HospitalInspections.org

Based on interview and record review the facility failed to ensure nursing staff documented an assessment of behaviors when administering psychotropic medications in 2 of 2 patients (Patient #8 and 11).

This deficient practice had the likelihood to cause harm in all psych patients presenting to the Emergency department (ED).

Findings include:

Review of the record of Patient #11 revealed she was a 19 year old female who presented to the ED on 11/012015 at 9:58 a.m. with a chief complaint of psychiatric problems.
Review of a medication administration record and nurses notes revealed the following:

*Anti-anxiety agent Ativan 1 milligrams (mgs) was administered intravenously (IV) at 10:45 a.m. and 11:35 a.m.. There was no documentation of the behaviors that warranted usage of the medication at the time of administration.
*At 11:42 a.m., there was documentation that Patient #11 was having visual and auditory hallucinations. After the documentation of the administration of the medication.
*Anti-anxiety agent Ativan 1 milligrams at 1:35 p.m. was administered.
*Anti-psychotic agent Haldol 5 milligrams intramuscularly at 1:38 p.m.
*Anti-anxiety agent Ativan 2 mgs at 2:24 p.m.
There was no documentation of the behaviors that warranted usage of the medication at the time of medication administration.

Review of the record of Patient #8 revealed she was a 57 year old female who presented to the ED on 05/14/2014 at 5:17 p.m., with chief complaints of manic behavior. At 5:27 p.m., staff documented Patient #8 was anxious, sad, tearful/crying and verbalized depression.
Review of the medication administration record and nurses notes revealed the following:
*At 5:43 p.m., the anti-anxiety agent Valium 5 milligrams was administered;
*At 7:30 p.m., Patient #8 was documented as becoming very aggressive and violent, screaming, cursing, threatening, and stripping clothes off. Patient #8 was trying to jump out of bed. Patient #8 jumped from the bed screaming that she had been medicated against her will, grabbing paper from the floor. Patient #8 was asked to get back in bed and put her clothes on. There was documentation that at that time Patient #8 tried to swing and hit the RN. Help was called in and per the doctor the patient was medicated.
*At 7:35 p.m., the anti- histamine Benadryl 25 milligrams and anti-psychotic Haldol 5 milligrams was administered:
*At 8:00 p.m., staff documented behaviors to warrant usage of a physical restraint that was being used.
*At 8:04 p.m. (29 minutes later after the last medication administration), the anti- histamine Benadryl 12.5 milligrams was administered and anti-psychotic Haldol 5 milligrams was administered.
*At 8:05 p.m., the anti-anxiety agent Ativan 1 milligrams was administered.
Nursing staff failed to document at the time of administration of the reason the medications were being used.
Staff #4 reported nursing was suppose to document the behaviors and confirmed the lack of nursing documentation of the reason for the administration of medications in the charts.