HospitalInspections.org

Based on interview and record review, the hospital failed to ensure staff were not physically abusive toward one patient (Patient A). This has the potential to result in the physical harm.

Findings:

The Chief Nursing Officer (CNO) written review of the 8/17/11, incident with Patient A, was reviewed on 10/13/11 at 9:30 AM. Under the "findings" column it read in part, "3. At 2202 (10:02 PM) the video shows [Mental Health Worker 1 (MHW 1)] pushing the patient (Patient A) into the seclusion room. When the patient was pushed into the seclusion room the patient is seen falling unto the carpetted (sic) floor..."

The "EMPLOYEE WARNING" dated 8/22/11, was also reviewed on 10/13/11 at 9:30 AM. The reason for the warning notice stated, "Patient (Patient A) called the hospital four times this morning wanting to meet with the hospital administration regarding some concerns she had about her treatment at the hospital while inpatient. The patient complained of being mishandled during a period of her hospitalization...In review of the video recording for Wednesday, August 17, 2011 at 22:02; it was easy to identify and support her allegations. She was observed being physically pushed into the quiet room...That employee is identified as (MHW 1)...Upon review of the video for that date and time, it shows the Mental Health Worker (MHW 1) shoving the patient (Patient A) into the room and the patient (Patient A) lands on the floor. The patient (Patient A) presenting today with bruises on her arms..."

During an interview with CNO, on 10/13/11 at 9:41 AM, after reviewing the personnel records for MHW 1, he stated the MHW was terminated on 8/23/11 secondary to the incident which occurred on 8/17/11.

Based on interview and record review, the hospital failed to ensure staff implemented appropriate protocol according to the hospital's policies and procedures when a patient (Patient A) was physically restrained. The staff failed to notify the charge nurse and therefore there was no documentation from the charge nurse appropriate protocol was followed when one patient (Patient A) was physically held down on the ground. This had the potential to result in unnecessary restraint of a patient which could result in physical harm.

Findings:

The clinical record for Patient A was reviewed on 10/13/11 at 11 AM. Patient A was admitted 8/15/11, voluntarily and was discharged 8/19/11. On 8/17/11 at 7:12 PM, the Licensed Psychiatric Technician 1 (LPT 1) documented, "Pt (Patient A) requiring constant redirecting coming to pound on door "My taxi waiting out side open the door" "I'm gonna call the police..." Appears pt (increased) psychosis, MD notified Zyprexa (antipsychotic medication) 5 mg (milligrams) po (by mouth) given x 1." On 8/17/11 at 10:03 PM, the LPT 1 documented, "Pt screaming "what did you do with my children...let me out"...MD notified of (increased) pschosis (sic)..." The MD prescribed medications for the patient's behavior. There was no documentation the patient was physically restrained on this particular day nor was there documentation the charge nurse was notified the patient may have been physically restrained.

During an interview with Mental Health Worker 2 (MHW 2), on 10/31/11 at 1:42 PM, she stated on the day of the occurrence 8/17/11, she assisted MHW 1 and the security guard take Patient A down when she was agitated. Patient A was "agitated" and striking out at staff and patients. "We take her down" near the pink rooms (seclusion/quiet rooms). She was held down on the floor for less than 5 minutes. She was asked, at this time, whether the charge nurse [Registered Nurse 1 (RN 1)] was notified of the "take down"? She replied, she could not recall whether RN 1 was notified of the take down when the patient was held on the floor for less than 5 minutes. Patient A was already up when RN 1 came.

RN 1's written account of what occurred on 8/17/11, was reviewed on 10/13/11. It read in part, "...(Patient A) was very agitated / aggressive, kept pacing on the hallway, loud, noisy banging walls + doors + even tried to hit staffs with her cane which was taking away from her. Despite being aggressive, I don't remember + did not witnessed (sic) any "takedown" done on her.."

During an interview with CNO, on 10/13/11 at 9:41 AM, after reviewing the personnel records for MHW 1, he stated the MHW was terminated on 8/23/11, secondary to the incident which occurred on 8/17/11.

The hospital's policy and procedure titled, "USE OF SECLUSION AND RESTRAINT" dated 9/08 defined the term "restraint" as either a physical restraint or a drug that is used as a restraint...Holding a patient and restricting his/her movement also constitutes restraint." The policy statement indicated, "A licensed physician, psychologist or registered nurse (RN) must identify and document the following:
Observed threat of harm to self or others
Less restrictive interventions attempted and patient's response
Appropriate orders from physician
Communication to the patient...of the need for...restraints and criteria for discontinuation of seclusion and/or restraint."
The policy and procedure continued and read, "A physician or other licensed independent practitioner must see the patient and evaluate the need for restraint...within one hour after the initiation of this intervention..."

During an interview with Quality Officer (QO), on 1/11/12 at 9:40 AM, he was informed MHW 1 did not follow the hospital's policy and procedure when he physically restrained Patient A on 8/17/11. No further information was provided.