HospitalInspections.org

A Federal (validation) life safety survey code inspection was conducted on April 17, 2013 through April 22, 2013. Based on observation and staff interview it was determined that the life safety code requirement was not met on the condition level.

The findings include:

Missing ceiling tiles and penetrations in two isolated locations, entrance doors to patient rooms on 3 West failed to close and latch into frame, the fire alarm annunciator panel indicated "Trouble" within the system, failing to ensure that all components of the fire alarm system are maintained in proper working order, missing escutcheon plates and standpipe caps that required tightening electrical panels were obstructed by storage.


Details of the deficient practices are cross referred under the life safety code National Fire Protection Association 101 Standards. Cross Reference to K Tags 015, 018, 052,062, 064, and 130.

The observations were made in the presence of Employees 1 and 2.

Based on the review of records (medical records, transfusion records, policies and procedures, and blood utilization reviews) and interviews with management staff, the hospital failed to ensure that each patient's medical record included blood product transfusion records, in accordance with its policies and procedures for two (2) of the twelve (12) patient's medical records randomly selected for review (Patients # 66 and #75)
The findings included:
1. According to the review of a quality assurance document entitled "Blood Product Use 2nd Quarter CY 2012" Patient #66 and #75 each received one (1) unit of blood on June 15, 2012 and on August 21, 2012, respectively. However, review of the patient #66's and 75's medical records failed to provide evidence of the "Transfusion Record".
2. According to the hospital's Policy #114.021 entitled "Administration of Blood Products" dated December 28, 2011, the nurse is to use the "Transfusion Record" to document the following: Transfusion Certification; Patient Education Consent; Transfusion Monitoring and Transfusion reaction.
There was no documented evidence that a "Transfusion Record" was completed in accordance with the hospital's policies and procedures for transfusion of blood and blood products for Patients #66 and #75 on June 15, 2012 and on August 21, 2012, respectively.
3. Interview with the hospital's management staff on April 18, 2013 at approximately 03:15 PM confirmed the fact that the "Transfusion Record" was missing from Patients #66"s and #75's medical records. Reportedly the Transfusion Record documentation was completed for each transfusion, however, the staff were unable to locate the records.

Based on medical record and policy review as well as staff interview, it was determined that the medical staff failed to authenticate the medication reconciliation process with timeliness, in three (3) of seven (7) records reviewed (Patients # 19, 20, and 22).

The findings include:

The MedStar National Rehabilitation Network Rules and Regulations of the Medical Staff, adopted June 2011 were reviewed. Part II, Conduct of Care; Section 4, pertaining to Health Information Medical Records, Subsection A entitled ' Medical Records Requirements - Inpatients ' , stipulated the following under Items 1 and 2.g.vii, respectively: Item 1, " Attending Physician shall be responsible for the preparation of a complete and legible medical record " ; and, Item 2.g.vii, " The medical record whether paper or electronic shall contain: ...Clinical observations, including ...integration of findings, treatments, interventions of multi discipline team ... "


The MedStar National Rehabilitation Network NRH Pharmacy Standard Practice Number 360.38 entitled ' Medication Reconciliation ' , effective July 1, 2006 was reviewed. The Responsibilities Section stipulates " ... 1.2 The Pharmacist will print a list of the medications ordered and compare that list to multiple information sources ...Any discrepancies will be noted to create the ' Admission Medication Reconciliation Progress Note ' that is signed by the pharmacist and placed in the progress note ... 2. Transition Point - The author of the patient ' s medication orders will review the current MAR [Medication Administration Record] and the Medication/Allergy History notes and confirm in writing that (s)he: 2.1 Agrees with continuing the medications as listed or; 2.2 Signify changes to the medication regimen by adding new orders or deleting listed drugs from the patient ' s medication orders ... "

A face to face interview was conducted with the Nurse Educator and the nursing leadership present during medical record review on April 17, 2013 at approximately 4:00 PM. The nurses were queried regarding the policy and/or protocol for medication econciliation.

The nurses replied in agreement that the medical staff was to sign off on the medication reconciliation form within 24 hours of the pharmacist ' s signature. One (1) of the unit ' s two (2) Nurse Coordinators confirmed with the unit pharmacist that the medical staff was to countersign/authenticate the medication reconciliation within 24 hours of the admission.

A face to face interview was also conducted with the Director of Pharmacy Services at 2:45 PM on April 19, 2013. The Pharmacy Director was queried as to the policy and protocol for medication reconciliation.

The Director confirmed that a ' stamp ' is placed at the end of the note which serves as the authentication when signed by the pharmacist and the medical staff.

The Director further explained that the pharmacist prints, stamps, and signs the medication reconciliation note, after which the medical staff acknowledges it by affixing a signature within 24 hours of the note being placed in the medical record.

The Director was then queried as to whether the medical staff can print the medication reconciliation note. The Director clarified that the reconciliation note can only be generated by the pharmacist. He/she stated that the medical staff does not have the capability to generate the note, nor does the medical staff have access to the form before process by the pharmacist.


A. Patient #19 was admitted April 15, 2013 with diagnoses which included Right Side Weakness Status Post Cerebrovascular Accident, and history of Degenerative Disc Disease, Diabetes Mellitus Type 2, Hyperlipidemia and Hypertension.

Review of the medical record on April 17, 2013 at approximately 2:00 PM revealed that the Admission Medication Reconciliation Progress Note was printed April 15, 2013 at 19:18 (7:18 PM). The authentication stamp was signed by the pharmacist on April 15, 2013 at 20:38 (8:38 PM).

The form lacked documented evidence of the medical staff signature for authentication as of the date of survey on April 17, 2013 at approximately 11:45 AM. This timeframe was greater than 24 hours after the pharmacist ' s initial acknowledgement/authentication.

The medical staff failed to authenticate the medication reconciliation with timeliness. The medical staff failed to adhere to the medication reconciliation process of authentication within 24 hrs.


B. Patient #20 was admitted March 30, 2013 with diagnoses which included Encephalopathy, History of Gastrointestinal Hemorrhage status post Gastrostomy Tube Placement, and past medical history of Hypertension and Gout.

Review of the medical record on April 17, 2013 at approximately 12:10 PM revealed the Admission Medication Reconciliation Progress Note which was printed March 31, 2013 at 10:03 AM. The authentication stamp was signed by the pharmacist on March 31, 2013 at 11:45 AM.

The form lacked evidence of the medical staff signature for authentication as of April 17, 2013 at 12:10 PM, the date of survey.

The medical staff failed to adhere to the medication reconciliation process of authentication within 24 hrs.


C. Patient #22 was admitted April 14, 2013 with diagnoses which included Cellulitis, Deconditioning and history of Pulmonary Embolus.

Review of the medical record on April 17, 2013 at approximately 12:25 PM revealed the Admission Medication Reconciliation Progress Note which was printed April 14, 2013 at 17:05 (5:05 PM). The authentication stamp was signed by the pharmacist on April 15, 2013 at 16:05 (4:05 PM). The form lacked documented evidence of the medical staff signature for authentication as of April 17, 2013 at approximately 12:25 PM.

The medical staff failed to adhere to the medication reconciliation process of authentication within 24 hrs.

Based on record review and staff interview, it was determined that the medical team failed to provide documented evidence that a clinical re-assessment and/or physical examination was performed on one (1) patient with a history of Traumatic Brain Injury (TBI) who demonstrated symptoms suggestive of a change in neurological status; and the medical team failed to document a detailed accounting of the clinical incident and subsequent plan of care directed for the patient at the time of occurrence. Patient # 1.

The findings included:

The Rules and Regulations of the Medical Staff, last revised in June 2011, included the following directives under Item II. Conduct of Care, Section 2 (C), 'Admission and Continued Stay of Patients'; and Section 4, A (2h), 'Medical Records Requirements, Progress Notes', respectively: Section 2 (C), "A physician member of the Active Medical Staff shall be responsible for the care and treatment of each patient in the hospital. Each practitioner shall be responsible for the prompt completion and accuracy of the patient's medical record..."; and, Section 4, A (2h), "The patient's clinical problems shall be clearly identified in the progress notes and correlated with specific orders...Progress notes shall also be documented when a patient is seen and a service charge is rendered...When rounds are made with the attending physician, and/or in the case has been discussed with the attending physician, the resident note shall reflect such activity."

Patient # 1 was admitted to the hospital for Traumatic Brain Injury (TBI) rehabilitation on April 10, 2013 after initially presenting to an outside hospital unresponsive and in a coma. The patient was subsequently determined to have suffered an intracranial hemorrhage. Diagnostic CT Scan (Computed Tomography Scan) revealed a large right basal ganglia hemorrhage with a midline shift and herniation. The patient was emergently taken to the operating room (OR) for a right decompressive craniectomy with placement of bone flap in the abdomen. The past medical history was inclusive and significant for Hypertension, and non-compliance with his/her prescribed medical treatment.

During a review of the medical record, it was determined that the occupational therapist documented the following observation related to the patient's neurological status at 10:30 AM on April 11, 2013: "Patient lethargic, difficulty to arouse. Resident MD present and ordered STAT head CT scan."

Previous observation and documentation by the therapist at 8:30 AM revealed that the patient had been: "lying awake in bed, pleasant and cooperative".

Review of the Physician's Orders, dated April 11, 2013 at 10:55 AM, revealed that the medical resident had written an order for the progressive monitoring of the patient's vital signs. The order was documented as follows: "Vitals Q (every) 15 minutes times four (4). Call House Officer (HO) with concerns." The order was countersigned by the attending physician.

A concurrent review of the "vital signs" flowsheet revealed that the nurse measured and recorded the patient's vital signs on three (3) occasions at 11:00 AM, 11:15 AM and 11:20 am. The results indicated that the patient's blood pressure had dropped significantly (15-20%) from the previous recording at 10:00 AM.

The vital signs were recorded as follows:
TimeBlood PressurePulse10:00 AM131/856711:00 AM112/536511:15 AM108/536611:20 AM104/5464
Subsequent review of the physician progress notes, for the date and times referenced above, revealed the following findings: there was no documented evidence of a corresponding physician note or summary in the medical record that addressed and/or acknowledged the suspected change in the patient's neurological condition or status; there was no documented summary explanation entered in the medical record by the medical team identifying a specific patient event or episode to clinically justify/support the order for frequent monitoring of the patient's vital sign; and, there was no documented evidence of a clinical re-assessment and/or physical examination performed by the medical team in response to the reported neurological observations of the therapist and the recorded changes in the patient's blood pressure measured by the nursing staff.

A face-to-face interview was conducted on April 17, 2013 at approximately 2:25 PM with the medical resident who documented the vital signs order. The medical resident verbally corroborated the findings documented by the occupational therapist. He/she confirmed that the patient was "lethargic and difficult to arouse" on the morning after his/her admission.

The resident further verbalized that given the patient's history of significant brain injury, he/she was "concerned" that a "possible change" in the patient's neurological status was emerging. Subsequently, he/she documented orders for the monitoring of the patient's vital signs and a diagnostic CT scan of the patient's head.

According to the medical resident, he/she then discussed the patient's clinical presentation and concern for possible neurological changes with his/her attending physician.

Further surveyor inquiry with the medical resident confirmed that he/she did not document evidence of the patient's clinical condition/status in the medical record; did not document evidence of a clinical examination or assessment of the patient; and did not document evidence of any subsequent findings related to an evaluation of the patient or consultation with the attending physician.

A face-to-face interview was also conducted with the attending physician, in the presence of the unit nursing director and the hospital's administrative escort on April 19, 2013 at approximately 12:15 PM.

The attending physician recalled discussion with the medical resident concerning the patient and the subsequent instructions that were given to the resident in terms of the prescribed management of care.

However, continued inquiry revealed that despite verbal acknowledgment by the attending physician concerning the above referenced findings, he/she also failed to include and document a detailed summary of this encounter in his/her progress notes; and failed to record and file evidence of a physical examination of the patient with documented clinical findings in the medical record.
The record review was completed on April 19, 2013.

Based on medical record and policy review as well as staff interview, it was determined that the clinical staff failed to consistently document evidence of on-going assessments and/or reassessments in three (3) of three (3) medical records reviewed (Patients # 16, 18, and 19).

The findings include:

NRH Nursing Clinical Policy Number 113.017 entitled Guidelines for Nursing Adult/Pediatric Ongoing Assessment, effective March 3, 2010, stipulated and included the following directives under the ' Policy ' section and the section entitled ' Documentation ' respectively: " Policy: 1. Nurses will complete an electronic Ongoing Assessment on all assigned patients during their assigned shifts ... 2. The electronic Ongoing Assessment provides documentation of routine nursing care, changes in patient ' s condition and patient ' s status during the assigned shift ...and, 6. Each area of the Ongoing Assessment that applies to the patient must be completed. Supporting data must be entered as appropriate ...; and ' Documentation ' : " ...5.2 Pain is assessed on admission, at least once a shift and anytime a PRN pain medication /intervention is provided ...5.4 The in-patient medical record must demonstrate evidence of interdisciplinary review of the pain management plan ... "


NRH Nursing Clinical Policy Number 108.007 entitled ' Wound Assessment ' , effective October 10, 2012, was reviewed. The Policy section stipulates " 1. The RN is responsible for assessing and documenting status of wound(s) via the Electronic Medical Record (EMR). 2. The RN is responsible for reporting any change in patient ' s wound status ...5. The following wound assessment will be assessed and carefully recorded in the EMR at each dressing change: 5.1 Type of wound; 5.2 Location of wound; 5.3 Size: 5.3.1 The size of the wound will be obtained on admission and thereafter, once a week and whenever a change occurs in the wound; and, 5.3.2 Use ruler to measure the longest and widest aspect of the wound surface in centimeters ... "


A. Patient #16 was admitted April 16, 2013 with diagnoses which included Congenital Spinal Stenosis status post Cervical Spinal Laminectomy with Fusion and History of Back Pain.

Review of the medical record on April 19, 2013 at approximately 8:55 AM revealed the patient was assessed for pain at least twice daily from the date of admission until record review.

The Electronic Medical Record reflected a pain assessment on April 17, 2013 at 10:52 AM, referencing a numeric pain score of seven of ten (7/10). The pain was described as aching at the neck. The Adult Ongoing Assessment reflected the acceptable pain level was five of ten (5/10), and the patient was comfortable. The Assessment lacked documented evidence of other interventions.

A subsequent pain assessment was documented at 11:00 AM by the Physical Therapist as five of ten (5/10) with an acceptable pain level of zero (0). The medical record lacked documented evidence of the therapist ' s notifications of the medical or nursing staff, or any interventions regarding the pain assessment. There were no further associated reassessments for the pain assessments documented. The clinical staff failed to consistently document all evidence of ongoing clinical assessments and/or reassessments.


B. Patient #18 was admitted March 20, 2013 with diagnoses which included Status Post Cerebrovascular Accident, Dysarthria, history of Locked-in Syndrome and Substance Use.

Review of the medical record on April 18, 2013 at approximately 9:08 AM revealed the patient was assessed for pain at least twice daily from the date of admission until record review.

The Electronic Medical Record reflected a pain assessment on April 10, 2013 at 12:26 AM referencing only a numeric pain score of five of ten (5/10). The pain assessment lacked documented evidence of any descriptors of pain to include but not limited to the location, quality of, or interventions regarding the pain assessment.

At 1:26 AM April 10, 2013 the associated reassessment reflected that a " prn medication " was administered and there was " no actual pain " . The reassessment lacked documented evidence of a numeric pain scale as verification of the reassessment. The clinical staff failed to consistently document all evidence of ongoing clinical assessments and/or reassessments.

Further, the Electronic Medical Record reflected that the patient was admitted with the following alterations in skin integrity - Tracheostomy Tube site, Gastrostomy Tube site, Suprapubic Catheter site and Skin Tear of the Left Ear.

The initial skin evaluation lacked descriptors of the Left Ear to include size approximation, features and characteristics.

On March 26, 2013 the nursing staff documented the presence of Skin Tear of the Right Buttocks. The patient was subsequently evaluated by the Wound Nurse on March 27, 2013. A subsequent treatment plan was recommended for the management of both the ear and buttock wounds to be carried out by the primary nursing staff.

The ensuing assessments performed by the primary nursing staff lacked documented evidence of descriptors of either wound to include size approximation, features and characteristics which would support the progression or regression of the wounds.

The clinical staff failed to consistently document evidence of ongoing assessments and/or reassessments.

A face to face interview was conducted with the Director of Nursing Education at approximately 10:25 AM on April 18, 2013. The Director explained that the Wound Nurse is consulted for all hospital acquired wounds.

If the wounds are determined to be in the following categories: Stage 1, Early Stage 2, skin tears, moisture associated, or suspected deep tissue injuries; then the wound care nurse documents his/her recommendations and subsequently releases the care of the patient to the clinical nursing staff. If the wounds regress, then the wound care nurse is re-consulted.

The Director stated that the clinical expectation, in accordance with the established hospital policies, is that the nursing staff will document complete wound descriptions upon admission and at every dressing change; and that wound measurements will be made weekly.


C. Patient #19 was admitted April 15, 2013 with diagnoses which included Right Side Weakness Status Post Cerebrovascular Accident, and history of Degenerative Disc Disease, Diabetes Mellitus Type 2, Hyperlipidemia and Hypertension.

Review of the medical record on April 17, 2013 at approximately 2:00 PM revealed that the patient was assessed for pain at least twice daily from the date of admission until surveyor record review.

The Electronic Medical Record reflected that a pain assessment was performed on April 17, 2013 at 8:00 AM, which referenced only a numeric pain score of ten of ten (10/10).

The pain assessment lacked documented evidence of any descriptors of pain to include but not limited to the location of pain, the quality or intensity of the pain, or the interventions used in response to the pain level assessed.

There were no associated reassessments for the pain assessment. The clinical staff failed to consistently document all evidence of ongoing clinical assessments and/or reassessments.

A face to face interview was conducted with the patient ' s primary nurse at approximately 3:40 PM. The primary nurse stated that s/he was not responsible for the 8:00 AM entry. The nurse further recalled that when the patient was assessed for pain during hourly rounding and shift assessment, the patient had reported that he/she had no pain. The nurse was subsequently able to determine that the entry was recorded by the Occupational Therapist.

On April 18, 2013 at approximately 2:10 PM, a face to face interview was conducted with the Occupational Therapist of record per the Electronic Medical Record. The therapist explained that the pain rating listed was based on information that had been recorded during another therapist ' s evaluation encounter on April 16, 2013 - not the final evaluation encounter of April 17, 2013 at 8:00 AM. S/he stated that the patient had denied pain during the encounter of April 17, 2013 at 8:00 AM.

The therapist explained that physical medicine evaluations are performed in stages, and different therapists may perform different stages of the evaluation.

Because of this, information entered into certain areas of the Electronic Medical Record is automatically carried over into each subsequent evaluation and the final document.

The therapist was queried as to the processes of pain evaluation. The therapist stated that when pain is reported during evaluation or therapy sessions, the nursing staff is immediately notified so that appropriate interventions can be administered.

The therapist was confident that the original therapist would have notified the nursing staff of the pain rating of ten (10).

The therapist was further queried regarding the documentation requirement. The therapist demonstrated the electronic forms, and where documentation of information regarding pain, notifications, and interventions were recorded.

The therapist was unable to locate the documentation evidence which would have demonstrated that the nursing or medical staff had been notified concerning the above referenced patient who experienced the ten of ten (10/10) pain level assessment; and whether any pain management interventions had been initiated.

The clinical staff failed to consistently document evidence of ongoing assessments and/or reassessments.

Based on observations during the survey period it was determined that dietary services were not adequate to ensure that foods are prepared and served in a safe and sanitary manner. These findings were observed in the presence of the Food Service Director.
The findings include:
1. During a tour of the Dietary Department, it was determined that the food grinder (disposal unit) was inoperable in the Pot and Pan Wash area. Staff were observed collecting leftover food from the Pot and Pan wash area and transporting leftover foods to the dishwasher disposal unit. Documentation was not available to show that a recent work order was generated to repair the grinder in a timely manner, in one (1) of three (3) observations, at approximately 10:10 am on April 17, 2013.
2. The flour scoop was observed to be improperly stored in the flour bin, creating a potential contamination issue, in one (1) of one (1) observation, at approximately 10:40 am on April 17, 2013.
3. The inner and outer shelf surfaces of Low Rater Carts were observed to be soiled and stained with accumulated debris, in three (3) of three (3) observations, at approximately 2:00 pm on April 17, 2013.
4. The bottom surface of chinaware (plates) were stained with a dark residue, in ten (10) of ten (10) observations at approximately 12:22 pm on April 17, 2013.
5. The inner and outer surfaces of hotel pans were not thoroughly cleaned after washing in the Pot and Pan area, as evidenced by leftover food particles, in addition pans were not allowed to dry before placing on racks for reuse, in fifteen (15) of twenty (20) observations at approximately 11:50 am on April 17, 2013.
6. Scoops, ladles, and hotel pans were observed to have fine particles of plastic residue (curly plastic) left on the serving surfaces of scoops and ladles, and the inner and outer surfaces of hotel pans, which originated from a worn scrubbing pad, that were used to scrub pots, pans and ladles, in 15 of 30 observations at approximately 12:10 pm on April 17, 2013.
7. Floor and the lower wall surfaces throughout the main kitchen were soiled and stained with a dark residue in addition the baseboard surfaces were also found to be stained with a dark residue in the retail and dishwasher area, in three (3) of three (3) observations approximately between 10:30 am and 4:00 pm on April 17, 2013.
8. Metal floor surfaces were observed to be uneven and unsecured in the Produce and Re-Therm refrigerators. A work order had been placed, however there was no response rendered within a timely manner, as of 4/19/13, in two (2) of two (2) observations approximately between 10:10 am and 2:00 pm on April 17, 2013.