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 Nov. 7, 2019
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
Based on record review, policy review, and staff interview, respiratory therapy staff failed to ensure the patient had a right to participate in the implementation of his plan of care by failing to provide communication in a language that the patient could understand, in one of one medical record reviewed (Patient #11).

The findings included ...

Cross Reference 0084
VIOLATION: CONTRACTED SERVICES Tag No: A0084
Based on medical record review, policy review, and staff interview, the governing body failed to ensure that Respiratory Therapists (RT's) were trained and provided care in an effective manner in one of one medical records reviewed (Patient #11).

Findings included ...

The St. Elizabeth's Hospital policy entitled "Language Interpretive Services" dated 08/26/05 showed that interpreters will be provided for language assistance to all non-English speaking patients who need or request language assistance. Staff training on language assistance and implementation will be included.

Review of the physician orders showed an order dated 10/27/19 at 2:13 PM for Albuterol Sulfate nebulizer four times a day as needed. An additional order dated 10/27/19 at 2:15 PM for nebulizer treatment breathing exercises and oxygen saturation.

Review of the medication administration record (MAR) for the breathing treatment dated 10/28/19 at 9:50 AM showed that the therapist documented "[Patient] unable to understand instructions to perform the breathing exercise." Review of the MAR for the breathing treatment dated 10/29/19 showed that the therapist documented "[Patient] unable to understand instructions to perform the breathing exercise 1:5".

Review of a respiratory therapist note dated 11/02/19 at 3:18 PM showed the therapist documented "[Patient] is not cooperating for [nebulizer treatment]. Unable to understand the instruction." Another respiratory therapist note dated 11/04/19 at 10:34 AM showed, "[Patient] is unable to understand the instructions to perform the 1:5 breathing exercise [physician name] made aware.

The surveyor conducted a face to face interview on 11/06/19 at 4:15 PM with Employee #25 regarding why he documented that Patient #11 did not understand the instructions. Employee #25 stated that Patient #11 does not speak English and cannot understand directions. When asked if he was aware that the hospital had interpreter services, he stated yes. When asked if he had ever used the service to communicate with a patient that did not speak English, he stated no. When asked if he was educated on the use of interpretive services, he stated "no".

The surveyor reviewed the educational records of Employees #25 and 58, Respiratory Therapists. The records lacked documented evidence of education related to the use of interpreter services.

The surveyor conducted a face to face interview on 11/07/19 at 4:00 PM with Employee #2, Interim Director of Nursing. She acknowledged the findings.
VIOLATION: QAPI Tag No: A0263
Based on Quality Assessment Performance Improvement (QAPI) Program review, record review, policy review, and staff interview, the hospital failed to set priorities for its performance improvement activities that focus on problem-prone areas related to collaboration of patient care between disciplines and failed to ensure compliance with the plan of correction (A-283).

The quality and patient safety program lacked evidence of structural, procedural or process changes to achieve sustainable remediation of deficient practices and care delivery issues. In addition, the corrective action plan (PoC) lacked evidence of implementation. Priorities and process improvement activities related to hospital-specific problem areas were lacking.

The quality plan failed to evaluate the quality of contracted services (respiratory) and ensure that those services are provided in a safe and effective manner.

The findings included...

The problem-prone areas identified by the surveyors include:

1. Failure to write medication orders in accordance with accepted standards of practice, and deliver safe and effective contracted (respiratory) services. Cross reference 482.12, A0049 and A0084 [medical staff and contracted services]

2. Failure to provide care and communicate in a language that the patient could understand. Cross reference
482.13, A0130 [patient rights]

3. Failure to administer antihypertensive medications as prescribed. 482.23, A0395 [nurse supervision]

4. Failure to deliver respiratory care as prescribed 482.57, A1160 [respiratory services]

5. Failure to document the administration and handling of controlled substances 482.25, A0494
[pharmaceuticals]

6. Failure to maintain the physical plant and environment in a safe and sanitary manner 482.41, A-0701 [physical plant maintenance]

7. Failure to lead the development of a comprehensive Emergency Preparedness Plan that encompasses all required components. Cross reference 42 CFR 482.15.

The cumulative effect of these systemic practices resulted in the hospital's failure to comply with conditions of participation in Quality Assessment and Performance Improvement Program.

On November 7, 2019, at approximately 4:00 PM, a face-to-face interview with Employees #2, #3 Nursing Performance Improvement, and #7, Compliance and performance Improvement Officers, was conducted to review the quality program and concerns identified during the complaint and revisit survey. It was conveyed that the hospital was in the process of procuring a new contract for the provision of respiratory services. The findings were reviewed, discussed, and acknowledged.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on review of the Quality Assessment Performance Improvement (QAPI) Program review, record review and staff interview, the hospital failed to set priorities for its performance improvement activities that focus on problem-prone areas related to the lack of: engagement with the Emergency Preparedness collaboration, collaboration of patient care between disciplines, respiratory care, and failure to ensure compliance with the plan of correction (POC).

Findings included ...

A. Review of the St. Elizabeth's Hospital Medical Staff Bylaws dated 2014, showed that the General Medical Officer (GMO) is responsible for " ...Referral of patients to appropriate medical, surgical, or subspecialty areas for physical medical needs and assurance of follow-up ..."

Review of the GMO noted dated 10/27/19 at 2:38 AM showed that nursing staff reported that Patient #11 had an oral temperature of 102.1 degrees Fahrenheit (F) and a dry cough. The note went on to say that a chest x-ray was ordered.

Review of physician orders showed an order dated 10/27/19 at 2:26 PM for a chest x-ray for Pneumonia and possible wheezing. Further review of the medical record lacked documented evidence of x-ray results on 11/04/19 at 3:25 PM, the time of the record review.

The surveyor conducted a face-to-face interview on 11/04/19 at 3:40 PM with Employee #15, Nurse Team Lead related to the chest x-ray results. She stated that she was unsure if the x-ray was complete, and stated that the doctor would know.

When asked about the process for the completion of the x-ray, she stated that the doctor puts the order in for the x-ray. The patient goes out for the test or the mobile service performs the test in the medical clinic. Employee #15 said that, the doctor retains the record of diagnostics such as x-rays, until they are scanned into the electronic medical record later.

The practice lacked evidence of a system of interdisciplinary collaboration between members of the healthcare team to ensure continuity of patient care.

During the review of the Quality Assurance and Performance Improvement (QAPI) program on 11/07/19 at 4PM, Employees #2, #3 Nursing Performance Improvement, and #7, Compliance and Performance Improvement Officers stated that the lack of collaboration between disciplines had been identified and brought to the attention of the governing body. They are in the process of addressing the issue.

B. Review of the physician orders showed an order dated 10/27/19 at 2:13 PM for Albuterol Sulfate nebulizer four times a day as needed. An additional order dated 10/27/19 at 2:15 PM for nebulizer treatment, breathing exercises and oxygen saturation.

Review of the medication administration record (MAR) for the breathing treatment dated 10/28/19 at 9:50 AM showed that the therapist documented "[Patient] unable to understand instructions to perform the breathing exercise." Review of the MAR for the breathing treatment dated 10/29/19 showed that the therapist documented "[Patient] unable to understand instructions to perform the breathing exercise..."

Review of a respiratory therapist note dated 11/02/19 at 3:18 PM showed the therapist documented "[Patient] is not cooperating for [nebulizer treatment]. Unable to understand the instruction." Another respiratory therapist noted dated 11/04/19 at 10:34 AM showed, "[Patient] is unable to understand the instructions to perform the 1:5 breathing exercise [physician name] made aware.

The surveyor conducted a face-to-face interview on 11/06/19 at 4:15 PM with Employee #25, Respiratory Therapist, regarding why he documented that Patient #11 did not understand the instructions. Employee #25 stated that Patient #11 does not speak English and cannot understand directions. Employee #25 acknowledged the findings at the time of the interview.

A. Record review of the hospital's policy titled, "Respiratory Therapy," revised 12/05/18, showed Respiratory assessment includes patient appearance, heart and respiratory rates, breath sounds, blood oxygen saturation, shortness of breath, and apparent hypoxemia.

Review of the physician orders showed an order dated 03/26/19 at 1:57 PM and a stop date of 01/01/20 at 12:04 PM for Albuterol Sulfate 0.083% and Ipratropium bromide 0.02% inhalation solution, three times a day for Chronic