HospitalInspections.org

Based on policy and procedure review, closed medical record reviews and staff interviews the emergency department staff failed to obtain an order for a chemical restraint per the hospital policy and procedure in 2 of 2 patients medical records reviewed in the emergency department (ED) (Patients #2 and #5).

The findings include:

Review of the Policy "Restraint of Patients, PC 17" Last Revised 03/2015 revealed "PURPOSE: The use of restraints is a therapeutic intervention implemented to prevent the patient from injuring himself/herself or from injuring others. The decision to use a restraint is driven by a comprehensive individual assessment. This document is used to provide consistent guidelines for the safe use of chemical and physical restraints and seclusion, if alternatives, as determined by an interdisciplinary team, have proven to be clinically ineffective to provide a safe environment for the patient."..DEFINITIONS: Chemical Restraints- drug used as a restraint; a medicine used to control behavior or to restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's medical or psychiatric condition......PROCEDURE FOR USE OF RESTRAINT: Initiation and Renewal of Orders Standing orders, protocols, and/or PRN orders are not permitted. When initiating the use of a restraint, the appropriate restraint physician's order form (Nonviolent or Violent/Self Destructive) must be completed and placed on the chart within 30 minutes. This original order is time-limited based on type of restraint and age of patient. ...The physician's/LIP's order must specify: *the restraint type *the justification for the restraint *date and time ordered *duration ...For Violent/Self-Destructive Restraints [V/SD] ..The time limit for Violent/Self-Destructive Restraints is: *4 hours for adults (18 years of age or older) ..."

1. Closed medical record review of Patient #2 revealed a 34 year old male who presented to the emergency department on 04/16/2015 at 1500 accompanied by law enforcement under Involuntary Commitment status (IVC). Record review revealed "Suicide Precaution Flow Sheet Behavior at 1715 as AG= aggressive, UN= uncooperative". Record review of nursing documentation revealed at 1759 "Pt given Haldol 5mg IM "without" his cooperation. Has still been pacing around the room and standing in his doorway". Record review revealed no physician order for a chemical restraint.

Interview with Interim Emergency Department Director on 07/01/2015 at 1300 revealed Haldol is given to patients who exhibit behaviors that are "combative, hitting, punching or aggressive". The interview confirmed the policy for use of chemical restraints was not followed by the facility staff.

2. Closed medical record review of Patient #5 revealed a 34 year old female patient who presented to the emergency department on 05/22/2015 at 0649 accompanied by law enforcement under Involuntary Commitment status(IVC). Record review of nursing documentation on 05/25/2015 at 1845 revealed "Haldol 2mg IM for attempting to walk out again, reinforcing with patient she will go back to room 7 no TV and restraints...." Record review revealed no physician order for a chemical restraint.

Interview with Interim Emergency Department Director on 07/01/2015 at 1300 revealed Haldol is given to patients who exhibit behaviors that are "combative, hitting, punching or aggressive". The interview confirmed the policy for use of chemical restraints was not followed by the facility staff.

Based on policy and procedure review, closed medical record reviews and staff interviews the emergency department staff failed to reassess a patient per the hospital policy and procedure in 6 of 9 emergency department (ED) records reviewed (#1, #2, #3, # 5, #7 and #11).

The findings include:

Review of the Emergency Department policy, "Assessments and Reassessments", last reviewed/revised 10/2014" ...B. REASSESSMENTS: 1. The frequency of reassessment is based on the patient's acuity, condition, history, and complaint, or as directed by the Physician or Physician Extender; minimally every four (4) hours.. 2. In the event that there are no beds available in the treatment area and a patient has been assigned a Triage Level Two or Three, reassessments should reflect individual patient clinical condition where close monitoring may be necessary...... Triage Level Two: The patient should be minimally reassessed every one (1) hour. Triage Level Three: The patient should be minimally reassessed every two (2) hours..3. Timing of reassessments should reflect the patient's status at any given moment they are in the treatment area, remembering that a patients' priority/acuity can change...5. All patients should be reassessed and have a complete set of vital signs, including temperature, when clinically indicated, within one (1) hour of patient's discharge..."

1. Closed medical record review on 06/30/2015 for Patient #1 revealed a 25 year-old male who presented to the Emergency Department via EMS on 4/2/15 at 0401 requesting evaluation of possible leg injury. Patient had been found by police, who stated patient appeared to be in a "manic state." Triage assessment was completed 4/2/15 at 0409 and review of the ED Triage report revealed patient was assigned an acuity score of "2". Review revealed (VS) vital signs (T-temperature, P-pulse, R-respirations, BP-blood pressure, O2-oxygen saturation) were T-97, P-112, R-18, BP-173/73, O2 97%. Record review revealed additional vital signs were obtained on 04/2/15 at 0758 (3 hours 49 minutes later), with results as P-84, R-16, BP 93/50, and O2 99%. Record review revealed additional VS taken at 1400(6 hours 2 minutes later) with results as P-82, R-20, BP-110/64, O2-96%. Record review revealed no further documentation of vital signs was available for review.

Interview with Informatics Nurse on 06/30/2015 at 1500 revealed no further documentation was available for review.

Interview with Interim ED Director on 07/01/2015 at 1300 revealed the "Assessment and Reassessment" policy in the emergency department was not followed by the nursing staff.

2. Closed medical record review on 06/30/2015 of Patient #2 revealed a 34 year-old male patient who presented to the emergency department under Involuntary Commitment orders (IVC) accompanied by law enforcement on 04/16/2015 at 1500. Triage assessment with vital signs (blood pressure, pulse, respirations, temperature, oxygen saturation) BP 143/57, Pulse 68, Respirations 20, Temperature 98.2 F (degrees Fahrenheit) 100% oxygen saturation (SpO2) was competed at 1510 and assigned a level two (2) acuity. Medical record review revealed vital signs were obtained on 04/16/2015 at 1930 (4 hours 20 minutes later) BP 130/77, pulse 66, respirations 20, temperature 98 F and SpO2 98%. and on 04/17/2015 at 0600 vital signs documented are BP 128/77, pulse 68, respirations 16, temperature 98 F, SpO2 98% ( 11 hours 30 minutes later). Record review revealed no further documentation available for review. Patient #2 was transferred to psychiatric facility in care of deputy on 04/17/2015 at 0752.

Interview with Informatics Nurse on 06/30/2015 at 1500 revealed no further documentation was available for review.

Interview with Interim ED Director on 07/01/2015 at 1300 revealed the "Assessment and Reassessment" policy in the emergency department was not followed by the nursing staff.

3. Closed medical record review on 06/30/2015 of Patient #3 revealed a 52 year-old male patient who presented to the emergency department on 04/16/2015 at 1953 for a chief complaint of "Crisis Evaluation Referral". Record review revealed at 2004 he was assigned a level two (2) acuity with vital signs documented BP 136/80, pulse 98, respirations 18, temperature 99.4 F and SpO2 96%. Record review revealed vital signs were documented on 04/17/2015 at 1546 BP 126/76, pulse 61, respirations 18, temperature 98.7 and SpO2 96% (15 hours 42 minutes later) and at 1800 BP 126/75, pulse 61, respirations 18, temperature 98.7 F and SpO2 96%. Record review revealed the Patient was transferred to a psychiatric facility on 04/17/2015 at 1800 in care of a deputy.

Interview with Informatics Nurse on 06/30/2015 at 1500 revealed no further documentation was available for review.

Interview with Interim ED Director on 07/01/2015 at 1300 revealed the "Assessment and Reassessment" policy in the emergency department was not followed by the nursing staff.

4. Closed medical record review on 06/30/2015 of Patient #5 revealed a 34 year-old patient who presented to the emergency department on 05/22/15 at 0649 under IVC with Warren county deputy. Record review revealed the patient was assigned a level two (2) acuity at triage at 0658 and vital signs BP 141/89, pulse 100, respirations 18, temperature 97.5 F and SpO2 100%. Record review revealed vital signs documented on 05/22/15 at 2000 BP 144/83, pulse 100, respirations 16, temperature 96.4 and SpO2 100% ( 13 hours 2 minutes later ) on 05/23/2015 at 2100 BP 140/86, pulse 100, respirations 18, Temperature 98 F and SpO2 100%. ( 25 hours later), on 05/24/2015 at 0920 BP 142/87, pulse 110, respirations 17, temperature 98.6 and SpO2 100% (12 hours 20 minutes later) on 05/24/2015 at 1925 BP 136/71, pulse 84, respirations 18, and SpO2 100% ( 12 hours 5 minutes later) on 05/25/2015 at 0720 BP 146/100 pulse 92, respirations 20, temperature 98 F and SpO2 98% (11 hours 55 minutes later) on 05/25/2015 at 1900 BP 135/78, pulse 88, respirations 18, temperature 96.8 F and SpO2 98% ( 11 hours 40 minutes later) on 05/26/2015 at 0500 BP 124/79, pulse 73, respirations 18 and SpO2 98% ( 10 hours later) on 05/26/2015 at 0800 BP 119/75, pulse 80, respirations 18, temperature 98 F and SpO2 99% (3 hours later) on 05/26/2015 at 1800 BP 114/68, pulse 90, respirations 18, temperature 96.4 and SpO2 100% (10 hours later) on 05/27/2015 at 0700 BP 115/73, pulse 75, respirations 20, temperature 98.3 F and SpO2 100% ( 13 hours later) on 05/27/2015 at 2130 BP 146/74, pulse 83, respirations 18, temperature 96.5 F and SpO2 98% ( 9 hours 30 minutes later) on 05/28/2015 at 0926 BP 118/75, pulse 97, respirations 18, temperature 97.8 F and SpO2 99% ( 11 hours 56 minutes later ) and on 05/27/2015 at 1136 BP 123/7, pulse 81, respirations 20, temperature 97.7 F and SpO2 98% (2 hours 10 minutes later. Record review revealed no further documentation available for review. Record review revealed on 05/27/15 at 1610 the patient was transferred to another medical center accompanied by Warren County Sheriff Department.

Interview with Informatics Nurse on 06/30/2015 at 1500 revealed no further documentation was available for review.

Interview with Interim ED Director on 07/01/2015 at 1300 revealed the "Assessment and Reassessment" policy in the emergency department was not followed by the nursing staff.

5. Closed medical record review on 07/01/2015 revealed a 14 year-old female patient who presented to the emergency department on 06/29/2015 at 1807. Record review revealed the patient was assigned a Level two (2) acuity and triage was completed at 1816. Record review revealed vitals signs at on 06/30/2015 at 0200 BP 115/76, pulse 82, respirations 18 and SpO2 98% ( 7 hours 44 minutes after triage) on 06/30/2015 at 0758 BP 110/59, pulse 88, respirations 16 and SpO2 99% ( 5 hours 58 minutes later) on 06/30/2015 at 1255 BP 114/60, pulse 88, respirations 18 and SpO2 99% (5 hours 3 minutes later) on 06/30/2015 at 1530 BP 98/59, pulse 90, respirations 18 and SpO2 98% ( 2 hours 35 minutes later) on 06/30/2015 at 2000 BP 112/60, pulse 88, respirations 18, temperature 97.8 F and SpO2 98% (4 hours 30 minutes later). Record review revealed no further documentation for review. Record review revealed the patient was transferred to psychiatric facility on 06/30/2015 at 2307 accompanied by officer.

Interview with Informatics Nurse on 06/30/2015 at 1500 revealed no further documentation was available for review.

Interview with Interim ED Director on 07/01/2015 at 1300 revealed the "Assessment and Reassessment" policy in the emergency department was not followed by the nursing staff.

6. Closed medical record review on 07/01/2015 revealed a 59 year-old male patient who presented to the emergency department on 04/16/2015 at 1645 by law enforcement officer under IVC status. Record review revealed at 1700 the triage assessment was completed and patient was assigned a level two (2) acuity and vital signs BP 148/64, pulse 84, temperature 99.2 F and SpO2 93% on 04/14/2015 at 0750 BP 131/86, pulse 76, respirations 20, temperature 96.9 F and SpO2 97% (14 hours 50 minutes later) on 04/14/2015 at 1600 BP 138/67, pulse 64, respirations 18, temperature 98 F and SpO2 100% (7 hours 10 minutes later) on 04/14/2015 at 2230 BP 128/68, pulse 68, respirations 18, temperature 98 F and SpO2 100% (4 hours 30 minutes later) on 04/15/2015 at 0742 BP 144/67, pulse 72, respirations 20, temperature 98.1 F, and SpO2 99% ( 8 hours 12 minutes later) and on 04/15/2015 at 1531 BP 132/71, pulse 70, respirations 18, temperature 96 F, and SpO2 99% (7 hours 49 minutes later). Record review revealed no further documentation for review. Record review revealed on 04/15/2015 at 1650 the patient was transferred to another medical facility in care of deputy.

Interview with Informatics Nurse on 06/30/2015 at 1500 revealed no further documentation was available for review.

Interview with Interim ED Director on 07/01/2015 at 1300 revealed the "Assessment and Reassessment" policy in the emergency department was not followed by the nursing staff.