HospitalInspections.org

Based on observation and staff interview, the hospital staff failed to ensure a safe patient environment, as evidenced by unsecured sharps, in eight of 14 observations.

Findings included ...

A. During a tour of the Emergency Department on 06/17/19 at approximately 10:50 AM, with Employee #11, ED Charge Nurse, the surveyor observed two unsecured intravenous supply carts, stored with various gauges of needles, angiocatheters, and vacutainers, in the hallway, available to passersby.

Additionally, suture cart #2, in room #35 was found unsecured. It contained scalpels, skin staplers, and surgical removal kits.

The practice failed to demonstrate that staff ensured safe patient settings.

During a face to face interview with Employee #11, at the time of the findings, she secured the carts and acknowledged the findings.


35226


B. During a tour of the Pediatric Intensive Care Unit (PICU) on 06/17/19 at approximately 10:45 AM, with Employee #114 PICU Charge Nurse, the surveyor observed five unsecured supply carts, stored with various gauges of unsecured needles. Additionally, scissors and vials of Lidocaine were located in an unlocked central line cart. Both were located in areas accessible to passersby.

The practice failed to demonstrate that the staff ensured safe patient settings.

The surveyor conducted a face to face interview with Employee #114 at the time of the observation, she acknowledged the findings.

Based on medical record review, policy review, and staff interview, the nursing staff failed to follow the plan of care related to hospital acquired pressure injury and gastrointestinal assessments, seizure precautions, cardiac monitoring, and vital signs, in seven of 10 records reviewed (Patient #50, 5, 6, 7, 15, 16, and 17).

Findings included ...

A. Record review of the hospital's policy, "Nursing Practice Guideline- Skin Care," last updated: 04/18 showed, wound assessments should be clearly documented, using a standardized assessment tool. Wound assessments should include the anatomical location, type of wound, and size of wound. The size of the wound should be measured in "centimeters (cm) for length x (by) width x depth."

Review of the integumentary assessment flowsheet for Patient #50, dated 06/03/19 at 1:34 PM, revealed the Wound Ostomy Continence Nurse (WOCN) documented that the wound on the bilateral sacral area was a Deep Tissue Pressure Injury (DTI), measuring, 5.0 cm in length x 11 cm in width, and 0.1cm depth. There was no open areas or excoriation.

Further review of the medical record, revealed on 06/12- 06/13/19 and 06/15/19, nursing staff documented that the wound was a suspected deep tissue pressure injury. The assessment included no characteristics or measurements.

The practice lacked evidence that the nursing staff followed the hospital policy for wound assessment and documentation.

The surveyor conducted a face-to-face interview with Employees #44, Advanced Nurse Practitioner, #50, Nurse Manager, and #52, Registered Nurse, on 06/18/19 at approximately 12:30 PM. All acknowledged the findings at the time of the record review.



34093


B. Review of the hospital policy titled, "Nursing Assessment and Reassessment," revised 04/15, showed that patients presenting to the Emergency Department (ED) should have an initial assessment, documented in the medical record, which includes a primary and secondary focused assessment, "based on signs and symptoms, chief complaint and past medical history, including pertinent vital signs ...Reassessment shows response to treatment and patient stability or instability."

Review of Patient #5's medical record on 06/17/19 at approximately 12:15 PM, with Employees #10, Nurse Manager and #11, Registered Nurse, revealed the patient presented to the ED with complaints of right lower quadrant abdominal pain and guarding.

Review of the nursing assessment and documentation on 06/17/19, lacked evidence that nursing staff assessed the gastrointestinal status to include bowel sounds or bowel movements.

The practice lacked evidence that nursing staff performed assessments, per hospital policy, based on the patient's presenting signs and symptoms and complaint.

During a face to face interview with Employee #11, the patient's bedside nurse, she acknowledged that she did not listen to the patient's bowel sounds or assess if the patient was having regular bowel movements.

C. Review of Patient #6's medical record on 06/17/19 at approximately 3:50 PM, with Employee #10, Nurse Manager, revealed the patient presented to the ED with complaints of having seizures and vomiting. The patient's history included Hydrocephalus, Ventriculoperitoneal Shunt, and Seizures.

The physician ordered seizure precautions and cardiac monitoring 06/17/19 at 10:53 AM.

Review of the nursing documentation lacked evidence that staff implemented seizure precautions or assessed and documented the patient's rhythm from the cardiac monitor.

The practice lacked evidence that nursing staff followed the plan of care and physician orders.

Employee #10 acknowledged the findings.

D. Review of Patient #7's medical record on 06/17/19 at approximately 3:38 PM, with Employee #10, Nurse Manager, revealed the patient presented to the ED with complaints of three episodes of nausea and vomiting. The patient's diagnosis was Gastritis.

Review of the nursing assessment and documentation on 06/17/19, lacked evidence that nursing staff assessed the patient's gastrointestinal status to include abdomen description, palpation, bowel sound and bowel movement.

The practice lacked evidence that nursing staff performed assessments, per hospital policy, based on the patient's presenting signs and symptoms and complaint.

Employee #10 acknowledged the findings.

E. Review of Patient #15's medical record on 06/20/19 at approximately 11:00 AM, with Employee #40, Clinical Supervisor, revealed the patient presented to the Gastrointestinal Clinic for Remicade (an infusion medication), to manage Crohn's Disease.

The physician ordered the infusion on 06/19/19 to run for one hour; and for vital signs to include the temperature, heart rate, respiratory rate, and blood pressure, every 15 minutes for the hour of infusion.

Review of the nursing documentation revealed nursing staff performed three sets of vital signs, one lacking the temperature, during medication infusion.

The practice lacked evidence that nursing staff followed the plan of care and physician orders.

Employee #10 acknowledged the findings.

F. Review of Patient #16's medical record on 06/20/19 at approximately 11:30 AM, with Employee #40, Clinical Supervisor, revealed the patient presented to the Gastrointestinal Clinic for Remicade (an infusion medication), to manage Crohn's Disease.

The physician ordered the infusion on 06/19/19 to run for one hour; and for vital signs to include the temperature, heart rate, respiratory rate, and blood pressure, every 15 minutes for the hour of infusion.

Review of the nursing documentation revealed nursing staff performed three sets of vital signs, one lacking the temperature, during medication infusion.

The practice lacked evidence that nursing staff followed the plan of care and physician orders.

Employee #10 acknowledged the findings.

G. Review of Patient #17's medical record on 06/20/19 at approximately 11:45AM, with Employee #40, Clinical Supervisor, revealed the patient presented to the Gastrointestinal Clinic for Remicade (an infusion medication), to manage Crohn's Disease.

The physician ordered the infusion on 06/19/19 to run for two hours; and for vital signs to include the temperature, heart rate, respiratory rate, and blood pressure, every 15 minutes for the first hour of infusion, and every 30 minutes for the second hour of infusion.

Review of the nursing documentation revealed nursing staff performed temperature measurement, only twice, during medication infusion.

The practice lacked evidence that nursing staff followed the plan of care and physician orders.

Employee #10 acknowledged the findings.


35226


Based on record review and staff interview, nursing staff failed to develop an individualized care plan to address the needs of patients with behavioral concerns, in three of three medical records reviewed (Patients #117, 5, and 112).

Findings included ...

A.The physician admitted Patient #117 for an Ileostomy Reversal related to Short Gut Syndrome.

Review of an Autism Behavior Consult note dated 06/08/19 at 5:00 PM, showed that Patient #117 is not Autistic. However, he presents with behaviors that interfere with his care and the ability to manage his ostomy.

Review of the medical record showed that nursing staff did not develop a plan of care, with goals and interventions, to address his behavior.

The surveyor conducted a face to face interview on 06/18/19 at 11:00 AM, with Employee #134, Registered Nurse in the Intestinal Rehabilitation Unit. She stated that there is no option to choose a Behavioral care plan from the list in the electronic medical record, and there was no ability to free text a problem with goals and interventions. She acknowledged the findings at the time of the interview.

B. The physician admitted Patient #5 for Acute Abdominal Pain. Additionally, there was a suspicion that she was a victim of sex trafficking.

Patient #5 was admitted with safeguards in accordance to hospital policy. Review of the medical record showed that nursing staff did not develop a plan of care, with goals and interventions, to address problems related to management of a patient with suspected sexual trafficking.

The surveyor conducted a face to face interview on 06/18/19 at 10:15 with Employee #121, Charge Nurse. She acknowledged the findings.

C. Patient #112 was admitted related to nutritional concerns and suspected Anorexia Nervosa, with a weight loss of 15 kilograms in 10 months.

Review of the medical record showed that the patient received a nutrition consult, a psychiatric consult, and had a 24-hour sitter.

Further review of the medical record showed that nursing staff did not develop a plan of care, with goals and interventions, to address behaviors related to her medical diagnosis, Anorexia.

The surveyor conducted a face to face interview on 06/17/19 at 3:15 with Employee #130, Shift Coordinator, regarding the development of care plans related to behavior. She stated that there was no option in the electronic medical record for a behavioral care plan, and there was no ability to free text. Employee #130 acknowledged the findings at the time of the interview.

The surveyor conducted a face to face interview on 06/18/19 at 3:00 PM with Employee #57, Informatics Nurse, regarding the ability to customize a care plan. She demonstrated that in the electronic medical record, the nurses can develop an individualized plan of care to address the needs of the patients.

Based on medical record review, policy review and staff interview, the hospital staff failed to document social work involvement and a pain assessment, in three of six medical records reviewed (Patient #65, 5, and 105).

Findings included ...

Record review of the hospital's policy titled, "Pain Management," updated, 2/14/19 showed, each patient should be screened for pain, when the patient presents for care. Additionally, a detailed clinical pain assessment should be completed for all patients who have positive pain screens. The pain history, includes the severity (pain score). Documentation of the pain score must be provided in the Electronic Medical Record (EMR) prior to the time of intervention.

A. Review of Patient #65's medical record showed the patient presented to the outpatient clinic with a chief complaint of "Elbow Injury." On examination, he was having significant pain with manipulation and palpation over the radial head and condyls. The patient was transferred to the emergency department via ambulance, for "Right elbow injury [rule/out] supracondylar [fracture]-severe pain."

A review of the electronic notes revealed the patient had a positive pain screen. The registered nurse administered Motrin 300mg by mouth one time, as prescribed by the physician, on 06/18/19 at 1:34 PM; however, she failed to document the pain severity score prior to motrin (medication) administration.

The practice lacked evidence that the registered nurse documented the pain assessment, before administration of the pain medication, in accordance with the hospital's pain management policy.

The surveyor conducted a face-to-face interview with Employee #75, Nurse Manager, on 06/20/19 at approximately 11:15 AM, regarding pain assessment and documentation. She acknowledged the aforementioned findings, at the time of the medical record review. Further stated, that the registered nurse is responsible for documenting the pain assessment.


34093


B. Review of the hospital policy titled, "Social Work Assessment and Documentation," reviewed 10/01/18, showed that staff are to record all professional activity, in the medical record, accurately, completely, and with timeliness.

Review of Patient #5's medical record on 06/17/19 at approximately 12:15 PM, with Employees #10, Nurse Manager and #11, Registered Nurse, revealed the patient presented to the Emergency Department (ED) on 06/16/19 at 6:37 PM, with complaints of right lower quadrant abdominal pain and guarding.

Review of the medical staff documentation, dated 06/16/19, revealed social work staff was notified of social concerns that required care coordination of social work staff and child protective services (CPS).

Further review of the medical record lacked documented evidence from the social work staff of their knowledge, involvement, or professional activity, regarding the patient.

During a face to face interview with Employee #17, Social Worker, on 06/17/19 at 12:50 PM, she was queried regarding social work involvement in the patient's case. She explained she received verbal report from the social worker, who worked on 06/16/19 that she provided guidance to the medical staff to report the concerns to CPS. Child Protective Services staff visited the patient in the ED on that day, and an active investigation was in progress. Employee #17 was asked to provide the social work documentation of that activity. She could not provide the requested documentation, stating there was no note in the medical record.

During a face to face interview on 06/17/19 at 2:50 PM, with Employee #15, Director of Social Work (SW) and #16, SW Manager, Employee #15 explained that staff are expected to document before the end of their day.

The practice lacked evidence that the social work staff provided necessary documentation to ensure continuity of care to monitor the patient's status.

Both employees acknowledged the findings.


35226


C.The Children's National Medical Center policy entitled, "Allow Natural Death " last updated 06/06, showed that " ...The goals of further treatment for the patient and family, as well as the burdens and benefits of Allow Natural Death. Limited Resuscitation order must be discussed with the patient and family, and their verbal agreement to the order must be documented in the patient's medical record ...The 'Limitation of Care' Power form must be completed by an attending physician."

Review of the medical record showed that Patient #150 arrived with a Glasgow Coma Score of 3, indicating that the patient was comatose. Before transfer to the hospital, Patient #150 coded three times, receiving three rounds of cardiopulmonary resuscitation, and the return of spontaneous circulation. On arrival from the outside hospital, the patient was transferred to the Pediatric Intensive Care Unit (PICU).

Further review of the medical record showed that while in the PICU, Patient #150 received care documented in a paper medical record between 2:20 AM and 4:43 AM on 04/29/19.

A death note was completed by the physician on 04/29/19 at 8:14 AM, indicating that the patient died at 7:17 AM on 04/29/19. There is no documented evidence of care and activity between 4:43 AM and 7:17 AM. The code status of the patient was listed as 'Allow Natural Death' (AND).

The medical record lacked documented evidence of an order for 'AND' and lacked the additional documentation required when ordering 'AND'.

The surveyor conducted a face to face interview on 06/19/19 at 1:30 PM with Employee #57, Informatics Nurse, she acknowledged the findings.

Based on a review of hospital documents to include Pyxis Automated Dispensing Machine (ADM) Schedule II, III, IV, and V Controlled Substance Transactions by patient report, physicians' orders, and the Medication Administration Record [MAR], the hospital staff failed to properly document the administration, wasting, or handling of controlled substances, in three of thirteen records reviewed (Patients #93, #,95, #99).

Findings included ...

On 06/20/19, the ADM, for controlled substances schedule II-V, generated a seventy-two (72) hour all stations event report, for nursing Units: the Neonatal Intensive Care Unit (NICU), 3 East, 3 MC, 4 Main and the Psychiatric Unit; and a twenty-four (24) report was generated for nursing units: Emergency Department (ED), Post Anesthesia Care Unit (PACU), and the Operating Rooms (OR). All patients were randomly selected for this audit. The survey of records was started on 06/20/19, at approximately 11:00 and was completed on 06/21/19, at approximately 11:00.

In the presence of Employees #105, the Director of Pharmacy, #106, Clinical Pharmacist, and #107 the Clinical Pharmacist in Emergency Department, ADM records, and the Electronic Medication Administration Record (eMAR) were reviewed for accuracy. Withdrawals from the ADM were compared with the dose administered, the administration times, and the dispositioning of the controlled substances. The following were observed:

On 06/14/19 at 01:52, Patient #93, in 3 MC, was ordered Fentanyl 14 mcg (micrograms) as needed for sedation and agitation. On 06/14/19, at 06:27 one dose was removed and administered at 08:04. The dose was administered over an hour later.

On 06/14/19, at 04:57, Patient #93, was ordered Midazolam 0.42 milligrams (mg), IV (intravenously) every hour as needed for sedation. On 06/14/19, at 08:13, one dose was removed and administered at 11:00. The dose was administered over two hours later. Additionally, 2 mg was documented as wasted. The correct waste is 1.58 mg.

On 06/16/19, at 09:41, Patient #95, on 3 East, was ordered Midazolam 0.8 mg was ordered. On 6/16/19, at 23:45 one dose was removed and 1.2 mg was documented as wasted. However, there was no documentation of administration or dispositioning of the 0.8 mg dose.

On 06/17/19, at 08:42, one dose was removed and administered at 13:38 for Patient #95. The dose was administered approximately five hours later.

On 06/12/19, at 08:00, Patient #99, in the psychiatric unit, was ordered Concerta18 mg once every morning. On 06/13/19, at 08:17 one dose was removed and administered at 09:31, over one hour late.

All findings were confirmed by Employees #105, 106, and 107.

Based on observations and staff confirmation, during the survey, dietary services were not adequate to ensure that foods were prepared and served, in a safe and sanitary manner. The surveyor observed the findings, in the presence of Employee #68, Director of Dietary Services.

Findings included ...

1. Sushi shrimp was stored in the refrigerator in temperature measured at 43.3 degrees Fahrenheit (°F); which is above the allowable 41°F temperature for cold foods.

2. Exhaust vents were soiled with dust accumulation, over the cooking and food preparation areas, in the Main Kitchen and in the Dishwasher areas.

3. The interior areas of convection ovens were soiled with grease and food spillages, in the Main Kitchen, in two of four observations.

4. Test tray temperatures were measured and cold foods were served above the minimum requirement of 41 degrees °F in the following instances: gluten free apple juice - 49° F; low sodium grapes - 50°F; regular tray fruit mix -43°F; milk - 45°F and cheddar cheese -59°F.

5. Exterior surface of trap doors, in the rear of steam kettles, were soiled and rusty in four of four observations.

6. Foods were improperly disposed of in trash receptacles, in the dish room, cafeteria serving area, deli area, and the sushi preparation area.

Employee #68 acknowledged the findings.

Based on the Life Safety Code Validation survey, conducted between June 17, 2019 and June 20, 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 and staff confirmation, during the survey, housekeeping and maintenance services were not adequate to ensure that the facility was maintained, in a safe and sanitary manner.

Findings included ...

1. The surveyor observed the findings, during a tour of the Cardiac Intensive Care Unit, on 06/19/19, at approximately 9:25 AM, in the presence of Employees #24 and #25, Nurse Managers, #70, Engineering Staff, and #69, Engineering Scribe.

A. Wall surfaces were marred, in Rooms 358, 364, 366, and 383.

B. Hot waters temperatures were below required minimum 105 degrees Fahrenheit (°F) in the following Rooms: Room 358-104 °F, Nutrition Room - 93 °F, Room 362-74 °F, Room 364-73°F, Room 366 -99 °F, Room 374-102 °F, and Room 383-94 °F.

C. Openings were observed between floor tiles near the door, in the Nourishment Room.

D. Floor surfaces marred; windows and windowsills soiled, and baseboards were separated from the wall, in Room 362.

E. The whiteboard holder on the side of the cabinet was soiled, in Room 364.

F. Floor surfaces were marred, chair seats were worn, and lower areas of chair, windows, windowsills, lower vents, and the white board holder were soiled with dust, and the shade chain cord was not secure, in Room 366.

G. Computer and electrical cords were on the floor, beneath the work counter, in the Nurses' Station.

H. Window and windowsills surfaces were soiled, in the buffer zone, in Room 372.

I. Sofa armrest surfaces were worn and damaged; floors were marred; bathroom exhaust vents soiled with dust; and chair seat surfaces were worn.

2. The surveyor observed the findings, during a tour of the Dialysis Unit, on 06/19/19, at approximately 10:15 AM, in the presence of Employees #70, Engineering Staff, and #69, Engineering Scribe, and #72, Dialysis Manager.

A. Floor surfaces at the water treatment and patient treatment areas were damaged; wall surfaces were soiled and damaged at the rear of the sink; and hard water stains were observed on the faucet.

B. Wall surfaces were marred and damaged, in the Patient Treatment Area.

C. Wall surfaces were marred in the Peritoneal Area.

3. The surveyor observed the finding, during a tour of the Operating Room, on 06/19/19, at approximately 12:10 PM, in the presence of Employees #70, Engineering Staff, and #69, Engineering Scribe, and #74, Endoscopy Staff.

A. Floor surfaces were separated at the entrance to the gastrointestinal scope cleaning area.

4. The surveyor observed the findings, during a tour of the Shaw Clinic, on 06/19/19, at approximately 2:30 PM, in the presence of Employees #70, Engineering Staff, and #69, Engineering Scribe, and #59, Nurse Manager.

A. Wall surfaces were marred in the Waiting Area and Exam Room #5.

B. Exhaust vents were soiled in the Clean Storage Area.

C. Floor surfaces were soiled, along the wall, in the Biohazard Room and the Janitorial Closet.

D. The mop sink was soiled in the Janitorial Closet.

E. Floor tiles failed to cover areas, in front of the Heating Ventilation Air Condition unit, in the Immunization room.

5. The surveyor observed the findings, during a tour of the Euclid Street Clinic, on 06/19/19, at approximately 3:45 PM, in the presence of Employees #70, Engineering Staff, and #69, Engineering Scribe, #60, Manager and #59, Nurse Manager.

A. Wall surfaces were marred in the Waiting Room, Medication Room, Exam Room #23, the Staff lounge, and Room #8.

B. Corner guards in Waiting Room and Reception area were marred.

C. Sprinkler heads were soiled with dust, in the Triage Area.

D. Door jams and floor tiles were marred and damaged and the sink drained slowly, in the Staff Restroom.

E. The backsplash area of the sink was damaged and floor tiles near the toilet were damaged, in Restroom #1.

F. Base boards were stained; the back splash area of the sink was damaged; and exhaust vents were soiled, in Restroom #2.

G. Floor tiles were damaged in the Janitorial Closet.

H. Floors surfaces were stained; cabinets under the sink were soiled on bottom shelf; and the cabinet door hinges were not secure, in Room #122.

I. Door and floor surfaces were marred and penetrations were observed in the cable, in the Supply Closet.

J. Blind surfaces were dusty; ceiling tiles were marred; and corking was soiled around the base of the toilet, in the Staff Lounge.

6. The surveyor observed the findings, during a tour of the Children's Health Center at THEARC Clinic, on 06/20/19, at approximately 10:00 AM, in the presence of Employees #70, Engineering Staff, and #69, Engineering Scribe, #76, Operations Manager and #77, Nurse Manager.

A. Electrical and computer wires were observed on the floor, in the Pod Areas.

B. Wall surfaces were dusty in the Medication Room.

C. Marks were observed on the examination table, in Exam Rooms 10 and 12.

D. Top surfaces of the lamp cover were dusty and wall surfaces were damaged, near the trash receptacle, in the Restroom.

E. Buckets of paint were stored on the floor; sticky cork was adhered to the floor; and a cardboard box was on the floor, in the electrical closet.

F. Walls were damaged in the restroom, in the Specialty Area.

G. Lower walls were marked in Exam Room #2.

H. The hot water temperature was 109 °F in the Eye Wash Station, which is above the required 100 degrees °F temperature.

I. Dust was observed on the Panoramic and the Intra-Oral X-ray machine, in the Dental Clinic.

7. The surveyor observed the findings, during a tour of the Children's National Medical Center Emergency Department at United Medical Center, on 06/20/19, at approximately 12:45 PM, in the presence of Employees #70, Engineering Staff, and #69, Engineering Scribe, #20 and #21, Nurse Managers.

A. Chair seats surfaces were worn in the Waiting Area; baseboards were not secured, in the Restroom, paint chipping was on top of the baseboards, and door jams were marred.

B. The housekeeping sink was soiled and door jams were marred, in Room C-1016.

C. Walls were damaged; baseboard surfaces were soiled; the laminated cover was not installed on the inside of the door, and water flow was restricted; in Restroom #2.

D. Walls were marred, the bedframe was dusty, the wooden cover, under the sink was not installed, and exhaust vents were soiled Room #14.

E. The Utility Room was soiled, the bottom of the entrance door was marred, penetrations were observed in walls, and cleaning equipment and exhaust vents were dusty.

F. Clean Utility Room door surfaces were marred and soiled at the bottom.

G. Lower wall surfaces, the cabinet under the sink, and the base of the intravenous poles were soiled, and the inner seal of the blanket warmer was worn, in Crisis Room #8.

H. Wall surfaces were marred; bedframe surfaces were dusty; and baseboards were soiled, in Bay 11.

I. The hot water temperature in the Medication Room was 83 °F, which is below the 105 °F minimum requirement.

J. Wall surfaces were marred; floor surfaces in front of chairs were marred; and the sink was clogged, in Room #8.

K. Floor, walls and baseboards were marred; top surfaces of the Workstation on Wheels were dusty; the exam light arm was dusty, and the water faucet flow was restricted, in Room #6.

L. The top of the monitor, overhead lamp, exam lamp arm, and bedframe were dusty; and walls were marred, near the chair, in Room #3.

M. The top of the bed and monitor were dusty; and hot temperatures measured 72 °F, which is below the 105 °F minimum requirement, in Room #2.

N. Ice machine chute surfaces were soiled, with hard water stains, near the Nurses' Station.

O. Computer and electrical wires were on the floor, in the Nurses' Workstations.

P. Baseboards separated from the wall and corner surfaces were soiled, in the triage hallway.

Q. Floor and wall surfaces were marred, in Triage Room #1.

8. The surveyor observed the findings, during a tour of the Emergency Department, on 06/20/19, at approximately 3:00 PM, in the presence of Employees #10, ED Manager, #70, Engineering Staff, and #69, Engineering Scribe, #20 and #21, Nurse Managers.

A. The facet leaked and failed to turn off the water supply; the ophthalmoscope was soiled on the interior; and the hot temperature measured 91 °F, which is below the 105 °F minimum requirement, in Room 2.

B. Baseboards were stained along wall surfaces in Rooms 108 and 111.

C. Wall surfaces were marred in Room 3.

D. The lower surfaces of chairs were soiled with dust, in Computerized Tomography Room 3.

E. Privacy curtain hooks were detached from the overhead ceiling rod; the top surfaces of the monitor and the transport stretcher were soiled with dust; and floor surfaces were marred, in Trauma Room 1.

F. Wall surfaces were marred, in Room 1.012B and in the hallway, outside of the room.

G. Floor surfaces were marred at the entrance to Room 15.

H. An opening was observed between floor tiles; wall surfaces were marred; and monitor surfaces were soiled with dust, in Room 17.

I. Walls, top surfaces of the trash receptacle, and floor surfaces were marred, in the Asthma Bay Area (Room 1.20002).

J. Privacy curtain hook were detached in Room 21.

K. Floor surfaces were marred; the water was off at the sink; floor tiles were recessed into walls, in the Psychological Area (Room 26).

L. Floor and door jamb surfaces were marred in Room 27.

M. Shower floor drains were soiled, in the Decontamination Area; and floor surfaces were stained in corners, where water entered through the door, from the outside, in Rooms 31 and 32.

Employees #70 and #69 acknowledged the findings.










Employees #70 and #69 acknowledged the findings.

Based on observation, policy review, and staff interview, the hospital staff failed to ensure supplies and equipment were maintained and stored in a safe and reliable manner, in eleven of 16 observations (Patients #107, 108, 118, 119, 120, 121, 122, 123, 124).

Findings included...

A. Review of the Greinier bi-one Vacuette blood collection system, manufacturer recommendations showed, "The recommended transport and storage temperature for tubes prior to use is 4-25 [Celsius] (°C ) 40-77 [Fahrenheit (°F). Exceeding the recommended storage temperature may lead to impairment of the tube quality."

https://www.gbo.com/fileadmin/user_upload/Downloads/Brochures/Brochures_Preanalytics/English/980102_Handhabungsempfehlungen_rev09_0314_e_lowres.pdf.

The Children's National Medical Center, Department of Laboratory Medicine policy entitled "Purchasing and Inventory Control" effective 12/2017, shows that "All supplies are stored and managed according to manufacturer instructions, and laboratory standard operating procedure ...In instances where the manufacturer defines a required storage condition ...these are followed and monitored ..."

The surveyor conducted a tour of Children's Health Center at THEARC Primary Care Clinic (Outpatient Clinic), on 06/19/19 at 3:00 PM, with Employee #122 Clinical Nurse Manager and Employee #123, Shift Coordinator. During a tour of the medication room, the surveyor observed blood collection tubes stored in a drawer in the room. There were 38 purple top tubes, 36 red top tubes, and 49 mini red top tubes. All had a maximum storage temperature of 77 degrees Fahrenheit (°F). The temperature reading in the room was 78.8 °F.

The surveyor conducted a face to face interview with Employees #122 and 123 at the time of the observation, regarding the room temperature. Employee #122 stated that the air conditioning in the building malfunctioned on 06/17/19 in the afternoon. The unit was fixed on 06/18/19, and the building took time to cool off. When asked if the staff monitors the temperature in the room where the collection tubes are stored, she stated "No." When asked if any lab draws were performed on the day of the observation, using the red and purple top tubes, Employee #123 said "Yes" and produced a list of nine patients, Patients #107, 108, 118, 119, 120, 121, 122, 123, and 124.

The surveyor conducted a face to face interview on 06/20/19 with Employee #140, Director of Laboratory Administration and Operations, regarding the storage of tubes and the labs drawn on patients. He stated that the pathologist reviewed all of the results for the labs drawn on those specific patients, and determined there were no adverse outcomes. He also noted that the outpatient clinic would begin monitoring the temperature in the medication room. Employee #140 acknowledged the findings.

B. During a tour of the ED on 06/17/19 at approximately 11:00 AM, with Employees #10, Nurse Manager and #18, Director of Professional Development, the surveyor observed the following expired sutures, stored in suture cart #2: Two - 3-0 Ethicon that expired 07/13; one - O silk Ethicon that expired 01/13; one - 3-0 Prolene that expired 01/16; 12 - 5-0 Ethicon that expired 07/18; one - 4-0 Ethicon that expired 07/17; and one - 4-0 Prolene that expired 01/18.

Additionally, in the medication room, there were seven #20 gauge needles that expired 03/19 and two that expired 01/18.

The practice lacked evidence that staff ensured expired supplies were removed and discarded as to prevent accidental use.

During a face to face interview with Employee #10, at the time of the observation, he removed the supplies and acknowledged the findings.

C. During a tour of the Diabetic Clinic on 06/19/19 at approximately 3:15 PM, with Employees #37, Nurse Manager and #38, Nurse Manager of Ambulatory Services, the surveyor observed 51 purple top blood collection tubes that expired on 05/31/19, stored on the counter, in the lab room.

The practice lacked evidence that staff ensured expired supplies were removed and discarded as to prevent accidental use.

During a face to face interview with Employee #37, at the time of the observation, she acknowledged the findings.

Based on observation, policy and procedure review, standards of care review and staff interview, the hospital staff failed to ensure infection prevention, related to protective equipment (PPE), hand hygiene, isolation precautions, and storage of medical supplies, in six of 14 observations (Patient #2).

Findings included...

Record review of the hospital's policy titled, "Hand Hygiene," dated 08/16, showed that staff are to perform hand hygiene immediately after removing PPE.

Review of the Centers for Disease Control (CDC)'s recommendations for the use PPE showed that healthcare personnel, caring for patients on Droplet Precautions should wear gown, gloves and mask, for all interactions that may involve contact with the patient. All PPE should be removed, before exiting all patients' room, except if a respirator is worn.
https://www.cdc.gov/hai/pdfs/ppe/PPE-Sequence.pdf

A. During a tour of the Pediatric Intensive Care Unit (PICU) on 06/18/19 at approximately 10:00 AM, with Employees #41, Clinical Manager, and Employee #42, Clinical Instructor, the surveyor observed Employee #139, Registered Nurse, exiting, a patient's room (who was on droplet precautions). She exited the room, with her mask under her chin, sanitized her hands, and proceeded to the Pyxis Medication Station.

The surveyor queried Employee #42, regarding the practice. She explained the nurse should have removed her mask, before exiting the patient's room.

The practice failed to demonstrate that the registered nurse followed acceptable standards of infection prevention practices.

Employee #42 acknowledged the findings at the time of the observation.



34093


B. During a tour of the Emergency Department (ED) on 06/17/19 at approximately 4:20 PM, with Employee #10, ED Manager, the surveyor observed Employee #8, Medical staff, exiting Patient #2's room (who was positive for Influenza), with her mask underneath her chin. She proceeded to the nursing station to communicate with staff, without removing the PPE or sanitizing her hands.

The practice failed to demonstrate that the medical provider followed acceptable standards of infection prevention practices, or the hospital's policy.

During a face to face interview on 06/17/19 at the time of the finding, the surveyor queried Employee #8, regarding the practice. She explained that she should have removed and discarded the mask, and sanitized her hands.

Employees #10 and 8 acknowledged the findings.

C. During a tour of the ED on 06/17/19 at approximately 4:25 PM, with Employee #10, ED Manager, the surveyor observed Employee #113, Registered Nurse, exiting room #8, with her mask under her chin. She proceeded to the nursing station to use the computer, without removing the PPE or sanitizing her hands.

The practice failed to demonstrate that nursing staff followed acceptable standards of infection prevention practices, or the hospital's policy.

During a face to face interview on 06/17/19 at the time of the finding, the surveyor queried Employee #113, regarding the practice. She acknowledged that she should have removed her PPE and sanitized her hands.

D. Review of the hospital's Standard Procedures for Oral Human Immunodeficiency Virus (HIV) Screening, undated, showed that a temperature log must be kept and the refrigerator temperature must be recorded daily.

During a tour of the ED on 06/17/19 at approximately 10:50 AM, with Employee #11, ED Charge Nurse, the surveyor observed two boxes of multiple Rapid Antibody testing kits for HIV, stored in the laboratory room.

Review of the refrigerator temperature log lacked documented evidence that staff monitored the temperatures from 06/01/19 to 06/09/19 and 06/16/19.

The practice lacked evidence that staff monitored the refrigerator temperature to ensure the integrity of the test controls and test kits.

During a face to face interview with Employee #14, Clinical Coordinator, on 06/17/19 at 10:55 AM, he explained that the temperature should be monitored daily. He acknowledged the missing days.



35226


E. The surveyor conducted a tour of the Pediatric Intensive Care Unit (PICU) on 06/17/19 at 10:20 AM. During the tour, Employee #141, Supply Personnel, entered a patient room that had signage indicating that the patient was on contact and droplet isolation. She entered the room with an isolation gown, gloves, and mask. She then exited the room with gown, gloves, and mask, retrieved items from the clean supply cart located outside of the room, and re-entered the room.

The surveyor conducted a face to face interview with Employee #141 at the time of the observation. She stated that she was unaware that she had to discard her personal protective equipment, before exiting the room when retrieving items from the supply cart. She acknowledged the findings in the presence of Employee #114, PICU Charge Nurse.

F. During a tour of the Pediatric Intensive Care Unit (PICU) on 06/17/19 at 11:20 AM, the surveyor observed a patient room with signage indicating contact and droplet isolation. Employee #142, Environmental Services Staff, exited the room wearing a mask, and proceeded down the hall.

The practice lacked evidence that staff ensured infection prevention.

The surveyor conducted a face to face interview with Employee #142 at the time of the observation. She acknowledged the findings.

Based on record review, policy review, and staff interview, respiratory staff failed to administer respiratory treatments per physician orders and notify physicians of omitted treatments, in two of three medical records reviewed (Patients #114 and 115).

Findings included ...

The Children's National Medical Center policy entitled "Medication Policy", last updated 12/28/18, showed that time-critical medications, administered late or missed should be recorded accordingly with the reason in the patient's medical record, and the physician should be contacted.

Patient #114 was admitted for exacerbation of Cystic Fibrosis and chronic respiratory insufficiency. She presented with a worsening cough and sternal retractions.

Review of physician orders showed an order dated 06/14/19 at 10:00 PM for a Hypertonic Saline nebulizer to be administered twice a day.

Review of the Medication Administration Record showed that on 06/16/19 at 2:05 PM, the Respiratory Therapist documented the medication was "Not given," the reason listed was "medication not available." The medical record lacked documentation of physician notification.

The surveyor conducted a face to face interview on 06/18/19 at 10:00 AM with Employee #120, Respiratory Shift Coordinator, regarding the process when medication is omitted. She stated that when the medication is not available, the therapist will reach out to the pharmacy and administer the medication once available depending on the medication schedule. When asked about the policy for notifying the physician, she stated that she was unsure if the department had a policy to govern that. She acknowledged the findings at the time of the interview.

B. Patient #115 was admitted for a diagnosis of Necrotizing Enteral Colitis, Status Epilepticus, and Respiratory Failure.

Review of the physician orders showed an order dated 06/07/19 at 12:00 AM, for Chest Physiotherapy every six hours.

Review of the medical record showed that on 06/13/19, the treatment was performed one time at 12:10 AM and one time at 9:20 PM. Documented reasons for the omission of the other treatments included "schedule conflict," and "not appropriate at this time."

Further review of the medical record showed that on 06/15/19 chest physiotherapy treatment was performed at 12:00 PM. Reasons listed included "task duplication." The medical history lacked documented evidence of physician notification related to the omission of treatment.

The surveyor conducted a face to face interview on 06/18/19 at 2:00 PM with Employee #61, Respiratory Clinical Supervisor. She reviewed the medical record and reported that she could not find additional documentation related to the omission of treatments. She acknowledged the findings at the time of the interview.

Based on medical record review and staff interview, respiratory staff failed to administer respiratory services, in accordance with acceptable standards, as evidenced by weaning a patient off oxygenation support, in the absence of a physician's order, for one of two patients (Patient #53).

Findings included ...

The hospital staff admitted Patient #53 on 06/15/19, with diagnoses that included Hypoxemic Respiratory Failure with Superimposed Pneumonia.

A review of the medical record reflected Patient #53 received high flow oxygen therapy by nasal cannula, initiated by respiratory therapy staff, in the Emergency Department. On 06/16/19 at 11:00 PM, the respiratory therapist initiated high flow weaning. However, the record lacked documented evidence of an order from an authorized, licensed provider for the weaning off high flow oxygen for Patient #53.

The surveyor conducted a face-to-face interview on 06/17/19 at approximately 2:30 PM, with Employee #61, Respiratory Supervisor, regarding weaning protocol for high flow oxygen. She stated, "There should have been a physician's order, prior to weaning the patient off oxygen." Additionally, there were no respiratory protocols for weaning patients off high flow oxygen. She acknowledged the findings at the time of the medical record review.