The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on observation, interview and record review, the facility failed to ensure the patient's rights to be free from all forms of abuse or harassment because it failed to ensure the presence of a hall monitor where patient rooms are located at all times at night to prevent a patient from entering another patient's room, failed to report an allegation of assault for 1 of 1 patients reviewed (Patient #1) by another patient (Patient #2) while receiving mental health services and failed to investigate and report/respond to the allegation of assault in accordance with the facility's Grievance/Complaint policy.

This deficient practice could affect the prevention of possible abuse, neglect or mistreatment for all patients in the facility by compromising their safety.

Findings Included:

During a tour of the adolescent psych unit on 01/18/17 at 9:33 a.m. accompanied by the Chief Executive Officer and the Director of Nurses, the Director of Nurses stated the
"patients are separated at night by gender depending on the census," "boys are at the far end of the hall and girls are closer to the nurse's station, and "Somebody is sitting in the hall all night from 8:30 or 9:00 p.m. until 6:30 a.m. or 7:00 a.m." The Chief Executive Officer stated, "The monitor sits at the 2nd door because that is where the patient rooms begin."

In an interview on 01/18/17 at 10:10 a.m. in the conference room, S#3 was asked about patient monitoring at night and stated that, "At night the tech sits on the hallway and does rounds every 10 minutes. The night tech starts getting them up in the morning and brings them to the day room by group. Another tech stays in the hall because there are others still in rooms." When asked about the incident on 09/21/16 involving patient #1, S#3 stated, "The 11-7 tech gave report at 7 a.m. and said patient so and so went into her room but they got to them on time. I kept an eye on them. The patient didn't say anything in the morning. I heard about it during shift change at 2:45 p.m. She was telling me about some other patient going into her room that he went to her room while she was asleep and then but she said he kissed her and bit her tongue. I told her I will address it with the charge nurse and if she had told me earlier I would keep that patient away from her. They were socializing earlier. They were sitting across the table socializing, talking. After she finished telling me, I finished giving report and told the tech I was giving report to, I was going to address it with the charge nurse and told her to keep an eye on them. I went to the charge nurse and did address it to her. I don't remember her name. The charge nurses work 7 A to 7 P and the techs 7-3. I don't remember the tech."

In an interview on 01/18/17, at 11:27 a.m. in the conference room, the Director of Nurses was asked about the complaint allegation regarding 09/21/16 and stated, "The girl told the nurse the next day. The boy was moved to another hallway but the charge nurse didn't document it in the notes. I tried by phone to call the Mother about the complaint but was unable to reach her." The Director of Nurses confirmed that the facility had not self-reported the complaint allegation of assault to the State and had not completed an incident report. The Director of Nurses confirmed the facility had not handled it as a grievance and had not sent the Mother a response letter. The Chief Executive Officer stated, "Normally we do that but in this particular case the letter came from the insurance company." The Director of Nurses further stated, "The mental health technician went to the nurse's station to get something, she was the hall monitor and she saw the other patient out of the corner of her eye."

Review on 01/18/17 at 1:10 p.m. of a nursing note dated 09/22/16 at 16:00 stated,
"Approached by pt complaining that her tongue hurts, when asked why, she told me that it was bitten last night by another pt, no injuries as assessed, started to disclosed that another pt went to her room and tried to kiss her and bit her tongue, hence, investigation was started, Dr. ___ notified, Risk manager aware, house supervisor, Director and administration, parents were notified of both parties involved. Paper works done, both placed on close observation and line of sight. PRN medication given as per orders. No reports was given to me by Night shift nurse about incedent."

Review of an untitled document identified by the Director of Nurses as a copy of "sticky notes" on 01/18/17 at 1:15 p.m. in the conference room revealed, "11:16 to :12 No hall monitor." The name of a mental health tech was listed and "11:16:57." The note also stated, "11:21:25 - removed by staff."

In an interview on 01/18/17 at 1:23 p.m., in the conference room, the Director of Nurses confirmed the above and confirmed that she had reviewed the video and it showed there had not been a hall monitor for 5 minutes. The mental health tech had not been sitting at her post in the hall for 5 minutes. The Director of Nurses was asked what "removed by staff " meant on the note and she clarified that it meant, "The boy was removed." The facility could not provide written documentation that hall monitoring had been addressed with the health tech assigned as a hall monitor or any other staff members after this incident occurred in an effort to prevent future occurrences. At 1:28 p.m., the Chief Executive Officer stated, "Our process failed."

Review of the facility ' s policy entitled, Grievance/Complaint Management policy on 01/19/17 revealed it was last revised on 7/1/16 and revealed the following in part:

Patient Grievance: A formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding hospital care or services which cannot be resolved promptly by staff present. The grievance may be submitted in person, in writing, by e-mail, telephone or fax. A grievance includes written or verbal complaints including the following:

3. Abuse, neglect and/or patient harm issues.

Policy: B. Each grievance will be resolved in a timely manner.

Procedure C: Resolution of a Grievance and Communication with Patient
1. When a verbal or written grievance is received, it will be forwarded to the appropriate manager or administrative representative and an investigation will be initiated.
2. All allegations of abuse or neglect will be reviewed immediately to ensure the safety of the patient in question.
3. In all cases, the hospital will provide a written response to the patient.

Review of the facility's policy entitled, Victims of Abuse, Assault, Exploitation, Incapacity, Neglect or Vulnerability - All Populations revealed it was last revised on 5/1/16 and revealed the following in part:

Policy - Any person having reasonable cause to believe that an individual is being abused, neglected or exploited is required to report to the appropriate agency in compliance with Texas State Law, a report must be made within 48 hours.

A. "Abuse" is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psycho-social well-being.

G. "Neglect" means failure of the caregiver of an individual to provide basic needs such as clothing, food, shelter, supervision and care for the physical and mental health for that individual or failure by an individual (self neglect) to provide such basic needs for himself.

In a telephone interview on 01/19/17 at 1:53 p.m., the Director of Nurses re-confirmed that the facility had not self-reported the complaint allegation and did not believe any other agencies had been notified. When asked if the police had been notified, the Director of Nurses stated, "I believe the Mother called the police."

During a tour of the adolescent psych unit on 01/18/17 at 10:00 a.m. accompanied by the Chief Executive Officer and Director of Nurses, observation of the Patient Rights signage revealed that the Health Facility Certification and Licensure Division was listed as a contact for complaints and was bolded but the phone number was not bolded, was in a smaller font, and was not easy to read. The Chief Executive Officer confirmed the above findings and stated, "We can make it larger."

In a telephone interview on 01/19/17 at 1:59 p.m., the Director of Nurse's was informed that the Patient's Rights signage did not include the information in Spanish and stated, "I think they are all in English." In an e-mail on 01/19/17 at 4:02 p.m., the Director of Nurse's confirmed that the rights were not posted in Spanish and would get them posted.