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Based on the review of the patient's medical record, hospital policy and procedures, witness statements, the Rights Advisor's investigation and staff interview, it was determined the patient received an intramuscular injection (IM) of medication for which no physician's order was written.

This 30 year old patient was admitted to Spring Grove Hospital (SGH) on 4/16/09 as a court ordered admission for competency evaluation to stand trial. On 8/7/09 he was deemed incompetent to stand trial and remanded to SGH for treatment. The patient has been resistant to treatment, with poor insight and judgement. He avoids groups and exhibits unpredictable violent outbursts. He refuses medication. He was described by his psychiatrist as "very psychotic, and explosive, and his anger comes out suddenly and strongly." His Axis I diagnosis is Schizophrenia, paranoid; history of alcohol abuse; Axis II: Personality disorder with borderline and antisocial traits. He has been described as "guarded, hostile, refuses to listen."

On 3/29/10 the patient talked to his psychiatrist about receiving an IM on 3/16/10. Patient reported receiving "Arbitrol, which is in all the needles." There was no record of any such treatment in the physician orders or the medication administration record (MAR). There is also no known medication named "Arbitrol. "Additionally, the nurse accused of administering the IM was not on duty on 3/16/10.

On April 5, 2010, the Head Nurse on the patient's unit reported to the Rights Advisor and the SGH police that an assault had occurred when the patient received the IM without a physician order. The patient was offered examination by the somatic physician, but declined. At this point the investigation was initiated. Upon review of the patient's medical record it was determined that no IM was received on 3/16/10. The patient did receive a cocktail of medications by mouth for agitation on that same date.

During the investigation it was determined the patient received an injection of medication for which there was no physician order or other documentation on March 13 or 14, 2010. Some of the witness statements are dated 3/13/10 and others have no date when the incident occurred. It was determined later that the Head Nurse put the wrong date on the information packet for the staff witnesses. The only day additional help was called from other units to respond to the patient's unit was March 14, 2010. It was those who responded and other staff already on the unit who reported witnessing the patient receive an injection in the arm.

Per the SGH Police, the nurse in question admitted via telephone interview that she injected the patient.

There are no physician's orders for an IM injection and no documentation on an MAR for 3/13 or 3/14/10. Furthermore, there is no progress note written to describe patient's behavior that would have necessitated the IM, nor is there a note to assess his reaction to the medication. It is still unknown what medication was administered to the patient. Per the SGH Police, the nurse in question admitted via telephone interview that she injected the patient.

The nurse who administered this unauthorized medication was the Charge Nurse for the unit. Her actions constitute abuse. She performed this act in flagrant violation of the State Nurse Practice Act and at great risk to patient safety.