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Based upon observation, record review, and interview, the nursing staff failed to follow physician's orders for emergency psychoactive medications, refrain from using prohibited "as needed" psychoactive medications for restraint, conduct a comprehensive patient assessment to determine the need for other types of interventions, and prevent use of psychoactive medication for staff convenience in 2 (#2 and 3) of 3 (#1-3) patients reviewed.

Refer to Tag A0160

Based upon record review, policy and procedure review, nursing staff failed to follow physician's orders for the use of emergency psychoactive medications, refrain from using "as needed" psychoactive medications for restraint, conduct a comprehensive patient assessment to determine the need for other types of interventions, and prevent use of psychoactive medication for staff convenience in 2 (#2 and 3) of 3 (#1-3) patients reviewed.

1.) Review of patient #2's admission orders revealed he was an 80 year old, male, admitted on 7/16/15, with a diagnosis of Dementia with mixed disturbance of emotion and conduct. The orders revealed he was voluntary, was on close 15 minute observations, on precautions for assault, falls, and choking.

Review of patient #2's physician orders revealed an "as needed" (PRN) order was found, written on 7/16/15, at 5:45PM. The order reads, "Ativan 0.5 po q 6 prn anxiety/agitation."

On 7/17/15, at 11:45AM, a verbal telephone physician order was found for "Haldol 2mg, Ativan 1mg and Benadryl 25mg po/IM q 6 hours prn agitation/psychosis," ordered by the psychiatrist but there was no legible nurse signature. At 4:30PM, another order was written by the psychiatrist for "Haldol 5mg, Ativan 2mg, and Benadryl 50mg po/IM q 4 hours prn agitation/psychosis/ 1st dose now."

A.) Review of the nursing Multi-Disciplinary Note dated 7/20/15, at 10:41PM, revealed patient #2 was having "bizarre behavior" and increased agitation. There was no further documentation found on patient #2 until 7/21/15, at 10:00AM, a total of 12 hours later.

Review of patient #2's Medication Administration Record (MAR) dated 7/21/15, at 10:00AM, revealed patient #2 received Haldol 5mg, Ativan 2mg, and Benadryl 50mg IM for agitation.

Review of the nursing Multi-Disciplinary Note dated 7/21/15, at 10:00AM, stated, "Very loud-intrusive-yelling/cussing unable to re-direct-verbally threatening staff. Attempted to re-direct with no effect. ABH given at this time- "you fucking bitch!" ongoing with yelling and cursing at staff. Continue with POC and monitor." Review of the MAR on 7/21/15, at 11:00AM, revealed the LVN documented, "decreased agitation." There was no further documentation found on patient #2 until 7/21/15, at 9:15 PM, which was 10 hours and 15 minutes later.

Review of patient#2's chart revealed no documentation of any nursing interventions before a chemical restraint was administered. The nurse had documented "re-direct attempted." There was no documentation found on how the staff had attempted to re-direct and what other interventions could have been used before administering a chemical restraint. There was no documentation found of an ongoing assessment after the administration of the medication.

Review of the chart revealed patient #2 did no face to face assessment was performed after the chemical restraint was given. There was no restraint paperwork in the patients chart or on the restraint log for the injection given on 7/21/15, at 10:00AM.

B.) Review of patient #2's MAR revealed, patient #2 received Haldol 5mg, Ativan 2mg, and Benadryl 50mg IM for agitation. The medications were administered on 7/23/15, at 8:15PM. Review of the Multi-Disciplinary Notes for 7/23/15, revealed the patient had fallen at 3:07PM, and hit his head causing a laceration. There was no documentation of behavioral issues. There was no documentation found of patient behaviors, why, where, and when the medication was administered. There was no documentation found for nursing assessments, interventions, MD notification nor restraint protocol followed.

Review of the nursing Multi-Disciplinary Note dated 7/23/15, at 8:35PM (20 minutes following injection), stated, "Pt sitting in Geri-chair in dining area eating snack. Cooperative with assessment at this time. No s/s of distress noted from fall today. No aggressive behavior noted. Continue medication regime. Redirect as needed. No change in behavior. Will continue to monitor for pt. safety and continue with POC."

C.) Review of patient #2's MAR revealed patient #2 received Haldol 5mg, Ativan 2mg, and Benadryl 50mg IM for agitation. The medications were administered on 7/24/15, at 7:05PM.

Review of the nursing Multi-Disciplinary Note dated 7/24/15, at 2:00PM, stated, "Late Entry pt. seated in activity room. Attempt made to check (illegible word) for neuro checks d/t resistance earlier. Pt redirection attempted. Pt making sexually inappropriate comments to staff. Will continue to redirect as needed." There was no further information if the nurse was able to perform the neuro check or any other interventions.

Review of the nursing Multi-Disciplinary Note dated 7/24/15, at 7:00PM, stated, "Late. Med nurse talked to (the patients wife) on phone to discuss with family member patient refusing medication at times. Family member suggested "give medication in milk calling it a snack." Therapist, DON, and psychiatrist informed of family member suggestion ref medication. Continue plan of Care."

There was no documentation found of patient behaviors, why, where, and when the medication was administered. There was no documentation found for nursing assessments, interventions, MD notification nor restraint protocol followed. There was no assessment found on the patient after the medication administration or if it was effective.

Review of the nursing Multi-Disciplinary Note dated 7/24/15, at 8:40PM, revealed the patient was confused and had requested to have his knife and a phone. "Pt continued to curse and speak loud. Pt not easily re-directed. No change in behavior." There was no documentation in the Multi-Disciplinary Notes or on a restraint flowsheet of the medication administration. There was no documentation of nursing interventions or assessments before or after.

On 7/25/15, at 12:30PM, the physician wrote an order that read, "Haldol 10mg, Ativan 2mg and Benadryl 50mg po/IM q 8 hours prn agitation/aggression/ 1st dose now, IM for po refusal."

D.) Review of patient #2's MAR revealed patient #2 received Haldol 10mg, Ativan 2mg, and Benadryl 50mg IM for agitation. The medications were administered on 7/25/15 at 12:50PM.

Review of the nursing Multi-Disciplinary Note dated 7/25/15, at 12:20PM, stated, "Pt attempting to help another patient thinking staff is harming her. Pt yelling at staff, cursing. Pt praying loudly over pt so that she can stand and walk. Pt became agitated when attempt made to remove him from the situation. Pt began to get louder, yelling at staff, being forceful. New order received and carried out shortly thereafter. Will continue to monitor. There was no documentation of what order was carried out, why, when, and how medication was administered. There was no documentation of nursing interventions, physical nursing assessment, or restraint protocol with a face to face. There was no nursing documentation of an ongoing assessment or medication effectiveness. The next nursing documentation was found on 7/25/15, at 7:48PM.

E.) Review of the nursing Multi-Disciplinary Note dated 7/25/15, at 7:48PM stated, "Pt. up at nurses station increased agitation/verbal aggression AEB demanding to use the phone, cursing stating he was going to call the police to get him out of here. Explore appropriate behaviors to increase insight. No change in behavior very demanding. Continue to monitor. Advise LVN need of PRN medications. Continue POC." There was no physical nursing assessment documented. There was no documentation of nursing interventions appropriate for this patient. There was documentation of MD notification.

Review of patient #2's MAR revealed patient #2 received Haldol 10mg, Ativan 2mg, and Benadryl 50mg po for agitation. The medications were administered on 7/25/15 at 9:50PM. The medication was administered 2 hours later from the original documented behavior. There was no documentation that the patient continued to have inappropriate behavior when medication was administered. The nurse failed to follow physician orders and gave the patient medication at 6 hours apart instead of 8. There was no ongoing nursing documentation after the administration of psychotropic medications to ensure effectiveness or side effects. The next time nursing documentation was found was on 7/26/15, at 8:00AM, which was a total of 10 hours later.

Review of patient #2's MAR revealed he received Haldol 10mg, Ativan 2mg, and Benadryl 50mg IM for agitation administered on the following dates and times;
7/27/15 at 2:15PM
7/28/15 at 9:30AM
7/30/15 at 12:45AM
7/31/15 at 4:45AM

There was no nursing interventions documented appropriate for this patient noted. There was no restraint procedures put into place for the injections given as a chemical restraint. There was no documentation found of the ongoing assessment or other alternatives before a chemical restraint was administered.


2.) Review of patient #3's physician orders revealed the patient was admitted on 10/20/15, as a voluntary patient. The admitting diagnosis was psychosis. Patient #3 was on a close observation every 15 minute check and on the following precautions; Suicide, Elopement, Seizure, Assault, Falls, Choking.

A.) Review of patient #3's MAR revealed patient #3 received Haldol 5mg, Ativan 1mg, and Benadryl 25mg IM for agitation. The medications were administered on 10/22/15, at 5:30PM.

Review of the physician orders dated on 10/21/15, at 5:15PM, stated, "Haldol 5mg, Ativan 1 mg, Benadryl 25 mg q 4hours prn po or IM for po refusal for anxiety/psychosis."

Review of patient #3's nursing Multi-Disciplinary Note dated 10/21/15, at 5:40PM, stated, "Pt escaped from patio area space and attempted to climb fence to exit unsuccessfully, MHT's and LVN quickly stopped patient and redirected indoors." At 8:05 PM the nurse's note stated, "Pt. in bed resting no s/s of distress. Continue to monitor." There was no documentation of nursing interventions, restraint protocol, a face to face, or ongoing assessment for effectiveness for patient #3.

B.) Review of patient #3's MAR revealed patient #3 received Haldol 2mg, Ativan 2mg, and Benadryl 25mg IM for agitation. The medications were administered on 10/26/15, at 12:45AM.

Review of the physician's verbal telephone order dated on 10/26/15, at 12:20AM stated, "Haldol 2mg, Ativan 2 mg, Benadryl 25 mg for agitation x 1 dose now."

Review of patient #3's nursing Multi-Disciplinary Note dated 10/26/15, at 12:45AM, stated, "Pt was sitting in his room when he was seen running out of his room up to the day area. Double doors were closed and pt. ran into them and then pushed on other door and ran into day area straight to front door and started hitting it. Pt given Haldol, Ativan, and Benadryl IM after pt. refused to take it orally. Will monitor of side effects." There was no nursing interventions documented, or restraint protocol followed for an emergency chemical restraint. There was no face to face or ongoing assessments documented.

Review of patient #3's nursing Multi-Disciplinary Note dated 10/26/15, at 12:45AM, stated, "Pt up in day area. Pt started picking up couch attempting to push it to window. Pt very agitated. Hard to redirect. Pt given Haldol, Ativan, and Benadryl. Will monitor for side effects. There was no nursing interventions documented, no physician notification, no documentation for a face to face, or ongoing assessment with medication effectiveness documented."

Review of patient #3's MAR on 10/26/15, at 12:45AM, revealed no documentation that the medication was administered.

C.) Review of patient #3's nursing Multi-Disciplinary Note dated 10/28/15, at 7:25PM, stated, "Pt up in day area. Pt came up behind female MHT and physically assaulted her with shoe across MHT's neck and shoulder on her right side. When attempted to redirect pt. he tried to lift recliner in day area. Unable to redirect pt. then walked to dining room area and picked up chair, chair taken from pt. Pt accompanied to chair by MHT and nurse. Pt agitated and irritable. Pt given prn medication for agitation and irritation. Continue medication regime. Redirect as needed. Redirection ineffective at this time. Cont. POC." There was no further documentation found of nursing interventions or attempts at other restraints before using a chemical restraint. There was no further nursing documentation until 10/28/15, at 9:30PM.

Review of the MAR dated 10/28/15, at 7:30PM, revealed patient #3 was administered Haldol 5 mg, Ativan 1 mg, and Benadryl 25 mg. The nurse failed to document the route of the medication. It was not determined if the medication was given by mouth or injection. There was no documentation of the effectiveness of the administered medication.

Review of patient #3's verbal physician orders dated on 10/28/15, at 9:30PM stated,
"1.) D/C Haldol 5mg, Ativan 1 mg, Benadryl 25 mg po or IM for po refusal q 4hours prn.
2.) Start Haldol 5 mg, Ativan 2 mg, Benadryl 25mg po/IM for PO refusal q 4 hrs PRN for agitation/psychosis.
3.) Ativan 1 mg po x 1 dose now if po refused may give Ativan 2 mg IM x 1 dose now for agitation."

Review of patient #3's nursing Multi-Disciplinary Note dated 10/28/15, at 9:30PM, stated, "Received new orders from psychiatrist. Pt. continues to be agitated/irritable. Hard to redirect by MHT. Will continue to monitor for pt. safety will administer medication as needed."

Review of patient #3's MAR for 10/28/15, revealed patient #3 was administered Ativan 2 mg IM now for agitation. However, the nurse failed to document what time the medication was administered on the MAR.

Review of the policy and procedure Emergency Restraint and Seclusion stated,
"Policy:
The facility's functional program is designed to ensure and respect the patient's right to be free from seclusion and/or restraints in any form that are not medically necessary or are used as means of coercion, discipline, convenience, or retaliation by staff.

* Chemical Restraint: As defined by 42 CFR 482.13(e)(1)(i)(B), a chemical restraint is a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition." Per State Regulation set Y.4.00 requirement 415.254 (a)(2), no intervention voluntary or involuntary shall be used for the purpose of convenience of staff members.

Initiate emergency restraint and seclusion in absence of physician post determination that alternative interventions were not effective or would not deter harm to self/others.
Notify physician as soon as possible and not more than one hour.
Document contact and physician order on Physician Order for Seclusion and Restraint Form.

Face-to-Face Evaluation:
(RN conducting face-to-face cannot be the RN who initiated restraint/seclusion and telemedicine technology cannot be utilized.):
Conduct face-to-face within one hour (if trained to do so) even if patient is no longer in restraint/seclusion and physician is not present. Document on Face-to-Face Evaluation Form:
Date/time
Behaviors
Alternative interventions to prevent restraint/seclusion
Medical review of patient's status post-intervention
Consult post face-to-face evaluation, review findings with physician.
Document contact/review.
Document continued need for intervention every one hour on flow sheet.
Conduct, when time limit for order expires, an in-person visual evaluation.
Consult post visual evaluation, review findings with physician. Document contact/review - follow orders of physician.
Evaluate treatment plan for changes to assist patient in regaining control.
Face-to-face re-evaluation hourly if physician is not present; conduct/review evaluation with physician and follow physician orders. Document on face to face Evaluation form.
NOTE: The physician must conduct an in person face to face evaluation by the time expiration of the second order for restraint or seclusion occurs. This cannot be delegated. Each use of restraint requires a separate order and justification.
Notify DON
Notify family as applicable with onset
Notify LAR
RN/MHT:
Monitoring:
Provide monitoring as indicated on Seclusion/Restraint Flow Sheet every 15 minutes.
Provide care for patient as indicated in Seclusion/Restraint Flow Sheets in time(s) indicated.
Psychoactive medication follows the same protocol and Procedure: every l5 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.
Current physical, emotional and behavioral condition status.
Medication administered(s) administered.
Type of care needed. "

Based upon observation, record review and policy and procedures, the facility failed to:

A.) follow its own policy and procedures to have RN supervision on each shift during break time, failed to have adequate staffing of licensed personnel.


Refer to Tag A0392



B.) Nursing staff failed to follow physician's orders for emergency psychoactive medications, refrain from using prohibited "as needed" psychoactive medications for restraint, conduct a comprehensive patient assessment to determine the need for other types of interventions, and prevent use of psychoactive medication for staff convenience.


Nursing staff failed to provide ongoing assessment of patient's medical condition throughout the hospitalization for 2 (#2, #3) of 3(1-3) patients review. Nursing failed to provide assessment and notify physician when a change of condition occurred, failed to document wound care, or monitor for potential falls for 2(#2, #3) of 3(1-3) patients reviewed.


Refer to Tag A0395

Based on chart reviews, interviews, and policy and procedures review, the facility failed to follow its own policy and procedures to have RN supervision on each shift during break time, failed to have adequate staffing of licensed personnel.


Review of the facility's policy and procedure titled "Nursing Staffing Plan" policy stated, "The facility is staffed utilizing a core staffing pattern with increase in nursing census utilized for acuity with a minimal staffing of 7.0 NHPPD and maximum hours based on the DON judgment and approval.

Staffing hours are adjusted based on the clinical decision of the DON regarding the needs of the unit. The staffing will be flexed up or down depending on the acuity, level of skills of staff, and other variables deemed appropriate by the DON."

Review of the patient census and staff scheduling revealed 24 patients is the maximum census. The grid revealed the following staffing pattern:

1.) 1 RN, 1 LVN, and 1 MHT per shift up to 5 patients.
2.) 1 RN, 1 LVN, 1 MHT's DAYS/1 RN, 1 LVN, 2 MHT's NIGHTS for 6-8 patients.
3.) 1 RN, 1 LVN, 2 MHT's per shift for 8-12 patients.
4.) 1 RN, 1 LVN, 3 MHT's per shift for 13-16 patients.
5.) 1 RN, 1 LVN, 4 MHT's per shift for 16-20 patients.
6.) 1 RN, 1 LVN, 5 MHT's per shift for 21-22 patients.
7.) 2 RN, 1 LVN, 5 MHT's per shift for 23-24 patients.

Review of the staffing schedules and the "daily staffing and census" sheets from 10/14/15 -10/28/15, revealed the facility did not have a RN available to cover for breaks and meal times for a total of 30 shifts. Review of those 30 shifts revealed 24 shifts had 18 or more patients.

An interview was conducted with the Administrator and the Director of Psychiatric Nursing (DPN) on 10/29/15. The DPN reported during the day there are RN's in the building to help relieve the RN to allow for a meal break. The DPN and administrator confirmed there was no one on weekends, nights, or holidays to relieve the RN. The DPN and administrator reported they have been advertising for more RN's but were having difficulties in finding appropriate staff. The DPN offered multiple pages of notes on attempts to interview and search for qualified RN's. The Administrator nor the DPN offered to decrease the census or a plan for RN coverage.

Based upon record review, policy and procedure review, nursing staff failed to follow physician's orders for emergency psychoactive medications, refrain from using "as needed" psychoactive medications for restraint, conduct a comprehensive patient assessment to determine the need for other types of interventions, and prevent use of psychoactive medication for staff convenience.

Nursing staff failed to provide ongoing assessment of patient's medical condition throughout the hospitalization for 2 (#2, #3) of 3(1-3) patients review. Nursing failed to provide assessment and notify physician when a change of condition occurred, failed to document wound care, or monitor for potential falls for 2(#2, #3) of 3(1-3) patients reviewed.

1.) Review of patient #2's admission orders revealed he was an 80 year old, male, admitted on 7/16/15, with a diagnosis of Dementia with mixed disturbance of emotion and conduct. The orders revealed he was voluntary, was on close 15 minute observations, on precautions for assault, falls, and chocking.

Review of patient # 2's physician orders revealed an "as needed" (PRN) order was written on 7/16/15, at 5:45PM. The order read, "Ativan 0.5 po q 6 prn anxiety/agitation."

On 7/17/15, at 11:45AM, a verbal telephone physician order was found for "Haldol 2mg, Ativan 1mg and Benadryl 25mg po/IM q 6 hours prn agitation/psychosis." Ordered by the psychiatrist but there was no legible nurse signature. At 4:30PM, another order was written by the psychiatrist for "Haldol 5mg, Ativan 2mg, and Benadryl 50mg po/IM q 4 hours prn agitation/psychosis/ 1st dose now."

A.) Review of the nursing Multi-Disciplinary Note dated 7/20/15, at 10:41PM, revealed patient #2 was having "bizarre behavior" and increased agitation. There was no further documentation found on patient #2 until 7/21/15 at 10:00AM a total of 12 hours later.

Review of patient #2's Medication Assessment Record (MAR) dated 7/21/15 at 10:00AM revealed patient #2 received Haldol 5mg, Ativan 2mg, and Benadryl 50mg IM for agitation.

Review of the nursing Multi-Disciplinary Note dated 7/21/15 at 10:00AM stated, "Very loud-intrusive-yelling/cussing unable to re-direct-verbally threatening staff. Attempted to re-direct with no effect. ABH given at this time- "you fucking bitch! " ongoing with yelling and cursing at staff. Continue with POC and monitor. "Review of the MAR on 7/21/15 at 11:00AM revealed the LVN documented, "decreased agitation." There was no further documentation found on patient #2 until 7/21/15 at 9:15 PM 10 hours and 15 minutes later.

Review of patient#2's chart revealed there was no documentation of any nursing interventions before a chemical restraint was administered. The nurse had documented "re-direct attempted." There was no documentation found on how the staff had attempted to re-direct and what other form of restraint could have been used before administering a chemical restraint. There was no documentation found of an ongoing assessment after the administration of the medication.

Review of the chart revealed patient #2 did not have a face to face performed after the restraint was given. There was no restraint paperwork in the patients chart or on the restraint log for the injection given on 7/21/15 at 10:00AM.


B.) Review of patient #2's MAR revealed patient #2 received Haldol 5mg, Ativan 2mg, and Benadryl 50mg IM for agitation administered on 7/23/15 at 8:15PM.

Review of the nursing Multi-Disciplinary Note dated 7/23/15 at 3:07PM stated, " Patient noted to have slid out of chair landing on floor, causing small 0.5cm laceration over left eye, moderate amount of blood noted, pupils equal round and reactive, responsive to light, responds well to commands, grips are equal and bilaterally. Pts wife notified. " There was no documentation of physician notification. There was no documentation of how the wound was treated.

Review of the Daily Nurses note dated 7/24/2015 from 7PM-7AM revealed the skin assessment of the note states there are no new issues. There is no further documentation on the patients head wound until 7/25/2015. A Skin and Braden Reassessment Documentation was found dated 7/25/2015. The skin assessment revealed patient #2 had steri- strips applied to the head laceration and steri- strips applied to a wound to the left forearm. There were no measurements to the wounds or documentation of wound care.

Review of the Neurological flow sheet date 7/24/15 at 9:00AM revealed patient #2 ' s blood pressure (B/P) was 177/91, pulse 104, respirations 18, temperature 97.6. There was no documentation that in the nurses notes about the elevated B/P. There was no documentation that the physician was notified of the elevated b/p or if the patient was symptomatic.

Review of the daily nurse ' s note dated 7/24/15 for the 7AM-7PM shift revealed the note had no time of completion. Review of the " Review of Systems " section was left blank on assessment of Cardio/Pulmonary, Breath Sounds, and Nutrition/Fluid was left blank. There was no found documentation of these systems.

Review of the daily nurse ' s notes on 7/25/15 for the 7AM-7PM shift revealed there was no documented pain assessment for the entire shift.


Review of the nursing Multi-Disciplinary Note dated 7/23/15 at 8:35PM stated, "Pt sitting in Geri-chair in dining area eating snack. Cooperative with assessment at this time. No s/s of distress noted from fall today. No aggressive behavior noted. Continue medication regime. Redirect as needed. No change in behavior. Will continue to monitor for pt. safety and continue with POC."

C.) Review of patient #2's MAR revealed patient #2 received Haldol 5mg, Ativan 2mg, and Benadryl 50mg IM for agitation administered on 7/24/15 at 7:05PM.

Review of the nursing Multi-Disciplinary Note dated 7/24/15 at 2:00PM stated, "Late Entry pt. seated in activity room. Attempt made to check (illegible word) for neuro checks d/t resistance earlier. Pt redirection attempted. Pt making sexually inappropriate comments to staff. Will continue to redirect as needed." There was no further information if the nurse was able to perform the neuro check or any other interventions.

Review of the nursing Multi-Disciplinary Note dated 7/24/15 at 7:00PM stated, "Late. Med nurse talked to (the patients wife) on phone to discuss with family member patient refusing medication at times. Family member suggested "give medication in milk calling it a snack." Therapist, DON, and psychiatrist informed of family member suggestion ref medication. Continue plan of Care."

There was no documentation found of patient behaviors, why, where, and when the medication was administered. There was no documentation found for nursing assessments, interventions, MD notification nor restraint protocol followed. There was no assessment found on the patient after the medication administration or if it was effective.

Review of the nursing Multi-Disciplinary Note dated 7/24/15 at 8:40PM revealed the patient was confused and had requested to have his knife and a phone. "Pt continued to curse and speak loud. Pt not easily re-directed. No change in behavior." There was no documentation in the Multi-Disciplinary Notes or on a restraint flowsheet of the medication administration. There was no nursing interventions or assessments before or after. There was no documentation in the Multi-Disciplinary Notes or on a restraint flowsheet of the medication administration.

On 7/25/15 at 12:30PM the physician wrote an order that read, "Haldol 10mg, Ativan 2mg and Benadryl 50mg po/IM q 8 hours prn agitation/aggression/ 1st dose now, IM for po refusal."

D.) Review of patient #2's MAR revealed patient #2 received Haldol 10mg, Ativan 2mg, and Benadryl 50mg IM for agitation administered on 7/25/15 at 12:50PM.

Review of the nursing Multi-Disciplinary Note dated 7/25/15 at 12:20PM stated, "Pt attempting to help another patient thinking staff is harming her. Pt yelling at staff, cursing. Pt praying loudly over pt so that she can stand and walk. Pt became agitated when attempt made to remove him from the situation. Pt began to get louder, yelling at staff, being forceful. New order to received and carried out shortly thereafter. Will continue to monitor. There was no documentation of what order was carried out, why, when, and how medication was administered. There was no documentation of nursing interventions, physical nursing assessment, or restraint protocol with a face to face. There was no nursing documentation of an ongoing assessment or medication effectiveness. The next nursing documentation was found on 7/25/15 at 7:48PM.

E.) Review of the nursing Multi-Disciplinary Note dated 7/25/15 at 7:48PM stated, "Pt. up at nurses station increased agitation/verbal aggression AEB demanding to use the phone, cursing stating he was going to call the police to get him out of here. Explore appropriate behaviors to increase insight. No change in behavior very demanding. Continue to monitor. Advise LVN need of PRN medications. Continue POC." There was no physical nursing assessment documented. There was no documentation of nursing interventions appropriate for this patient. There was documentation of MD notification.

Review of patient #2's MAR revealed patient #2 received Haldol 10mg, Ativan 2mg, and Benadryl 50mg po for agitation administered on 7/25/15 at 9:50PM. The medication was administered 2 hours later from the original documented behavior. There was no documentation that the patient continued to have inappropriate behavior when medication was administered. The nurse failed to follow physician orders and gave the patient medication at 6 hours apart instead of 8. There was no ongoing nursing documentation after the administration of psychotropic medications to ensure effectiveness or side effects. The next time nursing documentation was found was on 7/26/15 at 8:00AM a total of 10 hours later.

Review of patient #2's MAR revealed he received Haldol 10mg, Ativan 2mg, and Benadryl 50mg IM for agitation administered on the following dates and times;
7/27/15 at 2:15PM
7/28/15 at 9:30AM
7/30/15 at 12:45AM
7/31/15 at 4:45AM

There were no nursing interventions documented appropriate for this patient noted. There was no restraint procedures put into place for the injections given as a chemical restraint. There was no documentation found of the ongoing assessment or other alternatives before a chemical restraint was administered.
Review of the Multi-Disciplinary Note dated 7/28/2015 at 4:50AM revealed the patient had another fall. Patient #2 lost his balance and grabbed the door frame to keep from falling. The MHT grabbed the patient and went to the floor with patient #2. Nurse documented, " Patient sat on the floor for a couple of minutes and was helped up. Pt. then walked up to the nurse ' s station. Pt assessed at this time by this nurse. Laceration to right side of head above ear noted. Wound cleaned and photographed for documentation. Attempted to get vs from pt. Pt refused will continue to monitor. Notified physician of fall. Also notified family at this time but no answer at this time. " There was no further documentation of the patients wound, if family was ever notified, no neuro checks were performed or assessed. There was no further documentation of patient head wound or assessments.

2.) Review of patient #3's physician orders revealed the patient was admitted on 10/20/15 as a voluntary patient. The admitting diagnosis was psychosis. Patient #3 on a close observation every 15 minute check and on the following precautions; Suicide, Elopement, Seizure, Assault, Falls, Choking.

A.) Review of patient #3's MAR revealed patient #3 received Haldol 5mg, Ativan 1mg, and Benadryl 25mg IM for agitation administered on 10/22/15 at 5:30PM.

Review of the physician orders dated on 10/21/15 at 5:15PM stated, "Haldol 5mg, Ativan 1 mg, Benadryl 25 mg q 4hours prn po or IM for po refusal for anxiety/psychosis."

Review of patient #3' s nursing Multi-Disciplinary Note dated 10/21/15 at 5:40PM stated, "Pt escaped from patio area space and attempted to climb fence to exit unsuccessfully, MHT's and LVN quickly stopped patient and redirected indoors." At 8:05 PM the nurse's note stated, "Pt. in bed resting no s/s of distress. Continue to monitor." There was no documentation of nursing interventions, restraint protocol, a face to face, or ongoing assessment for effectiveness for patient #3.

B.) Review of patient #3's MAR revealed patient #3 received Haldol 2mg, Ativan 2mg, and Benadryl 25mg IM for agitation administered on 10/26/15 at 12:45AM.

Review of the physician verbal telephone order dated on 10/26/15 at 12:20AM stated, " Haldol 2mg, Ativan 2 mg, Benadryl 25 mg for agitation x 1 dose now.

Review of patient #3's nursing Multi-Disciplinary Note dated 10/26/15 at 12:45AM stated, "Pt was sitting in his room when he was seen running out of his room up to the day area. Double doors were closed and pt. ran into them and then pushed on other door and ran into day area straight to front door and started hitting it. Pt given Haldol, Ativan, and Benadryl IM after pt. refused to take it orally. Will monitor of side effects." There was no nursing interventions documented, or restraint protocol followed for an emergency chemical restraint. There was no face to face or ongoing assessments documented.

Review of patient #3's nursing Multi-Disciplinary Note dated 10/26/15 at 12:45AM stated, "Pt up in day area. Pt started picking up couch attempting to push it to window. Pt very agitated. Hard to redirect. Pt given Haldol, Ativan, and Benadryl. Will monitor for side effects. There was no nursing interventions documented, no physician notification, no documentation for a face to face, or ongoing assessment with medication effectiveness documented.

Review of patient #3's MAR on 10/26/15 at 12:45AM revealed there was no documentation that the medication was administered.

Review of patient #3 ' s Multi-Disciplinary Note dated 10/26/15 at 1:40PM revealed the social worker made an entry that stated, " Called pts niece POA to inform of pts fall/discussed pt. behaviors, concerns and d/c follow up. There was no found documentation of a fall for patient #3. Review of the daily nursing notes revealed there was no note for 10/26/15 for the 7AM-7PM shift.
Review of the Multi-Disciplinary Note dated 10/29/15 at 1:40PM stated, " Pt was sitting in the day room on recliner around SW/MHT, when pt. began to pick at items on the floor that were not there, when SW went to help pt. fell forward from sitting position hitting his face on the ground, causing a small laceration to FA, hematoma, bleeding from nose and laceration, First aid administered per med nurse, pt. v/s taken b/p 154/80, p 73, r 18, T 98.1. NP notified reviewed order to send pt out to ER, family notified. Pt confused more so after fall. 911 called and arrived to pick up pt to go to hospital for eval and tx. "
There were no documented neurological assessments performed on patient #3. There was no documentation or any nursing interventions to prevent falls after multiple PRN psychotropic medication administrations. There was no order written to send the patient to the hospital for evaluation.
Review of the daily nurses notes revealed there was notes missing from the chart for the following dates and shifts for both shifts on 10/25/15 and 10/26/15 day 7AM-7PM.

C.) Review of patient #3's nursing Multi-Disciplinary Note dated 10/28/15 at 7:25PM stated, "Pt up in day area. Pt came up behind female MHT and physically assaulted her with shoe across MHT's neck and shoulder on her right side. When attempted to redirect pt. he tried to lift recliner in day area. Unable to redirect pt. then walked to dining room area and picked up chair, chair taken from pt. Pt accompanied to chair by MHT and nurse. Pt agitated and irritable. Pt given prn medication for agitation and irritation. Continue medication regime. Redirect as needed. Redirection ineffective at this time. Cont. POC." There was no further documentation found of nursing interventions or attempts at other restraints before using a chemical restraint. There was no further nursing documentation until 10/28/15 at 9:30PM.

Review of the MAR dated 10/28/15 at 7:30PM revealed patient #3 was administered Haldol 5 mg, Ativan 1 mg, and Benadryl 25 mg. The nurse failed to document the route of the medication. It was not determined if the medication was given by mouth or injection. There was no documentation of the effectiveness of the administered medication.

Review of patient #3's verbal physician orders dated on 10/28/15 at 9:30PM stated,
" 1.) D/C Haldol 5mg, Ativan 1 mg, Benadryl 25 mg po or IM for po refusal q 4hours prn.
2.) Start Haldol 5 mg, Ativan 2 mg, Benadryl 25mg po/IM for PO refusal q 4 hrs PRN for agitation/psychosis.
3.) Ativan 1 mg po x 1 dose now if po refused may give Ativan 2 mg IM x 1 dose now for agitation. "

Review of patient #3's nursing Multi-Disciplinary Note dated 10/28/15 at 9:30PM stated, "Received new orders from psychiatrist. Pt. continues to be agitated/irritable. Hard to redirect by MHT. Will continue to monitor for pt. safety will administer medication as needed."

Review of patient #3's MAR for 10/28/15 revealed patient #3 was administered Ativan 2 mg IM now for agitation. However, the nurse failed to document what time the medication was administered on the MAR.

Review of the policy and procedure Emergency Restraint and Seclusion stated,
" Policy:
The facility's functional program is designed to ensure and respect the patient's right to be free from seclusion and/or restraints in any form that are not medically necessary or are used as means of coercion, discipline, convenience, or retaliation by staff.

* Chemical Restraint: As defined by 42 CFR 482.13(e)(1)(i)(B), a chemical restraint is a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition." Per State Regulation set Y.4.00 requirement 415.254 (a)(2), no intervention voluntary or involuntary shall be used for the purpose of convenience of staff members.

Initiate emergency restraint and seclusion in absence of physician post determination that alternative interventions were not effective or would not deter harm to self/others.
Notify physician as soon as possible and not more than one hour.
Document contact and physician order on Physician Order for Seclusion and Restraint Form.

Face-to-Face Evaluation:
(RN conducting face-to-face cannot be the RN who initiated restraint/seclusion and telemedicine technology cannot be utilized.):
Conduct face-to-face within one hour (if trained to do so) even if patient is no longer in restraint/seclusion and physician is not present. Document on Face-to-Face Evaluation Form:
Date/time
Behaviors
Alternative interventions to prevent restraint/seclusion
Medical review of patient's status post-intervention
Consult post face-to-face evaluation, review findings with physician.
Document contact/review.
Document continued need for intervention every one hour on flow sheet.
Conduct, when time limit for order expires, an in-person visual evaluation.
Consult post visual evaluation, review findings with physician. Document contact/review - follow orders of physician.
Evaluate treatment plan for changes to assist patient in regaining control.
Face-to-face re-evaluation hourly if physician is not present; conduct/review evaluation with physician and follow physician orders. Document on face to face Evaluation form.
NOTE: The physician must conduct an in person face to face evaluation by the time expiration of the second order for restraint or seclusion occurs. This cannot be delegated. Each use of restraint requires a separate order and justification.
Notify DON
Notify family as applicable with onset
Notify LAR
RN/MHT:
Monitoring:
Provide monitoring as indicated on Seclusion/Restraint Flow Sheet every 15 minutes.
Provide care for patient as indicated in Seclusion/Restraint Flow Sheets in time(s) indicated.
Psychoactive medication follows the same protocol and Procedure: every l5 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.
Current physical, emotional and behavioral condition status.
Medication administered(s) administered.
Type of care needed. "