HospitalInspections.org

Based on interview and record review, the facility failed to:

A. ensure patients' rights were protected from usage of unapproved restraints in 1 of 12 sampled patients (Patient #7). They failed to ensure there were policies which defined what chemical restraints were. They failed to have policies which addressed what medications could be used and what circumstances they could be used.

Patient #7 was a patient with a diagnosis of dementia who received a psychotropic medication which was not approved to be used.

B. ensure there was a policy which gave directives on identification, assessment and monitoring for patients when chemical restraints were used.

Patient #7 received a chemical restraint without appropriate documentation of justification, assessment and monitoring.


This deficient practice had the likelihood to cause harm to all patients who received psychotropic medications.


Findings include:


Review of the clinical record of Patient #7 revealed he was a 71-year-old male who was admitted on 10/13/2018 with diagnoses which included diabetes, chronic obstructive pulmonary disease, encephalopathy and dementia.

Review of home medication list dated 10/13/2018 revealed Patient #7 was on two psychotropic medications on a routine basis and they were Trazadone and Cymbalta.


Review of nurse notes revealed the following:

On 10/15/2018 at 8:20 p.m., Patient #7 was found on floor sitting on his buttock. Patient #7 was confused., bed low and locked, and side rails up x 3.

At 9:07 p.m., the physician was notified and new orders were received by a licensed vocational nurse.


Review of a physician order revealed the following:

On 10/15/2018 at 9:07 p.m., "Give Geodon IM 10 mg X 1 dose."

There was no documentation in the order for the reason the psychotropic was being administered.

Review of nurses notes dated 10/15/2018 revealed a section where restraint usage, monitoring, alternatives used, types of devices used, behavior justifying use, and activity could be documented. Staff had crossed through the section and indicated it was not applicable.

There was no documentation in the nurses notes to justify the usage of the psychotropic medication. There was no documented restraint assessment by a registered nurse prior to administration of the medication.



Review of nurses notes dated 10/24/2018 revealed the following:

At 8:40 p.m., Patient #7 refused meds ...

At 9:15 p.m., Patient #7 refused to allow his diaper to be checked. Checked anyway with assist of 1 other. Patient #7 became verbally and physically threatening and combative. Got up in gerichair with assist feet up and chair reclined, very combative, door left open for observation

At 10:00 p.m., "Patient hollering for help, charge nurse spoke with him, didn't get patient to accept HS meds ...remains in chair, knocking on window and calling for help, when answered he replies he wants to go home."

At 10:10 p.m., the doctor was called about patient's behavior and an order was received. A licensed vocational nurse called and received the order.


Review of a physician order revealed the following:

On 10/24/2018 at 10:12 p.m., "RE: Combativeness Give Geodon IM 10 mg X 1 now."


According to nurses notes at 10:38 p.m., "Geodon 10 mg IM x 1 dose administered right thigh with assist of 1 other, as patient become very combative with touch."

Review of nurses notes dated 10/15/2018 revealed a section where restraint usage, monitoring, alternatives used, types of devices used, behavior justifying use, and activity could be documented. Staff had crossed through the section and indicated it was not applicable.

There was no documentation in the nurses notes to justify the usage of the psychotropic medication. There was no documented assessment by a registered nurse prior to administration of the medication.



Review of the medication label revealed the following:

"WARNING

Increased Mortality in Elderly Patients with Dementia-Related Psychosis
Elderly patients with dementia related psychosis treated with antipsychotic drugs are at an increased risk of death .... Geodon is not approved for the treatment of patients with dementia-related psychosis ..."

Review of the facility's "RESTRAINT POLICY" dated 08/14/2017 revealed the following:

"All patients have the right to be free from restraints that are not medically necessary or are used or purposes other than patient benefit and safety. Restraints shall be used only where alternative methods are not sufficient to protect patients or others from injury and are not substituted for less restrictive forms of protective restraint ...all patients will have an assessment performed to determine the safety and protective needs of the patient prior to the application of restraints or medical protective device ...."

Underneath the category for definition of restraints revealed no documentation of the definition of chemical restraints and their usage. There was nothing documented to assist staff on identifying a chemical restraint ....

"Use of restraints will be based upon the assessed needs of the patient, and consideration of pertinent information obtained from the initial admission assessment. After attempts to use available alternatives are assessed to be ineffective staff will consult the Charge Nurse/RN, who will review the assessments and the use of alternative strategies. When determination has been made that restraints are clinically justified, the Charge Nurse/RN will obtain the appropriate restraint ...."

During an interview on 11/13/2018 after 3:10 p.m., Staff #1 confirmed the documentation in the chart. Staff #1 reported the physician wrote that type of order a lot (for Geodon). Staff #1 reported they did not have policies which addressed chemical restraints or psychotropic drug use. Staff #1 reported she had talked to their pharmacist and they did not know about the black box warning with the usage of Geodon.

Based on interview and record review, the facility failed to:

A. ensure patients' rights were protected from usage of unapproved chemical restraints in 1 of 12 sampled patients (Patient #7). They failed to ensure there were policies which defined what chemical restraints were. They failed to have policies which addressed what medications could be used and what circumstances they could be used.

Patient #7 was a patient with a diagnosis of dementia who received a psychotropic medication which was not approved to be used.

B. ensure there was a policy which gave directives on identification, assessment and monitoring for patients when chemical restraints were used.

Patient #7 received a chemical restraint without appropriate documentation of justification, assessment and monitoring.


This deficient practice had the likelihood to cause harm to all patients who received psychotropic medications.

Findings include:


Review of the clinical record of Patient #7 revealed he was a 71-year-old male who was admitted on 10/13/2018 with diagnoses which included diabetes, chronic obstructive pulmonary disease, encephalopathy and dementia.

Review of home medication list dated 10/13/2018 revealed Patient #7 was on two psychotropic medications on a routine basis and they were Trazadone and Cymbalta.


Review of nurse notes revealed the following:

On 10/15/2018 at 8:20 p.m., Patient #7 was found on floor sitting on his buttock. Patient #7 was confused., bed low and locked, and side rails up x 3.

At 9:07 p.m., the physician was notified and new orders were received by a licensed vocational nurse.


Review of a physician order revealed the following:

On 10/15/2018 at 9:07 p.m., "Give Geodon IM 10 mg X 1 dose."

There was no documentation in the order for the reason the psychotropic was being administered.

Review of nurses notes dated 10/15/2018 revealed a section where restraint usage, monitoring, alternatives used, types of devices used, behavior justifying use, and activity could be documented. Staff had crossed through the section and indicated it was not applicable.

There was no documentation in the nurses notes to justify the usage of the psychotropic medication. There was no documented restraint assessment by a registered nurse prior to administration of the medication.



Review of nurses notes dated 10/24/2018 revealed the following:

At 8:40 p.m., Patient #7 refused meds ...

At 9:15 p.m., Patient #7 refused to allow his diaper to be checked. Checked anyway with assist of 1 other. Patient #7 became verbally and physically threatening and combative. Got up in gerichair with assist feet up and chair reclined, very combative, door left open for observation

At 10:00 p.m., "Patient hollering for help, charge nurse spoke with him, didn't get patient to accept HS meds ...remains in chair, knocking on window and calling for help, when answered he replies he wants to go home."

At 10:10 p.m., the doctor was called about patient's behavior and an order was received. A licensed vocational nurse called and received the order.


Review of a physician order revealed the following:

On 10/24/2018 at 10:12 p.m., "RE: Combativeness Give Geodon IM 10 mg X 1 now."


According to nurses notes at 10:38 p.m., "Geodon 10 mg IM x 1 dose administered right thigh with assist of 1 other, as patient become very combative with touch."

Review of nurses notes dated 10/15/2018 revealed a section where restraint usage, monitoring, alternatives used, types of devices used, behavior justifying use, and activity could be documented. Staff had crossed through the section and indicated it was not applicable.

There was no documentation in the nurses notes to justify the usage of the psychotropic medication. There was no documented assessment by a registered nurse prior to administration of the medication.



Review of the medication label revealed the following:

"WARNING

Increased Mortality in Elderly Patients with Dementia-Related Psychosis
Elderly patients with dementia related psychosis treated with antipsychotic drugs are at an increased risk of death .... Geodon is not approved for the treatment of patients with dementia-related psychosis ..."

Review of the facility's "RESTRAINT POLICY" dated 08/14/2017 revealed the following:

"All patients have the right to be free from restraints that are not medically necessary or are used or purposes other than patient benefit and safety. Restraints shall be used only where alternative methods are not sufficient to protect patients or others from injury and are not substituted for less restrictive forms of protective restraint ...all patients will have an assessment performed to determine the safety and protective needs of the patient prior to the application of restraints or medical protective device ...."

Underneath the category for definition of restraints revealed no documentation of the definition of chemical restraints and their usage. There was nothing documented to assist staff on identifying a chemical restraint ....

"Use of restraints will be based upon the assessed needs of the patient, and consideration of pertinent information obtained from the initial admission assessment. After attempts to use available alternatives are assessed to be ineffective staff will consult the Charge Nurse/RN, who will review the assessments and the use of alternative strategies. When determination has been made that restraints are clinically justified, the Charge Nurse/RN will obtain the appropriate restraint ...."

During an interview on 11/13/2018 after 3:10 p.m., Staff #1 confirmed the documentation in the chart. Staff #1 reported the physician wrote that type of order a lot (for Geodon). Staff #1 reported they did not have policies which addressed chemical restraints or psychotropic drug use. Staff #1 reported she had talked to their pharmacist and they did not know about the black box warning with the usage of Geodon.