Too Few Staff Meant Behavioral ICU Patients Could Not Receive Assistance

The Florida Agency for Health Care Administration found that Emerald Coast Behavioral Hospital failed to staff the behavioral intensive care unit with adequate numbers of personnel to provide care to patients as needed.The unit includes patients who are low functioning and actively suicidal, aggressive, or unable to maintain themselves and likely to act out; records showed only 2-3 staff on the unit for 14 patients. Staff were observed spending most of their time providing assistance to patients and taking only a few breaks to complete paperwork, but “[e]ven with staff diligence, the numbers were inadequate to meet the needs of patients.” The records describe several failures in patient care, including:

  • One patient said she could not wipe herself in the bathroom and could not get help from staff to do it. She said that she was left to shower alone even though she had a fall-risk arm band, and had to wet herself at night due to lack of assistance to get out of bed and reach the bathroom. The one mental health tech staffing the unit confirmed that this patient’s bed was saturated with urine in the morning, and the MHT had to change the bedding. The patient also had a two-inch cut on her leg with no dressing despite a physician order to dress the wound twice a day. The patient was holding a pair of socks, but said she could not get help to put them on.
  • A second patient was observed “escalating in agitation and behaviors” during one afternoon. The patient was wearing no pants and no underwear. He was twice escorted to his bedroom by staff, but then came out into the day room where “no staff were observed in the unit or in the area.” He then “assaulted [another] patient by slamming him forcefully in the face with his pillow,” knocking off the patient’s glasses. Staff did not intervene until the patient stripped naked and banged on the glass of the nurse’s station repeatedly. This patient was injected with medication for behavior management three times on this day, with the third dose having “no corresponding documentation for assessment of need or effectiveness.”
  • A third patient “was observed to have a large wet area in the crotch of her pants,” and “[n]o staff were observed to notice this, or assist her in changing clothes.” She was still wearing the same pants 98 minutes later.
  • A fourth patient was observed to be unsteady on her feet, needing staff assistance to walk. On one morning she needed help to change out of urine-soaked pants. The patient was observed to be in bed during that afternoon, and staff “stated that the nurse wanted her to stay in bed because she was so unsteady on her feet.” On another day this patient was observed “wearing a paper shirt and pants that were way too large for her,” causing her to expose herself intermittently. The unit’s one mental health technician had to leave the unit to search for clothes that would fit her.

During lunch, staff delivered trays of food to the female patients and then left them alone to eat while delivering trays to the male patients. The female patients were not monitored while they ate and were not given napkins with their food. One patient obtained a roll of toilet paper to use as napkins. A patient “who was a brittle diabetic” ate very little of her food.

Additionally, the facility was cited for failing to meet infection control standards. A nurse was observed using a Glucometer to measure blood glucose levels of three different patients without cleaning the device between uses, which puts patients at risk for the spread of blood-borne pathogens. The facility “also failed to maintain a clean and sanitary environment” in this unit, as it was observed to have soiled floors and furniture. The unit was observed to have “dried spills, debris and food particles” on the female side and “an odor of urine and popcorn on the floor” on the male side.