HospitalInspections.org

Bringing transparency to federal inspections

5401 OLD COURT ROAD

RANDALLSTOWN, MD 21133

PATIENT RIGHTS

Tag No.: A0115

Based on review of policies and other documentation, 17 medical records inclusive of six records of restrained patients, and interviews with staff, it was determined that the hospital failed to meet the Condition of Patient Rights when:

1) A-131, Nursing catheterized patient #3 multiple times without patient consent or physician orders,
2) A-0154, failed to release patients #2 and #3 from restraints at the earliest possible time,
3) A-0168, restrained patients #2 and #3 without orders to do so,
4) A-0175, failed to provide care for restrained patients #2 and #3, and
5) A-0179, failed to conduct a complete a face to face for patient #3.

PATIENT RIGHTS: INFORMED CONSENT

Tag No.: A0131

Based on a review of patient #3's medical record, it was determined that nursing staff catheterized P3 multiple times during a lengthy 4-point restraint episode without patient consent or physician orders.

Patient #3 (P3) was a 50+ patient who presented to the ED via ambulance in January 2019 due to increasing agitation and aggression at P3's community placement. P3 had suffered a traumatic brain injury in the past and had a known psychiatric disorder. P3 was placed into 4-point restraints from day one at 1644 until day two at 0501. This was an approximate total of 12 hours. P3 was noted by ED staff to be incontinent of urine and was placed in a diaper for incontinence.

Further review of the record identified documentation at 2100 with pre-printed element of "Violent Restraint Hygiene/Elimination." The entry following this element was documented as "Urinary catheter." Further notes under Violent Restraint Activity for that time documented that the RN drew blood and straight catheterized P3 at 2100. (A straight catheterization refers to a urinary catheter that is inserted, the bladder drained, and the catheter then removed). Flow documentation revealed intermittent straight catheterization occurred at 2227 and 0814.

There was no documentation found identifying that the staff tried any alternative to this invasive and painful procedure. There also was no documentation indicating why P3 couldn't be taken to the bathroom and nothing to indicate that anyone tried to explain to P3 why this procedure was necessary or to elicit P3's consent and cooperation.

A review of all orders revealed no physician order for catheterization of P3 indicating that nursing catheterized P3 without authorization, and unnecessarily risked possible infection or urinary track damage.

Please see Tag A-0154 for an explanation of why the need for continued restraints over night was unsupported by behavioral documentation and may have been a matter of convenience for the staff. The lack of explanation to P3 of the procedure and the failure to discuss with the medical staff and obtain orders indicated that the catheterizations may also have been for the convenience of the staff.

USE OF RESTRAINT OR SECLUSION

Tag No.: A0154

Based on a review of 6 restraint/seclusion episodes for two patients, it was determined that patients #2 and #3 were not released from restraint at the earliest possible time.

Patient #2 (P2) was a young adult who self-presented to the emergency department (ED) in February 2019 with threats to self-harm. P1 was placed into 4-point restraints from day one at 2230 through day 2 at 0830. This was a total of 10 hours.

Review of documentation revealed RN behavioral documentation from 2300 to 0000 respectively of "Combative - Physical, Combative - Verbal, Aggressive, Kicking, Scratching, Spitting, Threatening," and "Combative - Verbal, Aggressive, Threatening."

Documented simultaneous to the aforementioned behaviors, P2 was also documented from 2300 to 2345 as sleeping for 1 hour, and then sleeping for 2 hours by 0000. This documentation supported that P2 could have been released from restraint because P2 had ceased demonstrating imminently dangerous behaviors but was kept in restraints for violent behavior until 0830 the next morning..

Behavioral documentation continued through 0830 with various combinations of electronic drop-down term selections such as "Combative, Verbal, Threatening, Aggressive, and Self-Destructive." No actual descriptors of behavior were found to support how P2 remained violent or posed a threat to self or others over the course of 10 hours. For instance, when nursing documented "self-destructive," it was not clear how P2 could continue with that behavior while in 4-point restraint. Further, no RN assessments were documented which justified ongoing restraints. Finally, neurologic assessments elsewhere in the record failed to support the descriptors of ongoing violent behaviors when they revealed P2 to be drowsy/sedated during the hours of 2300, 0000, 0012, 0530, 0646, and 0815.

Patient #3 (P3) was a 50+ patient with a history of head injury who presented to the ED via ambulance in January 2019 due to increasing agitation and aggression at P3's community placement. P3 was justifiably placed into 4-point restraints on day one at 1644 for violent behavior but was not released until day two at 0501. This was an approximate total of 12 hours.

Redundant nursing electronic documentation over the course of the 12 hours restraint episode attempted to justify continued restraint with documentation of "Aggressive, spitting, scratching" behaviors. However, the 1:1 sitter documentated from 1700- 1745 that P3 made attempts to "climb out of bed" and was "moaning" which contradicted the RN documentation which described P3's behaviors of "aggression" and "scratching." Review of sitter documentation found no attempts to scratch during the restraint and indicated that P3 has ceased the violent behavior within an hour of application of restraint.

From 0100 through the end of restraint at 0501, the sitter documented P3 as "calm...trying to climb out of bed...and sleeping." However nursing documentation continued to give attribution to "Aggressive, Scratching, Spitting" behaviors. Additionally, no objective RN behavioral descriptors were found in the medical record.

While limited electronic medical record choices could result in redundant documentation, no objective behavioral descriptors and no RN assessments for P2 or P3 related to release from restraint were found to justify continued restraint. Therefore, P2 and P3 were not released at the earliest possible time.

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0168

Based on a review of 6 restraints/seclusion events, for two patients, it was determined that patient #2 was restrained in 4-point restraint between 0630 and 0830 without orders to do so; and patient #3 was restrained in 4-point restraint between 0256 and 0501 without orders to do so.

Patient #2 (P2) was a young adult who self-presented to the emergency department (ED) in February 2019 with threats to self-harm. P2 was placed into 4-point restraints from day one at 2230 through day 2 at 0830. This was a total of 10 hours. P2 remained in 4-point restraints through 0830the following morning though only one other order at 0230 was found. Therefore, P2 was restrained for 2 hours beyond the expiration of the order.

Patient #3 (P3) was a 50+ patient who presented to the ED via ambulance in January 2019 due to increasing agitation and aggression at P3's community placement. P3 was placed into 4-point restraints from day one at 1644 until day two at 0501. This was an approximate total of 12 hours. Review of orders found that after 2256, no further orders for restraint were written. Therefore, P3 was restrained from approximately 2300 until 0501, also 2 hours beyond the expiration of the order.

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0175

Based on a review of 6 restraints events for two patients, it was revealed that the hospital failed to meet care standards for nutrition, hydration, elimination and Range of Motion (ROM) for patients #2 and #3 who were in 4-point restraint for several hours each.

Care standards and hospital policy required offering nutrition, hydration, and elimination care for restrained/secluded patients at a minimum of every two hours. During survey, the hospital offered a draft copy of the hospital Restraint & Seclusion policy without an effective date, but which superseded the September 7, 2018 version. Contained therein under "Care of the patient in Violent/Self Destructive Restraint:

iii. Every two hours:
Offer bedpan, urinal, or bathroom to meet elimination needs
Offer food and fluid according to order and nutritional needs. Meals are offered at regular intervals."

Patient #2 (P2) was a young adult who self-presented to the emergency department (ED) in February 2019 with threats to self-harm. P1 was placed into 4-point restraints from day one at 2230 through day 2 at 0830. This was a total of 10 hours.

Review of restraint documents identified only one notation for the care provision of Nutrition/Hydration and Hygiene/Elimination elements. This was documented at 0230 with the response to the element of "offer declined." This indicated that patient #2 had no appreciable care during 10 hours of restraint.

Patient #3 (P3) was a 50+ patient who presented to the ED via ambulance in January 2019 due to increasing agitation and aggression at P3's placement. P3 was placed into 4-point restraints from day one at 1644 until day two at 0501. This was an approximate total of 12 hours.

Review of care for P3 revealed that no Nutrition/Hydration or Hygiene/Elimination elements of care appeared in the record until 0215, 10 hours after the initiation of restraint. At that time, the nutrition/hydration element was not documented, but unrelated data was found. Further documentation of nutrition/hydration of 0230 revealed the entry of "offer declined" with no clarification as to what was declined.

While no nutrition/hydration was offered previous to 0215, at that time, staff began to document the offer of nutrition/hydration every 15 minutes. Documentation for nutrition/hydration alternately revealed "offered," but then failed to differentiate as to what was "offered," and failed to document any outcome of those offers. Consequently, no documentation existed identifying if P3 received any actual intake of nutrition or hydration during the entirety of the restraint event.

No IV fluids were administered during the 12 hours of restraint, though P3 received a 1000 ml bag of normal saline at 1159 which was 3 ½ hours following release from restraint. Instructions were to administer the fluid "wide open," an order commonly used with dehydrated patients.

Further review of P3's record revealed Range of Motion (ROM) was not completed every two hours per the standard of care. Documentation revealed ROM at 2100, then not again until 0215 which was 3 hours overdue. At 0230 through 0445, ROM was documented every 15 minutes. Based in the fact that ROM required release of limbs for range of motion one at a time, every 15 minute ROM was not a realistic expectation.

In summary, the hospital failed to provide the standard of care for P2 and P3 over prolonged 4-point restraint events

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0179

Based on a review of 6 restraint events for two patients, it was determined that the hospital failed to conduct a complete face to face for patient #3 who was restrained in 4-points.

Patient #3 (P3) was a 50+ patient who presented to the ED via ambulance in January 2019 due to increasing agitation and aggression at P3's placement. P3 was placed into 4-point restraints from day one at 1644 until day two at 0501. This was an approximate total of 12 hours.

Review of P3's face to face of 1642 revealed that while (A) Immediate Situation was documented, no documentation was found for parts (B), (C), and (D). Therefore, the hospital failed to complete the face to face for P3.

CONTENT OF RECORD

Tag No.: A0449

Based on review of hospital policy, 8 closed records and 9 open records, it was determined the hospital failed to document reassessments consistent with patient #1's condition in the emergency department (ED).

Patient #1 (P1) was an adult who presented via ambulance to the emergency department in October 2018. P1 was triaged at 2115 following evaluation and treatment at an urgent care facility. Review of Emergency Medical Services (EMS) documentation revealed that patient #1 was prioritized at an Emergency Severity level of 2 following P1's report of "10 out of 10 abdominal pain (where 10 is the worst pain), nausea and generalized weakness." P1 had been treated at the urgent care facility with fluids and insulin for an emergency condition related to high blood sugar, and then was sent to the hospital for continued emergency care.

Following presentation, the RN ordered lab work per triage protocol for abdominal pain at 2126. However, blood was not drawn until approximately 3 hours later at 0032 of the following morning.

This bloodwork resulted in multiple laboratory values which indicated an increasingly unstable metabolic status requiring further assessment and possible medical intervention. However, review of P1's record revealed only vitals taken at 0044, 0521, 0810. While vitals were within norms excepting elevated pulse rates, they did not reflect a clinical assessment of P1's actual condition relative to lab values. P1 was not seen by a physician until 0828 and had no assessment information or interventions for ongoing and worsening metabolic changes over the course of approximately 11 hours. P1 was subsequently admitted to the Intensive Care Unit.

In summary, record review identified that the hospital failed to document and assess P1 per the standard of care.