HospitalInspections.org

Based on observation, interview, and record review, the facility failed to ensure 5 of 17 sampled patients received care in a safe setting ( Patient ID # 1, 3, 4, 6, 15).

The facility failed to ensure :

1. A patient on suicide precautions did not have access to hazardous items (Patient # 3);

2. Patients were placed on appropriate safety precaution levels based on current observation and documented patient history (Patient # 4, 1, 6, 15, ); and

3. Staff understanding of precaution levels was consistent with facility policy.

Findings include:

TX 00293016
TX 00295030

Review of facility policy titled "Patient Bill of Rights,"dated 11/2017, read:"...Basic Rights for All Patients:...3. You have the right to a clean and humane environment in which you are protected from harm...5. You have the right to be free from mistreatment, abuse, neglect, and exploitation.."

1. Patient on suicide precautions: access to hazards:

Review of facility policy titled "Patient Belongings, Valuables, Contraband, & Restricted Articles", dated 10/2018, read: Restricted Items that are required to be locked up:....strings (sweatshirts, pants, etc..)..."

Review of facility policy titled "Levels of Observation and Precautions", dated 04/2018, read: "..Suicide Precautions...5. personal items that pose a threat to patients will be removed and locked..."

Review of a physician order, dated 10-16-18 (1600) for Patient # 3 read: "suicide precautions..."

Observation on 10-17-18 at 10:00 a.m. in Patient # 3's room revealed a shelf that contained a folded pair of sweat pants with a thick drawstring in them.

During an interview with Registered Nurse (RN) # 5 at the time of observation, she stated this patient was on suicide precautions ; and drawstrings in pants were not allowed. RN # 5 said the patient was to try on the pants upon her return from the the gym. If the pants fit, the drawstring would have been removed.


2. Appropriate Levels of Precautions:

Review of facility policy titled "Levels of Observation and Precautions," dated 04/2018, showed the facility had three (3) levels of observation : "every 15 minute observation"; "line of sight observation" and "1 to 1 monitoring". Special precautions listed were:" suicide precautions, aggression precautions, elopement precautions, and fall precautions." The policy did not include unit restriction; sexually acting out (SOA); or homicidal ideation precautions.

Patient # 4:

Observation on 10-17-18 at 10:45 a.m. in the common day area Patient # 4 was observed sitting next to Tech #8 having a conversation. Patient # 4 was overhead to say "I'd like to kill her. I'd love to see people's blood everywhere. Murdering is my most favorite thing in the world to do. No one here knows I want to kill them but I do...Sometimes (patient name) sets me off..."

Review of MD psychiatric progress note, dated 10-16-18 read: "...yesterday-wanted to kill people--not today.."

Review of MD psychiatric progress note, dated 10-17-18, read:..."Homicidal thoughts: 3 people here--finds pleasure in the thoughts of hurting others-continued audio hallucinations-they tell me how to kill others.."

Review of all physician orders and "Close Observation Records" for Patient # 4 failed to reveal any orders for"aggression precautions."

During an interview on 10-18-18 at 11:30 a.m. Quality Director # 4 she was informed of Patient # 4's conversation in dayroom prior day & also reviewed psychiatrist's progress notes. Quality Director # 4 stated Patient # 4 should have been placed on Assaultive precautions (AP) and line of sight observation with consideration given to 1:1 monitoring. She stated the facility did not have Homicidal Ideation (HI) as an established precaution level.

Patient # 1:

Record review of Patient # 1's clinical record revealed she was 14 year old female admitted to the facility on 10-11-18 following a suicide attempt.

Further review of a document titled "Level of Care/Psychosocial Assessment", dated 10-12-18, showed:" History of sexual abuse-rape case currently open"; "attempted to run away on 10-10-18 and 10-11-18."

"Inpatient Nursing Assessment" dated 10-12-18, read:"...History of sexual abuse by mother's boyfriend--his case is going on..."
During an interview on 10-18-18 at 11:30 a.m. with Quality Director # 4, she stated based on her recent documented history , Patient # 1 should have been placed on elopement precautions. Quality Director # 4 further stated the facility did not have Sexually Acting Out (SAO) as an established precaution level in their policy. She went on to say she was aware that SAO precautions were a standard of practice in the behavioral hospital community . She was unsure of the reason this facility did not have a SAO precaution level established.

Patient # 6:

Record review of Patient # 6's clinical record revealed she was a 16 year old female admitted to the facility on 10-12-18.

Review of "History & Physical" exam, dated 10-13-18 documented multiple suicide attempts, depression, and aggression; "10-11-18 physically assaulted someone."

Review of "Psychiatric Evaluation," dated 10-13-18 read:" ..destroyed property at school and assaulted a peer.."

Review of all physician orders and "Close Observation Records" for Patient # 6 failed to reveal any orders for "aggression precautions."

Patient # 15:

Record review of Patient # 15's clinical record revealed she was a 13 year old female admitted to the facility on 02-16-18 for major depression, suicidal ideation, and physical aggression.

Record review of History & Physical /preadmission psychiatric evaluation, dated 02-16-18, read: "...states she was raped by her brother 2 years ago and has been sexually abused by him since she was 6 or 7 years old.."

Review of Patient # 15's admission orders showed she was initially placed on aggression and suicide precautions; and later placed on unit restriction precautions. She was not placed on SAO precautions at time of admission on 02-16-18, as facility does not have SAO precautions in their policy.

Review of Registered Nurse (RN) narrative note, dated 2-21-18, documented that "patient reported that she engaged in oral sex with her roommate on Monday night (2-19-18)..."

During an interview on 10-18-18 at 11:30 a.m. with Quality Director # 4, she stated the facility did not have Sexually Acting Out (SAO) as an established precaution level in their policy. She went on to say, she was aware that SAO precautions were a standard of practice in the behavioral hospital community. She was unsure of the reason this facility did not have a SAO precaution level established.

3. Staff understanding of precaution levels was inconsistent with facility policy:

Review of facility policy titled "Levels of Observation and Precautions," dated 04/2018, showed the facility policy did not include a sexually acting out (SOA) precaution level.

During an interview on 10-18-18 at 10 a.m. with RN # 9 she stated the facility precaution levels included SAO.

During an interview on 10-17-18 at 9:45 a.m. with RN # 5 she stated the facility precaution levels included SAO.

Record review of physician order, dated 3-26-18 for Patient # 9 read: " Place on SAO precautions." This order was written in response to a documented incident of "sexual familiarity-peer to peer" that involved Patient # 9.

Based on interview and record review, the facility failed to investigate two(2) documented incidents of sexual boundary issues. [Citing Patients # 15, # 16, # 9, # 13 ]

Findings include:

TX 00293016

Review of facility policy titled "Patient Bill of Rights,"dated 11/2017, read:"...Basic Rights for All Patients:...3. You have the right to a clean and humane environment in which you are protected from harm...5. You have the right to be free from mistreatment, abuse, neglect, and exploitation.."

Review of facility policy titled "Incident Report Protocol, dated 01/2018, it read:" ..8. Severe Events:...alleged boundary violation between staff and patient or between patients..."

Patient # 15 and Patient # 16:

Review of complaint intake # TX 00293016, it read: "...today...Patient # 15's father took her out of facility against medical advice due to an incident that occurred on Monday night 2-19-18. Patient # 15 performed oral sex on her roommate ( Patient # 16) ..."

Patient # 15:

Record review of Patient # 15's clinical record revealed she was a 13 year old female admitted to the facility on 02-16-18 for major depression, suicidal ideation, and physical aggression.

Record review of Patient # 15's History & Physical /preadmission psychiatric evaluation, dated 02-16-18, read: "...states she was raped by her brother 2 years ago and has been sexually abused by him since she was 6 or 7 years old.."

Review of Registered Nurse (RN) narrative note, dated 2-21-18, documented that "patient ( #15) reported that she engaged in oral sex with her roommate on Monday night (2-19-18)..."

Patient # 16:

Record review of Patient # 16's clinical record revealed she was a 13 year old female admitted to the facility on 02-17-18 for suicidal ideation and physical aggression.

Review of facility documentation of the sexual incident that occurred on 02-19-18 failed to reveal that an investigation had been completed. The section titled " Findings of Investigation, Recommendation and Outcome: was left blank. The "Severity Index" was left blank. The signature and date by the risk manager was left blank.

Patient # 9 and Patient # 13:

Review of narrative note by Patient Care Assistant (PCA) dated 03-01-18, read : " I was making 2000 rounds . As I was getting ready to go into one of the female pt room, anther pt stated a male was in the pt room ( 604 A). Pt now in restroom and I turned the lights on to the room. I first called for the pt. She was in the bathroom. I asked her if she needed anything. She said no. I looked over the door and female pt and male pt both had their pants down to their knees. I opened the door and male pt walked out and the female pt, said thank you. I called the house supervisor immediately and let the nurses and tech on the unit know what happened."

Review of facility documentation of the sexual incident that occurred on 03-01-18 failed to reveal that an investigation had been completed. The section titled " Findings of Investigation, Recommendation and Outcome: was left blank. The "Severity Index" was left blank. The signature and date by the risk manager was left blank.

During an interview on 10-18-18 at Noon with Quality Director # 4 she stated there had been some investigations that had been missed. She reported the former Quality Director left the position in February 2018 and she had not assumed the role until the end of July 2018.