HospitalInspections.org

Based on medical record review, policy review, and staff interview, it was determined the hospital staff failed to administer medication in accordance with the physician orders in two (2) of 10 medical records reviewed (Patients #3 and 10).

The findings include:

State Operations Manual Appendix A §482.23 (c)(1) (A0405) Drugs and biologicals must be prepared and administered in agreement with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient's care.

Title 22B DCMR 2025.6 (c) (d) (145) - Each hospital shall develop and maintain for each inpatient individual medication administration record that includes, but is not limited to: (c) the date, time, dosage, method of administration or provision for each medication; and (d) identification of the person who administered or provided the medication and any refusal by the patient.

A. Patient #3 was admitted with diagnoses to include Chest Pain, Hypertension, Diabetes, and Coronary Artery Disease.

Review of the medical record on November 10, 2016, at approximately 12:42 PM revealed Patient #3 was brought into the Emergency Department by Emergency Medical Services ambulance on May 7, 2015, at 1414 for a complaint of Chest Pain for two (2) hours.

Patient #3 physician's orders for Diabetes Management, to start on May 7, 2015, included the following: Medium dose sliding scale Novolog insulin three times daily as needed and Lantus 20 units subcutaneously at bedtime. Patient #3 had episodes of elevated blood glucose levels requiring sliding scale correctional insulin without documented intervention: May 8, 2015, at 0836, 1201, and 2150; May 9, 2015, at 0815 and 1117; and May 11, 2015, at 1145. Also, there are episodes of elevated blood glucose levels with administration of insulin more than one (1) hour after blood glucose level obtainment. The episodes occurred as follows: May 9, 2015 at 1118- insulin administered at 1519; May 9, 2015 at 1634- insulin administered at 1800; May 10, 2015 at 1633- insulin administered at 1800; May 10, 2015 at 2013- insulin administered at 2115; and May 11, 2015 at 1610- insulin administered at 1730. There was an episode where the insulin administration occurred before the obtainment of the blood glucose level, May 11, 2015, at 0901- insulin administered at 0830.

The medical record lacked documented evidence rationale for the omission of insulin administration or late medication administration.

The surveyor held a face to face interview with Employee #2 on November 10, 2016, at 1:00 PM. The findings were reviewed, discussed, and acknowledged.


B. Patient #10 was brought to the Emergency Department by ambulance from an outside facility for complaints of Altered Mental Status, Hypotension, Unresponsiveness, and Sepsis.

Medical record review conducted on November 10, 2016, at 3:57 PM revealed physician orders for Non-epinephrine (Levophed) at 12:30 PM. A subsequent review of the medication administration record showed the hospital staff did not administer Levophed.

The nursing staff assessed Patient #10 at 2000 and documented "patient blood pressure has dropped with MAP [Median Arterial Pressure] below 60"; which means there is less blood getting to vital organs and cause the patient to go into shock. According to the nursing note, the physician was made aware that Patient #10 may need to go on pressors (medications used to increase arterial blood pressure, facilitating blood getting to vital organs).

The medical record lacked documentation of the reason for the failure to follow the physician order.

The surveyor conducted a face to face interview with Employee #2 on November 10, 2016, at 4:00 PM. The findings were reviewed, discussed, and acknowledged. Employee #2 was unable to provide insight into the omission of medication administration.

Based on medical record review, policy review, and staff interview, it was determined the clinical staff failed to document all necessary care and treatment provide to meets the needs of patients in two (2) of 10 records reviewed (Patient #3 and 10).

The findings include:


United Medical Center Rules and Regulations 1.2.2 (a) (b)- The medical staff responsibilities are (a) To provide quality patient care, and (b) To account to the Governing Body for the quality of patient care provided by all members authorized to practice in the hospital.


Patient #3 was admitted with diagnoses to include Chest Pain, Hypertension, Diabetes, and Coronary Artery Disease.

Review of the medical record on November 10, 2016, at approximately 12:42 PM revealed that in the 24-hour preceding the death of Patient #3, the nursing staff documented that the patient allegedly took ten Coreg tablets, and ten Norvasc tablets in a suicide attempt by overdose on May 9, 2015. The hospital staff did not document time of the alleged overdose. Patient #3 was seen by a psychiatrist on May 9, 2015, at 2:50 PM in consultation for the alleged overdose of prescription medications, while in the hospital. The psychiatrist plan for Patient #3 was to discharge patient home once cleared by the Medical-Surgical team, and suicidal thoughts cleared, and start Zoloft (antidepressant) 100 milligrams at bedtime. A sitter provided one to one (1:1) observations.

At 1:04 AM on May 10, 2015, Patient #3's experienced an increase in body temperature 101.7 degrees Fahrenheit. Tylenol two (2) tablets were administered. An episode of coughing and restlessness was documented at 4:55 AM on May 10, 2015. According to the Nursing Note, Patient #3 was medicated with Ativan two milligrams.

The medical record lacked documented evidence of an order for Ativan administration.

Review of the medical staff 'Progress Notes' revealed Patient #3 experienced an episode of bradycardia with heart rate slowing to 40- 45 beats per minute according to the cardiologist note on May 10, 2015, at 5:43 PM. The nephrologist noted a change in mental status to alert and confused, on May 11, 2015, at 11:07 AM. On previous assessments, Patient #3 was observed to be alert and oriented to person, place, and time.

The medical record lacked documented evidence of treatment plan to address the episode of bradycardia or change in mental status post suicide attempt by medication overdose.

The physician progress note from May 11, 2015, at 1:19 PM revealed that Patient #3 had not been seen by the attending physician over the weekend, according to the physician statement, "I was sick at home." The physician statement was documented in the patient's medical record. According to the physician, "weekend notes read."

The nursing staff documented on May 11, 2015, that Patient #3 was alert and lethargic; which was attributed to the overdose on May 10, 2015. According to the nursing staff, the physician was notified.

The medical record lack any further information related to the follow-up treatment plan to address concerns of lethargy noted by the nursing staff.

At 8:15 PM, Patient #3 was reported as not breathing or responding to the nurses. A "code" was called, and cardiopulmonary resuscitation began. Patient #3 was pronounced dead at 8:45 PM by the medical staff.

Review of Patient #3's cardiac monitoring rhythm strips revealed, Patient #3 experienced a series of VPC (Ventricular Premature Complexes) and asystole from 19:10:23 to 19:17:49 on May 11, 2015. Ventricular Premature Complexes are the abnormal rhythm in the ventricles. Also, cardiac monitoring rhythm strips dated May 11, 2015, at 19:17:49, 19:18:52, and 20:17:05 revealed Patient #3 experienced episodes of asystole (no discernible heart electrical activity).

The cardiac monitoring strips contained in the medical record were folded over and taped down obscuring some of the patient's data. As a result, a subsequent on-site visit was conducted on December 11, 2016, at approximately 3:30 PM. The paper copy of the chart revealed the presence of an additional cardiac monitoring strip attached to the Cardiopulmonary Resuscitation Summary. According to Employee #2, the terminal cardiac monitoring strip is obtained when the code is ended, and the patient is pronounced dead. The terminal cardiac rhythm strip was done "11 May 2015 19:47". The patient was pronounced dead approximately one hour after the final rhythm strip attached the Cardiopulmonary Resuscitation Summary.

The medical record lacked documented evidence of intervention or physician notification of the abnormal cardiac rhythms noted at times mentioned above.

During a face to face interview conducted on December 11, 2016, at approximately 3:40 PM with Employee #2, the findings were reviewed, discussed, and acknowledged.

Patient #10 was brought in the Emergency Department by ambulance from an outside facility for complaints of Altered Mental Status, Hypotension, Unresponsiveness, and Sepsis.

Review of the medical record conducted on November 10, 2016 revealed the medical staff conducted the initial History and Physical to include a Review of System on March 21, 2016 at 12:19 PM. Patient #10 general appearance was described as being in moderate respiratory distress with decrease breaths sounds, rhonchi, and tracheostomy tube in place. The patient was disoriented and obtunded.

The medical staff ordered a series of diagnostic studies and laboratory test. The results were significant for the following: elevated white blood cells (WBCs) - 51.9; potassium- 5.4, elevated creatinine- 4.6, elevated BUN (Blood Urea Nitrogen)- 78, elevated Pro-BNP (B-Type Natriuretic Peptide)- 3890, and chest x-ray- low lung volumes with prominent right basilar sub-segmental atelectasis.

The medical staff performed a reassessment at 4:01 PM and documented that based on clinical presentation; lab and imaging results, Patient #10 "required critical care monitoring". The attending physician consulted with the intensivist. At 4:59 PM, Patient #10 was assessed to be alert and oriented times three by the nursing staff and medical decision to "Admit to ICU [Intensive Care Unit]."

On March 21, 2016 at 10:00 PM, the patient remained in the Emergency Department with respiratory rate increased to "50+" breaths per minute; the medical staff was notified. It was determined the patient needed mechanical ventilation; however, the patient's tracheostomy tube needed to be replaced. Patient #10 was reported admitted to the Emergency Department with an uncuffed tracheostomy tube and a cuffed tracheostomy was required for mechanical ventilation. The hospital staff was unable to "obtain proper" sized tracheostomy tube. While respiratory therapy continued to search for a proper sized cuffed tracheostomy tube, Patient #10 blood pressure dropped (no blood pressure value documented). Medical staff was made aware of the patient's condition and was to start "pressors". The medical record lacked documented evidence that the "pressors" were administered.

At 12:52 PM on March 21, 2016, the cardiac rhythm was documented as "sinus tachycardia". There were no other cardiac rhythms documented in the medical record, to support cardiac monitoring occurred during the Emergency Department stay while awaiting a critical care bed.

The medical record lacked documented evidence of cardiac monitoring or assessments and evaluations while waiting for a bed on the Intensive Care Unit. Additionally, there is no documentation to demonstrate the facilitation of transferred to higher level of care when inpatient capacity exceeds the normal admission order to unit transfer time.

A face to face discussion was held with Employee #4 on November 10, 2016 at approximately 10:00 AM.

Based on medical record review, policy review and staff interview, it was determined the hospital staff failed to ensure that a patient was transferred to higher level of care or increased monitoring when assigned critical care status (Patient #10).


The findings include:

United Medical Center 'Transfer of Patient for Definitive Care' policy last reviewed April 2013 stipulates, "POLICY the transfer of patients from the Hospital will be based on the needs of the patient, the nature of the diagnosis, and the availability of services as The Hospital ...2. The attending physician is responsible for determining the stability of the patient for transfer ...4. The risks and benefits of transfer must be explained to the patient ...6. Transportation and the level of transport personnel will be determined by the attending physician."

United Medical Center Policy #: ED-016 titled 'Care of the Admitted Patient in the Emergency Department" last reviewed: June 2015 stipulates, "POLICY: 1. From time to time, inpatient capacity may warrant the boarding of admitted patient in the ED for a timeframe that exceeds the normal admission order to unit transfer time. When this occurs, the ED staff will retain responsibility for patient care of the admitted patient ...3. When patients are admitted but remain in the ED, the ED nursing staff will follow the orders of the admitting service. For regular care and telemetry patients, those orders marked "stat" will be prioritized in addition to patients who are assigned critical care status. Any disputes regarding patient management will be discussed between the ED physician and the admitting service."



Patient #10 was brought in the Emergency Department by ambulance from an outside facility for complaints of Altered Mental Status, Hypotension, Unresponsiveness, and Sepsis.

Review of the medical record conducted on November 10, 2016 revealed the medical staff conducted the initial History and Physical to include a Review of System on March 21, 2016 at 12:19 PM. Patient #10 general appearance was described as being in moderate respiratory distress with decrease breaths sounds, rhonchi, and tracheostomy tube in place. The patient was disoriented and obtunded.

The medical staff ordered a series of diagnostic studies and laboratory test. The results were significant for the following: elevated white blood cells (WBCs) - 51.9; potassium- 5.4, elevated creatinine- 4.6, elevated BUN (Blood Urea Nitrogen)- 78, elevated Pro-BNP (B-Type Natriuretic Peptide)- 3890, and chest x-ray- low lung volumes with prominent right basilar sub-segmental atelectasis.

The medical staff performed a reassessment at 4:01 PM and documented that based on clinical presentation; lab and imaging results, Patient #10 "required critical care monitoring". The attending physician consulted with the intensivist. At 4:59 PM, Patient #10 was assessed to be alert and oriented times three by the nursing staff and medical decision to "Admit to ICU [Intensive Care Unit]."

On March 21, 2016 at 10:00 PM, the patient remained in the Emergency Department with respiratory rate increased to "50+" breaths per minute; the medical staff was notified. It was determined the patient needed mechanical ventilation; however, the patient's tracheostomy tube needed to be replaced. Patient #10 was reported admitted to the Emergency Department with an uncuffed tracheostomy tube and a cuffed tracheostomy was required for mechanical ventilation. The hospital staff was unable to "obtain proper" sized tracheostomy tube. While respiratory therapy continued to search for a proper sized cuffed tracheostomy tube, Patient #10 blood pressure dropped (no blood pressure value documented). Medical staff was made aware of the patient's condition and was to start "pressors". The medical record lacked documented evidence that the "pressors" were administered.

At 12:52 PM on March 21, 2016, the cardiac rhythm was documented as "sinus tachycardia". There were no other cardiac rhythms documented in the medical record, to support cardiac monitoring occurred during the Emergency Department stay while awaiting a critical care bed.

The medical record lacked documented evidence of cardiac monitoring or assessments and evaluations while waiting for a bed on the Intensive Care Unit. Additionally, there is no documentation to demonstrate the facilitation of transferred to higher level of care when inpatient capacity exceeds the normal admission order to unit transfer time.

A face to face discussion was held with Employee #4 on November 10, 2016 at approximately 10:00 AM.

Based on medical record review, and staff confirmation, it was determined the respiratory care staff without physician notification in one (1) of 10 medical records reviewed (Patient #10).

The findings include:

Patient #10 was brought in the Emergency Department by ambulance from an outside facility for complaints of Altered Mental Status, Hypotension, Unresponsiveness, and Sepsis.

Review of the medical record conducted on November 10, 2016 revealed the medical staff conducted the initial History and Physical to include a Review of System on March 21, 2016 at 12:19 PM. Patient #10 general appearance was described as being in moderate respiratory distress with decrease breaths sounds, rhonchi, and tracheostomy tube in place. The patient was disoriented and obtunded.

On March 21, 2016 at 10:00 PM, the patient remained alert with respiratory rate increased to "50+" breaths per minute; the medical staff was notified. It was determined the patient needed mechanical ventilation; however, the patient's tracheostomy tube needed to be replaced. Patient #10 was reported admitted to the Emergency Department with an uncuffed tracheostomy tube and a cuffed tracheostomy was required for mechanical ventilation. The hospital staff was unable to "obtain proper". While respiratory therapy continued to search for a proper cuffed tracheostomy tube, Patient #10 blood pressure dropped (no blood pressure value documented). Medical staff was made aware of the patient's condition and was to start "pressors". The medical record lacked documented evidence that the "pressors" were administered.

At 10:30 PM, the nursing staff documented that Patient #10's tracheostomy "closed" and the medical staff was brought to the bedside. The hospital staff began to provide respiratory support through a bag value mask for manual resuscitation.

According to medical staff documentation on March 21, 2016 at 11:01 PM, the respiratory therapist was "going to switch pt.'s [patient's] uncuffed ett [endotracheal tube] to cuffed"; however, the patient blood pressure "dropped". Respiratory therapist informed the medical staff that the patient was difficult to bag through tracheostomy. However, the respiratory therapist changed the tracheostomy without notifying the medical staff. Patient #10 developed subcutaneous air in the face and upper chest. Additionally, the medical staff documented that a "presumed false lumen" was created when the respiratory therapist removed and attempted to replace the tracheostomy.

The medical record lacked documented evidence the respiratory therapy services were delivered in accordance with medical staff directives.

Consequently, Patient #10's heart rate began to fall and became pulseless. Cardiopulmonary Resuscitation (CPR) was started and resuscitation medications were administered. For a brief moment, patient's cardiac rhythm changed to ventricular fibrillation and 200 joules of electrical defibrillation was administered. The respiratory therapist staff unsuccessful attempted to insert an oral endotracheal tube and a smaller tracheostomy tube via original tracheostomy site without success. Patient #10 returned to asystole and resuscitation efforts were discontinued at 2252 and the patient was pronounced dead.

During a face to face interview conducted with Employee #2 on November 10, 2016 at approximately 2:00 PM, the findings were reviewed, discussed, and acknowledged.