HospitalInspections.org

Based on a review of 5 restraint/seclusions as part of a sample of 10 medical records and other documentation, it was determined that the hospital failed to conduct a safe, appropriate and authorized restraint of patient #1 (P1) which resulted in severe injury, and failed to conduct retraining for the staff member who caused the injury.

Patient #1 (P1) was a middle-aged patient, admitted for greater than 20 years to the psychiatric hospital. P1 had a history in part, of a low-average cognitive ability secondary to a genetic condition, and a history of osteopenia (weakened bones), and vitamin D deficiency (promotes bone growth). For these conditions, P1 received calcium, vitamin D and a medication to treat Osteoporosis (porous bone).

In September 2018 nursing documentation of 0845 described P1 in part as, "Physically and verbally threatening, spitting at staff and banging on the nursing station window." According to P1's record, banging on the nursing station was typical for P1 who had difficulty with impulsivity. P1 was focused on the supervising RN (SRN) who moved into the nursing station to reduce stimulus to P1. RN #2 was on the unit but was initially giving report to the psychiatrist at the time of the event.

Other documentation revealed statements from other staff present with details that after being spit on, DCA1 suddenly, and without licensed direction to do so, grabbed P1 forcefully and took P1 to the floor. One account in part, is as follows:
Clinician #1 (C1) stated in part " ...(DCA1) then lunged forward and grabbed (P1) in a bear-hug with his arms around P1 and they both quickly landed on the floor. (DCA 1) stated to (P1) 'You don't spit on people." There was no verbal command to (DCA1) or from (DCA1) to other staff prior to this to place hands on or take the patient to the floor."

C1 also documented that there was also " ...no non-verbal communication ... for the action based on the fact that both the SRN and the psychiatrist were in the nursing station at that time." Further, that C1 witnessed P1 landing on P1's right side and, "(P1) immediately yelling, "My leg my leg!" C1 stated, "(P1) was eventually lifted to a standing position escorted to the Seclusion Room, and placed in 4-point restraints. (P1) continued to state that (P1's) leg hurt and 'It's broken' throughout the process."

Clinician #2 (C2) who witnessed the event stated in part, " ...The force I observed was (DCA1) running toward (P1) and tackling (P1) near (P1's) knees and taking (P1) to the floor." Additionally, the C2 stated, "They carried (P1) to the seclusion room. (P1) was screaming 'my leg, you hurt my leg.' (P1) was told by staff that the doctor would be called to assess (P1's) leg."

P1 was subsequently found to have a fractured hip, fractured upper arm bone and other injuries. DCA1 was placed on administrative leave for 5 days during investigation. DCA1 was then brought back to the hospital to work. During review of DCA1's employee file Administrative staff stated that DCA1 was to have restraint re-training, though nothing was noted in the employee file specific to that and no re-training had been initiated. Therefore, at the time of survey, more than a month after the event, DCA1 continued working on the unit without having had re-training for a serious, and unsafe misuse of restraint techniques.

In summary, an unlicensed staff member inappropriately, and without direction, forcefully took P1 to the floor causing P1 serious injury. Following investigation, the hospital failed to re-train DCA1 in appropriate, safe, and authorized restraint processes.

Based on a review of 5 restraint/seclusions and other documentation, it was determined that the hospital failed to conduct an immediate assessment for complaints of a broken leg for patient #1, and failed to send P1 to the hospital in a timely manner for evaluation of P1's reported leg injury.

Patient #1 (P1) was a middle-aged patient, admitted for greater than 20 years to the psychiatric hospital. P1 had a history in part, of a low-average cognitive ability secondary to a genetic condition, and a history of osteopenia (weakened bones), and vitamin D deficiency (promotes bone growth). For these conditions, P1 received calcium, vitamin D and a medication to treat Osteoporosis (porous bone).

In September 2018 nursing documentation of 0845 described P1 in part as, "Physically and verbally threatening, spitting at staff and banging on the nursing station window." According to P1's record, banging on the nursing station was typical for P1 who had difficulty with impulsivity. P1 was focused on the supervising RN (SRN) who moved into the nursing station to reduce stimulus to P1. RN #2 was on the unit but was initially giving report to the psychiatrist at the time of the event.

Other documentation contained statements with details that after being spit on, DCA1 suddenly, and without licensed direction to do so, grabbed P1 forcefully and took P1 to the floor. One account in part, is as follows:

C1 documented witnessing P1 landing on P1's right side and, "(P1) immediately yelling, "My leg my leg!" CP stated, "(P1) was eventually lifted to a standing position escorted to the Seclusion Room, and placed in 4-point restraints. (P1) continued to state that (P1's) leg hurt and 'It's broken' throughout the process."

Clinician #2 (C2) who witnessed the event stated in part, " ...The force I observed was (DCA1) running toward (P1) and tackling (P1) near (P1's) knees and taking (P1) to the floor." Additionally, the C2 stated, "They carried (P1) to the seclusion room. (P1) was screaming my leg, you hurt my leg. (P1) was told by staff that the doctor would be called to assess (P1's) leg."

A face to face (f2f) at 0900 conducted by a psychiatrist had a checked box for "Medical Status has been assessed, with the notation, "states (right) leg pain." No assessment of the P1's complaints was documented despite P1's complaints and no notation was found in the record indicating why no physical assessment had been done. Instead, staff moved P1 to administer ordered intramuscular medication, moved P1 to a remote seclusion bed for further application of 4-point restraints lasting one hour, and then moved P1 again to P1's bedroom despite the fact that P1 continuously complained of severe leg pain.

RN restraint record documentation timed for 0845 revealed in part, " ...Spitting in staff faces 4 point bed restraints initiated after 2 minute physical restraint (with) spit sock. VS (vital signs) 96.2, 94, 20, 137/75;" and at 0900, " ...Hypertalkative about injuries and yelling out for staff. Not following staff direction to relax..., and, "patient spit on multiple staff before a spit sock could be applied. 2 minute physical hold was used from 0845-0847 and then 4-point restraints were applied at 847 am. Patient c/o right leg being "broken." No visible injuries noted ...PAC (physician assistant, certified) notified of need to see patient. Will monitor for continued aggression."

In an interview with P1 on 10/22/18 at approximately 1030, P1's asserted that after going to the floor, P1 felt severe pain and "screamed" about leg pain, "But they didn't believe me." P1 stated that staff believed there was an injury "after 15 minutes." However, when P1 was released from restraint at 0955, SRN documented the plan that P1 would go to P1's "Bedroom," and P1 was, "Allowed throughout appropriate areas of unit and bedroom." P1 was again moved without assessment of injuries to P1's bedroom at 1000 evidenced by the rounding sheet. P1 could not have walked to the bedroom because P1 lacked to ability to bear weight on the right leg, and no documentation was found regarding how P1 got to the bedroom.

According to both the psychiatric face to face and the RN note, neither clinician assessed P1 for P1's strongly reported, sometimes "screaming" report of a leg injury, instead deferring evaluation to the PA-C.

A PA-C was made aware that P1 complained of a broken leg and evaluated P1 at 1005, five minutes after P1 was noted to have been moved back in P1's room. The PAC note of 1020 revealed in part, Pt. s/p (status post) fall today (as pt. was taken for 4-point restraint) ...RLE (right lower extremity) externally rotated. Pt is unable to move RLE secondary to c/o pain ...X-ray STAT RLE (immediate xray ordered) requested to rule out fracture/injury. Orthopedic consult for now requested x-ray result pending, continue prn analgesia ..."

While it was clear to the PA-C that P1 had external rotation to the right leg which is one sign of a fractured hip, P1 was not sent to the emergency department (ED). Instead, P1 had to wait for x-rays which were not done until after 1300, 3 hours later. A PAC note of 1445 revealed in part, "Pt's x-ray reported result "Acute Right intertrochanteric femoral fracture." Pt is being sent to hospital for management /evaluation of fracture of R hip ..." No documentation was found regarding the very high risk for fracture due to P1's medical condition.

At the ED, P1 was found to have an acute right comminuted (break or splinter of bone in more than two pieces) hip fracture which required surgical intervention, as well as a right humerus (bone which connects shoulder to elbow) fracture, and scrotal swelling due to hematomas. P1 required surgery to repair the hip fracture.

Documentation indicated that P1's hip was fractured about 0845 for which P1 was able to strongly verbalize an injury. Despite P1's strong complaints of injury, and the obvious high risk for fracture due to osteoporosis, P1 was moved to administer intramuscular medication, then moved from the floor to a bed where all 4 of P1's extremities were restrained for one hour, and then moved again to P1's bedroom where P1 was finally seen by the PA-C. Despite the PA-C assessment of external rotation of P1's leg, the hospital waited did not send P1 out emergently, opting to conduct portable x-rays in the facility. Ultimately, P1 was not sent to the ED until approximately 1500, which delayed P1's full evaluation and care for at least 6 hours. This delay revealed no clinical evaluation or on-going monitoring after P1 was seen by a psychiatrist, and an RN, who both quoted P1's complaint, yet failed to complete an actual physical examination.