Austin Oaks Hospital

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 28421 Based on review of documentation and interview, it was determined that the facility failed to always provide for the needs of the patient population when procedures to protect and adequately secure the personal property of persons served, including clothing, was not met for Patient #1. Findings were: Facility policy entitled “Patient Valuables and Belongings” stated in part, “Once the patient’s skin check is completed, the patient is allowed on to the unit, and the clinical portion of the admissions process begins. A staff member will return to the belongings room, conduct the contraband search on the patient’s belongings, in constant view of the video camera. 1. Disposition of items will be as follows: a. Clothing and other allowed items will be placed in a paper bag and given to the patient. For adult and adolescent patients, clothing and items that the patients are allowed to keep are inventoried. All Patients, all clothing and items are logged in including the clothing the patient is wearing. b. Toiletries and allowed items that may be used with supervision will be placed in a small bin and kept behind the nursing station for access. c. Disallowed items will be inventoried and returned to the bin. Upon completion of inventory, the bin shall be closed and secured with a zip-tie tag, indicating it is ready for storage. The bin is then taken to the storage area. A copy of the Personal Belongings inventory form will be made. One copy will be given to the patient, and the original will be placed in the patient’s medical record. The belongings box and safe bags will not be opened at any time during the patient’s stay until discharge.” Patient # 1 was admitted to the hospital on 4/2/26 and was discharged on 4/7/26. He was not provided with his personal items and was forced to wear “dirty clothes” during his entire stay. In an interview with the Patient Advocate on 5/27/26, it was acknowledged that there was no inventory sheet that cataloged the patients belongings and clothing in the patient medical record.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 30250 Based on a review of documentation and interviews, the facility failed to ensure the use of restraint or seclusion was accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. Findings included: Facility based policy entitled “Seclusion/Restraint/Emergency Medications” PC-C-3 stated in part, “3.0 Physician Orders, Consultation, and Evaluation: 3.1 Restraint, seclusion, or emergency medications shall be used in emergency situations only and requires an order from a physician ... 3.1.2 In the absence of a physician, the registered nurse may authorize the initiation of restraint or seclusion in an emergency. Emergency medications must be ordered by the physician. 3.1.3 The physician must be contacted for an order either during the emergency initiation of the restraint/seclusion or immediately (within a few minutes) after the restraint/ seclusion has been initiated ... 3.2 The physician’s order for use of restraint, seclusion, or emergency medication will be recorded in the medical record and include the following: 3.2.1 Reason for using restraint/seclusion/emergency medication, including specific behaviors and safety issues; 3.2.2 Time limits not to exceed 15 (fifteen) minutes for personal/manual restraints, or for mechanical restraints/seclusion: 4 hours for adults, 2 hours for children and adolescents ages 9 to 17, and 1 hour for children underage 9; 3.2.3 The type of restraint or seclusion to be used; 3.2.4 Behavioral criteria for discontinuation of/release from restraint/seclusion; (for restraint/seclusion) 3.2.5 The nurse receiving the order, the physician giving the order, and the nurse transcribing the orders, with appropriate dates and times; ... Review of medical records revealed 2 of 4 patients with restraint and/or seclusion episodes did not have physician orders present for these interventions: * Patient #2 had a nursing note on 12/19/23 at 1355 stated in part, “ ...This nurse observed pt about to hit peer with an open hand. MHT initiated restraint on pt and escorted her into pt room.” In interview on 03/05/24 staff members # 11 and 12 verified that a personal hold (restraint) was initiated on this patient on 12/19/24 as this note indicated. There was no order for this restraint episode in this patient’s medical record. * Patient # 11 had a nursing note on 02/20/24 that indicated, “ ...Patient assaulted another patient and bit staff in the arm ...” The Patient Observation Record for 02/20/24 indicated this patient was in seclusion from 0745-12:15 (over four hours). There was no order for this initial seclusion or a second seclusion order to cover the time period over 4 hours documented in this patient’s medical record. In interview on 03/06/24, staff member #2 verified that likely the nurse caring for Patient #11 had to seek medical treatment for the bite, hence why there was not documentation of the seclusion episode. Staff member #2 verified there should have been a physician order for this seclusion. The missing orders for the above restraint and seclusion episodes were verified with staff members #1 and 2 on 03/07/24.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 30250 Based on a review of documentation and interviews, the facility failed to ensure that face to face evaluations were conducted by a Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. Findings included: Facility based policy entitled “Seclusion/Restraint/Emergency Medications” PC-C-3 stated in part, “5.0 Face to Face Evaluation by the Physician, LIP, or trained RN/PA: Within one hour of the initiation of restraint, seclusion, or emergency medication, the patient shall be evaluated in person by a physician, authorized LIP, or trained RN/PA, If the evaluation is completed by a RN, it must be completed by trained nurse not in involved in the initiation of the intervention ... “ Review of medical records revealed 3 of 4 patients had 1 hour face to face evaluation completed by the same nurse who initiated the interventions. One of the 2 nurses did not have the required training to complete the evaluation. * On 12/19/23 Patient #2 had a restraint episode from 1820-1825 and seclusion from 1825-1850. This seclusion episode was initiated by staff member #12, this same staff member (#12) conducted the 1-hour face to face evaluation of this patient. * On 12/19/23 Patient #9 had a restraint episode from 1820-1825 and seclusion from 1825-1850. This seclusion episode was initiated by staff member #12, this same staff member (#12) conducted the 1-hour face to face evaluation of this patient. * Review of the personnel file for staff member #12 revealed they had not completed Qualified Registered Nurse (QRN) which included the 1-hour face to face training in their HealthStream record. In interview on 03/06/24, staff member #12 verified they had not completed the Qualified RN training. * Patient #12 was in seclusion on 02/06/24 from 1005-1130. This seclusion episode was initiated by and the 1-hour face to face was completed by the same nurse (staff member #14). There also was no documented debriefing for this patient. Staff # 14 had complete Qualified RN training on 01/15/22 according to their personnel file. The above issues with the 1 hour face to face nursing evaluations not being completed by a nurse other than the registered nurse who initiated the use of restraint or seclusion, and the lack of Qualified RN training for 1 of 2 nurses was verified with staff members #1 and 2 on 03/07/24.”

“Adequate Staffing CFR(s): There must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient’s active treatment program. This Standard is not met as evidenced by: 30250 Based on a review of documentation and interviews, the facility failed to ensure there were adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care according to their staffing grid. Findings included: Review of the adolescent unit assignment sheet revealed 4 of 6 dates did not have adequate staffing according to the facility staffing grid: 01/27/24 there were 20 patients on the unit. Staffed with 1 Nurse 7AM-7PM and 4 MHTs 7AM-3PM, 1 Nurse 7PM-7AM and 4 MHTs 3PM-11 PM and 4 MHT from 11PM-7 AM (on 01/28/24), which is not adequate per the facility staffing grid. Per facility staffing grid with 20 patients 2 nurses are needed for 7AM-7PM and 7PM-7AM shifts, on this date the unit was short 1 nurse for both shifts. On 03/01/23 there were 20 patients with only 1 Nurse from 7PM-7AM. Per the staffing grid, 2 nurses are needed from 7PM-7AM. The unit was short a nurse for 12 hours. On 03/03/24 there were 20 patients with only 1 Nurse from 4:15AM-7AM. Per the staffing grid, 2 nurses are needed from 4:15AM-7AM. The unit was short a nurse for over 2 hours. On 03/04/34 there were 15 patients with only 1 Mental Health Technician (MHT) from 8:30PM-11PM. Per the staffing grid, 2 MHTs are needed from 8:30PM-11PM. The unit was short a nurse for over 2 hours. On 03/01/23 there were 20 patients with only 1 Nurse from 7PM-7AM. Per the staffing grid, 2 nurses are needed from 7PM-7AM. The unit was short a nurse for 12 hours. In interview on 03/07/24, staff member #1 verified that per the facility staffing grid, the adolescent was short staffed on the above dates.”