Bhc Mesilla Valley Hospital, LLC

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 47480 Based on record review and interview, the facility failed to ensure that the parent or guardian was able to participate in the minor patient’s treatment plan/plan of care for 2 (P[patients] P1 and P4) of 11 (P1-P11) patients reviewed by not informing them of changes in health status, incidents, or issues on the unit. This deficient practice could result in a minor patient’s parent or guardian being unaware of changes in health status, incidents or issues on the unit during the minor patient’s hospitalization that are necessary to allow them to fully participate in the patients’ care planning process. The findings are: A. Record review of the facility’s policy and protocol titled “Communication & Discharge Planning by Discipline Protocol” revised 03/31/24, revealed, under the “Nursing” section “Contact parent/guardian/support if patient is having issues on unit (codes, illness, etc.). In addition, document any phone calls from parent/guardian/support in the record. Document this on the [facility initials] Nursing Notes.” B. Record review of P1’s medical record, the document “[facility initials] Nursing Notes,” dated 04/14/2024, incident time “1730” (5:30 pm), revealed “Altercation c [with] peer pt [patient] punched wall c [with] R [right] hand result in obvious deformity to wrist area EMS [emergency medical service] transport to [initials of outside hospital].” Further review of medical record revealed the record did not contain any documentation of parent or guardian notification of incident or transport to the outside hospital. C. Record review of the facility’s Incident Log dated 01/01/24 through present, revealed incident number 24-103000, involved P1, type of incident, “Non-suicidal Self Injurious Behavior” “Outcome: Fracture”, intervention/treatment “Emergency Room,” Incident date 04/14/2024 incident time “1630” [4:30 pm], the record did not contain any documentation that the parent or guardian was notified of the incident. D. Record review of P1’s medical record, the document titled “Treatment Plan Review-Inpatient”, dated 05/03/2024, time 9:30 am, revealed the record did not contain any references to the 04/14/2024 incident. P1’s parent signature box states “Participated via phone”; with the parent’s quote “I want him to reduce thoughts and behaviors of self-harm”. P1’s parent does not appear to be aware of the incident causing an injury to P1’s right hand. E. Record review of P4’s medical record, the document titled “[facility initials] Nursing Notes”, dated 04/28/24 time “2100” (9:00 pm), revealed “[name of P4] reported sexual inappropriate touch by [name of other child] three days in a role [sic]. Appropriate measures taken to address this issue and it was reported to Dr. [name of physician].” The record did not contain any documentation that the parent or guardian was notified of the incident. F. Record review of the facility’s Incident Log dated 01/01/24 through present, revealed an incident number 24-117046, involved P4, type of incident “Sexual Boundary Verbal/Physical Non-Aggressive Breach” “No injury” incident date “04/28/2024” incident time “2100” (9:00 pm): “Pt reported that [name of other child] has been ‘smacking him in the buttock 3 days in a row’. [They] said it started after some of the girls on the unit mentioned that [they] has a nice buttocks. It was reported to me by [name of employee] because [they] witnessed it.” The record did not contain any documentation that the parent or guardian was notified of the incident. G. Record review of P4’s medical record, the documents titled “Treatment Plan Review-Inpatient”, revealed a treatment plan dated 04/24/2024 wet signed by the parent; and a treatment plan dated 04/26/2024 verbally signed by the parent. There was no treatment plan update following the 04/28/2024 incident. The record did not contain any documentation that the parent or guardian was notified of the incident. P4 was discharged on 05/01/2024. H. During an interview with Staff (S)2 Facility Risk Manager, S2 confirmed that the parent or guardian should be notified of any changes in a minor patient’s condition, any incident or illness, and it should be documented in the nursing notes.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 49844 Based on interviews and record review the facility failed to ensure Licensed Registered Nurses are following the facility’s procedure for completing incident reports within the facility when there is a physical confrontation between patients for 1 (P [patient] 2) of 10 (P1-P10) patients reviewed for incident reporting. This deficient practice of Licensed Registered Nurses not completing the in-house facility incident reports led to a patient presenting to an outside hospital (facility #2) with injuries of unknown origin that could have been identified if a related incident report was completed by the Licensed Registered Nurse. A. Record review of the facility’s nursing procedure for incident reporting within the facility, titled Behavioral Health Risk Management dated 2020, under the section “When to complete an incident report” stated “physical confrontation between two patients”. B. Record review of P2’s medical record from facility #1 revealed that P2 was admitted on 02/06/24. Under the skin assessment on admission stated, “no findings.” A nursing note made on 02/06/24 at 10: 30 PM revealed P2 was in a physical confrontation with another patient. “Pt [patient] is hyper-active and does not follow instructions. He is getting into fights and arguments with other patients. . . he bit one of the patient’s finger [sic].” A document titled “Patient Observation Rounds” in the patients’ medical record revealed the patient was sent to an outside hospital (Facility #2) on 02/09/24 at 9:00 PM. C. Record review of facility #1’s incident log revealed that there was no incident report filed regarding the P2’s physical confrontation. D. Record review of the P2’s medical record from Facility #2, a hospital Emergency Room, under “Exam” on 2/10/24 at 6:44 AM, revealed that P2 presented with “ecchymosis [bruising] to bilateral orbits [both eyes], to torso [upper body trunk], back, hip and buttocks and lower extremities [sic].” E. During an interview with Staff (S)3, Registered Nurse, on 02/27/24 at 3:45 PM. S3 confirmed that an incident report should be completed and submitted by the registered nurse if there is any physical altercation between patients. When asked if one still needs to be done if there is no harm, S3 stated “any altercation that is physical requires an incident report.” F. During an interview with S1, CNO (Chief Nursing Officer) on 02/29/24 at 11:15 AM, S1 confirmed that there should have been an incident report completed and submitted on the physical altercation involving P2.”