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.

HAVEN BEHAVIORAL HOSPITAL OF FRISCO 5680 FRISCO SQUARE BLVD, SUITE 3000 FRISCO, TX 75034 Oct. 31, 2018
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on Interview, Record Review and Observation the hospital failed two of 16 Patients (Patient #1, and #2) of care in a safe setting.

During the interview process, hospital staff #5 identified there was nothing that revealed patients were diagnosed to be a fall risk. Staff #5 stated that there used to be leafs on the doors to identify patients as being a fall risk. During interview Staff #5 stated the only way to identify that patients are a fall risk is to review the patients medical records.

During review of the patient's medical records, the records Identified Patient #1 as being a fall risk and needed a walker. The medical record for patient #2 identified the patient as being overweight and a fall risk. The medical record treatment plan of Patient #2 identified that the patient needed supervision with his ADL's and toileting. The patient's both fell without assistance in route to or from tolieting.

During the Observation of the hospital Geri Unit. There was nothing to identify these patients as being a fall risk. There were two patients who had on skid socks, but nothing that would identify the patients that extra support would be needed in areas described in the Patients Record.

Policy

The hospital Policy on Abuse dated 08/2017 reflected, "Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation ...this hospital to protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff members, students, volunteers, other patients, visitors or family members. The hospital mandate ...under the guidance of applicable laws, any healthcare worker having reasonable cause to believe that any person in the state of abuse, exploitation and/or neglect shall report the information to the appropriate regulatory agency. All allegations, observation or suspected cases of abuse, neglect or exploitation that occur in the hospital will be investigated by the hospital.

The hospital Policy on Patient Rights dated 06/2016 reflected, "It is the policy are protected and maintained. All patients are informed of their rights verbally and in writing upon admission. Any limitation of the patient's rights shall be made in accordance with applicable statutes and rules and only if the exercise of those rights would constitute harm to the patient or others."

The hospital Policy on Nursing Services dated 06/2016 reflected, "All patients admitted to the hospital will receive a thorough assessment and evaluation. Results of assessments are reviewed and integrated by the multidisciplinary team to prioritize identified problems with in the interdisciplinary treatment plan.

The hospital Falls Prevention and Monitoring Policy dated 10/2017 reflected, "It is the policy of Haven Behavioral Healthcare to provide evidence-based assessment and care related to fails prevention and treatment within the hospital."

The hospital Acuity Based Staffing Policy dated 02/2018 reflected, "The Nursing Department defines, implements and maintains a system for determining patient requirements of nursing care on the basis of demonstrated patient needs, appropriate nursing intervention and priority of care."
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on record review and interview the hospital failed 2 of 2 Patients (Patient #1 and Patient #2) by not ensuring staff personnel for each department or nursing unit to ensure when needed, the immediate availability of a bedside care of any patient.

Based on interview the hospital staff are unaware of patients individual needs or risk unless if the patient's medical records are reviewed. The hospital staff #5 indicated that if a patient was a fall risk there were leafs on their doors to identify the staff. There is nothing any longer that provides visual safety measures. The hospital staff #5 reported that the Treatment Plans are not being reviewed and followed. The hospital staff #1 reported that they were uncertain as to why the medical staff is not reviewing Patient Treatment Plans.


During the record review the records reflected that Patient #1 and Patient #2 were identified as fall risk. The treatment plan was updated and documented that Patient #1 needed assistance with tolieting and Patient #2 needed supervision with ADL's.


Policy

The hospital Policy on Abuse dated 08/2017 reflected, "Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation ...this hospital to protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff members, students, volunteers, other patients, visitors or family members. The hospital mandate ...under the guidance of applicable laws, any healthcare worker having reasonable cause to believe that any person in the state of abuse, exploitation and/or neglect shall report the information to the appropriate regulatory agency. All allegations, observation or suspected cases of abuse, neglect or exploitation that occur in the hospital will be investigated by the hospital.

The hospital Policy on Patient Rights dated 06/2016 reflected, "It is the policy are protected and maintained. All patients are informed of their rights verbally and in writing upon admission. Any limitation of the patient's rights shall be made in accordance with applicable statutes and rules and only if the exercise of those rights would constitute harm to the patient or others."

The hospital Policy on Nursing Services dated 06/2016 reflected, "All patients admitted to the hospital will receive a thorough assessment and evaluation. Results of assessments are reviewed and integrated by the multidisciplinary team to prioritize identified problems with in the interdisciplinary treatment plan.

The hospital Falls Prevention and Monitoring Policy dated 10/2017 reflected, "It is the policy of Haven Behavioral Healthcare to provide evidence-based assessment and care related to fails prevention and treatment within the hospital."

The hospital Acuity Based Staffing Policy dated 02/2018 reflected, "The Nursing Department defines, implements and maintains a system for determining patient requirements of nursing care on the basis of demonstrated patient needs, appropriate nursing intervention and priority of care."