Description

In the process of staff restraining this patient and placing him in a tray chair, the patient apparently suffered fractures of the ribs and sternum. The report determined that the facility staff lacked a team approach and consistency in their interactions with the patients, and improper methods were used in restraining this violent patient with the tray chair, an unauthorized restraint, in violation of the Mental Hygiene Law. No responsibility was clearly assigned to one treating physician as the focal point for all patient-related communications and continuity of care responsibility for this patient who was undergoing an acute medical episode.