HospitalInspections.org

Based upon interview and record review, the facility failed to ensure that documentation of the necessity of the administration of psychoactive medication in an emergency situation was provided by the physician in the emergency department (ED) as evidenced by:
Patient #1 was ordered an injection of Haldol, Ativan and Benadryl by MD # 78 with no documentation of necessity.

Findings included:

Record review of Certificate of Medical Examination with Order of Protective Custody by MD #78 dated 03/02/2015 [no time] revealed: Patient #1 " became aggressive at home toward mother ' s boyfriend, threatening him with a knife and threw a speaker out of the window of the house. He is easily irritated and agitated, starts talking fast and angrily about someone extorting his mother and his right to kill them. " MD #78 concluded that Patient #1 was likely to cause serious harm to himself and others.

Record review of Psychiatric Emergency Center Initial Psychiatric Evaluation by MD #78 on 03/02/2015 at 0634 revealed his urine drug screen (UDS) was positive for cocaine. He was paranoid and had homicidal ideation. At times he was labile, tearful then suddenly irritable. On arrival he appeared to be in cocaine withdrawal, only wanting to sleep; " however, now that he is alert, he is paranoid, irritable, labile, with ongoing homicidal ideation based on paranoid thoughts. " Risk assessment: High secondary to level of irritability with homicidal ideation.

Record review of All Medications and Administrations and ED Notes for Patient #1 dated 03/03/2015 revealed: At ...
· 1740, RN #79 documented, " Patient ... increasingly agitated, not following staff directives, on telephone repeatedly. Physician informed. "
· 1751, RN #79 documented that Haldol 5mg with Ativan 2mg with Benadryl 50mg was given by injection.
· 1800, RN #79 documented, " Patient ... intrusive, demanding, threatening staff and not following directives. Physician informed. "

Record review of ED Notes by RN #62 on 03/04/2015 (no time) revealed that Patient #1 was transported to Harris County Psychiatric Center (HCPC) by constables.

In an interview with MD #61 on 03/31/2016 at 1405, she stated that the physician should have documented the necessity for his order of the Haldol, Ativan and Benadryl injection to Patient #1 on 03/03/2016.

Record review of policy 7.26, "Consent to Treatment with Psychoactive Medication " (effective date 03/2011) revealed: " F. Administration of psychoactive medication in emergency situations: 1. The physician shall issue an order to administer psychoactive medication to a patient without the patient ' s consent. The physician will document in the clinical record: a. The necessity of the order in specific medical and behavioral terms. "

Based upon interview and record review, the facility failed to ensure that documentation of the necessity of the administration of psychoactive medication in an emergency situation was provided by the physician in the emergency department (ED) as evidenced by:
Patient #1 was ordered an injection of Haldol, Ativan and Benadryl by MD # 78 with no documentation of necessity.

Findings included:

Record review of Certificate of Medical Examination with Order of Protective Custody by MD #78 dated 03/02/2015 [no time] revealed: Patient #1 " became aggressive at home toward mother ' s boyfriend, threatening him with a knife and threw a speaker out of the window of the house. He is easily irritated and agitated, starts talking fast and angrily about someone extorting his mother and his right to kill them. " MD #78 concluded that Patient #1 was likely to cause serious harm to himself and others.

Record review of Psychiatric Emergency Center Initial Psychiatric Evaluation by MD #78 on 03/02/2015 at 0634 revealed his urine drug screen (UDS) was positive for cocaine. He was paranoid and had homicidal ideation. At times he was labile, tearful then suddenly irritable. On arrival he appeared to be in cocaine withdrawal, only wanting to sleep; " however, now that he is alert, he is paranoid, irritable, labile, with ongoing homicidal ideation based on paranoid thoughts. " Risk assessment: High secondary to level of irritability with homicidal ideation.

Record review of All Medications and Administrations and ED Notes for Patient #1 dated 03/03/2015 revealed: At ...
· 1740, RN #79 documented, " Patient ... increasingly agitated, not following staff directives, on telephone repeatedly. Physician informed. "
· 1751, RN #79 documented that Haldol 5mg with Ativan 2mg with Benadryl 50mg was given by injection.
· 1800, RN #79 documented, " Patient ... intrusive, demanding, threatening staff and not following directives. Physician informed. "

Record review of ED Notes by RN #62 on 03/04/2015 (no time) revealed that Patient #1 was transported to Harris County Psychiatric Center (HCPC) by constables.

In an interview with MD #61 on 03/31/2016 at 1405, she stated that the physician should have documented the necessity for his order of the Haldol, Ativan and Benadryl injection to Patient #1 on 03/03/2016.

Record review of policy 7.26, "Consent to Treatment with Psychoactive Medication " (effective date 03/2011) revealed: " F. Administration of psychoactive medication in emergency situations: 1. The physician shall issue an order to administer psychoactive medication to a patient without the patient ' s consent. The physician will document in the clinical record: a. The necessity of the order in specific medical and behavioral terms. "