HospitalInspections.org

Based on medical record review and staff interview it was determined that for eight (8) of eight (8) active sample patients and five (5) of five (5) non-sample patients there were written standing physician Orders for "Hydroxyzine 25 mg po (by mouth) q6h (every 6 hours) prn (as necessary) anxiety" and "Olanzapine 5 mg Zydis/ODT PO q8h PRN psychotic agitation or hallucinations" to be administered based on nursing staff assessment of patient's symptoms and the frequency to administer them as well as should they be used separately or in combination. This failure results in requiring the nursing staff to diagnose and prescribe which is outside their scope of practice. (Patients A1, A2, A3, A4, B1, B2, B3, B4, C1, C2, C3, C4 and C5).

The findings include----

I. Medical Record Review:

1. Patient A1: The Adult Physician Admission Order Form dated 9/8/2016 had both Hydroxyzine and/or Olanzapine orders to be used on a prn basis. This patient had no diagnosis of psychotic symptoms.

2. Patient A2: The Adult Physician Admission Order Form dated 9/8/2016 had both Hydroxyzine and/or Olanzapine orders to be used on a prn basis. This patient had no diagnosis of psychotic symptoms.

3. Patient A3: The Adult Physician Admission Order Form dated 9/7/2016 had both Hydroxyzine and/or Olanzapine orders to be used on a prn basis.

4. Patient A4: The Adult Physician Admission Order Form dated 9/7/2016 had only the
Hydroxyzine order to be used on a prn basis.

5. Patient B1: The Adult Physician Admission Order Form dated 9/7/2016 had both Hydroxyzine and/or Olanzapine orders to be used on a prn basis. This patient had been given both Hydroxyzine and Olanzapine on 9/11/2016. This patient had no diagnoses of psychotic features.

6. Patient B2: The Adult Physician Admission Order Form dated 9/9/2016 had both Hydroxyzine and/or Olanzapine orders to be used on a prn basis. This patient had no diagnoses of psychotic features.

7. Patient B3: The Adult Physician Admission Order Form dated 9/9/2016 had both Hydroxyzine and/or Olanzapine orders to be used on a prn basis. This patient had no diagnoses of psychotic features.

8. Patient B4: The Adult Physician Admission Order Form dated 9/7/2016 had both Hydroxyzine and/or Olanzapine orders to be used on a prn basis. Patient ' s mother did not consent for the use of Hydroxyzine. This patient had no diagnoses of psychotic features yet had a standing Order for the use of an antipsychotic medication on a prn basis.

9. Patients C1 (date of Order sheet in parenthesis) (9/14/2016), Patient C2 (9/14/2016, Patient C3 (9/14/2016) and Patient C4 (9/14/2016) all had available the Orders for Hydroxyzine and Olanzapine on a prn basis.

10. Patient C5: The Adult Physician Admission Order Form dated 9/14/2016 had both
Hydroxyzine and/or Olanzapine orders to be used on a prn basis. This patient did not have a
diagnosis of psychotic features.

II. Staff Interview:

On 9/14/2016 at 3:25 p.m. RN#1 told the surveyor "All the adolescent standing Orders are the same. I guess it is a nursing judgment" i.e. which medication to select and what patient
symptoms necessitated the use of an antianxiety agent (Hydroxyzine) and/or antipsychotic agent (Olanzapine).

2. On 9/15/2016 at 10:00 a.m. the clinical director, the Director of Nursing and the Director of Social Services met with the surveyors. The clinical director did not dispute that the phenomena of standing physician Orders for antipsychotic medications was a facility-wide practice. The clinical director acknowledged that as written these Orders necessitated nursing staff to function outside their scope of practice.

3. On 9/16/2016 at 9:30 a.m. the clinical director and the Quality Assurance staff member met. The clinical director again agreed with the findings. The Quality Assurance staff member reported to the surveyor that she had been instructed to remove these standing Orders including the one for "Trazadone 50mg PO qhs (every sleep time) PRN sleep {sic}: May repeat dose x1 after 1 hour if still awake" as of 9/15/2016 early afternoon.

4. When the use of an antipsychotic medication for a patient without psychotic symptoms or
diagnoses happens this is a form of chemical restraint. On 9/16/2016 at 10:55 a.m. the Director of Nursing told the surveyor that to the best of her knowledge no chemical restraints had occurred over the last 2 weeks. Thus, the facility did not consider these Olanzapine Orders as a form of chemical restraint (see occurrence for Patient B1). At 11:30 a.m. the Director of Nursing assured the surveyor that this form of usage is a method for chemical restraint and would be reported as such.