Patient’s death linked to restraints
Federal inspection points to failures by Hartford Hospital that led to Connecticut man’s embolism
A federal inspection of a Connecticut hospital revealed that a patient with severe physical and mental issues died as the result of being held in physical restraints, as recorded in the patient’s autopsy.
The Hartford Hospital inspection, conducted by the Centers for Medicare and Medicaid Services, a federal agency, and ending on
March 1, 2023, was triggered by a complaint.
It found the hospital “failed to ensure that restraints were discontinued when the patient no longer exhibited the behaviors that necessitated the restraint, failed to ensure that a new restraint order was written every 4 hours, failed to discontinue the use of restraints at the earliest possible time.”
It also found that Hartford Hospital “failed to ensure that the patient was evaluated face-toface by a provider within one hour of the initiation of each restraint order, and failed to ensure the patient’s immediate situation, reaction to the intervention, medical and behavioral condition, and the need to continue or terminate the restraint were assessed with each restraint order.”
The hospital also failed to ensure efforts to prevent deep vein thrombosis were not put in place, the report said. The patient developed a pulmonary embolism as a result, which was the immediate cause of the patient’s death, the report said.
According to the inspection report, posted on hospitalinspections.org, the autopsy report and an interview with the medical examiner on Jan. 25, 2023, the cause of the patient’s death was “deep vein thrombosis complicated by medical restraint for acute bipolar disorder. The Medical Examiner stated that the length of time the patient was in restraints caused the embolism.”
The inspection report said the patient “was restrained for 165 hours and 30 minutes over 8 days from 8/8/22 through 8/15/22. During this time frame, the restraint orders should have been ordered 41 times but were only ordered 23 times.”
The patient had been admitted Aug. 7 for rhabdomyolysis. According to the Centers for Disease Control and Prevention, it is “a serious medical condition that can be fatal or result in permanent disability. Rhabdo occurs when damaged muscle tissue releases its proteins and electrolytes into the blood. These substances can damage the heart and kidneys and cause permanent disability or even
death.”
The patient required restraints because of being “agitated, demanding, verbally abusive, pulling on IV lines, anxious and restless,” according to the report.
For almost 27 hours, “the patient was continuously restrained in 4-point bilateral locked restraints,” according to the report. “Although the shift nursing narrative notes identified the patient was agitated, demanding, and restless,” for 23 hours “the flow sheets … lacked documentation that the patient was assessed every two hours for behaviors, circulation, sensation and movement, respiratory status, and range of motion to both upper and lower extremities, per hospital policy.”
Also, during that time, “the 4-point locked restraints were not reordered every 4 hours per hospital policy (order required renewal five times but was only reordered 3 times),” the report states.
The same situation occurred again for 94 hours and 49 minutes, the report states.
Later, the patient was restrained with only a right wrist restraint, but complained of anxiety and inability to sleep and requested oxygen be administered.
On Aug. 15, restraints were removed, clonazepam (Klonopin) and Haldol were administered.
The patient was “observed to be in respiratory distress followed by respiratory arrest,” the report said. “CPR was initiated, and despite life saving treatments the patient was pronounced expired at 4:14 p.m.”
According to the inspection report, an interview with the director of patient safety and quality and the assistant director of hospitalists was held on Jan. 18, 2023. They stated that the hospital’s policy on restraints was reviewed and they “began reeducating staff on the use of restraints, placed a trigger warning in the clinical record to ensure all components are met, and began auditing clinical records for the use of restraints.
“Additionally, the Director stated that they are developing a Behavioral Time Out Huddle for patients to decrease the use of restraints,” the report states.
Elinor Cohen, a spokeswoman for Hartford HealthCare, issued a statement saying, “While we cannot comment on any specific patient, we are saddened by any loss. Hartford HealthCare is nationally recognized for the results we have achieved in patient safety and there is nothing more important to the organization.”
The website hospitalinspections.org is maintained by the Association of Health Care Journalists.