HospitalInspections.org

Based on a review of medical records, personnel records, video surveillance, facility documentation and staff interviews, the governing body failed to provide adequate oversight of the hospital as facility staff failed to follow the facility's policies and procedures. This had the potential to adversely affect all patients who are treated at the facility. The facility failed to meet the Condition of Participation for governing body as evidenced by:

a) the facility failed to follow several of their own policies and procedures including: Patient Rights and Responsibilities, Sexually Acting Out Precautions, Sexually [sic] Contact Between Patients, Levels of Observation and Master Treatment Plan. (Refer to A0395, A0396)

b) registered nurses (RN) did not effectively supervise and evaluate the nursing care for each patient within their scope of practice. (Refer to A0395)

c) the facility failed to ensure non-employee licensed nursing staff adhered to policies and procedures of the hospital and were adequately oriented and supervised. (Refer to A0398)

Based on a review of medical records, personnel records, hospital policies and procedures and staff interview, the facility failed to meet the Condition of Participation for patient rights as evidenced by:

a) the facility failed to protect and promote the rights of patients by failing to ensure the patients received care in a safe setting. (Refer to A0144)
b) the facility failed to ensure patients were monitored at the level of monitoring specifically ordered by a physician in the medical record. This could have resulted in a potentially unsafe care setting for patients. (Refer to A0144)
c) the facility failed to ensure patients were free from all forms of abuse or harassment because it failed to ensure proper monitoring of patients (Refer to A0145)

The cumulative effect of these systematic deficient practices resulted in noncompliance with the Condition of Participation 482.13 Patient Rights.

Based on facility policy review, medical record review, and staff interview, the facility failed to ensure that patients are given the right to make informed decisions regarding treatment with psychoactive medication.

Findings included:

Facility policy titled "Informed consent for psychoactive medications - Texas" stated in part, "Policy: It is the policy of Georgetown Behavioral Health Institute that patients ... be involved in the process of the patient's care. Prior to initiation of Psychoactive Agents, the person being treated ... shall be informed of the potential benefits and risk of prescribed medications.

Procedure:
Consents:
...2. Informed consent for the administration of each psychoactive medication will be evidenced by a completed copy of the Department's Form Consent to Treatment with Psychoactive Medications (MHRS 9-7 form) executed by the patient or his/her Legal Advocate Representative (LAR).

Refusal to Consent:
1. If the patient or his/her Legal Advocate Representative (LAR) consents to the administration of a psychoactive medication but refuses or is unable to execute the form, a witness to the consent will be obtained. The consent and its witnessing will be documented in the patient's medical record or on the MHRS 9-7 Form and placed in the medical record. The witness will confirm this consent by signing the consent form."

Review of the medical record for patient #3 revealed a Medication Administration Record indicated "Abilify 5 mg [milligrams] PO QHS [by mouth at bedtime] mood/psychosis" was given at 9:00 pm on 6/17/17. No consent was found for this medication.

Nursing note dated 6/18/17 at 12:35 am stated in part, "Pt [patient] medication compliant."

In an interview with the staff #3 on the morning of 12/12/17, staff #3 stated, "The initials mean she would have gotten the medication, I can almost guarantee that she didn't take any medications while she was here." When asked the procedure if a patient agreed to take a medication but refused to sign, staff #3 stated, "We would put; 'Patient verbally agreed to take,' and two nurses would witness and sign that they witnessed."

Based on facility document review, medical record review, facility video review, and staff interview, the facility failed to ensure:
A. patients received care in a safe setting.
B. patients were monitored at the level of monitoring specifically ordered by a physician in the medical record. This could have resulted in a potentially unsafe care setting for patients.

Findings included:

Texas Administrative Code Chapter 404, Subchapter E states in part, "(3) The right to a humane treatment environment that ensures protection from harm, provides privacy to as great a degree as possible with regard to personal needs, and promotes respect and dignity for each individual ..."

Review of the incident report dated 10/4/17 revealed patient #1 and patient #2 were left alone in a room for approximately two hours. After they were found, patient #1 and patient #2 admitted to having intimate relations. Review of patient #1's and patient #2's charts revealed no orders for SAO precautions and the incident was not addressed in their master treatment plans.

Review of the facility camera footage dated 10/4/17 revealed at 12:20 am, patient #1 enters patient #2's bedroom. 20 minutes later, patient #2 exits bedroom, grabs a blanket and returns into the bedroom. Staff #10 walked the halls approximately every 15 minutes, but failed to open the door to any patient rooms. At 2:06 am, staff #10 left for break and Staff #7 began rounds. Staff #7 discovered patient #1 was not in the correct room, staff #7 and staff #5 discover patient #1 in patient #2's room, both patients were laying on the mattress on the floor between the beds.

Review of patient #1's and patient #2's medical records revealed patient observation records dated 10/4/17 that stated from the hours of 12:00 am to 2:00 am each patient was "Location: R [bedroom]; Activity: 6 [Appears Asleep]."

Review of the unit census for the night of 10/3/17 revealed there were 24 patients on that unit. All 24 patients were at risk of harm because they had not been checked on from 12:20 am to 2:06 am.

The above was confirmed in an interview with staff #2 on the afternoon of 12/11/17.


B. Review of the medical record for patient #1 revealed the following discrepancies in levels of observation between nursing shift assessments and patient observation records [completed by MHTs, mental health technicians]:
*10/3: Nursing shift assessments precautions stated "other" and did not specify while patient observation record stated "Other: Elopement"
*10/4: nursing precautions for 7a-7p shift stated "other: SP [self-harm precautions]," nursing precautions for 7p-7a shift stated "none," while the observation record stated "SAO [sexually acting out precautions]"
*10/5: nursing precautions for 7a-7p stated "SAO" and "other: Aggression," 7p-7a stated "other: SP," patient observation record stated "None."
*10/6: 7a-7p nursing precautions stated "SAO" and "other: SP," 7p-7a was missing, patient observation record stated "SP"
*10/7: 7a-7p shift stated, "Other: SP," 7p-7a shift stated, "other: SP, detox," patient observation record stated "SP"
*10/8: 7a-7p nursing precautions stated "Detox," 7p-7a and observation record stated "SP/detox"
*10/9: 7a-7p and observation record stated "SP" while 7p-7a shift stated "SP/detox"
*10/10: 7a-7p stated "Detox," observation record stated "detox/SP" while there were no precautions for 7p-7a shift
*10/11: 7a-7p shift stated "other: SP," observation record stated "Detox/SP, while there were no precautions for 7p-7a shift
*10/12: 7a-7p shift had no precautions while the observation record and 7p-7a shift stated "SP"
*10/13: 7a-7p shift and observation record had no precautions


Review of the medical record for patient #2 revealed the following discrepancies in levels of observation between nursing shift assessment precautions and patient observation record precautions:
Admission orders dated 9/11/17 at 1:44 am stated in part, "Precautions: Suicide/self-harm (SP).
*9/16: Nursing precautions for 7a-7p shift stated "none," 7p-7a shift stated, "psychosis," patient observation record stated "none"
*9/17, 18 and 19: Nursing precautions for both shifts stated "none" while the patient observation record stated "other: SP/EP [elopement precautions]"
*9/20: nursing precautions for 7a-7p stated "aggression," 7p-7a shift and patient observation record had no precautions listed
*9/21: nursing precautions for 7a-7p and observation sheet had no precautions while 7p-7a shift stated "SP"
*9/22: nursing precautions for both shifts stated "SP" while the patient observation record had no precautions

Admission orders dated 10/2017 at 10:00 pm stated in part, "Precautions: AWOL/Elopement (EP), suicide/self-harm (SP)"
*10/3: nursing precautions for 7a-7p and patient observation record had no precautions while nursing precautions for 7p-7a stated "SP"
*10/4: nursing precautions for 7a-7p stated "SP" with the level of observation "Q 15 min [every 15 minutes], LOS [line-of-sight]; nursing precautions for 7p-7a stated "SP" with the level of observation "Q 15 min, LOS, 1:1 [one-to-one]; the observation record had no precautions marked with level of observation "LOS"
*10/5: nursing precautions for 7a-7p stated "SP" with the level of observation "1:1"; 7p-7a stated "SAO" with the level of observation "Q 15 min"; observation record stated "SAO" with level of observation "LOS; 1:1"
*10/6: nursing precautions for 7a-7p stated "SAO/SP" with the level of observation "Q 15 min"; 7p-7a stated "SAO" with the level of observation "Q 15 min"; observation record had no precautions or level of observation documented
*10/7: nursing precautions 7a-7p stated "SP ... Q 15 min, LOS"; 7p-7a stated "SP ... Q 15 min"; observation sheet had no precautions with level of observation documented as "LOS"
*10/8: nursing precautions 7a-7p stated "SP ... LOS"; 7p-7a had no precautions or level of observation documented; observation record had no precautions with level of observation "Q 15 min ... LOS at 10:00 am"
*10/9: nursing precautions 7a-7p stated "SAO, SP ... LOS"; 7p-7a had no precautions with level of observation "LOS"; observation record stated "SAO ... Q 15 min, LOS"
*10/10: nursing precautions 7a-7p stated "SP ... LOS"; 7p-7a stated "SP ... Q 15 min, LOS"; observation record stated "SAO ... Q 15 min, LOS"
*10/11: nursing precautions 7a-7p stated "none ... LOS"; 7p-7a stated "SP ... Q 15 min"; observation record stated "LOS" without precaution level documented
*10/12: nursing precautions 7a-7p stated "SAO ... Q 15 min"; 7p-7a stated "SP ... Q 15 min"; observation record had no level of observation or precautions documented
*10/13: nursing precautions 7a-7p had no precautions with level of observation of Q 15 min; observation record stated "SP ... Q 15 min"

Review of patient #2's chart revealed physician orders:
*dated 10/4/17 at 9:56 stated in part, "1) increase observation"
*dated 10/5/17 at 1:14 pm stated, "1) increase observation"
*dated 10/6/17 at 9:50 am stated in part, "1) increase observation"
*dated 10/8/17 at 10:00 am stated "increase observation"
*dated 10/11/17 at an unknown time stated "D/C [discontinue] increase observation - LOS"

In an interview with staff #3 on the afternoon of 12/11/17, when asked what level of observation the patient was on, staff #3 was unsure.

Based on review of facility documents, record review and staff interview, the facility failed to ensure the patients were free from all forms of abuse or harassment because it failed to ensure proper monitoring of patients.

Findings included:

Texas Administrative Code Title 40 Part 19 Chapter 711 Subchapter A stated in part, "(a) In this chapter, when the alleged perpetrator is a direct provider, neglect is defined as a negligent act or omission which caused or may have caused physical or emotional injury or death to an individual receiving services or which placed an individual receiving services at risk of physical or emotional injury or death."

Facility policy titled "Abuse Reporting" stated in part, "III. Definitions:
...Neglect or neglected: the inability or unwillingness of a parent, guardian or custodian of a child to provide that child with supervision, food, clothing, shelter or medical care if that inability or unwillingness causes substantial risk of harm to the child's health or welfare ...
...Vulnerable adult means an individual who is eighteen years of age or older and who is unable to protect himself from abuse, neglect or exploitation by others because of a physical or mental impairment.

Review of the incident report dated 10/4/17 revealed patient #1 and patient #2 were left alone in a room for approximately two hours. After they were found, patient #1 and patient #2 admitted to having intimate relations.

Review of the facility camera footage dated 10/4/17 for patient corridor 43 revealed at 12:20 am, patient #1 enters patient #2's bedroom. 20 minutes later, patient #2 exits bedroom, grabs a blanket and returns into the bedroom. Staff #10 walked the halls approximately every 15 minutes, but failed to open the door to any patient rooms. At 2:06 am, staff #10 left for break and Staff #7 began rounds. Staff #7 discovered patient #1 was not in the correct room, staff #7 and staff #5 discover patient #1 in patient #2's room, both patients were laying on the mattress on the floor between the beds.

Review of patient #1's and patient #2's medical records revealed patient observation records dated 10/4/17 that stated from the hours of 12:00 am to 2:00 am each patient was "Location: R [bedroom]; Activity: 6 [Appears Asleep]."

Review of the unit census for the night of 10/3/17 revealed there were 24 patients on that unit. All 24 patients were at risk of harm because they had not been checked on from 12:20 am to 2:06 am.

The above was confirmed in an interview with staff #2 on the afternoon of 12/11/17.

Based on review of facility documents, medical record review and staff interview, the facility failed to ensure registered nurses supervised and evaluated the nursing care for each patient within their scope of practice.

Findings included:

Review of the incident report dated 10/4/17 revealed patient #1 and patient #2 were left alone in a room for approximately two hours. After they were found, patient #1 and patient #2 admitted to having intimate relations. Camera review from patient corridor 43 for 10/4/17 revealed patient #1 entered patient #2's room at 12:20 am. At 12:40 am, patient #2 exits the room, grabs a blanket and returns to the room. Staff #10 walks the halls throughout the shift but does not open any doors. At 2:06 am, staff #10 [agency mental health technician] goes on break, staff #7 walks the halls, saw patient #1 was not in their room and found patient #1 and patient #2 laying on a mattress on the floor between the beds and separates the patients. Patient #1 had only underwear on and patient #2 was fully clothed.

In an interview with staff #3 on 12/11/17 at 11:38 am, when asked what other staff was doing during the two-hour block of time the patients were unchecked, staff #3 stated, "Stuffing charts, paperwork for the next day ..."

The registered nurse assigned to the unit did not supervise the care of all 24 inpatients on 10/4/17.

The Nurse Practice Act Section 301.002 stated in part, "(2) Professional nursing means the performance of an act that requires substantial specialized judgment and skill ... The term does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures. Professional nursing involves:
(A) the observation, assessment, intervention, evaluation, rehabilitation, care and counsel, or health teachings of a person who is ill, injured, infirm, or experiencing a change in normal health processes;
...(C) the administration of a medication or treatment as ordered by a physician ..."

Facility policy titled "Levels of Observation" stated in part, "Procedure" the level of observation is a matter of clinical judgment. The clinical judgment is based on clinical review of all available information and recorded in the medical record. In general, patients identified as a low risk should be assigned to Every (q) Fifteen (15) Minute observation status.
Patients identified as a moderate risk should be assigned to Line of Sight observation. Patients identified as high risk for danger to self or others, should be assigned to One to One observation status.
1. Levels of Observation
A. Fifteen minute observation
...2. Shift reports, provider rounds, and treatment team meetings will be used to communicate observations status for continuity of care indicating the status and type of precaution. This status will be documented on the Patient Observation Record and on the Nursing Daily Shift Assessment.
3. the patient's status may be changed or increased at the discretion of the nurse for the patient's safety or for the safety of others.
4. When the patient is noted to be sleeping, staff must observe the patient long enough to ensure the patient is breathing. If staff cannot observe chest or abdominal movements, the staff may need to gently touch the patient's shoulder to determine that the patient is responsive and breathing.

B. Line of Sight (LOS)
1. Patient assessment indicates a higher safety risk that cannot safely be managed with Every 15 Minute observation.
2. Increased observation may be initiate by the nurse based on patient assessment.
3. The provider may assess the need for increased observation. A provider order will be obtained for increased observation.
4. Nursing Leadership will determine the most appropriate increased observation status of the patient in order to manage the presenting risk.
...6. LOS observation is continuous for twenty-four (24) hours unless otherwise ordered by the provider. The order must be evaluated and re-ordered every 24 hours. The provider assessment and note shall include clinical justification for continued need for LOS observation or for decreasing the level of observation ordered.
...8. ...This status will be documented on the Patient Observation Record and on the Nursing Daily Shift Assessment.

C. One to One (1:1)
...2. One to One observation may be initiated by the nurse based on patient assessment.
3. The provider may assess the need for increased observation. A provider order will be obtained for 1:1 observation.
4. Nursing Leadership will determine the most appropriate increased observation status of the patient ...
...9. ...This status will be documented on the Patient Observation Record and on the Nursing Daily Shift Assessment."

Review of the medical record for patient #1 revealed the following discrepancies in levels of observation between nursing shift assessments and patient observation records [completed by MHTs, mental health technicians]:
*10/3: Nursing shift assessments precautions stated "other" and did not specify while patient observation record stated "Other: Elopement"
*10/4: nursing precautions for 7a-7p shift stated "other: SP [self-harm precautions]," nursing precautions for 7p-7a shift stated "none," while the observation record stated "SAO [sexually acting out precautions]"
*10/5: nursing precautions for 7a-7p stated "SAO" and "other: Aggression," 7p-7a stated "other: SP," patient observation record stated "None."
*10/6: 7a-7p nursing precautions stated "SAO" and "other: SP," 7p-7a was missing, patient observation record stated "SP"
*10/7: 7a-7p shift stated, "Other: SP," 7p-7a shift stated, "other: SP, detox," patient observation record stated "SP"
*10/8: 7a-7p nursing precautions stated "Detox," 7p-7a and observation record stated "SP/detox"
*10/9: 7a-7p and observation record stated "SP" while 7p-7a shift stated "SP/detox"
*10/10: 7a-7p stated "Detox," observation record stated "detox/SP" while there were no precautions for 7p-7a shift
*10/11: 7a-7p shift stated "other: SP," observation record stated "Detox/SP, while there were no precautions for 7p-7a shift
*10/12: 7a-7p shift had no precautions while the observation record and 7p-7a shift stated "SP"
*10/13: 7a-7p shift and observation record had no precautions

Review of the medical record for patient #2 revealed the following discrepancies in levels of observation between nursing shift assessment precautions and patient observation record precautions:
Admission orders dated 9/11/17 at 1:44 am stated in part, "Precautions: Suicide/self-harm (SP).
*9/16: Nursing precautions for 7a-7p shift stated "none," 7p-7a shift stated, "psychosis," patient observation record stated "none"
*9/17, 18 and 19: Nursing precautions for both shifts stated "none" while the patient observation record stated "other: SP/EP [elopement precautions]"
*9/20: nursing precautions for 7a-7p stated "aggression," 7p-7a shift and patient observation record had no precautions listed
*9/21: nursing precautions for 7a-7p and observation sheet had no precautions while 7p-7a shift stated "SP"
*9/22: nursing precautions for both shifts stated "SP" while the patient observation record had no precautions

Admission orders dated 10/2017 at 10:00 pm stated in part, "Precautions: AWOL/Elopement (EP), suicide/self-harm (SP)"
*10/3: nursing precautions for 7a-7p and patient observation record had no precautions while nursing precautions for 7p-7a stated "SP"
*10/4: nursing precautions for 7a-7p stated "SP" with the level of observation "Q 15 min [every 15 minutes], LOS [line-of-sight]; nursing precautions for 7p-7a stated "SP" with the level of observation "Q 15 min, LOS, 1:1 [one-to-one]; the observation record had no precautions marked with level of observation "LOS"
*10/5: nursing precautions for 7a-7p stated "SP" with the level of observation "1:1"; 7p-7a stated "SAO" with the level of observation "Q 15 min"; observation record stated "SAO" with level of observation "LOS; 1:1"
*10/6: nursing precautions for 7a-7p stated "SAO/SP" with the level of observation "Q 15 min"; 7p-7a stated "SAO" with the level of observation "Q 15 min"; observation record had no precautions or level of observation documented
*10/7: nursing precautions 7a-7p stated "SP ... Q 15 min, LOS"; 7p-7a stated "SP ... Q 15 min"; observation sheet had no precautions with level of observation documented as "LOS"
*10/8: nursing precautions 7a-7p stated "SP ... LOS"; 7p-7a had no precautions or level of observation documented; observation record had no precautions with level of observation "Q 15 min ... LOS at 10:00 am"
*10/9: nursing precautions 7a-7p stated "SAO, SP ... LOS"; 7p-7a had no precautions with level of observation "LOS"; observation record stated "SAO ... Q 15 min, LOS"
*10/10: nursing precautions 7a-7p stated "SP ... LOS"; 7p-7a stated "SP ... Q 15 min, LOS"; observation record stated "SAO ... Q 15 min, LOS"
*10/11: nursing precautions 7a-7p stated "none ... LOS"; 7p-7a stated "SP ... Q 15 min"; observation record stated "LOS" without precaution level documented
*10/12: nursing precautions 7a-7p stated "SAO ... Q 15 min"; 7p-7a stated "SP ... Q 15 min"; observation record had no level of observation or precautions documented
*10/13: nursing precautions 7a-7p had no precautions with level of observation of Q 15 min; observation record stated "SP ... Q 15 min"

Review of patient #2's chart revealed physician orders:
*dated 10/4/17 at 9:56 stated in part, "1) increase observation"
*dated 10/5/17 at 1:14 pm stated, "1) increase observation"
*dated 10/6/17 at 9:50 am stated in part, "1) increase observation"
*dated 10/8/17 at 10:00 am stated "increase observation"
*dated 10/11/17 at an unknown time stated "D/C [discontinue] increase observation - LOS"

In an interview with staff #3 on the afternoon of 12/11/17, when asked what level of observation the patient was on, staff #3 was unsure.

In an interview with staff #2 on the morning of 12/11/17, when asked what the order that stated "increase observation" meant, she stated, "If they're a Q 15 min, they can go up to line-of-sight or one-to-one." When asked what level patient #2 would have been on after this incident, staff #2 was unsure. When asked who determines the level of observation, staff #2 stated, "Nurse leadership talks about it and decides what level would be best ... They can increase or decrease the observation level status."

Nursing staff cannot increase or decrease observation levels without a physician order, according to the nurse practice act.

Based on review of facility documents, review of medical records and staff interviews, the facility failed to ensure staff kept a current care plan for each patient.

Findings included:

Facility policy titled "Master Treatment Plan" stated in part, "1. Policy:
A. Every patient will have an individualized, comprehensive Master Treatment Plan.
...F. The Master Treatment Plan includes: ... Short term goals (objectives) will be reevaluated and, as necessary, revised based on changes in the patient's condition, problems, needs and responses to care, treatment and services."

Facility policy titled "Sexually acting out precautions [SAO]" stated in part, "Policy: It is the policy of Georgetown Behavioral Health Institute to provide guidance for the observation of patients with a known history of sexually acting out, and/or those patients who have a high probability of demonstrating such behavior. Patients determined to be a danger to other patients due to sexually inappropriate behavior will be placed on SAO precaution status.
Procedure:
...3. ...Any patient who has demonstrated sexually inappropriate behavior during hospitalization will be placed on SAO and remain on SAO precautions for the remainder of the hospitalization ...
4. SAO precautions will be addressed on the Treatment Plan, and will be noted on the Precautions Sheets and Report Sheets to denote the appropriate concerns ...
...7. General Safety Procedures to be enforced:
a. Report and record all sexual remark and gestures.
b. Never leave patient unattended with other patients ..."

Review of the incident report dated 10/4/17 revealed patient #1 and patient #2 were left alone in a room for approximately two hours. After they were found, patient #1 and patient #2 admitted to having intimate relations. Review of patient #1's and patient #2's charts revealed no orders for SAO precautions and the incident was not addressed in their master treatment plans.

The above was confirmed in an interview the morning of 12/12/17 with staff #3.

Based on a review of facility records and staff interview, the facility failed to ensure non-employee licensed nursing staff adhered to policies and procedures of the hospital and were adequately oriented and supervised.

Findings included:

Facility policy titled "Levels of Observation" stated in part, "4. When the patient is noted to be sleeping, staff must observe the patient long enough to ensure the patient is breathing. If staff cannot observe chest or abdominal movements, the staff may need to gently touch the patient's shoulder to determine that the patient is responsive and breathing."

Review of the incident report dated 10/4/17 revealed patient #1 and patient #2 were left alone in a room for approximately two hours. After they were found, patient #1 and patient #2 admitted to having intimate relations. Camera review from patient corridor 43 for 10/4/17 revealed patient #1 entered patient #2's room at 12:20 am. At 12:40 am, patient #2 exits the room, grabs a blanket and returns to the room. Staff #10 walks the halls throughout the shift but does not open any doors.

Review of patient #1's and patient #2's medical records revealed patient observation records dated 10/4/17 that stated from the hours of 12:00 am to 2:00 am each patient was "Location: R [bedroom]; Activity: 6 [Appears Asleep]."


Review of personnel record for the agency mental health technician [MHT] involved revealed no orientation documentation.

In an interview with staff #2 on 12/11/17 at 10:59 am, when asked if there was any orientation for agency MHTs and nurses, staff #2 stated, "No, we would put them with our staff. There isn't any formal training. They would fill out a round sheet with the staff." When asked how long would they follow an MHT on staff, staff #2 stated, "A shadow shift. Just one shift. We haven't had any [agency staff] since then ... Since 10/5."

Based on facility document review, medical record review and staff interview, the facility failed to ensure the medical records were accurately written.

Findings included:

Review of patient #1's medical record revealed nursing notes:
*dated 10/4/17 at 2:45 am stated in part, "Pt inappropriate with peer transfer to mesquite [geriatric unit]."
*dated 10/4/17 at 4:00 am stated in part, "Pt arrived to mesquite unit at 4:00 am. Pt was escorted to room by MHT and house supervisor."
*dated 10/4/17 at 5:50 am stated in part, "Pt transferred to Gen. psych for threatening behavior towards female staff. Pt escorted by 2 RNs. Report given to [RN] in person ..."
*dated 10/4/17 stated in part, "Pt yelled 'Y'all get made when two people decide to f***.'"
*dated 10/4/17 at 9:00 am stated in part, "Pt arrived ambulatory to unit after getting to smoke a cigarette ..."

Review of the medical record for patient #1 revealed a medical history and physical dated 10/4/17 at 11:30 am stated in part, "Was put on unit (1) then tx [transferred] to genpsych [general psychiatric unit] for threatening staff. Was found being sexually inappropriate in a female pts [patient's] room. Was moved again to unit (1) where he was then transferred to PICU [psychiatric intensive care unit, a higher patient acuity unit]. This is what I gather from chart, unsure of certain [unreadable]."
Patient #1's Discharge summary dated 10/17/17 stated in part, "Hospital course ... The patient was transferred from longhorn unit to general psychiatry for threatening behaviors toward female staff. The patient was transferred to the Mesquite unit per provider order with a supervisor approval. Per the provider, the patient was more apparent for less acute unit with more programming but cannot be placed in general psychiatry ..."

No further documentation was found regarding the incident, what was done about the incident or how the facility planned to prevent further instances. No orders were noted to place patient on SAO [sexually acting out precautions]. The incident was not addressed in the patient's master treatment plan.

In an interview with staff #3 on the morning of 12/12/17, staff #3 stated, "It wasn't even addressed in [patient #1's] chart. In this one [patient #2's] let's document everything, in [patient #1's], it's like, it didn't happen ... With [patient #1], [patient #1] was so paranoid at the time, we could barely get [patient #1] to talk with the police, much less testing. We are all so, just angry about this ..."

Based on facility document review, medical record review and staff interview, the facility failed to ensure the medical records documented information necessary to monitor the patient's condition.

Findings included:

Review of patient #1's medical record revealed nursing notes:
*dated 10/4/17 at 2:45 am stated in part, "Pt inappropriate with peer transfer to mesquite [geriatric unit]."
*dated 10/4/17 at 4:00 am stated in part, "Pt arrived to mesquite unit at 4:00 am. Pt was escorted to room by MHT and house supervisor."
*dated 10/4/17 at 5:50 am stated in part, "Pt transferred to Gen. psych for threatening behavior towards female staff. Pt escorted by 2 RNs. Report given to [RN] in person ..."
*dated 10/4/17 stated in part, "Pt yelled 'Y'all get made when two people decide to f***.'"
*dated 10/4/17 at 9:00 am stated in part, "Pt arrived ambulatory to unit after getting to smoke a cigarette ..."

Review of the medical record for patient #1 revealed a medical history and physical dated 10/4/17 at 11:30 am stated in part, "Was put on unit (1) then tx [transferred] to genpsych [general psychiatric unit] for threatening staff. Was found being sexually inappropriate in a female pts [patient's] room. Was moved again to unit (1) where he was then transferred to PICU [psychiatric intensive care unit, a higher patient acuity unit]. This is what I gather from chart, unsure of certain [unreadable]."
Patient #1's Discharge summary dated 10/17/17 stated in part, "Hospital course ... The patient was transferred from longhorn unit to general psychiatry for threatening behaviors toward female staff. The patient was transferred to the Mesquite unit per provider order with a supervisor approval. Per the provider, the patient was more apparent for less acute unit with more programming but cannot be placed in general psychiatry ..."

No further documentation was found regarding the incident, what was done about the incident or how the facility planned to prevent further instances. No orders were noted to place patient on SAO [sexually acting out precautions]. The incident was not addressed in the patient's master treatment plan.

In an interview with staff #3 on the morning of 12/12/17, staff #3 stated, "It wasn't even addressed in [patient #1's] chart. In this one [patient #2's] let's document everything, in [patient #1's], it's like, it didn't happen ... With [patient #1], [patient #1] was so paranoid at the time, we could barely get [patient #1] to talk with the police, much less testing. We are all so, just angry about this ..."

Based on review of facility documents, review of medical records and staff interviews, the facility failed to ensure each patient had an individual comprehensive treatment plan.

Findings included:

Facility policy titled "Master Treatment Plan" stated in part, "1. Policy:
A. Every patient will have an individualized, comprehensive Master Treatment Plan.
...F. The Master Treatment Plan includes: ... Short term goals (objectives) will be reevaluated and, as necessary, revised based on changes in the patient's condition, problems, needs and responses to care, treatment and services."

Facility policy titled "Sexually acting out precautions [SAO]" stated in part, "Policy: It is the policy of Georgetown Behavioral Health Institute to provide guidance for the observation of patients with a known history of sexually acting out, and/or those patients who have a high probability of demonstrating such behavior. Patients determined to be a danger to other patients due to sexually inappropriate behavior will be placed on SAO precaution status.
Procedure:
...3. ...Any patient who has demonstrated sexually inappropriate behavior during hospitalization will be placed on SAO and remain on SAO precautions for the remainder of the hospitalization ...
4. SAO precautions will be addressed on the Treatment Plan, and will be noted on the Precautions Sheets and Report Sheets to denote the appropriate concerns ...
...7. General Safety Procedures to be enforced:
a. Report and record all sexual remark and gestures.
b. Never leave patient unattended with other patients ..."

Review of the incident report dated 10/4/17 revealed patient #1 and patient #2 were left alone in a room for approximately two hours. After they were found, patient #1 and patient #2 admitted to having intimate relations. Review of patient #1's and patient #2's charts revealed no orders for SAO precautions and the incident was not addressed in their master treatment plans.

The above was confirmed in an interview the morning of 12/12/17 with staff #3.

Based on facility document review, medical record review and staff interview, the facility failed to ensure progress notes recorded by the doctor of medicine responsible for the care of the patient reflected an accurate picture of each patient.

Findings included:

Review of the medical record for patient #1 revealed a medical history and physical dated 10/4/17 at 11:30 am stated in part, "Was put on unit (1) then tx [transferred] to genpsych [general psychiatric unit] for threatening staff. Was found being sexually inappropriate in a female pts [patient's] room. Was moved again to unit (1) where he was then transferred to PICU [psychiatric intensive care unit, a higher patient acuity unit]. This is what I gather from chart, unsure of certain [unreadable]."
Patient #1's Discharge summary dated 10/17/17 stated in part, "Hospital course ... The patient was transferred from longhorn unit to general psychiatry for threatening behaviors toward female staff. The patient was transferred to the Mesquite unit per provider order with a supervisor approval. Per the provider, the patient was more apparent for less acute unit with more programming but cannot be placed in general psychiatry ..."

No further documentation was found regarding the incident, what was done about the incident or how the facility planned to prevent further instances. No orders were noted to place patient on SAO [sexually acting out precautions]. The incident was not addressed in the patient's master treatment plan.

In an interview with staff #3 on the morning of 12/12/17, staff #3 stated, "It wasn't even addressed in [patient #1's] chart. In this one [patient #2's] 'let's document everything,' in [patient #1's], it's like, it didn't happen ..."

Based on facility document review, medical record review and staff interview, the facility failed to ensure progress notes were recorded by the nurse responsible for the care of the patient.

Findings included:

Review of patient #1's medical record revealed nursing notes:
*dated 10/4/17 at 2:45 am stated in part, "Pt inappropriate with peer transfer to mesquite [geriatric unit]."
*dated 10/4/17 at 4:00 am stated in part, "Pt arrived to mesquite unit at 4:00 am. Pt was escorted to room by MHT and house supervisor."
*dated 10/4/17 at 5:50 am stated in part, "Pt transferred to Gen. psych for threatening behavior towards female staff. Pt escorted by 2 RNs. Report given to [RN] in person ..."
*dated 10/4/17 stated in part, "Pt yelled 'Y'all get made when two people decide to f***.'"
*dated 10/4/17 at 9:00 am stated in part, "Pt arrived ambulatory to unit after getting to smoke a cigarette ..."

No further documentation was found regarding the incident, what was done about the incident or how the facility planned to prevent further instances. The incident was not addressed in the patient's master treatment plan.

In an interview with staff #3 on the morning of 12/12/17, staff #3 stated, "It wasn't even addressed in [patient #1's] chart. In this one [patient #2's] let's document everything, in [patient #1's], it's like, it didn't happen ... With [patient #1], [patient #1] was so paranoid at the time, we could barely get [patient #1] to talk with the police, much less testing. We are all so, just angry about this ..."