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 Oct. 18, 2016
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on a tour of the adolescent unit and review of patient #8's record, it was revealed that during a seclusion event for patient #8, there was no working lighting in the seclusion room room. and that staff failed to document every 15 minute monitoring data for the hour-long seclusion of patient #8.


Tour of the adolescent unit on 10/18/2016 revealed a seclusion room with no working light. Additionally, looking through the small window built into the door further blocked the available light from the hallway, greatly diminishing observation of the room and the patient.


Patient #8 is an adolescent female, admitted in late September 2016 from a group home due to elopements, for demonstrated risk-taking behaviors and the use of substances.

On 10/17 shortly after 1000, patient #8 became combative with peers and staff was placed into seclusion at 1013. Review of video revealed no discernible effect on the darkness of the room as seen from the door by those charged with monitoring patient #8. Patient #8 was effectively in the dark during the seclusion. At 1029 staff opened the door to administer medication. Following administration, the seclusion door was closed until 1110, when staff opened the door and the seclusion ended. Patient #8 had an approximate total time in seclusion of one hour.

Review of the record revealed no 15-minute monitoring data indicating that staff monitored patient #8 while she was in seclusion. Video revealed that staff were at the door, though not consistently for the the hour patient #8 was in seclusion. However, documentation of monitoring is not found in the record by which to show patient #1's behaviors, any care given to her and to monitor her safety .

Based on this, staff could not safely and effectively monitor patient #8 while she was secluded, and violated patient #8's right to a safe treatment environment.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on a review of patient #8's record, it was determined that patient #8 was secluded and subsequently restrained without orders.

Patient #8 is an adolescent female, admitted in late September 2016 from a group home due to elopements, demonstrating risk-taking behaviors and the use of substances.

On 10/17, patient #8 became combative with peers and staff. Video revealed that she was taken via an escort restraint to the seclusion room. A physician order for this initial restraint was written at 1013. There was no seclusion order on the medical record. There was also no a restraint order when at 1029, the staff held patient #8's arms and legs to administer medication.

Based on this, patient #8 was kept in the seclusion room for an approximate hour, and restrained at 4 points without physicians orders.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
Based on a review of patient #8's record, it was revealed that although patient #8 was restrained and secluded at 1013, there was no face to face evaluation completed until 1823, approximately eight hours later.

Patient #8 was an adolescent female, admitted in late September 2016 from a group home due to elopements, demonstrating risk-taking behaviors and the use of substances.

On 10/17, patient #8 became combative with peers and staff. Video revealed that she was taken via an escort restraint to the seclusion room at 1013. There, she was restrained again to administer medication. There was no face to face documentation in the medical record related to the restraints and seclusion until 1823, which was performed by an RN. Additionally, the face to face failed to document the physical and mental status of patient #8, and the patient's current situation.
Based on this, the facility failed to conduct a face to face evaluation of the patient as required. in a timely manner and including the required content..
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on a review of video, it was determined that while the adolescent unit appeared to be staffed appropriately, staff failed to monitor patient #8 effectively, resulting in a possible sexual encounter with a male peer.

Patient #8 is an adolescent female, admitted in late September 2016 from a group home due to elopement and demonstrating risk-taking behaviors and the use of substances.

Review of the adolescent unit in which she was treated revealed a coed milieu. Male and female bedrooms were set up on opposite ends of a long hallway, with boundaries of centrally located public rooms, a nursing station, and strategically placed staff monitors.

On day 23 of admission, video at approximately 1510 (approximately change of shift) revealed most staff were in the nursing station during report. Staff who continued monitoring the unit, failed to see and stop patient #8 from running down the hallway into a boys bedroom at 1512 where she remained for the next 9 minutes. Patient #8 was finally found by staff with her pants down, and three male peers in the room. Patient #8 was uncooperative with questioning, but did reveal her intention to have sexual relations with one of the male peers in the room.

A physician was notified and patient #8 was taken to the emergency department but refused examination, and denied that anything occurred in the room. However, and based on the video, staff failed to effectively monitor patient #8 , which allowed her to place herself at unnecessary risk.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on a review of 4 closed records, it was revealed that no discharge summary had been completed for patient #7 who had been discharged more than one month prior.

On 10/18/2016, the second day of survey, it was revealed that the closed record of patient #7 had no discharge summary. Based on this, the discharge summary which had to be completed by 10/8, which was within 30 days of discharge, was 10 days late.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on a review of video revealing a undocumented seclusion event, it was revealed that the medical record did not accurately reflect the patient's course of treatment..

The seclusion of patient #8 was recorded on video. However, the only reference to a seclusion in the patient record refers to the use of "quiet room" which is not considered to be seclusion. Where physician orders or other documentation serve for data collection, the omission of orders and other documentation results in data inaccuracies. Additionally, such omissions indicate quality deficits, which would not be addressed as they would remain unknown. Therefore, staff who fail to document accurate information regarding patient interventions fail to accurately reflect the patient's course of treatment and hinder the facilities ability to monitor its quality processes .
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of patient #6's record, it was revealed that Patient #6 was precipitously discharged without an appreciable change in the aggressive behaviors for which he had been admitted .

Patient #6 was a young adult male who was admitted on an involuntary basis in early September 2016 due to assaulting people in a public place and assaulting the officer who arrested him. Patient #2 stated to the officer that he would kill him. Patient #6 had multiple previous admissions for violence towards strangers, and police.

In a nursing note on day one of admission at 2127, patient #6 was destructive of his room, was spitting at peers, and attempted to destroy the phone line. When staff attempted to stop him, he grabbed staff's leg, ending up inside the patient room. However, he was compliant with medication.


On day two of admission, patient #6 threatened to harm staff and peers. At one point around 1948, he began kicking and pushing staff when he was not able to leave. He required emergency medication and restraint to calm down.


On day three of admission, he improved in that he banged on the nursing window and screamed his demands, but no threats were documented.


On day four of admission, patient #6 made a threat to kill his roommate, and to kill everyone. He continued to bang on the window or wall, and would not take redirection.


On day five of admission, a nursing note of 1103 stated " Patient woke up and approached the staff demanding to be in the long hallway. Pt presented angry affect and agitated. Charge nurse and staff denied patient request due to aggressive behavior. Staff tries to turn on the TV for the patient who tried to grab the remote and try to punch the staff when not able to get his demand. Patient asked RN if he can go to the other side which was denied. RN explained the reason for not allowing him. Patient responded and said " shut the f... up whore you ' re being stupid right now you dumb b.... " Patient went to the dayroom, grabbed several cups of water, and threw it at hallway aiming the window and the door. Afterward, patient started peeking on the fire alarm key hole. Staff continue encouraging patient to stop his poor behavior. Patient came after the staff and punched the staff face. Code green was called. MD made aware of the situation and order Haldol 10mg ( an antipsychotic medication), Ativan 2mg ( an anti anxiety medication) , and Benadryl 50mg IM ( a sedating antihistamine medication) which the patient refused to take willingly. Patient barricaded self in the dayroom and started fighting the staffs. Patient was kicking, punching, and spitting toward staff. Patient was physically hold, IM med given, and pt. was placed in hospital gown. Patient escorted in the seclusion room as he continued fighting the staff. 1:1 provided as patient was in the seclusion room for 24 minutes. After providing breakfast, patient was released from seclusion room (0840). RN had 1:1 with the patient who was fixated in getting his belongings. RN asked what we can do to help him and avoid the entire incident. Patient state " give me my clothes " while laughing inappropriately. Patient continued pacing the hallway seeking nurses ' attention while laughing inappropriately.. "


A Case Management note of 1321 stated in part, " The interim unit manager, charge nurse, and two psychiatrists agreed that pt could be discharged today. This SW did express concerns about pt's inappropriate and aggressive behaviors on the unit to the team, but the team felt that pt was exhibiting these behaviors because he was hospitalized rather than due to any mental health symptom. Pt is presenting as alert and oriented by 3. Pt was able to calm down once he learned he was being discharged today. Pt is denying SI/HI (suicidal or homicidal ideations) and AH/VH ...SW (Social Worker) provided pt with resources on walk-in shelters in Washington, DC, including ... Men's Shelter. Pt is denying feelings of hopelessness, helplessness, and worthlessness. He is goal and future-oriented. He is medication compliant and received a long-acting injection of Haldol prior to d/c. Pt reports he will take his medications and comply with his outpatient appointments with Family Services. Pt will also follow-up with his (homeless outreach counselor). "


A nursing discharge note of 1301 stated, in part, "Patient denied SI and HI at the moment. RN reviewed discharged plan and medication which he verbalized understanding. Patient jokingly said "l'm going to (mall) and beat people up. I'm just kidding. No, I'm gonna look for a job hopefully they call me soon." Patient continue having poor insight and judgement. Patient laugh when making inappropriate comment. Patient got Haldol [DATE]mg prior to discharge which he willingly took. Patient signed all discharge paper and a copy was provided along with his prescription. Patient verbalized understanding of his medication and discharge plan. Patient checked all his belongings and sign it off. Patient claimed going to his grandmother's home. Bus token provided as transportation arrangement. "


Based on all documentation, patient #6 was discharged back to the community though he continued with the aggressive behaviors for which he had been admitted .