HospitalInspections.org

Based on document review and interview, it was determined, for 3 of 3 (Pt's #1, 2 and 4) clinical records reviewed for patients whose rights were restricted by physical and/or chemical restraints, the Hospital failed to ensure a notice of restriction of rights was completed.

Findings include:

1. On 1/19/16 at 1:00 PM, Hospital policy #IV-C, titled, "Restriction of Rights", revised 3/4/15, was reviewed. The policy required, "Procedure... 2. A Restriction of Rights form will be completed and distributed according to the patient's request. The original form will remain with the medical record... 4. The physician or designee shall provide the patient with an explanation of any restriction of his/her rights..."

2. The clinical record of Pt. #1 was reviewed on 1/19/16. Pt. #1 was a 54 year old female who presented to the Emergency Department (ED) on 2/27/15 at 4:11 PM with the complaint of suicidal thoughts. The ED nursing notes dated 2/27/15 at 9:45 PM included, "at transfer to 901 (building), patient refuses to get on cart screaming and combative. Medicated as tolerated security/paramedics here times 4. Medicated as order band aids place to right and left deltoid (arm) injection sites as patient moves for injection" . The medication orders dated 2/27/15 included that Ativan (sedative) 2 mg (milligrams) IM (intramuscularly) was ordered at 9:45 PM and administered in the right deltoid muscle and Haldol (antipsychotic) 5 mg IM was administered in the left deltoid muscle at 9:59 PM. Restriction of Rights forms for the Haldol and Ativan were not found.

3. The clinical record of Pt. #2 was reviewed on 1/19/16. Pt. #2 was a 26 year old male, seen in the Emergency Department (ED) on 1/19/16, for a mental health evaluation. A progress note dated 1/19/16 at 9:35 AM, included Pt. #2 attempted to elope, struck at locked doors, and attempted to strike a Nurse. Pt. #2's physician order dated 1/19/16 at 9:45 AM, included behavioral restraint (4 extremities) for up to 4 hours. Pt. #2's physician order dated 1/19/16 at 10 AM, included chemical restraints - Haldol 5 mg, intramuscularly and Ativan (treat anxiety), 2 mg, IM. The restraint and medications were administered at the time ordered. Restriction of rights forms for restraint and Haldol and Ativan were not found.

4. The clinical record of Pt. #4 was reviewed on 1/19/16. Pt. #4 was a 45 year old female, seen in the Emergency Department (ED) on 2/24/14, with a complaint of intoxication and drug use. A progress note dated 2/24/15 at 7:29 PM, included, "Patient has become more and more belligerent... not getting what she wanted..." Pt. #4's physician order dated 2/24/15 at 6:38 PM, included a chemical restraint - Haldol, 5 mg, IM. Haldol was administered at 6:53 PM. A restriction of rights form for Haldol was not found.

5. On 1/19/16 at 1:53 PM, an interview was conducted with the ED Clinical Educator (E #4). E #4 stated there was no restriction of rights notice found for Pt. #2 and the ED does not complete a restriction of rights form for medications administered to manage psychiatric patients.

6. During an interview on 1/20/16 at 8:30 AM, the treating Physician (MD#1) of Pt. #1 acknowledged that a restriction of rights form was not completed and should have been.

Based on document review, observational tour, and interview, it was determined for 1 of 4 patient rooms (Pt. #7 in Room 201), the Hospital failed to ensure contraband items were not available to behavioral health patients, potentially affecting the safety of the 16 current patients on census.

Findings include:

1. On 1/20/16 at 11:05 AM, Facility policy #VI-I, titled, "Search Policy", reviewed 1/2011, was reviewed. The policy required, "Admission Search: A search of the patient's personal effects... will be performed at admission... Any contraband found will be turned over to the proper authority... Mental Health Contraband List 2014; Contraband Items Not Allowed... ink pens..."

2. On 1/20/16 at 9:30 AM, a tour was conducted in the Adult Mental Health Unit (2 North). In room 201 an ink pen was found on the dresser.

3. On 1/20/16 at 9:50 AM, Pt. #7's clinical record was reviewed. Pt. #7 was a 20 year old female, admitted on 1/13/16, with a diagnosis of Major Depressive Disorder. Pt. #1 was assigned to room 201. Pt. #7's safety sheets (15 minute safety checks) included observation for suicidal risk.

4. On 1/20/16 at 10:00 AM, an interview was conducted with the 2 North Unit Manager E #5. E #5 stated the person doing the 15 minute checks may have left the pen in the room by mistake.

Based on document review and interview, it was determined for 1 of 4 restrained patients (Pt. #8), the Hospital failed to ensure patients were removed from restraints at the earliest time.

Findings include:

1. On 1/20/16 at 11:15 AM, Facility policy #PC-040, titled, "Restraint Use and Indications", reviewed 11/11/14, was reviewed. The policy required, "14. Restraint Removal: As early as feasible in the restraint process, the individual is made aware of the rationale for restraint and the behavior criteria for its discontinuation. Restraint is discontinued as soon as the patient meets his or her behavior criteria. Example: ... whether an individual is oriented to the environment..."

2. On 1/20/16 at 10:25 AM, Pt. #8's clinical record was reviewed. Pt. #8 was a 22 year old male, admitted on 12/5/15, with a diagnosis of depression. Pt. #8's progress note dated 12/10/15 at 4:43 PM, indicated Pt. #8 refused to allow a Nurse to conduct a body and room search for contraband. Pt. #8 became agitated and behavioral restraints were ordered on 12/10/15 at 3:29 PM. The 15 minutes monitoring sheet indicated restraints were removed at 6:00 PM. However, the same monitoring sheets indicate that Pt. #8 was either quiet or asleep from 3:45 PM to 6:00 PM. A progress note at 5:20 PM, included, "... At approximately 5:00 PM, patient awakened and appeared drowsy, but responsive. Verbal explanation provided reviewing behavior which resulted in restriction. Behavioral expectations also explained, Patient acknowledges understanding..."

4. On 1/20/16 at approximately 1:00 PM, an interview was conducted with the 2 North Unit Manager E #5. E #5 stated the restraint order was for 4 hours.