HospitalInspections.org

Based on review of records, observations, and interview, the Governing Body failed to effectively carry out its oversight responsibilities for ensuring patient rights were protected for 9 of 9 patients (Patient # 3, 5, 14, 15, 34, 41, 42, 43, and 44). The Governing Body failed to ensure processes were developed with effective implementation of policies and procedures that provided patients with a safe, nonviolent environment. More specifically, the facility failed to:

A) Ensure 6 of 6 adolescent patients (Patient # 44, 41, 42, 43, 14, and 15) were protected from the unprovoked assaults by Patient #5. This failure resulted in 2 of the 6 patients (Patient #41 and Patient #14) requiring medical consults caused by the violent attack from Patient #5. In addition, the guardians of 2 of 6 patients (Patient #41 and Patient #14) filed criminal assault charges against Patient #5, resulting in the arrest of Patient #5;

B) Ensure levels of observation were increased for Patient #5 even though the Treatment Plan Addendum/Update identified "Increased Observations" as an additional strategy to be implemented that may reduce the potential for a future restrictive intervention when he assaulted 3 of 6 patients (Patient #44, #14, and #15);

C) Ensure levels of observation were adequately evaluated and increased for 1 of 1 violent, self-destructive patients (Patient #3). This failure resulted in 10 incidents of restraint or seclusion, culminating with an 11th incident in which Patient #3 climbed on a chair to reach the recessed ceiling light troffer, removed the plastic covering, broke the florescent lamp, and made 3 cuts on her left forearm with the broken glass. Two of the three cuts required staples - 12 staples for one cut and 17 staples for the other cut; and

D) Ensure 3 of 3 toilets, 2 on Unit 6 and 1 on Unit 7, were safe. This was evidenced by a 2"x3" cut out in the metal encasement of all three toilets. This cut out provided access to the recessed flushing mechanism. The thin metal edge of the cut out had the potential to be used for cutting and/or self-harm to a patient's fingers or wrists. There was potential for harm to 1 of 1 patients (Patient # 34) who was on Self-Harm Precautions.

Cross reference Tag 0144 for specific findings.

Based on observation, interview, and record review, the facility failed to ensure processes were developed with effective implementation of policies and procedures that provided patients with a safe, nonviolent environment.

The facility failed to:

A) Ensure that 6 of 6 patients (Patient # 44, 41, 42, 43, 14, and 15) were safe from unprovoked attacks during a three-week period by Patient #5, a 17yo. Because of these assaults, medical consults were needed for 2 of the 6 patients (Patient #41 and Patient #14). Patient #41 had a medical consult for left eye swelling, bleeding fingers, and a seizure. Patient #14, a 12yo, had a medical consult for right facial pain. The guardians of 2 of 6 patients (Patient #41 and Patient #14) filed assault charges against Patient #5. Patient #5 was arrested for assault.

Cross reference Tag A0144.


B) Ensure levels of observation were increased for Patient #5 even though the Treatment Plan Addendum/Update identified "Increased Observations" as an additional strategy to be implemented that may reduce the potential for a future restrictive intervention when he assaulted 3 of 6 patients (Patient #44, #14, and #15). Observations were not increased by Staff K, the attending physician for all patients;

Cross reference Tag A0144.


C) Ensure levels of observation were adequately evaluated and increased for 1 of 1 violent, self-destructive patient (Patient #3). This failure resulted in 10 incidents of restraint or seclusion, culminating with an 11th incident in which Patient #3 climbed on a chair to reach the recessed ceiling light troffer, removed the plastic covering, broke the florescent lamp, and made 3 cuts on her left forearm with the broken glass. Two of the three cuts required staples - 12 staples for one cut and 17 staples for the other cut;

Cross reference Tag A0144.


D) Ensure 3 of 3 toilets, 2 on Unit 6 and 1 on Unit 7, were safe. This was evidenced by a 2"x3" cut out in the metal encasement of all three toilets. This cut out provided access to the recessed flushing mechanism. The thin metal edge of the cut out had the potential to be used for cutting and/or self-harm to a patient's fingers or wrists. There was potential for harm to 1 of 1 patients (Patient # 34) who was on Self-Harm Precautions.

Cross reference Tag A0144.

Based on observation, interview, and record review, the facility failed to ensure processes were developed with effective implementation of policies and procedures that provided patients with a safe, nonviolent environment.

The facility failed to:

A) Ensure that 6 of 6 patients (Patient # 44, 41, 42, 43, 14, and 15) were safe from unprovoked attacks during a three-week period by Patient #5, a 17yo. Because of these assaults, medical consults were needed for 2 of the 6 patients (Patient #41 and Patient #14). Patient #41 had a medical consult for left eye swelling, bleeding fingers, and a seizure. Patient #14, a 12yo, had a medical consult for right facial pain. The guardians of 2 of 6 patients (Patient #41 and Patient #14) filed assault charges against Patient #5. Patient #5 was arrested for assault;


B) Ensure levels of observation were increased for Patient #5 even though the Treatment Plan Addendum/Update identified "Increased Observations" as an additional strategy to be implemented that may reduce the potential for a future restrictive intervention when he assaulted 3 of 6 patients (Patient #44, #14, and #15). Observations were not increased by Staff K, the attending physician for all patients;


C) Ensure levels of observation were adequately evaluated and increased for 1 of 1 violent, self-destructive patients (Patient #3). This failure resulted in 10 incidents of restraint or seclusion, culminating with an 11th incident in which Patient #3 climbed on a chair to reach the recessed ceiling light troffer, removed the plastic covering, broke the florescent lamp, and made 3 cuts on her left forearm with the broken glass. Two of the three cuts required staples - 12 staples for one cut and 17 staples for the other cut;


D) Ensure 3 of 3 toilets, 2 on Unit 6 and 1 on Unit 7, were safe. This was evidenced by a 2"x3" cut out in the metal encasement of all three toilets. This cut out provided access to the recessed flushing mechanism. The thin metal edge of the cut out had the potential to be used for cutting and/or self-harm to a patient's fingers or wrists. There was potential for harm to 1 of 1 patients (Patient # 34) who was on Self-Harm Precautions.



Findings for A): Unprovoked attacks by Patient #5.

Outline of the supporting documentation for section A:

" Policy POC - N149, "Levels of Observation"

" Medical Record of Patient #5

" 1st assault: Patient #44

" 2nd assault: Patient #41

" 3rd assault: Patient #42

" 4th assault: Patient #43

" 5th and 6th assaults: Patient #14 and Patient #15

" Medical Record of Patient #44

" Medical Record of Patient #41

" Medical Record of Patient #42

" Medical Record of Patient #43

" Medical Record of Patient #14

" Medical Record of Patient #15

" Interviews


Review of policy POC - N149, "Levels of Observation," last reviewed 2/2021, showed:

"Policy Statement: All patients will be routinely observed in compliance with physician orders and prescribed protocols. Patients exhibiting a risk potential for suicide, assault, ... elopement, ... will be placed on the appropriate precaution and level of observation per physician order, based on the level required for the individual patient.

To ensure patient safety when entering West Oaks Hospital, all patient routine Q [every] 15 [minutes] observations will start upon the pre-screening process in the Intake Department.

The physician will order one of three levels of observation at time of admission and as the patient's condition warrants a change:

Q 15 minutes (routine observation for patients ...)

Q 5 minutes (requires a specific precaution)

One-on-one (requires a specific precaution) ...

Action Steps:

1. The Charge nurse may increase observation of the patient for safety, based on his/her assessment of the patient. A physician's order must be obtained as soon as possible for any special precaution or level of observation."


Medical Record of Patient #5.

Review of Patient Demographic Profile [Face Sheet] showed admission date of 8/10/20. Date of birth December 13, 2002.

Review of the Initial Psychiatric Evaluation by Staff K (attending physician) dated 8/10/20 at 2:00pm showed a 17yo male with auditory hallucination. He stated the heard voices when he was mad or angry - "voices telling him to do things." He had multiple psychiatric hospitalizations. He had been consuming alcohol daily and using marijuana on weekends. His mood was depressed, angry, aggressive, irritable, and anxious. He reported suicidal and homicidal thoughts. Insight and judgement were poor.

Admission Diagnoses: Disruptive mood dysregulation disorder; major depressive disorder, recurrent, with psychosis, severe; history of attention deficit hyperactivity disorder

Review of [Admission] Intake Integrated Assessment by Staff KK (Admission RN) on 8/10/20 at 12:11am showed the following behaviors: running away, destruction of property, screaming, cursing, rebellious/defies authority, problems with peers, fighting, and gang involvement. In school, he was disruptive and fought with peers. He had a legal history of destroying property. He admitted to auditory and visual hallucinations. He was visibly agitated and psychotic.

Review of the High-Risk Notification Alert by Staff KK (Admission RN) dated 8/10/20 at 1:15am showed the following high-risk factors:
Assault/homicide - aggressive when angry
Suicide - guarded with plan

Review of Physician's Orders by Staff LL (admitting physician) dated 8/10/20 at 6:21am showed "Admit to Adult Psych In-Patient." [It will be noted that Patient #5 was admitted into the Adolescent Psych In-Patient, not the Adult Psych In-Patient.] Level of Observation - Every 15-minute observations. Precautions included Assault/Homicidal, Elopement Risk, and Suicidal.

Review of Psychosocial Assessment by Staff I (LMSW) dated 8/11/20 at 2:55pm showed a legal history of "following in dad's footsteps." He stated he was on probation with a pending court date of August 31, 2020. He was incarcerated in 2014, 2015, 2016, and 2018. He stated he had been admitted to West Oaks Hospital "many times" for aggression and depression. He reported being in CPS custody for four years because he was "drug dealing and gun charges."

Review of Family Therapy Clinical Summary by Staff I (LMSW) dated 8/11/20 at 3:00pm showed that Patient #5 met with his CPS caseworker. He stated he wanted to remain at West Oaks Hospital until his 18th birthday [12/13], at which point he could live with his uncle.

Review of Psychiatrist Daily Progress Notes by Staff K (attending physician) dated 8/11/20 at 6:00pm showed Patient #5 was hearing voices "sometimes mumbling."

Review of Psychiatrist Daily Progress Notes by Staff K (attending physician) dated 8/12/20 at 2:00pm showed Patient #5 stated he had "witnessed people getting killed." He admitted to having "mumbling" auditory hallucinations.

Review of Physician's Orders by Staff K (attending physician) dated 8/12/20 at 7:44pm showed Unit Restriction was discontinued.


1st assault: Patient #44

Review of Restraint/Seclusion/Emergency Medication Order/Record dated 8/12/20 at 9:05pm showed Thorazine 50mg and Benadryl 50mg Intramuscularly (IM) were ordered by Staff K (attending physician). The medications were administered at 9:15pm. Seclusion was also ordered for up to 2 hours but not used. Specific Behaviors Exhibited: Patient #5 started chasing another patient and attacked him for no reason. Review of Treatment Plan Addendum/Update dated 8/12/20 [not timed] by Staff MM (RN) showed the following modifications or additional strategies to be implemented that may reduce the potential for a future restrictive intervention: "Increased observations" and "utilize coping skills."

Review of Physician's Orders by Staff K (attending physician) dated 8/13/20 at 10:45am showed Unit Restrictions were reordered.

Review of RN Narrative Note by Staff MM dated 8/12/20 at 9:00pm showed that Patient #5 hit Patient #44. Staff K (attending physician) notified.

Review of Psychiatrist Daily Progress Notes by Staff K (attending physician) dated 8/13/20 at 8:00am showed Patient #5 was labile, easily agitated, and aggressive. He was restrained on 8/12/20.

Review of Psychiatrist Daily Progress Notes by Staff K (attending physician) dated 8/14/20 at 4:00pm showed Patient #5 was angry, easily agitated, cursing, and demanding.

Review of Psychiatrist Daily Progress Notes by Staff K (attending physician) dated 8/15/20 at 9:30am showed Patient #5 was impulsive, aggressive, and irritable.


2nd assault: Patient #41

Review of Restraint/Seclusion/Emergency Medication Order/Record dated 8/16/20 at 3:31pm showed Thorazine 50mg and Benadryl 50mg Intramuscularly (IM) were ordered by Staff K (attending physician). The medications were administered at 4:00pm. Specific Behaviors Exhibited: Patient #5 attacked a peer. Review of Treatment Plan Addendum/Update dated 8/16/20 [not timed] by Staff NN (RN) showed the following modifications or additional strategies to be implemented that may reduce the potential for a future restrictive intervention: "reinforce positive coping skills" and "review and utilize positive coping skills."

Review of RN Narrative Note by Staff NN (RN) dated 8/16/20 at 3:30pm showed that Patient #5 joined another patient to attack a third patient (Patient #41). Staff K (attending physician) was notified. Patient #41 pressed charges against Patient #5.

Review of Psychiatrist Daily Progress Notes by Staff K (attending physician) dated 8/16/20 at 6:00pm showed Patient #5 made an "unprovoked attack on another peer today." He was labile, aggressive, and threatening.

Review of Psychiatrist Daily Progress Notes by Staff K (attending physician) dated 8/17/20 at 2:00pm showed Patient #5 was easily frustrated, easily agitated, and aggressive. Poor insight.


3rd assault: Patient #42

Review of Restraint/Seclusion/Emergency Medication Order/Record dated 8/18/20 [not timed] showed Thorazine 50mg and Benadryl 50mg Intramuscularly (IM) were ordered by Staff K (attending physician). The medications were administered at 5:04pm. Physical restraint and seclusion were also utilized. Specific Behaviors Exhibited: Patient #5 attacked another patient. Review of Treatment Plan Addendum/Update by Staff QQ (RN) dated 8/18/20 [not timed] showed the following modifications or additional strategies to be implemented that may reduce the potential for a future restrictive intervention: "Encouraged patient to use coping skills. Administer medication as order. Review and establish new coping skills."

Review of RN Narrative Note by Staff QQ (RN) dated 8/18/20 at 4:50pm, showed Patient #5 attacked another patient (Patient #43) that was sitting watching TV. Patient #5 stated Patient #43 was looking at him. Patient #5 destroyed the seclusion rooms.

Review of Psychiatrist Daily Progress Notes by Staff K (attending physician) dated 8/18/20 at 6:00pm showed Patient #5 caused damage to property and fighting. Restrained and secluded. Easily agitated, aggressive, threatening.

Review of Psychiatrist Daily Progress Notes by Staff K (attending physician) dated 8/19/20 at 6:00pm showed Patient #5 was "very labile ... volatile, aggressive."

Review of Physician's Orders by Staff K (attending physician) dated 8/21/20 at 6:05pm showed Unit Restriction was discontinued.


4th assault: Patient #43

Review of RN Narrative Note by Staff OO (RN) dated 8/22/20 at 8:20pm showed that Patient #5 poured water on another patient and they got into a fight.

Review of RN Narrative Note by Staff QQ (RN) dated 8/27/20 at 11:40am showed an incident in which Patient #5 hit a patient that was in an altercation with yet another patient. Patient #5 stated he was "instigating peers to fight him. Staff K (attending physician) was notified and placed Patient #5 on Unit Restrictions. Patient #5 complained of pain in right hand. A medical consult was ordered.

Review of Physician's Orders by Staff K (attending physician) dated 8/27/20 at 2:23pm showed Unit Restrictions were reordered. Patient #5 was also ordered an Internal Medicine Consult for right hand bruise.

Review of Medical Consult Note by Staff S (DO) dated 8/27/20 at 3:00pm showed Patient #5 with "right hand pain after punching peer." The patient was able to make a fist. Mild swelling over 4th metacarpal was noted.

Review of Psychiatrist Daily Progress Notes by Staff K (attending physician) dated 8/27/20 at 7:00pm showed that Patient #5 "got in a fight with peers."

Review of Physician's Orders by Staff K (attending physician) dated 8/29/20 at 7:47pm showed Unit Restriction was discontinued.


5th and 6th assaults: Patient #14 and Patient #15

Review of Restraint/Seclusion/Emergency Medication Order/Record dated 8/31/20 at 8:05pm showed Thorazine 50mg and Benadryl 50mg Intramuscularly (IM) were ordered by Staff K (attending physician). The medications were administered at 8:05pm. Specific Behaviors Exhibited: Patient #5 attacked peers [Patient #14 and Patient #15] - one of the peers as he lay on his bed sleeping [Patient #14] Review of Treatment Plan Addendum/Update by Staff OO (RN) dated 8/31/20 [not timed] showed the following modifications or additional strategies to be implemented that may reduce the potential for a future restrictive intervention: "Increased observation, discuss coping skills, review of boundaries, discuss triggers."

Review of RN Narrative by Staff OO (RN) dated 8/31/20 at 8:05 pm showed that Patient #5 attacked Patient #14 "while he was asleep unprovoked." Patient #5 "also attacked yet another patient (Patient #15) ... while MHT was attempting to get Patient #5 to stop, he attacked the female MHT (Staff J)." At 10:00pm, Staff OO (RN) also documented that Staff j had been hit in the face.

Review of Physician's Orders by Staff K (attending physician) dated 9/1/20 at 3:18am showed Patient #5 was placed on Assault/Homicidal Precautions and Unit Restrictions. ."

Review of Physician's Orders by Staff K (attending physician) dated 9/1/20 at 1:31pm showed an order for an Internal Medicine Consult for cuts to right and left fingers due to trauma from patient punching the walls.

Review of RN Narrative Note by Staff QQ (RN) dated 9/1/20 at 6:35pm showed that Patient #5 was interviewed by the police due to assault charges filed by Patient #14's family. Patient #5 was taken to jail. Staff K (attending physician) was notified.

Review of After/Discharge Plan by Staff K (attending physician) dated 9/1/20 at 6:45pm showed a discharge into the care of the police to be taken to the Harris County Juvenile Detention Center


The medical records of the six patients that were attacked by Patient #5.

1st assault: Patient #44 attacked by Patient #5 on 8/12/20.

Review of Patient Demographic Profile [Face Sheet] showed Patient #44 was admitted on 8/7/20.

Record review of Physician Orders by Staff PP (Nurse Practitioner) dated 8/13/20 at 8:00am showed Patient #44 was ordered an Internal Medicine Consult but refused to be seen.

Review of Physician Orders by Staff K (attending physician) dated 8/13/20 at 10:00am showed Patient #44 was placed on Unit Restrictions.

Review of email from Staff B (Risk Manager) dated 4/9/21 at 4:45pm showed: Our documentation regarding the altercation between Patient #44 and Patient #5 is that "Patient #44 was attacked by another patient (Patient #5). Patient #44 was assessed. No apparent injury noticed. All authorities notified. Vital Signs: BP - 118/62, Oxygen Sat - 99%, Respirations - 18, Pulse - 86. All authorities notified"

Review of the RN Narrative Notes for Patient #44 for 8/12/20 showed no documentation of the altercation between Patient #44 and Patient #5.


2nd assault: Patient #41 attacked by Patient #5 on 8/16/20.

Review of Patient Demographic Profile [Face Sheet] showed Patient #41 was admitted on 8/15/20.

Review of Initial Psychiatric Evaluation by Staff K (attending physician) dated 8/16/20 [not timed] showed a 16yo male with aggression, anger, and runaway behavior. He had a history of seizure disorder. He also had cuts to his wrist and right index finger. Admitting Diagnosis: Disruptive mood dysregulation disorder

Review of Medical History and Physical Consultation by Staff PP (Nurse Practitioner) dated 8/16/20 at 10:15am showed: Patient #41 had a right index finger abrasion - surgical glove in place, superficial lacerations to right hand and left forearm, and seizure disorder - Seizure Precautions.

Review of RN Narrative Note by Staff NN (RN) dated 8/16/20 at 3:30pm showed: Patient #41 "was attacked by two of his peers. Patient said he did not do anything to them. Patient was separated from the fight, walked to the quiet room Patient noted shaking, had seizure in the quiet room. Staff K (attending physician) notified. Order for Ativan 2mg IM ... Patient sustained bruise and swollen left lower eye and was bleeding from the re-opening of injured fingers ... Ice applied to the swollen face ... medical consult tomorrow ... Patient requested to press charges ... Patient moved to Unit 8."

Review of RN Narrative Note by Staff QQ (RN) dated 8/17/20 at 9:30am showed that the CPS case worker wanted assault charges on the patients that "inflicted trauma" to Patient #41.

Review of RN Narrative Note by Staff OO dated 8/17/20 at 3:00pm showed that Patient #41 was interviewed by the Houston Police Department. He was asked to file assault charges at the major assault unit.

Review of Medical Consult by Staff S (DO) dated 8/17/20 at 6:00pm showed that Patient #41 was seen for seizure and facial trauma. He was punched in the face and hit in the back of the head on 8/16/20, after which he said he had a seizure. Patient #41 reported he was sensitive to head trauma, "which can easily trigger a seizure in the past." He also had a nose bleed when punched in face. He complained of pain and tenderness in the cheek bone. Assessment: left facial trauma and pain, seizure disorder


3rd assault: Patient #42 attacked by Patient #5 on 8/18/20.

Review of Patient Demographic Profile [Face Sheet] showed Patient #42 was admitted on 8/16/20.

Review of Initial Psychiatric Evaluation by Staff K (attending physician) dated 8/17/20 at 4:00pm showed a 15yo male that was "homicidal toward his family." He was defiant and rebellious and had multiple hospitalizations. Admitting Diagnosis: Disruptive mood dysregulation disorder

Review of Medical History and Physical Consultation by Staff S (DO) dated 8/17/20 at 4:00pm showed: Patient #42 had a history of asthma.

Review of RN Narrative Note by Staff #QQ dated 8/18/20 at 4:50pm showed Patient #42 was attacked by another patient. Patient #42 was hit on the right side of the face. Patient later complained of "twisting left ankle." Staff K (attending physician) was notified.


4th assault: Patient #43 attacked by Patient #5 on 8/22/20.

Review of Patient Demographic Profile [Face Sheet] showed Patient #43 was admitted on 8/19/20.

Review of Initial Psychiatric Evaluation by Staff K (attending physician) dated 8/20/20 at 6:00pm showed a 15yo male with a history of fighting his father and "other people." Admitting Diagnosis: Disruptive mood dysregulation disorder

Review of Medical History and Physical Consultation by Staff PP (Nurse Practitioner) dated 8/20/20 at 10:40am showed: Patient #43 had asthma.

Review of RN Narrative Note by Staff #QQ dated 8/22/20 at 8:10pm showed Patient #43 got into a fight with patient #5 because Patient #5 poured water on him.


5th assault: Patient #14 attacked by Patient #5 on 8/31/20.

Review of Patient Demographic Profile [Face Sheet] showed Patient #14 was admitted on 8/30/20.

Review of Notification of Emergency Detention for Patient #14 dated 8/29/20 at 8:44pm by a Peace Officer showed: " ... hearing voices and wants to hurt himself ... voices ... telling him to hurt himself ... the voices he is hearing are demons."

Review of Physician Admission Order for Patient #14 by Staff BB (MD) dated 8/30/2020 at 7:20pm showed: Admit to Adolescent In-Patient.

Review of Physician Orders for Patient #14 by Staff BB (MD) dated 8/30/2020 at 7:21pm showed: Admit to Child In-Patient. Level of observation: Every 15 minutes. Precautions: Assault/Homicidal, Elopement Risk, Suicide, and Unit Restrictions.

Review of High Risk Notification Alert for Patient #14 by Staff KK (Intake RN) dated 8/30/20 at 7:10pm showed command auditory hallucinations threatening others and self, and elopement risk.

Review of Initial Psychiatric Evaluation by Staff K (attending physician) dated 8/31/20 at 8:00pm showed a 12yo male with unstable mood, suicidal ideation, aggression, and psychosis. Admitting diagnoses: Disruptive mood dysregulation disorder; psychotic, not otherwise specified; and attention deficit hyperactivity disorder.

Review of RN Narrative Note by Staff #QQ dated 8/31/20 at 8:05pm showed that Patient #14 was attacked by Patient #5 while "asleep in bed." The attack was "unprovoked." Staff K (attending physician) notified.

Review of RN Narrative Note by Staff QQ dated 9/1/20 at 9:00am showed that the parents of Patient #14 want to file assault charges on Patient #5. Patient #14 complained of right jaw pain. Police interviewed Patient #14 later that evening (6:38pm).

Review of Medical Consult Note by Staff PP (Nurse Practitioner) dated 9/1/20 at 10:25am showed: Right facial pain. Patient #14 stated, "I don't know what happened. I was sleeping and he [Patient #5] punched my face." Diagnosis: Right facial pain. Plan: Ibuprofen as needed.


6th assault: Patient #15 attacked by Patient #5 on 8/31/20.

Review of Patient Demographic Profile [Face Sheet] showed Patient #15 was admitted on 8/28/20.

Review of Initial Psychiatric Evaluation by Staff K (attending physician) dated 8/31/20 at 8:00pm showed a 15yo male with suicidal thoughts. Admission Diagnoses: Major depressive disorder, recurrent, without psychosis; disruptive mood dysregulation disorder.

Review of RN Narrative Note by Staff #QQ dated 8/31/20 at 8:15pm showed that Patient #15 was attacked by Patient #5 "unprovoked." Staff K (attending physician) notified.


Interviews.

In an interview with Staff RR (Medical Director) on 4/1/21 at 9:30am, he stated, when questioned about Patient #5, that the goal of patients placed in the hospital is to stabilize and return to outpatient services, but the CPS system does not always work that way because of difficulty with placement. He stated that some of these patients with placement challenges believe they have nothing to lose and feel stuck in the environment. They create "issues on the unit." He further stated that the levels of observation were every 15 minutes, every 5 minutes and one-on-one. He outlined the various precautions. As far as the violent attacks by Patient #5 on his peers, Staff RR stated, "If I was his doctor, I could have put him on a Q5 or a one-on-one." He concluded by saying that with the challenges created by the COVID pandemic, there had been a problem getting staff for one-on-ones.

In an interview with Staff K (MD) on 4/1/21 at 11:00am, he stated the levels of observation included every 15 minutes, every 5 minutes and a one-on-one. He also stated he was the attending physician for Patient #5 and was familiar with the patient's admission and treatment. When questioned about Patient #5's violent attacks, he stated, "If combative and attacks, a code green is called," adding that he "may use" a one-on-one. He then discussed how a "Q5 is close to a one-on-one," adding that the patient's care is reevaluated every 24 hours.

In an interview with Staff NN (RN) on 3/31/21 at 3:00pm, she stated the levels of observation were every 15 minutes, every 5 minutes or one-on-one, adding that the every 15-minutes observation was the minimum level of observation. She also stated that a reason for an increase in the level of observation would be if a patient was actively homicidal; observations every 5 minutes or a one-on-one observation could be initiated. She concluded by saying that after the first episode of a patient being physically assaultive, the patient would be monitored every 5 minutes and, if the behavior continued, the patient would be placed on a one-on-one observation.

In an interview with Staff M on 3/31/21 at 3:06pm, she stated the level of observation should be increased if a patient has an increased risk to hurt self and/or others and/or has an increase in acuity level.

In an interview with Staff N (RN) on 3/31/21 at 3:15 pm, she stated that Q15 level of observation should be increased to Q5 minutes if the patient is very aggressive.



Findings for B): The Treatment Plan Addendum/Update (Patient #5)

In an interview with Staff TT (Clinical Services Director) on 4/1/21 at 2pm, she provided a blank copy of the "Treatment Plan Addendum/Update." She stated the form is completed by staff following an incident of restraint or seclusion. She also stated staff identify additional steps designed to decrease the chance of the aggressive or assaultive behavior happening again. She concluded that the form is part of the Treatment Plan.

Review of form WOH-590e (02/20), "Treatment Plan Addendum/Update" (following restrictive intervention), showed:

1. Was behavior that led to restrictive intervention related to current treatment goals and or identified risk in the Treatment Plan? If no, describe the behavior that led to the restrictive intervention.

2. In reviewing the Treatment Plan, what modifications or additional strategies will be implemented that may reduce the potential for a future restrictive intervention (include identified interventions on Individual Crisis Plan):
Patient Signature ... Nursing Signature ... Social Services Signature ...


Patient #44.

Review of Restraint/Seclusion/Emergency Medication Order/Record dated 8/12/20 at 9:05pm showed Thorazine 50mg and Benadryl 50mg Intramuscularly (IM) were ordered by Staff K (attending physician). The medications were administered at 9:15pm. Seclusion was also ordered for up to 2 hours but not used. Specific Behaviors Exhibited: Patient #5 started chasing another patient and attacked him for no reason.

Review of Treatment Plan Addendum/Update dated 8/12/20 [not timed] by Staff MM (RN) showed the following modifications or additional strategies to be implemented that may reduce the potential for a future restrictive intervention: "Increased observations" and "utilize coping skills."

Review of Physician's Orders by Staff K (attending physician) dated 8/13/20 at 10:45am showed Unit Restrictions were reordered. [Note: there was no increase in the level of observations as outlined in the Treatment Plan Addendum/Update.]


Patient #14.

Review of Restraint/Seclusion/Emergency Medication Order/Record dated 8/31/20 at 8:05pm showed Thorazine 50mg and Benadryl 50mg Intramuscularly (IM) were ordered by Staff K (attending physician). The medications were administered at 8:05pm. Specific Behaviors Exhibited: Patient #5 attacked peers [Patient #14 and Patient #15] - one of the peers as he lay on his bed sleeping [Patient #14]

Review of Treatment Plan Addendum/Update by Staff OO (RN) dated 8/31/20 [not timed] showed the following modifications or additional strategies to be implemented that may reduce the potential for a future restrictive intervention: "Increased observation, discuss coping skills, review of boundaries, discuss triggers."

Review of Physician's Orders by Staff K (attending physician) dated 9/1/20 at 3:18am showed Patient #5 was placed on Assault/Homicidal Precautions and Unit Restrictions." [Note: There was no increase in observations.]



38015

Findings for C): Levels of observation for self-destructive patient (Patient #3) included:


Review of policy POC - N149, "Levels of Observation," last reviewed 2/2021, showed:

"Policy Statement: All patients will be routinely observed in compliance with physician orders and prescribed protocols. Patients exhibiting a risk potential for suicide, assault, ... elopement, ... will be placed on the appropriate precaution and level of observation per physician order, based on the level required for the individual patient.

To ensure patient safety when entering West Oaks Hospital, all patient routine Q [every] 15 [minutes] observations will start upon the pre-screening process in the Intake Department.e physician will order one of three levels of observation at time of admission and as the patient's condition warrants a change:

Q 15 minutes (routine observation for patients ...)

Q 5 minutes (requires a specific precaution)

One-on-one (requires a specific precaution) ..."


Record review of Patient #3's clinical file revealed the following: The patient, a 15-year-old female, was admitted to facility on 5/22/20 from Child Protective Services (CPS) and released back to CPS on 8/11/20. Reason for admission was Suicidal Ideation (thoughts of suicide) with a plan to hang self, which she had previously attempted. During stay at facility, she was responsible for generating 10 Restraint/Seclusion (R/S) incidences on her behalf, 9 of which involved self-harm. The Level of Observation for the patient was only temporarily increased 2 times per R/S reports. After all 10 R/S incidences, the patient, was successful in cutting her left forearm deeply, requiring a visit to the Emergency Room (ER) where she received 17 staples on one cut and 12 staples on another cut, both to left forearm.

Record review of Restraint/Seclusions documents for Patient #3 showed the following:

1). 6/24/20 at 10:40 am; Patient was banging head on wall, punching "hard" at nurse's station's desk glass. She was given an emergency medication Thorazine 50 mg IM (intramuscularly), restrained and secluded. Patient remained on Every 15 Minutes Observation (Q15). (No increase in level of observation).

2). 6/24/20 at 11:08 am; Patient was banging head on nursing station window and broke it. Haldol 10 mg IM and Benadryl 50 mg IM given. Physical restraint ordered. (Patient remained on Q15 min observation level).

3). 7/3/20 at 16:45 pm; Patient attempting to self-harm. She had "Torn-down" the nurses station window and injured staff, cutting self with plastic, sustaining self-inflicted injury to left anterior forearm. Thorazine 100 mg IM given, and physical restraint. (Patient remained on Q15 min level of observation).

4). 7/4/20 at 14:00 pm, Patient eloped into courtyard. She had broken the door, "pulled out metal from door" and threw it. Haldol 10 mg IM and Benadryl 50 mg IM given. (Patient remained on Q15 level of observation).

5). 7/13/20 at 18:00 pm, Patient attempted to jump into nurse's station, then she climbed a chair and damaged part of ceiling and a light fixture, reaching glass (from broken light bulb) and trying
to harm self with the glass. Haldol 10 mg IM given. (No change in Level of Observation, remaining on Q15 minutes).

6). 7/14/20 at 12:00 pm, Patient punching wall, attempting to break exit light. The exit lights were located on ceiling. Records were unclear about how she was attempting to get to the ceiling and staff interviewed were unaware or could not remember. However, the patient had a history of climbing chairs. (Patient remained on Q15 observation level).

7). 8/4/20 at 14:35 pm, Banging on nurse's station, "Broke nurses station ...attempting to cut ...destroying property". Haldol 10 mg IM, Benadryl 50 mg IM given, patient secluded. (Patient remained on Q15 level of observation).

8). 8/4/20 at 14:55 pm, Patient attempting to kill self by scratching arm and climbing to get to ceiling. Patient was restrained and secluded. The patient was then placed on Q5 minute level of observation (every 5 minutes, from 8/4/20 to 8/6/20), then was placed back on Q15 minutes observation.

9.) 8/6/20 at 12:12 pm, Patient banging door, punching wall, punching nurse's station. Haldol 10 mg IM and Benadryl 50 mg IM given (Level of Observation remained at Q15 minutes).

10). 8/9/20 at 15:15 pm, Patient banging nurse's station with head and arms, cutting self, cursing and threatening to kill everyone. Haldol 10 mg IM, Benadryl 50 mg IM, and physical restraint. (Patient remained on Q15 level of observation).


Record review of an investigation report made by Risk Manager/Assistant Administrator (RM/AA)-Staff B showed that shortly after Patient#3 was released from Seclusion on 8/9/20, she then was able to climb up on a chair again, break plastic covering over light fixture as before, broke and grabbed glass lightbulb, and cut herself 3 times on left f