HospitalInspections.org

Based on Record Review and Interview the hospital failed 1 of 1 Patient (Patient #1) by failing to ensure that the medical staff is accountable to the governing body for the quality of care provided to patients.



During record review Patient #1's medical record did not reveal any information that he was medically assessed and medically cleared after making the allegation that the night staff had allegedly sexually assaulted Patient #1.

During Interview with hospital Staff #7 it was revealed, "Patient #1 was interviewed but failed to interview any staff regarding the alleged allegations. Staff #7 reported that Patient #1 was unable to identify who the staff member was. Staff #7 stated she did not notify the physician and did not ensure Patient #1 had medical assessment."


Policy
The hospital Policy on Patient Rights dated 07/17/2019, reflected, "The rights, benefits, responsibilities, and privileges guaranteed by the constitutions and laws of the United States of Texas unless they have been restricted by specific provisions of law. The rights include, but are not limited to, the right to impartial access to and provision of treatment, regardless of race, nationality, religion, sex, ethnicity, sexual orientation, age, or disability; the right to petition for habeas corpus; the right to register and vote at elections, the right to acquire use, and dispose of property including contractual licenses, permits, privileges and benefits under law, the right to religious freedom and rights concerning domestic relations."


The hospital Policy on Nursing Services dated 07/17/2019 reflected, "It is the policy of the Perimeter Healthcare Nursing Services Department to provide the highest attain able quality of nursing care to all patients consistent with the mission, values, vision and goals."

The hospital Policy on Administration/Personnel Perimeter Healthcare is dedicated to providing patient-centered care and working to understand each individual's needs in order to supply excellent, differentiated treatment plans. We strive to employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives.

The hospital Policy on assessment and reassessment of Patients 07/2019, revealed, "An accurate medical record of the patient's condition, care, and treatment is provided throughout the hospital visit ...Reassessments are documented when there is a significant change in patient status. Patient information obtained during reassessments will be documented in the patient's medical record ...Reassessments of patients are to be completed when there is a significant change in patient condition or status, post procedure, and as warranted and/or recommended by the physician and/or treatment team ...B. Patient Problems, interventions responses to treatment and changes in patient condition are identified and documented each shift by a licensed nurse. Any new/abnormal findings or changes in the patient's condition are documented in the medical record. Such findings are reported to the RN/Charge Nurse if identified by other than RN staff. A reassessment is then completed by the RN, if the information/assessment was given by other than RN staff. The physician is notified, as appropriate and nursing interventions physicians orders are implemented. Nursing reassessments will occur when there is a change in the patient's condition, physical complaint, with any Seclusion and or restraint procedures ...5. Documentation provides a complete, current, and concise description of the patient status, changes in condition and treatments given with the least duplication of information possible.

The hospital Policy on Emergency Behavioral Interventions Use of Restraint/Seclusion 07/2019 reflected, " IT is the policy of Perimeter Healthcare to create an environment that protects the patient health and safety and preserves his or her dignity, rights and well-being. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member or others. In recognition that the patient has the right to be free of seclusion or restraint in any form that is not medically necessary; seclusion and restraint are to be used only in clinically appropriate and adequately justified situations when other less restrictive intervention have been determined ineffective or inappropriate. The use of Seclusion or Restraints at Perimeter Healthcare will be initiated in response to a behavioral emergency, and when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm. It is the intent of Perimeter Healthcare to reduce the use of restraint and seclusion to the extent possible. Other less restrictive alternatives are to be attempted first, unless they are determined to be ineffective of are judged unlikely to protect the individual or others from harm. Before ordering restraint or seclusion, the physician and staff must consider identified contraindications and other information and factors indicative of negative results to patient care outcome(s).

The hospital Policy on Abuse, Neglect, Exploitation, Unethical or Unprofessional Conduct dated 06/2022 reflected, "Perimeter Healthcare promotes and requires professional, ethical and legal conduct of staff. The advocacy role of health care is maximized when addressing issues of conduct of staff. Perimeter Healthcare assess the condition of illegal, unethical and/or unprofessional conduct of staff. All health care service providers will immediately report to the appropriate supervisor, manager, or department head any suspected illegal, unethical and/or unprofessional conduct by another individual. Illegal, unethical and/or unprofessional conduct by any health care service providers are prohibited behaviors and will be grounds for disciplinary action and reporting to local and/or state regulatory and/or legal authorities as mandated by statute, hospital policy and/or regulation(s). It is the responsibility of all staff members and healthcare professionals of Perimeter Healthcare to report concerns regarding illegal, unethical and/or unprofessional conduct to hospital administration."

The hospital policy on Administration Perimeter Healthcare is dedicated to providing patient-centered care and working to understand each individual's needs in order to supply excellent, differentiated treatment plans. We strive to employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives.

The hospital Policy on SAO Behaviors Perimeter Healthcare provides psychiatric/mental health assistance to victims of alleged rape and sexual molestation. The medical and/or legal aspects of alleged rape and molestation may be referred to other facilities as warranted."

Based on Record Review and Interview the hospital failed 1 of 1 Patient (Patient #1) by failing to "provide a updated examination of the patient, including any changes in the patient's condition...The updated examination of the patient, including any changes in the patient's condition, must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oral and maxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy."




During record review Patient #1's medical record did not reveal any information that he was medically assessed and medically cleared after making the allegation that the night staff had allegedly sexually assaulted Patient #1.

During Interview with hospital Staff #7 it was revealed, "Patient #1 was interviewed but failed to interview any staff regarding the alleged allegations. Staff #7 reported that Patient #1 was unable to identify who the staff member was. Staff #7 stated she did not notify the physician and did not ensure Patient #1 had medical assessment."


Policy
The hospital Policy on Patient Rights dated 07/17/2019, reflected, "The rights, benefits, responsibilities, and privileges guaranteed by the constitutions and laws of the United States of Texas unless they have been restricted by specific provisions of law. The rights include, but are not limited to, the right to impartial access to and provision of treatment, regardless of race, nationality, religion, sex, ethnicity, sexual orientation, age, or disability; the right to petition for habeas corpus; the right to register and vote at elections, the right to acquire use, and dispose of property including contractual licenses, permits, privileges and benefits under law, the right to religious freedom and rights concerning domestic relations."


The hospital Policy on Nursing Services dated 07/17/2019 reflected, "It is the policy of the Perimeter Healthcare Nursing Services Department to provide the highest attain able quality of nursing care to all patients consistent with the mission, values, vision and goals."

The hospital Policy on Administration/Personnel Perimeter Healthcare is dedicated to providing patient-centered care and working to understand each individual's needs in order to supply excellent, differentiated treatment plans. We strive to employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives.

The hospital Policy on assessment and reassessment of Patients 07/2019, revealed, "An accurate medical record of the patient's condition, care, and treatment is provided throughout the hospital visit ...Reassessments are documented when there is a significant change in patient status. Patient information obtained during reassessments will be documented in the patient's medical record ...Reassessments of patients are to be completed when there is a significant change in patient condition or status, post procedure, and as warranted and/or recommended by the physician and/or treatment team ...B. Patient Problems, interventions responses to treatment and changes in patient condition are identified and documented each shift by a licensed nurse. Any new/abnormal findings or changes in the patient's condition are documented in the medical record. Such findings are reported to the RN/Charge Nurse if identified by other than RN staff. A reassessment is then completed by the RN, if the information/assessment was given by other than RN staff. The physician is notified, as appropriate and nursing interventions physicians orders are implemented. Nursing reassessments will occur when there is a change in the patient's condition, physical complaint, with any Seclusion and or restraint procedures ...5. Documentation provides a complete, current, and concise description of the patient status, changes in condition and treatments given with the least duplication of information possible.

The hospital Policy on Emergency Behavioral Interventions Use of Restraint/Seclusion 07/2019 reflected, " IT is the policy of Perimeter Healthcare to create an environment that protects the patient health and safety and preserves his or her dignity, rights and well-being. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member or others. In recognition that the patient has the right to be free of seclusion or restraint in any form that is not medically necessary; seclusion and restraint are to be used only in clinically appropriate and adequately justified situations when other less restrictive intervention have been determined ineffective or inappropriate. The use of Seclusion or Restraints at Perimeter Healthcare will be initiated in response to a behavioral emergency, and when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm. It is the intent of Perimeter Healthcare to reduce the use of restraint and seclusion to the extent possible. Other less restrictive alternatives are to be attempted first, unless they are determined to be ineffective of are judged unlikely to protect the individual or others from harm. Before ordering restraint or seclusion, the physician and staff must consider identified contraindications and other information and factors indicative of negative results to patient care outcome(s).

The hospital Policy on Abuse, Neglect, Exploitation, Unethical or Unprofessional Conduct dated 06/2022 reflected, "Perimeter Healthcare promotes and requires professional, ethical and legal conduct of staff. The advocacy role of health care is maximized when addressing issues of conduct of staff. Perimeter Healthcare assess the condition of illegal, unethical and/or unprofessional conduct of staff. All health care service providers will immediately report to the appropriate supervisor, manager, or department head any suspected illegal, unethical and/or unprofessional conduct by another individual. Illegal, unethical and/or unprofessional conduct by any health care service providers are prohibited behaviors and will be grounds for disciplinary action and reporting to local and/or state regulatory and/or legal authorities as mandated by statute, hospital policy and/or regulation(s). It is the responsibility of all staff members and healthcare professionals of Perimeter Healthcare to report concerns regarding illegal, unethical and/or unprofessional conduct to hospital administration."

The hospital policy on Administration Perimeter Healthcare is dedicated to providing patient-centered care and working to understand each individual's needs in order to supply excellent, differentiated treatment plans. We strive to employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives.

The hospital Policy on SAO Behaviors Perimeter Healthcare provides psychiatric/mental health assistance to victims of alleged rape and sexual molestation. The medical and/or legal aspects of alleged rape and molestation may be referred to other facilities as warranted."