Patient with seizure disorder placed in 4 holds and suffered serious injuries

Foundations Behavioral Inpatient Psychiatric Unit was cited during a licensing inspection completed by the Pennsylvania Department of Human Services (DHS, or formerly the Dept. of Public Welfare) for deficiencies related to adequate treatment and the contents of a treatment plan. Due to the repeat citations and additional deficiencies found during the inspection, DHS issued Foundations another 6-month provisional license for the period of May 17, 2013 to November 17, 2013.

DHS wrote in its inspection report that a Consumer was admitted to the facility with a medical diagnosis of “severe seizure disorder that is refractory to treatment.” Pennsylvania regulations state that “manual restraints should not be used on consumers who have medical or physical conditions where there is reason to believe that such use would endanger their lives or exacerbate a medical condition.”

However, upon further investigation, DHS found the following incident with the same patient at Foundations Behavioral Inpatient Psychiatric Unit:

“Consumer A was admitted to the facility on 1/29/13 at 10AM. Consumer was placed in four holds starting at 12:32PM – 3:23pm. Holds ranged in length from eight minutes to a half an hour. It is documented that Consumer verbalized “ow” sometime during the fourth hold…It is noted that Consumer A had a seizure at 11:45pm on 1/29. Nursing notes indicate Consumer A remained in bed and fell back to sleep upon completion of seizure, 90 seconds…Nursing notes indicate that Consumer A had difficult using left arm on the morning of 1/30 and was subsequently sent out to Abington Hospital. Final diagnosis received from CHOP indicated “broken ankle, fracture of left shoulder, broken arm and broken foot.”

During the investigation, DHS found video footage that “showed facility staff engaging in non-therapeutic physical contact with Consumer.” Abington Hospital’s ChildLine report documented “a significant amount of pressure would need to be applied to fracture the humerous, injuries are suspicious for non-accidental trauma or excessive force being used.”

DHS cited Foundations for repeat citations and wrote that the “documentation in the chart justifying need for mechanical restraint and use of less restrictive interventions did not reconcile with what surveyors observed on video during investigation.” Foundations Behavioral was also cited again for violations of adequate treatment regulations.

The facility submitted a plan of corrective actions to address these cited deficiencies. However, the hospital was not in full compliance with regulations for adequate treatment and contents of a treatment plan and was not given a full one year certificate of compliance.