HospitalInspections.org

Based on document review and interview it was determined that for 2 of 2 (Pt #5 and #6) patients reviewed for psychotropic medications, the Hospital failed to ensure informed consents were obtained as required by policy.

Findings include:

1. The Hospital policy titled, "Consent to and Psychotropic Medication Treatment" (Rev. 11/15) required, "If services include the administration of psychotropic medication, the physician shall advise the recipient in writing of the side effects of the education and his right to refuse psychotropic drug...documentation of the drug ordered and that the physician has discussed the risk and benefits of the drug with the patient. ... Purpose: To provide patients with instructions concerning the therapeutic indication as well as the potential side effect of psychotropic medications... when an order for psychotropic medication is written, it will list the patients's name and medication on a Notification of Psychotropic Medication form...If more than one psychotropic medication is ordered at the same time, it may be listed on one form."

2. The clinical record for Pt. #5 was reviewed on 8/2/16. Pt. #5 was a 37 year old male admitted on 7/24/16 with a diagnosis of schizoaffective disorder. Physician medication order dated 8/1/16 included Haldol (antipsychotic) 5 mg BID (2 times/day) PO (by mouth) and Ativan (antianxiety) 2 mg every 6 hours PRN (as needed). The MAR (Medication administration record) indicated Pt. #5 received the Haldol on 8/2/16 at 10:00 AM; and Ativan 2 mg on 8/2/16 at 12:04 AM. The Notification of Psychotropic Medication form that included a list of psychotropic medication was not signed by the patient or a witness, and the medications discussed was not identified from the list.

3. The clinical record for Pt. #6 was reviewed on 8/2/16. Pt. #6 was a 33 year old male admitted on 7/30/16 with a diagnosis of bipolar disorder. Physician medication order dated 8/2/16 included Paxil (antidepressant) 20 mg daily PO. The MAR indicated Pt. #6 received Paxil 20 mg on 8/2/16 at 9:42 AM. The Notification of Psychotropic Medication form that included a list of psychotropic medication was not signed by the patient or a witness, and the medications discussed were not identified from the list.

4. On 8/2/2016 at approximately 3:45 PM the Manager of the 3 West Unit was interviewed. The Manager did not elaborate on the requirement for completing the Notification of Psychotropic Medication form and only said "I see" when shown the incomplete forms. However he was heard instructing the nursing staff to ensure the form is completed.

Based on document review and interview, it was determined that for 1 of 1 patient (Pt. #1) the Hospital failed to ensure a physician examined the patient after sustaining an injury, as required by policy.

Findings include:

1. The Hospital policy titled "Unusual Occurrence Reporting: Patient and Visitor" (Rev. 6/14) required, "When an occurrence , event or situation takes place which is inconsistent with the care and treatment of a patient it must be reported to the Manager of the department providing services to the patient at the time of the occurrence.... When the occurrence involves possible or actual injury to a patient, the attending physician or house physician is notified to see and examine the patient as soon as possible."


2. The clinical record for Pt. #1 was reviewed on 8/2/16. Pt. #1 was a 49 year old male admitted on 2/2/16, with a diagnosis of Bipolar disorder. The clinical record contained an MHS note dated 2/6/16, at 12:51 PM, indicating: "...became combative and aggressive towards staff after staff attempts to intervene when started beating on wall, hitting desk and slamming his face into wall. Patient was physically aggressive, hit staff in the head patient appear to be responding to internal stimuli, talking to self. Staff set firm limits as needed, placed client in full restraint. Staff will continue to monitor patient 1:1 for safety. Patient remains unpredictable."The nursing documentation on 2/6/16, at 1:17 PM indicated "Went to assess pt. in restraints. Pt. is sleeping due to medication and some swelling was observed on the right side of Pt's face. House doctor was notified and as of now has not come to assess the patient." The clinical record lacked evidence that a physician examined Pt. #1 after sustaining the swollen face.

3. The above findings were discussed with the Vice President and Chief Nursing Officer (E #7), during an interview on 8/3/16 at approximately 11:30 AM, who stated that patients are seen by the house physician for injuries sustained during an incidence, and E #7 stated he could not find documentation of a physician examination of Pt. #1 for the 2/6/16 incident.

Based on documents review and interview, it was determined that for 1 of 2 (Pt #1) records reviewed with restraints and seclusion, the Hospital failed to ensure an order was obtained for seclusion of a patient as required by policy.

Findings include:

1. The Hospital policy titled: "Use of Restraints and Seclusion" (rev. 7/16) required, "...4. Restraints and Seclusion will be safely applied, monitored and removed by qualified staff. ...Definition...Seclusion is the involuntary confinement of a patient alone in a room or area from which the paten is physically prevented from leaving. ...Orders for Restraint or Seclusion: ...3. Orders should be entered before the initiation of Restraint or Seclusion except in an emergency. 4. In an emergency, a patient may be placed in Restraint or Seclusion to eliminate the immediate risk, and then an order obtained with in one (1) hour of the application of Restraint or Seclusion."

2. The clinical record for Pt. #1 was reviewed on 8/2/16. Pt. #1 was a 49 year old male admitted on 2/2/16, with a diagnosis of Bipolar disorder. The Mental Health Specialist (MHS) documented on 2/6/16, at 10:29 PM: "Pt was medicated at around 1915 (9:15 PM) ate dinner at 1930 (7:30 PM). However, after he finished his dinner he continued with his combative behavior. A staff along with myself had to force him back to his room after he walked out and refused to go back after direct orders for him to return into the quiet room was given. The door was closed to prevent him form leaving and to protect himself as well as other staff members." The clinical record lacked orders for the seclusion, including monitoring and length of seclusion.

3. The above findings were discussed with the Vice President and Chief Nursing Officer (E #7) during an interview on 8/3/16, at approximately 10:00 AM, who stated there should be an order for the seclusion.

Based on document review and interview it was determined that for 1 (Pt #9) of 3 clinical records reviewed for restraints, the Hospital failed to ensure the patient was evaluated within one hour after the application of restraint in accordance with policy.

Findings include:

1. Policy entitled "Use of Restraint and Seclusion (Reviewed 7/2016) indicated "Addendum B- Restraint and Seclusion , self-destructive patients in the Non-Psychiatric Unit Setting..Documentation of Restraint and Seclusion d. The time and results of every patient evaluating, monitoring, and reassessment, including but not limited to the one (1) hour face-to-face medical and behavioral evaluation...For the behavioral Health Units Only 4. Initial Evaluation: A physician LIP Licensed Independent Practitioner (LIP), trained registered nurse or physician assistant, must see the patient face-to-face within one (1) hour after the initiation of Restraint or Seclusion to evaluate a telephone call is not permitted."

2. On 8/2/2016, at approximately 3:30 PM the clinical chart of Pt #9 was reviewed. Pt #9 was admitted on 6/30/2016, with a diagnosis of Bipolar Disease. Pt #9's clinical record contained a physician's order for restraint dated 6/30/2016 at 11:40 AM for a 4 point lock restraint. Pt#9 remained in restraint on 6/30/2016 from 11:40 AM to 1:00 PM. The clinical chart failed to include the LIP one (1) hour face to face evaluation.

3. On 8/2/2016 at approximately 3:45 PM the Vice President/Chief Nursing Officer (E#7) was interviewed. E #7 stated the LIP face-to-face evaluation should be completed within an hour of restraint application.