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Restraining Violent Patient? Consider Malpractice Risks
Too often, ED staff don’t report violence due to onerous reporting processes, according to Terry Kowalenko, MD, clinical associate professor in the Department of Emergency Medicine at University of Michigan Health System in Ann Arbor. Research suggests that violent incidents occurring in EDs are far more frequent than statistics reveal.1-3
“Clearly, this is a big problem, and it is probably much bigger than we know,” says Kowalenko. He recommends that EDs make reporting processes quick and easy to get as much information as possible about when and how incidents are occurring.
“If you really get the numbers on who are the victims and perpetrators in your ED, then you can tailor an intervention that is aimed at controlling that,” says Kowalenko. For instance, the researchers were surprised to learn that physical assaults by ED patients were perpetrated roughly equally by men and women.
“It stands to reason that if you have a violent patient, it increases risks of injury to not only the workers but also the person themselves — and as a result, there could be some liability risks involved,” says Kowalenko.
Restrained ED patients pose significant malpractice risks for emergency physicians (EPs), however. “Once the patient does go into restraint, there are several potential allegations that EDs should be aware of and be cautious about, from a risk perspective,” says Karyn Finneron, RN, BSN, MA, BC-HN, senior risk management representative for Boston, MA-based Coverys, a provider of medical professional liability insurance.
Here are some allegations against EPs involving restrained patients that Finneron has seen:
• Lack of informed consent.
An agitated patient might have consented for treatment with certain drugs or dosages, but has escalated to the point at which the patient is a danger to him- or herself or others.
The drugs used for escalating behavior may be in the same class of drugs the patient is presently taking, but a higher dose may be prescribed to treat the patient in an emergent situation, adds Finneron.
“An emergent situation can circumvent the patient’s right to consent,” she says. “Once the patient is more manageable and the crisis has passed, the patient must be offered the opportunity to consent to the drugs or refuse them.”
• Lack of appropriate monitoring.
“Some of the elements of how much checking on the patient is required are dictated by state statute,” says Finneron. When safety checks regarding the patient are made, the EP needs to consider what is required by regulatory and accrediting bodies such as the Centers for Medicare & Medicaid Services, The Joint Commission, and/or state statute.
“In addition, standards of care dictated by the American College of Emergency Physicians and psychiatric societies must all be considered with regard to patients in restraints,” says Finneron.
An ED patient could sustain an injury to various joints from fighting restraints. These injuries could be simple sprains or strains, or more complicated such as a dislocation of the joint.
“If these injuries occurred as a result of inappropriate application of restraints or lack of monitoring the patient, the result could be allegations against the provider and/or the facility,” says Finneron.
• Failure to restrain a homicidal or suicidal patient.
Once there has been an assessment of potential homicidal and/or suicidal ideation, the facility must be on alert for a potential elopement of the patient or for the patient to leave against medical advice (AMA), says Finneron. The ED has a “duty to warn” potential victims or to involve law enforcement, as needed, to protect the patient from suicide.
“As an insurance company, we have seen claims brought against institutions or health care providers for lack of proper assessments, lack of documentation of the assessments, or not following through on the duty to warn issue,” says Finneron.
• Inappropriate use of restraint.
To defend against this allegation, good documentation is needed to show why restraints were needed, when applied, when the patient was checked, and an assessment of the patient’s condition before, during, and after restraints are removed, says Finneron.
“Any and all regulatory requirements regarding these issues, including time frames for documentation, must followed,” she says. “There needs to be good documentation, especially involving any behavioral health issue. This cannot be stressed enough.”
Finneron says anyone reading the chart should be able to see “a good flow of the situation from when you first noticed the patient’s behavior changing. Even subtle changes are important to document.”
For instance, a back pain patient waiting a lengthy period to be seen might also have a mental health history and, at one point, become agitated.
“If there’s not a good continuum of assessments, care, and documentation from the time the patient enters the ED to the time the disposition of the patient occurs, the result will often be gaps, where the defense of any allegations can and will most likely be compromised,” she says.
Finneron recommends that triage nurses monitor the waiting room as part of an ongoing process to note any potential behavioral changes in patients that can result in a patient’s perception of a long wait time to be seen or a sense of a lack of caring by the staff.
“Once the patient is brought into the ED exam area, the nurse attending to the patient needs to do an accurate and updated assessment,” she advises. “It should be noted if there are any changes, not only in physical condition, but also in behavioral issues.”
The ED nurse might document that the patient is demonstrating anger and frustration due to a long wait, for instance.
If the chart notes the patient was assessed at 9:45 a.m. and a follow-up by the EP at 11:15 a.m. with no substantial changes in behavior noted, it would be difficult to validate the patient being placed in restraints at 11:30 for a violent outburst.
If there is a lack of documentation to support treatment or a validation of escalating behavior, Finneron explains, “it would be very difficult to defend the rationale of a crisis that may have ensued, requiring the patient be placed in restraints.”
1. Kowalenko T, Walters BL, Khare RK, et al. Workplace violence: A survey of emergency physicians in the state of Michigan. Ann Emerg Med 2005;46(2):142-147.
2. Gacki-Smith J, Juarez AM, Boyett L, et al. Violence against nurses working in US emergency departments. Journal of Nursing Administration 2009;39(7-8): 340-349.
3. Gates D, Gillespie G, Kowalenko T, et al. Occupational and demographic factors associated with violence in the emergency department. Adv Emerg Nursing J 2011; 33(4):303-313.
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