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Based observation, record reviews and interviews, the governing body failed to ensure:

A. The facility enforced policies regarding reporting and investigating allegations of abuse and provide a safe setting for patient care. The facility also failed to follow policies for the use of restraints for 2 of 13 (#1, #9) patients reviewed. Patients were restrained without physician's orders.

Refer to Tag A0144

B. The facility followed up on two reports of alleged patient abuse.

Refer to Tag A0145

C. The facility intervened on behalf of 1 of 13 (#13) patient and allowed staff #13 to use the threat of restraint as means of coercion.

Refer to Tag A0154

D. The facility obtained valid orders for restraint use in 2 of 13 (#1 and #9) patients. The governing body also failed to ensure the facility followed their own policy on use of restraints.

Refer to Tag A0168

Based on record review and interview the facility failed to

A. act on behalf of patients by not following their process for reporting abuse, allowing patients to be restrained without physician's orders and allowed a nurse to use the threat of restraint as a means of coercion.

Refer to tag A0144

B. follow up on two reports of alleged patient abuse.

Refer to tag A0145

C. intervene on behalf of 1 of 13 (#13) patients and allowed staff #13 to use the threat of restraint as means of coercion.

Refer to Tag A0154

D. obtain valid orders for restraint use in 2 of 13 (#1 and #9) patients. The facility failed to follow their policy on use of restraints.

Refer to Tag 168

Based on observation, record review, and interviews the facility failed to:

A. follow the policies for reporting allegations of patient abuse.

B. respond to the report of a nurse using the threat of restraints as a means of coercion.

C. follow the policies for the use of patient restraints and allowed patients to be restrained without physicians' orders.

D. intervene when a patient was restrained in a wheel chair for long periods of time without intervention.

A. A review of the document titled, Reporting of Abuse, RI.1410 CDHS, revealed " Any staff member having reasonable cause to believe that a patient is being abused, neglected, or exploited is to notify the Social Worker. The Social Worker will interview the patient and/or family. The Social Worker is not to make a determination as to whether or not the patient is being abused, neglected, or exploited, but is to identify the appropriate resources to address the alleged incident. "

Further review of this one page document revealed in the last paragraph, " It is the responsibility of care providers and the Hospital to report any suspected abuse, neglect, or exploitation to the appropriate local agency (see attached procedure) and to document the referral. "

There was no "attached procedure" for review by the surveyor.

A review of the document titled " Quality Committee Variance Report " , dated 04/22/12, reported the suspected abuse of patient #1. This document revealed no evidence a Social Worker was notified of the suspected abuse of patient #1.

An interview with staff #1 on 04/26/12 at approximately 0930am in the conference room confirmed the Social Worker was not notified of the report of suspected abuse of patient #1. The interview with staff #1 also confirmed there were no referrals made to local agencies of the suspected abuse.

A phone with staff #3 on 04/26/12 at approximately 4:00pm confirmed the Social Worker was not notified of the report of suspected abuse of patient #1. The interview with staff #3 also confirmed there were no referrals made to local agencies of the suspected abuse.

B. A review of the document titled, " Restraints, ID. Tx.7400CDHS, III. Directive: D, " revealed " Restraints will not be used as a means of coercion, discipline, convenience, or staff retaliation. "

A review of a written statement by staff #13, dated 04/19/12, revealed staff #13 made repeated threats to restrain patient #13 with a vest restraint if she did not remain in bed.

Review of the document titled, " Dubuis Hospital of Beaumont/Port Arthur, Complaint Log 2012 " , revealed " Date and Time: 04/20/12 at 1230 pm, Person making the Complaint: Patient #13 in room 304, Complaint: staff #13 threatened to put on " straightjacket " , Follow up Date and Time: 04/23/12 AM with staff #13, Outcome, Date/Time, Resolved, Ongoing Required, Etc.: Resolved statement obtained. "

An interview on 04/26/12 in the conference room with staff #1 confirmed he was aware of staff #13 making repeated threats to restrain patient #13. Staff #1 stated he was made aware of the threats and had staff #13 make a written statement. Staff #1 confirmed no further follow up was conducted. The interview revealed no Social Worker was notified of the threats made by the staff member to the patient.

C. During an interview on 4/26/12 at 1:20pm in the medical records room, staff #6 reported the following:
-Patient #1 was moved to the nurses ' station on 4/21 at 9:45pm for close observation after a fall in her room
-On 4/21 at 9:45pm, patient #1 was restrained to the wheelchair with a gait belt, but at some point (around two hours after being moved to the nurses ' station), she " got loose " and started trying to get out of the chair
-At this time staff #6 and #7 held the patient in the chair, while staff #5 restrained the patient to the wheelchair with a sheet
-Staff #6 reported that the gait belt and the sheet would be considered restraints, but believed there was a current order for restraints that night

Review of patient #1 ' s chart revealed the following:
-4/21 at 9:45pm, the patient was found on the floor in her room- the patient denied pain and physical exam revealed no injuries
-The patient was, " Placed in wheelchair & wheeled to nurses ' station for close observation, " at 9:45pm
-The family was notified of the fall via phone
- At midnight, the patient was confused and agitated and remained in the wheelchair
-4/22 at 3:00am, the patient ' s status was unchanged- she was agitated and singing
-4/22 at 6:30am, " Remain on wheelchair, singing, confused & agitated "
-Further review of the chart revealed that the patient was restrained on 4/20 and 4/21 without a valid physician order (the order was not signed by a physician)

Review of patient #9 ' s chart revealed that he was restrained from 3/29 at 8:00pm until 3/30 at 6:00am without a physician order.

During a follow-up interview on 4/26/12 at 3:10pm in the Administrator ' s office, staff #1 reviewed patient #1 and #9 ' s charts and reported the following:
-Patient #1 was restrained on 4/20 and 4/21 without a valid physician order (order was not signed by the physician)
-Patient #1 was restrained in the early morning on 4/22 without a physician order
-Patient #9 was restrained from 3/29 at 8:00pm until 3/30 at 6:00am without a physician order
-Staff #1 confirmed that a gait belt and a blanket (wrapped around a patient ' s torso) would be considered restraints

A review of policy titled "Restraints ID.TX.7400CDHS; C3 policy Date: 12-2010" revealed " Physician/LIP issues the order for use of restraint
-RN may initiate restraint in response to a change in patient condition considered an emergency
-Nurse notifies the physician/LIP immediately and requests a verbal or written order
-Physician/LIP will evaluate the patient in person within 24 hours and complete a written order for restraint
-Continued use of restraint beyond 24 hours is based on patient examination by the ordering physician/LIP and a written order each calendar day
-Restraint will be discontinued as soon as possible following reassessment by a qualified RN
-Restraint will be discontinued when no longer clinically justified and patient's behavior no longer threatens the physical safety of the patient, staff or others"

During an observation tour of the facility on 4/26/2012 at approximately 9:30AM, patient #1 was found in the hallway by the nurses' station in a TLC chair (Tender Loving Care Chair) tied with a bed sheet around her waist to the chair with the knot behind the chair.

A review of the patients' medical record revealed an order was written using the " Restraint Order Form " dated 4/26/2012 and timed 7A-7P by staff #11(no time of when order was written by staff #11). Staff #11 documented on the "Patient Monitor Form" dated 4/26/2012 and time (left blank), patient observation section was timed 08 (8:00AM) and 10 (10:00AM). Staff #11 documented on the form restraint in use was a belt. It was observed by the surveyor that a bed sheet was used to restrain the patient in the TLC chair.

An interview with staff #11 on 4/26/2012 at approximately 2:00 PM, confirmed that patient
#1 was restrained with a bed sheet tied around patients' waist and to the TLC chair. Staff
#11 confirmed she wrote the order after the surveyor found the patient in restraints and she also reported she did not know the patient had been restrained. Questioned staff #11 did you notify the physician of the restraint order and she answered no, I just filled out the form and put in the chart slot for the physician to sign when he makes rounds on the floor this afternoon. Staff #11 confirmed the "Patient Monitor Form" was falsified; due to she had documented patient observation at 8:00 AM, and that the patient was restrained with a belt and the patient was observed with a bed sheet restraint. Staff #11 reported she did not know the patient was in restraints till after the surveyor observed the patient in restraints around 9:30 AM. Questioned staff #11 did you follow the facility policy for restraints and she reported she did not follow the facility policy.

D. A review of patient ' s medical record revealed the patient was placed in a wheelchair at the nurses ' station for 3 consecutive nights during the night shift (7P-7A). On 4/19/2012 the patient was placed in wheelchair at the nurses ' station at 2230 (10:30 PM) till 0630 (6:30 AM). On 4/20/2012 the patient was placed in wheelchair at the nurses ' station at 2330 (11:30 PM) till 0330 (3:30 AM). On 4/21/2012 the patient was placed in wheelchair at the nurses' station at 2145 (9:45 PM) till 0630 (6:30 AM).

Based on record review and interview the facility failed to follow up on two reports of alleged patient abuse.

A review of the document titled, Reporting of Abuse, RI.1410 CDHS, revealed " Any staff member having reasonable cause to believe that a patient is being abused, neglected, or exploited is to notify the Social Worker. The Social Worker will interview the patient and/or family. The Social Worker is not to make a determination as to whether or not the patient is being abused, neglected, or exploited, but is to identify the appropriate resources to address the alleged incident. "

Further review of this one page document revealed in the last paragraph, " It is the responsibility of care providers and the Hospital to report any suspected abuse, neglect, or exploitation to the appropriate local agency (see attached procedure) and to document the referral. "

There was no "attached procedure" for review by the surveyor.

A review of the document titled " Quality Committee Variance Report " , dated 04/22/12, reported the suspected abuse of patient #1. This document revealed no evidence a Social Worker was notified of the suspected abuse of patient #1.

An interview with staff #1 on 04/26/12 at approximately 0930am in the conference room confirmed the Social Worker was not notified of the report of suspected abuse of patient #1. The interview with staff #1 also confirmed there were no referrals made to local agencies of the suspected abuse.

A phone with staff #3 on 04/26/12 at approximately 4:00pm confirmed the Social Worker was not notified of the report of suspected abuse of patient #1. The interview with staff #3 also confirmed there were no referrals made to local agencies of the suspected abuse.

A review of the document titled, " Restraints, ID. Tx.7400CDHS, III. Directive: D, " revealed " Restraints will not be used as a means of coercion, discipline, convenience, or staff retaliation. "

A review of a written statement by staff #13, dated 04/19/12, revealed staff #13 made repeated threats to restrain patient #13 with a vest restraint if she did not remain in bed.

An interview on 04/26/12 in the conference room with staff #1 confirmed he was aware of staff #13 making repeated threats to restrain patient #13. Staff #1 stated he was made aware of the threats and had staff #13 make a written statement. Staff #1 confirmed no further follow up was conducted. The interview revealed no Social Worker was notified of the threats made by the staff member to the patient.

Based on record review and interview the facility failed to intervene on behalf of 1 of 13 (#13) patients reviewed and allowed staff #13 to use the threat of restraint as means of coercion.


A review of the document titled, " Restraints, ID. Tx.7400CDHS, III. Directive: D, " revealed " Restraints will not be used as a means of coercion, discipline, convenience, or staff retaliation. "

A review of a written statement by staff #13, dated 04/19/12, revealed staff #13 made repeated threats to restrain patient #13 with a vest restraint if she did not remain in bed.

Review of the document titled, " Dubuis Hospital of Beaumont/Port Arthur, Complaint Log 2012 " , revealed " Date and Time: 04/20/12 at 1230 pm, Person making the Complaint: Patient #13 in room 304, Complaint: staff #13 threatened to put on " straightjacket " , Follow up Date and Time: 04/23/12 AM with staff #13, Outcome, Date/Time, Resolved, Ongoing Required, Etc.: Resolved statement obtained. "

An interview on 04/26/12 in the conference room with staff #1 confirmed he was aware of staff #13 making repeated threats to restrain patient #13. Staff #1 stated he was made aware of the threats and had staff #13 make a written statement. Staff #1 confirmed no further follow up was conducted.

Based on observation, record review, and interview, the facility failed to obtain valid orders for restraint use in 2 of 13 (#1 and #9) patients. The facility failed to follow their policy on use of restraints.

Findings include:

During an interview on 4/26/12 at 1:20pm in the medical records room, staff #6 reported the following:
-Patient #1 was moved to the nurses ' station on 4/21 at 9:45pm for close observation after a fall in her room
-On 4/21 at 9:45pm, patient #1 was restrained to the wheelchair with a gait belt, but at some point (around two hours after being moved to the nurses ' station), she " got loose " and started trying to get out of the chair
-At this time staff #6 and #7 held the patient in the chair, while staff #5 restrained the patient to the wheelchair with a sheet
-Staff #6 reported that the gait belt and the sheet would be considered restraints, but believed there was a current order for restraints that night

Review of patient #1 ' s chart revealed the following:
-4/21 at 9:45pm, the patient was found on the floor in her room- the patient denied pain and physical exam revealed no injuries
-The patient was, " Placed in wheelchair & wheeled to nurses ' station for close observation, " at 9:45pm
-The family was notified of the fall via phone
- At midnight, the patient was confused and agitated and remained in the wheelchair
-4/22 at 3:00am, the patient ' s status was unchanged- she was agitated and singing
-4/22 at 6:30am, " Remain on wheelchair, singing, confused & agitated "
-Further review of the chart revealed that the patient was restrained on 4/20 and 4/21 without a valid physician order (the order was not signed by a physician)

Review of patient #9 ' s chart revealed that he was restrained from 3/29 at 8:00pm until 3/30 at 6:00am without a physician order.

During a follow-up interview on 4/26/12 at 3:10pm in the Administrator ' s office, staff #1 reviewed patient #1 and #9 ' s charts and reported the following:
-Patient #1 was restrained on 4/20 and 4/21 without a valid physician order (order was not signed by the physician)
-Patient #1 was restrained in the early morning on 4/22 without a physician order
-Patient #9 was restrained from 3/29 at 8:00pm until 3/30 at 6:00am without a physician order
-Staff #1 confirmed that a gait belt and a blanket (wrapped around a patient ' s torso) would be considered restraints


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A review of policy titled "Restraints ID.TX.7400CDHS; C3 policy Date: 12-2010" revealed " Physician/LIP issues the order for use of restraint
-RN may initiate restraint in response to a change in patient condition considered an emergency
-Nurse notifies the physician/LIP immediately and requests a verbal or written order
-Physician/LIP will evaluate the patient in person within 24 hours and complete a written order for restraint
-Continued use of restraint beyond 24 hours is based on patient examination by the ordering physician/LIP and a written order each calendar day
-Restraint will be discontinued as soon as possible following reassessment by a qualified RN
-Restraint will be discontinued when no longer clinically justified and patient's behavior no longer threatens the physical safety of the patient, staff or others"

During an observation tour of the facility on 4/26/2012 at approximately 9:30AM, patient #1 was found in the hallway by the nurses' station in a TLC chair (Tender Loving Care Chair) tied with a bed sheet around her waist to the chair with the knot behind the chair.

A review of the patients' medical record revealed an order was written using the " Restraint Order Form " dated 4/26/2012 and timed 7A-7P by staff #11(no time of when order was written by staff #11). Staff #11 documented on the "Patient Monitor Form" dated 4/26/2012 and time (left blank), patient observation section was timed 08 (8:00AM) and 10 (10:00AM). Staff #11 documented on the form restraint in use was a belt. It was observed by the surveyor that a bed sheet was used to restrain the patient in the TLC chair.

An interview with staff #11 on 4/26/2012 at approximately 2:00PM, confirmed that patient
#1 was restrained with a bed sheet tied around patients' waist and to the TLC chair. Staff
#11 confirmed she wrote the order after the surveyor found the patient in restraints and she also reported she did not know the patient had been restrained. Questioned staff #11 did you notify the physician of the restraint order and she answered no, I just filled out the form and put in the chart slot for the physician to sign when he makes rounds on the floor this afternoon. Staff #11 confirmed the "Patient Monitor Form" was falsified; due to she had documented patient observation at 8:00AM, and that the patient was restrained with a belt and the patient was observed with a bed sheet restraint. Staff #11 reported she did not know the patient was in restraints till after the surveyor observed the patient in restraints around 9:30AM. Questioned staff #11 did you follow the facility policy for restraints and she reported she did not follow the facility policy.