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Based on record review and interview the psychiatric hospital failed to ensure care in a safe setting. The deficient practice is evidenced by failure to assess 1(#2) of 1 reviewed patient with symptoms of alcohol withdrawal as ordered by the licensed practitioner.
Findings:

Review of the medical record for Patient #2 revealed admission on 06/07/2024 with a diagnosis of major depressive disorder, suicidal ideations, and alcohol use.

Review of the orders for Patient #2 revealed on 06/08/2024 at 11:50 a.m. an order was placed for, "CIWA [Clinical Institute Withdrawal Assessment], Every four hours. Request Type: Routine."

Review of the psychiatric evaluation for Patient #2 performed on 06/08/2024 at 2:01 p.m. revealed in part, "Patient also reported 'crawling out of my skin,' ongoing anxiety, and tremors noted to bilateral hands."

Further review of the medical record revealed the CIWAs were performed as listed:
06/08/2024 at 9:55 a.m.; Score 3;
06/08/2024 at 12:40 p.m.; Score 14;
06/08/2024 at 2:20 p.m.; Score 1;
06/08/2024 at 9:00 p.m.; Score 4;
06/09/2024 at 8:03 a.m.; Score 11;
06/09/2024 at 3:15 p.m.; Score 11;
06/09/2024 at 9:23 p.m. ; Score 16;
06/10/2024 at 3:39 p.m.; Score 19;
06/10/2024at 8:58 p.m.; Score 11;
06/11/2024 at 4:54 p.m.; Score 12;
06/11/2024 at 9:20 p.m.; Score 11;
06/12/2024 at 6:13 p.m.; Score 11;
06/13/2024- 7:30 a.m.; Score 2.

In interview on 06/24/2024 at 2:25 p.m., S2QD verified the assessments were rarely done within 4 hours of the previous assessment.

Based on record review and interview, the psychiatric hospital failed to ensure the use of chemical restraints was documented according to facility policy. The deficient practice is evidenced by failure to document the use of a chemical restraint in 1 (#4) of 4 (#1-#4) reviewed patient records.
Findings:

Review of Policy #NSG-71, "Seclusion and Restraints," revealed in part," Definitions: Restraint: . . . A restraint may also be a drug or medication (chemical restraint) when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom for movement and is not a standard treatment or dosage for the patient's condition." Further review of the policy revealed, "PROCEDURE: 1. Initiation: . . . The physician/NPP order must include the specific behaviors which constituted the behavioral emergency, specify the reason for restraint or seclusion, the type of restraint, and the duration of seclusion or restraint. . . . 4. Face-to-Face Evaluation: A one-hour face-to-face patient evaluation must be conducted in person by a physician or other NPP, or trained RN in the absence of the physician or NPP. . . . 7. Monitoring: . . . . The RN must assess the patient upon initiation of seclusion/restraint, after the first 15 minutes of seclusion/restraint, during the one-hour face-to-face assessment, every hour the patient remains in seclusion/restraint, and upon discontinuation of seclusion/restraint. . . . Emergency psychoactive medication administration follows the same protocol and procedure: every 15 minutes an assessment and vital signs must be conducted, and the one-hour RN assessment is performed. All patients receiving intramuscular psychoactive medication will be assessed at a minimum of every 15 minutes for one hour for vital signs, nutritional needs, and safety. A complete RN assessment will be performed at one hour and documented on the flow sheet . . . 9. Debriefing: Identify what led to the episode and what could have been handled differently."

Review of the medical record for Patient #4 revealed admission on 06/17/2024 with a diagnosis of dementia with behavioral disturbance.

Review of the orders for Patient #4 revealed on 06/18/2024 at 1:17 a.m. orders were entered for "haloperidol lactate (Haldol injectable) 5 MG/ML, 5 mg (1 mL) intramuscularly One Time Only. Medication Indication: agitation," and "diphenhydramine HCl (Benadryl) 50 MG/ML, 50 mg (1mL) intramuscularly One Time Only- Medication Indication: agitation."

Review of the medical record for Patient #4 revealed on 06/18/2024 at 1:24 a.m. S4LPN documented, "Patient in quiet room sitting on mattress taking off his gown and bed sheets when techs attempt to change patient and fix bedding patient becomes violent trying to hit and spit on staff, order received from S5NP for Benadryl 50 mg and Haldol 5 mg injection given in the right deltoid and tolerated well at this time. Care ongoing for patient." Further review of the medical record revealed a restraint/seclusion flowsheet was not filled out.

In interview on 06/27/2024 at 9:10 a.m., S2QD verified the medications administered were not part of the regular behavior management for the patient and qualified as a chemical restraint. S2QD verified the hospital's policy was not followed and there was no additional documentation of the incident in the medical record. S2QD verified there was no flow sheet in the medical record with documentation of the interventions and assessments.

Based on record review and interview, the psychiatric hospital failed to ensure a one-hour face-to-face asssessment was performed with the initiation of chemical restraints. The deficient practice is evidenced by failure to document a one-hour face-to-face in 1 (#4) of 1 reviewed patient record with the use of restraint.
Findings:

Review of Policy #NSG-71, "Seclusion and Restraints," revealed in part," Definitions: Restraint: . . . A restraint may also be a drug or medication (Chemical restraint) when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom for movement and is not a standard treatment or dosage for the patient's condition." Further review of the policy revealed, "PROCEDURE: 1. Initiation: . . . The physician/NPP order must include the specific behaviors which constituted the behavioral emergency, specify the reason for restraint or seclusion, the type of restraint, and the duration of seclusion or restraint. . . . 4. Face-to-Face Evaluation: A one-hour face-to-face patient evaluation must be conducted in person by a physician or other NPP, or trained RN in the absence of the physician or NPP. . . . 7. Monitoring: . . . . The RN must assess the patient upon initiation of seclusion/restraint, after the first 15 minutes of seclusion/restraint, during the one-hour face-to-face assessment, every hour the patient remains in seclusion/restraint, and upon discontinuation of seclusion/restraint. . . . Emergency psychoactive medication administration follows the same protocol and procedure: every 15 minutes an assessment and vital signs must be conducted, and the one-hour RN assessment is performed. All patients receiving intramuscular psychoactive medication will be assessed at a minimum of every 15 minutes for one hour for vital signs, nutritional needs, and safety. A complete RN assessment will be performed at one hour and documented on the flow sheet . . . 9. Debriefing: identify what led to the episode and what could have been handled differently."

Review of the medical record for Patient #4 revealed admission on 06/17/2024 with a diagnosis of dementia with behavioral disturbance.

Review of the orders for Patient #4 revealed on 06/18/2024 at 1:17 a.m. orders were entered for "haloperidol lactate (Haldol injectable) 5 MG/ML, 5 mg (1 mL) intramuscularly One Time Only. Medication Indication: agitation," and "diphenhydramine HCl (Benadryl) 50 MG/ML, 50 mg (1mL) intramuscularly One Time Only- Medication Indication: agitation."

Review of the medical record for Patient #4 revealed on 06/18/2024 at 1:24 a.m. S4LPN documented, "Patient in quiet room sitting on mattress taking off his gown and bed sheets when techs attempt to change patient and fix bedding patient becomes violent trying to hit and spit on staff, order received from S5NP for Benadryl 50 mg and Haldol 5 mg injection given in the right deltoid and tolerated well at this time. Care ongoing for patient." Further review of the medical record revealed a restraint/seclusion flowsheet was not filled out.

In interview on 06/27/2024 at 9:10 a.m., S2QD verified the medications administered were not part of the regular behavior management for the patient and qualified as a chemical restraint. S2QD verified the hospital's policy was not followed and there was no documentation the registered nurse performed a face-to-face assessment one hour after the restraint was initiated.

Based on record review and interview, the psychiatric hospital failed to ensure medications were administered as ordered and according to standard of care. The deficient practice is evidenced by failure to administer medications as ordered for 1 (#4) of 4 (#1-#4) reviewed patient records.
Findings:

Review of the medical record for Patient #4 revealed admission on 06/17/2024 with a diagnosis of dementia with behavioral disturbance.

Review of the orders for Patient #4 revealed an order from admission for "clonidine HCl 0.1 mg (1 tablet(s)) by mouth; Every 4 hours; PRN Systolic>160; Diastolic >90; Indication: hypertension."

Review of the vital signs revealed on 06/22/2024 at 1:00 a.m. Patient #4 had a blood pressure of 162/91 mmHg.

Review of the Medication Administration Record (MAR) revealed the medication was not administered.

In interview on 06/26/2024 at 9:04 a.m., S2QD verified the medication was not administered as ordered.