HospitalInspections.org

Based on interview and record review, the hospital failed to ensure that the rights of patients as delineated under this Condition of Participation were met as evidenced by the following:

1) No physician's orders were written for the physical restraint of Patient #1. Patient #1 was restrained twice while being held to the floor in a prone [face down] position and medicated each time with Haldol, Ativan and Benadryl IM (Intramuscular). Patient #1 was later found unresponsive in the seclusion room and subsequently died; and

2) Restraint/seclusion training was not current for one of 9 hospital personnel [Staff #9]. The hospital further failed to ensure 3 of 3 direct care staff [Staff #6, #7, and #8] were competent in the application of a physical restraint for 1 of 1 patient [Patient #1].

Cross Refer to Tags, 0168 and 0194

Based on interview and record review the hospital failed to ensure that there are restraint orders by a physician for 1 of 1 patient [Patient #1] who was physically restrained by hospital personnel.

Findings Included:

The Emergency Services Summary Report for Patient #1 dated 02/10/11 timed at 2:04 AM reflected, "patient arrived escorted by police on Peace Officer Application for Emergency Detention...chief complaint paranoid..."

The physician note dated 02/10/11 timed at 02:23 AM reflected, "paranoid, no known allergies...past medical history, paranoid schizophrenia, tobacco use, hyperlipidemia, obesity and lipid disorder...skin negative for rash, neurological negative for dizziness and headaches...cardiovascular positive for palpitations...patient is nervous/anxious..."

The nurses note for Patient #1 dated 02/10/11 timed at 02:34 AM reflected, "Per psych [Psychiatric] tech [Technician] the patient's right hand looks already red and patient accused him "you did put something in my hand." Patient became more paranoid also refusing his blood pressure to be checked. Patient stated, "I am refusing medical treatment and I want to leave right now...patient was ordering the staff to open the door for him so he could go out of the unit and leave. Patient is getting more agitated and not following verbal redirection from the staff. Patient is also getting belligerent and tried to fight with the staff. Placed into seclusion at 02:30 AM medicated with Haldol 5 mg [Milligrams] IM [Intramuscular], Ativan 2 mg and Benadryl 25 mg per physician order as emergency medications. Reason for seclusion and criteria for release explained..."

The nurses note dated 02/10/11 timed at 03:25 AM reflected, "3 psych tech's were holding the patient down using SAMA [Satori Alternatives to Managing Aggression] techniques while in the seclusion room and staff were trying to talk to the patient to cooperate. When patient calmed down, psych tech's departed the room...and a couple of minutes later he was noted to be unresponsive. Dr...notified..."

The physician progress note dated 02/10/11 timed at 03:39 AM reflected, "The patient was given a second dose of Haldol 5 mg, Ativan 1 mg, and Benadryl 25 mg IM around 03:20 AM since he continued to bang on the door and he attempted to fight with psych tech's. The patient did struggle with staff members as he was taken out of the center seclusion room where he tore up the tile...the patient required three psychiatric tech's to restrain him as he was kicking, yelling, and swinging his fists when he entered the new seclusion room. After he calmed down the psych technicians departed the room and a couple of minutes later he was noted to be unresponsive...Dr. notified..."

The Hospital Restraint/Seclusion death report worksheet for Patient #1 dated 01/10/11 timed at 04:23 AM [date error] under the section entitled, "Patient died" reflected, "Died while in restraint/seclusion, or both" The section entitled "Type: check all that apply" reflected, "physical restraint and seclusion checked." The section entitled, "If physical restraint, select type" the section reflected, "Take downs and other physical holds." Section C of the same document reflected, "reason for restraint/seclusion use...patient tore tile from floor, hit/kicked staff members...patient was transferred to another seclusion room..."

No physician restraint orders were found in the medical record.

On 05/04/11 at 12:11 AM Staff #7 was interviewed. Staff #7 was asked to describe the events which involved Patient #1. Staff #7 stated Patient #1 began to swing at the staff. Staff #7 stated himself and another hospital staff had to restrain Patient #1. Staff #7 stated the patient was placed on his stomach for the administration of an injection the first time for several minutes. The second time the hospital staff had to take the patient down was when he had to be removed from the seclusion room where he had pulled up a piece of tile and made a weapon out of it. Patient #1 was then placed in a different seclusion room. Staff #7 stated the second time Patient #1 was taken down, his arms were crossed in front of him and he was placed on his stomach [prone]. Staff #7 stated the nurse gave a second injection while he was on his stomach. The patient continued to struggle and the tech's continued to hold Patient #1 down. The physician came in and told the tech's to let the patient up. Staff #7 stated he was not sure of the exact time the patient was held down but it was at least ten to fifteen minutes. Staff #7 stated Patient #1 was released and was okay when he left.

On 05/04/11 at 11:30 AM Staff #3 was interviewed. Staff #3 was asked if physician restraint orders were obtained for Patient #1. Staff #3 stated, "No."

On 05/04/11 at 10:15 PM Staff #9 was interviewed. Staff #9 was asked how long Patient #1 was held down the first time he received an injection, and what position Patient #1 was placed in. Staff #9 stated maybe five minutes the technicians held Patient #1 down and he was placed on his stomach. Staff #9 stated the second time the patient was placed on his stomach for a second injection. The patient was still struggling with the technicians. Staff #9 was asked if he obtained physician restraint orders for Patient #1. Staff #9 stated, "No."

On 05/05/11 at 1:05 AM Staff #12 was interviewed. Staff #12 was asked if the second time Patient #1 was taken down did he inform the tech's to let Patient #1 up and release him. Staff #12 stated, "Yes." Staff #12 was asked what position Patient #1 was placed in and how long did the tech's hold him down. Staff #12 stated Patient #1 was on his stomach. He stated the tech's restrained him for ten to fifteen minutes. Staff #12 was asked if he wrote restraint orders. He stated, "No."

On 05/05/11 at 3:00 PM Staff #8 was interviewed. Staff #8 stated he attempted to do vital signs and bloodwork on Patient #1. The patient became agitated and refused care. The patient did not accept redirection and tried to hit the hospital staff. The first time the patient was taken down the patient's arms were crossed in front of his chest and he was placed on his stomach for an injection. The tech's held him down for approximately five to ten minutes and left him in the seclusion room. The second time three staff had to take Patient #1 down was when he was being moved to a different seclusion room because he had pulled up a piece of tile and was banging on the door of the seclusion room. Patient #1 would not go compliantly and attempted to hit the staff. The patient's arms were crossed in front of his chest and he was placed on his stomach. He received a second shot. The tech's restrained him about 10 to 15 minutes after the injection. The physician came in and told the tech's to let him up.

The policy entitled, "Non-Violent/Non-Self Destructive and Violent/Self Destructive Restraints" with a revision date of 08/10 was reviewed. The section entitled, "General Guidelines Related to Restraint Use" reflected, "Clinical justification for the use of restraints. The actual behavior justifying the use of a restraint must be documented...alternative measures tried, attempted and considered...a current LIP [Licensed Independent Practitioner] order depending upon the reason for the restraint...type of restraint used and evidence that the least restrictive restraint was chosen...results of all monitoring, reassessments and related interventions related to the restraint use..."

Based on interview and record review, the hospital failed to ensure all staff were trained in restraint and/or seclusion application for 1 of 9 training records reviewed [Staff #9]. The hospital further failed to ensure 3 of 3 direct care staff [Staff #6, #7 and #8] were competent in the application of physical restraint for 1 of 1 patient [Patient #1].

Findings Included:

The physician note for Patient #1 dated 02/10/11 timed at 02:23 AM reflected, "paranoid, no known allergies...past medical history, paranoid schizophrenia, tobacco use, hyperlipidemia, obesity and lipid disorder...skin negative for rash, neurological negative for dizziness and headaches...cardiovascular positive for palpitations...patient is nervous/anxious..."

The nurses note dated 02/10/11 timed at 02:34 AM reflected, "Per psych [Psychiatric] tech [Technician] the patient's right hand looks already red and patient accused him "you did put something in my hand." Patient became more paranoid also refusing his blood pressure to be checked. Patient stated, "I am refusing medical treatment and I want to leave right now...patient was ordering the staff to open the door for him so he could go out of the unit and leave. Patient is getting more agitated and not following verbal redirection from the staff. Patient is also getting belligerent and tried to fight with the staff. Placed into seclusion at 02:30 AM medicated with Haldol 5 mg [Milligrams] IM [Intramuscular], Ativan 2 mg and Benadryl 25 mg per physician order as emergency medications. Reason for seclusion and criteria for release explained..."

The nurses note dated 02/10/11 timed at 03:25 AM reflected, "3 psych tech's were holding the patient down using SAMA [Satori Alternatives to Managing Aggression] techniques while in the seclusion room and staff were trying to talk to the patient to cooperate. When patient calmed down, psych tech's departed the room and a couple of minutes later he was noted to be unresponsive. Dr...notified..."

The physician progress note dated 02/10/11 timed at 03:39 AM reflected, "The patient was given a second dose of Haldol 5 mg, Ativan 1 mg, and Benadryl 25 mg IM around 03:20 AM since he continued to bang on the door and he attempted to fight with psych tech's. The patient did struggle with staff members as he was taken out of the center seclusion room where he tore up the tile...the patient required three psychiatric tech's to restrain him as he was kicking, yelling, and swinging his fists when he entered the new seclusion room. After he calmed down the psych tech's departed the room and a couple of minutes later he was noted to be unresponsive...Dr. notified..."

The nurses notes dated 02/10/11 timed at 04:29 AM reflected, "At 03:32 observed Patient #1 to be lying in a prone position in seclusion room #1...observed right arm to be lying beneath him with his right hand pointed toward the ceiling. Per psych tech's, the patient had been moved from seclusion room #2 to seclusion room #1 as he had pulled up some tile/baseboard in room #2...the patient's hand was very mottled in appearance...the patient did not respond to verbal/tactile stimuli. He was turned from his stomach to a supine position. The patient's face was cyanotic, a radial pulse was present, but no spontaneous respirations...physician notified...CPR [ Cardiopulmonary Resuscitation]..."

On 05/03/11 at 1:30 PM Staff #5 was interviewed. Staff #5 was asked what his job was at the hospital. Staff #5 stated he was a psychiatric technician and he trained staff the SAMA [Satori Alternatives to Managing Aggression] training program. Staff #5 said when a patient was agitated we are to give them an opportunity to calm down and continue to communicate with the patient. Staff #5 stated he was not present when Patient #1 was admitted. Staff #5 stated hospital staff were taught not to lay a patient prone, on their stomach and/or face down. He stated if the patient was placed on their stomach they were to be repositioned right away in the side lying position so their airway was maintained. Hospital staff were to place the patient in a basket hold with the patient's arms crossed in front of their body, then sit the patient on the floor. The second person was to hold the legs. If they were to receive an injection the hip area was available for use. Staff #5 was asked to play the training DVD showing the basket hold. The surveyor observed the basket hold and was visualized as described. Staff #5 stated the purpose of the training was to contain movement, not placing the patient face down prevents possible medical compromise. Staff #5 was asked whether he has retrained any of the staff involved since the incident with Patient #1. Staff #5 stated, "No."

On 05/04/11 at 12:11 AM Staff #7 was interviewed. Staff #7 was asked to describe the events which involved Patient #1. Staff #7 stated Patient #1 began to swing at the staff. Staff #7 stated himself, and Staff #6 and Staff #8 had to restrain Patient#1 and take him down. Staff #7 stated the patient was placed on his stomach for the administration of an injection the first time for several minutes. The second time hospital staff had to take the patient down was when he had to be removed from the seclusion room where he had pulled up a piece of tile and made a weapon out of it. Patient #1 was then placed in a different seclusion room by Staff #6, #7 and #8. Staff #7 stated the second time the patient was taken down his arms were crossed in front of him and he was placed on his stomach [prone]. Staff #7 stated the nurse gave a second injection while he was on his stomach. The patient continued to struggle and the tech's continued to hold him down. The physician came in and told the tech's to let the patient up. Staff #7 stated he was not sure of the exact amount of time the patient was restrained but it was at least ten to fifteen minutes. The surveyor asked Staff #7 what type of restraint training he has had. Staff #7 stated he has had SAMA [Satori Alternatives to Managing Aggression] training. Staff #7 was asked what position according to the SAMA training were patient's to be placed in when taken down or given an injection. Staff #7 offered no response.

On 05/04/11 at 12:10 PM Staff #1 was asked by the surveyor for the restraint training for [Staff #6, #7, #8 and #9]. Staff #1 provided the training files. Staff #1 stated she could not find current training for Staff #9. All other staff training for Staff #6, #7 and #8 were current.

On 05/04/11 at 10:15 PM Staff #9 was interviewed. Staff #9 was asked if he had current restraint training. Staff #9 stated his restraint training had expired. Staff #9 was asked how long Patient #1 was held down the first time he received an injection, and what position Patient #1 was placed in. Staff #9 stated maybe five minutes the tech's held him down. He was positioned on his stomach. Staff #9 stated the second time Patient #1 was placed on his stomach for a second injection and when he left the seclusion room Patient #1 was still struggling with the tech's. Staff #9 was asked how the nurses monitor the technicians during a take down and/or restraint to ensure proper techniques were used. Staff #9 stated the tech's got control of the patient and then he administered the medication. He stated he left to chart.

On 05/05/11 at 1:05 AM Staff #12 was interviewed. Staff #12 was asked if the second time Patient #1 was taken down did he inform the technicians to let Patient #1 up and release him. Staff #12 stated, "Yes." Staff #12 was asked what position Patient #1 was placed in, and how long did the technicians hold him down. Staff #12 stated Patient #1 was on his stomach, and the tech's restrained Patient #1 for ten to fifteen minutes.

On 05/05/11 at 3:00 PM Staff #8 was interviewed. Staff #8 stated he attempted to do vital signs and bloodwork on Patient #1. The patient became agitated and refused care. The patient did not accept redirection and tried to hit the hospital staff. The first time the patient was taken down the patient's arms were crossed in front of his chest and he was placed on his stomach for an injection. The tech's held him down for approximately five to ten minutes and left Patient #1 in the seclusion room. The second time three tech's [Staff #6, #7 and #8] had to take Patient #1 down when he was being moved to a different seclusion room because he had pulled up a piece of tile and was banging on the door of the seclusion room. The patient would not go compliantly and attempted to hit the staff. The patient's arms were crossed in front of his chest and he was placed on his stomach. He received a second shot. The tech's held Patient #1 down about 10 to 15 minutes after the injection. The physician came in and told the tech's to let him up. Staff #8 was asked what position the patient should be placed in when a take down occurs. Staff #8 stated staff put the patient's on their stomach [prone].

On 05/05/11 at 5:10 PM Staff #13 was interviewed. Staff #13 stated she was looking in the seclusion room window along with the technician. She stated the technician told her [Patient #1] was remedicated. She stated when she looked in something did not seem right with the patient. The patient was face down [prone] on his stomach. The patients right arm was under him crossed to the other side. The other hand was by his side. She stated she could not find respirations, the physician responded, and a code blue was called. Staff #13 stated the training she had indicated the patients were to be placed on their side not on their stomach.

The policy entitled, "Non-violent/Non-self Destructive and Violent/self Destructive Restraints" with a revision date of 08/10 under the section entitled, "Training" reflected, "Staff competency in restraint management will be maintained...at a minimum, physicians, other licensed independent practitioners...authorized to order restraint or seclusion by hospital policy..."

Based on interview and record review the hospital failed to ensure the RN [Registered Nurse] supervised and evaluated the nursing care provided by the Psychiatric Technicians for 1 of 1 patient [Patient #1] who was physically restrained while in seclusion. The RN failed to monitor the physical condition, the safe application of restraints and the psychological well-being of Patient #1 during and after being physically restrained two times within approximately 35 minutes. Patient #1 sustained two focal abrasions to the left forehead while in the psychiatric ED [Emergency Department] and died shortly after being physically and chemically restrained.

Findings Included:

The psychiatric physician note for Patient #1 dated 02/10/11 timed at 02:23 AM reflected, "paranoid, no known allergies...past medical history, paranoid schizophrenia, tobacco use, hyperlipidemia, obesity and lipid disorder...skin negative for rash, neurological negative for dizziness and headaches...cardiovascular positive for palpitations...patient is nervous/anxious..." No documentation was found indicating [Patient #1] had abrasions to his forehead on admission.

The nurses note dated 02/10/11 timed at 02:34 AM reflected, "Per psych [Psychiatric] tech [Technician] the patient's right hand looks already red and patient accused him "you did put something in my hand." Patient became more paranoid also refusing his blood pressure to be checked. Patient stated, "I am refusing medical treatment and I want to leave right now...patient was ordering the staff to open the door for him so he could go out of the unit and leave. Patient is getting more agitated and not following verbal redirection from the staff. Patient is also getting belligerent and tried to fight with the staff. Placed into seclusion at 02:30 AM hours and medicated with Haldol 5 mg [Milligrams] IM [Intramuscular], Ativan 2 mg and Benadryl 25 mg per physician order as emergency medications. Reason for seclusion and criteria for release explained..."

The physician progress note for Patient #1 dated 02/10/11 timed at 02:57 AM reflected, "The patient was calm upon arrival and became abruptly agitated...due to his paranoia he began to accuse others of persecuting him and he tried to abruptly leave the seclusion area and tried to fight with the psychiatric tech's so he was emergently medicated with Haldol 5 mg, Ativan 2 mg and Benadryl 25 mg IM once and placed in closed door seclusion...while in seclusion patient remained paranoid and pulled a piece of tile off the seclusion room wall...he did have to be remedicated with Haldol 5 mg, Ativan 1 mg and Benadryl 25 mg IM once...unable to contract for safety...remains in imminent danger of harm to himself and others...we will proceed with OPC [Order of Protective Custody] and inpatient level of care for further stabilization..."

The nurses note dated 02/10/11 timed at 03:25 AM reflected, "3 psych tech's were holding the patient down using SAMA [Satori Alternatives to Managing Aggression] techniques while in the seclusion room and staff were trying to talk to the patient to cooperate. When patient calmed down, psych tech's departed the room and a couple of minutes later he was noted to be unresponsive. Dr...notified..."

The nurses notes dated 02/10/11 timed at 04:29 AM reflected, "At 03:32 observed the patient to be lying in a prone position in seclusion room #1...observed right arm to be lying beneath him with his right hand pointed toward the ceiling. Per psych tech's, the patient had been moved from seclusion room #2 to seclusion room #1 as he had pulled up some tile/baseboard in room #2...the patient's hand was very mottled in appearance...the patient did not respond to verbal/tactile stimuli. He was turned from his stomach to a supine position. The patient's face was cyanotic, a radial pulse was present, but no spontaneous respirations...physician notified...CPR [Cardiopulmonary Resuscitation]...staff from the main ED [Emergency Department] arrived, patient lifted onto a stretcher, CPR continued and transferred to main ED.

The Medical ED [Emergency Department] physicians physical exam note dated 02/10/11 timed at 04:10 reflected, "Patient received Haldol 10 mg, Benadryl 50 mg and Ativan 3 mg during his psychiatric ER [Emergency Room] stay. Last medication administered at 3:20 AM....patient noted to be unresponsive at 3:40 AM and code called...patient in asystole since arrival to main ED. Patient received four cycles of epinephrine and 4 cycles of atropine, one ampule of calcium chloride and one ampule of sodium bicarbonate...total duration of CPR [Cardiopulmonary Resuscitation] approximately 20 minutes...time of death 3:56 AM...review of systems....head small left sided frontal abrasion/contusion..."

The Medical Examiners report dated 02/10/11 timed at 1:00 PM reflected, "Two focal abrasions are located in the left forehead...a slight subscapular hemorrhage underlies the previously described abrasions...a focal contusion is located on the left forearm and right wrist..."

On 05/04/11 at 11:30 AM Staff #3 was interviewed. Staff #3 was asked if an event report was completed for Patient #1 which addressed the abrasions to Patient #1's forehead. Staff #3 stated, "No."

On 05/04/11 at 10:15 PM Staff #9 was interviewed. Staff #9 was asked if he observed any skin problems such as abrasions on Patient #1's forehead when he arrived. Staff #9 stated he did not notice any abrasions on his face. Staff #9 was asked how long Patient #1 was held down the first time he received an injection and what position Patient #1 was placed in. Staff #9 stated maybe five minutes the tech's held Patient #1 down and he was placed on his stomach. Staff #9 stated the second time the patient was placed on his stomach for an injection. He stated when he left the Patient #1 was still struggling with the tech's. Staff #9 was asked how he monitored the technicians during a take down/restraint and ensured proper techniques were used. Staff #9 stated the tech's get control of the patient and then the nurse gave the medication and left. Staff #9 stated he left the tech's holding Patient #1 down and went to chart.

The policy entitled, "Non-violent/Non-self Destructive and Violent/Self Destructive Restraints "with a revision date of 08/10 reflected under the section entitled, "Restraint", "Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to freely move his/her ars, legs, body or head...the section of the policy entitled, "Qualified Registered Nurse" reflected, "A registered nurse who has received training and demonstrates knowledge in the specific needs of patient population...identifying staff and patient behaviors as well as environmental factors that my trigger circumstances that require the use of restraints...identifying the risk of restraint use in vulnerable patient populations such as cognitively or physically limited patients...monitoring the physical and psychological well-being of the patient in restraints...safe application of restraints...Based on this training, the RN is authorized to initiate restraint or seclusion, and/or perform evaluations or re-evaluations of patients in restraint or seclusion and to assess their readiness for discontinuation or establish the need to secure a new order." The section entitled, "General guidelines related to Restraint Use" reflected, "The type of restraint...assessment of the patient and the situation have been completed...medical and nursing leadership of ....hospital approve the use of therapeutic restraint for patient safety...they are also committed to preventing, reducing, and eliminating excessive or inappropriate use of restraint and seclusion..." Staff #9 left the tech's while they were restraining and struggling with Patient #1 and went to "chart."

The policy entitled, "Nursing Documentation" with a revision date of 05/09 reflected, "Pertinent observations concerning treatments and patient outcome will be recorded...findings/observations/interventions applicable to the patient will be documented...a need, which warrants nursing action or interventions, must be documented in the chart...notes should include, but are not limited to the following: actions taken, patient response and any other information deemed necessary...care and/or treatment provided by all health care professionals will be based on each patient's specific needs...all relevant physical...needs will be the determining factor for the assessment process..."