HospitalInspections.org

Based on staff interview and record review, the hospital failed to ensure a patient's rights were protected regarding the right to refuse treatment related to medication administration in the Emergency Department for 1 of 10 patients in the targeted sample. (Patient #1) Findings include:

Patient #1 filed a complaint with the State Survey Agency regarding an alleged violation of his/her right to request or refuse care and treatment in the Emergency Department (ED) during March, 2018. Specifically, the patient alleged that s/he was not offered medications to be administered via the oral route prior to receiving the medications via an involuntary intramuscular (I.M.) injection. This happened on 2 dates during the patient's time in the ED, on 3/30/18 and again on 3/31/18.

The Patient was brought to the ED by police after receiving information regarding the patient's threatening and assaultive actions against others at a group residence. Per review of the D.O. 's (Doctor of Osteopathic Medicine) Emergency Psychiatry Consultation on 3/30/18 at 1108 hours, the patient had refused to stay in the ED voluntarily and had 'no insight into the dangerousness of their behavior'. The Patient '...stands up and gestures towards me in a threatening way .....longstanding mental illness ....episodes of violence can occur while... ill.' The recommendations included: Patient is on an EE (emergency evaluation), may not leave, do not d/c ... ... ...hold the patient until a second certification ... ....completed'. Additional recommendations by the D.O. included the following: "In the event of a psychiatric emergency: Haldol 5 mg., Lorazepam 2 mg. and Diphenhydramine 50 mg. IM X 1" was written.
Per review of the note by the Physician Assistant (PA) provider assuming care for this patient on 3/30/18 at 0653, the 'Patient became very agitated ....uncooperative ....required Haldol (IM), Ativan, (IM) and Benadryl (oral). The provider note did not document an assessment of the patient at the time, nor the imminent danger to self/others that required I.M. administration of the Haldol and the Lorazepam. The provider did not order oral medications to be offered first for the Haldol and the Lorazepam. The provider placed the orders for these I.M. medications on 3/30/18 as 'now X 1, at 1011 hours.

The RN providing nursing care wrote '....awoke and was extremely agitated ....aggressive ....yelling ....security called ....' The patient received Haldol 5 mg. (milligrams) IM, Benadryl 50 mg. PO and Ativan 2 mg IM .....with good effect'. The RN documented no specific less restrictive interventions attempted to calm the patient. It was noted that only one of the medications was ordered orally. (Later the same day, the patient did willingly take these same medications orally.)
Per review of the patient's MAR (medication administration record) and interview (6/27/18 at 10:30 AM), the RN who administered the injections, stated that another RN providing care requested that s/he administer the two I.M. medications after stating to her/him that the '...Patient won't take them PO (by mouth)...' The RN who administered the I.M. medications was asked if there was any type of physical hold on the patient during the medication administration and s/he stated that they could not remember.

On 3/31/18 at 3:51 PM, another P.A. provider ordered Haloperidol 5 mg. injection, Diphenhydramine 50 mg. injection and Lorazepam 2 mg. injection after the patient became 'agitated'. There was no evidence of any assessment prior to ordering the medications via the I.M. route. There was no documentation of the behavior that posed a risk of serious harm at the time. There were no orders to administer PO if the patient allowed. During a telephone interview with the P.A. on 6/27/19 at 7:35 AM, the provider confirmed that s/he was not in the room when the nurse administered the medications. S/he further stated that if there was a behavioral emergency, then most of the time, s/he would follow the recommendations of the consulting provider. The RN who administered the medications I.M. injected the medications into the left gluteus medius muscle; there was no documentation of whether there was a physical hold used during the injection.

Per interview on 6/26/28 at 9:12 AM, the RN Emergency Department Manager stated that when patients pose a serious threat of harm to self or others, we may give I.M. medications. we go through a thorough process, attempting redirection, offer PO medications (draw both medication routes), using the least restrictive intervention. Medications used in the ED for violent or dangerous behaviors are only used to treat the patient's symptoms.

In summary, per review of the sample of 10 medical records and interviews with hospital staff who provided care, Patient #1 was not offered medications PO (orally) prior to I.M. administrations.