HospitalInspections.org

Based on interview and record review, the facility :

a. failed to ensure nursing staff monitored vital signs per policy following the administration of emergency medication to three (3) of 4 sampled patients (Patients #4 ,7, 9 );

b. failed to provide effective education / training to nursing staff regarding drug /chemical restraints;

c. failed to develop complete and consistent policies related to drug / chemical restraints.

Findings included:

a. Emergency medications: failed to monitor vital signs per policy:

Record review of facility's policy titled,"Dr. Strong Behavioral Emergencies," dated 05-2020, showed: "...when intervention is needed managing a patient's behavior, a DR STRONG code...shall be paged...If emergency medication is ordered, the nurse assigned to the patient MUST (facility capitalization) take vital signs and oxygen saturation every 15 minutes x 1 hour minimum and is responsible for making sure it is documented in Meditech..."

Record review with Staff C, Quality Manager of three (3) patients' electronic medical records ( Patient # 4, 7, 9) showed they had each been administered an emergency medication to manage behaviors. Nursing notes and Medication Administration Records (MAR) were reviewed:

Patient # 4:

Patient 4 was administered the following emergency medication:

a. Haldol 2 mg (milligram) IM (intramuscular) given on 4/4/2021 at 5:44 PM: no documented vital signs or oxygen saturation measured during the hour after administration.

b. Ativan 2 mg IM given on 4/25/2021 at 10:32 PM: no oxygen saturation was documented.

c. Haldol 5 mg IM given on 03/20/2021 at 2 PM : no temperature was documented.

d. Thorazine 25 mg IM at 1259 PM : only one temperature was recorded during the hour; 2 oxygen saturation measurements were missed.

Patient # 7:

Patient 7 was administered the following emergency medication:

a. Haldol 5 mg IM given on 3/24/2021 at 9:05 AM: no documented oxygen saturation or any vital signs taken during the hour after administration.

b. Ativan 1 mg IM given on 3/24/2021 at 9:26 AM : no documented oxygen saturation or any vital signs taken during the hour after administration.

Patient # 9:

Patient # 9 was administered the following emergency medication:

Thorazine 50 mg IM mg given on 3/03/2021 at 2:25 PM: no documented temperature measurement; lacked 3 of 4 measurements of oxygen saturation during the hour after administration.

Record review of the behavioral assessment notes for Patients 4, 7, 9 with Staff C- failed to show documentation after emergency medication given that 'patient refused" or other rationale for not monitoring the patient per policy.

b. Ineffective education/ training regarding drug /chemical restraints:

Record review of facility policy titled "Restraints," dated 4/2018, showed: " '..lll. Definitions:...C. Drug used as a restraint: is a medication used to control behavior or to restrict patient's freedom of movement, and is not a standard treatment...for the patient's condition..."

During an interview on 04/28/2021 at 10 AM with Staff F, Registered Nurse (RN), she verbalized patient de-escalation techniques and process for calling a "Dr Strong" code. This was used if de-escalation was ineffective and patient's behavior was a danger to self or others . Staff F said often IM emergency medications were given during a Dr Strong situation. Staff F said she was "unsure if this medication was a restraint."

During an interview on 04/29/2021 at 9: 40 AM with Staff M, RN, she described de-escalation techniques to help manage patients' aggressive and combative behaviors. Staff M verbalized the processes for a therapeutic hold; Dr. Strong code process and IM emergency medication administration. Regarding IM emergency medication, Staff M stated : "Unsure..I don't think it is a restraint, as it is just doctor's orders for medication."

During an interview on 04/29/2021 at 12 NOON with Staff C, Quality Services Manager, she stated that IM emergency medications were chemical (drug) restraints.

c. Incomplete & conflicting policy development related to drug /chemical restraints:

a Clear identification of emergency medications:

During an interview on 04/29/2021 at 12:40 PM with Staff O, Pharmacy Director, he said that he considered IM ziprasidone, Ativan, Haldol, Thorazine- among others as emergency medications.

Record review of facility's policy titled "Psychiatric Emergency Medication Administration Procedure", dated 10-2020 , showed the sole medication listed and discussed was Versed (midazolam)-administered intra-nasally (IN) -along with the description of the reversal agent (flumazenil) procedures. There was no listing of any information regarding IM Haldol, Ativan, Thorazine, etc..

Record review of facility's policy titled,"Dr. Strong Behavioral Emergencies," dated 05-2020, showed a reference to emergency medication :"..If emergency medication is ordered..." Further review of this policy failed to show a list or description of what "emergency medications"were.

Record review of medical records of Patient 4, 7, and 9 showed consistent use of IM Ativan, Haldol, Thorazine (not all inclusive) as emergency medications to control behaviors that were documented as 'threat of harm to self or others.'

b. Patient monitoring after emergency medication given:

inconsistent and unclear description of patient monitoring process- two (2) different policies:

Record review of facility's policy titled,"Dr. Strong Behavioral Emergencies," dated 05-2020, showed: "...when intervention is needed managing a patient's behavior, a DR STRONG code...shall be paged...If emergency medication is ordered, the nurse assigned to the patient MUST (facility capitalization) take vital signs and oxygen saturation every 15 minutes x 1 hour minimum and is responsible for making sure it is documented in Meditech..." [emergency medications not listed or defined ]

Record review of facility policy titled "Restraints," dated 4/2018, showed: " '..lll. Definitions:...C. Drug used as a restraint: is a medication used to control behavior or to restrict patient's freedom of movement, and is not a standard treatment ..for the patient's condition..If the use of the medication for the patient meets the definition of a drug use as a restraint, the assessment, monitoring, and documentation requirements apply..." [Unclear in this policy which requirements were being referenced. It was implied these requirements were contained in this same policy.]

Continued review of this same policy showed a heading titled " V. Management ". This section had information for "Medical Restraints" and "Behavioral Restraints" [ both non-violent or non self-destructive type] . Requirements addressed : restraint orders; face to face assessment by physician or Qualified Licensed Professional (QLP) ;restraint application, on-going assessment; and required documentation. This policy failed to address these same components for chemical /drug restraints.

During an interview on 04/29/2021 at 1:15 PM with Staff C, Quality Services Manager, she confirmed the policy titled "Restraints" did not contain patient assessment, monitoring, and documentation requirements for chemical/ drug restraints.