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Based on record review, observation, and interview the facility's governing body failed ensure that patient (1) was treated in a safe environment and received appropriate care that followed its own policy and procedures leading to a death of a patient in its care.

Refer to A0174, A0175, A0196, A0395 for evidence of specific findings.

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

Based on observations, record reviews and interviews, the facility failed to ensure patient rights were protected and promoted and implement their written policy and procedures that protect and promote each patient's rights for 1 of 1 patient (Patient 1) reviewed.

Findings:

Specifically, the facility failed to ensure Patient #1's rights to be free from neglect by failing to implement interventions to prevent and protect Patient #1 from harm and death, when facility staff neglected to follow the proper techniques for restraint, and supervision or the restraint. The implementation of facility policies and procedures for Patient Restraint, Quite Room, Emergency Medication, and observation of the patient during a restraint was not utilized leading to a patient death.

Refer to A0174, A0175, A0196, A0395 for evidence of specific findings.

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

A) Based on record observation, and interview the facility failed to provide a safe environment as evidenced by leaving out personal care items.

1) In the bathroom during tour on 06/16/22 at 09:40 in room 602 a toothpaste tube, comb, toothbrush, and deodorant. Staff (O) verbally confirmed that personal care items should not be left in room when not in use.

2) During a tour at 09:42 in room 601 bed B, it was observed that a toothbrush, toothpaste, and comb were at bedside no patients were in the room. Staff (O) again confirmed that this is not their policy.

3) During a tour at 09:46 in room 801 bed A, toothpaste, toothbrush was noted at bedside.

4) During a tour at 09:40 on 06/16/22 a cart with paper bags with patient names was noted behind the nursing station Staff (O) explained that personal care items are picked up and handed out by staff and not kept at bedside.

5) Interview with staff (C) at 10:30 on 6/24/22 revealed that personal care item are picked up by staff or brought up to the nursing station by the patient after their morning shower.

6) Interview with staff (B) at 10:40 am on 6/24/22 revealed that personal care items are not to be left at bedside after use. personal care items(brushes, combs, deodorant, toothpaste and toothbrushes) are picked up by staff after use. They both said that not only is this a policy, but the practice throughout the hospital.

B) Based on record review, observation, and interview the facility failed to provide a safe environment as evidenced by unattended house keeping cart that contained contraband items.

1) Record review of the policy, "Contraband Items" dated 06/01/22, lists belts, cords, plastic bags, televisions.

2) During a tour at 09:50 a house keeping cart that was unlocked with plastic bags and cleaning supplies was left in front of room 801 to the right of the doorway in hall. The cart was unlocked and unattended and contained plastic bags, chemicals . The house keeping employee was in a different hallway and unable to see cart.

3) During a tour at 10:25 on Unit 8 a house keeping cart that was unlocked was noted to be at the end of the hall, the Housekeeper was noted be in room 227 with no view of the house keeping cart, the house keeping cart contained chemicals, plastic bags.

4) Interview with Staff (G) , verbalized that the cart for house keeping should never be left unattended.

C) Based on record review, observation, and interview the facility failed to provide a safe environment as evidenced by unsecured doors that allow unmonitored patient access to rooms with contraband objects.

1) During a tour at 10:05 room 227 is an employee breakroom that was left unlocked the room contained chemicals for cleaning out in the open, wires from a TV set. Spoke with Staff (O) who said the door should be locked at all times so patients can not access a non patient area.


D) Based on record review, observation, and interview the facility failed to provide suction equipment for the facility.

1)Record review of the code evaluation sheets asks the evaluator if the suction machine was functioning. The evaluator writes either not applicable, or not available.

2) In Three out of three videos of codes conducted at the hospital it was noted there was no suction on the scene of a choking patient, and two unresponsive patients.

3) An interview was conducted with the Staff (O) on 6/23/22 at 2:15 pm that they do not have suction machines on the units. The suction machines were ordered 06/24/22 and would be on the unit as soon as they arrive.



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E. Based on observation and confirmed in interview the facility failed to provide a safe environment as evidenced by an unsecured office door across from room 711A/B that allowed unmonitored patient access to the office with contraband objects.

Findings were:

1. During a tour of the facility at 10:00 am on 0616/2022 it was observed that the office door across from 711 A/B was unlocked and unoccupied. Observation of the room revealed that the room was an office with a desk, computer, telephone, 3 chairs and various cords including electrical, ethernet and telephone cords.

2. In an interview of staff G on 06/16/2022 at 10:09 am, she confirmed that the office was unlock and unoccupied.

3. In an interview of staff O Adolescent Coordinator on 06/16/2022 at 10:12 am in the hallway he stated the MD and therapist use the room. The door was getting jammed sometimes- maybe they left it open.

Based on record review, observation and interview the facility failed to ensure that a restraint was released at the earliest possible time when the patient was left on stomach while being held down, then while not moving. Leading to a patient death.

Findings:

1) Record review of policy "Use and Monitoring of Physical/Chemical Restraint and Seclusion Policy", date reviewed 06/01/22, revealed the following in it's policy:
The patient's rights, dignity, privacy, safety, and well-being will be supported and maintained. Restraint or seclusion will be discontinued as soon as possible.

2) In review of restraint hold video, patient (1) is seen being pinned to the floor on 06/09/22 with one Staff (M) on his legs while he is in a prone position at 03:10, while the other Staff (N) is watching. Staff M and N stopped pinning the patient to the floor when he was not moving. But did not turn patient over to supine position until 3:15 after an IM injection by staff (K).

3) Interview with Staff (A) on 6/21/22 at 1:30 pm revealed that the patient should have been allowed to walk around after being in the quiet room.

Based on record review, observation, and interview the facility failed to ensure that a licensed practitioner monitored the patient before or during the restraint hold that led to a patient death.

Findings:

1) Record review of Policy,"Use and Monitoring of Physical/Chemical Restraint and Seclusion Policy" section 4.1. revealed the following: Physical restraints (holds) may only be done using techniques trained through the Aggression Management Program. In no case may a patient be taken to the floor or held in prone or supine position.

2) In review of the restraint video for patient (1) it was observed on 06/21/22 that nurse (K) RN did not assess patient (1) at the time of hold on 6/09/22 at 2:59 or before calling a doctor for emergency medication to be given to the patient. RN (K) was not on the scene until 03:14 when the staff RN (K) gives an Intramuscularly injection (IM) with emergency medications.

3) Interview with Staff (A) on 6/21/22 at 12:30 revealed that placing a patient in the prone or supine positions is not allowed in Texas State, nor is part of their policy and procedure for a restraint of a patient. After viewing the restraint hold of patient (1) he verified that the patient was not assessed and medication should not have been given as the patient was quiet and not moving.

Based on a review of documentation and staff interview, the facility failed to document in staff personnel records that application of restraint/seclusion, monitoring, assessment, and care of the patient in a restraint training and competency was successfully completed for 1 of 4 employees (staff K) involved in a restraint and seclusion of patient #1 on 06/09/2022 in which the patient died.

Findings were:

1. A review of the facility policy Use and Monitoring of Physical/Chemical Restraint page 12 revealed that training and competency was required at least annually.

2. In an interview of staff G on 6/17/2022 at 2:10 PM in the conference room she stated that annual means "should be done before or by date due. For example, the annual skills in June should be done June or earlier, not in September."

3. A review of four personnel files of personnel present during the restraint and seclusion of Patient #1 on 06/09/22 , revealed that for 1 of 4 files (staff K) no current annual competency through facility's approved course for restraint/ seclusion program, HANDLE WITH CARE, was found. The last HANDLE WITH CARE competency checklist was dated 02/12/2021.

4. In an email received 06/23/2022 at 02:21 PM from staff F confirmed that there was no documentation that staff K completed the Handle With Care training in 2022.

Based on record review, observation, and interview the facility failed to ensure a nurse supervised and evaluated staff while initiating and maintaining a restraint.

1) Record review of policy "Use and Monitoring of Physical/Chemical Restraint and Seclusion Policy", date reviewed 06/01/22, "section 5.4",revealed the following in it's policy: An assessment of the patient's medical and behavioral conditions, to include a complete review of systems assessment, behavioral assessment, as well as a review and assessment of the patient's history, drugs, and medications, most recent lab work.

2) Record review of Policy,"Use and Monitoring of Physical/Chemical Restraint and Seclusion Policy" section 4.1. revealed the following: Physical restraints (holds) may only be done using techniques trained through the Aggression Management Program. In no case may a patient be taken to the floor or held in prone or supine position.

3) In review of restraint video observed on 06/21/22 it was noted that no RN staff were present while a restraint was initiated and maintained on patient (1) by staff M and N assigned to unit. Nor, did a RN assess the patient.

4) It was also observed in the restraint video, that the patient was placed in supine and prone positions no RN was present evaluating the patient to intervene in the inappropriate hold.

5) Interview with Staff (A) on 6/21/22 at 12:30 revealed that placing a patient in the prone or supine positions is not allowed in Texas State, nor is part of their policy and procedure for a restraint of a patient. After viewing the restraint hold of patient (1) Staff (A) verified that the patient was not assessed and the RN was not in attendance to monitor and evaluate staff (M and N).