HospitalInspections.org

A Federal (validation) life safety survey code inspection was conducted on January 12, 2011 through January 13, 2011. Based on observation and staff interview it was determined that the life safety code requirement was not met on the condition level. The facility failed to ensure that no fire or life safety hazards exists in the facility relative to the sprinkler system, proper storage of items off the floor surface, improper use of extension cords, and the presence of penetrations in ceiling and walls.

The findings include:

The automatic sprinkler system and standpipe caps were not continuously maintained in proper operating condition in one (1) of two (2) patient floors; automatic fire alarm system was not continuously maintained in proper operating condition in one (1) of two (2) patient floors and three (3) ancillary areas; storage of items was observed directly on the floor; extension cords were used for permanent fixtures in the Main Kitchen located by the steam table; and facility doors did not close flush and latch in frames.

Environmental staff persons were with the surveyors during the inspection and were made aware of the findings.

Details of the deficient practices are cross referred under the life safety code National Fire Protection Association applicable citations (see K130 Miscellaneous).

Based on medical record and policy review it was determined that the hospital staff failed to document the one-hour face-to-face assessment for the use of restraints in two (2) of seven (7) medical records reviewed of patients with restraints (Patients# 13 and 15).

The findings include:

A. Patient #13 was admitted December 30, 2010 with diagnoses including Respiratory Failure with Ventilator Dependence, Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, Anasarca, Encephalopathy, and Hypertension. Review of the medical record on January 13, 2011 at approximately 10:00 AM revealed the physician wrote orders for wrist restraints as follows: January 9, 2011 at 5:30 PM; January 10, 11 and 12, 2011 at 8:00 AM. The medical record lacked documented evidence of face-to-face assessment and/or reassessment supporting the restraint orders.


B. Patient #15 was admitted October 29, 2010 with diagnoses including Paraplegia of Bilateral Lower Extremities, Respiratory Insufficiency, Ventilator Dependence, Coronary Artery Disease, Diabetes Mellitus and Sacral Decubitus Ulcer. Review of the medical record on January 12, 2011 at approximately 11:05 AM revealed the physician wrote orders for wrist restraints on January 2, 3, 4, 5, 10, 11, and 12, 2011. The medical record lacked documented evidence of face-to-face assessment and/or reassessment supporting the restraint orders on January 3, 4, 10, 11, and 12, 2011.

Further, the restraint orders dated January 5, 2011 lacked a physician ' s attestation or justification as to the use of restraints or the type of restraint to be used.

1. Based on observation, record review and confirmed by staff interview for 12 records reviewed, it was determined that facility staff failed to assess pain and the effectiveness of pain control interventions for an isolated medical record. Patient #6.
The findings include:
Hospital policy number CS.022 entitled Pain Assessment and Management stipulates, Part II-A, " Patients shall have their pain assessed, treated and reassessed promptly and appropriately by competently trained staff ...IV-A Patients have the right to appropriate assessment and management of pain. This includes (1) initial assessment of pain on admission ...and at least once per shift (2) reassessment of pain after pain medication or non-pharmaceutical intervention ...".
Patient #6 was admitted December 28, 2010 with diagnoses that included End Stage Renal Disease on Hemodialysis, Hypertension, Chronic Back Pain and Urosepsis.

Physician ' s orders dated January 7, 2011 directed the administration of Percocet 2 tabs every 6 hours as needed for pain. The record revealed nursing staff utilized the numeric pain intensity scale ranging from 0 - 10 with " 0 " indicative of no pain and " 10 " indicative of severe pain. A review the medical record and the pain management section of the nursing flow sheets for the period of January 8 through 12, 2011 revealed nursing staff failed to consistently assess pain in correlation with the administration of pain medication and failed to reassess the patient ' s pain status after the administration of pain medication as follows:

On January 9, 2011, Percocet was administered (for pain) at 5:00 AM, 11:00 AM and 8:15 PM. The record lacked evidence of a pain assessment prior to the 5:00 AM Percocet administration. At 5:30 AM, the patient was assessed with moderate pain, 6/10, without documented evidence of interventions related to the lack of efficacy of the pharmaceutical intervention. At 9:55 AM the patient ' s pain was assessed as severe, 7/10 and intervention was implemented approximately one hour (1) later (Percocet administered at 11:00 AM). At 4:16 PM the patient was assessed with severe pain, 8/10 with no evidence of pain management intervention. There was no evidence of a pain assessment prior to the administration of the Percocet administered at 8:15 PM.

On January 11, 2011, Percocet was administered at 2:10 AM, 9:55 AM and 4:16 PM. The record revealed the patient ' s pain was assessed as severe, 7/10 at 1:00 AM and greater than an hour lapsed prior to pain management intervention (Percocet was administered at 2:10 AM). At 6:00 AM, the patient ' s pain was assessed as severe, 7/10 and there was no evidence of pain management intervention. The record lacked evidence that the patient ' s pain was assessed prior to or after the administration of the 9:55 AM and 4:16 PM Percocet administration.

Nursing staff failed to consistently assess and/or reassess the patient ' s pain in correlation with pharmaceutical pain management interventions and there was no evidence of assessments related to the efficacy (or lack thereof) of pharmaceutical interventions.

The findings were reviewed and confirmed during a face-to-face interview with the charge nurse on January 12, 2011 at approximately 3:00 PM.

2. Based on observation, medical record review and confirmed by staff interview for six (6) of 34 records reviewed, it was determined that nursing and respiratory staff failed to follow physician's orders. Patients #3, 5, 6, 20, 22 and 23.

The findings include:

A. Patient #3 was admitted January 5, 2011 with diagnoses that included End Stage Renal Disease on Hemodialysis, Hypertension, Lower Extremity Amputation and Decubitus Ulcer.

Physician ' s orders dated January 6, 2011 directed the administration of Duragesic 50 mcg patch every 72 hours for pain.

A review of the Medication Administration Record [MAR] revealed nursing staff administered Duragesic on January 7, 2011 at 10:00 PM and the succeeding dosage was administered on January 11, 2011 at 10:00 AM. Greater than 72 hours lapsed between doses.

A face-to-face interview was conducted with the nurse manager on January 12, 2011 at approximately 2:00 PM. He/she acknowledged that the succeeding dosage should have been administered on January 10, 2011.

B. Patient #5 was admitted January 4, 2011 with diagnoses that included Congestive Heart Failure exacerbation, Chronic Obstructive Pulmonary Disease, status post Pleural Effusion and Respiratory Failure.

Facility staff failed to act on a physician ' s order to educate the patient on the use of bronchodilator medications. Additionally, nursing staff failed to assess the patient ' s intake and output in accordance with physician ' s orders.

Physician ' s orders dated January 6, 2011 directed the respiratory therapist to " instruct the patient on how to use Advair and Spriva " [bronchodilators].

The medical record lacked evidence that the patient was instructed as ordered.

A face-to-face interview was conducted with the charge nurse and respiratory therapist on January 12, 2011 at 2:30 PM. They concluded that there was no documentation to support the patient had been educated.

Additionally, Patient#5 ' s record revealed physician ' s orders dated January 4, 2011 for the assessment of " strict intake and output, " indicated for the patient ' s history of Congestive Heart Failure.

A review of nursing flow sheets for the month of January 2011 revealed nursing staff inconsistently assessed the patient ' s intake and output. " BSC " [bedside commode] or " bedpan " was frequently documented in the output section allotted for void assessments. The section allotted for the amount of oral intake consumed most often remained blank.

The findings were reviewed and confirmed during a face-to-face interview with the nurse manager on January 12, 2011 at approximately 2:30 PM.

C. Patient #6 was admitted December 28, 2010 with diagnoses that included End Stage Renal Disease on Hemodialysis, Hypertension, Chronic Back Pain, Diabetes Mellitus and Urosepsis.

A review of Patient #6 ' s clinical record revealed nursing staff omitted a scheduled dosage of insulin without reason and failed to discontinue insulin in accordance with physician ' s orders.

Physician ' s orders dated January 2, 2011 directed the administration of Lantus insulin 15 units at bedtime.
The Medication Administration Record [MAR] revealed that nursing staff omitted Lantus insulin on January 11, 2011. The record lacked evidence as to why the insulin was not administered.
Physician ' s orders dated January 3, 2011 directed the discontinuance of Novolog insulin 5 units with meals.
The MAR revealed that nursing staff administered Novolog 5 mg with lunch and dinner on January 8, 2011, greater than 4 days after the order was discontinued.
The findings were reviewed and confirmed with the charge nurse on January 12, 2011 at approximately 4:00 PM.

D. Patient #20 was admitted on December 31, 2010 with diagnoses of Status post (S/P) Septic Shock secondary to Hypoxia, Respiratory Failure, End Stage Renal Disease and S/P Gastrointestinal (GI) Bleed. Review of the medical record revealed that the physician ordered ' Vitals Q 1 hour (?) x 3, then Q 4 hours on January 13, at 11:42 AM after a hypotensive episode in hemodialysis. The patient completed dialysis at 11:05 AM. Review of the hosptial flowsheet revealed vital signs were documented at 1:00 PM. There was no documented evidence that the nurse completed vital signs every hour, for two additional readings after 1:00 PM.

Interview with medical director on January 14, 2011 at approximately 11:30 AM revealed that s/he remembered the episode. According to the medical director, the patient had returned to the unit from dialysis and the dialysis nurse informed her/him directly of the patient ' s hypotensive episode while he was in dialysis. The medical director stated s/he then told the nurse assigned to the patient that shift about monitoring the patient ' s blood pressure. The physician stated she reviewed the orders with the nurse to include the vital signs.


E. Patient #22 was admitted on January 4, 2011 with diagnoses of Right Inguinal/Groin Abscess, S/P Right Food Amputation, with a history of Hypertension, Hepatitis B, and Intravenous Drug Abuse (IVDA). Review of the medical record on January 12, at 12:05 PM revealed on admission the physician ordered " Left SCD [sequential compression device] to Left Lower extremity and weigh patient on admission and weekly".

During walking rounds with the Nurse Manage and the nurse assigned to the patient on January 12, 2011 at approximately 10:45 AM, it was observed that the patient did not have the SCD on his left lower extremity. Upon review of the medical record, the order was brought to the Nurse Manager 's attention. The Nurse Manager confirmed that the patient did not have the SCD applied. The physician was notified and the SCD was discontinued.

Review of the medical record revealed that patient weights had not been documented since admission. The Nurse Manager confirmed that patient weights are obtained weekly on Sundays. Further review revealed no patient weight was documented on January 9, 2011. The medical record lacked documented evidence that the weight was completed.

The nursing staff failed to follow the physician orders regarding placement of the SCD on the patient ' s left lower extremity and weighing the patient.

F. Patient #23 was admitted on December 20, 2010 with diagnoses of Bilateral Lung Consolidation and Left Lung Effusion, Respiratory Failure, S/P Tracheostomy, Hypertension, and Diabetes Mellitus. The patient transferred from the Critical Care Unit on January 7, 2011.

Review of the medical record on January 13, 2011 at approximately 1:00 PM revealed the physician ordered " Finger sticks Q 6 hours with Medium Dose Novolog insulin coverage" on December 21, 2010. Review of the Glucose Monitoring Flow Sheet revealed the nursing staff failed to document results of finger sticks on December 24, 2010 for the 12:00 noon and 6:00 PM scheduled tests.

The findings were reviewed and acknowledged by the Nurse Manager during the record review.

3. Based on medical record review and staff interview for one (1) of 34 records reviewed, it was determined that facility staff failed to verify the accuracy of the Medication Administration Record [MAR] for the administration of an antihypertensive medication. Patient #1
The findings include:
A. Patient #1 was admitted November 29, 2010 with diagnoses that included Respiratory Failure status-post Tracheostomy, Chronic Debility, Contractures, Cerebrovascular Accident, Anoxic Brain Injury, Encephalopathy and Sepsis.
The clinical record revealed a physician's order dated December 2, 2010 that directed the administration of Clonidine (an antihypertensive medication) 0.1 mg by mouth (po) every 6 hours as needed (prn) for a systolic blood pressure [BP] greater than 170 mm Hg [millimeters of mercury] for a diastolic blood pressure greater than 105 mm Hg.
A review of the preprinted Medication Administration Records [MAR] for the months of December 2010 and January 2011 revealed the Clonidine order was inaccurately transcribed as " Clonidine 0.1 mg po every 6 hours prn for systolic blood pressure greater than 120 mm Hg ..."
During the period of December 2, 2010 through January 13, 2011, the MAR revealed nursing staff administered the Clonidine on eight (8) occasions when the patient ' s systolic BP was assessed less than 170 mm hg as follows: December 5, 2010 at 10:15 PM; December 27, 2010 at 7:00 AM and 6:30 PM; January 3, 2011 at 6:05 AM and 7:00 PM; January 5, 2011 at 2:30 PM; January 7, 2011 at 10:30 AM and January 11, 2011 at 11:00 AM.
Nursing staff failed to verify the accuracy of the MAR in accordance with physician ' s orders for the administration of the " prn " use of Clonidine.
The findings were reviewed and confirmed during a face-to-face interview with the nurse manager on January 14, 2011 at approximately 11:00 AM

Based on observation, record review and confirmation by staff interview for one (1) of twelve (12) records reviewed for patient's with behavior issues, it was determined that hospital staff failed to develop a care plan for behaviors for Patient #4.
The findings include:
Patient #4 was admitted December 28, 2010 with diagnoses that included Second Degree Burns to Upper and Lower Extremities, Schizophrenia and Mood Disorder.
A review of interdisciplinary progress notes for the period of January 5 - 12, 2011 revealed the patient exhibited episodes of challenging behaviors inclusive of loud verbalizations, demands, forceful movements, pacing, resisting care and verbalizing the presence of hallucinations. An observation of the patient on January 13, 2011 revealed the patient exhibited loud verbalizations, pacing and repetitive demands.
A review of the interdisciplinary care plan lacked evidence of problem identification, objectives and approaches to care for behaviors.
A face-to-face interview was conducted with the charge nurse and the case manager on January 13, 2011 at approximately 11:00 AM. They acknowledged the lack of care planning regarding behaviors. The record was reviewed January 13, 2011.

Based on record review and confirmed by staff interview for four (4) of nine (9) records reviewed of attending physician SHW #1, it was determined that the attending physician prescribed controlled substances in the absence of a current District of Columbia Controlled Substance Certificate. Patients #3, 6, 7 and 8.

The findings include:

District of Columbia Municipal Regulations for Hospitals, Title 22, ?22 DMR stipulates "2016.2 Each hospital shall ensure and maintain evidence of, for employees and contract staff, current active licensure, registration, certification or other credentials in accordance with applicable District of Columbia law prior to staff assuming job responsibilities and shall have procedures for verifying that the current status is maintained."
A review of personnel records on January 13, 2011 revealed an attending physician ' s District of Columbia Controlled Substance Certificate expired December 31, 2010. There was no evidence that the physician was authorized to prescribe controlled substances during the period of January 1, 2011 through the time of the review on January 13, 2011.
According to a review of clinical records, physician SHW#1 prescribed controlled substances during the period that he/she was unauthorized as follows:
A. Patient #3 was admitted January 5, 2011 with diagnoses that included End Stage Renal Disease on Hemodialysis, Hypertension, Lower Extremity Amputation and Decubitus Ulcer.

According to physician's orders dated January 6, 2011, Patient #3 was prescribed the following controlled substances: Duragesic [fentanyl] patch 50 mcg every 72 hours and Lyrica 50 mg by mouth three times daily.

B. Patient #6 was admitted December 28, 2010 with diagnoses that included End Stage Renal Disease on Hemodialysis, Hypertension, Chronic Back Pain, Diabetes Mellitus and Urosepsis.

According to physician's orders dated January 6, 2011, Patient #6 was prescribed Dilaudid 2 mg intravenously (IV) every 4 hours as needed for pain. On January 7, 2011, the physician discontinued the Dilaudid and ordered Percocet 10/325 mg 2 tablets by mouth every 6 hours as needed for pain. On January 8, 2011, Dilaudid 2 mg IV now (at 1630) was prescribed.

C. Patient #7 was admitted January 7, 2001 with a diagnosis of Encephalopathy.

According to physician's orders dated January 8, 2011, Patient# 7 was prescribed Percocet 5/325 mg 2 tablets by mouth every 6 hours as needed for pain.

D. Patient #8 was admitted December 20, 2011 with diagnoses that included Kidney failure, non-healing Surgical Wound and Leukocytosis.

According to physician's orders dated January 8, 2011, Patient #8 was prescribed Dilaudid 2 mg intravenously now (at 1530) and Dilaudid 2 mg by mouth every 6 hours for 2 days.

The findings for Patients #3, 6, 7 and 8 were reviewed and confirmed during a face-to-face interview with the nurse manager on January 13, 2011 at approximately 11:00 AM.

1. Based on record review and confirmation by staff interview, the hospital staff failed to follow the hospital's policies and procedures for transfusion of blood and blood products regarding documentation of the time a blood product is removed from a validated shipping container to ensure administration of the product within 30 minutes after removal. Records were reviewed from April 2010 through January 13, 2011.

The findings included:

According to the hospital's policy (Policy #CS.107) entitled Transfusion of blood/blood products" dated July 6, 2010, Blood product administration must begin within 30 minutes after being removed from the validated shipping container"
The hospital staff failed to ensure that the staff documented the actual time the unit of blood is taken out of the validated shipping container.
Review of a form entitled "TEMPERATURE QC VERIFICATION OF BLOOD PRODUCTS SHIPPED FROM [contract laboratory] revealed a lack of accurate documentation for the actual time a specific unit of blood product is removed from the container for transfusion. For example (a) According to the transfusion record for Patient #26 on January 9, 2011, the shipping box was opened to remove the first unit of blood product at 9:00 PM however , the time documented as being the transfusion start time was before 9:00 PM (at 8:55 PM). Example (b) According to the transfusion record for Patient #27 the second unit of blood was removed on November 10, 2010 at "0070" AM and the transfusion of the unit was initiated at 05:00 AM.
In addition, in some instances if more than one unit of blood product is packed in one container, there was no documentation indicating when the second unit was removed from the container to ensure administration within 30 minutes.
Interviews with supervisory nursing staff members from units 2 North and 3 North on January 18, 2011 at approximately 2:00 PM revealed that the time a blood product is removed from the container is the same as the time transfusion of the product is initiated.
However, review of the transfusion records failed to confirm the fact that the time a unit is removed from the container is the same as the transfusion start time. For example, According to the transfusion record for Patient #28 on November 16, 2010 the shipping box was opened to remove a unit of RBC at 1:30 AM however the transfusion was not initiated until 1:45 AM (15 minutes later).
2. Based on record review and confirmation by staff interview, the hospital staff failed to follow the hospital's policies and procedures for transfusion of blood and blood products to address temperature elevation for one of the one sampled patient's who had an elevated temperature at the end of transfusion. Patient # 27.
According to the hospital's policy (Policy #CS.107) entitled Transfusion of blood/blood products"dated July 6, 2010, if the patient experiences temperature elevation equal to or greater than 2 degrees Fahrenheit from baseline, the staff is instructed to "... stop the infusion and keep the line open and notify the physician/LIP. If the physician/LIP determines the temperature is not a suspected transfusion reaction, document on the Transfusion Reaction form and follow the physician/LIP recommendations and continue the transfusion."
Review of Patient # 27's transfusion records for revealed that during transfusion of a second unit of RBC on August 1, 2010 the patient's temperature elevated from 96.8 degrees Fahrenheit to 98.8 degrees Fahrenheit. There was no documentation on the transfusion record to provide evidence that the rise in temperature was brought to the physician/LIP's attention in accordance with the hospital's policy for blood transfusion.
According to an interview with staff from the hospital ' s Performance Improvement section, on January 18, 2011 at approximately 4:25 PM, the review of the transfusion records in its entirety is not one of the items monitored by the hospital ' s Performance Improvement committee. Currently the committee monitors /reviews transfusion records to ensure the documentation of shipping container temperature and documentation of two staff signature for transfusion certification. It should be noted that the hospital does not have a separate transfusion committee to review/monitor transfusion activities.

1. Based medical record and policy review and revealed that the hospital staff failed to follow the hospital policy regarding Time Out documentation in two (2) of thirteen (13) records reviewed for patients who received procedures. Patient #15 and 23.

The findings included:

Hospital Policy # CS.069 reviewed December 2009 entitled Procedure Time Out. Section III Procedure " ... 4. Document the time out on the Invasive Procedure Time Out form. "

A. Patient #15 was admitted October 29, 2010, with diagnoses including Paraplegia of Bilateral Lower Extremities, Respiratory Insufficiency, Ventilator Dependence, Coronary Artery Disease, Diabetes Mellitus and Sacral Decubitus Ulcer.

Review of the Invasive Procedure Time Out Form relative to a PICC line dated December 26, 2010 revealed the form was signed, dated, and timed, by two (2) Registered Nurses (RN). The RN performing the procedure signed the form in the signature block designated ' MD Signature ' at 12:30 PM. The second RN signed the signature block designated ' RN Signature ' at 1:00 PM. The record lacked documented evidence that the staff were in agreement on the actual time out. I addition, the RN performing the procedure signed in the signature section of the form designated for the physician.


B. Patient #23 was admitted on December 20, 2010 with diagnoses of Bilateral Lung Consolidation and Left Lug Effusion, Respiratory Failure, Status Post Tracheostomy, Hypertension, and Diabetes Mellitus. The patient transferred from the Critical Care Unit on January 7, 2011.

Review of the Invasive Time Form dated December 29, 2010 on January 13, 2011 at approximately 1:00 PM revealed the patient underwent a Scoring Debridement of Sacral Eschar procedure. The Time Out completed by the physician and the nurse revealed they documented different times. The nurse documented 1045:AM and the physician documented 11:00 AM. The staff did not agree on the time out.

Discussion with the Director of Nursing (DON) on January 13, 2011 during record review revealed that the staff was completing the time out form correctly according to hospital policy.


2. Based on observation, record review and interview for two (2) of 34 records reviewed, it was determined that pharmacy staff failed to accurately transcribe medication orders and ensure the accuracy of medication administration records. Patients #1 and 6.

The findings include:

A. Patient #1 was admitted November 29, 2010 with diagnoses that included Respiratory Failure status-post Tracheostomy, Chronic Debility, Contractures, Cerebrovascular Accident, Anoxic Brain Injury, Encephalopathy and Sepsis.
Pharmacy staff failed to accurately transcribe a physician ' s order for the administration of antihypertensive medication.
The clinical record revealed a physician ' s order dated December 2, 2010 that directed the administration of Clonidine (an antihypertensive medication) 0.1 mg by mouth (po) every 6 hours as needed (prn) for a systolic blood pressure greater than 170 mm hg or a diastolic blood pressure greater than 105 mm hg.
A review of the preprinted medication administration records [MAR] for the months of December 2010 and January 2011 revealed the Clonidine order was inaccurately transcribed as " Clonidine 0.1 mg po every 6 hours prn for systolic blood pressure greater than 120 mm hg (or diastolic blood pressure greater than 105 mm hg.)
During the period of December 2, 2010 through January 13, 2011, the MAR revealed nursing staff administered the Clonidine on 8 occasions when the patient's systolic BP was assessed less than 170 mm hg.
A face-to-face interview was conducted with the charge nurse, who acknowledged the findings on January 14, 2011 at approximately 11:00 AM. He/she stated that the pre-printed medication administration records were transcribed by pharmacy services. The record was reviewed January 14, 2011.

B. Patient #6 was admitted December 28, 2010 with diagnoses that included End Stage Renal Disease on Hemodialysis, Hypertension, Chronic Back Pain, Diabetes Mellitus and Urosepsis.

Pharmacy staff failed to ensure that the Medication Administration Record was accurate and up-to-date in relation to the prescribed insulin orders.

Physician's orders dated January 3, 2011 directed the discontinuance of Novolog insulin 5 units with each meal.
A review of the Medication Administration Record for the period of January 3, 2011 through January 12, 2011 revealed Novolog 5 mg with meals was consistently printed on the daily MAR as a scheduled medication. Nursing staff administered two dosages of insulin after it was discontinued.
A face-to-face interview was conducted with the charge nurse on January 12, 2011 at approximately 4:00 PM. He/she stated that the pre-printed Medication Administration Records were transcribed by pharmacy services. The MAR was updated on a daily basis to ensure the medication regimen was synchronous with current orders. The record was reviewed January 12, 2011.

1. Based on medical record review and confirmation by staff interview it was determined that the nursing staff failed to authenticate and complete medical record documentation in one (1) of 34 records reviewed. Patient #20.

The findings include:


Hospital Policy # CS.083 entitled Guidelines for Completing Nursing Flow Sheet revised June 2010 Section II Procedure stipulates: " Nurse will complete a head to toe assessment at the start of their shift and document finding in the appropriate column ...Wound documentation is to occur with each dressing change. If there is no wound draw a line through this section. Do Not Leave Blank. Documentation of wound is done q 12 hours. Documentation includes: location, type, stage, appearance. Drainage, odor and appearance and undermining. Location is identified by number and identified by drawing the location on the diagram. "


Patient #20 was admitted on December 31, 2010 with diagnoses of Status post (S/P) Septic Shock secondary to Hypoxia, Respiratory Failure, End Stage Renal Disease and S/P Gastrointestinal (GI) Bleed. The patient transferred from the Critical Care Unit on January 5, 2010.

Review of the medical record on January 14, 2011 at 9:50 AM revealed the nurse documented and accepted a telephone order from the physician on January 3, 2011 at 5:05 AM to " Give Clonidine 0.1 mg via GT x 1 for [increased] B/P " . Review of the Medication Administration Record (MAR) revealed a time of administration was documented but the nurse failed to document his/her initials for verification of the nurse and that the medication was given. The time of administration was documented at 2:00 PM, nine (9) hours past the receipt of the telephone order.

Review of the hospital flowsheet section entitled Wound Assessment, revealed the nursing staff failed to document complete wound assessments January 10 and 12, 2011.
On January 10, 2011 the nursing staff failed to document the wound location and stage, undermining present, current treatment and the drawing of the location on the diagram. The spaces were left blank.

On January 12, 2011 the nursing staff failed to document the wound stage, current treatment and complete the diagram specifying the location of the wounds. The nurse documented " multiple wounds "as the wound location. All other spaces were left blank.

Further review revealed the physician ordered Zyvox 600 milligrams (mg) by mouth (PO) BID (twice daily), Norvasc 10 mg PO Q (every) daily, and discontinue Vancomycin and Klonopin on January 10, 2011 at 2:20 PM. The order lacked documented evidence that the nursing staff authenticated, dated, or timed the order. Further review revealed that the 12 hour chart review was completed without authentication.


2. Based on medical record and policy review and staff interview it was determined that the medical staff failed to write complete restraint orders in one (1)of seven (7) records reviewed for patients who had restraints. Patient #20.

The findings include:

Hospital Policy # CS.76.1 revised September 2010 entitled Use of Restraints: Nonviolent & Non Self- Destructive Patients, Section VI. Subsection E " Physician Orders " stipulates: " 1) Each episode of restraints use requires an order (written/or telephone) by a physician or other licensed independent practitioner who is responsible for the care of the patient and is a member of the Medical Staff. 2) An order for restraint (s) to ensure the physical safety of the non-violent or non-self destructive patient may not exceed twenty-four (24) hours. The order for resident is to include: a. reason for restraint, b. Type of restraint, and c. Time limit not to exceed twenty-four (24) hours.


Patient #20 was admitted on December 31, 2010 with diagnoses of Status post (S/P) Septic Shock secondary to Hypoxia, Respiratory Failure, End Stage Renal Disease and S/P Gastrointestinal (GI) Bleed. Review of the medical record revealed that restraints were ordered from December 12, 2010 to January 14, 2011. Review of the Restraint Order Form revealed the physician failed to document the reason for the restraint on January 7 and January 10, 2011.

The record contained an additional Restraint Order Form which was signed by the physician, and lacked documented evidence of the date/time the order was written, the reason for the restraint, date/ time the physician signed the order, or a nurse ' s signature with date and time.

Further review revealed a Restraint Order Form dated January 13, 2011 at 1730 (5:30 PM). The form was completed by medical and nursing staff, however the nursing staff timed the form at 8:00 AM and the physician authenticated the order at 9:50 AM. The date was written over, indiscernible.

The findings were discussed with the Medical Director and Nurse Manager who were present during the record review on January 14, 2010 at approximately 11:30 AM.

Based on medical record review it was determined that the medical staff failed to date, time and authenticate orders to include verbal orders in two (2) of 34 records reviewed. Patient #20 and 21.

The findings include:

A. Patient #20 was admitted on December 31, 2010 with diagnoses of Status post S/P Septic Shock secondary to Hypoxia, Respiratory Failure, End Stage Renal Disease and S/P Gastrointestinal (GI) Bleed. Review of the medical record on January 14, 2011 at 9:50 AM revealed telephone orders were documented by the Wound Care Nurse on January 3, 2011 at 10:30 AM two (2) wound sites. The physician countersigned the orders but failed to include the date and time that the orders were countersigned.

B. Patient # 21 was admitted on December 23, 2010 with diagnoses of Respiratory Failure, Cerebellum Arteriovenous Malformation (AVM), S/P Craniotomy, External Ventricular Drain, Cerebral Vascular Accident (CVA), Ulcerative Colitis, Deep Vein Thrombosis (DVT), and Ileostomy. The patient was transferred from the Critical Care Unit on January 11, 2011.

Review of the medical record on January 13, at 9:45 AM revealed the physician signed a restraint orders dated January 11, 2011(not timed) and January 12, 2011 at 9:00 AM but failed to document the date and time the orders were signed. In addition the order written on January 11, 2011 also lacked a time the order was written.

The findings were discussed with and acknowledged by the Nurse Manager on January 13, 2011 at approximately 12:30 PM.

Based on medical record review and staff interview it was determined that the medical staff failed to authenticate verbal orders within 48 hours in two (2) of 34 medical records reviewed. Patients 20 and 21.

The findings include:

The Specialty Hospital of Washington- Capitol Hill Policy # CS.100 entitled Physician Telephone and Verbal Orders revised May 2009 Section II Item C stipulates: Telephone orders must be authenticated (verified) and countersigned by the prescribing practitioner or other responsible practitioner within forty-eight (48) hours of receipt.

A. Patient #20 was admitted on December 31, 2010 with diagnoses of Status post (S/P) Septic Shock secondary to Hypoxia, Respiratory Failure, End Stage Renal Disease and S/P Gastrointestinal (GI) Bleed.

Review of the medical record on January 14, 2011 at 9:50 AM revealed the nursing staff accepted and documented a telephone order from the physician on January 11, 2010 at 4:00 PM to " D/C Tele. " The medical record lacked documented evidence that the physician countersigned, date and time the telephone order by January 14, 2010 at 12:00 noon.

B. Patient # 21 was admitted on December 23, 2010 with diagnoses of Respiratory Failure, Cerebellum Arteriovenous Malformation (AVM), S/P Craniotomy, External Ventricular Drain, Cerebral Vascular Accident (CVA), Ulcerative Colitis, Deep Vein Thrombosis (DVT), and Ileostomy.

Review of the medical record on January 13, 2011 at 9:45 AM revealed the nurse accepted and documented a telephone restraint order dated January 7, 2011 timed at 8:00 from the physician. The medical record lacked documented evidence that the physician signed, dated and timed the restraint order by January 13, 2011 at the time of the record review..

The nursing staff documented and accepted a telephone order dated January 8, 2011 at 7:45 PM to " (1) Restart tube feeding tomorrow at 0600 " (6:00 AM); (2) "Run feeding as previously ordered. " The order lacked documented evidence of physician authentication with signature, date, and time by January 13, 2011 at the time of record review. The physician failed to sign both orders with 48 hours.

The findings were discussed and acknowledged by the Nurse Manager during the record review on January 13, 2011 at approximately 10:15 AM. .

Based on medical record review, policy review and interview it was determined that the medical staff failed to document properly executed informed consent forms in four (4) of twelve (12) medical records reviewed for patients that required informed consent for procedures. Patients 13, 15, 23 and 25 .

The findings include:

Hospital Form 245 entitled Consents for Surgery, Procedures, Anesthesia, Transfusion and Other Treatments contains a physician attestation statement, which stipulates " I attest that the patient (or legal guardian or closest relative available, _________) [indicating a name should be written] has received and understood an explanation of the nature .... "

A. Patient #13 was admitted December 30, 2010 with diagnoses including Respiratory failure, Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, Anasarca, Encephalopathy, and Hypertension. Review of the medical record on January 13, 2011 at approximately 10:00 AM revealed the following five (5) informed consents: January 3, 2011 for Peripherally Inserted Central Catheter (PICC), and Thoracentesis; January 6, 2011 for Transfusion and Flexible Laryngoscopy; and January 9, 2011 for Upper Endoscopy.

All of the aforementioned informed consent documents lacked identifying information within the physician attestation as to who received explanations and/or education regarding procedures to be performed. The medical staff failed to document properly executed informed consent forms.

The record was reviewed with the Clinical Nurse Manager for the unit who confirmed the findings.

B. Patient #15 was admitted October 29, 2010 with diagnoses including Paraplegia of Bilateral Lower Extremities, Respiratory Insufficiency, Ventilator Dependence, Coronary Artery Disease, Diabetes Mellitus and Sacral Decubitus Ulcer. Review of the medical record on January 12, 2011 at approximately 11:05 AM revealed the following three (3) informed consents: November 3, 2010 for Thoracentesis; December 25, 2010 for PICC; and December 20, 2010 for Debridement of Sacral Pressure Sore.

All of the aforementioned informed consent documents lacked identifying information within the physician attestation as to who received explanations and/or education regarding procedures to be performed. The medical staff failed to document properly executed informed consent forms.

Further, on the informed consent for PICC dated December 25, 2010, the hospital staff documented " T.O. Consent from patient ' s wife " . The notation lacked identifying information as to who the staff spoke to, and the telephone number used to contact the representative.

The record was reviewed with the Clinical Nurse Manager for the unit who confirmed the findings.


C. Patient #23 was admitted on December 20, 2010 with diagnoses of Bilateral Lung Consolidation and Left Lug Effusion, Respiratory Failure, S/P tracheostomy, Hypertension, and Diabetes Mellitus. The patient transferred from the Critical Care Unit on January 7, 2011.

Review of the medical record revealed that the physician obtained a consent on December 24, 2010 at 10:30 for a PICC Line Placement (Peripheral Inserted Central Catheter). The consent lacked documented evidence of a witness or the relative ' s signature. The physician did not indicate if this was a telephone consent. The procedure was completed on December 25, 2010.

The record was reviewed on January 13, 2011 at approximately 2:30 PM with the Clinical Nurse Manager for the unit who confirmed the findings.


D. Patient #25 was admitted on September 22, 2010 with diagnoses of Respiratory Failure, ventilator dependent, history of Spontaneous Pneumothorax Right Lung, Sacral Decubitus and Severe Anxiety Disorder. Review of the medical record revealed that a consent was obtained by the physician for a Fiber optic Bronchoscopy. The consent form lacked documented evidence of a date and time the consent was obtained or signed.

The record was reviewed on January 14, 2011 at approximately 11:00 AM with the Administrative Staff who confirmed the findings.

1. Based on medical record review, policy review and interview it was determined that the Rehabilitative Services staff failed to update patient progress on the interdisciplinary plan of care or progress notes in one (1) of six (6) records reviewed for patients requiring Rehabilitative Services. Patient 15.

The findings include:

Hospital policy CS.002 entitled Patient Assessment and Reassessment, reviewed February 2010, Section III (J) (2) stipulates " Physical Therapy reassessment of a patient will reflect, at a minimum, a review of patient specific data, pertinent changes, review of ongoing plan of treatment and response to interventions. "

Patient #15 was admitted October 29, 2010 with diagnoses including Paraplegia of Bilateral Lower Extremities, Respiratory Insufficiency, Ventilator Dependence, Coronary Artery Disease and Diabetes Mellitus. Physical Therapy orders were written by the physician on October 29, 2010. The initial Physical Therapy evaluation was conducted on October 30, 2010. Review of the medical record on January 12, 2011 at approximately 11:05 AM revealed that Interdisciplinary Rounds were conducted on November 29, December 6, 13, and 20, 2010. The medical record lacked documented evidence of the patient ' s progress in physical therapy towards goals and/or discharge.

A face-to-face interview was held with a member of the Physical Therapy staff on January 12, 2011 at approximately 2:30 PM. The therapist stated that pertinent information regarding patient progress is not detailed on the Interdisciplinary Round Flowsheet, but rather in the progress notes. Review of the progress notes with the therapist confirmed that pertinent information to include goal statements, progress toward goals, and update in the plan of care was not documented in the progress notes either. The therapist acknowledged and confirmed the findings.

2. Based on medical record and policy review it was determined that the Physical Medicine and Rehabilitation (PM&R) staff failed to perform an initial assessment in a timely manner in an isolated incident. Patient 13.

The findings include:

Hospital policy CS.002 entitled Patient Assessment and Reassessment, reviewed February 2010 stipulates the following: Section III (I) (2) - " Initial Physical Therapy Assessments are completed within forty-eight (48) hours after the Physician order written " ,and Section III (K) (3) - " Initial Occupational Therapy Assessments are completed within forty-eight (48) hours after the Physician order written. "

Patient #13 was admitted December 30, 2010 with diagnoses including Respiratory failure, Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, Anasarca, Encephalopathy, and Hypertension. Review of the medical record on January 13, 2011 at approximately 10:00 AM revealed on December 30, 2010 the physician ordered evaluations by Physical Therapy, Occupational Therapy, and Speech-Language Therapy services. The initial evaluations by Physical Therapy, Speech-Language Therapy and Occupational Therapy were performed on January 11, 2011. The Physical and Occupational Therapy initial assessments were not performed in a timely manner and not according to hospital policy.


3. Based on medical record review and staff interview it was determined the nursing staff failed to document vital signs per physician's order in one (1) of 34 records reviewed. Patient 20.

The findings include:

Patient #20 was admitted on December 31, 2010 with diagnoses of Status post S/P Septic Shock secondary to Hypoxia, Respiratory Failure, End Stage Renal Disease and S/P Gastrointestinal (GI) Bleed. Review of the medical record revealed that the physician ordered Vital Q 1? x3, then Q 4 hours on January 13, at 11:42 AM after a hypotensive episode in hemodialysis. The patient completed dialysis at 11:05 AM. Review of the hospital's flowsheet revealed vital signs were documented at 1:00 PM. There was no documented evidence that nurse completed vital sign Q 1 hours after 1:00 PM.

Interview with medical director on January 14, 2011 at approximately 11:30 AM revealed that s/he remembered the episode. According to the medical director, the patient had returned to the unit from dialysis and the dialysis nurse informed her/him directly of the patient ' s hypotensive episode while he was in dialysis. The medical director stated s/he then told the nurse assigned to the patient about monitoring the patient ' s blood pressure. The physician stated she reviewed the orders with the nurse to include the vital signs.

The Nurse Manager for the unit reviewed the medical record and confirmed findings.

4. Based on medical record review and policy review it was determined that the medical staff failed to complete medication reconciliation in one (1) of 34 records reviewed. Patient #23.

The findings include:

Hospital Policy #CS.096 entitled Medication Reconciliation revised June 9, 2009 Section III Admission stipulates: " ...The physician reviews the discharge medications as well as the accompanying Pharmacy Review Sheet and complete the Medication Reconciliation Form, indicating continuation or discontinuation, of each medication by placing a check in the appropriate column, involving the patient and/or family member as indicated ... "

Patient #23 was admitted on December 20, 2010 with diagnoses of Bilateral Lung Consolidation and Left Lug Effusion, Respiratory Failure, S/P tracheostomy, Hypertension, and Diabetes Mellitus. . Review of the " Physician Admission Order (cont ' d) Medication reconciliation " form revealed that 14 medications were documented on the form by the physician. The form lacked documented evidence that physician made a determination to continue or stop the 14 medications. The form was signed on December 21, 2010 at 12:20 AM.

The record was reviewed on January 13, 2011 at approximately 2:30 PM with the Clinical Nurse Manager for the unit who confirmed the findings.

1. Based on observations and interview during the survey it was determined that dietary services were not adequate to ensure that foods are prepared in a safe and sanitary manner.

The Findings include:

A. Grease and oil droplets were observed accumulated on the bottom surfaces of the mixer motor located above the mixing bowl in the Main Kitchen in one (1) of one (1) observation at 10:45 AM on January 12, 2011.

B. Three (3) shelves in the reach in box in the Main Kitchen were unsecured and held in place by a cloth like material that was soiled with debris in one (1) of one (1) observation at 11:00 AM on January 12, 2011.

C. Compressor fan covers located in the walk in refrigerator #12 and the walk in freezer were soiled and rusty in two (2) of two (2) observations at 10:50 AM on January 12, 2011.

E. Supply vents located over food preparation, dishwasher, pot and pan wash and cafeteria were soiled and stained with accumulated debris in four (4) of four (4) observations between 10:45 AM and 1:30 PM on January 12, 2011.

F. The Ansul System sensor lines cords and metal pipe covering cords were soiled with accumulated dust and grease over cooking areas in the cooks preparation area and cafeteria in three (3) of three (3) cooking hood observations between 10:45 AM and 3:50 PM on January 12, 2011.

G. Gear surfaces of the manual can opener were soiled with accumulated food deposits and debris in the cook ' s preparation area in one (1) of two (2) observations at approximately 11:00 AM on January 12, 2010.


H. Stainless steel wall surfaces were soiled with accumulated mineral deposits and floor surfaces were marred and in need of refinishing in the cart wash area of the Main Kitchen in one (1) of one (1) observation at 1:30 PM on January 12, 2011.

I. Baseboard surfaces were soiled with debris around the perimeter of the Main Kitchen in one (1) of five (5) observations at 2:30 PM on January 12, 2011.

J. Spoons were observed to be soiled with food deposits after washing in the mechanical dishwasher in 23 of 64 observations at 2:30 PM on January 12, 2011.

K. The sanitizer water in the three compartment sink was observed to have food deposits and deposits were observed on 6 of 14 pans that were observed between 2:45 and 3:00 PM on January 12, 2011.

L. Cutting boards stored in the pot and pan wash area were observed to be worn and deep grooves were observed in three (3) green, 1 red, and 1 white, this observation was made at 3:50 PM on January 12, 2011.

M. Floor tiles in the main kitchen in food preparation, tray line, ice machine, drain area of the ice machine and cooks preparation areas were uneven, separated and damaged in five (5) of five (5) observations between 10:45 AM and 4:00 PM on January 12, 2011.

N. A 220 volt cord originating from the steam table in the Main Kitchen was improperly attached to the sprinkler water supply line and was held in place by a metal wire and terminated into a 220 volt outlet two and one half feet parallel to the at a 220 volt outlet near the ceiling that was approximately two and one half feet from the sprinkler head; in addition a 110-115 Volt cord originating from the plate warmer in the tray line serving area was coiled around the sprinkler supply line and terminating above the sprinkler head in the ceiling above the tray line; presenting a serious potential fire and electrical hazard to staff working in the area in two (2) of two (2) 13:10 PM and 4:45 PM on January 12, 2011. NFPA 70

O. Floor surfaces in the Men ' s Toilet, Locker Room, were soiled wet, tiles were not secured, missing and damaged; in addition walls and lockers were in need of repainting on the exterior; female lockers were soiled and were in need of cleaning and refinishing on the exterior and interior surfaces in three (3) of three (3) observations at 10:30 AM on January 13, 2011.

1. Based on observations during the survey period the following findings were observed on the ICU between 11:20 and 3:30PM on January 13, 2011.

The findings include:

A. Sprinkler heads were soiled with dust over the patients bed, floor tiles were damaged and soiled in the rear of the toilet, hot water was measured and determined to be 52 degrees Fahrenheit at 11:20 AM and 62 degrees F at 3:00 PM in a patient room sink, the interior and exterior surfaces of exhaust vents were soiled with dust and door, door jamb surfaces were marred and scarred in Room 2001.

B. Venetian blind surfaces were soiled and damaged, doors surfaces were marred and damaged on the edges, Sprinkler head surfaces were soiled with dust, ceiling tiles and grids were soiled and stained in Room 2002.

C. Ceiling tiles and grids over the patient ' s bed were soiled, stained and not secured over the patients bed, venetian blinds were damaged, floor tiles in the rear of toilets were in disrepair, the interior surfaces of exhaust vents were soiled with dust in room in Room 2003.

D. Venetian blind were observed to have damaged slats, the lamp cover the patients sink lacked a protective cover, wall and medical gas panels were soiled and in need of refinishing in Room 2004.

E. The protective lamp cover above the sink was missing, wall surfaces in the room were marred, sprinkler heads over the patients bed were soiled with dust, wall head surfaces in the rear of the patients headboard were soiled with dust, floor surfaces under the patients toilet were in disrepair, exhaust vents were soiled on the interior with accumulated dust and door surfaces were marred and scarred on the edges in Room 2006.

F. Sprinkler heads were soiled and stained with dust, the Dynascope Monitor was dusty on the top surfaces, the protective lamp cover over the sink was missing in Room 2007.

G. The outlets on the lower headwall were observed to be very soiled, the lamp over the sink lacked a cover, wall panels were soiled and stained in the rear of the patients headboard, gnats were observe flying in the patients ' room, the exhaust vent cover in the bathroom was soiled with dust, baseboards were soiled and stained, venetian blind slats were bent and damaged and headboard walls were stained and soiled with dust in Room 2008.

H. Sprinkler heads were soiled with dust, electrical outlet plate covers were soiled, the lower outlet at the base of the headwall were soiled with accumulated dust, ceiling tile and grids above the patients ' bed were soiled, the interior surface of exhaust vents were soiled with dust in the bathroom, door and door jambs were marred and damaged on the edges, floor tiles were damaged under the bathroom toilet, the base surfaces of the patients IV Pole was soiled was rusty and soiled with spillages, door jamb surfaces were marred and damaged on the edges and a 10 x 12 inch opening was observed in wall surfaces above the patient ' s bed in Room 2010.

I. The protective lamp cover was missing on the lamp over the sink, ceiling tiles and grids were soiled and stained over the patients bed, floor and baseboard surfaces were very soiled with debris and patient call bells were not answered expediently, the top surfaces of the Dynascope Monitor and other monitors were soiled with dust, and blinds slats were damaged in Room 2014.

J. The lower surfaces of the of the patients IV Pole was soiled with spillages, lamp cover were missing over the sink, the horizontal surfaces of the patients bed frame were soiled with dust, sprinkler head surfaces were soiled with accumulated dust, venetian blinds were bent and damaged on the patients entrance door, hot water temperatures was measured and determined to be 92 degrees F, the horizontal surfaces of bed frames were soiled with accumulated dust, venetian blind slats were bend and damaged in Room 2015.

K. Cleaning equipment was stored on floor surfaces sink surfaces were very soiled, wall surfaces were marred and damaged and floor tiles were not secured and damaged in the Housekeeping Closet.

L. Protective Supplies such as gloves, mask and gowns were not always available outside of patient rooms; when staff and the surveyor attempted to enter the patients rooms on isolation; as evidenced by the lack of supplies when attempts were made outside of Rooms 2003, 2007, 2014 and 2015.

M. Ceiling tiles were soiled and not secured, lamp covers were missing over the patients sink, bed frame surfaces were soiled with dust, exhaust vents were soiled in the patients bathroom, call bells were not answered in a timely manner after testing the response, door and jamb surfaces were marred on the edge surfaces, baseboards were damaged and soiled, backsplash surfaces on the sink were in need of recaulking and hot water was not available in Room 2016.

N. The patient ' s exterior window was observed to be opaque due to a vacuum loss, bathroom floor tiles were very soiled and damaged, exhaust vents were soiled on the interior, wall surfaces were soiled in the patients ' Room 2013.

O. Sprinkler heads were soiled over the patients bed, lamp covers were missing over the sink, areas around the sink and counter are in need of recaulking, exhaust vents were soiled on the interior and exterior and the bathroom and entrance door surfaces were marred in room 2018.