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Based on observations during the incident investigation at MedStar Georgetown University Hospital, it was determined that the Governing Body failed to ensure that shower faucets used on the Psychiatric Unit are safe to prevent patients from causing harm to themselves.

These findings were determined during a review of records, a tour of the Patient's Rooms, Showers and Interviews with Administrative Staff.

The findings include:

Through observation; interviews with Administrative Staff; a tour of Unit 5 West and a tour of the patients rooms and shower areas.

It was determined that the Governing Body failed to ensure that showers handle/knob lacked a collar or cover to minimize stem exposure.

The patients shower in Room 5119 lacked a cover or collar to guard against attaching a cord to the exposed stem, allowing the patient to attach a cord around the shower faucet stem and neck to cut the supply of oxygen and asphyxiate himself.

This type of faucet handle and stem maximizes the potential for patients to harm themselves.

Rooms 5101, 5109 were observed to have a collar or cover to partially cover the faucet stem which protects patients from harming themselves.

The faucet stems were partially covered in the hallway showers with a collar or cover which will minimize the option of placing a ligature around the faucet stem.

Room 5113 shower is push button operated, which activates the flow of water; this type of handle//knob is the safest to use in this environment to protect patients from harming themselves.

Based on medical record and policy review and staff interview it was determined that the nursing staff failed to update and keep Patient#1's Interdisciplinary Treatment Plan current in one (1) of ten (10) records reviewed.

This deficiency was cited during the licensure survey February 11 through 18 2014.

The findings include:

Inpatient Psychiatry Unit Guide to Hospital Policy and Procedure, revised September 18, 2013, entitled Interdisciplinary Treatment Planning stipulates, " The admitting registered nurse initiates the Interdisciplinary Treatment Plan referred to hereinafter as the Plan, at the time of admission and not later than twenty-four hours after patient ' s admission. The Interdisciplinary Treatment Team will meet within 72 hours to complete the formulation of the Plan. The Plan will include current diagnosis, reasons for admission ...after care plans and estimated length of stay. The plan will identity the patient ' s current problems, as well as patient ' s goals and treatment approaches necessary to accomplish the stated goals. The Plan will also include identification of the disciplines participation in the each treatment approach and targets date for problem resolution. All team members should sign the Plan ... Procedure ... 2. The Treatment Plan will be documented on the Interdisciplinary Treatment Plan form and it will become part of the medical record. 3. Each patient ' s plan will be reviewed daily and the evaluation and outcome documented on the Problem List Update form when there is an appropriate reason...During the review period, any new identified problem can be incorporated into the Plan. A new problem can also be entered into the plan at any time by any member of the Treatment Team ... "

A face to face interview was conducted briefly with the Psychiatry Unit Charge Nurse on September 5, 2014 at approximately 11:30 AM during unit observations, regarding Interdisciplinary Meetings. The Charge Nurse stated that Interdisciplinary Meetings were conducted daily with the Attending, other psychiatrists, residents, medical students, registered nurses, case managers, counselors and the patient. The team completes safety assessments, reviews patient ' s status, reviews the past 24 hours of the patient ' s stay to include, medications taken, behavior, treatments provided, laboratory results, and changes the plan when needed, relative to anything that occurred within the 24 hours.

Patient#1 was admitted July 8, 2014 with diagnoses which included Depressive Disorder Not Otherwise Specified (NOS), Anxiety NOS, Rule-out Post Traumatic Stress Disorder, (in remission) and Alcohol Use, and medical history of Tinnitus, Hypertension, Gastroesophageal Reflux Disease, Atrial Fibrillation, and Pulmonary Embolism with Intravascular Filter. The patient was discharged for an outpatient procedure on July 18, 2014, and on return processed fully as a new admission to the Psychiatry Unit on July 18, 2014.

Review of the medical record on September 19, 2014 at approximately 10:00 AM revealed an Interdisciplinary Treatment Plan (the Plan) dated July 8, 2014 with two (2) clinical problems documented; Suicidal Ideation and Tinnitus.

According to the medical record there were multiple consultations from different disciplines that evaluated and made recommendations for the care of Patient #1. The consultation services included Cardiology, Otolaryngology, General Internal Medicine, Endocrinology, Gastroenterology, Physical Therapy and Occupational Therapy and Dental Service. General Internal Medicine evaluated Patient#1 daily; creating a separate clinical problems list.

Review of the physician and nursing progress notes, and the Discharge Summary covering July 8 to 18, 2014 admission, revealed the patient consistently complained of dental (tooth) pain and heartburn starting on July 9 and 10, 2014 respectively. The complaints continued through the July 18 to September 2, 2014 admission, resulting in several consultations and interventions to include an endoscopy procedure on July 18, 2014, Pain Service consult on July 22, 2014, and Dental consults on July 11, 24, 2014, August 7 and 28, 2014.

The Interdisciplinary Treatment Plan dated July 8, 2014 lacked documented evidence that the dental (tooth) pain and heartburn were included on the Psychiatric Interdisciplinary Treatment Plan ' s Problem List.

The medical record lacked documented evidence that a new plan was started on July 18, 2014 and/or that the Plan dated July 8, 2014 was updated to include Heartburn and/or Tooth Pain. The Plan dated August 18, 2014 lacked documented evidence that Heartburn was included on the Plan Problem List.

Additionally, the Psychiatry Team ordered Occupational Therapy to " Evaluate and Treat " : on the following dates: July 8, 2014; July 9, 2014 for additional treatments 2-4 times a week times two (2) weeks to address Activities of Daily Living (ADLs, functional transition; July 14, 2014 for Kohlman Evaluation Living Skills (KEL) Evaluation, and July 18, 2014.

Occupational Therapy completed an initial evaluation of July 9, 2014, and a follow up visit on July 10, 2014 at which time the patient was given the sock aid after a return demonstration. Multiple attempts were made by Occupational Therapy to complete therapy sessions, on July 10, 11, 15, 17, 18, 21, 22, 23 and 24 2014. The patient was scheduled for a procedure on July 17 and 18, 2014 however, the patient declined seven (7) Occupational Therapy sessions because of Tooth pain and/or Heartburn but subsequently agreed to be evaluated on July 25, 2014.

The medical and clinical staff (Interdisciplinary Team) failed to follow the Psychiatry Unit policy related to Interdisciplinary Treatment Planning relative to current problems of Tooth Pain and Heartburn and relative to other disciplines to include the General Internal Medicine, Gastroenterology, Dental Service, and the Occupational Therapy Services.

The policy stipulates that " ...A new problem can also be entered into the plan at any time by any member of the Treatment Team ... " The nursing staff failed to keep Patient #1 ' s Interdisciplinary Treatment Plan current and update per policy.


On October 27, 2014 at approximately 8:00 AM a telephone interview was conducted one of the unit ' s Charge Nurses.


When questioned regarding reason the Tooth Pain and Heartburn were not added to the Interdisciplinary Treatment Plan, the Nurse stated that the concern was the suicidal ideation and preventing the patient from harming self. The tooth pain and heartburn were secondary.

Based on medical record review and policy review and staff interview it was determined that the Interdisciplinary Team staff failed to follow the Psychiatry Unit's policy related to Interdisciplinary Treatment Planning for Patient #1 in one (1) of 10 record reviewed.


The findings include:

Inpatient Psychiatry Unit Guide to Hospital Policy and Procedure, revised September 18, 2013, entitled Interdisciplinary Treatment Planning stipulates, " The admitting registered nurse initiates the Interdisciplinary Treatment Plan referred to hereinafter as the Plan, at the time of admission and not later than twenty-four hours after patient ' s admission. The Interdisciplinary Treatment Team will meet within 72 hours to complete the formulation of the Plan. The Plan will include current diagnosis, reasons for admission ...after care plans and estimated length of stay. The plan will identity the patient ' s current problems, as well as patient ' s goals and treatment approaches necessary to accomplish the stated goals. The Plan will also include identification of the disciplines participation in the each treatment approach and targets date for problem resolution. All team members should sign the Plan ... Procedure ... 2. The Treatment Plan will be documented on the Interdisciplinary Treatment Plan form and it will become part of the medical record. 3. Each patient ' s plan will be reviewed daily and the evaluation and outcome documented on the Problem List Update form when there is an appropriate reason...During the review period, any new identified problem can be incorporated into the Plan. A new problem can also be entered into the plan at any time by any member of the Treatment Team ... "

A face to face interview was conducted briefly with the Psychiatry Unit Charge Nurse on September 5, 2014 at approximately 11:30 AM during unit observations, regarding Interdisciplinary Meetings. The Charge Nurse stated that Interdisciplinary Meetings were conducted daily with the Attending, other psychiatrists, residents, medical students, registered nurses, case managers, counselors and the patient. The team completes safety assessments, reviews patient ' s status, reviews the past 24 hours of the patient ' s stay to include, medications taken, behavior, treatments provided, laboratory results, and changes the plan when needed, relative to anything that occurred within the 24 hours.

Patient#1 was admitted July 8, 2014 with diagnoses which included Depressive Disorder Not Otherwise Specified (NOS), Anxiety NOS, Rule-out Post Traumatic Stress Disorder, (in remission) and Alcohol Use, and medical history of Tinnitus, Hypertension, Gastroesophageal Reflux Disease, Atrial Fibrillation, and Pulmonary Embolism with Intravascular Filter. The patient was discharged for an outpatient procedure on July 18, 2014, and on return processed fully as a new admission to the Psychiatry Unit on July 18, 2014.

Review of the medical record on September 19, 2014 at approximately 10:00 AM revealed an Interdisciplinary Treatment Plan (the Plan) dated July 8, 2014 with two (2) clinical problems documented; Suicidal Ideation and Tinnitus.

The medical record lacked documented evidence that the Plan was updated to reflect Patient #1 ' s current problems, as well as other disciplines which evaluated the patient, made recommendations relative to the completed inpatient consults.

According to the medical record there were multiple consultations from different disciplines that evaluated and made recommendations for the care of Patient #1. The consultation services included Cardiology, Otolaryngology, General Internal Medicine, Endocrinology, Gastroenterology, Physical Therapy and Occupational Therapy and Dental Service. General Internal Medicine evaluated Patient#1 daily and managed medical events; creating a separate clinical problems list.

Review of the physician and nursing progress notes, and the Discharge Summary covering July 8 to 18, 2014 admission, revealed the patient consistently complained of dental (tooth) pain and heartburn starting on July 9 and 10, 2014 respectively. The complaints continued through the July 18 to September 2, 2014 admission, resulting in several consultations and interventions to include an endoscopy procedure on July 18, 2014, Pain Service consult on July 22, 2014, and Dental consults on July 11, 24, 2014, August 7, 13 (telephone consult), and 28, 2014.

The Interdisciplinary Treatment Plan dated July 8, 2014 lacked documented evidence that the dental (tooth) pain and heartburn were included on the Psychiatric Interdisciplinary Treatment Plan ' s Problem List.

The medical record lacked documented evidence that a new plan was started on July 18, 2014 and/or that the Plan dated July 8, 2014 was updated to include Heartburn and/or Tooth Pain. The Plan dated August 18, 2014 lacked documented evidence that Heartburn was included on the Plan Problem List.

Additionally, the Psychiatry Team ordered Occupational Therapy to " Evaluate and Treat " : on the following dates: on July 8, 2014, on July 9, 2014 for additional treatments 2-4 times a week times two (2) weeks to address Activities of Daily Living (ADLs. functional transition; on July 14, 2014 for Kohlman Evaluation Living Skills (KEL) Evaluation, and on July 18, 2014.

Occupational Therapy completed an initial evaluation of July 9, 2014, and a follow up visit on July 10, 2014 at which time the patient was given the sock aid after a return demonstration. Multiple attempts were made by Occupational Therapy to complete therapy sessions, on July 10, 11, 15, 17, 18, 21, 22, 23 and 24 2014. The patient was scheduled for a procedure on July 17 and 18, 2014 however, the patient declined seven (7) Occupational Therapy sessions because of Tooth pain and/or Heartburn but subsequently agreed to be evaluated on July 25, 2014.

The medical and clinical staff (Interdisciplinary Team) failed to follow the Psychiatry Unit policy related to Interdisciplinary Treatment Planning relative to current problems of Tooth Pain and Heartburn and relative to other disciplines to include the General Internal Medicine, Gastroenterology, Dental Service, and Occupational Therapy Services.