HospitalInspections.org

Based on review of the Hospital's Internal Investigation and Corrective Action Plan related to a patient injury that occurred during a Code Gray (a team response for management of aggressive behavior) on 8/17/12, it was determined that the Hospital had not completely implemented the Corrective Action Plan.

Findings include:

The Hospital Internal Investigation related to the patient injury that occurred during the 8/17/12 Code Gray indicated that Patient #1 was wielding a metal butter knife and threatening to stab staff. Staff were attempting to de-escalate Patient #1's behavior when he/she suddenly lunged at Security Guard #1. Security Guard #1 took hold of Patient #1's hand and wrist and removed the knife. Security Guard #1 heard a popping sound during the process of removing the knife. A follow-up x-ray revealed a fractured wrist bone. The Hospital Internal Investigation identified issues related to the organization and management of the Code Gray and a Corrective Action Plan was developed.

The Corrective Action Plan called for: a.) revision of the Code Gray policy/procedure to clearly identify team member roles and responsibilities, b.) adding a behavioral health clinician to the Code Gray team, c.) staff education regarding the revised Code Gray policy/procedure and d.) Crisis Prevention Intervention training for Nursing Supervisors.

As of 9/26/12, the Corrective Action Plan was not implemented.