Description

The Commission and its Mental Hygiene Medical Review Board investigation into this case found that, while there may have been a necessity to place this patient in a camisole for prolonged periods during his stay on the intensive care unit, there was no documentation by a physician justifying its use. More disturbing was the evident failure of the psychiatric resident to examine the patient prior to authorizing the use of a camisole. This physician had attended to the patient earlier in the day when he was found to be perspiring, hyperventilating and agitated. He knew, or should have known, of the temperature control problems being experienced by the unit. In this case the medical rationale for medication doses exceeding Department of Mental Hygiene Drug Manual guidelines also was not subject to appropriate consultation, consent and documentation; medication orders were not clearly written and conditions for administration were not coordinated with nursing staff.