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Based on medical record review and staff interview, it was determined that the nursing staff failed to establish, implement and maintain a current plan of care for identified needs in one(1) of one (1) record reviewed. (Patient #25)

The findings include:

District of Columbia Municipal Regulations (DCMR) for Registered Nursing Chapter 54. Section 5414 entitled Scope of Practice, regulation 5414.1 stipulates " The practice of registered nursing means the performance of acts requiring substantial specialized knowledge, judgment, and skill based upon the principles of the biological, physical, behavioral, and social sciences in the following: (a) The observation, comprehensive assessment, evaluation and recording of physiological and behavioral signs and symptoms of health, disease, and injury, including the performance of examinations a testing and their evaluation for purpose of identifying the needs of the client and family.(b) The development of a comprehensive nursing plan that establish nursing diagnoses, set goals to meet identified health care needs, and prescribes and implements nursing interventions of a therapeutic, preventive, and restorative nature in response to an assessment of the client's requirements.(f) Evaluating responses and outcomes to interventions and the effectiveness of the plan of care."

Patient #25 was admitted on January 22, 2014 with diagnoses which included Depression, Asthma, Anemia, and Anxiety Disorder.

A medical record review was conducted on July 30, 2014 at approximately 9:46 AM which revealed Patient #25 sustained a Head Laceration on approximately July 27, 2014. According to the General Medical Officer Note dated July 28, 2014 at 3:29 PM, Patient #25 was seen for sick call of reported complaints of headache and difficulty seeing with right eye after an unwitnessed fall in the shower on July 27, 2014. Upon assessment by medical staff, Patient #25 was noted to have two parallel one inch laceration with dry blood, left parietal-occipital area with swelling and right occipital area swelling. In response to the findings upon assessment, Patient #25 was transported to the acute care Emergency Department for further evaluation.

Patient #25 refused medical treatment while at the Emergency Department and consequently was returned to the facility without treatment.

On July 29, 2014, Patient #25 was seen by the medical and psychiatry staff which documented the treatment plan would include every 15 minute checks to prevent head banging/ falls, and a skull x-ray secondary to Patient refusal to have Computerized Tomography Scan performed while at the Emergency Department.

The Physician Orders revealed orders for "every 15 minute checks for self-injurious behavior head banging/ falls" since admission to facility on January 22, 2014 through present; and skull x-ray order dated July 29, 2014 at 11:39 AM.

The medical record lacked documented evidence of the status of the skull x-ray.

A subsequent review of the Interdisciplinary Recovery Plan revealed the interdisciplinary team initiated the following 'focus areas': "psychiatric and Psychological, Physical Health, Enrichment, and Community Integration."

The Interdisciplinary Recovery Plan lacked documented evidence of nursing interventions and evaluations related to "every 15 minute checks" and high risk for falls related to self-injurious behaviors and head banging.

The nursing staff failed to establish, implement and maintain a current plan of care related to Patient #25's self-injurious behaviors and falls.

A face-to-face interview was conducted with the Unit Manager and the Deputy Director of Nursing on July 30, 2014 at approximately 10:30 AM. The findings were reviewed, discussed and acknowledged.

Based on medical record review and confirmation by staff interview it was determined that the Health Information Management (HIM) staff failed to maintain an accurately written and properly filed medical record in one (1) of two (2) records reviewed (Patient #8)

The findings include:

Patient #8 was admitted on January 17, 2014 with diagnoses of Schizophrenia, Paranoid Type, Cognitive Disorder, Aggressive Behavior, Hypertension, Chronic Hepatitis C, and Vitamin D Deficiency.

Review of the medical record on July 30, 2014 at approximately 11:38 AM revealed the General Medical Officer ordered "Continue 1:1 constant observations at line of sight from 7:00 AM to 11:00 PM and every 15 minutes checks from 11:00 PM to 7:00 AM to monitor and prevent intrusive and aggressive behavior", for the period of July 15 through 29, 2014.

Review of the RA (Recovery Associates) NOTES FOR INTENSIVE OBSERVATIONS for the period of July 15 through 29, 2014, the Day and Evening Shifts revealed the lack of documented evidence that the observation sheets for July 23, 2014 were completed.

A face to face interview was conducted with the Nurse Manager during the record review. The Manager stated that the observation sheets are placed in a specific box for HIM staff to collect daily, for processing the electronic medical record. The Nurse Manager questioned the unit' s staff about the observation sheets and the staff confirmed the information stated by the Nurse Manager.

Patient #8's information was requested and provided, however the observation sheets for July 23, 2014 were not with the packet.

Further reviewed of medical records of a second medical record revealed that Patient #8's observation sheets for July 23, 2014 were scanned into another medical record.

The HIM staff failed to scan pertinent information into the correct medical record.

The findings were reviewed, discussed and acknowledged by the unit's Nursing Manager on July 30, 2014 at approximately 12:00 noon and 2:55 PM.

Based on medical record review and staff interview, it was determined the hospital staff failed to ensure the medical record contained documentation to describe the Patient ' s progress and response to medications and treatment services in seven (7) of eight (8) records reviewed (Patients #7,11,12,20,21,22, and 25).


The findings include:


District of Columbia Municipal Regulations for Hospitals (DCMR) Title 22 Regulation 2030.3(j) stipulates "Each medical record must contain, when applicable, the following information ...Documentation of all care and treatment, medical and surgical."


District of Columbia Municipal Regulations (DCMR) for Registered Nursing Chapter 54. Section 5414 entitled Scope of Practice, regulation 5414.1 stipulates "The practice of registered nursing means the performance of acts requiring substantial specialized knowledge, judgment, and skill based upon the principles of the biological, physical, behavioral, and social sciences in the following: (a) The observation, comprehensive assessment, evaluation and recording of physiological and behavioral signs and symptoms of health, disease, and injury, including the performance of examinations a testing and their evaluation for purpose of identifying the needs of the client and family...(f) Evaluating responses and outcomes to interventions and the effectiveness of the plan of care."


Saint Elizabeths Hospital Nursing Procedure Manual Number: NPM 3-99 entitled: Assessing Change in Physical Status Effective November 1, 2010, revised May 15, 2013 stipulates "I. POLICY: Each individual receiving care at Saint Elizabeths Hospital shall have a comprehensive assessment performed by a Registered Nurse (RN) that results in identifying an individual' s needs and priorities for nursing care and services ...IV. GENERAL INFORMATION: The RN Change in Physical Status Note shall be used by RNs to document changes in an individual' s physical condition ...V. PROCEDURE: The RN shall: ...c. Conduct a nursing assessment, including vital signs and all relevant systems (e.g., respiratory, cardiac, neurological, gastrointestinal, etc.), and compare these findings to the most recent assessment and/or to the individual ' s baseline ...j. In all situations, the RN shall: iii. Document health information, assessment findings and descriptive summary, notifications, communication with the GMO or NP, and recommendations for treatment."

Saint Elizabeths Hospital Respiratory Care Services Policy and Procedures entitled Required Documentation in Avatar eMAR CLA 2/11 stipulates "PROCEDURE; When documenting in Patient's Avatar eMAR chart, the following guidelines should be used: Date, Time, Treatment Mode, Breath sounds (pre/post), Pulse rate (pre/post), O2 Saturation (pre/post), O2 ...L/m and mode of delivery, Quantity and type of medication(s), position and location of CPT if administered, Productivity of treatment, i.e. amount, color and thickness of secretion, and Patient's tolerance."

Hospital Nursing Practice Manual Number 3-99, entitled Assessing Change in Physical Status Policy, revised April 4, 2011 was reviewed. Section V references Procedures, and Item 3 details the duties of the Registered Nurse (RN), and stipulates "the RN shall ...c. conduct a nursing assessment, including vital signs and all involved systems...j. In all situations, the RN shall:...Document health information, assessment findings, notifications, communication with the GMO or NP, recommendations for treatment..."


A. Patient #7 admitted on January 1, 2009 with diagnoses of Paranoid Schizophrenia, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Emphysema, Hypertension and Blindness Right Eye.


Review of the medical record on July 30, 2014 at approximately 2:56 PM revealed the General Medical Officer ordered Albuterol 0.83 milligram per milliliter and Ipratropium bromide 0.02%, nebulization one (1) unit dose twice a day on October 21, 2013, for Chronic Obstructive Pulmonary Disease.



Review of the electronic Medication Administration Record and Respiratory Therapy entry notes for June 30 through July 26, 2014 revealed the lack of documented evidence of pre- and post- breath sounds after each nebulization treatment.



According to the documentation by nursing and respiratory staff, there were 54 opportunities for nebulization treatments of which 11 were refused and six (6) were not given when Patient #3 was on medical leave. The remaining 37 nebulization treatments lacked documented evidence of pre- and post- respiratory assessments by the Respiratory Therapy staff.



The respiratory staff failed to document pre- and post- respiratory assessments.



The findings were reviewed, discussed and acknowledged by the unit's Nursing Manager on July 30, 2014 at approximately 2:45 PM.



B. Patient #11 was admitted June 19, 2014 with diagnoses which included Schizoaffective Disorder, Bipolar Disorder and Dementia, Vascular Type; and medical history of Hypertension, Epilepsy, and status post Right Cerebellar Infarct.



Review of the medical record on July 30, 2014 at approximately 10:10 AM revealed
Patient #11 complained intermittently of pain between June 20, and July 29, 2014. On June 20, 2014 and July, 27, 2014 the General Medical Staff ordered Acetaminophen, 650 mg by mouth every four(4) to six (6) hours as needed for pain.



Concurrent review of the Electronic Medication Administration Record revealed Patient #11 had thirteen (13) opportunities for pain assessment from June 20, through July 29, 2014, and eleven (11) opportunities where the nursing staff intervened with administration of Acetaminophen. The medical record reflected that in nine (9) of eleven (11) interventions, the nursing staff failed to document a reassessment post medication administration.



The nursing staff failed to follow hospital policy relative to the documentation of reassessments.



The findings were confirmed by hospital staff, present at the time of record review.



C. Patient #12 was admitted August 13, 2013 with diagnoses which included Schizoaffective Disorder, and Polysubstance Abuse.



Review of the medical record on July 30, 2014 at approximately 2:30 PM revealed the General Medical Staff directed fingerstick blood glucose monitoring for Patient #12 twice weekly on Mondays and Thursdays.



The results of fingerstick blood glucose monitoring were reviewed for the period of May 29 through July 28, 2014, for a total of eighteen (18) opportunities. The medical record reflected that on June 2,16, and July 3, 2014 the nursing staff did not obtain fingerstick blood glucose measurements. The medical record lacked documented evidence of the measurement or acknowledgement of Patient #12's refusal to permit blood glucose measurements.



The nursing staff failed to follow hospital policy relative to the documentation of assessments.



The findings were confirmed by hospital staff, present at the time of record review.




D. Patient #20 was admitted on July 11, 2013 with diagnoses which include Sleep Apnea, Esophagitis, Hypertriglyceridemia, Osteoarthritis, and Physical or Sexual Abuse of Adult.



On July 31, 2014 at approximately 10:15 AM, a medical record review was conducted which revealed a Physician's Order dated July 11, 2013 at 4:28 PM for Continuous Positive Airway Pressure with nasal mask every night and whenever Patient goes to sleep (takes a nap) with note to "please monitor per shift" .



Review of the Electronic Medication Administration Record (eMAR) lacked documented evidence that the Continuous Positive Airway Pressure was initiated and used nightly and/or whenever Patient #20 was sleeping.



The nursing staff failed to document the nightly use of the Continuous Positive Airway Pressure and per shift monitoring related to the use of the Continuous Positive Airway Pressure.



A face-to-face interview was conducted with Director of Performance Improvement on July 31, 2014 at 10:14 AM. The findings were discussed and acknowledged.



E. Patient #21 was admitted on January 3, 2014 with diagnoses which included Hypertension, Edema, and Psychotic Disorder.


On July 29, 2014 at approximately 3:46 PM a medical record review was conducted which revealed a Nursing RN Note dated July 9, 2014 at 7:38 PM. Patient #20 was noted to have a complaint of Headache. The General Medical Officer was notified and Tylenol as needed was ordered.



Review of the Electronic Medical Record revealed the nursing staff administered Tylenol 650 milligrams on July 9, 2014 at 8:58 PM; July 10, 2014 at 6:52 AM and July 10, 2014 at 7:40 PM.



The medical record lacked documented evidence to demonstrate that a pre and post administration assessment was conducted.



The nursing staff failed to ensure the medical record contained documentation to describe the Patient ' s response to medication.



A face-to-face interview was conducted on July 29, 2014 at approximately 3:40 PM with the Unit Manager and the Deputy Director of Nursing. The findings were discussed, reviewed and acknowledged.



F. Patient #22 was admitted on October 27, 2007 with diagnoses which include Schizophrenia, Obesity, Hypercholesterolemia, Iron-deficiency Anemia, and Allergic Rhinitis.



On July 31, 2014 at 10:02 AM a medical record review was conducted which revealed a Physician's Order for Albuterol Sulfate nebulizer twice a day, dated May 4, 2014 at 11:36 PM.



The Electronic Medication Administration Record (eMAR) revealed that Albuterol Sulfate nebulizer was administered as ordered.



Further review of the medical record revealed Respiratory Care Notes for May 27, 2014, June 27, 2014 and July 28, 014.



The medical record lacked documented evidence that a respiratory assessment was conducted before and after the administration of the Albuterol Sulfate nebulizer treatment.


The respiratory staff failed to ensure the medical record contained documentation to describe the Patient's response to medications and treatments.



A face-to-face interview was conducted with Director of Performance Improvement on July 31, 2014 at approximately 10:15 AM. The findings were discussed and acknowledged.



G. Patient #25 was admitted on January 22, 2014 with diagnoses which included Depression, Asthma, Anemia, and Anxiety Disorder.



A medical record review was conducted on July 30, 2014 at approximately 9:46 AM which revealed Patient #25 sustained a Head Laceration on approximately July 27, 2014. According to the General Medical Officer Note dated July 28, 2014 at 3:29 PM, Patient #25 was seen in sick call for reported complaints of Headache and Difficulty Seeing with Right Eye after an unwitnessed fall in the shower on July 27, 2014. Upon assessment by medical staff, Patient #25 was noted to have two (2) parallel one (1) inch lacerations with dry blood, left parietal-occipital area with swelling, and right occipital area swelling. In response to the assessment findings, Patient #25 was transported to the acute care Emergency Department for further evaluation on July 28, 2014 at 12:58 PM.



The medical record lacked documented evidence the nurse conducted a comprehensive assessment of Patient #25 relative to the complaints of headache and visual disturbance reported to the General Medical Officer.



Patient #25 returned from the local Emergency Department at 3:50 AM on July 29, 2014. The Nursing RN Note dated July 29, 2014 4:58 AM revealed the following documentation: "[S/he] declined temperature assessment. [S/he] has an open area at back of [his/her] hair but [s/he] refused wound dressing."



The medical record lacked documented evidence a wound assessment was conducted upon Patient #25's return from Emergency Department.



The nursing staff failed to conduct a nursing assessment to include all relevant system findings.


A face-to-face interview was conducted with the Unit Manager and the Deputy Director of Nursing on July 30, 2014 at approximately 10:30 AM. The findings were discussed and acknowledged.




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Based on medical record review and staff interview, it was determined the hospital staff failed to ensure the medical record contained documentation to describe the Patient's progress and response to medications and treatment services in seven (7) of eight (8) records reviewed (Patients #7, 11, 12,20,21,22, and 25).


The findings include:


District of Columbia Municipal Regulations for Hospitals (DCMR) Title 22 Regulation 2030.3(j) stipulates "Each medical record must contain, when applicable, the following information ...Documentation of all care and treatment, medical and surgical. "


District of Columbia Municipal Regulations (DCMR) for Registered Nursing Chapter 54. Section 5414 entitled Scope of Practice, regulation 5414.1 stipulates "The practice of registered nursing means the performance of acts requiring substantial specialized knowledge, judgment, and skill based upon the principles of the biological, physical, behavioral, and social sciences in the following:(a) The observation, comprehensive assessment, evaluation and recording of physiological and behavioral signs and symptoms of health, disease, and injury, including the performance of examinations a testing and their evaluation for purpose of identifying the needs of the client and family.(f) Evaluating responses and outcomes to interventions and the effectiveness of the plan of care."


Saint Elizabeths Hospital Nursing Procedure Manual Number: NPM 3-99 entitled: Assessing Change in Physical Status Effective November 1, 2010, revised May 15, 2013 stipulates "I. POLICY: Each individual receiving care at Saint Elizabeths Hospital shall have a comprehensive assessment performed by a Registered Nurse (RN) that results in identifying an individual' s needs and priorities for nursing care and services ...IV. GENERAL INFORMATION: The RN Change in Physical Status Note shall be used by RNs to document changes in an individual's physical condition...V. PROCEDURE: The RN shall: ...c. Conduct a nursing assessment, including vital signs and all relevant systems (e.g., respiratory, cardiac, neurological, gastrointestinal, etc.), and compare these findings to the most recent assessment and/or to the individual's baseline ...j. In all situations, the RN shall: iii. Document health information, assessment findings and descriptive summary, notifications, communication with the GMO or NP, and recommendations for treatment."

Saint Elizabeths Hospital Respiratory Care Services Policy and Procedures entitled Required Documentation in Avatar eMAR CLA 2/11 stipulates "PROCEDURE; When documenting in Patient's Avatar eMAR chart, the following guidelines should be used: Date, Time, Treatment Mode, Breath sounds (pre/post), Pulse rate (pre/post), O2 Saturation (pre/post), O2...L/m and mode of delivery, Quantity and type of medication(s), position and location of CPT if administered, Productivity of treatment, i.e. amount, color and thickness of secretion, and Patient's tolerance."

Hospital Nursing Practice Manual Number 3-99, entitled Assessing Change in Physical Status Policy, revised April 4, 2011 was reviewed. Section V references Procedures, and Item 3 details the duties of the Registered Nurse (RN), and stipulates "the RN shall ...c. conduct a nursing assessment, including vital signs and all involved systems... j. In all situations, the RN shall: ...Document health information, assessment findings, notifications, communication with the GMO or NP, recommendations for treatment ..."


A. Patient #7 admitted on January 1, 2009 with diagnoses of Paranoid Schizophrenia, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Emphysema, Hypertension and Blindness Right Eye.

Review of the medical record on July 30, 2014 at approximately 2:56 PM revealed the General Medical Officer ordered Albuterol 0.83 milligram per milliliter and Ipratropium bromide 0.02%, nebulization one (1) unit dose twice a day on October 21, 2013, for Chronic Obstructive Pulmonary Disease.


Review of the electronic Medication Administration Record and Respiratory Therapy entry notes for June 30 through July 26, 2014 revealed the lack of documented evidence of pre- and post- breath sounds after each nebulization treatment.


According to the documentation by nursing and respiratory staff, there were 54 opportunities for nebulization treatments of which 11 were refused and six (6) were not given when Patient #3 was on medical leave. The remaining 37 nebulization treatments lacked documented evidence of pre- and post- respiratory assessments by the Respiratory Therapy staff.


The respiratory staff failed to document pre- and post- respiratory assessments.


The findings were reviewed, discussed and acknowledged by the unit's Nursing Manager on July 30, 2014 at approximately 2:45 PM.


B. Patient #11 was admitted June 19, 2014 with diagnoses which included Schizoaffective Disorder, Bipolar Disorder and Dementia, Vascular Type; and medical history of Hypertension, Epilepsy, and status post Right Cerebellar Infarct.


Review of the medical record on July 30, 2014 at approximately 10:10 AM revealed
Patient #11 complained intermittently of pain between June 20, and July 29, 2014. On June 20, 2014 and July, 27, 2014 the General Medical Staff ordered Acetaminophen, 650 mg by mouth every four(4) to six (6) hours as needed for pain.


Concurrent review of the Electronic Medication Administration Record revealed Patient #11 had thirteen (13) opportunities for pain assessment from June 20, through July 29, 2014, and eleven (11) opportunities where the nursing staff intervened with administration of Acetaminophen. The medical record reflected that in nine (9) of eleven (11) interventions, the nursing staff failed to document a reassessment post medication administration.


The nursing staff failed to follow hospital policy relative to the documentation of reassessments.


The findings were confirmed by hospital staff, present at the time of record review.


C. Patient #12 was admitted August 13, 2013 with diagnoses which included Schizoaffective Disorder, and Polysubstance Abuse.


Review of the medical record on July 30, 2014 at approximately 2:30 PM revealed the General Medical Staff directed fingerstick blood glucose monitoring for Patient #12 twice weekly on Mondays and Thursdays.


The results of fingerstick blood glucose monitoring were reviewed for the period of May 29 through July 28, 2014, for a total of eighteen (18) opportunities. The medical record reflected that on June 2,16, and July 3, 2014 the nursing staff did not obtain fingerstick blood glucose measurements. The medical record lacked documented evidence of the measurement or acknowledgement of Patient #12's refusal to permit blood glucose measurements.


The nursing staff failed to follow hospital policy relative to the documentation of assessments.


The findings were confirmed by hospital staff, present at the time of record review.



D. Patient #20 was admitted on July 11, 2013 with diagnoses which include Sleep Apnea, Esophagitis, Hypertriglyceridemia, Osteoarthritis, and Physical or Sexual Abuse of Adult.


On July 31, 2014 at approximately 10:15 AM, a medical record review was conducted which revealed a Physician's Order dated July 11, 2013 at 4:28 PM for Continuous Positive Airway Pressure with nasal mask every night and whenever Patient goes to sleep (takes a nap) with note to "please monitor per shift" .


Review of the Electronic Medication Administration Record (eMAR) lacked documented evidence that the Continuous Positive Airway Pressure was initiated and used nightly and/or whenever Patient #20 was sleeping.


The nursing staff failed to document the nightly use of the Continuous Positive Airway Pressure and per shift monitoring related to the use of the Continuous Positive Airway Pressure.


A face-to-face interview was conducted with Director of Performance Improvement on July 31, 2014 at 10:14 AM. The findings were discussed and acknowledged.


E. Patient #21 was admitted on January 3, 2014 with diagnoses which included Hypertension, Edema, and Psychotic Disorder.


On July 29, 2014 at approximately 3:46 PM a medical record review was conducted which revealed a Nursing RN Note dated July 9, 2014 at 7:38 PM. Patient #20 was noted to have a complaint of Headache. The General Medical Officer was notified and Tylenol as needed was ordered.


Review of the Electronic Medical Record revealed the nursing staff administered Tylenol 650 milligrams on July 9, 2014 at 8:58 PM; July 10, 2014 at 6:52 AM and July 10, 2014 at 7:40 PM.


The medical record lacked documented evidence to demonstrate that a pre and post administration assessment was conducted.


The nursing staff failed to ensure the medical record contained documentation to describe the Patient ' s response to medication.


A face-to-face interview was conducted on July 29, 2014 at approximately 3:40 PM with the Unit Manager and the Deputy Director of Nursing. The findings were discussed, reviewed and acknowledged.



F. Patient #22 was admitted on October 27, 2007 with diagnoses which include Schizophrenia, Obesity, Hypercholesterolemia, Iron-deficiency Anemia, and Allergic Rhinitis.


On July 31, 2014 at 10:02 AM a medical record review was conducted which revealed a Physician's Order for Albuterol Sulfate nebulizer twice a day, dated May 4, 2014 at 11:36 PM.


The Electronic Medication Administration Record (eMAR) revealed that Albuterol Sulfate nebulizer was administered as ordered.


Further review of the medical record revealed Respiratory Care Notes for May 27, 2014, June 27, 2014 and July 28, 014.


The medical record lacked documented evidence that a respiratory assessment was conducted before and after the administration of the Albuterol Sulfate nebulizer treatment.


The respiratory staff failed to ensure the medical record contained documentation to describe the Patient's response to medications and treatments.


A face-to-face interview was conducted with Director of Performance Improvement on July 31, 2014 at approximately 10:15 AM. The findings were discussed and acknowledged.


G. Patient #25 was admitted on January 22, 2014 with diagnoses which included Depression, Asthma, Anemia, and Anxiety Disorder.


A medical record review was conducted on July 30, 2014 at approximately 9:46 AM which revealed Patient #25 sustained a Head Laceration on approximately July 27, 2014. According to the General Medical Officer Note dated July 28, 2014 at 3:29 PM, Patient #25 was seen in sick call for reported complaints of Headache and Difficulty Seeing with Right Eye after an unwitnessed fall in the shower on July 27, 2014. Upon assessment by medical staff, Patient #25 was noted to have two (2) parallel one (1) inch lacerations with dry blood, left parietal-occipital area with swelling, and right occipital area swelling. In response to the assessment findings, Patient #25 was transported to the acute care Emergency Department for further evaluation on July 28, 2014 at 12:58 PM.


The medical record lacked documented evidence the nurse conducted a comprehensive assessment of Patient #25 relative to the complaints of headache and visual disturbance reported to the General Medical Officer.


Patient #25 returned from the local Emergency Department at 3:50 AM on July 29, 2014. The Nursing RN Note dated July 29, 2014 4:58 AM revealed the following documentation: "[S/he] declined temperature assessment. [S/he] has an open area at back of [his/her] hair but [s/he] refused wound dressing."


The medical record lacked documented evidence a wound assessment was conducted upon Patient #25's return from Emergency Department.


The nursing staff failed to conduct a nursing assessment to include all relevant system findings.


A face-to-face interview was conducted with the Unit Manager and the Deputy Director of Nursing on July 30, 2014 at approximately 10:30 AM. The findings were discussed and acknowledged.

Based on medical record and policy review and confirmed on interview it was determined that the nursing staff failed to consistently document all medication administration in accordance with physician orders in two (2) of five (5) medical records reviewed (Patients #3, 11 and 16)

The findings include:

Hospital Policy 206.09 entitled Medication Ordering and Administration, revised May 9, 2013 was reviewed. Section III, Standards, Item D addresses Nursing Services which stipulates "7. Documentation: a. The authorized RN who administers the medication shall document on the eMAR each time the medication is given to the individual in care. Pharmacy must electronically verify the order for the RN to be able to document in the eMAR drug administration screen ..."


Patient #3 was on May 23, 2014 with diagnoses of Paranoid Schizophrenia, Diabetes Mellitus, Hypertension, Tardive Dyskinesia, and Peptic Ulcer Disease.


Review of the medical record on July 29, 2014 at approximately 10:44 AM revealed the General Medical Officer orders to obtain finger sticks every Monday, Wednesday and Friday before breakfast.


The medical record lacked documented evidence that a fingerstick was completed. Further the nursing staff failed to document patient's refusal of fingerstick on July 25, 2014.

The nursing staff failed to document treatment according to physician's order.
The findings were reviewed, discussed and acknowledged by the unit's Nursing Manager on July 29, 2014 at approximately 12:15 PM.


Patient #11 was admitted June 19, 2014 with diagnoses which included Schizoaffective Disorder, Bipolar Disorder and Dementia, Vascular Type; and medical history of Hypertension, Epilepsy, and status post Right Cerebellar Infarct.

Review of the medical record on July 30, 2014 at approximately 10:10 AM revealed
Patient #11 complained intermittently of pain between June 20, and July 29, 2014. On June 20, 2014 and July, 27, 2014 the General Medical Staff ordered Acetaminophen, 650 milligram by mouth every four(4) to six (6) hours as needed for pain.

Concurrent review of the Electronic Medication Administration Record revealed Patient #11 had eleven (11) opportunities for pain assessment from June 26, through July 29, 2014. The following two (2) opportunities for pain assessment were without documented evidence of an intervention for pain relief: July 5, 2014 at 11:27 AM, generalized pain rated at nine of ten (9/10); and July 8, 2014 at approximately 10:15 AM, pain rated eight of ten (8/10).

The nursing staff was inconsistent in documenting medication administration in accordance with physician orders.

A face to face interview was conducted with the staff nurse reviewing medical records with the surveyor on July 30, 2014 at approximately 11:00 AM. When queried relative to the highlighted entries in the medical record, the nurse explained that the highlighted entries occur when staff does not authenticate medication administration. The staff nurse felt confident that the nursing staff intervened in Patient #11's reports of pain.

The findings were confirmed by hospital staff, present at the time of record review.



Patient #16 was admitted with diagnoses which included Paranoid Type Schizophrenia, and Cocaine Abuse, and medical history of Ante partum Pregnancy with Pregnancy Induced Hypertension, and Vitamin D Deficiency.

Review of the medical record on July 29, 2014 at approximately 2:30 PM revealed on June 25, 2014 the General Medical Staff ordered Sliding Scale Insulin Coverage for Type II Diabetes with the following parameters: Fingerstick glucose three (3) times daily; based on milligrams per deciliter glucose measurements, Regular Insulin was to be administered as follows - 151 to 200, two (2) Units; 201 to 250, three (3) Units; 251 to 300, four (4) Units; 301 to 350, five (5) Units; 351 to 400, six (6) Units; and greater than 400, six (6) Units and notify General Medical Officer.

From June 25, 2014 through July 12, 2014 50 opportunities for glucose monitoring were documented, of which two (2) opportunities were outside physician orders. On July 2, 2014 at 10:49 AM, Patient #16's glucose was measured at 290 milligrams per deciliter for which the nursing staff administered three (3) Units of Regular Insulin; and on July 4, 2014 at 5:06 PM, Patient #16's glucose was measured at 161 milligrams per deciliter for which the nursing staff did not document the administration of any Insulin, or reference as to why Insulin was not administered.

The nursing staff was inconsistent in documenting medication administration in accordance with physician orders.

A face to face interview was conducted with the Charge Nurse of the unit at approximately 2:45 PM on July 29, 2014. The Charge Nurse stated that the expectation is that the nursing staff verify orders, and administer medications accordingly.

The findings were acknowledged and confirmed by hospital staff present, at the time of record review.

1.Based on medical record and policy review, and confirmed on staff interview it was determined that the General Medical staff failed to consistently monitor all present on admission concerns/diagnoses as evidenced by General Medical staff ' s failure to document pertinent data within progress notes, in two (2) of two (2) records reviewed (Patients #11, and 13).

The findings include:

Hospital Policy 2018.10 entitled General Medical Services, revised April 4, 2011 was reviewed. Section III, Standards and Procedures, stipulates "...A. Individuals in care shall receive initial and ongoing assessments of their general medical status to ensure that acute and chronic medical conditions are identified, evaluated and treated in a timely manner and in accordance with generally accepted professional standards of care ... B. The recovery planning process shall include regular evaluation of the efficacy of medical interventions. All assessments and interventions shall be documented, except transient or mild medical or physical conditions expected to resolve in a short time (e.g. sore throat, common cold, athlete's foot, etc) may be addressed in the record as needed ...2. Ongoing assessments a. Quarterly assessment updates-The GMO or NP shall complete routine medical reassessments of individuals on a quarterly basis, at a minimum. The reassessment shall include the following: ...2). Updates in risk assessment and risk indicators during the interval period ...4). Examination findings...6). Significant data regarding findings...8). Assessment of overall status of the individual...9). Plan of care, including medication orders, diagnostic and laboratory studies, consultation referrals, risk management preventive care interventions and follow-up on consultants recommendation."



Patient #11 was admitted June 19, 2014 with diagnoses which included Schizoaffective Disorder, Bipolar Disorder and Dementia, Vascular Type; and medical history of Hypertension, Epilepsy, and status post Right Cerebellar Infarct.

Review of the medical record on July 30, 2014 at approximately 10:10 AM revealed
Patient #11 complained of dental pain on June 20, 2014 and intermittently until record review on July 30, 2014.

According to the Progress Notes of the General Medical Staff, a plan of care was documented to refer Patient #11 to Dentistry on June 20, July 2, 9, 16 and 23, 2014. The medical record reflected that the General Medical Staff was inconsistent in documenting evidence of an examination/assessment of Patient #11's complaint of dental pain, to include location, quality, quantity, aggravating of alleviating factors, and immediate interventions until the treatment plan was completed on July 24, 2014.

The General Medical Staff failed to document all pertinent information in the medical record.

The findings were acknowledged and confirmed by hospital staff, present at the time of record review.


Patient #13 was admitted July 8, 2014 with a diagnosis of Paranoid Type Schizophrenia, and medical history of Type II Diabetes Mellitus, Cellulitis with Abscess, Vitamin D Deficiency, Hypertension and Morbid Obesity.

Review of the medical record on July 29, 2014 at approximately 11:00 AM revealed a history and physical examination was performed on admission July 8, 2014. The admitting General Medical Officer documented erythema, edema, and increased warmth of Patient #13's bilateral lower extremities, consistent with the diagnosis of Cellulitis. The treatment plan for the Cellulitis was to continue Patient #13 on an oral antibiotic, as per the referring hospital's plan.

Further record review revealed Patient #13 refused all medications from July 8 through 14, 2014. According to the General Medical Staff notes dated July 14, 2014 at 7:37 PM, Patient #13 "refused [antibiotic]". The General Medical staff notes lacked specificity to include documented evidence of the location of the Cellulitis; an attempt and/or examination / inspection to determine progression or regression; and a care plan for refusal of medication relative to present on admission diagnoses, and how such refusal could affect psychiatric plan of care.

The General Medical staff failed to document all pertinent information in the medical record. The General Medical Staff failed to consistently monitor and care plan for all present on admission diagnoses/concerns.

The findings were acknowledged and confirmed by hospital staff, present at the time of record review.



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2. Based on policy, and documentation review and confirmation by pharmacy staff, it was determined that the clinical staff failed to consistently document accurate and complete administration, return and/or wasting of controlled substances in nine (9) of nine (9) units surveyed.

The findings include:


Title 22-B, District of Columbia Municipal Regulations for Hospitals Chapter 20, Regulation 2000.2 stipulates "In the absence of requirements in this chapter or in other applicable regulations, the management and operation of each hospital shall be in accordance with applicable Medicare Certificate of Participation requirements, and in the absence of other standards, in accordance with the Joint Commission standards, if applicable, and good medical, nursing and public health practices."

Policy #NPM 3-8.4, revised March 11, 2013, entitled, Utilizing E-MAR and Pyxis-Medication Administration stipulated, "H. Administering Medication. IX. All medication administered to one individual shall be recorded in eMAR before the next individual's medications can be administered."

Documentation review included Physician Order, electronic Medication Administration Record (eMAR), and the Automated Dispensing Machine's (ADM) "All Station Events Report "for all controlled substances dispensed.


On July 30, 2014 and July 31, 2014 a 72 hour "All Station Events Report" was requested for all Controlled Substances for Patient Care Units 1A, 1B, 1C, 1F, 1G, 2A, 2B, 2C, and 2D. The All Station Event Report listed all patients receiving any controlled substances ordered by physician and removed from the ADM. Unit surveys were conducted on July 30, 2014 from approximately 10:30 AM to 4 PM and July 31, 2014 from approximately 1:30 PM to 4:30 PM.

The observations were performed in the presence of the Director of Pharmacy.

It was determined that the hospital staff failed to maintain complete and accurate documentation of administration, return, and/or wasting of controlled substance.

A. On Patient Care Unit 1A, Patients #30, #31, and #32 eMAR indicated that medications were administered to patients before they were removed from the ADM. Actual time of administration could not be determined.

B. On Patient Care Unit 1B, Patients #33, #35, #34 eMAR indicated that medications were administered to patients before they were removed from the ADM. Actual time of administration could not be determined.

C. On Patient Care Unit 1C, Patients #37, #38 eMAR indicated that medications were administered to patients before they were removed from the ADM. Actual time of administration could not be determined. Patient #36 refused medications and controlled substances were not returned to ADM for over 3 hours. Patient #38 was ordered 2.5mg of diazepam 3 times a day. Diazepam 5mg was removed from ADM for every dose. Out of eight (8) doses administered only one (1) had documentation of 2.5mg being wasted.

D. On Patient Care Unit 1F, Patient #51 eMAR indicated that medication was administered to patient before it was removed from the ADM. Actual time of administration could not be determined.

E. On Patient Care Unit 1G, Patients #40, #41 eMAR indicated that medications were administered to patients before they were removed from the ADM. Actual time of administration could not be determined.

F.On Patient Care Unit 2A, Patients #42, #43, #44 eMAR indicated that medications were administered to patients before they were removed from the ADM. Actual time of administration could not be determined.

G. On Patient Care Unit 2B, Patients #45, #46, #47, #21 eMAR indicated that medications were administered to patients before they were removed from the ADM. Actual time of administration could not be determined.

H. On Patient Care Unit 2C, Patients #48, #49, #50, #51 eMAR indicated that medications were administered to patients before they were removed from the ADM. Actual time of administration could not be determined.

I. On Patient Care Unit 2D, Patients #52, #53, #57 eMAR indicated that medications were administered to patients before they were removed from the ADM. Actual time of administration could not be determined.

Based on policy and documentation review and confirmation by staff it was determined that the clinical staff failed to:


Based on policy review and document review, it was determined the hospital staff failed to consistently document the administration and/or waste of all controlled substances dispensed in three (3) of twenty-seven. (Patients #36, 37, 38)

The findings include:
Policy # NPM 3-8.4 "Utilizing E-MAR and Pyxis-Medication Administration" , Physician Order, electronic Medication Administration Record (eMAR), and the Automated Dispensing Machine's (ADM) "All Station Events Report"


A. Patients #37, #38 - On Patient Care Unit 1C: eMAR indicates that medications were administered to patients before they were removed from the ADM. Actual time of administration could not be determined.


B. Patient #38 was ordered 2.5mg of diazepam 3 times a day. Diazepam 5mg was removed from ADM. Out of eight (8) doses administered only one (1) had documentation of 2.5mg being wasted.


C. Patient #36 refused medications and controlled substances were not returned to ADM for over 3 hours.


The findings were reviewed in the presence of Director of Pharmacy.

Based on observation and confirmation by hospital staff it was determined that the pharmacy staff and clinic staff failed to periodically conduct inspection in the Optometry Clinic for outdated stock medications.

The findings include:

Saint Elizabeths Hospital Policy #206-09, revised May 9, 2013, entitled Medication Ordering and Administration: C Pharmacy Services 1) General Pharmacy Functions e. "Designated Pharmacy staff shall periodically inspect areas that stock drugs (including Pharmacy, Night Drug Cabinet, and clinical Units...",


On July 31, 2014, at approximately 3:45PM, the Optometry Clinic in room 115.06 was surveyed. A random survey of medications revealed expired eye drops in clinic. Six (6) out of seven (7) eye drops were expired. Expired medications were removed by hospital staff.

The Pharmacy staff and clinic staff failed to ensure expired medications were not accessible for use.

These observations were made in the presence of the Director of Pharmacy on July 31, 2014 at approximately 3:45 PM.

Based on observations during the dietary survey, it was determined that dietary services were not adequate to ensure that foods are always served in a safe and sanitary manner.
The findings include:
1. Quarts of Sweet Tea were observed stored in the Juice Box beyond the expiration date of July 28, 2014, at 9:30 AM on July 29, 2014 in 11 of 11 observations.
2. Trays of entrees were stored on carts without dome covers, exposing foods to potential contaminants while stored in the Retherm Refrigerator in 11 of 11 observations at 10:20 AM on July 29, 2014.

3. The inner and lower panels of convection ovens were observed soiled with food spillages in the cooks area in two (2) of two (2) observations.

4. The yellow electric cords, originating from a recoil device in the ceiling, were soiled with deposits on the lower surfaces in the cooks areas in two (2) of two (2) observations at 10:45 AM on July 29, 2014


5. The Ansul Extinguishing System lacked a recent inspection tag to indicate that the system was serviced and tested within the last six (6) months, to ensure that the system will operate properly in the event of an emergency. The last date of service on the inspection tag was September 2013 in one (1) of one (1) observation at 11:30 AM on July 29, 2014.

6. Mops, brooms, and dust pans were improperly stored on floor surfaces in the Janitorial Closet in one (1) of one (1) observation at 11:00 AM on July 29, 2014.

7. Floor tile surfaces in the Main Kitchen were damaged. Tiles surfaces were separated and the concrete surfaces were exposed and uneven near the Pot and Pan Wash Area and in the entrance to Storage Room 2 in two (2) of two (2) observations at 11:30 AM on July 29, 2014.


8. Hotel pans were not thoroughly cleaned after washing in the Pot and Pan Wash Area as evidenced by leftover foods left on the interior and exterior surfaces. Pans were stored wet and not allowed to dry before placing on shelves for reuse in the following instances:
A. 12- 12 X 18 X 2 inch pans were wet.
B. 10- 14 X 24 X 6 inch pans were wet.
C. 3- 14 X 24 X 6 inch pans were soiled and stored wet.
D. 11 of 20 Sheet Pans were stored wet and soiled with leftover foods in corner surfaces.

These observations were made at approximately 3:00 PM on July 29, 2014.

9. The interior surfaces of large bins, approximately 14 X 24 X 2 inches, used to store ladles and scoops were observed soiled on the bottom surfaces in five (5) of five (5) surfaces at 2:45 PM on July 29, 2014.

Based on observations during the survey, it was determined that housekeeping and maintenance services were not adequate to ensure that the facility is maintained in a safe and sanitary manner.

The findings include:

1. The following findings were observed during a tour of the Unit 1 B, between 9:30 AM and 10:40 AM on July 31, 2014.

A. The interior louver surfaces of exhaust vents were soiled with dust accumulation in Rooms 1A14, 1A29, 1A32, 1B42, 1B25, 1B26, 1B48, 1B44 and 1B54.

B. Wall surfaces were marred and damaged on the lower surfaces and around the perimeter in hallway A, Group Room, Medication Room and Rooms 1B20, 1B44, 1B62.

C. Door and door jamb surfaces were observed marred and scarred at the entrances to 1B20 and 1B66.

D. Privacy curtain hooks were detached from tracks in Rooms 1B24, 1B48 and 1B55.


E. The soap dispenser cover was not secured in Room 1B20.

F. Ceiling surfaces were damaged, paint was observed peeling around the perimeter of vents in Room 1B24.


G. A strong pugnacious odor was detected, and the faucet continued to run after the water supply had been turned off in Room 1B25.

H. Caulking around the base of the toilet was observed soiled and smeared on floor surfaces in Rooms 1B25, 1B46, 1B47, 1B48 and 1B54.

I. Mold growth was observed on the corner surfaces of shower handrails in Rooms 1B23 and 1B26.


J. The toilet seat was unsecured and damaged in Room 1B26.

K. The horizontal surfaces of the patients ' bed frames were observed soiled with accumulated dust in Rooms 1B28, 1B32 and 1B44.


L. The wardrobe was observed damaged and the door failed to move freely on the track in Room 1B44.

M. Window sill surfaces were observed soiled in Room 1B44.


N. Wall surfaces were observed soiled and marred in Hallways A and C.

O. Caulking around the base surface of the toilet was soiled, and excessive caulking was applied to floor surfaces in Room 1B55, and 1B54.


P. Kitchen door surfaces were marred; food bins were stored on floor in Room 1B03. The interior surfaces of the Cafeteria accordion door were soiled with accumulated debris. The interior surfaces of the Ice Machine chutes were soiled with accumulated mineral deposits. Linen carts were very soiled, and the interior surfaces of exhaust vents were soiled with dust in the Kitchen Area 1B03.

Q. The clean linen cart was soiled.


2. The following findings were observed during a tour of Unit 1A between 10:30 AM on July 15, 2014.

A. Floor surfaces were damaged, and needed repair or replacement in the Center Hallway.

B. The interior and exterior surfaces of exhaust vents were soiled with dust in Rooms 1A03, 1A05, 1A19, 1A25, Dietary Storage and Medication Room.


C. The backrest surfaces of the shower/toileting chair were worn and in need of replacement in Shower Room 1B52.

D. The faucet handle was broken and damaged in the Holding Area.


E Shelf surfaces were dusty, and the weighing scale was soiled with dust in the Nursing Supply Room 1A08.

F. The vacuum cleaner, bottom surfaces of the weighing scale and floor surfaces were soiled with dust in the Nursing Supply Room.


G. Caulk around the base surfaces of the toilet were soiled and excessively applied to floor surfaces in 1A23.

H. A small cart near the Therm Air Machine was soiled, and open drains were soiled with debris in Room 1A03.


I. Napkins, Plastic Cups and other dry goods were improperly stored on the floor in the Dietary Storage Room.

J. Accumulated dust was observed on the dryer ductwork, and the ductwork was separated from the dryer. Wall surfaces were marred in the hallway outside of the Laundry Room.


K. Shower curtain hooks were detached in Rooms 1A25 and 1A53.

L. Paint was observed peeling near the vent in Room 1A53.


M. The patient ' s bedside mat was soiled and stained with accumulated debris in Room 1A63.

N. The backrest, seat and leg rest surfaces of the patients Geri Chair were soiled with debris in 1A63.


O. The exterior window surfaces were soiled and stained.


P. Floor surfaces were soiled, stained, and damaged in room 1A62. Floor tile surfaces at the entrance to the shower room were damaged; and needed repair and tile surfaces needed caulking in rooms 1A25, 1A58 and 1A23.


Q. Wall surfaces were marred, damaged and were in need of repair behind sofa chairs; and sofa chair armrests were very worn in Hallway B.


R. The escutcheon ring around the sprinkler head in Room 1A48 was rusty.


S. A strong urine odor, and flying insects were detected; and the hot water temperature were 89 degrees Fahrenheit, in Room 1A47.


T. Door jamb surfaces were observed marred and scarred in room 1A45.


U. A large screw was observed protruding from the backrest of a chair in room 1A42.

V. The top surfaces of the patient ' s wardrobe were soiled with dust and debris in Room 1A39.


W. Wall surfaces in the Hallway C were observed marred and painted ceilings were damaged in Rooms 1A19, 1A28.


X. The Restroom privacy curtain was missing; and the base surface of the toilet was not secured to floor, in Room 1A25.


Y. Excessive caulk was observed around the toilet and floor surfaces in Room 1A25.


Z. The upper areas of the accordion door were soiled, and the sink was in need of cleaning in the Medication Room.


AA. The base surfaces of the portable blood pressure machine were soiled with accumulated debris in 1A19.


3. The following findings were observed during a tour of Unit 2B between 2:35 PM and 4:00 PM on July31, 2014.

A. The inner chute area of the Ice and Water dispensers on the Ice Machine were soiled with mineral deposits and other solid debris in the Nutrition Service Area.


B. Boxes of supplies were observed on floor surfaces in Room 267.


C. The bottom shelf surfaces of Soiled and Clean Linen Carts were very dusty in Rooms 2B05 and 2B06.


D. Hot water temperatures in the Kitchenette were measured and determined to be 92 degrees Fahrenheit which is below the minimum 95 degree Fahrenheit for hand washing in Room 2B03.


E. The Clean Linen Cart covers were worn, torn, and failed to fully cover in Room 2B06.


F. Shelf surfaces were very soiled with dust in four (4) of (4) shelves in 2B07.


G. Floor surfaces were observed soiled with dust and other products in Room 2B09; floor tiles and the threshold were damaged at the entrance to Room 2B24; dust accumulation was observed under the bed in Room 2B56; and floor surfaces in the rear of the dryer was soiled in the Laundry Room.


H. The interior and exterior surfaces of exhaust vents were soiled with dust in Rooms 2B09, 2B26, 2B42, 2B46, 2B52, 2B53 and 2B56.


I. Shelf surfaces in the Nursing Storage Room were soiled with dust.

J. Wall surfaces were marred and damaged in Rooms 2B20 and the Laundry Room 2B56.


K. Hard water stains were observed in the sink in Room 2B14.2.

L. Paint was observed peeling in the ceiling near exhaust vents in Rooms 2B23, 2B49 and 2B24.


M. The lower and upper Windows were soiled with dust on in Room 2B31.


N. A strong pugnacious odor was present in the patients ' rooms; and the top and track surfaces of the wardrobe were dusty in rooms 2B40 and 2B45.


O. The base surfaces of the toilet were soiled and caulk was observed spread unevenly on the floor in room 2B55.


P. Wall and floor surfaces in the rear of the washer and dryer were soiled with dust accumulation; and the ductwork was soiled with dust accumulation in Room 2B66 Laundry Room.


4. The following findings were observed during a tour of Materials Management at 9:30 AM on August 1, 2014.

A. Exhaust vents were soiled with dust in the Clean Linen Storage Area, and wall surfaces were marred in the hallway outside of the Clean Linen Storage Area.


5. The following findings were observed on Unit 1D between 9:50 AM and 12:00 PM on August 1, 2014.

A. Floor surfaces were soiled and marred in Rooms 1D08, 1D60 and 1D66.

B. Janitorial closet floor surfaces were observed damaged; and the buffer and vacuum cleaner machines were soiled with dust in Room 1D09.

C. Shelf surfaces were soiled and in need of cleaning; floor surfaces were in need of cleaning around the perimeter of the Special Storage Area Room 1D07.


D. Floor surfaces were soiled and stained around the perimeter and under the patients ' bed in Rooms 1D35, 1D56, 1D07, 1D56, 1D60, 1D66 and 1D69.

E. The toilet seat was not secured; the privacy curtain was observed missing; and the interior surfaces of exhaust vents and louvers were soiled with dust in Room 1D55.


F.. Exhaust vents were soiled; ductwork in the rear of and over dryers was soiled with dust accumulation in rooms Laundry Room, 1D16, 1D66, , 1D39, 1D07, 1D52, 1D55, 1D26, 1D40, 1D41, 1D47, 1D48, 1D53, 1D55, 1D69, Treatment Room and 1D19.

G. The exterior surfaces of the escutcheon ring around sprinkler heads were rusty in Shower Room 1D52.

H.The top surfaces of patient ' s wardrobe were soiled with dust in Room 1D62.

I. Floor surfaces in the rear of washers/dryers and ductwork above dryers was soiled with dust and accumulated debris in the Laundry Room.

J. The shower curtain was soiled in Room 1D53 and 1D55 and the shower liner was missing in 1D24.

K. The toilet seat was not fully secured and moved back and forth when examined, and the privacy curtains were missing to Rooms 1D54 and 1D55.

L. The faucet failed to turn the hot water supply off in the Staff Bathroom.

M. The shelf and frame surfaces of large carts were soiled with accumulated debris in Room 1D05.

N. The inner surfaces of storage bins containing condiments in the Multi- Purpose Room were soiled. The drain under the sink overflowed when the water faucet was turned on, in the Nutrition Room.

O. Hot water temperatures were measured and determined at 75.9 degrees Fahrenheit and below the minimum of 95 degrees Fahrenheit requirement in Room 1D07.

P. Metal drain covers located outside of the facility between the 1D Suites were covered with heavy accumulation of leaves and other debris.

Q. The exterior surfaces of the toilet were soiled; window pane surfaces were soiled on the interior and exterior; and the fall mat was soiled on the top and bottom surfaces in Room 1D31.

R. Door hinge surfaces were dusty; and the inner areas of the sink were heavily soiled, in Room 1D31.

S. During a tour of Unit 1 D, it was determined through staff interview that the patients toilet door (1D26) was removed approximately two (2) months ago and has not been replaced by engineering staff after a request was made by Unit 1D Staff.

T.. Graffiti was observed on wall surfaces, the sink lacked an aerator to avoid water splashes and the hot water temperature was 83.3 degrees Fahrenheit, which is below the minimum of 95 degrees Fahrenheit requirement in the room 1D25.

U. The exterior surfaces of escutcheon ring around sprinkler heads were soiled in Room 1D35.

V. A dark substance was observed around the perimeter of the soap dish and handrails which appears to mold and/or mildew growth in Rooms 1D23 and 1D48.

W. The C Area sofa chair arms were worn, and wall surfaces were marred behind chair head rest.

X. Terrace floor surface and furnishings were observed stained and needed cleaning on Unit 1D.

Y. Ceiling tiles were peeling near exhaust vents; floor surfaces were uneven; the shower liner was missing; and mold growth was observed on the sides of the faucet in Room 1D48.

Z. The hand sink lacked an aerator to prevent splashing; floor surfaces under and in the rear of equipment were soiled with dust; and chair seat surface was worn in 1D20.

AA. Caulking was separating from wall surfaces; the entrance door was marred and needed refinishing; and caulking was soiled and damaged at the entrance in Room 1D19.

6. The following findings were observed during a tour of the Medical Suite Treatment Areas between 11:58 AM and 12:30 PM.

A. Floor surfaces were needed cleaning in the Radiology Storage Area. Floor surfaces were needed caulking around the toilet in the staff restrooms near the Radiology Area.

B. The Specimen Refrigerator was soiled on the interior surfaces.


C. The treatment mat, blinds and the base surface of the parallel bars were soiled and stained in the Physical Therapy Area.

D. The top surface of the cubicle dividers were soiled with accumulated dust; and hot water temperature at the hand sink were 83.7 degrees Fahrenheit, below the minimum 95 degree requirement in the Dental and Physical Therapy Areas.


E. The sink drained slowly; the base of the Podiatry Treatment chair was soiled with dust; floor surfaces near the windows were soiled with dust; and the internal areas of ceiling lamps were soiled in the Podiatry Area.

F. The base surfaces of the Dental Chair were soiled, and a multiple outlet was observed on floor surfaces.

G. The top surfaces of the AED Cabinet were soiled with dust accumulation, and the base surfaces of the Welch Allen holder were soiled with debris in Room 117.02

H. The top surfaces of the Orthodontic X -Ray Machine were dusty in Room 117.06.

7. Based on observations during the survey period, it was determined that the Hot water boilers and mixing valves were not functioning properly to maintain hot water temperatures within the required temperature range.

The findings include:

During the Environmental Tour, it was determined that hot water temperatures were above the 120 degrees Fahrenheit limit, as required in District of Columbia Municipals Regulations for Hospitals, Title 22.
.
Hot water boilers and mixing valves were not operating or adjusted properly to ensure that domestic hot water temperatures are maintained within the required limits, which would protect patients from scalds and burns.

Temperatures in the 1A Medication Room were determined to be 128 degrees Fahrenheit. Elevated temperatures were also observed Unit 2B between 2:35 PM and 2:53 PM, in Rooms 2B06 and 2B26 at 128 and 127degrees Fahrenheit, respectively.