HospitalInspections.org

Based on record review and interview the facility failed to implement safe and appropriate restraint techniques as determined by the hospital policy in 1 (SP #4) out of 3 sampled patients.

Findings include:

Clinical record review of sample patient (SP) #4 revealed that he was admitted on 04/25/2020 to the Behavioral Health Unit with a diagnosis of Schizophrenia.

Record review showed on 05/2/2020 at 02:57 AM during safety rounds, Charge Nurse A states that SP#4 became aggressive and attacked staff injuring the Behavioral Health Technician (BHT-B) in the head and right leg. During the struggle, the patient and the BHT -B fell to the floor. Shortly after, the patient was assisted to a prone position and that's when the patient was noted to be unresponsive. Code Blue was called. Time of death called at 03:58 AM by Physician J.

On 06/26/2020 at 10:40 AM during an interview the Director of Behavioral Health stated that on 05/2/2020 at 02:56 AM, SP#4 got out of his room and was demanding food and drink. Staff redirected the patient to his room. (charge nurse A) will be prepared and administer the PRN (as needed) medication to the patient and directed BHT (staff F) to take the patient blood pressure. When asked if the staff considered calling a CODE BERT prior to entering the patient's room, she stated no because this the normal behavior for the patient. As she confirmed in the Narrative Summary, BHT -B entered the room and the assault began against the staff member. Code BERT activated. The Director stated that the patient was move from a side lying position to a prone position. BHT-B sat on the patient buttocks area. Other staff members were holding the patient legs. Finally, the Director states that less than a minutes after holding the patient legs, SP#4 became unresponsive. CODE BLUE activated.
Review of the Code Blue Summary report dated 05/02/2020. The Code Blue was called at 03:17 AM. Reason for the Code Blue: patient noted to be unresponsive. Code terminated at 03:58 AM (death).

Review of the "Miami-Dade County, Medical Examiner Department Autopsy Report" showed the Cause of Death: Asphyxia Due to: Restraint During Aggressive Schizophrenic Episode while hospitalized.

The Policy Subject: " Patient Restraint/ Seclusion" (05/01/2017) states physical holds: holding a patient in a manner that restricts the patient's movement against the patient's will is considered a restraint. Further states, if a patient is in a physical hold, a second staff person is assigned to observe the patient to ensure safety and the patient's airway is not compromised.

CORRECTIVE ACTION PLAN- BEHAVIORAL HEALTH (BH) (was intitiated but was not completed at the time of the survey. The completion date is 08/31/2020)
The Director of Behavioral Health is responsible for the implementation of the plan.
A. Staff Competencies- compliance with CPI techniques
100% of BH staff will complete CPI refresher training
100% of BH staff will participate in BERT Drills
100% of all BERT calls in BHU review by leadership
The completion date is 8/31/2020. Current status is ongoing. Immediate Person Responsible: Director of Behavioral Health Unit. Educational curriculum of the Nonviolent Crisis Intervention (CPI) Training Program provided. One of the topics discussed in the training program is High Risk Positions for Restrain Related to Positional Asphyxia. In addition, the Director of Behavioral Health provided a schedule for June, July, and August 2020 for CODE BERT drills, CPI training, BH Small Group Meeting-Attestation.
Monitoring: Training participation/attendance sign in sheets. Staff participation and completion of the CPI training program provided by copies of the staff CPI test.
Measure of Success: Direct Observation of staff performance-100% compliance with CPI techniques, and BH staff participates in BH Code BERT drill (25% each quarter).

B. BH Unit Leaders- Professional Development
100% of BH Unit leaders required to complete the following assigned HealthStream training: Supervisory skills for positive outcomes, critical thinking skills for charge nurse, leading change in a dynamic culture, coaching for excellence, and crucial conversations for charge nurse.
The completion date is 8/31/2020. Current status is ongoing.
Immediate Person Responsible: Director of Behavioral Health
Monitoring: HealthStream Training
Measure of Success: Certificates of Completion- 100% of the training completed by all Behavioral Health Unit leaders.

C. Staff Coaching and Mentoring
Small group and individual meetings with 100% of the BH staff to address culture of safety: verbal De-escalation, alternative treatment interventions, diversional activities, and BROSET assessments, physical holds, and escalation process.
The completion date is 8/31/2020. Current status is ongoing.
Immediate Person Responsible: Director of Behavioral Health Unit
Monitoring: Small Group Meetings, Individual Meetings, and Daily Huddles
Measures of Success: Sign Attestation-100% of BH staff. Well over 90% of the staff have completed/signed the culture of safety techniques. Culture of Safety Attestation documentation provided by the Director of Behavioral Health. Also provided BROCET assessment completion report by unit staff. This was completed via HealthStream.

D. Shift Safety Huddles
Hardwire Shift Safety Huddles
Immediate Person responsible: Director of Behavioral Health
The completion date is 7/26/2020. Current status is ongoing. Monitoring: Shift Safety Huddles, documentation provided for 6/25/2020.
Measure of Success: Behavioral Health will review shift safety huddle forms.

E. Staffing Assignments to Identify BH staff responding to psychiatric emergencies/codes.
Staffing assignment sheets will reflect the staff responsibility addressing patient related emergencies/codes. Unit leaders will make the assignment (including identification of lead) at the start of shift and will communicate with assigned team member.
The completion date was 6/26/2020. Status: Ongoing
Immediate Responsible Person: Director of Behavioral Health Monitoring: Daily Staffing Assignment Sheets. Behavioral Health Services assignment sheet documentation for 6/26/2020 provided.
Measure of Success: Documentation audit, concurrent reviews, and staff assigned on all shifts 100% of the time.

On 07/13/2020 at 10:00 AM in an interview, the Director of Behavioral Health states as for the Code Silent, its purpose is for staff to call for support from security situations instead of calling for Code BERT. It was implemented on 05/2020. Security personnel were train on the program through the CPI training. At the moment, Code Silent is a Pilot Program and has not been incorporated into hospital policy. As for BROSET assessment, the Golden and Bronze guidelines are address in the current BROCET hospital policy.

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Based on record review, policy review, and staff interview, the facility failed to report a restraint associated death to the Centers for Medicare and Medicaid Services (CMS) within the specified timeframe for 1 sample patient (SP#4) out of 3 patients.

Findings Include:

Record review showed on 05/2/2020 at 02:57 AM during safety rounds, Charge Nurse A states that SP#4 became aggressive and attacked staff injuring the Behavioral Health Technician (BHT-B) in the head and right leg. During the struggle, the patient and the BHT -B fell to the floor. Shortly after, the patient was assisted to a prone position and that's when the patient was noted to be unresponsive. Code Blue was called. Time of death called at 03:58 AM by Physician J.

On 06/26/2020 at 10:40 AM during an interview the Director of Behavioral Health stated that on 05/2/2020 at 02:56 AM, SP#4 got out of his room and was demanding food and drink. Staff redirected the patient to his room. (charge nurse A) will be prepared and administer the PRN (as needed) medication to the patient and directed BHT (staff F) to take the patient blood pressure. When asked if the staff considered calling a CODE BERT prior to entering the patient's room, she stated no because this the normal behavior for the patient. As she confirmed in the Narrative Summary, BHT -B entered the room and the assault began against the staff member. Code BERT activated. The Director stated that the patient was move from a side lying position to a prone position. BHT-B sat on the patient buttocks area. Other staff members were holding the patient legs. Finally, the Director states that less than a minutes after holding the patient legs, SP#4 became unresponsive. CODE BLUE activated.
Review of the Code Blue Summary report dated 05/02/2020. The Code Blue was called at 03:17 AM. Reason for the Code Blue: patient noted to be unresponsive. Code terminated at 03:58 AM (death).

Review of the "Miami-Dade County, Medical Examiner Department Autopsy Report" showed the Cause of Death: Asphyxia Due to: Restraint During Aggressive Schizophrenic Episode while hospitalized.


Review a copy of the "Report of a Hospital Death Associated with The Use of Restraint or Seclusion" Form CMS-10455 for the incident on 05/02/2020 showed it was electronically reported to CMS on 06/26/2020 at 06:55 AM during the survey. Reporting was beyond the timeframe.

On 07/13/2020 at 09:45 AM during an interview with the VP (Vice President) of Quality, she states that restraint death reporting to Centers for Medicare and Medicaid Services (CMS) is the responsibility of the of the Patient Safety and Risk Manager. When asked why it was not reported per the regulations, she stated that "we drop the ball".
Policy: "Patient Restraint/Seclusion, Reference Number: CSG.CSG.001", Effective Date: 05/01/2017. Appendix C: Hospital Reporting Requirement- states the Hospital must report restraint related death to CMS no latter than the close of business day following knowledge of a patient's death.

Above findings confirmed with the VP of Quality, the Risk Manager, and the Risk Management Coordinator on 06/26/2020 at 03:00 PM, and repeated again on 07/13/2020 during the exit conference at 03:30 PM in the presence of the Assistant CNO, VP of Quality, the Risk Manager, and the Risk Management Coordinator