HospitalInspections.org

Based on review of medical records and other documentation and interview with staff, it is determined that the hospital does not meet the requirements of the Condition of Participation for Patient Rights due to these cited standard level deficiencies:

1. The failure to obtain physicians' orders for 3 restraint and seclusion incidents cited at A 0168;
2. The failure to perform a face to face evaluation for 2 patients as cited at A 0179;
3. The failure to provide visitation information to patients as cited at A 0216;
4. The failure to reorder restraint and seclusion within the required time frames for three patients in the ED as cited at A 0171
5. The failure to modify the plan of care for 2 patients where restraint was used as cited at A 0166;
6. The failure to document the justification for the use of or continued use of seclusion or restraint for 4 patients as cited at A 0154 ; and
7. The failure to promptly resolve patient grievances as cited at A 0122.

Based on a review of the hospital Patient information booklet, the Complaints/Conflict Resolution policy, interview of a hospital administrator, review of the complaint log and review of 4 grievances, 1) the hospital does not currently distinguish between complaints and grievances, and therefore, grievances are not handled as required; and 2) the hospital patient booklet fails to describe the complaint/grievance process, and who to contact.

Interview with a hospital representative on 8/7/2013 at approximately 1:15pm reveals that the hospital keeps one complaint/grievance log which does not distinguish between complaints and grievances. Review of the log reveals multiple complaints, some which should have been handled as a grievance however, the documentation failed to identify the history. The hospital representative states that administrative discussion is currently underway to define what is and is not a grievance. Likewise, the hospital Complaint/Conflict Resolution policy (revised 1/13) makes no reference to a specific "Grievance" process.

Review of 4 identified non-billing grievances kept by the Risk Manager reveals appropriate documentation for acknowledgement and resolution letters, though resolution of cases kept in the main complaint log which was stated to contain grievances, is done primarily by phone.

Review of the Complaints/Conflict Resolution (CCRP) policy under Patient Rights and Responsibilities reveals in part that complainants will "Receive a prompt and courteous response to your complaints concerning the quality of care and service. If you feel the hospital has not addressed your concerns satisfactorily, then you have the right to file a complaint with the State ... "

An "unresolved" complaint not related to billing, would be considered a grievance. However, the patient booklet gives no grievance process instruction or contact person by which to further the complaint through hospital channels, and therefore, does not meet regulatory directives.

Based on review of the hospital Complaint/Conflict Resolution policy and identified grievance files, the hospital fails to meet the average 7-day grievance resolution time frame.

The Complaint/Conflict Resolution policy (CCRP) states in part, "The goal is to resolve and communicate the investigation and resolution to the complainant within thirty days." Review of 4 grievances unrelated to billing reveals an average 16 day resolution time which does not meet regulatory directives.

Based on a review of 17 patient records, inclusive of 2 open and 2 closed, and hospital seclusion/restraint policy and forms, it is determined that 1) the hospital did not have a justification for the restraint of patient #12; 2) Criteria for release from restraint and seclusion was not given to patients #11, 12, and 15 and the behavioral health written criteria does not meet regulatory requirements; 3) the documentation of ongoing restraint/seclusion justification is subjective and does not describe actual patient behaviors and statements.

Based on review of the Hospital policy Restraint and Seclusion Number: 31 (revised 11/12) states in part:

"C. 1. Indications: The decision to restraint or seclude is driven by ongoing, comprehensive, individual patient assessment. The comprehensive, individual patient assessment is also used to determine the use of least restrictive measures and discontinuation of restraint and/or seclusion at the earliest possible time, when the behavior or condition that was the basis for the restraint is resolved," and

2. Restraint will be used only for the protection of the patient/resident to ensure the immediate physical safety of the patient/resident, staff members, or others. Such indications must be present and documented at the initiation of and throughout the episode of restraint."


Patient #12 is a young adult male with a history of mental illness who presented via ambulance to the emergency department (ED) in July 2013 following a reported overdose on prescribed medications. Patient #12 is initially documented on presentation as "cooperative." Patient #12 received activated charcoal which was completed by 2104 (9:04PM) on the date of admission.

At 2244, nursing documented that patient #12 was placed in 4-point soft extremity restraints. However, the physician order of 2308 reveals that patient #1 was placed in tuff cuffs for violent behavior. A nursing note of 2245 states in part that "Pt uncooperative, trying to walk out of room and urinating floor (sic). 4 point restraints applied." A physician note of 2310 states in part "In ED pt getting more agitated (sic) refused to follow (sic) nurse and MD's order given Benadryl and Ativan no change pt is required to be restrained due to agitation (sic) danger (sic) to self and other. "

Based on this documentation of patient behavior such as, attempts to exit a room, agitation without description of a clear threat and even urinating on the floor do not demonstrate imminent dangerousness to justify restraining patient #12.

The hospital is currently in process of utilizing a relatively new electronic medical record. Electronic restraint records of patients' #11, #12, and #15 from the emergency department stay , do not document that staff gave restraint/seclusion termination criteria to each patient. Likewise, paper seclusion documentation as found on the behavioral health unit for patients #11, #13 and #15, document criteria, but not that criteria was given to patients #11, #13, and #15.

Further, printed criteria as found on the behavioral health unit seclusion form reveals, three criterion for release inclusive of the inappropriate criterion of "cooperative with good self control," and "Demonstrates ability to participate in care." For many inpatients, such criteria may be unrealistic, e.g. the manic patient, or intellectually disabled patient. The only appropriate criterion of the three listed is "Demonstrates ability to tolerate less restrictive measures."

Finally, the restraint/seclusion form of the behavioral health unit uses letter symbols to represent 15-minute behavioral documentation. However, symbols "D, E, F,G, and H" which respectively symbolize "Confused, agitated, combative, self-destructive, and other" behaviors, are subjective when not qualified by actual documented behaviors and patient statements. Likewise, they do not of themselves justify continued restraint or seclusion. While some nursing progress notes do document actual ongoing behaviors and statements, this is not consistent for every restraint/seclusion episode.

Based on a review of 17 patient records, inclusive of 2 open and two closed seclusion/restraint patient records, and hospital seclusion/restraint policy and forms, it is determined that: 1) the hospital does not consistently modify patient plan of care for patients requiring restraint/seclusion, and 2) did not modify the plans of care for patients #11 and #13.

The hospital behavioral health unit has recently implemented an electronic record. However, the staff continues to utilize a paper seclusion packet which provides more detail of seclusion events, and continue to utilize a hand written plan of care.

The hospital Restraint and Seclusion Number: 31 Policy, revised 11/2012, reads in part, "3. The use of restraint or seclusion constitutes a change in a patient's plan of care. The patient's written plan of care will be modified to indicate: 1. The type of restraint (including drugs or medications used as restraint as well as physical restraint) and 2. The goal of the restraint episode."

Patient #11, who was admitted to the behavioral health unit in July 2013, and who recently became an adult, was secluded on the behavioral health unit following an aggressive episode. Documentation on the Seclusion Restraint Debriefing part of the form reveals an area for staff response which states "Does treatment plan require modification?" Staff can choose from two check boxes to indicate "Yes" or "No." The "No" box is checked.

Likewise, the "No" box is checked for patient #13 a female secluded in early August 2013.

Based on the fact that staff could also have answered "Yes" it appears that some of the patients who require restraint and seclusion do have a modification to their care plan, although no examples of modification were found by the surveyor. The surveyor did ascertain that the hospital failed to modify the plans of care for patients #11 and #13 who required seclusion.

Based on a review of 17 patient records, inclusive of 2 open and 2 closed seclusion/restraint patient records, it is determined that, 1) electronic restraint orders reveal no time limitations for restraints for violent and assaultive behaviors; and 2) patients #11, #12 and #15 were missing continuation orders for a restraint and seclusion event.

Patient #11 who recently became an adult, and who presented to the emergency department (ED) in July 2013, was restrained in the ED due to threats of violence. Review of patient #11's ED record reveals a 4-point restraint order start time of 0203 (2:03 AM), though nursing documentation does not reveal when patient #11 was actually placed in 4-point restraint.

Patient #11 remained in 4-point restraint through 0820 (8:20 AM), although there is no documentation of a continuation of restraint order 4 hours later at 0603 (6:03 AM) as is required for individuals 18 years of age and older.

Additionally, a spit hood was applied at 0232 (2:32AM) due to patient #11 spitting. No order appears in the record for this restraint intervention, and likewise, there was no documentation to indicate when the hood was removed.

Patient #12 is a young adult male with a history of mental illness who presented via ambulance to the (ED) in July 2013 following a reported overdose on prescribed medications.

At 2244 (10:44 PM) , nursing documented that patient #12 was placed in 4-point soft extremity restraints. However, the order of 2308 reveals that patient #12 was actually placed in tuff cuffs for violent behavior. Patient #12 remained in restraint until 0359 when he was transferred to an inpatient unit. However, no restraint continuation order appears in the record which was due at 0244.

Based on a review of 17 patient records, inclusive of 2 open and 2 closed seclusion/restraint patient records, it is determined that electronic orders for restraint/seclusion, do not include time limitations per age group required for restraints for violent or assaultive behaviors.
The hospital is currently in process of utilizing a relatively new electronic medical record. Electronic restraint records of patients' #11, #12, and #15 as found in the emergency department, fail to document time limitations on orders for violent restraints for adults of up to 4 hours.

Based on a review of 17 patient records, inclusive of 2 open and 2 closed seclusion/restraint patient records, and physician/nursing training for conducting a face to face it is determined that: 1) face to face assessments were not done for patient #11 who was restrained in the ED and for patients #11, #13, and #15 who were secluded on the behavioral health unit; and 2) the training provided to nursing staff for the purpose of performing the face to face fails to provide the competencies necessary to perform a comprehensive evaluation required by this regulation.
Patient #11, an adult male, presented to the emergency department (ED) in July 2013, was restrained in the ED due to threats of violence. Review of patient #11's ED record reveals patient #11 was seen by the physician at 0202, and a 4-point restraint order was written at 0203.

At that time, the physician documented that patient #11 was " handcuffed, police/EMS in room, resisting police officer, previously spitting. Patient appears to be in mild distress." While the physician met face to face elements of the patient's immediate situation, and the medical/behavioral condition, the physician makes no reference related to the 4-point restraints he ordered, the patient response to them.

Additionally, patient #11, who was admitted to the inpatient unit, was also secluded due to destructive behaviors. No face to face appears in the record for this seclusion episode.

Patient #13 is a young adult female admitted to the behavioral health unit due to self-harming thoughts in August 2013. Patient #13 required seclusion during her inpatient stay due to threatening behavior toward a peer. No face to face is noted in the record.

Patient #15 is a young adult, admitted to the behavioral health unit in June 2013, due to psychosis with aggressive behaviors. During his admission, he was secluded due to threatening, destructive behaviors. Review of this seclusion episode reveals no face to face documentation.

Interview with the behavioral health unit manager on the day of survey reveals that physicians perform all face to face assessments. However, hospital Restraint and Seclusion policy reveals that nursing is also trained to perform this function. The extent of the training states in total:

1. The physician is responsible for the face to face. However, the RN trained in the use of restraint and seclusion will perform the face to face assessment in the absence of the physician.

2. The assessment will be accomplished within the first hour of the restraint application. This includes the patient's physical and psychological status.

Based on this training, the hospital fails to adequately train nursing to meet high level assessment required of the face to face.

In summary, the ED face to face assessment for patient #11 was incomplete, and without reference to the restraint intervention that the physician had ordered. Additionally, face to face assessments on the behavioral health unit for patients #11, 13, and 15 were not found. Finally, while no nursing performed face to face assessment was found in the records reviewed, training for nurses to perform the face to face does not meet the criteria required by this regulation.

Based on an interview with an emergency department nurse on 8/7/13 at approximately 10 am, it was revealed that some patients in 4-point restraints receive close observation at bedside, others do not, and this is based on the patient's level of agitation.
Interview with an emergency department nurse reveals that patients who are in 4-point restraint for violent behaviors are monitored from the nursing station except when they are very agitated, which is determined on an individual basis. This does not meet the Code of Maryland Regulations for Category I (violent) restraints which states in part:
"COMAR 10.21.12.08 A Clinical Interventions During Restraint. - Regardless of the physical setting in which the patient is placed, at a minimum, one staff member shall be assigned continuously while the patient is in a category I restraint."
By contrast, if a RN is able to determine that a patient is not agitated enough to require continuous monitoring, the patient in 4-point restraint requires release from those restraints, and a lower level intervention and monitor.

The hospital Patient Information Guide fails to detail the rights of the patients or support persons for visitation and the right to refuse visitation.
The hospital has multiple visitor policies which appropriately detail times of visitation for various clinical settings. These policies include that visitation may " include a person(s) not legally related to the individual. Members of family include spouse, domestic partners, and both different and same-sex significant other. Family includes minor patients' parents, regardless of the gender of either parent." However, patients do not get this information, as it is not contained in the Patient Visitor Information guide, nor is the fact that patients have a right to refuse visitors.

Based on a review of 17 patient records, inclusive of 2 open and 2 closed seclusion/restraint patient records, and hospital seclusion/restraint policy, and restraint/seclusion logs, it is determined that: 1) the hospital electronically tracks the quantity of restraint/seclusion episodes, but is inconsistent for tracking quality processes for restraint/seclusion; 2) quality tracking documentation on the behavioral health unit remains in each individual record where it cannot be collated, and shared; and 3) patients #11 and #13 have no quality tracking related to seclusion events on the behavioral health unit.
Restraint and Seclusion Number 31 policy reveals a quality form for " hospital-reported " restraint/seclusion events. On this form, the hospital monitors for multiple peri-restraint/seclusion objectives, such as the time and date of the face-to-face.
It is noted that all electronic restraint/seclusion orders begin with " Acute Medical Surgical Restraints " whether for violent or non-violent restraints, which fails to identify the type of restraint used. Thus, when unable to discern the type of restraint used, one cannot tell if the appropriate care was given, and cannot measure the quality of that care.
The Behavioral Health Unit (BHU) primarily utilizes hand-written seclusion forms, though there is a relatively new electronic form available. On the BHU, the seclusion form contains a quality piece which directs the "Head Nurse" to fill out. Once filled out, the data becomes part of the patient record, and though accessible, cannot be collated with other seclusion events for quality purposes.

On review of the records of patient #11 and #13 who were admitted to the BHU, no quality review was conducted for seclusion events which occurred in July and August 2013 respectively.