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Based on record review, staff interview and policy review, the facility failed to ensure patients were not chemically restrained in a medically induced coma with intubation to manage behaviors. (A0154)

Based on record review, staff interview and policy review, the facility failed to ensure patients were not chemically restrained in a medically induced coma with intubation to manage behaviors. This affected one (Patient #1) out of five patients reviewed for restraints. The hospital census was 130.

Findings include:

Review of the medical record for Patient #1 revealed he arrived at the facility emergency room on 08/16/25 at 5:03 P.M. via ambulance. Patient #1 came to the emergency room after attacking two staff members at his home facility and banging his head on the ground causing a laceration. The laceration required six staples to close. Patient #1 had a past medical history of moderate intellectual disability, antisocial personality disorder, anxiety, borderline personality disorder, and intermittent explosive disorder. Around 7:45 P.M. Patient #1 began demonstrating self-injurious behaviors such as banging his head causing his staples to bleed. Patient #1 was unable to be redirected. To control his behaviors he was placed in soft wrist and ankle restraints and administered the psychotropic medications Geodon and Ativan. Patient #1 was also given a one-on-one sitter. During this time Patient #1 reported he wanted to commit suicide. Psychiatric services were consulted. While restrained Patient #1 continued with self-injurious behaviors such as banging his head off the side rails and threatening to suffocate himself in the bed. Psychiatric services recommended an acute psychiatric stay and began working on placement and involuntary admission forms.

During his emergency room stay Patient #1 continued with periods of self-injurious behaviors and behaviors towards others. At one point he pushed a nurse into the wall forcefully. Patient #1 was given additional diagnoses of unspecified psychosis and depression.

On 08/18/25, while still in the emergency department, Patient #1 reported he was unable to urinate. Urology assessed Patient #1 in the emergency department and recommended a Foley catheter due to urinary retention. Patient #1 was then admitted to a general medical floor on 08/18/25 around 2:45 P.M. During his brief stay on the general medical floor Patient #1 had numerous behaviors including ripping out one of his staples and throwing it at a nurse. Patient #1 was placed in four-point leather restraints and the decision was made to admit Patient #1 to the Intensive Care Unit (ICU) for closer monitoring.

Patient #1 was transferred to the ICU on 08/18/25 at 7:00 P.M.. Once in the ICU Patient #1 was not able to be redirected, treated with medications, and while in four-point leather restraints he headbutted a nurse. The decision was made to place Patient #1 in medical sedation with intubation to protect staff and himself. Patient #1 was administered Propofol (a sedative-hypnotic anesthesia medication) and intubated on 08/18/25 at 11:47 P.M.

Review of the physician progress note dated 08/19/25 at 12:44 P.M. notes the patient has exhibited violent behavior toward staff, prompting transfer to the ICU for chemical restraint in order to protect staff and patient from physical harm. Chemical restraint agents required to provide protection to patient and staff, warranted intubation for airway protection.

Following the sedation and intubation Patient #1's discharge plan was admission to the facility's main campus where he could be extubated with psychiatric services onsite, however a bed was not yet available. The staff did attempt extubation of Patient #1 during his stay but each time he began pulling at his endotracheal tube attempting to self-extubate as he woke up.

On 08/21/25 Patient #1 began running a fever and experiencing tachycardia. Patient #1 was treated with Tylenol and medications to control his heart rate which in turn lowered his blood pressure. On 08/23/25 at 3:48 A.M. Patient #1 was transferred to the facility's main hospital still intubated and in a medically induced coma.

During a telephone interview on 09/17/25 at 7:39 A.M., Registered Nurse (RN) Staff O stated she was working in the emergency department when Patient #1 came in for a head injury. She reported about a half hour into his care he reported he wanted to kill himself. She reported this changed the trajectory of his care. Psychiatric services were consulted and Patient #1 began banging his head reopening his stitches. Patient #1 was medicated, which did not work, then he was restrained in four-point restraints. While in restraints Patient #1 was still banging his head off the bed rails and threatening to suffocate himself in the bed. Patient #1 was given a one-to-one sitter.

During a telephone interview on 09/17/25 at 9:11 A.M., RN Staff P stated she was the charge nurse on duty when Patient #1 was admitted from the emergency department to the general medical floor. She reported the plan was to get Patient #1 to urinate on his own and be released to a psychiatric facility for further care. Patient #1 was placed in a bed closest to the nursing station and he arrived on the unit with a one-on-one sitter. When Patient #1 arrived on the unit he was not using restraints. Patient #1 was cooperative and pleasant but unable to answer questions about his medical history. Patient #1 then began hitting his head and was able to be verbally deescalated. However, he quickly began hitting his head again. A Code Violet (an emergency situation where an individual is violent or combative) was called. He was placed in soft restraints and given medications for his behaviors. Another Code Violet was called after Patient #1 violently kicked an aide from his home facility who had been staying with him in the emergency department. Patient #1 began shaking the bed in an attempt to flip it. The physician consulted with the psychiatric provider and the intensive care physician. It was decided Patient #1 could benefit from closer monitoring. A plan was put into place for Patient #1 to be admitted to the intensive care unit. Staff P reported during his stay on her unit she had numerous conversations with Patient #1 about what therapeutic measures they could take to divert his behavior. Patient #1 reported he liked music. Staff P made sure a radio was placed in his room playing music he requested. Patient #1 also reported he did not like certain pillows and she replaced them with ones he liked. Staff P reported Patient #1 was calm and cooperative and able to verbalize his needs, but then would suddenly shove a spoon down his throat.

During an interview on 09/17/25 at 1:02 P.M., ICU Physician Staff S confirmed she was working in the ICU when Patient #1 was admitted on 08/18/25 and provided care for him until discharged on 08/23/25. Staff S revealed when Patient #1 arrived on the unit he was very aggressive towards staff and headbutted a nurse while in four-point leather restraints. Due to his history of assaulting an emergency room nurse, a floor nurse, and now headbutting another nurse, the decision was made, with consultation from the psychiatrist, for Patient #1 to be sedated and intubated. Staff S reported the plan was to get Patient #1 medicated with his regular medications. He had been accepted to their main campus ICU where he could be extubated with staff equipped to handle his mental crisis. Staff S confirmed Patient #1 had three to four attempts to extubate during his stay in the ICU. Each time Patient #1 was attempting to self-extubate when the Propofol was decreased. On 08/22/25, while still intubated and sedated, Patient #1 developed suspected neuro malignant syndrome and supportive treatment was initiated. Patient #1 had all symptoms except for rigidity. During this time a bed became available at the main campus and Patient #1 was eventually transferred. Staff S confirmed mechanical ventilation and sedation is not a common practice to control patient behaviors, but Patient #1 was an extraordinary patient and required it to maintain the safety of him and the staff.

During an interview on 09/17/25 at 1:22 P.M., Chief Medical Officer Staff C stated the plan for Patient #1 was get his urology situation resolved and get him to a psychiatric facility for further treatment. She reported his behaviors were erratic and he was sent to the ICU for closer monitoring and to be able to receive his medications reliably. Patient #1 was sedated and intubated due to his agitation, self-injurious behavior, and staff safety.

Review of the facility policy titled "Use of Restraints and Seclusion Adults and Pediatrics," dated October 2022, revealed a chemical restraint is a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. The hospital uses the least restrictive form of restraint or seclusion that protects physical safety of the patient, staff, or others. Chemical restraint is used only in the adult emergency department with ketamine administration.