HospitalInspections.org

In 1 of 33 medical records reviewed (patient #4), the hospital failed to provide evidence they monitored the patients placed in non-behavioral restraint while in the Emergency Department.


Patient #4 is a 65 year old male presented to the Emergency Department on 7/15/12 via EMS for seizure, unresponsiveness and alcohol abuse. The patient had endotracheal tube placed. At 9:10 pm the patient was described as awake and spontaneously opening eyes. The patient was not obeying commands and attempting to sit up and pull IV tubing and ETT. Bilateral soft wrist restraints were placed.


The ED nursing notes indicated that the staff had attempted less restrictive interventions but had to protect the patient ' s airway. The order was written and the physician was present during the application of the restraints. Per the hospital policy and procedure the patient is monitored with nursing staff making personal contact with the patient at least every two hours to observe and document. In this case the patient was intubated and placed on a ventilator, which required the nurse to be at the bedside constantly. Although the nurses notes validated the patient was monitored, the medical record review for patient #4, revealed the patient did not have a restraint flow-sheet documenting the care provided to the patient while in restraint.

In 1 of 33 medical record reviews (patient #4), the hospital failed to document the impact of the intervention on the patient's behavior as well as a plan for continued use.


Patient #4 is a 65 year old male presented to the Emergency Department on 7/15/12 via EMS for seizure, unresponsiveness and alcohol abuse. The patient had endotracheal tube placed. At 9:10 pm the patient was described as awake and spontaneously opening eyes. The patient was not obeying commands and attempting to sit up and pull IV tubing and ETT. Bilateral soft wrist restraints were placed.


Review of the nurse's notes revealed a description of the care provided to patient #4, but no specific documentation regarding the patient ' s behavior and continued need for the restraints.

Based on review of 33 medical records it was determined in one of 33 the medical records failed to contain documentation relative to the patient's refusal for treatment including the risks and benefits of leaving the ED and the reasonable steps taken to secure the patient 's written refusal to leave without treamnet as evidenced by:


Patient #1 is a 34 year old male who was transported to the University of Maryland Medical Center's Adult Emergency Department (AED) on June 19, 2012 at 8:09 am by his partner/next of kin. Patient #1 was subsequently triaged by the AED RN. At the time of triage Patient #1 informed the RN that he had just had a severe anxiety attack. Patient #1 denied having any suicidal or homicidal ideation but informed the nurse that he had stopped taking his bipolar medications because they were not working.

Vital Signs were taken and were in normal parameters with the exception of Patient #1's blood pressure which was elevated at 145/100. Normal range is less than 120 systolic and less than 80 diastolic. Patient #1 informed the triage RN that he had not taken his blood pressure in more than 6 months. Patient # 1 also informed the RN that he wanted to be seen in the Psychiatric Urgent Care (PUC), which is a psychiatric pod within the AED.

On further review of the medical record, at 8:45 am, the RN in the PUC documented that Patient #1 was brought to PUC with security and the patient's friend. The RN also documented that Patient #1's friend was not allowed to be on hospital grounds due to extenuating circumstances and was escorted out by security. According to the nursing note, at that time Patient #1 informed the PUC nurse that if his friend could not stay, he would get treatment elsewhere.

However, there is no indication or documentation that prior to Patient #1 leaving the hospital he was informed that he had the right to remain and receive care, was reassessed for his elevated blood pressure, suicidal or homicidal ideation, or that staff informed Patient #1 of any risk related to his leaving prior to receiving a physician assessment. Neither is there documentation that Patient # 1 was provided a Declination of Medical Screening Examination Form to sign prior to his leaving the hospital. Patient #1 subsequently did seek care at another local hospital' s emergency department.

At the time of the site, visit surveyors interviewed the PUC Unit Manager, Assistant Security Director, and the HR Generalist in regards to why Patient #1's partner/next of kin was not allowed to accompany and remain with Patient #1 while he was seeking treatment.

According to the PUC Manager and the HR Generalist, the former employee (Patient #1's partner/next of kin) had been discharged from employment and informed that he could not come onto hospital grounds unless seeking medical care. The Assistant Security Director also indicated that the security office had been notified by the manager that the employee could not come onto the hospital's grounds unless seeking medical care. In addition, the security office had also been provided a picture of the former employee so that security staff could identify the former employee.

Subsequently, surveyors inquired as to whether the former employee was provided written instruction not to come onto the hospital grounds unless seeking medical care, or could not accompany family or other persons seeking care onto the hospital grounds, and if the instructions had been placed into the employee personnel file. On review of documentation from the personnel file, it was determined that there was no documentation of having instructed the former employee not to come or accompany family or significant others onto the hospital grounds in the personnel file. In fact, on review of the letter that was sent to the former employee via Fed Ex and regular mail, the letter is void of any documentation instructing the former employee that he could only come onto the hospital grounds if seeking medical care.