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.

SHEPPARD AND ENOCH PRATT HOSPITAL, THE 6501 NORTH CHARLES STREET BALTIMORE, MD 21204 April 15, 2011
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on review of medical records, interviews with staff and review of policies procedures and other pertinent documentation, it was determined that patients #1 & 2 were kept in restraint for three days over a weekend based on a multidisciplinary treatment plan order and were not released from restraint until review by the treatment team on the following Monday morning. The continued use of restraint without regard to documented patient behavior, does not meet federal regulations for the continued use of restraint and as a result violates the patients rights to be free of restraint at the earliest possible time and poses the risk of immediate jeopardy and the potential for harm to the patients.
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on an onsite survey involving review of policy and procedure, interviews and review of 3 patient records, it is revealed that for patients # 1 and #2, two separate and unique multidisciplinary teams and Administrative Staff superseded facility policy for restraint assessment and termination criterion as evidenced by:

Patient #1 is a [AGE]-year-old male admitted on a voluntary basis, with a chief complaint of homicidal ideation. Patient #1 presented with grandiose thinking, pressured speech, and was positive for cocaine and cannabis. Patient #1 was released from jail on 3/30/2011, with a legal history including burglary, trespassing, assault, malicious property destruction and several drug related charges. He stated that the jail attempted to medicate him with Thorazine, which he refused. Patient #1 denied suicidal ideation, but reported he goes into a blind rage when angry.

During the Psychiatric Admission, patient #1 was irritable, easily angered, and endorsed homicidal ideation towards someone he would not name. He stated he could "Go off on anyone who upsets me." Patient #1 received Axis I diagnoses of [DIAGNOSES REDACTED].

On 4/2/2011 at 5:09 pm, patient #1 began cursing at staff, refused to follow direction, and threatening to harm the physician, stating that it would take five people to get him down. Peers revealed that he had hidden some knives and forks to use as weapons. A search found a fork, a knife, and a spoon under his mattress. Patient #1 also stated that he knew how to get to the strings in the windows (between panes) to hang himself. Patient #1 was changed to 1:1 for suicidal ideation (SO), though did not tolerated the 1:1 and became aggressive with staff, biting a staff on the shoulder, which required the staff to go to the emergency department.

Patient #1 was placed in 4-point restraints at 7:30 pm due to aggressive, assaultive behaviors and threats to harm the MD, staff and peers. Patient #1 went on to threaten that when he gets out of restraints, "You all will be in big s__t, and refused vitals, food, fluids and hygiene."

At 11:59 pm, the patient's Multidisciplinary Treatment Plan was revised to state, in part, " In consideration of pt's (patient's) past and recent legal history, his current symptom presentation, his persisting verbal threats to harm the attending and staff and other patients, his recent assault on staff (4/2/11) and his continued threats to harm others including the attending if released from restraints, the following plan of care is specific to the restraint event of 4/2/11 and is to remain in effect until evaluation by the attending Monday 4/4/11: The pt. is in 4-point bed restraints. He is to remain in NO LESS than 4-point bed restraint until he is evaluated by his attending on Monday 4/4/11. All policy requirements related to restraint will be followed per said policy. "

As often as is ordered and is necessary, the pt is to receive PRN medications in addition to his regularly scheduled medication to aid in stabilizing mood and decreasing aggression and violence potential. This plan has been discussed with and approved by the Unit Manager ___, the covering Attending Dr. ___, and the Chief Nursing Officer ___. "

Patient #2 is a [AGE]-year-old male who admitted [DATE] following him telling his therapist that he was having suicidal and homicidal ideations. He refused to tell the therapist the intended victim, or plan because he did not want to be hospitalized . He was emergency petitioned, but left her office and was found by the police on the side of an interstate highway.

Patient #2 has charges of stalking his ex-fiance and breaking a protective order. He has also had homicidal ideation about the mother of one of his children. Patient #2 was currently on bond with court dates for two violations of an expiate, and one count of stalking. He was reportedly delusional and suspicious, and eloped from the emergency department. Diagnoses were: Mood Disorder Not otherwise Specified (NOS), and Psychotic Disorder NOS.

On 3/18 at 8:51 am, a nursing note states "Pt. was isolative this morning, not talking to anyone, refusing meds. Pt unprovoked, ran down the exit hallway, and started kicking open the doors until it broke and opened, and ran off the unit. Pt. ran all the way to Towson University, and resisted coming back, so security and Towson University police needed to handcuff him and bring him back to the unit. Pt. was aggressive when police caught him so manual restraint was needed to bring him back to the unit. Criteria explained to pt for ending event: Patient is oriented to environment, patient ceases verbal threats, Other: Pt. ceases aggression and physical destruction." At the time of restraint, patient #2 is noted as oriented to "Person, Place, Time and Situation." No documentation indicates that patient #2 was verbally threatening, or aggressive towards staff. Additionally, he was not attempting to destroy property on return. Patient #2 was placed in 4-point restraint on 3/18 at 9:30 PM.

A Multidisciplinary Treatment Plan was modified to state "This is a very dangerous patient as evidenced by his recent behavior in the emergency room and on the unit as well a his legal history and his strong desire to leave the hospital. He is not accepting any treatment, refusing medications or interaction with staff, He needs to be weaned out of restraints cautiously and slowly. Because of his level of aggression, he soul remain in four point restraints over the weekend to be assessed by his treatment team on Monday. He has made it clear that if he were not in restraints, he would break down the door to try to elope again. This has been discussed with the Service Chief Dr. __ and approved by the Medical Director Dr.___.

The facility failed to ensure that the medical staff as a group are accountable to the governing body for the quality of care provided to patients who are being restrained.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0176
Based on an onsite survey consisting of interviews, review of policy and procedure and employee files, it is determined that the facility does not have documentation that the physicians have a working knowledge of hospital policy regarding the use of restraint or seclusion as evidenced by:

Hospital policy " Restraint (Inpatient and Partial hospitalization ) Directive No. 175, " under "Physician Training Requirements" states "Any physician authorized to order restraint must have a working knowledge of the restraint policy." A similar statement is found in the seclusion policy.

On interview with Administrative staff, it is revealed that physician employee files contain no confirmation that each physician has a working knowledge of the facility policies for restraint/seclusion. The hospital lacked documentation that the physicians have a working knowledge of facility restraint/seclusion policy.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on an onsite survey involving review of policy and procedure, interviews, educational materials, and review of 2 ( patient #2 and Patient #3) of 3 patient records, the face-to-face assessments performed by nursing did not meet regulatory standards to evaluate
1. The patient's immediate situation;
2. The patient's reaction to the intervention;
3. The patient's medical and behavioral condition; and
4. The need to continue or terminate the restraint or seclusion.

as evidenced by:

Interview with administrative staff reveals that Managerial nurses have been trained beginning 3/1/2011 to perform the face-to-face for patients in restraint and seclusion. Review of staff face-to-face education program revealed that the training appeared to be appropriate. However, as noted in the care of patient #1 and #2, the face to face was lacking.

Patient #1 is a [AGE]-year-old male admitted on a voluntary basis, with a chief complaint of homicidal ideation. Patient #1 presented with grandiose thinking, pressured speech, and was positive for cocaine and cannabis. Patient #1 was released from jail on 3/30/2011, with a legal history including burglary, trespassing, assault, malicious property destruction and several drug related charges. He stated that the jail attempted to medicate him with Thorazine, which he refused. Patient #1 denied suicidal ideation, but reported he goes into a blind rage when angry.

During the Psychiatric Admission, patient #1 was irritable, easily angered, and endorsed homicidal ideation towards someone he would not name. He stated he could "Go off on anyone who upsets me." Patient #1 received Axis I diagnoses of [DIAGNOSES REDACTED].

On 4/2/2011 at 5:09 pm, patient #1 began cursing at staff, refused to follow direction, and threatening to harm the physician, stating that it would take five people to get him down. Peers revealed that he had hidden some knives and forks to use as weapons. A search found a fork, a knife, and a spoon under his mattress. Patient #1 also stated that he knew how to get to the strings in the windows (between panes) to hang himself. Patient #1 was changed to 1:1 for suicidal ideation (SO), although he did not tolerate the 1:1 and became aggressive with staff, biting a staff on the shoulder, which required the staff to go to the emergency department.

Patient #1 was placed in 4-point restraints at 7:30 pm on 4/2/2011 due to aggressive, assaultive behaviors and threats to harm the MD, staff and peers. Patient #1 went on to threaten that when he gets out of restraints, "You all will be in big s__t, and refused vitals, food, fluids and hygiene."

On 4/3 at 1:18 am and 1:30, patient #1 is noted to be asleep. At some time between these times, staff woke patient #1 to perform range of motion (ROM) from which he became angry and cursing for staff to leave him alone.

On 4/3 at 3:30 am, patient #1 continued "Asleep." A nursing one-hour assessment stated criteria for release from restraint as: "Patient is oriented to environment." Nursing noted under the 3:30 am orientation assessment that he was oriented to: "Person, Place, Time and Situation." Orientation to the environment is not a criterion for restraint.

The same 3:30 am assessment documented his ability to follow directions as "Good," his behavior as "Cooperative, hostile," his thought process content as "Logical Organized Concrete," and his affect as "Sad, Angry, Blunted, Anxious, Depressed." None of the nursing assessments addressed homicidal ideation or finds cause for continued restraint, though patient #1 was maintained in restraint.

On 4/3 at 4:21 am, a nursing face-to-face, nearly one hour following the 3:30 am nursing assessment, states in part, "Patient Reaction to Intervention: Pt noted to be snoring at this time. Per report from nurse (referring to the 1:18 am assessment), patient was yelling and screaming demanding for the staff to leave him alone." This face-to-face refers to staff awakening patient #1 to perform ROM.

On 4/3 at 8:02 pm, a face-to-face found patient #1 " ...Currently calm and cooperative but per history has presented as violent and uncooperative in the past." The need to continue 4-point restraint was stated as "Due to patients unpredictability he will remain in 4 point restraints until evaluation by treatment team tomorrow per MTP." Restraint and seclusion cannot be based on history alone, or on "unpredictability." Additionally, a face-to-face is to assess the need for continued restraint/seclusion in real-time.

The face-to-face continues "Per MTP (Multidisciplinary Treatment Plan) patient is to remain in restraint." This same face-to-face is not current with patient behaviors, as it refers the reader to the nursing assessment one hour prior for patient #1's Immediate Behavior/Psychological Condition.

Though patient #1 had made an actual threat on or about 1:28 pm, name-calling and gestures are not criterion for continued restraint. While it would be helpful, patients have neither to state the reason for restraint, state their behavior after release, nor be oriented to their environment in order to be released from restraint. The only criterion is that the patient no longer exhibits behaviors that present an immediate danger to self or other. Additionally, while patient #1 made a threat on or about 4/3 at 1:28 pm, he had made no documented threats since 4/3 at 1:18 am, almost 12 hours earlier.

A nursing face-to-face of 4/4 at 4:06 am while patient #1 was asleep noted "Patient will remain in 4 point restraint per MTP plan. Will be assessed by treatment team to determine if this intervention is to be discontinued.

These face to face evaluations do not meet the requirements of this regulation.

Patient #2 is a [AGE]-year-old male who admitted [DATE] after he told his therapist that he was having suicidal and homicidal ideations. He refused to tell the therapist the intended victim, or plan because he did not want to be hospitalized . He was emergency petitioned, but left her office and was found by the police on the side of an interstate highway.

Patient #2 has charges of stalking his ex-fiance and breaking a protective order. He has also had homicidal ideation about the mother of one of his children. Patient #2 was currently on bond with court dates for two violations of an exparte, and one count of stalking. He was reportedly delusional and suspicious, and eloped from the emergency department. Diagnoses were Mood Disorder Not otherwise Specified (NOS), and Psychotic Disorder NOS.

On 3/18 at 8:51 am, a nursing note states "Pt. was isolative this morning, not talking to anyone, refusing meds. Pt unprovoked, ran down the exit hallway, and started kicking open the doors until it broke and opened, and ran off the unit. Pt. ran all the way to Towson University, and resisted coming back, so security and Towson University police needed to handcuff him and bring him back to the unit. Pt. was aggressive when police caught him so manual restraint was needed to bring him back to the unit. Criteria explained to pt for ending event: Patient is oriented to environment, patient ceases verbal threats, Other: Pt. ceases aggression and physical destruction." At the time of restraint, patient #2 is noted as oriented to "Person, Place, Time and Situation." No documentation indicates that patient #2 was verbally threatening, or aggressive towards staff. Additionally, he was not attempting to destroy property on return. Patient #2 was placed in 4-point restraint on 3/18 at 9:30 PM.

Face-to-face evaluations of 3/19 at 9:02 am, 3/19 at 5:49, 3/20 at 1:17 am, 3/20 at 9:57 am, and 3/20 at 1:17 am for the Patients' Immediate Behavior/Psychological Condition, refers the reader to "Please see nurse's initial assessment of behavior that led pt. into restraints" rather than evaluating the patient's current medical and psychiatric condition and the need for continued restraint.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0202
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of policy and procedure, interviews, staff education and 3 patient records, non-clinical staff monitoring patient #1 of 3 patients records reviewed, did not have the skills to identify a medical emergency as evidenced by:

A review of policies and procedures revealed that separate Restraint and Seclusion policies, Directives No. 175 and 178 respectively, address Staff Training and Competency by stating in part:

"A. All direct care staff will receive ongoing supervision and demonstrate an understanding in the use of preventive interventions and the proper and safe use of restraint. Training and assessment of competence will occur at orientation, before participating in the use of restraint and annually.

B. The components of training and demonstrated competence are:

6. recognizing signs of physiological/medical distress in patients who are being held or restrained, response to signs of physical and psychological distress and when to contact a physician to evaluate/treat the patient ' s medical status."

Interview with a facility Safety Officer determined that the facility does not train monitoring staff to recognize restrained/secluded patients in distress. Interview with an Educator determined that staff receives a week of general orientation, and 6 weeks of preceptor led orientation on a unit, with an annual review. The educator states that staff receive training for emergency medical conditions, i.e., difficulty breathing. Further, restraint/seclusion monitoring staff are trained to contact a nurse when a patient states their distress. However, distress is not defined, for example, [DIAGNOSES REDACTED], or the ramifications of such a condition which could lead to the loss of airway.. Additionally, employee files reveal umbrella titles for competencies, and do not define the actual competencies employees receive under those umbrella titles.

Patients were noted to be restrained in their own rooms, in their own bed, with a non-clinical 1:1 Mental Health Worker (MHW) who monitors the patient continuously. Interview with a Unit Manager reveals that the 1:1 monitoring MHW does not generally document, "Though they can" per administrative staff. A MHW that performs the 15-minute rounds makes documentation of the behaviors and verbalizations of the restrained patient, for every 15-minute time block. It was further revealed that there is no standard for conveying the behaviors and verbalizations of the patient within a 15-minute period from the 1:1 MHW to the rounding MHW to assure safety and accuracy. As previously stated, the 1:1 can yell for the nurse as needed.

Patient #1 is a [AGE]-year-old male admitted on a voluntary basis, with a chief complaint of homicidal ideation. Patient #1 presented with grandiose thinking, pressured speech, and was positive for cocaine and cannabis. Patient #1 was released from jail on 3/30/2011, with a legal history including burglary, trespassing, assault, malicious property destruction and several drug related cha rges. He stated that the jail attempted to medicate him with Thorazine, which he refused. Patient #1 denied suicidal ideation, but reported he goes into a blind rage when angry.

During the Psychiatric Admission, patient #1 was irritable, easily angered, and endorsed homicidal ideation towards someone he would not name. He stated he could "Go off on anyone who upsets me." Patient #1 received Axis I diagnoses of [DIAGNOSES REDACTED].

On 4/2/2011 at 5:09 pm, patient #1 began cursing at staff, refused to follow direction, and threatening to harm the physician, stating that it would take five people to get him down. Peers revealed that he had hidden some knives and forks to use as weapons. A search found a fork, a knife, and a spoon under his mattress. Patient #1 also stated that he knew how to get to the strings in the windows (between panes) to hang himself. Patient #1 was changed to 1:1 for suicidal ideation (SO), though did not tolerated the 1:1 and became aggressive with staff, biting a staff on the shoulder, which required the staff to go to the emergency department.

Patient #1 was placed in 4-point restraints at 7:30 pm due to aggressive, assaultive behaviors and threats to harm the MD, staff and peers. Patient #1 received IM haldol during his restraining event.

On 4/4 at 4:04 am, patient #1 is noted as sleeping. At 6:19 am, a MHW note states, "Pt. was awake and cooperative with range of motion. C/O tongue swollen, receive Benadryl IM for EPS. The time line for patient #1's complaint of a swelling tongue in unclear. A nursing face-to-face of 6:46 am makes no statement of patient #1's [DIAGNOSES REDACTED], or his response following injection of Benadryl, nor does an hourly nursing assessment of 7:22 am address the dystonic reaction. Therefore, at some time between 4:04 am and 6:19 am, patient #1 complained of tongue swelling.

A statement by the staff member who was sitting with patient #1 states "Per your request I shall relay to the best of my knowledge the conversation the pt and I had while he was in restraints. As I was scheduled to one-on-one sit with the pt he became and remained vocal about his agitation with his status. Pt was verbally threatening towards staff. Pt. made threat of death and bodily harm while in restraints. After a while pt complained of swelling in tongue and asked me to inform change nurse. As per hospital policy, I am not allowed to leave pt side while in restraints so I relayed message to other staff as soon as I saw someone. Pt was then seen by charge."

The staff member did not identify the [DIAGNOSES REDACTED] as a medical emergency and "Yell" to the Charge Nurse or anyone else. Instead, the MHW prioritized policy over patient #1's complaint and "Waited" for another staff to come by, a time span, which is not determined.

A nursing assessment of 6:46 am makes no mention of the IM, timeline, or any assessment of patient #1 who was experiencing a [DIAGNOSES REDACTED]. Neither does a nursing assessment of 7:22 am, mention the [DIAGNOSES REDACTED]. No concurrent clinical staff assessment of patient #1's [DIAGNOSES REDACTED] is found.

At 9:04 am, nursing documents, "Patient awake, irritable, demanding. 'They just should've told me,' hostile toward staff lacks very little insight. Threatens to sue hospital for giving him haldol that has caused some EPS. Criteria explained to pt. for ending event: Patient ceases verbal threats."

A Psychiatric Progress Note states in part, "The patient was seen in his room. He was in four point restraints from over the weekend. The patient seems to have difficulties communicating, as he was having [DIAGNOSES REDACTED] of his tongue. We gave him an IM injection of benztropine first then Benadryl." Based on the psychiatrist's note, patient #1 received benztropine prior to the Benadryl reported by the MHW. Patient #1 received three interventions for the [DIAGNOSES REDACTED].

The facility failed to provide adequate education for staff to identify medical emergencies related to restraint and seclusion monitoring.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0206
Based on an onsite survey involving review of employee files and interviews with administrative staff, it was revealed that the facility does not educate inpatient staff on First Aid.

Employee files show that cardiopulmonary resuscitation is a facility-wide competency. However, Administrative staff state that First Aid is a staff competency for only those staff working in the residential and assisted living units. Non-clinical staff are trained to bring equipment to a medical emergency, and to call a nurse when they believe an emergency medical condition is occurring. However, employee files are vague as to the specific conditions employees are trained to recognize and no other "First Aid" response information other than to "Call a nurse is found." Much of the employee training is hands-on, and verbally conveyed, and the specifics of actual content of training is unclear.

The facility failed to teach First Aid to facility inpatient staff.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of policy, procedures and 3 patient records, it was revealed that patient's #2 and #3 had incomplete initial nursing assessments as evidenced by:

Patient #2 is a [AGE]-year-old male who admitted [DATE] after he told his therapist that he was having suicidal and homicidal ideations. He refused to tell the therapist the intended victim, or plan because he did not want to be hospitalized . He was emergency petitioned, but left her office and was found by the police on the side of an interstate highway.

Patient #2 has charges of stalking his ex-fiance and breaking a protective order. He has also had homicidal ideation about the mother of one of his children. Patient #2 was currently on bond with court dates for two violations of an exparte, and one count of stalking. He was reportedly delusional and suspicious, and eloped from the emergency department. Diagnoses were Mood Disorder Not otherwise Specified (NOS), and Psychotic Disorder NOS.

On 3/18 at 8:51 am, a nursing note states "Pt. was isolative this morning, not talking to anyone, refusing meds. Pt unprovoked, ran down the exit hallway, and started kicking open the doors until it broke and opened, and ran off the unit. Pt. ran all the way to Towson University, and resisted coming back, so security and Towson University police needed to handcuff him and bring him back to the unit. Pt. was aggressive when police caught him so manual restraint was needed to bring him back to the unit. Criteria explained to pt for ending event: Patient is oriented to environment, patient ceases verbal threats, Other: Pt. ceases aggression and physical destruction." At the time of restraint, patient #2 is noted as oriented to "Person, Place, Time and Situation." No documentation indicates that patient #2 was verbally threatening or aggressive towards staff. Additionally, he was not attempting to destroy property on return. Patient #2 was placed in 4-point restraint on 3/18 at 9:30 PM.

Review of patient #2's record reveals an "Admission Nursing Assessment," which was attempted while the patient was asleep. Nearly all parts of the assessment state "Unable to assess pt. - asleep." No evidence that an RN went back to attempt assessment again is found.

Patient #3 is a [AGE]-year-old male admitted [DATE] with a chief complaint of depression and aggression, with worsening manic behaviors over weeks, as reported by the inpatient facility where he was receiving treatment. Patient #3 had been sexually inappropriate, destroying property and had been hitting himself with blunt objects. Patient admitted to alcohol and cannabis use. Patient #3 received diagnoses of Bipolar Disorder NOS (Not Otherwise Specified), ADHD (Attention Deficit Hyperactivity Disorder), and Reading and Math Disorder.

Patient #3 arrived to the facility at sometime prior to 1:30 pm. Patient #3 was secluded from 7:55 pm until 9:33 pm due to active hallucinations, an inability to follow commands, and incontinence of urine and stool onto the floor, and smearing feces on the wall. At 9:33 pm, astute nurses notified physicians that patient #3 blood work revealed a toxic lithium level of 2.04. Patient #3 was sent to the emergency department. Patient #3 returned to the facility and continued with treatment and intermittent seclusions over the next 4 days.

Review of patient #3's record reveals an initial Nursing Admission Assessment of 3/3/3011 at 11:24 PM is authored by an LPN (Licensed Practical Nurse), and includes only:
1) Translation needs, 2) Code status, 3) Allergies, and 4) Immunization information. No other RN assessment appears in the record.

Based on the fact that the nursing care plan is based in nursing assessment, the hospital failed to develop a care plan based on nursing assessment information.
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of records and interviews with staff, it was determined that for two of three patients reviewed the hospital failed to protect the rights of the patients. The findings include:

Restraints were continued for two of three patients through several days until they could be evaluated by the the team despite the patients no longer being a danger to self or others as noted in A 0154.

There was no documented evidenced that the physicians were knowledgeable of the requirements for the use of seclusion and restraint as noted in A 0176.

The face to face evaluations conducted by the nurses for two of three patients reviewed did not meet the requirements of A 0179.

The staff monitoring one of three patients reviewed did not have the training to understand and recognize the patient's complaint as possible [DIAGNOSES REDACTED] as noted in A 202; and

The staff did not have required training in first aid as noted in A 0206.