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.
| CHRISTUS SANTA ROSA MEDICAL CENTER | 2827 BABCOCK ROAD SAN ANTONIO, TX 78229 | June 26, 2018 |
| VIOLATION: PATIENT RIGHTS | Tag No: A0115 | |
| Based on observation, record review, and interview, it was determined the facility failed to ensure specific patient rights were protected and promoted; and failed to implement their written policy and procedures that protect and promote each patient's rights for 1 of 1 patients (Patient #1) reviewed with a patient rights violation complaint. Specifically, the facility failed to ensure Patient #1's rights in accordance with the facility's restraint policy and procedures during the implementation of restraints used for the management of violent behavior. On 05/28/18 at approximately 04:48 AM, Patient #1 was physically restrained by multiple facility staff due to aggressive behaviors following an attempt to leave the facility. Immediately following the physical restraint, Patient #1 alleged physical abuse against facility staff and also complained of an injury to her left eye. Patient #1 was transferred to another behavioral health facility- B on 5/28/18 at 13:51. Findings included the following: 1.) Patient #1's medical record did not have documentation of a physical restraint on 5/28/18 at approximately 04:48 AM. 2.) Patient #1's medical record did not have documentation of a physician order for restraint that occurred on 5/28/18. 3.) Patient #1's medical record did not have documentation of a physical face to face assessment following restraint on 5/28/18. 4.) Patient #1's medical record did not have documentation of a physical assessment for her complaint of injury to her eye following the physical restraint on 5/28/18 and/or following the allegation of physical abuse by facility staff. Refer to A0167, A0168, A0178, and A0185 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. |
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| VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION | Tag No: A0167 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, it was determined the facility failed to ensure specific patient rights were protected and promoted for 1 of 1 patients (Patient #1); and failed to ensure Patient #1's 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 violent behavior. Specifically, on 05/28/18 at approximately 04:48 AM, Patient #1 was physically restrained by multiple facility staff due to aggressive behaviors following an attempt to leave the facility. Immediately following the physical restraint, Patient #1 alleged physical abuse against facility staff and also complained of an injury to her left eye. Patient #1 was transferred to another behavioral health facility- B on 5/28/18 at 13:51. Specific failures included: 1.) Patient #1's medical record did not have documentation of a physical restraint on 5/28/18 at approximately 04:48 AM. 2.) Patient #1's medical record did not have documentation of a physician order for restraint that occurred on 5/28/18. 3.) Patient #1's medical record did not have documentation of a physical face to face assessment following restraint on 5/28/18. 4.) Patient #1's medical record did not have documentation of a physical assessment for her complaint of injury to her eye following the physical restraint on 5/28/18 and/or following the allegation of physical abuse by facility staff. The cumulative effect of these violations resulted in the facility's inability to meet Patient Rights requirements. Findings included: Review of the Department of State Health Services (DSHS) complaint TX 666 dated 6/4/18 that was referred by Child Protective Services (CPS) documented the following: Patient #1 stated she was assaulted while at this facility and sustained an injury. On 5/28/18, Patient #1, a [AGE] year old female, was brought in to the facility's Emergency Department (ED) for suspected overdose on ibuprofen specified that when she tried to leave the facility; facility staff (Certified Nurse Assistant-A) attempted to restrain her, punched her in the face, and then held her down using his forearm against her throat impeding her breathing. Patient #1 sustained a left black eye. Patient #1 was transferred to a local behavioral health hospital for psychiatric treatment. Review of the facility's internal incident reporting system, (MIDAS- not part of the patient's medical record), documented the following for Patient #1: On 5/28/18 at 05:00 AM, CNA-A documented that Patient #1 was trying to leave the hospital and that Patient #1 was "escorted back to room, and placed back in bed." Patient #1 then turned sidewise and kicked CNA-A in the face. Patient #1 was then "restrained" by CNA-A, other nursing staff, and security. Further review revealed documentation that at 05:45 Patient #1 "sustained a bruise on her left eye." Spoke to Charge Registered Nurse (RN) - A, who was also at the scene when incident occurred. Patient #1 alleged that CNA-A "punched her." At 06:15, Charge RN-A spoke to Patient #1's father and explained what happened, but he did not believe the staff. Review of the facility Restraint and Seclusion policy last revised 08/2013 revealed a restraint was any method (physical or chemical) of restricting a patient's freedom of movement, physical activity or normal access to his or her body that; 3. Does not promote the patient's independent functioning. b) Behavioral restraint: Emergency restraint use in any care setting to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others. C. Physical restraint: Any manual method, physical or mechanical device .....that reduces the ability of a patient to move his or her arms, legs, body or head freely and that he/she cannot easily remove. Types of physical restraints include: 6. Physical/Therapeutic Hold: a manual method to restrict patient movement. Process included, in part: A. Patient Assessment: The patient's behavior and the interventions used, alternatives to restraint and other patient safety issues. B. A Registered Nurse with current demonstrated competency may initiate restraint use in an emergency, based on an appropriate assessment of the patient. Restraint Orders for Violent or self-destructive behavior: 1. Restraints for behavioral reasons may be initiated by an RN in an emergency. The licensed independent practitioner (LIP) must be immediately notified (within one hour) to obtain an order for the restraint. 3. A RN, other than the nurse who initiated the use of restraint, who is trained to assess, medical and psychiatric stability and has demonstrated and documented competence or a LIP may conduct the face-to-face evaluation no later than one hour after the time the restraint was initiated. During a Telephone Interview on 6/13/18 at 4:57 PM with Patient #1, stated that when she tried to leave the hospital on [DATE], a male staff grabbed her by the arm and another male staff came from the hallway grabbing her also. Patient #1 specified the staff threw her onto the bed, and CNA-A was choking her with his arm on her neck to where she couldn't breathe. Patient #1 stated CNA-A hit her in the eye with his elbow while holding her head and she sustained an eye injury and a chipped tooth from the staff "hitting" her on her face. Patient #1 indicated she was "held down/restrained" and that CNA-A crushed her face with his elbow, choking her with his other arm. Patient #1 stated that another staff told CNA-A to get off of her, because "he was hurting me with his arm across my neck, and I couldn't breathe." Patient #1 stated that within 5 minutes following the restraint that her left eye was bruised, swollen, and turning black. During an interview with CNA-A on 06/13/18 at 6:08 PM in the conference room stated the following: On 5/28/18, he was coming out of ED room 7 and heard yelling; not to touch her and to leave her alone. Patient #1 was pushing people off her. He tried to get her to go back to her room. Patient #1 pushed him a couple of times. He put her back into bed. Security was with him. All the staff were telling her she could not leave; she needed to stay in bed. Patient #1 turned sideways and kicked him in the face, the right side. He then tried to restrain her, and she was kicking and fighting. The bed rails were up. He could not put his weight on her to try to keep her from flailing around. He asked the other staff to put the bed rail down. He put weight on her to try to keep her from hitting him or anyone else. She agreed to calm down. He left the room and did not go in again. CNA-A stated, he physically held her but said he, "did not put a restraint on her." CNA-A was asked if a physical hold was considered a restraint, and he responded that he did not remember, and would need to clarify; since it was not a "tied restraint" [2-4 point]. CNA-A stated he did not physically see her eye following the restraint because he left the room, but noticed she had a loop earring that came off, and she also had a tear with blood. CNA-A stated that ED MD-A asked him; "did someone punch her? She has a cut below her eye." During an interview with Charge RN on 06/13/18 at 7:07 PM in the conference room revealed the following: Charge RN was the ED charge nurse on 5/28/18 when security called him and reported that Patient #1 was "bolting out." He tried to talk to Patient #1 when she said, "I don't want to be here. I want to go home." Nurses were trying to deescalate the situation. CNA-A grabbed her wrists and was putting her back in to her room. She started kicking and punching. CNA-A got kicked by Patient #1. CNA-A tried to contain her by going over her. Patient #1 then wanted to file a complaint that CNA-A punched her after she had been contained. Charge RN-A stated he directed CNA-A to write a MIDAS report (internal reporting). Charge RN-A confirmed that Patient #1 had an injury to her eye following the incident/restraint. Charge RN-A stated that CNA-A did not punch her in the eye, she may have hit her own eye during the struggle. Charge RN- A stated he made a note about her eye in the MIDAS report. Charge RN-A confirmed he did not get a physician order for Patient #1's restraint, stating, "We were all in the room, and would not let her go to go get a Doctor's order." Charge RN was not able to indicate if the ED MD-A assessed Patient #1's eye following the physical hold/restraint. Observation of the Video Surveillance evidence titled ED Red Hall revealed on 5/28/18 at 04:44:47 AM (47 seconds) to 04:47 revealed the following: At 04:44:47 Patient #1 is attempting to leave her room. CNA-B grabs her wrists. Charge RN-A comes to assist. CNA-A is seen to come from around the corner. Patient #1 is attempting to exit the facility. CNA-A attempts to block her, and then grabs onto her wrists. Patient #1 breaks away and begins to head towards the ambulance doors exit. At 04:46:15 Patient #1 is seen being physically held, and escorted back to her room by CNA-A, with security directly behind assisting. Charge RN and CNA-B are following along when they all enter into Patient #1's room at 04:46:25; along with 2 other female staff nurses. At 04:47:15 CNA-A is seen to exit Patient #1's room, but immediately goes back into the room until 04:47:52 when CNA-A exits the room again, and then leaves the area. Review of Patient #1's ED Medical Record dated 05/28/28 revealed the following: Patient #1 arrived at 04:18 AM on 5/28/18 and was transferred to another behavioral health facility at 13:51 PM. Charge RN-A documented the following in the Nurses notes for 5/28/18: At 05:00, Patient #1 tried to run away and stated that she does not want to be here. Patient was "escorted" to room and explained to her about the risks of her conditions if she leaves. San Antonio Police Department (SAPD) contacted for Emergency Detention. At 05:02, While Patient is being escorted back to bed by CNA-A, CNA-B, and Charge RN, Patient #1 started "resisting and kicking." CNA-A was kicked on his right chin. At 05:04, Medical Doctor, (MD) at bedside, SAPD at bedside. At 05:53, RN-A documented a pain assessment for Patient #1's left eye with a pain intensity of "5." Further review of Patient #1's nurses notes for 5/28/18 revealed there was not a documented physical assessment following the restraint of Patient #1, or an assessment of Patient #1's eye following the allegation of physical abuse against CNA-A during the restraint. Review of Patient #1's History of Present Illness (HPI) completed by MD-A on 5/28/18 at 04:59 AM revealed MD-A assessed Patient #1 following the incident that occurred between 04:44-05:02. MD-A documented the chief complaints as, "overdose, suicide attempt." Physical Exam Details for Psych: documented Alert and Oriented x 3, normal mood, judgment intact. Eyes: "PERRL, EOMI, anicteric sclera, normal conjunctiva" [normal/negative findings]. Comments included; "she had no physical complaints." Mental Health Assessment Team has been consulted and their input is pending. Further review of the HPI completed by MD-A on 5/28/18 revealed there was not a documented physical assessment following the restraint of Patient #1, or an assessment of Patient #1's eye following the allegation of physical abuse against CNA-A during the restraint. Review of Patient #1's Physician Orders Summary set for 5/28/18 revealed there was not a documented physician order for Patient #1 to be physically held down/restrained. Review of the facility's documentation of interviews conducted by the Director of Human Resources (DHR) on 6/4/18 following the abuse allegation made by Patient #1 revealed the following: 1.) An interview with RN- B that documented RN-B indicated, "It appeared her left eye was swollen. There was a lot of commotion and it is possible it occurred during that time." 2.) An interview with RN-C that documented RN-C indicated, she recalled "seeing a tear [from eye] that was streaked with blood." Review of facility B's documentation following the transfer of Patient #1 from this facility (A) to facility (B) revealed; facility B sent Patient #1 to another facility (C) on 5/29/18 for evaluation of her left eye injury following the physician order for a Computed tomography (CT) maxillofacial to rule out (r/o) fracture. Facility C's documentation revealed Patient #1 presented with bruising and swelling to the left eye. Patient #1 stated a male at facility A punched her in the eye when she tried to escape. "Apparently there was an intervention with staff and patient that required some restraining to prevent elopement." Patient #1 "denies that her eye was examined or evaluation." Assessment included; Contusion of eyeball and orbital tissues, left eye. CT to r/o fracture. |
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| VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION | Tag No: A0168 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review of documentation and facility staff interviews, the facility failed to ensure the use of restraint was in accordance with an order of a physician or other licensed independent practitioner (LIP) who was responsible for the care of the patient as specified under 482.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law for 1 of 1 Patient reviewed, (Patient #1) with a complaint allegation following the implementation of a restraint. Specifically, on 05/28/18 at approximately 04:48 AM, Patient #1 was physically restrained by multiple facility staff due to aggressive behaviors following an attempt to leave the facility without a physician or LIP order. Findings included: Review of the Department of State Health Services (DSHS) complaint TX 666 dated 6/4/18 that was referred by Child Protective Services (CPS) documented the following: On 5/28/18, Patient #1, a [AGE] year old female, was brought in to the facility's Emergency Department (ED) for suspected overdose on ibuprofen specified that when she tried to leave the facility; facility staff (Certified Nurse Assistant-A) attempted to restrain her, punched her in the face, and then held her down using his forearm against her throat impeding her breathing. Patient #1 sustained a left black eye. Review of the facility's internal incident reporting system, (MIDAS), documented the following, in part for Patient #1: On 5/28/18 at 05:00 AM, CNA-A documented that Patient #1 was trying to leave the hospital and that Patient #1 was "escorted back to room, and placed back in bed." Patient #1 then turned sidewise and kicked CNA-A in the face. Patient #1 was then "restrained" by CNA-A, other nursing staff, and security. Review of the facility Restraint and Seclusion policy last revised 08/2013 revealed a restraint was any method (physical or chemical) of restricting a patient's freedom of movement, physical activity or normal access to his or her body that; 3. Does not promote the patient's independent functioning. b) Behavioral restraint: Emergency restraint use in any care setting to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others. C. Physical restraint: Any manual method, physical or mechanical device .....that reduces the ability of a patient to move his or her arms, legs, body or head freely and that he/she cannot easily remove. Types of physical restraints include: 6. Physical/Therapeutic Hold: a manual method to restrict patient movement. Restraint Orders for Violent or self-destructive behavior: 1. Restraints for behavioral reasons may be initiated by an RN in an emergency. The licensed independent practitioner (LIP) must be immediately notified (within one hour) to obtain an order for the restraint. During a Telephone Interview on 6/13/18 at 4:57 PM with Patient #1, stated that when she tried to leave the hospital on [DATE], a male staff grabbed her by the arm and another male staff came from the hallway grabbing her also. Patient #1 specified the staff threw her onto the bed, and CNA-A was choking her with his arm on her neck to where she couldn't breathe. Patient #1 indicated she was "held down/restrained" and that CNA-A crushed her face with his elbow, choking her with his other arm. During an interview with CNA-A on 06/13/18 at 6:08 PM in the conference room stated the following: On 5/28/18, he was coming out of ED room 7 and heard yelling; not to touch her and to leave her alone. Patient #1 was pushing people off her. He tried to get her to go back to her room. Patient #1 pushed him a couple of times. He put her back into bed. Security was with him. All the staff were telling her she could not leave; she needed to stay in bed. Patient #1 turned sideways and kicked him in the face, the right side. He then tried to restrain her, and she was kicking and fighting. The bed rails were up. He could not put his weight on her to try to keep her from flailing around. He asked the other staff to put the bed rail down. He put weight on her to try to keep her from hitting him or anyone else. During an interview with Charge RN on 06/13/18 at 7:07 PM in the conference room revealed the following: Charge RN was the ED charge nurse on 5/28/18 when security called him and reported that Patient #1 was "bolting out." He tried to talk to Patient #1 when she said, "I don't want to be here. I want to go home." Nurses were trying to deescalate the situation. CNA-A grabbed her wrists and was putting her back in to her room. She started kicking and punching. CNA-A got kicked by Patient #1. CNA-A tried to contain her by going over her. Charge RN-A confirmed he did not get a physician order for Patient #1's restraint, stating, "We were all in the room, and would not let her go to go get a Doctor's order." Observation of the Video Surveillance evidence titled ED Red Hall revealed on 5/28/18 at 04:44:47 AM (47 seconds) to 04:47 revealed the following: At 04:44:47 Patient #1 is attempting to leave her room. CNA-B grabs her wrists. Charge RN-A comes to assist. CNA-A is seen to come from around the corner. Patient #1 is attempting to exit the facility. CNA-A attempts to block her, and then grabs onto her wrists. Patient #1 breaks away and begins to head towards the ambulance doors exit. At 04:46:15 Patient #1 is seen being physically held, and escorted back to her room by CNA-A, with security directly behind assisting. Charge RN and CNA-B are following along when they all enter into Patient #1's room at 04:46:25; along with 2 other female staff nurses. At 04:47:15 CNA-A is seen to exit Patient #1's room, but immediately goes back into the room until 04:47:52 when CNA-A exits the room again, and then leaves the area. Review of Patient #1's ED Medical Record dated 05/28/28 revealed the following: Charge RN-A documented the following in the Nurses notes for 5/28/18: At 05:00, Patient #1 tried to run away and stated that she does not want to be here. Patient was "escorted" to room and explained to her about the risks of her conditions if she leaves. San Antonio Police Department (SAPD) contacted for Emergency Detention. At 05:02, While Patient is being escorted back to bed by CNA-A, CNA-B, and Charge RN, Patient #1 started "resisting and kicking." CNA-A was kicked on his right chin. At 05:04, Medical Doctor, (MD) at bedside, SAPD at bedside. Further review of Patient #1's nurses notes for 5/28/18 revealed there was not a documented verbal order from the physician for restraint. Review of Patient #1's Physician Orders Summary set for 5/28/18 revealed there was not a documented physician order for Patient #1 to be physically held down/restrained. |
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| VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION | Tag No: A0178 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review of facility documentation and staff interviews, the facility failed to have a physician or other licensed independent practitioner (LIP) see the patient; face-to-face within 1-hour after initiation of a restraint used for the management of violent or self-destructive behavior, and according to facility policy for 1 of 1 patient reviewed (Patient #1) with a complaint allegation following restraints. Findings included: Review of the Department of State Health Services (DSHS) complaint TX 666 dated 6/4/18 that was referred by Child Protective Services (CPS) documented the following: Patient #1 stated she was assaulted while at this facility and sustained an injury. On 5/28/18, Patient #1, a [AGE] year old female, was brought in to the facility's Emergency Department (ED) for suspected overdose on ibuprofen specified that when she tried to leave the facility; facility staff (Certified Nurse Assistant-A) attempted to restrain her, punched her in the face, and then held her down using his forearm against her throat impeding her breathing. Patient #1 sustained a left black eye. Review of the facility's internal incident reporting system, (MIDAS), documented the following for Patient #1: On 5/28/18 at 05:00 AM, CNA-A documented that Patient #1 was trying to leave the hospital and that Patient #1 was "escorted back to room, and placed back in bed." Patient #1 then turned sidewise and kicked CNA-A in the face. Patient #1 was then "restrained" by CNA-A, other nursing staff, and security. Further review revealed documentation that at 05:45 Patient #1 "sustained a bruise on her left eye." Spoke to Charge Registered Nurse (RN) - A, who was also at the scene when incident occurred. Patient #1 alleged that CNA-A "punched her." Review of the facility Restraint and Seclusion policy last revised 08/2013 revealed the following: 3. A RN, other than the nurse who initiated the use of restraint, who is trained to assess, medical and psychiatric stability and has demonstrated and documented competence or a LIP may conduct the face-to-face evaluation no later than one hour after the time the restraint was initiated. During an interview with Charge RN on 06/13/18 at 7:07 PM in the conference room revealed the following: Charge RN was the ED charge nurse on 5/28/18 when security called him and reported that Patient #1 was "bolting out." He tried to talk to Patient #1 when she said, "I don't want to be here. I want to go home." Nurses were trying to deescalate the situation. CNA-A grabbed her wrists and was putting her back in to her room. She started kicking and punching. CNA-A got kicked by Patient #1. CNA-A tried to contain her by going over her. Patient #1 then wanted to file a complaint that CNA-A punched her after she had been contained. Charge RN-A stated he directed CNA-A to write a MIDAS report (internal reporting). Charge RN-A confirmed that Patient #1 had an injury to her eye following the incident/restraint. Charge RN- A stated he made a note about her eye in the MIDAS (internal) report. Charge RN was not able to indicate if the ED MD-A assessed Patient #1's eye following the physical hold/restraint. Review of Patient #1's ED Medical Record dated 05/28/28 revealed the following: Charge RN-A documented the following in the Nurses notes for 5/28/18: At 05:00, Patient #1 tried to run away and stated that she does not want to be here. Patient was "escorted" to room and explained to her about the risks of her conditions if she leaves. San Antonio Police Department (SAPD) contacted for Emergency Detention. At 05:02, While Patient is being escorted back to bed by CNA-A, CNA-B, and Charge RN, Patient #1 started "resisting and kicking." CNA-A was kicked on his right chin. At 05:04, Medical Doctor, (MD) at bedside, SAPD at bedside. At 05:53, RN-A documented a pain assessment for Patient #1's left eye with a pain intensity of "5." Further review of Patient #1's nurses notes for 5/28/18 revealed there was not a documented physical assessment following the restraint of Patient #1, or an assessment of Patient #1's eye following the allegation of physical abuse against CNA-A during the restraint. Review of Patient #1's History of Present Illness (HPI) completed by MD-A on 5/28/18 at 04:59 AM revealed MD-A assessed Patient #1 following the incident that occurred between 04:44-05:02. MD-A documented the chief complaints as, "overdose, suicide attempt." Physical Exam Details for Psych: documented Alert and Oriented x 3, normal mood, judgment intact. Eyes: "PERRL, EOMI, anicteric sclera, normal conjunctiva" [normal/negative findings]. Comments included; "she had no physical complaints." Mental Health Assessment Team has been consulted and their input is pending. Further review of the HPI completed by MD-A on 5/28/18 revealed there was not a documented physical assessment following the restraint of Patient #1, or an assessment of Patient #1's eye following the allegation of physical abuse against CNA-A during the restraint. Review of the facility's documentation of interviews conducted by the Director of Human Resources (DHR) on 6/4/18 following the abuse allegation made by Patient #1 revealed the following: 1.) An interview with RN- B that documented RN-B indicated, "It appeared her left eye was swollen. There was a lot of commotion and it is possible it occurred during that time." 2.) An interview with RN-C that documented RN-C indicated, she recalled "seeing a tear [from eye] that was streaked with blood." Review of facility B's documentation following the transfer of Patient #1 from this facility (A) to facility (B) revealed; facility B sent Patient #1 to another facility (C) on 5/29/18 for evaluation of her left eye injury following the physician order for a Computed tomography (CT) maxillofacial to rule out (r/o) fracture. Facility C's documentation revealed Patient #1 presented with bruising and swelling to the left eye. Patient #1 stated a male at facility A punched her in the eye when she tried to escape. "Apparently there was an intervention with staff and patient that required some restraining to prevent elopement." Patient #1 "denies that her eye was examined or evaluation." Assessment included; Contusion of eyeball and orbital tissues, left eye. CT to r/o fracture. |
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| VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION | Tag No: A0185 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of documentation and staff interviews the facility failed to ensure the patient's medical record included; a description of the patient's behavior and the intervention used for 1 of 1 Patient reviewed (Patient #1) with a complaint allegation related to the implementation of restraint. Findings included: Review of the Department of State Health Services (DSHS) complaint TX 666 dated 6/4/18 that was referred by Child Protective Services (CPS) documented the following: On 5/28/18, Patient #1, a [AGE] year old female, was brought in to the facility's Emergency Department (ED) for suspected overdose on ibuprofen specified that when she tried to leave the facility; facility staff (Certified Nurse Assistant-A) attempted to restrain her, punched her in the face, and then held her down using his forearm against her throat impeding her breathing. Patient #1 sustained a left black eye. Review of the facility's internal incident reporting system, (MIDAS- not part of the patient's medical record), documented the following for Patient #1: On 5/28/18 at 05:00 AM, CNA-A documented that Patient #1 was trying to leave the hospital and that Patient #1 was "escorted back to room, and placed back in bed." Patient #1 then turned sidewise and kicked CNA-A in the face. Patient #1 was then "restrained" by CNA-A, other nursing staff, and security. Further review revealed documentation that at 05:45 Patient #1 "sustained a bruise on her left eye." Spoke to Charge Registered Nurse (RN) - A, who was also at the scene when incident occurred. Patient #1 alleged that CNA-A "punched her." Review of Patient #1's ED Medical Record dated 05/28/28 revealed the following: Patient #1 arrived at 04:18 AM on 5/28/18 and was transferred to another behavioral health facility at 13:51 PM. Charge RN-A documented the following in the Nurses notes for 5/28/18: At 05:00, Patient #1 tried to run away and stated that she does not want to be here. Patient was "escorted" to room and explained to her about the risks of her conditions if she leaves. San Antonio Police Department (SAPD) contacted for Emergency Detention. At 05:02, While Patient is being escorted back to bed by CNA-A, CNA-B, and Charge RN, Patient #1 started "resisting and kicking." CNA-A was kicked on his right chin. At 05:04, Medical Doctor, (MD) at bedside, SAPD at bedside. At 05:53, RN-A documented a pain assessment for Patient #1's left eye with a pain intensity of "5." Further review of Patient #1's nurses notes for 5/28/18 revealed there was not a documented restraint; the intervention used to control Patient #1's aggressive behaviors. Review of the facility Restraint and Seclusion policy last revised 08/2013 revealed the process included; the patient's behavior and the interventions used, alternatives to restraint and other patient safety issues. During an interview with Charge RN on 06/13/18 at 7:07 PM in the conference room revealed the following: Charge RN was the ED charge nurse on 5/28/18 when security called him and reported that Patient #1 was "bolting out." He tried to talk to Patient #1 when she said, "I don't want to be here. I want to go home." Nurses were trying to deescalate the situation. CNA-A grabbed her wrists and was putting her back in to her room. She started kicking and punching. CNA-A got kicked by Patient #1. CNA-A tried to contain her by going over her. Patient #1 then wanted to file a complaint that CNA-A punched her after she had been contained. Charge RN-A stated he directed CNA-A to write a MIDAS report (internal reporting). Charge RN-A confirmed that Patient #1 had an injury to her eye following the incident/restraint. Charge RN- A stated he made a note about her eye in the MIDAS (internal) report. Observation of the Video Surveillance evidence titled ED Red Hall revealed on 5/28/18 at 04:44:47 AM (47 seconds) to 04:47 revealed the following: At 04:44:47 Patient #1 is attempting to leave her room. CNA-B grabs her wrists. Charge RN-A comes to assist. CNA-A is seen to come from around the corner. Patient #1 is attempting to exit the facility. CNA-A attempts to block her, and then grabs onto her wrists. Patient #1 breaks away and begins to head towards the ambulance doors exit. At 04:46:15 Patient #1 is seen being physically held, and escorted back to her room by CNA-A, with security directly behind assisting. Charge RN and CNA-B are following along when they all enter into Patient #1's room at 04:46:25; along with 2 other female staff nurses. At 04:47:15 CNA-A is seen to exit Patient #1's room, but immediately goes back into the room until 04:47:52 when CNA-A exits the room again, and then leaves the area. |
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