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Based on review of 18 medical records (8 open and 10 closed), it was determined that 1 of the 8 open records lacked the face-to-face documentation.


Patient #17 presented to the Emergency Department (ED) on 4/14/15 due to bizarre behavior per his mother and threatening his mother with a knife. The patient's behavior continued to escalate with the patient pacing back and forth outside his room into the hallway. He refused medication by mouth. Patient #17 received Haldol IM and Lorazepam IV x 1 on 4/14/15 at 6:06 am. The medications were given with help from security and patient was brought back to his room. The patient continued to pace around the room and eventually lay down on the bed. A note written at 6:08 am revealed that the physician was at the bedside and spoke with the patient's mother. Review of the medical record revealed that a face-to-face was not performed for patient #17. The chemical restraint was given per the physician order but no documentation was found in the medical record of the physician's assessment of the patient within 1 hour of administration of the medication.

Based on review of 18 medical records (8 open and 10 closed), it was determined that in 1 of the 8 open records the hospital failed to document a clear description of the patient's behavior that warranted restraint.

Patient #17 presented to the Emergency Department (ED) on 4/14/15 with reported bizarre behavior and threatening his family with a knife. Once in the ED he began to pace in and out of his room and in the hallway. The patient was not able to be re-directed and refused medication by mouth. He received medication intramuscularly. The description of his behavior did not provide behavioral descriptors to justify the appropriateness of the intervention used.

Based on observation and review of a patient medical record and interview of the hospital's risk management staff, it was determined that a patient's Transfer Summary had been signed by the discharging physician without ensuring the accuracy of the patient's discharge medication regime. This was evident for 1 of 18 patient medical record reviews. The findings were:
Patient #1 was 85 years old, admitted to the hospital on 3/8/15 for abdominal pain with nausea, vomiting and diarrhea. The patient's medical condition was significant for diffuse metastatic disease and coagulopathy.

The patient prior to the hospitalization had been on Xarelto (anti-blood clotting agent) at a dosage of 15 milligrams (mg) at hour of sleep. During the hospitalization the patient was given Xarelto 15 mg on the following dates: 3/12/15, 3/13/15, 3/14/15 and 3/15/15.

The patient was discharged to a rehabilitation facility (Long Term Care) with the plan to eventually be discharged home with Hospice Service. The patient was discharged to the rehabilitation facility on 3/15/15. At the time of discharge, a "discharge package" of patient care information went with the patient to be reviewed and used by the receiving rehabilitation center in the provision of ongoing care. A review of the patient's Transfer Summary generated by the discharging physician, dictated on 3/14/15 and signed on 3/22/15, revealed that the physician had ordered Xarelto 50 mg (a 35 mg higher dose than the patient had originally been receiving at home and during the hospitalization). The Discharge Medication List had Xarelto 15 mg noted as to be given daily.

Failure by the physician to ensure the accuracy in medication dosages on the Discharge Medication List potentially placed the patient at risk for receiving the wrong dose of Xarelto and incurring a medication complication, i.e. excessive bleeding, even though the receiving rehabilitation facility would be expected to conduct their own medication reconciliation process.