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.
| WELLBRIDGE HEALTHCARE GREATER DALLAS | 4301 MAPLESHADE LANE PLANO, TX 75093 | March 8, 2021 |
| VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT | Tag No: A0145 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The hospital has failed 1 of 1 Patient (Patient #3). The right to be free from all forms of abuse. Findings Include: During interview Patient #6 was on assault protocol and had engaged in an earlier verbal confrontation with hospita Patient #3. The hospital failed to ensure that Patient #3 remained free from abuse by changing Patient #6's level of observation throughout the day. Patient #6 was able to follow Patient #3 into her room, and assaulted Pateint # while she was in her wheelchair and in her bathroom. Patient #3 was discovered on the doorway floor of her bathroom by hosptial Staff # and Staff #6. During record review the Avatar eMar HArd-Cop reflects Physician Order #9125 01/19/2021 at 09:30 PM through date of discharge 03/02/2021 at 08:09 PM for Assault Precaution. The order was not discontinued or updated until discharge, it was an "Open Ended order. Without a level of observation change for behavioral changes of the patient. During record review Patient #6 Notes refected, "The hospital Daily Nursing Notes dated 02/15/2021 at 0921PM reflected, "Pt. slept until early afternoon when Pt. came out of room and into hallway w/ no clothing on, redirected back to room and dressed w/gown. Pt. somewhat calmer until 1330 when peer approached and was too close/intrusive w/Pt. Pt. hit peer causing no injuries. PT. were separated to ensure safety...At approx. 1755 pt. followed peer into peer's room and pulled peer off w/c to kick and punch peer w/o provocation or known trigger. PT. was brought back to room. Dr. Mehta notified, received, order for Zydis 10 mg SL x1. When this nurse brought med to Pt., Pt. became angry, hit med out of hand and spit on this nurse. Received new orders for Zyprexa 10mg and Benadryl 50mg IM x1. Meds administered to left deltoid w/ no issues. Family and DON notified of incident.." Policy The hospital Patient Rights Policy dated 02/1/17 reflected, "This facility fully supports, endorses and enforces the rights of patients. This facility informs each patient, patient's guardian /or patient's family when appropriate, of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible. Patient rights include all federal and state requirements." The hospital Patient Rights Abuse dated 02/1/2017 reflected, "It is the policy of the hospital to make every effort to protect the fundamental human, legal and civil rights of the patients in its care. Employees are expected to treat each patient in a respectful and considerate manner and to immediately report any concern for a patient's safety." The hospital Policy Nursing Services Integrated assessment dated [DATE], "It is the policy of the facility to conduct a comprehensive assessment of all relevant factors contributing to the patient's current condition and goals of recovery." The hospital Policy on Quality of Care dated 02/1/2017 reflected, "A hospital shall develop, implement, and maintain an effective ongoing, hospital-wide, data driven quality assessment and performance improvement program ...Reflect the complexity of the hospital organization .... Involve all hospital departments and services, Specify the frequency and detail of data collected, Focus on high-risk, high volume, and problem prone areas." The hospital Policy on Physician Orders dated 12/2020 reflected, "It is the policy of the facility that all care, treatment, and services provided by the hospital are written directly or indirectly by a physician or licensed independent practitioner (LIP) credentialed by the hospital as outlined in the Medical Staff Bylaws; and that these orders are clear, concise, and in accordance with all other applicable policies. The hospital Level of Observation and Hand Off communication dated 12/2020 reflected, "It is the policy of the facility to provide levels in compliance with physician orders and prescribed protocols." |
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| VIOLATION: NURSING CARE PLAN | Tag No: A0396 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The hospital failed to ensure that the nursing staff kept current with the nursing care plan for 1 of 1 Pateint. (Pateint #6). The nursing care plan may be part of an interdisciplinary care plan. Findings Include Through interview with Hospital Staff #3 it was reported that the patients engaged in a verbal argument earlier in the day. The patients were separated at that time. Patient #3 went down the hallway to assigned room. Pateint #6 also went down the hallway and into Patient #3's room and followed into the bathroom assaulting Patient #3, pulling patient #3 to be found by hospital Staff #4 and Staff #6. Hospital Staff #4 assessed Patient #3 and remained with patient until calm. Through interview Hospital Staff #1 was informed that Patient #6 had a Assault Precaution Order in the medical record, that the hospital failed to ensure that the nursing staff kept current with the nursing care plan for Patient #6 causing Patient #3 to be assualted. After they had already engaged in verbal confrontation. The nursing staff did not follow their own Policy and change the level of observation of Patient #6 to help prevent this assault. Policy The hospital Patient Rights Policy dated 02/1/17 reflected, "This facility fully supports, endorses and enforces the rights of patients. This facility informs each patient, patient's guardian /or patient's family when appropriate, of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible. Patient rights include all federal and state requirements." The hospital Patient Rights Abuse dated 02/1/2017 reflected, "It is the policy of the hospital to make every effort to protect the fundamental human, legal and civil rights of the patients in its care. Employees are expected to treat each patient in a respectful and considerate manner and to immediately report any concern for a patient's safety." The hospital Policy Nursing Services Integrated assessment dated [DATE], "It is the policy of the facility to conduct a comprehensive assessment of all relevant factors contributing to the patient's current condition and goals of recovery." The hospital Policy on Quality of Care dated 02/1/2017 reflected, "A hospital shall develop, implement, and maintain an effective ongoing, hospital-wide, data driven quality assessment and performance improvement program ...Reflect the complexity of the hospital organization .... Involve all hospital departments and services, Specify the frequency and detail of data collected, Focus on high-risk, high volume, and problem prone areas." The hospital Policy on Physician Orders dated 12/2020 reflected, "It is the policy of the facility that all care, treatment, and services provided by the hospital are written directly or indirectly by a physician or licensed independent practitioner (LIP) credentialed by the hospital as outlined in the Medical Staff Bylaws; and that these orders are clear, concise, and in accordance with all other applicable policies. The hospital Level of Observation and Hand Off communication dated 12/2020 reflected, "It is the policy of the facility to provide levels in compliance with physician orders and prescribed protocols." |
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