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.

MILLWOOD HOSPITAL 1011 NORTH COOPER STREET ARLINGTON, TX 76011 March 27, 2019
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the hospital failed to ensure that a registered nurse evaluated the care and reassessed two of two patients (Patients # 14, #18) who experienced changes of condition during their hospital stay.


1) Patient #14 did not have any wounds on her arms when she was admitted to the hospital. Three days into her treatment, the patient responded to an incident of patient-to-patient sexual boundary violation with a self-harm attempt. Her wounds were not (re)assessed by a registered nurse.

2) Patient #18 did not have bruising or redness on her neck upon admission. The morning of her fourth hospital day, Patient #18 woke up with red marks/bruising on both sides of her neck inflicted on her by another patient. Patient #18's skin alterations were not (re)assessed by a registered nurse.


Findings included:

1) Record review of Patient #14's Comprehensive Psychiatric Evaluation dated 01/24/19 at 1100 reflected the patient was admitted with increased anxiety and depression. Patient #14 was suicidal and planned to cut her throat with a knife.

Patient #14's Initial Nursing assessment dated [DATE] at 0305 did not reflect any skin abnormalities.

Patient #14's Nursing Progress Notes dated 01/27/19 at 2105 reflected "scratches noted on pt's left forearm...triggered due to sexual complaint on her...incident happened yesterday (01/26/19)..." There was no documented evidence of wound assessments.

Registered Nurse Assessments dated 01/27/19, 01/28/19, and 01/29/19 did not reflect a change of the patient's condition and/or wound assessments.

Personnel #12 confirmed that there was no assessment of Patient #14's "scratches" during an interview on 03/27/19 at 1300.

2) Patient #18's Admission Nursing assessment dated [DATE] at 0741 did not note bruising or skin discoloration on the patient's neck.

Nursing Progress Notes dated 01/12/19 at 0930 reflected Patient #18 "woke up with hickies [temporary red marks or bruises on the skin produced by biting and/or sucking] on both sides of her neck..." There was no further documented assessment of the alterations in the patient's skin integrity.

Registered Nurse Assessments dated 01/12/19, 01/13/19, and 01/14/19 did not reflect a change in the patient's condition and/or assessment of the patient's skin.

During an interview on 03/27/19 at 1330, Personnel #11 reviewed Patient #18's clinical chart and stated to be unable to find nursing assessments and reassessments of the patient's red marks/bruises.

Personnel #2 stated during an interview on 03/27/19 at 1100 that another patient gave Patient #18 "hickies."
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure the right to receive care in a safe setting that prevented incidents of patient-to-patient sexual boundary violations for two out of two pediatric and/or adolescent patients (Patients #14, #18) and at least two unidentified patients.

1. Patient #14 was suicidal with unpredictable behavior patterns on admission. The patient had a history of sexual abuse. Three days into her hospital stay, Patient #14 had sexually inappropriate contact with another patient that triggered Patient #14 to harm herself a few hours later. In addition, Patient #14 had to be assessed for sexually transmitted diseases.

2. Patient #18 was suicidal and hopeless on admission. Four days into her stay, Patient #18 was noted with bruising/red marks on her neck that had been produced by biting and/or sucking. After the incident the patient's mood adversely changed to hostile. The patient displayed threatening and agitated behaviors with anger outbursts.

3. Patient #4 was noted with poor judgement and impulse control. Patient #4 was noted to have inappropriately touched at least two other, unidentified patients on at least three occasions.

Findings included:

1. Record review of Patient #14's Comprehensive Psychiatric Evaluation dated 01/24/19 at 1100 reflected the patient was admitted with increased anxiety and depression. Patient #14 was suicidal and planned to cut her throat with a knife.

Patient #14's Initial Nursing assessment dated [DATE] at 0305 did not reflect any skin abnormalities. The patient had a history of sexual abuse. Nursing assessed the patient to have unpredictable behavior.

Patient #14's Nursing Progress Notes dated 01/27/19 at 1750 reflected that the patient "reported having a sexual act with another female pt [patient]...admitted sexual inappropriate behavior with another peer...felt bad, cried..."

Patient #14's Nursing Progress Notes dated 01/27/19 at 2105 reflected "scratches noted on pt's left forearm....triggered due to sexual complaint on her...incident happened yesterday (01/26/19)...medical consult in...[the morning] to rule out STD [sexually transmitted disease]...."

Hospital Personnel #2 acknowledged the incident during an interview on 03/27/19 at 1100.


2) Patient #18's Comprehensive Psychiatric Evaluation dated 01/08/19 at 0840 reflected the patient had suicidal thoughts and wanted to die.

Patient #18's Psychosocial assessment dated [DATE] reflected the patient's plan to overdose on "any substance she can find...[I] don't want to live...anymore..." The patient was assessed to have severe stressors and felt hopeless. The patient was cooperative during the assessment.

Patient #18's Admission Nursing assessment dated [DATE] at 0741 did not note bruising or skin discoloration on the patient's neck.

Nursing Progress Notes dated 01/12/19 at 0930 reflected Patient #18 "woke up with hickies [temporary red marks or bruises on the skin produced by biting and/or sucking] on both sides of her neck..."

Patient #18's Psychiatric Physician Progress Notes dated 01/09/19 and 01/11/19 reflected the patient's depressed and anxious mood. Psychiatric Physician Progress Note dated 01/12/19 reflected the patient was hostile.

Patient #18's Nursing assessment dated [DATE] and 01/10/19 reflected the patient was cooperative. The Nursing assessment dated [DATE] for the 0700 to 1500 shift reflected Patient #18 displayed threatening, oppositional, and agitated behaviors with anger outbursts. The patient was noted to be sexually inappropriate.

Personnel #2 stated during an interview on 03/27/19 at 1100 that Patient #16 gave Patient #18 "hickies."

3) Patient #4's Outpatient Integrated Intake and Psychosocial assessment dated [DATE] reflected the patient had a history of exposing himself in a female bathroom at school The patient was assessed to be at "high risk" for violence to others.

Patient #4's Psychiatric Progress Notes dated 02/01/19, 02/04/19, 02/06/19, 02/11/19, 02/13/19, 02/18/19, 02/25/19, 03/04/19, and 03/11/19 reflected the patient's "poor" judgement and impulse control.

Patient #4's Treatment Plan Update dated 02/06/19 reflected the patient "has tried to touch other ...[patients'] privates ..." Treatment Plan Update dated 02/20/19 reflected "...on 02/18/19 [Patient #4] repeatedly... touched one patient's butt despite being told not to ..."

Progress Notes dated 02/20/19 at 1559 reflected Patient #4 "... began touching other group members." Progress Notes dated 02/18/19 at 1224 reflected another patient accused Patient #4 "of touching his bottom and when asked about it pt [Patient #4] said 'sometimes I touch other people and have touched their butts' ..."

Personnel #6 was interviewed on 03/25/19 at 1510 and stated two patients had told her that Patient #4 touched their private area and/or buttocks on top of their clothes. Personnel #6 denied a recall of the patients' names or dates/times of the incidents.

Personnel # 3 stated during an interview on 03/27/19 at 1055 that she was unable to determine which pediatric patients were involved in the incident.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital's executive staff failed their responsibility to ensure that clear expectations for safety on the patient units were established and incidents of patient-to-patient sexual boundary violations were reported to administration for investigation and tracking. At least two unidentified patients in the hospital's outpatient program were touched inappropriately by Patient #4, a patient with a history of sexually inappropriate behavior and poor impulse control. Staff aware of the incidents did not alert executive staff. Hospital administrative executives were unaware of the alleged incidents until surveyor inquiry.

Findings included:

Patient #4's Outpatient Integrated Intake and Psychosocial assessment dated [DATE] reflected the patient had a history of exposing himself prior to his hospital admission. The patient was assessed to be at "high risk" for violence to others.

Patient #4's Psychiatric Progress Notes dated 02/01/19, 02/04/19, 02/06/19, 02/11/19, 02/13/19, 02/18/19, 02/25/19, 03/04/19, and 03/11/19 reflected the patient's "poor" judgement and impulse control.

Patient #4's Treatment Plan Update dated 02/06/19 reflected the patient "has tried to touch other ...[patients'] privates ..." Treatment Plan Update dated 02/20/19 reflected "...on 02/18/19 [Patient #4] repeatedly... touched one patient's butt despite being told not to ..."

Progress Notes dated 02/20/19 at 1559 reflected Patient #4 "...began touching other group members." Progress Notes dated 02/18/19 at 1224 reflected another patient accused Patient #4 "of touching his bottom and when asked about it pt [Patient #4] said 'sometimes I touch other people and have touched their butts' ..."

Personnel #1 was interviewed on 03/25/19 at 1245. and denied any incidents of patients' inappropriate touch at the hospital's outpatient facility.

Personnel #6 was interviewed on 03/25/19 at 1510 and stated two patients had told her that Patient #4 touched their private area and/or buttocks on top of their clothes. Personnel #6 denied a recall of the patients' names or dates/times of the incidents. Personnel #6 denied that a report had been made out to notify administration of the alleged incidents and stated she "was not sure whether it constituted an incident report."

Personnel #2 was interviewed on 03/27/19 at 1010 and confirmed she did not have any knowledge of incidents involving Patient #4's alleged inappropriate touch with other patients prior to the survey.

Personnel # 3 stated during an interview on 03/27/19 at 1055 that she was unable to determine which pediatric patients were involved in the incident.

Record review of Hospital Policy ID 18 dated 05/2010 reflected the policy statement that "all patients are provided with a safe and healthy treatment environment..."