printed: 11/25/2011 department of health and human...

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IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

(X3) DATE SURVEY

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PRINTED: 11/25/2011FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

454089 11/17/2011

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HOUSTON, TX 77054

STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

INTRACARE MEDICAL CTR7601 FANNIN

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

B 000 INITIAL COMMENTS B 000

An unannounced follow-up survey was

conducted by federal contract surveyors from

November 15 2011 to November 17, 2011. The

census at the time of the survey was 59; the

active sample size was 8. Five patients were

added to the sample to review seclusion and

restraint (S/R) procedures.

B 118 482.61(c)(1) TREATMENT PLAN

Each patient must have an individual

comprehensive treatment plan.

This STANDARD is not met as evidenced by:

B 118

Based on interviews and record reviews, the

hospital failed to revise the Master Treatment

Plans of 2 of 2 sample patients (D2 and D5) who

had been in seclusion and/or restraint on multiple

occasions. Failure to update the treatment plans

in response to multiple seclusion and restraint

episodes leave staff with no new directions or

interventions with which to manage high-risk

behaviors.

A. Patient D2

1. On 11/15/11 at 2 p.m., patient D2 was

observed to be yelling, running in the hall, and

spitting at staff. The Director of Social Work was

on the unit and walked patient D2 to the Quiet

Room. Patient D2 was kept in the Quiet Room

approximately five minutes.

2. In a telephone interview on 11/15/11 at 1:45

p.m., Social Worker SW1 reported two incidents

of seclusion/restraint for patient D2 - one on

11/13/11, and the other on 11/14/11. Both events

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that

other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet of 41

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B 118 Continued From page 1 B 118

entailed physical holds by staff and time in the

Quiet Room.

3. In an interview on 11/15/11 at 2:10 p.m.,

charge nurse RN3 stated that patient D2 had

been physically restrained twice on 11/15/11--

once in the morning around 9:30 a.m. and once in

the afternoon at 2 p.m.

4. In an interview on 11/16/11 at 1:10 p.m., child

patient D2 stated that s/he had been in the

hospital five days and had been physically

restrained, carried, and put in the Quiet Room "a

lot." Patient D2 stated that s/he often felt angry

and would "go off over nothing."

5. A review of patient D2's medical record

revealed no reference in the Master Treatment

Plan of the patient's multiple episodes of

seclusion and restraint.

6. In an interview with the Assistant Director on

11/17/11 at 10:40 a.m., the treatment plan of

patient D2 was again reviewed to see if it had

been updated to address the patient's

seclusion/restraint events. The Assistant Director

acknowledged that the treatment plan had not

been updated since patient D2's admission.

2. Patient D5

a. In an interview on 11-15-11 at 12:30 p.m.,


hospital five days and had been taken to the quiet

room (QR) "a couple of times." When Patient D5

was asked if s/he had been held or carried to the

QR, s/he said "yes." Patient D5 reported one

incident in which s/he was taken to his/her


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bedroom and not allowed to leave. When asked

when this happened, the patient replied "not

today, not yesterday, before." Patient D5 was

asked when was the last time s/he was put in the

Quiet Room and could not leave. S/he stated that

it was the morning of this interview (11/15/11).

Patient D5 was asked whether s/he was ever

allowed to leave the QR once taken there. S/he

said "no" and added, "or your time starts over."

b. In an interview on 11/15/11 at 2:30 p.m.,

Mental Health Tech 1 verified that patient D5 had

been taken to the Quiet Room around 9:15 a.m.

that morning.

c. In an interview on 11/15/11 at 3:10 p.m., the

child unit charge nurse, RN3, stated that patient

D5 had been physically taken to the Quiet Room

that morning and kept in the Quiet Room by staff.

d. A review of Patient D5's medical record on

11/16/11 revealed no revisions on the treatment

plan to address the patient's seclusion/restraint

episodes.

e. In an interview with the Assistant Director on

11/17/11 at 10:40 a.m., the Master Treatment

Plan of patient D5 was reviewed to see if it had

been updated to address the patient's physical

holds and Quiet Room restrictions. After

reviewing the record, the Assistant Director noted

that the treatment plan had not been updated

since patient D5's admission on 11/11/2011.

B 136 482.62 SPECIAL STAFF REQS FOR PSYCH

HOSPITALS

The hospital must have adequate numbers of

qualified professional and supportive staff to

B 136


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evaluate patients, formulate written, individualized

comprehensive treatment plans, provide active

treatment measures and engage in discharge

planning.

This CONDITION is not met as evidenced by:

Based on observations, interviews, and records

review, the hospital failed to ensure the use of the

least restrictive methods for external control of

aggressive and agitated behavior based on

individual patient findings/needs. The hospital

used physical restraint and seclusion without

documented prior use of less restrictive methods.

The hospital also employed seclusion and

restraint without the required physician's order,

documentation, or face to face patient

assessments for 1 sample child patient (D5), 4

child patients added to the sample (D1, D2, D6

and D7) and one adolescent patient added to the

sample (C3). These patients were physically

restrained without physicians' orders. Staff

involved in the physical restraints did not record

the incidents in progress notes or describe the

methods they used to physically restrain patients

on the child and adolescent units. Face to face

evaluations were not conducted or documented

following the physical restraint episodes. The

child and adolescent patients also were restricted

to the quiet room or their bedrooms with no

physician orders, documentation of the seclusion,

or face-to-face evaluation following the seclusion.

The hospital has a seven page Behavioral

Emergency Evaluation Form that is supposed to

be completed for all seclusion and/or restraint

incidents. No Behavioral Emergency Evaluations

were completed for any of the seclusion and

restraint incidents involving the six children and


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adolescent patients. In addition, the Master

Treatment Plans of patients repeatedly subjected

to seclusion and restraint were not updated to

reflect changes in intervention techniques. Failure

to safely employ seclusion and restraint exposes

patients to an unsafe environment with the

potential for harm, and jeopardizes the patients'

right to safe treatment. An IMMEDIATE

JEOPARDY was declared on 11/16/2011 at 4

p.m., due to the inappropriate use of seclusion

and restraint, and hospital leaders were informed

at that time. (Refer to B144 and B148)

B 144 482.62(b)(2) MEDICAL STAFF

The director must monitor and evaluate the

quality and appropriateness of services and

treatment provided by the medical staff.


B 144

Based on observations, interviews, and

records/documents review, the Medical Director

failed to ensure that staff used the least restrictive

methods for external control of aggressive and

agitated behavior, based on individual patient

findings/needs. The staff also used seclusion and

restraint without the required physician orders,

documentation, and patient assessments for 1

sample child patient (D5), 4 child patients added

to the sample (D1, D2, D6 and D7), and one

adolescent patient added to the sample (C3).

Staff involved in the physical restraints did not

record the incidents in progress notes or describe

the methods they used to physically restrain the

patients on the child and adolescent units. The

face to face evaluations were not conducted or

documented following the physical restraint

episodes. The child and adolescent patients also


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were restricted to the quiet room or bedroom

(seclusion) without physician orders,

documentation of the seclusion or face-to-face

evaluation following the seclusion. The hospital

has a seven page Behavioral Emergency

Evaluation Form that is supposed to be

completed for all seclusion and/or restraint

incidents. No Behavioral Emergency Evaluations

were completed for any of the S/R incidents

involving the six child and adolescent patients. In

addition, the Master Treatment Plans of patients

repeatedly subjected to seclusion and restraint

were not updated to reflect changes in

interventions or treatment techniques. Failure to

safely employ seclusion and restraint exposes


potential for harm, and jeopardizes patients' right

to safe treatment.

Findings include:

A. Patient D5

1. Interviews




room (QR) "a couple of times." When Patient D5

was asked if staff held or carried him/her to the

QR, s/he said "yes." Patient D5 rolled up his/her

right shirtsleeve to show a small red scratch on

the right bicep and said, "I got this when (staff

name) grabbed me." Patient D5 stated that s/he

was taken to his/her bedroom and told to lie down

on the bed, and that when s/he tried to get up,

(staff name) pushed his/her chest back down on

the bed and told him/her that s/he could not get


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up. Patient D5 was asked when this had

happened; s/he replied "not today, not yesterday,

before." Patient D5 was asked when was the last

time s/he was put in the Quiet Room and could

not leave. S/he stated that it was the morning of

this interview (11/15/11). Patient D5 was asked

whether s/he was allowed to leave the QR or

bedroom once taken there. S/he said "no" and

added, "or your time starts over."


Mental Health Tech 1 verified that patient D5 had


that morning. MHT1 stated that he had to place

his hands on D5's shoulders to get (D5) to the

Quiet Room. Once there, patient D5 tried to push

past him (MHT1) several times as he (MHT1)

blocked the door with his body. MHT1 stated he

did not document this as a restraint in the

patient's medical record, nor did he document the

restriction to the Quiet Room. MHT1 stated that

he did not think these events were restraint or

seclusion.


child unit charge nurse, RN3, stated that patient

D5 had been physically taken to the Quiet Room

that morning and kept in the Quiet Room by staff.

RN3 stated that she did not document this as

physical restraint or seclusion. RN3 also

acknowledged that she did not seek a physician's

order for the physical restraint or seclusion, and

did not assess patient D5 after the incident. RN3

stated she was a "prn" employee who seldom

works with children and usually does home health

care with adults. RN3 was asked if she had

received training on the management of child

psychiatric patients. She replied, "not much." RN3


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stated she seldom works on the children unit

when she is called to work at this hospital. RN3

stated that she did not consider that morning's

incidents to be seclusion or restraint because

they were brief and done to avoid injury.

d. In an interview with the Assistant Director on



been updated to reflect that patient D5 had been

involved in multiple physical restraint and Quiet

Room restrictions. The Assistant Director


been updated since patient D5's admission on

11/11/2011.

2. Record Review

The medical record of patient D5 was reviewed.

There were no progress note entries since D5's

11/11/11 admission that described physical

restraints or seclusion. There were no Behavioral

Emergency Evaluations present in the chart.

There were no physician orders for seclusion or

restraint since admission.

B. Patient D1

a. In an interview on 11/16/11 at 12:35 p.m.,

patient D1 stated that s/he was carried to the

Quiet Room by MHT2 earlier that day. Patient D1

stated s/he asked to come out a couple of times

and was told "not yet."


MHT2 was asked if patient D1 had been placed in

a physical hold earlier that day. MHT2 stated that

while escorting patient D1 to the Quiet Room


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earlier that day, patient D1 dropped to the floor

and would not get up. MHT2 stated that when

patients drop to the floor, he (MHT2) picks them

up and carries them to the Quiet Room, as he did

that morning with patient D1. When asked

whether an order is required to carry a patient to

the Quiet Room, MHT2 stated "no." When asked

whether he (MHT2) had documented the physical

restraint of patient D1 or his restriction to the

Quiet Room, MHT2 said he had not done so.

c. In an interview on 11/16/11 at 11:30 a.m., the

Medical Director acknowledged that the medical

record of patient D1 did not contain any physician

orders, staff documentation of interventions used,

Behavioral Emergency Evaluations, or face to

face evaluations pertaining to the seclusion and

restraint episode.

C. Patient D2

1. Observations

a. On 11/15/11 at 2 p.m., patient D2 was

observed to be yelling, running in the hall, and


on the unit and began to walk patient D2 to the

Quiet Room, using his body to push the patient

and his outstretched arms to deflect the patient's

blows. Patient D2 struck the Director repeatedly

and attempted to bite him and push past him. The

Director of Social Work used his body to push the

patient into the Quiet Room alone as several

staff, including charge RN3, observed. Patient D2

was kept in the Quiet Room by the Director until

s/he (D2) was calm (approximately five minutes).

Despite RN3's and several MHTs' observations of

the incident, no staff intervened to assist the


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Director of Social Work with the physical

management (restraint) of Patient D2.

2. Interviews

a. In a telephone interview on 11/15/11 at 1:45

p.m., Social Worker SW1 stated that on 11/13/11,

patient D2 hit her during her group. She stated

that she then picked the patient up and carried

him/her out of the room into the hall, where she

gave him/her to RN4 and MHT3. SW1 stated that

RN4 and MHT3 took patient D2 to the Quiet

Room, and she (SW1) returned to her group.

SW1 stated that the next day (11/14/11), patient

D2 became aggressive in her group, and she and

MHT3 had to physically restrain him/her (D2) to

keep him/her from striking a peer. SW1 was

asked whether she documented either of these

incidents, both of which required physical restraint

and/or seclusion. SW1 stated she did not do this.


charge nurse RN3 acknowledged that patient D2

had been physically restrained twice on 11/15/11

-- once in the morning around 9:30 a.m. and once

in the afternoon at 2 p.m. (the event observed by

the surveyors). RN3 stated that the patient had

been physically restrained and taken to the Quiet

Room and held there by staff until calm. RN3

stated that these two incidents did not constitute

a restraint or seclusion because they did not

continue for over five minutes. RN3 stated she

did not seek an order for seclusion or restraint for

these incidents because they were brief. She also

did not complete a Behavioral Emergency

Evaluation for either incident.

c. In an interview with MHT1 on 11/15/11 at 2:30


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p.m., MHT1 stated that patient D2 became

aggressive that morning and urinated on the day

room floor at 9:30 a.m. MHT1 said that patient D2

stripped off his/her clothes and began to spit at

staff. MHT1 stated that he took patient D2 to the

Quiet Room, using his hands on the patient's

shoulders. MHT1 stated that he kept patient D2 in

the Quiet Room from 9:30 a.m. to 9:58 a.m. He

said that patient D2 tried to push past him in the

doorway 4 or 5 times, requiring MHT1 to block

(D2) with his body or use a physical hold. MHT1

stated that RN3 released patient D2 from the

Quiet Room once during that period (9:30 a.m. to

9:58 a.m.), but that patient D2 immediately

became aggressive, and that he (MHT1) had to

return D2 to the Quiet Room by holding the

patient's arm. MHT1 was asked whether it was

normal practice to carry child patients to the Quiet

Room. MHT1 stated that occasionally, patients

will drop to the floor in defiance and that if this

occurs, he (MHT1) will pick them up and carry

them. MHT1 was asked whether he had

documented the types of physical restraints he

had employed in this morning's (11/15/11)

incident which involved patient D2; he said he

had not done the documentations.

d. In an interview on 11/15/11 at 3:30 p.m., the

surveyors asked the Assistant Director to review

the chart of patient D2. SW1 had reported to the

surveyors by phone on 11/15/2011 at 1:45 p.m.

that she had physically held patient D2 on

11/13/2011, and again on 11/14/2011. The

Assistant Director was asked if she could find any

order, documentation, Behavioral Emergency

Evaluation, or face to face assessment of the

incidents. The Assistant Director acknowledged

there was none of this documentation on the


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chart for either incident.

e. In an interview on 11/15/11 at 4:10 p.m., the

Director of Social Work was asked to review the

chart of patient D2 regarding the physical

restraint which the Director had conducted two

hours earlier. The chart contained no

documentation of the incident. There was no

physician order for the restraint or seclusion. A

Behavioral Emergency Evaluation had not been

completed. No face-to-face evaluation had been

done or documented. The Director stated that he

did not consider the episode serious or that it

needed to be documented because he (the

Director) was able to block the patient's blows,

and the patient bit only his (the Director's ) shirt,

not his flesh. The Director of Social Work was

asked to review patient D2's medical record to

see if there was any documentation of the

physical restraints on 11/13/11 and 11/14/11 that

SW1 reported (by phone) on 11/15/11 at 1:45

p.m. The Director acknowledged that there was

no documentation of the incidents, nor was there

a physician's order for the restraint or a

Behavioral Emergency Evaluation.

f. In an interview on 11/16/11 at 10:50 a.m., RN2

acknowledged that there was no order in the

medical record for the two incidents of physical

restraint involving patient D2 on 11/15/11, nor

were the Behavioral Emergency Evaluations

completed. RN2 also acknowledged that no

face-to-face assessments were completed after

the two episodes on 11/15/11. RN2 stated that

she does not usually call for an order or complete

a Behavioral Emergency Evaluation when

patients are taken to the Quiet Room by staff.


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g. In an interview on 11/16/11 at 1:10 p.m.,


hospital five days and had been physically

restrained, carried, and put in the Quiet Room "a

lot." Patient D2 stated that s/he often felt angry

and would "go off over nothing." No orders for

restraint or seclusion were found in the chart of

patient D2, nor were any Behavioral Emergency

Evaluations completed since admission.

h. In an interview with the Director of Social Work

on 11/17/11 at 9:50 a.m., the surveyors again

reviewed the chart of patient D2 whom the

Director had physically restrained on 11/15/2011.

The Director of Social Work stated that in

hindsight, the incident was a restraint because he

needed to hold the patient to control him/her in

the Quiet Room. The Director stated that he

should have called a Code White (Behavioral

Emergency Code) to summon a nursing

supervisor to the unit and obtain a restraint order

from a physician. The Director was asked why he

would have needed to make that call since he

was involved in managing the patient while the

unit RN3 and several MHTs were observing. The

Director responded that RN3 or one of the MHTs

could have called the Code White. The Director

of Social Work was asked whether he

documented the physical restraint on patient D2's

chart; he replied that he had not done so. The

Director noted that he felt the incident was not

that serious because the patient's blows did not

connect and the patient only managed to bite his

shirt. The Director stated that he did not ask other

staff to assist in taking the patient to the Quiet

Room because "(patient D2) was not a threat."

i. In an interview with the Assistant Director on


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involved in multiple physical restraints and Quiet




11/11/2011.

2. Record Review

A review of patient D2's medical record on

11/16/11 at 2:30 p.m. revealed no staff notes that

documented the 11/15/11 2:30 p.m. restraint

incident noted above. There also were no

physician orders, Behavioral Emergency

Evaluations, or face-to-face evaluations for

seclusion/restraint.

D. Patient D6

In an interview on 11/16/11 at 12:30 p.m., patient

D6 stated that s/he was taken to the Quiet Room

on 11/15/11. When patient D6 was asked if s/he

could leave the Quiet Room, s/he stated s/he

could not because if s/he did, "they take you back

and double your time." No order or

documentation was evident on the chart of patient

D6 for a restriction to the Quiet Room on

11/15/11.

E. Discharged Patient D7

1. Interviews


p.m., Social Worker 1 reported that Patient D7

was acting out on 11/13/2011 and required the


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use physical hold/restraints to manage his/her

behavior. Social Worker 1 reported that a Code

White (Behavioral Emergency Code) was called

and that other staff helped to manage D7's

behavior. A physical hold was used without a

physician order, face-to-face assessment,

physical assessment, or documentation for

restraint use.

b. In an interview on 11/15/11 at 3:30 p.m., the

surveyors asked the Assistant Director to review

the medical record of patient D7 to locate any

order, documentation, Behavioral Emergency

Evaluation, or face-to-face assessment for the

11/13/11 restraint incident. The Assistant Director

acknowledged there was none of this

documentation in the medical record.

c. In an interview on 11/16/11 at 3:30 p.m. with

the CEO, the Director of Nursing, and the Director

of Programming, the CEO stated that hospital

leaders had contacted staff involved in a restraint

episode of patient D7 on 11/13/11. The CEO

stated "we have a problem" because they had

discovered that patient D7 had been restrained

on 11/13/11 and that staff failed to obtain a

physician's order, complete a Behavioral

Emergency Evaluation, or conduct a one hour

face to face assessment. The CEO stated

hospital leaders had spoken with MHT4 and the

supervisor RN5 who had conducted the restraint.

The CEO stated that confusion exists on the part

of nursing staff regarding the use of seclusion

and restraint, which he attributed to the lack of

implementation of training by the former DON

whom he terminated on 11/14/2011. The CEO

stated staff was not sure which regulations they

should follow and stated that hospital leaders had


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determined that the entire staff needed to be

retrained once policies were clarified.

d. In an interview on 11/17/11 at 10 a.m., RN5

reported that she responded to the Code White

involving Patient D7 on 11/13/2011. She stated

that D7 was hysterical, upset, yelling screaming,

and that he/she had hit his/her head. RN5 said

that the patient went to his/her room "by the

request of RN5 and RN6," and while in his/her

room, he/she "hyperventilated, was kicking, and

banged his head against the wall." RN5 reported

that she and RN6 tried to verbally de-escalate the

patient, but that they had to physically restrain the

patient by "grabbing his/her arms and legs when

s/he was kicking and swinging." The staff held the

patient's legs down so s/he could not kick. When

RN5 was asked how many times D7 banged

his/her head, she stated, "at least 3 times,

against the wall, closet door, and window." When

asked how long this incident took to manage,

RN5 stated that it "went on for about 40 minutes."

RN5 was asked why the staff did not use

mechanical restraints. RN5 replied, "That is our

last resort." When asked about an incident report

regarding the patient banging his head, RN5

stated, "No incident report was completed." When

asked about the documentation for the use of

seclusion and restraint, RN5 replied, "There has

been confusion with the procedure and with the

Texas and Federal laws, so we did not consider

this a restraint or seclusion." When RN5 was

asked about revisions on the treatment plan, she

stated, "There were none."

2. Record Review

a. The medical record for D7 showed that the


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patient was admitted on 11/11/2011. A progress

note entry on 11/13/11 at 4 p.m. by RN6 stated,

"Patient had visitation with his mother and father

on the unit. (D7) wanted to go home with (D7's)

parents. When dad said no, (D7) started kicking,

hitting, banging on the wall and glass windows,

throwing self on the floor, cursing staff, and using

foul language. (D7) attempted to jump over the

nurse's station and get access to the door without

any luck. Patients [sic] were notified and code

white called. Patient remains ouvr [sic]. Will

continue to monitor."

b. There were no notes in Patient D7's medical

record that described physical restraints or

seclusion, nor were there any Behavioral

Emergency Evaluations. There were no physician

orders for seclusion or restraints. There was no

description of the length of time this incident took

to manage. There were no revisions to the

treatment plan. There were no notes of a physical

assessment being completed, even after D7

banged his/her head three times against the wall,

closet door, and window.

F. Patient C3

1. Observations

On 11/15/11 at 3:30 p.m., an interview being

conducted with the DON on the adolescent unit

was interrupted by a patient yelling. The DON

responded to the incident. During the surveyor's

observation, the DON and another staff were

holding onto the adolescent patient's arms and

guiding him/her up and down the hallways. This

lasted about 15 minutes.


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2. Interviews

a. In an interview on 11/16/11 at 10 a.m., Patient

C3 reported that s/he has been confined to a

specific area like his/her room and not allowed to

come out for a specific time set by the staff.

When asked what would happen if s/he comes

out of the room, s/he stated, "The time starts

over."

b. In an interview on 11/16/11 at 10:30 a.m., RN1

stated that Patient C3 had an altercation with

another patient at the end of night shift (the

previous night). When asked what happened,

RN1 stated that he received a report that C3 had

hit another patient. When asked if there had been

a physical hold for patient C3, RN1 stated that in

the shift report, staff reported that the patients

had to be separated. The surveyor and RN1

reviewed a progress note in Patient C3's medical

record dated and timed 11/16/11 at 6:50 a.m.

which described the reported incident. RN1

stated, "not a good note."


surveyors asked the DON why she had not

documented her physical hold of adolescent

patient C3 during the incident on 11/15/11 (3:30

p.m.) The DON stated that there was significant

confusion on the part of all staff regarding what

constitutes a restraint or seclusion. The DON

stated that she felt the previous DON, who had

been in charge of training nursing staff, gave

inaccurate information to staff, and at times

withheld information from staff, until her

termination on 11/14/2011. When asked about

the RN who documented the incident on

11/15/11, the DON stated, "She is not a privileged


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RN." The DON explained that the nursing

supervisors are the only RNs trained to do the

face-to-face assessment and they are the "clinical

privileged RNs."

3. Record Review

a. The progress notes in Patient C3's medical

record were reviewed. A note by an RN

documented: "Patient pacing, agitated

(yelling/cursing) and removed from group. In

hallway patient threatens staff and clench's fist at

(C3's) sides. A tech holds (C3's) arms to prevent

patient from harming self or others. Tech, after 30

seconds, removes his hands and patient goes to

(C3's) room crying hyperventilating and holding

face in hands (and saying) 'I wanna leave this

place.' Patient has no distress/injuries from

having (C3's) arms held at sides. Patient given

his 1600 (4 p.m.) dose of Thorazine 25 mg PO

and is currently talking with staff calmly in his

room. Safety maintained q 15 min rounding by

staff."

b. Review of Patient C3's medical record revealed

that an assessment for a restraint incident was

documented by an RN who was not qualified to

complete the face-to-face per the hospital policy

No. 760.300.18 dated 10/11. The Policy states,

"Personal Restraint used less than five (5)

minutes is subject to evaluation by a CPRN

(clinically Privileged Registered Nurse). Personal

Restraint used for six (6) minutes or more and all

mechanical restraints are subject to evaluation by

a physician."

c. There were no Behavioral Emergency

Evaluations in Patient C3's medical record, nor


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were there any physician orders for seclusion or

restraint. There was no description of the length

of time the incident on 11/15/11 took to manage.

There were no revisions to the treatment plan.

G. Additional Interviews

a. In an interview on 11/16/11 at 9:20 a.m., the

DON stated that she was not yet familiar with the

hospital's policies because she was appointed

DON two days ago. The DON stated that during

the preceding year, she had been a supervisor on

the children's unit. The DON was asked whether

physical holds that lasted less than five minutes

were physical restraints, which required a

physician's order, a Behavioral Emergency

Evaluation, and a face-to-face assessment. The

DON stated that such incidents were not

considered restraint. When asked what directions

staff had been given in recent training on

seclusion and restraint. The DON stated she was

not certain because the former DON had

conducted the training and was terminated two

days ago (on 11/14/2011).

b. In an interview on 11/16/11 at 10 a.m., the

attending psychiatrist on the children's unit, MD1,

was asked to review the physical holds of patients

D5 and D1 on 11/15/11. MD1 acknowledged that

the progress notes did not contain any description

of the physical restraint methods used in these

incidents. MD1 stated that seclusion and restraint

is conducted by nursing, and that nursing staff is

in a better position to answer questions about it.

MD1 also acknowledged he did not give an order

for the restraint or seclusion of patients D2 or D5

on 11/15/2011.


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Medical Director told the surveyors that in an

attempt to reduce the use of chemical restraints,

the hospital had instructed staff to make greater

use of physical and mechanical restraints. The

Medical Director stated that the use of chemical

restraints had decreased, but acknowledged that

the hospital has not been monitoring the increase

in physical restraints. Code Whites, which

summon staff for physical holds, are not logged

or reported to him. The Medical Director

acknowledged that the medical records of

patients D1 and D5 did not contain any physician




restraint episodes of 11/15/11.

d. In an interview with the hospital CEO and

Medical Director on 11/16/11 at 11:45 a.m., the

CEO told the surveyors that he recently became

aware that the hospital's former Director of

Nursing was not implementing the recent training

on seclusion and restraint which hospital leaders

had conducted. The CEO stated that the former

DON was not training the staff as s/he had been

directed, and so the CEO terminated the DON on

11/14/11. The CEO stated that the hospital had

not achieved its goal of implementing the recently

conducted training on seclusion and restraint.

e. In an interview on 11/16/11 at 12:20 p.m.,

sample patient D10 stated s/he had been

admitted for aggression. When asked whether

s/he had been physically restrained during his/her

hospital stay, D10 stated s/he had not but that

"lots of kids" do get restrained or carried. Patient

D10 stated that in the last two days, patients D1,


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D2, D6 and D5 had gotten carried or put in the

Quiet Room.

H. Document Review

1. Hospital policy 760.300.18 titled Restraint and

Seclusion (Rev 10/11) states:

Page 1: "Clinical Timeout - a procedure in which

a patient, in voluntary response to verbal direction

from staff, cooperatively enters and remains in a

designated area from which egress is not

blocked."

Page 2: "Types of Restraint: Personal Restraint:

The application of physical force that restricts the

free movement of the whole, or a portion of an

[sic] patient's body in order to control physical

activity."

Page 2, 1b: "Staff may not use any physical

contact or personal restraint to direct the patient

to a clinical timeout area."

Page 2, 1g: "The patient may terminate a clinical

timeout any time."

Page 3: "Principles, #8: The treatment plan shall

be reviewed and revised to establish alternative

strategies for dealing with behaviors necessitating

the use of seclusion and restraint."

Page 3: "Principles, and #10: All physical contact

is subject to the reporting and monitoring

requirements of seclusion and restraint."

Page 6: "Documentation... #1: Initiate and

complete the Behavioral Emergency paperwork."

2. Hospital form titled "Behavioral Emergency

Evaluation" (undated)

The hospital requires a 7 page purple form titled

"Behavioral Emergency Evaluation" to be

completed in case of seclusion or restraint. This


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form was not completed for any of the seclusion

and restraint incidents involving patients D1, D2,

D5, D6, D7 or C3 cited in this report. The form

does not require or provide a place for staff to

describe types of holds, carries, or physical

measures that were involved in the seclusion or

restraint episodes.

3. Texas Administrative Code (contained in the

hospitals seclusion and restraint training packet)

"Title 25, Rule 415.291: Clinical Timeout and

Quiet Time ...1) Clinical Timeout ...e) Staff may

not use physical force or personal restraint to

direct the individual to a clinical timeout area. To

force or coerce the individual constitutes restraint

and/or seclusion and renders the procedure

subject to the requirements for restraint or

seclusion described in this subchapter."

4. The hospital's training program titled

"Prevention and Intervention of Aggressive

Behavior," defines "clinical time out" as: "A

procedure in which an individual, in voluntary

response to a verbal direction from staff,

cooperatively enters into and remains in a

designated area from which egress is not blocked

for a period of time not to exceed 30 minutes

without specific joint determination by the

individual and staff of the need for continuation.

B 147 482.62(d)(1) NURSING SERVICES

The director of psychiatric nursing services must

be a registered nurse who has a master's degree

in psychiatric or mental health nursing or its

equivalent from a school of nursing accredited by

the National League for Nursing, or be qualified

by education and experience in the care of the

B 147


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mentally ill.


Based on document review and interview, it was

determined that the interim Director of Nursing

(current acting DON) is not qualified for the DON

role on a psychiatric unit. She does not have a

master's degree in psychiatric mental health

nursing or sufficient education and experience in

the care of mentally ill patients to provide

leadership to nursing staff. Failure of the facility to

employ a qualified DON results in lack of

adequate supervision and oversight of nursing

services.

Findings include:

A. Document Review

1. Review of the interim DON's application for

employment and resume revealed no evidence of

qualifications of psychiatric nursing training.

There was no evidence of continuing education or

training in the care of psychiatric patients across

the life span, specifically child and adolescent

patients.

B. Interviews

1. In an interview with the hospital CEO and

Medical Director on 11/16/11 at 11:45 a.m., the

CEO told the surveyors that he recently became

aware that the hospital's former Director of

Nursing was not implementing the required

training on seclusion and restraint, so he

terminated the (former) DON on 11/14/11. The

CEO reported that the current DON is the interim


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DON until he is able to recruit a qualified DON.

He acknowledged that the current DON's

qualifications do not include a master degree

and/or psychiatric nursing experience.

2. In an interview on 11/16/2011 at 2:30 p.m.,

Physician 2 stated that there is a lack of trained

staff on how to work with psychiatric patients, and

that is the reason there is a lack of consistency

on how to manage psychiatric patients on all

three shifts.

3. In an interview on 11/17/11 at 9:45 a.m., the

current (interim) DON reported that she was a

nursing supervisor prior to her appointment as the

interim DON. She reported she has a 2 year

Associate Degree in Nursing. She reported that

she is not familiar with several of the policies and

procedures. The DON was not aware of the role

of a master prepared psychiatric nurse

consultant, and she stated that there was

significant confusion on the part of all staff,

including herself, regarding what does or does

not constitute a restraint or seclusion event. The

DON was not able to explain or describe the

procedure for seclusion and restraint, and not

able to demonstrate how she would guide and

direct nursing staff to safely use seclusion and

restraint.

B 148 482.62(d)(1) NURSING SERVICES

The director must demonstrate competence to

participate in interdisciplinary formulation of

individual treatment plans; to give skilled nursing

care and therapy; and to direct, monitor, and

evaluate the nursing care furnished.

B 148


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Based on observations, interviews, and records

and documents review, the Director of Nursing

failed to ensure that staff safely employed

seclusion and restraint. There was no required

physicians' order, documentation, or patient

assessment seclusion and/or restraint employed

for 1 sample child patient (D5), 4 child patients

added to the sample (D1, D2, D6 and D7), and

one adolescent patient added to the sample (C3).

Staff involved in physical restraints did not obtain

orders, record the incidents in progress notes, or

describe the methods they used to physically

restrain the child and adolescent patients. Face to

face evaluations were not conducted or

documented following the physical restraint

episodes. The child and adolescent patients also

were restricted to the quiet room or bedroom

(seclusion) without physician orders,

documentations, or face-to-face evaluation

following the seclusion. The hospital has a seven

page Behavioral Emergency Evaluation Form that

is supposed to be completed for all seclusion and

restraint incidents. No Behavioral Emergency

Evaluations were completed for any of the S/R

incidents involving the six child and adolescent

patients. The Master Treatment Plans of patients

repeatedly subjected to seclusion and restraint

also were not updated to reflect changes in

interventions or treatment techniques. Failure to

safely employ seclusion and restraint exposes


potential for harm, and jeopardizes patients' right

to safe treatment.

Findings include:

A. Patient D5


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room (QR) "a couple of times." Patient D5 was

asked if staff held or carried him/her to the QR

and s/he said "yes." Patient D5 rolled up the right

shirtsleeve of his/her t-shirt to show a small red

scratch on the right bicep and said, "I got this

when (staff name) grabbed me." Patient D5

stated s/he was taken to his bedroom and told to

lie down on the bed. Patient D5 stated that when

s/he tried to get up, (staff name) pushed his/her

chest back down on the bed and told him/her to

not get up. Patient D5 was asked when this had

happened. S/he stated "not today, not yesterday,

before." When asked when was the last time s/he

was put in the Quiet Room and could not leave,

Patient D5 stated that it was the morning of this

interview (11/15/11). Patient D5 was asked

whether s/he was allowed to leave the QR or

his/her bedroom once was taken there. S/he said

"no, or your time starts over."


Mental Health Tech 1 stated that patient D5 had


that morning. MHT1 stated that he (MHT1) had to

place his hands on D5's shoulders to get him/her

to the Quiet Room. Once there, MHT1 stated that

patient D5 tried to push past him several times as

he (MHT1) blocked the door with his body. MHT1

stated he did not document this physical restraint

in the patient's record. MHT1 stated he did not

document patient D5's restriction to the Quiet

Room because he did not think these episodes


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were restraint or seclusion.


children's unit charge nurse RN3 stated that

patient D5 had been physically held and taken to

the Quiet Room that morning, and kept in the

Quiet Room by staff. RN3 acknowledged that she

did not document this as physical restraint or

seclusion. RN3 stated she did not seek a

physician's order for the physical restraint or

seclusion, and that she did not assess patient D5

after the incident. RN3 stated that she was a

"prn" employee who seldom works with children

but usually does home health care with adults.

When RN3 was asked whether she had received

training on the management of child psychiatric

patients, she replied, "not much." RN3 stated she

seldom works on the children's unit when she is

called to work at this hospital. RN3 stated that

she did not consider that morning's incidents to

be seclusion or restraint because they were brief

and done to avoid injury.

d. In an interview with the Assistant Director on

11/17/11 at 10:40 a.m. ., the Master Treatment


been updated to reflect the fact that patient D5

had been involved in multiple episodes of

physical restraint and Quiet Room restrictions.

The Assistant Director acknowledged that the

treatment plan had not been updated since

patient D5's admission on 11/11/2011.

2. Record Review

The medical record of patient D5 was reviewed.

There were no progress notes since D5's

11/11/11 admission that described physical


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restraints or seclusion. There were no Behavioral

Emergency Evaluations present in the record.

There also were no physician orders for seclusion

or restraint since admission.

B. Patient D1

1. Interviews


patient D1 stated that s/he was carried to the

Quiet Room by MHT2 earlier that day. Patient D1

said that s/he asked to come out of the room a

couple of times and was told "not yet."


MHT2 was asked if patient D1 had been

physically restrained earlier that day. MHT2

stated that while escorting patient D1 to the Quiet

Room earlier that day, patient D1 dropped to the

floor and would not get up. MHT2 stated that

when patients drop to the floor, he (MHT2) picks

them up and carries them to the Quiet Room, as

he did that morning with patient D1. When asked

whether an order is required to carry a patient to

the Quiet Room, MHT2 stated "no." When asked

whether he had documented his physical restraint

of patient D1 or the patient's restriction to the

Quiet Room (seclusion), MHT2 said he had not

done this.

c. The Medical Director acknowledged that the

charts of patient D1 did not contain any physician




restraint episodes of 11/15/11.


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2. Record Review

a. Review of the medical record for patient D1

revealed no physician's order for seclusion or

restraint, no Behavioral Emergency Evaluation,

no progress note, and no face-to-face

assessment.

C. Patient D2

1, Observations

a. On 11/15/11 at 2 p.m., patient D2 was

observed to be yelling, running the hall, and


on the unit and began to walk patient D2 to the

Quiet Room using his body to push the patient,

and his outstretched arms to deflect the patient's

blows. Patient D2 struck the Director of Social

Work repeatedly and attempted to bite him and

push past him. The Director used his body to

push the patient into the Quiet Room alone as

several staff, including charge RN3, observed the

event. Patient D2 was kept in the Quiet Room by

the Director of Social Work until calm

(approximately five minutes). Despite RN3 and

several MHTs observation of the incident, no staff

intervened to assist the Director of Social Work

with the physical restraint or seclusion of patient

D2.

2. Interviews


p.m., Social Worker1 stated that on 11/13/11,

patient D2 hit her during her group and that she

picked the patient up and carried him/her out of

the room into the hall, where she gave him/her to


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RN4 and MHT3. SW1 stated that RN4 and

MHT3 took patient D2 to the Quiet Room and she

returned to her group. SW1 stated that the next

day (11/14/11), patient D2 became aggressive in

her group, and she and MHT3 had to physically

restrain (D2) to keep him/her from striking a peer.

b. In an interview on 11/15/11 at 2:10 p.m., RN3

stated that patient D2 had been physically

restrained twice on 11/15/11: once in the morning

around 9:30 a.m. and once in the afternoon at 2

p.m. (the incident that the surveyors observed).

RN3 stated that the patient had been physically

restrained and taken to the Quiet Room and held

there by staff until calm. RN3 stated that these

two incidents were not considered restraint or

seclusion because they did not continue for over

five minutes. RN3 also stated that she did not

seek an order for seclusion or restraint for these

incidents or complete a Behavioral Emergency

Evaluation.

c. In an interview on 11/15/11 at 2:30 p.m., MHT1

stated that patient D2 became aggressive that

morning and urinated on the day room floor at

9:30 a.m. Patient D2 stripped off his/her clothes

and began to spit at staff. MHT1 stated that he

took patient D2 to the Quiet Room using his

(MHT1's) hands on the patient's shoulders. MHT1

stated that he kept patient D2 in the Quiet Room

from 9:30 a.m. to 9:58 a.m., and that patient D2

tried to push past him in the doorway 4 or 5

times, requiring MHT1 to block the patient with

his own body or hold him/her. MHT1 stated that

RN3 released patient D2 from the Quiet Room

once during that period (9:30 a.m. to 9:58 a.m.),

but that patient D2 immediately became

aggressive and had to be returned to the Quiet


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Room by holding his/her arm. When asked

whether it was normal practice to carry child

patients to the Quiet Room, MHT1 stated that

occasionally, patients will drop to the floor in

defiance, and that when this occurs, he (MHT1)

picks the patient up and carries him/her. MHT1

was asked whether he had documented the types

of physical restraints he had employed in the

incident this morning (11/15/11) with patient D2;

he replied that he had not done so.

d. In an interview on 11/15/11 at 4:10 p.m., the

Director of Social Work was asked to review the

medical record of patient D2 regarding the

physical restraint which the Director had

conducted two hours earlier. The record

contained no documentation of the incident.

There was no order for the restraint or seclusion.

A Behavioral Emergency Evaluation had not been

completed. No face-to-face evaluation had been

done or documented. The Director stated that he

did not consider the episode serious or that it

needed documentation because he was able to

block the patient's blows and the patient bit only

his shirt and not his flesh.

e. In an interview on 11/16/11 at 10:50 a.m., RN2

acknowledged that there was no physician's order

in patient D2's medical record for the two

incidents of physical restraint on 11/15/11, nor

were the Behavioral Emergency Evaluations

completed. RN2 also acknowledged that no

face-to-face assessments were completed. RN2

stated that she does not usually call for an order

or complete a Behavioral Emergency Evaluation

when patients are taken to the Quiet Room by

staff.


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f. In an interview on 11/16/11 at 1:10 p.m., patient

D2 stated that s/he had been in the hospital five

days and had been physically restrained, carried,

and put in the Quiet Room "a lot." Patient D2

stated that s/he often felt angry and would "go off

over nothing."

g. In an interview with the Assistant Director on




involved in multiple physical restraints and Quiet




11/11/2011.

2. Record review

A record review on 11/16/11 at 2:30 p.m. showed

no documentation of the 11/15/11

seclusion/restraint incident that involved patient

D2. Further review of the patient's record found

no orders for restraint or seclusion, nor was there

any evidence that a Behavioral Emergency

Evaluation had been completed since admission.

C. Patient D6

1. Interviews


patient D6 stated s/he was taken to the Quiet

Room on 11/15/11. When patient D6 was asked if

s/he could leave the Quiet Room, s/he stated

s/he could not because if s/he did, "they take you

back and double your time."


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2. Record review

Review of the medical record of patient D6

revealed no physician's order or documentation

regarding the patient-reported seclusion/restraint

on 11/15/11.

E. Discharged Patient D7

1. Interviews

a. During a telephone interview on 11/15/2011 at

1:45 p.m., Social Worker 1 reported that D7 was

acting out on 11/13/2011 and required the use

physical hold/restraints to manage his/her

behavior. Social Worker1 reported that a Code

White was called and other staff helped to

manage D7's behavior. According to the report, a

physical hold was used without a physician order,

face-to-face assessment, physical assessment,

or documentation for restraint use.

b. In an interview on 11/17/2011 at 10 a.m., RN5

reported that she responded to the Code White

involving D7 on 11/13/2011. She said that she

was a trained "Privileged RN." RN5 stated that D7

was hysterical, upset, yelling screaming and hit

his/her head. The patient went to his/her room "by

the request of RN5 and RN6." RN5 stated that

when the patient was in his/her room, s/he

hyperventilated and was kicking, and that s/he

banged his/her head against the wall." According

to RN5, she and RN6 were trying to verbally

de-escalate the patient, but that they had to

physically restrain the patient by grabbing his/her

arms and legs when s/he was kicking and

swinging. The staff held the patient's legs down

so that s/he could not kick. When RN5 was asked


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how many times D7 banged his/her head, RN5

stated, "at least 3 times, against the wall, closet

door, and window." When asked how long this

incident took to manage, RN5 stated that it "went

on for about 40 minutes." RN5 was asked why

the nursing staff did not use mechanical

restraints. RN5 stated. "That's our last resort."

When asked about an incident report regarding

the patient banging his head, RN5 stated, "No

incident report was completed." When asked

about documentation of the seclusion/restraint,

RN5 replied, "There has been confusion with the

procedure and with the Texas and Federal laws,

so we did not consider this a restraint or

seclusion." When asked about the revisions to

the treatment plan, RN5 stated, "There were

none."

c. In an interview with the Assistant Director on

11/15/11 at 3:30 p.m., the surveyors asked to

review the chart of patient D7 to see if there was

any order, documentation, Behavioral Emergency

Evaluation, or face-to-face assessment after the

restraint incidents of 11/13/11. The Assistant

Director acknowledged there was none of this

documentation on the chart.

d. In an interview with the CEO, the Director of

Nursing, and the Director of Programming on

11/16/11 at 3:30 p.m., the CEO stated that

hospital leaders had contacted staff involved in

the restraint episode of patient D7 on 11/13/11.

The CEO stated "we have a problem" because

they had discovered that patient D7 had been

restrained on 11/13/11 and staff failed to obtain a

physician's order, complete a Behavioral

Emergency Evaluation, or conduct a one hour

face to face assessment. The CEO stated


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hospital leaders had spoken with MHT4 and the

supervisor RN5 who had conducted the restraint.

The CEO stated that confusion exists on the part

of nursing staff regarding the use of seclusion

and restraint; he attributed this to the lack of

implementation of training by the former DON

whom he terminated on 11/14/2011. The CEO

stated staff was not sure which regulations they

should follow. He stated that hospital leaders had

determined that the entire staff needed to be

retrained once policies were clarified.

2. Record Review

a. The medical record for D7 was reviewed. D7

was admitted on 11/11/2011. A progress note on

11/13/11 at 4 p.m. by RN6 stated, "Patient had

visitation with (D7's) mother and father on the

unit...wanted to go home with (D7's) parents.

When dad said no, s/he started kicking, hitting,

banging on the wall and glass windows, throwing

self on the floor, cursing staff, and using foul

language. S/he attempted to jump over the

nurse's station and the get access to the door

without any luck. Patients [sic] dad left the unit

and the patient become increasingly irritable and

out of control. NAM [sic] and MD were notified

and code white called. Patient remains ouvr [sic].

Will continue to monitor."

b. Further review of D7's medical record revealed

no notes that described physical restraints or

seclusion. There were no Behavioral Emergency

Evaluations or physician orders for seclusion or

restraints. There was no description of the length

of time the restraint incident took to manage.

There also were no revisions to the treatment

plan. There were no notes of a physical


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assessment being completed even after D7

banged his head three times against the wall,

closet door, and window.

F. Patient C3

1. Observations

An interview being conducted with the DON on

11/15/11 at 3:30 p.m. with the DON on the

adolescent unit was interrupted because of a

patient yelling. The DON responded to the

incident. During the surveyor's observation, the

DON and another staff were holding onto the

patient's arms and guiding him/her up and down

the hallways. This lasted about 15 minutes.

2. Interviews

a. In an Interview on 11/16/11 at 10 a.m., Patient

C3 reported that s/he has been confined to a

specific area like his/her room and not able to

come out for a specific time that is set by the

staff. When asked what happens if s/he comes

out, s/he stated, "The time starts over."

b. In an interview on 11/16/11 at 10:30 a.m. RN1

stated that C3 had an altercation with another

patient at the end of night shift. When asked what

happen, RN1 stated that he had received a report

that C3 had hit another patient. When asked if the

patient had been put in a physical hold, RN1

stated that in the shift report, staff said the

patients had to be separated. The surveyor and

RN1 reviewed a progress note in the patient's

medical record dated and timed at 11/16/11 at

6:50 a.m. which noted the incident. RN1

commented, "not a good note."


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surveyors asked the DON why she had not

documented her physical hold of adolescent

patient C3 during the incident on 11/15/11 at 3:30

p.m. The DON stated that there was significant

confusion on the part of all staff about what

constitutes a restraint or seclusion. The DON

stated that she felt the previous DON, who had

been in charge of training nursing staff, gave

inaccurate information to staff, and at times,

withheld information from staff, until her

termination on 11/14/2011. When queried about

the RN who documented the incident on

11/15/11, the DON stated, "She is not a privileged

RN." The DON explained that the nursing

supervisors were the only RNs trained to do the

face-to-face assessment and they are the "clinical

privileged RNs" The DON also confirmed that

there was not a revision to the treatment plan

based on the restraint incident.

3. Record Review

a. The progress notes for Patient C3 were

reviewed for the description regarding the

incident of 11/15/11. An RN note documented:

"Patient pacing, agitated (yelling/cursing) and

removed from group. In hallway patient threatens

staff and clench's fist at (his/her) sides. A tech

holds (his/her) arms to prevent patient from

harming self or others. Tech, after 30 seconds,

removes his hands and patient goes to his room

crying hyperventilating, and holding face in hands

(and saying) 'I wanna leave this place.' Patient

has no distress/injuries from having arms held at

sides. Patient given (his/her) 1600 (4 p.m.) dose

of Thorazine 25 mg PO and is currently talking


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with staff calmly in (his/her) room. Safety

maintained q 15 min rounding by staff."

b. The assessment for Patient C3's restraint

incident was documented by an RN who is not

qualified to complete the face-to-face per the

hospital policy No. 760.300.18 dated 10/11. The

policy states "Personal Restraint used less than

five (5) minutes is subject to evaluation by a

CPRN (clinically Privileged Registered Nurse).

Personal Restraint used for six (6) minutes or

more and all mechanical restraints are subject to

evaluation by a physician."

c. Further review of the medical record revealed

no Behavioral Emergency Evaluations or

physician orders for seclusion or restraint. There

was no description of the length of time the

restraint incident on 11/15/11 took to manage.

There were revisions to the treatment plan.

G. Additional Interview

In an interview with on 11/16/11 at 9:20 a.m., the

DON was asked whether physical holds that

lasted less than five minutes were physical

restraint which required a physician's order, a

Behavioral Emergency Evaluation, and a

face-to-face assessment. The DON stated that

such incidents are not restraint. The DON was

asked what directions staff had been give in

recent training on seclusion and restraint. She

stated that she was not certain because the

former DON had conducted the training and was

terminated two days ago on 11/14/2011.

H. Document Review


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1. Hospital Policy

Hospital policy 760.300.18 titled Restraint and

Seclusion (Rev 10/11) states:

Page 1: "Clinical Timeout - a procedure in which

a patient, in voluntary response to verbal direction

from staff, cooperatively enters and remains in a

designated area from which egress is not

blocked."

Page 2: "Types of Restraint...Personal Restraint:

The application of physical force that restricts the

free movement of the whole, or a portion of an

[sic] patient's body in order to control physical

activity."

Page 2, 1b: "Staff may not use any physical

contact or personal restraint to direct the patient

to a clinical timeout area."

Page 2, 1g: "The patient may terminate a clinical

timeout any time."

Page 3: "Principles, #8: The treatment plan shall

be reviewed and revised to establish alternative

strategies for dealing with behaviors necessitating

the use of seclusion and restraint."

Page 3: "Principles...#10: All physical contact is

subject to the reporting and monitoring

requirements of seclusion and restraint."

Page 6: "Documentation...#1: Initiate and

complete the Behavioral Emergency paperwork."

2. Hospital form titled: Behavioral Emergency

Evaluation (undated)

The hospital requires a 7 page purple form titled

"Behavioral Emergency Evaluation" to be

completed for all incidents of seclusion or

restraint. This form was not completed for any of

the seclusion and restraint incidents involving

patients D1, D2, D5, D6, D7 or C3 cited in this


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report. The form does not require or provide a

place for staff to describe types of holds, carries,

or physical measures that are involved in the

seclusion or restraint episodes.

3. Texas Administrative Code (contained in the

hospitals seclusion and restraint training packet)

states the following: "Title 25, Rule 415.291:

Clinical Timeout and Quiet Time.

...1) Clinical Timeout ...e) Staff may not use

physical force or personal restraint to direct the

individual to a clinical timeout area. To force or

coerce the individual constitutes restraint and/or

seclusion and renders the procedure subject to

the requirements for restraint or seclusion

described in this subchapter."

4. According to the hospital's training program

"Prevention and Intervention of Aggressive

Behavior" the definition for clinical time out is: "A

procedure in which an individual, in voluntary

response to a verbal direction from staff,

cooperatively enters into and remains in a

designated area from which egress is not blocked

for a prior of time not to exceed 30 minutes

without specific joint determination by the

individual and staff of the need for continuation."


printed: 11/25/2011 department of health and human...

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