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Based on staff interviews, review of policies and procedures, medical records, video monitoring, observation and other pertinent documentation, it was determined that the hospital failed to provide care in a safe setting.

As indicated in A0144, on April 25, 2014 Surveyors from the Maryland State Office of Health Care Quality conducted an unannounced Federal on-site Investigation at Northwest Hospital Center on behalf of the Centers for Medicare and Medicaid Services. At the time of the investigation the federal Conditions of Participation Quality Assessment and Performance Improvement (QAPI), Nursing Services, Patient Rights and Emergency Services were surveyed.

The investigation revealed that an elderly female patient who had soiled herself on the behavioral health unit was dragged to the shower after refusing to go to the shower room. Based on medical record reviews, policies and procedures, staff interviews, observation and other pertinent documentation, it was determined that the Condition of Participation was not met due to deficiencies cited at:

A 144 for failing to provide a safe environment by dragging a patient down the hall; and A142 for failing to provide personal privacy to the patient while dragging her down the hall.

Based on review of 19 medical records, it was determined that in 1 out of 19 medical records reviewed, the hospital failed to provide patient #7 and/or his representative of his rights, risk of transfer and obtain consent for transfer to a higher level of care. Per the medical record the patient ' s family was in the Emergency Department with the patient and could have signed the consents if the patient was unable to due to his condition. Page 2 of the transfer form, section II, is the section where the physician transferring the patient enter their name, the name of the receiving physician and hospital. There is a statement under the hospital's name as follows: " The potential benefits of such transfer, the potential risks associated with such transfer and the probable risks of not being transferred have been explained to me and I fully understand them. With this understanding, I agree and consent to be transferred." Under this space are blanks for signature of the witness, patient/representative, date and time and relationship to the patient. For patient #7 this entire space is blank. In addition, Section 1 on the first page for patient condition/consent is blank and the mode by which the patient is to be transferred has not been checked off. The failure of the hospital to complete the form calls into question if consent was obtained.

Based on review of video of staff interaction with patient and dragging her to the shower on a blanket and periodic exposure of the patient #1, it was determined that the hospital failed to maintain the privacy of the patient.

During the process of getting the patient to the shower by dragging her on a blanket, the video revealed two patients on the left side of the hallway wandering in and out of their rooms and two occasions when the patient, who was wearing two gowns without underwear, was exposed with both female and male staff around her. On 3/29/14 at 11:09 AM three staff pulling the blanket bringing the patient into the hallway. At one point the patient rolled on her side but her gown was up around her waist exposing her pelvic area. A female staff member did reach down and cover the patient with the gown a few minutes later. Then the patient was sitting up on the blanket on the floor while staff attempted to talk to her. Later on 3/29/14 at 11:22 AM a blanket was spread on the floor beside the patient and the patient rolled onto the blanket, her gown again was up above the waist and was pulled down by staff. The patient was surrounded by male and female staff during the process as a female patient was coming in and out of her room. The hospital failed to provide privacy to patient #1 at a vulnerable time.

Based on staff interviews, review of policies and procedures, medical record review, observation and other pertinent documentation, it was determined that the hospital failed to safely transport patient#1 in the clinical setting.

Patient #1 was admitted to the inpatient behavioral health unit and described as verbally abusive and refusing to speak to staff. She was irritable with fluctuations in mood. On 3/29/14 at approximately 10:39 AM, the patient soiled herself. She was sitting on the floor in the community room. The hospital investigation and review of video monitoring revealed the staff attempted to get patient #1 to shower and change her clothing without success. The staff offered the patient transport via a wheelchair but she would not get off the floor and instead rolled around on the floor. The staff, consisting of three nursing staff and one security staff laid a blanket on the floor placing the patient on the blanket and proceeded to drag the patient down the hallway to the shower. The patient was dressed in two hospital gowns without underwear. The video review revealed during transport the patient was half on and off the blanket and at times the gowns were up to her waist exposing her pelvic and buttock area. In addition, the video monitoring revealed another patient going in and out of her room in the hallway area where the staff was interacting with patient #1.

The daughter stated she informed the hospital regarding her mother's statements that she had been dragged by staff to her room and shower. The patient after her discharge on 4/4/14 to another facility complained of pain, in leg and hip with swelling noted by the daughter of the left leg and later a scar on her left buttock cheek.


Per the records and the video , the patient although uncooperative was not aggressive or imminent danger to herself or others. The patient was obese making lifting her safely difficult with the four available staff. Lifting this patient could have led to injury to the patient and/or staff. It can not be determined if the staff placement of the patient on the blanket and dragging her to the shower caused her subsequent pain, swelling and scar on the left buttock. Nonetheless dragging of the patient on the blanket was not only an unsafe transport but it was also an undignified way to transport the patient. The hospital failed to provide a physical and emotionally safe environment. The staff failed to provide care in a dignified manner and privacy of a vulnerable patient as well as failure to safely transport the patient.

Based on review of the medical record, video monitoring, staff interviews and policies and procedures, it was determined that the hospital failed to appropriately respond to the patient #1's care needs and ensure safe transport to the shower room in a dignified manner.

On 3/29/14 at approximately 1800, the RN failed to provided supervision during intervention to get the patient safely to the shower as evidenced by the following: 1) attempting to lift patient weighing over 200-lbs which could lead to injury to the patient and staff, 2) allowing the patient to be dragged on a blanket which could cause injury and pain, 3) failure to use least restrictive interventions to get the patient safely to the shower, 4) failure of the staff to implement the Dr. Down code a process for summoning additional staff for patients who have fallen, and 5) the nurse did not supervise care provided during the transport of the patient including providing privacy and clothing to cover the patient.

As stated in A144, the patient was dragged down the hallway to the shower room and during the process of getting the patient to the shower the patient buttocks and pelvic area was exposed and the video revealed the patient was not wearing underwear at the time of the event. The staff should have been given guidance on the safe transport of the patient into the shower while maintaining the patient ' s privacy and dignity.