HospitalInspections.org

Based on findings from medical record (MR) review and interview, in 1 of 1 MR reviewed for a patient (Patient A) who required application of a 4 point restraint, the qualified practitioner's face-to-face (FTF) evaluation did not include a physical assessment.

Findings include:

-- Review of Patient A's MR revealed the following information: She presented to the emergency department involuntarily on 7/02/13 at 12:15 pm due to increasing agitation, aggression and threats of harm to self and staff. The ED physician (MD #1) performed Patient A's medical screening examination noting Patient A's extremities were non-tender, and her left foot injury seen recently for an outpatient evaluation. With Patient A's continued impulsive/unpredictable combative behavior, the ED RN (RN #1) obtained orders for injectable medications for agitation (administered) and 4 point leather restraint (both wrists and both ankles) applied at 2 pm. RN #1 documented monitoring of Patient A every 15 minutes and also noted that MD #1 saw the patient at 2:50 pm. MD #1's documented patient "re-examined" after injectable medication and "improved." The restraints were discontinued by 3:15 pm. The physician evaluation did not assess for any new patient injury while in restraint or the impact of the leg restraint on the patient's left ankle injury.

Patient A was admitted for continued psychiatric treatment. The nurse practitioner's (NP #1) admission history and physical examination of Patient A on 7/03/13 included information about the left lower extremity injury, her ankle brace, and the outpatient evaluation done. Also noted is "She does have noted ecchymotic areas bilaterally to her wrists ...complete range of motion without pain .." NP #1's accompanying progress note indicated contusions to bilateral wrists status post 4 point restraint in the ED. NP #1 ordered Motrin for pain and ice to Patient A's left lower extremity and both wrists, and the possible use of crutches.

During interview with Nurse Manager (NM #1) on 7/25/13 at 2:20 pm, she/he verified that MD #1's re-examination of Patient A was as noted above and does not document evaluation of Patient A for injury. During interview of the Director of Regulatory Affairs on 7/17/13 at 4 pm, she/he verified that there was no hospital occurrence report submitted about Patient A's injuries while in restraint but there should be one.

Based on findings from document review and interview, in 1 of 1 MR, medical staff orders
lack sufficient instructions and parameters to nursing staff regarding when each of the 3 medications for agitation should be given, or if a combination of the 3 medications can be given.

Findings include:

-- Per review of the Patient A's MR, the physician's admission orders include the following 3 separate orders for agitation PRN: 1) Ativan 2 mg. po (orally) q4h (every 4 hours), 2) Haldol 5 mg po q4h and 3) Benadryl 50 mg po q4hr.
Further review of Patient A's medication administration records for PRN medications revealed the 3 medications for agitation (noted above) are separate medication entries. On 7/03/13 at 9:20 pm RN #2 administered Benadryl 50 mg orally to Patent A for agitation, and at 9:24 pm that day RN #3 administered Haldol 5 mg po and Ativan 2 mg po to Patient A for agitation. Whereas on 7/04/13 at 9:17 pm LPN #1 administered only Ativan 2 mg po to Patient A for agitation.

During interview with the Director of Pharmacy on 7/26/13 at 10 am, she/he acknowledged that the 3 separate medications for agitation in Patient A's MR need clarification from the prescriber about each medication's intended use.