HospitalInspections.org

Based on review of the Nonviolent Crisis Intervention - participant workbook, facility policy, medical records and interviews with facility staff, it was determined the nursing staff failed to assess patient psychiatric needs and ensure those needs were met in the least restrictive manner for psychiatric patients. This deficient practice affected 5 of 10 patient records reviewed, including Patient Identifier (PI) # 2, 3, 7, 10, 8 and had the potential to negatively affect all patients admitted to the Senior Behavioral Health Unit.


Findings include:

Nonviolent Crisis Intervention - Participant Workbook
Copywrite 2005

A Practical Approach for Managing Violent Behavior

Four Levels of Crisis Development

... The Anxiety Level

One of the first behaviors you observe in the crisis development sequence is the Anxiety level...

The Supportive Staff Response

During the Anxiety level, it is generally most effective to use a Supportive staff response. The supportive approach requires the staff to be empathic and actively listen to what is bothering the individual. In this mode of intervention, the staff member should avoid being judgmental and avoid dismissing the person as a "constant complainer" The individual who is in the Anxiety level does not need to be judged" she simply needs staff to listen.

Here is where most potentially explosive situations are defused. As human service providers intervene on a daily basis, they become very adept at offering support.

Facility Policy

04.001 - Patient Rights

1.0 Purpose: To ensure that care, treatment and services are provided in a way that respects and fosters dignity, autonomy, positive self-regard, civil rights, and involvement of patient...

3.0 Procedure

... F. The following patients rights are adhered to at all times on the unit:
1. A patient is provided with care, treatment, and services in the least restrictive environment in accordance with laws and regulations...


1. PI # 2 was admitted to the facility on 2/25/15 with Major Depression with psychotic features.

Review of the Patient Progress Note dated 2/26/15 at 11:09 AM, the Certified Nurse Assistant (CNA) documented the patient had been very rude and came out of group. The CNA instructed the patient to return to group and the patient said that he/she was going to his/her room. The Social Worker told the patient he/she could not take the cup to his/her room and the patient slammed the cup down and went to his/her room. The CNA further documented the patient returned and started yelling that he/she was a real bad diabetic and needed water. The CNA told the patient to lower his/her voice and the patient started yelling about the staff having an attitude and that he/she was leaving. There was no documentation of alternative interventions for the patient's behaviors, including re-direction or de-escalation of the patient's behaviors.

Review of the Senior Behavioral Care Unit 15 Minute Checks/ dated 2/26/15 revealed the Mental Health Technician (MHT) documented the following patient behaviors: 2:00 PM - sitting in the bedroom, 2:15 PM and 2:30 PM - eating in the dayroom, 2:45 PM - sitting in dayroom, 3:00 PM , 3:15 PM and 3:30 PM - walking in dayroom.

Review of the Patient Progress Note dated 2/26/15 at 3:00 PM revealed, the Registered Nurse (RN) documented, "...Increased agitation with orders rec'd (received per Dr. Strunk, given Haldol 5 mg (milligrams) and Ativan 2 mg IM (intramuscularly) X (times) 1 dose..." There was no documentation of alternative interventions, including re-direction or de-escalation for the patient's increased agitation.

Review of the Medication Administration Record (MAR) dated 2/26/15 at 3:00 PM, the patient received Haldol 5 mg (milligrams) and Ativan 2 mg IM (intramuscularly) for an undocumented reason. There was no documentation the nurse assessed the patient's behaviors or provided alternative interventions.

Review of the Patient Progress Note dated 2/27/15 at 2:22 PM, revealed the Licensed Practical Nurse (LPN) documented the patient, "... refused to attend group, raised voice to writer after she stated (he/she) needed to come to group... Pt (patient) is pacing the halls... Will cont. (continue) Plan of Care..." There was no documentation of alternative interventions, including re-direction or de-escalation of the patient's behaviors.

Review of the Patient Progress Note dated 2/27/15 at 3:39 PM, revealed the RN documented the patient followed directions, had a flat affect, was isolative/withdrawn, excessively worried, but, was easily redirected. On 2/27/15 at 20:39, the RN documented the patient's mood was calm/pleasant with intrusive behaviors, was having auditory and visual stimuli and had difficulty with directions and conversations. There was no documentation the nurse provided alternative interventions, including re-direction or de-escalation of the patient's behaviors.

On 2/27/15 at 20:50, the RN documented the patient was pacing in the hall with complaints of pain all over and Tylenol 650 mg was administered. On 2/27/15 at 9:20 PM, the RN documented the patient's pain had improved.

Review of the Physician's Orders dated 2/27/15 at 9:00 PM revealed orders for Librium 25 mg orally every 6 hours, PRN (as needed).

Review of the Senior Behavioral Care Unit 15 Minute Checks/1:1 Observation Check Sheet dated 2/27/15 revealed the MHT documented the patient was watching TV (television) in the Dayroom from 8:30 PM until 10:00 PM, at 10:30 PM and 10:45 PM the patient was lying on the bed in his/her room.

Review of the MAR dated 2/27/15 at 10:55 PM, revealed Librium 25 mg was administered for anxiety.

On 2/27/15 at 11:44 PM, the LPN documented the patient was resting quietly and at 11:45 PM, the LPN documented having given PRN (as needed) Librium, Tylenol. There was no documentation the nurse assessed the patient's behaviors or provided alternative interventions.

Review of the Patient Progress Note dated 2/28/15 at 1:21 PM, revealed the RN documented the patient was pleasant most of the time, by gets angry easily, paces the hallways at times, and could be easily redirected.

Review of the MAR dated 2/28/15 at 2:42 PM revealed Librium 25 mg was administered for anxiety. There was no documentation the nurse assessed the patient's behaviors or provided alternative interventions.

Review of the Patient Progress Note dated 2/28/15 at 7:24 PM, revealed the RN documented the patient was neatly groomed, appropriately dressed, followed conversations and directions, was moderately confused, discouraged with flat affect and had a broken sleep pattern.

Review of the Senior Behavioral Care Unit 15 Minute Checks/1:1 Observation Check Sheet dated 2/28/15 revealed the MHT documented the patient was watching TV (television) in the Dayroom from 8:30 PM to 10:30 PM.

Review of the MAR dated 2/28/15 at 10:00 PM revealed Librium 25 mg was administered for anxiety. There was no documentation the nurse assessed the patient's behaviors or provided alternative interventions.

Review of the Patient Progress Note dated 3/1/15 at 8:30 AM revealed the RN documented the patient was appropriately dressed, moderately confused, sad, isolative/fatigued, had a flat affect, had difficulty with directions at times, was excessively worried and was easily redirected.

Review of the MAR dated 3/1/15 at 10:11 AM revealed Librium 25 mg was administered for anxiety. There was no documentation the nurse assessed the patient's behaviors or provided alternative interventions.

Review of the Patient Progress Note dated 3/1/15 at 8:06 PM revealed the RN documented the patient was appropriately dressed, neatly groomed, followed conversation and directions, was calm/pleasant, tired/fatigued. had a flat affect, and was excessively worried and isolative/withdrawn, but was easily redirected.

Review of the Senior Behavioral Care Unit 15 Minute Checks/1:1 Observation Check Sheet dated 3/1/15 revealed the MHT documented the patient was watching TV (television) in the Dayroom from 8:30 PM to 10:00 PM.

Review of the MAR dated 3/1/15 at 8:55 PM revealed Librium 25 mg was administered for anxiety. There was no documentation the nurse assessed the patient's behaviors or provided alternative interventions.

An interview was conducted on 9/3/15 at 8:45 AM with Employee Identifier (EI) # 1, Social Worker who verified the above findings.

2. PI # 3 was admitted to the facility on 8/23/15 with diagnoses including Alzheimer's Dementia and Psychosis due to Organic Brain Disease. Review of the MAR revealed physician orders dated 8/23/15 at 10:10 PM for Haldol .25 mg (milligrams) orally twice a day, PRN.

Review of the Patient Progress Note dated 8/25/15 at 1:37 PM, the RN documented the patient was in the recliner sleeping off and on, when awake the patient got angry and wanted to get to his/her truck. When the nurse tried to explains that the patient's truck was at his/her house, the patient got angry and ripped wrist band off. The patient was constantly wanting to call spouse to come get him/her and he/she wanted to go home. The RN documented the patient was extremely confused. There was no documentation the RN provided alternative interventions for the patient including re-direction or de-escalation.

Review of the Patient Progress Note dated 8/25/15 at 2:00 PM the CNA documented having assisted the patient with personal care and became angry during his/her shower and tried to fight with the staff. The CNA further documented having grabbed the shower rod and broke it and started using foul language. There was no documentation the CNA attempted to provide alternative interventions, including re-direction or de-escalation.

Review of the MAR dated 8/25/15 at 9:30 PM revealed Haldol .25 mg was administered orally and the reason given was "Other". There was no documentation the nurse assessed the patient's behaviors or provided alternative interventions.

Review of the Patient Progress Note dated 8/27/15 at 10:21 AM revealed the RN documented the patient was neatly groomed, appropriately dressed, cooperative with activities of daily living (ADLs), was oriented to self only, was moderately confused, had difficulty with directions and conversations. The RN further documented the patient had poor impulse control, was excessively worried and was loud and had repetitive speech pattern and was difficult to redirect.

Review of the MAR dated 8/27/15 at 10:57 AM, revealed the patient received Haldol .25 mg orally for agitation. There was no documentation the nurse assessed the patient's behaviors or provided alternative interventions, including re-direction or de-escalation.

Review of the Patient Progress Note dated 8/28/15 at 2:59 PM revealed the RN documented the patient was sitting in a recliner at the nurses station. The patient was extremely groggy and unable to communicate. The patient was constantly trying to get up out to the chair, was difficult to redirect. The patient was placed in a wheelchair and took him/herself to his/her room and climbed in bed.

Review of the MAR dated 8/28/15 at 11:36 PM, revealed the patient received Haldol .25 mg orally for anxiety. There was no documentation the nurse assessed the patient's behaviors or provided alternative interventions, including re-direction or de-escalation.

Review of the MAR dated 8/29/15 at 9:54 PM revealed the patient received Haldol .25 mg orally for anxiety. There was no documentation the nurse assessed the patient's behaviors were assessed or provided alternative interventions, including re-direction or de-escalation.

Review of the MAR dated 8/30/15 at 9:11 AM revealed the patient received Haldol .25 mg orally for agitation. Review of the Patient Progress Note dated 8/30/15 at 9:22 AM revealed the Licensed Practical Nurse (LPN) documented the patient was at the nurse's station having increased agitation, resisting care and PRN Haldol was given. There was no documentation the nurse provided alternative interventions, including re-direction or de-escalation.

Review of the MAR revealed physician orders dated 8/30/15 at 11:45 AM for Haldol 2.5 mg (milligrams) orally every 6 hours, PRN.

Review of the Patient Progress Note dated 8/31/15 at 10:37 AM revealed the RN documented the patient was pacing in and out of his/her room and around the unit all day, was mumbling when he/she talked and was difficult to understand. The patient was compliant with medications, was difficult to redirect, but with staff constantly redirecting the patient was compliant with direction.

Review of the MAR dated 8/31/15 at 10:56 AM revealed the patient received Haldol 2.5 mg orally for anxiety. There was no documentation the nurse assessed the patient's behaviors were assessed or provided alternative interventions, including re-direction or de-escalation.

Review of the Patient Progress Note dated 8/31/15 at 9:32 PM revealed the RN documented the patient was easy to de-escalate after demanding to use the phone to call home, was medication compliant and was assisted with bedtime care, went to bed and was resting well.

Review of the MAR dated 8/31/15 at 11:49 PM, revealed the patient received Haldol 2.5 mg for anxiety. There was no documentation the nurse assessed the patient's behaviors or provided alternative interventions, including re-directing or de-escalation.

Review of the MAR dated 9/1/15 at 8:46 PM, revealed the patient received Haldol 2.5 mg orally for anxiety. There was no documentation the nurse assessed the patient's behaviors or provided alternative interventions, including re-directing or de-escalation.

An interview was conducted on 9/2/15 at 2:00 PM with EI # 5, Chief Quality Officer, who verified the above findings.

3. PI # 7 was admitted to the facility on 8/18/15 with diagnoses including Alzheimer's disease with mood disorder due to Organic Brain Disorder and Psychosis.

Review of the Senior Behavioral Care Unit 15 Minute Checks/ 1-1 Observation sheet dated 8/18/15 revealed the patient was in the dayroom during group activity from 7:30 PM to 8:30 PM, then in his/her bedroom sleeping at 8:45 PM.

Review of the MAR dated 8/18/15 revealed physician orders for Xanax .25 mg orally every 8 hours, PRN. Further review of the MAR dated 8/18/15 at 8:45 PM revealed the patient received Xanax .25 mg for anxiety. There was no documentation the nurse assessed the patient's behaviors or provided alternative interventions, including re-direction or de-escalation.

An interview was conducted on 9/3/15 at 8:40 AM with EI # 1, Social Worker, who verified the above findings.

4. PI # 10 was admitted to the facility on 8/27/15 with Bipolar Disorder, depressed phase. Review of the MAR dated 8/27/15 revealed physician orders for Klonopin .5 mg orally twice a day, PRN.

Further review of the MAR dated 8/29/15 at 8:44 PM revealed Klonopin .5 mg was administered orally for anxiety. There was no documentation the nurse assessed the patient's behaviors or provided alternative interventions, including redirection or de-escalation.

Review of the MAR dated 8/30/15 at 5:56 PM revealed Klonopin .5 mg was administered orally for anxiety. There was no documentation the nurse assessed the patient's behaviors or provided alternative interventions, including redirection or de-escalation.

Review of the MAR dated 8/31/15 at 10:33 AM and 9:12 PM revealed Klonopin .5 mg was administered orally for anxiety. There was no documentation the nurse assessed the patient's behaviors or provided alternative interventions, including redirection or de-escalation.

Review of the MAR dated 9/1/15 at 8:28 AM revealed Klonopin .5 mg was administered orally for anxiety. There was no documentation the nurse assessed the patient's behaviors or provided alternative interventions, including redirection or de-escalation.

An interview was conducted on 9/3/15 at 8:25 AM with EI # 5, who verified the above findings.




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5. PI # 8 was admitted on 7/22/15 with diagnoses including Alcoholic Hallucinosis and Persistent Alcoholic Dementia.

Review of the Physician Orders dated 7/22/15 revealed an order for Librium 25 mg every 6 hours as needed for DTs.

Review of the Patient Progress Note dated 7/23/15 revealed a nursing assessment at 10:03 AM by the RN who documented the patient had difficulty with direction at times, moderate confusion, agitated, excessively worried, and that he/she observed group only. The next nursing assessment was at 4:14 PM by the RN who documented "the patient sits quietly at times and then other times patient gets agitated. Patient will state that he is going home and that we have no right to keep him. Patient will come to desk and demand his medication. He will get angry when told that it is not time for his medication".

Review of the MAR revealed Librium 25 mg was administered at 4:01 PM and again at 9:40 PM for anxiety. There was no documentation of the patient's behavior resulting in the need for the medication nor was there documentation of alternative interventions implemented prior to administering the medication. There was no documentation of the patient's response to the medication.

Review of the Patient Progress Note dated 7/24/15 revealed an RN nursing assessment at 3:08 AM that stated "patient is isolative tonight, is confused to where he/she is, thinks he/she is in a nursing home, somatic reports pain and anxiety are increased, patient is difficult to get to follow conversation appropriately".

Review of the MAR dated 7/24/15 revealed Librium 25 mg at 9:03 AM for delirium tremens (DTs) (6 hours after the assessment). There is no documentation of the patient's behavior resulting in the need for the medication nor of alternative interventions implemented prior to administering the medication. There was no documentation of the patient's response to the medication.

Review of the Patient Progress Note dated 7/26/15 revealed an RN assessment note at 5:40 AM that documented "patient up once to use bathroom, needed assist back to bed, lethargic, sleeps rest of shift well".

Review of the MAR dated 7/26/15 revealed Librium 25 mg at 9:32 AM for anxiety. There is no documentation of the patient's behavior resulting in the need for the medication nor of alternative interventions implemented prior to administering the medication. There was no documentation of the patient's response to the medication. The next nursing documentation was at 11:40 AM. At 4:26 PM the RN documented "patient has been drowsy this shift but is easily arousable and vital signs are stable. Patient has had no aggressive behaviors today".

Review of the Patient Progress Note dated 7/27/15 revealed an RN assessment note at 10:08 AM that documented difficulty with direction, difficulty with conversations, sad, tearful, difficult to redirect at times, speech garbled, with sporadic program participation. Further review revealed an LPN note at 1:07 PM "prn Librium given per patient request". There is no documentation of the patient's behavior resulting in the need for the medication nor of alternative interventions implemented prior to administering the medication. There was no documentation of the patient's response to the medication.

Review of the MAR dated 7/27/15 revealed Librium 25 mg was administered at 11:26 AM for anxiety.

Review of the Patient Progress Note dated 7/28/15 revealed an RN assessment note at 3:39 PM "patient not as somatic today, attempts to make jokes with staff. Patient isolates self to room most of day. Would not get up and come out for lunch but patient did come to group".

Review of the MAR dated 7/28/15 revealed Librium 25 mg was administered at 3:48 PM for anxiety. There is no documentation of the patient's behavior resulting in the need for the medication nor of alternative interventions implemented prior to administering the medication. There was no documentation of the patient's response to the medication.

Review of the Patient Progress Note dated 8/2/15 revealed an RN assessment note at 11:15 AM that documented confusion: mild: easily re-oriented, flat affect, isolative/withdrawn, easily redirects, excessively worried, speech clear.

Review of the MAR dated 8/2/15 revealed Librium 25 mg was administered at 1:42 PM for anxiety. There is no documentation of the patient's behavior resulting in the need for the medication nor of alternative interventions implemented prior to administering the medication. There was no documentation of the patient's response to the medication.

Review of the MAR and Patient Progress Note dated 8/6/15 revealed Librium 25 mg was administered at 11:28 AM for anxiety. There is no documentation of the patient's behavior resulting in the need for the medication nor of alternative interventions implemented prior to administering the medication. The last nursing assessment documented prior to the medication administration was at 2:53 AM (8 hours prior). There was no documentation of the patient's response to the medication.

Review of the MAR dated 8/6/15 revealed Librium 25 mg was administered at 10:12 PM for anxiety. There was no documentation of the patient's behavior resulting in the need for the medication or alternative interventions implemented prior to administering the medication. Review of the Patient Progress Note dated 8/6/15 revealed the last nursing assessment prior to the 10:12 PM administration of Librium was at 2:54 PM (7 hours prior).

Review of the MAR and Patient Progress Note dated 8/7/15 revealed Librium 25 mg was administered at 10:29 AM for DT's. There was no documentation of the patient's behavior resulting in the need for the medication nor of alternative interventions implemented prior to administering the medication. The last nursing assessment prior to the medication administration was at 1:41 AM (9 hours prior).

Review of the MAR and Patient Progress Note dated 8/10/15 revealed Librium 25 mg was administered at 8:52 PM for anxiety. There is no documentation of the patient's behavior resulting in the need for the medication nor of alternative interventions implemented prior to administering the medication. The last nursing assessment prior to the medication administration was at 1:53 PM (7 hours prior). There is no documentation of the patient's response to the medication.

Review of the MAR and Patient Progress Note dated 8/11/15 revealed Librium 25 mg was administered at 3:56 PM for anxiety. There is no documentation of the patient's behavior resulting in the need for the medication nor of alternative interventions implemented prior to administering the medication. The last nursing assessment prior to the medication administration was at 08:43 (7 hours prior). There is no documentation of the patient's response to the medication.

An interview was conducted on 9/3/15 at 8:50 AM with EI # 5 who verified and agreed with the above findings.