HospitalInspections.org

Based on observation and interview, the facility failed to provide patients with personal privacy as shown by the lack of bathroom doors/curtains in 3 of 11 patient rooms.

Findings included:

Observation on 10/11/23 at 10:55 am of facility's Unit 300 patient bedrooms showed the following:

Rooms #309, 314, and 316 did not have a privacy curtain or a door in the patient bathrooms. In addition, when the bedroom door was open, it was possible to view part of the patient bathroom from the hallway.

In an interview on 10/11/23 at 11:00 am, MHT-Staff # Q, who was present at the time of findings, stated that not having doors for the bathrooms was a patient dignity issue and promised to alert management to fix the situation.

Based on record review and interview, the facility failed to ensure an RN (registered nurse) performed the shift assessment for six (6) of eight (8) charts reviewed (Patient ID#s 5, 8, 17, 18, 19 and 20).

Findings included:

Record review on 10/11/2023 of facility policy titled "Nursing Documentation Standards" dated 9/19/23 showed the following information:

Nursing daily assessments/progress notes

a. The daily nursing assessment is utilized to reassess and document the patient every shift on a 24-hour basis. It provides continuity on a 24-hour basis and is a valuable tool for all clinicians involved in patient care.

The facility policy failed to designate an RN for this duty.

Texas Board of Nursing RN Scope of practice. Rule 217.11. Standard of Nursing Practice.
Assessment: "The comprehensive assessment is the first step and lays the foundation for the nursing process. The comprehensive assessment is the initial and ongoing, extensive collection, analysis and interpretation of data. Nursing judgment is based on the assessment findings. The RN uses clinical reasoning and knowledge, evidence- based outcomes, and research as the basis for decision-making and comprehensive care. Based upon the comprehensive assessment the RN determines the physical and mental health status, needs, and preferences of culturally, ethnically, and socially diverse patients and their families using evidence-based health data and a synthesis of knowledge. Surveillance is an essential step in the comprehensive assessment process. The RN must anticipate and recognize changes in patient conditions and determines when reassessments are needed."

Evaluation and Re-assessment:
"A critical and fourth step in the nursing process is evaluation. The RN evaluates and reports patient outcomes and responses to therapeutic interventions in comparison to benchmarks from evidence-based practice and research findings and plans any follow-up care and referrals to appropriate resources that may be needed. The evaluation phase is one of the times when the RN reassesses patient conditions and determines if interventions were effective and if any modifications to the plan of care are necessary."

Record review of patient charts on 10/11/23 revealed the following six of eight charts in which an LVN performed a shift assessment on the following days:

Patient ID #5: 9/22/23, 9/23/23, 9/24/23, 9/25/23 x 2, 9/26/23, 9/27/23, 9/28/23, 9/29/23, 9/30/23, 10/1/23, 10/2/23, 10/5/23, 10/6/23, 10/7/23 and 10/10/23.

Patient ID# 8: 10/9/23 and 10/10/23.

Patient ID# 17: 9/8/23, 9/9/23 had no PM shift assessment documented, 9/11/23, 9/12/23 x 2, 9/14/23, 9/15/23 x 2, 9/16/23, 9/17/23, 9/18/23, 9/20/23, 9/21/23 had no PM shift assessment documented, 9/22/23, 9/29/23, 10/1/23, 10/3/23 and 10/7/23.

Patient ID# 18: 10/4/23.

Patient ID# 19: 10/7/23 and 10/8/23.

Patient ID# 20: 10/7/23 and 10/8/23.

Interview with Director of Clinical Services (ID R) on 10/11/23 at 11: 15 AM stated that patients are to have an RN assessment every 12 hours and the facility policy states this.

Interview with staff RN (ID K) on 10/11/23 at 11:45 AM confirmed the above medical record review findings.


38015


Based on record review and interview, the facility failed to ensure adequate supervision of nursing care for 8 of 15 patients as shown by:

A. The nursing policy for addressing precaution levels only addressed suicide precautions and made no mention of other patient precautions, including homicide, assault, self-harm, fall, sexually acting-out, or seizure precautions;

B. Physician orders for various precaution levels were not carried-out and communicated to Mental Health Technicians as shown by blank close observation sheets which listed patient precaution levels;

C. A patient exhibiting two episodes of violent behavior was not placed on assault precautions (Patient #5).


Findings included:


A. Review of facility nursing policy titled Suicide Prevention, #07, last revised 6/14/23 showed it only addressed suicide precautions and no other types of precautions that a physician might order.

In an interview on 10/11/23 at 12:10 pm, QD-Staff #A stated that the only policy the facility had to address all the various precautions that a patient could be on was the policy titled "Suicide Prevention". When questioned further if there was any policy that addressed other doctor-ordered precautions such as homicide, assault, self-harm, fall, and/or sexually acting-out precautions, Staff #A stated that there were no other policies addressing these precautions.

B. Record review of the following patient records' physician orders showed the following:

Patient #21: Seizure & Falls precautions.
Patient #22: Suicide Precautions.
Patient #23: Suicide Precautions.
Patient #24: Suicide Precautions.
Patient #26: Suicide Precautions.
Patient #27: Suicide Precautions.
Patient #28: Suicide Precautions.
Patient #29: Suicide Precautions.

In an interview on 10/11/23 at 10:25 am, RN-Staff #E stated the way physician orders for patient precautions were carried-out was through documenting on a form for each patient called "Patient Observation Form Q15" (POF). Staff would then know what precautions the patient was on and observe or take action for the patient accordingly.

Review of the Patient Observation Form Q15 (POF) showed at the top of each form the following precaution levels the facility used for each patient: Suicide, Homicide, Assault, Self-harm, Fall, SAO (Sexually Acting Out), Other___.

In an interview on 10/11/23 at 10:30 am, MHT-Staff #P stated he was caring for the first half of the patients in Unit 300. In the MHTs possession were the POF forms for the patients residing in the first half the unit. Review of the POFs showed there were no precautions at all listed for his patients. When asked what precaution levels the patients were on, the MHT was unsure and could not answer.

In an interview on 10/11/23 at 10:40 am, MHT-Staff #Q stated she was caring for the second half of patients in Unit 300. In the MHTs possession were the POF forms for patients residing in the second half of the unit. Review of these forms showed they were also left blank for all precaution levels. When questioned how it was possible to know what precautions the patients were on, MHT #Q stated that the various precaution orders for patients were discussed in morning huddle. However, the staff was unable to verbalize which patients were on which type of precaution.

C. Review of facility policy titled "Incident Reporting", #VQM.1.15, effective 8/1/22 showed that an Incident Report must be completed for every occurrence not consistent with routine care of the patient, and must be completed by the employee(s) who witnessed or discovered an occurrence within 24 hours. Included on the list of categories that required an incident report to be completed were "Threat alleged to peer or staff" and "Staff injury from patient".

Record review on 10/10/23 at 12:00 pm with RN-Staff #G of Patient #5's records showed that on 10/3/23 and 10/7/23, the patient was involved in two assaults. These assaults were documented on physician progress notes and LVN nursing progress notes respectively.

Record review of the facility's Incident/Variance Report logs failed to show any entries for the two episodes.

In an interview at the time of finding, RN-Staff #G stated there should have been incident reports generated for the two occurrences.