HospitalInspections.org

Based on interview and record review the hospital failed to ensure a writen modification to the care plan was completed for 1 of 1 patient reviewed [Patient #1] who was physically restrained while receiving an injection of Geodon [antipsychotic medicaton] for combative behavior.

Findings Included:

Patient #1 an 80 year old female was admitted to the medical hospital on 03/09/10 at 22:45 PM for complaints of chest pain. The discharge summary dated 04/09/10 reflected, "on 03/10/10, she had an abnormal small to moderate area of ischemia involving the inferolateral segment and was taken for a cardiac catheterization by Dr...on 03/11/10 had a stent placed in the circumflex vein graft...patient was very anxious...did sometimes refuse medication...had episodes of crying and then smiling and did refuse medications for depression..."

The physician orders dated 03/13/10 timed at 043 [sic] reflected, "Geodon 20 mg [Milligrams] IM [Intramuscular] now."

The physician progress notes dated 03/13/10 untimed reflected, "seen for Dr...this AM...very anxious confused and belligerent yesterday per nursing staff...ecchymosis over right hand [IV site bruise]...currently calmer after Geodon yesterday..."

The MAR [Medication Administration Record] dated 03/13/10 timed at 05:05 AM Geodon 20 mg IM now...given right hip..."

The clinical documentation record dated 03/13/10 timed at 02:30 AM reflected, "Patient at nursing station yelling...walked patient back to her room and spoke with patient. Patient verbalized wanting to speak with police. Security called...at 03:45 AM patient discontinued left IV [Intravenous] on own, bruising at site without hematoma/bleeding...04:30 AM spoke with Dr ...regarding patients agitation and order received...at 05:00 AM officer in room with ...patient combative and yelling Geodon given...patient received hostile, defensive, and highly anxious ...patient having diverse moods crying and raising voice at nurse...refused any physician assessment...left forearm noted bruised and swollen...refuses x-ray...family notified."

The Incident/Accident report dated 03/13/10 timed at 05:59 AM reflected, RN #8 documented the following; "Patient very agitated yelling at nursing staff and treating nursing staff [RN #6], [RN#7]. [Staff #3] verbalized that it would not be tolerated. [Patient #1] hit [RN #8], and other nurses and [Staff #3] held patient to give Geodon shot. Patient has skin tear on left hand Intravenous Site. 4x4 and tape placed on site. Patient then called 911 and [RN #8] spoke with police officer on patient's phone and informed they would contact [Staff #3]...the incident was referred to [RN #4]."

The Restraint/Policy and Procedure with a revision date of 02/10 reflected, "1) The RN assessment includes; signs of injury associated with restraint ...psychological status including level of distress or agitation, mental status and cognitive functioning ...2) Revise the plan of care, treatment and services as needed...3) The plan of care clearly reflects a loop of assessment, intervention, and evaluation for restraint and medications...4) Physically holding a patient during a forced psychotropic medication procedure is considered a restraint. If the patient is in a physical hold, a second staff person is assigned to observe the patient to ensure safety and the patient ' s airway is no compromised..."

On 11/17/10 at approximately 2:30 PM RN #1 was asked to review Patient #1's medical record and the event report provided by the hospital. RN #1 verified Patient #1 was physically restrained and the hospital staff should have care planned the restraint.

Based on interview and record review, the hospital failed to ensure physician orders were obtained and/or written for a physical restraint for 1 of 1 patient reviewed [Patient #1]. Patient #1 was physically restrained by hospital personnel RN #7, RN #8 and Staff #9 while being administered an injection of Geodon 20 mg [Milligrams] for combative behavior.

Findings Included:

Patient #1 an 80 year old female was admitted to the Hospital on 03/09/10 at 22:45 PM for complaints of chest pain. The discharge summary dated 04/09/10 reflected, "on 03/10/10, she had an abnormal small to moderate area of ischemia involving the inferolateral segment and was taken for a cardiac catheterization by Dr...on 03/11/10 had a stent placed in the circumflex vein graft...patient was very anxious...did sometimes refuse medication...had episodes of crying and then smiling and did refuse medications for depression..."

The physician orders dated 03/13/10 timed at 043 [sic] reflected, "Geodon 20 mg [Milligrams] IM [Intramuscular] now." No restraint orders were found in Patient #1's medical record.

The physician progress notes dated 03/13/10 untimed reflected, "seen for Dr...this AM...very anxious confused and belligerent yesterday per nursing staff ...ecchymosis over right hand [IV site bruise]...currently calmer after Geodon yesterday..." No documentation was found which addressed a physical restraint.

The MAR [Medication Administration Record] dated 03/13/10 timed at 05:05 AM Geodon 20 mg [Milligrams] IM [Intramuscular] now...given right hip..."

The clinical documentation record dated 03/13/10 timed at 02:30 AM reflected, "Patient at nursing station yelling at...walked patient back to her room and spoke with patient. Patient verbalized wanting to speak with police. Security called...at 03:45 AM patient discontinued left IV [Intravenous] on own, bruising at site without hematoma/bleeding...04:30 AM spoke with Dr ...regarding patients agitation and order received...at 05:00 AM officer in room with ...patient combative and yelling Geodon given...patient received hostile, defensive, and highly anxious ...patient having diverse moods crying and raising voice at nurse...refused any physician assessment...left forearm noted bruised and swollen...refuses x-ray...family notified."

The Incident/Accident report dated 03/13/10 timed at 05:59 reflected, RN #8 documented the following; "Patient very agitated yelling at nursing staff and treating nursing staff [RN #6], RN#7]. [Staff #3] verbalized that it would not be tolerated. [Patient #1] hit [RN #8], and other nurses and [Staff #3] held patient to give Geodon shot. Patient has skin tear on left hand Intravenous Site. 4x4 and tape placed on site. Patient then called 911 and [RN #8] spoke with Police Officer on patient's phone and informed they would contact [Staff #3]...the incident was referred to [RN #4]."

The Restraint/Policy and Procedure with a revision date of 02/10 reflected, "1) An order for restraint is obtained from an LIP [Licensed Independent Practitioner]/physician who is responsible for the care of the patient prior to the application of the restraint. The order specifies clinical justification for the restraint, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release ...2)Physically holding a patient during a forced psychotropic medication procedure is considered a restraint. If the patient is in a physical hold, a second staff person is assigned to observe the patient to ensure safety and the patient's airway is not compromised..."

On 11/17/10 at 3:30 PM Staff #5 was interviewed. Staff #5 reviewed Patient #1's medical record. She stated the unit keeps a log of restraints and she reviews it. Staff #5 stated this case should have been logged in as a restraint and a physician order should have been written.

Based on interview and record review the hospital failed to ensure 1 of 5 patient records reviewed [Patient #1's] documented the use of physical restraints and monitoring the patient's condition during and after physical force was used to administer an injection of Geodon 20 mg [Milligrams] to Patient #1 for combative behavior.

Findings Included:

Patient #1 an 80 year old female was admitted to the medical Hospital on 03/09/10 at 22:45 PM for complaints of chest pain. The discharge summary dated 04/09/10 reflected, "on 03/10/10, she had an abnormal small to moderate area of ischemia involving the inferolateral segment and was taken for a cardiac catheterization by Dr...on 03/11/10 had a stent placed in the circumflex vein graft...patient was very anxious...did sometimes refuse medication ...had episodes of crying and then smiling and did refuse medications for depression ..." The discharge summary did not reflect Patient #1 was physically restrained while receiving a shot of Geodon.

The physician orders dated 03/13/10 timed at 043 [sic] reflected, "Geodon 20 mg [Milligrams] IM [Intramuscular] now." No restraint orders were found in Patient #1's medical record.

The physician progress notes dated 03/13/10 untimed reflected, "seen for Dr...this AM...very anxious confused and belligerent yesterday per nursing staff...ecchymosis over right hand [IV site bruise]...currently calmer after Geodon yesterday..." No documentation was found which addressed a physical restraint.

The MAR [Medication Administration Record] dated 03/13/10 timed at 05:05 AM Geodon 20 mg IM now...given right hip..."

The clinical documentation record dated 03/13/10 timed at 02:30 AM reflected, "Patient at nursing station yelling...walked patient back to her room and spoke with patient. Patient verbalized wanting to speak with police. Security called...at 03:45 AM patient discontinued left IV [Intravenous] on own, bruising at site without hematoma/bleeding...04:30 AM spoke with Dr ...regarding patients agitation and order received...at 05:00 AM officer in room with...patient combative and yelling Geodon given...patient received hostile, defensive, and highly anxious ...patient having diverse moods crying and raising voice at nurse...refused any physician assessment...left forearm noted bruised and swollen...refuses x-ray...family notified."

The Incident/Accident report dated 03/13/10 timed at 05:59 AM reflected, [RN #8] documented the following; "Patient very agitated yelling at nursing staff and treating nursing staff [RN #6, RN #8 and RN #7]. [Staff #3] verbalized that it would not be tolerated. Patient #1 hit [RN #8], and other nurses and [Staff #3] held patient to give Geodon shot. [Patient #1] has skin tear on left hand Intravenous Site. 4x4 and tape placed on site. Patient then called 911 and [RN #8] spoke with police officer on patient's phone and informed they would contact [Staff #3]...the incident was referred to [RN #4]."

The Restraint/Policy and Procedure with a revision date of 02/10 reflected, "1) An order for restraint is obtained from an LIP [Licensed Independent Practitioner]/physician who is responsible for the care of the patient prior to the application of the restraint. The order specifies clinical justification for the restraint, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release...2) Patients are assessed by an RN immediately after restraints are applied to assure safe application...3) The RN assessment includes; signs of injury associated with restraint...psychological status including level of distress or agitation, mental status and cognitive functioning...4) Revise the plan of care, treatment and services as needed...5) The plan of care clearly reflects a loop of assessment, intervention, and evaluation for restraint and medications...6) The medical record contains documentation of assessment for risk of restraint, restraint alternatives employed, determination of effectiveness/ineffectiveness of restraint alternatives, review of need for restraint, order for restraint, restraint application ...7) Physically holding a patient during a forced psychotropic
medication procedure is considered a restraint. If the patient is in a physical hold, a second staff person is assigned to observe the patient to ensure safety and the patient's airway is no compromised ...8) The application of force to physically hold a patient, in order to administer a medication against the patient's wishes, is considered restraint. The patient has a right to be free of restraint and also has a right to refuse medications, unless a court has ordered medication treatment...some patients my be medicated against their will in certain emergency circumstances...health care staff is expected to use the least restrictive method of administering medication to avoid or reduce the use of force, when possible. The use of force in order to medicate a patient, as with other restraint, must have a physician's order prior to the application of restraint [use of force]..."

On 11/17/10 at 3:30 PM Staff #5 was interviewed. Staff #5 reviewed Patient #1's medical record. She stated the unit keeps a log of restraints and she reviews the log. Staff #5 stated this case should have been logged in as a restraint and a physician order should have been written.

On 11/17/10 at approximately 2:30 PM RN #1 was asked to review Patient #1's medical record and the event report provided by the hospital. RN #1 verified Patient #1 was physically restrained and hospital staff should have documented the restraint, care planned and obtained orders.

On 11/18/10 at 10:30 AM RN #4 was interviewed. RN #4 was asked to review the event report and medical record for Patient #1. RN #4 stated she remembered the patient. The patient slapped the nurse and the staff had to given her a shot. RN #4 stated at the time of her review she felt the staff acted appropriately. She stated after reviewing the medical record with the surveyor and the hospital policy on restraints she realized the hospital staff should have obtained a restraint order and documented the restraint in the medical record.

On 11/18/10 at 11:00 AM Staff #3 was interviewed. Staff #3 was asked what he could remember about the incident with Patient #1. Staff #3 stated he was called by unit staff. He stated the patient was agitated, hit the nurse and needed to be administered a shot. He stated he could not remember how he held the patient down exactly. He stated she was restrained by him and two other hospital staff.

On 11/18/10 at 11:45 PM RN #6 was interviewed. RN #6 was asked if she remembered Patient #1. RN #6 stated she remembered Patient #1 hit RN #8. Staff #3 and RN #7 held Patient #1 down so she could give her a shot. RN #6 was asked whether the restraint was documented. RN #6 stated she was not the patient's nurse and she did not feel it was restraint. The surveyor reviewed the restraint policy with RN #6. RN #6 offered no response