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. 11, 2016
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on review of staffing levels and review of 12 patient records, it is revealed that nursing failed to effectively implement a physician I & O order for patient #4.


Patient #4 was an adult female who admitted to the hospital at the end of January 2016 following a weight loss of 15 lbs in 2 weeks due to paranoia. Patient #4 had a history in part of of myocardial infarction with stent placement, and hypertension. Patient #4 also had a history of dehydration.


A physician wrote an order on 2/2/2016 at 1353 for encourage fluids give 8 oz every 2 hrs (hours) while awake and note percentage drank. Review of nursing I & O documentation revealed only 30 ml for the rest of the day and evening. However, nursing progress note documentation of 2223 reveals that she "ate soup and pudding ...Pt drunk her ensure ...Pt also accept water 240 ml."


On 2/3, no Intake and Output documentation was found on the medical record. However, nursing documentation at 1453 stated in part, " Pt in take included water, two Ensure shakes and two apple juices. This was the only documentation for the 24 hour period. Based on this, nursing failed to gather physician ordered data necessary for the effective care of patient #4.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on review of policy and procedure, other documentation and review of 10 patient records, it is revealed that nursing failed to address patient #1's actual and potential risk of choking on the interdisciplinary care plan following a choking event.

Patient #1 was Spanish-speaking female in her eighties admitted involuntarily to the psychiatric hospital in December of 2015 due to threats to others in the community. Patient #1 had co-morbidities of hypertension and heart-block, and had a pacemaker. Interpreter services were obtained to communicate with patient #1. A History and Physical revealed in part, " No difficulty swallowing. "

Patient #1 ' s initial Interdisciplinary Master Treatment Plan dated 12/11 revealed Hypertension as a problem. An order for Dietary Consult was written on 12/11, " secondary to documenting patient is on special diet and/or has nutritional risk factors. " On 12/12, a " No salt added " element was added to patient #1 ' s diet. On 12/14, patient #1 was assessed by the Registered Dietician for poor oral intake.

On 12/15, patient #1 received an order for 1:1 staffing due to being unsteady while walking. On 12/16 at patient #1 met with her social worker and reported being full " Up to her throat. " The 1:1 order continued through 12/21/15, when patient #1 choked on her breakfast, specifically, bacon. Staff were able to perform a successful Heimlich maneuver. Based on this choking event, orders for a Speech Language Pathology (SLP) evaluation; Pureed Diet (Dysphagia Level 1); 3 days documentation of all po (by mouth) intake ...; a consult to a nurse practitioner due to choking; and another dietary consult were made.


On 12/21/15, patient #1 choked on her breakfast, specifically, bacon. A psychiatric technician was able to perform a successful Heimlich maneuver. At 1528, the psychiatric technician wrote in part, " (Patient) had a rough start. She ate breakfast and when she got to the potatoes and bacon she began choking. I laid her on her side and got the food out of her mouth. She began breathing again and eventually got her breathing back to normal. We took her vitals which were stable and she felt very tired. She rested most of the day with us waking her every so often to check on her. She was able to drink nearly a whole OJ. She is drinking ensure but is having swallowing difficulties. We gave her some water and that helped, but she likely needs to get a swallow test. She was calm and by 2 pm she was awake and talking ... "

There were no nursing progress notes or assessments in the record related to this event for patient #1 on 1/15. Additionally, and critical to care planning for patient #1, no change was made to patient #1's interdisciplinary care plan identifying her high risk of choking with interventions for that potential.


Consults for a Speech Language Pathologist, a Modified Barium Swallow, a Nurse Practitioner and Dietary evaluations were written. In addition patient #1, was who had been on 1:1 already for unsteady walking, was continued on 1:1 and placed on a puree diet.

Patient #1 remained on 1:1 until 1/8/16 at 1004, and remained on the Puree diet until 1/12/16 at 1416 when she was changed to a " Soft Diet (Dysphagia level 3). Per the physician, nursing was to monitor for coughing with meals. Following these changes to patient #1 ' s observation and diet, no changes to her care plan were made.

In fact, no changes had been made to patient #1 ' s care planning throughout her stay since the care plan review of 12/17/15. Nurses were responsible for identifying the actual and potential problems affecting patient #1's care. However, even after an actual choking event of 12/21 for which nursing made no record entry or assessment, and the potential of another choking event which did occurred on 1/15/16, nursing failed to address the risk of choking for patient #1 in her care plan.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on the deficiencies cited as result of this survey , it was determined that there was series of failures involving nursing, dietary and medical that resulted in Patient #1 choking on her lunch despite numerous interventions on the part of the hospital to address the patient's nutritional and swallowing problems. Therefore the Condition of Patient Rights was not met as evidenced by:

Patient #1 was a Spanish speaking female in her eighties admitted involuntarily to the psychiatric hospital on December 11, 2015. During her hospitalization the staff recognized her need for nutritional and swallowing interventions and worked proactively to obtain the necessary diagnostic tests and evaluations to address her needs including pursuing diagnostic tests that her insurance had denied. The patient had experienced a choking incident where the patient responded well to the Heimlich maneuver. The hospital implemented a numerous interventions to address her choking including staffing 1:1; monitoring intake, a special consistency diet, and orders for dietary and Speech Language Pathology consults. The hospital attempted over several days to also obtain approvals for a SLP consult and a Modified Barium Swallow both of which were denied by her insurance. However, changes made in her staffing level and in the diet orders as well as a error in the menu item provided to the patient contributed to the patient choking on January 15, 2016 which resulted in her death. See the specific details of the incident under A 144
Further as noted at A0396 of this report Patient #1's care plan was never updated to reflect her dietary and swallowing problems even though the hospital had employed numerous interventions to prevent a reoccurrence of the first choking incident and had made attempts to obtain needed diagnostic testing some of which had been denied by the patient's insurance. The hospital developed a plan that included medical, nutritional and nursing interventions but nursing failed to address this in the care plan.

Therefore based on the above systemic breakdowns for patient #1, the Condition of Patient Rights was not met.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of dietary processes, policy, and patient #1's record, it was revealed that inconsistencies within dietary processes resulted in patient #1 receiving an inappropriate food choice leading to a choking event and her death as evidenced by:


Patient #1 was a Spanish speaking female in her eighties admitted involuntarily to the psychiatric hospital on December 11, 2015 due to threats to others in the community. Patient #1 had co-morbidities of hypertension and heart-block, and had a pacemaker. Interpreter services were obtained to communicate with patient #1. A History and Physical revealed in part, " No difficulty swallowing. "

An order for Dietary Consult was written on 12/11/15, " secondary to documenting patient is on special diet and/or has nutritional risk factors. " On 12/12, a " No salt added " element was added to patient #1's diet. On 12/14, patient #1 was assessed by the Registered Dietician for poor oral intake. Patient #1 was noted to refuse foods sent on her tray. Ensure supplements were added to patient #1's diet, as well as the recommendation to provide foods of Hispanic origin. Patient #1 was also ordered a "Regular diet (Age appropriate)."

On 12/15, patient #1 received an order for 1:1 due to her unsteady gait. On 12/16, patient #1 met with her social worker and reported being full " Up to her throat. " The 1:1 order continued through 12/21/15, when patient #1 choked on her breakfast, specifically, bacon. Staff was able to perform a successful Heimlich maneuver. Based on this choking event, orders for a Speech Language Pathology (SLP) evaluation; a Pureed Diet (Dysphagia Level 1); 3 days documentation of all po (by mouth) intake ...; a consult to a nurse practitioner due to choking; and another dietary consult were made.


Beginning on 12/22, the Care Manager attempted multiple times, and over many days to obtain the appropriate coding for insurance coverage with the new ICD 10 codes for a SLP consult, all of which were denied. This was communicated to the physician. On 12/23, an order for an XR (x-ray) Modified Barium Swallow (MBS) (w/video) was ordered. Likewise, the Care Manager encountered great difficulty obtaining insurance coverage for this as well. The Care Manager reached out to other intra- facility-hospitals and Administration in order to obtain the ordered diagnostic testing.

In the interim, patient #1 continued on 1:1 until 1/8 at 1004 when an order for close observation with constant visualization was made. Another order at 1446 was made for "close observation." "Close observation" means that the patient is observed within the milieu at least every 15 minutes.

Patient #1 also continued on a puree diet until 1/12 at 1416. Patient #1 had been complaining that she did not like the puree diet and had refused some of her meals. A physician wrote in part, "Since we are unable to get St (Speech therapy) eval here and patient has had no issues with choking or coughing will switch to mech (mechanical) soft diet and monitor her ... " While the physician wrote a progress note regarding a mechanical soft diet (Dysphagia 2), the physician actually wrote an order for a "Soft Diet (Dysphagia level 3)"

Per the hospital dietary manual, diets progress from Puree, to Mechanical Soft (Dysphagia 2), to Soft (Dysphagia 3). The difference between the mechanical soft Dysphagia 2 diet and the soft Dysphagia 3 diet is primarily that the Dysphagia 2 diet allows for only chopped or ground meat, and the Dysphagia 3 diet allows for whole pieces of meat which are " soft, tender. " Therefore, and based on the physician progress note, the physician either made an error or did not understand the differences between the diets. The physician also wrote another order for " Modified Barium Swallow w/video, " and in a progress note, wrote in part, " ...nurses to monitor (sic) for cough with meals. "

A dietary consult on 1/12 at 1434 states in part, " ...Review of chart revealed " Patient ate meals for 8 days which is about 73% of the time and refused to eat 3 days which is about 27% of the time. As reported, she ate approximately about 50%, 75% to 100% of her meals ...No Choking incident was reported since Puree Diet was served ...Moderate nutritional risk ...Recommend for Speech Therapist Consult to evaluate swallowing ability ...Patient was seen with an interpreter appearing stable mood & engaging well at this meeting ...Realized weight gain of about 1/4 lbs. " Care Plan: Recommend patient be on 1:1 at meal time to encourage/maximize PO ... " Patient #1 was not made 1:1 at meal time, but was continued on close observation.

Also on 1/12, and regardless of payment, the Modified Barium Swallow was scheduled for 1/15 at 1300. Patient #1 remained on close observation, and had no coughing or choking events on the new diet, until 1/15 when patient #1's lunch was sent to the unit.

According to interview with the Risk Manager, on 2/20/2016 at approximately 9:00 am, menus with identical food choices are given to all patients regardless of the patient diet. Patients fill-in their preferred choices, or are helped to do so. For 1/15/2016, patient #1 had chosen a lunch entre of " Crispy Chicken Tenders. " This means that at the outset of menu selection, she was given an unsafe choice of food preference.

Menus are then collected and sent to the dietary supervisor who, checks the menu against the ordered diet and allergies, and places a sticker naming the specific diet of each individual. In the case of patient #1, the sticker placed on the menu was " Soft, " indicating the ordered Soft Dysphagia 3 diet. Each menu then goes to the kitchen line staff, who based on the patient menu choices and the dietary supervisor's individualized stickers, must choose the appropriate food for each lunch tray.

Kitchen line staff are given training by the Dietician to identify the types of patient diets, and are " qualified " per hospital PC002 Tray Assembly, Distribution and Cart Delivery policy (revised 10/28/14) which states, " A qualified individual will check all trays for therapeutic accuracy and completeness. " However, the entree name of " Crispy Chicken Tenders" may have been misleading to the line staff who prepared patient #1 ' s tray, since patient #1 ' s ordered diet did include " tender " meats as part of the " Soft (Dysphagia 3) diet which allows whole pieces of meat which are Soft or " Tender. " Patient #1 ' s meal tray was not modified appropriate to her dietary needs.

Further review of the dietary processes revealed that per this policy, " Nursing passes meal trays to patients ... " While the trays are labeled with the patient name and diet, there is no consistent or redundant process for assuring patients get the correct diet once a tray is on the unit.

On 1/15, patient #1 received an inappropriate food choice and had a choking event which required 911 services and transfer to an acute hospital, where she later died . Based on all documentation, the hospital identified and made every effort to obtain the diagnostic services needed by patient #1, and protected patient #1 while awaiting those diagnostics. However, inconsistencies and confusion in the types of diets, and menu/tray management culminated in patient #1 receiving inappropriate food on her tray which caused her choking event, representing an unsafe condition.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on an onsite survey inclusive of review of 6 open and 4 closed patient records, it is revealed that for patient #8 who was restrained and secluded, an incomplete restraint order is found, but no order for seclusion is found in the record.

Patient #8 is an adult male admitted mid-January 2016 on voluntary following angry outbursts in the community with increasing paranoia an hallucinations. On 1/16 at approximately 2130, patient #8 escalated on unit A and lunged at another patient, then threw tables and chairs. A code was called, and it was decided that patient #8 could better be managed on unit B. He received IM emergency medication to help him calm down.

According to a nursing progress note of 1/17 at 0012 in part for 1/16 at approximately 2135, " ...he continued to refuse to cooperate, became increasingly agitated and threatening ...was pacing around the unit, eyes darting, fists balled, and he also stated, ' Someone ' s going to die tonight. Eventually placed in a physical restraint and IM medications administered, (patient #8) was escorted to the seclusion on unit B. Close observation initiated per protocol.

Review of the record reveals a physician order of 1/16 at 2200 for restraint. No documentation in the order specifies how many limbs were to be restrained. Based on this, nursing was left to decide how many points to apply. Further, no physician order for seclusion appears in the record.

Based on documentation, the hospital failed to obtain complete orders for restraint, and any order for seclusion as required by regulation.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
Based on an onsite survey inclusive of review of 6 open and 4 closed patient records, it is revealed that for patient #8 who was restrained and secluded, no assessment and monitoring documentation is found.


Patient #8 is an adult male admitted mid-January 2016 on voluntary following angry outbursts in the community with increasing paranoia an hallucinations. On 1/16 at approximately 2130, patient #8 escalated on unit A and lunged at another patient, then threw tables and chairs. A code was called, and it was decided that patient #8 could better be managed on unit B. He received IM emergency medication to help him calm down.

According to a nursing progress note of 1/17 at 0012 in part for 1/16 at approximately 2135, " ...he continued to refuse to cooperate, became increasingly agitated and threatening ...was pacing around the unit, eyes darting, fists balled, and he also stated, ' Someone ' s going to die tonight. Eventually placed in a physical restraint and IM medications administered, (patient #8) was escorted to the seclusion on unit B. Close observation initiated per protocol.

Review of the record reveals no RN assessments information related to the restraint and seclusion; criteria for removal from restraint and seclusion; no 15-minute care and behavioral monitoring; and no end time for restraint and seclusion

A psychiatric technician note of 1/17 at 0543 states in part, " At the beginning of shift pt was in the seclusion room. There he was not stable in mode (sic) while responding to medication. Pt kept shouting and screaming so load (sic). After he slept for about an hour he got up and asked to return to his room. While pt. in bedroom, pt kept getting out of bed violently and aggressively. Severally (sic) pt was redirected by staff and he complied. "

Not until 1/17 at 1502 did an RN document some information regarding the restraint/seclusion in part as, " per night shift report, seclusion/restraint ended ~ 0150 and pt was brought back to the unit ... " Based on all documentation, patient #8 did not receive appropriate monitoring during restraint and seclusion events.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
Based on an onsite survey inclusive of review of 6 open and 4 closed patient records, it is revealed that for patient #8 who was restrained and secluded, no face to face documentation is found.

Patient #8 is an adult male admitted mid-January 2016 on voluntary following angry outbursts in the community with increasing paranoia an hallucinations. On 1/16 at approximately 2130, patient #8 escalated on unit A and lunged at another patient, then threw tables and chairs. A code was called, and it was decided that patient #8 could better be managed on unit B. He received IM emergency medication to help him calm down.

According to a nursing progress note of 1/17 at 0012 in part for 1/16 at approximately 2135, " ...he continued to refuse to cooperate, became increasingly agitated and threatening ...was pacing around the unit, eyes darting, fists balled, and he also stated, ' Someone ' s going to die tonight. Eventually placed in a physical restraint and IM medications administered, (patient #8) was escorted to the seclusion on unit B. Close observation initiated per protocol.

Review of the record reveals no face-to-face regarding the restraint and seclusion for patient #8 by a physician, licensed independent practitioner, or trained RN. Based on this, patient #8 ' s condition during a restraint and seclusion was not assessed.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on interviews of staff , it was revealed that the facility had not been performing mock codes in preparation for the high likelihood of choking, aspiration, and cardiac emergencies in their patient population.


The facility is a psychiatric hospital with multiple units inclusive of a geriatric unit. Consequently, the likelihood of medical emergencies is high due to multiple causes of patient actions to harm self or other, medical comorbidities, and from medications given to the psychiatric population which can have dire side-effects.


Interview with the Risk Manager on 2/20/16 at approximately 1000 revealed that no mock codes had been conducted within an approximate years ' time. Interview with the new Chief Nurse on 2/20 at approximately 1200 revealed her intention to begin regularly scheduled mock codes for a number of emergency conditions. Interviews with unit staff revealed that elements of what to do in a code are reviewed at least once a year in a learning module`, though no mock codes were conducted.


While staff have a learning module for emergencies, the lack of mock codes impacts real-time evaluation of staff responses to emergent, and life-threatening situations. Therefore, the coordination and efficacy of staff responses to emergencies cannot be tracked, qualified, or known.