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Based on review of facility documents, review of medical records, and staff interview, the facility failed to evaluate the nursing care for each patient when they failed to reassess patient #2 every 12 hours.

Findings were:

Texas Administrative Code Chapter 411, subchapter J, Section 411.473. Nursing Services stated in part, "(f) Reassessment. An RN shall reassess a patient, based on the patient's needs, but at least every 12 hours after the initial comprehensive nursing assessment, required by subsection (e) of this section, is conducted."

Review of the medical records for patient #2 revealed they were admitted on 3/22/21 at 4:07 am which identified their Columbia-Suicide Severity Rating Scale (C-SSRS) [a questionnaire used to assess suicide risk] as a 4, which indicated "Moderate Risk." From admission through 3/29/21 at 7:00 pm, C-SSRS was completed once a shift with patient #2's results indicating no risk, low risk, and moderate risk (with scores ranging from 0-13). There was no C-SSRS completed the day before or the day of discharge (3/30/21 and 3/31/21).

Nursing assessments were completed on the day of admission and each shift from 3/22/21 at 4:07 am through 3/30/21 at 8:00 pm. There was no nursing assessment completed on the day of discharge, prior to the patient leaving the facility.

In an interview with staff #3, Director of Nurses of Behavioral Health, on the morning of 6/16/21, when asked how nurses know how/when to complete assessments, including suicide risk, staff #3 stated "We do training; there's a suicide assessment and reassessment in HealthStream [an electronic education system]. We have a week-long orientation [which includes information] about the reassessment and assessment." When asked if there was a policy detailing how often assessments need to be completed, staff #3 reported they found a policy in "archives" that was long and "not specific about assessing either. It says who assesses and how, but doesn't break down when they should do it ... We have a handbook but I don't think it's specific either."

When asked how often the C-SSRS needed to be completed, staff #3 stated, "It's my expectation that nurses fill it out every shift. If it is an expectation of mine, I think it needs to be in the policy ... The nurses do an assessment or else they would not be able to do a note that says they aren't suicidal." When asked again if there was a policy related, staff #3 reported there was "Nothing to guide assessments and reassessments."

In an interview with staff #8, Chief Nursing Officer, on the morning of 6/16/21, they provided the policy titled "Plan for the Provision of Care" policy number PC 091 and stated, "This is very long [137 pages] ... We are in the process of revising [this policy]." Staff #8 went on to discuss the new policy to be easier and more user friendly for nurses, so they can access what they need quickly. When asked what their expectation was for nursing assessments/reassessments, staff #8 stated, "I don't know behavioral health; I would have to defer to [Staff #3] and them over there." When stated staff #3 believed it should be every shift, staff #8 stated, "OK. We're definitely going to take a look at that and revise the policy."

The above was confirmed during an interview with administrative staff on the morning of 6/16/21.

Facility Policy titled, "Plan for the Provision of Care" policy number PC091 stated in part, "Patient Care Services
B. An RN must complete the initial assessment and conduct a daily assessment thereafter."

The Columbia Lighthouse Project website found at https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/evidence/ stated in part, "PROOF POSITIVE: THE EVIDENCE SUPPORTS USING THE COLUMBIA PROTOCOL TO ASSESS RISK
An unprecedented amount of research has validated the relevance and effectiveness of the questions that the Columbia Protocol - also known as Columbia-Suicide Severity Rating Scale (C-SSRS) - uses to assess suicide risk. This research makes the Columbia Protocol the most evidence-based tool of its kind. Research validates the questions - and the way they are structured and categorized - for assessing the likelihood that someone will make a suicide attempt. And research on the protocol's reliability confirms that the Columbia Protocol effectively identifies who is most at risk."

Based on review of facility policy, review of medical records, and staff interview, the facility failed to maintain medical record to describe the patient's progress when they failed to update patient #1's treatment plan when there was a significant change.

Findings were:

Texas Administrative Code Chapter 411, subchapter J. Standards of Care and Treatment in Psychiatric Hospitals, section 411.471. Inpatient Mental Health Treatment and Treatment Planning stated in part, "(a) Inpatient mental health treatment. A hospital shall provide inpatient mental health treatment to a patient under the direction of a physician and in accordance with the patient's treatment plan and this division. The treatment plan shall be appropriate to the needs and interests of the patient and be directed toward restoring and maintaining optimal levels of physical and psychological functioning.
... (d) Treatment plan review. In addition to the review required by subsection (c)(1)(D) of this section, the treatment plan shall be reviewed and its effectiveness evaluated:
(1) when there is a significant change in the patient's condition or diagnosis or as otherwise clinically indicated ...
(e) Treatment plan revision. In addition to a revision required by subsection (c)(1)(D) of this section, the treatment plan shall be revised, if necessary, based on the findings of any assessment, reassessment, evaluation, or re-evaluation, or as otherwise clinically indicated.
(f) Documentation of treatment plan review and revisions. A treatment plan review and revision shall be signed by all members of the IDT."

Review of the medical record for patient #1 revealed on 5/27/21, patient #1 alleged a sexually inappropriate incident occurred the night of 5/26/21. Facility staff immediately investigated, initiated action plans, and placed patient #1 on SAO [Sexually Acting Out] precautions, according to facility policy.

Review of the Interdisciplinary Master Treatment Plan and Treatment Team progress notes for patient #1 revealed no update/revision to the plan to include the new identified problem of SAO, new goals and interventions, any identified "triggers" or specific coping mechanisms to reduce the potential for sexually acting out.

The above was confirmed in an interview with Staff #1, #2, and #3 on the morning of 6/16/21.

Facility Policy titled, "Interdisciplinary Patient - Centered Care Planning" policy Number BH 006 stated in part, "Policy: It is the policy of Northwest Texas Healthcare System Behavioral Health Services to provide therapeutic services based upon a patient-centered, individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the patient and family/representative to collaboratively identify the patient's assessed needs to be addressed during treatment and develop appropriate goals and interventions. All therapeutic services that are beyond routine tasks to be provided to the patient are included in the plan and the treatment plans are routinely reviewed to assess the patient's progress and determine if any modifications are needed ...
Interdisciplinary Treatment Plan Update
1. Treatment Plan Review
...A treatment plan revision can be completed any time the treatment team decides to alter the proposed strategies based upon the patient's needs. Reviews of the treatment plan are documented on the appropriate treatment plan forms in the medical record.
The following would be cause for conducting a review of the plan and developing a revision:
*A new impairment/problem or significant information about an existing impairment is identified.
*A major change occurs in the patient's clinical condition, such as the need for the use of restraint or seclusion"

Facility Policy titled "High Risk Behavior Precautions" policy number BH 027 stated in part, "PROCEDURE:
Patients are assessed upon admission and reassessed throughout hospitalization by the interdisciplinary treatment team for any behavior or behavioral history that demonstrates need for high-risk precautions ...
NURSING/CLINICAL SERVICES-
...2. A physicians order will be obtained for each high risk behavior precaution identified upon admission or for any change to the high risk precautions during the course of treatment (an RN may initiate) *modifications to the interventions must be included in the physician order and must be reflected on the patients [sic] treatment plan ...
HIGH RISK BEHAVIOR PRECAUTION INTERVENTIONS-
The interdisciplinary team will implement specific behavioral interventions based on the high risk behaviors identified and will monitor and update the treatment plan as needed including but not limited to the following: *any modifications to the interventions must be approved via physician order
...Sexually Acting Out (SAO) Aggressor/victimization
...g. Behavior will be monitored closely for any identified 'triggers' of sexually acting out included in the treatment plan
h. The treatment plan will include specific coping mechanisms to reduce the potential for sexually acting out."