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PSYCHIATRIC INSTITUTE OF WASHINGTON DC 4228 WISCONSIN AVENUE, NW WASHINGTON, DC July 5, 2013
VIOLATION: CONTENT OF RECORD Tag No: A0449
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and staff interview it was determined that the clinical staff failed to document all information necessary to monitor the patient ' s condition as evidenced by the failure to provide documented evidence of medical follow-up by licensed, designated clinical medical staff for Patient #1 who was injured during restraint activity.

The findings include:

Patient #1 was admitted [DATE] with diagnoses which include Mood Disorder Not Otherwise Specified, and Parent-Child Relational Problems; as well as history of Bipolar Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Post Traumatic Stress Disorder.

According to the medical record a physical hold was performed on the patient on May 11, 2013 at approximately 5:50 PM. At an undesignated time after the physical hold was discontinued at 5:52 PM, the patient was noted to complain of Right Shoulder Pain and inability to lift and extend the Right arm. The patient was subsequently sent for evaluation and treatment an outside hospital emergency department, which concluded with diagnosis of Spiral Fracture of the Right Humerus.

The patient returned to the hospital at approximately 2:30 AM May 12, 2013. According to the Emergency Department discharge instructions, the patient was to keep the arm immobilized, and to follow up with Orthopedics within one (1) week. The patient was also prescribed Acetaminophen with Codeine for severe pain, and given instructions for the use of a sling and swathe for immobilization.

Review of the medical record revealed the Multidisciplinary Progress note written May 12, 2013 at 6:15 AM which detailed that the patient returned to the hospital at approximately 2:30 AM. A call was placed to the on-call physician, and the nursing staff was awaiting a return call. The medical record lacked documented evidence of a physician response to the aforementioned call.

The Multidisciplinary Progress notes of May 12, 2013 reflected that during the evening shift, the patient complained of Right Arm Pain. The medical record lacked documented evidence that a representative of the medical staff reviewed the medical record or evaluated the patient post injury after physical hold. Further, the medical record lacked documented evidence that the nursing staff assessed for pain, neurological deficits, or vascular deficits which could indicate regression of the status of the injury; or that the patient was monitored for proper application and /or use of the sling and swathe for immobilization.

The clinical staff failed to provide documented evidence that the patient was appropriately monitored following injury sustained during physical hold. The clinical staff failed to document all information necessary to monitor the patient ' s condition.
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and staff interview it was determined that the hospital's clinical staff failed to ensure the completeness of documentation in the medical record as evidenced by the failure of the staff to complete Section 5 of the Physical Hold/Seclusion/Leathers Documentation, related to patient debriefing in one (1) of ten (10) medical records reviewed (Patient #1).

The findings include:

The Psychiatric Institute of Washington Policy NSG.081 entitled Restraint and Seclusion, revised or reviewed September 2012, was reviewed. The Termination of Physical Hold, Restraint or Seclusion section, Item 3 stipulates " ... The patient and staff participate in a debriefing about the physical hold, restraint or seclusion episode as soon as is possible and appropriate but not longer than 24 hours. Family/significant other is included when appropriate ...Staff should: Identify what led to the incident ...When indicated, modify the patient ' s treatment plan ... "

The Psychiatric Institute of Washington Form #105-110 entitled Physical Hold / Seclusion / Leathers, revised June 2011 was reviewed. Page One (1) of the document details ' Documentation Directions ' and stipulates " ...4. Complete all areas of each Section (#1-6) ... " Page Four (4) entitled Staff Debriefing stipulates the following query " Was the patient or staff member(s) injured during the procedure: No or Yes. If yes, what caused the injury (complete a Hospital Occurrence Report and /or Employee Injury Report. " Page Six (6), Section #5 entitled Patient Debriefing stipulates " Must be completed within 24 hours of event " .

Patient #1 was admitted [DATE] with diagnoses which include Mood Disorder Not Otherwise Specified, and Parent-Child Relational Problems; as well as history of Bipolar Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Post Traumatic Stress Disorder.

According to the medical record a physical hold was performed on the patient on May 11, 2013 at approximately 5:50 PM. As per hospital policy, Form 105-110 - Physical Hold / Seclusion / Leathers was initiated. At an undesignated time after the physical hold was discontinued at 5:52 PM, the patient was noted to complain of Right Shoulder Pain and inability to lift and extend the Right Arm. The patient was subsequently sent for evaluation and treatment an outside hospital emergency department, which concluded with diagnosis of Spiral Fracture of the Right Humerus.

Review of the Physical Hold / Seclusion / Leathers form Section 4, entitled Staff Debriefing, revealed the staff member initiating the intervention was debriefed at 9:00 PM an May 11, 2013. The form detailed that the physical hold occurred emergently, due to the patient ' s agitation and threatening of staff members. The form queries regarding patient injury, and cause of injury. The form lacked documented evidence of the staff member ' s account of what caused the patients ' injury, detailing that the " patient complained of Right shoulder pain, not able to lift and extend Right arm. "

The Patient Debriefing portion, Section 5 was also reviewed. The section was not complete at the time of the off-site review on May 16, 2013 at 9:00AM. During an interview with the Nursing Supervisor on May 13, 2013 at 3:35PM, he/she stated that "since the physical hold form, in this incident was not completed, the patient's debriefing should have been done the next day and the patient's injury report should be considered a part of the debriefing". Also during an interview with the Charge Nurse on June 20, 2013 at 10:50AM he/she stated," the form must be completed within 24 hours post event... He/She felt very confident that he/she never had an occasion in which the blue sheet was not completed within 24 hours". The surveyors received a copy of the patient's medical record on May 13, 2013, at approximately 4:00 PM.

The hospital's clinical staff failed to ensure the completeness of documentation in the medical record through the failure of the staff to follow the policy and procedures related to physical hold debriefing and documentation of pertinent information regarding the cause of injury during physical hold.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of records and staff interview, it was determined that a physical hold was applied to Patient #1 that resulted in a fracture.


The findings include:

The Joint Commission ' s (TJC) 2011 Hospital Accreditation Standards for Provision of Care, Treatment, and Services stipulates in Item PC.03.05.03 " the hospital uses restraint or seclusion safely ...1. The hospital implements restraint or seclusion using safe techniques identified by the hospital ' s policies and procedures in accordance with law and regulation."


Patient #1 was admitted [DATE] with diagnoses which include Mood Disorder Not Otherwise Specified, and Parent-Child Relational Problems; as well as history of Bipolar Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Post Traumatic Stress Disorder.

According to the hospital ' s report, " ... During one physical hold, a patient ... was placed in a physical hold. Following the hold ... complained of arm pain and was sent to the ER [emergency room ] for evaluation ... returned to the unit from the hospital with the diagnosis of a fracture to the upper arm ... "

According to the medical record a physical hold was performed on the patient on May 11, 2013 at approximately 5:50 PM. At an undesignated time after the physical hold was discontinued at 5:52 PM, the patient was noted to complain of Right Shoulder Pain and inability to lift and extend the Right arm. The patient was subsequently sent for evaluation and treatment an outside hospital emergency department, which concluded with diagnosis of Spiral Fracture of the Right Humerus.

The hospital staff failed to assure the use of restraint (physical hold) was implemented in accordance with safe and appropriate techniques.

Face to face interviews were conducted with hospital employees and administrators on May 13, and 14, 2013. The employees and administrators acknowledged and confirmed that Patient #1 suffered a Fracture of the Right Arm.