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.

LAUREL REGIONAL MEDICAL CENTER 7300 VAN DUSEN ROAD LAUREL, MD 20707 Feb. 26, 2016
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on review of 2 restraint/seclusion records, and review of quality data, it is revealed that 1) the hospital failed to keep an emergency department restraint/seclusion log by which to conduct retrospective quality reviews; 2) the hospital failed to tract restraint and seclusion events to determine numbers of events, the quality of events, and compliance with restraint/seclusion regulations.

During review of the emergency department (ED), it was revealed that the ED keeps no restraint/seclusion logs by which to conduct retrospective quality reviews. Interview with the Risk Manager on 2/25 at approximately 1130, revealed that no restraint/seclusion tracking is conducted by the hospital. Therefore, the hospital is unable to state the numbers of, the quality of and the level of compliance with regulation related to the use of restraint and seclusions.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on the results of this survey, it was determined that there were systemic patient rights noncompliance regarding hospital restraint and seclusion processes resulting in the Condition of Patient Rights being out of compliance as evidenced by:

1) Interview with staff, determined that patient #1 was kept in seclusion though smeared in feces and urine, and that while in this condition, she was given a food tray; 2) that nursing secluded patient #1 for 6 hours without physician oversight, and without physician orders for seclusion; 3) for patients #1 and #2 who were restrained, the hospital failed to release patient #1 and #2 at the earliest possible time; 4) patient #1's physical condition was not assessed prior to her transfer; and 5) safe seclusion implementation was not practiced for patient #1. See the details under tags, A-0144, A-0168, A-0174, A-0175, and A-0194.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of 10 patient records, and interview with staff, it was determined that patient #1 was kept in seclusion while being smeared in feces and urine, and that while in this condition, she was given a food tray.

Patient #1 is a middle-aged female who presented to the emergency department (ED) on emergency petition in late January 2016 at 1036. Patient #1 was transported to the ED via police and emergency medical services (EMS) following an overdose, jumping from a moving car, and an expression of homicidal and suicidal ideation. Patient #1 ' s family was able to inform ED staff that patient #1 uses heroin daily, and gave a history of congestive heart disease, coronary artery disease, chronic obstructive pulmonary disease, and peripheral vascular disease. Patient #1 was certified as involuntary and an involuntary placement was sought.

Charge nurse documentation at 1101 on day two in the ED reveals in part, " Pt requested to use bathroom, accompanied pt to bathroom ...this writer advised pt to return to room. Pt refused. Pt began swinging her arms attempting to hit staff members. Pt placed in room with door closed. Pt began throwing objects in room. All objects removed from room. Hospital mattress left in room with linens. Order for medication rcvd, medication admin as ordered. "

According to interview on 2/25/2016 at 0839 with the RN assigned to patient #1, shortly after the door was closed, patient #1 began to defecate which she did at least twice within 6 hours, and urinate, which she did more than once as well. Patient #1 then smeared her body and the walls of the room with feces and urine. The RN stated that staff went into the room and removed all except the mattress and linens, and had environmental services attempt to clean the room as well. Staff offered patient #1 wash clothes in the seclusion room, and patient #1 would only clean her face and arms, but refused all other cleansing. No attempts to shower patient #1 were made.

While no record documentation reveals the episodes of fecal and urine smearing, it does reveal that patient #1 was given a meal at 1631. This means that while patient #1 was still smeared in feces and urine, she was given a meal to eat while in this condition. Additionally, patient #1 was transferred to the accepting hospital in this fecal-smeared condition.

Based on this information, the hospital failed to render care to patient #1 in a safe environment.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on review of 10 patient records and observations of the patient care , it is revealed that nursing secluded patient #1 for 6 hours without physician oversight, and without physician orders for seclusion.

Patient #1 is a middle-aged female who presented to the emergency department (ED) on emergency petition in late January 2016 at 1036. Patient #1 was transported to the ED via police and emergency medical services (EMS) following an overdose, jumping from a moving car, and an expression of homicidal and suicidal ideation. Patient #1 ' s family was able to inform ED staff that patient #1 uses heroin daily, and gave a history of congestive heart disease, coronary artery disease, chronic obstructive pulmonary disease, and peripheral vascular disease. Patient #1 was certified as involuntary and an involuntary behavioral health placement was sought.


Charge nurse documented at 1101 on day two in the ED stated in part, " Pt requested to use bathroom, accompanied pt to bathroom ...this writer advised pt to return to room. Pt refused. Pt began swinging her arms attempting to hit staff members. Pt placed in room with door closed. Pt began throwing objects in room. All objects removed from room. Hospital mattress left in room with linens. Order for medication rcvd, medication admin as ordered. "

The psychiatric portion of the ED has room doors that when open, are patient rooms, but when closed, have automatic locks which become seclusion rooms.


Interview on 2/24/2016 at 1155 with the same RN Charge who wrote the note revealed her belief that the automatic door lock was broken, and that the door could have been opened by patient #1. Interview with the ED Director immediately revealed that the lock on the door was repaired in December 2015. The Director then demonstrated to the surveyor that the door, once closed, could not be opened by a patient inside. Based on this, and contrary to the RN Charge statements, patient #1 had been secluded behind a locked door.


There was no documentation indicating a physician had ordered seclusion which began on or about 1101 and ended at the time of the patient transfer at approximately 1711. The Charge nurse obtained an order for, and administered emergency medications to the patient. However there is no indication that the physician was aware that patient #1 had also been secluded. Therefore there was no physician oversight of the seclusion. Therefore, patient #1 was secluded for 6 hours without physician oversight and the required physician orders for seclusion.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
Based review of 10 patient records, it is revealed that, for patients #1 and #2 who were restrained, the hospital failed to release patient #1 and #2 at the earliest possible time.

Patient #1 is a middle-aged female who presented to the emergency department (ED) on emergency petition in late January 2016 at 1036. Patient #1 was transported to the ED via police and emergency medical services (EMS) following an overdose, jumping from a moving car, and an expression of homicidal and suicidal ideation. Patient #1 ' s family was able to inform ED staff that patient #1 uses heroin daily, and gave a history of congestive heart disease, coronary artery disease, chronic obstructive pulmonary disease, and peripheral vascular disease. Patient #1 was certified as involuntary and an involuntary placement was sought.


The nurse's progress note of 1221 documented in part, " Patient able to demonstrate control of behavior. Notes: Pt removed from 2 point restraints (left leg and right arm)." Based on this documentation, patient #1 had met criteria for removal from restraints, however, the restraints were not entirely removed until 1440.


Patient #2 is a middle-aged female who presented to the emergency department (ED) in late February 2016 via emergency medical services and police following threats to harm herself. Patient #1 had a history in part, of pseudo seizure and diabetes mellitus.


On the morning of day two of her ED stay, patient #1 attempted to elope, and began fighting staff. A physician order of 0900 was written for 4-point " tuff cuff " restraint for violent behaviors. Patient #2 had also received intramuscular medication to help her calm down.

The Behavioral Observation Flow Sheet on which 15-minute behavioral observations are documented, stated in part, that from the time of restraint at 0900 through the time of release at 1050, patient #2 was noted as " calm, lying/sitting. " Therefore, patient #2 had met criteria but was not released from restraint until almost two hours later.

Based on all documentation, the hospital failed to release patient #1 and #2 at the earliest possible time.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
Based on interview, review of documentation, and review of 10 patient records, it was determined that patient #1's physical condition was not assessed prior to her transfer as evidenced by:

Patient #1 is a middle-aged female who presented to the emergency department (ED) on emergency petition in late January 2016 at 1036. Patient #1 was transported to the ED via police and emergency medical services (EMS) following an overdose, jumping from a moving car, and expressing homicidal and suicidal ideations. Patient #1 ' s family was able to inform ED staff that patient #1 uses heroin daily, and gave a history of congestive heart disease, coronary artery disease, chronic obstructive pulmonary disease, and peripheral vascular disease. Patient #1 was certified as involuntary and an involuntary placement was sought.

The charge nurse documentation at 1101 on day two in the ED, stated in part, " Pt requested to use bathroom, accompanied pt to bathroom ...this writer advised pt to return to room. Pt refused. Pt began swinging her arms attempting to hit staff members. Pt placed in room with door closed. Pt began throwing objects in room. All objects removed from room. Hospital mattress left in room with linens. Order for medication rcvd, medication admin as ordered. "


The patient was placed in seclusion however, there was no documentation of a physician's order for the seclusion which began on or about 1101 and ended when the patient was transferred on or about 1711. The Charge Nurse obtained an order for, and administered emergency medications, though based on the record, there is no evidence that the physician was aware that patient #1 had also been secluded or that physician or LIP oversight of the seclusion was performed. Therefore, patient #1 was secluded for 6 hours without physician oversight and the physician orders for that seclusion.


According to an interview on 2/25/2016 at 0839 by the surveyor with the RN assigned to patient #1, the patient #1 began to defecate shortly after being placed in seclusion. This occurred at least twice within 6 hours as well as urinating. Patient #1 then smeared her body and the walls of the room with feces and urine. The RN stated that staff went into the room and removed all except the mattress and linens, and had environmental services attempt to clean the room as well. Staff offered patient #1 wash cloths while she was in the seclusion room. However, patient #1 would only clean her face and arms, but refused all other cleansing. No attempts to shower patient #1 were made.


At the time of transfer, on or about 1711 via ambulance, patient #1 remained in a feces and urine-smeared state. There was no documentation in the records for the six hour period while the patient was in seclusion indicating the patient had smeared herself with feces and urine. Record documentation alternately states " Pt. sitting down on mattress ...Pt calm ...Pt sleeping ...Pt lying down on the floor ... " Further, no statement related to patient #1 ' s feces and urine smeared condition or stability appears in the record concurrent to transfer. Based on documentation and interview, no physician or LIP oversight was obtained during the 6-hour period in which patient #1 was secluded.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0194
Based on a review of staff training documentation and 10 patient records, it was revealed that though staff are trained in the safe implementation of restraint and seclusion, safe seclusion implementation was not practiced for patient #1 as evidenced by:

Patient #1 is a middle-aged female who presented to the emergency department (ED) on emergency petition in late January 2016 at 1036. Patient #1 was transported to the ED via police and emergency medical services (EMS) following an overdose, jumping from a moving car, and expressing homicidal and suicidal ideations. Patient #1's family was able to inform ED staff that patient #1 uses heroin daily, and gave a history of congestive heart disease, coronary artery disease, chronic obstructive pulmonary disease, and peripheral vascular disease. Patient #1 was certified as involuntary and an involuntary placement was sought.

Charge nurse documentation at 1101 on day two in the ED reveals in part, " Pt requested to use bathroom, accompanied pt to bathroom ...this writer advised pt to return to room. Pt refused. Pt began swinging her arms attempting to hit staff members. Pt placed in room with door closed. Pt began throwing objects in room. All objects removed from room. Hospital mattress left in room with linens. Order for medication rcvd, medication admin as ordered. "

This seclusion was not implemented in a safe manner based on:
1. No seclusion order, face to face, or oversight by a physician or licensed independent practitioner;
2. No documentation by staff that patient #1 was in seclusion
3. No 15-minute monitoring by staff, and no documentation of patient #1 ' s actual condition;
4. No care given to patient #1 related to cleansing her body, toileting, and fluids;
5. No food given to patient #1 until 1631, and this food was given to a feces-smeared patient;
5. No hourly assessments by nursing related to the seclusion
6. No criteria given to the patient, and no way for the patient to come out of the room even when her behaviors were documented from 1227 to 1434 as " Pt states she is fine ...calm ...sitting on mattress ...sleeping. "

Based on all documentation, staff failed to implement the training received by the hospital.