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Tag No.: A0131
Based on document review and interview it was determined that for 1 of 1 (Pt. #1) clinical record reviewed for admission to Behavioral Health Unit, the Hospital failed to ensure that Legal Guardian consent was obtained for admission and treatment.
Findings include:
1. The Hospital's policy titled, "Consent: For Treatment, Operation and Autopsy", dated 02/2019, was reviewed. The policy included, "To establish guidelines for obtaining Consent for Treatment ...A. General Guidelines: Hospital personnel have a legal duty to refrain from treating a patient unless the patient has authorized the treatment ...An incompetent adult patient is a person who has been declared incompetent by a court and for whom a "guardian of the person" has been appointed. Thereafter, the guardian consents for treatment on behalf of the incompetent patient ..."
2. On 03/10/2020 at approximately 9:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital on 02/04/2020 at 8:36 AM with a diagnosis of Schizophrenia (mental disorder).
- The document titled, "Letter of Office -Plenary Guardian of Person of a Disabled Person" dated 07/06/2015, included, "Pt. #1's (mother) and Pt. #1's (sister) has been appointed plenary co-guardian of the person of [Pt. #1] a disabled person, and is authorized to have under the direction of the court of the custody of the ward and to do all acts required by law."
- The clinical record of Pt. #1 did not include the Legal Guardian Consent for Admission and Treatment.
3. On 03/11/2020 at approximately 1:00 PM, an interview was conducted with the Manager BHU (E #8). E #8 stated, "I am not sure, why they did not obtain a consent for admission and treatment from the legal guardians as the patient was intellectually disabled."
Tag No.: A0144
Based on document review, observation and interview it was determined for 1 of 4 (Pt. #1) clinical records reviewed for restraints, the Hospital failed to ensure that care was provided in a safe environment while applying a physical hold that resulted Pt. #1 sustaining an injury. This potentially could affect all patients that require physical restraints.
Findings include:
1. The Hospital's policy titled, "Protective and Restraint Policy" dated 09/2019 was reviewed. The policy included, "Restraints are implemented ...to protect the immediate physical safety of patients ...A. Physical Restraints: Any direct physical, ...method which immobilizes, reduces or restricts the ability of a patient to move his/her arms, legs, body or head freely ..."
2. On 03/10/2020 at approximately 9:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital on 02/04/2020 at 8:36 AM with a diagnosis of Schizophrenia (mental disorder). Pt. #1 was discharged home on 02/14/2020 at 2:22 PM.
- The history and physical note, dated 02/04/2020 at 11:01 AM, included, "Patient (Pt. #1) seen in unit here in for becoming aggressive at home with his mother and brought in for further evaluation ...denies any past medical history ...assessment plan: aggressive behavior for psych (psychiatry) evaluation ..."
- The addendum nursing note by Registered Nurse (E #5), dated 02/07/2020 at 10:11 AM, included, "At about 3:50 PM, pt. (Pt. #1) was standing in hall by exit doors, asking to talk with social worker, MHW (mental health worker - E #1) tried to redirect patient back to day room or his room, he became agitated and became aggressive towards staff grabbing at staff, and at one point swinging at staff, the 2 MHW (E #1 and E #2) and one RN (E #3) tried to escort patient back to his room, he was very resistant, after he was assisted to his room he c/o (complained of) weakness and discomfort to left upper arm, a prn (as required) of Haldol (antipsychotic) and Ativan (antianxiety) was given and he accepted it. The house physician as called ...left arm x-ray was ordered, and the house doctor came to examine the patient (Pt. #1) ...awaiting x-ray to be obtained."
- The Resident Physician note dated 02/05/2020 at 5:24 PM, included, "Was called by the nurse (E #5) to come and evaluate the pt. (Pt. #1) Nurse (E #5) reports that pt. was physically aggressive with the incident. When I saw the pt. (Pt. #1) he was unable to move Lt. (left hand). Pt. (Pt. #1) does not provide information of what happened. However, reports pain in his arm, x-ray of left arm ..."
Tag No.: A0168
Based on document review and interview, it was determined for 1 of 4 (Pt. #1) clinical records reviewed for physical restraints, the Hospital failed ensure the physician' order was obtained for restraints.
Findings include:
1. The Hospital's policy titled, "Protective and Restraint Policy" dated 09/2019 was reviewed. The policy included, " ...B. Ordering Restraints: 1. Only a Licensed Independent Practitioners (LIP) may order restraint ...3. PRN orders are not permitted for restraint ..."
2. On 03/10/2020 at approximately 9:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital on 02/04/2020 at 8:36 AM with a diagnosis of Schizophrenia (mental disorder).
- The clinical record of Pt. #1 did not include a physician's order for the use of physical restraints.
3. On 03/10/2020 at approximately 12:45 PM, an interview was conducted with the Chief Medical Officer / Chairman of Department of Psychiatry (MD #1). MD #1 stated, "Patient (Pt. #1) was intellectually disabled. (Pt. #1) was admitted due to agitation and had developmental disability. They did hold the patient (Pt. #1) by his upper arm, instead of the torso or under arms. They did not follow the de-escalation techniques. They did the physical hold to bring the patient (Pt. #1) to the quiet room. There was no physician order for restraints obtained after the incident.
4. On 03/11/2020 at approximately 11:00 AM, an interview was conducted with the Registered Nurse (E #5). E #5 stated, "The (Pt. #1) was held by the arms and escorted to the quiet room. That is considered a physical restraint. I forgot to obtain an order for physical restraints from the physician."
Tag No.: A0186
Based on documentation, observation and interview it was determined that for 1 of 4 (Pt. #1) clinical record reviewed. The Hospital failed to ensure the least restrictive measures were followed prior to placing the patient in physical restraints.
Findings include:
1. The Hospital's policy titled, "Protective and Restraint Policy" (dated 09/2019) was reviewed. The policy included, "VIII. A. Application of restraint devices may occur in any of the following circumstances: ...when less restrictive interventions have been determined to be ineffective to protect the patient ...4. The type or technique of restraint used must be the least restrictive intervention that should be effective to protect the patient, caregiver, or other from harm ..."
2. On 03/10/2020 at approximately 9:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital on 02/04/2020 at 8:36 AM with a diagnosis of Schizophrenia (mental disorder).
- The addendum nursing note by Registered Nurse (E #5) dated 02/07/2020 at 10:11 AM, included, "At about 3:50 PM, pt. (Pt. #1) was standing in hall by exit doors, asking to talk with Social Worker (E #4), MHW (mental health worker - E #1) tried to redirect patient back to day room or his room, he became agitated and became aggressive towards staff grabbing at staff, and at one point swinging at staff, the 2 MHW (E #1 and E #2) and one RN (E #3) tried to escort patient back to his room, he was very resistant ..."
- The clinical record lacked the documentation indication the less restrictive methods were followed prior to physical restraints.
3. On 03/11/2020 at approximately 11:00 AM, an interview was conducted with the Registered Nurse (E #5). E #5 stated, "I did not see the Social Worker (E #4) speak with the patient (Pt. #1). I am CPI trained from another organization. We must talk with patient, satisfy the patient needs, clarification to the request, set limits or distance and redirect the patient calmly. I did not give the medication prior to the situation escalated."
54 On 03/11/2020 at approximately 1:00 PM, an interview was conducted with the Manager BHU (E #8). E #8 stated, "The nurse (E #5) should have administered the PRN (as required) medication prior to the whole situation got escalated."