HospitalInspections.org

Based on record review and interview, the facility failed to ensure;

1.
ensure chemical restraints that were administered Intramuscularly (IM) or Intravenous (IV) for behavioral emergencies were identified and monitored as chemical restraints in 2 of 2 (# 9 and # 10) patient charts reviewed.

Refer to Tag A0160

2.
chemical restraints were not ordered or administered as PRN (as needed) in 3 of 3 (#9, #10, and #6) patient charts reviewed.

Refer to Tag A0169

3.
the policy and procedure for restraint and seclusion instructed staff on determining appropriate frequencies of assessment and monitoring, after the administration of a chemical restraint in 3 of 3 (#9, 10, and 6) charts reviewed.

Refer to Tag A0175

4.
a face-to-face evaluation was conducted in person by a physician, licensed practitioner (LP), or trained RN after the administration of a chemical restraint in 3 of 3(#9, 10, and 6) charts reviewed.

Refer to Tag A0178

Based on record review and interview, the facility failed to ensure chemical restraints that were administered Intramuscularly (IM) or Intravenous (IV) for behavioral emergencies were identified and monitored as chemical restraints in 2 of 2 (# 9 and # 10) patient charts reviewed.

Patient #9
A review of patient #9 medical record (MR) revealed patient #9 was brought to the emergency room on 08/14/2023 at 10:51 a.m. by the police.

A review of the nurses notes dated 8/14/23 stated, "Psychiatric Evaluation (ARRIVED VIA SHERIFF'S DEPARTMENT WITH EDW IN PLACE TO OUR FACILITY BY _______( CHC worker) WITH CHC--WAS SENT OVER PER RECOMMENDATION OF CASEWORKER AT CHC--IT IS REPORTED BY CASEWORKER THAT PATIENT HAS BEEN HAVING AUDITORY HALLUCINATIONS WITH HOMICIDAL THREATS-IT IS REPORTED SHE HAD A MACHETE IN PLAIN SITE AND HAS THREATENED TO HARM HER HUSBAND AND CHC CASE WORKER--IT IS FELT SHE IS A DANGER TO HERSELF AND OTHERS--PT PRESENTS WITH FLIGHT OF IDEAS, CURSING AT SHERIFF DEPT STAFF AND HOSPITAL STAFF; SECURITY AT SIDE.)"

Patient #9 was ordered and administered the following medications on 8/14/23.
11:01 am Ativan (sedative) 2 mg IM once (there was no documented reason why the medication was ordered.) The medication was administered at 11:20 a.m.
11:10 am Benadryl (antihistamine) 50mg IM once (there was no documented reason why the medication was ordered.) The medication was administered IM at 11:25 a.m.
11:07 am Haldol (psychotropic) 10mg IM once. The medication was administered at 11:07 am. The physician order stated, " ...Adm instructions This medication is used within the pharmaceutical parameters based on standard of practice using established dosage parameters. Use of this medication is to allow the patient to be able to continue to interact/function with their environment. It is NOT being used to restrict their ability to interact with their environment." The physician documented that the drugs were being used as a therapeutic tool and not a restraint.
There was no documentation that Haldol, Ativan, and Benadryl were part of a patient's standard medical or psychiatric treatment and was administered within the standard dosage for the patient's condition that would be therapeutic to improve their level of functioning so patient #9 could participate in the milieu.

The physician documented the patient's unwanted behaviors on 8/14/23 as, "Abnormal behavior. Patient is disheveled. Patient is moving all extremities symmetrically. The patient's speech is not clear enough to be able to understand what she is saying. Occasionally I can understand statements like "fuck you."
The nurse documented on 8/14/2023 at 11:31 a.m. "PATIENT PRESENTS CURSING AT STAFF AND SHERIFF'S DEPARTMENT. WILL NOT COOPERATIVE (sic). PATIENT RAMBLING AND NOT MAKING SENSE."

There was no comprehensive patient assessment documented to assess the need for other types of interventions before using a drug or medication as a restraint. There was no documentation found of staff attempting to de-escalate the patient, seclusion, or even physical restraints as needed. The patient was not offered any medications by mouth.

Patient #9 was restricted by the medications which prevented her movement and participation with those around her causing this method of treatment to be a restraint.

On 8/14/23 at 1:41 p.m. the nurse documented, "CHC called and eval was attempted but pt was still sleeping and unable to stay awake long enough for eval, will call ____ (Mental health assessor) from CHC back once pt is awake enough for eval." A review of the sitter log revealed the patient was asleep from 12:30 p.m. on 8/14/23 until 7:15 a.m. on 8/15/23 a total of 19 hours.

On 8/15/23 at 7:30 a.m. the nurse documented, "PT THREW CUP OF WATER OF SECURITY GUARD (sic)."
There was no physician documentation for patient #9 on 8/15/23. Physician orders revealed on 8/15/23 at 12:03 p.m. patient #9 was ordered Haldol 5 mg IM once for agitation. The order read " ...Adm instructions This medication is used within the pharmaceutical parameters based on standard of practice using established dosage parameters. Use of this medication is to allow the patient to be able to continue to interact/function with their environment. It is NOT being used to restrict their ability to interact with their environment." The Haldol was documented as administered on 8/15/23 at 12:31 p.m.

On 8/15/23 at 12:02 p.m. patient #9 was ordered Benadryl 25mg IM stat once. There was no reason or documentation by the physician for the stat order of Benadryl. The medication was documented as administered on 8/15/23 at 12:32 p.m.

On 8/15/23 at 11:28 a.m. the physician's order stated Ativan 2 mg IV every 4 hours prn. There was no reason documented on the order or in the physician's notes why this sedative medication was ordered. The Ativan was not documented as given until 8/15/23 at 2:08 p.m., 2 hours and 10 minutes later.

On 8/15/23 at 1:54 p.m. the nurse documented, "Pt refuses to let staff get vital signs and continues to cuss at staff, vital signs unable to be obtained." There were no other descriptions of the patient's behaviors that warranted a threat to the safety of herself or others. There were no documented attempts to offer p.o. medications or any de-escalation attempts documented by the nurse or physician. A review of the q 15-minute activity checks revealed the patient was asleep from 2:30 p.m. on 8/15/23 until 5:15 a.m. on 8/16/23. Patient #9 was sedated for 15 hours after receiving Haldol, Ativan, and Benadryl.

A review of the nurse notes dated 8/18/23 at 11:40 stated, "SECURITY OFFICER, POLICE OFFICER X2, RN X2, AND CNA TO BEDSIDE FOR RESTRAINING PATIENT FOR MEDICATION ADMINISTRATION. TOLERATED POORLY PER PATIENT. PATIENT OBSERVED RUNNING AND JUMPING OFF OF BED, SWINGING PUNCHES TOWARDS CNA, OFFICER ABLE TO RESTRAIN PATIENT BEFORE THE PATIENT HIT OR MADE CONTACT WITH ANYTHING. PATIENT YELLING, OBSERVED PACING AROUND ROOM."

A review of patient #9's chart revealed there was no documentation that patient #9 had been seen or evaluated by a physician.

On 8/18/23 at 11:13 a.m. a verbal physician order was documented for a Haldol 5 mg injection (no clarification if IM or IV) stat as once for psychosis. A question on the order stated, "Is this being used as a chemical restraint?" the answer was documented as "yes." The medication was administered at 11:28 a.m. The physician electronically signed the order on 8/15/23 on 8/18/23 at 2:48 p.m.

On 8/18/23 at 11:12 a.m. a verbal physician order was documented for Benadryl 25 mg injection stat once and Ativan 2 mg administered at 11:26 a.m. from the PRN order written on 8/15/23.

A review of patient #9's chart revealed there was no documentation that the patient was evaluated by the physician or that a face to face was performed.

A review of the nursing flow sheet revealed the nurse documented on 08/18/23 at 1:48 p.m. "Anxious; Combative; Confused", however there was no interventions documented or an assessment of the patient performed. There were no vital signs obtained until 3:20 p.m. when the nurse documented respirations only. There was no documentation on the effectiveness of the medications and no face-to-face was performed.


Patient #10

A review of patient #10's chart revealed the patient was brought to the Emergency Room (ER) on 9/12/23 at 12:43 p.m. by ambulance. A review of the ER physician notes dated 9/12/2023 at 1:03 p.m. stated, "Patient is a 33-year-old with a history of some type of psychiatric disorder and was found at a local gas station saying he wanted to kill himself. He currently denies it but officers came in and said he went to the bathroom and said he had a pair of scissors and was going to end it all. Patient says he wants a refill on his Zyprexa but does not want to be a psychiatric patient. At the time of this dictation, officers were trying to get a hold placed on him via the local judge ...Psychiatric/Behavioral: Positive for agitation and behavioral problems."

A review of the laboratory results obtained on 9/12/23 revealed the patient was positive for amphetamines and marijuana.

A review of the physician orders on 9/12/23 at 12:48 p.m. revealed an order for Zyprexa (antipsychotic) 20mg by mouth. The medication was documented as given at 1:50 p.m.

A review of the physician's orders on 9/12/23 at 2:24 revealed an order for a haloperidol lactate (Haldol) injection of 5 mg IM once for agitation. The order stated next to the agitation comment "Haldol IV/IM is not approved for use for any other indication. Please order a different medication or access chemical restraints through the chemical restraint order panel." There was no documentation or indication that the physician followed the information given. There was no documentation by the physician of the patient's behavior at this time to indicate the need for this medication. The Haldol was documented as administered at 2:50 p.m.

A review of the physician's orders on 9/12/23 at 2:24 p.m. revealed an order for diphenhydramine (Benadryl) 25 mg IM once. There was no documented reason why the medication was ordered. The medication was administered at 3:07 p.m.

A review of the physician's orders on 9/12/23 at 2:24 p.m. revealed an order for Lorazepam (Ativan) 2 mg IM every 4 hours PRN. There was no documentation on why this sedative was ordered or why it was ordered PRN. The medication was administered at 3:11 p.m.

A review of the chart revealed that patient #10 allowed the nurse to obtain vital signs at 2:50 p.m. Other flowsheet entries stated, "RASS Score: Very Agitated Neurological Level of Consciousness: Alert. 3:00 p.m. nurse documented, "Interventions: Security at the bedside; Sitter; Additional staff at the bedside; ID band on Visual Checks: Continuous 1:1." 3:10 p.m. "PT MORE COOPERATIVE AT THIS TIME, FOLLOWING COMMANDS, CALM, AND DENIES SUDICAL/HOMICIDAL IDEATIONS (sic)." There was no face-to-face performed. There was no physician order to hold the patient for psychiatric medical clearance and no order for a sitter or 1:1. There was no documentation on who was the sitter and there were no q 15-minute observation sheets. There was no comprehensive patient assessment documented to assess the need for other types of interventions before using a drug or medication as a restraint. All available alternative treatment options should be considered before administering chemical or physical restraint, as it infringes on an individual's autonomy and dignity. There was no documentation found of staff attempting to de-escalate the patient, seclusion, or even physical restraints as needed. The patient was not offered any medications by mouth.

A review of the chart revealed patient # 10 was discharged out of the ED on 9/12/23 at 3:08 PM. The physician documented, "Discharge to home/self-care. Condition at discharge good." The physician had written an order to discharge before the patient had received all his medications, was evaluated, or assessed.

A review of the nurse notes dated 09/12/23 at 4:26 p.m. "WAITING FOR PD FOR RIDE." The patient was discharged to home with a follow-up appointment with the local mental health authority. Patient #10 was discharged to home 1 hour and 16 minutes after he had received chemical restraints.

A review of the restraint log revealed there were no chemical restraints listed for 2023. An interview was conducted with Staff #1 on 10/10/23. Staff #1 confirmed the facility was not identifying chemical restraints and placing them on the log. The facility was only adding physical restraints to the log. Staff # 2 stated that there was no quality data or analysis of data for chemical restraint administration for this hospital.

Based on record review and interview, the facility failed to ensure chemical restraints were not ordered or administered as PRN (as needed) in 2 of 2 (#10, and #6) patient charts reviewed.

Patient #10

A review of patient #10's chart revealed the patient was brought to the Emergency Room (ER) on 9/12/23 at 12:43 p.m. by ambulance. A review of the ER physician notes dated 9/12/2023 at 1:03 p.m. stated, "Patient is a 33-year-old with a history of some type of psychiatric disorder and was found at a local gas station saying he wanted to kill himself. He currently denies it but officers came in and said he went to the bathroom and said he had a pair of scissors and was going to end it all. Patient says he wants a refill on his Zyprexa but does not want to be a psychiatric patient. At the time of this dictation, officers were trying to get a hold placed on him via the local judge ...Psychiatric/Behavioral: Positive for agitation and behavioral problems."

A review of the laboratory results obtained on 9/12/23 revealed the patient was positive for amphetamines and marijuana.

A review of the physician orders on 9/12/23 at 12:48 p.m. revealed an order for Zyprexa (antipsychotic) 20mg by mouth. The medication was documented as given at 1:50 p.m.

A review of the physician's orders on 9/12/23 at 2:24 revealed an order for a haloperidol lactate (Haldol) injection of 5 mg IM once for agitation. The order stated next to the agitation comment "Haldol IV/IM is not approved for use for any other indication. Please order a different medication or access chemical restraints through the chemical restraint order panel." There was no documentation or indication that the physician followed the information given. There was no documentation by the physician of the patient's behavior at this time to indicate the need for this medication. The Haldol was documented as administered at 2:50 p.m.

A review of the physician's orders on 9/12/23 at 2:24 p.m. revealed an order for diphenhydramine (Benadryl) 25 mg IM once. There was no documented reason why the medication was ordered. The medication was administered at 3:07 p.m

A review of the physician's orders on 9/12/23 at 2:24 p.m. revealed an order for Lorazepam (Ativan) 2 mg IM every 4 hours PRN. There was no documentation on why this sedative was ordered or why it was ordered PRN. The medication was administered at 3:11 p.m.

A review of the chart revealed patient #10 was only given Ativan 2 mg IM prn only once but the order allowed the Nurses to use medical judgment to determine if a patient should be medicated based on a symptom and not objective parameters identified by the physician within the order.

A review of the restraint log revealed there were no chemical restraints listed for 2023. An interview was conducted with Staff #1 on 10/10/23 Staff #1 stated that the staff should have been documenting the behaviors that justified the chemical restraints and the staff had been trained previously not to administer any chemical restraints PRN. Staff #1 stated the facility should have been keeping a restraint log and monitoring the use of any restraints. .


Patient # 6

A review of patient #6's chart revealed the physician's history and physical (H&P) dated 8/4/2023 at 2:14 p.m. The H&P stated, "72-year-old female is found at a local nursing home to be more confused than usual and less interactive. EMS was called and when they arrived blood sugar of 17 was found. Treatment is initiated with D50 but only minimal improvement occurred. Work-up in the emergency department revealed persistent hypoglycemia and sepsis was identified with urinary tract infection. The patient's blood sugars eventually improved and with her urinary tract infection/sepsis, the decision was made to admit her to the hospital for continued treatment. Patient does have advanced dementia but does communicate although randomly at times. She is on full CODE STATUS. Overall this patient's prognosis is guarded."

A review of the chart revealed Patient #6 received a physician order for ziprasidone (GEODON) injection 10 mg, IM, Q8H PRN for DELIRIUM 8/5/23 at 09:41 AM. A review of the physician's progress notes on 8/06/23 states "She seems to calm down better with as-needed Geodon"

According to www.geodon.com Ziprasidone (Geodon) is a medication that works in the brain to treat schizophrenia. It is also known as a second-generation antipsychotic (SGA) or atypical antipsychotic. Ziprasidone rebalances dopamine and serotonin to improve thinking, mood, and behavior. There is no specific antidote to ziprasidone, and it is not dialyzable. The possibility of multiple drug involvement should be considered. Close medical supervision and monitoring should continue until the patient recovers.

GEODON injection 10 mg, IM, Q8H PRN for DELIRIUM was administered by the nurse on the following dates and times. (Delirium is a serious change in mental abilities. It results in confused thinking and a lack of awareness of someone's surroundings.)

There was no documented evidence by the physician that the Geodon was being used a standard treatment or dosage for delirium. The medication was not ordered on a scheduled basis and there was no orders for scheduled p.o medications. The order was for PRN (as needed) to manage the patient's behavior. There was no scale provided to the nurse to determine what level of delirium warranted an injection. The order left the decision at the nurses discretion.


8/5/23 at 5:42 p.m.- 6:23 p.m. the RN documented, " GEODON GIVEN PER MD ORDER. PT HAS REMOVED ALL LINES AND TUBES. SHE HAS REMOVED HER IV. MD AWARE. I WILL RESTART ONE IN THE MORNING BEFORE MEDICATION ARE DUE." The medication was given IM by an LVN (Licensed Vocational Nurse). A review of the chart revealed the patient was assessed at 7:18 p.m. The nurse documented prior to the medications "Pt moving and agitated at this time. Staff are unable to get manual blood pressure at this time." There was no further documentation of any medication side effects or effectiveness. There was no further documented assessment of any vital signs until 10:50 p.m.

8/6/23 at 9:41 a.m. Geodon IM was administered from the PRN order. There was no documentation on why the medication was administered or if the MD was aware. The medication was given as an IM by an LVN. There was no documentation that the RN was aware of the PRN administration. There was no documentation of medication effectiveness. There was no documentation of vital signs until 12:00 p.m. 3 hours and 20 minutes later. There was no indication charted on why the patient was given the medication or if any other alternatives were attempted first.

8/6/23 at 7:43 p.m. Geodon was administered IM from the PRN order. The medication was given by the LVN. There was no documentation that the RN was aware of the PRN administration. There was no documentation of medication effectiveness or patient assessment. At 7:45 p.m. The nurse documented, "Pt will not keep pulse oximeter on her finger. Pt agitated and combative with staff when staff tries to put one on." There was no further information documentation on why the medication was administered or if the MD was aware. There was no documentation of alternative options used such as diversions, p.o meds, or deesculation.The chart stated the patient was on a monitor that measures vital signs. There was no documentation of the vital signs until 8/7/23 at 7:00 p.m., 23 hours later.

Based on record review and interview, the facility failed to ensure the policy and procedure for restraint and seclusion instructed staff on determining appropriate frequencies of assessment and monitoring, after the administration of a chemical restraint in 3 of 3 (#9, 10, and 6) charts reviewed.

Patient #9
A review of patient #9 medical record (MR) revealed patient #9 was brought to the emergency room on 08/14/2023 at 10:51 a.m. by the police.

A review of the nurses notes dated 8/14/23 stated, "Psychiatric Evaluation (ARRIVED VIA SHERIFF'S DEPARTMENT WITH EDW IN PLACE TO OUR FACILITY BY _____(CHC Worker) WITH CHC--WAS SENT OVER PER RECOMMENDATION OF CASEWORKER AT CHC--IT IS REPORTED BY CASEWORKER THAT PATIENT HAS BEEN HAVING AUDITORY HALLUCINATIONS WITH HOMICIDAL THREATS-IT IS REPORTED SHE HAD A MACHETE IN PLAIN SITE AND HAS THREATENED TO HARM HER HUSBAND AND CHC CASE WORKER--IT IS FELT SHE IS A DANGER TO HERSELF AND OTHERS--PT PRESENTS WITH FLIGHT OF IDEAS, CURSING AT SHERIFF DEPT STAFF AND HOSPITAL STAFF; SECURITY AT SIDE.)"

Patient #9 was ordered and administered the following medications on 8/14/23.

11:01 am Ativan (sedative) 2 mg IM once (there was no documented reason why the medication was ordered.) The medication was administered at 11:20 a.m.

11:10 am Benadryl (antihistamine) 50mg IM once (there was no documented reason why the medication was ordered.) The medication was administered IM at 11:25 a.m.

11:07 am Haldol (psychotropic) 10mg IM once. The medication was administered at 11:07 am. The physician order stated, " ...Adm instructions This medication is used within the pharmaceutical parameters based on standard of practice using established dosage parameters. Use of this medication is to allow the patient to be able to continue to interact/function with their environment. It is NOT being used to restrict their ability to interact with their environment." The physician documented that the drugs were being used as a therapeutic tool and not a restraint.
There was no documentation that Haldol, Ativan, and Benadryl were part of a patient's standard medical or psychiatric treatment and was administered within the standard dosage for the patient's condition that would be therapeutic to improve their level of functioning so patient #9 could participate in the milieu.

The physician documented the patient's unwanted behaviors. On 8/14/23 the physician documented, "Abnormal behavior. Patient is disheveled. Patient is moving all extremities symmetrically. The patient's speech is not clear enough to be able to understand what she is saying. Occasionally I can understand statements like "fuck you."

The nurse documented on 8/14/2023 at 11:31 a.m. "PATIENT PRESENTS CURSING AT STAFF AND SHERIFF'S DEPARTMENT. WILL NOT COOPERATIVE (sic). PATIENT RAMBLING AND NOT MAKING SENSE."

A review of patient #9's medical record revealed there was nursing documentation of vital signs at 11:30 a.m., a pain, assessment, and documented the patient was alert, oriented, and "Obeys commands." There was no documentation found on the effectiveness of the medications or patients' responses. There were no further vital signs documented until 11:56 p.m., 12 hours and 25 minutes later.

There was no comprehensive patient assessment documented to assess the need for other types of interventions before using a drug or medication as a restraint. All available alternative treatment options should be considered before administering chemical or physical restraint, as it infringes on an individual's autonomy and dignity. There was no documentation found of staff attempting to de-escalate the patient, seclusion, or even physical restraints as needed. The patient was not offered any medications by mouth.

Patient #10

A review of patient #10's chart revealed the patient was brought to the Emergency Room (ER) on 9/12/23 at 12:43 p.m. by ambulance. A review of the ER physician notes dated 9/12/2023 at 1:03 p.m. stated, "Patient is a 33-year-old with a history of some type of psychiatric disorder and was found at a local gas station saying he wanted to kill himself. He currently denies it but officers came in and said he went to the bathroom and said he had a pair of scissors and was going to end it all. Patient says he wants a refill on his Zyprexa but does not want to be a psychiatric patient. At the time of this dictation, officers were trying to get a hold placed on him via the local judge ...Psychiatric/Behavioral: Positive for agitation and behavioral problems."

A review of the physician's orders on 9/12/23 at 2:24 revealed an order for a haloperidol lactate (Haldol) injection of 5 mg IM once for agitation. The order stated next to the agitation comment "Haldol IV/IM is not approved for use for any other indication. Please order a different medication or access chemical restraints through the chemical restraint order panel." There was no documentation or indication that the physician followed the information given. There was no documentation by the physician of the patient's behavior at this time to indicate the need for this medication. The Haldol was documented as administered at 2:50 p.m.

A review of the physician's orders on 9/12/23 at 2:24 p.m. revealed an order for diphenhydramine (Benadryl) 25 mg IM once. There was no documented reason why the medication was ordered. The medication was administered at 3:07 p.m.

A review of the physician's orders on 9/12/23 at 2:24 p.m. revealed an order for Lorazepam (Ativan) 2 mg IM every 4 hours PRN. There was no documentation on why this sedative was ordered or why it was ordered PRN. The medication was administered at 3:11 p.m.

A review of the chart revealed that patient #10 allowed the nurse to obtain vital signs at 2:50 p.m. Other flowsheet entries stated, "RASS Score: Very Agitated Neurological Level of Consciousness: Alert. 3:00 p.m. nurse documented, "Interventions: Security at the bedside; Sitter; Additional staff at the bedside; ID band on Visual Checks: Continuous 1:1." 3:10 p.m. "PT MORE COOPERATIVE AT THIS TIME, FOLLOWING COMMANDS, CALM, AND DENIES SUDICAL/HOMICIDAL IDEATIONS."

A review of the chart revealed patient # 10 was discharged out of the ED on 9/12/23 at 3:08 PM. The physician documented, "Discharge to home/self-care. Condition at discharge good." The physician had written an order to discharge before the patient had received all his medications, was evaluated, or assessed. There was no further documentation of the medication's effectiveness.

A review of the nurse notes dated 09/12/23 at 4:26 p.m. "WAITING FOR PD FOR RIDE." The patient was discharged to home with a follow-up appointment with the local mental health authority. Patient #10 was discharged to home 1 hour and 16 minutes after he had received chemical restraints. There was no further documentation of the patient outcomes or effectiveness of the medications administered.

A review of the restraint log revealed there were no chemical restraints listed for 2023. An interview was conducted with Staff #1 on 10/10/23. Staff #1 confirmed the facility was not identifying chemical restraints and placing them on the log. The facility was only adding physical restraints to the log. Staff # 2 stated that there was no quality data or analysis of data for chemical restraint administration for this hospital.

Patient # 6
A review of patient #6's chart revealed the physician's history and physical (H&P) dated 8/4/2023 at 2:14 p.m. The H&P stated, "72-year-old female is found at a local nursing home to be more confused than usual and less interactive. EMS was called and when they arrived blood sugar of 17 was found. Treatment is initiated with D50 but only minimal improvement occurred. Work-up in the emergency department revealed persistent hypoglycemia and sepsis was identified with urinary tract infection. The patient's blood sugars eventually improved and with her urinary tract infection/sepsis, the decision was made to admit her to the hospital for continued treatment. Patient does have advanced dementia but does communicate although randomly at times. She is on full CODE STATUS. Overall this patient's prognosis is guarded."

A review of the chart revealed Patient #6 received a physician order for ziprasidone (GEODON) injection 10 mg, IM, Q8H PRN for DELIRIUM 8/5/23 at 09:41 AM. A review of the physician's progress notes on 8/06/23 states "She seems to calm down better with as-needed Geodon"

According to www.geodon.com Ziprasidone (Geodon) is a medication that works in the brain to treat schizophrenia. It is also known as a second-generation antipsychotic (SGA) or atypical antipsychotic. Ziprasidone rebalances dopamine and serotonin to improve thinking, mood, and behavior. There is no specific antidote to ziprasidone, and it is not dialyzable. The possibility of multiple drug involvement should be considered. Close medical supervision and monitoring should continue until the patient recovers.

GEODON injection 10 mg, IM, Q8H PRN for DELIRIUM was administered by the nurse on the following dates and times. (Delirium is a serious change in mental abilities. It results in confused thinking and a lack of awareness of someone's surroundings.)

There was no documented evidence by the physician that the Geodon was being used a standard treatment or dosage for delirium. The medication was not ordered on a scheduled basis and there was no orders for scheduled p.o medications. The order was for PRN (as needed) to manage the patient's behavior. There was no scale provided to the nurse to determine what level of delirium warranted an injection. The order left the decision at the nurses discretion.


8/5/23 at 5:42 p.m.- 6:23 p.m. the RN documented, " GEODON GIVEN PER MD ORDER. PT HAS REMOVED ALL LINES AND TUBES. SHE HAS REMOVED HER IV. MD AWARE. I WILL RESTART ONE IN THE MORNING BEFORE MEDICATION ARE DUE." The medication was given IM by an LVN (Licensed Vocational Nurse). A review of the chart revealed the patient was assessed at 7:18 p.m. The nurse documented prior to the medications "Pt moving and agitated at this time. Staff are unable to get manual blood pressure at this time." There was no further documentation of any medication side effects or effectiveness. There was no further documented assessment of any vital signs until 10:50 p.m.

8/6/23 at 9:41 a.m. Geodon IM was administered from the PRN order. There was no documentation on why the medication was administered or if the MD was aware. The medication was given as an IM by an LVN. There was no documentation that the RN was aware of the PRN administration. There was no documentation of medication effectiveness. There was no documentation of vital signs until 12:00 p.m. 3 hours and 20 minutes later. There was no indication charted on why the patient was given the medication or if any other alternatives were attempted first.

8/6/23 at 7:43 p.m. Geodon was administered IM from the PRN order. The medication was given by the LVN. There was no documentation that the RN was aware of the PRN administration. There was no documentation of medication effectiveness or patient assessment. At 7:45 p.m. The nurse documented, "Pt will not keep pulse oximeter on her finger. Pt agitated and combative with staff when staff tries to put one on." There was no further information documentation on why the medication was administered or if the MD was aware. There was no documentation of alternative options used such as diversions, p.o meds, or deesculation.The chart stated the patient was on a monitor that measures vital signs. There was no documentation of the vital signs until 8/7/23 at 7:00 p.m., 23 hours later.

A review of the policy and procedure Restraints and seclusion stated, " ...Patient Monitoring and Documentation Violent or self-destructive behavior. The patient restrained/secluded for behavioral reasons is assessed at the Initiation of the restraint/seclusion event and every 15 minutes thereafter." The statement was followed by information concerning the patient in a physical restraint and not a chemical restraint. There was no guidance or instruction on how soon to evaluate the patient after the medication administration, how frequently, or for how long. There was no instruction on what to assess and what to report as a change in condition for a chemical restraint.

An interview was conducted with staff #1 on 10/10/23. Staff #1 confirmed there were no defined time frames in the policy and procedure for patient assessments, how frequent the assessments should be, or for how long after administering chemical restraints.

Based on record review and interview, the facility failed to ensure a face-to-face evaluation was conducted in person by a physician, licensed practitioner (LP), or trained RN after the administration of a chemical restraint in 3 of 3(#9, 10, and 6) charts reviewed.

Patient #9

A review of patient #9 medical record (MR) revealed patient #9 was brought to the emergency room on 08/14/2023 at 10:51 a.m. by the police.

A review of the nurses notes dated 8/14/23 stated, "Psychiatric Evaluation (ARRIVED VIA SHERIFF'S DEPARTMENT WITH EDW IN PLACE TO OUR FACILITY BY MARSHA WITH CHC--WAS SENT OVER PER RECOMMENDATION OF CASEWORKER AT CHC--IT IS REPORTED BY CASEWORKER THAT PATIENT HAS BEEN HAVING AUDITORY HALLUCINATIONS WITH HOMICIDAL THREATS-IT IS REPORTED SHE HAD A MACHETE IN PLAIN SITE AND HAS THREATENED TO HARM HER HUSBAND AND CHC CASE WORKER--IT IS FELT SHE IS A DANGER TO HERSELF AND OTHERS--PT PRESENTS WITH FLIGHT OF IDEAS, CURSING AT SHERIFF DEPT STAFF AND HOSPITAL STAFF; SECURITY AT SIDE.)"

Patient #9 was ordered and administered the following medications on 8/14/23.

11:01 am Ativan (sedative) 2 mg IM once (there was no documented reason why the medication was ordered.) The medication was administered at 11:20 a.m.

11:10 am Benadryl (antihistamine) 50mg IM once (there was no documented reason why the medication was ordered.) The medication was administered IM at 11:25 a.m.

11:07 am Haldol (psychotropic) 10mg IM once. The medication was administered at 11:07 am. The physician order stated, " ...Adm instructions This medication is used within the pharmaceutical parameters based on standard of practice using established dosage parameters. Use of this medication is to allow the patient to be able to continue to interact/function with their environment. It is NOT being used to restrict their ability to interact with their environment." The physician documented that the drugs were being used as a therapeutic tool and not a restraint.
There was no documentation that Haldol, Ativan, and Benadryl were part of a patient's standard medical or psychiatric treatment and was administered within the standard dosage for the patient's condition that would be therapeutic to improve their level of functioning so patient #9 could participate in the milieu.

The physician documented the patient's unwanted behaviors. On 8/14/23 the physician documented, "Abnormal behavior. Patient is disheveled. Patient is moving all extremities symmetrically. The patient's speech is not clear enough to be able to understand what she is saying. Occasionally I can understand statements like "fuck you."
The nurse documented on 8/14/2023 at 11:31 a.m. "PATIENT PRESENTS CURSING AT STAFF AND SHERIFF'S DEPARTMENT. WILL NOT COOPERATIVE (sic). PATIENT RAMBLING AND NOT MAKING SENSE."

A review of patient #9's medical record revealed there was nursing documentation of vital signs at 11:30 a.m., a pain, assessment, and documented the patient was alert, oriented, and "Obeys commands." There was no documentation found on the effectiveness of the medications or patients' responses. There were no further vital signs documented until 11:56 p.m., 12 hours and 25 minutes later. There was no face-to-face documented.

There was no comprehensive patient assessment documented to assess the need for other types of interventions before using a drug or medication as a restraint. All available alternative treatment options should be considered before administering chemical or physical restraint, as it infringes on an individual's autonomy and dignity. There was no documentation found of staff attempting to de-escalate the patient, seclusion, or even physical restraints as needed. The patient was not offered any medications by mouth. Patient #9 was restricted by the medications which prevented her movement and participation with those around her causing this method of treatment to be a restraint.

Patient #10

A review of patient #10's chart revealed the patient was brought to the Emergency Room (ER) on 9/12/23 at 12:43 p.m. by ambulance. A review of the ER physician notes dated 9/12/2023 at 1:03 p.m. stated, "Patient is a 33-year-old with a history of some type of psychiatric disorder and was found at a local gas station saying he wanted to kill himself. He currently denies it but officers came in and said he went to the bathroom and said he had a pair of scissors and was going to end it all. Patient says he wants a refill on his Zyprexa but does not want to be a psychiatric patient. At the time of this dictation, officers were trying to get a hold placed on him via the local judge ...Psychiatric/Behavioral: Positive for agitation and behavioral problems."

A review of the physician's orders on 9/12/23 at 2:24 revealed an order for a haloperidol lactate (Haldol) injection of 5 mg IM once for agitation. The order stated next to the agitation comment "Haldol IV/IM is not approved for use for any other indication. Please order a different medication or access chemical restraints through the chemical restraint order panel." There was no documentation or indication that the physician followed the information given. There was no documentation by the physician of the patient's behavior at this time to indicate the need for this medication. The Haldol was documented as administered at 2:50 p.m.

A review of the physician's orders on 9/12/23 at 2:24 p.m. revealed an order for diphenhydramine (Benadryl) 25 mg IM once. There was no documented reason why the medication was ordered. The medication was administered at 3:07 p.m.

A review of the physician's orders on 9/12/23 at 2:24 p.m. revealed an order for Lorazepam (Ativan) 2 mg IM every 4 hours PRN. There was no documentation on why this sedative was ordered or why it was ordered PRN. The medication was administered at 3:11 p.m. There was no documentation on why this medication was delayed for 45 minutes. There was no face-to-face documented.

A review of the chart revealed that patient #10 allowed the nurse to obtain vital signs at 2:50 p.m. Other flowsheet entries stated, "RASS Score: Very Agitated Neurological Level of Consciousness: Alert. 3:00 p.m. nurse documented, "Interventions: Security at the bedside; Sitter; Additional staff at the bedside; ID band on Visual Checks: Continuous 1:1." 3:10 p.m. "PT MORE COOPERATIVE AT THIS TIME, FOLLOWING COMMANDS, CALM, AND DENIES SUDICAL/HOMICIDAL IDEATIONS."

A review of the chart revealed patient # 10 was discharged out of the ED on 9/12/23 at 3:08 PM. The physician documented, "Discharge to home/self-care. Condition at discharge good." The physician had written an order to discharge before the patient had received all his medications, was evaluated, or assessed. There was no further documentation of the medication's effectiveness.

A review of the nurse notes dated 09/12/23 at 4:26 p.m. "WAITING FOR PD FOR RIDE." The patient was discharged to home with a follow-up appointment with the local mental health authority. Patient #10 was discharged to home 1 hour and 16 minutes after he had received chemical restraints. There was no further documentation of the patient outcomes or effectiveness of the medications administered. There was no face-to-face documented.

A review of the restraint log revealed there were no chemical restraints listed for 2023. An interview was conducted with Staff #1 on 10/10/23. Staff #1 confirmed the facility was not identifying chemical restraints and placing them on the log. The facility was only adding physical restraints to the log. Staff # 2 stated that there was no quality data or analysis of data for chemical restraint administration for this hospital.

Patient # 6

A review of patient #6's chart revealed the physician's history and physical (H&P) dated 8/4/2023 at 2:14 p.m. The H&P stated, "72-year-old female is found at a local nursing home to be more confused than usual and less interactive. EMS was called and when they arrived blood sugar of 17 was found. Treatment is initiated with D50 but only minimal improvement occurred. Work-up in the emergency department revealed persistent hypoglycemia and sepsis was identified with urinary tract infection. The patient's blood sugars eventually improved and with her urinary tract infection/sepsis, the decision was made to admit her to the hospital for continued treatment. Patient does have advanced dementia but does communicate although randomly at times. She is on full CODE STATUS. Overall this patient's prognosis is guarded."

A review of the chart revealed Patient #6 received a physician order for ziprasidone (GEODON) injection 10 mg, IM, Q8H PRN for DELIRIUM 8/5/23 at 09:41 AM. A review of the physician's progress notes on 8/06/23 states "She seems to calm down better with as-needed Geodon"

According to www.geodon.com Ziprasidone (Geodon) is a medication that works in the brain to treat schizophrenia. It is also known as a second-generation antipsychotic (SGA) or atypical antipsychotic. Ziprasidone rebalances dopamine and serotonin to improve thinking, mood, and behavior. There is no specific antidote to ziprasidone, and it is not dialyzable. The possibility of multiple drug involvement should be considered. Close medical supervision and monitoring should continue until the patient recovers.

GEODON injection 10 mg, IM, Q8H PRN for DELIRIUM was administered by the nurse on the following dates and times. (Delirium is a serious change in mental abilities. It results in confused thinking and a lack of awareness of someone's surroundings.)

There was no documented evidence by the physician that the Geodon was being used a standard treatment or dosage for delirium. The medication was not ordered on a scheduled basis and there was no orders for scheduled p.o medications. The order was for PRN (as needed) to manage the patient's behavior. There was no scale provided to the nurse to determine what level of delirium warranted an injection. The order left the decision at the nurses discretion.


8/5/23 at 5:42 p.m.- 6:23 p.m. the RN documented, " GEODON GIVEN PER MD ORDER. PT HAS REMOVED ALL LINES AND TUBES. SHE HAS REMOVED HER IV. MD AWARE. I WILL RESTART ONE IN THE MORNING BEFORE MEDICATION ARE DUE." The medication was given IM by an LVN (licensed Vocational Nurse). A review of the chart revealed the patient was assessed at 7:18 p.m. The nurse documented prior to the medications "Pt moving and agitated at this time. Staff are unable to get manual blood pressure at this time." There was no further documentation of any medication side effects or effectiveness. There was no further documented assessment of any vital signs until 10:50 p.m. There was no face-to-face documented.

8/6/23 at 9:41 a.m. Geodon IM was administered from the PRN order. There was no documentation on why the medication was administered or if the MD was aware. The medication was given as an IM by an LVN. There was no documentation that the RN was aware of the PRN administration. There was no documentation of medication effectiveness. There was no documentation of vital signs until 12:00 p.m. 3 hours and 20 minutes later. There was no face-to-face documented.

8/6/23 at 7:43 p.m. Geodon was administered IM from the PRN order. The medication was given by the LVN. There was no documentation that the RN was aware of the PRN administration. There was no documentation of medication effectiveness or patient assessment. At 7:45 p.m. The nurse documented, "Pt will not keep pulse oximeter on her finger. Pt agitated and combative with staff when staff tries to put one on." There was no documentation on why the medication was administered or if the MD was aware. The chart stated the patient was on a monitor that measures vital signs. There was no documentation of the vital signs until 8/7/23 at 7:00 p.m., 23 hours later. There was no face-to-face documented.

A review of the policy and procedure Restraints and seclusion stated, " ... G. If the face-to-face evaluation of a violent/psychiatric restrained or secluded patient is completed by a trained registered nurse or physician assistant, he/she must consult the attending physician or other licensed practitioner who is responsible for the care of the patient as soon as possible after the completion of the 1-hour face-to-face examination. Page 10- In order to reduce risk and promote patient safety, the records of patients restrained/secluded for behavioral reasons are reviewed and data is measured and analyzed for high-risk processes related to restraints/seclusion. Measurement and analysis may be performed on the following indicators ... 13. Evidence of face-to-face assessment by the licensed practitioner within one hour of restraint/seclusion application."

An interview was conducted with staff #1 on 10/10/23. Staff #1 confirmed the facility had failed to recognize chemical restraints as a restraint therefore the face-to-face assessments were not being performed after the administration of chemical restraints.

Based on document review and interview, the facility failed to;

1.
follow the nurse staffing plan for staffing measures, acuity levels, and grid/matrix in 2 of 2 (Medical /surgical and Transition Care Unit) patient care units reviewed.

It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possibly subsequently death due to the unsafe administration of blood products.

Refer to Tag A0392

2.
follow their own policy "Licensed Vocational/Practical Nurse Scope of Practice 3.500" to ensure the Licensed Vocational Nurse (LVN) had the required training to administer Intravenous (IV) medications. The policy failed to address the LVN's scope of practice for the administration of psychotropic medications in 2 of 2(#6 and #7) employee files reviewed.

Refer to Tag A0410

Based on document review and interview, the facility failed to follow the nurse staffing plan for staffing measures, acuity levels, and grid/matrix in 2 of 2 (Medical /surgical and Transition Care Unit) patient care units reviewed.

It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possibly subsequently death due to the unsafe administration of blood products.

A review of the staffing matrix/grid revealed a guideline for minimal staffing required to safely care for the patients on the nursing unit. A review of the nursing daily assignment sheets revealed Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), and Nurse Aides (NAs) were listed. The grid revealed that the RN and LVN were listed as the same discipline. An LVN must have supervision by an RN and cannot be scheduled as a Registered Nurse (RN). The grid did not clarify if an RN was to be scheduled or an LVN.

A review of the daily assignment sheets revealed that RNs, LVNs, and NAs were scheduled. There was no defined LVN per patient census schedule or acuity tool. The acuity tool allows the scheduler to determine when staffing should be increased or decreased for safe patient care. The acuity tool determines the level of care required for the patient's needs. The acuity tool is used to determine the level of care for the patient's needs and allows the scheduler to determine when staffing should be increased or decreased for the patient's needs.


A review of the policy and procedure "Nurse Staffing Plan" stated,
" POLICY:1. A Nursing Staffing Plan is developed collaboratively by the Nursing Management Team and the Nursing Staffing Advisory Council and recommended to the governing board for adoption, implementation, and enforcement ...
3. All nursing departments within CHRISTUS St. Michael support the provision of quality patient care in a safe, cost-effective manner by appropriately planning and maintaining adequate numbers and skill mix of qualified personnel to meet patient care needs.
4. Departmental staffing plans are determined on an annual basis during the budget process but may be evaluated and adjusted more frequently based on assessed needs. Staffing levels are based on nursing hours per patient day (NHPPD). Nursing hours vary depending on the patient need ( e.g. medical-surgical, telemetry, critical care) and skill mix ...
8. There is always an RN assigned to provide direct care and coordination of the nursing care activities by other nursing associates providing care for the patients.
9. The RN plans, coordinates, supervises, and evaluates the nursing care for each patient and assigns the nursing care to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available. The Registered Nurse is responsible for administering patient care which cannot be assigned to a Licensed Vocational Nurse (LVN) ...
11. A minimum of two (2) licensed nurses will be assigned to every nursing floor on which patients are located each shift. One of the licensed nurses must be an RN.
12. The RN is expected to remain on duty until adequate relief is available."

A tour of the facility was conducted on the morning of 10/9/23 with Staff # 1. Staff #1 stated the nursing floor had two separate units the Medical /Surgical Unit (MS) and the Transition Care Unit (TCU). Staff #1 stated the MS unit was for patients' medical issues and observation patients and the TCU was for patients that required more intense care such as intermediate care. Staff #1 stated that if the patient needed Intensive care, they would be transferred to the main campus hospital. A review of the nursing units revealed the MS and the TCU were on the same floor and shared a mutual nursing station. #1 stated again that they were two separate units. The facility also had an Emergency Department with 10 beds.

A review of the staffing schedule revealed the following.
A review of the staffing grid revealed there was a grid for MS and TCU. An interview was conducted with Staff #1 on 10/9/23 concerning staffing the two units. Staff #1 stated that the two units share staff and were not always staffed individually. The units were short-staffed according to the nursing staffing grid.

On 8/1/23 thru 8/5/23, there was only 1 RN on both units for the day shift. On 8/1 and 8/2/2023 the 7 p.m. to 7 a.m. shift revealed there was an RN and LVN scheduled on TCU. There was no documented evidence that an RN covered the LVN when the RN took a lunch break.

On 8/15/23 there was only an LVN scheduled for the MS floor for the night shift 7 p.m. to 7 a.m. There was no RN scheduled. The LVN did not have RN supervision for her unit.

On 9/11/23 there was only 1 RN scheduled for the TCU on the day shift and night shift. (A minimum of two (2) licensed nurses will be assigned to every nursing floor on which patients are located each shift. One of the licensed nurses must be an RN.)

On 10/1/23 1 LVN was scheduled for the MS unit on nights. There was no RN scheduled. The LVN was left unsupervised by an RN. There was only 1 RN scheduled for the day shift.

On 10/2/23 only one RN was scheduled for all units and shifts.

On 10/3/23 only one RN and a NA were scheduled for the night shift on both units. There was no evidence on who covered for the RN for breaks leaving the NA without supervision.

On 10/5/23 only one RN and an NA were scheduled for the night shift on both units. There was no evidence on who covered for the RN for breaks leaving the NA without supervision.

An interview was conducted with Staff # 1 and #9 on 10/10/23. Staff #9 stated that she schedules for the nursing units. Staff # 9 confirmed there was no written acuity tool to assist her in staffing the units. Staff #9 was asked how she determined when more staff needed to be added or decreased. Staff #9 confirmed that it was based on the judgment of the staffing individual and/or staff #1. Staff #1 confirmed there was no acuity tool to assist with staffing nor was there any training to determine appropriate staffing for acuity levels.

A review of the BON for LVNs was as follows:
" ...15.27 The Licensed Vocational Nurse Scope of Practice
The Texas Nursing Practice Act (NPA) and the Board's Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN). The LVN scope of practice is a directed scope of practice and requires appropriate supervision ...

The LVN Scope of Practice
The LVN serves as an advocate for the patient and the patient's family and promotes safety by practicing in accordance with the NPA and the BON Rules and Regulations. LVN's scope of practice does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures.4 The practice of vocational nursing must be performed under the supervision of an RN, advanced practice registered nurse (APRN), physician, physician assistant, podiatrist, or dentist.5 Supervision is defined as the process of directing, guiding, and influencing the outcome of an individual's performance of an activity.6 The LVN is precluded from practicing in a completely independent manner; however, direct and on-site supervision may not be required in all settings or patient care situations. Determining the proximity of an appropriate clinical supervisor, whether available by phone or physical presence, should be made by the LVN and the LVN's clinical supervisor by evaluating the specific situation, taking into consideration patient conditions and the level of skill, training, and competence of the LVN. An appropriate clinical supervisor may need to be physically available to assist the LVN should emergent situations arise ..."

Based on record review and interview the facility failed to follow their own policy "Licensed Vocational/Practical Nurse Scope of Practice 3.500" to ensure the Licensed Vocational Nurse (LVN) had the required training to administer Intravenous (IV) medications. The policy failed to address the LVN's scope of practice for the administration of psychotropic medications in 2 of 2(#6 and #7) employee files reviewed.


Findings include:

A review of the electronic health record revealed staff # 7 (LVN) administered patient #5 Haldol IV as needed (PRN) on 08/20/23 at 3:51 a.m.

A review of the electronic health record revealed staff # 6 (LVN) administered patient #7 Ativan IV PRN on 10/09/2023 at 11:14 PM.



A review of the facility's policy Licensed Vocational/Practical Nurse Scope of Practice 3.500 dated 02/2020 revealed the following:

"Medication administration

1. Upon hire the LVN/LPN will be required to successfully complete appropriate training
and skills validation requiring observation of IV drug administration by an RN or
authorized directing health care practitioner.

2. Following completion of appropriate training and skills validation, the LVN/LPN will be
allowed to administer a selected set of medications by IV administration, including:
a. Antiemetics
b. Anti-anxiety agents
c. Antibiotics
d. Diuretics
e. Steroids
f. H2 antagonists
g. Vitamins
h. Analgesics/controlled substances (see below for defining parameters)
i. Normal Saline &/or heparin flush

3. Antibiotics may be given either IV by direct injection reconstituted according to
manufacturer's recommendations, or more commonly, IV piggyback.

4. The LVN/LPN will be allowed to administer controlled substances by IV administration
under the following conditions.;.
a. In the adult hospitals, first doses of controlled substances will be administered
by an RN. Subsequent doses may be administered by an LVN/LPN.
b. Dosing parameters for morphine and Dilaudid have been determined for
LVN/LPN administration:
i. Morphine sulfate, 4mg incremental dose
ii. Hydromorphone (Dilaudid), 0.5mg incremental dose

5. LVNs/ LPN may not administer the following IV medications:
a. Chemotherapy agents
b. Vasoactive or antiarrhythmic medications
c. Digitalis products
d. lnsulin IV push or infusion
e. Anticonvulsant medications
f. Thrombolytic medications
g. Concentrated electrolytes
h. Neuromuscular blocking agents
i. Epidural medications
j. Pain medications administered via PCA pump (may not initiate or program
pump)
k. Moderate sedation agents
I. Amphotericin
m. IVIG
n. Drugs administered in the course of resuscitation
a. Initiate administration of blood or blood components, total parenteral
nutrition (TPN), investigational or experimental drug, or medication requiring
titration and continuous assessment.

6. While the LVN/LPN may not administer/initiate infusions previously noted, the
LVN/LPN may deliver nursing care for the patient receiving those medications within
the LVN/LPN scope of practice."

Psychotropic and Benzodiazepine drugs are not listed as approved medications for LVN administration per the facility policy.

A review of employee files #6 and #7 revealed no training was completed per the facility's policy. Also, it was noted that annual clinical skills training was last completed in 2021. There was no evidence that yearly training had been completed.

An interview was conducted on the afternoon of 10/10/2023 with Staff # 1 reported that "the Licensed Vocational Nurses are required to have training and show demonstration before intravenous administration of medication per the facilities policy. Staff #1 confirmed there was no training for the LVN's in the employee files.