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.

WELLBRIDGE HEALTHCARE FORT WORTH 6200 OVERTON RIDGE BLVD FORT WORTH, TX 76132 May 26, 2017
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review, interview, and observation, the hospital failed to protect and promote the right of 31 out of 31 suicidal patients (Patients #1, #2, #3, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #24, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #41) to receive care in a safe setting.


1) Although identified as a safety risk prior to survey, metal framed beds with multiple spaced bars potentially usable for ligature during a suicide attempt were assigned to all suicidal patients.

2) Staff observational rounds were not completed for all patients.


Refer to A 144
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on record review, interview, and observation, the hospital failed to ensure the right of 31 out of 31 patients on suicide precautions (Patients #1, #2, #3, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #24, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #41) to receive care in a safe setting.


1) Patients #1, #2, #3, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #24, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #41 were identified by hospital staff as on suicide precautions during the survey. The patients were assigned beds with metal frames that provided multiple ligature points.


2) Patient #24 was noted impaired, in need of close monitoring, and on suicide precautions. The patient was assigned a metal bed and had the opportunity for a suicide attempt during 43 minutes of no staff observation.


Findings included:


During an interview on 05/12/17 at 1314 Personnel #7 identified 17 patients (Patients #1, #2, #3, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, and #24) to be on suicide precautions.


Observations on the hospital's two-winged patient care unit on 05/12/17 between 0950 and 1245 reflected Patients #1, #2, #3, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, and #24 were assigned metal beds with spaced bars for multiple ligature points.


During an interview on 05/26/17 at approximately 1030, Personnel #1 provided the surveyor with a list that identified 14 patients (Patients #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #24) to be on 15-minute staff observation checks for suicide.


Personnel #8 stated on 05/26/17 at 1310 that Patient #41 was suicidal.


Observations on the hospital's patient care unit on 05/26/17 between 1310 and 1320 reflected Patients #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #24, and #41) were assigned metal beds with ligature risks.


Personnel #3 was interviewed on 05/12/17 at 1330. Personnel #3 stated metal beds had been identified as a ligature risk during a hospital safety meeting on 05/03/17 and would be replaced in "six to eight weeks."


Record review of Hospital Policy titled "Suicide Assessment and Prevention" dated 02/01/17 reflected the policy to "...provide a safe and supportive clinical setting..."



2) Record review of Patient #24's Complete Nurse Practitioner Evaluation dated 05/09/17 at 1411 reflected the patient had attempted suicide and needed inpatient care.


Patient #24's Physician Progress Note dated 05/12/17 at 1216 reflected the patient was "severely functioning impaired" and needed "careful supervision and monitoring."


Record review of Patient #24's staff 15-minute observation form dated 05/23/17 reflected no staff observation documentation between 1246 and 1329.


Personnel #9 acknowledged the finding during an interview on 05/26/17 at 1315.