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Based on record review, policy review, review of state and local laws, and staff interview, the governing body failed to ensure that a Licensed Graduate Social Worker (LGSW) met standards required by state and local law as evidenced by acting in the capacity of a Social Worker without appropriate supervision from a Licensed Independent Social Worker or a Licensed Independent Clinical Social Worker in one of one medical record reviewed (Patient #1).


Findings included ...


The "Health Occupations Revision Act of 2009" last revised 06/2015, Subchapter VIII. Categories and Qualification of Social Workers, showed that an LGSW may perform any function described as the practice of social work under the supervision of a social worker licensed under § 3-12080.3 Licensed Independent Social Worker (LISW) or §3-1208.04 Licensed Independent Clinical Social Worker (LICSW).


The George Washington University Hospital Standard Practice for Case Management, entitled, "Discharge Planning - Initial Assessment and Documentation" last reviewed 04/2017 showed, " ...A patient choice letter will be presented to the patient and/or appropriate decision makers. A signed copy will be placed in the medical record with a patient identifier (label) ..."


The George Washington University Hospital policy entitled "Discharge Planning" Effective 03/2013, showed that Case Management staff will conduct a baseline assessment of things including functional status, cognition, and family support.


Patient #1 was admitted on 05/22/19 for complaint of lower extremity edema and redness. Review of the physician documentation from the Emergency Department (ED) dated 05/22/19 at 3:15 PM, showed that the patient had a past medical history of Cellulitis. Additionally, the physician noted that Patient #1 was a poor historian with a history of cognitive decline who presented to the ED with her aid.


Review of the history and physical dated 05/23/19 at 1:00 AM showed that the patient had "poor memory" and noticed increased in pain and swelling in her legs about a week prior. " ...She doesn't think she was given antibiotics for it, but she is not sure because she has a [Home Health Aid] who just gives her medications ...Patient is wheelchair bound at baseline ..." The physician goes on to write "As previously mentioned, patient is poor historian and is not certain of her medications, allergies, but does report that multiple medications cause her to have a bad reaction ...Patient is very concerned about allergy list and wants to confirm with her sister, but would like not to call in the middle of the night ..."


Review of the Occupational Therapy (OT) Evaluation dated 05/23/19 at 3:22 PM, showed that Patient #1 reported living alone with Home Health Aid (HHA) services seven days a week to assist with Activities of Daily Living (ADL's). According to the OT, Patient #1 has a sister and a niece who are involved. Patient #1 has a psychiatric history for which she is being followed; however, she is uncertain of the medications and reports that her aids provide medication management. The OT recommendations are "Home[with] resumed HHA services."


Review of the Physical Therapy (PT) Evaluation completed on 05/23/19 at 4:22 PM showed that Patient #1 was a poor historian who lived by herself with HHA services seven days a week to assist with ADL's. The patient also stated that she had helpers " ...but was unable to tell the therapist how they help ..." PT recommendations were "Home with resumption of HHA."


Review of the Discharge Planning Assessment completed on 05/24/19 at 4:02 PM listed Emergency Contact information, Patient #1's sister and niece were listed. The case management note completed by Employee #1, Social Work Case Manager, showed that the patient was ready for discharge per the attending physician, and was recommended for home health. Employee #1 documented that Patient #1 had no prior history of a HHA, and had no preference for a home health agency. Employee #1 referred Patient #1 to a different home health agency than the one prior to discharge, and arranged for a wheelchair van to transport the patient home at 5:00 PM on that day.


The surveyor conducted a telephone interview on 09/01/19 at 9:19 AM with Family Member #1 regarding her complaint about Patient #1's discharge. She stated that she called the hospital on 05/24/19 and was told that her Aunt had been discharged home. She said that Patient #1 received home care services prior to being admitted to the hospital. She went on to say that Patient #1 was discharged without notification to the home care agency for resumption of care. Additionally, Family Member #1 stated that she had to call the home care agency to resume care, and that no one contacted her when her Aunt was discharged. Her concern was that Patient #1 has a very poor memory and requires assistance with most tasks. Family Member #1 stated that Patient #1 did not remember receiving discharge instructions, and did not remember receiving a prescription for home medications. According to Family Member #1, the paper prescription for an antibiotic was found in Patient #1's bag about a week later.


The surveyor conducted a telephone interview on 09/03/19 at 11:11 AM with Employee #1, Social Worker, regarding the discharge assessment and plan for Patient #1. Employee #1 stated that she has been employed at the hospital since 09/2018, and she is credentialed as an LGSW. When asked if she reviewed the patient's chart prior to discharging the patient, she stated that she did not. She said that when she spoke to the patient on the day of discharge, she was alert and oriented. She said that Patient #1 did not have an emergency contact listed and expressed no preference for a Home Health Agency. When asked if she presented the patient with a choice of agencies, she stated that the patient did not ask for one. When Employee #1 was asked about the level of supervision she received from an LISW she stated that she did not receive any supervision because she was acting in the capacity of a case manager working independently. Review of the signed job description for Employee #1 shows that her job title is Social Worker.


The surveyor conducted a telephone interview on 09/03/19 at 11:51 AM with Employee #2, Social Work Manager, regarding the documented supervision for LGSW; she stated that the LGSW's do not require supervision for the role of a Case Manager.


The surveyor reviewed a list of social work staff at the hospital, there are a total of 12 social workers with the designations LGSW, including Employee #2, Social Work Manager.


The surveyor conducted a telephone interview on 09/04/19 at 11:13 AM with Employee #3, Director of Case Management regarding the supervision of LGSW's. She stated that she was unaware that LGSW's required supervision from a Licensed Independent Social Worker of a Licensed Independent Clinical Social Worker. She acknowledged the findings at the time of the interview.

Based on record review and staff interview, nursing staff failed administer an antibiotic, in accordance with a physician order, in one of one medical record reviewed (Patient #1).


Findings included ...


Patient #1 was admitted on 05/22/19 for complaint of lower extremity edema and redness. Review of the physician documentation from the Emergency Department (ED) dated 05/22/19 at 3:15 PM, showed that the patient had a past medical history of Cellulitis. Additionally, the physician noted that Patient #1 was a poor historian with a history of cognitive decline who presented to the ED with her aid.


Review of physician orders showed an order dated 05/24/19 at 3:52 PM for Bactrim (Antibiotic), first dose stat (immediately). Review of the medication administration record showed that the stat dose was not administered to Patient #1.


Review of a nursing noted dated 05/24/19 at 8:09 PM completed by Employee #4, Registered Nurse, showed Patient #1, " ...was started on antibiotics and was told by [Physician Assistant] to give [patient] and extra dose of Bactrim and [patient] was not given by the nurse prior to leaving. We try to contact [patient] to notify but the phone number she left was not working. [Physician Assistant] was made aware ..."


The surveyor conducted a telephone interview on 09/05/19 at 8:45 AM with Employee #5, Registered Nurse, regarding the stat Bactrim order for Patient #1. She stated that at the time of Patient #1's admission, she was on orientation and was being trained by Employee #4. Employee #5 said that on the day of Patient #1's discharge, the physician's assistant wrote a stat order for Bactrim. They were waiting for the pharmacy to clarify the order when ambulance transport arrived to take the patient home. Patient #1 was discharged without receiving the medication.


The surveyor conducted a telephone interview on 09/05/19 at 10:41 AM with Employee #4 regarding the missed dose of medication for Patient #1. She also stated that while waiting for the pharmacy to clarify the medication order, ambulance transport came and took the patient. When asked if the physician was notified, she stated that she tried to notify the physician's assistant but could not get in touch with her.


The surveyor conducted a telephone interview on 09/05/19 at 11:30 AM with Employee #6, Interim Manager of Quality and Accreditation. She acknowledged the findings.

Based on record review, policy review, family and staff interview, social work staff failed to ensure that the discharge plan was discussed with designated care giver, for a patient with documented cognitive decline and memory issues in one of one medical record reviewed (Patient #1).


Findings included ...


The George Washington University Hospital policy entitled "Discharge Planning" Effective 03/2013, showed that Case Management staff will conduct a baseline assessment of things including functional status, cognition, and family support.


Patient #1 was admitted on 05/22/19 for complaint of lower extremity edema and redness. Review of the physician documentation from the Emergency Department dated 05/22/19 at 3:15 PM showed that the patient had a past medical history of Cellulitis. Additionally, the physician noted that Patient #1 was a poor historian with a history of cognitive decline who presented to the ED with her aid.


Review of the history and physical dated 05/23/19 at 1:00 AM showed that the patient had "poor memory" and noticed increased in pain and swelling in her legs about a week prior. " ...She doesn't think she was given antibiotics for it, but she is not sure because she has a [Home Health Aid] who just gives her medications ...Patient is wheelchair bound at baseline ..." The physician goes on to write "As previously mentioned, patient is poor historian and is not certain of her medications, allergies, but does report that multiple medications cause her to have a bad reaction ...Patient is very concerned about allergy list and wants to confirm with her sister, but would like not to call in the middle of the night ..."


The surveyor conducted a telephone interview on 09/01/19 at 9:19 AM with Family Member #1 regarding her complaint about Patient #1's discharge. She stated that she called the hospital on 05/24/19 and was told that her Aunt had been discharged home. She said that Patient #1 received home care services prior to being admitted to the hospital. She went on to say that Patient #1 was discharged without notification to the home care agency for resumption of care. Additionally Family Member #1 stated that she had to call the home care agency to resume care, and that no one contacted her when her Aunt was discharged. Her concern was that Patient #1 has a very poor memory and requires assistance with most tasks that she has to perform. Family Member #1 stated that Patient #1 did not remember receiving discharge instructions, and did not remember receiving a prescription for home medications.


The surveyor conducted a telephone interview on 09/03/19 at 11:11 with Employee #1, Social Worker regarding the discharge assessment and plan for Patient #1. When asked if she reviewed the patient's chart prior to discharging the patient, she stated that she had not. She said that when she spoke to the patient on the day of discharge, she was alert and oriented. She said that Patient #1 did not have an emergency contact listed and expressed no preference for a HHA. When asked if she presented the patient with a choice of agencies, she stated that the patient did not ask for one. Employee #1 was asked if she attempted to make contact with


Review of the Discharge Planning Assessment, completed by Employee #1, on 05/24/19 at 4:03 PM showed a section displaying contact information details. The emergency contacts are listed as Patient #1's sister and niece. The form also displayed a question asking if Patient #1 would like to designate a caregiver, Patient #1 responded yes. The patient's sister and niece are listed as the caregivers and the support contact. The form was signed and acknowledged by Employee #1.


The surveyor conducted a telephone interview on 09/03/19 at 11:51 AM with Employee #2, Social Work Manager, she acknowledged the findings.

Based on record review, policy review and staff interview, social work staff failed to ensure a patient was provided a list of Home Health Agencies (HHA) available, as part of a discharge plan that included referral to a home health agency, in one of one medical record reviewed (Patient #1).


Findings included ...


The George Washington University Hospital Standard Practice for Case Management, entitled, "Discharge Planning - Initial Assessment and Documentation" last reviewed 04/2017 showed,, " ...A patient choice letter will be presented to the patient and/or appropriate decision makers. A signed copy will be placed in the medical record with a patient identifier (label) ..."


Patient #1 was admitted on 05/22/19 for complaint of lower extremity edema and redness. Review of the physician documentation from the Emergency Department dated 05/22/19 at 3:15 PM showed that the patient had a past medical history of Cellulitis. Additionally, the physician noted that Patient #1 was a poor historian with a history of cognitive decline who presented to the ED with her aid.


Review of the history and physical dated 05/23/19 at 1:00 AM showed that the patient had "poor memory" and noticed increased in pain and swelling in her legs about a week prior. " ...She doesn't think she was given antibiotics for it, but she is not sure because she has a [Home Health Aid] who just gives her medications ...Patient is wheelchair bound at baseline ..." The physician goes on to write "As previously mentioned, patient is poor historian and is not certain of her medications, allergies, but does report that multiple medications cause her to have a bad reaction ...Patient is very concerned about allergy list and wants to confirm with her sister, but would like not to call in the middle of the night ..."


Review of the Discharge Planning Assessment completed on 05/24/19 at 4:02 PM showed listed Emergency Contact information, Patient #1's sister and niece were listed. The anticipated discharge date was listed at 05/27/19 with anticipated discharge listed as home independently. The case management note completed by Employee #1, Social Work Case Manager, showed that the patient was ready for discharge per the attending physician, and was recommended for home health. Employee #1 documented that Patient #1 had no prior history of a home health aid, and had no preference for a home health agency. Employee #1 referred Patient #1 to a home health agency and arranged for a wheelchair van to pick to transport the patient home at 5:00 PM.


The surveyor conducted a telephone interview on 09/01/19 at 9:19 AM with Family Member #1 regarding her complaint about Patient #1's discharge. She stated that she called the hospital on 05/24/19 and was told that her Aunt had been discharged home. She said that Patient #1 received home care services prior to being admitted to the hospital. She went on to say that Patient #1 was discharged without notification to the home care agency for resumption of care. Additionally Family Member #1 stated that she had to call the home care agency to resume care, and that no one contacted her when her Aunt was discharged. Her concern was that Patient #1 has a very poor memory and requires assistance with most tasks that she has to perform. Family Member #1 stated that Patient #1 did not remember receiving discharge instructions, and did not remember receiving a prescription for home medications.


The surveyor conducted a telephone interview on 09/03/19 at 11:11AM with Employee #1, Social Worker regarding the discharge assessment and plan for Patient #1. Employee #1 stated that she has been employed at the hospital since 09/2018, her credentials are as a Licensed Graduate Social Worker. When asked if she reviewed the patient's chart prior to discharging the patient, she stated that she had not. She said that when she spoke to the patient on the day of discharge, she was alert and oriented. She said that Patient #1 did not have an emergency contact listed, and expressed no preference for a HHA. When asked if she presented the patient with a choice of agencies, she stated that the patient did not ask for one.


The surveyor conducted a telephone interview on 09/04/19 at 11:13 AM with Employee #3, Director of Case Management. She acknowledged the findings at the time of the interview.