HospitalInspections.org

Based on record review and interview, nursing failed to follow its own policy and procedures to update the treatment plan after the application of a physical hold or administration of a chemical restraint. The treatment plan failed to reveal the restraint, assessments, treatment, interventions, or goals in 3(Patient #10, 19 and 20) of 3 patient charts reviewed.

Patient #20
Review of patient #20's chart revealed a physician order in the seclusion and restraint package. The order was dated 5/17/21 at 1400 (2:00PM). The order was for a manual hold of the patient due to "Violent self-destructive behavior to self" but there was no description of those behaviors on the order set.

Review of the Manual hold assessment by RN dated 5/17/21 stated the hold was initiated at 1350 (1:50PM).
The nurse documented the hold was due to "Violent self-destructive behavior to self" but there was no description of those behaviors.

Under Medication Administered During Restrictive Intervention the nurse documented, "Zyprexa 5 mg IM was administered at 1400 (2:00PM)", due to "aggression." There was no documentation of what staff members were involved during the restraint process and what staff member was holding the patient.

Review of POLICY AND PROCEDURE: 1000.37 Restraints and Seclusion stated, "Page 9, d. If physical restraint is indicated, 2 staff must participate in the physical hold application. If the physical restraint/hold is on a small statured patient, one staff may implement the hold (e.g. Modified PRT for very small children) while a second staff serves as a witness to monitor patient and staff safety for the duration of the hold."

Review of the restraint and seclusion monitoring sheet dated 5/17/21 revealed the observation started at 1350 (1:50PM) Patient #20 was "agitated, crying, and harm to self/others." Under nutrition and hydration section the nurse documented "other" with no explanation. In comments the nurse documented, "pt. became agitated in day room. Manual hold for 20 minutes. The nurse documented at 1400 (2:00PM) that patient #20 was still "agitated, crying, and harm to self/others." In comments the nurse documented, "Zyprexa 5 mg IM given to rt deltoid." The nurse documented at 1410 (2:10PM) that patient #20 was "oriented, cooperative and could perform self-care. Pt became calm and manual hold discontinued." Review of the chart revealed there was no further documented nursing observation of any vital signs, effectiveness of medication after hold release, behaviors, or general nursing care until 5/18/21 at 1:24AM; 11.5 hours later.

Review of POLICY AND PROCEDURE: 1000.37 Restraints and Seclusion stated, "Page 17, 9. Following the use of a restraint or seclusion a staff shall continue monitoring the patient for a minimum of thirty (30) minutes or as clinically indicated."

Review of patient #20's chart and restraint and seclusion packet dated 5/17/21 revealed there was no debriefing of patient or staff. The form for patient debriefing was marked through and stated, "n/a". There was no staff signatures date or time.

Review of POLICY AND PROCEDURE: 1000.37 Restraints and Seclusion stated, "Page 17, 1. 1. The use of restraint techniques or seclusion shall be discussed with all staff involved in the emergency safety intervention and the patient participates in a face-to-face discussion. This shall occur within the shift when the restraint or seclusion occurred but if the patient is unwilling, the facility has up to 24 hours to complete the debriefing.
2. This discussion may also include other staff and the patient's parent(s)/legal guardian(s) when it is deemed appropriate. The discussion must be in a language which is understood by all parties. The discussion will include:
a. An opportunity for both the patient and staff to discuss the circumstances resulting in the use of the restraint or seclusion
b. Strategies to be used by the staff, the patient, or others which could prevent the future use of a restraint or seclusion.
c. Evaluate if the patient's physical well-being, psychological comfort and right to privacy were addressed.
d. The de-briefing form will be placed in patient's chart
e. Provide counseling to the patient for any trauma which may have resulted from the incident.
f. All staff involved will meet in a post-intervention conference (debriefing) to discuss the event and offer feedback to one another before the end of shift concerning events which took place and possible alternate methods which could be used to change behaviors. The administrative staff are included in the staff debriefing process.
g. Patients Treatment Plan will be updated after each restraint or seclusion event."

Review of the Treatment Plan revealed there was no updated nursing documentation concerning Patient #20's behavioral emergency, manual hold or administration of a chemical restraint on 5/17/21.

Patient #10

Review of the Nursing Progress note dated 5/15/21 at 9:01AM stated, "_____ (patient #10) was in her room. She came outside stating she needed to go to the hospital, stating very loud that she was bleeding to death. She had her right leg uncovered, with the bottom of her pants on the right leg pulled up, showing her right lower leg. She tried to be redirected by tech and quickly got agitated, soon after getting out of control, started yelling louder, screaming, started running through the hall, and getting more agitated, not following any redirection attempts, started trying to grab tech in a very agitated state, proceeding to restrain her. ____(Nurse Practitioner) NP was called by _____RN and notified and orders obtained for lorazepam 2mg IM, haldol 10mg IM and benadryl 50mg IM all administered to right deltoid in 2 different syringes, benadryl in one syringe, lorazepam and haldol on the other syringe. Patient was very agitated, yelling very loud, thrashing, having to be restrained for 25 minutes until she calmed down. She stayed in hall unrestrained with other techs until she completely settled and went by herself back to her room."

Review of patient #10's chart revealed a physician order in the seclusion and restraint package. The order was dated 5/15/21 at 8:41AM. The order was for a manual hold from 8:41AM until 9:04AM. The order was for "violent self- destructive behavior towards others" but there was no description on the order of those behaviors.

Review of the "Manual Hold Assessment by the RN" in the restraint package revealed on 5/15/21 that the hold was "Unsuccessful. Did not deescalate." The only interventions documented on the form for alternative interventions performed was verbal De-escalation. The nurse documented that Patient #10 was administered Haldol 10mg IM, Benadryl 50mg IM and Lorazepam 2 mg IM at 8:47AM. There was no medication order in the packet for a chemical restraint. A physician order was found on the medication orders for the chemical restraint as a now order at 8:41AM only one minute into the physical hold. There was no documentation noted in the chart that the nursing staff used any other less restrictive restraint. The staff failed to use the seclusion rooms before administering chemical restraints.

Review of the face to face dated 5/15/21 at 9:38AM stated the patient behaviors that justified the actions were "attempted to grab tech while in a very agitated state. Yelling and screaming, very agitated for 25 minutes." On the chemical restraint portion of the form, the nurse performing the face to face failed to document the Benadryl and stated the patient refused vital signs. The nurse documented that respiratory status was within normal limits but there were no respirations documented. Respirations can be observed and counted without touching the patient. The nurse documented the circulatory status was within normal limits but there were unchecked boxes on pulses present and no vital signs obtained. The nurse documented on the monitoring sheet at 8:38AM and again at 9:04AM. There was no documentation that Patient #10 was observed every 15 minutes for at least 30 minutes per policy.

Review of the Debriefing form revealed there was no information on what staff member was holding the patient. The nurse documented that Patient #10 was given Seroquel (Antipsychotic) by mouth 100mg. There was no documentation on any of the nursing assessments (in the restraint package) that Patient #10 was offered any medications prior to the hold or chemical restraint. Review of the Medication Administration Record (MAR) revealed Patient #10 was given Seroquel 100mg by mouth at 8:18AM. The nurse documented the response to the medication as "tolerated." The response to the medication was documented on 5/16/21 at 9:44AM, over 24 hours later.

Review of the Nursing Progress note dated 5/15/21 at 9:29AM stated, At approximately 0841 pt was in restraint due to physical aggression and verbal aggression towards self and staff. _____NP was made aware, ordered Ativan, Haldol, and Benadryl IM Stat. Medications were administered to _____ (Patient #10) right arm. Tolerated well. This nurse witnessed restraint. Pt was shouting stating staff was sex traffickers trying to abduct her, stated she had STD's and wanted to infect staff, and also attempted to hit and bite staff. PT is now calm and cooperative sitting in dayroom having breakfast Fluids were encouraged."

There was no further documentation on the effectiveness of the medications. There was no further documentation of patient observation by the nurse until 5/15/21 at 1646 (4:16PM). There were no vital signs documented on the patient. The only documentation that vital signs were attempted was on 5/16/21 at 7:37AM and the patient refused.
Review of every 15-minute check sheet reveled at 8:45AM the MHT had marked over a previous documented behavior code and location code of "awake and alert -courtyard" to "psychotic and hall." The MHT documented at 9:00AM that Patient #10 was calm and in her room.

Review of the Treatment Plan revealed there was no updated nursing documentation concerning Patient #10's behavioral emergency, manual hold or administration of a chemical restraint on 5/15/21.


Patient #19

Review of patient #19's nursing progress notes dated 5/9/2021 5:50AM stated, "5/9/2021 05:50 Pt displayed increased agitation. pt yelling, using threatening vulgar language and attempting to charge staff. Informed provider on call, order received for Benadryl 50mg IM, Ativan 2mg IM and Haldol 10mg IM. Informed pt of plan of care, pt accepted and received IM to left and right deltoid at 0550. pt tolerated procedure well. AOC made aware.

Review of patient #19's chart revealed there was a restraint and seclusion physician order in a packet dated 5/9/21 at 5:50AM. The order revealed the reason for emergency medication "pt. yelling, threatening staff, disrupting the milieu, pt. charging staff, pt.___ (illegible) property." The patient was ordered, "Haldol 10mg IM at 5:50AM, Ativan 2 mg IM at 5:50AM, and Benadryl 50mg IM at 5:50AM."

The face to face was written as performed on 5/9/21 at 6:30AM but there was no signature of who completed the face to face. No debriefing was included in the packet for patient or staff. There were no documented vital signs, effectiveness of medications, other than the face to face assessment completed at 6:30AM there was no further nursing assessment documented until 5/9/21 at 11:26AM.

Review of patient #19's nursing progress notes dated 5/9/2021 1346 (1:46PM) stated, Patient being aggressive and threatening staff and peers. Patient slamming and hitting door. Attempted to redirect patient but was unsuccessful. Received an order for thorazine 50 IM and benadryl 25 mg IM from Rosemary. Patient was injected at 1310. 1320 Patient is asleep and show no signs of distress. Respirations are even and unlabored.

Review of patient #19's chart revealed there was a restraint and seclusion packet. The physician order dated 5/9/21 at 1310 (1:10PM) stated, "Thorazine 50mg IM at 1310 (1:10PM) and Benadryl 25mg IM at 1310 (1:10PM)." The reason for the medication was checked as "Violent self-destructive behavior towards others. There was no description of that behavior. The chemical restraint was a verbal order given by a nurse practitioner. The physician order form was incomplete, and the following questions were left blank:
"Physician /provider ordering communicated with attending physician yes or no, attending physician/provider concurred with intervention? Complications with restrictive intervention yes or no." There was no documented evidence that the physician was notified in a timely manner.


Patient #5

Review of Patient #5's chart revealed he was admitted to the Palms facility on 1/27/21 with psychosis and unstable moods. Patient #5 was admitted as involuntary, suicide precautions, with every 15-minute checks. Patient #5 was admitted under an Emergency Detention Order (EDW) good for 72 hour hold and signed by the judge on 1/27/21.

Review of the intake assessment dated 1/27/21 stated, "Per collateral information from emergency detention, patient has been in psychotic state, knocking on neighbors' doors at night, and going to other family members' home unwanted and making them feel threatened. Per crisis screening, patient was presenting with word salad, not making sense, was not redirectable, and stated he has not slept in 8 days.
Observation - Patient is in state of agitation at time of arrival, presenting with rambling and word salad, insisting he be provided chocolate and that his right foot is broken even though he is ambulating without difficulty. Patient throws himself on floor stating he is having difficulty breathing.
Sexual Acting Out Behaviors, Medication Non-Compliance and Psychosis Patient is reported to be medication non-compliant, though medications and duration of non-compliance is unknown. Patient is reported by crisis screener to be disorganized and presenting with word salad when questions were being asked, making statements such as, "Third squad, utilities, Arkansas, Arkansas Pass, Blue Blue. Probation, parole, house arrest, do you have their number," and when conducting suicide risk assessment stating, "I got choked today, black boot, razaunida, captain. It's my white name, McCook, ozarka, Milwaukee's best, bunny rabbits, ABCDE, killer with a pitch fork." When asked if he uses synthetic cannabis, patient stated, "Oh people die from that shit. Omeprazole or protonix for the ulcers. International code, Freddy Fender did he die, call channel five." At time of arrival to PBH patient continued with rambling and word salad, demanding chocolates, stating his leg was broken in spite of ambulating without difficulty, stating he traveled to Switzerland, showing his pedicured toe nails, and while alone in assessment room was in agitated state and spitting multiple times on the table.

MODERATE - Per patient's sister, patient was posting on Face Book that he had sex with a 10-year-old niece. While family do not believe patient actually did this, and that this may be a product of his psychosis, risk level is identified as moderate due to risk factors outweighing protective factors. (Per crisis screen, report has been made to CPS regarding the information above, and Mission Police Department is investigating the possible crime).

Psychosis and History of Psychiatric Treatment
Patient has been admitted to inpatient psychiatric treatment multiple times for
psychosis: PBH 6/17/20 to 6/25/20, PBH 6/1/20 to 6/16/20, 3/6/20 to 4/3/20, STBH 4/2/18."


Review of the restraint and seclusion packet revealed a physician order dated 1/27/21 at 1815 (6:15PM). Review of the order revealed a box checked chemical restraint and written out to the side "PRN Meds." There was no order for the drugs on the order set but was found in the physician orders Haldol 10mg IM one time only for psychosis, Ativan 2 mg IM one time only for Agitated-self harming, and Benadryl 50mg IM one time only for EPS Prophylaxis. The medication was charted as administered at 18:15 (6:15PM). There was no found nursing documentation of the incident or observation found in the nursing progress notes or nursing physical assessment.

Review of the restraint and seclusion packet dated 1/27/21 at 1815 (6:15PM). Revealed there was no nursing assessment performed. The nurse marked through the note "N/A". The face to face section was incomplete. The nurse dated the form but marked through the whole front page as "N/A." The nurse documented "tolerated well" under patient response to emergency medication. There were no vital signs, observations, nursing assessment documented or what staff members were involved in the restraint process.

Review of the Nursing Progress note dated 1/27/21 at 21:41 (9:41PM) stated, "_____ (Pt. #5) presented with aggression/agitation and was not redirectable requiring IM medication for treatment of safety. 10mg Haldol, 2mg Ativan, 50mg Benadryl administered with positive effect. Will continue to monitor for safety."

Review of Patient #5's chart revealed the medications Haldol 10mg IM one time only for psychosis, Ativan 2 mg IM one time only for Agitated-self harming, and Benadryl 50mg IM one time only for EPS Prophylaxis were ordered again on 1/27/21 at 1902 (7:02PM) but not administered until 2119 (9:19PM). There was no documentation on why there was a delay in administering an emergency behavioral medication, if the behavior was still ongoing at time of administration, or any other alternatives used. There was no restraint packet in the chart for the administration of the Emergency behavioral medications. There was no way to determine if the patient was injured during the hold when there was no documentation on who was involved and how the restraint was administered.

There was no documentation on the patients Treatment Plan concerning the patient's behaviors, use of emergency behavioral medications or plan of care.

The face to face was performed on 5/9/21 at 1400(2:00PM). The nurse stated the patient was being aggressive and threatening towards staff and peers. Patient asleep. The nurse stated patient "refused" vital signs but documented pt "asleep." No vital signs were obtained. The nurse documented that the patient denied pain or discomfort but was documented as asleep. The nurse documented the circulatory status was in normal limits but did not check pulses or vital signs. There was no debriefing with staff or patient.

Review of the Treatment Plan revealed there was no updated nursing documentation concerning Patient #19's behavioral emergency or administration of a chemical restraint on 5/09/21 at 5/9/21 at 6:30AM and again on 1310 (1:10PM).

Based on record review and interview, the facility failed to

1. follow its own policy and procedures for the application of a physical hold or administration of a chemical restraint,

2. ensure that appropriate assessments were performed and the patients were monitored for at least 30 minutes,

3. ensure physician orders and the restraint packets were completed in 4 of 4( Patient #5, 20,10, and 19) charts reviewed.

Patient #20
Review of patient #20's chart revealed a physician order in the seclusion and restraint package. The order was dated 5/17/21 at 1400 (2:00PM). The order was for a manual hold of the patient due to "Violent self-destructive behavior to self" but there was no description of those behaviors on the order set.

Review of the Manual hold assessment by RN dated 5/17/21 stated the hold was initiated at 1350 (1:50PM). The nurse documented the hold was due to "Violent self-destructive behavior to self" but there was no description of those behaviors. There was no documentation of what staff members were involved during the restraint process and what staff member was holding the patient.

Under Medication Administered During Restrictive Intervention the nurse documented, "Zyprexa 5 mg IM was administered at 1400 (2:00PM)", due to "aggression."

Review of POLICY AND PROCEDURE: 1000.37 Restraints and Seclusion stated, "Page 9, d. If physical restraint is indicated, 2 staff must participate in the physical hold application. If the physical restraint/hold is on a small statured patient, one staff may implement the hold (e.g. Modified PRT for very small children) while a second staff serves as a witness to monitor patient and staff safety for the duration of the hold."

Review of the restraint and seclusion monitoring sheet dated 5/17/21 revealed the observation started at 1350 (1:50PM) Patient #20 was "agitated, crying, and harm to self/others." Under nutrition and hydration section the nurse documented "other" with no explanation. In comments the nurse documented, "pt. became agitated in day room. Manual hold for 20 minutes. The nurse documented at 1400 (2:00PM) that patient #20 was still "agitated, crying, and harm to self/others." In comments the nurse documented, "Zyprexa 5 mg IM given to rt deltoid." The nurse documented at 1410 (2:10PM) that patient #20 was "oriented, cooperative and could perform self-care. Pt became calm and manual hold discontinued." Review of the chart revealed there was no further documented nursing observation of any vital signs, effectiveness of medication after hold release, behaviors, or general nursing care until 5/18/21 at 1:24AM; 11.5 hours later.

Review of POLICY AND PROCEDURE: 1000.37 Restraints and Seclusion stated, "Page 17, 9. Following the use of a restraint or seclusion a staff shall continue monitoring the patient for a minimum of thirty (30) minutes or as clinically indicated."

Review of patient #20's chart and restraint and seclusion packet dated 5/17/21 revealed there was no debriefing of patient or staff. The form for patient debriefing was marked through and stated, "n/a". There was no staff signatures date or time.

Review of POLICY AND PROCEDURE: 1000.37 Restraints and Seclusion stated, "Page 17, 1. 1. The use of restraint techniques or seclusion shall be discussed with all staff involved in the emergency safety intervention and the patient participates in a face-to-face discussion. This shall occur within the shift when the restraint or seclusion occurred but if the patient is unwilling, the facility has up to 24 hours to complete the debriefing.

2. This discussion may also include other staff and the patient's parent(s)/legal guardian(s) when it is deemed appropriate. The discussion must be in a language which is understood by all parties. The discussion will include:
a. An opportunity for both the patient and staff to discuss the circumstances resulting in the use of the restraint or seclusion
b. Strategies to be used by the staff, the patient, or others which could prevent the future use of a restraint or seclusion.
c. Evaluate if the patient's physical well-being, psychological comfort and right to privacy were addressed.
d. The de-briefing form will be placed in patient's chart
e. Provide counseling to the patient for any trauma which may have resulted from the incident.
f. All staff involved will meet in a post-intervention conference (debriefing) to discuss the event and offer feedback to one another before the end of shift concerning events which took place and possible alternate methods which could be used to change behaviors. The administrative staff are included in the staff debriefing process.
g. Patients Treatment Plan will be updated after each restraint or seclusion event."

Review of the Treatment Plan revealed there was no updated nursing documentation concerning Patient #20's behavioral emergency, manual hold or administration of a chemical restraint on 5/17/20.

An interview was conducted with Staff #4 and #2 on the morning of 5/26/21. Staff #4 stated part of the corrective action from the previous citation was to monitor the restraint packages and charts. The monitoring would ensure the restraints were properly documented and performed. Staff #4 provided a restraint log and stated that the indicators that are being monitored were on the log and was being looked at by the quality department and nursing administration. Staff #2 stated that he had not been reviewing the restraint packets. Staff #2 stated that he had just been placed in the role of Director of Nursing a week ago.

Review of the restraint log and monitoring tool provided by Quality revealed Patient #20 was listed as having a manual hold and chemical restraint on 5/17/21. The monitoring tool stated patient #20 discussed feelings, problem solving was attempted with the patient, and patient #20 was on a 1:1 with staff. There was no physician order found or documentation that Patient #20 was on a 1:1. There was no debriefing in the restraint packet or any nursing notes after the restraint or medication administration concerning the patients restraint or medical condition until the morning of 5/18/21.


Patient #10
Review of the Nursing Progress note dated 5/15/21 at 9:01AM stated, "_____ (patient #10) was in her room. She came outside stating she needed to go to the hospital, stating very loud that she was bleeding to death. She had her right leg uncovered, with the bottom of her pants on the right leg pulled up, showing her right lower leg. She tried to be redirected by tech and quickly got agitated, soon after getting out of control, started yelling louder, screaming, started running through the hall, and getting more agitated, not following any redirection attempts, started trying to grab tech in a very agitated state, proceeding to restrain her. ____(Nurse Practitioner) NP was called by _____RN and notified and orders obtained for lorazepam 2mg IM, haldol 10mg IM and benadryl 50mg IM all administered to right deltoid in 2 different syringes, benadryl in one syringe, lorazepam and haldol on the other syringe. Patient was very agitated, yelling very loud, thrashing, having to be restrained for 25 minutes until she calmed down. She stayed in hall unrestrained with other techs until she completely settled and went by herself back to her room."

Review of patient #10's chart revealed a physician order in the seclusion and restraint package. The order was dated 5/15/21 at 8:41AM. The order was for a manual hold from 8:41AM until 9:04AM. The order was for "violent self- destructive behavior towards others" but there was no description on the order of those behaviors.

Review of the "Manual Hold Assessment by the RN" in the restraint package revealed on 5/15/21 that the hold was "Unsuccessful. Did not deescalate." The only interventions documented on the form for alternative interventions performed was verbal De-escalation. The nurse documented that Patient #10 was administered Haldol 10mg IM, Benadryl 50mg IM and Lorazepam 2 mg IM at 8:47AM. There was no medication order in the packet for a chemical restraint. A physician order was found on the medication orders for the chemical restraint as a now order at 8:41AM only one minute into the physical hold. There was no documentation noted in the chart that the nursing staff used any other less restrictive restraint. The staff failed to use the seclusion rooms before administering chemical restraints.

Review of the face to face dated 5/15/21 at 9:38AM stated the patient behaviors that justified the actions were "attempted to grab tech while in a very agitated state. Yelling and screaming, very agitated for 25 minutes." On the chemical restraint portion of the form, the nurse performing the face to face failed to document the Benadryl and stated the patient refused vital signs. The nurse documented that respiratory status was within normal limits but there were no respirations documented. Respirations can be observed and counted without touching the patient. The nurse documented the circulatory status was within normal limits but there were unchecked boxes on pulses present and no vital signs obtained. The nurse documented on the monitoring sheet at 8:38AM and again at 9:04AM. There was no documentation that Patient #10 was observed every 15 minutes for at least 30 minutes per policy.

Review of the debriefing form revealed there was no information on what staff member was holding the patient. The nurse documented that Patient #10 was given Seroquel (Antipsychotic) by mouth 100mg. There was no documentation on any of the nursing assessments (in the restraint package) that Patient #10 was offered any medications prior to the hold or chemical restraint. Review of the Medication Administration Record (MAR) revealed Patient #10 was given Seroquel 100mg by mouth at 8:18AM. The nurse documented the response to the medication as "tolerated." The response to the medication was documented on 5/16/21 at 9:44AM, over 24 hours later.

Review of the Nursing Progress note dated 5/15/21 at 9:29AM stated, At approximately 0841 pt was in restraint due to physical aggression and verbal aggression towards self and staff. _____NP was made aware, ordered Ativan, Haldol, and Benadryl IM Stat. Medications were administered to _____ (Patient #10) right arm. Tolerated well. This nurse witnessed restraint. Pt was shouting stating staff was sex traffickers trying to abduct her, stated she had STD's and wanted to infect staff, and also attempted to hit and bite staff. PT is now calm and cooperative sitting in dayroom having breakfast Fluids were encouraged."

There was no further documentation on the effectiveness of the medications. There was no further documentation of patient observation by the nurse until 5/15/21 at 1646 (4:16PM). There were no vital signs documented on the patient. The only documentation that vital signs were attempted was on 5/16/21 at 7:37AM and the patient refused.
Review of every 15-minute check sheet reveled at 8:45AM the MHT had marked over a previous documented behavior code and location code of "awake and alert -courtyard" to "psychotic and hall." The MHT documented at 9:00AM that Patient #10 was calm and in her room.


Patient #19
Review of patient #19's nursing progress notes dated 5/9/2021 5:50AM stated, "5/9/2021 05:50 Pt displayed increased agitation. pt yelling, using threating vulgar language and attempting to charge staff. Informed provider on call, order received for Benadryl 50mg IM, Ativan 2mg IM and Haldol 10mg IM. Informed pt of plan of care, pt accepted and received IM to left and right deltoid at 0550. pt tolerated procedure well. AOC made aware.
Review of patient #19's chart revealed there was a restraint and seclusion physician order in a packet dated 5/9/21 at 5:50AM. The order revealed the reason for emergency medication "pt. yelling, threatening staff, disrupting the milieu, pt. charging staff, pt.___ (illegible) property." The patient was ordered, "Haldol 10mg IM at 5:50AM, Ativan 2 mg IM at 5:50AM, and Benadryl 50mg IM at 5:50AM."

The face to face was written as performed on 5/9/21 at 6:30AM but there was no signature of who completed the face to face. No debriefing was included in the packet for patient or staff. There were no documented vital signs, effectiveness of medications, other than the face to face assessment completed at 6:30AM there was no further nursing assessment documented until 5/9/21 at 11:26AM.

Review of patient #19's nursing progress notes dated 5/9/2021 1346 (1:46PM) stated, Patient being aggressive and threatening staff and peers. Patient slamming and hitting door. Attempted to redirect patient but was unsuccessful. Received an order for thorazine 50 IM and benadryl 25 mg IM from Rosemary. Patient was injected at 1310. 1320 Patient is asleep and show no signs of distress. Respirations are even and unlabored.

Review of patient #19's chart revealed there was a restraint and seclusion packet. The physician order dated 5/9/21 at 1310 (1:10PM) stated, "Thorazine 50mg IM at 1310 (1:10PM) and Benadryl 25mg IM at 1310 (1:10PM)." The reason for the medication was checked as "Violent self-destructive behavior towards others. There was no description of that behavior. The chemical restraint was a verbal order given by a nurse practitioner. The physician order form was incomplete, and the following questions were left blank:
"Physician /provider ordering communicated with attending physician yes or no, attending physician/provider concurred with intervention? Complications with restrictive intervention yes or no." There was no documented evidence that the physician was notified in a timely manner.

The face to face was performed on 5/9/21 at 1400(2:00PM). The nurse stated the patient was being aggressive and threatening towards staff and peers. Patient asleep. The nurse stated patient "refused" vital signs but documented pt "asleep." No vital signs were obtained. The nurse documented that the patient denied pain or discomfort but was documented as asleep. The nurse documented the circulatory status was in normal limits but did not check pulses or vital signs. There was no debriefing with staff or patient.


Patient #5
Review of Patient #5's chart revealed he was admitted to the Palms facility on 1/27/21 with psychosis and unstable moods. Patient #5 was admitted as involuntary, suicide precautions, with every 15-minute checks. Patient #5 was admitted under an Emergency Detention Order (EDW) good for 72 hour hold and signed by the judge on 1/27/21.

Review of the intake assessment dated 1/27/21 stated, "Per collateral information from emergency detention, patient has been in psychotic state, knocking on neighbors' doors at night, and going to other family members' home unwanted and making them feel threatened. Per crisis screening, patient was presenting with word salad, not making sense, was not redirectable, and stated he has not slept in 8 days.
Observation - Patient is in state of agitation at time of arrival, presenting with rambling and word salad, insisting he be provided chocolate and that his right foot is broken even though he is ambulating without difficulty. Patient throws himself on floor stating he is having difficulty breathing.
Sexual Acting Out Behaviors, Medication Non-Compliance and Psychosis Patient is reported to be medication non-compliant, though medications and duration of non-compliance is unknown. Patient is reported by crisis screener to be disorganized and presenting with word salad when questions were being asked, making statements such as, "Third squad, utilities, Arkansas, Arkansas Pass, Blue Blue. Probation, parole, house arrest, do you have their number," and when conducting suicide risk assessment stating, "I got choked today, black boot, razaunida, captain. It's my white name, McCook, ozarka, Milwaukee's best, bunny rabbits, ABCDE, killer with a pitch fork." When asked if he uses synthetic cannabis, patient stated, "Oh people die from that shit. Omeprazole or protonix for the ulcers. International code, Freddy Fender did he die, call channel five." At time of arrival to PBH patient continued with rambling and word salad, demanding chocolates, stating his leg was broken in spite of ambulating without difficulty, stating he traveled to Switzerland, showing his pedicured toe nails, and while alone in assessment room was in agitated state and spitting multiple times on the table.

MODERATE - Per patient's sister, patient was posting on Face Book that he had sex with a 10-year-old niece. While family do not believe patient actually did this, and that this may be a product of his psychosis, risk level is identified as moderate due to risk factors outweighing protective factors. (Per crisis screen, report has been made to CPS regarding the information above, and Mission Police Department is investigating the possible crime).

Psychosis and History of Psychiatric Treatment
Patient has been admitted to inpatient psychiatric treatment multiple times for
psychosis: PBH 6/17/20 to 6/25/20, PBH 6/1/20 to 6/16/20, 3/6/20 to 4/3/20, STBH 4/2/18."


Review of the restraint and seclusion packet revealed a physician order dated 1/27/21 at 1815 (6:15PM). Review of the order revealed a box checked chemical restraint and written out to the side "PRN Meds." There was no order for the drugs on the order set but was found in the physician orders Haldol 10mg IM one time only for psychosis, Ativan 2 mg IM one time only for Agitated-self harming, and Benadryl 50mg IM one time only for EPS Prophylaxis. The medication was charted as administered at 18:15 (6:15PM). There was no found nursing documentation of the incident or observation found in the nursing progress notes or nursing physical assessment.

Review of the restraint and seclusion packet dated 1/27/21 at 1815 (6:15PM). Revealed there was no nursing assessment performed. The nurse marked through the note "N/A". The face to face section was incomplete. The nurse dated the form but marked through the whole front page as "N/A." The nurse documented "tolerated well" under patient response to emergency medication. There were no vital signs, observations, nursing assessment documented or what staff members were involved in the restraint process.

Review of the Nursing Progress note dated 1/27/21 at 21:41 (9:41PM) stated, "_____ (Pt. #5) presented with aggression/agitation and was not redirectable requiring IM medication for treatment of safety. 10mg Haldol, 2mg Ativan, 50mg Benadryl administered with positive effect. Will continue to monitor for safety."

Review of Patient #5's chart revealed the medications Haldol 10mg IM one time only for psychosis, Ativan 2 mg IM one time only for Agitated-self harming, and Benadryl 50mg IM one time only for EPS Prophylaxis were ordered again on 1/27/21 at 1902 (7:02PM) but not administered until 2119 (9:19PM). There was no documentation on why there was a delay in administering an emergency behavioral medication, if the behavior was still ongoing at time of administration, or any other alternatives used. There was no restraint packet in the chart for the administration of the Emergency behavioral medications. There was no way to determine if the patient was injured during the hold when there was no documentation on who was involved and how the restraint was administered.

There was no documentation on the patients Treatment Plan concerning the patient's behaviors, use of emergency behavioral medications or plan of care.

Based on record review and interview, Nursing failed to

1. follow the restraint and seclusion policy and procedure to perform appropriate assessments after the administration of restraint for at least 30 minutes, document vital signs, effectiveness of chemical restraints, behaviors and responses of patients after a restraint.

2. monitor the Mental Health Technician documentation of patient observation, ensure pain levels were monitored, fall risk measures monitored, and ensure the patient was offered and received hygiene and nutritional needs were met in 4 of 4 (Patient # 5, 20,10, and 19) charts reviewed.


Patient #20
Review of patient #20's chart revealed a physician order in the seclusion and restraint package. The order was dated 5/17/21 at 1400 (2:00PM). The order was for a manual hold of the patient due to "Violent self-destructive behavior to self" but there was no description of those behaviors on the order set.

The nurse documented the hold was due to "Violent self-destructive behavior to self" but there was no description of those behaviors.

Under Medication Administered During Restrictive Intervention the nurse documented, "Zyprexa 5 mg IM was administered at 1400 (2:00PM)", due to "aggression." There was no documentation of what staff members were involved during the restraint process and what staff member was holding the patient.

Review of the restraint and seclusion monitoring sheet dated 5/17/21 revealed the observation started at 1350 (1:50PM) Patient #20 was "agitated, crying, and harm to self/others." Under nutrition and hydration section the nurse documented "other" with no explanation. In comments the nurse documented, "pt. became agitated in day room. Manual hold for 20 minutes. The nurse documented at 1400 (2:00PM) that patient #20 was still "agitated, crying, and harm to self/others." In comments the nurse documented, "Zyprexa 5 mg IM given to rt deltoid." The nurse documented at 1410 (2:10PM) that patient #20 was "oriented, cooperative and could perform self-care. Pt became calm and manual hold discontinued." Review of the chart revealed there was no further documented nursing observation of any vital signs, effectiveness of medication after hold release, behaviors, or general nursing care until 5/18/21 at 1:24AM; 11.5 hours later.

Review of POLICY AND PROCEDURE: 1000.37 Restraints and Seclusion stated, "Page 17, 9. Following the use of a restraint or seclusion a staff shall continue monitoring the patient for a minimum of thirty (30) minutes or as clinically indicated."

Review of Patient #20's chart revealed there was no nursing documentation of patient #20 receiving any oral hygiene or bathing.

Patient #20 was admitted on 5/12/21 and discharged on 5/21/21. Review of Patient #20's nursing progress notes and assessments revealed there was no found documentation that Patient #20 had any of her hygiene needs met.
Review of the Mental Health Technicians (MHT) monitoring log revealed on the back page was a place for the MHT to document vital signs, output (bowel movements), pain levels, hygiene, fall risk interventions, nutrition (percentage of what was consumed at each meal), nurse group attendance and sleep hours. The MHT and Nurse sign at the bottom on day shift and night shift. Three of the daily logs had no dates on them so they cannot be counted in the review. The logs that were dated revealed the following items were blank;

5/14/21-Days there was no documentation for vital signs, output, pain, hygiene, fall risk interventions, or nurse group attendance.
Nights- a set of vital signs were taken but no time when they were performed. There was no documentation for output, pain, hygiene, fall risk interventions, sleep, or nurse group attendance. The nurses signed the form after each shift.
5/16/21- Days there was no documentation for vital signs, output, pain, hygiene, fall risk interventions, or nurse group attendance.
Nights- a set of vital signs were taken but no time when they were performed. There was no documentation for output, hygiene, fall risk interventions, sleep, or nurse group attendance. The nurses signed the form after each shift.
5/17/21- Days- a set of vital signs were taken but no time when they were performed. There was no documentation for output, hygiene, fall risk interventions, or nurse group attendance.
Nights- "refused V/S" There was no documentation for output, hygiene, fall risk interventions, sleep, or nurse group attendance. The nurses signed the form after each shift.
5/18/21-Days- Days there was no documentation for vital signs, output, pain, fall risk interventions, or nurse group attendance. Patient #20 was documented as "completed shower". Only breakfast was documented. The MHT documented at "12:19 pt. was very upset." There was no documentation that any supplements were offered to the patient.
Nights- "refused V/S" There was no documentation for output, hygiene, fall risk interventions, sleep, or nurse group attendance. The nurses signed the form after each shift.


Patient #10
Review of patient #10's chart revealed a physician order in the seclusion and restraint package. The order was dated 5/15/21 at 8:41AM. The order was for a manual hold from 8:41AM until 9:04AM. The order was for "violent self- destructive behavior towards others" but there was no description on the order of those behaviors.

Review of the "Manual Hold Assessment by the RN" in the restraint package revealed on 5/15/21 that the hold was "Unsuccessful. Did not deescalate." The only interventions documented on the form for alternative interventions performed was verbal De-escalation. The nurse documented that Patient #10 was administered Haldol 10mg IM, Benadryl 50mg IM and Lorazepam 2 mg IM at 8:47AM. There was no medication order in the packet for a chemical restraint. A physician order was found on the medication orders for the chemical restraint as a now order at 8:41AM only one minute into the physical hold. There was no documentation noted in the chart that the nursing staff used any other less restrictive restraint. The staff failed to use the seclusion rooms before administering chemical restraints.

Review of the face to face dated 5/15/21 at 9:38AM stated the patient behaviors that justified the actions were "attempted to grab tech while in a very agitated state. Yelling and screaming, very agitated for 25 minutes." On the chemical restraint portion of the form, the nurse performing the face to face failed to document the Benadryl and stated the patient refused vital signs. The nurse documented that respiratory status was within normal limits but there were no respirations documented. Respirations can be observed and counted without touching the patient. The nurse documented the circulatory status was within normal limits but there were unchecked boxes on pulses present and no vital signs obtained. The nurse documented on the monitoring sheet at 8:38AM and again at 9:04AM. There was no documentation that Patient #10 was observed every 15 minutes for at least 30 minutes per policy.

Review of the debriefing form revealed there was no information on what staff member was holding the patient. The nurse documented that Patient #10 was given Seroquel (Antipsychotic) by mouth 100mg. There was no documentation on any of the nursing assessments (in the restraint package) that Patient #10 was offered any medications prior to the hold or chemical restraint. Review of the Medication Administration Record (MAR) revealed Patient #10 was given Seroquel 100mg by mouth at 8:18AM. The nurse documented the response to the medication as "tolerated." The response to the medication was documented on 5/16/21 at 9:44AM, over 24 hours later.

Review of the Nursing Progress note dated 5/15/21 at 9:29AM stated, At approximately 0841 pt was in restraint due to physical aggression and verbal aggression towards self and staff. _____NP was made aware, ordered Ativan, Haldol, and Benadryl IM Stat. Medications were administered to _____ (Patient #10) right arm. Tolerated well. This nurse witnessed restraint. Pt was shouting stating staff was sex traffickers trying to abduct her, stated she had STD's and wanted to infect staff, and also attempted to hit and bite staff. PT is now calm and cooperative sitting in dayroom having breakfast fluids were encouraged."

There was no further documentation on the effectiveness of the medications. There was no further documentation of patient observation by the nurse until 5/15/21 at 1646 (4:16PM). There were no vital signs documented on the patient. The only documentation that vital signs were attempted was on 5/16/21 at 7:37AM and the patient refused.
Review of every 15-minute check observation monitoring form reveled at 8:45AM the MHT had marked over a previous documented behavior code and location code of "awake and alert -courtyard" to "psychotic and hall." The MHT documented at 9:00AM that Patient #10 was calm and in her room.

Review of the Mental Health Technicians (MHT) monitoring log revealed the MHT failed to properly document the following items and were blank;

5/11/21-Days- there was no documentation for vital signs, output, pain, hygiene, fall risk interventions, nurse group attendance, and no percentages for breakfast or lunch. No MHT or RN signature.
Nights- There was no documentation for output, fall risk interventions, or sleep hours. The nurses signed the form after shift.
5/12/21-Days- there was no documentation for vital signs, output, pain, or nurse group attendance. The RN signed the form.
Nights- Vital signs were performed but there was no time documented. There was no documentation for output, hygiene, fall risk interventions, or sleep hours. The nurses signed the form after shift.
5/13/21- Every 15-minute monitoring had multiple mark overs and mark throughs on the observations sheet.
Days- there was no documentation for vital signs, output, pain, or nurse group attendance. The RN signed the form.
Nights- There was no documentation for output, hygiene, fall risk interventions, sleep hours and no percentage of dinner consumed. The RN signed the form.
5/14/21- Days- there was no documentation for vital signs, output, pain, hygiene, fall risk interventions, nurse group attendance or percentages for breakfast or lunch. The RN signed the form.
Nights- The whole from was blank but the nurse and MHT both signed a blank form.
5/15/21- Days-The whole form was bank except for breakfast and lunch percentages. The MHT and RN signed the sheet.
Nights- There was documented vital signs but no time when they were taken. The rest of the form was blank. The nurse and MHT signed the form.
5/16/21-Days- The whole from was blank but the nurse and MHT both signed a blank form.
Nights- The whole from was blank but the nurse and MHT both signed a blank form.
5/17/21- Days- Vital signs were taken with no time. Nurse group attendance was blank
Nights- Vital signs were taken with no time. Pain was assessed but all the other items were blank. The nurse and MHT both signed a blank form.
5/18/21-Days_ the only thing documented was vital signs with no time. The vital signs were scribbled out, written again and then marked over on the blood pressure. There was no RN or MHT signature.
Nights- Vital signs were documented with no time and pain was documented. The rest of the form was blank but the RN and MHT signed it.
5/19/21- Days- The from was blank but the RN and MHT signed the form.


Patient #19
Review of patient #19's nursing progress notes dated 5/9/2021 5:50AM stated, "5/9/2021 05:50 Pt displayed increased agitation. pt yelling, using threating vulgar language and attempting to charge staff. Informed provider on call, order received for Benadryl 50mg IM, Ativan 2mg IM and Haldol 10mg IM. Informed pt of plan of care, pt accepted and received IM to left and right deltoid at 0550. pt tolerated procedure well. AOC made aware.
Review of patient #19's chart revealed there was a restraint and seclusion physician order in a packet dated 5/9/21 at 5:50AM. The order revealed the reason for emergency medication "pt. yelling, threatening staff, disrupting the milieu, pt. charging staff, pt.___ (illegible) property." The patient was ordered, "Haldol 10mg IM at 5:50AM, Ativan 2 mg IM at 5:50AM, and Benadryl 50mg IM at 5:50AM."

The face to face was written as performed on 5/9/21 at 6:30AM but there was no signature of who completed the face to face. No debriefing was included in the packet for patient or staff. There were no documented vital signs, effectiveness of medications, other than the face to face assessment completed at 6:30AM, there was no further nursing assessment documented until 5/9/21 at 11:26AM.

Review of patient #19's nursing progress notes dated 5/9/2021 1346 (1:46PM) stated, Patient being aggressive and threatening staff and peers. Patient slamming and hitting door. Attempted to redirect patient but was unsuccessful. Received an order for thorazine 50 IM and benadryl 25 mg IM from Rosemary. Patient was injected at 1310. 1320 Patient is asleep and show no signs of distress. Respirations are even and unlabored.

Review of patient #19's chart revealed there was a restraint and seclusion packet. The physician order dated 5/9/21 at 1310 (1:10PM) stated, "Thorazine 50mg IM at 1310 (1:10PM) and Benadryl 25mg IM at 1310 (1:10PM)." The reason for the medication was checked as "Violent self-destructive behavior towards others. There was no description of that behavior. The chemical restraint was a verbal order given by a nurse practitioner. The physician order form was incomplete, and the following questions were left blank:

"Physician /provider ordering communicated with attending physician yes or no, attending physician/provider concurred with intervention? Complications with restrictive intervention yes or no." There was no documented evidence that the physician was notified in a timely manner.

The face to face was performed on 5/9/21 at 1400(2:00PM). The nurse stated the patient was being aggressive and threatening towards staff and peers. Patient asleep. The nurse stated patient "refused" vital signs but documented pt "asleep." No vital signs were obtained. The nurse documented that the patient denied pain or discomfort but was documented as asleep. The nurse documented the circulatory status was in normal limits but did not check pulses or vital signs. There was no debriefing with staff or patient.

Review of the Mental Health Technicians (MHT) observation monitoring form revealed the MHT failed to properly document the following items and were blank;

5/09/21-Days- the form was blank. The MHT and RN signed the form.
Nights- There were documented vital signs with no time. Documentation on the form stated 5/9/21 at 0545AM pt. agitated and aggressive-yelling out of control." The rest of the form was blank.
5/10/21 -Days- The form was blank with MHT and RN signatures.
Nights- vital signs only. MHT and RN signatures.
5/11/21- Days The observation times were pre charted from 11:44PM until 14:20PM (2:20PM). The MHT had marked over other codes and changed them without explanation. The patient was sent to the hospital at 11:44AM for medical testing and returned at 18:00(6:00PM).
Nights- there was no documentation for output, sleep hours, fall interventions. Nurse and MHT signed the form.
5/12/21- Days- Pt refused hygiene and breakfast was documented the rest of the form was blank. The RN and MHT signed the form.
Nights- Patient refused vital signs and pain level assessed all other items blank. The RN and MHT signed the form.
5/13/21- Days- no vital signs, output, pain, dinner percentage, or nurse group attendance. The RN and MHT signed the form.
Nights- only vital signs documented. The RN and MHT signed the form.
5/14/21- Days- Blank. The RN and MHT signed the form.
Nights- Vital signs were taken with no time documented. The rest of the form was blank. The RN and MHT signed the form.
5/15/21- Day- Blank. The RN and MHT signed the form.
Nights- Vital signs were taken with no time documented. The rest of the form was blank. The RN and MHT signed the form.
5/16/21- Days- Blank. The RN and MHT signed the form.
Nights- Vital signs were taken with no time documented. The rest of the form was blank. The RN and MHT signed the form.
5/17/21- Days- Vital signs were taken with no time documented. There was no documented dinner or group attendance. The RN and MHT signed the form.


Patient #5
Review of Patient #5's chart revealed he was admitted to the Palms facility on 1/27/21 with psychosis and unstable moods. Patient #5 was admitted as involuntary, suicide precautions, with every 15-minute checks. Patient #5 was admitted under an Emergency Detention Order (EDW) good for 72 hour hold and signed by the judge on 1/27/21.

Review of the intake assessment dated 1/27/21 stated, "Per collateral information from emergency detention, patient has been in psychotic state, knocking on neighbors' doors at night, and going to other family members' home unwanted and making them feel threatened. Per crisis screening, patient was presenting with word salad, not making sense, was not redirectable, and stated he has not slept in 8 days.
Observation - Patient is in state of agitation at time of arrival, presenting with rambling and word salad, insisting he be provided chocolate and that his right foot is broken even though he is ambulating without difficulty. Patient throws himself on floor stating he is having difficulty breathing.
Sexual Acting Out Behaviors, Medication Non-Compliance and Psychosis Patient is reported to be medication non-compliant, though medications and duration of non-compliance is unknown. Patient is reported by crisis screener to be disorganized and presenting with word salad when questions were being asked, making statements such as, "Third squad, utilities, Arkansas, Arkansas Pass, Blue Blue. Probation, parole, house arrest, do you have their number," and when conducting suicide risk assessment stating, "I got choked today, black boot, razaunida, captain. It's my white name, McCook, ozarka, Milwaukee's best, bunny rabbits, ABCDE, killer with a pitch fork." When asked if he uses synthetic cannabis, patient stated, "Oh people die from that shit. Omeprazole or protonix for the ulcers. International code, Freddy Fender did he die, call channel five." At time of arrival to PBH patient continued with rambling and word salad, demanding chocolates, stating his leg was broken in spite of ambulating without difficulty, stating he traveled to Switzerland, showing his pedicured toe nails, and while alone in assessment room was in agitated state and spitting multiple times on the table.

MODERATE - Per patient's sister, patient was posting on Face Book that he had sex with a 10-year-old niece. While family do not believe patient actually did this, and that this may be a product of his psychosis, risk level is identified as moderate due to risk factors outweighing protective factors. (Per crisis screen, report has been made to CPS regarding the information above, and Mission Police Department is investigating the possible crime).

Psychosis and History of Psychiatric Treatment
Patient has been admitted to inpatient psychiatric treatment multiple times for
psychosis: PBH 6/17/20 to 6/25/20, PBH 6/1/20 to 6/16/20, 3/6/20 to 4/3/20, STBH 4/2/18."


Review of the restraint and seclusion packet revealed a physician order dated 1/27/21 at 1815 (6:15PM). Review of the order revealed a box checked chemical restraint and written out to the side "PRN Meds." There was no order for the drugs on the order set but was found in the physician orders Haldol 10mg IM one time only for psychosis, Ativan 2 mg IM one time only for Agitated-self harming, and Benadryl 50mg IM one time only for EPS Prophylaxis. The medication was charted as administered at 18:15 (6:15PM). There was no found nursing documentation of the incident or observation found in the nursing progress notes or nursing physical assessment.

Review of the restraint and seclusion packet dated 1/27/21 at 1815 (6:15PM). Revealed there was no nursing assessment performed. The nurse marked through the note "N/A". The face to face section was incomplete. The nurse dated the form but marked through the whole front page as "N/A." The nurse documented "tolerated well" under patient response to emergency medication. There were no vital signs, observations, nursing assessment documented or what staff members were involved in the restraint process.

Review of the Nursing Progress note dated 1/27/21 at 21:41 (9:41PM) stated, "_____ (Pt. #5) presented with aggression/agitation and was not redirectable requiring IM medication for treatment of safety. 10mg Haldol, 2mg Ativan, 50mg Benadryl administered with positive effect. Will continue to monitor for safety."

Review of Patient #5's chart revealed the medications Haldol 10mg IM one time only for psychosis, Ativan 2 mg IM one time only for Agitated-self harming, and Benadryl 50mg IM one time only for EPS Prophylaxis were ordered again on 1/27/21 at 1902 (7:02PM) but not administered until 2119 (9:19PM). There was no documentation on why there was a delay in administering an emergency behavioral medication, if the behavior was still ongoing at time of administration, or any other alternatives used. There was no restraint packet in the chart for the administration of the Emergency behavioral medications. There was no way to determine if the patient was injured during the hold when there was no documentation on who was involved and how the restraint was administered.

There was no documentation on the patients Treatment Plan concerning the patient's behaviors, use of emergency behavioral medications or plan of care.

Review of Patient #5's chart revealed he was admitted to the Palms facility on 1/27/21 with psychosis and unstable moods. Patient #5 was admitted as involuntary, suicide precautions, with every 15-minute checks. Patient #5 was admitted under an Emergency Detention Order (EDW) good for 72 hour hold and signed by the judge on 1/27/21.

Review of the intake assessment dated 1/27/21 stated, "Per collateral information from emergency detention, patient has been in psychotic state, knocking on neighbors' doors at night, and going to other family members' home unwanted and making them feel threatened. Per crisis screening, patient was presenting with word salad, not making sense, was not redirectable, and stated he has not slept in 8 days.
Observation - Patient is in state of agitation at time of arrival, presenting with rambling and word salad, insisting he be provided chocolate and that his right foot is broken even though he is ambulating without difficulty. Patient throws himself on floor stating he is having difficulty breathing.
Sexual Acting Out Behaviors, Medication Non-Compliance and Psychosis Patient is reported to be medication non-compliant, though medications and duration of non-compliance is unknown. Patient is reported by crisis screener to be disorganized and presenting with word salad when questions were being asked, making statements such as, "Third squad, utilities, Arkansas, Arkansas Pass, Blue Blue. Probation, parole, house arrest, do you have their number," and when conducting suicide risk assessment stating, "I got choked today, black boot, razaunida, captain. It's my white name, McCook, ozarka, Milwaukee's best, bunny rabbits, ABCDE, killer with a pitch fork." When asked if he uses synthetic cannabis, patient stated, "Oh people die from that shit. Omeprazole or protonix for the ulcers. International code, Freddy Fender did he die, call channel five." At time of arrival to PBH patient continued with rambling and word salad, demanding chocolates, stating his leg was broken in spite of ambulating without difficulty, stating he traveled to Switzerland, showing his pedicured toe nails, and while alone in assessment room was in agitated state and spitting multiple times on the table.

MODERATE - Per patient's sister, patient was posting on Face Book that he had sex with a 10-year-old niece. While family do not believe patient actually did this, and that this may be a product of his psychosis, risk level is identified as moderate due to risk factors outweighing protective factors. (Per crisis screen, report has been made to CPS regarding the information above, and Mission Police Department is investigating the possible crime).

Psychosis and History of Psychiatric Treatment
Patient has been admitted to inpatient psychiatric treatment multiple times for
psychosis: PBH 6/17/20 to 6/25/20, PBH 6/1/20 to 6/16/20, 3/6/20 to 4/3/20, STBH 4/2/18."


Review of the restraint and seclusion packet revealed a physician order dated 1/27/21 at 1815 (6:15PM). Review of the order revealed a box checked chemical restraint and written out to the side "PRN Meds." There was no order for the drugs on the order set but was found in the physician orders Haldol 10mg IM one time only for psychosis, Ativan 2 mg IM one time only for Agitated-self harming, and Benadryl 50mg IM one time only for EPS Prophylaxis. The medication was charted as administered at 18:15 (6:15PM). There was no found nursing documentation of the incident or observation found in the nursing progress notes or nursing physical assessment.

Review of the restraint and seclusion packet dated 1/27/21 at 1815 (6:15PM). Revealed there was no nursing assessment performed. The nurse marked through the note "N/A". The face to face section was incomplete. The nurse dated the form but marked through the whole front page as "N/A." The nurse documented "tolerated well" under patient response to emergency medication. There were no vital signs, observations, nursing assessment documented or what staff members were involved in the restraint process.

Review of the Nursing Progress note dated 1/27/21 at 21:41 (9:41PM) stated, "_____ (Pt. #5) presented with aggression/agitation and was not redirectable requiring IM medication for treatment of safety. 10mg Haldol, 2mg Ativan, 50mg Benadryl administered with positive effect. Will continue to monitor for safety."

Review of Patient #5's chart revealed the medications Haldol 10mg IM one time only for psychosis, Ativan 2 mg IM one time only for Agitated-self harming, and Benadryl 50mg IM one time only for EPS Prophylaxis were ordered again on 1/27/21 at 1902 (7:02PM) but not administered until 2119 (9:19PM). There was no documentation on why there was a delay in administering an emergency behavioral medication, if the behavior was still ongoing at time of administration, or any other alternatives used. There was no restraint packet in the chart for the administration of the Emergency behavioral medications. There was no way to determine if the patient was injured during the hold when there was no documentation on who was involved and how the restraint was administered.

There was no documentation on the patients Treatment Plan concerning the patient's behaviors, use of emergency behavioral medications or plan of care.