, "To establish a uniform policy and procedures for reporting and responding to all allegations of neglect. To comply with Texas law that requires professionals to make a report within 48 hours first suspecting neglect. Neglect-is a negligent act or omission by any individual responsible for providing services in a facility rendering care or treatment which caused or may have caused injury or death to an individual with mental illness or which placed an individual with mental illness at risk of injury or death, and includes an act or omission such as the failure to establish or carry out an appropriate individual program plan or treatment plan for an individual with mental illness, the failure to provide adequate nutrition, clothing, or health care to an individual with mental illness, or the failure to provide a safe environment for an individual with mental illness, including the failure to maintain adequate numbers of appropriate trained staff."

The hospital Policy for the Assignment of Patient Care 01/2023, "It is the responsibility of Nursing Administration to provide an adequate number of nursing personnel to prove safe, therapeutic quality care to all patients. With input from the facility CEO and Medical Staff, staffing ratios are defined for each patient unit and an established patient acuity classification system is utilized in order to ensure adequate ratios that factor in acuity, census, etc. At least one RN will be assigned to all units on all shifts and a sufficient number of nursing personnel will be assigned to each unit. "

The hospital Policy 'Admission and Exclusionary Criteria, 01/2023, "This policy is to identify a process for recognizing the limitations of the facility's ability to treat patients with certain conditions. Staff shall contact the medical physician based on the established criteria. Treatment is offered without regard to race, color, religion, orientation, nationality, age or handicap."

The hospital Policy on Nursing Services dated 04/2017 reflected, "The delivery of nursing care at University Behavioral Health of Denton Shall be understood as the purposeful and perpetual application of diversified talents with the common goal of positively impacting the health status of those entrusted to our care. Therapeutic use of self shall be the central treatment modality with specialized cognitive experiential and managerial capabilities as the practice foundation."

The hospital Policy Assessment of Patients 02/2023, "All patients admitted to University Behavioral Health of Denton will receive a thorough assessment and evaluation. Results of assessments are reviewed and integrated by the multidisciplinary treatment team to prioritize identified problems within the interdisciplinary Treatment Plan. If the patient is unable to participate and/or provide information for an assessment, the reason will be documented with the date and time. Reattempts to complete an assessment will be made and documented. The documentation will include date and time of reattempt and if necessary, reason for inability to complete."