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.

JOHNS HOPKINS HOSPITAL, THE 600 NORTH WOLFE STREET BALTIMORE, MD 21287 June 5, 2019
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on a review of 8 open and 4 closed medical records, it was determined the hospital failed to provide 2 of 3 Medicare recipients with the standardized notice, "An Important Message from Medicare," (IMM) within the appropriate time frames of 48 hours of admission and within 48 hours of discharge.

Findings include:

Review of Patient #12's medical record showed no evidence or documentation of the IMM that is to be given within 24 hours of discharge.

Review of Patient #10's records showed that the initial IMM that is to be given within 48 hours of admission, was not signed until the 18th day of admission. There was also no IMM provided prior to discharge of Patient #10.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on review of 12 medical records and hospital policies and procedures, it was determined that the facility failed to respect one patient's right to refuse treatment or services.

Findings include:

Patient #2 (P2) was a 50+ year old patient that presented to the Emergency Department (ED) for evaluation of a possible psychiatric condition. Staff documentation described the behaviors as "mildly combative, cursing and spitting on the floor". P2 was accompanied by his/her caregiver. The documented plan was to admit the patient to the Behavioral Health Unit (BHU).

Within 8 hours of P2's arrival to the ED, it was documented that the patient was refusing blood work and a history and physical (H&P) examination. Provider orders were found stating "Physical hold" and "Required sedation in order to obtain blood draw and H&P". Nursing documentation was found stating "IM medication (classification: hypnotic/sedative) was given to obtain labs". Another nursing note from the next day stated "IM medication (classification: hypnotic/sedative) and physical hold to perform Activities of Daily Living (ADL's)" and "Urinated on self, refused to change. Will call MD if [patient] continues to be non-compliant for additional meds". That same day documentation was found stating the patient was held and medicated for a straight catheter procedure (a tube is inserted directly into the bladder to obtain a urine sample and then removed).

Patient's refusal of certain treatments and evaluations was documented on multiple occasions; however, these treatments and evaluations were ultimately performed against P2's wishes and no documentation was found indicating that the treatments/evaluations were necessary due to a suspected medical emergency.

See also A-0164
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on review of 12 medical records and hospital policy, it was determined that the hospital used physical holds and forced psychiatric medications on one patient who was not exhibiting emergently dangerous or harmful behaviors.

Findings include:

Hospital policy entitled "Restraint and seclusion, Management of Violent or Self-Destructive Patient Behavior", dated 11/5/2016, section F2. "Use the least restrictive method of restraint when administering the medication or delivering care in order to avoid or reduce the use of force".

Patient #2 (P2) was a 50+ year old patient who presented to the Emergency Department (ED) for evaluation of a possible psychiatric condition. Staff documentation described the behaviors as "mildly combative, cursing and spitting on the floor". P2 was accompanied by a caregiver. The documented plan was to admit the patient to the Behavioral Health Unit (BHU).

Within 8 hours of P2's arrival to the ED, it was documented that the patient was refusing blood work and a history and physical (H&P) examination. Provider orders were found stating "Physical hold" and "Required sedation in order to obtain blood draw and H&P". Nursing documentation was found stating "IM medication (classification: hypnotic/sedative) was given to obtain labs". Another nursing note from the next day stated "IM medication (classification: hypnotic/sedative) and physical hold to perform Activities of Daily Living (ADLs)" and "Urinated on self, refused to change. Will call MD if [patient] continues to be non-compliant for additional meds". That same day, documentation was found stating the patient was held and medicated for a straight catheter procedure (a tube is inserted through the urethra into the bladder to obtain a urine sample and then removed).

Physical holds and forced psychiatric medications were used on P2 with no documentation of attempted alternatives or less restrictive measures and with no documented harmful or dangerous behaviors. Instead, documentation indicated that these techniques were used for staff convenience while attempting to perform tests and procedures for which P2 had refused to cooperate.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
Based on staff interviews and observations of existing techniques for restraint and seclusion by staff during the survey on June 4, 2019 and review of policies and procedures, it was determined that the facility failed to identify and properly educate staff regarding the dangers of placing patients in the prone position during de-escalation and/or during the placement of restraints.

Findings include:

During observations of the Behavioral Health Unit (BHU) on June 4, 2019, a security guard (SG1) was interviewed regarding de-escalation training and appropriate restraint and seclusion techniques. The security guard was asked if placing a patient in the prone position was a technique used on this unit. The security guard replied yes, and the surveyor requested SG1 to demonstrate with another staff member. At this time, the security guard did a sweep of the staff RN's feet and brought the RN to the ground on his stomach. SG1 proceeded to place his elbow and arm on the RN's back. Present in the room during this demonstration were two other clinical staff RNs. At no time did any of the staff members, including the RN placed in the prone position, deny that this technique was used with patients.

During review of staff training titled "Crisis Prevention Management (CPM) Curriculum for Hands-On Training - Nonaggressive", the following was found under the subsection "Trauma Informed Care-direct care nursing (TIC)":

"Demonstrate the Recovery position and rationale"

"Arms need to be extended out so there is no leverage" and
"Stress safety dangers for the patient when on their stomach".

There was no further content that explained how having a patient's arms extended is a recovery position. There also was no content found that explained the safety dangers of placing patients in the prone position or forbid the use of the prone position. The content did not explain why this inherently unsafe technique would be appropriate for use with any patient including a non-aggressive patient.

During the exit conference, the above-mentioned observations were discussed with the Director of Security who denied that he/she teaches staff members the prone position. However, based on the findings, all hospital members present during the demonstration agreed that some staff members learned or were aware of this technique and were using it on BHU patients.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
Based on review of 12 medical records and hospital policy, it was determined that the facility failed to release a patient from locked door seclusion once the behaviors that facilitated the seclusion had ceased and the patient was no longer acting in a threatening manner.

Findings include:

Patient #9 (P9) was a 20+ year old patient that was brought to the Emergency Department (ED) for evaluation of aggressive behaviors. P9 showed intermittent aggression and agitation towards hospital staff upon arrival to the ED and per documentation, required emergency medication administration on multiple occasions, as well as locked door seclusion more than twice during his/her 14+ day stay.

On review of the hospital policy "Restraint and Seclusion, Management of Violent and Self-Destructive Patient Behavior and Behavior Presenting an Imminent Safety Risk to Others", Section V-L (2) stated that "Once the patient's behavioral criteria for discontinuation is achieved and the patient is no longer a threat to self, staff or others, the use of restraint or seclusion must be discontinued as quickly as possible".

Per medical record documentation, P9 was placed in locked door seclusion for being verbally threatening. Nursing documentation every 15 minutes for the next 5 hours stated the patient was "resting quietly" and "awake, quiet, no apparent distress". During that 5 hours, only two episodes were documented stating the patient was being "verbally aggressive" or "yelling". The longest period of time without an episode was 2 hours yet the patient remained in lock door seclusion, per documentation, during that entire time.

Despite P9 exhibiting behaviors consistent with the criteria to be released from locked door seclusion, he/she remained in seclusion for hours past the cessation of dangerous behavior and was not released at the earliest possible time.
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
Based on review of 12 medical records and the hospital's policies and procedures, it was determined that the hospital failed to provide accurate and consistent patient discharge instructions, per their policy for one of 3 patients reviewed as a discharge planning sample.

Patient #10 (P10) was a 65+ year old patient with a history of diabetes and other chronic illnesses who presented to the hospital for a planned surgical procedure. During the course of P10's 14+ day stay in the hospital, P10's blood sugars and blood pressures fluctuated initially, however the patient was eventually stabilized and discharged to a sub-acute rehab facility (SAR) for post-operative rehabilitation.

The instructions ("After Visit Summary" (AVS)) sent to the SAR with P10 listed all medications the patient was currently taking and medications that were taken in the past. Next to some of the medications the word "Start" was listed; however, other medications had no word next to them (ex. Start, Stop, Continue) but even old medications no longer taken by P10 listed the instructions for taking them, including time of day and dosage. P10 was discharged to the SAR with an unclear designation of a diabetes medication that had not been prescribed in the hospital. The SAR subsequently administered the medication to P10, causing a dangerous drop in blood sugar.

While reviewing and comparing discharge instructions from two other closed records, it was found that both of the other "After Visit Summary" documents clearly listed each patient's medications with a "Start" and "Stop" next to each medication.

Discharge instructions with information that is unclear and inconsistent contributed, in P10's case, to a medication error.