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BELMONT BEHAVIORAL HOSPITAL 4200 MONUMENT AVENUE PHILADELPHIA, PA July 24, 2014
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0160
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of facility policy, review of medical records (MR) and interview with staff (EMP), it was determined that the facility failed to identify and provide adequate justification for the use of medications as a chemical restraint for one of five medical records reviewed (MR1).

Findings include:

Review of facility policy "Use of Restraints/Seclusion on Inpatient Units," effective March 15, 2012, revealed "I. Policy A. ... Restraints and/or seclusion will only be used when necessary and required to prevent harm to self or others after less restrictive measures have been determined to be ineffective. Restraint/seclusion will not be imposed for the purpose of discipline or convenience. restraint/seclusion will be used in a manner assuring personal privacy and dignity for the patient. ... III. Philosophy Belmont strives to provide safe and effective behavioral health care with minimal or no use of restraint or seclusion. The decision to use a restraint or seclusion is driven by a comprehensive, individualized assessment that concludes the use of less restrictive measures poses a greater safety risk than the risk of using restraints or using seclusion for this patient at this time. IV. Definition Of Terms ... 3. Chemical restraint: a medication used as a restriction to manage a patient's behavior or to restrict the patient's freedom of movement and not a standard treatment or dosage for the patient's condition. ... V. Criteria for Use of Restraints and/or Seclusion I. Restraints/seclusion shall be used only: 1. to ensure the immediate physical safety of the patient, a staff member, or others when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm; 2. in accordance with safe and appropriate restraint techniques. ... I. Initial Assessment A. All patients will be assessed at the time of admission for risk of harm to self or others. For those patients determined to be at risk, the following will be assessed: 1. Methods that have been helpful in the past for behavioral control. 2. Medical and physical conditions that would increase risk during a restraint/seclusion episode. 3. History of physical or sexual abuse. 4. The assessment is documented in the designated section of the Interdisciplinary Assessment Form. II. Physician Orders A. Each restraint/seclusion episode requires a physican's order. 1. Orders may not be written as a standing order or an as needed (PRN) order. III. Procedure A. The Registered Nurse will: 1. Determine the need for the restraint/seclusion and identify the type of restraint needed for the current patient situation. ... 3. Document all less restrictive interventions attempted. ... VI. Documentation A. The Nursing Staff will: 1. Document all information related to the management of the patient in restraints on the Restraint Episode Record. Maintain form throughout the entire restraint episode. ... C. The Physician will: 1. Write an order designating type of restraint, reason for use, time and duration. ..."

Review of MR1 "Patient Transfer Form," dated June 13, 2014, revealed that the patient was transferred to the facility with a diagnosis of [DIAGNOSES REDACTED]"

Review of MR1 physician's orders, dated June 13, 2014, revealed " ... PRN Medication for Agitation: Haloperidol [Brand name- Haldol- a antipsychotic medication used to treat psychosis and that can have sedating effects] 5 MG IM [Intramuscular] Every Six Hours PRN [as needed] Agitation/Anxiety or Patient Preference; Lorazepam [Brand name- Ativan- a anxiolytic medication used to treat anxiety and that may cause drowsiness] 2 MG IM Every Six Hours PRN Severe Agitation/Anxiety or Patient Preference; Diphenhydramine [Brand name- Benadryl- used to prevent [DIAGNOSES REDACTED]-intermittent spasmodic or sustained contractions of the muscles in the body- a side effect that can be caused by the administration of Haloperidol]."

Review of MR1 progress notes, dated June 14, 2014 timed 1905, revealed " increase agitation. Paranoid. Loud. Making verbal threats and slurs toward staff. Unable to be redirected. Refused offer of PO [by mouth] PRN meds. Given PRN Haldol 5MG, Benadryl 50 MG, Ativan 2 MG IM in Right Deltoid at 1850 to assist in self-control. Awaiting relief." Review of MR1 progress notes, timed 2000, revealed "nursing meds with good effect. resting quietly in [patient's] room."

Review of MR1 progress notes, dated June 15, 2014 timed 0510, revealed "patient was received from the previous shift in bed asleep. ... Patient slept throughout the night. "

Review of MR1 psychiatry attending note, dated June 15, 2014 timed 0730, revealed "SI [suicidal ideation]: No HI [homicidal ideation]: No Delusions: Yes Paranoid ... encourage medications- if committed will need second opinion for IM meds."

Review of MR1 progress notes, dated June 15, 2014 timed 1500-2330, revealed "PRN A2 H5 B50 [Ativan 2MG, Haldol 2 MG, Benadryl 50 MG] MG IM 1900- [patient] was observed standing at the nurses' station listening to other patients information. When re-directed [patient] became very agitated making verbal threats toward the nurse ... Refused to leave the nurses' station argumentative demanding to talk to the nursing supervisor. Refused to go to ... room. PRN was offered and refused. [Patient] was being escorted to ... room by staff threw self on the floor... nursing supervisor came to the floor and talked with [patient]. [Patient] received A2 H5 B50 MG IM on right deltoid. ..."

Review of MR1 progress notes, dated June 16, 2014 timed 20:30, revealed "PRN A2 H5 B50 MG IM was very effective ... [Patient] ... in bed sleeping after PRN meds."

Review of MR1 progress notes, dated June 17, 2014 timed 05:30, revealed "Patient appeared to be resting (sleeping) during ... round checks without incident."

Interview on July 24, 2014, at 11:15 AM, with EMP1, revealed that the patien had orders for Ativan, Haldol, and Benadryl PRN [as needed], therefore the facility did not consider these medications or their combined usage as a chemical restraint. Review of MR1 revealed that during the patient's verbal outbursts on June 14 and June 15, the patient was offered medications by mouth, but refused. Nursing then administered a combination of Ativan, Haldol, and Benadryl, via injections, which resulted in the patient "resting" or going to sleep.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records (MR) and interviews with staff (EMP), it was determined that the facility failed to adequately develop and implement an appropriate plan of care related to one patient identified with psychosis and aggressive behavior for one of five medical records reviewed (MR1).

Findings include:

Review of MR1 physician's orders, dated June 13, 2014, revealed " ... PRN Medication for Agitation: Haloperidol [Brand name- Haldol- a antipsychotic medication used to treat psychosis and that can have sedating effects] 5 MG IM [Intramuscular] Every Six Hours PRN [as needed] Agitation/Anxiety or Patient Preference; Lorazepam [Brand name- Ativan- a anxiolytic medication used to treat anxiety and that may cause drowsiness] 2 MG IM Every Six Hours PRN Severe Agitation/Anxiety or Patient Preference; Diphenhydramine [Brand name- Benadryl- used to prevent [DIAGNOSES REDACTED]-intermittent spasmodic or sustained contractions of the muscles in the body- a side effect that can be caused by the administration of Haloperidol]."

Review of MR1 "Inpatient Psychiatry Interdisciplinary Assessment Psychiatric Summary," dated June 13, 2014, revealed "Provisional Diagnosis: Psychosis NOS [Not Otherwise Specified] ... hospitalization is required at this time for the following reason(s): Aggressive behavior. ..."

Review of MR1 progress notes, dated June 14, 2014 timed 1905, revealed " increase agitation. Paranoid. Loud. Making verbal threats and slurs toward staff. Unable to be redirected. Refused offer of PO [by mouth] PRN meds. Given PRN Haldol 5MG, Benadryl 50 MG, Ativan 2 MG IM in Right Deltoid at 1850 to assist in self-control. Awaiting relief." Review of MR1 progress notes, timed 2000, revealed "nursing meds with good effect. resting quietly in [patient's] room."

Review of MR1 progress notes, dated June 15, 2014 timed 0510, revealed "patient was received from the previous shift in bed asleep. ... Patient slept throughout the night. "

Review of MR1 psychiatry attending note, dated June 15, 2014 timed 0730, revealed "SI [suicidal ideation]: No HI [homicidal ideation]: No Delusions: Yes Paranoid ... encourage medications- if committed will need second opinion for IM meds."

Review of MR1 progress notes, dated June 15, 2014 timed 1500-2330, revealed "PRN A2 H5 B50 [Ativan 2MG, Haldol 2 MG, Benadryl 50 MG] MG IM 1900- [patient] was observed standing at the nurses' station listening to other patients information. When re-directed [patient] became very agitated making verbal threats toward the nurse ... Refused to leave the nurses' station argumentative demanding to talk to the nursing supervisor. Refused to go to ... room. PRN was offered and refused. [Patient] was being escorted to ... room by staff threw self on the floor... nursing supervisor came to the floor and talked with [patient]. [Patient] received A2 H5 B50 MG IM on right deltoid. ..."

Review of MR1 progress notes, dated June 16, 2014 timed 20:30, revealed "PRN A2 H5 B50 MG IM was very effective ... [Patient] ... in bed sleeping after PRN meds."

Review of MR1 "In-Hospital Interdisciplinary Treatment and Recovery Plan" revealed that the patient's care plan was initiated on June 16, 2014, three days after the patient was admitted to the facility. Further review of the patient's plan of care revealed no documented evidence that nonpharmacological interventions were developed and implemented to address the patient's history of psychosis and aggressive behavior, nor did it include the use of IM [intramuscular] medications to manage the patient's behavior.

These findings were reviewed during an interview on July 24, 2014, at 3:30 PM, with EMP1.