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JPS HEALTH NETWORK 1500 S MAIN ST FORT WORTH, TX 76104 May 8, 2014
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on interview and record review the hospital failed to ensure the patient's right to be free from physical abuse and/or coercion in that 1 of 1 patient (Patient #1) was placed in the seclusion room by hospital staff after an altercation with a peer. Upon arrival to the seclusion room (Patient #1) was not allowed to leave and no restraint/seclusion orders were obtained until after (Patient #1) attacked a staff member. (Patient #1) was then returned to the seclusion room with seclusion orders obtained.

Findings Included:

(Patient #1's) Demographic Information final diagnoses record reflected, "Paranoid Schizophrenia, Cannabis Abuse...Social Maladjustment..."

The close observation record dated 02/10/14 timed at 19:00 PM, reflected, "Day area, agitated, aggressive behavior and verbalizations...at 19:15 PM...time out room..." No physician order was found for this event.

The Seclusion and Violent Restraint Physician Order/progress notes dated 02/10/14 timed at 19:25 PM, reflected, "Patient kicked staff in the groin area and punched and kicked staff..."

The close observation record dated 02/10/14 timed at 19:30 PM, reflected, "Seclusion, agitated...seclusion until 21:15 PM..."

The Behavioral Seclusion or Restraint Flow Sheet dated 02/10/14 timed at 19:25 PM, reflected, "Placed in seclusion at 19:25 PM released at 21:15 PM..." (Patient #1) was in seclusion for one hour and fifty minutes.

The 02/11/14 nursing note timed at 12:34 AM, reflected, "Patient got angry and frustrated towards his family...another patient got involved...and they started fighting...staff intervened and separated the patients...patient escorted to the quiet room with staff, but still angry and verbally threatening...wanting to call police and go to jail instead...encouraged to get to the unit...still angry got up and kicked staff in the groin area...patient taken to seclusion..."

The 02/11/14 nursing note timed at 06:11 AM, reflected, "Lesser restrictive intervention were attempted by offering alternative quiet area...he was not cooperative with the intervention..."

On 05/08/14 at 02:45 AM, Personnel #15 was interviewed by telephone. Personnel #15 stated (Patient #1) got in an altercation with a fell ow peer and the staff had to intervene. Personnel #15 stated (Patient #1) was agitated, aggressive and was taken to the seclusion room on the order of the nurse. Personnel #15 stated the patient did not want to go into the seclusion room but the staff placed the patient in the room. Personnel #15 stated the nurse did not want to close the door which would have made it a seclusion and orders would have to be obtained. Personnel #15 stated the patient was still agitated and a short time later ("15 minutes or so") (Patient #1) kicked one of the staff in the groin.

On 05/09/14 at 12:45 AM, Personnel #14 was interviewed by telephone. Personnel #14 stated (Patient #1) was taken to the seclusion room. Personnel #14 stated when the door was going to be closed the nurse said, "no do not close the door." Personnel #14 stated (Patient #1) was very agitated and kept trying to leave the room but the staff would not let (Patient #1) leave the room. Personnel #14 stated the patient was placed into the seclusion room by staff but seclusion was not initiated until (Patient #1) kicked one of the staff in the groin.

The non-dated hospital PSY 106 procedure for Least Restrictive Interventions reflected, "Staff may not use physical force or personal restraint to direct to a clinical timeout area to force or coerce the patient constitutes restraint and/or seclusion and renders the procedure subject to the requirements for restraint/seclusion..."