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Based on interview and record review hospital nursing personnel administered emergent psychoactive medications in the Psychiatric ER [Emergency Room] for 2 of 6 patients [Patient #1 and #7] reviewed. The hospital failed to document the patient's progress and/or response to the administered medications.

Findings Included:

1) Patient #1 was admitted to Psychiatric ER on 02/18/10 at 1125. The triage assessment timed at 1128 reflected, "made verbal comments wanted to commit suicide...husband passed away this morning...police called..."

The physician orders dated 02/18/10 timed at 1430 reflected, "Haldol 5 mg by mouth or IM [Intramuscular], Ativan 2 mg by mouth or IM, Benadryl 50 mg by mouth or IM every 6 hours prn for agitation. The medication administration record indicated Patient #1 received the above medications at 1509.

The close observation/restraint/seclusion flowsheet dated 02/18/10 timed from 1145 to 1800 reflected no documentation indicating Patient #1 was agitated. The documentation indicated Patient #1 was either sitting quietly, awake or asleep.

The emergency patient record dated 02/18/10 timed at 1600 reflected, "medication given, Ativan, Benadryl, Haldol...reason given agitation, response to medications given...decrease agitation..." The next entry made at 2016 did not address the medications given to Patient #1 for agitation at 1600 and Patient #1's response and/or behaviors.

On 05/5/10 at approximately 2:15 PM the Director of the Psychiatric ER [Personnel #2] was interviewed. Personnel #2 was asked by the surveyor to review Patient #1's medical record in regard to the administration of emergency medication to Patient #1. Personnel #2 stated the nurse did not document adequately for administering the medications. Personnel #2 stated the nurses are to document what interventions were tried before administering medications and the patient should be reassessed after receiving the medications.

On 05/6/10 at approximately 1:35 PM RN #6 was interviewed. RN #6 was asked to review her nursing entry on 02/18/10 timed at 1600. RN #6 stated she gave the patient emergent medication for agitation. The surveyor asked RN #6 what Patient #1's behaviors were which warranted the use of the medication. RN #6 stated she should of described the patient behaviors and attempted deescalation or other less invasive interventions before giving the medication. RN #6 stated she did not follow-up on the effectiveness of the medications.

2) Patient #7 as admitted to the Psychiatric ER on 05/3/10 at 2116 with a past history of depression after she overdosed on medications.

The medication administration record dated 05/4/10 timed at 0722 reflected Patient #7 received Haldol 10 mg, Ativan 2mg and Benadryl 50 mg IM.

The assessment notes dated 05/3/10 at 2121 to 05/4/10 at 0910 reflected no nursing documentation indicating Patient #7 required the use of emergent medications and the justification for the administration of the medications. Additionally no documentation was found indicating what interventions were used prior to the IM medication.

On 05/6/10 at approximately 2:00 PM Personnel #2 was interviewed. Personnel #2 was asked by the surveyor to review Patient #7's medical record. Personnel #2 stated the nurse did not document in the notes what medication was given and the reason. Personnel #2 stated the nurses are to document in the notes and document what measures were attempted before giving the medications.

The policy entitled, "Use of Restraint/Seclusion" with a review date of 10/09 reflected, "all orders, observations, medical/nursing care...are documented in the medical record."

The policy entitled. "Organization-wide patient assessment" with a review date of 06/09 reflected, "in all levels of care, patients are reassessed as needed for significant changes in diagnosis, condition, circumstances or behavior..."

Based on interview and record review hospital nursing personnel administered emergent psychoactive medications in the Psychiatric ER [Emergency Room] for 2 of 6 patients [Patient #1 and #7] reviewed. The hospital nursing personnel failed to document the patient's progress and/or response to the administered medications.

Findings Included:

1) Patient #1 was admitted to Psychiatric ER on 02/18/10 at 1125. The triage assessment timed at 1128 reflected, "made verbal comments wanted to commit suicide...husband passed away this morning...police called..."

The physician orders dated 02/18/10 timed at 1430 reflected, "Haldol 5 mg by mouth or IM [Intramuscular], Ativan 2 mg by mouth or IM, Benadryl 50 mg by mouth or IM every 6 hours prn for agitation. The medication administration record indicated Patient #1 received the above medications at 1509.

The close observation/restraint/seclusion flowsheet dated 02/18/10 timed from 1145 to 1800 reflected no documentation indicating Patient #1 was agitated. The documentation indicated Patient #1 was either sitting quietly, awake or asleep.

The emergency patient record dated 02/18/10 timed at 1600 reflected, "medication given, Ativan, Benadryl, Haldol...reason given agitation, response to medications given...decrease agitation..." The next entry made at 2016 did not address the medications given to Patient #1 for agitation at 1600 and Patient #1's response and/or behaviors.

On 05/5/10 at approximately 2:15 PM the Director of the Psychiatric ER [Personnel #2] was interviewed. Personnel #2 was asked by the surveyor to review Patient #1's medical record in regard to the administration of emergency medication to Patient #1. Personnel #2 stated the nurse did not document adequately for administering the medications. Personnel #2 stated the nurses are to document what interventions were tried before administering medications and the patient should be reassessed after receiving the medications.

On 05/6/10 at approximately 1:35 PM RN #6 was interviewed. RN #6 was asked to review her nursing entry on 02/18/10 timed at 1600. RN #6 stated she gave the patient emergent medication for agitation. The surveyor asked RN #6 what Patient #1's behaviors were which warranted the use of the medication. RN #6 stated she should of described the patient behaviors and attempted deescalation or other less invasive interventions before giving the medication. RN #6 stated she did not follow-up on the effectiveness of the medications.

2) Patient #7 as admitted to the Psychiatric ER on 05/3/10 at 2116 with a past history of depression after she overdosed on medications.

The medication administration record dated 05/4/10 timed at 0722 reflected Patient #7 received Haldol 10 mg, Ativan 2mg and Benadryl 50 mg IM.

The assessment notes dated 05/3/10 at 2121 to 05/4/10 at 0910 reflected no nursing documentation indicating Patient #7 required the use of emergent medications and the justification for the administration of the medications. Additionally no documentation was found indicating what interventions were used prior to the IM medication.

On 05/6/10 at approximately 2:00 PM Personnel #2 was interviewed. Personnel #2 was asked by the surveyor to review Patient #7's medical record. Personnel #2 stated the nurse did not document in the notes what medication was given and the reason. Personnel #2 stated the nurses are to document in the notes and document what measures were attempted before giving the medications.

The policy entitled, "Use of Restraint/Seclusion" with a review date of 10/09 reflected, "all orders, observations, medical/nursing care...are documented in the medical record."

The policy entitled. "Organization-wide patient assessment" with a review date of 06/09 reflected, "in all levels of care, patients are reassessed as needed for significant changes in diagnosis, condition, circumstances or behavior..."

Based on interview and record review hospital nursing personnel administered emergent psychoactive medications in the Psychiatric ER [Emergency Room] for 2 of 6 patients [Patient #1 and #7] reviewed. The hospital failed to document the patient's progress and/or response to the administered medications.

Findings Included:

1) Patient #1 was admitted to Psychiatric ER on 02/18/10 at 1125. The triage assessment timed at 1128 reflected, "made verbal comments wanted to commit suicide...husband passed away this morning...police called..."

The physician orders dated 02/18/10 timed at 1430 reflected, "Haldol 5 mg by mouth or IM [Intramuscular], Ativan 2 mg by mouth or IM, Benadryl 50 mg by mouth or IM every 6 hours prn for agitation. The medication administration record indicated Patient #1 received the above medications at 1509.

The close observation/restraint/seclusion flowsheet dated 02/18/10 timed from 1145 to 1800 reflected no documentation indicating Patient #1 was agitated. The documentation indicated Patient #1 was either sitting quietly, awake or asleep.

The emergency patient record dated 02/18/10 timed at 1600 reflected, "medication given, Ativan, Benadryl, Haldol...reason given agitation, response to medications given...decrease agitation..." The next entry made at 2016 did not address the medications given to Patient #1 for agitation at 1600 and Patient #1's response and/or behaviors.

On 05/5/10 at approximately 2:15 PM the Director of the Psychiatric ER [Personnel #2] was interviewed. Personnel #2 was asked by the surveyor to review Patient #1's medical record in regard to the administration of emergency medication to Patient #1. Personnel #2 stated the nurse did not document adequately for administering the medications. Personnel #2 stated the nurses are to document what interventions were tried before administering medications and the patient should be reassessed after receiving the medications.

On 05/6/10 at approximately 1:35 PM RN #6 was interviewed. RN #6 was asked to review her nursing entry on 02/18/10 timed at 1600. RN #6 stated she gave the patient emergent medication for agitation. The surveyor asked RN #6 what Patient #1's behaviors were which warranted the use of the medication. RN #6 stated she should of described the patient behaviors and attempted deescalation or other less invasive interventions before giving the medication. RN #6 stated she did not follow-up on the effectiveness of the medications.

2) Patient #7 as admitted to the Psychiatric ER on 05/3/10 at 2116 with a past history of depression after she overdosed on medications.

The medication administration record dated 05/4/10 timed at 0722 reflected Patient #7 received Haldol 10 mg, Ativan 2mg and Benadryl 50 mg IM.

The assessment notes dated 05/3/10 at 2121 to 05/4/10 at 0910 reflected no nursing documentation indicating Patient #7 required the use of emergent medications and the justification for the administration of the medications. Additionally no documentation was found indicating what interventions were used prior to the IM medication.

On 05/6/10 at approximately 2:00 PM Personnel #2 was interviewed. Personnel #2 was asked by the surveyor to review Patient #7's medical record. Personnel #2 stated the nurse did not document in the notes what medication was given and the reason. Personnel #2 stated the nurses are to document in the notes and document what measures were attempted before giving the medications.

The policy entitled, "Use of Restraint/Seclusion" with a review date of 10/09 reflected, "all orders, observations, medical/nursing care...are documented in the medical record."

The policy entitled. "Organization-wide patient assessment" with a review date of 06/09 reflected, "in all levels of care, patients are reassessed as needed for significant changes in diagnosis, condition, circumstances or behavior..."

Based on interview and record review hospital nursing personnel administered emergent psychoactive medications in the Psychiatric ER [Emergency Room] for 2 of 6 patients [Patient #1 and #7] reviewed. The hospital nursing personnel failed to document the patient's progress and/or response to the administered medications.

Findings Included:

1) Patient #1 was admitted to Psychiatric ER on 02/18/10 at 1125. The triage assessment timed at 1128 reflected, "made verbal comments wanted to commit suicide...husband passed away this morning...police called..."

The physician orders dated 02/18/10 timed at 1430 reflected, "Haldol 5 mg by mouth or IM [Intramuscular], Ativan 2 mg by mouth or IM, Benadryl 50 mg by mouth or IM every 6 hours prn for agitation. The medication administration record indicated Patient #1 received the above medications at 1509.

The close observation/restraint/seclusion flowsheet dated 02/18/10 timed from 1145 to 1800 reflected no documentation indicating Patient #1 was agitated. The documentation indicated Patient #1 was either sitting quietly, awake or asleep.

The emergency patient record dated 02/18/10 timed at 1600 reflected, "medication given, Ativan, Benadryl, Haldol...reason given agitation, response to medications given...decrease agitation..." The next entry made at 2016 did not address the medications given to Patient #1 for agitation at 1600 and Patient #1's response and/or behaviors.

On 05/5/10 at approximately 2:15 PM the Director of the Psychiatric ER [Personnel #2] was interviewed. Personnel #2 was asked by the surveyor to review Patient #1's medical record in regard to the administration of emergency medication to Patient #1. Personnel #2 stated the nurse did not document adequately for administering the medications. Personnel #2 stated the nurses are to document what interventions were tried before administering medications and the patient should be reassessed after receiving the medications.

On 05/6/10 at approximately 1:35 PM RN #6 was interviewed. RN #6 was asked to review her nursing entry on 02/18/10 timed at 1600. RN #6 stated she gave the patient emergent medication for agitation. The surveyor asked RN #6 what Patient #1's behaviors were which warranted the use of the medication. RN #6 stated she should of described the patient behaviors and attempted deescalation or other less invasive interventions before giving the medication. RN #6 stated she did not follow-up on the effectiveness of the medications.

2) Patient #7 as admitted to the Psychiatric ER on 05/3/10 at 2116 with a past history of depression after she overdosed on medications.

The medication administration record dated 05/4/10 timed at 0722 reflected Patient #7 received Haldol 10 mg, Ativan 2mg and Benadryl 50 mg IM.

The assessment notes dated 05/3/10 at 2121 to 05/4/10 at 0910 reflected no nursing documentation indicating Patient #7 required the use of emergent medications and the justification for the administration of the medications. Additionally no documentation was found indicating what interventions were used prior to the IM medication.

On 05/6/10 at approximately 2:00 PM Personnel #2 was interviewed. Personnel #2 was asked by the surveyor to review Patient #7's medical record. Personnel #2 stated the nurse did not document in the notes what medication was given and the reason. Personnel #2 stated the nurses are to document in the notes and document what measures were attempted before giving the medications.

The policy entitled, "Use of Restraint/Seclusion" with a review date of 10/09 reflected, "all orders, observations, medical/nursing care...are documented in the medical record."

The policy entitled. "Organization-wide patient assessment" with a review date of 06/09 reflected, "in all levels of care, patients are reassessed as needed for significant changes in diagnosis, condition, circumstances or behavior..."