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.

HOLY CROSS GERMANTOWN HOSPITAL 19801 OBSERVATION DRIVE GERMANTOWN, MD 20876 Jan. 28, 2016
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records and policies and staff interviews it was determined that staff failed to obtain interpreter services for a patient who had limited English proficiency (LEP).

Patient #1 was admitted on [DATE]. According to his admission profile, Patient #1 was non-English speaking and required an interpreter. Patient #1's medical record lacked any documentation indicating that interpreter services were used to assess or communicate with the patient or that the patient was offered a qualified foreign language interpreter. It was noted in the medical record that the patient's son (caregiver) was used as an interpreter for most of his communication.

The Hospital's Interpreter Service policy states that family may only be used as an interpreter when specifically requested by the individual and only after the LEP patient has been offered an interpreter. This communication must be documented in the patient's record to assure that the competency of interpretation is considered.

Failure of the hospital staff to assure accurate communication to LEP patients and their
families by offering or providing interpreter services places the patient at risk for incomplete assessments and restricts his participation in the development and implementation of his plan of care.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on observations in the Emergency Department on 1/27/2016, review of medical records, hospital policies and other documents, and staff interviews it was determined that:

1. Staff had inconsistent knowledge of the policy for the documentation requirements when providing care as a 1:1 sitter/observer for a patient with suicidal ideation (SI).

2. The hospital policy for 1:1 sitter observation did not clearly designate a specific time frame for the required documentation for patients with SI.

On 1/27/2016 2 patients (patients #3 and #4) were observed in the behavioral health rooms of the Emergency Department (ED), rooms # 9 and #10. Patient #3 reported SI and had a positive suicide risk screening assessment, and patient #4 presented on several medications with positive SI. Both patients had been medically cleared at the time of observation and were awaiting inpatient Behavioral Health Unit (BHU) bed placement. There was one nursing technician assigned as the 1:1 sitter for both patients. The nursing technician sat in a hallway between the two rooms observing the patients through glass windows and completing hourly documentation for safety, behavior, toileting, meals, etc. for both patients in the electronic medical record (EMR).

Review of the patients' medical records with the nursing supervisor revealed orders for "1:1 sitter." The orders did not indicate the rationale for the sitter. The ED charge nurse presented a flowsheet about which staff had been educated concerning levels of patient observations. This flowsheet listed "observation, violent behavior- restraint, and non-violent behavior-restraint" with expected necessary documentation intervals of behaviors under each of the 3 headings. This flowsheet did not clearly address patients with SI and the need for increased or direct observation with documentation time intervals.

An interview on 1/28/2016 with the hospital Risk Manager and review of data presented at the 1/12/2016 Quality and Patient Safety Committee Meeting revealed that the BHU policy for patients with suicide risk or attempts needed to be clarified. Per the meeting minutes the policy stated that "suicide attempt precautions consist of constant and direct patient observation while patients are actually monitored every 15 minutes unless otherwise ordered." The paper documentation "At Risk Behavior Precautions Flowsheet" listed in the top banner that the behavior requiring 15 minute checks is risk of harm to self.

Review of the "Protecting Patients at Risk to Self and Others (Suicidal/Homicidal Behaviors)" revealed that the policy outlines the Nurses suicide assessment details and documentation, as well as safety checks to be completed. This policy does not state how often 1:1 sitters must document observations for a patient with positive SI or at high risk for SI.

Failure of providers to clearly order appropriate levels of observation of patient behaviors, and failure of staff to document timely intervals of behaviors places the patient at risk for self-harm.
VIOLATION: OUTPATIENT POST-ANESTHESIA EVALUATION Tag No: A1005
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of 7 closed and 4 open medical records, review of policies and staff interviews it was determined that anesthesia staff failed to complete a post anesthesia evaluation for two surgical patients within 48 hours after a surgery or procedure where anesthesia was administered.

Patient #7 underwent an Esophagogastroduodenoscopy (EGD) procedure on 1/20/2016 at 7:55 AM. The anesthesia intraoperative record was reviewed with nursing staff on 1/27/2016. The intraoperative anesthesia record indicated that patient #7 was intubated and received general anesthesia for the procedure. The reverse side of this form contained a printed outline of assessment information in which the post anesthesia evaluation was to be documented. This evaluation was not completed nor were there any progress notes from the anesthesia provider to indicate that a post anesthesia evaluation had been completed prior to the patient being discharged from the hospital on [DATE].

Patient #12 underwent a surgical procedure on 12/11/2015 in which general anesthesia was provided. The patient was discharged from the hospital on [DATE] and no post anesthesia evaluation was completed.

Failure of anesthesia providers to complete a post anesthesia evaluation within 48 hours of administering anesthesia places the staff at risk of failing to identify anesthesia related complications.