HospitalInspections.org

Based on record review and interview, the hospital failed to ensure all direct care staff demonstrated knowledge in the use of non-physical intervention skills. This deficient practice is evidenced by a mental health technician grabbing a violent patient and throwing him onto the floor for 1 (#2) of 5 patients sampled resulting in the patient obtaining an acute fracture of the left humeral head and neck.
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Findings:

Review of Patient #2's Daily Nursing Flow Sheet Addendum dated 11/21/19 at 1:25 p.m. revealed the following. Patient placed on visual observation while awake. Patient got violent with a staff and was taken down to the floor by a MHT.

Review of Patient #2's nurses note dated 11/22/19 at 4:22 p.m. revealed the following:
Medical Problems this Shift: Left arm pain. Put on a medical clipboard for review. Tylenol 650 mg given for pain to left arm.

Review of Patient #2's physician's orders revealed the following:
11/21/19 at 3:10 p.m. - Benadryl 50 mg IM now for physical aggression Haldol 10 mg IM
11/22/19 at 7:50 p.m. - Left shoulder x-ray 4 views secondary to (unable to read notes) routine in a.m.
11/23/19 at 4:41 p.m. - Apply sling , neuro checks q 8 hours, ice 20 min qid, schedule ortho apt with social worker

Review of Patient #2's Radiology Report dated 11/23/19 at 1:33 p.m. of left shoulder 2 views for pain revealed the following:
Acute fracture of the left humeral head and neck is seen, with mild complex appearance along the greater tuberosity.

In an interview on 12/5/19 at 1:51 p.m., S1DON said on 12/21/19 at 3:15 p.m. Patient #2 walked up to a female MHT's face and lunged at her. He said then S2MHT wrapped his arms around Patient #2 and put him to the ground. He said that is what caused Patient #2's arm injury. S1DON said he had been a CPI (Crisis Prevention Intervention) instructor since 1996. S1DON verified taking the patient down to the ground was not a CPI technique and was not an approved maneuver. He said S2MHT was reactive because of the situation.

In an interview on 12/6/19 at 9:03 a.m. with S2MHT, he said he was working the day Patient #2 attacked S3MHT. He said he was sitting in a chair on north end of hall and S3MHT was standing next to Patient #2. He said Patient #2 was calm and got up and walked towards S3MHT and he attacked her and so he grabbed Patient #3 from the side and took him to the ground. He said they do not learn takedowns in CPI. He said it was more of a reaction because it happened so fast.