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Based on record review and interview, the facility failed to ensure specific patient rights were protected and promoted. Specifically, the facility failed to ensure:

1.) patients were able to exercise their rights to request discharge and be informed of their commitement process. Refer to A0129 - A, B

2.) patients consented to their medical care. Refer to A0131

3.) they promoted patient safety and use the least restrictive intervention. Refer to A0154

4.) emergency behavioral medication orders included justification for the order by the provider and patients who received emergency behavioral medications were assessed and monitored per the facility policy Refer to A0160


The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Patient Rights.

Based on a review of the clinical record and confirmed in interview, the hospital failed to inform the patient of his/her patient rights for three (Patient #1, 6, 11) of eleven patients reviewed.


Findings included:

Random record review of patient charts revealed three (Patient #1, 6, 11) of eleven patients had no documentation of them receiving their Patient Bill of Rights.

An interview with Staff #C on 01/23/2024 in the administration conference room confirmed the above findings. She stated that the administration is responsible for getting the consents and providing the paperwork. She stated that for the above patients, the administration was 'medically unable' to get consents and acknowledged that there is no process to verify if consents are verified prior to treatment.

Based on review of the facility policy, patient clinical record, and confirmed in interview, the facility failed to follow its grievance policy for one of eleven (Patient #1) patients reviewed.

Findings included:

Review of the facility policy Patient Grievance and Complaint Management (Policy Stat ID 13184599, effective 03/2023) under Procedure it stated:

"Notification of Rights Regarding Complaint/Grievance Resolution

Each patient and/or patient representative is informed of the rights and responsibilities afforded patients upon entry into the facility, and the process by which they may lodge a complaint. Each patient receives information on how to lodge a grievance with the Texas Department of State Health Services upon entry to the facility. The Texas Department of State Health Services, phone number, and address are provided in the event that the patient decides not to use the internal grievance process. The patient may also contact the Quality Improvement Organization (QIO) if they have a complaint regarding the quality of care, disagree with a coverage decision, or wish to appeal a premature discharge.

B. Complaint Resolution Process

1. The staff routinely rounds in the facility to greet patients, ask questions about the patient's stay and determine whether their needs and expectations are being met during their stay. When a patient voices a complaint, the patient will be encouraged to discuss the complaint with their physician or unit nursing staff. The unit nurse director or nursing supervisor may be involved as needed. If the complaint is related to a particular department, a representative from that department may be invited to discuss the issue with the patient. A representative of the administrative staff may be involved as needed to assist with a prompt resolution.

2. Every effort will be made to resolve the complaint at the lowest level possible. Each staff member is empowered to respond and resolve promptly any complaint voiced by a patient and/or their representative. The staff member receiving the complaint will notify his/her supervisor when the issue cannot be immediately resolved. At each level of this process, the staff member will listen with concern to the patient's complaint, consider the circumstances and context of the complaint, and assure the patient that their complaint will be investigated and resolved as soon as possible.

3. At any point in the process, the complaint may become a grievance based on the aforementioned criteria.

C. Grievance Resolution Process

1. Grievances may be received written, verbally, via electronic mail or facsimile, or by telephone to any department. Complaints received via the Corporate Ethics Line are forwarded by the Corporate Ethics and Compliance Department to the facility ECo for coordination of the investigation and response to the complainant if identified.
Response to an anonymous complaint will be forwarded from the facility ECO to the Corporate Ethics and Compliance Department for posting on the Ethics Line. Other patient care complaints received at the Corporate Office may be forwarded to the CA Quality Standards Department. These complaints are directed to the attention of the facility CEO who is responsible for the completion of the investigation and communication of resolution to the complainant. The HCA Quality Standards Department facilitates this process to assure resolution and compliance with regulatory standards.

2. Upon receipt of a grievance, the appropriate department manager will be contacted.
The grievance will need to be entered into the grievance log maintained by the Risk Management Department. Notification to the Risk Department and or Quality Director will be conducted by the person receiving the complaint. The person conducting the investigation will write or call the patient to let them know that we have received the letter and that they will be investigating the concerns of the letter.

The director will review and investigate the grievance within seven days of receipt of the grievance, with the exception of complaints that endanger the patient (i.e., abuse or neglect). These grievances should be reviewed immediately given the seriousness of the allegation and the potential for harm to the patient.

1. A written response of the hospital's investigation and subsequent actions will be sent as soon as possible, in most cases within seven days. Occasionally, a grievance is complicated and may require an extensive investigation. If the grievance will not be resolved, or if the investigation is not or will not be completed within seven days, the complainant should be informed that the facility is still working to resolve the grievance and that the facility will follow up with a written response within 21 days.

2. The response will include the name of the contact person, steps taken to investigate, the results of the actions taken as applicable, and the date of completion. Either the appropriate Director or Administrator will provide this response. The written notice must be communicated appropriately to the patient or the patients representative in a language and manner the patient or the patient's representative understands.

3. At the discretion of the person conducting the investigation, other mechanisms may be utilized to resolve a grievance. For example, conducting a meeting with the complainant may be very effective.

4. Patient Appeal Process if Not Satisfied with Resolution of Grievance:
If a patient is not satisfied with the resolution of the grievance, the following shall occur in the event of a major complaint: the appropriate administrator shall review the complaint again, with the appropriate hospital personnel and confer with the CEO to review the resolution for possible modifications. A written response will be provided to the complainant within 10 days and the complainant will be invited to visit with the appropriate VP to obtain an oral explanation of the response to the appeal.
A grievance is considered resolved when the patient and/or the patient's representative is satisfied with the actions taken on their behalf. There may be situations where the organization has taken appropriate and reasonable actions on the patient's behalf in order to respond to the patient's grievance and the patient or patient's representative remains unsatisfied with the actions taken by the organization. In these situations, the Grievance Committee may consider the grievance closed for the purpose of the requirements of the conditions of participation.
o Grievance information is aggregated, tracked, trended, and communicated by the Risk Management Department to HCA Houston Healthcare Northwest management and leadership on an as-needed basis."
Review of Patient #1's medical record revealed no documentation the facility provided the patient information regarding the grievance policy.

Review of Patient #1's medical record revealed nursing notes on 01/16/2024 at 11:24 AM where Staff #M noted "Mom at BS [bedside] after multi [multiple] calls this AM, now demanding to see MD so informed him, also demanding meds for her 'UTI' and wants her to take shower"

Further review of Patient #1's nursing notes on 01/16/2024, Staff #N noted "PT [patient] mother called, explained that I was advised in report that she could not have phone calls at this time. Explained to mother she could contact the director in the morning. Pt then came to the window and asked the same, when attempting to explain to pt she would not listen and talked over nurse stating 'you don't like your job? Why you mad?' other nurse then addressed pt and explained that she could not have phone calls at this time."

Review of the grievance log from November 2023 to current revealed no documentation of the grievances/complaints from the Patient #1's mother regarding the above grievances per the facility policy.

An interview with Staff #C and Staff #D on 01/22/2024 at 12:00 PM in their office confirmed the above findings. They both stated that they had numerous conversations with Patient's mother throughout the patient stay. However, they both acknowledged that their discussions were not documented nor logged onto the grievance log.

No documentation was available for review to determine what was discussed and/or if grievances were noted and resolved.

A. Based on a review of facility policy, clinical record, and confirmed in interview, the facility failed to ensure the patients were able to exercise their rights as evidenced by failing to address requests appropriately and effectively for discharge for one of eleven (Patient #1) charts reviewed.

Findings:

Review of the facility policy Dismissal of Patient - AMA [against medical advice] stated in part,
"- Every effort should be made to determine the factors precipitating the patient's decision, and adequate correction of the problems should be attempted.
- The patient ultimately retains the right to make this decision.
- Physician is to be notified
- Nurse Manager/Nursing Supervisor is to be notified at time of incident.
- Document event in patient electronic medical record and per hospital standard.
- Involve the patient's family in this decision to leave, especially if the patient is not completely responsible for his decisions.
- Notify the physician of the patient's decision to leave.
- Notify the Nursing Manager/ Nursing Supervisor of the incident.
- Have patient or family sign the AMA form.
- Discuss risks of leaving AMA including possible death and document that in a Nursing Note.
- Witness the signature on the AMA form.
- If the patient or family refused to sign the form, note that information on the AMA form and sign on the witness line with a second RN.
- Document in patient electronic medical record and per hospital standard. Documentation should include whether the patient signed the AMA form, what attempts were made to dissuade the patient from leaving, including reviewing risks of leaving AMA with the patient and/or family including possible death. Additionally, document that the IV was removed if one is present and that the physician was notified."

Patient #1 was admitted to the ED (emergency department) on 01/14/2024 for an attempted suicide and swallowing pills. She was medically cleared on 01/15/2025 at 5:12 PM after 24 hours of no seizures and vitals along with consultation with Poison Control.

Review of the nursing notes from 01/15/2024 at 7:57 PM of Patient #1's medical record Staff #J noted the following: "Pt [patient] was in her room sitting on the bed in agitated mood. Pt was screaming stating 'I want to leave...you all can't keep me here. I am going to leave, and no one can stop me'" Staff #J also noted that Staff #E was informed and ordered 5 MG Midazolam.

This patient was admitted voluntarily on 01/14/2024 and an Emergency Detention Warrant (EDW) was simultaneously being processed the same day she requested discharge on 01/15/2024. It was faxed to the court on 01/15/2024 at 11:00PM and the warrant was executed on 01/16/2024 at 12:34 AM.

Review of the Patient #1's medical chart revealed no documentation of the AMA form per facility policy. No documentation was available for review that any staff discussed with the patient and/or family regarding her request for discharge. She was transferred involuntarily to a psych facility on 01/20/2024, five days after her initial request.

An interview with Staff #C on 01/23/2024 at 10:00 AM in the conference room confirmed the above findings.

B. Based on a review of facility policy, clinical record, and confirmed in interview, the facility failed to ensure the patients were able to exercise their rights as evidenced by failing to educate the patient and patient's family regarding the warrant/commitment process for one of eleven (Patient #1) charts reviewed.

Findings included:

Review of the facility document Emergency Detention Warrant and Order of Protective Custody Commitment (PolicyStat ID 9852590, effective 07/2023) stated:

"-patients have the right to request a re-evaluation by the physician to determine if they still meet commitment criteria.
- Patients under the warrant/commitment process retain the same rights as voluntary patients, including the right to refuse medications and treatment, except that the physician must write orders for the patient's privilege of leaving his/her assigned location with or without staff/family/associates.
If possible, request a psychiatric consult if the patient requires an EDW or OPC to address psychiatric medications. The Mental Health Assessment Team may not prescribe.
PATIENT/FAMILY EDUCATION
1. Explain the process to the family and request participation in taking information to the courts timely; and to attesting to the patient's behavior.
DOCUMENTATION
A physician order is needed to initiate an EDW and/or OPC. If appropriate, the patient and/or family will be informed of the application processes in a language they can understand. In certain cases, where it is not in the best interest of the patient and/or the family to be informed of a pending emergency detention, education may be given after the issuance of the EDW by HHH-NW staff or the County Constables or can take place at the accepting psychiatric facility.
For example, due to the emergent nature of the EDW, it may be best to delay patient and/or family education until the warrant has been issued, especially if behavioral escalation may be anticipated with the potential for harm to patients or others."

Review of Patient #1's medical record revealed no documentation of any staff member providing education regarding the commitment process to the patient or the family. No doctor's orders to initiate the EDW and/or OPC were available for review on the MAR (Medication Administration Record) per the facility policy; only the medical examination that attested for the need of involuntary hold and the paperwork submitted to the court were available for review.

An interview with Staff #O on 01/22/2024 at 2:45 PM in the conference room, he stated that his team would evaluate the patient and they typically would inform the patient of their involuntary status. He was unaware if that is documented anywhere. He acknowledged that there is no policy or procedure that they followed.
His team is also in charge of finding placement for inpatient psychiatric care. However, that is done offsite, and no records were available for review.

Furthermore, he stated that they do not routinely provide information regarding patient information to their assigned lawyer and/or information of their probable cause hearing.

Based on records review and confirmed in interview, the facility failed to ensure that all patients consented to medical treatment prior to receiving treatment. There was no documented general consent to medical care in 3 (Patient #1, 6, 11) of 11 patient medical records reviewed.

Findings include:

Review of the facility document titled, "Conditions of Admission and Consent for Outpatient Care," revealed that it is a document to be signed by the patient, indicating the patient was aware of and agreed to the following:

- Consent to treatment
- Communications about my healthcare
- Patient self-determination Act
- Acknowledgement of Notice of Patient Rights and Responsibilities

Review of patient medical records #1, 6, and 11 revealed no "Conditions of Admission and Consent for Outpatient Care," signed or unsigned.

An interview with Staff #C on 01/23/2024 in the administration conference room confirmed the above findings. She stated that the administration is responsible for getting the consents and providing the paperwork. She stated that for the above patients, the administration was 'medically unable' to get consents and acknowledged that there is no process to verify if consents are verified prior to treatment.

Based on review of the facility policy, medical chart, video surveillance, and confirmed in interview, the facility failed to use the least restrictive intervention that promote patient safety for one of eleven (Patient #1) patients reviewed.

Findings included:

Review of the facility policy Patient Restraint/Seclusion (Policy Stat ID 9411529, Effective 05/2021) provided the following definitions:

"Drugs as restraints: 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 is considered a restraint. When medications are used as restraints, it is important to
note that the decision as to whether they constitute restraint is not specific to the treatment setting, but
to the situation the restraint is being used to address. A medication that is not being used as a standard
treatment or in a dosage for the patient's medical or psychiatric condition and that results in controlling
the patient's behavior and/or in restricting his or her freedom would be a drug used as a restraint."

Further review of the policy provided the following procedure:
"Assessment for Risk for Restraint
a. The Registered Nurse (RN) performs an assessment for risk for restraint or seclusion when a
patient exhibits behavior that may place the patient at risk for restraint or seclusion. This risk assessment includes:
1. Does the patient have a medical device?
2. Does the patient understand the need to not remove the device?
3. Is the patient required to be immobile?
4. Does the patient understand the need to remain immobile?
5. Is the patient exhibiting aggressive, combative or destructive behavior?
6. Does this behavior place the patient/staff/others in immediate danger?

b. The assessment for the risk for restraint or seclusion also includes:
1. Patients who arrive in restraint.
2. Patients in restraint who have recovered from the effects of anesthesia and are
awaiting transfer to a bed.
Note: Patients in the NICU and nursery are excluded from the assessment for risk for restraint.
2. Alternatives to Restraint or Seclusion
Patients that are determined to be at risk for restraint or seclusion will have alternatives initiated
promptly. Appendix B contains a listing of alternatives to restraint or seclusion.
3. Determination That Alternatives to Restraint or Seclusion Have Failed
The RN determines that alternatives to restraint or seclusion have failed and that the patient will be safer
in restraints than continuing without restraint.
4. Second Tier of Review
A member of nursing administration/management (e.g., nursing supervisor/manager, charge nurse,
manager/director, CNO, etc.) will review the need for restraint or seclusion with the RN who has
determined that the patient requires restraint or seclusion. The second tier of review will occur with the
initial application of restraint or seclusion. Renewals of restraint or seclusion orders do not require a
second tier of review. The review includes:
a. Alternatives attempted
b. Reason for restraint or seclusion
c. Least restrictive type of restraint
d. Staff's knowledge of the cause of patient behavior (physiological, psychological,
environmental, medication)
e. Appropriate restraint for vulnerable patient populations
f. Staffing available for monitoring
g. Affirmation of partnering to meet the patient needs with safety and compassion
Note: In an emergency application of the restraint or seclusion, the above review will be done
immediately after the application of restraint.
5. Order for Restraint or Seclusion
a. An order for restraint or seclusion must be obtained from an physician or other licensed
practitioner who is acting within their State Scope of Practice, authorized by State law as
having authority for ordering restraints, and is responsible for the care of the patient prior to
the application of restraint or seclusion.3 A resident who is authorized by State law and the

Documentation Requirements
The medical record contains documentation of:
a. Assessment for risk for restraint or seclusion
b. Restraint or seclusion alternatives employed
c. The patient's condition or symptom(s) that warranted the use of the restraint or seclusion
d. Determination of effectiveness/ineffectiveness of restraint or seclusion alternatives
e. Second tier review of need for restraint or seclusion
f. Order for restraint or seclusion and any renewal orders for restraint or seclusion
g. Restraint or seclusion application/initiation
h. Family notification of restraint or seclusion use
i. Patient and family education regarding restraint or seclusion use
j. Assessment of the patient in restraint or seclusion
k. Monitoring of the patient in restraint or seclusion
l. Medical and behavioral evaluation for restraint or seclusion management of violent or self destructive
behavior
m. The patient's response to the intervention(s) used, including the rationale for continued use of
the intervention
n. Modifications of the plan of care
o. Physician notification of changes in patient condition
p. Restraint or seclusion removal/termination"

Random review of patient records revealed one of eleven patients (Patient #1) with no documentation to justify the need of the emergency behavioral medication administered.

Patient #1
Patient #1 a 20 year old female was seen in the emergency room on 01/14/2024 with increased depression, suicidal thoughts, and suicide attempt. EMS brought her in for medical clearance and psychiatric evaluation.

Review of Patient #1's medication administration records documented ED [emergency department] provider (staff #E) ordered on 01/15/2024 at 7:12 PM a onetime dose of Midazolam HCL 5 MG/mL IM (sedative) and on 1/15/2024 at 9:56 PM a onetime dose of Droperidol 5 mg/2 mL IM (antipsychotic medication). The physician orders did not include the rationale or justification for administering the medication. Both orders were signed off and administered by Staff #J at 7:41 PM and 10:01 PM respectively.

Surveyor reviewed video surveillance from 1/15/2024 and it provided the following timeline of events for Patient #1:
7:30 PM, Patient #1 was seen on the phone in front of nursing station of ED Pod D.
7:34 PM, MAT (mobile behavioral assessment team) reviewer (Staff # P) seen having discussion with Patient #1 by the phone
7:37 PM, Patient #1 goes back to patient room
7:43 PM, Patient #1 goes back to phone
7:48 PM, Patient #1 handed phone receiver to security (Staff #Q). Staff #Q is having discussion on the phone
7:50 PM, Patient #1 goes back to room along with 3 security officers and 3 nursing personnel
7:52 PM, Patient #1 walks to restroom accompanied by security and nursing staff
7:54 PM, Patient #1 walks back to room
7:55 PM - 9:30 PM, Patient #1 in the room

Review of the nursing notes from 01/15/2024 at 7:57 PM of Patient #1's medical record Staff #J noted the following: "Pt [patient] was in her room sitting on the bed in agitated mood. Pt was screaming stating 'I want to leave...you all can't keep me here. I am going to leave, and no one can stop me'" Staff #J also noted that Staff #E was informed and ordered 5 MG Midazolam.

Review of all available documentation revealed no documentation of any other de-escalation alternatives attempted prior to the emergency behavioral medication administered were available for review.

Further review of the video illustrated the following timeline:
9:30 PM, Patient #1 approached the nursing station in the ED Pod D
9:33 PM, Patient #1 walks back to room
9:47 PM, security is by Patient #1 doorway
9:48 PM, security (Staff #Q) and 4 other nursing personnel are seen in and out of Patient #1's room, with one nurse unraveling one soft restraint and entering the room (remaining bag of soft restraints on the floor outside of patient room)
9:50 PM, nurse handed bag of soft restraint to another nurse inside of patient room
10:06 PM, lights are turned off and all staff exit patient room

Review of documentation available revealed no documentation of the incident at 10:00 PM that corresponded to the emergency behavioral medication administered.

Review of documentation available revealed no documentation of any other de-escalation alternatives attempted prior to the emergency behavioral medication administered were available for review.

In an interview with Staff #G on 01/23/2024 at 12:50 PM in his office and after his review of the video, he acknowledged that the incident we reviewed warranted at least a code Bert (behavioral incident). However, no documentation was provided. He stated he was unaware why no one called a code.

An interview with the Staff #R on 01/23/2024 at 1:10 PM in Staff #G's office confirmed the above findings. When inquired about the soft restraints viewed on the video, she stated that the nurse only unraveled one and their nursing staff would need all 4 to utilize. She was unaware why the nurse would bring into the room and not use them however.

No documentation was available for review that the soft restraint were ordered or utilized.

In an interview with both Staff #G and Staff #R on 01/23/2024 at 1:15 PM, they both acknowledged that Patient #1 did not seem combative, nor did she try to elope after review of the video surveillance from 7:30 PM to 10:30 PM of 1/15/2024.

Review of the progress Behavioral Health Progress note signed by Staff #E stated "the patient was evaluated by the BHC [Behavioral Health Connections] mobile assessment team on 1/15/24 at 16:15 [4:15 PM] with involuntary inpatient psychiatric hospitalization and continues to require involuntary inpatient psychiatric hospitalization as evidenced by patient actively endorses suicide, threatened hospital personnel, and tried to elope. Patient has poor insight and judgement evidenced by refusing help and trying to elope."

Review of the facility incident log from January 2023 revealed no incident of patient #1 trying to elope.

A phone interview with Staff #Q via telephone on 01/23/2024 at 1:00 PM, she stated that she was on shift that day and interacted with patient #1 most of the afternoon and evening. She stated that Patient #1 never tried to elope, she just threatened to elope.

Based on review of the facility policy, medical chart, and confirmed in interview, the facility failed to ensure emergency behavioral medication orders included justification for the order by the provider and patients who received emergency behavioral medications were assessed and monitored per the facility policy for three of eleven patients (Patient #1, 5, 6) reviewed.

Findings included:

Review on 01/23/2024 of the facility's current policy Emergency Administration of Psychoactive Medications in a Psychiatric Emergency Without Patient Consent (Policy ID # 14928813, Effective 12/2023, Last Revised 12/2023) stated "Purpose: To define protocol and safe guidelines for the administration of intramuscular psychoactive medications during a psychiatric emergency in compliance with CMS Conditions of Participation requirements for restraints.

Definitions: Psychoactive Medications - medication that the primary intended therapeutic purpose is to treat or improve signs or symptoms of a mental disorder, or to modify mood, affect perception of behavior.

Behavioral Emergency - a situation in which a patient is behaving in a violent or self-destructive manner and verbal intervention was not effective in de-escalating the patient, and it is immediately necessary to restrain, seclude, or administer psychoactive medication to prevent a patient from harm to self or others. Significant agitation requiring intervention in the emergency setting.

Emergency Medication - a psychoactive medication administered during a psychiatric emergency with a physician's order for a one-time, immediate dose of an intramuscular medication or a combination of medications used to assist a patient in regaining control of their behavior. PRN medications are not in scope for this policy. Examples of medications in scope for this policy are antipsychotic, benzodiazepines, and other sedating medications administered via intramuscular route.

Procedure/Guidelines:
3. Documentation by the nurse shall include but is not limited to:
a. Information communicated to the patient by the nurse.
b. Precautions taken to assure patient safety during the administration of medication.
c. All measures implemented to obtain patient cooperation in an attempt to avoid more restrictive measures.
e. The condition of the patient following administration of the medication including the following assessments: a. vital signs (HR, RR, BP, SPO2) q 30 minutes x 2 hours, then q 1 hour x 2 hours for a total of 4 hours of monitoring (note if unable to obtain full set of vita signs due to threat to safety of staff or patients, minimum monitoring will include respiratory rate). b. psychological status and current behavior q 30 minutes x 2 hours. c. Response of the patient to the medication, including any adverse effects.
6. Within 1 hour post administration, a face to face assessment will be conducted and documented in medical record by a provider, or an RN specifically trained on the following: 1. Evaluation of the patient's immediate situation. 2. The patient's reaction to the intervention. 3. The patient's medical and behavioral condition and the need to continue or terminate the restraint or seclusion.
7. If 1 hour post administration face to face assessment is performed by specially trained nurse, that nurse will consult a provider to discuss findings. This consultation should include, at a minimum, a discussion of the findings of the 1-hour face-to-face evaluation, and the need for other interventions or treatments."

Random review of patient charts revealed three of eleven patients (Patient #1, 5, 6) who were administered emergency behavioral medication with no documentation of the rationale for the emergency behavioral medication and the required assessment and reassessment after administering the medication per the facility policy.

Patient #1
Patient #1 a 20 year old female was seen in the emergency room on 01/14/2024 with increased depression, suicidal thoughts, and suicide attempt. EMS brought her in for medical clearance and psychiatric evaluation.

Review of Patient #1's medication administration records documented ED provider (staff #E) ordered on 01/15/2024 at 7:12 PM a onetime dose of Midazolam HCL 5 MG/mL IM (sedative) and on 1/15/2024 at 9:56 PM a onetime dose of Droperidol 5 mg/2 mL IM (antipsychotic medication). The physician orders did not include the rationale or justification for administering the medication.
Both orders were signed off and administered by Staff #J at 7:41 PM and 10:01 PM respectively.

Review of patient #1's medical records revealed no documentation of the required nursing assessment of the condition of the patient following administration of the emergency medication. No assessment or reassessment by the physician pre or post administration of the emergency behavioral medication was documented. No documentation was found for the reason the patient received the emergency medication.

Patient #5
Patient #5 a 30-year-old male was seen in the emergency department on 01/20/2024 with suspected psychiatric illnesses including bipolar disorder, schizophrenia, and acute psychosis with medication noncompliance. EMS brought him in for from another hospital for medical clearance pending psychiatric evaluation.

Review of Patient #5's medication administration records documented emergency room provider, staff # H on 01/22/2024 at 12:43 PM ordered a onetime dose of Zyprexa 10 mg IM (antipsychotic medication). The physician order did not include the rationale or justification for administering the medication. The order was signed off and administered at 12:51 PM by staff # K a licensed vocational nurse.

Review of patient #5's medical records along with staff ID # L on 01/23/2024 at 1:30 PM failed to find documentation of the required nursing assessment of the condition of the patient following administration of the emergency medication. No assessment or reassessment by the physician pre or post administration of the antipsychotic emergency medication was documented. No documentation was found for the reason the patient received the emergency medication.

Patient #6
Patient #6 a 17-year-old female was seen in the emergency department on 01/19/2024. Patient brought in by EMS and has a history of depression, presenting for violent behavior and agitation after taking a large amount of acid at home with suicidal ideation with suicide attempt.

Review of patient #6's medication administration records documented emergency room provider, staff ID # I on 01/21/2024 at 2024 PM ordered Droperidol 5 mg IM (antipsychotic). The physician order did not include the rationale or justification for administering the medication. The order was signed off and administered at 8:29 PM by staff # J a licensed vocational nurse.

Review of patient #6's medical records along with staff ID # L on 01/23/2024 at 1:30 PM failed to find documentation of the required nursing assessment of the condition of the patient following administration of the emergency medication. No assessment or reassessment by the physician pre or post administration of the antipsychotic emergency medication was documented. No documentation was found for the reason the patient received the emergency medication.

Interview on 01/23/2024 at 14:30 PM with Emergency Room Manager, Staff ID # L confirmed the above findings.