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 Feb. 8, 2017
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on an onsite survey inclusive of unit tour, review of patient records, and policies, it was revealed that staff failed to appropriately monitor patient #2 who was 1:1 for his safety.

Patient #2 was a late-adolescent male who admitted to the acute adolescent unit during the last week of January 2017 due to disorganized, bizarre, and paranoid behaviors. Due to patient #2's bizarre and sometimes aggressive behaviors, his psychiatrist ordered 1:1 monitoring during each day of his stay including 2/7/2016, the first day of survey. The orders read, "1:1 Constant observation (Within arm's length)."

During a unit tour on 2/7 at approximately 0940, it was revealed that a group was being conducted in a dayroom on the unit. A unit schedule revealed the group was School/Music from 9 am to 10 am. Further tour revealed an open clean utility room door where patient #2 was observed sitting on the floor just inside the door, reading a bible. No staff was initially noted until a psychiatric tech moved from the interior of the room to the doorway.

The surveyor inquired of the tech if patient #2 was on 1:1 and the staff answered "Yes." Entry to the clean utility revealed numerous small bottles of sundry items which the staff was organizing, current patients' stored personal items, and myriad other items throughout the room. The tech was noted to be standing 4-5 feet from patient #2 during the organizing of these items.

Hospital policy manual for "Levels of Observation" revealed in part, "One-to-One Continuous Observation Level includes:

- 1:1 staff accompaniment (at arm's length) is required at all times ...
- No access to sharps, belts, cords, laces, extra linens or other personal items which may increase risk ..." Multiple items in the room could have represented a risk to patient #2.

Based on observation and hospital policy, it was determined that the hospital failed to keep patient #2 who was on 1:1 safe when staff increased patient #2 risk by allowing access to a room which was not considered a safe area for patients on 1:1, and when staff failed to keep patient #2 at arm's length.
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
Based on an onsite survey inclusive of unit tour, review of patient records, and policies, it was revealed that, 1) on 2/7/2017 staff failed include patient #2 who was 1:1 in his morning groups per his interdisciplinary treatment plan (ITP), and then failed to accurately document his attendance and whereabouts, and; 2) staff failed to update patient #3's ITP during her admission.

Patient #2 was a late-adolescent male who admitted to the acute adolescent unit during the last week of January 2017 due to disorganized, bizarre, and paranoid behaviors. Due to patient #2's bizarre and sometimes aggressive behaviors, his psychiatrist ordered 1:1 monitoring for each day of his stay including 2/7/2016, the first day of survey. The orders read, "1:1 Constant observation (Within arm's length)."

Review of patient #2's record revealed, a psychiatry note of 2/5/2017 at 1204 stated in part, "2. Milieu therapy: I encourage milieu therapy." An RN note of 2/5 at 1416 revealed "Today pt. has been happy and smiling, and dancing on the unit in front of peers during group activities." This documentation revealed that patient #2 had demonstrated successful participation in milieu groups.

During a unit tour on 2/7 at approximately 0940, it was revealed that a group was being conducted in a dayroom on the unit. A unit schedule revealed the group was School/Music from 9 am to 10 am. Further tour revealed an open clean utility room door where patient #2 was observed sitting on the floor just inside the door, reading a bible. No staff was initially noted in the room until a psychiatric tech moved from the interior of the room to the doorway.

Hospital policy manual for "Levels of Observation" revealed in part, "One-to-One Continuous Observation Level includes:

- The patient may attend group therapies on the secure unit with assigned staff ...
Medical record documentation for this precaution level includes:
- Reflect patient location and observed behaviors every 15 minutes
- A progress note by nursing every shift."

Review of patient #2's Interdisciplinary Care Plan (ITP) (updated 2/6/2017) revealed in part, "Pt will participate and concentrate in 75% of therapeutic groups. No clinical documentation on 2/7 was found as to a rationale for patient #2 to be excluded from his from 9 am to 10 am morning group.


A tech note of 2/7 at 1927 by the same tech who conducted the 1:1 that morning revealed "Pt had a great day today. Pt attended all groups without prompting ate all meals and snacks today pt went to the gym with his 1-1 where he played basketball with his peers. Pt was very sociable with staff and peers today he completed his am and pm hygiene. Pt made no complaints nor reported any problems to staff." Based on surveyor observation, this note was inaccurate. Additionally, review of 15-minute documentation for patient #2 from 0920 through 0959 revealed that patient #2 was documented as being in the dayroom (group area) at the same time he was sitting in the clean utility room. Further, no group note related to patient #2's lack of attendance was found in his record.


Based on inaccurate and omitted documentation, and non-clinical decision-making as to patient #2's whereabouts and activities during group time, the treatment team would not be able to accurately determine patient #2's progress within the treatment milieu and and his ability to tolerate groups over time.


Patient #3 was an adolescent female admitted in mid-January due to auditory hallucinations. An Interdisciplinary Treatment Plan (ITP) established on 1/14/2017 revealed a problem of Fear/Anxiety and Altered Thought processing.


Review of Hospital Policy, "Interdisciplinary Treatment Plan" (reviewed 02/13) revealed in part, " ...the treatment plan is to be reviewed weekly (every seven (7) days) during acute hospitalization ..." Interview with the Risk Manager on 2/7 at approximately 1000 however, revealed the ITP was to be reviewed every 5 days. Patient #3's ITP review date was documented in the ITP with a Goal Target Date of 1/19/2017 which confirmed the Risk Manager statement of an every-5-day review.


Further review of patient #3's ITP on the day of survey of 2/7/2017 revealed that the ITP had not been updated after the initiation date of 1/14. That meant that the treatment team failed to update and document patient #3's progress in her treatment plan 4 times since admission.


Based on observation, hospital policy, patient #2's ITP, later tech documentation for patient #2, and review of patient #3's ITP it was determined that the hospital failed to allow patient #2 who was 1:1 to attend his group, failed to provide a clinical rationale to exclude patient #2 from his group, failed to accurately document patient #2's actual group attendance commensurate with his treatment plan, and failed to provide any update to patient #3's ITP.