HospitalInspections.org

Based on interview, review of training files and review of 1 of 3 clinical records there was a failure to ensure a safe treatment environment by using an unapproved restraint procedure resulting in a patient injury.
Findings:

Citing patient #1, an 11 year old male, was admitted to the facility on 2/10/2011 due to severe aggressive behavior.
A progress note written by personnel #21, psychiatric technician(Psych Tech) reflected the following:

2/15/2011 12:50pm " Patient walked out of school saying his throat was hurting..........he sat in the hallway threatening a peer with "I ' m going to beat you up." Patient then went into another peers's room and scratched his arm. Writer intervened. The patient then attempted to hit peer with his fist then grabbed writer by the shirt. Writer grabbed patient by the wrists. Patient then threw himself to the ground. A pop from his arm was heard."

An X-ray performed on 2/16/2011 diagnosed: Supracondylar fracture of the left humerous.

Review of the personnel file for personnel #21 reflected current training in non violent crisis intervention. A post test following training noted " In order to diffuse a dangerous situation resist any temptation to grab the patient"

During interview at 8:15am on 4/12/2011 personnel #21 stated he did grab the patient's wrists and did not let go when the patient threw himself on the floor. Personnel #21 stated " grabbing the patient's wrists was a "natural reaction."