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.

PARIS REGIONAL MEDICAL CENTER 820 CLARKSVILLE ST PARIS, TX 75460 Aug. 19, 2016
VIOLATION: GOVERNING BODY Tag No: A0043
Based upon record review and interviews, the Governing Body failed to ensure the facility:

A. developed policies and procedures that clearly defined chemical restraints and the appropriate administration of chemical restraints;

B. prohibited the use of PRN (as needed)medications as chemical restraint;

C. documented comprehensive patient assessments to determine the need for other types of interventions before using a drug or medication as a restraint in 3 (#1-3) of 4 (#1-4) charts reviewed;

D. developed a policy for assessment and monitoring of the patient after being administered a chemical restraint.



Refer to Tag A0160
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based upon record review and interviews, the facility failed to:


A. develop policies and procedures that clearly defined chemical restraints and the appropriate administration of chemical restraints;

B. prohibit the use of PRN (as needed)medications as chemical restraint;

C. document comprehensive patient assessments to determine the need for other types of interventions before using a drug or medication as a restraint in 3 (#1-3) of 4 (#1-4) charts reviewed;

D. have a policy for assessment and monitoring of the patient after being administered a chemical restraint.


Refer to Tag A0160
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0160
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based upon record review and interviews, the facility failed to:

A. develop policies and procedures that clearly defined chemical restraints and the appropriate administration of chemical restraints;

B. prohibit the use of PRN (as needed) medications as chemical restraint;

C. document comprehensive patient assessments to determine the need for other types of interventions before using a drug or medication as a restraint in 3 (#1-3) of 4 (#1-4) charts reviewed;

D. have a policy for assessment and monitoring of the patient after being administered a chemical restraint.


Review of the facility's policy and procedure "Seclusion and Restraint Usage for Geropsych Management" defined a chemical restraint as follows: "a drug used as a restraint is medication used to control behavior or to restrict the patient's freedom of movement and is not a standard treatment for the patient's medical or psychiatric condition." On page three of this policy, under Prohibited Practices, stated, "The use of chemical restraints is prohibited." There was no direction found for chemical restraints in the policy and procedure.

Review of the "Behavioral Management Plan" revealed a plan to use levels of restriction such as:
"A. Environmental de-escalation techniques (soft lighting, calm milieu, etc.).
B. Verbal intervention.
C. Voluntary use of prescribed psychotropic medications.
D. Voluntary time out (in safe area, own room, or seclusion area with door open or closed but unlocked and unsecured).
E. Involuntary seclusion (locked door).
F. Involuntary vest or chair restraint.
G. Involuntary limb restraints."

Review of the "Behavioral Management Plan" revealed a section titled "Emergency Psychiatric Care" that stated: #2. "If the patient is in danger to self and/or others, the staff will utilize techniques of non-violent crisis intervention to attempt de-escalation of the situation. This may include utilization of a one-time emergency medication order by a physician at the time of the emergency. The emergency medication is utilized to stabilize the dangerous behavior documented in the medical record, but is not to be utilized as a restraint technique. If a "cocktail" order consisting of multiple (greater than two) psychotropic medications are utilized emergently, this WILL be considered a chemical restraint, and restraint/seclusion protocols will be initiated."

The facility failed to follow their own policy and procedure and failed to have procedures in place for staff to follow when administering a chemical restraint in the following patients:

Review of Patient #1's chart revealed the patient was admitted on [DATE] to the geriatric psychiatric unit with a diagnosis of Dementia with behavioral disturbances. Patient #1 was admitted involuntarily on an emergency detention warrant (EDW). A 90-day order of protective custody (OPC) with medication was initiated on 8/3/15 and granted on 8/5/15.

Review of the nurse's notes dated 7/31/15 revealed the patient had been assessed by the RN at 8:00AM. The RN documented, "Pt redirects after several attempts. Denies depression, S/H (suicidal/homicidal) idea or A/V (auditory/visual) hallucinations. Pt. very obsessed with going home. Agitated at times. Every 15 minute safety checks." There was no further nursing narrative documentation until 3:00PM.

On 7/31/15 at 3:00PM the nurse's note stated, "Pt. very agitated, anxious-shakes doors- threaten to (illegible) out window to get out. Bangs on the window. Unable to redirect. Called staff #9 (FNP) Orders received. 1535 (3:35PM) Haldol 2.5mg given in (lt) deltoid 22g 1 needle tol. well." There was no documentation of a comprehensive assessment or behavioral interventions attempted prior to administering the medication.

Review of the physician telephone orders dated 7/31/15 at 1520 (3:30PM) revealed an order for "Haldol (antipsychotic) 2.5 mg IM x1 now for severe agitation/aggression." The order was taken by staff #7 (LVN).

Review of the medication administration record (MAR) for 7/31/15 stated, "Haldol 2.5mg IM x 1 now. Given at 1535 (3:35PM) in the left deltoid with 22 gauge 1 needle." Staff #7 administered the injection. In the Nurse's notes staff #10 (RN) documented, "Haldol 2.5 mg given in lt deltoid 22g 1 tol well.(sic)" There was no further nursing documentation found for a face to face evaluation. There was no vital signs taken, neuro assessments, or any care that was provided during this time.

Review of the nurse's notes dated 7/31/2015 at 5:00PM stated, "Calmer but still wanting to leave." There were no vital signs, patient assessment, or a clear patient response to the effectiveness of the medication documented.

Review of the physician progress notes dated 8/1/2015 revealed staff #9 (FNP) had made a clinical visit with patient #1. Staff #9 documented,"It is of note that she did have significant behavioral issues around 3:00 p.m. with agitation and aggression and subsequently she did calm after a period of time and p.r.n medication and did not have any further agitation or aggression behavior yesterday evening. (sic)" Staff #9 failed to document the chemical restraint as a chemical restraint but did document a prn medication that was ordered and given as a one-time dosage for agitation and aggression.

Review of patient #1 nurse's notes dated 8/4/2015 at 2140 (9:40PM) stated, "pt. agitated, yelling, accusing people of coming into her room. Tries to barricade her door with chair. Notified staff #12 (psychiatrist) and received order for Haldol 2 mg IM x 1 now as emergency dose. Admin. To L gluteal using 22 g 1 needle and aseptic technique by staff #8. Pt tolerated without distress. Will monitor for effectiveness of med." There was no documentation of assessment or intervention prior to medication being given.

Review of the physician telephone order dated 8/4/16 at 2137 (9:37PM) Haldol 2mg IM x1 now as emergency dose for agitation and aggression. The order was taken by staff #8 (RN) Review of the MAR stated, "Haldol 2mg IM x 1 now as emergency dose for agitation and aggression. Given at 2140 (9:40PM) with 22 gauge 1 needle." Staff #8 administered the injection.

Review of patient #1 nurse's notes dated 8/4/2016 at 2215 (10:15 PM) stated, "Appears to be sleeping. Resp. even and unlabored. Med was effective. Will continue to monitor." There was no further nursing documentation found for a face to face evaluation. There were no vital signs taken, neuro assessments, or any care that was provided during this time.

Review of the physician progress notes dated 8/5/2015 revealed staff #12 (psychiatrist) had made a clinical visit with patient #1. Staff #12 documented, "The patient appears to be in better spirits. No behavioral issues have been noted. She is requiring occasional p.r.n.'s for now. We expect court ordered meds after a hearing this evening, and at that time I will begin patient on medication strategies to stabilize her behaviors and hopefully improve her cognition somewhat." Staff #12 failed to document the chemical restraint as a chemical restraint but did document prn medication was ordered and given.

Review of the physician telephone order dated 8/5/15 at 2030 (8:30PM) stated, "Haldol 2mg IM q 8 hrs. PRN agitation/ aggression." The order was taken by staff #8 (RN). There was no documentation on why the order was requested and a telephone order was written. There was no documentation that the medication was administered. The medication was placed on the MAR as a PRN psychotropic. There was no mention of the new order dictated in the physician progress notes.

Review of patient #1's treatment plan revealed there was a problem identified for impulsive behavior, current or recent threats of harm to others upon admission. The treatment plan had no documentation of patient's outbursts, behavioral medications ordered, chemical restraints administered, or any plan to monitor or implement any changes in care.

Review of patient #2's chart revealed the patient was admitted on [DATE], as an involuntary admission, with a diagnosis of mild neurocognitive disorder secondary to vascular dementia. Review of patient #2's physician orders dated 8/10/16 at 2110 (9:10PM) revealed a telephone order was written by staff #7 (LVN). The order read "Geodon 10mg IM Q8hrs prn: severe agitation." There was no narrative nursing documentation until 2140 (9:40PM). Staff #13 documented, "67 y/o female arrived to the floor via wc from ER. Confused state. Assessment completed. Refused to answer questions or movements as requested for exam. Multiple bruises on body and head. Pictures taken for chart. In bed with gown in place. Continually yelling out. Allowed time to verbalize thoughts and feelings. Wants to go home with her dog. Does not want to be here. Refused to answer questions. Became agitated with questions r/t assessment. Started screaming again and refused to answer. Scored 8/15 on Geriatric Depression Scale GDS. Seizure, fall, aggression precautions initiated. Initiate q 15 minute checks for safety. Reorient and redirect PRN. Assess needs r/t problem list."(sic) There was no documentation that Geodon was given when ordered.

Review of patient #2's telephone physician orders, dated 8/11/16 at 0035 (12:35AM) stated, "Geodon 10mg IM x 1 now as emergency dose for psychosis/agitation." The previous PRN order for Geodon was not discontinued.

Review of patient #2's nurses notes dated 8/11/16 at 0015 (12:15AM) revealed staff #13 documented, "Pt continues to cry/scream out with incomprehensible chatter. Keeps attempting to get out of bed. Denies need for BR. Refused food and drink. 0025 (12:25AM) Stuffed bear provided R/T increased and continued anxiety screaming out and requesting her dog. Pt hugging bear to face and crying. Encouraged to be quiet for other pts comfort. 0027 (12:27AM) Pt being quiet. No cries noted. Will continue to monitor. 0040 (12:40AM) Pt continues to scream/cry and trying to get out of bed. Attempt to reorient and redirect failed. Emergency dose of Geodon 10 mg IM obtained. 0055 (12:55AM) Geodon 10mg given in R GM R/T severe psychosis by LVN. Will continue to monitor. Pt got really quiet after receiving shot, closed her eyes as if in a deep sleep, then opened eyes and looked at us and started yelling again, speech unintelligible. 0110 (1:10AM) Pt continues to cry out. When name called, pt will look up start shaking and then close eyes and slump to left. After a moment she opens her eyes and starts yelling again. 0125 (1:25AM) resting with eyes closed. Respirations even and unlabored." The patient was never placed on a 1:1 for safety and no documentation of a comprehensive assessment found. There was no face to face evaluation following administration of a chemical restraint. There were no vital signs obtained until 8:00AM the next morning.

Review of patient #2's nursing notes, on 8/11/16 at 0925, revealed the LVN documented,"(9:25AM) Pt continues to yell and scream out with any attempt to decrease behavior with decrease stimuli, verbal redirection, offering teddy bear and reinforcing fall precautions. Pt will become louder when staff speaks with her and then act as if she passes out then immediately begins to yell again. NP called emergency dose of Haldol 5 mg IM for psychosis ordered. 0950 (9:50AM) Haldol 5mg IM given to l deltoid with 22g 1" pt yelled the entire time injection was given and then staff assists pt to eat pudding. 1155 (11:55AM) Pt lying in open air geri chair and yelling and continues to attempt to climb out of chair and will not remain in chair with staff at pts side verbally redirecting and encouraging with no success. NP called and new orders for Ativan 1 mg IM given to L gluteal with 22g 1.5" emergency dose. Pt. tolerated well. Will continue with current POC and Q15 for pt safety. 1545 (3:45PM) Pt yelling and attempting to throw leg over open geri chair and climb out without assist. Unable to verbally redirect, distract, and decrease stimuli NP on floor. New orders for Haldol 5mg, Ativan 1mg and Benadryl 25mg IM ordered emergency dose for psychosis."

There was no face to face evaluation found for the last three emergency medications administered as a chemical restraint. There was no nursing assessment of vital signs, neuro assessments, effectiveness of medications, or a progress note from the nurse practitioner ordering the medications.

Review of the patient's medications revealed the patient had the following psychotropic medications and pain medications in 24 hours:
8/11/16 12:55AM Geodon (antipsychotic) 10mg IM.
8/11/16 8:45AM Norco (an opioid pain medication) 5/325mg for pain by mouth.(for fx clavical pain.)
8/11/16 9:50AM Haldol (antipsychotic) 5mg IM.
8/11/16 11:55AM Ativan (benzodiazepine) 1mg IM.
8/11/16 2:40PM Norco 5/325mg for pain by mouth.
8/11/16 3:45PM Haldol 5mg, Ativan 1mg, and Benadryl 25mg IM.
8/11/16 9:00PM Thorazine (anti-psychotic) 25mg by mouth.
8/11/16 9:45PM Norco 5/325mg for pain by mouth.

Review of patient #2's treatment plan revealed there was a problem identified for "risk of harm to others: cognitive/perceptual impairment " upon admission. The treatment plan had no documentation of patient's outbursts, behavioral medications ordered, chemical restraints administered, or any plan to monitor or implement any changes in care.

Review of patient #3's chart revealed the patient was admitted involuntarily on 7/30/16 with a diagnosis of Major depressive disorder with suicidal ideations and polysubstance abuse.

Review of telephone physician orders dated 8/2/16 at 2150 (9:50PM) stated, "Vistaril 25mg po QID-PRN anxiety. Geodon 2 mg IM q12 hours for severe anxiety. At 2258 10:58PM an order clarification was found for Geodon 10mg IM q 12 hours PRN for severe anxiety."

There was no documentation why the patient was ordered a psychotropic medication as an "as needed" PRN medication for anxiety. There was no documentation the patient recieved the medication but the order was never discontinued and remained on the patients chart to administer at the nurses will as a PRN medication. The patient had no documentation that the Geodon was ordered as a therapeutic drug or part of the patients routine medications.

An interview with staff #5 revealed the facility was under the impression that a chemical restraint was when more than one psychotropic med was administered to control a patient's behavior or if it put the patient to sleep.

An interview with staff #7 reported that the patients were given chemical restraints but was not aware that a face to face evaluation would need to be done if it was not a "cocktail" of medications. Staff #7 was unable to identify when the use of a drug or medication is considered a chemical restraint. Review of RN staff #15, 16 and 17's employee education files revealed they did not have face to face training.

An interview with staff #14 revealed she was covering for the Director of Psychiatric Nursing (DPN) and was also the MSN available to monitor and provide the consultation hours to the DPN. Staff #14 confirmed the above findings.



Surveyor: Ready, Shanda