Pt found dead!!!

cannoli · Nov 16, 2003

I know of this same type of thing happening about 15 years ago.

I think the evening nurse had charted at 10:30 and then at 11:15 or so the night shift found the patient, he had tried to get out of bed and was over the side and had hung himself with the vest.

I think the vests are designed differently today though. I thought the redesign was supposed to prevent that from happening.

New CCU RN · Nov 16, 2003

Originally posted by glascow
Last month we had a patient die at our hospital, he was strangled from his posey vest.

The nurse who admitted the pt from ER was overwhelmed with 7 pts, this admit made her 8th patient. She made an admit note, placed him in a posey.

Her next entry in the chart is 4 hrs later, the patient was dead.
Needless to say, they have now discontinued the use of poseys at our facility, and all staff is required to attend a 2-hr inservice on use of restraints. This is on top of our already annual mandatory on restraints.

How awful is this?? I have heard the family is not going to pursue legal action.

The nurse caring for the pt recieved no counceling or support from the hospital. The hospital lawyer questioned her and wanted to know why she removed the restraint when she found him dead.

Thank you for updating us... it opens people's awareness and perhaps will make us all think before we go to use restraints next time. However, I wonder if it is right to be posting such a topic on a public bulletin board. Personally, I would be very weary of being public about such topics...you never know who is reading this board.

**canoehead, BSN, RN** · Nov 16, 2003

"the lawyer wanted to know why she had removed the vest when she found him dead??????"

Well, I don't think he was a fall risk anymore, do you? OMG.

nocngail · Nov 16, 2003

"the lawyer wanted to know......."

At a facility where I worked last yr, a CNA entered a room shortly after shift change, and found pt. with clear plastic trash bag (from small bedside trash can) over his head and with O2 tubing wrapped around his neck....pt. had committed suicide....no warning s/s at all according to staff.

This was a small unit, and RN was immediately in the room. Despite initial reflex to remove plastic bag, staff members left plastic bag as they found it after quickly determining the pt. was deceased (he was DNR).

Important point with the law officials....potential crime scene...evidence wasn't disturbed.

Enlightening post Glascow...Up in my part of the world, posey vests have been illegal to use, except in rare instances, for years.

Brita01 · Nov 17, 2003

Originally posted by glascow
The nurse caring for the pt recieved no counceling or support from the hospital. The hospital lawyer questioned her and wanted to know why she removed the restraint when she found him dead.

Of course the hospital refuses to admit the unsafe staffing level, right?

Furball · Nov 17, 2003

If the pt is confused and use of restraints are discouraged then the hospital should provide sitters to maintain safety.....but then many hospitals are too cheap for this and the burden is on the nurse...as usual.

mother/babyRN, RN · Nov 17, 2003

How horrible! Restraint issues are huge in both hospitals I work in..Even in OB if siderails are up one has to document that they are up with the patient's permission...In other areas, or with confused pts ( some of our GYNS), you have to document that you checked on them at least every hour....It is such a hassle that I thought it was ridiculous, until now....So sad...

debRNo1 · Nov 18, 2003

Originally posted by nocngail

...Up in my part of the world, posey vests have been illegal to use, except in rare instances, for years.

:confused: illegal

BarbPick · Nov 18, 2003

I have never had good results with poseys. Sometimes they still climb through the split siderails.

Most facilities have flow sheets to check Q 1 hour on restrained patients, maybe I will actully follow the instructions due to this post.

Every patient I have had to restrain must have been Harry Houdini in a former life.

Vsummer1 · Nov 18, 2003

The hospital I go to clinical in does not use posey vests (not sure if illegal or just hospital policy).

If you put a patient in physical restraints, you must document every 15 minutes! That basically means a sitter anyway. But, sometimes it really is the only thing to do to protect the patient and staff. Even with all the documentation (and it requires A LOT of documentation!) and checks required, I have seen it done 4 times in my limited capacity as a student nurse. Three on med/surg/tele and once in psych. Two of the med surg were my patients and d/t their condition chemical restraint was not possible. In one case they did have a sitter (in addition to the student nurse {me}, the RN and the LPN assigned to this patient). The psych patient was not assigned to me, but in the special care unit here and believe me, chemical restraint was doing nothing for this guy, yet he was only restrained after a code was called (and of course this was my FIRST day in psych) :eek:

They take protection of patient AND staff VERY seriously here, and now I understand why!

live4today, RN · Nov 18, 2003

Originally posted by Brita01
Of course the hospital refuses to admit the unsafe staffing level, right?

Wouldn't THAT be a miracle if the hospital stepped up to the plate and took care of business by protecting the patients with SAFE staffing. :rolleyes: HA! Who are WE kidding?