HospitalInspections.org

Based on review of Unit Manager Employee files, policies and procedures, Human Resources Employee files, Incident Reports, Restraint/Seclusion Logs, Restraint/Seclusion Reports, Physician Progress Notes, Patient Care Staff Roster, Staffing Schedules, Unit Safety Officer Job Description, Chief Executive Officer Memos and interviews, it was determined that the Facility failed to assure patients were not physically harmed by staff during physical holds; were not subjected to verbal altercations; staff did not react to patient behaviors with retaliation; and mental health patients were assured a therapeutic milieu.

Failure to assure staff applied safe physical hold/restraint did not assure patients did not receive injury while being restrained.

Failure to assure patients were not subjected to verbal altercations did not assure they were treated in a respectful and dignified manner.

Failure to assure staff did not retaliate against a patient's behavior did not assure patients were not physically and/or emotionally harmed.

Failure to assure mental health patients were provided a therapeutic milieu did not reinforce the importance of positive behaviors and was likely to negatively affect their emotional health and progress.

Those failed practices were likely to affect all 198 patients on current census. (See CMS 2567, A144, A145, A154 and A175)

Based on review of Unit Manager Employee Files, policies and procedures, Human Resource Employee Files, Incident Reports, Restraint/Seclusion Log, Restraint/Seclusion Reports, Patient Care Staff Roster, Staffing Schedules, Unit Safety Officer Job Description, Chief Executive Officer Memos and interviews, it was determined the Facility failed to assure a therapeutic milieu for mental health patients, failed to assure patients were monitored at all times, failed to assure staff did not instigate negative behavior toward patients by use of physical force during physical holds and failed to follow policy for a one-to-one patient observation by leaving the patient unattended.

Failure to assure patients had a therapeutic milieu did not reinforce the importance of positive behaviors and was likely to affect their emotional health and progress. Failure to assure patients were monitored at all times did not assure they were safe and free from harm. Failure to assure staff did not instigate negative behavior toward patients by use of physical force during physical holds did not assure patients' dignity was maintained and they were free from injury. Failure to follow policy for one-to-one patient observation by leaving the patient unattended did not assure the patient remained safe or unharmed. The failed practices were likely to affect all 198 patients on current census.

Findings follow:

A. Review of Unit Manager Employee file for Unit Safety Officer (USO) #1 revealed the following:

1) On 06/20/15, an email was sent from Registered Nurse #3 to Unit Manager, 5L which revealed, "USO #2 and USO #1 started to argue over the round book. I explained...the two were constantly fighting over everything. Even the patients were aware of their dislike for each other. Their fighting is constant, job related and often done around the patients. Their constant bickering is a chronic problem that is disrupting and crippling the functioning of the Unit."

2) On 06/26/15, a memo was sent from Unit Manager 5L (Lower) to USO #1. The memo revealed, "it is alleged that you have violated DHS (Department of Human Services) policy 1084.3.2 Compliance. You were assigned to a patient on 1:1 observation. It was observed that you left your one-to-one unattended and opened the treatment room to attend to another patient. It was also observed that you did not follow policy for Seclusion and Restraint in the incident on 06/15/15".


B. Review of Policy, Patient Observation revealed, One-to-One Observation Level, 1. Procedure, b. The employee performing 1:1 duty shall directly observe the patient at all times.


C. Review of the Human Resources Employee file for USO #1 revealed the following:

1) Review of Non-Disciplinary Counseling dated 02/09/15 revealed per reports from the Adult Unit and also from the Forensic Unit you have failed to demonstrate diligent and competent job performance on the days you were pulled to work on those Units. Forensic Supervisor reported you were found nodding and not monitoring your patients during assigned duty hours. The Adult Supervisor stated you gave a plastic bag to a patient with suicidal precautions to use as a vomit bag.

2) Review of Non-Disciplinary Counseling Statement signed 02/21/14 by Unit Manager D/E and USO #1 revealed on 02/19/14 you failed to perform your assigned duty for effective monitoring and accounting for all patients as evidenced by presenting unaccountable check sheet on one of your patients. This is a major deficiency and presentation of unsatisfactory job performance.

3) On 05/06/14 a memo was sent from Unit Manager 6L to USO #1 which revealed, on the morning of 05/05/15 at 0619, there was an incident where (Named) Patient reportedly grabbed you. Since (Named) Patient's PBSP (Positive Behavior Support Program) was being updated, Treatment Team felt video footage of the incident needed to be reviewed. Upon review of the footage, it was observed that your interactions with (Named) Patient were inappropriate and somewhat instigating. Some of your comments to (Named) Patient were completely out of line.

4) On 05/15/15 an email was sent from Unit Manager 6L to the Director of Nursing which revealed, "USO #1 and Charge Nurse #2 got into it last night and Charge Nurse #2 wants him moved to 5L."

5) On 05/19/15 a memo was sent from Unit Manager 6L (Lower) to USO #1 which revealed, "I am conducting an investigation for possible disciplinary action for a violation of DHS Policy 1084. The verbal exchange between you and your Supervisor on 05/14/15, beginning at 2006 was reviewed on video footage. Instead of following Supervisor's directive, you became angry, hostile and physically threatened to harm Supervisor. You were warned of an inappropriate verbal exchange you had with a patient back on the morning of 05/05/15, and told you were being given the opportunity to show you are capable of maintaining professionalism at all times even when provoked. Workplace behavior implies to both patients and co-workers."

6) On 05/28/15 a memo was sent from Unit Manger 6L to USO #1 which revealed, Outcome of Employee Investigation. This notification is provided in accordance with DHS Policy 1084, Employee Discipline Conduct/Performance, to inform you that a pre-disciplinary staffing (meeting) regarding the alleged violation of ...policy, took place on 05/22/15 at 1130. Once investigation was complete a second staffing was held 05/25/15 at 1330. It was decided that a Written Warning be implemented...

7) On 05/28/15 Notice of Disciplinary Action revealed Cause for disciplinary action was not following Supervisor's directive, anger outburst and physically threatening to harm Supervisor.


D. Review of Incident Report presented by the Regulatory Compliance Officer dated 04/07/15 at 2013 revealed Patient #4 went chest to chest with staff. Patient #4 then started swinging his fist toward staff. Patient #4 was placed in a two minute hold and transported to seclusion.


E. Review of Restraint/Seclusion Log presented by the Regulatory Compliance Officer for 04/15 revealed Patient #4 was placed in a two minute hold on 04/07/15 from 2013 to 2015. Patient Injury revealed scratches.


F. Review of the Seclusion and Restraint Report presented by the Regulatory Compliance Officer dated 04/07/15 revealed Patient #4 was placed in a 2-Person hold from 2013 to 2015, placed in seclusion from 2015 to 2040 and given a chemical restraint of Thorazine 50 mg at 2042. Face-to-Face revealed no behavioral concerns at this time. He has some scrapes to his elbows, shoulder and to his chin. 5b (Staff) Is there anything staff could have done differently to avoid this event was marked with an "X" in the yes box and hand written, "staff shouldn't have went into the patient's room. The patient slammed the door, but did not harm self or others. The report was signed by Registered Nurse #2 and Patient #4."


G. Review of Physician Progress Note dated 04/08/15 revealed Met with (Named) Patient #4 today on Unit to d/w (discuss with) him incident last pm (evening) and progress towards demonstrating respectful bxs (behaviors) and accepting redirection without arguing or being silly. Struggled last pm with point loss for boundaries - disagreed with pt. (point) loss, became angry and slammed door to room/cursed. Attempted to isolate self in room but was pursued by a certain staff member whose actions/statements further provoked and angered/frustrated (Named) Patient #4. During interview on 07/08/15 at 1810 with the Unit Manager for D/E, she confirmed the staff member identified was USO #1.


H. On 07/08/15 at 1810 during interview with the Unit Manager for D/E when asked about the incident which occurred on 04/07/15 with staff USO #1, she stated, "he (USO #1) should not have done that. He was removed from my Unit. When asked if anything was documented, she stated it was in the data base in (Named) Assistant Nursing Director's office.


I. Review of the HR Record for USO #1 revealed no evidence of the incident which occurred on 04/07/15 regarding inappropriate physical hold by USO #1 against Patient #4. On 07/08/15 at 1810 during interview with the Regulatory Compliance Officer and the Unit Manager for D/E, they were asked to review the HR (Human Resources) file of Disciplinary Actions for USO #1. They confirmed the Disciplinary Action for Written Warning determined on 04/10/15 was not included in the record. At that point, the Unit Manager for D/E stated it should be there, left the Conference Room, returned and presented the document.


J. Review of a spread sheet identified as the "Data Base" on 07/09/15 at 0910 during interview with the Assistant Director of Nursing on 07/09/15 at 0910 revealed USO #1 received Written Warning on 04/08/15 as a result of Inappropriate Physical Hold with a policy violation and on 05/19/15 received Written Warning for Unprofessional bx (behavior) towards RN with a policy violation.


J. On 07/09/15 at 1010 during interview with the Unit Manager for 6L, when asked what information was gathered for the staffing meeting to discuss an employee's disciplinary counseling, she commented she had access to the HR (Human Resources) record and had information in her Unit Manager's Employee File. She stated she brought information about the employee to the meeting to discuss what actions would be taken and that this information was obtained from the HR file, the Unit Manager's Employee file and information from the Data Base. During the interview, while reviewing her memo dated 05/28/15 which stated "Initially it was felt that a 3 day suspension was warranted" she was asked why the suspension was warranted but not done, she stated the employee had never had a Written Warning before. At that point, the Written Warning determined 04/10/15 for USO #1 was presented. She stated, "That was not in the file. I was under the impression he'd never received a Written Warning. If I had had access to that, he (USO #1) would have been suspended." When the Data Base was introduced to her with the Written Warning for 04/08/15, she stated, he (USO #1) had not ever received a Written Warning.


K. Review of the current Patient Care Staff Roster presented by the Regulatory Compliance Officer on 07/06/15 revealed USO #1 was a current employee.


L. Review of staffing schedules presented by the Regulatory Compliance Officer on 07/07/15 for 05/01/15-07/04/15 revealed USO #1 worked his assigned shifts as well as overtime shifts as scheduled and was confirmed during interview on 07/09/15 at 0910 with the Assistant Director of Nursing.


M. Review of Unit Safety Officer Job Description presented by the Regulatory Compliance Officer revealed the USO is responsible for helping the Unit team members ensure an emotionally safe environment for patients and staff under the direction of the Charge Nurse. Monitors assigned patients. Interacts with patients in a therapeutic manner. Maintains appropriate professional boundaries with patients. Demonstrates ability to address problems, difficulties or conflicts on the unit in a professional manner. Handles conflict in a professional manner. Relates to patients in a respectful therapeutic manner. Complies with all DHS (Department of Human Services) and ASH (Arkansas State Hospital) and assigned Unit policies and procedures. Accepts direction and feedback from supervisors. Ability to compassionately direct mentally ill patients and maintain order on the Unit. Ability to remain calm during high stress verbal/physical interaction. Ability to demonstrate behaviors that result in positive working relationships with superiors and co-workers. Skill de-escalating disruptive clients and performing principles and techniques of NAPPI (Non-Abusive Psychological and Physical Intervention) training with patients.


N. Review of DHS Employee Discipline Policy: Conduct/Performance presented by the Regulatory Compliance Officer on 07/07/15 revealed the procedures described in this policy are mandatory and the conduct and performance expectations are minimum requirements for all employees. Disciplinary Actions - Termination of employment. Discipline Level (A) Note: Divisions will consult with Office of Chief Counsel (OCC) when termination is being considered. Severity of Discipline - the level of discipline recommended is the minimum that may be applied. Discipline may be set at any higher level, including Discipline Level (A) based upon: the nature and extent of the non-compliance, the impact of the non-compliance on, for example, department clients, other state employees, DHS services operations, or funding. All previous disciplinary actions, non-compliance and poor/unsatisfactory performance. Neither a history of satisfactory or higher performance ratings nor the absence of previous discipline are mitigating factors or defenses to the discipline administration. Suspension from duty pending investigation - upon having reasonable cause to suspect that an employee may jeopardize (1) the health or safety of any person ...Compliance - employees must comply with workplace policies, rules and all job-related standards. Minimum Discipline Level (C). Some examples of non-compliance include: misconduct or unsatisfactory performance that relates to the employee ' s workplace behavior standards, job duties, or both. Professionalism - courteous behavior, even when provoked, compassion, and tolerance that does not belittle the skills, believes or teaching of others. Attachment A - Offenses that violate minimum behavior standards. 3. Employee's violations) involved fighting or threat of violence (Level A). Unacceptable conduct will result in discipline up to and including immediate termination.


O. Review of a memo from the Chief Executive Officer dated 08/08/12 presented by the Regulatory Compliance Officer on 07/06/15 revealed Zero Tolerance for Patient Abuse. "Zero Tolerance" for patient abuse is the policy at (Named) Facility. "Zero Tolerance" means that no abuse of any kind: physical, verbal or psychological will be tolerated at the (Named) Facility.


P. Findings listed as A, B and C were confirmed with the Regulatory Compliance Officer on 07/08/15 at 1810.

Based on review of Unit Manager Employee files, Incident Reports and interview it was determined the Facility failed to assure patients were not subjected to verbal, emotional or physical abuse by staff. Failure to assure patients were free from all forms of abuse did not assure patients were treated respectfully, safely and their mental health outcomes were protected. The failed practice was likely to affect all 198 patients on current census in the facility.

Findings follow:

A. Review of Unit Manager Employee file for Unit Safety Officer (USO) #1 during interview 07/08/15 at 1000 with the Unit Manager for 5 Lower revealed the following:

1) On 06/26/15 a memo was sent from Unit Manager 5L (Lower) to USO #1. The memo revealed, "it is alleged that you have violated DHS (Department of Human Services) policy 1084.3.2 Compliance. You were assigned to a patient on 1:1 observation. It was observed that you left your one-to-one unattended and opened the treatment room to attend to another patient. It was also observed that you did not follow policy for Seclusion and Restraint in the incident on 06/15/15.

2) On 05/06/14 a memo was sent from Unit Manager 6L to USO #1 which revealed, on the morning of 05/05/15 at 0619, there was an incident where (Named) Patient reportedly grabbed you. Review of video footage, it was observed that your interactions with (Named) Patient were inappropriate and somewhat instigating. Some of your comments to (Named) Patient were completely out of line. Any further incidents of inappropriate or unprofessional interactions will require progressive disciplinary action.

3) On 05/19/15 a memo was sent from Unit Manager 6L (Lower) to USO #1 which revealed, "I am conducting an investigation for possible disciplinary action for a violation of DHS Policy 1084. The verbal exchange between you and your Supervisor on May 14, 2015 beginning at 2006 was reviewed on video footage. Instead of following Supervisor's directive, you became angry, hostile and physically threatened to harm Supervisor...".

4) On 05/28/15 a memo was sent from Unit Manger 6L to USO #1 which revealed, Outcome of Employee Investigation. This notification is provided in accordance with DHS Policy 1084, Employee Discipline Conduct/Performance, to inform you that a pre-disciplinary staffing (meeting) regarding the alleged violation... It was decided that a Written Warning be implemented...

5) On 05/28/15 Notice of Disciplinary Action revealed Cause for disciplinary action was not following supervisor's directive, anger outburst and physically threatening to harm Supervisor.


B. Review of Incident Report dated 04/07/15 at 2013 revealed Patient #4 went chest to chest with staff. Patient #4 then started swinging his fist toward staff. Patient #4 was placed in a two minute hold and transported to seclusion. Findings were verified with the Unit Manager for D/E on 07/08/15 at 1810.

Based on review of Seclusion and Restraint Report, Physician Progress Notes and interview it was determined the Facility failed to assure staff did not react to patient behaviors with retaliation while interacting with or restraining them. Failure to assure staff did not retaliate against patients for their behavior did not assure patients were free from harm and their dignity was upheld. The failed practice was likely to affect all 198 patients on current census. Findings follow:

A. Review of the Seclusion and Restraint Report dated 04/07/15 presented by the Regulatory Compliance Officer on 07/07/15 revealed Patient #4 was placed in a 2-Person hold from 2013 to 2015, placed in seclusion from 2015 to 2040 and given a chemical restraint of Thorazine 50 mg at 2042. Face-to-Face revealed no behavioral concerns at this time. He has some scrapes to his elbows, shoulder and to his chin. 5b (Staff) Is there anything staff could have done differently to avoid this event was marked with an "X" in the yes box and hand written, "staff shouldn't have went into the patient's room. The patient slammed the door, but did not harm self or others".

B. Review of Physician Progress Note dated 04/08/15 revealed Met with (Named) Patient #4 today on Unit to d/w (discuss with) him incident last pm (evening) and progress towards demonstrating respectful bxs (behaviors) and accepting redirection without arguing or being silly. Struggled last pm with point loss for boundaries - disagreed with pt. (point) loss, became angry and slammed door to room/cursed. Attempted to isolate self in room but was pursued by a certain staff member whose actions/statements further provoked and angered/frustrated (Named) Patient #4.

Based on review of policies and procedures, clinical records, Facility memo and interview, it was determined the Facility failed to follow their policy for monitoring restrained patients for five (#7, #8, #10, #11 and #14) of 15 (#1 - #15) clinical records reviewed. Failure to follow established hospital policies did not assure Patient #7, #8, #10, #11 and #14 would be monitored to prevent injury and was likely to affect other chemically restrained patients. The findings were:

A. Review of Policy #ASH 05.01.07 revised 06/17/15 for "Use of Restraint or Seclusion" on 07/06/15 revealed the definition of restraint included: "The use of (Facility Named) approved ambulatory belts, mittens, humane wrap, 5- point bed restraints and 6-point chair restraints. Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely, including four side rails and bed-rails that the patient cannot remove and which restrict the patient's freedom to exit the bed. A drug or medication administered in non-standard treatment or dosage for the patient's condition and used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement." Section "VI. Orders for restraint or seclusion," Item "N. All one-time or NOW orders for medications that control behavior shall be considered orders for drug restraint, and the patient shall be observed every 15 minutes for one hour following administration of such medication." Section "VII. Caring for a Patient in restraint or seclusion," item B, "During seclusion or restraint used for violent self-destructive behavior or non-violent/non-self-destructive behavior:" Item 4, "Qualified staff shall monitor the patient's condition every 15 minutes for the entire duration of any seclusion, physical hold, or mechanical restraint and for the first hour after administration of a chemical restraint." Item 8,"For patients in 5-point bed or 6-point chair restraints assess pulse, respiration, blood pressure (BP) and circulation every 15 minutes. For each assessment that could not be accomplished, re-attempt every 15 minutes until accomplished or documentation states why assessment was not done."

B. A review of 15 clinical records on 07/08/15 revealed the Facility failed to follow their policy for monitoring patients for one hour following administration of chemical restraint for Patient #7, #8, #10, #11 and #14# and failed to document an assessment of pulse, respiration, blood pressure and circulation every 15 minutes for Patient #8 in a 6-point restraint. The findings were:
1) Patient #7 was admitted on 02/19/14. A Seclusion and Restraint Report (Chemical) revealed Zyprexa Zydis 10 mg, Ativan 1 mg, and Benadryl 50 mg were administered p.o. at 1715 on 05/11/15. At 1715 and 1716, the Behavior and Physical needs codes were documented as A (Bizarre behavior), B (Agitated or disruptive behavior), C (Destructive or dangerous behavior), D (Threatening lethal behavior) and 1(Observation direct). There was no further documentation of monitoring every 15 minutes for one hour as required per policy after administering chemical restraint.
a) A Seclusion and Restraint Report (Chemical) revealed Ativan 1 mg and Benadryl 50 mg were administered IM on 05/18/15 at 1755. At 1755 the patient Behavior and Physical needs codes were documented as A (Bizarre behavior), B (Agitated or disruptive behavior), C (Destructive or dangerous behavior), E (Restraints discontinued), 1 (observation direct) and 6 (Medication given). Behavior and observation were documented at 1810, 1825 and 1840. There was no further documentation of monitoring every 15 minutes for one hour as required per policy after administering chemical restraint.
b) A Seclusion and Restraint Report (Chemical) revealed Ativan 1 mg and Benadryl 50 mg were administered IM on 05/19/15 at 1236. At 1236 the Patient Behavior and Physical Needs codes were documented as A (Bizarre behavior), B (Agitated or disruptive behavior), 1(observation direct), 6 (Medication given). Behavior and observation were documented at 1251 and 1305. There was no further documentation of monitoring every 15 minutes for one hour as required per policy after administering chemical restraint.
c) A Seclusion and Restraint Report (Chemical) revealed Ativan 1 mg and Benadryl 50 mg were administered IM on 05/27/15 at 1315. At 1315 the Patient Behavior and Physical Needs codes were documented as: A (Bizarre behavior), B (Agitated or disruptive behavior), 1(observation direct), 6 (Medication given). Behavior and observation were documented at 1320, 1335 and 1350. There was no further documentation of monitoring every 15 minutes for one hour as required per policy after administering chemical restraint.
d) A Seclusion and Restraint Report (Chemical) revealed Zyprexa 10 mg, Ativan 2 mg and Benadryl 50 mg were administered IM on 05/29/15 at 0936. At 0936 the Patient Behavior and Physical Needs codes were documented as: A (Bizarre behavior), B (Agitated or disruptive behavior), C (Destructive or dangerous behavior), D (Threatening lethal behavior) and 1(observation direct). Behavior and observation were documented at 0936, 0946 and 1000. There was no further documentation of monitoring every 15 minutes for one hour as required per policy after administering chemical restraint.
e) A Seclusion and Restraint Report (Chemical) revealed Ativan 2 mg and Benadryl 50 mg were administered p.o. on 05/30/15 at 1219. At 1215 the Patient Behavior and Physical Needs codes were documented as: 1 (observation direct), 5 (Fluids offered every hour) and 6 (Medication given). Behavior and observation were documented at 1220, 1235, 1250, and 1252. There was no further documentation of monitoring every 15 minutes for one hour as required per policy after administering chemical restraint.
f) A Seclusion and Restraint Report (Chemical) revealed Ativan 2 mg, Haldol 10 mg and Benadryl 50 mg were administered IM on 06/05/15 at 1116. At 1116 the Patient Behavior and Physical Needs codes were documented as: A (Bizarre behavior), B (Agitated or disruptive behavior), 1 (observation direct) and 6 (Medication Given). Behavior and observation were documented at 1130, 1140 and 1155. There was no further documentation of monitoring every 15 minutes for one hour as required per policy after administering chemical restraint.
g) A Seclusion and Restraint Report (Chemical) revealed Benadryl 50 mg and Ativan 2 mg were administered IM on 06/14/15 at 1004. At 1004 the Patient Behavior and Physical Needs codes were documented as: A (Bizarre behavior), B (Agitated or disruptive behavior), I (Other: Stripped/Naked) and 6 (Medication Given). Behavior and observation was documented at 1035. There was no further documentation of monitoring every 15 minutes for one hour as required per policy after administering chemical restraint.

2) Patient #8 was admitted on 06/02/15. A Seclusion and Restraint Report (Mechanical) revealed a 6-point mechanical chair restraint was applied: 06/02/15 at 1109; 06/10/15 at 1757 and 06/16/15 at 1355. Review of the clinical record to include the Seclusion and Restraint report revealed there was no documentation of an assessment of Patient #8's pulse, respiration, blood pressure (BP) and circulation every 15 minutes, or documentation for each assessment that could not be accomplished, a re-attempt every 15 minutes until accomplished or documentation states why assessment was not done every 15 minutes as required by Facility policy for 6-point restraint.
a) Review of the Seclusion and Restraint Report (Chemical) revealed Thorazine 50 mg, Ativan 1 mg and Benadryl 50 mg were administered IM on 06/19/15 at 1115. At 1115 the Patient Behavior and Physical Needs codes were documented as: B (Agitated or disruptive behavior), C (Destructive or dangerous behavior) and 6 (Medication Given). Behavior and observation was documented at 1130. There was no further documentation of monitoring every 15 minutes for one hour as required per policy after administering chemical restraint.
b) Review of the Seclusion and Restraint Report (Chemical) revealed Ativan 2 mg and Thorazine 100 mg were administered IM on 07/04/15 at 1516. At 1516 the Patient Behavior and Physical needs codes were documented as H (Other: Physical Hold) and 6 (Medication Given). Behavior and observation was documented at 1517. There was no further documentation of monitoring every 15 minutes for one hour as required per policy after administering chemical restraint.
c) The Unit Manager for Units D and E confirmed the above findings of lack of vital signs as required per 6 point restraint and lack of monitoring for chemical restraint per policy for Patient #7 and #8 on 07/08/15 from 1530 - 1600.

3) Patient #10 was admitted on 03/17/15. A Seclusion and Restraint Report (Chemical) revealed Haldol 10 mg and Ativan 2 mg were administered p.o. on 06/19/15 at 0957. At 1000 the Patient Behavior and Physical needs codes were documented as D (Threatening lethal behavior), C (Destructive or dangerous behavior) and 1 (Observation direct). Behavior and observation was documented at 1015. There was no further documentation of monitoring every 15 minutes for one hour as required per policy after administering chemical restraint. The Unit Manager for Units D and E confirmed the above findings of lack of monitoring of chemical restraint per policy for Patient #10 on 07/08/15 at 1445.

4) Patient #11 was admitted on 03/13/15. A physician order on 06/04/15 at 0845 was noted for "Zyprexa Zydis 10 mg (milligram) p.o. (by mouth) x1 for increased aggression and Ativan 1 mg p.o. x1 now for increased aggression." The Seclusion and Restraint Report (Chemical) revealed Ativan 1 mg and Zyprexa Zydis 10 mg was administered p.o. to Patient #11 at 0847 on 06/01/15. At 0847 the patient Behavior and Physical needs codes were documented as B (Agitated or disruptive behavior), 1 (Observation), 5 (Fluids offered every hour), 6 (Medication given). Behavior and observation were documented at 0900 and 0907. There was no further documentation of monitoring every 15 minutes for one hour as required per policy after administering chemical restraint. The Unit Manager for Units D and E confirmed the above findings of lack of monitoring for chemical restraint per policy for Patient #11 on 07/08/15 at 1520.

5) Patient #14 was admitted on 04/03/15. A physician order on 05/18/15 at 1244 was noted for "Zyprexa 5 mg IM (intramuscular) now x1 for aggression." The Seclusion and Restraint Report (Chemical) revealed Zyprexa 5 mg was administered IM to Patient #14 at 1250. At 1250 the Behavior and Physical Needs codes were documented as A (Bizarre behavior), 1 (Observation, direct) and 6 (Medication given). Behavior and observation were documented at 1255. There was no further documentation of monitoring every 15 minutes for one hour as required per policy after administering chemical restraint.
a) A physician order on 06/01/15 at 1017 was noted for "Zyprexa Zydis 10 mg p.o x 1 dose now for increased aggression and Ativan 1 mg p.o. x 1 now for increased aggression." The Seclusion and Restraint Report (Chemical) revealed Ativan 1 mg and Zyprexa 10 mg were administered p.o. to Patient #14 at 1017. At 1017 the Behavior and Physical Needs codes were documented as A (Bizarre behavior), B (Agitated or disruptive behavior), C (Destructive or dangerous behavior), 1 (Observation direct), and 6 (Medication given). Behavior and observation were documented at 1031 and 1046. There was no further documentation of monitoring every 15 minutes for one hour as required per policy after administering chemical restraint.
b) A physician order on 06/01/15 at 1218 was noted for "Zyprexa 5 mg IM x1 dose now for continued agitation and aggression." The Seclusion and Restraint Report (Chemical) revealed Zyprexa 5 mg was administered IM on 06/01/15 at 1221. At 1221 on the Behavior and Physical Needs codes were documented as A (Bizarre behavior), B (Agitated or disruptive behavior), C (Destructive or dangerous behavior) and 6 (Medication given). Behavior and observation were documented at 1230. There was no further documentation of monitoring every 15 minutes for one hour as required per policy after administering chemical restraint. The Unit Manager for Units D and E confirmed the above findings of lack of monitoring for chemical restraint per policy for Patient #14 on 07/08/15 at 1605.

C. On 07/09/15 at 1245 the Regulatory Compliance Officer provided a copy of a Facility memo directed to "All Medical, Nursing and Pharmacy Staff" dated 11/21/13 regarding "Psychotropic PRN Use". Item #6 of the memo stipulated "Psychotropic medications used solely for behavioral control (i.e. aggression) are permitted when clinically indicated, but must be ordered as a one-time dose and must be treated as a chemical restraint."