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Based on medical record review, document review, and staff interview, the facility did not ensure that medication is appropriately ordered for the agitated patient and is in accordance with the facility's policy. This finding was evident in one (1) of 13 medical records reviewed. (Patient #1)



Findings:

Review of the medical record for Patient #1 identified; a 47 year old female, was brought to the Emergency Department (ED) in restraints on 1/31/16 2141 (9:41 PM) and was triaged by Staff A at 2202 (10:02 PM). The chief complaint was "Erratic behavior."
The patient was medicated at 11:30 PM with 2mg of Ativan (Sedative, also used in medical procedures to reduce anxiety; to produce a calming effect) and 5 mg of Haloperidol (Anti-Psychotic medication used to treat certain types of mental disorders). The medication was ordered STAT, for agitation, (State of extreme arousal. An agitated person may feel stirred up, excited, tense, confused, or irritable), according to the medication administration record (MAR).
There is no, clinical justification in the medical record for the use of Ativan and Haloperidol as a standard treatment for this patient's condition. There is no indication that the patient had been on these medications prior to her visit to the ED. The use of these medications meets the facility's definition on restraints. This definition includes "....A drug or medication 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." (Policy For The Use Of Patient Restraints And Seclusion, Revised 2/6/15).
The policy also states that chemical restraints are not allowed at the facility.

Based on medical record review, document review, and staff interview, the facility did not implement its policies and procedures for management of the agitated patient. This finding was evident in one (1) of 13 medical records reviewed. (Patient #1)


Findings:

Review of the medical record for Patient #1 identified; a 47 year old female, was brought to the Emergency Department (ED) in restraints on 1/31/16 at 2141 (9:41 PM). The Prehospital Care Report Summary noted; "patient has been acting out", and patient was placed in 4 point restraints at 22:02 (10:02 PM), approximately 20 minutes after presentation to the Emergency Department.

The triage nurse did not describe and document the full extent of the patient ' s behaviors and did not notify the Agitated Patient Management Team (APMT) in accordance with the facility's policy titled "Agitated Patient Management Team " , (APMT), revised 12/31/2014.
The policy notes, " ..violent and uncontrollable behavior will be managed by the APMT. The team collaborates to provide immediate treatment to the agitated or violent patient and treats and manages symptoms of aggression, violence and agitation using de-escalation. "
The Policy also requires that the Medical Emergency Department activate the (APMT).

In a document titled "Orders for Restraints " , Staff B, patient ' s primary nurse noted that a 4 point restraint was initiated on the patient on 01/31/16 at 2202 (10:02 PM). Although Staff B noted in the Restraint Assessment Form that the patient was restrained for " safety (indicated for non-violent /non-self-destructive behavior e.g., attempting to remove medical devices such as NGT, Foley Cath, ETT, IV), " there was no documentation that the patient had any invasive medical devices. Staff B however noted that the activity/behavior of the patient prior to the application of a 4-point restraint was " restless and yelling, " but did not document the extent of the patient ' s behavior. The facility ' s policy " For The Use Of Patient Restraints And Seclusion, " requires staff to " document adequate, appropriate, clinical, compelling justification for restraint use, based on a patient ' s immediate assessed needs. "

At interview with Staff E (Risk Manager), on 02/24/16 at approximately 2:30 PM, she acknowledged that the APMT should have been activated for this patient.

Based on medical record review, document review, and staff interview, the nursing staff did not implement the facility's policy and procedures to ensure a licensed independent practitioner (L.I.P.) was notified following the emergency application of restraints. This finding was evident in one (1) of 13 medical records reviewed. (Patient #1)



Findings:

Review of the medical record for Patient #1 identified; a 47 year old female, was brought to the Emergency Department (ED) in restraints on 1/31/16 2141 (9:41 PM) and was triaged by Staff A at 2202 (10:02 PM). The chief complaint was "Erratic behavior."
At 2202 (10:02 PM), Staff B initiated an order for 4 point restraint on the patient, noting "safety (non-violent/ non-self-destructive behavior e.g., attempting to remove medical devices such as NGT, Foley Cath, ETT, IV)," and "Yelling and Restless" as the reason for restraints. This order for restraint was not signed by a physician.


The facility's policy titled "Policy For The Use Of Patient Restraints And Seclusion," (revised 2/16/15), stated: "If an emergency situation exists in which the patient is engaged in activity that presents an immediate danger to himself or others and a L.I.P is not immediately available, an RN may place a patient in restraint/seclusion. The RN must notify an L.I.P immediately, and write a progress note. The L.I.P must perform a face to face examination of a patient within 30 minutes and write an order for restraint."

There is no documentation in the medical record that the RN notified a physician regarding the restraint use on Patient #1; there were no written orders for restraints, signed by an L.I.P; and there was no documentation of a face to face examination.


These failures were verified at interview on 2/24/16 at 2:30 PM with Staff E (Risk Manager).

Based on medical record review, document review, and staff interview, the facility did not implement its policies and procedures for the monitoring a patient after placement of 4 point restraint and after the administration of medications. This finding was evident in one (1) of 13 medical records reviewed. (Patient #1)


Findings:

Review of the medical record for Patient # 1 identified; a 47 year old female, was brought to the Emergency Department (ED) in restraint on 1/31/16 at 2141 (9:41 PM). The chief complaint was "Erratic behavior."
At 2202 (10:02 PM) on 1/31/16, Staff B initiated an order for 4 point restraint.
At 2319(11:19) Haldol (Anti-Psychotic) 5mgs and Ativan (Anti-Anxiety) 2mgs was given intramuscularly for agitation.

There is no documentation that the patient received ongoing monitoring while in restraint, in accordance with the facility's policy titled, "Policy for the Use of Patient Restraints and Seclusion," last revised 2/6/15. The policy requires patients with wrist/ankle/mittens (4 point) restraint to be observed every 30 minutes and these observations are to be documented.
The required form for documenting these observation was blank and there was no documentation of any monitoring activities for this patient.


At approximately 2319 (11:19) on 1/31/15, Staff B also noted that Haldol (Anti-Psychotic) 5mgs and Ativan (Anti-Anxiety) 2mgs was given to the patient. The orders revealed that the clinical indication was agitation. There is no documentation that the patient received ongoing monitoring after the medications were given. The Facility's Policy titled "Medication Administration," revised 03/31/14, notes that all patients' responses to medication will be monitored; however the policy does not state the frequency or duration for monitoring of patients.

At interview with Staff E on 02/24/16 at approximately 2:30 PM, she acknowledged the patient was not monitored in accordance with facility's restraints and seclusion policy.

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Based on medical record review, document review and interview, the facility failed to ensure that patients in the Emergency Department (ED) are assessed, evaluated and monitored by the clinical staff in a timely manner and in accordance with the facility's policy and procedure. This was evident in one (1) of thirteen records reviewed.

This delay in assessment and monitoring resulted in patient harm.


Findings include:

See: Tag A-1104.

Based on medical record review, document review and staff interview, the facility did not ensure that the patient in the Emergency Department (ED) was assessed, monitored and evaluated by the clinical staff in a timely manner and in accordance with the facility's policy and procedure. This was evident in one (1) of thirteen records. (Patient #1)
This delay in assessment and monitoring resulted in patient harm.

Findings include:
Review of the medical record of Patient #1 identified the following: A 47 year old female with a history of depression and anxiety, was brought to the ED by EMS on 1/31/16 at 9:41 PM. The chief complaint reported by the family member to EMS was that the patient was "acting out in the last hour." The family member explained that the patient had no history of drug abuse, and that this episode of irrational behavior was a new onset.
The patient was triaged at Level 3 (Urgent) on 1/31/16 at 2202 (10:02 PM) for the chief complaint of "Erratic behavior." The triage nurse noted that she was unable to obtain vital signs because of the patient's behavior. The patient was described as being uncooperative.
The facility's policy titled "Triage of Emergency Department Patients," requires the RN to assess the patient and determine the Emergency Severity Index (ESI) level. The ESI levels from 1 - 5 identifies the need for treatment, based on patient symptoms, within a specific time frame. For example, Level 1 requires immediate treatment, Level 2 requires treatment within 30 minutes, and Level 3 requires treatment within 1 hour.
The triage classification chosen by the nurse was not appropriate for this patient. Current practice based on the "Emergency Severity Index version 4 Implementation Handbook," recommends a Level 2 for a patient presenting with new onset altered mental status, confusion, severe pain or distress.
The lack of vital signs at the time of triage is contrary to the facility's policy. The failure to establish a baseline at the time of presentation may negatively impact a patient's treatment because it may hinder the practitioner's ability to identify some of the patient's needs. There is no documentation to determine if the nurse made another attempt to obtain this baseline assessment in a timely manner.
On 1/31/16 At 2319 (11:19 PM), approximately 1 hr and 20 minutes after arrival in the ED, the patient's primary nurse, Staff B, noted the Nursing ED Assessment: vital signs of Temperature 101.3 F (Fahrenheit, normal 97.8 degrees F to 99 degrees F for a healthy adult) , Pulse 105 beats per minute(normal 60 to 100 beats a minute), Blood Pressure 134/88, Respirations 20, Oxygen Saturation 98%. The nurse also noted the patient was alert and responsive to verbal stimuli by opening her eyes. The patient was connected to oxygen and continuous saturation monitoring. The patient's temperature and heart rate were abnormal and there was no documented evidence of monitoring or a follow-up investigation of these findings until after the patient coded at approximately 2:50 AM on 2/1/16.
There was no documentation by Staff B that the patient was in a 4 point restraint at this time.

Upon arrival to the ED and after removal of the EMS restraints, the patient was placed in 4 point restraints by the primary nurse, Staff B. This is documented on 1/31/16 at 2202 (10:02 PM). This 4 point restraints was initiated prior to Staff B's nursing assessment at 11:19 PM. The patient was transported to a side room; she was attached to a pulse oximeter monitor.
Post restraint application monitoring was not found in the patient's medical record. As per the facility's Policy for Restraints and Seclusion, a patient in 4 point restraints requires monitoring every 30 minutes.
The policy also requires a Licensed Independent Practitioner (L.I.P) to perform a face to face evaluation within 30 minutes to determine the need for continuation of the restraints. The L.I.P must document his findings in a progress note. There was no practitioner progress note documenting an evaluation, the full rationale for the use of the restraint and the patient's response to the restraint application. These elements are required by the facility's restraint policy and is the current standard of practice.

On 1/31/16 at 2330 (11:30 PM) Patient #1 was ordered for 2mg Lorazepam intramuscularly (IM) and 5 mg of Haloperidol IM by the provider, Staff C; the medications were administered by Staff B at 11:30 PM. Staff B noted Staff C was at the bedside when the patient was medicated with Lorazepam and Haloperidol as ordered.
A partial Initial History and Physical dated 1/31/16 at 2333 (11:33 PM) is noted by the provider, Staff C. The provider obtained much of his information from the family member present. He noted "Pt is sleeping and unable to assess neuro." With an incomplete assessment, the provider determined a primary diagnosis, namely; "Unspecified psychosis not due to a substance or known physiological condition."
The provider's documentation on the patient was produced after he had ordered the psychotropic medications, which were administered by the nurse. There was no documentation related to the order and or the rationale for ordering these medications.

At interview with Staff E on 2/24/16 at 2:30 PM, surveyors were informed that the usual practice at this facility is for physicians to assess their patients prior to ordering psychotropic medications. This practice was not reflected in the facility's "Medication Administration" Policy and this was not done by the provider in this case.

A notation by Staff B, the primary nurse at 1:05 am on 2/1/16, indicated the patient was resting in the stretcher NAD (no acute distress) with oxygen via nasal cannula in use at 2 liters/minute. The nurse drew blood and collected urine at that time. There is no documentation about the patient's restraints at that point. There is no indication that they were either released or removed in view of the fact that the patient was noted to be "resting, in no acute distress."

Patient #1 remained in the room until approximately 2:50 AM on 2/1/16 when she was found without a pulse by Staff B, the primary nurse. The patient was successfully resuscitated and intubated. She was moved to another area and was seen by cardiology services. She was started in intravenous antibiotics. She was admitted to the Medical Intensive Care Unit (MICU) and experienced four more episodes of cardiac arrest before she could be transported to the unit. She was pronounced dead after the last attempt at resuscitation at 8:22 AM on 2/1/16.

At interview on 2/25/16 at 11:15 AM with the Attending Physician, surveyors were informed that she was called about 2:55 AM while she was finishing placement of a central line on another patient. It was the first time she had seen Patient #1 and she admitted she did not know how the patient presented because she was with another patient at the time.






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