HospitalInspections.org

Based on an onsite survey for compliance with the Condition of Participation of Patient Rights which included a review of 10 open and 6 closed records, review of policies, procedures, other documentation and data; observations and interviews, it was determined that the hospital failed to meet the Condition of Participation for Patient Rights. The findings are:
1) A-0117 - The hospital failed to give notice of observation status to patient #14 and #5, and his/her representative as required by the Code of Maryland Regulations 10.07.01.29;
2) A-0131 - The hospital failed to support patient #15's right to refuse treatment, and failed to support patient #5's right to be involved in care planning.

3) A-0143 - The hospital failed to inform emergency department patients in three behavioral health rooms that they were continuously monitored by camera, thereby impacting their right to privacy;
4) A-144 - The hospital failed to provide for the safety of patients to clearly define the use of safe restraint processes in its policy on prone restraint; the failure to secure sharps, emergency carts, and medications in the emergency department; the failure to standardize triage processes in the ED ; and the failure to secure bulk laundry soap in the behavioral health unit laundry room; 5) A-0154, restrained one patient without justification and continued to restrain one patient without justification.
6) A-0160 - The hospital failed to modify the patients plan of care related to the use of restraint;
7) A-0168 - The hospital failed to have the nursing assessment of a restraint match the physician order for patient #1, and failed to restrain patient #13 with a physician order to do so;

Based on a review of 10 open and 6 closed records, it is revealed that the hospital failed to give notice of observation status to patient #14 and #5 or his/her representative as required by the Code of Maryland Regulations (COMAR) 10.07.01.29. the findings include:

Patient #14 was an elder female who was placed on observation for two presentations, on 6/13, and again on 6/26/2016. On 6/26, patient #14 had been on observation status for 10 days at the time of the onsite survey of 7/7/2016. Review of patient #14's record revealed a notice of observation status for the 6/13 presentation, but no notice of observation status was found for the 6/26 presentation. Based on this, the hospital failed to give notice of observation status to patient #14 or her representative as required by COMAR 10.07.01.29.

Patient #5 arrived to the ED 4/13/16 for altered mental status and chest pain. Patient #5 was placed into observation at 04/13/2016 at 1759. An observation/outpatient status form was presented to the patient. A witness signature from a registration clerk is present on the form. A signature for verification of receipt of observation status is present on the form. There is no relationship to patient information filled in on the form. The form was presented at 1836 on 4/13/2016. Without knowing who received and signed the form it is unknown if the patient or their representative was informed and educated about the status.

Based on a review of 10 open and 6 closed records, the hospital failed to support patient #15's right to refuse treatment, and failed to support patient #5's right to be involved in care planning.

Patient #15 was a female in her early 20's who was admitted to the behavioral health unit (BHU) from a medical unit. Patient #15 had a complex history included a gastrointestinal condition requiring a PEG tube (a Percutaneous endoscopic gastrostomy tube is a tube placed into the stomach to provide a means of administering nutrition and medications when oral intake is not adequate). Patient #15 was prescribed IV ( Intravenous) Zosyn (antibiotic) for possible aspiration pneumonia, and on the evening of 6/8/2016, had refused her dose at 1800.

A behavioral health unit RN note of 6/8 at 0230 states in part, " Patient awoke from sleep around 0200. Had not yet received midnight dose of Zosyn or further tube feeding, was about to be attempted. Pt insisted on walking, compromise made for one lap. Upon finishing lap, patient refused to return to room. Pt was verbally condescending to staff during lap. Voice began to escalate in tone and volume in the hallway. Pt was assisted back to room by two nurses, and grabbed onto the door frame to try to keep herself out of the room. Pt was further assisted into room and onto the bed, and four point restraints were initiated at 0220 with feet being restrained first. Orders for temporary hold, four point restraint and IM ( intramuscular) Geodon 20 mg received from on-call psychiatrist. Before hands could be restrained, patient struck the PCT (psychiatric care technician) with her. IM Geodon administered at 0222 ...Pt had been asking for pain medicine throughout this encounter, and Tylenol 650mg and oxycodone 10 mg via PEG tube at 0230. Tylenol was administered due to pt feeling warm to the touch, and having refused 1800 dose of Zosyn ...VS were stable at 109/72, P 98, po2 98%, ...97.3F ...Pt gradually fell asleep, and PEG tube feeding was initiated, along with IV Zosyn at 0300."

A physician face to face of 0306 revealed the patient reaction to the restraints as "Now calm." However, patient #1 was not released. She continued in restraint per the restraint log, until 1005.

An RN note of 0601 stated "Patient, when awake, requires continuous redirection and physical presence. Pt remains in restraints at time of the writing of this note, and Zosyn infusing via IV, and PEG tube feeding running as well. Pt has limited insight into behaviors that warrant medication and restraint." Limited insight was not a reason for continued restraint.

On 6/24, the Treatment Team added a Decision-making problem to patient #15's care plan. Multiple interventions are listed, including "discuss and support the differences between patient's view, family's view, and healthcare providers view, and determine a strategy to meet the patient/family needs."

Based on all documentation, staff restrained patient #15 in order to administer Zosyn against her express refusal. Additionally, Zosyn was administered to patient #15 during sleep, knowing patient #15 had previously refused the medication.

In addition to ignoring patient #15's right to refuse medication, staff restrained patient #15 for 8 hours and medicated patient #15 with psychoactive medication for no documented reason other than to administer medication against her will.

Patient #5 arrived to the ED 4/13/16 for altered mental status and chest pain. Patient #5 was exhibiting behavior dangerous to themselves and others at different times during their hospital stay. Patient #5 had an order written for Haldol 5mg/ml injection 1mg every 6 hours as needed for agitation. The patient did not have an order for by mouth medication offered and did not take Haldol as part of his/her regular medication regimen. The Haldol was given 04/14/2016 at 0220 and 4/16/2016 at 2154. There was no rationale or note as to why the patient was given this medication. The patient was unable to exhibit their right to refuse by not being offered the medical by mouth initially.

Based on observation of the emergency department behavioral health area on 7/7/16 at approximately 1130, it was determined that for three patients located in three private behavioral health rooms, no notification of constant video monitoring was found.

Observation of the emergency department behavioral health pod revealed a number of curtained bed areas occupied by patients who were visually monitored by staff. Additionally, there were three private bedroom areas, occupied by three patients who were resting in their beds, and who were not being monitored for emergent behaviors requiring seclusion or restraint. These rooms were on constant video monitoring at the nursing desk.

Interview with the Charge nurse regarding how staff informs patients in the rooms that they would be under constant video monitoring revealed the response of, " I tell them. " When asked if the nurse documents this or if there was any other method of notification, the nurse stated, she did not document those interactions, and that there was no other way patients were informed.

Based on this information, there was no consistent or verifiable way to know that patients were informed that they were under constant video monitoring. While monitoring of behavioral health patients is a standard in care, each patient has a right to know that they are under constant video monitoring which impacts their right to privacy.

Based on observations in the Emergency Department (ED) and Behavioral Health Units, it is revealed that; 1) The hospital restraint policy allows for prone positioning during the placement of restraints; 2) Multiple areas of the ED had unsecured drawers and cabinets containing syringes, IV catheters, 2 medications, and two emergency carts which appeared to be locked, were easily opened; 3) Nursing triage processes between the walk-in and the ambulance area vary related to direct assessment by nursing; and 4) The behavioral health unit laundry room contained an unsecured bucket container of powdered laundry detergent sitting on the floor. the findings include:

1) The hospital " Restraint/Seclusion Management of Violent or Self Destructive Patient Behavior and Behavior Presenting an Imminent Risk to Self or Others " policy (revised 8/14) revealed under " Application of Restraint, " that "the prone position may only be used as a temporary measure and only when necessary during the process of applying restraints ..., " and "A patient will never be left in a face down position after the restraints are in place. All restraints that apply place pressure on the patients back are removed, once the permanent restraints are in place."

Alternately, other hospital educational material includes a study by the Joint Commission citing that 40% of all patient restraint deaths were by suffocation; because of factors such as "Too much weight on their backs, when restrained in the prone position" and that "prone positioning increases the risk of suffocation."

Based on this knowledge; the fact that there is no quantitative measure for "too much weight," applied to a patient's back; and the fact that the hospital allows prone positioning for whatever period is required to place restraints, the hospital allows for an unsafe process within their policy which is not consistent with the training materials.

2) Observations in the Emergency Department (ED) on 7/7/2016 between 1000 and 1130 revealed 1) Triage Room #1 had an unlocked cabinet with 3 syringes, and an unlocked drawer with 13 syringes; 2) Triage room #2 had an unlocked drawer with a multi-dose bottle of Lidocaine, and a bottle of Proparicane ophthalmic solution; 3) Room #8 had a Pediatric code cart that appeared locked, but opened easily; 4) A code cart in the hallway appeared locked, but opened easily; and 5) Room #9 had an unlocked drawer holding a 20 gauge IV catheter.

3) Observation of the hospital ED revealed two triage areas. The first was the walk-in area where patients present by their own means, for instance via their own car. The second was the ambulance area where patients came in on gurneys via ambulance. The ED walk-in triage area revealed nursing staff, and at schedule times, Licensed Independent Practitioners (LIP ' s) who would make direct contact with presenting walk-in patients. Walk-in triage would include vital signs, discussion of the chief complaint, some history and other assessment parameters for accurately assigning a triage level.

However, in the ambulance triage area, it was noted that two patients coming by ambulance were not approached by the nurse, and that emergency medical technicians (EMTs) stated information about the two patients to the nurse who, from the other side of the counter, entered that information into a computer. The nurse was noted to remain behind the counter and never came around the counter to make direct contact with the presenting patients.

A query to the ED Administrator on 7/7/2016 at approximately 1130 regarding whether the triage nurse always approaches patients who arrive by ambulance, revealed his response of "Not always" and that "EMTs sometimes help by getting vitals." Based on observation and interview, the emergency department has no standardized triage process with direct nursing contact for baseline triage assessments. Additionally, for patients arriving by ambulance, nursing may rely on EMT reports and EMT vitals as the baseline assessment for determining a patient's triage level.

Therefore, while many patients arriving by ambulance could be deemed more critical than those patients who walk in, some nursing triages for ambulance patients lack the direct nursing contact, unlike patient triage for for walk in patients.

4) Observation on the inpatient behavioral health unit on 7/7/2016 revealed a small laundry room with a 3-5 gallon bucket of laundry soap on the floor. Inquiry into the laundry process revealed that a staff member enters the laundry room with the patient and supervises the patients placing laundry in the machines. Further, that patients take laundry soap from the bucket to add to each wash. Based on the fact that a staff member could be distracted from this duty, and the volume of open laundry chemical found in the room, the laundry process on the behavioral health unit failed to maintain a safe process, and presents a potential accidental or purposeful poisoning risk.

Based on a review of 10 open and 6 closed records, it was determined that the hospital restrained one patient (#15) for violent behavior without justification, and left another patient (#13) in restraints for several hours after the violent episode had passed.

Patient #15 was a female in her early 20's who was admitted to the behavioral health unit (BHU) from a medical unit. Patient #15's history included an episode of Gillian-Barre syndrome with residual leg weakness and difficulty walking. Patient #15 was a high fall risk due to an unstable gait, and was continuously on 1:1. Per interview with the BHU manager on 7/7/2016 at approximately 1130, patient #15 would often try to walk unassisted. Patient #15 had a walker and other special helps to do so, but continued to require assistance in the prevention of falls.

Patient #15 had a complex medical history in addition to comorbid mental illness diagnoses with episodic thoughts to harm herself and others. Patient #15 had an esophageal condition necessitating a PEG tube, from which she received nourishment and medication. Additionally patient #15 had episodes of vomiting and pseudo seizures, and was being treated for possible aspiration pneumonia with an IV antibiotic following an event of vomiting. Patient #15 also received supplemental oxygen based on her oxygen saturations. All of these conditions could be adversely impacted by the use of restraints.

On the evening of 6/7/2016, patient #15 had refused her IV Zosyn dose at 1800. A behavioral health unit RN note of 6/8 at 0230 stated in part, " Patient awoke from sleep around 0200. Had not yet received midnight dose of Zosyn or further tube feeding, was about to be attempted. Pt insisted on walking, compromise made for one lap. Upon finishing lap, patient refused to return to room. Pt was verbally condescending to staff during lap. Voice began to escalate in tone and volume in the hallway. Pt was assisted back to room by two nurses, and grabbed onto the door frame to try to keep herself out of the room. Pt was further assisted into room and onto the bed, and four point restraints were initiated at 0220 with feet being restrained first. Orders for temporary hold, four point restraint and IM Geodon 20 mg received from on-call psychiatrist. Before hands could be restrained, patient struck the PCT (psychiatric care technician) with her ...pt gradually fell asleep, and Peg tube feeding was initiated, along with IV Zosyn at 0300 ... "

A physician face to face of 0306 revealed the patient reaction to the restraints as "Now calm." However, patient #1 was not released.

No 15-minute close observation documentation was found for the safety, behavior and care monitoring of patient #15 who continued in 4-point restraint for the next approximate 8 hours. No ongoing documentation of the restraint is found at all until approximately 4 hours later. An RN note of 0601 stated "Patient, when awake, requires continuous redirection and physical presence. Pt remains in restraints at time of the writing of this note, and Zosyn infusing via IV, and PEG tube feeding running as well. Pt has limited insight into behavior that warrant medication and restraint."

An RN note of 0727 stated "Pt c/o generalized pain. Pt requesting repositioning to be off of her back, pt repositioned by multiple staff. Oxycodone 10 mg administered via PEG at 0717. Pt screaming at staff, using profanity and unable to understand reasoning behind being in restraints. Pt demanding to go use the telephone, but being in the milieu is not appropriate while highly agitated. Dr. __ contacted, verbal order for 20 mg Geodon IM received... "

The restraint log documents that patient #15 was released at 1005, but no other record documentation indicates a release until an MD note of 1341 which states in part, " Walking in the hallway with walker. Mentions she gets abdominal pain with antibiotics zosyn."

Based on this documentation, patient #15 was forced into her room, and forced onto her bed where she was administered emergency IM medication and restrained in 4-point violent restraints for approximately 8 hours based only on the fact that she desired to walk in the hallway. Patient #15 was restrained seemingly for the convenience of staff, so they could administer medications and tube feedings. According to documentation, patient #15 was not exhibiting violent of dangerous behavior, and in fact, did not strike out until she realized the staff intended to restrain her to administer medication she had previously refused.

Patient #13 was a late-adolescent female who presented to the emergency department in late April 2016 following an overdose. At 1527, patient #13 was justifiably placed in restraint due to combative behaviors in which she made threats of bodily harm to staff. Patient #1 made attempts to head-butt staff, and bit a security guards arm. However, documentation was conflicting throughout 16 hours of restraint which revealed that patient #13 was not released at the earliest possible time.


For instance, nursing documentation at 1650 revealed that patient #13 was "Awake, quiet, no apparent distress," but other documentation stated that she was "spitting at staff." No behavioral documentation appears in the record for the next hour until 1800. At that time through 1830, patient #13 was documented as "Moving around, thrashing, pulling at restraints." None of these documented behaviors were criterion for continuing restraint.


At 1839, patient #13 is documented as "Aggressive, physically aggressive, pt was biting, scratching, spitting earlier." Based on this, staff continued restraint based on history alone. From 1902 through 2140, patient #13 is alternately noted as "Resting quietly, no acute distress," "sleeping," and "unpredictable." Patient #13 demonstrated no behaviors indicating she required continued restraint. Additionally, use of the vague and subjective term "Unpredictable" described an opinion and not actual behaviors that could justify ongoing restraint.


At 2140, the nurse documented releasing two limbs, but because patient #13 attempted to climb out of bed, she was placed back into 4-point restraint. Based on this, staff restrained patient #13 based only on her attempts to leave the bed. Though no violent behaviors were noted, patient #13 was placed back into 4-point restraints.


While patient #13 had discreet periods in which she was described as "combative," documentation of ongoing restraints was often based on the fact that patient #13 attempted to remove the restraints. For instance, the following early morning at 0142 patient #13 was documented as "unpredictable." Staff then documented "Trialed by releasing one extremity d/t calm (intermittent) calm behavior after linen change, however pt was able to release herself from hand restraints," and "intermittently fighting off restraints." Based on this, patient #13 was being restrained for attempts to come out of restraints, which was not a criterion for continued restraint use as the patient presented no immediately dangerous behaviors.


From 0145 through 0340, patient #13 was documented as "moving around, thrashing and pulling at restraints." The use of these behavior descriptors is from the electronic medical record drop-down box and does not necessarily describe actual behaviors justifying continued restraint. At 0340, documentation revealed "resting quietly, no acute distress ...calm when asleep but when awoken, combative, abusive towards staff R wrist discontinued; no evidence of understanding of criteria."

Restraints continued until patient #13 was released at 0758. Justifications used to keep patient #13 in restraint included "Uncooperative," ... "Sleeping but when awake tries to elope to get high on drugs," ..., and "Unpredictable." In summary, staff was justified in placing patient #13 into restraints, but she was kept in restraints without appropriate justification for 16 hours, violating her right to be free of restraint.

Based on a review of open record documentation for behavioral health patient #15, it is revealed that there was no modification of patient #15's care plan addressing the use of restraints
Patient #15 is a female in her early 20s who was admitted to the behavioral health unit from a medical unit. Patient #15 had a complex medical history in addition to comorbid mental illness diagnoses with episodic thoughts to harm herself and others. Patient #15 had an esophageal condition necessitating a PEG tube, from which she received nourishment. Additionally patient #15 had episodes of vomiting and pseudo seizures, and was being treated for possible aspiration pneumonia. Patient #1 also received supplemental oxygen based on her oxygen saturations. All of these conditions could be adversely impacted by the use of restraints.
However, and while patient #15 had many restraint events, no modification of patient #15's care plan, alternatives to restraint. and the risk of restraining patient #15 related to her multiple medical conditions were noted in patient #15's care plan.

Based on the review of 6 closed medical records it was determined that the hospital failed to have the nursing assessment of restraint be consistent with the physician order for patient #1, and failed to write orders within the 4-hour time limitation for patient #13's record who was restrained for 16 hours.

Patient # 1 was admitted 06/30/2016 for abdominal pain, nausea/vomiting/diarrhea for 2 weeks, and for not eating. Patient #1 was admitted to the Intensive Care Unit (ICU). Patient #1 had an order for non-violent restraints (side rails x4) on 07/03/2016 at 1950. The restraints were initiated due to patient #1 pulling at lines and tubing, and to prevent the patient from removing medical equipment. Assessment by the nurse stated patient #1 was in bilateral upper limb restraints at 2000, 2200, 2300, 0400, and was discontinued at 0615 on 7/3/2016 into 7/4/2016. There was no order for wrist restraints present in the medical record.

Patient #13 was a late-adolescent female who presented to the emergency department in late April 2016 following an overdose. At 1527, patient #13 was justifiably placed in restraint due to combative behaviors in which she made threats of bodily harm to staff. However, no new order appears in the record until 2143, which effectively allowed patient #13 to be restrained without an order for more than two hours.

Based on a review of 10 open and 6 closed medical records it was determined the hospital failed to adequately document information necessary to monitor the patient's condition.

Patient #5 arrived to the ED 4/13/16 for altered mental status and chest pain. Patient #5 was placed into observation status and ordered a regular diet 04/13/2016 at 1759. The patient's diet later changed to a cardiac diet on 4/18/2016 at 1224, and later to a nothing by mouth diet on 4/24/2016 at 1705.

Per nursing documentation the patient had a sitter and required assistance with all activities of daily living. Meal intake was not consistently or completely documented throughout the stay. A nutrition consult was not ordered until 04/27/2016. Per nutrition consult, patient had minimal by mouth intake since admission. With no assessment, there is no way to determine if the patient had been eating and receiving nutrition.