HospitalInspections.org

Based on a review of documentation and interview, the facility failed to ensure the right to care in a safe setting, by failing to assess patients post fall, per facility policy.

Findings included:
Facility policy PC.3.07 entitled, "FALL RISK MANAGEMENT" stated in part,
"PROCEUDRE: [sic] ...

11. Patients who are on fall precuations [sic] will have a fall risk assessment completed once
every shift using the Edmonsons Fall Risk Assessment Tool for adults or the Humpty Dumpty Fall Risk Assessment for child and adolescent patients."

Review of the medical record for Patient #1 revealed the patient sustained a fall without injury on 07/17/24, that resulted in the patient being placed on "Q5 level of observation fall precautions" on 07/117/24 at 1401.

Review of Patient #1's medical record revealed no Edmonsons Fall Risk Assessment Tool assessments were present after this patient was placed on fall precautions on 07/17/24.

The above findings were verfied on 08/27/24 with staff members #1 and 3.

Based on a review of documents and interviews, the facility failed to ensure the medical record for patients included a description of the patient's behavior requiring interventions such as restraint or seclusion.

Findings included:

Facility policy PC.4.02 entitled, "RESTRAINT AND SECLUSION" stated in part,
"POLICY
Restraint or seclusion shall be only be utilized in a psychiatric emergency, where a patient's behavior presents imminent danger to self or others, as an intervention of last resort and after less restrictive measures have been attempted without success. (Policy is based on requirements set forth by the Texas Administrative Code (25 TAC §415.251-415.257)

DEFINITIONS
Psychiatric Emergency-A situation involving an individual who is behaving in a violent or self-destructive manner and in which preventive or verbal de-escalation techniques have been determined to be ineffective and restraint or seclusion is immediately necessary to prevent imminent probable death or substantial bodily harm to the individual or others as a result of acts or behavior in which the individual is engaged ...

PROCEDURE: ...

4. Physician's order - restraint and seclusion require an order from a physician that must be obtained as soon as possible during or immediately after the event ...

a. The initial physician's order shall: ...

2) Describe the specific behaviors which resulted in the intervention ...

Review of 10 Medical Records for patients restrained or secluded at the facility revealed that 4 of 10 patients did not have documentation to describe the specific behaviors which resulted in the intervention or that met the definition of a psychiatric emergency.
* Patient #1 had a physical hold episode on 07/10/24 from 1459-1508 and a seclusion episode on the same date from 1508-1530. Review of the Seclusion/Restraint Physician Order and Record form revealed the clinical justification had "imminent danger to others" with the check box indicated. The area to describe the specific behaviors displayed stated, "threatens staff". Patient #1 also had a seclusion episode on 08/02/24 from 1326-1415. Review of the Seclusion/Restraint Physician Order and Record form revealed the clinical justification had "imminent danger to others" with the check box indicated. The area to describe the specific behaviors displayed stated, "Pt very disruptive on the milieu. Intrusive at desk, loud & disruptive on unit. Pt refused staff vernal prompts several times to comply". These two events did not have descriptions of behavior that would support the definition of a "Psychiatric Emergency-A situation involving an individual who is behaving in a violent or self-destructive manner per facility policy and regulations.
* Patient #5 had a seclusion episode on 08/07/24 from 1601-1645. Review of the Seclusion/Restraint Physician Order and Record form revealed the clinical justification for the intervention had "imminent danger to others" with the check box indicated, the physician order did not describe specific behaviors displayed.
* Patient #7 had a physical hold on 08/17/24 from 1211-1212. Review of the Seclusion/Restraint Physician Order and Record form revealed the clinical justification for the intervention had "imminent danger to self" and "imminent danger to others" with check boxes indicated, the physician order did not describe specific behaviors displayed.
* Patient #8 had a physical hold on 08/17/24 from 1210-1220. Review of the Seclusion/Restraint Physician Order and Record form revealed the clinical justification for the intervention had "imminent danger to others" with the check box indicated, the physician order did not describe specific behaviors displayed.

The above findings were verified with staff members #1 and 3 on 08/27/24.