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.

ROCK PRAIRIE BEHAVIORAL HEALTH 3550 NORMAND DRIVE COLLEGE STATION, TX 77845 Dec. 12, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, review of records, and interview, the facility failed to ensure patient rights were protected and patients were cared for in a safe environment. The facility failed to ensure:

1) staff followed proper procedures for restricting patient rights in 1 (Patient #3) out of 4 (Patient #3, #4, and #5) patients reviewed. A nurse, Staff #9, removed bed sheets from a suicidal patient who was identified as making attempts to use sheets as a ligature. The nurse failed to update the suicide risk assessment form based on patient behaviors. The nurse failed to notify the physician to obtain new orders. The nurse failed to update the care plan and involve the interdisciplinary care team so that other interventions could be put in place without removing bed linen. The nurse failed to communicate the rights restriction to direct patient care staff. Direct patient care staff gave a sheet back to Patient #3. Patient #3 used the sheet to hang himself, resulting in death.

2) ligature-resistant hinges for doors were properly installed. Hinges on doors were installed with sufficient distance between top edge of metal hinge and first set of installation screws that Patient #3 was able to pry the hinge away from door and use to attach sheet. Patient #3 used the sheet to hang himself, resulting in death.

3) a vulnerable patient (Patient #3) was provided a humane and emotionally supportive environment. Patient #3 had an anger outburst and punched his bedroom wall. The bedroom wall was observed to have numerous holes punched into the wall board with visible blood smears. Patient #3 was made to remain in that room with the holes and blood smears for 2 days prior to Patient #3 committing suicide, rather than moving the patient into a room that was clean and in good repair.

4) staff were effectively trained in response to Code White/Code Blue (emergency medical response needed situations. Delays were observed in staff response that could have potentially improved the outcome of a Code White/Code Blue.

5) vulnerable patients were protected from emotional trauma during a Code White/Code Blue response. Patients were observed entering Patient #3's room immediately after Staff #10 called for assistance after finding Patient #3 hanging from a door. Patients were allowed to stand in the hallway and in the doorway and observe rescue efforts by staff.

6) suicidal patients were prevented from being placed in rooms with ligature hazards. Patient #6 was identified as being suicidal and was involuntarily committed as a result. Patient #6 was placed in a room with medical bed that had ligature attach points readily accessible.

7) patients and staff were protected in a safe environment from 1 patient (Patient #1) of 1 reviewed who was known to become violent, and assault other patients and staff. Despite multiple attacks on patients and staff by Patient #1, only two incidents were investigated and measures were not put in place to protect patients and staff throughout Patient #1's 25 days of inpatient stay.

8) processes were put in place to identify patient upon admission with significant sexual history and protect other patients from becoming sexually victimized by those with significant history in 1 (Patient #1) of 1 patient reviewed. Patient #1 was known have a significant history of sexual activity and aggressive/violent behavior, but was not identified upon admission to be a potential risk to other patients. Subsequently, she sexually victimized another patient.

9) staff had appropriate Basic Life Support Training in 1 required staff member (Staff #15) of two staff personnel files (Staff #13 and Staff #15) reviewed. Staff #15 was found to have training that was meant for the lay-person who does not work in healthcare.

These deficient practices were found to place all patients in Immediate Jeopardy of risk of harm and potential loss of life.

See Tag A0144

10) that 2 (Staff #24 and Staff #25) out of 12 Assessment and Referral (A&R) staff had received the required training on the Pre-Admission Screening Assessment in order to properly assess patients for admission and properly ensure patient rights were explained and protected.

See Tag A0117
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, review of records, and interview, the facility failed to ensure:

1) staff followed proper procedures for restricting patient rights in 1 (Patient #3) out of 4 (Patient #3, #4, and #5) patients reviewed. A nurse, Staff #9, removed bed sheets from a suicidal patient who was identified as making attempts to use sheets as a ligature. The nurse failed to update the suicide risk assessment form based on patient behaviors. The nurse failed to notify the physician to obtain new orders. The nurse failed to update the care plan and involve the interdisciplinary care team so that other interventions could be put in place without removing bed linen. The nurse failed to communicate the rights restriction to direct patient care staff. Direct patient care staff gave a sheet back to Patient #3. Patient #3 used the sheet to hang himself, resulting in death.

2) ligature-resistant hinges for doors were properly installed in 3 out of 3 rooms observed (Room #s 301, 302, and 305). Hinges on doors were installed with sufficient distance between top edge of metal hinge and first set of installation screws that Patient #3 was able to pry the hinge away from door and use to attach sheet. Patient #3 used the sheet to hang himself, resulting in death.

3) a vulnerable patient (Patient #3) was provided a humane and emotionally supportive environment. Patient #3 had an anger outburst and punched his bedroom wall. The bedroom wall was observed to have numerous holes punched into the wall board with visible blood smears. Patient #3 was made to remain in that room with the holes and blood smears for 2 days prior to Patient #3 committing suicide, rather than moving the patient into a room that was clean and in good repair.

4) staff were effectively trained in response to Code White/Code Blue (emergency medical response needed) situations in 1 out of 1 response reviewed. Delays were observed in staff response that could have potentially improved the outcome of a Code White/Code Blue.

5) vulnerable patients were protected from emotional trauma during a Code White/Code Blue response in 1 out of 1 response reviewed. Patients were observed entering Patient #3's room immediately after Staff #10 called for assistance after finding Patient #3 hanging from a door. Patients were allowed to stand in the hallway and in the doorway and observe rescue efforts by staff.

6) suicidal patients were prevented from being placed in rooms with ligature hazards in 1 (Patient #6) of 3 patients reviewed. Patient #6 was identified as being suicidal and was involuntarily committed as a result. Patient #6 was placed in a room with medical bed that had ligature attach points readily accessible.

7) patients and staff were protected in a safe environment from 1 patient (Patient #1) of 1 reviewed who was known to become violent, and assault other patients and staff. Despite multiple attacks on patients and staff by Patient #1, only two incidents were investigated and measures were not put in place to protect patients and staff throughout Patient #1's 25 days of inpatient stay.

8) processes were put in place to identify patient upon admission with significant sexual history and protect other patients from becoming sexually victimized by those with significant history in 1 (Patient #1) of 1 patient reviewed. Patient #1 was known have a significant history of sexual activity and aggressive/violent behavior, but was not identified upon admission to be a potential risk to other patients. Subsequently, she sexually victimized another patient.

9) staff had appropriate Basic Life Support Training in 1 required staff member (Staff #15) of two staff personnel files (Staff #13 and Staff #15) reviewed. Staff #15 was found to have training that was meant for the lay-person who does not work in healthcare.

These deficient practices were found to place all patients in Immediate Jeopardy of risk of harm and potential loss of life.

Findings for 1) included:

Review of Patient #3's chart revealed the following:

Patient #3 was a [AGE]-year-old male admitted involuntarily on 11-26-2018. On 11-28-2018, the attending physician signed a Physician's Certificate of Medical Examination for Mental Illness to present to the court for the purpose of seeking an Order of Protective Custody. Review of the physician's statement included the following:

"Patient is at imminent risk of harm towards self by active suicidal ideation's and self-injurious behavior. The patient endorses suicidal ideation's with a plan, but he would not disclose the plan. He has self-injurious behavior by punching holes in the wall in his room. He is emotionally unstable, and had to receive emergency medication, intramuscular. He is impulsive, highly depressed, anxious, and easily agitated. He is unstable at this time."

Despite the patient being admitted involuntarily and the physician assessment above, the patient was never placed on increased observation due to the patient was scored as low risk of suicide. The patient scored low risk of suicide on 7 out of 8 Rock Prairie Behavioral Health Suicide Risk Monitoring Tool forms completed by staff. On 11-29-2018, the form scored at low risk, but the night shift nurse who assessed the patient determined the patient to actually be at the medium risk. The line for the nurse to explain the higher assignment of risk was left blank.

No notes were found in the chart that indicated the patient had been observed making suicidal attempt by choking self.

Review of group therapy notes showed that the patient refused to attend group therapy throughout his stay.

During interview with Staff #21 on 12-5-2018, Staff #21 was asked about the lack of therapy provided to the patient. Staff #21 provided two Therapy Service Notes that were not in the original chart and signed by Staff #14. These notes were dated for 11-28-2018 and marked as "Late entry". They were signed by Staff #14 on 12-7-2018, seven days after the patient committed suicide. The note that was a documentation of events on 11-28-2018 at 4:03 PM read as follows:

"Therapist was informed by medical tech that he had just observed the patient using his bedding to harm himself by wrapping it around his neck. Therapist met with the patient in his room and we discussed the medical techs (sic) observations as well as what might be troubling him. The patient denied any suicidal ideation's and reported that he was not trying to harm himself with his pillow case. He reported that he was feeling ok and did come out of his room after we talked for a walk around the unit. Therapist, nursing staff of _______ (Staff #22) observations and requested his bedding be removed. Therapist observed the nurse discussing with the patient that we would have to remove his bedding and he reported that he understood."

This note was not in the chart and available to the physician prior to the patient committing suicide. MHT observations were not documented on the MHT's form for documentation of patient locations and behaviors.

Interview was conducted with maintenance staff (Staff #12) on 12-11-2018 at 1:00 PM. Staff #12 stated that he had entered Patient #3's room on the afternoon of 11-28-2018. He noticed a sheet laying by the writing desk that was balled up like a noose. He stated he notified the nurse (Staff #9), and she came in got the sheet off of the floor. Staff #12 stated Staff #9 then instructed the Mental Health Tech (MHT) on duty to remove all of the bed linen from the room. No documentation of sheets being removed was found in nursing notes or MHT notes. No order for sheets to be removed due to suicidal gestures was found in the chart.

Records of a statement made by the Physician Assistant (Staff #19) revealed that Staff #19 had witnessed the patient on 11-28-2018 in an apparent attempt to choke himself out with his bare hands. Staff #19 had Staff #22 watch the patient while she went to speak to the nurse (Staff #9) at the nurse station. In an interview with Staff 19 on 12-17-2018, Staff #19 confirmed that the record of statement attributed to her was correct. Staff #19 explained she had not documented the events because, after speaking with Staff #9, she had been assured that Staff #9 would immediately remove the linen from Patient #3 and contact the attending psychiatrist to advise and for further orders. Staff #19 explained that she was not authorized as the PA responsible for medical care, not psychiatric care, to write orders for increased level of observation of patients.

No record of physician notification was found by nursing staff, clinical staff, or medical staff that were witness to patient's active suicidal gestures.

Interview was conducted with Staff #11 on 12-11-2018 at 12:14 PM. Staff #11 stated she had given Patient #3 a sheet when he asked for it on 11-30-2018. Staff #11 stated she had not been informed of his previous suicide gestures until after the patient committed suicide. "Nobody said he wasn't supposed to have sheets." Staff #11 stated she knew he didn't have sheets on his bed, but thought someone had failed to give him clean sheets after they were changed for cleaning.

Review of the Texas Administrative Code, Rights: Persons Receiving Mental Health Services, 404.154(3), outlining the rights of psychiatric patient was as follows:

"The right to a humane treatment environment that ensures protection from harm, provides privacy to as great a degree as possible with regard to personal needs, and promotes respect and dignity for each individual."

Review of Policy #1800.4, Subject: Denial of Rights, was as follows:

"PROCEDURE:
1. Denial of basic patient rights, including restriction of phone access, unit restrictions, one-to-one observation, and visitation requires a physician order."

No record of a physician order restricting the patient from having bed linen (humane treatment, respect and dignity of the patient) was found in the chart. There was no documentation found in the chart that the patient was to be on right's restrictions with no access to sheets. No increased monitoring was ever ordered despite the patient's suicide risk identified by the physician during assessment for court commitment and suicide gestures that had been witnessed by maintenance, nursing, clinical, and medical staff. Patient #3 successfully committed suicide by hanging with a sheet on the afternoon of 11-30-2018.

Findings for 2) included:

On 12-10-2018, a tour of room #305 was conducted with Staff #1 and Staff #4. Room #305 was the room where Patient #3 had committed suicide on 11-30-2018. Staff #1 stated the room had been locked immediately after the event and the only person with keys to it was Staff #4. Staff #4 confirmed that the room had remained locked. A tour of the room revealed that the bathroom door used by the patient in committing the suicide was outfitted with suicide-resistant hardware, including door knobs, hinges, and stops. The hinge at the top of the door was observed to bent away from the door with sufficient space to allow Patient #3 to gain enough tension on a sheet to be able to hang himself. The first set of screws used to attach the hinge at the top of the door were observed to be installed approximately one inch below the top of the hinge. This provided sufficient distance for Patient #3 to bend the metal away from the door and attach a sheet. A tour was made of rooms 301 and 302 on 12-10-2018 at 2:40 PM. Bathroom door hinges were observed to have the same hinge installation as room #305.


Findings for 3) included:

Review of Patient #3's record revealed that the patient had an anger outburst on 11-28-2018. During this outburst at 4:40 AM, the patient punched holes in his bedroom wall causing abrasions to his hand.

Observation of Patient #3's room made on 12-10-2018 showed that the holes in the wall remained. The damaged wall board also had what appeared to be visible dried smears of blood on them from his abrasions sustained while punching the wall.

Staff #21 provided two Therapy Service Notes signed by Staff #14. These notes were dated for 11-28-2018 and marked as "Late entry". They were signed by Staff #14 on 12-7-2018, seven days after the patient committed suicide. The note that was a documentation of events on 11-28-2018 at 3:03 PM read as follows:

"Therapist met with patient individually after group therapy to check on patient's mental state. Patient appeared to be having overwhelming feelings and sitting in bed. Patient also appeared to be responding to auditory hallucinations and had his head in his hands. Patient had a hard time talking to therapist due to his mental state but chose to communicate non-verbally. Patient pointed to some holes in the wall and motioned to himself. Therapist probed the meaning of these actions. Patient was able to communicate that he had punched the wall last night and reported that the therapist wouldn't understand what he was feeling. Therapist helped patient reflect on his feelings. Patient reported that he punched the wall because he was upset and wanted to go home ..."

An interview was conducted with maintenance staff (Staff #12) on 12-11-2018 at 1:00 PM. Staff #12 stated he went into the patient's room to assess the damage to the walls on the afternoon of 11-28-2018. Staff #12 stated there were several holes on the wall with blood visible. Staff #12 stated he asked Staff #9 to move the patient to another room so that the room could be repaired. Staff #12 stated that Staff #9 told him no, because the patient would just damage another room and he would have to stay where he was.

Patient #3 was forced to stay in the room with the visual reminder of damaged walls and visible blood smears for two more days until he finally committed suicide.

Findings for 4) included:

On 12-10-2018 at 4:43 PM, an interview was conducted with Staff #8 who was the House Supervisor on duty on 11-30-2018. During the interview, Staff #8 was asked to give the sequence of her actions during the code for Patient #3's suicide. During Staff #8's sequencing of events, Staff #8 stated when she got to the patient's room, she found two staff members performing Cardiopulmonary Resuscitation (CPR), but there was no "crash cart" (a mobile cart containing all necessary equipment to provide emergency care). When an emergency bag arrived, Staff #8 stated she had an AMBU bag (a hand-held device used to assist with patients who are not breathing or are not breathing adequately). However, she did not have any oxygen to connect to the AMBU bag or an Automatic External Defibrillator (AED - a portable device used during an emergency to deliver an electric shock to the heart if necessary). Staff #8 stated other staff members had to be sent back to the front of the unit to retrieve these items.

Review of Policy # 1000.115, Subject: Code White Rapid Medical Response, Effective 11/2015 was made on 12-11-2018. On page 2, under the heading of "Procedure", item 5, the following action is to be taken when a code is called: "The emergency cart/bag will be en-route to the area that the TEAM had been called".

Review of video recorded of the hallway during the response to the suicide revealed the following:
The patient was discovered at 6:04:44 PM (hour:minute:second).
At 6:05:04 the MHT called down the hallway for assistance.
At 6:05:18 second MHT arrived at room.
At 6:05:46 another staff member can be observed coming down hallway to room.
At 6:05:54 a nurse can be seen entering the room.
At 6:05:59 2 more staff arrive.
At 6:06:33 Staff #8 was observed arriving.
At 6:06:47 Staff #8 was observed exiting the room and running up the hallway to the front of the unit.
At 6:08:17 Staff #8 was observed to return to the room carrying a bag.
At 6:08:21 a nurse was observed coming down hallway and entering room.
At 6:08:24 a MHT was observed coming down hallway and entering room.
At 6:08:35 Staff #5 was observed entering the room with a bag.
At 6:09:00 a staff member was observed bringing an oxygen tank to the patient room.
At 6:12:50 a staff member was observed bringing an AED to the room.

This resulted in an almost 4-minute delay in the patient receiving adequate supplemental oxygen and an almost 9-minute delay in the patient receiving a potentially life-saving electric shock to the heart. The delay was significant enough that it could have potentially had a negative effect on the patient outcome during this medical emergency.

Review of the Emergency Medical Services (EMS) documentation of response (Run Sheet) showed that EMS first assessed the patient at 6:14 PM. The assessment noted that the skin was cyanotic. Cyanosis is indicative of a lack of oxygen to the tissue. The run sheet noted that chest compressions applied by hospital staff were determined to be adequate for circulation of blood.

On 12-11-2018, Staff #21 was asked for any records of mock code drills for medical emergencies that had been completed since the beginning of 2018. Staff #21 confirmed that no mock code drills had been performed or recorded.

Interview was conducted with Staff #5 on 12-12-2018. Staff #5 stated that the facility did conduct mock drills and that she had participated in them. Upon further questioning, Staff #5 confirmed it had been over a year since she had participated in mock code for medical emergency.

Findings for 5) included:

Review of video recorded of the hallway during the response to the suicide revealed the following:

The patient was discovered at 6:04:44 PM (hour:minute:second).
At 6:05:46 a female patient was observed entering the room where rescue efforts were being performed on Patient #3.
At 6:06:00 the female patient was observed exiting the room while two other patients were observing the rescue efforts from the hallway.
At 6:06:18 a patient was observed leaning in the doorway, watching the rescue efforts.
At 6:06:58 more patients were observed to come down the hallway and were watching the rescue efforts from the hallway.
At 6:07:50 a staff member was observed to partially close the door so the scene could not be observed from the hallway, and patients were escorted up the hallway to the front of the unit.

For two minutes, vulnerable psychiatric patients were allowed to observe one of their peers after he had hung himself, along with the staff efforts to unsuccessfully perform lifesaving interventions.

The lack of staff skill in responding to a code and securing a scene exposed patients to unnecessary trauma.


Findings for 6) included:

On 12-10-2018, a review of Policy and Procedure # 1000.58, Subject: Unit and Bed Assignment, was made as follows:

"PROCEDURE:

...

2. ... Mechanical beds are located in rooms 201, 202, and 208.
a. To limit potential of harm to patient inherent with these beds, these beds are in close proximity to the nurse's stations.
b. There will not be any patient placed in these rooms with a suicide risk score above medium on the daily suicide risk assessment. These beds are marked by an orange color on our electronic bed board.
c. A&R staff members will also designate the assignment to one of the mechanical bed rooms on the High Risk Assessment.
d. Locator forms will have a special indicator for any patient in one of these rooms as a reminder to staff performing 15 minute checks, including a patient in a standard bed in the same room as a hospital bed.
e. Patient in a room with hospital beds will have indications about this risk factor incorporated into the treatment plans and reviewed on a regular basis."

Review of the semi-annual facility-wide risk assessment conducted on 10-2-2018 was made. The power cords were identified on the mechanical beds were identified as a patient risk. Recommendations for Risk Reduction included, "Power cords are secured to the frame of the Bed. Nursing has protocol for Patient Occupancy." However, the metal frame with numerous ligature attach points was not identified on the report as a potential risk.

A tour of Unit 200 was made on 12-11-2018 at 4:02 PM with Staff #1 and Staff #3. Room 202 was found to have two medical beds and was unoccupied and locked.

Room 208 was observed to be locked. Room 208 had 1 medical bed and 1 psychiatric safe bed. Two patients were assigned to the room. Both patients were admitted voluntarily and neither was admitted with suicidal ideation.

Room 201 was observed to be unlocked, but the door was closed. This prevented staff from observing the patient inside the room. Patient #6 was observed to be resting with her eyes closed in a psychiatric safe bed. The other bed in the room was a mechanical bed with ligature attach points. Review of Patient #6's chart revealed she had been admitted involuntarily for suicidal ideation with a plan and was on suicide precautions. Patient #6 had a suicide plan to overdose on medication. Since medications were controlled in the facility, the patient would need to develop a different plan if she wanted to commit suicide.

Staff #23, the nurse on duty, was asked why a suicidal patient was in a room with ligature attach points. Staff #23 stated that the patient had scored "low risk" on the Suicide Risk Monitoring Tool.

Staff #3 confirmed that it was acceptable practice in the facility for a patient who scored "low risk" on the Suicide Risk Monitoring Tool to be placed in a room with easily accessible ligature attach points provided by the mechanical beds. Staff #3 was reminded that a patient who continuously scored low on the Suicide Risk Monitoring Tool and was involuntarily admitted because he was suicidal had just successfully committed suicide in the facility 10 days earlier, despite scoring low risk on the Suicide Risk Monitoring Tool.

Findings for 7) included:

Review of Patient #1's admissions revealed that Patient #1 was admitted on [DATE] and discharged on [DATE]. Patient was readmitted on [DATE] through 10-10-2018. On the admission psychosocial assessment, it was noted that the patient claimed to be a previous gang member and her goal during her stay was to "not get in any fights". The patient was identified as assaulting staff and peers on multiple occasion with injuries noted. Assaults occurred on:

9-20-2018 - Nursing notes identify that patient charged at a peer and pulled her hair. Mental Health Technician (MHT) notes identify that patient pulled a peer's hair and was trying to fight her.

9-21-2018 - Nursing notes from 11:35 AM identify that Patient #1 stated she was going to fight with another patient. At 8:00 PM, the nursing notes identify that Patient #1 was involved in a Code Purple (additional staff needed to respond to a violent/aggressive patient) with a peer and assaulted an MHT. Code Purple paperwork indicate the MHT was injured with a contusion below the eye and eye injury.

9-22-2018 - Nursing notes identify that Patient #1 attempted to fight a peer, kicked staff, and slammed staff with her head.

9-30-2018 - Nursing notes identify that at 12:27 PM Pt #1 reported homicidal ideation towards two other patients. The nurse noted that the patient had to be restrained due to a "peer to peer conflict" at 4:45 PM. MHT notes identify that Patient #1 had a fight with a patient. That patient was one of the patients that Patient #1 had stated she had homicidal ideation towards.

10-2-2018 - Nursing notes identify that Patient #1 hit a peer in the head twice and pulled her hair at 10:00 AM. At 5:00 PM, nursing notes identify that Patient #1 "attacked a female peer in the dayroom". She "pulled her hair, hit her in the face and scratched peers (sic) arm." MHT notes identify that Patient #1 was "non-compliant had two incidents involving fight pt 2-01 pulled her hair out leaving patches and punching pt in face. Pt couldn't give a legitimate reason as to why pt 4-02 was a target and kept blaming others for her actions."

10-3-2018 - Nursing note at 1:55 AM reads, "______ (Patient #1) had several conflicts today, assaulting a peer. She is unpredictable and difficult to manage at times. Refused vital signs, is eating, does get along with peers at times. She needs to be watched."

10-5-2018 - Nursing notes identify that Patient #1 "had physical altercation with peer - pulled hair and verbally threatened peer + MHT ...". MHT notes from 1st shift identify that Patient #1 hit a peer and pulled her ponytail when leaving the lunchroom. MHT notes from 2nd shift read, "Pt. threatened several pt's. (sic) behind their backs. She was attempting to look tough to no avail. Pt. took meds showered and slept through the night."

10-9-2019 - Nursing noted identify that Patient #1 was involved in a Code Purple. Review of Code Purple paperwork revealed that Patient #1 was hitting and pulling the hair of a female peer. MHT notes identify that Patient #1 fought with a peer in the dayroom and was moved from Unit 600 to Unit 500 due to behavior. Once moved to Unit 500, she was given a roommate. She became upset with the roommate and started yelling. Patient #1 was, again, moved to another room.

Seven out of eight of these incidents resulted in a Code Purple being called and Patient #1 requiring restraint, seclusion, and/or emergency behavioral medication administrations.

Review of the Incident Log revealed that there was only 1 incident report submitted for the incident on 10-2-2018.

On 12-12-2018, Staff #2 was asked advised that surveyors had requested all investigations of incidents for Patient #1 and that the incident log only contained 1 incident. Staff #2 was asked about an injury to a MHT's eye. Staff #2 stated, "I know what you're talking about." Staff #2 left the room and returned shortly with an additional incident report for the 9-21-2018 events. No other incident reports were provided. No record of investigations into the assaults or interventions put into place in order to protect patients and staff was presented.

Despite 8 attacks on other patients throughout the two admissions, Patient #1's claims of homicidal ideation, and repeated warnings to different staff that she intended to fight other patients, the patient was never placed on increased observation in order to protect patients and staff.

Findings for 8) included:

Review of Patient #1's admission on 9-15-2018 revealed that she was admitted from a residential treatment center that serves adolescents who are victims of sex trafficking. Patient was also known to be violent and aggressive (see Finding for 7).

The Psychiatric Evaluation from 9-16-2018 identifies that the patient was introduced to Crack at [AGE] through prostitution.

Nursing notes from 9-22-2018 state that Patient #1 reported she slept with all three of her brothers and had sex with her sister.

MHT notes from 9-24-2018 identify that Patient #1 is "very friendly" with a male peer, referring to him as her boyfriend. The notes state that Patient #1 went into another patient's room and then lied about it. The note does not elaborate on whether the other patient was a male or female or details of why Patient #1 went into another patient's room.

Several MHT notes talk about "inappropriate boundaries" between Patient #1 and her peers.

Despite her significant sexual history and reported sexual contact with both males and females along with her significant aggressive and violent behavior, Patient #1 was never placed on Sexual Acting Out Precautions, in order to protect other patients from becoming sexually victimized.

Nursing notes from 10-10-2018 identify that Patient #1 reported she had entered a male patient's room (Patient #7) and that she and the male patient had sex.

A Therapy Services Note for Patient #7 for events of 10-9-2018 at 9:45 AM was reviewed. The therapist Signature is illegible, but was dated 10-10-2018 at 2:15 PM, after Patient #1 had revealed that she and Patient #7 had sex. The note read as follows:

"Pt asked to speak privately. Once in a consultation room, Pt disclosed that during the weekend, while he was showering in his room, a female Pt (---) [Patient #1's initials redacted for privacy] showed up in his room outside the shower. He reported that the female Pt was partially undressed an approached Pt. Pt reports that they had sex.
Pt reports he was later told by the female Pt that she was pregnant. Pt reported he was afraid and did not know who to tell or what to do ..."

A note from Staff #27, Patient Advocate, detailed Patient #7's statement of events. During his statement he claimed Patient #1 threatened that if he didn't have sex with her, she would tell the MHT's that he had raped her. He stated the t-shirt he was wearing during the interview was stretched out because Patient #1 kept pulling at it, trying to get him to kiss her. He stated that Patient #1 threatened that if he told on her that she would deny it and accuse him of raping her. Patient #7 also expressed concern that he may have impregnated Patient #1.

Interview was conducted with Staff #2 on 12-12-2018. Staff #2 stated that a Mini Root Cause Analysis had been conducted. Staff #2 reported the video of the that night showed Patient #1 entered Patient #7's room at 8:16 PM and exited the room at 8:29 PM. She stated that Patient #7 was in the room for 3 minutes with Patient #1 then exited the room fully clothed. He entered again for 2 minutes, the entered again for another 2 minutes. The investigation concluded that this wasn't possibly enough time for the two patients to engage in intercourse, so the allegations were false.

Despite the fact that both patients told the same story of events, and Patient #7 expressed concerns on two separate occasions that he may have impregnated Patient #1, the allegations were not taken as potentially true and acted upon accordingly. With Patient #1's known history of prostitution, Staff #2 was asked if Patient #7 was offered testing for sexually transmitted diseases, Staff #2 confirmed that he was not.

Review of Policy and Procedure 1000.33, Subject: Sexual Acting Out Precautions, Reviewed/Revised 04/2017 was as follows:

"POLICY:
Rock Prairie Behavioral Health follows this procedure in cases of suspected patient sexual activity or inappropriate sexual behavior during the period of hospitalization ."

This policy did not include the identification of patients upon admission who may need to be on Sexual Acting Out Precautions due to their significant sexual history.

Review of Policy and Procedure 1300.2, Subject: Room Occupancy Adolescent, Effective Date 03/2017 was as follows:

"Procedure
...

6. In the event, that a patient has been identified as not being appropriate for a roommate for example: a sexual predator, physically threatening behavior to roommate, etc. They will be assigned, when possible, their own room. If a single room is not available the patient will be placed on close observation until one is available." (sic)

No process for identifying patients who may be high risk for victimizing others, and needed increased monitoring due to that potential, was provided. During interview with Staff #2, Staff #2 confirmed that the policy for Sexual Acting Out Precautions only protected patients after an incident had occurred in the facility. This process exposed patient to potential victimization.




Findings for 9) included:

Review of Staff #15's personnel records showed that Staff #15 had a Heartsaver First Aid CPR AED card obtained on 2-7-18 and valid through 02/2020. Staff #15 had been hired on 4-13-2018 and had provided the card as proof of Basic Life Support. This card was accepted by the facility without requiring Staff #15 to obtain the appropriate Basic Life Support training for Healthcare Professionals.

Review of the American Heart Association website revealed:

"Heartsaver courses are designed for anyone with little or no medical training who needs a course completion card for job, regulatory (for example, OSHA), or other requirements ...
...
Healthcare Professional: Basic Life Support training reinforces healthcare professionals' understanding of the importance of early CPR and defibrillation, basic steps of performing CPR, relieving choking, and using an AED; and the role of each link in the Chain of Survival."

Retrieved on 10/2/18 from https://cpr.heart.org/AHAECC/CPRAndECC/Training/HeartsaverCourses/UCM_ 4_Heartsaver-Courses.jsp
VIOLATION: GOVERNING BODY Tag No: A0043
Based on review of records and interview, the Governing Body failed to ensure:

1) patients rights were protected. The Governing Body failed to ensure:

A) staff followed proper procedures for restricting patient rights in 1 (Patient #3) out of 4 (Patient #3, #4, and #5) patients reviewed. A nurse, Staff #9, removed bed sheets from a suicidal patient who was identified as making attempts to use sheets as a ligature. The nurse failed to update the suicide risk assessment form based on patient behaviors. The nurse failed to notify the physician to obtain new orders. The nurse failed to update the care plan and involve the interdisciplinary care team so that other interventions could be put in place without removing bed linen. The nurse failed to communicate the rights restriction to direct patient care staff. Direct patient care staff gave a sheet back to Patient #3. Patient #3 used the sheet to hang himself, resulting in death.

B) ligature-resistant hinges for doors were properly installed. Hinges on doors were installed with sufficient distance between top edge of metal hinge and first set of installation screws that Patient #3 was able to pry the hinge away from door and use to attach sheet. Patient #3 used the sheet to hang himself, resulting in death.

C) a vulnerable patient (Patient #3) was provided a humane and emotionally supportive environment. Patient #3 had an anger outburst and punched his bedroom wall. The bedroom wall was observed to have numerous holes punched into the wall board with visible blood smears. Patient #3 was made to remain in that room with the holes and blood smears for 2 days prior to Patient #3 committing suicide, rather than moving the patient into a room that was clean and in good repair.

D) staff were effectively trained in response to Code White/Code Blue (emergency medical response needed situations. Delays were observed in staff response that could have potentially improved the outcome of a Code White/Code Blue.

E) vulnerable patients were protected from emotional trauma during a Code White/Code Blue response. Patients were observed entering Patient #3's room immediately after Staff #10 called for assistance after finding Patient #3 hanging from a door. Patients were allowed to stand in the hallway and in the doorway and observe rescue efforts by staff.

F) suicidal patients were prevented from being placed in rooms with ligature hazards. Patient #6 was identified as being suicidal and was involuntarily committed as a result. Patient #6 was placed in a room with medical bed that had ligature attach points readily accessible.

G) patients and staff were protected in a safe environment from 1 patient (Patient #1) of 1 reviewed who was known to become violent, and assault other patients and staff. Despite multiple attacks on patients and staff by Patient #1, only two incidents were investigated and measures were not put in place to protect patients and staff throughout Patient #1's 25 days of inpatient stay.

H) processes were put in place to identify patient upon admission with significant sexual history and protect other patients from becoming sexually victimized by those with significant history in 1 (Patient #1) of 1 patient reviewed. Patient #1 was known have a significant history of sexual activity and aggressive/violent behavior, but was not identified upon admission to be a potential risk to other patients. Subsequently, she sexually victimized another patient.

I) staff had appropriate Basic Life Support Training in 1 required staff member (Staff #15) of two staff personnel files (Staff #13 and Staff #15) reviewed. Staff #15 was found to have training that was meant for the lay-person who does not work in healthcare.

These deficient practices were found to place all patients in Immediate Jeopardy of risk of harm and potential loss of life.

See Tag A0144

J) that 2 (Staff #24 and Staff #25) out of 12 Assessment and Referral (A&R) staff had received the required training on the Pre-Admission Screening Assessment in order to properly assess patients for admission and properly ensure patient rights were explained and protected.

See Tag A0117



2) a thorough Root Cause Analysis (RCA) was completed that identified all potential problems after a Sentinel Event. Because staff that were directly involved with the event were not included in the process other than initial statements, key contributing factors to the event and outcomes were not identified and investigated in the Root Cause Analysis.

3) corrective actions identified for the correction of deficient practices were fully implemented by hospital staff.




Findings for 2) included:

On 12-10-2018 at 1:52 PM, an interview was conducted with Staff #5 in regards to the events of a Sentinel Event that occurred on 11-30-2018. During the interview, Staff #5 identified problems with the team response to the code that had been called.

On 12-10-2018 at 4:43 PM, an interview was conducted with Staff #8 in regards to the events of a Sentinel Event that occurred on 11-30-2018. During the interview, Staff #8 identified problems with the team response to the code that had been called. Staff #8 was asked if she had been involved in the Root Cause Analysis process to identify potential gaps that may have contributed to the event and possible solutions to those gaps. Staff #8 stated she had not.

On 12-11-2018 at 8:40 AM, Staff #21 stated that the hospital had concluded the Root Cause Analysis and Staff #21 asked to share the findings with the surveyor. Findings reported were that Staff #10 had missed a 15-minute patient check and it had been over 30 minutes since staff had seen the patient before finding him hanging. Staff #21 also reported that the nurse, Staff #9, likely did not have oversight of the unit. Staff #9 allowed non-licensed staff to make their own patient assignments. Nursing staff also failed to move the patient closer to the nursing station when made aware of possible suicide attempts.

Staff #21 was asked why the Root Cause Analysis had been completed in 10 days of the event and why the staff that were involved with the event were not included in the Root Cause Analysis process. The only staff involvement was the when staff provided a statement soon after the event. Staff #21 stated that because it was a serious event, the organization did not want to wait to complete the report. Staff #21 indicated that one consideration for not including staff was that staff were not emotionally ready to be involved in the process. However, this would be a reason to extend the process, so that staff could be included.

Staff #21 was asked if she was aware that there were significant problems with the code response and had the code response been identified as a problem. Staff #21 stated she was not aware that there was a problem with the code response. Staff #21 was advised that problems with the code response had been identified by the surveyor by discussion with staff involved in the event.

On 12-11-2018 at 9:09 AM, an interview was conducted with Staff #10. Staff #10 described the unit as being very busy on 11-30-2018. Per Staff #10, there were 14 patients on the unit that day and only two Mental Health Technicians (MHTs). Per Staff #10, there were never more than two MHTs assigned to that unit unless the physician orders a one-to-one (1:1) level of observation for a patient. Then, that MHT is assigned to that patient, but does not help out with other duties on the unit. Staff #10 stated on 11-30-2018, there was one patient that was "provoking other patients". This patient was also on unit restrictions. A second patient was isolating to his room and aggressive (Patient #3). A third patient was very loud and "bouncing off the walls" with "random outbursts". A fourth patient was very upset and wanted to be moved to the geriatric unit. This patient had just been removed from unit restrictions. The third and fourth patient would "get in spats". A fifth patient was anxious and was being upset by the first patient that was provoking. When asked if they ever get additional staff to help when the unit is like this, Staff #10 stated no.

On 12-11-2018 at 12:14 PM, an interview was conducted with Staff #11. Staff #11 was the second MHT on the unit during the Sentinel Event and confirmed Staff #10's description of the patients. Staff #11 explained that when a patient is on unit restrictions and other patients are required to leave the unit for things like going to meals, one MHT has to remain on the unit and the second MHT is responsible for safely transporting the patients to their next destination. Staff #11 explained that on the previous Thursday she was responsible for moving 12 of the most acute patients in the hospital to the cafeteria by herself. All she had was a radio. However, if she were attacked by an aggressive patient, she may not be able to use the radio to call for assistance.

Staff #21 had not presented that staffing patterns and need to have a process for increasing staffing based on patient acuity (not just by physician order) as a potential contributing factor that needed to be investigated.in the Sentinel Event and subsequent Root Cause Analysis. Staff #10 and Staff #11 both confirmed during their interviews that they had not been included in group discussion for a Root Cause Analysis about possible factors that contributed to the events of 11-30-2018.

Interview was conducted by phone with Staff #19 on 12-17-2018. Staff #19 had provided a statement of the event. The surveyor was provided with an unsigned copy of Staff #19's statement. During the verification with Staff #19 that it was her statement, Staff #19 identified that she had been told that because she was for medical treatment and not psychiatric, she was not to write any orders for increased observation. This was why she notified the nurse, Staff #9, who assured her she would contact the psychiatrist. Staff #19 was asked if she had been involved in the Root Cause Analysis process other that making an initial statement. Staff #19 confirmed she had not. This represented another opportunity for the facility to identify causal factors and take action, such as reviewing Medical Staff Bylaws, Rules and Regulations to clarify Medical Staff member roles and responsibilities for patient safety.

Review of Policy and Procedure 200:12, Subject: Sentinel Event Review and Reporting, Reviewed/Revised: 01/2017 was made as follows:

"PROCEDURE:
...

4. If the definition is or appears to be met, the PI/Risk Manager will notify the Chief Executive Officer, patient's attending physician, medical director, associate medical director, appropriate department managers, and others as deemed appropriate by the CEO that a root cause analysis needs to be initiated. The Committee Chair will appoint a multi-disciplinary team to investigate the event."

The policy does not identify the need to involve staff with direct knowledge of the events in the root causes analysis process.

Review of the Centers for Medicare and Medicaid Services highlight the importance of involving staff with direct knowledge and involvement of the event.

Information retrieved from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/GuidanceforRCA.pdf

"Guidance for Performing Root Cause Analysis (RCA) with Performance Improvement Projects (PIPs)
...

Disclaimer: Use of this tool is not mandated by CMS, nor does its completion ensure regulatory compliance.
...

Step 2: Select the event to be investigated and gather preliminary information

The number of team members depends on the scope of the investigation. Individuals selected to serve as team members must be familiar with the processes and systems associated with the event. People who have personal knowledge of what actually happened should be included as team members or given an opportunity to contribute to the investigation through interviews.

Helpful Tips:

Team members should be selected for their ability to discuss and review what happened during the event in an objective and unbiased manner. In some situations, staff members personally involved in the event are the best people to serve as team members. In other situations, staff members not personally involved in the event are the best people to serve as team members with the people personally involved asked to share their experience during interviews. This may be appropriate if the people directly involved in the event are dealing with emotions and are not able to be objective. However, if this is the case, it is a good idea to provide those staff persons directly involved with counseling and support so that they are able to participate in the RCA process. Participating in the RCA process and hearing other's objective viewpoints can help them to deal with the situation in a positive manner."

Findings for 3) included:

On 12-11-2018 at 11:00 AM, a review of the Plan of Correction for previous identified deficient practices was conducted with Staff #2 and Staff #3. The plan of correction stated the 'All medical, nursing, and clinical staff with patient care responsibilities are being re-inserviced on the revised P&P on "Patient Rights Restrictions" and its related requirements that any restrain and seclusion must be used as a last response after less restrictive interventions are attempted; that a MD order is required to impose a restriction including a S/R; that a required restrictive order packet shall be used to ensure appropriate use of the interventions and proper monitoring of the patient before, during, and after any restrictive interventions; that a rights restriction is time-limited to 24 hours for daily consideration of discontinuation of rights restriction ... Staff not able to complete the inservice by the required date are required to attend make-up training prior to working their next shift with patient care responsibilities:"

The required date for training was listed as 10/25/18. When asked for proof of training for all medical, nursing, and clinical staff with patient care responsibilities, the surveyor was provided with a stack of training sign-in sheets, and the sign-in sheet for the Medical Executive Committee meeting held on 11/14/2018.

Staff #2 was asked if there was a master-list of staff who required training and the training completion dates. Staff #2 confirmed that there was not. When asked how she could be sure all required staff had been trained, Staff #2 confirmed she could not. Staff #2 was asked to make a master-list of all staff who required training and the training completion dates.

Later in the day, Staff #2 provided a master-list of staff who required training. The master-list did not contain all nursing and clinical staff with patient care responsibilities. Mental Health Technicians were not included in the training, even though they have the ability to inadvertently or purposefully restrict a patient's rights. Assessment and Referral (A&R) staff were not included in the training, even though they have the ability to inadvertently or purposefully restrict a patient's rights. Sixteen of the staff listed had not been trained at all. Eleven staff members were trained after the required training date of 10-25-18 with evidence that they were prevented from working a shift until the training had been completed.


Review of the Medical Executive Committee meeting sign-in sheet revealed that not members of the medical staff with direct patient care responsibilities had attended the meeting and received the training. Only three physicians and one nurse practitioner had been present. Staff #3 stated that the facility had felt like that was sufficient.

Staff #19 (a physician assistant and part of the medical staff) was involved in the Sentinel Event that included rights restrictions and had not been at the meeting on 11-14-2018. During interview with Staff #19 on 12-17-18, Staff #19 confirmed that she had not received any training from the facility on the appropriate process for implementing rights restrictions such as not allowing a patient to have linen for their bed (patient right to a humane environment and to be cared for with respect and dignity).

Upon continued review of the Corrective Action Plan on 12-11-2018 with Staff #2 and Staff #3, the plan called for "A random sample of 30% of inpatient medical records is being audited Monday through Friday to assess if patient rights have been imposed and, if so, if the procedure requirements of MD order, treatment plan entry, notification of the House Supervisor, and incident report completion has occurred.

Staff #2 explained that she completed a 30% audit and the House Supervisors completed a 30% audit. Review of the audit tool being used showed that there was no standardized audit tool. Staff #2 was only looking for Right Restriction, Order, and Treatment Plan. Staff #2 was not auditing for House Supervisor Notification or Completion of Incident Report. Review of the House Supervisor Audit tool showed that House Supervisors were only auditing for Treatment Plan for Restrictions. Review of House Supervisor audits for 12-7-2018 showed that Staff #7 had audited charts and had never been trained in the process for implementing rights restriction. Staff #2 was not able to provide written, detailed instructions on how to audit, what to audit for, and how to document audit.

Per the Corrective Action Plan, "The findings, conclusions, recommendations, and actions take regarding patient rights restrictions is being aggregated, analyzed, and reported on a monthly basis to the Quality/PI Counsel and the Medical Executive Committee and, on a quarterly basis to the Governing Board."

Staff #2 was asked to provide her monthly analysis and report of the findings, conclusions, recommendations, and actions taken regarding patient rights restrictions that were to be reported on a monthly basis to the Quality/PI Counsel and the Medical Executive Committee. Since everything was to be in place by 10-25-2018 and the current date was 12-11-2018, at least one prepared report should have been available. Staff #2 stated she had not analyzed and reported any data because there had not been a Quality/PI Counsel meeting in November. Staff #2 was not able to tell the surveyor how the data was going to be analyzed or how the report was going to be compiled or what the report would look like.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on review of records and interview, the facility failed to ensure that 2 (Staff #24 and Staff #25) out of 12 Assessment and Referral (A&R) staff had received the required training on the Pre-Admission Screening Assessment in order to properly assess patients for admission and properly ensure patient rights were explained and protected.

Findings included:

Interview was conducted with Staff #5 12-12-2018 at 9:30 AM on the use of the Comprehensive/Psychosocial Assessment Tool as the Pre-Admission Screening Assessment (PASA) that is required by the Texas Administrative Code. The PASA is required to be conducted by a Pre-Admission Screening Professional (PASP) with 8 hours of initial training and 8 hours of annual training.

Staff #5 confirmed that the Comprehensive/Psychosocial Assessment Tool was being used as the PASA and that staff were trained as PASPs. Review of Staff #15's personnel file had not included documentation of PASA training. Staff #5 was asked to provide documentation of training dates for all PASPs. Staff #5 provided a list of training that showed Staff #24 and Staff #25 had not received PASP training since June of 2017.

Staff #5 stated she had started in the position in September 2018. She was not able to find the previous director's training materials and had not completed developing the required training. Staff #5 confirmed that Staff #24 and Staff #25 were still conducting PASAs without the required training.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on review of records and interview, the facility failed to ensure that a current and appropriate staffing plan and staffing processes were in place to ensure safe staffing of all units. The nurse staffing plan provided was last reviewed/updated on 04/2017 and did not contain the required elements of a staffing plan to determine safe staffing levels. Records of staffing were found to be incomplete and inaccurate.

Findings included:

On 12-10-2018, during the survey entrance meeting, a list of documents requested was provided to the facility. This list included a request for the Nurse Staffing Plan with the Matrix (also referred to as a grid - provides the minimum acceptable staffing level for each unit). The Nurse Staffing Committee Meeting Minutes for 2018 were also requested.

On 12-10-2018 at 3:36, two Staffing Matrix forms were received. One form showed that all Units had a 1:10 Nurse ratio and a 1:6 Mental Health Tech Ratio. The second form was not identified by unit. It listed a census number, the number of hours allowed for a MHT and the number of hours allowed for a Registered Nurse (RN). Licensed Vocational Nurses (LVNs) were not addressed on the matrix. These forms did not have an associated policy number, approval date, or any information on who had reviewed and approved them as being safe and acceptable staffing levels.

On the afternoon of 12-10-2018, Staff #7, the DPN, was advised that the Nurse Staffing Plan had not been received and was still needed for review. Staff #7 asked, "What is that?" The surveyor explained it was the annual plan that identified nurse staffing needs. Staff #7 left the room. A short time later, Staff #1 entered the room and stated that Staff #7 said the surveyor was requesting the annual budget. The surveyor explained to Staff #1 that the surveyor had requested the DPN to provide the surveyor with the nurse staffing plan. On 12-11-2018, Staff #21 provided the Nurse Staffing Committee Meeting Minutes and Nurse Staffing Plan.

Review of Policy and Procedure 1300.7A, Subject: Staffing Plan for Provision of Care, Effective 03/2017, Reviewed/Revised 04/2017, was as follows:

"Introduction

To consider unique regulatory and professional requirements in the design of a staffing plan. This document serves to describe the Plan for the Provision of Patient Care."

Review of the contents showed that the Plan for the Provision of Patient Care did not contain the elements required by the Texas Administrative Code 411.473 (g), Staffing Plan.

Review of Policy and Procedure 1300.34, Subject: Nurse Staffing Committee, Effective 03/2017, Reviewed/Revised 04/2017, was as follows:

"PROCEDURE:

The governing body policy shall require the hospital administration adopt, implement and enforce a nurse staffing plan and policies that:
...
7. Comply with the following:
a. The hospital shall establish a nurse staffing committee as a standing committee of the hospital.
...
i. The committee shall be composed of:
1. At least 60% registered nurses who are involved in direct patient at least 50% of their work time and selected by their peers who provide direct care during at least 50% of their work time;
...
iv. The responsibilities of the committee shall be to:
1. Develop and recommend to the hospital's governing body a nurse staffing plan that meets the requirements of section (7.b.)
2. Review, assess and respond to staffing concerns expressed to the committee;
3. Identify the nurse-sensitive outcome measures the committee will use to evaluate the effectiveness of the official nurse serves (sic) staffing plan;
4. Evaluate, at least semiannually, the effectiveness of the official nurse service staffing plan and variations between the plan and the actual staffing; and
5. Submit to the hospital's governing body, at least semiannually, a report on nurse staffing and patient care outcomes, including the committee's evaluation of the effectiveness of the official nurse services staffing plan and aggregate variations between the staffing plan and actual staffing.

b. The hospital shall adopt, implement and enforce a written official nurse services staffing plan.
...
i. The official nurse services staffing plan and policies shall:
1. Require significant consideration be given to the nurse staffing plan recommended by the hospital's nurse staffing committee and the committee's evaluation of any existing plan;
2. Be based on the needs of each patient care unit and shift and on evidence relating to patient care needs;
...
6. Comply with subsection ii. The plan shall:
1. Set minimum staffing levels for patient care units that are:
a. Based on multiple nurse and patient considerations; and
b. Determined by the nursing assessment and in accordance with evidenced-based safe nursing standards; and
2. Include a method for adjusting the staffing plan shift to shift for each patient care unit to provide flexibility to meet patient needs;
3. Include a contingency plan when patient care needs unexpectedly exceed direct patient care staff resources;
4. Include how on-call time will be used;
...
6. Include a mechanism for evaluating the effectiveness of the official nurse services staffing plan based on patient needs and nursing sensitive quality indicators, nurse satisfaction measures collected by the hospital and evidence based nurse staffing standards; and
..."

Review of the Nurse Staffing Committee meeting minutes for 2018 did not reflect who the committee members were, how they were elected, or the items of staffing committee responsibility that were required by the policy above. Review of the Nurse Staffing Plan did not include the items required above.

Review was made of a patient incident report that was submitted on 10-10-2018. Allegations were made by Patient #1 and Patient #7 that they had a sexual encounter in Patient #7's room. Staff #26 was the MHT on duty during the alleged event and was placed on suspension during the allegation. Review of an email sent by Staff #26 on 10-11-2018 in response to her suspension was as follows:

"On Sunday October 7, 2018 the 600 hallway plotted to sneak a patient into the opposite sexes room. In the video it shows me doing my 1800 (6:00 PM) checks and then going to the dayroom and then my 1815, 1830, 1845, and 1900 (6:15 PM, 6:30 PM, 6:45 PM, and 7:00 PM) when I closed the dayroom. For the time in question there was a patient keeping watch making sure I was busy and the others were asking me questions because it was shower time so I was doing that as it shows on the video. Also I was helping with making sure everyone was taking the meds in an orderly fashion. They saw the opportunity and rushed her out of there. While I was getting supplies for a patient.
I was left on the hallway by myself I worked 4 days straight and every day my relief was taken from me because they said other halls needed it more. The video shows my hard work that night, I feel this isn't right I was placed on suspension when the proper staff wasn't on the hallway and I was doing my best with what I had."

In the review of the incident, the facility indicated Staff #26 was left on the hallway with 8 patients. The matrix that had been provided indicated the ratio of MHT to patients should be 1 MHT to 6 patients.

In an attempt to look at staffing, the surveyor found that the staffing sheets only list who was scheduled to work. They did not include:
the census or daily census sheets listing the patients on the unit;
which patients were assigned to which staff members (nursing and MHT assignments);
staff call-ins;
staff moved to other units;
admissions;
discharges;
or an evaluation of the level of acuity of patients on the unit.

The census sheet provided from the computer system showed that on the date of the incident, the patient was assigned to Unit 500, not Unit 600 (the unit the incident occurred on). It was found that the patient had been moved prior to her discharge and the computer reflected the room number from discharge date on all days of her stay, even though she had been in a room on Unit 600. Therefore, census sheets provided from the computer were not accurate and reliable for calculating the number of patients on a unit at any given time for the purpose of investigating if staffing levels were at the minimum level required by the matrix.

The facility was not able to show a process that could determine if staffing levels were safe on any given day in the hospital.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on review of records and interview, the facility failed to ensure that 2 (Staff #24 and Staff #25) out of 12 Assessment and Referral (A&R) staff had received the required training on the Pre-Admission Screening Assessment in order to properly assess patients for admission and properly ensure patient rights were explained and protected.


Findings:


Interview was conducted with Staff #5 on 12-12-2018, at 9:30 AM, regarding the use of the Comprehensive/Psychosocial Assessment Tool as the Pre-Admission Screening Assessment (PASA) that is required by the Texas Administrative Code. The PASA is required to be conducted by a Pre-Admission Screening Professional (PASP) with 8 hours of initial training and 8 hours of annual training.


Staff #5 confirmed that the Comprehensive/Psychosocial Assessment Tool was being used as the PASA and that staff were trained as PASPs. Review of Staff #15's personnel file had not included documentation of PASA training. Staff #5 was asked to provide documentation of training dates for all PASPs. Staff #5 provided a list of training that showed Staff #24 and Staff #25 had not received PASP training since June of 2017.


Staff #5 stated, she had started in the position in September 2018. She was not able to find the previous director's training materials and had not completed developing the required training. Staff #5 confirmed that Staff #24 and Staff #25 were still conducting PASAs without the required training.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, review of records, and interview, the facility failed to ensure:


1) staff followed proper procedures for restricting patient rights in 1 (Patient #3) out of 4 (Patient #3, #4, and #5) patients reviewed. A nurse, Staff #9, removed bed sheets from a suicidal patient who was identified as making attempts to use sheets as a ligature. The nurse failed to update the suicide risk assessment form based on patient behaviors. The nurse failed to notify the physician to obtain new orders. The nurse failed to update the care plan and involve the interdisciplinary care team so that other interventions could be put in place without removing bed linen. The nurse failed to communicate the rights restriction to direct patient care staff. Direct patient care staff gave a sheet back to Patient #3. Patient #3 used the sheet to hang himself, resulting in death.


2) ligature-resistant hinges for doors were properly installed in 3 out of 3 rooms observed (room #s 301, 302, and 305). Hinges on doors were installed with sufficient distance between top edge of metal hinge and first set of installation screws that Patient #3 was able to pry the hinge away from door and use to attach sheet. Patient #3 used the sheet to hang himself, resulting in death.


3) a vulnerable patient (Patient #3) was provided a humane and emotionally supportive environment. Patient #3 had an anger outburst and punched his bedroom wall. The bedroom wall was observed to have numerous holes punched into the wall board with visible blood smears. Patient #3 was made to remain in that room with the holes and blood smears for 2 days prior to Patient #3 committing suicide, rather than moving the patient into a room that was clean and in good repair.


4) staff were effectively trained in response to Code White/Code Blue (emergency medical response needed) situations in 1 out of 1 responses reviewed. Delays were observed in staff response that could have potentially improved the outcome of a Code White/Code Blue.


5) vulnerable patients were protected from emotional trauma during a Code White/Code Blue response in 1 out of 1 responsed reviewed. Patients were observed entering Patient #3's room immediately after Staff #10 called for assistance after finding Patient #3 hanging from a door. Patients were allowed to stand in the hallway and in the doorway and observe rescue efforts by staff.


6) suicidal patients were prevented from being placed in rooms with ligature hazards in 1 (Patient #6) of 3 patients reviewed. Patient #6 was identified as being suicidal and was involuntarily committed as a result. Patient #6 was placed in a room with medical bed that had ligature attach points readily accessible.


7) patients and staff were protected in a safe environment from 1 patient (Patient #1) of 1 reviewed who was known to become violent, and assault other patients and staff. Despite multiple attacks on patients and staff by Patient #1, only two incidents were investigated and measures were not put in place to protect patients and staff throughout Patient #1's 25 days of inpatient stay.


8) processes were put in place to identify patient upon admission with significant sexual history and protect other patients from becoming sexually victimized by those with significant history in 1 (Patient #1) of 1 patient reviewed. Patient #1 was known have a significant history of sexual activity and aggressive/violent behavior, but was not identified upon admission to be a potential risk to other patients. Subsequently, she sexually victimized another patient.


9) staff had appropriate Basic Life Support Training in 1 required staff member (Staff #15) of two staff personnel files (Staff #13 and Staff #15) reviewed. Staff #15 was found to have training that was meant for the lay-person who does not work in healthcare.


These deficient practices were found to place all patients in Immediate Jeopardy of risk of harm and potential loss of life.


The nurse failed to update the suicide risk assessment form based on patient behaviors. The nurse failed to notify the physician to obtain new orders. The nurse failed to update the care plan and involve the interdisciplinary care team so that other interventions could be put in place without removing bed linen. The nurse failed to communicate the rights restriction to direct patient care staff. Direct patient care staff gave a sheet back to Patient #3. Findings:


Review of Patient #3's chart revealed the following:


Patient #3 was a [AGE]-year-old male, admitted involuntarily on 11-26-2018. On 11-28-2018, the attending physician signed a Physician's Certificate of Medical Examination for Mental Illness to present to the court for the purpose of seeking an Order of Protective Custody. Review of the physician's statement included the following:


"Patient is at imminent risk of harm towards self by active suicidal ideation's and self-injurious behavior. The patient endorses suicidal ideation's with a plan, but he would not disclose the plan. He has self-injurious behavior by punching holes in the wall in his room. He is emotionally unstable, and had to receive emergency medication, intramuscular. He is impulsive, highly depressed, anxious, and easily agitated. He is unstable at this time."


Despite the patient being admitted involuntarily and the physician assessment above, the patient was never placed on increased observation due to the patient was scored as low risk of suicide. The patient scored low risk of suicide on 7 out of 8 Rock Prairie Behavioral Health Suicide Risk Monitoring Tool forms completed by staff. On 11-29-2018, the form scored at low risk, but the night shift nurse who assessed the patient determined the patient to actually be at the medium risk. The line for the nurse to explain the higher assignment of risk was left blank.


No notes were found in the chart that indicated the patient had been observed making suicidal attempt by choking self.


Review of group therapy notes showed that the patient refused to attend group therapy throughout his stay.


During interview with Staff #21 on 12-5-2018, Staff #21 was asked about the lack of therapy provided to the patient. Staff #21 provided two Therapy Service Notes that were not in the original chart and signed by Staff #14. These notes were dated for 11-28-2018 and marked as "Late entry". They were signed by Staff #14 on 12-7-2018, seven days after the patient committed suicide. The note that was a documentation of events on 11-28-2018 at 4:03 PM read as follows:


"Therapist was informed by medical tech that he had just observed the patient using his bedding to harm himself by wrapping it around his neck. Therapist met with the patient in his room and we discussed the medical techs (sic) observations as well as what might be troubling him. The patient denied any suicidal ideation's and reported that he was not trying to harm himself with his pillow case. He reported that he was feeling ok and did come out of his room, after we talked, for a walk around the unit. Therapist, nursing staff of _______ (Staff #22) observations and requested his bedding be removed. Therapist observed the nurse discussing with the patient that we would have to remove his bedding and he reported that he understood."


This note was not in the chart and available to the physician prior to the patient committing suicide. MHT observations were not documented on the MHT's form for documentation of patient locations and behaviors.


Interview was conducted with maintenance staff (Staff #12) on 12-11-2018 at 1:00 PM. Staff #12 stated that he had entered Patient #3's room on the afternoon of 11-28-2018. He noticed a sheet laying by the writing desk that was balled up like a noose. He stated he notified the nurse (Staff #9), and she came in got the sheet off of the floor. Staff #12 stated, Staff #9 then instructed the Mental Health Tech (MHT) on duty to remove all of the bed linen from the room. No documentation of sheets being removed was found in nursing notes or MHT notes. No order for sheets to be removed due to suicidal gestures was found in the chart.


Records of a statement made by the Physician Assistant (Staff #19) revealed that Staff #19 had witnessed the patient on 11-28-2018 in an apparent attempt to choke himself out with his bare hands. Staff #19 had Staff #22 watch the patient while she went to speak to the nurse (Staff #9) at the nurse station. In an interview with Staff 19, on 12-17-2018, Staff #19 confirmed that the record of statement attributed to her was correct. Staff #19 explained, she had not documented the events because, after speaking with Staff #9, she had been assured that Staff #9 would immediately remove the linen from Patient #3 and contact the attending psychiatrist to advise and for further orders. Staff #19 explained that she was not authorized as the PA responsible for medical care, not psychiatric care, to write orders for increased level of observation of patients.


No record of physician notification was found by nursing staff, clinical staff, or medical staff that were witness to patient's active suicidal gestures.


Interview was conducted with Staff #11 on 12-11-2018, at 12:14 PM. Staff #11 stated, she had given Patient #3 a sheet when he asked for it on 11-30-2018. Staff #11 stated she had not been informed of his previous suicide gestures until after the patient committed suicide. "Nobody said he wasn't supposed to have sheets." Staff #11 stated she knew he didn't have sheets on his bed, but thought someone had failed to give him clean sheets after they were changed for cleaning.



Review of Policy #1800.4, Subject: Denial of Rights, was as follows:

"PROCEDURE:

1. Denial of basic patient rights, including restriction of phone access, unit restrictions, one-to-one observation, and visitation requires a physician order."

No record of a physician order restricting the patient from having bed linen (humane treatment, respect and dignity of the patient) was found in the chart. There was no documentation found in the chart that the patient was to be on right's restrictions with no access to sheets. No increased monitoring was ever ordered despite the patient's suicide risk identified by the physician during assessment for court commitment and suicide gestures that had been witnessed by maintenance, nursing, clinical, and medical staff. Patient #3 successfully committed suicide by hanging with a sheet on the afternoon of 11-30-2018.



Failed to ensure that ligature-resistant hinges for doors were properly installed in 3 out of 3 rooms observed (room #s 301, 302, and 305). Hinges on doors were installed with sufficient distance between top edge of metal hinge and first set of installation screws that Patient #3 was able to pry the hinge away from door and use to attach sheet. Findings:


On 12-10-2018, a tour of room #305 was conducted with Staff #1 and Staff #4. Room #305 was the room where Patient #3 had committed suicide on 11-30-2018. Staff #1 stated, the room had been locked immediately after the event and the only person with keys to it was Staff #4. Staff #4 confirmed that the room had remained locked. A tour of the room revealed that the bathroom door used by the patient in committing the suicide was outfitted with suicide-resistant hardware, including door knobs, hinges, and stops. However, the hinge at the top of the door was observed to bent away from the door with sufficient space to allow Patient #3 to gain enough tension on a sheet to be able to hang himself. The first set of screws used to attach the hinge at the top of the door were observed to be installed approximately one inch below the top of the hinge. This provided sufficient distance for Patient #3 to bend the metal away from the door and attach a sheet. A tour was made of rooms 301 and 302 on 12-10-2018 at 2:40 PM. The bathroom door hinges were observed to have the same installation as room #305.



Patient #3 had an anger outburst and punched his bedroom wall. The bedroom wall was observed to have numerous holes punched into the wall board with visible blood smears. Patient #3 was made to remain in that room with the holes and blood smears for 2 days prior to Patient #3 committing suicide, Findings:


Review of Patient #3's record revealed that the patient had an anger outburst on 11-28-2018. During this outburst at 4:40 AM, the patient punched holes in his bedroom wall causing abrasions to his hand.


Observation of Patient #3's room made on 12-10-2018 showed that the holes in the wall remained. The damaged wall board also had what appeared to be visible dried smears of blood on them from his abrasions sustained while punching the wall.


Staff #21 provided two Therapy Service Notes signed by Staff #14. These notes were dated for 11-28-2018 and marked as "Late entry". They were signed by Staff #14 on 12-7-2018, seven days after the patient committed suicide. The note that was a documentation of events on 11-28-2018 at 3:03 PM read as follows:


"Therapist met with patient individually after group therapy to check on patient's mental state. Patient appeared to be having overwhelming feelings and sitting in bed. Patient also appeared to be responding to auditory hallucinations and had his head in his hands. Patient had a hard time talking to therapist due to his mental state but chose to communicate non-verbally. Patient pointed to some holes in the wall and motioned to himself. Therapist probed the meaning of these actions. Patient was able to communicate that he had punched the wall last night and reported that the therapist wouldn't understand what he was feeling. Therapist helped patient reflect on his feelings. Patient reported that he punched the wall because he was upset and wanted to go home ..."


An interview was conducted with maintenance staff (Staff #12) on 12-11-2018 at 1:00 PM. Staff #12 stated, he went into the patient's room to assess the damage to the walls on the afternoon of 11-28-2018. Staff #12 stated, there were several holes on the wall with blood visible. Staff #12 stated, he asked Staff #9 to move the patient to another room so that the room could be repaired. Staff #12 stated that Staff #9 told him no, because the patient would just damage another room and he would have to stay where he was.


Patient #3 was forced to stay in the room with the visual reminder of damaged walls and visible blood smears for two more days until he finally committed suicide.



Failed to ensure that staff were effectively trained in response to Code White/Code Blue (emergency medical response needed) situations in 1 out of 1 responses reviewed. Findings:


On 12-10-2018, at 4:43 PM, an interview was conducted with Staff #8 who was the House Supervisor on duty on 11-30-2018. During the interview, Staff #8 was asked to give the sequence of her actions during the code for Patient #3's suicide. During Staff #8's sequencing of events, Staff #8 stated, when she got to the patient's room, she found two staff members performing Cardiopulmonary Resuscitation (CPR), but there was no "crash cart" (a mobile cart containing all necessary equipment to provide emergency care). When an emergency bag arrived, Staff #8 stated, she had an AMBU bag (a hand-held device used to assist with patients who are not breathing or are not breathing adequately). However, she did not have any oxygen to connect to the AMBU bag or an Automatic External Defibrillator (AED - a portable device used during an emergency to deliver an electric shock to the heart if necessary). Staff #8 stated, other staff members had to be sent back to the front of the unit to retrieve these items.


Review of Policy # 1000.115, Subject: Code White Rapid Medical Response, Effective 11/2015 was made on 12-11-2018. On page 2, under the heading of "Procedure", item 5, the following action is to be taken when a code is called: "The emergency cart/bag will be en-route to the area that the TEAM had been called".


Review of video recorded of the hallway during the response to the suicide revealed the following:

The patient was discovered at 6:04:44 PM (hour:minute:second).

At 6:05:04 the MHT called down the hallway for assistance.

At 6:05:18 second MHT arrived at room.

At 6:05:46 another staff member can be observed coming down hallway to room.

At 6:05:54 a nurse can be seen entering the room.

At 6:05:59 2 more staff arrive.

At 6:06:33 Staff #8 was observed arriving.

At 6:06:47 Staff #8 was observed exiting the room and running up the hallway to the front of the unit.

At 6:08:17 Staff #8 was observed to return to the room carrying a bag.

At 6:08:21 a nurse was observed coming down hallway and entering room.

At 6:08:24 a MHT was observed coming down hallway and entering room.

At 6:08:35 Staff #5 was observed entering the room with a bag.

At 6:09:00 a staff member was observed bringing an oxygen tank to the patient room.

At 6:12:50 a staff member was observed bringing an AED to the room.


This resulted in an almost 4-minute delay in the patient receiving adequate supplemental oxygen and an almost 9-minute delay in the patient receiving a potentially life-saving electric shock to the heart. The delay was significant enough that it could have potentially had a negative effect on the patient outcome during this medical emergency.


Review of the Emergency Medical Services (EMS) documentation of response (Run Sheet) showed that EMS first assessed the patient at 6:14 PM. The assessment noted that the skin was cyanotic. Cyanosis is indicative of a lack of oxygen to the tissue.


On 12-11-2018, Staff #21 was asked for any records of mock code drills for medical emergencies that had been completed since the beginning of 2018. Staff #21 confirmed that no mock code drills had been performed or recorded.


Interview was conducted with Staff #5 on 12-12-2018. Staff #5 stated that the facility did conduct mock drills and that she had participated in them. Upon further questioning, Staff #5 confirmed it had been over a year since she had participated in mock code for medical emergency.



Failed to ensure that vulnerable patients were protected from emotional trauma during a Code White/Code Blue response in 1 out of 1 responsed reviewed. Patients were observed entering Patient #3's room immediately after Staff #10 called for assistance after finding Patient #3 hanging from a door. Patients were allowed to stand in the hallway and in the doorway and observe rescue efforts by staff. Findings:


Review of video recorded of the hallway during the response to the suicide revealed the following:

The patient was discovered at 6:04:44 PM (hour:minute:second).

At 6:05:46 a female patient was observed entering the room where rescue efforts were being performed on Patient #3.

At 6:06:00 the female patient was observed exiting the room while two other patients were observing the rescue efforts from the hallway.

At 6:06:18 a patient was observed leaning in the doorway, watching the rescue efforts.

At 6:06:58 more patients were observed to come down the hallway and were watching the rescue efforts from the hallway.

At 6:07:50 a staff member was observed to partially close the door so the scene could not be observed from the hallway, and patients were escorted up the hallway to the front of the unit.


For two minutes, vulnerable psychiatric patients were allowed to observe one of their peers after he had hung himself, along with the staff efforts to unsuccessfully perform lifesaving interventions.


The lack of staff skill in responding to a code and securing a scene exposed patients to unnecessary trauma.



Failed to ensure that suicidal patients were prevented from being placed in rooms with ligature risks in 1 (Patient #6) of 3 patients reviewed. Patient #6 was identified as being suicidal and was involuntarily committed as a result. Patient #6 was placed in a room with medical bed that had ligature attach points readily accessible. Findings:


On 12-10-2018, a review of Policy and Procedure # 1000.58, Subject: Unit and Bed Assignment, was made as follows:

"PROCEDURE: ...

2. ... Mechanical beds are located in rooms 201, 202, and 208.

a. To limit potential of harm to patient inherent with these beds, these beds are in close proximity to the nurse's stations.

b. There will not be any patient placed in these rooms with a suicide risk score above medium on the daily suicide risk assessment. These beds are marked by an orange color on our electronic bed board.

c. A&R staff members will also designate the assignment to one of the mechanical bed rooms on the High Risk Assessment.

d. Locator forms will have a special indicator for any patient in one of these rooms as a reminder to staff performing 15 minute checks, including a patient in a standard bed in the same room as a hospital bed.

e. Patient in a room with hospital beds will have indications about this risk factor incorporated into the treatment plans and reviewed on a regular basis."


Review of the semi-annual facility-wide risk assessment conducted on 10-2-2018 was made. The power cords were identified on the mechanical beds were identified as a patient risk. Recommendations for Risk Reduction included, "Power cords are secured to the frame of the Bed. Nursing has protocol for Patient Occupancy." However, the metal frame with numerous ligature attach points was not identified on the report as a potential risk.


A tour of Unit 200 was made on 12-11-2018 at 4:02 PM with Staff #1 and Staff #3. Room 202 was found to have two medical beds and was unoccupied and locked.


Room 208 was observed to be locked. Room 208 had 1 medical bed and 1 psychiatric safe bed. Two patients were assigned to the room. Both patients were admitted voluntarily and neither was admitted with suicidal ideation.


Room 201 was observed to be unlocked, but the door was closed. This prevented staff from observing the patient inside the room. Patient #6 was observed to be resting with her eyes closed in a psychiatric safe bed. The other bed in the room was a mechanical bed with ligature attach points. Review of Patient #6's chart revealed she had been admitted involuntarily for suicidal ideation with a plan and was on suicide precautions. Patient #6 had a suicide plan to overdose on medication. Since medications were controlled in the facility, the patient would need to develop a different plan if she wanted to commit suicide.


Staff #23, the nurse on duty, was asked why a suicidal patient was in a room with ligature attach points. Staff #23 stated that the patient had scored "low risk" on the Suicide Risk Monitoring Tool.


Staff #3 confirmed that it was a practice in the facility for a patient who scored "low risk" on the Suicide Risk Monitoring Tool to be placed in a room with easily accessible ligature attach points provided by the mechanical beds. Staff #3 was reminded that a patient who continuously scored low on the Suicide Risk Monitoring Tool and was involuntarily admitted because he was suicidal had just successfully committed suicide in the facility 10 days earlier, despite scoring low risk on the Suicide Risk Monitoring Tool.


Failed to ensure that patients and staff were protected in a safe environment from 1 patient (Patient #1) of 1 reviewed who was known to become violent, and assault other patients and staff. Despite multiple attacks on patients and staff by Patient #1, only two incidents were investigated and measures were not put in place to protect patients and staff throughout Patient #1's 25 days of inpatient stay. Findings:


Review of Patient #1's admissions revealed that Patient #1 was admitted on [DATE] and discharged on [DATE]. Patient was readmitted on [DATE] and stayed through 10-10-2018. On the admission psychosocial assessment, it was noted that the patient claimed to be a previous gang member and her goal during her stay was to "not get in any fights". The patient was identified as assaulting staff and peers on multiple occasion with injuries noted. Assaults occurred on:


9-20-2018 - Nursing notes identify that patient charged at a peer and pulled her hair. Mental Health Technician (MHT) notes identify that patient pulled a peer's hair and was trying to fight her.


9-21-2018 - Nursing notes from 11:35 AM identify that Patient #1 stated she was going to fight with another patient. At 8:00 PM, the nursing notes identify that Patient #1 was involved in a Code Purple (additional staff needed to respond to a violent/aggressive patient) with a peer and assaulted an MHT. Code Purple paperwork indicate the MHT was injured with a contusion below the eye and eye injury.


9-22-2018 - Nursing notes identify that Patient #1 attempted to fight a peer, kicked staff, and slammed staff with her head.


9-30-2018 - Nursing notes identify that at 12:27 PM Pt #1 reported homicidal ideation towards two other patients. The nurse noted that the patient had to be restrained due to a "peer to peer conflict" at 4:45 PM. MHT notes identify that Patient #1 had a fight with a patient. That patient was one of the patients that Patient #1 had stated she had homicidal ideation towards.


10-2-2018 - Nursing notes identify that Patient #1 hit a peer in the head twice and pulled her hair at 10:00 AM. At 5:00 PM, nursing notes identify that Patient #1 "attacked a female peer in the dayroom". She "pulled her hair, hit her in the face and scratched peers (sic) arm." MHT notes identify that Patient #1 was "non-compliant had two incidents involving fight pt 2-01 pulled her hair out leaving patches and punching pt in face. Pt couldn't give a legitimate reason as to why pt 4-02 was a target and kept blaming others for her actions."


10-3-2018 - Nursing note at 1:55 AM reads, "______ (Patient #1) had several conflicts today, assaulting a peer. She is unpredictable and difficult to manage at times. Refused vital signs, is eating, does get along with peers at times. She needs to be watched."


10-5-2018 - Nursing notes identify that Patient #1 "had physical altercation with peer - pulled hair and verbally threatened peer + MHT ...". MHT notes from 1st shift identify that Patient #1 hit a peer and pulled her ponytail when leaving the lunchroom. MHT notes from 2nd shift read, "Pt. threatened several pt's. (sic) behind their backs. She was attempting to look tough to no avail. Pt. took meds showered and slept through the night."


10-9-2019 - Nursing noted identify that Patient #1 was involved in a Code Purple. Review of Code Purple paperwork revealed that Patient #1 was hitting and pulling the hair of a female peer. MHT notes identify that Patient #1 fought with a peer in the dayroom and was moved from Unit 600 to Unit 500 due to behavior. Once moved to Unit 500, she was given a roommate. She became upset with the roommate and started yelling. Patient #1 was, again, moved to another room.


Seven out eight of these incidents resulted in a Code Purple being called and Patient #1 requiring restraint, seclusion, and/or emergency behavioral medication administrations.


Review of the Incident Log revealed that there was only 1 incident report submitted for the incident on 10-2-2018.


On 12-12-2018, Staff #2 was advised that surveyors had requested all investigations of incidents for Patient #1 and that the incident log only contained 1 incident. Staff #2 was asked about an injury to a MHT's eye. Staff #2 stated, "I know what you're talking about." Staff #2 left the room and returned shortly with an additional incident report for the 9-21-2018 events. No other incident reports were provided. No record of investigations into the assaults or interventions put into place in order to protect patients and staff was presented.


Despite 8 attacks on other patients throughout the two admissions, Patient #1's claims of homicidal ideation, and repeated warnings to different staff that she intended to fight other patients, the patient was never placed on increased observation in order to protect patients and staff.



Failed to ensure that processes were put in place to identify patient upon admission with significant sexual history and protect other patients from becoming sexually victimized by those with significant history in 1 (Patient #1) of 1 patient reviewed. Patient #1 was known have a significant history of sexual activity and aggressive/violent behavior, but was not identified upon admission to be a potential risk to other patients. Subsequently, she sexually victimized another patient. Findings:


Review of Patient #1's admission on 9-15-2018 revealed that she was admitted from a residential treatment center that serves adolescents who are victims of sex trafficking. Patient was also known to be violent and aggressive.


The Psychiatric Evaluation from 9-16-2018 identifies that the patient was introduced to Crack at [AGE] through prostitution.


Nursing notes from 9-22-2018 state that Patient #1 reported she slept with all three of her brothers and had sex with her sister.


MHT notes from 9-24-2018 identify that Patient #1 is "very friendly" with a male peer, referring to him as her boyfriend. The notes stated that Patient #1 went into another patient's room and then lied about it. The note does not elaborate on whether the other patient was a male or female or details of why Patient #1 went into another patient's room.


Several MHT notes talk about "inappropriate boundaries" between Patient #1 and her peers.


Despite her significant sexual history and reported sexual contact with both males and females along with her significant aggressive and violent behavior, Patient #1 was never placed on Sexual Acting Out Precautions, in order to protect other patients from becoming sexually victimized.


Nursing notes from 10-10-2018 identify that Patient #1 reported she had entered a male patient's room (Patient #7) and that she and the male patient had sex.


A Therapy Services Note for Patient #7 for events of 10-9-2018 at 9:45 AM was reviewed. The therapist Signature is illegible, but was dated 10-10-2018 at 2:15 PM, after Patient #1 had revealed that she and Patient #7 had sex. The note read as follows:


"Pt asked to speak privately. Once in a consultation room, Pt disclosed that during the weekend, while he was showering in his room, a female Pt (---) [Patient #1's initials redacted for privacy] showed up in his room outside the shower. He reported that the female Pt was partially undressed an approached Pt. Pt reports that they had sex. Pt reports he was later told by the female Pt that she was pregnant. Pt reported he was afraid and did not know who to tell or what to do ..."


A note from Staff #27, Patient Advocate, detailed Patient #7's statement of events. During his statement, he claimed Patient #1 threatened that if he didn't have sex with her, she would tell the MHT's that he had raped her. He stated, the t-shirt he was wearing during the interview was stretched out because Patient #1 kept pulling at it, trying to get him to kiss her. He stated that Patient #1 threatened that if he told on her that she would deny it and accuse him of raping her. Patient #7 also expressed concern that he may have impregnated Patient #1.


Interview was conducted with Staff #2 on 12-12-2018. Staff #2 stated that a Mini Root Cause Analysis had been conducted. Staff #2 reported, the video on that night showed Patient #1 entered Patient #7's room at 8:16 PM and exited the room at 8:29 PM. She stated that Patient #7 was in the room for 3 minutes with Patient #1 then exited the room fully clothed. He entered again for 2 minutes, the entered again for another 2 minutes. The investigation concluded that this wasn't possibly enough time for the two patients to engage in intercourse, so the allegations were false.


Despite the fact that both patients told the same story of events, and Patient #7 expressed concerns on two separate occasions that he may have impregnated Patient #1, the allegations were not taken as potentially true and acted upon accordingly. With Patient #1's known history of prostitution, Staff #2 was asked if Patient #7 was offered testing for sexually transmitted diseases, Staff #2 confirmed that he was not.


Review of Policy and Procedure 1000.33, Subject: Sexual Acting Out Precautions, Reviewed/Revised 04/2017 was as follows:

"POLICY:

Rock Prairie Behavioral Health follows this procedure in cases of suspected patient sexual activity or inappropriate sexual behavior during the period of hospitalization ."


This policy