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Based on medical record, document review and interview, in 6 of 6 medical records (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5 and Patient #6), the facility failed to recognize medications ordered to sedate violent and aggressive patients, were chemical restraints. The facility's restraint policy and procedure failed to provide direction to staff on monitoring patients that were chemically restrained.

Findings regarding 1) include:

-- Review of Patient #1's, Patient #2's, Patient #3's, Patient #4's, Patient #5's and Patient #6's medical records revealed they all exhibited violent and/or self-destructive behavior and were administered medications to manage their behavior e.g., Ketamine (a dissociative anesthetic used for induction and maintenance of anesthesia), Versed (a hypnotic-sedative drug used for anxiety with amnesic properties), Zyprexa (medication used to treat severe agitation), Benadryl (an antihistamine that can cause drowsiness), Haldol (an antipsychotic drug used to treat schizophrenia). These medications were used to sedate patients and were not identified as chemical restraints.

-- Review of the facility's policy and procedure revealed it failed to give direction to staff on monitoring patients that were chemically restrained.

-- Per interview of staff, many failed to understand the use of chemical restraints and subsequent patient monitoring.

See tag 0160

Based on medical record, document review and interview, in 6 of 6 medical records (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5 and Patient #6), the facility failed to recognize medications ordered to sedate violent and aggressive patients, were chemical restraints. The facility's restraint policy and procedure failed to provide direction to staff on monitoring patients that were chemically restrained.

Findings include:

-- Review of Patient #1's medical record indicated, on 11/14/2023 at 1:39 am, he presented to the emergency department after a self-inflicted wound to an extremity. Patient #1 was noted to be belligerent, combative, and yelling throughout triage. Verbal de-escalation was attempted by nursing and security staff. At 1:55 pm, 6 security guards were required to hold Patient #1 for the administration of Ketamine (general anesthetic that causes sedation) 400 milligrams intramuscularly, in the triage bay. Patient #1 became apneic (not breathing) with an oxygen saturation of 54%, and was intubated (insertion of a tube into the airway to provide oxygen). There was no documentation in the medical record indicating this medication was used as a chemical restraint.

--Per interview of Staff H, Registered Nurse, on 12/12/2023 at 8:00 am, Patient #1 was intoxicated and acting belligerent. Patient #1 attempted to hit police and leave the emergency department. A physician was notified about Patient #1's behavior and 400 milligrams of intramuscular Ketamine was ordered. Staff H and another registered nurse administered the Ketamine to Patient #1 on the ambulance stretcher. Patient #1 was taken into an empty room where he began to desaturate and was eventually intubated.

-- Review of Patient #2's medical record indicated, on 10/31/2023 at 8:06 am, he presented to the emergency department for an evaluation of back pain, abdominal pain, and visual and auditory hallucinations. Patient #2 became agitated and attempted to leave the emergency department after he was deemed to be an involuntary admission to the psychiatric unit, following a psychiatric evaluation. Patient #2 was placed in four point Twice as Tough restraints (hard restraints that limits the movement of all 4 limbs) with assistance of security at 1:15 pm and was given Ketamine 200 milligrams intramuscularly at 1:30 pm. At 3:00 pm, Patient #2 was re-evaluated by nursing staff and was found to be sleeping comfortably. Twice as Tough restraints were then removed by nursing staff. Provider documentation revealed Patient #2 required Ketamine sedation and is more calm following administration of Ketamine. There is no documentation in the medical records indicating this medication was given as a chemical restraint.

-- Review of Patient #3's (15-year old) medical record indicated, on 12/5/2023 at 7:43 pm, she presented to the emergency department via emergency medical services after a suicide attempt. Patient #3 was agitated and hostile.
When she was brought into the emergency department, chemical and physical restraints were applied, She was medicated with Zyprexa (medication used to treat severe agitation) 5 milligrams intramuscularly at 7:46 pm, Benadryl (medication used for mild agitation) 50 milligrams intramuscularly at 7:52 pm and Ketamine 300 milligrams intramuscularly at 7:56 pm. Following the administration of Ketamine, Patient #3 was sedated, nursing removed her restraints. There is no indication in the provider order that these medications were given as a chemical restraints.

-- Review of Patient #4's medical record indicated on 11/24/2023 at 3:44 am, he presented to the emergency room for direct transfer/admission after a cocaine-induced myocardial infarction (heart attack). Patient #4 was extremely agitated in route to the emergency department and received Versed (causes sedation) 5 milligrams intravenously by emergency medical services. Upon arrival to the emergency department, nursing documented the patient was fighting with staff in the back of ambulance. Security was able to restrain the patient. The patient was given Versed 10 milligrams intramuscularly by emergency medical services without effect. Patient #4 was then given Ketamine 300 milligrams intramuscularly in the emergency department. Patient #4 was sedated for severe agitation and intubated for airway protection. There is no indication in the provider order that these medications were given as a chemical restraints.

-- Review of Patient #5's medical record indicated on 11/18/2023 at 9:22 am, he presented with an overdose after being found on the ground with minimal respiratory effort (not breathing adequately) and was given Narcan (reverses an overdose) by emergency medical services. Upon arrival into the emergency department, Patient #5 was agitated and combative with staff and was an immediate threat to himself and others. At 9:30 am Patient #5 was placed in Twice as Tough restraints and given Ketamine 300 milligrams intramuscularly. At 10:00 am, Patient #5 continued to be agitated and was medicated with Zyprexa 10 milligrams intramuscularly. At 10:24 am, Patient #5 was medicated with Versed 2 milligrams intravenously. At 10:30 am, Patient #5 was medicated with Ativan (used for agitation) 2 milligrams intravenously. At 10:31 am, Patient #5 was given Benadryl 50 milligrams intravenously. At 10:40 am, Patient #5 was medicated with Haldol (antipsychotic medication used to treat agitation) 5 milligrams intravenously. At 11:16 am, Patient #5 was medicated with Valium (treats anxiety and agitation) 5 milligrams intravenously. At 12:06 pm, Patient #5 was given Precedex (sedative) via a continuous intravenous infusion. There is no indication in the provider order that these medications were given as a chemical restraints.

-- Review of Patient #6's medical record indicated on 10/7/2023 at 8:53 am, Patient #6 was hitting and scratching staff and was medicated with Zyprexa 5 milligrams intramuscularly. At 10:43 am, Patient #6 was medicated with Ketamine 200 milligrams intramuscularly. There is no indication in the provider order that these medications were given as a chemical restraints.

-- Review of the facility's policy and procedure titled "Restraint Standards for Non-Psychiatric Patient Care Units," last revised 5/2023, indicated that a "drug or medication when 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 is considered a restraint". The policy did not provide guidance on monitoring patients after the administration of chemical restraints.

--Per interview of Staff F, Director of Risk Management, on 2/16/2024 at 3:04 pm, he/she/they indicated "Ketamine Safety and Use in the Emergency Department for Pain and Agitation/Delirium: A Health System Experience" dated 1/2020, retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7081852/ was used to develop the facility's Ketamine policy and procedure titled "Ketamine Use in the Emergency Department," reviewed 2/2022.
This article indicated using dissosciative sedation Ketamine for severe agitation or excited delirium, patient monitoring should include "immediate availability of advanced airway equipment. Patients requiring dissosciative sedation Ketamine for severe agitation or delirium should have continuous direct patient observation for 15 minutes, continuous pulse oximetry, cardiac monitor, and end-tital carbon dioxide monitoring." The facilty's Ketamine policy and procedure did not describe patient monitoring requirements

-- Per interview of Staff A, Registered Nurse, on 12/11/2023 at 10:45 am, providers order intramuscular medications as one-time orders for agitation but they do not indicate that the medication is a chemical restraint.

--Per interview of Staff G, Physician on 12/11/2023 at 3:20 pm. intramuscular Ketamine doses range from 500 milligrams to 600 milligrams for severe agitation. Staff G would not expect a patient to require intubation following Ketamine administration. Staff G always prepares for the worst possible outcome when administering Ketamine and opines that patients should be monitored closely. Patients who are given Ketamine have their airway monitored. The choice to use Ketamine is provider specific.

-- Per interview of Staff B, Physician, on 12/12/2023 at 9:07 am, chemical and physical restraints are utilized when a patient is physically violent. The medical record has an order set for physical restraints but not chemical restraints. Medications needed for violent patients are ordered as needed for agitation. Staff B may order clinical monitoring such as telemetry and oximetry for a patient receiving as needed medications. There is no standardized clinical monitoring for patients following chemical restraints.

--Per interview of Staff J, Physician, on 12/12/2023 at 9:20 am. Ketamine is administered to patients intramuscularly by registered nurses and there is "perhaps a 1% chance" of it resulting in a patient requiring intubation.

-- Per interview of Staff C, Charge Nurse, on 12/12/2023 at 2:10 pm, if a patient continues to be violent, they should be placed in soft wrist restraints or 4-point soft restraints. The patient may be given Haldol or Zyprexa to calm down the behavior. Staff C does not consider the medications to be a chemical restraint. The patients do not have frequent vital signs done after receiving the medication unless the provider orders them.

-- Per interview of Staff D, Registered Nurse, on 12/12/2023 at 2:25 pm, a chemical restraint is any medication or sedative ordered to calm down a violent patient. Medications commonly used by the facility are Haldol and Zyprexa. When violent patients are placed in restraints and then medicated, within 15 - 20 minutes the restraints can usually be removed because the patient has calmed down. Patients are usually drowsy after being medicated but arousable. Staff D stated there is no policy that indicates staff need to obtain additional vitals signs after a patient receives a chemical restraint.

-- Per interview of Staff E, Clinical Trainer, on 12/12/2023 at 2:25 pm. Staff E has not seen a chemical restraint order, but does see chemical restraints used as needed for some patients.

-- Per interview of Staff DD, Registered Nurse, on 12/12/2023 at 2:30 pm. Staff DD has never seen documentation for chemical restraints. The provider may order medication such as Zyprexa as needed for agitation or violence.

-- During interview of Staff F, Director of Risk Management, on 12/27/2023 at 10:30 am, he/she/they acknowledged the above finding.

Based on document review and medical record review, in 1 of 1 (Patients #4) patients lacked a physician's order to physically restrain (hold) the patient in order to administer the medication.

Findings include:

-- Per review of the facility's policy and procedure titled "Restraint Standards for Non-Psychiatric Patient Care Units," revised 5/2023, "the application of force to physically hold a patient in order to administer a medication against the patient's wishes is considered a restraint. Each episode of restraint must be initiated in accordance with the order of a Physician, Resident, Nurse Practitioner or Physician Assistant who is responsible for the care of the patient."

-- Review of Patient #4's medical record indicated on 11/24/2023 at 3:44 am, he presented to the emergency room for direct transfer/admission after a cocaine-induced myocardial infarction. Upon arrival to the emergency department, nursing documented the patient was fighting with staff in the back of ambulance. Security was able to restrain (hold) the patient. The patient was given Versed (causes sedation) 10 milligrams intramuscularly by emergency medical services without effect. Patient #4 was then given Ketamine (general anesthetic that causes sedation) 300 milligrams intramuscularly in the emergency department.

There is no documentation of a provider order for a physical hold of the patient to administer a chemical restraint.

-- During interview of Staff F, Director of Risk Management, on 12/27/2023 at 10:30 am, he/she/they acknowledged the above finding.

Based on document review, medical record review and interview, 1 of 6 (Patient #5) patients requiring the use of violent or self-destructive physical restraints, lacked documentation of a one hour face-to-face with a provider after the initiation of restraints.

Findings include:

-- Per review of policy and procedure titled "Restraints Standards for Non-psychiatric Patient Care Units," last reviewed 5/2023, "the patient must be seen face-to-face by a Physician, Resident, Nurse Practitioner or Physician Assistant responsible for the care of the patient within 1 hour after initiation of the intervention, even if the restraint intervention is discontinued before the practitioner arrives to perform the 1 hour face-to-face evaluation. This evaluation must be documented in the electronic medical record and will include the following: The patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion."

-- Review of Patient # 5's medical record revealed a verbal order was obtained for four-point violent restraints on 11/18/2023 at 9:30 am. There was no documentation of the required face-to-face evaluation by the provider.

-- During interview of Staff F, Director of Risk Management, on 12/27/2023 at 10:30 am, he/she/they acknowledged the above finding.