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Based on staff interviews, policies and procedures, it was determined that the hospital failed to ensure proper identification of patient #1, before provision of care.

Patient #1 presented to MedStar Union Memorial Hospital for mammogram and ultrasound on August 21, 2012. The radiologist entered the exam room, she asked the patient about her prior cancer treatment. When the patient replied she has never been treated for cancer, she was asked her name. When the radiologist realized the error she apologized to the patient. The radiologist stated she relies on the technician to identify the patient except during invasive procedures.

The hospital has a policy and procedure for patient identification. The policy for departments that do not use identification bands must immediately verify patient identification, asking the patient to state his/her name, date of birth and match these to the medical record, requisition or order sheet.

The use of patient identifiers when providing care, treatment and services will accomplish two goals: reliable identification of the person for whom the service or treatment is intended and second, to match the service and treatment to that person. The use of patient identifiers must be used for every patient encounter.

Based on review of 3 open medical records and 8 closed records, it was determined that 1 out of 8 closed records lacked the face-to-face documentation.

Patient #11 presented to the Emergency Department on 6/3/12 kicking and screaming at staff. The patient's behavior continued to escalate with patient placement in 4 point hard restraints at 3:50 am. The restraint was discontinued at 4:35 am, 45 minutes later. Review of the medical record revealed no face-to-face was performed for patient #11. Although the restraint was discontinued before the practitioner arrived to perform the face-to-face, the practitioner is still required to see the patient face-to-face and conduct the evaluation within 1 hour after the initiation of the restraint.

Based on review of 3 open medical records and 8 closed records, it was determined that 3 out of 8 closed records revealed lack of the required listed elements for the face to face evaluation. This included the patient's current situation, reaction to the restraint/seclusion, medical and behavioral condition and the need to continue/terminate the restraint/seclusion. The space designated for the detailed completion of the face-to-face evaluation was blank.

Patient # 5 presented to the Emergency Department very agitated and intoxicated after being hit in the face with a bottle, causing a large laceration. The patient was placed in 4 point restraint on 8/19/12 on 2:15 am. The patient was taken out of restraints at 4:45 pm. The physician signed that he had evaluated the patient to determine the need to continue the use of restraint/seclusion as specified by this order but did not complete the specific elements of the face-to face documentation, this area was incomplete.

Patient # 9 was on the inpatient psychiatric unit, pacing and threatening staff. Patient behavior continued to escalate with the patient placed in locked door seclusion on 8/14/12 at 7:45 am. The seclusion was discontinued at 11:00 am. The physician signed, dated and timed that he had personally evaluated the patient, again the specific elements for the face-to-face was incomplete with one line which stated threatening to strike staff.

Patient #10 was placed in locked door seclusion on 7/26/12 at 945am and the seclusion discontinued at 1200pm. The physician signed, dated, and timed that he had evaluated the patient but did not complete the elements of the face-to-face.

Based on review of 3 open medical records and 8 closed records, it was determined that 3 out of 8 closed records lacked the documentation of the required elements for the face to face evaluation. The space designated for the detailed completion of the face-to-face evaluation was incomplete.

Patient # 5 presented to the Emergency Department very agitated and intoxicated after being hit in the face with a bottle causing a large laceration. The patient was placed in 4 point restraints on 8/19/12 on 2:15 am. The patient was taken out of restraints at 4:45 pm. The physician signed that he had evaluated the patient to determine the need to continue use of restraint/seclusion as specified by this order but did not complete the specific elements of the face-to face documentation, this area was left blank.

Patient #9 was on the inpatient psychiatric unit, pacing and threatening staff. Patient behavior continued to escalate with the patient being placed in locked door seclusion on 8/14/12 at 7:45 am. The seclusion was discontinued at 11:00 am. The physician signed, dated and timed notes that he had personally evaluated the patient, but the notes lacked the specific elements for the face-to-face with only one line stating "threatening to strike staff."

Patient #10 was placed in locked door seclusion on 7/26/12 at 9:45 am and the seclusion was discontinued at 12:00 pm. The physician signed, dated, and timed that he had evaluated the patient but the notes failed to document the required elements of the face-to-face, that section was left blank.

Based on review of 3 open records and 8 closed medical records, it was determined that 1 of the 8 closed records reviewed contained a discharge summary with blank spaces throughout the discharge summary and the summary was not signed by the physician.

Patient #7 was admitted to the hospital on 7/6/12 and discharged on 7/11/12. The patient's discharge summary has four blanks that were not filled in by the physician completing the summary. In addition, as of the survey date on 9/5/2012, the physician had not signed the discharge summary that had been dictated on 8/23/12 and transcribed on 8/26/12.

Based on a review of 3 open records and 8 closed medical records, it was determined that 1 of the 8 closed records reviewed contained discharge summaries that were not signed within the 30-day timeframe for closed records.

Closed record no. 7 was a patient who was in the hospital from July 6, 2012 to July 11, 2012. His discharge summary was dictated August 23 but was not signed as of the Setember 5, 2012 when this review was made, 56 days after discharge.
Closed record no. 8 was a patient who was in the hospital from July 13, 2012 to July 16, 2012. Her discharge summary was dictated on August 24, transcribed August 26 and signed on August 27, 2012, 42 days after discharge.

Closed record no. 11 was a patient who was in the hospital from June 3, 2012 to June 6, 2012. His discharge summary was dictated on July 19, 2012, transcribed July 20, 2012 and signed July 30, 2012, 54 days after discharge.