HospitalInspections.org

Based on interview, document review, and video review, the hospital failed to initiate a restraint in accordance with hospital policy for 1 of 10 patient's reviewed, when a staff member pushed Patient #1 (P3) over, and held him down in a manner not in compliance with the hospital restraint policy.

Findings include:

Medical record review revealed P3 was admitted to the hospital on 12/20/19, with diagnoses that included antisocial personality disorder, substance induced mood disorder, history of drug seeking behavior, psychosis-unspecified and rule out mania. P3 had multiple previous mental health admissions to this hospital, and others in the metro area, and a long history of aggression. P3's history included misuse of methamphetamine, anabolic steroids and testosterone. Prior to admission, P3's provisional discharge from a previous commitment was revoked related to refusal to take his medications, assaulting his mother and threatening to kill her. The patient was living at a group home and believed the staff were overdosing him on "roofies." He barricaded himself in his room refusing to let group home staff check on him. The patient had a history of sexual behavior, frequently targeting female staff and patients. The patient was on sexual and assault precautions. On 1/12/20, P3 was targeting a female patient on the unit. P3 swung at staff and was "taken to the ground" and restrained by staff at 10:45 a.m. P3 denied injury related to the restraint when asked, and no injury was documented.

A review of video, dated 1/12/20, revealed that at 10:40 a.m. P3 was sitting at a table with 2 females. Behavioral health assistant (BHA)-P approached the table and began conversing with P3. Suddenly P3 pushed BHA-P in the arm. P3 then settled back down and folded his arms. BHA-P then pushed P3 off of his chair onto the ground, hitting P3's head against a portable blood pressure machine. BHA-P then held P3 down on the ground with what appeared to be one arm across P3's upper chest.

On 2/25/20, at 1:00 p.m. behavioral nursing director (BND)-F stated she watched the video, and BHA-P did not follow the hospital's restraint policy during the restraint on 1/12/20. BND-F stated BHA-P did not use approved hold techniques. BND-F stated the staff member would be retrained.

The policy titled Restraint or Seclusion dated 6/17/19, directed under section 9. Training & Competencies, B: Staff are able to demonstrate competencies in application of restraints including appropriate hold techniques.