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Based on interview and record review, the facility failed to appropriately monitor one patient (Patient A) which resulted in the patient repeatedly harming herself.

Findings:

An allegation was received by the Department indicating in part that Patient A was not adequately monitored by the facility for safety.

The clinical record for Patient A indicated that she was admitted on January 28, 2010 with heightened suicidal/homicidal precautions. The "Suicide/Homicide/Self-Harm Assessment Tool" done at admission indicated the patient was at moderate risk. The policy titled "Suicide: Observation and Precautions" indicated in part, "A Suicide Risk Assessment form is completed by the admitting nurse. At least every 24 hours a new form is completed by the assigned nurse. Appropriate interventions are to be implemented according to the assessed risk level...An environmental safety check will be completed monthly, in patient care areas. If a patient is assessed as moderate to high risk for suicide, this safety check will be completed for the patient's room every 24 hours until assessed at low risk." No suicide risk assessments were found in the record after the initial admission assessment, and no environmental safety checks were found in the record for this admission. The patient was discharged on February 19, 2010.

At 6:45 PM the patient was ordered to be on "line of sight" observation due to being a danger to herself (cutting on herself). Despite the increased observation ordered, on January 29, 2010 at 7:00 AM, the patient was found with a two inch laceration to the left forearm and required a trip to the Emergency Room (ER) where steri-strips (strips of tape that hold wound edges closed and used in place of stitches), were applied. On January 30, 2010 at 11:15 AM, the patient was noted to have torn off all the steri-strips and reopened the wound which now required sutures. On January 31, 2010 at 7:25 PM, the patient was found cutting herself with a metal object. On January 31, 2010 at 7:35 PM, the physician ordered one-to-one observation for the patient.

During an interview with Quality Staff (QS) 1 on December 21, 2010 at 1:55 PM, he was asked how someone on line-of-sight monitoring could be able to hurt herself repeatedly. QS 1 replied, "Someone was given a break and the nurse went back to the nurses' station. That wasn't line-of-sight observation." When asked about the lack of suicide risk assessments and environmental safety checks, the QS 1 had no comment.

Based on interview and record review, the facility failed to implement restraint and/or seclusion for one patient (Patient A) in accordance with facility policies, which resulted in a lack of documentation of a denial of rights form, flowsheets, observation records, identifying causal factors, patient education, and debriefing.

Findings:

An allegation was received by the Department indicating in part that Patient A was contained while on voluntary status.

The clinical record for Patient A indicated that she was admitted on January 28, 2010 with heightened suicidal/homicidal precautions. Nursing Progress Notes (NPN) dated January 31, 2010 at 7:25 PM, indicated Patient A was taken to the "pink room" (seclusion room). Although the notes did not specify when the patient's containment (physical restraint) began, a NPN indicated the patient was released "from hold" (containment) at 8:00 PM, and then was taken back to her room at 8:10 PM.

During an interview with Quality Staff (QS) 1 on March 29, 2010 at 1:00 PM, he stated containments lasting 30 minutes or more are considered restraints. "(Patient A) was taken to...the seclusion room at (7:25 PM) until (8:10 PM), over the criteria for a time-out." QS 1 added on December 21, 2010 at 1:55 PM, "I don't think (Patient A) was in a hold (physical restraint) for 35 minutes...but I can't disprove it because the inference was there."

During an interview with Licensed Vocational Nurse (LVN) 1 on March 30, 2010 at 9:15 AM, she stated that during the incident on January 31, 2010 at 7:25 PM, Patient A was "taken down" (forced to the ground) by three staff, although this was not documented in the record.

The facility policy titled "Restraint, Seclusion and Immobilization Policy" indicates in part, "The seclusion and restraint flow sheet shall be maintained for every episode and placed in the progress notes of the medical record (eight different items mentioned in the policy were to be documented on the flow sheet.)...Following an episode of restraint the patient...shall participate in a debriefing by staff...to determine the sequence of events or circumstances that precipitated the need for restraint...Input from debriefing episodes should be analyzed and used to learn what led to the incident...to determine if revisions are needed...Document: Behavior necessitating the use of the restraint on the 'Behavior Management or Restraint/Adaptive/Protective Device or Seclusion Flow Sheet' (BMRAPDSFS) (Document:) Patient...education re: safety, expected care, and release criteria on Flow Sheet..."

The facility policy titled "Use of Seclusion and Restraint" indicates in part, "A Denial of Rights Form must be completed when seclusion and/or restraints are used for the patient...Holding a patient and restricting his/her movement also constitutes restraint...Seclusion is 'the involuntary confinement of a person in a room or an area where the person is physically prevented from leaving...The term 'restraint' includes either a physical restraint or a drug that is being used as a restraint...Licensed staff shall assess the patient every 15 minutes...and document the nursing care provided including the patient's response and/or behavior to the staff's interventions to assist patient meet (sic) criteria for release...A debriefing with involved staff and patient will be performed within 24 hours of episode...documented by the charge nurse."

The facility policy titled "Behavioral Restraint" indicates in part, "Seek to determine any causal factors or stressors in the environment which may be aggravating the patient's behavior."

Seclusion and Restraint Flowsheets, evidence of a debriefing, a Denial of Rights Form, BMRAPDS flow sheets, causal factors leading to the restraint/seclusion use and documentation of patient education regarding the episode of restraint/seclusion were not found in the record. The Intensive Observation/Treatment Record (documentation of 15 minute checks) did not specify the patient was in seclusion/restraint from 7:30 PM through 8:15 PM. NPN dated January 31, 2010 at 7:25 PM through 8:10 PM, did not specify any interventions geared to assist Patient A to meet criteria for release from restraint/seclusion, or what the release criteria might be.

During an interview with QS 1 on December 21, 2010 at 1:55 PM, he stated "yes" to the question of the lack of documentation regarding the above episode of seclusion/restraint. "They need to be more descriptive of what is happening, what is going on." When asked about the lack of the restraint/seclusion being documented on the 15 minute checks, QS 1 had no comment. When asked about the lack of causal factors documented, QS 1 had no comment. "It should be, after 30 minutes, a restraint...flowsheet, (and) denial of rights form...but we didn't consider it a restraint. We didn't contain (Resident A) for over 30 minutes, that's our contention but we can't prove it."

Based on interview and record review, the facility failed to obtain an order for restraint and/or seclusion used on one patient (Patient A), which resulted in a lack of authorization for the restrictive procedures.

Findings:

An allegation was received by the Department indicating in part that Patient A was contained while on voluntary status.

The clinical record for Patient A indicated that she was admitted on January 28, 2010 with heightened suicidal/homicidal precautions. Nursing Progress Notes (NPN) dated January 31, 2010 at 7:25 PM, indicated Patient A was taken to the "pink room" (seclusion room). Although the notes did not specify when the patient's containment (physical restraint) began, a NPN indicated the patient was released "from hold" (containment) at 8:00 PM, and then was taken back to her room at 8:10 PM.

During an interview with Quality Staff (QS) 1 on March 29, 2010 at 1:00 PM, he stated containments lasting 30 minutes or more are considered restraints. "(Patient A) was taken to...the seclusion room at (7:25 PM) until (8:10 PM), over the criteria for a time-out." QS 1 added on December 21, 2010 at 1:55 PM, "I don't think (Patient A) was in a hold (physical restraint) for 35 minutes...but I can't disprove it because the inference was there."

During an interview with Licensed Vocational Nurse (LVN) 1 on March 30, 2010 at 9:15 AM, she stated that during the incident on January 31, 2010 at 7:25 PM, Patient A was "taken down" (forced to the ground) by three staff, although this was not documented in the record.

The facility policy titled "Use of Seclusion and Restraint" indicates in part "A licensed physician, psychologist or registered nurse (RN) must identify and document the following: Appropriate orders from physician." No order was found for the above incident of restraint/seclusion.

During an interview with QS 1 on December 21, 2010 at 1:55 PM, he was asked for documentation of an order for the above episode of restraint/seclusion. "It should be, after 30 minutes, a restraint order...but we didn't consider it a restraint. We didn't contain (Patient A) for over 30 minutes, that's our contention but we can't prove it."

Based on interview and record review, the facility failed to consult the attending physician regarding restraint/seclusion for one patient (Patient A), which resulted in a lack of awareness of the situation by the individual who had overall responsibility and authority for the management and care of the patient.

Findings:

An allegation was received by the Department indicating in part that Patient A was contained while on voluntary status.

The clinical record for Patient A indicated that she was admitted on January 28, 2010 with heightened suicidal/homicidal precautions. Nursing Progress Notes (NPN) dated January 31, 2010 at 7:25 PM, indicated Patient A was taken to the "pink room" (seclusion room). Although the notes did not specify when the patient's containment (physical restraint) began, a NPN indicated the patient was released "from hold" (containment) at 8:00 PM, and then was taken back to her room at 8:10 PM.

During an interview with Quality Staff (QS) 1 on March 29, 2010 at 1:00 PM, he stated containments lasting 30 minutes or more are considered restraints. "(Patient A) was taken to...the seclusion room at (7:25 PM) until (8:10 PM), over the criteria for a time-out." QS 1 added on December 21, 2010 at 1:55 PM, "I don't think (Patient A) was in a hold (physical restraint) for 35 minutes...but I can't disprove it because the inference was there."

During an interview with Licensed Vocational Nurse (LVN) 1 on March 30, 2010 at 9:15 AM, she stated that during the incident on January 31, 2010 at 7:25 PM, Patient A was "taken down" (forced to the ground) by three staff, although this was not documented in the record.

The facility policy titled "Use of Seclusion and Restraint" indicates in part, "The treating physician must be consulted as soon as possible, if the patient's treating physician does not order the restraint or seclusion." No evidence was found that the treating physician was notified of the incident of restraint/seclusion.

During an interview with QS 1 on December 21, 2010 at 1:55 PM, he stated, "We didn't consider it a restraint. We didn't contain (Patient A) for over 30 minutes, that's our contention but we can't prove it."

Based on interview and record review, the facility failed to ensure restraint/seclusion was discontinued at the earliest possible time for one patient (Patient A), which had the potential to result in restraint/seclusion being used after the unsafe situation had resolved.

Findings:

An allegation was received by the Department indicating in part that Patient A was contained while on voluntary status.

The clinical record for Patient A indicated that she was admitted on January 28, 2010 with heightened suicidal/homicidal precautions. Nursing Progress Notes (NPN) dated January 31, 2010 at 7:25 PM, indicated Patient A was found "cutting herself with a metal object" resulting in several superficial cuts to the left forearm. Patient A was taken to the "pink room" (seclusion room). The NPN for 7:40 PM did not indicate the patient was still a danger to herself or that she still had access to the metal object. Although the notes did not specify when the patient's containment (physical restraint) began, a NPN indicated the patient was released "from hold" (containment) at 8:00 PM, and then was taken back to her room at 8:10 PM.

The facility policy titled "Use of Seclusion and Restraint" indicates in part, "Release patient from seclusion and/or restraints when he/she meets behavior criteria and no longer presents a threat of injury to self or others or there are less restrictive alternatives to prevent injury to self or others." No evidence was found that Patient A continued to be a threat after the seclusion was first initiated.

During an interview with Quality Staff (QS) 1 on March 29, 2010 at 1:00 PM, he stated containments lasting 30 minutes or more are considered restraints. "(Patient A) was taken to...the seclusion room at (7:25 PM) until (8:10 PM), over the criteria for a time-out." QS 1 added on December 21, 2010 at 1:55 PM, "I don't think (Patient A) was in a hold (physical restraint) for 35 minutes...but I can't disprove it because the inference was there."

Based on interview and record review, the facility failed to provide a face-to-face evaluation by a licensed practitioner within one hour of restraint/seclusion for one patient (Patient A), which resulted in a lack of prompt evaluation of the patient's behavior that led to the intervention, prompt evaluation of the factors that may have contributed to the violent or self-destructive behavior, and whether the intervention was appropriate to address the violent or self-destructive behavior.

Findings:

An allegation was received by the Department indicating in part that Patient A was contained while on voluntary status.

The clinical record for Patient A indicated that she was admitted on January 28, 2010 with heightened suicidal/homicidal precautions. Nursing Progress Notes (NPN) dated January 31, 2010 at 7:25 PM, indicated Patient A was taken to the "pink room" (seclusion room). Although the notes did not specify when the patient's containment (physical restraint) began, a NPN indicated the patient was released "from hold" (containment) at 8:00 PM, and then was taken back to her room at 8:10 PM.

During an interview with Quality Staff (QS) 1 on March 29, 2010 at 1:00 PM, he stated containments lasting 30 minutes or more are considered restraints. "(Patient A) was taken to...the seclusion room at (7:25 PM) until (8:10 PM), over the criteria for a time-out." QS 1 added on December 21, 2010 at 1:55 PM, "I don't think (Patient A) was in a hold (physical restraint) for 35 minutes...but I can't disprove it because the inference was there."

During an interview with Licensed Vocational Nurse (LVN) 1 on March 30, 2010 at 9:15 AM, she stated that during the incident on January 31, 2010 at 7:25 PM, Patient A was "taken down" (forced to the ground) by three staff, although this was not documented in the record.

The facility policy titled "Use of Seclusion and Restraint" indicates in part, "Licensed Independent Practitioner Responsibilities: The patient must be evaluated 'face-to-face' as to the appropriateness of seclusion and restraint as an intervention within one hour of the initiation of the intervention...The physician/psychiatrist must make a progress note entry including the following: the reasons seclusion and/or restraint had been implemented, that less restrictive measures that (sic) were attempted and that the measures were ineffective in protecting the patient and others from harm." No physician's progress note was found regarding the incident, nor was any evidence found that the attending physician was even notified of the incident.

During an interview with QS 1 on December 21, 2010 at 1:55 PM, he stated regarding the face-to-face evaluation by the physician, "It should be, after 30 minutes...a face-to-face within one hour...but we didn't consider it a restraint. We didn't contain (Resident A) for over 30 minutes, that's our contention but we can't prove it."

Based on interview and record review, the facility failed to adequately describe the behavior leading to restraint/seclusion for one patient (Patient A) and failed to adequately describe the interventions used, which resulted in a lack of information regarding the appropriateness of the restraint/seclusion.

Findings:

An allegation was received by the Department indicating in part that Patient A was contained while on voluntary status.

The clinical record for Patient A indicated that she was admitted on January 28, 2010. Nursing Progress Notes (NPN) dated January 31, 2010 at 7:25 PM, indicated Patient A was found cutting herself with a metal object and taken to the "pink room" (seclusion room). The note did not indicate that the patient was still exhibiting dangerous behavior after the metal object was found. A note at 7:40 PM indicated the patient had "several superficial cutting (sic) to left forearm." The notes did not specify when the patient's containment (physical restraint) began, or the type or circumstances of it. However, a NPN indicated the patient was released "from hold" (containment) at 8:00 PM, and then was taken back to her room at 8:10 PM.

During an interview with Licensed Vocational Nurse (LVN) 1 on March 30, 2010 at 9:15 AM, she stated that during the incident on January 31, 2010 at 7:25 PM, Patient A was "taken down" (forced to the ground) by three staff, although this was not documented in the record.

The facility policy titled "Restraint, Seclusion and Immobilization" indicates in part to document the following: "Initial behavior exhibited that requires protection from self...Time restraints applied. Type of restraint used."

During an interview with QS 1 on December 21, 2010 at 1:55 PM, he stated "yes" to the question of the lack of documentation regarding the above episode of seclusion/restraint. "They need to be more descriptive of what is happening, what is going on."

Based on interview and record review, the facility failed to document less restrictive measures attempted before using restraint/seclusion on one patient (Patient A) which had the potential to result in the use of an overly-restrictive method.

Findings:

An allegation was received by the Department indicating in part that Patient A was contained while on voluntary status.

The clinical record for Patient A indicated that she was admitted on January 28, 2010. Nursing Progress Notes (NPN) dated January 31, 2010 at 7:25 PM, indicated Patient A was found cutting herself with a metal object and taken to the "pink room" (seclusion room). The note did not indicate why a less-restrictive measure would have been ineffective, or why the patient was still a danger to herself after the metal object was found. A note at 7:40 PM indicated the patient had "several superficial cutting (sic) to left forearm." The notes did not specify when the patient's containment (physical restraint) began, the type or circumstances of it, or why it was necessary. However, a NPN indicated the patient was released "from hold" (containment) at 8:00 PM, and then was taken back to her room at 8:10 PM.

During an interview with Licensed Vocational Nurse (LVN) 1 on March 30, 2010 at 9:15 AM, she stated that during the incident on January 31, 2010 at 7:25 PM, Patient A was "taken down" (forced to the ground) by three staff, although this was not documented in the record.

The facility policy titled "Use of Seclusion and Restraint" indicates in part, "Seclusion or a restraint can only be used in emergency situations if needed to ensure the patient's physical safety and less restrictive interventions have been determined to be ineffective...Each episode of seclusion and/or restraint requires documented information in the patient's record. This includes...Alternatives to seclusion and restraint attempted. Rationale for type of restraint selected."

During an interview with the Nurse Manager (NM) on March 29, 2010 at 2:14 PM, she stated, "The documentation isn't clear, I think (Patient A) was contained because she wouldn't give up the metal."

Based on interview and record review, the facility failed to document the condition or symptom that warranted the use of restraint and/or seclusion for one patient (Patient A) which had the potential to result in the use of restraint or seclusion that was not necessary to ensure the immediate physical safety of the patient or others.

Findings:

An allegation was received by the Department indicating in part that Patient A was contained while on voluntary status.

The clinical record for Patient A indicated that she was admitted on January 28, 2010. Nursing Progress Notes (NPN) dated January 31, 2010 at 7:25 PM, indicated Patient A was found cutting herself with a metal object and taken to the "pink room" (seclusion room). The note did not indicate why the patient was still a danger to herself after the metal object was found. A note at 7:40 PM indicated the patient had "several superficial cutting (sic) to left forearm." The notes did not specify when the patient's containment (physical restraint) began, or why it was necessary. However, a NPN indicated the patient was released "from hold" (containment) at 8:00 PM, and then was taken back to her room at 8:10 PM.

During an interview with Licensed Vocational Nurse (LVN) 1 on March 30, 2010 at 9:15 AM, she stated that during the incident on January 31, 2010 at 7:25 PM, Patient A was "taken down" (forced to the ground) by three staff, although this was not documented in the record.

The facility policy titled "Use of Seclusion and Restraint" indicates in part, that staff "must identify and document the following: Observed threat of harm to self or others...The organization will ensure: That the type of restraint used is determined by the situation the restraint is being used to address..."

During an interview with QS 1 on December 21, 2010 at 1:55 PM, he stated "yes" to the question of the lack of documentation regarding the above episode of seclusion/restraint. "They need to be more descriptive of what is happening, what is going on."

Based on interview and record review, the facility failed to provide an adequate nursing assessment for the care needs of one patient (Patient A), which resulted in a lack of wound care.

Findings:

An allegation was received by the Department indicating in part that Patient A's laceration was not cared for in a timely manner.

The clinical record for Patient A indicated that she was admitted on January 28, 2010. On January 29, 2010 at 7:00 AM, the patient was found with a two inch laceration to the left forearm and required a trip to the Emergency Room (ER) where steri-strips were applied. On January 30, 2010 at 11:15 AM, the patient was noted to have torn off all the steri-strips and reopened the wound which now required sutures.

Discharge instructions from the ER dated January 30, 2010 indicated to keep the wound clean and dry, and replace the bandage if it becomes wet or dirty. Otherwise leave the bandage in place for the first 24 hours and then change it once a day or as directed. The wound was to be cleaned daily with soap and water, loosening any blood or crust that forms. Then apply a thin layer of antibiotic ointment, and reapply the bandage. Showering was permitted after the first 24 hours, but the area was not to be soaked in water.

Review of physician's orders dated January 30, 2010 through February 3, 2010, did not reveal that nursing obtained as orders, any of the above instructions.

During an interview with Quality Staff (QS) 1 on December 21, 2010 at 1:55 PM, he stated nursing staff "didn't plan (Patient A's) injuries."

Based on interview and record review, the facility failed to follow a policy for one patient (Patient A), which resulted in the patient being given an injection against her will.

Findings:

An allegation was received by the Department indicating in part that Patient A was given an injection she had not requested.

The facility policy titled "Medicating Patients in Emergencies" indicates in part, "Occasionally standing orders for IM (intramuscular) medication are found in charts, such as 'Haldol (antipsychotic) 10 mg (milligrams) PRN (as needed) PO/IM (by mouth or IM) for agitation'...To the extent that 'IM' connotes forcible administration of the medication, these orders are in violation of statute. The treating physician should be consulted each time an emergent situation arises to request orders for 'IM medication in an emergency.' In those instances where patients actually consent to medication by injection, it is required that the patient's agreement to IM medication be carefully documented in the treatment record."

Physician's orders for Patient A dated January 28, 2010 at 6:45 PM, indicated "Ativan (anti-anxiety) 2 mg PO or IM every four hours PRN for anxiety." The medication administration record (MAR) for the patient indicated the above order was utilized to give the patient IM Ativan on January 31, 2010 at 7:50 PM. No evidence was found to indicate the patient consented to the medication.

Nursing Progress Notes (NPN) dated January 31, 2010 at 7:25 PM, indicated Patient A was found "cutting herself with a metal object" resulting in several superficial cuts to the left forearm. The NPN for 7:40 PM did not indicate the patient was still a danger to herself or that she still had access to the metal object, even though the injection was given at 7:50 PM per the MAR. The NPN did not document that the injection was even given.

During an interview with Licensed Vocational Nurse (LVN) 1 on March 30, 2010 at 9:15 AM, she stated that during the incident on January 31, 2010 at 7:50 PM, Patient A did not consent to the Ativan IM.

During an interview with Quality Staff (QS) 1 on December 17, 2010 at 2:30 PM, he stated medications can be refused unless an emergent situation is documented where the patient is a danger to herself or others.

Based on interview and record review, the facility failed to document attempts to identify contraband in a timely manner, failed to document behavioral status, failed to adequately document the status of a wound, and failed to document the reason for and effectiveness of an intramuscular injection (IM) for one patient (Patient A). This resulted in repeated instances of the patient harming herself, resulted in a lack of information regarding the patient's principle diagnosis, the potential to result in delayed identification of deteriorated wound status, and resulted in lack of a rationale for and evaluation of the effectiveness of the IM medication.

Findings:

1. The clinical record for Patient A indicated that she was admitted on January 28, 2010 with heightened suicidal/homicidal precautions. Nursing Progress Notes (NPN) dated January 28, 2010 at 10:00 PM, indicated the patient "was cutting on herself early in the day as was reported by day shift." No documentation was found of an attempt to ascertain what object the patient was using to hurt herself. On January 29, 2010 at 7:00 AM, NPN specified the patient was found with a 2 inch by 1/2 inch laceration to the left forearm which required a trip to the Emergency Room (ER). Again, no documentation was found regarding staff trying to ascertain and remove the object the patient was using to harm herself.

2. The clinical record for Patient A was reviewed to find evidence of the behavioral episode alluded to in the NPN dated January 28, 2010 at 10:00 PM, noted above. No clarifying information from the day shift was found that documented the situation, antecedents, interventions, or the outcome of the patient cutting herself.

3. The clinical record for Patient A was reviewed to find documentation of any wound (or lack thereof) from the behavioral incident alluded to in the NPN dated January 28, 2010 at 10:00 PM noted above, but none was found. On January 30, 2010 at 11:15 AM, NPN specified the patient tore off all the steri-strips that had been required from the behavioral episode dated January 29, 2010 at 7:00 AM, and reopened the wound which now required sutures. After the patient returned from the ER, the record did not indicate how many sutures were needed.

4. Physician's orders for Patient A dated January 28, 2010 at 6:45 PM, indicated "Ativan (antianxiety) 2 mg PO or IM every four hours PRN for anxiety." The medication administration record (MAR) for the patient indicated the above order was utilized to give the patient IM Ativan on January 31, 2010 at 7:50 PM. Nursing Progress Notes (NPN) did not document the injection was given. The "PRN Medication Effectiveness Log" which documents the date, time, medication, reason, and effectiveness of PRN medication did not document that the injection was given.

During an interview with Quality Staff (QS) 1 on December 21, 2010 at 1:55 PM, he was asked about the lack of attempts to ascertain the object of harm and the lack of documenting a behavior incident regarding Patient A. QS 1 had no comment. Regarding the general lack of documentation in the chart, QS 1 stated, "It goes back to educating staff about documentation."

Based on interview and record review, the facility failed to refer one patient (Patient A) to the Mobile Evaluation Team (MET) in a timely manner, which resulted in the patient undergoing restraint and seclusion while on voluntary status.

Findings:

An allegation was received by the Department indicating in part that Patient A was contained and/or chemically restrained (injection) multiple times while on voluntary status but the MET team was not called until the fifth hospital day to evaluate the patient for a legal hold.

The clinical record for Patient A specified she was admitted January 28, 2010. Physician's orders dated January 28, 2010 at 7:00 PM, indicated "Ativan (anti-anxiety) 2 mg (milligrams) IM (intramuscular) times one now for increased anxiety and agitation." The medication administration record (MAR) specified the patient also received Ativan IM on January 31, 2010 at 7:50 PM for anxiety.

The facility policy titled "Medicating Patients in Emergencies" indicates in part, that giving medications IM "connotes forcible administration of the medication... In those instances where patients actually consent to medication by injection, it is required that the patient's agreement to IM medication be carefully documented in the treatment record." Documentation that Patient A agreed to the IM medications was not found in the record.

A form titled "Medication Information Sheet" (MIS) was found in the record describing the uses, side effects, interactions, and contraindications of Ativan. Patient A signed this form. The form, however, did not specify the patient consented to the use of the drug, by mouth or by injection.

During an interview with Quality Staff (QS) 1 on December 21, 2010 at 1:55 PM, he stated the MIS was what the facility used as consent for medication.

During an interview with Licensed Vocational Nurse (LVN) 1 on March 30, 2010 at 9:15 AM, she stated that during the incident on January 31, 2010 at 7:50 PM, Patient A did not consent to the Ativan IM.

Nursing Progress Notes (NPN) dated January 31, 2010 at 7:25 PM, indicated Patient A was taken to the "pink room." Although the notes did not specify when the patient's containment began, a NPN at 8:00 PM indicated the patient was released "from hold."

During an interview with Quality Staff (QS) 1 on March 29, 2010 at 1:45 PM, he stated the pink room was the seclusion room.

During an interview with Licensed Vocational Nurse (LVN) 1 on March 30, 2010 at 9:15 AM, she stated that during the incident of January 31, 2010 at 7:25 PM, Patient A was "taken down" by three staff, although this was not documented in the record.

Physician's orders indicated that on February 2, 2010 at 11:50 AM, the MET team was to be called and at 5:40 PM, Patient A was put on a legal hold.

A facility letter dated February 4, 2010 specified "Once containment or restraint has been initiated Good Samaritan will call the MET..."

During an interview with Quality Staff (QS) 1 on December 21, 2010 at 1:55 PM, he stated there may have been reasons why calling the MET team for Patient A was contraindicated, but when documentation to that effect was requested, no information was provided.