HospitalInspections.org

Based on a review of facility documentation and videotape, and staff interview, the facility failed to protect each patient's rights by failing to ensure the emotional health and safety of each in a manner which included respect, dignity and comfort. Due to the manner and degree to which the facility failed to protect the rights, the facility was not compliant with the requirements of this condition.

Findings were:

Staff at the facility put 1 of 10 adolescent patients [Patient #1] in a seclusion room without clothing or coverage of any type for approximately 20 minutes. Patient #1 is a 15-year-old female with a history of sexual abuse.

Cross refer: Tag A0144

Based on a review of facility documentation and videotape, and staff interview, the facility failed to ensure the emotional health and safety of each patient as the facility secluded, without clothing or coverage of any type, a 15-year-old female patient with a history of sexual abuse, thus failing to treat 1 of 10 patients [Patient #1] in a manner which included respect, dignity and comfort.

Findings were:

A review of facility clinical records and videotape revealed that for 1 of 10 adolescent patients [Patient #1], the facility secluded the patient without clothing or other coverage for approximately 20 minutes on 10/7/14.


A review of the medical record of Patient #1 revealed that she was a 15-year-old female, admitted to Austin Oaks Hospital on 10/7/14 at 3:55 p.m. An Admission Assessment completed by a facility LCSW on 10/7/14 at 3:15 p.m. stated in part:

"Abuse History (Physical/Sexual/Emotional)
Sexual - [by significant male relatives], ages 5-15...
Admitted to: Adol (adolescent unit)..."


A Psychiatric Evaluation dictated on 10/8/14 at 2:19 p.m. stated, "Chief Complaint/Reasons for Admission: [Patient #1] presents for inpatient hospitalization due to intrusive suicidal ideation...History of Present Illness: ...She reports stressor being [alleged sexual abuse] from the ages of 5-15...

h) Patient Trauma History:
Emotional/Physical/Sexual Abuse History: She was sexually abused by [significant male relative], reported from the ages of 5 to 15 and this has been reported..."


A review of Physician Orders for Patient #1 revealed the following:

? Telephone order by [Staff #4, facility psychiatrist] for Restraint and Seclusion Order on 10/7/14 at 7:10 p.m. which included the following:

"A. Clinical Justification for Intervention: ...Took metal paperclip from nurses station, attempted to swallow, punched, kicked, spit, scratched staff ...

G. Describe actions taken to lessen physical and/or psychological risk if indicated: clothes removed, gown given ...

H. Staff involved in restraint/seclusion ...[Staff #6 (male RN), Staff #8 (female RN), and Staff #7 (male RN)]


? Telephone order by [Staff #4, facility psychiatrist] for Restraint and Seclusion Order on 10/7/14 at 7:55 p.m. which included the following:

A. Clinical Justification for Intervention: ...Tore off piece of gown, wrapped around neck in suicide attempt, combative to staff ...

G. Describe actions taken to lessen physical and/or psychological risk if indicated: ...gown removed, to decrease risk of suicide attempt ..

.H. Staff involved in restraint/seclusion...[Staff #7 (male RN), Staff #10 (female Mental Health Worker), and Staff #6 (male RN)]


? Telephone order by [Staff #5, Advanced Practice Nurse] on 10/7/14 at 7:55 p.m. which included the following: "...remove all clothes until calm...Place on 1:1 while awake..."


A review of 12-Hour Nursing Assessment/Progress Note entries revealed the following, in part:

10/8/14: "1850 - Pt. reached over the nurse's station and obtained a paperclip and ran into seclusion room bathroom. Pt. placed paperclip in mouth and refused to remove it from her mouth. Staff in bathroom and attempted to remove paperclip and pt. became combative and punched, kicked and spit at staff. Pt. was restrained and paperclip was removed, pt. continued to be combative and bit, kicked, punched, and spit on staff. [Psychiatrist] notified at 1910, new orders of Thorazine 50 mg IM, Benadryl 50 mg IM x 1 dose now. Pt placed in seclusion room, pt.'s clothes removed because of risk of contraband and placed in gown, pt. continued to punch, kick, scratch, and bite at staff, the restraint was continued by staff for administration of the IM medications...

1945 - While in seclusion pt. tore off a piece of gown and tied around her neck in suicide attempt. Staff went into room and pt. became combative, kicked, punched, spit, and bit staff. Staff attempted to orient pt. to reality, attempted to calm pt., other staff came to pt. and attempted to calm but pt. continued to be combative and screaming obscenities towards staff...[Staff #4, Psychiatrist] notified and Benadryl 25 mg IM and Thorazine 25 mg IM, Ativan 1 mg IM, pt. to be placed on 1:1, and clothes/gowns to be removed until calm...

2010 - Pt. became calm, gown given back to pt. and seclusion door open..."


In an interview with the Staff #4, psychiatrist, on the morning of 10/14/14 in the facility meeting room, he stated, in part: "I've been the Medical Director here for about six months now ...She [Patient #1] came in for suicidal ideation from [another] facility...The night she came in she ended up in a procedure that night. She's still here - she's still acute ...Last night she had to go back into gowns. The two were working last night - the same two that were in that first incident she had here. I asked her what happened - I was speaking to her just this morning. I said to her, you know you got your clothes - so what happened last night?...So she was in paper gowns - when I asked her what happened, she said "Well, they were working again last night." So they really triggered her again last night...Normally we'd say you have to watch when you put hands on someone with a history of trauma, but ultimately you have to do what's best for the safety of the patient. They tried verbal de-escalation of course and we offer them verbal meds to get them to de-escalate ...I don't know who told them to do that, because it wasn't me [regarding the order for removal of all patient clothing]. It was the APRN who gave them that order. It sounds like they had the cloth gown on her and she used it to tie around her neck. It looks like they called the APRN that night rather than me. I told them we can't do that - we can't leave a patient without anything to wear. So the next morning when I found out I said "No, we can't do that." We use gowns, though, all the time..." Further in the interview the psychiatrist stated, "It's rare that patients are ordered into gowns. It happened again last night for this patient... it looks like at 2140 - patient was placed in the gown for 48 hours. I guess I'd rather err on the side of caution and if keeping her in a gown would keep her safe, well then that's better..."


In an interview with Staff #5, APRN on the afternoon of 10/14/14 in the facility meeting room, he stated, in part: "I received a telephone call and they were telling me the teenager was acting out and attempting to harm themselves. They had placed her in the quiet room and she was attempting from then on to use her clothes to strangle herself. So I gave them an order for 1:1 and to remove her clothes so that she could not strangle herself with them and to put her in paper gowns..." When asked if he had ordered to leave the patient completely without clothing, he stated in part, "Well, I wasn't here. This is the same procedure we use at other facilities - if there were a safety issue, we'd immediately remove their clothing and put them in paper gowns. So she would have been without clothing at least for that..."


In an interview with the Director of Nursing, Staff #3, on the afternoon of 10/14/14 in the facility meeting room, she stated in part: "Yes, I think at one point she was completely without clothes. "


In an interview with the treatment team therapist of Patient #1, Staff #11, on the afternoon of 10/14/14 in the facility meeting room, she stated in part: "[Patient #1] is extremely suicidal. She's in a little bit of a different situation than a lot of the patients here because she's in CPS custody. She's 15 now. She was raped by [a significant male relative] when she was 14. There's some substance abuse in the family. The [significant male relative] was arrested...She said it was one particular male staff member [that bothers her]...[the therapist gave a physical description of the male which she identified as being Staff #6]. She said that he had to take the gown off or something. And she said when he did that, it was very traumatic for her and that she felt like she was being raped. And she has been raped in the past. That's the protocol [putting a patient in a gown] for all kids or adults who are suicidal because they can use their clothing to hang themselves...[Patient #1] is so extremely violent when she self-harms and so intent on hurting herself using any means necessary, that I think that a lot of her behaviors take the staff by surprise...I haven't seen a single other patient who's this extreme..."


A viewing of the facility videotape of the seclusion of Patient #1 on the evening of 10/7/14 was conducted by this surveyor and the Director of Risk Management (DRM), Staff #2, on the afternoon of 10/14/14 in her office. The videotape was started at 7:10 p.m. on 10/7/14, and included views of three different cameras: the hallway outside the seclusion rooms, the anteroom of the two seclusion rooms, and Seclusion Room #2. The bathroom off the anteroom was not visible by camera as the door to the hallway blocked the view. Viewing of the video began when the patient was already in the bathroom of the seclusion room anteroom and could not be seen on camera. The DRM stated, "Two female nurses are in the bathroom with the patient trying to put a gown on her." The next approximately 40 minutes of video revealed a struggle with the patient and staff to get her into the seclusion room and administer medication. The patient was clearly kicking and fighting staff. The DRM identified staff as two male RNs [Staff #6 and #7], one female RN [Staff #8] and one female MHW (mental health worker) [Staff #10]. The patient was attired in a hospital gown and had nothing on under it. As the struggle continued, there were numerous moments when the gown was not covering her body. Emergency medication was brought in and administered to the patient by two male RNs and the female MHW. The patient continued to struggle. At approximately 7:54 p.m., one of the male nurses [Staff #6] grabbed the patient's gown with his right hand and ripped the gown off, leaving the patient completely nude. All staff then left the seclusion room and the door was shut. The only other item in the room was a mattress. The patient was naked in Seclusion Room #2 for approximately 23 minutes. A nurse returned to the room at 8:17 p.m. to hand the patient a gown. The video playback was stopped at that point.


Facility policy #PC-C-3 entitled Seclusion and Restraint, last revised 6/19/14, stated in part: "Use of restraint and seclusion is initiated only as an intervention of last resort in an emergency situation where a patient is in imminent danger of causing harm to self or others and all other less restrictive or invasive measures have been attempted and failed ...The treatment philosophy is centered on providing a positive, healing experience...

17. Staff members must respect and preserve the rights of an individual during restraint or seclusion...

Personal Possessions (facility's bold)

1. The individual's right to retain personal possessions and personal articles of clothing may be suspended during restraint or seclusion when necessary to ensure the safety of the individual or others...

4. If personal articles of clothing are taken from the individual, appropriate other clothing will be issued..."


The above findings were again confirmed in an interview on the afternoon of 10/14/14 with the Chief Executive Officer (CEO) and other administrative staff in the facility meeting room. The CEO stated in part, "We don't do that here. We don't leave patients without clothes." The Director of Nursing stated in part, "We've now addressed the issue with this staff member."