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Based on staff interviews and record review, the facility failed to ensure 1 of 28 sampled patients (Patient 27) was free from chemical restraints when Patient 27 was administered two different medications at the same time without documented evidence of assessment or clinical justification.

This practice had the potential to increase the use of chemical restraints and violate patient rights.

Findings:

On 6/6/18 at approximately 3 p.m., the record for Patient 27 was randomly selected from a list of patients who received medications after pharmacy business hours. The record was reviewed with Nursing Supervisor 1 (NS 1). Patient 27 was admitted to the facility on 6/5/19 at 6:15 p.m. On 6/5/19, at 7:50 p.m., (about 2 hours later) a telephone order was received and documented to give Haldol (an antipsychotic medication) 10 mg (milligrams: unit of measure) and Ativan 2 mg (medication used to reduce anxiety). Both medications were ordered to be administered by injection into the muscle (IM). These medications were ordered at the same time for "severe psychotic [sic] + agitation."

In the chart, a "Documentation of Emergency Medication Administration Form" indicated Patient 27 was "paranoid, pacing in the hallway, very anxious and agitated." The documentation on the form included: "These behaviors were determined to constitute a medical emergency as the patient was a danger to self and danger to others."

There was no documentation describing how the patient presented a danger to himself or others. The nursing note documented before the medications were administered was dated 6/5/19 at 7:50 p.m., and read: "[Patient 27] is a new admit...is very anxious and agitated in the lobby...is disorganized and delusional and paranoid...report(ed) fear that...is going to float away and die. The only thing done...is skin checked [sic]. Unable to talked [sic] to...properly....is pacing in the hallway after skin assessment done....is disruptive to the unit and others."

With further review, Patient 27's medical record was absent a description of what happened or the sequence of events to warrant the administration of IM Haldol and Ativan. The medical record was absent documentation of a comprehensive assessment by a provider or staff in an attempt to understand and determine the underlying cause of Patient 27's behaviors. Documentation of any attempts at less restrictive measures was missing. There was no clear indication in the record or clinical justification to restrain and control Patient 27's behaviors with IM Haldol and Ativan.

According to their perspective manufacturer's Ativan and Haldol have sedation (sleepiness) side effects. It is the sedative effects that is used to restraint patients and control their behavior. In fact, it was documented in the record, on 6/5/19 at 9:30 p.m., that Patient 27 was "asleep.... no further aggressive behavior noted"

NS 1 acknowledged the absence of detailed information about the behavior to warrant the use of the medications. NS 1 stated that agitation is subjective.

The facility was unable to provide the Department with a policy or procedure to guide staff in the appropriate and consistent use of medications as chemical restraints to control behaviors and ensure patient rights and safety.

During an interview with the Director of Pharmacy (DOP), the Director of Performance Improvement and Risk Management (RM) and NS 1 on 6/6/19 at 2 p.m., they confirmed the facility did not have a policy or procedure for Chemical Restraints.