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Based on document review, and interviews the hospital failed to protect the rights of Patient #1, when during a restraint procedure, Patient #1 sustained a displaced oblique fracture of her right arm. This failure places the Condition of Participation of Patient Rights out of compliance.


Refer to A144.

Based on interview and record review the facility failed to provide a safe environment for 1 of 5 patients (Patient #1) in the sample This failure resulted in a serious injury to the patient. Findings include:

A review of Patient #1's medical records documents that she has diagnoses including Attention Hyperactivity Disorder, Intermittent Explosive Disorder, and Oppositional Defiant Disorder. Her Comprehensive Treatment Summary, dated 3/11/2011 documents that she was admitted to the facility for significant "out-of-control" behaviors including self injurious behavior, suicidal ideations, and physical aggression toward adults. The goal of her therapy is to provide positive reinforcement for appropriate behavior. If self-injurious behavior or threats is noted, staff will initiate interventions to include: 1:1 discussions, time outs, holds, seclusions or restraints, if less restrictive methods fail.

A review of the internal investigation documentation established that on 3/21/2011 at 2:15 p.m., Patient #1 was talking on the phone, was raising her voice, and swearing. Health Services Technician (HST)/(J) told Patient #1 that she needed to end the conversation, and Patient #1 kicked HST/(J), and ran down the hall with the phone. Registered Nurse/(RN)/(I) went down the hall to talk to Patient #1, and asked her to end her conversation. Patient #1 threw the phone at RN(I). She then began to tear the door stopper from the wall. RN(I) told Patient #1 that she needed a time-out, and he approached Patient #1. As he approached her, she pushed him in the chest. RN(I) and HST(J) began to escort Patient #1 down the hallway toward the timeout room. RN(I) stated that he used an arm bar technique, in which he held Patient #1's right arm by the wrist, and with her palm facing back, he brought her arm straight up behind her body. HST(J) had Patient #1 by the left wrist and arm, and was holding it forward. Patient #1 began to swing her arms, and kick at HST(J). RN(I) stated that as they were escorting her, Patient #1 continued to struggle, and he then heard a "pop" sound. He and HST(J) placed Patient #1 onto the floor, assessed her, and called 911. She was transported to the hospital, and was diagnosed with "displaced oblique fracture" of her right arm. She underwent surgery which required a plate and screws to repair the fracture.

RN(I) was interviewed on 5/15/2012 at 10:30 a.m. and stated that on 3/21/2011, Patient #1 was kicking at HST(J) and refused to hang up the phone. He came to assist and was on the right side of Patient #1 and HST(J) was on the left, and they began to escort Patient #1 to the timeout room. He stated that his right hand was on Patient #1's wrist, and his left hand was half way up her forearm, and the palm of her hand was facing back. He stated that while they were walking her down the hall, Patient #1 continued to kick at HST(J). HST(J) stopped, and he took another step. He then heard a "pop" sound, and Patient #1 screamed that her arm hurt. They lowered Patient #1 to the ground, and called 911.

Employee (A)/Supervisor was interviewed on 4/23/2012 at 2:25 p.m., and stated she was the Officer of the Day on the day of the incident. She did not witness the incident, but was told that Employee (J) was holding Patient #1 by the elbow and wrist, and the AP was using the arm bar technique. One staff was on each side and had Patient #1 by the arm, and Patient #1 continued to scream and kick. Employee (J) stopped and the AP took another step, and they then heard a "pop" sound. 911 was called, and Patient #1 was transported to the hospital. Both staff were reeducated on the Personal Safety Techniques (PST) training following the incident.

Employee (E)/Staff Development was interviewed on 5/3/2012 at 9:20 a.m. and stated that all staff are trained on PST's. A physical intervention is used when a client is in imminent danger to self or others, or to escort the client to another location for a time-out. She stated that the technique for an arm bar restraint is used to secure the arm at a 45-90 degree angle (straight out to the side at shoulder level) with the wrist and palm facing up, so the shoulder rotates forward. The staff are to stand close to the patient's body on each side to reduce fighting. She stated that there is always a risk of injury with any restraint, and if the patient is combative, injuries can occur. A manual restraint is used in an emergency when everything else has failed, and only used when it is "safe to do so."

A review of the PST training documentation instructional steps for an arm bar technique documents that the arms are placed at a 45-90 degree angle from the shoulders, with the wrist and palm facing up, causing the shoulders to rotate forward.

RN(I) and HST(J)'s personnel records were reviewed for documentation of training in Physical Intervention and Personal Safety Techniques.

Interview and documentation review established that during the interraction with Patient #1, HST(J) stopped walking to avoid being kicked by Patient #1, and RN(I) continued to walk. This is when they heard a "popping" sound, and Patient #1 screamed that her arm hurt. In addition, the technique described by RN(I) as an arm bar, is not the proper technique used on Patient #1. The arm bar technique places the patient's arms out to the side at a 45-90 degree angle, and not straight back as stated by the RN(I).