WRAL Investigates

Violent psychiatric patient exposes policy, communication lapses in Rex ER

Posted May 5, 2015
Updated May 6, 2015

— Rex Hospital was cited by federal officials for a “lack of coordination and communication” between nursing and security staff while caring for a “psychiatric patient with known violent behavior” in its emergency department.

The hospital was placed in “immediate jeopardy” due to the citation, meaning it could lose federal Medicaid reimbursements if issues were not addressed. Rex officials said the hospital is now in compliance.

In a 281-page report from the U.S. Department of Health and Human Services, which was given to WRAL-TV on Tuesday following a Freedom of Information Act request, interviews with directors, nurses and doctors involved in the care of a 24-year-old man in January revealed a lack of preparation by hospital staff for the type of violence exhibited by the patient.

“Staff did not know how to approach the patient and realized they were out of their league,” the hospital’s emergency department director said in the report.

Hospital officials said the incident illustrates how emergency rooms are not equipped to handle violent mental health patients.

"They really need help and we need to have more in-patient beds for this patient population," Dr. Linda Butler, the hospital's chief medical officer, said in an interview on Tuesday.

Those interviewed for the report were not named, but referenced by their titles. The patient was also not named in the report.

‘I thought they were trained a lot better’

The patient arrived at Rex by ambulance on Jan. 24, one day after being released from prison for assaulting a relative. The patient was sent to a mental health crisis center upon release, but was involuntarily committed to Rex for “being too violent as he was verbally aggressive to staff members,” the report said.

The patient has a documented history of psychiatric disorders, including schizophrenia and post traumatic stress disorder, the report said.

While in an emergency department hallway, a security officer used a Taser on the patient after he punched two other security officers. He was then placed into four-point leather restraints “for the management of violent and self-destructive behaviors,” according to the document.

The hospital has procedures for removing patient restraints, but it is incomplete, the emergency department director said.

“When a patient is in four-point restraints, the practice of the ED staff is to ‘remove one intervention at a time to see if it works’ by performing a ‘trial’ or ‘progression,’” the report said. “Interview revealed, ‘There is no policy for a trial.’”

The director added that the policy is also limited.

“Until this point, the restraint training focused on (medical and surgical) restraints,” she said. “I thought they were trained a lot better than this.”

Doctors were hesitant to remove the restraints, the hospital’s protective services director said.

“There was a lot of talk about how we manage this patient,” he said. “I wanted to make sure to protect our folks. The physician was not willing to take the restraints off, at my request.”

During his 17-day stay, the patient was forced to wear a spit mask, was restrained daily due to being verbally and physically abusive to hospital staff, and a Taser was used on him a second time.

The second Taser use was “a direct result of communication breakdown,” the security director said.

“Staff made assumptions,” he said. “We didn’t review current hospital policy ‘Restraint and Seclusion.’”

In part, the policy states that restraints “are not used as a means of coercion, discipline, convenience or staff retaliation” and that “the least restrictive restraint to protect the patient/other’s physical safety is used.”

The report notes the use of Tasers by security officers, stating multiple times that the officers are not law enforcement and that the patient was not under arrest.

Hospital policy states that law enforcement is to be called every time a security officer uses a Taser. Law enforcement responded both times the weapon was used on the patient, but he was not taken into custody, the report said.

Lack of ‘safe patient environment’

Federal officials cited Rex for failing “to assure a safe patient environment” by allowing non-law enforcement personnel to use Tasers to subdue psychiatric patients, failing “to discontinue restraints at the earliest possible time” and not placing a patient known for violent behavior into the custody of law enforcement to be taken to a psychiatric hospital.

After the patient was transported to a psychiatric hospital by a sheriff’s deputy on Feb. 10, hospital officials created an action plan for future encounters with involuntarily committed patients, including patient risk assessments, crisis prevention intervention training for emergency department staff and auditing the “plan of care” for behavioral patients in the emergency department for more than 48 hours.

Federal officials thought that wasn’t enough.

“The hospital’s leadership failed to provide oversight and have systems in place to ensure the protection and promotion of patients’ rights, failed to have an organized nursing service and failed to provide emergency services to meet the patient's needs,” the report said. “There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital doesn’t have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body.”

Hospital staff admitted they were not prepared for a violent psychiatric patient.

“The nurses were aware of his homicidal/suicidal ideation,” the emergency department director said. “We have never had a patient to this level.”

The director went on to say “staff were not managing the patient well” and that “the nurses and security were not working together.”

While there were conversations regarding how to safely care for the patient, the security director told federal officials “we need to talk more and communicate better.”

“I don’t think people knew the patient was swinging or his patterns,” he said. “The patient’s disease process was not put on the table.”

Limited mental health beds statewide

The emergency department director described the ordeal as a “catastrophic communication failure.”

“I think the staff was terribly afraid of him,” she said, according to the report. “The problem was the patient has no plan of care.”

Hospital officials have since started training for future violent psychiatric patients.

“The nursing staff failed to reassess more frequently to get the patient out of restraints,” she said. “This was a tragedy, we have never had this happen before. We cannot say we did everything we could for him. This has been a call to action like you don’t know.”

Security officers have also stopped carrying Tasers, said Butler, the chief medical officer, who also defended the actions of her staff.

"We did what we had to do to protect our patient and co-workers," she said. "What we really need to do is get our patient to the right level of care."

Part of the reason behind the miscommunication is that emergency rooms are not intended to serve mental health patients, Butler said.

"It is difficult to deal with their care because an emergency department is not the right place for their care," she said. "They are here waiting for a bed at a behavioral health facility. Some people are here for weeks and this is just not the right place for them."

She added that the patient was in Rex's emergency department for over two weeks due to a lack of mental health beds statewide.

"We just don't have enough beds within North Carolina to accommodate all these patients, so it is a bigger societal issue," she said. "We are holding involuntary commitment patents everyday and it can vary from two to as many as 11, and some other hospitals hold even more. We have held patients as long as 21 days while they are waiting for a bed."


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  • Anna Stancil May 7, 2015
    user avatar

    And closing DDH was a good idea...said no one in the mental health field!

  • Charlie Jaxon May 6, 2015
    user avatar

    Sorry to burst some of your bubbles. But if you listen to the scanner radio for RPD, You will hear them talk about taking people to Dix all the time. I listen to this whole thing last night. But if you have no clue what happen to this person in his past, WHO are you to judge him? I guess that you have no problem judging others but you cannot stand to be judged by others! But that's right we do live in a state that thinks they are "Holier-Than-Thou".... Sadly now the only way you can get treatment is to go "crazy".

  • Andrea Hobbs May 6, 2015
    user avatar

    It is [b]UNFORTUNATE[b] that any hospital in North Carolina has been fined by a Federal group for any violations of this nature! I am sure that for at least the past 8-10 years and henceforth this is going to be a GROWING issue that any Hospital Emergency Department in North Carolina is going to face! Even UNC-CH doesn't have to accept the patients in their Emergency Department who are there for Involuntary Commitment if they don't have a bed for them in the Inpatient Psychiatric Treatment Unit. And in some cases, if they do have beds, the patient may be too violent for even that facility! The Prison system can't hold them if the only problem they have is being violently mentally ill, even model prison inmates can be mentally ill with violent tendencies and not be a bit of problem in prison! Also, once and inmate has completed ALL of the time on their sentence, the Prison System HAS TO LET THEM GO! It is really a wonder that Rex is the first hospital facing this kind of Fine!

  • Andrea Hobbs May 6, 2015
    user avatar

    Rob Douglas, the REASON Nobody Goes to Dix anymore, [i][b][b][/b][/i][/b][b]IS DOROTHEA DIX MENTAL HOSPITAL IS CLOSED!![b] Gee Dude what do you think ALL of the articles regarding Dorothea Dix Property, have been about??

  • Carol Smith May 6, 2015
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    What was wrong with putting him in restraints? He was a danger to the staff and other patients!!!!

  • Angie Cox May 6, 2015
    user avatar

    WRAL - Patient is spelled PATIENT not PATENT!

  • Angie Cox May 6, 2015
    user avatar

    View quoted thread

    Dorthea Dix is closed!

  • Mike DaRookie May 6, 2015
    user avatar

    View quoted thread

    its been 40 years since vietnam. if he's not fixed by now he never will be. just institutionalize the guy

  • Tiffany Morones-Suttle May 6, 2015
    user avatar

    I have a family member who deals with PTS from Vietnam, and he went to Rex. When his wife complained about the treatment, the lack of communication with the VA, who was willing to come and transport him to their facility for his treatment, she was removed from his room in the ED, and not allowed to be with him. He was left alone and scared and suffering in the back of a busy ED where they wouldn't allow anyone else to go and see him. They isolated him, ignored him, and wouldn't work with the VA who was better equipped to help him, and WILLING TO COME HELP HIM. There is ZERO excuses for this, training is key, and shouldn't be ignored.

  • Rob Douglas May 6, 2015
    user avatar

    No one goes to Dorthea Dix anymore anyways. Maybe there are just too many crazy people and not enough beds.