PRINTED: 11/25/2011 DEPARTMENT OF HEALTH AND HUMAN...
Transcript of PRINTED: 11/25/2011 DEPARTMENT OF HEALTH AND HUMAN...
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
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 Page 1 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
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.,
patient D5 stated that s/he had been in the
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 2 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 118 Continued From page 2 B 118
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 3 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 136 Continued From page 3 B 136
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 4 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 136 Continued From page 4 B 136
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.
This STANDARD is not met as evidenced by:
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 5 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 144 Continued From page 5 B 144
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
patients to an unsafe environment with the
potential for harm, and jeopardizes patients' right
to safe treatment.
Findings include:
A. Patient D5
1. Interviews
a. In an interview on 11-15-11 at 12:30 p.m.,
patient D5 stated that s/he had been in the
hospital five days and had been taken to the quiet
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 6 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 144 Continued From page 6 B 144
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."
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. 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.
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.
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 7 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 144 Continued From page 7 B 144
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
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 reflect that patient D5 had been
involved in multiple 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 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."
b. In an interview on 11/16/11 at 12:45 p.m.,
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 8 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 144 Continued From page 8 B 144
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
spitting at staff. The Director of Social Work was
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 9 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 144 Continued From page 9 B 144
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.
b. In an interview on 11/15/11 at 2:10 p.m.,
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 10 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 144 Continued From page 10 B 144
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 11 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 144 Continued From page 11 B 144
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.
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 12 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 144 Continued From page 12 B 144
g. 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." 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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 13 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 144 Continued From page 13 B 144
11/17/11 at 10:40 a.m., the Master Treatment
Plan of patient D2 was reviewed to see if it had
been updated to reflect that patient D2 had been
involved in multiple physical restraints and Quiet
Room restrictions. The Assistant Director
acknowledged that the treatment plan had not
been updated since patient D2's admission on
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
a. In a telephone interview on 11/15/11 at 1:45
p.m., Social Worker 1 reported that Patient D7
was acting out on 11/13/2011 and required the
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 14 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 144 Continued From page 14 B 144
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 15 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 144 Continued From page 15 B 144
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 16 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 144 Continued From page 16 B 144
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.
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 17 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 144 Continued From page 17 B 144
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."
c. In an interview on 11/17/11 at 9:45 a.m., the
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 18 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 144 Continued From page 18 B 144
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 19 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 144 Continued From page 19 B 144
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.
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 20 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 144 Continued From page 20 B 144
c. In an interview on 11/16/11 at 11:30 a.m., the
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
orders, staff documentation of interventions used,
Behavioral Emergency Evaluations, or face to
face evaluations pertaining to the seclusion and
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,
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 21 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 144 Continued From page 21 B 144
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 22 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 144 Continued From page 22 B 144
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 23 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 147 Continued From page 23 B 147
mentally ill.
This STANDARD is not met as evidenced by:
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 24 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 147 Continued From page 24 B 147
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 25 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 148 Continued From page 25 B 148
This STANDARD is not met as evidenced by:
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
patients to an unsafe environment with the
potential for harm, and jeopardizes patients' right
to safe treatment.
Findings include:
A. Patient D5
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 26 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 148 Continued From page 26 B 148
1. Interviews
a. In an interview on 11-15-11 at 12:30 p.m.,
patient D5 stated that s/he had been in the
hospital five days and had been taken to the quiet
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."
b. In an interview on 11/15/11 at 2:30 p.m.,
Mental Health Tech 1 stated that patient D5 had
been taken to the Quiet Room around 9:15 a.m.
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 27 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 148 Continued From page 27 B 148
were restraint or seclusion.
c. In an interview on 11/15/11 at 3:10 p.m., the
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
Plan of patient D5 was reviewed to see if it had
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 28 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 148 Continued From page 28 B 148
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
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
said that s/he asked to come out of the room a
couple of times and was told "not yet."
b. In an interview on 11/16/11 at 12:45 p.m.,
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
orders, staff documentation of interventions used,
Behavioral Emergency Evaluations, or face to
face evaluations pertaining to the seclusion and
restraint episodes of 11/15/11.
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 29 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 148 Continued From page 29 B 148
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
spitting at staff. The Director of Social Work was
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
a. In a telephone interview on 11/15/11 at 1:45
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 30 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 148 Continued From page 30 B 148
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 31 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 148 Continued From page 31 B 148
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.
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 32 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 148 Continued From page 32 B 148
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
11/17/11 at 10:40 a.m., the Master Treatment
Plan of patient D2 was reviewed to see if it had
been updated to reflect that patient D2 had been
involved in multiple physical restraints and Quiet
Room restrictions. The Assistant Director
acknowledged that the treatment plan had not
been updated since patient D2's admission on
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
a. In an interview on 11/16/11 at 12:30 p.m.,
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."
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 33 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 148 Continued From page 33 B 148
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 34 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 148 Continued From page 34 B 148
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 35 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 148 Continued From page 35 B 148
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 36 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 148 Continued From page 36 B 148
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."
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 37 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 148 Continued From page 37 B 148
c. In an interview on 11/17/11 at 9:45 a.m., the
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 38 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 148 Continued From page 38 B 148
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 39 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 148 Continued From page 39 B 148
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
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 40 of 41
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 11/25/2011FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
454089 11/17/2011
R
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)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 148 Continued From page 40 B 148
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."
FORM CMS-2567(02-99) Previous Versions Obsolete DSJE13Event ID: Facility ID: 810475 If continuation sheet Page 41 of 41