HospitalInspections.org

Based on observation, interview, and record review the facility to failed to uphold all patients' right to receive care in a safe setting. Three (3) of 3 nursing stations were unsecured; allowing patient access to potentially dangerous and hazardous objects [ Sunrise Unit, Meadows Unit, Willows Unit] :

a. Sunrise Unit: the design of the nursing station doors allowed continuous patient entry into the station. The nursing station counters were low enough to be breached by patients;

b. Willows Unit : the door to the nursing station was left unlocked on multiple days. This allowed patient access to : a TV remote control, computer & monitor, a rolling desk chair, portable vital sign machine, telephone with cords, stainless steel water bottle, and a hand held walkie-talkie radio;

c. Meadows Unit: two doors to the nursing unit were left unlocked on multiple days allowing patient access to computers, computer monitors, telephones with wires, portable vital signs machines, patient clinical charts in heavy plastic three-ring binders, pens, nurse's personal belongings, bags/backpacks with patient belongings including phone charging cables.

Findings included:

Review of facility policy titled "Patient Bill of Rights", ID#12462881, last revised 1/2021 stated that patients have the right to be protected from harm.

Review of facility's environmental risk assessment document titled "Environment of Care, Safety and Security Management" dated 2023, under the tab labeled "Proactive Risk Assessment" showed "Patients will not have access to the nurse station".

a. Sunrise Unit:

Observation on 6/7/23 at 1:30 pm of facility's Sunrise unit showed it had a double, swinging type 'saloon' door separating the nursing station from the common patient area. The doors did not have any locking capability and there was nothing in place to prevent patients from entering. In addition, the counters that separated the nursing station from the common patient area were approximately the average person's waist height and were easily able to be breached by the average person.

Further observation of the nursing station showed there were several unsecured objects present which included, but were not limited to, computers, computer monitors, telephones with wires, portable vital signs machines, patient clinical charts in heavy plastic three-ring binders, nurse's personal belongings, and pens.

In an interview on 6/7/23 at 1:35 pm, RN-Staff #O stated that there had been multiple instances in the past involving patients who were aggressive and violent, entering the nursing station through the door and also walking/jumping over the counter. They had grabbed objects from behind the station and attempted to harm other patients and staff. When asked if she could recall any specific instances, she was unable to remember, but added it occurred "lots of times".


23032

b. Willows Unit :

TX00457852

Review of a 5/15/2023 facility incident investigation, showed on 5/15/2023 at 9 PM a patient reported that his roommate, Patient ID # 26, was "cutting his wrists" in their shared room. During an interview on 06/08/2023 at 9:45 AM, with Staff-G, Quality Director, she stated Patient ID # 26 was immediately assessed and placed on 1:1 staff monitoring. Staff- G confirmed this incident occurred on the Willows Unit (adolescent ). Patient ID # 26 had attempted to cut his wrists using a TV remote control.

Observation on 06/07/2023 at 1:34 PM showed the Willows Unit nursing station was left unattended by any staff. The door to the nursing station was unlocked and station was accessible by patients. Further observation at this time showed there were several unsecured objects present which included, but were not limited to, a TV remote control, computer & monitor, a rolling desk chair, a portable vital sign machine, telephone with cords, stainless steel water bottle, and a hand held walkie- talkie radio.

Observation on 6/06/2023 between 9:15 and 11 AM, during initial tour on the Willows Unit, showed staff entering nursing station several times without unlocking the door. Surveyor entered the Willows Unit nursing station twice on 6/7/2023; the door was unlocked both times.


37490

c. Meadows Unit

Observation on 6/6/23 at 9:30 am and again on 6/7/23 at 10:00 am of facility's Meadows unit showed two doors on either side of the nurse's station. The doors were not locked and there was nothing in place to prevent patients from entering. Staff were observed utilizing both doors without keys.

Further observation of the nursing station showed there were several unsecured objects present which included, but were not limited to, computers, computer monitors, telephones with wires, portable vital signs machines, patient clinical charts in heavy plastic three-ring binders, pens, nurse's personal belongings, bags/backpacks with patient belongings including phone charging cables.

In an interview on 6/8/23 at 10:00 am, plant ops director (ID L), he stated that doors on the patient units that lead to the nurse's station should be locked. He went on to say that he checks that they are locked when he does his rounds on the unit and that he sometimes finds that staff has placed paper in the door latching mechanism to prevent them from locking.

In an interview with DON (ID B) on 6/8/23 at 10:25 am, she stated that the staff do not always keep the doors locked, but it would be better if they did.

Based on observation, interview and record review, the facility failed to ensure that a Registered Nurse (RN) was physically on the unit available to provide patient care at all times in 1 of 3 patient care unites (Willows unit).

Findings include:

Observation on June 7, 2023, at 1:35 pm upon entering the Willows unit, patients were observed in group, except for two patients that were in their rooms. The staff on the unit at this time was tech (ID Q) and therapist (ID N).

Observation on 6/7/23 at 2:21 pm on the Willows unit, RN (ID E) left the unit for two minutes with another unidentified male staff member.

Interview with staff (ID Q) on 6/7/23 at 2:36 she stated that there was not a nurse present on the unit at 1:35. She stated that the nurse had went to lunch, she called the nurse manager (ID I) to come to the unit to cover for her when she was told to by administrative staff (ID G) when we (survey team) arrived on the unit.

Interview DON (ID B) on 6/8/21 at 10:26 am stated that there should always be nurse on the unit. She stated that when she asked nurse (ID E) why she did not call for relief when going to lunch from the Willows unit on 6/7/23, she stated she forgot. DON (ID B) went on to say that there should always be a licensed staff member on the unit, she will sometimes utilize a Licensed vocational nurse (LVN) for lunch relief.

Record review of facility policy titled "Plan for the Provision of Nursing Care in Psychiatric Specialty Areas," dated 6/2021 showed the following information:

POLICY:
The hospital will provide outstanding psychiatric nursing care and response to individual needs of patients who have a mental disorder and/or substance use disorder as outlined in the most current DSM.

Staffing Plan Guidelines:
There shall be a sufficient number of qualified and competent registered nurses and PCA's on each unit to provide patients with nursing services that require the judgment and specialized skills of the competent nursing staff. Nursing staff shall also be sufficient to promptly recognize untoward changes in a patient's condition and to intervene appropriately utilizing nursing, medical, or hospital staff.


23032

Based on observation, interview, and record review, the facility failed to ensure adequate numbers of staff on the adolescent unit after the boys and girls units were combined to one unit. The facility failed to implement safe staffing measures as stated by the Director of Nursing (DON).

Findings included :

TX00383831 :

Record review of facility policy titled "Plan for the Provision of Nursing Care in Psychiatric Specialty Areas," dated 6/2021 showed the following information: Nursing Standards of Care: a. To provide safe, effective nursing care based on the needs of the patients...Staffing Plan Guidelines:..Staffing is based upon patient census, acuity, and relative treatment needs..

Observation on 6/6/2023 during initial tour of Willows Unit, showed a total of 6 patient rooms. The rooms were all located in one side of the hallway, each room contained 2 beds. The patient census this day was 11 patients: 4 female and 7 male adolescents.

During an interview with Staff -B, DON, on 6/7/23 at 2:15 PM she stated the adolescent boys and girls were previously admitted to separate units: boys on Cypress Unit; and girls on Willows Unit. She went on to say about twice a year the units were combined due to patient volume. The DON said the Cypress Unit was currently closed, but would likely be reopened to admit adults. She said the two units were just recently combined -on June 1, 2023.

Staff B, DON, acknowledged that housing the male/female adolescents together on one unit did raise the risk of inappropriate interactions especially during the night shift. The DON was asked how does the facility maintain a safe environment for the adolescents housed together -especially on the night shift? Staff B, DON said that core staffing was always at least 1 Registered Nurse (RN) and 1 Patient Care Assistant ( PCA) . Staff would be increased for any patients that required 1:1 monitoring.

Review of the "Nursing Unit Staffing Matrix" showed for the night shift for up to 12 patients: there was 1 RN and 1 PCA.

The DON said that safety measures implemented when the adolescent units were combined on June 1 were specific to the night shift. "We staffed up- we added one PCA to the night shift on the Willows Unit. In addition, a PCA is stationed mid-way down the hallway on a chair- during the night shift." The DON said this was not in writing but these processes were implemented.

On 6/08/2023 , surveyor and Staff-B , DON, watched closed circuit video footage of the Willows Unit hallway for June 2 and June 3, 2023 -[timeframe Midnight to 5 AM]. There were 11 patients on the unit both nights. The findings were:

- no PCA was stationed mid-way down the hall on either night from Midnight to 5 AM on either of the nights ( June 2 and 3) .

- On June 2 , 2023- there was no additional PCA assigned to the unit.

The video findings were verified with the DON at the time of review.

Review of facility nursing report forms (untitled), dated June 2 and 3, 2023 showed two patients were on "sexually acting out" (SAO) precautions on both nights [ Patient # ID 27; Patient ID # 28 ].

Based on observation, interview, and record review their facility failed to ensure nursing staff followed approved policy for patient identification for medication administration in 1 of 1 medication pass observation on the Meadows unit (ID 20).

Findings include:

Observation on 6/6/23 at 10:45 showed LVN (ID H) administer three medications to patient (ID 20) without confirming patient identification, patient (ID 20) was not wearing a patient identification band.

Interview with LVN (ID H) at the time of observation, she stated that se is supposed to scan the ID band of patients when administering medications. She stated that some patients do not keep their ID band on. She stated that there is a picture on the screen to help ensure patient identity along with name and date of birth.

Record review of facility policy titled "Patient Identification for Clinical Care and Treatment," dated 05/2020 showed the following information:

Policy:
The hospital will ensure that all patients are properly identified prior to any care, treatment or services provided.

Inpatient:
1. Hospital Arm Band
a. An arm band shall be prepared and affixed to the patient in the assessment department.

4. Before any procedure is carried out, the identification ban shall be on the patient and will be checked by their responsible care provider for the following two identifiers to ensure that the right patient is involved:
a. patient's name
b. patient's date of birth

6. Application must be confirmed using the two-identifier system prior to conducting any health care procedures. Procedures may include, but are not limited to:
a. Medication administration
f. Defective or missing bands shall be replaced immediately with new bands
f. The daily nursing staff round shall include spot checking the patients to ensure that they are wearing identification bands and that the information is legible.

Multiple patients on the unit were observed not wearing identification arm bands.