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Based on review of the facility's restraint data collection, policy review, medical record reviews, and staff and physician interviews, the facility staff failed to accurately measure, analyze and track quality indicators related to use of chemical restraints.

The findings included:

Review of the "Restraint and Seclusion" aggregated data collection for March 2021 through March 2022 revealed no documented use of chemical restraints.

Review of the policy titled "Restrictive Interventions" effective 01/08/2021 revealed "...POLICY Manual Hold is the only approved restrictive intervention used at (named facility)..."

Review of the policy titled "Administration of Psychotropic Medication to Non-Consenting Patients" effective 02/20/2019 revealed "...DEFINITIONS Psychotropic medication means medication with the primary function of treating mental illness. It includes, but is not limited to, antipsychotics, antidepressants, antianxiety agents, and mood stabilizers...POLICY...Psychotropic medication shall be administered to non-consenting patients only when it is determined to be in the best interest of the patient and when one or more of the following conditions exist: I. There is a significant possibility that the patient will harm himself or others before improvement of his condition is realized if the psychotropic medication is not administered..."

1. Review of a closed medical record on 04/13/2022 revealed Patient #3 was a 38-year-old male admitted to the hospital for treatment of cocaine and opioid use disorders. Medical record review revealed Patient #3 had a history of schizophrenia and borderline personality disorder. Review of a "DAILY NURSING PROGRESS NOTE" dated 02/14/2022 at 2307 revealed "...The patient was up trying to get out of the front doors, yelling and making threats. He tried to go after staff and kept saying that he wanted to leave. (Named physician) ordered some IM (intramuscular) medications to calm him down..." Review of the physician's order sheet revealed on 02/14/2022 at 2150 an order was written for Haldol (antipsychotic medication) 5 milligrams (mg) IM one time; Benadryl (antihistamine medication) 50mg IM one time; and Ativan (sedative medication) 2mg IM one time. Review of the "Discharge Summary" dated 02/16/2022 revealed "...patient was demanding to leave immediately, banging doors, patient refused to talk during that encounter he was irritable...He received Haldol 5mg IM, Ativan 2mg IM and Benadryl 50mg IM to prevent harm to self and others..." Medical record review revealed on 02/16/2022, Patient #3 discharged to home.

Review of the Restraint and Seclusion log failed to reveal Patient #3 listed.

Interview on 04/14/2022 at 1445 with the Quality and Standards Manager revealed the facility log for restraints did not contain patients because the facility had not utilized chemical or physical restraints. Interview revealed chemical restraints were considered EFM (emergency forced medications) and none had been administered in the past year. Interview revealed EFM are used in conjunction with physically holding a patient to administer the medication, and that had not been done.

Interview on 04/15/2022 at 1200 with a Psychiatrist (MD #1) revealed that Haldol, Ativan, and Benadryl were not considered chemical restraints at the facility. Interview revealed the facility did not consider the intent for medication administration when determining if they were ordering chemical restraints. Interview revealed the facility only considered the Haldol, Ativan, and Benadryl as chemical restraints when done as EFM (emergency forced medication). Interview revealed the provider did not consider it a chemical restraint because the patients did not refuse to take the medications.




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2. Closed medical record review of Patient #9 revealed a 36-year-old female who arrived to the facility on 03/03/2022 at 1820 with a chief complaint of Polysubstance Abuse. Review of the Medical History and Physical Assessment signed 03/04/2022 at 1749 revealed, "...On presentation, tt (sic) was impaired, manic, aggressive and staff was unable to assess. UDS (urine drug screen) + (positive) for Cocaine, BZ (benzodiazepine), Subutex... MH (mental health) h/o (history of) GAD (generalized anxiety disorder), MDD (major depressive disorder), PTSD (post traumatic stress disorder), Insomnia..." Patient #9 was subsequently admitted to the facility on 03/03/2022 at 1953. Review of Physician Orders dated 03/03/2022 at 2000 revealed, "give Haldol 5mg IM (intramuscularly) with Ativan 2mg IM, Benadryl 25mg IM (medications used to sedate) now x(times) 1 for aggressive/unpredictable behavior..." Review of Medication Administration Record at 03/03/2022 at 2059 revealed the administration of Diphenhydramine (Benadryl) 25mg IM, Haloperidol (Haldol) 5mg IM, and Lorazepam (Ativan) 2mg IM. Review of Physician Progress Note dated 03/03/2022 at 2025 revealed, "...she was erratic, labile, volatile, aggressive w/(with) extreme guarding. As a result of these behaviors, we were unable to complete the admission process and elected to admit her directly to the unit. Because of her unpredictable/lability, as well as safety concerns, she was given Haldol/Ativan/Benadryl by injection which she agreed to without needing EFM(emergency forced medication)... P (plan)... Give Haldol 5mg(milligram), Ativan 2mg, w/ 25mg of Benadryl IM for unpredictable/aggressive behavior..." Review of Nursing Triage Form for Admissions dated 03/03/2022 at 2030 revealed, "...Pt (patient) is non-compliant with triage. (named physician) notified. medication ordered to be given in Admission clinic & Pt will be transferred to (named unit)..." Review of Daily Nursing Progress Note dated 03/03/2022 at 2110 revealed, "Pt is a new admission who displayed very excitable behavior...Pt received the injection to her R(right) ventrogluteal muscle. Pt tolerated well. Pt was educated on the medications she received and the effects it would have..." Review of Daily Nursing Progress Note dated 03/03/2022 at 2150 revealed, "Pt arrived on the unit via wheelchair due to the sedation of the injection cocktail. Pt was taken to room and placed in bed. Resp(respirations) even and unlabored. Pt is also on 1:1(one to one observation)...". Review of the Discharge Summary dated 03/14/2022 at 1126 revealed, "...Mood is positive, and affect if full. Patient is oriented and memory is intact... Insight and judgement are good in terms of treatment and goals during patient's hospital course..." Medical record review revealed Patient #9 was discharged on 03/14/2022 at 0815 to home.

Review of the Restraint and Seclusion log failed to reveal Patient #9 listed.

Interview on 04/14/2022 at 1445 with Quality revealed the facility log for restraints did not contain patients because the facility had not utilized chemical or physical restraints. Interview revealed chemical restraints were considered EFM and none had been administered in the past year.

Interview on 04/15/2022 at 1200 with MD #1 revealed that Haldol, Ativan, and Benadryl were not considered chemical restraints at the facility. Interview revealed the facility did not consider the intent for medication administration when determining if they were ordering chemical restraints. Interview revealed the facility only considered the Haldol, Ativan, and Benadryl as chemical restraints when done as EFM (emergency forced medication).

NC00182076