HospitalInspections.org

Based on observation, interview and record review, the facility failed to ensure 1 of 3 patients' rights (Patient #3) to care in a safe setting, as evidenced by the failure of staff to ensure there were no items in patient #1's bedroom, who was on suicide precautions, that had the potential to cause self-harm.

Findings included:

TX00294193

In an interview on 10/25/18 at 9:45 am, MHT (Mental Health Technician) Staff #57 stated Patient #3 was currently on Suicide Precautions.

Observation on 10/25/18 at 10:00 of Patient #3's bedroom revealed there was a styrofoam cup present on a personal belongings/clothes shelf that was filled with several plastic eating utensils. These utensils could have been used to cause self-harm. In addition, the plastic utensils could have been broken to form sharper cutting edges with sharp pointed ends.

In an interview on 10/25/18 at 10:00 am with MHT #57, she stated the plastic utensils should not have been in the patient's room and removed them immediately.

Record review on 10/25/18 of Patient #3's clinical records revealed she was currently on Suicide Precautions, ordered by her physician.

Record review of facility policy titled "Contraband/Valuables Search and Storage" dated 11/19/10, stated sharp objects were considered "Contraband Items (Unapproved Items)". This policy applied to all patients, not just those patients on Suicide Precautions.


Based on record review and interview, the facility failed to properly document 2 of 8 sampled patients on Suicide Precautions (Patients #6 and #7) in their Close Observation Rounds documents.

Findings included:

TX00294193

Record review on 10/25/18 at 11:00 am of Patient #6 and Patient #7 medical records revealed doctors' orders for both patients to be placed on Suicide Precautions.

Further record review revealed that Patient #6 had three days of Patient Observation Rounds (aka 'Q 15 Minutes Rounds'), filled-out by both MHTs and nurses, which failed to indicate the patient was on Suicide precautions for 10/20/18, 10/21/18, and 10/22/18.

Record review on 10/25/18 at 11:10 of Patient #7's Patient Observation Rounds documents failed to indicate the patient was on Suicide Precautions on 10/24/18.

In an interview on 10/25/18 at 11:15 am, LVN Staff #59 stated that the Patient Observation Rounds documents should have indicated that Patients #6 and #7 were on Suicide precautions.

Record review of facility policy titled "Patient Observation Rounds" dated 3/2/13, stated the following: " .....MHT/MHW a. Review and update patient observation forms. Reflect changes in individual patient precaution levels, room or bed changes, new admissions, and/or discharges as they occur ... ... ....l. Hand off assigned patient-observation rounds to another staff member before leaving the patient treatment area.."