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 SHADY GROVE MEDICAL CENTER 9901 MEDICAL CENTER DRIVE ROCKVILLE, MD 20850 Feb. 20, 2020
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of 11 medical records, hospital policy, and other pertinent documents, as well as video surveillance footage review, it was determined that the hospital failed to provide a safe environment for 1 of 11 patients. This was evidenced by Patient #1's report of a sexual assault by a hospital staff member during their admission, and various hospital staff members involved in Patient #1's care breaching policy and protocols/procedures aimed at mitigating the risk of a sexual assault/patient abuse.

Patient #1 (P1) was a 25+ year old patient who was admitted to the hospital for treatment of an acute behavioral health issue for 10+ days. One day before the discharge, P1 reported that they had been sexually assaulted by a member of the hospital staff during the admission.

The hospital conducted an investigation of the allegation. The following information was shared with surveyors while on-site, and was confirmed through video surveillance footage review offsite. Per video review, the staff member, who P1 alleged had committed the assault, could be viewed standing in the doorway of P1's room, and entering P1's room between the hours of 3:00 pm and 5:00 pm. This staff person was observed entering P1's room on 3 occasions, remaining in the room for 2-3 minutes each time and standing in P1's doorway on 1 occasion for 12 minutes.

An informal interview conducted during the unit tour with the unit's nurse manager on February 19, 2020, highlighted expectations for staff roles and functioning within the unit. Per the unit nurse manager, the staff person, who P1 identified as committing the assault, should not have entered P1's room alone for that period of time. It was also noted that there had been a break in protocol when the staff had remained in P1's doorway during the 12 minutes identified on the video footage surveillance.

Surveyors were provided with the hospital's policy "Abuse and Neglect", last reviewed by the hospital in January 2020, which in part outlined the following steps for reporting of abuse:

" Procedure:
1. The person who directly observes or receives a complaint from a patient, family member, or others, of any type of abuse, neglect, mistreatment or misappropriation of patient funds is required to document the observation or complaint received.
2. Provide all appropriate assistance to the patient immediately.
3. Immediately activate the appropriate Chain of Command for notification."

Review of P1's medical record determined that P1 verbally reported the assault to their social worker one day before discharge.

The first documentation directly related to the report of the assault appeared in the discharge summary by P1's attending physician on the day of discharge, as, "On the day before discharge pt mentioned to [his/her] SW that [he/she] believed [he/she] was touched by a [male/female] on the unit. SW informed this writer and administration as well as risk management were notified. Directives from administration and risk management were followed and pt was seen by forensic nurse."

The social worker's note about the initial report of the assault was not documented in P1's chart until two days after the report had been made, at which time P1 had already been discharged from the hospital. Per social worker's note, "Pt [patient] stated that [he/she] had told [his/her] attending physician and also two nurses, but wanted to report to sw [social worker] that [he/she] was sexually assaulted yesterday by a staff member between 3-5 pm." No evidence was found in the medical record that the nursing staff documented the initial report of the assault received from P1. The only nursing staff documentation possibly related to this incident was found to be on the day of discharge in the form of a progress note which stated, "Initiated a compliant [complaint] and Forensic nurses from shady Grove hospital came to see [him/her]."

Lack of clear and timely documentation of the patient's initial report of the incident to hospital staff made it difficult to determine whether the protocol outlined by the hospital's policy for abuse reporting had been followed appropriately by the staff and if the patient had received the necessary support and resources in a timely manner.

In summary, during the review of this incident, surveyors observed multiple staff violations of the hospital's policy and protocols aimed at preventing, identifying, and addressing patient abuse. As a result, the hospital failed to provide a safe care setting to P1.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on review of 11 medical records, hospital policy, and other pertinent documents, as well as video surveillance footage review, it was determined that the hospital failed to ensure that 1 of 11 patients was free of sexual abuse. This was evidenced by Patient #1's report of a sexual assault by a hospital staff member during their admission, and lack of education aimed at mitigating the risk of abuse to patients available to staff.

Patient #1 (P1) was a 25+ year old patient who was admitted to the hospital for treatment of an acute behavioral health issue for 10+ days. One day before the discharge, P1 reported that they had been sexually assaulted by a member of the hospital staff during the admission.

During the review of the documentation and video footage related to this incident, surveyors identified multiple staff violations of the hospital's policy and protocols aimed at preventing, identifying, and addressing patient abuse (see tag A-0144).

Upon request, surveyors were provided with the facility's policy " Abuse and Neglect", last reviewed by the hospital in January 2020, which stated in part: "Education is an important part of preventing abuse. Training increases awareness, builds skills, and promotes greater sensitivity to patients. Training programs for all staff are essential to ensure that everyone knows what the rules are and how they will be applied. It is critical that employees understand how they are expected to handle certain situations." The policy went on to describe the elements of the effective abuse prevention training and expectations for staff attendance of the programs, frequency of training, etc.

While still on-site, a request was made by surveyors for the hospital to provide the education and/or training that was provided to the hospital staff regarding abuse prevention and reporting. While the hospital provided for review various education materials related to aggressive patient management and therapeutic communication, no education specific to the abuse training identified in the hospital's policy was received by surveyors.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0182
Based on review of 11 medical records, hospital policy, and other pertinent documents, it was determined that nursing staff failed to consult an attending physician after conducting a face to face assessment in 1 of 2 medical records reviewed for restraint documentation.

Patient #3 (P3) was a 30+ year old who was admitted for treatment of a mental health condition. During the course of admission, P3 was placed into involuntary seclusion due to violent behaviors. An order for seclusion was placed by the physician at 12:19 pm. P3 remained in seclusion for 21 minutes. The one hour face-to-face assessment was conducted by a trained registered nurse at 12:39 pm. No evidence was found in the medical record that the nurse consulted the physician after the face-to-face assessment had been conducted.

Furthermore, the hospital's policy for Restraints and Seclusion, reviewed by surveyors on-site, did not address the expected time frame for and the components of the consultation with the attending physician.