HospitalInspections.org

1. Based on review of medical records, hospital polices, and staff interviews, it was determined that the Governing Body failed to establish policies and procedures to assure how a patient's right to consent to treatment would be addressed or obtained in three (3) of 11 records reviewed.


The findings include:


A. Patient #1 was admitted with a history of Schizophrenia and diagnoses that included Drug-Induced Delirium and Strangulated Bowel, for which he underwent an Exploratory Laparotomy with Resection of Ileum, Cecum and Right Colon; resulting in an Ileostomy/ Jejunostomy.


On September 1, 2016 at approximately 4:20 PM, review of the medical record revealed the following:


The 'Pre-Admission Screening' performed by Employee #7 dated August 31, 2016 at 5:44PM indicated the patent was "Alert/Confused."


The patient's transfer form from United Medical center dated August 31, 2016 (no time documented), under 'Psycho-social Information' revealed the patient was "confused," and needed assistance with Activities of Daily Living (ADLs)/Mobility/Transfer.


The admission database revealed the patient was admitted on August 31, 2016 at 8:15 PM. The nursing note on the admission database dated September 1, 2016 at 3:00 AM revealed the patient was alert and oriented to person and place, sometimes to time, and had periods of confusion.


The medical record lacked documented evidence of verbal consent or written consent for transfer or treatment.


On September 1, 2016 at 4:39 PM, a telephone interview was conducted with Employee #7, in the presence of Employee #2. When asked about the patient's orientation status, Employee #7 stated, the patient was "Alert but his orientation was questionable. He knew his name and that he was in the hospital. He was unaware of the date and time ..."


When queried about the process to obtain consent for treatment. Employee #7 explained that the Clinical Liaisons (CL's) get the patient's verbal consent to transfer and the written consent is obtained when the patient is admitted. When asked how consent was obtained on the confused patient, Employee #7 explained s/he obtained a verbal consent from the patient, "I had to repeat the statement about three times ..." When asked if family was contacted for consent, he replied, "I did not speak to the family ..."


Employee #2 reviewed the record and explained that the hospital policy allows the facility 24 hours to obtain consent for treatment; however, she could not produce the policy, for review.


There was no evidence that Patient #1 or his/ her representative was provided the right to make informed decisions about his/her transfer to BridgePoint National Harbor Hospital (Long-term Acute Care, LTACH).


Employees #2 acknowledged the findings.


B. Patient #2 was admitted with diagnoses that included Endocarditis and Osteomyelitis of the Left Foot.


On September 2, 2016 at approximately 2:25 PM, review of the medical record revealed the patient was admitted to BridgePoint National Harbor Hospital (Long-term Acute Care, LTACH) on August 26, 2016.


The patient was alert and oriented to person and place, sometimes to time. Further review of the record revealed the patient has been receiving treatment at the hospital for seven (7) days, without evidence of consent for treatment.


On September 2, 2016 at approximately 2:35 PM, Employees #2 and 4 were asked to provide the patient's consent for treatment. Neither Employee could provide the consent.


The record lacked evidence of a written consent for treatment at BridgePoint National Harbor Hospital (Long-term Acute Care, LTACH).


Employees #2 and 4 acknowledged the findings.


C. Patient #3 was admitted with diagnoses that included Acute Hypercapnia and Schizophrenia.


On September 2, 2016 at approximately 4:10 PM, review of the medical record revealed the patient was admitted to BridgePoint National Harbor Hospital (Long-term Acute Care, LTACH) on August 18, 2016.


The patient was alert with occasions of disorientation to place and time. Further review of the record revealed the patient has been receiving treatment at the hospital for 15 days, without evidence of consent for treatment.


On September 2, 2016 at approximately 4:20 PM, Employees #2 and 4 were asked to provide the patient's consent for treatment. Neither Employee could provide the consent. Employee #2 explained the facility has made numerous attempts to contact the patient's family to obtain consent, with no avail.


The record lacked evidence of a written consent for treatment at BridgePoint National Harbor Hospital (Long-term Acute Care, LTACH).


Employees #2 and 4 acknowledged the findings.



2. Based on review of medical records, hospital polices, human resource and education files, and staff interviews, it was determined that the Governing Body failed to ensure the Clinical Liaisons (CL's) were trained in InteQual Level of Care Criteria to determine appropriateness for Long-term Acute Hospital (LTACH) admission, as per the 'Patient Admissions' policy.


The findings include:


The BridgePoint Hospital policy titled, 'Patient Admissions,' effective December 2014 stipulates ... "POLICY... 2. A clinical assessment shall be performed on all patients referred for admission to BridgePoint Hospital to determine appropriateness for Long-term Acute Hospital (LTACH) admission based on Inter-Qual criteria for LTACH ...PROCEDURE...2. The assigned Clinical Liaison is responsible to obtain pertinent clinical information on the patient to determine appropriateness for transfer to LTACH ...4. Upon the approval of transfer based on the Clinical Liaison's assessment for appropriateness of transfer, and verification of insurance eligibility, the admission process is initiated ..."


The BridgePoint Hospital's 'InteQual Level of Care Criteria 2012' stipulates ... "LEVEL OF CARE REVIEW TYPES Preadmission Review - Performed only for a planned admission to a level of care to determine the appropriateness of an admission. Reviews are completed using Severity of Illness Criteria (SI) only ...Preadmission Review Steps 1. Identify the level of care based on the patient's current or proposed level. 2. Select the appropriate subset based on the patient's predominant presenting clinical findings. 3. Obtain and review patient specific clinical information (e.g., history, physical, laboratory, imaging, ECG finding, progress notes, and medical practitioner orders). 4. Apply the SI rule by selecting the SI criteria based on clinical findings ..."


The BridgePoint Hospital policy # B.10.0, titled, 'Nursing Documentation-Nursing Flow Sheet,' effective December 2014 stipulates ... "POLICY 9. All information recorded is to be factual and accurate ..."


According to DCMR, title 17, section 5514.3, "The practice of practical nursing shall include the following ...(a) Participating in the performance of the ongoing comprehensive nursing assessment process of the client's biological, physiological, and behavioral health, including the client's reaction to an illness, injury, and treatment regimens by collecting data and performing focused nursing assessments; (b) Recording and reporting the findings and results of the ongoing nursing assessment process ..."


Patient #1 was admitted with a history of Schizophrenia and diagnoses that included Drug-Induced Delirium and Strangulated Bowel, for which he underwent an Exploratory Laparotomy with Resection of Ileum, Cecum and Right Colon; resulting in an Ileostomy/ Jejunostomy.


On September 1, 2016 at approximately 4:20 PM, review of the medical record revealed the following:


The Consultation for 'Psychiatric Evaluation' revealed dated August 29, 2016 at 3:10 PM revealed the patient had prior hospitalizations at a Behavioral Health Hospital and was linked with outpatient treatment. The recommendations were to continue Risperdal, discontinue Seroquel, and continue Haldol (as needed). Additional recommendation included continuing a sitter for the patient, "given the Pt. [patient] has limited insight into his medical condition and need for further inpatient treatment."


The Medication Administration Record from the transferring hospital revealed the patient's last dose of Seroquel was on August 29, 2016 at 10:04 PM.


The 'Pre-Admission Screening' performed by Employee #7 dated August 31, 2016 at 5:44PM indicated the patent was "Alert/Confused and had a history of Schizophrenia." The documentation also revealed the patient had a "PICC [Peripherally Inserted Central Catheter], and was dependent for eating, oral hygiene, toileting, wash upper body, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair to bed, toilet transfer and ambulation."


The patient's transfer form from United Medical center dated August 31, 2016 (no time documented), under 'Psycho-social Information' revealed the patient was "confused," and needed assistance with Activities of Daily Living (ADLs)/Mobility/Transfer.


The 'Physician Inpatient Progress Note' dated August 31, 2016 at 11:59 PM revealed the Patient had a left Internal Jugular Central line. The admission database performed by Employee #8 on August 31, 2016 at 8:15 PM revealed the patient had a left triple lumen Internal Jugular catheter (central line); was independent with ambulation, feeding, and toileting; and required assistance with dressing meal preparation, and bathing. The nursing note on the admission database dated September 1, 2016 at 3:00 AM revealed the patient was alert and oriented to person and place, sometimes to time, and had periods of confusion.


Further review of the medical record revealed that on September 1, 2016 at approximately 5:30 PM, Patient #1 was found face down on the floor, unresponsive with scissors in his/her right hand, a code blue was called, and cardiopulmonary resuscitation (CPR) was performed, with no success. During the code, it was noticed that the patient's left triple lumen Internal Jugular catheter was cut down to the hub and pieces of lumen were later found on the sink, in the patient's room.


The findings/assessment on the 'Pre-Admission Screening,' performed by Employee #7 lacked evidence to reflect an accurate patient status was documented. Additionally, the
'Pre-Admission Screening' lacked documented evidence of a psychiatric consult and/or recommendations. There was no evidence that Employee #7 followed the hospital's policy to ensure factual and accurate information was documented.


On September 1, 2016 at 4:39 PM, a telephone interview was conducted with Employee
#7, in the presence of Employee #2. Employee #7 was asked to explain his/her title, responsibilities, and interaction with Patient #1. Employee #7 explained that he was the Director of Business Development, was a licensed practical nurse (LPN), and his responsibilities included supervising the Clinical Liaison team, which included registered nurses (RNs), licensed practical nurses (LPNs), and respiratory therapists. S/he continued explaining that he performed a clinical assessment on Patient #1 for admission to LTACH and explained s/he obtained a verbal consent from the patient to transfer to BridgePoint National Harbor Hospital. When queried about the psychiatric consult, Employee #7 replied, "I did not see that documented on the chart." When queried about the District of Columbia Municipal Regulation for LPN scope of practice relative to performing initial assessments, Employee #7 stated that s/he is unaware that the regulation prohibits LPNs from performing an initial clinical assessment on patients.


The medical record lacked evidence that Employee #7 documented an accurate and appropriate clinical assessment to reflect the patient's clinical status.


Employee #2 shared that the CL's were performing 'Pre-Admission Screenings,' not clinical assessments. She was asked to provide the clinical assessment, which each patient is to have performed, as per policy. She could not provide the requested documentation. She was also asked to provide documentation to show the CL's had 'InteQual Level of Care Criteria' training. She could not provide the requested documentation.


On September 7, 2016 at 4:03 PM, a telephone interview was conducted with Ms. Employee #6, who was asked to provide the InteQual Level of Care Criteria training or have evidence that CL's had the training. Employee #6 shared that s/he does not provide the training and it is departmental specific.


There was no evidence that Employee #7 or the CL's were trained to perform clinical assessments to determine the patient's appropriateness for admission to LTACH and plan of care.


Employee #2 acknowledged the findings.



3. Based on medical record review, review of the District of Columbia Municipal Regulations (DCMR) for licensed practical nurses (LPNs), hospital polices, and staff interviews, it was determined that the Governing Body failed to ensure that staff followed the 'Patient Admissions' policy.


The findings include:


The BridgePoint Hospital policy titled, 'Patient Admissions,' effective December 2014 stipulates ... "POLICY... 2. A clinical assessment shall be performed on all patients referred for admission to BridgePoint Hospital to determine appropriateness for Long-term Acute Hospital (LTACH) admission based on Inter-Qual criteria for LTACH ...PROCEDURE...2. The assigned Clinical Liaison is responsible to obtain pertinent clinical information on the patient to determine appropriateness for transfer to LTACH ...4. Upon the approval of transfer based on the Clinical Liaison's assessment for appropriateness of transfer, and verification of insurance eligibility, the admission process is initiated ..."


The BridgePoint Hospital's 'InteQual Level of Care Criteria 2012' stipulates ... "LEVEL OF CARE REVIEW TYPES Preadmission Review - Performed only for a planned admission to a level of care to determine the appropriateness of an admission. Reviews are completed using Severity of Illness Criteria (SI) only ...Preadmission Review Steps 1. Identify the level of care based on the patient's current or proposed level. 2. Select the appropriate subset based on the patient's predominant presenting clinical findings. 3. Obtain and review patient specific clinical information (e.g., history, physical, laboratory, imaging, ECG finding, progress notes, and medical practitioner orders). 4. Apply the SI rule by selecting the SI criteria based on clinical findings ..."


Patient #1 was admitted with a history of Schizophrenia and diagnoses that included Drug-Induced Delirium and Strangulated Bowel, for which he underwent an Exploratory Laparotomy with Resection of Ileum, Cecum and Right Colon; resulting in an Ileostomy/ Jejunostomy.


On September 1, 2016 at approximately 4:20 PM, review of the medical record revealed the following:


The Consultation for 'Psychiatric Evaluation' revealed dated August 29, 2016 at 3:10 PM revealed the patient had prior hospitalizations at a Behavioral Health Hospital and was linked with outpatient treatment. The recommendations were to continue Risperdal, discontinue Seroquel, and continue Haldol (as needed). Additional recommendation included continuing a sitter for the patient, "given the Pt. [patient] has limited insight into his medical condition and need for further inpatient treatment."


The Medication Administration Record from the transferring hospital revealed the patient's last dose of Seroquel was on August 29, 2016 at 10:04 PM.


The 'Pre-Admission Screening' performed by Employee #7 dated August 31, 2016 at 5:44PM indicated the patent was "Alert/Confused and had a history of Schizophrenia." The documentation also revealed the patient had a " PICC [Peripherally Inserted Central Catheter], and was dependent for eating, oral hygiene, toileting, wash upper body, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair to bed, toilet transfer and ambulation."


The patient's transfer form from United Medical center dated August 31, 2016 (no time documented), under 'Psycho-social Information' revealed the patient was "confused," and needed assistance with Activities of Daily Living (ADLs)/Mobility/Transfer.


The 'Physician Inpatient Progress Note' dated August 31, 2016 at 11:59 PM revealed the Patient had a left Internal Jugular Central line. The admission database performed by Employee #8 on August 31, 2016 at 8:15 PM revealed the patient had a left triple lumen Internal Jugular catheter (central line); was independent with ambulation, feeding, and toileting; and required assistance with dressing meal preparation, and bathing. The nursing note on the admission database dated September 1, 2016 at 3:00 AM revealed the patient was alert and oriented to person and place, sometimes to time, and had periods of confusion.


Further review of the medical record revealed that on September 1, 2016 at approximately 5:30 PM, Patient #1 was found face down on the floor, unresponsive with scissors in his/her right hand, a code blue was called, and cardiopulmonary resuscitation (CPR) was performed, with no success. During the code, it was noticed that the patient's left triple lumen Internal Jugular catheter was cut down to the hub and pieces of lumen were later found on the sink, in the patient's room.


The findings/assessment on the 'Pre-Admission Screening,' performed by Employee #7 lacked evidence to reflect an accurate patient status was documented. Additionally, the
'Pre-Admission Screening' lacked documented evidence of a psychiatric consult and/or recommendations. There was no evidence that Employee #7 followed the hospital's policy to ensure factual and accurate information was documented.


On September 1, 2016 at 4:39 PM, a telephone interview was conducted with Employee
#7, in the presence of Employee #2. Employee #7 was asked to explain his/her title, responsibilities, and interaction with Patient #1. Employee #7 explained that he was the Director of Business Development, was a licensed practical nurse (LPN), and his responsibilities included supervising the Clinical Liaison team, which included registered nurses (RNs), licensed practical nurses (LPNs), and respiratory therapists. S/he continued explaining that he performed a clinical assessment on Patient #1 for admission to LTACH and explained s/he obtained a verbal consent from the patient to transfer to BridgePoint National Harbor Hospital. When queried about the psychiatric consult, Employee #7 replied, "I did not see that documented on the chart." When queried about the District of Columbia Municipal Regulation for LPN scope of practice relative to performing initial assessments, Employee #7 stated that s/he is unaware that the regulation prohibits LPNs from performing an initial clinical assessment on patients.


The medical record lacked evidence that Employee #7 documented an accurate and appropriate clinical assessment to reflect the patient's clinical status.


Employee #2 shared that the CL's were performing 'Pre-Admission Screenings,' not clinical assessments. She was asked to provide the clinical assessment, which each patient is to have performed, as per policy. She could not provide the requested documentation. She was also asked to provide documentation to show the CL's had 'InteQual Level of Care Criteria' training. She could not provide the requested documentation.


On September 7, 2016 at 4:03 PM, a telephone interview was conducted with Ms. Employee #6, who was asked to provide the InteQual Level of Care Criteria training or have evidence that CL's had the training. Employee #6 shared that s/he does not provide the training and it is departmental specific.


There was no evidence that Employee #7 or the CL's were trained to perform clinical assessments to determine the patient's appropriateness for admission to LTACH and plan of care.


There was no evidence the Governing Body assured a clinical assessment was performed by a CL and that the CL obtained pertinent clinical information on the patient, based on LTACH criteria.


Employee #2 acknowledged the findings.



4. Based on medical record review, review of the District of Columbia Municipal Regulations (DCMR) for licensed practical nurses (LPNs), hospital polices, and staff interviews, it was determined that the Governing Body failed to ensure compliance to state and local laws relative to LPNs performing initial assessments in the District of Columbia.


The findings include:


The BridgePoint Hospital policy titled, 'Patient Admissions,' effective December 2014 stipulates ... "POLICY... 2. A clinical assessment shall be performed on all patients referred for admission to BridgePoint Hospital to determine appropriateness for Long-term Acute Hospital (LTACH) admission based on Inter-Qual criteria for LTACH ...PROCEDURE...2. The assigned Clinical Liaison is responsible to obtain pertinent clinical information on the patient to determine appropriateness for transfer to LTACH ...4. Upon the approval of transfer based on the Clinical Liaison's assessment for appropriateness of transfer, and verification of insurance eligibility, the admission process is initiated ..."


The BridgePoint Hospital's ' InteQual Level of Care Criteria 2012 ' stipulates ... "LEVEL OF CARE REVIEW TYPES Preadmission Review - Performed only for a planned admission to a level of care to determine the appropriateness of an admission. Reviews are completed using Severity of Illness Criteria (SI) only ...Preadmission Review Steps 1. Identify the level of care based on the patient's current or proposed level. 2. Select the appropriate subset based on the patient's predominant presenting clinical findings. 3. Obtain and review patient specific clinical information (e.g., history, physical, laboratory, imaging, ECG finding, progress notes, and medical practitioner orders). 4. Apply the SI rule by selecting the SI criteria based on clinical findings ..."


The BridgePoint Hospital policy # B.10.0, titled, 'Nursing Documentation-Nursing Flow Sheet,' effective December 2014 stipulates ... "POLICY 9. All information recorded is to be factual and accurate ..."


According to DCMR, title 17, section 5514.3, "The practice of practical nursing shall include the following ...(a) Participating in the performance of the ongoing comprehensive nursing assessment process of the client's biological, physiological, and behavioral health, including the client's reaction to an illness, injury, and treatment regimens by collecting data and performing focused nursing assessments; (b) Recording and reporting the findings and results of the ongoing nursing assessment process ..."


Patient #1 was admitted with a history of Schizophrenia and diagnoses that included Drug-Induced Delirium and Strangulated Bowel, for which he underwent an Exploratory Laparotomy with Resection of Ileum, Cecum and Right Colon; resulting in an Ileostomy/ Jejunostomy.


On September 1, 2016 at approximately 4:20 PM, review of the medical record revealed the following:


The Consultation for 'Psychiatric Evaluation' revealed dated August 29, 2016 at 3:10 PM revealed the patient had prior hospitalizations at a Behavioral Health Hospital and was linked with outpatient treatment. The recommendations were to continue Risperdal, discontinue Seroquel, and continue Haldol (as needed). Additional recommendation included continuing a sitter for the patient, "given the Pt. [patient] has limited insight into his medical condition and need for further inpatient treatment."


The Medication Administration Record from the transferring hospital revealed the patient's last dose of Seroquel was on August 29, 2016 at 10:04 PM.


The 'Pre-Admission Screening' performed by Employee #7 dated August 31, 2016 at 5:44PM indicated the patent was "Alert/Confused and had a history of Schizophrenia." The documentation also revealed the patient had a " PICC [Peripherally Inserted Central Catheter], and was dependent for eating, oral hygiene, toileting, wash upper body, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair to bed, toilet transfer and ambulation."


The patient's transfer form from United Medical center dated August 31, 2016 (no time documented), under 'Psycho-social Information' revealed the patient was "confused," and needed assistance with Activities of Daily Living (ADLs)/Mobility/Transfer.


The 'Physician Inpatient Progress Note' dated August 31, 2016 at 11:59 PM revealed the Patient had a left Internal Jugular Central line. The admission database performed by Employee #8 on August 31, 2016 at 8:15 PM revealed the patient had a left triple lumen Internal Jugular catheter (central line); was independent with ambulation, feeding, and toileting; and required assistance with dressing meal preparation, and bathing. The nursing note on the admission database dated September 1, 2016 at 3:00 AM revealed the patient was alert and oriented to person and place, sometimes to time, and had periods of confusion.


Further review of the medical record revealed that on September 1, 2016 at approximately 5:30 PM, Patient #1 was found face down on the floor, unresponsive with scissors in his/her right hand, a code blue was called, and cardiopulmonary resuscitation (CPR) was performed, with no success. During the code, it was noticed that the patient's left triple lumen Internal Jugular catheter was cut down to the hub and pieces of lumen were later found on the sink, in the patient's room.


The findings/assessment on the 'Pre-Admission Screening,' performed by Employee #7 lacked evidence to reflect an accurate patient status was documented. Additionally, the
'Pre-Admission Screening' lacked documented evidence of a psychiatric consult and/or recommendations. There was no evidence that Employee #7 followed the hospital's policy to ensure factual and accurate information was documented.


On September 1, 2016 at 4:39 PM, a telephone interview was conducted with Employee
#7, in the presence of Employee #2. Employee #7 was asked to explain his/her title, responsibilities, and interaction with Patient #1. Employee #7 explained that he was the Director of Business Development, was a licensed practical nurse (LPN), and his responsibilities included supervising the Clinical Liaison team, which included registered nurses (RNs), licensed practical nurses (LPNs), and respiratory therapists. S/he continued explaining that he performed a clinical assessment on Patient #1 for admission to LTACH and explained s/he obtained a verbal consent from the patient to transfer to BridgePoint National Harbor Hospital. When queried about the psychiatric consult, Employee #7 replied, "I did not see that documented on the chart." When queried about the District of Columbia Municipal Regulation for LPN scope of practice relative to performing initial assessments, Employee #7 stated that s/he is unaware that the regulation prohibits LPNs from performing an initial clinical assessment on patients.


Employee #2 shared that the CL's were performing 'Pre-Admission Screenings,' not clinical assessments. She was asked to provide the clinical assessment, which each patient is to have performed, as per policy. She could not provide the requested documentation.


On September 9, 2016 at approximately 2:30 PM, review of Employee #7's job description lacked evidence that it included performing clinical assessments.


The practice lacked evidence that the Governing Body established mechanisms to ensure that initial clinical assessments were performed, in accordance with the District of Columbia regulations.


Employee #2 acknowledged the findings.



5. Based on review of the District of Columbia Municipal Regulations (DCMR) for licensed practical nurses (LPNs), hospital polices, and staff interviews, it was determined that the Governing Body failed to ensure that BridgePoint National Harbor Hospital (Long-term Acute Care, LTACH) policies relative to the practice of LPNs performing central venous catheter care and blood sampling was in compliance with the District of Columbia Municipal Regulations for LPN scope of practice.


The findings include:


The BridgePoint Hospital policy titled, 'Care and Maintenance of Central Venous Access [CVAD] Device and Catheters and Central Venous and Peripherally Inserted Central Catheters-PICC,' effective December 2014 stipulates ... "POLICIES...9. LPN ' s may perform central venous access device care for PICC lines only ...E. Drawing Blood from a Central Venous Access Device 1. Only RN's and LPN's who have completed a CVC/PICC line competency are allowed to access central venous devices for blood sampling."


According to DCMR, title 17, section 5514.9, "A practical nurse may perform the following infusion therapy acts:


(a) Insertion of a peripheral intravenous [PIV] catheter that is no more than three (3) inches in length;(b) Discontinuing peripheral intravenous catheters that are no more than three (3) inches in length ... (e) Adding intravenous fluids to an established peripheral line ... (g) Insertion of heparin locks, including flushing with normal saline or heparin 100 units; (h) Venipuncture or withdrawal of a blood specimen from a peripheral catheter site; and (i) Changing of injection cap or intravenous tubing for peripheral lines only."


During an interview on September 1, 2016 at 5:15 PM, Employee #2 was asked how the policy was incompliance with the DCMR regulations for LPNs. S/he could provide no answer.


During an interview on September 8, 2016 at 11:45 AM, Employee #6 shared s/he was unaware of the aforementioned hospital policy.


The review lacked evidence that the Governing Body assured the policy was in compliance with District of Columbia Municipal Regulations scope of practice for LPNs.


Employees #2 and 6 acknowledged the findings.

Based on medical record review, review of manufacturer's recommendations, and staff interviews, it was determined that the staff failed to ensure Patient #1's safety, as evidenced by improper handling of disposable supplies and equipment.


The findings include:


Patient #1 was admitted with a history of Schizophrenia and diagnoses that included Drug-Induced Delirium and Strangulated Bowel, for which he underwent an Exploratory Laparotomy with Resection of Ileum, Cecum and Right Colon; resulting in an Ileostomy/ Jejunostomy.


On September 1, 2016 at approximately 4:20 PM, review of the medical record revealed the following:


The 'Pre-Admission Screening' performed by Employee #7 dated August 31, 2016 at 5:44PM indicated the patent was "Alert/Confused."


The patient's transfer form from United Medical center dated August 31, 2016 (no time documented), under 'Psycho-social Information' revealed the patient was "confused," and needed assistance with Activities of Daily Living (ADLs)/Mobility/Transfer.


The admission database performed by Employee #8 revealed the patient had a left triple lumen Internal Jugular catheter (central line). The nursing note on the admission database dated September 1, 2016 at 3:00 AM revealed the patient was alert and oriented to person and place, sometimes to time, and had periods of confusion.


During a telephone interview on September 6, 2016 at approximately 2:48 PM, Employee #9 revealed s/he obtained report from the transferring facility that the patient talked to himself and was at risk for elopement. Employee #9 stated she provided verbal report and the written report to Employee #8.


During a telephone interview on September 6, 2016 at approximately 3:33 PM, Employee #8 revealed s/he admitted the patient to BridgePoint National Harbor Hospital on August 31, 2016 at 8:15 PM. S/he explained that approximately 2:30 AM, s/he changed the patient's central line dressing, abdominal dressing, and colostomy bag. S/he placed the scissors in one of the drawers of the patient's bedside dresser, once finished, but explained he/she cleaned the scissors, before using them again." Employee #8 continued that at 5:30 AM, when s/he went to administer the 6:00 AM medication, Patient #1 was found face down on the floor, s/he assessed the patient for unresponsiveness, called for assistance, and a code blue was called. S/he explained that when and staff lifted the patient from the floor to the bed to perform cardiopulmonary resuscitation (CPR), scissors dropped to the floor, from the patient's right hand. "We started CPR". S/he shared that during the code, when the doctor ordered to give medication is when they noticed the central line was cut. Employee #8 explained the line was cut down to the hub, sutures were holding part of the catheter in place, and pieces of the lumen were later found on the sink, in the patient's room.


When queried how placing scissors in the patient's bedside dresser ensured patient or visitor safety, s/he answered that the patient's bedside dresser, which is unlocked, is used for the patient's personal use, as well as for staff storage of supplies and it is the hospital's practice to place dressing items at the patient's bedside.


During a prior telephone interview with Employee #10, on September 1, 2016 at 11:29 PM, s/he revealed that s/he saw Patient #1, during rounds at 10:00 PM. S/he explained the patient was alert and cooperative but showing his "colostomy " and asking if someone could take it away from him/her. Employee #10 also revealed, "Sometimes we do keep scissors at the patient's bedside. Most of the time patients are bedridden and can't get to them."


On September 7, 2016 at approximately 4:03 PM, during a telephone interview with Employee #6, s/he revealed that the hospital's dressing and suture trays were disposable. Observation of evidence provided on September 8, 2016 by Employee #6 revealed the following:


The manufacturer's package directives on the label of the 'Suture Removal Tray' stipulate:
"Contents: Alcohol prep pad, Scissors, Forceps, Gauze ...Sterile ...Single use only."


The manufacturer's package directives on the label of the 'Dressing Change Tray with BIOPATCH' stipulate ...Do not use if package is open or damaged ...Do not reuse. Single use only ..."


The practice lacked evidence that ensured the proper disposal of single use supplies and patient safety.


Employees #2 and 3 acknowledged the findings.

1. Based on medical record review, review of the District of Columbia Municipal Regulations (DCMR) for licensed practical nurses (LPNs), hospital polices, and staff interviews, it was determined that the Governing Body failed to ensure compliance to state and local laws relative to LPNs performing initial assessments in the District of Columbia.


The findings include:


The BridgePoint Hospital policy titled, 'Patient Admissions,' effective December 2014 stipulates ... "POLICY... 2. A clinical assessment shall be performed on all patients referred for admission to BridgePoint Hospital to determine appropriateness for Long-term Acute Hospital (LTACH) admission based on Inter-Qual criteria for LTACH ...PROCEDURE...2. The assigned Clinical Liaison is responsible to obtain pertinent clinical information on the patient to determine appropriateness for transfer to LTACH ...4. Upon the approval of transfer based on the Clinical Liaison's assessment for appropriateness of transfer, and verification of insurance eligibility, the admission process is initiated ..."


The BridgePoint Hospital's ' InteQual Level of Care Criteria 2012 ' stipulates ... "LEVEL OF CARE REVIEW TYPES Preadmission Review - Performed only for a planned admission to a level of care to determine the appropriateness of an admission. Reviews are completed using Severity of Illness Criteria (SI) only ...Preadmission Review Steps 1. Identify the level of care based on the patient's current or proposed level. 2. Select the appropriate subset based on the patient's predominant presenting clinical findings. 3. Obtain and review patient specific clinical information (e.g., history, physical, laboratory, imaging, ECG finding, progress notes, and medical practitioner orders). 4. Apply the SI rule by selecting the SI criteria based on clinical findings ..."


The BridgePoint Hospital policy # B.10.0, titled, 'Nursing Documentation-Nursing Flow Sheet,' effective December 2014 stipulates ... "POLICY 9. All information recorded is to be factual and accurate ..."


According to DCMR, title 17, section 5514.3, "The practice of practical nursing shall include the following ...(a) Participating in the performance of the ongoing comprehensive nursing assessment process of the client's biological, physiological, and behavioral health, including the client's reaction to an illness, injury, and treatment regimens by collecting data and performing focused nursing assessments; (b) Recording and reporting the findings and results of the ongoing nursing assessment process ..."


Patient #1 was admitted with a history of Schizophrenia and diagnoses that included Drug-Induced Delirium and Strangulated Bowel, for which he underwent an Exploratory Laparotomy with Resection of Ileum, Cecum and Right Colon; resulting in an Ileostomy/ Jejunostomy.


On September 1, 2016 at approximately 4:20 PM, review of the medical record revealed the following:


The Consultation for 'Psychiatric Evaluation' revealed dated August 29, 2016 at 3:10 PM revealed the patient had prior hospitalizations at a Behavioral Health Hospital and was linked with outpatient treatment. The recommendations were to continue Risperdal, discontinue Seroquel, and continue Haldol (as needed). Additional recommendation included continuing a sitter for the patient, "given the Pt. [patient] has limited insight into his medical condition and need for further inpatient treatment."


The Medication Administration Record from the transferring hospital revealed the patient's last dose of Seroquel was on August 29, 2016 at 10:04 PM.


The 'Pre-Admission Screening' performed by Employee #7 dated August 31, 2016 at 5:44PM indicated the patent was "Alert/Confused and had a history of Schizophrenia." The documentation also revealed the patient had a " PICC [Peripherally Inserted Central Catheter], and was dependent for eating, oral hygiene, toileting, wash upper body, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair to bed, toilet transfer and ambulation."


The patient's transfer form from United Medical center dated August 31, 2016 (no time documented), under 'Psycho-social Information' revealed the patient was "confused," and needed assistance with Activities of Daily Living (ADLs)/Mobility/Transfer.


The 'Physician Inpatient Progress Note' dated August 31, 2016 at 11:59 PM revealed the Patient had a left Internal Jugular Central line. The admission database performed by Employee #8 on August 31, 2016 at 8:15 PM revealed the patient had a left triple lumen Internal Jugular catheter (central line); was independent with ambulation, feeding, and toileting; and required assistance with dressing meal preparation, and bathing. The nursing note on the admission database dated September 1, 2016 at 3:00 AM revealed the patient was alert and oriented to person and place, sometimes to time, and had periods of confusion.


Further review of the medical record revealed that on September 1, 2016 at approximately 5:30 PM, Patient #1 was found face down on the floor, unresponsive with scissors in his/her right hand, a code blue was called, and cardiopulmonary resuscitation (CPR) was performed, with no success. During the code, it was noticed that the patient's left triple lumen Internal Jugular catheter was cut down to the hub and pieces of lumen were later found on the sink, in the patient's room.


The findings/assessment on the 'Pre-Admission Screening,' performed by Employee #7, lacked evidence to reflect an accurate patient status. Additionally, Employee #7's 'Pre-Admission Screening' lacked evidence of a psychiatric consult and/or recommendations. There was no evidence that Employee #7 followed the hospital's policy to ensure information obtained was factual and accurate information.


On September 1, 2016 at 4:39 PM, a telephone interview was conducted with Employee
#7, in the presence of Employee #2. Employee #7 was asked to explain his/her title, responsibilities, and interaction with Patient #1. Employee #7 explained that he was the Director of Business Development, was a licensed practical nurse (LPN), and his responsibilities included supervising the Clinical Liaison team, which included registered nurses (RNs), licensed practical nurses (LPNs), and respiratory therapists. S/he continued explaining that he performed a clinical assessment on Patient #1 for admission to LTACH and explained s/he obtained a verbal consent from the patient to transfer to BridgePoint National Harbor Hospital. When queried about the psychiatric consult, Employee #7 replied, "I did not see that documented on the chart." When queried about the District of Columbia Municipal Regulation for LPN scope of practice relative to performing initial assessments, Employee #7 stated that s/he is unaware that the regulation prohibits LPNs from performing an initial clinical assessment on patients.


Employee #2 shared that the CL's were performing 'Pre-Admission Screenings,' not clinical assessments. She was asked to provide the clinical assessment, which each patient is to have performed, as per policy. She could not provide the requested documentation.


On September 9, 2016 at approximately 2:30 PM, review of Employee #7's job description lacked evidence that it included performing clinical assessments.


The practice lacked evidence that the Governing Body established mechanisms to ensure that initial clinical assessments were performed, in accordance with the District of Columbia regulations.


Employee #2 acknowledged the findings.



2. Based on medical record review, review of the District of Columbia Municipal Regulations (DCMR) for licensed practical nurses (LPNs), hospital polices, and staff interviews, it was determined that the Governing Body failed to ensure compliance to state and local laws relative to licensed practical nurses (LPNs) supervising the clinical practice of registered nurses (RNs) in the District of Columbia.


The findings include:


According to DCMR, title 17, section 5514.4, "A practical nurse shall not ... (b) Supervise the clinical practice of a registered nurse ..."


The BridgePoint Hospital policy titled, 'Patient Admissions,' effective December 2014 stipulates ... "POLICY... 2. A clinical assessment shall be performed on all patients referred for admission to BridgePoint Hospital to determine appropriateness for Long-term Acute Hospital (LTACH) admission based on Inter-Qual criteria for LTACH ...PROCEDURE...2. The assigned Clinical Liaison is responsible to obtain pertinent clinical information on the patient to determine appropriateness for transfer to LTACH ...4. Upon the approval of transfer based on the Clinical Liaison's assessment for appropriateness of transfer, and verification of insurance eligibility, the admission process is initiated ..."


Patient #1 was admitted with a history of Schizophrenia and diagnoses that included Drug-Induced Delirium and Strangulated Bowel, for which he underwent an Exploratory Laparotomy with Resection of Ileum, Cecum and Right Colon; resulting in an Ileostomy/ Jejunostomy.


On September 1, 2016 at approximately 4:20 PM, review of the medical record revealed the
The 'Pre-Admission Screening' performed by Employee #7 dated August 31, 2016 at 5:44PM indicated he/she was a LPN.


On September 1, 2016 at 4:39 PM, a telephone interview was conducted with Employee
#7, in the presence of Employee #2. Employee #7 was asked to explain his/her title and responsibilities. Employee #7 explained that he was the Director of Business Development, was a licensed practical nurse (LPN), and his responsibilities included supervising the Clinical Liaison team (who are responsible for performing clinical assessments on patients to determine appropriateness for admission). The team included registered nurses (RNs), licensed practical nurses (LPNs), and respiratory therapists. When queried about the District of Columbia Municipal Regulation for LPN scope of practice relative to supervising the clinical practice of RN's , Employee #7 stated that s/he is unaware that the regulation prohibits LPNs from supervising RN's.


The practice lacked evidence that the Governing Body assured staff adherence to the District of Columbia Municipal Regulations for LPNs scope of practice.


Employee #2 explained that s/he is aware that Employee #7 is an LPN. S/he acknowledged the findings.

Based on review of the District of Columbia Municipal Regulations (DCMR) for licensed practical nurses (LPNs) and the Independent Contractor Agreement, hospital polices, and staff interviews, it was determined that the Governing Body failed to ensure that contractor services provided for intravenous therapy were in compliance with the District of Columbia Municipal Regulations (DCMR) for LPNs.


The findings include:


The BridgePoint Hospital policy titled, 'Care and Maintenance of Central Venous Access [CVAD] Device and Catheters and Central Venous and Peripherally Inserted Central Catheters-PICC,' effective December 2014 stipulates ... "POLICIES...9. LPN ' s may perform central venous access device care for PICC lines only ...E. Drawing Blood from a Central Venous Access Device 1. Only RN's and LPN's who have completed a CVC/PICC line competency are allowed to access central venous devices for blood sampling.


According to DCMR, title 17, section 5514.1,"The practice of practical nursing means the following: (a) The performance of actions of preventive health care, health maintenance, and the care of persons who are ill, injured, or experiencing alterations in health processes at the direction of the delegating or supervisory registered nurse..."


According to DCMR, title 17, section 5514.9, "A practical nurse may perform the following infusion therapy acts:


(a) Insertion of a peripheral intravenous [PIV] catheter that is no more than three (3) inches in length;(b) Discontinuing peripheral intravenous catheters that are no more than three (3) inches in length ... (e) Adding intravenous fluids to an established peripheral line ... (g) Insertion of heparin locks, including flushing with normal saline or heparin 100 units; (h) Venipuncture or withdrawal of a blood specimen from a peripheral catheter site; and (i) Changing of injection cap or intravenous tubing for peripheral lines only."


According to DCMR, title 17, section 5514.4, "A practical nurse shall not ... (b) Supervise the clinical practice of a registered nurse ... (c) Supervise the practice of a graduate or student nurse (d) Administer the following medications ... (2) Antineoplastic agents; (3) Anesthesia or conscious sedation ... (6) Medications by way of intrathecal or epidural route ..."


On September 8, 2016 at approximately 11:30 AM, a telephone interview was conducted with Employee #3 regarding the contracted services for the intravenous therapy program. Employee #3 replied that s/he is aware of the program but that the educator handles the information for the program.


During an interview on September 8, 2016 at 11:45 AM, Employee #6 shared s/he was unaware of the aforementioned hospital policy and requested a copy of the hospital policy. When asked what education was provided to the LPNs, s/he stated that s/he has provided IV therapy education and had documented competencies for RNs, and the LPNs just sat in the class. Employee #6 added that s/he coordinates staff for Basic IV Therapy classes that are performed by [Named the Contractor], who contracted with BridgePoint Hospital. S/he explained s/he has competencies for training provided for PIVs, dressing change for PIV's, CVC's [Central Venous Catheters], IV pumps and IV tubing changes.


During an interview on September 8, 2016 at 1:47 PM, Employee #2 shared that to assist with nurse staffing issues, the hospital hired LPNs; however, the LPNs needed education and training to practice IV therapy and maintenance.[Contractor Name] was hired as a consultant for IV therapy training to BridgePoint National Harbor and BridgePoint Capitol Hill Hospitals, in May 2016. S/he shared the course was mandatory for new LPNs and RNs. The goal was "to expand the LPNs scope to administer some IVP (Intravenous Push) medications, specifically, Dilaudid and medications for pain management." Employee #2 was asked to provide the class outline, PowerPoint training material, the signed staff competencies and sign in sheet.


On September 8, 2016 at 4:45 PM, a review of the 'INDEPENDENT CONTRACTOR AGREEMENT' revealed " [Contractor Name], LPN, Contractor represents to BridgePoint that on the basis of training and experience, Contractor is knowledgeable regarding state and federal legal, and regulatory requirements pertaining to the Services regarding acute care hospitals, and that Contractor is qualified to perform and will use Contractor's best efforts to perform the duties set forth below:


A. Deliverables and Expectations: Contractor will provide training to nursing students in Basic IV Therapy with the expectation of receiving a Certificate upon completion of 7.5 contact hours for the course ...

B. III. IV Medication Administration b. Chemotherapy ...V. Central Venous Access Devices a. Indications b. Device types c. Care and Maintenance ... "


Review of the PowerPoint Presentation, "IV Insertion and Infusion," revealed training included: "Peripherally inserted Central Catheters, Epidural and Intrathecal Catheters, Central Venous Catheter (CVC) Care (which includes flushing and changing the cap), Obtaining blood specimen for CVCs and Medications and Therapies (which included Infusion Push (IVP), Administration of Antineoplastic Agents, Heparin Therapy, Intravenous Immunoglobulin (IVIG), Intravenous Pain Management, Transfusion Therapy, and Intravenous Conscious Sedation."


Review of the 'Competency Training: Clinical Nursing Skills' 'Changing the Dressing and Flushing Central Venous Access Devices' dated June 14, 2016 includes ... "10. Clamp all lines of the CVAD (Central Venous Access Device) and remove injection caps. Cleanse the catheter ends with antimicrobial swab and then apply new injection caps ..."


Review of the education documentation revealed one (1) RN and five (5) LPN competencies were evaluated and signed by the Contractor.


The findings lacked evidence to support that the practice of the LPN supervising the clinical nursing practice of RNs and student nurses; and performing care to any catheters and drawing blood from any catheters, other than peripheral line catheters is compliant with the LPN scope of practice, in the District of Columbia. Additionally, there was no evidence that the contractor (LPN) practiced clinical skills, under the supervision of a registered nurse.


The review and practices lacked evidence that the governing body ensured the BridgePoint National Harbor Hospital's Quality Assessment and Performance Improvement program assessed the services furnished for the Intravenous Therapy program to ensure compliance with the District of Columbia Municipal Regulations (DCMR) for licensed practical nurses.


Employees #2 and 3 acknowledged the findings.

Based on review of medical records, hospital polices, and staff interviews, it was determined that the staff failed to obtain a properly executed consent for treatment for three (3) of 11 records reviewed.


The findings include:


A. Patient #1 was admitted with a history of Schizophrenia and diagnoses that included Drug-Induced Delirium and Strangulated Bowel, for which he underwent an Exploratory Laparotomy with Resection of Ileum, Cecum and Right Colon; resulting in an Ileostomy/ Jejunostomy.


On September 1, 2016 at approximately 4:20 PM, review of the medical record revealed the following:


The 'Pre-Admission Screening' performed by Employee #7 dated August 31, 2016 at 5:44PM indicated the patent was "Alert/Confused."


The patient's transfer form from United Medical center dated August 31, 2016 (no time documented), under 'Psycho-social Information' revealed the patient was "confused," and needed assistance with Activities of Daily Living (ADLs)/Mobility/Transfer.


The admission database revealed the patient was admitted on August 31, 2016 at 8:15 PM. The nursing note on the admission database dated September 1, 2016 at 3:00 AM revealed the patient was alert and oriented to person and place, sometimes to time, and had periods of confusion.


The medical record lacked documented evidence of verbal consent or written consent for transfer or treatment.


On September 1, 2016 at 4:39 PM, a telephone interview was conducted with Employee #7, in the presence of Employee #2. When asked about the patient's orientation status, Employee #7 stated, the patient was "Alert but his orientation was questionable. He knew his name and that he was in the hospital. He was unaware of the date and time ... "


When queried about the process to obtain consent for treatment. Employee #7 explained that the Clinical Liaisons (CL's) get the patient's verbal consent to transfer and the written consent is obtained when the patient is admitted. When asked how consent was obtained on the confused patient, Employee #7 explained s/he obtained a verbal consent from the patient, "I had to repeat the statement about three times ... " When asked if family was contacted for consent, he replied, " I did not speak to the family ... "


Employee #2 reviewed the record and explained that the hospital policy allows the facility 24 hours to obtain consent for treatment; however, she could not produce the policy, for review.


There was no evidence that Patient #1 or his/ her representative was provided the right to make informed decisions about his/her transfer to BridgePoint National Harbor Hospital (Long-term Acute Care, LTACH).


Employees #2 acknowledged the findings.


B. Patient #2 was admitted with diagnoses that included Endocarditis and Osteomyelitis of the Left Foot.


On September 2, 2016 at approximately 2:25 PM, review of the medical record revealed the patient was admitted to BridgePoint National Harbor Hospital (Long-term Acute Care, LTACH) on August 26, 2016.


The patient was alert and oriented to person and place, sometimes to time. Further review of the record revealed the patient has been receiving treatment at the hospital for 7days, without evidence of consent for treatment.


On September 2, 2016 at approximately 2:35 PM, Employees #2 and 4 were asked to provide the patient's consent for treatment. Neither Employee could provide the consent.


The record lacked evidence of a written consent for treatment at BridgePoint National Harbor Hospital (Long-term Acute Care, LTACH).


Employees #2 and 4 acknowledged the findings.



C. Patient #3 was admitted with diagnoses that included Acute Hypercapnia and Schizophrenia.


On September 2, 2016 at approximately 4:10 PM, review of the medical record revealed the patient was admitted to BridgePoint National Harbor Hospital (Long-term Acute Care, LTACH) on August 18, 2016.


The patient was alert with occasions of disorientation to place and time. Further review of the record revealed the patient has been receiving treatment at the hospital for 15 days, without evidence of consent for treatment.


On September 2, 2016 at approximately 4:20 PM, Employees #2 and 4 were asked to provide the patient's consent for treatment. Neither Employee could provide the consent. Employee #2 explained the facility has made numerous attempts to contact the patient's family to obtain consent, with no avail.


The record lacked evidence of a written consent for treatment at BridgePoint National Harbor Hospital (Long-term Acute Care, LTACH).


Employees #2 and 4 acknowledged the findings.

Based on medical record review, review of manufacturer's recommendations, and staff interviews, it was determined that the staff failed to ensure Patient #1's safety, as evidenced by improper handling of disposable supplies and equipment.


The findings include:


Patient #1 was admitted with a history of Schizophrenia and diagnoses that included Drug-Induced Delirium and Strangulated Bowel, for which he underwent an Exploratory Laparotomy with Resection of Ileum, Cecum and Right Colon; resulting in an Ileostomy/ Jejunostomy.


On September 1, 2016 at approximately 4:20 PM, review of the medical record revealed the following:


The 'Pre-Admission Screening' performed by Employee #7 dated August 31, 2016 at 5:44PM indicated the patent was "Alert/Confused."


The patient's transfer form from United Medical center dated August 31, 2016 (no time documented), under 'Psycho-social Information' revealed the patient was "confused," and needed assistance with Activities of Daily Living (ADLs)/Mobility/Transfer.


The admission database performed by Employee #8 revealed the patient had a left triple lumen Internal Jugular catheter (central line). The nursing note on the admission database dated September 1, 2016 at 3:00 AM revealed the patient was alert and oriented to person and place, sometimes to time, and had periods of confusion.


During a telephone interview on September 6, 2016 at approximately 2:48 PM, Employee #9 revealed s/he obtained report from the transferring facility that the patient talked to himself and was at risk for elopement. Employee #9 stated she provided verbal report and the written report to Employee #8.


During a telephone interview on September 6, 2016 at approximately 3:33 PM, Employee #8 revealed s/he admitted the patient to BridgePoint National Harbor Hospital on August 31, 2016 at 8:15 PM. S/he explained that approximately 2:30 AM, s/he changed the patient's central line dressing, abdominal dressing, and colostomy bag. S/he placed the scissors in one of the drawers of the patient's bedside dresser, once finished, but explained he/she cleaned the scissors, before using them again." Employee #8 continued that at 5:30 AM, when s/he went to administer the 6:00 AM medication, Patient #1 was found face down on the floor, s/he assessed the patient for unresponsiveness, called for assistance, and a code blue was called. S/he explained that when and staff lifted the patient from the floor to the bed to perform cardiopulmonary resuscitation (CPR), scissors dropped to the floor, from the patient's right hand. "We started CPR". S/he shared that during the code, when the doctor ordered to give medication is when they noticed the central line was cut. Employee #8 explained the line was cut down to the hub, sutures were holding part of the catheter in place, and pieces of the lumen were later found on the sink, in the patient's room.


When queried how placing scissors in the patient's bedside dresser ensured patient or visitor safety, s/he answered that the patient's bedside dresser, which is unlocked, is used for the patient's personal use, as well as for staff storage of supplies and it is the hospital's practice to place dressing items at the patient's bedside.


During a prior telephone interview with Employee #10, on September 1, 2016 at 11:29 PM, s/he revealed that s/he saw Patient #1, during rounds at 10:00 PM. S/he explained the patient was alert and cooperative but showing his "colostomy " and asking if someone could take it away from him/her. Employee #10 also revealed, "Sometimes we do keep scissors at the patient's bedside. Most of the time patients are bedridden and can't get to them."


On September 7, 2016 at approximately 4:03 PM, during a telephone interview with Employee #6, s/he revealed that the hospital's dressing and suture trays were disposable. Observation of evidence provided on September 8, 2016 by Employee #6 revealed the following:


The manufacturer's package directives on the label of the 'Suture Removal Tray' stipulate:
"Contents: Alcohol prep pad, Scissors, Forceps, Gauze ...Sterile ...Single use only."


The manufacturer's package directives on the label of the 'Dressing Change Tray with BIOPATCH' stipulate ...Do not use if package is open or damaged ...Do not reuse. Single use only ..."


The practice lacked evidence that ensured the proper disposal of single use supplies and patient safety.


Employees #2 and 3 acknowledged the findings.

1. Based on review of medical records and the District of Columbia Municipal Regulations (DCMR) for licensed practical nurses (LPNs), hospital polices, personnel files, and staff interviews, it was determined that the staff failed to appropriately document the patient's clinical findings and status to support the patient's diagnoses and plan of care.


The findings include:


The BridgePoint Hospital policy titled, 'Patient Admissions,' effective December 2014 stipulates ... "POLICY... 2. A clinical assessment shall be performed on all patients referred for admission to BridgePoint Hospital to determine appropriateness for Long-term Acute Hospital (LTACH) admission based on Inter-Qual criteria for LTACH ...PROCEDURE...2. The assigned Clinical Liaison is responsible to obtain pertinent clinical information on the patient to determine appropriateness for transfer to LTACH ...4. Upon the approval of transfer based on the Clinical Liaison's assessment for appropriateness of transfer, and verification of insurance eligibility, the admission process is initiated ... "


The BridgePoint Hospital's 'InteQual Level of Care Criteria 2012' stipulates ... "LEVEL OF CARE REVIEW TYPES Preadmission Review - Performed only for a planned admission to a level of care to determine the appropriateness of an admission. Reviews are completed using Severity of Illness Criteria (SI) only ...Preadmission Review Steps 1. Identify the level of care based on the patient's current or proposed level. 2. Select the appropriate subset based on the patient's predominant presenting clinical findings. 3. Obtain and review patient specific clinical information (e.g., history, physical, laboratory, imaging, ECG finding, progress notes, and medical practitioner orders). 4. Apply the SI rule by selecting the SI criteria based on clinical findings ... "


The BridgePoint Hospital policy # B.10.0, titled, 'Nursing Documentation-Nursing Flow Sheet,' effective December 2014 stipulates ... "POLICY 9. All information recorded is to be factual and accurate ..."



According to DCMR, title 17, section 5514.3, "The practice of practical nursing shall include the following ...(a) Participating in the performance of the ongoing comprehensive nursing assessment process of the client's biological, physiological, and behavioral health, including the client ' s reaction to an illness, injury, and treatment regimens by collecting data and performing focused nursing assessments; (b) Recording and reporting the findings and results of the ongoing nursing assessment process ..."


Patient #1 was admitted with a history of Schizophrenia and diagnoses that included Drug-Induced Delirium and Strangulated Bowel, for which he underwent an Exploratory Laparotomy with Resection of Ileum, Cecum and Right Colon; resulting in an Ileostomy/ Jejunostomy.


On September 1, 2016 at approximately 4:20 PM, review of the medical record revealed the following:


The Consultation for 'Psychiatric Evaluation' revealed dated August 29, 2016 at 3:10 PM revealed the patient had prior hospitalizations at a Behavioral Health Hospital and was linked with outpatient treatment. The recommendations were to continue Risperdal, discontinue Seroquel, and continue Haldol (as needed). Additional recommendation included continuing a sitter for the patient, "given the Pt. [patient] has limited insight into his medical condition and need for further inpatient treatment. "



The Medication Administration Record from the transferring hospital revealed the patient's last dose of Seroquel was on August 29, 2016 at 10:04 PM.


The 'Pre-Admission Screening' performed by Employee #7 dated August 31, 2016 at 5:44PM indicated the patent was "Alert/Confused and had a history of Schizophrenia." The documentation also revealed the patient had a " PICC [Peripherally Inserted Central Catheter], and was dependent for eating, oral hygiene, toileting, wash upper body, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair to bed, toilet transfer and ambulation."


The patient's transfer form from United Medical center dated August 31, 2016 (no time documented), under 'Psycho-social Information' revealed the patient was "confused," and needed assistance with Activities of Daily Living (ADLs)/Mobility/Transfer.


The 'Physician Inpatient Progress Note' dated August 31, 2016 at 11:59 PM revealed the Patient had a left Internal Jugular Central line. The admission database performed by Employee #8 on August 31, 2016 at 8:15 PM revealed the patient had a left triple lumen Internal Jugular catheter (central line); was independent with ambulation, feeding, and toileting; and required assistance with dressing meal preparation, and bathing. The nursing note on the admission database dated September 1, 2016 at 3:00 AM revealed the patient was alert and oriented to person and place, sometimes to time, and had periods of confusion


Further review of the medical record revealed that on September 1, 2016 at approximately 5:30 PM, Patient #1 was found face down on the floor, unresponsive with scissors in his/her right hand, a code blue was called, and cardiopulmonary resuscitation (CPR) was performed, with no success. During the code, it was noticed that the patient's left triple lumen Internal Jugular catheter was cut down to the hub and pieces of lumen were later found on the sink, in the patient's room.


The findings/assessment on the 'Pre-Admission Screening,' performed by Employee #7 lacked evidence to reflect an accurate patient status was documented. Additionally, the
'Pre-Admission Screening' lacked documented evidence of a psychiatric consult and/or recommendations. There was no evidence that Employee #7 followed the hospital's policy to ensure factual and accurate information was documented.


On September 1, 2016 at 4:39 PM, a telephone interview was conducted with Employee
#7, in the presence of Employee #2. Employee #7 was asked to explain his/her title, responsibilities, and interaction with Patient #1. Employee #7 explained that he was the Director of Business Development, was a licensed practical nurse (LPN), and his responsibilities included supervising the Clinical Liaison team, which included registered nurses (RNs), licensed practical nurses (LPNs), and respiratory therapists. S/he continued explaining that he performed a clinical assessment on Patient #1 for admission to LTACH and explained s/he obtained a verbal consent from the patient to transfer to BridgePoint National Harbor Hospital. When queried about the psychiatric consult, Employee #7 replied, "I did not see that documented on the chart." When queried about the District of Columbia Municipal Regulation for LPN scope of practice relative to performing initial assessments, Employee #7 stated that s/he is unaware that the regulation prohibits LPNs from performing an initial clinical assessment on patients.


Employee #2 shared that the CL's were performing 'Pre-Admission Screenings,' not clinical assessments. She was asked to provide the clinical assessment, which each patient is to have performed, as per policy. She could not provide the requested documentation.


On September 9, 2016 at approximately 2:30 PM, review of Employee #7's job description lacked evidence that it included performing clinical assessments.


The medical record lacked evidence that Employee #7 documented an accurate and appropriate clinical assessment to reflect the patient's clinical status to determine the patient's appropriateness for admission and plan of care.


Employee #2 acknowledged the findings.



2. Based on review of medical records, hospital polices, and staff interviews, it was determined that the staff failed to ensure complete documentation on the patient's 'Code Blue' record to support the care and treatment provided.


The findings include:


The BridgePoint Hospital policy # E.06.01, titled, 'Code Blue,' effective December 2014 stipulates ... "Members of the Team and Their Duties 7. Recording Nurse (Patient Care Coordinator [PCC]) a. The PCC will record, in chronological order, all information on the Code Blue Form. This includes: ii. Interventions and times (drugs with dosages, venous access lines, intubation, defibrillation with joules) ..."


Patient #1 was admitted with a history of Schizophrenia and diagnoses that included Drug-Induced Delirium and Strangulated Bowel, for which he underwent an Exploratory Laparotomy with Resection of Ileum, Cecum and Right Colon; resulting in an Ileostomy/ Jejunostomy.


On September 1, 2016 at approximately 4:20 PM, review of the "Code Blue Record" lacked evidence of the time the patient's breath sounds, neurological status, and vital signs were assessed. Additionally, under the section, 'Defibrillation or Cardioversion' a time was documented, but no further documentation as to whether or not this was performed.


The record lacked evidence to ensure that staff followed the hospital's policy to ensure complete documentation on the Code Blue Record.


Employee #3 acknowledged the findings.