HospitalInspections.org

Based on a review of clinical records, review of hospital policies and procedures, hospital documentation and interviews, the hospital failed to protect and promote the rights of five (5) of eleven (11) patient's reviewed (Patients #1, 2, 4, 9, and 10) by failing to:

1. Ensure that consent for treatment was obtained from the next of kin when a change in condition was noted. (A-131)

2. Ensure that contraband was removed from the patient's possession in accordance with hospital policy. (A-144)

3. Ensure the clinical justification for administration of psychoactive medications. (A-160)

4. Ensure restraints utilized were the least restrictive intervention that would be effective to protect the patient or others from harm. (A-165)

5. Ensure restraints were applied based on a physician's order. (A-168)

6. Ensure that a qualified practitioner evaluated the patient in restraints within the stipulated timeframe. (A-179)

Based on a review of clinical records, hospital policies, and interview for one patient (Patient #1) that had a change in condition, the hospital failed to ensure that the next of kin designated in the record was contacted to discuss the patient's treatment options on the patient's behalf. The finding includes:

Patient #1 arrived at the ED on 2/23/14 at 9:59 A.M. with a chief complaint of congested cough, difficulty breathing and wheezing for the past three days. The patient was diagnosed with community acquired pneumonia, acute exacerbation of COPD, dyspnea and hypoxia and was admitted to the hospital. Review of the history and physical, dated 2/23/14 at 1:46 P.M., identified that Patient #1 requested full code status.

Record review and interview with the Registration Director and the ED Registration Manager, on 3/10/14 at 10:52 A.M., identified that during the ED registration process on 2/23/14 at 10:08 A.M. Patient #1 identified that s/he had not executed Advanced Directives, did not want information regarding Advanced Directives and listed Person #1 as the emergency contact (next of kin).

The Nursing Admission Assessment, dated 2/23/14 at 2:46 P.M., identified Patient #1 as alert and oriented to person, place and time, had not executed Advanced Directives and did not want information regarding Advanced Directives.

Record review and interview with MD #7, on 3/10/14 at 10:47 A.M., stated s/he telephoned Person #2 to obtain permission to place an invasive line for treatment when patient #1 had a change in medical status. Additionally, the patient's code status was discussed and changed from full code to do not resuscitate & do not intubate. MD #7 identified that s/he was aware that Person #1 was noted as the next of kin instead of Person #2.

Review of the Identification and Notification of Patient's Next of Kin policy identified that the term next of kin is used to describe the persons' closet living relative and the patient provides that information to the hospital.

Based on a review of clinical records, policy review, and interview, for 1 of 3 patient's reviewed for suicidal ideation (Patient #10) the hospital failed to ensure that contraband was removed from the patient's possession. The finding includes the following:

Patient #10 sent to the ED on 2/18/14 at 1:56 PM by his/her private physician for suicidal ideation (SI) without a plan. Review of the clinical record dated 2/18/14 at 2:27 PM identified that the patient changed into behavioral health clothing (e.g. johnny without strings). A nurse's note at 2:31 PM indicated that the patient was medically cleared, had a sitter assigned and was awaiting a bed in the psych ED. At 4:00 PM, a nurse's note identfied that a staff escorted the patient to the bathroom, the patient was found with cigarettes and a lighter (hidden in an undergarment) and subsequently became violent and hit a staff member. Interview with the ED Director on 3/10/14 at 1:00 PM stated that if a patient comes to the ED with SI, their clothing and belongings are removed and secured, however, the patient is allowed to keep their underwear. The hospital failed to remove all potentially harmful objects from the patient's possession to ensure safety.

Review of the Patient Observation Outside of Behavioral Health policy directed that street clothing, personal articles and potentially harmful objects are to be removed.

Based on review of clinical records, hospital policies and interviews for two of four patients (Patient #1 and 2) that received psychotropic medication, the hospital administered psychotropic medication without conducting a comprehensive assessment of the patient. Documentation failed to identify that least restrictive measures and/or alternative measures were tried and determined to be ineffective prior to administration of chemical restraints. Documentation further failed to specify the patient's specific behavior that posed a risk to self/others necessitating the use the chemical restraints. The findings include:

1. Patient #1 arrived at the ED on 2/23/14 at 9:59 A.M. with a chief complaint of congested cough, difficulty breathing and wheezing for the past three days. The patient was diagnosed with community acquired pneumonia, acute exacerbation of COPD, dyspnea and hypoxia and was admitted to the hospital.

a. Review of the clinical record with the Assistant Nurse Director of the Medical Intensive Care Unit (MICU) and the Medical Director of the Critical Care Unit and interview, on 3/10/14 at 12:35 P.M., identified a physician order dated 2/25/14 at 11:46 A.M. directed staff to administer Haldol 0.5 milligrams (mg) intravenously absent physician rationale/clinical justification and/or alternatives trialed. This medication was administered on 2/25/14 at 12:06 P.M.

b. Physician orders dated 2/26/14 at 10:00 A.M. directed staff to administer Haldol 0.5 mg and Haldol 2.5 mg intramuscularly (total of 3 mg administered) absent physician rationale/clinical justification and/or alternatives trialed. These medications were administered on 2/26/14 at 10:00 A.M.

c. Physician orders dated 2/26/14 at 1:00 P.M. directed staff to administer Haldol 2.5 mg and Ativan 2 mg intramuscularly absent physician rationale/clinical justification and/or alternatives trialed. These medications were administered on 2/26/14 at 1:20 P.M.

Review of the physician progress notes during this period of time identified that Patient #1 required the medications for agitation. Interview with the Medical Director of the Critical Care Unit, on 3/10/14 at 12:35 P.M., identified that the physician is not required to document the indication for the identified medications. Review of the physician progress notes during this period of time identified that Patient #1 required medications for agitation (not described).


2. Patient #2 arrived at the Emergency Department (ED) on 3/4/14 at 11:21 P.M. on a police emergency evaluation request (PEER) following an verbal outburst at home with a past medical history that included bipolar disorder and substance abuse. Patient #2 was diagnosed with anxiety disorder and drug abuse.


a. Review of RN #2's note dated 3/5/14 at 10:30 A.M. identified the patient was restless (not described), yelling at staff and visitors as they walked by, had a sitter at the bedside, the physician was notified and the patient was medicated. The physician's order dated 3/5/14 at 10:30 A.M. directed staff to administer Ativan 2 mgs and Haldol 5 mgs intramuscularly for nursing judgment. Interview with RN #2, on 3/6/14 at 10:00 A.M., stated although the sitter was with the patient, s/he did not direct/suggest alternative interventions in an effort to calm the patient prior to the administration of medication. The hospital administered chemical (medication) restraints without conducting a comprehensive assessment of the patient including documentation of alternative measures tried and specific behaviors that posed a risk to self/others that warranted the administration of chemical restraints.

Record review and interview with the Administrative Manager of Behavioral Health, on 3/6/14 at 9:05 A.M., lacked rationale for the medications from the ordering physician. Interview with the Medical Director of the ED identified the ordering physician was not available for interview and stated based on the record review; the patient had escalating behaviors per nursing staff.

b. Review of a physician's order dated 3/6/14 at 4:30 A.M. directed staff to administer Ativan 1 mg by mouth as needed for anxiety. The record reflected that Patient #2 requested medication for sleep and RN #3 administered Ativan. RN #3 failed to administer medication as intended and was unavailable for interview.

Review of the hospital policy and procedure, titled Medication Management and Documentation, identified that all medications will be administered in accordance with the practitioner order.

Review of the policy and procedure, titled Restraint and Seclusion, identified in part, that restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member or others. A comprehensive assessment of the patient must determine that the risks associated with the use of the restraint are outweighed by the risk of not using it, whether a less restrictive device or intervention could offer the same benefit at less risk. Alternatives to restraint must be considered prior to the application of restraint. Documentation in the patient's medical record for each episode of restraint use includes in part, clinical justification for use, clinical oversight, circumstances/behavior leading up to each use, alternatives tried or considered, and rationale for type.

Review of the policy and procedure, titled Restraint and Seclusion, identified that a restraint includes use of medication when it is used as a restriction to manage the patient's behavior to restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.

Based on a review of clinical records, policy review, and interview, for four of eleven patients (Patient #1, 2, 9, and 10) documentation failed to reflect that least restrictive measures were tried and determined to be ineffective prior to the implementation of restraints. The findings include the following:

1. Patient #1 arrived at the ED on 2/23/14 at 9:59 A.M. with the complaint of congested cough, difficulty breathing wheezing for the past three days with a medical history that included congestive heart failure with pacemaker and defibrillator insertion, Chronic Obstructive Pulmonary Disease (COPD) with past history of cigarette smoking, hypertension, respiratory failure with pneumonia, anemia, carotid stenosis and status post myocardial infarction. The patient was diagnosed with community acquired pneumonia, acute exacerbation of COPD, dyspnea and hypoxia and was admitted to the hospital.

a. Record review with the Assistant Nurse Director of the Medical Intensive Care Unit (MICU) and interview, on 3/10/14 at 12:35 P.M., identified that during the period of 2/26/14 at 7:09A.M. to 2/27/14 at 11:16 A.M., Patient #1 was placed in bilateral wrist restraints and/or four-point soft restraints with rationale for restraints documented as Medical/ Surgical. Non-specific behaviors exhibited by the patient during this period of time included agitation, restless, combative, irritable, and sleeping. Documentation failed to reflect a physicians order for these restraints and/or that less restrictive measures were tried and determined to be ineffective prior to the implementation of restraints.

b. Record review and interview with the Assistant Nurse Director of the MICU on 3/10/14 at 12:35 P.M., identified a physician order, dated 2/26/14 at 6:39 A.M., that directed staff to maintain a soft belt and left wrist restraint for the patient due to interference with medical devices/tubes/dressings. The Assistant Nurse Director of the MICU and/or hospital administration was unable to identify what a "soft belt" restraint was and/or how this device was utilized to prevent interference with medical devices.


2. Patient #2 arrived at the Emergency Department(ED) on 3/4/14 at 11:21 P.M. on a police emergency evaluation request (PEER) following a verbal outburst at home with a past medical history that included bipolar disorder and substance abuse. Patient #2 was diagnosed with anxiety disorder and drug abuse. Review of RN #2's note dated 3/5/14 at 10:30 A.M. identified the patient was restless (not described), yelling at staff and visitors as they walked by, had a sitter at the bedside, the physician was notified and the patient was medicated. The physician's order dated 3/5/14 at 10:30 A.M. directed the staff to administer Ativan 2 milligrams (mg) and Haldol 5 mg intramuscularly for nursing judgment. Interview with RN #2, on 3/6/14 at 10:00 A.M., stated although the sitter was with the patient, s/he did not direct/suggest alternative interventions in an effort to calm the patient prior to the administration of medication. Documentation failed to reflect that less restrictive measures were tried and determined to be ineffective prior to administration of psychotropic medications.

3. Patient #9 presented to the ED on 2/22/14 at 5:39 PM with paranoia and psychosis. The clinical record indicated that at 6:38 PM the patient was screaming, yelling, and threatening staff. The nurse's note indicated that security was present and the patient was placed in four-point locked restraints, medicated as ordered and had a 1:1 sitter assigned to the patient. Review of the LIP face to face evaluation dated 2/22/14 at 6:10 PM indicated the "patient was at risk to self and others" and directed Haldol 10 mg IM times one and Ativan 2 mg IM times one. The record indicated that the patient was placed in four-point restraints at 6:11 PM and received Haldol 10 mg IM at 6:14 PM and Ativan 2 mg at 6:15 PM. Review of the clinical record failed to reflect that least restrictive measures were tried and determined to be ineffective prior to the administration of chemical restraints.

4. Patient #10 was sent to the ED on 2/18/14 at 1:56 PM by his/her private physician for suicidal ideation (SI). The nurse's note at 2:31 PM indicated that the patient was medically cleared, awaiting a bed in the psych ED and had a sitter in place.

a. A nurse's note dated 2/18/14 at 4:00 PM identified the patient was escorted to the bathroom and was found with cigarettes and a lighter (hidden in an undergarment), the patient became angry, violent to staff, struck a staff member, security at bedside, four point soft locked applied and medicated as ordered. Review of PA#1's order dated 2/18/14 at 3:37 PM, directed the use of four point restraints, Haldol 10 mgs IM, Ativan 2 mgs IM and Benadryl 50 mgs IM. The clinical record indicated that the medications were administered at 3:53 PM and four point restraints were applied at 3:56 PM. Review of the clinical record failed to reflect that least restrictive measures were tried and determined to be ineffective prior to the administration of chemical restraints.


Review of the hospital quality program and interview with the Assistant Director of Performance Improvement on 3/10/14 at approximately 12:15 PM indicated that although restraint usage was monitored, the facility did not monitor the use of chemical restraints and/or the use of simultaneous restraints.

Review of the policy and procedure, titled Restraint and Seclusion, identified in part, that restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member or others. A comprehensive assessment of the patient must determine that the risks associated with the use of the restraint are outweighed by the risk of not using it, whether a less restrictive device or intervention could offer the same benefit at less risk. Alternatives to restraint must be considered prior to the application of restraint. Documentation in the patient's medical record for each episode of restraint use includes in part, circumstances/behavior leading up to each use, alternatives tried or considered, and rationale for type.









































19826

Based on a review of clinical records, hospital policies, and interviews, the hospital failed to ensure that physician orders were obtained for the use of bilateral wrist restraints and/or four-point soft and locked restraints and/or a posey vest restraint for two of five patients (Patients #1 and 4) that were restrained. The findings include:

1. Patient #1 arrived at the ED on 2/23/14 at 9:59 A.M. with the complaint of congested cough, difficulty breathing wheezing for the past three days with a medical history that included congestive heart failure with pacemaker and defibrillator insertion, Chronic Obstructive Pulmonary Disease (COPD) with past history of cigarette smoking, hypertension, respiratory failure with pneumonia, anemia, carotid stenosis and status post myocardial infarction. The patient was diagnosed with community acquired pneumonia, acute exacerbation of COPD, dyspnea and hypoxia and was admitted to the hospital.

a. Record review with the Assistant Nurse Director of the Medical Intensive Care Unit (MICU) and interview, on 3/10/14 at 12:35 P.M., identified that Patient #1 was placed in bilateral wrist restraints on 2/26/14 at 7:09A.M. to 7:30 A.M. absent physician orders and/or an initial assessment.

b. On 2/26/14 at 7:30 A.M. to 2:30 P.M., the nursing staff maintained Patient #1 in four-point soft wrist and ankle restraints absent physician orders and/or an initial assessment.

c. On 2/26/14 at 2:30 P.M. to 3:00 P.M., the nursing staff maintained Patient #1 in bilateral wrist restraints absent physician orders and/or an initial assessment.

d. On 2/26/14 at 3:00 P.M. to 6:30 P.M., the nursing staff increased Patient #1's restraints from bilateral wrists to four-point soft wrist and ankle restraints absent physician orders and/or an initial assessment.

e. On 2/26/14 at 6:30 to 2/27/14 at 11:16 A.M., the nursing staff maintained Patient #1 in bilateral wrist restraints absent physician orders and/or an initial assessment.

2. Patient #4 arrived at the ED on 2/24/14 at 12:17 P.M. via ambulance for witnessed seizure activity and was identified to be in a rapid atrial fibrillation. The patient's medical history included alcohol abuse and hypertension. The patient was admitted to the hospital with diagnoses of renal failure and urinary tract infection

a. Record review with the Assistant Nurse Director of the Medical Intensive Care Unit (MICU) and interview, on 3/6/14 at 10:10 A.M., identified that on 2/26/14 at 1:33 A.M. Patient #4 was placed in four-point locked restraints absent physician orders and/or an initial assessment.

b. On 2/26/14 at 3:51 A.M. documentation reflected that the patient was in four-point locked restraints and a posy-vest restraint absent physician orders and/or an initial assessment for double restraints.
Review of the policy and procedure, titled Restraint and Seclusion, identified that behavioral restraints are used for the management of violent or self-destructive behaviors that jeopardizes the immediate physical safety of the patient staff member or others and all restraints are in accordance with physician /providers orders.

Based on a review of clinical records, policy review, and interview, the hospital failed to ensure that two of eleven patients reviewed for restraint usage (Patients #4 and 9) were assessed within one hour following initiation of restraints in accordance with hospital policy. The findings include the following:

1. Patient #4 arrived at the ED on 2/24/14 at 12:17 P.M. via ambulance for witnessed seizure activity and was identified to be in a rapid atrial fibrillation. The patient's medical history included alcohol abuse and hypertension. The patient was admitted to the hospital with renal failure and urinary tract infection.

Record review and interview with the Assistant Nurse Director of the Medical Intensive Care Unit (MICU) on 3/6/14 at 10:10 A.M., identified that on 2/26/14 at approximately 1:38 A.M., Patient #4 assaulted staff members and attempted to leave the nursing unit. Four-point locked restraints were applied based on the physician's order, however, the physician failed to document his/her assessment of the patient within one (1) hour of the application of restraints including the patient's behavior and/or response to the restraints.

Review of the Security report, dated 2/26/14 at 1:16 A.M., identified that four security officers responded to staff call for assistance to place Patient #4 in four point locked restraints due to the patient assaulting two staff members and attempting to leave the nursing unit. The report further identified that MD #5 was present and directed that Patient #4 be placed in four point locked restraints.

2. Patient #9 presented to the ED on 2/22/14 5:39 PM with paranoia and psychosis. The clinical record indicated that at 6:38 PM the patient was screaming, yelling, and threatening staff. The note indicated that security was present and the patient was placed in four-point restraints and medicated as ordered. MD orders dated 2/22/14 directed Haldol 10 mg IM times one and Ativan 2 mg IM times one. The record indicated that the patient received Haldol 10 mg IM at 6:14 PM and Ativan 2 mg at 6:15 PM. Review of the LIP face to face evaluation indicated that the patient was a risk to self and others. The evaluation failed to identify the patients reaction to the interventions, the patient's medical/behavioral condition and or/or the ongoing need for restraints.

Review of the policy and procedure, titled Restraint and Seclusion, identified that behavioral restraints are used for the management of violent or self-destructive behaviors that jeopardizes the immediate physical safety of the patient, staff member or others and a face to face evaluation must be conducted by the physician/licensed provider as soon as possible for all behavioral restraints to assess the patient's immediate situation, reaction to the intervention, medical and behavioral condition and need to continue and/or terminate the restraint.