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Based on observation, review of medical records, and staff interviews, the facility failed to safeguard and uphold the rights of child and adolescent patients in the facility. This failure resulted in 5 of 5 patients (Patient #1, #2, #3, #4, and Patient #5) being ordered a combination of Haldol, Ativan, and Benadryl to be given intramuscular as a PRN chemical restraint. This failure was evidenced by:

A. 2 of 2 child and adolescent patients (Patient #1 and Patient #2) were ordered a combination of Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg to be given intramuscular every four (4) hours PRN [as needed] as a chemical restraint for agitation and aggression. There were numerous instances of the PRN chemical restraints being administered. Patient #1, eleven (11) instances and Patient #2 one (1) instance.

B. 2 of 2 adolescent patient (Patient #3 and Patient #4) were ordered a combination of Haldol 5 mg, Ativan 4 mg, and Benadryl 50 mg to be given intramuscular every four (4) hours PRN as a chemical restraint for agitation. There were numerous instances of the PRN chemical restraints being administered. Patient #4, sixteen (16) instances

C. 1 of 1 adolescent patient (Patient #5) was ordered a combination of Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg to be given intramuscular every eight (8) hours PRN [as needed] as a chemical restraint for agitation and aggression. There were numerous instances of the PRN chemical restraints being administered. Patient #5, four (4) instances.

Cross reference: CFR 482.13(e)(6) [A0169 - Patient Rights: Restrain or Seclusion]


D. In 32 of 32 instances in which 4 of 5 child and adolescent patients (Patient #1, #2, #4, and Patient #5) were administered a combination of Haldol, Ativan, and Benadryl intramuscular as a PRN [as needed] chemical restraint, the required face-to-face was not conducted by a qualified physician or other qualified licensed independent practitioner, registered nurse, or physician assistant within one-hour after the initiation of the intervention.

Cross reference: CFR 482.13(e)(12) [A0178 - Patient Rights: Restraint or Seclusion]

E. 2 of 2 nurse managers/supervisors (Staff I and Staff N) did not receive required training to function as a qualified RN in the assessment of the one-hour face-to-face exam. These nurses had been providing post-assessments of patients who had received chemical restraints.

Cross reference: CFR 482.13(f)(2)(vi) [A0205 - Patient Rights: Restraint or Seclusion]

Based on observation, review of medical records, and staff interviews, the facility failed to safeguard and uphold the rights of each patient in the facility. This failure resulted in:

A. 2 of 2 child and adolescent patients (Patient #1 and Patient #2) were ordered a combination of Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg to be given intramuscular every four (4) hours PRN [as needed] as a chemical restraint for agitation and aggression. There were numerous instances of the PRN chemical restraints being administered. Patient #1, eleven (11) instances and Patient #2 one (1) instance

B. 2 of 2 adolescent patients (Patient #3 and Patient #4) were ordered a combination of Haldol 5 mg, Ativan 4 mg, and Benadryl 50 mg to be given intramuscular every four (4) hours PRN as a chemical restraint for agitation. There were numerous instances of the PRN chemical restraints being administered.

C. 1 of 1 adolescent patient (Patient #5) was ordered a combination of Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg to be given intramuscular every eight (8) hours PRN [as needed] as a chemical restraint for agitation and aggression. There were numerous instances of the PRN chemical restraints being administered. Patient #4, sixteen (16) instances

Findings included:

Record review of policy SOP/COR/QUA/001, "Restraints," revised 4/2018, showed,
" ...Nexus Health Systems, Inc., ... will ensure that patient rights are respected and this policy is implemented ...
"A restraint includes a drug or medication used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition ...
"ÐRUG USED AS A RESTRAINT is a medication used to control behavior or to restrict the patient's freedom of movement, and is not a standard treatment or dosage for the patient's condition ... The use of PRN orders is PROHIBITED for drugs or medications that are being used as restraints ..."
Further review of the "Restraints" policy, showed that the policy did not include hospital procedure, management, assessment, documentation, or training for chemical restraints.

Patient #1.

Record review of Physician's Orders for Patient #1 by Staff J (PA-C), dated 6/4/2019 at 1:30 PM, showed: Give Haldol 5 mg, Ativan 2 mg, and Benadryl 50mg intramuscular (IM) together for agitation every 4 hours PRN agitation.

Record review of Administration History Detail for Patient #1 showed that Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg were given intramuscular as a PRN medication eleven (11) times:

6/14/2019 at 8:24 PM by Staff M
6/15/2019 at 10:36 AM by Staff N
6/16/2019 at 2:50 PM by Staff N
6/16/2019 at 3:07 PM by Staff N
6/19/2019 at 12:40 PM by Staff O
6/20/2019 at 5:47 PM by Staff N
6/20/2019 at 5:52 PM by Staff P
6/21/2019 at 10:30 AM by Staff I
6/22/2019 at 12:37 PM by Staff P
6/26/2019 at 11:53 AM by Staff Q
7/10/2019 at 3:21 AM by Staff R


Patient #2.

Record review of Physician's Orders for Patient #2 by Staff Z (NP), dated 7/22/2019 at 2:00 PM, showed: Give Haldol 5 mg, Ativan 2 mg, and Benadryl 50mg intramuscular (IM) together for agitation every 4 hours PRN agitation.

Record review of Administration History Detail for Patient #2 showed that Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg was given intramuscular as a PRN medication one (1) time: 8/1/2019 at 8:51 AM: order obtained by Staff P (RN) from Staff Z (NP)


Patient #3.

Record review of Physician's Orders for Patient #3 by Staff J (PA-C), dated 7/8/2019 at 10:45 AM showed: Give Haldol 5 mg, Ativan 4 mg, and Benadryl 50mg intramuscular (IM) together for agitation every 4 hours PRN agitation.

Record review of Administration History Detail for Patient #3 showed that Haldol 5 mg, Ativan 4 mg, and Benadryl 50 mg was never given.


Patient #4.

Record review of Physician's Orders for Patient #4 by Staff J (PA-C), dated 6/4/2019 at 1:30 PM, showed: Give Haldol 5 mg, Ativan 4 mg, and Benadryl 50mg intramuscular (IM) together for agitation every 4 hours PRN agitation.

Record review of Administration History Detail for Patient #4 showed that Haldol 5 mg, Ativan 4 mg, and Benadryl 50 mg were given intramuscular as a PRN medication sixteen (16) times:

2/19/2019 at 8:17 AM by Staff AA
2/20/2019 at 8:26 AM by Staff I
2/21/2019 at 4:50 PM by Staff S
2/22/2019 at 11:25 AM by Staff N
2/22/2019 at 11:58 AM by Staff N
2/23/2019 at 8:56 AM by Staff I
2/23/2019 at 9:15 AM by Staff I
2/25/2019 at 7:56 PM by Staff T
3/9/2019 at 9:55 AM by Staff U
3/13/2019 at 7:26 PM by Staff U
3/14/2019 at 5:16 PM by Staff V
3/17/2019 at 5:00 PM by Staff U
4/21/2019 at 6:34 PM by Staff W
5/7/2019 at 6:34 PM by Staff O
5/7/2019 at 7:29 PM by Staff O
6/23/2019 at 10:15 AM by Staff I


Patient #5.

Record review of Physician's Orders for Patient #5 by Staff K (NP), dated 3/15/2019 at 9:45 PM, showed: Give Haldol 5 mg, Ativan 2 mg, and Benadryl 50mg intramuscular (IM) together for agitation every eight (8) hours PRN severe agitation.

Record review of Administration History Detail for Patient #4 showed that Haldol 5 mg, Ativan 4 mg, and Benadryl 50 mg were given intramuscular as a PRN medication four (4) times:

5/14/2019 at 6:21 PM by Staff U
5/22/2019 at 5:18 PM by Staff X
6/1/2019 at 6:14 PM: order obtained by Staff Y
6/2/2019 at 1:18 PM by Staff BB

Based on interview and record review, the facility failed to ensure that 4 of 5 child and adolescent patients (Patient #1, #2, #4, and Patient #5) were seen face-to-face within one (1) hours after the initiation of a chemical restraint. This failure resulted in 32 instances in which these patients were administered a combination of Haldol, Ativan, and Benadryl intramuscular as a PRN chemical restraint with no required face-to-face being conducted by a physician or other qualified licensed independent practitioner, registered nurse, or physician assistant within one-hour after the initiation of the intervention.

Findings included:

Record review of policy SOP/COR/QUA/001, "Restraints," revised 4/2018, showed the policy defined a drug used as a restraint as "a medication used to control behavior or to restrict the patient's freedom of movement, and is not a standard treatment or dosage for the patient's condition ... The use of PRN orders is PROHIBITED for drugs or medications that are being used as restraints ..."

Further review of the "Restraints" policy, showed that the policy did not include hospital procedure, management, assessment (one-hour face-to-face evaluation), documentation of the assessment, or training for chemical restraints.

In an interview with Staff I (charge nurse) on 8/6/2019 at 2:00 PM, she stated that the house supervisor was to do a face-to-face assessment on patients that received chemical restraints such as intramuscular Haldol, Ativan, and Benadryl, within four (4) hours.

Patient #1:

Record review of Administration History Detail for Patient #1 showed that Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg were given intramuscular as a PRN medication eleven (11) times:

6/14/2019 at 8:24 PM, 6/15/2019 at 10:36 AM, 6/16/2019 at 2:50 PM, 6/16/2019 at 3:07 PM, 6/19/2019 at 12:40 PM, 6/20/2019 at 5:47 PM, 6/20/2019 at 5:52 PM, 6/21/2019 at 10:30 AM, 6/22/2019 at 12:37 PM, 6/26/2019 at 11:53 AM, and 7/10/2019 at 3:21 AM.

Further review of Patient #1's medical record showed that a face-to-face assessment was not documented by a qualified physician or other qualified licensed independent practitioner, registered nurse, or physician assistant within one-hour after the initiation of the intervention.

Patient #2:

Record review of Administration History Detail for Patient #2 showed that Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg was given intramuscular as a PRN medication one (1) time: 8/1/2019 at 8:51 AM

Further review of the Patient #2's medical record showed that a face-to-face assessment was not documented by a qualified physician or other qualified licensed independent practitioner, registered nurse, or physician assistant within one-hour after the initiation of the intervention.

Patient #4:

Record review of Administration History Detail for Patient #4 showed that Haldol 5 mg, Ativan 4 mg, and Benadryl 50 mg were given intramuscular as a PRN medication sixteen (16) times:

2/19/2019 at 8:17 AM, 2/20/2019 at 8:26 AM, 2/21/2019 at 4:50 PM, 2/22/2019 at 11:25 AM, 2/22/2019 at 11:58 AM, 2/23/2019 at 8:56 AM, 2/23/2019 at 9:15 AM, 2/25/2019 at 7:56 PM, 3/9/2019 at 9:55 AM, 3/13/2019 at 7:26 PM, 3/14/2019 at 5:16 PM, 3/17/2019 at 5:00 PM, 4/21/2019 at 6:34 PM, 5/7/2019 at 6:34 PM, 5/7/2019 at 7:29 PM, and 6/23/2019 at 10:15 AM.

Further review of Patient #4's medical record showed that a face-to-face assessment was not documented by a qualified physician or other qualified licensed independent practitioner, registered nurse, or physician assistant within one-hour after the initiation of the intervention.

Patient #5:

Record review of Administration History Detail for Patient #4 showed that Haldol 5 mg, Ativan 4 mg, and Benadryl 50 mg were given intramuscular as a PRN medication four (4) times:

5/14/2019 at 6:21 PM, 5/22/2019 at 5:18 PM, 6/1/2019 at 6:14 PM, and
6/2/2019 at 1:18 PM.

Further review of the Patient #5's medical record showed that a face-to-face assessment was not documented by a qualified physician or other qualified licensed independent practitioner, registered nurse, or physician assistant within one-hour after the initiation of the intervention.

Based on interview and record review, the facility failed to ensure that 2 of 2 nurse managers/supervisors (Staff I and Staff N) received training to function as a qualified RN in the assessment of the one-hour face-to-face assessment following the use of chemical restraints. These nurses had been providing assessments of patients who had received chemical restraints.

Findings included:

In an interview with Staff E (Quality Director) on 8/6/2019 at 3:30 PM, she stated that training to perform the one-hour face-to-face assessment following restraints was not part of orientation or the annual competency training. She also stated that nurses performing the one-hour face-to-face assessment should be specially trained.

Record review of the orientation material provided to the surveyor did not include training material on the one-hour face-to-face assessment.

Record review of the personnel files for Staff I and Staff N did not include training material on the one-hour face-to-face assessment.

In an interview with Staff I (charge nurse) on 8/6/2019 at 2:00 PM, she stated that she had not received any "specific training" on the one-hour face-to-face post restraint assessment, but did occasionally perform an 'assessment' after a patient restraint.