HospitalInspections.org

Based on record review and interview the hospital failed to endure care in a safe setting. The deficient practice is evidenced by 1) failure to perform observations as ordered by the physician in 1(#3) of 3 (#1-#3) reviewed patient records; 2) failure to notify the admitting practitioner, in a timely matter, after an alleged incident involving possible physical abuse in 1(#3) of 3 (#1-#3) reviewed patient records; 3) failure to ensure a patient who complained of back pain after an allegation of abuse was evaluated by the nurse or licensed practitioner in 1(#3) of 3 (#1-#3) reviewed patient records.
Findings:

1.
Review of hospital policy, "Safety Rounds/Accountability, TX.064, Last Revised 05/2023", revealed in part:
I. Policy- It is the policy of the hospital to provide a safe, secure environment for our patients by ensuring accountability for their well-being.
II. Guidelines for monitoring all Hospital patients as follows:

Safety Rounds Procedure:

Intake starts patient observation/monitoring plan upon arrival to intake area to prevent self-harm, worsening of their condition, elopement, etc. Intake conducts direct visual monitoring at a minimum of every 15 minutes. Intake documents handing off rounds sheets to unit staff.

The charge nurse assigns responsibility for completion of patient observation rounds at the beginning of each shift and will document the assignments on the unit staff assignment sheet.
1. Every patient not on one to one (1:1) precaution will be monitored at least every 15 minutes ...
2. The staff assigned to each inpatient will keep an individual patient round sheet which will be documented on every 15 minutes, beginning with admissions process. Staff will physically go and visualize the patient ...
10. Any staff working with the patient will take the responsibility for the round sheet at the time they are in their care. If the patient is taken to therapist's office or is with physician, the staff will notate that the patient is in meeting but must check on the patient every 15 minutes ...

Review of the medical record for Patient #3 revealed the patient was admitted under a Physician's Emergency Certificate on 05/15/2025 with a diagnosis of suicidal ideation. Review of the orders revealed the patient was placed on suicide precautions and observations were to be performed every 15 minutes. Patient #3 was admitted to the facility on 05/14/2025 and was discharged on 05/21/2025.

Review of the Observation Sheets for Patient #3 revealed:
5/15/25
Observation at 11:04AM completed and next observation was at 11:22AM (approx. 18 minutes)
Observation at 1:16PM was completed and next observation was at 1:49PM (approx. 33 minutes). The next observation was at 2:09PM (approx. 20 minutes).
Observation completed was at 2:19PM and the next observation was at 2:42PM (approx. 23 minutes)
Observation completed at 4:03PM and the next observation was at 4:21PM (approx. 18 minutes)

5/16/25
Observation completed at 5:53AM and the next observation was at 6:16AM (approx. 23 minutes)
Observation completed at 1:39PM and the next observation was at 1:59PM (approx. 20 minutes)
Observation completed at 7:00PM and the next observation was at 7:20PM (approx. 20 minutes)
Observation completed at 7:45PM and the next observation was at 8:08PM (approx. 23 minutes)

5/17/25
Observation completed at 8:00AM and the next observation was at 8:40AM (approx. 40 minutes)
Observation completed at 9:10AM and the next observation was at 9:29AM (approx. 18 minutes)
Observation completed at 9:02PM and the next observation was at 9:20PM (approx. 18 minutes)

5/18/25
Observation completed at 5:20AM and the next observation was at 5:38AM (approx. 18 minutes)
Observation completed at 10:58AM and the next observation was at 11:16AM (approx. 18 minutes)

5/19/25
Observation completed at 12:06AM and the next observation was at 12:24AM (approx. 18 minutes)
Observation completed at 9:49AM and the next observation was at 10:08AM (approx. 19 minutes)
Observation completed at 10:32AM and the next observation was at 10:55AM (approx. 23 minutes)
Observation completed at 11:09AM and the next observation was at 11:27AM (approx. 18 minutes) and the next observation was at 11:49AM (approx. 22 minutes)
Observation completed at 1:11PM and the next observation was at 1:29PM (approx. 18 minutes)
Observation completed at 1:42PM and the next observation was at 2:08PM (approx. 26 minutes)
Observation completed at 6:58PM and the next observation was at 7:17PM (approx. 19 minutes)
Observation completed at 8:12PM and the next observation was at 8:50PM (approx. 38 minutes)
Observation completed at 9:47PM and the next observation was at 10:09PM (approx. 22 minutes) and the next observation was at 10:27PM (approx. 18 minutes)
Observation completed at 10:41PM and the next observation was at 11:00PM (approx. 19 minutes) and the next observation was at 11:19PM (approx. 19 minutes)

5/20/24
Observation completed at 10:28AM and the next observation was at 10:47AM (approx. 19 minutes)
Observation completed at 10:05PM and the next observation was at 10:31PM (approx. 26 minutes)

In a interview on 05/29/2025 between 2:38 PM and 2:49 PM, S1 Performance Improvement (S1PI) verified that the facility had experienced problems with the electronic observation system. S1PI stated the problems were first noticed at the end of March or beginning of April of 2025 and they had been working with the corporate office to fix the issue. S1PI stated, "It took us a while to figure it out." S1PI stated initially the techs performing the observations complained that even though the patients were within range, the system was not recognizing the patient as in range. S1PI stated the techs were instructed to log out and then log back in. When the techs did this, sometimes it would produce observations that were late due to the time it took to reset the system. S1PI stated that she was not sure but thought that 90% of the issues were corrected by the end of April, but there were still some issues. When asked about Patient #3, who had late 15 minute observations documented in May, S1PI stated "I'm not going to say all the late observations were due to connectivity problems, but sometimes they are late because there are other things happening on the unit." S1PI stated the facility had already initiated a plan to monitor the work performed by the MHT. S1PI verified that a report is run every morning and if a certain MHT has too many observations outside of the range, the person monitoring will discuss it with the MHT. When asked if any of the MHT's responsible for the care of Patient #3 were interviewed about the timeliness of the observations for Patient #3, S1PI stated she was not sure. S1PI was then encouraged to provide all information she could about the issues with the observation monitoring system for review by the state health standards office.

2.
Record review of the hospital's final self-report dated 05/22/2025 revealed the following, in part:
Date of incident 05/15/2025, date discovered on 05/16/2025. The Physician was notified of alleged abuse on 05/20/2025.

In an interview on 05/29/2025 at 3:05 PM, S1PI verified the physician was not notified about the allegations in a timely matter.

3.
Record review of hospital's final self-report dated 05/22/2025 revealed the following, in part:
Date of incident was 05/15/2025 and was discovered on 05/16/2025. Time of discovery was 4:00 PM.
Patient #3 made accusations that S2MHT had pushed her against the wall while in the bathroom. Patient #3 indicated she was threatened by S2MHT that she would slap her when the patient stated she was going to tell her mom. Then Patient #3 stated S2MHT picked her up and carried Patient #3 to her room, threw her on her bed and she fell on the floor and hurt her back ...
Name the clinician that assessed the patient was marked as unknown at this time.
Date assessed was marked as unknown at this time.
Time assessed was marked unknown at this time.
Description on Patient #3's injury, Patient #3 complained of back pain.

In an interview on 05/29/2025 at 3:05 PM, S1PI verified Patient #3 did not have an appropriate assessment completed after Patient #3 complained of having back pain.