HospitalInspections.org

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

I. Assure that a physician order was obtained and a 1 hour face to face evaluation was completed and documented for 3 of 3 patients whose records were reviewed for manual restraint (active sample patient E10 and active non sample patients E19 and E20). These patients were manually restrained for an intramuscular injection, a blood draw, or a staff escort to an off-unit location. Nursing staff on the Sunrise (East) unit reported it was their understanding that a manual hold for less than 5 minutes did not require a physician order or complete restraint documentation. Failure to obtain a physician order for a restraint procedure and assess and document the patient's physical and mental status by a qualified professional within 1 hour of the procedure results in potential danger to patients needing restraint and violates patient's rights to be free from restraint except for the immediate protection of self and others.

II. Ensure that appropriate physician orders for the use of PRN [as necessary] medications were written and implemented for or 5 of 8 active sample patients (W2, W5, W7, W24 and E13). The physician PRN medication orders for these patients failed to provide specific parameters for their use. The orders were written for two different dosing levels and allowed nursing staff to choose what dose of medication to use for a single non-descriptive indication (agitation, anxiety or violence). Ambiguous physician orders encourage nursing staff to function outside of their scope of practice and can result in serious complications for patients as a result of improper medication administration.

Findings include:

I. Lack of physician orders, assessments, and documentations for manual holds

A. Specific Patient Findings

1. Patient E10, admitted 3/31/11, was restrained on 4/7/11 at 7AM.

a. Incident Report

The Incident Report included a descriptive note which read: "Client placed pt arm out [for a blood draw] for lab tech [laboratory technician]. After blood was drawn & before gauze & tape could be placed the client slapped away the tech's hands saying 'You have gonorrhea.' One MHT [mental health technician] then held client's feet and another EMT [sic] held client's hands so gauze & tape could be placed." The Unit Physician signature was by the unit PMHNP (psychiatric mental health nurse practitioner) and dated 4/7/11; no time was noted and no description of the patient's condition was documented.

b. Progress Note

A progress note by the night nurse on 4/7/11 at 7:10 AM stated, "5 min hold. Client agreed to have blood drawn from rt [right] arm for CHS, CBC w/ differential, BUN, Creatinine, & lytes [electrolytes] in her obs [observation] room. Client laid [sic] on bed & extended rt [right] arm & allowed the draw. Tech placed gauze & was reaching for tape when client slapped away her hand saying 'You've got gonorrhea.' Blood oozed from puncture, one CMT [sic] held clients [sic] hands and another EMT [sic] held clients [sic] feet until tech could place tape. No injuries to staff, client or tech. Will continue to monitor for safety & behavior."

c. In an interview on 6/2/11 at 11AM, RN3 reported that she had reviewed the record at the request of the surveyor and found no physician order for the manual hold.

2. Patient E19, admitted 2/24/11, was restrained on 4/5/11 at 7:20AM.

a. Incident Report

A note on the Incident Report stated, "RN spoke w/ [with] client telling her Haldol Dec [decanoate] was ordered for this AM. She could cooperate or else Dr ordered Hands On [manual restraint]. She stated she does not get shots & would not voluntarily cooperative [sic] 3 MHTs held client briefly while RN gave Haldol Dec 150 mgm [milligram] in R [right] hip clt [client] has a guardian and guardian OK Haldol Dec." [no signature] The RN signed the incident report on 4/5/11, there was no time noted. The PMHNP signed the form on 4/7/11; no time was noted.

b. Progress Note

A nursing progress note on 4/5/11 at 7:22AM stated, "Medical Hold X 1 min. 0720-0721. [7:20AM to 7:21AM]- Clt [client] informed @ approx 0715 [7:15AM] that she would be getting a Haldol Dec IM [intramuscular] this AM as ordered. 0719 [7:19AM] in clts [sic] room, clt lying on her bed head covered w/a blanket. Again explained MD ordered a Haldol shot, clt stated 'I don't get a shot I don't want one.' Asked clt to please turn over in order for injection to be given, clt stated 'no.' Layed [sic] hands on, assist clt to her L [left] side, Haldol Dec 150mgm given IM in R hip. Clt held approx 1 min 0 [no] injury to clt not from hold."

c. There was no physician order for the manual hold on the medical record. There was no documentation of physical and mental status of the patient within 1 hour of the restraint.

3. Patient E20, admitted 04/06/11, was restrained on 4/8/11 at 10:30AM.

a. Incident Report

A MHT [mental health technician] note dated 4/7/11 at 0700 (7:00AM) on the Incident Report was "Clt [client] was at the tx [treatment] mall next to the office clt [client] saw a male staff in the office and attempted to come into the office to get to the male staff. Clt had taken off her pants before entering the office. staff asked clt not to undress and to not come in the office. Clt continued coming into office. Staff layed [sic] hands on and escorted clt back down to the unit from the time that we layed [sic] hands on it took us 4 minutes to get her to the unit." The RN note on the Incident Report included checks for "Witnessed Incident," and "Reported to MD," and was signed on 4/8/11 with no time noted. The PMHNP also signed with no time noted.

b. Progress Notes

1) A progress note written on 4/8/11 at 10:50AM by the MHT who wrote the incident report above stated, "Taking clothes off. While clt [client] was at tx [treatment] mall standing next to the office clt saw a male staff in the office and attempted to come into the office clt took off her pants outside of the office door and came into the tx [treatment] mall office attempting to go to the male staff. Staff asked clt not to get undressed and to stop when she came into the office. Staff put hands on [means "hold" or manual restraint] and walked clt out of the office where she sat in the doorway, the nurse practitioner was present and talking to the client about not [unreadable] and walking back to the ward. Staff walked clt out towards the elevator to take her back to the ward. Clt sat down several times but would get up and walk a little way before sitting down again. Clt taken back to her ward where she was left sitting in the hall by the pay phones."

2) An RN progress note on 4/8/11 at 11:40AM stated, "PRN. Administered Ativan 2 mg IM and Haldol 5 mg IM per NOW order. (given at 1040)."

c. A Physician Order on 4/8/11 at 10:30AM was "Decrease to Safety Level 1. Haldol 5 mg IM Now with Ativan 2 mg IM Now." There was no order for the manual restraint. There was no documentation of the physical and mental status of the patient within 1 hour of the restraint.

B. Document Review

1. "Blue Mountain Recovery Center/EOCP [Eastern Oregon Psychiatric Center] Policy and Procedures Manual"... "The Use of Seclusion and Restraint PPM# 2.026" effective 02-21-06 includes the following statements:

Page 1: "Overview:"... "d. Significant Procedure Hold is limited to the physical contact initiated by the hospital staff that is required for an involuntary procedure, specifically that is ordered by a member of the Medical Staff..."

Page 2: "Principles: 1. All EOPC [now Blue Mountain Recovery Center] patients have the right to be free from seclusion and restraint, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Seclusion and restraint can be used only: c) When ordered by a physician."

2. Minutes from the 3/23/10 Blue Mountain Recovery Center Nurse's Meeting, provided by the Superintendent (acting DON), included the following statement on page 2: "Effective January 1, 2010 all restraint events are to be reported, even those less than 5 minutes"... "Procedures: All restraints are to have documentation on either a "Seclusion & Physical Restraint Report"...or a "Physical Hold Report"..." Examples: [bold type in document]

(1) When a client is placed in a wall or floor containment or manually held while administering medication, the Physical Hold Report packet (Entry Note, Summary, Incident Report and Physical Hold Report)...needs to be completed.

(2) If the client then goes to seclusion, a Seclusion pack (Entry Note, MTP Care Plan...Flow Sheet, Summary, Incident Report and Seclusion & Physical Restraint Report) needs to be completed.

(3) If staff 'lays hands on' [sic] a client without a floor or wall containment, only a seclusion [sic] packet needs to be completed, but with documentation of a 'Manual Hold' restraint."

C. Interview

1. In an interview on 6/2/11 at 10:40a.m., the Medical Director stated, "Yes, there should be a physician order for a manual hold."

2. In an interview on 6/2/11 at 10:55a.m., Nurse Manager 1 stated, "No orders are written for manual holds which last less than 5 minutes."

3. In an interview on 6/2/11 at 2:30p.m., the Superintendent (acting DON) agreed that a physicians order and complete seclusion/restraint documentation is needed for a manual restraint, including documentation of a face to face evaluation within one hour.

II. Ambiguous Medication Orders

A. Observation

During an observation on 6/1/11 at 11:00a.m. on the Sunset unit, Patient W5 came up to the nurse's station and asked the medication nurse for a prn (as needed) dose of Ativan (anti-anxiety medication), stating to the nurse (RN4), "I'm feeling like I can get agitated and I want some Ativan before I go there." The medication nurse replied "OK, what dose do you want?" Patient W5 stated, "How about 1 milligram?" and the nurse replied "OK."

B. Record Review

1. Patient W2: The Physician's Orders dated 5/21/11 (not timed) included the following ambiguous medication orders: "Lorazepam (Ativan) 1 mg. by mouth every 4 to 6 hours PRN for anxiety and agitation." The next line down on the page noted "Lorazepam 2mg. by mouth every 4 to 6 hours PRN for anxiety and agitation." Review of patient W2's Medication Administration Record (MAR) showed that W2 received 2 mg. of Lorazepam once daily as a prn medication from 5/21/11 to 6/1/11. The MAR documentation notes showed that nursing staff identified "nerves" as a reason for prn Ativan for 8 of the 10 days that the medication was administered. "Nerves" was too vague of a term to explain the use of Ativan and may not have been what the physician intended when the order was written for PRN agitation. Ativan does not have an FDA (Food and Drug Administration) approval for the indication of agitation.

2. Patient W5: The Physician's Orders dated 5/12/11 (not timed) noted the following medication orders: "Lorazepam 1-2 mg. po (by mouth) q6h (every 6 hours) prn agitation/violence." Review of the MAR showed that patient W5 received Lorazepam either 1 or 2 mg. 2 to 3 times a day between 5/25/11 and 6/1/11. The MAR documentation included the following patient verbalized reasons for requesting the medication: "Met with my lawyer"; "I'm gonna get agitated I feel it"; "Peer intimidating me" and "still wanting to fight." Ativan does not have an FDA approval for the indication of agitation or violence.

3. Patient W7: The Physician's Orders dated 3/22/11 at 9:30a.m. noted "Ativan 1-2 mg. q6h prn agitation/insomnia/MSE (mental status examination)." The MAR showed that patient W7 received Ativan either 1 or 2 milligrams nearly every night between 9:00p.m. and 1:30a.m. from 5/2/11 through 5/31/11(20 total doses). The MAR documentation identified "insomnia" as the reason for every administration. Ativan does not have an FDA approval for the indication of insomnia.

4. Patient W24: The Physician's Orders dated 5/24/11 at 11:20a.m., for a 90 day renewal of previous medication orders, included the following ambiguous orders: "Lorazepam (Ativan) 1 mg. by mouth every 6 hours PRN for agitation, psychosis, manic insomnia" and "Lorazepam 2 mg. by mouth every 6 hours PRN for agitation, psychosis, manic insomnia." Review of the MAR showed that patient W24 received either 1 or 2 milligrams of Ativan on a daily basis between 5/2/11 and 5/31/11. All of the doses were for "agitation." The MAR did not explain why 1 milligram was chosen instead of 2 milligrams and vice versa. Ativan is not FDA approved for the indications of manic insomnia, psychosis or agitation.

5. Patient E13: Physician's Orders dated 5/12/11 at 8:45p.m. noted the following: " May give Thorazine (antipsychotic) 100-200mg po q6 hours for agitation." The MAR for Patient E13 noted that the patient received 5 doses of either 100 or 200mg of Thorazine between 5/12/11 and 5/15/11. All 5 doses were given for "yelling and jumping." These are vague reasons for the use of Thorazine and may not reflect the intended use of the drug when the physician wrote the order.

C. Interviews

1. In an interview on 6/1/11 at 11:30a.m. with the RN4, the issue of "range of dose" of physician medication orders was discussed. RN4stated, "Patients can ask for how much med they need as a way to manage their own care."

2. In an interview on 6/1/11 at 1:30p.m., RN2 was asked about ambiguous medication orders. RN2 replied, "We use our judgment and experience to decide how much medication to give patients." When asked whether variation among nursing staff was a possible problem with dose range orders, RN2 said "Different nurses could make different choices given the situation."

3. In an interview on 6/1/11 at 3:45p.m., Patient W5 stated, "I choose my doses of Ativan all of the time; that's what I like about being here. I don't have to argue with the nurses about how I feel or if I need the medication or not."

4. In an interview on 6/2/11 at 9:30a.m., the Medical Director was shown examples of ambiguous medication orders. He agreed with the findings and stated, "I'm glad you found this problem; this is a practice we need to stop."

5. In an interview on 6/2/11 at 3:30p.m., the Chief Executive Officer, who was also the superintendent and acting Director of Nursing, was shown evidence of the ambiguous medication orders. She agreed with the findings and stated, "This has been a problem that we noticed happening."