10 May Patient #0017983

FACILITY ARCHIVE RECORDS SEARCH - SEARCHING… SEARCHING… SEARCHING… COMPLETE - FOUND 19 RESULTS FOR SEARCH TERMS “Patient #0017983″ CHRONOLOGICAL LISTINGS FOLLOW: 1.) ADMISSION FORM, PATIENT #0017983 - 11/18/05 15:12 Involuntary admittance requested by patient’s relatives in response to apparent self-destructive behavior cycle. Self-harm evident in physical exam: signs of past abrasions on head and neck, apparently due to self-inflicted scratching, and both fresh and partially-closed surface lacerations on arms and legs. Signs of extreme fatigue also evident - in examination patient admitted insomnia for, as quoted, “longer than you’d believe.” Patient unable to give exact time for length of insomnia, likely due to extended period of insomnia itself. Confusion and moderate delerium evident. PRELIMINARY MEDICATION ISSUED: Triazolam 0.25mg for insomnia, topical Bacitracin for wound care. 2.) ADMISSION EVALUATION, PATIENT #0017983 - 11/18/05 16:56 PERFORMED BY: Dr. Emil Lafayette. Self-harm confirmed. Patient removed dressings from arm lacerations, reopened wound while waiting for interviewer. Definite evidence of somniphobia in patient justifications for harm; patient refers to sleep with anxiety, and consistently acts against self to cause pain in response to lengthy periods of silence or other lack of stimuli. Issue of insomnia needs immediate attention, given evidence of exceedingly prolonged duration. Likewise possible agoraphobia. Patient requests an isolated bed, becomes withdrawn/agitated when request is denied, refuses to cooperate further with interview. Offers vague suggestion of hostile “other” in justification, but will not elaborate, as quoted, “because you’re not going to believe she exists until she hurts someone anyway.” Evidence for likely paranoid schizophrenia. Recommend further interview with full psychological spectrum testing for exact diagnosis. FINAL RECOMMENDATION: ADMIT PATIENT. PRELIMINARY MEDICATION ISSUED: Cancel Triazolam, instead 5mg Diazepam twice daily for insomnia, anxiety, and probable sleep disorders. 3.) FINAL ADMITTANCE REPORT, PATIENT #0017983 - 11/18/05 17:13 Patient issued bed in Room 409. Current occupant(s): Patient #0017802, Patient #0017983. Clothes from admission remanded to family of patient, three sets of common dress issued for immediate needs. Further psych eval scheduled for 10:00 11/19/05, determining future length of stay. 4.) WARD EVENT REPORT - 11/18/05 17:30 During routine new patient room check, Patient #0017802 places request with staff for transfer to, as quoted, “some other room.” Appears agitated, claims Patient #0017983 has been disturbing him. Patient #0017983 likewise requests transfer, to isolated bed. Both requests denied. ORDERLY NOTE: Followup room check suggested to avoid possible intrapatient conflict. 5.) WARD EVENT REPORT - 11/18/05 19:00 Followup room check. Patient #0017983 claims Dr. Lafayette has ordered him moved to Isolation. Patient #0017802 backs claim. Administration records demonstrate no such order. Upon informing room occupants, Patient #0017983 attempts to assault staff and Patient #0017802 becomes uncontrollably agitated. Additional personnel required to contain incident. Both patients restrained, sedated, forced into early lights out. ORDERLY NOTE: Exercise caution in all future room checks for 409. 6.) WARD EVENT REPORT - 11/18/05 23:57 Staff on Hall 1, Floor 4 report loud sounds from room 409 after facility lights out, disturbing other rooms and patients. Patient #0017983 found awake, extremely agitated and struggling against restraints. Demands lights be turned back on, as quoted, “before she comes.” Self-sustained injuries to wrists and ankles at points of restraint. Patient attempts to struggle against staff during trade to more comprehensive restraint, requiring additional personnel to contain incident. Additional sedation required for Patient #0017983. Patient #0017802 does not respond during course of event, likely due to sedation from earlier incident. ORDERLY NOTE: Maintain restraints on Patient #0017983 until further notice. Sedate patient before removing restraints for any reason. Recommend anti-psychotic be considered in future psych eval. 7.) WARD EVENT REPORT - 11/19/05 00:20 Staff on Hall 1, Floor 4 again report loud sounds from room 409. Patient #0017983 found catatonic on floor, with severe self-inflicted scratches on head and neck. Restraints are severed at connection points, with severe bruising on limbs possibly indicating more severe injury at restraint points with patient. Patient #0017802 is found deceased. Severe disfiguring wounds to face, complete with destruction (ORDERLY NOTE: Ingestion?) of patient’s eyes. Moved to room 101, locker 2, awaiting autopsy. Patient #0017983 transfered to Isolation, room 626, given injected dose of 100mg Zuclopenthixol on attending physician’s orders to control acute psychosis. ORDERLY NOTE: Recommend video observation to allow better control of future outbursts. Stay at least an arm’s length away from patient upper body restraints at all times. Just in case.