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Based on record review, policy review, staff interviews and patient representative interview, it was determined that the hospital staff failed to address the patient representative's complaint about hand hygiene and sanitary practices.

The findings include:

The GWUH Hospital Policy Number 713, effective February 2013, titled, 'Patient Grievance/Complaint Management, ' stipulates, " ... III. Definitions B. Patient Grievance: A grievance includes written or verbal complaints regarding the following: 5. If the patient or the patient ' s representative requests that a complaint be handled as a formal complaint or grievance or when the patient requests a response from the hospital, the complaint is considered a grievance ....Procedure: B. Complaint/Grievance Management 1. When a complaint/grievance is made by a patient or the patient ' s representative, the following process will be followed: a. As the representative of the hospital Grievance Committee, the hospital will coordinate the complaint and grievance process, and will receive the complaints and /or grievances for follow-up...d. The results of the investigation and resolution of each complaint will be promptly communicated to the patient by the manager or a representative from the hospital ...C. Resolution of a Grievance and Communication with Patient ...4. The expectation is that all grievances will be resolved within an average of seven (7) days. If the investigation and resolution of the grievance cannot be resolved within this timeframe, a letter of acknowledgement shall be sent to the patient or the patient ' s representative. The letter will contain an expected date that the resolution letter will be sent. 5. For those cases for which a resolution cannot be reached in an average of seven (7) days, a final written response regarding the hospital ' s investigation and resolution of the grievance shall be sent to the patient within 21 days of receipt of the formal grievance ...7. A grievance is considered resolved when the patient is satisfied with the actions take[n] on their behalf. The hospital must maintain documentation of its efforts."


Patient #1 was admitted with diagnoses that included Comminuted Fracture of the Left Humerus and Distal Left Radius Fracture, for which s/he underwent an Open Reduction Internal Fixation (ORIF) of the Left Humerus and Radius.

A review of the Patient #1's medical record revealed the following:

An 'Orthopaedic Surgery Initial Consult Note' dated November 27, 2015 at 4:02 PM that indicated Patient #1 had "displaced 3 part Proximal Humerus Fracture and Volarly Displaced Distal Radial Fracture ... small abrasions on dorsum of wrist and hand ...splint to left forearm ...sling and swath ...pain control ..." and "daughter considering transferring care to Anova [Inova] Fairfax."

The Case Management note performed on November 28, 2015 at 12:30 PM indicated the patient ' s family member requested information for the Administrator on Duty and was referred to the House Operation Supervisor.

Review of the Daily Progress Note dated November 30, 2015 at 11:38 AM revealed the family was concerned that sterile technique was not used [with Patient #1],during the Foley catheter insertion.

Nursing documented on November 30, 2015 at 4:48 PM that the patient's family member verbalized care concerns, mentioned the need to speak with " Employee #3 " in administration several times, and the nurse documented s/he left a message with " named Employee 3 ".

On March 14, 2016 at approximately 8:45 AM, a face-to-face interview was conducted with Employee #1, in the presence of Employee #4. Employee #1 was asked to provide all grievances and/or complaints from November 1, 2016 to March 14, 2016. Review of the information that was provided at approximately 3:55 PM failed to reveal any documentation of the complaint/grievance related to Patient #1. Employee #1 and 4 explained that there was no documentation related to concerns regarding Patient #1.

On March 27, 2016 at approximately 3:40 PM, a telephone interview was conducted with Patient #1's family member [Complainant] regarding concerns about the mother's care at GWUH hospital. The family member shared that s/he spoke with Employee #2, related to the staff 's lack of hand hygiene and sanitization, while caring for his/her mother. S/he explained s/he provided Employee #2 with a copy of the complaint and hand written notes, including compliment notes about two excellent nurses that were on the unit. S/he stated that Employee #2 commented that s/he was taking the complaint seriously and someone would get in touch with him/her. The family member added that several attempts to contact the patient advocate were made, without success and no one has contacted him/her regarding the complaint.

On March 30, 2016 at approximately 10:02 AM, a telephone interview was conducted with Employee #2 regarding the complaint made by Patient #1's family member. Employee #2 could not recall the specific complaint but explained the complaint process as it relates to him/her. S/he explained, "Some complaints, I can handle immediately but if it's a written complaint, " I fax it to the patient advocate, give the patient a copy, and I always tell the patient this will be looked into."

On April 22, 2016 at approximately 3:00 PM, a telephone interview was conducted with Employee #3 regarding the aforementioned complaint. Employee #3 explained the Complaints/Grievance Management process. S/he stated s/he did not receive any notification or a complaint or grievance regarding Patient #1.

The findings reveal the hospital staff failed to follow the hospital's policy to coordinate the complaint/grievance process to address the patient representative's complaint.

The findings were acknowledged by Employee #1.

A. Based on observation, policy review, staff interviews and patient representative interview, it was determined that the hospital staff failed to follow the hospital's policy relative to the practice of hand hygiene to prevent the spread of infection.

The findings include:

The George Washington University Hospital (GWUH) Policy Number document titled, 'Hand Hygiene Policy,' effective February 2016, stipulates, " ... V. Procedure: b. To use: ...ii. Rub hands together vigorously, interlacing fingers, including the back of the hands and wrists, for at least 15 seconds ...3. Use alcohol-based hand rub (ABHR) for other situations, unless hand are visibly soiled... a. Indications for using ABHR: i. Before and after direct patient contact ...iii. Before donning gloves (both sterile and clean) iv. After removing gloves v. Before inserting invasive devices vi. After contact with patient's intact skin vii. After contact with objects and equipment in the patient's immediate vicinity ... "

1. On March 14, 2016 at approximately 8:55 AM, a tour was conducted in the Emergency Department with Employee #5 and Employee #6. Employee #8 was observed at approximately 9:30 AM washing his/her hands in the sink, across from bed #10. S/he washed his/her hands for seven (7) seconds, not 15 seconds, as per the GWUH hospital policy.

On March 14, 2016 at approximately 9:35 AM, a face-to-face interview was conducted with Employee #8, regarding hand washing practice. Employee #8 was queried about the length of time considered appropriate for hand washing, per hospital policy. S/he replied, "about 20 seconds. " When asked if s/he washed his/her hands for at least 15 seconds, s/he replied, "I probably washed them a little less."

The observation revealed that staff failed to practice hand hygiene to prevent the spread of infection, according to the hospital's policy.

Employee #6 acknowledged the findings.

2. Patient #1 was admitted with diagnoses that included Comminuted Fracture of the Left Humerus and Distal Left Radius Fracture, for which s/he underwent an Open Reduction Internal Fixation (ORIF) of the Left Humerus and Radius.

On March 14, 2016 at approximately 9:45 AM, Employee #7 was observed in room #14, donning gloves and preparing intravenous fluid, hanging the fluid, documenting on the computer that was in the room, touching the patient and scanning the patient's bracelet, returning back and forth to the computer to document, opening drawers, drawing intravenous medication and administering it, removing soiled linen from the patient's bed, and turning off the computer (before disposing of the soiled linen).

Employee #7 did not remove the gloves to sanitize or wash his/her hands, before performing multiple tasks or after contact with the patient or objects and equipment. The observation was made in the presence of Employee #6.

The observation revealed that staff failed to practice hand hygiene to prevent the spread of infection, according to the hospital's policy.

Employee #6 acknowledged the findings.

B. Based on observation, policy review, and staff confirmation, it was determined that the hospital staff failed to perform sanitary practices to store linens in a clean and dry area.

The findings include:

The George Washington University Hospital (GWUH) Policy Number 9006, effective January 1, 2014, titled, ' Storage, Collection and Transportation of Linen, ' stipulates, " ...PROCEDURE: Clean Linen: The clean linens shall be stored in a clean, dry area that is easily accessible to patient care staff and out of the main traffic flow ..."

Patient #1 was admitted with diagnoses that included Comminuted Fracture of the Left Humerus and Distal Left Radius Fracture, for which s/he underwent an Open Reduction Internal Fixation (ORIF) of the Left Humerus and Radius.

On March 14, 2016 at approximately 8:55 AM, a tour was conducted in the Emergency Department with Employees #5 and 6. The following observation was made:

Two hospital gowns and two white sheets were observed in open plastic on the sink, near the water faucet, in Procedure Room labeled #22-25.

The observation revealed that staff failed to practice sanitary measures to prevent the spread of infection and ensure that linens were stored, according to the hospital's policy.

Employee #6 acknowledged the findings.