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Based on record review and interviews, the Hospital failed to ensure 1. the use of restraint was in accordance with the order of a physician or other licensed practitioner for 5 Patients (#1, #5, #6, #4, #8) and 2. orders for Haldol (an antipsychotic medication) as a chemical restraint were not written on an as needed basis (PRN) for two Patients (#7 & #8) out of a total sample of 10 patients.

Refer to tags A-0168 and A-0169

Based on record review and interviews, the Hospital failed to ensure the use of restraint was in accordance with the order of a physician or other licensed practitioner for 5 Patients (#1, #5, #6, #4, #8) out of a total sample of 10 patients.

Findings include:

The Hospital policy titled "Use of Restraints", revised 1/29/2019, indicated the following:
-Physical Restraints are 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 the forced removal of clothing.
-Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. A patient who is physically restrained in an unlocked room does not constitute seclusion.
-A chemical restraint as a drug or medication when it was used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.

-Restraints for Management of Violent or Self-Destructive Behavior
-An order must be obtained from a physician or physician assistant during or immediately after the restraint application. The person must provide a face-to-face evaluation within one hour of initiation.
-The order is time-limited as follows: 4 hours for adults 18 and older
-Orders may only be renewed for up to a total of 24 hours.
-If the restraint or seclusion is discontinued prior to the one hour face-to-face, an order must still be obtained.
-The face-to-face evaluation shall include the following: the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion.
-Restraint or seclusion should be discontinued at the earliest possible time, regardless of the length of time identified in the order.
-Criteria for restraint discontinuation: Patient demonstrates calm behavior and is able to listen to and follow instructions, the behavior that stimulated the sue of the restraint is no longer demonstrated.

1. Patient #1 was admitted to the Hospital Emergency Department on 4/10/22 with diagnoses of Autism, ADHD, and psychiatric evaluation.

Review of Patient #1's medical record indicated the Patient was transported to the Hospital Emergency Department on 4/10/22 by Emergency Medical Services (EMS) after becoming agitated on a walk with his/her group home staff in the community and indicating he/she wanted to kill a staff member. After evaluation in the Emergency Department, a discharge plan was developed to send Patient #1 back to his/her group home on the morning of 4/11/22 and staff from the group home would pick him/her up. On 4/11/22 at 9:36 A.M., Patient #1 refused to discharge from the Emergency Department while in the lobby. Patient #1 threw him/herself to the floor and became combative with Hospital staff; the Patient was returned to his/her room in the Emergency Department and placed in 4-point restraints and chemically restrained with medications. Patient #1 was released from the physical 4-point restraints on 4/11/22 at 11:45 A.M., then became physical aggressive with Hospital staff in the Emergency Department hallway and was placed back in 4-point restraints in his/her room. Review of Patient #1's Physician's orders failed to indicate any orders to physically restrain Patient #1 on 4/11/22 at 9:36 A.M. or 11:45 A.M., nor was a face-to-face evaluation documented by a physician regarding the use of physical restraints or the Patient's response to physical restraint for either of those instances on 4/11/22.

Further review of Patient #1's medical record indicated the Patient was again placed in 4-point physical restraints on 4/11/22 at 6:53 P.M.; the physician evaluation indicated the Hospital staff would again administer medications for agitation but failed to indicate any use of a physical 4-point restraint for the Patient. A Physician's order was entered on 4/11/22 at 7:08 P.M. for restraints violent, restraint type: seclusion continuous for up to 4 hours; further review of Patient #1's physician's orders failed to indicate any corresponding order for a 4-point restraint. On 4/12/22 at 11:26 A.M., Patient #1 became aggressive and was placed in 4-point restraints and chemically restrained; review of Patient #1's physician's orders failed to indicate an order for physical 4-point restraints for this incident. On 4/12/22 at 2:00 P.M., Patient #1's restraints to his/her arms were removed and he/she continued to have physical restraints to his/her lower extremities; Patient #1 was released from the physical restraints to his/her lower extremities at 3:25 P.M. to go to the bathroom, and then put back into 2-point physical restraints without a physician's order. On 4/12/22 at 6:20 P.M. Patient #1 was placed into 4-point restraints because he/she posed a risk to him/herself; there was no documented face-to-face physician evaluation of Patient #1 nor was there a physician's order for 4-point physical restraints at this time. Patient #1 was discharged to his/her group home at 8:33 P.M. on 4/12/22 and subsequently returned to the Emergency Department at 8:55 P.M.

Patient #1 was readmitted to the Hospital Emergency Department on 4/12/22 with aggressive behavior. On 4/12/22 at 10:48 P.M., Patient #1 was placed into 4-point physical restraints as he/she had aggressive behavior; there was no documented face-to-face physician evaluation of Patient #1 nor was there a physician's order for 4-point physical restraints at this time. On 4/14/22 at 7:00 P.M., Patient #1 was placed in seclusion due to imminent risk of harm to self or other; there was no documented face-to-face physician evaluation of Patient #1 nor was there a physician's order for seclusion at this time. On 4/17/22 at 10:09 A.M. Patient #1 was placed in a 4-point physical restraint after striking a registered nurse (RN); there was no documented face-to-face physician evaluation of Patient #1 nor was there a physician's order for 4-point physical restraints at this time. On 4/17/22 at 12:27 P.M. Patient #1 was placed in a 4-point restraint after throwing an object at security staff; there was no documented face-to-face physician evaluation of Patient #1 for physical restraint nor was there a physician's order for 4-point physical restraints at this time. Patient #1 was discharged to another hospital on 4/19/22.

During an interview with RN #2 on 9/27/22 at 7:15 A.M., he said security staff and nursing staff usually initiate physical restraints for patients in the Emergency Department. He said a physician may give a verbal order for physical restraints but will enter the order into the electronic medical record once the patient is stabilized and the physician must evaluate the patient as well. He said when physicians order chemical restraints such as intramuscular Haldol (an antipsychotic medication), they generally occur with 4-point physical restraints. RN #2 was unable to recall any details from Patient #1's hospitalization on 4/10/22 or 4/12/22.

During an interview with the Emergency Department Assistant Nurse Manager on 9/27/22 at 7:54 A.M., she said if a physician verbally orders a physical restraint, the physician must put the order in the electronic medical record after the patient is secure/safe.

During an interview with RN #1 on 9/27/22 at 8:16 A.M., he said any restraint applied to a patient should be ordered by a physician. He said nursing staff can begin the process to restrain a patient, but a physician must evaluate a patient being restrained physically. He said physical restraint of a patient usually accompanies chemical restraint of a patient. He said a physician's order for physical restraint needs to specify the type of restraint to be implemented to the patient such a seclusion or 4-point physical restraint. He said on the morning of 4/11/22, Patient #1 had been in the hallway of the Emergency Department, threw himself to the floor, struck a staff member, and was physically and chemically restrained.

During an interview with the Chair of Emergency Medicine on 9/27/22 at 8:59 A.M., he said there would not be a time when a physician would not be available in the Emergency Department. He said restraints can be ordered verbally but must be put in the electronic medical record by the physician after the patient is restrained.

During an interview with RN #3 on 9/27/22 at 9:25 A.M., she said RNs can make the decision to remove restraints from a Patient if the RN assesses the Patient to be safe. She said the orders for physical restraint are not discontinued in case a Patient needs to be put back in physical restraints. RN #3 said Patient #1 had been aggressive with Hospital staff in April 2022 and required to be physically restrained and was in and out of restraints during his/her hospitalization.

During an interview with Physician #1 on 9/27/22 at 9:55 A.M., he said nursing staff may begin the process of restraining a patient if the patient may be a risk to themselves or others and a physician must evaluate the patient being restrained. He said RNs can start the process of removing restraints and should communicate to the physicians when a Patient is removed from physical restraints. He said physician orders should be specific to the type of restraint intended to be implemented. He said the orders for physical restraints are not usually discontinued, generally the orders are left to expire.

During an interview with RN #5 on 9/27/22 at 10:23 A.M., she said if a patient becomes violent, nursing staff get security staff involved to restrain a patient. She said an overhead page will be made to get the physician to the room of the patient becoming violent. She said the physician should evaluate the patient, and the physician can verbally order physical and chemical restraints for the patient. She said physical restraint is often required to implement a chemical restraint. She said Patient #1 required 4-point physical restraints after he had become assaultive with staff in the Emergency Department.

During an interview with Physician #2 on 9/27/22 at 12:32 P.M., she said chemical and physical restraints often occur simultaneously. She said physical restraints must be written as a separate order. She said RNs may discontinue physical restraints for patients but should communicate to the physician if a RN assesses a patient's physical restraints must be reapplied.

During an interview with RN #6 on 9/28/22 on 9:03 A.M., he said the use of restraints for patients are situational. He said there are times a chemical restraint with medications can be applied to a patient without applying a physical restraint as well. He said Patient #1 required physical and chemical restraints during his/her hospitalization in April 2022 after becoming physically assaultive with Hospital staff.

Patient #1 was physically restrained on multiple instances during his/her Hospitalizations in April 2022 without physician orders present; the Hospital failed to ensure the use of restraint was in accordance with the order of a physician or other licensed practitioner for Patient #1.

2. Patient #5 was admitted to the Hospital Emergency Department on 4/11/22 with diagnoses of ETOH (alcohol) intoxication, agitation, and depression.

Review of Patient #5's medical record indicated on 4/11/22 at 11:04 P.M., Patient #5 escalated and became more aggressive to staff and required a chemical restraint (intramuscular Haldol) and was placed in a 4-point physical restraint. Further review of Patient #5's medical record failed to indicate any order for a physical 4-point restraint for 4/11/22.

Patient #5 admitted to the Hospital Emergency Department on 5/12/22 with a diagnosis of ETOH intoxication. Review of Patient #5's medical record indicated on 5/12/22 at 10:04 P.M., Patient #5 was clinically intoxicated, and was chemically restrained with Haldol 5mg intramuscularly per physician order. Patient #5 was put in 4-point physical restraints at 10:15 P.M. on 5/12/22; there was no documented face-to-face physician evaluation of Patient #1 for physical restraint nor was there a physician's order for a 4-point physical restraint at this time. An order for restraints violent, restraint type seclusion continuous up to 4 hours was entered on 5/12/22 at 10:18 P.M.

Patient #5 was admitted to the Hospital Emergency Department on 5/19/22 with a diagnosis of ETOH intoxication. Review of Patient #5's medical record indicated on 5/19/22 at 4:30 P.M., Patient #5 was placed in seclusion through 6:00 P.M. on 5/19/22. Further review of Patient #5's medical record failed to indicate any order for seclusion on 5/19/22.

During an interview with RN #2 on 9/27/22 at 7:15 A.M., he said security staff and nursing staff usually initiate physical restraints for patients in the Emergency Department. He said a physician may give a verbal order for physical restraints but will enter the order into the electronic medical record once the patient is stabilized and the physician must evaluate the patient as well. He said when physicians order chemical restraints such as intramuscular Haldol (an antipsychotic medication), they generally occur with 4-point physical restraints.

During an interview with RN #1 on 9/27/22 at 8:16 A.M., he said any restraint applied to a patient should be ordered by a physician. He said nursing staff can begin the process to restrain a patient, but a physician must evaluate a patient being restrained physically. He said physical restraint of a patient usually accompanies chemical restraint of a patient. He said a physician's order for physical restraint needs to specify the type of restraint to be implemented to the patient such a seclusion or 4-point physical restraint.

During an interview with the Chair of Emergency Medicine on 9/27/22 at 8:59 A.M., he said there would not be a time when a physician would not be available in the Emergency Department. He said restraints can be ordered verbally but must be put in the electronic medical record by the physician after the patient is restrained. He said an order is required to place a patient in seclusion, as the staff are actively preventing a patient in seclusion for leaving.

During an interview with Physician #1 on 9/27/22 at 9:55 A.M., he said nursing staff may begin the process of restraining a patient if the patient may be a risk to themselves or others and a physician must evaluate the patient being restrained. He said RNs can start the process of removing restraints and should communicate to the physicians when a Patient is removed from physical restraints. He said physician orders should be specific to the type of restraint intended to be implemented. He said the orders for physical restraints are not usually discontinued, generally the orders are left to expire.

Patient #5 was placed in physical 4-point restraints and seclusion without physician orders present for the restraints implemented.

3. Patient #6 was admitted to the Hospital Emergency Department on 6/17/22 with a diagnosis of ETOH intoxication.

Review of Patient #6's medical record indicated on 6/17/22 at 8:49 P.M., Patient #6 was physically restrained in 4-point restraints and placed in seclusion after striking a RN following a chemical restraint (Intramuscular Haldol, Ativan (a benzodiazepine medication), and Benadryl (an antihistamine medication)). On 6/17/22 at 9:57 P.M., a physician documented Patient #6 was combative and managed to break a restraint and ordered an additional Haldol chemical restraint. Further review of Patient #6's medical record failed to indicate any order for a physical 4-point restraint nor seclusion.

During an interview with RN #2 on 9/27/22 at 7:15 A.M., he said security staff and nursing staff usually initiate physical restraints for patients in the Emergency Department. He said a physician may give a verbal order for physical restraints but will enter the order into the electronic medical record once the patient is stabilized and the physician must evaluate the patient as well. He said when physicians order chemical restraints such as intramuscular Haldol (an antipsychotic medication), they generally occur with 4-point physical restraints.

During an interview with RN #1 on 9/27/22 at 8:16 A.M., he said any restraint applied to a patient should be ordered by a physician. He said nursing staff can begin the process to restrain a patient, but a physician must evaluate a patient being restrained physically. He said physical restraint of a patient usually accompanies chemical restraint of a patient. He said a physician's order for physical restraint needs to specify the type of restraint to be implemented to the patient such a seclusion or 4-point physical restraint.

During an interview with the Chair of Emergency Medicine on 9/27/22 at 8:59 A.M., he said there would not be a time when a physician would not be available in the Emergency Department. He said restraints can be ordered verbally but must be put in the electronic medical record by the physician after the patient is restrained. He said an order is required to place a patient in seclusion, as the staff are actively preventing a patient in seclusion for leaving.

During an interview with Physician #1 on 9/27/22 at 9:55 A.M., he said nursing staff may begin the process of restraining a patient if the patient may be a risk to themselves or others and a physician must evaluate the patient being restrained. He said RNs can start the process of removing restraints and should communicate to the physicians when a Patient is removed from physical restraints. He said physician orders should be specific to the type of restraint intended to be implemented. He said the orders for physical restraints are not usually discontinued, generally the orders are left to expire.

Patient #6 was placed in a physical 4-point restraint and seclusion without physician orders present for the restraints implemented.



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4. Review of Patient #4's medical record indicated he/she presented to the Hospital Emergency Department (ED) in September 2022, with complaints of anxiety, hallucinations, and a history of bipolar disorder.

During an interview on 9/27/22 at 1:00 P.M., the Manager of Protective Services said that security staff members are involved and complete every patient restraint at the hospital with the direction of medical staff when safety concerns are present. The Manager said security staff members document a Restraint Event (incident report) after each patient restraint.

The Restraint Event (an incident reported documented by Security Staff), dated 9/17/22 at 2:22 A.M., and the Nurse Violent or Self-Destructive Restraints Documentation, dated 9/17/22 at 2:30 A.M., indicated that due to safety concerns (danger to him/herself and/or others), Patient #4 required four-point (arms and legs) physical restraints, and Patient #4 was placed in seclusion. The Hospital failed to provide documentation of a written physician seclusion order.

The Nurse Violent or Self-Destructive Restraints Documentation, dated 9/17/22 at 3:48 A.M., indicated that nursing staff discontinued Patient #4's four-point physical restraints; however, Patient #4 remained in seclusion. The Hospital failed to provide documentation of a written physician seclusion order.

The Physician's Free Text, dated 9/17/22 at 7:06 A.M., and the Nurses Violent or Self-Destructive Restraints Documentation, dated 9/17/22 at 6:58 A.M. and at 7:59 A.M., indicated that Patient #4 was placed in four-point physical restraints (tough cuffs); additionally, Patient #4 remained in seclusion. The Hospital failed to provide a documented Restraint Event (incident report).

The Restraint Event, dated 9/18/22 at 12:45 A.M., indicated that Patient #4 required four-point restraints (velcro) due to safety concerns after he/she became physically violent with a staff member. The Hospital failed to provide documentation of a written physician restraint order.

The Restraint Event, dated 9/18/22 at 7:20 A.M., indicated that Patient #4 required four-point restraints (velcro) due to safety concerns after he/she became physically violent with a staff member. The Hospital failed to provide documentation of a written physician restraint order.

The Nurse Violent or Self-Destructive Restraints Documentation, dated 9/18/22 at 8:30 A.M., indicated that nursing staff discontinued Patient #4's four-point physical restraints; however, Patient #4 continued in seclusion. The Hospital failed to provide documentation of a written physician seclusion order.

The Nurse Violent or Self-Destructive Restraints Documentation, dated 9/18/22 at 10:31 A.M., indicated that staff placed Patient #4 in four-point physical restraints (tuff cuffs); however, Patient #4 continued in seclusion. The Hospital failed to provide documentation of a written physician restraint order, a written physician seclusion order, or a documented Restraint Event (incident report).

The Nurse Violent or Self-Destructive Restraints Documentation, dated 9/18/22 at 11:05 A.M., indicated that nursing staff discontinued Patient #4's four-point physical restraints; however, Patient #4 continued in seclusion. The Hospital failed to provide documentation of a written physician seclusion order.

The Restraint Event, dated 9/18/22 at 6:02 P.M., indicated that Patient #4 rushed out of his/her room and became physically aggressive with staff; therefore, Patient #4 was brought to the floor, lifted onto a stretcher, and placed in four-point restraints. The Hospital failed to provide documentation of a written physician restraint order.

The Nurse Violent or Self-Destructive Restraints Documentation, dated 9/18/22 at 7:00 P.M., indicated that nursing staff discontinued two (leg restraints) of the four-point physical restraints (tuff cuffs) for Patient #4; however, Patient #4 continued in seclusion. The Hospital failed to provide documentation of a written physician seclusion order.

The Nurse Violent or Self-Destructive Restraints Documentation, dated 9/18/22 at 8:00 P.M., indicated that Patient #4 continued in four-point physical restraints (tuff cuffs); however, Patient #4 continued in seclusion. The Hospital failed to provide documentation of a written physician restraint order, a written physician seclusion order, or a documented Restraint Event incident report.

The Nurse Violent or Self-Destructive Restraints Documentation, dated 9/18/22 at 10:00 P.M., indicated that nursing staff discontinued two (legs) of the four-point physical restraints (tuff cuffs) for Patient #4; however, Patient #4 continued in seclusion. The Hospital failed to provide documentation of a written physician seclusion order.

The Nurse Violent or Self-Destructive Restraints Documentation, dated 9/18/22 at 10:45 P.M., indicated that nursing staff discontinued Patient #4's physical restraint (left arm), and Patient #4 continued in seclusion. The Hospital failed to provide documentation of a written physician seclusion order, or a documented Restraint Event incident report.

The Restraint Event, dated 9/20/22 at 5:35 A.M. and the Nurse Violent or Self-Destructive Restraints Documentation, dated 9/20/22 at 5:48 A.M., indicated that staff placed Patient #4 in four-point physical restraints (tuff cuffs). The Hospital failed to provide documentation of a written physician restraint order.

The Physician's Free Text, dated 9/20/22 at 6:42 A.M., indicated Patient #4 was agitated required mechanical restraint. The Hospital failed to provide documentation of a written physician restraint order, or a documented Restraint Event (incident report).

Patient #4 was physically restrained on multiple instances during his/her Hospitalization in September 2022 without physician orders present; the Hospital failed to ensure the use of restraint was in accordance with the order of a physician or other licensed practitioner for Patient #4.

5. Review of Patient #8 presented to the Emergency Department (ED) in September 2022, on a Section 12 (involuntary transportation to a hospital) ordered by local law enforcement, after becoming physically aggressive with a family member at home, via emergency medical services (EMS) due to concerns of paranoia, psychosis, and a history of schizoaffective disorder.

The Nurse ED Note, dated 9/20/22 at 8:06 P.M. and the Physician's Free Text, dated 9/20/22 at 8:38 P.M., indicated Patient #8 became violent and was placed in a four-point restraint. The Hospital failed to provide documentation of a written physician restraint order, or a documented Restraint Event (incident report).

The Nurse Violent or Self-Destructive Restraints Documentation, dated 9/20/22 at 10:45 P.M., indicated that nursing staff discontinued Patient #8 leg restraints, but Patient #8 continued in two-point physical restraints (tuff cuffs). The Hospital failed to provide documentation of a written physician restraint order.

The Nurse Violent or Self-Destructive Restraints Documentation, dated 9/21/22 at 12:00 A.M., indicated that nursing staff discontinued Patient #8's four-point physical restraints, and Patient #8 continued in seclusion. The Hospital failed to provide documentation of a written physician seclusion order.

The Nurse Violent or Self-Destructive Restraints Documentation, dated 9/21/22 at 8:00 P.M. and the Restraint Event, dated 9/21/22 at 8:15 P.M. indicated that Patient #8 was placed in four-point physical restraints (tuff cuffs), and Patient #8 continued in seclusion. The Hospital failed to provide documentation of a written physician restraint order, or a written physician seclusion order.

The Nurse Violent or Self-Destructive Restraints Documentation, dated 9/21/22 at 11:30 P.M., indicated that nursing staff discontinued Patient #8's two-point arm physical restraints (tuff cuffs), but Patient #8 continued in seclusion. The Hospital failed to provide documentation of a written physician seclusion order.

The Nurse Violent or Self-Destructive Restraints Documentation, dated 9/22/22 at 8:30 A.M. and the Restraint Event, dated 9/22/22 at 8:33 A.M., indicated that Patient #8's was placed in four-point physical restraints (tuff cuffs), and Patient #8 continued in seclusion. The Hospital failed to provide documentation of a written physician restraint order, or a written physician seclusion order.

The Nurse Violent or Self-Destructive Restraints Documentation, dated 9/22/22 at 10:00 A.M., indicated that nursing staff discontinued Patient #8's four-point physical restraints (tuff cuffs), but Patient #8 continued in seclusion. The Hospital failed to provide documentation of a written physician seclusion order, or a documented Restraint Event incident report.

Patient #5 was physically restrained on multiple instances during his/her Hospitalization in September 2022 without physician orders present; the Hospital failed to ensure the use of restraint was in accordance with the order of a physician or other licensed practitioner for Patient #5.

Based on record review and interview, the Hospital failed to ensure orders for Haldol (an antipsychotic medication) as a chemical restraint were not written on an as needed basis (PRN) for two Patients (#7 & #8) out of a total sample of 10 patients.

Findings include:

Patient #7 was admitted to the Hospital Emergency Department on 8/31/22 with diagnoses of dementia dysregulation, Alzheimer's Disease, and a right had contusion; Patient #7 was transferred and admitted to an inpatient medical surgical unit.

Federal regulations indicate a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.

The Hospital policy titled "Use of Restraints", revised 1/29/2019, indicated the following:
-A chemical restraint as a drug or medication when it was used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.
-Orders must never be written as a standing order or on an as needed basis.

Review of Patient #7's medical record indicated on 9/9/22 around 7:00 P.M., Patient #7 became increasingly agitated, refused medications, and became increasingly aggressive. Patient #7 was restrained by security in his/her bed in his/her room. Physician #5 assessed Patient #7 and ordered 2mg (milligrams) intramuscular Haldol to be administered to Patient #7 for his/her safety and the safety of others on the unit, with the goal of attempting to minimize any further chemical restraint. A physician's order dated 9/9/22 indicated Haldol injection 2mg, intramuscular, every 6 hours PRN (as needed) for agitation. Further review of Patient #7's medical record indicated Patient #7 received 2 more doses of Haldol 2mg intramuscularly on 9/14/22 and 9/20/22 from the same PRN Haldol order from 9/9/22. On 9/22/22 the order for Haldol 2mg intramuscularly every 6 hours PRN was discontinued; Haldol 2.5 mg intramuscularly twice daily PRN for agitation was ordered.

During an interview with Physician #5 on 9/28/22 at 7:50 A.M., he said prior to administering any restraint other measures must first be attempted. He said medications ordered to be used for a chemical restraint (such as intramuscularly administered antipsychotics) should only be ordered for a one-time dose. He said if a RN (Registered Nurse) is concerned for the safety of a patient or others due to a patient's behaviors, a code gray should be called, and a physician should evaluate the patient. He said each time a chemical restraint is applied, it should be performed with a physician's evaluation of the patient and a physician's order. He said he did not intend to enter a standing PRN order for intramuscular Haldol for Patient #7 on 9/9/22.

The Hospital failed to ensure orders for Haldol (an antipsychotic medication) as a chemical restraint were not written on an as needed basis.




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2. Review of Patient #8's medical record indicated he/she involuntarily (Section 12, which was determined by law enforcement) presented to the Emergency Department (ED) in September 2022, with emergency medical services (EMS) after becoming physically aggressive with a family member at home. The Medical record indicated Patient #8 had paranoia, psychosis, and a history of schizoaffective disorder.

A Physician Order, dated 9/21/22 at 4:00 P.M., indicated Patient #8 was ordered a medication for chemical restraint, haloperidol lactate (Haldol) intramuscular (IM) (injection), five milligrams (mg), three times daily, as needed (PRN) for agitation.

Further review of Patient #8's medical record indicated he/she was administered the chemical restraint (Haldol) three times on an as needed basis: 9/21/22 at 7:53 P.M.; 9/23/22 at 8:30 A.M.; and 9/26/22 at 10:15 A.M.

During an interview on 9/28/22 at 7:50 A.M., Physician #5 said that a chemical restraint (such as intramuscularly administered antipsychotics) should only be ordered as a one-time dose. Physician #5 said that prior to administering a chemical restraint, a physician examination must be completed prior to providing a new restraint order, if appropriate.

During an interview on 9/28/22 at 9:35 A.M., the Nurse Manager said a patient cannot have a standing PRN order for a chemical restraint such as an intramuscular dose of Haldol.

The Hospital failed to ensure orders for Haldol (an antipsychotic medication) as a chemical restraint were not written on an as needed basis.

Based on record review and interview, the Hospital failed to ensure 1. Opportunities were identified for improvement and changes that will lead to improvement for the implementation of restraints for 5 Patients (#1, #5, #6, #7, #4) and 2. Actions were aimed at performance improvement to prevent injury for 1 Patient (#2) out of a total sample of 10 patients.

Refer to tag A-0283.

Based on record review and interview, the Hospital failed to ensure 1. Opportunities were identified for improvement and changes that will lead to improvement for the implementation of restraints for 6 Patients (#1, #4 #5, #6, #7, #8) and 2. actions were aimed at performance improvement to prevent injury for 1 Patient (#2) out of a total sample of 10 patients.

Findings include:

The Hospital Quality Assurance and Performance Improvement (QAPI) Plan, dated September 2021, indicated the following:
-The objective is to implement hospital-wide performance improvement and patient safety initiatives based on quality measure performance benchmarks.
-The Hospital uses analysis from safety event reporting, failure mode effect analysis, mortality review, peer and case review, and root cause analysis to identify and prioritize quality initiatives and opportunities for improvement.
-Hospital performance is measured and evaluated through clinical data management, internal and external reporting, and pay for performance contracts for financial incentives.

1A. Federal regulation indicated the use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law.

The Hospital policy titled "Use of Restraints", revised 1/29/2019, indicated the following:
-Physical Restraints are 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 the forced removal of clothing.
-Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. A patient who is physically restrained in an unlocked room does not constitute seclusion.
-A chemical restraint as a drug or medication when it was used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.
-An order must be obtained from a physician or physician assistant during or immediately after the restraint application. The person must provide a face-to-face evaluation within one hour of initiation.
-Orders must never be written as a standing order or on an as needed basis.

Patient #1 was admitted to the Hospital Emergency Department on 4/10/22 with diagnoses of Autism, ADHD, and psychiatric evaluation.

Review of Patient #1's medical record indicated Patient #1 was physically restrained in 4-point restraints without physician orders in the Hospital Emergency Department on 4/11/22, 4/12/22, 4/14/22, and 4/17/22.

Review of the Hospital's incident reports for Patient #1 indicated Patient #1 had been restrained on 4/11/22, 4/12/22, and 4/17/22.

During an interview with the Chair of Emergency Medicine on 9/27/22 at 8:59 A.M., he said there would not be a time when a physician would not be available in the Emergency Department. He said restraints can be ordered verbally but must be put in the electronic medical record by the physician after the patient is restrained.

During an interview with the Risk Manager on 9/28/22 at 1:30 P.M., she said Hospital staff enter incident reports into the Hospital's internal system and those reports become available to view on a dashboard for the system. She said she reviews the incident reporting system frequently. She said restraint incidents are entered into the internal system for tracking and trending purposes. She said the Clinical Nurse Specialist oversees the follow-up on the restraint reports submitted into the Hospital's internal system.

During an interview with the Clinical Nurse Specialist on 9/29/22 at 9:05 A.M., she said restraint incidents are entered into the incident reporting system and the Risk Manager sends the reports to her. She said she reviews the incident reports for restraints, then she reviews the corresponding medical record; she said her record review includes checking the physician's orders and flowsheets (assessments) for missed documentation. She said after she completes her review, she will email the Risk Manager and quality directors with her findings. She said she has observed in the past month in the Emergency Department that orders have not been in place for the use of restraints. She said she has also observed Registered Nurses (RN) continuing seclusion for patients when they are in 4-point restraints. She said she has informed the Emergency Department leadership regarding this information. She said corrective action/follow-up is usually done with unit leadership. She said she was not aware of Patient #1 being restrained multiple times without physician's orders.

Patient #1 was physically restrained multiple times without physician's orders and incidences of the physical restraint of the Patient were internally reported on multiple occasions, however, this had not been identified by the Hospital.

1B. Patient #5 was admitted to the Hospital Emergency Department on 4/11/22 with diagnoses of ETOH (alcohol) intoxication, agitation, and depression.

Review of Patient #5's medical record indicated Patient #5 was physically restrained on 4/11/22 and 5/12/22 without a physician's order and was placed in seclusion on 5/19/22 without a physician's order.

Review of Review of the Hospital's incident reports for Patient #5 indicated Patient #5 had been physically restrained on 4/11/22 and 5/12/22.

During an interview with the Chair of Emergency Medicine on 9/27/22 at 8:59 A.M., he said there would not be a time when a physician would not be available in the Emergency Department. He said restraints can be ordered verbally but must be put in the electronic medical record by the physician after the patient is restrained.

During an interview with the Risk Manager on 9/28/22 at 1:30 P.M., she said Hospital staff enter incident reports into the Hospital's internal system and those reports become available to view on a dashboard for the system. She said she reviews the incident reporting system frequently. She said restraint incidents are entered into the internal system for tracking and trending purposes. She said the Clinical Nurse Specialist oversees the follow-up on the restraint reports submitted into the Hospital's internal system.

During an interview with the Clinical Nurse Specialist on 9/29/22 at 9:05 A.M., she said restraint incidents are entered into the incident reporting system and the Risk Manager sends the reports to her. She said she reviews the incident reports for restraints, then she reviews the corresponding medical record; she said her record review includes checking the physician's orders and flowsheets (assessments) for missed documentation. She said after she completes her review, she will email the Risk Manager and quality directors with her findings. She said she has observed in the past month in the Emergency Department that orders have not been in place for the use of restraints. She said she has also observed Registered Nurses (RN) continuing seclusion for patients when they are in 4-point restraints. She said she has informed the Emergency Department leadership regarding this information. She said corrective action/follow-up is usually done with unit leadership.

Patient #5 was physically restrained twice without physician's orders and incidences of the physical restraint of the Patient were internally reported, however, this had not been identified by the Hospital.

1C. Patient #6 was admitted to the Hospital Emergency Department on 6/17/22 with a diagnosis of ETOH intoxication.

Review of Patient #6's medical record indicated Patient #6 was physically restrained on 6/17/22 and placed in seclusion without a physician's order.

Review of Review of the Hospital's incident reports for Patient #5 indicated Patient #5 had been physically restrained on 6/17/22.

During an interview with the Chair of Emergency Medicine on 9/27/22 at 8:59 A.M., he said there would not be a time when a physician would not be available in the Emergency Department. He said restraints can be ordered verbally but must be put in the electronic medical record by the physician after the patient is restrained.

During an interview with the Risk Manager on 9/28/22 at 1:30 P.M., she said Hospital staff enter incident reports into the Hospital's internal system and those reports become available to view on a dashboard for the system. She said she reviews the incident reporting system frequently. She said restraint incidents are entered into the internal system for tracking and trending purposes. She said the Clinical Nurse Specialist oversees the follow-up on the restraint reports submitted into the Hospital's internal system.

During an interview with the Clinical Nurse Specialist on 9/29/22 at 9:05 A.M., she said restraint incidents are entered into the incident reporting system and the Risk Manager sends the reports to her. She said she reviews the incident reports for restraints, then she reviews the corresponding medical record; she said her record review includes checking the physician's orders and flowsheets (assessments) for missed documentation. She said after she completes her review, she will email the Risk Manager and quality directors with her findings. She said she has observed in the past month in the Emergency Department that orders have not been in place for the use of restraints. She said she has also observed Registered Nurses (RN) continuing seclusion for patients when they are in 4-point restraints. She said she has informed the Emergency Department leadership regarding this information. She said corrective action/follow-up is usually done with unit leadership.

Patient #6 was physically restrained without a physician's order and the incidence of the physical restraint of the Patient was internally reported, however, this had not been identified by the Hospital.

1D. Federal regulations indicate a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.

Patient #7 was admitted to the Hospital Emergency Department on 8/31/22 with diagnoses of dementia dysregulation, Alzheimer's Disease, and a right had contusion; Patient #7 was transferred and admitted to an inpatient medical surgical unit.

Review of Patient #7's medical record indicated Patient #7 received a chemical restraint of Intramuscular Haldol (antipsychotic medication) on 9/9/22; a standing dose for an as needed (PRN) dose of Intramuscular Haldol was ordered on 9/9/22 and the Patient subsequently received two more doses of Haldol from this standing order.

Review of the Hospitals incident reports for Patient #7 indicated Patient #7 was physically restrained on 9/9/22. On 9/14/22, Patient #7 refused his/her medication and security staff assisted while the nursing staff administered medication (chemical restraint) to the Patient during a code gray due to aggressive behaviors. On 9/22/22 Patient #7 was aggressive again, and security staff intervened, and medication was administered to the patient by the nursing staff.

During an interview with Physician #5 on 9/28/22 at 7:50 A.M., he said prior to administering any restraint other measures must first be attempted. He said medications ordered to be used for a chemical restraint (such as intramuscularly administered antipsychotics) should only be ordered for a one-time dose. He said if a RN (Registered Nurse) is concerned for the safety of a patient or others due to a patient's behaviors, a code gray should be called, and a physician should evaluate the patient. He said each time a chemical restraint is applied, it should be performed with a physician's evaluation of the patient and a physician's order. He said he did not intend to enter a standing PRN order for intramuscular Haldol for Patient #7 on 9/9/22.

During an interview with the Risk Manager on 9/28/22 at 1:30 P.M., she said Hospital staff enter incident reports into the Hospital's internal system and those reports become available to view on a dashboard for the system. She said she reviews the incident reporting system frequently. She said restraint incidents are entered into the internal system for tracking and trending purposes. She said the Clinical Nurse Specialist oversees the follow-up on the restraint reports submitted into the Hospital's internal system.

During an interview with the Clinical Nurse Specialist on 9/29/22 at 9:05 A.M., she said restraint incidents are entered into the incident reporting system and the Risk Manager sends the reports to her. She said she reviews the incident reports for restraints, then she reviews the corresponding medical record; she said her record review includes checking the physician's orders and flowsheets (assessments) for missed documentation. She said after she completes her review, she will email the Risk Manager and quality directors with her findings. She said she had just reviewed Patient #7's reports on 9/29/22 (day of interview). She said it is not typical for standing orders to be placed for PRN intramuscular antipsychotic medications such as Haldol.

The Hospital failed to identify a standing order for a chemical restraint despite a restraint report being filed for Patient #7 on 9/9/22, and a medical/chemical restraint report being filed on 9/14/22.






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1E. Review of Patient #4's medical record indicated he/she presented to the Hospital Emergency Department (ED) in September 2022, with complaints of anxiety, hallucinations, and a history of bipolar disorder.

Review of Patient #4's medical record indicated he/she involuntarily presented to the Emergency Department (ED) in September 2022, with emergency medical services (EMS) after becoming physically aggressive with a family member at home. The Medical record indicated Patient #8 had paranoia, psychosis, and a history of schizoaffective disorder.

Review of Patient #4 ' s medical record indicated that staff physically restrained him/her eight times without a written physician physical restraint order on: 9/17/22 around 7:06 A.M.; 9/18/22 at 12:45 A.M., 7:20 A.M., 10:31 A.M., 4:02 P.M., 8:00P.M.; and 9/20/22 at 5:48 A.M., and 6:42?A.M.?

Further review of the medical record, dated 9/17/22 to 9/19/22, indicated Patient #4 was being continuously monitored while in seclusion (due to being a danger to him/herself and/or others); however, there was no documentation to support the Hospital obtained a written physician order to place Patient #4 in seclusion prior to 9/19/22 at 6:42 A.M.

Review of the Hospital ' s Restraint Events, dated 9/17/22 to 9/20/22, indicated that the Hospital failed to document a Restraint Event the following physically restraints applied to Patient #4: On 9/18/22 around 10:31 A.M., 8:00 P.M., 10:45 P.M., and 9/20/22 around 6:45 A.M.

The Hospital failed to identify that Patient #4 was placed in physical restraints and placed in seclusion, without a written physician restraint order, despite Restraint Event documentation being filed on 9/17/22, 9/18/22, and 9/20/22.

1F. Review of Patient #8 presented to the Emergency Department (ED) in September 2022, on a Section 12 (involuntary transportation to a hospital) ordered by local law enforcement, after becoming physically aggressive with a family member at home, via emergency medical services (EMS) due to concerns of paranoia, psychosis, and a history of schizoaffective disorder.

Review of Patient #8's medical record indicated that staff physically restrained him/her three times without a written physician physical restraint order on: 9/20/22 around 8:38 P.M., 9/21/22 around 8:15 P.M., and 9/22/22 at 8:30 A.M.

Further review of Patient #8's medical record indicated that an order for an as needed (PRN) chemical restraint (Haldol injection) was written for agitation by a physician on 9/21/22 at 4:00 P.M. The PRN Haldol was administered to Patient #8 three times by a registered nurse: 9/21/22 at 7:53 P.M.; 9/23/22 at 8:30 A.M.; and 9/26/22 at 10:15 A.M.

The Hospital failed to identify that Patient #8 was placed in physical restraints without a written physician restraint order, despite Restraint Event documentation being filed on 9/21/22 and 9/22/22. Additionally, the Hospital failed to identify a physician ordered an as needed chemical restraint for Patient #8.

2. Review of the Hospital policy titled "Heat and Cold Applications, use of", revised in July 2022, indicated the following:
-Excessive heat can damage tissue and cause burns.
-Use approved equipment only for purpose it was approved for.
-Do not allow patient to lie on a pack
-Direct heat treatment cannot be used on a patient at risk for hemorrhage (bleeding).
-Do not allow patients to use heat or cold therapy from home.
-Explain procedure to Patient and do not have a patient lie directly on a heating device because this reduces airspace and increases the risk of burns.
-Remove the device after 20 or earlier as ordered.

Patient #2 was admitted to the Hospital Emergency Department on 4/5/22 with a diagnosis of rectal bleeding and hemorrhoids and was subsequently admitted to the inpatient telemetry unit.

Review of Patient #2's medical record indicated a RN applied an electric heating pad brought in from the Patient's home to the Patient on 4/10/22; the electric heating pad was left under the Patient's back from 7:30 P.M. until 6:00 A.M. and the Patient sustained a burn to his/her back causing his/her skin to slough off in the affected area.

Review of the Hospitals incident reports for Patient #2 indicated Patient #2 sustained an electrical burn on 4/11/22 which required topical treatment.

During an interview with the Medical Surgical Nurse Manager on 9/28/22 at 9:35 A.M., she said the Hospital staff should not be using home electric heating pads to apply heat therapy to patients.

During an interview with the Risk Manager on 9/28/22 at 1:30 P.M., she said after the incident with Patient #2 the incident had been reviewed. She said a nursing practice alert had been sent to the Hospital nursing staff via email and the policy for use of heat had been revised. She said there was no tracking performed to ensure all nursing staff had reviewed the nursing practice alert sent in regard to the burn sustained due to the use of a non-hospital electric heating pad.

During an interview with the Clinical Nurse Specialist on 9/29/22 at 9:05 A.M., she said she had created the nursing practice alert that had been sent in April 2022 to the Hospital nursing staff regarding the burn sustained due to the use of a non-hospital electric heating pad. She said she did not have a method of tracking if nursing staff had reviewed the nursing practice alert or changes to the Hospital policy for application of heat to patients.

Based on record review and interview, the Hospital failed to ensure 1. licensed nurses providing services to patients adhered to the policies and procedures of the Hospital for 1 Patients (#2) and 2. Haldol (an antipsychotic medication) was administered in accordance with Federal regulations for two Patient (#7 & #8) out of a total sample of 10 patients.

Refer to tags A-0398 and A-0405.

Based on record review and interview, the Hospital failed to ensure licensed nurses providing services to patients adhered to the policies and procedures of the Hospital for 1 Patients (#2) out of a total sample of 10 patients; an electric blanket was applied to a patient's back by a registered nurse (RN) and the patient sustained a burn to his/her back prior to experiencing shock and transferring to the Intensive Care Unit (ICU).

Findings include:

Patient #2 was admitted to the Hospital Emergency Department on 4/5/22 with a diagnosis of rectal bleeding and hemorrhoids and was subsequently admitted to the inpatient telemetry unit.

Review of the Hospital policy titled "Heat and Cold Applications, use of", revised in July 2022, indicated the following:
-Excessive heat can damage tissue and cause burns.
-Use approved equipment only for purpose it was approved for.
-Do not allow patient to lie on a pack
-Direct heat treatment cannot be used on a patient at risk for hemorrhage (bleeding).
-Do not allow patients to use heat or cold therapy from home.
-Explain procedure to Patient and do not have a patient lie directly on a heating device because this reduces airspace and increases the risk of burns.
-Remove the device after 20 or earlier as ordered.

Review of Patient #2's medical record indicated a Physician's order dated 4/10/22 at to apply heat to the affected area back once. Patient #2's nursing progress note dated 4/10/22 at 4:57 P.M. indicated Patient #2 told the RN the K module heating pad applied to his/her back was not hot enough, and the pain in his/her back had not resolved; the nursing progress note failed to indicate a physician was notified the ordered heat to the Patient's back was ineffective and his/her pain had not resolved. Patient #2's nursing progress note dated 4/11/22 at 1:30 A.M. indicated Patient #2 skin had scattered bruising with no other abnormalities documented; the Patient reported 6/10 back pain and a heating pad had been applied, however, failed to indicate if the heating pad had been removed at all during the shift. Patient #2's Wound RN progress note dated 4/11/22 at 11:15 A.M. indicated Patient #2 had a large area of skin sloughing (dead tissue shedding) from his/her back after use of his/her own heating pad. Review of Patient #2's ICU H&P (History and Physical) indicated on 4/10/22 Patient #2 experienced burning in the middle to lower back due to sleeping on a heating pad brought in by a family member; the Patient was started on ciprofloxacin (antibiotic medication) for pseudomonas (infectious bacteria) coverage and Silvadene cream. The patient was admitted to the ICU with undifferentiated shock as his/her blood pressures had become hypotensive and temperature had dropped to 92.1 degrees Fahrenheit. There was a concern for hypovolemic versus septic verses cardiogenic shock. Patient #2 had a potential source of infection due to the new second-degree burn to the mid/lower back. Patient #2 expired on 4/14/22 with a diagnosis of undifferentiated shock.

Review of the Hospital investigation dated 4/12/22 indicated Patient #2's daughter had brought in his/her electric heating pad from home for the Patient, the heating pad had been plugged in and applied to the Patient, and he/she subsequently acquired an electrical burn. The investigation indicated on 4/10/22 the RN had applied the K thermia pad to the Patient's back around 2:00 P.M. The pad remained on Patient #2 for 20-30 minutes, then the Patient told the RN the pad was not hot enough, and the RN removed the pad. Patient #2's daughter brought his/her personal (electric) heating pad from home to the Hospital around 6:30 P.M. The RN covered the heating pad with a pillowcase and applied to Patient #2's back. The overnight RN assessed Patient #2 around 7:30 P.M.; the heating pad was in place on the patient's back and his/her skin was clear. During the investigation, the overnight RN said Patient#2 refused to turn and reposition on his/her side. On the morning of 4/11/22 at 6 A.M., the overnight RN said he did not see any changes to Patient#2's lower back; the Day RN assessed Patient #2 at 8:00 A.M., observed skin changes to Patient #2's back and notified the Physician. The investigation failed to indicate if the electric heating pad had ever been removed from Patient #2 nor if a physician was notified the Hospital heating pad was removed from the Patient and the Patient had his/her own electric heating pad applied to his/her back.

Further review of Patient #2's medical record failed to indicate any physician order for the use of Patient #2's home electric heating pad. Review of Patient #2's medical record also failed to indicate Patient #2 had ever refused to be repositioned by the Hospital staff, nor did the medical record indicate the electric heating pad had ever been removed from 7:30 P.M. on 4/10/22 to 6:00 A.M. on 4/11/22 (10.5 hours).

During an interview with the Medical Surgical Nurse Manager on 9/28/22 at 9:35 A.M., she said the Hospital staff should not be using home electric heating pads to apply heat therapy to patients.

The Hospital staff failed to apply heat to Patient #2's back as ordered by a physician according to the Hospital's policies and procedures.

Based on record review and interview, the Hospital failed to ensure Haldol (an antipsychotic medication) was administered in accordance with Federal regulations for two Patients (#7 & #8) out of a total sample of 10 Patients.

Findings include:

Patient #7 was admitted to the Hospital Emergency Department on 8/31/22 with diagnoses of dementia dysregulation, Alzheimer's Disease, and a right had contusion; Patient #7 was transferred and admitted to an inpatient medical surgical unit.

Federal regulations indicate a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.

The Hospital policy titled "Use of Restraints", revised 1/29/2019, indicated the following:
-A chemical restraint as a drug or medication when it was used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.
-Restraint or seclusion may only be used when less restrictive interventions have been determined ineffective.
-Orders must never be written as a standing order or on an as needed basis.
-When a restraint is applied that jeopardizes the immediate physical safety of the patient, staff member, or others, the patient must bee seen face-to-face within 1 hour by the physician.
-The physician will document the following at the time of the 1 hour face-to-face evaluation: the behavior that required the restraint, the patient's reaction to the restraint, the patient's medical and behavioral condition, and the need to continue or terminate the restraint.


Review of Patient #7's medical record indicated on 9/9/22 around 7:00 P.M., Patient #7 became increasingly agitated, refused medications, and became increasingly aggressive. Patient #7 was restrained by security in his/her bed in his/her room. Physician #5 assessed Patient #7 and ordered 2mg (milligrams) intramuscular Haldol to be administered to Patient #7 for his/her safety and the safety of others on the unit, with the goal of attempting to minimize any further chemical restraint. A physician's order dated 9/9/22 indicated Haldol injection 2mg, intramuscular, every 6 hours PRN (as needed) for agitation. On 9/14/22 Patient #7 was confused and agitated, tried to leave the medical surgical unit, and Haldol was administered intramuscularly at 5:55 P.M. The medical record failed to indicate a physician face to face encounter or evaluation occurred on 9/14/22 at the time the Haldol was administered; Patient #7's nursing progress notes failed to indicate any other interventions were attempted prior to administering the intramuscular Haldol. On 9/20/22, Patient #7 became agitated and aggressive, a code grey was called and Haldol 2mg was administered to the Patient intramuscularly at 4:39 P.M. Patient #7 was evaluated by a physician on 9/20/22 at 4:54 P.M. and the physician documented the patient does not have acute psych issues; the physician progress note dated 9/20/22 failed to indicate aggressive behaviors by Patient #7, nor any updated orders for Haldol.

During an interview with Physician #5 on 9/27/22 at 9:55 A.M., he said staff should try to de-escalate a patient with behaviors first. He said oral medication should be offered to the patient first and administer a medication intramuscularly if needed.

During an interview with Physician #5 on 9/28/22 at 7:50 A.M., he said prior to administering any restraint other measures must first be attempted. He said medications ordered to be used for a chemical restraint (such as intramuscularly administered antipsychotics) should only be ordered for a one-time dose. He said if a RN (Registered Nurse) is concerned for the safety of a patient or others due to a patient's behaviors, a code gray should be called, and a physician should evaluate the patient. He said each time a chemical restraint is applied, it should be performed with a physician's evaluation of the patient and a physician's order. He said he did not intend to enter a standing PRN order for intramuscular Haldol for Patient #7, and a RN should not administer an intramuscular dose of Haldol to restrain a patient without a physician evaluation.

During an interview with the medical surgical Nurse Manager on 9/28/22 at 9:35 A.M., she said other interventions should be attempted prior to implementation of physical or chemical restraint of an aggressive or behavioral patient. She said a patient cannot have a standing PRN order for a chemical restraint such as an intramuscular dose of Haldol.

The Hospital failed to ensure Haldol was administered as a chemical restraint to a Patient in accordance with federal regulations.





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2. Federal regulations indicate a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.

Review of Patient #8's medical record indicated he/she involuntarily (Section 12, which was determined by law enforcement) presented to the Emergency Department (ED) in September 2022, with emergency medical services (EMS) after becoming physically aggressive with a family member at home. The Medical record indicated Patient #8 had paranoia, psychosis, and a history of schizoaffective disorder.

Review of Patient #8's medical record indicated he/she involuntarily (Section 12, which was determined by law enforcement) presented to the Emergency Department (ED) in September 2022, with emergency medical services (EMS) after becoming physically aggressive with a family member at home. The Record indicated Patient #8 had paranoia, psychosis, and a history of schizoaffective disorder.

A Physician Order, dated 9/21/22 at 4:00 P.M., indicated Patient #8 was ordered a medication for chemical restraint, haloperidol lactate (Haldol) intramuscular (IM) (injection), five milligrams (mg), three times daily, as needed (PRN) for agitation.

Further review of Patient #8's medical record indicated he/she was administered the chemical restraint (Haldol) by nursing staff three times on an as needed basis: 9/21/22 at 7:53 P.M.; 9/23/22 at 8:30 A.M.; and 9/26/22 at 10:15 A.M.

During an interview on 9/28/22 at 7:50 A.M., Physician #5 said that a chemical restraint (such as intramuscularly administered antipsychotics) should only be ordered as a one-time dose. Physician #5 said that prior to administering a chemical restraint, a physician examination must be completed prior to providing a new restraint order, if appropriate.

During an interview on 9/28/22 at 9:35 A.M., the Nurse Manager said a patient cannot have a standing PRN order for a chemical restraint such as an intramuscular dose of Haldol.

The Hospital failed to ensure Patient #8 was administered chemical restraints in accordance with Federal Regulations.