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 Sept. 12, 2017
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
Based on a review of hospital Restraint/Seclusion policy 10 total restraint/seclusion records, and staff training materials, it is determined that 1) staff failed to provide ongoing monitoring of behaviors for patients #1 and #4; 2) failed in part to utilize appropriate criterion for release; and 3) failed to train nurses, in part, of appropriate restraint/seclusion release information.

Per hospital policy, "Restraint and Seclusion" (revised 7/2017) under "G. Reassessment/Monitoring," the frequency for "Violet/Self Destructive Restraint" is "Every 15 minutes." Review of this policy indicated that a reassessment would take place every 15-minutes regarding the patient readiness for release from restraint/seclusion.

Review of patient #1's September 2017 ED record revealed patient was placed in 4-point violent restraints from 1123 to 1210 and again at 1430 to 1733. No 15-minute monitoring was found for either restraint episode related to reassessment of patient #1's ongoing behaviors.

Review of patient #4's behavioral health unit (BHU) seclusion episode in September 2017 from 0758 to 0900 revealed only initiation behaviors, with no further reassessment of patient #4's ongoing behaviors.

Further review of patient #4's criterion for release revealed inclusion of "greater focus, and attention," both of which are inappropriate criterion for release.

The hospital uses a drop down box to select criterion for release when a patient is restrained or secluded. Included in this drop down is the criterion of "a safety contract." While a safety contract may be desirable to discuss with a patient, release from restraint or seclusion cannot be conditioned on the patient providing a verbal safety contract where only behavioral criterion apply.

Additionally, a review of training given to nurses included "c. Release from Restraints" which stated in part, "When a physician clinically determines that a patient is to be released from restraint, the physician shall order the release ..., and, "the RN shall order termination of the restraint with or without a physician's order, unless the physicians order specifically requires concurrence with the termination ..." If nurses are appropriately trained, no physician order is required for release from restraint or seclusion, and a provision for this physician order training may compel nurses to wait for the physician prior to the release of a patient who meets criteria for release.

Based on this information, it cannot be known if patients are released at the earliest possible time where the hospital failed to reassess behaviors; failed to utilize appropriate criterion for release; and failed to provide appropriate instruction to nurses regarding termination of restraint and seclusion.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
Based on a review of the hospital restraint/seclusion policy, and review of 10 total restraint/seclusion records, it is determined that 1) staff failed to provide ongoing monitoring of the patient condition and care for patients #1 and #4.

Per hospital policy, "Restraint and Seclusion" (revised 7/2017) under "G. Reassessment/Monitoring," the frequency for "Violent/Self Destructive Restraint" is "Every 15 minutes."

Review of patient #1's September 2017 ED record revealed patient was placed in 4-point violent restraints from 1123 to 1210 and again at 1430 to 1733. While vitals were taken at 1131, no 15-minute monitoring was documented which described the patient condition and nursing care during those restraint episodes. However, vitals were taken at 1131.
Further review revealed nursing note at the initiation of the 1430 restraint episode which stated in part, "circulation checks are WNL. (Patient) is stable," and a late nursing note of 1720 for 1430 that mentioned "Patient placed in 4-point restraints. VS WDL (within defined limits)."

Review of patient #4's behavioral health unit (BHU) seclusion episode in September 2017 from 0758 to 0900 revealed only initiation parameters of condition and care, with no further documented 15 minute flows by which described patient #4's condition and nursing care.

Based on these reviews, staff failed to demonstrate monitoring of the condition and the provision of care to patients #1 and #4 in restraint and seclusion respectively, consistent with policy, regulation and the standard of care.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
Based on a revisit review of 4 emergency department (ED) restraint records, and 3 behavioral health unit (BHU) seclusion records, it was determined that for 3 restraint and 1 seclusion episode for patients #1, 2, and #4, the hospital failed to conduct the required Face to Face evaluations.

Review of patient #1's September 2017 ED record revealed patient was placed in 4-point violent restraints from 1123 to 1210 and again from 1430 to 1733. There was no documentation that a face-to-face evaluation was completed for either episode.

Review of patient #2's August 2017 ED record revealed patient was placed in violent restraints from 1552 to 1706. There was no documentation that a face-to-face evaluation was completed for the restraint episode.

Review of patient #4's September 2017 BHU record revealed patient #4 was placed in seclusion from 0758 to 0900. There was no documentation that a face-to-face evaluation was completed for the seclusion episode.

Based on these findings, the hospital failed to improve processes related to conducting face to face evaluations as required by regulation.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
Based on a revisit review of staff training, and interview, it was determined that the hospital failed to provide retraining to the staff consistent with the Plan of Correction.

Interview with multiple staff on 9/12/2017 revealed differing responses to the question regarding staff re-training on restraint and seclusion. Interview with a staff nurse in the emergency department on the morning of 9/12 revealed she had no new restraint/seclusion training, and that she expected to receive annual training in October 2017.

Interview with a quality representative in the afternoon revealed that "huddles" had been done with nursing to disseminate re-training information, though a subsequent request for training logs revealed no logs were kept to monitor which nurses had huddle training and which had not.

A request for employee file training documentation revealed that no new training had been added to any employee files.

Based on this information, the hospital failed to implement the Plan of Correction which documented at least three "Rounds of training" but which did not occur.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on a revisit review, it was determined that the hospital failed to implement a Plan of Correction re-training to improve Restraint/Seclusion interventions for which the Performance Improvement Council was responsible.


Interview with multiple staff on 9/12/2017 revealed differing responses to the question regarding staff re-training on restraint and seclusion. Interview with a staff nurse in the emergency department on the morning of 9/12 revealed she had no new restraint/seclusion training, and that she expected to receive general annual training in October 2017.
Interview with a quality representative in the afternoon of 9/12 revealed that "huddles" had been done with nursing to disseminate re-training information, though a subsequent request for training logs revealed no logs were kept by which to monitor which RN's had huddle training and which had not.

A request for employee file training documentation revealed that no new training had been added to any RN employee files related to restraint and seclusion.

Review of the hospital Plan of Correction revealed three "Rounds of training" regarding approved restraint devices, and training and competency. However, no evidence of such training was found.

Based on this, the hospital failed to implement restraint and seclusion training as described in the Plan of Correction