Thursday, December 14, 2017
Restraint Violations Cited In Patient Death
By Walter F. Roche Jr.
An "agitated and belligerent" patient at a Camp Hill, Penn. hospital died of apparent asphyxiation when staffers, assisted by security guards, attempted to place him in both arm and ankle restraints.
Details of the Sept. 26 incident are contained in a critical report from the state Health Department, which cited the Holy Spirit Hospital for multiple violations of rules limiting the use of restraints and requirements to report serious incidents to state officials.
According to the report, which was just made public, the patient was being forcibly held down while others attempted to apply ankle and wrist restraints.
One staffer "held the patient's hands while his nurse applied the restraint to his left wrist. The patient continued to kick, yell and thrash around on the bed," a hospital employee told the state surveyors.
"The patient attempted several times to kick staff and security," the report continues, adding that the patient, at one point, bit one of the security guards.
"I was attempting to grab his right wrist," one staffer told state inspectors, "when the patient stopped struggling and I noticed that the patient began to foam at the mouth and his eyes began to close."
According to the report a "code blue" was called but attempts to revive the patient, whose face had turned blue, failed and he was declared dead.
Subsequent examination concluded he suffered "acute anoxic brain injury."
Holy Spirit, part of the Geisinger Health System, was cited for multiple violations including the failure to report a "serious event" to state officials within 24 hours of its occurrence. The 307-bed Cumberland County facility was also cited for failing to report the incident to the patient's parents.
The report states Holy Spirit refused to let the state inspectors question four employees believed to have knowledge of the incident, another violation.
Asked to comment on the incident, Holy Spirit spokeswoman, Lori Moran wrote in an email,"While we would prefer not to restrain patients, at times such measures are indicated for the safety of all involved."
"We are saddened whenever a patient passes away," the statement continues,"and are confident that the care our team provided was consistent with Geisinger Holy Spirit's mission of delivering professional and compassionate care to all."
As Moran indicated, the hospital did submit a corrective action plan to the state. The report shows the initial hospital response, however, was sent back and a subsequent submission was accepted.
The state report followed a two-day mid-October visit to the facility by investigators from the state Public Health Department.
The inspectors reviewed earlier records involving the patient which showed that while there was one order for the use of wrist restraints, it was amended a day later authorizing the use of mitts. There was no order for ankle restraints. The report notes a state requirement that any restraints be limited to the least restrictive form.
The records also show two of the staffers involved in the incident had not undergone annual education sessions on the use of restraints "including training in how to respond to signs of physical and psychological distress (for example positional asphyxia)."
Moran said the corrective action plan included new training for staffers, including the use of videos on the proper way to restrain patient and revised policies on the use of restraints and notification requirements.
As for reporting the incident within 24 hours, the records showed the hospital did not report it until Oct. 12 and that initial report did not disclose there was a death. On Oct. 23 a new report finally disclosed the death.
Asked for an explanation one staffer told the state inspectors,"I did not feel this was an usual incident."