HospitalInspections.org

Based on observation, interview and record review the hospital failed protect and promote patient's rights.

Findings where:

The facility failed to provide care in a safe, clean and comfortable environment when Patient #4 was held in a restraint for over 10 hours. Cross refer A144

The facility failed to follow the maximum time limits allowed by the facility policy for a restraint, for one (1) of ten (10) patients records reviewed for restraints.(Patient #4) Cross refer A171

The facility failed to provide a face-to-face medical evaluation for a patient placed in a behavioral restraint within one hour. (Patient #3) Cross refer A184

The facility failed to provide evidence that alternatives and less restrictive interventions were attempted for one (1) of ten (10) patient reviewed for restraints. (Patient #4) Cross refer A186

Based on observation, interview and record review the facility failed to provide care in a safe, clean and comfortable environment when Patient #4 was held in a restraint for over 10 hours.

Findings included:

Review of Patient #4's Psychiatric Evaluation dated 8/31/15 reflected he recently had a severe psychotic episode of unclear cause. The patient presented to Austin State Hospital (ASH) on a Protected Order of Emergency Detainment (POED) after he jumped out of a car. Patient #4 reported that he felt like everyone at home was picking on him and following him around and that "they" keep talking to him and yelling stuff out. He says he doesn't know what happened frequently.

Review of Patient #4's Intervention Progress note reflected on 8/14/15 at 10:41 a.m. Patient #4 was placed in a vertical hold for self-injurious behavior, at 10:44 a.m. he was moved to a horizontal hold for self-injurious behavior and at 10:51 a.m. he was placed in a restraint chair for self-injurious behavior. The ordering physician was Staff #14.

Patient #4's restrain orders reflected he remained in the restraint chair from 10:51 a.m. until 9:30 p.m.

Review of the facility Procedure # 4.05.05 titled Restraint Chair (effective May 2010) reflected,
General description- the emergency restraint chair is a rigid chair of steel frame construction. The chair seat and back consist of vinyl covered padding. Nylon straps are used at the shoulder, waist, wrist and ankle to securely restrain the patient in a sitting position. Locking wheels are used to safely move the chair to desired locations.

Observations made on 9/4/15 at 8:45 a.m. during a tour of the Specialty Unit and the private room that Patient #4 was held in, revealed an approximately 10 feet by 6 feet room with a stained laminate flooring and bare tan tiled walls, the grout was stained and dirty. The room contained one large window with two old dirt covered screens blocking any view through the dirty glass windows. The lighting in the room was adjustable with the highest level being dim. The room had a tall ceiling and with the bare walls, any conversation, including whispering, created an echo. The normal talking levels sounded loud and would not have been conducive to calming a patient in a restraint. The room did not have an individual temperature control.

During an interview on 9/4/15 at 12:05 p.m. Staff # 1, Chief Nursing Executive stated, "We do not put patients in restraints in the calming room." "That is used as a reward. No one wants to be in a restraint, if we put them in the calming room it would not serve the purpose." When the surveyor asked if the restraint and the seclusion room is a form of punishment; Staff #1 stated, "No." Staff #1 confirmed the room is noisy and the window could be cleaned. She stated, "The room is only used as a place to protect the patient's privacy."

Observation made on 9/3/15 at 9:00 a.m. in the administration building of a restraint chair revealed the chair seat and back padding to be approximately half an inch thick and covered in vinyl. The arm rests are made of a hard plastic. The chair only comes in one size and appeared large. There is no head or neck padding and no lumbar support. The chair will not recline and the feet cannot be elevated. The wrist, shoulder and ankle straps are made of a woven, unpadded, none pliable material.

Observation on 9/4/15 at 9:15 a.m. on Specialty Unit dining room revealed Patient # 4 to be approximately 5 feet 8 inches and approximately 160 lbs.
Review of Patient #4's Monitoring Checklist, dated 8/14/15, reflected range of motion is an intervention required every hour and requires an RN/MD to evaluate the range of motion. Review of the checklist reflected range of motion was only provided at 2:39 p.m.

Review of the facility Policy #4.05.03 Emergency Use of Seclusion and Restraint (Reviewed 5/2015) reflected:

-5.1. Personal restraint is to be utilized only for brief durations.
-5.2.3 A Physician must perform a fact-to-face assessment of the patient within 1 hour of initiation of the intervention.
-6.3.7 Documentation of monitoring and other care activities. Monitoring and care is documented. Enter the exact time of the patient observation. The applicable code(s) are entered to document the observed behavior or care provided. If the required care is not provided, the rationale for not providing the required care will be documented in a progress note ...
-6.3.8. Appropriate ventilation, temperature, and lighting will be maintained for the patient during the intervention.
-7.4.1 The extension of a mechanical restraint can only occur once. The extension of mechanical restraint or seclusion can then continue for up to four (4) hours for adults...

The Austin State Hospital Handbook of Consumer Rights provided to patients upon admission included a listing of patient rights. It included the following:
"The Right to Humane Care ...
You should receive care in the least restrictive appropriate setting but in a setting that protects you against any dangers which you might pose to yourself or others ..."

Based on interview and record review the facility failed to follow the maximum time limits allowed by the facility policy for a restraint, for one (1) of ten (10) patients records reviewed for restraints.(Patient #4.)

Findings included:

Review of the facility policy #4.05.03 Emergency Use of Seclusion and restraint (reviewed 5/2015) reflected:
7.4.1 The extension of a mechanical restraint can only occur once. The extension of mechanical restraint or seclusion can then continue for up to four (4) hours for adults ...

Review of Patient #4's physician's orders reflected the following:
On 8/14/2015 at 10:41 a.m. a Behavioral Restraint/Seclusion was obtained from
Staff #14,MD.
Order description: ADULT MECHANICAL-RESTRAINT CHAIR NTE (not to exceed) 4 HOURS USE PERSONAL RESTRAINT TO FACILITATE INITIATION OF MECHANICAL RESTRAINT STAT (NOW)

On 8/14/2015 at 2:39 p.m. a Behavioral Restraint/Seclusion was obtained from
Staff #14,MD. The order is to start at 2:40 p.m.
Order description: ADULT MECHANICAL-RESTRAINT CHAIR NTE (not to exceed) 4 HOURS USE PERSONAL RESTRAINT TO FACILITATE INITIATION OF MECHANICAL RESTRAINT STAT (NOW)

On 8/14/2015 at 7:18 p.m. a Behavioral Restraint/Seclusion was obtained from Staff #15, MD.
Order description: ADULT MECHANICAL-RESTRAINT CHAIR NTE (not to exceed) 4 HOURS USE RESTRAINT TO FACILITATE INITIATION OF MECHANICAL RESTRAINT STAT (NOW)

During an interview with Staff #13, RN on 9/3/15 at 4:00 p.m. in the administration meeting room she stated Staff #15, MD was informed this was a second reorder for the restraint.

During an interview with Staff #4, MD Clinical Director he stated the restraint order can only be renewed once. He stated he was informed of the extended retraint and had sent out an email to the Medical Staff to reinforce the policy.

Based on interview and record review the facility failed to provide a face-to-face medical evaluation for a patient placed in a behavioral restraint within one hour. (Patient #3)

Findings included:

A review of Patient #3's Client Profile- Order Details dated 8/23/15 reflected an order for Adult Mechanical-Restraint Chair NTE (not to exceed four hours) Use Personal Restraint to Facilitate Initiation of Mechanical Restraint STAT (Psychiatric Emergency)
Reason: Threatening to fight staff
Aggression- fighting staff
Threatening self injurious behavior
Start Date/Time: 8/23/15 3:35 p.m. Stop Date/Time: 8/23/15 7:34 p.m.

Review of Patient #3's Intervention Physician's Progress Note dated 8/23/15 reflected the physician's face to face assessment was conducted at 7:06 p.m., over 3.5 hours after the initiation of the restraint order.

Review of the facility policy #4.05.03 Emergency Use of Seclusion and Restraint (reviewed 5/2015) reflected:
5.2.3 A physician must perform a face-to face assessment of the patient within 1 hour of initiation of the intervention. This face-to-face must be documented by the physician in the medical record.
6.3.9 All Episodes of personal restraint, regardless of duration, require a physician's order, a face to face assessment by the physician within one hour of admission.

During an interview on 9/4/15 in the afternoon, in the administration meeting room, Staff #2 confirmed the findings.

Based on record review and interview the facility failed to provide evidence that alternatives and less restrictive interventions were attempted for one (1) of ten (10) patient reviewed for restraints. (Patient #4)

Findings included:

Review of Patient #4's Psychiatric Evaluation dated 8/31/15 reflected he recently had a severe psychotic episode of unclear cause. The patient presented to ASH (Austin State Hospital) on a POED (Protected Order of Emergency Detention) after he jumped out of a car. Reported that he felt like everyone at home was picking on him and following him around and that "they" keep talking to him and yelling stuff out. He says he doesn't know what happened frequently.

Review of Patient #4's Monitoring Checklist dated 8/14/15 reflected range of motion is an intervention required every hour and requires an RN/MD evaluation. Review of the checklist reflected range of motion was provided at 2:39 p.m. The monitoring checklist did not reflect the use of Patient #4's calming strategies.

Review of Patient #4's Nursing Intervention Progress notes dated 8/14/15 reflected the following:
-8/14/15 at 10:41 a.m., written by Staff # 16, LVN, Pt was placed in a vertical hold for self-injurious behavior, at 10:44 a.m. he was moved to a horizontal hold for self-injurious behavior and at 10:51 a.m. he was placed in a restraint chair for self-injurious behavior.
-8/14/15 at 1:15 p.m., written by Staff #16, LVN, Pt is in chair restrain [sic] for aggression, medicated with olanzapine 10 mg Im on right deltoid at 11:12 hrs with no effect informed Md -per charge nurse.
-8/14/15 at 2:23 p.m., written by Staff #16, LVN, Pt continued in the restrained chair for not being calm, repeatedly talking about sexual acts and his past ...olanzapine was given on left deltoid at 13:36, reassessed at 14:36, pt continue to be talking nonstop and has not been calm, charge nurse is aware of the situation and pt's current mental status.
-8/14/15 at 10:56 p.m., written by Staff #13, RN
6:10 p.m. OD (ordering doctor) notified that Patient #4 has been in the restraint chair 10:41 a.m. with current order starting at 2:40 p.m.
6:20 p.m. range of motion was documented as being completed. When arm out of restraint for range of motion, Patient #4 swung at nurse practitioner. Patient #4 is shivering. Offered Apple juice. He refused. Patient #4 has not urinated, eaten, or taken fluids. Order received to transfer Patient #4 to Hospital #1 via EMS. 9:30 p.m. Patient #4 released from restraint chair and transferred to EMS stretcher for transport to Hospital #1.
7:45 p.m., temperature is 98.6, Pulse 122, Respirations 20, Blood Pressure 115/72.

During an interview with Staff #13, RN on 9/3/15 at 4:00 p.m. in the administration meeting room she stated when she assumed Patient #4's care he was naked and covered in a blanket, he was already in the restraint chair. She stated she loosened up the straps under his arms because they were too tight. Patient #4 had redness under his arms where the straps had been pressing. She stated Patient #4 had been in the restraint chair since the morning shift. When the surveyor asked Staff #13 was there anything else they could have attempted, she stated the only thing we could have done is try to let him out of the chair and see what he would have done. She confirmed the Calming Strategies "indentified in Patient #4's Patient Safety Plan" were not implemented.

During an interview on the Specialty Unit on 9/4/15 at 9:00 a.m. Staff #10, RN charge nurse stated each patient's Patient Safety Plan has strategies that the staff use to calm a patient.

Review of Patient #4's Patient Safety Plan (last updated 11/14/14) reflected:
-Triggers:
Currently reports his triggers are AVH (audio, visual hallucinations), for example when he hears the television yelling at him.
Per History:
8." Restraints."

-Calming Strategies:
Currently reports walking and being left alone as calming strategies.
Per History:
2. Offer the "Safe Room."
4. Music, headset, drawing
5. Prefers a particular female staff member who he may talk to.
6. "Walk far away from it."
7. "Try to ignore it."

During an interview on 9/4/15 at 12:05 p.m. Staff #1, Chief Nursing Executive stated, "We do not put patients in restraints in the calming room." "That is used as a reward. No one wants to be in a restraint, if we put them in the calming room it would not serve the purpose." When the surveyor asked if the restraint and the seclusion room is a form of punishment; Staff #1 stated, "No." Staff #1confirmed the room is noisy and the window could be cleaned. She stated, "The room is only used as a place to protect the patient's privacy." She further stated the Calming strategies are not used once the patient is placed in restraints because they are too upset.

Based on observation, record review and interview the facility failed to ensure staffing schedules were reviewed and revised as necessary, and make adjustments in consideration of the training and experience of personnel to meet the patient care needs. A Registered Nurse that had not completed the unit orientation was the only RN on the unit. (Staff #9)

Findings included:

In an interview with Staff #9, Registered Nurse (RN) on 9/3/15 at 1:35 p.m. in the administration meeting room, she stated she had recently graduated nursing school last spring. She stated she did not have prior nursing experience before going into nursing school. Staff #9 stated, "I saw the schedule for the upcoming weekend (8/29/15 and 8/30/15), I was the only nurse scheduled for both days. I am still on Unit orientation. I asked my Supervisor who would be training me? The supervisor stated there would be a nurse to train me and there would be a LVN (Licensed Vocational Nurse) to pass medications on those two days."

When the surveyor asked what her training has been on the unit? Staff #9 stated, "I had been on the unit for the past three weeks, but had only been trained on passing medications. I hadn't been trained on being the front nurse or the charge nurse yet. When I came in on Saturday (8/29/15), I was the only nurse on the unit. I called the house supervisor to inform her. I was asked if I thought I could handle it by myself. I stated no. Another nurse was sent to the unit. I passed the medication for the day."

Staff #9 stated, "When I came in on Sunday (8/30/15), I was the only nurse on the unit. I did have plenty of PNAs (Patient Nursing Assistants). I called the house supervisor by 7:00 a.m. and let them know I needed help" "They called back and said they could not find anyone and that I should just do my best. I told them I think this is an unsafe condition. The house supervisors came over with Staff #6, a RN working on an adjacent unit, and stated I could work under his license. Staff #9 stated the house supervisors pulled two PNAs from her unit. My last day of orientation is September 10th. I was asked to come off orientation early but I don't think I am ready. I work tomorrow, (9/4/15) and I am scheduled to be the only RN."

During an interview with Staff #9, Registered Nurse (RN) on 9/4/15, the following day, at 8:00 a.m. on APS 7 she stated, "I called the House supervisor when I came in and told them I needed help. The other nurse arrived 45 minutes later."

In an interview with Staff #11, RN, the Nurse Educator on 9/3/15 at 10:30 a.m. in the administration meeting room, he stated "All nurses go through a Pre-Service training that is 13 days long. Once they go to the unit they get paired with an experienced staff for two weeks. A nurse in orientation would not be a charge nurse."

In an interview with Staff #2, Nursing Administrator, at 3:00 p.m. on the afternoon of 9/03/15 in the administration meeting room, he was asked about using nurses still on orientation for staffing on 8/29/15, 8/30/15 and on 9/4/15 day shift. He stated, "There is no rule for an orientation after pre-service training. It is determined by the individual unit. The orientation to the unit happens after the pre-service training. We (his department) have nothing to do with it." When asked would someone be taken off of orientation, to cover shifts, then is placed back on orientation, when short staffed, he stated, "No."

In an interview with Staff #4, Clinical Director on 9/4/15 at 1:15 p.m. in the administration meeting room he stated, "I supervise the Physician's in the Hospital. I do not supervise the Nursing Staff but I am on the Governing Body and attend the staffing meetings." When asked if he was aware that a newly graduated, still on orientation RN was performing multiple nursing positions unsupervised he stated, "I wasn't aware and that it would not be a good practice. They would need to be supervised."

In an interview with Staff #1, Chief Nursing Executive on 9/4/15 at 12:05 p.m. she stated she was informed of Staff #9, RN working on APS1 on 8/30/15. She stated the nurse on the adjacent unit was supervising her throughout the day. She was aware that two house supervisors, seasoned RNs had not stayed on APS 1to assist on APS 1. She was not aware the house supervisors had removed two PNAs from APS 1 that day. Staff #1 stated, "I spoke with the house supervisors and told them, one of them should have stayed on the unit. We thought we had it covered, but the nurse had requested off. I didn't look at the actual staffing sheets. I was told we have coverage."

Staff #1 stated, "There is no set time frame for new nurse orientation on the unit. Each nurse is handled individually. If a new employee needs more time, the orientation can be extended."

Review on 9/4/15 of Staff #9's training records did not reveal the completion of a unit orientation.

Review of Nurse Staffing Committee Meeting minutes dated August 28, 2015 reflected:

I) Effective Date of Plan: September 01, 2015
...
VI) Minimum Staffing Levels for Patient Unit ...members took into consideration unit-specific factors and needs. Included patient familiarity factors, medical complexity. The logistics and layout of each unit and their associated patient care areas ... Staffing plan excludes 1:1 precautions.
VII) Contingency Planning: The Nurse Supervisor for each of the units at ASH ...is responsible for developing a balanced monthly schedule and ensuring coverage within their unit; they coordinate and meet ...at a minimum of weekly to anticipate and or identify gaps and work together to meet coverage levels. The House supervisor reviews staffing information at the beginning of each shift and re-assigns nurses from one unit to another as needed.
VIII) Staff Experience, Education and Competency: All newly hired nurses...on-unit orientation is provided for all new nursing services staff.