HospitalInspections.org

Based on hospital policy review, medical record review, employee statement review, and staff and provider interview, the hospital failed to notify a provider of a restrictive intervention in 1 of 2 patients requiring a restraint intervention (Patient #23).

The findings included:

Review of hospital policy titled "Physical Restrictive Interventions and Seclusion" reviewed/revised: 05/24/2016 revealed, "...If the psychiatrist is not in the facility to order the use of a restrictive intervention, the registered nurse provides an emergency assessment, obtains the psychiatrist's verbal order at the time the emergency safety intervention is initiated..."

Closed medical record review on 02/27/2018 revealed Patient (PT) #23 was a 66 year old male, admitted under involuntary commitment on 01/31/2018, with a diagnosis of Bipolar Disorder and Homicidal Ideation.

Review on 02/27/2018 of an Employee Statement, written by Registered Nurse (RN) #1 on 02/14/2018 at 2345, revealed, "At approximately 2200 a code purple (a hospital specific designation for when additional assistance and personnel are required due to an escalating patient) was called on PT #23. The patient was belligerent and using racial slurs, and cursing at staff. The patient had to be placed in a hold to receive a PRN (as needed) IM (Intramuscular) injection. While the patient was in a standing position against the wall facing away from the wall with an (sic) MHT (Mental Health Technician) on each shoulder/arm and another MHT holding the legs to prevent kicking. Nurse (Named RN #2) was about to administer the injection when the patient spit in her face..."
Continued medical record review revealed no evidence any provider was notified of the restrictive intervention on 02/14/2018.

Telephone interview was conducted on 02/28/2018 at 1500 with RN #1. Interview revealed he recalled the restrictive intervention conducted on PT #23 on 02/14/2018. Interview revealed RN #2 was assigned to PT #23. Interview revealed RN #1 was not assigned to the area PT #23 was in, and only responded to the code purple called, and during the restrictive intervention, RN #2 had to be removed from the situation. Interview revealed RN #1 left the unit upon conclusion of the code purple, and thought a nurse assigned to the unit would notify a provider about the restrictive intervention.

RN #2 was not available for interview.

Telephone interview was conducted on 03/01/2018 at 1040 with Nurse Practitioner (NP) #3, who recalled PT #23. Interview revealed she was the provider on call for PT #23 on 02/14/2017, and was not notified of any restrictive intervention for PT #23 on that date. Interview revealed the next time she evaluated PT #23 was on 02/16/2018, with no injuries discovered on assessment. Interview revealed if there was a restrictive intervention, she should have been notified.

NC00135165; NC00136077; NC00135529; NC00135347; NC00136090; NC00135512; NC00135591; NC00135884; NC00135504