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.

SINAI HOSPITAL OF BALTIMORE 2401 WEST BELVEDERE AVENUE BALTIMORE, MD 21215 Oct. 30, 2018
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
Based on a review of patient #2's (P2) record during a re-visit survey on 10/30/18, it was determined that a provision of a behavior modification plan conditioned P2's meals based on compliance with medication and hygiene.

Patient #2 (P2) was an adult with dementia and a behavioral disturbance who admitted to the behavioral health unit. P2 had a guardian of person and was on a clinical review panel for forced medication. P2 was secluded multiple times for various outbursts.

A nursing note in the first week of October at 16:26 revealed, "Patient has been uncooperative with treatment plan. Patient has been refusing to take his meds by mouth after he was given options. Patient was encouraged to help himself and staff by taking his meds to get well without the intramuscular injections. Patient has been provided a behavior modification to not receive coffee or meal until he changes dirty clothing or takes his scheduled meds. Patient is doing better with verbal outbursts."

It was inappropriate to condition the basic human right to eat meals on whether the patient cooperates with a treatment plan.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0165
Based on a review of patient #1's restraint events during a re-visit survey on 10/30/18, it was determined that the physician wrote orders for soft restraints, though nursing applied TAT (twice as tough) restraints throughout the restraint event which failed to meet requirements for the least restrictive intervention.

Patient #1 (P1) was a child between 9-17 years of age who was non-verbal and had a diagnosis of autism. P1 presented to the hospital due to increasing aggression. P1 had multiple violent outbursts while in the emergency department and in-patient.
During restraint event A, in which P1 was placed in 4-point restraint for 13 hours, the physician initially wrote an order for the 4-points to be soft restraints. However, according to the nursing flow sheet, P1 was placed in twice as tough (TAT) hard restraints throughout the restraint event. The order for soft restraints was not changed to TAT until 8 hours after initiation of restraint. Based on this, nursing failed to complete the physician orders as written to place P1 in the least restrictive 4-point soft restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on a review of patient #1's (P1) restraint and patient #2's (P2) seclusion record during a re-visit survey on 10/30/18, it was determined that no orders were written for multiple manual restraint events for P1, and P2 was secluded for an approximate total of 5 hours without orders.

A nursing restraint note in P1's record in late October at 0930 revealed in part, " ...(Patient [P1] attacked the RN and CCT. Patient was held by RN until security arrived ..." No manual restraint order was found for this restraint event. Per a RN note at 11:15 in part, "2 security hold the pt [patient] and pt assisted back to room restraint re-applied." No order for manual restraint was found.

The following day, a nursing note of 00:19 stated in part, "3 security officers assisted in a straight cath ..." This indicated that P1 (a child between 9-17) was held by security while urine was obtained by catheter. No order was identified in the medical record.

Patient #2 (P2) was an adult with dementia and a behavioral disturbance who admitted to the behavioral health unit. P2 had a guardian of person and was on a clinical review panel for forced medication. P2 was secluded multiple times for various outbursts. During the course of one such seclusion, P2 remained in seclusion between the hours of 0702 and 1409. A new order was due at 1102, but not written until 1409, effectively secluding P2 without an order for an approximate 3 hours. Similarly, 4 days later, P2 was secluded from 0400 until 1407 without new orders at 0800 and 1200. P2 was secluded without orders for 6 hours.

Based on all documentation, the hospital failed to meet regulatory requirements for restraint and seclusion orders.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of restraints for patient #1, (P1) and patient #3 (P3) during a re-visit survey on 10/30/18, it was determined that the hospital failed to, 1) write appropriate time-limited orders for P1, and P3; and 2) renew orders, resulting in periods without appropriate orders.

Patient #1 (P1) was a child between 9-17 years of age who was non-verbal and had a diagnosis of autism. Patient #1 presented to the hospital due to increasing aggression. P1 had multiple violent outbursts while in the emergency department and in-patient. Multiple restraint events revealed apparent confusion related to time limitations for violent restraint orders. P1 had 4-hour orders, and/or orders written beyond 4-hours where related to age under 16, all violent orders required 2-hour increments for renewal.

For restraint event A, P1 was restrained over the course of 13 hours due to "severe agitation with physical harm to caregivers (sitter, ED RNs, providers)." The initial restraint order was written at 2002 with an stop date of the next day at 4:13:00 AM. However, a renewal order was written at 2228 (26 minutes late for 2 hours increments), and then no orders appear again despite P1 remaining in 4-point restraint until the following day at 0410. Based on this, P1 was restrained in violent restraints without appropriate orders for more than 5 hours.

For restraint event B, lasting 12 hours and 25 minutes, P1 was restrained without appropriate orders for 3 hours and 29 minutes.

For restraint event C, lasting 9 hours and 55 minutes, P1 was in 4 point violent restraints for 5 hours and 25 minutes without appropriate orders.

P3 was an adult patient who presented on an emergency petition for aggressive behavior. P3 was appropriately placed in violent 4 point (limb) restraints at 19:45. The restraint order was written for 8 hours (stop time 03:44) instead of the regulatory 4-hour increment. A renewal order was written the following morning at 02:54, which was 3 hours and 9 minutes late.

Documentation indicates that the hospital failed to write appropriate violent restraint orders for P1, a child between 9-[AGE] years old, and an adult, resulting in periods with no appropriate orders.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
Based on patient #2's history and review of Patient #2's (P2) seclusion records during a re-visit survey on 10/30/18, it was not possible to tell if P2 received enough hydration and food intake during seclusion, and no follow-up for an injury to P2's right toe was found.

Patient #2 (P2) was an adult with dementia and a behavioral disturbance who admitted to the behavioral health unit. P2 had a guardian of person and was on a clinical review panel for forced medication. P2 was secluded multiple times for various outbursts.

P2 had a pre-existing conditions of difficulty swallowing for which P2 would sometimes refuse food due to feelings that he was choking. In early October at 1155, a RN documented in part, " .... Patient has a good appetite and consumes most of food, but repeats he is often choking. Pt reminded of need to eat and drink slowly...," and, " ...Patient's right toe is necrotic [evidencing black and dead tissue] towards the tip and side. The site appears to have cracked as well, minimal bleeding noted. Pt has been noncompliant with covering feet even when provided with socks. He will wear them for only a brief period of time. Placed in H&P book."

On the same day at 1150 P2 was placed into seclusion, and subsequently secluded 3 times over the course of 5 days for 26, 42.5 and 30 hours respectively. This equaled a total of 98.5 hours. Electronic intake documentation grouped all intake together as, "Hydration/nutrition." Further, every two hour drop down options to respond to "hydration/nutrition" could be "offered," but did not indicate if accepted, or if the patient declined. Therefore, electronic documentation failed to give an accurate account of whether P2 took in offered food or fluids.

For one such seclusion event, documentation revealed 9 times that hydration/nutrition was declined (a period of 18 hours in 2-hour increments). Other nursing documentation revealed alternately, "Provided lunch tray" and "food and fluid left in room." Both of these nursing notes were for times that P2 was also documented as "declining" hydration/nutrition. Over the course of the 5 seclusion days, fluid intake was documented as a total of 2260 cc., which equaled an approximate 2 cups of fluid a day. Two cups a day was not an acceptable amount of fluids to sustain P2's health.

Additionally, no follow-up or ongoing assessment was found in any nursing or physician documentation related to P2's "necrotic" toe during the 6-day period reviewed.

While it was noted that the medical record was limited for documentation options, nursing had the ability to write narrative notes. However, nursing failed to assess the impact of seclusion on P2's pre-existing conditions.