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Based on a review of hospital policies and medical record documentation during the on-site investigation of complaint MD00136762, it was determined that the hospital was out of compliance with the condition of Patient Rights by following a practice of ordering and giving antipsychotics, mood stabilizers, and sedating medications to patients who refused medications for 72-hour periods of times regardless of whether patients exhibited violent or dangerous behavior. Following a practice of forced medication administration in non-emergency situations violated the rights of patients to refuse medications or treatments. In addition, the hospital physicians prescribed these emergency medications in some cases two days following a behavioral outburst, and the orders contained provisions for administering the medications by injection if the patient refused to take them orally. Orders written this way constituted standing orders for chemical restraint.

See the following Patient Rights citations.

Based on a review of the hospital policy for "Emergency and Other Medication Administration to the Objecting Patient" (EOMAOP) approved 5/3/2016, and 10 patient records, it was determined that the hospital failed to honor the rights of two patients (P1 and P2) to refuse medications; and hospital staff administered so-called emergency medications in non-behavioral emergency situations.

Review of the hospital EOMAOP policy revealed in part,

"III. Policy Medications may be administered to a patient against his/her expressed will only under one of the following conditions:
1. An emergency exists wherein a.) The patient's behaviors creates the likelihood of imminent serious physical harm to the patient or to others; or b). The patient's physical condition creates the likelihood of imminent mortality or serious morbidity ...and
4. Under the authority of a duly authorized and executed Clinical Review Panel (CRP) ..."

A CRP is, in part, a process by which a patient might be involuntarily medicated for up to 90 days by the decision of an objective panel of clinicians which would have included the following protections: 24 hour patient notification, patient legal representation, information regarding rights, and an appeal process by an administrative law judge.

However, further review of the EOMAOP policy revealed another way in which the hospital could give medication to an objecting patient which, unlike the CRP, had no rights protections whatsoever. This medication administration was as follows:

"IV. Procedure
In the event that a patient refuses medication and when in the opinion of the treating physician an emergency exists, medication may be administered for up to 72 hours upon the order of a physician. The nature of the emergency must be documented in the patient's record."

This meant that without any patient notification, decision from a CRP, legal representation, information regarding rights, and without any patient recourse or right to appeal a CRP decision, a single physician could decide to medicate a patient on an "emergency" basis for up to 72 hours. In one (P1) of the 10 patients reviewed, "72-hour Emergency Medication" was a misnomer where P1 was involuntarily medicated with antipsychotics and sedating medication for 72-hours whether displaying dangerous behaviors or not. Therefore, 72-hour involuntary medication would be a more accurate characterization of the process which also would more clearly define the lack of consideration for the rights of patients to refuse medications or treatments. The process involved orders written for by-mouth medication, and also intramuscular injections (IM) of medications to be given when the patient refused oral medications.

Additionally, further review of the policy revealed a provision which allowed for physician orders for two additional 72-hour periods for "emergency medication," and only then directed that a Clinical Review Panel must be requested before another 72-hour period of involuntary medication may be ordered, "If possible given the patients' legal status." Not only did the provision allow for a series of 72-hour emergency medication, but if a patient was still within the court-ordered evaluation stages of admission, no CRP could be convened on their behalf, and the patient would continue to be subject to periods of 72-hour involuntary medications if a single physician deemed it necessary.

On further review, found no references supporting a 72-hour emergency medication process.

Patient #1 (P1) was a young adult who in November 2018, was admitted by court-order for psychiatric evaluation of competency related to legal issues. P1 had a history of violence and had multiple events of violence during admission. P1 was ordered 72 hour involuntary medication a total of 4 times, initiated after P1 punched a peer. A psychiatric note of 1045 on the first day of initiation revealed in part, " ... (P1) is a danger to others & will initiate 72 hour medications on emergency basis (Cannot do CRP until pt adjudicated)." This meant that P1 did not receive the patient rights associated with a CRP as would others who had been adjudicated.

During the 72-hour periods, P1 sometimes received intramuscular medication (IM), but often took the medication by mouth. Though P1 often took medications by mouth, it was by coercion that P1 took any medication. In the note mentioned above, the clinician documented in part, "Patient refused to accept prescribed psychiatric medication upon admission ...," and, "was adamant that (P1) doesn't take any medication." Two weeks later, a note of 0910 stated in part, "Patient was placed on 72 hour emergency medication orders due to reported assaultive behaviors which were then renewed (the day before), resulting in the patient recently demonstrating medication compliance while strongly continuing to verbalize that (P1) would prefer to take no medications."

For P2, a 60+ year old court committed patient with a neurocognitive disability complicated by a physical deformity that made it very difficult to communicate verbally, the orders for 72 hour emergency medications were written with the apparent approval of the patient's court-appointed guardian (a sibling). It was unclear from the record whether this guardianship order specified that the guardian was authorized by the court to consent to involuntary medications and psychiatric treatment. Even if the order so specified, medications administered during a behavioral emergency to a patient who was dangerous or violent did not require consent. By referring to medications as emergency medications, the hospital did not need consent. However, documentation in P2's medical record failed to support behavioral emergencies lasting 72 hours although the medications were continued for that period of time on several occasions.

In summary, the hospital followed a policy and practice for P1 and P2 which had no basis in statute or regulation. This practice circumvented established and authorized processes which acknowledged patient rights, the right to refuse, and the right to appeal involuntary medication administration. Further, the policy and procedure promoted the administration of emergency medications for 72 hours in the absence of documentation of patient behaviors which constituted emergencies.

Based on a review of 10 medical records, it was determined that for two patients (P1 and P2), the hospital used chemical restraints in the absence of emergency behaviors by utilizing the 72-hour emergency medication policy. For P1, 72 hour emergency medications were initiate two days after P1 assaulted another patient and in P2, the sedative effects of these medications, coupled with P2's difficulty eating a regular diet, caused P2 to develop a hospital acquired pressure injury.

Patient #1 (P1) was a young adult who in November 2018, was admitted by court-order for psychiatric evaluation of competency related to legal issues. P1 had a history of violence and had multiple events of violence during admission. On a Saturday in December, P1 punched a staff person and another patient. After having been given forced medications during the actual emergency behavior, P2 was restarted on the 72 hour emergency medications two days later on Monday. The reason documented by the psychiatrist was the patient's behavior from two days prior.

P2 was a 60+ year old court patient sent to the hospital for an evaluation of competence to stand trial. P2 had a neurocognitive disability complicated by a physical deformity that made it very difficult to communicate verbally and increased the risk that P2 would aspirate or choke on food or fluids. P2 had three episodes of attempted assaultive behavior during the first seven days of the admission and had a very low tolerance for frustration.

On the seventh day of admission, P2 was placed on 72 hour emergency medications (an antipsychotic and a sedating antihistamine) after attempting to punch a staff person who informed P2 that coffee would not be available until breakfast time. Later that afternoon, a nurse documented "no threats or attempts made to hurt others. Meds given IM since (P2) refused the 72 hour emergency meds by mouth." The night nurse then charted near midnight "Pt. made no attempt to harm others, however he refused PO (per mouth) so IMs (injections) were administered at 5 PM."

On the following day, the day shift nurse documented that P2 refused PO medications so IMs were given. The evening nurse documented "Pt. very unpredictable. Pt. made no attempts to harm others. 72 hour emergency meds in progress."

The orders for 72 hour emergency medications were renewed by physicians twice over the following 10 days. Early on the 17th day of admission, the night nurse charted "Pt. sleeping majority of shift, possibly from the sedative effects of the PRN (as needed) IMs received on the previous shift." Three hours later, the day nurse documented "Mild redness to right hip and right ankle. No open areas." A pressure-relieving mattress was ordered for the patient.

Based on a review of 10 medical records, it was determined that the hospital used the emergency medication policy to administer chemical restraints via standing orders on at least two patients (P1 and P2).

Patient #1 (P1) was a young adult who admitted in November 2018 by court-order for psychiatric evaluation of competency related to legal issues. P1 had a history of violence and had multiple events of violence during admission. P1's orders for 72 hour emergency medications were renewed four times during a five-week hospitalization. As noted in Tags A-0131 and A-0160, the orders for 72 hour emergency medication administration included options for administering orally or if P1 refused or spit out the medications, they would be given via intramuscular injection. P1 was prescribed antipsychotics, sedating antianxiety medications, and a sedating antihistamine. In several orders, if P1 refused the antipsychotic, the order stated to give an injection of the antianxiety medication. While these medication changes were likely attempts by the medical staff to find something that would control P1's intermittently violent behavior, the orders also contained no behavioral parameters governing their use, and contained no instructions to notify the physician.

P2 was a 60+ year old patient sent to the hospital for an evaluation of competence to stand trial. P2 had a neurocognitive disability complicated by a physical deformity that made it very difficult to communicate verbally. P2 had three episodes of attempted assaultive behavior during the first seven days of the admission and had a very low tolerance for frustration. As noted in Tag A-0160, P2 was administered "emergency medications" on a standing basis for 72 hours at a time with no documented behaviors that constituted an emergency. Even when P2 attempted to strike out at staff, P2 was slow and uncoordinated and documentation indicates that, except in one instance, staff were easily able to avoid getting hit. While documentation indicated P2 was loud, incoherent, and made many verbal threats when frustrated, is difficult to see that P2 posed a threat sufficient to require standing orders for sedating medications.

The hospital called these orders "emergency" medication orders but, in both of these patients, the emergency had passed and the ordered medications constituted standing orders for sedating medications with no contemporaneous assessment of whether the presenting behavior actually represented emergency situations.

Based on observation, a review of the hospital Patient Rights and Responsibilities (PRR) policy (approved 11/19/2015); the Visitors policy (approved 10/31/17) and interviews, it was determined that patient visitors may be restricted from visitation on the basis of a lack of identification (ID), or a mandated type of identification.

The hospital had two admissions buildings, each building housed approximately 20+ patients on multiple units. Visitors entered into a central lobby by way of locked exterior and anteroom doors.

A walk-through metal detector was noted in the lobby, and an assigned security staff monitored the locked doorways, monitored visitors for contraband; had visitors lock belongings in provided lockers, and directed visitors through another locked door to appropriate units for visitation.

Review of the PRR revealed in part, "At reasonable visiting hours, all patients may visit and have private conversation with any visitor whom they wish to see, unless the visits are limited for medical reasons."

Review of the "Visitors" policy revealed the General Procedure for Visitors in part, "B. All visitors must provide an acceptable form of personal identification that includes a photograph (i.e. driver's license, Motor Vehicle Administration (MVA) identification, State of Maryland agency identification, passport, etc.)

Review of the PRR and the Visitors policy revealed that all patients may visit with any visitor whom they wish to see with the caveat that the visitor had an acceptable form of ID.

Interview with RN#1 on a unit of the admissions unit revealed the RN belief and expectation that ID's for visitation must be photo IDs and also "Current."

Interview on 4/3/2019 at approximately 0900 with a lead security staff (LSS) revealed that while photo IDs are mandatory, the LSS had made exceptions, and gave the example of a particular religious group who refuse to carry photo IDs. While this may have been an appropriate exception to the rule, it was not applied consistently across various security staff and did not apply to visitors who were not members of that particular religious group and who may not have had an "acceptable" form of ID, or no ID at all.

While no actual failures of visitation were noted, the visitation policy was not applied consistently. In summary, the hospital superimposed an arbitrary process over the right of patients to receive visitors.