HospitalInspections.org

Based on staff interview and record review, the hospital failed to assure that restraints or seclusion were used only to ensure the immediate safety of a patient or others for 1 of 3 patients in the targeted sample. (Patient #1). Findings include:

Per record reviews on 4/20/15 and 4/21/15, Patient #1 was restrained and secluded by staff without evidence of posing an immediate threat of serious harm to self or others during February, 2015. Based on a review of the EIP (Emergency Involuntary Procedure) dated 2/5/15, the CONs (Certificate of Need) for restraint/seclusion and emergency involuntary medication failed to show that a threat of imminent serious harm existed at that time. The physician documentation of justification for use of emergency involuntary procedures stated "pt was menacing to me and to staff 2 x earlier, persistent menacing behavior, getting worse....history of assaultive behavior including on 2/1/15."
Per review of nursing documentation, the patient 'was dysregulated and ran to their room, was setting off the door alarms...attempted to block the door...took his/her clothes off...threw water at staff'. The CON stated that the patient was walked to the seclusion room (hands on) and the door locked at 1337. The CON documented that at 1340 hours, emergency involuntary medications (Haldol 5 mg., Benadryl 50 mg and Ativan 2 mg,) were administered IM (intramuscularly). The patient was released from seclusion at 1400, per the CON. The physician orders for the CON stated that 'manual restraint and seclusion were ordered for the purposes of giving medication only'. There was no evidence of an immediate threat of serious harm to self or others prior to initiating these involuntary procedures, based on the physician and RN documentation of the events occurring at that time. This was confirmed during interview with the psychiatrist on 4/21/15 at 11:06 AM.

Based on staff interview and record review, Registered Nurses (RNs) failed to consistently document, and show evidence of, assessment of pain interventions for 1 applicable Patient in the targeted sample. (Patient #1). Findings include:

Patient #1 had diagnoses including chronic daily pain, with physician ordered analgesic medications PRN (as needed) daily and RNs failed to consistently document evidence of pain assessment after administration of these medications. RNs also failed to include evidence of on-going pain assessment information regarding effectiveness of the interventions being utilized. The VPCH (Vermont Psychiatric Care Hospital) Nursing Procedure, "Nursing Flowsheet Documentation", revised 04/07/14, states:"J. Pain Assessment, 3. If a patient reports pain, document the level of intensity, describe the nature of the pain...the interventions initiated, and the pain rating 1 hour after the intervention." The MD ordered Tylenol, 650 MG PO up to 2600 mg per day, and Naproxen 250 mg, 4 times daily PRN, and topical Bengay ointment PRN.
Per review of the Nursing Flowsheet Documentation Sheets for February, 2015, for approximately 50% of PRN medication administrations recorded, RNs failed to include any documentation of assessment of pain at 1 hour post analgesic medication administration; many times the numbers recorded at 1 hour post administration ranged from 4/10 - 6/10, after starting at 8/10 or 10/10. There was no evidence of a comprehensive assessment to determine what level (numeric rating scale) of pain was acceptable for this patient. This lack of assessment of pain management interventions was confirmed with the ADNS during interview on 4/21/15 at 3:10 PM.

Based on staff interview and record review, the facility failed to assure that nurses developed a care plan to address the patient's identified needs regarding pain management for 1 of 10 patients in the total sample. (Patient #1). Findings include:

Per record review on 4/20/15, Nurses failed to address the patient's chronic daily pain on the Comprehensive Treatment Plan. Per review of the medical record patient history, Patient #1 had a history of physical trauma resulting in chronic pain. Review of the Initial Treatment Plan and subsequent revisions revealed no interventions to provide for the management of the patient's chronic daily pain by nursing staff. The lack of planning to address this need was confirmed with the ADNS (Assistant Director of Nursing Services) on 4/21/15 at 3:10 PM.