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Based on document review and interview, it was determined that the Hospital failed to comply with the Condition of Participation 42 CFR 482.13 Patient Rights.

Findings include:

1. The Hospital failed to ensure that a court-ordered petition for medication was initiated and filed timely, when emergency medications were administered for greater than 72 hours. See deficiency at A-117 (A).

A. Based on document review and interview, it was determined for 1 of 2 (Pt #1), clinical records reviewed for patients requiring court orders for treatment, the Hospital failed to ensure that a "court-ordered petition for medication" was initiated and filed timely when emergency medications were administered for greater than 72 hours.

Findings include:

1. The Hospital's policy titled, "Administration of Psychotropic Medication" (dated 8/1/2017), was reviewed, and required, " ...Emergency Treatment may not be administered for more than 72 hours, excluding Saturdays, Sundays, and holidays, unless a petition for Psychotropic Medication or ECT [electroconvulsive therapy] is filed with the circuit court and the Emergency Treatment continues to be necessary. Once the petition is filed with the court, treatment may continue pursuant to these requirements until the final outcome of the hearing on the petition."

2. The clinical record for Pt #1 was reviewed on 12/4/2023. Pt #1 was involuntarily admitted to 2 South (Acute Adult Behavioral Health Unit) on 9/9/2023. Pt #1 was administratively discharged on 9/26/2023, for legal proceedings.

- Pt #1's Behavioral Health History and Physical (dated 9/10/2023), documented by the Psychiatrist (MD #1), included, " ...Patient was initially assessed at [local Hospital's emergency department] ...was brought to the hospital after running around neighborhood naked stating that [Pt #1] was 'running to a better place' ...According to the family, the patient is not compliant with medications. [Pt #1] was deemed appropriate for inpatient hospitalization due to the severity of [Pt #1] psychotic symptoms and unpredictable erratic behavior... [Pt #1] has been petitioned before and received long-acting injectable medications ..."

- 9/11/2023: " ...Patient lacks insight into [Pt #1's] psychiatric condition. [Pt #1] has no intention of being on medications and says that [Pt #1] does not need any medications at all ...Patient may need to be petitioned since [Pt #1] is a danger towards [self] and others prior to admission and this is due to the acuity of [Pt #1] psychiatric symptoms ... [Pt #1] has been petitioned in the past as well ..."
- 9/14/2023: " ...Patient is refusing medications. Due to the patient's severity of psychotic symptoms and behavior when [Pt #1] is not stable in the outpatient setting and [Pt #1] inability to take care of [Pt #1] basic needs, patient requires medications. Petition will be filed ..."
- 9/18/2023: " ...Over the weekend [Pt #1] had to receive multiple imminent danger antipsychotics [medications] as well as Benadryl. 2 days ago [Pt #1] received medications for imminent danger twice in a span of 6 hrs ...Patient will be petitioned ..."
- 9/22/2023: " ... [Pt #1] is one-to-one [sitter] due to [Pt #1] unpredictable behavior ...The last time [Pt #1] received mandated medications was yesterday morning/afternoon ...Patient will be petitioned. Patient has received multiple imminent danger medications ..."
- 9/25/2023: " ...Patient lacks insight. Patient needs treatment with medications and ECT [electroconvulsive therapy]. Patient will be petitioned ..."

- Pt #1's medication orders included the following IM (intramuscular) psychotropic medications: Lorazepam (Ativan/anti-anxiety) 1 mg every 6 hours, PRN, indication: imminent danger; Chlorpromazine (Thorazine/antipsychotic) 50 mg; Olanzapine (Zyprexa/antipsychotic) 10mg; Ziprasidone (Geodon/antipsychotic) 20 mg; and Haloperidol (Haldol/antipsychotic) 5 mg (to be given if patient refuses Haldol PO), One-Time, indication: imminent danger.

- Pt #1's MAR (Medication Administration Record), included the following emergency IM medications:
-Chlorpromazine (Thorazine) was given on 9/15 (twice), 9/17, 9/18, 9/20, and 9/21/2023.
-Lorazepam (Ativan) was given on 9/22 and 9/25/2023.
-Olanzapine (Zyprexa) was given on 9/17, 9/19, and 9/21/2023.
-Ziprasidone (Geodon) was given on 9/22 and 9/25/2023.

Pt #1 was admitted on 9/9/2023 and was refusing medications/treatment since admission. Pt #1 initially received an emergency IM injection on 9/15/2023, due to aggressive and threatening behavior. MD #1's notes from 9/15/2023 - 9/25/2023 included documentation indicating that a petition would be filed. Pt #1's clinical record included a petition for Psychotropic Medication. However, the petition was not filed until 9/26/2023 (11 days after initial dose was administered), which was greater than 72 hours.

3. On 12/5/2023 at 1:05 PM, an interview was conducted with a Psychiatrist (MD #1/Pt #1's Psychiatrist). MD #1 stated that Pt #1 was admitted due to an acute psychiatric episode where the patient was threatening and damaging property. MD #1 stated that Pt #1 was not in a mental state to consent to medication and required psychotropic medication to treat his symptoms. MD #1 stated that since Pt #1 was refusing oral medications, then the nurses should only administer IM medications for acute or catatonic episodes. MD #1 stated that a petition to obtain a court order for medication administration and for ECT (electroconvulsive therapy) was initiated on 9/26/2023.

4. On 12/5/2023 at 12:00 PM, an interview was conducted with the Director of Case Management (E #5). E #5 stated that we (case management team, State's Attorney, Psychiatrist, and Guardianship), went to court to force medications for Pt #1 since the patient was refusing oral medications. E #5 stated that prior to filing a petition for the medication court order, the nurses cannot give IM medications (other than emergency). E #5 stated that a petition for psychotropic medication was not filed until 9/26/2023, as the team was trying to decide what the next steps would be for Pt #1's treatment plan. E #5 stated that if an emergency medication, is given for more than 72 hours, then there needs to be a medication petition filed.

B. Based on document and interview, it was determined that 1 of 2 (Pt #1), clinical records reviewed for chemical restraints, the Hospital failed to ensure that a Notice of Restriction of Rights form for restraints was completed, when an emergency medication was administered, as required.

Findings include:

1. The Hospital's policy titled, "Administration of Psychotropic Medication" (dated 8/1/2017), was reviewed, and required, " ...Required Procedures: Emergency Treatment: A Notice Regarding Restricted Rights of Individuals must be completed and provided to the patient and the Guardian, if any ...A copy shall be placed in the patient's medical record ..."

2. The clinical record for Pt #1 was reviewed on 12/4/2023. Pt #1 was involuntarily admitted to 2 South (Acute Adult Behavioral Health Unit) on 9/9/2023. Pt #1 was administratively discharged on 9/26/2023.

3. Pt #1's medication orders included the following IM (intramuscular) psychotropic medications: Lorazepam (Ativan/anti-anxiety) 1 mg every 6 hours, PRN, imminent danger; Chlorpromazine (Thorazine/antipsychotic) 50 mg; Olanzapine (Zyprexa/antipsychotic) 10mg; Ziprasidone (Geodon/antipsychotic) 20 mg; and Haloperidol (Haldol/antipsychotic) 5 mg (to be given if patient refuses Haldol PO), One-Time, indication: imminent danger.

Pt #1's MAR (Medication Administration Record), included the following emergency IM medications:
-Chlorpromazine (Thorazine) was given on 9/15 (twice), 9/17, 9/18, 9/20, and 9/21/2023.
-Lorazepam (Ativan) was given on 9/22 and 9/25/2023.
-Olanzapine (Zyprexa) was given on 9/17, 9/19, and 9/21/2023.
-Ziprasidone (Geodon) was given on 9/22 and 9/25/2023.

Pt #1's clinical record included the Restriction of Rights form for 2 times that the emergency medications were administered (Zyprexa on 9/19 and Thorazine on 9/21/2023). However, the clinical record lacked the required form for the 11 other times that the emergency IM medications were administered.

4. On 12/6/2023 at 11:25 AM, an interview was conducted with the Director of Nursing (E #1). E #1 stated that if a medication is given IM as an imminent danger/emergency medication, then there should be a "Restriction of Rights" form completed with each instance.

Based on document review, observation, and interview, it was determined that for 1 of 5 behavioral health units, the Hospital failed to ensure patient safety, by not completing the environmental safety rounds sheets, as required.

Findings include:

1. The Hospital's "Environmental Rounds Checklist: [Hospital] Procedure, Reminders: What to look for during an environmental rounds checklist" (dated 2022) was reviewed and required, "Environmental Rounds Procedures/Reminder...Completed Daily: AM shift, PM shift. To ensure Patient and Staff safety."

2. On 12/4/2023 at 10:15 AM, an observational tour of the 2 South/Adult Acute care unit was conducted. During the tour, environmental (safety) rounding sheets were reviewed from 10/2023-11/30/2023. The rounding sheets include checks for environmental safety risks, such as plastic bags, garbage bin, shower wall, patient room, laundry rooms, and quiet rooms. The sheets require twice a day documentation (AM and PM). The sheets lacked the twice/day documentation on the following dates:

- (6 days): 10/3/2023, 10/8/2023, 10/12/2023, 10/14/2023, 10/16/2023, and 11/27/2023, lacked documentation of PM shift completion.
- (2 days): 10/17/2023, 10/19/2023, lacked documentation of AM shift completion.

3. On 12/6/2023 at 11:25 AM, an interview was conducted with the Director of Nursing (E #1). E #1 stated that the environmental rounds are to ensure patient safety, including ligature risks and anything that can cause harm. E #1 stated that the rounding sheets are required to be completed daily, AM and PM shift.