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.

GEORGETOWN BEHAVIORAL HEALTH INSTITUTE 3101 S AUSTIN AVENUE GEORGETOWN, TX Jan. 10, 2017
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on observation, interview and record review the facility's nursing administration failed to develop and enforce patient care policies and procedures when,

a.) Staff did not receive training on providing incontinence care and
b.) Staff #7, MHT did not wash his hands before putting on disposable gloves and after removing dirty disposable gloves

Findings include:

a.) During an interview on the morning of 1/9/17 on the Geriatric Unit Staff #7, MHT when asked if he had training on providing perineal care to incontinent patients Staff #7 stated, "I was trained to do Perineal care at my previous job...I was not trained here..."

During an interview on the morning of 1/9/17 on the Geriatric Unit Staff #15, MHT when asked if she had training on providing perineal care Staff #15 stated, "I was a CNA, (Certified Nursing Assistant) before working here... I was trained at ACC (Austin Community College)....not here."

During an interview on the morning of 1/9/17 on the Geriatric Unit Staff #17, MHT when asked if she had training on providing perineal care to incontinent patients stated, "I used to work in home health, I was trained there...I wasn't trained here."

Staff #2, Chief Nursing Officer was present during the tour and confirmed the finding and stated, "...We have patients that are incontinent...e don't train for Peri-Care..."

The facility was unable to provide a policy and procedure or staff competency checkoff for incontinence care.

b.) An observation made during the tour of the Geriatric Unit (Mesquite) on the morning of 1/9/2017 revealed Staff #7, MHT going up and down the patient hall picking up patient trash bags in the hallway. Staff #7 proceeded to go into multiple patient rooms. The DON stated he was straightening up the rooms. Staff #7 removed his gloves and threw them into the trash; he did not wash his hands between rooms or after throwing away his gloves. Staff #7 was asked if anyone was incontinent of bladder, he stated Patient #6 was and that he is checked every two hours when he is turned. Staff #7 did not wash his hands before putting on fresh gloves and went in to check Patient #6 for incontinence. Staff #7 reached into to the patients briefs to check for wetness then removed his dirty gloves and walked down the hallway to throw them in the trash. Staff #7 did not wash his hands and was observed touching patient doorknobs.

The DON confirmed the finding and stated, "Staff #7 did not wash his hands...."
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record review and interview the facility failed to provide a written notice to each patients grievance for (8) of (8) patients complaining of abuse.

Findings Include:

Review of the Facility based grievances for October 2106 thru December 2016 reflected the following patient complaints:

Patient #7 on 11/15/16- "...complaint of staff disrespecting patients, loud at night, talking down...."
Patient #8 on 12/21/16- "...workers are overworked ...need enough staff ...."
Patient #9 on 12/8/16- "... RN is retaliating against me because I reported her abusive and racist behavior."
Patient #10 on 12/3/16- "...treated like we're some piece of trash..."
Patient #11 on 11/14/16- "...Staff laugh and threaten patients..."
Patient #12 on 10/31/16- "...staff use disrespectful, harsh and condescending trigger tones towards patients...."
Patient #13 on 10/26/16- "...overnight staff not so great..."
Patient #14 on 10/24/16- "...staff cuss at patients and are rude..."

The complaint forms did not reflect investigations had been completed and the resolutions of the allegations were not recorded or the follow up communication to the patients making the complaints.

Basic Rights for All Patients (undated)
"... 5. You have the right to be free from mistreatment, abuse, neglect, and exploitation...."

During an interview on the afternoon of 1/10/17 in the facility conference room when Staff #3 CEO was asked if the facility had used the complaints as part of the Quality Improvement Program he stated, "When we get complaints the DON decides if it needs to be a counseling...you might not see that on the complaint form..."
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, interview and record review the facility failed to provide a safe environment when,

a.) Staff did not receive training on providing incontinence care and
b.) Staff #7, MHT did not wash his hands before putting on disposable gloves and after removing dirty disposable gloves

Findings include:

a.) During an interview on the morning of 1/9/17 on the Geriatric Unit Staff #7, MHT when asked if he had training on providing perineal care to incontinent patients Staff #7 stated, "I was trained to do Perineal care at my previous job...I was not trained here..."

During an interview on the morning of 1/9/17 on the Geriatric Unit Staff #15, MHT when asked if she had training on providing perineal care Staff #15 stated, "I was a CNA, (Certified Nursing Assistant) before working here... I was trained at ACC (Austin Community College)....not here."

During an interview on the morning of 1/9/17 on the Geriatric Unit Staff #17, MHT when asked if she had training on providing perineal care to incontinent patients stated, "I used to work in home health, I was trained there...I wasn't trained here."

Staff #2, Chief Nursing Officer was present during the tour and confirmed the finding and stated, "...We have patients that are incontinent...e don't train for Peri-Care..."

The facility was unable to provide a policy and procedure or staff competency checkoff for incontinence care.

b.) An observation made during the tour of the Geriatric Unit (Mesquite) on the morning of 1/9/2017 revealed Staff #7, MHT going up and down the patient hall picking up patient trash bags in the hallway. Staff #7 proceeded to go into multiple patient rooms. The DON stated he was straightening up the rooms. Staff #7 removed his gloves and threw them into the trash; he did not wash his hands between rooms or after throwing away his gloves. Staff #7 was asked if anyone was incontinent of bladder, he stated Patient #6 was and that he is checked every two hours when he is turned. Staff #7 did not wash his hands before putting on fresh gloves and went in to check Patient #6 for incontinence. Staff #7 reached into to the patients briefs to check for wetness then removed his dirty gloves and walked down the hallway to throw them in the trash. Staff #7 did not wash his hands and was observed touching patient doorknobs.

The DON confirmed the finding and stated, "Staff #7 did not wash his hands...."