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Based on medical record/document reviews, observations and interviews, the facility failed to:

I. Protect patients' rights by failing to ensure that the use of manual restraints ("Physical Management") was clearly identified as restraint and that all requirements for patient evaluation during the use of manual restraints were followed for 2 of 3 patients added to the sample to evaluate the use of restraint (B1 and B2). Failure to identify and complete required documentation for manual restraint violates the patients' rights to safe treatment in the least restrictive manner possible, including the right to be free from restraint except to prevent immediate physical harm to self or others. (Refer to B125 Part I.)

II. Protect a patient's right to be free from restraints of any form that are not medically necessary, and protect the patient from the proposed use of a manual restraint as a coercive measure for 1 of 9 active sample patients (E7). This patient was threatened with the use of a manual restraint for the purpose of obtaining a blood test which he refused, and for which there was no indication of a life-threatening emergency. This failure places patients at unnecessary risk for physical and emotional harm from the use of restraint without first exhausting less restrictive measures. (Refer to B125 Part II)

Based on record review and interview, it was determined that for 6 of 6 active sample patients admitted after 1/10/11 (A1, A3, A4, E7, E12, E23 and H13), the hospital failed to provide psychiatric evaluations that reported concentration, memory functioning and/or intellectual functioning in measurable, behavioral terms which clearly reflected the patient's ability to function in those areas. This failure compromises the database from which diagnoses are determined and from which changes in response to treatment interventions can be measured.

Findings include:

A. Record review

1. Patient A1: In a Psychiatric Evaluation dated 1/19/11, memory was described as "she is unable to do formal testing due to sedation." Concentration had a checkbox marked as "Impaired due to excess sedation." Intellectual function had a checkbox marked as "deficits more due to sedation." There was no information describing what type of testing was used to determine the results. There was no evidence by the time of the survey (1/31/11) that formal testing had been performed after 1/19/11.

2. Patient A3: In a Psychiatric Evaluation dated 1/19/11, memory was described as "memory is intact as he is giving a good account of his history in a timely fashion." Intellectual function had a checkbox marked as "average." Concentration had a checkbox marked as "normal." There was no information describing what type of testing was used to determine the results.

3. Patient A4: In a Psychiatric Evaluation dated 1/19/11, intellectual function had a checkbox marked as "average." Concentration had a checkbox marked as "normal." There was no information describing what type of testing was used to determine the results.

4. Patient E7: In a Psychiatric Evaluation dated 1/26/11, memory was described as "patient wasn't able to remember dates from the past." Intellectual function had a checkbox marked as "average." There was no information describing what type of testing was used to determine the results.

5. Patient E12: In a Psychiatric Evaluation dated 1/13/11, concentration had a checkbox marked as "normal." Intellectual function had a checkbox marked as "average." There was no information describing what type of testing was used to determine the results.

6. Patient E23: In a Psychiatric Evaluation dated 1/14/11, concentration had a checkbox marked as "impaired-unable to recall three items." this is a test for memory, not concentration. Memory was described as "very sketchy memory of his lifetime events because of flight of ideas and tangentiality." There was no information describing what type of testing was used to determine the results.

7. Patient H13: In a Psychiatric Evaluation dated 1/10/11, concentration had a checkbox marked as "impaired-unable to recall three items." This is a test for memory, not concentration. Memory was described as "Confused about the timing of events and jumping from on topic to another." This is a description of concentration, not memory. There was no information describing what type of testing was used to determine the results.

B. Interview

In an interview on 2/1/11 at 11:30a.m. with the Acting Medical Director, the psychiatric evaluations noted above were reviewed. She agreed that there was not enough specificity in descriptions of the testing used for memory, concentration and intellectual function. She stated "This is all new to us and we're just now learning how to do this right."

Based on medical record/document reviews, observations and interviews, the facility failed to:.

I. Protect patients' rights by failing to ensure that the use of manual restraints ("Physical Management") was clearly identified as restraint and that all requirements for patient evaluation during the use of manual restraints were followed for 2 of 3 patients added to the sample to evaluate the use of restraint (B1 and B2). For both patients, documentation in the records revealed that manual holds had been ordered and used on the patients, but no further assessment of the restraint use and effect on the patient was documented in the record; interview revealed that staff did not view these episodes as requiring patient assessment after initiation of restraint. Failure to identify and complete required documentation for manual restraint violates the patients' rights to safe treatment in the least restrictive manner possible, including the right to be free from restraint except to prevent immediate physical harm to self or others.

II. Protect a patient's right to be free from restraints of any form that are not medically necessary, and protect the patient from the proposed use of a manual restraint as a coercive measure for 1 of 9 active sample patients (E7). This patient was threatened with the use of a manual restraint for the purpose of obtaining a blood test which he refused, and for which there was no indication of a life-threatening emergency. Interview with staff revealed that staff believed that, because the patient was involuntarily detained, the patient had also lost the right to refuse treatment for any medical procedure the facility wished to pursue. This failure places patients at unnecessary risk for physical and emotional harm from the use of restraint without first exhausting less restrictive measures.

III. Protect patients' rights by failing to ensure that the use of chemical restraints was clearly identified in hospital policy as restraint and that all requirements for patient evaluation during the use of chemical restraints were identified in the same hospital policy. This failure became evident in the documentation related to medication usage for 2 of 3 patients added to the sample to evaluate the use of restraint (B1 and B2). Failure to identify and complete required documentation for chemical restraint violates the patients' rights to safe treatment in the least restrictive manner possible, including the right to be free from restraint except to prevent immediate physical harm to self or others.
Findings include:

I. Failure to identify manual restraints

Patients B1 and B2

A. Document Review

1. Review of the State of Michigan Department of Community Health (DCH) Policy # 10.7.1 effective May 14, 2010 entitled, "Use of Restraints and Physical Management", revealed a definition for "Physical Management" which stated, "A technique used by staff as an emergency intervention to restrict the movement of a recipient by direct physical contact to prevent the recipient from harming himself, herself or others."

2. Review of the Kalamazoo Psychiatric Hospital "Protocol For DCH Policy 10.7.1 Subject: Use of Restraints and Physical Management" (undated) revealed that the use of Physical Management was not addressed within the protocol, nor were there "Implementation Standards" for the use of Physical Management.

B. Specific Patient Findings:

1. Review of patient B1's record revealed a nursing progress note on 1/17/2011 at 4:00p.m. which stated that Patient B1 was angry with his roommates for "...playing head games, I'm going to hurt someone." The progress note further stated that Patient B1 "refused p.o. meds and was given Zyprexa 10 mg at 1550 (3:50p.m.) with physical management by staff..." Review of the Doctor's Orders for Patient B1 revealed an order dated 1/17/2011 for "Zyprexa Zydis 10mg p.o. NOW for agitation if he refuses give Zyprexa 10mg IM. If he refuses IM med, may put hands on to give injection." Review of the patient's medical record revealed that the "physical management by staff" was not documented as a manual restraint.

2. Review of patient B2's record revealed. a nursing progress note on 1/06/2011 at 1:45p.m which stated "Physical management needed to cease consumers attempts to self harm...Haldol 10mg IM and Ativan 2mg IM ordered for severe agitation." Review of the Doctor's Orders for Patient B2 revealed an order dated 1/06/2011 for "Hands on to prevent self injurious behavior AEB: (As Evidenced By) grabbing each side of abdominal incision and attempting to pull apart. Haldol 10mg IM once now (with) Ativan 2 mg IM once now." Review of the patient's medical record revealed that the use of "physical management" was not documented as a manual restraint."

C. Interviews:

1. In interview on 1/31/2011 at 10:40a.m., the Acting Clinical Director stated that writing "hands on" orders allowed the staff to hold a patient to give a one-time injection. When asked why these holds were not considered manual restraints, the Acting Clinical Director stated, "We don't have a doctor in house 24/7, we [medical staff] are on call. If we have to consider 'hands on' as a manual restraint then we [medical staff] would be here all the time."

2. In interview on 1/31/2011 at 1:30p.m., RN 2 stated that "We don't treat 'hands on' as a restraint. I get a 'hands on' order when I talk with the doctor for a prn. That way, I don't have to get another (order) if the patient refuses the medication."

3. In interview on 1/31/2011 at 11:15a.m., RN 1 stated that, "We haven't been treating holding a patient to give an injection as a restraint."

4. In interview on 1/31/2011 at 3:30p.m., the DON stated that the Kalamazoo Psychiatric Hospital "Protocol For DCH Policy 10.7.1 Subject: Use of Restraints and Physical Management" (undated) was "the most current policy."
II. Failure to protect patients' rights to be free from restraint that is not medically necessary

A. Observation

On 1/31/11 at 10:45am, the surveyor overheard MD#2 requesting nursing staff to "Restrain [Patient E7] to get a blood draw." Nursing staff did not respond to the physician. The physician then stated to the nurses that he had been told "it's OK to do it; [medical director] said it was OK as long as I wrote the order." The physician began writing the orders. The nursing staff advised him that they weren ' t comfortable restraining a patient for a routine blood draw.

B. Interviews

1. Just prior to the observation noted above on 1/31/11, at 10:35a.m., Patient E7 stopped the surveyor in the unit hallway. He stated that he had been "misunderstood and mistreated" by his current physician and wanted to talk with the surveyor. He stated that he had been medically worked-up at a community hospital just prior to coming to the facility on 1/24/11. He stated that he had been told by physicians at the community hospital that his blood tests were all normal. He said that he did not want any more blood tests and stated, "I feel fine."

2. In an interview on 1/31/11 at 10:50a.m. regarding Patient E7, MD#2 stated "These are patients here against their will and we're (doctors) allowed by the courts to do any medical treatment we want; if the patient refuses then we can hold them for any test we want." When the surveyor asked if there was a policy for denying a patient's right to refuse medical treatment, MD#2 stated that he did not know of one. He stated, "The medical director said to do it this way, so I just order it this way." The surveyor asked MD#2 if he thought that the blood draw was an emergency procedure (which might justify ignoring the patient's wishes).MD#2 stated "No."

During the interview, the unit medication nurse informed MD#2 that another (non-sample) patient had refused the last dose of an antibiotic regimen for a sexually transmitted disease. MD#2 then stated, "Let's physically hold this patient to give him his meds because he is a danger to himself and others." The nurse refused, and the physician stated, "He (patient) could be a danger if he has sex with someone and isn't fully treated." The surveyor asked MD#2 if missing one dose of medication was an emergency requiring restraint; MD#2 stated "No."

3. In an interview on 1/31/11 at 11:10a.m., the Acting Medical Director stated that she believed "the court gives us the right to physically hold an involuntary patient for medications and (any) treatment if they refuse when the judge signs the commitment papers." The surveyor then inquired about manual holds for medication refusal. The Acting Medical Director stated, "We do it all the time with a physician's order to hold the patient and give IM (intramuscular) meds." The surveyor asked if this procedure was considered a manual hold and thus a restraint procedure. The Acting Medical Director stated that the medical staff would have to be at the facility "all the time" if it was seen as a restraint and they are only there from 8:00a.m. to 5:00p.m. The Director added, "The doctor on-call couldn't come into the hospital for that many restraints every night."

C. Record Review

Patient E7: Copies of records from E7's admission at the community hospital prior to E7's admission to the surveyed facility showed a complete blood count drawn on 1/24/11 that was within normal limits.

III. Failure to identify chemical restraints

A. Document Review:

1. In a review of the State of Michigan Department of Community Health (DCH) Policy # 10.7.1 effective May 14, 2010 entitled, "Use of Restraints and Physical Management", a part of the definition of "Restraint" was stated as "...a drug or medication when it is used as a restriction to manage the recipient's behavior or restrict the recipient's freedom of movement and is not a standard treatment or dosage for the recipient's condition."

2. Review of the Kalamazoo Psychiatric Hospital "Protocol for DCH Policy 10.7.1 Subject: Use of Restraints and Physical Management" (undated) revealed that Chemical Restraints were not addressed in the protocol nor were there "Implementation Standards" for the use of Chemical Restraints. Although this protocol was undated, during an interview on 1/31/2011 at 3:30p.m., the DON stated that it was "the most current policy."

B. Specific Patient Findings:

Patients B1 and B2

1. Review of the record of non-sample patient B1 revealed that on 1/17/2011 at 4:00p.m. a nursing progress note stated that Patient B1 was threatening to "beat" his roommate and quoted the patient as stating, "I've already served 13 years in prison, what is 6 more months on assault charges?" The progress note further stated that the patient was "given Zyprexa 10 mg at 1550" (3:50p.m.). Review of the Doctor's Orders for Patient B1 revealed an order dated 1/17/2011 for "Zyprexa Zydis 10mg p.o. NOW for agitation if he refuses give Zyprexa 10 mg IM..." Review of the Medication Reconciliation/Order Form dated 1/09/2011 at 2:35p.m. (the most current order form at the time), showed that it did not list Zyprexa Zydis, or Zyprexa as a current scheduled medication, nor was there an order written to add either medication to the patient's scheduled medications during the time frame between the date of the Medication Reconciliation/Order Form (1/09/2011) and the administration of the medication on 1/17/2011. After examining the medication record on 01/31/2011 at 3:15p.m., RN1 acknowledged that Patient B1 was not receiving Zyprexa Zydis or Zyprexa as a scheduled medication. Although Zyprexa was not a part of the scheduled medications for Patient B1, there was no documentation that showed the facility considered this as possibly a prn restraint order and that its use would need to be documented as a restraint.

2. Record review also revealed a nursing progress note on 1/28/2011 at 9:15p.m. which stated that Patient B1 had refused his 4:00p.m. and 8:00p.m. medications and was "threatening to get (another patient's name) in his sleep or come up behind him with a chair." The progress note further stated that the patient was given Haldol 10 mg IM and Ativan 2mg IM at 8:45p.m. and was "cooperative (with) injections." Review of the Doctor's Orders for Patient B1 revealed an order dated 1/28/2011 for "Haldol 10mg IM NOW and Ativan 2mg IM NOW due to agitation and threatening behavior." Review of the Medication Reconciliation/Order Form dated 1/24/2011 at 4:00p.m. (the most current order form at the time), showed that it did not list Ativan as a current scheduled medication (Haldol was listed), nor was there an order written to add Ativan to the patient's scheduled medications during the time frame between the date of the Medication Reconciliation/Order Form (1/24/2011) and the administration of the Ativan on 1/28/2011. After examining the Medication Administration Record on 02/01/2011 at 10:30a.m., RN3 acknowledged that Patient B1 was not receiving Ativan as a scheduled medication. Although Ativan was not a part of the scheduled medications for Patient B1, there was no documentation that showed the facility considered this as possibly a prn restraint order and that its use would need to be documented as a restraint.

3. Review of patient B2's record revealed a nursing progress note on 1/06/2011 at 1:45p.m which stated that Patient B2 was having "bad thoughts" and "grabbed both sides of her surgical abdominal incision and attempted to reinjure area by pulling incision apart." The progress note further stated that "Haldol 10mg IM and Ativan 2mg IM ordered for severe agitation" and "Consumer given IM injections by LPN (no name) and RN (M1) in bilat (bilateral) deltoids." Review of the Doctor's Orders for Patient B2 revealed an order dated 1/06/2011 for "Haldol 10mg IM once now (with) Ativan 2mg IM once now." Review of the Medication Reconciliation/Order Form dated 1/01/2011 at 5:15p.m. (the most current order form at the time), revealed that it did not list Haldol or Ativan as current scheduled medications, nor was there an order written to add either medication to the patient's scheduled medications during the time frame between the date of the Medication Reconciliation/Order Form (1/01/2011) and the administration of Haldol and Ativan on 1/06/2011. After examining the medication record on 2/01/2011 at 9:00a.m., RN1 acknowledged that Patient B2 was not receiving Ativan or Haldol as scheduled medications. Although Ativan and Haldol were not a part of the scheduled medications for Patient B2, there was no docuemtnation that showed the facility considered this as possibly a prn restraint order and that its use would need to be documented as a restraint.

C. Interviews:

1. In an interview on 2/01/2011 at 9:00a.m., when asked if chemical restraints were used in the facility, RN1 stated, "Yes but I don't think they [staff] call them as such."

2. In an interview on 2/01/2011 at 9:05a.m., when asked if chemical restraints were used in the facility, RN2 stated, "Yes and most of the time there is a hands on [by staff]."

3. In an interview on 2/01/2011 at 10:45a.m., when asked if chemical restraints were used in the facility, Physician 1 stated, "We use it if we have to and it's very common that we have to. We usually use Haldol, Ativan, Zyprexa or some other anti-psychotic to calm them [patients] down." When asked if this use was documented as a restraint, Physician 1 stated, "No."

4. In an interview on 2/01/2011 at 10:50a.m., when asked if chemical restraints were used in the facility, RN3 stated, "Yes, when someone is extremely hostile and agitated we do use medications for that. It is really a restraint but we don't have to do forms like a restraint. We do an incident report." When asked if this use was ever documented as a restraint, RN3 stated, "No we don't do that."

5. In an interview on 2/01/2011 at 11:15a.m., the Acting Clinical Director stated, "we don't follow the department policy (DCH Policy # 10.7.1). We adapted it to our hospital."

Based on record review, policy review and interviews, the hospital failed to ensure that progress notes were written with sufficient frequency to address the acuity level of 2 of the 8 active sample patients whose records were reviewed for progress note documentation (E12 and E23). This failure makes it difficult to follow the patients' progress toward achieving their treatment goals and can prevent other team members, particularly when the physician is not present at the facility, from accessing physician input about patient progress.

A. Record Review

1. Patient E12, admitted 1/10/11, had handwritten psychiatric progress notes dated 1/12/11 and 1/25/11. There were no weekly dictated treatment notes by the psychiatrist in the record.

2. Patient E23, admitted 1/7/11, had handwritten psychiatric progress notes dated 1/10/11 and 1/14/11. There were no weekly dictated treatment notes by the psychiatrist in the record.

B. Policy Review

Kalamazoo Psychiatric Hospital, "Rules and Regulations Relating to the Medical Staff Bylaws," dated and signed 8/4/10, notes the following on page 2 under the section titled "Medical Staff Responsibilities Relating to Medical/Psychiatric Care:" "C: The frequency of progress notes is once weekly for eight weeks and then at least once a month thereafter."

C. Interview

1. In an interview on 2/1/11 at 9:45a.m. with MD#3 (the attending physician for Patients E12 and E23), the medical records for each patient were reviewed. MD#3 was unable to locate or identify any weekly progress notes, written or dictated, for either patient. MD#3 then acknowledged that he had not completed any weekly notes for either patient.

2. In an interview on 2/1/11 at 11:30a.m. with the Acting Medical Director, the progress notes for Patients E12 and E23 were discussed. She agreed that weekly progress notes should have done by MD#3. The Acting Medical Director stated that psychiatrists are required to dictate a weekly treatment note for each patient, and that the dictated note is to be placed in the patient's chart under the treatment plan section.

Based on record review, policy review, observation and interviews, the Acting Medical Director failed to:

I. Ensure that physicians completed psychiatric evaluations that included the reporting of memory functioning and/or intellectual functioning in measurable, behavioral terms which clearly reflected the patient's ability to function in those areas for 7 of 7 active sample patients admitted to the facility after 1/07/11 (A1, A3, A4, E7, E12, E23 and H13). This failure to adequately monitor and supervise the medical staff in the completion of the mental status examination compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured. (Refer to B116)

II. Protect a patient's right to be free from restraints of any form that are not medically necessary. The Medical Director failed to ensure that the use of manual restraints ("Physical Management") was clearly identified as restraint and that all requirements for patient evaluation during the use of manual restraints were followed for 2 of 3 patients (B1 and B2) added to the sample to evaluate the use of restraint (Refer to B125 Part I). In addition, the Medical Director failed to protect 1 of 9 active sample patients (E7) from the proposed use of a manual restraint as a coercive measure. This patient was threatened with the use of a manual restraint for the purpose of obtaining a blood test which he refused, and for which there was no indication of a life-threatening emergency. This failure places patients at unnecessary risk for physical and emotional harm from the use of restraint without first exhausting less restrictive measures. (Refer to B125 Part II)

III. Protect patients' rights by failing to ensure that the use of chemical restraints was clearly identified as restraint in hospital policy and that all requirements for patient evaluation during the use of chemical restraints were identified in the same policy. This failure became evident in the documentation related to medication usage for 2 of 3 patients added to the sample to evaluate the use of restraint (B1 and B2). Failure to develop policy related to chemical restraint usage and ensure its proper implementation jeopardizes the patients' rights to safe treatment in the least restrictive manner possible, including the right to be free from restraint except to prevent immediate physical harm to self or others. (Refer to B125-III)

IV. Ensure that progress notes were written with sufficient frequency to address the acuity level of 2 of the 8 active sample patients whose records were reviewed for progress note documentation (E12 and E23). This failure makes it difficult to follow the patients' progress toward achieving their treatment goals and can prevent other team members, particularly when the physician is not present at the facility, from accessing physician input about patient progress. (Refer to B126)

Based on record review and interview, the Director of Nursing failed to monitor nursing practice to ensure that:

I. Manual holds were identified as a restraint and documented as such for 2 of 3 patients added to the sample to evaluate the use of restraints (B1 and B2). Failure to identify and complete required documentation for manual restraint violates the patients' rights to safe treatment in the least restrictive manner possible, including the right to be free from restraint except to prevent immediate physical harm to self or others.
Findings include:

A. Document Review

1. Review of the State of Michigan Department of Community Health (DCH) Policy # 10.7.1 effective May 14, 2010 entitled, "Use of Restraints and Physical Management," revealed the following definition for "Physical Management:" "A technique used by staff as an emergency intervention to restrict the movement of a recipient by direct physical contact to prevent the recipient from harming himself, herself or others."

2. Review of the Kalamazoo Psychiatric Hospital "Protocol For DCH Policy 10.7.1 Subject: Use of Restraints and Physical Management" (undated) revealed that the use of Physical Management was not addressed within the protocol, nor were there "Implementation Standards" for the use of Physical Management.

B. Specific Patient Findings

1. Review of the Doctor's Orders for Patient B1 revealed an order dated 1/17/2011 for "Zyprexa Zydis 10mg p.o. NOW for agitation if he refuses give Zyprexa 10mg IM. If he refuses IM med, may put hands on to give injection." On 1/17/2011 at 4:00p.m., a nursing progress note stated that Patient B1 was angry with his roommates for "...playing head games, I'm going to hurt someone." The progress note further stated that Patient B1 "refused p.o. meds and was given Zyprexa 10 mg at 1550 (3:50p.m.) with physical management by staff..." Patient B1 "began threatening staff (after) injection. Review of the patient's medical record revealed that the "physical management by staff" was not documented as a manual restraint.

2. Review of the Doctor's Orders for Patient B2 revealed an order dated 1/06/2011 for "Hands on to prevent self injurious behavior AEB: (As Evidenced By) grabbing each side of abdominal incision and attempting to pull apart. Haldol 10mg IM once now (with) Ativan 2 mg IM once now." On 1/06/2011 at 1:45p.m., a nursing progress note stated, "Physical management needed to cease consumers attempts to self harm...Haldol 10mg IM and Ativan 2mg IM ordered for severe agitation." Review of the patient's medical record revealed that the use of "physical management" was not documented as a manual restraint."

C. Interviews

1. In interview on 1/31/2011 at 10:40a.m., the Acting Clinical Director stated that writing "hands on" orders allowed the staff to hold a patient to give an injection. When asked why these holds were not considered manual restraints, the Acting Clinical Director stated "We don't have a doctor in house 24/7; we [medical staff] are on call. If we have to consider 'hands on' as a manual restraint then we [medical staff] would be here all the time."

2. In interview on 1/31/2011 at 1:30p.m., RN 2 stated "We don't treat 'hands on' as a restraint. I get a 'hands on' order when I talk with the doctor for a prn. That way, I don't have to get another (order) if the patient refuses the medication."

3. In interview on 1/31/2011 at 11:15a.m., RN 1 stated, "We haven't been treating holding a patient to give an injection as a restraint."

4. In interview on 1/31/2011 at 3:30p.m., the DON stated that the Kalamazoo Psychiatric Hospital "Protocol For DCH Policy 10.7.1 Subject: Use of Restraints and Physical Management" (undated) was "the most current policy."

II. The DON also failed to protect patients' rights by failing to ensure that the use of chemical restraints was clearly identified as restraint in hospital policy and that all requirements for patient evaluation during the use of chemical restraints were identified in the same policy. This failure became evident in the documentation related to medication usage for 2 of 3 patients added to the sample to evaluate the use of restraint (B1 and B2). Failure to develop policy related to chemical restraint usage and ensure its proper implementation violates the patients' rights to safe treatment in the least restrictive manner possible, including the right to be free from restraint except to prevent immediate physical harm to self or others. (Refer to B125-III)