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Based on the review of records and interviews with staff it was determined that the Condition of Patients Rights was not met as evidenced by the deficiencies cited at A0131 and A0160 for violating Patient #5's rights to refuse treatment when she was forcibly medicated in order to draw blood for testing.

Based on a review of 11 patient records, the hospital failed to honor patient #5's expressed refusal of blood work in the emergency department

Patient #5 is a young adult female who presented to the emergency department with complaints of shortness of breath, depression and anxiety. Patient #5 had run out of her mood stabilizing one week prior to presentation and had recently become homeless. Patient #5 demonstrated capacity to make healthcare decisions. The physician wrote in part, "Compliant with history and physical and review of systems, but became upset when I went to examine her and refused all testing including EKG labs and urine ... "

Patient #5 was evaluated by a Crisis Response person, and at that time, expressed suicidal ideation. The evaluator completed a state of "Maryland Emergency Petition (EP)". The definition of "an examination for EP" in the Code of Maryland Regulation 10.21.15. (7) is "a face-to-face diagnostic interview and examination by a consultant physician that includes a medical history, an assessment of mental status, a neurological examination, an assessment of dangerousness, and a written report outlining the consultant physician's findings and conclusions."


While it would have been ideal had patient #5 consented to blood work and urine, neither was required to fulfill the emergency petition. Additionally, no medical emergency was indicated by the physician findings.

Physician documentation reveals in part, " Compliant with history and physical and review of systems, but became upset when I went to examine her and refused all testing including EKG labs and urine " ... " After the patient began to express suicidal ideation, I explained to her that it was necessary to obtain laboratory testing. She refused to have any laboratory testing at this time and became verbally aggressive to me and the staff and despite several warnings, she refused to comply with the phlebotomy and verbal de-escalation was unsuccessful. The patient was then physically restrained by staff and myself she was given intramuscular Haldol and Versed, phlebotomy performed. The patient became agitated and physically aggressive during restrainy (sic) she then was placed in four extremity leather restraints as she posed a danger to herself and the ER staff. She will be reassessed and the restraints removed when necessary " ... " the patient's labs are unremarkable we have yet to obtain urine from the patient."

As previously documented, the patient was restrained as she refused to cooperate with her
evaluation today after verbalizing suicidal ideation and verbally expressing threats toward myself and the staff including threats of harming us.
Nursing staff documented in part, " Security notified that patient had been placed under emergency petition and is at bedside. Patient informed that she would be medicated by IM (intramuscular) injection and blood would be drawn. Patient was held to stretcher by ED tech x 2, security, Dr. __ for IM injection. Patient did not resist. Patient was asked again to cooperate with blood draw. She refused. Patient held to stretcher by ED tech X 1, security and Dr. __ for blood draw. Patient did resist by trying to hold arms under body."
Based on all documentation, the hospital failed to honor the right of patient #5 and her expressed refusal of blood work. Patient #5 who had capacity, was unnecessarily chemically and physically restrained.

Based on hospital Restraint and Seclusion policy, review of 11 patient records, and observation of patient #5 who was restrained in the emergency department, it is revealed that patient #5 was given IM medication which in part, was given to obtain blood work against her will; was not a standard treatment for her condition, and which failed to facilitate her ability to participate in her care.
Hospital Restraint and Seclusion policy (reviewed 6/12) reveals in part, "We do not inappropriately use medication to restrain our patients. We do however, provide safety measures such as patient safety aides and medications for the purposes of calming, reducing agitation and for treating medical conditions. "

Patient #5 is a young adult female who presented to the emergency department with complaints of shortness of breath, depression and anxiety. Patient #5 had run out of her mood stabilizing medication one week prior to presentation and had recently become homeless. Patient #5 demonstrated capacity to make healthcare decisions. The physician wrote in part, "Compliant with history and physical and review of systems, but became upset when I went to examine her and refused all testing including EKG labs and urine ... " "After the patient began to express suicidal ideation, I explained to her that it was necessary to obtain laboratory testing. She refused to have any laboratory testing at this time and became verbally aggressive to me and the staff and despite several warnings, she refused to comply with the phlebotomy and verbal de-escalation was unsuccessful. The patient was then physically restrained by staff and myself she was given intramuscular Haldol (5 mg) and Versed (2 mg) phlebotomy performed."

Nursing staff documented in part, "Security notified that patient had been placed under emergency petition and is at bedside. Patient informed that she would be medicated by IM injection and blood would be drawn. Patient was held to stretcher by ED tech x 2, security, Dr. __ for IM injection. Patient did not resist. Patient was asked again to cooperate with blood draw. She refused. Patient held to stretcher by ED tech X 1, security and Dr. __ for blood draw. Patient did resist by trying to hold arms under body."

When seen by the surveyor, patient #5 was unconscious following IM medication and did not awaken for the RN who attempted to rouse her by calling her name and touching her. Patient #1 was simultaneously physically restrained in 4-point leather restraint though patient #5 was clearly not a threat at that time.

Based on documentation and observation, the hospital chemically restrained patient #5 in order to obtain blood work against her will, with medication (Versed) which is not a standard medication for her condition, and which severely impaired patient #5's ability to participate in her care.

Based on patient #5's record of 11 records reviewed, it is revealed that patient #5 had an order for 4-point leather restraint, but none for the manual restraint which preceded it.

Patient #5 is a young adult female who presented to the emergency department with complaints of shortness of breath, depression and anxiety. Patient #5 had run out of her mood stabilizing medication one week prior to presentation and had recently become homeless. Patient #5 demonstrated capacity to make healthcare decisions. The physician wrote in part, "Compliant with history and physical and review of systems, but became upset when I went to examine her and refused all testing including EKG labs and urine ... "

"After the patient began to express suicidal ideation, I explained to her that it was necessary to obtain laboratory testing. She refused to have any laboratory testing at this time and became verbally aggressive to me and the staff and despite several warnings, she refused to comply with the phlebotomy and verbal de-escalation was unsuccessful. The patient was then physically restrained by staff and myself she was given intramuscular Haldol (5 mg) and Versed (2 mg) phlebotomy performed. The patient became agitated and physically aggressive during during restrainy (sic) she then was placed in four extremity leather restraints as she posed a danger to herself and the ER staff. She will be reassessed and the restraints removed when necessary ... " and "the patient's labs are unremarkable we have yet to obtain urine from the patient." As previously documented, the patient was restrained as she refused to cooperate with her evaluation today after verbalizing suicidal ideation and verbally expressing threats toward myself and the staff including threats of harming us.
Nursing staff documented in part, "Security notified that patient had been placed under emergency petition and is at bedside. Patient informed that she would be medicated by IM injection and blood would be drawn. Patient was held to stretcher by ED tech x 2, security, Dr. __ for IM injection. Patient did not resist. Patient was asked again to cooperate with blood draw. She refused. Patient held to stretcher by ED tech X 1, security and Dr. __ for blood draw. Patient did resist by trying to hold arms under body."
When seen by the surveyor, patient #5 was unconscious following IM medication and did not awaken for the RN who attempted to rouse her by calling her name and touching her. Patient #1 was physically restrained in 4-point leather restraint though patient #5 was clearly not a threat at that time.
Based on documentation and observation, the hospital manually restrained patient #5 in order to give IM medication, and then restrained patient #5 with 4-point leather restraints. No order for manual restraint is noted in the record.

Based on observation and review of patient #5's of 11 records reviewed, it is revealed that no behavioral documentation was found after patient #5 was placed in restraint, and patient #5 was observed as unconscious and still in restraint.

The record of patient #5 reveals no behavioral documentation following her manual or 4-point leather restraints. All that is found in the record are the presence of pulses taken during the 4-point restraint. When observed by the surveyor as unconscious, and not awakening to the RN touch and verbalization to the patient, the RN stated "I was going to take her out after I finish my documentation." Based on this, the hospital did not release patient #5 from restraint at the earliest possible time.

Based on hospital Restraint and Seclusion policy, interview and observation, and review of 11 patient records, it is revealed that for patient #5 1) Hospital Restraint and Seclusion policy (reviewed 6/12) fails to specify the type of staff with the level of training to whom restraint tasks may be delegated, 2) the hospital fails to place trained staff to monitor patients who are in 4-point restraint, and 3) security staff are utilized to monitor patients in restraints, yet are not trained to determined when a patient is in distress.

Hospital Restraint and Seclusion policy (reviewed 6/12) reveals in part under Level of Responsibility "The RN may delegate the tasks application, removal, and monitoring of patient comfort and safety after RN assessment." Hospital policy does not specify to whom these responsibilities may be delegated, or what level of training staff must have to perform those delegated tasks.

Patient #5 is a young adult female who presented to the emergency department with complaints of shortness of breath, depression and anxiety. Patient #5 had run out of her mood stabilizing medication one week prior to presentation and had recently become homeless. Patient #5 demonstrated capacity to make healthcare decisions. The physician wrote in part, "Compliant with history and physical and review of systems, but became upset when I went to examine her and refused all testing including EKG labs and urine ... "

An electronic order entry of 1120 reveals "Initiate restraint policy, security to bedside." Interview with a security staff member who was monitoring patient #5 from the doorway of the room reveals that security does not apply restraint, but may help by holding a patient while nursing staff apply restraints. However, the security staff stated that his role also entails keeping a watch of the patient from the doorway to the room. When queried, the security staff stated that he does not receive training on how to tell when a patient is in distress.

When queried, nursing staff indicated that security staff do monitor patients who are in restraint, as was being demonstrated at that time.

In summary, the hospital fails to identify to which staff with what level of training RN's may delegate the monitoring of patients in restraint. Additionally, the hospital currently fails to place staff near the patient who have training specific to patient safety while in restraint, and can monitor to determine patient distress.