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Based on medical record review and staff interview, it was determined that the nursing staff failed to establish and maintain a current nursing care plan in four (4) of seven (7) records reviewed (Patients #17, 21, 22, and 23).

The findings include:

MedStar Georgetown University Hospital Policy #404 entitled "Medical Record Documentation" reviewed May 23, 2013 and revised June 25, 2013 stipulates "PROCEDURE: I. Inpatient and outpatient medical records shall contain sufficient information to identify the patient, support the diagnosis and treatment, document the course and results, and promote continuity of care among health care providers."



A. Patient #17 was admitted on February 4, 2014 with diagnoses which included End Stage Renal Disease and Hypotension.


Medical record review on February 12, 2014 at approximately 3:45 PM revealed Patient #17 had daily complaints of pain from February 8, 2014 through February 12, 2014. Patient #17 ' s complaints of pain included the following: February 8, 2014 at 12:51 AM pain score of ten (10); February 8, 2014 at 9:11 AM pain score ten (10); February 9, 2014 12:52 AM pain score of ten (10); February 9, 2014 9:20 AM pain score of (8); February 10, 2014 10:47 PM pain score of (8); February 11, 2014 1:15PM pain score of (9). The pain score is based on a scale of zero (0) to ten (10); zero indicates no pain and ten indicates the worst possible pain. The pain assessment included the pain score only, no further descriptors were provided.


The medical record lacked documented evidence that the nursing staff maintained a current plan of care relative to pain.


The nursing staff failed to establish and maintain a current nursing care plan.


The findings were reviewed, discussed and acknowledged by the Nurse Manager and Nursing Administrative Staff on February 12, 2014 at approximately 3:45 PM during the record review.


B. Patient #21 was admitted on December 23, 2013 with diagnoses which included Acute Respiratory Distress, Altered Mental Status, Urinary Tract Infection, Acute Renal Failure on Hemodialysis and Elevated Liver Enzymes.

Medical record review on February 11, 2014 at approximately 3:40 PM revealed Patient #21 developed alterations in skin integrity since admission to the hospital which included January 2, 2014 left elbow blister no measurements were documented; February 4, 2014 left buttock pressure ulcer measured as four (4) centimeters by two (2) centimeters; and February 5, 2014 neck skin tear no measurements were documented. The skin assessment for the aforementioned alterations in skin integrity lacked further descriptors related to the condition of the wound bed and/or surrounding tissue.


Further review of Patient #21 medical record revealed complaints of pain on a number of occasions to include February 4, 2014 at 9:40 PM pain score of six (6); February 7, 2014 at 12:52 PM pain score of eight (8); February 8, 2014 at 12:43 AM pain score of seven (7); and February 8, 2014 at 6:06 PM pain score of ten (10). The pain score is based on a scale of zero (0) to ten (10); zero indicates no pain and ten indicates the worst possible pain. Patient #21 required pharmacological intervention to alleviate the pain symptoms.


The medical record lacked documented evidence of an established, current nursing care plan to address skin integrity and/or pain.


The nursing staff failed to establish and maintain a current nursing care plan.


The findings were discussed and acknowledged by the Nurse Educator and Staff Nurse on February 11, 2014 at approximately 3:45 PM.



C. Patient #22 was admitted January 27, 2014 with diagnoses which included Perforated Diverticular Disease, Status Post Exploratory Laparotomy, Colostomy, Loop Ileostomy, and History of Prostate Cancer.


Medical record review on February 11, 2014 at approximately 12:00 PM revealed Patient #22 had multiple alterations in skin integrity to include the following: January 27, 2014 abdominal surgical incision measured as twelve (12) centimeters by thirteen (13) centimeters; January 27, 2014 left inner leg skin tear measured as three (3) centimeters by three (3) centimeters; January 29, 2014 sacral decubitus ulcer measured as two (2) centimeters by two (2) centimeters and February 4, 2014 left arm abrasion with no measurement documented.


Further review revealed Patient #22 ' s medical condition required ventilator support via tracheostomy, hemodialysis and multiple blood transfusions. Patient #22 received two (2) units for packed red blood cells on January 28, 2014, and twice on January 29, 2014.


The medical record lacked documented evidence that the nursing staff established and maintained a current nursing care plan as Patient #22 ' s medical condition changed.


The findings were discussed and acknowledge by the Nurse Educator and Staff Nurse on February 11, 2014 at approximately 12:00 PM during the medical record review.


D. Patient #23 was admitted on December 31, 2013 with diagnoses which included Respiratory Failure and Acute Renal Failure.


Medical record review on February 11, 2014 at approximately 4:40 PM revealed Patient #23 had multiple present on admission alteration in skin integrity which included excoriation under breast, abdominal surgical incision, sacrum pressure ulcer, right buttock redness, left hip, bilateral flank redness, and right inner thigh redness.


Interview with Staff Nurse on February 11, 2014 at approximately 4:40 PM revealed that Patient #23 continued to require treatment for alterations in skin integrity on the sacrum, and abdominal surgical incision at the time of survey. On February 4, 2014 the sacrum was measured as 12 centimeters by three (3) centimeters. On February 6, 2014 the abdominal surgical wound was measured as 28 centimeters by six (6) centimeters by three (3) centimeters.


Further review of the medical record revealed that January 2, 2014 at 10:20 AM care plans entitled "Pressure Ulcer Prevention and Management Adult Plan of Care" were initiated. On February 2, 2014 at 2:22 AM, the care plan entitled " Pressure Ulcer Management " was discontinued. Patient #23 alterations in skin integrity persisted at the time of record review.


The medical record lacked documented evidence that the nursing staff maintained a current plan of care relative to impaired skin integrity.


The nursing staff failed to establish and maintain a current nursing care plan.


The findings were discussed, and acknowledged by the Nurse Educator and Staff Nurse on February 11, 2014 at approximately 4:45 PM.

Based on medical record review and staff interviews, it was determined that the clinical staff failed to ensure that the medical record contained all pertinent information relative to the patient's progress and response to medication and services in five (5) of the five (5) records reviewed (Patients # 15, 17, 21, 22, and 23).

The findings include:


MedStar Georgetown University Hospital Policy #404 entitled "Medical Record Documentation" reviewed May 23, 2013 and revised June 25, 2013 stipulates "PROCEDURE: I. Inpatient and outpatient medical records shall contain sufficient information to identify the patient, support the diagnosis and treatment, document the course and results, and promote continuity of care among health care providers."

The policy was reviewed by the surveyor on February 11, 2014 at approximately 4:00 PM.

A. Patient #15 was admitted on August 19, 2013 with diagnoses which include Lung Cancer with Bone Metastasis, Thyroid Cancer, Respiratory Failure, and Laryngeal Cancer.

Medical record review on February 12, 2014 at approximately 11:16 AM revealed a physician's order January 14, 2014 "Acetylcysteine nebulization treatment 1 milliliter every six (6) hours and Duoneb nebulizer treatment one (1) unit dose every six (6) hours".

The Electronic Medication Administration Record revealed that February 8, 2014 at 1:30 PM Acetylcysteine was not administered "med not available"; February 9, 2014 at 11:00 PM Acetylcysteine was not administered "no to time available"; February 9, 2014 at 11:00 PM Duoneb was not administered "no time to available"; and February 10, 2014 at 5:00 AM Acetylcysteine was not administered "no to time available".

Interview with Director of Respiratory Services and Respiratory Therapist on February 12, 2014 at approximately 3:15 PM revealed respiratory therapy is responsible for the administration of nebulization treatments. If the medication is unavailable, the respiratory therapist will request a medication refill through the computerized system in the Electronic Medication Administration Record and notify the nurse. Once the medication is delivered, the respiratory therapist will return to administer the nebulization treatment.

Staff interview with the Nurse Manager on February 12, 2014 at approximately 4:00 PM revealed that the nursing staff does not administer aerosolized medications. The nursing staff notifies the respiratory therapist when the medication becomes available.

The medical record lacked documented evidence that the respiratory staff notify the pharmacy and/or the nurse responsible for Patient #15. Additionally, the medical record lacked documented evidence that the medical staff was notified of the inability to administer the aerosolized medication according to physician's orders.

Further review of the medical record on February 12, 2014 at 4:00 PM revealed that January 4, 2014 a physician's order "Chest Physiotherapy every six (6) hours". For period beginning February 4, 2014 through February 12, 2014, chest physiotherapy was documented as administered on February 4, 5, and 6, 2014 according to physician's order. The other dates lacked documented evidence that the clinical staff followed the physician's order and/or a reason for the omission.

The medical record lacked documented evidence that chest physiotherapy was provided according to the physician's order.

The respiratory staff failed to follow the physician's order relative to aerosolized nebulizer treatments and chest physiotherapy.

On February 5, 2014 at 6:40 PM, physician order was transcribed "neurological assessment every four (4) hours". The medical record review on February 12, 2014 at approximately 11:16 AM revealed neurological assessments were to be completed a total of 36 times from February 6, 2014 through February 11, 2014. The medical record revealed the nursing staff completed 25 out of 36 neurological assessments.

The medical record lacked documented evidence that the nursing staff followed the
physician's order.

The nursing staff failed to follow the physician's order relative to neurological assessments.

The findings were reviewed, discussed and acknowledged by the Staff Nurse and Nursing Administration on February 12, 2014 at approximately 4:00 PM at the time of record review.

B. Patient #17 was admitted on February 4, 2014 with diagnoses which included End Stage Renal Disease, and Hypotension.

Medical record review on February 12, 2014 at approximately 3:45 PM revealed Patient #17 had daily complaints of pain from February 8, 2014 through February 12, 2014. Patient #17's complaints of pain included the following: February 8, 2014 at 12:51 AM pain score of ten (10); February 8, 2014 at 9:11 AM pain score ten (10); February 9, 2014 12:52 AM pain score ten (10); February 9, 2014 9:20 AM pain score of (8); February 10, 2014 10:47 PM pain score of (8); February 11, 2014 1:15PM pain score of (9). The pain assessment included the pain score only, no further descriptors were provided.

Further review of Electronic Medication Administration Record revealed that the nursing staff administered pain medication and recorded effectiveness without a pain assessment on February 10, 2014 at 12:02 AM, 4:12 AM, 10:59 AM, 4:57PM, and 10:43 PM.

The medical record lacked documented evidence that the nursing staff completed a comprehensive pain assessment and/or reassessments.

The nursing staff failed to document a comprehensive pain assessment with specificity.

The findings were reviewed, discussed and acknowledged by the Nurse Manager and Nursing Administration on February 12, 2014 at approximately 4:00 PM during record review.


C. Patient #21 was admitted on December 23, 2013 with diagnoses which included Acute Respiratory Distress, Altered Mental Status, Urinary Tract Infection, Acute Renal Failure and Elevated Liver Enzymes.

Medical record review on February 11, 2014 at approximately 3:20 PM revealed that December 23, 2013 the physician ordered "weights every day" . Multiple dates lacked documentation of a weight which included February 3, 5, and11, 2014.

The medical record lacked documented evidence that nursing staff obtained daily weights as instructed in the physician ' s orders.

The nursing staff failed to obtain daily weights and document in the medical record.

Further review of Patient #21 medical record revealed numerous complaints of pain which included February 4, 2014 at 9:40 PM pain score of six (6), February 7, 2014 at 12:52 PM pain score of eight (8); February 8, 2014 at 12:43 AM pain score of seven (7); and February 8, 2014 at 6:06 PM pain score of ten (10). The pain score is based on a scale of zero (0) to ten (10); zero indicating no pain and ten indicating the worst possible pain. Patient #21 required pharmacological intervention to alleviate the pain symptoms. The pain assessments lacked specificity relative to location, description, duration, and alleviating factors.

The medical record lacked documented evidence that a comprehensive pain assessment and daily weights were performed to ensure Patient #21 ' s response to medication and treatment were available to assist with making decisions on provision of care.

The nursing staff failed to document a comprehensive pain assessment and daily weights to ensure the medical record contained Patient #21's response to medications and treatment received to assist with decision making relative to plan of care.

The findings were discussed, and acknowledged on February 11, 2014 at approximately 3:45 PM with Nurse Educator and Staff Nurse.


D. Patient #22 was admitted January 27, 2014 with diagnoses which included Perforated Diverticular Disease, Status Post Exploratory Laparotomy, Colostomy, Loop Ileostomy, and History of Prostate Cancer.

Medical record review on February 11, 2014 at approximately 12:05 PM revealed that January 27, 2014 at 11:46 AM the physician ordered weights daily. On February 4, 2014 the Nursing Flow Sheet reflected "Today's Weight: unable to weigh" . February 5, 2014 Nursing Flow Sheet reflected "Today's Weight: broken scale" . On February 8, 2014 the weight was recorded as 90 kilograms. The medical record did not contain any other weights from February 9, 2014 through February 11, 2014.

The medical record lacked documented evidence that the nursing staff obtained weights daily as ordered by the physician.

Additionally, the medical record review on February 11, 2014 at approximately 12:00 PM revealed Patient #22 had multiple alterations in skin integrity to include the following: January 27, 2014 abdominal surgical incision measured as twelve (12) centimeters by thirteen (13) centimeters; January 27, 2014 left inner leg skin tear measured as three (3) centimeters by three (3) centimeters; January 29, 2014 sacral decubitus ulcer measured as two (2) centimeters by two (2) centimeters and February 4, 2014 left arm abrasion with no measurement documented.

Further review revealed Patient #22's medical condition required ventilator support via tracheostomy, hemodialysis and multiple blood transfusions. On January 29, 2014 and February 1, 2014, Patient #22 received hemodialysis. Patient #22 received two (2) units for packed red blood cells on January 28, 2014, and twice on January 29, 2014.

The medical record lacked documented evidence that the nursing staff established and maintained a current nursing care plan which reflected changes in Patient #22's medical condition.

The nursing staff failed to ensure that the medical record content all pertinent information related to Patient #22's medical condition relative to hemodialysis, alteration in skin integrity, and nursing plan of care.

The findings were discussed and acknowledge by the Nurse Educator and Staff Nurse on February 11, 2014 at approximately 12:00 PM during the medical record review.

E. Patient #23 was admitted on December 31, 2013 with diagnoses which included Respiratory Failure and Acute Renal Failure.

Medical record review on February 11, 2014 at approximately 4:40 PM revealed Patient
#23 had multiple present on admission alteration in skin integrity which included excoriation under breast excoriation, abdominal surgical incision, sacrum pressure ulcer, right buttock redness, left hip, bilateral flank redness, and right inner thigh redness.

Interview with Staff Nurse on February 11, 2014 at approximately 4:40 PM revealed that Patient #23 continued to receive treatment for alterations in skin integrity on the sacrum, and abdominal surgical incision. On February 4, 2014 the sacrum was measured as 12 centimeters by three (3) centimeters. On February 6, 2014 the abdominal surgical wound was measured as 28 centimeters by six (6) centimeters by three (3) centimeters. The skin assessment lacked specificity relative to alterations in skin integrity.

The medical record lacked documented evidence of a comprehensive skin assessment with specificity.

The nursing staff failed to document a comprehensive skin assessment with specificity related to wound be and/or surrounding tissue.

The findings were discussed and acknowledged by the Nurse Educator and Staff Nurse on February 11, 2014 at approximately 4:40 PM at the time of record review.

1. Based on review of documents (Pyxis "Charges & Credits" report; physicians ' orders and patient's medical record, to include Medication Administration Records [MAR]), it was determined that nursing staff failed to record " PCA checks " as required in the Hospital Policy #105.

The findings include:

Hospital Policy #105, entitled "Patient Controlled IV/SQ Analgesia " , Section VI. C. 1., stipulates: "Pump setting, number of doses attempted, number of doses delivered, and patient responses are documented on the Pain Management and Sedation Infusion Sheet ... according to the guidelines listed in the event log with the frequency: 1. For adults: Upon initiation and q 1 hours times 2, and then q 4 hours thereafter .... "

1. On February 10, 2014, Patient #47. was prescribed Dilaudid PCA 20mg (100ml) . On February 14, 2014, in the presence of Hospital staff the patient's MAR and ADM transaction reviewed. It is documented on the patient's MAR that the PCA was started on February 10, 2014 at 16:59. There was no documentation in the medical record that reflected the "PCA checks" were done every hour for the first two hours after the PCA was initiated.

The nursing staff failed to follow the hospital's policy required documention for PCA checks on initiation of PCA. .

2. On February 10, 2014, Patient #49 was prescribed Dilaudid PCA 20 milligrams(mg) (100 milliter [ml]). On February 14, 2014, in the presence of Hospital staff the patient's MAR and ADM transaction reviewed. It is documented on the patient's MAR that the PCA was started on February 10, 2014 at 12:25. There was no documentation in the medical record that the required "PCA checks" were done every hour for the first two hours after the PCA was initiated.

The nursing staff failed to follow the hospital's policy related to PCA checks..

3. On February 6, 2014, Patient #51 was prescribed Fentanyl PCA 10 microgram (mcg)/ml (250ml). On February 14, 2014, in the presence of Hospital staff the patient's MAR and ADM transaction reviewed. It is documented on the patient's MAR that the PCA was started on February 11, 2014 at 00:42. There was no documentation in the medical record that the required "PCA checks" were done every hour for the first two (2) hours after the PCA was initiated.

The nursing staff failed to follow the hospital's policy related to PCA checks.

4. On February 10, 2014, Patient #52 was prescribed Dilaudid PCA 20mg (100ml). On February 14, 2014, in the presence of Hospital staff the patient's MAR and ADM transaction reviewed. It is documented on the patient's MAR that the PCA was started on February 10, 2014 at 14:09. There was no documentation in the medical record that the required "PCA checks" were done every hour for the first two hours after the PCA was initiated.

The nursing staff failed to follow the hospital's policy related to PCA checks.

The above findings were observed on February 14, 2014, at approximately 12:00 noon to 4:00 PM and the hospital staff present acknowledged and confirmed the findings.

The policy review was completed on February 12, 2014 at approximately 2:00 PM.

2. Based on review of documents (Pyxis "Charges & Credits report"; physicians' orders and patient's Medication Administration Records [MAR]), it was determined that nurses were removing controlled substances, Schedule II, from the automated dispensing machine (ADM) without documenting the administration and wasting of the controlled substance on the patient's Medication Administration Record.

The findings include:

1.On February 14, 2014, in the presence of Hospital staff the patient's MAR and ADM transactions were reviewed.

A On February 6, 2014, Patient #53 had an order written, "25 mcg every hour, as needed, IV push." On February 11, 2014 at 19:00, one 100 mcg ampule was removed from the Pyxis. There was no documentation on the Pyxis report, on or around that date and time, for the wasting of 25 mcg.

B. On February 11, 2014, at 6pm, Patient #53 had an order written for, "Fentanyl 250mcg X 1, IV push, IV" . It was noted that on February 11, 2014 at 14:22, two (2) 100mcg ampules and at 15:06, one (1) 100mcg ampule was removed from the Pyxis. There was no documentation on the Pyxis report, on or around that date and time, for the wasting of 50mcg.

The nursong staff failed to reconile Fentanyl rmoved from the Pyxis on February 11, 2014 times two (2); a total of 75 mcg.

2. On February 14, 2014, in the presence of Hospital staff the patient's MAR and ADM transactions were reviewed. On February 11, 2014 at 17:01, Patient #54 was ordered, "Fentanyl 25 mcg, IV push, every hour, as needed".
.
A. On February 11, 2014 at 19:36, one 100mcg ampule of Fentanyl was removed from the Pyxis and then wasted. The patient's MAR documents that 25mcg was administered at 20:14.

B. On February 12, 2014 at 04:19, one 100mcg ampule of Fentanyl was removed from the Pyxis. On or around that time, there is no documentation on the MAR indicating that Fentanyl was administered, nor any documentation on the Pyxis report that Fentanyl was wasted.

C. On February 12, 2014 at 06:04, one 100mcg ampule of Fentanyl was removed from the Pyxis. On or around that time, there is no documentation on the MAR indicating that Fentanyl was administered, nor any documentation on the Pyxis report that Fentanyl was wasted.

The nursing staff failed to reconcile Fentanyl removed from the Pyxis with a corresponding MAR for administration of the medication for Patient #54. .

3. On February 14, 2014, in the presence of Hospital staff the patient's MAR and ADM transactions were reviewed.

On February 12, 2014 at 18:35, Patient #57 was ordered, "Fentanyl 25 mcg, IV push, every 2 hour, as needed ". On February 12, 2014 at 20:20, one 100mcg ampule was removed from the Pyxis. It is documented on the Pyxis report that 25mcg were wasted. However, there is no documentation on the MAR, on or around that time, indicating that Fentanyl was administered.

The nursing staff failed reconile medication removed from the Pyxis with the corresponding MAR. The nursing failed to to document the adminstration of controlled substance. on the MAR.

4.On February 14, 2014, in the presence of Hospital staff the patient's MAR
ADM transactions were reviewed. On February 7, 2014 at 6:38, Patient #58 was ordered, "Morphine 2mg, IV push, every 2 hours, as needed."

A. On February 11, 2014 at 18:41, one 2mg syringe was removed from the Pyxis. There was no documentation on the patient's MAR, for that date and time, that morphine was administered.

B. It is documented on the patient's MAR, that 2mg of Morphine was administered on February 12, 2014 at 13:07. There was no documentation on the Pyxis report, for that date and time, that morphine was removed from the Pyxis.

The nursing failed to document the administraion of Morphine on the MAR and no documented evidence that Morphine was reconciled from Pyxis to corresponding MAR's date, time and dosage.


5.On February 18, 2014, in the presence of Hospital staff the patient's MAR and ADM transactions were reviewed.

On February 2, 2014 at 13:23, Patient #55 was ordered, Fentanyl 25 mcg, IV push, every hour, as needed. " On February 13, 2014 at 12:18, two 100mcg ampules were removed from the Pyxis. The patient's MAR indicated that at 12:20, 25 mcg was administered, at 14:00, 75 mcg was administered; and at 16:31, 50mcg was administered. There is no documentation on the patient's MAR or Pyxis report, that the remaining 50mcg was administered or wasted.

The nursings staff failed to reconcile 50 mcg of Fentanyl removed from the Pyxis (per Pyxis report) with corresponding MAR; no documented evidence that Fentanyl 50 mcg was administered.

6. On February 18, 2014, in the presence of Hospital staff the patient ' s MAR and ADM transactions were reviewed.

On February 11, 2014 at 03:11, Patient #37 was ordered, "Morphine 2mg, IV push, every 3 hours, as needed." The patient's MAR indicated that on February 13, 2014 at 08:28, 2 mg was administered. There is no documentation on the Pyxis report, that 2mg was removed from the Pyxis.

The nursing staff failed to reconcile the medications removed from the Pyxis prior to administration.

7. On February 18, 2014, in the presence of Hospital staff the patient's MAR and ADM transactions were reviewed. On February 10, 2014 at 16:30, Patient #41 was ordered, "Fentanyl 50 mcg, IV push, every 2 hours, as needed."

A. On February 12, 2014 at 07:16, a 100mcg ampule was removed from the Pyxis. And 50mcg was wasted. There was no documentation on the patient's MAR, for that date and time, that Fentanyl 50mcg was administered.

B. On February 12, 2014 at 07:22, a 100mcg ampule was removed from the Pyxis. And 50mcg was wasted. There was no documentation on the patient's MAR, for that date and time, that Fentanyl 50mcg was administered.

The nursing staff failed to document the adminstation of the Fentanyl on the MAR
after removal of the medication from the Pyxis times two (2) of February 12, 2014.

8. On February 18, 2014, in the presence of Hospital staff the patient's MAR and ADM transactions were reviewed. On February 11, 2014 at 17:11, Patient #43 was ordered, "Hydromorphone 1 mg, IV push, every 3 hours, as needed."

A.On February 13, 2014 at 03:25, a 1mg syringe was removed from the Pyxis.
The MAR lacked documetned evidence of a date and time the hydromorphone was
administered.

The nursing staff failed to document the administartion of the hydromorpone on the MAR.


The findings for Patients #37, 41, 43, 53, 54, 55, 57, and 58 were observed on February 14, 2014 12:00 to 4:00 PM and February 18, 2014 10:00 AM to 2:00 PM. The hospital staff present acknowledged and confirmed the findings.




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3. Based on medical record review, policy review and staff interview, it was determined the governing body failed to ensure that the clinical staff adhered to the previous Plan of Corrections to ensure proper correction of errors entered in the written medical record in four (4) of six (6) records reviewed (Patients #15, 16, 21 and 22).

These deficient practices were representative of repeated findings cited in the previous Licensure Surveys conducted on March 24, 21011, June 25, 2012 and September 6, 2013.

The findings include:

MedStar Georgetown University Hospital Policy #404 entitled "Medical Record Documentation" reviewed May 2, 2013 and revised June 25, 2013. The policy stipulates "...G. Any error in charting is to have a single line drawn through the erroneous information and the word "correction" written above it. The date and the initials of the person making the correction should be written near the word " correction ..."

The review of the above mentioned medical records during the survey period February 11 through 18, 2014 revealed the clinical and medical staff failed to consistently follow the hospital's policy regarding correction of errors in the written medical record.

This was evidenced by multiple instances where staff attempted to correct documentation errors through the use of multiple strikeovers of words, heavy writing over letters and/or numbers.

The findings were discussed and acknowledged by the Nursing Administrative staff at the time of record review on February 12, 2014 at approximately 4:00PM.

The policy was reviewed by the surveyor on February 12, 2014 at approximately 4:00 PM.

4. Based on medical record, policy and professional practice guidelines review and confirmation by staff interview, it was determined that the medical staff failed to document an American Society of Anesthesiologists (ASA) classification for patients receiving sedation in one (1) of two (2) Interventional Radiology records randomly selected for review.

The findings include:

MedStar Georgetown University Hospital, Policy number 108, entitled Moderate Sedation revised December 17, 2013, Section five (5) Care and Monitoring of Patients stipulates, "A.. The following should be ascertained and documented in writing in the patient record before moderate sedation is administered. 1. Physician's order for moderate sedation in the chart. 2. Statement by the physician present that the patient's level of consciousness and medical condition are appropriate for the selected sedation ...9. ASA status ..."

The American College of Radiology (ACR) and the Society of Interventional Radiology Practice Guideline for Sedation/Analgesia, revised 2010, Section five (5) Patient Selection references specific guidelines for ASA classification in radiology, for example, "Patient who are ASA class I or II qualify for sedations/analgesia (see Appendix A). Patient who are ASA class III or IV may require additional consideration." Appendix A is the "America Society of Anesthesiologists (ASA) Physical Status Classification."

Patient #35 was admitted on December 24, 2013 with a diagnosis of Abdominal Pain; underwent Arteriogram, Hepatic Selective on December 26, 2013 in Interventional Radiology.

Review of the medical record on February 18, 2014 at approximately 12:15 PM revealed the physician ordered intravenous sedation with Fentanyl 100 microgram and Versed 2 milligrams for an arteriogram on December 26, 2013. The medical record lacked documented evidence of an ASA classification prior to sedation and the procedure.

The Interventional Radiology medical staff failed to ensure that an ASA classification was documented prior to start of the procedure and sedation.

The findings were reviewed and discussed with the Center for Patient Safety Nursing staff during the record review on February 18, 2014 at 12:30 PM.

On February 18, 2014 at approximately 3:30 PM a telephone interview was conducted with the Director for Interventional Radiology (a Registered Nurse) through the Center for Patient Safety Nursing staff. The Interventional Radiology Director was questioned regarding the medical staff in Interventional Radiology completing ASA classifications for patient requiring sedation. The Director stated that the physician does an ASA classification for patients, but it is not necessarily documented in the medical record.

The policy and practice guidelines were reviewed on February 11, 2014 at approximately 4:30 PM and February 20, 2014 at approximately 10:00 AM respectively.

5. Based on medical record and policy review, as well as staff interview it was determined that the clinical staff failed to follow the hospital's policy related to pain assessment in one (1) of two (2) records reviewed (Patient #2).

The findings include:

Hospital Policy #105, entitled Patient Controlled IV/SQ Analgesia, last revised August of 2013, Section VI. Monitoring and documenting patient's response to PCA, C. stipulates, " Pump settings, number of doses attempted, number of doses delivered, and patient responses are documented on the Pain Management and Sedation Infusion Sheet according to the guidelines listed in the event log with the frequency: 1. For Adults: upon initiation and q [every] 1 hour times 2, and then q [every] 4 hours thereafter. ... D. Patient response measures include: 2. Pain score using the visual (faces) or numeric scale (0-10)."

Patient #2 was admitted on February 7, 2014 with diagnoses to include: Colon Cancer, Depression and Pain.

According to documentation contained in the medical record a palliative care consult was ordered on admission to address the patient's pain care needs during record review on February 12, 2014 at approximately 9:30 AM. The patient was subsequently ordered a Patient Controlled Analgesia (PCA) on February 7, 2014.

A detailed review of the patient's pain assessment documentation was performed on February 12, 2014 at approximately 10:38 AM, revealing clinical staff failed to document pain assessments on the patient from February 7, 2014 at 7:00 PM through February 9, 2014 at 1:00 PM.

Further review revealed clinical staff failed to document pain assessments between 8:00 PM and 3:59 AM on February 9 into February 10, 2014; on February 10, 2014 clinical staff failed to document pain assessments between 5:00 AM and 12:59 PM and between 2:00 PM and 10:59 PM and on February 11, 2014 the clinical staff failed to document a pain assessment on the patient between the hours of 4:00 AM and 9:59 AM.

The clinical staff failed to consistently document pain assessments per the hospital policy.

A face-to-face interview was conducted on February 12, 2014 at approximately 11:15 AM with the Charge Nurse and the Nurse Manager. They reviewed the documents referenced above and acknowledged the findings.

6. Based on medical record and policy review, as well as staff interview it was determined that the clinical staff failed to follow the hospital ' s policy related to patient education concerning transfusion reactions in one (1) of three (3) records reviewed (Patient #18).

The findings include:

Hospital Policy #107, entitled Blood Transfusions, last reviewed February of 2013, section V. Blood Component or Human Blood Plasma Product Transfusion, subsection J. Patient Education Concerning Transfusion Reactions stipulates the following, "1. The assigned caregiver will review with the patient the signs and symptoms of transfusion reactions and instruct them how to notify the nurse immediately if one occurs. 2. Record on the Transfusion Record that the patient verbalized an understanding of a transfusion reaction. If the patient is unable to verbalize an understanding of the signs and symptoms of a transfusion reaction, the nurse is to check the "NO" box and provide a reason why they cannot (example, Intubated)."

Patient #18 was admitted on February 10, 2014 with diagnoses to include: Hypertension, Metastatic Appendiceal Cancer, Bladder Cancer, and Gastroesophageal Reflux Disease (GERD).

Review of the medical record on February 12, 2014 at approximately 1:45 PM revealed the patient received two (2) units of Frozen Plasma on February 11, 2014. Further review of the Blood Product Transfusion Records revealed the transfusionist failed to document in Step 2 of the form titled Patient Education.

On February 11, 2014 at approximately 11:38 AM first unit of frozen plasma was released from the blood bank for Patient #18. The area designated on the Blood Product Transfusion Record for Patient Education was left blank. The form lacked documented evidence that patient education had been afforded to the patient.

Subsequently on February 11, 2014 at approximately 1:42 PM second unit of frozen plasma was released from the blood bank for Patient #18. The area designated on the Blood Product Transfusion Record for Patient Education was left blank. The form lacked documented evidence that patient education had been afforded to the patient.

The clinical staff failed to document patient education on the blood product transfusion record per the hospital policy.

A face-to-face interview was conducted on February 12, 2014 at approximately 2:00 PM with the Nurse Manager. He/she reviewed the documents referenced above and acknowledged the findings.

7. Based on medical record and policy review, as well as staff interview it was determined that the clinical staff failed to follow the hospital ' s policy related to documentation in the medical record related to telemetry strip interpretation and parental nutrition administration in three (3) of three (3) records reviewed (Patients 18, 19, & 20).

The findings include:

The Division of Nursing Clinical Standard #24 entitled Telemetry Monitoring for Non-ICU Adult Patients last reviewed and revised in 2014, under the subsection titled Standards of Care, F. Telemetry Strip Monitoring, stipulates, "1. Clinical nurses will interpret strips for their assigned patients Q[every] 4 hours and PRN [as needed]. "

The Division of Nursing Policy and Procedure #12 entitled Parenteral Nutrition last reviewed and revised in 2009 under Policy Statements stipulates, "1. Parenteral nutrition is a medication and an order is required. Always check the order sheet against the bag prior to administration and initial the bag. 2. Prior to administration, a registered nurse verifies contents of bag with order and signs order page."

A. Patient #18 was admitted on February 10, 2014 with diagnoses to include: Hypertension, Metastatic Appendiceal Cancer, Bladder Cancer, and Gastroesophageal Reflux Disease (GERD).

Medical record review on February 12, 2014 at approximately 2:20 PM revealed that on February 10, 2014 at approximately 3:37 AM, the physician entered an order for continuous cardiac monitoring for Patient #18 in the electronic medical record.

Further review of the medical record on February 12, 2014 at approximately 2:20 PM revealed the clinical staff failed to interpret the patient ' s telemetry strip every four (4) hours per the policy. On February 11, 2014 it was documented that the clinical staff retrieved the telemetry strip at 3:10 AM, the strip was not interpreted until 9:35 AM. An additional assessment was documented on February 11, 2014 at 12:10 PM; the patient ' s telemetry strip was not interpreted until 7:30 PM. There was no supporting documentation in the record indicating the reason for the clinical staff ' s delay in documenting on the patient's telemetry status.

The medical record lacked documented evidence that the clinical staff interpreted the telemetry strip according to the hospital policy.

The clinical staff failed to follow hospital policy related to telemetry interpretation documentation.

Face-to-face interview was conducted on February 12, 2014 at approximately 4:00 PM with the Nurse Manager. He/she reviewed the documents referenced above and acknowledged the findings.

B. Patient #19 was admitted February 6, 2014 with diagnoses to include: Type II Diabetes Mellitus, Deep Vein Thrombosis, Ventral Hernia, Hypertension and Morbid Obesity.

Medical record review on February 12, 2014 at approximately 3:20 PM revealed that on February 10, 2014 at 7:00 AM the physician completed a Parenteral Nutrition Order form for Patient #19. The electronic medical record contained documentation indicating that the Total Parenteral Nutrition was initiated by clinical staff on February 10, 2014 at 10:25 PM.

Subsequent review of the Nutrition Order page revealed the clinical staff failed to sign off on the order form that the bag had been verified by affixing his/her signature along with the date and time.

The medical record lack documented evidence that the clinical staff follow hospital policy related to verification of Nutrition Order related to Parenteral Nutrition.

A face-to-face interview was conducted on February 12, 2014 at approximately 4:00 PM with the Nurse Manager. He/she reviewed the documents referenced above and acknowledged the findings.

C. Patient #20 was admitted on February 10, 2014 for preoperative cardiac evaluation.

Review of the patient's medical record revealed telemetry strips were affixed to the Telemetry Flowsheet on February 12, 2014 during the following times: 7:13 AM, 1:29 PM and 3:29 PM.

The clinical staff documented on the telemetry strip from 7:13 AM indicating that the patient's cardiac functioning was irregular. The interpretation was documented as, "ST [segment] c [with] multifocal PVCs [Premature Ventricular Contractions]." The staff member circled the waveforms on the strip that were consistent with their interpretation.

The patient's telemetry strip was monitored six (6) hours later at 1:29 PM and again two (2) hours later at 3:29 PM, however the rate, regularity, and interpretation was left blank.

The clinical staff failed to document on the patient's telemetry strip every four (4) hours; they additionally failed to interpret the results of the monitoring as per the hospital ' s clinical standard.

A review of the policy was completed on February 19, 2014 at 2:00 PM.

A face-to-face interview was conducted on February 12, 2014 at approximately 4:00 PM with the Nurse Manager. He/she reviewed the documents referenced above and acknowledged the findings.

Based on medical record and policy review and staff interview, it was determined that the governing body failed to consistently provide and demonstrate administrative oversight to ensure that the clinical staff maintained compliance with the Plan of Correction (POC) from previous three (3) Licensure Surveys, most recent completed September 6, 2013. The clinical staff failed to adhere to the hospital ' s policy and the Medical Staff ' s Rules and Regulations related to the countersignature and authentication of telephone orders in two (2) of six (6) records reviewed (Patients # 21, 22).

The findings include:

MedStar Georgetown University Hospital Rules and Regulations of the Professional Staff, revised October 24, 2012, section entitled "Medical Records, Item 2.5.1 Telephone and Verbal Orders" stipulates "...A practitioner may issue telephone orders to a House Officer or, in the absence of a House Officer, a registered nurse or registered pharmacist per Policy# 109 Diagnostic and Therapeutic Orders. Verbal and Telephone orders should be signed as soon as possible ..."

A. Patient #21 was admitted on December 23, 2013 with diagnoses which included Acute Respiratory Distress, Altered Mental Status, Urinary Tract Infection, Acute Renal Failure and Elevated Liver Enzymes.

Medical record review on February 11, 2014 at approximately 3:20 PM revealed the following verbal/telephone orders transcribed by the nursing staff: January 8, 2014 at 5:30 PM, "Continue bags three (3) of three (3) ..., continue fluid replacement rate ...; January 13, 2014 at 8:00 AM, "Lower dialysis temperature to 35 degrees Celsius" .

The medical record lacked documented evidence of the authentication of the medical staff countersignature at the time of record review. The medical staff failed to adhere to the Rules and Regulations of the Medical Staff.

The governing body failed to ensure the medical staff adhered to the Plan of Correction to authenticate verbal/telephone orders.

The findings were discussed, reviewed and acknowledged by the hospital staff February 11, 2014 at approximately 3:20 PM at the time of record review.

The policy was reviewed on February 11, 2014 at approximately 4:00 PM.

B. Patient #22 was admitted January 27, 2014 with diagnoses which included Perforated Diverticular Disease, Status Post Exploratory Laparotomy, Colostomy, Loop Ileostomy, and History of Prostate Cancer.

Medical record review on February 11, 2014 at approximately 12:05 PM revealed the following verbal/telephone order transcribed by the nursing staff: January 29, 2014 at 5:30 PM, "Continue bags three (3) of three (3) ...

The medical record lacked documented evidence of the authentication of the medical staff countersignature at the time of record review. The medical staff failed to adhere to the Rules and Regulations of the Medical Staff.

The governing body failed to ensure the medical staff adhered to the Plan of Correction to authenticate verbal/telephone orders.

The findings were discussed, reviewed and acknowledged by the hospital staff February 11, 2014 at approximately 12:05 PM at the time of record review.

The policy was reviewed on February 11, 2014 at approximately 4:00 PM.

Based on the review of records and confirmation by staff interview conducted on February 12, 2014 and February 18, 2014 at approximately 1:00 PM and 3:30 PM respectively, the hospital failed to ensure that the patients' medical records included information regarding notification of the ordering physician/responsible party when laboratory tests were not done as ordered for two (2) of the sixteen (16) patients' laboratory test results randomly selected for review (Patients #89 and #91)

The findings include:

1. There was no documented evidence that attempts were made to notify Patient #89's physician and/or the patient's parents that the new born screening test was not performed due to the sample being unacceptable.

(a) According to the review of laboratory result for Patient #89, the New Born Screening test dated September 25, 2013 was not acceptable due to "Blood spots not soaked through to the back of the filter paper- unable to perform any testing. It is the responsibility of the submitter to obtain the repeat test for an insufficient sample."

(b) Further review of the Patient #89's medical record revealed that the patient was discharged on September 23, 2013.

(c) However, the Patient's medical record failed to provide documented evidence that a responsible party patient's pediatrician or parents were notified that the test was not performed.

2. There was no documented evidence that attempts were made to notify Patient #91's ordering physician/surgeon was notified that the pathology laboratory did not receive the left wrist mass, the sent on October 29, 2013 as detailed below:

(a) According to the review of Patient #91's medical record on October 29, 2013 the surgeon documented that "The mass was sent to pathology and also cultured." However, at the time of the survey there was no documented evidence in the patient's medical record that the patient's surgeon/or primary care physician were notified that the pathology laboratory did not receive the specimen and the test was not performed as ordered.

(b) Interview with the laboratory staff on February 18, 2014 at approximately 3:30 PM revealed that although a left wrist mass was received for culture no specimen or requisition slip was received for pathology for Patient #91 on October 29, 2013.

Interview with the hospital's quality improvement staff on February 12, 2014 at approximately 1:00 PM confirmed the lack of documentation in Patient's #89 and #91's charts to provide evidence that the ordering physician/responsible party were notified of the fact that the aforementioned tests were not performed as ordered.

Based on observations during the survey period it was determined that dietary services failed to ensure that specific food and dietetic requirements were met. These findings were observed in the presence of the Food Service Director.

The findings include:

1. The shelf surfaces of racks in the Milk Refrigerator were soiled and stained in three (3) of four (4) rack observations at 9:55 AM on February 11, 2014.

2. Foods such as breads and cucumbers were improperly disposed of in trash receptacles in the Salad and Cooks Preparation Areas of the Main Kitchen in two (2) of three (3) observations between 10:00 AM and 2:30 PM on February 11, 2014.

3. The interior surfaces of convection ovens in the Cooks Preparation Area were soiled with food spillages in three (3) of four (4) observations at 11:40 AM on February 11, 2014.

4. Drain pipes located under equipment in the Cooks Preparation Area were heavily soiled on the top surfaces with food and other debris. In addition, the inner surfaces of two (2) open drains and floor surfaces around the drains, steamer, deep fryers and the cooks work table were very soiled in six (6) of six (6) observations at approximately 1:30 PM on February 11, 2014.

5. Leftover foods such as cooked meats and other prepared foods were stored on sheet pans in the Leftover Food Box. The top tray was observed to be leaking and an unidentified liquid onto the trays below, potentially contaminating the trays below; staff immediately removed and discarded the potentially contaminated foods from the lower shelves. In addition, the frame surfaces of the food rack were soiled with food spillages in one (1) of one (1) observation at 12:45 PM on February 11, 2014.

6. During a test tray observation on the 7th Floor during Lunch Meal on February 11, 2014; it was determined Hot Foods were served below 140 degrees Fahrenheit and Cold Foods were served above 41 degrees Fahrenheit, which is in the Food Hazardous Temperature Zone, the following hot foods observations were made.

A. Hot Pureed Foods-Mashed Potatoes 114 degrees Fahrenheit, Turkey 111 degrees Fahrenheit, Green Peas 116 degrees, Tomatoes 139 degrees Fahrenheit and Apples 97 degrees Fahrenheit.

B. Cold Gluten Free Foods-Apple Juice 53 degrees Fahrenheit, Pears 48 degrees Fahrenheit, Cottage Cheese 53 degrees Fahrenheit.

C. Cold Veggie Diet-Salad with Cheese 52 degrees Fahrenheit, Dressing 64 degrees Fahrenheit and Tea 49 degrees Fahrenheit and Hot Veggie Foods-Tomato Soup 128 degrees Fahrenheit.

D. The 7th Floor Trays were not prepared in an expeditious manner, the first tray from the Tray Line was prepared at 1:00 PM and the last tray was prepared at 1:21 PM, before the cart was transported to the 7th Floor. The delay in preparing the trays potentially caused the hot foods to be below 140 degrees Fahrenheit and cold foods to be above 41 degrees Fahrenheit in one (1) of one (1) observation between 12:55 PM and 1:35 PM on February 11, 2014.

7. A staff person was observed removing clean plates from the dish machine and placing the clean plates on a cart and transporting the plates to the Plate Warmer in (1) of one (1) observation at 2:10 PM on February 11, 2014.

8. Through observation and interview, it was determined that silverware (Knives, Forks and Spoons) washed in the mechanical dishwasher were observed to be stained from the hard water. In addition staff were observed using a towel to remove hard water stains from the eating surfaces of silverware potential contaminating the washed silverware in three (3) of three (3) observations on February 11, 2014.

9. During the Pot and Pan wash observation, it was determined that sheet pans were not thoroughly cleaned of leftover food residue, as evidenced by leftover food in the corners and bottom surfaces of pans in seven (7) of 15 observations at 3:30 PM on February 11, 2014.

Based on observations during the survey period, it was determined the maintenance services were not adequate to maintain the hospital environment in a safe and sanitary manner.

The findings include:

The following findings were observed during a tour of the Physical Therapy Department on February 12, 2014 between 12:30 PM and 1:15 PM on February 12, 2014.

A. The lower frame surfaces of the stretcher were soiled with dust in Bays 5 and 6.

B. The Clean Linen Cart near Bay 7 was observed to be worn and in need of replacement.

C. The lower surfaces of three (3) stationary bikes and the Elliptical Machine were soiled dust on the lower surfaces.

D. The lower wall surfaces were observed to be damaged in Bay 2 and in the Storage/Tub Room.

E. The walking surfaces of Parallel Bars were marred and in need of refinishing and interior surfaces of exhaust vents were soiled with dust in the Pelvic Room.

2. The following findings were observed during a tour of the Morgue Areas on February 12, 2014 at 11:30 AM.

A. Hard water stains were observed on the top of stainless steel tables and work surfaces in the Autopsy Area.

B. Ceiling surfaces were observed to be damaged and stained from leaks near sprinkler heads.

3. The following findings were observed during a tour of the Respiratory Compressed Gas Storage Area on February 12, 2014 at approximately 11:50 AM.

A. Compressed gases stored in the Respiratory Gas Storage Room were not secured to prevent accidental tip over; as evidenced by chains loosely securing Oxygen and Nitrogen tanks.

B. Floor surfaces were very soiled with accumulated debris in the Respiratory Compressed Gas Storage Room.

4. The following were observed during a tour of the Emergency Department between 2:48 PM and 3:30 PM on February 12, 2014.

A. The toilet seat was not secured and moved back and forth when examined in the Male/Female Restroom.

B. Floor surfaces were damaged and uneven at the main entrance to the entrance to the Emergency Room which could potentially cause patients to trip or fall.

C. Floors were soiled and stained, wall surfaces were marred behind the bed in the Medication Room and the wall guard near the Medication Room was not secured.

D. The tray surfaces of the Ice Machine were soiled with mineral deposits and other debris.

E. The entrance door and door jamb surfaces were observed to be marred, the air supply vent louvers were observed to be soiled in Room 13.

F. Communication wires were observed to be comingled on floor surfaces under the Nurses Station.

B. Floor tiles were observed to be damaged at the entrance to the Emergency Room near the double doors.

C. Wall surfaces were observed to be damaged behind the stretcher headboard in Room 14.

D. Wall guards were observed to be loose and not secure near Room 14.

E. The tray surfaces of the Ice Machine were soiled with accumulated mineral deposits in the Break Room.

F. Door jamb surfaces were marred, wall surfaces were observed to be damaged and the overhead air supply vent was soiled with dust in Room 13.

G. Communication wires were observed to be comingled on floor surfaces under work counters and the bottom surfaces of chair foot rest in the Nurses Work Station were soiled.

H. The bottom surfaces of the Pyxis Machines near the Nurses Station were soiled with accumulated dust.

I. Floor and baseboard surfaces were soiled around the perimeter of Bay 8.

J. Wall surfaces were observed to be damaged in the Tank Room.

K. The lower shelves of the supply cart in the Soiled Utility Room were soiled and the inner areas of the sink were very soiled with debris.

L. Ceiling tiles were damaged and failed to fit into grids.

M. Wall surfaces were marred in Flex Area II and Flex Area III.

5. The following findings were observed during a tour of the Fourth Floor Surgical Intensive Care Unit at 3:56 PM on February 14, 2014.

A. The wall guard adjacent to the patients window was not secured, the hand sink was observed to be partially clogged when water faucets were turned on, the interior surfaces of exhausts vents and the horizontal surfaces of the patients bed frame were soiled with dust; the door jamb was observed to be marred in Room C4312.

B. The horizontal surfaces of the patients bed frame were soiled with dust in Room 9.

C. Door jamb surfaces were marred, exhaust vent surfaces were soiled with dust, the emergency outlet cover was not secured to the wall and the bottom shelf of the Pyxis was very soiled with dust in Room 4308A.

D. Door jamb surfaces were scarred and marred; the interior and exterior surfaces of exhaust vents were soiled with dust in Room 4315A.

6. The following findings were observed during a tour of the Small Core Area of the Operating Room at approximately 2:45 PM on February 14, 2014.

A. The frame surfaces of the C-Arm were soiled with dust, the fluid cabinet was soiled with finger prints; the entrance door and door jamb surfaces were marred in Room 2.

B. Wall surfaces were marred and damaged in the Small Core hallway.

C. The top surfaces of the Invasive Monitor and Anesthesia Machine was dusty and the base surfaces of the Intra Venous Pole and Anesthesia Machine were soiled with dust and spillages in Operating Room 4.

7. The following findings were observed during a tour of the Large Core Areas of the Operating Room on February 14, 2014 at approximately 2:30 PM.

A. Soiled debris was observed on stainless steel covers over the operating table in Room 7.

B. Door jamb surfaces were observed to be marred at the entrances to Rooms 6, 7 and 11.

8. The following findings were observed during a tour of the Post Anesthesia Care Unit on February 14, 2014 at 3:15 PM.

A. The horizontal surfaces of patient's stretchers were soiled with dust in Bays 6, 7, and 11.

B.The lower shelf surfaces of Pyxis Machines were soiled with dust in six (6) of 6 observations and floor surfaces were worn near

A. Sprinkler head surfaces were soiled with accumulated dust in the Scope Cleaning Area.

B. Floor surfaces were observed to be damaged, soiled and stained in Bays 2, 4, 8, 13, 14 and 15.
C. Privacy curtains were damaged and hooks were missing in Room 14.

D. The base surfaces of the Intravenous Pole were soiled with spillages Rooms 6 and 7.

E. The laminate covering on the outside of the Nurses Station was observed to be damaged.

8. The following findings were observed during a tour of the Radiology Department.

A. The entrance door and door jamb surfaces were marred and combination hoses were soiled with dust in ADAC Area.

B. The threshold strip located at the entrance to Room G2038 were missing and drapery hooks were missing.

C. Ceiling tile and wall surfaces were observed to be damaged and areas of the Siemens Fluoroscopy Machine were soiled with dust in the Fluoroscopy Room.

D. Wall surfaces were marred and damaged in X-Ray Room 14.

E. Baseboard and floor surfaces were soiled and damaged in the rear of the Computed Tomography Machine.

8. The following findings were observed during a tour of the Medical Intensive Care Unit at approximately 4:00 PM on February 14, 2013.

A. Entrance door surfaces were marred and the bottom surfaces of the patients Intravenous Pole was soiled with dust and spillages in Room 4201.

B. Entrance door surfaces were marred, the interior surfaces of exhaust vents were soiled with dust, floor surfaces under the cabinets and headboard were soiled with dust and the top and lens surfaces of the patient ' s lamp was soiled with dust in C4207.

C. The interior surfaces of exhaust vents were soiled with dust in Room C4210 and the bottom surfaces of the Pyxis Machine was soiled with accumulated dust in the hallway near C4212.

D. Entrance door surfaces were marred and damaged on the frontal surfaces, the interior surfaces of exhaust vents louvers were soiled with dust, the horizontal surfaces of the patient ' s bed was soiled with dust and ceiling tile surfaces were soiled with spillages in Room C4212.

9. The following findings were observed during a tour of the Dialysis Treatment Areas at approximately 2:15 PM on February 14, 2014.

A. During a tour of Dialysis Treatment Bays it was determined that staff failed to label bottles of Naturalyte Bicarbonate Solution before beginning Hemodialysis Treatments as described in the Policy and Procedure Manual in three (3) of four (4) observations.

10. The following findings were observed during a tour of the Labor and Delivery Areas between 11:25 AM and 12:10 PM on January 18, 2014.

A. Venetian blinds were observed to be damage and soiled in the patient ' s bathroom.

B. Floor and entrance door surfaces were marred in the Delivery Room.

C. Exhaust vents venetian blinds were soiled with dust and floor surfaces were marred in LDR3.

D. Chair armrest surfaces were worn and in need of refinishing, floor surfaces were marred, the base surfaces of Intravenous Pole were soiled and the closet/cabinet door knobs were loose and the entrance door surfaces were marred in LDR 4.

E. Entrance door surfaces were marred on the frontal and edge surfaces, the lower exhaust vent and filter were soiled with dust Operating Room II.

E. Ceiling surfaces were damaged in Operating Room I.

F. Door jamb surfaces were marred, chair armrest surfaces were worn and marred, the exhaust vent was soiled with dust in the patients bathroom, the backsplash area of the sink was in need of recaulking in LDR 7.

11. The following findings were observed during a tour of the Loading Dock, Materials Management and Receiving Department at approximately 9:45 AM on February 18, 2014.

A. Floor tiles were observed to be uneven and damaged in areas of the Loading Dock.

B. Several ceiling tiles were observed to be damaged and tiles were in need of replacement.

C. Floor surfaces were very worn and were in need of repainting in Materials Management ambulating areas.

12. The following findings were observed during a tour of the Sterile Processing Department at 10:14 AM on February 18, 2014.

A. Entrance doors to the Clean and Soiled sides were marred on the frontal surfaces, walls and floor surfaces were in need of repair around the perimeter of the Soiled Side.

Based on medical record, policy review and staff interview, it was determined that the respiratory staff failed to provide necessary respiratory treatments in one (1) of two (2) records reviewed (Patient #15).


The findings include:

MedStar Georgetown University Hospital Policy Number: 110 entitled "Reconciliation, Administering and Charting Medication " Reviewed April 28, 2010 and Revised November 29, 2010 stipulates "B. Aerosolized medication may be administered in accordance with established policies by a: 1. Registered Respiratory Therapist ...8. Registered Professional Nurse ... VII. Charting of Medication Administration ...E. If for any reason the scheduled medication is not administered, documentation: 1. in the scope of MedConnect will be done per MedConnect manual and will include the reason the medication is not administered. 2. In not in the scope of MedConnect, circle the initials next to the corresponding time block, reason for non-administration and any action taken will be documented on the allocated section of the Medication Administration Record.


Patient #15 was admitted on August 19, 2013 with diagnoses which include Lung Cancer with Bone Metastasis, Thyroid Cancer, Respiratory Failure, and Laryngeal Cancer.

Medical record review on February 12, 2014 at approximately 11:16 AM revealed a physician ' s order January 14, 2014 "Acetylcysteine nebulization treatment 1 milliliter every 6 hours and Duoneb nebulizer treatment one (1) unit dose every six (6) hours" .

The Electronic Medication Administration Record revealed that February 8, 2014 at 1:30 PM Acetylcysteine was not administered "med not available"; February 9, 2014 at 11:00 PM Acetylcysteine was not administered "no to time available"; February 9, 2014 at 11:00 PM Duoneb was not administered "no time to available" ; and February 10, 2014 at 5:00 AM Acetylcysteine was not administered "no to time available" .



Interview with Director of Respiratory Services and Respiratory Therapist on February 12, 2014 at approximately 3:15 PM revealed respiratory therapy is responsible for the administration of nebulization treatments. If the medication is unavailable, the respiratory therapist will request a medication refill through the computerized system in the Electronic Medication Administration Record and notify the nurse. Once the medication is delivered, the respiratory therapist will return to administer the nebulization treatment.


Interview with the Nurse Manager on February 12, 2014 at approximately 4:00 PM revealed that the nursing staff does not administer aerosolized medications. The nursing staff notifies the respiratory therapist when the medication becomes available.



The medical record lacked documented evidence that the respiratory staff notify the pharmacy and/or the nurse responsible for Patient #15. Additionally, the medical record lacked documented evidence that the medical staff was notified of the inability to administer the aerosolized medication according to physician's order.


Further review of the medical record on February 12, 2014 at 4:00 PM revealed that January 4, 2014 a physician's order "Chest Physiotherapy every six (6) hours". For period beginning February 4, 2014 through February 12, 2014, chest physiotherapy was documented as administered for February 4, 5, and 6, 2014 according to physician's order. The other dates lacked documented evidence that the clinical staff followed the physician's order and/or a reason for the omission.


The medical record lacked documented evidence that chest physiotherapy was provided according to the physician's order.



The respiratory staff failed to follow the physician's order relative to aerosolized nebulizer treatments and chest physiotherapy.



The findings were reviewed, discussed and acknowledged by the Director of Respiratory Services, Respiratory Therapist, Staff Nurse, and Nursing Administration on February 12, 2014 at approximately 4:00 PM at the time of record review.

The policy was reviewed on February 12, 2014 at approximately 4:30 PM.