HospitalInspections.org

Based on staff interview and record review, there was a failure to ensure the medical record for one applicable patient was accurately written describing correct interactions and medication administration. (Patient #1) Findings include:

Patient #1 presented to the Emergency Department (ED) on 4/25/24 for evaluation for alcohol withdrawal, requesting to be detoxified but expressing fear of withdrawal reporting s/he has past history of seizures during the withdrawal process. Patient #1 did report some delusions regarding mind control associated with computers. However, the ED provider described Patient #1 with "....appropriate mood and affect, the patient is calm and cooperative....does not appear that s/he is responding to internal stimuli at this point....". Patient #1 spoke with a member of a recovery program confirming his/her interest in a detoxification program after hospital discharge.

During the course of admission, Patient #1 was managed for alcohol withdrawal utilizing a CIWA (Clinical Institute Withdrawal Assessment Alcohol Scale) to treat alcohol withdrawal. During this process the patient is assessed frequently by nursing who monitor vital signs, anxiety, sweating, tremors and nausea. Medication (benzodiazepines) are administered depending upon CIWA score.

Shortly after inpatient admission to the hospital, Patient #1 began developing behaviors described as "....aggressive and violent". Staff discussed and attempts were made to have Patient #1 evaluated for a possible psychiatric hospitalization determining the patient to be an involuntary admission. During the course of the late evening multiple staff attempted to manage Patient #1's behaviors and initially was briefly seen during a "Telepsychiatric" evaluation by a psychiatrist. Patient #1 was determined to require further psychiatric intervention and s/he would be held as an "involuntary" inpatient pending psychiatric hospitalization.

Per review of the medical record, a Hospitalist note dated 4/26/24 states "....becoming verbally aggressive, threatening violence/homicide that patient should should be chemically restrained...". A second transcription by a Hospitalist states " USC" (United Counseling Services) later evaluated the patient after s/he received Haldol and felt s/he was able to make appropriate decisions.....". Further review confirmed via amended documentation, Patient #1 was never restrained nor did s/he receive emergency involuntary medications. Eventually, Patient #1 did allow a second interview with USC and was determined psychiatric hospitalization was not necessary and the patient was discharged against medical advice. Per interview on 8/8/24 at 2:30 PM the Patient Advocate confirmed errors were made in Patient #1's medical record and parts have been amended to reflect accuracy.