Medstar Harbor Hospital

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 42332 Based on unit observation and interviews, the facility failed to initially ensure that the special care nursery adhered to the Facility Guideline Institute (FGI) requirement for 120 square feet of clear floor space per infant in the special care nursery. This space limitation had the potential to compromise safe care delivery, effective infection control, and emergency response capabilities. Findings: During an observation of the Special Care Nursery (SCN) on September 18, 2024, nurse surveyors measured the space and noted that the 245 square feet space, held 5 infants. The FGI guideline specifies that each infant required 120 square feet, but the nursery provided only 49 square feet per infant. Interviews with a total of 3 SCN nurses on day 1 and day 2 of the survey, revealed that the space constraints made it challenging to manage equipment and maintain infection control practices. In an interview with 2 special care nursery nursing staff on September 19, 2024, at 10:00 am, Staff Nurse #2 and Staff Nurse #3 both stated that it took a lot of careful consideration for moving equipment, often resorting to using a single pole to attach multiple pieces of equipment onto it as needed by the baby. Both nurses also expressed concerns related to challenges with managaging infection control practices in the limited space, especially as it related to patient visitors. Based on findings during the investigation, on day two of the survey, the facility promptly separated the infants into two different areas to ensure compliance with the 120 square feet requirement per FGI guidelines. The surveyors confirmed that the second area was secured and equipped with appropriate monitoring and necessary equipment to support safe and effective infant care.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 48657 Based on a review of medical records, staff interviews, and video surveillance footage, it was determined that the facility failed to provide continuous one-to-one observation of a patient during a seclusion event as required by hospital policy. This was evident for 1 of 10 patients reviewed. The findings included: The surveyor reviewed the facility policy titled “Use of Restraints/Seclusion With Safety and Dignity,” last revised September 2021, on day 1 of the survey. The policy stated in part, “to provide 1:1 continuous observation for a patient in seclusion. Associates with appropriate training shall continuously visually observe the patient for current mental and physical status and potential for release.” The surveyor reviewed the educational PowerPoint presentation dated July 2024 titled “ Restraints” on day 1 of the onsite survey. The presentation showed that monitoring of the patient in restraint or locked door seclusion requires continuous one-to-one observation. The surveyor reviewed the medical records on day 2 of the onsite survey which provided the following information. Patient #1 (P1) was an 18+ year-old who presented to the emergency department (ED) with suicidal ideation and was admitted to the inpatient behavioral health unit. Approximately a half hour after being seen by the Physician Assistant (PA), P1 attempted to elope from the unit, refused to return to the unit, despite multiple verbal attempts by staff, and became aggressive with staff. P1 was placed in locked door seclusion following these behaviors for approximately 3 hours and 45 minutes. The surveyor interviewed the unit staff on days 3 and 4 of the onsite survey. Staff interviews included 2 staff Registered Nurses (RNs) and a charge RN. They were asked the following questions, “Does seclusion require a one-to-one observer during the use of this intervention? What is the time frame? And who [takes on the observer role]?” Registered Nurse #1 (RN1) stated, “Yes, the entire time. Typically, we will assign it to a counselor. If no counselor, then a nurse would be assigned. The one-to-one observer is sitting right outside the door at the window where they can see the patient.” Registered Nurse #2 (RN2) answered, “Yes. The nurse and our PCs (psych counselors). Usually, once we put them in there and they’re safe. The nurse or the PC will sit with the patient. We will sit right outside the door with direct observation.” Charge RN (RN3) responded, “Yes we use our counselors a lot of the time. Sometimes we use nurses too. They sit right outside the door in the ante-space at the seclusion room door.” The surveyor reviewed the video footage outside the seclusion room door on day 3 of the onsite survey for P1’s seclusion episode described above. It revealed no direct observation of P1 by hospital staff for approximately 2 hours and 45 minutes of the seclusion episode.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 48657 Based on a review of policies and procedures, medical records, and video surveillance footage, it was determined that the facility failed to discontinue a seclusion event at the earliest possible time. This was evident for 1 of 10 patients reviewed. The findings included: On day 1 of the onsite survey, the surveyor reviewed the facility policy titled “Use of Restraints/Seclusion With Safety and Dignity,” last revised September 2021. The policy review stated, “Stopping restraints or seclusion should be discontinued at the earliest possible time when the patient no longer exhibits the behavior requiring the restraints, regardless of the time limit of the enabling restraint order.” The surveyor reviewed the educational PowerPoint presentation, dated July 2024, titled “Restraints” on day 1 of the onsite survey. It stated, “restraints (including locked door seclusion) must be discontinued when patient no longer poses a threat of injury to self or others including patient asleep”. The surveyor reviewed medical records on day 2 of the onsite survey which provided the following information. Patient #1 (P1) was an 18+ year-old who presented to the emergency department (ED) with suicidal ideation and was admitted to the inpatient behavioral health unit. Approximately a half hour after being seen by the Physician Assistant (PA), P1 attempted to elope from the unit, refused to return to the unit, despite multiple verbal attempts by staff, and became aggressive with staff. P1 was placed in locked door seclusion following these behaviors for approximately 3 hours and 45 minutes. Documentation every 15 minutes for the last hour and 15 minutes of the seclusion episode revealed that P1 was, “lying down, awake, and quiet.” The surveyor reviewed the video footage of the seclusion event on day 3 of the onsite survey. Video footage of P1 inside the seclusion room revealed that P1 was lying down, quiet, and at times appeared asleep for the last approximate hour and 15 minutes of the seclusion episode; however, the patient remained in the seclusion.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 43028 Based on unit observation, staff interviews, and review of other pertinent documents, it was determined that the hospital failed to ensure the cleanliness and safety of the patient care environment on the inpatient psychiatric unit. This failure affected the right of all patients on the unit to have access to clean and sanitary environment of care and increased the risk of exposure to infections. The findings included: The surveyors conducted an observation of a 12-bed inpatient psychiatric unit on day one of the onsite survey. The surveyors were accompanied by the Care Transitions Manager, the Senior Director of Nursing, the Director of Nursing for Behavioral Health, and the Infection Prevention Manager. There were two seclusion rooms and a restroom with an ante-type space on the unit. The right-hand seclusion room had a disposable food tray on the floor and food particles splattered on the floor, as well as the walls. The left-hand seclusion room had a strong urine odor. The surveyors asked the accompanying staff when was the last time the rooms were used by patients; however, no one was able to recall the day/date, but it was stated the information could be located in the Seclusion/Restraint log kept in the nurses station. Upon review of the log, it was determined that the rooms had not been used for at least 24-hours. There were two shower rooms located in the main hallway on the unit. The shower room marked “#1” had a wet washcloth in the shower and a wet towel on the floor. It was unclear the last time the room was used.”