HospitalInspections.org

Based on record review and interview, the facility failed to ensure staff followed policies and procedures to ensure care in a safe setting for 1 of 10 patients reviewed (Patient ID #1). The facility failed:
1) To document a nursing and/or provider assessment immediately after medical restraint application, obtain an order, in a timely fashion for application of medical restraints and failed to document the date/time, indication for placement of the restraints, as well as who applied them.
2) To fully investigate a grievance, including an allegation of physical assault by a staff member in the clinical setting of a patient developing a bruise, which extended from the right side of mandible, down onto neck and extending to right upper chest below clavicle, that had no known cause/etiology, while the patient was hospitalized at the facility.
3) To notify the patient's attending physician of an allegation of assault by a staff member and ensure attending physician involvement/record completion.

Findings included:

Record Review of facility policy titled "Patient Rights and Responsibilities", updated 06/2023, stated "As a patient at Texas Children's, each patient has the below rights: ... Right to information about patient rights: The patient has the right to receive, at the time of admission, information about the hospital's patient rights policy(ies) and the mechanisms for initiation, review, and when possible, resolution for patient complaints concerning quality of care. Right to be free from abuse: The patient has the right to be free of all forms of abuse, neglect, harassment and exploitation. Right to be free from restrain or seclusion: The patient has the right to be free of restraints or seclusion, unless medically necessary." It further stated "Rights of recourse: Each patient or medical decision maker has the right to: Voice a complaint about quality of care or service through the following process: If your concern is not resolved, you may file a grievance by submitting it verbally or in writing. The hospital will explain the grievance process and the timeframe for processing. The hospital will send a written response of its decision, which will include: Name of Hospital contact person, steps taken on behalf of the patient to investigate the grievance, results of the grievance process and date of completion."

Record Review of facility policy titled "Restraint Procedure", effective 01/18/2023, stated "Definitions: Medical/Surgical Restraints: Use of mechanical device to involuntarily limit the movement of the whole or a portion of ta patient's body as a means to protect and improve the patient's well-being by preventing injury or the removal of lines/tubes needed for patient care and treatment. ... 6. Initiation and Ordering of Medical Surgical Restraints 6.1 The RN assesses the patient's mental, behavioral, and physical status in an attempt to determine the appropriate use of a medical surgical restraint. 6.2 The assessment must determine the risks associated with the use of the medical surgical restraints. The determination to use medical surgical restraints should outweigh the risk of not using the treatment. 7. Ordering of Medical Surgical Restraints 7.1 The order for a medical surgical restrain must be obtained from a physician or APP involved in the care of the patient prior to the application of the restraint, except in emergent situations. 8. Application of Medical Surgical Restraints 8.1 Medical Surgical Restraints are applied and reapplied by an individual with assessed and validated competencies. 9. Assessment and Documentation of the patient in Medial Surgical Restraints. 9.1 Patients in medical surgical restraints will be assessed immediately after restraints are applied to assure safe application/initiation. 9.2 The following information should be documented in the electronic medical record at the time of initiation of medical surgical restraints: Clinical judgement for use, Less restrictive alternatives attempted/utilized and their effectiveness, Time of application and type of restraint applied, Patient/Caregiver notification and education, Patient's response to restraints, Any and all orders related to medical surgical restraints, Care plan should be initiated within 24 hours of application, Physician or APP notifications regarding change in status, Skin assessment and Neurovascular status. 9.3 The RN will assess and document at least every 2 hours while the patient is in restraints..."

Record review of facility policy titled "Patient Abuse involving Workforce Staff Members", effective 09/26/2024, stated "1.2 Department/Unit Leadership 1.2.1 When allegations of suspected abuse are reported to leadership, the leadership should notify the House Supervisor and the affected patient's Attending Physician."

Record review of facility "Medical Staff Rules and Regulations", amended August1, 2020, stated "A-2. The attending physician shall be responsible for the overall medical care and treatment of each patient in the hospital, and for the prompt completion and accuracy of medical records."

Record review of Patient ID #1 electronic medical record on 7/23/2025 at 08:50 am with RN Staff ID #59 showed the following: Female toddler, admitted to facility on 6/8/2025 as a transfer into the Pediatric Intensive Care Unit. Medical restraints were documented on 6/9/2025 at 08:00 am in the nursing assessment as "continued" by Staff RN ID #72. The patient was extubated and subsequently transferred to the 10 West Tower medical floor on 6/11/2025 at 3:30 pm. Physician resident staff ID # 67 on 6/11/2025 at 4:28 pm stated "Bruising R side of neck and over neck and upper chest over collar bone." The physician "Neurology transfer note" written by physician Staff ID #67 stated that the mother alleged PICU nurse had held child down aggressively to the bed and this caused bruising. He stated he informed charge nurse and patient advocate. There was no documented discussion or report to the patient's attending physician of these allegations located in the medical record. The "Neurology transfer note" written by physician staff ID # 67 stated "Co-Sign Needed-Addendum." Quality Staff ID # 57 confirmed there was no evidence of physician attestation or involvement documented on the transfer note and that it should have been completed.

Record review of security detail report event #5624 completed on 6/12/2025 at 2:05 am regarding Patient ID #1 completed by Security officer Staff ID #91. Report stated "After completing the staff interviews, Security and TMC officers returned to West Tower to update (mom). Officers explained that based on information gathered "there was insufficient evidence to support criminal charges against Staff RN #70. The actions described by the medical staff were consistent with standard medical procedures and the bruising may not definitively indicate misconduct. Matter remains under review by family advocacy and hospital leadership and further investigation will be conducted as needed." The report stated "reported to police yes, reported to supervisor yes, requires investigation No."

Interview 7/23/2025 09:20 am with PICU Staff RN #59. She stated that the order for medical restraints is fired as a task for physician order when the clinical staff chart "applied" in their nursing assessment. She stated that because the nursing staff failed to document, at the time of application, it likely did not trigger the physician team to enter the order at or near the time of application. She stated that the staff have 24 hours to obtain an order for medical restraints.

Interview 7/23/2025 with Director of Quality (DQM) Staff ID # 57, she stated that the facility investigated a 30 minute period of time surrounding the time the mother reported observing clinical care in the Pediatric ICU unit with Staff RN #70. Staff ID # 57 was unable to provide evidence that the facility expanded the investigation to evaluate for other sources of bruising to the child's neck related to aggressive staff contact, medical device failure, etc.

Interview 7/24/25 at 5:00 pm with Police Officer Staff ID # 82. He stated the police investigation was dependent on the hospital's investigative process as the police officers are "not medical experts." He confirmed he observed bruising on the child's neck when he responded to the facility's call for officer assistance. He stated he felt that the bruising appeared "more fresh" as it had some reddened appearance to it and that the timeline did not match up. He confirmed he was the officer who wrote the official police report and participated in interviews of the witnesses. He confirmed there was no etiology provided for the bruising by the facility. He confirmed the case was closed based on the hospital's declaration that the care provided was the "standard of care."

Interview with Director of Patient Advocacy Staff ID # 85 with review of grievance process on 7/23/25 at 12:30 pm. She confirmed a grievance was received on 6/11/2025. She reported records reflected physician staff ID # 67 had contacted patient advocacy on 6/11/2025 and relayed the mom expressed concern about PICU staff patient care/contact resulting in bruising on her child. Patient advocate staff ID # 92 met with the mother who relayed numerous concerns including staff referring to her child as a "wild child", staff disagreement she witnessed about her child's care between staff RN # 70 and Physician assistant staff ID #93 on the same shift where she reported observing Staff RN #70 be excessively forceful while restraining child in Pediatric ICU. Grievance was referred to clinical staff. Records reflected a "6222 Meeting" was assembled related to the allegation of abuse by a staff member. However, there was no investigation or follow-up related to mother's other related concerns expressed in grievance. Staff ID #85 confirmed she did not have follow-up on those items (wild child, staff discord about care of Patient ID #1).