HospitalInspections.org

Based on observation, interview and record review, the facility failed to ensure that an antipsychotic medication was not used as a chemical restraint for staff convenience for one (#3) of six patients reviewed for chemical restraints out of a total sample of 10, resulting in a violation of the patient's right to be free of unnecessary restraints and the potential for irreversible side effects from the medication. Findings include:

On 11/7/18 at approximately 1220, during a tour of the geriatric psychiatric (Geri-Psych) unit of the facility, Patient #3 was interviewed. Patient #3 was alert and oriented to self, time and place and answered questions appropriately with good recall, but had trouble finding words and expressed frustration at her difficulty expressing herself, which she said was due to "old age and previous strokes." Patient #3 complained that sometimes she had trouble saying what she was trying to say and that sometimes it took too long to find the right words and people got impatient. Patient #3 stated that she was tired of living and hated feeling like her mind and body were deteriorating and that she was becomming a burden to others. Patient #3 was in a wheelchair but stated that she used the wheelchair in the hospital because she was a fall risk and had to ask for help to go to the bathroom during admission. Patient #3 stated that she walked and took herself to the bathroom independently at home. Patient #3 reported that she was going to be discharged home after lunch that day.

On 11/7/18 at approximately 1300, Patient #3's clinical record was revivewed with the Director of Nursing Services (DON) Staff D and the Geri-Psych Unit Facilitator (Nurse) Manager) Staff F. The following information was revealed:

Patient #3 was an 85 year old female who was admitted into the facility on 10/30/18 with diagnoses which included Depression and Bipolar Disorder (manic depression). Review of medications that patient #3 took at home revealed she was not prescribed any antipsychotic medications.

Review of Patient #3's prescribed medications in the facility revealed an order for a PRN (as needed) Intramuscular injection (IM) of haloperidol (an older antipsychotic medication with strong sedative effects.) Haloperidol carries a "Black Box Warning" from the Food and Drug Administration, advising that it should be prescribed with caution due to the risk of side effects known as Tardive Dyskinesias, which are irreversible involuntary muscle movements/tics.

Review of Nursing notes and Medication Administration Records for Patient #3 revealed she was administered a shot of IM haloperidol on 11/5/18 at 2200. A Nursing note dated 11/5/18 documented that the haloperidol injection was administered because Patient #3 refused to go back to bed and was becoming progressively more anxious. There was no documentation to indicate that staff attempted to find out if Patient #3 had an unmet care need, needed to toilet, was thirsty or in pain before giving her a shot of haloperidol. There was no documentation to indicate that other less restrictive methods of calming or redirecting Patient #3 were tried before haloperidol was given. There was no documentation to indicate that less potentially dangerous medications or any medications more specific to treat anxiety were considered before haloperidol was used. Patient #3 had no behavior care plans with interventions for redirecting anxious behaviors.

On 11/7/18 at approximately 1315, the Unit Facilitator Staff F reported that sometimes patients with dementia had "sundowning" and got more confused and anxious in the evenings and needed a shot of haloperidol to quiet them down. Staff F was unable to provide documentation of behavior plans or staff guidance for redirecting anxious behaviors in patients with dementia before administration of psychotrophic medications. When asked if Patient #3 was given a shot of haloperidol as a chemical restraint to "knock her out" so staff would not have to monitor her for falls, Staff F did not respond.

On 11/7/18 at approximately 1400, The Director of Nursing Staff D was interviewed regarding Patient #3 and stated that an antipsychotic medication was not the same as an antianxiety medication. Staff D stated that there was not enough documentation to explain why Patient #3 was given an injection of haloperidol, and noted that there was no documentation to indicate that staff attempted to see if Patient #3 had any unmet care needs causing her anxiety and refusal to get back in bed.

On 11/7/18 at approximately 1405, the CNO was interviewed and reported that the facility did not track and trend the use of PRN antipsychotics used for chemical restraint.

On 11/8/18 at approximately 1500, review of the facility policy entitled, "Restraints, Seclusion and Death Reporting, dated 3/7/16 revealed the following statements:

"(The Facility) recognizes the right of every patient to be free of restraints of every form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff or as a substitute for adequate staffing to monitor patients."

" A clinical assessment should be conducted for the purpose of ruling out physiological causes of agitated or maladaptive behavior."

"Before the application of a restraint, alternative less restricted strategies are attempted."

"Chemical Restraint: A drug used as a restraint is a medication used to control behavior or to restrict freedom of movement and not a standard treatment or dosage for the patient's medical or psychiatric condition."