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Based on staff interview and record review, the hospital failed to ensure an accurate and clear description of a patient's behavior that warranted the use of chemical and manual restraints for 1 applicable patient. (Patient #1) Findings include:

1. Per record review on 5/16/11, Patient #9 was brought to the Emergency Department (ED) on 8/9/10 at 12:11 for an evaluation after being found lying on a sidewalk and stating s/he had experienced a seizure, had a headache and was having flashbacks and wanted to his/herself.

Per nursing notes review: at 12:45 Patient visited by Washington County Mental Health screener; at 13:20 Screener leaves room; 14:20 "Slept in short naps.....informed s/he can not go out to smoke. Needs frequent reminders s/he needs to stay in room. 15:55 Psychiatrist stating patient to be admitted to Vermont State Hospital. "Pt now escalating and insisting to go outside/swearing/ Getting agitated when trying to redirect back to room ......MD....aware and Pt. to be medicated, several staff at bedside present". Documentation further indicates the patient was then administered involuntary medication at 16:10 to include Haldol 5mg intramuscular (IM) and Ativan 2 mg IM. At 16:15 the nurses note states "crying hysterically after given injection of med. stating s/he did not understand why we did this....."

The physical holding of Patient #9 for the forced administration of psychotropic medications is considered a restraint. Per review, the hospital's policy/procedure Use of Restraints/Seclusion for Psychiatric Reasons , effective 3/17/08, also identifies a restraint as "...any manual method or physical or mechanical device that restricts freedom of movement...." The policy also states staff are required to complete a Certificate of Need (CON) after involuntary treatment which requires the RN to document type of involuntary treatment used, the reason for use, a nursing assessment, the patient's response to involuntary medications, notification to the patient why the involuntary treatment was used, and alternative less restrictive treatment/interventions attempted. Patient #9's ED record did not include a CON. Nursing staff failed to justify in their documentation why the patient was restrained by staff and administered involuntary medication or that Patient #9 was demonstrating "...emergent, dangerous behavior....." (as per hospital restraint policy) or reflect any of the above mentioned hospital required documentation. This lack of necessary documentation was confirmed on 9/17/11 at 9:20 AM with the Nurse Manager for Emergency Services who stated "This is clearly an opportunity for improvement".

Based on staff interview and record review, the hospital failed to ensure documentation used for the provision of care and services by Emergency Department staff was complete for 1 of 14 applicable patients. (Patient #9) Findings include:

Per review, Patient #9 was admitted to the Emergency Department (ED) on 8/9/10 after experiencing a seizure and stating s/he wanted to harm his/herself. During the course of treatment in the ED, the patient was administered involuntary psychotropic medications after being restrained by ED staff. Per interview on 5/16/11 at 2:35 PM, Nurse #1 involved with Patient #9's care stated when s/he came on duty s/he recalled 3 staff members were attempting to keep Patient #9 in his/her room and described the patient's behavior as "out of control". S/he further confirmed responsibility for administering the involuntary medications to Patient #9. However, per review of Patient #9's record, there was no documentation the patient was "out of control" or who was in attendance in Patient #9's ED room. Nurse #1 also confirmed s/he had a conversation with the ED physician regarding the use of emergency involuntary medications and obtained an order to administer both Haldol and Ativan , however failed to follow hospital policy for the completion of the Certificate of Need for the Involuntary Treatment of the Violent/Casualties Patient (CON) required when administering involuntary psychotropic medication. Per interview on 5/16/11 at 3:05 PM, Nurse #2 confirmed they also failed to document an incident that had transpired between Patient #9 and the mental health screener, which according to a psychiatric consult note (dated 8/9/10), Patient #9 had attacked the screener. In addition, the ED physician failed to complete the Physician Assessment, a component of the CON documentation describing the clinical condition of the patient including behaviors that required involuntary treatment and the response to that treatment. The lack of documentation was confirmed on the morning of 5/17/11 by the Medical Director of the ED, the Nurse Manager of the ED and the Manager of Quality Management.