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.

NORTHWEST HOSPITAL CENTER 5401 OLD COURT ROAD RANDALLSTOWN, MD 21133 Feb. 26, 2013
VIOLATION: CONTENT OF RECORD - DISCHARGE DIAGNOSIS Tag No: A0469
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of 2 out of 10 closed medical records (patient #10 and #24), it was determined that discharge summary was not completed and signed in a timely manner.

Patient #10 was admitted on [DATE] and discharged on [DATE]. During the survey on 2/26/13 the medical record review revealed the discharge summary was dictated on 1/22/13, transcribed and signed on 1/23/13. The discharge summary was not completed and signed in the 30 day time period. The discharge summary was late by 11 days.

Patient #24 was admitted on [DATE] and discharged on [DATE]. The discharge summary was dictated and transcribed on 12/26/12 but was not signed electronically by the physician until 1/23/13.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of 16 open medical records and 10 closed medical records, it was determined that in 2 out of 16 open medical records reviewed, the hospital failed to provide patients #15 and #18 with notification of their discharge rights via the Important Message from Medicare (IM).

Patient #15 was admitted on [DATE] and remained inpatient at the time of survey on 2/26/13. Review of the medical record revealed the patient had an IM on the chart with hand written at the bottom of the form, "went straight to room 310." The form did not have the representative signature, date, time, or clock number on the form.

Patient #18 was admitted on [DATE] and remained inpatient at the time of survey on 2/26/13. Review of the medical record reveled the patient had an IM on the chart with hand written at the bottom of the form, "pt unable to sign, no one with pt." The form did not have the representative signature, date, time, or clock number on the form. There were no notes documented by the hospital representative to indicate their name, date, time, or clock number.

The hospital is not in compliance with the regulation since it did not provide the patient her IM within two days of admission nor did it provide the second IM prior to discharge.

In addition, based on review of 16 open medical records and 10 closed medical records, it was determined that in 5 out of 16 open medical records reviewed, the hospital failed to obtain the patient's consent for treatment for patients #5, #14, #15, #18, and #20. The consent forms were blank or incomplete. These forms include payment guarantee, consent for treatment, patient rights, responsibility for valuables, and release of information payment of insurance benefits. The rights form has a space which reads: Patient is unable to sign because which is completed by the staff giving the form to the patient or family. The staff must date, time, and sign with clock number.

Patient #5 was admitted on [DATE] and the admission rights form was blank.
Patient #14 was admitted on [DATE] and her admission rights form was blank.
Patient #15 was admitted on [DATE] and her admission rights form was blank.
Patient #18 was admitted on [DATE], next to the blank patient unable to sign because was written "pt is disabled and can't breathe." There was no hospital representative, date, time, or clock number.
Patient #20 was admitted [DATE], next to the blank patient unable to sign because "of med condition." There was no hospital representative, date, time, or clock number.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on review of the hospital policy and interview with the Director of Patient Safety on 2/26/13, it was determined that the hospital policy does not meet the expected length of time for resolution of grievances.

A review of the hospital's grievance policy under the section entitled Timeliness of Reporting/Responding revealed "the individual filing the complaint will receive a response as soon as possible, but not to exceed thirty (30) days." The hospital on average is completing the complaint/grievance and responding to the complainant within 7 days but the policy does not have the regulatory language. The hospital must attempt to resolve all grievances as soon as possible. The regulation requires the resolution of grievances with an expected resolution and written response within 7 days. If a grievance cannot be resolved within the 7 day time frame, the hospital will inform the patient or the patient's representative that the hospital will follow-up with written response within a stated number of days in accordance with the hospital's grievance policy.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on review of the hospital policy on restraint and seclusion, the hospital's policy failed to address the timely acquisition of the order for restraint or seclusion prior to its application or in emergency application situations.

The policy review revealed each order of seclusion or restraint requires a medical order. In emergencies, a registered nurse may initiate the use of restraints or seclusion before an order is obtained. However, in all cases a written medical order must be obtained within one hour.

The regulation requires the physician order to be obtained prior to the application of restraint or seclusion. In recognition that a restraint or seclusion intervention may occur so quickly that an order cannot be obtained prior to the application of restraint or seclusion, the regulation states that in these emergency application situations, the order must be obtained either during the emergency application of restraint or seclusion, or immediately (within a few minutes) after the restraint or seclusion has been applied. The hospital policy has not met the regulatory requirements since it does not address the process for timely acquisition of restraint and seclusion in its restraint and seclusion policy and procedure.
VIOLATION: PATIENT VISITATION RIGHTS Tag No: A0216
Based on review of the guide to patients and their families and the hospital visiting policy, the hospital's policy does not clearly outline the patient's visitation rights including those setting forth any clinical necessary or reasonable restriction or limitation that the hospital may need to place on such rights and the reasons for the clinical restriction or limitation.

Review of the hospital policy revealed the presence of family and friends provides emotional and social support to the patient and is an essential component of the healing process and visitation is open 24 hours a day, seven days a week. The hospital has an open visitation policy. The policy identifies special considerations or restrictions/clinical reasons where visitation would not be permitted or limited. However, the policy fails to reflect that the patient is informed of his/her right to have or deny visitation by the persons of their choosing. The hospital obtains the name of the patient's contact person but fails to specify that the contact person can act in the capacity of the patient's support person.
VIOLATION: PATIENT VISITATION RIGHTS Tag No: A0217
Based on review of the hospital's visitation policy and guide for patient and their families under patient rights and responsibilities, it was revealed that the hospital's visitation policy and the guide for patients and their families does not state that the visitation privileges are allowed regardless of the visitor or patient race, color, national origin, religion, sex, gender identity, sexual orientation or disability.

Review of the visitation policy and visitation under the guide for patients and their families, revealed visitation is open 24 hours a day, seven days a week. The policy identifies special considerations or restrictions/clinical reasons where visitation would not be permitted or limited. However, the policy fails to specify that visitation will be allowed regardless of the visitor's race, color, national origin, religion, sex, gender identity, sexual orientation or disability and in accordance with the patient's expressed preferences. The hospital failed to provide patients and their support persons (as appropriate) with details concerning the rights of visitations.