HospitalInspections.org

Based on record review, video review, staff interviews and policy review, the Medical Director failed to assure adequate medical staffing to provide psychiatric and medical care for a patient in seclusion (adolescent patient E-18). This patient was physically held and given IM medications two different times and secluded five different times in a span of fewer than 21 hours between 8/6/11 and 8/7/11 without being examined by the attending psychiatrist or the covering psychiatrist or medical physician. The Physician Assistant who was to evaluate the patient did not do so. Instead, medical staff ordered that the patient be transferred to an emergency department for evaluation. The patient, who was on a 1:1 because of aggressive behavior, and who had a history of homicidal ideation, eloped from the Emergency Room and was discharged from the facility subsequent to this. Failure to provide adequate medical staffing for psychiatric and medical care puts all patients at risk.

Findings include:

A. Record Review

1. Patient E-18, an adolescent (under 18 years old) was admitted on 8/4/11at 4:30AM with the diagnosis of Psychosis NOS (not otherwise specified), upon telephone order from the Medical Director. Patient was admitted under care of Psychiatrist Physician 2. The Initial Nursing Assessment on 8/4/11 at 4:30AM noted, "Patient has auditory hallucinations and visual hallucination, also patient is prone to get aggressive." The patient was transferred from the community hospital ER and his "K[potassium] level was 3.3 [low]." A "High Risk Notification Alert" form at the time of admission had "Homicidal" box checked off for"HI [homicidal ideation] directed toward family."

2.According to the nurses notes on 8/6/11, on Saturday, 8/6/11 the patient was placed in physical hold for eleven minutes from 12:20PM to 12:31PM, escorted to quiet room, given 25mg of Thorazine (antipsychotic) IM (intramuscular), and continued in seclusion until 6:00PM. Telephone Orders for Physical Hold at 12:20PM, Seclusion at 2:30PM and Seclusion at 4:30PM were obtained from the treating psychiatrist (Physician 2), who was out of state at the time (see interview below). The medical record showed no evidence of a psychiatrist or any other physician personally evaluating this patient during the entire time between 12:20PM and 6:00PM. A nursing note indicated inability to get vital signs throughout this period. The nursing note at 6 pm on 8/6/11 noted, "no longer striking out, vitals WNL...." Daily Nursing Progress Note dated 8/6/11 indicated patient ate 85 percent breakfast, refused lunch and ate 70 percent of dinner.

3. According to the nurses' notes on 8/7/11, on Sunday 8/7/11, the patient was placed in a physical hold at 6AM, given 25mg of Thorazine IM, and continued in seclusion until 9:08AM. Telephone orders for Physical Hold continuing into seclusion were obtained from Physician 2. At 8:15AM, Physician 2 gave another telephone order to "continue seclusion for another 2 hours." The medical record showed no evidence of a psychiatrist or any other physician personally evaluating this patient during this entire episode between 6:00AM and 9:08AM on 8/7/11, at which time the patient was released from seclusion. A nurses' note at 9:08AM stated the patient was "calmer and cooperative," but refused breakfast.

4. A nursing note on 8/7/11 at 10:10AM stated that Physician 2 asked the nursing staff to "contact Medical staff to notify of refusal to eat X 3days and administration of stat thorazine medications X 2." There was no evidence in the medical record that a Medical Physician or PA-C personally examined the patient on 8/6/11 or 8/7/11. The Doctor's orders on 8/7/11 at 1:40 PM had an entry by RN "T.O. (Telephone Order) (name of PA) PA-C, transfer to [community hospital] to be evaluated for possible dehydration and anorexia for 3 days with a staff escort."

5.The patient was transferred to a community hospital emergency department for evaluation of dehydration and anorexia at 3:10PM on 8/7/11. Staff stated that the patient was in five point restraint on a gurney; there was no order in the chart for restraint.

6. According to the nursing note on 8/7/11 at 4:15PM, "patient eloped from ER."

B. Staff Interviews

1. In an interview with Physician 2 on 8/10/11 at 10:15AM, he reported that he never saw the patient E-18 on 8/6/11 or 8/7/11, as "I was in Michigan." He stated that he was responsible for his patients at all times and that he had called the Medical Director, who was also covering for him, about patient E-18 and talked with the Medial Director about his (Physician 2's) plan to send the patient to an emergency department for medical evaluation as a way to get the lab work done, and evaluate the patient's status after the patient having been given IM Thorazine. When asked about under what circumstances a physician would return to the hospital to see a patient, Physician 2 said he has returned to see his patients but admitted most of the contact was via phone.

2. In an interview with Director of Medical Affairs (the head of the medical team) on 8/10/11 around 10:35am, he stated that his medical team, rather than a psychiatrist, was responsible for all the post-seclusion evaluations, as well as any medical problems for all the patients in the hospital. He reported that the PA-C on his medical team who was on call on 8/7/11 and asked to see the patient did not document anything in the medical record of patient E-18.

3. In an interview on 8/10/11 around 11AM, the Medical Director was asked about the coverage during off hours and weekends and he mentioned that each psychiatrist was responsible for his or her patients around the clock, seven days a week. He also stated that he and Physician 2 always covered each other and that he was covering for Physician 2 on 8/7/11. He stated that Physician 2 had talked about his plans to send the patient E-18 to the Medical ER. In light of this plan, he (Medical Director) did not feel the need to change his schedule in the morning of 8/7/11. "I was going to see the patient in the evening". When asked if he was aware of the seclusions of this patient on 8/6/11, he responded that he was aware.

C. Video Review

Video of the 8/7/11 seclusion of patient E-18 was reviewed around 1 PM on 8/10/11.
It revealed that LPN2 entered the seclusion room alone while PA-C waited outside the seclusion room at 8:39AM. The patient was sitting in the room without exhibiting any agitation. There was no sound for the video. As noted above, the nurse's note at 9:05AM stated patient was noted to be "calmer and cooperative," and was released from seclusion at that time, but refused to eat.

D. Policy Review

Hartgrove Hospital Policy NO: PC 615 revised 07/11 on Restraint and Seclusion, under Physician Order stated: "If an emergency order to restrain is initiated by a RN, a physician must examine the patient as soon as possible but at least within 24 hours and document such in the progress note or restraint/ seclusion record and co-sign the order."