Inspection Report - Austin Oaks Hospital

PRINTED: 03/02/2015
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________
(X3) DATE SURVEY

COMPLETED
C
454121
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
1407 WEST STASSNEY LANE
AUSTIN OAKS HOSPITAL

(X4) ID
PREFIX
TAG
10/14/2014
AUSTIN, TX 78745
SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 000 INITIAL COMMENTS
PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
A 000
An entrance conference was held with the facility

Chief Executive Officer, Director of Risk
Management and Director of Nursing on the
morning of 10/14/14. The purpose and process
of the complaint survey were discussed, and an
opportunity given for questions.
An exit conference was held with the facility Chief

Executive Officer, Director of Risk Management
and Director of Nursing on the afternoon of
10/14/14. Preliminary findings of the survey were
discussed, and an opportunity given for
questions.
Complaint #TX00204476 was substantiated with

deficiencies. The following Condition of
Participation, 42 CFR 482.13 Patient Rights was
not met.
A 115 482.13 PATIENT RIGHTS
A 115
11/28/14
A hospital must protect and promote each

patient's rights.
This CONDITION is not met as evidenced by:
Based on a review of facility documentation and
videotape, and staff interview, the facility failed to
protect each patient's rights by failing to ensure
the emotional health and safety of each in a
manner which included respect, dignity and
comfort. Due to the manner and degree to which
the facility failed to protect the rights, the facility
was not compliant with the requirements of this
condition.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
(X6) DATE
TITLE
11/06/2014
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
Event ID: U1JY11
Facility ID: 810876
If continuation sheet Page 1 of 10
PRINTED: 03/02/2015
FORM APPROVED

OMB NO. 0938-0391

A. BUILDING ______________________
(X3) DATE SURVEY

COMPLETED
C
454121
B. WING _____________________________

(X4) ID
PREFIX
TAG
10/14/2014
AUSTIN, TX 78745

A 115 Continued From page 1

DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
A 115
Findings were:
Staff at the facility put 1 of 10 adolescent patients
[Patient #1] in a seclusion room without clothing
or coverage of any type for approximately 20
minutes. Patient #1 is a 15-year-old female with
a history of sexual abuse.
Cross refer: Tag A0144
A 144 482.13(c)(2) PATIENT RIGHTS: CARE IN SAFE
SETTING
A 144
11/28/14
The patient has the right to receive care in a safe

setting.
This STANDARD is not met as evidenced by:
Based on a review of facility documentation and
videotape, and staff interview, the facility failed to
ensure the emotional health and safety of each
patient as the facility secluded, without clothing or
coverage of any type, a 15-year-old female
patient with a history of sexual abuse, thus failing
to treat 1 of 10 patients [Patient #1] in a manner
which included respect, dignity and comfort.
Findings were:
A review of facility clinical records and videotape
revealed that for 1 of 10 adolescent patients
[Patient #1], the facility secluded the patient
without clothing or other coverage for
approximately 20 minutes on 10/7/14.
A review of the medical record of Patient #1

revealed that she was a 15-year-old female,
admitted to Austin Oaks Hospital on 10/7/14 at
Event ID: U1JY11
Facility ID: 810876
PRINTED: 03/02/2015
FORM APPROVED

OMB NO. 0938-0391

A. BUILDING ______________________
(X3) DATE SURVEY

COMPLETED
C
454121
B. WING _____________________________

(X4) ID
PREFIX
TAG
10/14/2014
AUSTIN, TX 78745


DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
A 144
3:55 p.m. An Admission Assessment completed

by a facility LCSW on 10/7/14 at 3:15 p.m. stated
in part:
"Abuse History (Physical/Sexual/Emotional)
Sexual - [by significant male relatives], ages
5-15...
Admitted to: Adol (adolescent unit)..."
A Psychiatric Evaluation dictated on 10/8/14 at

2:19 p.m. stated, "Chief Complaint/Reasons for
Admission: [Patient #1] presents for inpatient
hospitalization due to intrusive suicidal
ideation...History of Present Illness: ...She reports
stressor being [alleged sexual abuse] from the
ages of 5-15...
h) Patient Trauma History:
Emotional/Physical/Sexual Abuse History: She
was sexually abused by [significant male relative],
reported from the ages of 5 to 15 and this has
been reported..."
A review of Physician Orders for Patient #1

revealed the following:
Telephone order by [Staff #4, facility psychiatrist]
for Restraint and Seclusion Order on 10/7/14 at
7:10 p.m. which included the following:
"A. Clinical Justification for Intervention: ...Took
metal paperclip from nurses station, attempted to
swallow, punched, kicked, spit, scratched staff ...
G. Describe actions taken to lessen physical
and/or psychological risk if indicated: clothes
removed, gown given ...
Event ID: U1JY11
Facility ID: 810876
PRINTED: 03/02/2015
FORM APPROVED

OMB NO. 0938-0391

A. BUILDING ______________________
(X3) DATE SURVEY

COMPLETED
C
454121
B. WING _____________________________

(X4) ID
PREFIX
TAG
10/14/2014
AUSTIN, TX 78745


DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
A 144
H. Staff involved in restraint/seclusion ...[Staff #6

(male RN), Staff #8 (female RN), and Staff #7
(male RN)]
Telephone order by [Staff #4, facility psychiatrist]

for Restraint and Seclusion Order on 10/7/14 at
7:55 p.m. which included the following:
A. Clinical Justification for Intervention: ...Tore off
piece of gown, wrapped around neck in suicide
attempt, combative to staff ...
G. Describe actions taken to lessen physical
and/or psychological risk if indicated: ...gown
removed, to decrease risk of suicide attempt ..
.H. Staff involved in restraint/seclusion...[Staff #7
(male RN), Staff #10 (female Mental Health
Worker), and Staff #6 (male RN)]
Telephone order by [Staff #5, Advanced Practice

Nurse] on 10/7/14 at 7:55 p.m. which included the
following: "...remove all clothes until calm...Place
on 1:1 while awake..."
A review of 12-Hour Nursing

Assessment/Progress Note entries revealed the
following, in part:
10/8/14: "1850 - Pt. reached over the nurse's
station and obtained a paperclip and ran into
seclusion room bathroom. Pt. placed paperclip in
mouth and refused to remove it from her mouth.
Staff in bathroom and attempted to remove
paperclip and pt. became combative and
Event ID: U1JY11
Facility ID: 810876
PRINTED: 03/02/2015
FORM APPROVED

OMB NO. 0938-0391

A. BUILDING ______________________
(X3) DATE SURVEY

COMPLETED
C
454121
B. WING _____________________________

(X4) ID
PREFIX
TAG
10/14/2014
AUSTIN, TX 78745


DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
A 144
punched, kicked and spit at staff. Pt. was

restrained and paperclip was removed, pt.
continued to be combative and bit, kicked,
punched, and spit on staff. [Psychiatrist] notified
at 1910, new orders of Thorazine 50 mg IM,
Benadryl 50 mg IM x 1 dose now. Pt placed in
seclusion room, pt.'s clothes removed because of
risk of contraband and placed in gown, pt.
continued to punch, kick, scratch, and bite at
staff, the restraint was continued by staff for
administration of the IM medications...
1945 - While in seclusion pt. tore off a piece of
gown and tied around her neck in suicide attempt.
Staff went into room and pt. became combative,
kicked, punched, spit, and bit staff. Staff
attempted to orient pt. to reality, attempted to
calm pt., other staff came to pt. and attempted to
calm but pt. continued to be combative and
screaming obscenities towards staff...[Staff #4,
Psychiatrist] notified and Benadryl 25 mg IM and
Thorazine 25 mg IM, Ativan 1 mg IM, pt. to be
placed on 1:1, and clothes/gowns to be removed
until calm...
2010 - Pt. became calm, gown given back to pt.
and seclusion door open..."
In an interview with the Staff #4, psychiatrist, on

the morning of 10/14/14 in the facility meeting
room, he stated, in part: "I've been the Medical
Director here for about six months now ...She
[Patient #1] came in for suicidal ideation from
[another] facility...The night she came in she
ended up in a procedure that night. She's still
here - she's still acute ...Last night she had to go
back into gowns. The two were working last night
- the same two that were in that first incident she
Event ID: U1JY11
Facility ID: 810876
PRINTED: 03/02/2015
FORM APPROVED

OMB NO. 0938-0391

A. BUILDING ______________________
(X3) DATE SURVEY

COMPLETED
C
454121
B. WING _____________________________

(X4) ID
PREFIX
TAG
10/14/2014
AUSTIN, TX 78745


DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
A 144
had here. I asked her what happened - I was

speaking to her just this morning. I said to her,
you know you got your clothes - so what
happened last night?...So she was in paper
gowns - when I asked her what happened, she
said "Well, they were working again last night."
So they really triggered her again last
night...Normally we'd say you have to watch when
you put hands on someone with a history of
trauma, but ultimately you have to do what's best
for the safety of the patient. They tried verbal
de-escalation of course and we offer them verbal
meds to get them to de-escalate ...I don't know
who told them to do that, because it wasn't me
[regarding the order for removal of all patient
clothing]. It was the APRN who gave them that
order. It sounds like they had the cloth gown on
her and she used it to tie around her neck. It
looks like they called the APRN that night rather
than me. I told them we can't do that - we can't
leave a patient without anything to wear. So the
next morning when I found out I said "No, we
can't do that." We use gowns, though, all the
time..." Further in the interview the psychiatrist
stated, "It's rare that patients are ordered into
gowns. It happened again last night for this
patient... it looks like at 2140 - patient was placed
in the gown for 48 hours. I guess I'd rather err on
the side of caution and if keeping her in a gown
would keep her safe, well then that's better..."
In an interview with Staff #5, APRN on the

afternoon of 10/14/14 in the facility meeting room,
he stated, in part: "I received a telephone call
and they were telling me the teenager was acting
out and attempting to harm themselves. They
had placed her in the quiet room and she was
attempting from then on to use her clothes to
Event ID: U1JY11
Facility ID: 810876
PRINTED: 03/02/2015
FORM APPROVED

OMB NO. 0938-0391

A. BUILDING ______________________
(X3) DATE SURVEY

COMPLETED
C
454121
B. WING _____________________________

(X4) ID
PREFIX
TAG
10/14/2014
AUSTIN, TX 78745


DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
A 144
strangle herself. So I gave them an order for 1:1

and to remove her clothes so that she could not
strangle herself with them and to put her in paper
gowns..." When asked if he had ordered to leave
the patient completely without clothing, he stated
in part, "Well, I wasn't here. This is the same
procedure we use at other facilities - if there were
a safety issue, we'd immediately remove their
clothing and put them in paper gowns. So she
would have been without clothing at least for
that..."
In an interview with the Director of Nursing, Staff

#3, on the afternoon of 10/14/14 in the facility
meeting room, she stated in part: "Yes, I think at
one point she was completely without clothes. "
In an interview with the treatment team therapist

of Patient #1, Staff #11, on the afternoon of
10/14/14 in the facility meeting room, she stated
in part: "[Patient #1] is extremely suicidal. She's
in a little bit of a different situation than a lot of the
patients here because she's in CPS custody.
She's 15 now. She was raped by [a significant
male relative] when she was 14. There's some
substance abuse in the family. The [significant
male relative] was arrested...She said it was one
particular male staff member [that bothers her]...
[the therapist gave a physical description of the
male which she identified as being Staff #6]. She
said that he had to take the gown off or
something. And she said when he did that, it was
very traumatic for her and that she felt like she
was being raped. And she has been raped in the
past. That's the protocol [putting a patient in a
gown] for all kids or adults who are suicidal
because they can use their clothing to hang
Event ID: U1JY11
Facility ID: 810876
PRINTED: 03/02/2015
FORM APPROVED

OMB NO. 0938-0391

A. BUILDING ______________________
(X3) DATE SURVEY

COMPLETED
C
454121
B. WING _____________________________

(X4) ID
PREFIX
TAG
10/14/2014
AUSTIN, TX 78745


DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
A 144
themselves...[Patient #1] is so extremely violent

when she self-harms and so intent on hurting
herself using any means necessary, that I think
that a lot of her behaviors take the staff by
surprise...I haven't seen a single other patient
who's this extreme..."
A viewing of the facility videotape of the seclusion

of Patient #1 on the evening of 10/7/14 was
conducted by this surveyor and the Director of
Risk Management (DRM), Staff #2, on the
afternoon of 10/14/14 in her office. The
videotape was started at 7:10 p.m. on 10/7/14,
and included views of three different cameras:
the hallway outside the seclusion rooms, the
anteroom of the two seclusion rooms, and
Seclusion Room #2. The bathroom off the
anteroom was not visible by camera as the door
to the hallway blocked the view. Viewing of the
video began when the patient was already in the
bathroom of the seclusion room anteroom and
could not be seen on camera. The DRM stated,
"Two female nurses are in the bathroom with the
patient trying to put a gown on her." The next
approximately 40 minutes of video revealed a
struggle with the patient and staff to get her into
the seclusion room and administer medication.
The patient was clearly kicking and fighting staff.
The DRM identified staff as two male RNs [Staff
#6 and #7], one female RN [Staff #8] and one
female MHW (mental health worker) [Staff #10].
The patient was attired in a hospital gown and
had nothing on under it. As the struggle
continued, there were numerous moments when
the gown was not covering her body. Emergency
medication was brought in and administered to
the patient by two male RNs and the female
MHW. The patient continued to struggle. At
Event ID: U1JY11
Facility ID: 810876
PRINTED: 03/02/2015
FORM APPROVED

OMB NO. 0938-0391

A. BUILDING ______________________
(X3) DATE SURVEY

COMPLETED
C
454121
B. WING _____________________________

(X4) ID
PREFIX
TAG
10/14/2014
AUSTIN, TX 78745


DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
A 144
approximately 7:54 p.m., one of the male nurses

[Staff #6] grabbed the patient's gown with his right
hand and ripped the gown off, leaving the patient
completely nude. All staff then left the seclusion
room and the door was shut. The only other item
in the room was a mattress. The patient was
naked in Seclusion Room #2 for approximately 23
minutes. A nurse returned to the room at 8:17
p.m. to hand the patient a gown. The video
playback was stopped at that point.
Facility policy #PC-C-3 entitled Seclusion and

Restraint, last revised 6/19/14, stated in part:
"Use of restraint and seclusion is initiated only as
an intervention of last resort in an emergency
situation where a patient is in imminent danger of
causing harm to self or others and all other less
restrictive or invasive measures have been
attempted and failed ...The treatment philosophy
is centered on providing a positive, healing
experience...
17. Staff members must respect and preserve
the rights of an individual during restraint or
seclusion...
Personal Possessions (facility's bold)
1. The individual's right to retain personal
possessions and personal articles of clothing may
be suspended during restraint or seclusion when
necessary to ensure the safety of the individual or
others...
4. If personal articles of clothing are taken from
the individual, appropriate other clothing will be
issued..."
Event ID: U1JY11
Facility ID: 810876
PRINTED: 03/02/2015
FORM APPROVED

OMB NO. 0938-0391

A. BUILDING ______________________
(X3) DATE SURVEY

COMPLETED
C
454121
B. WING _____________________________

(X4) ID
PREFIX
TAG
10/14/2014
AUSTIN, TX 78745


DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
A 144
The above findings were again confirmed in an

interview on the afternoon of 10/14/14 with the
Chief Executive Officer (CEO) and other
administrative staff in the facility meeting room.
The CEO stated in part, "We don't do that here.
We don't leave patients without clothes." The
Director of Nursing stated in part, "We've now
addressed the issue with this staff member."
Event ID: U1JY11
Facility ID: 810876

Inspection Report - Austin Oaks Hospital

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PRINTED: 03/02/2015

DEPARTMENT OF HEALTH AND HUMAN SERVICES

OMB NO. 0938-0391

(X3) DATE SURVEY

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

1407 WEST STASSNEY LANE

AUSTIN OAKS HOSPITAL

SUMMARY STATEMENT OF DEFICIENCIES

A 000 INITIAL COMMENTS

PROVIDER'S PLAN OF CORRECTION

An entrance conference was held with the facility

An exit conference was held with the facility Chief

Complaint #TX00204476 was substantiated with

A hospital must protect and promote each

Event ID: U1JY11

Facility ID: 810876

If continuation sheet Page 1 of 10

DEPARTMENT OF HEALTH AND HUMAN SERVICES

OMB NO. 0938-0391

(X3) DATE SURVEY

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

1407 WEST STASSNEY LANE

AUSTIN OAKS HOSPITAL

SUMMARY STATEMENT OF DEFICIENCIES

A 115 Continued From page 1

PROVIDER'S PLAN OF CORRECTION

The patient has the right to receive care in a safe

A review of the medical record of Patient #1

Event ID: U1JY11

Facility ID: 810876

If continuation sheet Page 2 of 10

DEPARTMENT OF HEALTH AND HUMAN SERVICES

OMB NO. 0938-0391

(X3) DATE SURVEY

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

1407 WEST STASSNEY LANE

AUSTIN OAKS HOSPITAL

SUMMARY STATEMENT OF DEFICIENCIES

A 144 Continued From page 2

PROVIDER'S PLAN OF CORRECTION

3:55 p.m. An Admission Assessment completed

A Psychiatric Evaluation dictated on 10/8/14 at

A review of Physician Orders for Patient #1

Event ID: U1JY11

Facility ID: 810876

If continuation sheet Page 3 of 10

DEPARTMENT OF HEALTH AND HUMAN SERVICES

OMB NO. 0938-0391

(X3) DATE SURVEY

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

1407 WEST STASSNEY LANE

AUSTIN OAKS HOSPITAL

SUMMARY STATEMENT OF DEFICIENCIES

A 144 Continued From page 3

PROVIDER'S PLAN OF CORRECTION

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

Telephone order by [Staff #4, facility psychiatrist]

Telephone order by [Staff #5, Advanced Practice

A review of 12-Hour Nursing