HospitalInspections.org

Based on medical record and facility document review, the facility failed to provide evidence that less restrictive interventions were attempted prior to the use of a chemical restraints for one (1) of twenty (20) patient records sampled.

The findings include:

On January 22, 2025, a review of Patient #1's medical record was reviewed.

Patient #1 was transported by local law enforcement to this facility's Emergency Department (ED) on December 12, 2024 at 2:40 PM under an Emergency Custody Order (ECO) and a Temporary Detention Order (TDO) with a chief complaint of psychosis. A rapid initial assessment documented by an ED Registered Nurse (RN) on December 12, 2024 at 3:08 PM, indicated "pt acting erratically and having violent outbursts...Patient having incoherent rants and shouting. Patient will not follow instructions and is struggling against police officers".

The ED Provider Note documented on December 12, 2024 at 2:51 PM indicated that an ED physician ordered for Patient #1 "B-52 injection" to be used as a chemical restraint which included one (1) time intramuscular injection of 50 mg of Diphenhydramine HCL, 5 mg of Haloperidol and 2 mg of Lorazepam. Patient #1 was administered the injection to the left thigh on December 12, 2024 at 2:55 PM. Patient #1's medical record didn't contain documentation of any less restrictive interventions were considered or tried to protect the safety of patient, staff and others prior to administration of the injection.

A review of the facility's policy "Patient Restraint/Seclusion", last revised 7/2023, indicated in part: "...12. Documentation Requirements: The medical record contains documentation of...b. Restraint or seclusion alternatives employed...C. Drugs as restraints...A medication that is not being used as a standard treatment or in a dosage for the patient's medical or psychiatric condition and that results in controlling the patient's behavior and/or in restricting his or her freedom would be a drug used as a restraint...".

Based on interviews, medical record and facility document review, the facility failed to implement and document the safe and appropriate restraints techniques according to facility policy.

The findings include:

On January 22, 2025, the surveyor reviewed Patient #1's medical record.

Patient #1 was transported by local law enforcement to this facility's Emergency Department (ED) on December 12, 2024 at 2:40 PM under an Emergency Custody Order (ECO) and a Temporary Detention Order (TDO) with a chief complaint of psychosis. A rapid initial assessment documented by an ED Registered Nurse (RN) on December 12, 2024 at 3:08 PM, indicated "pt acting erratically and having violent outbursts...Patient having incoherent rants and shouting. Patient will not follow instructions and is struggling against police officers".

An ED Provider Note documented on December 12, 2024 at 2:51 PM indicated that an ED physician ordered for Patient #1 "B52 injection" which consisted of a one (1) time intramuscular injection of 50 mg of Diphenhydramine HCL, 5 mg of Haloperidol and 2 mg of Lorazepam. The ED physician documented the "meet and greet" time with Patient #1 was 2:48 PM and the ED Provider Note documented "...Patient is sedated on arrival". Patient #1 was administered the ordered B52 injection to the left thigh on December 12, 2024 at 2:55 PM by Staff Member #10. The medical record didn't document any details about the administration of the injection i.e. if Patient #1 was lying down, refused the injection, struggled, was held down, by whom.

The "Rapid Initial Assessment" was documented on December 12, 2024 at 3:08 PM by the ED RN and indicated "...Patient will remain injury free while patient is in restraint or seclusion: Yes...".

On December 12, 2024 at 4:31 PM, an ED RN documented Patient #1's vital signs.

On December 12, 2024 at 5:00 PM, it was documented that a cardiac monitor was placed on Patient #1.

On December 12, 2024 at 5:10 PM, an ED RN documented that Patient #1's pain level was zero (0) and vital signs were assessed.

On December 12, 2024 at 6:46 PM, an ED RN documented a detailed assessment to include a suicide screening, and a fall risk assessment. The ED RN documented a CIWA-AR (Clinical Institute Withdrawal Assessment for Alcohol Revised) indicating that Patient #1 had no visible sweat, no anxiety and that Patient #1 was "oriented". The CIWA-AR score was zero (0).

On December 12, 2024 at 10:21 PM, an ED RN documented Patient #1's vital signs.

On December 12, 2024 at 11:16 PM, an ED RN documented "Pt seen leaving with PD at this time. PD stating that they are taking (Patient #1)." The departure information noted that Patient #1 was taken to a receiving facility.

The following were not found Patient #1's medical documentation: lesser alternative methods attempted, a second tier review conducted by a member of nursing administration/management, signs of injury associated with the restraint, effectiveness/ineffectiveness of the patient's restraint, respiratory and cardiac status, psychological status, hydration/nutritional needs were met, hygiene needs were met, the patient's rights, dignity and safety were maintained, the patient's understanding of reasons for the restraint and that a trained staff member monitored the patient at least three (3) times an hour for safety.

On January 22, 2025 at 2:15 PM an interview was conducted with Staff Member #10. Staff Member #10 recalled that Patient #1 came to the ED fighting with the police officers and destroying property. Staff Member #10 explained that they were working as the Charge RN that evening and "pulled and gave the B-52" injection to Patient #1 who was lying down on a side. Staff Member #10 recalled that during the injection Patient #1's upper torso was held by the two (2) police officers in the room and one (1) of the facility's Emergency Medical Technicians (EMT) held Patient #1's leg. Patient #1 was not in handcuffs at the time of the administration of the medication. Staff Member #10 indicated that the medication took some time to take effect, so the cardiac monitor and assessment of Patient #1 was not completed until after Patient #1 was calmer. Staff Member #10 stated that typically patients who have been administered medications as a restraint were monitored every fifteen (15) minutes for the first hour, every 30 minutes and then hourly and that this information should be documented in the patient's medical record.

A review of the facility's policy "Patient Restraint/Seclusion", last revised 7/2023, indicated in part:
"...7. Monitoring the Patient in Restraints or Seclusion...
b. An RN will assess the patient at least every two hours. The assessment will include where appropriate:
1. Signs of injury association with restraint...
2. Respiratory and cardiac status,
3. Psychological status, including level of distress or agitation, mental status and cognitive function...
5. hydration/nutritional needs are being met,
6. Hygiene, toileting/elimination needs are being met,
7. The patient's rights, dignity, and safety are maintained,
8. Patient's understanding of reasons for restraint and criteria for release from restraint,
9. Consideration of less restrictive alternatives to restraint.
c. More frequent monitoring an notification of the ordering physician or licensed practitioner occurs when...
3. The level of patient agitation/distress at being placed in restraint as evidenced by an escalation of behavior...
d. A trained staff member monitors each patient in restraint or seclusion at least three times an hour for safety and to confirm that the patient's rights and dignity are maintained. This check will be documented in either electronic record or on paper...
e...1. Patients in restraints or seclusion who are restrained or secluded on a unit without continuous or frequent in-person observations (e.g., intermediate care, "stepdown", telemetry, medical/surgical, etc.) must have an individual performing and documenting real time, ongoing safety, rights, and dignity checks (minimally, to include: respiratory and circulatory status, skin integrity, etc.)...
Appendix D: Definitions...C. Drugs as restraints: 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, is considered a restraint...A medication that is not being used as a standard treatment or in a dosage for the patient's medical or psychiatric condition and that results in controlling the patient's behavior and/or in restricting his or her freedom would be a drug used as a restraint..."

Based on interviews, medical record and facility document review, the facility failed to document a physician's order prior to the initiation of a physical hold.

The findings include:

On January 22, 2025, surveyor reviewed Patient #1's medical record.

Patient #1 was transported by local law enforcement to this facility's Emergency Department (ED) on December 12, 2024 at 2:40 PM under an Emergency Custody Order (ECO) and a Temporary Detention Order (TDO) with a chief complaint of psychosis. A rapid initial assessment documented by an ED Registered Nurse (RN) on December 12, 2024 at 3:08 PM, indicated "pt acting erratically and having violent outbursts...Patient having incoherent rants and shouting. Patient will not follow instructions and is struggling against police officers".

ED Provider Note documented in Patient #1's medical record on December 12, 2024 at 2:51 PM indicated that ED physician ordered "B52 injection" which consisted of a one (1) time intramuscular injection of 50 mg of Diphenhydramine HCL, 5 mg of Haloperidol and 2 mg of Lorazepam. Patient #1 was administered the ordered B52 injection to the left thigh on December 12, 2024 at 2:55 PM by Staff Member #10. The medical record didn't document any details about the administration of the injection i.e. if Patient #1 was lying down, refused the injection, struggled, was held down, by whom. The medical record didn't include a physician order for a physical hold for the administration of a chemical restraint.

On January 22, 2025 at 2:15 PM an interview was conducted with Staff Member #10. Staff Member #10 recalled that Patient #1 came to the ED fighting with the police officers and destroying property. Staff Member #10 explained that they were working as the Charge RN that evening and "pulled and gave the B-52" injection to Patient #1 who was lying down on a side. Staff Member #10 recalled that during the injection Patient #1's upper torso was held by the two (2) police officers in the room and one (1) of the facility's Emergency Medical Technicians (EMT) held Patient #1's leg. Patient #1 was not in handcuffs at the time of the administration of the medication.

Review of the facility's policy "Patient Restraint/Seclusion", last revised 7/2023, indicated in part:
"...F. Physical Holding for Forced Medications: The application of force to physically hold a patient, in order to administer a medication against the patient's wishes, is considered restraint...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 the restraint (use of force)...".

Based on interviews, medical record and facility document review, the facility failed to provide evidence that a patient who was chemically restrained was monitored according to facility policy.

The findings include:

On January 22, 2025, surveyor reviewed Patient #1's medical record.

Patient #1 was transported by local law enforcement to this facility's Emergency Department (ED) on December 12, 2024 at 2:40 PM under an Emergency Custody Order (ECO) and a Temporary Detention Order (TDO) with a chief complaint of psychosis. The ED physician documented that the "meet and greet" time with Patient #1 was 2:48 PM. An ED Provider Note documented on December 12, 2024 at 2:51 PM included an order for chemical restraint that consisted of a one (1) time intramuscular injection of 50 mg of Diphenhydramine HCL, 5 mg of Haloperidol and 2 mg of Lorazepam. Patient #1 was administered the chemical restraint to the left thigh on December 12, 2024 at 2:55 PM by Staff Member #10.

The "Rapid Initial Assessment" was documented on December 12, 2024 at 3:08 PM by the ED RN and indicated "...Patient will remain injury free while patient is in restraint or seclusion: Yes...".

On December 12, 2024 at 4:31 PM, an ED RN documented Patient #1's vital signs.

On December 12, 2024 at 5:00 PM, it was documented that a cardiac monitor was placed on Patient #1.

On December 12, 2024 at 5:10 PM, an ED RN documented that Patient #1's pain level was zero (0) and vital signs were assessed.

On December 12, 2024 at 6:46 PM, an ED RN documented a detailed assessment to include a suicide screening, and a fall risk assessment. The ED RN documented a CIWA-AR (Clinical Institute Withdrawal Assessment for Alcohol Revised) indicating that Patient #1 had no visible sweat, no anxiety and that Patient #1 was "oriented". The CIWA-AR score was zero (0).

On December 12, 2024 at 10:21 PM, an ED RN documented Patient #1's vital signs.

On December 12, 2024 at 11:16 PM, an ED RN documented "Pt seen leaving with PD at this time. PD stating that they are taking (Patient #1)."

On January 22, 2025 at 2:15 PM Staff Member #10 explained in an interview that typically patients who have been administered medications as a restraint are monitored every fifteen (15) minutes for the first hour, every 30 minutes and then hourly and that this information should be documented in the patient's medical record.

A review of the facility's policy "Patient Restraint/Seclusion", last revised 7/2023, indicated in part:
"...7. Monitoring the Patient in Restraints or Seclusion...
b. An RN will assess the patient at least every two hours. The assessment will include where appropriate:
1. Signs of injury association with restraint...
2. Respiratory and cardiac status,
3. Psychological status, including level of distress or agitation, mental status and cognitive function...
5. hydration/nutritional needs are being met,
6. Hygiene, toileting/elimination needs are being met,
7. The patient's rights, dignity, and safety are maintained,
8. Patient's understanding of reasons for restraint and criteria for release from restraint,
9. Consideration of less restrictive alternatives to restraint.
c. More frequent monitoring and notification of the ordering physician or licensed practitioner occurs when...
3. The level of patient agitation/distress at being placed in restraint as evidenced by an escalation of behavior...
d. A trained staff member monitors each patient in restraint or seclusion at least three times an hour for safety and to confirm that the patient's rights and dignity are maintained. This check will be documented in either electronic record or on paper...
e...1. Patients in restraints or seclusion who are restrained or secluded on a unit without continuous or frequent in-person observations (e.g., intermediate care, "stepdown", telemetry, medical/surgical, etc.) must have an individual performing and documenting real time, ongoing safety, rights, and dignity checks (minimally, to include: respiratory and circulatory status, skin integrity, etc.) ...
Appendix D: Definitions...C. Drugs as restraints: 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, is considered a restraint...A medication that is not being used as a standard treatment or in a dosage for the patient's medical or psychiatric condition and that results in controlling the patient's behavior and/or in restricting his or her freedom would be a drug used as a restraint..."

The following were not found Patient #1's medical documentation: signs of injury associated with the restraint, effectiveness/ineffectiveness of the patient's restraint, respiratory and cardiac status, psychological status, hydration/nutritional needs, hygiene needs, maintenance of the patient's rights, dignity and safety, the patient's understanding of reasons for the restraint and monitoring of the patient by a trained staff member at least three (3) times an hour for safety.

Based on medical record and facility document review, the facility failed to document alternatives or less restrictive interventions were attempted prior to the use of restraints in one (1) of twenty (20) patients included in the survey sample.

The findings include:

According to the medical record Patient #1 was transported by local law enforcement to this facility's Emergency Department (ED) on December 12, 2024 at 2:40 PM under an Emergency Custody Order (ECO) and a Temporary Detention Order (TDO) with a chief complaint of psychosis. A rapid initial assessment documented by an ED Registered Nurse (RN) on December 12, 2024 at 3:08 PM, indicated "pt acting erratically and having violent outbursts...Patient having incoherent rants and shouting. Patient will not follow instructions and is struggling against police officers".

The ED Provider Note documented on December 12, 2024 at 2:51 PM indicated that ED physician ordered for Patient #1 "B-52 injection" to be used as a chemical restraint which included one (1) time intramuscular injection of 50 mg of Diphenhydramine HCL, 5 mg of Haloperidol and 2 mg of Lorazepam. Patient #1 was administered the injection to the left thigh on December 12, 2024 at 2:55 PM. Patient #1's medical record didn't contain documentation of any less restrictive interventions or alternatives were considered or attempted prior to administration of the injection.

A review of the facility's policy "Patient Restraint/Seclusion", last revised 7/2023, indicated in part: "...12. Documentation Requirements: The medical record contains documentation of...b. Restraint or seclusion alternatives employed...C. Drugs as restraints...A medication that is not being used as a standard treatment or in a dosage for the patient's medical or psychiatric condition and that results in controlling the patient's behavior and/or in restricting his or her freedom would be a drug used as a restraint...".