HospitalInspections.org

Based on record reviews and interviews, the facility failed to ensure that patients are free from all forms of abuse for 1 of 1 patient (patient #1). The facility failed to:

-Ensure that patients were protected from on-going physical abuse by removing the alleged perpetrator from patient contact.

-Ensure facility staff followed facility policy and procedure in reporting physical abuse of a patient.

-Ensure nursing staff documented reports of alleged abuse and conducted an immediate physical assessment of the patient after the abuse was made known.

This deficient practice placed all patients in the facility at risk for experiencing serious harm and/or injury due to abuse.

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Patient Rights.

Refer to A0145 for evidence of findings.

Based on record reviews and interviews, the facility failed to ensure that patients are free from all forms of abuse for 1 of 1 patient (patient #1). The facility failed to:

-Ensure that patients were protected from on-going physical abuse by removing the alleged perpetrator from patient contact.

-Ensure facility staff followed facility policy and procedure in reporting physical abuse of a patient.

-Ensure nursing staff documented reports of alleged abuse and conducted an immediate physical assessment of the patient after the abuse was made known.

This deficient practice placed all patients in the facility at risk for experiencing serious harm and/or injury due to abuse.

Findings include:

Record review of the medical record for Patient #1 revealed that he was a 25-year-old male with diagnosis of: Anxiety, depression, Bipolar disorder, Post Traumatic Stress Disorder (PTSD) and Substance Use Disorder . Further review revealed that Patient#1 was brought in by police for Suicidal Ideation (SI) with a plan to walk into traffic or use a sharp object to cut himself. Patient #1 was also being monitored by a non-recorded and un-manned video camera at the nurse's station.

Record review of the facility Incident Report Records, dated 07/13/22 at 1841 revealed the following information:
-On 07/12/22 at 2246 Security Officer's (SO) #1 and SO#2 were dispatched to behavioral health to discharge patient#1.

-OS#1 made initial contact and informed patient#1 that he was being discharged. Shortly after this interaction, SO#2 entered patient #1's room with his discharge paperwork and further explained to him that he was being discharged to the hospital.

- Patient# 1 took on an agitated tone and after signing his discharge paperwork, began to implement stall tactics to prolong his stay. Patient#1 kept staying he was "tired and didn't want to leave."

- After about five minutes of this, SO#1 attempted to decline the chair. This prompted the chair to move away. Patient #1 continued to refuse to get up and placed his full weight against the chair; this prompted SO#1 that he was going to assist him to get up off the chair. When officers placed their hands on patient #1, he began to resist and fight back initially prompting both SO to reach back and grab him at which point patient #1reach back and grab him at which point patient #1 began to resist and fight back by kicking at SO#1. SO#1 attempted to control patient #1 legs and torso, at which point patient began to pull SO#1 in towards him. SO#1 escalated his use of force to break patient #1's grip by administering elbow strikes onto patient #1's arms and elbows.

Visual Review (No audio or time stamps) of the security video log for the Emergency Room, dated 07/12/22 to 07/13/22, between the hours of 10:00 pm and 12:00 am revealed the following:
- Patient #1 is seen sitting in a reclined geri-chair with a blanket covering his body. His body language is calm and non- threatening (he appears to be trying to sleep.) SO#1 is seen standing at the foot of the geri-chair holding paperwork.

- Patient #1 is still sitting quietly reclined in geri-chair covered with blanket. SO#1 is observed to use his foot to kick the elevated foot rest of patient#1's geri-chair. Patient #1 appears to have a startled response.

- SO#1 is then observed to throw paperwork on the floor and aggressively jump at patient #1, who is still reclining and laying in geri-chair (Patient #1 is not moving). SO#1 starts to punch patient #1 in the face and head repeatedly using closed fisted punches.

- Patient #1 starts to struggle and use his legs to kick and push SO#1 away. SO#2 attempts to restrain him. SO#1 is still striking patient #1 about the face and body. SO#2 is now striking patient #1 as well while still trying to restrain patient #1. Patient is still struggling to get away.

- Two Certified Nurses Aides (CNA) enter the room briefly and see the SO's struggling to restrain patient. They leave and are seen in camera #2 (hallway) to push the emergency button to alert nursing staff.

- Physician's assistant (PA) now arrives in room briefly. Patient #1 is still grappling with SO#1 and SO#2, (but striking has now stopped). PA looks around the room, picks up an object up off the floor, and leaves.

- SO#1 and SO#2 pick patient #1 up out of the geri- chair and walk him to the bathroom in the hallway.

- Patient #1 is escorted out of the hospital by SO#1 and SO#2 through the side street exit.


Record review of the ER record, dated 07/12/22 from 1500 to 2248 revealed the following:
Medical Decision Making:
- (Physician Discharge note) Patient #1 is clinically sober, appropriate, cooperative, and has agreed to an outpatient safety plan with resources given by behavioral health team who agrees he is safe for discharge.

-Further review revealed no evidence that Patient#1's physician was notified of the witnessed physical abuse of patient #1 that occurred on 07/12/22 and/ or that patient #1 was assessed by nursing staff for injury prior to discharge.

Record review of the facility employment records for Security Officer #1 (Perpetrator) revealed that he was still employed by the facility until 07/31/22 (and in contact with patients), until he voluntarily gave notice to terminate employment.

Record review of the facility employment records for Security Officer #2 (Perpetrator) revealed that he was still employed by the facility, and in contact with patients, as of the survey entry date (08/08/22).

Review of the facility adverse event documentation dated 07/12/22 to 8/11/22 revealed no evidence that facility staff reported the abuse to the Department of Health and Human Services.

Record review of the facility policy entitled: REPORTING OF ALLEGATIONS OF PATIENT NEGLECT OR PHYSICAL OR SEXUAL ABUSE OR ASSAULT, reviewed 07/ 08/2020, revealed the following information:

II. PURPOSE:
The purpose of this policy is to ensure the safety of any individual in a Facility and to ensure that the Administrator on Call immediately and effectively reports allegations of sexual or physical abuse, neglect or assault to the appropriate authorities and within the Company. This policy is intended to cover the reporting of allegations that could involve potential criminal conduct.

A. "Immediate" means at the time of witnessing conduct or receiving an allegation of conduct that is the subject of this policy. The requirements in this policy for "immediate notification" apply even if the incident occurs after hours and/or on weekends and holidays.

B. "Abuse" means any intentional action which harms another person. Abuse includes physical or sexual abuse.

IV. POLICY:
All individuals in Tenet Facilities, including patients, family members of patients, visitors, and employees and contractors have the right to be free of abuse, neglect and assault. The Administrator on Call (AOC) or designee of each Facility is responsible for immediately responding to allegations of abuse, neglect or assault occurring in the Facility so that the appropriate investigation of alleged criminal or other inappropriate conduct may be conducted in accordance with this Policy. The AOC's designee must be a senior-level or similar position with facility-wide responsibilities, such as a house supervisor, patient safety officer, or assistant Chief Nursing Officer, etc. All Facilities are responsible for immediately implementing measures
to protect any individual impacted by such conduct and for taking immediate and effective corrective action in response to such allegations.

V. PROCEDURE:

A.) Facility Implementation
-Response to Witnessing or Receipt of Allegation of Abuse Any employee or member of the Facility Medical Staff who witnesses or receives an allegation of sexual or, physical abuse, neglect or assault of any patient, or of any other individual in the Facility must immediately ensure the safety of that individual and must immediately make contact with the Facility AOC or designee. The Facility AOC or designee must verify the safety of the individual. The Facility AOC or designee shall immediately (within 24 hours) report the event to the local police department and/or other appropriate authorities (i.e., child services, adult social services, etc.) and send the Facility Operations Counsel an email about the allegation. If a competent adult complainant does not want the allegation reported to law enforcement, the Facility AOC or designee is not required to report the allegation to law enforcement but shall immediately (within 24 hours) report the incident by email to the Facility's Operations Counsel. (Additionally, the Facility AOC or designee may contact Facility Operations Counsel at any time for immediate advice using their office lines or mobile phones during normal business hours, or by utilizing the Abuse Hotline at (214) 458-0812 after hours and on weekends.

2.) Reporting Conduct to Operations Counsel directly or through Abuse Hotline
-All allegations under this Policy must be reported to Operations Counsel or to the Abuse Hotline immediately (within 24 hours) even if the Facility AOC or designee believes upon initial investigation that the allegation is unsubstantiated. Operations Counsel will direct all further actions in response to the event. Operations Counsel will advise on reporting to authorities, including law enforcement, state licensing agencies, and other agencies as appropriate or required by Federal, state or local law or regulation unless it appears that allegations are, beyond a reasonable doubt, factually unsubstantiated. Operations Counsel will also advise whether circumstances necessitate removal of personnel who are alleged to have engaged in the abusive behavior. Operations Counsel may be contacted directly using their office lines or mobile phones during normal business hours, or by utilizing the Abuse Hotline at (214) 458-0812 after hours and on weekends.

3.) Notifying Facility Leaders
-After the Facility AOC or designee notifies Operations Counsel of the allegation, the AOC or designee must also immediately notify the Facility's Compliance Officer, Patient Safety Officer, Human Resources Leader, Communications Officer and appropriate A-Team members, as appropriate depending upon the circumstances, regarding the incident. If the designee is making the notifications, the designee must notify the AOC. Notification must occur within 24 hours of notifying Operations Counsel.

5.) Investigating Allegations
-All internal reviews will be directed by Operations Counsel and, if appropriate, Employment Counsel. Before conducting interviews that are required to complete the root cause analysis indicated by the Sentinel Event Response and Reporting Policy, the Tenet Facility must coordinate with Operations Counsel to ensure that interviews do not conflict with interviews that may need to be conducted by local law enforcement. In responding to allegations of abuse, assault or neglect made by a patient, the Tenet Facility also is required to follow the Clinical Operations policy CO-2.004 Complaints and Grievances. During the investigation, past event reports may be consulted to determine whether allegations against the same individual have been reported previously.

6.) Documentation
-The Compliance Officer, Patient Safety Officer and/or Human Resources Director are each responsible, as appropriate under the circumstances, for maintaining complete documentation of all allegations of abuse, neglect or assault; the specifics of the allegations made; the specific steps taken by law enforcement and/or other appropriate authorities and the Facility to review the allegations; and the results of the review including the results of any review by law enforcement or other external agency. Documentation will be made in the Facility's appropriate documentation system and maintained according to administrative policy AD 1.11 Records Management and its Record Retention Schedule.


In an interview conducted on 08/08/22 at 11:45 am, the facility Security Director stated that he was made aware of the incident involving both Security officers (SO#1 and SO#2) striking patient #1 in the ER on 07/12/22. He further stated that it had been reported to him by the security officers themselves, and that they (the officers) had given him a written attestation of the events that had occurred. Surveyor asked Security Director if there was video tape of the incident from the ER security cameras. The Security Director stated, "Yes." Surveyor asked if he had viewed the video evidence in question, and the director confirmed that he had. The Security Director was asked to view the video with the surveyor again. After viewing the video evidence, The Security Director was asked by surveyor if an investigation had been conducted, and if so, what was the outcome. The Director stated that he had conducted an investigation regarding the incident and found that the officers had: "When the patient continued to refuse, light force was used to assist the patient up when it escalated by the patient resisting." Surveyor asked the Security Director to clarify if security staff had been given training in the use of non- violent interventional means to de-escalate mental health patients. He stated they had. Surveyor then asked if striking a patient was part of that training. The Director stated "No." He was then asked if the incident had been reported to the Department of Health and Human Services, he stated, "No, I have not."

In an interview conducted on 08/08/22 at 1:10 pm with the Director of Regulatory Compliance revealed that she was not aware of the incident of alleged abuse that had occurred involving SO's #1 and #2 striking Patient#1 in the ER on 07/12/22. She further stated that this was her first time viewing the recorded video evidence of the incident and confirmed that incident did in fact meet the facility's ANE policy Criteria for Abuse of a patient.

In an interview conducted on 08/08/22 at 2:05 pm, the Patient Safety Officer confirmed that she was aware of the allegation of abuse regarding patient #1 by Security Officers #1 and #2. She was asked by the surveyor if she had viewed the video evidence from the ER security cameras prior to survey entrance (07/08/22). She stated "Yes" and that the Security Director was handling the investigation. Surveyor then asked the Patient Safety Officer why neither Security Officers (SO#1 or SO#2) (perpetrators) were not removed from contact with patients for the duration of the investigation (and their employment). She stated that the staff were not removed because the Security Director had performed the investigation. When asked by the surveyor if the incident of abuse was called in to the Texas Department of Health and Human Services (HHSC), the Patient Safety Officer stated that they had not reported the incident yet because she thought it was still being investigated and they had "so many days to report it to HHSC."

Based on record reviews and interviews, the facility failed to ensure organized nursing services were provided in accordance with the needs of patients for 1 of 1 patients (#1) admitted to the facility. The facility failed to:

-Ensure Patient #1 received a specialized discharge and treatment planning from the registered nurse upon discharge, and

-Ensure Patient #1 recieved appropriate supervision from nursing staff during his admission to the Emergency Room for psychiatric treatment.

-Ensure Patient #1 was assessed and treatmented for potential injuries after being subjected to physical abuse within the facility prior to discharge.

As a result, Patient #1 was subjected to physical abuse by facility staff, and was discharged from the facility without being assessed for injury, receiving any treatment for potential injuries, and/or receiving any discharge instructions from nursing staff.


The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Nursing Services.


Refer to tag : A 0392.

Based on record reviews and interviews, the facility failed to ensure organized nursing services were provided in accordance with the needs of patients for 1 of 1 patients (#1) admitted to the facility. The facility failed to:

-Ensure Patient #1 received a specialized discharge and treatment planning from the registered nurse upon discharge, and

- Ensure Patient #1 recieved appropriate supervision from nursing staff during his admission to the Emergency Room for psychiatric treatment.

-Ensure Patient #1 was assessed and treatmented for potential injuries after being subjected to physical abuse within the facility prior to discharge.

As a result, Patient #1 was subjected to physical abuse by facility staff, and was discharged from the facility without being assessed for injury, receiving any treatment for potential injuries, and/or receiving any discharge instructions from nursing staff.

Findings include:

Observations conducted on 08/10/2022 from 09:30 am to 12:00 pm in the Emergency Room revealed the following:

-No nursing staff were present at the nurse's station. an un-manned video monitor was present which allowed visibility into the psychiatric unit of the Emergency Department (not visible from nurse's station) (Behind a solid wall).

- Surveyor entered the Psychiatric unit (fishbowl). Two Certified Nurse's Aides (CNA) were present, providing care to a psychiatric patient. No RN staff were present. The unit consisted of 6 single patient rooms equipped with only a geri-chair. According to the CNA's, the unit can hold a total of 8 patient if needed (using hallway space).

- Surveyor interviewed CNA's and asked if RN's are available to provide patient support/ care when needed. Both CNA staff responded that RN staff would come, but that the nurses "Real busy and we don't want to bother them if we don't have to."

- Surveyor exited the Psychiatric area (fishbowl), no nursing staff were observed to be viewing the psychiatric area monitor.

- Continued observations of the Emergency department revealed that it was a 27-bed unit which was large and split into multiple different areas of the facility's 1st floor. Making it difficult for nursing staff to navigate multiple patient assignments and/or communicate in the event of an adverse event.

Record review of the medical record for Patient #1 revealed that he was a 25-year-old male with diagnosis of: Anxiety, depression, Bipolar disorder, Post Traumatic Stress Disorder (PTSD) and Substance Use Disorder . Further review revealed that Patient#1 was brought in by police for Suicidal Ideation (SI) with a plan to walk into traffic or use a sharp object to cut himself. Patient #1 was also being monitored by a non-recorded and un-manned video camera at the nurse's station.

Record review of the facility Incident Report Records, dated 07/13/22 at 1841 revealed the following information:

-On 07/12/22 at 2246 Security Officer's (SO) #1 and SO#2 were dispatched to behavioral health to discharge patient#1.

-OS#1 made initial contact and informed patient#1 that he was being discharged. Shortly after this interaction, SO#2 entered patient #1's room with his discharge paperwork and further explained to him that he was being discharged to the hospital.

- Patient# 1 took on an agitated tone and after signing his discharge paperwork, began to implement stall tactics to prolong his stay. Patient#1 kept staying he was "tired and didn't want to leave."

- After about five minutes of this, SO#1 attempted to decline the chair. This prompted the chair to move away. Patient #1 continued to refuse to get up and placed his full weight against the chair; this prompted SO#1 that he was going to assist him to get up off the chair. When officers placed their hands on patient #1, he began to resist and fight back initially prompting both SO to reach back and grab him at which point patient #1reach back and grab him at which point patient #1 began to resist and fight back by kicking at SO#1. SO#1 attempted to control patient #1 legs and torso, at which point patient began to pull SO#1 in towards him. SO#1 escalated his use of force to break patient #1's grip by administering elbow strikes onto patient #1's arms and elbows.

Visual Review (No audio or time stamps) of the security video log for the Emergency Room, dated 07/12/22 to 07/13/22, between the hours of 10:00 pm and 12:00 am revealed the following:

- Patient #1 is seen sitting in a reclined geri-chair with a blanket covering his body. His body language is calm and non- threatening (he appears to be trying to sleep.) SO#1 is seen standing at the foot of the geri-chair holding paperwork.

- Patient #1 is still sitting quietly reclined in geri-chair covered with blanket. SO#1 is observed to use his foot to kick the elevated foot rest of patient#1's geri-chair. Patient #1 appears to have a startled response.

- SO#1 is then observed to throw paperwork on the floor and aggressively jump at patient #1, who is still reclining and laying in geri-chair (Patient #1 is not moving). SO#1 starts to punch patient #1 in the face and head repeatedly using closed fisted punches.

- Patient #1 starts to struggle and use his legs to kick and push SO#1 away. SO#2 attempts to restrain him. SO#1 is still striking patient #1 about the face and body. SO#2 is now striking patient #1 as well while still trying to restrain patient #1. Patient is still struggling to get away.

- Two Certified Nurses Aides (CNA) enter the room briefly and see the SO's struggling to restrain patient. They leave and are seen in camera #2 (hallway) to push the emergency button to alert nursing staff.

- Physician's assistant (PA) now arrives in room briefly. Patient #1 is still grappling with SO#1 and SO#2, (but striking has now stopped). PA looks around the room, picks up an object up off the floor, and leaves.

- SO#1 and SO#2 pick patient #1 up out of the geri- chair and walk him to the bathroom in the hallway.

- Patient #1 is escorted out of the hospital by SO#1 and SO#2 through the side street exit.

At no time during the video observation did surveyor observe facility RN staff enter the psychiatric holding area within the Emergency Room, even though CNA's pressed the emergency call button.


Record review of the ER record, dated 07/12/22 from 1500 to 2248 revealed the following:
Medical Decision Making:

- (Physician Discharge note) Patient #1 is clinically sober, appropriate, cooperative, and has agreed to an outpatient safety plan with resources given by behavioral health team who agrees he is safe for discharge.

-Further review revealed no evidence that Patient#1's physician was notified of the witnessed physical abuse of patient #1 that occurred on 07/12/22 and/ or that patient #1 was assessed by nursing staff for injury prior to discharge.

In an interview conducted on 08/11/22 at 11:00 am the facility Administrator/ Director of ER and ICU revealed that the ER charge nurse is responsible for running the ER log, staffing and intake (charge responsibilities) for the 27 bed ER as well as taking care of the patients in the "fishbowl" (ER Psychiatric Unit). When asked about the average length of nursing experience of the nurses staffing the ER, she stated that the Charge nurse on duty the night the incident occurred (07/12/22) only had 3 years of nursing experience total, and that this was the normal. She further stated that she had routinely expressed her concerns about staffing to upper nursing management but was told that there was nothing they could do about it.

Record review of the facility daily nurse staffing sheets for the Emergency Room revealed the following:
-07/11/22 to 07/12/22: (7pm-7am) 3 RN's (including charge nurse), 0 LVN's (Licensed Vocational Nurses), 1 CNA's.
-08/10/22: (7am-7pm) (day of observation) 4 RN's (including charge nurse), 0 LVN's, 2 CNS's.

Record review of the facility Emergency Room activity Log dated 07/12/2022, from 12:00 am to 11:59 pm, revealed at Emergency Room nursing staff treated a total of 117 patients.

Record review of the facility Employment record for RN#1 ( Acting Charge Nurse on 07/12/22) revealed that she was initally licensed as a Registered Nurse in June 2018.


Record review of the facility policy entitled: Constant Observer Assessment, Implementation, and Discontinuation for Patients Under Harm Precautions, Policy# RM-PS-20, revision date 01/2020, revealed the following:

II. PURPOSE
The purpose of this policy is to outline the process for the use of Constant Observers for patients at risk for suicide, harm to self or others (i.e. suicidal or violent patients), including patient assessment, ordering and initiation, staffing, implementation, discontinuation and monitoring/tracking of Constant Observers.

III. DEFINITIONS
A. "Competent Constant Observer" (CCO) means an individual who has successfully completed a facility-based competency assessment related to core elements required to monitor a patient under suicide/self-harm and harm to others precautions (see attachments).
B. "Tier One Constant Observers" are able to observe patients who are not suicidal or violent/combative such as high fall risk patients, cognitively impaired patients, etc. These constant observers are staff who have completed BLS and Constant Observer Competency Training.
C. "Tier Two Constant Observers" are required for patients that are suicide/self-harm risk, violent, homicidal, on Emergency Detention, or are in Violent Restraints. These Constant Observers are staff who have completed BLS, Constant Observer Competency Training, Non-Violent Crisis Intervention Training. Tier Two Constant Observers are also competent to provide observation for the types of patients observed by Tier One Constant Observers.
D. "One to One Observation" means one CCO to one patient within line of sight, in close proximity with no physical barriers in the same room/area unless there exists a risk to the constant observer.
E. "Close Observation" means one CCO to one or more patients in the same room/area.
F. "Line of Sight Observation" means one CCO in direct line of sight with one or more patients.
G. "Qualified Mental Health Professional" (QMHP) means an individual in the human services field who is trained and experienced in providing psychiatric or mental health services to individuals who have a mental illness. For BHS, this includes the Baptist Assessment Team (BAT).
H. "Qualified Medical Provider" (QMP) means a provider set forth in medical staff bylaws, rules and regulations, or policies that are approved by the governing body to complete the medical screening exam to determine if an emergency medical condition exists.

IV. POLICY

The Hospital recognizes that Constant Observers will be utilized in order to provide continuous observation of patients under suicide/self-harm and harm-to-others precautions to support safety. The Hospital will use a clinical assessment approach to determine clinically based assignment and implementation. The Hospital will have a process in place to monitor constant observer usage to ensure appropriate assignment and management of resources.

A. If an assessment reveals that a patient is a danger to self and/or others a constant observer will be implemented immediately. A constant observer at the bedside takes priority.
B. Family members may not be utilized as Constant Observers and are not to substitute for staff members. The Hospital retains responsibility for care of the patient.
C. BHS Policy RM-PS-21 Suicide Risk Assessment will be followed for all self-harm patients meeting criteria. The medical screening examination will determine the level of level of constant observation.

C. Implementation of Constant Observer

The nurse assigned to the patient remains responsible for the nursing care throughout the shift regardless of the presence of a Constant Observer.