HospitalInspections.org

Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for a patient's rights to a humane treatment environment that ensures protection from harm when,

a.) The air conditioning unit in the facility's Pediatric Unit seclusion rooms was not functioning, or placed out of use, placing any patients placed in the seclusion room at risk of heat cramps, heat exhaustion, and heat stroke.

b.) The facility's staff did not monitor and intervene when the pediatric boys were engaged in dangerous behaviors, placing the patients at risk of injury, and pain.

c.) The facility failed to obtain Physician's orders to place a patient (Patient #22) in seclusion, placing the patient at risk for an injury, or undue stress from an unauthorized confinement.


Cross refers to: A144, A168

Based on observation, interview, and record review, the facility failed to protect a patient's right to a humane treatment environment that ensures protection from harm, when,

a.) The facility staff placed a patient (Patient #22) in the Boy's Pediatric seclusion room when temperatures were 93F (degrees Fahrenheit) to 94F; the room's air conditioning was not functioning, and the room had not been blocked from use. This failure places patients being placed in the seclusion room at risk of heat cramps, heat exhaustion, and heat stroke.

b.) The facility staffs were not monitoring the patients to ensure their safety. This places patients at risk for injuries and possible elopement opportunities.

Findings include:

a.) Review of the facility provided policy, PATIENT RIGHTS AND RESPONSIBILITIES (revised 4/24/2024) reflected, "Perimeter Healthcare's policy is to preserve the patient's basic human rights during hospitalization, and that the patient's behavior... Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation."

An observation made during a tour of the Pediatric Unit along with the Staff #1, Quality and Risk Director on 6/26/24 at 1:50 pm revealed, a closed locked door that led to the seclusion room suite; the suite had an anti-room with a chair and a bathroom connected to the area. There were three locked doors, each had a long window, used to observed into the room. The rooms had no furnishings, only a high frosted-out window. The back walls were shared with the building's exterior wall, which was subjected to the outside temperatures. The seclusion rooms were unlocked, and the survey team entered the rooms, the rooms felt uncomfortably warm as did the anti-room. There was no signage showing the rooms were closed for repair. The isolation room temperature panel, behind the nurse's station, did not display the room temperature.

On 6/26/24 at 2:00 pm, Staff #3, Director of EOC (Environment of Care), was asked to take the temperature of the isolation room. Using the facility's infrared thermometer, the room to the far left registered 95 F (degrees Fahrenheit), the middle room registered 96 F, and the room to the far right registered 96 F.

During an interview on the afternoon of 6/26/24, on the pediatric unit, when asked if the nurse on duty was aware the air conditioning was not working in the seclusion room, Staff #7, RN stated, "No." When asked for any patients that had been placed in the Isolation room, Staff #7 provided Patient #22, a 7-year-old-male's, seclusion/Restraint record.

Review of the Seclusion Packet dated 6/25/24 reflected, Patient #22 was placed into the Seclusion room three times:
12:05 pm to 12:25 pm (20 minutes),
12:30 pm to 12:40 pm (10 minutes),
3:20 pm to 3:45 pm (25 minutes).

Review of, https://www.wunderground.com, reflected the temperatures for Arlington, TX on 6/25/24 from 1:00pm to 3:00 pm were 93F (degrees Fahrenheit) to 94F.

During a telephone interview on 07/02/2024, when asked about placing Patient #22 in the seclusion room on 6/25/24, Staff #8, RN, the nurse that determined Patient #22's placement into seclusion, stated, "We didn't keep him in the room too long, because the room was too warm. I notified the house supervisor."

When asked if she looked at or used the temperature gauge, located behind the nurse station, used to indict the seclusion room's temperature, before placing a patient in the room, Staff #8, RN stated, "No."

During an interview on the morning of 6/27/24, Staff #3, Director of EOC stated that he wanted to clarify what he told us yesterday. He stated yesterday that he had told us that the house supervisor reported the seclusion rooms being hot. He clarified that it was a therapist that told him their office was hot. Staff #3 confirmed the therapist office is close to the seclusions room where the AC was not working. The AC repairman was not here for the seclusion room; it was warm in the Therapist's office, that is why I called them out. I wasn't informed about the seclusion room.
- When asked about the process for implementing a repair order and communication with the nursing department, Staff #3 stated in part, "Historically, really no process on how to submit an order. The staff will sometimes just tell me when something is needing repair. It's been a
- When asked how he prioritizes the repair requests? Staff #3 stated, "High, would be a Life Safety issue, something like a Fire extinguisher that got released.
Medium, would be like a ligature issue, or a hole in a wall with sharp cutting edges exposed.
Low, would be a regulatory issue." Staff #3 confirmed the broken air conditioning had not be placed into the maintenance repair log.
- When asked if the items needing to be repaired are reviewed by the Quality/Risk Director to determine the impact on the patient care? Staff #3 stated, "Not necessarily."
- When asked if there was a process for informing staff when equipment or a patient care area is not usable? Staff #3 stated a sign is placed to inform them. We also discuss it at the morning huddles. Staff #3 stated he was new at the facility and was not aware that the broken AC was connected to the seclusion rooms.
- When asked what time was the broken AC reported on 6/25/24? Staff #3 was unable to provide a time of the notification, he did not record it in the maintenance repair logs.


Review of the 6/26/24 huddle did not reflect a mention of the seclusion room being removed from service and patient use.

b.) An observation on the morning of 6/27/24, on the facility's pediatric unit along with Staff #1, Quality Director revealed, four adolescent boys running past Staff#2, MHT, (mental health technician); the staff member did not stop the children from the activity. The surveyor observed Staff #2, MHT, watching a children's program on the television. The children continued to chase each other and nearly ran into the surveyor. The adolescent boys were chasing the leader of the boys around the room, until the leader jumped onto an approximately four-foot-high counter. The mental health technician did not turn to observe the children or intervene in this dangerous activity; he remained focused on the television. When this event was brought to the facility's Quality Director's attention, he interjected and instructed the staff to start a structured program.

Review of the facility provided Observation Rounds Policy, revised 2/20/24 reflected,
"1. POLICY:
An accurate record of the whereabouts and behavior of all patients will be maintained during each shift.
2. PROCEDURE:
A. An assigned staff member will have a list of all patients according to name and room number-, each shift.
B. Every patient must be seen by a staff member at a minimum of every fifteen-minutes.
C. A staff member will be assigned by the Nurse each shift to be responsible for the Patient
Observation Record.
D. The Nurse will be notified, and unit search done immediately for any patient not accounted for.
E. If patient cannot be located, institute Elopement policy and procedure.6. Document patient location and behavior when the observation occurs on the patient observation form ...

7. While monitoring hallways and patient care areas ensure patients are:
o Not entering rooms not assigned to them
o Not in rooms or areas that are designated "off limits· areas lo patients
o Not left in "treatment Areas" without direct staff supervision."

During an interview, on the morning of 6/27/24, on the boy's pediatric unit, Staff #1, Quality Director was witness to the mental health technician's not monitoring the patient activity and stated, "They must have just completed a program."

Based on interview, and record review, the facility failed to protect a patient's right to a humane treatment environment that ensures protection from harm, when the facility failed to obtain a physician's order for the restraint and seclusion of a patient on three separate occasions. (Patient #22). This failure places patients being placed in restraints or seclusion at risk of an injury, or undue stress from an unauthorized confinement.

Findings include:

Review of the facility provided policy EMERGENCY BEHAVIORAL INTERVENTIONS:
USE OF RESTRAINT/SECLUSION (EFFECTIVE: 7/17/19) reflected, "It is the policy of Perimeter Healthcare to create an environment that protects the patient's health and safety and preserves his or her dignity, rights and well-being. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others ...
11. Staff members must avoid causing undue physical discomfort and must not cause harm or pain to the individual when initiating or using restraint or seclusion ....
PHYSICIAN ORDER
1. A physician order from a member of the Hospital's medical staff is required for restraint or seclusion use as an emergency behavior management technique at Perimeter Healthcare. The physician's order for restraint or seclusion must:
A. Designate the specific intervention and procedures authorized, including any specific measures for ensuring the individual's safety, health, and well-being;
B. Specify the date, time of day, and maximum length of time the intervention and procedures may be used;
C. Describe the specific behaviors which constituted the emergency which resulted in the need for restraint or seclusion;
D. Describe the specific release behaviors that the individual must demonstrate before the restraint or seclusion will be discontinued; and
E. Be signed, timed, and dated by the physician or the registered nurse who accepted the prescribing physician's telephone order.
2. Because use of restraint and seclusion is limited to behavioral emergencies, and the physician may not be immediately available, a registered nurse (RN) is authorized by Perimeter Healthcare to assess the situation and initiate restraint or seclusion necessary for the safety of the patient and/or others.
A. The order from the physician must be obtained no longer than one (1) hour after the initiation of seclusion or restraint.
3. If restraint or seclusion was ordered by telephone, the ordering physician must personally sign, time, and date the telephone order within 2 days of the time the order was originally issued.
4. If the physician who ordered the intervention is not the attending physician, the physician ordering the intervention must consult with the attending physician or physician designee as soon as possible. The physician who ordered the intervention must document the consultation in the individual's medical record.
5. PRN or standing orders for seclusion or restraint are not acceptable or allowed.

Review of Patient #22's SECLUSION/ RESTRAINT & EMERGENY MEDICATION PACKET dated 6/25/24 reflected, "Complete Order (Completed by initiating nurse)
Physical Restraint, Seclusion, & Emergency Medication must have an order from a physician."

Review of Patient #22's seclusion/Restraint record dated 6/25/24 reflected the following placement times into the Seclusion room:
12:05 pm to 12:25 pm, 12:30 pm to 12:40 pm, and 3:20 pm to 3:45 pm.
The three placement times were documented on one form. The medical record review did not indicate a physician's order for the three placements into seclusion.


During an interview, on the morning of 6/26/24, Staff #1, Quality and Risk Director, confirmed there was no physician's order for patient #22's three placements into seclusion and that each time the patient is placed in seclusion, the staff are required to complete a new packet including a new order for the seclusion placement.