HospitalInspections.org

Based on record review and and interview, it was determined that the facility failed to ensure patients had the right to appropriate treatment in the least restrictive environment, while ensuring protection of the individual.

A review of 1 of 8 patient's (Patient #7) records revealed staff #4 initiated a restraint without evidence of less restrictive/de-escalation techniques had occurred prior to the physical restraint.

Cross Refer to Patient Rights: Restraint Or Seclusion Tag 0165


The facility failed to ensure restraints were ordered by an authorized physician or other licensed practitioner in accordance with facility policy and State law.

A review of of 8 patient's (Patient #7) records revealed that a Mental Health Technician had initiated restraints without physician's order or evidence that staff had attempted a less restrictive/de-escalation techniques before the physical restraint occurred.

Cross Refer to Patient Rights: Restraint Or Seclusion Tag 0168


The facility failed to ensure a restraint was ordered by a physician or other licensed practitioner in accordance with facility policy and State law.

A review of 1 of 8 patient's (Patient #7) records revealed that a Mental Health Technician had initiated restraints without physician's order or evidence that staff had attempted a less restrictive/de-escalation techniques before the physical restraint occurred.

Cross Refer to Patient Rights: Restraint Or Seclusion Tag 0179


Based on a review of documentation and interview, the facility failed to ensure that for restraint episodes, the patient medical records include alternative or other less restrictive interventions attempted (as applicable).

A review of 1 of 8 patients' (Patient #7) records revealed there was no documentation alternative or less restrictive interventions occurred prior to the restraint.

Cross Refer to Patient Rights: Restraint Or Seclusion Tag 0186


Based on record review, interviews, and video surveillance, it was determined the facility failed to ensure patients were free from physical harm.

Staff #4, Mental Health Tech was seen physically assaulting Patient #1 on video surveillance. Staff #4 uses both hands to push Patient #1 in the chest. The force of this action, resulted in the patient taking multiple steps backwards. Additionally, Staff #4 has 2 previous incidents of unauthorized use of physical force, and 1 write up for "defensive posturing and verbalization."

Cross Refer to Freedom From Abuse, Neglect, and Exploitation Tag 1566

Based on record review and and interview, it was determined the facility failed to ensure patients had the right to appropriate treatment in the least restrictive environment, while ensuring protection of the individual.

Findings:

A review of facility policy -RI-203 "Patient Rights and Responsibilities" states, in part:

"Policy:

ALH, its employees, contractors, physicians, and allied health providers shall ensure that all patients are afforded basic rights as set forth by the Texas Administrative [sic], to include the fundamental right to considerate care safeguarding personal dignity and respecting cultural, psychological, and spiritual needs."


A review of the facility document entitled "Basic Rights of All Patients" stated in part,

" ...3. You have the right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs, and are treated with respect and dignity.

4. You have the right to appropriate treatment in the least restrictive appropriate setting available. This is a setting that provides you with the highest likelihood for improvement and that is not restrictive of your physical or social liberties than is necessary for the most effective treatment and for protections against any danger which you might pose to yourself or others.

5. You have the right to be free from mistreatment, abuse, neglect, and exploitation."


A review of facility policy -PC-127 entitled "Emergency Intervention (Restraint and Seclusion)" stated in part:

... 2.0 Use of Less-Restrictive Measures: The RN and unit staff implement the least restrictive, non-physical intervention, utilizing patient identified preferred de-escalation preferences and information from the initial assessment prior to seclusion/restraint, including:

2.1.1 Redirecting the patient's focus

2.1.2 Employing verbal de-escalation

2.1.3 Separating patient from group or community

2.1.4 Engaging the patient 1:1 activity to promote safe expression of feelings

2.1.5 Offering the use of the quiet room to decrease stimuli and regain control

2.1.6 Offering food or drinks

2.1.7 Administering medication as ordered by a physician to help the patient more effectively function in his/her environment

2.1.8 Documents the alternatives attempted or the rationale for not using alternatives as well as the patient's response to those measure"


The "Nurses Progress Notes" for 5/26/2019 stated in part,

"1300 Per staff pt (Patient #7) became combative attempting to hit and swinging @ them while in shower... while trying to contain pt, he hit his head and facial area on Rt (right side) against the wall. Pt observed bleeding from nose moderately, and noted small amt (amount) from abrasion to Rt side of forehead area. Pt appeared very upset and not wanting to speak even with S.W. whom he usually will speak with. Pt refused any type of care, treatment or assistance from nursing staff. Would not allow nursing to touch him. Pt given gauze to apply to nose and facial areas to wipe blood away. Noted pt had scattered abrasions to anterior upper Lt (left) side of chest, upper Lt side of back. Small abrasion to Rt side of neck area. Pt demands staff leave out of his Rm (room).


The "Psychiatric Progress Note" for 2/26/2019 completed by Staff #13, Psychiatrist, stated in part,

"Patient #7 is seen today for evaluation and followup [sic]. He is not cooperative. Continues to isolate himself, not interacting [sic] anybody. He spent significant amount of time in shower today and he had to be physically removed from his shower because he was flooding the bathroom. The patient continues to get increasingly irritable and agitated ..."


The facility document titled "Record of Verbal Counseling" signed by Staff #4 on 03/04/2019 in regards to Patient #7 stated in part,

"Corrective Action: The situation with patient (#7) ... was one which was possibly avoidable, and would like you to take the time to search your own actions during this intervention and ask yourself how you could have provided other, less aggressive solutions. This patient (#7) could have received other interventions prior to physical. Let's take a different approach in the future and utilize all of our resources, only using physical intervention when necessary to avoid harm to patient or staff and only as a last resort ..."


In an interview with Staff #5 RN, House Supervisor on 9/24/2019, he stated in part,

"If someone is really upset, I encourage staff to ask open ended questions. I encourage staff to utilize those skill sets. In this specific instance, hands at this time didn't need to be put on this patient (Patient #7) ... Staff #4 is very good at de-escalation, one of our best. When asked if he could confirm if the patient (#7) was placed in a restraint he stated, "briefly". Staff #5 stated in part, "There should have been a restraint package completed. The order and then under special obs (observation) we normally keep that record."

Based on record review and interview, it was determined that the facility failed to ensure restraints were ordered by a physician or other licensed practitioner in accordance with facility policy and State law.

Findings:

A review of facility policy -PC-127 entitled "Emergency Intervention (Restraint and Seclusion)" stated in part:

"3.0 Physician Orders, Consultation and Evaluation

3.1 Restraint and seclusion shall be used in emergency situations only and requires an order from a physician. Prior to initiation of restraint or seclusion, the physician and nurse will be aware of any consideration that should be taken based upon the initial assessment completed at the time of admission ...

In the absence of a physician the registered nurse may authorize the initiation of restraint/seclusion in an emergency...
The physician must be contacted for an order either during the emergency initiation of the restraint/seclusion or immediately (within a few minutes) after the restraint/seclusion has been initiated."


A review of 1 of 8 patients (Patient #7) records revealed that a Mental Health Technician had initiated restraints without physician's order or evidence that staff had attempted a less restrictive/de-escalation techniques before the physical restraint occurred.


The "Nurses Progress Notes" for Patient #7 on 5/26/2019 stated in part,

"1300 Per staff pt (Patient #7) became combative attempting to hit and swinging @ them while in shower... while trying to contain pt, he hit his head and facial area on Rt (right side) against the wall. Pt observed bleeding from nose moderately, and noted small amt (amount) from abrasion to Rt side of forehead area. Pt appeared very upset and not wanting to speak even with S.W. whom he usually will speak with. Pt refused any type of care, treatment or assistance from nursing staff. Would not allow nursing to touch him. Pt given gauze to apply to nose and facial areas to wipe blood away. Noted pt had scattered abrasions to anterior upper Lt (left) side of chest, upper Lt side of back. Small abrasion to Rt side of neck area. Pt demands staff leave out of his Rm (room).

1500 Staff #12 (psychiatrist) was called and medical consult ordered. Staff #13 (medical doctor) came to unit and attempted to assess pt which he again refused to speak with and demanded we leave the Rm. 0 (no) further orders @ this time. Nursing will continue observing pt during shift.

1800 No change in pts status @ this time. Has remained mute on unit. No peer interactions or staff. Isolating in Rm this pm but, presents on unit during early evening. Pt conts (continues) to refuse nursing to assess or [sic] any injuries (abrasions) ..."


The facility document titled "Physician's Subsequent Orders Sheet" on 2/25/19 at 1:15 pm revealed a medical consult was ordered to assess Patient #7 "facial area." There were no other orders noting the restraint performed by Staff #4. Additionally, the restraint paperwork was omitted.


In an interview with Staff #5 RN, House Supervisor, on 9/24/2019, he stated in part, "If someone is really upset, I encourage staff to ask open ended questions. I encourage staff to utilize those skill sets. In this specific instance, hands at this time didn't need to be put on this patient (Patient #7) ... Staff #4 is very good at de-escalation, one of our best. When asked if he could confirm if the patient (#7) was placed in a restraint he stated, "briefly". Staff #5 stated in part, "There should have been a restraint package completed. The order and then under special obs (observation) we normally keep that record."

Based on record review and interview, it was determined that the facility failed to ensure a 1-hour face to face was completed after the initiation of a restraint, and failed to evaluate the patient's immediate situation, reaction, and the need to continue or terminate the restraint.

Findings:

A review of facility policy -PC-127 entitled "Emergency Intervention (Restraint and Seclusion)" states, in part:

" ... 5.0 Fact to Face Evaluation by the Physician or trained RN/PA: Within one hour of the initiation of restraint or seclusion, the patient shall be evaluated in person by a physician, or trained RN/PA. A telephone call or telemedicine methodology is not allowed for these evaluations. The evaluation will be documented in the medical record to include the following:

5.1 The date time of the evaluation

5.2 An assessment of the patient's immediate situation

5.3 An evaluation of the patient's reaction to the intervention

5.4 An assessment of the patient's medical and behavioral condition, 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, etc.

5.5 As assessment of the need to continue or terminate the restraint/seclusion."


A review of 1 out of 8 patient's patient #7) medical records revealed there was no evidence a 1 hour face to face had been initiated.


The "Psychiatric Progress Note" for 2/26/2019 completed by Staff #13, Psychiatrist stated in part,

"Patient #7 is seen today for evaluation and followup [sic]. He is not cooperative. Continues to isolate himself, not interacting [sic] anybody. He spent significant amount of time in shower today and he had to be physically removed from his shower because he was flooding the bathroom. The patient continues to get increasingly irritable and agitated ..."

Staff #2, Director of Risk Management was asked for evidence of an incident report/investigation for Patient #7's injury and "physical escort". Staff #2 was unable to provide evidence of incident report/investigation documentation for Patient #7. Staff #2 was not aware a restraint had occurred. The restraint was verified in an interview with Staff #5 who reported the restraint occurred "briefly". The facility was unable to provide evidence of a 1-hour face to face.

Based on a review of documentation and interview, the facility failed to ensure that for restraint episodes, the patient medical records include alternative or other less restrictive interventions attempted (as applicable).

Findings:

A review of facility policy -PC-127 titled "Emergency Intervention (Restraint and Seclusion)" states, in part:

"Policy:

It is the policy of Austin Lakes Hospital to support each patient's right to be free from restraint or seclusion and therefore limit the use of these interventions to emergencies in which there is an imminent risk of a patient physically harming him/herself or others ... The patient has a right to be free from restraint seclusion imposed as a means of coercion, punishment, discipline, or retaliation by staff. Restraint/seclusion use will not be based on history of past use or dangerous behavior, as a convenience for staff, or substitute for adequate staffing ...

The facility is committed to preventing, reducing, and striving to eliminate the use of restraints and seclusions, as well as preventing emergencies that have the potential to lead to the use of these interventions. Hospital leadership supports these efforts through ongoing staff training and performance improvement activities.

... 2.0 Use of Less-Restrictive Measures: The RN and unit staff implement the least restrictive, non-physical intervention, utilizing patient identified preferred de-escalation preferences and information from the initial assessment prior to seclusion/restraint, including:

2.1.1 Redirecting the patient's focus

2.1.2 Employing verbal de-escalation

2.1.3 Separating patient from group or community

2.1.4 Engaging the patient 1:1 activity to promote safe expression of feelings

2.1.5 Offering the use of the quiet room to decrease stimuli and regain control

2.1.6 Offering food or drinks

2.1.7 Administering medication as ordered by a physician to help the patient more effectively function in his/her environment

2.1.8 Documents the alternatives attempted or the rationale for not using alternatives as well as the patient's response to those measures

...13.0 Documentation of use of restraint/seclusion: The use of restraint/seclusion will be thoroughly documented in the patient's medical record. Documentation related to restraint/seclusion includes:

...13.3.2 Consideration or failure of non-physical interventions

...13.3.3 The rationale for use of restraint/seclusion

...13.3.5 Written orders for use- including each order for continuation."


The facility document titled "Physician's Subsequent Orders Sheet" on 2/25/19 at 1:15 pm revealed a medical consult was ordered to assess Patient #7 "facial area." There were no other orders noting the restraint performed by Staff #4. Additionally, the restraint paperwork was omitted.


An interview was conducted with Staff #5 on 5/24/2019 and when asked if he could confirm if the patient was placed in a restraint he stated, "briefly".


Staff #2, Director of Risk Management was not aware a restraint had occurred. The restraint was verified in an interview with Staff #5 who reported the restraint occurred "briefly". The facility was unable to provide evidence alternative or less restrictive attempts had occurred prior to the patient restraint.

Based on record review, interviews, and video surveillance, it was determined the facility failed to ensure patients were free from physical harm.

Findings include:

A review of facility policy -RI-107 "Abuse, Neglect and Exploitation" states, in part:

"Policy: Patient abuse and neglect by hospital employee, employee affiliates, and agents shall not be tolerated and shall be grounds for disciplinary action.

Definitions:

1. Abuse- An act or failure to act performed knowingly, recklessly, or intentionally, including incitement to act, which caused or may have caused physical injury or death to a person served, to include:

a. An act inappropriate or excessive force or corporal punishment, regardless of whether the act results in a physical injury to a person served

b. The use of chemical or bodily restraints on a person served not in compliance with federal and state laws and regulations

2. Physical Abuse-

a. Assault- a threat to contact the body of a person without his/her consent

b. Battery- contacting the body of a person with/out his/her consent ...

Procedure:

... 4. Investigation and action

a. Upon become aware of an allegation and depending on the nature of the allegation, the CNO or designee shall take immediate action to safeguard patient by removing the indicated staff from access to patients, to include temporary re-assignment or suspension

b. The Director of Risk Management shall promptly and objectively investigate each allegation of patient abuse, neglect or exploitation by a conducting case review and interviewing all persons involved.

c. All allegations of abuse, neglect or exploitation shall be reported by the Director of Risk Management to the Texas Department of Human Services and UHS Corporate Office as indicated. A person having cause to believe that and elderly person, a person with a disability, or an individual receiving services from a provider is in a state of abuse, neglect, or exploitation must report the information immediately to DFPS Statewide Intake (SWI) ...

d. In the event that a criminal act is suspected, the Director of Risk Management shall confer with the CEO to determine the most reasonable course of action, to include seeking corporate and notification of police ..."


Review of Video Surveillance on 6/25/2019 at approximately 9:24 am revealed,

5/14/2019

1:47 pm - Patient #1 appears to be attempting to communicate with another patient sitting in a chair on the unit. Staff #4 attempts to stand between the two patients. Staff #4 and patient #1 are standing in front of each other, and appear to be communicating. Staff #4 is then seen forcibly pushing Patient #1 with both hands in the chest in front of the "PICU half door". The force from this action resulted in Patient #1 taking multiple steps backwards.


Staff #4 has 2 previous incidents of unauthorized use of physical force, and 1 write up for "defensive posturing and verbalization."

The above findings were confirmed in an interview with Staff #3, Director or Risk Management.