The resident immediately complained of a tingling sensation, went into respiratory distress and stopped breathing. He was later revived at a local hospital emergency department. A review of the nurse's personnel records found no training or experience with flushing Hickman catheters and the facility said it relied on the nurse's claim she knew the procedure. Responding to a complaint, Department investigators observed a resident restrained in a wheelchair by a safety bar with a combination lock.
State law prohibits the use of safety bars with combination locks.
When asked to remove the lock, the administrator and a certified nurse aid were unable to do so. They were joined by a registered nurse and the three were eventually able to work the combination and get the bar loose. After reviewing resident files, investigators found other examples of residents restrained with devices not prescribed by their physicians. In addition, facility procedures requiring physicians to specify the type of safety device were not followed. The Department ordered Mercy Health Care Center to ensure safety devices are used properly and staff is trained in policies, procedures, monitoring, application and release of restraints.