HospitalInspections.org

The hospital failed the 2 of 2 Patients (Patients 1 and 2) the right to care in a safe setting

Findings Include

During interivew with hospital Staff #5 reported while she was working on the unit she was asked to cover visitation. At the time of visitation Staff #5 reported failing to follow the hospital Policy and Procedure. Staff #5 first indicated not verifying who each visitor was with the visitation sheet and government issued identification card. Staff #5 then indicated she did not identify each patient by their assigned identification number when approval of the families to enter the floor for visitation. Staff #5 stated she then left the hallyway door open after escorting the visitors to the visitation room assuming that the Staff #8 would be securing the door. Shortly after being seated in the visitation room a hospital 'Code' on the patient unit and Staff #5 left the visitation room leaving it unsupervised. Staff #5 reported being gone 2-3 minutes and upon her return Patient #1 and the Step-father had eloped from the facility.

During interview with hospital Staff #1 it was reported that Patient #1 was already scheduled for discharge, and paperwork had already been filled out by the hospital. During this day the communication had stopped and was not translated to the family. Staff #1 reported Patient #1 was going to be discharge during the day regardless. Staff #1 did agree that Staff #5 was recently transferred from orientation to the floor. Staff #1 reported Staff #5 was properly trained in all aspects of supervision of visitation. Staff #1 indicated that Staff #5 had to have forgotten not to leave visitors unsupervised in the hospital as well as patients. Staff #1 reported on 10/03/2022 all staff were retrained on visitation policy and procedures.

During Record review the hospital the hospital Nursing Progress Notes revealed Patient #3 entering Patient #2 room and kissed Patient #2 to wake up.

During Record review the hospital completed doucmentation (Incident Report) that reflected Patient #3 informed hospital Staff #14 that Patient #3 approached and informed Staff #14 of being in fear that peers were not going like Patient #3. Due to behaviors previous in the morning or that they would find out.


Policy
The hospital Policy on Patient Rights The hospital Policy on Patient Rights reflected,
1. Patients may not be denied appropriate hospital care because of the patient's race creed, color, national origin, religion, sex, sexual orientation, martial status, age , disability, or source of payment.
2. Patients shall be treated with consideration, respect and recognition of their individuality, including the need for privacy in treatment.
3. The individual patient's medical record, including all computerized medical information, shall be kept confidential in accordance with applicable federal state and local laws.

The hospital Policy on Nursing Assessment/Reassessment dated 02/2022 reflected, "Patients admitted to hospital will receive thorough assessment and evaluation. Results of assessments are reviewed by multidisciplinary team to prioritize problems in Treatment Plan."

The hospital Policy on Abuse/Neglect dated 12/2020 reflected, "Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation ...this hospital to protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff members, students, volunteers, other patients, visitors or family members. The hospital mandate ...under the guidance of applicable laws, any healthcare worker having reasonable cause to believe that any person in the state of abuse, exploitation and/or neglect shall report the information to the appropriate regulatory agency. All allegations, observation or suspected cases of abuse, neglect or exploitation that occur in the hospital will be investigated by the hospital."

The hospital Policy on Physical Environment 11/2022 reflected, "It is the policy of The Hospital to assign an individual or individual's to manage the Life Safety Program, These duties include the assessment for compliance with the NFPA101 Life Safety Code, creation and completion of the electronic Statement of Conditions, and management of the resolutions of deficiencies."


The hospital Policy on Nursing Services dated 05/2022 reflected, "The Nursing Services Plan reflects specific service needs to meet patient care and organizational needs. The plan delineates authority, responsibility duties of each category of nursing personnel, and a function and structure for cooperative planning. Evaluation of department specific needs and staffing requirements is a component of the annual budget process. Nursing Directors/Mangers and the Chief Executive Officer include input from continuous improvement projects, patients, families, employees and the Medical Staff when reviewing and updating department specific services needs to provide patient care and manager resources. In addition, the nursing Practicing Staffing Committee will review staffing plans on an annual basis as applicable by state requirements."

The hospital Policy on Elopement 05/2022 reflected, "Patient who leave the hospital without a discharge order are considered to have 'eloped.' This includes patients who are requesting AMA discharge but have not completed the discharge process. Staff shall make every effort to locate the patient and make notifications to designated persons regarding the elopement.

The hospital Policy on Covid-19 Screening and Screening Log 06/2022
reflected, "To decrease the risk of Covid-19 infection in the hospital and reduce the risk of the spread the following screening procedure has been put in place.
- Screen Patients-completed prior to admission, upon admission, upon admission on the nursing assessment and throughout patient stay via the daily nursing assessments.
- Screening of Staff-completed prior to start of every shift using the Staff/Visitor/Vendor Screen Log
- Screening of Visitor - completed prior to entry of patient care unit or admin area using he Staff/Visitor/Vendor Screening Log
- Vendors-completed prior to entry of patient care unit, admin/storage/kitchen areas using the Staff/Visitor/Vendor Screening Log
- Patients may be offered a face covering during their inpatient stay.

The hospital Visitation Procedure (For all Units)
The following hospital Procedure was not followed by the hospital.
Step 2 - You must verify that the visitor that has signed up for visitation is on the approved list located in White Visitation Binder on Chart cart on both units.
Step 3 - At 2:20PM - the person assigned EOC rounds 'Must" go down to the lobby and check in all visitors. (CODE RESPONDERS ARE NOT ALLOWED TO DO VISITATIONS AND THIS IS NON-NEGOTIABLE).
Step 5 - You MUST check the ID of the visitor that is waiting in the lobby and it MUST match whom is signed up. NO EXCEPTIONS unless previously acknowledged by a member of the social service department or leadership team.
Step 7 - ALWAYS ensure that all doors are closed behind the last person in line. (Patients and or visitors should not have access to walk freely around hospital or be left ALONE, at any time.)

The hospital Policy on HIPAA 07/2021, reflected, "The Policy applies to Hospitals [1] and Employees (as defined below) of Hospitals. Applicable terms of this Policy shall also apply to Haven and Haven's Employees when Haven is perform a role as Business Associate on behalf of one or more Hospitals.
[1] Current Hospitals include (i) Haven Behavioral Hospital of Frisco. The Privacy Officers of each Hospital, in consultation with Haven's Chief Compliance Officer and Chief Information Officer as necessary, shall have responsibility for the ongoing interpretation and administration of this Policy, as it applies to their respective Hospital. Revisions to this Policy shall be made in coordination among the Privacy Officers and Haven's Chief Compliance Officer."

The hospital Policy on Sentinel Events 05/2022 "The hospital will provide an effective mechanism for immediate investigation, analysis of information and response to Sentinel Events to assure continues improvement of safety and quality of care provided to our patients. Our goal is to seek out and understand the causes that underlie such an event in an effort to reduce the probability of Sentinel Events in the future. A 'sentinel' event signals the need for immediate investigation and response. The mechanism used to identify the basic or causal factors that underlie variation in performance is called Root Cause Analysis (RCA). After conducting the RCA, the hospital will develop an action plan designed to implement improvements to reduce risk and monitor the effectiveness of those improvements."

The hospital failed 1 of 1 Patient by discussing Patients Medical history and display of other Patient Medical Records at the front desk.


Findings Include;

Through Interview with hospital medical Staff #11, it was reported that they have been told not work on Patient Records at the front desk of the nursing station in plan site of other patients.

Through Interview with hosptial medical Staff #11 it was reported doctors sometimes stand in the doorways of Patients completing assessments.

Through Interview with hospital medical Staff #11 it was reported that nurse practitioners will assess, interview and discuss patient medical history at the nursing station.

Policy
The hospital Policy on HIPAA 07/2021, reflected, "The Policy applies to Hospitals [1] and Employees (as defined below) of Hospitals. Applicable terms of this Policy shall also apply to Haven and Haven's Employees when Haven is perform a role as Business Associate on behalf of one or more Hospitals.
[1] Current Hospitals include (i) Haven Behavioral Hospital of Frisco. The Privacy Officers of each Hospital, in consultation with Haven's Chief Compliance Officer and Chief Information Officer as necessary, shall have responsibility for the ongoing interpretation and administration of this Policy, as it applies to their respective Hospital. Revisions to this Policy shall be made in coordination among the Privacy Officers and Haven's Chief Compliance Officer."

The hospital Policy on Sentinel Events 05/2022 "The hospital will provide an effective mechanism for immediate investigation, analysis of information and response to Sentinel Events to assure continues improvement of safety and quality of care provided to our patients. Our goal is to seek out and understand the causes that underlie such an event in an effort to reduce the probability of Sentinel Events in the future. A 'sentinel' event signals the need for immediate investigation and response. The mechanism used to identify the basic or causal factors that underlie variation in performance is called Root Cause Analysis (RCA). After conducting the RCA, the hospital will develop an action plan designed to implement improvements to reduce risk and monitor the effectiveness of those improvements."

The hospital Policy on Elopement 05/2022 reflected, "Patient who leave the hospital without a discharge order are considered to have 'eloped.' This includes patients who are requesting AMA discharge but have not completed the discharge process. Staff shall make every effort to locate the patient and make notifications to designated persons regarding the elopement.

The hospital Policy on Patient Rights reflected,
1. Patients may not be denied appropriate hospital care because of the patient's race creed, color, national origin, religion, sex,
sexual orientation, martial status, age , disability, or source of payment.
2. Patients shall be treated with consideration, respect and recognition of their individuality, including the need for privacy in
treatment.
3. The individual patient's medical record, including all computerized medical information, shall be kept confidential in
accordance with applicable federal state and local laws.

The hospital failed 1 of 1 Patient (Patient #1) by not assigning personnel in accordance with the patient's needs and the specialized qualification and competence of the nursing staff available.

Findings Include

During Interview with hospital Staff #5 it was reported that Staff #5 recently completed the hospital's orientation. Staff #5 was unexpereienced in the area of checking in visitors, Staff #5 was told to wand the visitor down and bring them to the visitation to complete their visit. Staff #5 was not reminded immedidately about the identification verification. Staff #5 was not reminded to ensure visitation is being conducted in site and not to leave the visitation room under any circumstance.

During Interrview with hospital Staff #5 it was reported that it was immediatetly known when returning from the 'Code' that leaving the Post in visitation that an elopement had occurred.

During Interview with hospital Staff #1 it was reported in review of video footage, Staff #5 responded to the code, The step-father walked out into the hallway. Did not see staff and noticed the door in which he entered remained open. The step-father returned to
visitation room retrieved Patient #1 and eloped through the same doors in which were entered.


Policy
The hospital Policy on Nursing Services dated 05/2022 reflected, "The Nursing Services Plan reflects specific service needs to meet patient care and organizational needs. The plan delineates authority, responsibility duties of each category of nursing personnel, and a function and structure for cooperative planning. Evaluation of department specific needs and staffing requirements is a component of the annual budget process. Nursing Directors/Mangers and the Chief Executive Officer include input from continuous improvement projects, patients, families, employees and the Medical Staff when reviewing and updating department specific services needs to provide patient care and manager resources. In addition, the nursing Practicing Staffing Committee will review staffing plans on an annual basis as applicable by state requirements."

The hospital Policy on Elopement 05/2022 reflected, "Patient who leave the hospital without a discharge order are considered to have 'eloped.' This includes patients who are requesting AMA discharge but have not completed the discharge process. Staff shall make every effort to locate the patient and make notifications to designated persons regarding the elopement.

The hospital Policy on Covid-19 Screening and Screening Log 06/2022 reflected, "To decrease the risk of Covid-19 infection in the hospital and reduce the risk of the spread the following screening procedure has been put in place.
- Screen Patients-completed prior to admission, upon admission, upon admission on the nursing assessment and throughout patient stay via the daily nursing assessments.
- Screening of Staff-completed prior to start of every shift using the Staff/Visitor/Vendor Screen Log
- Screening of Visitor - completed prior to entry of patient care unit or admin area using he Staff/Visitor/Vendor Screening Log
- Vendors-completed prior to entry of patient care unit, admin/storage/kitchen areas using the Staff/Visitor/Vendor Screening Log
Patients may be offered a face covering during their inpatient stay.

The hospital Visitation Procedure (For all Units)
The following hospital Procedure was not followed by the hospital.
Step 2 - You must verify that the visitor that has signed up for visitation is on the approved list located in White Visitation Binder on Chart cart on both units.
Step 3 - At 2:20PM - the person assigned EOC rounds 'Must" go down to the lobby and check in all visitors. (CODE RESPONDERS ARE NOT ALLOWED TO DO VISITATIONS AND THIS IS NON-NEGOTIABLE).
Step 5 - You MUST check the ID of the visitor that is waiting in the lobby and it MUST match whom is signed up. NO EXCEPTIONS unless previously acknowledged by a member of the social service department or leadership team.
Step 7 - ALWAYS ensure that all doors are closed behind the last person in line. (Patients and or visitors should not have access to walk freely around hospital or be left ALONE, at any time.)

The hospital has failed 17 of 17 patients by failing to provide adequate numbers of qualified professionals, technical and consultavite personel to provide active treatment measurses as it relates to unit schedules as provided for patients to follow on daily basis.

Findings include;

Through observation of the hospital unit, upon arrival onto the unit. Hospital staff are all within the nursing station, besides two behavioral techs. Staff #3 enters the unit, and was asked why are all patients only seated within the milieu. In observation of the patients for a several minutes. The surveyor selected three patients to interview randomly and individually.

During Interview Patient #4 reported that the hospital does follow the schedule, but it never starts on time. The schedule reflects group is 1 hour but last 1/2 an hour most days. Patient #3 stated if its time for a group and we do not have any on show up to teach the group we have to just sit in the milieu everyday until they let us go to our rooms. Sometimes we sit there all day long. Patient #4 stated there are several opporunties through the day to attend groups but they are never on time. Patient indicated that the hospital is understaffed, and we have to wait on them.

During an Interview with Patient 5 it was reported that they patients are not allowed to watch television unti 4:30PM daily. Patient #5 reported the hospital does have groups for us to attend but they are never an hour as the schedule says.

During an Interviw with Patient #6 indicated only being in the hospital for the past 36 hours all we do is sit her in the milieu. There are no groups. we cant watch television until 4PM. I have been told the staff for groups never come on time and they dont last long when we do have them.

During Interivew with Hospital Staff #9, it is reported that the hospital Therapist are holding groups, but they are not often on time and it makes it difficulty to be on the same accord with them.

During an interview with hospital Staff #11 the groups particularly the Education group is not always on time all kids are not always attending, and it makes it difficult to manage the milieu and ensure proper documentation on each patient is completed timely and accurately. The schedule needs more consistency. Staff #11 indicated techs are not always able to conduct their groups.

During observation and interview with hospital Staff #1 it was reported, Process group or Education should be taking place at this time. Staff #1 informed the surveyor Patients are waiting for the educator to arrive on the unit. In the meantime, the patients just sit n the lobby and write, draw, or color. The patients were able to watch television previously, but now they just have to sit in the milieu all morning if group or some sort of therapy session is not in place. The allegation that groups are only being held for a half hour is found to be true, because of educators/therapist arriving late for groups.

Policy
The hospital Policy on Patient Rights reflected,
1. Patients may not be denied appropriate hospital care because of the patient's race creed, color, national origin, religion, sex, sexual orientation, martial status, age , disability, or source of payment.
2. Patients shall be treated with consideration, respect and recognition of their individuality, including the need for privacy in treatment.
3. The individual patient's medical record, including all computerized medical information, shall be kept confidential in accordance with applicable federal state and local laws.

The hospital Policy on Nursing Services dated 05/2022 reflected, "The Nursing Services Plan reflects specific service needs to meet patient care and organizational needs. The plan delineates authority, responsibility duties of each category of nursing personnel, and a function and structure for cooperative planning. Evaluation of department specific needs and staffing requirements is a component of the annual budget process. Nursing Directors/Mangers and the Chief Executive Officer include input from continuous improvement projects, patients, families, employees and the Medical Staff when reviewing and updating department specific services needs to provide patient care and manager resources. In addition, the nursing Practicing Staffing Committee will review staffing plans on an annual basis as applicable by state requirements."