HospitalInspections.org

Based on observation, document review, and interview the facility failed to:

A. ensure psychotropic medications given IM (intramuscular) or IV (intravenous) for behavioral emergencies were identified and monitored as a chemical restraint in 5 (Patient #1, #2, #3, #4, and #5) of 5 medical records reviewed.

B. ensure nursing consistently monitored and documented on patients that were administered a Chemical Restraint/ Emergency Behavioral Medication in 5 (Patient #1, #2, #3, #4, and #5) of 5 medical records reviewed.

C. monitor the use of chemical restraints through the Quality Assessment Performance Improvement Process (QAPI).

D. have a clear policy that gave a length of time to monitor a patient after the administration of a Chemical Restraint /Emergency Behavioral Medication (a medication administered to control violent or self-destructive behaviors).

Refer to Tag A0144



E. ensure a physician or qualified Registered Nurse (RN) completed a 1-hour face to face on patients after a chemical restraint was administered for a behavioral emergency in 5 (Patient #1, #2, #3, #4, and #5) of 5 medical records reviewed.


Refer to Tag A0179



The deficient practices identified under the following Conditions of Participation were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.


F. keep patients safe in an environment with known, identified ligature risks. Patients were allowed to be in areas of the geriatric unit that had identified ligature attach points without staff supervision. This provided patient with enough time to harm themselves and/or others without staff present to intervene.

Refer to Tag A0144

Based on observation, document review, and interview the facility failed to:

A. ensure psychotropic medications given IM (intramuscular) or IV (intravenous) for behavioral emergencies were identified and monitored as a chemical restraint in 5 (Patient #1, #2, #3, #4, and #5) of 5 medical records reviewed.

B. ensure nursing consistently monitored and documented on patients that were administered a Chemical Restraint/ Emergency Behavioral Medication in 5 (Patient #1, #2, #3, #4, and #5) of 5 medical records reviewed.

C. monitor the use of chemical restraints through the Quality Assessment Performance Improvement Process (QAPI).

D. have a clear policy that gave a length of time to monitor a patient after the administration of a Chemical Restraint /Emergency Behavioral Medication (a medication administered to control violent or self-destructive behaviors).


A review of medical records was conducted with Staff #1 and Staff #7 on 1/09/2023 after 12:00 PM.

Findings:

Patient #1
Patient #1 was admitted by an Emergency Detention Order (EDO) to the facility on 10/25/2021 with a diagnosis of Bipolar Mania with psychosis.

A review of the Psychiatric Evaluation revealed Patient #1 was a 44-year-old white female brought in on an Emergency Detention Order

10/28/2021
A review of a document titled. "Intervention Progress Note" dated 10/28/2021 at 9:30 AM by RN (Registered Nurse) #15 was as follows:

" ...Precursor Behaviors/Events: Disagreement with treatment decisions, Environment was crowded, Intrusive or disruptive behavior, On 1-1 or 2-1 supervision, pacing/rocking/other agitated motor bhvr, and refuses to move or leave area.

Alternative Intervention Attempted: Verbal intervention, Voluntary time out (staff offered), Emergency medication
Was Medication Administered During the Restraint/Seclusion (see MAR for Details): Yes
Relative Contraindications/Special Considerations: Yes
Accommodations or Other Comment: safety/benefit outweighs the risk.

Intervention Event Description: Event Type: Emergency Meds
General Location: On Unit-Bathroom
Start Date & Time: 10/28/2021 9:30 AM
Reason for Intervention: Imminent risk of violence-staff
Medication Detail: Ativan (antianxiety medication) Injection IM, Benadryl IM (intramuscular), Haldol (antipsychotic medication) IM.
Response to Meds: Resisted-effective

Name and title of Staff Applying the Restraint or implementing the seclusion: Staff #16, #17, #18, #19, #20, #21, and #22.
Name and title of Staff person observing/witnessing (but not applying) the intervention: Staff #15

Event Summary:
Precipitating Behavior: Patient was extremely disruptive to the unit milieu. She was yelling that she is God, flipping over tables and chairs, standing on the tables, throwing paper at staff.

Intervention attempted and Patients Comment: Staff attempted verbal redirection, she was offered a voluntary time out in her bedroom, and offered PO (oral) emergency medication, and patient stated, "f*** all of you".

Description of Episode: Patient was extremely disruptive to the unit milieu. She was yelling that she is God, flipping over tables and chairs, standing on the tables, throwing paper at staff, and making verbal threats to staff. Physician #23 was notified of patients behavior and placed orders for Ativan 2 mg po, Haldol 10 mg po, and Benadryl 50 mg po STAT. PO medication was offered to Patient #1, she snatched the medication from this RN's hands, threw the medication, then stated, "If you ask me about the medicine again I will attack you." She agreed to take the medications once she talked to the doctor, then she requested IM injections instead of PO medication. Once Physician #23 arrived on the unit, a few minutes later, she ran down the mens hallway into the mens bathroom. She went into a stall and started throwing her clothing at staff. She then stated she needed to use the bathroom, at that time she began throwing her feces and soaked toilet paper at staff, then stuck her head in the toilet, all while making verbal threats to the staff ...Patient #1 was placed in a personal hold at 9:27 AM, then placed into a mechanical (chair) restraint at 9:28 AM ...Physician #23 placed orders for Ativan 2 mg IM, Haldol 10 mg IM, and Benadryl 50 mg IM STAT. The medications were administered at 9:30 AM. Patient continued to make threats and pull at restraints while in the chair until she fell asleep. Criteria for release was met and she was released from the chair at 10:00 AM and laid in her bed. No further incidents noted ..."

A review of Physician #23's medication order on 10/28/2021 at 9:41 AM read, "Haldol 10 mg Injection IM Stat (NOW) and Benadryl 50 mg Injection IM Stat (NOW), and Ativan 2mg Injection IM Reason: Aggression-Agitation-Towards staff and disrupting the unit."

A review of the MAR (Medication AdministrationRecord) revealed the medication was administered by the nurse on 10/28/2021 at 9:25 AM.

Staff #7 confirmed the document titled "Restraint/Seclusion flowsheet" listed the Restraint Type as Mechanical. Staff #1 and #7 confirmed Patient #1 was placed in a restraint chair and was monitored per the facility policy for mechanical restraints. Staff #1 and #7 also confirmed there was no vital signs (blood pressure, temperature, pulse, respirations, and oxygen sats) documented for 10/28/2022. Respiratory status is noted as no distress, but there is no respiration count documented. There was no documentation of the emergency medications on the Restraint/Seclusion Flowsheet.

Staff #1 and #7 also confirmed there was no nursing assessment completed post IM Injection of the emergency medications and the only note documented by the nurse was the Intervention Progress Note at 11:21 AM on 10/28/2021 that read "Resisted-effective."



10/31/2021
A review of a document titled. "Intervention Progress Note" dated 10/31/2021 at 1:06 PM by the RN was as follows:

" ...Precursor Behaviors/Events: Environment was crowded, Environment was loud, Intrusive or disruptive behavior, On 1-1 or 2-1 supervision, pacing/rocking/other agitated bhvr.
Alternative Intervention Attempted: Verbal intervention, Voluntary time out (staff offered), emergency medication
Relative Contraindications/Special Considerations: Yes
Accommodations or Other Comment: History of sexual abuse/rape

Intervention Event Description:
Event Type: Emergency Meds
General Location: On Unit-Dayroom/Living Room/Lobby
Start Date & Time: 10/31/2021 12:40 PM
Reason for Intervention: Imminent risk of violence-staff
Medication Detail: Benadryl Injection IM, Haldol Injection IM
Response to Meds: Resisted-effective ...

Name and title of Staff Applying the Restraint or implementing the seclusion: No restraints applied
Name and title of Staff person observing/witnessing (but not applying) the intervention: None ...

Event Summary:
Precipitating Behavior: Patient was being intrusive, getting into peoples faces, challenging them to a fist fight. She actually assaulted one patient and swung her fists at staff ...

Description of Episode: Physician #12 returned call at 12:30 PM with telephone order to administer Benadryl 50 mg IM STAT x1 and Haldol 10 mg IM STAT x1 ... IM medications administered at 12:40 PM to each gluteal muscle ...

A review of Physician #12's medication order on 10/31/2021 at 12:30 PM read, " ...Haldol 10 mg IM Injection Stat (NOW) and Benadryl 50 mg IM Injection Stat (NOW), Reason: Agitation-disrupting unit and threatening staff ..."

A review of the MAR revealed the medication was administered IM by the nurse on 10/31/2021 at 12:40 PM and a follow up note documented on the MAR on 10/31/2021 at 1:43 that read "No adverse reaction."
Staff #1 and Staff #7 confirmed the only set of vital signs (blood pressure, temperature, pulse, respirations, and oxygen sats) taken post injection was at 5:29 PM on 10/31/2021.

Staff #1 and #7 also confirmed there was no nursing assessment completed post IM Injection and the only note documented by the nurse was the Intervention Progress Note at 1:06 PM on 10/31/2021 that read "Resisted-effective."

Staff #1 and #7 confirmed there was no documentation in the medical record that oral medications were offered or refused by the patient.

11/13/2021
A review of a document titled. "Intervention Progress Note" dated 11/13/2021 at 7:40 AM by the RN was as follows:

" ...Precursor Behaviors/Events: Environment was crowded, Environment was loud, Intrusive or disruptive behavior, pacing/rocking/other agitated bhvr, refused routine psychoactive medications, refuses to move or leave an area.

Alternative Intervention Attempted: Voluntary time out (staff offered), emergency medication

Relative Contraindications/Special Considerations: Yes
Accommodations or Other Comment: History of sexual abuse/rape

Intervention Event Description:
Event Type: Emergency Meds
General Location: On Unit-Dayroom/Living Room/Lobby
Start Date & Time: 11/13/2021 7:40 AM
Reason for Intervention: Agitation (meds only)
Medication Detail: Ativan Injection IM, Benadryl Injection IM, Haldol Injection IM
Response to Meds: Accepted-effective

Name and title of Staff Applying the Restraint or implementing the seclusion: No restraints applied
Name and title of Staff person observing/witnessing (but not applying) the intervention: None

Event Summary:
Precipitating Behavior: Upon arriving to unit before obtaining shift report, observed patient yelling and screaming at staff. Night nurse reported that patient stayed up all night writing on floor with crayons, waking patient up in the middle of the night, smearing Vaseline and lotions on the doors and handles, and throwing water on the floor ...
Description of Episode: Emergency medication detail: Physician #23 called with order to administer Ativan 2 mg IM, Benadryl 50 mg IM, and Haldol 10 mg Im. Patient lowered her pants immediately exposing self and stated that she would take the shots using profanity. LVN administered medications at 7:40 AM to bilateral gluteus ..."

A review of Physician #23's medication order on 11/13/2021 at 7:30 AM read, "Haldol 10 mg IM Injection Stat (NOW) and Benadryl 50 mg IM Injection Stat (NOW) Ativan 2mg IM Injection STAT (NOW), Reason: Agitation-threatening staff ..."

Staff #1 and Staff #7 confirmed a set of vital signs (blood pressure, temperature, pulse, respirations, and oxygen sats) was taken post injection at 2:01 PM on 11/13/2021. This was greater than 6 hours after IM administration of psychotropic medications.

Staff #1 and #7 also confirmed there was no nursing assessment completed post IM Injection and the only note documented by the nurse was the Intervention Progress Note at 12:22 PM on 11/13/2021 that read "Accepted-effective."

Staff #7 confirmed Patient #1 was placed on the restraint log on 10/28/2021 for the mechanical restraint and not the emergency behavioral medications. She also confirmed Patient #1 had a Restraint/Seclusion Flowsheet for 10/28/2021 while she was in the restraint chair that is required by the facility policy.

Patient #2
Patient #2 was admitted by an Emergency Detention Order (EDO) to the facility on 1/06/2023 with a diagnosis of Schizoaffective disorder.

A review of the Psychiatric Evaluation dated 1/06/2023 by Physician #3 revealed Patient #2 was a 61-year-old white female who has been brought in on an Emergency Detention Order and apparently, she was running in front of a school bus, made threats to the neighbors, destroys others property, growling at the neighbors, and speaking in word salad, psychotic, and erratic.

A review of a document titled. "Intervention Progress Note" dated 1/08/2023 at 7:05 PM by RN (Registered Nurse) #11 was as follows:

" ...Precursor Behaviors/Events: Intrusive or disruptive behavior, On 1-1 or 2-1 supervision
Alternative Intervention Attempted: Verbal intervention and Voluntary time out (staff offered)
Comments on Alternative Interventions Attempted: Patient is on 1:1 for aggression. Verbal redirection was attempted, encouraging the patient to get out of the area where the patients were upset with her. She would not comply at all.
Was Medication Administered During the Restraint/Seclusion (see MAR for Details): No
Relative Contraindications/Special Considerations: No
Accommodations or Other Comment: Restraint was not required.

Intervention Event Description: Event Type: Emergency Meds
General Location: On Unit-Bedroom
Start Date & Time: 1/08/23 06:40 PM
Reason for Intervention: Imminent risk of violence-other
Medication Detail: Benadryl 25mg IM (intramuscular), Haldol (antipsychotic medication)10mg IM

Name and title of Staff Applying the Restraint or implementing the seclusion: N/A
Name and title of Staff person observing/witnessing (but not applying) the intervention: N/A

Event Summary: Precipitating Behavior: Patient was being intrusive, getting into peoples faces, challenging them to a fist fight. She actually assaulted one patient and swung her fists at staff ...
Description of Episode: Patient was administered Benadryl 25mg IM and Haldol 10 mg IM into left deltoid muscle per patient request..."

A review of Physician #12's medication order on 1/08/2023 at 6:39 PM read, " ...Haldol 10 mg Injection Stat (NOW) and Benadryl 25 mg Injection Stat (NOW), Reason: Aggression-Patient is punching/attacking peers and swinging at staff ..."

Staff #1 and #7 confirmed there was no route on the medication order for the Emergency Medications of Haldol and Benadryl Injection.

A review of the MAR revealed the medication was administered by the nurse on 1/08/2023 at 6:47 PM and a follow up note documented on the MAR on 1/08/2023 at 7:46 PM that read "Pt. improved/improving."

Staff #1 and Staff #7 confirmed the only set of vital signs (blood pressure, temperature, pulse, respirations, and oxygen sats) taken post injection was at 9:59 PM on 1/08/2023. This was greater than 1 hour after the IM administration of emergency medications.

Staff #1 and #7 also confirmed there was no nursing assessment completed post IM Injection and the only note documented by the nurse was the Intervention Progress Note at 6:54 PM on 1/08/2023 that read "Accepted partially effective."

Staff #1 and #7 confirmed there was no documentation in the medical record that oral medications were offered or refused by the patient.

Patient #3
Patient #3 was admitted to the facility on 12/14/2022 with a diagnosis of Schizoaffective Disorder, bipolar type.
A review of the Psychiatric Evaluation by Physician #13 revealed Patient #13 was a 36-year-old white male with a history of schizoaffective disorder, bipolar type, cannabis use disorder, alcohol use disorder, nicotine use disorder who presented as a walk in with his brother.

A review of a document titled. "Intervention Progress Note" dated 12/15/2022 at 12:21 PM by RN was as follows:

" ...Precursor Behaviors/Events: Angry that request was no granted, Argument/threat turned to phy aggression, Intrusive or disruptive behavior.

Alternative Intervention Attempted: Verbal Intervention, Voluntary Timeout (staff offered), Emergency Medication
Was Medication Administered During the Restraint/Seclusion (see MAR for Details): No
Relative Contraindications/Special Considerations: No

Intervention Event Description: Event Type: Emergency Meds
General Location: On Unit-Bedroom
Start Date & Time: 12/15/22 11:07 AM
Reason for Intervention: Self injurious behavior
Medication Detail: Ativan (antianxiety medication) Injection IM, Benadryl Injection IM, Haldol Injection, IM

Name and title of Staff Applying the Restraint or implementing the seclusion: N/A MEDS ONLY
Name and title of Staff person observing/witnessing (but not applying) the intervention: N/A MEDS ONLY

Event Summary: Precipitating Behavior: Patient threatening staff, banging on back door and responding to internal stimuli. ...
Description of Episode: Patient was observed to be withdrawn and responding to internal stimuli. Patient was reported to be threatening staff with fist clinched as in ready to fight. Patient then went to the back door of the male hallway and started to bang and slam himself into the door intending to break free as he kept saying "You people need to let me out of here" Patient was verbally redirected and and (sic) offered timeout but refused. Patient continues to body slam himself onto the back door and staff tried verbally redirect him patient rushed onto staff as to fight them. Patient attending was called and notified patient behavior and an order for ATIVAN 2 MG IM, BENADRYL 50 MG IM and HALDOL 10 MG IM was ordered. Medication was administered at 11:07 AM and patient received medication in both deltoid muscle without incident
Response to Emergency Medication: Accepted and effective as patient is currently calm and interacting with peers.

No debriefing performed. Event was verbal intervention or Emergency Meds Only (no restraint or seclusion used).
RN Assessment Comments: medication only ..."

A review of the Physician's medication order on 12/15/2022 at 10:55 AM read, "Haldol 10 mg Intramuscular solution Stat (NOW), Benadryl 50 mg Intramuscular solution Stat (NOW), and Ativan 2mg Intramuscular solution STAT (now). Reason: Aggression-Patient threatening staff and slamming self in the door."

A review of the MAR revealed the medication was administered by the nurse on 12/15/2022 at 11:07 AM and a follow up note documented on the MAR on 12/15/2022 at 12:09 PM that read "No adverse reaction."

Staff #1 and Staff #7 confirmed a set of vital signs (blood pressure, temperature, pulse, respirations, and oxygen sats) was taken on 12/15/2022 at 11:48 AM and not again until 9:28 PM on 12/15/2022.

Staff #1 and #7 also confirmed the only nursing documentation post IM Injections of the emergency behavior medications was on the Intervention Progress Note that read, "Accepted and effective as patient is currently calm and interacting with peers ..."

Staff #1 and #7 confirmed there was no documentation in the medical record that oral medications were offered or refused by the patient.

Patient #4
A review of the Psychiatric Evaluation revealed Patient #4 was admitted to the facility as a Forensic patient form the Ellis County Jail with a diagnosis of schizoaffective disorder, depressed type.

A review of a document titled. "Intervention Progress Note" dated 12/28/2022 at 12:08 PM by RN #14 was as follows:

" ...Precursor Behaviors/Events: Environment was loud, Intrusive and disruptive behavior, refuses to move or leave an area, responding to internal stimuli, and self-conversing, delusional/oth (sic) verbal symp (sic)
Alternative Intervention Attempted: Verbal Intervention, Voluntary Timeout (staff offered), and Emergency Medication
Was Medication Administered During the Restraint/Seclusion (see MAR for Details): Yes
Relative Contraindications/Special Considerations: No

Intervention Event Description: Event Type: Emergency Meds
General Location: On Unit-Bedroom
Start Date & Time: 12/28/22 12:05 PM
Reason for Intervention: Imminent risk of violence-staff
Medication Detail: Ativan Injection IM, Thorazine (antipsychotic medication) Inj IM
Response to Meds: Accepted-effective
Clinician performing Face to Face-to-Face Assessment: RN #14

Name and title of Staff Applying the Restraint or implementing the seclusion: N/A Medication Only
Name and title of Staff person observing/witnessing (but not applying) the intervention: N/A Medication Only

Event Summary: Precipitating Behavior: Patient was constantly targeting and throwing property at staff
Description of Episode: Patient at breakfast was observed to kick the trash can towards this particular male staff and continued to yell and curse at him calling male staff all derogatory names "b****" "p****" "weakling" among others. Patient was verbally redirected away to his room to calm down. As a patient was moving towards his room patient threw the blanket he was holding into the face of the staff and yelled at him calling him names. Patient then doubled back into the staff face with a fist as in ready to fight the staff unprovoked. Per reports patient stated that the staff looks like rival that he had in jail. Patient became physically aggressive and would not respond to verbal redirection. Patient attending was notified of patient behavior and an order for THORAZINE 200 MG IM and ATIVAN 2 MG IM were ordered. Patient received medication without incident at 12:05 PM. At 12:30 PM on observation patient appeared calmer. Currently patient is lying in bed with eyes closed respirations even and unlabored. Will continue to monitor and maintain patient safety.
Response to Emergency Medication: Accepted and effective
No debriefing performed. Event was verbal intervention or Emergency Meds Only (no restraint or seclusion used).
RN Assessment Comments: Cardiac/respiratory monitored dur R/S ..."

A review of the Physician's medication order on 12/28/2022 at 11:50 AM read, " ...Thorazine 200 mg Intramuscular solution STAT (NOW) and Ativan 2mg Intramuscular solution STAT (now). Reason: Agitation: Patient physically aggressive towards staff and peer..."

A review of the MAR revealed the medication was administered by the nurse on 12/2/2022 at 12:05 PM and a follow up note documented on the MAR on 12/28/2022 at 1:06 PM that read "No adverse reaction."

Staff #1 and Staff #7 confirmed a set of vital signs (blood pressure, temperature, pulse, respirations, and oxygen sats) was taken on 12/28/2022 at 4:43 PM on 12/28/2022. This was greater than 4 hours after the IM administration psychotropic medications was administered for a behavior emergency.

Staff #1 and #7 also confirmed the only nursing documentation post IM Injection of Emergency Behavioral Medications was on the Intervention Progress Note that read, Accepted and effective ..."

Staff #1 and #7 confirmed there was no documentation in the medical record that oral medications were offered or refused by the patient.

Patient #5
A review of the Psychiatric Evaluation revealed Patient #5 was admitted to the facility on 12/11/2022 with a diagnosis of Bipolar disorder, Type 1 with severe psychosis.

A review of the Psychiatric Evaluation dated 12/11/2021 revealed Patient #5 was a 52-year-old male who was brought to the facility by the police department on a warrantless detention for suicidal and homicidal thoughts.
12/15/2022

A review of a document titled. "Intervention Progress Note" dated 12/15/2022 at 11:58 AM by the nurse was as follows:

" ...Precursor Behaviors/Events: Environment was loud, Intrusive and disruptive behavior, Pacing/rocking/other agitated motor bhvr (sic), Responding to Internal stimuli.
Alternative Intervention Attempted: Verbal Intervention, Voluntary Timeout (staff offered) and Emergency Medication
Was Medication Administered During the Restraint/Seclusion (see MAR for Details): No
Relative Contraindications/Special Considerations: N/A (Med only)

Intervention Event Description: Event Type: Emergency Meds
General Location: On Unit-Bedroom
Start Date & Time: 12/15/2022 at 11:35 AM
Reason for Intervention: Agitation (meds only)
Medication Detail: Ativan Injection IM, Benadryl Inj IM, Haldol Injection IM
Response to Meds: Accepted-partially effective
Event Summary: Precipitating Behavior: Environment was extremely loud, and pt appeared to be struggling to adapt to this environment, and stated, "I am having a panick attack."
Explanation provided to patient and patients understanding: Staff explained to pat that he was receiving emergency medications to provide comfort, and he verbalized understanding to this approach without further incident.

Description of Episode: Pt was observed in 7B hallway speaking loudly about delusions about the Bible. Staff approached pt trying to verbally redirect, but patient continued to scream and stated, "I'm having a panic attack, I need a shot of Haldol in my butt, and I can't do this anymore." Multiple verbal redirects by staff were unsuccessful.
Emergency Medication Detail: Haldol 10 mg, Benadryl 50mg, and Ativan 2 mg IM stat in bilateral upper lateral ventral gluteal muscles at 11:35 AM. Patient accepted these medications without incident.
Response to Emergency Medication: Pt is calm and showing no signs of acute distress, respirations are even and unlabored; will continue to monitor and report as needed.

A review of the Physician's medication order on 12/15/2022 at 11:28 AM read, "Benadryl Injection 50 mg Intramuscular STAT (NOW), Haldol 10mg Injection Intramuscular STAT (NOW), and Ativan 2mg Intramuscular solution STAT (now). Reason: Aggression: Patient physically threatening staff and hitting doors."

A review of the MAR revealed the medication was administered by the nurse on 12/15/2022 at 11:35 AM and a follow up note documented on the MAR on 12/15/2022 at 12:35 PM that read, "Pt improved/improving, no adverse reaction."

Staff #1 and Staff #7 confirmed a set of vital signs (blood pressure, temperature, pulse, respirations, and oxygen sats) were taken on 12/15/2022 at 12:18 PM and not again until 9:34 PM on 12/28/2022.

Staff #1 and #7 also confirmed the only nursing documentation post IM Injection of Emergency Behavioral Medications was on the Intervention Progress Note dated 12/15/2022 at 11:58 AM that read, "Accepted-partially effective."


12/21/2022
A review of a document titled. "Intervention Progress Note" dated 12/21/2022 at 10:38 AM by the RN #14 was as follows:

" ...Precursor Behaviors/Events: Argument/threat turned to phy (sic) aggression, Environment was loud, Intrusive and disruptive behavior, Pacing/rocking/other agitated motor bhvr (sic), Refuses to move or leave an area, Responding to Internal stimuli, self injurious behavior or threats.
Alternative Intervention Attempted: Verbal Intervention, Voluntary Timeout (staff offered) PRN medication offered, and Emergency Medication
Was Medication Administered During the Restraint/Seclusion (see MAR for Details): No
Relative Contraindications/Special Considerations: N/A (Med only)

Intervention Event Description: Event Type: Emergency Meds for self-injurious behavior
General Location: On Unit-Bedroom
Start Date & Time: 12/21/22 09:28 AM
Reason for Intervention: Self injurious behavior
Medication Detail: Ativan Injection IM, Benadryl Inj IM, Haldol Injection IM
Response to Meds: Accepted-partially effective

Initiating Clinician: RN #14

Name and title of Staff Applying the Restraint or implementing the seclusion: N/A Medication Only
Name and title of Staff person observing/witnessing (but not applying) the intervention: N/A Medication Only

Event Summary: Patient was yelling and running around the unit banging on doors and attempting to jump over the chairs on the lobby.

Explanation provided to patient and patients understanding: Patient was reported to sleep all night, this morning was observed running, yelling and attempting to jump over the furniture in the lobby. Patient was a danger to self and was observed running into peers on the unit. Patient would not adhere to verbal redirection and would not accept the offer of voluntary timeout. Patient on observation had rapid speech with a loud tone. Patient was observed to be have (sic) a labile mood. Patient attending was notified and an order for ATIVAN 2MG IM, HALDOL 10 MG IM, and BENADRYL 50 MG IM. Medication was administered at 9:28 AM on the bilateral deltoid muscle without incident. Patient accepted the medication without incident.
Emergency Medication Detail: Ativan 2mg IM, Haldol 10 mg IM, and Benadryl 50 mg IM.
Response to Emergency Medication: Accepted and effective.
No debriefing performed. Event was verbal intervention or Emergency Meds Only (no restraint or seclusion used) ..."

A review of Physician #24's medication order on 12/21/2022 read, "9:00 AM- Ativan 2mg Oral Tab STAT (now) Reason: Aggressive behavior-fighting with patient(s) Patient is agitated, intrusive to peers, hitting on doors, disruptive and difficult to redirect, and Haldol 10mg Injection Intramuscular STAT (NOW) Reason: Patient physically threatening staff and hitting doors."

An order by Physician # 24 at 9:47 AM- read, "Benadryl Injection 50 mg Intramuscular STAT (NOW) Reason: Patient physically threatening staff and hitting doors."

A review of the computerized MAR (Medication Administration Record) did not reveal a time the IM medications of Benadryl and Haldol were administered nor did it reveal when the Ativan Tablet was administered. No paper/handwritten MAR was presented for review.

A review of the Intervention Progress Note documented by the RN was as follows:
" ...Intervention Event Description
Event Type: Emergency Meds
Start Date & Time: 12/21/22 09:28 AM
Reason for Intervention: Self Injurious Behavior
Medication Detail: Ativan Injection IM, Benadryl Inj, IM, Haldol Injection, IM ..."

The RN documented on the Intervention Progress Note dated 12/21/2022 that Haldol 10 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM were administered at 9:28 AM on 12/21/2022.

Staff #25 confirmed there was no order for Ativan IM only an order for Ativan PO (by mouth) and the Benadryl Injection IM was not ordered until 9:47 AM.


Staff #1 and Staff #7 confirmed a set of vital signs (blood pressure, temperature, pulse, respirations, and oxygen sats) were taken on 12/21/2022 at 8:51 AM and not again until 12/2/2022 at 3:52 PM. This was greater than 6 hours after the Emergency medication was administered.

Staff #1 and #7 also confirmed the only nursing documentation post IM Injection of the Emergency Behavioral Medications was on the Intervention Progress Note dated 12/15/2022 at 11:58 AM that read, Accepted-partially effective ..."

Staff #1 and #7 confirmed there was no documentation in the medical record that oral medications were offered or refused by the patient.

An interview was conducted with Staff #1 and Staff #7 on 1/09/2023 after 1:30 PM. Staff #1 was asked if patients that received IM injections of Psychotropic medications for emergency behaviors were placed on the restraint log. Staff #1 responded that the only patients that were documented on the restraint log are those that had a physical or mechanical restraint. Staff #1 stated, "Our policy and the State of Texas do not allow chemical restraints to be administered. We do not recognize Emergency Behavioral Medications as a chemical restraint. We document all physical restraints on the log."
Staff #1 and #7 confirmed the emergency medications given to 5 (Patient #1, #2, #3, #4, and #5) of 5 patients reviewed were administered for behavioral emergencies.

A review of the restraint log dated 10/01/2021 revealed Patient #1 was listed as a restraint on 10/28/2021. Staff #1 confirmed Patient #1 was on the restraint log for the physical restraint and not the emergency medications on 10/28/2021. A review of the restraint log dated 12/01/2022 through 1/05/2023 did not reveal any patients receiving emergency medications for a behavior emergency.

A review of the facility policy titled, "Restraint/Seclusion procedure for violent or self-destructive behavior and for non-violent or non-self destructive behavior" with a last review date of 3/2021 was as follows:

" ...Definitions:
Chemical Restraint: The use of any chemical, including pharmaceuticals, through topical application, oral administration, injection, or other means, for purposes of restraining an individual and which is not a standard treatment for the individual's medical or psychiatric condition ...
Emergency Medication: A psychoactive medication that is used to treat the signs and symptoms of mental illness in a psychiatric emergency, as that term is defined in Chapter 415, Subchapter A of this title (relating to prescribing psychoactive medication) when other interventions are ineffective or inappropriate ...
Restraint: The use of any personal restraint or mechanical restraint that immobilizes or reduces the ability of the individual to move his or her arms, legs, body, or head freely ...
Prohibited Practices:
...7. Use of chemical restraint is prohibited ..."

Staff #1 and Staff #7 confirmed this policy was not followed by the staff when administering emergency medications to a patient for a behavioral emergency. The facility did not recognize psychotropic medications administered IM or IV for a behavior emergency met the definition of a chemical restraint.

A review of the facility policy titled, "Medication Monitoring" with a review date of 2/2022 was as follows:

" ...POLICY: It is the policy of __________(name of facility) Nursing services to ensure that all medications administered are monitored for patient response., side effects, and adverse drug reactions. The Registered Nurse assigned to the patient's care will disc

Based on record review and interview the facility failed to ensure a 1-hour Face to Face Evaluation was completed by a Physician or a Registered Nurse in 5 (Patient #1, #2, #3, #4, and #5) of 5 medical records reviewed.

Findings:

Medical record reviews were completed with Staff #1 and Staff #7 on 1/09/2023.


Patient #1
A review of the Psychiatric Evaluation revealed Patient #1 was a 44-year-old white female admitted to the facility on 10/25/2021 with a diagnosis of Bipolar Mania with psychosis. She was brought in by the police department on an Emergency Detention Order

Review of Patient #1's medical record revealed a Chemical Restraint/Emergency Behavioral Medication (EBM) was administered on 10/31/2021 and 11/13/2021.


10/31/2021
A review of a document titled. "Intervention Progress Note" dated 10/31/2021 at 1:06 PM by the RN was as follows:

" ...Precursor Behaviors/Events: Environment was crowded, Environment was loud, Intrusive or disruptive behavior, On 1-1 or 2-1 supervision, pacing/rocking/other agitated bhvr.

Intervention Event Description:
Event Type: Emergency Meds
Start Date & Time: 10/31/2021 12:40 PM
Reason for Intervention: Imminent risk of violence-staff
Medication Detail: Benadryl Injection IM (intramuscular), Haldol (antipsychotic medication) Injection IM
Response to Meds: Resisted-effective ...

A review of Physician #12's medication order on 10/31/2021 at 12:30 PM read, " ...Haldol 10 mg IM Injection Stat (NOW) and Benadryl 50 mg IM Injection Stat (NOW), Reason: Agitation-disrupting unit and threatening staff.

A review of the MAR (Medication Administration Record) revealed the medication was administered by the nurse on 10/31/2021 at 12:40 PM and a follow up note documented on the MAR on 10/31/2021 at 1:43 that read "No adverse reaction."

Staff #7 confirmed the medications Haldol and Benadryl were administered IM by the nurse for a behavior emergency.

Staff #1 and #7 confirmed there was no 1-hour Face to Face documented by the physician or the nurse in the medical record of Patient #1 for the chemical restraint administered on 10/31/2021.

11/13/2021

A review of a document titled. "Intervention Progress Note" dated 11/13/2021 at 7:40 AM by the RN was as follows:

" ...Precursor Behaviors/Events: Environment was crowded, Environment was loud, Intrusive or disruptive behavior, pacing/rocking/other agitated bhvr, refused routine psychoactive medications, refuses to move or leave an area.

Intervention Event Description:
Event Type: Emergency Meds
Start Date & Time: 11/13/2021 7:40 AM
Reason for Intervention: Agitation (meds only)
Medication Detail: Ativan (antianxiety medication) Injection IM, Benadryl Injection IM, Haldol Injection IM

Description of Episode: Emergency medication detail: Physician #23 called with order to administer Ativan 2 mg IM, Benadryl 50 mg IM, and Haldol 10 mg IM. Patient lowered her pants immediately exposing self and stated that she would take the shots using profanity. LVN administered medications at 7:40 AM to bilateral gluteus ..."

A review of Physician #23's medication order on 11/13/2021 at 7:30 AM read, "Haldol 10 mg IM Injection Stat (NOW) and Benadryl 50 mg IM Injection Stat (NOW) Ativan 2mg IM Injection STAT (NOW), Reason: Agitation-threatening staff."

Staff #7 confirmed the medications Haldol, Benadryl, and Ativan were administered IM by the nurse for a behavior emergency.

Staff #1 and #7 confirmed there was no 1-hour Face to Face documented by the physician or the nurse in the medical record of Patient #1 for the chemical restraint administered on 11/13/2021.


Patient #2
A review of the Psychiatric Evaluation dated 1/06/2023 by Physician #3 revealed Patient #2 was a 61-year-old white female who was admitted to the facility on 1/06/2023 with a diagnosis of schizoaffective disorder. Patient #2 was brought in on an Emergency Detention Order and apparently, she was running in front of a school bus, made threats to the neighbors, destroys others property, growling at the neighbors, and speaking in word salad, psychotic, and erratic.

A review of a document titled. "Intervention Progress Note" dated 1/08/2023 at 7:05 PM by RN (Registered Nurse) #11 was as follows:

" ...Precursor Behaviors/Events: Intrusive or disruptive behavior, On 1-1 or 2-1 supervision

Intervention Event Description: Event Type: Emergency Meds
Start Date & Time: 1/08/23 06:40 PM
Reason for Intervention: Imminent risk of violence-other
Medication Detail: Benadryl 25mg IM, Haldol 10mg IM

Event Summary: Precipitating Behavior: Patient was being intrusive, getting into peoples faces, challenging them to a fist fight. She actually assaulted one patient and swung her fists at staff.

Description of Episode: Patient was administered Benadryl 25mg IM and Haldol 10 mg IM into left deltoid muscle per patient request..."

A review of Physician #12's medication order on 1/08/2023 at 6:39 PM read, "Haldol 10 mg Injection Stat (NOW) and Benadryl 25 mg Injection Stat (NOW), Reason: Aggression-Patient is punching/attacking peers and swinging at staff."

A review of the MAR revealed the medication was administered by the nurse on 1/08/2023 at 6:47 PM and a follow up note documented on the MAR on 1/08/2023 at 7:46 PM that read "Pt. improved/improving."

Staff #7 confirmed the medications Haldol, Benadryl, and Ativan were administered IM by the nurse for an emergency behavior.

Staff #1 and #7 confirmed there was no 1-hour Face to Face documented by the physician or the nurse in the medical record of Patient #2 for the chemical restraint administered on 1/08/2023.

Patient #3
A review of the Psychiatric Evaluation by Physician #13 revealed Patient #3 was a 36-year-old white male admitted to the facility on 12/14/2022 with a diagnosis of Schizoaffective Disorder, bipolar type. He had a history of schizoaffective disorder, bipolar type, cannabis use disorder, alcohol use disorder, nicotine use disorder who presented as a walk in with his brother.

A review of a document titled. "Intervention Progress Note" dated 12/15/2022 at 12:21 PM by RN was as follows:

" ...Precursor Behaviors/Events: Angry that request was no granted, Argument/threat turned to phy (sic) aggression, Intrusive or disruptive behavior.

Intervention Event Description: Event Type: Emergency Meds
Start Date & Time: 12/15/22 11:07 AM
Reason for Intervention: Self injurious behavior
Medication Detail: Ativan (antianxiety medication) IM Injection, Benadryl IM Injection and Haldol Injection, IM
Event Summary: Precipitating Behavior: Patient threatening staff, banging on back door and responding to internal stimuli. ..."

A review of the Physician's medication order on 12/15/2022 at 10:55 AM read, "Haldol 10 mg Intramuscular solution Stat (NOW), Benadryl 50 mg Intramuscular solution Stat (NOW), and Ativan 2mg Intramuscular solution STAT (now). Reason: Aggression-Patient threatening staff and slamming self in the door."

A review of the MAR revealed the medication was administered by the nurse on 12/15/2022 at 11:07 AM and a follow up note documented on the MAR on 12/15/2022 at 12:09 PM that read "No adverse reaction."

Staff #7 confirmed the medications Haldol, Benadryl, and Ativan were administered by the nurse for an emergency behavior.

Staff #1 and #7 confirmed there was no 1-hour Face to Face documented by the physician or the nurse in the medical record of Patient #3 for the chemical restraint administered on 12/15/2022.

Patient #4
A review of the Psychiatric Evaluation revealed Patient #4 was admitted to the facility 0n 12/06/2022 as a Forensic patient form the County Jail with a diagnosis of schizoaffective disorder, depressed type.

A review of a document titled. "Intervention Progress Note" dated 12/28/2022 at 12:08 PM by RN #14 was as follows:
" ...Precursor Behaviors/Events: Environment was loud, Intrusive and disruptive behavior, refuses to move or leave an area, responding to internal stimuli, and self-conversing, delusional/oth(sic) verbal symp (sic)

Was Medication Administered During the Restraint/Seclusion (see MAR for Details): Yes

Intervention Event Description: Event Type: Emergency Meds
Start Date & Time: 12/28/22 12:05 PM
Reason for Intervention: Imminent risk of violence-staff
Medication Detail: Ativan Injection IM, Thorazine (antipsychotic medication) Inj IM
Event Summary: Precipitating Behavior: Patient was constantly targeting and throwing property at staff ..."

A review of the Physician's medication order on 12/28/2022 at 11:50 AM read, " ...Thorazine 200 mg Intramuscular solution STAT (NOW) and Ativan 2mg Intramuscular solution STAT (now). Reason: Agitation: Patient physically aggressive towards staff and peer..."

A review of the MAR revealed the medication was administered by the nurse on 12/2/2022 at 12:05 PM and a follow up note documented on the MAR on 12/28/2022 at 1:06 PM that read "No adverse reaction."

Staff #7 confirmed the medications Thorazine and Ativan were administered IM by the nurse for a behavior emergency.

Staff #1 and #7 confirmed there was no 1-hour Face to Face documented by the physician or the nurse in the medical record of Patient #4 for the chemical restraint administered on 12/28/2022.

Patient #5
A review of the Psychiatric Evaluation dated 12/11/2021 revealed Patient #5 was a 52-year-old male who was admitted to the facility on 12/11/2022 with a diagnosis of Bipolar Disorder Type 1 with severe psychosis. He was brought to the facility by the police department on a warrantless detention for suicidal and homicidal thoughts.

Review of Patient #5's medical record revealed a Chemical Restraint/Emergency Behavioral Medication (EBM) was administered on 12/15/2022 and 12/21/2022.

12/15/2022
A review of a document titled. "Intervention Progress Note" dated 12/15/2022 at 11:58 AM by the nurse was as follows:

" ...Precursor Behaviors/Events: Environment was loud, Intrusive and disruptive behavior, Pacing/rocking/other agitated motor bhvr (sic), Responding to Internal stimuli.

Intervention Event Description: Event Type: Emergency Meds
Start Date & Time: 12/15/2022 at 11:35 AM
Reason for Intervention: Agitation (meds only)
Medication Detail: Ativan Injection IM, Benadryl Injection IM, Haldol Injection IM
Event Summary: Precipitating Behavior: Environment was extremely loud, and pt appeared to be struggling to adapt to this environment, and stated, "I am having a panic attack."
Emergency Medication Detail: Haldol 10 mg, Benadryl 50mg, and Ativan 2 mg IM stat in bilateral upper lateral ventral gluteal muscles at 11:35 AM. Patient accepted these medications without incident ..."

A review of the Physician's medication order on 12/15/2022 at 11:28 AM read, "Benadryl Injection 50 mg Intramuscular STAT (NOW), Haldol 10mg Injection Intramuscular STAT (NOW), and Ativan 2mg Intramuscular solution STAT (now). Reason: Aggression: Patient physically threatening staff and hitting doors."

A review of the MAR revealed the medication was administered by the nurse on 12/15/2022 at 11:35 AM and a follow up note documented on the MAR on 12/15/2022 at 12:35 PM that read, "Pt improved/improving, no adverse reaction."

Staff #7 confirmed the medications Haldol and Ativan were administered IM by the nurse for a behavior emergency.

Staff #1 and #7 confirmed there was no 1-hour Face to Face documented by the physician or the nurse in the medical record of Patient #4 for the chemical restraint administered on 12/15/2022.

12/21/2022
A review of a document titled. "Intervention Progress Note" dated 12/21/2022 at 10:38 AM by RN #14 was as follows:

" ...Precursor Behaviors/Events: Argument/threat turned to phy (sic) aggression, Environment was loud, Intrusive and disruptive behavior, Pacing/rocking/other agitated motor bhvr (sic), Refuses to move or leave an area, Responding to Internal stimuli, self-injurious behavior or threats.

Intervention Event Description: Event Type: Emergency Meds for self injurious behavior
Start Date & Time: 12/21/22 09:28 AM
Reason for Intervention: Self injurious behavior
Medication Detail: Ativan Injection IM, Benadryl Inj IM, Haldol Injection IM
Event Summary: Patient was yelling and running around the unit banging on doors and attempting to jump over the chairs on the lobby ..."

A review of Physician #24's medication order on 12/21/2022 read, "9:00 AM- Ativan 2mg Oral Tab STAT (now) Reason: Aggressive behavior-fighting with patient(s) Patient is agitated, intrusive to peers, hitting on doors, disruptive and difficult to redirect, and Haldol 10mg Injection Intramuscular STAT (NOW) Reason: Patient physically threatening staff and hitting doors."

An order by Physician # 24 at 9:47 AM- read, "Benadryl Injection 50 mg Intramuscular STAT (NOW) Reason: Patient physically threatening staff and hitting doors."

A review of the computerized MAR (Medication Administration Record) did not reveal a time the IM medications of Benadryl and Haldol were administered nor did it reveal a time the Ativan Tablet was administered. No paper/handwritten MAR was presented for review.

A review of the Intervention Progress Note documented by the RN was as follows:
" ...Intervention Event Description
Event Type: Emergency Meds
Start Date & Time: 12/21/22 09:28 AM
Reason for Intervention: Self Injurious Behavior
Medication Detail: Ativan Injection IM, Benadryl Inj, IM, Haldol Injection, IM ..."

The RN documented on the Intervention Progress Note dated 12/21/2022 that Haldol 10 mg IM, Benadryl 50 mg IM, and Ativan 2 mg IM were administered at 9:28 AM on 12/21/2022.

Staff #25 confirmed there was no order for Ativan IM only an order for Ativan PO (by mouth) and the IM Benadryl Injection administered at 9:28 AM was not ordered until 9:47 AM.


Staff #7 confirmed the medications Haldol, Benadryl, and Ativan were administered IM by the nurse for a behavior emergency.

Staff #1 and #7 confirmed there was no 1-hour Face to Face documented by the physician or the nurse in the medical record of Patient #5 for the chemical restraint administered on 12/21/2022.


A review of the facility policy titled, "Restraint/Seclusion procedure for violent or self-destructive behavior and for non-violent or non-self-destructive behavior" with a last review date of 3/2021 was as follows:

" ...Definitions:
Chemical Restraint: The use of any chemical, including pharmaceuticals, through topical application, oral administration, injection, or other means, for purposes of restraining an individual and which is not a standard treatment for the individual's medical or psychiatric condition ...
Emergency Medication: A psychoactive medication that is used to treat the signs and symptoms of mental illness in a psychiatric emergency, as that term is defined in Chapter 415, Subchapter A of this title (relating to prescribing psychoactive medication) when other interventions are ineffective or inappropriate ...
Restraint: The use of any personal restraint or mechanical restraint that immobilizes or reduces the ability of the individual to move his or her arms, legs, body, or head freely ...
Prohibited Practices:
...7. Use of chemical restraint is prohibited
...
PROCEDURES
1. RESTRAINT AND SECLUSION OR SELF-DESTRUCTIVE BEHAVIOR
...
E. Physician Responsibility:
...5. The ordering physician must perform a face-to-face assessment of the patient within 1 hour of initiation of all personal and mechanical restraints/seclusions to personally verify the need and to approve continuation, if indicated. This face-to-face assessment must be immediately documented in the medical record with the following components:
a. Date/Time the face-to-face assessment occurred
b. Individual's current status and review of incident
c. Individual's reaction to the restraint or seclusion
d. Individual's medical and behavioral condition
e. The need to continue or terminate the restraint or seclusion
f. Authentication/Signature ..."

An interview was conducted with Staff #1 in the afternoon on 1/09/2023. Staff #1 was asked if the physician or the nurse does a 1-hour face-to-face assessment of a patient after they were placed in a mechanical restraint or received a chemical restraint. Staff #1 stated, "Our physicians are the only ones that complete the face-to-face assessments. We do not have any of our nurses doing this. The physicians complete them on the mechanical or physical restraints, but we do not do them for chemical restraints. Our policy and the State of Texas do not allow us to administer chemical restraints." Staff #1 was then asked if there was a face-to-face completed after the IM or IV administration of emergency medications for a behavioral emergency. Staff #1 replied there was not a face-to-face completed and the nurses document the effectiveness of the medication on the MAR if it is ordered as a STAT (NOW) dose for behavior interventions.

Staff #1 and Staff #7 confirmed this policy for Restraint and Seclusion was not followed by the staff when administering emergency medications to a patient for a behavioral emergency. The facility did not recognize psychotropic medications administered IM or IV for a behavior emergency met the definition of a chemical restraint.