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.

MEDSTAR UNION MEMORIAL HOSPITAL 201 EAST UNIVERSITY PARKWAY BALTIMORE, MD 21218 Sept. 2, 2014
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on staff interviews, review of policies and procedures, medical records, and other pertinent documentation, it was determined that the hospital failed to provide a safe environment for patients on the inpatient psychiatric unit as evidenced by the staff's failure to recognize and investigate patients allegations of feeling unsafe and/or being inappropriately touched by male patients.

Refer to A145

During medical record reviews, it was discovered that on three separate occasions the hospital failed to investigate allegations of inappropriate touching and possible sexual abuse on the behavioral health unit.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on 3 out of 5 medical records reviewed, it was determined that the hospital failed to recognize and investigate allegations of inappropriate touching. In one case the patient was determined to have consented to sex and in the other two cases there was no investigation into the patients' statements that they were inappropriately touched by male patients and the patients' statements were attributed to the patients' diagnoses or history of sexualized behavior.

Patient #1 is a [AGE] year old female who presented to the hospital (August 2014) with manic behavior including running nude in the street. The Mini Mental Status Exam included in the admission record information showed a score of 18 out of 30 (Moderate Impairment). Patient #1 was placed in quiet room and seclusion due to continued manic behavior including running and responding to internal stimuli. The Psychiatric Inpatient Multidisciplinary Treatment Plan reflected diagnoses of but not limited to Bipolar Disorder Manic with Psychotic Features . This document (August 2014) which was done the day after admission showed that the goal for Patient #2 was that he/she would accept staff orientation, reality orientation and take medications as prescribed throughout hospitalization . The problem area on the document indicated "Alteration in Thought." Approximately 24 hours after admission. Patient #1 was found in bed with Patient #2 in her bedroom. The patients were separated and per the medical records both patients stated the sex was consensual. The patient was seen by the psychiatrist and laboratory test ordered. The note by the psychiatrist did not document whether the patient had capacity to consent to sex. On interview with the surveyor on 8/22/2014, the Unit Manager acknowledge that staff were made aware that Patient #2 had sexual relations with Patient#1 and it was determined to be consensual. An event report was completed and both patients were informed that having sex on the unit was not allowed. Although the counselor found the two patients in bed on rounds, the hospital staff did not view the available video camera tape from the hallway to determine other factors such as how long the patients were in the bedroom together, the location and/or involvement of other patients at the time of the encounter as well as staff, etc. Patient #1's mental capacity was still in question as to her ability to consent to sex and she should have clearly been assessed and counseled regarding her options and reassessed regarding this issue once stable.

In addition, in 2 out of 2 medical records, it was determined that the hospital failed to investigate the patients' allegations that they were touched inappropriately by a male patient.

Patient #3 is a [AGE] year old female with diagnosis of IID (Individual with Intellectual Disability). She presented to the hospital (August 2014) with increasing aggression and made statements on admission regarding someone name John and sexualized comments. This appears to be the second patient mentioned in the complaint. Per the complainant on the same day as Patient #2's sexual encounter with Patient #1, he inappropriately touched Patient #3. Review of Patient #3's medical record and nursing progress note dated 8/10/14, it was revealed that an addendum note by a RN regarding Patient #3 waking up from a nap screaming "don't let that n...... rape me, don't let that n..... kill." In addition, the following was written "Pt. had inappropriate touching from a young AA male on Thursday 8/7/14." There was no event report or notation in either patients' medical records regarding the inappropriate touching. Two nurses were interviewed and state they had heard second hand that Patient #2 and Patient #3 had inappropriate touching. Both nurses thought that since the incident had occurred days before that the incident had been handled by other staff. Both nurses stated they heard this information from other nurses during hand-off. There is no documentation in the patients' medical record around the 8/7/14 date regarding her being touched inappropriately by the male patient. The staff stated that the patient was already making sexualized comments on admission. There was no indication that the staff investigated the patient's comments and reviewed the video tape to determine if the male patient entered the patient's room or the quiet room and possibly could have touched her inappropriately. In addition, the patient's comments blurted out when coming out of a nap should also have been pursued on 8/10/14 but again staff did not investigate and assumed that other staff members had already addressed the patient's concerns.

In addition, while the surveyor was reviewing complaints/grievances, a patient called into the Patient Advocate to complaint about her stay on 6 West (May 2014). Patient #4 was a [AGE] year old female admitted for suicidal ideations. The patient called to complain that the staff on the inpatient psychiatric unit was unconcerned about her safety in regards to another patient on the unit at the time who was uncontrolled by the staff. The patient alleged that she woke up to find patient #5 feeling on her and when she mentioned this to staff, she was told to lock her door but nothing was done to Patient #5 until he almost hit a nurse. The patient stated her room was one door down from the nurse's station and questioned why Patient #5 was not stopped. Patient #4 asked that the customer service representative review the video tape for that particular day. The next sentence stated, placed a call to the charge nurse. Review of the complaint process revealed there was no documented outcome regarding any follow-up into the allegations . The complaint/grievance file did not state what charge nurse the patient advocate spoke to nor whether the video tape had been reviewed. Based on the date of the complaint, if the hospital had reviewed the video tape they could have determined if anyone other than the patient had entered her room. The Interview with the charge nurse and unit manager revealed they were not aware of the complaint.

The hospital is responsible for investigating on some level all allegations of abuse regardless if the patient has mental illness or behavioral health issues. Based on the three examples stated above, there is evidence of a pattern of failure to acknowledge and investigate allegations of inappropriate touching by peers on the inpatient psychiatric unit. The patients' allegations were not investigated and their statements were solely attributed to their history and diagnoses. The hospital unit is coed with rounds made every 30 minutes except on special observation with rounds every 15 minutes. In addition, the video recording is taped over at two weeks intervals and the video camera on the west hallway was found not working on the first day of survey August 22, 2014. While the hospital has video monitoring that could be useful in determining if certain allegations are credible, the hospital staff indicated that this tool is not routinely used to investigate patient complaints or incidents. All patient allegations including but not limited to inappropriate touching, mistreatment and abuse requires that the hospital staff conduct an investigation to ensure patient safety and protect patients rights. When patient allegations are substantiated the hospital must take appropriate actions to address allegations that are substantiated, implement measures/interventions to prevent recurrences, monitor the effectiveness of the interventions and make changes as appropriate.

It was noted by the surveyor that this this failure appears to be isolated to the behavioral health unit is not a hospital wide practice.
VIOLATION: PATIENT SAFETY Tag No: A0286
Performance Improvement activities must track medical errors and adverse patient events, analyze their causes and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. Based on complaint investigation of August 22, 2014, it was determined that from a quality standpoint, the hospital failed to 1) document and investigate patient allegations of inappropriate touching, 2) assess Patient #1's capacity to consent to sex, and 3) failure to inform patient #1 of her laboratory results.

Refer to A145

Based on medical record reviews, policies and procedures, staff interviews, and other pertinent documentation, it was determined that the hospital failed to provide care and treatment in accordance with acceptable standards of practice when it failed to investigate complaints/allegations of inappropriate touching including physical and psychiatric assessments of the patients making the allegations as well as documentation of steps to investigate and outcomes.
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
Based on medical record review, it was determine that the hospital had no system/policy in place to ensure that lab results or other tests results that were completed for inpatients but not available prior to discharge were conveyed to the patients and/or other appropriate healthcare providers.

During the survey completed on 9/2/2014, the surveyor and the hospital staff realized that if a patient has laboratory test performed while inpatient and they are discharged before the results come back, the patients are not informed of the test results. The hospital currently has no mechanism in place to ensure the patient, their primary care provider or community provider are made aware of the results.