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Based on medical record review, interviews, and Hospital # 1's policy/procedure, staff failed to follow the facility's policy prior to physically restraining Patient Identifier (PI) # 1.
On 12/22/10 at 1345, PI # 1, an elderly male patient, allegedly hit a staff member and was manually restrained (in a chair) while an injection of antipsychotic medication was administered.
A Restraint Order Form, completed at 2030 (six hours and 45 minutes after the manual restraint was implemented) staff documented that two physical restraints, an enclosure/vail bed and a pelvic restraint, were needed to control or treat PI # 1's physical aggression and personal safety (to prevent PI# 1 from getting out of bed).
Documentation in Hospital # 1's policy/procedure includes specified times regarding examination times, maximum time for the restraint orders, frequency of assessments for aggressive patients, and less restrictive alternatives for behavior managment.
Staff failed to follow the hospital's policy befor using physical restraints to manage PI# 1's "agressive" behaviors.

This deficient practice effected one of ten sampled patients (PI# 1).

Findings Include:

1. PI # 1, an elderly patient, was transferred and admitted to Hospital # 1 on 12/15/10. PI # 1's diagnosis include Status post left hip hemiarthroplasty (12/12/10), secondary to a displaced left femoral neck fracture, and history of Cerebrovascular accident with residual right lower extremity weakness. The transferring hospital (Hospital # 2) documented that postoperatively, PI # 1 exhibited confusion and delusions. Hospital # 2 note PI # 1's rehabilitation potential was "...fair to unknown...due to delirium..."

On 12/14/10, Hospital # 1's Preadmission Screening Form noted that PI # 1 experienced a "...Recent decrease in function with deconditioning." Staff noted that prior to this last fall, PI # 1 was able to ambulate household distances, but family members reported PI # 1 had declined over the past few weeks, and this lastest fracture involved PI # 1's "...good leg."

On 12/15/10, the Nursing Progress Notes include:
1600: PI # is "extremely confused...and combative."
1830: "Pt. lying in bed-confusion noted..taking...clothes off...wants to get out of bed. Talked to daughter concerning getting a Vail bed for... protection in case he gets out of bed. Daughter stated...does not need...she will be staying...for the night."
2340: "Patient's (PI #1) daughter at bedside...pt. is restless and confused..."

On 12/16/10, the physician's History and Physical documents that PI # 1's post admission history and physical "...somewhat changed" as compared to the preadmission screening due to delirium. The physician noted PI # 1's delirium was likely temporary, but may interfere with therapy for several days, until the delirium is cleared. The Functional Status section noted the patient was refusing some simple commands and having "...episodes of delusion." These delusions are not described in the documentation.

On 12/16/10 the Physical Therapy (PT) noted:
At 0800: PI # 1 "Attempted to initiate eval (evaluation). Pt. (patient) very somnolent...unable to fully participate
At 09:30, staff documented in the Nursing Progress Notes that PI # 1 returned to floor from therapy. "...too groggy to participate...pulled all of clothes off."
At 10:00, the Therapy Notes noted the PI# 1 was "...seen for completion of initial eval. Pt. very lethargic...tx'd (transferred) to mat and become completely somnolent-unable to participate."
At 1230, therapy staff noted the patient "...Became combative. Wants pain med (medication)...refuses... spit half of med out. Has become agitated... Will hit at you for coming near..."
At 13:15, Occupational Therapy (OT) noted that PI # 1 "...refused to participate in OT eval..."

On 12/17/10
At 07:30, staff documented a Nursing Progress Note that PI # 1 was "...Sleeping...awakened but falls off to sleep."
At 09:50, the Physician Progress Note: Internal Medicine noted the patient was "...Agitated @ (at) times since surgery. Previous CVA..."
At 10:00, Physical Therapy (PT) documented "...Pt. [patient] unresponsive to 'verbally' - pt. shaken & answered but BP (blood pressure) downward arrow used as symbol for word (decreased) and skin cool to touch-Returned too room..." No BP is documented in the therapy notes.
...Returned to floor from therapy, states cold clammy, not able to participate in therapy because of sluggishness." The physician is documented as being notified and "...med. [medicine] order changed..."

On 12/18/10 at 11:00, the Physician Progress Note: Internal Medicine noted PI# 1 was "...Sedated."
The Physician Progress Note (Rehabilitation) notes include "...Patient agitated overnight...currently sedated."
No 12/18/10 therapy notes for 12/18/2010 were found in the medical record.

On 12/19/10 at 12:00 the Physician Progress Notes:
Internal Medicine noted PI # 11 "...Sedated. Prob (probably) oversedated now..."
The Rehabilitation Physician Progress Notes include: "...Sleeping. Difficult to arouse...Progress in OT (Occupational Therapy): Somnolence..."
At 16:00 the Daily Nursing Assessment noted PI# 1 was Lethargic, confused.
No 12/19/10 therapy notes found in the medical record.

On 12/20/10
At 10:30, the Physical Therapy noted "...Pt. not alert enough for education."
At 12:00, the Nursing Progress Notes note "...Patient (PI # 1) sedated..."
Occupational Therapy noted at 1200 that PI # 1 was "...unable to perform ROM (range of motion)...secondary to inability to follow directions or cooperate..."
At 18:00 the Rehabilitation Physician Progress Note "...sedation and...agitation."

On 12/21/10
At 10:00 the Physical Therapy notes record that PI # 1 was "...constantly keeps eyes closed...not talking appropriately at times..."
At 13:00, Occupational Therapy noted this "...Pt (patient) lethargic. Will not open eyes, follows no commands. Returned to nursing unit-unable to participate..."
At 02:30, the Nursing Progress Notes include: "...Patient was agitated...small skin to R (right) arm was clean and gauze 4x4 on the area due to patient kicking and wanting to get out of bed..."

The Rehabilitation Physician Progress Notes include "...Postoperative day # 9...Progress in PT: 6- step 11, Progress in OT: 1/4 goals met. Progress in cognition: no documentation. Barriers: weakness, endurance, balance, cognition...Continue current treatment plan: yes..."

On 12/22/10
At 10:30, the Internal Medicine Physician Progress Notes include:
"...No c/o (complaint by report...seems less labile or meds (medications) on board..."
At 13:45 the Nursing Progress Notes record the a "...Code Orange called to...gym. Pt. combative, restless, hitting with gait belt clinched in R (right) wrist. Pt. will not let therapists or nurses @ (at) side. Threatens to hit with gait belt if anyone gets near. Haldol 2 mg. IM injected in R thigh..."
At 1410: "Pt. brought back to room with assistance from Maintenance, Therapy and Nsg (Nursing)...transferred back to bed safely with a four man transfer."
At 1915: "Quiet and cooperative..."
At 2030: "Pt. to vail bed without difficulty, cooperative verbalizing appropriately at times..."

The Rehabilitation Physician Orders include: "Vail bed tonight..." The Rehabilitation Physician Progress Note records that PI # 1 exhibited "...Aggressive physical behavior last PM and today...Will arrange geri (geriatric) psychiatric evaluation..."

On 12/22/10 and 12/23/10 two Physical Assessment and Physician Order forms were completed. The forms includes: "...Assessment: Medical condition/clinical issue indicating the need for a protective intervention to prevent the patient from walking/getting out of bed/having access to a medical device:
Observations: (check all that apply)
-impaired memory and /or judgement
- confused, disoriented
- aggressive or destructive behavior
- inability to follow instructions
- gait and /or balance disorder
- danger to self
- danger to others
- attempt to ambulate without required assistance

Less restrictive Alternatives: (check all that apply)
- diversion activities
- increased supervision, monitoring
- self releasing seat belt
- low bed
- upper side rails up for assistance with bed mobility...
- reality orientation
- discontinue unnecessary tubes/treatments
- modify environment to decrease stimulation

Type of Restraint Utilized and Reason:
Reason for Restraint: Unaware of physical limitations
Medical/Surgical Non-Violent
- Pelvic restraints
- Bed Enclosure

There is no time documented to indicate when this 12/22/10 restraint assessment was completed by the registered nurse (RN) or signed by the physician.

On 12/23/10 at "8" (AM/PM not indicated) the Physician Ordered "...Transfer to Hospital...(# 2)..." Beside this order a "Late entry 1/26/11..." (signed by the physician.)
At 09:15 the Nursing Progress Note records "...Pt. transported to (Hospital # 2) via EMS (Emergency Medical Services)...family with patient."

The 12/23/10 Restraint Assessment and Physician Order includes the same assessment, observation, alternatives, and restraint type as noted above. This assessment has no time to indicate when completed by the RN or the physician.

Hospital # 1's Policy and Procedures include a policy entitled:
"...Use of Restraints in a Non-Psychiatric Hospital (Hospital # 1)" has abn effective date of 2/2009, a Form/File Name of 260, and includes:
"...I. Policy: "Hospital # 1 is dedicated to promoting individualized care...to support independence...When these methods prove to be ineffective and the patient is assessed to be at risk for injury to self or others...restraints may be clinically necessary. The need for the use of restraints will be determined only after an appropriate assessment of the patient and evaluation of effectiveness of non-restraint interventions...The requirements are specific to the patient's behaviors necessitating the use of restraints."

"A comprehensive assessment of the patient, including a physical assessment to identify medical problems that may be causing behavior changes, must determine that the risks associated with the use of restraints are outweighed by the risk of not using restraints...Restraints may only be employed while the unsafe condition continues."

"Definitions: Restraint is the direct application of physical force to a patient, with or without the patient's permission, to restrict his...freedom of movement. The physical force may be any human, manual method, physical or mechanical device...equipment or a combination thereof that immobilizes or reduces the ability of the patient to move his...arms, legs, or head freely. Restraint has the potential to produce serious consequences, such s physical or psychological harm, loss of dignity, violation of individual rights, and even death..."

"A drug used as restraint is medication used as a restriction to manage the patient's behavior or restrict the patient's movement, and is not a standard treatment or dosage for the patient's medical or psychiatric condition..."

Types of Restraints:
"Medical/Surgical: Restraints applied...in a non-psychiatric setting....for patients that require intervention to promote health...and patient safety..."

"Behavioral (non-psychiatric setting): Restraints applied in non-psychiatric settings for behavioral issues such as violent or self destructive behaviors that jeopardize the immediate physical safety of the patient, staff, others. This use applies ONLY to emergencies when the patient is in imminent danger of physical harm to self, staff, or others and nonphysical techniques have been ineffective or are not viable."

II. Procedure
A. "Restraints may only be initiated after care assessment of the patient and a determination that alternatives have proven to be ineffective or pose greater safety threat than the use of restraints."

The procedure for violent/self destructive behavorial issues includes:
1. Assessment every four hours by LIP (Licensed Independent Practitioner or RN);
2. Continuous in person monitoring...
3. Requires LIP in person assessment every eight hours for adults...
4. Within one hour a face to face evaluation will be conducted by the LIP (or specially trained RN with immediate notification of the LIP)...documentation must...include findings from the physician face to face assessment supporting the continued use os restraints.
5. Order renewal every four hours...
6. Examination by LIP within one hour of application...evaluation must include the patient's immediate situation...reaction to the intervention, the patient's medical and behavioral condition and the need to continue the intervention...
7. Monitoring every 15 minutes through observation, interaction, direct examination...
8. Documentation of monitoring results every 15 minutes...
9. When the risks identified during the assessment no longer exist, the restraint is to be removed...

Interviews
On 1/25/11 at 1615, Employee Identifier Number, (EI#) 1, the Director of Therapy, said PI # 1 suddenly became aggressive, during the afternoon of 12/22/10, and hit an Occupational Therapist in the head with a buckled gait belt. According to EI # 1, this gait belt did not belong to the hospital and PI # 1 would not release the belt. EI# 1 stated that PI # 1 said, " I don't want to hurt you. I'm using it as a weapon." According to EI # 1, the patient became increasingly agitated, the gym was cleared of patients, and a Code Orange was called. EI # 1 said PI # 1 was "held therapeutically" while an injection (documented as an antipsychotic medicine) was administered. This witness recalled that PI # 1 was calm 30 minutes after the injection, enabling staff to pull the patient up in his wheelchair and staff returned PI # 1 to his room and transferred the patient to bed. EI # 1 reviewed the documentation with the surveyor and verified there is no written documented description of this incident by the therapist allegedly hit by PI # 1, this therapist documented the word combative as the reason for PI # 1's missed OT session.

EI # 2, the Nurse Manager, recalled during an interview on 1/25/2011 at 1630, responding to the "Code Orange" (a code indicating a patient is displaying out of control behavior) on 12/22/10 around 1345. EI# 2 recalled observing PI # 1 in the therapy room alone, except for staff. PI # 1 had a pelvic restraint in hand and would not let staff near. EI # 2 stated that a senior Occupational Therapist (OT) was talking to PI # 1, trying to get PI # 1 to release the restraint. PI # 1 told everyone to get away and had already hit another Occupational Therapist. EI # 2, recalled PI # 1 was kicking, screaming, and talking about war during the incident. EI # 2 explained that multiple staff respond to a code, and described the staff responding as a team. This responding team includes members nursing, therapy, and maintenance staff. When staff members arrive they approached PI # 1 as a team, and each staff member grasped and held one of PI #1's extremities and as an injection of Haldol (antipsychotic medication) was administered. EI# 2 states after receiving the injection, PI # 1 "became much calmer" and released the belt. According to EI # 2, PI # 1 was transported via wheelchair to his room, accompanied by four staff members, who lifted PI # 1 from his wheelchair into the bed.

EI # 3, the Occupational Therapist (OT) allegedly hit by PI # 1, was interviewed on 1/27/2011 at 9:15 AM. EI # 3 described the 12/22/10 incident that occurred during the 10:00 session. According to EI# 3, PI # 1 followed simple commands, was alert and oriented to person and time, and was able to follow simple commands (for the first time during hospitalization), and exhibited no aggressive behavior.
When PI # 1 returned to therapy around 13:00 or 13:30, EI # 3 recalled PI # 1 saying that the footrest (on the wheelchair) needed to be adjusted. EI # 1 stated she was bending down to adjust the footrest when PI # 1 struck her in the head with a cloth gait belt that had a metal clip on the end of the belt. According to the EI# 3, the patient's (PI # 1) eyes got big and he stated, "It wasn't me. I didn't do anything." When asked if anyone witnessed this incident, EI # 3 stated, No, as back turned at the time. She recalled that PI # 1 "looked like" he was going to strike again and she asked the patient to give her the belt, but the patient refused. According to EI# 3, therapy staff cleared the gym (of other patients) and "...made me leave."

EI # 4 (PI # 1's attending physician) stated during an interview on 1/26/2011 at 0830, that staff thought PI # 1's delirium would improve, based on PI # 1's high level of function prior to surgery. EI # 4 recalled he received three telephone calls, within a sixteen hour period, about PI # 1's increased aggressive behavior. EI # 4 stated PI # 1 hit three staff members.
During a second interview on 1/27/11 at 0820, EI # 4 said PI # 1 was calm at 1700 on 12/22/10 when he was in the patient's room. According to EI # 4, the enclosure/vail bed was ordered between 1700 and 1800 on 12/22/10 due to PI # 1's combative and unpredictable behavior, and to protect the patient and staff. According to EI # 4, PI # 1 tried to get out of bed, hit a pregnant therapist, and "After the violent behavior peaked..." PI # 1 "needed control - enclosure [vail] bed." EI # 4, stated the implementation of the enclosure/vail bed was a "compromise" for the night to protect the patient and staff.

During an interview on 1/282011 at 0915, the EI # 5, Hospital # 1's CNO (Chief Nursing Officer), stated the use of restraints is strictly for medical/surgical issues.

Although there is no documentation in the medical record to indicate PI # 1 continued to exhibit physical aggression after the incident of physical aggression towards staff at 1345 on 12/22/10, the enclosure/vail bed was not discontinued until 12/23/10 at 0915, when PI # 1 was transferred to Hospital # 2.

The enclosure/vail bed was not discontinued when the unsafe conditions identified during PI # 1's assessment no longer existed.

This citation written as a result of the investigation of Complaint AL00023681.

Based on medical record review, interviews and facility policy, Hospital # 1's staff administered Ativan and Haldol to Patient Identifier (PI) # 1's on 12/22/10 at 13:45, after the patient PI # 1 reportedly hit a therapy staff member. Facility staff continued to administer medications to manage and or control PI # 1's behavior (after the 12/22/10 incident) without a thorough
asessment, to determine the reason for the initial incident or identify interventions (other than medications or physical restraints), to manage or control PI# 1's maladaptive behaviors (identified as non specific aggression).
As a result, PI # 1 was unable to fully participate in the multiple therapies that were a integral part of this patient's rehabilitation.

This deficient practice effect one of ten sampled patients (PI # 1).

Findings Include:

On 12/14/10, Hospital # 1 completed a Preadmission Screening Form pending PI# 1 transfer from Hospital # 2 for rehabilitation. Documentation on this Preadmission Screening Form includes:
Onset: Admitted to Hospital # 2 after a fall at home resulting in a femoral neck fracture and left hip hemiarthroplasty. History of CVA (cerebrovascular accident) in 2005 with residual right LE (lower extremity) weakness. "Recent decrease in function with deconditioning." No falls, but near falls. Prior to fall, PI # 1 was able to ambulate household distances. According to the family, PI # 1 has declined over the past few weeks. The fracture is to the patient's "good leg."

On 12/15/10, Hospital # 1 admitted PI # 1, an 82 year old male, as a transfer from Hospital # 2. PI #1's admission diagnoses include Status post left hip hemiarthroplasty (12/12/10) secondary to a displaced left femoral neck fracture, History of cerebrovascular accident and residual right lower extremity weakness. Information with the patient on admission indicate that postoperatively, PI # 1 exhibited confusion and delusions and the patient's rehabilitation potential is documented to be "fair to unknown...due to delirium."

On 12/15/10 at 16:00 the Nursing Progress Note records that PI # is "extremely confused...and combative." MD contacted.
At 1630: "Ordered medication given."
At 1830: "Pt. lying in bed-confusion noted..taking...clothes off...wants to get out of bed. Talked to daughter concerning getting a vel bed for...protection in case he gets out of bed. Daughter stated...does not need...she will be staying...for the night."
At 2340: "Patient's (PI #1) daughter at bedside. Pt's (patient's) daughter request for patient to receive another dose of Ativan and Haldol IM because pt. is restless and confused. MD notified of pt (patient) request and ordered Ativan 1 mg. IM and Haldol 1 mg. IM. Pt. settled down and rest for an hour after injections..."

On 12/16/10, the physician noted in the History and Physical (dated 12/1/6/10) that PI # 1's post admission history and physical is "somewhat changed" as compared to the preadmission screening due to the patients' delirium. The physician documents PI # 1's delirium is likely temporary, but may interfere with therapy for several days until the delirium is cleared and the medications are adjusted.
Functional Status: PI # 1 is refusing some simple commands as far as taking medications. PI # 1 is having "episodes of delusions." These delusions are not described in the documentation.

On 12/16/10
At 08:00, the Therapy Notes / Physical Therapy (PT) noted "...Attempted to initiate eval (evaluation). Pt. (patient) very somnolent...unable to fully participate..."
At 0930, the Nursing Progress Notes record that PI # returned to floor from therapy. "...too groggy to participate...pulled all of clothes off."
At 1000: the Therapy Notes / Physical Therapy notes record that PI # 1 "... seen for completion of initial eval. Pt. very lethargic...tx'd (transferred) to mat and become completely somnolent-unable to participate."
At 1230, the Nursing Progress Notes record that PI # 1 "...Became combative. Wants pain med (medication), refuses...spit half of med out. Has become agitated...Will hit at you for coming near."
At 13:15, Occupational Therapy (OT) noted "...Pt. [patient] refused to participate in OT eval [evaluation]..."

On 12/17/10
At 00:00 the Nursing Progress Notes include "...SL (slight) agitation, daughter in agreement that pt. should be given Haldol and Ativan...given IM...confused when awake much of the time..." There is no physician order in PI # 1's medical record for the adminsitration of this medication.
At 07:30, the nurse noted PI # 1 was "...Sleeping...awakened but falls off to sleep."
At 09:50, the Physician Progress Note: Internal Medicine document PI # 1 "...Agitated @ (at) times since surgery. Previous CVA (cerebrovascular accident)..."
At 10:00, Physical Therapy (PT) noted "...Pt. unresponsive to verbally - pt. shaken & answered but BP (blood pressure) downward arrow used as symbol for word (decreased) and skin cool to touch-Returned too room..." No BP is documented in the therapy notes.
"...Returned to floor from therapy, states cold clammy, not able to participate in therapy because of sluggishness." The physician was notified and the "med. order changed."

At 10:55, the Physician Orders direct staff to "...Give Haloperidol 2 mg [milligrams] every four hours prn as needed. Give Lorazepam 1 mg. IM [intramuscular] every four hours for severe agitation and delirium as needed. Give Risperidone 0.25 mg. oral twice a day 0800 and noon - hold if sedated." This order was written by an RN (Registered Nurse) as a telephone order from a physician.

On 12/18/10 at 11:00, the Physician Progress Note: Internal Medicine not PI # 1 was "...sedated."
At 11:00 the Physician Orders include "...Increase Risperidal 0.5 mg. @ (at) 0800 and 1200 N (noon) daily - hold if sedated..."
The Physician Progress Note (Rehabilitation) describe PI # 1 as "...Patient agitated overnight...currently sedated."

On 12/19/10 at 12:00, the Physician Progress Notes: Internal Medicine describe PI# 1 as "...Sedated. Prob (probably) oversedated now."
At 12:00, the Physician Ordered "...decrease Ativan 0.5 mg. IM q (every) 6 hours prn (as needed) agitation..."
The Rehabilitation Physician Progress Notes record PI# 1 was "...Sleeping. Difficult to arouse...Progress in OT (Occupational Therapy): Somnolence..."
At 16:00 the Daily Nursing Assessment noted PI # 1 was "...Lethargic, confused..."

On 12/20/10
At 10:30, the Physical Therapy (PT) notes PI # 1 was "...not alert enough for education."
At 12:00, the Nursing Progress Notes noted "...Risperidone held. Patient sedated."
The Occupational Therapy noted (at 1200) the patient was "...unable to perform ROM (range of motion)...secondary to inability to follow directions or cooperate..."
At 18:00, the Rehabilitation Physician Progress Note records "...sedation and ...agitation."
At 19:00, the Nursing Progress Notes record that "...Risperidone 0.5 mg po..." given.

On 12/21/10 at 02:30, the Nursing Progress Note reveals PI # 1 was "...agitated and Ativan 0.5 mg IM...was administered...small skin to R (right) arm was clean and gauze 4x4 on the area due to patient kicking and wanting to get out of bed..."
The Rehabilitation Physician Progress Notes include: Postoperative day # 9...Progress in PT: 6- step 11, Progress in OT: 1/4 goals met. Progress in cognition: no documentation. Barriers: weakness, endurance, balance, cognition. Continue current treatment plan: yes.
At 10:00, Physical Therapy documents that PI # 1 "...constantly keeps eyes closed...not talking appropriately at times..."
At 13:00, Occupational Therapy noted "...Pt (patient) lethargic. Will not open eyes, follows no commands. Returned to nursing unit-unable to participate..."

On 12/22/10 at 10:30, the Internal Medicine Physician Progress Note records "...No c/o (complaint by report...seems less labile or meds (medications) on board..."
At 13:45, the Nursing Progress Notes record that a "...Code Orange called to...gym. Pt. combative, restless, hitting with gait belt clinched in R (right) wrist. Pt. will not let therapists or nurses @ (at) side. Threatens to hit with gait belt if anyone gets near. Haldol 2 mg. IM injected in R thigh..."
1410: "Pt. brought back to room with assistance from Maintenance, Therapy and Nsg (Nursing)...transferred back to bed safely with a four man transfer."
At 1915, staff noted PI # 1 was "...Quiet and cooperative..."

The 12/22/10, Rehabilitation Physician Progress Note: "Aggressive physical behavior last PM and today...Will arrange geri (geriatric) psychiatric evaluation..."

Hospital # 1's Policy and Procedures include a policy entitled:
Use of Restraints in a Non-Psychiatric Hospital (i.e. Hospital # 1)
Effective Date: 2/2009. This policy includes:
"...I. Policy: "Hospital # 1 is dedicated to promoting individualized care...to support independence...When these methods prove to be ineffective and the patient is assessed to be at risk for injury to self or others...restraints may be clinically necessary...the need for the use of restraints will be determined only after an appropriate assessment of the patient and evaluation of effectiveness of non-restraint interventions...The requirements are specific to the patient's behaviors necessitating the use of restraints..."

"A drug used as restraint is medication used as a restriction to manage the patient's behavior or restrict the patient's movement, and is not a standard treatment or dosage for the patient's medical or psychiatric condition..."

The Medication Administration Record records that PI # 1 received Risperidone 0.5 mg (milligrams) po (by mouth) as ordered each evening at 1900. No physician's order for the Risperidone was found in the medical record and hospital staff (interviewed during the survey) were unable to explain how this medication was given without an order. Based on documentation PI #1 received Risperidone (0.5 mg at 19:00) on the following dates: 12/16/10, 12/17/10, 12/18/10, 12/19/10, 12/20/10, and 12/22/10.

Interviews:
On 1/25/11 at 16:15, Employee Identifier (EI) # 1, the Director of Therapy, stated during an interview that PI # 1 suddenly became aggressive during the afternoon of 12/22/10 and hit an Occupational Therapist (EI# 2) in the head with a buckled gait belt. According to EI # 1, this belt did not belong to the Hospital # 1 and PI # 1 would not release the belt. EI # 1 stated that PI # 1 said, "...I don't want to hurt you. I'm using it [the belt] as a weapon..." EI # 1 stated PI # 1 became increasingly agitated and a Code Orange was called and PI # 1 was "...held therapeutically" as an injection was administered.

On 1/25/11 at 16:30, EI # 2, the Nurse Manager, recalled responding to the "Code Orange" and explained that this code indicates a patient is displaying out of control behavior. EI # 2 stated the Code Orange was called on 12/22/10 around 1345. According to this witness, PI # 1 had a pelvic restraint in his hand and would not let staff near. A senior Occupational Therapist (OT) was talking to PI # 1, trying to get PI # 1 to release the restraint. PI # 1 told everyone to get away. EI # 2 said PI # 1 had already hit another Occupational Therapist recalled PI # 1 was kicking, screaming, and talking about war. EI # 2 described staff who responded to the code as the team, and this team includes members of the nursing staff, therapy, and maintenance staff. EI # 2 states the team approached PI # 1. Each member of the team held one of PI # 1's extremities, while an injection of Haldol (antipsychotic medication) was administered.

On 1/26/2011 at 08:30, EI # 4, PI # 1's attending physician, stated during an interview that PI # 1's Risperdal could not be increased because of the resulting sedation. Instead, Haldol and Ativan were used as needed.

On 1/282011 at 09:15, EI # 5, the CNO (Chief Nursing Officer), said that the use of restraints is strictly for medical/surgical issues.


This citation written as a result of the investigation of Complaint AL00023681.

Based on interview and medical record review, the hospital failed to develop and or implement a discharge plan for Patient Identifier (PI) # 1, one of ten sampled patients.
On 12/23/10, PI # 1 was discharged and transferred to another acute care hospital. There is no documentation in medical record regarding a discharge plan and documentation that details PI # 1's discharge and transfer to another acute care hospital (i.e. the name of the accepting physician, involvement of PI # 1's family).

Findings Include:

Medical Record Review:
On 12/15/10, Hospital # 1 admitted PI # 1, an elderly male, as a transfer from Hospital # 2 with diagnoses that include; Status post a left hip hemiarthroplasty (12/12/10), secondary to a displaced left femoral neck fracture, complicated by a history of cerebrovascular accident and residual right lower extremity weakness. PI 1's medical record indicates that postoperatively, PI # 1, exhibited confusion and delusions.

The Physician Progress Note, dated 12/22/10 at 1700 includes:
"...Will arrange Geri Psychiatric Evaluation."

The Physician's Order, dated 12/22/10 between 1700 and 1800, documents: "...Family will make arrangements for Geri Psychiatric Hospital Admission at Hospital...(# 2)."

On 12/23/10, the Physician Order at 8 (unable to determine if AM or PM) directs "...Transfer [PI # 1] to Hospital...(# 2)." A "Late entry 1/26/11" documented beside this 12/23/10 is signed by the attending physician with no additional notations.

On 1/26/11 at 08:30 and 1/27/2011 at 08:20, Employee Identifier (EI) # 4, the attending physician for PI # 1, stated he (doctor) discussed the need to transfer PI # 1 with the patient's daughter on 12/22/10. EI # 4 stated the transfer was medically necessary for PI # 1 to receive Geriatric Psychiatric treatment/hospitalization. EI # 4 said that he told PI # 1's daughter that he talked with hospital administration (a Nurse Manager and Therapy Director) and it was agreed that transfer was appropriate for PI # 1. The patient's daughter declined to a transfer to Hospital # 3, a faciltiy suggested by EI # 4. According to EI# 4, the PI # 1's daughter asked that PI # 1 go to Hospital # 2, where her (daughter's) husband, a physician. knew three physicians who specialized in psychiatry. EI # 4 stated he requested that PI # 1's daughter have her husband (the physician) call, so they could arrange the transfer to the hospital of her (daughter's) choice. EI # 4 stated he thought everything was fine when he left the patient's room on 12/22/10. EI # 4 stated PI # 1 needed more supervision than was available at Hospital # 1 and when a physician from Hospital # 2 (not PI # 1's daughter's husband) called, within thirty minutes after he talked with the PI #1's daughter, he discussed the transfer with PI # 1. The physician at Hospital # 2 agreed to accept PI # 1, and the patient was transferred on 12/23/10. EI # 4, he reported this discussion and the plan to transfer PI # 1 to Hospital # 1's Case Manager. When asked about the use of the vail bed, EI # 4, stated the implementation of the Vail enclosure bed was a "compromise" for the night to protect the patient and staff.

On 1/26/2011 at 1120, the Complainant was interviewed. The complainant states that prior to 12/22/10, she was contacted by a Case Manager who suggested the family consider a nursing home for PI # 1. The complainant was very upset about this suggestion. She discussed her concern with PI # 1's physician who stated a nursing home was not being considered. The plan was to continue to adjust PI # 1's medications.
On 12/22/10, after being informed of PI # 1's alleged aggressive episode in therapy, the complainant reportedly asked to speak to the Attending Physician. According to the complainant, on 12/22/10 the physician came to PI # 1's room and said, "They're (MD defined as Administration ) not going to let me keep him (PI # 1). They've gotten calls from Physical Therapy. I said I need to call my husband. He (Attending) said you don't understand. He has to go tonight." The complainant reports she questioned this decision and told the physician she was aware a review of this decision by a third party was an option. Allegedly, the physician said if he, "Could smooth it out with Administration," she (PI # 1's daughter) would have to agree to place PI # 1 in a special bed for the night. The complainant reports her husband, PI # 1's primary care physician, arranged the transfer, without assistance from Hospital # 1.

On 1/26/11 at 16:20, EI # 7 (Hospital # 1's administrator) denied being contacted by PI # 1's Attending Physician (EI # 4) about PI # 1's discharge. EI # 7 stated he was not aware of this issue prior to PI # 1's discharge.

On 1/27/2011 at 9:15 AM, EI # 3 (the Occupational Therapist (OT), allegedly hit by PI # 1) denied any knowledge of plans to send PI # 1 to another facility. EI # 3 stated, "...I thought we were adjusting medications."

This citation written as a result of the investigation of Complaint AL00023681.