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Based on staff interview and record review, the hospital failed to provide care in accordance with its policy and procedure, Physical and Chemical Restraint Policy regarding the use of a chemical restraint for 1 applicable patient in the sample. (Patient #1). Findings include:

Per record review during a survey related to a complaint regarding patient care, a hospital provider ordered chemical restraints for Patient #1 in violation of hospital policy and a RN (Registered Nurse) failed to provide the required documentation per the hospital policy, Physical and Chemical Restraints.

1. Patient #1's provider ordered chemical restraints for the patient due to increasingly agitated behaviors. The provider entry of 5/11/16 at 0041 hours noted the patient 'continued to strike out at staff' and 'not able to be calmed down....swinging arms'..
The provider wrote orders for "Restraint Violent Patient, RN Q2H" at 0031 on 5/11/16. The provider noted that the family agreed to have a chemical restraint used and wrote orders for Zyprexa 2.5 mg. (milligrams) every 4 hours. Per review of the hospital's restraint policy under section H. Provider Guidelines (MD, PA, NP), #3. "PRN Orders for the use of restraints are not acceptable". The provider had written orders for a chemical restraint to be administered more than 1 time, in effect, making the order PRN very 4 hours. This process violates the hospital's policy. Per the order set under the Protocol Text - Provider Guidelines, any orders for restraint (physical and/or chemical) for an adult would need to be renewed every 4 hours, for a maximum of 24 H, (not routinely every 4 H as ordered).

2. Nursing staff documented that the medication Zyprexa was administered to the patient at 0138 and 0558 on 5/11/16. The policy Physical and Chemical Restraints, also stated under section I. Nursing Guidelines, 5. Documentation, a. Documentation will be completed for every patient restraint episode upon initiation, and will be maintained in the medical record., b. The following elements will be included: c. Chemical Restraints, Describe the specific behaviors necessitating chemical restraint., d., Monitoring of vital signs, sedation and behavior each time a chemical restraint is administered and every 15 minutes for 2 hours.

For the 0558 administration of Zyprexa IM, there were no documented complete VS (vital signs) found from the time of administration until 0900, when the patient's blood pressure (B/P) was recorded as 83/47. Additionally, the Registered Nurse (RN) wrote in the medical record at 0142 hours "Zyprexa 2.5 mg. administered IM to patient's right thigh. Patient fought nurse during administration, but medication was successfully administered."
The documentation failed to note if any other staff were present at the time and whether the patient's actions posed a safety risk to the patient and /or the nurse. The RN did not document a note after administering the 0558 dose of IM Zyprexa; there was no information of how the injection affected the patient at that time, including information on whether or not they "fought" the nurse.

Per interview with an RN supervisor during the survey, s/he stated that when administering IM medication as a chemical restraint, they would ask 2 staff (1 at each limb), to be there for administration of the medication, and to calm the patient.

These above findings were confirmed during interviews with the Interim Vice President of Patient Care, RN Supervisor and the Director of Quality during survey.

Refer also to C- 0302

Based on staff interview and record review, the Hospital failed to conduct an annual review of it's policy related to use of physical and chemical restraints for 1 applicable patient in the targeted sample. (Patient #1). Findings include:

Per review of the hospital's policy entitled Physical and Chemical Restraint Policy
on 6/10/16, the policy was last reviewed/on 6/20/14 and expired on 6/20/15. During interview, the Director of Quality confirmed that the policy/procedure was not reviewed on an annual basis. Although hospital staff had recently begun a revision of the policy, it was not complete and approved as required.

Based on staff interview and record review, the hospital failed to maintain a complete and accurately documented record for one of four patients in the sample. (Patient #1). Findings include:

Per record review during a survey related to a complaint regarding patient care, hospital staff failed to document required elements per the hospital's Physical and Chemical Restraint Policy.

1. Patient #1's provider ordered chemical restraints for the patient due to increasingly agitated behaviors. The provider entry of 5/11/16 at 0041 hours noted the patient 'continued to strike out at staff' and 'not able to be calmed down....swinging arms'..
The provider wrote orders for "Restraint Violent Patient, RN Q2H" at 0031 on 5/11/16. The provider noted that the family agreed to have a chemical restraint used and wrote orders for Zyprexa 2.5 mg. (milligrams) every 4 hours. Per review of the hospital's restraint policy under section H. Provider Guidelines (MD, PA, NP), #3. "PRN Orders for the use of restraints are not acceptable". The provider had written orders for a chemical restraint to be administered more than 1 time, in effect, making the order PRN very 4 hours. This process violates the hospital's policy. Per the order set under the Protocol Text - Provider Guidelines, any orders for restraint (physical and chemical) for an adult would need to be renewed every 4 hours, for a maximum of 24 H, (not routinely every 4 H as ordered).

2. Nursing staff documented that the medication was administered to the patient at 0138 and 0558 on 5/11/16. The policy also stated under section I. Nursing Guidelines, 5. Documentation, a. Documentation will be completed for every patient restraint episode upon initiation, and will be maintained in the medical record., b. The following elements will be included:, c. Chemical Restraints, Describe the specific behaviors necessitating chemical restraint., d., Monitoring of vital signs, sedation and behavior each time a chemical restraint is administered and every 15 minutes for 2 hours.

For the 0558 administration of Zyprexa IM, there were no documented complete VS (vital signs) found from the time of administration until 0900, when the patient's blood pressure (B/P) was recorded as 83/47. Additionally, the Registered Nurse (RN) wrote in the medical record at 0142 hours "Zyprexa 2.5 mg. administered IM to patient's right thigh. Patient fought nurse during administration, but medication was successfully administered."
The documentation failed to note if any other staff were present at the time and whether the patient's actions posed a safety risk to the patient and /or the nurse. The RN did not document a note after administering the 0558 dose of IM Zyprexa; there was no information of how the injection affected the patient at that time, including information on whether or not they "fought" the nurse.

Per interview with an RN supervisor during the survey, s/he stated that when administering IM medication as a chemical restraint, they would ask 2 staff (1 at each limb), to be there for administration of the medication, and to calm the patient.

These above findings were confirmed during interviews with the Interim Vice President of Patient Care, RN Supervisor and the Director of Quality during survey.

Refer also to C-0271

Based on staff interview and record review, the hospital failed to use data collected on restraint use to identify opportunities to improve the safety of patients and eliminate inappropriate use of restraints, as stated in it's policy, Physical and Chemical Restraint Policy.
This practice has the potential to affect all patients who are restrained.
Findings include:

Per review of the hospital policy, Physical and Chemical Restraint Policy,
section G. Quality Assurance & Improvement, 1. c. Reports of restraints use and compliance with the restraint standards will be reported to the Quality Committee at least quarterly., d. Use the results of data analysis on the use of restraint to identify opportunities to improve the safety of patients and eliminate inappropriate use of restraint.
The RN Supervisor for days on the medical-surgical unit confirmed during interview that s/he was responsible for conducting an audit of each instance of restraint use on the unit and then forwarded the results of the audit to QA staff. (The restraint use is entered into an electronic log, available to other departments).The audit used for this purpose does not identify nor review provider orders for appropriateness and adherence to hospital policies. The RN had not noted in the audit of this case (Patient #1) that the provider order was written as a PRN and violated the hospital policy.
Per interview with the Director of Quality, all restraint incidents are also reviewed by the QA staff for adherence with policy guidelines and regulatory compliance. They are discussed at the monthly Safety Committee Meetings and quarterly at QA Committee meetings. For the restraint review for Patient #1, although the QA department staff had identified that the provider order was in violation of the hospital policy on restraints, there was no systemic plan/involvement to use the results of the restraint audits to identify opportunities to improve the safety of patients and eliminate inappropriate use of restraints. The Director identified that different units of the hospital use different audit tools for restraint reviews and there is not a hospital wide review protocol in practice currently at the hospital.

Refer also to C-0271 and C-0302.