HospitalInspections.org

Based on record review and interview, the facility failed to protect the patient's right to make informed decisions on their care in 4 of 10 patients. The facility failed to:

A. Ensure that patients or their representatives were provided with risks and benefits as related to their medical prognosis prior to procedures or treatments in 2 (Patient #'s 2 and 3) of 10 charts reviewed. The facility failed to ensure that patients or their representatives were provided with risks and benefits as related to their medical prognosis prior to procedures or treatments in 2 (Patient #'s 2 and 3) of 10 Patient charts reviewed. The facility used psychotropic medication as a behavior management medication and did not document obtaining consent or discussion of risks and benefits with the Patient.

Refer to Tag A160


B. Obtain consent for treatment on admission in 2 (Patient #2 and 3) of 10 patient charts reviewed.

Refer to Tag A131


C. Failed to follow their own policy and procedures on Informed Consent and Restraints and Seclusion. The facility failed to have guidelines in the facility policy for monitoring and assessment for a patient chemically restrained.

Also, the facility failed to restrict the ordering of medications used for chemical restraints or emergency behavioral medication without a well-defined order that indicated why the drug was given and ensure less restrictive methods were attempted prior to use. This was found in 2 (Patient #2 and Patient #3) of 10 patient charts reviewed.

Refer to Tag A0154

Based on record review and interview, the facility failed to protect the patient's right to make informed decisions on their care for 6 (Patient's #2, #3, #6, #7, #9, and #10) of 10 patients. The facility failed to ensure that patients or their representatives were provided with risks and benefits as related to their medical prognosis prior to procedures or treatments in 2 (Patient's #2 and #3) of 10 Patient charts reviewed. The facility used psychotropic medication as a behavior management medication and did not document obtaining consent or document discussion of risks and benefits with the Patient. In addition, the facility failed to obtain consent for treatment on admission in 6 (Patient's #2, #3, #6, #7, #9, and #10) of 10 patient charts reviewed. Also, the facility failed to follow their own policy and procedures on Informed consent and Restraints and Seclusion.

This deficient practice had the likelihood to cause harm to all patients presenting to the Emergency department (ED).


Findings include:



CONSENT FOR TREATMENT


Review of Patient #2's medical record revealed the following:


Review of the nursing triage assessment on Patient #2 revealed she was a 48-year-old female who was transported to the ED on 12/19/2017 at 6:41 am with chief complaint of being suicidal.


"General consent for treatment" was witnessed on 12/19/2017 at 6:46 am stating Patient was unable to sign. There was no documentation on the "general consent for treatment" why the patient was unable to sign consent and there was no attempt to obtain consent from family. There was notation in the chart that family was present in Emergency room (ER) at various times.

Ambulatory Assessment/History Report show patient #2's Glasgow Coma Scale was 15/15. (Glasgow Coma Scale (GCS) is a neurological scale which aims to give a reliable and objective way of recording the conscious state of a person for initial as well as subsequent assessment.)

The Glasgow Coma scale for patient #2 was scored as follows:
Eyes-4, Spontaneous
Verbal -5, Oriented, Alert, Appropriate
Motor - 6, Obeys Commands

Mood/Behavior - Agitated, Restless
Memory - No Memory Deficits"



Review of Patient #3's medical record revealed the following:


Review of the nursing triage assessment on Patient #3 revealed he was a 40-year-old male who transported to the ED on 1/22/2018 at 12:19 PM with a chief complaint of being suicidal.

"General consent for treatment" was witnessed on 1/22/2018 at 1216 PM stating Patient unable to sign due to status. There was two staff member's signature and a statement that read, "advised not to enter room". There was no documentation on the "general consent for treatment" why the patient was unable to sign consent and there was no attempt to obtain consent from family. There was notation throughout the chart that family was present in Emergency room (ER) at various times.

Ambulatory Assessment/History Report did not show Glasgow Coma Scale on Patient #3. Review of "Emergency Physician Record" dated 1/22/2018 at 12:21 PM showed Patient #3 was Alert, Oriented x4, and no acute distress.


Staff #4 confirmed the above findings.



CHEMICAL RESTRAINT CONSENT

Review of the nursing triage assessment on Patient #2 revealed she was a 48-year-old female who was transported to the ED on 12/19/2017 at 6:41 am with chief complaint of being suicidal.


Review of Patient #2's medical record revealed the following:

Review of the nursing triage assessment on Patient #3 revealed he was a 40-year-old male who transported to the ED on 1/22/2018 at 12:19 PM with a chief complaint of being suicidal.

Patient was given Ziprasidone (Generic name for Geodon) 10 mg on 12/20/2017 at 1:35 PM Right Deltoid.

Patient was given Ziprasidone (Generic name for Geodon) 20 mg on 12/21/2017 at 2:35 PM PO (by mouth) in capsule form.

Home medication documented in the medical record were psychotropic medications, Seroquel and Remeron.

There was no documented discussion with patient on risks or benefits of receiving psychotropic drugs as a behavior treatment. There was no consent signed or verbal consent noted in medical record for this treatment.



A review of Patient #3's medical record revealed the following:

Review of the nursing triage assessment on Patient #3 revealed he was a 40-year-old male who transported to the ED on 1/22/2018 at 12:19 PM with a chief complaint of being suicidal.

Ziprasidone (Generic name for Geodon) 20 mg was given on 1/22/2018 at 6:29 PM in the Left Deltoid.

Patient #3 was not on any psychotropic home medications.

There was no documented discussion with patient on risks or benefits of receiving psychotropic drugs as a behavior treatment. There was no consent signed or verbal consent noted in medical record for this treatment.

Staff #4 confirmed the above findings.


An interview with Staff #4 on 4/17/2018 after 9:00 am revealed the following:

Staff #4 was asked if they attempted to get consent from the patient or family when a patient was not able to make decisions regarding their medical treatment. Staff #4 said that if they had a detention warrant in place that would cover the consent to treat.

Staff #4 confirmed that the facility failed to obtain consent for treatment for 4 of 10 Patients admitted to the emergency department. Staff #4 confirmed that the facility failed to obtain consent or discuss the risks and benefits of using a psychotropic medication as behavior management in 2 of 10 Patients. Also, Staff #4 confirmed that the facility failed to follow their policy on consents.



Based on interview and record review, the facility failed to ensure patient safety and prevent the inappropriate use of restraint and seclusion for 2 of 10 Patients, (Patient's #2 and #3).

a. The facility failed to have guidelines in the facility policy for monitoring and assessment for a patient chemically restrained.

b. The facility failed to restrict the ordering of medications used for chemical restraints or emergency behavioral medication without a well-defined order that indicated why the drug was given and ensure less restrictive methods were attempted prior to use.


This deficient practice had the likelihood to cause harm for all patients who received psychotropic medications in the Emergency department.


Findings include:


Review of the nursing triage assessment on Patient #2 revealed she was a 48-year-old female who was transported to the ED (Emergency Department) on 12/19/2017 at 6:41 am with chief complaint of being suicidal.


There was documentation of two home medications for Patient #2 on the Ambulatory Assessment/History Report. The home medications were Seroquel and Remeron. The dose and history of the medications were listed as unknown.

Review of Patient #2's vital sign report revealed one set of vital signs taken during her stay. The vitals were 12/19/2017 at 6:52 am. Blood pressure was 129/81, O2 saturation was 98%, Respirations 20, Temperature 98.7.



An order for Geodon 10 mg IM (Intramuscular) q day (Every Day) dated 12/20/2017 at 1:51 PM. There was no reason documented for administration of the medication or parameters given for the order.


Medication Administration Record report review showed the following:

Ziprasidone (Generic name for Geodon) 10 mg IM given on 12/20/2017 at 1:35 PM Right Deltoid.

The first assessment after the medication given on 12/20/2017 at 1:35pm was documented at 4:24 PM; three hours after the medication was given. The reassessment did not document vital signs or patient condition.


An order for Geodon 20 mg PO (by mouth) once dated 12/21/2017 at 2:19 PM. There was no reason documented for administering the medication or parameters given for the order.

There was no reason documented for administration of the medication or parameters given for the order.

Ziprasidone (Generic name for Geodon) 20 mg given on 12/21/2017 at 2:35 PM given PO (by mouth) in capsule form. There was no reason documented for administration of the medication or parameters given for the order.

The first assessment documented after the medication administration on 12/21/2017 at 2:35 PM was documented at 3:35 PM. The reassessment did not document vital signs or patient condition.


There was no documented discussion with the patient on risks or benefits of receiving psychotropic drugs as a behavior treatment. There was no consent signed or verbal consent noted in medical record for this treatment.



Review of Patient #3's medical record revealed the following:


Review of the nursing triage assessment on Patient #3 revealed he was a 40-year-old male who transported to the ED on 1/22/2018 at 12:01 PM with a chief complaint of being suicidal.



CPOE (Computerized physician order entry) Orders report review showed the following:

An order for Geodon 20 mg IM once was written on 1/22/2018 at 6:00 PM. There was no reason documented for administration of the medication or parameters given for the order.



Medication Administration Record report review showed the following:


Ziprasidone (Generic name for Geodon) 20 mg was given at 1/22/2018 at 6:29 PM and was given in the Left Deltoid.

A list of home medications was documented in the record. The patient was not on any psychotropic medications. There was an order that stated, "give home meds as rx'd" written on 1/22/2018 at 6:00 PM.

Review of Patient #3's vital sign report revealed no entries for 1/22/2018.


The first assessment documented after the medication administration on 1/22/2018 at 6:29 PM was at 8:02 PM. The reassessment did not document vital signs or patient condition.


There was no documented discussion with the patient on risks or benefits of receiving psychotropic drugs as a behavior treatment. There was no consent signed or verbal consent noted in medical record for this treatment.


Staff #4 confirmed the above findings.



An interview with Staff #4 on 4-17-18 after 9:00 am revealed the following:

Staff #4 was asked why the medication Impassioned (Geodon) was given to Patient #2 and patient #3. Staff #4 reported as far as she could tell they were given for agitation. Staff #4 was asked if the order for the behavioral medication indicated why they were given. Staff #4 confirmed they did not.

Staff #4 confirmed that the facility gave psychotropic medications for behavior management and did not ensure less restrictive methods were attempted prior to use. Staff #4 also confirmed that monitoring and assessment was not done after administering those medications, and that they did not follow the facility policy.



Review of the facility policy and procedure, "Restraints and Seclusion" dated 01/02 (year was not listed) revealed the following:


"PURPOSE:

The leadership of Titus Regional Medical Center is committed to preventing, reducing and striving to eliminate the use of restraints and seclusion. The leaders recognize that the use of restraints/seclusion has the potential to produce serious consequences, such as physical and psychological harm, loss of dignity, violation of an individual's rights, feelings of isolation, and even death. Restraint or seclusion will be used only when clinically justified and only to protect the immediate physical safety of the patient, staff, or others and when alternative methods have proved unsuccessful. Restraints or seclusion are never utilized for the purposes of discipline, coercion, convenience, retaliation of staff or in place of medical or nursing care ...

POLICY:

... Chemical Restraint - A drug or medication used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and it is not a standard treatment or dosage for the patient's condition.


PROCEDURE

A. LEAST RESTRICTIVE ALTERNATIVES

Prior to the use of any restraint or seclusion, least restrictive alternatives will be considered. Based upon assessment of the patient's needs, the hospital staff will use alternative methods such as family involvement and/or diversional activity and the least restrictive mechanism of protection. Further, the rights of other patients receiving care within the therapeutic environment will be respected during the decision making process necessary to determine if a patient poses a serious disruption to a therapeutic environment.

1. Documentation - Documentation of Least Restrictive Measures attempted, whether they were successful or if the alternative failed will be documented in the medical record.
all inclusive ...

C. INTIATION OF RESTRAINT/SECLUSION BY ORDER OF AN LIP OR DESIGNEE.

2. No standing orders or PRN (as needed) orders are acceptable. All orders must be in writing ...

4. The order will be documented on the Restraint/Seclusion Order Form and must include:

a. Clinical justification/reason for restraint to continue and to discontinue;

b. The type of restraint used; and

c. The time limit of the order ...

E. REASSESSMENT/MONITORING
Monitoring/reassessment of the patient ensures that use is minimally restrictive and is discontinued as soon as possible. Monitoring determines the following:

a. The patient's physical and emotional well-being;

b. That the patient's rights dignity, and safety are maintained;

c. Whether less restrictive methods are possible

d. Changes in the patient's behavior or clinical condition needed to initiate the removal of restraints/seclusion;

e. Whether the restraint has been appropriately applied, removed, or reapplied, including signs of any injury associated with the restraint or seclusion.

2. Time frames for monitoring are:

o Every 2 hours for Nonviolent restraints,

o Every 15 minutes for Violent/Self-Destructive Restraints and Seclusion ...


5. Documentation will also include:

o Description of the patient's behavior and the intervention used

o Alternative or other less restrictive interventions attempted (as applicable)

o Patient condition or symptom(s) that warranted the use of restraints

o Patient response to the intervention(s) used; including the rationale for continued use of the intervention ..."



10135

Review of the nursing triage assessment on Patient #9 revealed he was a 44 year old male who presented to the ED on 04/14/2018 at 10:38 p.m., with chief complaints of being suicidal.

Review of a nursing assessment dated 04/14/2018 at 10:45 p.m., revealed Patient #9 was disoriented and had confused speech.

Review of the "GENERAL CONSENT FOR TREATMENT" dated 04/14/2018 at 11:31 p.m. (almost an hour after presenting), revealed the following documentation on the consent:

"Pt unable to sign consent."

There was documentation that facility staff signed the consent as the witness.
There was no documentation on the consent for the reason Patient #9 was not able to give consent. There was also no documentation of an attempt being made to get consent from family or a responsible party.


Review of the nursing triage assessment on Patient #10 revealed he was a 65 year old male who presented to the ED on 04/10/2018 at 10:27 a.m., with chief complaints of having violent behavior.

Review of a nursing assessment dated 04/10/2018 at 11:00 a.m., revealed Patient #10 was disoriented and had confused speech.

Review of the "GENERAL CONSENT FOR TREATMENT" dated 04/10/2018 at 11:36 a.m. (over an hour after presenting), revealed the following documentation on the consent:

"Pt unable to sign at registration"

There was documentation that facility staff signed the consent as the witness.

There was no documentation on the consent for the reason Patient #10 was not able to give consent. There was also no documentation of an attempt being made to get consent from family or a responsible party.




Review of the nursing triage assessment on Patient #6 revealed he was a 41 year old male who presented to the ED on 04/8/2018 at 11:13 p.m., with chief complaints of an elevated blood sugar ">500".

Review of a nursing assessment dated 04/8/2018 at 11:20 p.m., revealed Patient #6 was disoriented and had confused speech.

Review of the "GENERAL CONSENT FOR TREATMENT" dated 04/8/2018 at 11:30 p.m., revealed the following documentation on the consent:

"Pt is unable to sign consent"

There was documentation that facility staff signed the consent as the witness. There was no documentation on the consent for the reason Patient #6 was not able to give consent.

Review of a nursing assessment dated 04/9/2018 at 12:38 a.m., revealed Patient #6 was alert and oriented to person, place, time and situation.

There was also no documentation of an attempt to get informed consent from Patient #6 when he was alert and oriented.




Review of the nursing triage assessment on Patient #7 revealed he was a 40 year old male who presented to the Emergency department (ED)on 04/06/2018 at 5:15 p.m.. Patient #7 presented with complaints of hyperglycemia (high blood sugar).

Review of the physician's emergency medical screen at 5:34 p.m. revealed Patient #7 had altered mental status and was not able to give a history.

Review of a nursing assessment dated 04/06/2018 at 6:30 p.m. revealed Patient #7 was oriented, alert and appropriate verbally.

Review of the "GENERAL CONSENT FOR TREATMENT" dated 04/06/2018 at 7:00 p.m.(over 1.5 hours after presenting), revealed the following documentation on the consent:

"Pt unable to sign consent."

There was documentation that facility staff signed the consent as the witness.

There was no documentation on the consent for the reason Patient #7 was not able to give consent. There was also no documentation of an attempt being made to get consent from family or a responsible party.

During an interview on 04/17/2018 after 9:00 a.m., Staff #4 confirmed the consents.


Review of the facility policy titled, "Consents, General and Informed" dated 3/94 (Year not listed) revealed the following:


"PURPOSE:

To assure that all patients who receive care, treatment, or services at Titus Regional Medical Center have given general consent for treatment upon admission.

AND

To assure that all patients who undergo the procedures outlined by the Texas Medical Disclosure Panel have given informed consent prior to the procedure being performed.


POLICY:

It is the policy of Titus Regional Medical Center to obtain general consent for treatment from the patient or person authorized to give consent upon admission.

AND

It is the policy of Titus Regional Medical Center to fully comply with the Texas Medical Disclosure Panel's rules on informed consent for medical treatment and surgical procedures.


DEFINITIONS:

1. General Consent: Voluntary agreement to receive treatment within the hospital system.

2. Informed Consent: A legal condition whereby a person can be said to have given consent based upon an appreciation and understanding of the facts and ...implications (including risks, benefits, hazards, alternatives, and potential complications) of any actions ...


PROCEDURES RELATED TO ANY CONSENT:

1. All patients must have a General Consent for Treatment signed prior to or at the time of entry into the hospital system for treatment.

2. All patients undergoing any procedure listed on the Texas Disclosure Panel's list of procedures requiring Informed Consent must have received information from the physician to allow for giving informed consent and must sign an appropriate Informed Consent form. prior to the procedure being performed.

3. Patients must sign their own consent form unless they are an incompetent adult, a minor, or an emergency exists whereby the patient cannot consent ...


ELIGIBILITY FOR PROVIDING CONSENT:
All consents (General and Informed) must be obtained based on whether the patient is a competent adult, an incompetent adult, a minor, or whether an emergency exists ...


...INFORMED CONSENT:

Article 4509i of the Texas Civil Statutes provides that, before a patient or a person authorized to consent for a patient gives consent to any medical treatment that appears on the Texas Medical Disclosure Panel's list requiring disclosure, the physician must disclose to the patient, or person authorized to consent for the patient, the risks and hazards involved in the proposed treatment."

Based on interview and record review, the facility failed to ensure patient safety and prevent the inappropriate use of restraint and seclusion for 2 of 10 Patients, (Patient's #2 and #3).

a. The facility failed to have guidelines in the facility policy for monitoring and assessment for a patient chemically restrained.

b. The facility failed to restrict the ordering of medications used for chemical restraints or emergency behavioral medication without a well-defined order that indicated why the drug was given and ensure less restrictive methods were attempted prior to use.


This deficient practice had the likelihood to cause harm for all patients who received psychotropic medications in the Emergency department.


Findings include:


Review of the nursing triage assessment on Patient #2 revealed she was a 48-year-old female who was transported to the ED (Emergency Department) on 12/19/2017 at 6:41 am with chief complaint of being suicidal.


There was documentation of two home medications for Patient #2 on the Ambulatory Assessment/History Report. The home medications were Seroquel and Remeron. The dose and history of the medications were listed as unknown.

Review of Patient #2's vital sign report revealed one set of vital signs taken during her stay. The vitals were 12/19/2017 at 6:52 am. Blood pressure was 129/81, O2 saturation was 98%, Respirations 20, Temperature 98.7.



An order for Geodon 10 mg IM (Intramuscular) q day (Every Day) dated 12/20/2017 at 1:51 PM. There was no reason documented for administration of the medication or parameters given for the order.


Medication Administration Record report review showed the following:

Ziprasidone (Generic name for Geodon) 10 mg IM given on 12/20/2017 at 1:35 PM Right Deltoid.

The first assessment after the medication given on 12/20/2017 at 1:35pm was documented at 4:24 PM; three hours after the medication was given. The reassessment did not document vital signs or patient condition.


An order for Geodon 20 mg PO (by mouth) once dated 12/21/2017 at 2:19 PM. There was no reason documented for administering the medication or parameters given for the order.

There was no reason documented for administration of the medication or parameters given for the order.

Ziprasidone (Generic name for Geodon) 20 mg given on 12/21/2017 at 2:35 PM given PO (by mouth) in capsule form. There was no reason documented for administration of the medication or parameters given for the order.

The first assessment documented after the medication administration on 12/21/2017 at 2:35 PM was documented at 3:35 PM. The reassessment did not document vital signs or patient condition.


There was no documented discussion with the patient on risks or benefits of receiving psychotropic drugs as a behavior treatment. There was no consent signed or verbal consent noted in medical record for this treatment.



Review of Patient #3's medical record revealed the following:


Review of the nursing triage assessment on Patient #3 revealed he was a 40-year-old male who transported to the ED on 1/22/2018 at 12:01 PM with a chief complaint of being suicidal.



CPOE (Computerized physician order entry) Orders report review showed the following:

An order for Geodon 20 mg IM once was written on 1/22/2018 at 6:00 PM. There was no reason documented for administration of the medication or parameters given for the order.



Medication Administration Record report review showed the following:


Ziprasidone (Generic name for Geodon) 20 mg was given at 1/22/2018 at 6:29 PM and was given in the Left Deltoid.

A list of home medications was documented in the record. The patient was not on any psychotropic medications. There was an order that stated, "give home meds as rx'd" written on 1/22/2018 at 6:00 PM.

Review of Patient #3's vital sign report revealed no entries for 1/22/2018.


The first assessment documented after the medication administration on 1/22/2018 at 6:29 PM was at 8:02 PM. The reassessment did not document vital signs or patient condition.


There was no documented discussion with the patient on risks or benefits of receiving psychotropic drugs as a behavior treatment. There was no consent signed or verbal consent noted in medical record for this treatment.


Staff #4 confirmed the above findings.



An interview with Staff #4 on 4-17-18 after 9:00 am revealed the following:

Staff #4 was asked why the medication Impassioned (Geodon) was given to Patient #2 and patient #3. Staff #4 reported as far as she could tell they were given for agitation. Staff #4 was asked if the order for the behavioral medication indicated why they were given. Staff #4 confirmed they did not.

Staff #4 confirmed that the facility gave psychotropic medications for behavior management and did not ensure less restrictive methods were attempted prior to use. Staff #4 also confirmed that monitoring and assessment was not done after administering those medications, and that they did not follow the facility policy.



Review of the facility policy and procedure, "Restraints and Seclusion" dated 01/02 (year was not listed) revealed the following:


"PURPOSE:

The leadership of Titus Regional Medical Center is committed to preventing, reducing and striving to eliminate the use of restraints and seclusion. The leaders recognize that the use of restraints/seclusion has the potential to produce serious consequences, such as physical and psychological harm, loss of dignity, violation of an individual's rights, feelings of isolation, and even death. Restraint or seclusion will be used only when clinically justified and only to protect the immediate physical safety of the patient, staff, or others and when alternative methods have proved unsuccessful. Restraints or seclusion are never utilized for the purposes of discipline, coercion, convenience, retaliation of staff or in place of medical or nursing care ...

POLICY:

... Chemical Restraint - A drug or medication used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and it is not a standard treatment or dosage for the patient's condition.


PROCEDURE

A. LEAST RESTRICTIVE ALTERNATIVES

Prior to the use of any restraint or seclusion, least restrictive alternatives will be considered. Based upon assessment of the patient's needs, the hospital staff will use alternative methods such as family involvement and/or diversional activity and the least restrictive mechanism of protection. Further, the rights of other patients receiving care within the therapeutic environment will be respected during the decision making process necessary to determine if a patient poses a serious disruption to a therapeutic environment.

1. Documentation - Documentation of Least Restrictive Measures attempted, whether they were successful or if the alternative failed will be documented in the medical record.
all inclusive ...

C. INTIATION OF RESTRAINT/SECLUSION BY ORDER OF AN LIP OR DESIGNEE.

2. No standing orders or PRN (as needed) orders are acceptable. All orders must be in writing ...

4. The order will be documented on the Restraint/Seclusion Order Form and must include:

a. Clinical justification/reason for restraint to continue and to discontinue;

b. The type of restraint used; and

c. The time limit of the order ...

E. REASSESSMENT/MONITORING

Monitoring/reassessment of the patient ensures that use is minimally restrictive and is discontinued as soon as possible. Monitoring determines the following:

a. The patient's physical and emotional well-being;

b. That the patient's rights dignity, and safety are maintained;

c. Whether less restrictive methods are possible

d. Changes in the patient's behavior or clinical condition needed to initiate the removal of restraints/seclusion;

e. Whether the restraint has been appropriately applied, removed, or reapplied, including signs of any injury associated with the restraint or seclusion.

2. Time frames for monitoring are:

o Every 2 hours for Nonviolent restraints,

o Every 15 minutes for Violent/Self-Destructive Restraints and Seclusion ...

5. Documentation will also include:

o Description of the patient's behavior and the intervention used

o Alternative or other less restrictive interventions attempted (as applicable)

o Patient condition or symptom(s) that warranted the use of restraints

o Patient response to the intervention(s) used; including the rationale for continued use of the intervention ..."

Based on record review and interview, the facility failed to ensure that patients who received medications used as a restriction to manage the patient's behavior or freedom were monitored and assessed prior to and after administration of the medications. Also, the facility failed to ensure that physician orders for those medications were complete and accurate. This deficient practice was found for 2 of 10 Patients, (Patient's #2 and #3) reviewed.

This deficient practice had the likelihood to cause harm for all chemically restrained patients at the facility.


Findings include:


Review of the nursing triage assessment on Patient #2 revealed she was a 48-year-old female who was transported to the ED (Emergency Department) on 12/19/2017 at 6:41 am with chief complaint of being suicidal.


There was documentation of two home medications for Patient #2 on the Ambulatory Assessment/History Report. The home medications were Seroquel and Remeron. The dose and history of the medications were listed as unknown.

Review of Patient #2's vital sign report revealed one set of vital signs taken during her stay. The vitals were 12/19/2017 at 6:52 am. Blood pressure was 129/81, O2 saturation was 98%, Respirations 20, Temperature 98.7. There was no reason documented for administering the medication or parameters given for the order.


Computerized physician order entry (CPOE) Orders report review shows the following:

An order for Geodon 10 mg IM (Intramuscular) q day (Every Day) dated 12/20/2017 at 1:51 PM. There was no reason documented for administering the medication or parameters given for the order.


Medication Administration Record report review shows the following:

Ziprasidone (Generic name for Geodon) 10 mg given on 12/20/2017 at 1:35 PM Right Deltoid.

The first assessment after the medication given on 12/20/2017 at 1:35pm was documented at 4:24 PM; three hours after the medication was given. The reassessment did not document vital signs or patient condition.


An order for Geodon 20 mg PO (by mouth) once dated 12/21/2017 at 2:19 PM. There was no reason documented for administering the medication or parameters given for the order.

Ziprasidone (Generic name for Geodon) 20 mg given at 12/21/2017 at 2:35 PM given PO (by mouth) in capsule form. There was no reason documented for administering the medication or parameters given for the order.

The first assessment documented after the medication administration on 12/21/2017 at 2:35 PM was documented at 3:35 PM. The reassessment did not document vital signs or patient condition.


There was no documented discussion with patient on risks or benefits of receiving psychotropic drugs as a behavior treatment. There was no consent signed or verbal consent noted in medical record for this treatment.


Review of Patient #3's medical record revealed the following:


Review of the nursing triage assessment on Patient #3 revealed he was a 40-year-old male who transported to the ED on 1/22/2018 at 12:01 PM with a chief complaint of being suicidal.

Review of Patient #3's vital sign report revealed no entries for 1/22/2018.

A list of home medications was documented in the record. The patient was not on any psychotropic medications. There was an order that stated, "give home meds as rx'd" written on 1/22/2018 at 6:00 PM.


CPOE (Computerized physician order entry) Orders report review shows the following:


An order for Geodon 20 mg IM once was written on 1/22/2018 at 6:00 PM. There was no reason documented for administration of the medication or parameters given for the order.


Medication Administration Record report review shows the following:

Ziprasidone (Generic name for Geodon) 20 mg was given at 1/22/2018 at 6:29 PM was given in the Left Deltoid.


The first assessment documented after the medication administration on 1/22/2018 at 6:29 PM was documented at 8:02 PM The reassessment did not document vital signs or patient condition.


There was no documented discussion with patient on risks or benefits of receiving psychotropic drugs as a behavior treatment. There was no consent signed or verbal consent noted in medical record for this treatment.


Staff #4 confirmed the above findings.


An interview with Staff #4 on 4-17-18 after 9:00 am revealed the following:

Staff #4 was asked why the mediation Ziprasidone (Geodon) was given to Patient #2 and Patient #3. Staff #4 said as far as she could tell they were given for agitation. Staff #4 was asked if the order for the behavioral medication indicated why they were given. Staff #4 confirmed they did not.

Staff #4 confirmed that the facility gave psychotropic medications for behavior management and did not ensure less restrictive methods were attempted prior to use. Staff #4 also confirmed that monitoring and assessment was not done after administering those medications, and that they did not follow the facility policy.




Review of the facility policy and procedure, "Restraints and Seclusion" dated 01/02 (year was not listed) revealed the following:

"PURPOSE:

The leadership of Titus Regional Medical Center is committed to preventing, reducing and striving to eliminate the use of restraints and seclusion. The leaders recognize that the use of restraints/seclusion has the potential to produce serious consequences, such as physical and psychological harm, loss of dignity, violation of an individual's rights, feelings of isolation, and even death. Restraint or seclusion will be used only when clinically justified and only to protect the immediate physical safety of the patient, staff, or others and when alternative methods have proved unsuccessful. Restraints or seclusion are never utilized for the purposes of discipline, coercion, convenience, retaliation of staff or in place of medical or nursing care ...

POLICY:

... Chemical Restraint - A drug or medication used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and it is not a standard treatment or dosage for the patient's condition.

E. REASSESSMENT/MONITORING

Monitoring/reassessment of the patient ensures that use is minimally restrictive and is discontinued as soon as possible. Monitoring determines the following:

a. The patient's physical and emotional well-being;

b. That the patient's rights dignity, and safety are maintained;

c. Whether less restrictive methods are possible

d. Changes in the patient's behavior or clinical condition needed to initiate the removal of restraints/seclusion;

e. Whether the restraint has been appropriately applied, removed, or reapplied, including signs of any injury associated with the restraint or seclusion.


2. Time frames for monitoring are:

o Every 2 hours for Nonviolent restraints,

o Every 15 minutes for Violent/Self-Destructive Restraints and Seclusion ...

5. Documentation will also include:

o Description of the patient's behavior and the intervention used

o Alternative or other less restrictive interventions attempted (as applicable)

o Patient condition or symptom(s) that warranted the use of restraints

o Patient response to the intervention(s) used; including the rationale for continued use of the intervention ..."

Based on interview and record review, the facility failed to ensure the Emergency department (ED) was organized in a manner to ensure timely emergency services was provided to 1 of 10 patients (Patient #7). The facility failed to ensure Patient #7, who presented with a critical blood sugar level and was receiving an insulin drip, received physician ordered monitoring.

This deficient practice had the likelihood to cause harm to all patients who presented with problems with blood sugar levels.

Findings include:



Review of the nursing triage assessment on Patient #7 revealed he was a 40 year old male who presented to the Emergency department (ED) on 04/06/2018 at 5:15 p.m..Patient #7 was assessed as having an emergency severity index of 2 (meaning urgent). There was documentation on the assessment that Patient #7 presented with chief complaints of hypoglycemia (low blood sugar).

Review of the narrative on the triage assessment revealed the following:

" Patient arrived via EMS from friends house, reports hyperglycemia (high blood sugar)-out of insulin x 3 days."

Review of a physician's orders dated 04/06/2018 at 5:40 p.m. revealed an order for an accucheck.

There was no documentation of a blood sugar being taken during the assessment.

Review of lab results collected on 04/06/2018 at 6:02 p.m., revealed Patient #7 had an elevated glucose level of 1075 with reference ranges being 70-110.


Review of medication administration records dated 04/06/2018 revealed at 6:16 p.m. an insulin drip infusing at 6 milliliters per hour was started.


Review of medication administration records dated 04/06/2018 revealed 5 units of Regular insulin was administered at 6:24 p.m. per intravenously push.


Review of a physician's orders dated 04/06/2018 at 7:30 p.m. revealed an order for an accucheck.

There was no documentation of a blood sugar being taken.

Review of medication administration records dated 04/06/2018 revealed at 8:03 p.m. the insulin drip infusing at 8 milliliters per hour.

Review of physician orders revealed an order was receive to admit Patient #7 to the intensive care unit on 04/06/2018 at 8:17 p.m. There was orders timed 8:50 p.m. revealed nursing was to get an accucheck every hour while the patient was on the insulin drip. Then every 2 hours routinely once the glucose was maintained at 150-200 milligrams/deciliter x 2 hours/


Review of Emergency department (ED)nursing notes dated 04/06/2018 at 9:30 p.m., revealed the following:

"Patient received on insulin drip at 8 units/kg/hr. Checked blood sugar and it was more than 500. Lab results was 800+. 10 units of insulin bolus given. Titrated insulin drip to 12 units/kg/min. Will continue to monitor."
This was the first documentation of an accucheck by nursing on Patient #7 who presented over 4 hours prior to this.

Review of the vital sign report revealed Patient #7 was in the ED at 9:37 p.m. and in the intensive care unit at 9:52 p.m.

Review of a "Measurements Report" dated 04/06/2018 at 11:00 p.m., revealed Patient #7 had a blood sugar of 435 in the ED and was now in the intensive care unit.



During an interview on 04/17/2018 after 9:00 a.m., Staff #4 confirmed that staff had not obtained the accuchecks as ordered. Staff #4 confirmed the insulin drip protocol which called for accucheck monitoring was written while the Patient #7 was still in the ED, but was not started in the ED.