University of MD Capital Region Medical Center

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 40926 Based on a review of medical records, and other pertinent documents, it was determined that the hospital failed to support the rights of Patient #11 (P11) as evidenced by the administration of sedative medications to perform a procedure that was initially refused by the patient. Findings include: P11 was a 20+ year old patient who was transported by law enforcement to the emergency department (ED) for an emergency psychiatric evaluation. According to the patient’s family members, P11 had been acting irrationally, was under the influence of illegal substances and was showing aggression towards their parent. P11 was triaged by nursing staff and evaluated by an ED physician within an hour of his/her arrival to the ED. Nursing staff documented that P11 refused to allow bloodwork to be drawn and asked to speak to the physician. Approximately four minutes later an order was written for P11 to receive antipsychotic and sedative medications via intramuscular injection. Less than an hour after administration of the medications, nursing staff documented “labs collected.” No documentation was found to support that the chemical restraint was related to negative behaviors by the patient.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 40926 Based on a review of medical records, hospital policies and procedures and other pertinent information it was determined that the hospital failed to support Patient 11’s (P11) right to refuse treatment and failure to release P11 from restraints at the earliest possible time. Findings include: Surveyors reviewed the hospital’s policy titled; Use of Restraints effective 03/2025. It states in part under section I. Violent Restraints, “1. Process: a. types of restraints iii. Chemical restraint, iv. Physical hold. Furthermore, it states that, “b. Criteria for use of Violent restraints: i. imminent danger to harm self/others and ii. Disruptive to the therapeutic environment. Additionally, this policy states, “h. the need for restraint should be assessed per standards to ensure that the patient is released from restraint at the earliest possible time,” and “j. if a patient is no longer a danger to self or others all restraints must be removed (all four limbs must be removed at the same time).” P11 was a 20+ year old patient who was transported by law enforcement to the emergency department (ED) for an emergency psychiatric evaluation. According to the patient’s family members, P11 had been acting irrationally, was under the influence of illegal substances and was showing aggression towards their parent. P11 was triaged by nursing staff and evaluated by an ED physician within an hour of his/her arrival to the ED. Nursing staff documented that P11 refused to allow bloodwork to be drawn and asked to speak to the physician. Approximately four minutes later an order was written for P11 to receive antipsychotic and sedative medications via intramuscular injection. Less than an hour later, nursing staff documented “labs collected.” No aggressive or other behaviors were noted to support the administration of medications being used as a chemical restraint. Approximately four hours later, P11 was noted as showing aggression and an order was written for four-point (both arms and both legs) restraints to be applied. At the time of initiation, nursing staff documented, “patient calm in restraints.” During the first hour in restraints, P11 was documented as “cooperative, asleep.” The following hour P11 was allowed to have a free hand (right hand) while eating; however, the other three restraints remained in place. While eating, P11 was again noted to be “cooperative.” P11 was in restraints for 2+ hours without an indication of need for restraint, as the behaviors causing the restraint episode had been documented as ceased.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. This Standard is not met as evidenced by: 40926 Based on a review of medical records, hospital policies and procedures and other pertinent documentation it was determined that the hospital applied restraints (physical hold and chemical restraint) after it was documented that less restrictive interventions were effective. Findings include: Surveyors reviewed the hospital’s policy titled; Use of Restraints effective 03/2025. Under section I. Violent Restraints, it states in part, “1. Process: a. types of restraints iii. Chemical restraint, iv. Physical hold. Furthermore, it states that, “b. Criteria for use of Violent restraints: i. imminent danger to harm self/others and ii. Disruptive to the therapeutic environment. P13 was a 20+ year old patient who was transported by law enforcement to the emergency department (ED) for an emergency psychiatric evaluation. P13 was documented as being aggressive, threatening and attempting to hurt family members. P13 was evaluated and determined that he/she would require inpatient stabilization and treatment and was admitted to the inpatient behavioral health unit. The following day, P13 was noted as acting aggressive towards a peer. Nursing staff documented that the situation was successfully de-escalated verbally and the patient was held back. It was also documented that the psychiatrist was present on the unit and informed of the incident. The psychiatrist wrote an order for three medications to be administered intramuscularly (including an antipsychotic medication used in emergency situations) after the situation had been deescalated. Additionally, an order was written for a physical hold for administration of the medications. An evaluation was completed by both nursing and the physician stating P13 was held from 12:09 pm to 12:13pm for medication administration; however, a nursing note stated that the medications were administered without a physical hold. No documentation was found to support the need for the medications after de-escalation techniques were documented as successful or whether the patient was held against their will for the administration.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 40926 Based on a review of medical records, staff interviews and other pertinent information it was determined that the hospital failed to utilize the nursing standards for medication administration for Patient #1 (P1) as evidenced by administration of the wrong medication to the patient. Findings include: Surveyors reviewed the hospital policy titled; Medication Management effective 08/2024. The policy states in part under ‘Administration of Medications’ that “before administering a medication, the healthcare professional is responsible for the following: before administering a new medication, the patient or family is informed about potential clinically significant adverse drug reactions or other concerns ....” Additionally, this hospital policy states that, “When administering medication, the staff member will provide patient education including: name of medication, type and reason for use” and “five rights of medication administration (right patient, right medication, right dose, right route and right time) are assessed prior to medication administration.” P1 was a 30+ year old pregnant patient who presented to the hospital with complaints of leaking amniotic fluid (fluid surrounding the baby in the uterus). On evaluation, it was confirmed that P1 was leaking fluid leaving them at risk for infection and preterm labor. Due to P1 still being early on in the pregnancy the decision was made to admit the patient for the remainder of the pregnancy. Approximately one week into this admission an order was placed by the physician for P1 to receive an anti-viral medication. After administration of the medication, the nurse questioned the patient about a diagnosis related to the medication at which time P1 denied a diagnosis that matched the need for this medication and attempted to vomit the medication out. The physician was notified and it was determined that the medication was ordered in error and was meant for another patient. On April 11, 2025 at 11:00 am surveyors interviewed the registered nurse (RN1) who administered the medication. During the interview, it was determined that prior to this medication being administered, the name of the medication and verification of the correct patient receiving this medication was not verified. RN1 administered the medication during this inpatient admission without following the hospital’s policy.”