HospitalInspections.org

Based on document review and interview the facility failed to:

A. ensure that chemical restraints/emergency behavioral medications (EBM) administered were identified as a chemical restraint in 3 of 3 (Patient #1, #2, and #3) patient medical records reviewed.

B. ensure staff was educated on the administration of chemical restraints/EBM for side effects, respiratory or cardiac distress, and assessment of medication effectiveness and safety after administration in 3 of 3 (Patient #1, #2, and #3) patient medical records reviewed.

C. ensure chemical restraints were added to the restraint log and monitored through Risk and Quality in 3 of 3 (Patient #1, #2, and #3) patient medical records reviewed.

D. ensure the policy and procedure gave clear guidelines on assessing and reassessing a patient after administering a chemical restraint/EBM.

E. Ensure a face-to-face by the provider or trained RN was completed within one hour of the administration of a chemical restraint

The deficient practices were identified under the following Condition of Participation, CFR 482.13 Patient Rights, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death.

Refer to A0160

Based on document review and interview the facility failed to:

A. ensure that chemical restraints/emergency behavioral medications (EBM) administered were identified as a chemical restraint in 3 of 3 (Patient #1, #2, and #3) patient medical records reviewed.

B. ensure staff was educated on the administration of chemical restraints/EBM for side effects, respiratory or cardiac distress, and assessment of medication effectiveness and safety after administration in 3 of 3 (Patient #1, #2, and #3) patient medical records reviewed.

C. ensure chemical restraints were added to the restraint log and monitored through Risk and Quality in 3 of 3 (Patient #1, #2, and #3) patient medical records reviewed.

D. ensure the policy and procedure gave clear guidelines on assessing and reassessing a patient after administering a chemical restraint/EBM.

E. Ensure a face-to-face by the provider or trained RN was completed within one hour of the administration of a chemical restraint/EBM.



The deficient practices were identified under the following Condition of Participation, CFR 482.13 Patient Rights, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death.


A review of medical records was completed on December 13-14, 2023, with Staff #6, #7, and #15.

Findings:

Patient #1
Patient #1 was a 74-year-old male admitted to the hospital ER on 11/05/2023 at 9:28 PM. He was transferred from an outside Emergency Room with left upper quadrant pain, progressive dyspnea on exertion (shortness of breath while walking), and, increased bilateral lower extremity edema (swelling in the legs). He had a past medical history of Atrial Fibrillation, arrhythmia, Congestive Heart Failure, Coronary Artery Disease, Hypertension, Ischemic Cardiomyopathy, and Myocardial Infarction.

A review of the H&P documented by Physician #18 on 11/05/2023 at 10:55 PM revealed Patient #1 was negative for confusion, memory loss, anxiety, depression, and agitation. He was awake, alert, and oriented to time place, and person.

11/06/2023
A review of the medical record with Staff #6 revealed Patient #1 was given a chemical restraint/emergency behavioral medication on 11/06/2023 at 3:30 AM and 11/07/2023 at 2:23 AM.

A review of the progress note dated 11/06/2023 at 3:00 AM by RN Staff #19 was as follows:

"Found pt on the side of the bed. Pt confused. Called UT (Unit tech) to help RN (Registered Nurse) get pt back to bed. Pt refuses. Charge RN notified. Pt states "I got to go home to my wife." Reoriented pt that he's at the hospital. Called pt's wife to speak to pt. Pt refuses. Pt started cursing and threatening to leave. NP (Nurse Practitioner) called at bedside. See NP (Nurse Practitioner) notes and orders."


A review of the progress note dated 11/06/2023 at 3:07 AM by NP Staff #10 was as follows:

"Called by bedside RN that patient is very aggressive and trying to leave. Also, that patient has refused all nursing care. On arrival, patient 74 Y.O male being managed for left upper abdominal pain was seen sitting at the edge of the bed agitated and asking to go home. Patient refused to answer questions and all efforts to redirect and get him to calm down failed including charge RN arranging for patient's wife to speak to him. Patient denies pain of any kind. Charge RN paged security and code BERT (Behavioral Emergency Response Team) team to bedside.
Plan -IM Haldol 2mg x1 -Monitor."

A review of the document titled, "BERT TEAM" was as follows:

"WHEN A PATIENTS BEHAVIOR ESCALATES BEYOND THE CAPABILITY OF THE NURSING STAFF-ACTIVATE CODE BERT BY DIALING EXT. ****.
EXAMPLES INCLUDE BUT NOT LIMITED TO:
*VIOLENT BEHAVIOR
*THREATENING BEHAVIOR
*RISK OF VIOLENT BEHAVIOR
*HARM TO SELF OR OTHERS
*BEHAVIOR REQUIRING PHYSICAL HOLD
*THREATENING AMA WITHOUT DECISION-MAKING CAPACITY

B.E.R.T. (BEHAVIORAL EMERGENCY RESPONSE TEAM) WILL RESPOND TO THE ACTIVATION AND CONSISTS OF THE FOLLOWING PEOPLE:
*HOUSE SUPERVISOR
*CHARGE NURSE FOR THE UNIT
*PRIMARY NURSE FOR THE PATIENT
*SECURITY PERSONNEL
*DURING WORKING HOURS THE FOLLOWING WILL RESPOND: CLINICAL DIRECTOR, TEAM LEADER, SOCIAL WORKER."

During an interview with RN Staff #6 on 12/13/2023, RN Staff #6 confirmed the BERT TEAM was used for de-escalation or assistance when a patient became aggressive or violent. She was asked if the patient became physically aggressive with the staff or if Patient #1 was actively trying to leave. She confirmed there was no documentation of any physical aggression and that he was only threatening to leave. He also refused to answer any questions and refused all nursing care. She stated they tried to talk to him and get him to talk to his wife on the phone, but he refused that also. RN Staff #6 was asked if any oral medications were offered to him at the time before the IM injection and she confirmed there was no documentation that any oral medications were offered or given to the patient. She also confirmed there was no documentation of who arrived for the Code BERT, who assisted with the code, and what was done.

An email dated 11/06/2023 at 5:39 AM from Security Staff #25 titled "Significant Events" provided for review was as follows:
"Patient disturbance for the patient in room D381. Patient #1 was confused and being aggressive towards staff. Staff gave patient some medication with no issues. Security was stand by only."

RN Staff #6 confirmed there was no documentation that a Physician was notified that a chemical restraint/EMB was ordered by NP Staff #10 on 11/06/2023.


A review of the medication order dated 11/06/2023 at 3:23 AM by NP Staff #10 was as follows:

" ...Haldol 2mg (antipsychotic medication) IM (intramuscular) Routine Once

Indications for Use: Severe agitation
Indications comment: Acute Undifferentiated Agitation
Is this medication being used for a chemical restraint? No.
This drug or medication is used within the pharmaceutical parameters based on standard of practice using established dosage parameters. Use of this medication is to allow the patient to be able to continue to interact/function with their environment and return to normal behavior. It is not being used to restrict their ability to interact with their environment ..."

Haldol 2mg IM was administered by RN Staff #19 on 11/06/2023 at 3:30 AM.

RN Staff #6 confirmed the Haldol medication given to Patient #1 was to control his unwanted behavior. The medication was not given to make the patient therapeutic in his environment at 3:30 AM. The patient was not given any other options such as oral medications.


Further review revealed NP Staff #10 wrote additional orders on 11/06/2023 at 3:23 AM. The orders were as follows:

" ...BP (blood pressure), HR (Heart rate), RR (respiratory rate), SPO2 (oxygen level), and LOC (level of consciousness) immediately prior to administration

Vital signs (BP, HR, RR, SPO2, and LOC).
Order Comments: Monitor vital signs every 15 mins x 4, every 30 mins x 2, then every hour until RASS is 0/-1. Once the RASS is = to 0/-1, stop with frequent vitals, continue with previously ordered vitals

Richmond Agitation Sedation Scale (A scale that is mostly applied in mechanically-ventilated patients, but may be used for any individual who is hospitalized. Regular administration and assessment is particularly useful for patients who are critically-ill, are receiving sedative medications, and/or demonstrate fluctuating levels of consciousness) Comments: Monitor RASS 15 mins x 4, every 30 min x 2, then every 1 hour until RASS 0/-1. Patient needs to be in line of sight at all times ..."

A review of the vital signs flow sheet dated 11/06/2023 documented by RN Staff #19 revealed vital signs (BP, Pulse, Respirations, Temperature, and O2 Saturations) were documented at 12:15 AM. Patient #1 refused all vital signs at 3:30 AM. Staff #6 confirmed the next set of vital signs was taken at 5:36 AM and 7:01 AM.

RN Staff #19 documented a RASS score at 3:30 AM-Very agitated (+3), 3:45 AM- alert and calm (0), 4:00 AM -drowsy (-1), 4:15 AM - drowsy (-1), 4:30 AM -drowsy (-1).

According to asahq.org, the Richmond Agitation Sedation Scale was as follows:
" ...+4- Combative
+3- Very agitated
+2- Agitated
+1- Restless
0 -Alert and calm
-1 Drowsy
-2 Light sedation
-3 Moderate Sedation
-4 Deep sedation
-5 Unarousable ..."

Staff #6 confirmed there was no further documentation explaining the missed vital signs or RASS Score documentation.

An interview was conducted with RN Staff #7 and RN Staff #15 on 12/14/2023 at 11:05 AM. RN Staff #7 was asked how frequently and how long the nurse was supposed to monitor the patient after a chemical restraint/EBM was given. RN Staff #7 stated, "If a medication is ordered as a chemical restraint an additional order will populate and give strict instructions on how often and how long the patient is to be monitored. If the medication order is not ordered as a chemical restraint, then the provider gives additional orders for the monitoring of the patient or the patient will be monitored according to the original orders when they were admitted."


11/07/2023
A review of the medication order dated 11/07/2023 at 1:57 AM by NP Staff #10 was as follows:

"Haldol 2mg IM Routine Once
Indications Comment: Acute Undifferentiated Agitation.
Is this medication being used for a chemical restraint? No.
This drug or medication is used within the pharmaceutical parameters based on standard of practice using established dosage parameters. Use of this medication is to allow the patient to be able to continue to interact/function with their environment and return to normal behavior. It is not being used to restrict their ability to interact with their environment ..."
Haldol 2mg IM was administered by Staff #17 on 11/07/2023 at 2:23 AM.

Further review revealed NP Staff #10 wrote additional orders on 11/07/2023 at 1:57 AM. The orders were as follows:

" ...BP, HR, RR, SPO2, and LOC immediately prior to administration.

Vital signs - BP, HR, RR, SPO2, and LOC.
Order Comments: Monitor vital signs every 15 mins x 4, every 30 mins x 2, then every hour until RASS is 0/-1. Once the RASS is = to 0/-1, stop with frequent vitals, continue with previously ordered vitals.

Richmond Agitation Sedation Scale (RASS)
Order Comments: Monitor RASS 15 mins x 4, every 30 min x 2, then every 1 hour until RASS 0/-1. Patient needs to be in line of sight at all times..."

A review of the vital signs flow sheet revealed the only set of vital signs taken before the Haldol IM injection was given was at 12:07 AM on 11/07/2023. The Haldol IM injection was given to Patient #1 at 2:23 AM. The UT (unit tech) documented that Patient #1 was irritable, and no vital signs were taken at 3:00 AM and the next vital signs were taken at 5:36 AM. This was greater than 3 hours after the Haldol injection was administered IM.

RN Staff #6 confirmed there was no further documentation explaining the missed vital signs and no documentation that the patient refused his vital signs.

A RASS Score was documented by RN Staff #17 on 11/07/2023 at 2:23 AM as very agitated (+3), RN Staff #29 documented a RASS Score at 7:15 AM as Alert and calm (0), and Staff #30 documented a RASS Score at 8:43 PM as Alert and calm (0).

RN Staff #6 confirmed there was no progress note by a physician or NP that documented the patient's behaviors before ordering the chemical restraint/EBM to control the patient's unwanted behavior. It was also confirmed there were no de-escalation techniques documented or oral medication offered before the IM Haldol administration.


A review of a progress note dated 11/07/2023 at 5:56 AM by RN Staff #20 was as follows:

" ...Patient unable to rest and became agitated last night and threatening the staff while trying to leave his room. IM (Intramuscular) Haldol given by charge nurse. Patient able to rest afterwards ..."

RN Staff #6 confirmed there was no documentation in the medical record that the patient's behavior or imminent threat to himself or others described the need for an IM injection of antipsychotic medication for the use of a chemical restraint/emergency behavioral medication. There was also no documentation on how this medication would benefit the patient in a therapeutic situation if it was for medical use.


A review of the progress note dated 11/07/203 at 5:32 PM by RN Staff #29 was as follows:

"Patient's wife expressed concerns over patient left upper arm swelling and significant bruising stating "What happened to his arm, this wasn't there yesterday". Patient was given Haldol last night due to confusion and aggressive behavior threatening staff members and threatening and attempting to leave. The patient states a man tried to stop him from leaving grabbed his arm and threw him back in the bed. An ultrasound of the patient's left arm was completed this afternoon which showed no signs of DVT but a large hematoma. Patient has been drowsy on and off this shift. Patient's wife states she believes patient has dementia but that he has not been diagnosed with it. Patient is currently sitting up in chair eating his dinner, on room air and calm and cooperative. Sitter is in room and tele sitter will also be placed in room this evening to monitor patient."

During an interview with Staff #7 on 12/13/2023, RN Staff #7 stated," It looks like the staff gave the medication for the patient's behavior but they failed to document what the behavior was for several hours after the antipsychotic medication was administered.


An interview was conducted on 12/13/2023 after 11:00 AM with Physician #8, CMO (Chief Medical Officer). He was not the patient's treating physician, nor was he involved in his care.
CMO, Physician #8 stated the medications given IM to Patient #1 were not given as a chemical restraint/emergency behavioral medication but were given to the patient to control his delirium. CMO, Physician #8, stated, "The patient was already on this classification of medication."

During the interview with the CMO, Physician #8, it was confirmed the documentation by the staff read the IM Haldol medication was given for an unwanted behavior that needed to be stopped before the patient hurt himself or the staff on 11/06/2023. Then given to the patient again on 11/07/2023 but there were no documented aggressive behaviors until hours after the medication was given on 11/07/2023.
The surveyor went over the findings with the CMO, Physician #8 concerning the fact that Patient #1 was not monitored closely or according to the physician's orders and that any patient receiving Haldol should be monitored closely for heart arrhythmia and other complications. CMO Physician #8 said, "Well the warning is for a possible QT-prolongation and that is rare."



According to the Texas Administrative Code, Rule 415.260 (b)(1) only a physician member of the facility's medical staff may order restraint or seclusion for a behavioral emergency. Nurse Practitioners were not allowed to order restraint or seclusion for behavioral emergencies.

CMO Physician #8 stated, "Well they are not ordering them as a restraint. If the provider orders the medication as, "Management of Acute Agitation/Delirium or Undifferentiated Agitation/Delirium (to allow the patient to better interact with his/her environment)" it was not a chemical restraint or an emergency behavioral medication."

During an interview on 12/14/2023 at 9:20 AM with RN Staff #3 and RN Staff #5, RN Staff #3 stated, "If the patient has a history of an illness and they are already on the same classification of antipsychotic medications then an IM injection was not considered a chemical restraint."


According to the FDA, precautions must be taken when administering Haldol to patients
.
" ...PRECAUTIONS HALDOL (haloperidol) should be administered cautiously to patients: ? with severe cardiovascular disorders, because of the possibility of transient hypotension and/or precipitation of anginal pain ..."

Patient #1 had a known history of Atrial Fibrillation, arrhythmia, Congestive Heart Failure, Coronary Artery Disease, Hypertension, Ischemic Cardiomyopathy, and Myocardial Infarction.
Without proper monitoring of patients receiving IM Haldol, patients are at a greater risk of complications and subsequent death.


RN Staff #6 and RN Staff #7 confirmed there was no 1-hour face-to-face evaluation completed by a physician, LIP (Licensed independent practitioner), or a trained RN for the chemical restraints/emergency behavioral medications administered to Patient #1 on 11/06/2023 or 11/07/2023.


Patient #2
Patient #2 was a 68-year-old female who arrived at the hospital by ambulance on 11/21/2023 at 11:12 PM. She had a history of alcohol abuse and high blood pressure. Her chief complaint was nightmares/hallucinations.

A review of the History documented by Physician #34 at 11:13 PM was as follows:

" ...68-year-old female with a history of alcohol abuse and Hypertension presents to the ER by EMS (Emergency Medical Services) complaining of nightmare. Pt declined to provide more information. Review of systems limited due to patient being uncooperative ...
Physical Exam: Neurological: She is alert and oriented to person, place, and time.
Psychiatric: Behavior is uncooperative ..."

RN Staff #35 documented at 11:43 PM that the patient was recently discharged after being admitted on 11/11/2023 for ETOH (alcohol) withdrawal. Got home and started hallucinating.

The nursing assessment documented on 11/21/2023 at 11:48 PM revealed the patient was alert, hallucinating, had poor concentration, and was confused. The patient was placed on suicide precautions and a sitter was assigned for observations. Behavioral monitoring by the RN was scheduled for every hour. RN Staff #21 was assigned as the primary nurse at 1:17 AM on 11/22/2023.

A review of the documentation by RN Staff #35 dated 11/22/2023 at 1:00 AM was as follows:
" ...Patient was anxious, non-compliant, uncooperative, aggressive verbally, angry, and confused. Sitter at bedside."

On 11/21/2023 at 1:25 AM Physician #22 documented that the RN notified her that the patient was requesting to leave. Further documentation revealed, "Upon re-evaluation pt denies SI, HI. Pt has very poor insight, with rambling and nonsensical answers to questions. Do not feel discharge appropriate at this time. Discussed with RN that pt will need to be evaluated for POW if she tries to elope."
At 1:42 AM RN Staff #21 documented, "RN contacted Tyler PD and spoke with **** to establish POW (police Officers Warrant). RN was informed that an officer would be up here at the ER shortly. MD aware."

Further review of the medical record revealed Physician #22 placed an order for Zyprexa. The order was as follows:

" ...11/22/2023 at 1:43 AM Zyprexa 10mg IM STAT Once
Indication of use: Severe Agitation
Indications comment: Bipolar Mania ...
Is this medication being used for a chemical restraint? No.
This drug or medication is used within the pharmaceutical parameters based on standard of practice using established dosage parameters. Use of this medication is to allow the patient to be able to continue to interact/function with their environment and return to normal behavior. It is not being used to restrict their ability to interact with their environment ..."

Zyprexa (antipsychotic medication) 10mg IM was administered by the RN at 1:55 AM on 11/22/2023.

RN Staff #6 confirmed vital signs were taken by RN Staff #23 on 11/22/2023 at 1:55 AM and a RASS Score of "Very Agitated" was documented by Staff #23 at 1:55 AM. This was completed at the same time the Zyprexa medication was given IM to the patient. RN Staff #23 completed another RASS Assessment at 2:00 AM with a RASS score of "Alert and Calm". The next set of vital signs was not taken until 11/22/2023 at 7:24 AM. This was greater than 4 hours after the administration of a chemical restraint/EBM.

A review of the Behavioral Monitoring documented on 11/22/2023 at 1:00 AM revealed the patient was anxious, noncompliant, uncooperative, confused, and verbally aggressive.

RN Staff #6 confirmed that Behavioral Monitoring was usually completed every hour on a patient in the Emergency Room (ER). RN Staff #6 confirmed there was no documentation of less restrictive interventions attempted before giving a chemical restraint/emergency behavioral medication to Patient #2 to control the patient's behavior. She also confirmed there was no documentation of the effects of the Zyprexa or the patient's response to the medication.

Further review of the physician orders revealed;

" ...11/22/2023 at 9:31 PM Haldol 5mg IM STAT Once
Indication of use: Severe Agitation ...
Is this medication being used for a chemical restraint? No.
This drug or medication is used within the pharmaceutical parameters based on standard of practice using established dosage parameters. Use of this medication is to allow the patient to be able to continue to interact/function with their environment and return to normal behavior. It is not being used to restrict their ability to interact with their environment ..."

Staff #6 confirmed the behavioral monitoring documented on 11/22/2023 at 9:00 PM revealed the patient was calm and sleeping. Haldol IM was given at 9:58 PM and the behavioral monitoring at 10:00 PM was documented as the patient was awake and verbally aggressive.

Haldol 5mg IM was administered by the RN at 9:58 PM on 11/22/2023.


" ...11/23/2023 at 3:47 PM Haldol 5mg IM STAT Once
Indication of use: Psychosis ...
Is this medication being used for a chemical restraint? No.
This drug or medication is used within the pharmaceutical parameters based on standard of practice using established dosage parameters. Use of this medication is to allow the patient to be able to continue to interact/function with their environment and return to normal behavior. It is not being used to restrict their ability to interact with their environment ..."

Haldol 5mg IM was administered by the RN at 5:41 PM on 11/23/2023. This medication was administered 1 hour and 54 minutes after a STAT order was placed for Psychosis.
Staff #6 confirmed there was no documentation that the physician was notified of the late administration of the IM Haldol and no documentation was found if the patient was still experiencing a behavioral emergency that required an emergency behavioral medical/chemical restraint. There was no documentation of the behaviors the patient was exhibiting at the time the RN gave the IM injection. Vital signs were taken at the time of the administration of the IM Haldol and not again until 12:24 AM on 11/24/2023. This was greater than 6 hours after the chemical restraint/emergency behavioral medication was administered.

An interview was conducted on 12/14/2023 after 10:00 AM with RN Staff #12 and RN Staff #13. RN Staff #12 was asked what was the least restrictive restraint used on a patient who was a threat to himself or others. RN Staff #12 replied, "I would think it would be a shot." Staff #13 was asked if he would try to de-escalate the patient or place them in restraints before giving medication to control the patient's behavior. RN Staff #13 replied, "We do not have a vest or a restraint chair and we prefer not to tie the patient down so we would give them a shot if we were not able to redirect them or de-escalate them by talking to them."

RN Staff #13 was not aware that the "shot" was the most restrictive form of restraint due to no antidote was available for the injection. The medication cannot end immediately and would require hours for the medication to metabolize.


Patient #3
Patient #3 was a 63-year-old male admitted to the Emergency Room on 12/03/2023 after a fall at the Nursing Home. He was transferred to the ICU (Intensive Care Unit) on 12/03/2023. The patient had a medical history of Chronic back pain, Chronic Obstructive Pulmonary Disease (COPD), Stroke, Depression, Type 2 Diabetes, Gastroesophageal Reflux Disease, Hypertension, Seizures, and at the time of admission he was positive for COVID-19.

A review of the ER Physician note dated 12/03/2023 at 7:16 AM revealed the patient was alert and oriented to person, place, and time with no cranial nerve deficit on admission. His behavior was noted as normal.

RN Staff #13 documented a verbal order was given to the ER Nurse to start Precedex (a medication used for sedation) on 12/03/2023 at 1:00 PM. There was no indication for use documented on the medication order. Staff #15 also confirmed there was no documentation in the ER medical record indicating the need for a sedating medication. Patient #3 was started on an IV (intravenous) continuous infusion of Precedex on 12/03/2023 at 1:00 PM for agitation. Precedex was discontinued by Physician #31 on 12/05/2023 at 9:34 due to bradycardia (low heart rate).

A review of Physician #36's documentation on 12/05/2023 at 8:35 AM revealed the patient was on Precedex for agitation.

A review of the medication order dated 12/05/2023 at 9:36 AM by Physician #31 was as follows:

" ...Zyprexa (antipsychotic medication) 5mg IM Routine Once
Indications for Use: Severe agitation
Is this medication being used for a chemical restraint? No.
This drug or medication is used within the pharmaceutical parameters based on standard of practice using established dosage parameters. Use of this medication is to allow the patient to be able to continue to interact/function with their environment and return to normal behavior. It is not being used to restrict their ability to interact with their environment ..."

Zyprexa 5 mg IM was administered by RN Staff #33 on 12/05/2023 at 10:24 AM.

A review of the chemical restraint/frequent monitoring documentation dated 12/05/2023 at 10:18 AM with RN Staff #15 revealed the patient was physically and verbally aggressive, he was severely confused, had impaired judgment, combative, climbing out of bed, violent towards self, and others, and unable to control destructive behavior.

RN Staff #15 confirmed the Zyprexa 5mg IM administered on 12/05/2023 at 10:24 AM was not ordered by Physician #31 as a chemical restraint

Further review revealed Physician #31 wrote additional orders on 12/05/2023 at 9:36 AM. The orders were as follows:

" ...BP, HR, RR, SPO2, and LOC immediately prior to administration.

Vital signs (BP, HR, RR, SPO2, and LOC).
Order Comments: Monitor vital signs every 15 mins x 4, every 30 mins x 2, then every hour until RASS is 0/-1. Once the RASS is = to 0/-1, stop with frequent vitals, continue with previously ordered vitals.

Richmond Agitation Sedation Scale (Richmond Agitation Sedation Scale-a scale used to determine the sedation score of someone deeply sedated in the ICU on a ventilator) Comments: Monitor RASS 15 mins x 4, every 30 min x 2, then every 1 hour until RASS 0/-1. Patient needs to be in line of sight at all times ..."

A review of the progress note dated 12/05/2023 at 6:27 PM by RN Staff #33 was as follows:
" ...Multiple attempts to hit at staff, verbally aggressive
Continuously yells out despite attempts to calm
Continuously attempts to jump out of the bed
10 mg Zyprexa IM given total- ineffective
10 mg Geodon given- ineffective ..."

A review of the progress note dated 12/05/2023 at 6:40 PM by Physician #31 stated, " ... Patient is agitated and combative, restless, Precedex causes bradycardia, Zyprexa, x 2, and Geodon x 1 administered during the shift ..."


Further review of the medical record on 12/14/2023 with RN Staff #15 revealed vital signs were taken at 10:00 AM, 11:00 AM, 11:30 AM, 12:00 AM, 1:00 PM, and 1:30 PM.
RN Staff #15 confirmed nursing staff failed to monitor Patient #3's vital signs as ordered by Physician #31.

RN Staff #7 was asked how she was able to monitor chemical restraints if the IM/IV psychotropic medications were not ordered as a chemical restraint. She stated, "The medications have to be ordered as a chemical restraint for them to populate to the restraint log. If they are not ordered correctly then they do not populate to the restraint log and there is no way for me to know that the medication was given. We do monitor the medications that are used and identified as a chemical restraint. It is clear that we are not capturing all of these restraints that are ordered for behavioral emergencies because of the way they are ordered by the provider.

Further review of medication orders for Patient #3 revealed the following:

" ...12/05/2023 at 12:52 AM by Physician #31
Zyprexa 5mg IM STAT (immediate/rush) Once
Indications for use: Aggressive Behavior and Severe Agitation.
Is the patient an immediate threat to self or others? Yes
Is this being used as a chemical restraint? Yes
Chemical Restraint: Use of a sedating psychotropic drug to manage, control behavior or restrict patients freedom that's not a usual or customary standard of treatment for patients medical or psych conditions.
Have non-chemical restraints been used and failed: Yes ..."

Zyprexa 5 mg IM was administered on 12/05/2023 at 1:45 PM by RN Staff #33. This was 52 minutes after Physician #31 ordered the medication STAT when Patient #3 was experiencing a behavioral emergency exhibiting Aggressive Behavior and Severe Agitation.


Further review revealed Physician #31 wrote additional orders on 12/05/2023 at 12:52 PM. The orders were as follows:

" ...BP, HR, RR, SPO2, and LOC immediately prior to administration.

Vital signs (BP, HR, RR, SPO2, and LOC).
Order Comments: Monitor vital signs every 15 mins x 4, every 30 mins x 2, then every hour until RASS is 0/-1. Once the RASS is = to 0/-1, stop with frequent vitals, continue with previously ordered vitals.

Richmond Agitation Sedation Scale (Richmond Agitation Sedation Scale-a scale used to determine the sedation score of someone deeply sedated in the ICU on a ventilator) Comments: Monitor RASS 15 mins x 4, every 30 min x 2, then every 1 hour until RASS 0/-1. Patient needs to be in line of sight at all times ..."


A review of the medical record with RN Staff #15 confirmed Vital signs were taken at 1:30 PM, 2:50 PM (pulse only), 3:00 PM, 3:30 PM (pulse only), and 4:00 PM.
It was also confirmed the RASS Score was documented at 2:00 PM, 2:15 PM, 2:30 PM, 3:00 PM, and 3:30 PM. All times were documented as Very Agitated/+3 RASS Score.

RN Staff #15 confirmed vital signs and RASS assessments were not conducted according to Physician #31's orders.

Further review of medication orders for Patient #3 revealed the following:

" ...12/05/2023 at 2:24 PM by Physician #31
Geodon (antipsychotic medication) 10 mg IM STAT Once
Indications for use: Aggressive Behavior and Severe Agitation.
Is the patient an immediate threat to self or others? Yes
Is this being used as a chemical restraint? Yes
Chemical Restraint: Use of a sedating psychotropic drug to manage, control behavior or restrict patients freedom that's not a usual or customary standard of treatment for patients medical or psych condition.
Have non-chemical restraints been used and failed: Yes ..."

Geodon (antipsychotic medication) 10mg IM STAT was administered on 12/05/2023 at 3:03 PM by Staff #33. This was 38 minutes after Physician #31 ordered the medication STAT when Patient #3 was experiencing a behavioral emergency due to Aggressive Behavior and Severe Agitation.

Further review revealed Physician #31 wrote additional orders on 12/05/2023 at 2:24 PM. The orders were as follows:

" ...BP, HR, RR, SPO2, and LOC immediately prior to administration.

Vital signs (BP, HR, RR, SPO2, and LOC).
Order Comments: Monitor vital signs every 15 mins x 4, every 30 mins x 2, then every hour until RASS is 0/-1. Once the RASS is = to 0/-1, stop with frequent vitals, continue with previously ordered vitals.

Richmond Agitation Sedation Scale: Order Comments: Monitor RASS 15 mins x 4, every 30 min x 2, then every 1 hour until RASS 0/-1. Patient needs to be in line of sight at all times ..."

A review of the medical record with RN Staff #15 confirmed Vital signs were taken at 3:00 PM (no blood pressure), 4:00 PM, 4:30 PM, 5:00 (no blood pressure), 5:08 PM, and 5:30 PM.
It was also confirmed the RASS Score was documented at 3:00 PM, 3:30 PM, 3:45 PM, 4:00 PM, 4:30 PM, 5:00 PM, and 5:30 PM. All times were documented as Very Agitated/+3 RASS Score.

Staff #15 confirmed vital signs and RASS assessments were not conducted according to Physician #31's orders.


A review of the progress note dated 12/05/2023 at 6:44 PM was as follows:

" ...Patient is agitated and combative, restless, Precedex causes bradycardia, Zyprexa, x 2, and Geodon x 1 administered during the shift ..."

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