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8550 HUEBNER ROAD

SAN ANTONIO, TX 78240

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

Based on review of records and interviews, the facility's staff failed to ensure patient's rights to receive care in a safe setting for 3 of 3 Patients (Patient #1, #2 and #3) reviewed for Patient Rights; and in accordance with the facility's policies.

Specifically, facility nursing staff failed to:
1.) ensure a safe environment/milieu by failing to conduct a thorough skin and contraband search for Patient #2 who was found with "Xanax" bars that Patient #2 reported she brought through admissions; to the inpatient unit.
As a result, Patient #2 provided Patient #1 with "Xanax" who took a "Xanax" pill and Patient #2 offered Patient #3 a "Xanax" pill, however refused, and reported this to the facility.

2.) thoroughly assess and document a physical assessment for Patient #1 to evaluate potential harm and side effects following an incident where it was reported she took "Xanax" provided by Patient #2.

Findings included:

Review of Complaint TX00414498 Intake information dated 4/4/22 revealed the following, in part:

Patient #1, a 14-year-old female took a "Xanax" she received from another child (Patient #2, a 17-year-old female) who "snuck it into the facility." It is believed that Patient #1 took one "Xanax," though she may have obtained two.

1.) Review of the facility's incident report for Patient (Pt.) #2 revealed the following, in part:
Incident date: 4/2/22, Incident and report time:1900. Report completed by was blank for the Name; and Title indicated "RN" (Registered Nurse).
Description of incident:
Patient #2 was found to have a "baggie containing 2-3 Xanax bars" and had cigarettes also. Patient #2 states that she brought them through admissions in her underwear. Physician #9 notified.

Review of Patient #2's Intake Assessment dated 3/31/22 revealed Patient #2 had a history of substance abuse including "Xanax, Alcohol and Marijuana" all last taken on 3/30/22. Patient #2's laboratory results dated 3/31/22 at 03:50 AM from another facility revealed positive urine results for Benzodiazepine, Cannabinoid and Cocaine.

In an interview during the entrance conference on 4/11/22 at 11:45 AM with the facility's Chief Executive Officer (CEO) stated that Patient #2 refused to have a full skin and safety contraband search completed by refusing to take off her underwear; and that the facility cannot make the Patient's comply with a search because of the "Patient Rights." The CEO expressed past concerns with another agency regarding Patient Rights related to the skin assessment and contraband search that had negative outcomes.

In an interview during the entrance conference on 4/11/22 at 12:00 PM with the facility's Risk Manager stated the facility did not have a specific policy or procedure to address a Patient's refusal of a full skin and safety contraband search.

In an interview on 4/11/22 at 2:15 PM with Admission RN #3 stated each patient was to have a skin assessment and safety check for contraband search conducted in the Admissions area with a 2nd staff present before they are transferred to the inpatient unit. RN #3 stated the contraband search included, "they do need to remove underwear and inspect." RN #3 additionally stated the patient would stand behind a privacy screen and would then be asked to "sit like a frog and cough 3 times" to see if anything falls from the genital area onto the floor. RN #3 was asked what the facility process was for Patient's who refuse to remove their underwear or any part of the skin assessment and safety search, and she indicated the Patient would be asked to go back to the admission holding area/lobby where the patient could think about allowing the skin and safety assessment. RN #3 stated she had to ensure the skin assessment and safety search was completed and the patient "cleared" on her end before allowing a patient to go to the inpatient unit.

Review of Patient #2's Nursing Admission Assessment form for Skin/Body Check for Contraband completed by RN #5 on 3/31/22 at 17:06 documented an assessment which included Top of Left hand slightly red from fall. No swelling. There was a "T" documented on the left and right arm for "Tattoos." For Genitourinary, the box was checked for "Difficulty Urinating." Gastro was checked for "WNL" (within normal limits). There was no indication on the Skin/Body Check Assessment that Patient #2 refused or that this was incomplete skin and safety assessment.

In an interview on 4/11/22 at 3:30 PM with RN #5 who conducted Patient #2's skin assessment and contraband search in Admissions on 3/31/22 at 17:06 stated that it was her 1st day on the floor working in admissions after she had completed orientation. RN #5 stated she began Patient #2's skin assessment and safety contraband check after Patient #5 had a "fall in the lobby." Patient #2 went to the exam room and was in paper scrubs from another facility. RN #5 indicated once she began the assessment for Patient #2, she began "crying inconsolably;" stating her left hand/wrist was hurting. RN #5 stated she then "aborted" the skin assessment and safety contraband check and took Patient #2 to the consult room where there was a recliner; gave her a blanket and allowed Patient #2 to calm down and she stayed in the consult room for a couple of hours. RN #5 stated she only checked Patient #2's arms (both) and her chest area during the skin assessment and safety contraband search before aborting the assessment and confirmed she did not return back for a thorough assessment once Patient #2 calmed down. RN #5 further stated that Patient #2 should have gone back to the exam room to "red-do the skin/safety assessment;" after going to the consult room. RN #5 confirmed Patient #2 went from the Consult room to the unit without a thorough skin and safety/contraband search. RN#5 stated she did not know what the procedures were for a patient who refused to take off their underwear or refused a contraband search; as she "had not encountered that yet" and it was her understanding that the patient had to have a "full exam, skin assessment/contraband search before going to the unit." RN #5 further stated she was just recently told the patient needs to "squat down and cough" while she stands behind the curtain/privacy screen.

Review of the facility's policy titled, Admissions of Patients, Policy #PC.1.07 last revision on 02/01/2021 revealed on page 2 of this document under general rule F states: "The Admissions nurse shall escort patient to the exam room and conduct a skin assessment and safety / contraband check, in the presence of a second staff". The policy did not have further procedures for when a patient refuses a skin assessment and safety/contraband check.

Review of the facility's Training document titled "Skin Assessment and Contraband Search" for general hospital orientation presentation, presented by admissions and undated revealed the following procedures, in part;
The purpose of the skin assessment and contraband search was to ensure patient and staff safety on the units, eliminate contraband in the hospital, ......
For the "SKIN ASSESSMENT; THE PATIENT MUST UNDRESS COMPLETELY.
PLEASE REFER TO THE HOUSE SUPERVISOR ON ANY CONCERNS REVEALED DURING A SKIN ASSESSMENT".

"ITEMS TO BE REMOVED FROM THE PATIENT DURING CONTRABAND SEARCH" included "CONTRABAND SUCH AS LIGHTERS, WEAPONS, DRUGS, MEDICATIONS, ETC."

"SEARCHING THE PATIENTS CLOTHING" included "THE PATIENT NEEDS TO REMOVE ALL ARTICALS OF CLOTHING TO INCLUDE BRAS, SOCKS, UNDERWEAR, HAIR ACCESSORIES, JEWELRY, MAXI PADS/TAMPONS DURING THE SEARCH. ALL OF WHICH MUST BE SEARCHED THOROUGHLY. THE PATIENT MUST SQUAT AND COUGH, UNLESS THERE ARE LEGITIMATELY PHYSICALLY UNABLE TO DO SO ....."

2.) Review of the facility's incident report for Patient (Pt.) #1 revealed the following, in part:

Pt #1 Incident date: 4/2/22 [when reported], Incident time: 1830, Report date:4/3/22 [date incident report completed]. Incident report completed by RN #4.

Description of incident:
Patient #1 disclosed to Mental Health Technician (MHT) #8 and RN #4 that she had accepted a "Xanax" pill the day before; on 4/1/22 and reported taking the pill. The "Xanax" pill came from another peer, Pt. #2.

Further review of the incident report in "RN summary" indicated a check mark for "RN Assessed & Documented, Vitals Taken & Documented." Notifications indicated that Physician #7 was notified on 4/3/22 at 18:30 [the next day after incident reported 4/2/22].

Review of Patient #1's Daily Nursing Assessment/Progress Note dated 4/2/22 at 14:00 indicated RN #4 documented, Pt #1 disclosed she had accepted a contraband "Xanax" bar brought in by another peer (Pt. #2), the previous day and had taken the "Xanax" pill at that time "as well yesterday." Patient #1's RN nursing assessment/progress note did not include physical assessment documentation for vital signs or notification to Physician #7 upon discovery or notification of the incident. The Daily Nursing Assessment/Progress Note dated 4/2/22 had vital signs documented at the top of page 1 by RN #4 which included, Blood pressure 81/60, Pulse 46, Respirations 18 (no time of vital signs taken).

In an interview with RN #4 on 4/11/22 at 2:45 PM stated the vital signs documented on Page 1 of the RN Nursing assessment/progress note for 4/2/22 had been completed "early on; in the morning" of 4/2/22 before it was reported that Patient #1 took a "Xanax" pill. RN #4 says the MHT's take the patients vital signs.

Review of Patient #1 vital signs chart documentation form for 4/2/22 documented vital signs on 4/2/22 and for Time it was indicated, "PM" [no documented actual time]. Blood Pressure 111/71, Pulse 86.

Interview with RN #4 on 4/11/22 at 2:45 PM confirmed the vital signs documented on Patient #1's vital signs documentation for 4/2/22 were not timed and further stated the vital signs were done at "shift change" on 4/2/22 because she had asked the MHT to complete Patient #1's vital signs after Patient #1 reported on 4/2/22 at 18:30 that she took a "Xanax" pill given to her.

Patient #1's Daily Nursing Assessment/Progress Note for the overnight shift; 7PM 4/2/22 to 7:00 AM 4/3/22 was not available in Patient #1's records. Further interview with RN #4 confirmed this progress note was not in the patient's record.

Patient #1's Physician #7 Progress Note dated 4/3/22 at 8:27 AM documented for Assessment: Patient presents to the hospital for Suicide Ideation. Patient appears "out of it, per nursing staff."

Review of the facility's policy for Incident Reports, Policy #RI.1.05, last revised 1/25/2017 revealed the following in part; an Incident Report is to be completed by the employee(s) who witnessed the event or discovered the event. The categories included, but not limited to: Contraband. In the case of a patient incident, facts related to the treatment rendered should be documented in the patient's record. The incident report form includes an area to be completed by the nurse including clinical intervention and documentation of any injury to the patient.

3.) Pt #3 Incident date: 4/2/22, Incident Time: 1820, Incident report date 4/3/22 completed by RN #4

Description of incident:
Patient #3 disclosed to MHT #8 that a peer, Pt. #2 from BB1 [Blue Bonnet 1] offered her "contraband Xanax", to which the Pt reports she declined. Following this the BB2 staff informed the BB1 staff of Pt #2 being in possession of contraband. When the BB1 staff notified RN #6 on BB1 just before shift change, RN #6 replied, "let's leave that for night shift to deal with". The staff on BB1 and myself (RN #4) insisted "we as day shift handle this, then proceeded to talk to [Pt #2] about the contraband which she handed over, this included Xanax pills and cigarettes." Further investigation on the contraband done by BB1.

Review of the facility's Patient's Bill of Rights that is presented to the Patient, last revised 4/15/2006 revealed the following in part:
3. You have the right to a clean and humane environment in which you are protected from harm.
17. You have the right not to be unnecessarily searched unless your physician believes there is a potential danger and orders a search.



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