HospitalInspections.org

Based on a review of facility documentation and staff interview, the hospital failed to review and update each patient's plan of care after an episode of patient restraint and seclusion for 1 of 1 patients restrained and secluded.

Findings were:

Patient #1 was admitted to the facility on 3/31/15. He experienced an incident of personal restraint and seclusion on 4/14/15. The patient was discharged from the facility on 4/16/15. There was no update to the patient's treatment plan after the episode of restraint and seclusion available for surveyor review.

Facility policy entitled Multidisciplinary Treatment Planning, date issued 09/01/09, stated in part:
"1. Initial Treatment Plan - completed at the time of admission by the Admission/Referral Assessment employees...
3. Additional Multidisciplinary Treatment Plan Reviews - completed at least every seven (7) days or according to the Treatment Team members based on the needs of the patient..."

Facility policy #CS1-10 entitled Restraints/Seclusion,date adopted 12/20/2007, included the following:
"DEFINITIONS
Restraints: Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of patient to move his or her arms, legs, body, or head freely...
Seclusion: Patient is placed in sole confinement in a room that is not within the control of the person confined to leave...
All Restraint/seclusion documentation standards: The use of restraints must be documented in the medical record, and must include the following information (as applicable):...
7. Revisions to the treatment plan by the qualified nurse..."

These findings were confirmed in an interview with the facility Chief Executive Officer and other administrative staff on the afternoon of 6/10/15 in the facility admission room.

Based on a review of facility documentation and staff interview, the facility failed to ensure that each use of restraint and/or seclusion was made in accordance with the order of a physician or other licensed independent practitioner for 1 of 1 patients who experienced a restraint and seclusion.

Findings were:

A review of the clinical record of Patient #1 revealed the following Nursing Notes:
4/14/15 at 4:30 a.m.: "...Pt continues to yell & be loud. Nurse attempted to get to nurse's desk & pt. pushed nurse in an attempt to follow nurse. Redirection unfruitful, MHT & nurse restrained pt. but pt. continued to fight. Assisted pt. to floor after multiple attempts of kicking & attempts to punch. [Staff #8], LVN called [Staff #11, psychiatrist] & received new orders."
4/14/15 at 4:45 a.m.: "Released from staff secure hold. Up to feet without assistance. Pt. continues to be loud and calling staff names, "I can't believe you can be so stupid." "You stupid bastards." "I don't want to fight you, I just want my pants & leave." Redirected to pt's room, to attempt isolation as ordered, accompanied by two staff. Gets into closet & take off clothes. Clothes had a note, "[Patient #1], do not put on until D/C on Tues." Pt. read, "Do not put on until December." Increased agitation noted. Redirection attempts unfruitful. Staff stayed in room."
4/14/15 at 5:30 a.m.: "Pt. continues to calm down but attempts exit of room. Easily redirected. Pt. lay on bed supine. Does not close eyes. Insists on lights kept on. MHT at pt. entrance away from pt's sight. Denies needs or pain, but insists on leaving..."

A review of a Physician's Order on 4/14/15 revealed the following relevant items:
· 4/14/15 at 4:30 a.m.
" 1. Attempt isolating pt for aggressive behavior, if unsuccessful give
2. Zyprexa 10 mg IM x 1 dose now..."
No medication was given to the patient. The incident was not considered a seclusion by the facility, despite the involuntary nature of the "isolation."

Facility policy #CS1-10 entitled Restraints/Seclusion,date adopted 12/20/2007, included the following:
"DEFINITIONS
Restraints: Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of patient to move his or her arms, legs, body, or head freely...
Seclusion: Patient is placed in sole confinement in a room that is not within the control of the person confined to leave...
ORDERS
The LIP primarily responsible for the patient's ongoing care must order the use of a restraint/seclusion...
All Restraint/seclusion documentation standards: The use of restraints must be documented in the medical record, and must include the following information (as applicable):
9. The identity of the physician, or other LIP who ordered the restraint...
12. Orders for restraint or seclusion..."

The above findings were confirmed in an interview with the Chief Executive Officer and other administrative staff on the afternoon of 6/10/15 in the facility admissions room.

Based on a review of facility documentation and staff interview, the facility failed to ensure that for each use of restraint and/or seclusion the patient was seen face-to-face within 1-hour after the intervention was initiated for 1 of 1 patients who experienced a restraint and seclusion.

Findings were:

A review of the clinical record of Patient #1 revealed the following Nursing Notes:
4/14/15 at 4:30 a.m.: "...Pt continues to yell & be loud. Nurse attempted to get to nurse's desk & pt. pushed nurse in an attempt to follow nurse. Redirection unfruitful, MHT & nurse restrained pt. but pt. continued to fight. Assisted pt. to floor after multiple attempts of kicking & attempts to punch. [Staff #8], LVN called [Staff #11, psychiatrist] & received new orders."
4/14/15 at 4:45 a.m.: "Released from staff secure hold. Up to feet without assistance. Pt. continues to be loud and calling staff names, "I can't believe you can be so stupid." "You stupid bastards." "I don't want to fight you, I just want my pants & leave." Redirected to pt's room, to attempt isolation as ordered, accompanied by two staff. Gets into closet & take off clothes. Clothes had a note, "[Patient #1], do not put on until D/C on Tues." Pt. read, "Do not put on until December." Increased agitation noted. Redirection attempts unfruitful. Staff stayed in room."
4/14/15 at 5:30 a.m.: "Pt. continues to calm down but attempts exit of room. Easily redirected. Pt. lay on bed supine. Does not close eyes. Insists on lights kept on. MHT at pt. entrance away from pt's sight. Denies needs or pain, but insists on leaving..."

A review of a Physician's Order on 4/14/15 revealed the following relevant items:
· 4/14/15 at 4:30 a.m.
" 1. Attempt isolating pt for aggressive behavior, if unsuccessful give
2. Zyprexa 10 mg IM x 1 dose now..."
No medication was given to the patient. The incident was not considered a seclusion by the facility, despite the involuntary nature of the "isolation." As a result, the facility could provide no documented evidence that the patient was seen face-to-face within 1-hour after the initiation of the intervention by a physician or trained registered nurse.

Facility policy #CS1-10 entitled Restraints/Seclusion,date adopted 12/20/2007, included the following:
"DEFINITIONS
Restraints: Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of patient to move his or her arms, legs, body, or head freely ...
Seclusion: Patient is placed in sole confinement in a room that is not within the control of the person confined to leave ...
Behavioral Restraints/Seclusion: A physician or other LIP responsible for the care of the patient must evaluate the patient in-person within one hour of the initiation of behavioral restraints/seclusion.
The in-person evaluation must include the following:
1. An evaluation of the patient's immediate situation
2. The patient's reaction to the restraints;
3. The patient's medical and behavioral condition; and
4. The need to continue or terminate the restraints ...
Behavioral Restraint/Seclusion Standards: Patients must have continuous in-person observation ...
All Restraint/seclusion documentation standards: The use of restraints must be documented in the medical record, and must include the following information (as applicable):...
6. Individual patient assessment and reassessment..."

In an interview with the Chief Executive Officer and Staff #5, Nurse Manager, on the afternoon of 6/10/15 in the facility admission room, the CEO acknowledged there was no documented evidence in the clinical record of Patient #1 to indicate a face-to-face assessment had been completed after one hour. She stated the facility had not considered this to be a patient seclusion, but rather an "isolation."

The above findings were confirmed in an interview with the Chief Executive Officer and other administrative staff on the afternoon of 6/10/15 in the facility admissions room.

Based on a review of facility documentation and staff interview, the facility failed to document in staff personnel records that restraint/seclusion training and competency were successfully completed.

Findings were:

A review of personnel files of personnel present during the restraint and seclusion of Patient #1 on 4/14/15 included files of several RNs, LVNs and Mental Health Techs (MHTs). The following items were noted:
Staff #6, Mental Health Technician- no competency test for S.E.C.U.R.E.(non-violent crisis intervention program) training; no competency test for restraint/seclusion.
Staff #7, agency RN - no competency test for S.E.C.U.R.E.; no competency test for restraint/seclusion.
Staff #8, LVN - no restraint/seclusion competency.

Despite several requests on 6/10/15 for documented restraint/seclusion competency testing of the above individuals, the facility could provide no evidence of it prior to surveyor exit.

The above findings were confirmed with the Chief Executive Officer and other administrative staff on the afternoon of 6/10/15 in the facility admission room.

Based on a review of facility documentation and staff interview, the facility failed to ensure each member of the medical staff was re-appointed to membership by the governing body according to the medical staff bylaws of the facility for 1 of 1 physician credentialing files reviewed.

Findings were:

A review of the credentialing file of Staff #11, facility psychiatrist, revealed a Delineation of Privileges Sheet - Psychiatry for the period 1/31/13 to 1/31/15 was present. There was no current credentialing letter included in the file, nor was there a current list of facility privileges for the physician.

In an interview with Staff #12, the individual identified as responsible for credentialing, on the afternoon of 6/10/15 in the facility admission room, she stated, "I know we talked about it. I think it just got dropped. I must have missed that ...He'd be the one signing it, though. It's just him."

A review of the Medical Staff Bylaws of Allegiance Behavioral Health Center of Plainview revealed the following:
"3.1 Nature of Medical Staff Membership
Medical Staff membership is a privilege extended by the Hospital and is not a right of any person. Membership on the Medical Staff or the exercise of temporary privileges shall be extended only to professionally competent licensed practitioners and AHPs and persons who continuously meet the qualifications, standards and requirements set forth in these Bylaws. Membership on the Medical Staff shall confer on the practitioner only such clinical privileges and prerogatives as have been granted by the Board in accordance with these Bylaws. No person shall admit patients to, provide services to patients in the Hospital, unless he/she is a member of the Medical Staff or has been granted temporary privileges...
3.4 (b) Reappointments
Reappointments to the Medical Staff shall be for a period of not more than two (2) years..."

These findings were confirmed with the facility Chief Executive Officer and other administrative staff on the afternoon of 6/10/15 in the facility admission room.

Based on observation, interview and record review the facility failed to maintain the condition of the physical plant and the overall hospital environment in good repair.
The failure to maintain the facility in good condition has the potential to affect the safety and well-being of all patients admitted to the facility.
Findings include:
Observation on 6/10/15 at 10:15 am in the Patient's Day room revealed (4) four wall corners with chipped, cracked and missing drywall, exposing metal. The walls along the base boards were unpainted and there were multiple scrapes and missing paint on the walls.
Observation on 6/10/2015 at 10:20 am in the facility's dining room revealed missing/broken laminate on the sink countertops with exposed wood. In a cabinet under the sink there was a large can of deodorizer spray and a large plastic tub of Bleach Sani wipes, the cabinet door was unlocked.
Interview on 6/10/2015 at 10:15 am with Staff #2, the Director of Social Services, confirmed the above findings. She revealed that patients spend most of their day in the Day room. Staff #2 stated that the walls have been repaired multiple times but that the patients continue to damage the walls. Staff #2 stated the chemicals should not be stored were patients have access, and the chemicals were removed.
Further observations of the dining revealed a refrigerator containing puddings and snacks. The temperature log was attached to the front of the freezer for recording the internal temperatures of the freezer and refrigerator. The June 2015 temperature log reflected missing temperatures for 6/1/15, 6/2/15, 6/3/15, 6/6/15, and 6/7/25.
During an interview on 6/10/15 at 2:30 pm in the conference room Staff # 5, the Safety Officer and Nurse Manager stated the temperature logs are supposed to be checked and recorded daily. Staff #5 stated there was no specific policy on the storage of chemicals.