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Based on observation, interview, and review of records, revealed that the facility failed to provide a safe setting for the psychiatric patients. The facility failed to ensure that patients were protected by monitoring the patient at the level of monitoring specified in the patient's medical record, including suicide precautions, assault precautions, elopement precautions, line of sight observation, and one-to-one observation.


Ligature risks were observed and identified during the tour of the geriatric unit. The presence of ligature risks in the physical environment of a psychiatric patient, including any setting where psychiatric patients may be present, even for a short period of time, compromises their right to receive care in a safe setting.
The facility failed to ensure that clinical staff assessed or reported a patient's allegation of sexual molestation. Cross refer to CFR 482.13(c)(2) Patient Rights: Care in a Safe Setting (A0144)


Review of records and interview revealed that the facility failed to ensure that direct care staff maintained current training in non-violent crisis intervention and restraint/seclusion training and skills demonstration and competence assessment. Cross refer to CFR 482.13(f) Patient Rights: Restraint or Seclusion (A0194)

Based on a review of available documentation, interview, and email communication, the governing body failed to adopt, implement and enforce policies to address privileging for mid-level practitioners after their initial/provisional appointment, and the facility failed to provide documented evidence that a mid-level practitioner (Staff #14) had current privileges to provide services at the hospital.


Findings:


The personnel and credentialing records of Staff #14 were reviewed the afternoon of 1/29/19 in an unused facility day room with Staff #1. A signed letter was provided stating that Staff #14 had "been granted privileges at Nix Health care System as a Nurse Practitioner(NP). This appointment is Provisional for a period of one year from February 23, 2017 to February 23, 2018. After that time you will be evaluated by your sponsoring physician who must be a member of the Medical Staff."


A request was made by the survey team for current privileging/appointment documentation for Staff #14 from 2/23/18 to the present and for the medical staff bylaws process for credentialing a nurse practitioner at the facility.


A telephone interview was conducted on 1/29/19 at 10:35 am with Staff #16, Medical Staff Coordinator, who stated that Staff #14 was "automatically moved into the Advanced Professionals Category after one year." When a request was made by the survey team to review the medical staff bylaws supporting this process for Staff #14, Staff #16 responded via email at 11:18 am that the facility medical staff bylaws are currently being updated as "our bylaws do not specify set privilege dates/years for APPs [advanced practice professionals]." Further communication provided to the survey team stated, " ...We just have the understanding that his privileges are good for 2 years since there is no other category he would be able to transition to."


There was no documented evidence provided to the survey team of current privileges/appointment for Staff #14. The above findings were confirmed during the interview and email communication was provided by Staff #1 the afternoon of 1/29/19.

Based on facility policy review, record review, and interview, the governing body failed to ensure the facility followed established policies and procedures.


Findings:


Facility-based Policy titled "Occurrence Reporting" stated in part, "III. Definitions: A. Occurrence - Any event with or without harm OR near miss that involves a patient, visitor or staff member and deviates from hospital policy or that results in actual or potential injury.

...IV. Policy: It is the policy of NHCS to document and report any event that deviates from hospital policy, results in actual or potential injury, to a patient ...

V. Procedure:

...B. Occurrences Involving Patient:

1. Occurrence involving patients may include but are not limited to:

...f. Against medical advice (AMA) discharges

...2. All incidents involving patients will have a confidential electronic event report completed by the employee involved, supervisor/director, charge nurse, or the employee discovering the incident. Once the Reported completes the event it is immediately routed in electronic event reporting system to the designated Management Reviewer for the occurred location ...

D. Disposition of Occurrence Reports:

...4. Follow-up should include the investigation of the cause and action(s) taken to prevent the incident from occurring in the future ..."


Facility-based policy titled "Against Medical Advice Dismissals" stated in part, "Purpose: To provide guidance when a patient requests to leave the hospital against medical advice ... Procedure/Text:

1. ...The charge nurse and/or nursing supervisor are notified of the patient's request and will interact with the patient to educate him/her as to the potential ramifications of his/her discharge against the physician's advice. In the event the patient's request is based on discontent with the care rendered the immediate supervisor/Nursing Supervisor will assist in addressing the concerns.

2 ... Nursing Administration and the business office is notified of all 'AMA' dismissals.

3. An occurrence report will be completed.

Operational Responsibility:

All nursing staff is sensitive to the psychosocial needs of patients and the implications of the perceptions they have concerning their care and factors relating to it. Senior nursing staff in the nursing area should be involved anytime a patient initiates an 'AMA' discharge process. A Case Manager and the attending physician are contacted when circumstances permit to intervene and attempt to dissuade the patient from his/her anticipated course of action."


Review of the medical records for 5 of 5 patients [patients #1, 2, 9, 10, and 11] who left AMA revealed no occurrence or incident reports filed.


In an interview with staff #11 on 1/29/19, when asked if an occurrence report is completed for a patient who discharges AMA, staff #11 stated, "No, that is just a discharge."


In an interview with staff #1 on 1/29/19 when asked if nursing leadership is involved as stated in facility policy, staff #1 stated, "I don't think so ... I think, it's handled by the charge nurse on the unit."


The facility was asked for a list of AMA status patients and the tracking and trending the facility does regarding these patients several times throughout the survey process. None was provided.


The above was confirmed in an interview with staff #1 and #8 the evening of 1/29/19.

Based on observation, record review, and interview, the facility failed to provide a safe setting for the psychiatric patients. The facility failed to ensure that patients were protected by monitoring the patient at the level of monitoring most recently specified in the patient's medical record, including suicide precautions, assault precautions, elopement precautions, line of sight observation, and one-to-one observation for 6 out of 13 patient records reviewed.


The facility failed to ensure that clinical staff assessed or reported a patient's allegation of sexual molestation. This is not in compliance with facility policy and state law referenced in the facility policy.


Ligature risks were observed and identified during the tour of the geriatric unit. The presence of ligature risks in the physical environment of a psychiatric patient, including any setting where psychiatric patients may be present, even for a short period of time, compromises their right to receive care in a safe setting.


Findings:


Observation for line of sight observation, and one-to-one observation not conducted:


Patient #5

Review of the medical record for Patient #5 revealed an order on 9/10/18 at 2 pm that stated, "Place patient on 1:1 supervision due to violently targeting a team member (pregnant) danger to others." The order was not discontinued until 9/21/18 at 9:40 am.


Review of the Patient Observation forms for Patient #5 revealed no documented evidence that Patient #5 was observed on 1:1 supervision between 9/10/18 and 9/19/18 (10 days) for violent behavior and danger to others as ordered. The block on the form for "Continuous 1:1" was unchecked and left blank for the following dates: 9/10/18, 9/11/18/, 9/12/18, 9/13/18, 9/14/18, 9/15/18/, 9/16/18, 9/17/18, 9/18/18, 9/19/18. In addition, even though Patient #5 was supposed to be monitored 1:1 for violent behavior and already had an order for Assaultive observations, there was no documentation that Assaultive observations were monitored on 9/10/18, 9/12/18, 9/13/18, 9/14/18, 9/15/18, 9/16/18, 9/17/18, 9/18/18. This presents a risk to the safety of all patients and staff on the unit.


Review of the medical record for Patient #5 revealed an order on 8/15/18 at 12:20 pm that stated, "Line of sight while awake reason: Delirium."
On 8/19/18 at 1850 the physician order for Patient #5 stated, "D/C line of sight today."


Review of the Patient Observation forms for Patient #5 for 8/18/18 and 8/19/18 revealed that the box for "Within line of eyesight" was not checked on 2 of the 5 days the patient was on line of sight observation. This presents a safety risk for Patient #5.



Patient #12

Review of the medical record for Patient #12 revealed an order on 1/23/19 at 9:30 which stated, "1. Place patient on 1:1 while awake for safety.
There was an order on 1/24/19 at 1550 which stated, "Discontinue 1:1 observations."


Review of the observation sheet dated 1/23/19 indication for "Continuous 1:1" was not checked. This presents a safety risk for Patient #12.


Special Precautions, including suicide precautions, assault precautions, and elopement precautions, not monitored per physician order.



Patient #5

Review of the medical record for Patient #5 revealed an admission order dated 7/12/18 that stated in part, "Special Precautions: Assaultive ...Elopement"


Review of the Patient Observation form revealed that the staff did not check "Assaultive/Aggression" for observation for Patient #3 for the following dates:
7/12/18, 7/13/18, 7/14/18, 7/15/18, 7/16/18, 7/17/18, 7/18/18, 7/19/18, 7/20/18, 7/21/18, 7/22/18, 7/23/18 ,7/24/18, 7/25/18, 7/26/18, 7/27/18, 7/28/18, 7/29/18, 7/30/18, 7/31/18, 8/3/18, 8/4/18, 8/5/18, 8/6/18,8/7/18, 8/8/18, 8/9/18, 8/10/18, 8/11/18, 8/12/18, 8/13/18, 8/14/18, 8/15/18, 8/16/18, 8/17/18, 8/18/18, 8/19/18, 8/20/18, 8/21/18, 8/22/18, 8/23/18, 8/24/18, 8/25/18, 8/26/18, 8/27/18, 8/28/18, 8/29/18, 8/30/18, 8/31/18, 9/1/18, 9/2/18, 9/3/18, 9/4/18, 9/7/18, 9/8/18, 9/9/18, 9/10/18, 9/12/18, 9/13/18, 9/14/18, 9/15/18, 9/16/18, 9/17/18, 9/18/18.


Patient #3

Review of the medical record for Patient #3 revealed an admission order dated 7/28/18 that stated, in part, "Special Precautions: Every 10 minute checks ...Suicide ...Paranoid"


Observation sheets for Patient #3 revealed no patient observation for "Paranoid" on the following dates: 7/30/18, 7/31/18, 8/1/18, 8/2/18 ,8/8/18, 8/9/18, 8/14/18, 8/16/18, 8/20/18, 8/21/18, 9/4/18, 9/5/18.



Patient #12

Review of the medical record for Patient #12 revealed an admission order dated 12/17/18 that stated in part, "Special Precautions: ...Assaultive ...Elopement ..."
Observation sheets for Patient #12 revealed no patient observation for "Elopement" on the following dates:1/1/19, 1/2/19, 1/3/19, 1/4/19, 1/5/19, 1/6/19, 1/7/19, 1/8/19, 1/9/19, 1/10/19, 1/11/19, 1/12/19, 1/13/19, 1/14/19, 1/15/19, 1/16/19, 1/17/19, 1/18/19, 1/20/19, 1/21/19, 1/22/19, 1/23/19, 1/24/19, 1/25/19, 1/26/19, 1/27/19, 1/28/19.


Observation sheets for Patient #12 revealed that "Assaultive" had a line drawn through and "Aggression" was underlined, though there was no change in the physician orders for the following dates: 1/4/19, 1/5/19, 1/6/19, 1/11/19, 1/13/19, 1/14/19, 1/19/19, 1/20/19, 1/22/19, 1/25/19, 1/27/19.



Patient #4

Review of the medical record for Patient #4 revealed an admission order dated 7/17/18 that stated in part, "Special Precautions: ...Assaultive ...Elopement ..."
Observation sheets for Patient #4 revealed no patient observation for "Elopement" on the following dates: 7/17/18, 7/18/18, 7/20/18, 8/12/18, 8/13/18.


Observation sheets for Patient #4 revealed that "Assaultive" had a line drawn through and "Aggression" was underlined, though there was no change in the physician orders for the following dates: 7/21/18, 7/22/18, 7/23/18, 7/27/18, 7/28/18, 7/29/18, 8/3/18, 8/4/18, 8/5/18, 8/10/18, 8/11/18.


Patient #1

Review of the medical record for Patient #1 revealed an admission order dated 5/10/18 that stated in part, "Special Precautions: Suicide ..." Observation sheet dated 5/10/18 indicated no patient observation for suicidal ideation but an observation for "psychosis."


Review of the clinical record for patient #1 revealed admission orders dated 5/10/18 that stated in part, "Special Precautions: ...Other: Q [every] 10 min." Observation sheets for patient #1 were complete except for the sheet dated 5/10/18; patient #1 arrived to the unit at 11:15 pm and was not observed every 10 minutes as ordered until midnight on 5/11/18.


Patient #2

Review of the medical record for Patient #2 revealed an admission order dated 12/7/18 that stated in part, "Special Precautions: Assaultive ..." Observation sheets dated 12/7/18 and 12/8/18 revealed no special precautions indicated.


Review of the clinical record for patient #2 revealed admission orders dated 12/7/18 that stated in part, "Special Precautions: ...Other: Q 10 monitoring." observation sheets were not complete at the following times: 12/7/18 from 11:20 pm through midnight. 12/8/18 at 6:00 pm."



Facility-based Policy titled "Nursing Rounds" stated in part, "Purpose: To ensure a safe environment.

...Procedure/Texas:

...C. The assigned staff member(s) personally locates each patient listed and documents the patient's location the Rounds Sheet under the appropriate time column. The staff member places his/her initials at the top of the column above the time. At the time of joint rounds, staff members initial the Rounds Sheet.

D. While making rounds, the staff member observes the environment for unsafe conditions and check all Exit doors to assure they are locked.


Failure to assess and report patient allegation of sexual molestation:

The medical record of patient #3 was reviewed the afternoon of 1/28/19 in the facility conference room. On 8/3/18 at 16:27, Staff #14, Nurse Practitioner documented in the Physician Progress Note, " ...He is reporting having been sexually molested by staff member. Directed to speak to charge nurse and patient advocate." There was no documented evidence in the medical record that the patient's report was assessed or reported by Staff #14 on 8/3/18.


A face to face interview was conducted with Staff #14 on 1/28/19 at approximately 2:55 pm in the facility conference room. When asked by the survey team if he recalled Patient #3, Staff #14 stated, "vaguely" and confirmed his documentation above on 8/3/18 at 1627 in the medical record that Patient #3 told him that he had been sexually molested.


When asked by the survey team if he had assessed the patient or reported the statement by Patient #3 that he had been sexually molested, Staff #14 stated that he thought the other staff were aware of the allegations of sexual abuse by Patient #3 and so he did not address it and directed the patient to speak to the charge nurse and patient advocate about his sexual molestation.


Staff #14 stated that other staff had documented the allegations earlier in the day. Staff #14 looked through the printed medical record and referred to a progress note dated 8/3/18 at 1303 which stated, " ...one of the staff allegedly touched him inappropriately ...".


Staff #14 stated that he did not confirmed that Patient #3 was telling him about the incident documented at 1303, or whether there had been a different or subsequent incident of sexual molestation when he met with him approximately 3 hours later.


Staff #14 stated that he did not know if Patient #3 was reporting the same incident that had been reported earlier in the day, or if there had been another incident when he documented the report at 1627.


Staff #14 stated that he did not question or assess Patient #3 with regard to the patient's statement that he had been sexually molested.


When asked if Staff #14 reported the incident per professional licensure requirement and facility policy, Staff #14 stated that he did not.


When asked if he was aware of his duty to report allegations of sexual abuse as a licensed professional, Staff #14 stated, "Yes."


An interview was conducted with Staff #1 Risk Manager on 1/28/19 at approximately 3 pm in the facility conference room, who stated that there was no incident of sexual molestation of Patient #3 reported by Staff #14.



Facility policy, "Assessment and Reporting of Abuse and Neglect", policy #24007, stated in part,

"POLICY 1. All employees should recognize signs and symptoms of abuse, neglect, or financial exploitation in order to report to regulatory agencies as appropriate and to heighten patient safety. NHCS will train all healthcare personnel regarding the identification of abuse, neglect, and unprofessional or unethical conduct in healthcare facilities ...

PROCEDURE/TEXT: 1. Reporting allegations of abuse and/or neglect occurring while the patient is under the care of Nix Health care System:
All alleged violations concerning abuse, neglect, or misappropriation of property, occurring while the patient is under the care of Nix Healthcare System, will be immediately reported to the Director of Risk Management or designee, who will advise the on-call administrator/designee ...

REFERENCES
Texas Family Code, Chapter 261
Texas Human Resources Code, Chapter 48
Texas Health and Safety Code, Chapter 161.132 ..."



Ligature Risk:

A tour of the facility Geriatric Heritage II Unit was conducted at approximately 3:56 pm on 1/29/19, accompanied by Staff #1 and Staff #15 (charge nurse). In 3 of 3 patient rooms (rooms #2120, 2121, 2122), there were cloth shower curtains hanging in the patient bathroom which presented a risk for patient hanging, strangulation or death by anoxia caused by wrapping the curtain around the neck tightly enough to cut off blood flow to the brain.


Staff #15 confirmed the shower curtains presented a ligature risk and stated, "Those are the old curtains. They shouldn't be here. We have new curtains now that aren't like these. We had trouble getting the new ones, so someone must have put up the old ones. I don't know why these curtains are here." Staff #1 confirmed the above findings.


"It is up to the facilities team-along with other departments and staff-to understand, identify, and correct physical environment fixtures and objects that may pose a ligature, or hanging, risk to behavioral health patients ...

Some examples of risks include ... shower heads and curtains ...

The smallest risks must be identified and eliminated ..."

Giovinazzo, G. (2018) Healthcare Facilities Today. Compliance 101: Mitigating ligature risks in behavioral health patient care environments. Retrieved 1/30/2019 from https://www.healthcarefacilitiestoday.com/posts/Compliance-101-Mitigating-ligature-risks-in-behavioral-health-patient-care-environments--17684

The above was confirmed in an interview with staff #1 the afternoon of 1/29/19.




36594



Based on a review of facility documents, clinical records, and staff interview, the facility failed to ensure each patient had the right to receive care in a safe setting.


Findings:


Facility-based Policy titled "Non-Discrimination, Patient rights & Responsibilities" stated in part, "I. Purpose ...b. To ensure that all patients/families receiving services from the Nix Health Care System (NHCS) understand their right and responsibilities within the health care delivery system.

...V. Procedure
Patients have the RIGHT to:
...RESPECT AND DIGNITY

*Expect considerate and respectful care that respects the patient's psychosocial, spiritual and cultural values and beliefs
...PERSONAL SAFETY
...Receive care in a safe setting."

The above was confirmed in an interview with the risk manager on the afternoon of 1/29/19.


Facility-based Policy titled "Occurrence Reporting" stated in part, "III. Definitions: A. Occurrence - Any event with or without harm OR near miss that involves a patient, visitor or staff member and deviates from hospital policy or that results in actual or potential injury.

...IV. Policy: It is the policy of NHCS to document and report any event that deviates from hospital policy, results in actual or potential injury, to a patient ...

V. Procedure:

...B. Occurrences Involving Patient:

1. Occurrence involving patients may include but are not limited to:

...f. Against medical advice (AMA) discharges

...2. All incidents involving patients will have a confidential electronic event report completed by the employee involved, supervisor/director, charge nurse, or the employee discovering the incident. Once the Reported completes the event it is immediately routed in electronic event reporting system to the designated Management Reviewer for the occurred location ...

D. Disposition of Occurrence Reports:

...4. Follow-up should include the investigation of the cause and action(s) taken to prevent the incident from occurring in the future ..."


Facility-based policy titled "Against Medical Advice Dismissals" stated in part, "Purpose: To provide guidance when a patient requests to leave the hospital against medical advice ... Procedure/Text:

1. ...The charge nurse and/or nursing supervisor are notified of the patient's request and will interact with the patient to educate him/her as to the potential ramifications of his/her discharge against the physician's advice. In the event the patient's request is based on discontent with the care rendered the immediate supervisor/Nursing Supervisor will assist in addressing the concerns.

2 ... Nursing Administration and the business office is notified of all 'AMA' dismissals.

3. An occurrence report will be completed.

Operational Responsibility:

All nursing staff is sensitive to the psychosocial needs of patients and the implications of the perceptions they have concerning their care and factors relating to it. Senior nursing staff in the nursing area should be involved anytime a patient initiates an 'AMA' discharge process. A Case Manager and the attending physician are contacted when circumstances permit to intervene and attempt to dissuade the patient from his/her anticipated course of action."



Review of the medical record for patient #1 revealed they were admitted on 3/28/18 for suicidal ideations with a plan and a diagnosis of bipolar disorder with psychotic features.

Request for Release form dated 4/2/18 at 12:42 pm stated in part, "It is my understanding that I have a right to leave the hospital within four (4) hours after filing this request for release ... I am refusing treatment and discharging myself for the following reasons: I had an incident last night by staff where I felt unsafe and talk to in a threatening fashion. I felt discrimated [sic] against. I want to be discharged." This was signed by patient #1 and the nurse.


Nursing note dated 4/2/18 at 1:45 pm stated in part, "Pt [patient] has been isolative to self. Appears irritable and guarded. Pt feels [they are] being discrimintated [sic] against. Hesitant to speak with staff. Signed a request to be released and this was given to the physician. 'This place is making my depression worse.' Pt denies SI/HI/AVH [homicidal ideation/auditory/visual hallucinations]. RN attempted to speak with patient about what was causing [them] to feel this way and [patient #1] refused to speak with writer."


The physician saw patient #1 within the 4-hour timeframe and discharged her AMA.


Patient #1 was discontent with the care rendered and did not feel safe, yet there was no evidence the immediate supervisor/Nursing Supervisor assisted in addressing patient #1's concerns or was involved in the AMA discharge process.


When asked about further documentation related to patient #1 feeling unsafe in the facility or staff addressing patient #1's concerns, staff #1 verified there was no further documentation or occurrence reports.


Review of the medical records for 5 of 5 patients [patients #1, 2, 9, 10, and 11] reviewed who left AMA revealed no occurrence or incident reports filed.


In an interview with staff #11 on 1/29/19, when asked if an occurrence report is completed for a patient who discharges AMA, staff #11 stated, "No, that is just a discharge."


In an interview with staff #1 on 1/29/19 when asked if nursing leadership is involved as stated in facility policy, staff #1 stated, "I don't think so ... I think, it's handled by the charge nurse on the unit."


The facility was asked for a list of AMA status patients and the tracking and trending the facility does regarding these patients several times throughout the survey process. None was provided. Without occurrence reports or nursing management being involved in the AMA discharge process, there was no chance for follow-up discussing the cause and action(s) taken to prevent these incidents from occurring thing the future.


The above was confirmed in an interview with staff #1 and #8 the evening of 1/29/19.

Based on review of records and interview, the facility failed to ensure that direct care staff maintained current training in non-violent crisis intervention and restraint/seclusion training, skills demonstration, and competence assessment. This presents a risk that patient interventions may not be conducted in a safe manner.


Findings:


Review of the personnel records of Staff #5, RN, and Staff #13, RN, the afternoon of 1/29/19 revealed that both unit RNs were not current in SAMA training (Satori Alternative to Managing Aggression). Staff #5 had a "SAMA Performance Checklist" in her personnel records which had been initialed and signed by the employee dated 10/8/18. However, there was no documented evidence of a trainer or instructor verification of competency or attendance at the course. Staff #13 also had a "SAMA Performance Checklist" in his personnel records which had been initialed and signed by the employee dated 12/1/18; there was no documented evidence of a trainer or instructor verification of competency or attendance at the course.


Staff #1 confirmed the above findings that Staff #5 and Staff #13 were not current in SAMA training, the facility's restraint and crisis training, as there was no documented evidence of training or that demonstration of competency was ever assessed.