HospitalInspections.org

Based on a review of documentation and interview, the facility failed to ensure that restraint was only imposed to ensure the immediate physical safety of the patient, a staff member, or others.

Findings included:

Facility based policy entitled, "Behavioral Restraint and Seclusion" stated in part,
"DEFINITIONS:
Emergency Situation: Is an instance in which there is imminent risk of an individual harming him/her or others including:
Physically assaultive behavior by a patient toward another patient, staff, or other person, that if no immediate intervention is initiated, may result in serious injury.
Discovery of a patient actively engaged in self-harm, that if no immediate intervention is initiated, may result in serious injury...

Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time...

POLICY: It is the policy of The Pavilion to support each patient's right to be free from restraint and seclusion and therefore limit the use of these interventions to emergencies in which there is imminent risk of a patient physically harming themselves or others. This 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. Restraint or seclusion may only be used in emergency situations and when less restrictive measures have been determined to be ineffective to protect the patient or others from harm."

Review of the medical records for patients requiring physical restraint revealed 2 of 4 patients requiring a physical restraint did not meet the criteria of being imposed ensure the immediate physical safety of the patient, a staff member, or others:

Patient #3 was placed in personal hold on 04/03/17 at 0946 due to "Ran to another pts. rm and climbed in his bed. She is in a hyper anxious state AEB stating she is 'going to hell'. Sending staff to 'hell'. Verbal threats to 'stab' staff or have 'god stab people'.
* This patient was in a peers room and made verbal threats (no weapon was available to the patient) and was not posing immediate danger to themselves or others, thus this physical restraint did not meet the definition of an emergency situation that would requires a physical intervention.

Patient #4 was placed in personal hold on 05/02/17 at 1610 due to "broke through door on AAU (magnet did not hold) and escaped the unit".
* A nursing progress note stated, "At 1555 Pt was reported by [nurse] that she was able to break through a magnetic door into the quiet area in attempt to leave. She was able to go to the hallway when a [nurse] was coming into the area. This writer went
into the hallway and did not see patient or [nurse]...She ran toward the childrens unit and was asked to go back to AAU. She turned around and turned toward the lobby again rather go back to AAU and was placed in a modified PRT by this writer at 1610 secondary to pregnancy. She was escorted to the quiet area of AAU and released."
* This patient was in a locked area of the facility and was not posing immediate danger to themselves or others, thus this physical restraint did not meet the definition of an emergency situation that would requires a physical intervention.

The above findings were confirmed in an interview with staff member #2 and 10 on 06/14/17.

Based on a review of documentation and interviews, the facility failed to use restraint in accordance with a written modification to the patient's plan of care.

Findings included:

Facility based policy entitled, "Behavioral Restraint and Seclusion" stated in part,
"15.0. Treatment Plan Review/Revision: When the patient has presented behavior that is dangerous to themselves or others so that restraint or seclusion was indicated, a review and modification of the treatment plan is indicated. Based upon the consultation with the
attending physician, information gathered from the debriefing with the patient, and the one (1) hour face-to-face evaluation, the RN will review and update the treatment plan within 12 hours. The entire treatment team will review the plan at the next scheduled review. A special treatment team plan will be conducted and developed for patients experiencing multiple seclusion or restraint events. The updated treatment plan will reflect:
a. The identification of an assessed problem associated with the use of restrain or seclusion, if problem has not been previously identified.
b. Goals related to prevention of the further use of restraint or seclusion
c. Interventions which define alternative approaches to address the identified problem. Responsibility for each intervention is assigned.
d. Review of the plan with the patient."

Patient #3 had 5 personal hold restraints during April 2017. There was no update or modification to this patient's treatment plan per regulations and facility policy.

Based on a review of documentation and interview, the facility failed to ensure that when restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention.

Findings included:

Facility based policy entitled, "Behavioral Restraint and Seclusion" stated in part,
"7.0. Face to Face Evaluation by the Physician or trained Qualified RN (QRN): Within one hour of the initiation of restraint or seclusion, the patient shall be evaluated in person by a physician, or trained QRN. A telephone call or fax is not allowed for these
evaluations. The evaluation will be documented in the medical record to include the following:
a. The date and time of the evaluation;
b. An assessment of the patient's immediate situation;
c. An evaluation of the patient's reaction to the intervention including effectiveness and appropriateness of the intervention;
d. 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.
e. Provided consent had been obtained during admission assessment, the family member/guardian or support person is to be notified and documented. Discussion with the patient regarding the policy is provided in a language understood by the patient. If necessary, interpretation or translation services are obtained.
f. An assessment of the need to continue or terminate the restraint or seclusion. At the time of the in-person. evaluation, the qualified individual conducting the evaluation works with the patient and staff to identify ways to help the patient
regain control, make necessary revisions to the patient's treatment plan, and if necessary, provide a new order."

Review of the medical records for patients requiring physical restraint revealed 1 of 4 patients requiring a physical restraint did not have a no post intervention evaluation documented within 1 hour:
* Patient #3 had 1 personal holds on 04/01/17 at 1225 no post intervention evaluation documented for these episodes.

The above findings were confirmed in an interview with staff member #2 and 10 on 06/14/17.

Based on a review of documentation and interview the facility failed to follow state requirements by statute or regulation that are more restrictive than those contained in paragraph (e)(12)(i) of this section.

Findings included:

The Texas Administrative Code Title 25 Part II states in part,
"§415.273. Actions To Be Taken Following Release of an Individual from Restraint or Seclusion Initiated in Response to a Behavioral Emergency...

(b) As soon as possible after an episode of restraint or seclusion, available staff members involved in the episode, supervisory staff, the individual, the LAR, and, (with the consent of the individual) family members must meet to discuss the episode. The purpose of the debriefing is to:
(1) identify what led to the episode and what could have been handled differently;
(2) identify strategies to prevent future restraint or seclusion, taking into consideration suggestions from the individual and the individual's advanced directive, if any;
(3) ascertain whether the individual's physical well-being, psychological comfort, and right to privacy were addressed;
(4) counsel the individual in relation to any trauma that may have resulted from the episode;
(5) when indicated, identify appropriate modifications to the individual's treatment plan; and
(6) when clinically indicated or upon request of individuals who witnessed the restraint debrief persons who witnessed the restraint."

Facility based policy entitled, "Behavioral Restraint and Seclusion" stated in part, "13.0. Post-Restraint/Seclusion Debriefing: Debriefing following the use of restraint or seclusion is important in reducing the use of recurrent restraint or seclusion. The patient and staff participate in a debriefing session following the restraint or seclusion episode. The patient and, if appropriate, the patient's family or support person, participate with the staff who ~ere
involved in the episode and who are available, in a debriefing about each episode of restraint or seclusion use unless the staff member is excused due to potential of the presence of that staff person jeopardizing the well-being of the patient. The debriefing occurs as soon as possible, and as appropriate, but no longer than 24 hours after the episode. The debriefing is used to:
a. Identify what led to the incident and what could have been handled differently;
b. Ascertain that the individual's physical well-being, psychological comfort, and right to privacy were addressed;
c. Provide medical care for, including transfer to medical facility if indicated, or any actions that may have resulted in injuries from the incident and/or counsel the individual involved for any trauma that may have resulted from the incident, and;
e. When indicated, modify the treatment plan.
13.1. Information obtained from debriefing is used in performance improvement activities.
13.2. Documentation of the debriefing, including staff participation, is maintained in the
patient's medical record.
14.0 Staff/ Administrative Debriefing: Within 24 hours of the initiation of any seclusion or restraint episode, all staff involved in the incident participate with administrative/supervisory staff in a debriefing that includes, at a minimum, a review and discussion of:
a. The emergency safety situation that required the intervention, including a discussion of the precipitating factors that led up to the intervention;
b. Alternative techniques that may have prevented the use of the seclusion or restraints. The procedures, if any, which staff are to implement to prevent any recurrence of the use of seclusion and restraint;
d. The outcome of the intervention, including any injuries to patient or staff that have resulted from the use of seclusion or restraint;
e. A plan to prevent future injuries, if indicated; and
f. Documentation of the debriefing, including staff attendance, will be maintained in the patient's medical record."

Review of the medical records for patients requiring physical restraint revealed 2 of 4 patients requiring a physical restraint did have a debriefing documented within 24 hours:
* Patient #3 had 2 personal holds on 04/01/17 at 1905 and 04/01/17 at 2010 with no debriefings documented for these episodes.
* Patient #6 had a personal hold on 05/07/17, no debriefing was documented for this episode.

The above findings were confirmed in an interview with staff member #2 and 10 on 06/14/17.

Based on review of facility policy and review of documentation, the nursing service did not have adequate numbers of licensed registered nurses and other personnel to provide nursing care to all patients as needed.

Findings included:

Facility policy titled "Assignment of Patient Care" stated in part, "Scope: It is the responsibility of Nursing Administration to provide an adequate number of nursing personnel to provide safe, therapeutic, quality care to all patients. With input from the facility CEO and Medical Staff, staffing ratios are defined for each patient unit and an established patient acuity classification system is utilized in order to ensure adequate ratios that factor in acuity, census, etc."

Facility policy titled "Plan for Providing Nursing Care" stated in part, "B. Staffing Plan
2. Staffing grids are developed using current care hour standards and/or best practices, and reviewed at the unit level by the Department Director, and approved by the Chief Nursing Officer. Nurses involved in direct patient care provide input through the Nurse Staffing Committee."

Facility policy titled "Behavioral Heath Written Plan for Providing Care" stated in part "VIII. Staffing
A. General Staffing
Staffing patterns for inpatient are determined by a combination of employees per occupied bed ratio and census expectations with considerations given to the individual patient needs in each program. A core staff level is determined for each inpatient unit consisting of a Charge Nurse, Mental Health Technician, Therapist, and Activity Therapist. Staffing for outpatient services is determined based on the scope of services offered, attendance and program size.

B. Nursing Staffing
Nursing care is prescribed, delegated and coordinated by Registered Nurses. Members of nursing staff include Registered Nurses, Licensed Vocational Nurses and mental health technicians.
Assignments for nursing care are made according to programmatic and patient acuity needs as defined in the hospital plan for nursing care.
Adjustments to the core staffing levels are made on the basis of more severe acuity. Such adjustments for planned staffing are made daily by the DON or his/her designee based on patients' individual needs."

On 6/13/17, a review of staffing assignment sheets was conducted for the Pavilion (for April and May for 2017). Numbers and types of staff present were compared to numbers and types of staff required by the facility's staffing grid. The facility's staffing grid was signed for authentication by staff #1 on 6/13/17 at 4:40 pm. Staff shortages were as follows:
*AAU [Acute Adult Unit]:
-4/7/17: 1 staff member on the PM shift
-4/11/17: 1 staff member on the AM shift
-4/25/17: 1 staff member on the AM shift
*GOU [Geriatric and Older Adult Unit]:
-4/30/17: 1 staff member on the PM shift
*GAU [General Adult Unit]:
-4/6/17: 1 staff member on the PM shift from 6:30 pm until 12:30 am
*CAU [Child Adolescent Unit]:
-4/12/17: I staff member on AM shift
-4/16/17: 1 staff member on AM shift
-4/17/17: 1 staff member on AM shift
-4/22/17: 1 staff member on PM shift
-4/23/17: 1 staff member on PM shift
-4/26/17: 1 staff member on AM and 1 staff member on PM shift
-4/29/17: 1 staff member on AM and 1 staff member on PM shift
-4/30/17: 1 staff member on AM shift and 1 on PM shift
-5/1/17: 1 staff member on AM shift and 1 on PM shift
-5/2/17: 1 staff member on AM shift and 1 on PM
-5/3/17: 1 staff member on AM shift from 3:00 pm until 6:30 pm
-5/4/17: 1 staff member on AM shift
-5/17/17: 1 RN on the PM shift
-5/18/17: 1 RN on the PM shift
-5/19/17: 1 RN on the PM shift
-5/20/17: 1 RN on the PM shift
-5/21/17: 1 staff member on the PM shift
-5/24/17: 1 RN on the PM shift
-5/25/17: 1 RN on the PM shift
-5/26/17: 1 staff member on the AM shift

In an interview with staff #9 at 3:50 pm on 6/13/17, staffing grid B was provided and stated CAU used this as a guide for staffing. Staffing grid B was different than the grid provided by staff #10 on 6/12/17.

In an interview with staff #1 at 4:40 pm on 6/13/17, staff #1 stated the original provided grid was "the staffing guidelines we gave them [the Pavilion] and they should follow." Staff #1 stated they had never seen staffing grid B.

In an interview with staff #13 the morning of 6/14/17, she verified staffing grid B was not discussed in the nurse staffing committee or approved by the governing body.

The above was confirmed in an interview with staff #2 and #10 on the morning of 6/14/17.

Based on review of facility policy, review of medical records and staff interview, the facility failed to ensure records contained all information necessary to monitor the patient's condition.

Findings included:

Facility policy titled "Plan for Providing Nursing Care" stated in part, "A. Delivery of Care
1. The RN maintains overall responsibility for the nursing process, utilizing a systematic approach to provide individualized, goal-directed nursing care by performing comprehensive nursing assessments, developing a plan of care based on the nursing assessment, implementing nursing care, and evaluating the patient's responses to nursing interventions. A comprehensive assessment is an extensive data collection (initial and ongoing) addressing anticipated changes in patient conditions as well as emergent changes in a patient's health status; recognizing alterations to previous conditions; synthesizing the biological, psychological, spiritual and social aspects of the patient's condition; evaluating the impact of care, and using this broad and complete analysis to make independent decisions and nursing diagnoses; planning nursing interventions, evaluating the need for different interventions and the need to communicate and consult with other health team members."

Facility policy titled "Behavioral Heath Written Plan for Providing Care" stated in part, "VII. Description of Clinical Services
...7. Medical Services
Medical services may be provided by a qualified physician or FNP [family Nurse Practitioner] under the direction of the admitting psychiatrist. The physician is responsible for a complete medical history, general physical exam and a neurological assessment ... The physician is also responsible for the diagnostic work-up and test evaluation of any detected or suspected medical disorders, as well as their clinical management. A qualified medical specialist may be requested to consult on the care of any patient with specific medical needs.
8. Nursing Services
Psychiatric nursing is a specialized area of professional nursing practice, which employs theories of human behavior and interpersonal relationships. One of the primary activities of nursing staff is the establishment of a trusting, therapeutic relationship with individual patients accomplished through daily consistent contact. Additional responsibilities of nursing staff include, but are not limited to: ...on-going patient assessment and observation ... detection and care for somatic aspects of the patient's health problems, including responses to medications and other treatments ... participating in planned and informal group meetings to identify the planning for the implementation and evaluation of patient care ..."

Review of the medical record for patient #8 revealed patient #8 was physically attacked by another patient on 04/17/17.
A physician progress note dated 04/14/17 at 3:53 pm stated in part, "Subjective: Left lower lip pain and laceration from a fight and trauma from another patient's fist ...
Assessment: 1. We will send the patient to the emergency room for rest suture of the laceration laceration [sic] of his lip ..."

Patient #8 refused to be treated in the ER [emergency room], left against medical advice and returned to the behavioral health hospital.

There was no documentation by the behavioral health staff indicating:
*The patient went to the ER
*The patient refused treatment in the ER for the injuries sustained
*The patient was assessed after refusal of treatment in the ER
*The nursing staff notified a physician of the patient's refusal of treatment


Review of the medical record for patient #10 revealed patient #10 was physically attacked by another patient on 4/21/17.
There was no physician documentation of the physical attack or the assessment of injuries sustained.

The above was verified in an interview with staff #4.

Based on a review of documentation and interview, the facility failed to ensure that the discharge summary for patients contained outcome of hospitalization, disposition of care and provisions for follow-up care.

Findings included:

Patient #7 was discharged on 04/21/17 after an altercation with a peer. This patient was to be discharged to police custody, but was discharged to the Salvation Army instead. This was confirmed in an interview with staff member #9 on 06/13/17.

A nursing progress note on 04/21/17 stated, "Patient discharge to Salvation Army. He was given taxi pass for transportation. He accepted discharge without incident. Personal items were given to patient. Security escorted him to taxi. Patient voiced no complaint during process."

The discharge summary for this patient stated, "He presented to the unit, assessed and evaluated, precautions applied as necessary. He was cooperative and compliant, attended groups as prescribed, and developed some insight as a result. The acute presenting symptoms of psychosis were targeted; medication trials were initiated, such as titration of risperidone, lurasidone, alprazolam and trazodone. He developed positive clinical response. He was active in the unit, had improved sleep and appetite, interacting with staff.

Upon discharge, he was not in any acute distress; he denied any endangering ideation of harm to self or others.

Discharge plans were discussed with him and he verbalized understanding and agreed to be compliant with follow up care."

This discharge summary did not include the patient's episodes of aggression or the issues with finding a suitable discharge destination. The summary also did not include the actual provisions of follow up care for this patient.

The above findings were confirmed in an interview with staff member #2 and 10 on 06/14/17.