inspection report - austin oaks hospital

8/19/2019 Inspection report - Austin Oaks Hospital

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A. BUILDING ______________________

(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

(X3) DATE SURVEY

COMPLETED

PRINTED: 03/02/20

FORM APPROV

(X2) MULTIPLE CONSTRUCTION

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-03

454121 10/14/2014

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

1407 WEST STASSNEY LANEAUSTIN OAKS HOSPITAL

AUSTIN, TX 78745

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)

A 000 INITIAL COMMENTS A 000

An entrance conference was held with the facility

Chief Executive Officer, Director of Risk

Management and Director of Nursing on the

morning of 10/14/14. The purpose and process

of the complaint survey were discussed, and an

opportunity given for questions.

An exit conference was held with the facility Chief

Executive Officer, Director of Risk Management

and Director of Nursing on the afternoon of

10/14/14. Preliminary findings of the survey were

discussed, and an opportunity given for

questions.

Complaint #TX00204476 was substantiated with

deficiencies. The following Condition of

Participation, 42 CFR 482.13 Patient Rights wasnot met.

A 115 482.13 PATIENT RIGHTS

A hospital must protect and promote each

patient's rights.

This CONDITION is not met as evidenced by:

A 115 11/28/14

Based on a review of facility documentation and

videotape, and staff interview, the facility failed to

protect each patient's rights by failing to ensure

the emotional health and safety of each in a

manner which included respect, dignity and

comfort. Due to the manner and degree to which

the facility failed to protect the rights, the facility

was not compliant with the requirements of this

condition.

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

11/06/201

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

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

ollowing 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

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

rogram participation.

ORM CMS-2567(02-99) Previous Versions Obsolete U1JY11Event ID: Facility ID: 810876 If continuation sheet Page 1 o


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454121 10/14/2014

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AUSTIN, TX 78745




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A 115 Continued From page 1 A 115

Findings were:

Staff at the facility put 1 of 10 adolescent patients

[Patient #1] in a seclusion room without clothing

or coverage of any type for approximately 20

minutes. Patient #1 is a 15-year-old female with

a history of sexual abuse.

Cross refer: Tag A0144

A 144 482.13(c)(2) PATIENT RIGHTS: CARE IN SAFE

SETTING

The patient has the right to receive care in a safe

setting.

This STANDARD is not met as evidenced by:

A 144 11/28/14

Based on a review of facility documentation and

videotape, and staff interview, the facility failed to

ensure the emotional health and safety of each

patient as the facility secluded, without clothing or

coverage of any type, a 15-year-old femalepatient with a history of sexual abuse, thus failing

to treat 1 of 10 patients [Patient #1] in a manner

which included respect, dignity and comfort.

Findings were:

A review of facility clinical records and videotape

revealed that for 1 of 10 adolescent patients

[Patient #1], the facility secluded the patient

without clothing or other coverage for

approximately 20 minutes on 10/7/14.

A review of the medical record of Patient #1

revealed that she was a 15-year-old female,

admitted to Austin Oaks Hospital on 10/7/14 at



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454121 10/14/2014

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3:55 p.m. An Admission Assessment completed

by a facility LCSW on 10/7/14 at 3:15 p.m. stated

in part:

"Abuse History (Physical/Sexual/Emotional)

Sexual - [by significant male relatives], ages

5-15...

Admitted to: Adol (adolescent unit)..."

A Psychiatric Evaluation dictated on 10/8/14 at

2:19 p.m. stated, "Chief Complaint/Reasons for

Admission: [Patient #1] presents for inpatient

hospitalization due to intrusive suicidal

ideation...History of Present Illness: ...She reports

stressor being [alleged sexual abuse] from the

ages of 5-15...

h) Patient Trauma History:

Emotional/Physical/Sexual Abuse History: She

was sexually abused by [significant male relative],

reported from the ages of 5 to 15 and this hasbeen reported..."

A review of Physician Orders for Patient #1

revealed the following:

Telephone order by [Staff #4, facility psychiatrist]

for Restraint and Seclusion Order on 10/7/14 at

7:10 p.m. which included the following:

"A. Clinical Justification for Intervention: ...Took

metal paperclip from nurses station, attempted to

swallow, punched, kicked, spit, scratched staff ...

G. Describe actions taken to lessen physical

and/or psychological risk if indicated: clothes

removed, gown given ...



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H. Staff involved in restraint/seclusion ...[Staff #6

(male RN), Staff #8 (female RN), and Staff #7

(male RN)]

Telephone order by [Staff #4, facility psychiatrist]

for Restraint and Seclusion Order on 10/7/14 at

7:55 p.m. which included the following:

A. Clinical Justification for Intervention: ...Tore off

piece of gown, wrapped around neck in suicide

attempt, combative to staff ...

G. Describe actions taken to lessen physical

and/or psychological risk if indicated: ...gown

removed, to decrease risk of suicide attempt ..

.H. Staff involved in restraint/seclusion...[Staff #7

(male RN), Staff #10 (female Mental Health

Worker), and Staff #6 (male RN)]

Telephone order by [Staff #5, Advanced Practice

Nurse] on 10/7/14 at 7:55 p.m. which included the

following: "...remove all clothes until calm...Place

on 1:1 while awake..."

A review of 12-Hour Nursing

Assessment/Progress Note entries revealed the

following, in part:

10/8/14: "1850 - Pt. reached over the nurse's

station and obtained a paperclip and ran into

seclusion room bathroom. Pt. placed paperclip in

mouth and refused to remove it from her mouth.

Staff in bathroom and attempted to remove

paperclip and pt. became combative and



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punched, kicked and spit at staff. Pt. was

restrained and paperclip was removed, pt.

continued to be combative and bit, kicked,

punched, and spit on staff. [Psychiatrist] notified

at 1910, new orders of Thorazine 50 mg IM,

Benadryl 50 mg IM x 1 dose now. Pt placed in

seclusion room, pt.'s clothes removed because of

risk of contraband and placed in gown, pt.

continued to punch, kick, scratch, and bite atstaff, the restraint was continued by staff for

administration of the IM medications...

1945 - While in seclusion pt. tore off a piece of

gown and tied around her neck in suicide attempt.

Staff went into room and pt. became combative,

kicked, punched, spit, and bit staff. Staff

attempted to orient pt. to reality, attempted to

calm pt., other staff came to pt. and attempted to

calm but pt. continued to be combative and

screaming obscenities towards staff...[Staff #4,

Psychiatrist] notified and Benadryl 25 mg IM and

Thorazine 25 mg IM, Ativan 1 mg IM, pt. to beplaced on 1:1, and clothes/gowns to be removed

until calm...

2010 - Pt. became calm, gown given back to pt.

and seclusion door open..."

In an interview with the Staff #4, psychiatrist, on

the morning of 10/14/14 in the facility meeting

room, he stated, in part: "I've been the Medical

Director here for about six months now ...She

[Patient #1] came in for suicidal ideation from

[another] facility...The night she came in she

ended up in a procedure that night. She's still

here - she's still acute ...Last night she had to go

back into gowns. The two were working last night

- the same two that were in that first incident she



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had here. I asked her what happened - I was

speaking to her just this morning. I said to her,

you know you got your clothes - so what

happened last night?...So she was in paper

gowns - when I asked her what happened, she

said "Well, they were working again last night."

So they really triggered her again last

night...Normally we'd say you have to watch when

you put hands on someone with a history oftrauma, but ultimately you have to do what's best

for the safety of the patient. They tried verbal

de-escalation of course and we offer them verbal

meds to get them to de-escalate ...I don't know

who told them to do that, because it wasn't me

[regarding the order for removal of all patient

clothing]. It was the APRN who gave them that

order. It sounds like they had the cloth gown on

her and she used it to tie around her neck. It

looks like they called the APRN that night rather

than me. I told them we can't do that - we can't

leave a patient without anything to wear. So the

next morning when I found out I said "No, wecan't do that." We use gowns, though, all the

time..." Further in the interview the psychiatrist

stated, "It's rare that patients are ordered into

gowns. It happened again last night for this

patient... it looks like at 2140 - patient was placed

in the gown for 48 hours. I guess I'd rather err on

the side of caution and if keeping her in a gown

would keep her safe, well then that's better..."

In an interview with Staff #5, APRN on the

afternoon of 10/14/14 in the facility meeting room,

he stated, in part: "I received a telephone call

and they were telling me the teenager was acting

out and attempting to harm themselves. They

had placed her in the quiet room and she was

attempting from then on to use her clothes to



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strangle herself. So I gave them an order for 1:1

and to remove her clothes so that she could not

strangle herself with them and to put her in paper

gowns..." When asked if he had ordered to leave

the patient completely without clothing, he stated

in part, "Well, I wasn't here. This is the same

procedure we use at other facilities - if there were

a safety issue, we'd immediately remove their

clothing and put them in paper gowns. So shewould have been without clothing at least for

that..."

In an interview with the Director of Nursing, Staff

#3, on the afternoon of 10/14/14 in the facility

meeting room, she stated in part: "Yes, I think at

one point she was completely without clothes. "

In an interview with the treatment team therapist

of Patient #1, Staff #11, on the afternoon of

10/14/14 in the facility meeting room, she statedin part: "[Patient #1] is extremely suicidal. She's

in a little bit of a different situation than a lot of the

patients here because she's in CPS custody.

She's 15 now. She was raped by [a significant

male relative] when she was 14. There's some

substance abuse in the family. The [significant

male relative] was arrested...She said it was one

particular male staff member [that bothers her]...

[the therapist gave a physical description of the

male which she identified as being Staff #6]. She

said that he had to take the gown off or

something. And she said when he did that, it was

very traumatic for her and that she felt like she

was being raped. And she has been raped in the

past. That's the protocol [putting a patient in a

gown] for all kids or adults who are suicidal

because they can use their clothing to hang



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themselves...[Patient #1] is so extremely violent

when she self-harms and so intent on hurting

herself using any means necessary, that I think

that a lot of her behaviors take the staff by

surprise...I haven't seen a single other patient

who's this extreme..."

A viewing of the facility videotape of the seclusionof Patient #1 on the evening of 10/7/14 was

conducted by this surveyor and the Director of

Risk Management (DRM), Staff #2, on the

afternoon of 10/14/14 in her office. The

videotape was started at 7:10 p.m. on 10/7/14,

and included views of three different cameras:

the hallway outside the seclusion rooms, the

anteroom of the two seclusion rooms, and

Seclusion Room #2. The bathroom off the

anteroom was not visible by camera as the door

to the hallway blocked the view. Viewing of the

video began when the patient was already in the

bathroom of the seclusion room anteroom andcould not be seen on camera. The DRM stated,

"Two female nurses are in the bathroom with the

patient trying to put a gown on her." The next

approximately 40 minutes of video revealed a

struggle with the patient and staff to get her into

the seclusion room and administer medication.

The patient was clearly kicking and fighting staff.

The DRM identified staff as two male RNs [Staff

#6 and #7], one female RN [Staff #8] and one

female MHW (mental health worker) [Staff #10].

The patient was attired in a hospital gown and

had nothing on under it. As the struggle

continued, there were numerous moments when

the gown was not covering her body. Emergency

medication was brought in and administered to

the patient by two male RNs and the female

MHW. The patient continued to struggle. At



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approximately 7:54 p.m., one of the male nurses

[Staff #6] grabbed the patient's gown with his right

hand and ripped the gown off, leaving the patient

completely nude. All staff then left the seclusion

room and the door was shut. The only other item

in the room was a mattress. The patient was

naked in Seclusion Room #2 for approximately 23

minutes. A nurse returned to the room at 8:17

p.m. to hand the patient a gown. The videoplayback was stopped at that point.

Facility policy #PC-C-3 entitled Seclusion and

Restraint, last revised 6/19/14, stated in part:

"Use of restraint and seclusion is initiated only as

an intervention of last resort in an emergency

situation where a patient is in imminent danger of

causing harm to self or others and all other less

restrictive or invasive measures have been

attempted and failed ...The treatment philosophy

is centered on providing a positive, healing

experience...

17. Staff members must respect and preserve

the rights of an individual during restraint or

seclusion...

Personal Possessions (facility's bold)

1. The individual's right to retain personal

possessions and personal articles of clothing may

be suspended during restraint or seclusion when

necessary to ensure the safety of the individual or

others...

4. If personal articles of clothing are taken from

the individual, appropriate other clothing will be

issued..."



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The above findings were again confirmed in an

interview on the afternoon of 10/14/14 with the

Chief Executive Officer (CEO) and other

administrative staff in the facility meeting room.

The CEO stated in part, "We don't do that here.

We don't leave patients without clothes." The

Director of Nursing stated in part, "We've now

addressed the issue with this staff member."


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