Maryland health officials have recommended sanctions against a Prince George's County hospital that kept an 18-year-old mentally retarded man in restraints in an emergency room cubicle for 11 days while social workers tried to place him in another facility.
Throughout the extraordinary stay last fall at Doctors Community Hospital in Lanham, the unidentified man was tied down at the wrists and ankles and, at times, with a special vest anchored to the bed. He was watched round-the-clock by a nurse's aide and freed only for brief walks and to go to the bathroom. For four of those days, he was relegated to a stretcher.
State officials describe this week's action as a response to an unheard-of violation of patient rights protections that bar confinement by staff as a means of coercion, discipline, convenience or retaliation. They have asked the federal Medicare and Medicaid programs to step up scrutiny of the hospital.
But officials at Doctors Community Hospital contend that the measures were necessary and said they would take them again. An on-call psychiatrist diagnosed the 5-foot-10, 180-pound man as violent, dangerous and in need of involuntary psychiatric care for an impulse control disorder. But he was never admitted to a patient room because the 175-bed hospital has no licensed psychiatric unit or seclusion rooms, hospital officials said.
The hospital's executive vice president, Thomas J. Crowley, said the patient rights rules could be waived because of the man's mental disability.
"This patient was unable to give consent, so a different set of standards applies," he said. The restraints prevented the patient from harming himself and thousands of workers, patients and families who passed through the emergency room from Oct. 25 to Nov. 6, Crowley said. Meanwhile, hospital social workers scoured the region for an appropriate facility, he said.
State officials say a patient's mental disability does not exempt a hospital from adhering to rules governing patient rights. They contend that the threat of violence was vastly overblown because the medical record noted that the patient was sedated, calm and cooperative for most of the 11 days.
The state inspection report said hospital officials and doctors are unfamiliar with the national rules -- even though they are in the hospital's own written policies.
"This is a pretty black-and-white issue," said Carol Benner, chief of Maryland's Office of Health Care Quality. "The hospital has a policy. They didn't follow it. Both federal and state regulations govern how to use restraints, and the hospital didn't comply. . . . I've never seen anything quite like this, where an individual was kept in the ER in four- or five-point restraints most of the time."
The hospital must document valid reasons for any restraint lasting more than four hours and demonstrate that less restrictive alternatives were tried first, such as putting the patient in seclusion. A physician must renew a restraint order daily. The hospital's psychiatrist renewed the order every other day.
Disability rights advocates were appalled. "It is horrifying that a person could end up for 11 days in restraints waiting for someone to figure out what to do," said Cristine Marchand, executive director of the Arc of Maryland, a statewide advocacy group for the retarded.
Philip Fornaci, executive director of the Maryland Disability Law Center, called the episode "disgusting" and "unbelievable."
"The fact that anyone could claim ignorance in a medical setting is extraordinary," Fornaci said. "They didn't want to take the trouble to do other things to handle the person's behavior. There are ways to handle things that are more difficult. It's a lot easier to tie someone up and treat them like an animal, which they did."
The patient put his fist through a window Oct. 25 at his group home, inspectors said. Caretakers from the unidentified group home, where the patient had lived for two years, said he showed increased aggressiveness. He spit at people in the ER, inspectors reported. The hospital's unidentified on-call psychiatrist ordered restraints, Crowley said.
"The psychiatrist concurs to this day that the patient was treated absolutely appropriately in our facility," Crowley said. "He commends us that during the 11 days, the young man did not do further damage to himself or others."
Benner said Crowley's assertion shows that the hospital staff does not understand patient protections. Maryland law and rules for the Medicare and Medicaid programs require hospitals to use the least restrictive restraints available, to document a doctor's orders for continued restraint at least once a day and to reassess the patient every four hours.
"None of that was done," Benner said. "They claimed that this person was a danger to himself and to others, and yet in the medical record, there was little evidence of any behavioral issues."
The issue of restraints has received national attention in the wake of deaths that occurred while people were being tied or held down. In 2001, a 17-year-old student suffered cardiac arrest after being placed in a restraint hold by a staff member at the state-licensed Edgemeade-Raymond A. Rogers Jr. School in Upper Marlboro, an institution for emotionally troubled youths.
A staff member grabbed the student around the chest during a scuffle, and an autopsy found that the oxygen flow to the student's brain was fatally blocked. The staff member was acquitted of manslaughter and child abuse charges. Benner's office investigated but did not recommend a ban on restraint holds at the school.
In the case at Doctors Community Hospital, Benner recommended that the Centers for Medicare and Medicaid Services (CMS) sanction the hospital, and a decision is expected next week, said CMS spokeswoman Jennifer Olson.
CMS could decide to disregard the hospital's national accreditation and require the state to perform special inspections. If the hospital resists corrective actions, CMS could take the rare step of kicking the hospital out of Medicare and Medicaid. Such action would essentially put the hospital out of business.
Crowley said the facility is the victim of bureaucrats and repeated rejections of the patient by 18 area hospitals.
"We contacted every state agency known to us . . . on a daily basis," he said. "They were all aware he was here and a problem, and none of them seemed either able or willing to help us with placement. . . . We never got a return call from anybody. It seemed to be nobody's problem but ours. We were left holding the bag."
The man's parents each visited him once during the stay, and the mother signed consent forms for his care, Crowley said.
On Nov. 6, the hospital went to court to obtain an emergency order to transfer the man for a psychiatric evaluation. A county sheriff's deputy transported him to Prince George's Hospital Center for a psychiatric evaluation, but the ER there was temporarily closed to patients because it was busy.
The deputy then drove to Laurel Regional Medical Center, where the patient was kept in the ER for five more days awaiting placement.
At Laurel Regional, Benner said, the man was cared for properly. He was transferred to another group home and is fine now, she said.