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.

NIX HEALTH CARE SYSTEM 414 NAVARRO, SUITE 600 SAN ANTONIO, TX 78205 June 27, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on observation of facility video surveillance, record reviews, and staff interviews, it was determined that the facility failed to ensure specific patient rights were protected and promoted for 1 of 1 patients (Patient #1) by failing to ensure Patient #1 was free from abuse and ensure patient rights in accordance with the facility's restraint policy and procedures during the implementation of restraints used for the management of behavior.

Specifically, the facility's video recording dated 11/21/16 revealed, Patient #1, a [AGE] year old male diagnosed with mental illness, had unauthorized and undocumented physical holds/restraints by facility staff to manage maladaptive behaviors displayed. Immediately following a physical restraint at 10:06 AM, Patient #1 was pushed to the ground by the staff. This act by the facility staff rendering care and treatment to Patient #1 has the likelihood to caused injury to the patient.

Specific failures included:

1.) The facility had not identified potential abuse by the facility staff against Patient #1 following the act exhibited where staff pushed Patient #1 to the ground on 11/21/16.

2.) Patient #1's medical record did not have documentation of physical restraints for 11/21/16 or any physical restraints documented for his entire inpatient visit.

2.) Patient #1's medical record did not have documentation of a physician order for restraint that occurred on 11/21/16.

3.) Patient #1's medical record did not have documentation of a physical face to face assessment following restraint on 11/21/16.


Refer to A0167 and A0145 for evidence of specific findings.


The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Patient Rights.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on observation of facility video surveillance, record reviews, and staff interviews, it was determined that the facility failed to ensure their policies and procedures protected patient's rights to be free from all forms of abuse or harassment. A patient in the facility, 1 of 1 patient reviewed (Patient #1) had a complaint of abuse against facility staff.


The facility failed to identify potential abuse by staff against Patient #1 following review of the facility's video recording dated 11/21/16. The video recording revealed, Patient #1, a [AGE] year old male, had unauthorized and undocumented physical holds/restraints by facility staff to manage maladaptive behaviors displayed. Immediately following a physical restraint at 10:06 AM, Patient #1 was pushed to the ground. This act by the facility staff rendering care and treatment to Patient #1 has the likelihood to cause injury to the patient.

This deficient practice could affect the prevention of possible unidentified abuse, neglect, or mistreatment for all patients in the facility by compromising their safety.


Findings included:


The Disability Rights of Texas (DRTx) conducted an independent investigation and submitted their concerns to DSHS on 4/2/18 following observation review of the video recording dated 11/21/16 which showed definitive proof of improper and unauthorized restraints. The video recording showed staff pushing Patient #1 to the ground.

DRTx observations of the video included the following:

1.) At 15:51-16:00, the boys were back in the middle of the court and chasing each other. Patient #1 was chasing after another boy who has the basketball, both boys fall to the ground. Patient #1 appeared to be trying to get the ball from the other boy. The staff moved towards Patient #1, grabbed him by the arm and Patient #1 fell to the ground. Staff grabbed him again by his arm and the pushing game between staff and Patient #1 started. The pushing continued up until Patient #1 tried to step on staff's feet; at that point, staff grabbed Patient #1, twisted his arms to the back, then "pushes him to the ground" where he fell to the ground. A few minutes later, a peer grabbed Patient #1 in a similar way as staff had done, and threw Patient #1 to the ground, time at 16:12-16:38.

2.) At 18:25, Patient #1 tried to move away from the corner but staff kept pushing him back into the corner, obviously not allowing him to go elsewhere on the playground.


During the survey, a copy of the entire video recording was obtained and viewed in its entirety. The video was determined to be 22 minutes and 56 seconds long. The video recording was dated 11/21/16 started at 9:50 AM (initially documented as 9:30 AM, in error). The video ended at 10:13 AM. After review of the video in its entirety, it was concluded that the observations presented by DRTx above were confirmed with concerns identified as follows:

1.) At 10:06 AM and 17 seconds (16:12 time mark), MHT-A grabbed Patient #1 by his arms (above the elbow), twisted them behind him; extended, and facing away from MHT-A. MHT-A was then observed to push Patient #1 by extending both of his arms forward and outward in a pushing motion (at time mark 16:16). Patient #1 fell to the ground following the push and then rolls over a few times before he got back up again.


The DRM was interviewed during the entrance conference on 06/07/18 at 1:00 PM and according to her:

When informed that DRTx had concerns following review of the video recording dated 11/21/16 for Patient #1 she stated, "There is only one video" and confirmed the video is for 11/21/16 at 9:50 AM. Further interview at 3:55 PM, the DRM stated, MHT-A was holding Patient #1 by the arms and she confirmed this was a restraint.

MHT-A was interviewed on 06/07/18 at 2:53 PM. He was asked about the incident that occurred on 11/21/16 in the outside area and according to him when the video was viewed with this surveyor. At time mark 16:12: he was asked if that was considered a restraint he said, "Yes, considered a restraint, trying to stop him, playing too rough." He stated, you're not supposed to hold their arms from behind, and he was corrected on that. He was asked what happened at the time mark 16:16, immediately after the restraint and he stated, "Let go of him, didn't push him, let him go shouldn't hold him like that."

MHT-A was asked if he was made of aware of any allegations of physical abuse and responded, "No." MHT-A stated he met with the DRM and the RN Nurse Manager-A a week after the 11/21/16 incident and the DRM counseled him on it. He was told it was considered a restraint and next time to go get a nurse.

Review of Mental Health Technician (MHT)-A's employee record documented an employee communication warning on 11/30/16 by the RN Nurse Manager-A of the Children's Adolescent Unit for an unauthorized physical hold and failed to notify nursing staff based on the incident where this MHT-A was monitoring "boys during outside play" and one of the children (Patient #1) started escalating in behavior. Patient #1's behavior continued for about 20 minutes with no resolution. At that point, MHT-A "performed an unauthorized physical hold and failed to get nursing staff." There was no documentation of a consultation related to any physical abuse allegations.

In a follow-up interview on 6/27/18 at 2:30 PM with the DRM confirmed the facility had not identified or confirmed any physical abuse allegations against Patient #1 by MHT-A; even after review of the video where at the 16:16 time mark MHT-A is observed to push Patient #1 by extending both of his arms forward and outward; in a pushing motion.

Review of the facility's Satori Alternatives to Managing Aggression (SAMA) study guide revised 2011, revealed approved physical hold containment procedures did not include the video observed physical hold on 11/21/16 by MHT-A where he held Patient #1's upper arms twisting them behind him; extended, and facing away from MHT-A.


The definition of abuse according to the facility's policy titled, Assessment and Reporting of Abuse and Neglect, last reviewed September 2016:

Child abuse- Defined as:

-Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or

-An act or failure to act which presents an imminent risk of serious harm.


Further review of the policy revealed, the facility "prohibits neglect, mental or physical abuse or misappropriation of property, of patients by staff, visitors, or other patients." The facility "will report allegations and release information to the proper authorities, according to federal regulations, state specific rules and regulation and [facility] practice guidelines."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**




Based on observation of facility video surveillance, record reviews, and staff interviews, it was determined the facility failed to ensure patient rights were implemented in accordance with safe and appropriate restraint techniques as determined by the hospital's restraint policy and procedures during the implementation of restraints used for the management of behavior for 1 of 1 patient reviewed (Patient #1).

The facility's video recording dated 11/21/16 revealed, Patient #1, a [AGE] year old male diagnosed with mental illness, had unauthorized and undocumented physical holds/restraints by facility staff to manage maladaptive behaviors displayed. Immediately following a physical restraint at 10:06 AM, Patient #1 was pushed to the ground. This act by the facility staff rendering care and treatment to Patient #1 has the likelihood to have caused injury to the patient.

Failures included:

1.) The facility had not identified potential abuse by the facility staff against Patient #1 following the act exhibited where staff pushed Patient #1 to the ground on 11/21/16.

2.) Patient #1's medical record did not have documentation of physical restraints for 11/21/16 or any physical restraints documented for his entire inpatient visit.

2.) Patient #1's medical record did not have documentation of a physician order for restraint that occurred on 11/21/16.

3.) Patient #1's medical record did not have documentation of a physical face to face assessment following restraint on 11/21/16.

The cumulative effect of these violations resulted in the facility's inability to meet Patient Rights requirements.


Findings included:

The Disability Rights of Texas (DRTx) conducted an independent investigation and submitted their concerns to DSHS on 4/2/18 following observation review of the video recording dated 11/21/16 which showed definitive proof of improper and unauthorized restraints.

DRTx observations of the video included the following:

1.) At the bottom of the video, timed 3:44, Patient #1 and staff start pushing each other back and forth, almost like a game, until staff grabs Patient #1 and holds on to him so he won't move;

2.) At 4:02, after an episode where staff was still struggling to keep Patient #1 in place, staff grabs Patient #1, picked the patient up to where his feet were off the ground, then swang him out and around;

3.) At 15:51-16:00, the boys were back in the middle of the court and chasing each other. Patient #1 was chasing after another boy who has the basketball, both boys fell to the ground and Patient #1 appeared to be trying to get the ball from the other boy. The staff move towards Patient #1 and grabbed him by the arm. Patient #1 fell to the ground. The staff grabbed him again by his arm and the pushing game between staff and Patient #1 started. The pushing continued up until Patient #1 tried to step on staff's feet; at that point, staff grabbed Patient #1, twisted his arms to the back, then "pushes him to the ground" where he fell to the ground. A few minutes later, a peer grabbed Patient #1 in a similar way as staff had done, and throws Patient #1 to the ground, time at 16:12-16:38.

4.) At 18:25 Patient #1 tried to move away from the corner but staff kept pushing him back into the corner, obviously not allowing him to go elsewhere on the playground.


A copy of the entire video recording was obtained and viewed in its entirety. The video was determined to be 22 minutes and 56 seconds long. The video recording was dated 11/21/16, beginning at 9:50 AM (initially documented as 9:30 AM, in error). The video ends at 10:13 AM. After review of the video in its entirety, it was determined that the observations presented by DRTx above were confirmed with concerns identified as follows:

1.) At 9:54 AM and 06 seconds (also at the 4:02 time mark), MHT-A picked Patient #1 off of his feet and swang him around.

2.) At 10:06 AM and 17 seconds (16:12 time mark) MHT-A grabbed Patient #1 by his arms (above the elbow), twisted them behind him; extended, and facing away from MHT-A. MHT-A was then observed to push Patient #1 by extending both of his arms forward and outward in a pushing motion (at time mark 16:16). Patient #1 fell to the ground following the push and then rolls over a few times before he gets back up again.


The DRM was interviewed during the entrance conference on 06/07/18 at 1:00 PM and according to her, when informed that DRTx had concerns following review of the video recording dated 11/21/16 for Patient #1 she stated, "There is only one video" and confirmed the video is for 11/21/16 at 9:50 AM. Further interview at 3:55 PM, the DRM stated MHT-A was holding Patient #1 by the arms and she confirmed this was a restraint. The DRM stated, she met with MHT-A and told him he should have involved nursing, that was a problem. The DRM indicated she told him, "Because you did that, there is disciplinary action for failure to involve nursing, you failed to get nursing staff and there was an unauthorized hold." The disciplinary action was on 11/30/16 as documented herein.


MHT-A was interviewed on 06/07/18 at 2:53 PM. He was asked about the incident that occurred on 11/21/16 in the outside area and according to him when the video was viewed with this surveyor.

1.) At time mark 3:44: He was trying to get him away from the corner. MHT-A said, "He was trying to run through me and I was trying to direct him another way." MHT-A stated, he did not mean to pick him up, he was just trying to get him to go another way by trying to turn him. He acknowledged that picking the patient up was a restraint. He was just trying to stop him from going into the corner. He did not want him to hurt himself. He was not trying to lift him and did not think he was that light. He was trying to block him.

2.) At time mark 16:12: He was asked if that was considered a restraint he said, "Yes, considered a restraint, trying to stop him, playing too rough." He stated, you're not supposed to hold their arms from behind, and he was corrected on that. He was asked what happened at the time mark 16:16, immediately after the restraint and he stated, "Let go of him, didn't push him, let him go shouldn't hold him like that."

MHT-A was asked if he was made of aware of any allegations of physical abuse and responded, "No." MHT-A stated, he met with the DRM and the RN Nurse Manager-A a week after the 11/21/16 incident and the DRM counseled him on it. He was told it was considered a restraint and next time to go get a nurse.

Review of Mental Health Technician (MHT)-A's employee record documented an employee communication warning on 11/30/16 by the RN Nurse Manager-A of the Children's Adolescent Unit for an unauthorized physical hold and failed to notify nursing staff based on the incident where this MHT-A was monitoring "boys during outside play" and one of the children (Patient #1) started escalating in behavior. Patient #1's behavior continued for about 20 minutes with no resolution. At that point, MHT-A "performed an unauthorized physical hold and failed to get nursing staff." It was communicated by the RN Nurse Manager-A that MH-A received an "inservice" on "documentation." There was no documentation of a consultation related to any physical abuse allegations.

In a follow-up interview on 6/27/18 at 2:30 PM with the DRM confirmed the facility had not identified or confirmed any physical abuse allegations against Patient #1 by MHT-A; even after review of the video where at the 16:16 time mark MHT-A was observed to push Patient #1 by extending both of his arms forward and outward in a pushing motion. The DRM also stated she did not remember having a discussion with this surveyor during the first investigation conducted 3/22/17-3/30/17 regarding a restraint on the playground for Patient #1.

Review of the facility's Satori Alternatives to Managing Aggression (SAMA) study guide revised 2011, revealed approved physical hold containment procedures did not include the video observed physical hold on 11/21/16 by MHT-A where he held Patient #1's upper arms placing them behind him; extended, and facing away from MHT-A.


Review of the facility's Restraint and Seclusion Policy last reviewed January 2015 revealed the following:

Definition of Restraint- is the direct application of physical force to a patient, with or without the patient's permission, to restrict his or her freedom of movement of the whole or a portion of an individual's body in order to control physical activity.

D. Restraint Application

The following clinical interventions will be considered prior to applying restraints:

1. An assessment of the need for restraint is completed by an RN.

3. Orders must be obtained from a Licensed Independent Practitioner (LIP).

- As soon as possible after the initiation of restraint or seclusion in Emergency Behavioral situations, a clinically competent RN notifies and obtains an order (telephone or written) from the treating physician and consults with the physician about the patient's physical and psychological condition. This notification must occur within a timeframe which allows a physician and/or qualified RN to complete a face-to-face assessment within one hour of initiation of the restraint or seclusion.


I. Documentation -

The policy outlined specific detailed documentation to be included in the patient's Electronic Medical Record (EMR) for the patient which included the following: in part,

1. Assessments,
3. Criteria for restraints and alternatives used,
4. Physician contact (date and time), and
5. Type of restraint used.