HospitalInspections.org

A. Based on document review and interview, it was determined for 1 of 10 ( Pt #7 ) psychiatric patient, the Hospital failed to ensure the one hour assessment after a physicial hold/restraint was applied was documented.

Findings include:


1. The clinical record of Pt #7 was reviewed on 8/3/2015 at approximately 1:00 PM. Pt #7 was admitted to the hospital on 3/14/15 with a diagnosis of dementia. On 4/13/15 at 1:09PM Pt #7 was placed in a physical hold/restraint for agitation. There was no documentation indicating the one-hour face to face assessment was completed after the physical hold was placed.

2. Hospital policy entitled, "Restraints and Seclusion" required, "...Page 3. i. One-hour Face to Face Assessment: A responsible licensed or RN with competency in comprehensive medical/behavioral assessment as it relates to the need for restraints shall perform a face-to-face assessment of the patient's physician (physical) and psychological status, including the patient's reaction to restraint, within one (1) hour of the initiation of restraint..."

3. On 8/4/2015 at 3:10 PM an interview was conducted with the Psychiatric Facilitator (E #3). E #3 confirmed there was no documentation of a one (1)hour face to face assessment after a restraint was applied. E #3 stated, "This should have been documentated."

Based on document review and interview, it was determined for 2 of 10 (Pt #5 and Pt #8) psychiatric patients, the Hospital failed to ensure assessment of the effectiveness of a PRN (as needed) medication was documented.

1. The clinical record of Pt #5 was reviewed on 8/2/2015 at approximately 1:30 PM. Pt #5 was admitted to the hospital on 6/1/2015 with a diagnosis of depression. On 6/12/15 at 08:23 AM Pt #5 received Quetiapine Fumarate a PRN (as needed) medication for anxious agitation. There was no documentation indicating the effectiveness of the PRN medication was evaluated.

2. The clinical record of Pt #8 was reviewed on 8/3/2015 at approximately 2:00 PM. Pt #8 was admitted to the hospital on 4/30/2015 with a diagnosis of depression-suicidal ideation. On 5/2/15 at 1:56 PM and 5/3/2015 at 11:38 AM Pt #8 received 2 milligrams of lorazapam a PRN (as needed) medication for agitation. There was no documentation indicating the effectiveness of the PRN medication was evaluated.

3. Hospital policy entitled, "Medication Management" required, " ...Page 12. 10. Monitoring: a. Patient assessment and reassessment are performed with PRN (as needed) medication".

4. On 8/4/2015 at 3:00 PM an interview was conducted with the Psychiatric Facilitator (E#3). E #3 confirmed there was no documentation of the effectiveness of the PRN medications for Pt #5 and Pt #8. E #3 stated, "An evaluation should have been performed and charted in the patients chart."