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NORTHWESTERN MEDICAL CENTER INC 133 FAIRFIELD STREET SAINT ALBANS, VT 05478 Oct. 25, 2011
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0161
Based on staff interview and record review, the hospital failed to assure that patients were free from physical restraints during the administration of medication for 1 applicable patient in the sample. (Patient # 1 ) Findings include:

Per record review on 10/24/11 and 10/25/11, nursing staff physically restrained Patient #1 on 12/4/10 in order to administer a newly ordered anti-psychotic medication without evidence of an assessment to determine need and without a physician order for a physical and/or chemical restraint. A nursing progress note dated 12/4/10, 2201, stated "pt. continually talking to self and combative when touched, given IM Zyprexa (3 assist to help keep pt. still)". There was no physician order to restrain the patient per review of the medical record.

Nursing progress notes from another inpatient stay by the same patient on 6/29/11, 0640 stated "Pt. in hall attempting to leave unit. Yelling at staff. Charge RN received orders for IM (intramuscular) Zyprexa X 1. Given with 3 assist." Although the charge nurse obtained a telephone physician order to chemically restrain the patient at 0639 on 6/29/11, there was no evidence of a face to face assessment within 1 hour by the ordering physician, per policy for restraints used for violent behavior

The CMS (Centers for Medicare and Medicaid Services) interpretive guidelines for hospitals for A-0161 state that "the application of force to physically administer a medication against the patient's wishes, is considered restraint". During interview on 10/25/11 at 2 PM, the RN Clinical Resource Nurse confirmed that she had not considered 'holding a patient momentarily to give a medication a restraint'. The Director of Quality and the Director of Risk Management, who were also present at the time, agreed there was no physician order to restrain the patient for medication administration on 12/4/10 and there was no evidence of a physician 1 hour face to face with the patient after the chemical restraint was implemented on 6/29/11. They also agreed that a physician order for a restraint for violent behaviors written on 6/22/11 for this patient was inappropriate and included potential use of all physical restraints listed on the order sheet without evidence of need.