HospitalInspections.org

Based on video observation, interview, and document review, the hospital failed to provide adequate Patient Rights protections for 1 of 10 patients reviewed (P1), when a staff member restrained the patient with an unapproved restraint technique. The patient was injured and indicated it was as a result of the restraint.

Due to the serious nature of this failure the hospital is unable to ensure adequate Patient Rights.

Therefore the hospital is unable to meet the Conditions of Participation of Patient Rights at 42 CFR 482.13.

Findings include:
See A144: Based on video review, interview, and document review, the hospital failed to provide care in a safe setting for 1 of 10 patients reviewed (P1), when mental health associate (MHA)-J placed P1 in an unapproved manual restraint and the patient developed shoulder pain later that day.

See A164: Based on video review, interview, and document review, the hospital failed to ensure restraints were used only used when less restrictive measures had been determined to be ineffective for 1 of 10 patients reviewed (P1), when mental health associate (MHA)-J placed P1 in a manual restraint when P1 did not pose an imminent threat to staff or other patients.

Based on video review, interview, and document review, the hospital failed to provide care in a safe setting for 1 of 10 patients reviewed (P1), when mental health associate (MHA)-J placed P1 in an unapproved manual restraint and the patient developed shoulder pain the next day.

Findings include:

Medical record review revealed P1 was admitted to the hospital's emergency room on 3/14/19, and to the hospital's mental health unit on 3/15/19, with diagnoses that included Schizoaffective Disorder. P1's admission History and Physical dated 3/16/19, revealed upon admission the patient was displaying manic behavior with rapid speech and suicidal statements. The patient was threatening to kill her mother, and had a physical altercation with her mother before admission. The patient had a history of stabbing her mother, and a history of being committed as mentally ill and dangerous. P1 was placed on a 72 hour hold.

A physician behavior restraint progress note, written by MD-N, titled Violent Behavior Face to Face Evaluation dated 3/16/19, revealed the patient demonstrated agitated behavior, spitting at staff, and she was restrained by staff.

A progress note dated 3/16/19, written by MHA-J revealed: At approximately 8:50 a.m. P1 approached the nursing desk and ask to check her weight. After she was weighed, she became agitated, swearing, and raising her voice and running around the area. The patient spat on registered nurse (RN)-M who was sitting behind the nursing desk. MHA-J manually restrained P1 and walked her to the seclusion room alone.

A nursing note dated 3/17/19, at 5:31 a.m. revealed P1 complained of left shoulder pain rated 4/10. P1 was given Ibuprofen for shoulder pain.

A video of the restraint was reviewed on 4/3/19, at 8:30 a.m. with hospital staff. The video revealed that P1 spoke with staff at the nursing desk, weighed herself with the assist of MHA-J, and then paced the area. P1 walked up to the nursing desk and spat on RN-M. P1 started walking away from the desk, staff, and other patients. MHA-J immediately grabbed P1's arms, forcefully pulled them up and behind her head and back, and walked her to the seclusion room alone.

During an interview on 4/2/19, at 3:05 p.m. MHA-J stated that he restrained P1 in a manual restraint that was not one of the approved manual restraints. MHA-J stated it was more like a "half-Nelson." Although MHA-J stated he used un unapproved restraint technique, he thought he had to, because the patient was escalating and he feared for the staff and other patients. He stated in an ideal world, he would have waited for the assist from other staff, but stated he did not think he could wait. MHA-J stated he did not try to call for help. MHA-J further stated P1 did not fight the restraint, and he did not think it was forceful.

During an interview with RN-E (administrative RN) on 4/3/19, at 8:30 a.m. she stated the restraint MHA-J implemented on P1 seen in the video was an unapproved restraint technique according to the hospital's restraint training. RN-E stated MHA-J's level of response to the incident seemed out of proportion, given the circumstances. RN-E stated P1 later complained of pain in her shoulder, but the pain in her shoulder was not brought to a physician's attention, so was not assessed by a physician. RN-E stated the pain complaint should have been brought to a medical provider's attention.

During an interview on 4/9/19, at 10:35 a.m. the P1 stated she spat on the nurse behind the desk, and then started to walk away. She stated MHA-J grabbed her from behind, and then crunched her shoulders together so much that he broke her collarbone. P1 stated she is scheduled to have surgery on the broken bone on 4/16/19.

The hospital's training for restraints titled Personal Safety and Physical Intervention Manual dated 2019 - 2020 revealed:

Staff who are designated as Code Green Responders must have education, training and demonstrate competence in the following:
5. Demonstrate the safe application and use of all types of restraint used in the hospital setting.
Whenever possible: Staff is encouraged to take evasive action and escape in lieu of physically engaging the patient alone in a physical altercation that could result in serious and debilitating injury to staff or the patient....If physical intervention is required, staff is to inform the team that we need to move hands on by clearly articulating the words: "Take Control." It is important that staff initiate the physical contact together as a team and avoid a single staff putting hands on the patient prior to the rest of the team...Two person escort. The escort should be used only if the person must be moved and less intrusive measures such as verbal redirection, gesture, or gentle guidance are not effective.

A review of the Code Green education materials revealed there were no safe manual holds described for only one staff person to initiate alone.

The policy titled Restraints and Seclusion - Management of violent and/or Self Destructive Behavior and dated approved August 2018, and provided by hospital staff revealed under staff training: To minimize the use of restraint and seclusion, all direct care staff and any other staff involved in the use of restraint and seclusion must receive education, training and demonstrate knowledge based on the specific needs of the patient population in at least the following:...The safe application and use of all types of restraint or seclusion used in the hospital.

Based on video review, interview, and document review, the hospital failed to ensure restraints were used only used when less restrictive measures had been determined to be ineffective for 1 of 10 patients reviewed (P1), when mental health associate (MHA)-J placed P1 in a manual restraint when P1 did not pose an imminent threat to staff or other patients. Findings include:

Medical record review revealed P1 was admitted to the hospital's emergency room on 3/14/19, and to the hospital's mental health unit on 3/15/19, with diagnoses that included Schizoaffective Disorder. P1's admission History and Physical dated 3/16/19, revealed upon admission the patient was displaying manic behavior with rapid speech and suicidal statements. The patient was threatening to kill her mother, and had a physical altercation with her mother before admission. The patient had a history of stabbing her mother, and a history of being committed as mentally ill and dangerous. P1 was placed on a 72 hour hold.

A physician behavior restraint progress note written by MD-N titled Violent Behavior Face to Face Evaluation dated 3/16/19, revealed the patient demonstrated agitated behavior, spitting at staff, and she was restrained by staff.

A progress note dated 3/16/19, written by MHA-J revealed: At approximately 8:50 a m. P1 approached the nursing desk and ask to check her weight. After she was weighed, she became agitated, swearing, and raising her voice and running around the area. The patient spat on registered nurse (RN)-M who was sitting behind the nursing desk. MHA-J manually restrained P1 and walked her to the seclusion room alone.

A video of the restraint was reviewed on 4/3/19, at 8:30 a.m. with hospital staff. The video revealed that P1 spoke with staff at the nursing desk, weighed herself with the assist of MHA-J, and then paced the area. P1 walked up to the nursing desk and spat on RN-M. P1 started walking away from the desk, staff, and other patients. MHA-J immediately grabbed P1's arms, forcefully pulled them up and behind her head and back, and walked her to the seclusion room.

During an interview on 4/2/19, at 3:05 p.m. MHA-J stated that he restrained P1 in a manual restraint. Although MHA-J stated he placed P1 in a manual restraint, he stated he thought he had to because the patient was escalating and he feared for the staff and other patients. MHA-J stated he did not try to call for help. MHA-J further stated P1 did not fight the restraint.

During an interview with RN-E (administrative RN) on 4/3/19, at 8:30 a.m. she stated the restraint MHA-J implemented on P1 seen in the video was an unapproved restraint technique according to the hospital's restraint training. RN-E stated MHA-J's level of response to the incident seemed out of proportion, given the circumstances, and it appeared to be an inappropriate use of restraint. RN-E stated she would have expected MHA-J to call for help before initiating the restraint, attempt some de-escalation before initiating the restraint, and confirmed that the patient was walking away when the restraint was initiated, and therefore she was not an imminent threat.

During an interview on 4/9/19, at 10:35 a.m. P1 stated she spat on the nurse behind the desk, and then started to walk away. She stated MHA-J grabbed her from behind and then crunched her shoulders together so much that he broke her collarbone. P1 stated she is scheduled to have surgery on the broken bone on 4/16/19.

The hospital's training for restraints titled Personal Safety and Physical Intervention Manual dated 2019 - 2020 revealed:

Staff who are designated as Code Green Responders must have education, training and demonstrate competence in the following:
5. Demonstrate the safe application and use of all types of restraint used in the hospital setting.
Whenever possible: Staff is encouraged to take evasive action and escape in lieu of physically engaging the patient alone in a physical altercation that could result in serious and debilitating injury to staff or the patient....If physical intervention is required, staff is to inform the team that we need to move hands on by clearly articulating the words: "Take Control." It is important that staff initiate the physical contact together as a team and avoid a single staff putting hands on the patient prior to the rest of the team...Two person escort. The escort should be used only if the person must be moved and less intrusive measures such as verbal redirection, gesture, or gentle guidance are not effective.