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MEDSTAR FRANKLIN SQUARE MEDICAL CENTER 9000 FRANKLIN SQUARE DRIVE BALTIMORE, MD 21237 April 18, 2017
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
Based on the onsite investigation conducted on April 18, 2017, review of 13 records, seven open and six closed. It was determined that one patient was kept in 4-point restraints for violent behavior for four days with insufficient documented justification.


Patient #1 was admitted to the hospital for violent behavior status post a fall at home. It was documented on admission that the patient was agitated, combative, and argumentative. The patient's initial order for 'Restraint Violent Patient 18 years and older' started on the day of admission. The order documented: "Danger to self and others, 4-point, Bilateral Lower Extremity | Bilateral Upper Extremity, Hitting/ punching, Order will expire in four hours. " This order was renewed every four hours continually for four days until hospital discharge.


There was no documentation in the medical record that shows that the staff tried to discontinue the 4-point restraints or decrease to two extremity versus four extremity. Documentation was lacking in the actual behavior that the patient was exhibiting to warrant remaining in 4-point restraints. Of the nine nursing progress notes entered during the 4 days admission only two entries describe actual behavior that attempted to justify continued restraint use. The first note written when patient arrived on to the unit and the second was made two days post admission. Other nursing notes mention the patient sleeping or calm, but the patient remained in 4-point restraints. Example RN#1 noted "Pt sleeping but woke up and was able to take meds in applesauce without any problem started being restless but is back to sleep, 4-point restraints on."

The physician's medicine progress notes does acknowledge that the patient was combative, agitated, and not cooperative upon admission; however, it does not validate ongoing violent behavior. The medicine progress notes do not give parameters for removal of restraints if the patient is no longer a threat to self or others. A note by nursing also states "MD #1 gave a verbal order to continue restraint if patient is awake, but will put the written order for 4-point restraint(s)." This verbal order doesn't explain or describe the specific behaviors justifying the need for the patient to be restrained.

Patient #1 was transferred to a psychiatric facility on day four. The final order for 4-point restraints was written four hours before transfer.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
Based on the onsite investigation conducted on April 18, 2017, review of 13 records, seven closed and six closed. It was determined that the hospital failed to ensure that face-to-face practitioner evaluations were completed for one patient who remained in restraints for violent behavior for four days.

Patient was admitted to the hospital for violent behavior status post a fall at home. It was documented on admission that the patient was agitated, combative, and argumentative. The patient was placed in restraints on the day of admission. No evidence was present in the chart of any face-to-face assessment (initial or daily) documented in the patient's record for this 4 day admission.