Allegation:
The resident’s father alleges that the residential community facility in which he resided used improper de-escalation and hold techniques resulting in a comminuted fracture of his left arm.
Case Details
This case highlights the importance of having de-escalation and workplace violence policies in place and providing regular training to clinicians and staff.
A 22-year-old male was living in a residential community facility. The resident was diagnosed with ADHD, autism, and mood disorder, and exhibited extreme self-injurious behavior. His father was his appointed conservator. The resident had been placed in the facility two years prior when his father could no longer provide for him at home. The resident is of larger build, so he required 1:1 staffing with a male staff member. On the day in question, the resident refused to feed himself and slammed his plate on the ground. Two direct support staff (DSS) began cleaning up the food on the floor. The resident approached the female DSS and was in her personal space but was not aggressive. Hoping to de-escalate the situation, the male DSS took the resident by the arm, twisted and held it behind his back, walked him over to a bench in the kitchen, and told him to sit on the bench on his hands.
The resident immediately began to complain of pain and stated that his arm hurt. The DSS worker spoke to his supervisor who instructed him to take the resident to the emergency room. X-rays at the hospital revealed a closed, displaced, comminuted fracture of the distal half of the shaft of the left humerus. The injury necessitated surgery and placement of a long-arm splint, but the patient eventually made a full recovery.
The resident’s father brought suit on his behalf against the residential facility alleging that staff violated policies and procedures and used improper de-escalation techniques resulting in injury to the resident.
Expert Testimony
The orthopedic surgery expert for the defense, after analyzing the statements, x-rays, and medical records, excluded a potential defense that the fracture occurred prior to the resident’s arm being placed in the hold. He felt that the fracture was entirely consistent with the injury occurring when the resident’s arm was twisted and held behind his back.
The behavior support plan in place at the facility provided numerous methods to distract the resident to prevent behavior from escalating including providing him small toys, spinners, or headphones. The facility crisis support plan included de-escalation methods such as telling him “personal space” and “stop.” Physical re-direction methods in the plan included pinning the resident’s arms from behind and moving him to a safe area before releasing the hold. The facility’s Crisis Prevention & Intervention (CPI) instructor stated that the technique used on the resident in this case was improper and put too much pressure on his arm. That method was not included in any of the clinic’s policies or plans. Staff did state, however, that the improper hold had been used previously in de-escalation situations with the resident.
Resolution
Due to staff not following the facility’s policies and de-escalation plans, a settlement was reached at mediation.
Risk Reduction Strategies
Develop disruptive patient/resident behavior and de-escalation policies and procedures.
- Include signs and potential triggers of disruptive behavior.
- Identify how to appropriately manage these aggressive behaviors.
- Describe how to apply acceptable de-escalation techniques.
- Identify which techniques are not acceptable.
Train clinicians and staff to mitigate and respond to disruptive patient/resident behavior, including the management of their own stress and frustration that may arise during the encounter.
- Provide training that includes education on the policies and procedures in place and the importance of following them.
- Encourage staff to reach out to supervisors and colleagues to discuss challenging situations or if they are experiencing significant stress.
- Employ diligent training efforts to allow staff members to develop skills and practice procedures that keep both patients/residents and themselves safe during a disruptive patient event.
Conduct risk assessments regularly to evaluate preparedness for disruptive patients/residents and to mitigate workplace violence.
- Thoroughly document all incidents of disruptive patient/resident behaviors or workplace violence.
- Perform debriefs after an incident to analyze how the incident was managed and identify any areas for improvement.
- Incorporate program evaluation and ongoing monitoring to assess the workplace violence prevention and mitigation strategies.
Establishing policies and procedures and staff training on de-escalation and violence prevention are crucial to preventing incidents and to mitigating risk to patients, residents, and staff. Staff need to understand the possible ramifications of not following procedures. If a lawsuit is filed stemming from a de-escalation technique, failing to follow an organization’s own policies and procedures make a case virtually impossible to defend.
For more information on this topic, review the Risk Management Bundle on Workplace Violence in Healthcare. The bundle contains additional risk mitigation strategies to help keep your clinicians, staff, and patients safe.
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If you have questions on this topic, please contact us at RiskAdvisor@ProAssurance.com or 844-223-9648.
