The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ADVENTIST HEALTHCARE SHADY GROVE MEDICAL CENTER 9901 MEDICAL CENTER DRIVE ROCKVILLE, MD 20850 Feb. 20, 2013
VIOLATION: PATIENT VISITATION RIGHTS Tag No: A0216
Based on review of the guide to patients and their families and the hospital visiting policy, the hospital's policy does not clearly outline the patient's visitation rights including those setting forth any clinical necessary or reasonable restriction or limitation that the hospital may need to place on such rights and the reasons for the clinical restriction or limitation. Review of the hospital policy revealed the presence of family and friends provides emotional and social support to the patient and is an essential component of the healing process, visitation is open 24 hours a day, seven days a week. The hospital has an open visitation policy. The policy identifies special considerations or restrictions/clinical reasons where visitation would not be permitted or limited. However, the policy fails to reflect that the patient is informed of his/her right to have or deny visitation by the persons of their choosing. The hospital obtains the name of the patient's contact person but fails to specify that the contact person can act in the capacity of the patient's support person.
VIOLATION: PATIENT VISITATION RIGHTS Tag No: A0217
Based on review of the hospital's visitation policy and guide for patient's and their families under patient rights and responsibilities, it was revealed that the hospital's visitation policy and the guide for patients and their families does not state that the visitation privileges are allowed regardless of the visitor or patient race, color, national origin, religion, sex, gender identity, sexual orientation or disability.

Review of the visitation policy and visitation under the guide for patients and their families, revealed visitation is open 24 hours a day, seven days a week. The policy identifies special considerations or restrictions/clinical reasons where visitation would not be permitted or limited. However, the policy fails to specify that visitation will be allowed regardless of the visitor's race, color, national origin, religion, sex, gender identity, sexual orientation or disability and in accordance with the patient's expressed preferences.
VIOLATION: LICENSURE OF PERSONNEL Tag No: A0023
Based on review of the personnel file for the dental assistant and the hospital's policy No. 2.54 entitled " Background Investigations " , it was determined that the hospital failed to ensure that the applicant was eligible for employment.

On February 14, 2013 the surveyor reviewed the personnel file of a dental assistant. The personnel file was incomplete, lacking current CPR, background check and education or dental school information. The hospital later provided a current CPR card and a general evaluation report regarding the dental assistant's education. The hospital's policy stated the standard level background investigation includes the following:
? Analyzed Social Security Number Search
? County Criminal Records Search
? Statewide Sexual Offenders Registry Searches
? National Sex Offenders Database Search
? Education History Verification
? Basic Employment History Verification

The hospital failed to complete the required background check to ensure compliance with State and local laws or policy. The hospital employed the dental assistant without a background check even though this individual through the job would have contact with children and adults.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on the interviews with staff and review of policies and procedures and observations of the hospital staff, it was determined that the hospital staff failed to protect the patients' right to privacy.

As indicated in A0142, on February 14, 2013 at 9:30 am , the surveyors observed clinical staff openly discussing a patient's condition in the surgical waiting room in a manner that failed to protect the confidentiality of the patient's condition.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on review of the hospital's policy and interview with the Associate Vice President of Quality Improvement and Medical Staff Services on 2/14/13, it was determined that the hospital does not meet the expected length of time for resolution of grievances.

A review of the hospital's policy titled "Patient Complaint Management" under Timeliness of Reporting/Responding revealed "the individual filing the complaint will receive a response as soon as possible, but not to exceed thirty (30) days." Per interview with the Associate Vice President of Quality Improvement and Medical Staff Services on 2/14/13, "the hospital response to complaints on average is 30 days." The regulation requires the resolution of grievances with an expected resolution and written response on average within 7 days. If a grievance cannot be resolved within the 7 day time frame, the hospital will inform the patient or the patient's representative that the hospital will follow-up with written response within a stated number of days in accordance with the hospital's grievance policy.
VIOLATION: PATIENT RIGHTS: PRIVACY AND SAFETY Tag No: A0142
Based on observation of staff interaction with patients, families, and significant others in the surgical waiting area, it was determined that the hospital failed to maintain the privacy of the patients including their name and health information as required by the Standards for Privacy of Individuals Identifiable Health Information (the Privacy Rule).

On February 14, 2013 two surveyors made observations in the Surgical waiting and testing area . There was a reception desk in the hallway. To the left of the desk was a glass door that led into the Testing Area. To the right of the desk is a large open glass enclosed area which was the surgical waiting area for patients and their families/significant others. Inside the waiting area immediately to the left is an enclosed desk, straight ahead was a frosted glass nutrition office, a tracking board suspended on the wall and a large waiting area with rows of 4-6 seats along partitions, perimeters and in the middle of the room. During the time the surveyors were in the area there were about 25 persons sitting in the area waiting to be called back or waiting for friends or family who were receiving treatment or testing.

On February 14, 2013 at 9:30 am, while interviewing staff in the waiting area, one surveyor observed two individuals dressed in scrubs in the surgical waiting area walk toward a row of 4 chairs in front of a window. The clinical staff began speaking to a male sitting on one end of the row of seats. Sitting one chair over from the male was a couple who weren't with the male. In addition, there was an adjacent wall partition next to the staff in the scrubs but on the opposite side of that partition were another row of occupied seats where two people could have easily heard the conversation. This surveyor entered the waiting room and sat across from the staff speaking to the male in Spanish. One staff was translating information. This interaction went on for 2 minutes at which point the Associate Vice President of Quality Improvement and Medical Staff Services walked over to the two staff and ask them to take the male, who later was identified as the father of a child who had dental caries removed, back to one of the conference rooms to discuss the procedure results and discharge plans. Beside the surveyor there had been at 7 least persons who could have overheard the discussion with the child's father.

The surveyor observed staff call another patient by name then approach the patient in the waiting room area while beginning to discuss patient sensitive medical information before the patient was taken back to the pre-operative area. The surveyor interviewed a staff nurse in the pre-operative area on February 14, 2013 at 9:40 am. The staff nurse stated that she had been concerned with the hospital using the patients' names. She stated in the past they had beepers to summon the patients, their family or friends but the beepers were stolen and replacement became expensive.

The hospital practice of speaking to patients, family and significant others in the surgical waiting area without affording the patient privacy or limiting the disclosure of the patient's information including their presence in the hospital, name, age address or health information without prior consent does not meet the regulatory requirements nor is it in accordance with State law.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on review of the hospital policy "Restraint Policy #101-01-027", the hospital failed to address the timely acquisition of the order for restraint or seclusion prior to application of restraint/seclusion or in emergency application situations. The policy review under "orders" 2a revealed the LIP (Licensed Independent Practitioner) will provide a verbal order (in an emergency) telephone or written order within one hour of initiation of the restraint. In addition under orders 2b the policy stated a written order based on an examination of the patient by a LIP shall be entered into the patient's medical record within 24 hours of initiation of the restraint.

However, the regulation requires the physician order to be obtained prior to the application of seclusion or restraint. In recognition that a restraint or seclusion intervention may occur so quickly that an order cannot be obtained prior to the application of restraint or seclusion, the regulation states that in these emergency application situations, the order must be obtained either during the emergency application of restraint or seclusion, or immediately (within a few minutes) after the restraint or seclusion has been applied. The hospital policy has not met the regulatory requirements since it does not address the process for an immediate acquisition of restraint or seclusion in the restraint/seclusion policy and procedure.