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Tag No.: A0115
Based on observation of facility video surveillance, record reviews, and staff interviews, it was determined that the facility failed to protect and promote patient's rights to be free from all forms of abuse/neglect for 2 of 2 patients reviewed.
Specifically, on 2/25/19 during the 7:00 PM to 7:00 AM shift, the facility failed to ensure Patient's #1 and #2 received one to one (1:1) staff supervision as ordered by the physician for patient safety, and in accordance with the facility's policy and procedures
As a result of this failure, Patient's #1 and #2 destroyed facility property successfully in an attempt to inflict self- harm when they broke a piece of metal from the bottom of the door frame; were pouring multiple cups of water on the floor affecting the safety of other patients, tearing strips of sheets to place around their neck, banging on doors, obtained sharp metal objects, etc.
Refer to A0145.
Tag No.: A0145
Based on observation of facility video surveillance, record reviews, and staff interviews, it was determined that the facility failed to ensure patient's rights to be free from all forms of abuse/neglect for 2 of 2 patients reviewed; Patient #1 and #2.
Specifically, on 2/25/19 during the 7:00 PM to 7:00 AM shift, the facility failed to ensure Patient's #1 and #2 received one to one (1:1) staff supervision as ordered by the physician for patient safety and in accordance with the facility's policy and procedures
As a result of this failure, Patient's #1 and #2 destroyed facility property successfully in an attempt to inflict self- harm when they broke a piece of metal from the bottom of the door frame; were pouring multiple cups of water on the floor affecting the safety of other patients, tearing strips of sheets to place around their neck, banging on doors, obtained sharp metal objects, etc.
Findings:
Surveyor reviewed the facility's report titled, "Camera Review of Event" for 2/25/19 at 09:45 PM which included evidence that 1 to 1 staff (MHT-A) did not maintain 1 to 1 supervision of Patient #1. The report included lack of direct supervision after review of the video. There were instances where Patient #1 and #2 where alone spilling water on the floor and turning a chair over. Patients were displaying out of control behavior by banging on the doors, pouring water on the floors, and being overtly loud. The report did not document that Patient #1 broke a metal piece from the door and broke it in half.
Review of Patient #1's Records revealed the following:
The Patient Registration dated 2/5/19 indicated patient swallowed two screws and a metal piece.
The History and Physical dated 2/6/19 documented a history of suicidal ideation, and depression with ingestion of foreign body.
Review of Physician Orders (handwritten) revealed the following:
2/18/19 at 11:35 AM, Place patient 1 to 1 [supervision].
2/26/19 at 12:00 PM, 1. Continue 1 to 1 [supervision] for safety. 2. Check [x-ray] kidney, ureter, and bladder (KUB).
Following the incident on 2/25/19, the physician ordered a 20-foot rule from Patient #2; for safety on 2/26/19 at 12:30 PM.
Review of the radiology report dated 2/25/19 concluded a paperclip projects over proximal descending colon.
Review of Patient #2's Records revealed the following:
Intake Assessment dated 12/4/18 revealed patient with a history of suicidal ideation with a plan to either cut herself or hang herself. Patient #2 had a history of suicidal attempts.
Physician Orders for Patient #2 documented the following Physician Orders:
2/20/19 at 08:53, place patient on 1 to 1 ATC, paper scrubs, finger foods for safety.
2/21/19 at 13:00, Continue 1:1 supervision.
2/26/19 at 15:38, 20 feet rule with Patient #1.
3/1/19 at 01:00, Discontinue Unit Restrictions/1 to 1 at 18:30.
Following review of Patient #1 and Patient #2's records, it was determined that both Patient's had physician orders for 1 to 1 supervision on 2/25/19 during the time of these incidents which included where Patient #1 broke off a metal piece from the bottom of the door, broke it in half, and began scratching/cutting herself.
Review of Patient #2's Observation/MHT notes dated 2/25/19 documented Patient #2 was on "1:1" supervision with every 15-minute documentation for the 11 PM to 7 AM shift, and the 7 AM-3 PM shift. On the 3 PM-11 PM; the observation level for 1:1 was not checked and was not implemented.
Review of the RN-A nursing assessment/progress note for 2/25/19 shift 7:00 PM to 7:00 AM documented at about 23:00 Patient #2 and #1 became loud, hyperactive, and disturbing sleep to peers in the unit. Patient #2 and Patient #1 went and (sic) dislodged the (sic) slid in the door of the "BB2" conference and "used the debris to cause harm to themselves." Patient #2 escalated her aggressiveness towards the furniture and the staff banging on the doors, cussing out staff, and hiding sharp objects under her bra and underwear. The physician was notified with an order to obtain a body search. Patient #2 was found to have some sharp objects and had a pin in her mouth.
Review of the facility's staffing, Nursing Assignment Sheet dated 2/25/19 for 7 AM-7 PM documented Patient #1 and Patient #2 were both 1 to 1 with an assigned staff. The facility was not able to locate the staffing, Nursing Assignment Sheet for the 7 PM-7 AM shift (2/25/19).
Review of the Employee Corrective Action Report dated 3/1/19 revealed a Written Warning for MHT-A for a safety violation and policy violation. The written warning stated, on 2/25/19 at approximately 21:45; MHT-A was observed leaving the side of a child assigned to for 1 to 1 supervision. While away, the patient damaged the physical structure of the unit. This Patient (#1) has a history of swallowing anything she can get her hands on. The MHT-A exposed the child to the ability to harm herself.
Observation on 3/6/19 of the video surveillance from 02/25/19 at 9:45 PM to 11:51 revealed the following, in part (no audio available):
At 09:45 PM, Patient #1 and #2 were at the other end of the hallway from MHT-A.
At 09:47 PM, MHT-A approached Patient's #1 and #2 when they split off and walk away to another hallway end.
At 09:50 PM they begin tearing off the plastic molding from the bottom of wall.
At 09:51 RN -A comes and verbally communicates with Patient's #1 and #2.
At 09:53 Patient's #1 and #2 return to the other end of the hallway, sit down on the floor and begin to take off the metal plate from the bottom of the door.
At 09:54, both Patient's (#1 and #2) leave this area.
At 09:58 PM, Patient's (#1 and #2) return to the area and pour water on the floor.
At 10:00 PM, Patient's (#1 and #2) pouring more water on the floor.
At 10:02 PM, both Patient's (#1 and #2) pouring more water on the floor.
At 10:07 PM, RN-A comes to talk to Patient's #1 and #2 (there were 6 empty cups on the floor from the water).
At 10:20 PM, Patient's #1 and #2 move a chair towards the door, and they turn the chair over, upside down.
At 10:23 PM, MHT-A goes towards Patient's #1 and #2 and removes the chair.
At 10:28 PM, Patient's #1 and #2 leave the area again.
At 10:29 PM, Patient's #1 and #2 return to the area with blankets and begin to tamper with the bottom of the door.
At 10:33 PM House Supervisor, RN-B stands at the end of the hallway and communicates to the patients.
At 10:41 PM, Patient #2 adjusting pants, urinates on the floor while Patient #1 continues to tamper with the metal from the bottom of the door.
At 10:51 PM, Licensed Vocational Nurse (LVN)-A verbally communicates with Patient's #1 and #2 while MHT-A remains at the other end of the hallway. Patient#1 continues to tamper with the metal from the bottom of the door.
At 10:56 PM, Patient #1 appears to have removed metal piece from the door.
At 11:00 PM, RN-A comes to the end of the hallway near Patient's #1 and #2 to communicate with them.
At 11:01 PM, RN- retrieves the metal piece from Patient's #1 and #2 and hands the contraband to another staff.
At 11:06 PM, RN-A separates Patient's #1 and #2.
At 11:09 PM, Patient #2 is tampering with a sheet while sitting on the floor.
At 11:27 PM, Patient's #1 and #2 are seen tearing the sheet into strips.
Review of the facility's Critical Incident Review (CIR) dated 3/8/19 identified that the MHT-A assigned to conduct one to one supervision on 2/25/19 for Patient #1 had not followed the facility's policy and procedures for conducting this level of supervision. The CIR had not identified that Patient #2 should have also been on one to one supervision on 2/25/19 for 3 PM-11 PM as ordered by the physician on 2/20/19.
During an interview on 3/6/19 at 12:37 PM with MHT-A stated the following:
On 2/25/19 she arrived at 06:45 PM and was assigned one to one staff supervision for Patient #1. She stated Patient #1 was assigned one to one staff, but that Patient #2 was not on one to one supervision during this shift. She stated that both Patient #1 and #2 displayed maladaptive behaviors during her shift and around bedtime, they were "feeding off of each other." They were "threatening to hit" and continued to attempt to get contraband items; which became "a game." MHT-A stated she was "scared of them hitting me." Patient #1 took MHT-A's pen from her. Patient #2 obtained a paper clip and hairbrush pieces; trying to put in her nose. She also noticed a screw on the toilet that was loose and tried to obtain it. Patient #2 then grabbed multiple cups of water, pouring them on the hallway floor. After pouring the water on the floor, Patient #2 stated she was "going to pee; stood up, pulled her pants down and peed in the hallway while encouraging [Patient #1] to pee also."
MHT-A stated she could not stand in between Patient #1 and Patient 2; she "could only stand in the hallway and watch them." MHT-A stated that Patient #1 and #2 were at the double doors and "ripped the metal off the hallway door." Patient #1 kept pulling at the metal piece trying to remove it and "hurt her fingers from pulling and pulling." Patient #1 finally pulled the metal piece off and "started to cut herself." Patient #2 stated to MHT-A "I'm going to kill myself," and then Patient #1 gave Patient #2 half of the metal piece she removed from the door.
MHT-A stated she told Patient #1 and #2 that "people were watching on the cameras." MHT-A stated she could not take the metal piece from them or it was "going to be a fight; I could only watch them, and [Patient #1] was cutting herself."
MHT-A stated she told the Registered Nurse (RN)-A, who talked to them, obtained the metal piece, and then gave Patient #1 "a shot". Patient #1 then went to bed after receiving her shot. Patient #2 continued by grabbing a bedding sheet, ripped it and placed it around her neck requiring a "code green" to be called. MHT-A stated that multiple staff tried "talking with them" to not do these things. MHT-A stated she was not certain if Patient #1 had any injuries to her arm, because she "did not get closer to her" when she obtained the metal piece from the door.
MHT-A further indicated that if you were assigned as a one to one staff that your sole priority was that patient you were assigned to, at all times "within arm's length" from the Patient. MHT-A stated Patient #1 had been on one to one for self-harm; "swallowing, ingesting items." Interventions included to be right next to Patient #1's side to "watch every little thing." If Patient #1 obtains any items she could swallow, she was supposed to take them from her.
MHT-A stated that she continued to report Patient #1 and #2's behaviors displayed to the RN-A on duty. She stated multiple staff attempted to verbally redirect Patient #1 and #2 but they continued their behaviors as described above, "they would not listen." MHT-A stated she did not physically intervene because Patient #1 and #2 "could be aggressive." MHT-A confirmed there were no interventions used for Patient #1 and #2 except for verbal redirection. MHT-A confirmed that she was not "within arm's length" of Patient #1 and had not maintained one to one supervision for Patient #1 when she tore the metal piece from the door while at the other end of the hallway.
Interview on 3/13/19 at 02:05 with the Clinical Manager- A confirmed that Patient #2 was not on one to one supervision on 2/25/19 for the 3 pm to 11 pm shift. The Clinical Manager-A confirmed the last physician orders for Patient #2 were one to one supervision on 2/20/19 at 08:53 AM for safety and there had not been any subsequent orders to discontinue the one to one staff supervision.
Interview on 3/13/19 at 02:15 PM with the Regional Director of Risk Management (DRM) confirmed that Patient #2 had a physician order for one to one supervision on 2/20/19 and did not have a physician order to discontinue the one to one supervision as of 2/25/19; the time of this incident. The DRM confirmed that one to one supervision cannot be discontinued unless there was a physician order to discontinue; in accordance with the facility's policy. After review of Patient #2's observation/MHT notes for 2/25/19 the DRM confirmed the 3 PM-11 PM failed to document the observation level for one to one supervision on the check sheet; stating she should have been on one to one supervision.
Review of the facility policy for Patient Observation Rounds Policy # PC.3.01 last revised 2/12/19 revealed the following, in part:
Levels of Special Observation included: "one to one (1:1) - This level of observation is the most intense level and is utilized only when a patient is an imminent danger to self or others or if the patient's behavior places the patient in imminent threat of harm. Definition: One staff is assigned the single responsibility of maintaining one patient under constant supervision, within arm's length at all times.
a.) staff is not assigned duties other than the 1:1
b.) Staff must remain in arm's length of patient at all times.
f.) Patient is to remain at a minimum of arm's length away from other patients
Observation Levels: b. Special Observation- included; any indication of suicidal intent, increasing agitation, assaultive behavior, expressed desire to elope ... ...
1.) Special Observation may be initiated by a Registered Nurse (RN) or Physician.
2. If initiated by a RN, a Physician's Order must be obtained and the order must state the clinical indication for the Special Observation.
7.) A Physician's Order is necessary to discontinue or change Special Observation.
Review of the Abuse, Neglect, and Exploitation Reporting, Investigation and Response policy #RI.1.16, last revised 1/25/17 indicated upon employment staff are educated on the definition of abuse, neglect and exploitation as stated in the Texas Administrative Code (TAC), and the staff's responsibilities in responding and reporting allegations or actual instances of abuse, neglect or exploitation.
Review of the facility's training provided to staff (power point) titled Abuse, Neglect, and Exploitation (printed 3/6/19) revealed Neglect included: a negligent act or omission by an individual responsible for providing services to a person served, which caused or may have caused physical or emotional injury or death to a person served or which placed a person served at risk of physical or emotional injury or death.
The following is the definition of neglect according to the Texas Administrative Code (TAC) code RULE §134.46 (Title 25, Part 1, Chapter 134, Subchapter C, in part:
(C) Neglect (as the term is defined in 42 USC, §10801 et seq.) is a negligent act or omission by any individual responsible for providing services in a facility rendering care or treatment which caused or may have caused injury or death to an individual with mental illness or which placed an individual with mental illness at risk of injury or death, and includes an act or omission such as the failure to establish or carry out an appropriate individual program plan or treatment plan for an individual with mental illness, the failure to provide adequate nutrition, clothing, or health care to an individual with mental illness, or the failure to provide a safe environment for an individual with mental illness, including the failure to maintain adequate numbers of appropriately trained staff.