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.

ROCK PRAIRIE BEHAVIORAL HEALTH 3550 NORMAND DRIVE COLLEGE STATION, TX Sept. 25, 2018
VIOLATION: GOVERNING BODY Tag No: A0043
Based on review of records and interview, the Governing Body failed to ensure adequate oversight of patient rights in the hospital to protect patients. The facility failed to protect 2 (Patient #1 and Patient #4) of 12 patients reviewed from improper restriction of rights. The patients had privileges restricted without obtaining physician orders. The patient was secluded without physician order. Review of documentation showed that restrictions were punitive rather than for the safety of the patient, staff, or other patients.

See Tag A0145
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of records and interview, the facility failed to protect 2 (Patient #1 and Patient #4) of 12 patients reviewed from improper restriction of rights. Review of records showed Patient #4 was caused emotional distress and was crying over being secluded. The patients had privileges restricted without obtaining physician orders. The patient was secluded without physician order. Review of documentation showed that restrictions were punitive rather than for the safety of the patient, staff, or other patients.

See Tag A0145
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of records and interview, the facility failed to protect 2 (Patient #1 and Patient #4) of 12 patients reviewed from improper restriction of rights. The patients had privileges restricted without obtaining physician orders. The patient was secluded without physician order. Review of records showed Patient #4 was caused emotional distress and was crying over being secluded. Review of documentation showed that restrictions were punitive rather than for the safety of the patient, staff, or other patients.

Findings included:


Patient #1

Review of Patient #1's chart revealed, she was admitted on [DATE] and discharged on [DATE]. The nursing notes on 6-18-2018 at 4:00 PM were as follows:

"Other pts. going out for a smoke break but (Patient #1) had been misbehaving so she was to stay on the floor. She tried to slap the MHT (mental health technician) and push her out of the way and elope. Tech grabbed her wrist so she couldn't hit her and then (Patient #1) started kicking her"

As a result of this aggressive outburst after being restricted from going outside with Patient #1's peers, the physician was notified at 4:13 PM. Orders for an Emergency Behavioral Medication Administration and Seclusion were given. At 4:35 PM the nurse charted that the patient was medicated and placed in seclusion. At 4:45 PM the nurse charted that the patient was out of seclusion.

Review of the Restraint and Seclusion package, Patient Self De-Briefing Form showed the patient answers to the following questions:

"5. Things staff did that DID NOT HELP: wouldn't let me go out and smoke

6. Possible things that staff could do to help me in the: future - let me smoke"


Staff #1 was asked if smoke breaks were also used as fresh-air and outdoor exercise breaks. Staff #1 confirmed that there were scheduled times for everyone on the unit to be able to go outside and smoke, enjoy the fresh air, or just visit with their peers.


Staff #10 was interviewed on the morning of 9-25-2018. Staff #10 stated, she was not sure what the patient had specifically done that was "misbehaving" as documented in her notes. Staff #10 was not able to locate notes in the chart that described the behaviors, other than "misbehaving", that led up to the smoke break restriction that, in turn, caused the patient to become aggressive. Staff #10 stated, she believed that the staff may have had difficulty with getting the patient to come back onto the unit when she was off the unit for activities and, therefore, may have been at risk for elopement. Staff #10 denied speaking to the physician, prior to restricting her smoke break, about concerns that the patient was an elopement risk if she were allowed to leave the unit or go on smoke breaks . No orders to restrict the patient to the unit were obtained immediately prior to this incident or after this incident. Review of patient monitoring records show the patient continued to be allowed off the unit for dining and the courtyard after the incident.


Review of Physician orders for 5-18-2018 show an order written by the physician, Staff #13, as follows:
"Restrict to unit due to yelling, shouting, banging wall." This order did not contain a time limitation.


On 5-24-2018, Staff #13 wrote another order as follows:
"Restrict to unit." This order did not contain clinical justification or a time limit.


No other orders for the patient to be restricted to the unit and denied access to the courtyard area were found.

Review of Policy and Procedure: 1800.4, Subject: Denial of Rights, was made as follows:
"POLICY: All staff will comply with legal parameters when involved in denial of patient rights.
PROCEDURE:
1. Denial of rights, including restriction of phone access, requires a physician's order.
1.1. The order must delineate the clinical justification for the denial of rights.
1.2. The order must specify which right(s) are to be denied.
1.3. The order must be time-limited to 7 days."


Patient #4

Review of Patient #4's chart revealed, she was admitted on [DATE] and discharged on [DATE].

On 8-12-2018, Staff #17 charted the following:

8:30 PM "Pt stays @ nsg station will not stay behind red line. Pt who was in seclusion was taken out and (Patient #4) kept cussing @ her telling her to die and F you then she went @ pt to hit her flinging fists. I stepped in to prevent other pt from getting hit. Pt cussed me and threatened me too. Dr Q notified and MO received - Haldol 5 mg and Benadryl 50 mg given IM for aggression."

A corresponding Restraint and Seclusion package was found for this Emergency Behavioral Medication Administration.


On 8-12-2018 at 9:30 PM, Staff #17 charted the following:

"Pt is still up has not gone to sleep - still agitated, limits set (with) pt- verbalized understanding but pt continues (with) her behavior. Refuses to stay behind red line, cussing @ nurse entire time she is reminded. Pt escorted to quiet room - also demanded she be taken out to smoke.

On 8-13-2018 at 1:20 AM, Staff #17 charted:

"Pt still refusing to go to bed demanding she be taken out to smoke. Once more escorted to the quiet room.

No orders for secluding the patient to the quiet room were found. No Restraint and Seclusion packages were found to be initiated.


On 8-14-2018 at 9:30 PM, Staff #17 charted the following:

"Pt standing @ med window refuses to stay behind red line- Tries to prevent other pts from recieving (sic) their meds, being very obnoxious to staff and peers, when pt escorted out of the way so peers can take their meds she stands right behind them looking over their shoulder and has to be escorted behind red line - Told to go to her room and pt says she has to smoke first - When it was time to go smoke pt refused and demanded her meds, Meds were given but states "Give me my medicine so I can go smoke - Pt escorted to quiet room so that meds can be passed to her peers"


At 11:45 PM, Staff #17 charted:

"Pt has been asked several x's if she wanted to get out of (seclu had been written, lined through, initialed) quiet room pt finally stated she was going to bed"

No orders for secluding the patient to the quiet room were found. No Restraint and Seclusion packages were found to be initiated.


On 8-21-2018 (note was not timed), Staff #17 charted:

"Pt has been sexually inapprient (sic) trying to go in another male peer's rooms, states she is gonna have sex (with) him - Says she is pregnant - Pt constantly comes to nsg station and stands in front whether she wants something or not has been instructed on staying behind the red line on floor - and out of male peers room - Limit set (with) pt became loud and cursing - Pt escorted to quiet room told when she could follow unit rules she could come out"

No orders for secluding the patient to the quiet room were found. No Restraint and Seclusion packages were found to be initiated.


On 8-28-2018, Staff #17 charted (two times for same note written, 10:00 PM 11:00PM, unclear when events occurred):

"Pt denies SI/HI (suicidal ideation and homicidal ideation) - Pt continues to refuse to follow unit rules, will not stand by red line, wants to stay standing in front of med window - After redirecting pt many times - and be cursed @ each time, calls staff bitch says fuck you, I wish you would die - Pt escorted to quiet room - Told when she felt she follow rules she could come out - ..."

At 6:00 AM on 8-29-2018, Staff #17 charted:
"Pt came out of her room only once ..."

No orders for secluding the patient to the quiet room were found. No Restraint and Seclusion packages were found to be initiated.


On 9-7-2018, Staff #18 initiated a Restraint and Seclusion Package. Review of Restraint and Seclusion package dated 9-7-2018, at 3:38 PM, indicated Patient #4 was placed in seclusion by Staff #18 because she was saying things to another patient about that patient's children. This was upsetting the other patient. The documentation showed that the nurse initiating the seclusion, Staff #18, was also the nurse that completed the One Hour Face to Face Evaluation. No documentation of a physician order for the seclusion was found.

The patient's response to the intervention was described as "Pt doesnt (sic) like quiet room, was crying + stated she would not say hurtful things again re: people kids"

A treatment plan was initiated due to the seclusion. The Long Term Goal listed on the treatment plan was "(Patient #4) will be compliant when talking to other pts."


Review of nursing notes for Patient #4 written on 9-8-2018 at 9:00 AM were as follows:
"Pt is cooperative and med compliant. Pt is programming as orders as possible d/t (due to) her being on unit restrictions."

No orders for the patient to be restricted to the unit were found.


Staff #18 charted at 3:38 PM:

"(Patient #4) put in quiet room. She was saying things to another pt + inciting her to violence. Escorted + made to stay about 10 min until pt apologized + stated she wouldn't talk about peoples (sic) kids again."


Staff #1 interviewed. Staff #1 stated it was not hospital policy to place patients in the quiet room because they did not follow rules or would not apologize. Staff #1 stated that this was against hospital policy and that there is zero tolerance for the abuse of restraints and seclusion.


Review of Policy and Procedure: 1000.57, Subject: seclusion and Physical or Chemical Restraint was as follows:

"POLICY:
1. Each patient has the right to be free from restraint or seclusion, of any form, used as a means of coercion, discipline, convenience, or retaliation. Restraint or seclusion shall be in a way which is humane and caring and used in a way in which the patient rights, dignity, well-being, and safety are assured.

2. Rock Prairie Behavioral Health will utilize nonphysical interventions in an effort to prevent restraint or seclusion. The use of verbal de-escalation (i.e., calming techniques, redirection, refocus, etc.) are utilized. Restraint or seclusion is used only when non-physical interventions are not effective or not viable and when there is an imminent risk of a patient physically harming himself or herself, staff or others.

...

10. After all reasonable attempts at lesser alternatives (least restrictive approach) to seclusion or restraint have been attempted, the Registered Nurse will consult with the psychiatrist who is provided a clear assessment of the patient's current status and the client's physical and psychological condition. Only Registered Nurses can obtain orders for restraint or seclusion.

... For a physical restraint or seclusion episode, the Registered Nurse must obtain a telephone or written order from the client's treating psychiatrist as soon as possible, but no longer than 1 hour of implementation of an emergency safety intervention

...

13. Restraint or seclusion must not result in harm or injury to the patient and must be used only:

a. To ensure the safety of the patient or others during an emergency situation. An emergency safety situation means unanticipated patient behavior which places the patient or others at serious threat of violence or injury if no intervention occurs and it calls for an emergency safety intervention as defined in this policy.

b. Until the emergency safety situation has ceased and the patient's safety and safety of others can be ensured, even if the restraint or seclusion order has not expired."