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Based on Record Review, Interview and Observation the hospital failed 5 of 5 Patients the right to receive care in a safe setting.

Findings Include:

During Record Review in the Psychiatric Nursing Notes 11/21/2024, 9:10 AM, "Patient #1 reported that another patient (Patient #2) engaged in Sexually Acting Out behavior toward Patient #2.

During Record Review a witness Statement written on 11/21/2024 at 9:21 AM, Patient #1 wrote, 'Last night, 'Patient #2'' raped me. I (Patient #1) was half asleep in my bed. "

During Record Review a witness Statement written on 11/21/2024 at 9:10 AM, Patient #2 wrote, 'Patient #1 and I made out x7. We gave each other hickeys, on right side of neck. Patient #1 said she wasn't going to say anything and she agreed as well. We were touching each others thighs, vagina and titties. Patient #1 and I were biting each others lips and neck."

During Interview with hospital Staff #2 on 12/19/2024 at 11:30 AM. Staff #2 indicated that these two patients were roommates. Patient #2 was admitted the day the allegations occurred. The patients admitted the allegations occurred. Staff #2 further was questioned about Staff Observations and rounding. Staff #2 indicated that the staff were rounding but they were not changing their routine and they were predictable with their rounding, causing the patients to know when the staff were going to come into their room and check on them.

During Interview with hospital Staff #8 on 12/19/2024 at 2:15 PM It was reported that Patient #1 and Patient #2 did confirm the incident happened. The Patients reported that the incident was consensual but they were angry with one another the following day and attempted to fight that next morning. Staff #8 reported that the patients did receive a medical assessment and from the nursing staff it was confirmed that hickey's were discovered on each patient.

Policy

The hospital Policy on Abuse, 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 abuse, neglect or exploitation of a child or person 65 years or older or an adult with disabilities."

The Hospital Policy on Quality Care and Treatment 'Plan for Patient Care and Professional Services' 08/2023, "University Behavioral Health of Denton is committed to the provision of quality behavioral health services to our community. This commitment is demonstrated through the facility's mission and supported through effective strategic and budget planning efforts. Resources are utilized to meet individual patient, family, and staff goals in the most effective and efficient manner possible."

The hospital Policy on Patient Observation Levels 01/2024, "Patient observation levels are defined as specific levels of staff awareness and attention to patient safety/security needs that require the initiation of specific protocol and supplemental documentation."

The hospital Sexually Acting Out (SAO) Prevention and Incident/Allegation Response 09/2024, "It is the policy of this hospital to ensure provision of safety and therapeutic environment of care which includes prevention of patient to patient sexual incidents.

Based on Record Review, Interview and Observation the hospital failed 1 of 1 Patient (Patient #3) by failing Patient #3 the right to be free from all forms of abuse or harassment. Patient #3 was experiencing a psychotic episode and during the episode Patient #3 was not willing to comply with hospital staff and was combative towards staff. For Patient #3 to obtain his composure he was struck in the face by a peer causing the Patient #3 to have a blackeye.

Findings Include:

During Record Review the hospital Seclusion/Restraint/Emergency Medication Packet 11/21/2024, 4:34 AM. "Patient #3 Suddenly running to other patient without any reason to attack others ...MHT stopped him from attacking peer by restraining ...Seroquel 200mg, PO agitation at 11:07 AM ...Patient is pacing. Facial expressions, agitation. Ativan 2mg IM aggression. Patient assault peer and staff.

During Record Review Witness Statement by Patient #31 reflected, "Patient #31 reported, I was asleep woke up to a guy (Patient #3) hitting the nurses. Me and my roommate (Patient #5) stepped in to help the nurses stop this fighting."

During Interview Staff #14 on 12/20/2024 at 12:30 PM, Patient #3 indicated working the unit along with another female Tech (Staff #15). Staff #14 indicated we were rounding together to try and ensure safety. While rounding we noticed Patient #3 on up on the unit and pacing and then sitting in the hallway. Patient #3 was inwas asked if he was okay and requested to go back to room and try and get some sleep and not to sit in hallway. Patient #3 did go into his room, but then he started to assault roommate. We heard the punches in the room. Staff #14 amd Staff #15 entered the room, and Patient #3 immediately stopped punching roommate and turned anger towards the staff. Patient #3 then started punching, pushing and kicking both Staff. Staff #14 reported being able to elude Patient #3 and enter into the nursing station and call a code. The response team responded but the incident was ended due to another male patient waking up and witnessing the event and the male Patient #5 punched Patient #3 to stop his assault on female staff. Staff #3 indicated that there was a radio (walkie-talkie) at the nursing station, but had never used it, had not been trained on it and had not witnessed anyone using it or heard it in use. Staff #14 confirmed Patient #3 was punched in the face by another Patient #5 in the hospital leaving Patient #3 with a blackeye.

During Observation on 12/20/2024 at 11:00 AM, Staff #1 provided a laptop to watch video footage. Patient #3 was observed experiencing a psychotic break attacking staff with a closed fist, kicking, slapping at Staff. This causing the Staff #14 to go flying onto the floor and into the wall hitting head. Patient #3 was able to elude hospital Staff #14 and Staff #15 over powering them. Staff #14 was observed able to get into the nursing station and calling a code. The two male Patients awaoke Patient #31 and Patient #5. Patient #5 was observed striking Patient #3 in face causing his blackeye.

Policy:
The hospital Policy on Patient Rights 10/2022, "University Behavioral Health of Denton shall protect the rights of patients as per the Patient Bill of Rights and Texas Law. The staff shall be trained on the 'Patient Bill of Rights' and upon admission, patients will be fully informed of their rights as outlined below. Restriction of patient rights is done only in those situations where the safety, security and welfare of the patient mandates such restriction."

The hospital Policy on Abuse, 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 abuse, neglect or exploitation of a child or person 65 years or older or an adult with disabilities."

The hospital Policy on Nursing Services 10/2023, "The delivery of nursing care at University Behavioral Health of Denton shall be understood as a 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 of the health status of those entrusted to our care."

The Hospital Policy on Quality Care and Treatment 'Plan for Patient Care and Professional Services' 08/2023, "University Behavioral Health of Denton is committed to the provision of quality behavioral health services to our community. This commitment is demonstrated through the facility's mission and supported through effective strategic and budget planning efforts. Resources are utilized to meet individual patient, family, and staff goals in the most effective and efficient manner possible

During Record Review and Interview the hospital failed all patients by failing to ensure, the hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. The hospital failed to ensure a Master level nurse was on duty at the time complaint Investigation conducted.

Findings Inlcude:


During Interview on 12/19/2024 at 2:00 PM with Staff #6 information was verified that the employee Staff #6 was not a Master Level DON. Staff #6 is Bachelor Level RN.

During Interview and Record Review on 12/20/2024 at 11:30 AM with Staff #5 information was verified through the Employee Human Resources Record Staff #6 was hired as Interim DON. Staff #6 is not a Master's Level DON. Staff #6 is a Bachelor's Level DON. Staff #6 was informed of Interim DON role and willingly relinquished those responsibilites.

During Record Review the hospital Education Qualification calls for the following background: Bachelor's degree from an accredited school of nursing; Master's Degree in psychiatric nursing or related field preferred.


Policy
The hospital Policy on Nursing Services 10/2023, "The delivery of nursing care at University Behavioral Health of Denton shall be understood as a 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 of the health status of those entrusted to our care."

The Hospital Policy on Quality Care and Treatment 'Plan for Patient Care and Professional Services' 08/2023, "University Behavioral Health of Denton is committed to the provision of quality behavioral health services to our community. This commitment is demonstrated through the facility's mission and supported through effective strategic and budget planning efforts. Resources are utilized to meet individual patient, family, and staff goals in the most effective and efficient manner possible."

The hospital Policy on Patient Rights 10/2022, "University Behavioral Health of Denton shall protect the rights of patients as per the Patient Bill of Rights and Texas Law. The staff shall be trained on the 'Patient Bill of Rights' and upon admission, patients will be fully informed of their rights as outlined below. Restriction of patient rights is done only in those situations where the safety, security and welfare of the patient mandates such restriction."