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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.

Findings included:

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..."