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.

ST ELIZABETHS HOSPITAL 1100 ALABAMA AVENUE, SE WASHINGTON, DC 20032 Aug. 21, 2019
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, video footage, hospital policy review, and/or staff interview, the hospital staff failed to promote and protect patient rights, during patient handling, to ensure safety, in two of six observations (Patient #42).

Findings included ...

Review of the hospital's policy titled, "Care of Individuals in Seclusion or Restraint for Behavioral Reasons," revised 10/24/16 showed, " ...seclusion and restraints shall only be used in emergency situations that pose an immediate risk of individual physically harming him/herself or others, when least restrictive measures are not viable or are ineffective...the registered nurse will direct the staff members when to initiate the safety care techniques to prevent harm to the individual and others ..."

Review of the hospital's behavior safety training manual, titled, "Safety-Care," dated 1997-2016, showed, " ...Physical management procedures must be used only when there is no other safe alternative ... Physical management interventions should always be applied in the least restrictive manner that is safe, with the minimum physical force necessary for safety and stability ...Do not carry, even if staff are larger and stronger than the person."

Review of the hospital's policy titled, "Code 13 Response," revised 01/25/18, revealed that a Code 13 occurs when a psychiatric or behavioral crisis has the possibility of exceeding the capacity of the nursing staff to safely address the behavioral episode, usually when, "A behavioral disturbance is ongoing such that the person's behavior remains threatening and cannot be de-escalated, even after using basic de-escalation strategies".

A. The hospital staff admitted Patient #42 on 04/15/19 with diagnoses to include Schizophrenia, Hypertension, Tobacco and Cannabis Use.

A review of the medical record revealed that Patient #42 had been exhibiting hostile, aggressive and agitated behavior, during the admission process and continued the behavior after being admitted to the unit. The patient was not receptive to re-direction from medical and nursing staff.

Further review of the medical record revealed, a nurse's note dated 04/19/19 at 06:48 AM, showing, at 12:20 AM, a "Code 13" was called on Patient #42, for his agitated and aggressive behavior; and not being receptive to repeated de-escalation strategies. The documentation revealed that the patient began, "yelling, and using explicit and incomprehensible language", wandering into other patient rooms and barricaded himself in his room.

A physician's order dated 04/19/19 at 12:30 AM and 12:35AM, directed staff to initiate a physical hold and to move Patient #42, to the restraint room; and place in 4-point restraints.

On 08/15/19 at approximately 2:45 PM, the surveyor viewed video footage of the actions related to the psychiatric emergency event [Code 13] on 04/19/19. The video revealed four staff persons manually carried Patient #42 out of his room, holding his wrists and lower extremities, while under the supervision of medical and nursing staff.

The practice lacked evidence that hospital staff followed the hospital's protocols for safe patient handling.

The surveyor conducted a face-to-face interview on 08/20/19, at approximately 8:58 AM, with Employee #62, Psychiatrist, who wrote the restraint order and responded to the Code 13 on 04/19/19. He stated that Patient #42 repeatedly refused to cooperate with assessments and the established interdisciplinary treatment plan. He required restraint, and seclusion interventions to manage behaviors and was unresponsive to de-escalation strategies. The restraint was ordered on [DATE] to ensure patient safety, as staff were unable to determine patient safety, once he barricaded himself in his room.

A face-to-face interview was conducted with Employees #5, Interim Chief Nursing Officer, on 08/15/19 at approximately 2:00 PM, and Employee #13, Director of Education, on 08/19/19 at approximately 2:10 PM. After review of the video footage that showed staff carrying Patient #42, both acknowledged that staff did not use proper handling techniques to transport the patient to the restraint room. Both further stated that the hospital's safe handling protocols were revised to reflect not to pick up, carry or drag patients.

Cross Reference to A-0395-1






B. Record review of the hospital's policy 407.01 titled, "Prohibited Items," dated 04/25/15, showed prohibited items included, "Electric/Electronic Items...any item with a cord."

During a tour of Unit 2A (1 of 12 units in the hospital) on 08/15/19 at approximately 3:35 PM, with Employees #47, Nurse Manager, and 39, Infection Control Coordinator/Escort, the surveyor observed a patient using a telephone that was mounted on the wall, next to the nurse station. The handset cord of the phone pooled onto the floor.

The practice lacked evidence that the hospital staff promoted patient safety to secure items that pose a potential safety risk.

The surveyor conducted a face to face interview with Employee #48, Registered Nurse, on 08/15/19 at approximately 3:55 PM, regarding the telephone observed on Unit 2A. She stated that patients are directly supervised when they use the telephone. Once, the phone is no longer in use, it is removed from the wall and secured at the nurses station. The phone is scheduled for replacement as done on other units.

Employees #47, 48 and 39 acknowledged the findings, at the time of the observation.
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review, policy review, and staff interview, the psychiatrist failed to follow the hospital policy to perform monthly psychiatric assessments, for two of 39 patient records reviewed (Patient #12 and Patient #44).

Findings included ...

Review of the hospital's policy's titled, "Assessments", revised 09/28/12, under Psychiatric Assessments and Updates showed, "Psychiatric assessments updates shall be completed, at least 30 days from the date of the last note written; additionally, as clinically indicated."

A. Review of Patient #12's medical record on 08/19/19 at approximately 3:00 PM, showed the psychiatry staff documented the most current psychiatric assessment note on 04/02/19.

The medical record lacked documented evidence that the psychiatrist completed psychiatric assessment updates by 05/02/19, 06/02/19, 07/02/19 and 08/02/19, for four consecutive months.

The practice showed that the psychiatry attending staff failed to document current and up to date assessments on the patient, per hospital policy.

Employees #24, Nurse Manager, and #6, Nursing Director of Quality, acknowledged the findings on 08/19/19 at 3:00 PM and 4:30 PM, respectively.





B. The hospital staff admitted Patient #44, whose diagnoses included Disorganized Schizophrenia.

A review of the medical record on 08/22/19 at approximately 10:30 AM, revealed a psychiatry monthly assessment dated [DATE]. There were no monthly psychiatrist assessments for the months of July, August, September and November, 2018.

The practice lacked evidence that psychiatry staff completed assessments at least every 30 days, in accordance with the hospital policy.

During a face-to-face interview conducted on 08/22/19, at approximately 10:35 AM, with Employee #61, Registered Nurse, she acknowledged the findings, at the time of the medical record review.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, video review, record review, policy and protocol review, and staff interview, the hospital failed to promote and protect patient rights, as evidenced by failure to implement safe patient handling techniques to ensure a safe patient environment (A-0144); and failed to perform and document required patient assessments, during restraint and seclusion (A-0175).

The cumulative effect of these systemic practices resulted in the hospital failure to comply with conditions of participation for Patient Rights.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
Based on medical record review, hospital policy review, and staff confirmation, the nursing staff failed to follow hospital policy to perform and document assessments every 15 minutes, for the duration of seclusion or restraints on two occasions, for one of 11 patient records reviewed (Patient #25).

Findings included ...

Review of the hospital's policy titled, "Restraint and Seclusion for Behavioral Reasons," revised 10/20/16, showed the registered nurse will conduct and document regular assessments of the patient to include 15 minute assessments for signs of injury or medical distress, circulation and skin, mental health status, readiness for discontinuation of restraints or seclusion and advising the individual behavioral criteria for release of restraints.

The surveyor conducted a review of Patient #25's medical record, with Employee #56, Registered Nurse, on 08/19/19 at approximately 11:00 AM. The patient was admitted to the hospital with diagnoses to include Schizoaffective Disorder, Autism Spectrum, Substance Abuse Use and Intellectual disability.

The physician ordered the patient to be placed in seclusion on 10/02/18 at 2:53 PM; and ordered the patient to be placed in four point restraints on 10/18/18 at 7:35 PM. The record lacked evidence that nursing staff performed and documented 15 minute assessments, for the duration of the time the patient was placed in seclusion or in restraints, as required by hospital policy.

The practice lacked evidence that the nursing staff promoted patient rights to ensure patient safety.

Employee #56 acknowledged the findings, at the time of the medical record review.
VIOLATION: UNUSABLE DRUGS NOT USED Tag No: A0505
Based on observation, policy review, and staff confirmation, the hospital staff failed to ensure expired medications and biologicals were not stored and available for use (Patients #17 and 76).

Findings included ...

Review of the hospital policy titled, "Storage of Medications" showed, "Expired, contaminated or potentially contaminated medications and open multi-dose vials that have reached the beyond use date are discarded in the appropriate designated waste container or returned to the Pharmacy."

Review of the hospital policy titled, "Multi-Dose Vials and Single-Dose Vials, showed the multi-dose containers must be labeled with the beyond use date based of 28 days from the date the container is opened.

During a tour of Unit 1A on 08/20/19, at 11:30, the surveyor observed a jar of used Silvadene 1% (percent) cream for Patient #17, with an expiration date of 08/14/19; and two cans of sunscreen spray, with expiration dates of 04/19, stored in the medication cabinet. Additionally, one used Ventolin metered dose inhaler for Patient #76, failed to include the open and expiration date.

The findings were confirmed by Employees #10, Director of Pharmacy and #18, Registered Nurse.
VIOLATION: ORGANIZATION Tag No: A0619
Based on observations during the survey, the dietary services staff failed to ensure that foods were prepared and served in a safe and sanitary manner.

Findings included ...

The following observations were on 08/16/19 between 9:50 AM and 3:45 PM, in the presence of Employee #9, Director of Dietary Services.

1. Ceiling surfaces, in front of compressor fans, in walk in refrigerator #KC5, were soiled and splattered with a dark substance.

2. Three containers of prune juice, in walk in refrigerator #KC5, were damaged.

3. An aluminum side panel, in the walk in refrigerator #KC5, was separated from the wall, which exposed the insulation.

Employee #9 acknowledged the findings.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation during the survey period, the hospital staff failed to ensure housekeeping and maintenance services were maintained, in a safe and sanitary manner.

Findings included ...

The observations were in the presence of Employees #8, Director of Facilities, 43, Housekeeper Foreman, and 44, Inventory Manager.

1. The following findings were observed, during a tour of Unit 1A, between 10:00 AM and 10:40 AM, on 08/19/19 through 08/21/19.

A. Floor surfaces were soiled with debris in the Treatment Room.

B. Wall surfaces were scarred and marred, in Rooms 1A20, 1A64, and 1A63.

C. The caulking around the base of the toilet was stained and soiled, in Room 1A14.3.

D. Floor surfaces were marred and damaged, in the Day Room, Rooms 1A14.1 and 1A45, under the sink in Hallway B, and near the Main entrance door.

E. Door and door jamb surfaces were marred, in Rooms 1A28, 1A64, at the Main Entrance and the entrance, near the Nurses Station.

F. The access door panel in Room 1A24 was rusty.

G. The exhaust vent in Room 1A25 was not secured to the ceiling.

2. The following findings were observed, during a tour of Unit 1B, between 11:45 AM and 11:55 AM, on 08/19/19.

A. Door and door jamb surfaces were marred at the main entrance to Unit 1B; the door near the Nurses Station, and doors at the entrances to Rooms, 1A28, 1B20, and 1B61.

B. Wall surfaces were marred in Room 1B57.

C. Exhausts vent surfaces were soiled with dust, in Room 1A25.

D. Floor surfaces were damaged at the entrance to the Supply Area, 1B14.1; in the patient sitting area near the hallway; and in Room 1B28.

E. Floor surfaces were soiled, in the rear of the crash cart; and wall surfaces were marred in Room 1B20.

F. Floor surfaces were stained and the electric junction box was soiled, in Room 1B24.

G. The frontal areas of the Nurses Station were marred.

H. Floor surfaces were stained and damaged, in open areas of the Day Room, on Unit 1B and in the hallway area of Sitting Room A.

I. The lower surfaces of the doorjamb were damaged at the entrance to the Seclusion Room; and floors were damaged in the sitting area of Hallway A.

J. The backrest of the shower chair was damaged, in the shower of 1B23.

K. The lower shelf surfaces were damaged in Room 1B24.

L. Privacy curtain shelf surfaces were damaged and the access panel door was rusty, in Room 1B26.

M. Floor tiles were damaged, at the entrance to the shower, and the access panel was soiled in Room 1B26.

N. Floor surfaces were marred and damaged, in Rooms 1B52 and 1B28.

O. Door surfaces were marred and windowsill surfaces were dusty, in Room 1B61.

P. Wall surfaces were marred, near the bed headboard, and doorjamb surfaces were marred in Room 1B61.

Q. Wall surfaces were marred, near the bed headboard, in Rooms 1B45, 1B56, 1B31, 1B33, and 1B57.

R. Hallway surfaces near the main entrance door, to unit 1B, and the entrance door near the Nurses Station were marred.

S. The bed frame surfaces were dusty, in Room 1B31.

T. Floor surfaces were marred and damaged, in the Lounge, Day Room Areas, and Room 1B52.

U. The shower chair back support was worn and damaged, in Room 1B48.

V. Privacy curtain hooks were detached, in Room 1B47.

W. The base surfaces of the toilet were soiled and stained, and the top surfaces of the mattress were stained, in Room 1B42.

X. The faucet failed to shut off the water supply in Room 1B55.

Y. Door and wall surfaces were marred, in Room 1B58.

Z. Wheel Chair surfaces were soiled, on the spoke and frame, in Room 1B60.

3. The following findings were observed, during a tour of Unit 2A at 1:25 PM on 08/19/19.

A. Wall surfaces were marred in the hallways, near Room 2A07.

B. Cleaning supplies were improperly stored on the floor, in Room 2A09.

C. Exhaust vents were soiled on the interior; and the entrance door and door jambs were marred in the Staff Bathroom, Rooms 2A45, 2A52, 2A55, and the Nutrition Area.

D. Privacy curtains were detached in Room 2A55.

E. The lower wall surfaces were marred, and a green substance was observed on windowsills, in Room 2A57.

F. Floor surfaces were damaged, in front of the Nurses Station Work Area, and in Room 2A63.

G. Floor tile surfaces were damaged at the entrance to Room 2A46.

H. Window and bed frame surfaces were soiled, in Room 2A45.

I. Sticky labels were on the rear of the door; and floor surfaces were marred, in Room 2A44.

J. Floor surfaces were stained, in Rooms 2A40 and 2A43.

K. Window sill surfaces were soiled with dust; and the top of the closet was soiled with dust, in Rooms 2A38 and 2A40.

L. Walls in the rear of the Pyxis and the lower wall surfaces were marred, in Room 2A21.

M. Floor and window sill surfaces were soiled with dust, in Rooms 2A40 and 2A21.

N. Wall surfaces, in the Seclusion Room and Room 2A21, were soiled.

O. Entrance door surfaces were marred to Room 2A19.

4. The following findings were observed, during a tour of Unit 2B, at 3:25 PM, on 08/19/19.

A. The bottom shelves of carts, in the Soiled Linen Room 2B05, were dusty.

B. The upper cabinet door was missing, in Room 2B05.

C. The ice machine drain was clogged, in the 2B Nutrition Area.

D. Door jamb surfaces were marred at the entrance to the Laundry Room.

E. The lower wall surfaces were marred, in Room 2B20.

F. Walls were damaged in Rooms 2B23 and 2B52.

G. The exhaust vent, over the refrigerator in the Nutrition Room and in Room 2B48, were soiled with dust.

H. The lower wall surfaces were marred, in 2B20.

I. The corner surfaces of the vent, in Room in 2B28, were damaged.

J. Floor surfaces were marred in Room 2B34.

K. Floor surfaces, in the Lounge Area and Day Room, were damaged and marred.

L. The interior surfaces of the exhaust vent was soiled, in Rooms 2B25 and 2B28.

M. Bed covering was soiled and stained, in Room 2B56.

N. Floor surfaces were stained in the Laundry Room.

5. The following findings were observed, during a tour of the 2TR Unit, at 10:15 AM on 08/20/19.

A. Floor surfaces were soiled with dust, in Room 276.

B. Floor surfaces were marred in Rooms 278 and 290.

C. A penetration was observed around the wall outlet, in Room 284.

D. Floor surfaces were marred in Room 288.

6.The following findings were observed during a tour of the Medical Clinic, at 9:00 AM on 08/20/19.

A. The Dental Chair was soiled with a buildup of wax, on the base surfaces.

B. The top and bottom surfaces of the Panoramic X Ray Machine was soiled with dust.

C. The interior surfaces of the exhaust vent was soiled with dust, in Room 117.07.

D. The Laboratory entrance door was marred, in Room 115.03.

E. Wall surfaces were marred in the Treatment Room, 114.07.

7. The following findings were observed, during a tour of the Transition Area, at 10:30 AM on 08/20/19.

A. The exterior surfaces of the air supply vent were soiled with dust, in Room 122.01.

B. Wall surfaces were marred in the Multi-Purpose Room.

C. Walls were stained and tiles were damaged, in the Transition Area and in the bathroom of the Respiratory Treatment Area.

D. Door surfaces were marred at the entrance to Room 122.

8. The following findings were observed, during a tour of the Unit 1F, at 11:25 AM on 08/21/19.

A. Floor surfaces in the Day Room and Rooms 1F31 and 1F32 were soiled.

B. Shower wall surfaces were stained and soiled, in Rooms 1F48 and 1F49.

C. The entrance door made contact with the floor, when an attempt was made to open the door; and the shower curtain was soiled, in Room 1F49.

D. Wall surfaces were stained and adhesive stickers adhered to the back of the door, in Room 1F39.

E. The main entrance door to Unit 1F was marred and stained.

F. Hard water stains and dust was on the lower shelf surfaces of carts, in Rooms 1F05.

G. The top surface of the buffing machine and cleaning equipment was soiled; and the inner surfaces of the mop sink was soiled, in Room 1F09.

H. Cleaning equipment was improperly stored, on the floor, in the Nutrition Area.

I. The inner surfaces of the exhaust vent were soiled and floor tile surfaces were damaged, in Room 1F67.

J. Wall surfaces were marred and floor surfaces were dusty, in the Medication Room 1F21.

K. Wall surfaces were marred, behind equipment, in the Treatment Room.

L. Floor surfaces were soiled and graffiti was on the wall surfaces, in 1F19.

M. Wall and floor surfaces in the hallway, outside of the Seclusion Room, were stained.

N. Wall surfaces were stained in the Lounge Area, outside of Hallway A.

O. Wall surfaces were stained and damaged, in Room 1F24.

Employee #8 acknowledged the findings.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
1. Based on review of video footage, policy review, and staff interview, the nursing staff failed to follow the hospital policy to ensure safe patient transport, in one of 10 observations (Patient #42).

Cross Reference A-0144- A.







2. Based on record review, policy review, and staff interview, the nursing staff failed to perform blood pressure measurements, for two of three patients, who required blood pressure management (Patients #18 and 19).

Findings included ...

Record review of the hospital's policy titled, "Utilizing e-MAR [electronic medication administration record] and Pyxis - Medication Administration," revised 08/10/18, showed that medications are administered following the '10 Rights'- right individual, right medication, right dose, right time, right route, right to refuse, right to be educated, right to assessment, right to evaluation, and right for documentation. The results of medications dependent upon set parameters must be assessed and compared before the individual receives the medication, and recorded on the e-MAR.

A. Review of Patient #18's medical record on 08/19/19 at approximately 11:50 AM, with Employees #22, Registered Nurse, revealed physician orders for 8:00 AM medication administration of Metoprolol, started on 11/02/17 and continued to present, with parameters to hold the medication for a systolic blood pressure (SBP) of 90 and diastolic blood pressure (DBP) of 60, and to call medical staff for a SBP of 170 and DBP of 110. Patient #18's medication regimen included Lisinopril, ordered 02/14/19, with parameters to hold the medication for a SBP less than 100 or DBP less than 50, and to call medical staff. An additional order for Norvasc, started 02/01/18 and continued to present, for a daily 8:00 PM dose, showed parameters to hold the medication for a SBP of 90 and DBP of 60, and to call medical staff for a SBP of 170 and DBP of 110.

Review of the e-MAR and nursing documentation lacked evidence that nursing staff performed blood pressure measurements on 08/11/19 for the AM medication administration; however, nursing staff administered the medications to the patient. Additionally, on 08/16/19 and 08/19/19, the AM medications were administered but the blood pressure measurement was performed two and a half hours before medication administration. Further review revealed that staff failed to perform blood pressure measurements on 08/10/19, 08/11/19, 08/14/19 and 08/15/19, prior to the PM dose of Norvasc. However, nursing staff administered the medication to the patient.

The practice lacked evidence that the nursing staff followed the hospital's medication administration policy.

During a face to face interview with Employee #16, Nurse Manager, on 08/19/19 at approximately 12:30 PM, she acknowledged the findings, explaining that the nursing staff should have performed blood pressure measurement, before medication administration.

B. Review of Patient #19's medical record on 08/19/19 at approximately 9:30 AM, with Employee #22, Registered Nurse, revealed a physician order dated 08/06/19, for Lasix every morning, with parameters to hold the medication for a SBP less than 100, and DBP less than 55. A second order for Lisinopril every day, started 01/30/18 and continued to present showed parameters, to hold the medication for a SBP less than 100, and DBP less than 55, and to call medical staff.

Review of the e-MAR and nursing documentation lacked evidence that nursing staff performed blood pressure measurements on 08/10/19 through 08/13/19 and on 08/16/19; however, nursing staff administered the medications to the patient.

The practice lacked evidence that the nursing staff followed the hospital's medication administration policy.

During a face to face interview with Employee #16, Nurse Manager, on 08/19/19 at approximately 12:30 PM, she acknowledged the findings, explaining that the nursing staff should have performed blood pressure measurement, before medication administration.

Cross Reference to A-0405
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on record review, policy review, and staff interview, the nursing staff failed to perform blood pressure measurements, for two of three patients, who required blood pressure medication management (Patients #18 and 19).

Findings included...

Cross Reference A-0395- 2.
VIOLATION: PHARMACY DRUG RECORDS Tag No: A0494
Based on a review of hospital documents to include Pyxis Automated Dispensing Machine (ADM) Schedule II, III, IV, and V Controlled Substance Transactions by patient report, physicians' orders, and the Medication Administration Record [MAR], the hospital staff failed to properly document the administration or handling of controlled substances, in 10 of 37 records reviewed (Patients #21, 31, 32, 39, 50, 53, 55, 59, 65, and 68).

Findings included ...

On 08/20/19, the ADM, for controlled substances schedule II-V, generated a seventy-two (72) hour all stations event report for nursing Units: 1A, 1B, 1C, 1D, 1E, 1F, 1G, 2A, 2B, 2C, and 2D. All patients were randomly selected for this audit. The survey of records was started on 08/20/19, at approximately 10:00 and was completed on 08/21/19, at approximately 11:00.

In the presence of Employee #10, Director of Pharmacy, the physician order, ADM records, and the Electronic Medication Administration Record (e-MAR) were reviewed for accuracy. Withdrawals from the ADM were compared with the dose administered, the administration times, and the dispositioning of the controlled substances. The following were observed:

A. On 08/09/19, at 15:02, Patient #21, on Unit 1A, was ordered, Clonazepam 2 mg (milligrams), once every morning. On 08/17/19, at 19:18, one dose was removed and administered at 20:25, over one hour later.

B. On 08/09/19, Patient #31, on Unit 1A, was ordered Lorazepam 1.5 mg, by mouth every night at bedtime. On 08/17/19, at 19:22, one dose was removed and administered at 20:40, over one hour later.

C. On 08/09/19, at 13:27, Patient #32, on Unit 1A was ordered Lorazepam 2 mg, three times a day. On 08/17/19, at 19:36, one dose was removed and administered at 20:55, over one hour later.

D. On 08/15/19, at 14:05, Patient #39, on Unit 2A, was ordered Tramadol 50 mg, three times a day as needed for pain. On 08/18/19, one dose was documented as administered at 11:04; however, there was no record that the medication was removed from the ADM.

E. On 08/09/19, at 13:09, Patient #50, on Unit 1A, was ordered Clonazepam 0.5 mg, by mouth twice a day. On 08/17/19, at 19:15, one dose was removed and administered at 20:50, over one hour later.

F. On 08/09/19, at 15:09, Patient #53, on Unit 1A was ordered Clonazepam 0.5 mg, by mouth once every morning. On 08/18/19, at 04:55, one dose was removed and administered at 06:25, over one hour later.

G. On 7/23/19, at 13:32, Patient #55, on Unit 1B, was ordered Clonazepam 1 mg, by mouth twice a day. On 08/18/19, at 07:36, one dose was removed and administered at 08:45, over one hour later.

H. On 07/31/19, at 17:36, Patient #59, on Unit 1D, was ordered Clonazepam 1 mg, by mouth three times a day. On 08/18/19, at 08:49, the dose was removed and administered at 08:30. The dose was documented as administered before removal from the ADM.

On 08/18/19, at 13:19, one dose of Clonazepam 1 mg was removed for Patient #59 and documented as administered at 14:54; over one hour later. However, there was no record that the medication was removed from the ADM.

I. On 08/08/19, at 12:38, Patient #65, on Unit 1F, was ordered Clonazepam 1 mg, by mouth three times a day. On 08/18/19, at 07:54, one dose was documented as administered; however, there was no record that the medication was removed from the ADM.

J. On 08/08/19, at 14:44, Patient #68, on Unit 2B was ordered Lorazepam 0.5 mg, by mouth three times a day. On 08/08/19, at 12:27, one dose was documented as administered; however, there was no record that the medication was removed from the ADM.

All findings were confirmed by Employee #10, Director of Pharmacy.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, policy review, standards of care review, and staff interview, the hospital staff failed to ensure infection prevention, in two of 10 observations (Patient # 22).

Findings included ...

Record review of the hospital's policy titled, "Hand Hygiene Program," effective 08/01/16, showed that hand hygiene must be performed before donning and after doffing gloves.

Review of the Centers for Disease Control and Prevention recommendations for the appropriate use of personal protective equipment, showed that hand hygiene should be performed immediately after the removal of gloves.
https://www.cdc.gov/handhygiene/providers/index.html\

A. During an observation of administration of an albuterol nebulizer treatment on Unit 1A, on 08/19/19 at approximately 2:20 PM, the surveyor observed Employee #35, Respiratory Therapist, prepare and administer the nebulizer treatment to Patient #22. He removed and disposed of his gloves, after applying the mask. He failed to sanitize, and then put his hands in his pocket.

The practice failed to demonstrate that the respiratory therapist followed acceptable standards of infection prevention practices and the hospital policy.

During a face to face interview on 08/19/19 at approximately 2:30 PM, the surveyor queried Employee #35, regarding the practice. He acknowledged the findings.

B. During a tour of Unit 1A on 08/20/19 at approximately 2:00 PM, with Employee #39, Infection Control Coordinator, the surveyor observed Employee #17, Registered Nurse, remove his gloves, after assisting with patient care, and proceed to manipulate the computer, without disposing the gloves or sanitizing his hands.

The practice failed to demonstrate that the nurse followed acceptable standards of infection prevention practices and the hospital policy.

During a face to face interview on 08/19/19 at approximately 2:10 PM, the surveyor queried Employee #17, regarding the practice. He acknowledged the findings, disposed of the gloves and sanitized his hands.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observation and staff interview, the hospital staff failed to ensure preventative maintenance of 16 blood pressure machines and one scale, in 17 observations.

Findings included ...

During a tour of patient care units, on 08/15/19, two Welch Allyn blood pressure machines (#identifier) were found, with preventative maintenance service due dates of 07/18 as follows:

Unit 2B, at approximately 3:50 PM, # 9 and Unit 2D at approximately 4:30 PM, # 6

The following 14 Welch Allyn blood pressure machines were found that same day, with preventative maintenance service due dates of 07/19 as follows:

Unit 1B at approximately 3:45 PM, # 5 and # 5
Unit 2D at approximately 4:30 PM, # 7
Unit 1E at approximately 12:30 PM, # 6 and # 7
Unit 1A at approximately 4:30 PM, #JA 7 and # 0
Unit 2B at approximately 3:50 PM, # 8
Unit 2A at approximately 3:30 PM, # 6 and # 7
Unit 2TR at approximately 3:30 PM, DC
Unit 1G at approximately 4:05 PM, 1
Unit 1F at approximately 4:00 PM, # 1 and # 2

Additionally, a weight scale was found on Unit 1B on 08/15/19 at approximately 3:45 PM, with a preventative maintenance due date of 07/19.

The practice lacked evidence that hospital staff maintained essential equipment to ensure patient safety.

During a face-to-face interview on 08/21/19 at approximately 3:30 PM with Employee #5, Interim Chief Nursing Officer, and #8, Director of Facilities, they acknowledged the findings.
VIOLATION: RESPIRATORY CARE SERVICES POLICIES Tag No: A1160
Based on medical record review, policy review, and staff interview, the respiratory therapist failed to follow the hospital policies, related to respiratory assessments for medication administration, in one of two patient records reviewed (Patient #22).

Findings included ...

Record review of the hospital's policy titled, "Utilizing e-MAR [electronic medication administration record] and Pyxis - Medication Administration," revised 08/10/18, showed that medications are administered following the '10 Rights'- right individual, right medication, right dose, right time, right route, right to refuse, right to be educated, right to assessment, right to evaluation, and right for documentation. The results of medications dependent upon set parameters must be assessed and compared before the individual receives the medication, and recorded on the e-MAR.

Record review of the hospital's policy titled, "Respiratory Therapy," revised 12/05/18, showed that the respiratory therapist shall assess the medical provider's orders and parameters in the e-MAR. Respiratory assessment includes patient appearance, heart and respiratory rates, breath sounds, blood oxygen saturation, shortness of breath, and apparent hypoxemia.

Review of Patient #22's medical record on 08/19/19 at approximately 2:20 PM, with Employee #22, Registered Nurse, revealed a physician order dated 03/26/19 for Albuterol Sulfate inhalation (nebulizer) treatments, twice a day.

On 08/19/19 at approximately 2:20 PM, the surveyor observed Employee #35, Respiratory Therapist, prepare and administer the nebulizer medication treatment to Patient #22, without first performing a pre -treatment assessment of the patient's respiratory status to include his breath sounds.

During a face to face interview with Employee #35, at approximately 2:25 PM, he acknowledged that he did not listen to the patient's breath sounds because he did not have a stethoscope. He asked Employee #31, Register Nurse, who was performing constant observation on the patient, if he had a stethoscope. Employee #31 shared that the medication nurse had one. He used that stethoscope and auscultated the breath sounds, during the patient's treatment. However, he documented a pre-treatment respiratory assessment, in the e-MAR.

The practice lacked evidence that that the respiratory therapist followed the hospital policies and e-MAR, which revealed respiratory pre and post assessment documentation, for the medication administration.

During a subsequent face to face interview with Employees' #4, Medical Director and 34, Supervisor of Respiratory Services, on 08/21/19 at approximately 10:55 AM, they both acknowledged the findings.
VIOLATION: RESPIRATORY SERVICES Tag No: A1164
Based on medical record review, policy review, and staff interview, the respiratory therapist failed to document medical staff notification, when nebulization medications were not administered as ordered, for four of six patient records reviewed (Patient #4, 8, 13 and 22).

Findings included...

Record review of the hospital's policy titled, "Respiratory Therapy," revised 12/05/18, showed that the respiratory therapist shall communicate all treatment and medication refusal with the ordering practitioner and document the communication in the medical record. Ongoing progress notes include services provided or refused, notification and a summary of treatment refusals or changes. The respiratory therapist shall notify the attending provider in the event of three standing order treatment refusals.

A. Review of Patient #4's medical record on 08/16/19 at approximately 10:30 AM, showed the medical staff ordered Albuterol 0.083% (percent) nebulization 2.5 milligrams (mg) twice a day on 01/29/19 for Chronic Obstructive Pulmonary Disease.

The surveyor conducted a review of nebulizer treatments for the dates of 08/01/19 through 08/15/19. The review showed the patient refused nebulizer treatments on the following dates and times: 08/02 3:00 PM, 08/03 at 3:20 PM, 08/05 at 9:20 AM and 3:00 PM, 08/09 at 9:40 AM and 2:18 PM, 08/10 at 3:10 PM, 08/11 at 3:35 PM, 08/12 at 9:00 AM, 08/13 at 9:05 AM and 08/14 at 3:20 PM.

Further review showed that the medical record lacked documented evidence that the respiratory therapy staff notified the medical staff, per policy, regarding the patient's medication refusal.

The practice lacked evidence that the respiratory therapist notified and documented medical staff notification, for the missed nebulizer treatments, per hospital policy.

Employee #55, Nurse Manager, and 66, Registered Nurse, acknowledged the findings on 08/16/19, during the review at approximately10:30 AM.

B. Review of Patient #8's medical record on 08/19/19 at approximately 10:15 AM, showed the medical staff ordered Ipratropium Bromide 0.2% (percent) nebulization, twice a day, on 01/14/19 for Chronic Obstructive Pulmonary Disease.

The surveyor conducted a review of nebulizer treatments for the dates of 08/01/19 through 08/15/19, which showed the patient's refused 11 nebulizer treatments on the following dates and times: 08/01 at 3:00 PM, 08/02/ 3:00 PM, 08/03 at 2:45 PM, 08/04 at 2:00 PM, 08/05 at 8:50 AM and 3:00 PM, 08/06 at 3:00 PM, 08/07 at 3:00 PM, 08/09 at 3:30 PM, 08/11 at 2:15 PM, 08/12 at 9:00 AM and 3:45 PM, 08/13 at 3:51 PM and on 08/15 at 3:45 PM.

Further review showed that the medical record lacked documented evidence that the respiratory therapy staff notified the medical staff, per policy, regarding the patient's refusal of medication.

The practice lacked evidence that the respiratory therapist notified and documented medical staff notification, for the missed nebulizer treatments, per hospital policy.

Employee #55, Nurse Manager, and 66, Registered Nurse, acknowledged the findings on 08/19/19 during the review at 10:30 AM.

C. Review of Patient 13's medical record on 08/19/19 at approximately 3:00 PM, showed the medical staff ordered Albuterol 0.083% (percent) nebulization 2.5 mgs twice a day, as needed, on 06/03/19 for Chronic Obstructive Pulmonary Disease.

The surveyor conducted a review of nebulizer treatments for the dates of 08/11/19 through 08/15/19 which showed the patient refused two nebulizer treatments on 08/11 at 9:10 AM, 08/12 at 8:30 AM and 3:10 PM, 08/14 at 8:30 AM and 08/15 at 8:30 AM.

Further review showed that the medical record lacked documented evidence that the respiratory therapy staff notified the medical staff, per policy, regarding the patient's refusal of medication

The practice lacked evidence that the respiratory therapist notified and documented medical staff notification, for the missed nebulizer treatments, per hospital policy.

Employees #24, Nurse Manager, and #46, Registered Nurse, acknowledged the findings.






D. Review of Patient #22's medical record on 08/19/19 at approximately 2:20 PM, with Employee #22, Registered Nurse, revealed a physician order dated 03/26/19 for Albuterol Sulfate inhalation (nebulizer) treatments, twice a day. Further review revealed the patient missed and/or refused nebulizer medications on 08/14/19, 08/16/19, and 08/17/19 at 8:00 AM and on 08/13/19, 8/16/19, and 8/17/19 at 2:00 PM. However, the record lacked documented evidence that the respiratory therapy staff notified the medical provider.

The practice lacked evidence that the respiratory therapist notified and documented medical staff notification, for the missed nebulizer treatments, per hospital policy.

During a subsequent face to face interview with Employees' #4, Medical Director and 34, Supervisor of Respiratory Services, on 08/21/19 at approximately 10:55 AM, they both acknowledged the findings.