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Based on a review of 30 open and 12 closed records inclusive of six records of patients who were restrained and/or secluded in the prior six months, it was determined that patient #4 received an injection of a long-acting antipsychotic medication even though patient #4 had not yet had a retention hearing by an administrative law judge or a Clinical Review Panel authorizing forced medications. In addition, no documentation of patient #4's agreement to that medication was found in the medical record.


Patient #4 was a 60-plus-year-old patient who was brought to the emergency department in October 2017 via police for an emergency evaluation following a period of medication non-compliance in the community resulting in threatening behaviors. Patient #4 was involuntarily admitted to the hospital's behavioral health unit.


Following an involuntary admission, patients are evaluated over and up to a ten-day period. At that time, involuntary patients go to hearing with an administrative law judge who determines if the patient will be retained for treatment or will be released. During that 10-day period, if a patient chooses to refuse oral medication, they have the right to do so unless their behavior is dangerous. In the case of an objecting patient who is also dangerous, they may be ordered emergency antipsychotic intramuscular medication. Antipsychotic medications help organize thought processes so a psychotic patient can perceive reality. Medications may be forced on a resisting patient who is not immediately dangerous only under a very narrow set of circumstances. The most common mechanism for forced medications is the Clinical Review Panel, an organized, formal process by which psychiatrists and psychiatric professionals decide if antipsychotic medications can be forced on an otherwise objecting patient who is deemed dangerous to self or others, and/or will likely require a prolonged hospital stay.


In a Psychiatric History & Physical written at admission, the psychiatrist documented that the patient was "a challenge to adequately stabilize while on an inpatient unit ... Historically medication noncompliant. LAI (long-acting injectable) medication(s) has/have been recommended in the past but Pt. is noncompliant with same d/t c/o (due to complaints of) distaste for needles" and "Will order Haldol 5 mg PO (by mouth) qAM (every morning) + 10 mg PO qHS (bedtime). May benefit from Haldol Dec (Haldol Decanoate). Benefit outweighs risk and Pt is unlikely to be compliant with same long-term, however, duration of clinical improvement may be more lasting."

A long-acting injectable (LAI) in this case, is a long-acting antipsychotic, which is not for emergency use. The effects of Haldol Deconoate generally last three to four weeks and help reduce aggression and hallucinations in psychotic patients while helping bring a psychotic patient back to reality. Because the duration of effect is long, it can also have serious, long lasting side effects. In the absence of a Clinical Review Panel to force a LAI, education regarding the risks and benefits and agreement of the patient are the minimum standard for their administration.


Patient #4 was so threatening and psychotic as to justifiably require restraint and then seclusion for some consecutive days. During that time, patient #4 refused most of the oral doses of antipsychotic medication that were offered. Consequently, patient #4 was given intramuscular doses of antipsychotics as emergency medication for ongoing dangerous behaviors.


On day three of admission, patient #4 was given an injection of the LAI of Haldol Decanoate. While documentation in psychiatry progress notes revealed a general statement that "Medication risks and benefits discussed with patient," no evidence of any discussion regarding patient agreement for the LAI was found in the record. Further, at the time the LAI was administered, patient #4 was in seclusion and documented by nursing as "Agitated, Unable/Refusal to follow direction."


A psychiatric progress note written approximately one hour following the LAI administration noted patient #4 to be "Agitated with delusions and paranoia, and with a disorganized thought process, and only oriented to person and place." Based on this description, patient #4 is unlikely to have been able to take part in a reality-based discussion regarding the risks and benefits of the LAI.


Based on all documentation, the hospital inappropriately administered a LAI medication without any documented evidence of the patient's understanding and agreement for that medication administration and without going through the clinical review panel process.

Based on a review of the hospital's Advanced Directive policy, 30 open and 12 closed patient records, it was determined that for two patients (#1 and #3), consents for surgery, anesthesia, transfusion, and vascular access were signed by family members though neither patient had a documentated Advance Directive, guardian, surrogate healthcare decision-maker, or healthcare Power of Attorney, nor was an evaluation of either patient's capacity to make decisions found in their records.

Patient #1 was an elderly patient who was admitted through the emergency department (ED) in early December 2017 for surgery to repair a hip fracture suffered in a fall at home. According to documented assessments from the ED physician and the nurse, pt.#1 was "alert and oriented to person, place, time, and situation." Once admitted, the surgeon's consult and the nurse's notes again describe the patient as alert and oriented. Patient #1 did not have an advance directive or assignment of a surrogate decision maker.


A consent form titled "Consent for Operation or Other Procedure" was signed by patient #1's family member A the day of admission at 2211. In addition, Family member A also signed anesthesia and blood consents on the initial day of surgery and on admission day 3.


Because of evolving medical problems, patient #1's hip repair had to be postponed several times. In the interim, patient #1's mental status deteriorated, with delirium and periods of confusion. Another consent for anesthesia was signed on day 4 by family member B (who had same legal standing as family member A), again with no evaluation of patient #1's capacity to make his or her own decisions.


Elder patient #3 presented to the hospital in November 2017. Patient #3's history included developmental delay. Patient #3 was admitted for abdominal surgery. Review of patient #3's record revealed no Advance Directive, guardianship, healthcare decision-maker, or healthcare Power of Attorney. Review of surgical, anesthesia, transfusion and vascular access consents revealed signatures by a family member.


Further review of patient #3's record revealed no physician's evaluation of capacity.


Based on all documentation, the hospital failed to assess whether patients #1 and #3 lacked decision making capacity, or certify an incapacity by which to appropriately obtain consents for treatment from surrogate decision makers.

Based on a review of 30 open and 12 closed medical records, including six records from patients who were restrained or secluded for violent behavior for the proceeding six months prior to the survey. it was determined that one patient did not have a properly executed face to face evaluations for one restraint and one seclusion episode.


Patient # 2 was placed in "Twice as Tough"(TAT) restraints for violent behavior while in the emergency department. The restraint order was initiated at 1222, the face to face was documented at 1400. The documented face-to-face for this restraint episode was not completed within the 1 hour required time frame. The face-to-face documented at 1400 did not contain all four required elements of a face-to-face, lacking the patient's reaction to the intervention, a determination on the need to continue or terminate the restraint, and the patient's current medical and behavioral condition.


Patient # 2 was admitted to the inpatient Behavioral Health unit. While on the Behavioral Health unit, four days into admission, the patient was placed in seclusion for one hour and twenty minute. Review of documentation from this seclusion episode revealed the 1-hour face-to-face did not have all four components completed. The face-to-face on the medical record for this seclusion episode was missing the patient's current medical condition.


Patient #2 was secluded and restrained in two separate episodes with inadequate assessments of the patient's physical and behavioral status.

Based on the deficiencies cited as result of the survey for compliance with the Life Safety Code it was determined that the Condition of Physical. Environment was not met . Review of documentation and a tour of the hospital revealed that the hospital failed to ensure a safe patient environment as a result of the failure to maintain an automatic self closing corridor smoke barrier door on 6 West in operable condition and the failure to test the water based fire suppression systems as required by NFPA. See the deficiencies cited at K0353 and K0223.