HospitalInspections.org

Based on a review of documentation, interview and observation through facility's video surveillance, the facility failed to provide a safe setting.

Findings included:

A review of the facility policy Rights of Voluntary Patients Seeking Discharge states in part:
"Basic Right for All Patients ... 3. You have the right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs, and are treated with respect and dignity."
Facility document titled "Seclusion and Restraint" stated in part,
" ...Policy Use of restraint and seclusion is initiated only as an intervention of last resort in an emergency situation where a patient is in imminent danger of causing harm to self or others and all other less restrictive or invasive measures have been attempted and failed.
General Principles: ...
17. Staff members must respect and preserve the rights of an individual during restraint or seclusion.
18. Staff members must provide a protected, private, and observable environment that safeguards the personal dignity and well-
being of an individual placed in restraint or seclusion.
19. Staff members must avoid causing undue physical discomfort and must not cause harm or pain to the individual when initiation
or using restraint or seclusion.
20. Staff members may use only the minimal amount of physical force that is reasonable and necessary to implement restraint or
seclusion".

A video timeline was documented by Staff #1 Risk Manager on 2/27/2019 and revealed,
"2/22/19 2:58:48 Staff #5, Staff #6, and Staff #7 attempt to escort Patient #1 from her room to the seclusion room. Staff #5 is seen standing behind Patient #1 with his arms under her arms attempting to walk the patient to the seclusion room. Patient #1 lays down in the hallway. The three staff members attempt to get Patient #1 up and moving toward the seclusion room but Patient #1 refuses to stand. This struggle continues until 3:00:41.
3:00:41 Staff #5 grabs Patient #1's wrists and starts to drag her to the seclusion room.
3:01:00 Staff are able to get Patient #1 into the seclusion room, shut, and lock the door.
Patient #1 stands at the door in the seclusion room banging/picking at the window until 04:23 at which point she sits down.
4:54:20 Patient #1 is released from the seclusion"

The above findings were confirmed in an interview with Staff #1 the Risk Manager.

Based on a review of documentation, interview and observation through facility's video surveillance, the facility failed to ensure that all patients were free from abuse.

Finding included:
A review of the facility policy Abuse Neglect Allegations: Reporting, Response, Investigation, stated in part, "Policy: Austin Oaks respects the rights of individuals to receive treatment, care and services that protect the rights of individuals served and promotes the human dignity of the individual and the support system of that individual. All allegations of abuse, neglect or rights violations will be investigated, corrected and reported ... Response to Allegations a. Upon becoming aware of an allegation and depending on the nature of the allegations, the CNO shall take immediate action to safe guard patient .... Procedures ... C. Response to allegations or witnessed event a. Upon becoming aware of an allegation and depending on the nature of the allegation, the CNO shall take immediate action to safeguard patient in the event of an allegation or witnessed event involving staff, the indicated staff shall be removed from access to patients, to include temporary re-assignment or suspension as indicated."

A review of the "Employee Corrective Action Report" revealed the following:

Incident: "During review of incident due to patient complaint, it was witnessed that Staff #5 used improper restraint technique resulting in patient harm."
History of Corrective Action: Has employee Been Previously Counseled or Disciplined for Same/Similar Reason, "NO"

Incident: "During review of incident due to patient complaint, it was witnessed that Staff #6 used improper restraint technique resulting in patient harm."
History of Corrective Action: Has employee Been Previously Counseled or Disciplined for Same/Similar Reason, "NO"

Incident: "During review of incident due to patient complaint, it was witnessed that Staff #7 used improper restraint technique resulting in patient harm."
History of Corrective Action: Has employee Been Previously Counseled or Disciplined for Same/Similar Reason, "NO"

A video timeline was documented by Staff #1 Risk Manager on 2/27/2019 and revealed,
"2/22/19 2:58:48 Staff #5, Staff #6, and Staff #7 attempt to escort Patient #1 from her room to the seclusion room. Staff #5 is seen standing behind Patient #1 with his arms under her arms attempting to walk the patient to the seclusion room. Patient #1 lays down in the hallway. The three staff members attempt to get Patient #1 up and moving toward the seclusion room but Patient #1 refuses to stand. This struggle continues until 3:00:41.
3:00:41 Staff #5 grabs Patient #1's wrists and starts to drag her to the seclusion room.
3:01:00 Staff are able to get Patient #1 into the seclusion room, shut, and lock the door.
Patient #1 stands at the door in the seclusion room banging/picking at the window until 04:23 at which point she sits down.
4:54:20 Patient #1 is released from the seclusion"

The above findings were confirmed in an interview with Staff #1 the Risk Manager.