HospitalInspections.org

Review of documents and interviews revealed the facility failed to ensure a patient's ability to exercise their right to receive their personal property in a timely manner.
Cross refer: CFR 482.13(b)


Review of documentation and interviews revealed that the facility failed to ensure that telephonic consent to treatment with psychoactive medication by a foster parent for a child was witnessed when the foster parent was unable to execute the form in person.
Cross refer: CFR 482.13(b)(2)


Review of documents, observation, and interviews revealed that the facility failed to ensure a patient had the right to personal privacy as a mental health tech hit and physically abused an 83 year old patient, took a video of himself hitting the patient and posted it on social media which was witnessed by another mental health tech.
Cross refer: CFR 482.13(c)(1)


Review of documents, observation, and interviews, revealed that the facility failed to ensure a patient had the right to care in a safe setting as an allegation of patient abuse, a staff member hitting an 83 year old male patient on 4/7/18 was reported by a mental health tech to a registered nurse/charge nurse at the beginning of the 3-11 shift on 4/8/18.

The mental health tech who hit and physically abused the 83 year old patient took a video of himself hitting the patient and posted it on social media which was witnessed by another mental health tech. After being informed of a patient abuse allegation, the charge nurse did not report the incident to the house supervisor or to the hospital administration or to the Texas Department of State Health Services.

The nurse failed to report alleged physical abuse of an elderly person to the employer, appropriate legal authority, and/or licensing board, failed to accurately and completely report and document contacts with other health care team members concerning significant events regarding client's status, and by not reporting, failed to implement measures to promote a safe environment for clients and others. As the allegation was not reported by the license nurse, the tech that abused the elderly patient consequently worked two full shifts (4/8/18 and 4/9/18) in direct patient care after the abuse had been reported. As the registered nurse did not report the allegation of patient abuse, the allegation was not addressed until the mental health tech made a second report via anonymous letter which was received on 4/10/18, when the allegation was confirmed.

Despite an anonymous report on 4/10/18 which stated that the allegation had been reported to the charge nurse on 4/8/18, there was no documented response or action with regard to the lack of reporting by the registered nurse when informed of the allegation on 4/8/18, which was not in compliance with facility policy. Members of facility administration stated on 9/25/18 and on 10/2/18 that they did not realize that the mental health worker reported the allegation to a registered nurse on 4/8/18.

The facility failed to ensure that patients were protected by monitoring a patient at the level of monitoring most recently specified in the patient's medical record, including fall precautions, suicide precautions, assault/homicide precautions, and one-to-one observation. The facility failed to ensure that a nursing assessment, neurological checks, or indication of pain, loss or level of consciousness, or other assessment was conducted for a patient who suffered a fall and hit her head prior to being transported via ambulance to a medical hospital. This presents a safety risk for patients and staff members when they are not monitored or observed as ordered or assessed for potential injury.
Cross refer: CFR 482.13(c)(2)


Review of facility records, observation, and interviews, revealed that the Hickory Trail Hospital failed to ensure that confidential protected health information of patients was protected from unauthorized use, as a patient medical records with specific health information was observed in employee personnel records. Placing patient protected confidential health information in an employee's personnel folder is an unacceptable and unauthorized use of clinical record information without the patient's written consent.Cross refer: CFR 482.13(d)(1)


Review of records and interview, revealed that the facility failed to ensure that direct care staff maintained current training which had not expired in non-violent crisis intervention and restraint/seclusion training and skills demonstration and competence. This was not in compliance with facility policy and state regulation that the facility ensure that staff maintain current training. The facility allowed a staff member to be on duty with patients without documentation that the staff member was compliant in training, which presents a risk that interventions may not be conducted in a safe manner. This was not in compliance with facility policy or state regulation.
Cross refer: CFR 482.13(f)

Based on interviews and review of documents, the facility failed to ensure a patient's ability to exercise their right to receive their personal property in a timely manner.

Findings were:

Review of the medical record for Patient #12 in a facility conference room on the morning of 10/02/18 revealed, the facility failed to ensure the patient's ability to exercise his right to receive his personal clothing in a timely manner.

Review of the hospital admission packet included "The Basic Rights for All Patients" that read in part:

"3. You have the right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs, and are treated with respect and dignity."

10. You have the right to keep and use your personal possessions including the right to wear your own clothing and religious or other symbolic items. You have the right to wear suitable clothing which is neat, clean and well-fitting."


A telephonic interview was conducted with Staff #20, Mental Health Technician (MHT) at approximately 3:00pm on 10/2/18 in the facility conference room. Staff #20 was asked how are patient's clothes delivered to patients when family members deliver them to the facility. Staff #20 stated, "To the best of my knowledge when clothing is approved and items are brought to the front receptionist desk the receptionist calls back to the unit and notifies us. It's the responsibility of one of the techs to walk to the front to retrieve the items." Staff #20 was asked how could a patient's belongings get placed in storage without being given to the patient first. He stated. "The only other time I found items in unit storage was if a new tech or a nurse saw the bag of clothes and didn't know what to do with it and they may have just misplaced the clothes by accident. The staff member was not aware of the correct procedure and unfortunately, the patient doesn't receive the property." Staff #20 was asked how were patient's belongings identified and he stated, "As far as I am aware the receptionist that received the item write patients' name and patients' ID number on the outside of the brown bag."

Based on a review of documentation and interview, the facility failed to ensure that telephonic consent to treatment with psychoactive medication by a foster parent for a child was witnessed when the foster parent was unable to execute the form in person.

Findings included:

Review of the medical record for Patient #7 revealed that Melatonin, Vistaril, and Wellbutrin, psychotropic medications requiring consent were prescribed. Consent forms were observed in the medical record which were signed by an RN, Staff #8, on 9/21/18 at 1332. Staff #8 documented in the "Informed Consent Granted via Telephone" with a name, however, the "Relationship to Patient" space was left blank. Staff #8 also signed in the space for the Witness and there was no documented evidence that the telephonic consent for psychotropic medications was witnessed. A staff member may not be their own witness. The physician signed the form on 9/22/18, however did not witness the informed consent granted via telephone the previous day.

The above findings were confirmed in an interview the afternoon of 9/25/18 with Staff #2 in the facility conference room.

Based on observation, interviews, and review of documents, the facility failed to ensure a patient had the right to personal privacy as a mental health tech hit and physically abused an 83 year old patient and took a video of himself hitting the patient and posted it on social media which was witnessed by another mental health tech.


Findings included:


Review of the medical record for Patient #2 revealed, he was an 83 year old male, admitted to Hickory Trail Hospital on 4/4/18 and placed on Fall Precautions and Assault/Homicide Precautions on one-to-one 24-hours a day monitoring on the date of admission for safety reasons, which included "fall/agitation/safety round the clock".


The facility Event Description was provided to the surveyor the morning of 9/24/18, which summarized the history and hospital stay for Patient #2, and included an incident of physical abuse by a staff member. Facility investigation stated that, "On 4/10/18 an anonymous note was noted to be found in the Risk Manager's office..." The note stated that "on the night of April 7 at approximately 8pm-9pm the writer, [Staff #5], MHT witnessed [Staff #4] hitting the patient [Patient #2] in the upper arms, and chest, and [Patient #2] hitting him back ...[Staff #5] stated she then witnessed [Staff #4] actually hit the patient in his upper arms, and chest, and [Patient #2] was hitting him back and [Staff #4] handled the patient aggressively in the bed and did not utilize proper transferring techniques ...[Staff #5] also stated that she confided in a coworker, [Staff #23], mental health tech, who told her that there was a (now deleted) snap chat video of [Staff #4] fighting with the 1:1 patient [#2] on camera. A statement was taken from [Staff #23] who stated that the video had [Staff #4] and [Patient #2] both hitting each other and goes on to say that [Staff #4] was actually punching the patient with a closed hand. [Staff #23] also states that the events took place on April 7, 2018 and the video was uploaded to snapchat."


Attached to the Investigation report was a color copy of a headshot photo of Patient #2, who had a fair complexion, with long-ish, mussed, loose white hair around his face, thin on top, and white facial hair.


Witness Statements were provided to the surveyor the afternoon of 9/24/18 in the facility conference room. An anonymous, typed witness statement, dated April 8, 2018, provided to the surveyor stated, "Hickory Trail Staff Re: Possible patient abuse. On last night (Saturday April 7, 2018, at approximately 8:00-9:00pm I witnessed a tech, [Staff #4] hitting a 1:1 patient ...I was later told by another mht that there was a (now deleted video) on snap chat of the same mht fighting with another 1:1 patient."


Staff #5 submitted a typed and signed witness statement, dated April 11, 2018, provided to the surveyor on 9/24/18 which stated, "Hickory Trail Staff On Saturday April 7,2018, I witnessed a MHT, [Staff #4] hitting a 1:1 patient. I was working 3-11pm shift as an MHT, and he was the mht assigned to the 1:1 patient ...As the night progressed, approximately 8:00-9:00, I WITNESSED the mht actually hit the patient in his upper arms, and chest, and the patient hitting him back...I also confided in a co-worker, who told me that there was a (now-deleted) snap chat video of the same mht fighting with another 1:1 patient on camera. This is my sworn statement to what I observed." The witness statement was signed by Staff #5.


A handwritten witness statement by Staff #23, MHT, dated "4-12-18" stated, "[Staff #23] In regards to the conversation I had with [Staff #5] about [Staff #4] hitting a Geri patient, and uploading the video on social media. The video had [Staff #4] and the Patient both hitting each other, [Staff #4] was actually punching the patient w/ a closed hand. This took place on April 7, 2018. The video was uploaded to snapchat. And, April 17, 2018 I actually seen the video of [Staff #4] hitting the patient w/ my own eyes."


An interview was conducted with Staff #5, MHT on 9/25/18 at 10:05 am in the facility conference room. When asked by the surveyor if she knew anything about Patient #2 and Snapchat social media, Staff #5 stated, "They asked me did I tell anybody else besides [Staff #10]. I did. I had a coworker and told him, I felt comfortable telling him [Staff #23]. He asked, 'Was it a white guy?' I said, 'No, he was on 1-1 with this patient. [Staff #5 pointed to a photo of Patient #2]. He made a video on snapchat. I knew he had to see it because he never worked on Unit 3. He wouldn't know the patient. [Staff #23] worked on unit 5."

Staff #5 stated that she said, "[Staff #23], I saw [Staff #4] hitting a patient last night, and he said, 'I believe you. Was it a white patient?' 'No it's a Mexican guy. He posted a video of him with a white guy and him fighting?"


Staff #5 stated, while pointing to a photo of Patient #2, "That patient was the patient that he posted the snapchat video. Then I knew there was no doubt."


A telephonic interview was conducted with Staff #23, former employee and MHT at the facility on 10/2/18 at 4:19 pm. Staff #23 stated that he remembered the incident involving a Snapchat video uploaded of staff member Staff #4 fighting with a patient. When asked by the survey team how many videos were uploaded and how many different patients were involved, Staff #23 stated that there was "just one video that [Staff #4] has uploaded. That one patient that I had seen. The video stayed on Snap Chat 24 hours." When asked if Staff #23 remembered the patient, he stated, "I do remember that patient." When asked if Staff #23 could describe the patient, he stated, that the patient was "heavy set, Caucasian, bald on top with white hair all around his face. He was in a wheelchair." The description provided by Staff #23 was consistent with the photo of Patient #2.


Facility policy, "HR 100.65 Social Media" stated, in part, "Employee Responsibilities When Using Social Media For Personal Reasons ...

An employee's online communications and engagement in Social Media must never conflict with the employee's duty to the Facility, its patients ...Nothing an employee does online should ever: ...

3. reveal any information that is confidential, specific to patients or patient health information (i.e., including information that is contrary to HIPAA regulations) ...

Employees may never post video, audio, or any photo that taken at or in Facility of a patient ...

Employees may never post any information that is confidential or specific to patients ..."


The above findings regarding the physical abuse of Patient #2 were confirmed in an interview with Staff #1 and Staff #2 the afternoon of 10/2/18 in the facility conference room.

Based on observation, interviews, and review of documents, the facility failed to ensure a patient had the right to care in a safe setting as an allegation of patient abuse, a staff member hitting an 83 year old male patient between 8 pm and 9 pm on 4/7/18 was reported by a mental health tech to a registered nurse/charge nurse at the beginning of the 3-11 shift on 4/8/18. The mental health tech who hit and physically abused the 83 year old patient took a video of himself hitting the patient and posted it on social media which was witnessed by another mental health tech.

After being informed of a patient abuse allegation, the charge nurse did not report the incident to the house supervisor or to the hospital administration or to the Texas Department of State Health Services. The nurse failed to report alleged physical abuse of an elderly person to the employer, appropriate legal authority and/or licensing board, failed to accurately and completely report and document contacts with other health care team members concerning significant events regarding client's status, and by not reporting, failed to implement measure to promote a safe environment for clients and others.

As the allegation was not reported by the license nurse, the tech that abused the elderly patient consequently worked two full shifts (4/8/18 and 4/9/18) in direct patient care after the abuse had been reported. As the registered nurse did not report the allegation of patient abuse, the allegation was not addressed until the mental health tech made a second report via anonymous letter which was received on 4/10/18, when the allegation was confirmed.

Despite an anonymous report on 4/10/18 which stated that the allegation had been reported to the charge nurse on 4/8/18, there was no documented response or action with regard to the lack of reporting by the registered nurse when informed of the allegation on 4/8/18, which was not in compliance facility policy. Members of facility administration stated on 9/25/18 and on 10/2/18 that they did not realize that the mental health worker reported the allegation to a registered nurse on 4/8/18.

The facility failed to ensure that patients were protected by monitoring the patient at the level of monitoring most recently specified in the patient's medical record, including fall precautions, suicide precautions, assault/homicide precautions, and one-to-one observation.

The facility failed to ensure that a nursing assessment, neurological checks, or indication of pain, loss or level of consciousness, or other assessment was conducted for a patient who suffered a fall and hit her head prior to being transported via ambulance to a medical hospital. This presents a safety risk for patients and staff members when they are not monitored or observed as ordered or assessed for potential injury.


Findings:


Review of the medical record for Patient #2 revealed, he was an 83 year old male, admitted to Hickory Trail Hospital on 4/4/18 and placed on Fall Precautions and Assault/Homicide Precautions on one-to-one 24-hours a day monitoring on the date of admission for safety reasons, which included "fall/agitation/safety round the clock".


The facility Event Description was provided to the surveyor the morning of 9/24/18, which summarized the history and hospital stay for Patient #2, and included an incident of physical abuse by a staff member. Facility investigation stated that, "On 4/10/18 an anonymous note was noted to be found in the Risk Manager's office. After further investigation it was noted the writer was an MHT who worked on the same shift as [Staff #4]." The note stated that "on the night of April 7 at approximately 8pm-9pm the writer, [Staff #5], MHT witnessed [Staff #4, MHT] hitting the patient [Patient #2] in the upper arms, and chest, and [Patient #2] hitting him back ...[Staff #5] stated she then witnessed [Staff #4] actually hit the patient in his upper arms, and chest, and [Patient #2] was hitting him back and [Staff #4] handled the patient aggressively in the bed and did not utilize proper transferring techniques.

During interview [Staff #5] demonstrated how [Staff #4] threw [Patient #2] on the bed. [Staff #5] stated that the roommate for [Patient #2] then began telling her that [Patient #2] and [Staff #4] had been in his room fighting. [Staff #5] also stated that she confided in a coworker, [Staff #23], mental health tech, who told her that there was a (now deleted) snap chat video of [Staff #4] fighting with the 1:1 patient [Patient #2] on camera. A statement was taken from [Staff #23] who stated that the video had [Staff #4] and [Patient #2] both hitting each other and goes on to say that [Staff #4] was actually punching the patient with a closed hand. [Staff #23] also states that the events took place on April 7, 2018 and the video was uploaded to snapchat."


The facility investigation report stated that a review of the unit video was conducted by the risk manager, assistant director of nursing, and the clinical services director. The CEO reviewed the video later. "Interviews were conducted with [Staff #4] and [Staff #5] on 4/11/18. Interviews were conducted with [Staff #23] on 4/12/18. Statements were gathered from all parties ...After conducting follow up interviews it was determined that the two MHT's did not know of [Staff #4] hitting any other patients ...Actions taken regarding [Staff#4] was suspended pending further investigation on 4/11/18. [Staff #4] was then terminated following investigation 4/13/18."


Attached to the Investigation report was a color copy of a headshot photo of Patient #2, who had a fair complexion, with loose white hair around his face, thin on top, and white facial hair.


An interview was conducted with Staff #2 Risk Manager on 9/25/18 at 9:35 am in the facility conference room, who confirmed the documented incident above as reported. Staff #2 stated that Staff #4 was suspended on 4/11/18 and terminated on 4/13/18. Staff #2 stated that the police department was notified and all staff were trained on patient rights and incident reporting. Staff #2 stated that the facility was unaware of the patient abuse allegation until 4/10/18, when an anonymous note was found in the morning under her door.


However, review of witness statements from Staff #5 dated 4/8/18 and 4/11/18, and interviews conducted by the survey team with Staff #5 MHT, and Staff #10, RN, revealed that a licensed registered nurse at the facility was aware of the allegation of physical abuse of a patient at the beginning of the 3-11 shift on 4/8/18 as Staff #5 reported the allegation to Staff #10. Staff #10, RN, failed to report the alleged physical abuse allegation, which was not in compliance with facility policy. On 4/10/18, after Staff #5 reported the incident to Staff #10, Staff #5 made a second report of the physical abuse of Patient #2 by leaving an anonymous note under the door of the risk manager ' office, which was found by the risk manager, Staff #2, the morning of 4/10/18.


Witness Statements were provided to the surveyor the afternoon of 9/24/18 in the facility conference room. An anonymous, typed witness statement, dated April 8, 2018, provided to the surveyor stated,

"Hickory Trail Staff Re: Possible patient abuse.
On last night (Saturday April 7, 2018, at approximately 8:00-9:00pm I witnessed a tech, [Staff #4] hitting a 1:1 patient. At first, I wasn't sure if he was hitting him, or if he was just blocking licks from an aggressive patient. However, I continued to observe and monitor the action from time to time, from the nurses station, (unseen,) and I'm positive I saw licks passed and rough, aggressive handling of the patient, by the MHT. About an hour later I had to relieve the mht for a 15 minute break, and sit with the patient my self. At that time, the patients roommate revealed to me that his roommate and the mht was in the room fighting earlier and that's why he could not sleep. I was shocked.
I went home to taka (sic) in what I saw and was told, and at the beginning of my shift today, I went and spoke with the charge nurse of that unit. I was later told by another mht that there was a (now deleted video) on snap chat of the same mht fighting with another 1:1 patient. This communication is only intended to investigate and solve possible abuse, and insure the safety of the patients I care for. Thank you."


An interview was conducted with Staff #2 at approximately 11: 45 am on 9/25/18 in the facility conference room, who was asked when she received the above anonymous allegation of patient abuse. Staff #2 stated that she received the allegation on Tuesday, April 10th [2018] in the morning when she arrived to work and stated it was a typed, anonymous note which had been placed under her office door.


After the identity of the anonymous reporter was determined by facility administrative staff, administrative staff requested that Staff #5 submit a typed and signed witness statement. The second, signed witness statement from Staff #5 was dated April 11, 2018 and stated,

"Hickory Trail Staff
On Saturday April 7,2018, I witnessed a MHT, [Staff #4] hitting a 1:1 patient. I was working 3-11pm shift as an MHT, and he was the mht assigned to the 1:1 patient ...As the night progressed, approximately 8:00-9:00, I WITNESSED the mht actually hit the patient in his upper arms, and chest, and the patient hitting him back. I also observed the mht aggressively handling the patient in bed, (not using proper moving techniques to move the patient around.) When I was sure the mht actually was hitting the patient I went into the room on several occasions to calm the situation. I did not address the mht at that time, and the mht did not hit the patient when he knew I was looking, but I did speak to the patient politely in a way that the mht knew I saw the licks between them both ...At one point I had to relieve the mht for his 15 minute break, and I was assigned to sit with the 1:1 patient. Upon sitting down I noticed that his roommate was still awake, so I spoke to him and asked him was he tired, (because I noticed him yawning,) he then began to tell me that the 1:1 patient and the mht had been in his room fighting, and that's why he could not sleep. I did not speak to anyone that night about it but, before my shift began the next day, I went to that unit, and spoke with the charge nurse on that unit to inform her of what I saw. I also confided in a co-worker, who told me that there was a (now-deleted) snap chat video of the same mht fighting with another 1:1 patient on camera. This is my sworn statement to what I observed." The witness statement was signed by Staff #5.


A handwritten witness statement by Staff #23, MHT, dated "4-12-18" stated, "[Staff #23] In regards to the conversation I had with [Staff #5] about [Staff #4] hitting a Geri patient, and uploading the video on social media. The video had [Staff #4] and the Patient both hitting each other, [Staff #4] was actually punching the patient w/ a closed hand. This took place on April 7, 2018. The video was uploaded to snapchat. And, April 17, 2018 I actually seen the video of [Staff #4] hitting the patient w/ my own eyes."


There was no witness statement provided to the surveyor from [Staff #10], RN, identified as the charge nurse to whom Staff #5 reported the abuse within 24 hours on 4/8/18, at the beginning of the evening shift. There was no documentation that Staff #10, the charge nurse who received the allegation of abuse, ever reported the allegation or took any action after the allegation was reported to her.


An interview was conducted with Staff #2, Risk Manager on 9/25/18 at 9:35 am in the facility conference room, who stated that Staff #4 worked two shifts on a unit with patients in direct care after the incident occurred, since the patient abuse was "not reported." Staff #2 acknowledged that something bad could have happened during those two shifts (4/8/18 and 4/9/18) and there could have been further abuse by Staff #4 during the two shifts Staff #4 worked after the patient abuse occurred.


Review of the iSeries Timekeeper: Hickory Trail 4/7/18 through 4/9/18 sheets for employee Staff #4 revealed that he worked on 4/7/18, 4/8/18, and 4/9/18 on the evening shift at the facility as a MHT.


In an interview with Staff #2 at 2:55 pm on 9/25/18, the surveyor asked if she had discussed the incident with Staff #10, RN, the charge nurse to whom Staff #5 reported the incident on 4/8/18. Staff #2 stated, "No, we have not." When asked if anyone at the facility talked to Staff #10 about her duty or failure to report the incident since Staff #5 reported the incident to her, Staff #2 stated, "No." When asked if a statement was obtained from Staff #10 regarding the MHT reporting an allegation of patient abuse, Staff #2 stated, "No." When Staff #2 was asked if she was aware that Staff #5 reported the incident to Staff #10 on 4/8/18 at the beginning of her shift, Staff #2 stated, "No."


The witness statements from Staff #5, MHT, were reviewed with Staff #2. The witness statement dated 4/8/18 found by Staff #2 on 4/10/18 stated, in part, " ...I went home to taka (sic) in what I saw and was told, and at the beginning of my shift today, I went and spoke with the charge nurse of that unit." Additionally, the witness statement dated 4/11/18 stated, in part, " ...I did not speak to anyone that night about it but, before my shift began the next day, I went to that unit, and spoke with the charge nurse on that unit to inform her of what I saw."


After review of the witness statements, Staff #2 confirmed that Staff #5 documented on the statement received under the door of Staff #2 on 4/10/18 and the second statement submitted on 4/11/18 that she reported the allegation of physical abuse to the charge nurse at the beginning of the shift of 4/8/18.


After review of the witness statements on 9/25/18, Staff #2 confirmed that the alleged patient abuse was reported within 24 hours to a licensed nurse, a charge nurse on duty, who did not report the incident to facility administration, therefore, Staff #4 did work on the unit with patients for an additional two shifts, on 4/8/18 and 4/9/18 after the patient abuse allegation was reported by Staff #5 to Staff #10, RN at the beginning of the shift on 4/8/18.


An interview was conducted with Staff #5, MHT on 9/25/18 at 10:05 am in the facility conference room. When provided with the medical record and a photo for Patient #2, Staff #5 stated that she remembered the patient.


Staff #5 was asked about the alleged patient abuse involving Patient #2 and Staff #4, MHT and the statements that she provided to the facility. Staff #5 stated that, "I did report what happened. I was not scheduled for that unit that day [4/7/18], I had been working on kids unit and it was 3-11, roughly around 7 o ' clock, I got a call I was needed on unit 3, short staffed, go to that unit. When I walked in, [Staff #4] was 1 to 1 with a patient ...They went into the room, [Staff #4] and [Patient #2] ...Later on as time passed by, I saw [Staff #4] in day area, not really letting the patient move around free, holding the back of his shirt. Sometimes aggressive, he was holding back of shirt ...I went into the room, [Patient #2] had a roommate. I do know that he [the roommate] knew enough to talk to you, to have a full conversation with the roommate.


Staff #5 stated that from the nurses station, you can look directly into room and can see into room. I saw hand motions. I thought maybe he [Staff #4] was blocking [Patient #2]'s arms. I thought I will pay attention. I thought I saw hit him, but I didn't want to make allegations. I started paying attention more. I saw what I saw. I got up, walked to room. I said, "Are you okay, [Staff #4]? [Patient #2], are you fighting [Staff #4]?" He [Patient #2] was like, 'yea, he's fighting me.' I started watching even more. I had to relieve [Staff #4] for a break. I sat in the room with the patient. The roommate used foul language. He [roommate] said, 'They been fighting like a mf.' I asked the patient, "Did he hit the tech or the tech hit the patient?' The roommate said, 'They were fighting.' Other things I had seen how he was handling him in bed - he was sitting on the patient's bed, hitting him in the chest area [Staff #5 physical demonstrated pushing, and leaning against a patient lying down]."


Staff #5 stated, "I reported it the next day to the charge nurse. I worked 3-11 the next day and reported it to the charge nurse, [Staff #10]. I knocked on the med room door, told her what I saw and that I was nervous. I reported it to her because she was charge nurse that day. She told me she would keep an eye out, whatever my decision was. I told her I was going to report it to [Staff #2, Risk Manager] ...I typed the letter after I talked to the nurse."


When asked by the surveyor if she knew anything about Patient #2 and Snapchat (social media), Staff #5 stated, "They asked me did I tell anybody else besides [Staff #10]. I did. I had coworker and told him, I felt comfortable telling him [Staff #23]. He asked, 'Was it a white guy?' I said, 'No, he was on 1-1 with this patient. [Staff #5 pointed to a photo of Patient #2]. He made a video on snapchat. I knew he had to see it because he never worked on Unit 3. He wouldn't know the patient. [Staff #23] worked on unit 5." Staff #5 stated that she said, "I saw [Staff #4] hitting a patient last night, and he said, 'I believe you. Was it a white patient?' 'No it's a Mexican guy. He posted a video of him with a white guy and him fighting?" Staff #5 stated, while pointing to a photo of Patient #2, "That patient was the patient that he posted the snapchat video. Then I knew there was no doubt."


A telephonic interview was conducted with Staff #23, former employee and MHT at the facility on 10/2/18 at 4:19 pm. Staff #23 stated that he remembered the incident involving a Snapchat video uploaded of staff member Staff #4 fighting with a patient. When asked by the survey team how many videos were uploaded and how many different patients were involved, Staff #23 stated that there was "just one video that [Staff #4] has uploaded. That one patient that I had seen. The video stayed on Snapchat 24 hours." When asked if Staff #23 remembered the patient, he stated, "I do remember that patient." When asked if Staff #23 could describe the patient, he stated that the patient was "heavy set, Caucasian, bald on top with white hair all around his face. He was in a wheelchair." The description provided by Staff #23 was consistent with the photo of Patient #2.


A telephonic interview was conducted at 6:54 pm on 9/26/18 with Staff #10, RN to whom Staff #5 reported the patient abuse allegation on 4/8/18. Staff #10 confirmed that she worked on 4/7/18 and on 4/8/18. When asked if she could relate what happened with Patient #2, Staff #10 stated that on 4/8/18, "[Staff #5], one of the mental health techs comes to me and says, 'you know last night while I was trying to put that patient's roommate to bed,' she said, 'well, they were fighting all night, they've been fighting all night.'... I asked her, did she see it. She said, 'that's what he said while I was put him to bed.' I asked her what time was this. She said, 'well, maybe 9 o'clock.' ... So now I was busy trying to serve dinner and usually around that time it gets really busy to the end of the shift. I said her, you know what, go talk to the supervisor because I wasn't here when that happened and I have no way of investigating and I told her, you know what you can do also, I think [Staff #2] is the Patient Advocate, so you need to notify her because they have access to cameras and they can watch what ' s happening at that time. So I asked her, 'did you talk to the nurse on duty at that time?' She said no.

So I told her just go talk to the supervisor right now and write something for [Staff #2] so when they get here in the morning they investigate that. Now this was the day after the 7th. This was a Sunday."

When asked by the surveyor if she reported the alleged patient abuse to anybody, Staff #10 stated, "I did not. I was going to follow up with [Staff #2] to see if they found out what happened and before I could even do - as soon as she got there that morning [4/11/18], she called and said, 'oh by the way, we're having a root cause analysis.' "

When asked by the surveyor if she reported the allegation of patient abuse to the house supervisor, Staff #10 stated, "Because I did not have the details and it sounded like a hearsay, I did not."

When asked if Staff #10 followed up with the house supervisor or the risk manager to see if the alleged patient abuse had been reported, Staff #10 stated, "I did not."

When asked if Wednesday 4/11/18 when Staff #10 returned to work was the first time Staff #10 followed up on the alleged patient abuse, Staff #10 stated, "Correct."

When asked if Staff #10 was familiar with facility policy of reporting and if it had been reviewed with her, Staff #10 stated, "They did at that point and I guess because I got so busy I just kind of got lost in the whole situation. At this point, yeah, I know I could have done a couple of things differently."

When asked if Staff #10 was aware of the duty to report as a registered nurse, Staff #10 stated, "I do realize that, yes. What held me back is that I did not know that there was an actual thing that happened."

When asked if Staff #10 felt like it was her responsibility to make that decision, whether something really happened or not, Staff #10 stated, "Probably not. No."

When asked if Staff #10 wrote a statement at any time about the alleged patient abuse, Staff #10 stated, "I did not."

When asked if a request was made for Staff #10 to write a statement by anybody at the facility, Staff #10 stated, "No."

When asked if there was discussion of Staff #5 reporting the alleged physical abuse to Staff #10 at the facility meeting held on 4/12/18, Staff #10 stated, "They did tell me that [Staff #5] talked to you on the phone when she came in [on 4/8/18] and I agreed that yes she did ...All I know is this is what one person said, the patient said this, and did [Staff #5] told you that, and I said yes."


A second interview was conducted with Staff #5, MHT at 7:50 am on 10/2/18 in the facility conference room. Staff #5 stated, that "After I saw everything, I went home, I didn't report it that night [4/7/18]. I was scheduled the very next day to work on the kids unit. I was on unit 6, the kids unit. I didn't report to my unit right away. [Staff #10] was on unit 3, [Patient #2] ' s unit. I went back there [Unit 3] for two reasons. First, to report chain of command, to the charge nurse on the unit. Another reason I did it, I didn't want him [Staff #4] to be back on that unit with that patient again ...On the 8th, when I reported to work, I went to Unit 3. When I went to Unit 3 to report it, I reported it around 2:45, 3 pm. I told her [Staff #10] what I saw, [Staff #4] hitting on a patient, and what patient [Patient #2]. I found out about it the night it happened [4/7/18]. I told [Staff #23] before I told [Staff #10]. On the 8th, when I came to work, I reported it to [Staff #10] at beginning of the shift. I said, 'I really need to tell you something' and I told her what I saw."


Staff #5 continued, "Once I told [Staff #10], I felt like my duty was done and I reported it in the time frame I was supposed to do it ...I wrote the letter after I went home. I wrote this letter [the anonymous letter dated 4/8/18] at home...it was Monday night [4/9/18]. I just did the chain of command, if there was a gap, that's where the ball dropped."


When asked if Staff #10 instructed her to talk to the house supervisor, Staff #5 stated, "No, she didn't tell me to report it to anybody. I told her my plans to go tell the Patient Advocate, [Staff #2]. Staff #10 said 'I think that's the right thing to do.' I did not talk to the house supervisor. Staff #10 didn't say anything about writing it up and reporting it, because later I found out I was supposed to be issued a form. She didn't tell me to do anything. I took initiative on my own to do type it up. I printed it from their printer in the copy room. And on Monday night I put it under [Staff #2]'s door. I didn't even go to my unit, I went straight to tell her on Sunday when I got there."


When asked about the facility meeting on 4/12/18, to review the patient abuse, Staff #5 stated, "Yes, [Staff #10], the charge nurse was at the meeting when I came." When asked if there was any discussion at the meeting that Staff #5 had reported the alleged patient abuse to Staff #10 the next day, Staff #5 stated, "Yes, it was all discussed that I told the charge nurse. [Staff #10] was there."


In an interview with Staff #2 and Staff #1 the afternoon of 10/2/18, they stated that they "completely overlooked" the fact that the mental health tech [Staff #5] reported the alleged patient abuse to the registered nurse [Staff #10] at the beginning of the shift on 4/8/18 which was not reported and resulted in no action and Staff #4 working in direct patient care for two shifts. Staff #2 and Staff #1 stated that the failure of the registered nurse to report the alleged patient abuse was not addressed with the registered nurse.


A face to face interview was conducted on 10/2/18 at 8:36 am with Staff #17, the house supervisor for the 3-11 shift on 4/7/18. When asked if she was notified about an incident involving a staff member hitting a patient on the 3-11 shift on 4/7/18 or 4/8/18, Staff #17 stated, "No they never told me anything about that."


Facility policy, "PR 100.01 Patient Rights" stated, in part, "III BASIC RIGHTS FOR ALL PATIENTS ...

3. You have the right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs and are treated with respect and dignity ...

5. You have the right to be free from mistreatment, abuse neglect and exploitation."


Facility policy, "PR 100.02 Patient Abuse/Neglect" stated, in part, It is the policy of Hickory Trail Hospital to report all incidents of patient abuse, neglect, and exploitation within twenty-four (24) working hours of the time the incident occurred ...

The following shall govern abuse, neglect, and exploitation reporting:

1. Any person who reasonably believes or who knows of information that would reasonably cause a person to believe that a patient has been, is, or will be adversely affected by abuse or neglect, shall, as soon as possible, report the information to the Texas Department of Health.

2. Abuse or neglect of elderly or disabled persons ...shall be reported to the Texas Department of Health.
The definition for "Abuse" includes:

Any act or failure to act by an employee of a hospital which was performed or which was failed to be performed knowingly, recklessly, or intentionally and which caused or may have caused, injury or death of a patient, and includes such acts as ...

2. The striking of a patient;"


Facility policy, "PI 100.06 Critical Incident Reporting" stated, in part, "Critical incidents are defined as those incidents falling into one of the following categories: ...

7. Major altercation or threat between patients or between staff and patients.

8. Physical harm to others, occurring during treatment or within 30 days of discharge ...The Risk Manager or designee should report any Critical Incidents within 24 hours to the Hospital Administrator and Medical Director."


Facility policy, "HR 100.42 Employee Conduct & Work Rules" stated, in part, "The types of misconduct identified below are merely examples of the conduct that may lead to such corrective action. This is not an all-inclusive list of all types of conduct that can result in corrective action up to and including immediate employment termination.
A. Verbal or physical abuse/threats, intimidating, swearing, disruptive, or coercing behavior directed toward ... a patient, visitor or Facility employee."


Facility policy, "HR 100.65 Social Media" stated, in part, "Employee Responsibilities When Using Social Media For Personal Reasons ...

An employee ' s online communications and engagement in Social Media must never conflict with the employee ' s duty to the Facility, its patients ...Nothing an employee does online should ever: ...

3. reveal any information that is confidential, specific to patients or patient health information (i.e., including information that is contrary to HIPAA regulations) ...
Employees may never post video, audio, or any photo that taken at or in Facility of a patient ...
Employees may never post any information that is confidential or specific to patients ..."


Review of the Texas Nurse Practice Act 217.12, Unprofessional Conduct, states, in part,

"The following unprofessional conduct rules are intended to protect clients and the public from incompetent, unethical, or illegal conduct of licensees. The purpose of these rules is to identify behaviors in the practice of nursing that are likely to deceive, defraud, or injure clients or the public. Actual injury to a client need not be established. These behaviors include but are not limited to ...

(6) Misconduct--actions or conduct that include, but are not limited to:

(C) Causing or permitting physical, emotional or verbal abuse or injury or neglect to the client or the public, or failing to report same to the employer, appropriate legal authority and/or licensing board;"


The above findings regarding the physical abuse of Patient #2 were confirmed in an interview with Staff #1 and Staff #2 the afternoon of 10/2/18 in the facility conference room.


Review of the medical record for Patient #3 revealed that he was a 10 year old male on Suicide Precautions on 8/24/18. Nursing progress note at 10:42 on 8/24/18 stated, in part, " ...He looks sad by affect. He denied SI, SVH, HI and anger. He endorses depression and rated 9/10 and anxiety 5/10. Patient said he was having suicidal thoughts on admission but not anymore ..." Nursing progress note at 12:05 on 8/24/18 stated, in part, "MHT said patient and his roommate were talking sexually inappropriate and make inappropriate gesture too ..."


Review of the Hickory Trail Hospital Observations form for 8/24/18 revealed that Patient #3 was observed at 1715, but there was no observation documented again until 1845. Patient #3, a patient on suicide precautions with 15 minute observations with 9/10 depression and sexual acting out was not observed for 1 1/2 hours, which presents a safety risk for Patient #3 and for other patients and staff in the unit due to sexual acting act.


Review of the medical record for Patient #2 revealed that he was an 83 year old male admitted on 4/4/18 and was placed on Fall Precautions and Assault/Homicide Precautions with Q 15 minute observation with 1:1 monitoring on 4/4/18. During the Intake Psychiatric Assessment at 1749 on 4/4/18, the physician documented that Patient #2 was admitted for attempted harm to others, specifically "pushed lady out of her wheelchair" and that he "tried to hit staff member during assessment", that he "puts everything in his mouth", and that he was "trying to pick up 'nothing' off the ground."


Review of the Hickory Trail Hospital Q15 Observation Form for 4/4/18 revealed that Patient #2 was observed at 1900, but there was no observation documented again until 1945. Patient #2, a patient on fall precautions, assault/homicide precautions, and 1:1 observation was not observed for 45 minutes, which presents a safety risk for Patient #2 for a fall or injury, and a safety risk for other patients and staff due to his recent aggressiveness.


Review of the medical record for Patient #11 revealed that she was on Assault/Homicide precautions with Q15 minute Observations. Review of the Hickory Trail Hospital Q15 Observation Form for 4/28/18 revealed that Patient #11 was observed at 1330, but there was no observation documented again until 1415, with no observation for 45 minutes documented.


The above findings, the lack of observation for Patient #2 and Patient #3 were confirmed with Staff #2 at 11:30 am on 9/25/18 in the facility conference room.
The lack of observation for Patient #11 was confirmed with Staff #12 at 3:30 am on 10/2/18 in the facility conference room.


Facility policy, "NS 600.14 Levels of Observation" stated, in part, "All patients will be routinely observed in compliance with physician orders and prescribed protocols ...F. Staff completes the patient observation record as rounds are made, using the coding system described o

Based on review of facility records, observation, and interviews, it was determined that this hospital failed to ensure that confidential protected health information of patients was protected from unauthorized use in that protected patient medical records with specific health information were observed in employee personnel records. Placing patient protected confidential health information in an unrelated employee's personnel folder is an unauthorized use of clinical record information without the patient's written consent.


Findings:

Review of the personnel record of Staff #10 revealed copies of protected health information of a patient, with 11 pages of patient specific information from May 2016 about the patient's health and treatment including a patient stamp on the pages with identifying information, name, date of birth, treating physician, and admission date. The records of the patient consisted of interdisciplinary progress notes, observations notes, and 24 hour nursing assessments.


Review of the personnel record of Staff #4 revealed protected health information from the medical record of a patient with the patient's name, date of birth, and other identifying information.


Facility policy, "HP100.04 Patient Rights Under the HIPAA Privacy Rule" stated, in part, "Recognizing the importance of a patient's privacy rights, UHS maintains a comprehensive system of policies and procedures to help ensure that a patient's privacy rights are protected."


Review of the hospital admission packet included "The Basic Rights for All Patients" that stated in part:

"18. You have a right under HIPAA (Health Insurance Portability and Accountability Act) to have your confidentiality rights explained to you at admission. You will be provided a written copy of your confidentiality rights, including how to make a complaint ....

20 You have the right to have your records kept private and to be told about the conditions under which information about you can be disclosed without your permission, as well as how you can prevent any such disclosures."


There was no documented evidence of a facility policy or procedure referencing accepted professional standards and practices which allowed protected health information of patients to be used for employment or personnel issues. There was no documented evidence that the facility patients had consented to the above use of their confidential health information.

The above findings were confirmed in an interview with Staff #2 the afternoon of 10/2/18 in the facility conference room.

Based on review of records and interview, the facility failed to ensure that direct care staff maintained current training in non-violent crisis intervention and restraint/seclusion training and skills demonstration and competence which had not expired. This was not in compliance with facility policy and state regulation that the facility ensure that staff maintains current training. The facility allowed a staff member to be on duty with patients without confirmation or documentation that the staff member was compliant in training, which presents a risk that interventions may not be conducted in a safe manner. This was not in compliance with facility policy or state regulation.

Findings included:

The personnel record for Staff #10 was reviewed the morning of 9/25/18. Review of the personnel record for Staff #10, RN, revealed that her CPI (Crisis Prevention Institute) training expired on 4/2018. The expired CPI card was confirmed in an interview the morning of 9/25/18 with Staff #2.
Staff #10 confirmed in an interview the afternoon of 9/26/18 that she had worked on the unit after 4/2018.

The afternoon of 9/26/18 at 4:26 pm, an email was received from Staff #2 providing a copy of a CPI card for Staff #10 expiring 10/2018.
Staff #2 acknowledged that the facility failed to ensure and should have confirmed that Staff #10 was competent in CPI with a copy in her personnel folder in compliance with facility policy before she worked with patients.


Facility policy, "NS 400.16 Seclusion and Restraint" stated, in part, "N. Staff Training and Competence Assessment: As part of orientation, before performing any of the actions outlined in this policy, and at least annually, training occurs as outlined below. Medical staff, Direct care staff, and RNs/PAs are oriented to the standards for the use of restraint/seclusion. Direct care staff ...are required to attend aggression management training and show evidence of competency related to participating in a code situation, application of restrains, or the monitoring, assessment and care of a patient in restraints or seclusion ...All records documenting completion of training and competency demonstration will be maintained in staff personnel files or credential files."


The facility position description for Staff Nurse (R.N.) provided to the surveyor on 9/25/18 stated, in part, "Qualifications Additional Requirements: CPR certification and training in appropriate use of Seclusion and Restraint within 30 days of employment. Successful completion of CPI training and Service Excellence Training within 90 days of employment."

The above findings were confirmed in an interview the afternoon of 9/25/18 in the facility conference room with Staff #2.

Review of records and interview, revealed that the facility failed to ensure that patients were monitored by a registered nurse every four hours while on a 1:1 observation level. This presents a risk for safety to staff and patients when a patient is not assessed in accordance with facility policy.

The facility failed to ensure that an injury to the eye of a patient was assessed and documented and that the family was notified.

The facility failed to ensure that a nursing assessment, neurological checks, or indication of pain, loss or level of consciousness, or other assessment was conducted for a patient who suffered a fall and hit her head prior to being transported via ambulance to a medical hospital. This presents a safety risk for patients and staff members when they are not monitored or observed as ordered or assessed for potential injury.

Cross refer: CFR 482.23(b)(3)


Review of documentation and interviews, revealed that the facility failed to ensure that patient's needs were met as a patient with urinary incontinence did not have hygiene care provided and incontinent pads were not ordered until approximately 10 hours after the patient was admitted.

The facility failed to ensure that all staff members were competent in basic life support cardio-pulmonary resuscitation (CPR) as there was no documented evidence of hands-on skills practice and in-person assessment and demonstration of BLS CPR skills for an RN. Additionally, 2 RNs were not current in Basic Life Support CPR, but only Heartsaver, a course designed for anyone with little or no medical training. This presents a risk that clinical staff may not be competent to respond in a medical emergency. Two direct care staff, an RN and an MHT, did not have a signed or acknowledged job description. Lack of a job description presents a risk that staff members will not understand the duties, responsibilities, skills, and knowledge necessary to provide safe patient care.

Cross refer: CFR 482.23(b)(5)

Based on review of records and interview, the facility failed to ensure that patients were monitored by a registered nurse every four hours while on a 1:1 observation level. This presents a risk for safety to staff and patients when a patient is not assessed in accordance with facility policy.

The facility failed to ensure that an injury to the eye of a patient was assessed and documented and that the family was notified.

The facility failed to ensure that a nursing assessment, neurological checks, or indication of pain, loss or level of consciousness, or other assessment was conducted for a patient who suffered a fall and hit her head prior to being transported via ambulance to a medical hospital. This presents a safety risk for patients and staff members when they are not monitored or observed as ordered or assessed for potential injury.

Findings included:

Facility policy, "NS 600.14 Levels of Observation" stated, in part, "All patients will be routinely observed in compliance with physician orders and prescribed protocols ...

I. One-to-One Observation (1:1)

4. The RN assesses the need for continued 1:1 observation every four hours and document the assessment in the daily progress note. The RN documents criteria from Practice Guidelines for Levels of observation as being present or absent to continue the need for 1:1 observation."


Facility policy, "NS 300.26 Assessment and Reassessment of Patients" stated, in part, "A. The Registered Nurse will assess each patient at a minimum every shift and more often as deemed necessary. Assessment will include the patient's mental and physical status. Findings will be documented on the Patient Assessment and Activity Record. Any pertinent findings are documented on the Multidisciplinary Progress note."


Review of the medical record for Patient #2 revealed that he was placed on Fall Precautions and Assault/Homicide Precautions on 4/4/18, and started on a one-to-one 24-hours a day monitoring on the date of admission for safety reasons, which included "fall/agitation/safety round the clock". He remained on 1:1 fall precautions until 4/11/18 at 1315. However, he was again placed on 1:1 precautions on 4/18/18 at 1820 until he was discharged on 4/23/18 at 1330.


Patient #2 did not have an RN assessment progress note (PN) documented every four hours as follows:

4/5/18 RN assessment PN at 0430, next RN assessment PN was not until 4/5/18 at 1000.

4/5/18 RN assessment PN at 2045, next RN PN was 4/6/18 at 1040.

4/6/18 RN assessment PN at 1630, next RN PN was 4/6/18 at 2232

4/6/18 RN assessment PN at 2232, next RN PN was 4/7/19 at 0430

4/8/18 RN assessment PN at 0100, next RN PN was 4/8/18 at 0530.

4/9/18 RN assessment PN at 2208, next RN PN was 4/10/18 at 0418.

The 1:1 for Patient #2 was discontinued at 1315 on 4/11/18.

Patient #2 was placed back on 1:1 precautions on 4/18/18 at 1820.

An RN assessment PN was documented on 4/18/18 at 2035, however the next RN assessment progress note was not until 4/19/18 at 0900.

4/19/18 RN assessment PN at 2100, next RN PN was 4/20/18 at 0930.

4/21/18 RN assessment PN at 0100, next RN PN was 4/21/18 at 0800.

4/21/18 RN assessment PN at 2215, next RN PN was 4/21/18 at 0700.

4/22/18 RN assessment PN at 1745, next RN PN was 4/22/18 at 2300.

4/22/18 RN assessment PN at 2300, next RN PN was 4/23/18 at 1700 (PN was undated, but was the discharge note).


The above findings were confirmed by Staff #1 and 2 the afternoon of 10/2/18 in the facility conference room.



The medical record for Patient #1 was reviewed on 9/24/18. The "Hickory Trail Hospital Q15 Observation Form" for 4/1/18 indicated that Patient #1 was in the gym from 1100 to 1115 and from 1515 to 1645. Review of nursing progress notes for 4/1/18 revealed an untimed note with no documented evidence of a patient injury or incident in the gym with a basketball. There was no documented evidence of a patient injury or incident in the gym with a basketball in a second nursing progress note on 4/1/18 at 2000.

Nursing Progress Note on 4/2/18 at 12:30 stated, "Found bruise under his right eye this morning during assessment. Asked him and patient stated ball hit him yesterday while playing and he told to nurse yesterday. MHT said that was happened yesterday at gym."

Nursing Progress Note on 4/2/18 at 1625 stated, "Patient discharge from unit ...He was escorted to lobby by staff ...He discharge with [name of foster mother]. There were explained about aftercare and medications. No issues at this time."


A facility report was made on 4/1/18, Sunday, on the first shift. There was minimal documentation on the form, which stated "Patient injured - no classification". The injury was noted as a "bruise", however, the report did not state where the bruise was on his person, the size, the color or any other description. The documentation of the cause of the injury was "N/A", and the treatment or intervention was "N/A". The site of the event was "Gym". There was no description of how the injury occurred or any indication that the patient was hit in the eye with a basketball. There was no documentation that an assessment of the eye area occurred, and no documentation of vital signs, neuro checks, or an assessment of [Patient #1]'s vision occurred after being hit in the eye with a basketball hard enough to sustain a bruise or "black eye."

The notification of family and the attitude of family after notification was left blank on the form. There was no documentation on the form that the family or legally authorized representative was notified of the injury.

There was no documentation in the medical record for Patient #1 of an injury or incident in the gym involving a basketball or a blow to the head. There was no nursing assessment after the reported injury to Patient #1 of a blow to his eye and head that resulted in a bruise or "black eye."

There was no documentation that his physician was notified of the injury. Patient #1 was hit in the eye with a basketball, hard enough to leave a bruise, yet there was no vision check or neurological check documented or conducted. There was no documentation that the family/legally authorized representative was notified of the injury until the patient notified his foster mother that he was injured. The nurse documented the bruise under his right eye the following day, however there was no assessment of a vision assessment or neurological assessment or a documented description of the bruise to include size, color, or swelling.

There was no documentation of a bruise around his eye or a blow to the head for Patient #1 in the physician Discharge Summary for 4/2/18.


An interview was conducted with Staff #6, RN in the facility conference room at 9:21 am on 9/25/18. Staff #6 stated, she worked on the day after the incident, not on the day of the incident. She stated, "I saw the bruise, asked what happened. He told me the ball hit him playing basketball. He said, "I told nurse" and stated that there was no pain, no problem. [Patient #1] was discharged to his foster mom. He told his foster mom during the discharge in front of me that the ball hit him while he was playing basketball. The foster mom said that, "no body called me yesterday." I called her the next day to see if she has questions about incident. Left a voice mail after discharge. She did not call back."

Staff #6 stated that, "it is the facility policy to report the injury. Whoever fills out the incident report calls the doctor or CPS, the parents and the house supervisor."


The medical record for Patient #11 was reviewed the afternoon of 10/2/18. On 5/1/18 at 2130, Staff #16, RN documented, "Was sitting in chair in lobby, Fell forward out of chair onto floor hitting head.

2135 - [Physician] notified, orders rec'd to transport to hospital.

2140 - BP 152/63, P. 89, R 16, O2 Sat 99% [Staff #16], RN

2143 - BP 112/73, P. 90, R. 16. O2Sat 99% [Staff #16], RN

2150 - BP 108/59, P. 88, R 16. O2 Sat 98% [Staff #16], RN

Allegiance notified at 2137. [Staff #16], RN

2215 - Allegiance ambulance here to transport pt. Transported to Charlton Methodist ER at 2230. [Staff #16], RN
2230 - Husband notified and here at hospital. [Staff #16], RN

0155 5/2/18, [Patient #11] is admitted to the hospital at this time. [Staff #16], RN


Review of the Memorandum of Transfer revealed that Patient #11 was transferred to Charlton Methodist Medical Center and diagnosis or reason for transfer was "Evaluation of fall" and that initial contact with receiving hospital was 5/1/18 at 2230.

Per the Discharge summary, "Patient was also observed sitting on a chair in the lobby and fell forward off the chair and hitting her hear on the floor. Patient was transported to Charlton Methodist Hospital and husband notified of transfer." At that point, on 5/2/18, Patient #11 was discharged from Hickory Trail Hospital.

The medical record nursing progress note for Patient #11 related to a fall on 5/1/18 at 2130 was reviewed with Staff #12, DON on 10/2/18 at 11:22 am in the facility conference room.

When asked about the actions taken by the nurse if a patient falls, Staff #12 stated, "We do a neuro assessment and we also update the treatment plan with the post fall."


Review of the record revealed that Patient #11 fell and hit her head at 2130, but was not transported from the facility until 2230, an hour after the fall. There was no documented nursing assessment of Patient #11except for vital signs taken in the first 20 minutes after she hit her head in a fall. The ambulance did not arrive until 2215 (25 minutes after last blood pressure).

There was no documented description of what happened, whether the fall was witnessed, whether the patient was moved, whether or not the patient lost consciousness, what her level of consciousness was until she was transported, what the patient may have said, whether any injuries were sustained, and there was no documentation of a neurological assessment, including pupil reactivity, grip strength, extremity movement, or range of motion. There was no assessment of pain as a result of the fall. There was no reassessment of the vital sign change from 152/63 to 108/59 in 10 minutes; admission blood pressure was documented as 130/77.

Looking at and pointing to the nursing progress note, Staff #12 stated, "This is where she should have documented it, she just documented vital signs. She should have documented the status of the patient, not just the vital signs."


Facility policy, "NS 600.12 Fall Risk Prevention" stated, in part, "4. If a patient has a fall on any unit, a Post Fall Assessment will be conducted on the patient and submitted to the DON AND Risk Manager. The physician will be notified for orders, if applicable. Emergency care will be provided base (sic) on RN Assessment and consultation with the physician. A post fall treatment plan will be initiated ..."


The "POST FALL PACKET" Provided to the survey team on 11/2/18 at 11:20 am stated, in part,
"4) Complete Post Fall Audit ...
7) Complete Documentation on Progress Note."


Review of the "Neurological Assessment Flow Sheet" provided to the survey team on 10/2/18 included the following assessments of Eyes Open, Best Verbal Response, Best Motor Response, Glascow Coma Scale Total, Pupil Reaction, Arms, Legs, Reflexes," and stated, "part of the medical record."


Review of "Hickory Trail Hospital Post-Fall Audit Tool" provided to the survey team on 10/2/18 states, " ...Why do YOU think the patient fell (based on your nursing assessment of the following):

-Environmental Assessment ...

-Fall history, fall circumstances, and fall risk factors assessment

-Health history and functional status ...

-Vital signs & Pain Assessment ...

-Gait, Balance, or Musculoskeletal/Foot ...

-Depression Screening ...

-Treatment Plan modified ...

BE SURE to document patient fall in nursing assessment and report in Hand-Off Communication."


Facility policy, "NS 300.26 Assessment and Reassessment of Patients" stated, in part, "A. The Registered Nurse will assess each patient at a minimum every shift and more often as deemed necessary. Assessment will include the patient's mental and physical status. Findings will be documented on the Patient Assessment and Activity Record. Any pertinent findings are documented on the Multidisciplinary Progress note."


Hickory Trail Hospital Position Description for Staff Nurse (R.N.), provided to the surveyor on 9/25/18 stated, in part, "Position Summary

The Staff Nurse (R.N.) is a registered professional nurse who prescribes, coordinates, and evaluates patient care through collaborative efforts with health team members in accordance with the nursing process and the standards of care and practices ...
Standards of Performance ...

Assessment

1. Document patient information and nursing care in the provision of nursing services.

2. Document and reassess any significant changes in the patient's condition in compliance with facility policy ...

Performance ...

3. Act as the patient's advocate and assure that patient rights are upheld ..."


Review of the Texas Nurse Practice Act 217.11, Standards of Nursing Practice, states, in part,

"(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall:

(A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice;

(B) Implement measures to promote a safe environment for clients and others; ...

(D) Accurately and completely report and document:

(i) the client's status including signs and symptoms;

(ii) nursing care rendered;

(iii) physician, dentist or podiatrist orders; ...

(v) client response(s); and

(vi) contacts with other health care team members concerning significant events regarding client's status;"


The above findings for Patient #11 related to a fall on 5/1/18 at 2130 were reviewed with Staff #12, DON on 10/2/18 at 11:22 am in the facility conference room.

Based on review of documentation and interviews, the facility failed to ensure that patient's needs were met as a patient with urinary incontinence did not have hygiene care provided and incontinent pads were not ordered for a patient until approximately 10 hours after the patient was admitted.

The facility failed to ensure that all staff members were competent in basic life support cardio-pulmonary resuscitation (CPR) as there was no documented evidence of hands-on skills practice and in-person assessment and demonstration of BLS CPR skills for an RN. Additionally, 2 RNs were not current in BLS CPR, but only Heartsaver, a course designed for anyone with little or no medical training and not in accordance with the standard of care. This presents a risk that clinical staff may not be competent to respond in a medical emergency. Two direct care staff, an RN and an MHT, did not have a signed or acknowledged job description. Lack of a job description presents a risk that staff members will not understand the duties, responsibilities, skills, and knowledge necessary to provide safe patient care.


Findings included:


Review of the medical record for Patient #11 revealed that she was admitted and on the unit at 0010 on 4/26/18. Patient #1 had a documented medical diagnosis of urinary incontinence.

There was no documentation on the Q15 Minute Observation Form for Patient #11 to indicate that incontinence care or hygiene was performed on 4/26/18. There were no narrative notes written in the space provided on the back of the form, page 2 of 2, indicating that incontinent pads were provided or that hygiene was performed.


The Q15 Observation Form for 4/26/18 and indicated the following activities for Patient #11:

7 am - 8 am sitting in day room.

8:15 - 8:30 was at breakfast

8:45 sitting in day room

9-9:15 talking on phone in day room.

9:30 am talking with staff

9:45 am talking with staff

10 talking with staff

10:15 sitting in day room ...


The complaint allegation stated that the complainant was on the phone with the patient and at 9:30 am on 4/26/18, Patient #11 was incontinent and "soaked in urine" and was told by staff that she could not have incontinent pads until she had been seen by a doctor. Review of the physician orders for Patient #11 revealed no order for incontinence pads until 4/26/18 at 1010, which stated, "bladder incontinence pads - daily - incontinence".


An interview was conducted with Staff #14, RN on 10/2/18 at 8:56 am regarding Patient #11. When asked about a requirement for a physician order for incontinent pads, Staff #14 stated, "Yes, it requires a physician order. If they are incontinent, we tell the doctor and get an order ...We would call the doctor."


The medical record for Patient #11 was reviewed with Staff #14, including the admission in the middle of the night for Patient #11. The Initial Skin Assessment was documented on 4/25/18 at 23:37 and the Initial Nursing Assessment and Admission Data was documented on 4/26/18 at 0010. The physician order for incontinent pads for Patient #11 was not written until 1010 on 4/26/18.


When asked what would happen if a patient was incontinent and there was no order for incontinent pads, Staff #14 stated, "If the patient came in incontinent, this is what we've done ...If soaked in urine, then I would ask if incontinent. Nurses judgement, I can give incontinent pads ...If we do rounds, we walk the floor, talk to the patient, get a brief idea, what they come in for, what's going on, if she mentions she needs pads, we get an order from doctor. There is always doctor on call - both a psychiatrist and a medical doctor."
The survey team asked, "So you would chart if she was wet, that she needed incontinence pads?" Staff #14 stated, "I would document that."

The surveyor requested, "Would you look at your nurses notes to see what you documented on 4/26? I don't see anything in your note about incontinence ...Who received the 1010 order for incontinence pads?" Staff #14 confirmed and stated, "I did ..."


The surveyor asked, "When the techs provide hygiene for an incontinent patient, is there a place where they document the hygiene on the observation sheet for the patient? Staff #14 reviewed the Q15 Observation Form for 4/26/18 and stated, "Most of the day she was laying down.
From 7 am until about 8 o ' clock, sitting in day room.
8:15 - 8:30 was at breakfast
8:45 sitting in day room
9-9:15 talking on phone in day room.
9:30 am talking with staff
9:45 am talking with staff..."


The surveyor noted that the staff documented that Patient #11 was on the phone at approximately the same time that the author of the complaint allegation stated that she was talking on the phone. Patient #11 stated that she was "soaked in urine" and was allegedly told she could not have incontinent pads until she had been seen by the doctor. The staff then documented that Patient #11 was talking with staff, as the complaint alleged, and subsequently a physician order was written at 1010 for Patient #11 to have incontinent pads.


An interview was conducted on 10/2/18 at 1:35 pm with Staff #12, DON regarding the allegation that Staff #11 was soaked in urine and not allowed to have incontinent pads until seen by a doctor. Staff #12 stated, "If they are incontinent, get an order from the doctor for incontinent pads."


The surveyor reviewed that Patient #11 was incontinent, was on the unit from approximately midnight, and there was an allegation was that she was soaked in urine and called her cousin to make a complaint around 9:30 am. There was no order for incontinent pads until 10:10 am.

When asked if the techs should document hygiene for an incontinent patient, Staff #12 stated, "I would say that because the techs check on them that frequently. If they clean her up while she ' s in bed, yes, they should write it."


The Q15 Minute Observation Form was reviewed. On page 2 of 2 of the form is a space provided which states, "Narrative Required for Every Patient on Every Shift (any behavior while awake an uncooperative)."

When asked if the techs could document the care provided on the back of the sheet, Staff #12 stated, "They could. It's a learning process for us."


Review of the Q15 Minute Observation Sheet revealed no documented evidence that hygiene was provided for Patient #11 on 4/26/18 on page 1 or page 2.


Facility policy, "NS 300.26 Assessment and Reassessment of Patients" stated in part, "A. The Registered Nurse will assess each patient at a minimum every shift and more often as deemed necessary. Assessment will include the patient's mental and physical status. Findings will be documented on the Patient Assessment and Activity Record. Any pertinent findings are documented on the Multidisciplinary Progress note."

The above findings were confirmed in an interview was conducted on 10/2/18 at 1:35 pm with Staff #12 in the facility conference room.


Review of the personnel record for Staff #3, RN the afternoon of 9/24/18 only revealed a current certificate for online CPR with no documented evidence of hands-on skills practice and in-person assessment and demonstration of CPR skills. The facility failed to ensure that she was competent in CPR skills demonstration until surveyor requested documentation. In an interview with Staff #2, the afternoon of 9/24/18, Staff #2 confirmed the above findings and stated that she knew online only CPR was not acceptable. The afternoon of 9/25/18, documentation of a current CPR card for Staff #3 was provided to the surveyor, however Staff #2 acknowledged that the facility failed to ensure and should have confirmed that Staff #3 was competent in CPR before she worked with patients.


Review of the Health & Safety Institute and the National Safety Council website found at http://news.hsi.com/onlineonlycpr reveals that, "No major nationally recognized training program in the United States endorses certification without practice and evaluation of hands-on skills. According to the Occupational Safety and Health Administration (OSHA) online training alone does not meet OSHA first aid and CPR training requirements."


The above findings were confirmed by Staff #2 the afternoon of 9/25/18 in the facility conference room.


Review of the personnel record for Staff #16, RN revealed she did not have current certification in Basic Life Support CPR; there was only a card in her personnel folder for Heartsaver First Aid CPR AED which expired on 3/2019.


Review of the personnel record for Staff #15, RN revealed he did not have current certification in Basic Life Support CPR; there was only a card in his personnel folder for Heartsaver First Aid CPR AED which expired on 6/2019.


Review of the American Heart Association website revealed, "Heartsaver courses are designed for anyone with little or no medical training who needs a course completion card for job, regulatory (for example, OSHA), or other requirements ...

Healthcare Professional: Basic Life Support training reinforces healthcare professionals' understanding of the importance of early CPR and defibrillation, basic steps of performing CPR, relieving choking, and using an AED; and the role of each link in the Chain of Survival."

Retrieved on 10/2/18 from https://cpr.heart.org/AHAECC/CPRAndECC/Training/HeartsaverCourses/UCM_473174_Heartsaver-Courses.jsp

The above findings were confirmed by Staff #12 the afternoon of 10/2/18 in the facility conference room.


Review of the personnel records for 2 out of 4 direct care staff (staff #5, MHT and #6, RN) revealed no documented evidence of a signed or acknowledged job description in their personnel folders. Staff #2 acknowledged that the RN and the MHT did not have specific job descriptions detailing qualifications and duties for their position.

Lack of a job description presents a risk that staff members will not understand the duties, responsibilities, skills, and knowledge necessary to provide safe patient care.


Hickory Trail Hospital Position Description for Staff Nurse (R.N.), provided to the surveyor on 9/25/18 stated, in part, "Position Summary

The Staff Nurse (R.N.) is a registered professional nurse who prescribes, coordinates, and evaluates patient care through collaborative efforts with health team members in accordance with the nursing process and the standards of care and practices ...

Qualifications ...Additional Requirements: CPR certification ...
Standards of Performance ...

Assessment

1. Document patient information and nursing care in the provision of nursing services.

2. Document and reassess any significant changes in the patient's condition in compliance with facility policy ...

Performance ...

3. Act as the patient's advocate and assure that patient rights are upheld ..."

The above findings were confirmed by Staff #2 the afternoon of 9/25/18 in the facility conference room.

Based on interviews and review of documents, the facility failed to ensure a patient admitted to the inpatient unit on 6/21/18 with suicidal ideations had a psychiatric evaluation and mental status examination completed in a timely manner after admission by a psychiatrist. This could have resulted in the possible delay of a correct individualized treatment plan for the patient.

Findings were:

Review of the medical record for Patient #12 in a facility conference room on the morning of 10/02/18 revealed a nursing note dated 06/22/18 at 2228 stated in part "Mother of pt called earlier in the shift inquiring into if pt was seen by the MD. Advised pt's mother, after verifying her identity, that the AM nurse advised that pt was called to see DR but eventually was not seen by MD. AM ns also stated she called [Staff #24] about pt not seen but pt was not seen by MD today after the phone call. Advised pt's mother that pt will be seen by a Doctor the following day. Pt was told the same thing this PM during assessment. Supervisor as also communicated about the situation. Pt was reassured that he will be seen the next day. "

A nursing note dated 6/23/18 at 1100 stated in part "Pt was reviewed by the Psychiatrist this am and medication adjustments made."

Review of the psychiatric evaluation for Patient #12 revealed it was performed by Staff #24 on 6/23/18 at 0800.
Review of the facility "Medical Staff Rules and Regulations" read in part "2.7 The Psychiatric Evaluation and Mental Status Examination shall, in all cases, be completed and dictated within 24 hours after admission of the patient by a psychiatrist and the admission note will be entered in the progress notes at the time of evaluation.

An interview was conducted with Staff #12, RN, Director of Nursing (DON) at approximately 11:35am on 10/2/18 in the facility conference room. Staff #12 was asked how soon are patients supposed to receive a psychiatric evaluation by a psychiatrist after admission according to facility policy. Staff #12 stated a new patient was to have a psychiatric evaluation by a psychiatrist within 24 hours of admission. After review of the medical record of Patient #12, Staff #12 acknowledged that Patient #12 who was admitted on 06/21/18 with suicidal ideations did not receive a psychiatric evaluation by a psychiatrist until 6/23/18 at 8:00am.

Based on a review of documentation and interviews, the facility failed to ensure that treatment plans developed were based on the findings of the physical examination and the psychiatric evaluation; the facility failed to ensure that a list of all diagnoses to be treated or that could impact the patient's hospitalization were included in the treatment plan; the facility failed to ensure that the initial treatment plan contained a list of the problems and needs to be addressed during a patient's hospitalization; and the facility failed to ensure that initial treatment plans contained a description of all treatment interventions. These findings could result in inadequate care of the patient's physical and psychiatric needs. 

Findings included:

Facility policy, "MT 100.01 Master Treatment Plan/Master Treatment Plan Review" stated, in part, "III. PROCEDURE ...B. The initial treatment plan will be initiated by the admitting nurse in collaboration with the attending physician within 8 hours of admission on the Individualized Master Treatment Plan.
1. The initial treatment plan will contain the following:
a. Initial Diagnosis (both psychiatric & Medical if applicable)
b. Initial Problem List (both psychiatric & Medical if applicable)"

Review of the medical record for Patient #11 the afternoon of 10/2/18 in the facility conference room revealed the following diagnoses from the Medical History & Physical Exam was performed on 4/26/18: chronic cough, vulvovaginal candidiasis, urinary incontinence, neck pain/knee pain, nausea, and asthma.

Review of the Treatment Plan for Patient #11 signed by Staff #16, RN on 4/26/18 revealed a handwritten check mark next to "None" in the space for "Medical Problems." The word, "None" was also handwritten under "Medical Problems" on the Interdisciplinary Master Treatment Plan on 4/26/18, and the space for "Chronic/Stable Medical Problems" was left blank. Though Patient #11 had medical diagnoses of chronic cough, vulvovaginal candidiasis, urinary incontinence, neck pain/knee pain, nausea, and asthma, any of which could have required treatment or could have interfered with treatment during the patient's hospitalization, none of these diagnoses were included on the Treatment Plan for Patient #11.

The Treatment Plan for Patient #11 was reviewed with Staff #12, DON on 10/2/18 at 1:40 pm, who confirmed that the medical problems for Patient #11, including urinary incontinence, were not included on the Treatment Plan. Staff #12 stated, "We did not document the medical problems and we should have."