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.
|UNIVERSITY BEHAVIORAL HEALTH||2026 WEST UNIVERSITY DRIVE DENTON, TX||Nov. 16, 2011|
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the Hospital failed to ensure the RN (Registered Nurse) evaluated and/or assessed 1 of 2 patients (a child) (Patient #1) after an incident of sexually inappropriate behavior was discovered by 1 of 1 staff (Personal #6) while doing Q (every) 15 minute observation rounds.
Patient #1's admission physician's orders dated 09/03/11 timed at 23:11 PM reflected, "admitted to child unit...working provisional diagnosis were ADHD (Attention Deficit Hyperactivity Disorder) with aggression...Q (every) 15 min (minute) precautions..."
The clinical assessment dated [DATE] reflected, "Mom stated last weekend patient jumped off neighbors roof and onto a trampoline, broke it and then took a pair of scissors and pulled off a piece of his braces...patient had been suspended from school for aggression...and not cooperating at school...mother denied patient was sexually victimized and/or unsafe sexual practices...gets in fights with classmates and family...denied history of abuse...or history of perpetration..."
The Patient Data Assessment narrative (nursing) dated 09/07/11 timed at 21:00 PM reflected, "MHT (mental health technician) entered the room and (Patient #1) was being sucked on...inappropriate sexual behavior by another peer (Patient #3)...patient stated he had sucked on peers earlier in day during quiet time...parent was notified..." No documentation was found in the medical record from nursing which indicated Patient #1 was assessed by the nurse after the incident occurred.
The Patient Rounds Progress Note dated 09/07/11 timed at 21:15 PM, reflected, "Patient was caught engaging in oral sex with his roommate...I was doing by 15 minute rounds when I opened the door and observed (Patient #3) underneath covers...(Patient #1's) pants were down...escorted both patient's to day area, notified RN (Registered Nurse)..."
The physician progress note dated 09/09/11 timed at 4:00 PM reflected, "Reported I was playing with my pee pee...patient started on LOS (Line of sight) for inappropriate sexual behavior..."
On 11/16/11 at 1:10 PM, Personnel #7 was asked to review Patient #1's medical record for any documentation which indicated Patient #1 was assessed by the nurse after the sexually inappropriate behavior was discovered. Personnel #7 said she could not find an assessment by the RN and/or that vital signs were taken.
On 11/17/11 at 11:35 AM Personnel #5 was interviewed. Personnel #5 stated she did assess Patient #1. The surveyor asked Personnel #5 where the documentation was. Personnel #5 said she did not document her assessment as it had been a busy evening.
The Hospital policy and procedure entitled, "Assessment of Patients" with an issue date of 10/01/05 reflected, "All patients admitted to...will receive a thorough assessment and evaluation...a functional assessment is completed when indicated by patient needs/conditions as determined..."