Date of incident: March 2013
Notice of incident number: 2013117640062
Employer: Long-term care facility

Incident summary
A mentally-ill patient assaulted a psychiatric rehabilitation worker (PRW). Agitated, the patient had gone to his room after refusing to take anti-psychotic medication. Three members of his care team — including the PRW, a nurse, and another care worker — followed the patient into the room, attempting to administer the medication. The patient became even more agitated, lunging past the nurse and the care worker before punching the PRW. The PRW was treated at the hospital, and released the same day.

Investigation conclusions

Cause

• Patient assaulted care worker. The mentally-ill patient, who had a history of reacting violently, assaulted a psychiatric rehabilitation worker, resulting in injuries.

Contributing factors

• Patient suffering from delusions. The patient suffered from delusions throughout the day, and these seemed to suddenly increase in severity.
• Medication not provided as needed. Care staff did not administer anti-psychotic medication during the day to control the patient's delusional thinking. Care staff may not have fully appreciated the seriousness of the patient's delusions.
• Patient refused to take medication. The patient refused to accept medication as needed after a shift change. Care staff attempted to administer the medication in accordance with the patient's care plan, but the patient reacted violently.

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