VICTOR VALLEY HOSPITAL CITED
L&C Demands Corrective Action

Victorville, California

Corrective Action for Complaint Number CA00022144

  1. Policy revision -10/04 Restraint/Seclusion Management in Behavior Health Unit (BHU)(8610 TX.3.)
    This police was revised to specifically reflect the required documentation of attempts of less restrictive alternatives prior  to placing a patient into seclusion and administering psychotropic medications.  The police now states, "In the event of an emergency, safety shall be the guiding principle when deciding appropriate interventions.  Whenever less restrictive interventions are bypassed for safety, staff will document clinical justification for this action"  (Exhibt A) This revised policy will be presented in October 2004 to the Medical Staff Department, Medical Executive Committee and the Board of Directors. 
    Corrective Action

    1. Staff Counseling - 1/04 Employees involved with this specific incident were counseled according to hospital personnel policies and procedures (available for review upon request).

    2. Staff Inservice/Education - 1/12/04 Staff inservices were held on 1/12/04 on seclusion and restraint.  An additional review was conducted on 9/24/04, which included changes in the policy (Exhibit B).

    3. Monitor for Compliance 4th Q 2004

    4. A specific monitor for compliance with seclusion and restraint documentation has been developed.  100% of all seclusion and restraint charts will be reviewed with outcomes reported to the Quality Council bi-annually.
       

  2. Policies: Involuntary psychotheraptic medications are only used in an emergency situation in which the well being of the patient, staff, or the unit may be jeopardized. Emergency Telephone Orders (6340) outlines the purpose, policy and procedure for such situations. "In emergency cases, telephone orders shall be accepted by licensed staff. An emergency is defined as, "A situation in which a patient's well being would be jeopardized if the medications were not given and the patient is physically acting out in the attempts to harm self or others or causing property damage" (Exhibit C).
     
    Medication Consent/Psychotherapeutic Medications policy outlines when administrations of a psychotropic medication is appropriate. "...at least one of the following three conditions are met: The client/patient has given informed consent, an emergency exists, or a court order of incompetence has been obtained."  Documentation of the event and conditions surrounding the event are to be documented. "Each time a dose of emergency medication is given, there must be documentation stating the patient's specific behavior to justify the need and/or continued need for the medication on an emergency basis" (Exhibit D).
    Corrective Action

    1. Staff Counseling - 1/04 Employees involved with this specific incident were counseled according to hospital personnel policies and procedures (available for review upon request).

    2. Staff Inservice/Education - 1/12/04 & 9/24/04 Staff inservices were held on 1/12/04 on using psychotherapeutic medications in an emergency situation. An additional review was conducted on 9/24/04.

    3. Monitor for Compliance 4th Q 2004

      1. A specific monitor for compliance on the use of psychotherapeutic medications - involuntary had been developed.  100% of all events in which a psychotherapeutic medication was administered in an emergency situation and involuntary will be reviewed with outcomes reported to the Quality Council bi-annually. 
         

  3. Policies: The policy Restraint/Seclusion Management in Behavioral Health Unit (BHU)(8610 TX.3.) outline obtaining the order for placing a patient in restraint or seclusion. "In clear case of an emergency (immediate danger to self/others).
    Corrective Action

    1. Staff Counseling - 1/04 Employees involved with this specific incident were counseled according to hospital personnel policies and procedures (available for review upon request).

    2. Staff Inservice/Education - 1/12/04 Staff inservices were held on 1/12/04 on seclusion and restraint.  An additional review was conducted on 9/24/04, which included changes in the policy (Exhibit B).

    3. Monitor for Compliance 4th Q 2004

      1. A specific monitor for compliance with seclusion and restraint documentation has been developed.  100% of all seclusion and restraint charts will be reviewed with outcomes reported to the Quality Council bi-annually.
         

    4. Policies: Patients Rights and Responsibilities (8610) & The policy, Denial of Patients Rights (6340) & The policy, Restraint/Seclusion Management in the Behavioral Health Unit (BHU)(8610 TX.3.)
      Corrective Action

      1. Staff Inservice/Education - Staff inservices were held on 1/12/04 on patients' rights, the denial of these rights and the use of restraint and seclusion.  An additional review was conducted on 9/24/04, which included changes in policy (Exhibit B).

      2. Monitor for Compliance 4th Q 2004

        1. A specific monitor for compliance with seclusion and restraint, which involves a denial of patient rights, has been developed.  100% of all seclusion and restraint charts will be reviewed with outcomes reported to the Quality Council bi-annually. 
           

    5. Policies: The policy Restraint/Seclusion Management in the Behavioral Health Unit (BHU) (8610 TX.3.) outlines obtaining the order for placing a patient in restraint or seclusion.  "The clear case of emergency (immediate danger to self/others), a patient may be placed in seclusion or restraints by RNs, LVNs, CNAs, or MHWs at the direction or an RN.  The physician shall see the patient, evaluate the need for the seclusion or restraint and write an order within one (1) hour.  IN the absence of the primary physician, the ED or Urgent Care physician on duty may evaluate the patient and write the order and document his/her assessment on the Restraint and Seclusion Evaluation form.  Behavioral restraints may be utilized in other areas of the hospital, but seclusion may only be implemented on the BHU" (Exhibit ).
      Corrective Action

      1. Staff Counseling - 1/04 Employees involved with this specific incident were counseled according to hospital personnel policies and procedures (available for review upon request).

      2. Staff Inservice/Education - Staff inservices were held on 1/12/04 on patients' rights, the denial of these rights and the use of restraint and seclusion.  An additional review was conducted on 9/24/04, which included changes in policy (Exhibit B).

      3. Monitor for Compliance 4th Q 2004

        1. A specific monitor for compliance with seclusion and restraint documentation has been developed, 100% of all seclusion and restraint charts will be reviewed with outcomes reported to the Quality Council bi-annually.