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Based on a review of medical records, policies and procedures, observations, and staff interviews, it was determined that the facility failed to promote and protect the rights of one patient (P) #3 out of five sampled patients. Specifically, P#3's rights were violated when the facility failed to obtain informed consent and notify P#3's legal guardian on 9/15/23 when physical intervention occurred and medication was administered.


Cross refer to A-0131 as it relates to the facility's failure to obtain informed consent and notify the legal guardian of an incident that involved the use of physical intervention and administration of medication to one patient (P#3) out of five sampled patients.

Based on a review of medical records, video recording, policies and procedures, and staff interviews, it was determined that the facility failed to obtain informed consent and notify the legal guardian of an incident that involved the use of physical intervention and administration of medication to one patient (P)#3 out of five sampled patients (P#1, P#2, P#4, and P#5).


Findings:

A review of Patient (P)#3's medical record (MR) revealed that P#3 was admitted via 1013 (involuntarily) on 9/9/23 at 2:24 p.m. with a diagnosis of major depressive disorder without psychosis (a mood disturbance). P#3 had a past medical history of depression.

A review of the nursing notes documented by Registered Nurse (RN) AA dated 9/15/23 at 5:14 a.m. revealed that P#3 refused to comply with the staff's instructions. P#3 became aggressive towards staff and was medicated. Further review of the nursing notes revealed that P#3 was administered PRN (as needed) medications, Zyprexa (an antipsychotic medication used to treat severe mental disorders like schizophrenia- a disorder that affects a person's ability to think, feel, and behave clearly) and Benadryl (a medication that helps with feelings of anxiety).

A review of MR revealed that P#3 was discharged home with his mother on 9/16/23.

A review of the MR failed to reveal any detailed documentation of the incident that occured on 9/14/23.

A review of video footage dated 9/14/23 revealed the following:
20:36:30 - P#3 was observed standing with Mental Health Technician (MHT) FF and MHT JJ close to the nurse's station.

20:37:50 - P#3 was observed stepping away slightly from the nurse's station but still standing close by. MHT FF, MHT JJ, and MHT MM were all seen standing at the nurse's station and talking to another patient and staff.

20:39:16 - Another patient threw an object at a staff member while the staff was walking away. As the staff turned back around, the patient picked up a chair and threw it at the same staff. The MHTs immediately restrained the patient for the staff's and patient's safety. P#3 was observed standing close to the nurse's station during this incident.

20:41:20 - P#3 was seen walking from the nurse's station towards his room.

20:41:25 - RN KK was observed talking to P#3 as P#3 was walking away and smiling.

20:41:27 - RN AA was seen pointing at P#3 while MHT JJ appeared to be gesturing to P#3 to return to the nurses' station.

20:41:53 - MHT JJ was observed holding P#3 by the arms, and as P#3 struggled to escape from MHT JJ's grip. MHT FF stepped in, got hold of P#3, and threw P#3 onto the floor.

20:41:59 - MHT JJ and MHT MM joined MHT FF to hold down P#3 while he was still on the floor as RN AA administered P#3 an injection.

20:42:20 - MHT FF and MHT MM slowly released their hold on P#3 while MHT JJ was still holding onto P#3's right shoulder with both hands and observed to be talking to P#3.

20:42:30 - RN AA was observed holding another injection to administer to P#3, and P#3 was seen struggling to get away. MHT FF, MHT JJ, MHT MM, RN KK, and RN NN were observed holding onto P#3 to keep P#3 still for RN AA to administer the injection.

20:42:58 - The injection was administered, and all the staff let go of their grip on P#3 while P#3 sat on the floor.

20:44:18 - P#3 was observed expressing himself to the staff and walking towards RN AA.

20:44:35 - MHT FF grabbed P#3's shoulders and threw P#3 onto the floor as MHT JJ stepped in to hold onto P#3.

20:45:42 - P#3 was seen being taken away from the nurse's station by MHT FF, MHT JJ, and MHT MM.

20:57:00 - P#3 was seen walking with RN NN alongside another staff member, and P#3 sat down at the nurse's station.

20:58:35 - P#3 was still seated at the nurses' station and was offered a cup of water by the staff.

21:03:09 - P#3 was observed leaving the nurse's station and walking to his room.

A review of the facility's "Patient Rights policy," Policy #12, last revised 1/2023, stated that the policy of the facility was to abide by and respect all patient rights without regard to race, religion, creed, ethnicity, gender, age, sexual orientation, or handicap, and would support and protect the fundamental human, civil, constitutional and statutory rights of the individual patient recognizing and respecting personal dignity of the patient at all times.

A review of the facility's "Administration of Psychotropic Medication Against the Patient's Will in Emergency Situations policy" Policy #7, last reviewed 1/2023, stated that if an adult recipient of services, or if the recipient is under guardianship, the recipient's guardian should be given the opportunity to refuse generally accepted mental health services or medication. If such services were refused, they should not be given unless such services were necessary to prevent the recipient from causing serious and imminent physical harm to themselves or others. The facility's director should inform a recipient or guardian who refused such services of alternate services available and the risks of such alternate services as well as possible consequences to the recipient of refusal of such services.

A review of the facility's "Restraint and/or Seclusion policy," Policy #137, last revised 1/2023, stated that the facility was committed to preventing, reducing, and eliminating the use of physical and chemical restraint and seclusion in the care of the patients. At the same time, the facility recognized that restraint and/or seclusion may be required in emergent situations in which there was an imminent risk of a patient physically harming him/herself or others. When such emergencies appear imminent, therapeutic, non-physical interventions were always preferred; however, if restraint or seclusion is deemed clinically necessary, these procedures were to be carried out in a way that respected the dignity, privacy, and safety of each patient, conformed in every respect to the policies and procedures described in this document and ensured that these measures were discontinued as soon as clinically indicated.

A telephone interview took place in the conference room on 10/3/23 at 9:30 a.m. with RN AA. She stated that she had to medicate P#3 because he was uncooperative and refused to go to bed after several attempts. RN AA said that the unit was a bit disruptive as one of the patients had injured one of the staff, and P#3 was encouraging other patients due to his refusal to go to bed, leading to the unit becoming more disruptive. RN AA stated that she initially tried verbal de-escalation with P#3 as per policy. Still, it was ineffective, and she had to prioritize her staff and maintain safety. RN AA stated that she failed to notify P#3's parent about the incident and that she takes full responsibility for that.

An interview took place in the conference room on 10/3/23 at 10:30 a.m. with the Psychiatric-Mental Health Nurse Practitioner (PMHNP) BB, who stated that the psychiatrist could order or prescribe a PRN medication if the patient was psychotic, aggressive, and had behavioral issues that could be a danger to self, the other patients, or staff. PMHNP BB further stated that patients should not be given PRN medications because they are not cooperative unless they become aggressive. A parent/legal guardian should be called for notification/update.

An interview took place in the conference room on 10/3/23 at 10:50 a.m. with Psychiatrist (PSY) CC, who stated that he could recall that P#3 was depressed, had suicidal thoughts, and was isolated. PSY CC said that he last saw P#3 on 9/14/23 and could not recall having any report of P#3 being aggressive.
PSY CC stated that when he got a call from Social Worker (SW) II and was informed that P#3 had received a PRN medication, he was in disbelief because he never expected that P#3 could be that aggressive. PSY CC further stated that chemical restraint should only use if a patient was a danger to themselves, another patient, or staff, or if the patient became psychotic and started threatening or throwing things.

An interview took place in the conference room on 10/3/23 at 12:20 p.m. with SW II, who stated that she usually communicated with parents two or three times during the patient's admission to give updates and notify parents of the discharge date. SW II said that when she called P#3's parent to inform her of the discharge date for P#3, she (SW II) did not have the details of the incident as she was not on duty. SW II expected that the nurses should have updated the parent.

Based on a review of medical records, policies and procedures, observations, and staff interviews, it was determined that the facility failed to provide adequate nursing services when one patient (P) #3 out of five sampled patients was not assessed for injuries and reassessed for pain after an incident involving physical intervention/restraints.

Cross refer to A-0392 as it relates to the facility's failure to assess for injuries or perform a pain reassessment after one patient (P#3) out of five sampled patients was involved in a physical intervention/restraint.

Based on a review of medical records, video recording, policy and procedure, and staff interviews, it was determined that the facility failed to provide an ongoing assessment of one patient (P) #3 out of five sampled patients (P#1, P#2, P#4, and P#5) to determine if there was any physical injuries or pain after an incident involving the use of physical intervention/restraint.
Findings:

A review of Patient (P)#3's medical record revealed that P#3 was admitted via 1013 (involuntarily) on 9/9/23 at 2:24 p.m. with a diagnosis of major depressive disorder without psychosis (a mood disturbance). P#3 had a past medical history of depression.

A review of the nursing documentation by Registered Nurse (RN) AA dated 9/15/23 at 5:14 a.m. revealed that P#3 refused to comply with the staff's instructions. P#3 became aggressive towards staff and was medicated.
Further review of the nursing documentation revealed that P#3 was administered PRN (as needed) medications, Zyprexa (an antipsychotic medication used to treat severe mental disorders like schizophrenia- a disorder that affects a person's ability to think, feel, and behave clearly) and Benadryl (a medication that helps with feelings of anxiety).

A review of nursing documentation dated 9/15/23 at 10:00 a.m. revealed that P#3 had a pain score of seven (7) with shoulder and back pain complaints. Further review revealed that P#3 interacted with peers but appeared anxious and annoyed at the events of yesterday.

Documentation from the Medication Administration Record revealed that Tylenol (pain medication) was administered to P#3 on 9/15/23 at 10:49 a.m.

A review of P#3's medical record failed to reveal documentation of any physical (head-to-toe) assessment to check for injuries or bruises.

Futher review of the MR failed to reveal detailed documenattion of the incident that occured on 9/14/23.

P#3 was discharged home with his mother on 9/16/23.

A review of an Urgent Care Report revealed that P#3 visited the urgent care center on 9/16/23 at 12:45 p.m. and was diagnosed with acute pain in the left shoulder and injury of the left hip. P#3 had an X-ray (procedure to check for fractures/dislocation), which was negative for fracture and dislocation. P#3 was discharged home from the urgent care center in stable condition at 1:50 p.m. with a final diagnosis of Shoulder Injury/Pain and Hip Injury/Pain (Sprain/Strain) and a prescription for Ibuprofen.

A review of video footage dated 9/14/23 revealed the following:
20:36:30 - P#3 was observed standing with Mental Health Technician (MHT) FF and MHT JJ close to the nurse's station.

20:37:50 - P#3 was observed stepping away slightly from the nurse's station but standing nearby. MHT FF, MHT JJ, and MHT MM were all seen standing at the nurse's station and talking to another patient and staff.

20:39:16 - Another patient threw an object at a staff member while the staff was walking away. As the staff turned back around, the patient picked up a chair and threw it at the same staff. The MHTs immediately restrained the patient for the staff's and patient's safety. P#3 was observed standing close to the nurse's station during this incident.

20:41:20 - P#3 was seen walking from the nurse's station towards his room.

20:41:25 - RN KK was observed talking to P#3 as P#3 was walking away and smiling.

20:41:27 - RN AA was seen pointing at P#3 while MHT JJ appeared to be gesturing to P#3 to return to the nurses' station.

20:41:53 - MHT JJ was observed holding P#3 by the arms, and as P#3 struggled to escape from MHT JJ's grip. MHT FF stepped in, got hold of P#3, and threw P#3 onto the floor.

20:41:59 - MHT JJ and MHT MM joined MHT FF to hold down P#3 while he was still on the floor as RN AA administered P#3 an injection.

20:42:20 - MHT FF and MHT MM slowly released their hold on P#3 while MHT JJ was still holding onto P#3's right shoulder with both hands and observed to be talking to P#3.

20:42:30 - RN AA was observed holding another injection to administer to P#3, and P#3 was seen struggling to get away. MHT FF, MHT JJ, MHT MM, RN KK, and RN NN were observed holding onto P#3 to keep P#3 still for RN AA to administer the injection.

20:42:58 - The injection was administered, and all the staff let go of their grip on P#3 while P#3 sat on the floor.
20:44:18 - P#3 was observed expressing himself to the staff and walking towards RN AA.

20:44:35 - MHT FF grabbed P#3's shoulders and threw P#3 onto the floor as MHT JJ stepped in to hold onto P#3.

20:45:42 - P#3 was seen being taken away from the nurse's station by MHT FF, MHT JJ, and MHT MM.

20:57:00 - P#3 was seen walking with RN NN alongside another staff member, and P#3 sat down at the nurse's station.

20:58:35 - P#3 was still seated at the nurses' station and was offered a cup of water by the staff.

21:03:09 - P#3 was observed leaving the nurse's station and walking to his room.


A review of the facility's policy titled "Assessments Policy," policy #16, last revised 1/2023, revealed that patients would be reassessed when a significant change occurred in their condition and in an ongoing manner to determine their response to treatment.


An interview took place in the conference room on 10/3/23 at 11:00 a.m. with the Director of Risk Management and Safety (DRM) DD, who stated that she watched the incident on a video, and she could observe that P#3 was aggressive, which was why he had to be medicated. DRM DD also stated that patients are not usually assessed after an incident where physical/manual intervention had to be used as a technique for de-escalation and behavior management unless the patient complained.


An interview took place in the conference room on 10/3/23 at 11:20 a.m. with Assistant Chief Nursing Officer (ACNO) EE, who stated that nurses should assess a patient after any physical hold/restraint to ensure the patient did not sustain any bruises or injuries.