The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

BON SECOURS HOSPITAL 2000 W BALTIMORE STREET BALTIMORE, MD 21223 March 18, 2013
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on review of the hospital policy the governing body has not delegated in writing the responsibility to review and resolve grievances to a grievance committee. The hospital refers all grievances to the Patient Advocate who assigns a ticket owner to manage the grievance documentation and notify the managers of any involved departments/units. The ticket owner provides a written response to the patient/patient representative. The hospital failed to meet regulatory requirements since the complaint/grievance policy does not delegate the responsibility in writing to a grievance committee or the Patient Advocate.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on the medical records of patient #1, and #2, policies and procedures, staff interviews, observations, and other pertinent information, the hospital failed to provide care in a safe setting when a patient alleges she was raped in the bathroom of her bedroom.
Patient #1 was a female patient admitted on [DATE] and discharged on [DATE].
Patient #2 was a male patient admitted on [DATE] and discharged on [DATE].
The unit had males on the South hallway and females on the North hallway. Patient #1 alleges she was in her bathroom of her bedroom and that a male patient approached her for sex. The patient alleges she had vaginal sex with the male. It was 48 hours after discharge that patient #1 returned to the hospital via the Emergency Department and stated she was raped during the admission on 2/14/13.
The inpatient psychiatric unit has a North hallway for female rooms and South hallway for males. Per the staff interview with the charge nurse and review of the assignment sheets it was revealed that a staff member is posted at each end of the hallway; and when this staff makes 15 minute rounds the nurses takes their place to monitor the hallways. Patients admitted to the inpatient psychiatric unit are in various states of orientation, agitation, depression and altered thought process requiring close monitoring to ensure a safe environment for all. It must be noted that during the safe exam on 2/16/13 patient #1 stated the rape occurred on 2/13/13 sometime after breakfast. Per the rounds sheets, which are performed every fifteen minutes, patient #1 was documented in her bedroom from 9:00-9:30am and patient #2 was in the hallway 8:15-9:45am. For an hour and 30 minutes patient #2 was in the hallway. In addition, a male nursing assistant stated that he was asked by a female staff to come to the North side to ask patient #2 to leave the area. Patient #2 was sitting on the laundry cart on the North side. The male nursing assistant stated he approached patient #2 and asked him to leave the area which the patient complied. He is not sure of the time but it was in the early morning.
In conclusion, the patient population on the inpatient unit has psychiatric and cognitive limitations that make them vulnerable. The fact that the hospital has staff posted at each end of the hallways and rounds are made every 15 minutes indicates that the hospital is aware of that monitoring is an essential means of keeping the environment safe. The failure of the hospital to monitor the hallways and redirect patient #2 would have given him the opportunity to slip into patient #1's room. Both patients stated the sex occurred in the bathroom of patient #1 ' s bedroom. The hospital failed to provide a safe setting for its vulnerable patients when it failed to monitor the environment per unit protocol.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on review of the hospital policy #R-10 on restraint and seclusion, the hospital's policy failed to address the timely acquisition of the order for restraint or seclusion prior to its application or in emergency application situations.
The policy review revealed under initiation of restraint or seclusion when credentialing practitioner is not available, a qualified RN may initiate the restraint/seclusion, but must obtain a time-limited order for the episode as soon as possible. As soon as possible is defined as within 45 minutes. The regulation requires the physician order to be obtained prior to the application of restraint or seclusion. In recognition that a restraint or seclusion intervention may occur so quickly that an order cannot be obtained prior to the application of restraint or seclusion, the regulation states that in these emergency application situations, the order must be obtained either during the emergency application of restraint or seclusion, or immediately (within a few minutes) after the restraint or seclusion has been applied.
The hospital policy has not met the regulatory requirements since it does not address the process for timely acquisition of restraint and seclusion in its restraint and seclusion policy and procedure.