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Based on observation of video surveillance, record reviews and interviews, it was determined the facility failed to ensure specific patient rights were protected and promoted in accordance with the facility's restraint policies and procedures during the implementation of restraints used for the management of behaviors for 5 of 7 patients (Patient's #1, #2, #3, #4 and #7) reviewed with a patient rights violation complaint.

Specifically, the facility failed to:

1.) Ensure physical restraints were implemented in accordance with safe and appropriate restraint techniques as determined by the hospital's restraint policy; and in accordance with State law during the implementation of restraints when used for the management of behavior for Patient's #2, #3 and #4 when they were physically held in a restraint on the floor in a prone position which could result in positional asphyxia;

2.) Ensure the use of restraint was in accordance with an order of a physician or other licensed independent practitioner who was responsible for the care of the patient and authorized to order a restraint in accordance with hospital policy and State law for Patient's #1, #2, and #3 when they were physically held in restraint without a physician's order; and

3.) Ensure a face-to-face assessment was conducted within 1-hour after the initiation of a restraint, seclusion or administration of medication used for the management of violent or self-destructive behaviors; and in accordance with the facility's policies for Patient's #1, #3, and #7.

These deficient practices could compromise patient safety for all patients in the facility.

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Patient Rights.

Refer to tags A 0167, A 0168, and A 0178 for evidence of specific findings.

Based on observation of facility video surveillance, record reviews, and interviews, it was determined the facility failed to ensure physical restraints were implemented in accordance with safe and appropriate restraint techniques as determined by the hospital's restraint policy; and in accordance with State law during the implementation of restraints when used for the management of behavior for 3 of 7 patients (Patient's #2, #3 and #4) reviewed for restraints.

Specifically, Patient's #2, #3 and #4 were physically held in a restraint on the floor in a prone position which could result in positional asphyxia, which occurs when a person's body position prevents them from breathing normally.

Findings included:

Review of Complaint Intake TX00517608, received 9/24/2024, alleged patients are often restrained on the floor, and in prone position even though the facility does not train its staff on floor restraints. Further review of the complaint indicated that according to video that had been reviewed, the video footage showed that on 8/25/24 at 4:15 PM, Patient #2 was taken down into a physical restraint on the ground with a male staff member positioned on top of Patient #2, who was lying face down.

Observation review on 10/17/24 at 1:00 PM of the 2 minute and 59 seconds video provided from the facility titled, 20240918 BVBH Camera 026, for Patient #3's physical restraint on 9/18/24 at 8:17 PM revealed the following:
At 34 seconds into the video, Patient #3 is taken down to the floor in a physical restraint by Mental Health Tech (MHT) - B in a prone position with MHT- B positioned on top of Patient #3. Other staff are seen walking by, and not assisting with the restraint. At the 1:21 minute mark of the video, Patient #3 attempts to get up and MHT- B continues to struggle to keep a physical hold of her. Another MHT- C comes to assist with the physical hold and then both MHT - B and C are seen holding down Patient #3 in a prone position. At the 2:37 minute mark, she is assisted up and then goes into her room.

During an interview on 9/30/24 at 6:09 PM with Patient #2 who was asked about physical hold restraints and stated that she had one restraint by Mental Health Tech (MHT)- A (on 8/25/24 at 16:15) that made her feel uncomfortable. Patient #2 stated that MHT-A took me down to the ground by himself and laid on top of her, putting his leg "super high" in between her legs making her feel unsafe and triggered by her past trauma. Patient #2 stated she was face down (in prone position) during the restraint by MHT-A.

During an interview on 9/30/24 at 6:25 PM with Patient #4 who was asked about physical hold restraints stated she had "only one bad one" (date unknown) when she was restrained "'face down, and they're not supposed to be restraining me face down like that and pulling my arms upwards and I couldn't breathe."

During an interview on 9/30/24 at 10:11 AM with Registered Nurse (RN)-A stated that personal hold restraints that are done on the floor are to be "side laying" on the floor. RN-A stated that staff get "very little" training regarding floor restraints.

During an interview on 9/30/24 at 11:45 AM with the House Supervisor RN/CPI (Crisis Prevention Institute) trainer stated the following: There is very little physical restraint taught with CPI and nothing about taking a patient to the ground to restrain a patient. The restraint on the ground only happens if the patient is on the floor already or goes to the floor on their own, not staff taking them intentionally to the ground. Our facility teaches child hold with two-person restraint and escort techniques.

During an interview with the Director of Nursing (DON) on 10/17/24 at 1:37 PM stated staff are not supposed to restrain patients in a prone position.

Review of the facility's Patient Restraint Policy, last revised 12/2023 stated the following, in part:
Safe Application: Staff will be trained and able to demonstrate competency in the safe application of all types of restraint and seclusion used in this facility, including training to recognize and respond to signs of physical and psychological distress.

Review of the CPI Nonviolent Crisis Intervention Training Participant Workbook, 2nd edition, 2020 indicated in part, on page 68, Positional Asphyxia and Restraint Position; that a relatively small number of restraint-related deaths reported are perceived to have occurred as a result of positional asphyxia. This had led to organizations advocating the unhelpful and largely unsupported view that prone restraint is the main risk and therefore should be abolished in favor of alternative positions which are perceived as less harmful. The principles of holding patients only included holding in a seated position, holding in a standing position, and holding in a standing position, "team control position." The CPI training did not include training on floor restraints.

Review of Texas Administrative Code, Title 25 Chapter 415.255 (b) A prone or supine hold shall not be used during a personal restraint. Should an individual become prone or supine during a restraint, then any staff member involved in administering the restraint shall immediately transition the individual to a side lying or other appropriate position.

Based on record review of documentation and interview, the facility failed to ensure the use of restraint was in accordance with an order of a physician or other licensed independent practitioner who was responsible for the care of the patient and authorized to order a restraint in accordance with hospital policy and State law for 3 of 7 Patient's (Patient's #1, #2, and #3) reviewed for restraints.

Specifically,

Patient #2 was physically restrained on 8/25/24, released from the physical restraint and then re-restrained without obtaining a new physician order for restraint;

Patient #1 was physically held on 8/22/24 for the administration of emergency medications without obtaining a physician order for restraint; and

Patient #3 was physically held on 8/21/24 without obtaining a physician order for restraint.

Findings included:

1.) Review of Compliant Intake TX00517608 dated 9/24/24 indicated that Patient #2 was physically restrained on 8/25/24, released from the physical restraint and then re-restrained without obtaining a new physician order for restraint.

Review of Nursing Note on 8/25/24 at 5:45 PM by Registered Nurse (RN)-A documents Patient #2 kicking the wall, breaking the sheetrock, making a large hole in the wall. Patient #2 became physically aggressive with Mental Health Tech (MHT)- A as they attempted to redirect her away from the area and was restrained. "She was released but began to do the same behaviors and was restrained and then taken to seclusion."

Review of Patient #2's physician orders for physical restraints on 8/25/24 revealed only one physical hold restraint order at 4:15 PM.

During an interview on 10/17/24 at 3:19 PM with the Director of Nursing (DON) confirmed there was not a second and/or new physician order for Patient #2 when she was re-restrained after being released from the first restraint that was initiated at 4:15 PM.

2.) Review of nurses note dated 8/22/24 at 6:42 PM stated that Patient #1 went to her room and slammed the door. Patient #1 began kicking the door from the inside of the room. Patient #1 then began banging her head. Patient #1 then gritted her teeth and balled up her fists in a threatening manner. She was asked to walk to exclusion room but refused. The staff then escorted her to seclusion room where at the door she was placed on side lateral position for injections (Intramuscular) IM ordered by the doctor. The staff released her, and she remained in seclusion until she calmed down.

Review of Patient #1's physician orders for physical restraints on 8/22/24 revealed there was not a physical hold restraint order when Patient #1 was placed on side lateral position and administered IM emergency medications on 8/22/24 at 5:17 PM.

During an interview on 10/18/24 at 10:35 AM, the Nurse Manager confirmed there was not a physician's order in Patient #1's record for the physical hold on 8/22/24 when Patient #1 was held and administered IM emergency medications.

3.) Review of Complaint Intake TX00517608 dated 9/24/24 indicated that according to video footage that was reviewed; on 8/21/24 at 10:58 AM, two staff members yank Patient #3 off the floor and drag her to the seclusion room, in what is not an approved restraint.

Review of Patient #3's physician orders for 8/21/24 revealed there was only a physician's order for seclusion at 10:55 AM. There was not a physician's order dated 8/21/24 for a physical restraint that was seen on the video footage at 10:58 AM.

During an interview on 10/17/24 at 2:35 PM with the Nurse Manager confirmed there was not a physician's order for a physical restraint for Patient #3 on 8/21/24.

Review of the facility's Patient Restraint Policy, last revised 12/2023 stated the following, in part:
5. Order for Restraint or Seclusion
a. An order for restraint or seclusion must be obtained from a physician or other licensed practitioner who is acting within their State Scope of Practice, authorized by State law as having authority for ordering restraints, and is responsible for the care of the patient prior to the application of restraint or seclusion.
2. If a patient was recently released from restraint or seclusion, and exhibits behavior that can only be handled through the reapplication of restraint or seclusion, new order is required.

Review of Texas Administrative Code, Title 25 Chapter 415.260(b)(1)(C)
(b) Physician's order. Only a physician member of the facility's medical staff may order restraint or seclusion.
(1) The physician's order for restraint or seclusion shall:
(C) describe the specific behaviors which constituted the behavioral emergency which resulted in the need for restraint or seclusion;

Based on record review of the facility documentation and staff interviews, the facility failed to ensure a face-to-face assessment was conducted within 1-hour after the initiation of a restraint, seclusion or administration of medication used for the management of violent or self-destructive behaviors; and in accordance with the facility's policies for 3 of 7 patients reviewed (Patient #1, #3, and #7) for restraints.

Findings included:

1.) Patient #1
A sampled record review of Patient #1's restraints, seclusion and emergency medications used for the management of violent or self-destructive behaviors revealed the following:

a.) On 8/25/24, Patient #1's electronic Medication Administration Report (eMAR) documented;
-Ativan 2 milligrams (mg) Injection (INJ) administered at 11:12 AM,
-Haloperidol Lactate 5mg/1 milliliter (ml) INJ at 11:12 AM,
-Diphenhydramine HCL 50mg/1ml INJ (25mg) administered at 11:12 AM, and
-Diphenhydramine HCL 50mg/1mg INJ administered at 11:22 AM for emergency management of behaviors.

Further review of Patient #1's record revealed there was not a face-to-face assessment conducted within 1-hour after the administration of medication used on 8/25/24 at 11:12 AM and 11:22 AM for the management of behaviors.

Review of the Restraint Documentation for Patient #1 on 8/25/24 revealed a physical restraint at 11:08 AM.

Patient #1's record revealed there was not a face-to-face assessment conducted on 8/25/24 within 1-hour after the initiation of a physical restraint implemented for the management of behaviors.

Review of the Seclusion Documentation for Patient #1 on 8/25/24 revealed she was in seclusion from 11:08 AM to 12:45 PM.

Patient #1's record revealed there was not a face-to-face assessment conducted on 8/25/24 within 1-hour after the initiation of seclusion implemented for the management of behaviors.

During an interview on 10/18/24 at 10:38 AM with the Nurse Manager confirmed there were not any face-to-face assessments completed for Patient #1 on 8/25/24 within 1 hour after the initiation of a restraint, seclusion and administration of medication used for the management of violent or self-destructive behaviors. The Nurse Manager further stated he did not understand why the electronic health record (EHR) did not have a hard stop built in that would require the documentation of the face-to-face assessments after a restraint, seclusion and/or emergency medications administered.

b.) On 8/22/24, Patient #1's eMAR documented at 5:24 PM for Thorazine INJ 50mg IM, Administered at 5:17 PM for emergency management of behaviors.

Further review of Patient #1's record revealed there was not a face-to-face assessment conducted within 1-hour after the administration of medication used on 8/22/24 at 5:17 PM for the management of behaviors.

During an interview on 10/18/24 at 10:33 AM with the Nurse Manager confirmed there was not a face-to-face assessment completed for Patient #1 on 8/22/24 within 1 hour after the administration of medication used for the management of behaviors.

Review of the Seclusion Documentation for Patient #1 on 8/22/24 revealed she was in seclusion from 5:15 PM to 7:05 PM. Review of Patient #1's record documented a face-to-face assessment completed by Registered Nurse (RN) - B at 5:15 PM; the exact time of the implementation of seclusion and not after the initiation of the intervention to assess the patient's reaction to the intervention.

c.) On 7/21/24, Patient #1's eMAR documented the following administered emergency medications to Patient #1 for the management of behaviors without evidence of a face-to-face assessment conducted within 1 hour of administration.
-Benadryl 25mg (50mg) at 4:22 PM
-Haldol 5mg at 4:22 PM
-Ativan 1mg (2mg) at 4:22 PM
-Thorazine 50mg INJ at 6:56 PM
-Benadryl 50mg INJ at 6:56 PM

During an interview on 10/18/24 at 10:20 AM with the Nurse Manager confirmed Patient #1's was administered the above emergency medications without evidence that a face-to-face assessment was conducted within 1 hour of administration.

2.) Patient #3

Review of Complaint Intake TX00517608 indicated that according to video footage reviewed; on 8/21/24 at 10:58 AM, two staff members yank Patient #3 off the floor and drag her to the seclusion room, in what is not an approved restraint.

Further review of Patient #3's record revealed there was not a face-to-face assessment conducted within 1-hour after the physical hold restraint on 8/21/24 at 10:58 AM; used for the management of behaviors.

Review of Patient #3's Seclusion documentation revealed on 8/21/24 seclusion was initiated at 10:55 AM and discontinued at 11:40 AM. Review of Patient #1's record documented a face-to-face assessment completed by Registered Nurse (RN) - B at 10:55 AM; the exact time of the implementation of seclusion and not after the initiation of the intervention to assess the patient's reaction to the intervention.

On 8/21/24, Patient #3's eMAR documented at 11:13 AM Olanzapine (Zyprexa) 10mg/vial was administered IM for emergency management of behaviors.

Further review of Patient #3's record revealed there was not a face-to-face assessment conducted within 1-hour after the administration of medication used on 8/21/24 at 11:13 AM for the management of behaviors.

During an interview on 10/17/24 at 2:40 PM with the Director of Nursing (DON) confirmed Patient #3 did not have a face-to-face assessment for the physical restraint and did not have a face-to-face assessment after the administration of emergency medications.

3.) Patient #7

Review of the Restraint Documentation for Patient #7 on 9/13/24 revealed a physical restraint at 8:10 AM.

Review of Patient #7's record documented a face-to-face assessment completed on 9/13/24 at 8:10 AM; the exact time of the implementation of the physical restraint, and not after the initiation of the intervention to assess the patient's reaction to the intervention.

During an interview on 10/17/24 at 2:48 PM with RN-B stated she was trained to conduct the face to face assessment "at the same time" of the intervention.

Review of the facility's Patient Restraint Policy, last revised 12/2023 stated the following, in part:

11. Face-to-face assessment by a Physician or Licensed Practitioner: A face-to-face assessment by a physician, licensed practitioner, RN or physician assistant with demonstrated competence, must be done within one hour of restraint or seclusion initiation or administration of medication to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others.

The purpose of the one hour face-to-face evaluation is to complete a comprehensive review of the patient's condition and determine if other factors such as drug or medication interactions, electrolyte imbalances, hypoxia, sepsis, etc., are contributing to the patient's violent or self-destructive behavior.

Review of the facility's policy titled Emergency Administration of Psychoactive Medications in a Psychiatric Emergency without Patient Consent, last revised 12/2023 indicated the following, in part;

6. Within 1 hour post administration, a face to face assessment will be conducted and documented in medical record by a provider or an RN specifically trained on the following:
a. Evaluation of the patient's immediate situation,
b. The patient's reaction to the intervention,
c. The patient's medical and behavioral condition and the need to continue or terminate the restraint or seclusion.