HospitalInspections.org

Based on document review and interview, it was determined, for 2 of 2 clinical records reviewed (Pts. #3 & 4) for patients receiving psychotropic medication, the Hospital failed to ensure patients consented to taking psychotropic medications prior to administration.

Findings include:

1. Hospital policy number IMMC-123-071, titled, "Informed Consent for Mental Health Treatment provided in a Mental Health Facility", published on 9/14/15, was reviewed on 11/5/15 at 11:25 AM. The policy required, "II. Policy... Consent for administration of psychotropic medication or electroconvulsive therapy (ECT) may be authorized for a patient in the following ways: 1. By a patient, 18 years or older, capable of making treatment decisions. If a patient objects, no treatment can be administered except as an emergency or by court order..."

2. On 11/2/15 at 10:35 AM, Pt. #3's clinical record was reviewed. Pt. #3 was a 54 year old male, admitted on 10/27/15, with a diagnosis of schizophrenia. Pt. #3's
physician order dated 10/28/15 at 9:00 AM, included Depakote (to treat bipolar mania), 250 mg tablet, every 12 hours. Pt. #3's physician order dated 11/1/15 at 9:00 AM, included Haldol (to treat psychosis), 100 mg intramuscular, every 4 weeks. Pt. #3's medication administration record (MAR) included administration of Depakote from 10/28/15 through 11/2/15 and Haldol on 11/1/15. Pt. #3's consent for psychotropic medication had not been completed.

3. On 11/2/15 at 10:40 AM, Pt. #4's clinical record was reviewed. Pt. #4 was a 56 year old male, admitted on 10/28/15, with a diagnosis of bipolar disorder. Pt. #4's
physician order dated 10/31/15 at 9:00 PM, included Seroquel (to treat bipolar depression), 200 mg tablet, at bedtime. Pt. #4's MAR included administration of Seroquel from 10/31/15 through 11/1/15. Pt. #4's consent for psychotropic medication had not been completed

4. On 11/2/15 at 10:40 AM, an interview was conduced with a BHU Nurse Clinician III (E #5). E #5 stated the psychotropic consent forms should be completed within 24 hours of admission.

Based on document review, observation, and interview, it was determined, for 3 of 3 patients (Pts. #8, 9, and 10) on suicide precautions, on the behavioral health unit (BHU), the Hospital failed to ensure patient safety checks were completed every 15 minutes, as required by policy.

Findings include:

1. Hospital policy IMMC-123-025, titled, "Suicide Precautions (Behavioral Health)", published on 9/14/15, was reviewed on 11/5/15 at 10:00 AM. The policy included, "III. Definitions... Suicidal precautions 'SP2' - 15 minutes randomized checks: 1. The patient is expressing suicidal ideation, does not have a specific plan... IV. Procedure... Specific to SP2: 1. Patients on SP2 are rounded on every 15 minutes by designated staff, documenting their location and behavior on the special observation/behavior checklist."

2. On 11/2/15 at 9:45 AM, an observational tour was conducted in the BHU. The 15 minute safety rounding sheets (special observation/behavior checklists) were reviewed, but had not been completed since 9:00 AM. Documentation for 9:15 AM and 9:30 AM had not been done. There were 25 patients on the BHU on 15 minute safety checks. Nine of the patients were on suicidal precautions. Three examples include:

- Pt. #8 was a 43 year old male, admitted on 11/1/15, with diagnoses of bipolar disorder and depression. Pt. #8's physician order dated 11/1/15 at 6:42 AM, included, SP2 precaution on 15 minute safety checks.

- Pt. #9 was a 43 year old male, admitted on 10/31/15, with a diagnosis of schizophrenia. Pt. #9's physician order dated 10/31/15 at 2:49 PM, included, SP2 precaution on 15 minute safety checks.

- Pt. #10 was a 29 year old female, admitted on 11/1/15, with a diagnosis of bipolar disorder. Pt. #10's physician order dated 11/1/15 at 11:45 AM, included, SP2 precaution on 15 minute safety checks.

3. On 11/2/15 at 10:35 AM, an interview was conducted with the BHU Clinical Nurse Manager (E #2). E #2 stated that the 15 minute checks had been completed, but not documented.

Based on document review and interview, it was determined, for 1 of 3 clinical records reviewed (Pt. #7) for emergency department (ED) patients in restraint or seclusion, the Hospital failed to ensure a secluded patient was provided face to face assessment by a qualified individual after 16 hours of continuous seclusion, as required by policy.

Findings include:

1. Hospital policy number SYS-017-031 titled, "Utilization of Restraint and Seclusion", published on 10/15/15, was reviewed on 11/5/15 at 12:50 PM. The policy required, "IV. Procedures: D. Restraint and Seclusion for Violent or Self-destructive behavior: 1. Physician Orders and Physician Assessment: g) If the patient continues to require restraint or seclusion for more than 16 hours, the physician or appropriately trained RN will complete a face-to-face assessment before a new order can be written..."

2. On 11/4/15 at 1:45 PM, Pt. #7's clinical record was reviewed. Pt. #7 was a 48 year old female, arriving in the ED on 11/4/15, for psychiatric evaluation following alleged assault to another person. Pt. #7's initial seclusion order was dated 10/27/15 at 9:30 AM. The order was continuously renewed for over 28 hours, through 10/28/15 at 2:00 PM, and Pt. #7 remained in seclusion. There was no face to face documentation after the initial order.

3. On 11/4/15 at 2:35 PM, an interview was conducted with the ED Manager (E #6). E #6 stated ED nurses do not do face to face assessments for restrained or secluded patients. The physicians need "specific education" to provide face to face assessment after 16 hours of continuous restraint or seclusion.