HospitalInspections.org

The hospital failed 1 of 1 Patient (Patient #2) the right to recieve care in a safe setting. The hospital failed to notifiy administration and insure patient safety to place any patient precautions or immediate changes in patient plan of care.

Findings Include:

The medical record revealed Patient #2 had a patient lay in his lap while outside and he exposed himself. The record also reveals that Patient #2 attempted to urinate while outside. The patient was removed, placed in a blocked room, but a phyisician was not notified by the hospital Nurse Supervisor after the incident occurred.

The medical record revealed that Patient #2's level of care was unchanged. The medical recorded revealed there was no change in the Patients treatment plan. The medical record revealed there were no new physician orders in regards to the patients level of care.

During the interview with hospital staff #3 it was verified that Patient #2 had a female patient laying her head in his lap outside seated on the bench. Patient #2 then exposed his genitals to the female patient. The Patients were immediately separated and Patient #2 was not placed on SAO Precautions (Sexually Acting Out). Staff #3 indicated that Patient #1 did not have any contact that the staff was made aware of. Staff #3 indicated that Patient #1 did not document or report any complaint or grievances during his hospital stay. Staff #3 was asked, Why didn't the hospital follow its own Policy in regards to this incident? What should have been done? Staff #3 indicated that the hospital found a separate room, but Patient #2 was already in a blocked room according to the hospital staff #1. Patient #2 was not placed on any precautions and the hospital staff did not know what was happening that night. The doctor nurse supervisor was notified but failed to notify the doctor.
Staff #3 was informed that there are no doctor's orders that address such behavior. There are no notes that reflect the patient was plan of care was changed or placed on any special precautions. The hospital failed to follow its own policy.

Policy
The hospital policy Patient's Bill of Rights dated 11/2017 reflected, "When you apply for or receive mental health services in the State of Texas, you have many rights ...These rights apply to all persons unless otherwise restricted by law or court order. A judge or lawyer will refer to the actual laws ...You have the right to appropriate treatment in the least restrictive appropriate setting available ...You have the right to receive treatment of any physical problems which affect your treatment ...You have to right to be told about ...all the medications and treatment you will receive ...You have the right not to be given medication you don't need or too much medication, including the right to refuse medication ...You have a the right to receive a list of the medications prescribed for you by your physician, including the name, dosage, and administration schedule within four hours of the facility."

The hospital Abuse Policy "Suspected Adult Abuse" dated 07/2019, reflected, to comply with local and state laws about mandated abuse reporting in order to ensure that patients are safe and free from mental, physical and verbal abuse, neglect and exploitation ... Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation. It tis the policy of this Facility to protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff members, student, volunteers, others patients, visitors or family members. This Facility mandates that, under the guidance of applicable 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 ...All allegations, observations or suspected cases of abuse that occur in the Facility will be investigated by the Facility."
3. Sexual Abuse
a. Sexual contact, sexual intercourse, sexual conduct, sexual penetration with a foreign object, incest, sexual
assault or sodomy inflicted on, shown to or intentionally practiced in the presence of a child or dependent
adult, if the child or dependent adult, is present only to arouse or gratify the sexual desires of any person.
b. Failure to make a reasonable effort to prevent sexual contact, sexual intercourse, sexual conduct, sexual assault
or sodomy inflicted on, shown to or intentionally practiced in the presence of a child or dependent adult, if the
child or dependent adult is present only to arouse or gratify the sexual desires of any person.
c. Compelling of encouraging the person to engage in sexual conduct.
d. Causing, permitting, encouraging or allowing the photographing, filming or depicting of the person knew or
should have known that the resulting photograph, film or depiction if obscene or pornographic.

8. The following criteria may be used to assist in the identification of abuse:
b. Rape/other forms of sexual abuse:
1. Involving the patient in any practice or scheme of conduct that may include sexual contact for the purposes of arousal of gratification of the offender.
2. Trauma to the penis, vulvar and/or anal region
3. Sexual manipulation of penis, vulvar and/or anal region with a foreign object.

The hospital Policy on Sexual Acting Out (SAO) dated 12/2019 reflexed "Sexual behavior of any kind is prohibited in the Facility. Reports of sexual acting out between patients will be investigated. All allegations or observations of sexual behavior will be investigated by the facility."

The hospital Policy on Falsification of Records "Records Retention and Destruction" dated, 08/2021 reflected, "The Policy & Procedure applies to Springstone Inc., its affiliated entities including Behavioral Health and Substance Abuse Facilities, as well as any and all of their agents, servants, employees, and contracted personnel, and to all records generated un the course of Springstone's, its subsidiaries and affiliates' operations, including both original document's and reproductions.

The hospital Policy on Administration and Personnel 'On-Call Policy' dated 07/19/2021. "To establish a process of notifying the Administrator on Call (AOC) of any significant issues or events at the hospital. These events may include, but are not limited to, staffing concerns, diversion, possible EMTALA events, law enforcement notification, significant complaints, significant risk issues, regulatory visits etc. An Administrator On Call is available by pager or telephone, 6:00PM - 6:00AM daily and 24 hours a day on Saturday and Sunday."

The hospital Incident Report Protocol & Patient Safety Events Policy dated 05/2021, reflected, "Our culture of safety promotes reporting of patient safety incidents to continuously improve patient safety and minimize and/or prevent the occurrence of errors, events and system breakdowns leading to harm to patients, staff, volunteers, visitors, and others through proactive risk management and patient safety activities. Patient Safety Incidents must be captured via the incident reporting system. If is the responsibility of all staff to report all patient safety incidents, accidents, or injuries involving patients or visitors and to report such occurrences using the Incident Reporting system along with notifying their supervisor immediately."

The hospital failed 1 of 1 Patient (Patient #2) by failing to ensure that the nursinging staff develops, and keeps current, a nursing care plan. The nursing care plan may be part of an interdisciplinary care plan. The hospital failed to notifiy administration and ensure any patient precautions or immediate changes in patient plan of care.

Findings Include:

The medical record revealed Patient #2 had a patient lay in his lap while outside and he exposed himself. The record also reveals that Patient #2 attempted to urinate while outside. The patient was removed, placed in a blocked room, but a phyisician was not notified by the hospital Nurse Supervisor after the incident occurred.

The medical record revealed that Patient #2's level of care was unchanged. The medical recorded revealed there was no change in the Patients treatment plan. The medical record revealed there were no new physician orders in regards to the patients level of care.

During the interview with hospital staff #3 it was verified that Patient #2 had a female patient laying her head in his lap outside seated on the bench. Patient #2 then exposed his genitals to the female patient. The Patients were immediately separated and Patient #2 was not placed on SAO Precautions (Sexually Acting Out). Staff #3 indicated that Patient #1 did not have any contact that the staff was made aware of. Staff #3 indicated that Patient #1 did not document or report any complaint or grievances during his hospital stay. Staff #3 was asked, Why didn't the hospital follow its own Policy in regards to this incident? What should have been done? Staff #3 indicated that the hospital found a separate room, but Patient #2 was already in a blocked room according to the hospital staff #1. Patient #2 was not placed on any precautions and the hospital staff did not know what was happening that night. The doctor nurse supervisor was notified but failed to notify the doctor.
Staff #3 was informed that there are no doctor's orders that address such behavior. There are no notes that reflect the patient was plan of care was changed or placed on any special precautions. The hospital failed to follow its own policy.

Policy
The hospital policy Patient's Bill of Rights dated 11/2017 reflected, "When you apply for or receive mental health services in the State of Texas, you have many rights ...These rights apply to all persons unless otherwise restricted by law or court order. A judge or lawyer will refer to the actual laws ...You have the right to appropriate treatment in the least restrictive appropriate setting available ...You have the right to receive treatment of any physical problems which affect your treatment ...You have to right to be told about ...all the medications and treatment you will receive ...You have the right not to be given medication you don't need or too much medication, including the right to refuse medication ...You have a the right to receive a list of the medications prescribed for you by your physician, including the name, dosage, and administration schedule within four hours of the facility."

The hospital Abuse Policy "Suspected Adult Abuse" dated 07/2019, reflected, to comply with local and state laws about mandated abuse reporting in order to ensure that patients are safe and free from mental, physical and verbal abuse, neglect and exploitation ... Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation. It tis the policy of this Facility to protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff members, student, volunteers, others patients, visitors or family members. This Facility mandates that, under the guidance of applicable 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 ...All allegations, observations or suspected cases of abuse that occur in the Facility will be investigated by the Facility."
3. Sexual Abuse
a. Sexual contact, sexual intercourse, sexual conduct, sexual penetration with a foreign object, incest, sexual
assault or sodomy inflicted on, shown to or intentionally practiced in the presence of a child or dependent
adult, if the child or dependent adult, is present only to arouse or gratify the sexual desires of any person.
b. Failure to make a reasonable effort to prevent sexual contact, sexual intercourse, sexual conduct, sexual assault
or sodomy inflicted on, shown to or intentionally practiced in the presence of a child or dependent adult, if the
child or dependent adult is present only to arouse or gratify the sexual desires of any person.
c. Compelling of encouraging the person to engage in sexual conduct.
d. Causing, permitting, encouraging or allowing the photographing, filming or depicting of the person knew or
should have known that the resulting photograph, film or depiction if obscene or pornographic.

8. The following criteria may be used to assist in the identification of abuse:
b. Rape/other forms of sexual abuse:
1. Involving the patient in any practice or scheme of conduct that may include sexual contact for the purposes of arousal of gratification of the offender.
2. Trauma to the penis, vulvar and/or anal region
3. Sexual manipulation of penis, vulvar and/or anal region with a foreign object.

The hospital Policy on Sexual Acting Out (SAO) dated 12/2019 reflexed "Sexual behavior of any kind is prohibited in the Facility. Reports of sexual acting out between patients will be investigated. All allegations or observations of sexual behavior will be investigated by the facility."

The hospital Policy on Falsification of Records "Records Retention and Destruction" dated, 08/2021 reflected, "The Policy & Procedure applies to Springstone Inc., its affiliated entities including Behavioral Health and Substance Abuse Facilities, as well as any and all of their agents, servants, employees, and contracted personnel, and to all records generated un the course of Springstone's, its subsidiaries and affiliates' operations, including both original document's and reproductions.

The hospital Policy on Administration and Personnel 'On-Call Policy' dated 07/19/2021. "To establish a process of notifying the Administrator on Call (AOC) of any significant issues or events at the hospital. These events may include, but are not limited to, staffing concerns, diversion, possible EMTALA events, law enforcement notification, significant complaints, significant risk issues, regulatory visits etc. An Administrator On Call is available by pager or telephone, 6:00PM - 6:00AM daily and 24 hours a day on Saturday and Sunday."

The hospital Incident Report Protocol & Patient Safety Events Policy dated 05/2021, reflected, "Our culture of safety promotes reporting of patient safety incidents to continuously improve patient safety and minimize and/or prevent the occurrence of errors, events and system breakdowns leading to harm to patients, staff, volunteers, visitors, and others through proactive risk management and patient safety activities. Patient Safety Incidents must be captured via the incident reporting system. If is the responsibility of all staff to report all patient safety incidents, accidents, or injuries involving patients or visitors and to report such occurrences using the Incident Reporting system along with notifying their supervisor immediately."