HospitalInspections.org

A. Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #3) clinical records reviewed, the Hospital failed to document use of emergency medication, as necessary, to ensure that patient rights to request or refuse treatment was upheld.

Findings include:

1. On 2/23/2022, the Hospital's policy titled, "Restraint and Seclusion" (effective 7/2019) was reviewed and required, "... Emergency Behavioral Health Medication Administration: A situation in which it is immediately necessary to administer medication to mitigate the signs and symptoms of patient's mental illness... Patient Rights and Plan of Care... A patent may refuse treatment unless such services are deemed necessary to prevent the recipient from causing serious imminent physical harm to themselves or others and no less restrictive alternative is available..."

2. On 2/23/2022, the clinical record of Pt. #2 was reviewed. Pt. #2 was admitted to the Hospital's Adult Behavioral Health Unit on 9/28/2021 due to aggression. The clinical record included:

- A physician's order, dated 9/29/2021, to administer Haldol (medication that can cause sedation) 5 (mg/milligrams) intramuscular injection every six hours PRN ( as needed) for emergency use only for agitation. Haldol was administered on 10/10/2021 at 11:28 PM and on 10/15/2021 at 7:10 PM. The clinical record lacked documentation that Pt. #2 was exhibiting behaviors that could cause imminent physical harm to themselves or others.

- A physician's order dated, 2/14/2022, to administer Haldol 5 mg every six hours for severe behavioral emergencies. Haldol was administered on 2/21/2022 at 7:52 PM. The clinical record lacked documentation that Pt. #2 was exhibiting behaviors that could cause imminent physical harm to self or others.

3. On 2/23/2022 at approximately 11:45 AM, a telephone interview was conducted with MD #3 (Medical Director, Psychiatry). MD #3 stated that emergency means that the order is given in situation when the patient is at imminent risk of harming thenselves or others. In emergency situation, MD #3 stated that there should be documentation warranting the emergency use of a medication including restriction of rights.

B. Based on document review and interview, it was determined that for 2 of 4 patients' (Pt. #1 and Pt. #3) clinical records reviewed, the Hospital failed to complete the Notice Regarding Restricted Rights of Individuals, to ensure the patients' right to being informed of his care or treatment.

Findings include:

1. On 2/22/2022, the Hospital's policy titled, "Restraints and Seclusion" (effective 7/2019) was reviewed and included, "... Page 14... In accordance with the Illinois State Law... In the event patient's rights are restricted, documentation of the event will be provided to the client by nursing staff (Notice Regarding Restricted Rights of Individuals) and, if indicated, a guardian/designee will be notified.

2. On 2/22/2022, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital's Adult Behavioral Health Unit on 2/13/2020, with a diagnosis of schizoaffective disorder, bipolar type with psychotic features. The clinical record included:

- A physician's Orders for IM (intramuscular) Olanzapine (antipsychotic) included the following: 5 mg IM injection, every 6 hours PRN for severe agitation. Give with IM benztropine (for side effects). Give if patient refuses PO olanzapine. First line for severe agitation. Start: 2/13/2020 at 11:28 AM; 10 mg IM injection (Olanzapine), every 8 hours, PRN for severe agitation. Start 2/17/2020 at 1:12 PM.

- Medication Administration Records (MAR) indicated the following medication administrations of Olanzapine:
2/14/2020: 5mg IM at 1:36 AM, 9:02 AM, and 3:02 PM; and 10 mg IM at 9:15 PM.
2/15/2020: 5 mg IM at 8:10 AM and 5:25 PM.
2/16/2020: 5 mg IM at 12:48 AM, 8:22 AM, and 11:57 PM.
2/21/2020: 10 mg IM at 6:29 PM and 5 mg IM at 7:45 PM.
2/22/2020: 10 mg IM at 2:31 AM.
2/23/2020: 10 mg IM at 3:40 PM.
2/25/2020: 10 mg IM at 12:45 AM.
2/26/2020: 10 mg IM at 12:08 AM and 5 mg IM at 4:45 AM.
3/1/2020: 10 mg IM at 4:30 AM .
- Restriction of Rights Notices for Pt. #1 were reviewed and included the following:
2/15/2020 at 8:10 AM: Pt. #1 was placed in physical hold and administered emergency medication. Reason: "Patient displayed inability to manage his behavior, inciting agitation amongst peers and presenting an
imminent risk of harm to self and others."
2/15/2020 at 8:16 AM: Pt. #1 was placed in physical hold and administered emergency medication. Reason: "Pt evidenced increasing agitation; became physically assaultive with staff, requiring immediate
intervention to ensure patient safety and restore order in the milieu."
2/16/2020 5:00 PM - 2/17/2020 5:00 PM: Restriction placed on telephone use. Reason: "Pt had been calling police and telling them that he had been kidnapped. Modified - supervise phone call by staff. Staff to
dial telephone # for him."
2/21/2020 at 7:45 PM: Pt. #1 was administered emergency medication. Reason: "Pt made threats, refused to contract for safety, patient received Zyprexa 5mg IM at 7:45 PM for severe aggression ."

- The record lacked documentation of any other Restriction of Rights provided to Pt. #1 for the other administrations of IM Olanzapine on 2/14/2020 (3 doses); 2/15/2020 (2nd dose at 5:25 PM); 2/16/2020 (3 doses); 2/21/2020 (2 doses); 2/22/2020 (1 dose); 2/23/2020 (1 dose); 2/25/2020 (1 dose); 2/26/2020 (2 doses); and 3/1/2020 (1 dose), despite documentation that Pt. #1 continued to refuse olanzapine as per physician and nursing and notes (see above).

3. On 2/23/2022, the clinical record of Pt. #2 was reviewed. Pt. #2 was admitted to the Hospital's Adult Behavioral Health Unit on 9/28/2021 due to aggression. The clinical record indicated that medications were administered due to behavioral emergency on 10/10/2021 at 11:28 PM,10/15/2021 at 7:10 PM, and on 2/21/2022 at 7:52 PM . The clinical record lacked documentation that the Restriction of Rights was provided to the patient or his guardian.

4. On 2/23/2022 at approximately 11:45 AM, a telephone interview was conducted with MD #3 (Medical Director, Psychiatry). MD #3 stated that in emergency situation, there should be documentation warranting the emergency use of a medication including provision of restriction of rights to the patient or designee.

C. Based on document review and interview, it was determined that for 2 of 4 patients' (Pt. #1 and Pt. #3) clinical records reviewed, the Hospital failed to complete the Consent to Medication Form, to ensure the rights to make informed decision was upheld.

Findings include:

1. On 2/22/2022, the Hospital's policy titled, "Medication Education for Psychotropic Medications" (effective 11/2019) was reviewed and required, "... Procedure... 3. Physician will complete the Consent to Medication Education Form. This form will include the name of the psychotropic medication for all regularly schedule and PRN psychotropic medications as well as dosage ranges.

2. On 2/22/2022, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital's Adult Behavioral Health Unit on 2/13/2020, with a diagnosis of schizoaffective disorder, bipolar type with psychotic features. A Consent to Medication Form, dated 2/13/2020 at 1:45 AM, was signed by Pt. #1 and a physician. The form had a list of psychotropic medications listed such as lorazepam (Ativan/anti-anxiety medication), hydroxyzine (anti-anxiety), diphenhydramine (Benadryl/medication used to treat side effects of antipsychotics and has sedating effects), and olanzapine (Zyprexa/antipsychotic). The consent form did not include the dosage range for each medication listed.

3. On 2/23/2022, the clinical record of Pt. #2 was reviewed. Pt. #2 was admitted to the Hospital's Adult Behavioral Health Unit on 9/28/2021. A Consent to Medication Form, dated 10/1/2021 at 3:00 PM, was signed by Pt. #2's guardian and a physician. The form had a list of psychotropic medications such as depakote (mood stabilizer), risperdone (for mood), and lorazepam. The consent form did not include the dosage range for each medication listed.

4. On 2/23/2022 atapproximately 11:43 AM, a telephone interview was conducted with one of Pt. #1's Physicians (MD #4). MD #4 stated that the consent for medication form should include the dosage range/day for each medication listed.

Based on document review and interview, it was determined that for 1 of 3 records reviewed (Pt. #1) for restraint use, the Hospital failed to ensure that a physician's order was obtained for a patient that was placed in a physical hold to administer a forced medication.

Findings include:

1. The Hospital's policy titled, "Restraints and Seclusion" (effective 7/19/2021), was reviewed on 2/23/2022 and required, "The use of force in order to medicate a patient, as with other restraint(s), must have a physician's order prior to the application of the restraint (use of force)..."

2. The clinical record of Pt. #1 was reviewed on 2/22/2022 and 2/23/2022. Pt. #1 was admitted to the Hospital's Adult Behavioral Health Unit (8 East/8E) on 2/13/2020, with a diagnosis of schizoaffective disorder, bipolar type with psychotic features. Restriction of Rights Notices, dated 2/15/2020 at 8:10 AM and 8:16 AM, indicated that Pt. #1 was placed in a physical hold and administered emergency medication (involuntarily); however, the record lacked documentation of a physician's order.

3. A telephone interview was conducted with one of Pt. #1's Physicians (MD#4) on 2/23/2022, at approximately 11:43 AM. MD#1 stated that if a patient needs to be restrained (by hard restraints or physical hold) to give a medication, an order should be placed in the record and a face-to-face evaluation completed within 1 hour.

Based on document review and interview, it was determined that for 1 of 3 records reviewed (Pt. #1) for restraint use, the Hospital failed to ensure that a 1-hour face-to-face evaluation was completed for a patient that was placed in a physical hold to administer a forced medication.

Findings include:

1. The Hospital's policy titled, "Restraints and Seclusion" (effective 7/19/2021), was reviewed on 2/23/2022 and required, "...If physical holding for forced medication is necessary with a violent patient, the 1-hour face-to-face evaluation requirement by the Credentialed Practitioner (CP) would also apply..."

2. The clinical record of Pt. #1 was reviewed on 2/22/2022 and 2/23/2022. Pt. #1 was admitted to the Hospital's Adult Behavioral Health Unit (8 East/8E) on 2/13/2020, with a diagnosis of schizoaffective disorder, bipolar type with psychotic features. Restriction of Rights Notices, dated 2/15/2020 at 8:10 AM and 8:16 AM, indicated that Pt. #1 was placed in a physical hold and administered emergency medication (involuntarily); however, the record lacked documentation that a physician face-to-face evaluation was conducted within 1-hour after the application of the physical hold.

3. A telephone interview was conducted with one of Pt. #1's Physicians (MD#4) on 2/23/2022, at approximately 11:43 AM. MD#1 stated that if a patient needs to be restrained (by hard restraints or physical hold) to give a medication, an order should be placed in the record and a face-to-face evaluation completed within 1 hour.