HospitalInspections.org

Based on review of records and interview, the facility failed to identify, develop policy and procedure, and appropriately manage the use of psychotropic medications when used as a behavioral restraint when a patient's behavior placed them at risk of harm to self or others in 4 of 4 charts reviewed (Patient #1, #7, #9, and #10).

Cross-Refer to Tag A0160

Based on review of records and interview, the facility failed to identify, develop policy and procedure, and appropriately manage the use of psychotropic medications when used as a behavioral restraint when a patient's behavior placed them at risk of harm to self or others in 4 of 4 charts reviewed (Patient #1, #7, #9, and #10).

Findings:

On 5-14-2019, a list of patients who had received psychotropic medications given Intramuscularly (IM - injected into a muscle) or Intravenously (IV - injected into a vein) was provided by the hospital pharmacy department. A sample of patients who had received Haldol or Geodon injections was reviewed.

Patient #1

Patient #1 was admitted on 5-1-2019 and was still in the hospital at the time of the survey.

Patient Physical Therapy records indicated that the patient was performing task on 5/3/2019 and 5/6/2019 with minimal assistance and supervision. Nursing notes on 5/6/2019, up until 1720 (5:20 PM) do not indicate any problems with patient behaviors or confusion.

Nursing note at 1940 (7:40 PM) stated, "Receive pt in be confused, not easily redirected, pt pulling at telemetry + CVL [telemetry is used to monitor the patient's heart and CVL is a central venous line that is inserted into a large vein for medication administration]. Pt placed back in bed + [illegible] to stay for safety, need met. HOB [head of bed] [symbol for up] bed locked in position, SR [side rails] up x 4, bed alarm set + call light in reach." At 2330 (1130 PM), the nurse noted, "[Physician] notified upon rounds of patient increased confusion + spouse's concerns, prn [as needed] ordered + given, 0 other needs." At 0438 (4:38 AM), the nurse noted, "pt attempting to get OOB [out of bed] + pulling at lines + CVL. prn given IVP, 0 other needs."

Review of physician orders on 5/6/2019 show that the physician wrote an order at 23:17 (11:17 PM) for Geodon, 10 milligrams (mg) to be given IM every 8 hours PRN (as needed) for agitation. The nurse wrote a verbal order for Lorazepam, 1 mg to be given every 6 hours PRN for agitation directly under the physician's signed order and squeezed between a signed order written at 11:34 PM by the same physician. The second order from the physician changed the Geodon to a one-time order. The verbal order written by the nurse for Lorazepam was not dated or timed or signed by the physician.

Medication Administration Records (MAR) showed that the patient had been given the Geodon at 2330 (11:30 PM) on 5/6/2019 and the Lorazepam at 04:38 (4:38 AM) on the morning of 5/7/2019.

On 5/7/2019, the day shift nurse notes at 7:20 AM that the patient was "very groggy" after "Ativan early this AM". By 9:20 AM, the nurse noted the patient was "more alert and awake".

Physical Therapy Treatment Record on 5/7/2019 at 2:45 to 3:15. Record indicated patient needed minimal assistance (Performs 75% to 99%). Note from Physical Therapy: Patient to gym for above treatment. Patient with increased confusion but able to follow instructions without difficulty, some increased weakness noted with gate, lower extremities flexed. Continue plan of care.

At 7:15 PM, the night shift nurse noted that the patient was placed back in bed with the HOB up, bed locked in the low position, all 4 side rails up, and the bed alarm set. At 0005 (5 minutes after midnight) the nurse charted, "Pt removing telemetry, has removed CVL drsg [dressing] + sitting through side rails. Pt assisted to BSC [bedside commode] with difficulty due to being weak + placed back to bed. Pt continues to attempt going over side rails, prn for agitation given, CVL drsg change completed."

The MAR shows that lorazepam 1mg IV Q6 hours as needed for "anxiety" was given on 5/8/2019 at 0005 95 minutes after midnight). The order had been written for the indication of agitation.

Physical Therapy Treatment Record on 5/8/2019 at 10:05 to 10:28. Records indicated patient needed moderate assistance (Performs 50% to 74%). Note from Physical Therapy: Patient transferred out of bed to wheelchair with moderate assistance. Patient unable to awaken fully to participate, returned to bed with moderate assistance.

Nursing notes for the morning of 5/8/2019 show that the nurse was paged to the gym at 10:30 AM by Physical Therapy due to the patients change in condition. The nurse assessed the patient, notified the physician of the change in condition, and the patient was transported by ambulance to the nearest hospital emergency room for evaluations of symptoms for possible stroke "facial droop and lethargy". Patient was cleared of a stroke, his condition improved, and he was transferred back to Post Acute Medical Specialty Hospital later that evening.

An interview was conducted with Staff #7, who was his nurse on 5/8/2019. Staff #7 stated that was her first day with the patient during this admission. She had cared for him on previous admissions. Staff #7 stated he had a recent history of stroke and was concerned that his symptoms could be more than medication side-effects. Staff #7 stated, after speaking to the physician the decision was made to transfer to the local emergency department for patient safety. Staff #7 stated, it was normal for the patient to attempt to get out of bed. Staff #7 stated he did that on his previous admissions and had a low bed with floor mats.

An interview was conducted with Staff #5 who was caring for Patient #1 on 5-14-2019. When asked how agitation was defined and when she would give medications for agitation, Staff #5 stated, when the patient swings, bites, kicks, curses, or pulls at lines.

An interview was conducted with Staff #1 on 5-14-2019 at 1:04 PM. Staff #1 was asked the same question. Staff #1 stated, when a patient was pulling at lines, tubes, or was a threat to harm themselves or others. Staff #1 was asked how anxiety would be assessed for prn medications. Staff #1 stated, she would look for increased heart rate, increased respiration rate, or a patient reporting they were anxious.

Neither Staff #5 or Staff #1 considered medication to control the patient behaviors while agitated as a behavioral restraint. Staff #1 acknowledged that the behaviors listed could be managed with soft wrist restraints, a patient sitter, or other less restrictive interventions.

Review of the chart showed that the medications that were given to Patient #1 were not given to improve his level of functioning so that he could participate more actively in his treatment, but rather to control behaviors of pulling at lines, removing dressings, and getting out of bed. In addition, the patient movement was restricted by the use of 4 bed rails with documented attempts of the patient sitting with his legs through the bed rails and attempting to climb over the bed rails. This inappropriate use of bed rails to keep the patient from exiting the bed placed the patient at increased risk of injury.

Review of Policy and Procedure Subject: Restraints; Publication: NSG46; Revised January 28, 2019 revealed there was no provision for staff to use medications as behavioral restraints when the patient's behavior presented a danger to themselves and others, and when less restrictive measures had been attempted and failed or had been considered and rejected by the physician due to specific conditions. Under the heading, Definitions, the policy stated:

"2. A Restraint is any drug or medication when it is used as a restriction to manage the patient's behavior or restrict the freedom of movement and is not a standard treatment or dosage for the patient's condition.

3. Post Acute Medical does not use chemical restraints"

The policy listed examples of Physical Restraints as "4 side-rails up (except during a transport on a bed or gurney, on seizure precautions or to prevent other involuntary movement, immediately post-procedure or anesthesia, or for safety.)


Patient #7

Patient #7 had been admitted on 3/2/2019 as a Do Not Resuscitate (DNR) with a diagnosis of Acute Respiratory Failure and Pneumonia. The patient expired on 3/4/2019 at approximately 4:30 AM. As part of the hospital review, Physician Staff #11 (who was not involved in the patient's plan of care) conducted a Drug Regimen Review on 3-4-19 at 16:30 (4:30 PM) and determined "No issues found during review" for any "clinically significant medication issue".


Review of the home medication list showed that the patient was on Geodon 20 mg twice a day.

Review of admission orders showed that the physician had ordered Geodon, 10 mg to be given IM every 4 hours PRN for agitation.

Review of the MAR showed that the medication was given on 3/3/2019 at 0045 (45 minutes after midnight on the morning of 3/3/2019. The medication was given again at 0900 (9:00 AM) on 3/3/2019.

Nursing notes from 3/3/2019 were reviewed as follows:

"0045 Geodon 10 mg IM given, will f/u [follow up] for effectiveness. [unreadable] per staff. [unreadable] in SA [sinus arrhythmia] with her increased 190"

"0230 [2:30 AM] Sedate, 0 distress. Geodon effective"

"0705 VSS. [vital signs stable] Resp labored [with] accessory muscle use. LLE [left lower extremity] mottled. Mittens in use to protect lines. Not tied down. F/C [Foley catheter] draining dark yellow urine. Full assessment per flowsheet. Pt not responding to questions. Opens eyes when name is said. Safety precautions in place. 96% O2 sat.

0900 Meds passes per MAR. 0 difficulty at this time. CL [call light] in reach. Resting comfortably @ this time.

1300 VSS. Repositioned. CL in reach. Pt resting quietly with eyes closed."

No notes were found demonstrating how the nursing staff determined the patient was agitated, what was attempted to reduce the agitation prior to medication use, or why a prn psychotropic medication was necessary at those times. Follow-up nursing notes after medication administration indicated that the patient was not participating in her treatment after the medication administrations; but was "sedate" and "resting quietly with eyes closed".


Patient #9

Patient #9 had been admitted on 3-27-2019 with a diagnosis of acute respiratory failure and was still a patient at the time of the survey.

Review of nursing notes indicated that on 4-9-2019 and 4-10-2019, the patient was reported to be having increased change in mental status and hallucinations. The patient had a Computed Tomography (CT) scan of the brain for "Decreased level of consciousness." The scan did not show any abnormalities that would cause this.

Review of nursing notes for 4-11-2019 showed the following:

At 1900 (7:00 PM), the nurse found that the patient had pulled the injection port to the brown port on the triple lumen catheter (a line that goes into a vein with 3 separate connections for administering medications) with approximately 10 milliliters of blood found on the patient and the bed linens. The patient was placed in bilateral soft wrist restraints to protect the patient and keep her from pulling out her central line. A restraint package was found to be initiated.

At 2215 (10:15 PM), the nurse gave medications that had been crushed and placed in chocolate pudding. Oral care was provided. The nurse noted that the patient was appreciative. Stimulation was decreased and the patient relaxed.

At 0040 (40 minutes after midnight on the morning of 4-12-2019), the nurse noted that the patient had her eyes closed at the time and remained undisturbed.

Review of the physician orders for 4-11-2019 at 2249 (10:49 PM), showed that the physician wrote an order for Geodon, 10 mg to be given IM every 6 hours as needed for agitation. This was after the nurse had documented that stimulation had been decreased and the patient had relaxed.

Review of the MAR showed the nurse gave the Geodon on 4-12-2019 at 0005 (5 minutes after midnight on the morning of 4-12-2019. No documentation of an assessment of need for medication was found. No documentation of behaviors that would require the medication to be given was found. The patient was in soft wrist restraints at the time of the medication administration.


Patient #10

Patient #10 was admitted on 4-12-2019 with a diagnosis of respiratory management and pneumonia and was still a patient at the time of the survey.

Review of the MAR showed that the patient had an order for Haldol 5 mg to be given IV every 4 hours as needed for agitation or anxiety starting on 4/13/2019 at 0947 (9:47 AM) with an automatic stop date of 5-13-2019 at 0946 (9:46 AM). The MAR indicated the medication was given at 10:00 AM, 3:05 PM, and 9:00 PM on 4/13/2019

Review of nursing notes showed for 4/13/2019 were as follows:

At 7:30 AM, the nurse noted the patient to be awake, alert, and only oriented to one indicator (does not specify what that indicator is, such as name, day of week, location, time, etc.). The nurse noted the patient was confused and continued to scream out and was adamant about going home. The nurse noted that the patient was receiving 2 liters of oxygen by way of a nasal cannula and no distress was noted.

At 9:45 AM, the nurse noted that the patient was screaming loudly and crying to go home. A new order for Haldol was given by the physician.

At 3:00 PM, the nurse noted that the patient was awake and anxious, crying and yelling. Haldol was given.

At 9:00 PM, the nurse noted that the patient was awake and yelling out. Haldol was given.

The notes did not indicate what less restrictive measures were attempted to calm the patient who had been admitted the day before to a new and unfamiliar location. The notes did not indicate that an attempt to place a sitter with the patient to help calm her and keep her oriented, or her response to such actions.

Review of the MAR for 4-14-2019 showed that Haldol PRN for agitation or anxiety had been administered at 11:20 AM and 10:35 PM.

Review of nursing notes showed that at 11:15 AM, the patient was awake with family at the bedside. The patient was adamant that she was short of breath. Her blood oxygen saturation level was checked and were at 97%, good. Her blood gasses were checked to ensure she was not having a change in carbon dioxide levels in her blood. Those were found to be good. The nurse determined that the shortness of breath was the result of anxiety and administered Haldol.

At 10:35 PM the nurse noted that the patient was yelling out and pulling at her PICC line (an intravenous line inserted into a large vein for administering medication). The PICC line was noted to have blood return in it so the nurse flushed the line with fluid and then gave the PRN Haldol for agitation to prevent the patient from continuing to pull at her lines.


Review of the MARs showed that the patient had not been given the Haldol again until 4-22-2019, 8 days.

Review of nursing notes on 4-22-2019 showed that the patient was scheduled to go to a local hospital for a scheduled test. The nurse charted, "Pt getting ready to transfer to [local hospital] for US [ultrasound]. Pts daughter requested anxiety medication for pt because she states she is going to freak out. See MAR." The medication was given at the daughter's request without any documented assessment that the patient was in need of this medication. No documentation was found of the nurse notifying the physician of the patient's daughter's request and receiving an
order to pre-medicate the patient for the test.

Review of the MARs showed that the patient was given Haldol again on 4-27-2019 at 2:10 PM.

Review of nursing notes on 4-27-2019 at 2:10 PM were as follows: "Pt yelling out, increase confusion noted. PRN Haldol given. Will continue to monitor." No notes were found of an assessment to rule out anything medical or unmet needs that would be the cause of the change in mental status. No notes were found of any less restrictive interventions being attempted.

Review of the MARs showed that the patient was given Haldol again on 4-28-2019 at 8:40 AM.

Review of nursing notes for 4-28-2019 were as follows:

"0700 Received [up] in bed resting quietly, resp. equal + unlabored, 0 distress or needs ...

0842 AM meds given [with] PRN for agitation, 0 other needs"

No notes were found of an assessment indicating that the patient was in any way agitated.

Review of MARs showed that the patient was given Haldol again on 5-4-2019 at 9:10 AM.

Review of nursing notes for 5-4-2019 showed that the nurse documented the morning assessment at 8:00 AM with no mention of any behaviors or symptoms that would indicate the patient was anxious or agitated. The next note was made at 12:00 noon and stated the patient was resting in bed with family at bedside. No documentation was found to indicate why the patient would need an injection of a psychotropic medication.

Review of the MARS showed that the patient was given Haldol again on 5-5-2019 at 12:50 PM.

Review of nursing notes for 5-5-2019 were as follows:

"1250 Pt. confused and agitated [with] family at bedside - Haldol IM given as ordered. Will cont to monitor"

The order for Haldol was for it to be given IV, not IM. No evidence of an order to change the route of administration was found. No documentation was found that showed any interventions that were less restrictive were attempted.

Review of the MARS showed the patient was given Haldol again on 5-6-2019 at 8:55 PM.

Review of nursing notes for 5-6-2019 were as follows:

The nurse charted the initial shift nursing assessment at 7:20 PM, noting that the patient was pleasantly confused. At 8:55 PM, the nurse charted, "HS [before bedtime] meds given, 0 other needs" No assessment was found that documented a need for a psychotropic medication to be given. No documentation of behaviors or less restrictive interventions attempted was found.

Review of MARS showed the patient was given Haldol again on 5-10-2019 at 2:00 PM.

Review of the nursing notes for 5-10-2019 were as follows:

1400 [2:00 PM] Screaming & agitated. PRN Haldol given IM R [right] Deltoid [a muscle in the upper arm]. See MAR.

No documentation of an assessment to find out why the patient was screaming or what objective evidence there was that the patient was agitated was found. No documentation of less restrictive interventions that were attempted was found. The order for Haldol was for it to be given IV, not IM. No evidence of an order to change the route of administration was found.

The patient was repeatedly medicated throughout her stay without documented evidence that the medication was warranted and/or that other interventions had been attempted. The patient was given the medication via the wrong documented route (IM instead of IV) on two occasions.