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Based on a review of the environment on the behavioral health unit and review of the hospital procedures, it is determined that the behavioral health unit protocol for approaching patients during a barricade situation failed to provide definitive direction to staff on how to safely accomplish the goals of approaching an agitated patient by way of the anti-barricade door.

Patient #9 is an early middle-aged pregnant female who transferred to the hospital behavioral health unit following another hospitals diagnosis of psychosis. Patient #9 was quite agitated and adamantly denied her pregnancy. On occasion, patient #9 would barricade herself into her room, using her desk and towels under the door.

The hospital rooms are equipped with anti-barricade doors, comprised of a smaller door which opens into the hallway mounted on a piano hinge mounted inside the larger bedroom door. These doors are equipped with a window for patient observation, and are effective for providing emergency assess to patient rooms that have been barricaded. Inquiry into the use of the anti-barricade door reveals there was no protocol on how to approach the patient in the room using the anti-barricade door until 6 days after patient #9 had barricaded herself into her room. The protocol was needed since only one staff person may pass through the smaller anti-barricade door at any given time.

The protocol "Patient Barricade Situation-Protocol" for the use of the anti-barricade doors states in part, " #1) On the adult units, the anti-barricade door is employed to enter the room, and push obstacles away from the door, and #3) Security is contacted for assistance with the response, and #5) Staff will attempt continuous verbal contact with the patient until the patient is released from the room. "

While this protocol describes some staff actions, the protocol lacks direction on offering progressive steps and definitive direction to staff on how to safely accomplish the goals of approaching an agitated patient by way of the smaller anti-barricade door. The protocol failed to include basic elements of managing a patient in a barricade situation, staffing needs and other safety considerations that could minimize risk to the patient and staff.

Based on a review of 10 patient records, patient care plans, and direction to nursing staff for the responsibilities of and initiation of admissions, it is revealed that 1) nursing is directed to initiate the Interdisciplinary Care Plan, including the filling out of Diagnostic Axis I-V which is not within the RN scope of care, 2) nursing enters inappropriate diagnostic information into these Axis, and/or fails to address potential and actual health problems as found in the record of patient #3, and #9, and 3) Nursing failed to address specific health issues for patient #9 in the treatment plan.

A behavioral health unit checklist "RN Admission Responsibilities" reveals multiple tasks which RNs admitting new patients to the unit are required to perform. Of these tasks, under the Initiate ITP (Interdisciplinary Treatment Plan) section, the RN is instructed to "Complete Axis I-V, and Choose all appropriate problems on the Index of Problems (including "Health Condition" if there are any active Axis III problems).

Patient #3 is a late-middle-aged female who admitted to the behavioral health unit in late June 2014. A History and Physical Psychiatry Assessment reveals Axis I as Psychotic disorder NOS (not otherwise specified), r/o (rule out) Schizoaffective disorder; and Mood disorder NOS. The Axis III reveals health concerns as DM (diabetes mellitus), hypothyroid, hyperlipidemia, GERD (gastroesophageal reflux disease); h/o (history of) pulmonary edema; s/p (status post) tubal ligation. However, the initial ITP begun by the RN reveals, an Axis I of "Mania, Psychosis," and the Axis III reveals "None."

Patient #9 is a pregnant (twins), diabetic adult female admitted in late May 2014. Patient #9 was noted to be in denial of her pregnancy and noncompliant with related health care for her pregnancy and diabetes. While the nursing assessment identifies patient #9 as pregnant and diabetic, "none" is documented under Nutritional Risks. "

Additionally, while the ITP reveals an Axis III of "Pregnant, DM" and patient #9 did receive appropriate obstetric care with the later addition to the ITP of related problems and interventions, nursing failed to identify and address problems related to the denied pregnancy in the initial ITP. Based on this, patient #9 who was a potential risk to her unborn children had no nursing interventions listed had she become an actual risk to her fetuses.