HospitalInspections.org

Based on a review of documentation and interview it was determined the facility failed to ensure the seclusions were discontinued at the earliest possible time.

Findings were:

Facility based policy 13310-C entitled, "Restraint and Seclusion" stated in part,
"M. Ongoing Monitoring:
1. Violent/Self Destructive ...
c. The patient shall be monitored continuously while in restraint/seclusion by the RN/assigned trained staff. The selection of an intervention and determination of the frequency of assessment and monitoring needs to take into consideration the patient's condition, cognitive status, and risks associated with the use of the chosen intervention. The assessment includes:..
(5) Readiness for discontinuation of restraint/seclusion ...

N. Discontinuance/release of patient:
1. Violent/Self-Destructive:
a. Based on an individual patient assessment determining that the patient does not pose a threat to himself/herself or others, an RN trained in the use of violent/self-destructive may remove the restraints ...

R. The use of restraint/seclusion will be thoroughly documented in the patient's medical record. Documentation related to restraint/seclusion includes;..
3. Documentation of each episode of restraint/seclusion includes: ...
f. Behavioral criteria for discontinuation of restrain/seclusion ...
o. Treatment plan review/revisions following the episode of restraint/seclusion will include treatment intervention to prevent future use.

3. The training must enable staff to show competency in the following areas: ...
f. Clinical identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary;".

Review of the medical record for Patient # 3 (1 of 10 medical records reviewed) revealed that the patient had had 3 episodes of seclusion since their admission to facility. 1 of the 3 seclusion episodes had documentation that indicated the seclusion was not discontinued at the earliest possible time.

Patient # 3 was placed in seclusion on 10/14/14 at 0716 related to, "Pt. increasingly angry, delusional. Pt. became aggressive towards staff AEB: shoving staff member and raising fists at two staff members face. Verbally threatening." The patient was in seclusion until 1114.

The Restraint/Seclusion Patient Observation Form for this seclusion episode revealed the following documentation:
? At 0914, "Pacing talking about God and Killing Melissa."
? At 0930, "Calm, allowed me to check HR 83, strong and regular. Pt. agreed to lay down."
? At 0941, "Pt standing talking with Dr., pt. asked to go home, pt calm".
? At 0945, "Pt. using the bathroom, talking to God."
? At 0955, "Pt. calm taking a shower in seclusion bathroom."
? At 1011, "Pt. calm, walking around seclusion area."
? At 1027, "Pt. calm, walking around seclusion talking about God giving him a baby in 3 yrs 9 mos."
? At 1037, "Pt. sitting in chair talking about going home."

There was documentation for over an hour that the patient was calm, not agitated or aggressive. This behavior indicated the patient would have been appropriate to release from seclusion. The seclusion room door was not opened, releasing the patient from seclusion until 1114 after the patient fell asleep at 1112.

In an interview on 10/15/14, staff member # 1 and 2 confirmed the above findings.

Based on a review of medical records and policy, the facility failed to ensure that informed consent was obtained for procedures as required by the Texas Administrative Code Chapter 414, Subchapter I of this title (relating to Consent to Treatment with Psychoactive Medication--Mental Health Services) which states in part,
"?414.405. Documentation of Informed Consent.
(a) Informed medication consent must be obtained for each individual medication, not by medication class.
(b) Informed consent for the administration of each psychoactive medication will be evidenced by a completed copy of the department's form, Consent to Treatment with Psychoactive Medication (MHRS 9-7 form (or other format including the same information)) executed by the patient or his or her LAR. A copy of which may be obtained by contacting TDMHMR, Office of Policy Development, P.O. Box 12668, Austin, TX 78711-2668...

?414.406. Patients Admitted under Texas Statutes.

(a) Psychoactive medications will not be administered to patients admitted to a mental health facility under the voluntary provisions of the Texas Health and Safety Code (THSC) or detained at a mental health facility under the THSC emergency detention or order of protective custody (OPC) provisions without informed consent from the patient or the patient's legally authorized representative unless the patient is in an psychiatric emergency and medication is administered as provided in ?414.410 of this title (relating to Psychiatric Emergencies)."

Findings were:

Facility based policy #NS-020 entitled, "Psychoactive Medication, Emergency Use" stated in part,
"1. Psychoactive medication will not be administered to a patient without informed consent from the patient or the patient's legally authorized representative unless an emergency exists. Actions by the patient, which determines lack of consent, are: ...
b. The patient communicates though behavior that he/she refuses psychoactive medication, e,g. refusing to swallow oral medication, refusing to submit to hypodermic injection of psychoactive medication ....
2. An emergency situation defined by the Texas Department of Health as imminent probable death or substantial bodily harm to the patient because the patient:
a. Is overly or continually threatening or attempting to commit suicide or suicide or serious bodily harm; or
b. Is behaving in a manner that indicated that patient is unable to satisfy their need for nourishment, essential medical care, or
c. Self protection; or
d. Imminent physical or emotional harm to others because of threats, attempts, or other acts the patient overtly or continually makes or commits."

Review of the medical record for Patient # 1 (of 10 medical records reviewed) revealed the patient received the following intramuscular injections of medication :
? On 3/22/14 at 23:34 Zyprexa 5 mg IM and at 23:44 Ativan 2 mg IM were administered to the patient.
? On 3/23/14 at 23:31 the patient was administered Zyprexa 5 mg IM and Ativan 2 mg IM.
? On 3/24/14 at 22:46 the patient was administered Zyprexa 5 mg IM.
? On 03/25/14 at 10:09 the patient was administered Zyprexa 5 mg IM.

The Zyprexa 5 mg IM was ordered as PRN (as needed) medication every 4 hours for agitation.
? There were narrative notes documenting the administration of IM medication on 03/22 and 03/24.
? There were no narrative note about the administration of IM medication on 03/23 or 03/25.
? The only documentation indicating that the patient requested/accepted the Zyprexa 5 mg IM PRN was on 03/22/14.
? There was no documentation on 03/23, 03/24, or 03/25 that the patient requested/accepted the PRN Zyprexa.

The patient had current psychoactive medication consents for all medication administered with the exception of Zyprexa. The consent for Zyprexa was not obtained until 03/23/14, after the first administration of the medication.

The above finding were confirmed in an interview on 10/15/14 with staff member #1.