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During Record Review Observation and Interview the hospital failed 1 of 1 Patient the Right to recieve care in a safe setting.

Findings Include

During Record Review the Psychiatric Evaluation 06/20/2024 reflected Patient #1 was non compliant, nonverbal, and admitted on an involuntary basis. It was requested that Patient #1 be admitted involuntary. The request was denied by the District Attorney's Office. Regardless the Patient was reassed in the Intake department and readmitted into the hospital.

During Record Review 06/20/2024 the Hospital Incident Report 06/20/2024 at 2:23PM second shift. Patient Fall observed. "Patient was in the day area, staggered, and fell on the floor by the nursing station door. No injury noted. Vital signs checked BP 109/59, P 107, R 18, 02 99%. Medical doctor notified, MD came to the unit and assessed patient. No new orders."

During Observation of video footage, Patient #1 fell on her right side at 2:23Pm on 6/20/2024. There is no video footage of the doctor on the unit examining Patient at this time. The video footage revealed Patient #1 seated for short period of time. Staff attempting to adjust the patient seated in the chair, and pushing another chair to elevate the Patients legs/feet. The patient did get up shortly after and ambulate on own accord.

During Interview with Staff #1 they were informed the phyicians wanted to readmit Patient #1 on an involuntary status. However, Why did they think it was not important to send the patient out or have a mobile x-ray unit arrive to the facility to further assess this Patient head and neck areas after the fall. There was a previous head and neck x-ray at previous referring hospital allegedly due to being a victim of domestic violence, which revealed they were unremarkable. Why did the hospital not follow up with another evaluation to enusre Patient safety.

Policy
The hospital Policy (UBH-Denton) Patient Rights 08/2023, Recognizing the importance of a patient's privacy rights, UHS maintains a comprehensive system of policies and procedures to help ensure that patient's privacy rights are protected. Below is a summary Patient Rights and the polices that address them. Patients will receive a description of their individual privacy rights in the Facility's notice of privacy practice.

The hospital Policy on Patient and Family Grievances/the Role of the Patient Advocate, '08/2023, "It is the policy of UBH Denton to encourage responsive and open communication with patients at all levels in the hospital with the objective of resolving grievances through appropriate problem solving actions. All patients shall be informed of the grievance process and the availability of the Patient Advocate upon admission. It is the responsibility of each staff member to respond in a timely manner to any concern or complaint voiced by patients and their families no matter how trivial the complaint may appear to be. Presentation of a grievance will not, in itself, serve to compromise a patient's future access to care."

The hospital Policy on Neglect 12/2022, "To establish a uniform policy and procedures for reporting and responding to all allegations of abuse and neglect. To comply with Texas law that requires professionals to make a report within 48 hours of first suspecting neglect of a child or person 65 years or older or an adult with disabilities."

The hospital Policy on Quality Assurance and Performance Plan 08/2023, "UBH Denton is committed to providing high quality and efficient care for its patients and other consumers. The Quality Assurance & Performance Improvement Plan (QAPI) developed by UBH Denton guides the facility's efforts in achieving excellence in patient care and is in accordance with the mission and vision of the organization and that of Universal Health Services, Inc."

The hospital Policy on Falls Prevention & Management 08/2023, "during their inpatient stay, patients are continually assessed/reassessed throughout their admission to identify fall risk factors that prompt initiation of/or change in fall precaution/levels of monitoring, using an evidence based tool that is approved by the medical staff. Patients are continually assessed/reassessed throughout their admission to identify fall risk factors that prompt initiation of/or change in fall precaution/levels of monitoring."

Through Record Review, Observation, and Interview the hospital failed 1 of 1 Patient (Patient #1), (3) That clear expectations for safety are established.

Findings Include:

During Record Review there was no documentation that reflected there is a Falls committee in place to address hospital falls, standardized or treatment. There is a Fall Precaution Policy.

During Record Review Hospital Incident Report 06/20/2024 at 2:23PM second shift. Patient Fall observed. "Patient was in the day area, staggered, and fell on the floor by the nursing station door. No injury noted. Vital signs checked BP 109/59, P 107, R 18, 02 99%. Medical doctor notified, MD came to the unit and assessed patient. No new orders. "

During Observation nursing notes Patient was noted as being drowsy, but there is no documentation of a falls assessment completed. Patient is not identified during the first admission with a high risk for Falls, but there is no Falls Assessment completed after identifying Patient is drowsy and she had an unsteady gate.

During Interview with hospital Staff #7, Patient #1 non-compliant and she was drowsy. Staff #7 reported that she did not document that information in medical notes and it was not reported to the physician. Staff #7 reported that Patient #1 is non-compliant and unable to assess.

During Interview with hospital Staff #6 it was reported that Patient #1's fall was not witnessed but it was heard. "I heard the slap onto the ground."


Policy
The hospital Policy (UBH-Denton) Patient Rights 08/2023, Recognizing the importance of a patient's privacy rights, UHS maintains a comprehensive system of policies and procedures to help ensure that patient's privacy rights are protected. Below is a summary Patient Rights and the polices that address them. Patients will receive a description of their individual privacy rights in the Facility's notice of privacy practice.

The hospital Policy on Neglect 12/2022, "To establish a uniform policy and procedures for reporting and responding to all allegations of abuse and neglect. To comply with Texas law that requires professionals to make a report within 48 hours of first suspecting neglect of a child or person 65 years or older or an adult with disabilities."

The hospital Policy on Quality Assurance and Performance Plan 08/2023, "UBH Denton is committed to providing high quality and efficient care for its patients and other consumers. The Quality Assurance & Performance Improvement Plan (QAPI) developed by UBH Denton guides the facility's efforts in achieving excellence in patient care and is in accordance with the mission and vision of the organization and that of Universal Health Services, Inc."

The hospital Policy on Falls Prevention & Management 08/2023, "during their inpatient stay, patients are continually assessed/reassessed throughout their admission to identify fall risk factors that prompt initiation of/or change in fall precaution/levels of monitoring, using an evidence based tool that is approved by the medical staff. Patients are continually assessed/reassessed throughout their admission to identify fall risk factors that prompt initiation of/or change in fall precaution/levels of monitoring."