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Based on policy review, medical record review, security report review, executive summary report, and staff interviews, the hospital's nursing staff failed to assess and monitor a patient during a chemical restaint in 2 of 2 sampled Involuntary Commitment (IVC) patients (Patient #4 and #5) and during a forensic restraint (handcuffs) for 1 of 2 sampled IVC patients (Patient #4) in the ED.

The findings included:

Review on 11/24/2017 of the hospital's policy and procedure "RESTRICTIVE INTERVENTIONS" Reviewed/Revised: 05/17 revealed "I. POLICY A. The use of restraints shall be limited to clinically appropriate and adequately justified situations in manner that protects the patient's health and safety and preserves the patient's dignity, rights, and well-being ... B. The use of restraint is in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient ... II. DEFINITION AND EXPECTATIONS ...D. Chemical Restraint: Any medication used for the specific purpose of restricting the patient's movement which is not a standard treatment for the patient's medical or psychiatric condition ...G. Assessment/monitoring/patient care: violent self destructive restrictive intervention utilization 1. Assess and document at initiation and every 15 minutes..."

1. Review on 11/14/2017 of the medical record Patient #4 revealed a 23-year-old male with a history of schizoaffective disorder with bipolar type presented to the ED for evaluation of altered mental status on 10/24/2017 under IVC (Involuntary Commitment). Review revealed Patient #4 was seen by the Behavioral Health team on 10/25/2017. Review revealed on 10/24/2017 the police was called twice and Patient #4 was sedated three times due to aggressive behaviors. Review of Physician orders written on 10/24/2017 at 2207 revealed a onetime order for Geodon (Antipsychotic medication) 10 milligram (mg) intramuscularly (IM), and Ativan (medication used to treat anxiety by producing a calming effect) 2 mg IM. Review revealed Patient #4 received the Geodon at 2218 and the Ativan at 2208. Continued review revealed a physician order written for a onetime order on 10/25/2017 at 2058 for Benadryl (antihistamine medication that may promote sleep) 50 mg IM, Haldol (antipsychotic medication used to treat behavior problems) 5 mg IM, and Ativan 2 mg IM. Review revealed Patient #4 received the Benadryl, Haldol and the Ativan at 2059. Additional review revealed a physician order written on 10/28/2017 at 0350 for Geodon 10 mg IM. Review revealed Patient #4 received the Geodon at 0357. Futher review revealed no documentation of assessment and monitoring of restraints.

Review on 11/16/2017 of a Security Report created by SO #1 and submitted on 10/26/2017 revealed Security was called on 10/24/2017 at 1813 by Patient's #4 nurse for assistance in controlling the patient as Patient #4 attempted to elope. Further review revealed Patient #4 refused medications offered by RN (Registered Nurse) #1 and security personnel assisted RN #1 with the administration of the ordered medications. Review revealed SO #4 was called on 10/25/2017 at 0845 to assist with Patient #4. Review revealed SOs "controlled the patient's limbs while Patient #4 was on his chest down on his mattress and waited for assistance". Review revealed "Police Officer entered the room and applied handcuffs".

Review on 11/16/2017 of an Executive Summary Report created by the Training Investigations Division on 11/06/2017 revealed on 10/25/2017 at approximately 1815 SO #1 was requested by RN #1 to assist with an IVC patient, Patient #4 in ED room 10. Prior to the arrival of SO #1, Patient #4 walked out and was attempting to elope. Review revealed SO #2 arrived and assisted SO #1 in controlling Patient #4. Review revealed the Officers attempted to control Patient #4 using the CPI two-person escort technique. Review revealed Officer #1 and 2 moved Patient #4 against the wall to better control his resistance. Review revealed after an unsuccessful attempt to place Patient #4 in a wheelchair, Officer #1 and 2 placed Patient #4 on the wall again. Review revealed Officer #1 placed his forearm against the patient "brachial plexus origin" in order to keep the patient on the wall while resisting. Review revealed Officer #1 stated that Patient #4's breathing was not compromised, as evidenced by his continued resistance and verbal threats. Review revealed RN #1 "repeatedly telling officers to use CPI and placed herself in immediate proximity to the patient while Officers were attempting to control Patient #4". Review revealed the Officers were able to place Patient #4 in a wheelchair and transported him to his room. Review revealed Patient #4 remained non-compliant when RN #1 approached with medication. Review revealed "Officers had to hold Patient #4 against the wall so RN #1 could administer an injection of medication".

Interview on 11/14/14 at 1500 with Administration revealed RN #1, the primary care nurse on 10/25/2017, was not available for interview.

Interview on 11/15/2017 at 1615 with RN #2/House Supervisor revealed a facility SO attempted to subdue Patient #4 after being agitated [date and time unknown]. Interview revealed the SO and two local Police Officers took control of Patient #4 by "taking him to the ground and held him down for a moment".

Interview on 11/15/2017 at 2000 with RN #4 revealed RN #4 cared for Patient #4 on multiple occasions; 10/24/2017, 10/25/2017 and 10/26/2017. Interview revealed on 10/25/2017 around 2100 the local Police Officer was present on the Unit after Patient #4 had assaulted a SO. Interview revealed Patient #4 remained verbally abusive and threatening the staff. Interview revealed the Police Office cuffed Patient #4 behind his back in prone position with face on the side. Interview revealed Patient #4 was cuffed for under ten minutes while RN #4 obtained a onetime order of Haldol 5 mg, Benadryl 50 mg, and Ativan 2 mg. Patient remained in handcuff during the medication administration. Interview revealed "this was a restraint because he was cuffed". Interview revealed chemical restraint was defined as medication used to subdue a patient, to bring a patient to the level where he could understand his behavior. Interview revealed Patient #4 did not have an order for restraint. Further interview revealed "there is no policy to monitor a patient while in forensic restraints".

Interview on 11/16/2017 at 0927 with SO #1 revealed Patient #4 had violent tendencies and unstable. Interview revealed the primary nurse called on 10/24/2017 at 1813 and requested assistance because Patient #4 "took off". Interview revealed during that encounter Officers placed Patient #4 in a dual hold in an upright position while the Nurse administered his medication.



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2. Closed medical record review of Patient #5 revealed a 46 year old female who presented to the ED on 10/17/2017 at 2017 for suicide attempt by ingestion of medications. Review revealed the patient has a history of bipolar disorder. Review revealed Patient #5 was placed under IVC (involuntary commitment status) by the ED Physician on 10/18/17 at 0105. Record review of nursing documentation on 10/18/2017 at 1400 (Affect/Behavior) revealed "Patient found with socks tied around her neck by sitter at approximately 1400. RN and MD were called into the room for assistance. The patient had to be aroused to tactile stimuli. Following the event the patient was alert and combative." Review of Physician documentation on 10/18/2017 "This is a late entry of event that occurred at 4 pm [sic] today. I was the physician alerted after sitter noted that pt. attempted to choke herself with our socks. When I arrived pt was stiffed and holding her breath, with generalized shaking which resolved with noxious stimuli to L (left) nare with Q tip. She did have mild epistaxis after she jerked and started spitting at me and nursing staff. Subsequently, pt became physically aggressive therefore she received IM (intramuscularly) haldol, ativan. Minor abrasion in [sic] her neck for choking herself... CT head and neck showed no acute findings..." Review of MAR (Medication Administration Record) revealed Ativan 2 mg administered IM in right vastus lateralis (hip area) at 1413 and Haldol 5mg administered IM in right vastus lateralis at 1412. Record review revealed no assessment and monitoring of restraints.

Interview on 11/15/2017 at 0940 with RN # 7 revealed we don't do chemical restraints. Interview revealed the medication given to patients is so they can be "brought to a level of functioning to participate in their treatment." The medications that are given are also to treat their medical conditions.

Interview on 11/15/2017 at 1515 with RN #5 revealed she was the primary nurse on several occasions for Patient # 5. Interview revealed restraints are to restrict patients movement. Interview revealed the medication given to Patient # 5 was to "bring her to a level to participate in her medical treatment."

NC 00132874