HospitalInspections.org

Based on record review, policy review, interviews and observation, the facility failed to properly document evaluation of patients and to properly treat patients on the inpatient unit. Specifically, the facility failed to:

1. Protect 2 of 8 patients active sample patients (A3 and B1) from the use of chemical restraint in non-emergency situations. The facility maintained a preprinted admission order form that allowed for the administration of these medications on a prn (as needed) basis for "extreme psychosis." Patient B1 received two doses of intramuscular medication combinations of sufficient potency to have the effect of chemical restraint on February 1, 2010 without documentation that the patient was a danger to self or others, which is a requirement for the appropriate use of chemical restraint. Patient A3 received several doses of combination intramuscular injections (Geodon 20 mg. [antipsychotic], Benadryl 25 mg. [antihistamine] and Ativan 2mg. [benzodiazepine]) over a period of 5 days (01/27/10-01/31/10) ordered for an indication of "extreme agitation" and an intramuscular injection of Haldol 5 mg. [antipsychotic], Benadryl 25mg. and Ativan 2 mg. on 02/03/10 for an indication of "agitation." There was no documentation in physician progress notes or nursing progress notes that that identified Patient A3 being in a state where there was a state of danger to self or others as indicated for the appropriate use of chemical restraint. (Refer to B125-I)

2. Protect two patients (sample patient A3 and non-sample patient C1) from potential or actual preventable side-effects from intramuscular injections. In the case of patient A3, the patient was given an IM injection of a medication to which the patient was noted to be allergic, with potential risk of serious injury or death from an allergic reaction. In the case of patient C1, the patient was given a series of injections at an inappropriate injection site, which compromised the patient's well-being and added increased morbidity (pain and infection). (Refer to B125-II)

These failures resulted in patients being subjected to inappropriate medication administrations, some to the level of chemical restraint, without adequate justification, and led to a condition of IMMEDIATE JEOPARDY initiated on February 2, 2010 at 2:00 p.m.
In addition, based on record review and interview, the facility failed to:

3. Document a psychiatric evaluation for 1 of 1 sample patients assigned to a non-psychiatrist attending physician (B3). Absence of this patient information hinders the treatment team's ability to formulate an appropriate problem list, and plan for appropriate treatment. (Refer to B110)

4. Provide psychiatric evaluations that reported orientation, memory functioning and/or intellectual functioning in measurable, behavioral terms for 8 of 8 active sample patients (A1, A2, A3, A4, A6, B1, B2 and B3). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured. (Refer to B116)

5. Provide psychiatric evaluations that included an assessment of patient assets in descriptive fashion for 8 of 8 active sample patients (A1, A2, A3, A4, A6, B1, B2, and B3). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's strengths in therapy. (Refer to B117)

6. Develop and document comprehensive Master Treatment Plans (MTPs) for 8 of 8 active sample patients (A1, A2, A3, A5, A6, B1, B2 and B3). None of these patients' written MTPs included physician (MD/psychiatrist) interventions. Some of the MTPs also were missing required components, e.g., identification and utilization of patient strengths/assets (Patients A1, A2, A3, A5, A6, B1, B2 and B3), substantiated diagnoses (Patients A2, B2 and B3) and physician signatures (A1, A3, A6, B1 and B2). Patient signatures on the MTPs also were obtained during the weekly Treatment Team Planning meetings before explanation and/or discussion of the treatment plans. (Refer to B118)

7. Obtain written patient consent before administering psychotropic medications to Patients A3 and B1 who were given combination doses of Haldol, Ativan and Benadryl. The nursing staff failed to obtain written patient consent prior to administering these medications to the patients. This failure is a violation of patient rights to informed consent for the administration of psychotropic medication. (Refer to B125- III)

8. Ensure that physician orders gave nursing staff proper guidance on the administration of antianxiety medications used for detoxification and/or pain medications for 2 of 8 active sample patients (A2 and B1). In the case of Patient A2, physician orders were written on a PRN (as necessary) basis for the non-specific condition of "pain," with a choice of different medications without instruction as to the order in which the medications were to be administered. Nurses could choose to administer the medications based on their own decision or on patient decision. Nursing used medications outside of the parameters given for detoxification. For Patient B1, the medications were administered by nursing outside of the indications in the orders. These failures resulted in nursing staff making prescriptive decisions and therefore functioning outside the scope of nursing practice. Further, ambiguous physician orders can result in serious complications from improperly administered PRN medications. (Refer to B125-IV)

9. Ensure a discharge summary that summarized all the treatment received in the hospital and the patient's response to treatment other than to medication administration in 1 of 8 discharge summaries reviewed (D1); and ensure that discharge summaries were dictated, transcribed and filed within 14 days of discharge as required by hospital policy for 1 of 8 discharge records reviewed (D2). These deficiencies compromise the effective transfer of the patient's care to the next care provider. (Refer to B133 I and II)

Based on policy review, record review and interview, it was determined that for 1 of 1 active sample patients (B3) under the care of a non-psychiatrist physician, the facility failed to document a psychiatric evaluation. The absence of this patient information hinders the treatment team's ability to formulate an appropriate problem list, and plan for appropriate treatment.

Findings are:

A. Policy review

Riverside Center for Behavioral Health, Policies and Procedures #24, titled "Assessment of Patients" last updated 01/2010, in Section 4.0, "History and Physical" states the following: "For patients on the Chemical Dependency Unit, a psychiatric evaluation will be ordered upon admission as a consult if the patient's admitting physician is not a psychiatrist." (Bold type was in the policy). Section 5.0, "Initial Psychiatric Evaluation," states: "Within 24 hours of admission to the inpatient [sic], the attending physician of [sic] designee will complete Initial Psychiatric Evaluation (IPE)."

B. Record Review

a. Patient B3, admitted to he chemical dependency program 01/30/10 for detoxification and assigned to a non-psychiatric attending physician per the daily census dated 02/01/10, did not have an IPE [Initial Psychiatric Evaluation] in the record as of the date of the survey 02/03/10. A Dictated History and Physical, dated 01/31/10 and unsigned, did not contain a psychiatric history or mental status examination.

b. Admitting orders dated 01/30/10 did not contain an order for a psychiatric consultation. The designated fill-in area for the consultation on the admitting orders page was left blank.

c. A psychiatric consultation was ordered by the attending physician on 02/01/10 (more than 24 hours after admission). As of 02/03/10 at 9:00 am, the medical record did not contain a Psychiatric Evaluation.

B. Interview

In an interview on 02/03/10 at 11:20 a.m., the Medical Director agreed with the findings noted above.

Based on policy review, record review and interview, the hospital failed to provide psychiatric evaluations that reported orientation, memory functioning and/or intellectual functioning in measurable, behavioral terms for 8 of 8 active sample patients (A1, A2, A3, A4, A6, B1, B2, and B3). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured.

Findings are:

A. Policy Review

Riverside Center for Behavioral Health, Policies and Procedures #24, titled "Assessment of Patients" last updated 01/2010, under Section 5.0 "Initial Psychiatric Evaluation" states: "The IPE (Initial Psychiatric Evaluation) must include, but it not limited to: ...H. Mental Status Exam. 1. Test memory- list patient's response. 2. Test orientation- list patient's response. 3. Test cognitive function- list patient's response. 4. Test intellectual function- list patient's response."

B. Record Review

1. Patient A1: in an IPE dated 01/17/10, there was no evidence of specific, reproducible testing of intellectual function or all areas of memory function. It stated: "The patient's intelligence is average. He is unable to recall any of his medications...but memory apparently is in the normal range as the patient is able to give details about his early diagnosis and the partial hospitalization."

2. Patient A2: in an IPE dated 01/18/10, it stated: "Cognitive functions, she can name current President and current date. Memory functions, she is able to recall contents of morning meal." There was no additional information in the record to verify what the contents of the meal were. There was no description of intellectual functioning.

3. Patient A3: in an IPE dated 01/29/10, there was no evidence of testing for memory function, intellectual function, nor a description of the patient's orientation status.

4. Patient A4: in an IPE dated 01/18/10 it stated, "Cognitive functions, she can name current President and current date. Memory functions, she is able to recall contents of morning meal." There was no additional information in the record to verify what the contents of the meal were. There was no description of intellectual functioning.

5. Patient A6: in an IPE dated 01/31/10, there was no estimation of intellectual function noted.

6. Patient B1: admitted 01/28/10; in an IPE dated 01/29/10, there was no evidence of testing for memory function, intellectual function, nor a description of the patient's orientation status.

7. Patient B2: admitted 01/29/10: in an IPE dated 01/30/10, there was no evidence of testing for memory function; it stated: "As the patient was still intoxicated, memory testing was not done." There was no estimation of intellectual functioning. As of the date of the survey, 02/03/10, there had been no follow-up evaluation performed.

8. Patient B3, admitted 01/30/10: there was no IPE in the record at the time of the survey 02/01/10 through 02/03/10.

C. Interview

In an interview on 02/03/10 at 11:20 a.m., the Medical Director agreed with the above findings.

Based on policy review, record review and interview, the facility failed to provide psychiatric evaluations that included an assessment of patient assets that could be used in designing treatment for 8 of 8 active sample patients (A1, A2, A3, A4, A6, B1, B2, and B3). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy.

Findings are:

A. Policy Review

Riverside Center for Behavioral Health, Policies and Procedures #24, titled "Assessment of Patients" last updated 01/2010, under Section 5.0 "Initial Psychiatric Evaluation," states: "The IPE (Initial Psychiatric Evaluation) must include, but it not limited to: ...

1. A description of assets and liabilities: "1. Personal Strengths 2. Personal attributes."

B. Record Review

1. Patient A1: No descriptions of assets were noted in an IPE dated 01/17/10.

2. Patient A2: In an IPE dated 01/19/10, assets were noted as: "Ability to understand instructions."

3. Patient A3: No descriptions of assets were noted in an IPE dated 01/29/10.

4. Patient A4: In an IPE dated 01/19/10, assets were noted as: "Ability to understand instructions."

5. Patient A6: No descriptions of assets were noted in an IPE dated 01/31/10.

6. Patient B1: No descriptions of assets were noted in an IPE dated 01/29/10.

7. Patient B2: No descriptions of assets were noted in an IPE dated 01/30/10.

8. Patient B3: Did not have an IPE in the record at the time of the survey 02/01/10 through 02/03/10.

C. Interview

In an interview on 02/03/10 at 11:20 a.m., the Medical Director agreed with the findings noted above.

Based on record review, observations and interview, the hospital failed to develop and document comprehensive Master Treatment Plans (MTPs) for 8 of 8 active sample patients (A1, A2, A3, A5, A6, B1, B2 and B3). None of these patients' written MTPs included physician (MD/psychiatrist) interventions. Some of the MTPs also were missing required components, e.g., identification and utilization of patient strengths/assets (Patients A1, A2, A3, A5, A6, B1, B2 and B3), substantiated diagnoses (Patients A2, B2 and B3) and physician signatures (A1, A3, A6, B1 and B2). Patient signatures on the MTPs also were obtained during the weekly Treatment Team Planning meetings before explanation and/or discussion of the treatment plans.

Findings are:

I. Failure to specify the treatment roles of physicians for 8 of 8 active sample patients (A1, A2, A3, A5, A6, B1, B2 and B3).

A. Record Review (MTP dates in parentheses)

The facility's MTP form included a typed section titled "Medical Doctor Interventions" for each identified problem. A review of the MTP forms revealed the following:

1. Patient A1 (MTP 1/17/10). There were no "Medical Doctor" interventions on the MTP for the identified problems "Thought Disorder" or "Hypertension." There also were no notations regarding physician interventions on the Interdisciplinary Treatment Plan Evaluation/Update forms (1/19/10; 1/26/10).

2. Patient A2 (MTP 1/18/10). There were no "Medical Doctor" interventions on the MTP for the identified problem "Substance Dependence," "Infection/Inflammation (Acute Pharyngitis)," "High Blood Pressure," "Asthma," "Pain." There also were no notations regarding physician interventions on the Interdisciplinary Treatment Plan Evaluation/Update forms (1/19/10; 1/26/10).

3. Patient A3 (MTP 1/27/10). There were no "Medical Doctor" interventions on the MTP for the identified problem "Mood Disorder," "Thought Disorder" or "Infection/Inflammation" (unspecified).

4. Patient A5 (MTP 1/17/10). There were no "Medical Doctor" interventions on the MTP for the identified problems "Mood Disorder," "Thought Disorder," "Anxiety," "High Blood Sugar" or "High Blood Pressure."

5. Patient A6 (MTP 1/30/10). There were no "Medical Doctor" interventions on the MTP for the identified problems "Mood Disorder," "Pain," or "Danger to Self."

6. Patient B1 (MTP 1/28/10). There were no "Medical Doctor" interventions on the MTP for the identified problems "Detox," "Substance Dependence," "Fall Risk," "Pain," "Seizure Disorder" or "Acute Respiratory Infection."

7. Patient B2 (MTP 1/29/10). There were no "Medical Doctor" interventions on the MTP for the identified problems "Substance Dependence," "Detox," "Acute Bronchitis," "Fall Risk," "Hypertension" or "Seizure Disorder."

8. Patient B3 (MTP 1/30/10). There were no "Medical Doctor" interventions on the MTP for the identified problem "Fall Risk." The only MD interventions for the problem "Substance Dependence" was "Discuss weekly the treatment plan via Tx. Team." The only MD intervention for "Detox" was "Perform initial physical exam to determine...other [checked on form]"

There were MD/attending Psychiatrist signatures on the MTPs and "Interdisciplinary Treatment Plan Evaluation/Update" forms for Patients A2, A5 and B3, verifying physician approval of the incomplete treatment plans. At the time of review (2/2/10), there were no physician (MD) signatures on the MTPs of Patients A1 (MTP 1/17/10; updates 1/19/10 and 1/26/10), A3 (MTP 1/27/10), A6 (1/30/10), B1 (1/28/10) or B2 (MTP 1/29/10).

II. Failure to identify and/or utilize patient strengths/assets in the treatment plans (MTPs) of 8 of 8 active sample patients (A1, A2, A3, A5, A6, B1, B2 and B3).

A. Record Review (MTP dates in parentheses)

The MTP form included a pre-printed checklist of "Strengths/Abilities/Preferences to be utilized while in Tx [treatment]." on the face sheet. Additional items could be written in. A review of MTP forms revealed the following notations about patient strengths/assets:

1. Patient A1 (MTP 1/17/10). The only strength checked on the MTP form was "Motivated to seek treatment." There were no items written in. Neither the MTP nor the Interdisciplinary Treatment Plan Evaluation/Update forms (1/19/10; 1/26/10) specified how the patient's motivation was to be utilized in treatment.

2. Patient A2 (MTP 1/28/10): Strengths checked on the MTP form were "Healthy support system," "Good communication," "Average intelligence level" and "Motivated to seek treatment." There were no items written in. Neither the MTP nor the Interdisciplinary Treatment Plan Evaluation/Update forms (1/19/10; 1/26/10) specified how these assets were to be utilized in treatment.

3. Patient A3 (MTP 1/27/10). There were no patient strengths checked or written in on the MTP form. Further review of the MTP problem, goal, and intervention lists uncovered no documentation of patient strengths/assets.

4. Patient A5 (MTP 1/17/10). Strengths checked on the MTP form were "Good communication" and "Motivated to seek treatment." There were no items written in. Neither the MTP nor the Interdisciplinary Treatment Plan Evaluation/Update forms 1/19/10; 1/26/10) specified how the identified strengths were to be utilized in treatment.

5. Patient A6 (MTP 1/30/10). Strengths checked on the MTP form were "Healthy support system" and "Motivated to seek treatment." There were no items written in. The MTP did not specify how the identified strengths were to be utilized in treatment.

6. Patient B1 (MTP 1/28/10). Strengths checked on the MTP form were "Average intelligence level" and "Motivated to seek treatment." There were no items written in. The MTP did not specify how the identified strengths were to be utilized in treatment.

7. Patient B2 (MTP 1/29/10). Strengths checked on the MTP form were "Healthy support system," "Good communication skills" and "Motivated to seek treatment." There were no items written in. The MTP did not specify how the identified strengths were to be utilized in treatment.

8. Patient B3 (MTP 1/30/10). Strengths checked on the MTP form were "Average Intelligence Level" and "Motivated to seek treatment." There were no items written in. The MTP did not specify how the identified strengths were to be utilized in treatment.

B. Observations

The weekly Interdisciplinary Treatment Planning meeting for Physician MD1's team was observed on the psychiatric wing of the treatment unit on 2/2/10 from 9:40 a.m. to 10:15 a.m. During the observation, there was no mention of patient strengths/assets or how they were being utilized in treatment.

C. Interview

In an interview on 2/03/10 at 10:00 a.m., the Discharge Planner acknowledged that the MTPs did not specify how the identified strengths/assets were to be used to support the treatment plan. She also acknowledged that the treatment team did not attempt to add patient strengths to the plan after the initial MTP was developed.

III. Failure to document a substantiated diagnosis (or diagnoses) on the MTPs of 3 of 8 active sample patients (A2, B1, B3).

A. Record Review (MTP dates in parentheses)

Review of the MTPs provided by the facility on 2/1/10 revealed no substantiated diagnosis on the MTP for Patients A2 (1/18/10), B1 (1/28/10) and B3 (1/30/10). Interdisciplinary Treatment Team Planning meetings had been held for Patients A2 (1/19/10 and 1/26/10) and B3 (2/1/10), with documentation on the "Interdisciplinary Treatment Plan Evaluation/Update" form. However, none of the "Interdisciplinary Treatment Plan Evaluation/Update" forms documented that the team had substantiated the diagnoses during the team meetings.

B. Interview

In an interview on 2/03/10 at 10:00 a.m., the Discharge Planner stated that she did not realize that the "Substantiated Diagnoses" meant that the admission diagnoses were to be discussed and substantiated by the treatment team after presentation of all available assessment data.

IV. Physician and patient signatures on the MTPs

A. Record Review and Interview (MTP dates in parentheses)

1. Review of the sample patients' MTPs provided by the facility revealed no physician signatures on the face page of the MTP by 2/1/10 for Patients A1 (1/17/10), A3 (1/27/10), A6 (1/30/10), B1 (1/28/10) and B2 (1/29/10).

B. Observation

During an observation of the weekly Interdisciplinary Treatment Planning meeting for Physician MD1's team on the psychiatric wing of the treatment unit on 2/2/10 from 9:40 a.m. to 10:15 a.m., the team reviewed the current patients' treatment plans. Each patient was then individually brought into the meeting. When Patient A2 entered the meeting, he was immediately given the written MTP and was asked to sign it (in 3 places). There was no explanation of the treatment plan or discussion of how it was formulated before obtaining the patient's signature. When the patient asked what the signature was for, a staff member replied "It shows you were here." During the subsequent discussion, there was no review of the goals for inpatient treatment or the patient's progress in achieving these goals. The focus was on discharge planning.

C. Interview

In an interview on 2/03/10 at 10:00 a.m., the Discharge Planner acknowledged the missing MD signatures on the above MTPs. When asked about patients signing the MTP forms before discussion of the treatment plans, she noted that there is not time to go over the treatment plan with the patients in the treatment planning meeting.

The absence of integrated, comprehensive treatment plans (MTPs) with active involvement of all interdisciplinary team members and inclusion of all required components results in lack of coordinated and organized treatment and possible failure to address all of the patients' treatment needs. Failure to actively involve patients in the formulation and updates of the treatment plan during the hospitalization limits the patient's ability to fully participate in the treatment process.

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

I. Protect 2 of 8 patients active sample patients (A3 and B1) from the use of chemical restraint in non-emergency situations. Patient A3 was given an intramuscular (IM) injection of the combination medication "Haldol 5mg, Ativan 1mg and Benadryl 25mg" on 2/3/10 without clear evidence impending harmfulness to self or others. Patient B1 received two doses of the same IM medication combination on 2/1/10 without the clear indication of impending harmfulness to self or others. Staff did not recognize these medication combinations as "chemical restraints" and did not follow procedures for "Seclusion/Restraint." These failures are a violation of patient rights to be free from restraint except to ensure the immediate physical safety of self or others.

II. Protect two patients (sample patient A3 and non-sample patient C1) from potential or actual preventable side-effects from intramuscular injections. In the case of patient A3, the patient was given an IM injection of a medication to which the patient was noted to be allergic, with potential risk of serious injury or death from an allergic reaction. In the case of patient C1, the patient was given a series of injections at an inappropriate injection site, which compromised the patient ' s well-being and added increased morbidity (pain and infection). (Refer to B125 Part II)

III. Obtain written patient consent before administering psychotropic medications to Patients A3 and B1 who were given combination doses of Haldol, Ativan and Benadryl. The nursing staff failed to obtain written patient consent prior to administering these medications to the patients. This failure is a violation of patient rights to informed consent for the administration of psychotropic medication.

IV. Ensure that physician orders gave nursing staff proper guidance on the administration of antianxiety medications used for detoxification and/or pain medications for 2 of 8 active sample patients (A2 and B1). Physician orders for these patients were written on a PRN (as necessary) basis. In the case of Patient A2, for the non-specific condition of "pain," the orders were written with a choice of different medications without instruction as to the order in which the medications were to be administered. Nurses could choose to administer the medications based on their own decision or on patient decision. Nursing used medications outside of the parameters given for detoxification, and in the case of Patient B1, outside of the indication written in the order. These failures resulted in nursing staff making prescriptive decisions and therefore functioning outside the scope of nursing practice. Further, ambiguous physician orders can result in serious complications from improperly administered PRN medications.

Findings are:

I. Failure to protect 2 of 8 patients active sample patients (A3 and B1) from the use of chemical restraint in non-emergency situations.

A. Patient A3

1. The surveyor was on the acute care unit on 02/03/10 between 9:15 am and 10:15 am. Patient A3 came to the door of the nurse's station to request from her attending physician "I would like another shot." The attending physician responded to A3 by stating "We're not allowed to give that combination of medications anymore; let's try Vistaril instead." The patient stated "Vistaril doesn't work for me." One of the staff nurses present at the time stated [Patient] "may be abusing Geodon...she abused Vistaril before she came in. She (A3) seems to ask for the injections on a regular basis, she's early today." Both surveyors noted that Patient A3 did not appear agitated during the observations that morning.

2. The surveyor returned to the unit at 11:15 am on 02/03/10. The surveyor found an order for "Haldol 5mg, Ativan 1mg, Benadryl 25mg IM now for agitation" in the patient's medical record. This order was written at 10:00 a.m. and was administered by nursing staff at 11:00 a.m. The patient's attending physician was present on the unit, and there was no evidence that the physician had initiated any seclusion or restraint progress notes identifying the reason for chemical restraint. There were no nursing notes present in the patient's chart regarding the administration and/or monitoring of the use of the combination of medications as of 02/03/10 at 11:50 a.m.

B. Patient B1

1. Patient B1 was admitted to the facility on 01/28/10 for opiate detoxification; the patient had no previous history of psychiatric illness or psychotropic medication prescriptions. There was no evidence of psychotic symptoms on admission per the Initial Psychiatric Evaluation dated 01/29/10.

2. The Physician Order dated 02/01/10 at 10:10 am noted "Haldol [antipsychotic] 5mg, Ativan [antianxiety] 2 mg. Benadryl [antihistamine] 50 mg. all IM [intramuscular] q12hrs [every 12 hours], prn [as needed] agitation."

3. The Medication Administration Record (MAR) noted that the combination of medications noted above was given at 10:20 am on 02/01/10; a second dose was given at 10:00 pm on 02/01/10 [less than 12 hours between doses]. The reverse side of the MAR page for 02/01/10 noted that the patient had been given the medications for agitation as he did respond to the first dose. The note stated "Pt. sleeping, helpful." The MAR response notation for the second dose of these medications noted an indication as "c/o [complaining of] anxiety" and noted that the dosing was "ineffective." There was no evidence in the patient record that this incident was treated as a chemical restraint; there was no evidence of an evaluation by an L.I.P. (licensed independent practitioner) nor was there any evidence that nursing staff had initiated seclusion/restraint monitoring of chemical restraint.

4. Physician progress notes dated 02/01/10 and 02/02/10 made no mention of the effect of these two medication dosing episodes.

5. The surveyor attended the treatment team meeting for Patient B1 on 02/02/10 at 9:50 a.m. The attending physician interviewed patient B1 and described the use of Haldol, Ativan and Benadryl as "to help you sleep, did it work?" B1 responded "No."

6. A nursing progress note dated 02/01/10 at 11:11 am noted: "Pt. c/o not being able to sleep with increased anxiety agitation, pt was seen by (attending MD) in AM, pt given Ativan 2mg, Haldol 5 mg, Benadryl 50 mg. IM administered and Valium 5 mg. for anxiety/agitation. Pt energy level is low with poor appetite...pt in bed most of the day, isolates to self."

7. A nursing progress note dated 02/02/10 at 3:05 a.m. noted no information about the second dosing of prn IM Haldol, Ativan and Benadryl.

8. In an interview on 02/02/10 at 9:00 a.m., after discussing the combination medications given to Patient B1, the Director of Nursing stated "our procedures were not followed for this patient." She added that "Doctors in this hospital order these medications to give patients a nap (making hand gestures indicating quotation marks)," and stated "I gave a patient these meds this way this last weekend when I worked on the unit."

9. In an interview on 02/02/10 at 1:20 p.m., the Medical Director was shown the information noted above; he agreed with the findings and stated that "this combination of medications should only be used for nearly out of control patients." He agreed that Patient B1 was not out of control when he received these medications.

II. Failure to protect two patients (sample patient A3 and non-sample patient C1) from potential or actual preventable side-effects from intramuscular injections.

A. Patient A3

1. Review of the medical record revealed a physician order for a combination IM dose of Haldol, Ativan and Benadryl, written on 2/3/10 at 10:00 a.m. On the physician's order page, there was a line near the top of the page which was a fill-in section titled "Drug Allergies:" Written in red ink was the word "Haldol."

2. Review of the patient's History and Physical Examination, dated 01/28/10 at 9:12 p.m., revealed the following notation: "Allergies: The patient is allergic to HALDOL."

3. The Medication Administration Record (MAR) verified that A3 received the prescribed combination dose of Haldol, Ativan and Benadryl on 2/3/10 at 11:00 a.m. IM (intramuscularly). The top of the MARs page noted "Allergies: Haldol." The Medication Administration record showed that on 02/03/10, A3 received Vistaril 25 mg. p.o. (by mouth) at 10:00 a.m. and then received Haldol, Ativan and Benadryl at 11:00 a.m. IM (intramuscularly). The top of the page noted "Allergies: Haldol." The back of the MAR page noted that the dose of Vistaril given at 10:00 a.m. had "decreased Anx [sic]" with the nursing observation timed at 11:00 am on 02/03/10. The nursing observation for the effectiveness of the IM injection given at 11:00 a.m. had not been noted in the MAR as of 11:30 a.m. on 02/03/10.

4. The surveyor interviewed the medication nurse LVN1 (licensed vocational nurse) at 11:15 a.m. on 02/03/10. LVN1 stated that he had given the IM Haldol, Ativan and Benadryl as ordered at 11:00 am. The surveyor showed LVN1 the MAR with the Haldol allergy notation. LVN1 responded "I didn't see that; oh my goodness." The surveyor asked to see the written consent form for Haldol. LVN1 responded that he hadn't obtained one yet. The surveyor then showed the MAR to the charge nurse so that the patient could be monitored for safety due to the allergy alert.

5. In an interview on 02/03/2010 11:15 a.m., Patient A3 reported that she had not been informed that the IM medication she received that morning (11:00 am) was different from the one she received "every day." She stated "I thought they gave me the same medicine I had before. Did they give me something different?" When queried about a signed consent, Patient A3 reported that she had not signed a consent form for the IM injection she received that morning (02/03/10) at 11:00am.

6. The surveyor interviewed the Director of Nursing and the Medical Director at 11:20 a.m. on 02/03/10. The surveyor showed the information noted above to them. The Director of Nursing responded with "...this shouldn't have happened." The Medical Director stated "This combination shouldn't have been used like this."

B. Patient C1

1. The surveyor was reviewing the "Staff Meeting" notes dated December 2 & 5, 2009. Under the section for "In-Service Training" in the POC attachments provided by the Director of Nursing, the surveyor saw the following typed notations: [Item] "46. IMs- Here is a picture of an arm following an IM. I am told that we are documenting where IMs are given and that is not okay. That is basic requirement in Nursing 101-location. As a result a patient got repeated Toradol shots in one arm. I am told this happened HERE before. That makes it even worse if that is true. Repeating the same mistake is not acceptable. So effective immediately ALL injections will have documentation of location." The Director of Nursing clarified on 02/01/10 at 3:00 p.m. that these notes were her minutes, emphasizing that she was talking in first person to her staff members.

2. The photographs referred to above were three photos identifying bruising over 75% of the patient's right upper arm. The photographs were not dated and did not have any patient identifiers on the page.

3. After reading the Staff Meeting notes and seeing the photographs, the surveyor asked the Director of Nursing for the patient's medical record. The Director of Nursing stated that she didn't know who the patient was or when the event occurred, and that she would have to ask staff if they remember the patient's name. The surveyor then asked if an incident report or investigation had been completed. The Director of Nursing answered that neither action had been taken by her or by her staff.

4. The facility's preprinted admission order form (page 2 of 2) included a listing (with a check box for the order) for "Ketorolac tromethamine [Toradol] 30 mg, IM [intramuscular] q6h/prn[every 6 hours as needed] for severe pain x [times] 5 days." The form also said "Note: Ketorolac order is for 5 days only; D/C [discontinue] all other NSAIDS [antiimflammatories]; do not exceed 120 mg/24hrs." This notation did not take into account the FDA "black box" warning that lowers the total dose limit of Toradol for patients who are elderly, have renal disease, or are under a certain weight. When queried about the order, the Director of Nursing acknowledged that the nursing staff and medical staff did not monitor these special limits for Toradol on a routine basis.

5. On 02/02/10, the Director of Nursing identified the patient involved in the incident noted above as Patient C1.

6. Review of C1's record revealed:

a. Orders for Toradol were as follows:

11/16/09 at 4:30 p.m.: "Toradol 30mg IM once daily for complaints of severe pain."

11/18/09 at 7:30 p.m.: "Toradol 15mg IM q day prn pain or severe headache." The previous 30mg dose was not discontinued.

b. The Medication Administration Record (MAR) included the following seven IM medication administrations over seven days:

Toradol 30 mg. IM on 11/14/09 at 6:00 p.m.
Promethazine [antinausea medication] 25mg. IM on 11/14/09 at 6:00 p.m.
Ativan 1mg. IM on 11/18/09 at 5:00 p.m.
Toradol 15mg. IM on 11/19/09 at 5:45 p.m.
Ativan 2mg. IM on 11/19/09 at 8:00 p.m.
Ativan 2mg. IM on 11/20/09 at 8:35 p.m.
Toradol 15mg. IM on 11/21/09 at 11:30 a.m. (7 days after the first Toradol injection)

None of the prn (as needed) IM medications had nursing notations showing location of the injection.

c. An Internal Medicine Progress Note dated 11/21/09 at 4:45 p.m. (5 hours after last Toradol injection) noted:

"Pt is feeling pain in the right shoulder after an injection. Pt. is feeling pain. Right arm: swelling, subcutaneous maceration present and warmth and tender. Pt has been given 3-4 IMs. Plan: Cipro [antibiotic] for possible infection."

d. A Family Practice Progress Note dated 11/22/09 at 9:30 am noted:

"Pt. wants her hematoma examined. States after shot IM injection developed...ecchymosis right upper arm with persistent pain. Shot 11/20/09. Pain level 10/10 when moving."
"Objective: Right arm: large ecchymosis ? of upper arm. No apparent swelling or hematoma. Pt states pain is 10/10 over deltoid area. Assessment: 1. Contusion right upper arm plus/minus cellulitis given degree of pain. Will cover empirically with Keflex [antibiotic] 500mg. q6 [every 6 hours] x 10d [for 10 days]. Monitor."

e. There were no further Internal Medicine or Family Practice notes during the rest of the hospitalization. The discharge was dated 11/25/09.

6. Psychiatric Progress Notes dated 11/22/09, 11/23/09, 11/24/09 did not mention the arm injury.

7. Nursing progress notes were as follows:

11/22/09 4:00 p.m.: "Infection from a shot during hospitalization. Pt. was medicated with Keflex 500mg. for the infection." No other reference noted.

11/22/09 8:00 p.m.: No reference to arm injury in the note.

11/23/09 7:00 a.m.: No reference to arm injury in the note.

11/23/09 9:25 a.m.: "She complains of pain 9/10 in right arm on touch and moving it around. She does have discoloration on upper right arm. Picture of arm taken and given to DON (Director of Nursing)."

11/23/09 10:40 p.m.: "She is still complaining of pain in her right shoulder/arm."

11/24/09 6:35 p.m.: No reference to arm injury in the note.

11/24/09 1:30 a.m.: (actually referred to 11/25/09 not 11/24/09 per charge nurse who confirmed this note on 02/03/09 at 9:45 am): "Is getting antibiotics for arm infection."

11/25/09 2:50 p.m.: No reference to arm injury in the note.

8. The Discharge Summary dated 11/24/09 had no information regarding an adverse reaction or for the treatment of an iatrogenic arm injury.

9. In an interview on 02/01/10 at 3:45 p.m., the Director of Nursing (DON) reported that she believed the patient had received "several injections" in her right arm. The DON said she thought that "Toradol shouldn't be given in the arm at all."

III. Failure to obtain written patient consent before administering Haldol, Ativan and Benedryl to Patients A3 and B1

A. Patient A3

1. Patient A3 was administered a physician prescribed IM dose of Haldol, Ativan and Benadryl on 2/3/10 at 11:00 a.m. In an interview on 02/03/10 11:15 a.m., Patient A3 reported that she had not been informed that the IM medication she received that morning (11:00 am) was different from the one she received "every day." She stated "I thought they gave me the same medicine I had before. Did they give me something different?" When queried about a signed consent, Patient A3 reported that she had not signed a consent form for the IM injection she received that morning (02/03/2010) at 11:00am.

2. The physician surveyor interviewed the medication nurse (LVN1) on 02/03/10 at 11:15 a.m. LVN1 verified that he had given the IM Haldol, Ativan and Benadryl as ordered at 11:00 a.m. The surveyor asked to see the written consent form for Haldol. LVN1 responded that he hadn't obtained one yet.

B. Patient B1

1. Patient B1 was administered combination doses of Haldol, Ativan and Benadryl on 2/1/10 at 10:20 a.m. and 10:00 p.m. When interviewed by the surveyor on 2/02/10 at 8:50 a.m., B1 stated that he had not been told what specific medicines he had received by injections the day before, only that "they were to help me sleep." He stated that he did not sign any written consent forms for the intramuscular medications prior to the injections.

2. In an interview on 02/02/10 at 8:45 a.m. the medication nurse could not find a signed, written consent form for the Haldol, Ativan or Benadryl administered to patient B1.

C. Policy Review

1. Riverside Center for Behavioral Medicine, Policies and Procedures, Policy No: 52, "Subject: Informed Consent for Psychotropic Medication," Issued 8/2002, last revised 10/2009 has the following statements:

2. "Scope: This procedure will apply to all adult patients, voluntarily admitted to Riverside Center for Behavioral Medicine, who are prescribed and/or administered neuroleptics, lithium, antidepressant, anxiolytics or medications used to control cravings for drugs of abuse."

3. "Method: ...2. The explanation of the medication use, benefits and potential side effects as well as obtaining the patient's consent for treatment and signature on the consent form shall be the responsibility of the prescribing physician or the charge nurse at the time the mediation is ordered."

4. "9. No medication(s) as defined in this policy will be administered in the absence of a signed consent form."

IV. Failure to ensure that provide physician orders gave nursing staff proper guidance on the administration of antianxiety medications used for detoxification and/or pain medications for 2 of 8 active sample patients (A2 and B1).

A. Patient A2

1. A review of the medical record for Patient A2, admitted 01/18/10, revealed the following physician medication orders:

"Toradol 30 mg IM (intramuscular) q12h (every 12 hours) prn (as needed) for pain" dated 01/19/10.

"Vicodin one po (orally) q8h (every 8 hours) prn pain" dated 01/19/10 (given once on 01/19/10 at 6:00 p.m. and discontinued)

"Norco 10/325 mg one po bid (twice a day) prn pain" dated 01/19/10

"Magnesium sulfate 500mg IM q4h (every 4 hours) prn pain" dated 01/28/10.

There was no guidance written in the orders as to how nursing should choose among the medications for treating the patient's pain complaints, nor guidance as to what kind of pain should be treated with any of these medications.

2. The Medication Administration Record (MAR) review revealed the following medication administrations:

a. Toradol 30 mg IM: 01/19/10 doses at 12:30 a.m. and 12:30 p.m.; 01/20/10 dose at 1:09 p.m.; 01/21/10 dose at 2:05 a.m.; 01/22/10 dose at 12:00 p.m.; 01/23/10 doses at 11:30 a.m. and 11:00 p.m. (less than 12 hours apart as ordered); 01/24/10 dose at 6:05 p.m.; 01/25/10 dose at 10:00 a.m.

b. Vicodin (no dosage written): given on 01/19/10 at 6:00 p.m.


c. Norco 10/325mg: 01/19/10 doses at 9:30 a.m.; 01/20/10 doses at 8:40 a.m. and 5:00 p.m.; 01/21/10 doses at 7:00 a.m. and 3:00 p.m.; 01/22/10 doses at 7:00 a.m. and 3:00 p.m.; 01/23/10 doses at 6:45 a.m. and 3:00 p.m.; 01/24/10 doses at 6:50 a.m. and 3:00 p.m.; 01/25/10 doses at 6:00a.m. and 3:00 p.m.; 01/26/10 doses at 6:00 a.m. and 3:00 p.m.; 01/27/10 doses at 6:50 a.m. and 3:00 p.m.; 01/28/10 doses at 6:00 a.m. and 3:00 p.m.; 01/29/10 doses at 6:00 a.m. and 3:00 p.m.; 01/30/10 doses at 6:00 a.m. and 2:00 p.m.; 01/31/10 doses at 6:45 a.m. and 2:30 p.m.; 02/01/10 doses at 6:00 a.m. and 3:00 p.m.

d. Magnesium sulfate 500mg IM: 01/28/10 dose at 10:45 a.m.; 01/29/10 doses at 9:00 a.m.

B. Interview

1. The surveyor interviewed the medication nurse on the unit on 02/01/10 at 2:30 p.m. regarding which medication was given for pain on an "as needed" basis; the nurse responded that "I let the patient choose, the patient knows what will work for them. [sic]"

2. The surveyor interviewed Patient A2 on 02/02/10 at 8:45a.m. The patient reported "I have so much pain I take whatever I can get."

3. The surveyor interviewed the attending physician on 02/02/10 at 9:00 a.m. The physician reported that "the nurses decide which medication to give."

B. Patient B1

1. Record Review:

a. Preprinted physician admission orders dated 01/28/10 had check boxes marked for the following orders:

"PRN Taper/Diazepam"

"Diazepam (Valium) 5mg. po q1h for mild S/S-W/D, 1+ tremors, or HR>90, SBP>130, NTE 120mg/24h x 7 days" [Valium 5mg orally every hour for mild signs/symptoms of withdrawal, mild tremor, pulse greater than 90, systolic blood pressure greater than 130, not to exceed 120mg. in 24 hours for 7 days].

"Diazepam (Valium) 10mg. po q1h for moderate S/S-W/D, 2+ tremors, or HR>95, SBP>140, NTE 120mg/24h x 7 days" [Valium 5mg orally every hour for moderate signs/symptoms of withdrawal, moderate tremor, pulse greater than 95, systolic blood pressure greater than 140, not to exceed 120mg. in 24 hours for 7 days].

"Diazepam (Valium) 20mg. po q1h for severe S/S-W/D, 3+ tremors, or HR>105, SBP>150, NTE 120mg/24h x 7 days" [Valium 20mg orally every hour for severe signs/symptoms of withdrawal, marked tremor, pulse greater than 105, systolic blood pressure greater than 150, not to exceed 120mg. in 24 hours for 7 days].

b. Medication Administration Records

Patient B1 received Valium with the following notations by nursing staff:

Valium 10mg given 01/30/10 at 12:40 p.m.: "c/o tremor [complaining of tremor]." No notation of tremor grade was reported. No vital signs were reported.

Valium 10mg given 01/31/10 at 3:00 a.m.: "tremor, restlessness." No notation of tremor grade was reported; no vital signs were reported.

Valium 10mg given 01/31/10 at 10:15 a.m.: "+1 tremor, (up arrow) anxiety". No vital signs were reported. [Note: Valium 10 mg. was to be given for +2 tremor, not + 1 tremor].

Valium 10mg given 02/02/10 at 7:00 a.m.: "c/o anxiety, 6/10". Valium was not ordered for the treatment of anxiety. There was no notation regarding vital signs or tremor.

Valium 10mg given 02/02/10 at 1:31p.m.: "c/o anxiety, 8/10". Valium was not ordered for the treatment of anxiety. There was no notation regarding vital signs or tremor.

2. Interview

a. The surveyor interviewed the medication nurse on the unit on 02/02/10 at 4:15 p.m. The nurse was shown the MAR information noted above and agreed that Valium was not indicated for treating anxiety and stated "We don't always have time to get vital signs before giving the meds."

b. The surveyor interviewed the Medical Director on 02/03/10 at 9:40 a.m. The Medical Director agreed with the findings and stated "We're getting rid of these forms, they cause too much confusion."

Based on record review, policy review and interview, the facility failed to:

I. Provide a discharge summary that summarized all the treatment received in the hospital and the patient's response to treatment, other than medication administered in 1 of 8 discharge summaries reviewed (D1). This deficiency compromises the effective transfer of a patient's care to the next care provider by failing to provide information that identifies effective (or ineffective) treatment strategies for the individual patient.

II. Ensure that discharge summaries were dictated, transcribed and filed within 14 days of discharge in 1 of 8 discharge records reviewed (D2). This deficiency results in a failure to communicate in a timely manner, the final diagnosis, current medications, course of treatment, summary of relevant labs and testing, and the discharge plan and anticipated problems with outpatient providers.

Findings are:

I. Inadequate Description of Hospital Course of Treatment

A. Policy Review:

Riverside Center for Behavioral Health Medical Staff Rules and Regulations, issued 8/2002, under Section X. "Discharge Summaries" states: "B. Documentation to be Included...The discharge summary will contain a statement on the outcome of hospitalization and disposition of the case to include: 1. The patient and family's achievement of treatment goals... 4. Documentation of treatment."

B. Record Review

1. Patient D1 (discharge summary dated 01/15/10).

Documentation of hospital treatment only described the patient's response to medications: "HOSPITAL COURSE: The patient showed fair resolution of anxiety, guilt and depressive symptoms with her current dose of Wellbutrin, which is at 150mg. po qAM [antidepressant, orally, each morning]. The patient had a brief trial of Seroquel, but it was discontinued secondary to the patient's excessive anxiety and concerns regarding weight gain."

C. Interview

On 02/03/10 at 11:20 a.m. the Medical Director agreed with the findings.

II. Timeliness of Discharge Summary

A. Policy Review

Riverside Center for Behavioral Health Medical Staff Rules and Regulations, issued 8/2002, Section X. "Discharge Summaries" "A. Completion Time Frame" states: "The discharge summary shall be entered into the patient's record within a reasonable period of time and not to exceed fourteen (14) days following discharge."

B. Record Review

Patient D2, discharged 01/13/10, had a discharge summary dated 01/29/10. (16 days after discharge).

C. Interview

On 02/03/10 at 11:20 a.m. the Medical Director agreed with the surveyor's findings.

Based on Record review and interviews, the Medical Director failed to adequately monitor the orders written by medical staff: the Director failed to assure that the orders were properly written by physicians in relation to total dosages prescribed and to indications for combinations that were effectively chemical restraints, and that proper consent was obtained from patients prior to administration. (Refer to B144)
In addition, the facility failed to have proper oversight of nursing staff in the administration of medications, with both potential and actual adverse effects on the patients in the facility, failed to recognize a serious medication error in one patient (A3), failed to properly document an adverse reaction for one patient (C1) with an incident report, and failed to administratively review the incident. (Refer to B148).
These failures place patients at risk for possible harm , and in the case of patient C1, actual harm, resulting in a condition of IMMEDIATE JEOPARDY initiated on February 2, 2010 at 2:00 PM.






28205

Based on Record review and interviews, the Medical Director failed to adequately monitor the orders written by medical staff. The Medical Director failed to assure that the orders were properly written by physicians in relation to total dosages prescribed and indications for combinations medications that were effectively chemical restraints, and that proper consent was obtained from patients prior to administration of these medications. (Refer to B144-I)

In addition, the facility failed to have proper oversight of nursing staff in the administration of medications, with both potential and actual adverse effects on the patients in the facility, failed to recognize a serious medication error in one patient (A3), failed to properly document an adverse reaction for one patient (C1) with an incident report, and failed to administratively review the incident. (Refer to B148-I).

These failures place patients at risk for possible harm, and in the case of patient C1, actual harm, resulting in a condition of IMMEDIATE JEOPARDY initiated on February 2, 2010 at 2:00 p.m.

Based on Record review and interviews, the Medical Director failed to properly monitor the care provided at the facility. Specifically the Medical Director failed to:

I. Assure that the orders were properly written by physicians in relation to total dosages prescribed and to indications for medication combinations that were effectively chemical restraints, and that proper consent was obtained from patients prior to administration. In the case of at least one medication (Toradol), the facility allowed the use of a preprinted order form, written in a manner that could cause a patient to suffer significant kidney damage if the medication as ordered was administered at maximum dosage and not adequately screened or monitored. The pre-printed admission order also provided for a medication combination of Haldol, Benadryl and Ativan, effectively a chemical restraint to be used on a prn (as needed) basis, allowing nursing staff to continue giving these medications without adequate monitoring. Patients were administered medications prior to consent having been obtained; in the case of one patient (A3), the patient received an IM dosage of a medication without knowing what it was, and with information in the record that she was allergic to one of the drugs in the combination administered. These failures put patients at risk of preventable adverse medication effects, and at risk of chemical restraint without proper indication for its use.

Findings are:

A. General Chart orders:

Record review revealed pre-printed admission forms with pre-printed orders which, if used as written, could be a risk to certain patients:

1. The facility's preprinted admission order form (page 2 of 2) included a listing (with a check box for the order) for "Ketorolac tromethamine [Toradol] 30 mg, IM [intramuscular] q6h/prn [every 6 hours as needed] for severe pain x [times] 5 days." The form also said "Note: Ketorolac order is for 5 days only; D/C [discontinue] all other NSAIDS [anti-inflammatory]; do not exceed 120 mg/24hrs." This notation did not take into account the FDA "black box" warning that lowers the total dose limit of Toradol for patients who are elderly, have renal disease, or are under a certain weight. When queried about the order, the Director of Nursing acknowledged that the nursing staff and medical staff did not monitor these special limits for Toradol on a routine basis.

2. On page 2 of 2 of the preprinted "Physicians Order Sheet," approximately two-thirds of the way down the page, was the following check box order choice: "Lorazepam [Ativan] 2mg. Diphenhydramine [Benadry] 50mg. Haloperidol [Haldol] 5mg. (all IM) q4h/prn[every 4 hours as needed], for severe psychosis x[times] 7 days." The indication of "severe psychosis" is improper for medications which are effectively chemical restraint. In addition, chemical restraint should not be ordered on a "prn" basis, but must be ordered after patient evaluation for each individual episode requiring its use.


B. Patient Specific Findings:

I. Patient A3

a. Record Review:

1. On 02/03/10 the surveyor noted an order for "Haldol 5mg, Ativan 1mg, Benadryl 25mg IM now for agitation" in patient A3's medical record. This order was written at 10:00am and was signed off and given by nursing staff at 11:00 a.m. Also on the order page, there was a line near the top of the page which was a fill-in section titled "Drug Allergies:" Written in red ink was the word "Haldol." Administration of the medication, in spite of the notation of allergy to it had the potential of serious side effects if the patient had adversely reacted to the Haldol.

2. The History and Physical Examination dated 01/28/10 at 9:12 p.m. noted: "Allergies: The patient is allergic to HALDOL."

3. No written consent for Haldol administration was found in the patient's record.

b. Interview

1. During an interview on 02/03/10 11:15 a.m. Patient A3 reported that she had not been informed that the IM medication she received that morning (11:00 a.m.) (including Haldol) was different from the one she received "every day." She stated "I thought they gave me the same medicine I had before. Did they give me something different?" When queried about a signed consent, Patient A3 reported that she had not signed a consent form for the IM injection she received that morning (02/03/2010) at 11:00 a.m.

2. In an interview at 11:20 a.m. on 02/03/10, the Director of Nursing and the Medical Director reviewed the information noted above, related to the lack of consent, lack of proper indication for the medication combination prescribed, as well as the allergy issue. The Director of Nursing responded with "...this shouldn't have happened."

II. Patient B1

A. Record Review

1. The attending physician failed to obtain written patient consent prior to administering medications for patient B1. In addition, the Physician Order for patient B1, dated 02/01/10 at 10:10 a.m., noted "Haldol [antipsychotic] 5mg, Ativan [antianxiety] 2 mg, Benadryl[antihistamine] 50 mg. all IM[intramuscular] q12hrs[every 12 hours], prn[as needed] agitation." This combination of medications is effectively chemical restraint, but there was not a proper indication for its use in the order (danger to self or others) and evaluation for the use of restraint was not in the record. In addition, the order was written as a standing order, rather than individually prescribed at each episode where it was believed to be necessary.

2. The Medication Administration Record (MAR) recorded that the combination of medications noted above was given at 10:20 a.m. on 02/01/10; a second dose was given at 10:00 pm on 02/01/10. Physician progress notes dated 02/01/10 and 02/02/10 made no mention of use, consent, or effect of these two medication dosing episodes.

3. The medication nurse was interviewed by the surveyor on 02/02/10 at 8:45 a.m. in the medication room; the nurse could not find a signed, written consent form for the Haldol, Ativan or Benadryl, given to patient B1.

B. Interviews

1. In an interview on 02/02/10 at 8:50 a.m., patient B1 noted that he had not been told what specific medicines he had received by injections the day before, only that "they were to help me sleep." He stated that he did not sign any written consent forms for the intramuscular medications prior to the injections. Although the indication for the order was "agitation," the patient did not show any severe symptoms during the interview and denied any psychotic symptoms to the physician surveyor. He was polite and cordial, not pacing or fidgeting (he uses crutches to ambulate because of bilateral knee braces). He did not appear overly distressed.

2. The Director of Nursing confirmed on 02/02/10 at 9:00 a.m. that "our procedures were not followed for this patient." She noted that "Doctors in this hospital order these medications to give patients a nap (making hand gestures indicating quotation marks)," and stated "I gave a patient these meds this way this last weekend when I worked on the unit."

C. Policy Review

Riverside Center for Behavioral Medicine, Policies and Procedures, Policy No: 52, "Subject: Informed Consent for Psychotropic Medication," Issued 8/2002, last revised 10/2009 has the following statements:

"Scope: This procedure will apply to all adult patients, voluntarily admitted to Riverside Center for Behavioral Medicine, who are prescribed and/or administered neuroleptics, lithium, antidepressant, anxiolytics or medications used to control cravings for drugs of abuse....

"Method: ... 2. The explanation of the medication use, benefits and potential side effects as well as obtaining the patient's consent for treatment and signature on the consent form shall be the responsibility of the prescribing physician or the charge nurse at the time the mediation is ordered....

"No medication(s) as defined in this policy will be administered in the absence of a signed consent form."

III. Patient C1

A. Record Review

1. Orders for Toradol were as follows:


11/16/09 at 4:30pm: "Toradol 30mg IM once daily for complaints of severe pain."

11/18/09 at 7:30pm: "Toradol 15mg IM q day prn pain or severe headache." The previous 30mg dose was not discontinued.

2. The Medication Administration Records (MAR) for patient C1 included at least seven IM medication administrations over seven days:

Toradol 30 mg. IM on 11/14/09 at 6:00 p.m.
Promethazine [antinausea medication] 25mg. IM on 11/14/09 at 6:00 p.m.
Ativan 1mg. IM on 11/18/09 at 5:00 p.m.
Toradol 15mg. IM on 11/19/09 at 5:45 p.m.
Ativan 2mg. IM on 11/19/09 at 8:00 p.m.
Ativan 2mg. IM on 11/20/09 at 8:35 p.m.
Toradol 15mg. IM on 11/21/09 at 11:30 a.m. (7 days after the first Toradol injection)

3. An Internal Medicine Progress Note dated 11/21/09 at 4:45 pm (5 hours after last Toradol injection) noted:
"Pt is feeling pain in the right shoulder after an injection. Pt. is feeling pain. Right arm: swelling, subcutaneous maceration present and warmth and tender. Pt has been given 3-4 IMs. Plan: Cipro [antibiotic] for possible infection."


4. A Family Practice Progress Note dated 11/22/09 at 9:30 am noted:
"Pt. wants her hematoma examined. States after shot IM injection developed...ecchymosis right upper arm with persistent pain. Shot 11/20/09. Pain level 10/10 when moving."

"Objective: Right arm: large ecchymosis ? of upper arm. No apparent swelling or hematoma. Pt states pain is 10/10 over deltoid area. Assessment: 1. Contusion right upper arm plus/minus cellulitis given degree of pain. Will cover empirically with Keflex [antibiotic] 500mg. q6 [every 6 hours] x 10d [for 10 days]. Monitor."

5. There were no further Internal Medicine or Family Practice notes during the rest of the hospitalization. The discharge was dated 11/25/09.

6. Psychiatric Progress Notes dated 11/22/09, 11/23/09, 11/24/09 did not mention the arm injury.

7. The Discharge Summary dated 11/24/09 had no information regarding an adverse reaction or for the treatment of an iatrogenic arm injury.

8. No incident report was found for the adverse event. The DON was not able to find any policy regarding reporting of incidents of this nature.

B. Interview

The Medical Director was interviewed by the surveyors on 02/02/10 at 1:20 p.m. He acknowledged that the Toradol medication incident with Patient C1 had not been reviewed in any committee meeting, including pharmacy and therapeutics committee, quality council, medical executive committee and peer review committee. He stated "this is the first I'm hearing of this."


II. Ensure psychiatric evaluations for 1 of 1 sample patients admitted to a non-psychiatric physician for detoxification (B3). Absence of this patient information hinders the treatment teams' ability to formulate an appropriate problem list and plan for appropriate treatment. (Refer to B110)

III. Ensure that psychiatric evaluations reported orientation, memory functioning and/or intellectual functioning in measurable, behavioral terms for 8 of 8 active sample patients (A1, A2, A3, A4, A6, B1, B2 and B3). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured. (Refer to B116)

IV. Ensure that psychiatric evaluations included an assessment of patient assets that would be used in treatment for 8 of 8 active sample patients (A1, A2, A3, A4, A6, B1, B2 and B3). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy. (Refer to B117)

V. Ensure that physician (MD/psychiatrist) interventions were included in the Master Treatment Plans (MTPs) for 8 of 8 active sample patients (A1, A2, A3, A5, A6, B1, B2 and B3). Other aspects of the plans also were incomplete: plans lacked identification and utilization of patient strengths/assets in 8 of 8 sampled records (Patients A1, A2, A3, A5, A6, B1, B2 and B3); lacked substantiated diagnoses in 3 of 8 sampled records (Patients A2, B2 and B3); and lacked physician signatures in 5 of 8 sampled records (A1, A3, A6, B1 and B2). In addition, observation revealed that patient signatures on the MTPs were obtained during the weekly Treatment Team Planning meetings before explanation and/or discussion of the treatment plans. (Refer to B118)

VI. Ensure that physician orders gave nursing staff proper guidance on the administration of antianxiety medications used for detoxification and/or pain medications for 2 of 8 active sample patients (A2 and B1). Physician orders for these patients were written on a PRN (as necessary) basis for the non-described condition of "pain," with a choice of different medications or without clear instruction as to how the medications were to be administered. Nurses could choose to administer the medications based on their own decision or on patient decision. Nursing used medications outside of the perimeters given for detoxification and outside of the indication for Patient B1. These failures resulted in nursing staff making prescriptive decisions and therefore functioning outside the scope of nursing practice. Further, ambiguous physician orders can result in serious complications from improperly administered PRN medications. (Refer to B125-IV)

VII. Ensure a discharge summary that summarized all the treatment received in the hospital and the patient's response to treatment other than medication in 1 of 8 discharge summaries reviewed (D1), and ensure that discharge summaries were dictated, transcribed and filed within 14 days of discharge for 1 of 8 discharge records reviewed (D2). These deficiencies compromise the effective transfer of the patient's care to the next care provider. (Refer to B133 I and II)

Based on Record Review and interview, the Director of Nursing failed to:

I. Adequately train and monitor nursing staff in the proper administration of medications, and to assure that medications were administered for the correct indications, at the correct dosage intervals, in a safe manner, and with patients' informed consent. This failure jeopardizes patient safety, and puts them at risk for chemical restraint without appropriate indication.

Findings are:

A. Patient A3

1. The nursing staff failed to obtain written patient consent prior to administering an injection of a new medication for patient A3. Review of the record revealed that there was no written consent form in the record for Haldol. In the case of patient A3, the MAR and the History and Physical both clearly indicated the patient had an allergy to Haldol, and yet this medication was prescribed and given on 02/03/10. (For details, refer to the patient information for patient A3 under B144.) The Medication Administration record showed that on 02/03/10 A3 received Vistaril 25 mg. po (by mouth) at 10:00 a.m. and then received Haldol, Ativan and Benadryl at 11:00 a.m. IM (intramuscularly). The top of the page noted "Allergies: Haldol". The back of the MAR page noted the dose of Vistaril given at 10:00 a.m. "decreased Anx [sic]," with the nursing observation timed at 11:00 a.m. on 02/03/10. The nursing observation for the effectiveness of the intramuscular injection given at 11:00 a.m. had not been noted in the MAR as of 11:30 a.m. on 02/03/10.

2. In an interview at 11:15 a.m. on 02/03/10, the medication nurse stated that he had given the IM Haldol, Ativan and Benadryl as ordered at 11:00 a.m. The surveyor showed the nurse the MAR with the Haldol allergy notation. The medication nurse responded "I didn't see that, oh my goodness." The surveyor asked to see the written consent form for Haldol. The medication nurse responded that he hadn't obtained one yet. The surveyor then showed the MAR to the charge nurse so that the patient could be monitored for safety due to the allergy alert.

3. In an interview on 02/03/2010 at 11:15 a.m., Patient A3 reported that she had not been informed that the IM medication she received that morning (11:00 a.m.) was different from the one she received "every day." She stated "I thought they gave me the same medicine I had before. Did they give me something different?" When queried about a signed consent, Patient A3 reported that she had not signed a consent form for the IM injection she received that morning (02/03/10) at 11:00 a.m.

4. In an interview at 11:20 a.m. on 02/03/10, the Director of Nursing reviewed the information noted above which highlighted the lack of consent, the incorrect indications for medication administration, as well as the allergy issue. The Director of Nursing responded with "...this shouldn't have happened."

5. Riverside Center for Behavioral Medicine, Policies and Procedures, Policy No: 52, "Subject: Informed Consent for Psychotropic Medication," Issued 8/2002, last revised 10/2009 has the following statements:

"Scope: This procedure will apply to all adult patients, voluntarily admitted to Riverside Center for Behavioral Medicine, who are prescribed and/or administered neuroleptics, lithium, antidepressant, anxiolytics or medications used to control cravings for drugs of abuse"....

"Method: ... 2. The explanation of the medication use, benefits and potential side effects as well as obtaining the patient's consent for treatment and signature on the consent form shall be the responsibility of the prescribing physician or the charge nurse at the time the mediation is ordered....

"No medication(s) as defined in this policy will be administered in the absence of a signed consent form."

B. Patient B1

1. The nursing staff failed to obtain written patient consent for Haldol prior to administering medications for patient B1. Valium also had been ordered 01/28/10 for withdrawal symptoms along with vital sign parameters. There was no reference in the record (progress notes or MAR) that the nurse documented vital signs prior to giving the Valium dose, and there was no reference for the use of Valium for the indication of anxiety or agitation in the physician order dated 01/28/10 (no time indicated). A nursing progress note dated 02/02/10 reported that Valium 10mg. was given at 11:55 p.m. There was no notation related to vital signs or moderate withdrawal symptom status associated with the dosing as required by the physician order dated 1/28/10 (no time indicated).

2. In addition, the Physician Order for patient B1, dated 02/01/10 at 10:10 a.m., noted "Haldol [antipsychotic] 5mg, Ativan [antianxiety] 2 mg. Benadryl [antihistamine] 50 mg. all IM [intramuscular] q12hrs [every 12 hours], prn [as needed] agitation." The Medication Administration Record (MAR) recorded that the combination of medications - Haldol, Benadryl and Ativan - was given to the patient at 10:20 a.m. on 02/01/10; a second dose was given at 10:00 p.m. on 02/01/10, less than 12 hours between doses, as the order required. The reverse side of the MAR page for 02/01/10 noted that the patient had been given the medications for agitation as he did respond to the first dose. The note stated "Pt. sleeping, helpful." The MAR response notation for the second dose of these medications noted an indication as "c/o [complaining of] anxiety" (wrong indication as per physician orders) and noted that the dosing was "ineffective." A nursing progress note dated 02/02/10 at 3:05 a.m. noted no information as to indication for or response to the second dosing of prn IM Haldol, Ativan and Benadryl. There also were no documentations regarding monitoring as required when chemical restraints are employed.

3. In an interview on 02/02/10 at 8:50 a.m., B1 noted that he had not been told what specific medicines he had received by injections the day before, only that "they were to help me sleep." He stated that he did not sign any written consent forms for the intramuscular medications prior to the injections. Although the order indicated the medication was to be given for "agitation," the patient did not present with any such symptoms during the interview and denied any psychotic symptoms to the physician surveyor. He was polite and cordial, not pacing or fidgeting (he uses crutches to ambulate because of bilateral knee braces). He did not appear overly distressed.

4. The medication nurse was interviewed by the surveyor on 02/02/10 at 8:45 a.m. in the medication room; the nurse could not find a signed, written consent form for Haldol, Ativan or Benadryl.

5. The Director of Nursing confirmed on 02/02/10 at 9:00 a.m. that "our procedures were not followed for this patient." She noted that "Doctors in this hospital order these medications to give patients a nap (making hand gestures indicating quotation marks)," and stated "I gave a patient these meds this way this last weekend when I worked on the unit."

C. Patient C1

Adverse Reaction to Intramuscular Medications

1. "Staff Meeting" notes dated December 2 & 5, 2009 showed the following typed notations under item 46: "46. IMs [intramuscular injections] - Here is a picture of an arm following an IM. I am told that we are documenting where IMs are given and that is not okay. That is basic requirement in Nursing 101-location. As a result a patient got repeated Toradol shots in one arm. I am told this happened HERE before. That makes it even worse if that is true. Repeating the same mistake is not acceptable. So effective immediately ALL injections will have documentation of location." The Director of Nursing clarified on 02/01/10 at 3:00 pm that these notes were her minutes, emphasizing that she was talking in first person to her staff members.

2. The photographs referred to above were three photos identifying bruising over 75% of the patient's right upper arm. The photographs were not dated and did not have any patient identifiers on the page.

3. The Director of Nursing stated that she didn't know who the patient was or when the event occurred, and that she would have to ask staff if they remember the patient's name. The surveyor then asked if an incident report or investigation had been completed. The Director of Nursing answered that neither action had been taken by her or by her staff.

On 02/02/10, the Director of Nursing identified the patient involved in the incident noted above as Patient C1; the record was reviewed.

4. Orders for Toradol were as follows:

11/16/09 at 4:30 p.m.: "Toradol 30mg IM once daily for complaints of severe pain."

11/18/09 at 7:30 p.m.: "Toradol 15mg IM q day prn pain or severe headache" The previous 30mg dose was not discontinued.


5. The Medication Administration Records (MAR) included at least seven IM medication administrations over seven days:

Toradol 30 mg. IM on 11/14/09 at 6:00 p.m.
Promethazine [antinausea medication] 25mg. IM on 11/14/09 at 6:00 p.m.
Ativan 1mg. IM on 11/18/09 at 5:00 p.m.
Toradol 15mg. IM on 11/19/09 at 5:45 p.m.
Ativan 2mg. IM on 11/19/09 at 8:00 p.m.
Ativan 2mg. IM on 11/20/09 at 8:35 p.m.
Toradol 15mg. IM on 11/21/09 at 11:30 a.m. (7 days after the first Toradol injection)


None of the above prn (as needed) IM medications had nursing notations showing location of the injection.

6. Nursing progress notes were as follows:

11/22/09 4:00 p.m.: "Infection from a shot during hospitalization. Pt. was medicated with Keflex 500mg. for the infection." No other reference noted.

11/22/09 8:00 p.m.: No reference to arm injury in the note.

11/23/09 7:00 a.m.: No reference to arm injury in the note.

11/23/09 9:25 a.m.: "She complains of pain 9/10 in right arm on touch and moving it around. She does have discoloration on upper right arm. Picture of arm taken and given to DON (Director of Nursing)."

11/23/09 10:40 p.m.: "She is still complaining of pain in her right shoulder/arm."

11/24/09 6:35 p.m.: No reference to arm injury in the note.

11/24/09 1:30 a.m.: (actually referred to 11/25/09 not 11/24/09 per charge nurse who confirmed this note on 02/03/09 at 9:45 am): "Is getting antibiotics for arm infection."

11/25/09 2:50 p.m.: No reference to arm injury in the note.

7. No incident report was found for the adverse event. The DON was not able to find any policy regarding reporting of incidents of this nature.

8. In an interview on 02/01/10 at 3:45 p.m., the Director of Nursing (DON) reported that she believed the patient had received "several injections" in her right arm and thought that "Toradol shouldn't be given in the arm at all." The DON acknowledged that she had failed to educate staff regarding the safe use of Toradol, and failed to make the preprinted physician order sheet detailed enough. The DON also acknowledged that she failed to initiate an incident report when nursing staff gave her the photographs of the injury and did not sufficiently monitor nursing documentation as related to IM injection sites.

II. Monitor the administration of medications used for detoxification and/or pain control for 2 of 8 active sample patients (A2 and B1), assure that ambiguous orders were clarified, and assure that nurses did not make medication decisions outside of the scope of nursing practice. Physician orders for these patients were written on a PRN (as necessary) basis, with various choices of different medications and/or dosages. Nurses were allowed to determine what specific medication and/or what dosage to administer, based on their own judgment or the patient's request. In the case of patient A2, medications were administered outside of the parameters given for detoxification; in the case of patient B1, medication was given for the wrong indication. Failure to monitor medication administration, and assure that ambiguous orders are clarified and that nurses do not make decisions outside of nursing practice can result in serious complications from improperly administered medications.


Findings are:

A. Patient A2

1. A review of the medical record for Patient A2, admitted 01/18/10, revealed the following physician medication orders:

"Toradol 30 mg IM (intramuscular) q12h (every 12 hours) prn (as needed) for pain" dated 01/19/10; "Vicodin one po (orally) q8h (every 8 hours) prn pain" dated 01/19/10 (given once on 01/19/10 at 6:00 p.m. and discontinued); "Norco 10/325 mg one po bid (twice a day) prn pain" dated 01/19/10; "Magnesium sulfate 500mg IM q4h (every 4 hours) prn pain" dated 01/28/10.

There was no evidence that nurses had attempted to clarify how they should choose among these various medications for treating the patient's pain complaints, nor what kind of pain should be treated with any of these medications.

2. The Medication Administration Record (MAR) review revealed the following medication administrations:

a. Toradol 30 mg IM: 01/19/10 doses at 12:30 a.m. and 12:30 p.m.; 01/20/10 dose at 1:09 p.m.; 01/21/10 dose at 2:05 a.m.; 01/22/10 dose at 12:00 p.m.; 01/23/10 doses at 11:30 a.m. and 11:00 p.m. (less than 12 hours apart as ordered); 01/24/10 dose at 6:05 p.m.; 01/25/10 dose at 10:00 a.m.

b. Vicodin (no dosage written): given on 01/19/10 at 6:00 p.m.


c. Norco 10/325mg: 01/19/10 doses at 9:30 a.m.; 01/20/10 doses at 8:40 a.m. and 5:00 p.m.; 01/21/10 doses at 7:00 a.m. and 3:00 p.m.; 01/22/10 doses at 7:00 a.m. and 3:00 p.m.; 01/23/10 doses at 6:45 a.m. and 3:00 p.m.; 01/24/10 doses at 6:50 a.m. and 3:00 p.m.; 01/25/10 doses at 6:00a.m. and 3:00 p.m.; 01/26/10 doses at 6:00 a.m. and 3:00 p.m.; 01/27/10 doses at 6:50 a.m. and 3:00 p.m.; 01/28/10 doses at 6:00 a.m. and 3:00 p.m.; 01/29/10 doses at 6:00 a.m. and 3:00 p.m.; 01/30/10 doses at 6:00 a.m. and 2:00 p.m.; 01/31/10 doses at 6:45 a.m. and 2:30 p.m.; 02/01/10 doses at 6:00 a.m. and 3:00 p.m.


d. Magnesium sulfate 500mg IM: 01/28/10 dose at 10:45 a.m.; 01/29/10 doses at 9:00 a.m.


3. Interview

a. The surveyor interviewed the medication nurse on the unit on 02/01/10 at 2:30 p.m. regarding which medication was to be given for pain on an "as needed" basis; the nurse responded that "I let the patient choose, the patient knows what will work for them. [sic]."


b. The surveyor interviewed Patient A2 on 02/02/10 at 8:45a.m. The patient reported "I have so much pain I take whatever I can get."


B. Patient B1

1. Record Review:

a. A preprinted physician admission order sheet, dated 01/28/10, had check boxes marked for the following orders:

"PRN Taper/Diazepam"

"Diazepam (Valium) 5mg. po q1h for mild S/S-W/D, 1+ tremors, or HR>90, SBP>130, NTE 120mg/24h x 7 days" [Valium 5mg orally every hour for mild signs/symptoms of withdrawal, mild tremor, pulse greater than 90, systolic blood pressure greater than 130, not to exceed 120mg. in 24 hours for 7 days].

"Diazepam (Valium) 10mg. po q1h for moderate S/S-W/D, 2+ tremors, or HR>95, SBP>140, NTE 120mg/24h x 7 days" [Valium 5mg orally every hour for moderate signs/symptoms of withdrawal, moderate tremor, pulse greater than 95, systolic blood pressure greater than 140, not to exceed 120mg. in 24 hours for 7 days].

"Diazepam (Valium) 20mg. po q1h for severe S/S-W/D, 3+ tremors, or HR>105, SBP>150, NTE 120mg/24h x 7 days" [Valium 20mg orally every hour for severe signs/symptoms of withdrawal, marked tremor, pulse greater than 105, systolic blood pressure greater than 150, not to exceed 120mg. in 24 hours for 7 days].

b. Medication Administration Records

Patient B1 received Valium with the following notations by nursing staff:

Valium 10mg given 01/30/10 at 12:40 p.m.: "c/o tremor [complaining of tremor]." No notation of tremor grade was reported. No vital signs were reported.

Valium 10mg given 01/31/10 at 3:00 a.m.: "tremor, restlessness." No notation of tremor grade was reported; no vital signs were reported.

Valium 10mg given 01/31/10 at 10:15 a.m.: "+1 tremor, (up arrow) anxiety." No vital signs were reported. [Note: Valium 10 mg. was to be given for +2 tremor, not +1 tremor].

Valium 10mg given 02/02/10 at 7:00 a.m.: "c/o anxiety, 6/10". Valium was not ordered for the treatment of anxiety. There was no notation regarding vital signs or tremor.

Valium 10mg given 02/02/10 at 1:31p.m.: "c/o anxiety, 8/10". Valium was not ordered for the treatment of anxiety. There was no notation regarding vital signs or tremor.

There was no evidence that the staff had received any supervision on the proper administration of the Valium, or that there was any follow-up on the missing documentations.

2. Interview

The surveyor interviewed the medication nurse on the unit on 02/02/10 at 4:15 p.m. The nurse was shown the MAR information noted above and agreed that Valium was not indicated for treating anxiety and stated "We don't always have time to get vital signs before giving the meds."

III. Ensure that incident forms are completed for all medication errors, and that all incidents are reported to appropriate committees (pharmacy and therapeutics committee, quality council, nursing executive committee, medical executive committee, and peer review committee).

Findings are:

A. Document Review

A review of incident report forms provided by the facility revealed no incident report forms documenting: a) the use of combination medications (Haldol; Ativan; Benedryl) as chemical restraints for active sample patients A3 and B1, b) the adverse effects of an IM administered medication (Toridol) to non-sample patient C1, or c) failure to obtain patient consent forms for the combination medications (Haldol, Ativan; Benedryl) given to Patients A3 and B1.

B. Interview

1. In an interview on 02/02/10 at 1:20 p.m., the Medical Director stated that the Toradol medication incident with Patient C1 had not been reviewed in any committee meeting, including pharmacy and therapeutics committee, quality council, medical executive committee and peer review committee. He stated "this is the first I'm hearing of this."

IV. Assure that all nursing staff received timely inservice training on Seclusion and Restraint (S/R) procedures, including "RN Evaluator" training for one hour face-to-face evaluations for patients in S/R, and procedures and documentations needed when using chemical restraints (e.g., combination psychotropic medications used for behavior control).

Findings are:

A. Document Review

1. The facility's Seclusion and Restraint (S/R) procedures provided by the facility had been revised in January 2010. The new procedures noted on page 2: "RN Evaluator staff must be upon orientation and annually thereafter, trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion." As of 2/3/10, none of the RNs had been trained to do the one hour assessments for patients in seclusion/restraint.

B. Observation

The surveyors attended a session of the required nursing staff meeting on 2/3/10 from 8:10 a.m. to 8:45 a.m., convened on the research unit. During the meeting, the Director of Nursing stated that the seclusion room (on the acute unit) is not yet ready for use but is "being prepared." She noted that the new S/R procedures "need some revisions" before use, and that she "will" meet with each RN individually to give them training on doing the 1 hour assessments for patients. A staff member remarked: "I've been here 5 years and we haven't done this...will we get retraining?" The DON replied that there will be "future" classes with "Doc" (person who does S/R training) who will "teach about take downs and putting patients in restraints."

V. Ensure that nursing staff 1:1 observations for active sample patient A5 followed the facility's hospital policy. MHT staff providing 1:1 observations for this patient did not maintain "arms length" distance from the patient as required by hospital policy. The 1:1 assigned staff also allowed another patient to be between themselves and the observed patient, and they drank coffee and attended to other matters while on 1:1 observation.

Findings are:

A. Policy Review

The hospital's policy, "One to One Observation, Physician Ordered," (issued August 2002; last reviewed October 2009) states on page 1 under "Method:" "2. If indicated, a one-to-one observation will be initiated when the patient arrives on the unit or at any time throughout patient's hospitalization. This status refers to observation that places a staff person within arm's reach of the patient at all times, including bathroom and shower use and during sleep hours."

B. Observations

1. During an observation on the psychiatric wing of the acute unit on 1/1/10 at approximately 8:45 a.m., the surveyor noted that the Mental Health Worker (MHT1) who was assigned to do 1:1 observation for Patient A5 (who was on 1:1 monitoring because of self cutting the previous day) was not within arm's distance from the patient as required by hospital policy. In the AT (exercise) group at 9:30 a.m., MHT1 was carrying a clipboard and a cup of coffee while providing the 1:1 with Patient A5. Later that morning, during the "Discharge Planning" group (10:30 a.m. - 11:20 a.m.), MHT1 sat across the room from Patient A5, drinking coffee. The patient left the room about half way through the meeting. MHT1 followed the patient. The surveyor then noted that the MHT was carrying her purse as well as a cup of coffee. This would limit immediate attention to the patient if she (patient) attempted to inflict self-injury.

2. At approximately 9:40 a.m., the DON was observed talking in a loud angry voice with MHT1 in the hallway of the psychiatric wing. Another MHT was standing in the doorway of Patient A5's bedroom, observing the patient. Another female patient was sitting on a chair at the bottom of Patient A5's bed, talking to Patient A5.

3. Patient A5 was observed in an AT group at 3:30 p.m. on 1/2/10. The MHT doing the 1:1 observation was across the room from the patient (not within arm's distance).

4. During an observation of the nursing staff meeting on 2/3/10 (8:45 a.m.-9:15 a.m.), the Director of Nursing reminded the staff that they were not always keeping patients on 1:1 observation within arm's distance as required by hospital policy.