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.

MILLWOOD HOSPITAL 1011 NORTH COOPER STREET ARLINGTON, TX 76011 Sept. 19, 2018
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on a review of documentation and interviews, the facility failed to ensure that an order for each episode of restraint and seclusion was signed or authenticated by a physician within 48 hours for 1 out of 1 restraint/seclusion records at the Excel Center PHP. This was not in compliance with facility policy and state regulation that telephone orders for restraint or seclusion shall be signed and dated within 48 hours of the time the order was originally issued.

Findings included:

Review of the medical record for Patient #2 revealed that he was restrained by staff in a physical restraint and then secluded on 10/2/17 between 1215 and 1300. There was no physician signature or other authentication on the verbal order for restraint and seclusion.

Facility policy, "Restraint or Seclusion", last approved 3/2018, stated, in part, "PHYSICIAN ORDERS The following are necessary elements for restraint/seclusion orders:
Each and every restraint/seclusion episode requires a physician's order.
In a behavioral emergency, the Registered Nurse (RN) may initiate the use of restraint or seclusion. A physician's order (written/verbal) for restraint or seclusion must be obtained as soon as possible but within one hour ..."

Review of 25 TAC (Texas Administrative Code) Chapter 415 Provider Clinical Responsibilities - Mental Health Services, psychiatric hospital regulations, stated, in part, "415.260(b) Physician's order. Only a physician member of the facility's medical staff may order restraint or seclusion ...
(2) If restraint or seclusion was ordered by telephone, the ordering physician shall personally sign and date the telephone order, including the time of the order, within 48 hours of the time the order was originally issued."

The above findings were confirmed in an interview with Staff #1 the morning of 9/19/18 in the facility library.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0194
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of records and interview, the facility failed to ensure that direct care staff maintained current training which had not expired in non-violent crisis intervention and restraint/seclusion training and skills demonstration and competence. This was not in compliance with facility policy and state regulation that the facility ensure that staff maintains current training. The facility allowed a staff member to be on duty with patients while not compliant in training, which presents a risk that interventions may not be conducted in a safe manner.

Findings included:

Review of the personnel record for Staff #6, RN, revealed that her CPI (Crisis Prevention Institute) training expired on [DATE]. When requested, a current CPI "Blue Card" was provided to the surveyor documenting that Staff #6 completed CPI training on 3/6/18. There was no documented evidence provided to the surveyor that Staff #6 was current in CPI or other non-violent crisis intervention and restraint/seclusion training between 1/20/18 and 3/6/18.

In an interview the afternoon of 9/19/18 in the Excel Center conference room, Staff #4 stated that she spoke to Staff #6 by phone and was told by Staff #6 that she did not have documentation of CPI training between 1/20/18 and 3/6/18.

Review of the Employee Time Card for Staff #6 provided to the surveyor by Staff #1 revealed that Staff #6 worked the following 10 dates between 1/20/18 and 3/6/18:
1/29/18, 2/7/18, 2/9/18, 2/13/18, 2/15/18, 2/16/18, 2/19/18, 2/22/18, 2/23/18, and 2/28/18.

Facility policy, "Restraint or Seclusion", last approved 3/2018, stated, in part, "Staff Training/ Competence All nursing and direct care staff participates in ongoing education and training designed to encourage creativity and innovation in providing less restrictive or non-restrictive alternatives. Staff demonstrates competency via Verbal De-Escalation training and a skills class regarding the following elements ... "

Review of 25 TAC (Texas Administrative Code) Chapter 415 Provider Clinical Responsibilities - Mental Health Services, psychiatric hospital regulations, stated, in part, "415.257(c) Before assuming job duties involving direct care responsibilities, and at least annually thereafter, staff members other than physicians must receive training and demonstrate competence in at least the following knowledge and applied skills that shall be specific and appropriate to the population(s) the facility serves:
(1) using team work, including team roles and techniques for facilitating team communication and cohesion;
(2) identifying the causes of aggressive or threatening behaviors of individuals who need mental health services, including behavior that may be related to an individual's non-psychiatric medical condition;
(3) identifying underlying cognitive functioning and medical, physical, and emotional conditions;
(4) identifying medications and their potential effects;
(5) identifying how age, weight, cognitive functioning, developmental level or functioning, gender, culture, ethnicity, and elements of trauma-informed care, including history of abuse or trauma and prior experience with restraint or seclusion, may influence behavioral emergencies and affect the individual's response to physical contact and behavioral interventions;
(6) explaining how the psychological consequences of restraint or seclusion and the behavior of staff members can affect an individual's behavior, and how the behavior of individuals can affect a staff member;
(7) applying knowledge and effective use of communication strategies and a range of early intervention, de-escalation, mediation, problem-solving, and other non-physical interventions, such as clinical timeout and quiet time; and
(8) recognizing and appropriately responding to signs of physical distress in individuals who are restrained or secluded, including the risks of asphyxiation, aspiration, and trauma."

The above findings were confirmed in an interview the afternoon of 9/19/18 in the Excel Center Conference room with Staff #4 and Staff #6.