St. Barnabas Hospital
Statement of Deficiency - Tag numbers A1100 and A1101; Event ID XX5911Inspection release June 14, 2013
Based on record review, documents, and interviews, it was evident that the hospital
failed to provide monitoring of a patient who was restless and agitated and was
restrained. This finding was identified in 1 out of 10 applicable Emergency medical
records reviewed. (MR#1)
Findings include:
Review of MR#1 on 5/29/13 found that the patient who had presented to the ED with
altered mental status was placed in 2 point arm restraints on 5/11/13 at 0335 hours
(3:35AM). However, the restraint record did not indicate its discontinuance. The
surveyor reviewed three security reports, written by three different officers which were
all dated 5/11/13 and timed at 0405 hours (4:05 AM).
The first security report stated that the patient who was on close observation in bed #1
kept falling out of her bed during the eight hour tour. At one point, the officer was asked
to pick the patient up and called a worker from Emergency Medical Services, who
"grabbed the patient under her arms from her back and pulled her up."
Security report #2 at 4:05 AM stated that the patient fell out of her bed to the floor and
that he and and a security guard #1 put her back to bed and the patient was placed in
wrist restraints by nursing staff. This report stated that fifteen minutes later the patient
got out the restraints and fell out of the bed again.
Security report #3 noted that the patient fell out of bed and that this officer assisted the
other two officers and one emergency medical worker to put the patient back to bed.
There was no evidence that the medical staff assessed the patient's agitation or
persistent vomiting. The patient was administered an antiemetic. The patient was
restrained ( 2 point ) to keep her from " falling". An order for Versed 4mg IV was ordered
at 0225 AM on 5/11/13 and was administered at 0229. There was no evidence that the
patient's vomiting was taken into consideration in the use of restraints. There was no
evidence that the patient's history of being found at the foot of a staircase was reexamined for delayed signs of trauma. There was no evidence of re-assessment of the
patient even after she fell out of the stretcher even while restrained to rule out further
head trauma. The medical record indicated that the patient had been on "security
monitoring. "At interview with the administrative and clinical ED staff on 5/28/13 at 10
AM it was stated that this the patient was on "close observation. " However, this level of
close security monitoring permits an assignment of 1 security officer to 13 patients.

 This patient's creatine phospokinase (CPK) result at 1659 hours found it to be 531 IU/L
which is high out of range (38-174 IU/L). There was no evidence this matter was
promptly addressed and hence this patient did not receive an appropriate level of
monitoring.
Despite security documentation of falling out of bed while in restraints, there was no
documentation of this course of events in the patient record. Review of MR#1 found no
reference to the patient removing her restraints and them having to be re-applied.
Security officers' reports documented on 5/11/13 at 0405 AM noted the patient had
gotten out of restraints and had fallen out of bed in the emergency room at that time. It
was noted on this report "an unknown Emergency Medicine Technician (EMT) asked us
to move out of the way while he placed his arms under the patient and lifted her."
Security placed the patient back on the bed and the patient was placed in wrist
restraints by nursing staff. A security supervisory report at 0405 AM on 5/11/13 stated
that fifteen minutes after this incident (about 4:20 AM on 5/11/13) the patient got out the
restraints and fell out of the bed again.
The record stated that the patient was on "cardiac monitoring". There were, however, no
rhythm strips or record of any alarm going off when the patient went into ventricular
fibrillation.
The patient was found in cardiac arrest in a prone position at 0500 (5:00AM). The
patient was pronounced dead at 5:34 AM on 5/11/13. It is evident that there was no
documentation of monitoring from 4:20 AM to 5:00 AM, when the patient was found
prone and in cardiac arrest.