HospitalInspections.org

Based on review and interview the Governing Body failed to:



1.) ensure the safety of 1(#1) of 5 (1-5) patients receiving care at the facility. Patient #1 was assaulted by a security guard. The facility also failed to document the cause of Patient #1's injuries and the physician care received for those injuries. The facility failed to ensure appropriate personnel action was taken to keep patients safe from injury by staff.

The condition and deficient practices were identified and determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Refer to Tag A0144




2.) follow its own policy and procedure to perform and document a patient face to face, patient assessments considering immediate situations, patient reaction to interventions, and inform the patient of seclusion release criteria. The physician failed to document the clinical justification in the individual's record for the simultaneous use of more than one mechanical restraint device and personal restraint, a mechanical restraint device and seclusion, or personal restraint or seclusion in 2 (#1 and #4) of 2 charts reviewed.

Refer to Tag A0160



3.) document nursing assessments after the administration of psychotropic medications in 2 (#1 and #4) of 2 charts reviewed. Nursing also failed to evaluate and document physician notifications of patient injuries and document blood sugar readings.

Refer to Tag A0395

Based on record review and interview the facility failed to;

1.) ensure the safety of 1(#1) of 5 (1-5) patients receiving care at the facility. Patient #1 was assaulted by a security guard. The facility also failed to document the cause of Patient #1's injuries and the physician care received for those injuries. The facility failed to ensure appropriate personnel action was taken to keep patients safe from injury by staff.

The condition and deficient practices were identified and determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Refer to Tag A0144




2.) follow its own policy and procedure to perform and document a patient face to face, patient assessments considering immediate situations, patient reaction to interventions, and inform the patient of seclusion release criteria. The physician failed to document the clinical justification in the individual's record for the simultaneous use of more than one mechanical restraint device and personal restraint, a mechanical restraint device and seclusion, or personal restraint or seclusion in 2 (#1 and #4) of 2 charts reviewed.


Refer to Tag A0160

Based on review of records and interviews, the facility failed to ensure the safety of 1(#1) of 5 (1-5) patients receiving care at the facility. Patient #1 was assaulted by a security guard. The facility also failed to document the cause of Patient #1's injuries and the physician care received for those injuries. The facility failed to ensure appropriate personnel action was taken to keep patients safe from injury by staff.

The condition and deficient practices were identified and determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.


Review of patient #1's physician psychiatric exam revealed the patient was admitted to the forensic wing on 6/22/16. "Patient was a 26 yr old white male with hx of schizophrenia vs schizoaffective disorder (bipolar type) and seizure d/o who presented to Palestine Regional Medical Center (PRMC) to forensic competency restoration unit on court order for observation/treatment for period not exceeding 120 days in hopes of restoring competency. Apparently, pt is currently charged with harassment by person in correctional facility." Patient had a history of seizure activity and medication non-compliance.

Review of patient #1's patient care notes stated, "9/18/16 17:00 Patient attended all meals and snacks. Patient attended no activities. Patient has been labile but direct able thus far today."

"9/18/16 17:50 Patient became agitated outside. Patient came in to dining room cursing and hollering. Patient got into a verbal altercation with a peer. Another peer got involved in the verbal altercation and it became physical with patient hitting his peer in the side of the head. I stepped in between patient and peer and patient was redirected to his room. Patient was still extremely agitated coming in and out of his room. MD was notified and emergency medications given per order. Patient then came out of his room and bowed up to security guard. Patient spit in security guards face."

Review of the physician orders dated 9/18/16 17:56 revealed patient #1 was ordered Geodon 40mg IM NOW and Benadryl 100mg IM NOW "Emergency medication for aggression and agitation."

There was no further information documented in the patient care notes or psychiatric flow sheet regarding the medication administration, patient behavior or patient status. Review of the psychiatric flow sheet revealed the nurse did a patient assessment at 8:00PM (2 hours later) on 9/18/16 and stated, "Patient somewhat drowsy post emergency medication exhibiting no psychotic behavior at this time."

The nurse continued to document that patient #1 had wounds as follows:
"1.) Wound to the front of head left temporal, small contusion 3cm diameter.
2.) Upper left area of back abrasion 2 cm x11cm crescent abrasion.
3.) Front of shoulder multiple small abrasions of left deltoid.
4.) Upper chest crescent abrasion from axillary to sternum approximately 3 cm x 13 cm, skin is red and bruised.
5.) Inner elbow abrasion approximately 2 cm x 7 cm.
6.) Front of left ear lobe small laceration approximately 0.3cm in length and 0.1 cm in depth. Area was red and bloody."

There was no nursing documentation found of how the patient received the wounds, when, or what treatment was offered. There was no documentation that the physician was contacted or informed of Patient #1's new wounds.

Review of the incident report dated 9/18/16 revealed patient #1 at 18:10 (6:10PM) "had an altercation with peer. Patient was redirected to his room and emergency medications were given. Patient then came out of his room and bowed up to the security guard and put up his fist. Patient then spit in the security guards face and they engaged in a physical altercation." The incident report revealed there were two security guards involved and one RN. There was no documentation on the incident report if the second security guard intervened or if he was involved in the altercation.

Review of the Quality Director's statements written on 9/19/16 revealed the incident was reported to the Regulatory Services Division. The timeline comments revealed the following:

9/18/2016 @ 2104 (9:04PM) Director of Psychiatric Nursing (DPN) received a call from the charge nurse about the incident.

9/18/2016 @ 2130 (9:30PM) DPN arrived on the unit and reviewed the video footage and pictures of the patient's injuries. MD notified and came to see patient. _____(Staff #8) was no longer on the unit and had gone to the ER to be assessed for his injuries.

9/18/2016 @ 2215 (10:15PM) the DPN notified the house supervisor at the main campus to let them know of the incident and inquired about _____(Staff #8). She was informed he was discharged from the ER.

9/18/2016 @ 2236 (10:36PM) the DPN notified the Administrator on call of the incident.

9/18/2016 @ 2240 (10:40PM) "The DPN asked the security personnel to contact their supervisor to find a replacement due to the incident for _____(Staff #8) since he was not scheduled to work at the PRMC in the AM."

9/18/2016 @ 2250 (10:50PM) the DPN called the director of security and explained the incident that was viewed on the video. Pending investigation, _______(Staff #8) would be suspended until investigation was completed.

Staff #5 stated the information of the incident was not put in patient #1's chart. Staff #5 stated, "We didn't feel that information needed to go in the patient's chart." Staff #5 stated she reviewed the video of the incident and staff #8 and patient #1 had exchanged punches with fist. Staff #8 had placed the patient in a head lock and was punching the patient in multiple areas of face and body.

Review of the statement made by staff #8 (Security Guard) dated 9/18/16 at 5:45PM revealed the following statement:

"I noticed ________(Patient #1) strike _______( Patient #2) on the left side of his face so I went over to observe & report, & only assist when or if needed. ______(Patient #1) had been instructed to go to his room where he continued cursing & making racial slurs & as we waited for the shot, he repeatedly tried to walk out his room so I stayed with _____(Staff #10-RN) until assistance could arrive with the shot. When the shot came,_______ (Patient #1) took the shot without incident, but as _______(Staff #9) and I both asked ______(Patient #1) to return to his room & as we asked him he spit in my face. I tried to turn him to put him in a standing PRT but he scratched my eye & couldn't see, so the only thing I could do was pin against the door until assistance could arrive to take over the restraint. Assistance came and I let go as soon as I could see there were no other patients around. Our incident took place between 1800-1810. And I notified captain immediately." (SIC)

Review of statement made by staff #9 (Security Guard) dated 9/18/16 at 1810. Staff #9 revealed the following statement:

"________(Patient #1) was being extremely racist using the N-word Inside the TV room/towards _______ (patient #3). _______(Patient #2) stepped between them and ________(patient #1) punched him in the face, then charged at _________staff #8 and spit in his face. ________(staff #8) then attempted to restrain ________(patient #1) I officer and RN. _______Staff #10 grabbed _______(patient #1) arms and escorted him to his room." (SIC)

Review of staff #10's (RN) statement revealed she was the RN involved with patient #1 during a patient staff altercation. There was no date or time on the statement. The statement stated, "Patient was in his room after receiving emergency medications for prior outburst episode with male peer. Nurse staff and security officers were standing outside the patient's door in an attempt to protect patient and other patients on unit. Patient came busting out of his room and immediately directed his attention to ____(staff #8). Patient was agitated and screaming/yelling loudly, making racial slurs, cursing, and in defensive stance with fist drawn. Nurse staff intervened and tried to redirect patient but patient continued to approach Security Officer (Staff #8). (Staff #8)______ stood with his arms at his side while patient was in his face yelling with fist drawn. Patient then spat in ______(staff #8's) face. At no time did staff nurse authorize ______ (staff #8) to restrain patient, ______(staff #8) acted in his own accord. ________(Staff #8) and patient exchanged punches with one another. _________(Staff #8) then placed patient in a head lock and continued to punch patient in and around head/facial area. At this time more staff members arrived and all staff helped with taking down ______(Staff #8) and separating the two men. Staff nurse placed patient in his room while ______(staff #8) exited the unit. Once _______(Staff #8) was off the unit, staff nurses escorted patient to the seclusion room to assess patient and clean wounds. ______(Staff #11-MD) was notified of the incident, and ________, DON was notified. Patient was assessed by ______(Staff #11-MD)."


A review of an email dated 9/21/16 revealed it was written by the head of hospital security. The email stated, "...... we had an incident between _____(staff #8) and _____(patient #1). After a thorough investigation I have come to the conclusion that ______(staff #8) allowed himself to be provoked by ______(patient #1) by verbal racist comments and spitting on him. Upon being spat on, ______(staff #8) took it upon himself to physically engage the patient. The initial swing by ______(staff #8) is clear on video surveillance, contradicting his written incident report. Furthermore bruises and contusions on the patient with his fist stopping only after staff and _______(officer #9) intervened and separated them. I am concerned that _______(officer #9) was very vague in his statement but understand the want to cover for his co-worker." Staff #9 was still employed with the facility and working with patients. There was no documentation that staff #9 had been counseled, retrained, or disciplined for not accurately documenting the incident.

An interview with staff #2, #3, and #5 was conducted on 11/8/16. Staff #3 confirmed that the security guard who assaulted the patient was terminated. Staff #3 confirmed the second security guard, staff #9, called for help and when help arrived he assisted in pulling the security guard and patient apart. Staff #3 did confirm staff #9's (security guard) statement was inaccurate but he was not terminated and was still working on the unit. Neither security guard reported in their statements that the patient was struck by staff #8.

Staff #2, 3, and 5 all confirmed that there had been meetings held with the staff and teaching had been done on appropriate care with patients in regards to the incident. Staff #3 reported the security guards were through a contracted service. The security supervisor reported to the hospital administration that he had done re-training with the security guards in appropriate patient care. Staff #3 reported that he had not done anything in writing. The security supervisor had just talked to the staff individually but had no written proof.

Staff #5 stated she had done training with staff after the incident on appropriate patient care and had reviewed the tape with the staff. Staff #5 was unable to provide written documentation of any training or meetings.

Staff # 3 supplied emails on what needed to be brought forward to quality to follow up. However, staff #3 was unable to provide any written follow ups or quality/performance documentation in relation to this incident. Staff #1, 2, 3 and 5 confirmed they had no written evidence to prove the hospital administration had implemented corrective action or had aggressively moved forward to address the issue of patient safety. There was no evidence provided that the patients were safe from physical abuse of the staff.

Surveyor: Ready, Shanda

Based on record review and interview the facility failed to follow its own policy and procedure to perform and document a patient face to face, patient assessments considering immediate situations, patient reaction to interventions, and inform the patient of seclusion release criteria. The physician failed to document the clinical justification in the individual's record for the simultaneous use of more than one mechanical restraint device and personal restraint, a mechanical restraint device and seclusion, or personal restraint or seclusion in 2 (#1 and #4) of 2 charts reviewed.



1.) Review of patient #1's physician psychiatric exam revealed the patient was admitted to the forensic wing on 6/22/16. "Patient was a 26 yr old white male with hx of schizophrenia vs schizoaffective disorder (bipolar type) and seizure d/o who presented to Palestine Regional Medical Center (PRMC) to forensic competency restoration unit on court order for observation/treatment for period not exceeding 120 days in hopes of restoring competency. Apparently, pt is currently charged with harassment by person in correctional facility." Patient had a history of seizure activity and medication non-compliance.


Review of patient #1's chart revealed he was ordered chemical and behavioral physical restraints on the following dates:


Review of the patient care notes revealed the RN documented, "6/28/16 08:45 PATIENT IN HALLWAY SCREAMING, CURSING, THREATENING, USING RACIAL SLURS, AND THREATENING OTHERS. NURSE SPOKE WITH PATIENT AND HE WENT INTO HIS ROOM AND SEEMED TO CALM DOWN. HE HAD QUIT SCREAMING AND CURSING, BUT SUDDENLY CAME OUT OF ROOM AND BEGAN SCREAMING AT GUARD, SHAKING FIST AT GUARD, AND THREATENING THE GUARD. PATIENT WAS MAKING RACIAL SLURS, BODY LANGUAGE AGGRESSIVE TOWARD OTHERS, SCREAMING AND WALKING TOWARD STAFF IN THREATENING MANNER. GUARD VERBALLY REDIRECTED PATIENT AND PATIENT LUNGED AT GUARD AND SPIT IN HIS FACE. GUARD PERFORMED PHYSICAL RESTRAINT ON PATIENT WITH ASSISTANCE OF TECHS ANTHONY AND JOHNATHAN. PATIENT WAS PHYSICALLY RESTRAINED UNTIL HE QUIT STRUGGLING AND THEN WAS MOVED TO SECLUSION ROOM. 0855-PATIENT IN SECLUSION. HE WAS SCREAMING, CURSING, USING RACIAL SLURS AND THREATENING OTHERS. PATIENT SUDDENLY STRIPPED AND BEGAN HITTING WALLS AND WINDOWS OF SECLUSION ROOM. WHEN HE STRUCK THE WINDOW, BLOOD SPATTERED ALL OVER THE WINDOW AND DECISION WAS MADE TO PLACE HIM IN RESTRAINT CHAIR."


Review of the physician orders revealed an order was obtained on 6/28/16 at 9:03AM, "HALDOL LACTATE 5 MG/ML SOLN Dose: 5 MG Route: INTRAMUSCULAR Frequency: GIVE ONE DOSE NOW Start: 6/28/16 09:01 End: 6/28/16 13:01 # of Doses: 16/28/16 9:03 diphenhydramine (BENADRYL) 50 MG/ML SOLN Dose: 50 MG Route: INTRAMUSCULAR Frequency: GIVE ONE DOSE NOW Start: 6/28/16 09:02 End: 6/28/16 13:02 # of Doses: 1."


Review of the patient care notes reveled the RN documented on 6/28/16 at 9:07AM, "PATIENT WAS PLACED IN RESTRAINT CHAIR DUE TO DANGER TO SELF AND OTHERS. 0910-PATIENT WAS GIVEN HALDOL 5MG AND BENADRYL 50MG IM TO LEFT DELTOID. PATIENT WAS SCREAMING, "GIVE ME A SHOT. GIVE ME A SHOT." 0912-STACY JACOBS HERE FOR FACE TO FACE. 0916-PATIENT BEGAN HAVING A SEIZURE. ALL RESTRAINTS STOPPED. PATIENT WAS TAKEN OUT OF RESTRAINT CHAIR AND PLACE ON BED IN SECLUSION ROOM WITH DOOR OPEN AND MULTIPLE STAFF AT BEDSIDE. HE WAS TURNED TO HIS LEFT SIDE. 02 AT 8L PER MASK. V/S 124/78, PULSE 99, O2SAT 95%. PATIENT UNRESPONSIVE AT THIS TIME. EMS CALLED FOR TRANSPORT TO ER. V/S 106/58, PULSE 78. O2 SAT 98%. PATIENT BEGINNING TO WAKE. 0923-EMS HERE. CARE TRANSFERED TO EMS. "


Review of patient #1's chart revealed three different restraint forms for the same incident on 6/28/16.


The first seclusion restraint form dated 6/28/16 revealed the patient was put in seclusion room at 8:55AM.


Review of the second seclusion restraint form dated 6/28/16 revealed the patient was put in a restraint chair at 9:07AM, due to patient #1 hitting walls and causing the skin on the knuckles to break open. The form was checked that the physician was notified but the date and times were left blank.


Review of the third seclusion restraint form dated 6/28/16 revealed the patient was put in a restraint chair at 9:07AM and removed at 9:16AM due to a seizure. There was no physical assessment of the patient's condition found.


Review of the policy and procedure "Restraints and Seclusion" page 16 #7 stated, "One hour face to face assessment: The physician, LIP, or a qualified registered nurse or physician' assistant shall perform a face to face assessment of the individuals physical and psychological status within 1 hour of the initiation of restraint. The face to face assessment is performed even in those situations where the person is released early (prior to one hour). This assessment shall include and be documented in the medical record:

The patient's immediate situation
The patient's reaction to the intervention
The patient's medical and behavioral condition the need to continue or terminate the restraint or seclusion.

F. All forms of restraints, as well as a form of restraint in conjunction with seclusion, are intended to be used independently of one another. The physician shall document the clinical justification in the individual's record for the simultaneous use of more than one mechanical restraint device and personal restraint, a mechanical restraint device and seclusion, or personal restraint or seclusion."


Review of the patient care notes revealed the DPN documented, "6/28/16 09:35 Face to Face discussed with Dr. _______(Staff #11), Psych Director, unable to reach Dr. ______ by phone. Agreed with actions taken by staff and patients transfer to ER for further evaluation." There was no further documented information found. The assessment failed to have the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion.


Review of the physician orders revealed an order was obtained on 6/28/16 at 9:41AM, "Lorazepam (ATIVAN) 2 MG/ML SOLN Dose: 2 MG Route: INTRAMUSCULAR Frequency: GIVE ONE DOSE NOW Start: 6/28/16 09:40 # of Doses: 1 Comments: Emergency Dose for severe agitation and reaction to Haldol IM. One time telephone order."


Review of the patient care notes revealed the RN documented, 7/12/16 9:00AM patient pacing up and down the hall yelling racial statements making jumping motions at staff. Refusing to take his medication. Unable to redirect patient. 9:15AM agreed to take am medication taken at this time patient continues to yell and cuss calling racial names jumping at staff as if he will attack. New order received for IM injection. IM injection given per 3 injection to buttocks patient layed (SIC) down on bed and stated that he would take without problems. Tolerated well. After injection patient got up and grabbed sock and wrapped around neck stating I will hang myself. Sock removed from patient as well as sheets patient jumped at staff took off shoes and throw them at two nurses then tried to hit staff patient place in personal hold per hospital protocol then taken to seclusion patient removed all of his cloths which was removed from seclusion room pacing around playing with self continue to observe. 10:03AM patient laying on mattress eyes closed breathing even and unlabored. Door opened and patient covered with blanket.


Review of the physician orders revealed a telephone order dated 7/12/16 at 9:19AM, "Diphenhydramine (BENADRYL) 50 MG/ML SOLN Dose: 50 MG Route: INTRAMUSCULAR Frequency: GIVE ONE DOSE NOW Start: 7/12/16 09:18 End: 7/12/16 13:18 # of Doses: 1."


Review of the seclusion and restraint form revealed the patient was put in a personal hold and seclusion on 9/12/16 at 9:25AM. The nurse failed to complete the form. The block marked #7 stated check when completed. The following was not checked;
"Procedure explained to the patient
Search and removal of dangerous items
Room and mattress check
Physician notified and orders obtained
Physician order includes; type of restraint, time limit, and justification for intervention.
Observation person assigned.
Patient informed of the necessary behavior to be released for seclusion.
Physician /independent practitioner assessed the patient within 1 hour. "


Patient was released at 1200PM. There was no information on the seclusion sheet that the patient had fallen asleep and was released. The reason stated, "Calmer no longer assaultive or agitaive (sic) to self or others." There was no information on the seclusion restraint form about the chemical restraint. There was no face to face documentation found.


2.) Review of patient #4's admission sheet stated the patient was admitted on 9/29/16 at 10:20AM. While the patient was in admissions a physician order was written for the following psychotropic medications:

"9/29/16 10:48AM Haloperidol (HALDOL) 5 MG/ML SOLN Dose: 10 MG Route: INTRAMUSCULAR Frequency: GIVE ONE DOSE NOW Start: 9/29/16 10:46 End: 9/29/16 14:46 # of Doses: 1Comments: delusions, psychosis.
Lorazepam (ATIVAN) 2 MG/ML SOLN Dose: 2 MG Route: INTRAMUSCULAR Frequency: GIVE ONE DOSE NOW Start: 9/29/16 10:47 End: 9/29/16 14:47 # of Doses: 1Comments: agitation."


Review of the Medication Administration Record (MAR) revealed the medications were administered at 10:47AM. There is no nursing documentation concerning the patient's behaviors to warrant the medication, that the physician was notified, or how the patient received the medications. There was no documentation found on the follow-up on the effectiveness of the drug until 12:26PM. The assessment stated, "Patient sleeping."
Review of patient care notes dated 9/29/16 at 1700 (5:00PM) "Chief Complaint: Assault bodily injury to a family member, paranoid delusions, psychosis, has a history of claiming to be raped almost every night in the jail, claimed that the deputies that brought her here had raped her with snakes, claimed that one of the nurses in the room that was standing 3 feet away was raping her right then, claimed that Jeb Bush was raping her while nuses (SIC) were giving her the emergency injections of medications that the Dr. ordered. When nurses tried to reassure pt. that she was safe and that she was in a hospital she stated that we had told her to "go fuck a bush". Pt is very uncooperative and had to be forced to leave the triage room because she was trying to get out the back door. Pt refused to believe that she had a court order to be here. Pt is very combative and uncooperative."


Patient #4 was forced to leave the triage room but there was no documentation of a restraint hold to remove the patient or to administer medication.


Review of the physician progress notes revealed there was no documentation in the psychiatrist evaluation concerning the behavioral incident, why the order was necessary or other treatments that was considered, but was rejected and rational.


Review of patient #4's nurses patient care notes dated 10/10/16 at 08:03AM revealed the RN documented, "during shift report pt extremely agitated, could be heard by staff in hallway yelling and screaming. pts agitation/anger continued to escalate throughout vital signs and breakfast. pt threatening to kill staff and stating, "i will f***ing kill you, you b***h. don't you f***ing touch me. im not f***ing taking that medicine". pt then stormed off to room slamming the door. pt could be heard in room throwing items, self-conversing/ responding to internal stimuli. When staff approached pt room for safety check pt begin yelling and screaming once again, "dont f***ing come in here. get the f*** out of my room. im warning you, get the f**k out". staff placed call to dr kamble, new orders received to intervene with po medication of haldol 10 mg, ativan 2 mg and cogentin 1 mg. if pt refuses po medications, im medications are warrented." (SIC)There was no found documentation of interventions.


10/10/16 08:34AM RN documented, "PT REFUSED PO MEDICATIONS ORDERED BY DR KAMBLE. PT MADEAWARE THAT IM MEDICATIONS WERE TO BE ADMINISTERED IF PTREFUSED. PT YELLED AT STAFF STATING, "F**K YOU! F**K YOU! GET OUT !".


Review of the physician orders on 10/10/16 8:39AM stated, "Lorazepam (ATIVAN) 2 MG/ML SOLN Dose: 2 MG Route: INTRAMUSCULAR Frequency: GIVE ONE DOSE NOW Start: 10/10/16 08:39 End: 10/10/16 12:39 # of Doses: 1Comments: EMERGENCY DOSE.


10/10/16 8:38 Haloperidol (HALDOL) 5 MG/ML SOLN Dose: 10 MG Route: INTRAMUSCULAR Frequency: GIVE ONE DOSE NOW Start: 10/10/16 08:36 End: 10/10/16 12:36 # of Doses: 1 Comments: EMERGENCY DOSE."


Review of the patient clinical notes the RN documented , "10/10/16 09:00AM im medications administered to pt. personnal hold deemed necessary d/t staff unable to redirect pt, pt kicking and refusing to bare buttucks area. ______(Staff #11)made aware of situation, ______(Staff #5) don, performed face to face, and necessary paperwork has been documented." (SIC)

Review of the Seclusion and Restraint Documentation form dated 10/10/16 at 9:00AM revealed the patient was placed in a personal hold. The RN documented the patient was undirectable, hostile behavior towards staff and peers, threatening yelling/screaming, slamming doors, splashed coffee all over walls."

Review of the patient #4's chart revealed a face to face was performed for the physical hold by staff #5 on 10/10/16 at 10:00AM. Staff #5 documented, "10/10/2016 09:00 emergency dose of geodon and ativan given no personal hold required, patient agreed to tkae (sic) medications." Patient #4 was given Haldol not Geodon IM for behavioral issues. Nursing documented in the patient care notes and restraint documentation that the patient was put in a personal hold to administer medications. There was no nursing assessment performed or vital signs performed. There was no nursing documentation until 11:56; stated, "Sleeping."

Based on record review and interviews, nursing failed to document nursing assessments after the administration of psychotropic medications in 2 (#1 and #4) of 2 charts reviewed. Nursing also failed to evaluate and document physician notifications of patient injuries and document blood sugar readings.

Refer to TAG A0395

Based on record review and interviews, nursing failed to document nursing assessments after the administration of psychotropic medications in 2 (#1 and #4) of 2 charts reviewed. Nursing also failed to evaluate and document physician notifications of patient injuries and document blood sugar readings.

The findings below contained documentation and statements that included proper names of individuals involved and are represented in the statement with a blank line followed by the patient/staff identifier.

1.) Review of patient #1's physician psychiatric exam revealed the patient was admitted to the forensic wing on 6/22/16. "Patient was a 26 yr old white male with hx of schizophrenia vs schizoaffective disorder (bipolar type) and seizure d/o who presented to Palestine Regional Medical Center (PRMC) to forensic competency restoration unit on court order for observation/treatment for period not exceeding 120 days in hopes of restoring competency. Apparently, pt is currently charged with harassment by person in correctional facility." Patient had a history of seizure activity and medication non-compliance.

Review of patient #1's patient care notes stated, "9/18/16 17:00 Patient attended all meals and snacks. Patient attended no activities. Patient has been labile but directable thus far today."

"9/18/16 17:50 Patient became agitated outside. Patient came in to dining room cursing and hollering. Patient got into a verbal altercation with a peer. Another peer got involved in the verbal altercation and it became physical with patient hitting his peer in the side of the head. I stepped in between patient and peer and patient was redirected to his room. Patient was still extremely agitated coming in and out of his room. MD was notified and emergency medications given per order. Patient then came out of his room and bowed up to security guard. Patient spit in security guards face."

Review of the physician orders dated 9/18/16 17:56 revealed patient #1 was ordered "Geodon 40mg IM NOW and Benadryl 100mg IM NOW Emergency medication for aggression and agitation."

There was no further information documented in the patient care notes or psychiatric flow sheet regarding the medication administration, patient behavior or patient status. Review of the psychiatric flow sheet revealed the nurse did a patient assessment at 8:00PM on 9/18/16 and stated, "Patient somewhat drowsy post emergency medication exhibiting no psychotic behavior at this time." The nurse continued by documenting that patient #1 had wounds as follows:
"1.) Wound to the front of head left temporal, small contusion 3cm diameter.
2.) Upper left area of back abrasion 2cmx11cm crescent abrasion.
3.) Front of shoulder multiple small abrasions of left deltoid.
4.) Upper chest crescent abrasion from axillary to sternum approximately 3mmx13cm, skin is red and bruised.
5.) Inner elbow abrasion approximately 2cm x 7cm.
6.) Front of left ear lobe small laceration approximately 0.3cm in length and 0.1 cm in depth. Area was red and bloody."

There was no nursing documentation found of how the patient received the wounds, when, or what treatment was offered. There was no documentation that the physician was contacted or informed of Patient #1's new wounds.

Review of the incident report dated 9/18/16 revealed patient #1 at 18:10 (6:10PM) "had an altercation with peer. Patient was redirected to his room and emergency medications were given. Patient then came out of his room and bowed up to the security guard and put up his fist. Patient then spit in the security guards face and they engaged in a physical altercation." The incident report revealed there were two security guards involved and one RN. There was no documentation on the incident report if the second security guard intervened or if he was involved in the altercation.

Review of the Quality Director's statements written on 9/19/16 revealed the incident was reported to the Regulatory Services Division. The timeline comments revealed the following;
9/18/2016 @ 2104 (9:04PM) staff #5 Director of Psychiatric Nursing (DPN) received a call from the charge nurse about the incident.
9/18/2016 @ 2130 (9:30PM) staff #5 arrived on the unit and reviewed the video footage and pictures of the patient's injuries. MD notified and came to see patient. Staff #8 was no longer on the unit and had gone to the ER to be assessed for his injuries.
9/18/2016 @ 2215 (10:15PM) the DPN notified the house supervisor at the main campus to let them know of the incident and inquired about staff #8. She was informed he was discharged from the ER.
9/18/2016 @ 2236 (10:36PM) the DPN notified the Administrator on call of the incident.
9/18/2016 @ 2240 (10:40PM) " The DPN asked the security personnel to contact their supervisor to find a replacement due to the incident for staff #8 since he was not scheduled to work at the PRMC in the AM. "
9/18/2016 @ 2250 (10:50PM) the DPN called the director of security and explained the incident that was viewed on the video. Pending investigation, staff #8 would be suspended until investigation was completed.

Staff #5 reported the information of the incident was not put in patient #1's chart. Staff #5 stated, "We didn't feel that information needed to go in the patient's chart." Staff #5 stated she reviewed the video of the incident and staff #8 and patient #1 had exchanged punches with fist. Staff #8 had placed the patient in a head lock and was punching the patient in multiple areas of face and body.

Review of staff #10's (RN) statement revealed she was the RN involved with patient #1 during a patient/staff altercation. There was no date or time on the statement. The statement was as follows, "Patient was in his room after receiving emergency medications for prior outburst episode with male peer. Nurse staff and security officers were standing outside the patient's door in an attempt to protect patient and other patients on unit. Patient came busting out of his room and immediately directed his attention to ____(staff #8). Patient was agitated and screaming/yelling loudly, making racial slurs, cursing, and in defensive stance with fist drawn. Nurse staff intervened and tried to redirect patient but patient continued to approach Security Officer (Staff #8). (Staff #8)______ stood with his arms at his side while patient was in his face yelling with fist drawn. Patient then spat in ______(staff #8's) face. At no time did staff nurse authorize ______ (staff #8) to restrain patient, ______(staff #8) acted in his own accord. ________(Staff #8) and patient exchanged punches with one another. _________(Staff #8) then placed patient in a head lock and continued to punch patient in and around head/facial area. At this time more staff members arrived and all staff helped with taking down ______(Staff #8) and separating the two men. Staff nurse placed patient in his room while ______(staff #8) exited the unit. Once _______(Staff #8) was off the unit, staff nurses escorted patient to the seclusion room to assess patient and clean wounds. ______(Staff #11-MD) was notified of the incident, and ________, DON was notified. Patient was assessed by ______(Staff #11-MD)."

An interview with staff #2 was conducted on 11/8/16. Staff #2 confirmed that the chart did not have information documented on the patient incident and how he received the wounds. Staff #5 confirmed it was just in the incident report and not a part of the patients medical record.


2.) Review of patient #4's admission sheet stated the patient was admitted on 9/29/16 at 10:20AM. While the patient was in admissions a physician order was written for the following psychotropic medications;
"9/29/16 10:48AM Haloperidol (HALDOL) 5 MG/ML SOLN Dose: 10 MG Route: INTRAMUSCULAR Frequency: GIVE ONE DOSE NOW Start: 9/29/16 10:46 End: 9/29/16 14:46 # of Doses: 1 Comments: delusions, psychosis.
Lorazepam (ATIVAN) 2 MG/ML SOLN Dose: 2 MG Route: INTRAMUSCULAR Frequency: GIVE ONE DOSE NOW Start: 9/29/16 10:47 End: 9/29/16 14:47 # of Doses: 1 Comments: agitation."

Review of the Medication Administration Record (MAR) revealed the medications were administered at 10:47AM. There was no nursing documentation concerning the patient's behaviors to warrant the medication, that the physician was notified, or how the patient received the medications. There were no vital signs or assessment of systems documented after the administration of psychotropic medications. The next set of vital signs documented was at 8:00PM; 5 hours later. There was no documentation found on the follow-up on the effectiveness of the drug until 12:26PM. The assessment stated, "Patient sleeping."

Review of patient #4's chart revealed the patient was a type 2 diabetic and orders were obtained to place the patient on a 1800 calorie diabetic diet and start the drug metformin (GLUCOPHAGE) 500 MG Route: BY MOUTH Frequency: TWICE DAILY AFTER MEALS Start: 9/29/16 17:30. Patient #4 had physician orders to monitor her blood sugar. 6 out of 15 orders had no found results documented in the chart.
GLUCOSE POINT OF CARE TESTING Start: 10/06/16 6:45 NO RESULTS DOCUMENTED
GLUCOSE POINT OF CARE TESTING Start: 10/06/16 16:58 NO RESULTS DOCUMENTED
GLUCOSE POINT OF CARE TESTING Start: 10/08/16 3:48 NO RESULTS DOCUMENTED
GLUCOSE POINT OF CARE TESTING Start: 10/09/16 12:46 NO RESULTS DOCUMENTED
GLUCOSE POINT OF CARE TESTING Start: 10/12/16 2:01 NO RESULTS DOCUMENTED
GLUCOSE POINT OF CARE TESTING Start: 10/20/16 8:07 NO RESULTS DOCUMENTED

Review of patient #4's physician orders revealed on 10/20/16 ciprofloxacin (CIPRO) 500 MG TABS Dose: 500 MG Route: BY MOUTH Frequency: TWICE A DAY. Review of the MAR revealed the patient was administered the medication at 9:00AM. There was no documentation found in the nursing assessment on why the patient was ordered the antibiotic or if the patient tolerated the antibiotic.

Review of the RN's patient care notes dated 9/30/16 14:15 (2:15PM) stated, "PATIENT WAS SPEAKING WITH STAFF ABOUT HER DIAGNOSIS AND HER CONCERNS ABOUT ADMISSION HERE. PATIENT HAD A PENCIL IN HER HAND. SUDDENLY SHE JABBED HER HAND TOWARDS STAFFS FACE. STAFF FELT SOMETHING GO INTO HER NOSE AND SCRATCH THE INSIDE OF HER NOSE. PATIENT WAS ANGRY AND HOSTILE TOWARD STAFF. THREATENING TO "HURT" STAFF. DOCTOR NOTIFIED NEW ORDER REC'D FOR HALDOL, ATIVAN, AND COGENTIN. PATIENT DID AGREE TO TAKE INJECTIONS. AFTER INJECTIONS, PATIENT DID AP0LOGIZE FOR HURTING STAFF. 9/30/16 15:32 (3:32PM) PATIENT IS IN HER ROOM. SHE IS CALM AT THIS TIME. RESPIRATIONS EVEN/UNLABORED. NO DISTRESS NOTED."

Review of the physician orders revealed, "9/30/16 14:20 (2:20PM) Haloperidol (HALDOL) 5 MG/ML SOLN Dose: 10 MG Route: INTRAMUSCULAR Frequency: GIVE ONE DOSE NOW Start: 9/30/16 14:19 End: 9/30/16 18:19 # of Doses: 1 Comments: emergency medication for aggression. Patient stabbed staff with a pencil.
9/30/16 14:20 (2:20PM) Lorazepam (ATIVAN) 2 MG/ML SOLN Dose: 2 MG Route: IV PUSH Frequency: GIVE ONE DOSE NOW Start: 9/30/16 14:19 End: 9/30/16 18:19 # of Doses: 1 Comments: emergency medication for aggression. Patient stabbed staff with a pencil."

Review of the order revealed the Ativan was ordered IV push. Review of patient #4's MAR also stated the Ativan was given IV push. There was no further nursing documentation on how or where the medication was administered. There was no following documentation until 9/30/16 15:32 (3:32PM). The RN documented, "PATIENT IS IN HER ROOM. SHE IS CALM AT THIS TIME. RESPIRATIONS EVEN/UNLABORED. NO DISTRESS."

Review of the physician psychiatric evaluation written on 9/30/16 at 1729 revealed there was no mention of the patients behavior resulting in an Emergency Behavioral Medication or why the order was necessary or other treatment that was considered, but was rejected and rational. There was no documentation on why the patient was administered Ativan IV push.

Review of patient #4's nurses patient care note dated 10/10/16 at 08:03AM revealed the RN documented, "during shift report pt extremely agitated, could be heard by staff in hallway yelling and screaming. pts agitation/anger continued to escalate throughout vital signs and breakfast. pt threatening to kill staff and stating, "i will f***ing kill you, you b***h. don't you f***ing touch me. im not f***ing taking that medicine". pt then stormed off to room slamming the door. pt could be heard in room throwing items, self-conversing/ responding to internal stimuli. When staff approached pt room for safety check pt begin yelling and screaming once again, "dont f***ing come in here. get the f*** out of my room. im warning you, get the f**k out". staff placed call to dr kamble, new orders received to intervene with po medication of haldol 10 mg, ativan 2 mg and cogentin 1 mg. if pt refuses po medications, im medications are warrented." (SIC)There was no found documentation of interventions.

10/10/16 08:34AM RN documented, "PT REFUSED PO MEDICATIONS ORDERED BY DR KAMBLE. PT MADE AWARE THAT IM MEDICATIONS WERE TO BE ADMINISTERED IF PT REFUSED. PT YELLED AT STAFF STATING, "F**K YOU! F**K YOU! GET OUT !".

Review of the physician orders on 10/10/16 8:39AM stated, "Lorazepam (ATIVAN) 2 MG/ML SOLN Dose: 2 MG Route: INTRAMUSCULAR Frequency: GIVE ONE DOSE NOW Start: 10/10/16 08:39 End: 10/10/16 12:39 # of Doses: 1 Comments: EMERGENCY DOSE.
10/10/16 8:38 Haloperidol (HALDOL) 5 MG/ML SOLN Dose: 10 MG Route: INTRAMUSCULAR Frequency: GIVE ONE DOSE NOW Start: 10/10/16 08:36 End: 10/10/16 12:36 # of Doses: 1 Comments: EMERGENCY DOSE. "

10/10/16 09:00AM RN documented, "im medications administered to pt. personnal (SIC) hold deemed necessary d/t staff unable to redirect pt, pt kicking and refusing to bare buttucks(SIC) area. _______ (Staff #11-MD)made aware of situation, _______(staff #5), performed face to face, and necessary paperwork has been documented."

Review of the Seclusion and Restraint Documentation form dated 10/10/16 at 9:00AM revealed the patient was placed in a personal hold. The RN documented the patient was undirectable, hostile behavior towards staff and peers, threatening yelling/screaming, slamming doors, splashed coffee all over walls."

Review of the patient #4's chart revealed a face to face was performed for the physical hold by staff #5 on 10/10/16 at 10:00AM. Staff #5 documented, "10/10/2016 09:00 emergency dose of geodon and ativan given no personal hold required, patient agreed to tkae (sic) medications." Patient #4 was given Haldol not Geodon IM for behavioral issues. Nursing documented in the patient care notes and restraint documentation that the patient was put in a personal hold to administer medications. There was no nursing assessment performed or vital signs performed. There was no nursing documentation until 11:56; stated, "Sleeping."

The physician progress notes dated 10/10/16 revealed there was no mention of the restraint hold or emergency medications ordered. There was no documentation on why the order was necessary or other treatments that was considered, but was rejected and rational.