HospitalInspections.org

Based on chart reviews and interviews the facility failed to have the patient or patients representative sign consents for treatment and acknowledgement of patient rights in 1(#1) of 5(1-5) charts reviewed.

Review of patient #1's chart revealed her consents to treat, patient rights, and medicaid acknowledgement were blank.

An interview with staff #2 reported the patient was confused when she came in and was unable to sign the consents. Staff #2 confirmed the daughter of the patient should have been given the opportunity to sign the consents and receive patient right information.

Based on review of patient charts, policy and procedures, and conducted interviews the facility failed to ensure policy and procedures were being followed with chemical restraints. The facility failed to recognize a chemical medication used as a restraint in 1(#1) of 5 (1-5) charts reviewed.
Review of patient #1's medical record revealed the patient was sent to the facility's Emergency Room (ER) from the Nursing Home for aggression and refusal to take medications. Patient #1 was admitted with a diagnosis of uncontrolled agitation, schizophrenia, urinary tract infection, and cellulitis of both legs.
Review of the facility's policy and procedure for Restraint Policy stated, "Chemical Restraint Definition: A chemical restraint is a medication used to sedate patients or restrict freedom of movement that is not a standard part of treatment for their medical or psychiatric condition. On the rare occasion that chemical restraint is used in the acute setting, it accompanies the initiation of a Violent, Self destructive restraint. The protections afforded patients for Violent, Self- destructive restraints also ensures patient rights for chemical restraint.
Violent, Self- destructive Restraint ;
2.) Consideration of less restrictive means.
5.) Orders: The order for restraint will include the type of restraint to be applied and will be based on specific behaviors that indicate restraint.
7.) A physician or LIP must see and evaluate the need for restraint within 1 hour after the initiation of the intervention.
8.) Notification of the Nurse Manager.
10.) Patient Monitoring."

Review of the ER nursing notes dated 5/19/15 revealed Patient #1 continues to be combative after nursing interventions performed.
Review of the ER physicians orders revealed an order dated 5/19/15 at 7:45 pm "Geodon 40 mg IM" There was no frequency ordered for this medication. There was no reason documented in the order for the administration of a psychoactive medication.
Review of patient #1's home medications revealed she did not take Geodon (antipsychotic) as part of her medication regimen.
Geodon was administered 40 mg IM on 5/19/15 at 7:45 pm. Geodon was documented as effective. There was no documentation found for consideration of less restrictive means, Notification of the Nurse Manager, or a physician face to face within 1 hour.
An interview was conducted with staff #2 and #3. Staff #2 and #3 confirmed there has been an education issue with chemical restraints. Staff #2 reported the policy and procedure was in the process of being updated and revealed documentation of policy revisions and computer updates to follow. A process improvement was in place for restraints and documentation.