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.

ADVENTIST HEALTHCARE WHITE OAK MEDICAL CENTER 11890 HEALING WAY SILVER SPRING, MD 20904 Oct. 24, 2013
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on review of 4 patient restraint and seclusion records, it is determined that no modification to care plan related to seclusion and restraint are noted for patients #1, #4, and #6.
Patient #1 is a middle-aged female who was admitted involuntarily to the behavioral health unit (BHU) in October 2013 following suicidal ideations with psychosis and aggression toward others. On the second day of admission, patient #1 attempted to hit staff, and was secluded. No modification is noted to her care plan related to that seclusion.
Patient #4 is a late-middle-aged male admitted to the hospital medical service in late September 2013 for an altered mental status related to seizure activity. On the 8th day of admission, patient #4 was restrained in 2-point soft wrist restraint. No modification to his care plan is noted related to restraints.
Patient #6 was a elderly male who admitted to the medical service of the hospital in August of 2013 due to an altered mental status. Patient #6 was placed in 2-point wrist restraint. No modification is noted to his care plan related to restraint.
The hospital failed to meet regulatory requirements to modify care plans related to seclusion and restraint.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0162
Based on review of 4 patient seclusion and restraint records, it is determined that patient #1 was kept in the seclusion room beyond the time she no longer represented a danger to self and others.
Patient #1 is a middle-aged female who was admitted involuntarily to the behavioral health unit (BHU) in October 2013 following suicidal ideations with psychosis and aggression toward others. On the second day of admission, patient #1 attempted to hit staff, and was secluded following a brief restraint in which she received intramuscular medication. An order appears in the record for the restraint, though none is noted for the seclusion.
A same-day untimed group note states "Patient had been intrusive and agitated, grabbing cleaning supplies + sent to quiet room." A nursing note states "Pt got very agitated when he (sic) was asked to move out from the wet floor. She tried to hit staff broke his glasses, yelling and __ Korean language. He (sic) was taken to the quiet room because he was disruptive. Pt continued kept trying to hit others. PRN Ativan 1 mg IM ( intramuscular) and Zyprexa 10 mg IM was given @ 0906. Pt. was put in seclusion because she was trying to come out and fight. Seclusion was discontinued at 0958 because she fell asleep."
There was no nursing documentation of any criteria given to patient #1 by which to exit the seclusion room. Seclusion 15-minute documentation reveals that patient #1 was placed in the seclusion room (labeled SR) starting at 9:15 am, and that through 9:30 am, her behavior was physically aggressive, and threatening to staff and peers. According to the 15-minute flows, SR continued through 11 am, with no sleeping documentation as stated in the nursing progress note. Patient #1's behavior is documented only as irritable, then restless and pacing through 11 am. Neither irritability nor restlessness and pacing are justification for continued seclusion. Additionally, the 15-minute documentation does not support that patient #1 was released from seclusion at 0958.
Patient #1 remained in the same room "sleeping" from 11:15 am until 12:15 pm, now labeled (CR), for "comfort room" though no further documentation indicates that patient #1 was actually released from seclusion, or that she began a quiet room process. Patient #1 remained in the same room sleeping, now labeled (QR) for Quiet Room from 12:30 pm through 1:30 pm though no further documentation describes the actual intervention used.
Based on all documentation, patient #1 was not released from seclusion when she was no longer a danger to herself and others.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on review of 4 patient restraint and seclusion records, it is determined that 1) no seclusion orders are found for patient #1 who had two seclusion events, and 2) No initial nonviolent restraint orders, are found for patients #1, #4, and #6.
Patient #1 is a middle-aged female who was admitted involuntarily to the behavioral health unit (BHU) in October 2013 following suicidal ideations with psychosis and aggression toward others. On the second day of admission, patient #1 attempted to hit staff. A Restraint/Seclusion order sheet of 9:05 am reveals a physician signed, but not dated or timed order for "physical hold" in order to administer emergency medication. While the order form reveals an end time of 9:58 am, and other progress note documentation indicates that patient #1 went into seclusion following medication administration, no actual attribution on the form indicates that patient #1 was in seclusion.
Patient #4 is a late-middle-aged male admitted to the hospital medical service in late September 2013 for an altered mental status related to seizure activity. On the 8th day of admission, patient #4 was restrained in 2-point soft wrist restraint. Three renewal orders are noted, but no initial order, indicating that patient #4 was restrained at some time prior to the renewal order without an order.
Patient #6 was a elderly male who admitted to the medical service of the hospital in August of 2013 due to an altered mental status. On 9/15 at 1405, a nursing note states in part, "Patient very confused and restless, he is disrupting invasive lines such as IV catheter and oxygen tubing ... " Patient #6 was placed in 2-point wrist restraint at some time following this writing. Nursing flows reveal a restraint assessment on 9/15 at 2100. A nursing note of 9/15 at 2314 states in part, " ...Patient placed on B/L (bilateral) soft limb wrist restraint. A renewal order for 2-point bilateral soft wrist restraint is noted in the record on 9/16 at 12 noon. However, no initial order is found, indicating that patient #6 was restrained at some time prior to the renewal order without an order.
The hospital failed to meet regulatory requirements to provide a physician order for the use of seclusion and restraint.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of 10 patient records, it is revealed that nursing failed to consistently conduct restraint assessments of patient #6 who was in non-violent restraints for medical interventions.

Patient #6 was an elderly male who admitted to the medical service of the hospital in August of 2013 due to an altered mental status. On 9/15 at 1405, a nursing note states in part, " Patient very confused and restless, he is disrupting invasive lines such as IV catheter and oxygen tubing ... " Patient #6 was placed in 2-point wrist restraint at some time following this writing, though no initial order is found.

Nursing documentation reveals a restraint assessment on 9/15 at 2100, but no other full restraint assessment until 9/16 at 2000, a period of 20 hours. While RN progress notes indicate that patient #6 continued in restraint, only one RN progress note of 9/16 at 1201 indicates that patient #6 was being assessed for circulation during this period until 2200.

Again between 9/17 at 0800 and 1400 (6 hours), no full restraint assessment is found. RN progress notes for this period reveal a circulation assessment at 1043, but no other restraint related assessment. Additionally, on 9/17 from 2300 through 9/18 at 0700 am (8 hours), and from 9/18 at 1200 through 1900 (7 hours), no restraint assessment appears in the record.

On 9/20, an RN note of 0136 states in part, "Patient demanded for his BIPAP out, same removed by the respiratory therapist. Still in his restraint. Patient #6 expired on ,d+[DATE] at 1815. While the use of restraint does not appear to have been a factor in patient #6's death, nursing assessments failed to meet regulatory requirements, and therefore cannot exclude that patient #6 was not released at the earliest possible time.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on a review of 10 patient records, patient #1 received no initial nursing assessment

Review of the patient record reveals that patient #1 was not cooperative with initial assessments. While some assessment elements required a response from patient #1, multiple assessment points did not require patient #1's cooperation. Additionally, patient #1 had multiple previous admissions which could have been utilized for history. The initial nursing assessment for patient #1 had largely not been completed by the time of survey, approximately five days following patient #1's admission.