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Based on the hospital's policy review, medical record review and staff interview, the hospital staff failed to document restraint use in the patient's plan of care in 1 of 2 sampled restrained patients with physical restraints (#15).

The findings include:

A review of the hospital's policy and procedure "Protective and Behavioral Restraints and Seclusion" (reviewed 12/2009) revealed that "An entry is made on the interdisciplinary problem list as potential for injury or other appropriate problem statement."

A closed medical medical review for patient #15 a 59 year old male, revealed that the patient was admitted to the hospital on 05/15/2010 through 05/17/2010 with a diagnosis of "Congestion, Dyspnea and Hypertension" in the hospital's intensive care unit. Further documentation in the medical record revealed that the patient was admitted to the intensive care unit for "drug overdose and alcohol intoxication." The documentation revealed that the patient had a documented telephone order by a registered nurse from a physician as "4-point restraint" on 05/15/2010 with no time. Further documentation in the patient's medical record revealed another order for restraints on 05/15/2010 at 1010 with 4 point restraints to prevent harm to self or others. The documentation revealed that the restraint orders never were time-limited for up to 4 hours in length by the patient's physician. The documentation further revealed that the patient was let out of restraints on 05/16/2010 at 0945 when he left the hospital against medical advice. The review of the patient's plan of care in the medical record revealed that no documentation was found where the nursing staff modified or documented the patient's restraint use from 05/15/2010 through 05/16/2010.

An interview on 06/23/2010 at 1230 with the hospital's nursing administration revealed that the patient did not have modification done to his plan of care regarding restraints. The interview also revealed that the hospital's policy does not really include the guidelines that requires restraints to be included in the plan of care.

Based on the hospital's policy review, medical record review and staff interview, the hospital's nursing staff failed to obtain a physician's restraint order in 1 of 1 sampled patients physically held for forced medications (#2).

The findings include:

A review of the hospital's policy and procedure "Protective and Behavioral Restraints and Seclusion" (reviewed 12/2009) revealed that "Any method of physically or chemically restricting a person's freedom of movement, physical activity, or normal access to his/her body, from which the person cannot easily remove himself is defined as a restraint." The policy further revealed "When the physician, LIP (Licensed Independent Practitioner), medical assistant or advance practice registered nurse responsible for the patient's care is not immediately available to assess the patient and determine the need for restraint, an RN may assess the patient and determine that application of restraint is indicated. The written and/or verbal order of the physician and/or LIP, or other qualified professional is obtained at the earliest possible opportunity, but no later than one hour after the initial use of restraint."

A closed medical record review on 06/22/2010 for patient #2, a 52 year old female, revealed that the patient was admitted to the hospital's behavioral health unit under involuntary commitment on 04/17/2010 with a diagnosis of Major Depression, Schizoaffective and Bipolar Disorder" until 04/27/2010 when she was discharged from the hospital. Review of the patient's medication administration record and progress notes by the hospital's registered nurse (nurse #2) revealed that the patient became "hostile and very loud screaming and yelling" on 04/22/2010 at 2045. The documentation revealed from nurse #2 that the patient became angry and refused her medications and fingerstick blood sugar check then getting more loud and hostile. Further review of the documentation by the nurse revealed "Agitated I gave her Haldol (anti psychotic medication) and Ativan (anti anxiety medication) injection. Patient was assaulting me while __(illegible documentation)." The review of the patient's medication administration record revealed that nurse #2 administered the medications Ativan 2 milligrams intramuscularly on 04/22/2010 at 2115 and Haldol 5 milligrams intramuscularly on 04/22/2010 at 2116 both in the right vastus laterallus thigh. No documentation was found in the medical record that a physician's order for restraint of the patient was obtained or that a forced medication was administered by the nursing staff to the patient. No documentation was found that the patient's physician was notified by the nursing staff of the forced medication administrations.

An interview on 06/23/2010 at 1045 with nurse #2 revealed that the nurse did administer forced medications to the patient on 04/22/2010. The interview revealed "The patient became mad over her telephone use and went off about the phone. She would not settle down and we gave Haldol and Ativan. I put my body against her with her against the wall and gave the medications in her thigh. I do not remember if she had pants on or not. I would have given the medication injection through her pants if she did have them on."

An interview on 06/23/2010 at 1025 with registered nurse (nurse #3) that assisted nurse #2 with the forced medication administration to the patient on 04/22/2010, revealed that the patient was making lots of noise at the time the medications were given. The interview revealed, "I remember us mixing the Ativan and Haldol together and gave her one shot." The interview revealed that the nurse did not remember anything else specific to the administration of the medications on 04/22/2010.

An interview by telephone on 06/23/2010 at 1225 with the patient's attending physician revealed that she did not ever give or receive a call from the nursing staff in order to force medications on the patient. The interview revealed that the physician was aware of the administered medications, but was not aware of the staff leaning on her against the wall.

An interview with the behavioral health director on 06/23/2010 at 1059 revealed that she did not know of any forced medications given to the patient. "I was not aware of the patient being held against the wall by the nurse leaning on her." The interview revealed that the hospital did not have any forced medication policies in place.

Based on the hospital's policy review, medical record review and staff interview, the hospital staff failed to obtain a time limited order of up to 4 hours for a patient with self-destructive behavior in 1 of 2 sampled patients with documented self-destructive behavior (#15).

The findings include:

A review of the hospital's policy and procedure "Protective and Behavioral Restraints and Seclusion" (reviewed 12/2009) revealed "If a patient requires restraint or seclusion longer than 4 hours, the physician must issue a new order for a period up to 4 hours."

A closed medical medical review for patient #15 a 59 year old male, revealed that the patient was admitted to the hospital on 05/15/2010 through 05/17/2010 with a diagnosis of "Congestion, Dyspnea and Hypertension" in the hospital's intensive care unit. Further documentation in the medical record revealed that the patient was admitted to the intensive care unit for "drug overdose and alcohol intoxication." The documentation revealed that the patient had a documented telephone order by a registered nurse from a physician as "4-point restraint" on 05/15/2010 with no time. Further documentation in the patient's medical record revealed another order for restraints on 05/15/2010 at 1010 with 4 point restraints to prevent harm to self or others. The documentation revealed that the restraint orders never were time-limited for up to 4 hours in length by the patient's physician. The documentation further revealed that the patient was let out of restraints on 05/16/2010 at 0945 when he left the hospital against medical advice.

An interview on 06/23/2010 at 1230 with the hospital's nursing administration revealed that the patient did not have any time-limited order for behavioral restraints. The interview revealed that the physician never ordered or reviewed the telephone order for the patient's restraints to be as long as 24 hours in length. The interview did reveal that the patient should have had the restraint order no longer than 4 hours in length.

Based on the hospital's policy review, medical record review and staff interview, the hospital staff failed provide continuous monitoring for patients with behavioral restraint guidelines in 1 of 2 sampled behavioral restrained patients (#15).

The findings include:

A review of the hospital's policy and procedure "Protective and Behavioral Restraints and Seclusion" (reviewed 12/2009) revealed guidelines for behavioral restrained patients as "Initiate continuous observation, and document observations every 15 minutes."

A closed medical medical review for patient #15 a 59 year old male, revealed that the patient was admitted to the hospital on 05/15/2010 through 05/17/2010 with a diagnosis of "Congestion, Dyspnea and Hypertension" in the hospital's intensive care unit. Further documentation in the medical record revealed that the patient was admitted to the intensive care unit for "drug overdose and alcohol intoxication." The documentation revealed that the patient had a documented telephone order by a registered nurse from a physician as "4-point restraint" on 05/15/2010 with no time. Further documentation in the patient's medical record revealed another order for restraints on 05/15/2010 at 1010 with 4 point restraints to prevent harm to self or others. The documentation revealed that the restraint orders never were time-limited for up to 4 hours in length by the patient's physician. The documentation further revealed that the patient was let out of restraints on 05/16/2010 at 0945 when he left the hospital against medical advice. The documentation review of the hospital's "24 hour Restraint or Seclusion Observation" form for the patient dated 05/15/2010 through 05/16/2010 revealed that the patient was monitored every 1 hour by the patient care staff. The review revealed no documentation that the patient was ever monitored while in restraints every 15 minutes by any hospital staff.

An interview on 06/23/2010 at 1230 with the hospital's nursing administration revealed that the patient was not monitored for restraints every 15 minutes. The interview revealed that the staff should have followed the hospital policy for four point restraints by monitoring the patient every 15 minutes.

Based on the hospital's policy review, medical record review and staff interview, the hospital failed to ensure that 1 of 1 sampled patients receiving forced medications was seen within 1 hour by a physician, licensed independent practitioner (LIP) or other qualified professional (#2).

The findings include:

A review of the hospital's policy and procedure "Protective and Behavioral Restraints and Seclusion" (reviewed 12/2009) revealed "A physician, LIP, or other qualified professional must confirm the order within 1 hour by telephone, and the patient must be seen face to face by a physician, LIP, or other qualified professional within 1 hour of the initiation of behavioral restraint physical or chemical."

A closed medical record review on 06/22/2010 for patient #2, a 52 year old female, revealed that the patient was admitted to the hospital's behavioral health unit under involuntary commitment on 04/17/2010 with a diagnosis of Major Depression, Schizoaffective and Bipolar Disorder" until 04/27/2010 when she was discharged from the hospital. Review of the patient's medication administration record and progress notes by the hospital's registered nurse (nurse #2) revealed that the patient became "hostile and very loud screaming and yelling" on 04/22/2010 at 2045. The documentation revealed from nurse #2 that the patient became angry and refused her medications and fingerstick blood sugar check then getting more loud and hostile. Further review of the documentation by the nurse revealed "Agitated I gave her Haldol (anti psychotic medication) and Ativan (anti anxiety medication) injection. Patient was assaulting me while __(illegible documentation)." The review of the patient's medication administration record revealed that nurse #2 administered the medications Ativan 2 milligrams intramuscularly on 04/22/2010 at 2115 and Haldol 5 milligrams intramuscularly on 04/22/2010 at 2116 both in the right vastus laterallus thigh. No documentation was found that the physician on call was notified or saw the patient for a face to face assessment within 1 hour.

An interview with the hospital's nursing administration on 06/23/2010 at 1230 revealed that no face to face was done by the physician for the patient. The interview revealed that the staff did not consider the medication administration a restraint and no order or face to face to done.

Based on the hospital's policy review, medical record review and staff interview, the hospital failed to ensure adequate numbers of nursing staff available to verify dosage of the hospital's designated high- risk/alert medications before administered in 1 of 3 sampled patients receiving hospital designated high- risk/alert medications (#2).

The findings include:

A review of the hospital's policy and procedure "High Alert Medication Policy: Look Alike Sound Alike Medications/High Risk Medications" (revised 07/2009) revealed that the policy was to "Develop a process for managing high-risk or high-alert medications in order to ensure patient safety. The hospital identifies high-risk or high-alert medications used within the facility. All Insulin (diabetic medication) products require a 2nd nurse or healthcare professional to verify the number of units or milliliters of insulin drawn in syringe to be administered to the patient."

A closed medical record review on 06/22/2010 for patient #2, a 52 year old female, revealed that the patient was admitted to the hospital's behavioral health unit under involuntary commitment on 04/17/2010 with a diagnosis of Major Depression, Schizoaffective and Bipolar Disorder" until 04/27/2010 when she was discharged from the hospital. Record review revealed that the patient was ordered the medication "Levemir Insulin 43 units subcutaneous at bedtime" on 04/18/2010 for her secondary diagnosis of diabetes. The review of the medication "Levemir Insulin" revealed that the medication was listed on the hospital's high-risk and alert medication list that required a second verification check by another nurse or healthcare professional.

A review of the patient's medication administration record for the dates of 04/19/2010 and 04/25/2010 revealed that the patient was administered the medication "Levemir Insulin" subcutaneously the hospital's registered nurse (nurse #1) working on the behavioral health unit. The documentation by nurse #1 revealed that she administered the Insulin on 04/19/2010 at 2037 and on 04/25/2010 at 2032 without having a second nurse or healthcare professional verify the dosage of the high-risk/alert medication to the patient. Documentation by the nurse in the medication administration record revealed that "No RN (registered nurse) available to witness" No other documentation was found in the medical record that indicated why the high-risk/alert medication did not have a second verification check.

An interview on 06/23/2010 at 1021 with nurse #1 revealed that she did not have another RN witness patient #2's "Levemir Insulin" on 04/19/2010 and 04/25/2010. The interview with the nurse revealed that she did not have another nurse due to being the only licensed nurse on the behavioral health unit on those dates. The nurse stated "Probably was only me and one CNA (certified nursing assistant) on the unit those nights. We have that most of the time. It was not our standard, but I could not find another nurse. We can't use the ED (emergency department) nurses because they don't use our system and the house supervisor must of been tied up." The interview with nurse #1 verified that the patient was administered Insulin without a second RN or healthcare professional.

An interview on 06/23/2010 at 1125 with the hospital's Director of Pharmacy revealed that it it the hospital policy and expectation for a second nurse to verify the medication "Levemir Insulin" before administering it to patients.

An interview on 06/23/2010 at 1059 with the hospital's Unit Manager of the Behavioral Health revealed that sometimes staffing for the behavioral health unit does only staff a RN and CNA. The interview did not reveal any reason why a second nurse did not verify the hospital's high-risk/alert insulin that was administered the patient. The interview did revealed that the nursing staff should also be following the hospital's policies and procedures.

Based on medical record review and staff interview, the hospital's nursing staff failed to provide nursing care planning for 1 of 6 patients sampled for nursing care plans that were admitted as inpatients at the hospital (#15).

The findings include:

A closed medical medical review for patient #15 a 59 year old male, revealed that the patient was admitted to the hospital on 05/15/2010 through 05/17/2010 with a diagnosis of "Congestion, Dyspnea and Hypertension" in the hospital's intensive care unit. The review revealed no documentation in the medical record that the nursing staff ever developed nursing care planning for the patient. No documentation was found where the nursing care plan was part of the patient's medical record.

An interview on 06/23/2010 at 1230 with the hospital's nursing administration staff revealed that no nursing care plan could be found for the patient in his medical record. No reason was given as to why the patient's medical record did not have any nursing care plan. The interview further revealed that it was an expectation for the nursing staff to complete a nursing care plan for every patient in the hospital that was admitted.



Reference #NC00063944.