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Based on interview and patient record review, the hospital failed to assure that the restraint of one of one patient (Patient #3) was in accordance to state law in that Patient #3 was transferred to a different hospital in a transfer jacket with a physician order not specifying a reason, age appropriate time limit or behavioral expectation for release of restraint as specified in the Texas Administrative Code Title 25 Part 1 Chapter 404 Subchapter E Rule 404.154(26) Rights of All Persons Receiving Mental Health Services.

Findings included:

Patient #3's Preadmission Exam and Certification dated 04/17/13 reflected Patient # 3 was a 15 year old male with at least twenty previous suicide attempts including the attempt to hang himself. He also wanted to stab his mother. Patient #3's admitting diagnoses included Bipolar, Major Depressive Disorder with Psychotic Behavior.

Patient #3's admission seclusion and restraint assessment tool reflected that pacing, taking a walk or a nap and listening to music were interventions that helped Patient #3 to regain control during episodes of agitation or loss of control.

The Emergency Intervention Order/Initiation dated 04/23/13 at 11:05 AM reflected a seclusion order with the clinical justification that Patient #3 was a danger to others when he "jumped over [the] nurses' station and became assaultive towards nursing staff." The physician post intervention assessment timed at 11:58 AM reflected that Patient #3 was "still in locked seclusion, sleeping." The time of termination was noted to be 1:50 PM. The document noted a staff perception of the events leading to the restraints was that Patient #3 "became agitated for no known reason."

Patient #3 Physician Orders dated 04/22/13 at 12:00 PM reflected an order to discharge the patient "tomorrow...use transport jacket for transfer." A second order dated 04/24/13 at 09:00 AM reflected to "use transport jacket for transfer..."There was no documentation of reason, length of time, or behaviors necessary for Patient #3 to be removed from the transport jacket.

Patient #3's Precaution Checklist dated 04/24/13 reflected Patient #3 slept in his room until 8:00 AM, was quiet in his room at 08:15 AM, interacted socially in the large lounge and dining room until 8:45 AM, and ate in the dining room at 9:00 AM. and 9:15 AM.

Patient #3's Assessment and Activity Record dated 04/24/13 reflected he had 9 hours of uninterrupted sleep.

The Multidisciplinary Progress Notes dated 04/24/13 at 9:00 AM reflected the Patient #3 was discharged to another hospital "wearing a transport jacket."

During an interview on 04/24/13 at 3:15 PM, Hospital Personal #1 stated the patient was transferred from the pediatric unit where staff was not used to discharging patients in transfer jackets.

During an interview on 04/24/13 at 2:45 PM Hospital Personnel #9 stated the patient had been in restraints before and was anxious about going to the state hospital.

The hospital's restraint/seclusion policy "7/02 " and "1/10" reflected the policy to "support each patient's right to be free from restraint or seclusion and therefore limit the use of these interventions to emergencies in which there is an imminent risk of a patient physically harming him/herself or others... [and] restraint/seclusion use will not be based on history of past use or dangerous behavior..." The policy defined a transfer jacket as "mechanical restraint" and required a physician order for use of restraint or seclusion to include justification including specific behaviors, age related time limit, and behavioral criteria for release.