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.


Based on a review of patient restraint records, the hospital failed to evaluate one of three patient reviewed (#4) for less restrictive measures as evidenced by:

Patient #4 is a [AGE]-year-old male who on 3/12/2012 was found by police to be punching trees and pushing over trash cans. On approach, patient #4 was observed to be responding to internal stimuli. When police stopped him, he began to fight with the police who brought him in to the ED. A taser was reportedly used, which had little effect on the patient. Additionally, police had also used pepper spray.

An ED nursing progress note at that time of the patient's arrival states " Pt was brought in by police, was found punching trees pt rambling not making sense, psych w/u (work-up) done, medications given."

On the clinical, pre-printed Glascow Coma Scale assessment, the RN checked findings in part, that patient #4 was "confused" and "follows commands." On the pre-printed Psychosocial Assessment, the RN checked "restless, anxious, agitated" and thoughts that were "Vague/Disconnected."

No documentation on the medical records was found indicating that patient #4 was violent on arrival or remained a danger to himself or to others. Additionally, a Physician ' s Restraint Order Form (PROF) reviewed had no rationale for restraint.

The " Restraint & Seclusion Plan of Care " (RSPOC) sheet which is the observation and flow sheet for restraint and seclusion, has a date of 3/12/2012 at 1800. The RSPOC is broken into multiple areas, the first being, "Alternatives considered," which is further broken into hourly segments. No alternatives of any kind are documented on the form. However the records indicate that patient #4 was placed in 4-point restraints at 6 pm. There is no documentation that the hospital evaluated or employed less restrictive measures for patient #4 prior to applying 4 point restraints.
Review of policy, and three patient restraint records revealed three of three patients where there was no face-to-face documentation after restraints were ordered as evidenced by:

While physicians or licensed independent practitioners are required to see each patient at the initiation of restraint/seclusion, per the reviewed hospital policy, physicians are not responsible for performing the one-hour face to face. Interview with the ED Director reveals that Nursing Management staff of the ED and Behavioral Health Unit are trained to perform the one-hour face-to-face evaluation.

The Restraint and Seclusion Policy (effective December 2011) also states "4. The manager/ nursing supervisor must see the patient within 1 hour of the initiation of physical hold, mechanical restraint or seclusion to complete a face-to-face assessment to evaluation the need for restraint or seclusion ...If the patient quickly recovers and is released before the nurse manager/nursing supervisor arrives to perform the assessment, that nurse manager/nursing supervisor must see the patient and complete the face-to-face."

Hospital training for nurses performing face-to-face evaluations is done via an article entitled "Clinical Practice Guideline 1-Hour Face-to-Face Assessment of a Patient in a Mechanical Restraint." While all the nurses selected for training appeared to receive the training, documentation of face-to-face evaluations for patients 4, 9, and 12 was not found.

A section of the Physician Restraint Order Form (PROF) entitled "LIP/RN Evaluator: Behavioral Health Face to Face Evaluation within one hour of application" reveals a pre-printed statement of "I have personally examined this patient and have determined his/her suitability for restraint application/seclusion and validate the order(s) above. While signed for patient #12, this area for patient #4 and #9 is not signed by an RN. Whether signed or not, this section of the PROF fails to meet regulatory directives for the four components of the face to face, which are :
(A) The patient's immediate situation;
(B) The patient's reaction to the intervention;
(C) The patient's medical and behavioral condition; and
(D) The need to continue or terminate the restraint or seclusion

Additionally, no provision was made for the face to face, which must occur when a patient remains in restraint for 8 hours per state regulations, as was the case for patient #9.

The hospital failed to provide face-to-face evaluations for patients #4, 9, and 12 per policy and regulation

Based on a review of 3 patient restraint records, it was revealed that in all three records (patients #4, 9, and 12) staff failed to document assessments and care activities per hospital policy and the Code of Maryland Regulations (COMAR).

CO[DATE].21.12.08 Clinical Interventions During Restraint states in part, that staff must:
"(3) Closely observe the patient at least every 15 minutes, and document each observation by the observer; "

The Hospital Policy stated in the " Care of Patient in Seclusion and/or Restraint " states in part:
"7. " ...A nurse will reassess the patient in seclusion or restraints at least every 15 minutes. The reassessment will be recorded on the Restraint/Seclusion Checklist. The reassessment will include:
-Signs on injury associated with the application of restraint or seclusion
-Circulation and range of motion in extremities
-Hygiene and elimination
- Physical and psychological status and comfortable body temperature, the patient ' s dignity, mental status and emotional well-being
- Readiness for discontinuation of physical hold, restraint or seclusion."

The "Restraint & Seclusion Plan of Care" (RSPOC) sheet is used to document ongoing restraint/seclusion (R/S) assessments and care activities. The RSPOC has multiple category areas, which correspond to the COMAR. The second category is entitled "Restraint Monitoring, which includes in part, every 15-minute observations. The 15-minute monitoring is found to be alternately documented by staff as "A" for awake and "S" for sleep, as a check mark, or initials signed in each block.

Other than "A" and "S" indicating the consciousness level of , there was documentation of 15-minute mental status data for patients #4, 9 and 12, nor did any staff address the patient's readiness for discontinuation. There was no provision on the form to document actual patient behaviors during 15-minute observations.

The COMAR continues:
"(4) Unless contraindicated by circumstances as assessed and documented by a physician or registered nurse, at least hourly, make and document personal contact with the patient for the purpose of:
(a) Determining if the patient has any special needs which need attention;
(b) Checking circulation of the extremities restrained;
(c) Adjusting the restraint; and
(d) Realigning the body or massaging the extremities restrained, or both;"

The RSPOC for patient #4 who was in restraints from 6 pm through 11:30 pm, and patient #12 who was in restraints from 5:40 pm until 9 pm, document no evaluation of special needs, circulation and skin assessment, restraint adjustment, or hourly realignment of the body.

The COMAR continues in part:
"(5) Unless contraindicated by circumstances as assessed and documented by a physician or registered nurse, offer or provide the following:
(a) Full range of motion, every 2 hours;
(b) Toilet facilities, at least every 2 hours;
(d) Meals, at the regularly scheduled hours and under the supervision of nursing personnel;"

The RSPOC for patient #4 and shows no range of motion, no toileting, and no meals. Patient #4 came into the hospital around 6 pm, but was not offered a meal, and received no food until the following morning. Likewise, though patient #12 is documented as sleeping much of the time he was in restraint, no RN documentation acknowledges the aforementioned requirements for either patient.

The COMAR continues:
"C. At least once every 2 hours, a physician or registered nurse shall assess the appropriateness of continuing the restraint and document the factors supporting the assessment in the patient's medical record."

The Hospital Policy makes no provision for 2-hour RN assessments, though at the head of four RSPOC sections, the form states the patient is "Evaluated Every 2 Hours." Additionally, the form has an area that states "Clinical justification and Identified Patient Activity Causing Unsafe condition or Interfering with Medical Treatment/Assessment for continued Need." This is further divided into Clinical Restraint (non-violent) and Behavioral restraint (violent).
The RN may use a check with her initials in hourly-timed boxes next to the selected justification for continuation of restraint, i.e. "Unable to follow safety directions" or "Marked agitation or combativeness which involves physically aggressive threatening behavior toward another individual. Violent and destructive." Again, the RSPOC form makes no provision for the documentation of actual patient behaviors to justify the continuation of restraint. Additionally, and as shown, RN progress note documentation for the RN 2-hour assessment time frames failed to include the focus, content or decision-making required.

The RSPOC, for patient #4 reveals no two-hour RN restraint assessments. Additionally, a nursing note of 3/12/2012 at 8:13 pm, the approximate time for reassessment, states only "CT head completed. Awaiting results." A nursing note of 10 pm states "resting with eyes closed. Easily arousable. Will continue to monitor." A phone interview with patient #4's nurse at that time reveals her statement that patient #4 came out of restraint around 8:30 or 9 pm. No documentation of any kind is found to support that patient #4 came out of restraint prior to 11:30 pm. Therefore patient #4 should have received an RN assessment at 8 and 10 pm respectively.

The RSPOC for patient #12 reveals no two-hour RN restraint assessment which should have been performed at 7:25 pm. A nursing progress note of 7:45 pm states, Pt remains sedated/unresponsive with 4 pt (point) restraints and direct line of sight in progress. " A second RN progress note of 7:45 pm reveals the RN giving report to the oncoming RN who removed patient #12 from restraint at 9 pm.

Both patient #4 and 12 received no 2-hour RN assessment that directly addressed whether restraint should be continued, and if so, the rationale for continuing restraint.

The hospital failed to implement restraint as determined by hospital policy in accordance with the Code of Maryland Regulations.