PRINTED: 111011201? DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE 8: MEDICAID SERVICES 0MB N0. 0938-0391 srsreuem or: DEFICIENCIES on) PROVIDERISUPPLIERJCLIA 1x2) momma consrnucnon rxa) DATE suaver AND PLAN OF connecnon IDENTIFICATION nausea: ?moms commerce . 454140 '1 NAME OF PROVIDER oR SUPPLIER smear ADDRESS. crrv. STATE. ZIP cone osoo snnueu. DLvo TIMBERLAWN MENTAL HEALTH SYSTEM DALLAS, TX 75223 (x4) .9 sunnoev smrenenr or DEFICIENCIES ID PLAN OF CORRECTION (x5) men): (EACH DEFICIENCY MUST BE PRECEDED BY FULL men): (EACH CORRECTIVE 50110" SHOULD BE COMMEIION m3 REGULATORY OR IDENTIFYING ma TO THE APPROPRIATE WE DEFICIENCY) A 000 INITIAL COMMENTS A 000 A 000 The (Statement of De?ciencies) is an Sme'ss'O? or this plan Of Forrecuon ?5 of?cial. legal document. All information must an admission that the citations are correct remain unchanged except for entering the p13" of or that the Hospital violated the rules. The correction. correction dates' and the signature Hospital submits thisoplan of correction in space. Any discrepancy In the original de?ciency response to the de?crency statement in citation(s) will be reported to the Dallas Regional accordance mm the ?1'35 and survey Of?ce (R0) for referral to the Of?ce of the Procedures- lnspector General (OIG) for possible fraud. It . information is inadvertently changed by the Hospital leadersmp VBVieV?fed and Con?rmed 10/2011? providerjsupplier. [he Sta?e Survey Agency thBY'began investigating Patient #1?5 should be noti?ed Immediately allegations immediately. and during the week of 1010912017. they self-reported them to the state survey agency and then OMS. which led to the survey. Hospital leadership also reviewed and 11/01/17 An entrance conference was held the early con??ned that the CM 57 W35 the afternoon of roman? with the Hospital Chief notification the Hospi of an Executive Officer and the Hospital Ciinical immediate jeOPaI?dY- 4/ eh) Director. The purpose and process of the 0 ?6 complaint survey were explained and an Hospital lea rship revre llcle 11110117 opportunity given for questions. The survey was processes, changes. conducted to determine the facility's compliance immediate and and with 42 CFR 15482, Conditions of Participation for implemented ongoi con?rm Hospitals. staff?s understanding of and compliance. For details. please see the responses to A An exit conference was held the early afternoon 083, A 144. A 395, and A 396. of 10119117 with the Hospital Chief Executive Of?cer and other administrative staff. Preliminary findings of the survey were presented and an opportunity given for discussion. All questions were answered. An opportunity was also provided for the facility to provide evidence of compliance with those requirements for which non-compliance was found during the survey. No other eat it ds provide suf?cient protection to the patients . date at survey whether or not a plan at correction days to owing the data these elements are made available to the followl mein'nronv DIR 'crons OR PRO SIGNATURE Any de?cion mTerme?tED'dm?Wt en??erisk a de?ciency which the institution at See instructions.) Except for nursing homes. the ?ndings stated above are disciosabie 90 days Is provided. For nursing homes. the above ?ndings and plans of correction are 14 facility. It de?ciencies are cited. an approved pian or correction Is requisite to continued program participation. TITLE (?50 ay be excused from correcting providing It Is detem'lined that rxei one 4/01/33? FORM Previous Versions Obsolete Event Factiin ID. 81103? It continuation shoot Page 1 of 35 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 11?01l2017 FORM APPROVED CENTERS FOR MEDICARE 8. VIEDICAID SERVICES OMB N0. 0938-0391 STATEMENT OF DEFICIENCIES {in PROVIDERISUPPLIERICLIA ixz; MULTIPLE CONSTRUCTION (xai DATE AND PLAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED A. BUILDING 45414" 5- Wm 10:19:201 7 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY. STATE. ZIP CODE TIMBERLAWN MENTAL HEALTH SYSTEM ?00 SAMUELL BLVD DALLAS. TX T5228 m, "3 SUMMARY STATEMENT OF DEFICIENCIES in PLAN OF CORRECTION (x5) pRE?x (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG . REGULATORY OR IDENTIFYING INFORMATIONI TAG CROSS-REFERENCED To THE APPROPRIATE WE I I A 000 Continued From page 1 A DUO such evidence was either alleged or proffered. The staff was thanked for their time and cooperation during the survey process. Complaint intake TX00271526 was substantiated and de?ciencies were Cited. The following Conditions of Participation were not met: I CFR 482.12 Governing Body CFR 482.13 Patient Rights CFR 482.23 Nursing Services Based on observations. interviews and document review it was determined that the de?cient practices found posed an Immediate Jeopardy to the health and safety of patients that caused harm. likelihood for harm. serious injury. and death. It was determined that: 1) The hospital failed to ensure a safe Setting for patients in that a 17-year old male who had been placed on special precautions for potential sexual aggression, had unsupervised access to and entered a female patient room the late evening of 10108117 at a time when all adolescent patients had room time with lights out. The next day the female reported sexual abuse and emergently evaluated for sexual assault at a medical hospital. Clinical and administrative staff members had been unaware of the 17-year old patient's precautionary status until surveyor inquiry. At the time of survey. night shift staf?ng left three rooms with patients on sexual precautions I unsupervised at times when staff completed room FORM Previous Versizns Obsolete Event ID Fanny ID 31103? If continuation sheet Page 2 of 35 PRINTED: 11f01f2017 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES 0MB N0. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER. A. COMPLETED 45414? ?t 10:19:2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 4600 SAMUELL BLVD DALLAS. TX 75228 TIMBERLAWN MENTAL HEALTH SYSTEM checks in an angled-off patient hallway. Hospital staff failed to document patients' location and behavior for close to one hour the evening of 10f09117. The patients were on suicide precautions, had displayed active suicidal, depressive. andlor sexually inappropriate behavior during the course of their hospitalization. andior were noted with poor insight and judgment. None of the Six mental health technicians assigned to work the nights shift on the adolescent unit had evidenced training and demonstrated competence to target the speci?c developmental needs of the adolescent patient population. This failure presents a risk for serious patient harm or death and is in violation of facility policies regulations. Cross refer: A0144 2) The hospital failed to ensure that nationally accepted standards of nursing were followed and failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient. The nurses failed to conduct nursing assessments after two female patients disclosed distraught over sexual abuse andior observation of sexually inappropriate behaviors during current hospitalization. These de?cient practices were not consistent with nationally accepted standards of practice. hospital policy. and state regulations and have the likelihood to (x4, ID SUMMARY STATEMENT or DEFICIENCIES ID PROVIDERS PLAN or CORRECTION (st (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY oR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE DEFICIENCY) A 000 Continued From page 2 A 000 FORM OMS-255710289) Previous Versrons Obsolete Event ID JXPJII Facility 811037 If continuation sheet Page 3 of 35 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES PRINTED: 1110112017 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF OEFICIENCIES AND PLAN OF CORRECTION (X 1) LIA IDENTIFICATION 454140 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING DATE SURVEY COMPLETED 1011912017 NAME OF PROVIDER OR SUPPLIER TIMBERLAWN MENTAL HEALTH SYSTEM STREET ADDRESS. CITY. STATE. ZIP CODE 4600 SAMUELL BLVD DALLAS. TX 75228 (x4) "3 SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ID PLAN OF CORRECTION PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG I CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) IX5I COMPLETION DATE A 000 Continued From page 3 cause serious harm to all patients seeking inpatient treatment for issues related to their illness. Cross refer: A0395 3) The hospital failed to ensure that the adolescent patients' treatment plans were updated and addressed serious patient concerns that included the patients' sexual abuse related emotional statuses. potential sexual aggressive behaviors. andlor physical conditions that effected the patients' health and well-being on a daily basis. This failure presents a risk for serious patient harm or death and is in violation of facility policy regulations. Cross refer: A0396. A 043 482.12 GOVERNING BODY There must be an effective governing body that is legally responsible for the conduct of the hospital. - If a hospital does not have an organized governing body. the persons legally responsible for the conduct of the hospital must carry out the functions speci?ed in this part that pertain to the governing body This CONDITION is not met as evidenced by: Based on record review and interview. the hospital failed to ensure that an effective governing body was responsible for the conduct of the hospital. 0n 101091?17, a female adolescent patient had made an emotional disclosure about a male patients presence in her room that resulted in an unwanted sexual encounter the night before. Hospital administration investigated . the incident and was unaware of the male patients order for staff to observe patient for potential sexual agression until surveyor inquiry A 000 A043 A 043 The Governing Body reviewed the survey 11103117 ?ndings and directed the CEO and senior leadership team to take actions as needed to address cited de?ciencies and to provide routine reports on process changes made. For details, please see the response to A 083. FORM Previous Obsolete Event ID.JXPJ11 Facility ID 8' If continuation sheet Page 4 of 35 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 11IO1I2D17 FORM APPROVED CENTERS FOR MEDICARE 8: MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION (x3; DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 454140 '1 10:19:2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE TIMBERLAWN MENTAL HEALTH SYSTEM 4600 BLVD DALLAS. TX 75228 on) SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (st PREHX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY DR IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DATE I DEFICIENCY043 Continued From page 4 A 043 during the onsite survey. ACTIONS 8: EDUCATION: Cross refer: 48212 A 083 482.12(e) CONTRACTED SERVICES The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and Standards for the contracted services. This STANDARD is not met as evidenced by: The hospital's governing body failed to ensure that services provided on the hospital's adolescent unit meet the health and Safety of patients. Male Patient #3 was allowed to stay in a room approximately five steps across the hallway to a female patient's room. On 10f07117, a physician ordered Patient #3 to be observed for potential sexual aggression. Approximately 24 hours later, Patient #3 was left unsupervised by staff and entered Patient #1'5 room. The next day. Patient #1 was sent to a medical hospital for emergent examination due to sexual assault . Clinical and administrative staff were unaware of the physician's order for sexual acting out behavior observation for Patient #3 until surveyor enquired about it during the onsite survey. Findings included: Patient #3?s Physician's Certi?cate of Medical The Human Resources Director and Nurse 10/20l17 A 033 Manager con?rmed to the CEO that on 10/15/2017 they provided disciplinary counseling to the RN who incorrectly transcribed the physician's order for SAD precautions for Patient #3 and also provided retraining. The Human Resources Director and Nurse 10l20117 Manager con?rmed to the CEO that on 10/13/2017 they terminated the RN who failed to document patient Observation rounds accurately on Patients #1 and #3 as identi?ed in the citation. Upon receipt of the de?ciency statement. 11/03?? the Interim DON and designees reviewed 100% of the current Open medical records to con?rm that any patients demonstrating sexually aggressive behaviors had appropriate precautions ordered, the orders were correctly transcribed on the Patient Observation Checklists. and the nursing staff on duty were all aware of the ordered precautions. The Interim DON reviewed and affirmed that the policies ?Observation Rounds" and ?I-IandOff Communication" provided adequate direction to staff regarding correcti performance and documentation of 11102117 ?observation rounds and appropriate communication of critical patient information to other staff on duty and as part of the handoff process from Shift to shift. FORM Previous Versaons Obsolete Event ID ID- 81103? If continuation Sheet Page 5 of 35 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 11/01/2017 FORM APPROVED CENTERS FOR MEDICARE 81 MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) 1x2) MULTIPLE CONSTRUCTION ixai DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 454140 e. WING 10/19/2017 NAME OF PROVIDER DR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE MENTAL HEALTH SYSTEM 4600 SAMUELL BLVD DALLAS. TX 75228 (x4) .0 SUMMARY STATEMENT OF DEFICIENCIES Io PROVIDERS PLAN OF CORRECTION (st (EACH DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) m3 TO THE APPROPRIATE DATE DEFICIENCY) A 083 Continued From page 5 Examination for Mental Illness dated 10/02/17 re?ected. "The patient slashed his mom's tires. threatened to kill himself by cutting his wrists then threatened to kill his mom and and irritable mood, suicidal and homicidal ideation's, poor insight and judgment." Patient #3'5 Physician's Orders dated 10/07/17. timed at 2245. reflected, "Place patient on SAO-P [sexual acting out- perpetrator] Patient #3'5 Patient Observation Checklist dated 10/07/17. 10/08/17. and 10/09/17 did not re?ect the patient was on sexual acting put precautions. Patient #3's Nursing Note dated 10/07/17 did not re?ect any documentation by nursing as to why the patient was placed on sexual acting out precautions per physician orders dated 10/07/17. Patient #1's Multidisciplinary Progress Note dated 10/13/17 (late entry) for Monday 10/09/17 at approximately 1730 re?ected Patient #1 came to Personnel #5 during dinner and reported that [Patient came into my room and touched he started kissing told him to stop but then he got on top Of me and continued to kiss not stop kissing me and kept telling me 'you know you want he then took his pants off and then he took my pants off and my panties then patient got back on top of me and started kissing me he stuck his thing in me. then took it out and stuck it in again and we had you think I'm ?The Interim DON developed a Transcription 11/03/17 A 033 of Physician Orders Policy that provides speci?c direction to the RN staff on the process for fully transcribing physician's orders, which may include transmission of orders to pharmacy or dietary, addition of precaution orders to the Patient Observation Checklists, and/or completion of requisitions. and which also includes informing other staff Of new orders. The Interim DON also revised the Sexual 11/02/17 Acting Out Precautions Policy to include de?ning boundary violations and the potential of those behaviors as precursors to SAO behavior, additional interventions to prevent SAO behavior, and expectations for response to alleged or actual SAO incidents, including the movement Of patients to alternate rooms and the investigation required. The new and revised policies were 11/03/17 approved by the MEC and the Board. The Interim DON provided retraining to all 11/10/17 RNs on management of SAD precautions with emphasis on: Correct transcription of SAD orders to include the addition of the new precaution order on a Patient Observation Checklist. - Notation of the SAC precautions on the' current Patient Pass-Along form for report to the next shift - Communication of any new order to all staff on duty 0 Of sexually aggressive behavior, and appropriate nursing interventions including changing the room assignment if needed to move a patient on SAO precautions farther from FORM OMS-258710289) Previous Mormons Obsolete Event ID JXPJ11 Facility ID 311037 If continuation sheet Page 8 of 35 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 11/01/2017 FORM APPROVED CENTERS FOR MEDICARE 8: MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF OEPICIENCIES Ixzi MULTIPLE CONSTRUCTION (x31 DATE AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 454140 3- 10/19/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. CODE TIMBERLAWN MENTAL HEALTH SYSTEM mo BLVD DALLAS. Tx 75223 (x4, .9 SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (st (EACH DEFICIENCY MUST DE PRECEDED BY FULL IEACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY DR IDENTIFYING INFORMATION) TAG I CROSS-REFERENCED To THE APPROPRIATE DATE DEFICIENCY) i a I A 083 other patients at risk and to a room where the patient on 8A0 precautions would not have a roommate The Senior Leadership Team created a map of the units and a new process for reviewing all patients' - Documentation Of rationale for Special precautions and ongoing documentation of assessments/reassessments of patients - Requirement for maintaining appropriate observations/supervision of patients on SAO precautions, with emphasis on the responsibility for correct assignment and oversight of nursing staff's performance of observation rounds - Updating the patient's treatment plan to re?ect the special precautions. Competency and understanding of expectations was assessed via post-test and signed attestation. 11/10/17 The Interim DON provided retraining to all MHTs on the management of patients on SAO precautions with emphasis on: - of sexually aggressive behavior - Reporting patient behaviors to the RN - Maintaining appropriate observations/supervision of patients on 8A0 precautions Correct process for handing off rounds to another MHT or an RN whenever staff needs to leave the unit or perform a task that would interfere with completion of rounds. 11/10/17 Competency and understanding of expectations was assessed via post-test and signed attestation. Any nursing staff member who has not received the training by 11/10/2017 will not be allowed to work a shift until he or she has completed the training. 11/10/17 The Interim DON reviewed and modi?ed the nursing orientation to provide greater emphasis on nursing/MHT responsibilities in care of patients on precautions. including patients with sexually aggressive behaviors: - Correct transcription of SAD orders to include addition of the precautions to the Patient Observation Checklist - Notation of any new precautions on the Patient Pass-Along form for report to the next shift - Communication of any new order for precautions to all staff on duty of sexually aggressive behavior, and appropriate nursing interventions including changing a patient's room assignment, such as moving the patient farther away from other patients who might be at risk, and placing the patient in a room without a roommate - Documentation of rationale for special precautions and ongoing documentation of assessments/reassessments of patients Requirement for maintaining appropriate observations/supervision of patients on SAO precautions. including the RN's responsibility for assignment and oversight of MHT performance of observation rounds - Updating the patient?s treatment plan to re?ect the special precautions. 11/10/17 11/10/17 FORM Previous Obsolete Event ID Facility 311037 If continuation sheet Page 6 of 35 Page 6a DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11/01/2017 FORM APPROVED 0MB NO. 0938-0391 the corner rooms and the day room. MONITORING: special precautions. Body. Responsible Staff: Interim DON implemented the practice of keeping the corner rooms in the units locked and not using them when census is low. When census on a unit increases to the point where the corner rooms need to be used. the unit will then be staffed with at least three nursing staff members to enable concurrent monitoring of For a period of at least three months or until full compliance is achieved. the Interim DON/designees are monitoring all patient records daily to determine 1) if any patients have SAO precautions ordered, 2) if those precaution orders have been correctly transcribed, 3) if the Patient Observation Checklists correctly re?ect ordered precautions, 4) if the precautions have been noted on the Pass-Along Form. 5) if all staff have been informed of the SAC precaution order via communication from the RN transcribing the order or through shift report. and 6) if the patient?s treatment plan has been updated to re?ect the For an initial period of 30 days or until full compliance is achieved, a member of the Senior Leadership Team is accompanying each nursing staff member doing observation rounds on at least one set of observations rounds each shift on each unit to monitor compliance with observation round documentation. to observe and confirm their competency. and provide any appropriate feedback. Documentation of the coaching/competency rounding is maintained on a new audit tool. After the initial 30 days, the Senior Leadership Team will continue monitoring at least one set of observation rounds on at least one unit every shift for an additional 90 days to con?rm that the practice has been systematized. During this intensive monitoring process, any non-compliance will be addressed with feedback, re-education, and/or progressive disciplinary action as appropriate. The Interim DON provides results of record reviews and results of rounding with the nursing staff performing observation rounds to the Morning Leadership Meeting each weekday and aggregated results to the Quality Council and Medical Executive Committee. and quarterly to the Governing STATEMENT OF DEFICIENCIES (X1) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 454140 10/19/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY. STATE. ZIP CODE TIMBERLAWN MENTAL HEALTH SYSTEM mo SAMUEL BLVD DALLAS. Tx 75223 {x4} SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION I (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLENON TAG REGULATORY on LSC IDENTIFYING TAG CROSS-REFERENCE) TO THE APPROPRIATE WE DEFICIENCY) A 083 room assignments each weekday morning in light of their precautions to con?rm whether the room assignments are appropriate. To enhance the ability to observe and monitor the milieu on each unit. the Senior Leadership Team 1 1/10/17 11/10/17 11/10/17 11/10/17 11/10/17 FORM Previous Versions Obsolete Event ID JXPJ11 Facility ID 8111331r If continuation sheet Page 6 of 35 Page 6b DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 11f01f2017 FORM APPROVED CENTERS FOR MEDICARE 8. MEDICAID 0MB N0. 0933?0391 STATEMENT OF DEFICIENCIES PROVIDERISUPPLIERJCLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE AND PLAN OF CORRECTION IDENTIFICATION NUMBER. a BUILDING COMPLETED 454140 B. 1011912017 NAME OF PROVIDER OR SUPPUER STREET ADDRESS CITY. STATE. ZIP CODE TIMBERLAWN HEALTH SYSTEM 4600 SAMUELL BLVD DALLAS, TX 75228 (x4) .0 SUMMARY STATEMENT OF DEPICIENCIES ID PLAN OF CORRECTION {st (EACH DEFICIENCY MUST BE PRECEDED aY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION m3 . REEULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE I I A 083 Continued From page 6 A 083 Patient #1's 10!09l17 physician orders. timed at 2015. re?ected to transfer the patient to pediatric emergency care for evaluation. Personnel #3 stated during an interview on 10l13i17 at 1320 that the incident had been investigated by management staff. Personnel #3 was asked by the surveyor whether Patient #3 had been on sexual acting out precautions. Personnel #3 denied knowledge of it. During an interview on 10113117 at approximately 1430. Personnel #1 denied awareness of Patient #3'5 precautionary Observation status for sexual acting out. A115 432.13 PATIENT RIGHTS A115 A115 A hospital must protect and promote each patients rights. This CONDITION is not met as evidenced by: Based on Observation. record review. and interview. the hospital failed to protect the rights of each patient and failed to provide a safe environment for 13 out of 13 patients (Patients #17, and asleep in their rooms according to the unit schedule. staff failed to supervise Patient a male. who had unrestricted access to a female Patient #1's room, close-by. Patient #3 entered 1. #10. #11. #13. #15. and 1) On 10108117. at a time when patients had to be Hospital leadership reviewed policies and 11l10l17 processes. made changes, provided immediate and extensive training. and implemented ongoing monitoring to confirm staff's understanding of procedures and compliance. jFor detail. please see response to A 144. FORM Previous Versuons Obsolete Event ID JXPJ11 Fac-lIty L0 $1103? If continuation sheet Page 7 of 35 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 11l01f2017 FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) Ixzi MULTIPLE CONSTRUCTION ixai DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 454140 3* 10:1 9:201? NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 4600 SAMUELL SLvo TIMBERLAWN MENTAL HEALTH SYSTEM DALLAS. TX 75228 {x4} .9 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION {st mm (EACH DEFICIENCY MUST BE PRECEDEO av FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION m3 REGULATORY OR LSC IDENTIFYING INFORMATION) TAO CROSS-REFERENCED TO THE APPROPRIATE WE . I DEFICIENCY) I I 144: A 115 Continued From page 7 A115 Patient #1'5 room and stayed for about six 1) ACTIONS 8: EDUCATION: minutes before returning to the hallway. Approximately 20 hours later. Patient #1 The Human Resources Director and Nurse 10/20/17 disclosed unwarranted sexual encounter with Manager con?rmed to the CEO that on Patient Patient #1was emergently sent for a 10/15/2017 they provided disciplinary SANE (Sexual Assault Nurse Examiner) counseling to the RN who incorrectly examination at a medical hospital. Until the transcribed the physician's order for SAD surveyors inquiry during the survey. clinical and precautions for Patient #3 and also administrative staff were unaware that Patient #3 provided retraining. had been placed on Special precautionary Observation level for potential sexual aggression The Human Resources Director and Nurse 10/20l17 approximately 24 hours prior to the incident. Manager con?rmed to the CEO that on 10/13/2017 they terminated the RN who failed to document patient observation 2) Twelve out Of thirteen patients on the hospital's rounds accurater on Patients #1 and #3 as adolescent unit (Patients 1. identi?ed in the citation, #10. #11. #13. #15. #17. and #18) were left Without documentation 0f their Iocation and Upon receipt Of the de?ciency statement. 11103117 behavior for more than 45 minutes on 10109117. the Interim DON and designees reviewed The patients were on suicide precautions. had 100% of [he Gun-ant open medica] records active suicidal andlor sexually inappropriate to con?rm that any patients demonstrating thoughts andior behavior. andior were noted with sexually aggressive behaviors had 900' "Bight and IUdgment- appropriate precautions ordered. the orders were correctly transcribed on the Patient Observation Checklists. and the nursing 3) At the time Of survey. none of the night-Shift Staff on duty were a" aware of the ordered assigned mental health technicians had precautions. evidenced training to address age speci?c and developmental needs of the hospital's adolescent The Interim DON reviewed and af?rmed 11 [02,17 that the policies ?Observation Rounds" and ?Handoff Communication" provided adequate direction to staff regarding correcli Cm? ?are? A0144 performance and documentation Of A 144 PATIENT RIGHTS: CARE IN SAFE A 144 SETTING The patient has the right to receive care in a safe setting. 0 Observation rounds and appropriate communication of critical patient information to other staff on duty and as part Of the handoff process from shift to shift. FORM Previous Vets or II Ohm-isle Event ID JXPJ11 81103? "continuation sheet Page 8 of 35 PRINTED: 111'0112017 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) rx2) MULTIPLE CONSTRUCTION (x3) DATE sunvEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A COMPLETED 454140 a. wINo 1011912017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 43011 SAMUELL TIMBERLAWN MENTAL HEALTH SYSTEM DALLAS. TX 75228 (x4, "3 SUMMARY STATEMENT OF DEFICIENCIES Io PLAN or CORRECTION (x5) pay-1x (EACH DEFICIENCY MUST BE PRECEDED BY FULL . PREFIX (EACH CORRECTIVE ACTION SHOULD BE Winn-57'0" m3 REGULATORY OR IDENTIFYING INFORMATION) TAO CROSS-REFERENCED To THE APPROPRIATE We i I i DEFICIENCY) I {The Interim DON developed a Transcription! 11103117 A 144 Continued From page 8 A 144 of Physician Orders Policy that provides specific direction to the RN staff on the This STANDARD is not met as evidenced by: process for IUIIY i'af'scribing Based on observation, interview. and record orders. Whic? may transmi??ion Of . review. the hospital failed to ensure that a safe orders pharmacy 0" d'emfyi add't'on 0f environment was provided for 13 of 13 patients PrecaUtlon orders to the Patient (patients a 1' #10. #11. Observation Checklists, and/or completIon #13. #15. #17? and of requisitions. and which also includes informing other staff of new orders. 1) patient a male. was placed on 5A0-p The Interim DON also revised the Sexual 11102117 (sexually acting out- perpetrator) precautions on ACtinQ out PrecaUtions POIICY I0 10107117 per physician's order. Neither clinical de?ning boundary ?uid the nor administrative staff was aware that Patient #3 POtenIiaI Of ?1053 baha?l?iors 35 was placed on special precautions for staff to to SAO behavior. additional interventions to observe the patient's potential sexual aggressive Prevent 3A0 behaVior. and expectations fOIi behavior. Without staff observation. Patient #3 response to alleged or actual SAO entered a female patient's (Patient room, incidents. including the movement of unrestricted, on the evening Df10108117. at a time patients to alternate rooms and the when staff documented that the patients were in investigation required. the day room and10r dining area. Patient #3 remained in Patient #1's room for about six The new and revised policies were 11103117 minutes. Approximately 20 hours later, and after approved by the MEC and the Board. Patient #3?5 discharge. Patient #1 reported an unwarranted sexual encounter with Patient #3 to The Interim DON provided retraining to all 11110117 staff. Patient #1 was sent for emergency RNS on management of SAO precautions evaluation for sexual assault at a medical with emphasis on: hospital. - Correct transcription of SAD orders to include the addition of the new precaution order on a Patient Observation Checklist, 2) Twelve out of thirteen adolescent patients on - Notation of the SAC precautions on the suicide Precautions (Patients current Patient Pass-Along form for report #10. #11. #13. #15, #17. and #18) were left to the next shift without staff documentation of the patientS' - Communication of any new order to all location and behavior for more than 45 minutes staff on duty on 10109117. The patients had a history of suicide - of sexually attempt(s) prior to admission. active suicidal aggressive behavior, and appropriate ideetien. deities-Ste". Sexually inappropriate nursing interventions including changing behavior during the course of hospitalization. the room assignment if needed to move a I andierwere noted With ineight and patient on SAO precautions farther from . FORM OMS-2567ioz-99) Previous Versions Obsolete Event ID JXPJ11 FaciIIty ID 811037 If continuauon sheet Page 9 of 35 PRINTED: 11/01/2017 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES 0MB NO. 0938-0391 OF OEPICIENCIES (x1) 1x2} MULTIPLE CONSTRUCTION txa) OATE SURVEY PLAN OF CORRECTION IOENTIPICATION NUMBER: A. BUILDING COMPLETED 45414" 3' 10:19:2017 NAME OF PROVIDER OR SUPPLIER STREET CITY. STATE. zap COOE HEALTH SYSTEM 4600 SAMUELL euro TIMBERLAWN MENTA DALLAS. TX 75228 {x4} .9 SUMMARY STATEMENT OF DEFICIENCIES Io PROVIDERS PLAN or CORRECTION (x5) paenx DEFICIENCY MUST BE PRECEOEO SY FULL ACTION SHOULD BE 1 COMPLETION TAG REGULATORY OR 1.50 IOENTIPYINC INPORMATIONI TAG CROSSREPERENCEO To THE APPROPRIATE ME I DEFICIENCY) 'other patients at risk and to a room where A 144 Continued From page 9 A 144 the patient on SAO precautions would not judgment. have a roommate - Documentation of rationale for special precautions and ongoing documentation of 3) None of the six mental health technicians assessmeptyreassessmg?? 9? Patients (MHTS) assigned to work the night shift on the Reguwement adolescent unit had evidenced training and ObsewatlonS/Supen?smn 0f demonstrated competence to target the speci?c Patients?" 3A0 Prefal-ltlons. Vftlii'i developmental needs of the adolescent patient emphaSpopulation, correct aSSIgnment and overSIght of staff's performance of observation rounds Updating the patient's treatment plan Findings included: to re?ect the special precautions. Competency and understanding of 11/10/17 1) Patient #3?5 Physician's Certi?cate of Medical eXPeCtationS was assessed Via Examination for Mental illness dated 10/02/17 80d Signed attestation. reflected, "The patient slashed his mom's tires, threatened to kill himself by cutting his wrists then The interim DON provided retraining to all 11/10/17 threatened to kill his mom and MHTs on the management of patients on and irritable mood. suicidal SAO precautions with emphasis on: and homicidal ideation's, poor insight and - of sexually judgement." aggressive behavior - Reporting patient behaviors to the RN Patient #3'5 Physician's MOT Orders and Maintaining appropriate Preliminary Plan of Care dated 10/02/17, timed at observations/supervision of patients on 1100. re?ected. "Precautions..assaultive. 8A0 precautions of minutes." - Correct process for handing off rounds to another MHT or an RN whenever staff Patient #3'5 Physician's Orders dated 10/07/17, needs to leave the unit or perform a task timed at 2245. re?ected. placed the patient on that would interfere with completion of SAC-P (sexual acting out-perpetrator) rounds, precautions. Competency and understanding of 11/10/17 Patient #3'5 Observation Checklist dated expectations was assessed via post.test 10/07/17. 10/03/17. and 10/09/17 re?ected and signed attestation. Any nursing staff Patient #3 was on 15-minute Observation member who has not received the training for suicide and assault. The documents did not by 11/10/2017 will not be allowed to work 3 reflect special observations for sexual acting out Shift until he or she has completed the I behavior. The checklist dated 10/08/17, at 2230 i ltraining FORM Previous VerSIons Obsolete Event ID JXPJ11 Faculty 811037 [f continuation sheet Page 10 of 35 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FDR MEDICARE a. MEDI AID SERVICES gr txri PRDVIDEWSAPPHENCUA mam" 0F coflfific'lflu IDENHFIEAYIDN muses mun time or movrpsa ca HEALTH swarm rm to starvaur or ansrix as av rutL n4; biz immune A144 From page to and 2245, reflected Patient its ate in me dining roam. Personnel 113 was interviewed on 10/13/17. at 1320. and stated Personnel #12 was in charge at supervising the patients. Personnel <<125 documentation 'dld not match whetwe saw an camera ,,[Persunrrel #12] lelsiried the documents," 0n 10/13/17Jl tt5t. Personnel as was lmerviewed. Personnel #6 that Finerthe lime of the alleged sexual encounter Patient EveluatronlManagemerrt Diagnostic Evaluallurl Medical Servioes) dated 10/05/11. trmed at tsls, reheated. arents laund a nooee made out at a hall and shoe sirin under ..,sexually anused presenlty incarcerated tar and abuslng ..patient..precautions suictdet..leval ol observation 015 minutes Petiertr M's Registered Nurse (RN) Admission Assessment dated 10/05/17. timed at 2045. reflected the patlenr was not sexually active It noted the 13 year old presents (at anxiety and stated her intention to roam hum-a litmus base-r. em in .txmt lle sensreuenon a comma A 144 the nursing urieulatiun to provide greater PRINTED: tllutlzon FORM APPROVED OMB No. 09384391 smear/mazes. an. em: the code (no sAquLL DALLAS. rx mu vaowaea-s mm or rrs. sttdutu as master caussasraameen ro armeucvr 'The lnlellm DON reviewed and modlfied 11/10/17 emphasis on nursingiMH'r responsibilities in care at patients on preceuudns. rneluding patients with sexually aggressive behaviors: . - Correct lranseriptien at SAC orders to include eddrticn oi the precaulioru lo the Peiient Observation Checklist - Notation at any new precaulions on the Palienl Pass-Along lonn tar rspurl to the next shift - Communication at any new order for preeautiuns to all srait an duly bl sexually aggressive behavior. and appropriate nursing interventions including changing a patients ream assignment. such as moving the patient terther away irern other patients who mightbe at risk. and piecing the patient in a room without a roommate - Documentation o1 rationale tor special precautions and unguing documentation at assessments/reassessmems of pallenls Requirement for maintaining appropriate ubsenratrons/supervisian or patients on 5A0 precautions. Including the RN's respunsibility tor assignment and oversight oi MHT perlormance ot observation rounds Updating the palienl's treatment plan tc reflect the speclal precautions, The Senior Leadership Team created a tilt 0/17 map at the units and a new proeess reviewing all parents room assignments each weekday morning in 'ght of their precautions to ccnlirm whether the room assignments are appropriate. Fainvln moat ltaerrurw-hpnemt rap. nuts: PRINTED DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB No. 0935mm c: ixtr ixl) Mu."le commotion ix]: one suRva mo mu or connection A WW6 Asulu "we 1nl19m17 we or PROVIDER ca sonata: cirv SVAIE no code mo aLvo anus," ism umERuINu ulsum HEALTH my to sturdva statement or to anovtosns rum 0' connection our MusY BE av sou poem connector: ivcnon SMOULD as m; aeotutoav on LSC INFWAWJHI mi to MWFROVRIAYE we 'To enhanoe the a lo observe and 11/10/17 A MA Continued Front page 11 A 144 monitor the milieu on each unit. the Senior mm by hang t. Leadership Team implemented the practice oi kaeplng the corner rooms in the units Fang," "is Assessmem locked and not using them when census is Adalascentdaled term/17. timed at calm, Wm?" census 0" a increases '0 retteeted, "Fallen! wrote sulctde note, attempted the Palm where'lhewmer mums fleet? to hang "mum Em Mm" We. be used. the unit than he slatted with sl "may 1 page". my 3 least three nursan stetf members to enaole 1 ears ale may. mm by concurrent monitoring at the corner rooms "madame Patient M's Observatkm dated mica/17 reitected. "015 minute "mutton, my 22.5 Me," For a period or at least three months or unti 11/10/17 interacting socutty the day full compliance is achieved, the Interim DON/designees are monitoring all patient oh ton 8/17. at am. Personnel us was rewrds daily l0 deterl'rline 1) ii any Patienls Interviewed. Personnel "Swag asked to review have 5A0 precautions ordered, 2) II those Patient M's observation reocrd tor 10/03/17. precaution orders have been correctly Personnel ate stated based on the video tootaoe transcribed, a) it the Patient Observallnn the patient was In her room oetwaart 2230 to Checklisls coweclly reflect ordered 2245 during the time ot the alleged sexual precautions. 4) If the precautions have enoounterand veritied the document incorrectly been noted on the Pass-Along Form, 5) documented the patient was In in the day area all stafl have been tnlormed ol the SAC tprecaution order via communication train the RN transonoing the order or through shift report. and 5) ii the palienl's treatment The Progress Note dated plan has been updated to rellect the special 10/13/17 rsfleclcd Patient approached precautions. Personnel as on 10mm ataoout I730 and reported that- [Patient came into my room For an initial period ct 30 days or until full "110/17 and touched me. .then he started compliance is achieved, a member or the told him to stop out then he got on top at me and Senlor Leadership Team is accompanying . continued to kiss me would not stop kissing the each nursing stafl member doing arrd kept telling me 'ynu know you want observation rounds on at least one set at then look his pants off and men he tank my pants observations rounds each shift on each unit a" and my names -- sol hack on top at me and to monitor compliance with observation started kissing me more ..then he stuck his lung 'muna documentation, to observe and In me. then took it out and stuck it in again and confirm their competency. and provide any we Vlad sen-10 lieu mink I'm P'Bgnaf'L-7" appropriate feedback, Documentalion oi Pom Emu to mutt rum to erroar tremor."an not as DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 11/01/2017 FORM APPROVED CENTERS FOR MEDICARE 8: VIEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES Ixn (x2) MULTIPLE CONSTRUCTION (x3; DATE AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 45414? 3- 10:1 9:201? NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE TIMBERLAWN MENTAL HEALTH SYSTEM 4600 SAMUELL BLVD DALLAS. TX 75228 pm, In SUMMARY STATEMENT OF DEPICIENCIES I In PLAN OF CORRECTION i (As) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD as COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSSREPERENCED TO THE APPROPRIATE DATE DEFICIENCY) I I 'the coaching/competency rounding is A 144 Continued From page 12 A 144 maintained on a new audit tool. After the initial 30 days. the Senior 11/10/17 Patient #1's Multidisciplinary Progress Note dated 10/09/17 at 1910 reflected the patient's physician was noti?ed of [emergency care hospital] was contacted for an MOT (Memorandum of Transfer) and police. Of?cers arrived at approximately 2000 to speak to the patient. Nursing informed the patient's [family member] that the patient was about to be transferred to care hospital] and to meet Police there nurse met with police Officer was transported via [emergency medical services] Patient #1'5 physician orders dated 10/09/17. timed at 2015. reflected an order to transfer patient [pediatric emergency care] for patient AMA (against medical advice)." Patient #1'5 (Pediatric Emergency Care) Emergency Department Provider Note dated 10/09/17 at 2334 reflected the patient had been admitted for for sexual assault prior to of lower abdominal and pelvic The notes timed at 0153 (on 10/10/17) reflected examination Patient #1'5 (Pediatric Emergency Care) Child Life Specialist Progress Note dated 10/10/17. at 0220. reflected Patient #1 received a SANE (Sexual Assault Nurse Examiner) examination. On 10/13/17. at 1245, Personnel #5 was interviewed. Personnel #5 stated that on Monday, 10/09/17. at dinner time. Patient #1 told him that "one of the boys came into her Leadership Team will continue monitoring .at least one set of observation rounds on at least one unit every shift for an additional 90 days to con?rm that the practice has been systematized. During this intensive monitoring process, any non-compliance will be addressed with feedback. re-education. and/or progressive disciplinary action as appropriate. The Interim DON provides results of record 11/10/17 reviews and results of rounding with the nursing staff performing observation rounds. -to the Morning Leadership Meeting each weekday and aggregated results tol the Quality Council and Medical Executive Committee. and quarterly to the Governing Body. Responsible Staff: Interim DON 2) ACTIONS EDUCATION: The CEO con?rmed that on the last day of 10/20/17 the survey he and the Interim DON reviewed video of the 45 minutes referred to in the citation and confirmed that. although the Observation rounds were not documented. all 12 cited patients were in the dining hall eating dinner, safe. and under the supervision of two MHTs. It should also be noted that the surveyor was shown the video that demonstrated that although the documentation of rounds was not completed correctly. all patients were safe in the dining hall and under the direct .supervision of nursing staff at the times FORM Previous Versions Obsolete Event Facillty ID 511037 If continuatIDn sheet Page 13 of 35 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 111'01i'2017 FORM APPROVED CENTERS FOR MEDICARE 8: MEQICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA Ixz; MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 0 4541413 no WING 1011 912017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 4500 SAMUELL BLVD MENTAL HEALTH SYSTEM DALLAS. TX 75228 (x4, .9 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED av PULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION m3 REGULATORY OR LSC IDENTIFYING INFORMATION) TAO CROSS-REFERENCED TO THE APPROPRIATE WE DEFICIENCY) i I ?noted in the de?ciency statement. A 144 Continued From page 13 A 144 . . room and touched her. Patient #1 told Patient #3 The Diregqr 0f Chmpal Sen'ces (DOS) 11,07?? "no" and "stop" and "pushed him but Patient took dISCIpIInary action against the MHT on #3 to kiss me kept kissing me duty who. faded to the . damning me "got up and pulled his pants Observatlon rounds thle the patIents-were down. pulled my jeans off and my panties, tank In the dInIng hall. The 080 also provrded his thing and stuck it in me. pulled it out, and retra'n'ng stuck it back in. and we had sex." Personnel #5 . stated that Patient #1 became very emotional at The Intent", DQN reV'eWEd and af?rTed 11102117 that time and asked Personnel #5 whether she that the Whey ,Obsewatton Rounds was pregnant. Personnel #5 stated he told Patient 3" pattents to be Obsen?ed a #1 that "the nurses will keep you safe from here mm'mum 0t every ?fteen (15) mm on." Patient and Patient #35 rooms were those rounds documented on the Pat'ent approximate? ?ve to ten feet apart; the alleged Observatlon Checklist: even If the patients incident happened on Sunday. 10:03:17 between are together in the dining n3?. the day 2230 and 2245. Personnel #5 stated he informed 'roo'nn 0" thOtVEd in a group aCtiVitY- the nurses and administration of the reported incident. At the time of alleged incident. Patient The tntenm DON PFOthed retraining to 3" 11/10/17 roommate. Patient was not in her room nUVSth Staff on the EXPeCtattonS for although all patients had to be in their rooms with compliance the Obsen?atinn Rounds lights out as of 2200. Personnel #5 was asked by Done}! With en?PnESiS 0n: the surveyor whether Patient #3 was on Mandatory documentation 0f precautions for sexual acting out behavior and Obsentation rounds at teaSt eVeW ?fteen stated he did not know. Personnel #5 stated he (15) mtnUteS. even it the Patients are 3" reviewed unit surveillance video footage and "we together in a group such as in the dining saw Patient #3 go into a female room at about hall I 1040 [2240] and leave about 1043 [2243]." - Handoff required when a staff member cannot complete Observation rounds Required RN supervision/responsibility Personnel #1 stated during an interview on for observation rounds by MHTs 10113117. at 1345, that Personnel #12, assigned to supervise 16 patients "was not where she was Competency was assessed via post-test 11/1011? supposed to be the [unit] nurses acknowledged that they did not know #12] Personnel #1 acknowledged that Patient #1'5 room was in the same hallway and close to Patient #35 room. During an interview on 10113117. at 1430. Personnel #1 denied awareness Of Patient #3?3 and signed attestation. Any nursing staff member who has not received the training by 11/10/2017 will not be allowed to work a shift until he or she has completed the training. MONITORING: i FORM Previous Versions Obsolete Event ID: JXPJ11 Facility ID 811037 If continuation sheet Page 14 of 35 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 11f01i'2017 FORM APPROVED CENTERS FOR MEDICARE 8: MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEPICIENCIES (x1) PROVIDEFUSUPPLIERJCLIA MULTIPLE CONSTRUCTION txai DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 454140 10I19f2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. CODE MENTAL HEALTH SYSTEM 46? SAMUELL BLVD DALLAS, Tx 75228 W) .0 SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (x5) pREnx IEACH DEFICIENCY MUST EE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLERON TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE I I ?For an initial period of 30 days or until full 11/10/17 A 144 Continued From page 14 A 144 Compliance is achieved, a member of the order to be observed for sexual perpetrator semor LeaderSh'p Team '5 acFompany'ng I hehavior? each nurSIng staff member dorng observation rounds on at least one set of Observations rounds each shift on each unit] Personnel #6 was interviewed by telephone on to mon'tor compl'a_nce W'th Obsewat'on 10l17117, at 1134. Personnel #6 stated Personnel round documentat'onr to Observe at?d #12. assigned to supervise the patients. had "left con?rm Ihe'r competency! and provfde any the unity appropnate feedback. Documentation of the coachingicompetency rounding is maintained on a new audit tool. Personnel #8 was interviewed by telephone on 10i17117. at 1222. and denied awareness of any After the tnItIal 30 days. the Senlor 11l10/17 incident but the unit was "usually short-handed." Personnel #8 stated that on Sunday, 10i09i17. the unit was staffed with one MHT we should have had two..the patients were other RN (Registered Nurse) tried to wrangle can't make them go to their rooms." Personnel #8 stated she was not aware that Personnel #12 had left the unit and i did not #12] but we have faith that the techs take Care of the was a disorganized guess, I was charge nurse Personnel #8 denied awareness that Patient #3 had been on sexual acting out (3A0) observational status on 10I08117. Observations on the hospital's adolescent patient unit on 10l18i17. at 0600. re?ected one MHT, Personnel #21. supervised nine patients. Three rooms occupied with male patients on 8A0 precautions were not immediately visible to Personnel #21 while conducting room checks at an angled-off patient hallway. During an interview on 10!18!17, at 0630. Personnel #22 acknowledged the above Leadership Team will continue monitoring at least one set of observation rounds on at least one unit every shift for an additional 90 days to con?rm that the practice has been systematized. During this intensive monitoring process. any non-compliance will be addressed with feedback. re-education. and/or progressive disciplinary action as appropriate. The Interim DON provides results of record 1111 0117 reviews and results of rounding with the nursing staff performing observation roundsl in the Morning Leadership Meeting each weekday and aggregated results to: the Quality Council and Medical Executive Committee. and quarterly to the Governing Body. ADDITIONAL ACTIONS MONITORING: Noting that all 12 cited patients who were in- 11108117 the dining hall were on suicide precautions, the Interim DON and DOS reviewed and con?rmed the Hospital?s policy on Suicide and Self Injury Prevention: Early Identi?cation. ObservationIPrecautions. FORM Previous Versions Obsolete Event ID JXPJ11 Facility ID 811037 If continuation sheet Page 15 of 35 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 11I01f2017 FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0933-0391 STATEMENT OF DEFICIENCIES PROVIDERISUPPLIERICLIA 0(2) MULTIPLE CONSTRUCTION (XS) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 454140 3? 10:19:2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE TIMBERLAWN MENTAL HEALTH SYSTEM 4600 SAMUELL BLVD DALLAS. TX 75228 (x4) In SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE mm; DEFICIENCY) A 144 Continued From page 15 observation and stated that nurses were expected to observe the milieu but it was "not realistic that the nurse always watches the patients when the tech makes rounds." 2) Patient #1's Preadmission EvaluationlManagement 'l'Imberlawn Mental Health System Diagnostic Evaluation with Medical Services) dated 10I05l17. timed at 1515, re?ected the patient had been admitted for suicidal ideation. Patient #1's level of observation was every 15 minute checks. Patient #1'8 observation checklist dated 10109117 re?ected the patient was on every 15 minute observations for suicide precautions. There was no evidence of staff documentation regarding the patient's behavior and location for 1T15. 1730. and 1745. The patient observation Check list was left incomplete for that time. Patient #2?5 Physician's MOT (Memorandum of Transfer) Orders and Preliminary Plan of Care dated 10105117. timed at 1000, re?ected the patient was on suicide precautions and staff was to observe her every 15 minutes. Patient #2'5 Observation Checklist dated 10l09l17 re?ected. ?Observation status 15 minute checks suicide The observation rounds document was left incomplete for 1715, 1730. and 1745. Patient ill-4's Physician MOT Orders dated 101081'17, at 0119. re?ected the patient was on I detox and suicide precautions and was to be Interventions and Response Noti?cation. A144 Similar to the SAC Policy, the SP policy requires RNs to update each Patient's Observation Checklist to re?ect the current precautions and level of monitoring, notify the staff member assigned to the patient of any change in precautions of monitoring level, document and communicate the patient's status in the Pass-Along Form and. shift report, and update the patient's treatment plan. Additionally, RNs reassess each patient's suicidal and self-harm ideation every shift. The SP policy also includes the following directions for nursing staff when patients are on Suicide/Self-lnjury Precautions (SP): Limit the personal belongings allowed in the patient's room; - Provide the patient with access to linens during sleep time only; - Closely supervise patients with pencils during written activities; Routinely conduct environmental safety checks for potential contraband, unlocked windows/doors, and other available means of self harm; Encourage patient participation in unit programming: Be vigilant for behaviors that indicate increased risk of suicidelself-harm and immediately communicate to the Charge Nurse any signi?cant signs of concern, including: Verbalized threats, intent, or other indications of planning of a suicide attempt; 0 Written notes. journaling, or other correspondence indicating suicide threat, planning. overwhelming loss. hopelessness; 0 Giving away personal items; 0 Isolating self from others: FORM Previous Versions Obsolete Event ID JXPJII Facility in 81103? If continuation sheet Page 16 of 35 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 11/01/2017 FORM APPROVED CENTERS FOR MEDICARE 8 MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION A. BUILDING COMPLETED 454140 3? 10:19:2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE TIMBERLAWN MENTAL HEALTH SYSTEM 4m BLVD DALLAS. Tx 75228 "3 SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION 1 (x5) PREFIX DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DATE I DEFICIENCY) Secretive behavior; A 144 Continued From page 16 A 144 0 Dramatic change in affect/mood; observed every 15 minutes. Prior to admission. Patient #4 reported he did not want to live any longer and wanted to commit suicide. The patient had used marijuana. Xanax. and "some other pill" within 24 hours prior to admission. Patient #4'5 Observation Checklist dated 10/09/17 re?ected Patient #4's suicide precautions. The observation rounds document was left blank for 1715. 1730. and 1745. Patient #B's Physician MOT Orders dated 09/3011 7. timed at 0032. re?ected admitting diagnoses that included Mood (Affective) Disorder. The patient was placed on suicide precautions to be staff observed every 15 minutes. Physician Orders dated 10/05/17 at 1235 re?ected the patient was placed on "Sexual Acting Out" precautions. Physician Progress Note dated 10/05/17. at 0830. re?ected Patient #6 displayed of sexual inappropriate behavior. Patient #B's Observation Checklist dated 10/09/17 re?ected the patient's precaution status for suicide and sexual acting out. The patient?s behavior and location were supposed to be documented every 15 minutes. The observation rounds document was left blank for 1715. 1730, and 1745. Patient #7's Physician's Preadmission Examination orders dated 10/05/17. at 1618. re?ected admitting diagnoses that included Major Depressive Disorder. Patient #7 was placed on 15-minute observation for suicide precaution. Physician Progress Note dated 10/09/17. at 1420. re?ected the patient was sad. withdrawn. and had increased depressive Patient #7's I Observation Checklist dated 10/09/17 re?ected and Circumstantial life changes, such as loss of a pet. family member, or girlfriend/boyfriend. The Interim DON covered all precautions, 11/10/17 including suicide precautions. in the retraining described above for RNs and MHTs on managing SAO precautions. The retraining also included maintaining appropriate observations and supervision of patients on precautions. and handing off rounds appropriately whenever a staff member doing observation rounds needs to leave the unit or perform a task that would . interfere with completion of rounds. Competency and understanding were I assessed via post-test and signed attestations. The Interim DON reviewed and con?rmed 11/10/17 that nursing orientation covers implementation. management. and observation/supervision of patients under any precautions. As described above. the Senior Leadership 11/10/17 Team created a map of the units and a newi process for reviewing all patients' room assignments each weekday morning in light of their precautions to con?rrn whether the room assignments are appropriate. This review takes into account whatever precautions have been ordered for each patient. Also as described above. to enhance the 11/10/17 ability to observe and monitor the milieu on .each unit. the Senior Leadership Team FORM Previous Versions Obsolete Event JXPJ11 Facility 311037 If continuation sheet Page 17 of 35 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 1110112017 FORM APPROVED CENTERS FOR MEDICARE 8. MEDICAID SERVICES OMB N0. 0938-0391 STATEMENT OF DEFICIENCIES PROVIDEFUSUPPLIERICLIA {x2} MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 454140 a. WING 1011912017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE TIMBERLAWN MENTAL HEALTH SYSTEM ?no BLVD DALLAS, TX 75228 (x4) .0 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER-S PLAN OF CORRECTION (x5) paenx (EACH DEFICIENCY MUST BE PRECEOED DY FULL I (EACH ACTION SHOULD BE COMPLETION TAG REGULATORY DR LSC IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE 1 DEFICIENCY) i A 144 Continued From page 17 1 the patient's suicide precautionary status. The observation rounds document was left blank for . 1715. 1730. and 1745. Patient Physician MOT Orders dated 09124717, timed at 0921. re?ected the patient was admitted with diagnoses including Major Depressive Disorder. He was placed on suicide precautions. Physician Orders dated 10705717. at 1400. required staff to Observe the patient for sexual acting out behavior. Physician Progress Note dated 10107117. at 1159, re?ected Patient statement that his "depression meds [medications] are not working expressing thoughts to harm self." Patient 119's Observation Checklist dated 10109117 reflected the patient?s precaution Status for suicide and sexual acting out behavior. The Observation rounds document was left blank for 1715, 1730, and 1745. Patient #1 0'3 Physician MOT Orders dated 10104117 at 1525 re?ected the patient's admitting diagnoses that included Major Depressive Disorder. The patient was placed on 15-minute staff Observations for suicide precautions. Physician Progress Notes dated 10709117. at 1219. re?ected the patient was anxious. His judgement and insight were "poor." Patient #10?5 Observation Checklist dated 10709117 re?ected the patient's precaution Status for suicide. The observation rounds document was left blank for 1715. 1730. and 1745. Patient #11's Physician MOT Orders dated 10705117 at 2244 re?ected the patient was admitted with diagnoses that included Major implemented the practice Of keeping the A 144 comer rooms in the units locked and not using them when census is low. When census on a unit increases to the point where the corner rooms need to be used, the unit will then be staffed with at least three nursing staff members to enable concurrent monitoring of the comer rooms and the day room. During the 120 days when Senior 11710117 Leadership Team members are monitoring observation rounds by accompanying nursing staff members on a set of Observations rounds, Senior Leadership Team members are evaluating the nursing staff performance with regard to whatever precautions apply to each patient and providing feedback and further education as indicated. The Interim DON provides results Of 11/10/17 rounding with nursing staff to the Morning Leadership Meeting each weekday and aggregated results to the Quality Council and Medical Executive Committee, and quarterly to the Governing Body. Responsibie Staff: Interim DON 3) ACTION EDUCATION: The Interim DON reviewed the Nursing 11106717 Orientation program and confirmed that new nursing staff members receive extensive training on policies and procedures for taking care Of patients with mental health and substance use disorder conditions. FORM OMS-256710239) Pravious Versions Obsoieta Event ID Faculty ID: 311037 "continuation sheet Page 10 of 35 PRINTED: 11l01l'2017 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE VIEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES Ixn PROVIDERISUPPLIERICLIA MULTIPLE CONSTRUCTION Ixai DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 454140 9- 1011912017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY. STATE. ZIP CODE asoo SAMUELL TIMBERLAWN MENTAL HEALTH SYSTEM TX 1, 5 2 2 8 {x4} .9 SUMMARY STATEMENT OF DEFICIENCIES In women PLAN OF CORRECTION :st mam (EACH DEFICIENCY MUST BE PRECEDED DY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAO CROSS-REFERENCED To THE APPROPRIATE WE I The lnterim DON enhanced the Nursing 11/06/17 A144 Continual From Page 18 A144 Orientation program to include age-Speci?c Depressive Disorder. He was placed on training related to adolescent growth and 15-minute Observational staff rounds for suicide. development. Physician Progress Note dated 10(07117, at 1056. re?ected Patient #11 had suicidal ideation. was The Interim DON provided age-speci?c 11110117 depressed. sad. ?at. worried. and was noted to training related to adolescent growth and have poor judgement and insight. The Daily development to all RNs and MHTS Nursing Flow Sheet dated 10108117, at 2015, assigned to the Adolescent Unit. re?ected the patient was isolative and did not Competency was assessed via post-test. interact with other patients. Patient #11's Observation Checklist dated 10109117 reflected MONITORING: the patient's precaution status for suicide. The observation rounds document was left blank for The HR Director is responsible for 11/10/17 1715. 1730. and 1745. reviewing 100% of new nursing staff members' training ?les at the completion of orientation to con?rm that any RN or MHT that may be assigned to the adolescent unit Patient #13 was hospital admitted on 10103117. at has completed training on adolescent 1922, according to the patient's Physician MOT growth and devempmem Aggregated Orders- Admitting diagnoses inducted Major results will be reported to the Depressive Disorder. Physician Progress Note Quauty Councn and quarterly to the dated 10707117, at 1055. re?ected the patient was Governing Body_ sad. ?at. and depressed. Her judgement and insight were physician noted to be "poor." Responsibre Staff: Interim DON Observation Checklist dated 10109717 re?ected the patient?s precaution status for suicide. Daily Nursing Flow Sheet dated 10i09717, at 1750. re?ected the patient was discharged. There was no documented evidence that staff observed the patient's behavior and location during the last 30 minutes prior to her discharge. The observation rounds document was left blank for 1715. 1730, and 1745. The rounds check timed at 1800 noted the patient's discharge. Patient #15" Physician MOT Orders dated 10:07117 at 1510 re?ected the patient was admitted with Major Depressive Disorder. He was I placed on suicide precautions with 15-minute FORM Previous Versions Obsolete Event ID JXPJ11 Fac?ity 10 311037 If continuation sheet Page 19 of 35 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8. MEDICAID SERVICES PRINTED: FORM APPROVED OMB NO. 0938-0391 staff observation rounds. Patient #15'5 Intake Assessment dated 10!07f17 at 1932 re?ected the patient witnessed violence and experienced family loss. He had been using hallucinogens, stimulants including cocaine and meth, marijuana. alcohol. and opiates for up to three years prior to his admission. Patient #15 had attempted to commit suicide "numerous" times since the age of 13. and methods included overdosing. suffocation. eating plastic or glass. slashing of throat. hanging. and access to at 1429 re?ected the patient was hearing voices and had suicidal ideation. He was noted to be anxious, and with poorjudgement and insight. Patient #15's Observation Checklist dated 10!09!1 7 re?ected the patient's precaution status for suicide. The observation rounds document was left blank for 1715, 1730. and 1745. Patient #17's Physician MOT Orders dated 10f05i17 at 0347 re?ected she was admitted with diagnoses that included Major Depressive Disorder. Patient was placed on suicide precautions with 15-minute staff observation rounds. Patient #17?5 Observation Checklist dated 1003?? re?ected the patient?s precaution status for suicide. The observation rounds document was left blank for 1715. 1730. and 1745. Patient #18'5 Physician's MOT Orders dated 10l07117 at 0527 re?ected admitting diagnoses that included Major Depressive Disorder. The patient was placed on detox and suicide precautions with 15-minute staff observation I rounds. Daily Nursing Flow Sheet dated 10l08117 ?rearms. Physician Progress Note dated 10(09117 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 0 454140 9* 1011912017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE TIMBERLAWN MENTAL HEALTH SYSTEM ?on SAMUELL BLVD DALLAS, TX 75228 (x4) [9 SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED av FULL PREFIX (EACH CORRECTIVE ACTION SHOULD as consumer; TAG REGULATORY OR LSC IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) I I I I I A144 Continued Frorn page 19 A 144 FORM Previous Obsolete Event Faculty ID 811037 If continuation sheet Page 20 of 35 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 1110172017 FORM APPROVED CENTERS FOR MEDICARE SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES ixn PROVIDEFUSUPPLIERICLIA ixzi MULTIPLE CONSTRUCTION ixai DATE AND PLAN OP CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 45414? We 1071912017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY. STATE. ZIP CODE TIMBERLAWN MENTAL HEALTH SYSTEM 4500 SAMUELL BLVD DALLAS. TX 75220 my ID SUMMARY STATEMENT OF DEFICIENCIES in PLAN OF CORRECTION (x5) PREHX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH ACTION SHOULD BE TAG REGULATORY on Lee IDENTIFYING INFORMATION) TAG CROSS-REPERENCED To THE APPROPRIATE WE A 144 Continued From page 20 A 144 at 1205 re?ected the patient did not have any medical problems. Daily Nursing Flow Sheet dated 10108?? at 1945 re?ected the patient had "super?cial and deep cuts over lower and upper extremities." Physician Progress Note dated 10I09717 at 1430 re?ected the patient minimized her says she is not depressed despite signi?cant self-harm Patient #18'5 Observation Checklist dated 10109717 re?ected the patient?s precaution status for suicide. The Observation rounds document was left blank for 1715. 1730. and 1745. On 10718717 at 1151 Personnel #5 was interviewed by telephone. Personnel #6 further reviewed the 10!09!17 Observation record and veri?ed the 1715. 1730 and 1745 rounds were not completed and left blank for Patients 2 and Personnel #15 acknowledged the above ?ndings on 10l191?17 at approximately 1130. The policy titled Patient ObservationlLevel of Observation dated 0372017 re?ected "level of observation will consist of monitoring every 15 on ?fteen minute checks can expect to be checked 3 minimum of every ?fteen minutes to maintain codes will be completed on all patients at each to ensure patient safety. as well as, to provide a process for observing and documenting patient location and observe patients when behind Closed doors on bedroom and bathroom that they are Stepping into the room for the door and visually observe the safety of the Charge NurseiNursing FORM Previous Versuons Obsolola Event ID.JXPJ11 Facility ID 311037 If continuation shoot Page 21 of 35 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED: 111011'2017 FORM APPROVED (X1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER. 4541 40 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING 0111359. 0933-0391 (X3) DATE SURVEY COMPLETED 1011912017 NAME OF PROVIDER OR SUPPLIER TIMBERLAWN MENTAL HEALTH SYSTEM STREET ADDRESS. CITY. STATE. ZIP CODE 4600 SAMUELL BLVD DALLAS, TX 75228 1X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING ID PLAN OF CORRECTION PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION one I A 144 Continued From page 21 SupervisoriTeam Leader before leaving an off the Patient Observation Rounds forms to person responsible for completing observations in your 3) Personnel #21 interviewed on the hospital's adolescent unit on 10118111 at 0600. and stated the night shift was staffed with one nurse and one MHT. Personnel #21 stated helshe had started to work the adolescent unit "last week" and denied . age speci?c training for the adolescent unit. Personnel #16 was asked by the surveyor to A 385 review Personnel #21?5 employee ?le during an interview on 10118117. at 1020. Personnel #16 denied that Personnel #21 had received training and demonstrated competence that target the speci?c developmental needs of the adolescent patient population. Personnel #16 reviewed ?ve additional employee ?les (Personnel #11. #17, #18. #10. and #19) during an interview on 10119117. at 1005. Personnel #16 stated the MHTs were assigned to work night shift on the adolescent unit. Personnel #16 denied that that the MHTs had training and demonstrated competence that targeted the speci?c developmental needs of the adolescent patient population 482.23 NURSING SERVICES The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or A144 A 335 A 335: Hospital leadership reviewed policies and processes. made changes, provided immediate and extensive training. and 11110117 FORM Previous Version: Obsolete Event JXPJ 11 Family ID 511037 If continuation sheet Page 22 01'35 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 11f01i?2017 supervised by a registered nurse. This CONDITION is not met as evidenced by: Based on interview and record review. the hospital failed to have an organized nursing service. Nursing failed to reassess and evaluate two of female patients (Patients #1 and after emotional disclosure of experiencing andlor observing sexually inappropriate behavior by their unit peers. Patient a 13 year old female made an outcry on 10109?? that Patient a 17 year old male. entered her room and had a sexual encounter with her on the evening of 10l08117. Patient #1 was not assessedlevaluated by the nurse after her outcry. Patient #2 made an outcry that she was having ?ashbacks of past sexual abuse after seeing peers being sexually inappropriate. No further nurse assessment/evaluation was found after the original outcry was made. Cross refer: A0395 Nursing failed to update and address physical andlor emotional needs of six of six patients' care plans (Patients #24. #25. and #15) for their mental and physical well-being. 1) Patient #1'3 past history of sexual abuse with interventionslgoals. 2} Patient #2'5 ?ashback from past sexual abuse cause by visualizing peers engage in sexually inappropriate behavior. FORM APPROVED CENTERS FOR MEDICARE 8. MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (x2) MULTIPLE cousmuc?rlou (x3; SURVEY AND PLAN or coenecnon IDENTIFICATION NUMBER. A BUILDING COMPLETED 454140 3- 10r1er2017 NAME OF PROVIDER on SUPPLIER STREET ADDRESS. CITY. ZIP CODE TIMBERLAWN MENTAL HEALTH SYSTEM mo BLVD DALLAS, TX 75228 (x4, .9 SUMMARY STATEMENT OF DEFICIENCIES In Pnovioee's PLAN OF (st paeplx (EACH DEFICIENCY MUST BE PRECEDED er FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION m3 REGULATORY on IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE DEFICIENCY) I -. . . - Implemented ongomg monitorlng to con?rm. A 335 Continued From page 22 A 385 staff?s understanding of procedures and compliance. For details. please see responses to A 395 and A 396. FORM Previous Obsolete Event ID 911037 If continuation sheet Page 23 of 35 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: FORM APPROVED CENTERS FOR MEDICARE 8. MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION Ixa) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING COMPLETED 454140 8- WING 1011 912017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE Tl BERLAWN MENTAL HEALTH SYSTEM ?00 SAMUELL BLVD DALLAS. TX 75228 1x4, .9 SUMMARY STATEMENT OF DEPICIENCIES ID PROVIDER-S PLAN OF CORRECTION (st PREFIX (EACH DEFICIENCY MUST BE PRECEDED eY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A 385 Continued From page 23 A 385 3) Patient #3'3 SAO-P (sexually acting out-perpetrator) precautions, 4) Patient #24'3 precautions. 5) Patient #25?5 inability to safely digest milk and dairy products without stomach ache. 6) Patient #15?5 lactose intolerance that caused nausea. vomiting, rash, and diarrhea. Cross refer: A0396 A 395 RN SUPERVISION OF NURSING A 395 CARE A registered nurse must supervise and evaluate A 395: the nursing care for each patient. ACTIONS EDUCATION: This STANDARD is not met as evidenced by: Based on interview and record review. the The Interim DON reviewed and af?rmed 11/05/17 hospital failed tO ensure 2 Of 2 patients (Patient that the policy ?Assessment and #1 and Patient were reassessed 30d!? Reassessment of Patients? correctly directs evaluated by a Registered Nurse. the RN staff on expectations for documentation Of assessments/reassessments following any 1) Patient #1 . a 13 year Old female. made and actua or a eged incident. outcry on 10(09117 that Patient a 17 year old ma"?3- entered her and had a semi" The Interim DON provided retraining to all 11l10/17 encounter with her on the evening of 10l08!17. Patient #1 made the outcry after Patient #3 was discharged. Patient #1 was not assessedlevaluated by the nurse after her outcry. 2) Patient #2 made an outcry that she was having ?ashbacks Of past sexual abuse after seeing peers being sexually inappropriate. No further nurse assessmentlevaluation was found after the RNs on assessment expectations as outlined in the policy with emphasis on: - Assessment Of patients for any actual or alleged incident - Reassessment, at least once and until issue is resolved, following any actual or alleged incident - Documentation of all assessments and reassessments Competency was assessed via post-test. FORM Versions Obsolete Event JXPJ11 Facility ID 81103: If continuation sheet Page 24 of 35 DEPARTMENT OF HEALTH AND HUMAN SERVICES s-rAvEuEm or panoramas Am putt or wnaecnort (XII PioleEflsUFPuER/cuA IDENYIFICMIDN <> :quesrmz mm oera swarm 0F (EACH DEFICIENCY Mus? a: pasoseepar FULL on IDENIIFVING A :55 Continued lett page 24 onglnal outcry was made included- Review 0! the hasptal Policy titled "Assessment and Reassessmanl n1 Patents" a tevlew date or uslzan reiterated "The Regulated Nurse will assess each patient at a rrurnnrunr every and rnere as deemed necessary, assessment will include the patients mental and physical be frequent assessments ot patients may be needed when the patient ts having a physical problem, change of RN assess the patient and document findings in a pmgless The Texas Board at (20w) noted nursing the observation' ewenllon. evaluation rehaoilrtetian, care and counsel, or health teachings ata patsm who is ill injured infirm or axpetianung a change In mrnral health prdcesses. cllca_m asp). 1) Pallem rtl-s Freadnrissiarr Dragnosttc Evaluation with Medtcal Services) dated 10/05/17' timed at 1515, rellected, "Pet intake. 13 year old was discharged weeks ag .parenls lound a noose made au sunderher ID ream rm reavtnses rust or cuiREcvlaN curtrtecnve ANION Sum/m as neossxerewertcsu to INEAWROPAIAYE MONITORING: A395 For a perlnd 0' at least Ihtee months or unli' 11/10/17 tull compliance is achieved the Interim 'DONldeslgnea is monitoring the records at patients involved in any actual or alleged 'incldenls |u verily there are nursing assessments and reassessment: i documented in the record. Results oi review are reported each weekday In the Morning Meeting and laggregated data is reported to the lauality Council and Medical Executive Committee and quarterly to the Governing Body. Any non-cumpliance is being addressed with additional training and/or disciplinary action as appropriate Responsible Staff: Inlarim DON it walnuaunn men yesmss PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE a. MEDICAID SERVICES OMB No. 9938-0391 smaaem or DEFICIENCIES w) wanna Ann run or common IDENYIFIDIVION tween A mum 45mm a min -- msz? slam wants: an. em: zll= conE <> sumlen nuaEnuwu HEALTH SVSYEPI IKAI ID airway sulEuENv or DEFIEIENCIES in memoirs me or wamnm anerrx aaemx m: neamony on Lee lemme lwoiwmom ms anossaerznencsm ms nerrerennvl A 395 Conllnued me page 25 A 395 fist ch Ia exually mm is presently lnweevaled tar molesting and abusing. "renter.QO ns suiciae . level or observation 015 minutes abused The 10Ml17 aatly nursing new street, timed etaenn' talented, 'Petient ts alen/arienled times is r-alnr amt compliant mitt medlcaliuns aml stult assessment ..dellias suicidal and homicidal Ihoughls. .ltallucrn one and in ..na issues at distress noted lime: The Mullidisuipllnary Nola dated remain at 1910 inflected nutilied nl "sexual allegations." "..,Hospilal was contacted ier an MOT (Memorandum aIYtansIer) and unlit--a. allieers amved at approximately 2000 to speak In the patlent Ninath rnlormea the patient net the natlent was about to he transletrea Hoepital and la meal Palice mere. Fauenlifl's tutu nulsing tnat he telused In allaw the patient In return to (nintrertawn) east the assessment at..ttoapital The patient was disdl rged against medical advice rnulti sci nary pmgrass nuts mad at 2100 lelleclud, 'This nurse met wiln police unicelwllu was leavlng In meet. at magnet and explained physicians uruera ands esponse..,palienl was "amplified yia.. Iraninon. alert/oriented tlmes 2245 stall mamber ealtea raulny..relusen In Sign, discharge paparwark., was teleasafl try I In parenrs cusIody." No nursing assenmanl ailne patient was duannamed alter Patient M's eulelyv row Plum- am am In mm View In it WMImallen mu pay. 2. 04 as PRINTED: 1110112017 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB N0. 0938-0391 STATEMENT OF DEFICIENCIES (X1) LIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION A. BUILDING COMPLETED 454140 Bo WING 10119I2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE TIMBERLAWN MENTAL HEALTH SYSTEM ?on SAMUELL BLVD DALLAS, TX 75228 (X4) SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE A 395 Continued From page 26 A 395 The Multidisciplinary Progress Note dated 10.113117 (late entry) for Monday 10109117 at approximately 1730 re?ected. "Patient came to (Personnel during dinner and reported that patient (Patient came into my room and touched he started kissing told him to stop but then he got on top of me and continued to kiss me not stop kissing me and kept telling me "you know you want it" he then took his pants off and then he took my pants off and my panties then patient got back on top of me and started kissing me he stuck his thing in me. then took it out and stuck it in again and we had else you want to but do you think I'm don't know but I'm going to make sure the nurses know your concerns and that you are safe and checked said ok. thank you." No patient assessment was found for Patient On at 1151. Personnel #6 was interviewed by telephone. Personnel #5 was asked to review Patient #1'5 medical record. Personnel #6 was asked to review the multidisciplinary note dated 10!13!17, late entry for 10109?? and the nursing note dated 1010917, timed at 1912 to 2245. Personnel #6 veri?ed a nursing note which addressed the nursing assessment of the patient after her outcry could not be found. 2) Patient #2's Precaution Noti?cation Alert dated 10105? 7 reflected, "Precaution ideation's with multiple I victimization..indicators history of FORM Previous Versions Obsolete Event ID JXPJ11 Facilin in 81103? If continuation sheet page 27 of 35 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 111013017 FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES 0MB NO. 0938-0391 STATEMENT OF DEFICIENCIES 1x11 PROVIDERISUPPLIERICLIA ixzi MULTIPLE CONSTRUCTION ixai DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING COMPLETED 454140 5- WING 10119i2017 NAME OF PROVIDER DR SUPPLIER TIMBERLAWN MENTAL HEALTH SYSTEM STREET ADDRESS. CITY. STATE. ZIP CODE 46110 SAMUELL BLVD DALLAS. TX 75223 {x4} .9 SUMMARY STATEMENT OF DEFICIENCIES io PROVIDERS PLAN OF CORRECTION (x5) pnenx (EACH DEFICIENCY MUST BE PRECEDED eY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION m; REGULATORY OR IDENTIFYING INFORMATION) TAG To THE APPROPRIATE WE DEFICIENCY) A 395 Continued From page 27 A 395 Of The Evaluation dated 10105117 timed at 1009 reflected. "Depressed. suicidal, is also dealing with rape by ex-boyfriend in The RN Admission Assessment dated 10106117 timed at 0220 re?ected. ?States She has been suicidal and She has been sexually abused several times by family and Close she really has been suppressing her feelings and now she feels she cannot go on The Assessment-Adolescent dated 10106117. timed at 1050, re?ected. "15 year old suicidal ideation has been there for about three thoughts of slitting throat or shooting December 2016 patient reports rape by molestation by patient was The 10107117 Multidisciplinary Progress Note. . timed at 2300, reflected, "Reports increased anxiety 10110 and increased past ?ash backs after I saw some kids sexually acting back memories about my sexual abuse time providing emotional 30 minutes to calm No further documentation or assessment was found in the medical record which addressed the flash backs the patient suffered related to past sexual abuse. 0n 10118117 at 1130 Personnel #6 was interviewed by telephone. Personnel #6 was asked to review Patient #25 medical record. The I 10107?? nursing note was reviewed by Personnel FORM Prayious Versions Obsolele Event ID.JXPJ11 311037 If continuation sheet Page 28 of 35 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 11f01l'2017 FORM APPROVED CENTERS FOR MEDICARE 8. VIEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES 1x1) Ixzi MULTIPLE CONSTRUCTION ixa) DATE AND PLAN OF CORRECTION IDENTIFICATION A. BUILDING COMPLETED 45414? 3- 10:1 9:201? NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE TIMBERLAWN MENTAL HEALTH SYSTEM ?on SAMUELL BLVD DALLAS. TX 75228 (x4, ID SUMMARY STATEMENT OF DEFICIENCIES Io PROVIDERS PLAN OF CORRECTION (st (EACH DEFICIENCY MUST BE PRECEDEO BY FULL CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR IDENTIFYING TAG CROSSREFERENCED TO THE APPROPRIATE WE DEFICIENCY) '1 . A 395 Continued From page 23 A 395 Personnel #6 veri?ed no follow-up assessment andlor further interventions were provided for the patient after she disclosed having ?ashbacks after witnessing peers being sexually inappropriate. A 396 NURSING CARE PLAN A 396 A 396: The hOSpital must ensure that the nursing staff ACTION EDUCATION: develops, and keeps current. a nursing care plan for each patient. The nursing care plan may be part of an interdisciplinary care plan This STANDARD is not met as evidenced by: Based on interview and record review, the hospital failed to ensure 6 of 6 patients' (Patients #2 #24, #25. #15) care plan was updated ahdfor addressed 1) Patient #1'5 past history of sexual abuse with interventionsigoals. 2) Patient #2'5 ?ashback from past sexual abuse cause by visualizing peers engage in sexually inappropriate behavior. 3) Patient #3'5 SAO-P (sexually acting out-perpetrator) precautions. 4) Patient #24'5 SAO-P precautions, 5) Patient #25'5 to safely digest milk and dairy products without stomach ache. 6) Patient #15'8 lactose intolerance that caused nausea. vomiting, rash, and diarrhea. Findings included: The Director of Clinical Services (DOS) 1 1/0211? reviewed and af?rmed that the policy "Treatment Planning? provides correct direction to staff on the expectation that all problems identified during the intake and admission assessments must be included in the patient?s treatment plan. They furtheri con?rmed that the policy re?ects the expectation that any issues that arise after admission are added to patients' treatment plans. The Interim DON and 008 provided retraining to all RNs and Social Services staff on the expectation for inclusion of all identi?ed probiems in the patient's treatment plan, including those medical problems identified after the patient's initial assessments. Competency was assessed via post-test. 11110117 MONITORING: For a period of 90 days. the DON and 008 11/10/17 are monitoring 100% of treatment plans following initial development and reviews to con?rm that all problems have been addressed in the treatment plan. Audit results are presented at the Morning I FORM Previous Obsolete Event ID JXPJ11 Fac my ID 311037 If continuation sheet Page 29 of 35 DEPARYMENI OF HEALTH AND HUMAN SERVICES PRINTE vol/2M1 FORMAPFROVED CENTERS FOR MEDICARE 1. Manama SERVICES OMB no, 093541391 srAvEMEm or uEFlclEMclEs le) my :oNslnucnoM my M15 swiva man>>. or wuaER A 3mm chPLEvEn l: mm a wa-- "mam" mm or Paovlbfin an sums>> eraser clrv, sum up cane IIMBERLAWN MENIAL HEALYN svel'em lmurs, 1x 7522: (mm summv sl'ArsMEm er H) mu rxar pwEle gem-2m as MECEHED av surr paw rem cmnsenye Acnml sHouLu as era-planar m; aseuurmm or red mermer rnronwrnum us canssaerzasudzn ro rue w: A 396 Conlinued Flam page 29 1) Pallenlxl'e Evaluallon/Managemenl lrmed 5(1515' reflected' Per intake. .13 yearald was from ma weeks ago parenls lound a nurse made uu| ole bell and shoe under her wha rs preaenlly incarceraled lor and ahuslng.. palienl suicide, pmhlem' lsurcrdal ldeallerl'sl plan lo hang heraell n! sll| her lhvuaL cul problem dangerlo sell ND ardnlenr was ldenhfizd addressed palrenrs sexual abuse and -- concerns The lnlerdrsuplinary Plan daled 10/07/17 reflected' problem llsLudepressmn, sulcldal mealion's, sell-harm The Psyolrasocral AssessmenlAddleseenl da|ed 10/07117Ilmed at owl) reflecled' "Fabem wrdre sul de nme" ahempled to hang hersell and cm hersell once adnnhed patianl had a period al normallry belween lu-ll years old. .sexually anAcMS-Zssilm-eslPl-mus Evalualron Medrdal Servlces) dared 10/05117, The 16/05/17 lnllial Treelmenl Plan da|ed ln/osm unlea a| 1735 revealed. menlrned aclrue Ever" rd mull Leaders Mee each weekday and A 395 aggregaled dale ls presenled lo me Quality Council and Medical Execulive and quanerly lo lhe Governing Bodyr Nan-compliance expeclalions is being addlessed adullronal relralning and/cl nrseiplrnery aellon es approprlale Staff: ln|erlm DON Mayra rreanrmuauaran..re . males DEPARTMENT OF HEALTH AND HUMAN SERVICES - AR MEDI AID SERVICES SYAYEMW or nemlencles lxu my mm or IDENHFIGAYION lumen mm was a? muvmm on rut-men nuasnuwu "sum svnzul smeuzm or lam wet as necenzu av FULL newnom on L5: lnEmvaluGlIFoMAmm A :96 Continued From page 30 abused l- on wusm at 1151 Peleennelwewae inlemawed by mlanhnne. Personnel #6 was asked In rel/law Patienm's medleal remrd. Persunnel we verified the medal lewd net addvess In: gatenrs hlslory e1 aexual vlc|im?anon Fenmnel as revewed lne inl|ial and master lreannent plan Fersonnet no vermod me dowmenle ned rm dueumenutlun Idemtred tne patients peel abuse and sexual mnmy concerns. 1) Pallenl uz-a Flecaullnn Nottficalinn Alan dated 10:05:17 renamed "Preceulmn idaatlan's multiple nlans.,.sexual nielary at elmm'ng The Evaluamn dated tales/17 "mad at 1009 lellecled. "nepraeaed. suladal, . palienl IS alea deallng rape by ex-boyhlend in 2016 The RN Admissan Aisassmarn deled lame/17 umed atozzn relleeted, "States she nae been euludal and she nae been sexually abused several mm by lamin and due rnenda.,.slatee she really nae been suepveaalng be! leellnge and new sne teels she cannot go on Ytle (ulna/17 lnilial Treatment Plan tuned to220 reflected "Suleldal ldeatmn, Depressian. The document which includes Interventions and goals not address pallenr: ment rape/mntestalinn. roam Fl-mu Vinny" 5mm 1le MULIIFLE A. a we smEEYmEss, cm, swE 2w cone unn semen. awn DALLAS, 01 75223 unmask: I'uw 0F cumumrt IEAEN coifiEcINE Amen 91mm: a: to DEAPMOPRIAYE lellv 1e mun PRINTED: mat/2m FORM APPROVED OMB No. 093 1 m) DAVE my met me :1 ms DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES PRINTED: 111'0112017 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES Ixn Ixzi MULTIPLE CONSTRUCTION Ixai DATE AND PLAN OF CORRECTION IDENTIFICATION COMPLETED A. BUILDING 45414" 1011912017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE TIMBERLAWN MENTAL HEALTH SYSTEM ?00 BLVD DALLAS. TX 75228 W) .0 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION {x5} (EACH DEFICIENCY MUST BE PRECEDED EY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSSREFERENCED TO THE APPROPRIATE WE DEFICIENCY) I I I I A 396 Continued From page 31 A 396 The 10IOTI17 Multidisciplinary Progress Note timed at 2300 re?ected. "Reports increased anxiety 10110 and increased past ?ash backs after I saw some kids sexually acting back memories about my sexual abuse time providing emotional 30 minutes to calm at in even and No further documentation or assessment was found in the medical record which addressed the ?ash backs the patient suffered related to past sexual abuse. No interventions andlor goals were found in the medical record. The Interdisciplinary Master Treatment Plan dated 10107117 re?ected. Mood. Danger to Self, Major Depressive The interventions and goals did not address the patients' recent rapelmolestation andlor recent event which involved ?ashbacks from seeing peers be sexually Inappropriate. On 10l18l17 at 1130 Personnel #6 was interviewed by telephone. Personnel #6 was asked to review Patient #2'5 medical record. Personnel #6 veri?ed the treatment plan did not address the ?ashbacks Patient #2 had after witnessing peers being sexuatly inappropriate. The care plan. treatment plan was not updated and did not address the event andior provide interventions and goals to address ?ashbacks of being rapedlmolested. 3) Patient #3'5 Physician's Certi?cate of Medical Examination for Mental Illness dated 10l02!17 FORM Previous Versions Obsolete Event ID. 31103? It continuation Sheet Page 32 of 35 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: FORM APPROVED CENTERS FOR MEDICARE VIEDICAID SERVICES 0MB NO. 0938-0391 STATEMENT OF DEFICIENCIES (xi) PROVIDERISUPPLIERICLIA (x21 MULTIPLE CONSTRUCTION ixa) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A BUILDING COMPLETED 454140 B. WING 10l1912017 NAME OF PROVIDER OR SUPPLIER TIHBERLAWN MENTAL HEALTH SYSTEM STREET ADDRESS. CITY. STATE. ZIP CODE 46110 SAMUELL BLVD DALLAS. TX 75223 re?ected. "The patient slashed his mom's tires, threatened to kill himself by cutting his wrists then threatened to kill his mom and and irritable mood. suicidal and homicidal ideation?s. poor insight and judgement." The Physician's Orders dated 10l07i17 timed at 2245 re?ected, "Place patient on SAO-P (sexually acting The Interdisciplinary Master Treatment Plan dated 10(0511 7 re?ected. "Unstable mood. suicidal ideation and homicidal No update which included interventions. goals was found regarding the sexually acting out precautions Patient #3 was placed on 10I07l17. 0n 10l18117 at 1206 Personnel #6 was interviewed by telephone. Personnel #6 was asked to review Patient #35 medical record. Personnel #6 veri?ed the patient was placed on sexually acting out precautions on 10!07!17 at 2245. Personnel #6 veri?ed the care planttreatment plan did not address the sexually acting out precautions ordered. 4) Patient #24'5 Physician Evaluation 1 dated 10!08!17 at 1500 reflected the patient?s diagnoses that included Major Depressive Disorder. Severe, with Physician's Orders dated 10113117 at 1435 re?ected the patient was placed on SAD-P. Multidisciplinary Progress Notes dated 10l13117. untimed, unsigned. unauthenticated. re?ected {x4} "3 SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (st pREplx DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION m3 REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE WE A 396 Continued From page 32 A 396 FORM Premus Obsolete Event ID 8?037 If continuation sheet Page 33 of 35 PRINTED: 11i'01l'201? DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE VIEDICAID SERVICES 0MB NO. 0933-0391 STATEMENT OF OEFICIENCIES 1X1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING COMPLETED 454140 3- WING 1011912017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY. STATE. ZIP CODE TIMBERLAWN MENTAL HEALTH SYSTEM 4600 SAMUELL BLVD DALLAS, TX 75223 "3 SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (X5) PREHX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 'l I A 396 Continued From page 33 A 396 "the therapist was informed during a family session with another patient #24] entered her room one night and that he might have kissed her or Personnel #7 was interviewed on 10118117 at 0817. Personnel #7 was asked to review the patient's care plan and stated the SAO-P precautions were not on Patient #24'5 treatment plan. Patient #24 was placed on SAO-P after a female patient reported that Patient #24 had entered her room and "kissed her or something." 5] Patient #25 was observed by the surveyor on the hospital?s adolescent unit day room on 10118117, at 0711. Patient #25 told the surveyor that her stomach hurt "every time" she drank milk or ate cheese. Patient #25 stated she had told a nurse about her stomach pain after eating cheese and "we eat a lot of cheese here." Personnel #24 stated on 10/18117, at 0715 that Patient #25 "hasn't said anything." Personnel #24 informed Patient #25 that changes in the patient's dietary regimen were made at that time. Patient #25'5 Nutrition Consult dated 10112?? at 1200 re?ected the patient had [secondary to] eating lots of Recommendations included for the "registered dietician to follow up per treatment team consultation pm [as needed]." Patient #25's Interdisciplinary Master Treatment Plan dated 10i14117 did not address Patient #25'5 milk or milk product intolerance without gastrointestinal discomfort. OHM Previous Versions Obsolete Event ID JXPJ11 Facility ID 011037 If continuation sheet Page 34 of 35 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE IMEDICAID SERVICES 0MB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) ixzi MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 10II1912017 454140 3- WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 4600 SAMUELL BLVD TX 75228 (x4) .0 SUMMARY STATEMENT OF DEFICIENCIES Io PLAN OF CORRECTION (st (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX i CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE WE TIMBERLAWN MENTAL HEALTH SYSTEM A 396 Continued From page 34 A 396 6) Patient #1 5'5 Intake Assessment dated 10I07i17 at 1932 re?ected the patient's allergies included lactose intolerance. Patient Physician MOT (Memorandum of Transfer) Orders dated at 2030 re?ected Patient #15 had "no known drug or food allergies." RN Admission Assessment dated 10101717 at 2045 reflected the patient was lactose intolerant and reacted with "nausea. vomiting, rash. and diarrhea." Patient #15'3 Master Treatment Plan Updated dated 101151?17 did not re?ect the patient's lactose intolerance. The document did not re?ect a nurse Signature. Personnel #6 acknowledged the above ?ndings during an interview on at approximately 1130. FORM PreYIouS Versions Obsolete Event ID JXPJ11 FacilIly 311037 Ii continuation sheet Page 35 of 35