HospitalInspections.org

Based on document review and interview the facility failed to insure the right of 1 of 1 psychiatric patient identified.

A. A-154 482.13 (e)
Based on interview and documentation the facility failed to insure the use of restraint (chemical,and mechanical) were not used for convenience as evidenced by 1 of 1 patient reviewed.
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B. A 159 482.13.(e) (1) (i) (A)
Based on document review and interview the facility failed to develop and implement policies and procedures for the use of restraint
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C. A 0160 482.13 (e)(1)(i)(A)
Based on document review and interview the facility failed to insure the rights of 1 of 1 psychiatric patient identified.
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D. A 166 482.13 (e) (4) (i)
Based on document review and interview the facility failed to modify the patients treatment plan to reflect the use of seclusion in 1 of 1 patient identified.
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Based on interview and documentation the facility failed to insure the use of restraint (chemical,and mechanical) were not used for convenience as evidenced by 1 of 1 patient reviewed.

On 12/1/2011 at 10:30 AM in the Senior Care unit Staff #3 was interviewed and confirmed there were no specific policies and procedure for restraint and seclusion for the Senior Care unit. When asked how long would a patient stay in seclusion she stated, "a couple of hours or until they calmed down or the physician said let them out"

On 12/1/2011 at 11:00 AM in the conference room patient #1 medical record was reviewed and revealed the following nurses narrative:
1.) 5/18/2011 1714 hours (hrs). Patient #1 was involuntarily admitted to the Senior Care unit. Documentation reveals patient #1 was pleasant and cooperative neat clean and ambulatory.
2.) 5/19/2011 at 0441 hrs the following: "Pt awake, denies pain or discomfort, assisted in to Geri--chair and moved closer to nurses station..."
3.) 5/19/2011 1916 hrs. "Pt sitting near nurses station in Geri-chair.... 5/19/2011 0042 hrs...Assisted to bed from Geri-chair..."
4.) 5/21/2011 1035 hrs "Pt sitting (in Geri-chair) in front of the nurses station..." 5/21/2011 1058 hrs. "Pt agitated, raising voice beating on the tray on his chair. Pt stated "I don't know who I am or what I am doing" Geodon 10 mg. IM (intramuscularly) given without resistance. Assisted to the bathroom and was not combative or aggressive. 1:1 monitoring cont".
5.) 5/22/2011 1200 hrs. "Frequent contact with patient, camera monitored room..."
6.) 5/23/2011 2001 hrs. "Pt sleeping quietly at present....Pt is level 3 f/p (fall/precaution) resting in Geri-Chair at this time".
7.) 5/24/2011 0614 hrs. "Pt sleeping quietly....resting in Geri-Chair near nurses station..."
8.) 5/25/2011 0528 hrs. "Pt finally sleeping quietly since 2:00 AM...at present sleeping in Geri-chair near nurses station".
5/25/2011 1425 hrs. "has been sleeping at nurses station in reclining Geri-chair since this AM".
5/25/2011 1540 hrs. "is becoming agitated, redirect ineffective. All interventions ineffective. Assaulted 3 staff called staff #4 orders received for locked door seclusion". Late entry 1830 hrs
5/25/2011 1800 hrs "Earlier attempt at locked door seclusion ineffective. Pt breaking door down. Security and police called. Placed in handcuff by police and was effective in subduing pt, allowing staff to administer medications to pt for sedation..." Late entry 1845 hrs.
5/25/2011 2024 hrs. "Staff #4 notified of patient condition with new order for Geodon 10 mg IM administered at 1715 pt remains in police handcuffs at this time pt calmer at 1815 police remove handcuffs and new order for wrist restraints obtained per staff #4 Bilateral soft wrist restraints applied pt in room in bed ....."
5/25/2011 2359 hrs. "Pt is in bed with wrist restraint...."
9.) 5/26/2011 0100 hrs "Unable to remove wrist restraints patient continues to be hostile toward caregiver".
5/26/2011 0353 hrs. "still unable to remove restraints, patient still aggressive, hostile, danger toward others".
5/26/2011 0432 hrs. "Pt is still in wrist restraints but agitation is increasing, cursing,bawling like an animal, banging his heels on the foot of the bed kicking as staff approach him..."
5/26/2011 0500 hrs. "Geodon 5mg IM ineffective. patient continues sitting up in bed with wrist restraints on. sliding down to the foot of the bed shaking the bed so hard the top of the bed is rising off the floor patient is about to turn bed over on himself. staff #4 contacted new order received Geodon 10 mg IM left thigh at 0500, ankle restraints applied".
5/26/2011 0546 hrs. "Pt is more calm, has stopped yelling but is still sitting up in bed with all restraints on ...."
5/26/2011 0835 hrs. "Pt continues to be calm at present wrist restraint on, ankle restraints removed pt tolerated removal no kicking or moving about in bed at this time...."
5/26/2011 1855 hrs. "wrist restraints removed per staff #4 at 0945 hrs...."

On 12/1/2011 at 11:30 AM a review of patient #1 medical record revealed there were no physician's orders for the placement of patient #1 in a Geri-chair with a tray. Restraint records which begin on 5/25/2011 do not include a Geri-chair with a tray as a restraint.

Although the Patient #1 demonstrated aggressive combative behavior the facility had no policy or procedure to guide staff in what was considered a restraint. How and when to apply the restraint. How frequently restraints had to be released or how to monitor a patient in restraints. The patient was restraint out of staff fear of his aggressive history.

Further review of medical record for Patient #1 revealed the following:
1.) Physician's order 5/18/2011 1630 hrs. Geodon 10 mg IM (intramuscularly) Q (every) 6 hours, PRN (as needed) combativeness was ordered.

2.) Physician's orders sheet 5/19/2011 1100 hrs. decrease Geodon 5mg IM Q6 hrs PRN combativeness.

3.) Further review of medical record revealed nurses narrative dated 5/20/2011 1844 hrs. "Pt became very restless...given Seroquel 50 mg. Pt continues to escalate and constantly walking around the unit without his walker. Geodon 10 mg IM given without difficulty or resistance. Pt has not been combative but body language indicates he could..."
The order is written for Geodon as needed for combativeness. The patient was not combative or even resistive.

4.) Nurses narrative dated 5/21/2011 1058 hrs. "Pt agitated. raising voice beating on the tray on his chair ...Pt given Geodon 10 mg IM without resistance. Assisted to bathroom was not combative or aggressive".
The order is written for Geodon 5mg as needed for combativeness. The nurse administered 10 mg Geodon IM without an order. (The patient is already restrained in a Geri-chair)The patient was not combative or even resistive.

5.) Nurses narrative dated 5/22/2011 0000 hrs. "Seroquel ineffective, patient still restless, swinging arms, behavior unpredictable, Geodon 5mg IM left arm..."
The Geodon was administered without combativeness observed or documented.

6.) Nurses narrative dated 5/23/2011 1544 hrs. "Pt became restless, yelling at nurse and shaking fist at nurse....Pt cont to escalate and walk into other rooms difficult to redirect. Geodon 5mg IM given without difficulty or resistance..."
The order for Geodon is for combative behavior. The patient was either combative no resistant. He was difficult to redirect.

7.) Nurses narrative dated 5/24/2011 0151 hrs. "Pt continues to be awake restless and agitated. Seroquel 50 mg PO (by mouth) given x 2 PRN not effective. Geodon 5 mg given IM in right thigh for restlessness and agitation."
The order is Geodon as needed for combative behavior not restless agitation.

8.) Nurses narrative dated 5/25/2011 1425 hrs. "(Pt) has been asleep at nurses station in reclining Geri-chair since this AM". Nurses narrative dated 5/25/2011 1640 hrs. "is becoming agitated redirect ineffective. All interventions ineffective assaulted 3 staff. Called staff #4 orders received for locked door seclusion."

There is no documentation for the time between 1425 hrs and 1640 hrs. The narrative reads as if the patient went to sleep and woke up assaulting 3 staff. Although the narrative reads that no interventions altered the behavior no actual intervention are listed.

Geodon IM was given five (5) times for the staffs convenience as no combative behavior was observed or documented until 5/25/2011.

Based on document review and interview the facility failed to develop and implement policies and procedures defining a restraint or the need for and the use of restraint (chemical and mechanical) and seclusion as evidenced by 1 of 1 patient reviewed.

On 12/1/2011 at 10:30 AM in the Senior Care unit Staff #3 was interviewed and confirmed there were no specific policies and procedure for restraint and seclusion for the Senior Care unit. When asked how long would a patient stay in seclusion she stated, "a couple of hours or until they calmed down or the physician said let them out"

On 12/1/2011 at 1:00 PM in the conference room the policies and procedures for the Sr Care unit were reviewed and revealed the following:
1. Senior Care Unit Policy and Procedure manual table of contents.
Section V: Special Treatment Procedures which include; Mechanical restraint, protective & supportive devices, seclusion clinical time out and quiet time, Transferring patients from / to Medical services and Prohibited practices has a line drawn across the page and a hand written note which reads...See SrCare policy & Procedure manual for 500-501 & 501. It is signed by a staff member and dated 4/10/09. These policies were not found in the SrCare policy manual.
2. There was no policy for chemical restraint.
3. There was no policy for outside assistance in restraint (Police intervention)

On 12/1/2011 at 11:00 AM in the conference room patient #1 medical record was reviewed and revealed the following:
1.) Nursing documentation reflects 5/18/2011 1714 hours (hrs). Patient #1 was involuntarily admitted to the Senior Care unit. Documentation reveals patient #1 was "pleasant and cooperative neat clean and ambulatory".
2.) Nursing assessment 5/19/2011 at 0441 hrs the following: "Pt awake, denies pain or discomfort, assisted in to Geri--chair and moved closer to nurses station..."
3.) Nurses narrative 5/19/2011 1916 hrs. "Pt sitting near nurses station in Geri-chair.... 5/19/2011 0042 hrs...Assisted to bed from Geri-chair..."
4.) Nurses narrative 5/21/2011 1035 hrs "Pt sitting (in Geri-chair) in front of the nurses station..."5/21/2011 1058 hrs. "Pt agitated, raising voice beating on the tray on his chair. Pt stated "I don't know who I am or what I am doing" Geodon 10 mg. IM (intramuscularly) given without resistance. Assisted to the bathroom and was not combative or aggressive. 1:1 monitoring cont".
5.) Nurses narrative 5/22/2011 1200 hrs. "Frequent contact with patient, camera monitored room..."
6.) Nurses narrative 5/23/2011 2001 hrs. "Pt sleeping quietly at present....Pt is level 3 f/p (fall/precaution) resting in Geri-Chair at this time".
7.) Nurses narrative 5/24/2011 0614 hrs. "Pt sleeping quietly....resting in Geri-Chair near nurses station..."
8.) Nurses narrative 5/25/2011 0528 hrs. "Pt finally sleeping quietly since 2:00 AM...at present sleeping in Geri-chair near nurses station".
5/25/2011 1425 hrs. "has been sleeping at nurses station in relining Geri-chair since this AM". 5/25/2011 1540 hrs. "is becoming agitated, redirect ineffective. All interventions ineffective. Assaulted 3 staff called staff #4 orders received for locked door seclusion". Late entry 1830 hrs
5/25/2011 1800 hrs "Earlier attempt at locked door seclusion ineffective. Pt breaking door down. Security and police called. Placed in handcuff by police and was effective in subduing pt, allowing staff to administer medications to pt for sedation..." Late entry 1845 hrs.
5/25/2011 2024 hrs. Staff #4 "notified of patient condition with new order for Geodon 10 mg IM administered at 1715 pt remains in police handcuffs at this time pt calmer at 1815 police remove handcuffs and new order for wrist restraints obtained per staff #4 Bilateral soft wrist restraints applied pt in room in bed .....".
5/25/2011 2359 hrs. "Pt is in bed with wrist restraint...."
9.) Nurses narrative 5/26/2011 0100 hrs "Unable to remove wrist restraints patient continues to be hostile toward caregiver".
5/26/2011 0353 hrs. "still unable to remove restraints, patient still aggressive, hostile, danger toward others".
5/26/2011 0432 hrs. "Pt is still in wrist restraints but agitation is increasing, cursing,bawling like an animal, banging his heels on the foot of the bed kicking as staff approach him..."
5/26/2011 0500 hrs. "Geodon 5mg IM ineffective. patient continues sitting up in bed with wrist restraints on. sliding down to the foot of the bed shaking the bed so hard the top of the bed is rising off the floor patient is about to turn bed over on himself. staff #4 contacted new order received Geodon 10 mg IM left thigh at 0500, ankle restraints applied".
5/26/2011 0546 hrs. "Pt is more calm, has stopped yelling but is still sitting up in bed with all restraints on ...."
5/26/2011 0835 hrs. "Pt continues to be calm at present wrist restraint on, ankle restraints removed pt tolerated removal no kicking or moving about in bed at this time...."
5/26/2011 1855 hrs. "wrist restraints removed per staff #4 at 0945 hrs...."

On 12/1/2011 at 11:30 AM a review of patient #1 medical record revealed there were no signed physician's orders for the placement of patient #1 in a Geri-chair with tray. Restraint records which begin on 5/25/2011 do not include a Geri-chair with a tray as a restraint. Geodon which is given five (5) times to control Patient #1 out burst and is not identified as a restraint on any monitoring document. There was no policy or procedure to guide staff in what was considered a restraint, how to use the restraints, or when a restraint might be needed.

Based on record review the facility failed to insure that As Needed (PRN) medications were not used to manage patients behavior and restrict the patients movement in 1 of 1 patients identified.

On 12/1/2011 at 11:00 AM in the conference room the medical record for patient #1 was reviewed and revealed the following:
1.)Physician's order reflects 5/18/2011 1630 hrs. Geodon 10 mg IM (intramuscularly) Q (every) 6 hours, PRN (as needed) combativeness was ordered.

2.) Physician's orders sheet 5/19/2011 1100 hrs. reflects decrease Geodon 5mg IM Q6 hrs PRN combativeness.

3.) Further review of medical record revealed nurses narrative dated 5/20/2011 1844 hrs. "Pt became very restless...given Seroquel 50 mg. Pt continues to escalate and constantly walking around the unit without his walker. Geodon 10 mg IM given without difficulty or resistance. Pt has not been combative but body language indicates he could..."
The physician's order is written for Geodon as needed for combativeness. Nursing documentation reflects the patient was not combative or even resistive. Geodon 10 mg IM was not ordered by the physician but was given by the nurse.

4.) Nurses narrative dated 5/21/2011 1058 hrs. "Pt agitated. raising voice beating on the tray on his chair ...Pt given Geodon 10 mg IM without resistance. Assisted to bathroom was not combative or aggressive".
The physician's order is written for Geodon 5mg as needed for combativeness. The nurse administered 10 mg Geodon IM without an order. Nurses narrative reflects the patient is already restrained in a Geri-chair. The nurses reflects the patient was not combative or even resistive. Geodon 5mg IM was ordered by the physician but Geodon 10 mg IM was given by the nurse.

5.) Nurses narrative dated 5/22/2011 0000 hrs. "Seroquel ineffective, patient still restless, swinging arms, behavior unpredictable, Geodon 5mg IM left arm..."
Nurses narrative does not document combative behavior from the patient yet Geodon was administered IM

6.) Nurses narrative dated 5/23/2011 1544 hrs. "Pt became restless, yelling at nurse and shaking fist at nurse....Pt cont to escalate and walk into other rooms difficult to redirect. Geodon 5mg IM given without difficulty or resistance..."
The physician's order if for Geodon for combative behavior. Nurses narrative does not reflect the patient was combative. Nurses documentation reflects he was difficult to redirect.

7.) Nurses narrative dated 5/24/2011 0151 hrs. "Pt continues to be awake restless and agitated. Seroquel 50 mg PO (by mouth) given x 2 PRN not effective. Geodon 5 mg given IM in right thigh for restlessness and agitation."
The physician's order is for Geodon as needed for combative behavior not restless agitation. Nurses narrative does not reflect combative behavior.

8.) Nurses narrative dated 5/25/2011 1425 hrs. "(Pt) has been asleep at nurses station in reclining Geri-chair since this AM". Nurses narrative dated 5/25/2011 1640 hrs. "is becoming agitated redirect ineffective. All interventions ineffective assaulted 3 staff. Called staff #4 orders received for locked door seclusion."

There is no documentation for the time between 1425 hrs and 1640 hrs. The nurses narrative reads as if the patient went to sleep and woke up assaulting 3 staff. Although nurses narrative reads that no interventions altered the behavior, no actual intervention are listed.

Geodon IM was given five (5) times for the staffs convenience to manage the patient's behavior. No combative behavior was observed or documented until 5/25/2011.

Based on document review the facility failed to modify the patients treatment plan to reflect the use of restraints and seclusion in 1 of 1 patient identified.

On 12/1/2011 at 11:00 AM in the conference room the medical record for patient #1 was reviewed and revealed the following:
1. The treatment plan did not address the use of chemical, mechanical, physical restraint or seclusion at any point during patient #1 stay in the facility. Patient #1 was admitted on 5/18/2011 and discharged on 5/28/2011, 10 days.
2. Nurses narrative reveals the patient spent a portion of each day in a Geri-chair with a lap tray without physician's order.
3. Nursing documentation reflects patient #1 was given five (5) IM injections without combativeness documented. The "As Needed" order from the physician was for combative behavior.
4. The nurses narrative dated 5/25/2011 1540 hours, reflect a physician's order was obtained for locked door seclusion.
5. Nurses narrative dated 5/25/2011 1800 hours, reflect staff were unable to get the patient safely into the seclusion room and opted for police intervention and as needed medication for combativeness instead.

The treatment plan did not reflect interventions for any behavioral outburst or any restraints during the 10 day stay in the facility.