HospitalInspections.org

Based on record review, staff interviews, review of policies/procedures, and review of other related documents and video tape, the hospital failed to ensure one Emergency Department (ED) patient was treated in a safe setting by not providing continuous monitoring while in seclusion, failing to follow the hospital policy/procedure, and by failing to develop a policy/procedure depicting the specific roles and duties of ED staff in such situations. Failure to provide a safe environment places all ED patients in restraints/seclusion at risk for self harm.

Findings include:

1. The hospital policy/procedure titled "Restraints/Seclusion" Was reviewed on October 11, 2010. The policy/procedure states "Behavioral Restraints/Seclusion, 15. Ensure the patient is continuously monitored. This represents direct visualization that is uninterrupted. A patient may be watched through a window or doorway if the presence of the staff agitates the patient more., 16. For a patient in seclusion, the patient must be continually monitored for the first hour and then may progress to audio-visual monitoring. However, a staff must be designated to watch the monitor, plan ahead for breaks." and "Simultaneously Restraints and Seclusion Use, 1. Restraints and Seclusion may not be used simultaneously unless the patient is continually monitored mace-to-face by an assigned staff member for the first hour., 3. The patient will be continuously monitored. This can be accomplished by "direct presence line of sight or video observation," such as through a window or doorway in the event staff presence in the room could be dangerous or add to the agitation of the patient, 5. After the first hour and if the individual is not in a physical hold and individual is in seclusion only, the individual either is continually monitored by staff face-to-face or by using both video and audio equipment. If using video and audio equipment, this monitoring must be in close proximity to the patient and be done by a dedicated qualified staff person who can respond to the individual at any given moment."

2. I interviewed a quality director and an ED manager regarding the use of the restraint/seclusion policy/procedure in the ED. Both stated there was no specific ED policy/procedure that outlines the duties and responsibilities of staff while monitoring a patient in restraints/seclusion

3. Patient #1 was brought to the hospital ED by police officers for a mental health evaluation after violence at a local motel. The police officers were familiar with the individual and feared violence against ED staff and police officers. The police officers asked that no staff member be in direct contact with the patient unless a hospital security officer and/or a police officer was also present.

Nursing documentation in the patient's ED medical record noted the patient was placed in locked seclusion with suicide precautions for safety to self and others pending an evaluation. The seclusion room was monitored by camera to provide continuous observation.

4. A quality director was interviewed on October 11, 2010. She stated the patient had been in seclusion for the sake of safety to self and others. She stated that since the seclusion room was locked from the outside it would be considered a restraint as well.

5. A hospital security officer was also present outside the room to observe the patient through a window in the door. The security officer remained at the observation post for approximately 3 and 1/2 hours, at times entering the room with ED nursing staff when they provided treatments. In an interview on October 11, 2010, the security officer stated she left the observation post at 2:22 PM to attend to another hospital security issue and checked out of the ED after reporting to the nursing staff.

The security officer stated she returned to the ED at 2:46 PM and noted on the camera monitor at the nursing station that the patient was pacing and acting "jittery." She reported the patient's behavior to both an ED nurse then to an ED physician. She stated the physician then decided it was critical to obtain a urine sample from the patient so they could conduct toxicity tests to determine what drugs the patient had taken which were affecting behavior. She stated she continued to observe the patient alternating from the seclusion door to the camera monitor at the nursing station while additional police officers were asked for to assist with catheterization of the patient for the urine sample.

The security officer stated she entered the seclusion room at 3:23 PM along with police officers. Upon entry she stated she noted the patient was not breathing and had no pulse. She stated she called a "Code Blue" or a request for assistance with resuscitation of the patient. Resuscitation efforts were not successful and the patient expired at 3:51 PM.

6. A video recording of the patient's stay in the ED was viewed on August 17, 2010 and a printed timeline of the video contents was reviewed on October 11, 2010. On the actual video recording 2:25 PM the patient was seen taking a packet of some substance from under the blanket and throwing the packet to the far corner of the room behind him. At 2:46 PM the patient was seen to get out of bed and grab the packet off the floor. The patient is then seen pouring the packet contents into his hand, ingesting the substance, and then drinking apple juice. At 2:47 PM the patient is seen getting back into bed and he starts moving and rocking back and forth. The video recording continues and shows the patient talking and pointing and becoming very fidgety. At 3:16 PM the patient's behavior begins to slow and at 3:20 PM there is no discernable patient movement on the recording. Police officers and a security officer enter the room at 3:23 PM and note the absence of a pulse and breathing and a resuscitation begins.

7. When asked who had continuously monitored the patient in seclusion during the time the security officer had left the ED and when the patient was seem ingesting a substance with behavior changes, a quality director stated based on her interviews no ED had been watching the video recording and/or seen the events during that time. The patient had not been continuously monitored for a period of 22 minutes during which time he was seen to inflict self-harm and died as a result when he was unable to be resuscitated.