UPDATE, Dec. 11, 2019:

It turns out the California Department of Public Health never wound up citing St. Joseph Hospital for the incidents described in our original post, despite a voicemail from an employee of that agency saying it would. 

On Feb. 14, 2019, the CDPH conducted an “abbreviated survey” in response to four complaints, during which no deficiencies were identified. 

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Original post:

The California Department of Public Health has given Eureka’s St. Joseph Hospital a pair of “deficiencies,” reprimanding the facility for using restraints on bed-ridden patients rather than employing less-restrictive methods, such bedside caregivers.

James Ladika, a nurse in the hospital’s intensive care unit, said the citations aren’t surprising given recent cost-cutting measures at the hospital, including a round of layoffs back in September. Some of those who lost their jobs were bedside caregivers, known as “sitters,” and Ladika said hospital administrators have made it increasingly difficult to employ such caregivers.

“They started putting more pressure on us, [requiring] more documentation,” he said. “It got to the point where the hardest thing to do was to get a sitter for your patient.”

As an example, Ladika forwarded the Outpost a copy of the hospital’s “Sitter Needs Assessment,” a 10-item checklist that nurses must fill out before a sitter can be approved by the administrative supervisor. While the document instructs nurses to “consider less restrictive measures” before using restraints, it appears to contradict that instruction further down the page with a bullet point that says the first nine items on the checklist, including restraints, must be attempted before a sitter is deemed appropriate.

With sitters so difficult to come by, Ladika said nurses have turned more frequently to using restraints. These can vary from mittens that prevent patients from getting a grip on their bedrails to straps around a patient’s wrists or even full-body tie-downs for delirious patients who may try to get out of bed or pull out their lines and tubes.

“That’s harder to watch because they will really fight the restraints,” Ladika said. He argued that bedside caregivers are more humane. “A sitter just gently reminds them, ‘You can’t pull that tube out,’ or they will hold [the patient’s] arm down. It’s much more gentle to have somebody’s soft hands and have them reminding you, orienting you, versus being in a room by themselves strapped to a bed.”

Ladika said he took his concerns to hospital administrators as well as the board of trustees but heard nothing back for weeks, prompting him to file complaints with the state.

Ladika received a voicemail on Tuesday from a woman with the California Department of Public Health (CDPH) concerning his complaints. He forwarded the voicemail to the Outpost. On it, the CDPH worker says the hospital will be receiving two deficiencies, “the first for implementing restraints instead of a sitter for a patient with a history of severe post-traumatic stress disorder and sex trafficking.”

“The second deficiency,” she says, “is going to be for failure to consider less-restrictive interventions, including using a sitter prior to implementing restraints on the facility’s patients.” She goes on to say that the hospital will be notified of the citations by phone and in writing, and administrators will be required to implement a plan of correction. 

In response to the citations, the California Nurses Association issued a press release, which you can read in full below. It accuses the hospital of “too often going straight to the use of patient restraints, a violation of both state and federal law on patients’ rights.”

Asked for a response to the union’s press release, St. Joseph Hospital spokesperson Christian Hill forwarded the following statement:

It’s important to note this was a single incident involving a patient with behavioral health needs and we have yet to receive a report from CDPH detailing their findings. We do not agree with CNA’s statement indicating a sitter would have been the solution in this case. To protect the privacy of this individual we will not share additional details publically [sic].

We always appreciate and invite feedback from outside agencies like CDPH. In fact, we frequently self-report any potential occurrence directly and transparently.  We continually assess and work to improve processes and policies in support of the needs of behavioral health patients, and when appropriate, develop an action plan for improvements. We also work to continually improve conditions for caregiver safety and security. Protecting both patients and caregivers from harm is our utmost concern as we continue to provide quality care to an increasing population of individuals with behavioral health needs.

Ladika disputed this statement’s claim that the citations concerned “a single incident.”

“There was definitely more than one, and it was absolutely not an isolated event,” he said. In fact, he said the excessive use of restraints is a “systemic problem that is ongoing” at St. Joseph Hospital. 

The nurses’ union has repeatedly clashed with hospital administrators over staffing levels and cost-cutting measures since 2016, when St. Joseph Health merged with Providence Health & Services to create Providence St. Joseph Health, one of the largest nonprofit health care organizations in the country. It operates more than 50 hospitals and 800 clinics across the western U.S.

Here’s the press release from the California Nurses Association:

Providence St. Joseph Hospital Eureka Cited by State for Excessive Patient Restraint Use, RNs Call For Return of ‘Sitters’

CA Dept. of Public Health Mandates Hospital Correct Issue, Nurses Urge Hospital to Comply

The California Department of Public Health (DPH) has found merit in a complaint from Providence St. Joseph Hospital Eureka registered nurses that the hospital excessively used patient restraints, rather than using Constant Care Attendants (or “sitters”), whose job is to protect patients in need of continuous care, the California Nurses Association announced today.

“Bedside caregivers know that sitters are an integral part of what we do every day, yet hospital administration thinks they are disposable and unnecessary. Fortunately, the state agrees with us,” said Intensive Care Unit RN James Ladika, Chair of the Hospital’s Professional Practice Committee (PPC), a working group of nurses from units throughout the hospital, who meet to advance patient care issues.

“Registered nurses respect the inherent dignity and worth of every patient and call on the administration of Providence St.Joseph Hospital Eureka to reevaluate their use of patient restraints, given this finding by the California Department of Public Health,” said Chief Nurse Rep and Inpatient Rehab RN Lesley Ester. “We should always use the least restrictive measures possible when caring for our patients who, in our professional judgment, need one-to-one attention for safety.”

Nurse leaders say they submitted a complaint to the California DPH after complaints to management and hospital administration went unanswered. The DPH announced this week that merit was found in the complaint, and a citation requiring a written plan of correction has been issued against the hospital.

“Nurses went out of our way to let everybody from managers all the way up to the board of trustees know that this was a problem,” said Ladika, “The hospital was using restraints excessively, and this was harmful to our patients. They ignored our warning, and the state had to step in and make them do the right thing.”

According to nurses, the issue began this summer when Providence St. Joseph Hospital changed internal policy to reduce situations in which sitters were deemed necessary. An early August ICU memo, for example, stated that sitters could only be used for suicide risk. After artificially reducing the necessity for the position, say nurses, the hospital let all eight official “Constant Care Attendants”— or sitters — go in a September round of layoffs.

With no dedicated sitters, nurses say the hospital was too often going straight to the use of patient restraints, a violation of both state and federal law on patients’ rights, dictating that restraint can only be imposed to ensure the safety of a patient, and must be discontinued at the earliest possible time. In the case of requesting aides to act as sitters, RNs explain that not only meant an aide could no longer do the assigned work of assisting nurses with care duties, but the hospital also added hurdles and forms to fill out, making the ask prohibitively complicated for nurses.

“The hospital created a culture where restraints were more acceptable than using a sitter,” said Ladika, “They took the option of a sitter away from nurses by asking, ‘Do you want aides on your floor or do you want patients to have sitter[s]?’ — which is a false choice. You can’t throw someone in restraints just to save money. It’s not appropriate, and it’s not legal.”

Nurses say they feel vindicated that the state has stepped in to hold the hospital accountable, and RNs call on Providence St. Joseph Hospital to bring back the sitters.

“We have asked repeatedly that the Constant Care attendants that were laid off in September be returned to duty so that our Emergency Department and inpatient units are not required to reassign floor personnel to provide a calming and safe environment or, even worse, to utilize restraints for our patients,” said Ester.

“This is about people’s lives, people’s dignity and their wellbeing,” said Ladika.