HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 3 (Pts. #2) clinical records reviewed for emergency medication administration, the Hospital failed to complete and provide the Notice Regarding Restricted Rights of Individuals, to ensure the patients' right to be informed of the events/details of the restriction and to notify a guardian/designee, if indicated, of the restriction.

Findings include:

1. The Hospital's policy titled, "Patient Rights Restrictions" (dated November 2014), was reviewed on 2/28/2022 and included, "...Nursing staff will provide clear explanation for any restriction in a patient's rights as these relate to issues of safety and security. In the best interest of the patient, nursing staff will enforce restrictions in patient rights that the physician has deemed necessary to provide for the patients' safety and security..."

2. The Hospital's policy titled, "Patient Rights" (dated November 2014), was reviewed on 2/28/2022 and included, "...Patient Rights include the following rights: ...to refuse any drug test, procedure, or treatment and to be informed of risks and benefits of this action... Patient rights are guaranteed. However, under special circumstances, certain rights may be limited or restricted as part of emergency and non-emergency interventions... The patient's therapist will be responsible (with consent) for notifying the family, guardian (without consent) or other significant other of the restriction..."

3. The clinical record of Pt. #2 was reviewed on 2/28/2022. Pt. #2 was admitted to the Hospital on 1/13/2022, with a diagnosis of bipolar disorder. The Psychotropic Medication Notice and Consent Form, dated 1/13/2022, indicated that Pt. #2 refused to sign the form and did not consent to the administration of any psychotropic medications (including Haldol/antipsychotic or Ativan/anti-anxiety). Nursing, Physician, and Treatment Team notes from 1/13/2022-1/26/2022 indicated that Pt. #2 continued to refuse all psychotropic medications during this admission.

Physicians Medication Orders included the following:
- Haldol PO (by mouth): Start at 1/13/2022 at 7:53 PM; 5mg (milligrams) tablet; Q12H (every 12 hours) PRN (as needed) for Agitation,
- Ativan PO: Start 1/13/2022 at 7:53 PM; 2mg tablet; Q12H PRN for Anxiety.
- Haldol IM (intramuscular): Start 1/13/2022 at 7:53 PM; 5mg for Agitation if Pt refuses PO.
- Ativan IM: Start 1/13/2022 at 7:53 PM; 2mg for Anxiety if Pt refuses PO.
- Haldol: 1/17/2022 at 4:11 PM; One Time 10 mg injection for Agitation
- Ativan: 1/17/2022 at 4:10 PM; One Time 2 mg injection for Agitation

The Medication Administration Record (MAR) from 1/13/2022-1/26/2022 was reviewed and indicated that Pt. #2 refused all PO Psychotropic Medications ordered. The MAR indicated that Pt. #2 received the following IM injections of Haldol and Ativan.
- 1/17/2022 at 8:25 AM: Haldol 5mg IM for Agitation and Ativan 2 mg for Anxiety (Pt refuses PO)
- 1/17/2022 at 4:10 PM: Ativan 2mg IM for Agitation
- 1/17/2022 at 4:11 PM: Haldol 10mg IM for Agitation

All Restriction of Rights Notices for Pt. #2 were reviewed and included:
- 1/17/2022 at 8:25 AM: "Administered emergency medication. Patient was agitated, screaming and yelling [at] the staff, saying profanity towards all staff and presenting as a danger to herself and others requiring PRN haldol 5 mg IM, ativan 2 mg IM to relieve agitation and maintain safety."
- The record lacked a Restriction of Rights Notification for the emergency medications administered on 1/17/2022 at 4:10 PM and 4:11 PM.

4. An interview was conducted with the Chief Nursing Officer (E#8) on 3/1/2022, at approximately 9:10 AM. E#8 provided a copy of all Restriction of Rights found for Pt. #2 and stated, "This is all of them. We document them electronically now (when asked about paper/hardcopy forms)." E#8 stated that a Restriction of Rights Notice must be completed each episode that a patient is given emergency medication administration.

5. An interview was conducted with Nurse Manager (E#2) on 3/1/2022, at approximaetely 11:40 AM. E#2 stated that each time a patient is administered emergency medications, a restriction of rights notice must be completed for each instance. E#2 flipped through Pt. #2 hard (paper) chart and was not able to find any Restriction of Rights notices.

Based on document review and interview, it was determined that for 3 of 3 (Pts. #3, #4, & #5) open psychiatric patients' records reviewed, the Hospital failed to ensure that patients received care in a safe setting by not ensuring the completion of observations as ordered.

Findings include:

1. On 2/28/2022, the Hospital's policy titled, "Observation Levels," revised July 2019, was reviewed. The policy required, "... 9. Special Precautions Levels and protocol guidelines that may be ordered include... d. High Risk Close Observation every 10 minutes - Guidelines for implementation of this level of precaution include, but are not limited to the following... (4) A Patient Rounding Sheet reflects the patient's location and observed behaviors, completed every 10 minutes."

2. On 2/28/2022, 3 patient records (Pts. #3, #4, & #5) were reviewed. All three patients had physician orders for high risk with close observation safety checks every 10 minutes. There were gaps in the 10 minute close observation safety checks as follows:

- Pt. #3 was admitted on 2/23/2022 with a diagnosis of major depressive disorder. Pt. #3's safety precaution order, dated 2/23/2022 at 6:31 PM, included, "High Risk Precaution" "Level of Observation: Q [every] 10 minutes. Reason: Unable to contract".

Pt. #3's safety rounding sheet lacked 10 minutes close observation safety checks as follows:
On 2/26/22 from 3:18 AM until 4:02 AM (44 minutes);
On 2/25/22 from 11:15 PM to 2/26/22 at 12:49 AM (94 minutes);
On 2/25/2022 from 1:16 PM to 2:12 PM (56 minutes).

- Pt. #4 was admitted on 2/20/2022 with a diagnosis of paranoid schizophrenia (brain disorder - the mind doesn't agree with reality). Pt. #4's safety precaution orders, dated 2/20/2022, included, "Level of Observation: Q 10 minutes. Reason: Psychosis". "Assault/Aggression Precaution". "Elopement Precaution". "Homicidal Precaution". "Suicidal Precaution and High Risk".

Pt. #4's safety rounding sheet lacked 10 minutes close observation safety checks as follows:
On 2/26/22 from 3:18 AM to 4:03 AM (45 minutes);
On 2/25/22 from 11:16 PM to 2/26/22 at 12:49 AM (93 minutes);
On 2/25/2022 from 1:18 PM to 2:14 PM (56 minutes);
On 2/23/22 from 1:23 PM to 2:37 PM (77 minutes); and
On 2/21/22 from 2:12 AM to 3:26 AM (74 minutes).

- Pt. #5 was admitted on 2/23/2022 with diagnoses of major depression and schizoaffective disorder (symptoms of hallucinations and delusions). Pt. #5's safety precaution order, dated 2/24/2022 at 4:44 AM, included, "Level of Observation: Q 10 minutes... Suicidal Precaution, Self-Harm Precaution and High [Risk]".

Pt. #5's safety rounding sheet lacked 10 minutes close observation safety checks as follows:
On 2/26/22 from 9:47 AM until 10:53 AM (66 minutes);
On 2/25/22 from 11:13 PM to 2/26/22 at 12:49 AM (96 minutes);
On 2/25/2022 from 1:16 PM to 2:12 PM (56 minutes).

3. On 2/28/2022 at 10:30 AM, an interview was conducted with a Registered Nurse (E #2), who reviewed the safety rounding sheets for Pts. #3, #4, & #5. E #2 provided documentation and stated that when the safety rounding sheets had extensive time intervals between observations, there was a "unit disruption" on the floor which required the rounding person to assist with a disruptive patient.

Based on document review and interview, it was determined that for 1 of 4 (Pt#1) patient records reviewed for abuse allegations, the Hospital failed to ensure that the patient was free from all forms of abuse by failing to offer the patient the opportunity to file a police report or receive a medical evaluation for allegations of sexual abuse.

Findings include:

1. On 2/28/2022, the Hospital's policy titled, "Patient Abuse and Neglect" (revised June 2019) was reviewed and required, "... m) At the request of the alleged victim, they can be sent out to a local emergency department for medical evaluation, notes and reports from these collateral medical providers require review. n) At the request of the alleged victim, they can contact or be assisted in contacting local law enforcement to file a police report, notes and reports from these collateral law enforcement agents require review."

2. On 2/28/2022, Pt#1's clinical record was reviewed. Pt#1 was admitted on 1/15/2022 with a diagnosis of Brief Psychotic Disorder, and was discharged on 1/24/2022. The record included a physician's psychiatric progress note, dated 1/21/2022, that indicated a Social Worker (E#1) received report from Pt. #1's daughter, that Pt. #1 was "raped and drugged" in the Hospital.

3. On 2/28/2022, an Incident Report Form dated 1/21/2022, that was completed by the Nurse Manager (E#5), was reviewed. The report indicated that the Social Worker (E#1), "received a call from sister of [Pt#1], stating that [Pt#1] keeps calling her and stating she is being raped and drugged. Message was relayed from SW [E#1] to Psychiatric MD ... Per [Pt#1] conversation patient stated, "I was drugged and held down 7 days ago by men. I don't know if I been raped cause my underwear is missing."" There was no indication that Pt#1 was offered an opportunity to file a police report or be assessed by a physician.

4. On 2/28/2022, at 2:53 PM, an interview was conducted with the Nurse Manager (E#5). E#5 stated that he filled out the incident report and submitted it to the Patient Advocate, and the Patient Advocate was supposed to follow up with Pt#1 and her family. E#5 stated that he knows he offered Pt#1 a rape kit, which she declined. After reviewing the incident report, E#5 stated that he must have forgotten to document that he offered her a rape kit. E#5 stated that he did not offer to call the police for Pt#1, but that he normally would offer that to a patient who claimed abuse was happening.

5. On 3/1/2022, at 10:05 AM, an interview was conducted with the Patient Advocate (E#4). E#4 stated that she asked Pt#1 if she wanted to contact the local authorities, and she knows that E#5 offered Pt#1 an opportunity for a rape kit, but Pt#1 declined. E#4 stated that it was not documented in the incident report that Pt#1 was offered the opportunity to call the local authorities, be examined by a physician, or have a rape kit performed.

Based on document review and interview, it was determined that for 2 of 2 clinical records (Pts. #1 and #2) reviewed for chemical restraint use, the Hospital failed to ensure that the patient's response to the intervention(s) used was documented in the record after each emergency medication administration.

Findings include:

1. The Hospital's policy titled, "Use of Restraint" (dated November 2014), was reviewed on 3/1/2022 and included, "Chemical Restraint: A drug or mediation 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... Documentation requirements: ... e. The effect of the restraint on the patient..."

2. On 2/28/2022, Pt. #1's clinical record was reviewed. Pt. #1 was admitted on 1/15/2022 with a diagnosis of Brief Psychotic Disorder, and was discharged on 1/24/2022.
- Physician's Orders on 1/15/2022 included Haldol 5mg (milligram) intramuscular PRN (as needed) for agitation - IF patient refuses PO and Lorazepam solution 2mg intramuscular PRN for anxiety - IF patient refuses PO.
- On 1/15/2022, at 3:32 PM, Pt. #1 was administered haloperidol (antipsychotic/sedative) 5mg IM injection and lorazepam (anti-anxiety/sedative) IM injection. Pt. #1 was given a Notice Regarding Restriction of Rights. Nurses Note indicated that Pt. #1 was very agitated, yelling, and kicking the wall. When the staff tried to redirect Pt. #1, she became more agitated and was unpredictable and delusional. The record lacked documentation of Pt. #1's response to the medication/intervention.
- On 1/20/2022, at 7:48 PM, Pt. #1 was administered haloperidol 5mg IM injection and lorazepam IM injection. Pt.#1 was given a Notice Regarding Restriction of Rights. Nurse Note indicated that Pt. #1 was verbalizing homicidal ideations towards staff and was disruptive on the unit. The record lacked documentation of Pt. #1's response to the medication/intervention.

3. The clinical record of Pt. #2 was reviewed on 2/28/2022. Pt. #2 was admitted to the Hospital on 1/13/2022, with a diagnosis of bipolar disorder and was discharged on 1/26/2022. The Psychotropic Medication Notice and Consent Form, dated 1/13/2022, indicated that Pt. #2 refused to sign the form and did not consent to the administration of any psychotropic medications (including Haldol or Ativan). Nursing, Physician, and Treatment Team notes from 1/13/2022-1/26/2022 indicated that Pt. #2 continued to refuse all psychotropic medications during this admission.

Physicians Medication Orders included the following:
- Haldol PO (by mouth): Start at 1/13/2022 at 7:53 PM; 5mg (milligrams) tablet; Q12H (every 12 hours) PRN (as needed) for Agitation,
- Ativan PO: Start 1/13/2022 at 7:53 PM; 2mg tablet; Q12H PRN for Anxiety.
- Haldol IM (intramuscular): Start 1/13/2022 at 7:53 PM; 5mg for Agitation if Pt refuses PO.
- Ativan IM: Start 1/13/2022 at 7:53 PM; 2mg for Anxiety if Pt refuses PO.
- Haldol: 1/17/2022 at 4:11 PM; One Time 10 mg injection for Agitation
- Ativan: 1/17/2022 at 4:10 PM; One Time 2 mg injection for Agitation

The Medication Administration Record (MAR) from 1/13/2022-1/26/2022 was reviewed and indicated that Pt. #2 refused all PO Psychotropic Medications ordered. The MAR indicated that Pt. #2 received the following IM injections of Haldol and Ativan.
- 1/14/2022 at 6:27 PM: Haldol 5mg IM for Agitation (Pt refuses PO)
- 1/14/2022 at 6:28 PM: Ativan 2mg IM for Anxiety (Pt refuses PO)
- 1/17/2022 at 8:25 AM: Haldol 5mg IM for Agitation and Ativan 2 mg for Anxiety (Pt refuses PO)
- 1/17/2022 at 4:10 PM: Ativan 2mg IM for Agitation
- 1/17/2022 at 4:11 PM: Haldol 10mg IM for Agitation
- 1/19/2022 at 9:00 PM: Haldol 5mg IM for Agitation and Ativan 2mg for Anxiety (Pt refuses PO)
- 1/20/2022 at 11:23 PM: Haldol 5mg IM for Agitation and Ativan 2mg for Anxiety (Pt refuses PO)
- 1/21/2022 at 11:31 AM: Haldol 5mg IM for Agitation and Ativan 2mg for Anxiety (Pt refuses PO)

Nursing Notes and Restriction of Rights Notices from 1/13/2022-1/26/2022 were reviewed and indicated that Pt. #2 received the above IM injections as emergency medication administrations to restrict/manage Pt. #2's behavior when Pt. #2 was becoming increasingly agitated, threatening, and/or combative; however, the records lacked documentation of Pt. #2's response to the medications.

4. An interview was conducted with a Pharmacist (E#9) on 3/1/2022, at approximately 2:02 PM. E#9 stated that Haldol and Ativan are typically ordered as PRNs for agitation/anxiety and not generally as scheduled medications for treatment of a particular disorder/condition. E#9 stated that staff are able to administer these medications in emergency situations (i.e. patient is threatening or combative) using the PRN orders, or they have the option of having the physician order an one-time dose. E#9 stated that either way is acceptable. E#9 stated that it would be expected that nursing staff make note of the patient's response to these medications.

5. An interview was conducted with the Chief Nursing Officer (E#8) on 3/1/2022, at approximately 3:00 PM. E#8 stated that ideally the nurse's should document the patient's response to PRN medications in the clinical record. E#8 stated that a PRN medication used to manage/restrict a patient's behavior in a emergency situation (combative/threatening) could be considered a chemical restraint and should be evaluated for effectiveness of the intervention. E#8 stated, "That is something we'll need to work on."