HospitalInspections.org

Based on document review and interview, it was determined for 3 of 4 (Pt. #s 3, 8 and 9)clinical records reviewed for restraints, the Hospital failed to ensure the patients and their representatives were notified rights were being restricted.

Findings include:

1. Hospital policy #1680894 (last revised 07/2014), entitled, "Patient Rights Restriction - Notification" requires, "When a patient is placed in seclusion or restraints, the patient is to be notified that his/her rights are restricted... Nurse completes the Restriction of Rights Notice (see Form #158)... Nurse charts that Notice of Restriction of Rights Form is completed (even when no one is to be notified)... RN and/or Designee places original Restriction of Rights Notice in the chart..."

2. The clinical record of Pt. #3, reviewed on 09/16/15 at 9:45 A.M., included that Pt. #3 was a 10-year-old female admitted 08/10/15 with diagnoses of Bipolar Affective Disorder, Posttraumatic Stress Disorder, and rule out Attention Deficit Hyperactivity Disorder. The record included a physician's order dated 08/18/15 at 2:30 P.M. to give Zyprexa (antipsychotic) 5 mg by mouth, and if the patient refuses, give intramuscularly (by needle injection), for increased agitation. An entry dated 08/18/15 at 2:30 P.M. in the clinical record on the PRN[as needed] and STAT [immediately] Administration Record, included that Zyprexa 5 mg was administered intramuscularly to Pt. #3 for increased agitation. The record lacked documentation that a restriction of rights had been completed.

3. The clinical record of Pt. #8, reviewed on 09/16/15 at 9:45 A.M., included that Pt. #8 was a 11-year-old male admitted 08/06/15 with a diagnosis of Bipolar Affective Disorder, not otherwise specified. The record included a physician's order dated 08/20/15 at 6:30 P.M. to give Benadryl (antihistamine with sedative properties) 50 mg by mouth, and if the patient refuses, give intramuscularly (by needle injection), for increased agitation. An entry dated 08/20/15 at 6:30 P.M. in the clinical record on the PRN[as needed] and STAT [immediately] Administration Record, included that Benadryl 50 mg was administered intramuscularly to Pt. #8 for increased agitation. The record lacked documentation that a restriction of rights had been completed


27125


4. The clinical record of Pt. #9 was reviewed on 9/16/15. Pt. #9 was an 8 year old male admitted on 5/21/15 with the diagnoses of Bipolar disorder and attention deficit hyperactivity disorder. A physician's order dated 6/11/15 at 1:00 PM included, "give thorazine (antipsychotic) 25 mg (milligrams) PO (by mouth), if refused give Thorazine 25 mg intramuscularly for agitation." The PRN (as necessary) Administration Record included that Pt. #9 was given Thorazine 25 mg IM for aggression. The clinical record lacked documentation that a restriction of rights had been completed.

5. During an interview with the Chief Compliance/Nursing Officer (CCNO) on 09/16/15 at approximately 1:30- 2:00 P.M., the CCNO confirmed there was no documentation that a restriction of rights had been completed for Pt. #3, Pt. #8 or Pt. #9 for the above incidences.

Based on document review and interview, it was determined for 4 of 8 (Pt. #4, 9, 3 and 8) clinical records reviewed for patients on psychotropic medications, the Hospital failed to ensure consent was obtained to administer the medications.

Findings include:

1. Hospital policy titled, "Informed Consent Pediatrics & Adolescents (revised 6/2012)" required, "Nurse: Notifies the parent/legal guardian of the MD's order and requests verbal consent via the telephone to administer and titrate medication per physician's orders. Has second staff member verify with parent/guardian that consent has been given. Documents... "

2. The clinical record of Pt. #4 was reviewed on 9/16/15. Pt. #4 was a 7 year old female admitted on 9/15/15 with the diagnosis of suicidal ideation. A physician's order dated 9/15/15 at 8:00 PM included an order for Adderall (psychostimulant), Zyprexa (antipsychotic), and melatonin (help sleep). The nurse obtained a phone consent from Pt. #4's guardian; however, did not have a witness to the consent. Pt. #4 was administered these medications on 9/16/15 at 9:00 AM.

3. The clinical record of Pt. #9 was reviewed on 9/16/15. Pt. #9 was an 8 year old male admitted on 5/21/15 with the diagnoses of Bipolar disorder and attention deficit hyperactivity disorder. A physician's order dated 5/22/15 included orders for Risperdal (antipsychotic), Lithium (mood stabilizer) and Ritalin (stimulant). Per the "Patient Consent for Psychotropic Medications" form, the nurse obtained a phone consent from Pt. #9's father; however, did not have a witness to the consent. Pt. #9 was administered these medications on 5/23/15 at 9:00 AM.


15166


4. The clinical record of Pt. #3, reviewed on 09/16/15 at 9:45 A.M., included that was a 10-year-old female admitted 08/10/15 with diagnoses of Bipolar Affective Disorder, Posttraumatic Stress Disorder, and rule out Attention Deficit Hyperactivity Disorder (ADHD). The record included a "Patient Consent for Psychotropic Medications" dated 08/10/15. The Consent included documentation of verbal consent obtained by a nurse from Pt. #3's mother for Latuda (antipsychotic) and Depakote (anticonvulsant/mood stabilizer) on 08/10/15, and Lithium (mood stabilizer) on 08/20/15. The Consent lacked documentation of a witness' signature as required by policy/consent form 204. The record further included documentation that Pt. #3 received all 3 of the above medications prior to receipt of properly obtained informed consent.

5. The clinical record of Pt. #8, reviewed on 09/16/15 at 9:45 A.M., included that Pt. #8 was a 11-year-old male admitted 08/06/15 with a diagnosis of Bipolar Affective Disorder, not otherwise specified. The record included a "Patient Consent for Psychotropic Medications". The Consent included documentation of verbal consent obtained by a nurse from Pt. #8's mother for Focalin (psychostimulant for treatment of ADHD) dated 08/16/15, and Seroquel (antipsychotic) undated. The Consent lacked documentation of a witness' signature as required by policy/consent form 204. The record further included documentation that Pt. #8 received both of the above medications prior to receipt of properly obtained informed consent.

6. During an interview with the Chief Compliance/Nursing Officer (CCNO) on 09/16/15 and 09/17/15 at approximately 1:30 P.M.- 2:00 P.M., the CCNO stated she agreed there was no documentation of a witness' signature for the above mentioned verbal consents obtained by the nurse.

Based on document review and interview, it was determined for 1 of 3 (Pt. #3) clinical records reviewed for patients with orders for safety/precautions monitoring, the Hospital failed to ensure monitoring as ordered.

Findings include:

1. Hospital policy #1711822 (last revised 09/2013) entitled, "Precautions and Observations", was reviewed on 09/16/15. The policy required, "Sexual Acting Out (SAO)... may be instituted with a known history and/or demonstrated sexually problematic behavior... Behaviors to consider... Common identifiers... include... Interventions to consider... At the beginning of each shift the Unit Staff, verifies patients' observation level/precautions with census board. Observes patients and documents on the Patient Observation/Precautions Form... the whereabouts of each patient every 15 minutes or as indicated per Physician order..."

2. The clinical record of Pt. #3, reviewed on 09/16/15 at 9:45 A.M., included that Pt. #3 was a 10-year-old female admitted 08/10/15 with diagnoses of Bipolar Affective Disorder, Posttraumatic Stress Disorder, and rule out Attention Deficit Hyperactivity Disorder. The record included a physician's order dated 08/14/15 at 10:30 A.M. for SAO due to inappropriate comments and poor boundaries with male peers. The Patient Observation/Precautions Forms and progress notes lacked documentation that Pt. #3 was monitored on SAO precautions on the following dates and shifts: 08/14/15 (day and evening shifts), 08/15/15 (day, evening, and night shifts), and 08/25/15 (day and evening shift).

3. During an interview with the Chief Compliance/Nursing Officer (CCNO) on 09/16/15 at approximately 1:30 P.M., the CCNO stated she agreed there was no documentation that Pt. #3 was monitored on SAO precautions on the above dates and shifts.