HospitalInspections.org

Based on record review and interview, the facility's governing body failed to carry out responsibilities in accordance with the facility's written policy and procedures to ensure specific patient rights were protected and promoted.
Specifically, the governing body failed to ensure:

A.) Patient #1's rights to be free from all forms of abuse by failing to prevent, protect, investigate, and report/respond to an allegation of physical abuse against a facility mental healthcare worker (MHW).

Patient #1, who was a minor, sustained scratches to his neck and a bruise to his face while voluntary admitted inpatient at the psychiatric hospital from 04/12/15 to 04/18/15. On 04/18/15, Patient #1 reported to the Charge Registered Nurse (RN) an allegation of physical abuse against a facility staff (MHW-A) following two undocumented restraints/containment. The physical abuse allegation was immediately reported to the Medical Doctor, the Chief Nursing Officer (CNO), and Patient #1's mother/guardian; however, this allegation was not reported to the state health care regulatory agency by any facility employees, the CNO, or Risk Manager in accordance with their policy. This allegation was not thoroughly investigated by the facility's governing body for the possible identification of physical abuse or mistreatment; and the MHW-A continued to work with patients following this allegation.

Refer to A 0145 for evidence of specific findings.

B.) Patient #2's Rights when facility staff allowed other patients in the facility to use interventions of ice, water, and contain/hold Patient #2 during episodes of night terrors; where he would display aggression.

Refer to A 0154 for specific evidence of 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 record review and interview, the facility failed to ensure specific patient rights were protected and promoted, and implement their written policy and procedures that protect and promote each patient's rights for 2 of 2 patients (Patient #1 and #2) reviewed with complaints of rights violations. Specifically, the facility failed to ensure:

A.) Patient #1's rights to be free from all forms of abuse by failing to prevent, protect, investigate, and report/respond to an allegation of physical abuse against a facility mental healthcare worker (MHW).

Patient #1, who was a minor, sustained scratches to his neck and a bruise to his face while voluntary admitted inpatient at the psychiatric hospital from 04/12/15 to 04/18/15. On 04/18/15, Patient #1 reported to the Charge Registered Nurse (RN) an allegation of physical abuse against a facility staff (MHW-A) following two undocumented restraints/containment. The physical abuse allegation was immediately reported to the Medical Doctor, the Chief Nursing Officer (CNO), and Patient #1's mother/guardian; however, this allegation was not reported to the state health care regulatory agency by any facility employees, the CNO, or Risk Manager in accordance with their policy. This allegation was not thoroughly investigated by the facility for the possible identification of physical abuse or mistreatment; and the MHW-A continued to work with patients following this allegation.

Refer to A 0145 for evidence of specific findings.

B.) Patient #1 and #2's Rights during the implementation of restraints and seclusion.
1.) Patient #1
a.) On 04/18/15 Mental Health Worker (MHW)-A implemented an undocumented restraint/containment that occurred in his bedroom without physician orders, monitoring, or a follow-up assessment; and MHW-A prevented egress for Patient #1 while in the seclusion room by using her foot to hold the door closed as a form of seclusion; without a physician order or documentation. As a result, Patient #1 reported to the Charge Registered Nurse (RN) an allegation of physical abuse against MHW-A immediately following the restraint and seclusion.

b.) On 04/18/15 Patient #1 received an emergency medication, Geodon, by intramuscular injection (IM) in his buttocks while he was restrained/held on his bed during the administration of this emergency medication. There was no documented evidence of physician orders for the emergency medication and restraint. There was no documentation of the restraint, monitoring, or a follow-up assessment.

2.) Patient #2

a.) Facility staff, RN's, allowed other patients in the facility to use interventions of ice, water, and contain/hold Patient #2 during episodes of night terrors; where he would display aggression.

Refer to A 0154 for specific evidence of findings.

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

Based on interview and record review, the facility failed to ensure the patient's rights to be free from all forms of abuse or harassment by failing to prevent, protect, investigate, and report/respond to an allegation of physical abuse in accordance with their policy, for 1 of 1 patients reviewed (Patient #1) with a complaint allegation of physical abuse against a facility mental healthcare worker (MHW).

Patient #1, who was a minor, sustained scratches to his neck and a bruise to his face while voluntary admitted inpatient at the psychiatric hospital from 04/12/15 to 04/18/15. On 04/18/15, Patient #1 reported to the Charge Registered Nurse (RN) an allegation of physical abuse against a facility staff (MHW-A) following two undocumented restraints/containment. The physical abuse allegation was immediately reported to the Medical Doctor, the Chief Nursing Officer (CNO), and Patient #1's mother/guardian; however, this allegation was not reported to the state health care regulatory agency by any facility employees, the CNO or Risk Manager in accordance with their policy. This allegation was not thoroughly investigated by the facility for the possible identification of physical abuse or mistreatment; and the MHW-A continued to work with patients following this allegation.

This deficient practice could affect the prevention of possible unidentified abuse, neglect, or mistreatment for all patients in the facility; by compromising their safety.

Findings Included:

Review of the facility's Policy and Procedures titled, Investigation of Abuse/Neglect Allegations, last reviewed January 2015 revealed, "All allegations of abuse, neglect or rights violations will be investigated, corrected, and reported." Each employee, affiliated staff members, and volunteers shall conform to the child abuse, neglect, and exploitations state rules of the State of Texas.

The policy indicated, in part: 12. Any staff member believed to have been involved in the abuse, neglect, or exploitation of a patient shall be suspended immediately pending an investigation of the circumstances. 13. As determined by the incident in question, the allegation is reportable to external agencies. 14. If determined to be reportable, the Risk Manager, or his designee, will notify the appropriate agency of the allegation within 24-hours of the time that the allegations was made. 15. Using Texas Family Code chapter 261 as a guide, if event is deemed reportable the report will be made to the appropriate agency: including (1) any local or state law enforcement agency; (2) the department; (3) the state agency that operates, licenses, certifies, or registers the facility in which the alleged abuse or neglect occurred; or (4) the agency designated by the court to be responsible for the protection of children. 17. Investigation methodology may consist of the following: a. Interviewing and/or obtaining written statements from the patient alleging abuse or neglect. b. Interviewing and/or obtaining written statements from other patients who have knowledge of the circumstances surrounding the allegation. c. Interviewing and/or obtaining written statements from the staff member (s) alleged against, or from, other staff members who were present at the time the alleged incident occurred. 19. The Risk Manager will maintain a central file of all documentation relevant to an abuse or neglect investigation.


Record review of the medical record of Patient #1 revealed he was an 8 year-old male admitted voluntarily to the psychiatric facility on 04/12/15 with diagnoses of Disruptive Mood Dysregulation Disorder, Oppositional Defiant Disorder, and Attention Deficit Hyperactivity Disorder. Further review of Patient #1's records revealed the following:


Review of the Nursing Progress Note dated 04/19/15 at 0005 completed and provided by Charge Registered Nurse (RN)-A on 06/25/15 revealed in part; On 04/18/15 at Navasota Unit, Staff [MHW-A] reported Patient #1 was having increased physical aggression. LVN A processed with Patient #1 and administered intermuscular (IM) Geodon. A little bit later, patients down the children's; boys' hall called for staff to come. I, Charge RN-A went to Patient #1's room where he was present with MHW- A. Patient cried out that she tried to choke him. D/t [due to] patients severe agitation at that time, he was escorted by staff to the quiet room. MHW-A stayed at quiet room door while Patient #1 continued to scream and cry in agitation. I, Charge RN-A, asked MHW-B to take over for MHW-A in attempt to calm Patient #1 down. Then MHW-B called me [Charge RN-A] over and showed me "redness and abrasions around [patient #1] pt.'s neck; that [patient #1] pt. claimed staff caused." I, Charge RN-A assessed Patient #1. I, Charge RN-A called and reported incident to the Chief Nursing Officer (CNO), RN. Supervising RN-A called unit after that and said for MHW-A to go to another unit (to work). After that, Patient #1's mother/guardian called to speak to patient. I, Charge RN-A spoke to Patient #1's mother and explained that Patient #1 had increased aggression with staff and required an injection but that Patient #1 was calm now. So I transferred the call to Patient #1. Patient #1's mother called Charge RN-A after speaking with him and she was very upset. The mother said Patient #1 "told her that he was hit in head by staff tonight." Patient #1's mother was very angry and said Patient #1 had reported to her on about "3 other occasions" of his stay that staff hurt him. Patient #1's mother said she wanted to discharge patient. I, Charge RN-A notified Medical Doctor (M. D.- A) and he said to discharge patient Against Medical Advice (AMA); if Patient #1's mother would not agree to keep him at the facility. After that; I, Charge RN-A, talked to Patient #1 and asked him what happened. Patient said, "he wouldn't go to bed when [MHW-A] was telling him to; and didn't want to say what else he did, but he did say that he called [MHW-A] the N word and the B word; and then he said she pushed his face into a pillow and put her hand around his neck." Patient #1's mother came around 2145 to discharge AMA. She said she would take him home and then to another Hospital tomorrow.

Record review of the AMA Discharge Assessment dated 04/18/15 at 2130 completed by Charge RN-A revealed Patient/Families concerns: Reasons for requesting discharge: "My son feels unsafe here;" per Patient #1's mother/guardian, "I suspect that my son was being abused."

Interview on 06/25/15 at 2:20 PM with the facility's Risk Manager (RM) indicated that she was aware of the alleged physical abuse allegation made by Patient #1 on 04/18/15 against MHW-A. The RM indicated that she had MHW-A complete a written statement. The RM confirmed that she had not reported the physical abuse allegation made by Patient #1 on 04/18/15 against MHW-A to the state health care regulatory agency, Department of State Health Services (DSHS); and further stated that she relocated from another state and would get confused on which agency she needed to report allegations to. The RM further confirmed the facility had not completed an investigation by initiating an incident analysis, special cause analysis, or root cause analysis with documented findings specific to this allegation.


Interview on 06/25/15 at 3:00 PM with Charge RN-A confirmed the Nursing Progress Note written on 04/19/15 at 0005 regarding Patient #'1's physical abuse allegation against MHW-A. Charge RN-A indicated she was called down to Patient #1's room by other patients in the unit; where MHW-A was alone in the room with Patient #1. MHW-B also came to assist MHW-A; and Patient #1 was taken to the seclusion room. Charge RN-A indicated she was then notified by MHW-B while Patient #1 was in the seclusion room of "redness to his neck." Charge RN-A stated the redness looked like a "fresh red." Charge RN-A stated Patient #1 alleged that MHW-A "choked him." Charge RN-A stated she notified the CNO and M.D.-A of the allegation. Charge RN-A stated that the Supervising RN-A asked her to write a statement (Nursing Progress Note dated 04/19/15 at 0005); which was then provided to him. Charge RN-A confirmed that she had not reported the physical abuse allegation made by Patient #1 against MHW-A to the state health care regulatory agency (DSHS).

Interview on 06/29/15 at 12:00 PM with MHW-B revealed on 04/18/15 during shower/bed time (approximately 7:00PM), she was called down the hall of the unit by other male patients that indicated a staff member, MHW-A, needed assistance because Patient #1 was hitting people. MSW-B indicated she went into Patient #1's room where MHW-A was in there with Patient #1 and "helped him up and walked him to the seclusion room." MHW-B indicated she stayed at the door with Patient #1 because "he was scared of the staff member [MHW-A] who was with him in his room." MHW-B indicated Patient #1 then proceeded to mention that "she [MHW-A] had choked him" and asked MHW- B not to leave him or allow MHW-A to be around him. MHW-B indicated she did notice "redness around his neck" and mentioned it to the Charge RN-A on shift.

Interview on 06/29/15 at 1:00 PM with the CNO confirmed that she was notified on 04/18/15 by Charge RN-A of the physical abuse allegation made by Patient #1 against MHW-A. The CNO also confirmed that she had read Charge RN-A's statement dated 04/19/15 at 0005. The CNO indicated that on 04/18/15 she directed Supervising RN-A to assess Patient #1 and to "handle the investigation." The CNO indicated that Supervising RN-A reported to her that Patient #1 had "all stages of bruises," with a "history of physical aggression with others." The CNO further stated that she had "looked at the video" but because the allegation occurred in Patient #1's bedroom; there was no evidence other than what staff stated. The CNO confirmed that she had not reported the physical abuse allegation made on 04/18/15 by Patient #1 against MHW-A to the state health care regulatory agency (DSHS) and did not have documented findings of the final determination by the facility regarding this physical abuse investigation.

Interview on 06/30/15 at 11:25 AM with MHW-A revealed on 04/18/15 Patient #1 had been displaying physical aggression towards others; and was "in and out of seclusion many times." MHW-A stated that after Patient #1 received an IM injection of Geodon at 1855 administered by LVN-A; he was "pissed and mad at me for holding him down for the shot" in his buttocks, and became "combative." MHW-A stated that Patient #1 then called her profanity names. MHW-A redirected him to his room and he then spit in her face and threw water into her face. MHW-A stated she had to do a containment, "bear hug hold" in his bedroom by herself because he was combative towards her. MHW-A indicated while she was holding him she yelled out to the other patients to get other staff for help because he was "head-butting, kicking, and calling me fat black bitch, [n-word], every cuss word." MHW-A stated that MHW-B came to assist and they escorted Patient #1 to the seclusion room. MHW-A stated she was told by Charge RN-A nurse that MHW-B would take over; and that she needed to leave the unit. MHW-A stated that Patient #1 did make comments while he was being escorted to the seclusion room that, "we beat him up." MHW-A stated the required paperwork, Specialized Treatment Procedure (STP), for the restraints/containments during the hold on 04/18/15 at 1855 for the IM Geodon administration; and the "bear hug hold" completed in his bedroom by MHW-A were not completed on 04/18/15 because it was the nurses responsibility to complete; and Charge RN-A did not want to complete the STP paperwork. MHW-A confirmed that she was never suspended, pending an investigation by the facility. MHW-A stated on 04/18/15 she was transferred to another unit following Patient #1's allegation against her.

Interview on 07/05/15 at 2:40 PM with Supervising RN-A indicated on 04/18/15 he was called down to the Navasota unit because Patient #1 was fighting. Supervising RN-A stated he received the allegation of physical abuse made by Patient #1 against MHW-A; that "he was choked." Supervising RN-A indicated that when he went to assess Patient #1 following the allegation; where he was in in his room with the lights off; and heavily medicated. Supervising RN-A stated during his assessment he noticed "superficial scratches" and "redness" to "both sides" of his neck. Supervising RN-A stated there was a bruise on his cheek; but that was "older." Supervising RN-A stated that he was unable to interview Patient #1 because he was "medicated" and then his mother came to discharge him AMA from the facility. Supervising RN-A stated he was in contact with the CNO regarding the physical abuse allegation and confirmed the allegation "needed investigating." Supervising RN-A confirmed he had not reported the physical abuse allegation made by Patient #1 against MHW-A to the state health care regulatory agency (DSHS).

Based on record review and interview, the facility staff failed to ensure patient rights in accordance with the facility's policy during the implementation of restraints and seclusion for 2 of 2 patients (Patient #1 and #2) reviewed with complaint allegations during the use of restraints. Specifically,
Patient #1

1.) On 04/18/15 Mental Health Worker (MHW)-A implemented an undocumented restraint/containment that occurred in his bedroom without physician orders, monitoring, or a follow-up assessment; and MHW-A prevented egress for Patient #1 while in the seclusion room by using her foot to hold the door closed as a form of seclusion; without a physician order or documentation.

As a result, Patient #1 reported to the Charge Registered Nurse (RN) an allegation of physical abuse against MHW-A immediately following the restraint and seclusion.

2.) On 04/18/15 Patient #1 received an emergency medication, Geodon, by intramuscular injection (IM) in his buttocks while he was restrained/held on his bed during the administration of this emergency medication. There was no documented evidence of physician orders for the emergency medication and restraint. There was no documentation of the restraint, monitoring, or a follow-up assessment.

Patient #2

1.) Facility staff, RN's, allowed other patients in the facility to use interventions of ice, water, and contain/hold Patient #2 during episodes of night terrors; where he would display aggression.

Findings included:

Review of the facility's Policy, Special Treatment Procedures (STP) for Seclusion and Restraints, last reviewed January 2015, specified the following, in part:

Seclusion was defined as, "Any involuntary confinement of a patient alone in a room or area where he/she is physically prevented from leaving. This includes situations where a staff physically prevents the patient from leaving."

Physical Restraints/Hold/Containments were defined as, "Any manual or physical method of holding the patient against the patient's will that restricts freedom of movement or normal access to one's body. For example, holding a patient to give a forced psychotropic medication in a manner that restricts his or her movement constitutes a physical restraint."

The Restraint/Seclusion Procedures and Responsibilities of staff included;

- The Physician/RN assessed the need for restrictive intervention and a written or telephonic order is obtained from the physician for the seclusion/restraint on the Seclusion/Restraint Order form. A physician must order the use of containment or seclusion.

- If physical restraint is indicated, two (2) staff must participate in the physical hold application. If the physical restraint/hold is on a child patient, one staff may implement the hold while a second staff serves as witness to monitor patient and safety for the duration of the hold.

- Assigned staff conducting continuous in-person observation/monitoring for the duration of the seclusion/restraint episode documents patient observations on the STP Seclusion/Restraint Hourly Flow Sheet that included the following, in part;
Reviews for signs of injury
Evaluates patient behavior, staff interventions and patient responses
Monitors for circulation and skin integrity
Obtains vital signs

The Restraint/Seclusion policy indicated within one hour of the initiation of containment or seclusion, a physician or qualified RN trained in the use of emergency safety interventions and permitted by the Texas Administrative Code and the organization to assess the physical and psychological well-being of residents must conduct a fact-to-face assessment of the physical and psychological well being of the patient.

The Restraint/Seclusion policy designated Direct Care Staff to document in the patient's chart that the seclusion/restraint was the least restrictive intervention that protects the patient's safety and that its utilization was based on an individualized patient assessment. Documentation was to be completed on the STP; Seclusion/Restraint Clinical Note section.

Review of the facility's STP form used for documentation of Restraints, Seclusion, and Emergency Medications last updated 11/01/14 revealed it included the required documentation for; observation/monitoring of the patient, interventions used, staff involved, reintegration, debriefing, nursing assessments, follow-up assessment, clinical reviews, documentation of Physician Orders (PO's) obtained, and final review of the Quality RN and/or MD.

Patient #1

1.) Review of the complaint allegation "Intake information" dated 04/20/15 indicated that on 04/18/15 Patient #1 had an altercation with two staff members, MHW-A and C, because he did not want to go to sleep at an "early bedtime". Patient #1 indicated that MHW-A contained Patient #1 in his bedroom and also pushed his head into the bed. Patient #1 indicated that MHW-A had her hand on his face and her thumb on his neck during restraint. Further allegation by Patient #1 indicated that MHW-A threw him on the bed of a seclusion room; where he banged on the door and told the person who answered the door about the "physical abuse."

Record review of the medical record of Patient #1 revealed he was an 8 year-old male admitted voluntarily to the psychiatric facility on 04/12/15 with diagnoses of Disruptive Mood Dysregulation Disorder, Oppositional Defiant Disorder, and Attention Deficit Hyperactivity Disorder. Further review of Patient #1's records revealed the following:

The Nursing Progress Note dated 04/19/15 at 0005 completed and provided by Charge Registered Nurse (RN)-A during an interview on 06/25/15; and was not part of Patient #1's record revealed in part; On 04/18/15 Staff, MHW-A, reported Patient #1 was having increased physical aggression. Licensed Vocational Nurse (LVN)-A administered IM Geodon. A little bit later, patients down the children's; boys' hall called for staff to come. I, Charge RN-A went to Patient #1's room where he was present with MHW- A. Patient cried out that she tried to choke him. D/t [due to] patients severe agitation at that time, he was escorted by staff to the quiet room. MHW-A stayed at quiet room door while Patient #1 continued to scream and cry in agitation. I, Charge RN-A, asked MHW-B to take over for MHW-A in attempt to calm Patient #1 down. Then MHW-B called me [Charge RN-A] over and showed me "redness and abrasions around [patient #1] pt.'s neck; that [patient #1] pt. claimed staff caused." I, Charge RN-A assessed Patient #1. I, Charge RN-A called and reported incident to the Chief Nursing Officer (CNO), RN. Supervising RN-A called unit after that and said for MHW-A to go to another unit (to work). After that, Patient #1's mother/guardian called to speak to patient. I, Charge RN-A spoke to Patient #1's mother and explained that Patient #1 had increased aggression with staff and required an injection but that Patient #1 was calm now. So I transferred the call to Patient #1. Patient #1's mother called Charge RN-A after speaking with him and she was very upset. The mother said Patient #1 "told her that he was hit in head by staff tonight." Patient #1's mother was very angry and said Patient #1 had reported to her on about "3 other occasions" of his stay that staff hurt him. Patient #1's mother said she wanted to discharge patient. I, Charge RN-A notified Medical Doctor (M.D. A) and he said to discharge patient Against Medical Advice (AMA); if Patient #1's mother would not agree to keep him at the facility. After that; I, Charge RN-A, talked to Patient #1 and asked him what happened. Patient said, "he wouldn't go to bed when [MHW-A] was telling him to; and didn't want to say what else he did, but he did say that he called [MHW-A] the N word and the B word; and then he said she pushed his face into a pillow and put her hand around his neck." Patient #1's mother came around 2145 to discharge AMA.

Interview on 06/30/15 at 11:25 AM with MHW-A stated on 04/18/15 at approximately 1900 she kept redirecting Patient #1 to "go to bed;" while she was monitoring the hallway right outside of Patient #1's bedroom. MHW-A stated that Patient #1 became verbally aggressive; spit at her, and threw a cup of water at her face. MHW-A stated she notified LVN-A of Patient #1's aggression and he was administered a shot (Geodon 20mg IM) in his room, on his bed by LVN-A. MHW-A stated that she and MHW-C held Patient #1 face down on his bed while LVN-A administered the Geodon into his buttocks. MHW-A stated that immediately after the injection Patient #1 "targeted" her because he was "pissed and mad at me because I had to hold him down for the shot." MHW-A stated that after MHW-C and LVN-A left the bedroom, Patient #1 was verbally and physically aggressive towards her; and she implemented a "bear hug" type containment by herself in his bedroom. MHW-A stated that during the containment, Patient #1 "head-butted" her and was kicking. MHW-A indicated she yelled out for other staffs' help. MHW-A indicated that MHW-B came to assist her with Patient #1 and she and MHW-B then escorted Patient #1 to the seclusion room; "holding the door closed with foot" to prevent him from leaving the seclusion room. MHW-A stated that she was then told to leave the unit by RN-A and MHW-B took over Patient #1's care while he remained in the seclusion room. MHW-A indicated that on 04/18/15 Patient #1 was displaying aggression towards others and had been taken "in and out of seclusion" multiple times. MHW-A stated STP forms were to be completed during patient seclusion only when the seclusion door "was locked by staff"; or if a restraint/containment was used on a patient. MHW- A stated that she kept Patient #1 from leaving the seclusion room by placing her foot on the bottom of the door, keeping the door shut; but not locking the lock on the door. MHW- A confirmed that she did not complete the STP form regarding Patient #1's restraint in his room while she held him down for the Emergency Medication injection. MHW-A further confirmed that she did not complete STP form for the "bear hug" restraint/containment when she held Patient #1 in his bedroom. MHW-A confirmed that she did not complete the STP form for holding the seclusion door shut with her foot; and further confirmed that by her holding the door shut with her foot was considered seclusion because it prevented egress from the room by Patient #1. MHW-A stated she had been trained to implement restraints only with two staff, and to complete the STP forms along with the assistance from the Charge RN; and further stated there was not any staff around when she needed to contain Patient #1 on 04/18/15 and further stated the Charge RN indicated to her that she did not want to complete STP paperwork.

Review of MHW-A's documented statement dated 06/30/15 revealed on 04/18/15 during shower and bed time, Patient #1 was being non-compliant and disrespectful by refusing to go to bed and calling MHW-A profanity names. MHW-A stated she had to use the "bear-hug technique, holding him from behind" after Patient #1 was calling her names, hitting, and throwing water on her. MHW-A stated that MHW-B came to escort Patient #1 to the seclusion room and, "he accused staff of hurting him and saying we hit him."

Review of Patient #1's Special Treatment Procedures (STP) forms in his record where facility staff were to document Restraints, Seclusions, and Emergency Medications revealed there was no evidence the STP form was completed by any facility staff for the "bear hug" restraint/hold MHW-A implemented in Patient #1's bedroom on 04/18/15 after 1900; or for holding the seclusion room door shut with her [MHW-A] foot; preventing Patient #1's egress from the room.

Review of Patient #1's Physician Orders (PO) for 04/18/15 from 0100 to 2000 revealed there was not a physician telephone order or written order for the use of restraint or seclusion. The only PO documented from 0100 to 2000 was at 0921 a telephone order (TO) for Benadryl IM, 100 mg to be administered now; and at 2000 for discharge AMA.

2.) Review of Patient #1's Medication Administration Record (MAR) revealed on 04/18/15 at 1855 Patient #1 was administered a One Time Emergency Medication, Geodon 20 milligrams (mg), IM; into his buttocks by Licensed Vocational Nurse (LVN) A due to "severe agitation."

Review of Patient #1's PO for 04/18/15 from 0100 to 2000 revealed there was not a physician telephone order or written order for the Emergency Medication, Geodon 20mg administered IM on 04/18/15 at 1855.

Review of Patient #1's STP forms in his record where facility staff were to document Restraints, Seclusions, and Emergency Medications revealed there was no evidence the STP form was completed by any facility staff for the Emergency Medication, Geodon, administered at 04/18/15 at 1855 IM; to include the physical restraint/hold completed by MHW-A and B during the administration of this medication; as stated by MHW-A during interview.

Review of the facility's tracking system for significant events related to Restraint, Seclusion, and Emergency Medications titled, General Event Reports (GER) for 04/18/15 for Patient #1 revealed only one GER at 1315 completed by RN-B. RN-B documented that Patient was throwing objects at staff, kicking, and punching staff. Physical restraint was implemented from 1245 to 1246. Seclusion was implemented from 1245 to 1315, and emergency medication, Benadryl IM, was administered at 1348. There was no documentation of a GER for Restraint, Seclusion, or Emergency Medication for any events after 1358 on 04/18/15 for Patient #1.

Interview on 07/06/15 at 2:00 PM with the CNO confirmed there was not a verbal or written PO in Patient #1's chart for the Geodon 20mg administered to Patient #1 on 04/18/15 at 1855 by LVN-A. The CNO confirmed there was no evidence that STP forms were completed for the emergency medication administration of Geodon on 04/18/15 at 1855; or the restraint/hold completed by MHW-A and C during the administration of this emergency medication. The CNO also confirmed there was no evidence that STP forms were completed by facility staff for Patient #1's restraint/containment by MHW-A in his bedroom on 04/18/15. The CNO indicated it was the MHW and Charge RN's responsibility to ensure the STP forms were completed for any Restraint, Seclusion, and Emergency Medication. The CNO stated the STP forms included all the required documentation for monitoring, follow-up assessments, and were signed by the MD.

Patient #2

Record review of Patient #2's medical record revealed he was a 30 year old male admitted to the facility on 02/24/14 to 04/20/15 in the military unit for Post-Traumatic Stress Disorder (PTSD). Patient #2 suffered from violent night terrors; insomnia.

Review of the Complaint Form completed by Patient #2, received 05/07/15 indicated during his admission at the facility; "the patients, not staff, have sprayed water in my face, slapped me, held me down, put ice down my back, feet, etc."

Review of the Nursing Progress Note dated 03/10/15 completed by RN-E at 0429 revealed in part; "observed yelling, being held lightly by another patient, who guided him back to the quiet room."

Review of the Nursing Progress Note dated 03/16/15 completed by RN-F at 0600 revealed in part; Pt. "screaming and yelling. Four peers came to his aid, kept him from banging head on door [and] placed ice in his hand while reassuring him of his safety [and] surroundings. Assisted back to mat in quiet room by peers. Peers VERY helpful [with] keeping pt. contained [and] safe."

Review of the Nursing Progress Note dated 03/26/15 completed by RN-C revealed the following, in part:
At 0505 Patient #2 appears to be suffering from a nightmare.
At 0510 Male Peers (Patient #3 and #4) at bedside; positioned on either side of Patient #2. Both men (Patient #3 and #4) proceeded to "touch, shake, apply ice to face and feet" of Patient #2. Unable to wake Patient #2. Patient rolled out of bed onto floor.
At 0515 Peers (Patient #3 and #4) finally lifted patient from floor back into bed.
At 0625 Patient (#2) able to discuss feelings with nursing staff. States no injuries from nightmare or "peer interventions of ice/water/physical holding."

Review of the Nursing Progress Note dated 03/28/15 completed by RN-C revealed the following, in part:
At 0705 Patient yelling. Begins to strike out at peers. Patient (pt.) "struggling [with] peers holding him to keep from being struck. Applying ice to face, waking pt." Pt. screaming, kicking, hitting out. Peers cautioned to let go if pt. continues to increase aggressive behavior.

Review of the Nursing Progress Note dated 03/28/15 completed by RN-D revealed the following, in part:
At 0700 Pt. was yelling and screaming and seemed to still be in a nightmare. "Peers wee spraying water in the pt.'s face and holding his arms so they wouldn't get hit." Pt. awake from nightmare. Pt. upset and felt like peers were hitting him when in the nightmare.

Review of the Physician's Progress Note dated 03/28/15 revealed Patient #2 stated that he "felt like he was abused by his peers" when they tried to wake him up. Patient #2 stated to the Physician that his face hurt and his sternum hurt.

Review of Patient #2's PO revealed on 03/28/15 at 1144 a PO; "Please do not touch patient during sleep terrors; intervene physically only if patient acute danger to self or others; do not use water to wake patient. (Per patient's request)."

Review of Patient #2's Master Treatment Plan dated 02/24/15 for his trauma related issues of nightmares, flashbacks, and night terrors did not include any designated interventions or assistance from peers during trauma related issues. There also were no designated interventions for the use of ice, water, or physical holding during night terror episodes in attempt to wake/orient Patient #2.

Review of the facility Policy and Procedures (P & P) for Special Treatment Procedures, last reviewed January 2015, revealed in the area of staff responsibilities; "1. Only staff members who have completed the [facility] Hospital training in the response to patient aggression and who are up to date with the annual requirement for that training may participate in the seclusion or containment of a patient or resident."

Review of the facility P & P for Verbal De-escalation and use of CPI (behavioral interventions), last reviewed January 2015, revealed under Procedures that staff responsibilities included; "2. Ensure all patients/visitors not involved in the situation in their assigned rooms or away from area."

Interview on 06/25/15 at 4:05 PM with RN-C confirmed that she knew that other patients were not to be assisting with interventions for Patient #2 during his night terror episodes. RN-C stated that the other patients felt like they needed to intervene and assist Patient #2 because the peers/patients were his "battle buddies" and they had a "comrade" mentality to help each other. RN-C stated that she knew that using ice and water as interventions were "not approved therapies," but she felt pressured by the other patients, who were "dominant." RN-C stated she allowed the other patients to assist with interventions and "hold" Patient #2; otherwise the unit would have to call codes constantly to assist with Patient #2's aggression. RN-C stated that she had communicated these concerns with her supervisor and physician; without any "clear direction." RN-C indicated that she felt like she was Patient #2's target during his night terror episodes and his peers were better to assist him; due to the "us and them" culture of the unit. RN-C stated after Patient #2 complained about his peers/other patients intervening by stating he was "being tortured/hurt;" the unit was changed and expectations were implemented for peers and staff to ensure everyone was safe.

Interview on 06/24/15 with the RN Director of Nursing (DON)- Unit Supervisor at 11:20 AM revealed it was difficult and a "delicate situation to balance when redirecting other patients away" from Patient #2 during night terror episodes, "because they would get upset, and we could have a riot if we don't address situation delicately." The RN DON confirmed it was not allowed for other patients to restrain Patient #2 and when it was identified as an issue; "corrective action" had been taken.

Further interview on 06/25/15 with the RN DON-Unit Supervisor at 12:00 PM stated she had "talked" to the RN's on the unit; to not allow other peers/patients to assist in interventions of Patient #2. RN-Unit Supervisor stated she had not completed any formal written in service training or corrective action with the unit RN's regarding the facility's P & P for Special Treatment Procedures.

Based on record review and interview, the Chief Nursing Officer (CNO) failed to adequately direct, monitor, and evaluate the quality of nursing care provided to patients in accordance with the facility's policy and procedures for 2 of 2 patients reviewed (Patient #1 and #2). Specifically, the CNO failed to ensure:


1.) Patient #1's rights to be free from all forms of abuse by failing to prevent, protect, investigate, and report/respond to an allegation of physical abuse against a facility mental healthcare worker (MHW).

Patient #1, who was a minor, sustained scratches to his neck and a bruise to his face while voluntary admitted inpatient at the psychiatric hospital from 04/12/15 to 04/18/15. On 04/18/15, Patient #1 reported to the Charge Registered Nurse (RN) an allegation of physical abuse against a facility staff (MHW-A) following two undocumented restraints/containment. The physical abuse allegation was immediately reported to the Medical Doctor, the CNO, and Patient #1's mother/guardian; however, this allegation was not reported to the state health care regulatory agency by any facility employees, the CNO, or Risk Manager in accordance with the facility's policy. This allegation was not thoroughly investigated by the facility's governing body for the possible identification of physical abuse or mistreatment; and the MHW-A continued to work with patients following this allegation.

2.) Patient #2's Rights when facility RN's, allowed other patients in the facility to use interventions of ice, water, and contain/hold Patient #2 during episodes of night terrors; where he would display aggression.

Findings included:
1.) Review of the facility's Policy and Procedures titled, Investigation of Abuse/Neglect Allegations, last reviewed January 2015 revealed, "All allegations of abuse, neglect or rights violations will be investigated, corrected, and reported." Each employee, affiliated staff members, and volunteers shall conform to the child abuse, neglect, and exploitations state rules of the State of Texas.

The policy indicated, in part: 12. Any staff member believed to have been involved in the abuse, neglect, or exploitation of patients shall be suspended immediately pending an investigation of the circumstances. 13. As determined by the incident in question, the allegation is reportable to external agencies. 14. If determined to be reportable, the Risk Manager, or his designee, will notify the appropriate agency of the allegation within 24-hours of the time that the allegations was made. 15. Using Texas Family Code chapter 261 as a guide, if event is deemed reportable the report will be made to the appropriate agency: including (1) any local or state law enforcement agency; (2) the department; (3) the state agency that operates, licenses, certifies, or registers the facility in which the alleged abuse or neglect occurred; or (4) the agency designated by the court to be responsible for the protection of children. 17. Investigation methodology may consist of the following: a. Interviewing and/or obtaining written statements from the patient alleging abuse or neglect. b. Interviewing and/or obtaining written statements from other patients who have knowledge of the circumstances surrounding the allegation. c. Interviewing and/or obtaining written statements from the staff member (s) alleged against, or from, other staff members who were present at the time the alleged incident occurred. 19. The Risk Manager will maintain a central file of all documentation relevant to an abuse or neglect investigation.


Record review of the medical record of Patient #1 revealed he was an 8 year-old male admitted voluntarily to the psychiatric facility on 04/12/15 with diagnoses of Disruptive Mood Dysregulation Disorder, Oppositional Defiant Disorder, and Attention Deficit Hyperactivity Disorder. Further review of Patient #1's records revealed the following:

Review of the Nursing Progress Note dated 04/19/15 at 0005 completed and provided by Charge Registered Nurse (RN)-A on 06/25/15 revealed in part; On 04/18/15 at Navasota Unit, Staff [MHW-A] reported Patient #1 was having increased physical aggression. LVN A processed with Patient #1 and administered intermuscular (IM) Geodon. A little bit later, patients down the children's; boys' hall called for staff to come. I, Charge RN-A went to Patient #1's room where he was present with MHW- A. Patient cried out that she tried to choke him. D/t [due to] patients severe agitation at that time, he was escorted by staff to the quiet room. MHW-A stayed at quiet room door while Patient #1 continued to scream and cry in agitation. I, Charge RN-A, asked MHW-B to take over for MHW-A in attempt to calm Patient #1 down. Then MHW-B called me [Charge RN-A] over and showed me "redness and abrasions around [patient #1] pt.'s neck; that [patient #1] pt. claimed staff caused." I, Charge RN-A assessed Patient #1. I, Charge RN-A called and reported incident to the Chief Nursing Officer (CNO), RN. Supervising RN-A called unit after that and said for MHW-A to go to another unit (to work). After that, Patient #1's mother/guardian called to speak to patient. I, Charge RN-A spoke to Patient #1's mother and explained that Patient #1 had increased aggression with staff and required an injection but that Patient #1 was calm now. So I transferred the call to Patient #1. Patient #1's mother called Charge RN-A after speaking with him and she was very upset. The mother said Patient #1 "told her that he was hit in head by staff tonight." Patient #1's mother was very angry and said Patient #1 had reported to her on about "3 other occasions" of his stay that staff hurt him. Patient #1's mother said she wanted to discharge patient. I, Charge RN-A notified Medical Doctor (M. D.- A) and he said to discharge patient Against Medical Advice (AMA); if Patient #1's mother would not agree to keep him at the facility. After that; I, Charge RN-A, talked to Patient #1 and asked him what happened. Patient said, "he wouldn't go to bed when [MHW-A] was telling him to; and didn't want to say what else he did, but he did say that he called [MHW-A] the N word and the B word; and then he said she pushed his face into a pillow and put her hand around his neck." Patient #1's mother came around 2145 to discharge AMA. She said she would take him home and then to another Hospital tomorrow.

Record review of the AMA Discharge Assessment dated 04/18/15 at 2130 completed by Charge RN-A revealed Patient/Families concerns: Reasons for requesting discharge: "My son feels unsafe here;" per Patient #1's mother/guardian, "I suspect that my son was being abused."

Interview on 06/25/15 at 2:20 PM with the facility's Risk Manager (RM) indicated that she was aware of the alleged physical abuse allegation made by Patient #1 on 04/18/15 against MHW-A. The RM indicated that she had MHW-A complete a written statement. The RM confirmed that she had not reported the physical abuse allegation made by Patient #1 on 04/18/15 against MHW-A to the state health care regulatory agency, Department of State Health Services (DSHS); and further stated that she relocated from another state and would get confused on which agency she needed to report allegations to. The RM further confirmed the facility had not completed an investigation by initiating an incident analysis, special cause analysis, or root cause analysis with documented findings specific to this allegation.

Interview on 06/25/15 at 3:00 PM with Charge RN-A confirmed the Nursing Progress Note written on 04/19/15 at 0005 regarding Patient #'1's physical abuse allegation against MHW-A. Charge RN-A indicated she was called down to Patient #1's room by other patients in the unit; where MHW-A was alone in the room with Patient #1. MHW-B also came to assist MHW-A; and Patient #1 was taken to the seclusion room. Charge RN-A indicated she was then notified by MHW-B while Patient #1 was in the seclusion room of "redness to his neck." Charge RN-A stated the redness looked like a "fresh red." Charge RN-A stated Patient #1 alleged that MHW-A "choked him." Charge RN-A stated she notified the CNO and M.D.-A of the allegation. Charge RN-A stated that the Supervising RN-A asked her to write a statement (Nursing Progress Note dated 04/19/15 at 0005); which was then provided to him. Charge RN-A confirmed that she had not reported the physical abuse allegation made by Patient #1 against MHW-A to the state health care regulatory agency (DSHS).

Interview on 06/29/15 at 12:00 PM with MHW-B revealed on 04/18/15 during shower/bed time (approximately 7:00PM), she was called down the hall of the unit by other male patients that indicated a staff member, MHW-A, needed assistance because Patient #1 was hitting people. MSW-B indicated she went into Patient #1's room where MHW-A was in there with Patient #1 and "helped him up and walked him to the seclusion room." MHW-B indicated she stayed at the door with Patient #1 because "he was scared of the staff member [MHW-A] who was with him in his room." MHW-B indicated Patient #1 then proceeded to mention that "she [MHW-A] had choked him" and asked MHW- B not to leave him or allow MHW-A to be around him. MHW-B indicated she did notice "redness around his neck" and mentioned it to the Charge RN-A on shift.

Interview on 06/29/15 at 1:00 PM with the CNO confirmed that she was notified on 04/18/15 by Charge RN-A of the physical abuse allegation made by Patient #1 against MHW-A. The CNO also confirmed that she had read Charge RN-A's statement dated 04/19/15 at 0005. The CNO indicated that on 04/18/15 she directed Supervising RN-A to assess Patient #1 and to "handle the investigation." The CNO indicated that Supervising RN-A reported to her that Patient #1 had "all stages of bruises," with a "history of physical aggression with others." The CNO further stated that she had "looked at the video" but because the allegation occurred in Patient #1's bedroom; there was no evidence other than what staff stated. The CNO confirmed that she had not reported the physical abuse allegation made on 04/18/15 by Patient #1 against MHW-A to the state health care regulatory agency (DSHS) and did not have documented findings of the final determination by the facility regarding this physical abuse investigation. The CNO stated that MHW-A was moved off of the unit upon knowledge of the allegation and further confirmed that MHW-A was not suspended pending the outcome of the allegation.

Interview on 06/30/15 at 11:25 AM with MHW-A revealed on 04/18/15 Patient #1 had been displaying physical aggression towards others; and was "in and out of seclusion many times." MHW-A stated that after Patient #1 received an IM injection of Geodon at 1855 administered by LVN-A; he was "pissed and mad at me for holding him down for the shot" in his buttocks, and became "combative." MHW-A stated that Patient #1 then called her profanity names. MHW-A redirected him to his room and he then spit in her face and threw water into her face. MHW-A stated she had to do a containment, "bear hug hold" in his bedroom by herself because he was combative towards her. MHW-A indicated while she was holding him she yelled out to the other patients to get other staff for help because he was "head-butting, kicking, and calling me fat black bitch, [n-word], every cuss word." MHW-A stated that MHW-B came to assist and they escorted Patient #1 to the seclusion room. MHW-A stated she was told by Charge RN-A nurse that MHW-B would take over; and that she needed to leave the unit. MHW-A stated that Patient #1 did make comments while he was being escorted to the seclusion room that, "we beat him up." MHW-A stated the required paperwork, Specialized Treatment Procedure (STP), for the restraints/containments during the hold on 04/18/15 at 1855 for the IM Geodon administration; and the "bear hug hold" completed in his bedroom by MHW-A were not completed on 04/18/15 because it was the nurses responsibility to complete; and Charge RN-A did not want to complete the STP paperwork. MHW-A confirmed that she was never suspended, pending an investigation by the facility. MHW-A stated on 04/18/15 she was transferred to another unit following Patient #1's allegation against her.

Interview on 07/05/15 at 2:40 PM with Supervising RN-A indicated on 04/18/15 he was called down to the Navasota unit because Patient #1 was fighting. Supervising RN-A stated he received the allegation of physical abuse made by Patient #1 against MHW-A; that "he was choked." Supervising RN-A indicated that when he went to assess Patient #1 following the allegation; where he was in in his room with the lights off; and heavily medicated. Supervising RN-A stated during his assessment he noticed "superficial scratches" and "redness" to "both sides" of his neck. Supervising RN-A stated there was a bruise on his cheek; but that was "older." Supervising RN-A stated that he was unable to interview Patient #1 because he was "medicated" and then his mother came to discharge him AMA from the facility. Supervising RN-A stated he was in contact with the CNO regarding the physical abuse allegation and confirmed the allegation "needed investigating." Supervising RN-A confirmed he had not reported the physical abuse allegation made by Patient #1 against MHW-A to the state health care regulatory agency (DSHS).

2.) Review of the facility's Policy and Procedures (P &P), Special Treatment Procedures (STP) for Seclusion and Restraints, last reviewed January 2015, specified the following, in part:

Physical Restraints/Hold/Containments were defined as, "Any manual or physical method of holding the patient against the patient's will that restricts freedom of movement or normal access to one's body. For example, holding a patient to give a forced psychotropic medication in a manner that restricts his or her movement constitutes a physical restraint."

The Restraint/Seclusion Procedures and Responsibilities of staff included;

- The Physician/RN assessed the need for restrictive intervention and a written or telephonic order is obtained from the physician for the seclusion/restraint on the Seclusion/Restraint Order form. A physician must order the use of containment or seclusion.

"1. Only staff members who have completed the [facility] Hospital training in the response to patient aggression and who are up to date with the annual requirement for that training may participate in the seclusion or containment of a patient or resident."

Review of the facility P & P for Verbal De-escalation and use of CPI (behavioral interventions), last reviewed January 2015, revealed under Procedures that staff responsibilities included; "2. Ensure all patients/visitors not involved in the situation in their assigned rooms or away from area."

Record review of Patient #2's medical record revealed he was a 30 year old male admitted to the facility on 02/24/14 to 04/20/15 in the military unit for Post-Traumatic Stress Disorder (PTSD). Patient #2 suffered from violent night terrors; insomnia.

Review of the Complaint Form completed by Patient #2, received 05/07/15 indicated during his admission at the facility; "the patients, not staff, have sprayed water in my face, slapped me, held me down, put ice down my back, feet, etc."

Review of the Nursing Progress Note dated 03/10/15 completed by RN-E at 0429 revealed in part; "observed yelling, being held lightly by another patient, who guided him back to the quiet room."

Review of the Nursing Progress Note dated 03/16/15 completed by RN-F at 0600 revealed in part; Pt. "screaming and yelling. Four peers came to his aid, kept him from banging head on door [and] placed ice in his hand while reassuring him of his safety [and] surroundings. Assisted back to mat in quiet room by peers. Peers VERY helpful [with] keeping pt. contained [and] safe."

Review of the Nursing Progress Note dated 03/26/15 completed by RN-C revealed the following, in part:
At 0505 Patient #2 appears to be suffering from a nightmare.
At 0510 Male Peers (Patient #3 and #4) at bedside; positioned on either side of Patient #2. Both men (Patient #3 and #4) proceeded to "touch, shake, apply ice to face and feet" of Patient #2. Unable to wake Patient #2. Patient rolled out of bed onto floor.
At 0515 Peers (Patient #3 and #4) finally lifted patient from floor back into bed.
At 0625 Patient (#2) able to discuss feelings with nursing staff. States no injuries from nightmare or "peer interventions of ice/water/physical holding."

Review of the Nursing Progress Note dated 03/28/15 completed by RN-C revealed the following, in part:
At 0705 Patient yelling. Begins to strike out at peers. Patient (pt.) "struggling [with] peers holding him to keep from being struck. Applying ice to face, waking pt." Pt. screaming, kicking, hitting out. Peers cautioned to let go if pt. continues to increase aggressive behavior.

Review of the Nursing Progress Note dated 03/28/15 completed by RN-D revealed the following, in part:
At 0700 Pt. was yelling and screaming and seemed to still be in a nightmare. "Peers wee spraying water in the pt.'s face and holding his arms so they wouldn't get hit." Pt. awake from nightmare. Pt. upset and felt like peers were hitting him when in the nightmare.

Review of the Physician's Progress Note dated 03/28/15 revealed Patient #2 stated that he "felt like he was abused by his peers" when they tried to wake him up. Patient #2 stated to the Physician that his face hurt and his sternum hurt.

Review of Patient #2's PO revealed on 03/28/15 at 1144 a PO; "Please do not touch patient during sleep terrors; intervene physically only if patient acute danger to self or others; do not use water to wake patient. (Per patient's request)."

Review of Patient #2's Master Treatment Plan dated 02/24/15 for his trauma related issues of nightmares, flashbacks, and night terrors did not include any designated interventions or assistance from peers during trauma related issues. There also were no designated interventions for the use of ice, water, or physical holding during night terror episodes in attempt to wake/orient Patient #2.

Interview on 06/25/15 at 4:05 PM with RN-C confirmed that she knew that other patients were not to be assisting with interventions for Patient #2 during his night terror episodes. RN-C stated that the other patients felt like they needed to intervene and assist Patient #2 because the peers/patients were his "battle buddies" and they had a "comrade" mentality to help each other. RN-C stated that she knew that using ice and water as interventions were "not approved therapies," but she felt pressured by the other patients, who were "dominant." RN-C stated she allowed the other patients to assist with interventions and "hold" Patient #2; otherwise the unit would have to call codes constantly to assist with Patient #2's aggression. RN-C stated that she had communicated these concerns with her supervisor and physician; without any "clear direction." RN-C indicated that she felt like she was Patient #2's target during his night terror episodes and his peers were better to assist him; due to the "us and them" culture of the unit. RN-C stated after Patient #2 complained about his peers/other patients intervening by stating he was "being tortured/hurt;" the unit was changed and expectations were implemented for peers and staff to ensure everyone was safe.

Interview on 06/24/15 with the RN Director of Nursing (DON)- Unit Supervisor at 11:20 AM revealed it was difficult and a "delicate situation to balance when redirecting other patients away" from Patient #2 during night terror episodes, "because they would get upset, and we could have a riot if we don't address situation delicately." The RN DON confirmed it was not allowed for other patients to restrain Patient #2 and when it was identified as an issue; "corrective action" had been taken.

Further interview on 06/25/15 with the RN DON-Unit Supervisor at 12:00 PM stated she had "talked" to the RN's on the unit; to not allow other peers/patients to assist in interventions of Patient #2. RN-Unit Supervisor stated she had not completed any formal written in service training or corrective action with the unit RN's regarding the facility's P & P for Special Treatment Procedures.