The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

HIGHLANDS REGIONAL MEDICAL CENTER 5000 KENTUCKY ROUTE 321 PRESTONSBURG, KY 41653 Sept. 18, 2012
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interview, clinical record review, and review of the facility's policies and procedures, it was determined the facility failed to ensure patient rights were protected and promoted for patients selected for review. The facility failed to ensure patients had the right to be free from all forms of abuse/harassment (A0145), failed to ensure all patients were free from restraints imposed as means of coercion, discipline, or convenience of staff (A0154), failed to ensure the use of restraints was in accordance with the patients' written plan of care (A0166), failed to ensure the use of restraints was in accordance with the physician's order (A0168), and failed to ensure written policies/procedures related to the patient's right for visitation had reasonable restrictions (A0215).
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on observation, interview, record review, and facility policy review, it was determined the facility failed to protect the right of each patient to be free from all forms of abuse. A review of documentation revealed two of ten patients selected for review (Patient #1 and Patient #4) exhibited physically aggressive and sexually inappropriate behaviors and, as a result, other patients were subjected to Patient #1 and Patient #4's abusive behaviors. Patient #4 exhibited sexually inappropriate behaviors of kissing, rubbing, and touching other patients' private areas. The facility failed to develop a plan of care for Patients #1 and #4 with interventions that address the patients' sexually inappropriate and physically aggressive behaviors to ensure the rights/safety of the other patients were protected.

The findings include:

A review of the facility's Abuse, Neglect, Prevention and Investigation policy, revised November 2008, revealed each patient would be free from abuse and mistreatment. The review of the policy revealed abuse included physical harm, pain, mental anguish, verbal abuse, sexual abuse, or involuntary seclusion, and it was "the responsibility of all staff to provide a safe environment for the patients." In addition, the policy revealed suspected cases of patient abuse, neglect, or mistreatment would be reported immediately, thoroughly investigated, documented by the Administrator, and reported to the appropriate state agencies, physician, and families. According to the policy, abuse could occur between patient to patient, staff to patient, family to patient, or visitor to patient. The policy revealed, "If the accused is a patient, the individual should be placed in a supervised temporary separation in order to ensure that the rights of the patients will be protected." The review revealed all alleged violations of abuse of a patient would be immediately reported to the House Director, Chief Executive Officer (CEO), Vice President of Patient Care Services, and the facility's Social Services Department. In addition, according to the policy, the Administrator would thoroughly investigate and take steps to ensure and prevent further potential abuse during the investigation.

1. Review of Patient #4's medical record revealed the facility admitted the patient from a long term care facility on 08/31/12, due to reports that the patient exhibited sexually inappropriate behaviors (kissing and touching other patients/staff) and that staff was unable to redirect the patient. Patient #4's diagnoses at the time of admission included Alzheimer's type Dementia with behavioral disturbance.

A review of documentation in the physician's progress notes revealed on 09/04/12, Patient #4 exhibited sexually inappropriate and combative behaviors "overnight." Documentation in physician's progress notes also revealed on 09/06/12, Patient #4 had been "mean" to other patients, had been very "touchy" (touching/kissing others) and had been difficult to redirect. In addition, a review of documentation in physician's progress notes revealed on 09/09/12, at 11:04 PM, Patient #4 exhibited inappropriate behaviors with other patients such as kissing, touching, and wandering into other patients' rooms and that it had been difficult for staff to redirect the patient.

A review of Patient #4's nurse's progress notes revealed on 09/08/12, at 4:13 AM, on 09/09/12, at 1:03 AM, on 09/10/12, at 4:45 AM, and on 09/13/12, at 4:31 AM, Patient #4 wandered into other patients' rooms, was sexually inappropriate with other patients (attempted to hug and kiss the other patients), and the patient had been difficult to redirect on those occasions.

Review of Patient #4's Plan of Care revealed facility staff noted Patient #4 exhibited behaviors of agitation, aggression, biting, hitting, and stripping off clothes. In addition, documentation revealed Patient #4 exhibited sexual behaviors with male and female patients. A review of a plan of care developed by the facility to address Patient #4's behaviors revealed goals had been established for the patient to allow care/procedures without any episodes of agitation for three consecutive days, and for the patient's behaviors to improve to the point the patient could return safely to the previous living environment. Continued review of the plan of care revealed the facility had identified interventions which included to provide therapeutic group/individual sessions, to provide medications and monitor the effects of the medications, to provide support care, to encourage attendance in group activities and socialization, to allow the patient to vent his/her feelings, and for staff to redirect the patient when needed. However, the facility failed to develop interventions that addressed Patient #4's sexually inappropriate behaviors toward other patients to ensure the safety of the other patients.

An interview conducted on 09/13/12, with Patient #1's family member revealed during a visit on 09/03/12, the family member witnessed Patient #4 touch Patient #1 and other patients on the unit in a sexually inappropriate manner. The family member stated even though staff observed the behaviors and told the patient to stop, staff did not intervene to protect the other patients or prevent Patient #4's inappropriate behaviors.

An observation conducted on 09/17/12, at 12:50 PM, revealed Certified Nursing Assistant (CNA) #2 attempted to direct Patient #4 to sit at a table and eat his/her lunch meal. Patient #4 became agitated, cursed, and pulled away from the CNA. CNA #2 reapproached the patient and encouraged him/her to sit at the table to eat the lunch meal. Continued observation revealed at that time, Patient #4 smiled at the staff, placed his/her arm around CNA #2's back and under the arm, hugged the staff, and then inappropriately touched the staff member's breast. CNA #2 instructed Patient #4 not to touch the staff member's breast.

An interview conducted on 09/17/12, at 5:05 PM, with CNA #1 revealed staff was instructed to redirect patients that exhibited sexually inappropriate behaviors. According to CNA #1, there was a younger patient on the unit who preferred to be shirtless and Patient #4 would frequently "rub" the patient's chest. In addition, the CNA stated Patient #4 kissed and hugged other patients but because Patient #4 was cognitively impaired, the behaviors were not considered to be sexually inappropriate. CNA #1 stated she did not remember any patients being placed on one-to-one supervision for sexually inappropriate behaviors, and stated the one-to-one supervision was only utilized for patients that exhibited violent behaviors.

An interview conducted on 09/17/12, at 3:40 PM, with Registered Nurse (RN) #2 revealed staff would attempt to keep patients with sexually inappropriate behaviors away from other patients and "watch them." RN #2 stated Patient #4 exhibited sexually inappropriate behaviors and staff attempted to redirect the patient; however, there was no evidence any further interventions had been attempted to address Patient #4's sexually inappropriate behaviors or to provide a safe environment to the other patients.

An interview conducted on 09/17/12, at 4:30 PM, with the Psychiatrist revealed when patients were sexually inappropriate, staff could provide one-to-one supervision and attempt redirection. The Psychiatrist confirmed Patient #4 was admitted to the facility due to sexually inappropriate behaviors and stated the patient continued to have the behaviors even with multiple medication adjustments. According to the Psychiatrist, staff was to attempt different interventions to keep the patient and other patients safe.

Interviews conducted on 09/18/12, at 3:40 PM, with the Vice President of Patient Care Services and the Director of Nursing Operations revealed staff was required to separate patients who exhibited sexually inappropriate behaviors for the patient's own safety and the safety of the other patients. The interview revealed staff should also notify the House Supervisor, the patient's physician, and responsible party along with the appropriate state agencies of any sexually/physically abusive behaviors. According to the Director of Nursing Operations, the facility should also conduct an internal investigation and continue to ensure the safety of the other patients.

2. Review of Patient #1's medical record revealed the facility admitted the patient from a long term care facility on 08/31/12, due to the patient exhibiting agitative, delusional, and physically aggressive behaviors toward other patients. Patient #1's diagnoses at the time of admission to the facility included Dementia with behavioral disturbance.

Review of Patient #1's physician progress notes revealed on 09/01/12, the patient was agitated and combative; on 09/04/12, the patient exhibited wandering behavior and threatened others throughout the night; and on 09/06/12, the patient urinated on the floor.

A review of nurse's notes revealed on 09/06/12, at 4:24 AM, Patient #1 disrobed and climbed into bed with the roommate while naked, and staff was unable to redirect the patient. Continued review of nurse's notes revealed on 09/08/12, at 4:26 AM, the patient was agitated, disrobed, was difficult to redirect, and became combative; and on 09/09/12, at 1:23 AM, the patient disrobed and urinated on the floor.

Review of Patient #1's Plan of Care revealed staff identified the patient had an agitative mood with a history of hitting, punching, and pinching staff. In addition, the plan of care revealed Patient #1 was fixated on a female patient and would become agitated with the female patient. Continued review of the plan of care revealed staff developed goals for the patient to have three or less episodes of agitation in a day for three consecutive days and for the patient's symptoms to improve to the point the patient could return safely to his/her previous living environment. Staff also identified interventions to assist the patient to reach the established goals that included the provision of therapeutic group and individual sessions; to provide medications and monitor the medication effects; to provide care support to the patient; to encourage the patient's socialization and attendance/participation in group activities; and to allow the patient to vent his/her feelings and redirect the patient when needed. However, the facility failed to ensure interventions were developed or implemented that addressed Patient #1's agitative, delusional, and physically aggressive behaviors toward other patients to ensure the safety of staff and other patients.

An interview conducted on 09/17/12, at 5:05 PM, with CNA #1 revealed one-to-one supervision was utilized for patients that exhibited violent behaviors, however, one-to-one supervision had not been provided for Patient #1.

Interview with the Psychiatrist on 09/17/12, at 4:30 PM, confirmed Patient #1 was admitted due to aggressive and agitative behaviors. The psychiatrist also stated Patient #1 was easily agitated, had bonded with Patient #4 at the facility, and thought Patient #4 was his/her spouse. In addition, the Psychiatrist stated he attempted multiple medication adjustments in an effort to manage Patient #1's behaviors.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure six of ten patients selected for review were free from restraints, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff (Patients #1, #2, #4, #6, #8, and #9). Facility staff physically held the six patients and administered intramuscular (IM) injections because the patients refused to take their oral medications. In addition, facility staff failed to obtain a physician's order for use of a physical restraint in accordance with facility policy.

The findings include:

A review of the facility policy titled Patient Rights and Responsibilities, dated 09/04/96, revealed patients have the right to accept or refuse medical care and to be informed of possible consequences. The policy further revealed that medication and treatment are ordered under the direction of the attending physician.

Review of the facility policy titled Restraint and Seclusion, dated 02/27/96, revealed patients have the right to be free from restraint of any form imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraints may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others. Review of the policy further revealed only physicians who have been appropriately credentialed are allowed to order restraints unless it is an emergency situation, at which time the restraint can be initiated by a Registered Nurse. In addition, according to the policy, the orders for the use of a restraint must be obtained from the patient's attending physician. The policy also revealed the facility defined a restraint as any manual method, physical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his arms, legs, body, or head freely.

Interview with Registered Nurse (RN) #1 on 09/17/12, at 2:50 PM, revealed when patients refuse oral anti-psychotic medications, the patient's attending physician would be contacted, and an order would be obtained to administer the medications by IM injection. The RN stated that when patients refused to take the IM medications, the staff would "hold" the patient down and administer the medication injection to the patient. According to RN #1, she did not obtain an order to restrain the patients because "the physician says to give the medication." RN #1 stated that staff held all patients down that received IM injections and acknowledged that "holding" a patient down was a form of restraint.

Interview with RN #2 on 09/17/12, at 3:40 PM, revealed when patients refused their oral medications an order was obtained to administer the medication by IM injections. RN #2 stated she had held patients down to administer IM injections and stated she had never obtained an order to restrain a patient. RN #2 acknowledged that "holding" a patient down was a form of restraint, but she "never thought of it like that."

Interview with Certified Nursing Assistant (CNA) #1 on 09/17/12, at 5:05 PM, revealed that she had assisted with physically holding patients so the nurse could administer medications by injection.

1. A review of Patient #1's closed medical record revealed the facility admitted the patient on 08/31/12. Patient #1 was diagnosed with Dementia with behavioral disturbance. Review of Patient #1's Medication Administration Record (MAR) revealed from 09/01/12 thru 09/11/12, staff had administered 1 milligram (mg) of Ativan (a Benzodiazepine to treat anxiety by slowing activity of the brain) by intramuscular (IM) injection, seven times, to Patient #1 due to agitation. The MAR further revealed staff administered 10 mg of Geodon (treats Schizophrenia and strong inappropriate behaviors) by IM injection to Patient #1, on five different occasions from 09/01/12 thru 09/11/12, for agitation. The physician's orders did not contain evidence of an order to restrain Patient #1.

2. Review of Patient #2's medical record revealed the facility admitted Patient #2 on 08/27/12. The patient was diagnosed with Delusional Disorder NOS, rule out Dementia. Review of Patient #2's MAR revealed from 08/27/12 thru 09/16/12 the staff administered 1 mg Ativan by IM injection, eight times, due to agitation. The MAR further revealed staff administered 10 mg of Geodon by IM injection, on eight different occasions from 08/27/12 to 09/05/12, and 15 mg of Geodon by IM injection from 09/06/12 thru 09/16/12 to Patient #2, on two different occasions, for agitation. A review of documentation revealed facility staff had not obtained an order to physically restrain the patient in order to administer the medication.

Interview with Patient #2 on 09/18/12, at 12:50 PM, revealed at the time of the interview the patient had been admitted to the facility for 23 days. Patient #2 stated if patients didn't take their medications by mouth, staff would hold them down and "jab you with needles." Patient #2 stated that he/she refused to take his/her medication and two men and two women held him/her down to administer an injection.

3. Review of Patient #4's medical record revealed the facility admitted the patient on 08/31/12, due to being sexually inappropriate by kissing and rubbing other patients at the nursing home, and was not redirectable. The patient was diagnosed with Alzheimer's type Dementia with behavioral disturbances. Review of Patient #4's MAR revealed from 09/07/12 thru 09/11/12 the staff administered 1 mg of Ativan by IM injection, on nine different occasions. Further review of Patient #4's MAR revealed between 09/05/12 and 09/11/12, staff administered 10 mg of Geodon by IM injection, nine times. A review of physician's orders revealed no evidence of an order to restrain Patient #4.

4. Review of Patient #6's medical record revealed the facility admitted Patient #6 on 09/12/12 with diagnoses of Delusional Disorder and Dementia. Review of Patient #6's MAR revealed that on 09/06/12 staff administered 1 mg of Ativan and 20 mg of Geodon by IM injection. There was no evidence in the physician's orders that staff had obtained an order to physically restrain the patient in order to administer the IM medication.

5. Review of Patient #8's medical record revealed the facility admitted Patient #8 on 09/09/12 with a diagnosis of Dementia with Behavioral Disturbance. Review of Patient #8's MAR revealed that between 09/10/12 and 09/16/12 staff administered 1 mg of Ativan by IM injection, on three different occasions. There was no evidence in the physician's orders that staff had obtained an order to physically restrain the patient in order to administer the IM medication.

6. Review of Patient #9's medical record revealed the facility admitted Patient #9 on 09/12/12 with a diagnosis of Dementia, Alzheimer's type with behaviors. Review of Patient #9's MAR revealed staff administered 20 mg of Geodon by IM injection on 09/12/12. There was no evidence in the physician's orders that staff had obtained an order to physically restrain the patient in order to administer the IM medication.

Interview with the facility Psychiatrist on 09/17/12, at 4:30 PM, revealed he had ordered IM injections for patients that refuse to take their oral medications. The interview further revealed that he did not give an order to restrain the patient and stated, "Holding the patient isn't like tying them to a bed or chair and it isn't for a long time." The interview further revealed the Psychiatrist was aware staff physically held patients down to administer IM mediations and stated if physically holding the patient was ordered as a restraint, then "we will have to do all that paperwork and such."

Interviews with the facility Vice President of Patient Care Services and the Director of Nursing Operations on 09/17/12, at 3:40 PM, revealed physically holding a patient to administer IM medications would be considered a restraint and should be documented, ordered, and assessed as per the facility policy. The interviews revealed neither was aware staff was physically holding patients to administer IM medications and not following the facility's restraint policy.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the use of restraints for six of ten patients selected for review was in accordance with the patient's plan of care (Patients #1, #2, #4, #6, #8, and #9). Interview revealed Patients #1, #2, #4, #6, #8, and #9 were physically restrained by staff in order to administer intramuscular (IM) injections; however, staff failed to ensure each patient's plan of care had been developed/updated to include the use of the physical restraint.

The findings include:

Review of the facility policy titled Restraint and Seclusion, dated 02/27/96, revealed patients have the right to be free from restraint of any form imposed as a means of coercion, discipline, convenience, or retaliation by staff. The review revealed the use of restraints must be in accordance with a written modification to the patient's plan of care. The policy also revealed the facility defined a restraint as any manual method, physical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his arms, legs, body, or head freely.

Interviews with Registered Nurse (RN) #1 on 09/17/12, at 2:50 PM, and RN #2 at 3:40 PM, revealed when a patient refused an oral medication, the nurse contacted the patient's attending physician and obtained an order to administer the medication by intramuscular (IM) injection and staff would "hold" the patient down and administer the injection to the patient. The RNs stated staff held all patients down to administer IM injections. Although the RNs acknowledged that "holding" a patient down to administer the medication was a form of restraint, the RNs stated they had never developed and/or updated the care plan to reflect the use of restraints.

1. Interview with Patient #2 on 09/18/12, at 12:50 PM, revealed at the time of the interview the patient had been admitted to the facility for 23 days. Patient #2 stated if patients did not take their medications by mouth staff would hold them down and "jab you with needles." Patient #2 stated that he/she refused to take his/her medication and two men and two women held him/her down to administer an injection.

Review of Patient #2's medical record revealed the facility admitted Patient #2 on 08/27/12. The patient was diagnosed with Delusional Disorder NOS, rule out Dementia. Review of Patient #2's Medication Administration Record (MAR) revealed from 08/27/12 thru 09/16/12 the staff administered 1 milligram (mg) of Ativan (a Benzodiazepine to treat anxiety by slowing activity of the brain) by IM injection, eight times, due to agitation. The MAR further revealed staff administered 10 mg of Geodon (treats Schizophrenia and strong inappropriate behaviors) by IM injection, on eight different occasions from 08/27/12 to 09/05/12, and 15 mg of Geodon by IM injection from 09/06/12 thru 09/16/12, to Patient #2, on two different occasions, for agitation. However, based on a review of the patient's medical record and care plan, facility staff failed to include the use of the physical restraint to aid in the administration of the IM injection in the care plan.

2. A review of Patient #1's closed medical record revealed the facility admitted the patient on 08/31/12. Patient #1 was diagnosed with Dementia with behavioral disturbance. Review of Patient #1's MAR revealed from 09/01/12 thru 09/11/12, staff administered 1 mg of Ativan by IM injection, seven times, to Patient #1 due to agitation. The MAR further revealed staff administered 10 mg of Geodon by IM injection to Patient #1, on five different occasions from 09/01/12 thru 09/11/12, for agitation. However, based on a review of the patient's care plan facility staff failed to include the use of the physical restraint to aid in the administration of the IM injection in the care plan.

3. Review of Patient #4's medical record revealed the facility admitted the patient on 08/31/12, due to being sexually inappropriate by kissing and rubbing other patients at the nursing home, and was not redirectable. The patient was diagnosed with Alzheimer's type Dementia with behavioral disturbances. Review of Patient #4's MAR revealed from 09/07/12 thru 09/11/12, the staff administered 1 mg of Ativan by IM injection, on nine different occasions. Further review of Patient #4's MAR revealed between 09/05/12 and 09/11/12, staff administered 10 mg of Geodon by IM injection, nine times. Facility staff failed to include the use of the restraint in the medical record and failed to revise the patient's plan of care to reflect the use of the physical restraint.

4. Review of Patient #6's medical record revealed the facility admitted Patient #6 on 09/12/12, with diagnoses of Delusional Disorder and Dementia. Review of Patient #6's MAR revealed that on 09/06/12 staff administered 1 mg of Ativan and 20 mg of Geodon by IM injection. Documentation revealed staff failed to document the use of the physical restraint and had not revised the plan of care to reflect the use of the physical restraint.

5. Review of Patient #8's medical record revealed the facility admitted Patient #8 on 09/09/12, with a diagnosis of Dementia with Behavioral Disturbance. Review of Patient #8's MAR revealed that between 09/10/12 and 09/16/12 staff administered 1 mg of Ativan by IM injection, on three different occasions. Based on documentation, staff failed to ensure the use of the physical restraint was included in the plan of care.

6. Review of Patient #9's medical record revealed the facility admitted Patient #9 on 09/12/12, with a diagnosis of Dementia, Alzheimer's type with behaviors. Review of Patient #9's MAR revealed staff administered 20 mg of Geodon by IM injection on 09/12/12. However, based on a review of the patient's medical record and care plan, facility staff failed to ensure the use of the physical restraint to aid in the administration of the IM injection was included in the patient's plan of care.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on interview, record review, and facility policy review, it was determined the facility failed to ensure the use of physical restraints was in accordance with a physician's order for six of ten patients selected for review (Patients #1, #2, #4, #6, #8, and #9). Facility staff physically held Patients #1, #2, #4, #6, #8, and #9 in order to administer intramuscular (IM) injections because the patients had refused to take their oral medications. However, interview and a review of documentation revealed staff failed to obtain a physician's order for the use of a physical restraint.

The findings include:

Review of the facility policy titled Patient Rights and Responsibilities, dated 09/04/96, revealed patients have the right to accept or refuse medical care and to be informed of possible consequences. The policy further revealed that medication and treatment are ordered under the direction of the attending physician.

Review of the facility policy titled Restraint and Seclusion, dated 02/27/96, revealed patients have the right to be free from restraint of any form imposed as a means of coercion, discipline, convenience, or retaliation by staff. Review of the policy revealed the use of restraints must be in accordance with the order of a physician who was responsible for the care of the patient and authorized to order restraints in accordance with state law. The policy further revealed the definition of a restraint was any manual method, physical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his/her arms, legs, body, or head freely.

Interview with Patient #2 on 09/18/12, at 12:50 PM, revealed at the time of the interview the patient had been admitted to the facility for 23 days. Patient #2 stated if patients didn't take their medications by mouth, staff would hold them down and "jab you with needles." Patient #2 stated that he/she refused to take his/her medication and two men and two women held him/her down to administer an injection.

Interviews with Registered Nurse (RN) #1 on 09/17/12, at 2:50 PM, and RN #2 at 3:40 PM, revealed when patients refused to take oral medications, staff would physically "hold" the patient down and administer the medications by means of an IM injection. The RNs stated the physician would be contacted to obtain an order to administer the medications by injection and even though they acknowledged physically "holding" a patient down to administer medications was a form of restraint, the RNs stated they failed to obtain a physician's order to physically restrain the patient.

Interview with Certified Nursing Assistant (CNA) #1 on 09/17/12, at 5:05 PM, revealed that she had assisted with physically holding patients so the nurse could administer medications by injection.

1. A review of Patient #1's closed medical record revealed the facility admitted the patient on 08/31/12. Patient #1 was diagnosed with Dementia with behavioral disturbance. Review of Patient #1's Medication Administration Record (MAR) revealed from 09/01/12 thru 09/11/12, staff had administered 1 milligram (mg) of Ativan (a Benzodiazepine to treat anxiety by slowing activity of the brain) by intramuscular (IM) injection, seven times, to Patient #1 due to agitation. The MAR further revealed staff administered 10 mg of Geodon (treats Schizophrenia and strong inappropriate behaviors) by IM injection to Patient #1, on five different occasions from 09/01/12 thru 09/11/12, for agitation. However, based on documentation, staff failed to obtain a physician's order for the use of the physical restraint to aid in the administration of the injection of the medication.

2. A review of Patient #2's medical record revealed the facility admitted Patient #2 on 08/27/12. The patient was diagnosed with Delusional Disorder NOS, rule out Dementia. Review of Patient #2's MAR revealed from 08/27/12 thru 09/16/12 the staff administered 1 mg Ativan by IM injection, eight times, due to agitation. The MAR further revealed staff administered 10 mg of Geodon by IM injection, on eight different occasions from 08/27/12 to 09/05/12, and 15 mg of Geodon by IM injection from 09/06/12 thru 09/16/12 to Patient #2, on two different occasions, for agitation. A review of documentation revealed facility staff had not obtained an order to physically restrain the patient in order to administer the medication.

3. Review of Patient #4's medical record revealed the facility admitted the patient on 08/31/12, with a diagnosis of Alzheimer's type Dementia with behavioral disturbance. Review of Patient #4's MAR revealed from 09/07/12 thru 09/11/12 the staff administered 1 mg of Ativan by IM injection, on nine different occasions. Further review of Patient #4's MAR revealed between 09/05/12 and 09/11/12, staff administered 10 mg of Geodon by IM injection, nine times. However, based on documentation, even though staff reportedly performed physical holds on patients to administer medications by IM injection, staff failed to obtain a physician's order for use of the physical restraint.

4. Review of Patient #6's medical record revealed the facility admitted Patient #6 on 09/12/12 with diagnoses of Delusional Disorder and Dementia. Review of Patient #6's MAR revealed that on 09/06/12 staff administered 1 mg of Ativan and 20 mg of Geodon by IM injection. There was no evidence in the physician's orders that staff had obtained an order to physically restrain the patient in order to administer the IM medication.

5. Review of Patient #8's medical record revealed the facility admitted Patient #8 on 09/09/12 with a diagnosis of Dementia with Behavioral Disturbance. Review of Patient #8's MAR revealed that between 09/10/12 and 09/16/12 staff administered 1 mg of Ativan by IM injection, on three different occasions. There was no evidence in the physician's orders that staff had obtained an order to physically restrain the patient in order to administer the IM medication.

6. Review of Patient #9's medical record revealed the facility admitted Patient #9 on 09/12/12 with a diagnosis of Dementia, Alzheimer's type with behaviors. Review of Patient #9's MAR revealed staff administered 20 mg of Geodon by IM injection on 09/12/12. There was no evidence in the physician's orders that staff had obtained an order to physically restrain the patient in order to administer the IM medication.

Interview with the facility Psychiatrist on 09/17/12, at 4:30 PM, revealed he had ordered IM injections for patients that refuse to take their oral medications and, even though he had not instructed staff to physically hold the patients in order to administer the IM medications, he was aware staff physically held patients down to administer IM medications. According to the Psychiatrist, "Holding the patient isn't like tying them to a bed or chair and it isn't for a long time." The Psychiatrist stated if physically holding the patient was ordered as a restraint, then "we will have to do all that paperwork and such."

The Vice President of Patient Care Services and the Director of Nursing Operations stated in an interview conducted on 09/17/12, at 3:40 PM, they were unaware facility staff was physically holding patients to administer IM medications. According to the Vice President of Patient Care Services and the Director of Nursing Operations, physically holding a patient to administer IM medications would be considered a restraint and staff should obtain a physician's order for use of the restraint, should document the restraint, and should assess the restraint use in accordance with facility policy.
VIOLATION: PATIENT VISITATION RIGHTS Tag No: A0215
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure policies that pertained to visitation rights were implemented for ten of ten patients selected for review (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10). Facility staff placed restrictions on the visitation rights of patients in the Psychiatric Unit and informed patient family members that the patients were not allowed to have visitation rights during the first seventy-two hours of the patient's hospitalization .

The findings include:

Review of the facility's Patient Rights and Responsibilities policy, revised 02/04/04, revealed a summary of Patient's Rights and Responsibilities would be given to each patient at the time of registration. The policy stated the facility would allow family members, friends, or other individuals of the patient's choice to be present with the patient for emotional support during the course of stay. The review revealed visitation privileges would not be limited or restricted on the basis of race, color, national origin, religion, sex, sexual orientation, gender identity, or disability.

Review of the facility's Family Information sheet given to the patients' families upon admission, revealed the visitation rights on the Psychiatric Unit were different from on the medical/surgical floors. The information sheet revealed due to group sessions and activities scheduled throughout the day patient calls and visitation were scheduled for specific times of day. According to the information sheet, telephone hours were every day from 6:00 AM to 8:00 AM, 11:00 AM to 12:00 PM, and 6:00 PM to 8:00 PM, and visitation hours were Monday thru Friday from 5:30 PM to 7:00 PM, and Saturday and Sunday from 2:00 PM to 4:00 PM, and 5:30 PM to 7:00 PM.

An observation conducted on 09/17/12, at 1:00 PM, revealed signage posted on the locked entrance door to the Psychiatric Unit that also indicated visiting hours were Monday thru Friday from 5:30 PM to 7:00 PM, and Saturday and Sunday from 2:00 PM to 4:00 PM, and 5:30 PM to 7:00 PM.

However, interviews conducted on 09/17/12, at 2:50 PM, with Registered Nurse (RN) #1, at 3:40 PM with RN #2, and at 5:05 PM, with Certified Nurse Assistant (CNA) #1 revealed upon each patient's admission to the Psychiatric Unit, family members were instructed there would be no visitation for the first three days of the patient's in-patient stay.

A review of the medical record of Patient #1 revealed the patient was admitted on [DATE]. An interview conducted on 09/12/12 with Patient #1's family member revealed facility staff had informed the family member that visitation was prohibited for the first three days of Patient #1's admission to the facility.

An interview on 09/17/12, at 4:30 PM, with the Psychiatrist on the Unit revealed visitors were restricted because at times visitors made patients more agitated.

Interviews with the facility Vice President of Patient Care Services and the Director of Nursing Operations on 09/17/12, at 3:40 PM, revealed they were not aware visitors to the Psychiatric Unit were turned away.