Violent psychiatric patient exposes policy, communication lapses in Rex ER

The hospital was placed in “immediate jeopardy” due to the citation, meaning it could lose federal Medicaid reimbursements if issues were not addressed. Rex officials said the hospital is now in compliance.

“Staff did not know how to approach the patient and realized they were out of their league,” the hospital’s emergency department director said in the report.

Hospital officials said the incident illustrates how emergency rooms are not equipped to handle violent mental health patients.

"They really need help and we need to have more in-patient beds for this patient population," Dr. Linda Butler, the hospital's chief medical officer, said in an interview on Tuesday.

Those interviewed for the report were not named, but referenced by their titles. The patient was also not named in the report.

The patient arrived at Rex by ambulance on Jan. 24, one day after being released from prison for assaulting a relative. The patient was sent to a mental health crisis center upon release, but was involuntarily committed to Rex for “being too violent as he was verbally aggressive to staff members,” the report said.

The patient has a documented history of psychiatric disorders, including schizophrenia and post traumatic stress disorder, the report said.

While in an emergency department hallway, a security officer used a Taser on the patient after he punched two other security officers. He was then placed into four-point leather restraints “for the management of violent and self-destructive behaviors,” according to the document.

The hospital has procedures for removing patient restraints, but it is incomplete, the emergency department director said.

“When a patient is in four-point restraints, the practice of the ED staff is to ‘remove one intervention at a time to see if it works’ by performing a ‘trial’ or ‘progression,’” the report said. “Interview revealed, ‘There is no policy for a trial.’”

The director added that the policy is also limited.

“Until this point, the restraint training focused on (medical and surgical) restraints,” she said. “I thought they were trained a lot better than this.”

Doctors were hesitant to remove the restraints, the hospital’s protective services director said.

“There was a lot of talk about how we manage this patient,” he said. “I wanted to make sure to protect our folks. The physician was not willing to take the restraints off, at my request.”

During his 17-day stay, the patient was forced to wear a spit mask, was restrained daily due to being verbally and physically abusive to hospital staff, and a Taser was used on him a second time.

The second Taser use was “a direct result of communication breakdown,” the security director said.

“Staff made assumptions,” he said. “We didn’t review current hospital policy ‘Restraint and Seclusion.’”

In part, the policy states that restraints “are not used as a means of coercion, discipline, convenience or staff retaliation” and that “the least restrictive restraint to protect the patient/other’s physical safety is used.”

The report notes the use of Tasers by security officers, stating multiple times that the officers are not law enforcement and that the patient was not under arrest.

Hospital policy states that law enforcement is to be called every time a security officer uses a Taser. Law enforcement responded both times the weapon was used on the patient, but he was not taken into custody, the report said.

Federal officials cited Rex for failing “to assure a safe patient environment” by allowing non-law enforcement personnel to use Tasers to subdue psychiatric patients, failing “to discontinue restraints at the earliest possible time” and not placing a patient known for violent behavior into the custody of law enforcement to be taken to a psychiatric hospital.

After the patient was transported to a psychiatric hospital by a sheriff’s deputy on Feb. 10, hospital officials created an action plan for future encounters with involuntarily committed patients, including patient risk assessments, crisis prevention intervention training for emergency department staff and auditing the “plan of care” for behavioral patients in the emergency department for more than 48 hours.

Federal officials thought that wasn’t enough.

“The hospital’s leadership failed to provide oversight and have systems in place to ensure the protection and promotion of patients’ rights, failed to have an organized nursing service and failed to provide emergency services to meet the patient's needs,” the report said. “There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital doesn’t have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body.”

Hospital staff admitted they were not prepared for a violent psychiatric patient.

“The nurses were aware of his homicidal/suicidal ideation,” the emergency department director said. “We have never had a patient to this level.”

The director went on to say “staff were not managing the patient well” and that “the nurses and security were not working together.”

While there were conversations regarding how to safely care for the patient, the security director told federal officials “we need to talk more and communicate better.”

“I don’t think people knew the patient was swinging or his patterns,” he said. “The patient’s disease process was not put on the table.”

The emergency department director described the ordeal as a “catastrophic communication failure.”

“I think the staff was terribly afraid of him,” she said, according to the report. “The problem was the patient has no plan of care.”

Hospital officials have since started training for future violent psychiatric patients.

“The nursing staff failed to reassess more frequently to get the patient out of restraints,” she said. “This was a tragedy, we have never had this happen before. We cannot say we did everything we could for him. This has been a call to action like you don’t know.”

Security officers have also stopped carrying Tasers, said Butler, the chief medical officer, who also defended the actions of her staff.

"We did what we had to do to protect our patient and co-workers," she said. "What we really need to do is get our patient to the right level of care."

Part of the reason behind the miscommunication is that emergency rooms are not intended to serve mental health patients, Butler said.

"It is difficult to deal with their care because an emergency department is not the right place for their care," she said. "They are here waiting for a bed at a behavioral health facility. Some people are here for weeks and this is just not the right place for them."

She added that the patient was in Rex's emergency department for over two weeks due to a lack of mental health beds statewide.

"We just don't have enough beds within North Carolina to accommodate all these patients, so it is a bigger societal issue," she said. "We are holding involuntary commitment patents everyday and it can vary from two to as many as 11, and some other hospitals hold even more. We have held patients as long as 21 days while they are waiting for a bed."