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.

Based on record review and interview, the facility staff failed to ensure patient rights in accordance with the facility's policy during the implementation of a restraint for 1 of 1 patient reviewed (Patient #1) who was a minor; resulting in complaint allegations in the area of patient rights.

Specifically, on 08/04/16 Out Patient (OP) facility staff and staff from the contracted ambulance service implemented an undocumented physical hold and restraint on Patient #1 following verbal physician orders; which occurred in the facility's OP Program. The facility failed to ensure the required nursing documentation, written physician orders, monitoring, and a follow-up one hour face-to-face assessment following the implementation of the physical hold and restraint; in accordance with the facility's policy.

Findings included:

Review of Patient #1's Guardian Complaint reported to the Department of State Health Services (DSHS) complaint hotline on 08/08/16 stated that on 08/04/16 Patient #1 was being transferred from the OP facility to the Acute Inpatient facility because he was running from the building and the OP staff had no way to stop him per policy because he was voluntary and they could not physically stop him or restraint him because he was a minor. Patient #1's Guardian stated she arrived to the OP Program to find out the Doctor ordered Patient #1 to be transferred to the facility's Inpatient Program. Patient #1's Guardian refused to transport him and the facility called the contracted ambulance service to facilitate the transfer. Patient #1's Guardian indicated once the ambulance service arrived Patient #1 was crying and refused to get onto the gurney. Patient #1's Guardian was told by staff they could not physically put him on the gurney and told her that "you can"; because they were not supposed to. Patient #1's Guardian stated the facility staff agreed to do it and then it took 6-7 people who "physically restrained him, while he was kicking and screaming. They physically restrained him, they were back and forth between the doctors and hospitals discussing the restraint process." Patient #1's Guardian stated that Patient #1 was then transferred back to the inpatient hospital and that during the 3 hours admission process she kept asking to speak with a nurse supervisor and she was told no one was available.

Review of the Ambulance Service report dated 08/04/16 from 12:08 PM to 01:21 PM documented they received Patient (PT) #1 from the facility's OP center and transferred to facility's Acute Inpatient Center. Patient stable throughout. Patient underage and upset, unable to take vitals. Per sending Physician A, "soft restraints were authorized for PT" and crews safety. "Staff at sending facility had to restrain him and put him on the stretcher because PT refused. PT's Mother stated to do what we think is necessary but to make sure it was written down in the report." Behavior was documented as "Combative/agitated behavior" and "Danger to self/others."

Record review of Patient #1's OP record revealed a Progress Note dated 08/04/16 completed by the Licensed Professional Counselor (LPC) intern- A that documented the following: Therapist was called in to aid Patient #1 in adjustment along with the Emergency Medical Technicians (EMT's) transporting Patient #1 to the facility's acute inpatient. Patient rose from his seated position on the floor, ran at therapist and became combative and began hitting therapist on the left bicep. Patient was already agitated and EMT's were waiting to transport patient to the inpatient center. Further documentation dated 08/08/16 from LPC intern A documented on 08/04/16 therapist was asked to enter the room to help the patient transition to the gurney for the ambulance. Patient was hiding behind a chair. Patient refused to get onto the gurney himself. Patient became combative. Mother of Patient #1 was informed that this is a facility where we do not restrain patients. Patient was screaming and combative. EMT's conferred with mother about helping the patient onto the gurney. Patient became even more combative and began to attempt to bite EMT's and staff. Mother of patient stood back away from patient and gurney. Therapist remained at the head of the gurney speaking to the patient. Patient did require soft restraints; an order was obtained by sending physician -A, and was cleared with EMT's supervisor.

Record review of the Progress note dated 08/05/16 by Mental Health Tech (MHT) A documented that Patient #1's mother asked staff to assist with placing patient on the gurney due to patient being very combative, her not wanting to be responsible. I (MHT-A) assist by placing my hands on PT legs and placing patient on gurney.

Review of Patient #1's records revealed there was not a Special Treatment Procedures (STP) form in his record where facility staff were to document Restraints, Seclusions, and Emergency Medications; and there was no evidence the STP form was completed by any facility staff for the physical restraint/hold and soft wrist restraints implemented in the OP Center by MHT-A, LPC intern A, EMT's, and other OP facility staff.

Review of Patient #1's Physician Orders (PO) for 08/04/16 revealed there was not a documented physician telephone order or written order for the use of a physical hold or soft-wrist restraints used. The only PO documented from 12:00 to 1:30 PM was at 13:01 (1:01 PM) a physician telephone order (TO) by OP Physician - A taken by OP Registered Nurse -A for Hydroxyzine 25 milligrams (mg) by mouth or intramuscular every 4-6 hours as needed (PRN).

Interview on 08/09/16 at 11:25 AM with Patient #1's Mother/Guardian stated that she met with the facility's Patient Advocate (PA) to review Patient #1's restraint implemented on 08/04/16 and she was told by the PA, who read the ambulance report, that they tried to get him on the gurney into the ambulance and the EMT's had to restrain him and he went to the hospital. Patient #'1 mother stated that was not what happened; that there were 6 OP facility staff present and the EMT's who tried to get her son onto the gurney. Patient #1 then refused and became combative. Patient #1's mother indicated the EMT's stated that if they could not get Patient #1 to go voluntarily then they would need to call the Police Department for transport and restraint. Patient #1's mother stated there were phone calls going back and forth and then the OP staff agreed to "restrain him and put onto the gurney." Patient #1's mother stated there were OP staff including MHT-A and the Therapist (LPC intern -A) that restrained him; "held him down, picked him up off the floor" placed him on the gurney; while the EMT placed the restraints (soft-wrist) on him. Patient #1's mother stated he then was transferred to the facility's inpatient acute hospital where they waited in admission for 3 hours and Patient #1 was not assessed, seen by a nurse or doctor following him being held and restrained. Patient #1's mother stated she felt the facility was "lying about the restraint" and failed to document the incident as it actually occurred.

Interview on 08/10/16 at 9:40 AM with LPC intern- A stated on 08/04/16 Patient #1 was attempting to elope from the OP center building. Patient #'1 mother was contacted who came to the OP facility. Patient #1's mother was notified that the Doctor ordered Patient #1 to be transferred to the acute inpatient facility and she refused to transport Patient #1. The ambulance service was called and then Patient #1 refused to get onto the ambulance gurney. LPC-A stated he was screaming, shouting, crying and became combative towards her. Patient #1's mother requested a PRN medication, but the facility did not have any PRN medications to administer. LPC-A stated that Patient #1's mother refused to assist Patient #1 onto the ambulance gurney. LPC-A stated when the EMT's put their hands on Patient #1 to assist him on the gurney he tried to bite them. LPC-A stated the EMT's contacted their supervisor and the RN-A contacted Doctor A to get an order for restraint. LPC-A stated there were 6 OP facility staff who were assisting and named 6 OP staff; and 2 EMT's that were trying to assist Patient #1 in the transfer from the floor onto the gurney. LPC-A stated the OP staff and EMT assisted Patient #1 from the floor onto the gurney and he was restrained by the EMT staff on the gurney for transport.

Interview on 08/10/16 at 9:55 AM with OP MHT-A stated she was working the front office on 08/04/16 when Patient #1 was attempting to elope from the building. Doctor -A was notified and ordered Patient #1 from the OP center to the Acute Inpatient facility. MHT-A stated that Patient #1's mother was notified and came to the facility. MHT-A stated that the ambulance service was called for transport because Patient #1's mother did not want to transport him. MHT-A stated that Patient #1 became combative and kicking when he was told he was being transferred. MHT-A stated Patient #1's mother and LPC- A were trying to convince him to get on the gurney. The EMT told the mother that they could only assist and help him; if she requested his help. MHT-A stated that Patient #1's mother kept saying she did not want to be liable; and said, "go ahead." MHT-A named 4 staff and the EMT who tried to assist him onto the gurney. MHT-A stated she was "holding" Patient #1's legs while he was kicking and MHT-B was "holding his arms." MHT- A stated there were 3 staff and an EMT who placed him onto the gurney and then the EMT strapped him down while she and MHT-B held his limbs. MHT-A stated the 2nd EMT was on the phone in the doorway; and then later came to help.

Interview on 08/10/16 at 10:20 with Doctor/Physician A stated on 08/04/16 she was called at her private practice by RN-A requesting authorization for "soft restraints" because Patient #1 was kicking and biting.

Interview on 08/10/16 at 10:24 with OP RN-A stated that on 08/04/16 she was asked to call Doctor- A to get an order for soft restraints because Patient #1 was kicking and biting and the EMT's needed an order to apply soft restraints. RN-A was asked where the TO would be documented in Patient #1's record; as this surveyor could not locate the TO/PO. RN-A indicated she thought she documented the TO in the Progress Notes of Patient #1's record.

Interview on 08/10/16 at 12:30 PM with the Director of Performance Improvement (PI) confirmed there was not a verbal or written PO in Patient #1's chart for the hold/restraint and soft wrist restraints authorized by Doctor A and implemented on 08/04/16 by facility staff. The Director of PI further confirmed there was no evidence that STP forms were completed for the implementation by facility OP staff for Patient #1's hold/restraint and soft wrist restraints implemented by the EMT. Further interview at 03:40 PM, The Director of PI confirmed Patient #1's record did not have evidence of the required nursing documentation, written physician orders, monitoring, and a follow-up one hour face-to-face assessment following the implementation of the physical hold and restraint. The Director of PI stated that restraints were not typically implemented at the OP facility and this was an isolated unusual incident. The Director of PI stated the facility was not aware they needed to follow through with paperwork since the restraint was applied by the EMT during a transfer.

During the exit conference on 08/15/16 at 04:45 PM the facility's Chief Executive Officer (CEO) stated the OP/PHP and/or EMT's should have notified the Police Department for the transfer of Patient #1 on 08/04/16 when he refused to voluntarily be transferred by the contracted ambulance service. The CEO stated the OP/PHP does not restrain patients unless the patient was in imminent danger; which made this situation circumstances unusual. The CEO stated the OP/PHP staff would be re-trained.

Interview on 08/10/16 at 2:20 PM with the Director or Risk Management stated the OP center program utilized the hospital facility policy for Special Treatment Procedure last reviewed January 2012 regarding restraints, and a copy was provided. In addition to the STP policy was an addendum for the OP program also known as the Partial hospitalization Program (PHP) lasted reviewed January 2012.

Review of the OP/PHP Special Treatment Procedures for Restraints, last reviewed January 2012 revealed the PHM was committed to prevent the use of seclusion/restraint. Nonphysical interventions were preferred and the "only acceptable method of intervention." The use of seclusion/restraint "is not used in the Partial hospitalization Program." Further review revealed in the event that a patient becomes agitated or presented as a danger to self or others, do the following: 1. Provide safety by separating the agitated patient from other patients. 2. Contact the person/personnel identified by the treatment team as most appropriate in deescalating patient to intervene and calm patient down.

Review of the facility's Policy, Special Treatment Procedures for Seclusion and Restraints, last reviewed January 2015, specified the following, in part:

Physical Restraints/Hold/Containments were defined as, "Any manual or physical method of holding the patient against the patient's will that restricts freedom of movement or normal access to one's body. For example, holding a patient to give a forced psychotropic medication in a manner that restricts his or her movement constitutes a physical restraint."

The Restraint/Seclusion Procedures and Responsibilities of staff included;

- The Physician/RN assessed the need for restrictive intervention and a written or telephonic order is obtained from the physician for the seclusion/restraint on the Seclusion/Restraint Order form. A physician must order the use of containment or seclusion.

- If physical restraint is indicated, two (2) staff must participate in the physical hold application. If the physical restraint/hold is on a child patient, one staff may implement the hold while a second staff serves as witness to monitor patient and safety for the duration of the hold.

- Assigned staff conducting continuous in-person observation/monitoring for the duration of the seclusion/restraint episode documents patient observations on the STP Seclusion/Restraint Hourly Flow Sheet that included the following, in part;
Reviews for signs of injury
Evaluates patient behavior, staff interventions and patient responses
Monitors for circulation and skin integrity
Obtains vital signs

The Restraint/Seclusion policy indicated within one hour of the initiation of containment or seclusion, a physician or qualified RN trained in the use of emergency safety interventions and permitted by the Texas Administrative Code and the organization to assess the physical and psychological well-being of residents must conduct a fact-to-face assessment of the physical and psychological well-being of the patient.

The Restraint/Seclusion policy designated Direct Care Staff to document in the patient's chart that the seclusion/restraint was the least restrictive intervention that protects the patient's safety and that its utilization was based on an individualized patient assessment. Documentation was to be completed on the STP; Seclusion/Restraint Clinical Note section.

Review of the facility's STP form used for documentation of Restraints, Seclusion, and Emergency Medications last updated 11/01/14 revealed it included the required documentation for; observation/monitoring of the patient, interventions used, staff involved, reintegration, debriefing, nursing assessments, follow-up assessment, clinical reviews, documentation of Physician Orders (PO's) obtained, and final review of the Quality RN and/or MD.