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BAPTIST HEALTH MEDICAL CENTER-LITTLE ROCK 9601 INTERSTATE LITTLE ROCK, AR 72205 April 28, 2015
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of clinical records and interview, it was determined the Facility failed to demonstrate the intervention, PRN (as needed) medication, used for agitation was the least restrictive intervention based on the individual assessment for 4 (#9, #1, #6 and #7) of 11(#9, #1, #5-#7, #15-#17, #19, #22 and #23) patients that received Haldol for agitation. This failed practice affected patients (#9, #1, #6 and #7) and had the likelihood to affect all patients admitted to the Behavioral Health Unit. The findings were:

1. Clinical record review for Patient #9 revealed Patient #9 was admitted [DATE] through 03/10/15. Review of the History and Physical revealed a diagnosis: Alzheimer ' s dementia with behavioral disturbance.
A. Progress Note dated 03/03/15 at 1930 revealed " Pt (patient) received this shift up in dayroom. Mood anxious at this time. A&O (alert and oriented) to name only. Keep stating she wants to go home. Pt wandering in & out of other patient ' s rooms. Given Haldol 3 mg PO (by mouth) at 2050. Pt helped to bed ... " . There was no evidence how the Nurse determined the milligram (1-5) of Haldol to use based on the level of agitation. Patient #9 had only one dose of Haldol during administration however Haldol for agitation was not part of the Patient #9 ' s home medications nor was it continued after discharge.
B. Medications-All Orders revealed:
1) An order for haloperidol (HALDOL) 2mg/mL (concentrated solution) 1-5mg. Every 6 hours PRN 03/02/15-03/10/15 for agitation. The order was not clear and concise to address the level of agitation to administer Haldol 1mg versus the maximum of 5mg.
2) An additional order for haloperidol (HALDOL) (injection) 1-5mg. Every 6 hours PRN 03/02/15-03/10/15 for agitation.
C. Multi-Disciplinary Problems (Active) revealed no evidence agitation was a problem. There were no interventions listed to try before administration of PRN medication for agitation.
D. It was determined the patient ' s behavior was documented but there was no evidence the underlying reason for the agitation was assessed.
E. The above information was verified on 04/28/15 at 1005 by the Unit Supervisor of Behavioral Services.
2. Clinical record review for Patient #1 revealed Patient #1 was admitted [DATE] through 01/06/15. Review of the Admission Diagnosis revealed a diagnosis: Dementia with psychotic symptoms.
A. Progress Note dated 12/09/14 revealed " ...confused with situation at times, does not realize she is in the hospital. Took meds without difficulty. Ambulated to bedroom with staff assist. 25mg Vistaril PO for agitation at 0141, wanted to call her Daddy to tell him where is was. Back to bed. Awake again asking to phone home, 1mg Haldol IM given at 0254. Calmed down and returned to her bed. " Vistaril 25mg PO was ordered for anxiety not agitation. There was no assessment of the level of the patient ' s agitation to warrant the use of Haldol. Haldol for agitation was not part of the Patient #1 ' s home medications nor was it continued after discharge.
Additional Progress Note dated 12/12/14 revealed " Patient awake and sitting on side of bed. She is complaining of a " gas leak " and points to the foot of her bed and says, " Don ' t your see that? Can ' t you hear that? ...those pipes are leaking, they are spewing, can ' t you hear that." Haldol concentrated solution given at 02:36 per orders PRN ... " . There was no assessment of the level of the patient ' s agitation to warrant the use of Haldol.
B. Medications-All Orders revealed:
1) An order for haloperidol lactate (HALDOL) (injection) 1 mg. Every 4 hours PRN 12/07/14 through 01/06/15 for Agitation.
2) An additional order for haloperidol 2mg/mL (concentrated solution) 1mg. Every 4 hours PRN 12/07/14 through 01/06/15 for Agitation.
3) An order for hydroxyzine (Atarax) (tablet) 25mg. Every 4 hours PRN 12//07/14 through 01/06/15 for anxiety
C. Multi-Disciplinary Problems (Active) revealed no evidence agitation was a problem. There were no interventions listed to try before administration of PRN medication for agitation.
D. It was determined the patient ' s behavior was documented but there was no evidence the underlying reason for the agitation was assessed.
E. The above information was verified on 04/28/15 at 1005 by the Unit Supervisor of Behavioral Services.
3. Clinical record review for Patient #6 revealed Patient #6 was admitted [DATE] and discharged [DATE]. Review of the History and Physical revealed a tentative diagnosis of Dementia of the Alzheimer's Type with behavioral disturbance.
A. Progress Note dated 10-22-14 at 0319 revealed "0248 Awoke yelling about the bed sheets. Having visual hallucinations of the bed being on fire, began crying and stated, "I'm scared of the man shaking the bed". Administered Haldol 1mg IM." There was no assessment of the level of the patient's agitation to warrant the use of Haldol.
B. Medications-All Orders revealed:
1) haloperidol (HALDOL) 2mg/mL (concentrated solution) 1 mg Every 4 hours PRN 10/21/14-10/28/14 for Agitation
2) haloperidol (HALDOL) (injection) 1 mg Every 4 hours PRN 10/21/14-11/03/14 for Agitation
3) haloperidol (HALDOL) (injection) 3mg Every 4 hours PRN 10/22/14-10/22/14 for Agitation
4) haloperidol (HALDOL) (injection) 5mg Every 4 hours PRN 10/22/14-10/23/14 for Agitation
5) haloperidol (HALDOL) (injection) 2mg Every 4 hours PRN 10/23/14-11/03/14 for Agitation
6) haloperidol (HALDOL) 2mg/mL (concentrated solution) 1-5mg Every 4 hours PRN 10/28/14-11/03/14 for Agitation There was no evidence how the Nurse determined the milligram (1-5) of Haldol to use based on the level of agitation. The order was not clear and concise to address the level of agitation to administer Haldol 1mg versus the maximum of 5mg.
7) haloperidol (HALDOL) 2mg/mL (concentrated solution) 2-5mg Every 4 hours PRN 10/28/14-11/03/14 for Agitation There was no evidence how the Nurse determined the milligram (1-5) of Haldol to use based on the level of agitation. The order was not clear and concise to address the level of agitation to administer Haldol 1mg versus the maximum of 5mg.
C. Multi-Disciplinary Problems (Active) revealed no evidence agitation was a problem. There were no interventions listed to try before administration of PRN medication for agitation.
D. It was determined the patient's behavior was documented but there was no evidence the underlying reason for the agitation was assessed.
E. The above information was verified on 04/28/15 at 1005 by the Unit Supervisor of Behavioral Services.
4. Clinical record review for Patient #7 revealed Patient #7 was admitted [DATE] and discharged [DATE]. Review of the History and Physical revealed a tentative diagnosis of Dementia of the Alzheimer's Type with behavioral disturbance.
A. Progress Note dated 01/01/15 at 1041 revealed "Patient continues to yell out, demanding with staff, complaining of pain to leg, patient repositioned for comfort, continues to yell out and on the call light, water given, Haldol 5 mg given PO (by mouth)." There was no assessment of the level of the patient's agitation to warrant the use of Haldol.
Additional Progress Note dated 01/01/15 at 1819 revealed " Patient in her room, patient yelling out at this time, she has ripped her diaper off and threw it her gown in the floor, unable to redirect her at this time, Haldol 5 mg po given ... " . There was no assessment of the level of the patient ' s agitation to warrant the use of Haldol. Haldol for agitation was not part of the Patient #7 ' s home medications nor was it continued after discharge.
B. Medications-All Orders revealed:
1) haloperidol (HALDOL) 2mg/L (concentrated solution) 5mg Every 4 hours PRN 12/31/14-01/09/15 for Agitation
2) haloperidol lactate (HALDOL) (injection) 5mg Every 4 hours PRN 12/31/14-01/09/15 for Agitation
C. Multi-Disciplinary Problems (Active) revealed no evidence agitation was a problem. There were no interventions listed to try before administration of PRN medication for agitation.
D. It was determined the patient ' s behavior was documented but there was no evidence the underlying reason for the agitation was assessed. Under Imaging-All Results XR Hip Left 2 Vw performed on 01/02/15 the following was documented: " 1. The films are not optimal in positioning. However, there does appear to be a subcapital femoral fracture on the left. "
E. The above information was verified on 04/28/15 at 1005 by the Unit Supervisor of Behavioral Services.