HospitalInspections.org

Based on a review of the hospital "Patient Rights" information given to patients along with patient #5 (P5) and patient #6 (P6) emergency department records during the survey on 12/6/18, it was determined that the hospital held P5 against P5's will without obtaining appropriate authorization to do so, and the hospital gave P6 IM medication after P6 expressed refusal of oral medication.

Review of hospital Patient Rights information revealed in part, " ...Right to Decide. Patients have the right, in collaboration with their physician, to have information to enable them to make informed decisions involving their health care. This includes the right to accept or refuse medical care and treatment ..."

P5 was an adult who in September 2018, presented voluntarily at 2328 via police for evaluation of chest pain which was determined to be related to substance use. The following morning by 0123, documentation indicated that P5's cardiac symptoms were negative for specific concerns, but P5 was expressing suicidal thoughts. At that time, staff decided that P5 should have a psychiatric evaluation.

At 0730, nursing documented in part, "Pt standing out in hallway asking to leave, [asked] pt to go back into [P5] room and not be out in the hallway ...RN told [P5] that [P5] was not allowed to leave prior to being seen by psych [psychiatry] ..." Documentation indicated P5 insisted on being discharged, and P5 became verbally aggressive and threatened to leave then became combative when approached by security. Eventually P5 required restraints and medications.

While a psychiatric evaluation to determine if P5 was a danger to self or others was appropriate, the hospital failed to provide any form of authorization when it kept P5 against P5's will when P5 refused care and treatment.

P6 was an adult who presented to the emergency department in August 2018 for psychiatric evaluation via a family member. A physician note on day one of presentation revealed in part, a plan for, "[an antipsychotic] 5 mg, [sedative] 50 mg, [antianxiety] 2 mg PO/IM q6h PRN for agitation. This meant that these medications could be given either by mouth (PO) or intramuscular (IM). Actual written orders for those medications were found to be written as STAT medications. "STAT" means "instantly" or "immediately." STAT medications are given immediately, one time, and are then discontinued. However, these STAT medications had a 2-day expiration, indicating that the medications were not STAT but that the orders were suspended until and if the nurse determined they should be given.

Other medication documentation listed under "Active List of Orders" revealed the same medications listed as PO (by mouth) and intravenous for [sedative] and also intramuscular (IM) for [antianxiety] and [antipsychotic] Q6H (every 6 hours) PRN (as needed). This indicated that a nurse could offer the medication PO, but then give the medication IM if the refused to take by mouth and nurse decided to do so, without consulting with the physician. This also allowed a nurse to circumvent the patient right to refuse the medication PO, and give an IM instead.

A nursing note on day two of presentation revealed, "This RN educated Pt that (P6) was placed in restraints due to (P6) being both verbally and physically abusive to staff. Pt states "I only did that after you medicated me" ... (P6) became verbally and physically abusive when staff came to medicate (P6)... (P6) was medicated due to (P6) aggressive behavior prior to need for medication. Pt states "I told you when you offered medications I wasn't going to take them, I said I took my morning medication, and I wasn't going to take medications until tonight."

According to the medical administration record, P6 had been given [antipsychotic] 5 mg IM at 1600. No documentation revealed that PO [antipsychotic] had been offered. No documentation revealed any emergent behaviors necessitating IM medication. P6 refused the medication offered by the RN as was P6's right to do. However, the RN then circumvented P6's right to refuse the medication and gave the IM [antipsychotic] PRN.

Sitter documentation from 1400 through 1600 revealed P6 was cooperative. P6 was only documented as "agitated" after receiving medication against his will at 1600.

In summary, the hospital failed to obtain authorization to keep P5 against P5's will for evaluation, and failed to honor P6 right to refuse medication which resulted in an unnecessary restraint.

Based on a review of patient #6's (P6) restraint record during the survey on 12/6/18, it was determined that nursing increased the number of restrained limbs without obtaining another order to do so.

P6 was an adult who presented to the emergency department in August 2018 for psychiatric evaluation. P6 was restrained in 4-point restraint at 1604 on day two of presentation. A nursing note of 1653 revealed, "During 15 minute observation, this RN noted pt left wrist restraint not tied to bed. Restraint not tied at this time due to risk of awakening and further irritating pt. 1:1 sitter remains at bedside, this RN informed sitter if pt arouses and becomes irritable again." This meant that P6 remained in 3-point restraint, was asleep, and no longer demonstrating dangerous behaviors.

An RN note of 1722 revealed in part, " ...1:1 sitter states pt using left hand which was previously noted to not be fastened to the bed, to untie right wrist restraint. This RN went to Pt room and educated pt since he was trying to remove restraint, the left wrist would have to be fastened to the bed." This meant that P6 was taken from 3-point and placed again into 4-point. No physician order was found to do so.

Based on a review of patient #6's (P6) restraint record during the survey on 12/6/18, it was determined that hospital failed to release P6 at the earliest possible time.

P6 was restrained in 4-point restraint at 1604. At 1653, an RN note stated in part, "During 15 minute observation, this RN noted pt left wrist restraint not tied to bed at this time due to risk of awakening and further irritating pt. 1:1 sitter remains at bedside ..." This means that P6 was asleep and no longer demonstrating dangerous behaviors.

An RN note of 1722 stated in part, " ...1:1 sitter states pt is using left had ...to untie right wrist restraint ...educated pt since he was trying to remove restraints, the left wrist would have to be fastened to bed." Based on this, the RN failed to make an appropriate assessment for the continued need of restraint. Nursing flows redundantly reflected a need for restraint based on subjective documentation of "agitated/restless," neither of which singly, or together indicated a need for continued restraint.

An RN documented at 1808 the RN's belief that P6 "Would never be calm enough to have restraints removed," and (P6) cannot be reasoned with or understand explanations of why (P6) is in restraints and the actions (P6) needs to take to be removed from the restraints." This record information indicated that the RN erroneously believed termination of P6's restraint to be an intellectual rather than a behavioral goal. P6 was not fully released until 1900 following instruction from the psychiatrist to the RN. In summary, the hospital staff failed to release P6 at the earliest possible time.

Based on a review of four restraint/seclusion records, it was determined that one of four patients (P6) had no face to face documentation in the record.

A review of patient #6's restraint record revealed no face to face was completed for a 4-point violent restraint on day two of emergency department presentation.

Based on a review of patient #6 (P6) care, it was revealed that nursing administered every 6 hour PRN orders for the same but different route medications more frequently than ordered.

P6 was an adult who presented to the emergency department in August 2018 for psychiatric evaluation via a family member.

The Medication Administration Record (MAR) for P6 revealed an order for an antipsychotic injection 5 mg every 6 hours PRN (as needed). This was given IM on day two of presentation at 1600.

Another order for [antipsychotic] tablet 5 mg every 6 hours PRN was given at 1806. This meant that without consulting a physician, P6 received two doses of [antipsychotic] 5 mg for a total of 10 mg by two different routes within 2 hours of one another.

P6 was ordered [sedative] 50 mg capsule every 6 hours PRN. P6 received the medication twice on day two of presentation at 1614 and 1806. This meant that against the expressed orders of the physician, nursing administered 100 mg of the medication within 2 hours.

P6 had an order for [antianxiety] 2 mg every 6 hours PRN. P6 received this medication twice on day two of presentation at 1600 and 1806. This meant that against the expressed orders of the physician, nursing administered 4 mg of medication within 2 hours.

In summary, nursing failed to administer medications in accordance with physician orders and accepted standards of practice.