HospitalInspections.org

Based on a review of 7 open and 4 closed patient records, it was revealed that patient #8 received ibuprofen to which patient #8 was allergic.

Patient #8 was admitted to the psychiatric unit in July 2017. A psychiatry note on the date of admission revealed in part, an allergy to ibuprofen. However, inpatient medication orders revealed that the physician wrote an order for ibuprofen 600 mg every 6 hours for pain. Documentation revealed that on the second day of admission, patient #8 received 600 mg of ibuprofen at 1231. A subsequent physician note of 1506 revealed in part, "Also complained of low back pain which improved with ibuprofen."


While the patient did not experience any adverse effects related to the ingestion of ibuprofen, the hospital failed to provide patient #8 with safe care when it gave patient #8 a known allergies to ibuprofen

Based on review of 11 medical records it was revealed that the hospital had conflicting information in patient #11's emergency department (ED) record related to a partially documented restraint, which the hospital stated did not occur.

On the day of survey, patient #11's record was selected from the ED restraint log. Review of Patient 11's ED record revealed that at 9:02 am, patient #11 was brought into the ED by law enforcement for a Psychiatric Emergency Petition (EP). An electronic order for 4 point restraints was placed at 9:08 am with a rationale of "potential injury to others." Face to face elements within the order were completed at 9:08 am inclusive of::
· "Patient's Immediate Situation" as "Physically Threatening/Aggressive;"
· "Patient's Reaction to Intervention" as "Improved;"
· "Patient's Medical/ Behavioral Condition," as "Review Complete;"
· "Continue/Terminate Restraints," as "Continues to Be a Threat to Others."


Patient #11's record also included documentation for "Close observation monitoring", which was documented under a pre-printed form titled, "Restraint Information." There were no entries for close observation until 09:37, a full half hour after patient #11's arrival. The initial entry revealed the comment, "Patient requesting release." There was no corresponding explanation to indicate that patient #11 was requesting release from restraint.

Close observation continued until 20:30 with no corresponding care documentation. The ED physician conducted a medical screening examination at 10:38. There was no mention of the use of restraints in the physician's note. Nursing documentation at 18:08 stated "Pt resting comfortably ... Close observation ongoing." A decision to admit the patient to the inpatient psychiatric unit was made at 18:14. Patient #11 was transported to the behavioral health unit around 20:38.

Though patient #11 was added to the ED restraint log; had an order for 4-point restraints; a physician face to face; and received every 15-minute close observation; there were no nursing or physician progress notes referring to patient #11 having been in restraints. Further, interview with hospital personnel revealed their belief that patient #11 was never placed in restraints as staff were able to de-escalate patient #11's behavior. While that may be correct, it was not possible to tell if a poorly documented restraint had occurred, a prn (as needed) restraint order had been written, or as staff stated, the restraint order did not get canceled when patient #11 calmed.