HospitalInspections.org

Based on a review of clinical records, facility documentation, observation and an interview with staff, the facility failed to ensure the right to care in a safe setting.

Findings were:

Review of the clinical record for patient #1 revealed that the patient was admitted to Glen Oaks Hospital (GOH) on 12-21-20 after engaging in an argument with her brother and making statements to the police that she intended to kill herself.

While still in the intake department, patient #1 became upset and told a staff member that she wanted to leave immediately. While the staff member was talking to her, patient #1 grabbed the staff member's lanyard (on which hung her keys) from around her neck and used the keys to exit the facility. The staff searched for the patient but were unable to find her. The police were contacted and found the patient approximately 45 minutes later, next door at an equine therapy facility. Her leg was noted to be injured and she was taken to a nearby medical hospital and found to have a left tibia fracture. The fracture was stabilized and she was transported back to GOH for continued treatment.

The facility conducted an internal investigation following the event. An area under "Root Cause Analysis Findings" stated "Staff should not wear lanyards around their neck with keys as it poses easy access for patients to grab." The plan of action for this finding was "Memo sent to all staff not to wear lanywards(sic) around neck." The action plan also stated "Update HR056 to include staff not to have keys in a visible area such as on a lanyard." "Root Cause Analysis Findings" also stated "During orientation, explain that wearing keys publically(sic) poses a risk for patients to be able to easily obtain tehm(sic) from a staff member."

A review of facility policy HR056 titled "Dress Code" revealed no mention of keys or how to properly carry them. The policy had been reviewed and/or revised in February 2021, 2 months after patient #1 eloped.

A review of facility training/orientation materials revealed only the following reference to keys was a statement in the safety officer's handout that stated:
"Key Check!! Show me your keys please!! You must have a red and yellow key on you at all times. Do not leave keys unattended at any time. Do not attach your keys to you(sic) badge. You must report lost or stolen keys immediately." No mention was made regarding wearing keys on a lanyard around the neck.

During a tour of the facility's 3 units on 6-27-22, direct-care staff #5 (Restore Unit) was noted to be wearing her keys on a lanyard around her neck.

Staff #4 (who accompanied the surveyor on the unit tour) confirmed these findings.

Based on a review of the clinical record, facility documentation and interviews with staff, the facility failed to protect the patient's right to be free from all forms of abuse or harassment.

Findings were:

Review of the clinical record for patient #4 revealed that the patient, a 56 year old female, was admitted to GOH on a voluntary basis on 8-21-21 at 10:45 pm. The patient had attempted suicide by overdosing on melatonin tablets. She was admitted with a primary diagnosis of major depressive disorder, recurrent, severe and without psychosis. She was placed on q 15 minute location and behavior checks as well as suicide precautions.

A nursing note written on 8-25-21 at 9:25 am stated "The patient [#4] reports she was assaulted in her room. May be delusional." There was no documentation in the clinical record to indicate that the nurse had reported the patient's outcry of abuse/assault. Staff #3 & #4 were asked to check the clinical record for any such documentation, but were unable to locate any.

Facility policy CS033 titled "Abuse/Neglect Victims" states, in part:
"Procedure:
...
In the event that abuse is suspected and/or validated, the reporting of Suspected Abuse is to occur. Social Services staff will report the suspected abuse as required by State Law ...The suspected abuse shall also be communicated to the attending psychiatrist and the treatment team."

Facility policy CS014 titled "Alleged Patient Abuse, Neglect and Exploitation" states, in part:
"Policy: It is the policy of Glen Oaks Hospital that all suspected abuse and neglect be reported in accordance with Texas law.

Procedure: The staff member receiving information regarding the possibility of abuse/neglect of a person meeting the above criteria shall:
-Any staff person having reason to believe that a child, adolescent, disabled adult, adult, or geriatric patient's physical health, mental health, or welfare has been affected by abuse or neglect shall immediately report this concern to the patient's physician and to the Director of Social Services. After determining that the report should be made, the 'outcry witness' (the staff person who was told about the abuse' should make a report to the appropriate authority.
...
Physical Assault Potential Criteria:
-patient reports physical assault to you or hints of physical abuse.
...
Rape or other Sexual Molestations Potential Criteria:
-reporting that one has been raped or molested."

The above was confirmed in an interview with the PI Director and Risk Manager on 6-29-22.