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| BEHAVIORAL HOSPITAL OF BELLAIRE | 5314 DASHWOOD, SUITE 200 HOUSTON, TX 77081 | Oct. 15, 2020 |
| VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING | Tag No: A0144 | |
| Based on review of documentation and staff interview, the facility failed to ensure that a patient had the right to care in a safe setting as clinical staff failed to assess or report a patient's allegation of sexual assault and no action was taken. This is not in compliance with facility policy or patient rights. Findings included: Review of the medical record for Patient #3 revealed he was a patient at Behavioral Hospital of Bellaire. Patient Observation Notes for Patient #3 written by Staff #8 in an untimed note on 8/4/2020 documented that "Pt stated staff sexually assaulted him." There was no documentation that Staff #8 reported, clarified, or otherwise addressed the statement by Patient #3 that he had been sexually assaulted by staff. The above Patient Observation Note for 8/4/2020 was signed by two nurses in the blank for 7p-7a". Review of the Nursing Shift Progress & Assessment Note revealed that Staff #9, RN documented the nursing shift assessment for Patient #3 on 8/4/2020 at 2240. The narrative assessment note from Staff #9 stated, "Pt was aggressive towards his roommate talking some racial slurs to his roommate and the same time attempt to fight him. Redirected several time but pt was not following direction. Staff gave him PRN medication pt refused but pt increase his aggression paranoid and yelling/scream along the hallway/common area. Staff notified MD and Ativan 1 mg IM, Haldol 5 mg IM and Benadryl 50 mg IM was given for one time dose - staff will continue to monitor and provide Q15 min of safety observation during this shift." There was no documentation by Staff #9 that an assessment was conducted regarding the statement by Patient #3 that he was sexually assaulted by staff. There was no documentation in the medical record provided to the survey team that Patient #3 was assessed by any staff after reporting he had been sexually assaulted. The "BHB Hospital Nursing Assignment Sheet" for 8/4/20, 7p-7a shift was provided to the survey team and reviewed. Staff #10, RN and Staff #9, RN were the charge nurses for the unit where Patient #3 was assigned. The sheet had two columns of patient names with Staff #10 listed at the top of one column, and Staff #9 listed at the top of the second column. Patient #3 was listed in the second column listed under Staff #9, RN. The above information on the "BHB Hospital Nursing Assignment Sheet" was confirmed with Staff #15, who confirmed that Patient #3 was assigned to Staff #9 and confirmed that Staff #9 conducted and documented the shift assessment on Patient #3 for the shift on 8/4/2020. A telephonic interview was conducted with Staff #9 on 10/14/20 at 7:44 am. When asked if Staff #9 recalled Patient #3, Staff #9 stated, "I cannot recall specific patients, I work with a lot of patients." The surveyor reviewed the "BHB Hospital Nursing Assignment Sheet" for 8/4/20, 7p-7a shift with Staff #9, including that Patient #3 was assigned to him and that his signature was identified by staff at the hospital confirming that he signed the MHT's Patient Observation Note sheet on 8/4/2020, on which Staff #8 had documented the patient's allegation that he was sexually assaulted. When asked if Staff #9 recalled whether Staff #8 reported the sexual assault to him on that shift, Staff #9 stated, "No ma ' am I didn ' t recall." When asked if anyone told him that Patient #3 reported that he had been sexually assault by staff, Staff #8 stated, "No ma ' am." When Staff #9 was told he signed the observation report which stated Patient #3 had stated he was sexually assaulted, Staff #9 stated, "I don ' t know if I signed anything like that. I don ' t recall if that happened." When asked if Staff #9 read the documentation by Staff #8 before signing the note, Staff #9 stated, "I didn ' t know anything about that." When asked if Staff #9 was aware of the facility policy that requires reporting of any allegation of sexual assault within an hour and completing an incident report within 2 hours, Staff #9 stated, "No, ma ' am, I was not aware of that." When Staff #9 was asked if he completed an incident report, he stated, "No, I was not aware of that." An interview was conducted with Staff #4, CNO and Staff #15 in the facility conference room on 10/14/2020 at 3:30 pm. Staff #4 confirmed the documentation in the medical record of Patient #3 with the survey team, specifically the statement written by Staff #8 that, "Pt stated staff sexually assaulted him." Staff #4 confirmed the name and signatures of Staff #9 on the Patient Observation Note on 8/4/2020 for Patient #3, the Nursing Shift Progress & Assessment Note for 8/4/2020 completed by Staff #9, and the BHB Hospital Nursing Assignment Sheet for 8/4/2020 on 7p - 7a, showing Patient #3 in the assignment column under the name of Staff #9. When asked, Staff #4 and Staff #15 stated they had not been notified at any time of the statement by Patient #3 that he had been sexually assaulted by staff. Staff #4 and Staff #15 stated they were unaware of the allegation and there was no incident report filed and stated they would have been aware if an incident report was filed or if an allegation of sexual assault had been reported. Staff #4 stated that Staff #8 was unavailable for interview. There was no means to determine during the survey if Staff #8 reported the allegation to anyone at the facility, however Staff #4 confirmed that Staff #9 signed the MHT note written by Staff #8. Staff #4 and Staff #15 confirmed that there was no incident report filed by Staff #8, Staff #9 or any other staff member of the allegation by Patient #3 that staff sexually assaulted him. The facility policy was confirmed with Staff #4, which required verbal reporting of sexual assault allegations within an hour and documentation within 2 hours. Staff #4 stated that the statement by Patient #3 should have been verbally reported within an hour and an incident report completed within two hours. Staff #4 stated the alleged sexual assault was not reported and there was no incident report. In an interview with Staff #5, Performance Improvement Director on 10/14/2020 at 8:45 am, he confirmed that there were no incident reports, complaints, or grievances filed about or on behalf of Patient #3 regarding an allegation of sexual assault during his stay. Facility policy, "Patient Abuse and Neglect In-House Patients" provided to the survey team, stated in part, "Abuse or neglect of persons served by the hospital shall be grounds for appropriate action including reporting to law enforcement authorities, reporting to licensing boards and agencies, and disciplinary action up to and including termination. DEFININTIONS: 1. Class I Abuse: ... B. Any sexual assault or sexual exploitation involving an employee, agent, or contractor and a person served, without regard to injury ... Policy Behavioral Hospital of Bellaire promotes respect, dignity, and safety to all its patients and their rights. Therefore, allegations of patient abuse or neglect will be investigated in accordance with the aforementioned law ... Procedure: 1. Any hospital employee, agent, or affiliate who observes or suspects or becomes aware of a situation at anytime after the fact of patient abuse shall report the suspicion to the CEO verbally within one (1) hour. Written documentation of the report shall be made within two (2) hours via the hospital's Incident Report. 2. Failure to report within the allotted time period without sufficient justification shall be considered a violation of abuse/neglect regulations and make the employee subject to disciplinary action and possible criminal prosecution ..." Facility policy, "Incident Reporting" provided to the survey team, stated in part, "Procedure: 1. The employee who is directly involved in the occurrence or incident, either through witnessing the event or being told by a patient that an event has occurred, should initiate and document the incident through Midas Remote Data Entry Incident Report. This should be done as soon as possible after the incident occurs (if witnessed) or as soon as one becomes aware of such an occurrence (receiving information from another person), and no later than before the shift is complete. 2. Once an incident has been observed or reported, the patient ' s attending physician or designee, the Nursing supervisor, and the patient ' s parent or legal guardian (if a minor or under guardianship) should be notified. 3. Instructions for completing the Incident Report form (HPR): A. Complete every section of the Incident Report in Midas ... D. The fully completed form will be sent through Midas to the Nursing Supervisor for review and then submitted to the Director of RM for review. 4. All occurrences involving patients should be charted in the patient ' s medical record ..." Facility policy, "Patient Rights and Responsibilities" provided to the survey team, stated, in part, "Patients have the right to be free from mental, physical, sexual and verbal abuse ... Procedures: RIGHTS ... G. Respect and Dignity: The patient has the right to considerate, respectful care at all times and under all circumstances, with recognition of his/her personal dignity ... I. Personal Safety: The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned." Facility policy, "Patient Observation Rounds" provided to the survey team, stated, in part, "Purpose: To ensure patient safety, as well as, to provide a process for observing and documenting patient location and behavior ... Charge Nurse/Nursing Supervisor/Team leader: a. Assigns responsibility for completion of patient observation rounds at the beginning of each shift ... c. Ensures the Patient Observation Rounds are occurring as ordered, 24 hours per day, seven days a week. d. Sign off on the Patient Observation Rounds sheets at a minimum of twice per shift with a minimum of six (6) times evenly distributed over a 24 hour period. MHT/MHW: a. Review and updated patient observation forms ... g. Document patient location and behavior when the observation occurs on the patient observation form ... m. Identify and report any findings while conducting observation rounds ... -Report any findings to the Charge Nurse" Facility policy, "Observation Levels" provided to the survey team, stated, in part, "Observation levels are defined as levels of staff awareness and attention to patient safety/security needs requiring the initiation of specific protocols and supplemental documentation ... B. Routine patient Observation every 15 minutes Guidelines for implementation of this level of observation include, but are not limited to, the following ... (4) A Patient Rounds Sheet, which reflects the patient's location and observed behaviors every 15 minutes, is maintained. (5) A Nurse on the Unit is required to conduct oversight of patient observation rounds and provide documentation by Signature on the Patient Observation Rounds sheets a minimum of every (2) two hours." Review of the personnel folder for Staff #9, RN, revealed current licensure as an RN in the state of Texas; required training, including CPR and PMAB were current. Review of the personnel folder for Staff #8, MHT, revealed required training, including CPR and PMAB were current. The above findings, that Patient #3 reported that staff sexually assaulted him and there was no action taken, Patient #3 was not assessed after he reported sexual assault, a verbal report of the alleged sexual assault was not made, and an incident report was not completed in accordance with facility policy was confirmed in an interview with Staff #5 the morning of 10/15/2020 in the facility conference room. |
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