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.

GREATER BALTIMORE MEDICAL CENTER 6701 NORTH CHARLES STREET BALTIMORE, MD 21204 May 30, 2019
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0169
Based on a review of patient #4 record, it was revealed that 2 orders for restraint were found, though there was no apparent implementation for the second order.

Patient #4 was a middle-aged patient who presented to the emergency department under court order for evaluation of increasing aggression. Review of the record revealed a restraint order of 0100 justified by behaviors of hitting, and kicking from which P4 was released at 0420.

Another restraint order of 0652 was noted in the record. The order revealed the type of restraint at "Physical restraint and physical hold." No other record documentation related to this order revealed that P4 had been restrained, or why the order was written.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observations of care on the telemetry/oncology unit, and staff interviews during the survey on 5/30/19, it was determined that 1) The hospital failed to ensure the safety of patients and visitors on the telemetry/oncology unit to be free from injury due to unsecured needles, intravenous (IV) kits, and other sharps material. In addition, staff-demonstrated restraint options for controlling patients revealed control techniques which failed to meet the standard of care including a lowering to the floor into a temporary prone position and the use of pressure positions.

1) During tour and observation there were two caddies stationed on top of the outer counter of the nursing station. These open caddies contained supplies for drawing blood, starting IV peripheral line, and administrating injectable medication. Unit staff were questioned about the caddie, it was reported that the caddies were stationed on this counter for accessibility and convenience of nursing staff. The caddies were not located in the inner area where the nurses and other hospital staff occupy, but were located on the outer counter easily accessible and closest to patients and visitor.

2) A demonstration of restraint control methods by the lead security officer on the morning of 5/30/19 revealed in part that one control was accomplished by lowering the patient to the floor into a prone position where "The nurse monitors for breathing." Other verbal information indicated that patients are turned from a prone position immediately. However, intentionally proning a patient results in an unnecessary increased risk of injury which failed to meet the standard of care. Other optional restraint control methods resulted in the patient wrist being bent enough to incur pain, and a patient arm being placed behind the back.

A query to the patient safety office regarding any injuries from restraint revealed no injuries were noted for any patient who was restrained.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on a review of two restraint records, it was determined that patient #4 was not released at the earliest time due to 1) a staff failure to determine when P4 had met criterion for removal; and 2) disparities of behavioral documentation which failed to justify ongoing restraint.

Patient #4 was a middle-aged patient who presented to the emergency department under court order for evaluation of increasing aggression. Review of the record revealed a restraint order of 0100 justified by "hitting" and "kicking." P4 was placed into 4-point restraints (both wrists and both ankles) with a start time of 0130. P4 also received an injection of an anti-anxiety medication. Clinical justification for restraint was documented as, "Imminent risk of harm to others." Criterion for release was documented as the "Absence" of those behaviors.

Every 15-minute documentation by a sitter revealed that P4 was "Quiet" at 0215, 0230, 0238, 0300, 0305, 0315, 0317, 0320, and 0327, and sleeping at 0330. However, the hourly RN assessment at 0230, found P4 to have "Aggression," and at 0330 found P4 to have "Aggression" with "Harm to others." The RN failed to identify that P4 was ready for release as early as 0215, resulting in continued restraint until 0420. No other documentation verified that P4 continued the behaviors for which P4 was restrained. The disparate RN assessments resulted in continued restraint where there was no actual justification to do so. Therefore, P4 was not released at the earliest possible time.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0202
Based on a review of documentation and interviews with staff on 5/30/19, it was determined that the hospital failed to implement a plan of correction resulting from prior deficiencies of 12/18/2018 and due for completion by 3/13/2019 to standardize restraint training between nursing, hospital security and contracted security guards (CSG). This resulted in the continued inability for nursing clinicians give safe oversight of restraint processes by security and CSG.

A hospital plan of correction resulting from prior deficiencies of 12/18/2018 and due for completion by 3/13/2019 to standardize restraint training between nursing, hospital security and contracted security guards (CSG) was not done. This resulted in the continued inability for nursing clinicians give safe oversight of restraint processes by security and CSG.

Interview on 05/30/2019 at approximately 1330 with a hospital representative for patient safety revealed that the hospital plan to standardize restraint practices between nursing, security and contracted security guards was not met by the end date of 3/13/2019, but is now scheduled to occur in 8/2019. While it was described that great activity had occurred regarding the standardization, the hospital failed to meet hospital established timelines. This meant that in an ongoing way, nursing continues to be unable to give safe oversight of restraint processes.