HospitalInspections.org

Based on interview and document review, the facility failed to meet the Condition of Participation requirements for Patient Rights. This failure had the potential to affect all patients receiving services in the hospital. The facility failed to ensure compliance with restraint/seclusion requirements:


A. The facility failed to have a policy that identified intramuscular (IM) antipsychotic and sedative drugs as restraints when used to control patients during psychiatric behavioral emergencies, and;


B. Nurses interviewed did not consider the administration of intramuscular antipsychotic and sedative medications to be restraints when used to control patients during behavioral emergencies.

(Cross reference tags A-160, A-175, A-179)

Based on record review and interview, the facility failed to identify and treat intramuscular (IM) antipsychotic and sedative medications used to control patients during behavioral emergencies as restraints:

A. The facility restraint policy was unclear that the use of IM medications given to patients during behavioral emergencies were restraints and it did not address all regulatory requirements for this type of restraint usage;

B. Nursing staff were unaware that IM emergency medications used to control patients during behavioral emergencies were restraints;

C. There was no tracking of emergency behavioral medication use;

D. Record review of 1 of 5 sampled patient records showed there was an administration of IM antipsychotic & sedative drugs used to control a patient's aggressive behaviors (Patient #1) during a behavioral emergency. There was no required post-administration documentation of patient monitoring or required face-to-face assessment within 1-hour post restraint initiation (refer to tags A-175 and A-179).




Findings included:


A. Facility restraint policy:

Review of facility's Senior Behavioral Health Unit (SBU) policy titled "Restraint", last revised/reviewed 12/2019 showed that "The term restraint refers to a physical restraint". The policy then described physical restraints as either being a hold by staff or use of a mechanical devise. There was nothing in the policy regarding the use of emergency behavioral medications as restraints.

In an interview on 10/13/23 at 10:30 am, QD-Staff #B stated that there was no facility policy for restraints that addressed medications used as restraints.


B. Nurses unaware IM antipsychotics & sedatives used in behavioral emergencies were restraints:

Observation and review of staffing assignments on 10/13/23 at 8:50 am showed there were two nurses on duty working in the facility's SBU that morning; Staff #F and #G.

In an interview on 10/13/23 at 9:05 am, RN-Staff #F stated that when IM meds are given to control patients during behavioral emergencies, they were not considered to be restraints.

In an interview on 10/13/23 at 9:15 am, LVN-Staff # G stated that IM meds given to control patients during behavioral emergencies were not considered to be restraints.

In both interviews, the nurses could not differentiate between IM antipsychotics and/or sedatives used for calming agitated patients or to control their hallucinations, versus these medications used for psychiatric emergencies where violent, out of control patients were safety threats to themselves or others.


C. No tracking of IM antipsychotic and sedative medications:

In an interview on 10/13/23 at 9:30 am, SBU Manager-Staff #C stated that the only place IM emergency behavioral meds could be tracked were in the patients' Medication Administration Records (MARs) which are in all patient records, intermixed with every other medication patients are given. There was no central log for administration of IM emergency behavioral medications, nor were they included in the facility's Restraint & Seclusion logs.

Based on record review and interview, the facility failed to ensure 1 of 5 patients who received intramuscular (IM) antipsychotic & sedative medications during a behavioral emergency (Patient #1) was treated as a restraint, as shown by staff not monitoring and assessing the patient post administration.



Findings included:



Review of facility's policy for their Senior Behavioral Health Unit (SBU) titled "Restraint", last revised/reviewed 12/2019 showed that "The term restraint refers to a physical restraint". The policy then described physical restraints as either being a hold by staff or use of a mechanical devise. There was nothing in the policy regarding the use of emergency behavioral medications as restraints.


Record review Patient #1's clinical records showed that on 9/2/23, she became aggressive and was hitting and kicking staff. She was administered intramuscular (IM) Haldol 5 mg and IM Ativan 2 mg, while staff held her.

Further record review failed to show the patient was monitored and assessed after medication administration. There was no incident report generated and the emergency medication administration event was not in the facility's restraint log.

In an interview on 10/13/23 at 9:05 am, SBC RN-Staff #F stated that when IM meds are given to control patients during a behavioral emergency, they were not considered to be restraints. Staff #F added that the only monitoring done after giving any IM antipsychotics and sedatives was keeping the patient within line of sight in the unit's dayroom and monitoring for falls or adverse drug reactions. In addition, their bedroom doors were kept locked which prevented patients from going into their rooms, forcing them to remain in staff's view. Staff #F stated there was no formal documented monitoring done after administration.

In an interview on 10/13/23 at 9:15 am, SBC LVN-Staff #G also stated that any IM meds given to control patients during behavioral emergencies were not considered to be restraints. The only monitoring done was keeping a closer eye on the patients after administration of IM antipsychotics and sedatives to check their effectiveness and to see if there were any adverse drug reactions. Staff #G stated there was no formal documented monitoring done after administration.

In both interviews, the nurses could not differentiate between IM antipsychotics and/or sedatives used for calming agitated patients or to control their hallucinations, versus these medications used for psychiatric emergencies where violent, out of control patients were safety threats to themselves or others.

In an interview on 10/13/23 at 9:30 am, SBC Manager-Staff #C stated that the only place IM meds could be tracked were in the patients' MARs (Medication Administration Records) which are located in all patient records documented for every medication given. There was no formal or central log used for IM emergency medication administration and they were not included in the facility's Restraint & Seclusion log.

Based on record review and interview, the facility failed to ensure staff performed a face-to-face evaluation of the patient within 1 hour after the initiation of restraint intervention for 1 of 1 patients (Patient #1).


Findings included:


Review of facility's policy for their Senior Behavioral Unit (SBU) titled "Restraint", last revised/reviewed 12/2019 showed that "The term restraint refers to a physical restraint". The policy then described physical restraints as either being a hold by staff or use of a mechanical devise. There was nothing in the policy regarding the use of emergency behavioral medications as restraints.


Record review of Patient #1's clinical chart showed that on 9/2/23, the patient became aggressive and was hitting and kicking staff. She was briefly held by staff and administered intramuscular (IM) Haldol 5 mg and IM Ativan 2 mg. There was no evidence of any face-to-face exam performed within one hour post administration intervention.


In an interview on 10/13/23 at 9:05 am, SBU RN-Staff #F stated when IM meds were given to control patients during a behavioral emergency, they were not considered to be restraints and no formal assessments were performed and documented after the patient were given these medications.


In an interview on 10/13/23 at 9:15 am, SBU LVN-Staff #G also stated that any IM meds given to control patients during behavioral emergencies were not considered to be restraints and no formal assessments were performed or documented afterwards.