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Based on medical record review, staff interviews, and facility policy and procedure review, it was determined that:

1) For 6 of 20 active sample patients (Patients A6, P1, P2, P3, P5, P6) the facility failed to ensure that Physician orders gave specific parameters for the administration of both antianxiety and antipsychotic medications. In five of the six records cited (P1, P2, P3, P5, P6), Ativan was written for "Anxiety," an ill-defined state, and Haldol was written for "Agitation," again an ill-defined state. In the sixth record (patient A6) the single medication ordered was given for a range of symptoms. Therefore, the type of medication to be utilized and the purpose of the medication usage were left to the judgment of the various RNs on duty. In addition, the RNs could repeat the medications at frequencies based on their interpretation of the patient's emotional state or behavior (be it agitation and/or anxiety), allowing RNs to select medications and frequency based on their judgments. This failure results in physicians not providing Nursing Staff proper guidance for the administration of antipsychotic and/or antianxiety medications, and ambiguous Physician Orders can result in serious complications from improperly administered PRN medications. (Refer to B125-I)

(2.) For 1 of 20 sample patients (SJ5) the administration of chemical restraints followed current protocols that necessitate a face-to-face evaluation within 1 hour in order to protect patient rights and allow evaluation of the appropriateness or effectiveness of the intervention. The failure to follow standard procedures for the usage of chemical restraints results in the violation of the patient's rights to be free of restraints except in emergency situations. (Refer to B125-II)

Based on medical record review and staff interview it was determined that the facility failed to ensure that Psychiatric Evaluations for 20 of 20 patients (Patients A1, A2, A3, A4, A5, A6, A7, A8, P1, P2, P3, P4, P5, P6, SJ1, SJ2, SJ3, SJ4, SJ5, and SJ6), described memory functioning in a manner that disclosed how statements such as "Intacta" (Intact) and "Menoscabada" (Impaired) were determined. This failure to provide a database makes it difficult to utilize future assessments to measure positive or negative response to treatment.

Findings include:

I. Medical Record Review:

The following patients (Psychiatric Evaluation dates in parentheses) had no description of the methods used to determine and conclude how the physician was able to choose the ambiguous statements "Intacta" and "Menoscabada" checked on the preprinted forms.

A1 (1/05/2011); A2 (1/4/2011); A3 (1/6/2011); A4 (1/3/2011); A5 (1/4/2011); A6 (10/28/2011); A7 (1/2/2011); A8 (1/4/2011); P1(3/10/2011); P2 (2/22/2011); P3 (3/12/2011); P4 (3/11/2011); P5 (3/8/2011); P6 (3/13/2011); SJ1 (3/11/2011); SJ2 (2/22/2011); SJ3 (3/12/2011); (SJ4 (3/11/2011); SJ5 (3/8/2011); and SJ6 (3/13/2011).

II. Staff Interview:

In an interview on 1/11/2011 at 2:10PM with the Medical Director, she agreed that there was not a description by the psychiatrists of the databases upon which their assessments of memory functioning in 3 distinct spheres i.e. immediate, recent and remote recall had been made.

Based on medical record review, staff and patient interviews, policy and procedure review and observations, it was determined that the facility failed to ensure that:

(I). Standing Physician PRN (as necessary) Orders were written for clearly defined behaviors and emotions for 6 of 20 active patients (A6, P1, P2, P3, P5, P6), with clearly defined maximum daily dosages included in the orders. In five of the six records cited, Ativan was written for "Anxiety," an ill-defined state, and Haldol was written for "Agitation," again an ill-defined state. In the sixth record (patient A6) the medication ordered was given for a range of symptoms. Therefore, when and which type of medication was to be utilized was left to the judgment of the various RNs on duty. In addition, the RNs could repeat the medications at frequencies based on their interpretation of the patient's emotional state or behavior (be it agitation and/or anxiety), allowing RNs to select medications and frequency based on their judgments. This failure results in physicians not providing Nursing Staff proper guidance for the administration of antipsychotic and/or antianxiety medications, and ambiguous Physician Orders can result in serious complications from improperly administered PRN medications.

(II.) Chemical Restraint usage followed appropriate protocol to ensure patient safety and patient rights for one of 20 active sample patients (Patient SJ5). The failure to follow standard procedures for the usage of chemical restraints may result in the violation of patient's rights.
(III.) An unusual unilateral gross tremor was investigated as to etiology and possible relationship to presenting symptoms for a first admission patient for 1 of 20 active sample patients (Patient SJ6). This failure precludes determining if the abnormal neurological findings are related to the presenting symptoms or represent an independent condition.

Findings include:

I. Improperly written Standing PRN Orders:

A. Record Review (All quotes are substantiated in translation by the DON throughout this document)

1. Patient A6: On 10/27/2010 the physician had ordered "Vistaril 50mg po (by mouth) q(every) 8hrs (hours) prn anxiety, agitation, aggressivity". On 10/28/2011 the above Order was discontinued and "Resperdol Mtabs 3mg po cada (every) 8 hours prn agitation, if the patient does not take Haldol 5mg IM cada 8hrs prn agitation."

2. Patient P1: On 3/9/2011 the physician had ordered "Ativan 2mg 1po q6h prn for anxiety; if patient does not take; Ativan 2mg IM (intramuscularly) q6h prn for anxiety" and "Haldol 5mg 1 po q6h prn for agitation; if patient does not take; Haldol 5mg IM q6h prn for agitation [sic]."

3. Patient P2: On 2/21/2011 the physician had ordered "Ativan 2mg 1po q6h prn for anxiety; if patient does not take; Ativan 2mg IM q6h prn for agitation" and "Haldol 5mg 1po q6h prn for agitation; if patient does not take; Haldol 5mg IM q6h prn for agitation [sic]."

4. Patient P3: On 3/10/2011 the physician had ordered "Ativan 2mg 1 po q6h prn for anxiety; if patient does not take; Ativan 2mg IM q6h prn for anxiety" and "Haldol 5mg 1 po q6h prn for agitation; if patient does not take; Haldol 5 mg q6h prn for agitation [sic]."

5. Patient P5: On 3/7/2011 the physician had ordered "Ativan 1mg 1 po q6h prn for anxiety; if patient does not take; Ativan 1mg IM q6h prn for anxiety" and "Haldol 1mg po q6h prn for agitation; if patient does not take; Haldol 2mg IM q6h prn for agitation [sic]."

6. Patient P6: On 3/12/2011 the physician had ordered "Ativan 2mg 1 po q6h prn for anxiety; if patient does not take; Ativan 2mg IM q6h prn for anxiety [sic]" and "Haldol 5mg 1 po q6h prn for agitation; if patient does not take; Haldol 5mg IM q6h prn for agitation [sic]."

II.Chemical Restraint Usage:

A. Observation:

1. On March 16, 2011 at approximately 9:30AM on the San Juan unit, the surveyor observed Patient SJ5 to be unsteady on his feet, holding onto the wall for support, slowed movements and verbal responses, slurred speech, and shuffling gait. He had to be assisted by an MHT throughout this time. Patient SJ5 was added to the survey sample and his record was reviewed.

2. Patient SJ5 was observed about every hour from approximately 9:30AM to approximately 1:30PM. Throughout this time, he continued to exhibit an unsteady gait, psychomotor retardation, had to hold onto the wall to stabilize himself, exhibited shuffling gait, and had a Mental Health Technician (MHT) with him throughout that time frame. He was not able to participate in any group activity.

B.Medical Record Review:

1. Patient SJ5 was a 66 year old male who was admitted on March 11, 2011 with the diagnoses of Dementia with psychosis, hallucinations and delusions. His PRN (as needed) orders dated March 14, 2011, 12PM were written as follows: "For anxiety, Haldol 2 mg PO (by mouth) every six hours PRN, if not able to swallow give intramuscular (IM) and Ativan 1 mg PO every six hours PRN, if not able to swallow give intramuscular".

2. On March 14, 2011 at noon, Patient SJ5 received Haldol lactate 2 mg IM and Ativan 1 mg IM in accordance to his PRN order for these medications. He also received this combination of medications on March 15, 2011 at 2:56PM. The Progress Notes for these dates were reviewed with the Director of Nursing and there was no documentation found to explain why an intramuscular route versus an oral route was chosen.

C.Staff Interview:

1. Per an interview on March 16, 2011 at approximately 2:00 PM with RN1, she was asked if Patient SJ5's orders as described above were chemical restraint doses. She replied, "yes." In addition, she stated that the patient had been combative. Although these were considered chemical restraints by the nursing staff, there is no documentation of a one hour face to face evaluation by a physician or trained nurse for these medication administrations (March 14 at noon or March 15 at 2:56PM). Haldol was not a part of his routine medication regime.

2. In an interview on March 16, 2011 at approximately 3:00PM with RN1, she was asked if Patient SJ5 received any more doses of Haldol or Ativan that day (March 16). RN1 looked at Patient SJ5's orders and stated that the patient had received Ativan 0.5mg, because it was part of his routine medication regimen: "Ativan 0.5 mg TID and 2 mg QHS".

3. In an interview on March 15, 2011 at 2:00PM, the Director of Nursing (DON) was asked about the use of Ativan and Haldol as PRN orders. She was asked if a patient had a physician order for Ativan for anxiety and another physician order for Haldol for agitation, would the nurse have the discretion to give those medications together or administer them separately. She stated "yes" and offered an example, "that it could be done in combination because the patient was most likely anxious before he became agitated."

D. Policy Review:

Policy (translated with the help of the Director of Nursing) -Restraints and Seclusion, March, 2010- ("Restricciones Y Aislameinto, Marzo, 2010") - (No number was assigned to this policy) "...Chemical Restraints - When you have to use a medicine that is not part of the established medical or psychiatric treatment, for modifying the conduct of a patient, and that has a temporary effect in restricting his freedom of movement....patient has to have a face to face evaluation." It did not include the within one hour time frame for a face-to-face evaluation of the patient's physiological and/or psychological conditions.

III. Neurological Impairment:

A. Observation

In an observation on 3/16/2011 at 10:30AM, Patient SJ6 was observed on the Unit sitting and moving his left hand in a rapid alternating motion, apparently out of his control since he was observed to occasionally grasp his left hand with his right hand as if to halt the movements.

B. Record Review

1. Patient SJ6 was a 66 year old who was admitted for the first time on 3/11/2011.The pt. received an initial physical examination (3/11/2011), a nursing evaluation (3/11/2011) and a psychiatric evaluation (3/12/2011). None of these examinations addressed the involuntary movement, a gross alternating tremor, present in the patient's left hand. The lack of documentation of the involuntary movements in any of the exams was substantiated by the Director of Nursing who also reviewed the exams and aided with translation at approximately 11:30AM on 3/16/2011.

2. In a Progress Note by the attending psychiatrist dated 3/14/2011 it was noted that the use of Haldol was "tolerated" [this word was written in English in the record] by the patient and that the left hand tremor was present.

3. The Master Treatment Plan dated 3/12/2011 did not list this impairment as either a Problem to be addressed, nor was it acknowledged as present as an issue on the Axis III of this Plan.

C. Interview

1. In an interview on 3/16/2011 at 12:30PM with Patient SJ6 with the Director of Nursing in attendance, Patient SJ6 stated the tremor had been present before admission.

2. In an interview on 3/16/2011 at approximately 12:30PM, the attending psychiatrist stated that if this issue needed a neurological consult this could be obtained, but none had been sought to determine the etiology. He also acknowledged that the Treatment Plan (3/12/2011) failed to list this as either a Problem or been included as a diagnosis on Axis III of the Treatment Plan.

Based on observation, medical record review, staff and patient interviews, and facility policy and procedure review it was determined that the clinical director failed to ensure that:

1. Psychiatric Evaluations for memory functioning included the database from which generalized statements were made. (Refer to B116)

2. Physician orders for PRN medications were written in a manner that provided Nursing staff with clearly defined parameters for administering medications for "anxiety" and "agitation." (Refer to B125-I)

3. Chemical Restraint usage followed current protocols for the use of this intervention, specifically face-to-face evaluations within 1 hour. The Medical Director failed to ensure that policy and procedure related to seclusion and restraint were detailed enough to protect a patient's right to be treated in the least restrictive environment by not clearly delineating a time frame for face-to-face evaluations. (Refer to B125-II)

4. Physicians identified and evaluated a first time admission patient with an unusual neurological issue for the etiology and possible relationship to presenting symptoms. (Refer to B125-III)

Based on Observation, record review, policy reviews, and staff interview, the Director of Nursing failed to:

I) Ensure that chemical restraint usage included a one-hour face to face evaluation for sample patient SJ5.

II) Ensure that nurses only accepted physicians' orders that contained clearly defined administration parameters for 6 of 20 active sample patients (A6, P1, P2, P3, P5, P6).

Findings include:

I. Chemical restraints

A. Observations:

1. On March 16, 2011 at approximately 9:30AM on the San Juan unit, the surveyor observed Patient SJ5 to be unsteady on his feet, holding onto the wall for support, exhibiting slowed movements and slowed verbal responses, slurred speech, and shuffling gait. He had to be assisted by a Mental Health Technician (MHT) throughout this time. Patient SJ5 was added to the survey sample and his record was reviewed.

2, Patient SJ5 was observed about every hour from approximately 9:30AM to approximately 1:30PM. Throughout this time, he continued to exhibit an unsteady gait, psychomotor retardation, needing to hold onto the wall to stabilize himself, and exhibited shuffling gait. He had a Mental Health Technician (MHT) with him throughout that time frame. He was not able to participate in any group activity.

B. Record Review:

Patient SJ5 was admitted on March 11, 2011 with diagnoses of Dementia with psychosis, hallucinations and delusions. Patient SJ5's PRN (as needed) orders, written March 14, 2011 at 12PM, were written as follows: "For anxiety, Haldol 2 mg PO (by mouth) every six hours PRN, if not able to swallow give intramuscular (IM) and Ativan 1 mg PO every six hours PRN, if not able to swallow give intramuscular".

Per the Medication Administration Record for Patient SJ5; on March 14, 2011 at noon, Patient SJ5 received Haldol lactate 2 mg IM and Ativan 1 mg IM in accordance to his/her PRN order for these medications. Patient SJ5 also received this combination of medications on March 15, 2011 at 2:56PM.

C. Interviews:

1. In an interview on March 16 at 2:00PM with RN1, s/he was asked if Patient SJ5's orders above cited were chemical restraint doses. She replied, "Yes." In addition she stated that the patient had been combative. There was no documentation of a one hour face to face evaluation having been performed for these orders (March 14 at noon or March 15 at 2:56PM).

2. In an interview on March 16, 2011, at 3:00PM RN1 was asked if Patient SJ5 had received any more doses of Haldol or Ativan that day (3/16/11). RN1 looked at Patient SJ5's orders and stated that "[s/he] had received Ativan 0.5mg, because now [s/he] had a new order for Ativan 0.5 mg TID and 2 mg QHS." Ativan was given because, with the new orders, it had become one of the patient's routine medications.

D. Policy Review:

Policy (translated) - Restraints and Seclusion, March, 2010- ("Restricciones Y Aislameinto, Marzo, 2010") - (No number was assigned to this policy)..."Chemical Restraints - When you have to use a medicine that is not part of the established medical or psychiatric treatment, for modifying the conduct of a patient, and that has a temporary effect in restricting his freedom of movement....patient has to have a face to face evaluation." The policy was translated for the surveyors by the Director of Nursing. The policy did not include that there needed to be a one hour face to face evaluation by either a Registered Nurse who had been trained in conducting it or by a physician.

II. Improperly written Standing PRN Orders:

A. Record Review

1. Patient A6: On 10/27/2010 the physician had ordered "Vistaril 50mg po (by mouth) q (every) 8hrs (hours) prn anxiety, agitation, aggressivity". On 10/28/2011 the above Order was discontinued and "Resperdol Mtabs 3mg po cada (every) 8 hours prn agitation, if the patient does not take Haldol 5mg IM cada 8hrs prn agitation".

2. Patient P1: On 3/9/2011 the physician had ordered "Ativan 2mg 1po q6h prn for anxiety; if patient does not take; Ativan 2mg IM (intramuscularly) g6h prn for anxiety [sic]" and "Haldol 5mg 1 po q6h prn for agitation; if patient does not take; Haldol 5mg IM q6h prn for agitation [sic]."

3. Patient P2: On 2/21/2011 the physician had ordered "Ativan 2mg 1po q6h prn for anxiety; if patient does not take; Ativan 2mg IM q6h prn for agitation [sic]" and "Haldol 5mg 1po q6h prn for agitation; if patient does not take; Haldol 5mg IM q6h prn for agitation [sic]."

4. Patient P3: On 3/10/2011 the physician had ordered "Ativan 2mg 1 po q6h prn for anxiety; if patient does not take; Ativan 2mg IM q6h prn for anxiety [sic]" and "Haldol 5mg 1 po q6h prn for agitation; if patient does not take;(sic) Haldol 5 mg q6h prn for agitation [sic]."

5. Patient P5: On 3/7/2011 the physician had ordered "Ativan 1mg 1 po q6h prn for anxiety; if patient does not take; Ativan 1mg IM q6h prn for anxiety [sic]" and "Haldol 1mg po q6h prn for agitation; if patient does not take; Haldol 2mg IM q6h prn for agitation [sic]."

6. Patient P6: On 3/12/2011 the physician had ordered "Ativan 2mg 1 po q6h prn for anxiety; if patient does not take; Ativan 2mg IM q6h prn for anxiety [sic]" and "Haldol 5mg 1 po q6h prn for agitation; if patient does not take; Haldol 5mg IM q6h prn for agitation [sic]."

B. Interview

In an interview on March 15, 2011 at 2:00PM with the Director of Nursing (DON) in reference to the usage of PRN (as needed) medication orders, she was asked about the use of Ativan and Haldol as PRN orders. The DON was asked if a patient had an order for both PRN Ativan for anxiety and PRN Haldol for agitation, would the nurse have the discretion to give those medications together or administer them separately. The DON stated "yes," and offered as an example, that it could be done together because the patient was most likely anxious before he became agitated.

Based on medical record review, staff interviews, and facility policy and procedure review, it was determined that:

1) For 6 of 20 active sample patients (Patients A6, P1, P2, P3, P5, P6) the facility failed to ensure that Physician orders gave specific parameters for the administration of both antianxiety and antipsychotic medications. In five of the six records cited (P1, P2, P3, P5, P6), Ativan was written for "Anxiety," an ill-defined state, and Haldol was written for "Agitation," again an ill-defined state. In the sixth record (patient A6) the single medication ordered was given for a range of symptoms. Therefore, the type of medication to be utilized and the purpose of the medication usage were left to the judgment of the various RNs on duty. In addition, the RNs could repeat the medications at frequencies based on their interpretation of the patient's emotional state or behavior (be it agitation and/or anxiety), allowing RNs to select medications and frequency based on their judgments. This failure results in physicians not providing Nursing Staff proper guidance for the administration of antipsychotic and/or antianxiety medications, and ambiguous Physician Orders can result in serious complications from improperly administered PRN medications. (Refer to B125-I)

(2.) For 1 of 20 sample patients (SJ5) the administration of chemical restraints followed current protocols that necessitate a face-to-face evaluation within 1 hour in order to protect patient rights and allow evaluation of the appropriateness or effectiveness of the intervention. The failure to follow standard procedures for the usage of chemical restraints results in the violation of the patient's rights to be free of restraints except in emergency situations. (Refer to B125-II)

Based on medical record review and staff interview it was determined that the facility failed to ensure that Psychiatric Evaluations for 20 of 20 patients (Patients A1, A2, A3, A4, A5, A6, A7, A8, P1, P2, P3, P4, P5, P6, SJ1, SJ2, SJ3, SJ4, SJ5, and SJ6), described memory functioning in a manner that disclosed how statements such as "Intacta" (Intact) and "Menoscabada" (Impaired) were determined. This failure to provide a database makes it difficult to utilize future assessments to measure positive or negative response to treatment.

Findings include:

I. Medical Record Review:

The following patients (Psychiatric Evaluation dates in parentheses) had no description of the methods used to determine and conclude how the physician was able to choose the ambiguous statements "Intacta" and "Menoscabada" checked on the preprinted forms.

A1 (1/05/2011); A2 (1/4/2011); A3 (1/6/2011); A4 (1/3/2011); A5 (1/4/2011); A6 (10/28/2011); A7 (1/2/2011); A8 (1/4/2011); P1(3/10/2011); P2 (2/22/2011); P3 (3/12/2011); P4 (3/11/2011); P5 (3/8/2011); P6 (3/13/2011); SJ1 (3/11/2011); SJ2 (2/22/2011); SJ3 (3/12/2011); (SJ4 (3/11/2011); SJ5 (3/8/2011); and SJ6 (3/13/2011).

II. Staff Interview:

In an interview on 1/11/2011 at 2:10PM with the Medical Director, she agreed that there was not a description by the psychiatrists of the databases upon which their assessments of memory functioning in 3 distinct spheres i.e. immediate, recent and remote recall had been made.

Based on medical record review, staff and patient interviews, policy and procedure review and observations, it was determined that the facility failed to ensure that:

(I). Standing Physician PRN (as necessary) Orders were written for clearly defined behaviors and emotions for 6 of 20 active patients (A6, P1, P2, P3, P5, P6), with clearly defined maximum daily dosages included in the orders. In five of the six records cited, Ativan was written for "Anxiety," an ill-defined state, and Haldol was written for "Agitation," again an ill-defined state. In the sixth record (patient A6) the medication ordered was given for a range of symptoms. Therefore, when and which type of medication was to be utilized was left to the judgment of the various RNs on duty. In addition, the RNs could repeat the medications at frequencies based on their interpretation of the patient's emotional state or behavior (be it agitation and/or anxiety), allowing RNs to select medications and frequency based on their judgments. This failure results in physicians not providing Nursing Staff proper guidance for the administration of antipsychotic and/or antianxiety medications, and ambiguous Physician Orders can result in serious complications from improperly administered PRN medications.

(II.) Chemical Restraint usage followed appropriate protocol to ensure patient safety and patient rights for one of 20 active sample patients (Patient SJ5). The failure to follow standard procedures for the usage of chemical restraints may result in the violation of patient's rights.
(III.) An unusual unilateral gross tremor was investigated as to etiology and possible relationship to presenting symptoms for a first admission patient for 1 of 20 active sample patients (Patient SJ6). This failure precludes determining if the abnormal neurological findings are related to the presenting symptoms or represent an independent condition.

Findings include:

I. Improperly written Standing PRN Orders:

A. Record Review (All quotes are substantiated in translation by the DON throughout this document)

1. Patient A6: On 10/27/2010 the physician had ordered "Vistaril 50mg po (by mouth) q(every) 8hrs (hours) prn anxiety, agitation, aggressivity". On 10/28/2011 the above Order was discontinued and "Resperdol Mtabs 3mg po cada (every) 8 hours prn agitation, if the patient does not take Haldol 5mg IM cada 8hrs prn agitation."

2. Patient P1: On 3/9/2011 the physician had ordered "Ativan 2mg 1po q6h prn for anxiety; if patient does not take; Ativan 2mg IM (intramuscularly) q6h prn for anxiety" and "Haldol 5mg 1 po q6h prn for agitation; if patient does not take; Haldol 5mg IM q6h prn for agitation [sic]."

3. Patient P2: On 2/21/2011 the physician had ordered "Ativan 2mg 1po q6h prn for anxiety; if patient does not take; Ativan 2mg IM q6h prn for agitation" and "Haldol 5mg 1po q6h prn for agitation; if patient does not take; Haldol 5mg IM q6h prn for agitation [sic]."

4. Patient P3: On 3/10/2011 the physician had ordered "Ativan 2mg 1 po q6h prn for anxiety; if patient does not take; Ativan 2mg IM q6h prn for anxiety" and "Haldol 5mg 1 po q6h prn for agitation; if patient does not take; Haldol 5 mg q6h prn for agitation [sic]."

5. Patient P5: On 3/7/2011 the physician had ordered "Ativan 1mg 1 po q6h prn for anxiety; if patient does not take; Ativan 1mg IM q6h prn for anxiety" and "Haldol 1mg po q6h prn for agitation; if patient does not take; Haldol 2mg IM q6h prn for agitation [sic]."

6. Patient P6: On 3/12/2011 the physician had ordered "Ativan 2mg 1 po q6h prn for anxiety; if patient does not take; Ativan 2mg IM q6h prn for anxiety [sic]" and "Haldol 5mg 1 po q6h prn for agitation; if patient does not take; Haldol 5mg IM q6h prn for agitation [sic]."

II.Chemical Restraint Usage:

A. Observation:

1. On March 16, 2011 at approximately 9:30AM on the San Juan unit, the surveyor observed Patient SJ5 to be unsteady on his feet, holding onto the wall for support, slowed movements and verbal responses, slurred speech, and shuffling gait. He had to be assisted by an MHT throughout this time. Patient SJ5 was added to the survey sample and his record was reviewed.

2. Patient SJ5 was observed about every hour from approximately 9:30AM to approximately 1:30PM. Throughout this time, he continued to exhibit an unsteady gait, psychomotor retardation, had to hold onto the wall to stabilize himself, exhibited shuffling gait, and had a Mental Health Technician (MHT) with him throughout that time frame. He was not able to participate in any group activity.

B.Medical Record Review:

1. Patient SJ5 was a 66 year old male who was admitted on March 11, 2011 with the diagnoses of Dementia with psychosis, hallucinations and delusions. His PRN (as needed) orders dated March 14, 2011, 12PM were written as follows: "For anxiety, Haldol 2 mg PO (by mouth) every six hours PRN, if not able to swallow give intramuscular (IM) and Ativan 1 mg PO every six hours PRN, if not able to swallow give intramuscular".

2. On March 14, 2011 at noon, Patient SJ5 received Haldol lactate 2 mg IM and Ativan 1 mg IM in accordance to his PRN order for these medications. He also received this combination of medications on March 15, 2011 at 2:56PM. The Progress Notes for these dates were reviewed with the Director of Nursing and there was no documentation found to explain why an intramuscular route versus an oral route was chosen.

C.Staff Interview:

1. Per an interview on March 16, 2011 at approximately 2:00 PM with RN1, she was asked if Patient SJ5's orders as described above were chemical restraint doses. She replied, "yes." In addition, she stated that the patient had been combative. Although these were considered chemical restraints by the nursing staff, there is no documentation of a one hour face to face evaluation by a physician or trained nurse for these medication administrations (March 14 at noon or March 15 at 2:56PM). Haldol was not a part of his routine medication regime.

2. In an interview on March 16, 2011 at approximately 3:00PM with RN1, she was asked if Patient SJ5 received any more doses of Haldol or Ativan that day (March 16). RN1 looked at Patient SJ5's orders and stated that the patient had received Ativan 0.5mg, because it was part of his routine medication regimen: "Ativan 0.5 mg TID and 2 mg QHS".

3. In an interview on March 15, 2011 at 2:00PM, the Director of Nursing (DON) was asked about the use of Ativan and Haldol as PRN orders. She was asked if a patient had a physician order for Ativan for anxiety and another physician order for Haldol for agitation, would the nurse have the discretion to give those medications together or administer them separately. She stated "yes" and offered an example, "that it could be done in combination because the patient was most likely anxious before he became agitated."

D. Policy Review:

Policy (translated with the help of the Director of Nursing) -Restraints and Seclusion, March, 2010- ("Restricciones Y Aislameinto, Marzo, 2010") - (No number was assigned to this policy) "...Chemical Restraints - When you have to use a medicine that is not part of the established medical or psychiatric treatment, for modifying the conduct of a patient, and that has a temporary effect in restricting his freedom of movement....patient has to have a face to face evaluation." It did not include the within one hour time frame for a face-to-face evaluation of the patient's physiological and/or psychological conditions.

III. Neurological Impairment:

A. Observation

In an observation on 3/16/2011 at 10:30AM, Patient SJ6 was observed on the Unit sitting and moving his left hand in a rapid alternating motion, apparently out of his control since he was observed to occasionally grasp his left hand with his right hand as if to halt the movements.

B. Record Review

1. Patient SJ6 was a 66 year old who was admitted for the first time on 3/11/2011.The pt. received an initial physical examination (3/11/2011), a nursing evaluation (3/11/2011) and a psychiatric evaluation (3/12/2011). None of these examinations addressed the involuntary movement, a gross alternating tremor, present in the patient's left hand. The lack of documentation of the involuntary movements in any of the exams was substantiated by the Director of Nursing who also reviewed the exams and aided with translation at approximately 11:30AM on 3/16/2011.

2. In a Progress Note by the attending psychiatrist dated 3/14/2011 it was noted that the use of Haldol was "tolerated" [this word was written in English in the record] by the patient and that the left hand tremor was present.

3. The Master Treatment Plan dated 3/12/2011 did not list this impairment as either a Problem to be addressed, nor was it acknowledged as present as an issue on the Axis III of this Plan.

C. Interview

1. In an interview on 3/16/2011 at 12:30PM with Patient SJ6 with the Director of Nursing in attendance, Patient SJ6 stated the tremor had been present before admission.

2. In an interview on 3/16/2011 at approximately 12:30PM, the attending psychiatrist stated that if this issue needed a neurological consult this could be obtained, but none had been sought to determine the etiology. He also acknowledged that the Treatment Plan (3/12/2011) failed to list this as either a Problem or been included as a diagnosis on Axis III of the Treatment Plan.

Based on observation, medical record review, staff and patient interviews, and facility policy and procedure review it was determined that the clinical director failed to ensure that:

1. Psychiatric Evaluations for memory functioning included the database from which generalized statements were made. (Refer to B116)

2. Physician orders for PRN medications were written in a manner that provided Nursing staff with clearly defined parameters for administering medications for "anxiety" and "agitation." (Refer to B125-I)

3. Chemical Restraint usage followed current protocols for the use of this intervention, specifically face-to-face evaluations within 1 hour. The Medical Director failed to ensure that policy and procedure related to seclusion and restraint were detailed enough to protect a patient's right to be treated in the least restrictive environment by not clearly delineating a time frame for face-to-face evaluations. (Refer to B125-II)

4. Physicians identified and evaluated a first time admission patient with an unusual neurological issue for the etiology and possible relationship to presenting symptoms. (Refer to B125-III)

Based on Observation, record review, policy reviews, and staff interview, the Director of Nursing failed to:

I) Ensure that chemical restraint usage included a one-hour face to face evaluation for sample patient SJ5.

II) Ensure that nurses only accepted physicians' orders that contained clearly defined administration parameters for 6 of 20 active sample patients (A6, P1, P2, P3, P5, P6).

Findings include:

I. Chemical restraints

A. Observations:

1. On March 16, 2011 at approximately 9:30AM on the San Juan unit, the surveyor observed Patient SJ5 to be unsteady on his feet, holding onto the wall for support, exhibiting slowed movements and slowed verbal responses, slurred speech, and shuffling gait. He had to be assisted by a Mental Health Technician (MHT) throughout this time. Patient SJ5 was added to the survey sample and his record was reviewed.

2, Patient SJ5 was observed about every hour from approximately 9:30AM to approximately 1:30PM. Throughout this time, he continued to exhibit an unsteady gait, psychomotor retardation, needing to hold onto the wall to stabilize himself, and exhibited shuffling gait. He had a Mental Health Technician (MHT) with him throughout that time frame. He was not able to participate in any group activity.

B. Record Review:

Patient SJ5 was admitted on March 11, 2011 with diagnoses of Dementia with psychosis, hallucinations and delusions. Patient SJ5's PRN (as needed) orders, written March 14, 2011 at 12PM, were written as follows: "For anxiety, Haldol 2 mg PO (by mouth) every six hours PRN, if not able to swallow give intramuscular (IM) and Ativan 1 mg PO every six hours PRN, if not able to swallow give intramuscular".

Per the Medication Administration Record for Patient SJ5; on March 14, 2011 at noon, Patient SJ5 received Haldol lactate 2 mg IM and Ativan 1 mg IM in accordance to his/her PRN order for these medications. Patient SJ5 also received this combination of medications on March 15, 2011 at 2:56PM.

C. Interviews:

1. In an interview on March 16 at 2:00PM with RN1, s/he was asked if Patient SJ5's orders above cited were chemical restraint doses. She replied, "Yes." In addition she stated that the patient had been combative. There was no documentation of a one hour face to face evaluation having been performed for these orders (March 14 at noon or March 15 at 2:56PM).

2. In an interview on March 16, 2011, at 3:00PM RN1 was asked if Patient SJ5 had received any more doses of Haldol or Ativan that day (3/16/11). RN1 looked at Patient SJ5's orders and stated that "[s/he] had received Ativan 0.5mg, because now [s/he] had a new order for Ativan 0.5 mg TID and 2 mg QHS." Ativan was given because, with the new orders, it had become one of the patient's routine medications.

D. Policy Review:

Policy (translated) - Restraints and Seclusion, March, 2010- ("Restricciones Y Aislameinto, Marzo, 2010") - (No number was assigned to this policy)..."Chemical Restraints - When you have to use a medicine that is not part of the established medical or psychiatric treatment, for modifying the conduct of a patient, and that has a temporary effect in restricting his freedom of movement....patient has to have a face to face evaluation." The policy was translated for the surveyors by the Director of Nursing. The policy did not include that there needed to be a one hour face to face evaluation by either a Registered Nurse who had been trained in conducting it or by a physician.

II. Improperly written Standing PRN Orders:

A. Record Review

1. Patient A6: On 10/27/2010 the physician had ordered "Vistaril 50mg po (by mouth) q (every) 8hrs (hours) prn anxiety, agitation, aggressivity". On 10/28/2011 the above Order was discontinued and "Resperdol Mtabs 3mg po cada (every) 8 hours prn agitation, if the patient does not take Haldol 5mg IM cada 8hrs prn agitation".

2. Patient P1: On 3/9/2011 the physician had ordered "Ativan 2mg 1po q6h prn for anxiety; if patient does not take; Ativan 2mg IM (intramuscularly) g6h prn for anxiety [sic]" and "Haldol 5mg 1 po q6h prn for agitation; if patient does not take; Haldol 5mg IM q6h prn for agitation [sic]."

3. Patient P2: On 2/21/2011 the physician had ordered "Ativan 2mg 1po q6h prn for anxiety; if patient does not take; Ativan 2mg IM q6h prn for agitation [sic]" and "Haldol 5mg 1po q6h prn for agitation; if patient does not take; Haldol 5mg IM q6h prn for agitation [sic]."

4. Patient P3: On 3/10/2011 the physician had ordered "Ativan 2mg 1 po q6h prn for anxiety; if patient does not take; Ativan 2mg IM q6h prn for anxiety [sic]" and "Haldol 5mg 1 po q6h prn for agitation; if patient does not take;(sic) Haldol 5 mg q6h prn for agitation [sic]."

5. Patient P5: On 3/7/2011 the physician had ordered "Ativan 1mg 1 po q6h prn for anxiety; if patient does not take; Ativan 1mg IM q6h prn for anxiety [sic]" and "Haldol 1mg po q6h prn for agitation; if patient does not take; Haldol 2mg IM q6h prn for agitation [sic]."

6. Patient P6: On 3/12/2011 the physician had ordered "Ativan 2mg 1 po q6h prn for anxiety; if patient does not take; Ativan 2mg IM q6h prn for anxiety [sic]" and "Haldol 5mg 1 po q6h prn for agitation; if patient does not take; Haldol 5mg IM q6h prn for agitation [sic]."

B. Interview

In an interview on March 15, 2011 at 2:00PM with the Director of Nursing (DON) in reference to the usage of PRN (as needed) medication orders, she was asked about the use of Ativan and Haldol as PRN orders. The DON was asked if a patient had an order for both PRN Ativan for anxiety and PRN Haldol for agitation, would the nurse have the discretion to give those medications together or administer them separately. The DON stated "yes," and offered as an example, that it could be done together because the patient was most likely anxious before he became agitated.