HospitalInspections.org

Based on video surveillance review, medical record review, physician and staff interviews, the nursing staff failed to communicate a forced medication administration to the emergency department provider for 1 of 1 patients. Patient #2.

Findings included:

Review on 04/08/2025 of hospital policy "RESTRAINTS/RESTRICTIVE INTERVENTIONS", last reviewed 12/12/2024 [stated by facility as July 2024 version] revealed, " ...II. PROCESS ... C. INITIATION OF INTERVENTION ...In an emergency where an LP [Licensed Practioner]/ APP [Advanced Practice Practioner] is not readily available, a registered nurse may initiate restraints and restrictive interventions. The LP/APP must then be contacted, and an appropriate order received as soon as possible, but no later than 1 hour. ..."

Review of Video Surveillance reviewed on 04/09/2025 at 1350 of the forced medication encounter with Patient #2 on 07/27/2024 starting at 0100.55 [minutes/seconds] revealed:
0101:57- Patient #2 pacing outside of room pacing.
0102:31 Officer #8, and Officer #9 arrived standing by in the dayroom.
0103:56 Officers are talking with Patient #2 in dayroom.
0103:56 Patient #2 sits down on sofa in dayroom.
0104:23 Nursing Staff enter the dayroom.
0104:39 Patient #2 stands and lunges toward Nurse with medication syringes. Officers #8 and #9 on each side of Patient #2, assist Patient #2 to sit back down on the sofa, holding bilateral arm/hand. Other staff are holding Patient #2's legs. 4 staff at Patient #2's side.
105:04 Injections given IM in the left thigh [Patient #2 remains sitting for IM administration]
105:16 Nursing staff leave the dayroom. Officers release Patient #2, standing by.
105:30 Officers leave the dayroom. Patient #2 talking to glass barrier. Goes to the Nurses station door.
105:32 Patient #2 hitting glass, with both fists. Yelling at glass.
105:42 Patient #2 goes into her room.
106:23 Patient #2 out of her room, yelling at glass barrier, hitting glass with both fists.
107:00 Officers disperse into dayroom. Patient #2's goes into her room. Officers follow her into room.
107:55 BHU staff arrive and go into Patient #2's room.
Video ends, no further video available for review.

Closed medical record review on 04/08/2025 revealed Patient #2, a 48-year-old female patient who arrived at the facility emergency department [ED] voluntarily by EMS [emergency medical services] on 07/26/2024 at 2254 stating "my boyfriend wants to kill me." Triaged at 2304, ED Registered Nurse [RN] #3 documented "patient hyperverbal, denies SI/HI [suicidal/homicidal], 'I quit hearing voices 3 months ago'. Patient #2 assigned an acuity score of 2-emergent and placed in behavioral health unit [BHU] room #3. At 2307, a Psychiatric Nurse Assessment was completed by Psyche RN #4 "current presentation agitated, alert, awake, cooperative, inappropriate paranoid, psychosis ...comment little hypomanic, hyperverbal, tangential, grandiose delusional, paranoid delusional ..." Patient #2 was assigned a 1:1 sitter at 2309, ED BHU Sitter #5, "constant observation." At 2314 ED RN #3 documents "following commands, and blanket and verbal reassurances." At 2324, and 2330 the ED BHU Sitter #5 documents "observation: fidgety/restless." The ED Provider Note dated 07/26/2025 at 2330 by ED Medical Doctor [MD] #6 revealed "[named] presents with hyper verbality and concerned that her boyfriend is going to kill her. She is effusive and hyperverbal here and has tangential dialogue. She says she proposed to her boyfriend tonight and thinks this alarmed him. She says all her life she has had voices that she hears, but they stopped about 3 months ago and this alarmed her. She does think she needs to be admitted to the hospital for her psychiatric condition. She denies any somatic concerns whatsoever ... Findings Psychiatric: bipolar disorder [mood dysregulation], PTSD [post-traumatic stress disorder] and schizophrenia [disorder disrupting thought process, perceptions, emotional responsiveness, and often involves hallucinations, delusions and disorganized thinking.] Additional Psychiatric: OCD [obsessive compulsive disorder]. ... ED Physical Exam: ... Psychiatric: anxiety, hyperverbal, normal behavior, calm demeanor and cooperative; no visual hallucination(s), no suicidal thoughts, no auditory hallucination(s), or no homicidal thoughts." On 07/27/2024 at 0045 Patient #2 requests Ativan, [medication used to manage acute agitation and aggression]. Ativan 0.5 milligrams tablet was given with physician order, by ED RN #3. Review of the ED Nursing Note 07/27/2024 at 0059 by Certified Nursing Assistant [CNA] #7 "Dr. [named MD #6] and [named Psyche RN #4] speaking to pt [patient], telling pt that she will be IVC'd [involuntarily committed], pt becomes agitated and yelling at Dr. and [named psyche RN], Pt leaves room hitting window and wall, throwing things, hospital law enforcement officer and nurse notified at this time." On 07/27/2024 at 0059 ED Physician Orders for Haloperidol [medication used to manage acute agitation and aggression] 5mg/ml injection 5 mg "IM [intramuscular] NOW ONE" [one time order/dose], and Lorazepam [Ativan] 1 mg were ordered by ED MD #6 for Patient #2. Review of the ED Provider Note Addendum [no date or time] by ED MD #6 revealed "When psyche resource nurse came to admit patient, she then said she would be refusing admission and wanted to be discharged. I went back to her and spoke to her about this. She was nearly completely incoherence [sic], and I could not appreciate a logical train of thought. She had difficulty explaining why she had come to the emergency department in the 1st place was severely tangential dialogue. She was intermittently quite combative. Eventually she required Haldol and Ativan for chemical restraint/sedation for her safety and the safety of those around her, and I did take out petition for involuntary commitment due to her apparent lack of ability to remain safe and to her irrational and psychotic state which did not appear safe for discharge." On 07/27/2024 at 0106 ED RN #3 administered the medications of Haldol and Ativan with hospital law enforcement officers and ED Nursing Staff [4] holding Patient #2 in a sitting position in the BHU dayroom. Review of the ED Nursing Note 07/27/2024 at 0106 by ED RN #3 revealed " ...She is hitting doors/windows, slamming doors in BH [behavioral health]. When she saw the needle for IM [intramuscular] meds, she charged toward this RN. Hospital police at bedside, meds administered." Review of the IVC documents revealed the petition was signed at 0110 by ED MD #6. Review of the medical record failed to reveal a nursing communication to the ED physician alerting them of the forced medication administration that had occurred at 0106. On review there were no Physician orders, or documentation following the encounter with Patient #2. Patient #2's behavior continued to escalate. Patient #2 was admitted to the inpatient BHU on 07/27/2024 at 0444. Patient #2 was discharged home with her Mother on 07/30/2024 at 1500 from inpatient hospitalization.

Telephone interview on 04/09/2025 at 1030 with ED MD #6 revealed he did not recall Patient #2 and had reviewed the medical record/encounter. Regarding the manual hold for Haldol and Ativan administration on 07/27/2024 at 0106 " ...I wouldn't be aware, behavioral health is physically a far distance from where I am sitting. There is a wall there. If no one tells me, I wouldn't know. I am aware law enforcement officers do restrain patients when they are a danger to others. If I don't know, I can't take ownership." The interview revealed that nursing staff did not communicate with MD #6 regarding the forced medication administration for Patient #2 in which included a manual hold.

Interview on 04/09/2025 at 1535 with ED RN #3 revealed " ... with forced medications I make sure the hospital police are present. They are there for staff safety. ...I did tell with MD how things escalated. I don't remember if the MD called or came back, I just can't remember."

Interview on 04/10/2025 at 1115 with ED Nurse Leader #11 revealed "we try to avoid forced medication. The RN should always inform the physician if a forced medication had occurred."

NC00228697 NC00227889 NC00228716 NC00224496