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The hosptial failed 1 of 1 Patient (Patient #1). The hospital failed Patient #1 by not providing Patient #1 care in a safe setting.

Finding Included:

Through record review video documentation, Patient #1 was left alone after receiving Emergent Medication, to help control Patient #1's behavior.

Through hospital record review Code Blue/Medical Emergency Documentation dated 10/22/2019 reflected, "Pt. found on the floor on the hallway. Screaming for help. Pt hit head and observe stitch on. Left forehead. Medical alert initiates 911 call. Pt. sent out. Dr. Mehta notified." "What could have been done differently? 'We should never leave the patient alone after the emergent med was given especially when the pt. was confused and using wheelchair.'"

The hospital failed to follow its own Policy in observation for the Patient. The hospital staff #1 indicated that, "The nursing supervisor to this unit failed to assign a person to monitor this patient after Emergent Medications were administered."

The hospital failed to follow its own Policy in administering Emergent Medications and not using the less Restrictive Measures to a Patient. Through documentation review the medical records reflect Physician's Order on 10/22/2019 at 1740 "Zyprexa 5mg I, Benadryl 25mg IM." Through Documentation review the The hospital Medical Executive Committee, November 4, 2019 reflected, "Seclusions & Restraints ...Falls Emeds within 72 hours is too long of time frame for measuring effect of med on fall ...Patient non-compliance with safety commands attributed to 63% of falls ...Staff #2 announced resignation from Geriatric Medical Director ...Staff #3 completed FPPE on Staff #2 for geriatric fall with fracture ...Noted observation regarding use of anticholinergic and antipsychotic medications that may have contributed to fall potential."


Policy
The hospital Policy Patient Rights dated 01/10/14 reflected, "On admission to the facility and during the patient's hospitalization, the patient will be informed of his/her rights according to federal and state rules and regulations."

The hospital Abuse/Neglect Identification and Reporting Abuse and Responsibilities Policy dated 09/2015, reflected, "The purpose of this policy is to insure patient safety, to insure employee compliance with the law and assist staff with identifying signs of abuse and neglect."

The hospital Policy on Proper Use of Restraint and Seclusion dated 09/2008 reflected, "It is the policy of Garland Behavioral Hospital to support each patient's right to be free from restraint or seclusion and therefore limit the use of these interventions to emergencies in which there is an imminent risk of a patient physically harming him/herself or others. Restraint or seclusion may only be used in emergency situations and when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm. Restraint or seclusion requires an order from physician. In situations that the need for a restraint or seclusion intervention occurs so quickly that an order cannot be obtained prior to the application of restraint or seclusion, the order must be obtained by a Registered Nurse either during the emergency application of the restraint or seclusion, or immediately after the restraint or seclusion has been applied. Restraint and seclusion use will not be based on history of past use or dangerous behavior, as a convenience for staff, or a substitute for adequate staffing appropriate to the severity of the behaviors, and the patient's chronological and developmental age, size gender, physical, medical and psychiatric conditions, and personal history including any history."

Medication (Chemical) Restraint: The administration of a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. Non-standard use alone does not make the use of a drug a restraint. If the non-standard use of the drug did not reduce the patient's ability to deal with the world around them, nor did the use of the drug reduce the patient's ability to move, the drug's use would not be a drug used as restraint. Whether or not an order for a drug or medication is PRN or a standing-order does not determine whether or not the use of that drug or medication is considered a restraint. Use of a drug or medication may be considered a chemical restraint if it is a not being used as a standard treatment for the patient's medical or psychiatric condition, and results in restricting the patient's freedom of movement, including sedation. The use of PRN orders for drugs or medications is only prohibited when a drug or medication is being used as a restraint. This does not apply to the clinical treatment of patients who are suffering from serious mental illness and who need therapeutic doses of medication to improve their level of functioning so that they can more actively participate in their treatment.

CHEMICAL RESTRAINTS ARE NOT PERMITTED AT GARLAND BEHAVIORAL HOSPITAL.

The hospital Policy on the Levels of Observation dated 09/2017 reflected, "It is the policy of GBH to use Levels of Observation based on the assessment of patient's need for observation in order to provide for safety ...A state of increased watchfulness, that is initiated through assessments of patient's words and actions that indicates that he/she may be ...potentially dangers ...and/or confused/disoriented."

The hospital failed 1 of 1 Patient, (Patient #1) by using a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedome of movement and is not a standard treatment or dosage for the Patient's condition.

Findings Included

Through record review the hospital Physician's Orders 10/22/2019 at 1740, "Zyprexa 5mg IM, Benadryl 25mg, IM ...psychosis EPS prev."

Through record review the hospital Restraint/Seclusion Order/Documentation Record, "At 1820, Pt. is lying down on the floor in the hallway after a fall incident not related to the restraint ...Pt. is confused, oriented x1, unable to give coherent answers ...Pt. was angry and threatening nurse she would 'get' her for giving her a shot. Yelling at other staff involved."

Through record review the hospital reported, "Hospital Findings, "Dosage for emergency medications was not best practice in light of the patient's age and medical history, Staff reported EM medication was given in patient room did not utilize bed alarm to aid with monitoring patient. Also reported during medical code no simple O2 masks were available and the mask they had was not working properly."

Policy
The hospital Policy on Proper Use of Restraint and Seclusion dated 09/2008 reflected, "It is the policy of Garland Behavioral Hospital to support each patient's right to be free from restraint or seclusion and therefore limit the use of these interventions to emergencies in which there is an imminent risk of a patient physically harming him/herself or others. Restraint or seclusion may only be used in emergency situations and when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm. Restraint or seclusion requires an order from physician. In situations that the need for a restraint or seclusion intervention occurs so quickly that an order cannot be obtained prior to the application of restraint or seclusion, the order must be obtained by a Registered Nurse either during the emergency application of the restraint or seclusion, or immediately after the restraint or seclusion has been applied. Restraint and seclusion use will not be based on history of past use or dangerous behavior, as a convenience for staff, or a substitute for adequate staffing appropriate to the severity of the behaviors, and the patient's chronological and developmental age, size gender, physical, medical and psychiatric conditions, and personal history including any history."

Medication (Chemical) Restraint: The administration of a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. Non-standard use alone does not make the use of a drug a restraint. If the non-standard use of the drug did not reduce the patient's ability to deal with the world around them, nor did the use of the drug reduce the patient's ability to move, the drug's use would not be a drug used as restraint. Whether or not an order for a drug or medication is PRN or a standing-order does not determine whether or not the use of that drug or medication is considered a restraint. Use of a drug or medication may be considered a chemical restraint if it is a not being used as a standard treatment for the patient's medical or psychiatric condition, and results in restricting the patient's freedom of movement, including sedation. The use of PRN orders for drugs or medications is only prohibited when a drug or medication is being used as a restraint. This does not apply to the clinical treatment of patients who are suffering from serious mental illness and who need therapeutic doses of medication to improve their level of functioning so that they can more actively participate in their treatment.

CHEMICAL RESTRAINTS ARE NOT PERMITTED AT GARLAND BEHAVIORAL HOSPITAL.

The hospital failed 1 of 1 Patient (Patient #1), by a registered nurse must assign the nursing care of each patient to other nuring personnel in accordance with the patient's need's and the specialized qualifications and competence of the nursing staff available.

Findings Include:

Through interview with Staff #1 it was reported, "this incident happened on the unit and after it took place all the staff went to debrief the incident that took place. The supervisor on duty failed to assign a staff member to remain with the patient and monitor the patient closely after the patient received Emergent Medication.."

Through record review, "The hospital Code Blue/Medical Emergency Documentation dated 10/22/2019 reflected, "Pt. found on the floor on the hallway. Screaming for help. Pt hit head and observe stitch on. Left forehead. Medical alert initiates 911 call. Pt. sent out. Staff #2 notified." "What could have been done differently? 'We should never leave the patient alone after the emergent med was given especially when the pt. was confused and using wheelchair.'"

Through record review the hospital failed to follow its own Policy, "The hospital Policy on the Levels of Observation 09/2017 reflected, "It is the Policy of GBH to use levels of Observation based on the assessment of patient's needs for observation in order to provide for safety, security and interactions ...A Level of Observation, 'A state of increased watchfulness, that is initiated through assessment of patient's words and actions that indicates that he/she ...potentially dangerous ...and/or confused/disoriented.'"

Policy

Medication (Chemical) Restraint: The administration of a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. Non-standard use alone does not make the use of a drug a restraint. If the non-standard use of the drug did not reduce the patient's ability to deal with the world around them, nor did the use of the drug reduce the patient's ability to move, the drug's use would not be a drug used as restraint. Whether or not an order for a drug or medication is PRN or a standing-order does not determine whether or not the use of that drug or medication is considered a restraint. Use of a drug or medication may be considered a chemical restraint if it is a not being used as a standard treatment for the patient's medical or psychiatric condition, and results in restricting the patient's freedom of movement, including sedation. The use of PRN orders for drugs or medications is only prohibited when a drug or medication is being used as a restraint. This does not apply to the clinical treatment of patients who are suffering from serious mental illness and who need therapeutic doses of medication to improve their level of functioning so that they can more actively participate in their treatment.

CHEMICAL RESTRAINTS ARE NOT PERMITTED AT GARLAND BEHAVIORAL HOSPITAL.

The hospital Policy on the Levels of Observation 09/2017 reflected, "It is the Policy of GBH to use levels of Observation based on the assessment of patient's needs for observation in order to provide for safety, security and interactions ...A Level of Observation, 'A state of increased watchfulness, that is initiated through assessment of patient's words and actions that indicates that he/she ...potentially dangerous ...and/or confused/disoriented.'"

The hospital Failed 1 of 1 Patient (Patient #1), The physican orders were written and acted upon without providing patient safety, of drugs and biologicals must be controlled and distriuted with applicable standards of practice.

Findings Include:

Through record review, "The hospital Medical Executive Committee, November 4, 2019 reflected, "Seclusions & Restraints ...Falls Emeds within 72 hours is too long of time frame for measuring effect of med on fall ...Patient non-compliance with safety commands attributed to 63% of falls ...Staff #3 completed FPPE on Staff #2 for geriatric fall with fracture ...Noted observation regarding use of anticholinergic and antipsychotic medications that may have contributed to fall potential."

Through record review, "The hospital Medical Executive Committee, November 4, 2019 reflected, "Training, CEO presented training on 'BEERS LIST' Evidenced Based prescribing practices for elderly. Staff #3 discussed limiting use of Ativan/Benzo in elderly, but preferable to use of anticholinergics. Staff #3 discussed limiting use of antipsychotics in elderly ...Staff #$ discussed availability to consult on medication regimes related medical issues and interactions."

Policy

Medication (Chemical) Restraint: The administration of a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. Non-standard use alone does not make the use of a drug a restraint. If the non-standard use of the drug did not reduce the patient's ability to deal with the world around them, nor did the use of the drug reduce the patient's ability to move, the drug's use would not be a drug used as restraint. Whether or not an order for a drug or medication is PRN or a standing-order does not determine whether or not the use of that drug or medication is considered a restraint. Use of a drug or medication may be considered a chemical restraint if it is a not being used as a standard treatment for the patient's medical or psychiatric condition, and results in restricting the patient's freedom of movement, including sedation. The use of PRN orders for drugs or medications is only prohibited when a drug or medication is being used as a restraint. This does not apply to the clinical treatment of patients who are suffering from serious mental illness and who need therapeutic doses of medication to improve their level of functioning so that they can more actively participate in their treatment.

CHEMICAL RESTRAINTS ARE NOT PERMITTED AT GARLAND BEHAVIORAL HOSPITAL.