St Francis Hospital & Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 29048 Based on clinical record review, review of facility documentation and interviews for one sampled patient reviewed for abuse (Patient #1) the hospital failed to protect the patient from abuse when two staff members were observed to physically and forcefully throw the patient on the bed and placed the patient in a therapeutic hold, the patient was then slapped in the face and dragged to the seclusion room which resulted in Immediate Jeopardy (A145). In addition, the hospital failed to identify a medication prescribed to restrict and manage behaviors was considered a chemical restraint as outlined in the hospital’s policy (A160), failed to ensure a physician’s order was written to indicate use of restraints (A168), failed to ensure a face-to-face evaluation of the patients was completed within one hour of the initiation of the restraint (A178), and failed to document and monitor the patient’s behaviors while in restraints in accordance with hospital policy (A185). An immediate action plan was submitted the Department on 7/22/24 that included staff education regarding abuse, restraints, patient rights, and chain of command. Cross Reference: 482.13(c)(3) Patient Rights: Free from Abuse/harassment (A0145) 482.13(e)(1(i)(B) Patient Rights: Restraint or Seclusion (A0160) 482.13(e)(5) Patient Rights: Restraint or Seclusion (A0168) 482.13(e)(12) Patient Rights: Restraint or Seclusion (A0178) 482.13(e)(16)(ii) Patient Rights: Restraint or Seclusion (A0185)”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 29048 This condition is not met by: The hospital failed to ensure a physician order was obtained for intramuscular Benadryl prior to nurse administration resulting in an adverse outcome for the patient (A409) and failed to the blood transfusion policy was followed (410). Cross Reference 482.23(c)(3)(iii) orders for drugs and biologicals (A0409) 482.23(c)(4) blood transfusion and IV medications (0410)”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 29048 Based on clinical record review, review of facility documentation and interviews, for one sampled patient reviewed for abuse (Patient #1) the hospital failed to protect the patient from abuse when two staff members were observed to physically and forcefully throw the patient on the bed and placed the patient in a therapeutic hold, the patient was then slapped in the face and dragged to the seclusion room which resulted in a finding of Immediate Jeopardy. The finding includes: Patient #1 was admitted to the hospital on 6/2024 with diagnoses that included disruptive mood dysregulation disorder, post-traumatic stress disorder and attention deficit hyperactive disorder. Review of the behavioral health progress notes dated 7/2/24 at 10:51 PM indicated the patient became angry and agitated when informed by staff he/she could not have an additional snack. The patient began throwing objects at staff, shouting racial slurs and profanities, posturing and attempting to bite staff. The patient was placed in a therapeutic hold while fighting staff, attempting to bite and spit at staff. Review of hospital documentation dated 7/2/24 identified RN #1 heard screaming and yelling with racial slurs and profanity coming from patient #1’s room. The RN entered the room and observed Mental Health Worker (MHW) #2 and MHW #3 physically lift the patient and aggressively and forcefully throw the patient on the bed. The patient was placed in therapeutic hold by the mental health workers. It was reported that staff observed MHW #2 forcefully slap the patient on the left side of the face and continued to aggressively yell at the patient. The RN called a Code 1 (security assistance needed) and upon returning to the patient’s room observed MHW #2 and MHW #3 pick up the patient and forcefully drag him/her to the seclusion room (seclusion room was directly across from the patient’s room). The patient complained of left cheek tenderness. Interview with Security Guard #1 on 7/19/24 at 11:42 AM indicated he responded to a Code 1 on the evening of 7/2/24 (unable to recall the specific time) and upon arrival to the unit he observed two staff dragging the patient into the seclusion room, then threw the patient into the room like “a rag cloth” and the patient struck his/her head on the floor. Security Guard #1 further identified that upon arrival to the seclusion room RN #2 indicated the patient should not be in the seclusion room and the patient was then brought back to his/her room. Interview with RN #2 on 7/9/24 at 12:17 PM identified that he responded to a code 1 and upon arrival to the unit Patient #1 was observed in the seclusion room and he directed the staff present to remove patient from the seclusion room. RN #2 further indicated that it was safer and easier to put the patient in his/her bed. Interview with MHW #1 on 7/19/24 at 12:45 PM identified that she was doing a 1:1 observation with patient #1 and he/she requested an additional snack at bedtime and was told snack time was over. MHW #1 indicated the patient began calling her names and threw a juice box and a brown paper bag with clothes at her. MHW #1 stated patient #1 attempted to hit her, and she held both hands by the wrist and said “you can’t hit me”. MHW #1 further indicated MHW #2 and MHW #3 then entered the room, grabbed patient #1, and threw him/her on the bed forcefully and they were yelling at the patient. The patient spit at MHW #2 who then open handed slapped the patient on the left side of his/her face. After the slap MHW #2 and MHW #3 picked the patient up and brought him/her into the seclusion room. Interview with MHW #2 on 7/19/24 at 2:04 PM identified that patient #1 was acting out and threw a bag at a coworkers head so she and another MHW stepped in and placed the patient in a therapeutic hold. MHW #2 further indicated patient #1 was spitting and she put her hand over the patient’s mouth, and he/she bit her on the right middle finger. MHW #2 further indicated she along with MHW #3 put the patient in the seclusion room however cannot recall getting direction from the nurse to utilize the seclusion room. MHW #2 indicated that although it was reported that she hit patient #1 she denied this. MHW #2 indicated putting her hand over patient’s mouth was not part of the Crisis Prevention Institute (CPI) training. Interview with MHW #3 on 7/22/24 at 2:30 PM identified that during the evening shift on 7/2/24 she overheard another staff member telling patient #1 that he/she could not have another snack and the patient attacked the staff member. MHW #3 indicated that she went to assist, she grabbed the patient’s left arm and MHW #2 simultaneously came to help and grabbed the patient’s leg. The patient was screaming, spitting and biting so they brought the patient into the seclusion room. After bringing the patient to the seclusion they were directed to remove the patient from the seclusion room and return to his/her room. MHW #3 further indicated that she worked the remainder of her shift however did not care for this patient and the following day was informed that she would be on administrative leave pending investigation. Interview with RN #1 on 7/19/24 at 2:55 PM identified that she heard patient #1 screaming and while standing at the patient’s door, she witnessed MHW #2 slap the patient in the face during a therapeutic hold. RN #1 further indicated she did not direct the mental health workers to put patient #1 in the seclusion room. RN #1 indicated patient #1 is not a candidate for the seclusion room because the patient has a history of head banging. RN #1 further indicated that she went to the desk to page the supervisor and call a code for additional assistance. Interview with RN #3 (Supervisor) on 7/19/24 at 1:14 PM indicated the incident occurred about 8:30 PM and MHW #2 was removed from the unit immediately pending investigation, however, MHW #3 worked the remainder of the shift. RN #3 further indicated she was more concerned with removing the staff who allegedly hit the patient and did not think to remove the other MHW who was aggressive with the patient. RN #3 further indicated that a debriefing was done after the incident and management was notified. Review of the staff timecards dated 7/2/24 identified that MHW #2 punched out at 8:44 PM and MHW #3 punched out at 11:23 PM. Interview with Nurse Manager #1 on 7/24/24 at 11:26 AM indicated the incident occurred on 7/2/24 and education was rolled out on 7/8/24 for all behavioral health workers. Nurse Manager #1 indicated that she sent an email to staff on 7/12/24 as a reminder to complete the mandatory abuse education with associated materials and the sign off sheet is located at the nurses’ station. The nurse manager further indicated the expectation is for staff to complete the education at the start of the shift and it is the shift supervisor’s responsibility to ensure education is complete. Further interview and review of facility documentation with Nurse Manager #1 on 7/22/24 identified a total of six additional staff who worked on the unit after education was rolled out, however have not provided attestation that they have completed the abuse education. The six staff identified they worked between 1 to 5 shifts since 7/8/24. On 7/22/24 at 10:20 AM, MHW #4 was observed conducting a constant observation with patient #1. During interview MHW #4 indicated she worked on the unit on 7/15, 7/16, 7/18, 7/19, 7/20 and 7/22. MHW #4 indicated she was aware of the incident of abuse regarding patient #1 and received an email reminder directing her that she needs to complete education however she did not complete the education. The hospital staff failed to follow CPI standards, the nursing supervisor failed to remove both staff involved in the abuse of patient #1 placing other patients at risk, and hospital leadership failed to ensure all staff were educated on the abuse policy after an allegation of abuse. Review of the Child Abuse Identification and Response policy indicated all medical and clinical staff and their supervisors with direct service care responsibilities for children and or adolescents shall participate in mandatory education in the identification, treatment, and reporting of child abuse and neglect. Ongoing staff education will be provided. Review of the hospital patients’ rights and responsibility response to suspected or alleged patient abuse or neglect identified management will remove the individual from any or all patient care during the investigation Review of the hospital restraint policy identified that all patients have the right to be free from restraints or seclusion of any form imposed as a means of coercion, discipline, convenience or retaliation by staff. Restraints or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member or other and must be discontinued at the earliest possible time. Review of the facility documentation for seclusion for assaultive and violent behavior indicated seclusion should be used only after less restrictive measures have proven ineffective at containing or redirecting the behavior. Seclusion may never be used as a punishment or coercion, in place of adequate staffing, for the convenience of staff members or for staff retaliation.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(B) [A restraint is-] (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. This Standard is not met as evidenced by: 48364 Based on clinical record review, review of hospital policy, and staff interviews for 1 of 4 sampled patients who were reviewed for chemical restraint (P #4), the hospital failed to categorize the administration of Benadryl administered to this patient as a form of a chemical restraint as outline in the hospital’s policy. The finding includes: Patient #4’s diagnoses included suicidal ideation. Review of the physician’s order dated 6/14/24 at 6:40 PM directed violent restraint: seclusion for harm to self or others. Physician order dated 6/14/24 at 7:00 PM directed to administer Benadryl 25mg IM once. Review of Patient #4’s restraint flow sheet indicated that a chemical restraint was started on 6/14/24 at 7:00 PM for being physically aggressive towards staff, yelling, posturing and cursing. Interview and review of patient #4’s clinical record with Manager #1 on 7/24/24 at 11:02 AM identified the patient received Benadryl 25mg on 6/14/24 to help control/subdue escalating behaviors but that it is not considered a restraint according to hospital policy. An interview with APRN #1 on 7/24/24 at 1:32 M indicated that they use Benadryl to help with sleep, aggression, and anxiety. She further indicated that Benadryl is used for its sedation properties and that it helps to “slow down” the patients when they have escalating behaviors. APRN #1 further stated that they use Benadryl as a means to restrict and manage behaviors. Review of the hospital policy for restraints identified a physician’s order must be obtained for the use of restraints and that a chemical restraint is a medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 48364 Based on clinical record review, review of hospital policy, and staff interviews for 3 of 4 sampled patients reviewed for restraints (Patient #1, #3, and #4), the hospital failed to obtain a physician’s order for the use of restraints. The findings include: a. Patient #1’s diagnoses included attention deficit hyperactive disorder (ADHD) and disruptive mood dysregulation disorder. Review of patient #1’s restraint flow sheet with Manager #1 on 7/24/24 at 11:27 AM indicated that a chemical restraint was started on 6/28/24 at 6:03 PM for being physically aggressive towards staff, throwing toys at staff, and punching a RN in the face. The clinical record indicated patient #1 received 0.5mg of Ativan intramuscularly (IM) on 6/28/24 at 6:03 PM. Further review of the clinical record with Manager #1 failed to identify a physician’s order was written for the use of the chemical restraint (Ativan). b. Review of patient #1’s restraint flow sheet indicated that a chemical restraint was started on 6/29/24 at 9:14 AM for being physically aggressive towards staff, yelling, and cursing. Interview and review of patient #1’s restraint flow sheet with Manager #1 on 7/24/24 at 11:27 AM indicated that a violent restraint was initiated on 6/29/24 at 9:14 AM for a therapeutic hold for being harmful to self and others and patient #1 received 0.5mg of Ativan IM on 6/29/24 at 9:14 AM. Further interview with Manager #1 on 7/27/24 at 11:27 AM, stated the clinical record lack documentation to indicate that physician’s order was received for the therapeutic hold or the chemical restraint (Ativan). c. Review of patient #1’s restraint flow sheet with manager #1 indicated that a violent restraint was initiated on 6/29/24 at 2:58 PM for a therapeutic hold for being harmful to self and others and a chemical restraint was started on 6/29/24 at 3:00 PM for being harmful to self and others, cursing, and yelling towards staff. Review of the significant events notes by MD #1 dated 6/29/24 at 3:08 PM identified that patient #1 had received 2 doses of IM Ativan to assist as a chemical restraint. Interview and review of the clinical record on 7/24/24 at 11:27 AM with Manager #1 indicated that patient #1 received 0.5mg of Ativan IM on 6/29/24 at 2:58 PM. Further interview with Manager #1 on 7/27/24 at 11:27 AM failed to indicate that a physician orders had been placed for the therapeutic hold or the chemical restraint (Ativan). d. Review of patient #1’s restraint flow sheet indicated that a chemical restraint was started on 6/30/24 at 10:30 AM for being physically aggressive towards staff, throwing toys at staff, and punching a RN in the face. Further review of the restraint flow sheet indicated that another chemical restraint was started on 6/30/24 at 11:00 AM. Interview and review of patient #1’s clinical record with Manager #1 on 7/24/24 at 11:27 AM indicated that patient #1 received 25mg of Benadryl IM on 6/30/24 at 10:30 AM and 0.5mg of Ativan IM on 6/30/24 at 10:34 AM. Manager #1 identified that patient #1 received 25mg of Thorazine IM on 6/30/24 at 11:15 AM. Further interview with Manager #1 on 7/27/24 at 11:27 AM it was identified that a violent restraint was initiated on 6/30/24 at 2:58 PM for a therapeutic hold for being harmful to self and others. Manager #1 further indicated indicate she could not locate a physician’s order for the therapeutic hold or the chemical restraint (Benadryl, Ativan and Thorazine). e. Review of patient #1’s restraint flow sheet indicated that a therapeutic hold and chemical restraint was started on 7/2/24 at 8:45 PM for being physically aggressive towards staff, yelling, biting, and spitting. Review of the medication administration record dated 7/2/24 at 8:45 PM indicated that patient #1 was administered 25mg of IM Benadryl. Review of the behavioral health progress notes dated 7/2/24 at 9:53 PM stated that a code 1, (an emergency response by staff to the behavioral health unit) was called, patient #1 was placed in a therapeutic hold and was given 25mg of IM Benadryl. The behavioral health progress note on 7/2/24 at 10:51 PM indicated that a therapeutic hold and chemical restraint had been initiated. Interview and review of patient #1’s clinical record with Manager #1 on 7/27/24 at 11:27AM indicated that a physician’s order had not been placed for the therapeutic hold or the chemical restraint. f. Patient #3’s diagnoses included disruptive mood dysregulation disorder and post-traumatic stress disorder. Review of patient #3’s restraint flow sheet indicated that a chemical restraint was started on 6/9/24 at 6:40 PM for being physically aggressive towards staff, yelling, and cursing. Interview and review of patient #3’s clinical record with Manager #1 on 7/27/24 at 11:27 AM indicated that a violent restraint was initiated on 6/9/24 at 6:40 PM for a therapeutic hold for being harmful to self and others and patient #3 received 50mg of Thorazine intramuscularly (IM) on 6/9/24 at 6:40 PM. Further interview with Manager #1 failed to indicate that a physician’s order was written for the use of a chemical restraint (Thorazine). g. Patient #4’s diagnoses included suicidal ideation. Review of patient #4’s restraint flow sheet with Manager #1 indicated that a violent restraint was initiated on 6/14/24 at 6:40 PM for seclusion for being harmful to self and others and a chemical restraint was started on 6/14/24 at 7:00 PM for being physically aggressive towards staff, yelling, posturing and cursing. Further review of the clinical record with Manager #1 indicated that patient #4 received 25mg of Benadryl intramuscularly (IM) on 6/14/24 at 7:00 PM. Review of physician’s orders with Manager #1 failed to indicate that a physician’s order was written for the chemical restraint. Interview with Manager #1 on 7/24/24 at 11:30 AM indicated that Ativan was considered a chemical restraint according to policy. She further indicated that all restraints should have an order placed in the patient’s chart. Interview with APRN #1 on 7/24/24 at 1:32 PM indicated that they use Benadryl to help with sleep, aggression, and anxiety. She further indicated that Benadryl is used for its sedation properties and that it helps to “slow down” the patients when they have escalating behaviors. APRN #1 further stated that they use Benadryl as a means to restrict and manage behaviors. Review of the hospital policy for restraints identified a physician’s order must be obtained for the use of restraints and that a chemical restraint is a medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 48364 Based on clinical record review, review of hospital policy and staff interview for 1 of 4 sampled patients reviewed for restraints (Patient #1), the hospital failed to ensure a face-to-face evaluation of the patients was completed within one hour of the initiation of the restraint. The findings include: Patient #1 diagnoses included attention deficit hyperactive disorder (ADHD) and disruptive mood dysregulation disorder. a. Review of patient #1’s restraint flow sheet with Manager #1 on 7/24/24 at 11:27 AM indicated that a violent restraint was initiated on 6/29/24 at 9:14 AM for a therapeutic hold for being harmful to self and others. The restraint flow sheet indicated that a chemical restraint was also initiated on 6/29/24 at 9:14 AM for being physically aggressive towards staff, yelling, and cursing. Record review and interview with Manager #1 on 7/24/24 at 11:27 AM indicated that patient #1 received 0.5mg of Ativan intramuscularly on 6/29/24 at 9:14 AM as a chemical restraint. Review of the clinical record failed to identify whether a physician or licensed practitioner had completed a face-to-face evaluation within 1 hour of the initiation of restraints. b. Review of patient #1’s restraint flow sheet with Manager #1 on 7/24/24 indicated that a violent restraint was initiated on 6/29/24 at 2:58 PM for a therapeutic hold for being harmful to self and others. The restraints flow sheet further identified that a chemical restraint was started at 3:00 PM for being harmful to self and others, cursing, and yelling towards staff. Review of the clinical record and interview with Manager #1 on 7/24/24 at 11:27 AM indicated that Patient #1 received 0.5mg of Ativan intramuscularly on 6/29/24 at 2:58 PM as a chemical restraint. Record review failed to identify whether a physician or licensed practitioner had completed a face-to-face evaluation within 1 hour of the initiation of restraints. c. A review of patient #1’s restraint flow sheet with Manager #1 on 7/24/2024 at 11:27 AM indicated that a chemical restraint was started on 6/30/24 at 10:30 AM for being physically aggressive towards staff, throwing toys at staff, and punching a RN in the face. Further review of the restraint flow sheet indicated that another chemical restraint was started on 6/30/24 at 11:00 AM. Record review failed to identify whether a physician or licensed practitioner had completed a face-to-face evaluation within 1 hour of the initiation of restraints. d. Review of patient #1’s physician orders indicated that a violent restraint was initiated on 6/30/24 at 2:58 PM for a therapeutic hold for being harmful to self and others. Review of patient #1’s clinical record and interview with Manager #1 on 7/24/24 at 11:27 AM indicated that patient #1 received 25mg of Benadryl intramuscularly on 6/30/24 at 10:30 AM and 0.5mg of Ativan intramuscularly on 6/30/24 at 10:34 AM as a chemical restraint and therapeutic hold on 6/30/24 at 2:58 PM. The record failed to identify a face-to-face evaluation was completed by a physician or licensed practitioner within one hour of the initiation of restraints on 6/30/24. A review of hospital policy for restraints directed that a physician/licensed independent practitioner must evaluate the patient face to face with one hour after the initiation of mechanical, seclusion, or chemical restraints. The evaluation must include at a minimum behavior and assessment necessitating the use of mechanical, seclusion or chemical restraint”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(ii) [there must be documentation in the patient’s medical record of the following:] A description of the patient’s behavior and the intervention used. This Standard is not met as evidenced by: 48364 Based on clinical record review, review of hospital policy and staff interview for 1 of 3 sampled patients reviewed for restraints, (Patient #1), the hospital failed to document and monitor the patient’s behaviors while in restraints in accordance with hospital policy. The findings include: a. Patient #1s diagnoses included attention deficit hyperactive disorder (ADHD) and disruptive mood dysregulation disorder. Review of patient #1’s restraint flow sheet indicated that a therapeutic hold and chemical restraint was started on 6/22/24 at 1:05 PM for being physically aggressive towards staff, yelling, and spitting. The restraints were discontinued on 6/22/24 at 2:05 PM. A review of the restraint monitoring behavior observation flow sheet dated 6/22/24 at 1:20 PM through 6/22/24 at 2:00 PM and interview with Manager #1 on 7/24/24 at 9:56 AM failed to indicate what behaviors patient #1 was exhibiting while in the restraints. b. Review of patient #1’s restraint flow sheet indicated that a therapeutic hold and chemical restraint was started on 6/28/24 at 6:03 PM for being physically aggressive towards staff, yelling, cursing, and harmful to self. A review of the restraint monitoring behavior observation flow sheet dated 6/28/24 at 6:03 PM through 6/28/24 at 7:03 PM failed to indicate what behaviors patient #1 was exhibiting while in the restraint. Interview with Manager #1 on 7/24/24 at 9:56 AM indicated that once a patient is in a restraint or seclusion, the expectation is that the observer/mental health care worker or RN document behaviors in the electronic medical record (EMR). A review of the hospital policy for restraints directed that the management of the patient with violent or self-destructive behavior will have monitoring/observations that are consistent with the behaviors observed upon initiation of the restraint and every 15 minutes or as determined by the patients’ condition and needs. A review of the hospital policy for observation guidelines indicated that the RN will direct the observer to perform and record observations in the electronic medical record: behavioral observations every 15 minutes.”

“ORDERS FOR DRUGS AND BIOLOGICALS CFR(s): Orders for drugs and biologicals may be documented and signed by other practitioners, not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This Standard is not met as evidenced by: 29048 Based on clinical record review, review of facility documentation and staff interviews for 1of 4 patients reviewed for medication administration (Patient #1) the hospital failed to ensure a physician’s order was obtained for intramuscular Benadryl prior to nurse administration. The finding includes: a. Patient #1 was admitted to the hospital with diagnoses that included disruptive mood dysregulation disorder, post-traumatic stress disorder and attention deficit hyperactive disorder. Review of the clinical record identified that the patient’s weight was 63 pounds. Review of the physician’s orders dated 6/30/24 at 10:34 AM directed the administration of IM Ativan 0.5mg and physician order dated 6/30/24 at 11:11 AM directed to administer IM Thorazine 25mg. Review of the medication administration record (MAR) identified IM Benadryl 25mg and IM Ativan 0.5mg were administered on 6/30/24 at 10:34 AM and IM Thorazine 25mg was administered at 11:15 AM. Review of the nurses’ notes dated 6/30/24 at 11:47 AM identified the patient was banging his/her head against the window and biting fingers and staff placed the patient on the bed to keep safe. Patient began screaming and yelling and spitting at staff. Patient was medicated with intramuscular (IM) Ativan 0.5mg and Benadryl 25mg. The patient continued to yell and was medicated with Thorazine 25mg IM 45 minutes later. Shortly after this administration, the patient became quiet and nonverbal, would not respond verbally but continued to have respirations. A rapid response was called (a response team that responds to an urgent clinical patient situation) and 911was initiated. Review of MD #1 progress note date 6/30/24 at 9:01 PM indicated a rapid response was called at 11:20 AM, the patient was evaluated by MD #1 and transferred to the Emergency Room for further work-up. Review of patient #1’s clinical record identified a cabinet override (a process of bypassing pharmacist review of a medication order to obtain a medication from the pyxis) order for Benadryl 50mg/ml on 6/30/24 at 11:34 AM, administer undiluted maximum rate 25mg/min. Review of the documentation failed to identify an ordering provider and an authorizing provider. The current dispensing information indicated order unverified by the pharmacy or the physician. Interview with the Director of Nursing on 6/24/24 at 1:40 PM identified that on 6/30/24, RN #15 overrode the Pyxis machine and retrieved Benadryl for patient #1, however she could not find a physician’s order for the administration of Benadryl. The DON indicated nurses can take verbal or telephone orders in a crisis situation and the provider will need to cosign within a reasonable time frame. The DON further stated she was unable to locate documentation to identify that the provider verified the order for IM Benadryl 25mg. Interview with MD #1 on 7/25/24 at 12:32 PM identified that she gave an order for Ativan 0.5mg to be administered to patient #1 however did not verbalize or write an order for Benadryl. MD #1 further indicated the patient had Ativan the previous day and tolerated it well and she would not have ordered Benadryl secondary to the patient’s size and concern with oversedation. Interview with MD #2 on 7/25/24 at 12:55 PM identified that she ordered Thorazine 25mg for the patient based on behaviors. MD #2 further indicated she was not aware the patient was given Benadryl, and she did not place an order for Benadryl. Interview with RN #15 on 7/24/24 at 1:55 PM indicated she got a telephone order from the on-call physician for Ativan 0.5mg and Benadryl 25mg however the Benadryl needed to be verified by the pharmacy and the order was not in EPIC so when she got to the Pyxis to retrieve the Ativan, she overrode the Pyxis for the Benadryl. RN #15 indicated she went to the MAR in epic and scanned the vial of Benadryl. RN #15 further indicated she did not document in the clinical record that she received a verbal order for Benadryl and the physician did not verify the order in the clinical record. RN #15 indicated that whenever a verbal or oral order is obtained the nurse should document it in clinical record. Although RN #15 indicated she received a telephone order for Benadryl 25mg, MD #1 and MD #2 indicated they did not give her a telephone order for Benadryl. Review of the hospital medical order policy identified that verbal orders are orders for medications, treatments, interventions or care communicated verbally in person or via telephone. Verbal orders must include date, time, and authentication by the person receiving the order and must include the full name and title of the practitioner giving the order. The prescribing practitioner must authenticate the verbal order as soon as possible but no later than 24 hours after giving the order.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 47454 Based on clinical record reviews, review of facility documentation and interviews for 1of 3 sampled patients (Patient #11) who was reviewed for blood transfusions, the hospital failed to ensure the clinical record was complete and accurate to include documentation of the completion of blood transfusions. The finding includes: a. Review of patient #11’s clinical record identified a physician’s order dated 7/15/24 that directed to administer 2 units of Packed Red Blood Cells (PRBCs) over 3 hours per unit. Review of the blood transfusion documentation flowsheet identified that RN #10 and RN #11 administered a bag of blood (Blood A) on 7/15/24 at 9:45 PM at a rate of 75 milliliters (ml) per hour and the transfusion was completed on 7/16/24 at 4:31 AM by RN #12 and vital signs were recorded in the clinical record. The flowsheet identified that on 7/16/24 at 2:05 AM, LPN #1 and RN #13 administered the second unit of blood (Blood B) at a rate of 150 ml/hr. Review of the blood transfusion documentation flowsheet failed to identify the date and time that Blood B was completed. Review of the blood transfusion documentation flowsheet with the Quality Specialist on 7/24/24 at 2:50 PM identified that Blood B had no documented date and time of completion. Interview with LPN #1 on 7/25/24 at 2:21 PM identified that he assisted in hanging the second unit of blood (Blood B) but did not assist at the completion of the transfusion. Interview and review of the clinical record with RN #14 (Assistant manager) on 7/25/24 at 2:21 PM identified that there was no documentation indicating the second unit of blood was complete and the expectation is for nurses to conduct a full set of vital signs and also document the time the unit of blood was completed. A review of the “Procedure Guideline on Blood and Blood Product Transfusion” identified to start the blood transfusion at a slow rate as prescribed and increase the rate as prescribed if no signs of a reaction occur to ensure the completion of the transfusion within 4 hours. The procedure guideline additionally identified that on the transfusion record document the date and time the transfusion was started and completed.”