HospitalInspections.org

Based on review of the hospital's complaint policy (revised 12/16), it was determined the hospital failed to establish a grievance process.

Request for the hospital grievance policy and grievance log, revealed only a complaint policy and a log of complaints. Upon interviewing the Patient Advocate, on 2/28/2017 at approximately 2 pm it was found that the Patient Advocate treated all concerns as complaints and was unaware of regulatory grievance regulations and procedures. There was no documentation that indicated the hospital 's governing body had delegated the grievance process . Based on this information, the hospital Governing Body failed to establish and implement a grievance process as required.

Based on a tour of four units, and the tween and adolescent inpatient units it was revealed 1) compact disks (CD's) were laying out on various level surfaces which were readily accessible to patients, and 2) file drawers containing hanging files and metal hangers were unlocked and accessible to patients.

During a tour of the adolescent unit on 2/28/2017 it was observed that a number of unsecured compact discs were laying on horizontal surfaces accessible to the patients. Compact discs if broken, can be used as a sharp for self-harming/other harming behaviors and should be kept secured.

During a tour of the tween unit on the same date, the surveyors observed an open file cabinet containing files secured by metal hangers . These hangers if removed, could also be used for self-harming/other harming behaviors.


Based on these observations, the hospital failed to secure all potentially harmful environmental hazards in the interest of a safe setting.

Based on a review of hospital policy for Restraint and Seclusion (revised 9/15), 10 patient records, hospital Time Out policy, and a request for the hospital Quiet Room policy, it was revealed that for patient #4; 1) the hospital developed a behavior plan for inclusive of involuntarily remaining in the quiet room which in practice, was a seclusion process; 2) the hospital uses a Quiet Room process with no actual policy by which to define a voluntary process; and, 3) that the hospital policy for Time Out intervention is an involuntary process equivalent to seclusion.

Review of hospital policy Restraint & Seclusion on 2/28/2017 revealed in part, " ...restraint and seclusion a treatment intervention of last resort, only to be used when there is an imminent danger of the patient hurting himself/herself or hurting others ..." Seclusion was further defined as, "Seclusion is the involuntary confinement of a patient in a room where he or she is physically prevented from leaving."

A review of the medical records for Patient #4 revealed that Patient #4 was an adolescent admitted to the hospital in mid-February 2017 due to self-harming behaviors. On the evening of 2/26/17, patient #4 became agitated, attempted to engage a male peer in rioting on the unit against staff; became violent against staff; and threw a chair. Per a progress note of 11:21 PM, patient #4 had "Time out in quiet room x's 1." An RN Shift Assessment & Progress Note of 11:30 PM revealed in part, "Patient labile, oppositional. Patient and peer engaged in aggressive violent behavior against staff and peers ...patient in quiet room at this time." The progress note was checked for all risk Assessment factors and interventions of "Was/is in restraints; Was/is in seclusion; Was/is in quiet room.


Tour of the seclusion room on the day of survey (2/28/17) revealed patient #4 lying in a seclusion room with the door open. It was explained by the Unit Manager at approximately 1030 am that day that patient #4 had slept in the Quiet Room due to his behavior on 2/26 and that he was placed on a Behavior Plan. Further, that based on patient #4's behavior, he would be functioning from the Quiet room to attend therapeutic groups and return to the Quiet room in between those groups.


A Miscellaneous Order form for patient #4 revealed in part, the 12/27/17 order of 1253 , which stated, "Funtion (sic) out of Quiet Room on 2/27 and start behavior plan." Another order of 12/27 at 1301 stated "Function out of Quiet room on 2/27 and start behavior plan on 2/28."


A request for "Quiet Room" policy revealed no existing hospital policy, though as demonstrated, Quiet Room was used as a behavioral intervention without regard to Code of Maryland Regulations which requires no physician order due to the voluntary nature of the intervention. No documentation was found regarding a discussion with staff to indicate that patient #4 was in the room voluntarily.


A review of "Behavior Contract for (Patient #4)" revealed in part, "QUIET ROOM LEVEL - After any incident where the patient has demonstrated emotional dysregulation with unsafe behaviors that has resulted in the patient going to the quiet room patient needs to complete the steps below to move on to the next level - Complete 30 minutes of safe time with no activity other than behavior management work to be tuned into nursing staff if completed***If at any time during this process the patient demonstrates unsafe behaviors his time will start over." Based in the fact that patient #4 was required to remain in the Quiet Room alone and could not come out voluntarily, this behavioral plan was equivalent to a seclusion process.


The Behavioral Contract continued in part, "PRE-GROUP LEVEL - Patient will need to demonstrate his ability to verbally process through the situation that resulted in the Quiet Room Intervention with a staff member before moving forward. Patient will remain in Quiet Room during this level." Again, the patient was required to remain in the quiet room involuntarily indicative of seclusion .


A review of the Hospital policy "Therapeutic Intervention for escalating client behavior (revised 3/16) revealed a "Time Out Process," which stated in part, "When a client is placed on a time out staff must: ...inform the client of the length of time for time out, inform client of clear (realistic) expectations during time out (to stay in room ...These would be individualized depending on client's capabilities..."


While the time out process gives guidance of one minute for every year of age, it has no provision for educating patients as to the voluntary nature of the time out. According to policy, ;patients are informed they must stay in the room.



Based on all reviewed policies and documentation, the hospital demonstrated a physician ordered quiet room process and a behavioral plan, both which mandated the patient remain in the quiet room. Further, the hospital Time Out process also mandates a patient to remain in their room. All are equivalent to seclusion and do not provide for patient education about the voluntary nature of the use of a quiet room .

Based on review of restraint/seclusion training, and other documentation it was determined that the hospital included inappropriate criterion for the cessation of restraint /seclsuion which were subjective, coercive, and unrelated to immediate dangerous patient behaviors as evidenced by:

Review of the staff "1-Hour Face to Face Assessment of Client in Restraints or Seclusion" training slides revealed appropriate criterion for termination of restraint/seclusion which may include: "Originating behavior is no longer evident, client is no longer threat to self or others." However there were additional criterion that were not appropriate which included "improved mental status, ability to comply with expected behavior and verbally contracting for safety." The latter three criterion are subjective, and in some cases , could be coercive.

Based on the latter, patients admitted for acute mental illness might not, at a baseline, demonstrate an improved mental status, or be able to comply with expected behaviors, yet might also be free of dangerous behaviors. Additionally, the cognitive/developmental status of a patient may preclude their capability to understand and form a safety contract.

While mental status may be assessed, expected behaviors may be encouraged, and a safety contract may be discussed, the termination of restraint or seclusion is a behavioral rather than an intellectual goal based only on the cessation of the behavior which necessitated the intervention.

Review of actual restraint/seclusion forms revealed other listed criterion inclusive of,
- "Originating behavior of _______is no longer evident;
- does not demonstrate risk of danger to others;
- does not demonstrate risk of danger to self;
- is willing to respond to directions given
- verbally contracts to comply with safety plan;
- is responding to alternate /less restrictive measures;
- Has been sleeping (greater than) 30 min.
- Other _________

The use of restraint and seclusion are based on actual and imminently dangerous behaviors, for instance, threats of harm. A "Risk" of danger without additional observed behaviors are potentials, which do not represent objective, real-time justification for restraint and seclusion.

A patient can only respond to alternate/less restrictive measures, following cessation of the dangerous behavior which required the intervention. Less restrictive measures would mean a release from restraint and seclusion.


Based on all restraint/seclusion documentation, the hospital uses both appropriate and inappropriate criterion for release from restraint and seclusion, where the only criterion is the cessation of the dangerous behavior which necessitated the intervention.