The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

BAYLOR SCOTT & WHITE PAVILION - TEMPLE 2401 S 31ST ST TEMPLE, TX 76508 Dec. 29, 2014
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
This standard is not met as evidenced by:

Based on staff interview and review of patient records the facility failed to provide a physicians order for the use of restraints in four out of ten patient records reviewed.

The findings include:
A review of Scott and White Use of Restraint or Seclusion Policy, policy number SW.029, Use of Restraint for Non-violent or Non-self Destructive: states, "The initial order for use of Non-Violent or Non Self-Destructive is obtained from a physician, fell ow or resident. APP's may not write the initial order but may write for renewal of non-violent/von self-destructive restraint."

"Orders for restraints are renewed each calandar day and specify the reason for the restraint(i.e. the medical necessity as well as the indication that the restraint use is to improve the patient's well being) type of restraint and the duration for the restraint application."

Restraint for Management of Violent or Self destructive:
"An order for use of Violent/Self-Destructive Restraintand /or Seclusion is obtained from a physician, fell ow or resident responsible for the care of the patient."

A review of patient records reveals patient # 1 did not have documentation of a valid physicians order in their record for a restraint at the time of the incident, patient # 9 did not have documentation of a physicians restraint order in their records for 1 day out of the 4 days patient was in restraints, patient # 10 did not have documentation of a physicians restraint order in their records for 1 day out of the four days the patient was in restraints and patient # 11 did not have documentation in their records of a physicians order for 1 day ( out of 13 days the patient was in restraints.

In an in-person interview with staff number 3 on 12/29/2014 at 4:15 pm stated, "I did not find physicians orders for restraints for those patients on 2/23/2014, 3/5/2014 or on 3/22/2014."
VIOLATION: PATIENT RIGHTS:RESTRAINT/SECLUSION DEATH RPT Tag No: A0213
This standard is not met as evidenced by:
Based on review of hospital policy and interview with the Regulations Manager indicated that no documentation was available for review that a notification of death had been given to the Centers for Medicare and Medicaid.

Based on review of facility policy Use of Restraint or Seclusion Policy, policy # SW.029, section H, Requirements for Death Reporting:
"The Scott and White Director of Risk Management or designee will report the following to the Centers for Medicare Services (CMS):
"Each death known to the hospital that occurs within one week after restraint or seclusion where it is reasonable to assume that the use of restraint or placement in seclusion contributed directly or indirectly to a patient's death "reasonable to assume" in this context includes, bit is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing or asphyxiation."
"Each death referenced as above is to be reported to CMS by telephone/fax no later than the close of business day following knowledge of the patient's death."

In an in-person interview with the Regulations Manager on 12/29/2014 at 10:30 am stated," I can't find any paperwork that we reported the death to CMS. We may have needed to report to CMS, but let me put in the date of death into my algorithm and check for a possible reason why we didn't report the death and I will get back to you."
In an in-person interview with the Regulations Manager on 12/29/2014 at 11:30 am stated, "We didn't feel the death met criteria according to our policy to report to CMS. It wasn't "reasonable to assume" that the restraint contributed to the patient's death."