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 Oct. 6, 2017
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of medical records, hospital policies, procedures, and staff training records , interviews with staff and review of the video recordings from the morning of 10/02/17, it was determined that Condition of Patient Rights was not met. The findings determined that the facility failed to ensure the safety of a vulnerable patient and failed to internally report an incident as noted in the citation at A0145. As a result the survey team declared an immediate jeopardy requiring immediate corrective action on the part of the hospital.

On October 2, 2017 at approximately 0257, video recordings recorded on the Behavioral Health unit showed a security staff #1 physically assault patient #1. Patient #1 was forcefully pushed to the floor by security staff #1 . Review of the video recording revealed that the incident was witnessed by two other security officers. However, the survey team found no evidence that the two other security staff reported the incident to their supervisor or completed an incident report. The hospital had investigated and had suspended security staff #1 prior to this survey.

The nursing staff requested the presence of security on the unit due to Patient #1's agitation on 10/2/2017 at approximately 0257 . However, there was no documentation that nursing monitored or assessed the patient during or immediately after the security staff involvement with patent #1. There was also no evidence on the video recordings that nursing monitored the patient during the behavioral emergency.

Further, patient #1 reported this incident to the psychiatric CRNP claiming bullying and being beaten by security staff. However, the CRNP did not investigate further or report it to the unit management or the psychiatrist.

The nursing staff requested the presence of security on the unit due to patient #1's agitation on the morning of 10/2/2017 . However, there was no documentation of the nurses' assessment of patient #1's behavior during or after the security staff arrived on the BHU.

Lastly while the hospital has an internal reporting system for events, the hospital abuse policy does not address specific reporting or documentation procedures for staff to report abuse that occurred within the hospital by their staff.

As a result of these findings the staff of the Office of Health Care Quality findings were determined to be an immediate jeopardy. The hospital was provided a written notice that the immediate jeopardy existed at 1606 and provided a plan to abate the immediate jeopardy. Prior to leaving the hospital the survey team was able to verify that security staff #1 had been suspended, the other security staff would not be working with patients until further training occurred and that staff on the BHU were immediately being retrained. The immediate jeopardy was abated at 1800 on October 6, 2017.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of medical records, training documents and policies and procedures, review of video recordings from the hospital's security cameras and interview with staff it was determined that patient #1 was forcefully pushed to the floor by security staff #1 which constitutes abuse and staff who witnessed the event or who were made aware of the he incident failed to report the abuse or follow up on the allegations from the patient as evidenced by:


Per interviews with staff, it was determined that on October 2, 2017 at approximately 0300 , the night shift nursing staff requested the presence of security on the behavioral health unit (BHU) to assist with an agitated patient. Per patient #1's medical record, nursing stated on the facility "Close Observation/ Suicide Precaution Form " that the patient was in the activity room, awake banging at 0300 on 10/2/2017.


On October 6, 2017 the surveyors reviewed video footage from the BHU for this time period on 10/02/17. The surveyors observed that at 0257 three officers responded to the BHU and were noted to initially be waiting at the nurses' station. Patient #1 was observed standing in a doorway reading a book, then proceeded to walk down the hallway towards the security staff. Security staff #1 walked toward the patient, intercepted him, physically turned the patient and escorted him to his room. When security staff #1 and the patient got close to the room security staff #1 forcefully pushed patient #1 causing the patient to fall and slide across the floor. The patient rose and went into the room. Security staff #1 was seen on the recording following the patient into the room. The other two security staff had come down the hall and stood within the doorway. When the patient and security staff #1 were in the room, there was no video recording available for review. A few moments later all three security staff exit the room. However, security staff #1 was then observed briefly entering patient #1's room again. All three officers exited the BHU at 0308.

When the surveyors requested to review the incident report it was reported that the three officers present and nursing did not complete an incident report or report the incident up the chain of command.

A review of the patient #1's medical record found no evidence that nursing documented the incident or assessed the patient after the incident. The medical record did contain a note from the psychiatric nurse practitioner (CRNP) dated 10/3/2017 that stated "patient reported that he is being bullied and has been beaten by the security for reading the bible." There was no documentation to indicate that this allegation was referred to the psychiatrist, to the unit management or that the CRNP pursued patient #1's statement about being abused any further.

A review of the hospital policy on "Event Reporting"' (last revised on April 15, 2015) was performed by the surveyors. The policy references that event reporting can be done by any employee or physician who discovers, witnesses, or becomes aware of circumstances indicative of an event. There was no documentation or other evidence that the CRNP or security staff followed this procedure. There was no internal reporting of this incident prior to an OHCQ inquiry to the facility on [DATE], that led to the hospital's initial investigation and disclosure of the abuse to the Office of Health Care Quality. The hospital's policy "Abuse (child, adult, domestic violence)" (last revised on August 8, 2017), lacked specific instruction for reporting abuse or neglect that occurs within its facility nor did it reference the hospital's "Event Reporting" policy. The hospital abuse policy lacked specific instruction to staff on how staff are to report allegations of abuse committed by staff members and how those events are to be documented.

It was determined that a hospital security staff #1 forcefully pushed patient #1 to the floor on October 2, 2017, and that staff who were aware of the incident failed to report the incident up the chain of command or use the hospital internal reporting system. Additionally, the hospital policy specific to abuse, lacked specific instructions for reporting of abuse occurring internally at the hospital.

See tag A-286 QAPI
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0200
Based on record review and staff interviews, it was determined that the facility failed to provide training required for one of the three security staff who worked with patients in the behavioral health unit as evidenced by:

In July 2016, the hospital transitioned to the use of "Management of Aggressive Behavior (MOAB)" as its training model. The MOAB training was rolled out in three tiers, with the first tier including staff from 4 areas (the ED, BHU, 4C and Security). The hospital's quality tracking data revealed that as of July 2017, the security staff were the last tier one levels being trained with only 58% of security staff trained in MOAB.

Training documents were reviewed from the file of security staff #1 by the surveyor. Security staff #1 had previously worked at Northwest Hospital and returned to work at the hospital in April of 2017 . The records found in his file were all dated from his previous employment with Northwest Hospital between 2009-2014. There was no documentation of current training present in his file since being rehired by the hospital in April of 2017. During an interview with the Director of Security and the Security Manager on October 6, 2017 at 1400, it was revealed that training is done based on a rolling calendar and security staff would receive training as scheduled offerings became available.

There was no evidence to indicate that Officer #1 had been trained in the hospital's current behavior management and de-escalation techniques or MOAB.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on the review of training documents, interviews, policies and procedures it was determined that the facility lacked policies and procedures that address prevention, screening, identification, training, protecting, investigation, reporting and response to actual and potential abuse that occurred in the hospital.

The hospital's policy "Abuse (child, adult, domestic violence)" was last revised on August 8, 2017. However, it lacked specific instructions for abuse or neglect that occurred within the hospital. The current policy on abuse focused events that occurred outside of the hospital such as patients who presented with signs of possible abuse. Although the hospital has an internal reporting process that focuses on adverse events, the hospital abuse policy lacked specific instruction in how allegations of abuse involving staff and/ or occurring with the hospital are reported and documented. During an interview with the Director of Security and the Security Manager on October 6, 2017 at 1015, it was revealed that both officers that witnessed the incident assumed that the other had reported the incident. The hospital process designates that any person assigned to the area reports the incident, even if they are involved in the incident which did not occur for the incident of October 2, 2017 at approximately 0300.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on the review of medical records, observation of staff, review of the video footage and interviews with staff , it was determined that the facility failed to provide appropriate nursing supervision to a patient during a behavioral incident involving security involvement . During the incident nursing staff contacted security and requested their presence on the Behavioral Health Unit ( BHU) . However, no evidence presented that nursing remained with Patient #1 during the Patient #1's interaction with Security . Nor was there evidence of nursing documentation of the event or a nursing assessment after Patient #1 was pushed to the ground.


Based on the October 6, 2017 surveyor review of the video recording from October 2, 2017 at 0257 it was observed that security responded to the unit, met and initially appeared to be waiting at the nursing station. Security reported that the nurses were preparing medications to give to the patient. Patient #1 was observed during this time standing in the door way reading. Patient #1 then began walking towards the nurse's station. Security staff #1 was observed walking towards the patient, intercepted the patient, physically turned and escorted the patient back toward his room. When security staff #1 and patient #1 got close to the room, Security staff #1 forcefully pushed the patient causing the patient to fall and slide across the floor. The patient rose and went into the room . Security staff #1 followed the patient into the room. The bedrooms are not equipped with video monitoring equipment so there was no video recording to determine what interactions occurred in the room between patient #1 and security staff #1. The other two security staff were observed walking down the hall and stood within the doorway as patient #1 and security staff #1 were in the room. A brief time later the three officers exited the room. Security staff #1 was observed to briefly return to the patient's room a second time. The three security staff were observed leaving the unit at 0308. There were no observations of that nursing monitored or patient #1. No evidence was presented that that security and nursing spoke or debriefed after the incident.

A review of the medical records was performed by the surveyor on 10/6/2017 . The only documentation related to the incident by nursing was recorded on the facility "Close Observation/ Suicide Precaution Form " for patient #1 that stated the patient was in the activity room, awake banging at 0300. There was no documentation or other evidence that the nursing staff assessed the patient or gave any medications that were reportedly being prepared for patient. There was no post incident note related to the patient's behavior or to determine if he was injured.

Based on the lack of visual recordings or documented interactions, there is no evidence that the nursing staff monitored or evaluated patient #1's condition or provided care during or after the incident involving security the morning of October 2, 2017 at approximately 0300.