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Feds to Release 8 Quality Measures for Psych Unit Care

Cheryl Clark, for HealthLeaders Media, January 16, 2014

Four of these measures will be reported for the first time on Hospital Compare as soon as April, while others will follow a few months later or next year.

Now let me recall the story of Jeffrey Christopher, a 25-year-old California man who was being treated for schizophrenia at Sharp Grossmont Hospital's inpatient psychiatric unit and had become agitated after playing cards during a visit with his mother. As I reported in 2008:

The unit's workers took Christopher to his room and had him lie down on his stomach. They secured him to his bed with restraints at the wrists, ankles and waist, keeping his head and neck above the mattress. They also gave him several medications for his schizophrenia, including ativan and thorazine. 

Although nurses continuously monitored Christopher, they did from a chair facing his feet instead of following the standard practice of checking a patient's face. One nurse assigned to his room said she saw him "scoot and wiggle himself lower onto the bed until his face was on the mattress," according to a report by the county's medical examiner, who conducted an autopsy on Christopher.

"He then began violently hitting his face against the mattress and metal frame of the bed," and held his breath, the medical examiner's report said. During a staffing rotation, another nurse entered the room and saw that Christopher had turned blue.

The Medicare report said a nurse tried to resuscitate Christopher, but did not follow American Heart Association guidelines because he had not been trained adequately. Christopher died that night.

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