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Based on review of the internal investigation and review of 1 of 2 clinical records, hospital personnel used unapproved restraint techniques resulting in patient injury.
Findings:

Citing patient #1, a 17 year old male was admitted to the facility on 9/20/10 due to extremely aggressive and violent behavior including punching his mother with his fists and threatening to kill his mother, teachers at school, his probation officer and others by shooting them.

Record review reflected that throughout hospitalization the patient was noted to be verbally threatening and physically aggressive with his peers and resistant to staff redirection.
On 10/3/10 at 1400 it was noted the patient was verbally and physically aggressive, pulling a younger peer by the neck. He refused to go the quiet room and went to his room and began throwing chairs.
A mental health technician(MHT), personnel #53 entered the patient's room and the patient tried to hit him. The MHT used a brief physical hold to restrain the patient. The patient was resistant and the MHT fell backward and the patient fell on top fracturing his left arm.

Review of the internal investigation revealed the MHT used an unapproved frontal basket hold , an unapproved non violent patient intervention technique due to the risk of patient/staff injury.

Based on interview, review of the internal investigation, review of facility policy and procedures and review of 1 of 1 clinicals records there was a failure to ensure an effective quality assurance program by failing to investigate a patient event with a fatal outcome.
Findings:

Citing patient #2, a 37 year old female admitted to the psychiatric intensive care unit (PICU) on 10/13/2010 with a diagnosis of bipolar disorder and uncontrolled diabetes mellitus. The record reflected the patient was in no physical distress until 0605 on 10/18/2010 when it was noted the patient was found unresponsive with no pulse;no breath.

This event was investigated by the facility with no problems identified as of 10/25/2010

However, review of the cardiopulmonary arrest record revealed the following:

1. It was noted the time code blue was called was 0605 in one place on the form. In another place on the form it was noted code blue was called at 0607. The code was not called until 2 minutes after the patient was found unresponsive.

2. It was noted CPR was not started until 0608, three minutes after the patient was found unresponsive.
Personnel #54 stated 0n 10/25/2010 that when she arrived on the unit at 0608 CPR was not in progress.

3. It was noted the Automated External Defibrillator (AED) was not placed on the patient until 0615,
10 minutes after the patient was found unresponsive.

4. It was noted the time 911 was called was 0620, 15 minutes after the patient was found unresponsive.

5. It was noted the time 911 arrived on the unit was 0626, and pronounced the patient deceased
4 minutes later at 0630, 25 minutes after the patient was found unresponsive.

6 A post code blue event conference to evaluate the code process was not held , as required by the code blue hospital policy.