HospitalInspections.org

Based on findings from document review and interview, the facility did not implement and follow through with their corrective action plan after an investigation into a patient's potential elopement. The lack of follow through could result in staff being unprepared to deal with disoriented, threatening and/or combative patients.


Findings include:

-- Per medical record review, Patient #1 was an 89 year old male diagnosed with pneumonia. His physical exam revealed he was oriented to person, place, and time with a normal mood and affect. The patient reported some malaise and fatigue. He had walked 8 miles daily prior to September 2015.

-- Per interview with Staff A, on 1/14/16 at 10:00 am, Patient #1 was transferred to another unit on 11/2/15 at 10:30 pm. Later that night, Patient #1's bed alarm went off. Staff A and Staff B checked on the patient. As the staff were leaving Patient #1's room, he jumped out of bed and stated he was leaving. He indicated he had been kidnapped and locked in a cold lonely room by himself so they could experiment on him. He started to pull his intravenous (IV) line out. Patient #1 was not oriented. He indicated he was going to walk home. Patient #1 walked out of his room with his belongings. Staff asked him to wait while they contacted a family member. He refused and continued walking off the floor. He repeatedly accused the staff of experimenting on him. Staff A walked behind the patient who headed down a staircase. When the patient was nearing the exit, Staff A walked in front of the patient. Patient #1 punched Staff A in the face and two times in the chest. The patient then headed back up the stairs to his floor. Upon arriving on the floor, 2 nursing staff and a medical staff member were there. The nurses attempted to get the patient back to his room. The patient started to swing and punch the nurses. He also verbally threatened them. He shoved one of the nurses into a door. The patient wanted the police notified that the hospital was trying to do experiments on him. A security officer (Staff C) arrived and spoke with Patient #1. The patient again attempted to leave the unit. Staff C touched Patient #1's arm to get his attention. The patient started yelling and swinging at the security guard. Staff C had to physically restrain Patient #1.

-- Per interview with Staff D on 1/15/16 at 7:30 am, he/she and another nurse attempted to redirect Patient #1 to his room. Patient #1 "slammed him/her into a door frame." Staff D stated the patient was punching at staff and talking about being kidnapped and that hospital was experimenting on him.

--Per interview with Staff B, on 1/15/16 at 7:50 am, Patient #1 was very strong and he was punching at staff, using profanity and stating they were experimenting on him.

--Per interview (via telephone) with Staff E on 1/21/16 at 3:00 pm, Patient #1 experienced delirium, he was combative and not able to be reoriented.

-- Per interview with Staff C on 1/15/16 at 8:15 am, Patient #1 was swinging and punching and trying to leave the facility. He/she had to physically restrain the patient. He stated he used profanity towards the patient.

-- Per interview with Staff F on 1/14/16 at 2:30 pm and on 1/15/16 at various times this event was reviewed and an investigation was conducted. The patient was appropriately physically restrained however, the use of profanity by a security guard was identified as a lack of professionalism. It was determined that this was an isolated incident. An opportunity for improvement to re-educate security staff on professionalism and communication was deemed an appropriate action and to be completed by week of 11/23/15. However, this re-education did not occur.

-- Also, per review of the completed investigation of this event, dated 11/10/15, it was documented that some staff did express they did not feel conformable in knowing how to de-escalate violent patients.

Per interview of Staff D on 1/15/16 at 7:30 am, staff need more training to deal with this type of combative behavior.

Per interview with Staff B, on 1/15/16 at 7:50 am, nursing staff need education in dealing with combative patients.

Per interview with Staff E (via telephone) 1/21/16 at 3:00 pm, he/she indicated more training in verbal and physical de-escalation is needed.

Per review of the facility's investigation, even though hospital staff stated they needed more training in how to de-escalate violent patients, the hospital did not identify as an opportunity for improvement.