HospitalInspections.org

Based on record review and interview, the facility failed to ensure that registered nurses evaluated nursing care for a patient, as evidenced by 3 of 4 Nursing Assessments not addressing a patient's condition (Patient #1).


Findings included:


Review of facility policy #16527162 titled "Nursing Re-assessment of a Patient", last revised 12/2021, showed that a change in a patient's condition will be documented on the Daily Nursing Assessment within the patients' electronic health record. Also, any abnormal findings are to be documented on the RN Narrative section of the Daily Nursing Assessment.

Record review during time of survey of Patient #1's clinical chart showed the following:

Patient was admitted to facility on 9/9/24 from Texas Children's Hospital after self-harming by inserting a safety pin into her urethra (urinary tube) and having it lodge partially into her bladder. She needed surgery to remove it. The patient also had a history of other self-harm behaviors.

History and Physical Exam dated 9/10/24 showed the reason for admit was "presented to ED with safety pin in her partially in the urethra and bladder".

Initial Psychiatric Exam dated 9/10/24 showed the patient's diagnoses were Bipolar disorder, severe with psychosis; Post Traumatic Stress disorder; Autism Spectrum disorder.

Mental Health Technician (MHT) progress notes dated 9/15/23 at 2:05 from MHT-Staff #K, revealed the patient claimed she inserted her plastic patient wristband into her urethra and could not remove it. The notes showed that patient stated " ...my peepee hurts I just stuck my green band up there and its stuck".

A nursing progress note dated 9/15/24 at 2:35 PM by RN-Staff #F showed the patient reported "I stuck my band up my pee hole". The notes further showed that per her physician, the patient should continue to be monitored.

Nursing Assessment on 9/15/24 day shift signed at 4:04 PM by RN-Staff #F, showed "GU (genitourinary)/Renal: Reports no problem or burning during urination". Nursing note narrative in Nursing Assessment failed to address follow-up assessment about the wristband

Nursing Assessment on 9/15/24 evening shift signed at 8:43 PM by RN-Staff #G, showed "GU/Renal: Reports no problem or burning during urination". Nursing note narrative in Nursing Assessment also failed to address any follow-up information regarding the wristband.

MHT progress notes from MHT-Staff #J on 9/15/24 at 10:44 PM, showed the patient complained that her "private part was hurting because she tried to put her greenband inside herself". Staff advised her to sit on the toilet to try to remove it but the patient reported it was in too far.

The next nursing assessment addressed the wristband issue; Nursing Assessment on 9/16/24 morning shift signed at 9:38 AM by RN-Staff #H, showed that the patient complained the green band was still inside her, it was burning, and her doctor was considering transfer to the emergency room. The GI/GU portion of the assessment showed "Pt stated stuck green band to her pee hole".

However, the next following Nursing Assessment, again, failed to address anything about the wristband; Nursing Assessment on 9/16/24 evening shift signed at 8:37 PM by RN-Staff #I, showed "GU/Renal: Reports no problem or burning during urination". Nursing note narrative in Nursing Assessment failed to address any follow-up information about the wristband still lodged inside the patient's urethra.

Further record review of nursing progress notes (not part of the shift's nursing assessment) dated 9/16/24 signed by RN-Staff #I at 10:12 PM, showed the patient spoke with her father, reported that the wristband was stuck inside her, and complained that nothing was done about it. The father then requested to speak with RN-Staff #I and demanded that the patient be sent to the ER. The patient was then sent to Texas Children's Hospital via ambulance at 8:30 PM "per father's request".

Review of a subsequent nursing progress note entry on 9/17/24 signed by RN-Staff #L at 8:14 AM, showed that X-rays were performed at the ER, an object was found inside her bladder, and the patient was waiting for a surgical procedure to remove it.

In an interview on 9/25/24 at 9:30 AM, CNO-Staff #B acknowledged that the three shifts of nursing assessments did not address or contain any follow-up information regarding the patient having a foreign object inside her urethra, despite the patient claiming that her wristband was stuck inside her since the early afternoon of 9/15/24.

In an interview on 9/25/24 at 1:50 PM, RN-Staff #F stated that the patient gave the impression she placed the wristband in her vagina and was unaware of notes made by other staff, including MHT-Staff #K, showing the wristband was stuck inside her.

In an interview on 9/25/24 at 2:00 PM, RN-Staff #I stated the patient had never complained to her about pain and was unaware the wristband was stuck inside of her; she only found out after the father had complained to her on the phone.