HospitalInspections.org

Based on a review of the clinical record, facility documentation, and interviews with staff, the facility failed to protect and promote each patients rights, as evidenced by:

* Failure to ensure the patients' right to safety and care in a safe setting by bringing a potential patient directly into the patient care unit without medical acceptance by the facility physician, a physician's order to admit the individual for care, an intake assessment, or an admission assessment by a Registered Nurse. Following the individual's arrival on the unit, he was immediately placed in a locked seclusion room for 25 minutes without a physician's order or a search for possible contraband, which could have been used to hurt himself or other patients.

Refer to A0144 and A0168

Based on a review of the clinical record, facility documentation, and interviews with staff, the facility failed to protect the patient's right to care in a safe setting by bringing an individual into a patient care unit without physician acceptance, without a physician's order to admit the patient to the facility, without an intake assessment, and without being checked for contraband. Failure to perform these steps could have resulted in serious harm or death to any patients on the unit.

Findings were:

Review of the clinical record for patient #1, a 20 year old male, revealed that patient #1 was brought to the hospital by law enforcement officers on an emergency detention order on 6-17-21 at approximately 2:53 pm. Patient #1 had been found in someone's truck, where he then pulled a knife on the person. Patient #1 then took off on foot towards a major highway in the area and was apprehended by law enforcement officers. When apprehended, patient #1 told the law enforcement officer that he wanted to "run into traffic and end it all". He stated that he had a history of schizophrenia and bipolar disorder but had not been taking his medications. Patient #1 had received medical clearance at a local emergency department.

Following medical clearance, patient #1 was taken to this hospital after being accepted administratively by the intake nurse on duty (staff #5). Upon arrival to the facility, the intake assessment completed by staff #6 (Intake Director) "additional comments" section read as follows:

"Pt [#1] went straight back to unit upon arrival to the hospital. [Pt #1] is here on EDO. [Pt #1] was found in someone's truck. He was found by SAPD and told them he wanted to jump into traffic and send it all. Dx [diagnosed] c schizophrenia and bipolar. [Pt #1] is not taking meds."

Review of [Pt #1's] clinical record contained no physician's order to admit him to the facility. Review of [Pt #1's] clinical record also contained no documentation that a nursing admission assessment was performed within the first 8 hours and no documentation to indicate that it had been attempted. In addition to assessing vital signs, cognitive status, allergies, multi-organ systems, family history, history of infectious diseases, a tobacco screening, barriers to learning, nutritional status, immunization status, pain, risk for falls, and a skin check. The admission nursing assessment (which was not performed on patient #1) also required that a verification of security check be performed. This security check contained the following instructions:

* Ensure the safety of the environment

* Secure the patient's belongings

* Perform a contraband check

* Remove all sharps

* Ask for any medications brought in by the patient

* Remove belts, shoelaces etc.

Admission orders [for patient #1] were provided by telephone on 6-17-21 at 4:26 pm, 1 hour and 37 minutes after [patient #1] was brought to the unit. The admission orders stated that [patient #1] was to be observed on q 15-minute checks as well as aggression and elopement precautions. He was to be provided a regular diet.

Nursing notes stated the following:

* 6-17-21 at "approx. 1500 [3:00 pm]" - "Pt [#1] received without intake assessment secondary to combative and aggressive. Pt taken to unit. Refused to cooperate with staff. Confused and did not know where he was. Taken to room to sleep. Continue to monitor [pt #1] q 15 minutes for safety."

* 6-17-21 at 9:00 pm - "Pt [#1] has been asleep in bed. Resp[irations] even and unlabored. No distress noted. Continue 15 minute checks for safety."

* 6-18-21 at 11:15 am - "Pt [#1] became agitated after speaking with physician. Pt [#1] wanted to make a phone call but unable to do so due to phone not being available. Pt [#1] went down the hall and kicked a window out then proceeded to go out the window. Pt [#1] then jumped over the fence. SAPD [San Angelo Police Department] was notified of pt's elopement. Will continue to await results of pt's return or not."

* 6-18-21 at 12:15 pm - Pt [#1] was taken into custody by SAPD. Pt [#1] will not be returning to RCH."


A review of surveillance video that began seconds prior to patient #1's arrival on the unit on 6-17-21 showed the following:

* 2:46:38 [2:26 pm & 38 seconds] - Staff behind nurse's station (where seclusion room is located) begin moving furniture and medical equipment out of the path to the seclusion room.

* 2:48:57 - Staff #4 (identified by staff #3 as the Intake Director), appears in the view in front of the seclusion room door; unlocks and opens the door.

* 2:49:06 - Patient #1 and 4 individuals, (identified by staff #3 as law enforcement officers; 2 of which were mental health authorities, and 2 were San Angelo police officers) enter the room. Patient #1 was brought into the room in a wheelchair and assisted to the mattress on the floor by the officers and all hardware (handcuffs and shackles) are removed from patient #1. Officers leave the room with the wheelchair.

* 2:51:12 - Staff #4 (Intake Director) closes door to the point where [staff #4] can still fit between door and jamb. Staff #4 is facing the interior of the seclusion room and can be seen nodding and shaking her head.

* 2:51:44 - Seclusion room door is closed and locked by staff #4.

* 2:55:00 - Staff #4 and law enforcement officers leave unit.

* 2:55:06 - Staff #7 (identified by staff #3 as a mental health technician) begins observing patient #1 through seclusion room window.

* 3:16:30 - Seclusion room door is unlocked by staff identified as staff #6, the unit RN.


In an interview with staff #4 at 4:13 pm on 6-23-21, staff #4 was asked how long she had been working in the intake department. Staff #4 stated that she had been employed for 2 years and had been with the intake department for 6 weeks and was the Intake Director.

Staff #4 was asked to recount the events of 6-17-21 as they pertained to patient #1. Staff #4 stated that patient #1 had arrived in the company of approximately 6 law enforcement personnel on the afternoon of 6-17-21. Staff #4 stated that, for safety, [staff #4] had patient #1 taken straight to the unit and placed in the seclusion room. When asked if she [staff #4] had obtained a physician's order to admit patient #1 prior to escorting patient #1 to the unit, staff #4 stated that she had not. When asked if [staff #4] had performed an intake assessment prior to escorting the patient to the unit, staff #4 stated that she had not.


In an interview with staff #7 (mental health technician) on 6-24-21 at 0858, staff #7 was asked how long she had been working at the hospital and she stated that she [staff #7] had been working for 11 months. When asked to recount patient #1's arrival on the unit on 6-17-21, staff #7 stated "He [patient #1] came in, I saw him being wheeled in by deputies in a wheelchair, 4 police officers, he [patient #1] was in shackles, and then they took him directly to the seclusion room. By that time I had went back there to assist them in case they needed help. They [law enforcement] then took the shackles off, and they shut the door. I then started a q 15 because we didn't have any paperwork on him [patient #1], so I started a q 15 while he [patient #1] was in the seclusion room, I just volunteered."

When asked if the door to the seclusion room had been locked, staff #1 stated, "yes, I believe they did that because he [patient #1] was fighting the police and they just didn't know. It was probably about 2:30 when they took him [patient #1] in there. We finally got him up roughly an hour later. He [patient #1] was only in there an hour." When asked what the patient [#1] was doing in the seclusion room, staff #7 stated "laying down." When asked if [patient #1] was asleep, she said "he had fallen asleep in the middle, yeah, he was crying at first."


Facility policy titled "PC/NAR Admission Procedure" states, in part:

"Purpose:
It is the policy of River Crest Hospital to utilize a standard procedure in the admission of patients that reinforces safety, quality care, and efficiency in communication with other team members. This will ensure that the patient's initial introduction to the hospital setting is positive, informative, as free from stress as possible, and to ensure a safe therapeutic environment for both patients & staff.
...
Procedure:
1. Admission Procedure
...
2.0 complete wanding process as indicated b the "Patient Searches and Electronic Search of Patients" policy.
...
6.0 The Licensed professional will conduct the assessment interview.

7.0 the assessor will make treatment recommendations.
...
9.0 If the assessor determines that the patient meets criteria for admission, they will notify the patient and persons accompanying the patient of the decision. They will then notify the on call psychiatrist or video conference physician and continue with the remainder of the admission process.
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10.0 If the physician determines that the patient is appropriate for admission, the assessor will begin the admission process which will include:
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10.2 Securing the physician order to admit. No patient shall be escorted to the unit until a physician's order for admission has been received and documented by a nurse.
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16.0 Completing the wanding process a second time before the patient is escorted to the unit (see the Patient Searches and Electronic Search of Patient's policy)."


Facility policy titled "PC/NAR Admission Services, Responsibilities and Functions" states, in part:

"Purpose:
To delineate the responsibilities and functions of Admissions Services.
...
2. Admission Services shall be organized to provide the following physician services:
A. River Crest Hospital shall insure all patients admitted to inpatient, or partial hospitalization services have an attending physician assigned, and written orders to admit when they are admitted to the program."


Facility policy titled "Needs Assessment and Referral - Patient Searches and Electronic Search of Patients/Visitors while in Needs Assessment and Referral" states, in part:

"Policy:
It is the policy of River Crest Hospital that all patients being admitted through the Needs Assessment & Referral office during its regular hours of operation will have a pocket and an electronic search at a minimum of two times before going back to the unit.

Procedure:
1. Patients are wanded and/or searched for contraband items prior to being escorted from the Lobby to the Intake Department.

The following will be done with the contraband search:

1.1 The Needs Assessment Staff will separate the patient from any luggage/bags/coats. The patient will be asked to empty all their pockets, turning them inside out, placing their belongings in a container.

1.2 The patient's body should not be touched during the search process.

1.3 The patient will be asked to step away from any metal furniture.

1.4 The patient is to stand with feet approximately should width apart and arms outstretched.

1.5 The staff will scan the patient's front, back and sides using a sweeping motion. The staff will also scan the patient's shoes.

1.6 Should any contraband or dangerous article be found the patient will be asked to remove it and place it in the container along with their other items.

1.7 Once all items have been secured and the patient has been wanded properly, the patient may be escorted to the intake department; staff carrying the container and any belongings the patient brought with them.

If the patient is escorted directly to the Intake Department via Law Enforcement/Ambulance, the above must be completed immediately upon arrival to the Intake Department.
...
6. Prior to a patient being escorted to the Unit the Needs Assessment Staff or designee will again perform the same electronic search; 1.2 through 1.6.
...
8.2 the following will be done on the unit by the admitting nurse:

8.2.1. Patient will be asked to be remove(sic) all personal clothing and be placed in blue scrubs.

8.2.2. Clothing will be searched by hand and wanded to assure no items are hidden.

8.2.2.1. Should any contraband or dangerous items be found, they will be secured by the Admitting nurse. The items should be inventoried and locked-up until a family/spouse/guardian/friend can pick up the items or the patient picks them up on discharge.

8.2.3. if the patient refuses to allow a search, the patient will be wanded for metal items and be placed on increase(sic) monitoring to assure the safety of the staff and patients."

Facility policy titled "Patient Rights - Rights and Responsibilities" states, in part:
" ...
Patients (or as appropriate a Surrogate) are entitled to:
...
Receive care in a safe setting."


The above was confirmed in an interview with the CEO and other administrative staff on 6-24-21.

Based on a review of the clinical record, facility documentation, and interviews with staff, the facility failed to ensure that the use of restraint or seclusion was in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy.

Findings were:

Review of the clinical record for patient #1, a 20 year old male, revealed that patient #1 was brought to the hospital by law enforcement officers on an emergency detention order on 6-17-21 at approximately 2:53 pm. Patient #1 had been found in someone's truck where he then pulled a knife on the person. Patient #1 then took off on foot towards a major highway in the area and was apprehended by law enforcement officers. When apprehended, patient #1 told the law enforcement officers that he wanted to "run into traffic and end it all". He stated that he had a history of schizophrenia and bipolar disorder but had not been taking his medications. Patient #1 had received medical clearance at a local emergency department.

Following medical clearance, patient #1 was taken to this hospital after being accepted administratively by the intake nurse on duty (staff #5). Upon arrival to the facility, the intake assessment completed by staff #6 (Intake Director) "additional comments" section read as follows:

"Pt [#1] went straight back to unit upon arrival to the hospital. [Pt #1] is here on EDO. [Pt #1] was found in someone's truck. He was found by SAPD and told them he wanted to jump into traffic and send it all. Dx [diagnosed] c schizophrenia and bipolar. [Pt #1] is not taking meds."

A review of surveillance video that began seconds prior to patient #1's arrival on the unit on 6-17-21 showed the following:

* 2:46:38 [2:26 pm & 38 seconds] - Staff behind nurse's station (where seclusion room is located) begin moving furniture and medical equipment out of the path to the seclusion room.

* 2:48:57 - Staff #4 (identified by staff #3 as the Intake Director), appears in the view in front of the seclusion room door, unlocks and opens the door.

* 2:49:06 - Patient #1 and 4 individuals, (identified by staff #3 as law enforcement officers, 2 of which were mental health authorities and 2 were San Angelo police officers) enter the room. Patient #1 was brought into a room in a wheelchair and assisted to the mattress on the floor by the officers and all hardware (handcuffs and shackles) are removed from patient #1. Officers leave the room with the wheelchair.

* 2:51:12 - Staff #4 (Intake Director) closes door to the point where [staff #4] can still fit between door and jamb. Staff #4 is facing the interior of the seclusion room and can be seen nodding and shaking her head.

* 2:51:44 - Seclusion room door is closed and locked by staff #4.

* 2:55:00 - Staff #4 and law enforcement officers leave unit.

* 2:55:06 - Staff #7 (identified by staff #3 as a mental health technician) begins observing patient #1 through seclusion room window.

* 3:16:30 - Seclusion room door is unlocked by staff identified as staff #6, the unit RN.


Review of [Pt #1's] clinical record contained no physician's order to admit him to the facility. Admission orders [for patient #1] were provided by telephone on 6-17-21 at 4:26 pm, 1 hour and 37 minutes after [patient #1] was brought to the unit. No order for seclusion was found.


In an interview with staff #4 at 4:13 pm on 6-23-21, staff #4 was asked how long she had been working in the intake department of the hospital. Staff #4 stated that she had been employed for 2 years and had been with the intake department for 6 weeks, and was the Intake Director. Staff #4 was asked to recount the events of 6-17-21 as they pertained to patient #1. Staff #4 stated that patient #1 had arrived in the company of approximately 6 law enforcement personnel on the afternoon of 6-17-21. Staff #4 stated that, for safety, [staff #4] had patient #1 taken straight to the unit and placed in the seclusion room. When asked if she [staff #4] had obtained a physician's order to admit patient #1 prior to escorting patient #1 to the unit, staff #4 stated that she had not. When asked if [staff #4] had performed an intake assessment prior to escorting the patient to the unit, staff #4 stated that she had not.

In an interview with staff #7 (mental health technician) on 6-24-21 at 0858, staff #7 was asked how long she had been working at the hospital and she stated that she [staff #7] had been working for 11 months. When asked to recount patient #1's arrival on the unit on 6-17-21, staff #7 stated, "he [patient #1] came in, I saw him being wheeled in by deputies in a wheelchair, 4 police officers, he [patient #1] was in shackles, and then they took him directly to the seclusion room. By that time I had went back there to assist them in case they needed help. They [law enforcement] then took the shackles off, and they shut the door. I then started a q 15 because we didn't have any paperwork on him [patient #1], so I started a q 15 while he [patient #1] was in the seclusion room, I just volunteered."

When asked if the door to the seclusion room had been locked, staff #1 stated "yes, I believe they did that because he [patient #1] was fighting the police and they just didn't know. It was probably about 2:30 when they took him [patient #1] in there. We finally got him up roughly an hour later. He [patient #1] was only in there an hour." When asked what the patient [#1] was doing in the seclusion room, staff #7 stated "laying down." When asked if [patient #1] was asleep, she said "he had fallen asleep in the middle, yeah, he was crying at first."


Facility policy titled "Proper use and Monitoring of Restraint, Emergency Medications and Seclusion - Provision of Care" states in part:

"Policy:
It is the policy of River Crest 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. Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm. 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 a substitute for adequate staffing.

The patient's rights, dignity privacy, safety and well-being will be supported and maintained. Restraint or seclusion will be discontinued as soon as possible. Patients in restraints/seclusion will be closely monitored and evaluated and immediately assisted if a potentially dangerous situation exists, i.e. choking, seizure, etc. PRN [as needed] orders may not be used to authorize the use of restraint or seclusion.
...
Definitions:
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Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave the room, the room is considered locked, whether or not the door is actually locked or not.
...
Less Restrictive Interventions:

Measures which modify the environment, enhance interpersonal interaction, or provide treatment so as to minimize or eliminate the problems/behaviors which place the patient at risk. Examples of less restrictive measure include, but are not limited to:

1. Verbal interventions such as talking quietly with the patient

2. Environmental intervention through reduction of stimuli

3. Relaxation techniques

4. Physical activity

5. Psychoactive medications

6. Reality Orientation

7. Quiet time

8. Time out/time away
...
Procedure:
...
3.0 Physician Orders, Consultation, and Evaluation:

3.1 Restraint, seclusion or emergency medications shall be used in emergency situations only and requires an order from a physician.
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3.1.2 In the absence of a physician the registered nurse may authorized(sic) the initiation of restraint or seclusion in an emergency.

3.1.3 The physician/LIP 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.
...
3.2 the Physician's/LIP's order for use of restraint, seclusion, or emergency medication will be recorded in the medical record ...
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4.0 Restraint application and assessment/monitoring during the use of restraint/seclusion:
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4.2 The patient will be informed of the reason he/she was placed in restraint or seclusion and the behavior necessary to be released.

4.3 The RN immediately will assign a staff member, trained and deemed competent in the usage and monitoring of seclusion and restraints, to conduct continuous in-person observation/monitoring for the duration of the seclusion/restraint episode.
...
Any patient placed in seclusion will be continuously observed by staff standing immediately outside the seclusion room.

4.4 Any personal belongings that may be used to harm self or others will be removed from the patient with documentation of inventory and securing of items by two staff members.
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5.0 Face to Face Evaluation by the Physician, LIP or trained RN/PA;

Within one hour of the initiation of restraint, seclusion, or emergency medication, the patient shall be evaluated in person by a physician, authorized LIP (facility to definie authorized LIP), or trained QRN/PA. A telephone call or telemedicine methodology is not allowed for those evaluations. The evaluation will be documented in the medical record ...
...
13.0 Documentation of use of restraint/seclusion: The use of restraint/seclusion will be thoroughly documented in the patient's medical record ..."


The above was confirmed in an interview with the CEO and other administrative staff on 6-24-21.