HospitalInspections.org

Based on observation, interview, and document review, the facility failed to:

a. secure patient access to a weighted object that was used as a weapon and resulted in injuries to three staff members.

b. ensure the right to safety for patients and staff in the intake/admission area resulting in a patient assault of staff causing head lacerations to 3 of 3 admission/intake employees (#'s 11, 12 and 13).

Cross reference tag A 144.

The deficient practices identified under the following Condition of Participation, CFR 482.13 Patient Rights, were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Based on observation, interview, and document review, the facility failed to:

a. secure patient access to a weighted object that was used as a weapon and resulted in injuries to three staff members.

b. ensure the right to safety for patients and staff in the intake/admission area resulting in a patient assault of staff causing head lacerations to 3 of 3 admission/intake employees (#'s 11, 12 and 13).

Findings included

Observation 07/27/23 at 12:10 pm showed multiple unit staff begin running toward the intake area during a Code Green (patient behavioral emergency) announcement on facility PA system being called. As the door opened to the intake hallway female screams could be heard. Observation showed multiple blood streaks on the Intake hallway floor. Patient #Q was sitting in an intake room talking with pressured speech about what he hated and had to do. "She shouldn't be in here." There were two male Mental Health Technicians (MHTs) in the intake room with him and blocking the door to the hallway to keep him inside.

During an interview at 07/27/23 12:15 pm employee #1, CEO stated patient #Q assaulted three female staff with the pliers used to fasten patient identification bands. He stated he heard staff scream and came out into the hall. Employee #13 was on the floor of the hall with patient #Q hitting employee #13 on the head area with pliers. He stated, and demonstrated, the patient swinging his arms in a circular motion to hit the employee. He added that when he approached the patient with male staff and instructed the patient to stop, patient #Q stopped. Employee #1 said patient #Q told him he "attacked because he doesn't like women."

Employee #12 Intake Director entered the intake hallway at 12:20 pm. During an interview at 07/27/23 12:23 pm employee #12, stated she heard the yelling and came out of her office, which is just around the corner, to see what was causing it. She saw patient #Q assaulting employee #T. When the patient saw her, he turned and struck her causing a cut on her left eye. She immediately withdrew to her office for safety and was not followed by the patient. Employee #12 had a triangular cut approximately 0.5 inches in length just above the corner of her left eye on the upper occipital orbit (bone). She also had several small abrasions on her left cheek area.

Employee #11 Intake Coordinator was seated in the intake room across the hall from the intake room with patient #Q. She was tremulous and an unidentified staff was taking her vitals. When interviewed 07/27/23 at 12:25 pm Employee #11 stated "He hit my head." Employee #11 went on to say she was in the intake room with patient #Q when he took pliers off the intake table and began to hit the two lone female staff in the room with the pliers. She stated he was aiming at their heads. She was gently touching the upper left side of her head. No open areas were noted. A swollen area of approximately 2 x 1 x 0.5 inches high was observed. Her scalp was not visible due to sewn in hair. Employee #11 was transported via facility van to a local emergency room at approximately 13:40 pm.

Employee #13 Intake Registered Nurse (RN) was seated and slumped, on a hallway floor adjacent to the intake room that held patient #Q. Three unidentified staff and Employee #15 Quality Director were photographing wounds, wiping blood off her and the surrounding area, applying pressure to an open laceration on her scalp and cleaning blood on her and the surrounding area. Employee #13 had a deep curved laceration approximately 1.5 inches long and a laceration and abrasion in her hairline, left side between her temple and ear.

In an interview 07/27/23 at 12:45 pm Employee #13 stated "He hit me. It was so fast. I tried to get away, but he was on me." When asked what she was hit with she said, "the pliers." Employee #13 did not move from the floor until an ambulance arrived at approximately 1:20 pm.

After the episode patient #Q remained in the intake room with two unidentified male employees. He had several verbally aggressive outbursts with cursing and threats. He stood up quickly and was observed to have a thin muscular build. He remained in the intake room with the two unidentified male employees until Harris County Sheriff deputies arrived at and took him in handcuffs to jail at approximately 3:45 pm.

Policy:
1. Admission and Continued Stay PC-01 Revised 06/01/21

Scope: This policy applies to all Oceans Healthcare facilities.

Purpose: To establish criteria to be used to determine appropriateness for admission and continued stay in least restrictive level of care.

Procedure:
Cannot exhibit violence to the extent it cannot be managed by therapeutic modalities in this setting, and it poses an immediate threat to other patients.

Level of Care Determination: Symptoms and behaviors indicative of the need for services.

Exclusion Criteria: All programs:

Primary Diagnoses is Intellectual Developmental Disability
Moderate to Severe Intellectual Developmental Disability
Has medical devices that would conflict with or prevent therapeutic goals
Acute/Critical medical/surgical status deemed by physician to be medically unstable
Continuous IV
Continuous Feeding Tube
*Unmanageable violence
ETOH level 200 or more, or as deemed by physician
Airborne Illness

Patient #Q's form "Application for Emergency Detention" dated 07/26/23 and completed by Employee # 20, Community Liaison, lists substantial risk of harm to himself or others as: Combative, agitated, aggressive, boxing at others, property aggressive and hallucinating.


Based on observation, record review and interviews the facility failed to ensure the effective implementation of policies and procedures that promoted care in a safe setting for 5 of 19 patients (#L, M, N, O & P) on the men's unit. Specifically, the facility failed to ensure that Staff #8 LVN and Staff #9 Mental Health Technician (MHT's) were able to locate all 19 patients they had been entrusted to conduct rounds on. This resulted in failure to document rounds for four hours and 15-minute from 9:15 am through 11:15 am (two hours) am for patients # L, M, N, O & P.

The findings include:

POLICY: "Level of Observations" CS-23 Revised 03/01/23

Procedure:

Every 15 Minute Observation:

RN assigns staff members to Q-15-minute observations.
Assigned Nursing Staff (Mental Health Technicians/MHT) preforms:

Visually observes the patient every 15 minutes to monitor their location and activity
Physically walks to find each patient on Q 15-minute observation
Documents patient's location and reports risk to registered nurse (RN) when indicated
Initials the form every 15 minutes.
Notifies the Charge nurse immediately of any patient who cannot be observed or located.

During an initial unit tour 07/26/23 at 11:05 am the men's side of the
dayroom was entered by one surveyor and employee (#1), the Chief Nursing Officer. There were eleven men present with one unlicensed Technician (Tech #9) sitting at a table, next to the patient rounds board in front of her. The men were sleeping and lounging in the dayroom.

Tech #9 was asked for every 15-minute rounds sheets to review. There were nineteen rounds' sheets. Five round sheets were blank from 09:15 am to 11:15 am (2 hours). When interviewed 07/26/21 at 11:05 am. Employee #9 was asked who was missing. Employee #9 counted the sheets and responded, "they're around here" but could not point them out nor did she get up to check. She stated she was helping and normally did not do rounds. She stated nineteen patients was too much for her to keep up with and Employee #4 LVN, was going to "fill them in when she got a chance."

When interviewed 7/26/23 at 1:25 pm hrs Employee #8 stated she "did rounds this morning by seeing the patients and telling Employee #9 where they were. When asked if this is how rounds are to be done Employee #8 respond it was not, but it was the best that could be done when she also needed to assist patients.

When interviewed 07/26/21 at 2:45 pm employee #1, CNO confirmed round sheets for patients (#L, M, N, O & P) were blank for 7/26/23 from 09:15 am through 11:15 am.