HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 3 clinical records (Pt #1) reviewed for psychotropic medication consents, the Hospital failed to ensure Pt. #1 had consents for psychotropic medication.

Finding include:

1 .On 4/16/2024, the Hospital's policy titled, "Administration of Psychotropic Medication" (dated 7/1/2022) was reviewed and indicated, "Purpose of this policy is to ensure patients receiving mental health services are advised of their rights to refuse generally accepted mental health or developmental disability services, including psychotropic medications and to provide written information about treatments and to obtain appropriate informed consent prior to administering these medications other than in an Emergency ... Patients Lacking Capacity - The physician or the physician's designee shall provide to the patient's guardian or substitute decision maker, if any, the same written information that is required to be presented to the patient. The consent or refusal of the psychotropic medication will be noted in the medical record."

2. On 4/15/2024, Pt. #1's clinical record (dated 1/6/2024 thru 1/23/2024) was reviewed and included:
-Pt. #1 with a history of dementia and Parkinson's disease who presents from the nursing home with worsening mood, increased agitation and aggressive behaviors.
-Physician orders (dated 1/6/2024 thru 1/23/2024) noted the following psychotropic medication orders:
Seroquel (antipsychotic medication) 25 mg every night (ordered on 1/7/2024 and discontinued on 1/9/2024)
Seroquel 37.5 mg TID (three times a day) ordered on 1/11/12024 and discontinued on 1/16/2024.
The medication administration record indicated that Seroquel was administered as ordered. However, there was no documentation of consent for administration of psychotropic medication for Seroquel.

3. On 4/16/2024 at 10:45 AM, an interview was conducted with the Regional Director of Regulatory & Compliance (E #1). E #1 stated that Pt. #1 came to the Hospital on Seroquel, so there was no need to get a consent.

Based on document review and interview, it was determined that for 1 of 1 Behavioral Health Unit/BHU (Older Adult/Geriatric), the Hospital failed to ensure that the environment of care rounds were completed daily, at each change of shift, per policy. This had the potential to affect all patients on census in the BHU.

Findings include:

1. The Hospital's policy titled, "Patient Safety Rounds Environment of Care Safety Rounds" (effective 1/11/2024) was reviewed and required, "...At each change of shift patient safety and environment of care safety rounds will be performed by two staff members, one from present shift and one from incoming shift... b. Environment of care rounds..."

2. During a tour of the Older Adult BHU on 4/15/2024, the Change of Shift Rounds were reviewed from 4/8/2024 to 4/15/2024. The form, dated 4/12/2024, lacked documentation of room checks for contraband during the evening shift at 7:00 PM. Environment of care rounds for March and early April 2024 were requested from the Director of Behavioral Health Services (E#11) on 4/15/2024, at approximately 11:00 AM. No records were provided by the end of day on 4/15/2024, at approximately 3:30 PM.

3. An interview was conducted with the Assistant Manager of Behavioral Health (E#9) on 4/15/2024, at approximately 10:47 AM. E#9 stated that they conduct the environmental contraband rounds at change of shift every day. E#9 stated that they work 12-hour shifts, so these rounds are done at 7:00 AM and 7:00 PM.

4. On 4/15/2024, at approximately 3:30 PM, the Regional Director of Regulatory and Compliance (E#1) stated that the older logs are destroyed every week after they are reviewed. E#1 stated they keep no record that the logs were reviewed before they are destroyed.

Based on document review and interview, it was determined that for 1 of 2 non-violent restraint records (Pt. #9) reviewed, the Hospital failed to ensure that restraints were used in accordance with a physician's order.

Findings include:

1. The Hospital's policy titled, "Restraint Management" (dated 11/28/2023), was reviewed and required, "...Each episode of restraint... must be ordered by a physician or an authorized licensed practitioner responsible for the patient's ongoing care. The order shall include the type of restraint..."

2. The clinical record of Pt. #9 was reviewed on 4/16/2024. Pt. #9 was admitted on 3/20/2024 with a diagnosis of altered mental status. Physician's orders for non-violent restraints for bilateral (right and left) soft wrist restraints was placed on 3/21/2024 at 3:42 AM. Restraint flowsheets indicated that Pt. #9 was placed in bilateral soft wrist restraints, bilateral soft mitt restraints, and side rails up x4 starting on 3/20/2024 at 9:00 PM. The record lacked physician's orders for use of bilateral mitt restraints and side rails (x4) as restraints.

3. An interview was conducted with the Patient Safety Specialist (E#12) and Assistant Nurse Manager (E#13) on 4/16/2024, at approximately 10:00 AM. E#13 stated that there were no orders in the system for the mitts and side rails. E#12 stated that if all 4 side rails are up, they are considered restraints and require an order for use.

Based on document review and interview, it was determined that for 1 of 2 violent restraint (Pt. #8) record reviewed, the Hospital failed to ensure that orders were renewed when the episode of restraint exceed 4 hours for an adult patient.

Findings include:

1. The Hospital's policy titled, "Restraint Management" (dated 11/28/2023), was reviewed and required, "...No event of restraint and/or seclusion of the patient with violent or self-destructive behaviors shall be continued beyond the patient's age-defined limit unless orders are renewed: a. Four (4) hours for an adult age 18 years or older..."

2. The clinical record of Pt. #8 was reviewed on 4/16/2024. Pt. #8 presented to the Hospital's emergency department on 3/29/2024 with paranoia. Physician's orders for violent 4 point locking restraints were placed on 3/30/2024 at 5:05 AM. Restraint flowsheets indicated that Pt. #8 was placed into the restraints on 3/30/2024 at 4:25 AM. The restraint orders were not renewed until 3/30/2024 at 9:26 AM, approximately 5 hours after the restraint episode was initiated.

3. An interview was conducted with the Regional Director of Regulatory and Compliance (E#1) on 4/16/2024, at approximately 2:10 PM. E#1 stated that the restraint order should be renewed before exceeding 4 hours since the time of initiation.

Based on document review and interview, it was determined that for 1 of 2 violent restraint (Pt. #8) records reviewed, the Hospital failed to ensure that restraints were discontinued at the earliest possible time.

Findings include:

1. The Hospital's policy titled, "Restraint Management" (dated 11/28/2023), was reviewed and required, "...Restraint and seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others... and 3) must be discontinued at the earliest possible time once the unsafe situation ends regardless of the scheduled expiration of the order..."

2. The clinical record of Pt. #8 was reviewed on 4/16/2024. Pt. #8 presented to the Hospital's emergency department on 3/29/2024 with paranoia. Physician's orders for violent 4 point locking restraints were placed on 3/30/2024 at 5:05 AM with a renewal order on on 3/30/2024 at 9:26 AM. Restraint flowsheets indicated that Pt. #8 was placed into the restraints on 3/30/2024 at 4:25 AM. At 7:15 AM, the record indicated that Pt. #8 was asleep and remained asleep until 10:00 AM (nearly 3 hours later) when the restraints were discontinued. The record lacked documentation as to why the restraints were not removed earlier when the patient no longer exhibited dangerous behaviors.

3. An interview was conducted with the Assistant Nurse Manager (E#13) on 4/16/2024, at approximately 9:32 AM. E#13 stated that ideally restraints should be discontinued when the patient no longer exhibits the need for them.