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Based on review of medical record, policies and procedures and staff interview, it was determined that the hospital failed to clinically and behaviorally justify the use of restraint (medication) in the care of patient #14.

As indicated in A0154, on June 1, 2015, through staff interviews and review of medical record review for patient #14, it was revealed that a 81 year old patient after admission to the hospital on 5/23/15 received multiple doses of psychotropic medication over a course of 9 days (10 occasions of administration) via IV to the point of over-sedation. The hospital failed to consistently document a description and assessment of the patient ' s behaviors requiring restraint, failed to document least restrictive alternative tried before administration of restraint, failed to monitor the patient every two hours while in restraint to determine if the restraint could be terminated, failed to offer less restrictive interventions such as oral medication and sitters, and finally failed to modify the patient plan of care to include alternative interventions and consultation from psychiatry and/or neurology for assistance in managing the patient ' s care including medication.

Based on an onsite investigation of June 1, 2015 which included observations in the emergency department psychiatric area, and interview, it is determined that 2 patients in their respective rooms were monitored by camera without evidence that they had been informed of the camera surveillance; thus resulting in a violation of their right to privacy.

Surveyor observation of the nursing station in the psychiatric portion of the emergency department on 6/1/2015 revealed a bank of monitors at a desk on which all occupied patient bedrooms could and were constantly monitored by the tech sitting at the desk. At the time of observation, there were at least two occupied rooms in which the two patients were either sitting or lying on their respective beds. Therefore, neither of the patients observed were demonstrating imminently dangerous behaviors.

Both patients had been searched, and their rooms were devoid of objects by which they might harm themselves. Additionally, each room was relatively close to the nursing station, no room being more than approximately 30 feet from the station.

During an interview with the Charge RN on 6/1/2015 at approximately 1:30 PM she stated that the patients were informed on entry to the area that there are active surveillance cameras in the rooms. When asked for documentation of the information received by the patient, the RN was unable to produce any.

Based on the lack of a documented consent and observations of the area , it was determined that the hospital did not have a verifiable process or a policy to confirm that patients in the rooms were aware that they were under constant surveillance, therefore violating their right to privacy.

In addition, on the 6th floor Special Care Unit on 6/1/15 at 8:30 AM during tour of the unit with the unit Charge Nurse and Director of Acute Care Services, it was noted that there was a camera mounted on the wall in an empty room. The surveyor was informed that there are cameras in all rooms on the Special Care Unit on the 6th floor and that the cameras are for monitoring to ensure patient safety. When asked if the patient and family from a privacy stand-point are informed they are being monitored. The charge nurse stated they inform the patient or family during the admission process to the unit but there is no formalized process in place that staff can verify that the patient and/or family have been informed and consented to the camera use. Patient #2 and patient # 3 were not aware of the camera but also had cognitive issues.

The hospital's practice of using cameras within patient rooms without informing the patient and/or family of the monitoring without prior consent does not allow for the patient to have personal privacy.

Based on observation of the Emergency Department Services, consultation and interview of the hospital's administrative nursing staff during a tour on 05/27/15 between 9:25 AM-11:10 AM of the Main ED, it was determined that the the hospital demonstrated a pattern of failing to protect health information (electronically and paper documents) when protected health information was left out in plain view. This was evident for one separate observation made during tour of 9 out of 33 patient ED rooms. The findings were as follows:
A tour of the Main ED made at 9:25 AM revealed a computer monitor, located on a waist height shelf tucked into the wall, parallel to the entry into the back area of the work station area, and feet from the main corridor. The monitor displayed a patient's chest x-ray opened on the screen and in full view to staff, visitors, and the general public. The patient's name, date of birth, and other pertinent information was displayed at the top of the electronic record. At the time of the observation, no staff was in close proximity to the publicly displayed information. The surveyor stepped out of the corridor or hallway and into the area (approximately 2-3 foot) when this discovery was made. The surveyor intervened by informing the nursing administrative escort staff that the information should be collapsed when not in use.

In addition, tour of the Main ED made at 11:10 AM revealed that patient information such as Initial Triage Data, consents, EKG reports, and chief complaint information was placed in wall mounted chart holders outside the respective ED room with the patient information facing outward to the hallway and in view of anyone passing by. Main ED rooms observed with the patient information in view were rooms #50, #75, #77, #54, #57, #63, #64, #70 and #76.
Failure by staff to consistently safeguard patient information violates the patient's right to confidentiality and privacy of personal and clinical information.

Based on review of the medical record, policies and procedures, and staff interviews, it was determined that the hospital failed to clinically and behaviorally justify the use of restraint (medication) in the care of patient #14.

Patient # 14 was admitted to Anne Arundel Medical Center on 5/23/15 with the diagnosis of Acute Renal Failure (ARF). The patient was treated at the hospital for a stroke on 5/3/15 and discharged on 5/11/15 to a skilled nursing facility (SNF). The patients other significant diagnosis was dementia/sun downing prior to admission. The patient's medication reconciliation performed on admission 5/23/15 revealed the patient was not on any psychiatric medications. This patient was reported to be intermittently confused and, at times and pulling on necessary medical tubes and intravenous (IV) lines.

Medical record review on 6/1/15 at 11:10 AM revealed that patient #14 received a total of 10 doses of Haldol (medication) IV beginning on 5/23/15 at 21:07 PM through 5/31/15. Timeline of events regarding administration and staff documentation of use of medication as follows:

· 5/23/15 at 4:10 PM: An order was written for Haldol 1mg every 12 hours PRN (As needed), no indication written in order for the use of medication
· 5/23/15 at 4:38 PM: A nurse administered Haldol 1mg IV without no documentation of physician or nurse description of the patient's behavior to justify use of the PRN
· 5/23/15 at 7:39 PM: A second order was written for Haldol 1mg IV every 4 hours PRN, no indication for medication was written in order
· 5/23/15 at 9:07 PM: A nurse administered Haldol 1mg IV again without documentation by any physician or nurse describing the patient behavior at this time, nor of medication effectiveness.
· 5/24/15 at 2:42 AM: A nurse administered Haldol 1mg IV, then documents at 2:48 AM, " Pt restless, keeps pulling at Foley catheter, screaming out loud, taking gown off. Pt confused, redirected. MD paged. New orders. Will continue to monitor. " No physician documentation or assessment noted at this time.
· 5/24/15 at 9:30 AM: Physician documents " Was agitated and confused overnight pulling on his Foley catheter. AMS (mental status): Probably multifactorial due to ARF, recent CVA (stroke), dehydration on top of underlying dementia with some sun downing. Will check CT brain, B12, folate, RPR, NH3 " . No mention of response to Haldol noted at time of administration or need to continue use of an IV antipsychotic medication in this elderly patient.
· 5/24/15 at 9:31 PM: A nurse administered Haldol 1 mg IV.
· 5/25/15 at 2:18 AM: A nurse administered Haldol 1mg IV.
· 5/25/15 at 6:37 AM: A nurse documented " Patient agitated most of the night. Haldol was given x2 @2130 and 0218. Patient slept for a couple of hours and started getting agitated and yelling again at 0400-can be redirected for about 5 minutes but starts yelling and agitation again " .
· 5/25/15 at 10:01 AM: A nurse administered Haldol 1mg IV. No documentation of patient behavior or assessment by nurse of physician.
· 5/25/15 at 3:28 PM: A nurse administered Haldol 1mg IV. No nursing note describing patient ' s behavior.
· 5/25/15 at 4:26 PM: A new order was written to increase the dose of Haldol to 2mg IV every 4 hours PRN (no indication written in order for use).
· 5/25/15 at 4:37 PM: A physician note indicated " Confused, still agitated. " CT of brain and labs reviewed. " IV Haldol prn " . No reasonable rationale was found to utilize an IV antipsychotic medication or to increase the dose of the same for this elderly patient.
· 5/25/15 at 9:53 PM: A nurse administered Haldol 2mg IV. Again without any documentation of patients behavior justifying the PRN use of the IV antipsychotic.
· 5/26/15 at 4:47 PM: A physician progress note indicated " Noted last night events, patient was more agitated, combative, required multiple doses of IV Haldol, now more sedated, unable to voice any concerns. Desaturated (no documentation noted of desaturation result, for example 82%) today and placed on oxygen. IV Haldol prn, will reduce dose to 1mg TID. " (Although the dose was lowered, at this point the patient had been over-sedated and yet there was still no documentation found reflecting that any staff recognized or questioned the need to reevaluate the use of IV antipsychotics to manage agitation in this elderly patient.)
· 5/26/15 at 1:45 PM: New order for Haldol 1mg IV every 8 hours prn (no written indication for use of medication).
· 5/27/15 at 5:57 PM: Physician noted states " Confused. IV Haldol prn. Chest CT bilateral pleural effusion " .
· 5/30/15 at 7:51 PM: Nurse administers Haldol 1mg IV. No documentation provided describing patient ' s behavior and needs for medication.
· 5/31/15 at 4:54 PM: Nurse administers Haldol 1mg IV. No documentation provided describing patients behavior of need for medication.

The medical record revealed that patient #14 was medicated with psychotropic medications on 10 occasions without adequate description of behavior and justification, without reevaluation of the care plan, without documentation that less restrictive measures were considered or attempted, without documentation that behavior assessments were performed to assess whether there was any legitimate need for IV Haldol at the time of each of these 10 administrations, and at times without documentation of effectiveness of the intervention after the IV administration.

Review of the medical record for patient #14 revealed the following:
1) the medical record failed to demonstrate an effective and individualized care plan was actually driving care delivery,
2) the documentation lacked descriptions of patient behaviors and therefore lacked justification for the ongoing administration of the IV antipsychotic medication;
3) the medical record documentation failed to sufficiently support or clarify that if the use of chemical restraint was medically supported or if the use was addressing behavioral needs; and,
4) regardless of the type of restraint in use, there was no indication that the least restrictive interventions were tried and failed.

The patient was medicated with Haldol IV in varying doses until he/she became oversedated on 5/26/15. The record revealed that patient #14 was over-sedated, could not be awakened to perform assessment for up to 12 hours, and suffered decreased oxygen saturation levels. Even then, there was no reevaluation by any staff to determine if care plan revisions were necessary for patient #14.

The hospital's failure to meet the individualized needs of the resident resulted in overly sedating patient #14 and increased the risk for a serious preventable adverse event related to care management.

The hospital's failure to comply with minimum requirements set forth in this standard placed patient #14 at risk for injury.


Reference also Federal Tag A 164.

Based on review of 1 out of 14 medical records, it was determined that the hospital failed to use less restrictive interventions before the use of chemical (medication) restraint. In 10/10 administrations of IV Haldol (an antipsychotic) staff failed to document sufficient attempts or use of less restrictive measures, and in 10/10 administrations of the chemical restraint staff failed to document behaviors that might have justified the administration.

For example on 5/23/15 at 4:38 PM a nurse administered Haldol 1mg IV without no documentation of physician or nurse description of the patient's behavior to justify use of the PRN and with no documentation the sufficient attempts were made at less restrictive measure before utilizing the IV dose.

For additional detail see Federal Tag A 154.

Based on a review of 14 medical records, it was determined that in 1 out of 14 medical records the hospital failed to reevaluate and revise the plan of care for patient #14 for whom, the hospital employed the use of chemical restraint without sufficient rationale for prescribing and without sufficient documented justification for administering, even after the patient had become over-sedated. The failure to follow the prescribed care planning process to ensure that care is both safe and effective resulted in continued use of unnecessary IV chemical restraint and placed the patient at increased risk for a serious preventable adverse event.

Patient #14 ' s medical record on 6/1/15 revealed that the plan of care was not reevaluated or revised over many days while the elderly patient continued to receive an IV antipsychotic medication that lacked sufficient rationale for use, lacked sufficient descriptions of behavior to justify administrations, and resulted in the patient becoming overly sedated by 5/26.

Reference Federal Tag A 154

Based on an onsite investigation of June 1, 2015 which included observations in the emergency department, interview, and review of staff training, it is determined that security guards who have occasion to assist placing patients in restraint, and to monitor patients, are not provided education on how to determine when a patient is in distress.

Interview with security guard #1 who had been hired one month prior, revealed he had received training on how to deescalate a patient, and how to restrain a patient if asked to do so by the nurse. When asked of what education he received related to determining when a patient is in distress, he stated he could not remember receiving such education. When asked if he sometimes monitors patients in restraint, he responded that sometimes security does relieve staff for short periods.

Review of training given to security guard #1 revealed safe restraint application techniques, however, no education regarding how to determine when a patient is in distress or how to respond to it. Based on interview and documentation, it is determined that the hospital's training failed to include information to the security staff regarding signs that a patient may be experiencing distress while in restraints or seclusion.

Based on the review of medical records and interview with the unit manager, it was determined that in 1 out of 14 patients reviewed (patient #14) nursing staff failed to ensure that the patient had an effective care plan individualized to the patient's needs

ADD Paragraph here to state what was in the existing care plan.

Review of patient #14's medical record and interview with the unit manager on 6/11/15 at 9:25 AM, revealed that nursing staff failed to update the patient's Care Plan when the staff utilized IV chemical restraint on an ongoing basis to manage the patient's agitation. The Care Plan documentation addressing the patient's need for restraints (medication), and the patient's mental status (confusion and agitation) was not completed by staff on 5/25/15, 5/26/15, 5/28/15, and 6/1/15. When interviewed the unit manager confirmed the incomplete Care Plan documentation and stated to the surveyor that patient Care Plans are required to be updated at least every 24 hours and as the patient's medical needs change.

Based on observation of the Emergency Department Services, consultation and interview of the hospital ' s licensed administrative nursing staff during a tour on 6/1/15 between 9:25 AM -11:10 AM of the Main ED, it was determined that intravenous carts were unlocked and unattended by staff.
The findings were:
Observation of the ED Services in different areas revealed that intravenous carts were placed for staff use in hallways. Intravenous carts are stocked with various intravenous supplies such as intravenous catheters (needles) of various sizes and gauges. However, during the tour 3 intravenous carts were found unlocked, unattended by staff, and unsecured. These carts were found in the EDTU area, main ED section 4A and 4B.
Failure by staff to keep intravenous carts locked and secured potentially can create a: 1) delay in treatment if needed supplies are empty or missing and 2) a tampering and thievery opportunity for any individual coming through the ED whether a patient or visitor.