HospitalInspections.org

The facility failed to ensure that the hospital had an organized nursing service that provided 24-hour nursing services as evidence by:

1. Based on review of documentation and interview the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient, Patient #1, in accordance with current standards of practice. An RN failed to reassess a patient based on the patient's needs and acuity, failed to ensure that a patient was provided q15 minute observations as ordered by the physician and determined in the treatment plan, and failed to ensure that patient observations were monitored and documented as ordered.
Cross refer to A0395 RN Supervision of Nursing.

2. Based on interview and record review the facility failed to provide appropriate treatment for a patient, Patient #1, at risk for suicide when his refusal of medications, barricading himself in his room, and the treatment team were planning to get a court order requiring the patient to take his medications, were not addressed in the treatment plan. The patient barricaded his room the following night and committed suicide. Cross refer to A0396 Nursing Care Plan.

Based on record review and interview, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient in accordance with current standards of practice. An RN failed to reassess a patient, Patient #1, based on the patient's needs and acuity, failed to ensure that a patient was provided q15 minute observations as ordered by the physician and determined in the treatment plan, and failed to ensure that patient observations were monitored and documented as ordered.


Findings included:

Review of the Texas Board of Nursing rule §217.11. Standards of Nursing Practice reflected:
(1) "Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall:
... (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; ..."


Review of the facility policy "ObservSmart Rounding Policy", last reviewed/revised 1/2023, reflected:
" ...5. Unit Nurse: The unit nurse is responsible for ensuring all assigned staff are meeting the hospital's compliance goals. This is best accomplished by completing his/her assigned rounding while monitoring the feedback bar of their assigned staff throughout the shift. Entering information onto the compliance log and giving constructive feedback ensures that every employee is working to improve patient safety outcomes as stated in the PI Plan.
6. Rounders: It is the responsibility of each BHT [Behavioral Health Technician] to assure the previous BHT has logged out. If not, it becomes the oncoming BHT responsibility to log out previous BHT and log themselves in.
7. Routine Rounds: Regular 15 minute [sic] safety rounds are done throughout each shift on every patient until the patient is discharged. Patients admitted through Admissions to an inpatient unit will be passively logged out during the admission process. Active rounds will begin once the patient is escorted to his/her assigned unit. At that time, the unit BHT will immediately login the patient and begin rounding.
8. Bedroom Observations: Staff must, always day or night, enter the patient's room to ensure their wellbeing by monitoring for breathing (rise/fall of the chest) prior to confirming an observation ..."

Review of Patient #1's medical record reflected "a 54-year-old man with bipolar I disorder (current episode depressed with psychotic features) and alcohol dependence, was admitted involuntarily on 15 June 2025 for active suicidal ideation and converted to voluntary status the following day. His medical history included COPD, hepatitis C, cirrhosis complicated by hepatocellular carcinoma, hypertension, pancytopenia and thrombocytopenia. Ongoing conflict with his sister over their father's care was a significant psychosocial stressor. He had two prior suicide attempts earlier in 2025 and an extensive history of psychiatric and substance-use treatment." Review of physician order, dated 6/15/25 at 9:00 am reflected "Suicide Risk - Moderate per orders..."

Review of Patient #1 nurse's note, dated 7/2/25 02:27 am, reflected the following " ... Became agitated. He blocked his room with another bed to prevent staff from monitoring him. In and out of his room Pacing. and paranoid. monitored and redirected. Will continue to monitor."
Review of the nurse's note, dated 7/3/25 at 08:51, am reflected the following " ... in and out of his room to the day room. AAOX4 (Alert And Oriented times 4). denies SI (Suicidal Ideations), HI (Homicidal Ideations), or AVH (Auditory Visual Hallucinations). Blocked his door again, but this time he is just quietly doing it because of his delusions and Paranoia. Compliant with all his medications. will continue to monitor. @2100 (9:00 pm) Pt. went to the dayroom get some drink give his medications.
2130 (9:30 pm) came back to the day room and ask for his Permethrin cream. I told him I don't have it for the moment i will just bring it to his room
2200 (10:00 pm) knocking at his door told him I got his cream he push [sic] back the door when I open it. Start cursing.
12 MN (12:00 am) tech informed me that he start [sic] barricading his room. ask another Tech for help and tried to open it but failed. inform supervisor [sic]
0300 (3:00 am) Tech last felt that he was pushing back [sic]
0430 (4:30 am) 2 tech were able to unlock the door and notify Rn seen pt. on the floor upon assessment. I ran to tell the supervisor that we have a code blue.
0431 (4:31 am) called code blue
0435 (4:35 am) CPR started.
0438 (4:38 am) called 911
0445 (4:45 am) EMS arrived a took over CPR.
0502 CPR stopped." The patient was deceased.

Review of the Patient #1's monitoring sheet, dated 7/3/25 night shift, reflected the patient was on q15 minute observations with fall precautions and suicide risk-moderate. Documentation from 12:00 am-04:53 am reflected the patient was in his bedroom and the patient was asleep. There was no documentation related to the patient being barricaded in his room and the tech was unable to visualize the patient.

During an interview, on the afternoon of 7/9/25, Staff #12, MD, reported that she was not notified about Patient #1 barricading himself in his room. She continued that had she known she would have increased his observations. When asked if staff typically notify her during the night about patient issues, she reported that none of the nurses have any problem calling her. She continued that the nurses will even call her if one of the other physicians doesn't answer.

During an interview, on the morning of 7/9/25, Staff #6, House Supervisor, reported that on the night of the incident he was not told about the Patient #1 barricading his room. He continued that he made rounds around 1:00-1:30 am on that unit and that he spent most of the night working at the nurses' station for that unit. He continued that around 4:30 am the nurse "called me to tell me that the patient was found on the floor and to call a code. The patient was on the floor, and there was no pulse. The tech cut the scrubs off the patient's neck because they were wrapped so tight. When EMS [Emergency Medical Services] arrived, they took over the code."

During a telephone interview, on the morning of 7/9/25 and the afternoon of 7/10/25, Staff #5, BHT, reported that around midnight she noticed that Patient #1 had barricaded himself in his room. She continued she and the nurse, and another tech tried to get the door open but couldn't. "I told the nurse to let the house supervisor know what was going on. Later in the night she just acted like nothing was going on. At around 4:30 am I told her that we need to get the house supervisor. [Staff #7] asked what was going on and then he got the door open." When asked why she was documenting that she saw the patient she reported that "When I kept trying to go into his room his beacon would trigger that I was with him. I put that he was asleep so it would keep me up with my patients. I was relying on my nurse to get help and she didn't follow through."

During a telephone interview, on the evening of 7/8/25, Staff #7, BHT, reported that he was working on another unit the night of the incident. He had gone to the geriatric unit to have his lunch. He overheard the staff discussing the patient barricading himself in his room and that they couldn't get him to open the door. At this point he went to the patient's room and pushed the door until he was able to get into the patient's room. At this point he saw the patient on the other side of the bed. He told the nurse to call a code. He reported that the patient had wrapped his scrub pants around his neck. It was so tight we had to cut it off in three spots for the nurses to be able to perform CPR.

During an interview, on the afternoon of 7/9/25 Staff #1, CNO verified these findings.

Based on interview and record review the facility failed to provide appropriate treatment for a patient ,Patient #1, at risk for suicide when his refusal of medications, barricading himself in his room, and the treatment team were planning to get a court order requiring the patient to take his medications, were not addressed in the treatment plan. The patient barricaded his room the following night and committed suicide.

Findings include:

Review of Patient #1's medical records reflected the patient is a 54-year-old male admitted involuntarily following medical clearance at another facility due to active suicidal ideation with a specific plan to harm himself using a cleaver.

Review of the physician orders dated 6/15/25 at 08:00 reflected "Observation Q 15-Suicide Mod QSHIFT_12 HOURS Suicide Risk - Moderate per orders, Request Type: Now". No new orders were found related to observations.

Review of physician progress notes, dated 6/27/25, reflected "Reportedly he asked his sister to bring a gun so he can shoot himself. He is still isolating refusing to take the antipsychotics.
According to the staff he was calling a lawyer, and he was preoccupied about it. No management problems noted." No new orders for patient monitoring were found.

Review of the nurse's note dated 7/2/25 reflected in part "Pt. report PTSD [post-traumatic stress disorder] and Anxiety 8/10 observed to have hallucinations when he ran into another Pt's room saying, "they are here", inability to sleep. Pt. refused his Trazadone. Became agitated. He blocked his room with another bed to prevent staff from monitoring him. In and out of his room Pacing. and paranoid. monitored and redirected. Will continue to monitor."
Further review of an addendum nurse's note, dated 7/2/25 at 02:27, reflected "Pt Pacing going to another Pt's room. Redirected at times. He blocked his room with the extra bed preventing staff to monitor him. Staff opened his room and sat at his door to monitor. Pt. become agitated keep banging his door trying to block his door. Supervisor notified. Advised to call on call MD for order. Called On call Doctor at 0105. Ordered PRN meds IM. Pt, explained of the action of the medication and consented without struggle. Gently and carefully administered to his right ventrogluteal without any struggle. Pt. still get up out of bed Pacing in the hallway. Redirected when needed. Vitals refused. Will continue to monitor."

Further review of Patient #1's treatment plan showed no increase in monitoring or change in care plan after this incident.

Review of the Physician discharge summary, dated 7/3/25, reflected in part:
"The team decided that he was doing better and decided was decided to be discharged. His sister was supposed to pick him up and he asked his sister to bring him a gun, as he believed people were waiting for him outside the hospital, when she comes to pick him up. His discharge was canceled because the team and the sister felt it was not safe for him to discharge and the discharge was canceled. Patient was delusional that all his family members were slaughtered, and it was coming on the news. It was explained that family was in contact, and they were safe, but he was paranoid. He was recommended long-acting injection, but he refused and agreed to take it by mouth. At that point team decided to do involuntary and file opc (order of protective custody) and get court-ordered medications if he refuses. Due to his paranoia and delusions his discharge was canceled 2nd time, and he was started on Invega 6 mg at HS because of his delusions. He started taking for couple of days. His sister was happy about it. His sister he was kept updated during his stay. He was also started on permethrin topical for scabies and his room was blocked he was barricading himself in his room. He was agitated and he was given emergency medications on 7/01. On 07/03 he was found unresponsive in the early hours. The writer was notified in the morning. Staff called 911 and did CPR but was unsuccessful and they were not able to revive, and he was pronounced dead."

During an interview, on the afternoon of 7/9/25, Staff #12, MD, reported that she was not notified about Patient #1 barricading himself in his room. She continued that had she known she would have increased his observations. When asked if staff typically notify her during the night about patient issues, she reported that none of the nurses have any problem calling her.

During an interview, on the afternoon of 7/9/25 Staff #3 reported that there was no incident report or notification related to Patient #1 barricading his door reported.

During an interview, on the afternoon of 7/9/25, Staff #1, CNO, verified these findings.