HospitalInspections.org

The hospital failed 2 of 2 Patients (Pateint#1 and Pateint #2) the right receive care in a safe setting.

Findings Include:

During video footage review, Staff #6 failed to monitor the hospital unit according to its own policy and procedure. Patient #2 entered into Patient #1 assigned room kissed and touched Patient #1 inappropriately.

During Interview with hospital Staff #6 it was reported that they were monitoring the unit to the hospital's Plan of Care. The video footage clearly revealed Staff #6 walk by the assigned room of Patient #1 with Patient #1 inside the room and the room door was closed. The hospital rule is when Patients are in their assigned rooms the room door should be open.

During Interview with hospital Staff #3 it was reported Patient #2 confirmed kissing Patient #1 and touching Patient #1's buttocks and private areas inappropriately.

During Interivew with hospital Staff #4 it was reported that we were aware of one incident involving Patient #1 but there were not two incidents involving sexual acting out.

Policy
The hospital policy Patient Rights dated 05/2021 reflected, "UHS recognizes a patient's right to request privacy protection for PHI, including a restriction of the uses or disclosures and/or a request to receive communications of PHI by an alternative means or at alternative locations. As described by and subject to the restrictions in this Policy, Facilities will permit and consider requests by patients or their representatives for the restriction of the uses and disclosures of their PHI to carry out treatment, payment, and operations, or to an individual involved in the patient's care, such as a family member, other relative, or a close personal friend of the patient, or any other person identified by the patient. Facilities will also accommodate reasonable requests by patients to receive communications of PHI at an alternative address or by an alternative means as described below."

The hospital Policy Neglect 04/17 reflected, "University Behavioral Health of Denton promotes respect, dignity, and safety to all its patients and their rights. Therefore, allegations of patient abuse or neglect will be investigated in accordance with the aforementioned law. Threats or restrictive actions in response to patient's request for discharge shall be considered abuse and are prohibited."

The hospital Policy on Abuse 04/17 reflected, "University Behavioral Health of Denton promotes respect, dignity, and safety to all its patients and their rights. Therefore, allegations of patient abuse or neglect will be investigated in accordance with the aforementioned law. Threats or restrictive actions in response to patient's request for discharge shall be considered abuse and are prohibited."

The hospital Policy on Pharmaceutical Services 09/2022 reflected, "it is the policy of University Behavioral Health= Denton to support each patient's right to be free from restraint seclusion and therefore limit the use of these interventions to emergencies in which there is an imminent risk of a patient physically harming him/herself or others. Restraints or seclusions may only be used when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm. The patient has the right to be from restraint/seclusion imposed as a means of coercion, punishment, discipline or retaliation by staff. Restraint/seclusion use will not be based on history of past use or dangerous behavior, as a convenience for staff, or a substitute for adequate staffing. The patients rights, dignity privacy, safety and well-being will be supported and maintained. Restraint or seclusion will be discontinued as soon as possible. Patients in restraints/ seclusion will be closely monitored and evaluated and immediately assisted if a potentially dangerous situation exists, i.e. chokings, seizures, etc. PRN orders may not be used t authorize the use of restraint or seclusions. This facility is committed to preventing, reducing and striving to eliminate the use of restraints and seclusion as well as preventing emergencies that have the potential to lead to the use of these inventions. Hospital leadership supports these effort through ongoing staff training and performance improvement activities."

The hospital Policy on Nursing Services dated 04/2017 reflected, "The delivery of nursing care at University Behavioral Health of Denton Shall be understood as the purposeful and perpetual application of diversified talents with the common goal of positively impacting the health status of those entrusted to our care. Therapeutic use of self shall be the central treatment modality with specialized cognitive experiential and managerial capabilities as the practice foundation."

The hospital Policy on Patient Observation Levels 10/2022 reflected, "Patient observations levels are defined as specific levels of staff awareness and attention to patient safety/security needs that require teh initiation of specific protocols and supplemental documetnation. It is the policy of University Behavioral Health of Denton (UBH-Denton) to provide a safe and secure environment for pateitns during their hospitalization. Clinical staff will assess the patietn's risk factors and the RN will notify the patietn's physician. All patients, regardless of the obsrervation level will have certain items removed such as belts, shoelaces, sharps, lighters, drawstrings, cords and other personal items that present a safety risk (Contraband Procedure Policy).

The hospital failed 2 of 2 patients (Patient #1 and Patient #2) to provide nursing care to all patietns as needed.

Findings Include

During interview Staff #3 revealed Staff #7 exited the unit leaving Staff #6 to monitor the unit. Staff #6 failed to properly monitor and observe each patient according to the hospital policy and procedures. Patient #2 entered Patient #1's assigned room and touched Patient #1 inappropriately and they engaged in kissing.

During record review Staff #6 signed the Patient #1's observation sheets as if Patietn #1 was properly being monitored.

Policy
The hospital policy Patient Rights dated 05/2021 reflected, "UHS recognizes a patient's right to request privacy protection for PHI, including a restriction of the uses or disclosures and/or a request to receive communications of PHI by an alternative means or at alternative locations. As described by and subject to the restrictions in this Policy, Facilities will permit and consider requests by patients or their representatives for the restriction of the uses and disclosures of their PHI to carry out treatment, payment, and operations, or to an individual involved in the patient's care, such as a family member, other relative, or a close personal friend of the patient, or any other person identified by the patient. Facilities will also accommodate reasonable requests by patients to receive communications of PHI at an alternative address or by an alternative means as described below."

The hospital Policy Neglect 04/17 reflected, "University Behavioral Health of Denton promotes respect, dignity, and safety to all its patients and their rights. Therefore, allegations of patient abuse or neglect will be investigated in accordance with the aforementioned law. Threats or restrictive actions in response to patient's request for discharge shall be considered abuse and are prohibited."

The hospital Policy on Abuse 04/17 reflected, "University Behavioral Health of Denton promotes respect, dignity, and safety to all its patients and their rights. Therefore, allegations of patient abuse or neglect will be investigated in accordance with the aforementioned law. Threats or restrictive actions in response to patient's request for discharge shall be considered abuse and are prohibited."

The hospital Policy on Pharmaceutical Services 09/2022 reflected, "it is the policy of University Behavioral Health= Denton to support each patient's right to be free from restraint seclusion and therefore limit the use of these interventions to emergencies in which there is an imminent risk of a patient physically harming him/herself or others. Restraints or seclusions may only be used when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm. The patient has the right to be from restraint/seclusion imposed as a means of coercion, punishment, discipline or retaliation by staff. Restraint/seclusion use will not be based on history of past use or dangerous behavior, as a convenience for staff, or a substitute for adequate staffing. The patients rights, dignity privacy, safety and well-being will be supported and maintained. Restraint or seclusion will be discontinued as soon as possible. Patients in restraints/ seclusion will be closely monitored and evaluated and immediately assisted if a potentially dangerous situation exists, i.e. chokings, seizures, etc. PRN orders may not be used t authorize the use of restraint or seclusions. This facility is committed to preventing, reducing and striving to eliminate the use of restraints and seclusion as well as preventing emergencies that have the potential to lead to the use of these inventions. Hospital leadership supports these effort through ongoing staff training and performance improvement activities."

The hospital Policy on Nursing Services dated 04/2017 reflected, "The delivery of nursing care at University Behavioral Health of Denton Shall be understood as the purposeful and perpetual application of diversified talents with the common goal of positively impacting the health status of those entrusted to our care. Therapeutic use of self shall be the central treatment modality with specialized cognitive experiential and managerial capabilities as the practice foundation."

The hospital Policy on Patient Observation Levels 10/2022 reflected, "Patient observations levels are defined as specific levels of staff awareness and attention to patient safety/security needs that require teh initiation of specific protocols and supplemental documetnation. It is the policy of University Behavioral Health of Denton (UBH-Denton) to provide a safe and secure environment for pateitns during their hospitalization. Clinical staff will assess the patietn's risk factors and the RN will notify the patietn's physician. All patients, regardless of the obsrervation level will have certain items removed such as belts, shoelaces, sharps, lighters, drawstrings, cords and other personal items that present a safety risk (Contraband Procedure Policy).