HospitalInspections.org

Based on medical record review, policy review and staff interview, the physician failed to complete a Mallampati Class prior to a patient operative procedure, in accordance to hospital policy, for one of one medical record reviewed (Patient #32).

Finding included...

Mallampati Class is a visual assessment of the distance from the tongue base to the roof of the mouth used to predict the ease of endotracheal intubation if a patient required respiratory assistance.

Record review of the hospital's policy "Moderate Sedation For Procedures," revised 10/03/19, showed that "Moderate Sedation/Analgesic ("Conscious Sedation") is a drug induced depression of consciousness during which the patient responds purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway and spontaneous ventilation is adequate...III...Mallampati measurement = [equals] Class IV, is considered one of the subset of patients undergoing moderate sedation for either elective/urgent procedures, where the patient's physician should consider performing the procedure in the operating room with anesthesia administered sedation and monitoring; or having the sedation and monitoring portion of the procedure administered by an Anesthesiologist/CRNA [Certified Registered Nurse Anesthetist] /AA[Anesthesiologist Assistant] in the procedural area..."

Review of Patient #32's medical record showed the patient presented to the Cath Lab on 11/22/19, for a "Left Upper Extremity Fistulogram" procedure with "Conscious Sedation, Possible Intervention."

Further review of the medical record revealed the registered nurse checked the box on the "Safe Procedure Checklist", to indicate that the Mallampati Assessment form was completed.

Review of the Mallampati Assessment form revealed the Mallampati Class and the ASA [American Society of Anesthesiologists] classification was not completed by a physician.

The practice lacked evidence that the physician followed the hospital's conscious sedation policy.

The surveyor conducted a face-to-face interview on 11/25/19 at approximately 12:30 PM, Employee #69, Charge Nurse and #82, Director of Cath Lab. acknowledged the findings at the time of the review.

Based on medical record review, policy review and staff confirmation, the nursing staff failed to follow the hospital's restricted extremity policy, in one of one patient records reviewed (Patient # 94).

Findings included...

Record review of the hospital's policy, number 57, titled, "Identification of Patients, Risk Factors and Known Allergies" dated 10/03/19, showed patients identified with a "Restricted Extremity," will have a pink colored arm band.

Review of Patient #94's medical record on 11/20/19 at approximately 10:15 AM, in the presence of Employees #121, Registered Nurse (RN), 125, Clinical Manager and 126, Clinical Educator, revealed the patient's diagnoses included history of Metastatic Breast Cancer, and Left Mastectomy with Left Axillary Node Dissection.

The surveyor observed the patient wearing a pink armband on the left forearm 11/20/19 at approximately 10:30 AM.

Additionally, review of the medical record showed nursing staff obtained Patient #94's blood pressure measurements using the restricted limb, the left arm on 11/16/19 and 11/17/19.

The record lacked evidence of problem identification, goals and approaches to prevent the potential complications to include lymphedema.

Employees #121, 125, and 126 acknowledged the findings.

Cross reference to A-396

Based on medical record review, policy review, and staff interview, the nursing staff failed to complete and document pain reassessment after medication intervention for pain management in seven of 11 medical records reviewed (Patients #41, #34, #32, 67, 90, 91 an #85).

Findings included...

Record review of the hospital's policy titled, "Assessment and Management of Pain in the Adult Patient" revised 08/18, showed that the "nursing staff reassess the pain using a numerical rating scale 30 minutes after intravenous, subcutaneous, intramuscular medication; and 60 minutes after oral pain medication administration. Pain should be assessed on admission, after a change in medical status, prior to, during and after a procedure, as appropriate, and with routine physical assessment, but not less than once a shift. Interventions include (a) collaborate with the multidisciplinary team to assure appropriate interventions are addressed. The nurse is to document the admission pain history, assessments/reassessments, interventions, monitoring and education... (c) comprehensive pain assessment to include: body area(s) involved, Intensity, Type of sensations (e.g. stabbing, throbbing), duration/frequency, Relieving/aggravating factors and Root cause if known..."

A. Review of Patient #41's medical record showed the physician ordered acetaminophen-oxycodone (Percocet) 5/325 milligrams (mg) - one tablet every four hours by mouth for pain (4 to 6) as needed.

Review of the electronic Medication Administration Record (eMAR) showed that nursing staff administered Percocet 5/325 mgs (1 tablet) on 11/20/19 at 10:18 AM in response to the patient's complaint of pain, voiced at a score of "10." The numeric pain scale utilizes a scoring system of zero to 10 with zero, meaning no pain and 10 indicating the worst pain. The pain was reassessed at a numeric score of "8." The medical record lacked documented evidence the nursing staff provided interventions for the patients pain score of '8".

The practice lacked evidence that the nursing staff followed the hospital's pain assessment and management policy.

The surveyor conducted a face-to-face interview conducted with Employees #89, Clinical Manager and #90, Quality Coordinator on 11/20/19 at approximately 11:00 AM regarding the aforementioned findings. Both acknowledged the finding at the time of the review.

B. Review of Patient #34's medical record showed the physician ordered Oxycodone 10mg- two tablets - every four hours for pain (7 to 10) as needed and Oxycodone 5mg- 1 tablet, every four hours for pain (4 to 6) as needed.

Review of the electronic Medication Administration Record (eMAR) showed that nursing staff administered Oxycodone 5 mg (1 tablet) on 11/20/19 at 4:15 AM in response to the patient's complaint of pain, voiced at a score of "9." The numeric pain scale utilizes a scoring system of zero to 10 with zero, meaning no pain and 10 indicating the worst pain. The nurse reassessed at a numeric score of "10" on 11/20/19 at 5:15 PM; and documented, "Pain level unacceptable, [and] collaborate with provider."

The medical record lacked documented evidence the nursing staff collaborated with the physician regarding reassessment and interventions.

The practice lacked evidence that the nursing staff followed the hospital's pain assessment and management policy.

A face-to-face interview conducted with Employees #80, Clinical Manager and #90, Quality Coordinator on 11/21/19 at approximately 10:00 AM regarding the aforementioned findings. Both acknowledged the findings at the time of the review.


C. Review of Patient #32's medical record showed the patient presented to the Cath Lab on 11/22/19, for a "Left Upper Extremity Fistulogram" procedure.

Review of the pre-procedural assessment screening form, showed that nursing staff failed to conduct a pain assessment.

The practice lacked evidence that the nursing staff followed the hospital's pain assessment and management policy.

The surveyor conducted a face-to-face interview with Employees #69, Charge Nurse and #90, Quality Coordinator on 11/25/19 at approximately 10:00 AM regarding the aforementioned findings. Both acknowledged at the time of the review.


38011


D. The surveyor conducted a medical record review for Patient # 67, on 11/20/19 at approximately 9:26 AM, with Employees # 95, Registered Nurse (RN), 99, Management Support, and 100, RN. The physician admitted the patient with a diagnosis of Right Foot Second Digit Infection, for Possible Amputation.

The physician ordered Oxycodone 10 milligrams (mg) by mouth every three hours for pain rated as four to six on 11/15/19 and Oxycodone 15milligrams (mg) by mouth every three hours for pain rated as seven to 10 on 11/15/19.

On 11/15/19 at 4:05 PM and 10:36 PM, with pain level eight and nine respectively. The nurse administered Oxycodone 15 mg administered without completing a comprehensive pain assessment.

On 11/16/19 at 2:38 AM, 5:38 AM and 9:28 AM, with pain levels of nine, 10, and 10 respectively. The nurse administered Oxycodone 15 mg without a comprehensive pain assessment.

On 11/18/19 at 10:31 PM, the patient's pain level was 10. The nurse administered Oxycodone 15 mg administered without completing a comprehensive pain assessment.

The practice lacked evidence that the nursing staff completed a comprehensive pain assessment in accordance with hospital policy.

At the time of the medical record review, Employees #95, 99, and 100 acknowledged the findings.


E. The surveyor conducted a medical record review for Patient # 91, on 11/21/19 at approximately 11:00 AM, with Employees # 95, RN, 99, Management Support, and 100, RN.

The physician admitted the patient with a diagnosis of a Chronic Non-Healing Left Lower Leg Wound with multiple debridements.

The physician ordered Oxycodone five milligrams (mg) by mouth every four hours for pain rated as four to six on 11/15/19 ; and Oxycodone 10 milligrams (mg) by mouth every four hours for pain rated as seven to 10 on 11/13/19.

On 11/15/19 at 3:04 AM, pain was rated at a nine; at 10:29 AM, pain was rated as an eight, and 4:45 PM, pain was rated as a seven. No comprehensive pain assessment were completed.

The practice lacked evidence that the nursing staff completed a comprehensive pain assessment in accordance with hospital policy.

At the time of the medical record review, Employees #95, 99, and 100 acknowledged the findings


F. The surveyor conducted a medical record review for Patient # 90, on 11/22/19 at approximately 11:30 AM, with Employees # 95, RN, 105 charge RN, and 97, Clinical Director. The physician admitted the patient with a diagnosis of a Left Foot Diabetic Wound, complicated by Osteomyelitis, and Pain.

The physician ordered Oxycodone five milligrams (mg) by mouth every four hours for pain rated as four to six on 11/05/19 and Oxycodone 10 milligrams (mg) by mouth every four hours for pain rated as seven to 10 on 11/05/19.

No comprehensive pain assessments were completed for the following shifts: 11/08/19- PM Shift, 11/09/19- AM Shift, 11/10/19- PM Shift, 11/12/19 -PM Shift, 11/15/19 -AM and PM Shift, 11/16/19- PM Shift, 11/18/19 -PM Shift, and 11/19/19- AM Shift.

The practice lacked evidence that the nursing staff completed a comprehensive pain assessment in accordance with hospital policy.

At the time of the medical record review, Employees #95, 105, and 97 acknowledged the findings.


G. The surveyor conducted a medical record review for Patient # 85, on 11/22/19 at approximately 12:00 PM, with Employees # 95, RN, 108, RN Charge, and 109, Clinical Manager. The physician admitted the patient with diagnosis to include Alcohol Intoxication, and Chronic Obstructive Pulmonary Disease.

The physician ordered Oxycodone 10 milligrams by mouth every four hours for pain, on 11/04/19. On 11/07/19 at 9:39 AM, the patient reported a pain scale of nine, and the nurse administered Oxycodone 10 mg by mouth. Upon reassessment for pain at 10:39 AM, the patient reported a pain scale of 9.

On 11/11/19 at 12:49 PM, the patient reported a pain scale of 8, and Oxycodone 10 mg administered by mouth. Upon reassessment for pain at 1:49 PM, the patient reported a pain scale of 5. On both occasions, the nurse documented the findings of pain reassessment with "Pain unacceptable, add other interventions", without further documentation of any other interventions.

The practice lacked evidence that the nursing staff provided other interventions, when the pain level documented as unacceptable.

At the time of the medical record review, Employees #95, 108, and 109 acknowledged the findings.

Based on medical record review, hospital policy review, and staff interview, the nursing staff failed to develop nursing care plans based on the individual nursing care needs, as part of the interdisciplinary care plan in five of 11 records reviewed (Patients # 84, 89, 92, 67, 94).

Findings included ...

Record review of the hospital policy titled, "Contemporary Primary Nursing," dated March 2019, showed that the primary nurse is to initiate and customize the relevant Individualized Plan of Care (IPOC)

A. The surveyor reviewed the medical record for Patient # 84, on 11/22/19, at approximately 2:30 PM, with Employees # 95, Registered Nurse (RN), 109, RN, and 110, RN. The physician admitted the patient on 10/26/19 with diagnosis to include Chronic Right Lower Extremity Wounds. The Nursing Care Plan failed to include wound care.

The practice lacked evidence that the nursing staff included wound care as part of the interdisciplinary care plan.

At the time of the medical record review, Employees #95, 109, and 110 acknowledged the findings.


B. The surveyor conducted a medical record review of Patient # 89, on 11/21/19 at approximately 3:30 PM, with Employees # 95, RN, 105 Charge RN, and 97, Clinical Director. The physician admitted the patient on 11/18/19 with a diagnosis of hypotension. The IPOC failed to include hypotension in the nursing care plan.

The practice lacked evidence that the nursing staff included hypotension as part of the interdisciplinary care plan.

At the time of the medical record review, Employees #95, 105, and 97 acknowledged the findings.


C. The surveyor conducted a review of the medical record for Patient # 92, on 11/21/19 at approximately 11:00 AM, with Employees # 95, RN, 97, Director, and 96, Clinical Educator. The physician admitted the patient on 11/01/19 with a diagnosis of Right Lower Extremity Ulcer, and a history of Hypertension (HTN). The IPOC failed to include wound care and HTN in the nursing care plan.

The practice lacked evidence that the nursing staff included wound care and HTN as part of the interdisciplinary care plan.

At the time of the medical record review, Employees #95, 97, and 96 acknowledged the findings.


D. The surveyor conducted a medical record review for Patient # 67, on 11/21/19 at approximately 10:00 AM, with Employees # 95, RN, 97, Director, and 96, Clinical Educator. The physician admitted the patient on 10/28/19 with a diagnosis of a second toe infection, and a history of Diabetes Mellitus (DM). The IPOC failed to include DM in the nursing care plan.

The practice lacked evidence that the nursing staff included DM as part of the interdisciplinary care plan.

At the time of the medical record review, Employees #95, 97, and 96, acknowledged the findings.


Cross reference A-0144

Based on medical record review, review of hospital policy, and staff interview, the nursing staff failed to document a patients' refusal for finger stick blood glucose testing for correctional insulin coverage, in one of three patient medical records reviewed (Patient # 67).

Findings included ...

Review of the hospital policy titled, "Administration and Charting of Medication," dated 10/26/16, shows that with missed or late administration of medications, "nursing is to document a reason ..."

The surveyor conducted a review of the medical record for Patient # 67, on 11/20/19 at approximately 9:26 AM, with Employees # 95, Registered Nurse (RN), 99, Management Support, and 100, RN.

The physician admitted the patient with a diagnosis of Right Foot Second Digit Infection for possible amputation and Diabetes Mellitus- insulin dependency.

The physician ordered Lispro correctional insulin on 10/28/19 for insulin coverge at bedtime. On 10/29/19 the physican ordered finger stick blood glucose testing and correctional dose insulin as needed, three times a day with meals, and at bedtime. The orders included Lispro correctional dose insulin coverage three times a day with meals.

On 11/16/19 at 5:00 PM, 11/18/19 at 8:00 AM, 11/18/19 at bedtime, 11/19/19 at 1:00 PM, and 11/19/19 at 5:00 PM, the patient refused the finger stick blood glucose testing for correctional insulin.

The nursing staff failed to notify the physician about the patient's multiple refusals' of finger stick blood glucose testing for the management of diabetes.

The practice lacked evidence that nursing staff informed the medical team of the patients' refusal of finger stick blood glucose testing for diabetes management and determination of the need for correctional insulin.

At the time of the face to face interview, Employees # 95, 99, and 100 acknowledged the findings.

Based on record review, policy review and staff interview, the nursing staff failed to adhere to the hospital's administrative policy related to accurate documentation (Patient #36).

Findings included ...

Record review of the hospital's policy titled, "Medical Record Documentation," revised 6/28/16, showed that "all entries into the medical record shall be made on a timely basis and general guidelines includes: "Per the Center for Medicare Services, the current date and time shall be recorded on the patient's record at the time of each entry if manual entry."

A physician's order dated 11/20/19 at 4:25 PM and 11/21/19 at 7:54 AM, directed to transfuse Patient #36 one unit of blood over three hours per unit.

Review of the Transfusion Administration Records showed nursing staff documented the first blood transfusion stopped on 10/20/19 (month of October) at 06:35 AM; and the second transfusion started on 10/21/19 (month October) at 8:20 AM.

The medical record lacked evidence that the nursing staff manually documented the correct dates for the administration and discontinuation of the blood.

The practice lacked evidence that the nursing staff followed the hospital's medical record documentation policy for accuracy.

The surveyor conducted a face-to-face interview with Employees #128, Charge Nurse and #90, Quality Coordinator, on 11/21/19 at approximately1:00 PM. Both acknowledged the findings at the time of the medical record review.

1. Based on medical record review and staff interview, the medical staff failed to follow applicable standards and the hospital's policy relative to medical record documentation in one of one patient records reviewed (Patient #99).

Findings included...

Review of the hospital's policy number 404, titled "Medical Record Documentation", and dated 06/28/16, showed all handwritten entries in the medical record shall be made in black or blue ink.

A review of Patient #99's medical record on 11/22/19 at approximately 11:00 AM, revealed the patient underwent Laminectomy with Neurogenic Claudication on 11/18/19. Additional review of the medical record showed Safe Surgery Checklist for Perioperative Services dated 11/18/19. The form showed the "#1 Procedure physician/ surgeon" dated and signed using a purple inked, felt tipped pen.

The practice lacked evidence that medical staff followed the hospital's policy relative to the requirement for the use of black or blue ink, in the medical record.

During a face-to-face interview on 11/22/19 at approximately 11:00 AM, Employees # 118, 120, and 121 acknowledged the findings.


2. Based on medical record review, policy review, and staff interview, the hospital staff failed to complete the communication documentation for patient transport, in 12 of 12 "Ticket-to-Ride" patient transport sheets reviewed (Patient # 92).

Findings included...

Review of the hospital policy titled, "Ticket to Ride", dated 01/12/17, shows that the Ticket-to-Ride is a communication form used to transport patients throughout the hospital, to ensure safe, efficient transport. The policy shows a transport communication sheet is used to accompany a patient throughout the hospital. The transport sheet gives information regarding; code status, allergies, fall risk, peripheral intravenous line location, lifting status, oxygen status, as well as the signatures and date and time for each stage of the transport, both to and from the transport location. The sending nurse will print out the ticket from the electronic medical record to ensure order entry detail and fall risk score are completed, and signed by the sending associate. The hospital transport associate will verify the information with the patient and sign under transporter number one, with date and time. At the receiving department, the person receiving the patient will sign under the receiving department associate number one, with date and time. After the procedure, the reverse is done with transporter number two and receiver number two signing, with date and time.

The surveyor reviewed the medical record for Patient # 92, on 11/21/19 at approximately 10:30 AM, with Employees # 95, Registered Nurse (RN), 99, Management Support, and 100, RN. The medical record contained 12 "Ticket-to-Ride" communication sheets; however, the twelve forms were not completed.

The practice lacked documented evidence that the hospital and nursing staff followed hospital policy for "Ticket-to-Ride" communication transport sheets.

At the time of the medical record review, Employees # 95, 99, and 100 acknowledged the findings.

Based on medical record review and staff interview, the hospital staff failed to ensure the proper execution of an informed consent for treatment, in one of three patient records reviewed (Patient #99).

Findings included...

A review of Patient #99's medical record on 11/22/19 at approximately 11:00 AM revealed the patient underwent Laminectomy with Neurogenic Claudication on 11/18/19. Additional review of the medical record showed an informed 'Consent for Administration of Blood, Blood Components and/or Human Blood Plasma Products', dated 11/18/19 that was signed by the patient. However, the form was not authenticated by the signature of a witness.

The area on the form titled "Witnesses' Signature" showed a blank space.

The practice lacked evidence that staff obtained a properly executed informed consent.

He surveyor conducted a face to face interview on 11/22/19 at approximately at 11:00 AM, with Employees #120, Registered Nurse (RN), 121, RN and 122, RN who acknowledged the findings at the time of the record review.

Based on a review of Facility documents, Pyxis [ADM] -Schedule 2,3,4, and 5 Controlled Substances Activity Report, physicians' orders, and patient electronic Medication Administration Record [eMAR]); the hospital staff did not properly document the administration, wasting, or handling of controlled substances.

Findings included ...

On November 21, 2019, a seventy-two (72) hour Controlled Substances Report (All Device Events Report), for schedule II to V medications, for all patients receiving a controlled substance was requested for Patient Care Units: NICU, 3BLES, 5BLES, 5 West, C43, M61, and M63. The date range of the report was from 00:00, on 11/17, 2019 through 23:59, on 11/20/2019. All patients were randomly selected.

A twenty-four (24) hour report was requested for Patient Care Units OR, ED, and PACU; date range 00:00, on 11/19/2019 through 23:59, on 11/20/2019. Patients were randomly selected for this audit. The physician's orders and eMAR were also requested for review. The survey of records was started on 11/22/2019 and completed on 11/26/2019.

A review of records was done in the presence of hospital staff: Employee #74, Employee #75 and Employee #76. The physicians' orders and eMAR were reviewed for accuracy. The time from the ADM Report was compared to the time that the medication was administered to the patient as well as the verification of the medication order and the dispositioning of controlled substances. Five (5) out of twenty-five (25) patients surveyed had documentation errors.

A. On November 14, 2019, at 23:39, Patient #57 on patient care unit 5W was ordered Zolpidem 5mg by mouth at bedtime as needed for insomnia. On November 17, 2019, at 21:47 Zolpidem 5mg was removed from ADM and administered to the patient at 23:15. Approximately one and one-half hours late.

November 18, 2019, at 22:19, Zolpidem 5mg was removed from ADM and eMAR is documented an administration time of 21:53. Failure to document the correct time of administration, medication was removed from ADM after administration.

B. On November 17, 2019, at 06:00, Patient #58 on patient care unit 5W was ordered Buprenorphine-Naloxone 8mg-2mg, 1 tablet under the tongue every 24 hours. On November 17, 2019, at 06:34, one Buprenorphine-Naloxone 8mg-2mg tablet was removed from ADM. Documentation on the eMAR indicates that the medication was administered at 06:00; one-half hour before the tablet was removed from ADM.

Patient #58 was ordered Buprenorphine-Naloxone 8mg-2mg, on November 16, 2019, at 20:01 tablet under the tongue every 24 hours. On November 17, 2019, at 19:29, one Buprenorphine-Naloxone 8mg-2mg tablet was removed from ADM and administered to the patient at 21:00. Over one and one-half hours late.

C. On November 17, 2019, at 12:00, Patient #59 on patient care unit 5W was ordered Lorazepam 1mg tablet by mouth three times a day. On November 17, 2019, at 12:42 Lorazepam 1mg was removed from ADM. The documented time of administration on eMAR is 12:00; forty-two minutes before removing medication from ADM.

D. On November 19, 2019, at 08:43, Patient #60 on patient care unit 5BLES was ordered Oxycodone 5mg by mouth every 4 hours as needed for pain 5 to 10 on the pain scale. On November 19, 2019, eMAR indicates that Oxycodone 5mg was administered to the patient at 09:57. However, no Oxycodone 5mg tablet was removed from ADM for this patient.

E. On November 18, 2019, at 12:55, Patient # 68 on patient care unit M61 was ordered Oxycodone 10mg by mouth every 3 hours as needed for pain score of 5-10. On November 19, 2019, at 06:13, 2 tablets of Oxycodone 5mg were removed from ADM. There is no record of administration, waste, or return of medication.

Based on observations and documentation review dietary services were not adequate to ensure that foods are prepared and served in a safe and sanitary manner.

These findings were observed and acknowledged in the presence of the Director of Dietary Services, Employee # 23, on November 20, 2019 between 10:45 AM and 3:30 PM.

Findings included...

1. Splash guards located at the entrance area to the washer side of the dish machine were soiled, with food and other debris.

2. The top surfaces of the dish machine was soiled, with dust and other debris, ceiling tiles surfaces above the dish machine were soiled and paint was peeling in the ceiling.

3. The inner surfaces of hotel pans, were soiled with leftover food particles, and a greasy residue was on the inner, and bottom surfaces of pans, in 19 of 19 observations.

4. The inner surfaces of sheet pans were soiled in corners with food residue after washing, in 9 of 9 observations.

5. The head and shaft surfaces of sprinkler heads were soiled in the main kitchen over food preparation areas, in 4 of 4 observations.

6. The top surfaces of oven burners, in the cook's preparation area, were soiled, with spilled food and other debris.

7. A 2-3 inch penetration was observed, in ceiling surfaces around a sprinkler located in Room 44 in the Main Kitchen.

8. Loaves of Multivitamin Bread, were stored in the walk in refrigerator, beyond the expiration date of 11/11/19; this observation of expired breads was made on 11/20/19.

9. A small penetration was observed in wall surfaces in the Brown Bag Area.

10. The exhaust vent over the Brown Bag tray line was dingy, and soiled with dust.

11. The entrance area to cooler # 3 lacks a threshold to help prevent trips or falls, and to maintain cold temperatures within the refrigeration unit.

Based on the Life Safety Code Validation survey, conducted between November 25, 2019 through December 2, 2019, the Condition of Physical Environment is not met. Those deficient practices and the associated regulations can be found in the respective Life Safety Code survey.

Based on observations during the environmental survey Housekeeping and Maintenance Services were not adequate, to ensure that the facility is maintained in a safe and sanitary manner.

These observations were made and acknowledged in the presence of Employee #22, Director of Health Safety and Security.

Findings included ...

1. The surveyor observed the following findings during a tour of the Emergency Department at 3:50 PM on 11/21/19, in the presence of Employees #22, Director of Environmental Health and Safety, and #89, Clinical Manager Emergency Department.

A. Wall surfaces outside of the restroom in the Waiting Room were marred.

B. Floor surfaces outside of the Emergency Department were soiled, and chewing gum was observed on floor surfaces.

C. The bottom interior shelf surfaces of the Pyxis Dispensing Machines were soiled with dust in the Medication Room, Supply Room, and Main Treatment Area.

D. Double doors near the Laboratory Area were marred and damaged.

E. The escutcheon ring was missing around a sprinkler head in the bathroom, near the double doors.

F. Walls surfaces and the entrance door were marred in the Psychological Safe Bathroom.
G. Door jamb surfaces were marred at the entrances to Rooms 5 and 6.

H. The overhead lamp cover was missing, floor tiles were stained, door and doorjamb surfaces were marred, in the Soiled Utility Room.

I. Wall surfaces were marred in the Flex End Room.

J. Ceiling tiles were stained in Flex Rooms 9, 10, and 12.

K. Privacy curtain hooks were detached from the track in Flex Room 6.

2. The surveyor observed the following findings during a tour of the Sterile Processing Department, in the presence of Employees # 22, Director of Environmental and Health, and # 24, Director of Sterile Processing, on 11/21/19 at 11:45 AM.

A. Floor tiles under storage racks on the Clean Side were damaged.

B. Lower wall surfaces were damaged at the entrance to the Clean Side.

C. Floor tiles and baseboards were damaged in front of the washers and along the perimeter of the Decontamination Room.

D. Floor tiles were soiled and rusty under urinals, and baseboards were soiled around the perimeter of the Men's Room.

E. The finish on horizontal benches were worn and damaged and baseboards were damaged around the perimeter.

F. Six bags of sterile water, stored on racks on the Clean Side/Supply Area, were held beyond the expiration date of 8/19/19, this finding was observed on 11/21/19.


3. The surveyor observed the following findings a tour of Unit 4-Bles, on 11/22/19 at 9:15 AM, in the presence of Employees # 22, Director of Environmental Health and Safety and #67, Nurse Manager 4B.

A. Floor surfaces were stained, near the entrance to the unit 4-Bles. The bathroom near the entrance to the unit, the lower surfaces of shower walls were damaged, baseboards and door jambs were marred and damaged.

B. The top surfaces of the lamp, the top of the monitor and the top surfaces of the wall cabinet was dusty, and baseboard surfaces were soiled near the door, in Room 4011.

C. A metal strip was not secured on the exterior door surfaces, of the Electric Closet in the hallway.

D. Door and doorjamb, surfaces were marred at the entrances to Rooms 4007A and 4007B.

E. Chair armrest surfaces were worn, and in need of refinishing in Room 4026B.

F. The ceiling lamp cover was missing; the top of the monitor, and bed frame surfaces were dusty; the lower walls in the rear of the toilet; door jambs, floors and baseboards surfaces near the toilet were damaged, in Room 4023.

G. A strip located on the bottom of the Heating Ventilation and Air Conditioner Unit was not secured; wall surfaces were marred, and excessive personal items were on the floor, in the Staff Locker Room.

H. The lower surfaces of bathroom tiles were soiled, marred and in a state of disrepair in Room B403.


4. The surveyor observed the following findings during a tour of the Morgue at 2:15 PM on 11/22/19, in the presence of Employee # 22, Director of Environmental Health and Safety.

A. Two ceiling tiles were marred in the ante area; floor surfaces were soiled in the Ladies and Men's Bathrooms.

B. The interior and exterior surfaces of the overhead lamp cover were soiled in the Ladies Restroom.

C. A panel under the eyewash station was damaged, in the Autopsy Area.

D. The inner and outer surfaces of the entrance door were marred and damaged on the edges.


5. The surveyor observed the following findings during a tour of the Cardiac Catherizztion Labs, on 11/22/19 at 4:20 PM, in the presence of Employees # 22 Director of Environmental Health and Safety, and #69, Charge Nurse.

A. Floor surfaces were soiled with dust in the supply closet and ceiling tiles, ceiling tile were cracked
B. Wall surfaces were marred near the C-Arm, and in the Bronchial Suite.

6. The surveyor observed the following findings during a tour of the of Operating Suites, and Post Anesthesia Care Unit (PACU) at 11:11 AM on 11/25/19, in the presence of Employee # 22 Director of Environmental Health and Safety and #39, Clinical manager of the Operating Room.

A. Door surfaces were marred at the entrances to Operating Suites # 2, 3, and 19.

B. Floor and baseboard surfaces were soiled, in Bay 3 in the PACU.

C. The multiple electrical outlet was in use on the floor, instead of mounting on the wall to ensure safe use of the outlet in Bay 5, in the PACU.

D. Floor surfaces were soiled in corners in Bay 6, in the PACU.

E. The upper walls were marred, in the Clean Utility Room, in the PACU.

F. Floor surfaces were soiled, in corners, in Surgical Rooms 5 and 11.

G. The top surface of the headwall was dusty, in Bay 11.

H. Door jamb surfaces were marred at the entrance to Room 10 and the electrical Closet.

I. The Large Core Supply Room lacks signage on the outside of the Room.

J. Hallway walls were marred near Operating Room 4.

K. Door and doorjamb surfaces were marred at the entrance to Operating Room 4.


7. The following findings were observed at the entrance to the Phase I, Post Anesthesia Care Unit on 11/25/19 at approximately 11:30 AM.

A. The top and lower surfaces of the mobile work station, was soiled with dust; in Rooms 1 and 11.

B. The top of the over bed lamp and headwall surfaces were soiled with dust, in Rooms 3, 11 and 14.


8. The surveyor observed the following findings during a tour of the Labor and Delivery Department, at 9:55 AM on 11/25/19, in the presence of Employees #22 Director of Environmental Health and Safety and # 55, Clinical Nurse Manager.

A. The interior surface of exhaust vents in Operating Room 2, were soiled with dust.

B. Baseboards were separated near the counter in Room 19.

C. Window sill and headboard surfaces were soiled with dust in Room 18.

D. Wall surfaces were soiled near the handwashing area in Room 30.

E. The interior surfaces of the exhaust vent was soiled with dust in Operating Room 2.

F. The outer surfaces of the Infrared Resuscitator was dusty in Room 9.

G. Baseboards were separated from the base of the counter in Room 19.

H. Window sill and the top of the heater was dusty, Room 18.

I. Wall surfaces were damaged in the handwashing area near the sink in the Ante Room.


9.The surveyor observed the following findings during a tour of Unit 5 North, Main Infusion Unit, at 4:30 PM on 11/25/19, in the presence of Employee # 22, Director of Environmental Health and Safety.

A. Wall surfaces were marred in Rooms 7 and 9.

B. Proper signage was not listed on the outside or within bays.

10. The surveyor observed the following findings observed during a tour of the Endoscopy and Gastro Intestinal Unit at 11:50 AM on 11/25/19.

A. The wooden chair armrest surfaces were worn in Room 9.

B. Calcium deposits were observed on the tray and inner areas of the ice machines, water and ice chutes.

C. Floor and mat surfaces in the scope decontamination area were soiled.

11. The surveyor observed the following findings during a tour of the Generator Room at 10:50 AM on 11/26/19, in the presence of Employees # 22, Director of Environmental Health and Safety and # 73, Engineer.

A. Sheetrock covering a pillar in the Emergency Generator Room was damaged.

B. Wall surfaces in the upper level hallway, above the Emergency Generator Room, were marred and damaged.

1. Based on observation, interview, and documentation review, the biomedical staff failed to conduct preventive maintenance inspection on a hypo/hyperthermia unit (Criticool) used on Patient #19 in the Neonatal Intensive Care Unit (NICU) in one of one observation.

Findings included ...

The surveyor toured the NICU on 11/21/19 at approximately 11:15 AM, with Employee # 49, Nurse Manger and Employee # 65, Quality and Safety staff, the surveyor observed a Criticool Unit attached to a planet on Patient #19. Employee# 49 said that the machine was for the cooling blanket to lower the patient's temperature. The surveyor checked the cooling unit for the preventive maintenance (PM) date. The label on the cooling unit showed an expiration date of 6/19. Employee #49 confirmed the date and stated she would refer to biomedical to verify the expired date.

The practice lacked evidence that the biomedical staff inspected and maintained the cooling unit for safety and reliability.

The surveyor conducted face-to-face interview with Employee #25 Director of Clinical Engineering on 11/26/19 at 8:55 AM. Employee #25 stated two Cooling Blankets are available for the NICU and required service annually by the manufacturer. He provided documents that revealed the blankets were due for PM in June 2019. He acknowledged that the biomedical did not perform the PM.


2. Based on observation, policy review, and staff interview, the Operating Room staff failed to check the Operating Room emergency code carts and emergency equipment and initial the Emergency Equipment Checklist (EEC) daily per policy in five of five observations.

Findings included...

Record review of the hospital's policy titled "Policy for Checking Emergency Equipment" dated 10/09/18, showed that "all code carts and other emergency equipment outlined on the Emergency Checklist are to be checked once every 24 hours, or once a day the unit/department is open...The Emergency Equipment Checklist is to be completed and initialed each the equipment is checked..."

The surveyor toured the Main Operating Rooms on 11/20/19 at between approximately 11:00 AM to 12:00 PM, with Employees #39, Clinical Manager and # 65, Employees #65, Quality/Safety staff. The surveyor checked the emergency carts and the Emergency Equipment Checklist (EEC) during the tour. Three adult and two pediatric code carts lacked documented evidence from the review of Emergency Equipment Checklists that the nursing staff checked the code carts and equipment on 11/12/19. The nursing staff failed to authenticate the Emergency Equipment Checklist with initials, which showed evidence that the staff checked the code carts and equipment.

The practice lacked evidence that the nursing staff checked the code carts and equipment daily in accordance with the hospital policy.

The surveyor conducted a face-to-face interview with Employee # 39, Clinical Manager, on 11/20/19 at approximately 11:30 AM. The employee stated the responsibility for checking the code carts and emergency equipment belongs to the night shift nursing staff. Employee #39 checked the five Emergency Equipment Checklists and emergency carts with the surveyor in the presence of Employees #65, Quality, and Safety staff.

Employees #13, Associate Vice President of Perioperative Services, #39, and 65 acknowledged the findings at the of the observations.

1. Based on observation and staff interview, the nursing staff failed to follow accepted standards of practice, to prevent the spread of infection, in one of one observation.

Findings included...

Review of the hospital's policy number 22, titled "Insertion, Maintenance and Removal of an Indwelling Urinary Catheter", and revised November 2018, showed the drainage bag should be hung on the bed frame below the level of the bladder. Ensure the tubing is not kinked, there are no dependent loops, and that no component of the collection bag is in contact with the floor.


During a tour of the 4 Bles Unit on 11/20/19 at approximately 10: 30 AM, with in the presence of Employees #121, Registered Nurse (RN), 125, Clinical Manager and 126, Clinical Educator, the surveyor observed Patient #94 lying in bed with a urinary drainage bag secured to the bed frame. The surveyor observed the drainage tubing hanging off the side of the bed forming a dependent loop below the level of the drainage bag, and obstructing the flow of urine into the bag.

The practice lacked evidence that the nursing staff followed the hospital policy for "Maintenance of the Indwelling Urinary Catheter".

Employees #121, 125 and 126 acknowledged the findings at the time of the observation.


2. Based on observation and staff interview, the hospital staff failed to follow accepted standards of practice for soiled linen management, to prevent the spread of infection, in one of one observation.

Findings included...

Review of the hospital's policy number 305, titled "Standard and Transmission Based Precautions", and revised February 6, 2018, showed that used linen must be handled, transported, and processed in a manner that prevents skin and mucous membrane exposures and contamination of clothing and that avoids transfer of microorganisms. Soiled linen must be transported in a closed container.

The surveyor conducted a tour of the unit 4 Bles, on 11/20/19 at approximately 10: 35 AM, while in the presence of Employees #121, Registered Nurse (RN), 125, Clinical Manager and 126, Clinical Educator. The surveyor observed a soiled linen cart in the hallway, with linen protruding over the side of the covered soiled linen cart. The soiled linen cart was over-filled, preventing complete closure, of the cart lid.

The practice lacked evidence that hospital staff stored soiled linen in a safe and sanitary matter, consistent with accepted standards of practice, to prevent the spread of infection.

Employees #121, 125 and 126 acknowledged the findings at the time of the observation.


35226

3. Based on observation and staff interview, nursing staff failed to ensure wound care was provided in a manner as to prevent the spread of infection in two of two observations (Patient #4).

Findings included ...

A. The surveyor conducted a wound care observation on 11/21/19 at 11:05 AM, provided by Employee #29, for Patient #4, who was admitted with a Stage 4 Pressure Injury. Employee #29 was observed removing the dressing with gloved hands; she cleaned the wound using a 10-milliliter syringe of normal saline without removing dirty gloves and sanitizing her hands. Employee #29 then retrieved a pair of clean gloves from the glove box and placed them over the soiled gloves that were used to remove the dressing and cleanse the wound.

She then packed the wound with wet gauze and covered the wound with a clean dressing. Employee#29 then removed the top pair of gloves and proceeded to clean the patient's Flexi-seal (internal fecal management device) tube that was soiled with fecal matter.

Nursing staff failed to ensure the prevention of the spread of infection during wound care.

The surveyor conducted a face-to-face interview on 11/21/19 at 11:30 AM with Employee #29 in the presence of Employee #36, Clinical Manager Neuro IMC, regarding the observation. Employee #29 acknowledged the findings.



38011


B. The surveyor observed a sacral wound care dressing change for Patient # 89, on 11/22/19 at approximately 9:00 AM, with Employee # 106, RN. Employee # 106 sanitized her hands and doffed gloves, rolled the patient onto his right side and removed the soiled wound dressing.

The patient was noted to have fecal matter surrounding his rectal area at the time of the wound dressing removal. Employee # 106 proceeded to use pre-filled syringes of normal saline and sterile four-by-four bandages to clean the wound and surrounding area. Employee # 106 placed a new under pad beneath the patient, and proceeded to apply Santyl medication to the wound with four-by-four gauze pads, covered the wound with abdominal pads, and a sterile dressing cover.

Employee # 106 returned the patient to his prior position, and proceeded to straighten up the room, handling various objects such as the bedside rails, a water glass, and a television remote.

The Employee then removed her gloves, sanitized her hands, and with a cleansing wipe, cleaned the outside box for the medication, prior to replacing the medication back into the patients' medication drawer in the rolling medication cart.

The surveyor conducted a face to face interview with Employee # 106, in the presence of Employees # 95, RN, 105 Charge RN, and 97, Clinical Director. The surveyor queried Employee # 106 as to why hand sanitization and changing gloves was not done during the entire dressing change, Employee # 106 responded "My gloves never touched the skin of the patient, and were not dirty". When asked about her infection control education and wound care protocols, she responded that she took an annual class.

The practice lacked evidence that the nursing staff followed accepted standards of infection control practices as to reduce the spread of infection during a wound treatment.

At the time of the observation, Employees # 95, 105, and 97 acknowledged the findings.

Based on record review, policy review, and staff interview, the hospital failed to ensure that rehabilitation services were adequate to provide the treatment prescribed as evidenced by missed occupational therapy treatments in one of three medical records reviewed (Patient #1)

Findings included ...

Review of the Medstar Georgetown University Hospital policy entitled, "Physical Medicine and Rehabilitation Leave Requests and Minimum Staffing" last revised 06/2017 showed that the minimum amount of staffing necessary for inpatient adult care was five therapists. There was no documented minimum staffing requirement for weekends.

Patient #1 was admitted to the hospital after a concern of seizure activity and a past medical history of a Cerebral Vascular Accident in October 2019 with residual right sided weakness.

A review of physician orders showed an order dated 11/12/19 at 12:59 PM for Occupational Therapy two to four times a week for two weeks.

A review of rehab documentation, conducted on 11/20/19 at 10:30 AM, lacked documented evidence of visits from Occupational Therapy.

The surveyor conducted a face-to-face interview on 11/20/19 at 11:10 AM, with Employee #32, Occupational Therapist. She stated that the staff prioritizes patients to see because of the amount of staff that they have.

Review of staffing numbers for Sunday, 11/10/19 through 11/16/19 showed that there was one Occupational Therapist (OT) on Sunday 11/10/19; six on 11/11/19; seven OT's on 11/12/19; eight OT's on 11/13/19; seven OT's on 11/14/19; seven OT's on 11/15/19; and two OT's on Sunday 11/16/19.

The surveyor conducted a face-to-face interview on 11/21/19 at 9:45 AM with Employee #26, Director of Rehabilitation Services, regarding OT staffing and the correlating staffing matrix. She stated that the hospital is currently filling open positions. She said that the goal of the department is to see 85% of the patients at the prescribed frequency, and the staff is meeting that goal. When asked why the staff is only meeting 85% of the frequency for patient visits, she stated that the policy is two years old, and the staff has started seeing patients on new units [7-Main-research and the Emergency Department] since the policy was revised.

When asked about the staffing matrix for the weekends, Employee #26 stated that the total OT staff needed is one therapist for Saturday and one therapist for Sunday. When asked what that number is based on, Employee #26 could offer no further insight. She acknowledged the findings at the time of the interview.


38011



B. The surveyor reviewed the medical record for Patient # 84, on 11/22/19 at approximately 2:30 PM, with Employees' # 95, Registered Nurse (RN), 109, RN, and 110, RN. The physician admitted the patient on 10/26/19 with diagnosis to include chronic right lower extremity wounds, wheelchair-bound. On 10/30/19 the physician ordered Physical therapy (PT) was ordered for two to four times a week, and Occupational therapy (OT) for two to three times a week, starting on 10/30/19. Documentation for the week of 11/17/19 showed both PT and OT occurred one time, on 11/20/19.

The practice lacked evidence that PT and OT staff provided services following the physicians' orders.

At the time of the medical record review, Employees #95, 109, and110 acknowledged the findings.

Based on record review, policy review, and staff interview, the respiratory staff failed to administer a respiratory treatment in a timely manner, in one of five medical records reviewed (Patient #42).

Findings included ...

Record review of the hospital's policy titled, "Medication Turnaround Time," revised 12/16, shows that the "target turnaround time for the administration of "STAT" medications is within 15 minutes."

Review of Patient #42's medical record on 11/20/19 at approximately 1:00 PM, showed the patient presented to the emergency department from pulmonary clinic on 11/19/19, with chief complaints of chest congestion, wheezing and chest pain.

Review of physician's orders dated 11/19/19 at 7:53 PM, directed the patient to have a one-time nebulization treatment; Albuterol-ipratropium (bronchodilator), STAT (immediately).

Review of the respiratory assessment flow sheet showed the respiratory therapist administered the nebulization treatment on 11/21/19 at 12:19 AM; approximately four hours later, after order written for "STAT."

There were no adverse outcomes documented.

The practice lacked evidence that respiratory therapist followed the hospital's medication turnaround time policy.

The surveyor conducted a face-to-face interview with Employees #89, Clinical Manager and #90, Quality Coordinator, at approximately 2:30 PM, regarding the aforementioned findings. Both acknowledged the findings at the time of the record review.

Based on a review of the Emergency Preparedness Communication Plan, the hospital staff failed to complete an annual review of the Communication plan.

Findings included ...

The surveyor conducted a review of the Emergency Preparedness Communication Plan, on 11/21/19 at 10:00 AM, with Employee #22, the Director of Environmental Health and Safety and Employee #117, Director of Emergency Preparedness and Planning. According to Employee #117, the Emergency Preparedness Communication Plan was not reviewed since the developement and implementation of the plan.

The practice lacked evidence that the hospital staff conducted an annual review of the Emergency Preparedness Communication Plan.

Employees #22 and #117 acknowledged the findings, at the time of the review,