HospitalInspections.org

Based on Interview, Record Review and Observation the hospital failed 1 of 1 Patient (Patient #1) the right to receive care in a safe setting. Patient # 1 was restrained inappriopriately not causing bodily injury.

Findings Include:

Based on Interview with Staff #1 reported Staff #8 slapped or punched the basketball back towards Patient #1, as Patient #1 approached the direction of the basketball, Staff #8 walked back towards the Patient. The two were locked eyes, and Staff #8 appeared to be stepping around Patient #1, and then quickly attempted to restrain him. Staff #1 reported not witnessing Patient #8 being abused, but the use of an illegal restraint was applied.

Based on Interview with hospital Staff #4 Patient #8 has gone through Handle with Care Training a couple of time this year. Staff #4 reported discussing with Staff #8 the importance of knowing his peers, and knowing if they are experiencing to many stressful moments while on a shift and being able to stay in tact with their emotions. Staff #4 indicated as being a Handle with Care instructor it is not believed that Patient #1 was abused during the restraint. It is believed that Staff #8 used an inappropriate technique to restrain Patinet #1. This is not what the staff was taught. Staff #4 taught about releasing the patient and when to release a patient.

Based on Interview with hospital Staff #5 it was reported that Patient #1 was Staff #8 inappropriately restrained Patient #1. Staff #5 indicated that Staff #8 also had to be restrained to release Patient #1. When Staff #3 initially tried to ask Staff #8 to release Patient #1, Staff #8 responded 'No!" Once Staff #8 released Patient #1, Staff #8 took a few seconds to relax and continued to sit on the floor with Staff #5 still holding Staff #8. Staff #8 then got up and was escorted out of the gym and to the administrative offices.

Based on Interview with hospital Staff #6 it is reported that words were exchanged between Staff #8 and Patient #1. What was being said was inapproprate but could not be heard by Staff #6. Staff #6 indicated that the restraint witnessed was inappropriate and the word exchange between staff and patient were inappropriate on behalf of the staff.

Based on interview with hospital Staff #7 it was reported that the incident occrred and the investigation started immediately. Staff #7 indicated in revew of the video footage it is believed by this staff that Patient #1 was not abused by Staff #8, and that is why Staff #8 was allowed to return to regular dutires immediately and then after completing 2 hours of training (Handle with Care) on 07/31/2023. Hospital Staff #7 in review of video footage it was not witnessed of abuse. What was witnessed was inapprorpirate restraint technique by Staff #8 that did not cause any physical injury to Patient #1.

During Record Review Hospital Staff #8 has recently had retraining and had final notice in the employee record due to previous incident of Not following instruction, Training, inappropriate use of restraint. Staff #8 received retraining in April 2023 *Handle with Care).

During video footage observation at 13:18 Patient #1 is observed shooting the Baskeball in the gym. The ball does bounce off of the rim and inthe direction of Staff #8. Staff #8 punches/slaps the ball back towards the direction of Patient #1. Patient #1 appears to be walking in the direction of the ball. Staff #8 appears to be walking in the direction of Patient #1. The two are verbally sparing back and fordh during this time. Staff #8 appears to be attempting to step behind Patient #1 and then swings his arm across Patient #1's chest. Staff #1 then picks Patient #1 up and puts him on the ground. As a result of this incident the surveyor did not see abuse, but this incident should have been prevented. Other staff were present and observed the incident. The surveyor finds the allegations of abuse unsubstantiated, but substantiates the Patient Rights have been violated. The hospital failed to follow their own policy ensuring Patient Safety. and ensuring this staff was on his final notice.

Policy

The hospital Policy on Patient Rights 09/2022, "Dallas Behavioral Healthcare Hospital shall respect and protect patient rights by ensuring that every individual admitted, their family/significant party and all staff are informed of the rights to which all patients are entitled, in accordance with all Federal and State Regulatory requirements.
1. Patients may not be denied appropriate hospital care because of the
patient's race creed, color, national origin, religion, sex, sexual
orientation, martial status, age, disability, or source of payment.
2. Patients shall be treated with consideration, respect and recognition of
their individuality, including the need for privacy in treatment.


The hospital Policy on Nursing Assessment/Reassessment dated 02/2022 reflected, "Patients admitted to hospital will receive thorough assessment and evaluation. Results of assessments are reviewed by multidisciplinary team to prioritize problems in Treatment Plan."

The hospital Policy on Reporting and Investigating Abuse/Neglect and Exploitation dated 08/2022 reflected, "All patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and harassment. Dallas Behavioral Healthcare Hospital shall protect patients from real or perceived abuse, neglect or exploitation, including if the suspected r known abuser is a Dallas Behavioral Healthcare Hospital health care professional, contracted staff, visitor or other patient.
Dallas Behavioral Healthcare Hospital mandates that, under the guidance of applicable state and federal laws, any healthcare worker having reasonable cause to believe that any person is in the state of abuse, exploitation or neglect shall report the information to the appropriate regulatory agency. Pursuant to the Texas Health and Safety Code.
No supervisor, administrator or physician shall impede the reporting duties, and no person making the report shall be subject to any sanction for making the report.

The hospital Policy on Restraint and Seclusion 08/2022, "Restraint shall be used safely and only when less-restrictive means would not be effective to protect the patient. Restraint and seclusion practices shall comply with applicable statutes regulations and the standards adopted by agencies that accredit this hospital regulations and the standards adopted by agencies that accredit this hospital."