HospitalInspections.org

Based on document review and interview, it was determined for 1 of 2 (Pt. #1) clinical records reviewed for restriction of rights, the hospital failed to ensure that a notice of Restriction of Rights form was completed, when an emergency medication was administered, as required.

Findings include:

1. The Hospital's policy titled "Restriction of Rights Notifications" (Last Revised 9/19/2022) included: " ...Behavioral Health and Non-Behavioral Health and ED's - 1. Restriction of Rights form is to be completed in the following instances ...b. Administering psychotropic medication without the patient's consent ..."

2. The clinical record of Pt. #1, reviewed on 2/18/2025, included that "Pt. #1 presents to the emergency department after asking someone to call the paramedics. Patient is hyperverbal with word salad and unable to have a linear conversation ...Patient is unable to give any meaningful history or answers questions in any kind of linear capacity. Patient unable to give consent, cannot hold a linear conversation, doesn't answer questions appropriately...ED [Emergency Department] Medical Decision Making ...Presentation concerning for acute psychosis..."

The record included the following physician's orders for medication and administration documentation:

- 10/3/2024 at 11:32 AM to give Midazolam (anti-anxiety medication) 2 mg (milligrams) IV (intravenous) once. An entry dated 10/3/2024 at 11:58 AM in the clinical record, indicated that Midazolam 2 mg was administered intravenously to Pt. #1.
- 10/3/2024 at 12:02 PM to give Haloperidol Lactate (antipsychotic medication) 5 mg IM (intramuscular) once. An entry dated 10/3/2024 at 12:04 PM in the clinical record, indicated that Haloperidol Lactate 5 mg was administered intramuscularly to Pt. #1.
- 10/3/2024 at 11:32 AM to give Haloperidol Lactate 5 mg IV once. An entry dated 10/3/2024 at 1:47 PM in the clinical record, indicated that Haloperidol 5 mg was administered intravenously to Pt. #1.
- 10/3/2024 at 8:40 PM to give Droperidol (antipsychotic medication) 2.5 mg IM once. An entry dated 10/3/2024 at 8:46 PM in the clinical record, indicated that Droperidol 2.5 mg was administered intramuscularly to Pt. #1.
- 10/3/2024 at 8:40 PM to give Midazolam 5 mg IM once. An entry dated 10/3/2024 at 8:46 PM in the clinical record, indicated that Midazolam 5 mg was administered intramuscularly to Pt. #1.
- 10/4/2024 at 11:13 PM to give Haloperidol Lactate 5 mg IM once. An entry dated 10/5/2024 at 12:51 AM in the clinical record, indicated that Haloperidol 5 mg was administered intramuscularly to Pt. #1.
The record lacked documentation that a Restriction of Rights form had been completed for the above-mentioned instances when a psychotropic medication was administered.

3. On 2/19/2025 at approximately 2:05 PM, an interview with a Registered Nurse (E#8). E#8 stated that best practice dictates that a Restriction of Rights form be completed for each instance of administering a psychotropic medication.