HospitalInspections.org

Based on unit observations, interviews with staff, and review of policies and procedures, it was determined that the hospital failed to provide care in a safe setting to patients on its behavioral health unit (BHU), when a security officer assigned to the unit failed to secure hospital-approved weapons (pepper spray and baton) prior to entering the unit.

During an observation of the inpatient BHU in the afternoon of 06/23/2021, the surveyors conducted an informal interview with a security officer (SO1) stationed within the nurse's station. SO1 stated that the unit had a 24-hour security presence. The surveyors asked SO1 if he/she had any weapons on his/her person. SO1 replied in the affirmative, stating that he/she was carrying a pepper spray and a baton.

In an interview with the Director of Security (SO2) on 6/24/2021 at 10:00 am, the surveyors asked if SO1 was permitted to carry a pepper spray and a baton on the locked inpatient behavioral health unit. SO2 responded that the security officer in question was initially posted outside of the hospital; however, his/her posting location was changed to within the hospital. SO2 acknowledged the expectation was for all security officers to secure their weapons prior to entering onto the locked inpatient BHU. SO2 stated there was a box in which security personnel could secure weaponry located in the conference room within the sally-port entrance onto the unit.

The surveyors asked if there were any written policies outlining this expectation. SO2 could not state there was an official policy, but maintained that the restriction of weapons on the inpatient behavioral health unit was a standard to which security personnel staff were expected to adhere.

Surveyors reviewed multiple hospital policies pertaining to presence and use of weapons in the hospital, including: Authorized Weapon policy (effective 5/07/2021), Use of Self Defense Instruments policy (effective 12/2006), and the Sentinel Event policy (effective 6/05/2020). None of the aforementioned policies included wording which addressed the prohibited presence of weaponry on the inpatient behavioral health unit.

The hospital's failure to establish an official process for securing weapons prior to entry to BHU and failure to monitor security staff adherence to this process created an unsafe environment of care on the BHU and placed all patients, staff, and visitors at risk.

Based on review of 10 patient medical records, hospital policy, and other pertinent documents, it was determined that the hospital failed to assure that a provider entered a restraint order within 1 hour of the implementation of the intervention for 2 of 10 patients reviewed.

The surveyor reviewed the policy titled "Restraint and/or Seclusion for the Patient with Violent/Self-Destructive Behavior Policy. Section IV. C. 1. a. stated, "If an authorized prescriber is not available to issue an order for Restraints and/or Seclusion, a registered nurse may initiate Restrains and/or Seclusion based upon an appropriate assessment of the patient. A verbal or written time-limited authorized prescriber order must be obtained promptly but no later than 1 hour." This policy complied with the requirements of Code of Maryland Regulations, Sec. 10.21.12.05.

Patient #5 (P5) was a 30 + year old patient who was brought by police to the Emergency Department (ED) for an emergency psychiatric evaluation. P5 called 911 with threats of suicide twice prior to being transported to the ED.

Approximately ten minutes after arrival to the ED, nursing staff documented that the patient was "carried to room" after being "aggressive with security." The Registered Nurse's (RN) note approximately a half an hour after the intervention stated, "Patient arrived combative and cursing at staff ...Patient was undressed by two female security guards." Restraint order and face-to-face assessments were documented by the provider in the medical record approximately 6.5 hours after the incident, according to the time stamp in the medical record.

Patient #10 (P10) was a minor who was brought into the Emergency Department (ED) by a family member due to aggression, self-injurious behavior, and inability to sleep. On the day of presentation, the patient received intramuscular (IM) emergency medications. The nurse's note stated, "Patient not cooperative with lab draw, aggressive, MD ordered [medication], patient became combative with IM attempt, security called and patient given IM injection with minimal holding." There was no restraint order entered in the medical record that coincided with this incident.

Without a timely provider order for the restraint episode, the surveyors were not able to verify that a physician had an oversight of the restraint episodes.

Based on 10 patient medical record, hospital policy, and other pertinent documents, it was determined that the hospital failed to ensure that a face-to-face evaluation was completed within an hour of the implementation of the restraint for 2 of 10 patients reviewed.

The surveyor reviewed the policy, titled "Restraint and/or Seclusion for the Patient with Violent/Self-Destructive Behavior Policy". Section IV. B. 3. of the policy stated: "Within 1 hour of applying Restraints and/or initiation of Seclusion, an in-person (face-to-face) evaluation must be performed by an authorized prescriber." Section IV. B. 3. B. of the policy stated: "The face-to-face evaluation shall include: i. The patient's immediate situation. ii. The patient's reaction to the intervention. iii. The patient's medical (temperature elevations, hypoxia, hypoglycemia, electrolyte imbalances, drug interactions and side effects) and behavioral condition. iv. The need to continue or terminate the Restraint/Seclusion."

Patient #5 (P5) was a 30 + year old patient who was brought by police to the Emergency Department (ED) for an emergency psychiatric evaluation. P5 called 911 with threats of suicide twice prior to being transported to the ED.

Approximately ten minutes after arrival to the ED, nursing staff documented that the patient was "carried to room" after being "aggressive with security." The Registered Nurse's (RN) note approximately a half an hour after the intervention stated, "Patient arrived combative and cursing at staff ...Patient was undressed by two female security guards." Restraint order and face-to-face assessments were documented by the provider in the medical record approximately 6.5 hours after the incident, according to the time stamp in the medical record.

Patient #10 (P10) was a minor who was brought into the Emergency Department (ED) by a family member due to aggression, self-injurious behavior, and inability to sleep. On the day of presentation, the patient received intramuscular (IM) emergency medications. The nurse's note stated, "Patient not cooperative with lab draw, aggressive, MD ordered [medication], patient became combative with IM attempt, security called and patient given IM injection with minimal holding." There was no restraint order or face-to-face documentation in the medical record that coincided with this incident.

Based on interviews with staff and review of personnel files, it was determined that Cardiopulmonary Resuscitation (CPR) certification was not a requirement for hospital security or for contracted security staff who participated in the application of physical and/or mechanical restraints.

On 6/24/2021 at approximately 10:30 AM, the surveyors interviewed the Director of Security. The interview revealed that the hospital did not require CPR certification for hospital-employed or contracted security staff. The surveyors reviewed 5 personnel record of security officers employed by the hospital for 0-10 years. The review identified no CPR certifications for any of the staff reviewed. Review of the documentation related to contracted security staff revealed that there was a modified CPR course included in onboarding training; however, the hospital failed to mandate biennial CPR certifications for employed and contracted security staff who would be involved in restraint practices.

Failure to ensure that all staff involved in application of restraints had education and demonstrated knowledge of CPR placed all patients involved in restraint episodes at risk.