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Based on review of 10 medical records, video surveillance footage, policies and procedures, and other pertinent documentation, unit observations, and staff interviews, it was determined that the hospital was out of compliance with the Condition of Participation of Patient Rights, as evident by multiple standard level violations listed below:

1. The hospital failed to uphold the right of 1 patient (Patient #1) to make informed decisions and agree to or refuse procedures and treatment. Cross-reference tag A-0131.
2. The hospital failed to provide a safe environment of care when: 1) the hospital staff failed to prevent an elopemet of a vulnerable patient (Patient #1) who sustained injuries during the elopement; 2) the hospital ED staff failed to perform complete and timely nursing assessments for an ED patient (Patient #2) and failed to relay abnormal vital signs to triage nurse or provider per hospital policy; and 3) the staff of the Behavioral Health Unit failed to adhere to cleanliness and safety standards of the patient care environment. Cross-reference tag A-0144.
3. The hospital failed to complete and document the one-hour face-to-face evaluation for 1 patient (Patient #1) who was placed in physical restraints. Cross-reference tag A-0184.

The cumulative effect of these failures created an unsafe environment of care that did not protect or promote the rights of patients in the hospital.

Based on review of 10 medical records, hospital policies, and other pertinent documents, it was determined that the hospital failed to honor the right of patients to be involved in health care decisions regarding treatment and procedures for 1 of 10 patients reviewed, as evidenced by failure to accurately document the capacity status for Patient #1 (P1) before obtaining an invasive procedure consent from the patient's family.

The findings include:

1) The surveyor reviewed the "Advanced Directives/Durable Power of Attorney for Healthcare" Policy. Appendix C. "Advance Directive Procedure for Maryland-based Healthcare Organization," under the "Certification of Incapacity" sections stated, "1. Unless otherwise stated in the AD (Advanced Directive), the AD only becomes effective after the declarant has been certified as lacking capacity to make an informed decision. 2. Certification must be written by the attending physician and a second physician. One of the physicians must have examined the patient within 2 hours before the certification."

The surveyor also reviewed the policy titled "Informed Consent, for Procedures/Treatment, Anesthesia and Blood." Section V. E. 2. "Assessment of Decision-Making Capacity" a. stated, "Prior to providing, withholding, or withdrawing treatment or procedure on the bases of a Health Care Agent or surrogate decision-making, an AICP (Attending Involved in the Care of the Patient) and a second independently licensed physician, must document that the patient is incapable of making an informed decision regarding the treatment. A resident or fellow may serve as the second physician only if he/she has obtained an individual State Medical License. Both physician must have examined the patient, one within 2 hours of the capacity document." Appendix C. of this policy is the "Documentation of Patient Decision-Making Capacity" form required by the facility.

Patient #1 (P1) was a 20 + year old patient who was brought to this hospital's Emergency Department (ED) by ambulance with police on an Emergency Petition (EP) following a self-inflicted injury. A patient presenting to the hospital under an EP receives an evaluation by a mental health provider in order to establish the need for inpatient mental/behavioral health treatment. P1 had a recent history of concerning behaviors and drug use, along with a strong familial psychiatric history. The patient was initially unresponsive, but breathing on presentation. Following the ED stay, P1 was transferred to a medical floor for observation and medical treatment of the self-inflicted injury.

Per medical record review for P1, a discussion with psychiatry was documented in P1's chart approximately 1 day after presentation to the ED, whereby a lumbar puncture was recommended. The provider further documented in this progress note that, " ...Patient is unwilling to cooperate with assessment, unable to assess capacity - patient currently does not have capacity due to lack of cooperation." The coordinating order for the procedure was written by a provider approximately 2 days after presentation to the ED and noted, "Does the patient have the capacity for consent? Yes."

The surveyor located the Consent for Performance of Procedure, Treatment, and/or Operations in P1's medical record for this procedure. The family member's name was entered as the "Legally Authorized Health Care Decision-Maker," as P1, "Was incapacitated." The form was signed by a provider, as well as a witness.

Despite two other entries by providers, one before the above procedure and one after, the surveyor found no "Documentation of Decision Making Capacity" form in the medical record.

Based on review of 10 medical records, hospital policies and procedures, and other pertinent documentation, unit observations, staff interviews, and review of the video surveillance footage, it was determined that the hospital failed to provide a safe environment of care to its patients when: 1) the hospital staff failed to prevent an elopemet of a vulnerable patient (Patient #1) who sustained injuries during the elopement; 2) the hospital Emergency Department (ED) staff failed to perform complete and timely nursing assessments for an ED patient (Patient #2) and failed to relay abnormal vital signs to triage nurse or provider per hospital policy; and 3) the staff of the Behavioral Health Unit failed to adhere to cleanliness and safety standards of the patient care environment.

The findings include:

1) Patient #1 (P1) was a 20 + year old patient who was brought to this hospital's Emergency Department (ED) by ambulance with police on an Emergency Petition (EP) following a self-inflicted injury. A patient presenting to the hospital under an EP receives an evaluation by a mental health provider in order to establish the need for inpatient mental/behavioral health treatment. P1 had a recent history concerning behaviors and drug use, along with a strong familial psychiatric history.

The patient was initially unresponsive, but breathing on presentation. Following the ED stay, P1 was transferred to a medical floor for observation and medical treatment of the self-inflicted injury. To promote the patient's safety from self-harm, the facility implemented 1:1 observation, which consisted of a staff person (sitter) remaining within arm's reach of the patient at all times.

Approximately 2 days after presentation to the ED, a RN documented " ... [patient] wanted to leave, security was called, physician came to see [patient], I also talked to patient regarding staying in hospital. Physician ordered [anti-anxiety medication] for patient, however, it was not given due to patient calming down and going to sleep." The RN note went on to state: "At [time, 5.5 hours after statement] patient ran past sitter and left building by way of side door to [unit] courtyard, Charge Nurse, sitter and myself followed, security called to search for patient."

The corresponding Resident "Significant Event" note corroborated the RN's statement above: " [P1] had escaped from [his/her] room. [P1] reportedly ran past [the] sitter and out the doors of the unit. I was told that security had been contacted and was searching the premises for the patient. I was subsequently notified [15 minutes later] by the charge nurse that the patient was now in custody." Further record review determined that approximately 30 minutes later, the Resident was notified that the patient was taken to another local hospital. "Reportedly, [P1] ran through [building] into the [unit] courtyard and proceeded to jump off the roof of the hospital. [P1] landed on a car and continued running, before being apprehended by [Police]."

The surveyors reviewed the video surveillance footage provided by the hospital of P1's elopement and confirmed that P1 had jumped off the 3rd floor and landed on the car parked on the hospital ground. The patient was observed lying on the ground for approximately 1 minute after the jump, then getting up and running out of the view of the camera.

The surveyors also reviewed documentation from the local Emergency Medical Services (EMS) and the local hospital (Hospital #2) where P1 was transported after being apprehended by the police. The review determined that P1 was assessed and treated by EMS and Hospital #2 for traumatic injuries, and was ultimately diagnosed with a spinal injury.

On April 21, 2021, the surveyors performed observations of the unit where P1 was placed and the route that P1 used to elope. The surveyors were accompanied by the Director of Nursing of Neurosciences, the Nurse Educator, and a unit nurse. The unit, where P1 was located, was a third floor unlocked medical unit. The hospital staff informed the surveyors that the patient came out of the unit, turned right, and went out of a glass door to an enclosed rooftop courtyard. This was where P1 climbed an approximately 8 foot wooden fence, ran across the rooftop, and jumped.

In an interview w/ the Director of Nursing of Neurosciences (DNNS) during the tour of the unit/area where the elopement occurred, DNNS stated that the two units on this floor had been previously unoccupied and had recently re-opened for patient care. DNNS further stated that the area in which the patient had jumped was intended for staff use only. However, the facility failed to lock the staff exit when the 2 units reopened for patient use.


2) Patient #2 (P2) presented to the hospital ' s Emergency Department (ED) with a complaint of an acute exacerbation of thoracic/chest pain, not relieved with over the counter pain medications. P2 admitted that his/her primary care physician and an urgent care facility had previously diagnosed the cause of the pain; however, P2 believed the pain alluded to a more serious condition.

P2 was assigned an Emergency Severity Index (ESI) score of 4. An ESI score is assigned to patients based on presenting signs and symptoms of illness and other factors, during the triage process. The ESI score ranges from 1-5, with 1 being assigned to patients with the most urgent needs, while 5 identifies patients with the least urgent needs.

The surveyor reviewed the hospital policy titled "Triage Process in the Adult Emergency Department" which stated in part:

"For all patients not in critical care, a complete set of vital signs is due at least every 4 hours including those in the external wait. Any changes or concerns by the staff or patient are reported to the triage nurse or waiting room nurse for an assessment to be completed."

In other hospital-provided documentation, it was stated that a "complete set of vital signs include: Temperature, Pulse, Respirations, Blood Pressure, Pulse Oximetry, and Pain score on all patients." This document also stated vital signs are, "More frequent based on patient condition or for abnormal vital signs." Abnormal vital signs were further described in a subsection below this statement, including the clinical threshold for a systolic (top number) blood pressure reading as less than 90 mm Hg (millimeters of mercury) or greater than 150 mm Hg.

In an interview with an ED triage nurse on day 1 of the survey, the nurse further corroborated the hospital ' s policy regarding vital signs being performed every 3-4 hours (the hospital ' s policy stated every 4 hours). However, review of P2's medical record showed that vital sign measurements were not taken every 4 hours, did not include all of the components of a complete set of vital signs, and failed to document any acknowledgement or interventions concerning P2's abnormal blood pressure.

The surveyor reviewed P2's medical record on April 21, 2021, including all of the vital signs documented during P2's 20 hour ED visit, and noted the following:

- The first set of vital signs was documented within an hour of the patient's arrival in the ED. This assessment was significant for the pain level documented at 9 out of 10 pain.

- Approximately 6 hours after the documentation of the initial set of vital signs, nursing staff recorded P2's second set of vital signs which included the blood pressure reading of 190/82 mm Hg. The vital signs performed at this time failed to document a pain assessment for P2, who had previously complained of 9 out of 10 pain.

- P2's third set of vital signs was recorded approximately 12 hours after the first set and included the blood pressure reading of 163/90 mm Hg. This set did not include the documentation of the patient's rate of respirations.

- There was no documented evidence that the patient's abnormal blood pressure readings of 190/82 mm Hg and 163/90 mm Hg were communicated to the triage nurse or the ED provider assigned to the patient or resulted in more frequent assessments, as required by the policy.

3) During observations on a 16-bed inpatient psychiatric unit on April 21, 2021, the surveyors, accompanied by the DNNS, Nurse Educator, Unit Nurse Manager, and Unit Lead Clinical Nurse, identified a brown trash bag in a red receptacle in the treatment room, toiletries and used washcloths in a shared patient bathroom, disposable drinking cups with fluid in them on the floor in the milieu, and what appeared to be unflushed human waste in the toilet in the seclusion/quiet room bathroom.

The hospital failed to provide a clean and safe patient care environment on the psychiatric unit.

Based on review of 10 medical records, hospital policies and procedures, and other pertinent documents, it was determined that the hospital failed to complete and/or document a one-hour face-to-face assessment following a restraint episode for 1 of 10 patients reviewed.

The findings include:

The surveyor reviewed the policy titled "Restraint and/or Seclusion for the Patient with Violent/Self-Destructive Behavior Policy." Appendix B. "Maryland Restraint and/or Seclusion Requirements for Violent/Self-destructive Patient Behavior," discussed the following requirements:

1. Face-to-Face Evaluation within 1 hour of initiation.
2. An initiation note by the RN that addresses the behaviors that led to the restraint, the specific type of restraint used, the alternative interventions, any changes in the patient's condition, and the patient's response.
3. Continued documentation of behaviors that necessitate the continuation of the intervention.
4. Assessments for potential release from the intervention.
5. Updates of the treatment plan.

Patient #1 (P1) was a 20 + year old patient who was brought to this hospital's Emergency Department (ED) by ambulance with police on an Emergency Petition (EP) following a self-inflicted injury. A patient presenting to the hospital under an EP receives an evaluation by a mental health provider in order to establish the need for inpatient mental/behavioral health treatment. P1 had a recent history concerning behaviors and drug use, along with a strong familial psychiatric history.

The patient was initially unresponsive, but breathing on presentation. Following the patient's ED stay, P1 was transferred to a medical floor for observation and medical treatment. The facility implemented 1:1 observation, which consisted of a staff person (sitter) remaining within arm's reach of the patient at all times.

The surveyor located a four-point restraint order in P1's medical record approximately 1 day after presentation to the ED. The order noted that the intervention was discontinued 25 minutes after the initiation; however, no documentation of the 1-hour face-to-face assessment was found in the patient's medical record.

Based on review of 10 medical records and other pertinent documents, it was determined that the hospital failed to document accurate patient disposition for 1 of 10 patients reviewed.

The findings include:

Patient #1 (P1) was a 20 + year old patient who was brought to this hospital's Emergency Department (ED) by ambulance with police on an Emergency Petition (EP) following a self-inflicted injury. A patient presenting to the hospital under an EP receives an evaluation by a mental health provider in order to establish the need for inpatient mental/behavioral health treatment. P1 had a recent history concerning behaviors and drug use, along with a strong familial psychiatric history.

The patient was initially unresponsive, but breathing on presentation. Following the ED stay, P1 was transferred to a medical floor for observation and medical treatment of the self-inflicted injury. To promote the patient's safety from self-harm, the facility implemented 1:1 observation, which consisted of a staff person (sitter) remaining within arm's reach of the patient at all times.

Approximately 2 days after presentation to the ED, a RN documented that P1 had stated, " ... [he/she] wanted to leave, security was called, physician came to see [him/her], I also talked to patient regarding staying in hospital. Physician ordered [anti-anxiety medication] for patient, however, it was not given due to patient calming down and going to sleep. At [time, 5.5 hours after statement] patient ran past sitter and left building by way of side door to [unit] courtyard, Charge Nurse, sitter and myself followed, security called to search for patient."

The corresponding Resident "Significant Event" note stated that the patient was "intermittently agitated and uncooperative with nursing." It went on to state that the Resident was notified of the patient's expressed desires to leave the hospital. "I explained to [him/her] this was not an option, and that [he/she] would have to stay here for [his/her] own safety. [He/she] continued to express [his/her] desire to leave, but the whole time [he/she] remained seated in a chair and made no motions to actually exit the room. I reiterated to nursing that the patient was incapacitated and was not permitted to leave AMA (Against Medical Advice)." The Resident stated that the patient had removed their IV (intravenous access) and it was unable to be replaced due to agitation. The anti-anxiety medication was ordered; however, the patient, "abruptly became calm and appeared to go to sleep." Approximately 5.5 hours later, the Resident was contacted by nursing staff to relay that P1, " ...had escaped from [his/her] room. [P1] reportedly ran past [the] sitter and out the doors of the unit. I was told that security had been contacted and was searching the premises for the patient. I was subsequently notified [15 minutes later] by the charge nurse that the patient was now in custody." Per the direction of the emergency services coordinator, the resident placed discharge orders. Approximately 30 minutes later, the Resident was notified that the patient was taken to another local hospital. "Reportedly, [P1] ran through [building] into the [unit] courtyard and proceeded to jump off the roof of the hospital. [P1] landed on a car and continued running, before being apprehended by [Police]."

On April 21, 2021, the surveyor reviewed the Patient Log which identified P1's "Discharge Disposition" as "Left Against Medical Advice."

The surveyors reviewed P1's medical record. Throughout P1's medical record, the disposition was documented as "elopement" in a nurse-to-provider notification and the description located in the discharge summary; however, the final disposition was documented as "Left Against Medical Advice" in the disposition of the discharge summary, the discharge order, and the discharge information section of the visit information document.