HospitalInspections.org

Based on observations, policy review and staff confirmation, it was determined that the hospital staff failed to maintain the confidentiality of patients' electronic medical records (EMRs) that were left open and unattended, in three (3) of three (3) observations (Patients' #1, 3 and 5).

The findings include:


The George Washington University Hospital Policy titled, 'Patient Rights and Responsibilities,' last reviewed August 2010, stipulates,"...III. Patient Rights A. Patients of the George Washington University Hospital have the right to ...13. Receive confidentiality of all information and records regarding care..."


The George Washington University Hospital Policy titled, 'Privacy-De-Identification & Minimum Necessary,' effective August 2014, stipulates, " ..III. Policy...provisions must be made to ensure limitation on the protected health information to the Minimum Necessary to accomplish the intended purposes of the use, disclosure or request.


A. Patient #1 was admitted with a diagnosis of Acute Hypoxia.

On May 2, 2016 at approximately 10:29 AM, during a tour in the Intensive Care Unit 2, the computer located in the nursing station was observed unattended and the electronic medical record (EMR) for Patient #1 was left open, displaying personal identifiers and a picture of his/her chest x-ray. The observation was made in the presence of Employees #17, 19 and 25.

The observation failed to provide evidence that the staff ensured the privacy and confidentiality of Patient #1's private health information was maintained.

The findings were acknowledged and confirmed by Employee #19.



B. Patient #3 was admitted with a diagnosis of Sepsis.

On May 2, 2016 at approximately 3:00 PM, a mobile computer was observed open and unattended near Patient #2's bed, displaying personal identifiers, diagnosis and other health information for Patient #3. In addition, Patient #2 had a visitor at the bedside. Employee #27 entered the room. When asked who was using the computer, s/he acknowledged leaving the EMR open and unattended. The observation was made in the presence of Employees #18 and 25.

The observation failed to provide evidence that the staff ensured the privacy and confidentiality of Patient #3's private health information was maintained.

Employee #27 confirmed the findings.


C. Patient #5 was admitted with a diagnosis of 40 Weeks Contractions.

On May 4, 2016 at approximately 3:10 PM, during a tour in the Intensive Care Unit 6, the computer located in the nursing station was observed unattended and the electronic medical record (EMR) for Patient #5 was left open, displaying personal identifiers, diagnosis and other health information. The observation was made in the presence of Employees #19 and 20.

The observation failed to provide evidence that the staff ensured the privacy and confidentiality of Patient #5's private health information was maintained.

Employee #19 acknowledged and confirmed the findings.

Based on medical record review, policy review and confirmed by staff interview, it was determined the hospital staff failed to ensure that each patient's care was consistently supervised and evaluated by a registered nurse in 12 of 16 records reviewed.


The findings include:


The George Washington University Hospital procedure titled "Delegating Care" introduced July, 10, 2015 stipulates, Delegation is a process by which a nurse can direct another health care worker to perform certain nursing tasks and interventions ...Portions of care can be delegated; however, functions of the nursing process (such as assessment, planning, and evaluation) cannot ...The health care facility plays a role in the effective delegation of care;
it's responsible for providing adequate resources to support delegation, including sufficient staffing with an appropriate staff mix, documentation of staff competence, and policies on delegation that are developed with active nursing participation ...Implementation ...Monitor the delegate to make sue the tasks are being performed according to established standards ...Acknowledge the delegate's successful completion of the tasks..."


District of Columbia Municipal Regulations for Practical Nursing Scope of Practice 5514.2 stipulates; "A practical nurse shall accept only those assigned nursing activities and responsibilities as set forth in the ACT and this chapter, which the practical nurse can safely perform. That acceptance shall be based on the following requirements in each practice setting which shall include ...(b) The degree of supervision by a registered nurse ...(f) The established policies, procedures, standards of practice, and communication channels, which lend support to the model of nursing services offered by the agency or facility."


On May 5, 2016 at approximately 11:30 AM, a review of personnel list revealed that the hospital employs eight (8) Licensed Practical Nurses; of which five (5) are assigned to inpatient units and three (3) to the Emergency Department. However, according to the "Shifts Scheduled Reports" and the unit shift staffing sheets, the Licensed Practical Nurses were identified as "RN [Registered Nurse]".



A face to face discussion was conducted with Employee #9 on May 5, 2016 at approximately 2:00 PM. According to Employee #9, the identification of the Licensed Practical Nurses as Registered Nurses is "an error" . The staff is aware that the employees are Licensed Practical Nurses and not Registered Nurses. When queried about how the supervision and oversight of the Licensed Practical Nurses are performed, s/he stated "the charge nurse is responsible for the supervision and the co-signature of the assessments" performed by the Licensed Practical Nurses. Employee #9 disclosed how the attestation by the Registered Nurse is displayed in the electronic medical record. The verification screen for assessments will display the status as "Auth (verified) [authorization verified]". A random sample of patients assigned to Licensed Practical Nurses on varying dates was selected for review as follows:


1. On May 6, 2016 at approximately 3:00 PM a random sample of five (5) patients assigned to Employee #69 on May 5, 2016 revealed that two (2) of the six (6) patient's assessments were not countersigned. The verification screen for the assessments documented the status as "unauth [unauthorized]".


2. On May 9, 2016 at approximately 8:30 AM a random sample of four (4) patients assigned to Employee #67 on April 29, 2016 revealed four (4) of four (4) patient's assessments, to include head/neck, cardiovascular, respiratory, and gastrointestinal, were not countersigned. The verification screen for the assessments documented the status as "unauth [unauthorized]".


3. On May 9, 2016 at approximately 9:00 AM, a random sample of three (3) assigned to Employee #65 on May 2, 2016 revealed three (3) of three (3) patient's assessments, to include respiratory, gastrointestinal, musculoskeletal, and integumentary, were not countersigned. The verification screen for the assessment documented the status as "unauth [unauthorized]".


4. On May 9, 2016 at approximately 9:9:20 AM, review of a random sample of three (3) patient assigned to Employee #68 on May 1, 2016 revealed three (3) of three (3) patient's assessments, to include gastrointestinal, respiratory, cardiovascular, and musculoskeletal, were not countersigned. The verification screen for the assessment documented the status as "unauth [unauthorized]".


On May 9, 2016 at 9:59 AM a face to face interview was conducted with Employee #9 and #6. The aforementioned findings were discussed and acknowledged. According to the employees, it is the expectation that the charge nurse oversees the Licensed Practical Nurses' assignments and co-signs the assessments, as an indication of supervision and oversight.

Based on review of Facility documents, Pyxis [Automated Dispensing Machine (ADM)]- "All Station Events" report for Schedule II, III, IV, and V Controlled Substances Transactions by patient report, physicians' orders, and the Electronic Medication Administration Record [eMAR], it was determined that criteria was not met for the following reasons; the physician order was not followed; medication not wasted; medication not administered in a timely manner; and medication on eMAR was administered but not removed from the ADM in 10 out of 33 patients surveyed. The survey was in the presence of Employees #8 and #44.



The findings include:


A. On April 22, 2016 at 10:26, Patient #54 was ordered Fentanyl 25mcg (micrograms) intravenous push every hour as needed for severe pain, on a pain scale 7-10. On May 3, 2016, at 03:15, the eMAR indicated that 25mcg of Fentanyl was administered to patient; however, no Fentanyl was removed from the ADM at the corresponding time for this patient.


B. On April 28, 2016 at 22:00, Patient #70 was ordered Clonazepam 0.5mg (milligram) by mouth two times a day for anxiety. On May 1, 2016, at 07:38, Clonazepam 0.5mg was removed from the ADM and administered to the patient at 09:38 (two hours after removal from ADM).


On May 2, 2016 at 07:30, Clonazepam 0.5mg was removed from the ADM and was administered to the patient at 09:34 (two hours after removal from the ADM).


C. On April 29, 2016 at 01:29, Patient #71 was ordered Lorazepam 1mg injected intramuscularly every 4 hours as needed for anxiety. On May 1, 2016, at 13:18, Lorazepam 2mg/ milliliter (ml) was removed from the ADM and 2mg of Lorazepam 2mg/ml was wasted at 15:12. The eMAR indicated that 1mg of Lorazepam was administered to the patient at 13:23.




D. On April 29, 2016 at 12:00, Patient #73 was ordered Hydromorphone 0.25mg intravenous push every 6 hours. All administrations for this order were entered incorrectly on the eMAR. They were entered as being administered for an order for Hydromorphone 0.5mg.


E. On April 16, 2016 at 09:41, Patient #74 was ordered Tramadol 25mg by mouth every 4 hours as needed for cough. On April 30, 2016, at 16:38, Tramadol 50mg was removed from the ADM and 50mg was administered to the patient. The wrong dose was given to the patient.


F. On May 2, 2016 at 14:30, Patient #76 was ordered Oxycodone/Acetaminophen 5/325 one (1) tablet by mouth every 4 hours for moderate to severe pain, pain scale 4-10, may repeat 1 tablet if dose is ineffective. On May 2, 2016, one tablet Oxycodone/Acetaminophen 5/325 was removed from ADM at 16:31; eMAR indicates that Oxycodone/Acetaminophen 5/325 was administered at 15:30 (one hour before it was removed from ADM).


G. On May 3, 2016 at 09:09, Patient #77 on was ordered Hydromorphone 0.5mg intravenous push every 10 minutes as needed for severe pain, on a pain scale 7-10. On May 3, 2016 at 09:34, Hydromorphone 1mg/ml ampule was removed from the ADM. The eMAR indicated that 2 doses were administered from one single dose ampule.



H. On April 27, 2016 at 12:00, Patient #79 was ordered Oxycodone 2.5mg Oral Solution by mouth every 8 hours. On April 30, 2016, 13:08 Oxycodone Solution 5mg/5ml was removed from the ADM and 2.5mg was administered to the patient; however, there was no record of the wasting of 2.5mg.


On May 1, 2016 at 14:11, Oxycodone Solution 5mg/5ml was removed from the ADM and 2.5mg was administered to the patient at 17:12 (almost three (3) hours after removal from the ADM).


On May 1, 2016 at 21:48, Oxycodone Solution 5mg/5ml was removed from the ADM and 2.5mg was administered to the patient at 01:18, on May 2, 2016, (almost three (3) and one half hours after removal from the ADM).


I. On May 1, 2016, at 19:53, Patient #80 was ordered Tramadol 50mg by mouth every 6 hours for moderate pain, pain scale 4-6. On May 1, 2016, at 20:08, two (2) Tramadol 50 mg tablets were removed from the ADM and only one (1) was administered; the other tablet was unaccounted for.


J. On April 22, 2016, at 15:37, Patient #82 was ordered Oxycodone 5mg by mouth every morning for moderate to severe pain, pain scale 4-10, may repeat once in 16 minutes; if pain severe may give 10mg. The eMAR dates 4/30/16 through 5/2/16 showed this medication was administered six (6) times ranging in times of one (1) to four (4) hours (not per physician order).

Based on medical record review, and staff interview it was determined the hospital staff failed to ensure the documentation of all pertinent information to support diagnoses and treatment and continued hospitalization in three (3) of three (3) records reviewed (Patient #13, #12, and #14).


The findings include:


A. Patient #13 was admitted with diagnosis of Acute Cerebrovascular Accident.


During a face to face interview with Employee #78 on May 10, 2016 at 2:10 PM, s/he stated that Patient #13 was awaiting insurance approval to facilitate transfer to a subacute rehabilitation facility for therapy.


Review of the medical record on May 2, 2016 at 2:15 PM revealed Neurology Progress notes dated April 30, 2016 and May 1, 2016. The "Attending Note and Attestation" comment stated "may DC [discharge] home if BP [blood pressure] is controlled with outpatient 2D echo [technique is used to see the actual motion of the heart structures] and follow-up in stroke clinic."


The medical record lacked documented evidence the clinical staff documented a discharge assessment and/or information to facilitate a timely discharge to an appropriate level of care.


A face to face interview was conducted with Employee #82 on May 2, 2016 at approximately 2:10 PM. S/he explained that discharge planning assessments are completed 24 to 48 hours from admission and documented using Midas. When queried about the discharge plan for Patient #13, she stated that s/he is uninsured and is waiting insurance to facilitate transfer to a subacute rehabilitation facility. However, s/he was unable to explain the contradictory discharge plan documented in the medical record by the medical staff and physical therapy.


The aforementioned findings were discussed with Employee #5 on May 5, 2016 at approximately 10:35 AM. According to Employee #5, another medical record was conducted to locate the discharge planning assessment. S/he was unable to locate the discharge planning assessment. Consequently, the findings were acknowledged.


B. Patient #14 was admitted to the Intensive Care Unit for diagnoses to include Cardiac Arrest and Hypertension.


Medical record review conducted on May 3, 2016 at approximately 11:02 AM revealed that the nursing staff initiated "Adult Patient History" assessment on April 26, 2016 at 2:36 AM; however, the form was never completed. According to the "Adult Patient History" form, the "Advance Directive, Functional, Past Medical History, Social History... DC [Discharge] Needs" sections were not completed to screen for discharge needs.


The medical record lacked documented evidence the nursing staff documented complete information to include, discharge planning needs, social history, and past medical history.


The findings were confirmed that the discharge planning assessment and "Adult Patient History" was not completed, in accordance with the hospital's policy, on May 3, 2016 at 11:45 AM.


C. Patient #12 was admitted with diagnoses of Right Ankle Fracture and Brain Tumor.


Medical record review conducted on May 2, 2016 at approximately 3:00 PM revealed the discharge planning assessment, "Adult Patient History" and initial comprehensive assessment were not completed.


A discussion was conducted with Employee #80 regarding the completion of the initial assessments and discharge assessment on May 2, 2016 at approximately 3:15 PM. According to Employee #80, it is the expectation the initial assessment and discharge screen be completed upon admission. Further review of the medical record revealed the first "head to toe assessment" was completed on April 28, 2016 at 2:44 PM upon transfer to 4 North, approximately six days after admission. S/he was unable to provide insight into the omission of the initial assessment and/or discharge assessment.


The medical record lacked documented evidence the nursing staff documented complete information to include, discharge planning needs, social history, past medical history, and comprehensive assessment upon admission.


The findings were confirmed, and acknowledged on May 2, 2016 at approximately 3:55 PM.

1. Based on observation, record review, policy review and staff interview, it was determined that the medical staff failed to write a complete restraint order in two (2) of three (3) records reviewed (Patient #2 and 4).

The findings include:


The George Washington University Hospital Policy titled, 'Seclusion and Restraints,' effective April 2016 stipulates, "... I. Orders ... 2. Non-Violent/Non-self-destructive ... b. Each order for restraints used for non-violent/non self-destructive behavior will contain the following information ... (4) Specific intervention (type of restraint used) ... "IV. Policy...F. The use of restraint must be in accordance with the order of a physician or physician assistant who is responsible for the care of the patient and is authorized to order restraints by hospital policy and medical staff by-laws ..."


A. Patient #2 was admitted with a diagnosis of Seizures.

On May 2, 2016 at approximately 2:55 PM, Patient #2 was observed to have on bilateral mittens and bilateral soft limb restraints. The observation was made in the presence of Employees #17 and 18.


Review of the medical record on May 2, 2016 at approximately 3:00 PM revealed physician orders dated May 1, 2016 at 10:45 PM for an "Immobilizer" to the Right Upper Extremity and an "Immobilizer" to the Left Upper Extremity of Patient #2 for "interfering with medical treatment/healing."


On May 2, 2016 at approximately 3:20 PM, a face-to-face interview was conducted with Employee #27, in the presence of Employees #17 and 21. Employee #27 was asked to explain the order for an "Immobilizer." S/he explained that it meant the patient was in restraints. When queried regarding the type of restraint, s/he could provide no explanation; however, added the patient was placed in soft limb restraints to both upper extremities. Employee #21 was asked to provide the order for soft limb restraints. S/he could not provide an order that indicated the specific type of restraint.

The observation failed to provide evidence that the medical staff documented a complete order to specify the type of intervention used for restraints.

Employee #21 acknowledged and confirmed the findings.



B. Patient #4 was admitted with a diagnosis of Incarcerated Right Inguinal/Scrotal Hernia.

On May 4, 2016 at approximately 12:00 PM, Patient #4 was observed to have on bilateral soft limb restraints to the upper extremities. The observation was made in the presence of Employees #19 and 20.


Review of the medical record on May 4, 2016 at approximately 12:05 PM revealed a physician order dated April 27, 2016 at 9:17 AM for bilateral soft limb restraints to the upper extremities for "interfering with medical treatment/healing...valid for one calendar day". On May 2, 2016 at 7:48 PM, the physician ordered bilateral soft limb restraints to the upper extremities for Patient #4.


Further review of the nursing documentation, under 'Restraint Information,' revealed that the patient was in bilateral soft limb restraints from 12:00 AM April 28, 2016 to 7:47 PM May 2, 2016, without an order for the restraints.

On May 4, 2016 at approximately 12:10 PM, a face-to-face interview was conducted with Employee #19, in the presence of Employee's #20 and 21. Employee #19 was asked to explain why the patient had been in restraints, without an order. S/he explained that staff may not be aware that the hospital just changed its restraint policy at the end of April to include criteria to extend or discontinue the restraint order based on the patient' s behavior; and while the patient is assessed daily by the physician, the order doesn't change daily, unless there are variances. Employee #19 was shown and apprised that the physician ordered the restraints for one calendar day. Employee #19 could provide no further insight.

The medical record lacked documented evidence of a physician order for restraints from 12:00 AM April 28, 2016 to 7:47 PM May 2, 2016.

Employees #19 and 21 acknowledged the findings.

2. Based on medical record review, policy review, and staff confirmation, it was determined that the anesthesia staff failed to ensure that all entries in the medical record were timed and dated in three of (3) of 10 records reviewed (Patient #10, 11 and 98).

The findings include:

The George Washington University Hospital Medical Staff Rules and Regulations, revised and approved January 21, 2015, Section III entitled, 'Medical Records,' subsection three (3), 'Entries,' stipulates, "...All clinical entries in the patient record shall be accurately dated, timed and signed electronically or manually..."

A. Patient #10 underwent Colonoscopy.
Review of the medical record on May 5, 2016 at approximately 11:45 AM revealed the record lacked evidence of a date on the 'Anesthesiology Preoperative Evaluation' form; and no date and time on the 'PACU [Post Anesthesia Care Unit]' and 'Post-op [post- operative]' notes. The review was performed in the presence of Employees #20 and 42.

The medical record review lacked documented evidence that the anesthesia staff entered the date and time on the record.

B. Patient #11 underwent Colonoscopy .
Review of the medical record on May 5, 2016 at approximately 12:00 PM revealed the record lacked evidence of a date on the 'Anesthesiology Preoperative Evaluation' form; and no date and time on the 'PACU [Post Anesthesia Care Unit]' and 'Post-op [post- operative]' notes. The review was performed in the presence of Employees #20 and 42.

The medical record review lacked documented evidence that the anesthesia staff entered the date and time on the record.

C. Patient # 98 was admitted with diagnoses of Epigastric Pain and underwent Esophagogastroduodenoscopy and a Colonoscopy.

Review of the medical record on May 6, 2016 at approximately 3:00 PM revealed the record lacked documented evidence of a date on the 'Anesthesiology Preoperative Evaluation' form and no date and time on the 'Post Anesthesia Evaluation' and 'Post- Operative' notes.

The medical record review lacked documented evidence that the anesthesia staff entered the date and time on the record.

The findings were reviewed, discussed and acknowledged by Employee #88.

Based on review of Facility documents, Pyxis [Automated Dispensing Machine (ADM)] - "All Station Events" report for Schedule II, III, IV, and V Controlled Substances Transactions by Patient report, physicians' orders, and Electronic Medication Administration Record [eMAR] it was determined that medication was not wasted properly or in a timely matter in three (3) out of 33 patients surveyed in the presence of Employees #8 and #44.


The findings include:


A. On April 29, 2016, at 14:00, Patient #69 was ordered Clonazepam 0.25 milligram (mg) by mouth three (3) times a day for anxiety/withdrawal. On April 30, 2016, at 12:47, Clonazepam 0.5mg was removed from the ADM. Clonazepam 0.25mg (1/2 tablet) was administered to patient. There was no evidence of the wasting of 0.25mg of Clonazepam.


B. On May 2, 2016, at 15:00, Patient #76 was ordered Fentanyl 25 micrograms (mcg) for a one (1) time dose. Fentanyl 100 mcg /two (2) milliliter (ml) was removed from the ADM at 16:32; eMAR indicates that 25mcg was administered to the patient at 15:30 (one hour before it was removed from the ADM). The ADM printout indicates a waste of Fentanyl; however, a metric quantity is not given.


C. On April 27, 2016, at 12:00, Patient #79 on Patient Care Unit 4 North was ordered Oxycodone 2.5mg Oral Solution by mouth every 8 hours. On May 2, 2016, at 09:11, Oxycodone Solution 5mg/5ml was removed from the ADM and not administered to the patient. This dose was not wasted until 17:07.

Based on observation and staff confirmation, it was determined that the hospital staff failed to ensure expired medications and biologicals were not stored and available for use in two (2) of two (2) medication storage observations in the Post Anesthesia Care Unit.

The findings include:

A. On May 5, 2016 at approximately 11:30 AM, a medication storage observation was conducted in the Post Anesthesia Care Unit with Employees #13 and 42, in the presence of Employee #20. The findings revealed three (3) ten milliliter ampules of Diltiazem [heart and blood pressure medication] with expiration dates of October 2015.

The hospital staff failed to ensure that expired medications were not stored and readily available for use.



Employees #13 and 42 acknowledged and confirmed the findings.


B. On May 5, 2016 at approximately 11:00 AM, an observation was made in the Ambulatory Surgery Center with Employees #13 and 41, in the presence of Employee #20. The findings revealed one (1) "Foley Catheter Tip Punch " with a "use by" date of June 2015 and the following expired suture supplies:

One (1) box of 3-0 Vicryl with an expiration date of July 2015.

Two (2) boxes of 3-0 Chronic Gut with expiration dates of January 2016.

One (1) box of 4-0 Nurolon with an expiration date of January 2016.

Eight (8) 4-0 Mersilene sutures with expiration dates of January 2016.

The hospital staff to ensure that expired supplies were not stored and readily available for use.


Employees #13 and 41 acknowledged and confirmed the findings.

Based on observations during the survey period, it was determined that dietary services were not adequate to ensure that foods were prepared and served in a safe and sanitary manner.

The findings include:

1. Ceiling surfaces over cooking and serving areas, in the Main kitchen and Cafeteria, were soiled with oily deposits and dust. In addition, ceiling surfaces were soiled with dust and other debris in the Main Storage Room, Tray Production and Serving Areas, refrigerator # 2; and in Sushi Serving and Preparation Areas, in six (6) of 11 observations between 9:40 AM and 2:00 PM.

2. Floor surfaces were soiled and stained in the following areas in the Cafeteria and Main Kitchen: the production box; walk in refrigerator #2, cafeteria grill; pot and pan wash areas; and under deep fryers, steamers, and equipment in the preparation and serving areas, in nine (9) of 14 observations between 9:50 AM and 3:00 PM. Open drains under work stations and equipment were soiled and damaged, in six (6) of six (6) observations between 9:50 AM and 3:00 PM.

3. The inner food storage compartment of the Blast Chiller, unit coils and bases; and surfaces, adjacent to the food storage compartment were soiled with debris and rust, in one (1) of one (1) observation at 10:05 AM.

4. Two (2) pans of steak sausage stored in refrigerator #7 lacked labels to identify the entrée and the expiration date of the entrée, in two (2) of two (2) observations at 10:20 AM.

5. Four (4) pans of hamburger with an expiration date of April 28, 2015 and one (1) pan of slice turkey with an expiration date of May 1, 2014 were stored beyond the expiration dates, in the preparation box, in five (5) of five (5) observations at 10:22 AM.

6. The interior surfaces of cooking hoods, filter covers, over cooking areas, were soiled with dust and grease in the Main Kitchen and Cafeteria, in seven (7) of seven (7) observations between 10:15 AM and 3:30 PM.

7. The interior surfaces of deep fryers, gas supply lines, areas near burner surfaces, side panels, and electrical wires were soiled with food and grease deposits, in four (4) of four (4) observations between 10:45 AM and 11:40 AM.

8. The interior and exterior surfaces of the grill and convection ovens and the exterior surfaces of the steamer were soiled with spillages and food deposits, in the cook's preparation area, in five (5) of five (5) observations at 1:50 PM.

9. The side panel surfaces of a cabinet in the sushi preparation area were damaged, in one (1) of one (1) observation at 12:40 PM.

10. The interior surfaces of cooking vessels cleaned in the pot and pan wash area were soiled with leftover food particles. The following pans were not allowed to dry and were placed on shelves for reuse:

A. At 2:58 PM, fourteen, 14 X 6 X6 inch pans

B. At 3:05 PM, eighteen, 2 inch pans

11. The interior surfaces of large bins used for storing scoops and ladles were soiled with dust and other debris on the interior bottom surfaces, in three (3) of five (5) observations at 3:10 PM.

12. Cutting boards (Red, White and Green) stored in the pot and pan wash area were worn and deep grooves were in board surfaces, in six (6) of 28 observations at 3:25 PM.

The above findings were observed and acknowledged by Employee #83 on May 2, 2016.

A Federal (Validation) life safety survey code inspection was conducted on May 2 to 9, 2016. Based on observation, staff interview, and review of documentation, it was determined that the life safety code requirement was not met on the condition level. The facility's fire alarm system had devices (smoke detectors, sprinkler heads, and standpipes) that had the potential to not function as designed. The facility had missing ceiling tiles and penetrations in various locations; an entrance door that failed to close and latch into frame; missing escutcheon plates; standpipes overly tightened; dust laden sprinklers; corroded sprinkler head; gap greater than 1/8 inch between entrance door; extension cords were used as permanent wiring; improper hold devices and corridors blocked 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, 054, 062, 064, and 130.

The findings include:


1. During observations made May 2, 2016 through May 6, 2016 between 10:00 AM and 2:00 PM, in three (3) of 12 observations the following areas had wall penetrations:


1. Elevator machine room inside of the mechanical room next to motor #4
2. Room 51010 (office area)
3. Room 41096 (office area)


The wall penetrations pose a potential fire hazard, in the event of an emergency.

2. During observations on May 2, 2016 through May 6, 2016 at approximately 10:00am through 2:00pm, four (4) of 20 observations revealed the following areas had ceiling tile penetrations:


1. Room 51096 (office area)
2. Room 41096 (office area)
3. Room 41086 (office area)
4. Room 41084 (office area)


The ceiling tile penetrations create a potential fire hazard for staff and patients, in the event of an emergency.

3. During observations on May 2, 2016 through May 6, 2016 at approximately 10:00 AM through 2:00 PM, 22 of 30 observations revealed missing ceiling tiles in the following areas:


1. North side offices (former school section)
2. Room 61300 (vacant office)
3. Room 61120 (vacant office)


The missing ceiling tiles create a potential fire hazard for staff and patients, in the event of an emergency.

4. During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, two (2) of 300 doors in the following areas failed to close flush and latch into the frame:


1. Stairway 3 exit door on 6th floor
2. 6th floor Northside Men's restroom


The failure of the doors to close flush and properly latch into the frame creates a potential fire hazard for staff and patients, in the event of an emergency.


5. During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, one (1) of 300 facility doors had a gap greater than 1/8 inch, failing to prevent the passage of smoke. The swinging wood doors leading to the Psychiatry Unit on the 6th floor had a gap greater than 1/8th of an inch.


A gap between the swinging doors creates a potential fire hazard for staff and patients, in the event of a fire.

6. During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, in three (3) of 300 observations the doors were held open with door chucks and tape, preventing the release of doors, when pushed or pulled in the following areas:


1. Room B1072 (office area)
2. Room B1113 (office area)
3. Room B1039 (office area)


The use of door chucks and tape to hold open doors create a potential hazard for staff and patients, in the event of an emergency.

7. During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, two (2) of 300 facility smoke detectors facility smoke detectors were missing in the following areas:


1. Room 41176 (occupied office)
2. Room 41184 (occupied office)


The missing smoke detectors create a potential fire hazard for staff and patients, in the event of an emergency.


8. During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, one (1) of 20 standpipe caps, located on the rooftop beside Stairwell 3 exit door was tightened at a level that prevented easy removal, in the event of a fire.


The standpipe cap creates a potential fire hazard for staff and patients, in the event of an emergency.


9. During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, two (2) of five (5) sprinkler caps on 6 South, in the large room were missing. The large room was being used for storage.

The failure to maintain the sprinkler caps in reliable operating condition pose a potential fire hazard, in an event of an emergency.


10. During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, one (1) of 300 sprinkler heads on 6 South (vacant) large room area was observed not mounted flush with the ceiling.


The failure to properly maintain the sprinkler head poses a potential fire hazard, in the event of an emergency.


11. During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, 31 of 500 sprinkler heads were observed dust laden in the following areas:


Main Hospital
1. Stairwell 2 exit on the 6th floor (2).
2. Kitchen production area (2)
3. Kitchen freezer #4 (2)

George Washington University -Outpatient Rehabilitation Center 6th floor (8 of 8)
4. Office (8)

GW-Pain Management (3 of 10)
6. Exam room #7 (1)
7. Inside of physician's office (1)
8. Inside of exam room #5 (1)

GW-Cardiac Surgery Center (10 of 20)
9. Front lobby (4 of 9)
10. Inside of supply closet (1 of 1)
11. Inside of restroom (1 of 1)
12. Director of cardiac surgery office (3 of 3)
13. Inside of administrative cubicles (1 of 3)

George Washington University-Surgery Center (4 of 10)
14. Exit coming from nourishment (1 of 1)
15. Inside of sit-up and nourishment (1 of 5)
16. Inside of consultation area (1 of 1)
17. In front of housekeeping by nourishment (1 of 3)


The dust laden sprinkler heads pose as a potential fire hazard, in an event of an emergency.


12. During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, five (5) of 500 escutcheon plates were observed missing in the following areas:

Main Hospital
1. NICU equipment room (3 of 7)

George Washington University-Outpatient Rehabilitation Center
2. Near the mechanical room (1 of 7)

George Washington University -Cardiac Surgery Center
3. Elevator lobby outside of main entry door (1 of 6)


The missing escutcheon plates create a potential fire hazard for staff and patients, in the event of an emergency.


13. During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, one (1) of 500 sprinkler heads, located in the nourishment area at the George Washington University -Surgery Center, in front of the clean work station was observed with corrosion.


The corroded sprinkler head creates a potential fire hazard for staff and patients, in the event of an emergency.

14. During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, in five (5) of five (5) observations corridors were used for storage in the following areas:


1. Room next to B1078 (office area)
2. Room across from B2038 (office area)
3. Room B1CO2 (office area)
4. Room 209
5. Bio Med next to elevator lobby


The improper storage in corridors created a potential fire hazard for staff and patients, in the event of an emergency.

15. During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, in three (3) of three (3) observations, storage was blocking the exit in the following areas:


1. Ambulance entry door (2 of 2)
2. Room 22036 (1 of 1)


Storage blocking exits create a potential hazard for staff and patients, in the event of an emergency.


During observations on May 2, 2016 to May 6, 2016 at approximately 10:00 AM through 2:00 PM, six (6) of six (6) extension cords were used as permanent wiring in the following areas:


1. Room G2018 (office area)
2. Room 11102(office area)
3. 6th floor conference room
4. Room 61120 (office area)
5. Room 51170 (office area)
6. Room 41084 (office area)


Extensions cords used as permanent wiring pose a fire potential hazard.

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

The findings include:

1. The following findings were observed during a tour of the Emergency Department between 9:30 AM and 10:30 AM on May 3, 2016.

A. The handrail along the wall and the interior and exterior surfaces of exhaust vents were soiled, in the Room 8 in (2) of two (2) observations.

B. The backsplash area of the hand washing sink was damaged in Bay #8, in one (1) of one (1) observation.

C. The privacy curtain was torn and damaged in area MH4 (Recliner Area), in one (1) of one (1) observation.

D. Hot water temperatures were below the required minimum temperature of 105 degrees Fahrenheit (°F) (Guidelines for Design and Construction of Health Care Facilities, 2014 Edition). The observed temperature was 74 °F in Room ED15, in one (1) of one (1) observation.

E. Baseboards and the top surfaces of monitors were soiled with dust in Room 18, in one (1) of one (1) observation.

F. The hand washing sink was clogged, near Room 17, and hot water temperature was 91°F at the sink in the Waiting Area, in two (2) of (2) observations.

G. Electrical and computer wires were comingled under the Nurses Work Station, in one (1) of one (1) observation.

H. The tray surfaces of the ice machine, near the Nurses Work Station, were soiled with mineral deposits in one (1) of one (1) observation.

I. The backsplash area of the sink, in the staff restroom, was damaged and exhaust vents were soiled on the interior, in two (2) of two (2) observations.

J. Wall surfaces were marred and the sink surfaces were soiled in the medication room, in two (2) of two (2) observations.

K. Ceiling tiles were soiled and stained in Triage Room OL1, in one (1) of one (1) observation.

L. The base surfaces of stretchers were soiled with dust in Fast Track Area UC 5, UC 10, and UC 12, in three (3) of three (3) observations.

M. Privacy curtain hooks were detached in room UC5, in one (1) of one (1) observation.

N. The top ledge surfaces were soiled with dust; privacy curtain hooks were detached; and the backsplash area of the sink was damaged, in Room UC5 in three (3) of three (3) observations.

O. Wall surfaces were marred and damaged in Room UC 12, in one (1) of one (1) observation.

P. Wall surfaces were marred, in the rear of the bed headboard; floor surfaces were marred; and privacy curtains were torn in Room C4, in three (3) of three (3) observations.

Q. Water failed to drain from the sink; floor surfaces were soiled; the side rail surfaces of the bed were marred and soiled; and floor tiles were damaged in Room C1B, in four (4) of four (4) observations.

R. Floor tiles and threshold surfaces near the entrance to the Emergency Room were damaged, in one (1) of one (1) observation.

S. The top cover surfaces over shower heads in the Decontamination Showers and shower heads surfaces were soiled with debris, in three (3) of three (3) observations.

T. Floor covering and the threshold located at the entrance to the Emergency Department, from the Ambulance Entrance, were soiled, in two (2) of two (2) observations.

U. Door and door jamb surfaces were marred and scarred at the entrance to Emergency Department Rooms 3 and 4, in two (2) of two (2) observations.

2. The following findings were observed during a tour of the Cardiac Care Unit between 10:50 AM and 11:10 AM on May 3, 2016.

A. Privacy curtain hooks were detached and the base surfaces of the stretcher were soiled in Room 22, 24 and 25, in three (3) of three (3) observations.

3. The following findings were observed during a tour of the Laboratory Service Department on May 3, 2016 at 11:50 AM.

A. Wall and floor surfaces were soiled, in the rear of the Vitron 5600B (Analyzer), in one (1) of one (1) observation.

B. The counter and sink surfaces in the Immunology Area were soiled and stained and cabinet surfaces were stained, in one (1) of one (1) observation.

C. Floor surfaces near the sink were soiled and with rust stains; and the faucet continued to drip after the water supply was turned off, in two (2) of two (2) observations.

D. Cabinets under the sink and the ice maker filter were soiled; the Blood Bank Agitator was stained and soiled; and floor tiles were damaged, in the rear of the Blood Bank work areas, in four (4) of four (4) observations.

4. The following findings were observed during a tour of the Endoscopic Area on May 4, 2016 at 10:40 AM.

A. Graduated cups or cylinders were not used to check the accuracy of disinfectants used to clean and decontaminate scopes, in one (1) of one (1) observation.

B. Wall and baseboards surfaces were marred and damaged in the Public Restroom, near the Endoscopy Area, in one (1) of one (1) observation.

5. The following findings were observed during a tour of the Post Anesthesia Care Unit in the Pre-Operating Area on May 4, 2016 10:00 AM.

A. The based surfaces of stretchers were soiled with dust in the Bays 1, 7, 10 and 15, in four (4) of four (4) observations.

B. Privacy curtains hooks were detached from tracks in Bays 1, 6 and 13 in three (3) of three (3) observations.

C. The top surfaces of the monitor; the television extension arm, and stretcher wheels were soiled with dust; and floors were soiled and marred in Bay 15, in three (3) of three (3) observations.

D. Monitor surfaces were soiled with dust in Phase 1 Bay Areas 18, 20, 25 and 26, in four (4) of four (4) observations.

E. Privacy curtain hooks were detached from tracks in Phase 1 Bay Areas, 18, 25 and 30, in three (3) of three (3) observations.

F. The mesh surfaces of curtains were torn and damaged and wall surfaces were marred and damaged in Bay 32 Phase 1, in one (1) of one (1) observation.

6. The following findings were observed during a tour of the Intensive Care Unit between 10:50 AM and 11:25 AM on May 4, 2016.

A. Floor surfaces and bed frames were soiled and stained and privacy curtains were detached from the tracks in Areas 288A and 288B, in four (4) of four (4) observations.

B. The linen cover, on a cart stored in the hallway outside of Room 288, was worn and damaged, in one (1) of one (1) observation.

C. Floor surfaces were marred and soiled in the corners; the base surfaces of the intravenous pole were soiled and stained; and the base of the bedside table was soiled, in three (3) of three (3) observations.

D. The lower interior shelf surfaces of the Pyxis Machine, in the Clean Utility Room, were soiled with dust in Room 282, in one (1) of one (1) observation.

E. Counter top surfaces were soiled and stained and walls were marred and damaged in the Soiled Utility Room, in one (1) of one (1) observation.

7. The following findings were observed during a tour in the Labor and Delivery Area at on May 4, 2016 at 11:25 AM.

A. The exterior surfaces of windows and exhaust vent louvers were soiled; headwall surfaces were dusty; floor surfaces were stained, near the bed and the backsplash area of the sink was damaged in Room 371, in five (5) of five (5) observations.

B. The bed frame and wheel surfaces were soiled; and the interior and exterior surfaces of exhaust vent louvers were soiled with dust, in one (1) of one (1) observation in Room 355.

8. The following findings were observed during a tour of the Neonatal Intensive Care Unit between 11:38 AM and 11:55 AM on May 4, 2016.

A. The base surfaces of the intravenous poles were soiled with spillages in areas 5 and 6, in two (2) of two (2) observations.

B. Wall surfaces were marred and damaged, adjacent to Isolette 25, in one (1) of one (1) observation.

C. Dark stains were observed on floor surfaces; near Bay 19, hot water temperature was observed at 72 °F, which was below the minimum temperature of 105 °F.

D. A multiple outlet was observed on floor surfaces and the thresholds at the entrance to Sleep Room were soiled, in two (2) of two (2) observations.

E. Carpet surfaces were soiled in Sleep Room 2, in one (1) of one (1) observation.

F. The interior and bottom shelf surfaces of the Pyxis Machine were soiled, in one (1) of one (1) observation.

9. The following findings were observed during a tour of the Behavioral Health Unit between 2:00 PM and 2:45 PM on May 4, 2016.

A. Bathroom exhaust and air supply vent louvers were soiled with dust; and floor surfaces were soiled in Room 618, in one (1) of one (1) observation.

B. Floor surfaces, bathroom vents and baseboards were soiled and stained in Room 615 in, three (3) of three (3) observations.

C. Dust was observed in the rear of the washer and dryer in the Laundry Room, in one (1) of one (1) observation.

D. Penetrations were observed in wall surfaces above the sink; and door surfaces were marred in the Clean Utility Room, in two (2) of two (2) observations.

E. Baseboards were soiled, stained and separated from wall surfaces; exhaust and supply vents were soiled with dust; wall surfaces were marred near the headboard; bathroom exhaust vents were soiled; and a small penetration was observed around the plate cover in Room 613, in seven (7) of seven (7) observations.

F. The horizontal surfaces of the bed frame and exhaust vents were soiled with dust; the toilet seat was not secured; and baseboards were not secured to wall surfaces, in five (5) of five (5) observations.

G. Floor surfaces were marred in the Occupational Therapy Area, in one (1) of one (1) observation.

H. Baseboard and floor surfaces were damaged, exhaust vent louvers were soiled with dust; and the proper security covering was not installed over the bathroom vent (a regular louver covered the vent), in three (3) of three (3) observations.

10. The following findings were observed during a tour of the Oncology Services Unit on May 4, 2016 at 2:50 PM.

A. Floor surfaces were soiled near the Pyxis machine and dust was observed on the bottom shelf of the machine, in one (1) of one (1) observation.

B. The horizontal surfaces of bed frames and baseboards were soiled with dust and privacy curtain hooks were detached from tracks in Room 501, in three (3) of three (3) observations.

C. Shower curtain surfaces were soiled with debris on the lower surfaces; shower hooks were detached; baseboards were soiled and damaged around the perimeter of the room; the enamel around the shower drain cover was damaged; baseboards under the sink were damaged; bath exhaust vents were soiled with dust; and the hot water faucet handle was damaged in Room 502, in seven (7) of seven (7) observations.

D. Hard water stains were observed on the tray and frontal surfaces of the ice machine; and the interior water and ice chutes were soiled with debris in the Nourishment Room, in two (2) of two (2) observations.

E. Window surfaces, exhaust vents, baseboards, bathroom floors and the lower shower curtain surfaces were soiled with debris in Room 508, in three (3) of three (3) observations.

F. Floor surfaces were marred and soiled; the horizontal surfaces of the bed frame were soiled; the shower faucet continued leaking, after the water supply had been turned off; the threshold at the entrance to the shower door was damaged; exhaust vents were soiled; and caulking was deteriorated in Room 509, in four (4) of four (4) observations.

G. Baseboard, floor surfaces and exhaust vents were soiled; wall surfaces were damaged, near the sink; and the sink was damaged in Room 510, in four (4) of four (4) observations.

H. Bathroom exhaust louvers were soiled, the shower threshold was soiled and with rust, and privacy curtain hooks were detached from rods, in Room 414, in four (4) of four (4) observations.

11. The following findings were observed during a tour of the Physical Therapy area on May 4, 2016 at 3:55 PM.

A. Exhaust vents were soiled and the parallel bar floor surfaces were soiled and worn in the Treatment Area in two (2) of two (2) observations.

B. The hot water faucet handle was not secured and the exhaust vent was soiled with dust in the Activities for Daily Living Area, in two (2) of two (2) observations.

C. The base surfaces of the intravenous pole were soiled with debris in Room 471, in one (1) of one (1) observation.

D. Bathroom exhaust vents and the lower surfaces of the shower curtain were soiled in in Room 466, in two (2) of two (2) observations.

12. The following findings were observed during an inspection of the Operating Rooms between 11:00 AM and 11:45 PM on May 5, 2016.

A. The exterior surfaces of the white hoses, near the anesthesia machine and the lamp over the stretcher were soiled with dust, in Operating Room 3, in two (2) of two (2) observations.

B. The wall was damaged in the Anesthesia Work Room, in one (1) of one (1) observation.

C. The lower wall surfaces were damaged near the X-Ray Machine and the rear floor mats were torn and damaged in Operating Room 5, in four (4) of four (4) observations.

D. Floor surfaces were damaged along the lower walls in Operating Room 8, in one (1) of one (1) observation.

E. Trauma elevator door tracks were soiled with debris, in one (1) one (1) observation.

F. Floor and baseboard surfaces were separated from around the perimeter of the room; ceiling tiles were soiled; and the ceiling surfaces were marred, near the surgical lamp, in Operating Room 5, in three (3) of three (3) observations.

G. The interior surfaces of the lower exhaust vent were soiled with dust in Operating Room 4, in one (1) of one (1) observation.

H. The top surfaces of the generator for the shaver power supply, was soiled with dust in Operating Room 3, in one (1) of one (1) observation.

13. The following findings were observed during a tour of Outpatient Rehabilitation Clinic on May 5, 2016 at 1:15 PM to 1:30 PM.

A. Venetian blind slats were damaged and the privacy curtain lacked sufficient hooks to ensure complete privacy in the Occupational Treatment Area, in two (2) of (2) observations.

14. The following findings were observed during a tour of the Pain Clinic on May 5, 2016 at 1:10 PM.

A. Hot water temperatures were measured an in Room 2, which is below the minimum required temperature of 105°F.

B. The heating ventilation and air conditioning unit covers and control panels were soiled in Rooms 4 and 5, in two (2) of two (2) observations.

15. The following findings were observed during a tour of the Ambulatory Surgical Clinic between 10:58 AM and 12:10 PM on May 5, 2016.

A. Baseboard surfaces were soiled in the Pre-Operation Area and privacy curtains were soiled in Bay 5, in one (1) of one (1) observation.

B. Privacy curtain hooks were detached in Bay 2 and Bay 3, in two (2) of two (2) observations.

C. The base surfaces of the pain table were soiled with debris; floor surfaces were soiled, exhaust vents over the C-ARM were soiled with dust, the power strip on the floor was soiled; and personal belongings bags were left in the Operating Room, during a procedure, in Operating Room 2, in five (5) of five (5) observations.

D. The shelves and interior surfaces in the hallway Pyxis machine were soiled, in one (1) of one (1) observation.

E. Reference materials stored on shelves in Endoscopy 1 were not covered, in one (1) of one (1) observation.

16. The following findings were observed during tour of the Boiler Rooms on May 6, 2016 at 2:50 PM.

A. Floor surfaces in the upper level staff bathroom were damaged; and painted floor surfaces were damaged in the upstairs boiler room, in two (2) of two (2) observations.

B. Floor surfaces were damaged and peeling in the lower level Chiller Area, in one (1) of one (1) observation.

C. The rubber insulated covers on the Chiller water inlet and outlet supply and return lines were worn and damaged on both Chillers, in two (2) of two (2) observations.

17. The following findings were observed during tour of the Sterile Processing Area between 11:50 AM and 12:20 PM on May 5, 2016.

A. The access panel door was not secured and vents were soiled on the clean side, in two (2) of two (2) observations.

B. The faucet's hot water handle, in the Anesthesia Storage Room, required adjustments to shut off the water supply, in one (1) of one (1) observation.

C. The ice machine in the Recovery Area continuously dripped, while in the off position, in one (1) of one (1) observation.

D. The privacy curtains, in Phase II Bay 9, were torn and damaged in one (1) of one (1) observation.

E. The top surfaces of the monitor were soiled with dust in Phase II Bay 10, in one (1) of one (1) observation.

F. Wall surfaces were marred and damaged in Phase II Bay 12, in one (1) of one (1) observation

The findings were observed and acknowledged by Employee # 84, 85, 86 and 87 on May 2, 2016.

Based on observation, policy review and staff interview, it was determined the hospital administrative staff failed to ensure staff was knowledgeable of their responsibilities relative to the fire plan when the fire alarm system failed to operate according to its intended use in one (1) of one (1) observation.


The findings include:


The George Washington University Hospital Environment of Care Policy titled, "Fire Plan (Mr. Red)," last reviewed on December 2015 stipulates; "B. If you hear the fire alarm but the fire is not in your area: 1. Determine the location of the alarm by listening to the overhead page announcement ...2. Fire Alarm System ...3. Visual Alarm: At every firm alarm bell is a strobe light intended to notify the hearing impaired. Additionally, fire alarms also visually alarm at annunciator panels in the main lobby, Security Control Center, and at every nursing unit. A. The main lobby and Control Center annunciator panels visually display the location of the alarm, and may be used by emergency responders. B. Nursing unit annunciators also visually display the location of the alarm. 5. Areas or individuals not in the fire area or immediate life threatening risk, use the "Defend in Place" concept. A. Patient and visitors are advised to remain in patient rooms, or treatment/therapeutic rooms with doors closed ...b. Advise patients and visitors to remain in rooms until advised otherwise by nursing staff. "


On May 5, 2016 at approximately 12:51 PM, the fire alarm strobe lights were observed flashing in the conference room where the surveyor team was meeting. At the time of strobe light activation, the audible fire alarm did not sound. The team coordinator contacted the hospital's administrative team to determine the nature of the alarm and next steps to be taken. Employee #5 stated s/he was unsure of the nature of the alarm; however, a call would be made to determine that status of the fire alarm. Employee #5 was unable to provide insight into the fire alarm strobe activation. In addition, guidance was not provided to the survey team relative to the fire plan.


Survey team members located in the hospital main entrance lobby, during the fire alarm activation, observed patients, employees, and visitors entering the building, using the elevators, and congregating in the lobby. The Security Staff stationed in the lobby was queried about the nature of the fire alarm and fire plan. Security Staff was unable to provide guidance to the surveyor or other persons entering and walking through the facility.


During the period of 12:51 PM to 1:01 PM on May 5, 2016, the hospital's administrative team was unable to provide guidance to the survey team as to the fire plan or appropriate next steps to be taken. The fire strobes continued until approximately 1:01 PM when an "All Clear" was announced overhead.


A face to face interview was conducted with Employee #87 on May 5, 2016 at approximately 3:01 PM. S/he explained that the smoke detector above the boiler in the area above the sixth floor was activated by the release of steam. As a result, the fire alarm system was activated and allegedly sounded from the "penthouse to the third floor". When queried about the fire plan, s/he indicated that each department has assigned duties when responding to a fire alarm. S/he was unable to provide insight into the reason why security and administration was unaware of the fire plan.


A subsequent meeting was held on May 6, 2016 at approximately 1:25 PM with the survey team and fire inspector present. Employee #87 explained that the fire system main panel was being exchanged for a new one and the contractor failed to reconnect the system and/or notify the facility of the status of the fire alarm system. Employee #87 was unable to articulate the appropriate steps to be taken to ensure the safety of the patients and visitors in the event of a malfunctioning fire alarm system.

Based on policy review, review of engineering refrigerator temperature logs and staff interview, it was determined that the refrigerator temperature was not within the range for medication storage.


The findings include:


The George Washington University Hospital Environment of Care policy titled, 'Refrigerator Temperature Requirements,' effective: June 2000, revised September 2009 and last reviewed May 2015 stipulates; "II. Policy 1. Patient medication refrigerators are monitored by the Pharmacy Department and the patient nourishment refrigerators are monitored by the Engineering Department. 2. Temperature ranges will be registered in a computerized software spreadsheet and the set points ...4. Corrective action taken must be input in the comment sheet of the software program. III. Responsibilities Pharmacy and Engineering departments will be responsible for checking the alarms when they come in via email and voice mail. When an alarm comes in, it is the Department's responsibility to go check the refrigerator and determine why the alarm was activated and correct the problem and then go back to the monitoring computer and input the corrective actions."


On May 6, 2016, in Patient Care Unit L&D [Labor & Delivery], at approximately 12:00 the medication refrigerator's temperature read 50 degrees Fahrenheit (o F) (normal temperature range for medication storage 36o F to 46o F). When the inspector inquired about this temperature reading, Employee #55 and #88 stated that the temperature was monitored by engineering and they were not notified by anyone that the refrigerator temperatures were out of compliance.


Currently, the hospital's policy does not instruct the staff to notify engineering when temperatures are out of range, per Employee #88.


The inspector requested a copy of twenty-four (24) hour monitoring data. The hospital provided data for 21 hours from May 2, 2016 at 15:00 to May 3, 2016 at 12:00. The refrigerator was out of compliance for roughly fifteen (15) hours out of 21 hours. No notification was sent to the Nursing Unit, the Pharmacy or to anyone else.


According to Employee #88, a new refrigerator monitoring system was installed throughout the hospital and an updated policy does not exist to include provide notification guidance to the staff when temperature are out of range.

Based on observation, policy review and staff interviews, it was determined that the staff failed to follow the hospital hand hygiene policy and recommendations to prevent the spread of infection in two (2) of 23 observations.

The findings include:


The George Washington University Hospital Policy titled, ' Hand Hygiene,' effective February 2016 stipulates, " ..3. Use alcohol-based hand rub (ABHR) for other situations, unless hands are visibly soiled...a. Indications for using ABHR ... ii. Upon entry into or exit from a patient room as delineated by doorway or curtain ...6. d. Gloves should not be worn in the hallways, elevators or waiting rooms unless active patient care is in progress and/or contact with OPIM [other potentially infectious materials] is actively occurring ..."

1. On May 2, 2016 at approximately 3:30 PM, during a tour of Intensive Care Unit 5, Employee #28 was observed exiting room #588 with gloved hands. The observation was made in the presence of Employees #17 and 18.

On May 2, 2016 at approximately 3:31 PM, a face-to-face interview was conducted with Employee #28 regarding the hospital policy as it relates to hand hygiene. Employee #28 immediately removed the gloves, stating, "I'm supposed to sanitize going in [the room] and remove my gloves and sanitize before coming out [the room].

The hospital staff failed to demonstrate the practice of hand hygiene to prevent the spread of infection.

Employee #18 acknowledged and confirmed the findings.

2. On May 3, 2016 at approximately 11:30 AM, during a tour of Unit 5 South, Employee #40 was observed exiting room #508 with gloved hands. The observation was made in the presence of Employees #9 and 20.

On May 3, 2016 at approximately 11:31 AM, a face-to-face interview was conducted with Employee #40 regarding the hospital policy as it relates to hand hygiene. Employee #40 removed the gloves and stated, "I know I'm supposed to take off the gloves and wash my hands."

The hospital staff observation failed to provide evidence to demonstrate support the practice of hand hygiene to prevent the spread of infection.

Employees #9 and 20 acknowledged the findings.

1. Based on medical record review, policy review, and confirmed by staff interview, it was determined the hospital staff failed to follow the discharge planning policy to ensure that all patients were screened and evaluated in three (3) of records reviewed (Patients #13, #12, and #14).


The findings include:


The George Washington University Hospital Practice Policy titled "Discharge Planning" last revised March 2013 stipulates, "I. Purpose: To describe the discharge planning process at The George Washington University Hospital ...V. Responsibilities for Discharge Planning ...F. Patient Care Staff responsible for the nursing care component of discharge planning. 1. The Registered Nurse is to a.) Assess every patient on admission using the Screening Criteria and available preadmission information. Complete pertinent discharge planning information on the nursing database to identify patients that have potential discharge needs ...C. Case Management Staff services and responsibilities: 1. Conduct an initial assessment of the patient including patient demographic and current living arrangements including high level assessment of environmental factors such as location of bedroom, bathroom and stairs. Assess baseline functional status, cognition, family support, and financial resources available to obtain the necessary prescription medications. Document initial assessment and ongoing discharge planning activity in the patient's electronic medical record."


The George Washington University Hospital Standard Practice policy titled "Discharge Planning- Initial Assessment and Documentation" last revised March 2016 stipulates;
"PURPOSE: To adequately prepare patients and families for their planned transition to post-hospital care. To ensure that discharge planning assessments are thorough and timely to facilitate the development of a high quality, comprehensive plan for patients' ongoing care after discharge ...III. Policy: Case Management will conduct within 48 hours, discharge planning assessment for all patient identified by their physicians or through early screening as needing discharge planning services ...IV. Procedure ...1A. The Social worker or RN Case Manager will screen their assigned patients within 48 hours of their hospital stay utilizing the following criteria: over the age of 80, impaired mobility/self-care skills, poor cognitive status, low health literacy ...uninsured or underinsured ...history of recent falls ... conditions requiring a lifestyle change (e.g. Cancer, Diabetes, CVA, Myocardial Infarction) ...2. The assessment will be completed within 48 hours so that arrangements for post-hospital care are made before discharge and so that unnecessary delays in discharge are avoided."


A. Patient #13 was admitted with diagnosis of Acute Cerebrovascular Accident.


Observations on May 2, 2016 at approximately 1:57 PM revealed Patient #13 standing beside the bed, attempting to place a telephone charger in the closet. Patient #13's balance was observed unsteady, with body drifting to the right side. The unit's staff offered Patient #13 assistance with placing the charger in the closet.


Subsequently, a face to face interview was conducted with Patient #13 on May 2, 2016 at 2:08 PM. Patient #13 expressed satisfaction with care; however, does not know the reason for the delay in discharge. According to Patient #13, discharge was scheduled for May 2, 2016 and will occur after the completion of one additional test. Patient #13 alleged that the medical staff has not been in to discharge plan.


During a face to face interview with Employee #78 on May 10, 2016 at 2:10 PM, s/he stated that Patient #13 was awaiting insurance approval to facilitate transfer to a subacute rehabilitation facility for therapy.


Review of the medical record on May 2, 2016 at 2:15 PM revealed Neurology Progress notes dated April 30, 2016 and May 1, 2016. The "Attending Note and Attestation" comment stated "may DC [discharge] home if BP [blood pressure] is controlled with outpatient 2D echo [technique is used to see the actual motion of the heart structures] and follow-up in stroke clinic."


The Physical Therapy Evaluation completed on May 1, 2016 recommended discharging patient with home physical therapy.


The medical record lacked documented evidence the clinical staff documented a discharge assessment to facilitate a timely discharge of Patient #13.


A face to face interview was conducted with Employee #82 on May 2, 2016 at approximately 2:10 PM. S/he explained that discharge planning assessments are completed 24 to 48 hours from admission and documented using Midas [electronic health record system]. When queried about the discharge plan for Patient #13, she stated the patient is uninsured and is awaiting insurance to facilitate transfer to a subacute rehabilitation facility. However, s/he was unable to explain the contradictory discharge plan documented in the medical record by the medical staff and physical therapy.


The aforementioned findings were discussed with Employee #5 on May 5, 2016 at approximately 10:35 AM. According to Employee #5, another medical record review was conducted to locate the discharge planning assessment. S/he was unable to locate the discharge planning assessment. Consequently, the findings were acknowledged by Employee #5.


B. Patient #14 was admitted to the Intensive Care Unit for diagnoses to include Cardiac Arrest and Hypertension.


Medical record review conducted on May 3, 2016 at approximately 11:02 AM revealed that the nursing staff initiated an "Adult Patient History" assessment on April 26, 2016 at 2:36 AM; however, the form was never completed. According to the "Adult Patient History" form, the "Advance Directive, Functional, Past Medical History, Social History... DC [Discharge] Needs" sections were not completed to screen for discharge needs.


Further review of the medical record failed to reveal the completion of a discharge planning assessment. While reviewing the electronic medical record, Employee #79 asked if s/he could enter the discharge plan s/he was currently working on, in the Midas [electronic health record system]. The discharge plan assessment was time stamped for May 3, 2016 at 11:45 AM.


A face to face interview was conducted with Employee #79 on May 3, 2016 at 11:54 AM. According to Employee #79, it is the expectation that discharge assessments are completed with 48 hours of admission. Patient #14 was initially admitted to the Intensive Care Unit and subsequently transferred to 4 South on May 1, 2016. S/he was responding to the admission of Patient #14 to his/her unit, by completing the discharge assessment. S/he was unable to provide insight into why the discharge assessment was not completed within 48 hours of admission.


The medical record lacked documented evidence the hospital staff completed a discharge assessment, in accordance with the hospital's discharge planning policy.


The findings were confirmed that the discharge planning assessment was not completed, in accordance with the hospital's discharge planning policy on May 3, 2016 at 11:45 AM.



C. Patient #12 was admitted with diagnoses of Right Ankle Fracture and Brain Tumor.


Medical record review conducted on May 2, 2016 at approximately 3:00 PM revealed the discharge planning assessment, "Adult Patient History" and initial comprehensive assessment were not completed.


A discussion was conducted with Employee #80 regarding the completion of the initial assessments and discharge assessment on May 2, 2016 at approximately 3:15 PM. According to Employee #80, it is the expectation the initial assessment and discharge screen be completed upon admission. Further review of the medical record revealed the first "head to toe assessment" was completed on April 28, 2016 at 2:44 PM upon transfer to 4 North, approximately six days after admission. S/he was unable to provide insight into the omission of the initial assessment and/or discharge assessment.


The medical record lacked documented evidence the hospital staff completed a discharge assessment, in accordance with the hospital's discharge planning policy.


The findings were confirmed, and acknowledged on May 2, 2016 at approximately 3:55 PM.




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2. Based on record review, policy review and staff interviews, it was determined that the Case Management staff failed to follow hospital policy to conduct discharge planning assessments, within 48 hours in two (2) of 11 patient records reviewed (Patients #1, and 7).

The findings include:


The George Washington University Hospital Policy Number, titled, 'Discharge Planning- Initial Assessment and Documentation,' revised March 2016 stipulates, "...III. Policy Case Management will conduct, within 48 hrs. [Hours], a discharge planning assessment for all patients identified by their physicians or through early screening as needing discharge planning services ..."


A. Patient #1 was admitted with a diagnosis of Acute Hypoxia.

Review of the medical record on May 2, 2016 at approximately 10:58 AM revealed the patient was admitted on March 16, 2016 and was identified through the nursing admission assessment as needing discharge planning services.

Further review of the medical record revealed the initial case management note was performed on April 27, 2016. The review was performed in the presence of Employees #26 and 19.

The medical record lacked documented evidence the case management staff followed the hospital's policy relative to the performance of discharge planning assessments.

Employee #19 acknowledged the findings.

B. Patient #7 was admitted with a diagnosis of Subarachnoid Hemorrhage.

Review of the medical record on May 3, 2016 at approximately 3:40 PM revealed the patient was admitted on March 29, 2016 and was identified through the nursing admission assessment as needing discharge planning services.

Further review of the medical record revealed the initial case management note was performed on April 6, 2016. The review was performed in the presence of Employees #9, 20, and 34.

The medical record lacked documented evidence the case management staff followed the hospital's policy relative to the performance of discharge planning assessments.

Employee #34 acknowledged the findings.