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.

GREATER BALTIMORE MEDICAL CENTER 6701 NORTH CHARLES STREET BALTIMORE, MD 21204 June 20, 2013
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of 10 patient records, it is revealed that closed records of patients 1, 2, and 4 were missing face-to-face assessments for seclusion and restraint.

Patient #1 is a [AGE]-year-old male who presented to the hospital emergency department for increasing aggression towards self, and other. Patient #1 has a history of developmental disability with poor verbal skills.


Patient #1 was placed in seclusion on 5/14/13 at 1945. On 5/15 from 0400, patient #1 was restrained in a roll belt, and from 1200 patient #1 was placed again in seclusion. No face to face is noted in the record for any of these events.


Patient #2 is an 18-year-old, nonverbal developmentally disabled male who presented via his parents to the emergency department due to increasing mood swings with aggressive outbursts. Patient #2 was placed in seclusion on 5/9/2013 at 0929, on 5/10 at 0245, on 5/11 at 1025, on 5/13 at 0450, on 5/14 at 1135, and on 5/15 at 0720. No face to face assessments are noted in the record for each of the seclusion events.


Patient #4 is a [AGE]-year-old male who presented to the ED after having outbursts with attempts to harm himself at his detention center. On 6/6 at 0650, patient #4 became severely agitated and aggressive with nursing staff. He was placed in seclusion. Review of his record reveals no face-to-face by a physician.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on a review of the hospital Grievance Policy and 10 closed grievance files, the hospital failed to resolve grievances within an average 7 days time frame.

Hospital Policy " Patient Complaints and Grievances Policy " approved 6/29/2011, reveals in part, " Most grievances are resolved within seven days of receipt. If however, it takes more than seven days to complete the investigation, the Grievant is notified and an approximate date of resolution is explained to the Grievant. "

Review of actual grievance files reveals a robust, and thorough investigation process, with detailed resolution letters sent to the grievants. However, the hospital investigation and response to the complainant reveals an average of 13 days to resolution. A hospital administrator reveals that to achieve a thorough treatment of each grievance, it is often not possible to complete grievances on an average of 7 days, and maintain the quality of the investigation, though the hospital strives to do so. However, the hospital failed to make resolution within an average of 7 days as required by regulation.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on a review of 6 open, 4 closed records, and hospital seclusion policy, it is determined that nursing acted on the direction of patient #2's parent for the decision to seclude patient #2 of 10 patients reviewed.


Patient #2 is an 18-year-old, nonverbal developmentally disabled male who presented via his parents to the emergency department due to increasing mood swings with aggressive outbursts.


Patient #2 required periods of seclusion during his emergency department stay. However, on 5/11/13 at1052, a nursing note states in part, " Pt awoke and became upset and physically aggressive and unable to be redirected. Locked door seclusion initiated at the request of pt father. Pt mother now at bedside .... " While patient #2 may have required seclusion, the decision to seclude or not to seclude per regulation, must always be a clinical decision by trained, licensed staff.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
Based on a review of 6 open, 4 closed records, and hospital seclusion policy, it is determined that 1) for patients #2 and #4 who required seclusion for violent behaviors; hospital staff locked family/caregivers in seclusion with them creating a safety issue and 2) for patient #2) the mother and father who brought patient #2 to the ED due to increasingly assaultive behaviors towards them, were placed in the role of attempting to handle his violent outbursts while in the ED as well.


Patient #2 is an 18-year-old, nonverbal developmentally disabled male who presented via his parents to the emergency department due to increasing mood swings with aggressive outbursts.


Patient #2 required periods of restraint/seclusion during his emergency department stay. On 5/9/2013 at 0929, a nursing note states "client irritated, screaming, spitting and kicking, security physical holding client down." However, a physician note of 1442 reveals in part, "Pt is non-verbal, needed constant hands-on redirection by father while in (Crisis Unit)."


On 5/10 at 0245, per flow documentation, patient #2 was coming out of his exam room, "screaming and yelling" with behaviors that were "aggressive" and "dangerous to self" and "dangerous to other." Flow documentation reveals that staff, security and patient #2's mother participated in secluding him. Additionally, flow documentation reveals the number "24" documented from 0245 and every 15-minutes through the entirety of the seclusion episode until 0945, which corresponds to "Visitors in room." Presumably, patient #2's mother or father occupied seclusion with him. Persons who are non-clinical are not appropriate to occupy a seclusion room with patients who are deemed a danger to themselves and other.


On 5/11 from 1025 until 2115, patient #2 was again placed in seclusion due to physical aggression. A nursing note of 1052 states in part, " Locked door seclusion initiated at the request of father. Pt ' s mother now at bedside ... " and 1530 documentation states that " Pt. remains agitated and requiring constant physical redirection by mother. "


On 5/13, patient #2 was in seclusion starting at 0450. Nursing documentation at 0439 states in part, " Patient yelling and combative with staff and parents. Locked door release terminated, " and at 0449, " Door locked at mothers request. "


On 5/14 at 1135, a nursing note states in part, " Patient continues in LDS (locked door seclusion) d/t (due to) aggressive behavior and inability to redirect. Parents in room with patient and aware of LDS. Room opened @ any request of parents. Pt. toileted by father. "


At 1841, physician documentation states in part, " Mother says her son continues to cry out and bang on the door. Nurses had to keep door locked with mother inside " and " Pt tried to push himself out of the room when door was opened and pushed into this writer. He required his mother to restrain him. "


On 5/15 at 0720, a nursing note states in part, " Patient mother requesting locked door. Dr. __ aware and door locked. Patient continues to scream and pace. "


In summary, patient #2 ' s parents brought him to the ED to gain evaluation and help for patient #2 ' s increasingly aggressive and assaultive behaviors. During a protracted ED stay in which patient #2 required multiple seclusion events, clinical staff allowed his parents to continue physically managing his behavior, even unto locking patient #2 ' s parents alternately, and sometimes, at their request, into seclusion with him.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of 10 patient records, patient #1 was found to have no orders for seclusion or restraint during his emergency department stay.


Patient #1 is a [AGE]-year-old male who presented to the hospital emergency department for increasing aggression towards self, and other. Patient #1 has a history of developmental disability with poor verbal skills.


Patient #1 was placed in seclusion on 5/14/13 at 1945. On 5/15 from 0400, patient #1 was restrained in a roll belt, and from 1200 patient #1 was placed again in seclusion. No orders are noted in the record for any of these events.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0169
Based on a review of 6 open, 4 closed records, and hospital seclusion policy, it is determined that for patient #2, staff used a trial release, then restarted seclusion without a new physicians order to do so.


Patient #2 is an 18-year-old, nonverbal developmentally disabled male who presented via his parents to the emergency department due to increasing mood swings with aggressive outbursts. Patient #2 was placed in seclusion on 5/13 at 0450, on 5/14 at 1135, and on 5/15 at 0720. No face to face assessments are noted in the record for each of the seclusion events.


On 5/13, patient #2 was in seclusion, though flow documentation reveals #20 which indicates a trial release. Nursing documentation at 0439 states in part, " Patient yelling and combative with staff and parents. Locked door release terminated, " and at 0449, " Door locked at mothers request. " No order appears in the record for this seclusion until a renewal of 0719.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0202
Based on interviews, staff training and other documentation, it is revealed that the manual restraint training for hospital security staff lacks elements for recognition signs of physical and psychological distress.

A review of restraint training for hospital staff reveals that nursing staff on units other than the emergency department (ED) receive training in recognizing the signs of physical and psychological distress. However, security staff and ED nursing staff receive a relatively new type of training. On direct and repeated request to the hospital, no actual content of training was provided, though a letter was provided from the Chief Instructor of the training model stating in part, " The training encompasses legal issues and review of CMS and Joint Commission regulations, and specifically of those sentinel events that are relevant to their work environment, such as sentinel event 8 and discussion on identifying distress signs possibly exhibited by patients as results of restraint efforts."

Interview with three staff, inclusive of two security guards from the emergency department reveal one guard who when asked about identifying signs of distress in patients under manual restraint stated, that you " just grab a hand, and a leg and take them down. " A second security guard could state some signs of distress based on previous training he had, admitted ly based in another type of manual restraint training he had previously. Additionally, he stated that the current training did not include recognition of signs of distress. Another interviewed hospital staff member stated that the identification of signs of distress was not part of the training they received.

Therefore, based on the fact that the hospital could not produce the content of actual training for review of the manual restraint model used by security and ED nursing, and based on the candid responses of those interviewed, the facility fails to train security and ED nursing staff to recognize the signs of distress in restrained patients.