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Based on review of facility policies, random review of patient charts from June and July 2023 and confirmed in interview, the facility failed to protect and promote each patient's rights. The facility failed:

A. To Ensure staff identified the use of a chemical restraint/emergency behavioral medication for two of ten charts (Patient #C and Patient #EE) reviewed. Refer to A0160

B. To establish and monitor a process for continuous monitoring of a chemical restraint/emergency behavioral medication for side effects, respiratory or cardiac distress, and assessment of medication effectiveness and safety after administration within 1 hour in three of ten (Patients #BB, Patient #CC, and Patient #Z) patient charts reviewed. Refer to A0178

C. To establish a policy and procedures to ensure a face-to-face was conducted by a trained individual that was not part of the restraint process in three of ten (Patients #BB, Patient #CC, and Patient #Z) patient charts reviewed. Refer to A0178

The deficient practices were identified under the following Condition of Participation, CFR 482.13 Patient Rights, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death.

An acceptable plan of removal of the IJ was provided on 07/14/2023 at 5:00 PM and surveyor confirmed the IJ was abated on 07/14/2023.

Based on review of facility policies, random review of patient charts from June and July 2023 and confirmed in interview, the facility failed to Ensure staff identified the use of a chemical restraint/emergency behavioral medication for two of ten charts (Patient #C and Patient #EE) reviewed.

The deficient practices were identified under the following Condition of Participation, CFR 482.13 Patient Rights, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death.

An acceptable plan of removal of the IJ was provided on 07/14/2023 at 5:00 PM and surveyor confirmed the IJ was abated on 07/14/2023.

Findings included:

Review of the policy Medicating Patients in Emergencies (Policy ID 12912426, revised 03/2017) it stated "the treating physician should be consulted each time an emergent situation arises to request orders for 'IM' medication in an emergency. In those instances where patients actually consent to medication by injection, it is required that the patient's agreement to IM medication be carefully documented in the treatment record."

In an interview with the nursing manager on 07/13/2023 at 3:40 PM in the conference room, he stated that if the nursing staff is able to get consent to administer a chemical restraint/emergency behavioral medication, their policy is to not treat it as a chemical restraint.

In an interview with the nursing educator on 07/14/2023 at 3:00 PM she stated that the facility recently implemented the above changes. She then provided an inservice for the nursing staff done on 01/17/2023 that included the Emergency Medications Procedure.

Review of the Emergency Medications Procedure (no revision or effective date) revealed:
"Emergency medications are the only medications patient can receive without consent.
o Emergency medications are ordered during a psychiatric emergency. When a psychiatric emergency is no longer imminent or present, medications prescribed without consent on an emergency basis must be discontinued.
(TAC 414.410)
o Before calling the doctor, find out if the patient is willing to take PO meds.
PO meds MUST be offered prior to requesting injections.
o When IM medications are used in psychiatric emergencies use the
'EMERGENCY ORDERS' template to place the orders and complete the
'EMERGENCY ADMINISTRATION OF PSYCHOTROPIC MEDICATION' documentation.
If a patient is requesting injection with or without an emergency, consent must be obtained before administering medication.
o ANY MEDICATION ADMINISTERED WITHOUT CONSENT HAS TO HAVE SUPPORTING DOCUMENTATION OF A PSYCHIATRIC EMERGENCY."

Patient #C
Review of Patient #C medical chart revealed RN (Personnel#12) administered Benadryl 50 mg IM, Ativan 2 mg IM and Haldol 10 mg IM in response to a behavioral incident on 07/02/2023 at 1:00 PM.

Review of the Interdisciplinary Notes for 07/02/2023 at 2:11 PM the RN (Personnel #12) noted "Pt [patient] was brought back to the unit by MHT [mental health technician] staff from lunch and he immediately began cursing and threatening RN attempting to pick up computer and threw items at RN. Pt was unable to be redirected. Dr. (Personnel #13) was notified and ordered Benadryl 50 mg IM, Ativan 2 mg IM and Haldol 10 mg IM times one dose now which was administered at 1305 to the left and right deltoid using aseptic technique. Pt was compliant with medication administration and signed consent."

Review of the Interdisciplinary Notes for 07/02/2023 for Active Medication it stated "Diphenhydramine HCL Injection (BENADRYL INJECTION) Inject 50 mg One Time Only Indication
Haloperidol Lactate Injection (Haldol Injection) 5 MG/ML, 10 mg (2 mL) intramuscularly One Time Only Indication: severe aggression
LORazepam Injection (Ativan Injection) 2 MG/ML, 2 mg (1 mL) intramuscularly One Time Only Indication: severe aggression."

Patient #EE
Review of Patient #EE medical chart revealed RN (Personnel #15) administered Thorazine 200 mg IM in response to a a behavioral incident on 07/12/2023 at 12:35 PM.

Review of the Interdisciplinary Notes for 07/12/2023 at 12:35 PM, the RN (Personnel #15) noted "After the failure of multiple therapeutic interventions/de-escalations methods by this nurse and another nurse ,Patient was medicated
Thorazine 200mg IM for continues threat to hurt a staff or destroy property. 'I feel to hurt somebody or destroy property' he said repeatedly. Patient willingly took in the injection in the gluteal."

Further review of the Interdisciplinary Notes for Active Medication it stated "Chlorpromazine HCL (Thorazine INJ 50mg/2ml) Inject 200 mg One Time Only Patient is a danger to others related to ineffective coping skills
AEB his statement: " I feel to hurt somebody or destroy property.' Indication: Increased Agitation. ****CONSENT OBTAINED****"

Review of the above patient charts for Patient #C and #EE revealed no documentation of the 'EMERGENCY ADMINISTRATION OF PSYCHOTROPIC MEDICATION' in response to the chemical restraint/emergency behavioral medication initiated on 07/02/2023 at 07/12/2023, respectively.

An interview with the nursing manager and the nursing educator on 07/14/2023 at 1:00 PM in the conference room confirmed the above findings. Neither were aware that the medications given were still an emergency behavioral medication that warrants the assessment after initiation and even after the consent obtained.

Based on review of facility policies, random review of patient charts from June and July 2023 and confirmed in interview, the facility failed

-to establish and monitor a process for continuous monitoring of a chemical restraint/emergency behavioral medication for side effects, respiratory or cardiac distress, and assessment of medication effectiveness and safety after administration within 1 hour in three of ten (Patients #BB, Patient #CC, and Patient #Z) patient charts reviewed.

-to establish a policy and procedures to ensure a face-to-face was conducted by a trained individual that was not part of the restraint process in three of ten (Patients #BB, Patient #CC, and Patient #Z) patient charts reviewed.

The deficient practices were identified under the following Condition of Participation, CFR 482.13 Patient Rights, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death.

An acceptable plan of removal of the IJ was provided on 07/14/2023 at 5:00 PM and surveyor confirmed the IJ was abated on 07/14/2023.

Findings included:

The Nursing Educator provided a copy of the QRN [Qualified RN] Competency Restraint and Seclusion Required Training on 07/14/2023. Review of the training powerpoint included "[one hour face to face evaluation] must be completed within one hour of initiating the restraint/seclusion event."

Patient #BB
7/9/2023
Review of the medical chart for Patient #BB revealed RN (Personnel #16) administered Haldol 10 mg IM, Ativan 2 mg IM, and Benadryl 50 mg IM in response to a behavioral incident on 07/09/2023 at 11:43 AM.
Review of the Interdisciplinary Notes from 07/09/2023 the RN (Personnel #16) noted "psychotic behavior" as the justification for the chemical restraint/emergency behavioral medication.
Review of the Emergency Administration of Psychotropic Medication for the chemical restraint/emergency behavioral medication administered revealed Personnel #16 initiated the restraint at 07/09/2023 at 11:43 AM and assessed at 2:10 PM (elapsed time 2 hours 27 minutes) by the same nurse (Personnel #16).
7/03/2023
Review of the medical chart for Patient #BB revealed RN (Personnel #17) administered Haldol 10 mg IM, Ativan 2 mg IM, and Benadryl 50 mg IM in response to a behavioral incident on 07/03/2023 at 9:38 PM.
Review of the Emergency Administration of Psychotropic Medication for the chemical restraint/emergency behavioral medication administered revealed Personnel #17 initiated the restraint at 07/03/2023 at 09:37 PM and assessed on 07/04/2023 at 1:04 AM (elapsed time 3 hours 27 minutes) by a differing nurse (Personnel #14).

Patient #CC
7/14/2023
Review of the medical chart for Patient #CC revealed RN (Personnel #18) administered Haldol 10 mg IM, Ativan 2 mg IM, and Benadryl 50 mg IM in response to a behavioral incident on 07/14/2023 at 02:50 AM.
Review of the Emergency Administration of Psychotropic Medication from 07/14/2023 the RN (Personnel #18) noted "pt [patient] is physical punching, attacking, and kicking people" as the justification for the chemical restraint/emergency behavioral medication.
Further review of the Emergency Administration of Psychotropic Medication for the chemical restraint/emergency behavioral medication administered revealed Personnel #18 initiated the restraint at 07/14/2023 at 02:50 AM and assessed at 04:04 AM (elapsed time 1 hours 14 minutes) by the same nurse (Personnel #18).

7/13/2023
Review of the medical chart for Patient #CC revealed RN (Personnel #19) administered Haldol 10 mg IM, Ativan 2 mg IM, and Benadryl 50 mg IM in response to a behavioral incident on 07/13/2023 at 03:45 PM.
Review of the Emergency Administration of Psychotropic Medication from 07/13/2023 the RN (Personnel #19) noted "pt [patient] is physical punching, attacking, and kicking people" as the justification for the chemical restraint/emergency behavioral medication.
Further review of the Emergency Administration of Psychotropic Medication for the chemical restraint/emergency behavioral medication administered revealed Personnel #19 initiated the restraint at 07/13/2023 at 03:45 PM and assessed at 07:08 PM (elapsed time 3 hours 23 minutes) by a differing nurse (Personnel #15).

07/12/2023
Review of the medical chart for Patient #CC revealed RN (Personnel #20) administered Haldol 10 mg IM, Ativan 2 mg IM, and Benadryl 50 mg IM in response to a behavioral incident on 07/12/2023 at 08:32 PM.
Review of the Emergency Administration of Psychotropic Medication from 07/12/2023 the RN (Personnel #20) noted "****Patient in acute psychosis, combative, physically and verbally aggressive, fighting staffs,
disrupting the unit, and non redirectable****" as the justification for the chemical restraint/emergency behavioral medication.
Further review of the Emergency Administration of Psychotropic Medication for the chemical restraint/emergency behavioral medication administered revealed Personnel #20 initiated the restraint on 07/12/2023 at 08:32 PM and assessed on 07/13/2023 at 03:02 AM (elapsed time 6 hours 30 minutes) by a differing nurse (Personnel #21).

07/09/2023
Review of the medical chart for Patient #CC revealed RN (Personnel #19) administered Haldol 10 mg IM, Ativan 2 mg IM, and Benadryl 50 mg IM in response to a behavioral incident on 07/09/2023 at 10:40 AM.
Review of the Emergency Administration of Psychotropic Medication from 07/09/2023 the RN (Personnel #19) noted "+++: Physically attacking people, severe combative and aggression, stripping self naked+++" as the justification for the chemical restraint/emergency behavioral medication.
Further review of the Emergency Administration of Psychotropic Medication for the chemical restraint/emergency behavioral medication administered revealed Personnel #19 initiated the restraint at 07/09/2023 at 10:40 AM and assessed at 11:55 AM (elapsed time 1 hour 15 minutes) by the same nurse (Personnel #19).

07/03/2023
Review of the medical chart for Patient #CC revealed RN (Personnel #19) administered Haldol 10 mg IM, Ativan 2 mg IM, and Benadryl 50 mg IM in response to a behavioral incident on 07/03/2023 at 08:25 AM.
Review of the Emergency Administration of Psychotropic Medication from 07/03/2023 the RN (Personnel #19) noted **Refuses: ATTACKING PEOPLE***Yelling screaming, triggering the unit. Disruptive, Combative to
attack peer****" as the justification for the chemical restraint/emergency behavioral medication.
Further review of the Emergency Administration of Psychotropic Medication for the chemical restraint/emergency behavioral medication administered revealed Personnel #19 initiated the restraint at 07/03/2023 at 08:25 AM and assessed at 10:51 AM (elapsed time 2 hour 26 minutes) by a differing nurse (Personnel #15).

Patient #Z
Review of the medical chart for Patient #Z revealed RN (Personnel #20) administered Zyprexa 10 mg IM and Benadryl 50 mg IM in response to a behavioral incident on 07/12/2023 at 11:40 PM.
Review of the Emergency Administration of Psychotropic Medication from 07/12/2023 the RN (Personnel #20) noted **Patient in acute psychosis, combative, poor boundaries, fighting peers and disoriented" as the justification for the chemical restraint/emergency behavioral medication.
Further review of the Emergency Administration of Psychotropic Medication for the chemical restraint/emergency behavioral medication administered revealed Personnel #20 initiated the restraint at 07/12/2023 at 11:40 PM and assessed on 07/13/2023 at 02:45 AM (elapsed time 3 hour 5 minutes) by the same nurse (Personnel #20).

Review of the patient charts for Patient #BB, #CC, and #Z revealed no documentation of the face to face evaluation within one hour of initiating the above chemical restraints/emergency behavioral medication.



Patient #BB
7/9/2023
Review of the medical chart for Patient #BB revealed RN (Personnel #16) administered Haldol 10 mg IM, Ativan 2 mg IM, and Benadryl 50 mg IM in response to a behavioral incident on 07/09/2023 at 11:43 AM.
Review of the Interdisciplinary Notes from 07/09/2023 the RN (Personnel #16) noted "psychotic behavior" as the justification for the chemical restraint/emergency behavioral medication.
Review of the Emergency Administration of Psychotropic Medication for the chemical restraint/emergency behavioral medication administered revealed Personnel #16 initiated the restraint at 07/09/2023 at 11:43 AM and assessed at 2:10 PM by the same nurse (Personnel #16).

Patient #CC
7/14/2023
Review of the medical chart for Patient #CC revealed RN (Personnel #18) administered Haldol 10 mg IM, Ativan 2 mg IM, and Benadryl 50 mg IM in response to a behavioral incident on 07/14/2023 at 02:50 AM.
Review of the Emergency Administration of Psychotropic Medication from 07/14/2023 the RN (Personnel #18) noted "pt [patient] is physical punching, attacking, and kicking people" as the justification for the chemical restraint/emergency behavioral medication.
Further review of the Emergency Administration of Psychotropic Medication for the chemical restraint/emergency behavioral medication administered revealed Personnel #18 initiated the restraint at 07/14/2023 at 02:50 AM and assessed at 04:04 AM by the same nurse (Personnel #18).

07/09/2023
Review of the medical chart for Patient #CC revealed RN (Personnel #19) administered Haldol 10 mg IM, Ativan 2 mg IM, and Benadryl 50 mg IM in response to a behavioral incident on 07/09/2023 at 10:40 AM.
Review of the Emergency Administration of Psychotropic Medication from 07/09/2023 the RN (Personnel #19) noted "+++: Physically attacking people, severe combative and aggression, stripping self naked+++" as the justification for the chemical restraint/emergency behavioral medication.
Further review of the Emergency Administration of Psychotropic Medication for the chemical restraint/emergency behavioral medication administered revealed Personnel #19 initiated the restraint at 07/09/2023 at 10:40 AM and assessed at 11:55 AM by the same nurse (Personnel #19).

Patient #Z
Review of the medical chart for Patient #Z revealed RN (Personnel #20) administered Zyprexa 10 mg IM and Benadryl 50 mg IM in response to a behavioral incident on 07/12/2023 at 11:40 PM.
Review of the Emergency Administration of Psychotropic Medication from 07/12/2023 the RN (Personnel #20) noted **Patient in acute psychosis, combative, poor boundaries, fighting peers and disoriented" as the justification for the chemical restraint/emergency behavioral medication.
Further review of the Emergency Administration of Psychotropic Medication for the chemical restraint/emergency behavioral medication administered revealed Personnel #20 initiated the restraint at 07/12/2023 at 11:40 PM and assessed on 07/13/2023 at 02:45 AM by the same nurse (Personnel #20).

Review of the patient charts for Patient #BB, #CC, and #Z revealed no documentation of the on hour face to face evaluation by a different nurse who initiated the above chemical restraints/emergency behavioral medication.

An interview with the nursing manager and the nursing educator on 07/14/2023 at 1:00 PM in the conference room confirmed the above findings. They both stated that they are aware of the delay of the assessment (past 1 hour) and the need for another nurse to assess after the initiation of the chemical restraint.