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Based on review of 10 medical records, inclusive of 1 record of a restrained patient, hospital policies and other pertinent documentation, security video surveillance, and interviews with staff, it was determined that the hospital failed to meet the Condition of Participation for Patient Rights, as evidenced by:

1. Failure to perform an incapacity evaluation and certification before allowing a general consent form to be signed by a health care agent for Patient #3 (see tag A-0131).
2. Staff's possession of a holstered weapon on a behavioral health unit (see tag A-0144).
3. Failure to conduct a Face-to-Face assessment for Patient #1 after physical restraints were applied (see tag A-0179).
4. Failure to appropriately apply physical restraints to Patient #1, resulting in a leg fracture (A-0194).

Based on review of 10 medical records, hospital policy, and other pertinent documents, it was determined the hospital failed to allow 1 of 10 patients to participate in health care decision making. A surrogate decision maker for Patient # 3 (P3) was allowed to sign consents for P3 when the patient was not deemed to lack capacity.

The surveyors reviewed the hospital's "Administrative Policy Manual: Consent, General and Informed" which stated: "The patient... has the right to make informed decision regarding his/her care. The patient's rights include being informed of his/her health status, participating in the development and implementation of treatment/care plan; participating in the development and implementation of the discharge plan; and being able to request or refuse treatment". The policy also stated: "When the patient's treating physician determines that a patient lacks decision-making capacity as defined above, the following process will be utilized to obtain authorization for treatment and informed consent: 1. Two physicians licensed in the state of Maryland shall attempt to consult with the patient regarding the proposed health care and certify in writing that clear and convincing evidence exists that the patient is incapable of making a responsible decision regarding the proposed health care".

P3 was a 70+ year old who presented to the Emergency Department (ED) from P3's community placement for a change in mental status and low blood sugar. P3 was initially assessed by the nurse as being alert and oriented to person, place and time. The physician in the emergency room assessed P3's mental status as being alert to self and place (city/state); the physician stated that P3 was not oriented to time (month/ day, President of the United States). P3 had a written advance directive located within P3's medical record that named P3's spouse as the medical power of attorney.

Throughout P3's stay at the hospital, P3's spouse signed the Consent for Treatment, Medicare Outpatient/Observation Notice, Important Message from Medicare notice, and discharge documents. At discharge, P3 was assessed as being alert and oriented to person, place, time, and situation with some forgetfulness. There was no documentation found in the medical record that stated P3 lacked capacity to make informed decisions, which would then allow the hospital to defer decision making to P3's spouse.

The hospital failed to allow this patient to meaningfully participate in their care planning and be informed of their admission and discharge rights by allowing P3's spouse to sign consent forms and other care related documents for P3.

Based on review of patient medical records, interviews with staff, and review of video surveillance footage, it was determined that the hospital failed to provide care in a safe setting for 1 of 10 patients reviewed, as evidenced by presence of a holstered weapon on a security officer on the Behavioral Health unit.

Patient #1 (P1) was a 40+ year old who was brought to the ED for a psychiatric evaluation after exhibiting increasingly bizarre behaviors with multiple threats made to family. After a mental health evaluation, P1 was certified by two physicians for an involuntary inpatient psychiatric admission. P1 attempted to elope on at least 3 occasions during their stay, which prompted the hospital staff to activate a Code Purple. In this hospital, a Code Purple was used to alert hospital staff of the need for a security personnel response.

During interviews with security officers (SO), Security Officer #1 (SO1) and Security Officer #2 (SO2), on November 14, 2019 at 11:50 am, both SO's stated that weapons were not permitted on the behavioral health units (identified as "Station 3" and "Station 7" in the ED and the inpatient behavioral health unit known as "3 South"). SO's also stated that all weapons were to be secured in a designated locked box prior to entering any behavioral health unit. The room that contained the locked box had been identified during the on-site tour of the ED and could also be seen on video surveillance. This room was adjacent to the unit known as Station 3, where P1 was located.

Review of video surveillance footage showed that during P1's first elopement attempt there was initially 1 SO present within Station 3. Additional SO's were also seen arriving on the unit in response to the Code Purple. Of the five SO's who responded, three were observed entering the room that contained the locked box, which was used to secure weapons. They were later seen on the footage within Station 3 with empty holsters. One of the other two responding SO's was seen with a holstered weapon on the left side of their duty belt while within Station 3.

The security officer's failure to remove a weapon prior to entering a weapon-restricted area of the ED created an unsafe environment of care, as the possession of a weapon on a behavioral health unit could present an unnecesary risk of harm to patients and staff.

Based on review of two restraint events for Patient #1, it was determined that the hospital failed to conduct a complete face-to-face assessment after the second physical hold restraint by security officers during medication administration.

Patient #1 (P1) was a 40+ year old who was brought to the ED for a psychiatric evaluation after exhibiting increasingly bizarre behaviors with multiple threats made to family. After a mental health evaluation, P1 was certified by two physicians for an involuntary inpatient psychiatric admission. Review of P1's medical record revealed that P1 had to be physically restrained after multiple elopement attempts. On two occasions, during the physical holds, P1 received medications while being held by security.

The physician placed the first order for 'Physical Restraint for Holding Patient for Meds' at 3:33 pm. The physician conducted an in-person evaluation of P1, known as a face-to-face assessment at 3:34 pm.

The physician later placed another order for a 'Physical Restraint for Holding Patient for Meds' at 10:51 pm. There was no documentation found in P1's medical record of a face-to-face assessment being conducted after the second order was placed. Further review of P1's record determined that the patient sustained a fracture to the right leg during this restraint episode which was not discovered or assessed until 2 hours after the incident took place.

Without the face-to-face assessment, it was unclear what behaviors were present prior to the second intervention, what other redirection attempts were completed that did not work, the patient's response to the intervention, including assessment of any injuries.

Based on review of 3 restraint episodes in Patient #1's medical record and other pertinent documentation, interviews with staff onsite, as well as offsite review of video surveillance footage, it was determined that the hospital failed to utilize appropriate restraint techniques in 2 of 3 reviewed restraint episodes, one of which resulted in a leg fracture to Patient #1.

During an interview with the Security Officer #1 (SO1), on November 13, 2019 at approximately 11:30 am, surveyors asked if patients were placed in a prone (laying on one's stomach) position during security intervention. SO1 stated that the preferred position was supine (laying on one's back) position, and if patients were proned they were to be immediately turned to their backs for a supine position.

During an interview with the Security Officer #2 (SO2), on November 14, 2019 at approximately 11:50 am, surveyors asked about de-escalation and hands-on techniques used by the security officers. While talking about hands-on techniques, SO2 stated that the officers used the least amount of force to handle the situation.

Patient #1 (P1) was a 40+ year old who was brought to the ED for a psychiatric evaluation after exhibiting increasingly bizarre behaviors with multiple threats made to family. After a mental health evaluation, P1 was certified by two physicians for an involuntary inpatient psychiatric admission, which meant they could not leave the hospital voluntarily. Review of P1's medical record determined that P1 attempted to elope from the emergency room on at least three occasions, which resulted in a security response each time. Further record review showed that P1 had to be physically restrained after these elopement attempts.

Video surveillance footage of three elopement attempts was reviewed by surveyors offsite.

During P1's first elopement attempt, 1 SO was seen securing P1 to the floor in a sitting position. Five additional SO's responded, but did not physically touch P1. P1 brought self to lay on the floor for 2 minutes and 39 seconds and was then assisted back to P1's room.

During P1's second elopement attempt, P1 was seen coming out of the room to speak to the two SO's who were positioned at the unit's entrance. Both SO's were standing as P1 attempted to leave the unit. One SO took P1's right arm. The second SO took P1's left arm and placed their forearm on the upper portion of P1's back. Both officers were seen taking P1 down to the floor in a prone position. P1 remained on the floor for 1 minute and 15 seconds and there was no evidence that the officers attempted to change the patient's position to supine. P1 was then assisted back to P1's room.

The third elopement attempt occurred within 5 minutes of the second elopement attempt. P1 was observed on the video surveillance footage hurrying out of P1's room. Four SOs who were standing in front of P1's room, approximately 2-3 feet away, immediately engaged P1. One of the SO's held P1 from behind and attempted a leg maneuver around P1's right leg which caused P1 and two other security officers to fall to the floor. P1 partially landed on the SO who held them from behind. An additional SO appeared to fall onto P1's right side. P1 was on the floor for 2 minutes and 27 seconds. P1 was given medications via intramuscular injection by the physician and the nurse while on the floor. P1 was assisted off the floor and back to the room by security personnel. P1 was observed to be non-weight bearing on the right leg and noticeably limped back to bed. An evaluation 2 hours later determined that P1 sustained a closed fracture to the right leg.

Failure to utilize appropriate de-escalation and safe restraint techniques during the second and third elopement attempts resulted in a preventable injury to P1's right lower extremity.

Based on review of medical records, medical bylaws, and hospital policy, it was determined that the hospital failed to complete a history and physical examination within 24 hours of admission for 1 of 2 behavioral health patients reviewed.

Surveyors reviewed Medical Bylaws which stated: "Staff rules (1) An admission history and pertinent physical examination (H&P) shall be entered into the electronic medical record (EMR) by a member of the Medical Staff with clinical and admitting privileges within twenty-four (24) hours of admission. (3) Each provider must provide timely, adequate care for his/her patients in the hospital, or have an eligible alternative provider, who has similar clinical privileges, designated to provide care in his/her absence. (4) Any patient known or suspected to be suicidal, or who has attempted suicide, must be evaluated, once medically stable, by a member of the Department of Psychiatry".

Surveyors also reviewed the policy titled "Patient Care Manual - Behavioral Health Services: Scope of Service", which stated: "Assessment and Evaluation Process: the attending provider performs the psychiatric evaluation within 24 hrs of admission. The provider performs the history and physical within 24 hours of admission".

Patient #10 (P10) was a 35+ year old patient who was brought to the Emergency Department (ED) for a psychiatric evaluation by police after an attempted suicide. Review of P10's record determined that P10 was evaluated by a behavioral health professional while in the ED and a decision was made at 12:17 pm for a voluntary admission to the hospital's inpatient psychiatric unit. The documented time of admission to the psychiatric unit was listed as 1:32 pm. Further review of P10's record revealed that the admitting H&P by the psychiatry provider was documented 26+ hours after the admission took place, at 5:55 pm on the following day.

By failing to perform a timely initial H&P examination upon admission to the psychiatric unit for P10, the hospital failed to timely collect the information essential to determining the appropriate course of treatment and to allow P10 to be actively involved in their care planning.