Aug. 07--The St. Luke's University Hospital security guard assigned to keep constant watch on a trauma patient who jumped out of a sixth-floor hospital window to his death in June had not been fully trained in monitoring patients, a state Department of Health investigation has found.
The patient, who had been diagnosed with an "impulse control disorder," was under "continual observation" at the Fountain Hill hospital but was allowed to use the bathroom without being monitored, the report says. After locking the bathroom door, the patient, Jonathan Hanchick of Bethlehem Township, broke through a double-paned locked window and suffered fatal injuries in the fall.
By allowing Hanchick to escape out the window, despite the personal monitoring and restrictions on his movement, St. Luke's failed to provide a safe patient environment, the report says. Specifically, security staff "did not attend or receive continual observation training."
Nurses usually provided continual observation and were trained for it, said Carol Kuplen, chief nursing officer. Security staff have been trained but hadn't had the nurses' continual observation training before the June 4 incident, she said.
Continual observation means just that, and even when a patient needs to use the bathroom, the observer is supposed to go in with the patient or at least leave the door open as a safety precaution.
Regulators look for hospitals to use the least restrictive means of restraint in dealing with unruly or disturbed patients, only recommending physical or chemical restraints when patients are a danger to themselves or others. Restraints are supposed to be eased as soon as the threat abates.
Hanchick's death led to operational and physical changes at the hospital, but it also sheds light on the difficult balance health-care providers face in ensuring patients' rights, accessibility to care and the safety of staff from unstable patients.
As part of its response to the report, St. Luke's agreed to provide continual observation training to security guards. In addition, the hospital replaced privacy locks on all single-patient inpatient bathrooms with passage sets that cannot lock.
"St. Luke's strives to provide patient care in the safest possible hospital environment for patients and employees, while maintaining an atmosphere conducive to health and healing," said Kenneth Szydlow, vice president of marketing and public relations.
The inspection noted seven other cases of patients' leaving the hospital without signing out in the 15 weeks before Hanchick's fall, as well as other breakdowns in operations. The report, prepared by the Department of Health on behalf of the federal government, was completed June 27 and made public Wednesday.
The department accepted the plan of action St. Luke's instituted after its surveyors visited the Fountain Hill campus.
Attorney Erv McClain, who has represented Hanchick's family, was not available for comment.
Hanchick was in St. Luke's after injuring his head in a motorcycle accident in May. According to the report, which does not identify patients or employees by name, Hanchick had twice "eloped," or left the hospital without officials' knowledge.
But the report also says that on the day of his final escape, Hanchick demonstrated "improved behavior," according to one physician's progress notes. The physician recommended no restraints for 48 hours, a minimum requirement before an individual could be placed in a room on a behavioral health floor, Kuplen said.
In the meantime, Hanchick was in a room in the Intensive Care Unit, a locked unit that gave hospital staff better control of his movements, she said.
Hanchick walked two laps around the ICU at 11:20 a.m. with a nurse and a security guard, as required, the report says. Later, Hanchick again wanted to go for a walk, but a second staffer was unavailable. He also wanted to make a phone call but could not because the phone's battery was charging.
"At 1:39 p.m. the patient became agitated and started walking from the bed, to the chair, to the bathroom located in the patient's room," the report goes on. "The patient then went into the bathroom, closed the door and locked the door."
The guard was unable to unlock the door as he heard banging on the wall and then glass shatter, the report says.
It notes that patient rooms in the ICU "were not specifically outfitted to accommodate patients with active behavioral symptoms, such as aggressive and impulse behavioral disturbances." The report does not indicate whether the design of the unit or the windows violated safety standards, however.
Patients admitted with serious physical injuries and placed on medical-surgical floors may have a secondary behavioral issue as well, Kuplen said. The individual's physical injuries need to be treated first, she said.
During its review of other patients' files, state investigators found that nurses and physicians needed to be retrained on proper record-keeping when using continual observation or documented patient checks every 15 minutes.
The state also took St. Luke's to task for failing to implement performance improvement measures regarding other patient elopements. It noted the seven other instances since mid-February in which inpatients had left the hospital without telling anyone. Previously, St. Luke's only investigated elopements from the emergency department.
Kuplen said the hospital now is tracking inpatient elopements, although she said patients who left more than once would have reached her attention. Inpatient elopements also are a tiny fraction of admissions -- about 15 people last year out of roughly 25,000 admissions, she said.
While the record-keeping issue warranted investigators' attention, the report also shows the challenges health-care workers face in dealing with patients with behavioral problems. One patient screamed at staffers, threw tantrums, tossed specially made food in the trash and refused to eat, so his blood sugar levels could not be checked, the report says.
-- St. Luke's failed to provide a safe setting for patients.
The hospital is now:
-- Training all security officers in continual observation training and reporting trends on inpatient elopements to safety committees by the patient safety officer.
-- St. Luke's already has replaced all privacy locks on single-patient inpatient bathroom doors with passage sets.
STATEMENT FROM ST. LUKE'S
"We express our sympathy to the family of the patient who died while attempting to elope from our hospital. After we notified authorities of this incident, Department of Health (DOH) surveyors conducted a review process regarding our elopement procedures. St. Luke's immediately completed and instituted action plans that have met the DOH's requirements and approval. As always, St. Luke's strives to provide patient care in the safest possible hospital environment for patients and employees, while maintaining an atmosphere conducive to health and healing."
-- Kenneth Szydlow, St. Luke's vice president of marketing and public affairs
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