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 April 27, 2015
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
Based on review of 20 medical record , it was determined that 1 out 20 records revealed lack of the required listed elements for the face to face evaluation including the patient ' s current situation, reaction to the restraint/seclusion, medical and behavioral condition and the need to continue/terminate the restraint/seclusion.

Patient #14 was secluded on 4/9/15 at 1910 for violent behavior. The seclusion was discontinued at 2030. The patient was seen by the physician to perform the face-to-face but instead of using the electronic template for the face-to-face documentation the physician completed a progress note which did not include all of the elements. The space designated for the detailed completion of the face-to-face evaluation is a template in the physician's documentation.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on documentation reviews and interviews with key staff persons, it was determined that the hospital failed to provide adequate oversight of the Behavioral Health Inpatient Services. The Behavioral Health Inpatient Services implemented a new process in August 2014 which allowed the treatment team to implement a clinical review panel (CRP) to force medication before the patient had their administrative hearing to determine if the patient would be committed to the hospital for treatment. At this hearing the patient's commitment status is determined, whether the patient will be admitted or discharged .
An interview of the Behavioral Health Unit Medical Director was conducted at 8:10AM in the Outpatient Therapy conference room. The Medical Director provided the following information about the involuntary admission process and patient management:
1) CRP is initiated by the treatment team when the patient refuses to take medication for which he or she would receive benefit;
2) CRP consists of the patient advocate and (3) providers (which can be comprised of 2 psychiatrists and a psychiatric CRNP). The involuntary admitted patient is extended an invitation to attend the CRP;
3) if the patient is not taking the medication and the patient's hearing is delayed for another week, the CRP is convened before the patient's hearing so as not to delay the patient's treatment.
The Medical Director also mentioned that there have been judges that are aware that the patients had a CRP before the hearing. The Medical Director stated that the thought was that the treatment team was acting in "Good Faith" and not wanting to delay care. The Medical Director also, stated that this has been discussed with the hospital's legal department and this has been the process of patient management since 08/14/2014. On 08/14/2014, an In-service training was provided to the Behavioral Health Unit staff by the legal department of the hospital about hoding the CRP Process before the hearing, as the "benefits" to the patients seemed obvious. The Medical Director was not sure if the legal counsel for the hospital had spoken to somebody at the State of Maryland pertaining to this process. The Medical Director also shared that there have been no patient or family complaints to date since the revised Behavioral Health Unit involuntary admission process was implemented in 08/14/2014. The Medical Director further explained that often after the CRP, the patient, is offered oral medication and the patient does not require Intramuscular injections. The hospital legal counsel and Behavioral Health Unit staff were unsure if counsel had spoken to anybody in the Attorney General's Office. The Medical Director mentioned that he had worked in the DC area and that a hearing before a CRP was not mandated in order to treat the patient.

In April of 2015 after a patient complained, the Public Defender met with the treatment team regarding convening the CRP before the patient had her hearing. The Maryland laws under the Health General Articles speaks to the patient's rights as an involuntary admission to Psychiatric Facility. The patient is entitled to an administrative hearing to determine commitment within 10 days of the initial confinement. Although the hospital had spoken to their attorney prior to implementing the change, when a question arose again in April 2015 regarding whether this practice violated the patient's rights, the hospital failed to revisit the topic and clarify whether the new process violated the patient' s rights.

While behavioral health staff identified that there was a delay in treatment for patient's that refused medication and whose hearings were postponed, the hospital failed to evaluate and revise the process within the confines of the law (Health General Articles) as evidenced by the fact that the hospital convened clinical review panels on patients who refused medication before they had their administrative hearing to determine their commitment status. Key behavioral health staff persons including the Medical Director were operating unaware that the new process was in violation of the patient ' s rights. The hospital failed to ensure that patients had their administrative hearing before convening CRP to force medications.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation and review of patient medical records on the Behavioral Health Unit(BHU) and interview of the Risk Management and BHU Medical Director on 04/22/15 at 3:30PM, it was determined that patients with medication allergies were not fully assessed by the nursing staff for verification of their allergy status. This was evident for 1 out of 10 sampled BHU patient reviews.
The findings were:
Patient #4 was [AGE] years old, admitted [DATE] to the BHU on an involuntary admission status (emergency petition by the police) from the emergency department (ESI Level-3), with behaviors of screaming, spitting, and trying to punch staff. The patient was admitted on [DATE] at 13:39.
The staff (emergency department and BHU staff) administered to the patient Haldol (anti-psychotic agent) 5 milligrams (mg) intramuscular (IM) on 02/11/15 at 11:45, 12:06, and at 18:32, for a total of (3) doses.
Further medical record review revealed that the nursing admission assessment completed by the registered nurse (R.N.) on 02/12/15 at 03:42 AM indicated that patient was allergic to Haldol. Review of the Internal Medicine Consultation Final Report for the patient's history and physical dated 02/12/15 dictated by a Physician's Assistant(PA),[NS] at 14:17 noted Haldol as an allergy. The nurse entered no additional information in the patient's medical record to indicate: 1) how and where the allergy information was obtained for allergy verification or that 2) the physician was contacted to assess the extent of the patient's alleged allergy.
Interview of the BHU Medical Director and Risk Management Staff at 3:30PM revealed that they were unable to locate in the patient medical record any assessment note made by a medical staff member that addressed the patient's allergy.
Failure by the BHU Nursing staff to ensure that a patient's allergy status was re-assessed or verified through medical staff consultation placed the patient in a situation for having an incomplete evaluation of their patient care needs
VIOLATION: NURSING CARE PLAN Tag No: A0396
Nursing staff failed to develop a care plan for Patient #4 related to the patient's noted medication allergy which was documented the day after the patient ' s admission to the BHU. Refer to A-0395 for details.
VIOLATION: PATIENT RIGHTS Tag No: A0115
As indicated in A0129, on April 22, 2015 at 7:55am, the staff interviews revealed that patients admitted to the hospital on involuntary status were being forcibly medicated before their Judicial hearing by an Administrative Law Judge to determine commitment status, in other words before the patient was committed to the hospital for treatment clinical review panels were convened and medications forcibly given.
VIOLATION: PATIENT RIGHTS: EXERCISE OF RIGHTS Tag No: A0129
Based on review of medical records, policies and procedures, staff interviews and other pertinent information, it was determined that patient's admitted to the hospital on involuntary status were being forcibly medicated through clinical review panel prior to having their administrative hearing to determine if the patient would be involuntary admitted to the hospital or released.

The standard is not met as evidenced by:

Any patient admitted involuntarily to a Maryland Psychiatric facility on 2 certificates for Involuntary Admission (Health General Article, 10-616-619) has the right to: an administrative hearing to be held within 10 days of the initial confinement to determine if the individual will be involuntarily admitted or released. The hearing may be postponed for good cause for no more than 7 days, and the postponement shall be on the record (Health General Article, 10-632).

On April 22, 2015 at 7:55 a.m. in the Behavioral Health Unit conference room during surveyor interviews with the Medical Director of the Behavioral Health Unit and the Clinical Supervisor it was revealed that patients were having clinical review (medication) panels to force medication prior to the administrative hearing to determine if the patient will be admitted involuntarily or released.

The surveyors reviewed a total sample size of 10 medical records from the hearing docket. The record reviews focused on finding patients that had their hearings postponed and had clinical review panels (CRP) convened prior to their hearing. The review revealed 3 patients (patient #1, #3, and #5) out of 10 who met this criteria. The findings are as follows:

An interview of the Behavioral Health Unit Medical Director was conducted at 8:10AM in the Outpatient Therapy conference room. The Medical Director provided the following information about the involuntary admission process and patient management:
1) CRP is initiated by the treatment team when the pt. refuses to take medication that would likely benefit the patient;
2) the CRP consists of the patient advocate and (3) providers (which can be comprised of 2 psychiatrists and a psychiatric CRNP);
3) The involuntarily admitted patient is extended an invitation to attend the CRP if the pt. is not taking the medication and the patient's hearing is not for another week. ,
4) the CRP is convened before the patient's hearing so as not to delay the patient's treatment.

The Medical Director also mentioned that there have been judges that are aware that the patients had a CRP before the hearing. The Medical Director stated that the thought was that the treatment team was acting in " Good Faith " and not wanting to delay care. The Medical Director also, stated that this has been discussed with the hospital's legal department and this has been the process of patient management since 08/14/2014.

On 08/14/2014 an In-service training was provided to the Behavioral Health Unit staff by the legal department of the hospital about the CRP Process before hearing, as the "benefits " to the patients seemed obvious. The Medical Director was not sure if the legal counsel for the hospital had spoken to somebody at the State of Maryland pertaining to this process. The Medical Director also shared that there have been no patient or family complaints to date since the revised Behavioral Health Unit involuntary admission process was implemented in 08/14/2014. The Medical Director further explained that often after the CRP, the patient, is offered oral medication and the patient does not require Intramuscular injections. The hospital legal counsel and Behavioral Health Unit staff were unsure if counsel had spoken to anybody in the Attorney General ' s Office. The Medical Director mentioned that he had worked in the DC area and that a hearing before a CRP was not mandated in order to treat the patient.

Additional inquiry of the Medical Director and Social Worker as to whether there were any recent complaints in the last weeks/months regarding the CRP process implemented prior to the patient ' s involuntary admission hearing . It was shared that the Public Defender's office had learned that a patient had complained about having a CRP before hearing. The Medical Director and Social Worker stated that the Public Defender ' s office had informed them in 4/2015 after the patient ' s complaint that it was a violation of Patient ' s Rights to have a CRP to forcibly medicate prior to the involuntary admission hearing.

At 8:35 AM the hospital risk manager returned to the Outpatient Therapy conference room stating that she had been in telephone contact with the attorney for the hospital stating that the counsel had not been in contact with the Maryland Attorney's General Office for consultation, but simply had reviewed the involuntary admission state statues. The surveyors asked what statutes specifically the counsel reviewed. As a result of that question the Risk Manager texted the legal counsel about the specific statute he had reviewed. At 8:50 AM on Risk Manager's cell phone a telephone interview was conducted with the hospital legal counsel. The counsel stated that he reviewed the general statues of the involuntary admitted patient and could not recall the specific facts or details related to those statues (with regard to hearing and CRPs).

At 9:05 AM the Risk Manager provided the surveyors a copy of the In-service training material (booklet) provided the Behavioral Health Unit staff in 08/14/14. This review revealed that a booklet provided by the state of Maryland regarding Patient Rights and the Involuntary Admission Process was dated back to 2002(13 years ago). The Medical Director pointed out to the surveyors that the 2nd to the last page of the booklet when read/reviewed does not indicate that a CRP cannot be done before a patient's hearing based on how it reads. The surveyors pointed out that the literature of reference would have to be checked for the most current information and the Patient Rights Process, before commenting on the " interpretation " of the written booklet information. Surveyors shared that regulations usually have interpretative guidelines so that the intent of the regulation can be met.

The surveyor asked the Behavioral Health Unit Social Worker Supervisor for the hearing docket and CRP logs. It was learned that the Behavioral Health Unit staff in general keep no logs of CRP(s), but that there had been only a few CRP(s) in the past year with that information retrievable from the computer.

The surveyors reviewed a Behavioral Health Unit patient sample of 10 from the docket that had their hearings postponed. . One patient review revealed a patient was identified with a Haldol Allergy the day after admission to the Behavioral health Unit, but the origin of this notation of allergy could not be determined during the record review or by the Risk Manager's review. No further assessment of the patient's allergy was found by the any of the staff as to the type and extent of the patient's allergy could be found. The Behavioral Health Unit Medical Director on interview and after his review concluded he had no answer for this oversight by staff either. While the reviews revealed that the patient ' s had two physician certifications, applications for involuntary admission and commitment, in addition no documentation could be found in the electronic/paper medical record to indicate " why " the patient ' s hearing was postponed. Therefore, the progress and status of patient care was not clearly noted in the patient's medical record. The Risk Manager was asked by the surveyor to check all 5 patient's EMR for this documentation. The Risk Manager reported that she could not find any documentation in the patient ' s EMR(s) to explain why the patient's hearing was postponed.
The combined surveyor's reviews confirmed that some Behavior Health Unit involuntary admission patients (3 out of 10) had CRP(s) done before having the opportunity of a hearing as required by Patient Rights.
The hospital was informed that the patient commitment status should be determined via the hearing before clinical review panels are convened. The hospital agreed to stop this practice immediately. They felt the patient should be receiving treatment while waiting for the hearing and their hospital attorney did interpret that regulation allowed the facility to convene the clinical review panel. In addition, the medical record review revealed only 1 out of the 10 sample medical records documented that the patient ' s hearing were postponed. The surveyor contacted the Assistant Attorney General who was able to provide guidance regarding the interpretation of the law. Per the Assistant Attorney General the patient must have their hearing regarding their commitment status before a CRP is convened to give medication. In addition, the CRP forms have three types of admission status for the hospital to check off one before the hearing is convened. The three types of admission status before the hearing include the retained patient at hearing, court committed incompetent or court committed not criminally responsible. The surveyor spoke via telephone on 4/22/15 at 4:30 p.m. to the Assistant Director of Hospitals and the Chief Nurse to discuss whether an Immediate Jeopardy should be called. It was felt that the hospital attempted before implementing the process to review with their legal department whether there would be any problems (violation of patient ' s rights) and was told based on legal department interpretation of the law and the booklet " Rights of Persons in Maryland ' s Psychiatric Facilities " that there was no problem with convening the CRP before the patient had their hearing. The hospital would stop the practice immediately and wrote out a corrective action letter signed by the Medical Director of Behavioral Health Services and the Director of Risk Management. The action plan included the following:
1) Effective immediately, No medication panels will be convened until after a Judicial Hearing has occurred and an Administrative Law Judge (ALJ) has determined that the patient is to be committed.
2) The organization will align policies and procedures to reflect the new process with respect to how patients are evaluated for medication paneling.
3) In addition, the organization will devise and implement a procedure for documenting if and why any judicial hearing is postponed.

Patient #1 was admitted to the Behavioral Health Unit on involuntary admission 3/27/15 with hearing scheduled for 4/1/15. The hearing was postponed but nothing was entered into the medical record regarding the postponement. The patient on April 1, 2015 was informed of the convening of a clinical review panel. The patient informed the Patient Advocate on 4/1/15 that she had tried medication in the past and didn't like the way they made her feel sleepy and dizzy. The Patient Advocate agreed to share the patient's concerns with the medication panel. The patient took a multivitamin by mouth. She was given Benadryl for side-effects from medication. The progress notes revealed the patient refused her psycho-active medications. The clinical review panel determined that patient #1 would receive Abilify 10-30 mg by mouth every day and if she refused, the patient received Abilify 5.25 mg IM every day. The patient was not scheduled for her next hearing until 4/8/15. Per the medication administration record, patient #1 was placed on Abilify 5mg tablet by mouth on 4/1/15 and took the medication at 11:52 a.m. The patient refused the medication the next day 4/2/15. On 4/3/15 she received Abilify 5 mg tablet at 8:55 a.m. The patient was started on Abilify 5.25 mg intramuscular (IM) on 4/3/15 at 10:41 a.m. The patient refused the medication by mouth on 4/4/15 and 4/5/15. The patient received Abilify 5.25 mg IM at 11:28 a.m. on 4/5/15. It ' s clear by the timeline of medication administration that the patient received medication per the clinical review panel before determination of her commitment status. Per the social worker, patient #1's public defender had expressed her concern with the treatment team regarding a patient being forcibly medicated prior to hearing and determination of commitment status.


Patient #3 was admitted on involuntary status to the Behavioral Health Unit on 4/3/15. His administrative hearing was scheduled for 4/8/15 and per the docket postponed. Again there is nothing in the medical record regarding the reason for postponement of the hearing. On 4/10/15 a clinical review panel was held at 3:00 p.m. with orders for Abilify 10 mg-30 mg by mouth every day, Abilify 5.25 mg -30 mg every day IM, and Benadryl 12.5 mg by mouth or IM every day. Per the patient's medication administration record and progress notes revealed that patient #3 was informed if he refused medication scheduled for the today (4/13/15) that the medication panel would require he take his medication involuntarily. The patient refused the Abilify by mouth on 4/13/15 and was given Abilify 9.75 mg IM at 9:57 a.m. Again the patient was forcibly medicated per order of the CRP before there was determination of commitment status.

Patient #5 was admitted on involuntary status to the Behavioral Health Unit on 1/24/15 with administrative hearing scheduled for 1/28/15. Per the hearing docket, patient #5 ' s hearing was postponed. The Clinical Review Panel was convened on 1/29/15 since the patient refused to take her Abilify and Depakote. The patient refused medication from 1/24/15 to 1/27/15 but began taking the medication by mouth on 1/28/15. She did not require IM medication.

The hospital followed the clinical review panel process as provided under the law but failed to ensure the patient had their administrative hearing to determine commitment status before convening the CRP panel which is in violation of the patient 's rights.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on review of 20 medical records, in 1 out of 20 records, it was determined that the patient's care plan was not updated to include the use of restraint/seclusion.

Patient #14 was secluded on 4/9/15 at 1910 for violent behavior. The seclusion was discontinued at 2030. Review of the patient ' s care plan in both paper and electronic format revealed the staff failed to update the plan to include the use of restraint/seclusion.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on review of 20 medical records, in 1 out of 20 records, it was determined that the hospital failed to obtain an order for manual hold for patient #15.

Patient #15 was placed in 4 point restraint on 3/27/15 at 1250, the patient was held to administer medication prior to 4 point restraint which constitutes a manual hold. Review of the medical record revealed order for the 4 point restraint but the hospital failed to obtain an order for the manual hold to give the patient medication.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
Based on review of 1 of 20 medical records, it was determined that the record lacked the face-to-face documentation.

Patient #13 was secluded on 4/13/15 at 1730 for violent behavior. Although the seclusion ended on 4/13/15 at 1803, review of the medical record revealed no face-to-face was performed for patient #13. Although the restraint was discontinued before the practitioner arrived to perform the face-to-face, the practitioner is still required to see the patient face-to-face and conduct the evaluation within 1 hour after the initiation of the restraint/seclusion.
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
Based on observation, review of patient medical records and interview of the Behavioral Health and Risk Management Staff, it was determined that involuntarily admitted patients to the Behavioral Health Unit (BHU) had hearings that were noted as postponed without a documented reason in the patient ' s medical record. This was evident for 5 out of 10 sampled behavioral health patients reviewed.
The findings were:
Patients #1 - #5 medical records (randomly selected) were observed and reviewed on 04/22/15 in the medical records department (HIM: Health Information Office). The patients were listed on the Behavioral Health Unit ' s, docket sheet For Scheduled IVA (NCR/Forced Med) hearing ' s listing. Patients #1-#5 had noted on the sheet for " Disposition " a postponed note for the hearings with no other details.
For example, Patients #4, #2, #1, and #5 were listed on the 02/18/15 docket listing with a postponement notation. No other details related to the postponement were noted on the sheet or found in the patient's electronic medical record review (EMR). Interview and the request that the Risk Manager [PS] on 04/22/15 at 4:30PM review the patients ' EMR for additional postponement details , confirmed that no other details or information was found to explain the reason for postponement and when the next hearing would be provided. Patient # 3 was listed on the 02/25/15 docket sheet and also had a postponement notation without any other details about the postponement found in the patient ' s EMR.
Failure by the BHU Staff to document the details around a patient's postponed hearing, potentially placed the staff at risk for not having the necessary information needed for the monitoring of the patient's condition. In addition, documented details of patient care by treatment staff is important in the collaboration and coordination efforts to meet patients' continuing needs.