Holly Hill Medical Director Admitted "We've gotten sloppy" with PRN orders of Zyprexa

The Centers for Medicare and Medicaid Services (CMS) cited the governing body of Holly Hill Mental Health Services for failing to provide leadership oversight, not promoting and protecting patient rights, and not ensuring an organized nursing service. CMS informed the facility that

These deficiencies have been determined to be of such serious nature as to substantially limit limit your hospital’s capacity to render adequate care and prevent it from being in compliance with all the Conditions of Participation for hospitals.

The patient rights deficiencies relate to incidents in which the facility administered anti-psychotic medications and injections without guardian consent to two out of four adolescent patients whose treatment was reviewed by CMS. One 13-year-old boy was given Zyprexa 21 times for agitation without any parental consent. A 15-year-old boy was injected with Zyprexa twice during his treatment with no proper consent documented.

Patient rights deficiencies were also cited due to violations of seclusion and restraint protocols for four out of five patients who were restrained or secluded during the review period:

  • Four out of the five patients were not debriefed within 24 hours as required;
  • Three out of the five patients did not have time-limited restraint or seclusion orders;
  • Two out of five were not monitored as required during restraint or seclusion; and
  • Two out of five were not assessed by a physician or otherwise qualified nurse within 1 hour of restraint or seclusion as required.

CMS also found that the facility “failed to demonstrate an organized nursing service, as evidenced by failing to ensure safe medication use practices.” These deficiencies included:

[F]ailing to assess the need for and response to PRN (as-needed) medications; failing to monitor vital signs per physician orders, and/or failing to ensure lab work was done per physicians’ orders for 5 of 6 sampled patients.

The patients affected included several adolescent patients who received injections of Zyprexa, and an adult who received Haldol, Cogentin and lorazepam.

When interviewed, the hospitals’ Medical Director told CMS:

“When [Zyprexa Protocol was] developed, it was intended to be used for emergency doses of medication. It seems we have started using it as (orders for) regular PRNs, rather than writing orders… The physician should always review and sign the protocol order sheet… We have gotten sloppy with the protocols.”

In order to correct its cited deficiencies, the facility was required to submit a plan of correction, and remain under Medicare State Agency supervision until compliance was established.