PRINTED: 02/21/2018
FORM APPROVED
OMB NO 0938-0391

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(Xl) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

QQMl.1RE
A

RHN

B

WING

(X3) DATE SURVEY
COMPLETED

CONSTRUCTION

C
210038

01/12/2018
STREET ADDRESS, CITY, STATE, ZIP

NAME OF PROVIDER OR SUPPLIER

CODE

UNIVERSITY OF MD MEDICAL CENTER MIDTOWN CAMPUS
(X4) ID
PREFIX
TAG

A 000

A 043

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

ID
PREFIX
TAG

A 000

INITIAL COMMENTS

On January 11, 2018, based on media reports
surrounding the discharge of a patient from the
Emergency Department, an EMTALA survey was
conducted. Based on findings of the EMTALA
investigation, the survey was expanded to include
Conditions of Participation (CoPs) for Patient
Rights, Governing Body, Nursing Services and
QAPI. The following deficiencies delineate the
findings of complaint numbers of the survey for
the Conditions of Participation. (#MD00121632)
GOVERNING BODY
CFR(s): 482.12
There must be an effective governing body that is
legally responsible for the conduct of the hospital.
If a hospital does not have an organized
governing body, the persons legally responsible
for the conduct of the hospital must carry out the
functions specified in this part that pertain to the
governing body ...
This CONDITION is not met as evidenced by:
Based on interviews with staff, document reviews
and observations during a survey on January 1112,2018, it was determined the hospital was out
of compliance with the Condition of Governing
Body.
Specifically, the Emergency Department (ED)
identified a problem with patient access in August
2017, yet no evidence was found during the
survey that leadership was aware of the situation
or involved in remediation. In meeting minutes
from the ED quality council in August, 2017 nd
reviewed by the surveyors on January 11, 2018,
ED staff identified that the process of security
personnel turning away patients presenting for

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER

~3z2('

REPRESENTATIVE'S

827 LINDENAVENUE

BALTIMORE, MD 21201

A 043

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

(X5)

COMPLETION
DATE

The events that occurred at the University of
Maryland Medical Center, Midtown Campus on
January s" 2018, clearly represent an aberration
from our commitment to high quality patient care,
As part of taking full responsibility, we have
conducted an immediate internal Root Cause
Analysis, engaged outside experts to perform an
independent RCA,and received the feedback from
the for-cause audit performed by the Joint
Commission. As a result we have taken actions to
address these findings. Our corrective action plan
addresses the deficiencies cited in this CMSaudit
summary. We remain committed to delivering the
highest quality patient care to our community, and
appreciate the opportunity to provide our
responses.
he EDQuality committee is known as the ED
2-20-2018
Comprehensive Unit-based Safety Program (CUSP).
he finding in the report indicates that there was no
documented follow up from a meeting that occurred
in August 2017 that identified a potential problem
regarding accessvia security manned entrance point.
Upon further follow up discussion with the senior
leadership team, it was determined that this issue
had been escalated to the VP of operations and
ollow up was performed. The EMTALA log will be
reviewed monthly by the Quality Improvement
Coordinator assigned to the EDto ensure that all
patients are reregistered upon revisit to the EDand
receive a new MSE.
On February 20, 2018, the CMO completed a review
of all of 2017 minutes from the ED CUSPto identify
any unresolved issues or opportunities for follow up
hat did not occur. There were no other unresolved
oncerns identified. On February 27, 2018, the CMO
and Director of Patient Safety established new
meeting standards to include the completion of
meeting minutes within 7 days, The CMO and ED
2-27-2018
leadership will review the completed minutes and
twill communicate follow-up expectations with
individuals and team to ensure timely follow-up
occurs, CUSPactivities will be reported bimonthly

SIGNATURE

TITLE

(X6) DATE

Mohan Suntha, MD, MBA, UMMC President and CEO

March 2, 2018

Any deficiencystatementendingwithan asterisk(*) denotesa deficiencywhichthe institutionmaybe excusedfrom correctingprovidingit is determinedthat other
safeguardsprovidesufficientprotectionto the patients.(Seeinstructions.)Exceptfor nursinghomes,the findingsstatedaboveare disclosable90 daysfollowingthe date of
surveywhetheror not a planof correctionis provided.Fornursinghomes,the abovefindingsand plansof correctionaredisclosable14 daysfollowingthe datethese
documentsare madeavailableto the facility.If deficienciesare cited,an approvedplanof correctionis requisiteto continuedprogramparticipation.
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:M41Tll

Facility ID: MDHP25

If continuationsheet Page 1 of 10

 PRINTED: 02/21/2018
FORM APPROVED
OMB NO 0938-0391

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

210038

~lR.E

B

C
01/12/2018
STREET ADDRESS, CITY, STATE, ZIP
CODE 827 LINDEN AVENUE

UNIVERSITY OF MD MEDICAL CENTER MIDTOWN CAMPUS

A 043

(X3) DATE SURVEY
COMPLETED

WING

NAME OF PROVIDER OR SUPPLIER

(X4) ID
PREFIX
TAG

CONSTRUCTION

A~

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

Continued From page 1

BALTIMORE, MD 21201
ID
PREFIX
TAG

A 043

treatment prior to any clinical assessment was
problematic. An education plan was derived.
However, no further documentation could be
found indicating what, if anything, staff or hospital
leadership did to remediate this practice. In
addition, current QAPI data reviewed during the
survey on 1/11118 indicated no additional followup or data collection. In addition, leadership also
failed to identify inaccuracies in the ED Log,
possibly unsafe discharge practices and possible
patient harassment by security staff.

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

(X5)
COMPLETION
DATE

hrough the Patient Safety & HROCommittee, and
ultimately to the Quality and Safety Committee of
he University of Maryland Medical Center Board of
he Directors. A quarterly review of agendas,
meeting minutes, data reporting and progress
regarding committee goals will be conducted by the
Director of Patient Safety to ensure that ongoing
progress is sustained and that issues are continually
addressed, The CMO is responsible for
implementing this POCo

See A0283
A 115

PATIENT RIGHTS
CFR(s): 482.13

A 115

A hospital must protect and promote
each patient's rights.
This CONDITION is not met as evidenced by:
Based on interviews with staff, document reviews
and observations, during the survey on January
11-12,2018, it was determined the hospital is out
of compliance with the Condition of Patient
Rights. Specifically, the hospital enacted barriers
to patients receiving care in the Emergency
Department, failed to discharge a patient in a
safe manner from the Emergency Department,
and failed to protect one patient from harassment
and potential harm as cited in more detail under
A0144, A0145, and A0146.
A 144

PATIENT RIGHTS: CARE IN SAFE SETTING
CFR(s): 482.13(c)(2)
The patient has the right to receive care in a
safe setting.
This STANDARD is not met as evidenced by:

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:M41T11

A 144

In efforts to provide a safe care environment for staft
and patients, there was a longstanding practice of
keeping the interior EDentrance doors locked,
requiring Security to buzz people in upon arrival.
~he surveyors thought that this practice resulted in
nonclinical staff determining who could receive
reatment in the ED.
Facility ID: MDHP25

If continuation

sheet Page 2 of 10

 PRINTED: 02/21/2018
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

210038

OMB NO 0938-0391
~1Rf

CONSTRUCTION

A

Rlfl'Ir.

B

WING

NAME OF PROVIDER OR SUPPLIER

X3) DATE SURVEY
COMPLETED

C
01/12/2018
STREET ADDRESS, CITY, STATE, ZIP
CODE 827 LINDEN AVENUE

UNIVERSITY OF MD MEDICAL CENTER MIDTOWN CAMPUS
(X4)ID
PREFIX
TAG

A 144

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

Continued From page 2

BALTIMORE, MD 21201
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

On January 12, 2018, a communication occurred to
security staff to require them to allow accessto any
one arriving in the ED lobby seeking medical care.
EMTALAeducation was provided to all EDsecurity
and was completed by February 28, 2018 with a
special emphasis on patient rights to unencumbered
accessto emergency department.
While security staff is still present at the entrance to
maintain a safe environment, the automatic closing
mechanism on the doors was disabled and doors
were placed in the open position on February 22,
2018. In addition, on February 22 the automatic
locking function was disabled by facilities and
modified as to not allow the doors to be relocked if
hey do close.
Facilities installed functional door handles on
February 24,2018 to allow entry to the ED registrar
and triage area.
Due to the fact that these are smoke barrier doors,
ecurity implemented a protocol on February 23,
2018 to close these doors during a fire alarm event.
Leadership rounding will be completed by Security
Director and Security Manager at least weekly to
reinforce security staff knowledge and
understanding of EMTALAand Patient Rights.
Daily rounding will be conducted by security
supervisors to ensure that the EDentrance doors
remain open. The Director of Security will be
responsible for ongoing monitoring.
The CaseManager who reported that she was
unable to reenter through the ambulance doors was
educated that those doors are intended for EMS
accessand emergency use only, and that reentry was
restricted for safety reasons. If staff were to exit
hrough those doors, there is a video doorbell that
ould be used, or staff can enter through the main
EDentrance.

A 144

Based on observations and interviews in the
emergency department (ED and review of
documentation on January 11,2018, it was
determined that the hospital failed to provide
care in a safe setting for emergency department
patients as evidenced by the physical layout of
the ED access point which prevented patient
access to the ED, and by the fact that not all ED
staff have badge access through locked
entrance and exit doors.
Surveyors observed that the entrance door for
walk-in patients to the ED was locked with
access controlled by hospital security
personnel. During an interview on 1111/8,
security personnel indicated that they would turn
patients away if they were "unruly" or otherwise
acting inappropriately. This practice meant that
non-clinical personnel determined who could
receive treatment in the ED.
In addition, in a review of documentation on
1/11/18 regarding patient #1, who was seen in the
ED on 119/18, it was determined that the case
manager who saw patient #1 in the ED was
unable to assess patient needs because the case
manager's badge would not open the exit door.

A 145

Pt# 1 departed the ED prior to the case
manager's assessment and the case manager
attempted to exit the ED as Pt# 1 left the ED
vicinity. The hospital did not provide a
functioning ID badge to case management
personnel and the case manager was denied
access through a secured exit door, preventing
the case manager from completing the
evaluation of pt. #1. PATIENT RIGHTS: FREE
FROM ABUSE/HARASSMENT

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:M41T11

(X5)

COMPLETION
DATE

A 145

1-12-2018

2-28-2018

2-22-2018

2-24-2018

2-23-2018

Once an ERpatient is medically cleared for
discharge, the patient's nurse is responsible for
establishing and communicating the plan for safe
discharge in consultation with the patient's
provider and other members of the EDclinical and

Facility ID: MDHP25

If continuation

sheet Page 3 of 10

 PRINTED: 02/21/2018
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO 0938-0391
~lR.E

CONSTRUCTION

A

RII"I\r.

B

WING

X3) DATE SURVEY
COMPLETED

C
210038
NAME OF PROVIDER OR SUPPLIER

01/12/2018
STREET ADDRESS, CITY, STATE, ZIP
CODE 827 LINDEN AVENUE

UNIVERSITY OF MD MEDICAL CENTER MIDTOWN CAMPUS
(X4) 10
PREFIX
TAG

A 145

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

Continued From page 3

SALTIMORE, MD 21201
10
PREFIX
TAG

A 145

CFR(s): 482.13(c)(3)
The patient has the right to be free from all
forms of abuse or harassment.
This STANDARD is not met as evidenced by:
Based on review of medical records, interviews
with staff, and security camera footage on
1/11/2018, it was determined the hospital
neglected to keep Patient #1 safe from harm as
evidenced by the failure of Emergency
Department (ED) staff to properly execute Pt#
1's discharge plan.

A 146

Documentation indicated that Pt# 1 was admitted
to the ED via ambulance with a head injury from a
fall off of a motorized bicycle on an early January
2018 evening. Pt# 1 was triaged, examined and
medically cleared for discharge by medical staff at
2300. Pt# 1 was resistant to discharge and
refused to get dressed into street clothes when
requested by nursing. Pt# 1's discharge plan was
documented as transport via taxi cab to a coldweather shelter where a female bed had been
arranged by case management. Medical record
documentation indicated that Pt#1 agreed to the
discharge plan but the patient became resistant to
going and stopped responding to staff. Nursing
requested assistance from the security staff. At
approximately 2330, Pt# 1 was given her
belongings escorted out of the ED by security staff
while wearing only a hospital gown and socks to a
nearby bus stop and was left there in
approximately 30 degree Fahrenheit weather. The
documentation failed to indicate whether it was
nursing or security who made the decision to
remove pt #1 from the ED.
PATIENT RIGHTS: CONFIDENTIALITY OF

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:M41T11

A 146

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

(X5)
COMPLETION
DATE

support team. The specific elements of the
discharge plan are communicated verbally
among the patient's care team members and
also documented in the patient's electronic
medical record so that members of the care
team are able to review the discharge plan. In
this instance, a case manager assisted nursing
with the discharge plan and arranged for the
safe discharge to include a taxicab transport of
the patient to a shelter. When the patient
became uncooperative, the plan was not carried
out due to communication failure among the
care team members. The immediate plan to
ensure the safe discharge of difficult discharge
1-13-2018
patients was instituted on January 13, 2018.
This plan requires communication with a Health
System resource prior to effectuating the
discharge. This resource ensures appropriate
communication has occurred between all team
members and a safe discharge plan is achieved.
The plan for correcting this failure will also
include 1) re-education of all members of the ER
clinical and support team on the discharge plan
communication process and 2) implementation
of a Nursing Log for Discharged Patients who
Require Assistance from Security. A formalized
document that outlines chain of command was
created and all ERstaff received this education
2-28-2018
by February 28,2018. Nursing will continue to
hold the primary responsibility for formulating
and communicating the plan for safe discharge
of all patients. Other members of the care team
will continue to be called upon to help
formulate and implement the plan including
CaseManagement, Social Work, EDBUcrisis
evaluators, and others as needed. Each person
involved in implementing the plan will continue
to document pertinent information for the
individualized discharge plan in a progress note
and in the assessment screens for each
discipline or department in the EHR. Any
member of the ERclinical and support team
who has concerns about any element of the
Facility 10: MDHP25

If continuation

sheet Page 4 of 10

 PRINTED: 02/21/2018
FORM APPROVED
OMB NO 0938-0391

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

~lRf
A

RlrI>.r.

B

WING

CONSTRUCTION

X3) DATE SURVEY
COMPLETED

C
210038
NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP
CODE 827 LINDEN AVENUE

UNIVERSITY OF MD MEDICAL CENTER MIDTOWN CAMPUS
(X4) ID
PREFIX
TAG

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

A 146 Continued From page

BALTIMORE, MD 21201
ID
PREFIX
TAG

A 146

4 RECORDS
CFR(s): 482.13(d)
Patient Rights: Confidentiality

of Records

This STANDARD is not met as evidenced by:
Based on documents reviewed at the time of the
survey, it was determined the hospital failed to
ensure the confidentiality of patient records in 1
of 25 records reviewed. Review of Pt# 1's
medical record and related documents revealed
statements by non-clinical staff that non-clinical
staff had access to or were made aware of
portions of Pt #1 's medical history and physical
examination findings. Pt# 1 presented to the
Emergency Department where diagnostic
processes were performed. Non-clinical staff
assisted clinical staff in the discharge of Pt# 1. A
subsequent written statement by non-clinical staff
that pertained to Pt# 1's discharge included
confidential diagnostic and medical history
information not required in the execution of their
prescribed duties.
A 273 DATA COLLECTION & ANALYSIS
CFR(s): 482.21 (a), (b)(1),(b)(2)(i), (b)(3)

A 273

(a) Program Scope
(1) The program must include, but not be limited
to, an ongoing program that shows measurable
improvement in indicators for which there is
evidence that it will improve health outcomes ...
(2) The hospital must measure, analyze, and
track quality indicators ... and other aspects
of performance that assess processes of
care, hospital service and operations.
(b) Program Data
(1) The program must incorporate quality
FORM CMS-2567(02-99) Previous Versions Obsolete

01/12/2018

Event ID:M41T11

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

(X5)
COMPLETION
DATE

A 145 CONTINUED:
discharge plan will escalate concerns using the
chain of command before the patient leaves the ER.
(SeeAttachment A) All ED providers and staff will
be re-educated on elements of a safe discharge
plan. Specific education regarding the importance
of effective communication among team members,
verbally and documented in the medical record, will
be added to the unit-based orientation plan for all
new providers, clinical and support staff who
practice in the emergency department. Education
will also be reinforced in all monthly ERunit based
nursing and provider staff meetings.
A monthly review of the Nursing Log for Discharged
Patients who Require Assistance from Security will
be compared to the Security Log to ensure
adequate communication has occurred in every
circumstance. In addition, these logs will be
monitored for trends. Care Management staff (ED
& House-wide) were educated on importance of
effective communication in the discharge process
this was completed on February 28, 2018.
2-28-2018
On January 10, 2018 Provider staff received
education on the importance of effective verbal
1-10-2018
communication and documentation of discharge
plans.
A monthly chart audit will be conducted to assess
that the discharge has been appropriately
documented. The Quality Department will conduct
a review of the Nursing Log with the Security Log to
ensure that appropriate communication has
occurred about all difficult discharges. Director of
Nursing Medical Services is responsible for
implementing the Poe.
One of the key tenets of the organization is
respectful and dignified treatment of patients,
visitors and each other. This incident represented a
failure in the outlined expectations of staff and will
require re-training of service standard expectations.
The plan includes: Immediate and general reeducation of the expectations to treat all individuals
with respect and dignity; A new educational flyer
(SeeAttachment 8) was created and posted in
Facility ID: MDHP25

If continuation

sheet Page 5 of 10

 PRINTED:02/21/2018
FORMAPPROVED
OMB NO 0938-0391

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

~lR.E
A

CONSTRUCTION

RIll\[.

X3) DATE SURVEY
COMPLETED

C
210038

B WING

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP
CODE 827 LINDEN AVENUE

UNIVERSITYOF MDMEDICALCENTERMIDTOWNCAMPUS
(X4) ID
PREFIX
TAG

01/12/2018

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

BALTIMORE,MD 21201
ID
PREFIX
TAG

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

2-27-2018

A 145 CONTINUED:
A 273 Continued From page 5

A 273

indicator data including patient care data, and
other relevant data, for example, information
submitted to, or received from, the hospital's
Quality Improvement Organization.
(2) The hospital must use the data collected to-(i) Monitor the effectiveness and safety of
services and quality of care; and ....
(3) The frequency and detail of data collection
must be specified by the hospital's governing
body.

This STANDARD is not met as evidenced by:
Based on review of records, quality initiatives,
quality data, and staff interviews, it was
determined the hospital tracked metrics related to
72-hour Emergency Department (ED) Return
Visits but failed to compile and utilize accurate
aggregate data to monitor the safety and
effectiveness of care due to a flawed collection
process. Staff interviews and a review of records
revealed staff re-opened the medical record of 1
of 25 patients retuming to the Emergency
Department (ED) within two hours of discharge
and continued documentation of the return visit in
the original visit record. Additionally, surveyors
discovered the "2-hour process" was a routine
hospital practice where patients discharged from
the ED who again presented to the ED within two
hours of that discharge, had only one visit record
for what would be considered two separate ED
visits.
A 283 QUALITY IMPROVEMENTACTIVITIES
CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3)

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:M41T11

A 283

(X5)
COMPLETION
DATE

the Emergency Department on 2/27/18; Ensurin~
that employees complete the My Team Care
program. Every Security Guard was re-educated
regarding appropriate treatment
of patients;
mandating respectful and dignified care, free 0
abuse or harassment, Jan 11 - Feb 28, 2018. Eve!)
Security Guard will complete the service excellence
training provided through the UMMC Midtown M~
Team Cares program.
Upon completion of an
internal Root Cause Analysis (RCA), appropriate HR
action was taken with involved employees. Upon
hire, Security team members and all Midtown staft
attends the required New Employee Orientation tha
emphasizes Respect, Integrity, Teamwork and
Excellence. Orientation has been revised to include
Patient Rights and Responsibilities. This information
will be reviewed annually to ensure appropriate and
thorough knowledge of expectations and practice.
Accountability for My Team Cares program
completion will be validated through a required
sign-in sheet provided at all training sessions,
schedules for training have been established and
will be executed. Security Team Training - Providing
Dignified & Respectful Care: March 5, 2018. ED
Staff Training - Providing Dignified & Respectful Care
March 5, 2018. UMMC Midtown staff - My Team
Cares,completed by March 31, 2018. Completion
of training will be verified by the Senior Director of
Service and Performance Excellence. In addition,
2-28-2018
patient complaints and grievances will be formally
reviewed monthly by the Sr. Director of Service and
3-5-2018
Performance Excellenceto identify breaches in
these specific service standards practice and
3-31-2018
behavioral expectations. Manage observations of
staff practice and behavior that do not meet
expectations will be addressed in real-time with
corrective action, as necessary. Sr. Dir. of Service
and Performance Excellence and Dir of Security
Service are responsible for implementing the POC.
Facility ID: MDHP25

If continuation sheet Page 6 of 10

 PRINTED: 02/21/2018
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO 0938-0391
QQ1vU.lRf
A

RlrI\r.

B

WING

X3) DATE SURVEY
COMPLETED

CONSTRUCTION

C
210038

01/12/2018
STREET ADDRESS, CITY, STATE, ZIP

NAME OF PROVIDER OR SUPPLIER

CODE

UNIVERSITY OF MD MEDICAL CENTER MIDTOWN CAMPUS
(X4) 10
PREFIX
TAG

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

827 LINDEN

AVENUE

BALTIMORE, MD 21201
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

10
PREFIX
TAG

(X5)

COMPLETION

DATE

A 146
A 283 Continued From page 6

A283

(b) Program Data
(2) [The hospital must use the data collected to '" ]
(ii) Identify opportunities for improvement and
changes that will lead to improvement.
(C) Program Activities
(1) The hospital must set priorities for its
performance improvement activities that-(i) Focus on high-risk, high-volume,
or problem-prone areas;
(ii)Consider the incidence, prevalence, and
severity of problems in those areas; and
(iii) Affect health outcomes, patient safety,
and quality of care.
(3) The hospital must take actions aimed at
performance improvement and, after
implementing those actions, the hospital must
measure its success, and track performance
to ensure that improvements are sustained.

This STANDARD is not met as evidenced by:
Based on review of medical records, quality
initiatives and meeting minutes, surveyors
determined hospital Quality personnel identified
inconsistencies in the Emergency Department
(ED) process for handling "violent patients" who
presented to the ED and were subsequently
denied access prior to receiving triage, a medical
screening exam (MSE), or any other clinical
assessments.

HIPAAand Patient Confidentiality Education is
provided upon hire and annually. All staff sign a
Confidentiality Agreement that is maintained within
Human Resource department.
In this situation, the EDclinical team was unaware
that that the level of detail provided to security was
more than what is allowable under HIPAAand
Patient Confidentiality rules. All staff who works
within the emergency department were reeducated
to limit the sharing of clinical information to only
vital information necessaryto ensure a safe
discharge.
In-person education provided to staff via in-services,
huddles and staff meetings was completed by
February 28th, 2018. For staff unavailable to attend
any of the in-person training sessions, a self-Iearnin€
packet was completed with an attestation
statement confirming understanding and
2-28-2018
completion.
Leaders of Security, Nursing, Patient Accessand
Providers will continue to reinforce education by
conducting ongoing rounding with EDteam
members to ascertain their comprehension and
practice related to HIPPA/Patient Confidentiality.
The Medical Director and Director of Nursing for the
EDare responsible for the implementation of the

POCo

A 273
In the past, when a patient returned to the EDwithin
2 hours of a prior visit, the original encounter was reopened using "un-discharge" functionality and no
new encounter was created. The clinicians believed
hat this aided in providing continuity of care. During
he survey, it was identified that the practice of the
informal 2 hour rule resulted in the patient not being
aptured on the EMTALA log.

In meeting minutes from the ED quality council in
August, 2017, ED staff identified that the process
of security personnel turning away patients
presentingfor treatment prior to any clinical
FORM CMS-2567(02-99) PrevIous Versions Obsolete

Event ID:M41T11

Facility 10: MDHP25

If continuation sheet Page 7 of 10

 PRINTED: 02/21/2018
FORM APPROVED
OMB NO 0938-0391

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

210038

~1ru

CONSTRUCTION

A RlfN

B

X3) DATE SURVEY
COMPLETED

C
01/12/2018

WING

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP
CODE 827 LINDEN AVENUE

UNIVERSITY OF MD MEDICAL CENTER MIDTOWN CAMPUS
(X4)ID
PREFIX
TAG

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

A 283 Continued From page 7

BALTIMORE, MD 21201
10
PREFIX
TAG

(X5)

COMPLETION
DATE

2-8-2018

A 283

assessment was problematic. An education plan
was derived. However, no further documentation
could be found indicating what, if anything, staff
or hospital leadership did to remediate this
practice. In addition, current QAPI data reviewed
during the survey on 1/11/18 indicated no
additional follow-up or data collection.
A 438 FORM AND RETENTION OF RECORDS
CFR(s): 482.24(b)

A438

The hospital must maintain a medical record for
each inpatient and outpatient. Medical records
must be accurately written, promptly completed,
properly filed and retained, and accessible. The
hospital must use a system of author
identification and record maintenance that
ensures the integrity of the authentication and
protects the security of all record entries.
This STANDARD is not met as evidenced by:
Based on interview and review of patient #1's
emergency department (ED) record, it was
determined that the hospital failed to keep
accurate records for patient #1 and other patients
presenting again within two hours of discharge
from the ED.
On survey of 1/11/2018 at approximately 0930, a
request to a Quality staff member for two ED
records of the same-day belonging to patient #1
revealed in part, that patient #1 had only one
record. This was due to an unwritten policy which
instructed patient access staff to reopen an initial
ED record of patients who return to the ED within
2 hours of ED discharge. Interview at 0930
revealed that, ''The prior record (initial
presentation) is reopened for continuity of care.

FORM CMS-2567(02-99) Previous Versions Obsolete

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

Event ID:M41T11

A 273 CONTINUED:
On February 8, 2018, ED registration staff was
educated that they must ceasethe practice of using
he "un-discharge" button.
On February 28, 2018 the "un-discharge'
~unctionality was disabled, and therefore, each
patient visit will appear in the EMTALA log.
jrhe EMTALAlog will be reviewed monthly by the
Quality Improvement Coordinator assigned to the
EDto ensure that all patients are reregistered upon
revisit to the ED. If the log shows evidence of
patients having more than one encounter within two
hours, the process will be deemed compliant.
Historically, EDleadership reports that
~pproximately 3 patients per month return within 2
hours, If the audit shows that no patients are found
o have more than one encounter within two hours
for a period of 30 days, 70 records will be audited to
heck for any evidence of notes entered after the
irst discharge time which may indicate a revisit,
~iven that we monitor all patients who are deemed
high utilizers, (meaning that they have more than 6
~isits in the past 6 months) to address population
health need, we will use this population to perform
audlts, We have performed this validation for the
month of February 2018 and note that 41 patients
returned to the EDwithin 24 hours, 2 of which were
ound to have been registered within 2 hours on
February 22, 2018. We will continue this audit on a
monthly basis. The results of this audit will be
presented to the ED Department Comprehensive
Unit-based Safety Program, to the Patient Safety &
HROCommittee, which will report to the Quality
Board of the Medical Center. The Director of Quality
will be responsible for ongoing monitoring.
he Director of Patient Access is responsible for
implementing the acceptable pac.

Facility ID: MDHP25

If continuation

2-28-2018

sheet Page 8 of 10

 PRINTED: 02/21/2018
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMS NO 0938-0391
WJ-lRE
A

CONSTRUCTION

X3) DATE SURVEY
COMPLETED

R trW-

C

01/12/2018

B WING

210038

STREET ADDRESS, CITY, STATE, ZIP

NAME OF PROVIDER OR SUPPLIER

CODE 827 LINDEN AVENUE

UNIVERSITY OF MD MEDICAL CENTER MIDTOWN CAMPUS
(X4) 10
PREFIX
TAG

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

BALTIMORE, MD 21201
10
PREFIX
TAG

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

(X5)

COMPLETION
DATE

A 283
A 438 Continued From page 8

A 438

Interview at approximately 9:45 am with the
Director of Patient Access revealed knowledge of
the 2-hour rule, but identified that there was no
written policy. Further, that when it is noted at the
registrar that a patient had been seen 2-hours
prior, the ED RN was to be notified. Interview at
approximately 1030 with the Regional Medical
Director for contracted ED providers revealed
knowledge of the 2-hour rule and the statement
that upon the second presentation, the
expectation is that a provider enter an addendum
progress note into the re-opened record.
Patient #1 was a young adult who presented to
the ED in January 2018 at 1304 (12:04PM) via
ambulance following a fall from a motorized bike,
which resulted in striking a curb and an apparent
minor head injury. On arrival, an MSE was
conducted inclusive of Computed Tomography
(CT) of the head. Followingthe MSE, patient #1
was found to be free of an emergency medical
condition and was cleared for discharge.
Patient #1 was resistant to discharge and would
not dress. Patient #1 was subsequently escorted
from the hospital by security staff while still in a
hospital gown on or about 2340 (11:40 PM), but
was brought back via ambulance at 0013
(12:13AM). Ambulance documentation revealed
patient #1's chief complaint was "I do not feel
normal, and do not know what normal is." On
arrival to the ED the second time, the initial ED
record was reopened.

FORM CMS-2S67 02-99 Previous Versions Obsolete

Event ID.M41T11

The ED Quality committee is known as the ED
Comprehensive Unit-based Safety Program (CUSP).
he finding in the report indicates that there was no
~ocumented follow up from a meeting that occurred
in August 2017. Upon discussion with the Executive 2-20-2018
Leadership team, it was determined that follow up
had been performed to address the concern, and had
been performed by the VP of Operations (who is
responsible for the Security department). On
2-27-2018
February 20, 2018, the CMO completed a review of all
pf 2017 minutes from the ED CUSPto identify any
unresolved issues or opportunities for follow up that
~id not occur. There were no other unresolved
oncerns identified.
pn February 27, 2018, the CMO and Director 0
Patient Safety established new meeting standards to
include the completion of meeting minutes within 7
~ays. The CMO and ED leadership will review the
ompleted minutes and will communicate follow up
~xpectations with individuals/teams to ensure timely
ollow up occurs. CUSP activities will be reported
bimonthly through the Patient Safety & HRO
~ommittee, and ultimately to the Quality and Safety
~ommittee of the University of Maryland Medical
~enter Board of the Directors. A quarterly review 0
~gendas, meeting minutes, data reporting and
progress regarding committee
goals will be
onducted by the Director of Patient Safety to ensure
hat ongoing progress is sustained and that issuesare
ontinually addressed. The CMO is responsible foi
mplementing the acceptable POe. In efforts to
provide a safe care environment for staff and
patients, there was a longstanding practice of keeping
he interior ED entrance doors locked, requiring
Securltv to buzz people in upon arrival. The surveyors
hought that this practice resulted in nonclinical staff
~etermining who could receive treatment in the ED.
pn January 12, 2018, a communication occurred to
securltv staff to require them to allow access to an\
pne arriving in the ED lobby seeking medical care,
including those with unruly behavior patients.
Facility 10: MDHP25

If continuation sheet Page 9 of 10

 A 283 CONTINUED:
EMTALAeducation was provided to all EDsecurity and was completed by February 28, 2018 with a special emphasis on patient rights to unencumbered
accessto emergency department even for patients who display unruly behavior. For anyone displaying concerning behavior, Security will accompany
patients into the treatment area to provide a safe environmental for staff and other patients. While security staff is still present at the entrance to
maintain a safe environment, the automatic closing mechanism on the doors was disabled and doors were placed in the open position on February 22,
2018. In addition, the automatic locking function was disabled by facilities and modified as to not allow the doors to be relocked if they do close. Facilities
installed functional door handles on February 24, 2018 to allow entry to the ED registrar and triage area. Due to the fact that these are smoke barrier
doors, security implemented a protocol on February 23, 2018 to close these doors during a fire alarm event.
Leadership rounding will be completed by Security Director and Security Manager at least weekly to reinforce security staff knowledge and understanding
of EMTALAand Patient Rights. Daily rounding will be conducted by security supervisors to ensure that the EDentrance doors remain open. The Director
of Security will be responsible for ongoing monitoring.
Quality team will perform a monthly review of data obtained from Complaint logs, Security Reporting system and RL6event system to identify events that
require Quality monitoring. The quality team will validate the retention of knowledge regarding principles of EMTALA,HIPAA,and Patient Rights. Quality
review of event logs and complaint data occurred February 28, 2018. Quality team validation of education will begin March 7, 2018. Director of Quality
is responsible for implementing the acceptable POe.

A 438 - Forms and Retention of Records
The previous practice of re-opening a patient's chart for documentation was ceased with a hard stop that was created in the EMR on February 28, 2018
to not allow it to recur. Eachvisit will create a new encounter and will generate a new record.
In the past, when a patient returned to the EDwithin 2 hours, the original chart was re-opened and no new encounter was created. This process was
stopped on February 8th, 2018. Every patient who comes to the EDwill be re-registered and will generate a new medical record every time that they
present which will ensure an accurate EMTALA log. The 2 hour rule has been discontinued and a hard stop in the EMRwas implemented to prevent reopening of a patient record. By creating a new encounter, the system will ensure that there is a separate record for each patient visit.
The EMTALAlog will be audited monthly by the Quality Department to ensure that all patients are reregistered upon revisit to the EDand a new medical
record is created. The results of this audit will be presented to the ED Department Comprehensive Unit -based Safety Program, to the hospital level
Quality Improvement Committee, and the Patient Safety & HROCommittee. Director of Patient Access is responsible for implementing the pac.

Page 10 of 10