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Based on hospital policy review, medical record review and staff interview, the nursing staff failed to obtain a physician order for a therapeutic hold restraint in 1 of 2 (Pt. #9) chemical restraint patient records reviewed.

Findings include:

Review on 03/16/2022 of the hospital policy "Restraints, Security Alert/Violent/Self-Destructive Behavior Restraints and Seclusion; Chemical Restraints - PC 210.43" last revised 04/2019, revealed " ... F. Initiation of Violent/Self-Destructive Behavior Restraints, Chemical Restraints or Seclusion: ... 3. When chemical restraint is required, an order must be obtained for the medication and the chemical restraint PRIOR to administering the medication. The chemical restraint order and medication order are one time orders. If a CPI (Crisis Prevention Intervention) hold is required to administer the medication, then an order for the CPI hold is required in addition to the order for the medication and the chemical restraint. ..."

Open medical record review of Patient #9 revealed a 78-year-old male patient that presented to the Emergency Department on 03/14/2022 at 1859 with a chief complaint of IVC (Involuntary Commitment) per family for behaviors. The medical record review revealed a Verbal Physician Order placed by a Registered Nurse, dated 03/14/2022 at 2005 for Ativan 2 milligrams (mg) Intramuscular (IM), Haldol 5 milligrams IM and Benadryl 25 milligrams IM times one dose. Review of the Emergency Department Timeline revealed documentation that Patient #9 was administered Ativan 2 mg IM, Haldol 5 mg IM and Benadryl 25 mg IM on 03/14/2022 at 2010. The medical record review revealed a Verbal Provider Order for Restraints violent or self-destructive adult dated 03/14/2022 at 2038 with a start date of 03/14/2022 and a start time of 2006. Review of the order revealed " ... Restraint Type Medication Restraint ..." Review of the nursing notes dated 03/14/2022 at 2010 revealed documentation of "Restraint Type Therapeutic Hold ..." Review of the medical record revealed no available documentation of a Physician Order for a Therapeutic Hold Restraint.

Interview on 03/16/2022 at 1150, during the medical record review with RN #1 revealed there was no available documentation of a Physician order for the Therapeutic Hold. Interview confirmed the hospital staff did not follow the hospital policy.

Based on hospital policy review, medical record review and staff interview the nursing staff failed to monitor a chemical restraint patient per the hospital policy in 2 of 2 (Pt. #4 and Pt. #9) chemical restraint patient records reviewed.

Findings include:

Review on 03/16/2022 of the hospital policy "Restraints, Security Alert/Violent/Self-Destructive Behavior Restraints and Seclusion; Chemical Restraints - PC 210.43" last revised 04/2019, revealed " ... H. Assessment, reassessment, monitoring: ... C. Chemical Restraints 1. Patients who have received a Chemical Restraint are assessed at 30 minute intervals X(times)2 after the medication is administered ...

1. Open medical record review of Patient #4 revealed a 90-year-old female patient that presented to the Emergency Department via ambulance with police on 03/15/2022 at 0006 with a chief complaint of confusion and IVC (Involuntary Commitment) per family for behaviors. The medical record review revealed a Verbal Physician Order placed by a Registered Nurse, dated 03/15/2022 at 0627 for Ativan 2 milligrams (mg) Intravenous (IV) times one dose. Review of the Emergency Department Timeline revealed documentation that Patient #4 was administered Ativan 2 milligrams IV at 0627. The medical record review revealed a Verbal Provider Order for Restraints violent or self-destructive adult dated 03/15/2022 at 0738 with a start date of 03/15/2022 and a start time of 0630. Review of the order revealed " ... Restraint Type Medication Restraint Therapeutic Hold ..." Review of the nursing notes revealed no available documentation of Patient #4 being assessed/monitored at 30 minute intervals times two (2).

Interview on 03/15/2022 during the medical record review with RN #1 revealed there was no available documentation of a 30 minute assessment times two (2) completed after the initiation of the chemical restraint intervention on 03/15/2022 at 0627. Interview confirmed the hospital staff did not follow the hospital policy for assessment after initiation of a chemical restraint.

2. Open medical record review of Patient #9 revealed a 78-year-old male patient that presented to the Emergency Department on 03/14/2022 at 1859 with a chief complaint of IVC (Involuntary Commitment) per family for behaviors. The medical record review revealed a Verbal Physician Order placed by a Registered Nurse, dated 03/14/2022 at 2005 for Ativan 2 milligrams (mg) Intramuscular (IM), Haldol 5 milligrams IM and Benadryl 25 milligrams IM times one dose. Review of the Emergency Department Timeline revealed documentation that Patient #9 was administered Ativan 2 mg IM, Haldol 5 mg IM and Benadryl 25 mg IM on 03/14/2022 at 2010. The medical record review revealed a Verbal Provider Order for Restraints violent or self-destructive adult dated 03/14/2022 at 2038 with a start date of 03/14/2022 and a start time of 2006. Review of the order revealed " ... Restraint Type Medication Restraint ..." Review of the nursing notes revealed no available documentation of Patient #4 being assessed/monitored at 30 minute intervals times two (2).

Interview on 03/16/2022 at 1150, during the medical record review with RN #1 revealed there was no available documentation of a 30 minute assessment times two (2) completed after the initiation of the chemical restraint intervention on 03/14/2022 at 2010. Interview confirmed the hospital staff did not follow the hospital policy for assessment after initiation of a chemical restraint.

Based on hospital policy review, medical record review and staff interview the hospital staff failed to ensure a face-to-face assessment within 1 hour after initiation of a chemical restraint intervention was completed per the hospital policy in 2 of 2 (Pt. #4 and Pt. #9) chemical restraint patient records reviewed.

Findings include:

Review on 03/16/2022 of the hospital policy "Restraints, Security Alert/Violent/Self-Destructive Behavior Restraints and Seclusion; Chemical Restraints - PC 210.43" last revised 04/2019, revealed " ... F. Initiation of Violent/Self-Destructive Behavior Restraints, Chemical Restraints or Seclusion: ... 5. When Violent/Self-Destructive restraints, Chemical restraints or seclusion are initiated, the MD (physician), other LIP (licensed independent practitioner) or QRN (qualified registered nurse) must see and evaluate the need for restraint or seclusion within one (1) hour after the initiation of the restraint intervention (which includes CPI [crisis prevention intervention] holds and seclusion). ..."

1. Open medical record review of Patient #4 revealed a 90-year-old female patient that presented to the Emergency Department via ambulance with police on 03/15/2022 at 0006 with a chief complaint of confusion and IVC (Involuntary Commitment) per family for behaviors. The medical record review revealed a Verbal Physician Order placed by a Registered Nurse, dated 03/15/2022 at 0627 for Ativan 2 milligrams (mg) Intravenous (IV) times one dose. Review of the Emergency Department Timeline revealed documentation that Patient #4 was administered Ativan 2 milligrams IV at 0627. The medical record review revealed a Verbal Provider Order for Restraints violent or self-destructive adult dated 03/15/2022 at 0738 with a start date of 03/15/2022 and a start time of 0630. Review of the order revealed " ... Restraint Type Medication Restraint Therapeutic Hold ..." Review of the medical record revealed no available documentation of a one (1) hour face-to-face assessment completed by a MD, LIP or QRN.

Interview on 03/15/2022, during the medical record review with RN #1 revealed there was no available documentation of the one (1) hour face-to-face assessment completed after the initiation of the chemical restraint intervention on 03/15/2022 at 0627. Interview confirmed the hospital staff did not follow the hospital policy for obtaining or conducting a 1 hour face-to-face assessment after initiation of a chemical restraint.

2. Open medical record review of Patient #9 revealed a 78-year-old male patient that presented to the Emergency Department on 03/14/2022 at 1859 with a chief complaint of IVC (Involuntary Commitment) per family for behaviors. The medical record review revealed a Verbal Physician Order placed by a Registered Nurse, dated 03/14/2022 at 2005 for Ativan 2 milligrams (mg) Intramuscular (IM), Haldol 5 milligrams IM and Benadryl 25 milligrams IM times one dose. Review of the Emergency Department Timeline revealed documentation that Patient #9 was administered Ativan 2 mg IM, Haldol 5 mg IM and Benadryl 25 mg IM on 03/14/2022 at 2010. The medical record review revealed a Verbal Provider Order for Restraints violent or self-destructive adult dated 03/14/2022 at 2038 with a start date of 03/14/2022 and a start time of 2006. Review of the order revealed " ... Restraint Type Medication Restraint ..." Review of the medical record revealed no available documentation of a one (1) hour face-to-face assessment completed by a MD, LIP or QRN.

Interview on 03/16/2022 at 1150, during the medical record review with RN #1 revealed there was no available documentation of the one (1) hour face-to-face assessment completed after the initiation of the chemical restraint intervention on 03/14/2022 at 2010. Interview confirmed the hospital staff did not follow the hospital policy for obtaining or conducting a 1 hour face-to-face assessment after initiation of a chemical restraint.

Interview on 03/17/2022 at 1124 with MD #2 revealed MD #2 stated he did reassess Patient #9 after the restraint intervention but was not completed within the one-hour time frame.

Based on policy review, medical record review and staff interview the hospital staff failed to document a post-blood transfusion temperature for 1 of 3 (Pt. # 5) sampled blood transfusion records reviewed.

Findings include:

Review on 03/17/2022 of the hospital policy "Blood / Blood Products/Blood Derivatives Administration - PC 210.78" last revised 11/2021, revealed " ... B. Administration & Monitoring of Blood ... ...12. Monitor and record vital signs (TPR & BP - Temperature, Pulse, Respirations and Blood Pressure) ... d. at discontinuation. ..."

Review of the closed medical record for Patient #5 revealed a 65-year-old male that presented to the Emergency Department on 01/16/2022 at 2002 with a chief complaint of GI (Gastrointestinal Bleed) and weakness. Review of the medical record revealed Patient #5 received orders to Transfuse 4 units of Packed Red Blood Cells (PRBCs). Review of the blood transfusion nursing notes revealed Patient #5 received the four (4) units of PRBCs from 2035 to 2215. Review of the nursing documentation revealed the fourth (4th) unit was completed at 2215. Review of the vital signs documentation revealed no documentation of the Patient's Temperature at the discontinuation (completion) of the blood transfusion.

Interview on 03/17/2022, during the medical record review with RN #1 revealed there was no documented Patient's Temperature post blood transfusion completion. Interview revealed the staff failed to follow the hospital policy.

NC00185524