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Based on interview, record review, and observation, the facility failed to ensure that the Qualified RN completed the face-to-face evaluation within one hour after the administration of an emergency medication. This failure was evidenced by 3 of 7 face-to-face evaluations (patient #1 and patient #9) that did not include an evaluation of the patient's immediate situation, reaction to the emergency medication, medical and behavioral condition, and need to continue or terminate the restraint.

Findings included:

Medical Record Reviews.

Patient #1.
Record review of the Emergency Psychotropic Medication Order showed Haldol 5mg and Benadryl 50mg IM one time was ordered by Staff L (MD) on 4/7/2020 at 1:55am due to threats toward staff.

Record review of the face-to-face evaluation for the administration of Haldol 5mg and Benadryl 50mg IM, by Staff BB (RN), dated 4/7/2020 at 2:10am showed: "Tolerated well." Vital Signs: Temperature 96.9; Pulse 82; Respirations 18; Blood Pressure 127/75.


Patient #9 - first emergency medication.
Record review of the Emergency Psychotropic Medication Order showed Thorazine 50mg IM, Ativan 2mg IM, and Benadryl 50mg IM one time now was ordered by Staff HH (MD) on 5/2/2020 at 9:25am due to physical threats toward a peer and provocation of peers.

Record review of the face-to-face evaluation for the administration of Thorazine 50mg IM, Ativan 2mg IM, and Benadryl 50mg IM, by Staff G (RN), dated 5/2/2020 at 10:25am showed no documentation of the Qualified RN's assessment. Vital Signs: "Refused."


Patient #9 - second emergency medication.
Record review of the Emergency Psychotropic Medication Order showed Thorazine 50mg IM, Ativan 2mg IM, and Benadryl 50mg IM one time now was ordered by Staff HH (MD) on 5/3/2020 at 7:25am due to threats toward a peers and staff.

Record review of the face-to-face evaluation for the administration of Thorazine 50mg IM, Ativan 2mg IM, and Benadryl 50mg IM showed the Qualified RN assessment form to be blank.


Staff Interviews.

In an interview with Staff C (PI) on 6/17/2020 at 11:28am, he stated the term "tolerated well" was adequate documentation for the Qualified RN's assessment within one hour of the administration of an emergency medication. The exact verbiage of the regulation was then reviewed by Staff C with the surveyor. He stated that the term "tolerated well," along with the vital signs, was sufficient documentation by the Qualified RN in the evaluation of the patient's immediate situation, reaction to the emergency medication, medical and behavioral condition, and need to continue or terminate the restraint.

In an interview with Staff B (CNO) on 6/17/2020 at 11:40am, she stated the facility has Qualified RNs that perform a face-to-face evaluation within one hour after the administration of an emergency medication. She also stated that the term "tolerated well," along with the vital signs, was NOT sufficient documentation by the Qualified RN, adding that the term "tolerated well" did not address the regulatory requirements of evaluation of the patient's immediate situation, reaction to the emergency medication, medical and behavioral condition, and need to continue or terminate the restraint.


Review of Policies.

Record review of policy, "Use of Restraint," revised 12/17/2018, showed: "The physician or Qualified Registered Nurse (QRN) must see and evaluate the patient face-to-face within one hour of ... restraint ... The Qualified RN completes a face-to-face patient assessment within one hour of each occurrence." The policy does not reference the regulatory requirements that are to be evaluated and documented by the Qualified RN.

Record review of policy, "Emergency Psychotropic Medication," reviewed 11/2019, showed no reference to the one-hour face-to-face evaluation by a Qualified RN.

Record review of policy, "Qualified Registered Nurse (QRN)," revised 11/2019, showed: "It is the policy of Behavioral Hospital of Bellaire to assess all patients that require ... emergency psychotropic medication within one (1) hour of administration by a QRN or physician ... The QRN assessment of patient response to medications completed within 1 hour of administration. (Lower portion of Emergency Psychotropic Medication Order Form-pink form)
A. Review pink order form: Patients precipitating event, medication order received, reason for administering medication, and were less restrictive interventions attempted;
B. Assess vital signs, if abnormal call MD;
C. Assess current behavior-asleep, agitated, calmer, redirectable;
D. Assess patient's reaction to intervention-tolerated well;
E. Was medication forced;
F. Check to see if the treatment plan was modified;
G. QRN sign, date and time evaluation."


Review of Literature.

Record review of Nursing 2020, June 2002, volume 32, issue 6, page 65 on "Accurate Documentation," by Sue Masoorli, RN: "[N]urses have come to rely on a few common phrases to describe a patient's response: 'patient tolerated procedure well'" The author went on to say that this documentation was "unacceptable" because it "lacks sufficient meaning."

Record review of All Nurses, September 4, 2010, "Charting Tips,": "Charting 'patient tolerated procedure well' ... lets the reader know zero ... how do you know they tolerated it?"