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.

CHRISTUS GOOD SHEPHERD MEDICAL CENTER- LONGVIEW 700 EAST MARSHALL AVENUE LONGVIEW, TX 75601 May 8, 2015
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observation, document review and interview, the governing body failed to:
A. resolve the patient's complaint and advise the patient of the facility's internal process and response of the complaint /grievance process.

Refer to Tag A0118


B. ensure physicians document notification of the next of kin, of an incapacitated patient, when a care decision required an informed consent. The physician failed to document the patient was in an emergent life threatening situation to justify an unsigned consent for an invasive procedure.

Refer to Tag A0131


C. ensure patients have the right to be free from restraint or seclusion, of any form, imposed as a means of staff convenience.


D. to document a patient assessment, offer interventions, or justification before the administration of a chemical restraint for agitation and anxiety.


E. have clear documentation in the patient's medical record describing the steps or interventions, document less restrictive measures were tried, or considered used prior to use of restraints physical or chemical.


F. ensure physician orders for a chemical restraint must never be written as a PRN (as needed bases) order.


G. conduct a one hour face to face for a restrained behavioral patient, and ensure the practitioner is trained to conduct the 1 hour face to face.


H. the physician's failed to document clinical justification of restraints or type of least restrictive device. The physician failed to document the one hour face to face.


Refer to Tags A0154, A0154, A0160, A0165, A0169, A0178, A0184
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, document review and interview the facility failed to:
A. resolve the patient's complaint and advise the patient of the facility's internal process and response of the complaint /grievance process.

Refer to Tag A0118


B. ensure physicians document notification of the next of kin, of an incapacitated patient, when a care decision required an informed consent. The physician failed to document the patient was in an emergent life threatening situation to justify an unsigned consent for an invasive procedure.

Refer to Tag A0131


C. ensure patients have the right to be free from restraint or seclusion, of any form, imposed as a means of staff convenience and for restraint to be discontinued at earliest possible convenience.


D. to document a patient assessment, offer interventions, or justification before the administration of a chemical restraint for agitation and anxiety.


E. have clear documentation in the patient's medical record describing the steps or interventions, document less restrictive measures were tried, or considered used prior to use of restraints physical or chemical.


F. ensure physician orders for a chemical restraint must never be written as a PRN (as needed) order.


G. conduct a one hour face to face for a restrained behavioral patient, and ensure the practitioner is trained to conduct the 1 hour face to face.


H. the physician's failed to document clinical justification of restraints or type of least restrictive device. The physician failed to document the one hour face to face.

Refer to Tag A0154, A0154, A0160, A0165, A0169, A0178, A0184



These deficient practices were determined to pose Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on record reviews, policy and procedures, and interviews, the facility failed to follow its own policy and procedures. The facility failed to resolve the patient's complaint and advise the patient of the facility's internal process and response of the complaint /grievance process in 1 (#1) of 10 (#1-10) charts reviewed.
Review of patient #1's medical records revealed that he was taken to the facility's emergency room (ER) on 1-16-2015, for stomach pain and breathing issues. He was diagnosed with pneumonia and admitted to the medical floor for further care.

Review of patient #1's nurse's notes dated 1/18/2015, at 3:00 AM, stated, "3:00 AM patient at nurse's station states he heard someone laughing on the call light when he called for pain medication and didn't like it. Patient accompanied back to room. 3:14 AM Patient given Norco 10 at this time. 3:45AM Notified doctor of wife requesting something for him for his anxiety, order given. 4:09 AM Gave Haldol 5 mg IM to left hip. 5:30 AM Patient resting quietly without any signs or symptoms of distress."
A written statement from patient #1's spouse revealed after the nurse returned patient #1 to the room that he was very upset and anxious, nearly having a panic attack. At 4:00 AM, the nurse came back in to monitor his vital signs and blood sugar. Patient #1 asked for a Klonopin for his anxiety and staff #10 (RN) said, "Ok." Staff #10 returned without the Klonopin and informed patient #1 that he could not have the Klonopin but she had a shot for him. Patient #1 asked what the medication was after he received the shot and could they have a print out. Staff #10 brought a print out to patient #1 and his spouse. Patient #1's spouse stated, "We were terrified. There were numerous stated reasons and 3 warnings why he should have not been given the drug, due to all the serious life threatening side effects."
Patient #1's spouse asked staff #10 if there was a medication that he could take to reverse the drug Haloperidol (Haldol). Staff #10 confirmed that there was no medication to reverse this drug. Neither patient #1 nor his spouse was given any reason why he could not have his Klonopin and was given Haldol. Patient #1's spouse confirmed patient #1 had never received this medication before.
Patient #1's spouse reported that the patient became more confused after the medication and started to hallucinate. Patient #1's spouse was very upset and reported this to the day charge nurse. The charge nurse referred her to staff #15 (RN House Supervisor.) Staff #15 came to patient #1's room and talked to patient #1 and his spouse. Patient #1 felt staff #15 was being one sided and "was thru talking to her." Patient #1's spouse stated, "She (staff #15) then said patient #1 was told if he wanted to leave he could but he said he wanted to stay and be treated for what he came in for." Patient #1's spouse confirmed they were not satisfied with the outcome.
Patient #1's spouse reported patient #1 decided to call 911 and reported that he had been given a shot against his will. The 911 dispatcher told him that was a civil matter and could not help him. Patient #1 then called the police and wanted to make a report concerning the injection. Patient #1's spouse confirmed they did not know who to complain to. Patient #1was able to talk to "another supervisor and convinced us to stay." Patient #1's spouse reported that she was not informed of how to report a grievance.
Review of the House Supervisors notes dated 1/18/2015, 6:00am-6:00pm, revealed that staff #15 did go to patient #1's room. Staff #15 wrote, "Spoke with patient on S300 room 1357, was angry that the nurses gave him Haldol for agitation last night." There was no further documentation found.
Review of the Grievance Log on 5/6/2015, was reviewed and there was no evidence found of a grievance/complaint made for patient #1 from 1/2015- 5/6/2015.
An interview on 5/6/2015, with staff #18 (Guest Relations Specialist) revealed that she had not taken a complaint/grievance on patient #1 and did not recognize the name.
Review of the facility's policy and procedure "Patient Complaint/Grievance Management" stated, "The following shall be regarded as a grievance:
1) Complaints from patients, or individuals on behalf of the patient, that cannot be resolved promptly by staff present. Staff present includes any hospital staff present at the time of the complaint or who can quickly be at the patients' location to resolve the patient's complaint. If a verbal patient care complaint cannot be resolved at the time of the complaint by staff present, it is referred to other staff for later resolution, requires investigation or action, then it is considered a grievance for the purpose of these requirements.
2.) Written complaints, whether from an inpatient, outpatient, discharged patient, or their representative, regarding the patient care provided.
3.) Telephone calls from patient, or patient's representative, with complaints regarding care issues.
4.) All verbal or written complaints regarding abuse, neglect.
5.) Any request by patient or patient's representative to file a formal grievance.
Documents Required:
All complaints and grievances will be documented in the following manner:
1. Complaint/grievances is documented on the Patient Complaint Form, via the confidential complaint/management system accessible on GSNet and forwarded to the guest Relations/Health and safety department to be included in hospital complaint management database. All associated actions, follow-up letters, and documentation of verbal discussions should be included."
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on chart reviews, policy and procedures, and interviews, the facility failed to follow its own policy and procedures. The nurse failed to inform and instruct the patient on a new medication prior to administration. The patient or patient representative, was not given information needed in order to make an informed decision regarding his health care. The physician failed to document notification of the next of kin, of an incapacitated patient, when a care decision required an informed consent. The physician failed to document the patient was in an emergent life threatening situation to justify an unsigned consent for an invasive procedure in 2 (#1 and #9) out of 10 (#1-10) charts reviewed.

1.) Review of patient #1's medical records revealed that he was taken to the facility's emergency room (ER) on 1-16-2015, for stomach pain and breathing issues. He was diagnosed with pneumonia and admitted to the medical floor for further care.
Review of patient #1's nurses notes dated 1/18/2015, at 3:00 AM, stated, "3:00 AM patient at nurse's station states he heard someone laughing on the call light when he called for pain medication and didn't like it. Patient accompanied back to room. 3:14 AM Patient given Norco 10 at this time. 3:45AM Notified doctor of wife requesting something for him for his anxiety, order given. 4:09 AM Gave Haldol 5 mg IM to left hip. 5:30 AM Patient resting quietly without any signs or symptoms of distress."
A written statement from patient #1's spouse revealed that Patient #1 had gone to the nurses station to complain about someone laughing at him over the call light. After the nurse returned patient #1 to the room, he was very upset and anxious, nearly having a panic attack. At 4:00 AM, the nurse came back in to monitor his vital signs and blood sugar. Patient #1 asked for a Klonopin for his anxiety and staff # 10 (RN) said, "Ok" Staff #10 returned without the Klonopin and informed patient #1 that he could not have the Klonopin but she had a shot for him. Patient #1 asked what the medication was after he received the shot and could they have a print out. Review of patient #1's chart revealed no documentation found of medication instruction before administration of Haldol.
Staff #10 brought a print out to patient #1 and his spouse. Patient #1's spouse stated, "We were terrified. There were numerous stated reasons and 3 warnings why he should have not been given the drug, due to all the serious life threatening side effects."
Patient #1's spouse asked staff #10 if there was a medication that he could take to reverse the drug Haloperidol (Haldol). Staff #10 confirmed there was no medication to reverse this drug. Neither patient #1 nor his spouse was given any reason why he could not have his Klonopin and was given Haldol. Patient #1's spouse confirmed patient #1 had never received this medication before.
A phone interview was conducted with staff # 10 on 5/7/2015, at 2:45PM. Staff #10 confirmed that she did remember caring for patient #1. Staff #1 stated, "He was acting agitated. He kept coming up to the nurse's station raising his voice. I tried to calm him down." Staff #10 confirmed that patient #1's spouse asked for a medication for anxiety but could not remember what drug it was. Staff #10 stated, "I called the doctor and got an order for Haldol. I went down and gave him the medication. I gave them a print out of the drug when they asked for it but I don't remember if I told them anything before the injection."
A phone interview with patient #1 on 5/13/2015, at 11:45, confirmed that patient #1 would never have agreed to take the medication, Haldol, if he had been given the information on the drug beforehand. Patient #1 stated, "I have Parkinson's disease and you are not supposed to give that drug to a person with Parkinson's. I had side effects for two weeks after given that stuff."
Review of patient #1's History and Physical for the admitted [DATE], revealed under past medical history stated, "Parkinson's."

Review of the drug Haldol (haloperidol) from the U.S. National Library of Medicine revealed under warnings:
" When Not To Use:
You should not receive this medicine if you have had an allergic reaction to haloperidol, or if you have Parkinson's disease. This medicine should not be given to patients with severe brain disease "

Review of the hospital's Policy and Procedure "Patient Rights" stated, "All patients will be provided, upon admission, written materials and verbal explanations of their rights. A copy of the patient rights materials and verbal explanations of their rights. A copy of the patient rights materials will be posted adjacent to Good Shepherd Medical Center's license."

During a tour of the hospital on [DATE], there were no patient rights postings found on display in the main lobby adjacent to the facility's license, hallway, or surgical waiting room on the first floor. There were no patient rights posted in the Medical Intensive Care Unit waiting room. Staff #6 confirmed there were no postings found in these areas.

2.) Review of patient #9's medical record revealed that he has been in the ER multiple times for drug related issues. Patient #9 was found to have an elevated white blood cell count and running fever. A lumbar puncture was performed on patient #9 to rule out Meningitis. The test came back negative but patient #9 was admitted with Rhabdomyolysis and altered mental status.

Rhabdomyolysis is breakdown of muscle fibers. Muscle breakdown causes the release of myoglobin into the bloodstream. Myoglobin can cause kidney damage.

Review of patient #9's emergency room (ER) nurses notes stated, "6:53 PM Pt found in PD custody, combative and uncooperative on scene and required PD intervention. Possible K2/Meth usage. Pt is alert and very uncooperative, somewhat combative. Speaking gibberish and sounding paranoid-thinks we are going to kill him, states, "you know what you've done" and "that's what the windshield wiper fluid told you." Behavior is agitated, anxious, restless, uncooperative. The patient is oriented to person, the patient is disoriented. Patient home medication was provided by the previous visit. The patient is unable to provide a social history due to altered mental status.

6:53PM Psychological: Behavior: Patient is combative with staff by yelling, kicking or swinging extremities violently, making threats to staff, Appears anxious. Suicidal ideations verbalized "Just shoot me with dope to kill me now." Suicide Risk Screening unable to assess due to altered mental status."

Review of the facility's Policy and Procedure "Consents to Medical Treatment" stated, "Who may give consent:
A. c. In emergency situations in which the adult patient is unable to sign and where a delay in treatment presents a substantial risk to the life or health of the patient, consent is implied. The treating physician should make such notation in the medical record.
A. d. For adult patients who are comatose, incapacitated or incapable of communication, the following persons in order of priority are deemed surrogate decision- makers:
6.) Patient's nearest living relative.
B. a. The attending physician shall describe the patient's comatose state, incapacity, or other physical or mental inability to communicate and the proposed medical treatment in the patient's medical record.
B. b. The attending physician shall make a reasonable diligent effort to contact or cause to be contacted the persons eligible to serve as segregate decision-makers and efforts will be documented in the medical record."

Review of # 9's ER nurses notes dated 4/22/2015, at 10:30 PM, revealed, staff # 25 (RN) assisted the physician in performing a Lumbar Puncture on patient # 9. This procedure requires informed consent. Review of the patient consent for #9's Lumbar Puncture dated 4/22/2015 at 10:00 PM revealed staff #26 (MD) signed on the patient signature line and staff #24 (RN) signed on the witness line.

Review of patient #9's ER chart revealed no documentation of nearest relative, emergency person contacted or attempted to contact to give consent. There was no documentation found in the physician notes verifying an emergent procedure was warranted.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on chart reviews and interviews, the facility failed to ensure patients have the right to be free from restraint or seclusion, of any form, imposed as a means of staff convenience in 2 (#1 and #8) of 10 (#1-10) patients reviewed.
The facility also failed to ensure restraints were discontinued at the earliest possible convenience in 1(#8) of 10 patients reviewed.

1.) Review of patient #1's medical records revealed that he was taken to the facility's emergency room (ER) on 1-16-2015, for stomach pain and breathing issues. He was diagnosed with [DIAGNOSES REDACTED]
Review of patient #1's nurses notes dated 1/18/2015, at 3:00 AM, stated, "3:00 AM patient at nurse's station states he heard someone laughing on the call light when he called for pain medication and didn't like it. Patient accompanied back to room. 3:14 AM Patient given Norco 10 at this time. 3:45 AM Notified doctor of wife requesting something for him for his anxiety, order given. 4:09 AM Gave Haldol 5 mg IM to left hip. 5:30 AM Patient resting quietly without any signs or symptoms of [DIAGNOSES REDACTED]
A written statement from patient #1's spouse revealed that after the nurse returned patient #1 to the room he was very upset and anxious, nearly having a panic attack. At 4:00 AM, the nurse came back in to monitor his vital signs and blood sugar. Patient #1 asked for a Klonopin for his anxiety and staff # 10 (RN) said, "Ok." Staff #10 returned without the Klonopin and informed patient #1 he could not have the Klonopin but she had a shot for him. Patient #1 asked what the medication was after he received the shot and could they have a print out. Staff #10 brought a print out to patient #1 and his spouse. Patient #1's spouse stated, "We were terrified. There were numerous stated reasons and 3 warnings why he should have not been given the drug, due to all the serious life threatening side effects."
Patient #1's spouse asked staff #10 if there was a medication he could take to reverse the drug Haloperidol (Haldol). Staff #10 confirmed there was no medication to reverse this drug. Neither patient #1 nor his spouse was given any reason why he could not have his Klonopin and was given Haldol. Patient #1's spouse confirmed patient #1 had never received this medication before.

Review of the nurse's notes revealed there were no documented interventions found before patient #1 was given Haldol for agitation and anxiety.

Review of the physician order dated 1/18/2015 revealed staff # 10 received a verbal order from staff #23 (MD Hospitalist). The order was given at 3:45 AM and stated, "Haldol 5mg IM or IV q4 Prn for agitation." Staff #23 did not electronically sign the order until 2/19/15 at 6:67 AM (33 days later).

A phone interview was conducted with staff #10 on 5/7/2015, at 2:45PM., Staff #10 confirmed she did remember caring for patient #1. Staff #10 stated, "He was acting agitated. He kept coming up to the nurse's station raising his voice. I tried to calm him down." Staff #10 confirmed that patient #1's spouse asked for a medication for anxiety but could not remember what drug it was. Staff #10 stated, "I called the doctor and got an order for Haldol. I went down and gave him the medication. I gave them a print out of the drug when they asked for it but I don't remember if I told them anything before the injection." Staff #10 was asked by the surveyor if the drug Haldol was given for the convenience of the staff to prevent patient #1 from coming up to the nurse's station? Staff #10 stated, "Yeah, I guess you could say that, we had to do something to get him calmed down until we could do something else with him."
Staff #8 confirmed there was no justification found in physician documentation for the psychoactive medications.






2.) Review of medical record revealed patient #8, a [AGE] year old female, with severe Intellectual Disability and Autism and reported to have the mental capacity of a one year old. Patient was brought to the facility on [DATE], from a residential group home by EMS (Emergency Medical Services) due to severe agitation and aggressiveness. The staff at the group home reported that patient had become increasingly agitated and aggressive over the past week as evidenced by hitting, biting, and pulling hair of other residents. What incited the change in behavior is unclear but patient recently had changes to her environment and caregivers. Patient's father was her primary caregiver but he had a stroke and had to be placed in a nursing home. Since that time, the patient was placed in the group home and also had been started on Seroquel (antipsychotic medication) 200 mg. at bedtime for behavioral issues and sleep disturbance approximately 2 months prior.
Police were called to the group home after patient became violent and attempting to choke a staff person. Police were unable to calm patient and called EMS to take her to the emergency department (ED) for evaluation. EMS staff used gauze rolls, sheets and belts on the stretcher for restraints to transport to the emergency room . Patient was given Versed (Central Nervous System Depressant) 5 mg. Intranasally X2 due to combativeness while in route to the ED. No effect noted from the Versed.
Patient arrived at the ED on 4/15/15, at 1817 (6:17 pm). Physician's notes revealed, "patient presents with ACTING IRRATICALLY. Onset: The symptoms/episode began/occurred today. Severity of symptoms: At worst the symptoms were moderate, in the emergency department the symptoms are unchanged. Unable to obtain HPI (History and Physical) due to patient distress, mental status." A review of physician's orders revealed orders at 1818 (6:18 PM) for "Geodon (antipsychotic)40 mg IM once, Restrain - up to 4 hours, and elopement precautions." Further review of the physician orders revealed an order for Ativan (anti-anxiety 1 mg. IVP (Intravenous Push) at 2000 (8:00 PM) and also for Morphine (narcotic) 4 mg. IVP was written at 2002 (8:02 PM). There was no documentation in physician's orders or progress notes of the clinical justification/reason for the restraints, type of restraints, or the reason the medications were given.
The next order written was at 2200 (10:00 PM) - "Restrain-up to 4 hours. Verbal Order received at 2200." The next physician's order was Valium (anti-anxiety)5mg. IVP @ 0055 (00:55 AM)on 4/16/15. The order did not contain a reason for the restraints or medication, did not identify the type of restraint, and the nurse's notes did not contain documentation to justify a reason for the restraints or medication being given. Valium 5 mg. IVP was given again at 0116 (1:16 AM) which was 21 minutes later. The order did not contain a reason for the medication and the nurse's notes did not contain documentation to justify a reason for the medication being given. Order to "Restrain - up to 4 hours (Adult >17 years of age)" ordered at 0200. Order did not justify the reason for the restraints or the type of restraints.

The following is a list of physician orders for physical and chemical restraints and how they were written:
Order for "Haldol 5 mg. IV once" at 0536.
Order to "Restrain - up to 4 hours (Adult >17 years of age)" ordered at 0600.
Order for "Ativan 2 mg. IVP once" at 0655.
Order for "Ativan 2 mg. IVP once" at 0814.
Order for "Valium 5 mg. IVP once" at 0831.
Order to "Restrain - up to 4 hours (Adult >17 years of age)" ordered at 1000.
Order for "Valium 5 mg IVP once" at 1020.
Order for "Benadryl (antihistamine) 25 mg IVP once" at 1043.
Order for "Valium 5 mg IVP once" at 1043.
Order for "Valium 5 mg. IVP once" at 1049.
Order for "Clonidine (antihypertensive) 0.2 mg PO once" at 1049.
Order for "Haldol 5 mg. IV once" at 1102.
Order for "Haldol 5 mg. IV once" at 1153.
Order for "Haldol 5 mg. IV once" at 1244.
Order for "Ketamine(sedative/analgesic)1mg/kg IVP once" at 1403.
Order to "Restrain - up to 4 hours (Adult >17 years of age)" ordered at 1400.
Order for "Clonidine 0.2 mg. PO once" at 1552.
Order for "Ketamine 0.5 mg/kg IVP once" at 1554.
Order for "Ketamine 1.0 mg/kg IVP once" at 1657.
Order for "Rocuronium (muscle relaxer) 100 mg IV once" at 1706.
Order for "Propofol(anesthetic) 100 ml IV at 10 mcg/kg/min once" at 1706. Administered at 1819.
Order for "Etomidate (anesthetic) 20 mg IVP once at 1706" . Administered at 1753" .

Review of ER physician documentation revealed, the physician failed to document the clinical justification/reason, type of least restrictive device, and signature of the individual giving the order for the physical restraint. The numerous orders for medications as a chemical restraint failed to document the clinical justification/reason for the administration of the medications.

Review of ER physician documentation revealed the following notes for staff #35 (ER physician):

"18:05 - Medical screening exam complete.

18:10 - Patient presents to ER via Longview Fire Dept with unknown complaint.

18:31 Patient presents with ACTING ERRATICALLY. Onset: The symptoms/episode began/occurred today. Severity of symptoms: At worst the symptoms were moderate, in the emergency department the symptoms are unchanged. Unable to obtain HPI due to patient distress, MENTAL STATUS. Physicians Note: 19 Y0 FEMALE PT WITH A HX OF SEVERE ID/AUTISM PRESENTED TO THE ED VIA EMS C/O ACTING ERRATICALLY. EMS STATES THAT THE PT WAS REPORTED TO HAVE CHOCKED(sic) ONE OF THE STAFF MEMBERS AT THE GROUP HOME. PT HAS BEEN COMBATIVE, BITING PD/EMS STAFF. PT WAS GIVEN 5 MG VERSED IN ROUTE. NO OTHER SX, HX, OR COMPLAINTS ARE ABLE TO BE OBTAINED SECONDARY TO PTS MENTAL STATUS/DISTRESS.

Historical:
1. Seroquel 200 mg oral tab 1 tab nightly

2. Clonidine 0.1 mg oral tab 1 tab 3 times per day

- PMHx(Past Medical History: autism; severe intellectual disability;

- Social History: The social history from nurses notes was reviewed and I
agree with the nursing documentation. Patient uses no alcohol, no tobacco,
no IV drugs, no street drugs. Smoking History: Never smoker.
Nurses Notes: The history from nurses notes was reviewed and generally
agree with what's documented up to this point. The history from nurses
notes was reviewed and generally agree with what ' s documented up to this
point.

- Immunization history: Last tetanus immunization: unknown. Unable to obtain
flu information. Unable to obtain pneumonia vaccine information Unable to
obtain flu information. Unable to obtain pneumonia vaccine information.

- Code Status: Full code.

23:30 - unable to obtain ROS due to patient distress, MENTAL STATUS.
Exam:

23:30 Head/Face: Normocephalic, atraumatic. Normal fontanels Eyes: PERRL. Normal conjunctiva. No sclera icterus. No periorbital edema, [DIAGNOSES REDACTED] or
Swelling.

ENT: TM's normal with no [DIAGNOSES REDACTED], EAC' s clear. Normal nasal mucosa
with no [DIAGNOSES REDACTED], no lesions, and no discharge. Post pharynx is normal with
no [DIAGNOSES REDACTED], no exudates and no evidence of obstruction. Membranes are moist.
Neck: Supple. Trachea midline. No lymphadenopathy or masses. Normal ROM withno evidence of vertebral point tenderness. No meningismus

Respiratory: Clear to auscultation bilaterally, no respiratory distress and normal work of
breathing. No wheezing, tales or rhonchi. No stridor or nasal flaring

Chest/axilla: Normal chest wall appearance and motion. Nontender with no
deformity. No lesions are appreciated

Back: Normal inspection with no obvious deformity. No tenderness

Skin: Warm and dry with normal turgor.

Capillary refill <2 seconds. No cyanosis, pallor or rash MB! Extremity: No
evidence of focal tenderness or deformity. No edema

Constitutional: The patient appears AWAKE, VIOLENT, COMBATIVE

Cardiovascular: SLIGHTLY TACHYCARDIC.

Abdomen/Gl: BENIGN

Neuro: Motor/peripheral: moves all fours, SEVERE MR/AUTISM

Psych: Behavior/mood is aggressive, VIOLENT, ATTACKING STAFF. NOT
FOLLOWING DIRECTIONS.
01:01 - Differential Diagnosis: [DIAGNOSES REDACTED]"


There was no physician documentation by the ER physician (staff #36) from 0101(1:01AM) until 0621 (6:21 AM) on 4/16/15.
Review of staff #33 (ER physician) progress notes revealed the following:
"0621- PT W/ BEHAVIOR DISORDER, MR. INCREASED AGITATION AT HER GROUP HOME. SENT HERE DUE TO HER BEHAVIOR. MEDICALLY STABLE, BUT PLACEMENT ISSUES ABOUND. WILL BE WORKING TO GETPLACEMENT ARRANGED.

12:51 - PT BROUGHT TO ED YESTERDAY EVENING FOR INCREASING OUTBURSTS, VIOLENT TOWARDS OTHERS AND VIOLENT TOWARDS STAFF AT GROUP HOME. SHE HAS MR AND AUTISM. UP UNTIL 6 MONTHS AGO, SHE STAYED WITH FATHER PRIMARILY, UNTIL HE HAD A MAJOR STROKE. HAS LIVED AT A GROUP HOME SINCE THAT POINT. PT WAS AGGRESSIVE TOWARDS STAFF OVERNIGHT, REQUIRING PHYSICAL AND CHEMICAL RESTRAINTS, BOTH TO PROTECT PT FROM HARM AND PROTECT STAFF FROM HER. SHE HAS BEEN SPITTING/BITING AT PEOPLE DESPITE THE RESTRAINTS. I HAVE GIVEN A CONSIDERABLE AMOUNT OF SEDATION HERE IN ED AND SHE IS STILL INCOMPLETELY SEDATED. UNFORTUNATELY DUE TO HER STRUGGLING AGAINST RESTRAINTS, SHE IS NOW IN MILD RHABDOMYOLYSIS(Rhabdomyolysis is the rapid destruction of skeletal muscle).

12:56 - I HAVE DISCUSSED W/ OUR HOSPITALIST, WHO REQUESTS WE SEE ABOUT OTHER FACILITIES THAT HAVE PSYCHIATRY CONSULTATION AVAILABLE, AS PT HAS REQUIRED SO MUCH SEDATION TO PROTECT HER FROM HARMING HERSELF OR OTHERS.

14:26 - 1MG/KG KETAMINE INFUSED OVER 10 MINUTES TO GOOD EFFECT. CONTINUE IVF AT 250CC/HR, RECHECK CK AT 6PM (CK - CREATINE KINASE - an enzyme (a protein that facilitates chemical reactions in the body) also in the muscle cells. The level of this protein can be measured in blood to monitor the degree of muscle injury).
AT CURRENT TIME, PT NEEDS IVF AS WELL AS SEDATION OVER AND ABOVE WHAT I FEEL CAN BE ACCOMPLISHED ON FLOOR. WE HAVE
NO PSYCHIATRY SPECIALIST AVAILABLE TO EVALUATE/CONSULT WITH INTERNIST TO HELP MANAGE PATIENT. WE HAVE INVOLVED SOCIAL WORK AND HOUSE SUPERVISOR. IF PT NEEDS MORE SEDATION, CONSIDER KETAMINE 1MG/KG OVER 10 MINUTES THEN KETAMINE DRIP AT 1-1.5 MG/KG/HR.
14:37- SO FAR, PT HAS RECEIVED GEODON 40MG, HALDOL 20MG, ATIVAN 7MG, VALIUM 30MG, AND KETAMINE 80MG. CURRENTLY RESTING COMFORTABLY. "

The progress notes that follow were written by staff #34 (ER Physician):

"15:43 - PT CURRENTLY SEDATED, IN 4 POINTS RESTRAINTS. SHE HAS BITTEN AND RIPPED OUT ALL IV ' S EXCEPT FOOT IV. IVF ARE SLOWLY INFUSING. GIVEN CK ELEVATION, PT NEEDS MUCH MORE IVF. WILL NEED TO KEEP SEDATE ENOUGH TO MAINTAIN A LARGE BORE IV. MAY NEED AIRWAY PROTECTION TO KEEP SEDATION ADEQUATE. WILL ATTEMPT IV AND BOLUS AND RE- EVAL.

18:23- Intubation: Intubated orally using GLIDESCOPE with 6.0 Fr. Eli. Intubation was successful on the first attempt. Ventilated with ventilator. Patient
tolerated well. 20 MG ETOMIDATE AND 100 MG OF ROCURONIUM.

18:30 - I HAVE INDEPENDENTLY REVIEWED AND AGREE WITH THE RADIOLOGIST FINDINGS OF ET TUBE IN PLACE PER CXR.

18:56 CK INCREASING, PT REQUIRES CONTINOUS RESTRAINTS HEAVY SEDATION TO MAINTAIN IV. UNSAFE TO REMAIN THIS WAY. HAVE INTUBATED TO ALLOW RESTRAINT REMOVAL AND MORE IVF. "

Review of nurses notes on 4/16/15 at 18:27 revealed the following:

"1827 - Assessment: Pulses are all present, are palpable in right radial artery, right brachial artery, left radial artery and left brachial artery. Skin is intact with normal color, has good turgor. Edema distal to restraints is absent. Capillary refill is 3 seconds or less distal to restraints Patient respiratory status is per ventilator. Patient is asleep.

1828 - Restraint Application Assessment: Assessment: restraints removed.

2020 - admitted to ICU accompanied by nurse, family with patient, via stretcher, with oxygen, on monitor, with chart. Condition: stable.


Review of the facility policy titled "Restraint and Seclusion: Use of Least Restrictive Devices" revealed the following definitions of Restraints:

"Restraint for non-violent non-self-destructive behavior (Previously referred to as
Medical/Surgical Care): Used to ensure immediate physical safety of non-violent or non-self-destructive patient.

Restraint/seclusion for violent/self-destructive behavior (Previously referred to as
Behavioral Care): Used for management of violent, self-destructive patient that
jeopardizes immediate physical safety of patient, staff member, or others.
Chemical Restraint: A drug or medication when used as a restriction to manage
patient behavior or restrict patient freedom of movement and is not a standard treatment or dosage for patient's condition. Medications that comprise a patient's medical regimen including PRN medications are not considered chemical restraints if:

a. Approved by United States Food and Drug Administration (USFDA) and used
in accordance with approved indications and label instructions, including listed
dosage parameters

b. Use follows national practice standards established or recognized by medical
community and/or professional medical association or organization; and

c. Used to treat specific patient's clinical condition and is based on that patient's
symptoms, overall clinical situation, and on Physician/Licensed Independent
Practitioners (LIP'S) knowledge of that patient's expected and actual response.
Restraint/Seclusion Order Guidelines:
A. A physician/licensed independent practitioner (LIP) may write or give a
telephone order for restraints.

B. The attending physician or designee must be consulted as soon as possible if
he or she is not the one who ordered the restraints. When the attending
physician is unavailable, responsibility for the patient must be delegated to
another physician, who would then be considered the attending physician.
Physical chart documentation by the attending physician, whether or not it
directly addresses restraint use shall constitute evidence that the physician
was notified of the restraint episode.

C. The order must be will indicate the clinical justification/reason, date, time, time
limit (if applicable), type of least restrictive device, and signature of the
individual giving the order. The order must be obtained either during
application or immediately (within a few minutes) afterwards.

D. PRN orders are NOT to be used to authorize the use of restraints under any
circumstances. Staff cannot discontinue a restraint/seclusion and then later
restart it using the same order. This situation is the same as a PRN order.
"Trial release" constitutes PRN restraint/seclusion use is not permitted. If
restraint/seclusion is discontinued prior to original order expiration, a new
order must be obtained prior to restarting restraint/seclusion use.

E. When restraint/seclusion is used to manage non-violent behavior,
physician/LIP must examine the patient within 24 hours of initiation. The
clinical justification for continued restraints must be documented in the
patient's medical record daily.

Special Assessment Requirement Specific to Violent/Self-Destructive Behavior
Patients (Face-To-Face Evaluation):

A. When restraint/seclusion is used to manage violent or self-destructive behavior,
physician/LIP must conduct a face-to-face patient evaluation in person within 1
hour after restraint/seclusion initiated. A telephone call or telemedicine method is
not permitted. If patient's violent or self-destructive behavior resolves and
restraint/seclusion is discontinued before practitioner arrives to perform face-to-face evaluation, practitioner is still required to see patient face-to-face and
conduct evaluation within 1 hour after restraint/seclusion initiated.

B. This face-to-face evaluation requirement also applies when a medication is used
as a restraint/seclusion to manage violent or self-destructive behavior.

C. The patient must be seen face-to-face within 1 hour after the initiation of the
intervention to evaluate:

I) The patient's immediate situation;

2) The patient's reaction to the invention;

3) The patient's medical and behavioral condition;

4) The need to continue or terminate the restraint or seclusion.

Once the initial order is obtained and if the patient remains in restraints more
than 24 hours, the RN and physician/LIP documents the need for
continued restraint usage daily.

A new restraint order would be required if restraints have been
discontinued for any reason.

May only be obtained and renewed in accordance with following limits for up to
a total of 24 hours:
Up to 4 hours for adults [AGE] and older
Up to 2 hours for children andadolescents ages 9 to 17
Up to 1 hour for patients under age 9.
Physician/LIP must conduct a face-to-face patient evaluation in person within 1
hour after restraint/seclusion initiated.
If patient remains in restraint/seclusion 24 hours after original order,
physician/LIP must see patient and conduct a face-to-face re-evaluation.


Review of the patient's inpatient record revealed, patient #8 was admitted to ICU on 4/16/15, at 2009. Patient was on the ventilator, sleeping due to sedation, with siderails up X3. Patient had a nasogastric tube to low intermittent suction. Patient continued on ventilator with sedation until 4/18/15. Review of physician's progress notes on 4/18/15 at 7:18 revealed, "Sedation vacation today. Patient was intubated to sedate her due to severe agitation. Will place on restraints and see if she is okay to take off sedation". Further review of medical record revealed patient was extubated on 4/18/15, at 1046. On 4/18/15, at 1400, patient was given Ativan 2 mg. IV q2hrs. as needed for agitation.
Review of physician's telephone order dated 4/18/15, at 1730, revealed order for non-behavioral restraints to bilateral wrist and bilateral ankles. There was no documentation for the type of restraint to be used or justification/reason for the restraint. There was no nursing documentation to justify the need for restraints, or that restraints were initiated. On 4/18/15, at 1940, a telephone order was written for "Geodon 20 mg. IM q6hr prn, restless/agitation" and was documented on the MAR as given at 2052 (over an hour after the telephone order was taken).
On 4/18/15, at 2200, a telephone order was written for "Behavioral Restraints". There was no time limit, no justification/reason for the restraints noted. This telephone order was never signed by the physician (Staff #38). There was no documentation of a 1 hour face to face evaluation being done. Nursing documentation revealed restraint monitoring began at 2215 and continued every 15 minutes. There was no documentation that alternative interventions were attempted prior to the order for the restraints. On 4/19/15, at 0200, a telephone order was written for "Continue Behavioral Restraints". There was no time limit or justification/reason for the restraints noted. There was no documentation of a 1 hour face to face evaluation being done. On 4/19/15 at 0600, a telephone order was written for "Continue Behavioral Restraints" . There was no time limit or justification/reason for the restraints noted. There still was no documentation of a physician conducting 1 hour face to face evaluation ever being conducted.
On 4/19/15, at 1200 pm., a physician's order was written for "D/C (discontinue) Behavioral restraint. Use Non-behavioral restraint to protect her IV line." There was no time limit for the restraints or attempts at alternative interventions attempted. Nursing documentation revealed patient was assessed at 1416 (2:16 pm), 1533 (3:33pm), and 1820 (6:20pm). Review of the Medication Administration Record (MAR) revealed patient was given Ativan 2 mg. IV as needed for agitation at 1441 (2:41pm), 2154 (9:54pm), and on 4/20/15 at 0328 (3:28 pm) on 4/20/15.
On 4/20/15, at 0930 am., a telephone order was written for "Transfer to medical with sitter. 4 point restraints per restraint order sheet. Assess restraints per facility policy. May get out of bed when LOC (level of consciousness) improves." This order was never signed by the physician. On 4/20/15, at 1300, a physician's order was written for "non-behavioral restraint to both wrist and both ankles". Neither of these orders contained justification/reason or type of restraint to be used. Review of the MAR revealed patient received Ativan 2 mg. IV for agitation at 0937 (9:37am), 1048 (10:48pm), 1241 (12:41pm), 1747 (5:47pm), 1956 (7:56pm). Patient also received Geodon 20 mg. IM for agitation at 1241(12:41 pm), and 0326 (3:26 pm) on 4/21/15. There was no nursing documentation of increased agitation or aggressiveness to justify the prn medication or documentation of patient's response to the medications.
On 4/21/15, at 1300, a telephone restraint order was written for "Non-violent Behavior, Soft restraints, All Extremities". This order did not contain justification/reason for use of restraints. This order was never signed by the physician. Review of the MAR revealed patient received Ativan 2mg. IV for agitation at 1221 (12:21pm), 1535 (3:35pm) 1805 (6:05 pm), and 2250 (10:50 pm). Patient also received Geodon 20 mg IM at 1215 (12:15pm), and 1815 (6:15 pm). There was no nursing documentation of increased agitation or aggressiveness to justify the prn medications.
On 4/22/15, there was no order for restraint written. There also was no documentation that the physician assessed the patient for continued need for restraints. The nursing documentation did not contain documentation of the patient being transferred to the medical floor from ICU but there was a difference in the documentation from ICU that occurred at approximately 2025 on 4/22/15. There was no documentation of a nursing assessment done when patient arrived on the medical floor. The documentation revealed a shift assessment was conducted on 4/23/15, at 0527. Review of the MAR revealed patient received Ativan 2 mg. by mouth for agitation on 4/22/15, at 2200 and on 4/23/15, at 0600. There was no documentation what precipitated the need for the Ativan and there was no documentation how the patient responded to the medication. Nursing did document behavior monitoring every 2 hours but the documentation never changed to indicate a change in behavior or alternatives attempted.
The next order for restraints was a telephone order written on 4/23/15 at 1527, "4 point soft restraints for non-violent pulling of IV and lines. On 4/23/15, patient received Haldol 5mg. IV at 1508 and Benadryl 50 mg. by mouth at 1700 in addition to daily medication of Ativan 1 mg. TID (3x day) and Geodon 10 mg. IM every 6 hours. On 4/24/15, at 1212, a restraint order was written for non-violent behavior, soft restraints to all extremities. On 4/24/15, no prn (as needed) medication was given for agitation or aggressiveness but patient remained restrained. Nursing documentation for 4/25/15, at 1104, revealed the statement, "Unable to keep patient in restraints, patient chews them off." Documentation revealed patient was discharged at 1212 on 4/25/15 (One hour after patient "chewed" off her restraints).
Review of discharge summary dated 4/25/2015, revealed the following statements: "She is being discharged back to the group home to be followed up by regular psychiatrist. The group home did express that she was still a danger to herself and to other residents. Due to lack of psychiatric services available at this facility at this time, the patient was deferred to outpatient psychiatric evaluation and treatment within a week. According to nursing staff, the patient did seem to calm down and not require any definite supervision when she was a not in restraints and when she was given things, books to play with or toys to play with. She is, therefore, being discharged as stated above."
Record review revealed patient was hospitalized from [DATE] - 4/25/15 and was restraint free from physcial restraints only while on ventilator and heavily sedated (approximately 45 hours), and 1 hour prior to discharge.


These deficient practices were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0160
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on chart reviews and interviews, the facility failed to document a patient assessment, offer interventions, or justification before the administration of a chemical restraint for agitation and anxiety in 3 (#1, #8, #9) of 10 patients reviewed.
The facility failed to instruct the patient on an antipsychotic drug before administration. The facility failed to protect the patient from the use of a restraint(chemical) for staff convenience.
The facility failed to ensure antipsychotic medications were not ordered as a PRN (as needed) medication. The nurse failed to recognize the antipsychotic administered was contraindicated for a patient with Parkinson's disease in 1 (#1) of 10 (#1-10) patient charts reviewed.

1.) Review of patient #1's medical records revealed he was taken to the facility's emergency room (ER) on 1-16-2015, for stomach pain and breathing issues. He was diagnosed with [DIAGNOSES REDACTED]
Review of patient #1's nurses notes dated 1/18/2015, at 3:00 AM, stated, "3:00 AM patient at nurse's station states he heard someone laughing on the call light when he called for pain medication and didn't like it. Patient accompanied back to room. 3:14 AM Patient given Norco 10 at this time. 3:45 AM Notified doctor of wife requesting something for him for his anxiety, order given. 4:09 AM Gave Haldol 5 mg IM to left hip. 5:30 AM Patient resting quietly without any signs or symptoms of [DIAGNOSES REDACTED]
Review of the nurse's notes revealed there were no documented interventions found before patient #1 was given Haldol for agitation and anxiety.
A written statement from patient #1's spouse revealed, after the nurse returned patient #1 to the room he was very upset and anxious, nearly having a panic attack. At 4:00 AM, the nurse came back in to monitor his vital signs and blood sugar. Patient #1 asked for a Klonopin for his anxiety and staff #10 (RN) said, "Ok." Staff #10 returned without the Klonopin and informed patient #1 he could not have the Klonopin but she had a shot for him. Patient #1 asked what the medication was after he received the shot and could they have a print out. Staff #10 brought a print out to patient #1 and his spouse. Patient #1's spouse stated, "We were terrified. There were numerous stated reasons and 3 warnings why he should have not been given the drug, due to all the serious life threatening side effects."
Patient #1's spouse asked staff #10 if there was a medication he could take to reverse the drug Haloperidol (Haldol). Staff #10 confirmed that there was no medication to reverse this drug. Neither patient #1 nor his spouse was given any reason why he could not have his Klonopin and was given Haldol. Patient #1's spouse confirmed patient #1 had never received this medication before. Patient #1's spouse confirmed patient #1 was not diagnosed with [DIAGNOSES REDACTED]
A phone interview was conducted with staff #10 on 5/7/2015, at 2:45PM. Staff #10 confirmed she did remember caring for patient #1. Staff #10 stated, "He was acting agitated. He kept coming up to the nurse's station raising his voice. I tried to calm him down." Staff #10 confirmed that patient #1's spouse asked for a medication for anxiety but could not remember what drug it was. Staff #10 stated, "I called the doctor and got an order for Haldol. I went down and gave him the medication. I gave them a print out of the drug when they asked for it but I don't remember if I told them anything before the injection." Staff #10 was asked by the surveyor if the drug Haldol was given for the convenience of the staff to prevent patient #1 from coming up to the nurse's station? Staff #10 stated, "Yeah, I guess you could say that, we had to do something to get him calmed down until we could do something else with him."
Review of the physician order dated 1/18/2015, revealed, staff # 10 received a verbal order from staff #23 (MD Hospitalist). The order was given at 3:45 AM and stated,"Haldol 5mg IM or IV q4 Prn for agitation." Staff #23 did not electronically sign the order until 2/19/15 at 6:67 AM (33 days later).
Review of Patient #1's MAR (Medication Administration Record) revealed the last dose of Klonopin (benzodiazepine) was on 1/17/2015 at 5:52 PM.

Review of the drug Klonopin (benzodiazepine) from the U.S. National Library of Medicine stated, "Klonopin is indicated for the treatment of panic disorder, with or without agoraphobia, as defined in DSM-IV. Panic disorder is characterized by the occurrence of unexpected panic attacks and associated concern about having additional attacks, worry about the implications or consequences of the attacks, and/or a significant change in behavior related to the attacks.
Haldol-Haloperidol (anti-psychotic) is used to treat certain mental/mood disorders (e.g., schizophrenia, schizoaffective disorders). This medicine helps you to think more clearly, feel less nervous, and take part in everyday life. It can also help prevent suicide in people who are likely to harm themselves. It also reduces aggression and the desire to hurt others. It can decrease negative thoughts and hallucinations.
When Not To Use:
You should not receive this medicine if you have had an allergic reaction to haloperidol, or if you have Parkinson's disease. This medicine should not be given to patients with severe brain disease "

Review of physician progress notes dated 1/18/2015, at 8:00AM, revealed, staff #11(Resident) documented, "Pt was worse last night. Klonopin held and 5 mg Haldol given, but now agitating. Agitation likely paradoxical rxn from Haldol, will D/C."
Review of physician progress notes dated 1/18/2015, at 8:48 AM, revealed, staff #28 (Resident) documented, "The patient was agitated this morning. He states he was anxious and he was given Haldol instead of his Klonopin. The nurse staff notes he was agitated prior to this complaint. There was some reason for respiratory depression so he was given Haldol to treat both his agitation and anxiety. Him and his wife notes hallucinations and worsening agitation after administration of Haldol. These hallucinations have now resolved. By my evaluation, the patient is noted to have stable vital signs (not hypertensive/ not tachycardic/ O2 sat is stable) and his wheezing has notably improved. I will D/C Haldol and resume Klonopin. I discussed the reasoning behind Haldol use and he verbalized understanding. In the instance his breathing does become compromised, I told him we may need to hold the Klonopin again."
Review of the physician progress report was found in this record dated 1/18/2014 with no time. Staff # 29 (MD) documented, "Apparently, pt had hallucinations last night ( he has been getting hallucinations on and off for several months-is being followed at local mental health authority psychology/psychiatry) IMP- hx of Schizophrenia/ Anxiety DI - Parkinson's/mild dementia/chronic back pain PLAN- D/C Haldol."
Review of patient #1's History and Physical (H&P) and Discharge Summary revealed no documentation found of Schizophrenia as a diagnosis.
Review of patient #1's chart revealed the last 3 documented vital assessments, prior to the Haldol administration, There was no documentation found in the nurses notes of respiratory depression or out of range respirations. Vital signs are as follows:
"Archived Vital Signs Sheet
1/17/15 at 8:00 PM
Temperature Oral 97.4 (97.6-99.6)
Pulse Rate 86 (50-100 beats/min)
Respiratory Rate 18 (12-24 breaths/min)
Pulse Oximetry 94 (95-100)
Oxygen Delivery Method - room air
Blood Pressure 155/76 (100/60-150/90 mm hg) Automatic Cuff
Position was Supine (lying on back)

1/18/15 at 12:00 AM
Temperature Oral 97.6 (97.6-99.6)
Pulse Rate 77 (50-100 beats/min)
Respiratory Rate 19 (12-24 breaths/min)
Pulse Oximetry 93 (95-100)
Oxygen Delivery Method - room air
Blood Pressure 140/71 (100/60-150/90 mm hg) Automatic Cuff
Position was Supine (lying on back)

1/18/15 at 4:00 AM
Temperature Oral 97.6 (97.6-99.6)
Pulse Rate 52 (50-100 beats/min)
Respiratory Rate 22 (12-24 breaths/min)
Pulse Oximetry 93 (95-100)
Oxygen Delivery Method - room air
Blood Pressure 145/77 (100/60-150/90 mm hg) Automatic Cuff
Position was Supine (lying on back) "

2.) Review of patient #9's medical record revealed, he has been in the ER multiple times for drug related issues. Patient #9 was found to have an elevated white blood cell count and running fever. A lumbar puncture was performed on patient #9 to rule out Meningitis. The test came back negative but patient #9 was admitted with Rhabdomyolysis and altered mental status.
Rhabdomyolysis is breakdown of muscle fibers. Muscle breakdown causes the release of myoglobin into the bloodstream. Myoglobin can cause kidney damage.
Review of patient #9's emergency room (ER) nurses notes on 4/22/2015, stated, "6:53 PM Pt found in PD custody, combative and uncooperative on scene and required PD intervention. Possible K2/Meth usage. Pt is alert and very uncooperative, somewhat combative. Speaking gibberish and sounding paranoid- thinks we are going to kill him, states, "you know what you've done" and "that's what the windshield wiper fluid told you."Behavior is agitated, anxious, restless, uncooperative. The patient is oriented to person, the patient is disoriented. Patient home medication was provided by the previous visit. The patient is unable to provide a social history due to altered mental status.
Review of patient #9's nurse's notes dated 4/22/2015, at 7:15PM, stated,"Pt continuing to trash/make threats while attempting to insert new IV. Pt flung hand up at staff and was making threats. MD informed. Order for restraints received."
Review of patient # 9's ER nurses notes dated 4/22/2015, at 7:17PM, stated,"Restraint Order Physician Order for invasive line protection, behavior management restraint Type of restraint: leather wrist restraints, leather ankle restraints. Restraint Application Assessment: The following criteria /clinical justification support the decision for use of restraint: Patient is at risk for harm to self and others. Patient's behavior disrupts the environment so that treatment cannot take place. Behavioral Restraint: patient is at risk of harm to self and/or others related to: Patient is agitated by continuing to yell at staff, kick or swing violently, make threats to staff, come of bed, Patient is combative by continuing to yell at staff, kick or swing violently, make threats to staff, fight against restraints, come of bed, overt actions and/or threats toward staff, behavior is intervening with patient treatment, confusion and/or disorientation, Alternatives attempted: Orienting the patient to person, place and time. Bed assignment for optimal observation of patient by nursing staff. Environment modification: Restraint education given to the patient. Patient needs ongoing instructions related to restraint use.

Review of the facility's policy and procedure "Restraints and Seclusion" stated, "Restraint/Seclusion Order Guidelines:
C. The order must be will indicate the clinical justification/reason, date, time, time limit(if applicable), type of least restrictive device, and signature of the individual giving the order. The order must be obtained either during application or immediately (within a few minutes) afterwards.
D. PRN orders are NOT to be used to authorize the use of restraints under any circumstances. Staff cannot discontinue a restraint/seclusion and then later restart it using the same order. This situation is the same as a PRN order. "Trial release" constitutes PRN restraint/seclusion use is not permitted. If restraint/seclusion is discontinued prior to original order expiration, a new order must be obtained prior to restarting restraint/seclusion use.

Review of patient #9's ER physician orders on 4/22/15, at 7:16PM, stated, "Restrain -up to 4 hours (Adult>17 years of age); Complete Time 7:20PM. "There was no documentation found on Physician ER notes or orders of clinical justification or type of least restrictive device. There was no documentation found of a physician face to face performed for restraint necessity or continued use.
Review of patient #9's ER nurses notes dated 4/22/2015, at 19:50, stated, "Assessment: Pulses are all present. Skin is intact with normal color, has good turgor. Edema distal to restraints is absent. Capillary refill is 3 seconds or less distal to restraints. Patient respiratory status is unlabored. Patient is agitated by continuing to Patient is restless. Patient is disoriented, fight against restraints."

Review of the drug Geodon (Ziprasidone) from the U.S. National Library of Medicine stated, "Acute Treatment of Agitation in Schizophrenia/Intramuscular Dosing
GEODON is indicated for the treatment of schizophrenia, as monotherapy for the acute treatment of bipolar manic or mixed episodes, and as an adjunct to lithium or valproate for the maintenance treatment of bipolar disorder.
The recommended dose is 10 mg to 20 mg administered as required up to a maximum dose of 40 mg per day. Doses of 10 mg may be administered every two hours; doses of 20 mg may be administered every four hours up to a maximum of 40 mg/day. Intramuscular administration of ziprasidone for more than three consecutive days has not been studied ."

Review of patient #9's ER physician notes for 4/22/2015, at 7:45PM, stated, "Geodon 10mg IM once and Ativan 1 mg IVP once." There was no physician documentation found for justification of psychoactive medication administration. Dispensed Medications: 8:03PM Drug: Geodon 10MG Route: IM Site left deltoid. Ativan 1mg Route: IVP."
Review of patient #9's ER nurses notes dated 4/22/2015, at 8:50PM, stated, "Assessment: Pulses are all present. Skin is intact with normal color, has good turgor. Edema distal to restraints is absent. Capillary refill is 3 seconds or less distal to restraints. Patient respiratory status is unlabored. Patient is combative by continuing to Patient is restless. Patient is disoriented, fight against restraints."
Review of patient #9's ER physician notes for 4/22/2015, at 8:54PM, stated, "Geodon 10mg IM once and Ativan 1 mg IVP once." There was no physician documentation found for justification of psychoactive medication administration. Dispensed Medications: 9:00PM Drug: Ativan 1mg Route: IVP; 9:04PM Infused Over: 1 mins. Geodon 10MG Route: IM Site: right deltoid."
Review of patient #9's chart revealed a physician order with the title "General Admission" the orders were three pages long. The order stated staff # 23 is the attending physician. The order read, "2.) Geodon 10mg IM q4h PRN for agitation tonight." The order had no physician signature, time, or date.
Review of the Geodon administered was retrieved from the Medication Discharge Summary dated 4/23/15-4/27/15. The Medication Discharge Summary read, Geodon (Ziprasidone Mesylate 20mg vial) 10 mg IM Q4H/PRN PRN Reason: Agitation Comments: Max Daily Dose: 40mg. "The General admission orders state, "tonight" The limited time period was not transcribed to the Medication Discharge Summary. Geodon 10mgs was administered on the following dates and times;
1. 4-22-15 at 7:45PM 10 mg given IM 1 time order in the ER, 8:54PM 10 mg given IM 1 time order in the ER.
4-23 15 at 12:17AM 10mg, 8:25AM 10mg, 5:12PM 10mg = a total of 50 mg in a 24 hour period.
2. 4-24-15 at 2:17AM 10mg, 11:52AM 10 mg, 5:28PM 10mg. NO MD ORDERS FOUND.
3. 4-25-15 at 5:21AM 10mg, 10:18AM 10mg, 4:27PM 10mg, 9:26PM 10mg. NO MD ORDERS FOUND.
4. 4-26-15 at 12:25AM 10mg, 1:29PM 10mg, and 5:26 PM 10 mg. NO MD ORDERS FOUND.

Review of patient #9's nursing notes dated 4/27/2015, at 8:00AM, stated, "Pt yelling out at staff and soitter. Called his mother and told her that he was dying. Mother called crying and will be at BS soon."
Review of patient #9's physician orders revealed an order for Geodon 10 mg IM q4H PRN was obtained on 4/27/2015, at 8:23AM.
Medication Discharge Summary dated 4-27-15, at 8:23 AM showed Geodon 10 mg was given IM. There was no further documentation of medication effectiveness.
Review of patient #9's nursing notes dated 4/27/2015, at 9:45AM, stated; "Charge RN called Social worker and House supervisor about Pt wants to be D/Ced. Confirmed he is not a threat to himself or others and okay for D/C with family. Discharge paper work completed by Charge RN and reviewed with patient and family." Patient #9 had been medicated 1 hour and 22 minutes prior to discharge for disruptive behavior.






3.) Review of medical record revealed patient #8, a [AGE] year old female with severe Intellectual Disability and Autism and reported to have the mental capacity of a one year old. Patient was brought to the facility on [DATE], from a residential group home by EMS (Emergency Medical Services) due to severe agitation and aggressiveness. The staff at the group home reported that patient had become increasingly agitated and aggressive over the past week as evidenced by hitting, biting, and pulling hair of other residents. What incited the change in behavior is unclear but patient recently had changes to her environment and caregivers. Patient's father was her primary caregiver but he had a stroke and had to be placed in a nursing home. Since that time the patient was placed in the group home and also had been started on Seroquel (antipsychotic medication) 200 mg. at bedtime for behavioral issues and sleep disturbance approximately 2 months prior.
Police were called to the group home after patient became violent and attempting to choke a staff person. Police were unable to calm patient and called EMS to take her to the emergency department (ED) for evaluation. EMS staff used gauze rolls, sheets and belts on the stretcher for restraints to transport to the emergency room . Patient was given Versed (Central Nervous System Depressant) 5 mg. Intranasally X2 due to combativeness while in route to the ED. No effect noted from the Versed.
Patient arrived at the ED on 4/15/15, at 1817 (6:17 pm). Physician's notes revealed "patient presents with ACTING IRRATICALLY. Onset: The symptoms/episode began/occurred today. Severity of symptoms: At worst the symptoms were moderate, in the emergency department the symptoms are unchanged. Unable to obtain HPI (History and Physical) due to patient distress, mental status." A review of physician ' s orders revealed orders at 1818 (6:18 PM) for "Geodon (antipsychotic)40 mg IM once, Restrain - up to 4 hours, and elopement precautions." Further review of the physician orders revealed an order for Ativan (anti-anxiety 1 mg. IVP (Intravenous Push) at 2000 (8:00 PM) and also for Morphine (narcotic) 4 mg. IVP was written at 2002 (8:02 PM). There was no documentation in physician's orders or progress notes of the clinical justification/reason for the restraints, type of restraints, or the reason the medications were given.
The next order written was at 2200 (10:00 PM) - "Restrain-up to 4 hours. Verbal Order received at 2200." The next physician's order was Valium (anti-anxiety) 5mg. IVP @ 0055 (00:55 AM) on 4/16/15. The order did not contain a reason for the restraints or medication, did not identify the type of restraint, and the nurse's notes did not contain documentation to justify a reason for the restraints or medication being given. Valium 5 mg. IVP was given again at 0116 (1:16 AM) which was 21 minutes later. The order did not contain a reason for the medication and the nurse's notes did not contain documentation to justify a reason for the medication being given. Order to "Restrain - up to 4 hours (Adult >17 years of age)" ordered at 0200. Order did not justify the reason for the restraints or the type of restraints.

The following is a list of physician orders for physical and chemical restraints and how they were written:
Order for "Haldol 5 mg. IV once" at 0536.
Order to "Restrain - up to 4 hours (Adult >17 years of age)" ordered at 0600.
Order for "Ativan 2 mg. IVP once" at 0655.
Order for "Ativan 2 mg. IVP once" at 0814.
Order for "Valium 5 mg. IVP once" at 0831.
Order to "Restrain - up to 4 hours (Adult >17 years of age)" ordered at 1000.
Order for "Valium 5 mg IVP once" at 1020.
Order for "Benadryl (antihistamine) 25 mg IVP once" at 1043.
Order for "Valium 5 mg IVP once" at 1043.
Order for "Valium 5 mg. IVP once" at 1049.
Order for "Clonidine (antihypertensive) 0.2 mg PO once" at 1049.
Order for "Haldol 5 mg. IV once" at 1102.
Order for "Haldol 5 mg. IV once" at 1153.
Order for "Haldol 5 mg. IV once" at 1244.
Order for "Ketamine(sedative/analgesic)1mg/kg IVP once" at 1403.
Order to "Restrain - up to 4 hours (Adult >17 years of age)" ordered at 1400.
Order for "Clonidine 0.2 mg. PO once" at 1552.
Order for "Ketamine 0.5 mg/kg IVP once" at 1554.
Order for "Ketamine 1.0 mg/kg IVP once" at 1657.
Order for "Rocuronium (muscle relaxer) 100 mg IV once" at 1706.
Order for "Propofol(anesthetic) 100 ml IV at 10 mcg/kg/min once" at 1706. Administered at 1819.
Order for "Etomidate (anesthetic) 20 mg IVP once at 1706" . Administered at 1753" .

Review of ER physician documentation revealed, the physician failed to document the clinical justification/reason, type of least restrictive device, and signature of the individual giving the order for the physical restraint. The numerous orders for medications as a chemical restraint failed to document the clinical justification/reason for the administration of the medications.

Review of ER physician documentation revealed the following notes for staff #35 (ER physician):

"18:05 - Medical screening exam complete.

18:10 - Patient presents to ER via Longview Fire Dept with unknown complaint.

18:31 Patient presents with ACTING ERRATICALLY. Onset: The symptoms/episode began/occurred today. Severity of symptoms: At worst the symptoms were moderate, in the emergency department the symptoms are unchanged. Unable to obtain HPI due to patient distress, MENTAL STATUS. Physicians Note: 19 Y0 FEMALE PT WITH A HX OF SEVERE ID/AUTISM PRESENTED TO THE ED VIA EMS C/O ACTING ERRATICALLY. EMS STATES THAT THE PT WAS REPORTED TO HAVE CHOCKED(sic) ONE OF THE STAFF MEMBERS AT THE GROUP HOME. PT HAS BEEN COMBATIVE, BITING PD/EMS STAFF. PT WAS GIVEN 5 MG VERSED IN ROUTE. NO OTHER SX, HX, OR COMPLAINTS ARE ABLE TO BE OBTAINED SECONDARY TO PTS MENTAL STATUS/DISTRESS.

Historical:
1. Seroquel 200 mg oral tab 1 tab nightly

2. Clonidine 0.1 mg oral tab 1 tab 3 times per day

- PMHx(Past Medical History: autism; severe intellectual disability;

- Social History: The social history from nurses notes was reviewed and I
agree with the nursing documentation. Patient uses no alcohol, no tobacco,
no IV drugs, no street drugs. Smoking History: Never smoker.

Nurses Notes: The history from nurses notes was reviewed and generally
agree with what ' s documented up to this point. The history from nurses
notes was reviewed and generally agree with what ' s documented up to this
point.

- Immunization history: Last tetanus immunization: unknown. Unable to obtain
flu information. Unable to obtain pneumonia vaccine information Unable to
obtain flu information. Unable to obtain pneumonia vaccine information.

- Code Status: Full code.

23:30 - unable to obtain ROS due to patient distress, MENTAL STATUS.
Exam:

23:30 Head/Face: Normocephalic, atraumatic. Normal fontanels Eyes: PERRL. Normal conjunctiva. No sclera icterus. No periorbital edema, [DIAGNOSES REDACTED] or Swelling.

ENT: TM's normal with no [DIAGNOSES REDACTED], EAC' s clear. Normal nasal mucosa
with no [DIAGNOSES REDACTED], no lesions, and no discharge. Post pharynx is normal with
no [DIAGNOSES REDACTED], no exudates and no evidence of obstruction. Membranes are moist.
Neck: Supple. Trachea midline. No lymphadenopathy or masses. Normal ROM withno evidence of vertebral point tenderness. No meningismus

Respiratory: Clear to auscultation bilaterally, no respiratory distress and normal work of
breathing. No wheezing, tales or rhonchi. No stridor or nasal flaring

Chest/axilla: Normal chest wall appearance and motion. Nontender with no
deformity. No lesions are appreciated

Back: Normal inspection with no obvious deformity. No tenderness

Skin: Warm and dry with normal turgor.

Capillary refill <2 seconds. No cyanosis, pallor or rash MB! Extremity: No
evidence of focal tenderness or deformity. No edema

Constitutional: The patient appears AWAKE, VIOLENT, COMBATIVE

Cardiovascular: SLIGHTLY TACHYCARDIC.

Abdomen/Gl: BENIGN

Neuro: Motor/peripheral: moves all fours, SEVERE MR/AUTISM

Psych: Behavior/mood is aggressive, VIOLENT, ATTACKING STAFF. NOT
FOLLOWING DIRECTIONS.
01:01 - Differential Diagnosis: [DIAGNOSES REDACTED]"


There was no physician documentation by the ER physician (staff #36) from 0101 (1:01AM) until 0621 (6:21 AM) on 4/16/15.

Review of staff #33 (ER physician) progress notes revealed the following:
"0621- PT W/ BEHAVIOR DISORDER, MR. INCREASED AGITATION AT HER GROUP HOME. SENT HERE DUE TO HER BEHAVIOR. MEDICALLY STABLE, BUT PLACEMENT ISSUES ABOUND. WILL BE WORKING TO GETPLACEMENT ARRANGED.

12:51 - PT BROUGHT TO ED YESTERDAY EVENING FOR INCREASING OUTBURSTS, VIOLENT TOWARDS OTHERS AND VIOLENT TOWARDS STAFF AT GROUP HOME. SHE HAS MR AND AUTISM. UP UNTIL 6 MONTHS AGO, SHE STAYED WITH FATHER PRIMARILY, UNTIL HE HAD A MAJOR STROKE. HAS LIVED AT A GROUP HOME SINCE THAT POINT. PT WAS AGGRESSIVE TOWARDS STAFF OVERNIGHT, REQUIRING PHYSICAL AND CHEMICAL RESTRAINTS, BOTH TO PROTECT PT FROM HARM AND PROTECT STAFF FROM HER. SHE HAS BEEN SPITTING/BITING AT PEOPLE DESPITE THE RESTRAINTS. I HAVE GIVEN A CONSIDERABLE AMOUNT OF SEDATION HERE IN ED AND SHE IS STILL INCOMPLETELY SEDATED. UNFORTUNATELY DUE TO HER STRUGGLING AGAINST RESTRAINTS, SHE IS NOW IN MILD RHABDOMYOLYSIS(Rhabdomyolysis is the rapid destruction of skeletal muscle).

12:56 - I HAVE DISCUSSED W/ OUR HOSPITALIST, WHO REQUESTS WE SEE ABOUT OTHER FACILITIES THAT HAVE PSYCHIATRY CONSULTATION AVAILABLE, AS PT HAS REQUIRED SO MUCH SEDATION TO PROTECT HER FROM HARMING HERSELF OR OTHERS.

14:26 - 1MG/KG KETAMINE INFUSED OVER 10 MINUTES TO GOOD EFFECT. CONTINUE IVF AT 250CC/HR, RECHECK CK AT 6PM (CK - CREATINE KINASE

- an enzyme (a protein that facilitates chemical reactions in the body) also in the muscle cells. The level of this protein can be measured in blood to monitor the degree of muscle injury).
AT CURRENT TIME, PT NEEDS IVF AS WELL AS SEDATION OVER AND ABOVE WHAT I FEEL CAN BE ACCOMPLISHED ON FLOOR. WE HAVE
NO PSYCHIATRY SPECIALIST AVAILABLE TO EVALUATE/CONSULT WITH INTERNIST TO HELP MANAGE PATIENT. WE HAVE INVOLVED SOCIAL WORK AND HOUSE SUPERVISOR. IF PT NEEDS MORE SEDATION, CONSIDER KETAMINE 1MG/KG OVER 10 MINUTES THEN KETAMINE DRIP AT 1-1.5 MG/KG/HR.

14:37- SO FAR, PT HAS RECEIVED GEODON 40MG, HALDOL 20MG, ATIVAN 7MG, VALIUM 30MG, AND KETAMINE 80MG. CURRENTLY RESTING COMFORTABLY. "

The progress notes that follow were written by staff #34 (ER Physician):

"15:43 - PT CURRENTLY SEDATED, IN 4 POINTS RESTRAINTS. SHE HAS BITTEN AND RIPPED OUT ALL IV ' S EXCEPT FOOT IV. IVF ARE SLOWLY INFUSING. GIVEN CK ELEVATION, PT NEEDS MUCH MORE IVF. WILL NEED TO KEEP SEDATE ENOUGH TO MAINTAIN A LARGE BORE IV. MAY NEED AIRWAY PROTECTION TO KEEP SEDATION
ADEQUATE. WILL ATTEMPT IV AND BOLUS AND RE- EVAL.

18:23- Intubation: Intubated orally using GLIDESCOPE with 6.0 Fr. Eli. Intubation was successful on the first attempt. Ventilated with ventilator. Patient
tolerated well. 20 MG ETOMIDATE AND 100 MG OF ROCURONIUM.

18:30 - I HAVE INDEPENDENTLY REVIEWED AND AGREE WITH THE RADIOLOGIST FINDINGS OF ET TUBE IN PLACE PER CXR.

18:56 CK INCREASING, PT REQUIRES CONTINOUS RESTRAINTS HEAVY SEDATION TO MAINTAIN IV. UNSAFE TO REMAIN THIS WAY. HAVE INTUBATED TO ALLOW RESTRAINT REMOVAL AND MORE IVF. "

Review of nurses notes on 4/16/15 at 18:27 revealed the following:

"1827 - Assessment: Pulses are all present, are palpable in right radial artery, right brachial artery, left radial artery and left brachial artery. Skin is intact with normal color, has good turgor. Edema distal to restraints is absent. Capillary refill is 3 seconds or less distal to restraints Patient respiratory status is per ventilator. Patient is asleep.

1828 - Restraint Application Assessment: Assessment: restraints removed.

2020 - admitted to ICU accompanied by nurse, family with patient, via stretcher, with oxygen, on monitor, with chart. Condition: stable.


Review of the facility policy titled "Restraint and Seclusion: Use of Least Restrictive Devices" revealed the following definitions of Restraints:

"Restraint for non-violent non-self-destructive behavior (Previously referred to as
Medical/Surgical Care): Used to ensure immediate physical safety of non-violent or non-self-destructive patient.

Restraint/seclusion for violent/self-destructive behavior (Previously referred to as
Behavioral Care): Used for management of violent, self-destructive patient that
jeopardizes immediate physical safety of patient, staff member, or others.
Chemical Restraint: A drug or medication when used as a restriction to manage
patient behavior or restrict patient freedom of movement and is not a standard treatment or dosage for patient's condition. Medications that comprise a patient's medical regimen including PRN medications are not considered chemical restraints if:

a. Approved by United States Food and Drug Administration (USFDA) and used
in accordance with approved indications and label instructions, including listed
dosage parameters

b. Use follows national practice standards established or recognized by medical
community and/or professional medical association or organization; and

c. Used to treat specific patient's clinical condition and is based on that patient's
symptoms, overall clinical situation, and on Physician/Licensed Independent
Practitioners (LIP'S) knowledge of that patient's expected and actual response.
Restraint/Seclusion Order Guidelines:
A. A physician/licensed independent practitioner (LIP) may write or give a
telephone order for restraints.

B. The attending physician or designee must be consulted as soon as possible if
he or she is not the one who ordered the restraints. When the attending
physician is unavailable, responsibility for the patient must be delegated to
another physician, who would then be considered the attending physician.
Physical chart documentation by the attending physician, whether or not it
directly addresses restraint use shall constitute evidence that the physician
was notified of the restraint episode.

C. The order must be will indicate the clinical justification/reason, date, time, time
limit (if applicable), type of least restrictive device, and signature of the
individual giving the order. The order must be obtained either during
application or immediately (within a few minutes) afterwards.

D. PRN orders are NOT to be used to authorize the use of restraints under any
circumstances. Staff cannot discontinue a restraint/seclusion and then later
restart it using the same order. This situation is the same as a PRN order.
"Trial release" constitutes PRN restraint/seclusion use is not permitted. If
restraint/seclusion is discontinued prior to original order expiration, a new
order must be obtained prior to restarting restraint/seclusion use.

E. When restraint/seclusion is used to manage non-violent behavior,
physician/LIP must examine the patient within 24 hours of initiation. The
clinical justification for continued restraints must be documented in the
patient's medical record daily.

Special Assessment Requirement Specific to Violent/Self-Destructive Behavior
Patients (Face-To-Face Evaluation):

A. When restraint/seclusion is used to manage violent or self-destructive behavior,
physician/LIP must conduct a face-to-face patient evaluation in person within 1
hour after restraint/seclusion initiated. A telephone call or telemedicine method is
not permitted. If patient's violent or self-destructive behavior resolves and
restraint/seclusion is discontinued before practitioner arrives to perform face-to-face evaluation, practitioner is still required to see patient face-to-face and
conduct evaluation within 1 hour after restraint/seclusion initiated.

B. This face-to-face evaluation requirement also applies when a medication is used
as a restraint/seclusion to manage violent or self-destructive behavior.

C. The patient must be seen face-to-face within 1 hour after the initiation of the
intervention to eval
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0165
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on chart reviews policy and procedures, and interviews, the facility failed to have clear documentation in the patient's medical record describing the steps or interventions used prior to use of restraints, physical or chemical. The facility failed to document less restrictive measures were tried or considered in 3(#1, #8 and #9) out of 10 (1-10) patient charts reviewed.
1.) Review of patient #1's medical records revealed he was taken to the facility's emergency room (ER) on 1-16-2015, for stomach pain and breathing issues. He was diagnosed with [DIAGNOSES REDACTED]
Review of patient #1's nurses notes dated 1/18/2015, at 3:00 AM, stated, "3:00 AM patient at nurse's station states that he heard someone laughing on the call light when he called for pain medication and didn't like it. Patient accompanied back to room. 3:14 AM Patient given Norco 10 at this time. 3:45 AM Notified doctor of wife requesting something for him for his anxiety, order given. 4:09AM Gave Haldol 5 mg IM to left hip. 5:30AM Patient resting quietly without any signs or symptoms of [DIAGNOSES REDACTED]
Review patient #1's nurse's notes dated 1/18/2015, revealed there were no documentation found of interventions or if less restrictive interventions were tried before patient #1 was given Haldol for agitation and anxiety.
A written statement from patient #1's spouse revealed that after the nurse returned patient #1 to the room he was very upset and anxious, nearly having a panic attack. At 4:00AM, the nurse came back in to monitor his vital signs and blood sugar. Patient #1 asked for a Klonopin for his anxiety and staff # 10 (RN) said, "Ok." Staff #10 returned without the Klonopin and informed patient #1 he could not have the Klonopin but she had a shot for him. Patient #1 asked what the medication was after he received the shot and could they have a print out. Staff #10 brought a print out to patient #1 and his spouse. Patient #1's spouse stated, "We were terrified. There were numerous stated reasons and 3 warnings why he should have not been given the drug, due to all the serious life threatening side effects."
Patient #1's spouse asked staff #10 if there was a medication he could take to reverse the drug Haloperidol (Haldol). Staff #10 confirmed there was no medication to reverse this drug. Neither patient #1 nor his spouse was given any reason why he could not have his Klonopin and was given Haldol. Patient #1's spouse confirmed patient #1 had never received this medication before. Patient #1's spouse confirmed patient #1 was not diagnosed with [DIAGNOSES REDACTED]
A phone interview was conducted with staff #10 on 5/7/2015, at 2:45PM. Staff #10 confirmed she did remember caring for patient #1. Staff #10 stated, "He was acting agitated. He kept coming up to the nurse's station raising his voice. I tried to calm him down." Staff #10 confirmed that patient #1's spouse asked for a medication for anxiety but could not remember what drug it was. Staff #10 stated, "I called the doctor and got an order for Haldol. I went down and gave him the medication. I gave them a print out of the drug when they asked for it but I don't remember if I told them anything before the injection." Staff #10 was asked by the surveyor if the drug Haldol was given for the convenience of the staff to prevent patient #1 from coming up to the nurse's station? Staff #10 stated, "Yeah, I guess you could say that, we had to do something to get him calmed down until we could do something else with him."
Review of the physician order dated 1/18/2015, revealed staff # 10 received a verbal order from staff #23 (MD Hospitalist). The order was given at 3:45 AM and stated, "Haldol 5mg IM or IV q4 Prn for agitation." Staff #23 did not electronically sign the order until 2/19/15 at 6:67 AM (33 days later).

Review of the facility's policy and procedure "Restraints and Seclusion" stated, "Restraint/Seclusion Order Guidelines:
C. The order must be will indicate the clinical justification/reason, date, time, time limit(if applicable), type of least restrictive device, and signature of the individual giving the order. The order must be obtained either during application or immediately (within a few minutes) afterwards.
D. PRN orders are NOT to be used to authorize the use of restraints under any circumstances. Staff cannot discontinue a restraint/seclusion and then later restart it using the same order. This situation is the same as a PRN order. "Trial release" constitutes PRN restraint/seclusion use is not permitted. If restraint/seclusion is discontinued prior to original order expiration, a new order must be obtained prior to restarting restraint/seclusion use.

2.) Review of patient #9's medical record revealed he has been in the ER multiple times for drug related issues. Patient #9 was found to have an elevated white blood cell count and running fever. A lumbar puncture was performed on patient #9 to rule out Meningitis. The test came back negative but patient #9 was admitted with Rhabdomyolysis and altered mental status.
Rhabdomyolysis is breakdown of muscle fibers. Muscle breakdown causes the release of myoglobin into the bloodstream. Myoglobin can cause kidney damage.
Review of patient #9's emergency room (ER) nurses notes on 4/22/2015, stated, "6:53 PM Pt found in PD custody, combative and uncooperative on scene and required PD intervention. Possible K2/Meth usage. Pt is alert and very uncooperative, somewhat combative. Speaking gibberish and sounding paranoid- thinks we are going to kill him, states, "you know what you've done" and "that's what the windshield wiper fluid told you. Behavior is agitated, anxious, restless, uncooperative. The patient is oriented to person, the patient is disoriented. Patient home medication was provided by the previous visit. The patient is unable to provide a social history due to altered mental status.
Review of patient #9's chart revealed a physician order with the title "General Admission" the orders were three pages long. The order stated staff # 23 is the attending physician. The order read, "2.) Geodon 10mg IM q4h PRN for agitation tonight." The order had no physician signature, time, or date.

Review of the drug Geodon (Ziprasidone) from the U.S. National Library of Medicine stated, "Acute Treatment of Agitation in Schizophrenia/Intramuscular Dosing
GEODON is indicated for the treatment of schizophrenia, as monotherapy for the acute treatment of bipolar manic or mixed episodes, and as an adjunct to lithium or valproate for the maintenance treatment of bipolar disorder
The recommended dose is 10 mg to 20 mg administered as required up to a maximum dose of 40 mg per day. Doses of 10 mg may be administered every two hours; doses of 20 mg may be administered every four hours up to a maximum of 40 mg/day. Intramuscular administration of ziprasidone for more than three consecutive days has not been studied ."

Review of the Geodon administered was retrieved from the Medication Discharge Summary dated 4/23/15-4/27/15. The Medication Discharge Summary read, "Geodon (Ziprasidone Mesylate 20mg vial) 10 mg IM Q4H/PRN PRN Reason: Agitation Comments: Max Daily Dose: 40mg." The General admission orders state, "tonight" The limited time period was not transcribed to the Medication Discharge Summary. Geodon 10mgs was administered on the following dates and times;
1. 4-22-15 at 7:45PM 10 mg given IM 1 time order in the ER, 8:54PM 10 mg given IM 1 time order in the ER.
4-23 15 at 12:17AM 10mg, 8:25AM 10mg, 5:12PM 10mg = a total of 50 mg in a 24 hour period.
2. 4-24-15 at 2:17AM 10mg, 11:52AM 10 mg, 5:28PM 10mg. NO MD ORDERS FOUND.
3. 4-25-15 at 5:21AM 10mg, 10:18AM 10mg, 4:27PM 10mg, 9:26PM 10mg. NO MD ORDERS FOUND.
4. 4-26-15 at 12:25AM 10mg, 1:29PM 10mg, and 5:26 PM 10 mg. NO MD ORDERS FOUND.

Review of patient #9's nursing notes dated 4/27/2015, at 8:00AM stated, "Pt yelling out at staff and sitter. Called his mother and told her that he was dying. Mother called crying and will be at BS soon." There was no intervention documentation found before administration of psychoactive medication.
Review of patient #9's physician orders revealed an order for Geodon 10 mg IM q4H PRN was obtained on 4/27/2015, at 8:23AM.
Medication Discharge Summary dated 4-27-15, at 8:23 AM shows 10 mg were given IM. There was no further documentation of medication effectiveness.










3.) Review of medical record revealed patient #8 was a [AGE] year old female with severe Intellectual Disability and Autism and reported to have the mental capacity of a one year old. Patient was brought to the facility on [DATE] from a residential group home by EMS (Emergency Medical Services) due to severe agitation and aggressiveness. The staff at the group home reported that patient had become increasingly agitated and aggressive over the past week as evidenced by hitting, biting, and pulling hair of other residents. What incited the change in behavior is unclear but patient recently had changes to her environment and caregivers. Patient ' s father was her primary caregiver but he had a stroke and had to be placed in a nursing home. Since that time the patient was placed in the group home and also had been started on Seroquel (antipsychotic medication) 200 mg. at bedtime for behavioral issues and sleep disturbance approximately 2 months prior.
Police were called to the group home after patient became violent and attempting to choke a staff person. Police were unable to calm patient and called EMS to take her to the emergency department (ED) for evaluation. EMS staff used gauze rolls, sheets and belts on the stretcher for restraints to transport to the emergency room . Patient was given Versed (Central Nervous System Depressant) 5 mg. Intranasally X2 due to combativeness while in route to the ED. No effect noted from the Versed.
Patient arrived at the ED on 4/15/15 at 1817 (6:17 pm). Physician ' s notes revealed " patient presents with ACTING IRRATICALLY. Onset: The symptoms/episode began/occurred today. Severity of symptoms: At worst the symptoms were moderate, in the emergency department the symptoms are unchanged. Unable to obtain HPI (History and Physical) due to patient distress, mental status. " A review of physician ' s orders revealed orders at 1818 (6:18 PM) for " Geodon (antipsychotic)40 mg IM once, Restrain - up to 4 hours, and elopement precautions. " Further review of the physician orders revealed an order for Ativan (anti-anxiety 1 mg. IVP (Intravenous Push) at 2000 (8:00 PM) and also for Morphine (narcotic) 4 mg. IVP was written at 2002 (8:02 PM). There was no documentation in physician ' s orders or progress notes of the clinical justification/reason for the restraints, type of restraints, or the reason the medications were given.
The next order written was at 2200 (10:00 PM) - " Restrain-up to 4 hours. Verbal Order received at 2200. " The next physician ' s order was Valium (anti-anxiety)5mg. IVP @ 0055 (00:55 AM). The order did not contain a reason for the restraints or medication and the nurse ' s notes did not contain documentation to justify a reason for the restraints or medication being given.
Valium 5 mg. IVP was given again at 0116 (1:16 AM) which was 21 minutes later. The order did not contain a reason for the medication and the nurse ' s notes did not contain documentation to justify a reason for the medication being given. Order to " Restrain - up to 4 hours (Adult >17 years of age)" ordered at 0200. Order did not justify the reason for the restraints or the type of restraints.
The next order written was for Haldol 5 mg. IV once" at 0536.
Order to " Restrain - up to 4 hours (Adult >17 years of age)" ordered at 0600.
Order for " Ativan 2 mg. IVP once" at 0655.
Order for " Ativan 2 mg. IVP once" at 0814.
Order for " Valium 5 mg. IVP once" at 0831.
Order to " Restrain - up to 4 hours (Adult >17 years of age)" ordered at 1000.
Order for " Valium 5 mg IVP once" at 1020.
Order for " Benadryl (antihistamine) 25 mg IVP once" at 1043.
Order for " Valium 5 mg IVP once" at 1043.
Order for " Valium 5 mg. IVP once" at 1049.
Order for " Clonidine (antihypertensive) 0.2 mg PO once" at 1049.
Order for " Haldol 5 mg. IV once" at 1102.
Order for " Haldol 5 mg. IV once" at 1153.
Order for " Haldol 5 mg. IV once" at 1244.
Order for " Ketamine(sedative/analgesic) 1mg/kg IVP once" at 1403.
Order to " Restrain - up to 4 hours (Adult >17 years of age) ordered" at 1400.
Order for " Clonidine 0.2 mg. PO once" at 1552.
Order for " Ketamine 0.5 mg/kg IVP once" at 1554.
Order for " Ketamine 1.0 mg/kg IVP once" at 1657.
Order for " Rocuronium (muscle relaxer) 100 mg IV onc" at 1706.
Order for " Propofol(anesthetic) 100 ml IV at 10 mcg/kg/min once" at 1706. Administered at 1819.
Order for " Etomidate (anesthetic) 20 mg IVP once" at 1706. Administered at 1753.
Review of ER physician documentation revealed the physician failed to document the clinical justification/reason, type of least restrictive device, and signature of the individual giving the order for the physical restraint. The numerous orders for medications as a chemical restraint failed to document the clinical justification/reason for the administration of the medications.
Review of ER physician documentation revealed the following notes for staff #35 (ER physician):

" 18:05 - Medical screening exam complete.
18:10 - Patient presents to ER via Longview Fire Dept with unknown complaint.
18:31 Patient presents with ACTING ERRATICALLY. Onset: The symptoms/episode began/occurred today. Severity of symptoms: At worst the symptoms were moderate, in the emergency department the symptoms are unchanged. Unable to obtain HPI due to patient distress, MENTAL STATUS. Physicians Note: 19 Y0 FEMALE PT WITH A HX OF SEVERE ID/AUTISM PRESENTED TO THE ED VIA EMS C/O ACTING ERRATICALLY. EMS STATES THAT THE PT WAS REPORTED TO HAVE CHOCKED(sic) ONE OF THE STAFF MEMBERS AT THE GROUP HOME. PT HAS BEEN COMBATIVE, BITING PD/EMS STAFF. PT WAS GIVEN 5 MG VERSED IN ROUTE. NO OTHER SX, HX, OR COMPLAINTS ARE ABLE TO BE OBTAINED SECONDARY TO PTS MENTAL STATUS/DISTRESS.
Historical:
1. Seroquel 200 mg oral tab 1 tab nightly
2. Clonidine 0.1 mg oral tab 1 tab 3 times per day
- PMHx(Past Medical History: autism; severe intellectual disability;
- Social History: The social history from nurses notes was reviewed and I
agree with the nursing documentation. Patient uses no alcohol, no tobacco,
no IV drugs, no street drugs. Smoking History: Never smoker.
Nurses Notes: The history from nurses notes was reviewed and generally
agree with what ' s documented up to this point. The history from nurses
notes was reviewed and generally agree with what ' s documented up to this
point.
- Immunization history: Last tetanus immunization: unknown. Unable to obtain
flu information. Unable to obtain pneumonia vaccine information Unable to
obtain flu information. Unable to obtain pneumonia vaccine information.
- Code Status: Full code.
23:30 - unable to obtain ROS due to patient distress, MENTAL STATUS.
Exam:
23:30 Head/Face: Normocephalic, atraumatic. Normal fontanels Eyes: PERRL. Normal conjunctiva. No sclera icterus. No periorbital edema, [DIAGNOSES REDACTED] or
Swelling.
ENT: TM ' s normal with no [DIAGNOSES REDACTED], EAC ' s clear. Normal nasal mucosa
with no [DIAGNOSES REDACTED], no lesions, and no discharge. Post pharynx is normal with
no [DIAGNOSES REDACTED], no exudates and no evidence of obstruction. Membranes are moist.
Neck: Supple. Trachea midline. No lymphadenopathy or masses. Normal ROM withno evidence of vertebral point tenderness. No meningismus
Respiratory: Clear
to auscultation bilaterally, no respiratory distress and normal work of
breathing. No wheezing, tales or rhonchi. No stridor or nasal flaring
Chest/axilla: Normal chest wall appearance and motion. Nontender with no
deformity. No lesions are appreciated
Back: Normal inspection with no obvious deformity. No tenderness
Skin: Warm and dry with normal turgor.
Capillary refill <2 seconds. No cyanosis, pallor or rash MB! Extremity: No
evidence of focal tenderness or deformity. No edema
Constitutional: The patient appears AWAKE, VIOLENT, COMBATIVE
Cardiovascular: SLIGHTLY TACHYCARDIC.
Abdomen/Gl: BENIGN
Neuro: Motor/peripheral: moves all fours, SEVERE MR/AUTISM
Psych: Behavior/mood is aggressive, VIOLENT, ATTACKING STAFF. NOT
FOLLOWING DIRECTIONS.
01:01 - Differential Diagnosis: [DIAGNOSES REDACTED]"


There was no physician documentation by the ER physician (staff #36) from 0101(1:01AM) until 0621 (6:21 AM) on 4/16/15.
Review of staff #33 (ER physician) progress notes revealed the following:
" 0621- PT W/ BEHAVIOR DISORDER, MR. INCREASED AGITATION AT HER GROUP HOME. SENT HERE DUE TO HER BEHAVIOR.
MEDICALLY STABLE, BUT PLACEMENT ISSUES ABOUND. WILL BE WORKING TO GETPLACEMENT ARRANGED.

12:51 - PT BROUGHT TO ED YESTERDAY EVENING FOR INCREASING OUTBURSTS, VIOLENT TOWARDS OTHERS AND VIOLENT TOWARDS STAFF AT GROUP HOME. SHE HAS MR AND AUTISM. UP UNTIL 6 MONTHS AGO, SHE STAYED WITH FATHER PRIMARILY, UNTIL HE
HAD A MAJOR STROKE. HAS LIVED AT A GROUP HOME SINCE THAT POINT. PT WAS AGGRESSIVE TOWARDS STAFF OVERNIGHT, REQUIRING PHYSICAL AND CHEMICAL RESTRAINTS, BOTH TO PROTECT PT FROM HARM AND PROTECT STAFF FROM HER. SHE HAS BEEN SPITTING/BITING AT PEOPLE DESPITE THE RESTRAINTS. I HAVE GIVEN A CONSIDERABLE AMOUNT OF SEDATION HERE IN ED AND SHE IS STILL INCOMPLETELY SEDATED. UNFORTUNATELY DUE TO HER STRUGGLING AGAINST RESTRAINTS, SHE IS NOW IN MILD RHABDOMYOLYSIS(Rhabdomyolysis is the rapid destruction of skeletal muscle).
.
12:56 - I HAVE DISCUSSED W/ OUR HOSPITALIST, WHO REQUESTS WE SEE ABOUT OTHER FACILITIES THAT HAVE PSYCHIATRY CONSULTATION AVAILABLE, AS PT HAS REQUIRED SO MUCH SEDATION TO PROTECT HER FROM HARMING HERSELF OR OTHERS.

14:26 - 1MG/KG KETAMINE INFUSED OVER 10 MINUTES TO GOOD EFFECT. CONTINUE IVF AT 250CC/HR, RECHECK CK AT 6PM (CK - CREATINE KINASE - an enzyme (a protein that facilitates chemical reactions in the body) also in the muscle cells. The level of this protein can be measured in blood to monitor the degree of muscle injury).
AT CURRENT TIME, PT NEEDS IVF AS WELL AS SEDATION OVER AND ABOVE WHAT I FEEL CAN BE ACCOMPLISHED ON FLOOR. WE HAVE
NO PSYCHIATRY SPECIALIST AVAILABLE TO EVALUATE/CONSULT WITH INTERNIST TO HELP MANAGE PATIENT. WE HAVE INVOLVED SOCIAL WORK AND HOUSE SUPERVISOR. IF PT NEEDS MORE SEDATION, CONSIDER KETAMINE 1MG/KG OVER 10 MINUTES THEN KETAMINE DRIP AT 1-1.5 MG/KG/HR.
14:37- SO FAR, PT HAS RECEIVED GEODON 40MG, HALDOL 20MG, ATIVAN 7MG, VALIUM 30MG, AND KETAMINE 80MG. CURRENTLY RESTING COMFORTABLY. "

The progress notes that follow were written by staff #34 (ER Physician)

" 15:43 - PT CURRENTLY SEDATED, IN 4 POINTS RESTRAINTS. SHE HAS BITTEN AND RIPPED OUT ALL IV ' S EXCEPT FOOT IV. IVF ARE SLOWLY INFUSING. GIVEN CK ELEVATION, PT NEEDS MUCH MORE IVF. WILL NEED TO KEEP SEDATE ENOUGH TO MAINTAIN A LARGE BORE IV. MAY NEED AIRWAY PROTECTION TO KEEP SEDATION
ADEQUATE. WILL ATTEMPT IV AND BOLUS AND RE- EVAL.

18:23- Intubation: Intubated orally using GLIDESCOPE with 6.0 Fr. Eli. Intubation was successful on the first attempt. Ventilated with ventilator. Patient
tolerated well. 20 MG ETOMIDATE AND 100 MG OF ROCURONIUM.

18:30 - I HAVE INDEPENDENTLY REVIEWED AND AGREE WITH THE RADIOLOGIST FINDINGS OF ET TUBE IN PLACE PER CXR.
18:56 CK INCREASING, PT REQUIRES CONTINOUS RESTRAINTS HEAVY SEDATION TO MAINTAIN IV. UNSAFE TO REMAIN THIS WAY. HAVE INTUBATED TO ALLOW RESTRAINT REMOVAL AND MORE IVF. "

Review of nurses notes on4/16/15 at 18:27 revealed the following:
" 1827 - Assessment: Pulses are all present, are palpable in right radial artery, right brachial artery, left radial artery and left brachial artery. Skin is intact with normal color, has good turgor. Edema distal to restraints is absent. Capillary refill is 3 seconds or less distal to restraints Patient respiratory status is per ventilator. Patient is asleep.
1828 - Restraint Application Assessment: Assessment: restraints removed.
2020 - admitted to ICU accompanied by nurse, family with patient, via stretcher, with oxygen, on monitor, with chart. Condition: stable.


Review of the facility policy titled " Restraint and Seclusion: Use of Least Restrictive Devices " revealed the following definitions of Restraints:

" Restraint for non-violent non-self-destructive behavior (Previously referred to as
Medical/Surgical Care): Used to ensure immediate physical safety of non-violent or non-self-destructive patient.

Restraint/seclusion for violent/self-destructive behavior (Previously referred to as
Behavioral Care): Used for management of violent, self-destructive patient that
jeopardizes immediate physical safety of patient, staff member, or others.
Chemical Restraint: A drug or medication when used as a restriction to manage
patient behavior or restrict patient freedom of movement and is not a standard treatment or dosage for patient ' s condition. Medications that comprise a patient ' s medical regimen including PRN medications are not considered chemical restraints if:
a. Approved by United States Food and Drug Administration (USFDA) and used
in accordance with approved indications and label instructions, including listed
dosage parameters
b. Use follows national practice standards established or recognized by medical
community and/or professional medical association or organization; and
c. Used to treat specific patient ' s clinical condition and is based on that patient ' s
symptoms, overall clinical situation, and on Physician/Licensed Independent
Practitioners (LIP ' S) knowledge of that patient ' s expected and actual response.
Restraint/Seclusion Order Guidelines:
A. A physician/licensed independent practitioner (LIP) may write or give a
telephone order for restraints.
B. The attending physician or designee must be consulted as soon as possible if
he or she is not the one who ordered the restraints. When the attending
physician is unavailable, responsibility for the patient must be delegated to
another physician, who would then be considered the attending physician.
Physical chart documentation by the attending physician, whether or not it
directly addresses restraint use shall constitute evidence that the physician
was notified of the restraint episode.
C. The order must be will indicate the clinical justification/reason, date, time, time
limit (if applicable), type of least restrictive device, and signature of the
individual giving the order. The order must be obtained either during
application or immediately (within a few minutes) afterwards.
D. PRN orders are NOT to be used to authorize the use of restraints under any
circumstances. Staff cannot discontinue a restraint/seclusion and then later
restart it using the same order. This situation is the same as a PRN order.
" Trial release " constitutes PRN restraint/seclusion use is not permitted. If
restraint/seclusion is discontinued prior to original order expiration, a new
order must be obtained prior to restarting restraint/seclusion use.
E. When restraint/seclusion is used to manage non-violent behavior,
physician/LIP must examine the patient within 24 hours of initiation. The
clinical justification for continued restraints must be documented in the
patient ' s medical record daily.

Special Assessment Requirement Specific to Violent/Self-Destructive Behavior
Patients (Face-To-Face Evaluation):
A. When restraint/seclusion is used to manage violent or self-destructive behavior,
physician/LIP must conduct a face-to-face patient evaluation in person within I
hour after restraint/seclusion initiated. A telephone call or telemedicine method is
not permitted. If patient ' s violent or self-destructive behavior resolves and
restraint/seclusion is discontinued before practitioner arrives to perform face-to-face evaluation, practitioner is still required to see patient face-to-face and
conduct evaluation within 1 hour after restraint/seclusion initiated.
B. This face-to-face evaluation requirement also applies when a medication is used
as a restraint/seclusion to manage violent or self-destructive behavior.
C. The patient must be seen face-to-face within 1 hour after the initiation of the
intervention to evaluate:
I) The patient ' s immediate situation;
2) The patient ' s reaction to the invention;
3) The patient ' s medical and behavioral condition;
4) The need to continue or terminate the restraint or seclusion.
Once the initial order is obtained and if the patient remains in restraints more
than 24 hours, the RN and physician/LIP documents the need for
continued restraint usage daily.
A new restraint order would be required if restraints have been
discontinued for any reason.
May only be obtained and renewed in accordance with following limits for up to
a total of 24 hours:
Up to 4 hours for adults [AGE] and older
Up to 2 hours for children andadolescents ages 9 to 17
Up to 1 hour for patients under age 9.
Physician/LIP must conduct a face-to-face patient evaluation in person within 1
hour after restraint/seclusion initiated.
If patient remains in restraint/seclusion 24 hours after original order,
physician/LIP must see patient and conduct a face-to-face re-evaluation.


Review of the patient ' s inpatient record revealed patient #8 was admitted to ICU on 4/16/15 at 2009. Patient was on the ventilator, sleeping due to sedation, with siderails up X3. Patient had a nasogastric tube to low intermittent suction. Patient continued on ventilator with sedation until 4/18/15. Review of physician ' s progress notes on 4/18/15 at 7:18 revealed, " Sedation vacation today. Patient was intubated to sedate her due to severe agitation. Will place on restraints and see if she is okay to take off sedation " . Further review of medical record revealed patient was extubated on 4/18/15 at 1046. On 4/18/15 at 1400, patient was given Ativan 2 mg. IV q2hrs. as needed for agitation.
Review of physician ' s telephone order dated 4/18/15 at 1730 revealed order for non-behavioral restraints to bilateral wrist and bilateral ankles. There was no documentation for the type of restraint to be used or justification/reason for the restraint. There was no nursing documentation to justify the need for restraints, or that restraints were initiated. On 4/18/15 at 1940, a telephone order was written for " Geodon 20 mg. IM q6hr prn, restless/agitation " and was documented on the MAR as given at 2052 (over an hour after the telephone order was taken).
On 4/18/15 at 2200, a telephone order was written for " Behavioral Restraints " . There was no time limit, no justification/reason for the restraints noted. This telephone order was never signed by the physician (Staff #38). There was no documentation of a 1 hour face to face evaluation being done. Nursing documentation revealed restraint monitoring began at 2215 and continued every 15 minutes. There was no documentation that alternative interventions were attempted prior to the order for the restraints. On 4/19/15 at 0200, a telephone order was written for " Continue Behavioral Restraints " . There was no time limit or justification/reason for the restraints noted. There was no documentation of a 1 hour face to face evaluation being done. On 4/19/15 at 0600, a telephone order was written for " Continue Behavioral Restraints " . There was no time limit or justification/reason for the restraints noted. There still was no documentation of a physician conducting 1 hour face to face evaluation ever being conducted.
On 4/19/15 at 1200 pm., a physician ' s order was written for " D/C (discontinue) Behavioral restraint. Use Non-behavioral restraint to protect her IV line. " There was no time limit for the restraints or attempts at alternative interventions attempted. Nursing documentation revealed patient was assessed at 1416 (2:16 pm), 1533(3:33pm), and 1820(6:20pm). Review of the Medication Administration Record (MAR) revealed patient was given Ativan 2 mg. IV as needed for agitation at 1441 (2:41pm), 2154 (9:54pm), and on 4/20/15 at 0328 (3:28 pm) on 4/20/15.
On 4/20/15 at 0930 am., a telephone order was written for " Transfer to medical with sitter. 4 point restraints per restraint order sheet. Assess restraints per facility policy. May get out of bed when LOC improves. " This order was never signed by the physician. On 4/20/15 at 1300, a physician ' s order was written for " non-behavioral restraint to both wrist and both ankles " . Neither of these orders contained justification/reason or type of restraint to be used. Review of the MAR revealed patient received Ativan 2 mg. IV for agitation at 0937 (9:37am), 1048 (10:48pm), 1241 (12:41pm), 1747 (5:47pm), 1956 (7:56pm). Patient also received Geodon 20 mg. IM for agitation at 1241(12:41 pm), and 0326 (3:26 pm) on 4/21/15. There was no nursing documentation of increased agitation or aggressiveness to justify the prn medication or documentation of patient ' s response to the medications.
On 4/21/15 at 1300, a telephone restraint order was written for " Non-violent Behavior, Soft restraints, All Extremities " . This order did not contain justification/reason for use of restraints. This order was never signed by the physician. Review of the MAR revealed patient received Ativan 2mg. IV for agitation at 1221(12:21pm), 1535 (3:35pm) 1805(6:05 pm), and 2250(10:50 pm). Patient also received Geodon 20 mg IM at 1215(12:15pm), and 1815 (6:15 pm). There was no nursing documentation of increased agitation or aggressiveness to justify the prn medications.
On 4/22/15, there was no order for restraint written. There also was no documentation that the physician assessed the patient for continued need for restraints. The nursing documentation did not contain documentation of the patient being transferred to the medical floor from ICU but there was a difference in the documentation from ICU that occurred at approximately 2025 on 4/22/15. There was no documentation of a nursing assessment done when patient arrived on the medical floor. The documentation revealed a shift assessment was conducted on 4/23/15 at 0527. Review of the MAR revealed patient received Ativan 2 mg. by mouth for agitation on 4/22/15 at 2200 and on 4/23/15 at 0600. There was no documentation what precipitated the need for the Ativan and there was no documentation how the patient responded to the medication. Nursing did document behavior monitoring every 2 hours but the documentation never changed to indicate a change in behavior or alternatives attempted.
The next order for restraints was a telephone order written on 4/23/15 at 1527, " 4 point soft restraints for non-violent pulling of IV and lines. On 4/23/15, patient received Haldol 5mg. IV at 1508 and Benadryl 50 mg. by mouth at 1700 in addition to daily medication of Ativan 1 mg. TID (3x day) and Geodon 10 mg. IM every 6 hours. On 4/24/15 at 1212, a restraint order was written for non-violent behavior, soft restraints to all extremities. On 4/24/15, no prn (as needed) medication was given for agitation or aggressiveness but patient remained restrained. Nursing documentation for 4/25/15 at 1104 revealed the statement, " Unable to keep patient in restraints, patient chews them off. " Documentation revealed patient was discharged at 1212 on 4/25/15(One hour after patient " chewed " off her restraints).
Review of discharge summary dated 4/25/2015 revealed the following statements: " She is being discharged back to the group home to be followed up by regular psychiatrist. The group home did express that she was still a danger to herself and to other residents. Due to lack of psychiatric services available at this facility at this time, the patient was deferred, the patient was deferred to outpatient psychiatric evaluation and treatment within a week. According to nursing staff, the patient did seem to calm down and not require any definite supervision when she was a not in restraints and when she was given things, books to play with or toys to play with. She is, therefore, being discharged as stated above. "

2.) Review of medical record revealed patient #8 was a [AGE] year old female with severe Intellectual Disability and Autism and reported to have the mental capacity of a one year old. Patient was brought to the facility on [DATE] from a re
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0169
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on chart reviews and interviews the facility failed to ensure physician orders for a chemical restraint must never be written as a PRN (as needed bases) order. The facility failed to ensure a drug would not be used to restrain the patient for the convenience of the staff in 2(#1,#8 and# 9) of 10 (1-10) charts reviewed.

1.) Review of patient #1's medical records revealed he was taken to the facility's emergency room (ER) on 1-16-2015, for stomach pain and breathing issues. He was diagnosed with [DIAGNOSES REDACTED]
Review of patient #1's nurses notes dated 1/18/2015, at 3:00 AM stated, "3:00 AM patient at nurse's station states he heard someone laughing on the call light when he called for pain medication and didn't like it. Patient accompanied back to room. 3:14 AM Patient given Norco 10 at this time. 3:45 AM Notified doctor of wife requesting something for him for his anxiety, order given. 4:09 AM Gave Haldol 5 mg IM to left hip. 5:30 AM Patient resting quietly without any signs or symptoms of [DIAGNOSES REDACTED]
A written statement from patient #1's spouse revealed that after the nurse returned patient #1 to the room he was very upset and anxious, nearly having a panic attack. At 4:00 AM, the nurse came back in to monitor his vital signs and blood sugar. Patient #1 asked for a Klonopin for his anxiety and staff # 10 (RN) said, "Ok." Staff #10 returned without the Klonopin and informed patient #1 he could not have the Klonopin but she had a shot for him. Patient #1 asked what the medication was after he received the shot and could they have a print out. Staff #10 brought a print out to patient #1 and his spouse. Patient #1's spouse stated, "We were terrified. There were numerous stated reasons and 3 warnings why he should have not been given the drug, due to all the serious life threatening side effects."
Patient #1's spouse asked staff #10 if there was a medication he could take to reverse the drug Haloperidol (Haldol). Staff #10 confirmed there was no medication to reverse this drug. Neither patient #1 nor his spouse was given any reason why he could not have his Klonopin and was given Haldol. Patient #1's spouse confirmed patient #1 had never received this medication before.
Review of the nurse's notes revealed there were no documented interventions found before patient #1 was given Haldol for agitation and anxiety.
Review of the physician order dated 1/18/2015, revealed staff # 10 received a verbal order from staff #23 (MD Hospitalist). The order was given at 3:45 AM and stated, "Haldol 5mg IM or IV q4 Prn for agitation." Staff #23 did not electronically sign the order until 2/19/15 at 6:67 AM (33 days later).
A phone interview was conducted with staff #10 on 5/7/2015, at 2:45PM. Staff #10 confirmed she did remember caring for patient #1. Staff #10 stated, "He was acting agitated. He kept coming up to the nurse's station raising his voice. I tried to calm him down." Staff #10 confirmed that patient #1's spouse asked for a medication for anxiety but could not remember what drug it was. Staff #10 stated, "I called the doctor and got an order for Haldol. I went down and gave him the medication. I gave them a print out of the drug when they asked for it but I don't remember if I told them anything before the injection." Staff #10 was asked by the surveyor if the drug Haldol was given for the convenience of the staff to prevent patient #1 from coming up to the nurse's station? Staff #10 stated, "Yeah, I guess you could say that, we had to do something to get him calmed down until we could do something else with him."

2.) Review of patient #9's medical record revealed he has been in the ER multiple times for drug related issues. Patient #9 was found to have an elevated white blood cell count and running fever. A lumbar puncture was performed on patient #9 to rule out Meningitis. The test came back negative but patient #9 was admitted with Rhabdomyolysis and altered mental status.

Rhabdomyolysis is breakdown of muscle fibers. Muscle breakdown causes the release of myoglobin into the bloodstream. Myoglobin can cause kidney damage.

Review of patient #9's emergency room (ER) nurses notes on 4/22/2015, stated, "6:53 PM Pt found in PD custody, combative and uncooperative on scene and required PD intervention. Possible K2/Meth usage. Pt is alert and very uncooperative, somewhat combative. Speaking gibberish and sounding paranoid- thinks we are going to kill him, states, "you know what you've done" and "that's what the windshield wiper fluid told you." Behavior is agitated, anxious, restless, uncooperative. The patient is oriented to person, the patient is disoriented. Patient home medication was provided by the previous visit. The patient is unable to provide a social history due to altered mental status.
Review of patient #9's chart revealed a physician order with the title "General Admission" the orders were three pages long. The order stated staff # 23 is the attending physician. The order read, "2.) Geodon 10mg IM q4h PRN for agitation tonight." The order had no physician signature, time, or date.

Review of the drug Geodon (Ziprasidone) from the U.S. National Library of Medicine stated, "Acute Treatment of Agitation in Schizophrenia/Intramuscular Dosing
GEODON is indicated for the treatment of schizophrenia, as monotherapy for the acute treatment of bipolar manic or mixed episodes, and as an adjunct to lithium or valproate for the maintenance treatment of bipolar disorder
The recommended dose is 10 mg to 20 mg administered as required up to a maximum dose of 40 mg per day. Doses of 10 mg may be administered every two hours; doses of 20 mg may be administered every four hours up to a maximum of 40 mg/day. Intramuscular administration of ziprasidone for more than three consecutive days has not been studied ."

Review of the Geodon administered was retrieved from the Medication Discharge Summary dated 4/23/15-4/27/15. The Medication Discharge Summary read, Geodon (Ziprasidone Mesylate 20mg vial) 10 mg IM Q4H/PRN PRN Reason: Agitation Comments: Max Daily Dose: 40mg." The General admission orders state, "tonight" The limited time period was not transcribed to the Medication Discharge Summary. Geodon 10mgs was administered on the following dates and times;
1. 4-22-15 at 7:45PM 10 mg given IM 1 time order in the ER, 8:54PM 10 mg given IM 1 time order in the ER.
4-23 15 at 12:17AM 10mg, 8:25AM 10mg, 5:12PM 10mg = a total of 50 mg in a 24 hour period.
2. 4-24-15 at 2:17AM 10mg, 11:52AM 10 mg, 5:28PM 10mg. NO MD ORDERS FOUND.
3. 4-25-15 at 5:21AM 10mg, 10:18AM 10mg, 4:27PM 10mg, 9:26PM 10mg. NO MD ORDERS FOUND.
4. 4-26-15 at 12:25AM 10mg, 1:29PM 10mg, and 5:26 PM 10 mg. NO MD ORDERS FOUND.

Review of patient #9's nursing notes dated 4/27/2015, at 8:00AM, stated, "Pt yelling out at staff and sitter. Called his mother and told her that he was dying. Mother called crying and will be at BS soon." There was no intervention documentation found before administration of psychoactive medication.
Review of patient #9's physician orders revealed an order for Geodon 10 mg IM q4H PRN was obtained on 4/27/2015 at 8:23AM.
Medication Discharge Summary dated 4-27-15 at 8:23 AM shows 10 mg were given IM. There was no further documentation of medication effectiveness.







3.) Review of medical record revealed patient #8, a [AGE] year old female with severe Intellectual Disability and Autism and reported to have the mental capacity of a one year old. Patient was brought to the facility on [DATE], from a residential group home by EMS (Emergency Medical Services) due to severe agitation and aggressiveness. The staff at the group home reported that patient had become increasingly agitated and aggressive over the past week as evidenced by hitting, biting, and pulling hair of other residents. What incited the change in behavior is unclear but patient recently had changes to her environment and caregivers. Patient ' s father was her primary caregiver but he had a stroke and had to be placed in a nursing home. Since that time the patient was placed in the group home and also had been started on Seroquel (antipsychotic medication) 200 mg. at bedtime for behavioral issues and sleep disturbance approximately 2 months prior.
Police were called to the group home after patient became violent and attempting to choke a staff person. Police were unable to calm patient and called EMS to take her to the emergency department (ED) for evaluation. EMS staff used gauze rolls, sheets and belts on the stretcher for restraints to transport to the emergency room . Patient was given Versed (Central Nervous System Depressant) 5 mg. Intranasally X2 due to combativeness while in route to the ED. No effect noted from the Versed.
Patient arrived at the ED on 4/15/15, at 1817 (6:17 pm). Physician's notes revealed "patient presents with ACTING IRRATICALLY. Onset: The symptoms/episode began/occurred today. Severity of symptoms: At worst the symptoms were moderate, in the emergency department the symptoms are unchanged. Unable to obtain HPI (History and Physical) due to patient distress, mental status." A review of physician's orders revealed orders at 1818 (6:18 PM) for "Geodon (antipsychotic)40 mg IM once, Restrain - up to 4 hours, and elopement precautions." Further review of the physician orders revealed an order for Ativan (anti-anxiety 1 mg. IVP (Intravenous Push) at 2000 (8:00 PM) and also for Morphine (narcotic) 4 mg. IVP was written at 2002 (8:02 PM). There was no documentation in physician's orders or progress notes of the clinical justification/reason for the restraints, type of restraints, or the reason the medications were given.
The next order written was at 2200 (10:00 PM) - "Restrain-up to 4 hours. Verbal Order received at 2200." The next physician's order was Valium (anti-anxiety)5mg. IVP @ 0055 (00:55 AM)on 4/16/15. The order did not contain a reason for the restraints or medication, did not identify the type of restraint, and the nurse's notes did not contain documentation to justify a reason for the restraints or medication being given. Valium 5 mg. IVP was given again at 0116 (1:16 AM) which was 21 minutes later. The order did not contain a reason for the medication and the nurse's notes did not contain documentation to justify a reason for the medication being given. Order to "Restrain - up to 4 hours (Adult >17 years of age)" ordered at 0200. Order did not justify the reason for the restraints or the type of restraints.

The following is a list of physician orders for physical and chemical restraints and how they were written:
Order for "Haldol 5 mg. IV once" at 0536.
Order to "Restrain - up to 4 hours (Adult >17 years of age)" ordered at 0600.
Order for "Ativan 2 mg. IVP once" at 0655.
Order for "Ativan 2 mg. IVP once" at 0814.
Order for "Valium 5 mg. IVP once" at 0831.
Order to "Restrain - up to 4 hours (Adult >17 years of age)" ordered at 1000.
Order for "Valium 5 mg IVP once" at 1020.
Order for "Benadryl (antihistamine) 25 mg IVP once" at 1043.
Order for "Valium 5 mg IVP once" at 1043.
Order for "Valium 5 mg. IVP once" at 1049.
Order for "Clonidine (antihypertensive) 0.2 mg PO once" at 1049.
Order for "Haldol 5 mg. IV once" at 1102.
Order for "Haldol 5 mg. IV once" at 1153.
Order for "Haldol 5 mg. IV once" at 1244.
Order for "Ketamine(sedative/analgesic)1mg/kg IVP once" at 1403.
Order to "Restrain - up to 4 hours (Adult >17 years of age)" ordered at 1400.
Order for "Clonidine 0.2 mg. PO once" at 1552.
Order for "Ketamine 0.5 mg/kg IVP once" at 1554.
Order for "Ketamine 1.0 mg/kg IVP once" at 1657.
Order for "Rocuronium (muscle relaxer) 100 mg IV once" at 1706.
Order for "Propofol(anesthetic) 100 ml IV at 10 mcg/kg/min once" at 1706. Administered at 1819.
Order for "Etomidate (anesthetic) 20 mg IVP once at 1706" . Administered at 1753" .
Review of ER physician documentation revealed the physician failed to document the clinical justification/reason, type of least restrictive device, and signature of the individual giving the order for the physical restraint. The numerous orders for medications as a chemical restraint failed to document the clinical justification/reason for the administration of the medications.
Review of ER physician documentation revealed the following notes for staff #35 (ER physician):

"18:05 - Medical screening exam complete.

18:10 - Patient presents to ER via Longview Fire Dept with unknown complaint.

18:31 Patient presents with ACTING ERRATICALLY. Onset: The symptoms/episode began/occurred today. Severity of symptoms: At worst the symptoms were moderate, in the emergency department the symptoms are unchanged. Unable to obtain HPI due to patient distress, MENTAL STATUS. Physicians Note: 19 Y0 FEMALE PT WITH A HX OF SEVERE ID/AUTISM PRESENTED TO THE ED VIA EMS C/O ACTING ERRATICALLY. EMS STATES THAT THE PT WAS REPORTED TO HAVE CHOCKED(sic) ONE OF THE STAFF MEMBERS AT THE GROUP HOME. PT HAS BEEN COMBATIVE, BITING PD/EMS STAFF. PT WAS GIVEN 5 MG VERSED IN ROUTE. NO OTHER SX, HX, OR COMPLAINTS ARE ABLE TO BE OBTAINED SECONDARY TO PTS MENTAL STATUS/DISTRESS.

Historical:

1. Seroquel 200 mg oral tab 1 tab nightly

2. Clonidine 0.1 mg oral tab 1 tab 3 times per day

- PMHx(Past Medical History: autism; severe intellectual disability;

- Social History: The social history from nurses notes was reviewed and I
agree with the nursing documentation. Patient uses no alcohol, no tobacco,
no IV drugs, no street drugs. Smoking History: Never smoker.

Nurses Notes: The history from nurses notes was reviewed and generally
agree with what ' s documented up to this point. The history from nurses
notes was reviewed and generally agree with what ' s documented up to this
point.

- Immunization history: Last tetanus immunization: unknown. Unable to obtain
flu information. Unable to obtain pneumonia vaccine information Unable to
obtain flu information. Unable to obtain pneumonia vaccine information.

- Code Status: Full code.

23:30 - unable to obtain ROS due to patient distress, MENTAL STATUS.
Exam:

23:30 Head/Face: Normocephalic, atraumatic. Normal fontanels Eyes: PERRL. Normal conjunctiva. No sclera icterus. No periorbital edema, [DIAGNOSES REDACTED] or
Swelling.

ENT: TM's normal with no [DIAGNOSES REDACTED], EAC' s clear. Normal nasal mucosa with no [DIAGNOSES REDACTED], no lesions, and no discharge. Post pharynx is normal with no [DIAGNOSES REDACTED], no exudates and no evidence of obstruction. Membranes are moist.

Neck: Supple. Trachea midline. No lymphadenopathy or masses. Normal ROM withno evidence of vertebral point tenderness. No meningismus
Respiratory: Clear to auscultation bilaterally, no respiratory distress and normal work of
breathing. No wheezing, tales or rhonchi. No stridor or nasal flaring

Chest/axilla: Normal chest wall appearance and motion. Nontender with no deformity. No lesions are appreciated

Back: Normal inspection with no obvious deformity. No tenderness

Skin: Warm and dry with normal turgor.

Capillary refill <2 seconds. No cyanosis, pallor or rash MB! Extremity: No evidence of focal tenderness or deformity. No edema

Constitutional: The patient appears AWAKE, VIOLENT, COMBATIVE

Cardiovascular: SLIGHTLY TACHYCARDIC.

Abdomen/Gl: BENIGN

Neuro: Motor/peripheral: moves all fours, SEVERE MR/AUTISM

Psych: Behavior/mood is aggressive, VIOLENT, ATTACKING STAFF. NOT FOLLOWING DIRECTIONS.

01:01 - Differential Diagnosis: [DIAGNOSES REDACTED]"


There was no physician documentation by the ER physician (staff #36) from 0101(1:01AM) until 0621 (6:21 AM) on 4/16/15.
Review of staff #33 (ER physician) progress notes revealed the following:
"0621- PT W/ BEHAVIOR DISORDER, MR. INCREASED AGITATION AT HER GROUP HOME. SENT HERE DUE TO HER BEHAVIOR. MEDICALLY STABLE, BUT PLACEMENT ISSUES ABOUND. WILL BE WORKING TO GETPLACEMENT ARRANGED.

12:51 - PT BROUGHT TO ED YESTERDAY EVENING FOR INCREASING OUTBURSTS, VIOLENT TOWARDS OTHERS AND VIOLENT TOWARDS STAFF AT GROUP HOME. SHE HAS MR AND AUTISM. UP UNTIL 6 MONTHS AGO, SHE STAYED WITH FATHER PRIMARILY, UNTIL HE HAD A MAJOR STROKE. HAS LIVED AT A GROUP HOME SINCE THAT POINT. PT WAS AGGRESSIVE TOWARDS STAFF OVERNIGHT, REQUIRING PHYSICAL AND CHEMICAL RESTRAINTS, BOTH TO PROTECT PT FROM HARM AND PROTECT STAFF FROM HER. SHE HAS BEEN SPITTING/BITING AT PEOPLE DESPITE THE RESTRAINTS. I HAVE GIVEN A CONSIDERABLE AMOUNT OF SEDATION HERE IN ED AND SHE IS STILL INCOMPLETELY SEDATED. UNFORTUNATELY DUE TO HER STRUGGLING AGAINST RESTRAINTS, SHE IS NOW IN MILD RHABDOMYOLYSIS(Rhabdomyolysis is the rapid destruction of skeletal muscle).

12:56 - I HAVE DISCUSSED W/ OUR HOSPITALIST, WHO REQUESTS WE SEE ABOUT OTHER FACILITIES THAT HAVE PSYCHIATRY CONSULTATION AVAILABLE, AS PT HAS REQUIRED SO MUCH SEDATION TO PROTECT HER FROM HARMING HERSELF OR OTHERS.

14:26 - 1MG/KG KETAMINE INFUSED OVER 10 MINUTES TO GOOD EFFECT. CONTINUE IVF AT 250CC/HR, RECHECK CK AT 6PM (CK - CREATINE KINASE - an enzyme (a protein that facilitates chemical reactions in the body) also in the muscle cells. The level of this protein can be measured in blood to monitor the degree of muscle injury).
AT CURRENT TIME, PT NEEDS IVF AS WELL AS SEDATION OVER AND ABOVE WHAT I FEEL CAN BE ACCOMPLISHED ON FLOOR. WE HAVE
NO PSYCHIATRY SPECIALIST AVAILABLE TO EVALUATE/CONSULT WITH INTERNIST TO HELP MANAGE PATIENT. WE HAVE INVOLVED SOCIAL WORK AND HOUSE SUPERVISOR. IF PT NEEDS MORE SEDATION, CONSIDER KETAMINE 1MG/KG OVER 10 MINUTES THEN KETAMINE DRIP AT 1-1.5 MG/KG/HR.

14:37- SO FAR, PT HAS RECEIVED GEODON 40MG, HALDOL 20MG, ATIVAN 7MG, VALIUM 30MG, AND KETAMINE 80MG. CURRENTLY RESTING COMFORTABLY. "

The progress notes that follow were written by staff #34 (ER Physician):

"15:43 - PT CURRENTLY SEDATED, IN 4 POINTS RESTRAINTS. SHE HAS BITTEN AND RIPPED OUT ALL IV ' S EXCEPT FOOT IV. IVF ARE SLOWLY INFUSING. GIVEN CK ELEVATION, PT NEEDS MUCH MORE IVF. WILL NEED TO KEEP SEDATE ENOUGH TO MAINTAIN A LARGE BORE IV. MAY NEED AIRWAY PROTECTION TO KEEP SEDATION
ADEQUATE. WILL ATTEMPT IV AND BOLUS AND RE- EVAL.

18:23- Intubation: Intubated orally using GLIDESCOPE with 6.0 Fr. Eli. Intubation was successful on the first attempt. Ventilated with ventilator. Patient
tolerated well. 20 MG ETOMIDATE AND 100 MG OF ROCURONIUM.

18:30 - I HAVE INDEPENDENTLY REVIEWED AND AGREE WITH THE RADIOLOGIST FINDINGS OF ET TUBE IN PLACE PER CXR.

18:56 CK INCREASING, PT REQUIRES CONTINOUS RESTRAINTS HEAVY SEDATION TO MAINTAIN IV. UNSAFE TO REMAIN THIS WAY. HAVE INTUBATED TO ALLOW RESTRAINT REMOVAL AND MORE IVF. "

Review of nurses notes on 4/16/15 at 18:27 revealed the following:

"1827 - Assessment: Pulses are all present, are palpable in right radial artery, right brachial artery, left radial artery and left brachial artery. Skin is intact with normal color, has good turgor. Edema distal to restraints is absent. Capillary refill is 3 seconds or less distal to restraints Patient respiratory status is per ventilator. Patient is asleep.

1828 - Restraint Application Assessment: Assessment: restraints removed.

2020 - admitted to ICU accompanied by nurse, family with patient, via stretcher, with oxygen, on monitor, with chart. Condition: stable.


Review of the facility policy titled "Restraint and Seclusion: Use of Least Restrictive Devices" revealed the following definitions of Restraints:

"Restraint for non-violent non-self-destructive behavior (Previously referred to as
Medical/Surgical Care): Used to ensure immediate physical safety of non-violent or non-self-destructive patient.

Restraint/seclusion for violent/self-destructive behavior (Previously referred to as
Behavioral Care): Used for management of violent, self-destructive patient that
jeopardizes immediate physical safety of patient, staff member, or others.
Chemical Restraint: A drug or medication when used as a restriction to manage
patient behavior or restrict patient freedom of movement and is not a standard treatment or dosage for patient's condition. Medications that comprise a patient's medical regimen including PRN medications are not considered chemical restraints if:

a. Approved by United States Food and Drug Administration (USFDA) and used
in accordance with approved indications and label instructions, including listed
dosage parameters

b. Use follows national practice standards established or recognized by medical
community and/or professional medical association or organization; and

c. Used to treat specific patient's clinical condition and is based on that patient's
symptoms, overall clinical situation, and on Physician/Licensed Independent
Practitioners (LIP'S) knowledge of that patient's expected and actual response.
Restraint/Seclusion Order Guidelines:
A. A physician/licensed independent practitioner (LIP) may write or give a
telephone order for restraints.

B. The attending physician or designee must be consulted as soon as possible if
he or she is not the one who ordered the restraints. When the attending physician is unavailable, responsibility for the patient must be delegated to another physician, who would then be considered the attending physician. Physical chart documentation by the attending physician, whether or not it directly addresses restraint use shall constitute evidence that the physician was notified of the restraint episode.

C. The order must be will indicate the clinical justification/reason, date, time, time limit (if applicable), type of least restrictive device, and signature of the individual giving the order. The order must be obtained either during application or immediately (within a few minutes) afterwards.

D. PRN orders are NOT to be used to authorize the use of restraints under any
circumstances. Staff cannot discontinue a restraint/seclusion and then later restart it using the same order. This situation is the same as a PRN order. "Trial release" constitutes PRN restraint/seclusion use is not permitted. If restraint/seclusion is discontinued prior to original order expiration, a new order must be obtained prior to restarting restraint/seclusion use.

E. When restraint/seclusion is used to manage non-violent behavior, physician/LIP must examine the patient within 24 hours of initiation. The clinical justification for continued restraints must be documented in the patient's medical record daily.

Special Assessment Requirement Specific to Violent/Self-Destructive Behavior Patients (Face-To-Face Evaluation):

A. When restraint/seclusion is used to manage violent or self-destructive behavior, physician/LIP must conduct a face-to-face patient evaluation in person within 1 hour after restraint/seclusion initiated. A telephone call or telemedicine method is not permitted. If patient's violent or self-destructive behavior resolves and restraint/seclusion is discontinued before practitioner arrives to perform face-to-face evaluation, practitioner is still required to see patient face-to-face and conduct evaluation within 1 hour after restraint/seclusion initiated.

B. This face-to-face evaluation requirement also applies when a medication is used as a restraint/seclusion to manage violent or self-destructive behavior.

C. The patient must be seen face-to-face within 1 hour after the initiation of the intervention to evaluate:

I) The patient's immediate situation;
2) The patient's reaction to the invention;
3) The patient's medical and behavioral condition;
4) The need to continue or terminate the restraint or seclusion.

Once the initial order is obtained and if the patient remains in restraints more than 24 hours, the RN and physician/LIP documents the need for continued restraint usage daily.

A new restraint order would be required if restraints have been discontinued for any reason.

May only be obtained and renewed in accordance with following limits for up to a total of 24 hours:
Up to 4 hours for adults [AGE] and older
Up to 2 hours for children andadolescents ages 9 to 17
Up to 1 hour for patients under age 9.

Physician/LIP must conduct a face-to-face patient evaluation in person within 1 hour after restraint/seclusion initiated.
If patient remains in restraint/seclusion 24 hours after original order, physician/LIP must see patient and conduct a face-to-face re-evaluation.

Review of medical record revealed patient #8 was a [AGE] year old female with severe intellectual Disability and Autism and reported to have the mental capacity of a one year old. Patient was brought to the facility on [DATE], from a residential group home by EMS (Emergency Medical Services) due to severe agitation and aggressiveness. The staff at the group home reported that patient had become increasingly agitated and aggressive over the past week as evidenced by hitting, biting, and pulling hair of other residents. What incited the change in behavior is unclear but patient recently had changes to her environment and caregivers. Patient ' s father was her primary caregiver but he had a stroke and had to be placed in a nursing home. Since that time the patient was placed in the group home and also had been started on Seroquel (antipsychotic medication) 200 mg. at bedtime for behavioral issues and sleep disturbance approximately 2 months prior.
Review of the patient's inpatient record revealed patient #8 was admitted to ICU on 4/16/15, at 2009. Patient was on the ventilator, sleeping due to sedation, with siderails up X3. Patient had a nasogastric tube to low intermittent suction. Patient continued on ventilator with sedation until 4/18/15.
Review of physician's progress notes on 4/18/15, at 7:18 revealed, "Sedation vacation today. Patient was intubated to sedate her due to severe agitation. Will place on restraints and see if she is okay to take off sedation". Further review of medical record revealed patient was extubated on 4/18/15, at 1046. On 4/18/15, at 1400, patient was given Ativan 2 mg. IV q2hrs. as needed for agitation.
Review of physician's telephone order dated 4/18/15, at 1730 revealed order for non-behavioral restraints to bilateral wrist and bilateral ankles. There was no documentation for the type of restraint to be used or justification/reason for the restraint. There was no nursing documentation to justify the need for restraints, or that restraints were initiated. On 4/18/15, at 1940, a telephone order was written for "Geodon 20 mg. IM q6hr prn, restless/agitation" and was documented on the MAR as given at 2052 (over an hour after the telephone order was taken). There was no documentation of justification /reason for the Geodon being given.
On 4/18/15, at 2200, a telephone order was written for "Behavioral Restraints". There was no time limit, no justification/reason for the restraints noted. This telephone order was never signed by the physician (Staff #38). There was no documentation of a 1 hour face to face evaluation being done. Nursing documentation revealed restraint monitoring began at 2215 and continued every 15 minutes. There was no documentation that alternative interventions were attempted prior to the order for the restraints. On 4/19/15, at 0200, a telephone order was written for "Continue Behavioral Restraints". There was no time limit or justification/reason for the restraints noted. There was no documentation of a 1 hour face to face evaluation being done. On 4/19/15, at 0600, a telephone order was written for "Continue Behavioral Restraints" . There was no time limit or justification/reason for the restraints noted. There still was no documentation of a physician conducting 1 hour face to face evaluation ever being conducted.
On 4/19/15, at 1200 pm., a physician's order was written for "D/C (discontinue) Behavioral restraint. Use Non-behavioral restraint to protect her IV line." There was no time limit for the restraints or attempts at alternative interventions. Nursing documentation revealed patient was assessed at 1416 (2:16 pm), 1533(3:33pm), and 1820(6:20pm). Review of the Medication Administration Record (MAR) revealed patient was given Ativan 2 mg. IV as needed for agitation at 1441 (2:41pm), 2154 (9:54pm), and on 4/20/15 at 0328 (3:28 pm) on 4/20/15. There was no documentation of justification /reason, alternative interventions attempted for the Ativan being given.

On 4/20/15, at 0930 am., a telephone order was written for "Transfer to medical with sitter. 4 point restraints per restraint order sheet. Assess restraints per facility policy. May get out of bed when LOC (level of consciousness) improves." This order was never signed by the physician.
On 4/20/15, at 1300, a physician's order was written for "non-behavioral restraint to both wrist and both ankles". Neither of these orders contained justification/reason or type of restraint to be used. Review of the MAR revealed patient received Ativan 2 mg. IV for agitation at 0937 (9:37am), 1048 (10:48pm), 1241 (12:41pm), 1747 (5:47pm), 1956 (7:56pm). Patient also received Geodon 20 mg. IM for agitation at 1241(12:41 pm), and 0326 (3:26 pm) on 4/21/15. There was no nursing documentation of increased agitation or aggressiveness to justify the prn medication or documentation of patient's response to the medications.
On 4/21/15, at 1300, a telephone restraint order was written for "Non-violent Behavior, Soft restraints, All Extremities". This order did not contain justification/reason for use of restraints. This order was never signed by the physician. Review of the MAR revealed patient received Ativan 2mg. IV for agitation at 1221(12:21pm), 1535 (3:35pm) 1805(6:05 pm), and 2250(10:50 pm). Patient also received Geodon 20 mg IM at 1215(12:15pm), and 1815 (6:15 pm). There was no nursing documentation of increased agitation or aggressiveness to justify the prn medications.
On 4/22/15, review of the MAR revealed patient received Ativan 2 mg. by mouth for agitation on 4/22/15 at 2200 and on 4/23/15 at 0600. There was no documentation what precipitated the need for the Ativan and there was no documentation how the patient responded to the medication. Nursing did document behavior monitoring every 2 hours but the documentation never changed to indicate a change in behavior or alternatives attempted.
The next order for restraints was a telephone order written on 4/23/15 at 1527, "4 point soft restraints for non-violent pulling of IV and lines. On 4/23/15, patient received Haldol 5mg. IV at 1508 and Benadryl 50 mg. by mouth at 1700 in addition to daily medication of Ativan 1 mg. TID (3x day) and Geodon 10 mg. IM every 6 hours. There was no documentation of justification /reason for the Haldol being given. Nursing documentation did not indicate any changes in behavior or agitation.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on chart reviews, policy and procedures, and interviews the facility failed to follow its own policy and procedures, conduct a one hour face to face for a restrained behavioral patient, and ensure the practitioner is trained to conduct the 1 hour face to face in 2 (#1, #8)) out of 10 (1-10) charts reviewed.
Review of the policy and procedure "Restraint and Seclusion" stated, "Special Assessment Requirement Specific to Violent/ Self-Destructive Behavior patients (Face to Face) evaluations.
A. When restraint /seclusion is used to manage violent or self-destructive behavior, physician/LIP must conduct a face to face patient evaluation in person within 1 hour after restraint/seclusion initiated.
B. This face to face evaluation requirement also applies when a medication is used as a restraint/seclusion to manage violent or self-destructive behavior.
C. The patient must be seen face to face within 1 hour after the initiation of the intervention to evaluate.
1.) The patient's immediate situation;
2.) The patient's reaction to the intervention;
3.) The patient's medical and behavioral condition;
4.) The need to continue or terminate the restraint or seclusion.

1.) Review of patient #1's medical records revealed he was taken to the facility's emergency room (ER) on 1-16-2015 for stomach pain and breathing issues. He was diagnosed with pneumonia and admitted to the medical floor for further care.
Review of patient #1's nurses notes dated 1/18/2015, at 3:00 AM stated, "3:00 AM patient at nurse's station states he heard someone laughing on the call light when he called for pain medication and didn't like it. Patient accompanied back to room. 3:14 AM Patient given Norco 10 at this time. 3:45 AM Notified doctor of wife requesting something for him for his anxiety, order given. 4:09 AM Gave Haldol 5 mg IM to left hip. 5:30 AM Patient resting quietly without any signs or symptoms of distress. "
A written statement from patient #1's spouse revealed after the nurse returned patient #1 to the room he was very upset and anxious, nearly having a panic attack. At 4:00 AM the nurse came back in to monitor his vital signs and blood sugar. Patient #1 asked for a Klonopin for his anxiety and staff #10 (RN) said, "Ok." Staff #10 returned without the Klonopin and informed patient #1 he could not have the Klonopin but she had a shot for him. Patient #1 asked what the medication was after he received the shot and could they have a print out. Staff #10 brought a print out to patient #1 and his spouse. Patient #1's spouse stated, "We were terrified. There were numerous stated reasons and 3 warnings why he should have not been given the drug, due to all the serious life threatening side effects."
Patient #1's spouse asked staff #10 if there was a medication he could take to reverse the drug Haloperidol (Haldol). Staff #10 confirmed there was no medication to reverse this drug. Neither patient #1 nor his spouse was given any reason why he could not have his Klonopin and was given Haldol. Patient #1's spouse confirmed patient #1 had never received this medication before.
Review of the nurse's notes revealed there were no documented interventions found before patient #1 was given Haldol for agitation and anxiety.
Review patient #1's physician order dated 1/18/2015 revealed staff #10 received a verbal order from staff #23 (MD Hospitalist). The order was given at 3:45 AM and stated, "Haldol 5mg IM or IV q4 Prn for agitation." Staff #23 did not electronically sign the order until 2/19/15 at 6:67 AM (33 days later).
Review of the chart revealed there was no documentation of a one hour face to face performed by physician or LIP. An interview on 5/6/2015 revealed Staff #2, 9, and 14 confirmed all patient's requiring restraints were to be reported to the Registered Nurse (RN) House Supervisors (HS). The RNHS would assess the patient for restraints. No restraints were on the units only the house supervisor can distribute the restraints to the nurse.
An interview was conducted with staff #14 on 5/6/2015 at 11:40 AM. Staff #14 was asked about patients in restraints and what was the RNHS role. Staff #14 reported if a patient was in need of a medical or behavioral restraint the nurse was to notify the RNHS. The RNHS would assess the patient and take the restraints with him or her.
Staff #14 confirmed he has assisted in placing patients in restraints and done the one hour face to face. Staff #14 was asked about the training the RNHS have obtained to do a one hour face to face. Staff #14 reported when a psychiatrist was working in the hospital last year she did some training with the RNHS for the one hour face to face. Staff #14 reported the psychiatrist told them how to assess the patients but there was no formal training and nothing was in writing. Review of staff #14, #15, #31, and #32 employee files revealed there was no documentation of one hour face to face training.
Staff #14 reported he was not aware he needed to keep up with the chemical restraints and those had not been on the restraint log. Staff #14 stated, "I was not aware the staff needed to notify me for chemical restraints. I mean if a patient is out of control and fighting, the floor nurse notifies me to control the situation, then I would know about a chemical restraint. If they just call the doctor and get an order I wouldn't know."
Review of the facility's policy and procedure " Restraint and Seclusion " there is no information on the procedure the nurse is to follow if the patient is having disruptive behavior and requires a restraint. The policy starts with Patient assessed. The need for a restraint is indicated. Review of the algorithm for restraints in the policy " Restraint and Seclusion " states the following:
1.) Patient assessed. The need for a restraint is indicated.
2.) Initial order obtained from the physician/LIP. Enter order into computer. Notify house supervisor for restraints.
3.) Violent/ Self- Destructive Guidelines (previously referred to as behavioral care)
4.) Physician/LIP needs to examine the patient within 1 hour of initiation.
Staff #14 sent a medical and behavioral restraint log to the surveyor. The log had 10 patient identification stickers on them and the dates were from 1/27/2015- 4/27/2015. Staff #14 stated, "That's all the restraints that I am aware of." The administration assistant brought in a restraint log for medical and behavioral restraints that had 43 patient names dating from 1/2/2015- 4/23/2015. There were no further documented restraints past 4/23/2015. Staff #14 was made aware of the restraint log with 43 patient names. Staff #14 was asked how all these restraints got past the RNHS if all restraints were to be distributed by the RNHS. Staff #14 stated, "Well, that's a good question. I have no idea they must have restraints on the floor." Staff #14 was asked if any patients were in restraints on 5/6/2015. Staff # 14 stated, "I am not aware of any." Staff #14 was asked to call the Medical Intensive Care Unit and the Surgical Intensive Care Unit to see if any patients were in restraints. Staff #14 reported there were no patients in restraints.
During a tour of the Medical Intensive Care Unit on 5/6/2015 at 2:00PM a patient was found to be in restraints. Staff # 30 (RN) confirmed she had patient #6 in medical restraints. Staff #6 confirmed patient #6 had been in restraints for at least 2 days There was no documentation of patient #6 on the restraint log. A search was conducted by the surveyor for restraints in the MICU nurses station. In a drawer by the charge nurse desk a set of soft restraints were found. Staff # 6 confirmed the findings and that patient #6 was not on the patient restraint log.







2.) Review of medical record revealed patient #8 was a [AGE] year old female with severe Intellectual Disability and Autism and reported to have the mental capacity of a one year old. Patient was brought to the facility on [DATE] from a residential group home by EMS (Emergency Medical Services) due to severe agitation and aggressiveness. The staff at the group home reported that patient had become increasingly agitated and aggressive over the past week as evidenced by hitting, biting, and pulling hair of other residents. What incited the change in behavior is unclear but patient recently had changes to her environment and caregivers. Patient's father was her primary caregiver but he had a stroke and had to be placed in a nursing home. Since that time the patient was placed in the group home and also had been started on Seroquel (antipsychotic medication) 200 mg. at bedtime for behavioral issues and sleep disturbance approximately 2 months prior.
On 4/18/15 at 2200, a telephone order was written for "Behavioral Restraints". There was no time limit, no justification/reason for the restraints noted. This telephone order was never signed by the physician (Staff #38). There was no documentation of a 1 hour face to face evaluation being done. Nursing documentation revealed restraint monitoring began at 2215 and continued every 15 minutes. There was no documentation that alternative interventions were attempted prior to the order for the restraints. On 4/19/15 at 0200, a telephone order was written for "Continue Behavioral Restraints". There was no time limit or justification/reason for the restraints noted. There was no documentation of a 1 hour face to face evaluation being done. On 4/19/15 at 0600, a telephone order was written for "Continue Behavioral Restraints" . There was no time limit or justification/reason for the restraints noted. There still was no documentation of a physician conducting 1 hour face to face evaluation ever being conducted.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0184
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on patient chart reviews, policy and procedures, and interviews the facility failed to follow its own policy and procedure. The physician's failed to document clinical justification of restraints or type of least restrictive device. The physician failed to document the one hour face to face in 2 (#1,#8, and #9) of 10 (#1-10) patients reviewed.
1.) Review of patient #9's medical record revealed he has been in the ER multiple times for drug related issues. Patient #9 was found to have an elevated white blood cell count and running fever. A lumbar puncture was performed on patient #9 to rule out Meningitis. The test came back negative but patient #9 was admitted with Rhabdomyolysis and altered mental status.
Rhabdomyolysis is breakdown of muscle fibers. Muscle breakdown causes the release of myoglobin into the bloodstream. Myoglobin can cause kidney damage.
Review of patient #9's emergency room (ER) nurses notes on 4/22/2015 stated, "6:53 PM Pt found in PD custody, combative and uncooperative on scene and required PD intervention. Possible K2/Meth usage. Pt is alert and very uncooperative, somewhat combative. Speaking gibberish and sounding paranoid- thinks we are going to kill him, states, "you know what you've done" and "that's what the windshield wiper fluid told you. Behavior is agitated, anxious, restless, uncooperative. The patient is oriented to person, the patient is disoriented. Patient home medication was provided by the previous visit. The patient is unable to provide a social history due to altered mental status.
Review of patient #9's nurse's notes dated 4/22/2015 at 7:15PM stated, "Pt continuing to trash/make threats while attempting to insert new IV. Pt flung hand up at staff and was making threats. MD informed. Order for restraints received."
Review of patient # 9's ER nurses notes dated 4/22/2015 at 7:17PM stated, "Restraint Order Physician Order for invasive line protection, behavior management restraint Type of restraint: leather wrist restraints, leather ankle restraints. Restraint Application Assessment: The following criteria /clinical justification support the decision for use of restraint: Patient is at risk for harm to self and others. Patient's behavior disrupts the environment so that treatment cannot take place. Behavioral Restraint: patient is at risk of harm to self and/or others related to: Patient is agitated by continuing to yell at staff, kick or swing violently, make threats to staff, come of bed, Patient is combative by continuing to yell at staff, kick or swing violently, make threats to staff, fight against restraints, come of bed, overt actions and/or threats toward staff, behavior is intervening with patient treatment, confusion and/or disorientation, Alternatives attempted: Orienting the patient to person, place and time. Bed assignment for optimal observation of patient by nursing staff. Environment modification: Restraint education given to the patient. Patient needs ongoing instructions related to restraint use."
Review of the facility's policy and procedure "Restraints and Seclusion" stated, "Restraint/Seclusion Order Guidelines:
C. The order must be will indicate the clinical justification/reason, date, time, time limit(if applicable), type of least restrictive device, and signature of the individual giving the order. The order must be obtained either during application or immediately (within a few minutes) afterwards.
D. PRN orders are NOT to be used to authorize the use of restraints under any circumstances. Staff cannot discontinue a restraint/seclusion and then later restart it using the same order. This situation is the same as a PRN order. "Trial release" constitutes PRN restraint/seclusion use is not permitted. If restraint/seclusion is discontinued prior to original order expiration, a new order must be obtained prior to restarting restraint/seclusion use."
Review of patient #9's ER physician orders on 4/22/15 at 7:16PM stated, "Restrain -up to 4 hours (Adult>17 years of age); Complete Time 7:20PM." There was no documentation found on Physician ER notes or orders of clinical justification or type of least restrictive device. There was no documentation found of a physician face to face performed for restraint necessity or continued use.
Review of patient #9's ER nurses notes dated 4/22/2015 at 19:50 stated, "Assessment: Pulses are all present. Skin is intact with normal color, has good turgor. Edema distal to restraints is absent. Capillary refill is 3 seconds or less distal to restraints. Patient respiratory status is unlabored. Patient is agitated by continuing to Patient is restless. Patient is disoriented, fight against restraints."
Review of patient #9's ER physician notes for 4/22/2015 at 7:45PM stated, "Geodon 10mg IM once and Ativan 1 mg IVP once." There was no physician documentation found for justification of psychoactive medication administration. Dispensed Medications: 8:03PM Drug: Geodon 10MG Route: IM Site left deltoid. Ativan 1mg Route: IVP."
Review of patient #9's ER nurses notes dated 4/22/2015 at 8:50PM stated, "Assessment: Pulses are all present. Skin is intact with normal color, has good turgor. Edema distal to restraints is absent. Capillary refill is 3 seconds or less distal to restraints. Patient respiratory status is unlabored. Patient is combative by continuing to Patient is restless. Patient is disoriented, fight against restraints."
Review of patient #9's ER physician notes for 4/22/2015 at 8:54PM stated, "Geodon 10mg IM once and Ativan 1 mg IVP once." There was no physician documentation found for justification of psychoactive medication administration. Dispensed Medications: 9:00PM Drug: Ativan 1mg Route: IVP; 9:04PM Infused Over: 1 mins. Geodon 10MG Route: IM Site: right deltoid."
Review of #9's physician orders revealed the last documented physical restraint order was on 4/22/2015 at 11:10PM for a behavioral restraint. The order would expire at 3:10AM. The patient was in physical restraints for 7 hours and 50 minutes without an order.
Review of the following documented restraint order was on 4/23/2015 at 11:00AM. The order stated, "Behavioral; Violent behavior. [AGE] and older renew order every 4 hours.
Type of Intervention Ordered. Soft restraints. All Extremities.
Nursing Orders;
* Complete patient Monitoring Assessment every 2 hours
* Complete Nursing Reassessment every 4 hours
* Update restraint Care Plan daily. "
Review of patient #9's chart revealed he left the ER on 4/23/2015 at 1:09AM and was received as an inpatient.
Review of patient #9's nurse's notes on 4/23/2015 from 11:41AM until 2:45PM, under "Behavior Observation Monitoring", revealed the patient was in ankle and wrist restraints with q 15 minute observation checks. Review of the documented checks revealed the patient was calm, oriented, not suicidal, or combative. Patient #9 had a sitter at the bedside. Review of the Behavior Observation Monitoring record revealed patient #9 was sleeping without distress from 12:30PM-3:29PM in four point restraints and sitter at bedside. During this time there is no documentation of patient attempting to be combative, confused, or attempting to pull lines or devices that are medically necessary. There was no documentation found of interventions performed or less restrictive measures applied.
Review of the nurse's notes under "Behavior Observation Monitoring" on 4/23/2015 at 3:28PM, Restraint monitoring record; Restraint removed and ROM assessed stated, "NO: Pt. sleeping."
2.) Review of patient #1's medical records revealed he was taken to the facility's emergency room (ER) on 1-16-2015 for stomach pain and breathing issues. He was diagnosed with pneumonia and admitted to the medical floor for further care.
Review of patient #1's nurses notes dated 1/18/2015 at 3:00 AM stated, "3:00 AM patient at nurse's station states he heard someone laughing on the call light when he called for pain medication and didn't like it. Patient accompanied back to room. 3:14 AM Patient given Norco 10 at this time. 3:45 AM Notified doctor of wife requesting something for him for his anxiety, order given. 4:09 AM Gave Haldol 5 mg IM to left hip. 5:30 AM Patient resting quietly without any signs or symptoms of distress."
A written statement from patient #1's spouse revealed after the nurse returned patient #1 to the room he was very upset and anxious, nearly having a panic attack. At 4:00 AM the nurse came back in to monitor his vital signs and blood sugar. Patient #1 asked for a Klonopin for his anxiety and staff #10 (RN) said, "Ok." Staff #10 returned without the Klonopin and informed patient #1 he could not have the Klonopin but she had a shot for him. Patient #1 asked what the medication was after he received the shot and could they have a print out. Staff #10 brought a print out to patient #1 and his spouse. Patient #1's spouse stated, "We were terrified. There were numerous stated reasons and 3 warnings why he should have not been given the drug, due to all the serious life threatening side effects."
Patient #1's spouse asked staff #10 if there was a medication he could take to reverse the drug Haloperidol (Haldol). Staff #10 confirmed there was no medication to reverse this drug. Neither patient #1 nor his spouse was given any reason why he could not have his Klonopin and was given Haldol. Patient #1's spouse confirmed patient #1 had never received this medication before.
Review of the nurse's notes revealed there were no documented interventions found before patient #1 was given Haldol for agitation and anxiety.
Review of the physician order dated 1/18/2015 revealed staff # 10 received a verbal order from staff #23 (MD Hospitalist). The order was given at 3:45 AM and stated, "Haldol 5mg IM or IV q4 Prn for agitation." Staff #23 did not electronically sign the order until 2/19/15 at 6:67 AM (33 days later).
Review of the chart revealed there was no documentation of a one hour face to face performed by physician or LIP.











3.) Review of medical record revealed patient #8 was a [AGE] year old female with severe Intellectual Disability and Autism and reported to have the mental capacity of a one year old. Patient was brought to the facility on [DATE] from a residential group home by EMS (Emergency Medical Services) due to severe agitation and aggressiveness. The staff at the group home reported that patient had become increasingly agitated and aggressive over the past week as evidenced by hitting, biting, and pulling hair of other residents. What incited the change in behavior is unclear but patient recently had changes to her environment and caregivers. Patient ' s father was her primary caregiver but he had a stroke and had to be placed in a nursing home. Since that time the patient was placed in the group home and also had been started on Seroquel (antipsychotic medication) 200 mg. at bedtime for behavioral issues and sleep disturbance approximately 2 months prior.

On 4/18/15 at 2200, a telephone order was written for "Behavioral Restraints". There was no time limit, no justification/reason for the restraints noted. This telephone order was never signed by the physician (Staff #38). There was no documentation of a 1 hour face to face evaluation being done. Nursing documentation revealed restraint monitoring began at 2215 and continued every 15 minutes. There was no documentation that alternative interventions were attempted prior to the order for the restraints. On 4/19/15 at 0200, a telephone order was written for "Continue Behavioral Restraints". There was no time limit or justification/reason for the restraints noted. There was no documentation of a 1 hour face to face evaluation being done. On 4/19/15 at 0600, a telephone order was written for "Continue Behavioral Restraints" . There was no time limit or justification/reason for the restraints noted. There still was no documentation of a physician conducting 1 hour face to face evaluation ever being conducted.