HospitalInspections.org

Based on review of personnel files, it was determined that the hospital failed to comply with Maryland state licensing law for licensed professional counselors as evidenced by the following:

Based on review of the personnel file of Therapist #1, it was noted that Therapist #1 was not (at the time of the review) licensed to practice counseling by the state of Maryland. Therapist #1 was licensed as an LPC (Licensed Professional Counselor) in Washington, DC, and was hired by the hospital on the condition that Maryland licensure be obtained within one year of Therapist #1's hire date of April, 2007.

In order to be licensed in the state of Maryland as an LCPC (Licensed Clinical Professional Counselor) Therapist #1 needed to complete one more course. Therapist #1 completed the course but the state did not accept it, forcing Therapist #1 to complete a second course. The second course Therapist #1 completed was accepted by the state of Maryland, and the final step that Therapist #1 had to complete was to pass a state law examination. Therapist #1 was scheduled to take the state law examination in March, 2010. Consequently, Therapist #1 had practiced counseling at the hospital for almost three years without a Maryland license.

Based on interviews with staff and review of medical records, policies, procedures and other pertinent documentation, it was determined that the hospital failed to appropriately assess and evaluate Patient #2's behavioral health needs, failed to certify her for involuntary placement for behavioral health care while maintaining her as a "voluntary" patient who required restraints to keep her from leaving the hospital against medical judgement.

Patient #2 was an 18-year-old female who presented to the Emergency Department at Laurel Regional Hospital on 2/11/10 at 4:17 pm for a psychiatric evaluation related to her chief complaint of possible suicidal ideation and "having bad thoughts." The record showed that Patient #2 was triaged in the main Emergency Department (ED) at 4:45 pm. She was triaged at a level of 3 on a 5 point scale where 1 is most urgent and 5 is least urgent. The record indicated that Patient #2 presented with a labile mood, sometimes appearing catatonic and not responding, and sometimes with an angry affect "snapping easily at staff."

While in the ED, Patient #2 was not certified as requiring an involuntary placement for behavioral health care. A nursing entry in the ED record on 2/11/10 at 10:00 pm stated that Patient #2 walked out to her door telling staff she was discharged and she was therefore given her belongings. She got dressed and proceeded to leave. The nurse consulted with both the physician and "psych" who both said she was not discharged. The nursing note indicated that Patient #2 continued to walk toward exit and then Security was called. The house supervisor went outside the building either with or after the patient (the nursing note is unclear on this point). Security had been called by this time and the patient was outside of the building. The note indicated that the patient continued to refuse to return to the room but at 10:55 pm the patient was in the ED again. The record entry did not state how she returned to the ED at 10:00 pm. Thus despite a triage assessment indicating that patient #2 was not at high risk for suicide, and despite her voluntary status, security was called to hold her in the ED against her will when she tried to leave the premises. If patient #2's suicidal risk was high, a certification should have been completed and she should not have been in voluntary status. If her risk was not high as documented in the triage at level 3 and the volutary status ascribed to her, then patient #2 should have been allowed to leave against medical advice when she tried.

At 10:55 pm an order was entered into the record to place Patient #2 into 4-point restraints because she "expressed desire to hurt self." Then at 11:00 pm, a nursing note indicated that patient #2 was in the ED wandering about but still refused to take off her clothing or return to room. This note indicated that she "became very combative while trying to elope again requiring security assist to restrain her." Lacking certification for involuntary commitment the patient retained the right to leave the hospital. A voluntary patient "trying to elope" is insufficient cause to deny the patient their right to refuse treatment, and to deny the patient the right to leave against medical advice, and /or to initiate the use of restraints.

At 6:03 pm on 2/12/10, the psychiatric evaluation note indicated that the patient was an "elopement risk" and she "attempted to elope before the evaluation." The evaluation revealed that patient #2 presented as disorganized, disoriented, and easily agitated. The evaluation also showed that patient #2 had suicidal ideation and had made a recennt attempt to jump out of a car, though she did not report any specific plan to interviewer. Under the disposition section the writer noted that "this patient was referred to at the time when she appeared to be heading toward involuntary status. agreed that the patient could be referred to 4A if patient continued to request admission ..." At some point the patient had in fact signed consent for voluntary admission (the date is scratched over and not legible). Regardless, the Application for Voluntary Admission indicates that the patient "is able to give continuous assent to retention by the facility." However, the record clearly demonstrated that by her actions patient #2 was not giving continuous consent for retention.

The record showed that at 12:00 pm on 2/12/10 patient #2 went from the ED to the voluntary behavioral health unit. The admission note on the unit indicated that when brought to the unit, she was very agitated, crying, accompanied by Security, and an emergency Code Green (behavioral emergency code) had to be called. Seven hours later another nursing note entered on the behavioral health unit at 7:00 pm documented that patient #2 was labile and "walking to exit door to leave ... Patient has gone to the exit door at main entrance twice and security was called. Prince Georges Police Department was called to take patient based on the emergency petition paperwork completed by if she absconds from the unit. said that they will not take the patient if she absconds from the unit. The officers said that the government rules are strict about emergency petitions. The officers said they would have to witness the unsafe behavior to take the patient in their custody. Staff will continue attempts at verbal de-escalation when patient becomes combative and makes attempts to abscond." At 7:15 pm the next nursing note indicated that patient #2 was agitated, wanted to leave, and made "many attempts at the door." Family visited and helped "pacify patient." The hospital psychiatrist was notified and ordered medications. The record showed that patient #2 was given Haldol 2.5 mg and Benadryl 25 mg PO at 7:15 pm. Though an emergency petition was discussed in the nursing notes, no emergency petition was found in the medical record. As of 7:15 pm on 2/12/10 patient #2 had still not been certified as needing involuntary placement. Nonetheless, she was still being held against her will on the voluntary-only behavioral health unit.

Not until 2/13/10 was the patient finally certified as requiring involuntary placement. The record indicated that the psychiatric admission note was not written until the date of discharge. The admission note dated 2/13/10 (the date of discharge) states that patient was admitted voluntarily but "upon evaluation today, the patient does not meet criteria for voluntary admission, but does meet criteria for involuntary admission as she cannot give informed consent for treatment, acutely disorganized, dangerous to self and others, refusing to stay on unit and demanding to leave and she is in no shape to leave." This note was not timed but two certifications for incvoluntary placement were completed on this date at 11:00 am and 11:30 am.

Thus, the hospital held Patient #2 against her will on a voluntary unit, without adequate assessment or evaluation of her needs, and without certification for nearly two full days.

Based on interviews with staff, and review of medical records, policies, procedures, and other pertinent documentation, it was determined that the hospital failed to ensure that restraint was only imposed to ensure the immediate physical safety of the patient, a staff member, or others, as evidenced by the following:

Patient #2 was an 18-year-old female who presented to the Emergency Department at Laurel Regional Hospital in Laurel, Maryland on 2/11/10 at 4:17 pm with the need for a psychiatric evaluation related to her chief complaint of possible suicidal ideation and "having bad thoughts."

The record showed patient #2 was placed into 4-point restraints at 12:15 pm on 2/13/10. The nursing note revealed that the patient's behavior may have justified consideration of restraint, but by the time that restraints were applied the nurse indicated that patient #2 had already calmed down. The nursing note stated that at the time restraints were initiated: patient #2 was "very quiet, just staring at floor then started saying 'I ok' repeatedly. Patient then asked 'am I pregnant?' Patient sat up in bed with restraints on." The face to face-to-face attestation included no narrative of the behavior that would justify continued restraint and the flow-sheet only showed that the patient was "awake." The documented behavior did not indicate any immediate threat to the physical safety of the patient, a staff member, or others and did not justify use of restraint at the time of application..

Based on review of the medical record of Patient #1, it was determined that the hospital failed to ensure that the use of restraint or seclusion was in accordance with the order of a physician or other licensed practitioner who was responsible for the care of the patient as evidenced by:

Patient #1 is an 86-year-old female admitted to Laurel Regional Hospital on 1/7/10 with elevated temperature, heart rate, low blood pressure, and tremors. The patient was diagnosed with CVA (stroke) and sepsis (infection). The medical record documents that the patient was confused, constantly trying to get out of the chair, fell, pulled out her IVs and became combative while undergoing a scan in Radiology. The medical record also documented that prior to placing the patient in a Posey vest, staff tried using lesser interventions, including using chairs and placing the patient in the hallway within staff's eyesight, education of the patient and family, sitters, distraction, and medication. The initial restraint order was written on 1/8/10 at 9:00 pm and the patient was in and out of the Posey vest for a total of eight days.

Patient #1's medical record revealed no physician/LIP's order for restraints on 1/15/10, although the patient was pulling at her IV tubing and trying to get out of the chair and other less restrictive interventions were unsuccessful. The nursing staff documented the patient was placed in a Posey restraint, completed assessments every eight hours and completed the restraint portion of the Patient Care/Treatment Record for that date.

Based on interviews with staff, and review of medical records, policies, procedures, and other pertinent documentation, it was determined that the hospital failed to ensure that restraint use was discontinued at the earliest possible time as evidenced by the following:

Patient #2 was an 18-year-old female who presented to the Emergency Department at Laurel Regional Hospital in Laurel, Maryland on 2/11/10 at 4:17 pm with a need for a psychiatric evaluation related to her chief complaint of possible suicidal ideation and "having bad thoughts."

At 10:55 pm on 2/11/10, Patient #2 was placed in 4-point restraints after she "expressed desire to hurt self." Documentation of the required face-to-face evaluation/attestation was not completed and no description of the patient's behavior was entered in the restraint documentation. A nursing note only stated that Patient #2 "became very combative" when trying to elope from the ED. No flow-sheet documentation was found in the record evidencing monitoring of the patient during the use of restraints, and the time the restraint ended was not found documented in the record. Therfore the record did not sufficiently support the initiation of restraints and there was insufficient documentation indicating the any continued need for restraints. Therefore based on record documentattion, they should have ended immediately.

A nursing note from 12:00 pm documented behavior that would justify consideration of restraint, but 12:15 pm documentation in the record indicated that she had already calmed down. Nonetheless, at 12:15 pm on 2/13/10, patient #2 was placed into 4-point restraints. The record documented the "immediate response" to restraint as "patient very quiet, just staring at floor then started saying 'I ok' repeatedly. Patient then asked 'am I pregnant?' Patient sat up in bed with restraints on." The face-to-face attestation was signed at 12:30 pm, but it was only a checklist and included no narrative justifying the continued use of restraint after the 12:30 pm face-to-face evaluation. The restraint flow-sheet showed only that the patient remained "awake" for the restraint episode that lasted without sufficient justification documented for three hours (from 12:15 pm until 3:15 pm). Thus for this three-hour period, the patient remained in restraint without documented justification and the hospital failed to ensure that restraint use was discontinued at the earliest possible time.

Based on review of patient #2's medical record, the facility failed to ensure the patient was seen face-to-face by a practitioner within one hour of being placed in restraints as evidenced by the following:

At 10:55 pm on 2/11/10 patient #2 was placed in 4-point restraints after she "expressed desire to hurt self." No documentation of the required face-to-face evaluation was found documented in the medical record. .

Based on review of the medical record, the facility failed to ensure that Patient #2 was seen face-to-face within one hour after the initiation of 4-point restraints to specifically evaluate:
(1) the patient's immediate situation,
(2) the patient's reaction to the intervention;
(3) the patient's medical and behavioral condition; and
(4) the need to continue or terminate the restraint or seclusion.


At 12:15 pm on 2/13/10 Patient #2 was placed in 4-point restraints. A nursing note revealed that her behavior may have justified consideration of restraint, but the note when restraints were applied indicates she had calmed down by the time they were applied. The record documented the "immediate response" to restraint as "patient very quiet, just staring at floor then started saying 'I ok' repeatedly. Patient then asked 'am I pregnant?' Patient sat up in bed with restraints on." The face-to-face evaluation signed at 12:30 pm was only a checklist and included no narrative justifying the continued use of restraint after the 12:30 pm face-to-face. There was no narrative associated with the face-to-face assessment documenting the patient's immediate situation, the patient's reaction to the intervention; the patient's medical and behavioral condition; and/or the need to continue or terminate the restraint or seclusion as required by this regulation.

Based on review of the medical record of Patient #1, it was determined that the hospital failed to document a description of the patient's behavior that warranted the use of restraint within the physician's order and progress note.

Patient #1 is an 86-year-old female admitted to Laurel Regional Hospital on 1/7/10 with elevated temperature, heart rate, low blood pressure and tremors. The patient was diagnosed with CVA (stroke) and Sepsis (infection). It is documented in the medical record that the patient was confused, constantly trying to get out of the chair, fell, pulled out her IVs and was combative during a Q scan in Radiology.

Patient #1's medical record review revealed three different ways to write orders for restraint/seclusion.

The hospital has a formatted Restraint/Seclusion Order form which includes Med/Surg reasons for restraint/seclusion on the left side of the page and Behavioral Health reasons on the right. At the top of the order form are the check-off boxes and spaces for the type of restraint, time limit, and the reassessment intervals. At the bottom of the form is the face-to-face statement and categories or reasons for the use of restraint or seclusion.

The restraint/seclusion order can also be written on the standard Physician Order form as well as on the Telephone Order Form. When orders are written on these other two forms, they require the physician or LIP (Licensed Independent Practitioner) to hand write the specifics of the order as stated above.

Review of the medical records of Patient #1 revealed orders written on all three order formats that lack the reason for use of the restraint.

The following orders for Patient #1 lack the reason for use of restraint: 1/8/10 at 9:00 pm (order also written on telephone order form); 1/9/10 at (order has no time); 1/10/10 at 8:30 pm; 1/11/10 at 8:00 pm; 1/12/10 at 5:00 pm; 1/13/10 at 4:00 pm; 1/14/10 at 4:50 pm.

Based on review of personnel records as well as interviews with hospital staff, it was determined that the hospital failed to require hospital staff involved in restraints/seclusion to demonstrate competency in physical holds used during restraint/seclusion episodes as evidenced by the following:

Based on review of Section 6, Paragraph E, No. 8 of the hospital Policy Number 901-037, it states that the 'safe application and use of all types of physical holds, takedowns, and restraint/seclusion application and removal' are a part of required orientation and annual competencies. However, interview with staff involved in carrying out restraints/seclusion revealed that no one (including ED, Behavioral Health, and Security personnel) is required to demonstrate any physical holds or takedowns during completion of annual competencies. One staff stated that it had been so many years since they last had to demonstrate a physical hold during competency completion that he/she could no longer remembered what that year was.

Based on review of the medical record, the facility failed to ensure that Patient #1's restraint orders were dated and timed.

Patient #1's medical record revealed the following orders were written by the practitioner without dates or times: 1/8/10 - no documented time; 1/9/10 - no documented time;
1/10/10 - has signature only, no documented date or time; 1/12/10 - no documented time.