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NORTHWEST HOSPITAL CENTER 5401 OLD COURT ROAD RANDALLSTOWN, MD 21133 Aug. 12, 2011
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the medical record and policies and procedure, it was determined that the hospital failed to to obtain an order from a licensed independent practitioner for seclusion for patient #1.

Patient #1 is a [AGE] year old male who presented to Northwest Hospital Center Emergency Department (ED) after decompensating at home and Emergency Petitioned after the police were called. The patient was described as more paranoid and responding to internal stimuli. The patient was described and 6 feet tall and weighing 280 pounds. He patient refused to answer questions in the ED and was described as angry, hostile, labile, disheveled, threatening, responding to internal stimuli and laughing inappropriately to himself. The patient believes NSA is watching him and tapping his phone. He stated the "banks were going to run out of money tomorrow." While in the ED the patient began disrobing, could not follow directions, removed the monitoring equipment, pacing, responding to internal stimuli, and jumping up off the stretcher with periods of screaming to periods of completed silence and refusal to speak. The patient was placed in soft wrist restraints to provide care and prevent removal of monitoring equipment. The patient was medically cleared and transported to the inpatient psychiatric unit by one security and one emergency department staff.

Once on the inpatient psychiatric unit the patient appeared sleepy and slow to respond to staff directions. The soft wrist restraints were removed and the patient was asked to sit in a chair to complete the admission process. At this point without warning, the patient jumped off the stretcher, grabbed the security staff taking her to the floor where he proceeded to punch her about the head, shoulder, and back. The ED staff tried to assist the security staff, when the patient turned on the ED staff. The patient straddled the ED staff at her hips and proceeded to punch her and attempt to poke her in the eyes. Additional staff were called over security walkie talkie. A male security arrived and attempted to get the patient off the ED staff when the patient turned on the security staff, taking him to the floor and punching him and attempting to poke him in the eyes. Another two male security staff arrived on the unit only to be taken to the floor and beaten by the patient. The hospital staff called 911. The police arrived and also had difficulty getting the patient's behavior under control. The patient was tasered by the police along with medications administered by the nursing staff. The patient was placed in four point restraint and eventually down-graded to seclusion.

Due to the level of dangerousness exhibited by patient #1, he was secluded for an extended period of time to keep the patient and others safe. It was during this extended seclusion time that the patient had a face to face performed by the nursing staff, which justified continued seclusion but no order was written. The patient's had an order for seclusion written on 6/13/11 at 6:59 PM. Review of the medical record revealed that the patient remained in seclusion but the next order was written on 6/14/11 at 1:59 AM. Since justification had been written in the medical record to continue seclusion, the next order should have been written by 10:59 PM. No order could be found in the medical record for this time frame, therefore the hospital was in violation of the patient's rights when it did not obtain a seclusion order.