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.

UT HEALTH EAST TEXAS TYLER REGIONAL HOSPITAL 1000 SOUTH BECKHAM STREET TYLER, TX 75701 June 22, 2011
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on document review the facility failed to develop a written care plan addressing the needs of a psychiatric patient and failed to evaluate and update the restraints in 1 of 1 patient's reviewed. .

On 6/15/2011 at 11:00 AM the patient's medical record was reviewed for care planning and the following was identified:

There was no Nursing Care Plan for this patient, who was admitted with Polysubstance intoxication, for withdrawal from Polysubstance abuse.
There was no Nursing Care Plan documented for this patient for suicide precautions.
There was no Nursing Care Plan documented for this patients for the use of mechanical restraints.
There was no Nursing Care Plan for this patient for least restrictive interventions.
There was no Nursing Care Plan for this patient's discharge to Rusk State Hospital.

There was no documented nursing care plan with interventions, assessments or updates for any identified patient care need.

Case Management discharge plan dated 6/5/2011 hrs until 6/22/2011-Tentative discharge to state mental health facility.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on patient records review, the facility failed to provide the least restrictive environment for 1 of 1 patients. Documentation revealed the patient was mechanically restrained 20 hours total without evidence of imminent danger to self or others. While mechanically restrained, the patient had 1:1 staff, police officer present and medication administered for agitation. Of the 20 hours the patient was in restraint, documentation shows the patient was asleep for 7 1/2 hours. The facility failed to ensure the right of the patient to be free from seclusion. Pt was secluded in pt room in body net restraints with police officer and 1:1 staff present. The facility also failed to follow it's own policy to ensure patient was free from restraints and failed to ensure a psychiatric evaluation was done. Further review revealed the facility failed to document and administer medications as prescribed by physician. Nursing also failed to document assessment of patient's behavior to justify need for PRN medication. The facility also failed to develop a written care plan addressing the needs of a psychiatric patient in restraints.


REFER TO TAG A154, A160, A162, A164, A166
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on Patient record review and interview, the facility failed to follow it's own policy to ensure 1 of 1 patients was 1) free from restraints and 2) failed to ensure a psychiatric evaluation was done on 1 of 1 patients' reviewed.

Example: Facility Policy #1
Administrative Manual - Suicide Precautions Code 19-16 Page #1
(The facility policy 19-16 corresponds to page #3 1.10 of the facilities approved Medical Staff Rules and Regulations as noted below)
For the protection of patient's, the medical, and nursing staffs, and the Hospital, certain principles are to be met in the care of the potentially suicidal patient:
a.) Any patient developing suicidal intent after admission to the Hospital shall be transferred to the facility of their choice, as appropriate, where suitable facilities are available.
b.) Any Patient known or suspected to be suicidal must have consultation by a member of the psychiatric medical staff.
c.) When time comes for a suicidal patient to be transferred from a critical care unit, the patient will be transferred to an appropriate psychiatric setting where suitable facilities are available for follow-up care.

Statement of Policy:
Patients admitted through the emergency room for medical or surgical problems requiring treatment following a suicidal attempt, and/or inpatients expressing suicidal ideation with medical or surgical conditions prohibiting transfer to a psychiatric hospital, will be subjected to the precautions described in the following procedure.
Page #2 Procedure
Any patient meeting the above criteria is to be observed according to assigned level of observation as follows:
Level I - Frequent Observation:
* Patient has thoughts of suicide but no plan to do self harm
Level II - Constant Observation"
* Patient has thought of suicide and has a plan to do self harm.
* Patient shall be in view of a staff member at all times; there shall be supportive documentation of observation and verbal contact to back up this observation.
Level III - Special Constant Observation
* Patient had thoughts of suicide and has means, mode and method or has already attempted self harm.
* The patient shall be attended on a 1:1 staff/patient ratio due to verbalization of intent to harm self; or following medical stabilization post suicide attempt, and awaiting psychiatric evaluation prior to transfer to a psychiatric facility, the patient can be transferred from the intensive care unit to unit appropriate for the patient's condition.
Page #3 Suicide precautions
1. The levels of observation may be ordered by the attending physician or initiated by a Registered Professional Nurse:
a.) the physician writing the order for "suicide precautions" should also write the level of observation.
b.) the Registered Nurse may initiate the assignment of the level and shall document the rational for establishing that level: and he/she shall immediately notify the attending physician of the level of observation chosen, documenting as verbal order physician concurrence, or alternate level ordered;
c.) the level of observation may be changed only upon order of the physician;
d.) the designated level of observation shall continue on all three shifts for a 24 hour period of time, after which the patient will be released by the attending physician or his appropriately appointed designee.
2. Patients will be assigned to the appropriate floor based on the comprehensive assessment of their unique needs.
3. There shall be psychiatric consultation and evaluation on all patients under suicide precautions; refer to Page #1 of this policy, Medical Staff rules and Regulations.
4. There shall be concurrent documentation in the medical record to verify that suicide precautions are maintained during each shift.

Page #4
5. Patients assigned to any of the observation levels shall not be allowed to leave the unit without constant staff accompaniment. (i.e. diagnostic tests, treatment)
6. Patients may not remain on suicide precautions for longer than 24 hours; without a documented re-evaluation by the attending physician and the Registered Nurse responsible for the patient; and only the attending physician on call may discontinue suicide precautions documenting his/her assessment on the patient's current clinical state upon which the order to discontinue the precautions is based.

Review of the medical record revealed the patient's History and Physical was dictated by an ACNP, FNP (Advanced Cardiac Nurse Practitioner, Family Nurse Practitioner) and signed by the Internal Medical physician who accepted the patient. There is no documentation a psychiatric medical staff member interviewed/consulted this patient while the patient was in the Acute Care Facility.

On 6/22/2011 at 9:30 AM, a review of the patient's medical record revealed: On 6/05/2011 at 1850 hours (hrs) the patient called 911. The patient (Pt) arrived at 1917 hrs in the Emergency Department (ED). He was escorted by city police under an Emergency Detention Without Warrant (EDW). The patient tested positive for Cocaine, Benzodiazipines and Canniboids. The patient voiced suicidal ideation with a plan to the police officer who brought him in and the Crisis worker from the local Mental health Authority who evaluated him in the Emergency Department at 2129 hrs. The Crisis Worker's documented recommendation was to transfer the patient to a State Mental Health Facility or local Behavioral Health Care facility. The record reflects the State Mental Health Facility had a bed available and the patient was cleared to transfer pending the doctor to doctor clearance on 6/5/2011. There was no physician to physician documentation found in the patient medical record.
The Patient's medical record reflects the review of systems was conducted in the ED on 6/5/2011 at 1947 hrs, by the the ED physician whose specialty is emergency medicine. This Document titled "ED Physician Note" includes a section titled "PSYCH" and includes the following:
Behavior: uncooperative (would not speak with physician)
Appearance: Avoids eye contact,
Affect/mood: Depressed,
Insight: With in Normal Limits (WNL),
Thought content: WNL,
Hallucinations: NONE .
The mental status exam was not filled out by the ED physician.

The admission documentation revealed an order for 23 hour observation, needs sitter. Intravenous (IV)orders for normal saline 150 milliliters a hour (ML/HR) was ordered. Suicide precautions was ordered on the document entitled "Emergency Department/Pulmonary Specialist Admission Orders.

The medical record reflects the patient was admitted from the ED into the hospital's medical surgical unit on 6/6/2011 at 0730 hrs and the patient's care was transferred to an Internal Medicine Physician. The nurses narrative reflects "Assessment complete per system review, VSS (Vital Signs Stable), no concerns or needs voiced. Pt under suicide precautions, sitter at bedside. Will continue to monitor". The nursing assessment system review included information under the psychological/Social section:
Behavior/Affect: Appropriate to age/situation.
Willing to communicate: Yes
Anxiety: NO
Fatigue: NO
Noncompliance: Yes
Despondency: Yes

Policy #2
Review of the facility policy CODE 18-08 for Restraint revealed the following: Page #1 of 7; Purpose:To ensure a patient's right to be free from the use of any form of restraint or seclusion is protected. To ensure the immediate physical safety of the patient, a staff member, or others.
Policy:
Paragraph #1; All patients have the right to be free from physical abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion of any form, imposed as as means of coercion, discipline, convenience, or retaliation by the staff....
Paragraph #2; Seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.
Paragraph #3; The decision to use a restraint is not driven by diagnosis, but by a comprehensive individual patient assessment. This comprehensive individual patient assessment is used to determine whether the use of less restrictive measures poses a greater risk that the risk of using a restraint or seclusion.
Paragraph #4; Restraint or seclusion may only be employed while the unsafe situation continues. Once the unsafe situation ends, or the patient's needs have been addressed using less restrictive methods, the decision to discontinue the use of restraint or seclusion should be discontinued by an RN or physician.
Page #3 of 7 Definitions:
Restraint-any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely.
Chemical restraint-a drug or medication when it is used as a restriction to manage the patient's behavior or restrict he patient's freedom of movement and is not a standard or dosage the the patient's condition.
Seclusion- the involuntary confinement of a patient alone is a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior. Seclusion is practiced in the Behavioral Health units only.
Page #5 Behavioral (violent and aggressive behavior)
* Restraint that is primarily used to protect the patient against injury to self or others because of an emotional or behavioral disorder.
* Restraint that is used for the management of violent or self destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member or others.
A) Make attempts to de-escalate the situation by:
1.) secure the environment
2.) Address the behavior and discuss it
3.) Ask what would make the situation better
4.) Avoid power struggles
5.) Do not lie or threaten the patient
6.) Give the patient choices and tell them you will honor their choices
7.) Notify your supervisor
8.) Call Code "White"
B) Initial orders
1.) Requires an order by a physician, and allows an RN to place the patient in restraint emergently and then call for an order.
2.) Requires the physician to examine the patient within an hour of application.
3.) The care plan will be initiated and modified as needed.
C.) Orders for Behavior uses can not be written for a time period that exceeds the following:
*4 hrs for 18 years or older
* 2 hrs for 9-17 years of age
*1 hr for less than 9 years of age
1.) A physician must see the patient, assess the patient, and write a new order
2.) Monitor every 15 minutes for the following:
* Signs of injury associated with restraint application
* Nutrition and hydration
* Circulation and Range of Motion
* Vital signs
* Hygiene and elimination
* Physical and psychosocial status and comfort
* Readiness for discontinuing restraint/seclusion
3.) Criteria for release:
* Imminent danger no longer exists
* Least restrictive interventions are successful

The Emergency Detention Without Warrant (EDW) reads in part as follows:
(d) A peace officer who takes a person into custody under Subjection
(a) shall immediately transport the apprehended person to:
(1) the nearest appropriate inpatient mental health facility; or
(2) a mental health facility deemed suitable by the local mental health authority if an appropriate mental health facility is not available.

The facility, in which the patient was taken by the police officer, was licensed as an Acute Care Facility without a Mental health Care Unit on campus.

The facilities General Nursing Orientation section G Module 15 Use of Restraint page #8 slide #43
* There must be evidence that there is "Imminent" danger to the patient or others in order to justify the need for applying a restraint or seclusion for behavioral reasons.
* Threatening to do something is not acceptable. Patients must be in the "act of" or "process of attempting" to do something that could result in injury or damage to self, others or to you.


Further review of the patient's medical record reveals 6/6/2011 at 0925 hrs the following nurses narrative: "Patient shouting out obscenities and stating that he is leaving because he hasn't seen a Doctor and no longer wishes to harm himself. Pt requested to use the phone to call police, and called and asked if he had any warrants. Pt state that he is leaving now and if any one gets in his way he will hurt us. Pt then left room and walked to elevator. Security called and notified of Pt's EDW (Emergency Detention Warrant). Pt could not be found on hospital grounds".

Further patient record review reveals the following nurses narrative: 6/6/2011 10:30 "Pt brought back to unit by city PD (Police Department). Pt taken back to room and Dr. called for restraint orders. Pt stating he will just leave again after the police leave. Pt has EDW (Emergency Detention Without Warrant) and was educated on why we could not let him leave. Pt threatening everyone with their life"

Further review of nurse narrative reveals 6/6/2011 at 1100 hrs "City police and facility security applying wrist and ankle restraints per doctors orders. Pt agitated and shouting threats"

A phone interview with Police officer #9, the Day Sergeant for the City Police Department, revealed city police officer #10 documented the pt was picked up off campus. The patient told the officer he no longer wanted to hurt himself. The officer and his partner returned the patient to the hospital, to his room and hospital security obtained Nylon restraints that were placed on the patient's wrists and ankles by the police officer and the hospital security officer. There was no physicians order for wrist and ankle restraints found in the patient medical record.

On 6/6/2011 at 11:02 AM a Doctors order was written as follows: Ativan 1 mg (milligram) PO (by mouth) IM (intramuscular), IV (intravenously), q 30 (every thirty minutes) prn (as needed) agitation. 1st dose now hold if sedated."

On the same page and below the hand written physician order for medication, the following Physician's telephone order was written: 6/6/2011 1045 hrs Behavioral restraints X 24 hrs (hours) See restraint protocol.

A review of the restraint/seclusion physician order form that is used in the facilities behavioral health unit reveals the following physician's order for "physical hold to body net beginning at 11:00 AM. The Behavioral criteria for release from restraint was "Psychiatry declares no longer danger to self or others". The patient was NEVER seen by a Psychiatrist for consult or evaluation for release of restraint during his 38 hour Inpatient admission.

The only documentation by the internal medicine physician who was the attending physician reads as follows: 6/6/11 1057 hrs, "Pt examined, agree with choice placement arrange at Rusk tomorrow after 24 hrs of detox from substance abuse".

After review of the patient's medical record, at no time was there documentation the patient physically aggressed toward any staff member, visitor, Police officer or himself. There was no documentation of imminent danger. There is also no documentation of any intervention of less restrictive nature other than the facility supplied sitter. The criteria for Behavioral restraint type is documented by the attending physician as "Physical hold to Body Net". There was never a physician's order for ankle and wrist restraints. The patient was never evaluated by a psychiatric medical staff member during his hospitalization as required by hospital policy Code 19-16. There was no comprehensive assessment by either the admitting physician or the Registered Nurse before or after any restraint was applied or released. There was no level of suicide precaution written by the admitting physician or the receiving physician. The patient was not transferred for 38 hours. There was no physician's order to remove the patient from suicide precautions and no re-evaluation by the physician documented.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0160
Based on record review the facility failed to document and administer medications as prescribed by physician in 1 of 1 patient records reviewed. Nursing also failed to document assessment of patient's behavior to justify need for PRN medication for 1 of 1 patients reviewed.

On 6/22/2011 at 10:00 AM in the board room the patient's record revealed that, after the patient had eloped from the medical surgical unit on 6/6/2011 and was returned by city police at 10:45 AM the same day, the physician wrote an order that reads as follows: 6/6/2011 1102 hrs Ativan 1 mg PO/ IM/IV q 30 minutes PRN agitation first dose now, hold if sedated. Review of the Medication Administration Record (MAR) documented the initial dose of Ativan was given on 6/6/2011 at 1220 hrs. 1 hour and 20 minutes after the "Now" dose of medication was ordered.

The patient received a total of 5 doses of Ativan on 6/6/2011. A review of the Restrain/Seclusion monitoring log revealed the documented behavior that warranted IM Ativan at 12:30 on 6/6/2011 was yelling and talking to staff. Further review of the same record revealed a second dose was given on 6/6/2011 at 1310 for "yelling and talking with staff." Continued review of the Restraint/ Seclusion monitoring log reveals a third dose was given PO on 6/6/2011 at 1830. The documented behavior was "quiet and talking with staff."
Continued review reflects On 6/6/2011 at 2155 the patient received Ativan 1 mg IM for throwing things. The restraint/seclusion monitoring log does not document behaviors for the dose given on 6/6/2011 at 2100 hrs . This dose was recorded on the medication administration record as PO and the nurses narrative which records; "Pt getting agitated. Pushed bedside table in my direction spilling a glass of water onto the floor. Informed the patient I was going to give him an IM Ativan shot to help him relax. Pt compliant and held still while receiving injection"

The patient's medical record documented one dose of Ativan that was given on 6/6/2011 at 1830 hrs to the patient while he was quiet and talking with staff and one does was given 6/6/2011 at 2100 hrs without behavioral documentation recorded on the Behavioral monitoring log. The record does reflect a polysubstance abuse patient sat compliantly for an IM dose of Ativan which was documented on the MAR as given PO.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0162
Based on record review and interview the facility failed to ensure the right of the patient to be free from seclusion in 1 of 1 patient record reviewed. Pt was secluded in pt room in body net restraints with police officer and 1:1 staff

On 6/6/2011 at 10:00 AM the patients medical record revealed on 6/6/2011 at 0730 hrs patient was calm and was admitted to a medical surgical unit. At 0925 hrs the nurses narrative of the patient's medical record reflects the patient left the unit via the elevator and was returned to the unit by City police and Facility security at 1030 hrs the same day. The medical record reflects the patient was placed into wrist and ankle restraints at 1100 hrs in his room. Further review of the nurses narrative reflects the patient is still in restraint at 1445 hrs. The pt has now been in restraints 4 hours and 45 minutes.

Further review of medical record reveals a new restraint order was written a 1500 hrs to end at 1900 hrs. This order was not signed by the physician and there was no documentation that an assessment was done by the physician when restraint orders were renewed.

There is no nurses narrative for the hours between 1500 and 1830 on 6/6/2011, however the restraint/seclusion monitoring log documents the patient as sleeping and restrained. The medical record shows the following entry: "staff met with pt and discussed with him his behavior leading up to restraints and what we need him to do if restraints are removed. Pt will need to remain in hospital room until RSH (Rusk State Hospital) comes to get him in the am and not to be inappropriate with staff. Pt voiced that he would stay here and act good. Restraints released at this time will continue to monitor"

The record showed the patient was calm until 1930 hrs when he walked off the unit. He was returned to the unit once again by city police at 2030 hrs the same day and restraints were reapplied.

A review of the restraint/seclusion order form revealed an order for restraint/seclusion for 4 hours beginning at 2000 hrs and ending at 0000 hrs. The order was signed by a physician but there was no documented evaluation by the physician of the necessity of the restraint.

A review of the nurses narrative of the patient's medical record does not reflect what type of restraint, however the Restraint/Seclusion log documents a body net was applied. The city police officer stayed on the unit along with the facility's sitter. The patient record reflected he was cooperative when he returned yet was returned to his room and ordered in mechanical restraint, facility sitter in the room and city police officer on the unit.

Further review revealed a restraint/seclusion order for 4 hours from 6/7/2011 0000 hrs to 0400 hrs. This order was not signed. There was no documentation that an assessment was done by the physician when restraint orders were renewed.

Review of orders revealed a restraint/seclusion order for 4 hours on 6/7/2011 from 0400 hrs to 0800. The order was signed by a physician but there was no documented evaluation done by the physician of the necessity of the restraint.

The patient was restricted to the confines of his room with mechanical restraint, chemical restraint, facility sitter and city police, during the hours of 11:00 to 21:50 on 6/6/2011. There was no documentation the facility evaluated the patient for suicidal risk. There was no documentation there was ever a risk of imminent danger from the patient toward staff members, visitor,police or himself. The patient was restrained for the convenience of the staff. There was no documentation that less restrictive intervention was attempted other than conversation from the staff at 18:30 on 6/6/2011 explaining if the patient would remain In HIS ROOM and not be inappropriate with staff the restraints would be released.

On 6/21/2011 at 8:00 AM a phone interview with staff #3 confirmed "patients on EDW (Emergency Detention Without Warrant)leave all the time and we bring them back to their room"
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
Based on 1 of 1 patient records review, The facility failed to provide the least restrictive environment for 1 of 1 patients. Documentation revealed the patient was mechanically restrained 20 hours total without evidence of imminent danger to self or others. While mechanically restrained, the patient had 1:1 staff, police officer and medication administered for agitation. Of the 20 hours the patient was in restraint, documentation shows the patient was asleep for 7 1/2 hours.

Review of the facilities General Nursing Orientation printed 3/2011 Section G Module 15 page #8 slide #43 reads as follows: "There must be evidence that there is "imminent" danger to the patient or others in order to justify the need for applying a restraint or seclusion for behavioral reasons. Threatening to do something is not acceptable. Patient's must be in the "act of" or "process of attempting" to do something that could result in the injury or damage to self, others or you."

There was no documentation that patient was in the "act of" or "process of" doing harm to any one. He was in the "act of" or "process of" attempting to leave the facility.

On 6/6/2011 at 10:30 Am in the board room the facility restraint policy CODE 18-08 was reviewed as follows: Purpose To ensure a patient's right to be free from the use of any form of restraint or seclusion is protected. To ensure the immediate physical safety of the patient, staff member, or others.
Policy All patient's have the right to be free from physical restraint or mental abuse, and corporal punishment. All patient's have the right to be free from restraint seclusion of any form, imposed as a means of coercion, discipline, convenience, or retaliation by the staff.

Restraint or seclusion may be imposed to ensure the immediate physical safety of the patient, staff member or others and must be discontinued at the earliest possible time.

Definitions:
Restraint; any manual method,or physical or mechanical device, material or equipment that immobilizes or reduced the ability of a patient to move his arms, legs, body,or head freely.
Chemical Restraint; A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment of dosage for the patient's condition.
Seclusion:The involuntary confinement, of a patient alone in a room or from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self destructive behavior. Seclusion is practiced in Behavioral health units only

On 6/22/2011 at 10:30 AM, in the board room the patient's medical record was reviewed, it revealed the following: On 6/6/2011 at 0925 hrs the patient walked off the unit AMA (against medical advice). At 1030 hrs documentation revealed the "Patient brought back to unit by city police, taken back to room and Dr. called for restraint orders. Pt stating he will just leave again after the police leave. Pt has an EDW and was educated on why we couldn't let him leave. Pt threatening everyone with their life. On 6/6/2011 at 1100 hrs documentation records "city police and facility security applying wrist and ankle restraints per doctors orders. Pt agitated and shouting threats.

Further review of the patient's medical record revealed, a physician's order for Ativan 1 mg PO/IM/IV Q 30 minutes for agitation "now" was not ordered when the patient was admitted to the hospital. The Ativan was not ordered in anticipation of treating drug abuse and/or withdrawal, rather the Ativan was ordered to calm an angry man who left the hospital AMA and was brought back to the hospital against his will. This order was written on 6/6/2011 at 1102 hrs after the patient was returned to the unit on 6/6/2011 at 1030 hrs and threatened to leave again as soon as police left. A telephone order for a physical hold to bed net was the only other intervention physician ordered. However, the nurses narrative documents the patient being restrained by police and security by applying wrist and ankle restraints. The patient was understandably agitated and shouting out threats.

There was no evaluation by a Registered Nurse documenting the need for the initial dose of Ativan. There is no documentation in the nurses narrative that the initial dose of Ativan IM was given, however the restraint /seclusion monitoring log record the dose given at 1230 hrs and the MAR records the initial dose of Ativan at 1220 hrs. There was no nursing documentation of alternative interventions considered prior to giving the Ativan IM. Further nursing documentation revealed after the patient awoke at 1800 hrs he asked for some thing to eat and to be released. Documentation records "the patient has been sleeping since 1515 hrs". The medical record does not indicate the patient was released from restraints, even while asleep as required by State hospital regulation Y2172 (b) If the individual is determined to be asleep, the clinically competent registered nurse will instruct authorized staff to immediately release the individual from restraint or unlock the seclusion room door. Authorized staff will maintain continuous face-to-face observation until the individual is awake and re-evaluated by the clinically competent Registered Nurse and the hospitals' policy Code 18-08 reads "Restraint/Seclusion may be imposed to ensure the immediate physical safety of the patient, staff member or others and must be discontinued at the earliest possible time.

Continued review of the patient's medical record restraint/seclusion monitoring log reveals on 6/6/2011 at 1830 hrs the patient was given a PRN medication for agitation, yet the nurses narrative records 6/6/2011 at 1800 hrs records the patient woke up asking for something to eat and to be released. At 1830 hrs the record indicates the restraints were removed and at 1841 hrs "Pt sitting up in bed watching TV. No distress noted, he is calm."

Continued review of the patient's medical record reveals 6/6/2011 at 1930 hrs "Pt walking off unit with sitter in "tail" Called out to pt to not leave floor and followed off unit down stairs. Staff RN calling security to notify. Pt ran out exit through loading dock and took off down the street". The patient was returned to the unit by city police at 2030 hrs. The Patient's medical record reads "Pt escorted back to room by police and security. Sitter in room. Restraints reapplied. Pt cooperative at this time. States he was at his buddy's house and smoked a cigarette. Discussed poc for this shift. Police remain on the unit." On 6/6/2011 at 2150 documentation reveals "Pt getting agitated. Pushed bedside table in my direction spilling a glass of water onto the floor. Informed pt I was going to give him an Ativan shot to help him relax. Pt compliant and held still while receiving injection". Pt was restrained in a bed net at the time he pushed the bedside table toward the staff.

Nurses narrative ends at 2150 hrs on 6/6/2011. There was no further nurses narrative for release of restraints or assessment of effectiveness of Ativan. There is no nurse narrative until 0730 6/7/2011 when the nurses narrative reads; "rec'd patient sitting at bedside with sitter and police officer in the room". A review of the restraint/seclusion monitoring log documents the patient was last released from restraint at 1830 hrs on 6/6/2011. The restraint/seclusion monitoring log had no documentation past 0645 on 6/7/2011. Nurses narrative records the patient was discharged at 0920 hrs transported by police to Rusk State Hospital.

Review of the Restraint Orders Monitoring Logs revealed, restraint orders for 4 hour duration were renewed 5 times for a total of 20 hours, the patient was asleep for 7 1/2 hours of the 20 hours. Review of hospital policy "Code 18-08" titled "Restraints revealed the following: "Restraint or seclusion may be imposed to ensure the immediate physical safety of the patient, staff member or others and must be discontinued at the earliest possible time." There was no documentation the patient was evaluated by a Registered Nurse once he was observed asleep. There is no documentation that while asleep the patient was released from restraint.

There was no documentation the patient was released from the wrist and ankle restraints when given an initial dose of IM Ativan. There was no documentation the patient was released from the wrist and ankle restraints when documentation revealed he was placed in a bed net. There was no documentation in the nurses narrative or the restraint/seclusion monitoring log the patient was released from wrist and ankle restraints or bed net restraint until 1830 hrs on 6/6/2011. There was no documentation the patient attempted harm to himself. There was no documentation the patient attempted harm to others during this episode.