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.

ADVENTIST HEALTHCARE BEHAVIORAL HEALTH & WELLNESS 14901 BROSCHART ROAD ROCKVILLE, MD 20850 Nov. 19, 2015
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on a review of the hospital's policy for Grievance Procedure and review of 4 grievance files it was determined that the hospital failed to send resolution letters to 2 complainants.

The hospital Grievance Procedure: Resolution of Conflicts, Dilemmas in Care, or Treatment Decisions (reviewed/revised in 3/2013) policy states in part, "All formal grievances will receive a letter of response ..."

Grievance #1 was opened on 2/2/2015 and was closed on 2/3/2015. Grievance #3 was opened on 9/6/2015 and was closed on 9/9/2015. While there was phone contact with both complainants regarding investigative outcomes, the hospital failed to document those outcomes in a resolution letter to the complainants. Therefore the hospital failed to comply with regulatory requirements.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of hospital policy and a medical record it was determined that hospital staff failed to perform an admission assessment and failed to document as to why the assessment was not completed.

The hospital "Admission Process and Documentation Requirements" policy (effective July 1, 2015) states in part, "Completion of the Admission Database: initiated within the shift and completed within 24 hours of admission."

Patient #4 was an adult male involuntarily admitted on [DATE] following threats to go to the police station to get his confiscated guns. In a nursing progress note of 9/10/2015 the RN wrote in part, "Patient was admitted on the (unit) on September 8, 2015 via stretcher accompanied by a nurse and two security officers. His assessment was not done because patient was verbally aggressive and refused to talk." A review of the patient's admission record revealed no progress note or other descriptive documentation related to patient #4 being "verbally aggressive." Though patient #4 was described as refusing to talk, nursing did not require that he answer questions about himself in order to make an initial assessment of his behavioral status. Based on this information nursing failed to document in a timely manner patient #4's behavioral status and the content of "verbally aggressive" statements upon admission to the inpatient level of care
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on review of Patient Safety and Quality reports, staff interviews and medical record reviews it was determined that the hospital failed to analyze and track all reported patient safety events.
An online system is used by the hospital staff to report patient safety concerns and adverse events. On 11/19/2015 three events were randomly selected for review. One of three events that had occurred had no documentation of the outcome of the investigation after the incident was reported.
Event #1 involved a patient who had become violent and a safety risk to himself and to others. A "Code Green" was called. An order for an intramuscular injection was given and administered. After the injection a nurse who had been assisting was handed the uncapped needle. She was stuck with the used needle. The patient was then escorted to seclusion.
During an interview the manager from the affected unit and the quality staff stated that when a "Code Green" is called the incident is reported but it is not required that a review of all "Code Greens" be completed. The unit manager also stated that he was aware of the event and that he did review the incident details. The manger and quality staff were not able to report how many staff arrived to assist the nurse when the "Code Green" was called, nor was the manager able to produce any documentation of the review of the incident or counseling and education provided to the staff after the review.
Failure of quality staff and management staff to document how the incident was analyzed with the results of that review leads to the potential of the same safety risk occurring to other patients and staff by failing to implement preventative actions throughout the hospital.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on review of 7 nursing department employee files and review of policies and procedures it was determined that the hospital failed to ensure and document that all new nurses and psychiatric technicians hired receive the necessary unit specific education and training/preceptorship prior to working independently on their designated units.

According to the Employee Orientation Policy (number 2.59 last reviewed 6/2010) the assessment and documentation of new staff competencies are tailored based on competency assessment and job responsibilities. The policy states "assessment and documentation should be updated at the conclusion of the 90/120 day introductory period and annually thereafter." As of 11/19/2015, staff #2 (hired in 10/2014) and staff #4 (hired in 11/2014) had no orientation competency/validation skill documentation and had no documented evaluation of performance.

Failure of the hospital leadership to ensure that the necessary education and preceptorship is completed, validated and documented on all new nursing staff placed patients and staff at risk for potential harm.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on a review of hospital policy related to dating insulin bottles upon opening, and observation of unit #1's medication room refrigerator on 11/18/2015, it was revealed that an open and undated multi-dose bottle of insulin was kept in the refrigerator.

Hospital policy "Diabetic Care Management" (Revised 2/2013) states in part, "B. Insulin must be refrigerated and dated and be discarded after 28 days." Observation of unit #1's medication room revealed a refrigerated multi-dose bottle of Levimir insulin 100 Units. The bottle had been opened and insulin had been taken from the bottle, evidenced by a missing closure cap, and an insulin level in the bottle, approximately to full. An interview with the RN at approximately 10:30 AM revealed that the patient to whom the insulin was administered had been discharged .

The staff did not follow the policy regarding the dating of the bottle in order to determine an expiration date. Further, staff kept the insulin bottle in the refrigerator though the expiration date was unknown. Further administration of this insulin would have been unsafe. Therefore, the nursing staff failed to maintain safety for the administration of this medication.