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Based on document review, medical record review and staff interview, the facility failed to: 1) fully identify opportunities for improvement in the performance improvement review related to the management of agitated/intoxicated patients, and 2) to develop corrective actions. This finding was evident in the review of one (1) of 17 medical records reviewed. (Patient #2)

The impact of not implementing a complete quality improvement analysis has the potential to contribute to poor patient health outcomes.

Findings include:

Review of the medical record for patient #2 identified: a 49 year- old male with a history of alcohol intoxication and seizure disorder, presented to the ED on 4/23/2017 at 1:20 AM with abrasion and swelling to the head. He was assessed by the physician upon arrival at the ED. He was treated for agitation with Haldol 5mg and Lorazepam 2 mg IM at 1:43 am. A head CT was ordered at 1:47 AM. The patient was noted to be still agitated at 2:01 AM and at 2:09 AM, he was given 5mg of Versed IM. The patient was found unresponsive at 3:25 AM. There is no documentation of monitoring or the status of the patient after treatment, by either the nurse or the physician. This lapse was not addressed in the facility's quality improvement review or corrective action plan.

A review of the document titled, "Staff Communication: Physiologic Monitoring of Agitated/Intoxicated Patients in the ED," developed by the facility and presented at the ED Quality meeting of 5/02/17, outlined the practice guidelines for managing agitated and intoxicated patients. This guideline did not clearly indicate where significant changes to a patient's status during the hospital course will be documented and it does not designate the team member who would provide this assessment.

At interview with Staff A, Director of Nursing, on 11/09/17 at 11:15 AM, he stated that the management of agitated patients is a team effort which uses staff from all disciplines.

At interview with Staff E, RN on 11/13/17 at 2:35 PM, she stated that there is a team approach to managing agitated patients and that the patient is closely monitored every 15 minutes until the patient is awake.