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.

SIBLEY MEMORIAL HOSPITAL 5255 LOUGHBORO RD NW WASHINGTON, DC 20016 Feb. 11, 2020
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of medical records, hospital policy, and staff interviews, the hospital staff failed to inform the patient's legal representative and Skilled Nursing Facility prior to providing care, and prior to discharge in one of 10 medical records reviewed, (Patient #1).

Findings included ...

Review of the hospital's policy number ADM - POL020, titled "Consent", and dated 10/31/19, showed that the 'General Consent to Treat' form should be signed upon the patient's admission to the hospital as part of the admission procedure, either in the Admitting Department, the Emergency Department.


Review of the hospital's policy number ADM - POL020, titled "Consent' shows that once a person has been certified as lacking the capacity to make health care decisions, decisions must be made by a legal representative.


Review of the hospital's policy number EMDE - POL009, titled "ED Discharge", and dated 11/12/19, states "It is the responsibly of the medical doctor, Physician Assistant, or Registered Nurse discharging the patient to discuss discharge instructions and follow-up care with the patient and/or responsible party ...

Patient #1, an [AGE]-year-old female, cognitively and functionally impaired, with Dementia, and resident of a Skilled Nursing Facility (SNF), transported by Emergency Medical Service (EMS), to the Emergency Department with Shortness of Breath, and Trouble Breathing on 01/30/2020 at approximately 10:35 AM.

Medical record review showed Employee # 79, Receptionist, made an entry on the document titled 'ED In-Patient Agreement,' dated 01/30/2020 "Unable to sign Dementia/ No family Present"...'.Grand Daughter listed Power of Attorney, and in the section under 'Status,' showed "Unable to obtain".

Additional review of the medical record showed Employee #51, a Registered Nurse, recorded findings of Patient #1's neurological assessment - disoriented to place, time, and situation.

Further review of the medical record lacked documented evidence that hospital staff obtained consent for treatment, from the legal representative or nursing facility for a patient the ED medical and clinical staff assessed the patient as disoriented and confused.

The practice lacked documented evidence that medical and clinical staff obtained consent for treatment from a legal representative or nursing facility. Furthermore, there was no documentation regarding the discharge plan of care to the nursing facility.

The surveyor conducted a face to face interview with Employee #87, Operations Manager for Admissions, on 02/10/2020 at approximately 10:00 AM. Employee #87 reported that it is the nursing or physician's responsibility to obtain consent for treatment involving a confused or disoriented patient.
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 emergency department discharge practices.

The quality and patient safety program lacked evidence of procedural and/or process changes to achieve sustainable remediation of deficient practices related to ensuring the emergency needs of patients are met in accordance with acceptable standards of practice.

The findings included...

1. Failure to ensure the safe discharge of a vulnerable patient and ensure another patient was discharged with weather-appropriate clothing following the completion of services rendered in the hospital's emergency department. Cross reference 482.55; A1100 Emergency Services

2. Failure to integrate and utilize available case management and social service resources, to ensure the safe discharge of patients, from the Emergency Department (ED) Cross reference 482.55, A1103

The surveyor conducted a face-to-face interview with Employee #75, Senior Director of Patient Safety and Quality Improvement on 02/11/2020 at approximately 5:00 PM who confirmed the findings.

The cumulative effect of these systemic practices resulted in the hospital's failure to comply with conditions of participation for Quality Assessment and Performance Improvement Program.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on reviews of the hospital's Quality Assessment Performance Improvement Program (QAPI), medical records, hospital policies, and staff interviews, the hospital failed to identify, quantify, measure, analyze, implement, and track effective mechanisms, for setting quality priorities to ensure performance improvement activities and address problem-prone areas that resulted in unsafe discharge practices from the Emergency Department for vulnerable patients.

Findings included...

The surveyor conducted a face-to-face interview with Employee #75, Senior Director of Patient Safety and Quality Improvement on 02/11/2020 at approximately 5:00 PM.

At that time Employee #75 confirmed the findings of the lack of identifiers, quantifiers, measures, and implementation of safe tracking mechanisms to promote safe discharges from the ED.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
1. Based on record review and staff interview, the nursing staff failed to weigh a patient, in accordance with the physician order, in one of one medical records reviewed (Patient #11).

Findings included ...

Review of Patient #11's medical record on 02/10/2020 at approximately 11:00 AM, showed the physician admitted the patient, with diagnoses to include Urosepsis, Hyponatremia, and Failure to Thrive.

Review of a physician order dated, 12/16/19 at 10:15 AM, directed the patient to have daily weights.

Review of the medical record revealed weights were not recorded on 12/19 through 12/22, 12/30/19, 01/09 through 01/14/2020, 01/24 through 01/27, 01/31, 02/04, 02/07, and 02/09/2020.

The practice lacked evidence that the nursing staff weighed the patient as per physician order.

The surveyor conducted a face-to-face interview with Employee #51, Nurse Manager, on 02/10/2020 at approximately 3:00 PM, regarding the aforementioned findings. She confirmed the findings at the time of the record review.

2. Based on medical record review and staff confirmation, the nursing staff failed to clarify the parameters for administration of an anti-hypotensive medication for one of five medical records reviewed (Patient # 15).

Findings included...

The physician admitted Patient #15, with diagnoses to include Adrenal Insufficiency, Hypotension and End Stage Renal Disease. The patient was receiving hemodialysis on Tuesday, Thursday and Saturday.

A physician order dated 02/02/2020 at 9:06 AM directed Midodrine (blood pressure medication to treat low blood pressure), 5 milligrams (mg) by mouth three times a day.

A review of the electronic medication administration record (eMAR), for February 2020, showed the patient refused the medications on 02/06 and 02/07; and the registered nurse did not administer the medication on 02/04/2020 at 4:30 PM; reason documented was "SBP (Systolic Blood Pressure) 130."

There was no evidence that the nursing staff notified the medical staff regarding the patient's refusal of the Midodrine, and the nurse not administering the medication on 02/04/2020. Additionally, the nursing staff failed to clarify the parameters for the administration of the anti-hypotensive medication for Patient #15.

The surveyor conducted a face-to-face interview on 01/08/2020 at 11:58 AM, with Employee # 51, Manager, regarding the aforementioned findings. She confirmed the findings at the time of the medical review.





3. Based on medical record review, hospital policy review, and staff confirmation, the nursing staff failed to follow physician orders to clamp a nasal gastric tube, for thirty minutes, post medication administration, in one of six medical records reviewed (Patient # 107).

Findings included ...

The surveyor conducted a medical record review for Unit 7B Patient # 107 with Employee # 29 Registered Nurse Manager, on 02/05/2020 at approximately 3:00 PM. The physician admitted Patient # 107 on 01/31/2020 for a complex left Adnexal Mass, Exploratory Laparotomy, and Left Salpingo-Oophorectomy and Hypertension.

The patient was ordered nothing by mouth (NPO), had a nasal gastric tube in place. The physician ordered Norvasc 5 milligram (mg), by mouth (PO), daily, and Cozaar 100mg PO daily, with instructions to clamp the nasal gastric tubing for 30 minutes post administration of blood pressure medications. Blood pressure (BP) measurements from 01/31/2020 through 02/04/2020 show a steady increase in BP, from 01/31/2020 of 116/70 millimeters of mercury (mm Hg), to 153/102 mm Hg on 02/04/2020, at 3:18 AM.

Further review of the medical record shows no nursing documentation of clamping the nasal gastric tube after administration of blood pressure medications, as ordered. The practice was corrected at the time of the finding.

A face to face interview was conducted with Employee # 29, Nurse Manager, at the time of the finding. When queried as to where in the medical record would have documentation of the NGT clamping would be located, he stated that he could not find the documentation.

Employee # 29 confirmed the findings at the time of the medical record review.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on review of the medical record, hospital policy, and staff interview, the nursing staff failed to provide individualized patient care plans, in five of 12 patient medical records reviewed, (Patients # 103, 104, 105, 106, and 107).

Findings included ...

Review of hospital policy titled, "Appendix A: Inpatient Nursing Documentation Guidelines Addendum," dated 05/24/19, "Nurse shall document to a standard by selecting the appropriate response to the norm (WDL) (within defined limits : indicated the entire norm statement accurately reflects the patients status ...changes in patient's condition and any interventions or pertinent patient activity and/or events shall be documented throughout the shift ...the registered nurse/licensed practical nurse shall modify the plan of care for changes in patient condition/priorities and as goals are achieved".

A. The surveyor conducted a medical record review for Unit 6B, Patient # 104, on 02/06/2020 at 4:09 PM, with Employees # 45, RN (Registered Nurse), Charge Nurse, and 27, RN Nurse Manager. The physician admitted Patient #104 on 01/27/2020, with a diagnosis to include left hip pain. Nursing notes regarding the patient's need for a one to one sitter was addressed on 02/01/2020, as "delirium". On 02/03/2020, Employee # 59, Registered Nurse documented, "patient highly agitated overnight, ripped out intravenous line, and attempted to pluck out surgical staples". Physical Therapist Employee # 61, wrote for "Active Problems" [on 02/03/2020], "Delusional".

There was no documentation in the nursing care plan that the patient was delusional or agitated, and no mention that the patient required a sitter. The surveyor queried the aforementioned employees regarding another possible drop down option in the nursing care plan section of the EMR (an electronic medical record). In response to the surveyor's query, the employees pointed out " ...Psychosocial, with confusion, anxiety, and cognitive impairment ...." as another option.

The practice lacked evidence that the nursing staff individualized the nursing care plan to the patient's care needs.

Employee #27, confirmed the findings at the time of the nursing care plan review.

B. The surveyor conducted a medical record review for Unit, 5A Patient # 103 on 02/06/2020 at approximately 11:35 AM, with Employees # 58, RN, (Registered Nurse), and # 26, Nurse Manager. The physician admitted the patient for rectal fistula, gastrointestinal bleeding, and hypertension. Employee # 58, reported that the patient has an unsteady gait, requires a walker, and had fallen in the bathroom at 3:21 AM on 02/06/2020. A review of the nursing care plan did not show fall risk. Further review of the nursing care plan did not mention the patient's Total Parenteral Nutrition (TPN) status, due to a rectal fistula.

The practice lacked evidence that the nursing staff individualized the nursing care plan for the patient's care needs of fall precautions, NPO (nothing by mouth), and TPN status.

Employees # 58 and 26, confirmed the findings at the time of the nursing care plan review.

C. The surveyor conducted a medical record review for Unit 7A Patient # 105 on 02/05/2020, at 11:45 AM, with Employees # 28, Nurse Manager, 46, Charge Nurse, and 60, Registered Nurse (RN). The physician admitted the patient on 02/01/2020 with abdominal pain with nausea and vomiting, and a change in mental status. A psychiatric consult progress note showed agitation and confusion. The nursing care plan did not list confusion as part of the patient's problem list. The surveyor queried the aforementioned employees regarding another possible drop down option in the nursing care plan section of the EMR (an electronic medical record). In response to the surveyor's query, the employees pointed out " ...Psychosocial, with confusion, anxiety, and cognitive impairment ...." as another option.

Further review of the nursing care plan failed to show the patient as an elopement risk, as reported by her nurse at the time of the medical record review, Employee # 60, RN.

The practice lacked evidence that the nursing staff individualized the nursing care plan for Patient # 105, to include confusion, and elopement risk as care needs.

Employees #28, 46, and 60 confirmed the findings at the time of the nursing care plan review.

D. The surveyor conducted a medical record review for Unit 7B Patient #107, on 02/05/2020 at approximately 2:30 PM, with Employee # 29, Nurse Manager. The physician admitted Patient # 107 on 01/31/2020 for a complex left adnexal mass, exploratory laparotomy, left Salpingo-Oophorectomy and Hypertension. The patient was ordered nothing by mouth, (NPO), on 01/31/2020. The patient's supplemental oxygen administration via nasal cannula, was discontinued less than one hour after admission to Unit 7B. The nursing care plan did not document hypertension, NPO status, or the discontinuation of oxygen needs upon transfer to Unit 7B.

The practice lacked evidence that the nursing staff individualized the nursing care plan to the patient's needs, to include documentation regarding hypertension, NPO nutrition status, and the patient's resolved supplemental oxygen administration via nasal cannula requirements.

Employee #29 confirmed the findings at the time of the nursing care plan review.

E. The surveyor conducted a medical record review for Unit 7A, Patient # 106, on 02/07/2020, at 11:30 AM, with Employees # 28, Nurse Manager, 46, Charge Nurse, and 60, Registered Nurse (RN). The physician admitted the patient on 11/07/19 with cognitive decline. A psychiatric consult diagnosed "Dementia, likely Alzheimer's", on 11/27/19. The nursing care plan listed neurosensory, as a problem related to seizures. There is no documentation of dementia or Alzheimer's disease in the patient's nursing plan of care. The surveyor queried the aforementioned employees regarding another possible drop down option in the nursing care plan section of the EMR (an electronic medical record). In response to the surveyor's query, the employees pointed out " ...Psychosocial, with confusion, anxiety, and cognitive impairment ...." as another option.

The practice lacked evidence that the nursing staff individualized the nursing care plan for Patient # 106, to include Alzheimer's disease or dementia as care needs.

Employees # 28 and 46, confirmed the findings at the time of the nursing care plan review.
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review, policy review, and staff confirmation, nursing staff failed to document essential data on the Emergency Department (ED) discharges "Ticket to Discharge", for five of 10 medical records reviewed, (Patients # 1, 2, 7, 6, and 9)

Findings included...

A review of the hospital's policy titled, "ED Discharge," dated 11/12/19, showed that guidelines included for the discharge of patients from the Emergency Department included, the social worker/case management should see all vulnerable patients, and ensure that the patient has a method of transportation or arrange for transportation needs to a specific address.

A review of the 'Ticket to Discharge form', directed "30 second team huddle/ review of form and final approval signatures/ Patient Ready to Leave the ED".

The hospital unable to provide a hospital policy, related to the "Ticket to Discharge" requested during the survey.

A. Patient #7 arrived in the ED at approximately 4:31 PM on 01/29/2020, via ambulance. The chief complaint listed was, "Alcohol Intoxication, Chest Pain."

A nurse's discharge note dated 01/30/2020 at 1:16 PM, showed, "Discharge Transport ...mobility: Cane. Accompanied by: Self (gait steady, will take roundtrip Uber ride to home address on file as confirmed by pt. [patient)."

A review of the Ticket to Discharge form, showed no printed name and signature for the Staff Nurse under the final approval signatures, indicating patient ready to leave the emergency department.

The practice lacked evidence that emergency department staff followed the emergency department guidelines.

A face-to-face interview was conducted with Employees # 12, Director, and #73, Nurse Informatics on 02/06/2020 at approximately 4:00 PM. She acknowledged the findings at the time of the medical record review.

B. Patient #9 arrived in the ED at approximately 2:59 PM on 01/29/2020 via ambulance. The chief complaint listed was "Alcohol Intoxication, with a history of Homelessness and Depression."

A nurse's discharge note dated 01/30/2020 at 7:06 AM showed, "Discharge Transport: Mobility: Ambulatory, Accompanied by self. Patient discharged via lyft to court house in DC (District of Columbia) 500 Indiana [Avenue]. Per patient has to meet with his attorney. Patient to waiting room to wait on lyft ..."

The medical record lacked that the abuse indicators and resource planning assessment was completed.

A review of the Ticket to Discharge form, [no date and time of signatures], the clothing, and destination and transportation section was not completed. Additionally, there was no printed name and signature for the Team Lead/Charge Nurse.

The practice lacked evidence that emergency department staff followed the emergency department guidelines.
A face-to-face interview was conducted with Employees # 12, Director, and #73, Nursing Informatics on 02/06/2020 at approximately 3:00 PM. She acknowledged the findings at the time of the medical record review.


C. Patient #6 arrived in the ED at approximately 5:37 PM on 01/29/2020 via ambulance. The chief complaint listed was "Generalized Weakness, with a history of Depression, Schizophrenia and Bipolar Disorder. Reports she has been thinking about hurting herself, but states, "nothing to serious." Patient reported she drinks alcohol and uses cocaine and lives in a shelter. Suicide Risk Assessment conducted.

According to a Psychiatric Social Work note dated 01/30/2020 at 11:03 AM, revealed "spoke with on-call psychiatrist [psychiatrist named], who agrees that pt. (patient) is stable for discharge with plan to follow-up with APRA (Addiction Prevention [and] Recovery Administration for substance use treatment." Patient was scheduled for visit at APRA after discharge from the emergency department.

Suicide Risk Assessment conducted by Psychiatric Social Worker on 01/30/2020 at 2145 (9:15 PM), revealed the patient had no thoughts of suicide in past month and have never made a suicide attempt. Additionally, on the face sheet, the patient's address showed, "No Fixed Address."

Subsequent nursing Quick note dated 01/30/2020 at 11:00 AM revealed, "Pt is in the hall way unable to sign the AVS (After Visit Summary). Pt was discharged at 11:09 AM via cab (accompanied to cab).

A review of the Ticket to Discharge form, [no date and time of signatures], showed under paperwork, a checks in the boxes indicated the After Visit Summary was given to the patient and signed.

The practice lacked evidence that emergency department staff followed the emergency department guidelines.
A face-to-face interview was conducted with Employees # 12, Director, and #73, Nursing Informatics on 02/06/2020 at approximately 3:30 PM. She acknowledged the findings at the time of the medical record review.


D. The surveyor conducted a review of Patient #2's medical record on 11/13/19 at approximately 12:00 PM with Employee #77, RN/ Patient Safety/Quality.

Patient #2 a [AGE] year old male, with Bilateral Leg Pain was transported by Emergency Medical Service (EMS), to the Emergency Department (ED) on 10/31/19 at approximately 3:35 PM. The physician documented " ...Patient is not answering questions when asked ...continues to sing non-coherent words aloud ...disoriented to place, situation and time ..."

The plan of care included administration of intravenous fluids, and Ativan one milligram was administered intravenously for agitation.

The medical record showed Patient #2 was discharged from the ED on 10/31/19 at 12:20 PM.

The hospital staff provided the patient with paper scrubs, hospital socks and wrapped in a blanket. Employee # 49, discharged the patient via wheelchair to the hospital front entrance lobby on 10/31/19 at 12:31 PM, to await bus transportation to an out-patient treatment facility.

After approximately 45 minutes elapsed, Employee # 12 observed the patient "somnolent".
Patient #2 was returned to the ED, and subsequently was admitted to in-patient for extended stay.

A review of the 'Ticket to Discharge form' showed six lines; 3 lines for 'Print Name', and 3 lines for 3 individual 'Staff Signatures' including: Staff, Team Lead /Charge Nurse, and the Provider.

Additionally, review of the form showed all required sections for printed names and signatures were completed by ED staff, indicating the patient was ready to leave the ED.

A review of the 'Ticket to Discharge form', showed no printed name and signature for the Staff Nurse under the final approval signatures, indicating patient ready to leave the emergency department.

The practice lacked evidence that emergency department staff followed the emergency department guidelines.

The surveyor conducted a face to face interview with Employee #49, ED RN on 11/12/19 at approximately 2:00 PM, who reported the patient was frequent seen in the ED for substance abuse and was known to be homeless.

E. Patient #1, an [AGE] year old female, cognitively and functionally impaired, with Dementia, and resident of a Skilled Nursing Facility (SNF), transported by Emergency Medical Service (EMS), to the Emergency Department with Shortness of Breath, and Trouble Breathing on 01/30/2020 at approximately 10:35 AM.

Review of the medical record on 02/05/2020, at approximately 2:30 PM, showed Employee # 79, Receptionist, made an entry on the document titled 'ED In-Patient Agreement', dated 01/30/2020 "Unable to sign Dementia/ No family Present"...'Power of Attorney on File', showed the "NO" ...Grand Daughter listed Power of Attorney, and in the section under 'Status', showed "Unable to obtain".

Additional review of the medical record showed Employee #51, a Registered Nurse, disoriented to place, time and situation. The Registered Nurse acknowledged Patient #1's cognitive status, associated with her diagnosis of Dementia.

A review of the 'Ticket to Discharge form' showed six lines; 3 lines for 'Print Name', and 3 lines for 3 individual 'Staff Signatures' including: Staff, Team Lead /Charge Nurse, and the Provider.

Further review of the form showed all required sections for printed names and signatures were completed by ED staff, indicating the patient was ready to leave the ED.

Nursing documentation dated 01/30/19 at 11:21 AM, revealed the primary nurse discharged the patient. She did not reassess Patient #1's neurological status or provide patient instructions or education at discharge. The Abuse Indicators and Resource Planning Assessment revealed nursing staff identified a Case Management/Social Work Consult was needed; however, the record lacked documented evidence that staff provided care coordination with Employee #40, the case management/social work and the physician or the patient's assigned nurse to determine the patient's discharge plan of care.

The medical lacked evidence that ED staff collaborated with the Social Worker who was assigned to the Emergency Department to provide social work/ case management.

Review of the Emergency Department schedule of Case Coordination Coverage for 01/30/19, showed the assigned Licensed Social Worker was onsite, and available.

Patient #1, who is non-ambulatory and wheelchair dependent was assisted into a 'Lyft' vehicle and transported unsupervised, and inadequately attired wearing a hospital gown, socks and wrapped sheet, for the approximately 40 degrees Fahrenheit outdoor temperature, on the evening of 01/20/20.

The practice lacked evidence that emergency department staff followed the emergency department guidelines.

The surveyor conducted a face to face interview on 02/05/2020 at approximately 12:40 PM, with Employee #43, RN/ED Charge Nurse who confirmed the findings. She added that Patient #1 would not fit the criteria for Lyft transport.



Surveyor: Lewis, Margaret
VIOLATION: PHARMACY DRUG RECORDS Tag No: A0494
Based on review of Facility documents, Pyxis [Automated Dispensing Machine (ADM)] - "All Station Events" report for Schedule II, III, IV, and V Controlled Substances Transactions by Patient report, physicians' orders, and Electronic Medication Administration Record [eMAR] (in the presence of Hospital Staff). It was determined that hospital staff failed to administer the doses of medications in a timely manner. Also, there were doses of medications that were administered to patients and not removed from ADM and medications removed from ADM and not administered.

Findings included ...

On February 6th, 2020, a seventy-two (72) hour or twenty-four (24) hour "All Station Events" report generated by the Facilities' Automated Dispensing Machine (ADM) for controlled substances schedule II through schedule V. The seventy-two (72) hour reports were printed for Patient Care Units; 3A (Labor & Delivery); 4A (Post-Partum); 5A (Medical/Surgical, Oncology; 6B (Orthopedics); 7West (Psychiatry); 7W; and ICU. The twenty-four (24) hour reports were printed for Patient Care Units Emergency Department, Labor and Delivery, Post Anesthesia Care Unit, OR, Endoscopy, and Sibley Ambulatory Surgery Center (controlled substances administered during the procedure). All patients were randomly selected. The survey of records was started on February 7, 2020, at approximately at 09:30 and completed on February 10, 2020, at approximately 13:30.


In the presence of hospital staff (Employee # 19, Clinical Director Pharmacy # 43, Charge Nurse ED and # 44, Charge Nurse ICU), the physician order and Medication Administration Record (MAR) or Electronic Medication Administration Record (eMAR) were reviewed for accuracy and withdrawals from the ADM were compared with administration times. For four (4) out of thirty five (35) patients surveyed, it was found that criteria were not met for the administration of medications within thirty minutes of removal from ADM.


A On January 21, 2020, at 016:41, Patient #30 on Patient Care Unit (PCU) 6B was ordered Oxycodone 5mg by mouth every 4 hours as needed for moderate pain 4 to 6 on pain scale. On February 4, 2020, eMAR shows 5mg Oxycodone was administered at 12:10. Pyxis report does not show that Oxycodone 5mg was removed.


B. On February 3, 2020, at 10:29, Patient #32 on PCU 7W was ordered Lorazepam 1mg by mouth three times a day. On February 6, 2020, at 11:32, Lorazepam 1mg was removed from Pyxis but, was not administered until 15:30. Late administration.


C. On January 31, 2020, at 18:39, Patient #45 on PCU -ICU was ordered Diazepam 5mg by mouth three times a day as needed for muscle spasms. On February 4, 2020, at 07:34, 5 mg of Diazepam was removed from Pyxis but was not administered to patient until 08:15; Late administration.


D On February 6, 2020, at 14:28, Patient #55 on PCU SASC was ordered Oxycodone 5mg by mouth every 4 hours as needed for moderate pain 4-6 on pain scale. On February 6, 2020, at 13:44, 5mg Oxycodone was removed from Pyxis but, there is no indication of administration on eMAR.
VIOLATION: ORGANIZATION Tag No: A0619
Based on observations during the survey, it was determined that dietary services, were not adequate to ensure that foods are prepared and served in a safe and sanitary manner, these findings were observed and acknowledged in the presence of employees #13 Dietary Services, #41 Infection Prevention and # 78 Quality Manager.

The findings included ...

1. The rack surfaces of the milk cart were soiled, with spillages in the Dairy Box.

2. Ceiling tiles near the entrance to the Prep-Box were soiled with dust; exhaust vent louver over food preparation areas were soiled, and the storage cart shelf surfaces in the refrigerator were soiled.

3. Floor surfaces were worn, damaged and in need of repair in the Male and Female Bathrooms.

4. Sheet pans cleaned in the Pot and Pan Wash Area, were not thoroughly cleaned of food residue, as evidenced by food particles on the inner and bottom surfaces after washing in 6 of 16 observations.

5. China ware plates, washed in the dish machine were not thoroughly cleaned of foods during the dishwashing process; 14 of 35 plates were soiled with leftover foods.

6. The eating surfaces of silverware (forks) washed in the dish machine were not thoroughly cleaned of food residue in 8 of 42 observations.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observations during the survey, it was determined that Housekeeping and Maintenance Services were not adequate to ensure that the facility is maintained in a safe and sanitary manner; these findings were observed in the presence of employees # 41 Infection Prevention, # 78 Quality Management, and # 83 Administrative Resident.

The findings included ...

1.The following findings were observed during a tour of the Morgue at 9:45 AM on 2/6/20, in the presence of employees # 41 Infection Prevention and #78 Quality Management.

A. Entrance doors to the Morgue Areas were marred and damaged.

B. Floor surfaces were stained, marred and wall surfaces near the entrance were damaged.

C. Hallway floors outside of the Morgue were marred and wall surfaces were marred.

2. The following findings were observed during a tour of the Ambulatory Care Suite, at 11:10 AM on 2/6/20 in the presence of Employees # 41 Infection Prevention; # 78 Quality Management, and # 20 Nurse Manager.

A. The edge surface of the headwall and lower of the chair were soiled with dust in Pre-operating Room 3.

B. The top surfaces of the Monitor were soiled with dust, in Bay 1 Phase 1.

C. The hot water temperature at the eyewash station was 113 degrees Fahrenheit, and is elevated above the recommended range of between 60 degrees Fahrenheit and 105 degrees Fahrenheit. "I don't have a policy for this finding we may have to delete the finding, I asked for the policy, but it was not delivered the temperature elevation has been corrected."

D. Stretcher frame surfaces were dusty in Bay 4.

E. The lower surfaces of the stretcher frame, was soiled with dust in Bay 4.

F. The lower surfaces of the workstation on wheels was soiled with dust.

G. The top surfaces of the Pyxis Machines were soiled with dust, between areas A and B and C and D.

H. Two of four scrub sinks outside of the Operating Suite, failed to operate when tested .

3. The following finding were observed during a tour of the Main Sterile Processing Area, at approximately 12:30 PM on 2/6/20 in the presence of employees # 32 Sterile Processing Manager, # 41 Infection Control, and # 78 Quality Manager.

A. The entrance door to the Decontamination Area, in Sterile Processing Department were marred and damaged on the frontal and edge surfaces.

4. The following findings were observed, during a tour of the Intensive Care Unit at 4:50 PM on 2/7/20 In the presence of employees # 35 Clinical Coordinator, # 41 Infection Prevention and # 78 Quality Management.

A. Bedframes surface were dusty and chair armrest worn in Room 9.

B. Privacy curtain mesh surface were torn and penetrations were observed in wall surface in Room 10.

C. Wall surfaces were stained with a dark substance and chair arm surfaces were worn in Room 14.

D. Window sill and bedframe surfaces were dusty, and arm chair surface were worn in Room

5. The following findings were observed during a tour of the Endoscopy Center, at 9:35 AM on 2/7/20; In the presence of Employees #17, Director of Perioperative Services, # 41 Infection Prevention and # 83, Administrative Resident.

A. The interior surfaces of exhaust vent and arm surfaces of the computer on wheels were dusty in Prep Room 3.

B. The internal surfaces of exhaust vents were dusty in Prep Room 2.

C. Post Op Area- baseboards and lower walls surfaces soiled and stained.

D. Baseboards were soiled in Bay 5.

E. Top of the monitor surfaces were dusty in Bay 7.

F. Stretcher frame surfaces were dusty in Bay 6.

G. The top surfaces of the overhead lamp was dusty in patients' restroom.

H. The louver surfaces of exhaust vents were dusty Endoscopy Procedure Room 1.

6. The following finding observed in the Cardiac Cath Lab, at 11:30 AM on 02/07/20 in the presence of Employees #17, Director of Perioperative Services, # 41 Infection Prevention and # 83, Administrative Resident.

A. A multiple outlet strip was on the floor instead of mounting on wall in the Cardiac Catheter Control Room.

7. The following finding were observed in the Post Anesthesia Care Unit- Phase II, at 2:40 PM on 02/06/20 in the presence of Employees #17, Director of Perioperative Services, #21 Nurse Manager, # 78 Quality Safety and #83 Administrative Resident.

A. Head wall surfaces were dusty; the hot water temperature was 64 degrees Fahrenheit, which is below the required minimum on 105 degrees Fahrenheit in Bay 8.

B. The hot water temperature was 64 degrees Fahrenheit and is below the required minimum temperature of 105 degrees Fahrenheit in the Patient's Bathroom.

C. Wall surfaces were marred and damaged in front of Bay 16.

8. The following findings were observed during a tour of the Post Anesthesia Care Unit Phase I, at 3:00 PM on 2/7/20.

A. The interior and outer surfaces of the exhaust vent were rusty and the hot water temperature was 89 degrees Fahrenheit and below the required minimum temperature of 105 degrees Fahrenheit.

9. The following findings were observed during a tour of the Emergency Department at 1:30 PM on 2/11/20, in the presence of employees # 42 Infection Prevention, and # 83 Administrative Resident.

A. The top and lower surfaces of the equipment was soiled with dust in Fast Track Room 6.

B. Walls in the Fast track Team Station, were marred and the top surfaces of the Pyxis machine were soiled with dust in room G119.

C. The horizontal surfaces of the bed frame were soiled with dust, in Room 13 and on the Main Side Treatment Room 22.

D. The top surfaces of the overhead lamp were soiled with dust and the hot water temperature was 68 degrees Fahrenheit and below the required minimum temperature of 105 degrees Fahrenheit in Main Side Treatment Area 22.

E. The horizontal surfaces of the bed frame was soiled with dust in Fast Track 3.

F. The top surfaces of equipment was soiled with dust, stretcher wheels were soiled with dust in Fast Track 5, and the hallway outside of Fast Track 5.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
1. Based on observation, and staff confirmation, hospital staff failed to ensure essential equipment; Electrosurgical Unit, in the cardiac catheterization lab, was reviewed for preventive maintenance as specified per manufacturer in one of one observation.

Findings included ...

A review of the hospital's manufacturer documents for the "Force FX Electrosurgical Generator C" (surgical device) revealed safety checks are performed every six months to verify the generator is functioning properly.-

During a tour of the Cardiac Catherization Laboratory on 02/10/2020, at approximately 2:00 PM, the surveyor observed an electrosurgical generator, without a preventive maintenance inspection sticker.

There was no evidence of scheduled maintenance (e.g. preventive maintenance) inspections at least every six months as stipulated by the manufacturer.

During a face-to-face interview on 02/10/2020 at approximately 2:30 PM, Employees #17, Director of Perioperative Services, and # 69, Lead Technologist, explained that biomedical should have performed preventive maintenance.

During a subsequent face-to-face interview on 02/10/2020 at approximately 4:00 PM, Employee # 10, Director of Clinical Engineering, and stated the last preventive maintenance was in 2017, and it was an oversight. He confirmed the findings.


2. Based on observation, staff interview, review of the quality control log, nursing staff failed to consistently perform quality control testing for three of three glucometers in one observation.

Findings included ...

During a tour of the Emergency Department on 02/05/2020, at approximately 11:00 AM, the surveyor reviewed the quality control monitoring from 10/01/19 through 12/31/19 on the glucometers, in the presence of Employees #91, Infection Preventionist, and #20, Director. The results revealed that quality controls were not consistently performed during the months of October, November and December 2019.

The practice failed to ensure that staff performed quality control testing to ensure proper functioning of the glucometers.

During a face-to-face interview on 02/05/2020 at approximately 11:30 AM, Employee #20 explained that quality controls are to be performed every 24 hours. She confirmed the findings at the time of the observation.






3. Based on observation and staff confirmation, the hospital staff failed to secure a rolling phlebotomy cart; observed unlocked and unattended, in a hallway of Unit 7A, between rooms 708 and 709.

Findings included ...

The surveyor conducted a tour of Unit 7A on 02/05/2020 at approximately 10:20 AM, with Employees # 28, Nurse Manager, and 46, Charge Nurse. Observed unattended, unsecure, and unlocked was a rolling phlebotomy cart, with #20, size 20 gauge needles, and #23, size 23 gauge needles, open and available to passersby. The Employees were queried regarding the unlocked and unattended cart, and both responded that the cart should not be left unlocked and unattended, and is kept in the locked equipment room when not in use. The cart was removed to the equipment room at that time.

The practice lacked evidence that the hospital staff kept the phlebotomy cart attended and secured during a tour.
Employees # 28 and 26, confirmed the findings at the time of the observation.
VIOLATION: EMERGENCY SERVICES Tag No: A1100
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on medical record review, hospital policy review, staff interviews and review of video surveillance for one (1) of 10 emergency department (ED), patient records reviewed, it was determined that hospital staff failed to prevent neglect as evidenced by failing to ensure the safe discharge of a vulnerable patient [Patient #1] following the completion of services rendered in the hospital's emergency department. Additionally, another patient (Patient #2) was discharged from the ED with inadequate clothing.

Findings included ...

Patient #1, an [AGE] year old female, cognitively and functionally impaired, and resident of a Skilled Nursing Facility (SNF), was transported by Emergency Medical Services (EMS), to the Emergency Department with Shortness of Breath, and Trouble Breathing on 01/30/2020 at approximately 10:35 AM.

Review of the ED clinical record revealed Patient #1's diagnoses included Dementia, Bronchitis Hypoxia, and Altered Mental Status with medical history of Diabetes Mellitus, Hypertension, Seizures, and Stroke. The patient was assessed as "disoriented and confused."

Physician's order dated 1/30/2020 at 3:35 PM directed Patient #1 be discharged to the skilled nursing facility "ED Disposition: Set to Discharge"

According to the ED clinical record, Employee #51, the assigned nurse recorded "no" in an entry 1/30/2020 at 11:26 AM, in response to an inquiry in the electronic medical record, "Case management/Social work consult needed?" Additionally, Employee #51checked [affirmative] that Patient #1 "is wearing weather appropriate clothing" at the time of discharge.

Employee #51, the assigned nurse arranged for the patient to return to the skilled nursing facility via a rideshare contractor [Lyft].

A review of the hospital's video footage for 1/30/2020 at approximately 4:50 PM revealed hospital staff escorted Patient #1 to the rideshare vehicle via wheelchair and assisted the patient into the rear seat. The patient's attire was a gown, blanket and socks. According to Accuweather, the out-of-doors temperature was approximately 40 degrees Fahrenheit at the time of departure.
https://www.accuweather.com/en/us/washington/ /january-weather/ 9

Through interview with Employee #92, social worker from the receiving facility [outside skilled nursing facility], Patient #1 was met in the driveway of the skilled nursing facility (SNF) in a rideshare vehicle at approximately 5:20 PM on 1/30/20. The patient was observed slumped over and unsecured (seatbelt not applied) in the rear seat of the vehicle. The SNF staff obtained a wheelchair and assisted the patient out of the vehicle. It was confirmed that Patient #1 is cognitively impaired, has little/no trunk control to sit upright, does not ambulate and requires maximum assistance for transfer.

The hospital failed to implement discharge practices from the emergency department in accordance with accepted standards and in a manner as not to endanger patient safety.

Patient #1, who was cognitively and functionally impaired was discharged to return to her skilled nursing facility, unattended by a responsible party and via a rideshare transportation company that was not a certified medical transport company. Additionally, the patient was inappropriately attired for the climate.

2. Patient #2 a [AGE] year old male, with Bilateral Leg Pain was transported by Emergency Medical Service (EMS), to the Emergency Department (ED) on 10/31/19 at approximately 12:10 AM. The physician documented " ...Patient is not answering questions when asked ...continues to sing non-coherent words aloud ...disoriented to place, situation and time ..."

History of present illness was altered mental status with a past medical history of polysubstance abuse and leg pain. The treatment plan included hydration and diagnostics (labs, CT scan etc.).

The medical record showed the ED Staff discharged Patient #2 from the ED on 10/31/19 at 12:20 PM.

The hospital staff provided the patient with paper scrubs, hospital socks and a blanket. Employee # 49 transported the patient via wheelchair to the hospital's front entrance lobby on 10/31/19 at 12:31 PM, to await bus transportation to an outpatient treatment facility.

According to Accuweather, the out-of-doors weather was rainy, with a temperature of approximately 40 degrees Fahrenheit on October 31, 2019 at 12:30 PM.
https://www.accuweather.com/en/us/washington/ /january-weather/ 9

After approximately 45 minutes, Patient #2 continued to sit in the hospital lobby in the wheelchair. Employee #12 observed the patient "somnolent", and returned the patient to the ED. Patient #2 was subsequently admitted , "somnolence due to polysubstance use, requires hospital stay."

The hospital staff failed to implement discharge practices from the emergency department in accordance with accepted standards as evidenced by failure to provide weather-appropriate attire and/or seek alternative resources such as case management assistance to ensure a safe discharge for Patient #2.

The cumulative effect of these systemic practices resulted in the hospital's failure to comply with condition of participation for Emergency Services.
VIOLATION: INTEGRATION OF EMERGENCY SERVICES Tag No: A1103
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of the medical record, hospital policy, and staff interviews, the hospital staff failed to integrate and utilize available case management and social services resources, to ensure the safe discharge of patients, from the Emergency Department (ED), for two of 10 ED patients reviewed, (Patients #1 and #2).

Findings included ...

A review of the hospital's policy titled, "Discharge Planning" dated 03/22/19, showed discharge or transition planning is a collaborative partnership between the patient ...case coordinators, physicians, nurses, and other key disciplines in order to determine level of care needs beyond the hospital setting ...identification of patients in need of discharge include: homeless, behavioral illness ..."

A review of the hospital's policy titled, "ED Discharge," dated 11/12/19, showed that guidelines included for the discharge of patients from the Emergency Department included, the social worker/case management should see all vulnerable patients, and ensure that the patient has a method of transportation or arrange for transportation needs to a specific address.

1. Patient #1, an [AGE] year old female, cognitively and functionally impaired, with Dementia, and a resident of a Skilled Nursing Facility (SNF), was transported by Emergency Medical Service (EMS), to the Emergency Department with Shortness of Breath, and Trouble Breathing on 01/30/2020 at approximately 10:35 AM.

Physician's order dated 1/30/2020 at 3:35 PM directed Patient #1 be discharged to the skilled nursing facility "ED Disposition: Set to Discharge"

The ED clinical record revealed Employee #51, the assigned nurse recorded "no" in an entry 1/30/2020 at 11:26 AM, in response to an inquiry in the electronic medical record, "Case management/Social work consult needed?"

Employee #51, the assigned nurse arranged for the patient to return to the skilled nursing facility via a rideshare contractor [Lyft] unattended by a responsible party and improperly attired for the weather.

Review of the ED schedule of case coordination coverage for 1/30/20 showed a social worker was assigned, on duty and available.

There was no evidence that the assigned nurse collaborated with the social worker to provide case management services for Patient #1.

A face-to-face interview was conducted with Employee #40, social worker assigned to the ED. He confirmed that Patient #1 would have been an appropriate candidate for case management services.

2. Patient #2 a [AGE] year old male, with Bilateral Leg Pain was transported by Emergency Medical Service (EMS), to the Emergency Department (ED) on 10/31/19 at approximately 12:10 AM.

The medical record showed the ED Staff discharged Patient #2 from the ED on 10/31/19 at 12:20 PM.

The hospital staff provided the patient with paper scrubs, hospital socks and a blanket at the time of discharge. Employee # 49 transported the patient via wheelchair to the hospital's front entrance lobby on 10/31/19 at 12:31 PM, to await bus transportation to an outpatient treatment facility.

According to Accuweather, the out-of-doors weather was rainy, with a temperature of approximately 40 degrees Fahrenheit on October 31, 2019 at 12:30 PM.
https://www.accuweather.com/en/us/washington/ /january-weather/ 9

A case manager/social worker was consulted for discharge destination; however, there was no evidence that the social worker was consulted to ensure the patient was provided weather-appropriate attire for discharge.

ED staff failed to integrate and utilize available resources of case management and social services to ensure safe discharge from the emergency department.
VIOLATION: RESPIRATORY SERVICES Tag No: A1163
Based on medical record review and staff confirmation, respiratory staff failed to administer respiratory services, in accordance with acceptable standards, as evidenced by weaning a patient off oxygen support, in the absence of a physician's order, for one patient (Patient #13).

Findings included ....

The hospital staff admitted Patient #13 on 02/05/2020, to the Intensive Care Unit, with diagnoses that included Hypoxemic Hypercarbic Respiratory Failure, and requiring Bi-level Positive Airway Pressure (BIPAP) for oxygenation.

A review of the medical record reflected Patient #13 received oxygen therapy by BIPAP, initiated by respiratory therapy staff, in the Emergency Department. On 02/07/2020 between the hours of 08:00 AM and 10:00 AM, the respiratory therapist initiated oxygen weaning off of Oxygen. However, the record lacked documented evidence of an order from an authorized, licensed provider for the weaning off oxygen for Patient #13.

The surveyor conducted a face-to-face interview on 02/02/2020 at approximately 02:15 PM, with Employees #51, Manager, #10, Director of Respiratory Therapy, and Employee #108, Intensivist, regarding the weaning protocol for oxygen. Employee #10, stated, there should have been a physician's order, prior to weaning the patient off of oxygen. Furthermore, on admission, the physician includes weaning protocol with parameters for oxygen titration in the "ICU Admission Set Orders."

At the time of the chart review, Employee #108, demonstrated how the ICU admission set orders, should be initiated at the time of admission.

All employees confirmed there were no physician orders for weaning and titration of oxygen at the time of the medical record review.