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Based on policy review, case report review, medical record review, physician and staff interviews, the hospital failed to have a physician's order for the application of restrictive interventions for a patient and failed to perform a 1-hour face to face evaluation in 1 of 3 records reviewed. (Patient #2)

Request on 07/11/2023 for a Forced Medication policy revealed none was available.

Review of the policy RESTRICTIVE INTERVENTIONS, approval date 06/02/2022 revealed "...I. POLICY ...B. The use of restraint is in accordance with the order of a physician, physician assistant (PA) or nurse practitioner (NP) who is responsible for the care of the patient ... I. Violent/Self-destructive Restraint Orders ...2. The attending physician must be notified as soon as possible after the application of restraint if the attending physician did not order the restraint. 3. A face to face evaluation of the patient is to occur within one (1) hour of the application of restraint (even if the restraint is removed within 1 hour of application.) ... 5. The nursing supervisor/designee will see the patient, make a determination the restraint intervention is necessary and appropriate, assure the physician has been notified and that appropriate monitoring is in place...II. DEFINITION AND EXCEPTIONS A. A restraint is any manual method, physical or mechanical device...that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; ..."

Review on 07/12/2023 of Case Report dated 06/06/2023 at 1402 by Hospital Security Officer (HSO) #5 revealed (named) HSO#6 had radioed and requested assistance in ED (emergency department) room 18. "...The patient was being uncooperative and verbally acting out screaming at the top of his lungs. We placed the patient in room 18 so that (named NP#2) could talk with and assess the patient. RN (named RN #1) was assisting getting vitals and we stood by in the room. The patient would not cooperate or calm down. NP (named) ordered medication and we controlled the patient's body and limbs so that RN (named RN#8) could give him medications. After a room in the ED Behavioral Holding Area was available, we escorted the patient from room 18 to room 20. We continued to stand by until the medication took effect and the patient laid down and went to sleep. I cleared the call at 1402 hours..."

Review on 07/12/2023 of Case Report dated 06/07/2023 at 1449 by HSO #9 revealed "...On June 07, 2023 at approximately 1430 hours I, Sgt. (named -HSO#9) was standing by with aggressive IVC (involuntary commitment) patient (named-Patient#2) due to his combative and disruptive behavior...Numerous patients made comments to myself and RN (named-RN#1) about not feeling safe and feeling afraid because of (named -Patient #2) behavior...The patient refused medication, even after repeated attempts to verbally persuade him to take them. Officers and I (named-HSO#10) and (named-HSO#11) assisted in controlling the patient on the bed so that RN (named-RN#1) could administer the medications. Once she gave the medications, the patient was immediately released. Officers will continue to standby as the patient is a 'high risk for violence' patient..."

Review on 07/12/2023 of Case Report dated 06/07/2023 at 1532 by HSO #9 revealed "...On June 07, 2023, at approximately 1520 hours, I Sgt. (named -HSO#9) was standing by with aggressive patient (named-Patient#2) ...the patient continued his behavior, yelling and cursing at staff and threatening staff by states "explicit language"(sic). I was then told by RN (named RN#1) that the patient would be medicated again, when we entered the room to assist staff with administering the medicine the patient lunged off his bed toward me. He grabbed onto my vest and attempted to take me to the ground. Officers (named HSO#10 and HSO#11) were also present to assist and quickly assisted me in controlling the patient on the ground so the medication could be administered. Once the medication was administered, the patient still continued to fight and resist so officers held him until he calmed down (no more than five minutes). Once the patient calmed down, he was immediately released. Officers will continue to stand by as this is a 'high risk for violence' patient with an extensive history of assaulting staff. End of report."

Closed medical record review 07/11/2023 revealed Patient #2, a 32-year-old male patient who arrived via police custody under involuntary commitment (IVC-under court order) for a mental health evaluation on 06/06/2023 at 1307. Review of the ED Patient Care Timeline revealed Patient #2 was immediately roomed to ED-18. At 1309 Nurse Practioner (NP) #2 was assigned. At 1314 triage nurse, Registered Nurse (RN) #1 assigned patient acuity as ESI (emergency severity index) 2 (emergent) a note: "Mental Health Problem (Pt. (patient) comes in IVC from (named) police department. Pt. (patient) is psychotic at this time, screaming at staff at this time." At 1327 Verbal orders were given by NP #2 for Ativan (medication used for a sedative) 2mg (milligrams) injection Intramuscular, Droperidol (anti-psychotic/nausea medication) 2.5 mg injection IM and Benadryl (antihistamine/medication used for mild aggression) 50 mg IM, and were administered by the charge nurse, RN #3 to Patient #2 for violent behavior. Patient #2 was moved to the ED behavioral health unit at 1354, had a one-to-one sitter assigned at 1400, and a Tele psyche consult/evaluation completed by Medical Doctor (MD) #4 on 06/06/2023 at 1811 recommending "inpatient psychiatric hospitalization at this time for safety and stabilization." Review of the ED Provider Note dated 06/07/2023 at 0710 ED MD #14 revealed Patient #2 was in ED Observation, was stable at this time. At 1000 Sitter Checks by RN #1 "Yelling/crying/talking loudly*; No aggression noted." At 1056 medication Orders Placed by NP #2 for Droperidol 5mg injection, and Benadryl 25mg injection, at 1100 these medications were placed on "Medication Hold -reason: order parameters not met" 1100 Sitter Check by RN #1 "yelling/crying talking loudly*." 1300 Sitter Checks by RN #1 "Behavior observed: Pacing*." At 1448 Patient #2 behaviors started to escalate again, and at 1521 RN #1 gave Droperidol 5mg IM, and Benadryl 25mg IM per NP #2. At 1532 RN #1 again gave Benadryl 25mg IM, Zyprexa (medication used for mental disorders)10mg, and Ativan 2mg IM per order NP #2. Sitter checks occurred every 15 minutes, and RN #1 assessed and documented hourly Patient #2 in the post medication period. Review failed to reveal a physician's order for restrictive intervention-physical holds for forced medications on a violent patient and failed to reveal a 1-hour face to face evaluation was performed by a provider on 1. 06/06/2023 at 1327, and 2. 06/07/2023 at 1521 and 3. 06/07/2023 at 1532 for Patient #2. Patient #2 was transferred to an acute care psychiatric hospital on 06/09/2023 at 0639 with law enforcement escort.

Request to interview ED MD #14 revealed she was unavailable for interview.

Telephone interview on 07/12/2023 at 1045 with ED Nurse Practioner, NP #2 revealed she remembered the patient. "...I medicated him on 06/06/2023 because he was head butting the door. No one could get close to him. So, he could participate in his care, to calm him down, I was trying to understand what was wrong, not to sedate him. I was not present for the IM administration. I never witnessed holding him down. I signed out to the ED Physician at the end of my shift for the initial encounter. As for the next day, I did not establish care for this patient, he was having an issue, I was the provider available, I stepped back in the pod and saw him, and ordered more meds. I do not feel there was excessive force during my care 1300-1900 on 06/06/2023. I did not go see him again on 06/07/2023 after I ordered medications." Interview revealed NP #2 was not made aware Patient #2 had a physical hold with forced medication administration on 06/06/2023 or 06/07/2023. Interview revealed there was not a provider order for a restrictive intervention-physical hold for forced medications for a violent patient, or a 1-hour face to face evaluation completed by NP#2. Interview revealed hospital policy was not followed for Patient #2.

Interview on 07/12/2023 at 1150 with ED RN #1 revealed before for the first medication pass on 06/07/2023 she had tried all day to negotiate with Patient #2 and he continued to escalate. RN #1 had called the Tele Psyche Physician and was awaiting a return call when the patient shoved his bed up against the wall screaming causing another patient in the unit to start crying. "I called (named NP #2) for assistance, and she came and saw the patient and ordered medication. Security was present, and the patient sat on the bed, security lightly placed hands on him, so I could give the IM injection in the deltoid. I don't remember security taking him to the floor, I do remember I had to remove his bed from the room, and he was on a mattress. I did give him medications in the arm and the thigh again while officers were with me the second time on 06/07/2023. I did not witness excessive force on either day I cared for him..." Interview revealed RN #1 did not remember if she discussed a physical hold or forced medications with NP #2 for 06/07/2023. Interview revealed the patient was medicated for violent behavior. Interview revealed hospital policy was not followed for Patient #2.

Interview on 07/13/2023 at 1052 with ED Nurse Manager, RN #13 revealed "...We have a culture of teamwork. My expectation is to work within policy. We make the physician aware and get guidance. The charge nurse assists the RN with communicating with the MD when needed..." Interview revealed the ED RN should make the physicians aware when any restraint-physical hold or forced medication had occurred. Interview hospital policy was not followed for Patient #2.

Interview on 07/14/2023 at 1022 with the Chief Medical Officer revealed the expectation was for physicians to write an order for a restrictive intervention- physical hold when indicated. Interview revealed the physician would need to follow up on the patient within expected timeframes when treating a violent patient with forced medications. Interview revealed hospital policy was not followed for Patient #2.

NC00203462

Based on policy review, case report review, medical record review, and staff interviews the hospital failed to complete an incident report for a patient in a 3-person physical hold for forced medication in 1 of 3 records reviewed. (Patient #2).

Review on of the policy Care Event Reporting, revised 02/10/2022 revealed "...The purpose of this system is to identify patient safety issues, potentially compensable events and opportunities for improvement... (Named Health System) expects its employees to complete a CARE Event for any occurrence which occurs in the facility or on its premises that is not consistent with routine patient care or operation of the facility that either did or could directly result in injury to a patient or visitor. DEFINITIONS A. Event: 1) is any unexpected or unintended incident/accident/occurrence relating to patients, or visitors...PROCEDURE A. The person discovering, directly involved, or closest to the event should complete an online CARE Event Report within 24 hours..."

Review on 07/12/2023 of a Case Report dated 06/07/2023 at 1449 by HSO #9 revealed "...On June 07, 2023 at approximately 1430 hours I, Sgt. (named sergeant -HSO#9) was standing by with aggressive IVC patient (named-Patient #2) due to his combative and disruptive behavior...Numerous patients made comments to myself and RN (named-RN#1) about not feeling safe and feeling afraid because of (named -Patient #2) behavior...The patient refused medication, even after repeated attempts to verbally persuade him to take them. Myself and Officers (named-HSO#10) and (named-HSO#11) assisted in controlling the patient on the bed so that RN (named-RN #1) could administer the medications. Once she gave the medications, the patient was immediately released. Officers will continue to standby as the patient is a 'high risk for violence' patient..."

Review on 07/12/2023 of Case Report dated 06/07/2023 at 1532 by HSO #9 revealed "...On June 07, 2023, at approximately 1520 hours, I Sgt. (named sergeant -HSO#9) was standing by with aggressive patient (named-Patient#2) ...the patient continued his behavior, yelling and cursing at staff and threatening staff by states "I'll f__ you up". I was then told by RN (named RN#1) that the patient would be medicated again, when we entered the room to assist staff with administering the medicine the patient lunged off his bed toward me. He grabbed onto my vest and attempted to take me to the ground. Officers (named HSO#10 and HSO#11) were also present to assist and quickly assisted me in controlling the patient on the ground so the medication could be administered. Once the medication was administered, the patient still continued to fight and resist so officers held him until he calmed down (no more than five minutes). Once the patient calmed down, he was immediately released. Officers will continue to stand by as this is a 'high risk for violence' patient with an extensive history of assaulting staff. End of report."

Closed medical record review 07/11/2023 revealed Patient #2, a 32-year-old male patient who arrived via police custody under involuntary commitment (IVC-under court order) to the emergency room for a mental health evaluation on 06/06/2023 at 1307. Review of the ED (emergency department) Patient Care Timeline revealed Patient #2 was immediately roomed to ED-18. At 1314 triage nurse, Registered Nurse (RN) #1 assigned patient acuity as ESI (emergency severity index) 2 (emergent). On 06/06/2023 at 1811 a Telemedicine Psychiatrist consult/evaluation completed by Medical Doctor (MD) #4 recommending "inpatient psychiatric hospitalization at this time for safety and stabilization." Review of the ED Provider Note dated 06/07/2023 at 0710 ED MD #14 revealed Patient #2 was in ED Observation, was stable at this time. At 1000 Sitter Checks by RN #1 "Yelling/crying/talking loudly*; No aggression noted." At 1056 Medication Orders Placed by Nurse Practitioner (NP) #2 for Droperidol (medication used for psychotic behavior) 5mg injection, and Benadryl (medication used for treatment of behavior disorders) 25mg injection, at 1100 these medications were "Medication Hold -reason: order parameters not met" At 1100 Sitter Check by RN #1 "yelling/crying talking loudly*." 1300 Sitter Checks by RN #1 "Behavior observed: Pacing*." At 1448 Patient #2 behaviors started to escalate again, and at 1514 RN #1 wrote in ED Quick Updates: "Messaged Tele psych regarding meds (medications). I see he had his interview with Dr. (Named -MD #4) however due to continuous repeated behaviors we are needing PRNs (as needed medication) for him. He continues to cause disturbances and poses a threat to staff and other patients." At 1521 RN #1 gave Droperidol 5 mg (milligrams) IM (intramuscular), and Benadryl 25mg IM per NP #2 previously ordered. At 1532 RN #1 again gave Benadryl 25mg IM, Zyprexa (medication used to treat mental disorders) 10mg, and Ativan (medication used for a sedative) 2mg IM per order NP #2. Sitter checks occurred every 15 minutes, and RN #1 assessed and documented hourly Patient #2 in the post medication period. Review of the record failed to reveal a 3-person physical hold for forced medications on a violent patient had occurred on 06/07/2023 at 1521 and 06/07/2023 at 1532 for Patient #2. Patient #2 was transferred to an acute care psychiatric hospital on 06/09/2023 at 0639 with law enforcement escort.

Telephone interview on 07/12/2023 at 1045 with ED Nurse Practioner, NP #2 revealed she remembered the patient. Interview revealed once Tele psyche was consulted, they usually ordered medications for behavioral health patients. Interview revealed NP #2 was not assigned to Patient #2 on 06/07/2023 but responded when RN #1 requested help. Interview revealed "...I did not establish care for this patient, he was having an issue, I was the provider available, I stepped back in the pod and saw him, and ordered more meds... I did not see him again on 06/07/2023." Interview revealed NP #2 was not made aware Patient #2 had a physical hold with forced medication administration on 06/07/2023. Interview revealed NP #2 was not informed Patient #2 had a 3-person physical hold for forced medication on 06/07/2023.

Interview on 07/12/2023 at 1150 with ED RN #2 revealed that before for the first medication pass on 06/07/2023 she had tried all day to negotiate with Patient #2 and he continued to escalate. RN #2 had called the Tele psyche Physician and was waiting for a return call when the patient shoved his bed up against the wall screaming causing another patient in the unit to start crying. "I called (named NP #2) for assistance, and she came and saw the patient and ordered medication. Security was present, and the patient sat on the bed, security lightly placed hands on him, so I could give the IM injection in the deltoid (upper arm). I don't remember security taking him to the floor, I do remember I had to remove his bed from the room, and he was on a mattress. I did give him medications in the arm and the thigh again while officers were with me. I did not witness excessive force on either day I cared for him..." Interview revealed RN did not remember if she discussed physical hold and forced medications with NP #2. Interview revealed the patient was medicated for violent behavior. Interview revealed hospital policy for Care Event Reporting was not followed for Patient #2.

Interview on 07/13/2023 at 1052 with ED Nurse Manager, RN #13 revealed "...We have a culture of teamwork. My expectation is to work within policy. We make the physician aware and get guidance. The charge nurse assists the RN with communicating with the MD when needed..." Interview revealed the ED RN should make the physicians aware when any restraint-physical hold or forced medication had occurred and complete a Care Event Report when indicated. Interview revealed "...A Care Event Report should have been completed in this case..." Interview hospital policy was not followed for Care Event Reporting for Patient #2.

Interview on 07/14/2023 at 1021 with the Chief Nursing Officer revealed "...Anything out of the ordinary should be reported so that we can review the process to see if appropriate care was given, and if there were opportunities for improvement..." Interview revealed a Care Event Report should have been completed for Patient #2.

NC00203462