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Summary: In dealing with violent, abusive or angry psychiatric patients, the safety of the patient and staff are the priority concerns. When restraints or seclusion are deemed necessary, justification for the measures must be documented concisely. In this case, an unruly patient angered the nurse caring for him. When leather restraints were applied and maintained for a prolonged period of time, the patient would object and later sue for damages.
The patient was admitted after taking an overdose of acetaminophen. This admission was not voluntary. As an inpatient, the patient was noncompliant with therapy and uncooperative. He consistently ridiculed both the nurses caring for him and physicians. He was verbally abusive and difficult to care for.
The physician, social workers, nursing and
hospital staff attempted to help the patient prepare for discharge. This included arranging employment interviews and searching for a place for him to go after he left the facility. Throughout this the patient refused to cooperate and continued the abusive behavior.
The point was reached that continued treatment and counseling were discontinued by the physician. The order was written for the patient to be discharged and taken home by a family member the next morning.
In his discharge assessment, the physician clearly stated that the patient did not appear to be a "danger to himself or others." That night, in a particularly disturbing outburst, the patient began screaming at the nurse on duty and began throwing things. No items were thrown at the nurse or other staff.
The nurse clearly upset by the patient "acting out" contacted the physician and obtained an order for physical restraints and seclusion of the patient. This was around six p.m. in the evening.
The patient would be placed in four point leather restraints and kept in seclusion.
"Seclusion refers to the involuntary confinement of a patient alone in a room, from which the patient is physically prevented from leaving, for any period of time. . .
Restraints may be physical or chemical. Chemical restraint involves the use of psychotropic drugs or sedatives or paralytic agents. Physical restraint involves the use of physical or mechanical devices to restrain movement. Physical restraints may be cloth, leather, metal handcuffs or shackles, car seats, or seat belts."2
The patient would not be seen by the physician who gave the order for a full six hours following restraint placement. This was the same doctor who had been caring for the patient during the present stay. The doctor was in the
hospital for the full first six hours that the patient was restrained.
Arguments have been made that excessive use of restraints can be linked to other problematic issues in hospitals, nursing homes and psychiatric facilities.
"The Department of Justice "will document a high use of seclusion and restraint and tie this directly into inadequate staffing, inadequate treatment programming, inadequate delivery of rehabilitative services, and finally, into the overuse of psychopharmacologic interventions," Geller wrote."3
At several points following the initial application of restraints, the patient asked that they be removed and that the physician be contacted. The nurse did relay these messages to the physician. The doctor did not change the order or come to see the patient aside from the single visit.
The patient would remain in restraints and seclusion the entire night. This is a patient that aside from outbursts and verbal abuse, had not gotten violent with the staff.
The decision to use restraints carries with it a huge responsibility to the patient and major risks and liability to the nursing staff,
hospital and physician.
"Restraint and seclusion are some of the most precarious of interventions in psychiatry and have long been associated with injury and death, added Dr. Lion, a professor of psychiatry at the University of Maryland, Baltimore. But there are no national statistics on the morbidity and mortality associated with these practices."4
A lawsuit would be brought against the Nursing staff,
hospital and physician. The suit alleged the "restraint and seclusion" had been ordered as a "punishment" for the patient's angry outbursts and ridicule of the nursing/medical staff.
The patient filed a formal complaint under a "tort claims" statute. Initially, his complaint would be dismissed. On appeal judgement would be made against the hospital.
1. Was the use of restraints and placement of the patient in seclusion justified by his actions and behavior?
2. Was the length of the restraint use utilized by the nurse appropriate to reduce the risk of injury to the patient or staff or excessive?
3. Was the physician negligent in his observation and assessment of a patient whom he ordered into four point leather restraints?
Restraint use has been steadily declining in both nursing homes and
hospital facilities.
Regulatory oversight and inspections by accrediting agencies of policies and procedures as a condition of continued reimbursement is now commonplace. Death, injury and excessive use have led to increasing scrutiny of their application.
"A Clear Pattern of Abuse Exposed
In October 1998, The Hartford Courant published an investigative five-part series that revealed an alarming number of deaths resulting from the inappropriate use of physical restraints in psychiatric facilities across the United States. A 50-state survey conducted by the newspaper documented at least 142 deaths in the past decade connected to the use of physical restraints or to the practice of seclusion."5
On examination of the documented behavior of the client by both the nursing and medical staff, little justification for the use of restraints could be found. Under existing nursing, psychiatric and medical standards, their use in this case was clearly inappropriate. The patient though screaming and throwing items about the room was not threatening to hurt himself or others. This was not the first time that the patient had demonstrated this behavior during the current
hospital stay.
This would raise the possibility that the nursing staff, angered by the patient's behavior, sought to "punish" the patient by calling the physician and ordering restraints. The nurse making the phone call was likely familiar with the fact that the patient had been abusive to the physician also.
Knowing the physician's mindset towards the patient, the nurse could have guessed that an order for restrictive measures would not be difficult to obtain.
In the absence of documentation substantiating the use of restraint and seclusion with "dangerous" behavior on the part of the patient, a violation of applicable standards of care was clearly demonstrated.
There is the possibility that the nurse "thought" violence was likely and was acting to prevent it from occurring. Even if this was the case, neither the use of restraints nor seclusion in this case was justified.
"Patients and staff in mental hospitals have a right to be free from violent assault, but it must be balanced against the right of patients to be free of unnecessary medication and seclusion. Some staff members fear that whatever approach they take, they will be held legally liable, but both harm and legal damages are likely to be lower if they err on the side of preventing violence." 6
Restraints, when used are to be used only for so long as is necessary to get the patient under control. Continued use past the "emergency" period is illegal, unethical and dangerous. The so called "emergency" in this case was not legitimate by the hospital's procedures and protocols. The nurse requested the order regardless. It would have been interesting to have the transcript of the call available for comparison with what the nurse documented as the reason for calling the physician.
"The use of involuntary mechanical or human restraints or involuntary seclusion is only justified as an emergency safety measure in response to imminent danger to one's self or others. These extreme measures can be justified only so long as, and to the extent that, the individual cannot commit to the safety of themselves and others."7
The physician in this case shared in the negligence for not checking on the status of the patient sooner. Four point Leather restraints alone are classified as a heavily restrictive measure. The perceived need to add seclusion to the order would be appropriate only in the case of a medical emergency. This type of situation commands immediate attention by the physician or member of the medical staff.
With the physician present on the
hospital grounds at the time, his six hour delay in assessing the patient himself was inexcusable. Instead he relied on the questionably motivated report/assessment of the nurse to base his treatment.
Even after assessing the patient six hours later, the physician chose to let the patient remain restrained and in seclusion. The court felt it was appropriate that he share responsibility in the negligent claim for his delayed assessment and inaction later.
For the part of the nurse, it would seem that the decision to call for the restraint/seclusion order was motivated more by emotion than by legitimate observations.
When making the decision to determine if restraints are necessary, the safety of the patient and the staff must be considered. The nurse must be fully aware that the recommendation/order for restraints will often be based at least partially on nursing assessments and information given to a physician. Both the nurse and the physician will often share responsibility for untoward events resulting from their use.
August 22, 1999: Psychiatric Nurse, Sued By Hospital After Developing Relationship With Client?
Wright v. Mercy Hosp. Of Janesville - 557 N.W. 2d 846 - WI (1996)
Summary: Doctors and Nurses by nature of their positions deal with patients when they are vulnerable, off-balance and emotionally needy. When the population includes the psychiatric patient, the potential exists for a client to develop "feelings" for the caregiver. In this case, a sexually abused mother of three was admitted for multiple mental disturbances. During the course of the treatment, a relationship developed and led to sexual encounters following discharge. When it came to light, the patient successfully sued. The
hospital would attempt to recover damages against the nurse following her testimony in defense of the facility. This is commonly called a Subrogation action.
http://www.nursefriendly.com/nursing/clinical.cases/082299.htm
August 15, 1999: Violent Psychiatric Patient Attacks Nurse,
No Legal Recourse Against Facility or Psychiatrist?
Charleston v. Larson, 696 N.E. 2d 793 – IL 1998
Summary: It would seem absurd, that if a physician admits and facility assigns a nurse to care for a known violent patient, that it has no legal obligation to protect that nurse against violence. In this case, a psychiatric patient sought admission
to facility. On admission, he threatened to attack a nurse. When the patient would follow through on his threat, the nurse was denied legal recourse against the psychiatrist who could have taken precautions against the attack.
http://www.nursefriendly.com/nursing/clinical.cases/081599.htm
August 8, 1999: Pregnant Prison Inmate Complains of Miscarriage, Corrections Nurse On Duty Ignores Symptoms?
Ferris v. County of Kennebec, 44 5. Supp.2d 62 –ME (1999)
Summary: Nursing assessment skills are one of our most valuable assets. They allow us to effectively evaluate our patients and communicate significant findings to physicians and other members of the healthcare team. In this case, a pregnant woman with a previous history of miscarriage complained of vaginal bleeding and abdominal discomfort. The assessment performed by the nurse fell negligently short of the required standard of care.
http://www.nursefriendly.com/nursing/clinical.cases/080899.htm
August 1, 1999: Nursing Duty To Patient, "Does Not Guarantee" Safety Or Quality Of Care.
Summary: When a nurse accepts report and responsibility for the care of a patient a duty to the patient is also accepted. This duty is to provide a reasonable standard of care as defined by the Nurse Practice Act of the individual state and the facility Policy & Procedures. In this case, a post-op abdominal aneurysm repair patient was injured after falling from his bed to the floor. When a lawsuit was filed the court initially mistook expert testimony to imply the role of the nurse includes a guarantee of safety.
Downey v. Mobile Infirmary Med. Ctr. - 662 So. 2d 1152 (1995).
July 4, 1999: Diabetic Coronary Artery Bypass Patient, Septic & Noncompliant. Nursing Duty and Responsibility Questioned.
Patient noncompliance can present serious challenges to
nurses and physicians providing care. If aware of the proper measures to be taken, what happens when the patient does not agree or comply with the course of treatment? In this case, a patient after
having a coronary artery bypass grafting developed a sternal infection. When advised by a nurse to return for treatment, the patient refused.
Kind v. State Ex Rel. Dept. of Health, 728 S.o. 2d 1027 -LA (1999).
http://www.nursefriendly.com/nursing/clinical.cases/070499.htm
June 27, 1999: Elderly Patient Repeatedly Injured In Nursing Home "Accidents." Negligence, Coincidence or Abuse?
As the elderly population continues to increase, more and more families are faced with the decision to place loved ones in nursing homes. When a family member is placed in a facility,
a certain standard of care is expected. In this case, a resident was injured repeatedly while under their care. When the patient died
a few days after being "dropped" the family sued.
Brickey v. Concerned Care of Midwest Ince. 988 S.W. 2d 592 MO (1999)
http://www.nursefriendly.com/nursing/clinical.cases/062799.htm
June 6, 1999:
Emergency Department Nurse Verbally Abused, Physician History Well Documented
Official tolerance for verbal abuse and sexual harassment is approaching zero. It is clear that both are still prevalent in healthcare settings today. Enforcing and reporting instances of abuse are critical to an end being put to the situation. In this case, a physician had a "history" of verbal abuse in the facility involved.
It was the documentation of previous events that made formal action and administration of a suspension feasible.
http://www.nursefriendly.com/nursing/clinical.cases/060699.htm
Gordon v. Lewiston Hospital, 714 A.2d 539 – PA (1998)
May 30, 1999: Patient Left Unrestrained, Patient Injured. Nurses Judgement Call
The decision to use or not use restraints
must be made with caution and good judgement. Their intended purpose must be to protect either the patient or others who may be injured by the patient including the staff caring for the client. The ultimate determination of necessity is left with the physician. Often, the moment to moment necessity is determined by the nurse. In this case a nurse did not feel restraining
the patient was necessary. When an injury occurred, the patient sued.
Gerard v. Sacred Heart Medical Center - 937 P. 2d 1104 (1997)
Sources:
1. 37 RRNL 10 (March 1997)
2. American Academy Of Pediatrics. March 1997. The Use of Physical Restraint Interventions for Children and Adolescents in the Acute Care Setting (RE9713). Retrieved September 19, 1999 from the World Wide Web: http://www.aap.org/policy/re9713.html
3. Martz, Micheal. September 15, 1998. Left Behind / Some Patients Have Been Institutionalized For Years. Richmond Times-Dispatch. Retrieved September 19, 1999 from the World Wide Web: http://gatewayva.com/rtd/special/mentalhealth/mhces15.shtml
4. Nidecker, Anna. 1998. Newspaper Series Puts Spotlight on Restraints. Clinical Psychiatry News. Retrieved September 19, 1999 from the World Wide Web: http://pharmacotherapy.medscape.com/IMNG/ClinPsychNews/1998/v26.n12/cpn2612.08.01.html
5. National Alliance for the Mentally Ill (NAMI). February 17, 1999. Seclusion and Restraint. Retrieved September 19, 1999 from the World Wide Web: http://www.nami.org/update/unitedrestraint.html
6. President and Fellows of Harvard College. 1991. Violence and Violent Patients. The Harvard Mental Health Letter. Retrieved August 15, 1999 from the World Wide Web: http://www.mentalhealth.com/mag1/p5h-vio2.html
7. National Alliance for the Mentally Ill (NAMI). February 17, 1999. Use Of Restraints And Seclusion. Retrieved September 19, 1999 from the World Wide Web: http://schizophrenia.nami.org/update/990217.html
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