HospitalInspections.org

Based on observation, interview, and document review, the facility failed to meet the requirements of the Condition of Participation for Patient Rights. This failure had the potential to affect all patients receiving services in the hospital.

The facility failed to ensure:

1. Patients received care in a safe setting :

a. failure to ensure two ( 2) patients on suicide precautions were visually observed by staff during the night shift per policy (Patient ID 12, 20);

b. failure to identify and repair a ligature tie-off point observed in patient room 106.

(Refer to Tag A-0144]

2. Compliance with Restraint/Seclusion requirements:

a. failure to uphold Patient ID # 10's right to be free of restraint. He was improperly restrained for 11 hours during 1 night shift; almost 1 hour on a 2nd night shift. ( Refer to Tag A-0154)

b. failure to meet regulatory and facility policy requirement for safe / appropriate restraint use:

-Unsafe and inappropriate restraint technique ( A-0167)
-no physician order for restraint ( A-0168)
-no time-limit for restraint usage (A-0171)
-no patient monitoring during time in restraint (A-0175)
-no one hour face to face evaluation (A-0179)

Based on observation, video / record review, and interview, the facility failed to provide care in a safe setting by:

a. failure to ensure two ( 2) patients on suicide precautions were visually observed by staff during the night shift per policy (Patient ID 12, 20);

b. failure to identify and repair a ligature tie-off point observed in patient room 106.

Findings included :

TX00443995

a. Patients on suicide precautions not observed by staff:


Review of facility policy titled "Patient Rights Texas," dated 01/11/2016, showed patient rights included :" The right to a humane treatment environment that ensures protection from harm..."

Review of facility policy titled "Suicide/Homicide Risk Assessment,"revised date 02/01/2023, showed:

-prevention techniques will be accomplished by a comprehensive approach that identifies and mitigates issues that can contribute to self harm.
-all patients are assessed for suicide risks: low, moderate, or high risk.
-any patient assessed at any suicide risk level is placed on every 15 minute observation and is monitored for changes in suicidal ideation or behavior.

Patient ID # 12 :

Record review of Patient ID # 12's admission orders, dated 02/27/2023, showed a physician order for "suicide precautions." Further review of the medical record failed to show this order had been discontinued.

Review of facility patient census for 03/03/2023 showed Patient # 12 was currently on suicide precautions. This was verified by Staff -B, Director of Nurses (DON) at the time of review.

Surveyor and Staff -B, Director of Nurses (DON), reviewed video camera footage from the night shifts [ time period 9 PM until 5 AM ] for March 3/4; 10/11; and 12/13. 2023. Observations included : the day room area by the big TV and hallway areas / doors to patient room #s: 103, 104, 105, 106, and 108.

Patient # 12, on suicide precautions, was in room 106. Review of the video footage for the night shift for March 3, 2023 showed the staff went in to his room only once during the the 7 hours of video footage reviewed. This was verified by the DON.


Patient ID # 20 :

Record review of Patient ID # 20's admission orders, dated 03/09/2023, showed a physician order for "suicide precautions." Further review of the medical record failed to show this order had been discontinued.

Review of facility patient census for 03/10 and 03/12/2023 showed Patient # 20 was currently on suicide precautions. This was verified by Staff -B, Director of Nurses (DON) at time of review.

Surveyor and Staff -B, DON, reviewed video camera footage from the night shifts [ time period 9 PM until 5 AM ] for March 3, 11, and 13, 2023. Observations included : the day room area by the big TV and hallway areas / doors to patient room #s: 103, 104, 105, 106, and 108.

Patient # 20, on suicide precautions, was in room 106. Review of the video footage for the night shift for March 10/11 and March 12/13, 2023 showed the staff went in to his room only twice during the the 14 hours of video footage reviewed. This was verified by the DON.

During an interview with the DON at the time of the video review, she said all patients were to be visually observed every 15 minutes. The DON said this meant "staff had to walk into the patient room to observe them."


b. Ligature tie-off point not identified and repaired :

Review of facility policy titled "Room Checks," dated 01/11/2016 , showed: Environment of Care staff is responsible to ensure that the physical plant is safe and any broken items are repaired or removed.

Observation on 03/14/2023 at 9:30 AM during initial facility tour, showed an unlocked patient closet in room # 106. Upon opening the closet door, it was noted the top door hinge was broken off from the interior closet wall. Half of the metal hinge was left tightly secured to the upper edge of the closet door. During an interview at the time of observation with Staff J, Quality Director, she said this exposed metal hinge was a ligature risk. It would be repaired right away.

Based on video footage review, record review, and interview, the facility failed to ensure a patient's right to be free of restraint [Patient ID # 10].

Findings included:

TX00443995

Review of facility policy titled "Patient Rights Texas," dated 01/11/2016, showed :

Seclusion and Restraints:

*The patient has the right to not be secluded or have physical restraints applied, unless a physician has prescribed it;
*If restraint is utilized, the reason, the length of time, patient behaviors necessary for removal--should all be explained to the patient;
*The restraint should be discontinued as soon as possible.

Review of facility policy titled "Seclusion and Restraints," revised dated 08/01/2021, showed :

POLICY:The facility's therapeutic program is designed to ensure and respect the patient's right to be free from seclusion and/or restraint in any form that are not medically necessary.

Definition of Restraint: "any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely..."

Review /observation of video camera footage from the night shifts for March 3, 10, and 12, 2023 was done by surveyor and the Director of Nurses.

Observation areas included : the day room area by the big TV and hallway areas / doors to patient room #s: 103, 104, 105, 106, and 108. Time periods reviewed were from 9 PM until 5 AM (** review time was extended to 9 AM on March 4).

Observation # 1:

Review of camera footage on March 3 and 4 , 2023 showed the following :

- Patient ID # 10 was positioned in a chair located directly against the wall in the day room. There was a table placed near his chest, with an additional table buttressed up against the first table. The chair and both tables were heavy, "psych-safe" furniture, not easily moved. The video showed Patient ID # 1 remained continuously seated in this chair for 11 hours: from 10 PM on March 3 until 9 AM on March 4, 2023.

-Patient ID # 10 attempted several times during the 11 hours to get up and was unable to do so. He was observed waving his arms and trying unsuccessfully to move the table and stand up.

The DON stated at the time of the video review this was unsafe and not acceptable nursing practice. It was considered a restraint.

Observation #2:

An additional review of camera footage of the night shift March 12, 2023 by surveyor and DON showed :

-Staff member directed Patient ID # 10 to sit in a chair in the day room; he was observed ambulating. As soon as he sat down, staff was observed placing a "pscyh-safe", heavy table next to his chest; and placing another table up against the first. This was the same 2-table set up as observed on March 3, 2023 night shift video footage.

-Patient ID # 10 attempted to stand several times but his movement was observed to be restricted by the positioning of the tables. Patient ID # 10 was restrained in this manner for almost an hour.

Based on review of video footage, interview, and record review, facility staff failed to utilize safe and appropriate technique per facility policy to restrain Patient ID # 10.

Findings included :

TX00443995

Review of facility policy titled "Seclusion and Restraints," revised dated 08/01/2021, showed :

Definition of Restraint: "any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely..."

Further review of the retraint policy failed to show evidence that "pscyh safe" chairs and tables are acceptable methods of physical restraints.

During an inteview with Staff-D, Facilities Director, on 03/16/2023 at 11 AM he stated he did not have any policies related to the "psych- safe" tables and chairs.

Review /observation of video camera footage from the night shifts for March 3, 10, and 12, 2023 was done by surveyor and the Director of Nurses.

This camera footage review showed the following:

Observation # 1:

- Patient ID # 10 was positioned in a chair located directly against the wall in the day room. There was a table placed near his chest, with an additional table buttressed up against the first table. The chair and both tables were heavy, "psych-safe" furniture, not easily moved. The video showed Patient ID # 10 remained continuously seated in this chair for 11 hours: from 10 PM on March 3 until 9 AM on March 4, 2023.

-Patient ID # 10 attempted several times during the 11 hours to get up and was unable to do so. He was observed waving his arms and trying unsuccessfully to move the table and stand up. His body movement was restricted.

The DON stated at the time of the video review this was unsafe and not acceptable nursing practice. It was considered a restraint.

Observation #2:

An additional review of camera footage of the night shift March 12, 2023 by surveyor and DON showed :

-Staff member directed Patient ID # 10 to sit in a chair in the day room; he was observed ambulating. As soon as he sat down, staff was observed placing a "pscyh-safe", heavy table next to his chest; and placing another table up against the first. This was the same 2-table set up as observed on March 3, 2023 night shift video footage.

-Patient ID # 10 attempted to stand several times but his body movement was observed to be restricted by the positioning of the tables. Patient ID # 1 was restrained in this manner for almost an hour.

Based on review of video footage, interview, and record review, facility staff failed to obtain a physician order per facility policy to restrain Patient ID # 10.

Findings included :

TX00443995

Review of facility policy titled "Seclusion and Restraints," revised dated 08/01/2021, showed :

Definition of Restraint: "any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely..."

Further review of the restraint policy showed:

-The physician /non-physician practitioner (NPP) and/or a trained RN may initiate an emergency application of a restraint.
-The physician/NPP will be notified as soon as possible after the initiation of a restraint.
-The RN will document physician/NPP contact and physician order on Physician Order for Seclusion and Restraint Form.
-The physician/NPP order must include the specific behaviors which constituted the behavioral emergency, specify the reason for restraint, type of restraint, and duration of restraint.
~~~~~~~~~~~~~~~~~~~

Review /observation of video camera footage from the night shifts for March 3, 11, and 13, 2023 was done by surveyor and the Director of Nurses.

This camera footage review showed the following:

Observation # 1:

- Patient ID # 10 was positioned in a chair located directly against the wall in the day room. There was a table placed near his chest, with an additional table buttressed up against the first table. The chair and both tables were heavy, "psych-safe" furniture, not easily moved. The video showed Patient ID # 10 remained continuously seated in this chair for 11 hours: from 10 PM on March 3 until 9 AM on March 4, 2023.

-Patient ID # 10 attempted several times during the 11 hours to get up and was unable to do so. He was observed waving his arms and trying unsuccessfully to move the table and stand up.

The DON stated at the time of the video review this was unsafe and not acceptable nursing practice. It was considered a restraint.

Observation #2:

An additional review of camera footage of the night shift March 12, 2023 by surveyor and DON showed :

-Staff member directed Patient ID # 10 to sit in a chair in the day room; he was observed ambulating. As soon as he sat down, staff was observed placing a "pscyh-safe", heavy table next to his chest; and placing another table up against the first. This was the same 2-table set up as observed on March 3, 2023 night shift video footage.

-Patient ID # 10 attempted to stand several times but his movement was observed to be restricted by the positioning of the tables. Patient ID # 10 was restrained in this manner for almost an hour.

Record review on 03/16/2023 of Patient ID #10's clinical record failed to reveal any physician / NPP orders for restraint.

Based on review of video footage, interview, and record review, facility staff failed to obtain a physician order with a time-limit for restraint per facility policy to restrain Patient ID # 10.

Patient ID # 10 was restrained for almost 12 hours without a time-limited order.

Findings included :

TX00443995

Review of facility policy titled "Seclusion and Restraints," revised dated 08/01/2021, showed :

Definition of Restraint: "any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely..."

Further review of the restraint policy showed:

-The physician /non-physician practitioner (NPP) and/or a trained RN may initiate an emergency application of a restraint.
-The physician/NPP will be notified as soon as possible after the initiation of a restraint.
-The RN will document physician/NPP contact and physician order on Physician Order for Seclusion and Restraint Form.
-The physician/NPP order must include ....the duration of restraint.
~~~~~~~~~~~~~~~~~~~

Review /observation of video camera footage from the night shifts for March 3, 10, and 12, 2023 was done by surveyor and the Director of Nurses.

This camera footage review showed the following:

Observation # 1:

- Patient ID # 10 was positioned in a chair located directly against the wall in the day room. There was a table placed near his chest, with an additional table buttressed up against the first table. The chair and both tables were heavy, "psych-safe" furniture, not easily moved. The video showed Patient ID # 10 remained continuously seated in this chair for 11 hours: from 10 PM on March 3 until 9 AM on March 4, 2023.

-Patient ID # 10 attempted several times during the 11 hours to get up and was unable to do so. He was observed waving his arms and trying unsuccessfully to move the table and stand up. His body movement was restricted.

The DON stated at the time of the video review this was unsafe and not acceptable nursing practice. It was considered a restraint.

Observation #2:

An additional review of camera footage of the night shift March 12, 2023 by surveyor and DON showed :

-Staff member directed Patient ID # 10 to sit in a chair in the day room; he was observed ambulating. As soon as he sat down, staff was observed placing a "pscyh-safe", heavy table next to his chest; and placing another table up against the first. This was the same 2-table set up as observed on March 3, 2023 night shift video footage.

-Patient ID # 10 attempted to stand several times but his movement was observed to be restricted by the positioning of the tables. Patient ID # 10 was restrained in this manner for almost an hour.

Record review on 03/16/2023 of Patient ID #10's clinical record failed to reveal any physician / NPP orders for restraint that included a time-limit.

Based on review of video footage, interview, and record review, facility staff failed to monitor Patient ID # 10 per facility policy when he was restrained.

Patient ID # 10 was restrained for almost 12 hours without the required monitoring.

Findings included :

TX00443995

Review of facility policy titled "Seclusion and Restraints," revised dated 08/01/2021, showed :

Definition of Restraint: "any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely..."

Further review of the restraint policy showed:

Monitoring:

-The RN will assign a qualified and trained staff member to continually ensure adequate respiration and circulation of the patient.

-The RN must assess the patient upon initiation of restraint, after the first 15 minutes, during the one- hour face-to-face assessment, every hour the patient remains in restraint, and upon discontinuation of restraint.

-At a minimum, respiratory status, circulation, and skin integrity will be documented as indicated on the restraint flow sheet every 15 minutes by assigned, qualified, and trained staff member.

-the assigned staff will also monitor for signs of injury associated with the use of restraint.

- The assigned staff member will perform range of motion exercises for each extremity, one at a time, for at least 5 minutes during every hour a that a patients is in a mechanical restraint.

~~~~~~~~~~~~~~~~~~~

Review /observation of video camera footage from the night shifts for March 3, 10, and 12, 2023 was done by surveyor and the Director of Nurses.

This camera footage review showed the following:

Observation # 1:

- Patient ID # 10 was positioned in a chair located directly against the wall in the day room. There was a table placed near his chest, with an additional table buttressed up against the first table. The chair and both tables were heavy, "psych-safe" furniture, not easily moved. The video showed Patient ID # 10 remained continuously seated in this chair for 11 hours: from 10 PM on March 3 until 9 AM on March 4, 2023.

-Patient ID # 10 attempted several times during the 11 hours to get up and was unable to do so. He was observed waving his arms and trying unsuccessfully to move the table and stand up.

The DON stated at the time of the video review this was unsafe and not acceptable nursing practice. It was considered a restraint.

Observation #2:

An additional review of camera footage of the night shift March 12, 2023 by surveyor and DON showed :

-Staff member directed Patient ID # 10 to sit in a chair in the day room; he was observed ambulating. As soon as he sat down, staff was observed placing a "pscyh-safe", heavy table next to his chest; and placing another table up against the first. This was the same 2-table set up as observed on March 3, 2023 night shift video footage.

-Patient ID # 10 attempted to stand several times but his movement was observed to be restricted by the positioning of the tables. Patient ID # 10 was restrained in this manner for almost an hour.

Record review on 03/16/2023 of Patient ID #10's clinical record failed to reveal documentation of any required monitoring during the time periods he was restrained in Match 3, 4 and 13. 2023. In addition, there was no observation that he was assessed by an RN, particularly for respiratory status and circulation. No observation of range- of - motion performed by staff to Patient ID # 10's lower extremities.

Based on review of video footage, interview, and record review, facility staff failed to perform a face-to-face evaluation within one (1) hour of restraining Patient ID # 10.

Findings included :

TX00443995

Review of facility policy titled "Seclusion and Restraints," revised dated 08/01/2021, showed :

Definition of Restraint: "any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely..."

Further review of the restraint policy showed:

Face-to-face Evaluation:

-A one-hour face-to-face patient evaluation must be conducted in person by a physician or other NPP, or trained RN (other than the RN who initiated the restraint).

-Conduct one-hour face-to-face , if trained to do so, even if patient is no longer in restraint and physician is not present.

-Document on Face-to-Face Evaluation Form:

-Date/time
-The patient's immediate situation
-The patient's reaction to the intervention
-The patient's medical and behavioral condition
-The need to continue or terminate the restraint
-Behaviors
-Alternative interventions to prevent restraint
-Medical review of patient's status post-intervention .

~~~~~~~~~~~~~~~~~~~

Review /observation of video camera footage from the night shifts for March 3, 10, and 12, 2023 was done by surveyor and the Director of Nurses.

This camera footage review showed the following:

Observation # 1:

- Patient ID # 10 was positioned in a chair located directly against the wall in the day room. There was a table placed near his chest, with an additional table buttressed up against the first table. The chair and both tables were heavy, "psych-safe" furniture, not easily moved. The video showed Patient ID # 10 remained continuously seated in this chair for 11 hours: from 10 PM on March 3 until 9 AM on March 4, 2023.

-Patient ID # 10 attempted several times during the 11 hours to get up and was unable to do so. He was observed waving his arms and trying unsuccessfully to move the table and stand up.

The DON stated at the time of the video review this was unsafe and not acceptable nursing practice. It was considered a restraint.

Observation #2:

An additional review of camera footage of the night shift March 12, 2023 by surveyor and DON showed :

-Staff member directed Patient ID # 10 to sit in a chair in the day room; he was observed ambulating. As soon as he sat down, staff was observed placing a "pscyh-safe", heavy table next to his chest; and placing another table up against the first. This was the same 2-table set up as observed on March 3, 2023 night shift video footage.

-Patient ID # 10 attempted to stand several times but his movement was observed to be restricted by the positioning of the tables. Patient ID # 10 was restrained in this manner for almost an hour.

Record review on 03/16/2023 of Patient ID #10's clinical record failed to show documentation of a Face-to-face Evaluation with the required components either of the times he was restrained.

Based on observation, interview, and document review, the facility failed to meet the requirements of the Condition of Participation for Nursing Services. This failure had the potential to affect all patients receiving services in the hospital.

1. Based on observation, interview, and record review, the facility failed to ensure nursing care was provided per physician orders and facility policy for 14 of 14 patients [Patient ID #: 1, 8, 9,10,11, 12,13,14,15,16,17,18,19,20]

-Mental Health Techs (MHT) failed to conduct every (Q) 15 minute observations for three (3) night shifts observed (via video footage review). This deficient practice placed the above-listed 14 patients at risk for possible suicide attempts; self-harm; or falls with serious injury.

Refer to Tag A-0392


2. Based on observation, interview, and record review, the facility failed to ensure that a Registered Nurse (RN) supervised the care of 14 sampled patients per policy and according to the Texas Board of Nursing "Standards of Nursing Practice" [ Patient # 1, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20]. RN staff failed to:

a. conduct RN nursing rounds every 2 hours on the night shift per policy for the above 14 patients.

b. supervise MHT night shift care & treatment of the above 14 patients.

[On three (3) of 3 night shifts- video footage review]

Refer to tag A-0395

Based on observation, interview, and record review, the facility failed to ensure nursing care was provided per physician orders and facility policy for 14 of 14 patients [Patient ID #: 1, 8, 9,10,11, 12,13,14,15,16,17,18,19,20]

-Mental Health Techs (MHT) failed to conduct every (Q) 15 minute observations for three (3) night shift observed. This deficient practice placed the above- listed 14 patients at risk for possible suicide attempts; self-harm; or falls with serious injury.

Findings included:

TX0044395

Record review of facility policy titled "Level of Observations,"dated 03/01/2023, showed:

-The initial patient observation level is determined and ordered by the physician on admission.
-Staff members utilize the close observation form (Q15 check sheet) to document the ongoing observation and location of the patient. Additional information regarding activities are included on the form when relevant ( i.e. water offered, activities of daily living). The observing staff initials the 15 minute increments in the form to indicate the patient was observed.

Review of facility census forms for March 3, 10,12, 2023 night shifts- [for rooms 103, 104, 105, 106, and 108 ] showed:

-March 3/4, 2023 : eight (8) patients: [Patients : # 8, 9,10,11,12,13,14,15]
-March 10/11, 2023: ten (10) patients: [Patients # 10,11,13, 14,15,16,17,18,19, 20]
-March 12/13, 2023: ten (10) patients: [Patients # 1,10,11,14,15,16,17,18,19,20]

Record review of the physician admission orders for Patient IDs #: 1, 8, 9, 10,11, 12,13,14,15,16,17,18,19,20 showed all had orders for Q ( every) 15 minute observations. Review also showed two (2) patients had orders for suicide precautions : Patient ID# 12 ( March 3/4) and Patient ID # 20 ( March 10/11 and 12/13). All 14 patients had orders for fall precautions.

On 3/16/2023 , Surveyor and Director of Nurses (Staff B) reviewed camera footage for the following night shift timeframes:

-March 03, 2023 at 10 PM until March 04, 2023 at 5 AM
-March 10, 2023 at 10 PM until March 11, 2023 at 5 AM
-March 12, 2023 at 10 PM until March 13, 2023 at 5 AM

Observation areas visible in camera footage area were: the day room area by the big TV and hallway areas / doors to patient room #s: 103, 104, 105, 106, and 108.

Observation of the camera footage showed:

- MHT rounding was observed only twice during the review of all three (3) night shirts. [policy requires 4 times per hour for each patient ]

- Several patient doors were closed during the three night shifts reviewed.

- On March 3 and 10 : staff failed to open the door to occupied rooms 104 and 108 during the entire night shift reviewed from 10PM until 5 AM.

During an interview with Staff B, DON at the time of camera footage review, she stated this lack of observation rounding was "entirely unacceptable" and she was "shocked to see it." The DON went on to say that a Q15 minute observation meant that an MHT goes into a patient's room (or other area patient might be) and actually observes them.

Based on observation, interview, and record review, the facility failed to ensure that a Registered Nurse (RN) supervised the care of 14 sampled patients ( Patient # 1, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 ). RN staff failed to:

a. conduct RN nursing rounds every 2 hours on the night shift per policy for the above 14 patients.

b. supervise MHT night shift care & treatment of the above 14 patients per policy and according to the Texas Board of Nursing "Standards of Nursing Practice".

[On three (3) of 3 night shift video footage reviewed]

Findings included:

Record review of Texas Administrative Code (TAC) Title 22; PART 11 Texas Board of Nursing ; CHAPTER 217 ; RULE §217.11 "Standards of Nursing Practice" showed:

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

(B) Implement measures to promote a safe environment for clients and others;
(D) Accurately and completely report and document: (ii) nursing care rendered;
(U) Supervise nursing care provided by others for whom the nurse is professionally responsible.

~~~~~~~~~~~~~~~~~~~~~~

a. Failed to conduct RN rounds every two(2) hours:

Record review of facility policy titled "Level of Observations,"dated 03/01/2023, showed: The Registered Nurse (RN) will conduct routine rounds to visually observe each patient for safety at least once every 2 hours and will validate rounds by initialing in the appropriate section of the form.

~~~~~~~~~~~~~~~~~~~~~~~~~~~

Review of facility census forms for March 3, 10,12, 2023 night shifts- [for rooms 103, 104, 105, 106, and 108 ] showed:

-March 3/4, 2023 : eight (8) patients: [Patients : # 8, 9,10,11,12,13,14,15]
-March 10/11, 2023: ten (10) patients: [Patients # 10,11,13, 14,15,16,17,18,19, 20]
-March 12/13, 2023: ten (10) patients: [Patients # 1,10,11,14,15,16,17,18,19,20]

Record review of the physician admission orders for Patient IDs #: 1, 8, 9, 10,11, 12,13,14,15,16,17,18,19,20 showed all had orders for Q ( every) 15 minute observations. Review also showed two (2) patients had orders for suicide precautions : Patient ID# 12 ( March 3/4) and Patient ID # 20 ( March 10/11 and 12/13). All 14 patients had orders for fall precautions.

On 3/16/2023 , Surveyor and Director of Nurses (Staff B) reviewed camera footage for the following night shift timeframe:

-March 03, 2023 at 10 PM until March 04, 2023 at 5 AM
-March 10, 2023 at 10 PM until March 11, 2023 at 5 AM
-March 12, 2023 at 10 PM until March 13, 2023 at 5 AM

Observation areas visible in camera footage area were: the day room area by the big TV and hallway areas / doors to patient room #s: 103, 104, 105, 106, and 108.

Observation of the camera footage showed: there was no RN rounding observed during the review of all three (3) night shifts ( 10PM to 5 AM) . During an interview with Staff B, DON at the time of camera footage review, she verified there was no RN rounding performed / observed. She said this was "entirely unacceptable." The DON went on to say RNs were to make rounds on every patient every 2 hours, more frequently if needed.


b. RNs failed to supervise MHTs:

Record review of facility policy titled "Staffing Plan," dated 09/01/2022, showed:

-An RN plans, assigns, supervises and evaluates the nursing care of each patient daily.

-An RN is responsible for supervising all Licensed Practical/Vocational Nurses (LPN/LVN), Mental Health Technicians (MHT), and Certified Nursing Assistants (CNA).
Record review of Texas Administrative Code (TAC) Title 22; PART 11 Texas Board of Nursing ; CHAPTER 217 ; RULE §217.11 "Standards of Nursing Practice" showed:

(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall:
(B) Implement measures to promote a safe environment for clients and others;
(D) Accurately and completely report and document: (ii) nursing care rendered;
(U) Supervise nursing care provided by others for whom the nurse is professionally responsible.


Observation of the camera footage reviewed by surveyor and DON for March 3/4; 10/11; 12/13, 2023 showed:

- MHT rounding was observed only twice during the review of all three (3) night shirts. [policy requires 4 times per hour for each patient ]

- Several patient doors were closed during the three night shifts reviewed.

- On March 3 and 10 : staff failed to open the door to occupied rooms 104 and 108 during the entire night shift reviewed from 10PM until 5 AM.

During an interview with Staff B, DON at the time of camera footage review, she verified there was no RN rounding observed/ performed. She went on to say that when the RN signs the Q15 rounding sheet, the RN is attesting that the MHT is making the Q 15 observations; and RN is making the 2 hour nursing rounds.

Based on observation, interview, and record review, the facility failed to ensure that medical record were accurately written for 14 of 14 sampled patient records (Patient # 1, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 ).

-RN and MHT patient observation rounding was documented as performed on 3 night shifts. Review of video footage showed the observations were not done.

Findings included:

Record review of Texas Administrative Code (TAC) Title 22; PART 11 Texas Board of Nursing ; CHAPTER 217 ; RULE §217.11 "Standards of Nursing Practice" showed:

(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall:
(D) Accurately and completely report and document:
(ii) nursing care rendered;
(iii) physician, dentist or podiatrist orders;

Record review of facility policy titled " Documentation," dated 01/01/2023, showed : "...Routine: The RN documents pertinent and factual information...."

Record review of facility policy titled "Level of Observations,"dated 03/01/2023, showed:

-The initial patient observation level is determined and ordered by the physician on admission.
-Staff members utilize the close observation form (Q15 check sheet) to document the ongoing observation and location of the patient. Additional information regarding activities are included on the form when relevant ( i.e. water offered, activities of daily living). The observing staff initials the 15 minute increments in the form to indicate the patient was observed.
-The observing staff initials the 15-min increments on the form to indicate the patient was observed.
-The Registered Nurse (RN) will conduct routine rounds to visually observe each patient for safety at least once every 2 hours and will validate rounds by initialing in the appropriate section of the form.

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On 3/16/2023 , Surveyor and Director of Nurses (Staff B) reviewed camera footage for the following night shift timeframe:

-March 03, 2023 at 10 PM until March 04, 2023 at 5 AM
-March 10, 2023 at 10 PM until March 11, 2023 at 5 AM
-March 12, 2023 at 10 PM until March 13, 2023 at 5 AM

Observation areas visible in camera footage area were: the day room area by the big TV and hallway areas / doors to patient room #s: 103, 104, 105, 106, and 108. Review of video footage showed MHTS and RNs not performing patient rounds per policy . [REFER to TAG A-0395 for video review findings]

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Record review of the "Observation Check Sheet/ Graphic Flowsheet" for Patient IDs# 1, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 [ for applicable dates: March 3/4; March 10/11; March 12/13, 2023) showed: MHT initials in every allotted space for Q 15 observations: documentation included patient behaviors ; location ; incontinence checking ( every 2 hours). Further review or these same observation sheets showed: RN initials every 2 hours that showed patient rounds conducted ; and RN signature and date at the bottom of the form.

During an interview at the time of review with Staff B, DON, she stated that after reviewing the night shift videos, all of these observation forms showed falsification of records.