Mary Washington Hospital

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 36946 Based on staff interview and document review, it was determined the hospital failed to ensure nurse staffing was sufficient to meet patient needs based on acuity in the Intensive Care Unit (ICU). Findings: An interview was conducted with EMP12 on June 7, 2026, at 9:30 AM. EMP12 indicated that from approximately January through May 2026, 1:3 nurse-to-patient ratios occurred frequently in the Intensive Care Unit (ICU) due to a new staffing matrix and a house-wide census increase. EMP12 indicated that when non-ICU patients were held in the unit, a single ICU nurse was assigned to four (4) patients not requiring ICU level of care. An interview with EMP13 on June 7, 2026, verified that unit has 12 (twelve) vacant Registered Nurse FTEs (full-time equivalent) out of an allotted 76.97 and has hired multiple new graduate nurses the past year. EMP13 indicated that the ICU lacks an objective acuity tool or established parameters to guide 1:3 assignments, and that assignments are made based entirely on individual nursing judgment. Interviews with ICU nurses, EMP14, EMP15, EMP16, EMP17, EMP18, and EMP19, nd EMP20 were held throughout the morning of June 7, 2026, between 9:45 AM and 11:30 AM. Seven (7) of seven (7) employees confirmed they frequently worked a three-patient assignment between January and May 2026. Six (6) of seven (7) of the nurses interviewed (EMP14, EMP15, EMP17, EMP18, EMP19, and EMP20) reported that there were times when their three patient assignment was inappropriate for patient acuity. EMP18 reported the 1:3 ratio was “overwhelming” and because multiple nurses were simultaneously tripled (having three patients), no peer assistance was available. EMP19 indicated the 1:3 load caused the 12 to 15 new graduate nurses on the unit to “struggle.” EMP15 indicated a decreased attention to detail, shifts worked without meal breaks, and indicated that if a lunch break was taken, a single cross-covering nurse became responsible for six (6) ICU patients as the charge nurse was frequently off the floor for “hours” responding to other events in the hospital. EMP14 indicated that during frequent 1:3 shifts, the two sicker patients received most of the clinical attention, causing the third assigned patient to be “forgotten about for hours” while occupied with more critical tasks. EMP20 reported that quality of care declined on the unit since the frequent three-patient assignments began in January, specifically referencing an increase in the unit’s pressure ulcer rate. The ICU pressure injury data was reviewed and indicated in 2024 there were 70 all stage pressure ulcers, in 2025 there were 67 all stage pressure ulcers, and in the first six (6) months of 2026 there were 69 pressure ulcers in the ICU indicating the overall pressure injury rate has doubled. Regarding stage III, stage IV, and unstageable pressure ulcers, the facility recorded two (2) in 2024, zero (0) in 2025, and four (4) in the first quarter of 2026, with an additional two (2) likely, but pending final investigation, indicating the frequency and severity of the patient’s skin injuries has increased coinciding with the implementation of the new staffing matrix. A review of the facility’s staffing sheets confirmed there had been no instances of 1:3 ratios in the last two (2) weeks. A review of staffing sheets from May 20, 2026 - May 26, 2026, was conducted and these dates did contain instances of multiple tripled assignments; however, due to the lack of an objective acuity tool, it could not be determined that staffing levels were adequate to meet patient needs. An interview with the hospital’s Director of Nursing (DON, EMP1) was conducted June 7, 2026, at 11:45 AM. EMP1indicated that the ICU had implemented a new staffing matrix in January 2026 causing an increase in 1:3 patient assignments. EMP1 was made aware that staff had voiced concerns about the safety of such assignments and town hall meetings were scheduled to discuss their concerns. The hospital provided the surveyor with email invitations for the town halls that occured on June 1, 2026, June 3, 2026, and June 22, 2026, but no minutes or agenda were recorded. EMP1 confirmed the ICU lacks an established tool to reconcile staffing assignments against actual patient acuity. EMP1 indicated the electronic medical record (EMR) has a built-in acuity tool, but the tool was currently not in use in the ICU. EMP1 indicated that because of staff concerns, a short-term change had been recently implemented prohibiting 1:3 patient assignments in the ICU while the hospital works on defining what types of patients are appropriate for such assignments. The facility’s policy, “Staffing Plan - Nursing,” last revised August 2023 was reviewed and reads in part, “ ...The following criteria are utilized as part of the overall staffing plan ...Patient clinical information is used in identifying patient requirements for care. Census, care service standards of care and recommendation of Director/Manager and Assistant Nurse Managers in relation to experience and educational level of care team members are also considered ...””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 42725 Based on employee (EMP) interview, document review, and review of medical records (MR), it was determined the hospital failed to ensure nurses adhered to the policies and procedures of the hospital. Specifically, nursing staff failed to follow the procedure for skin and wound management (MR8). Findings: Facility document, Skin and Wound Management: Care of the Adult Inpatient, was reviewed and documented the following, in part: “... Definitions: ... Braden Scale: A validated risk assessment tool utilized to identify patients at risk for developing pressure injuries. Factors assessed include sensory perception, moisture, activity, mobility, nutrition, and friction and shear... Pressure injury: A pressure injury is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. Pressure injury stages: Suspected Deep Tissue Injury - Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Moistening the skin may aid in the identifying these pressure injuries... Clinical Assessment and Care 1. An assessment of skin integrity is to be performed on each inpatient upon admission, every shift, and upon patient transfer to another unit... b. A Braden Scale will be documented on all adult medical, surgical, and critical care patients during the admission assessment, every shift (transition of caregiver), and PRN [as needed] upon change in patient’s condition to monitor for risk of pressure injury development... 5. To maintain optimum skin integrity, all patients scoring 18 or less on the Braden Scale will be considered at risk for pressure injury development and will be placed on the Non-Surgical Wounds and Pressure Injury Prevention Protocol. This protocol will provide preventative and treatment measures wounds as well as consult criteria for the Wound Care Nurse and nutrition as indicated. refer to Attachment B Pressure Injury Prevention Measures/Skin Treatment Measures... Treatment and Management 1. Implement preventative and treatment measures per the Non-Surgical Wounds and Pressure Injury Prevention Protocol... 4. Provide appropriate pressure distribution: a. For trunk wounds utilize an appropriate bed surface... b. For foot wounds utilize pillows floating the hells or pressure redistribution boot... Consultation Process 1. All patient who have or develop any of the following staged pressure injuries: ... Deep Tissue Pressure Injury, will have a WCN [wound care nurse] and dietary consult...”. The document was revised in May 2025. Attachment B, Pressure Injury Prevention Measures/Skin Integrity Treatment Measures was reviewed and documented the following, in part: “... If patient’s Braden Score is 18 or less or patient has any pressure injury, the following is to be implemented: 1. Turn every 2 hours ... with positioning pillows or TAP system if the patient is unable to self-position to relieve pressure to the coccyx/sacral/ischial area... 4. Every shift, nurse will assess skin integrity around tubes, lines, splints, devices ... and bony prominences... 9. Off-load heels with pillows placed lengthwise...”. An attachment to the skin and wound management titled, Therapeutic Bed Tip Sheet, was reviewed and documented the following, in part: “... Braden Scale at or less than 18 and any of the following: severe moisture associated skin damage, head of bed at 45 degrees or higher, aspiration precautions, shortness of breath, single stage 3,4, stage 1 & 2 on two or more surfaces, single unstagable, single DTPI [deep tissue pressure injury], or less than 300 lbs... Medical conditions which increase the risk... low air loss, P500 [bed], ... All pts. need to be repositioned Q2hrs., even if on a therapeutic bed. Heels MUST be floated with off-loading boots or pillows placed lengthwise per leg...”. Review of MR8 revealed that MR8’s initial skin assessment did not reveal any skin breakdown, but did reveal that MR8 was at risk for breakdown. The skin assessments were documented inconsistently based on the facility’s policy. At the time of admission (September 6, 2025), an order was entered to elevate the patient’s heels; however, the first documented heel elevation was on September 9, 2025. There was documentation that a specialty bed was obtained for MR8, however, there was no indication the bed was used because on September 9, 2025 at 6:05 AM, EMP24 documented “P500 attachment in place, however at this time unable to locate black cord to plug in to power on...”. On September 13, 2025, seven days after admission, skin documentation entries indicated that MR8 had a “deep tissue injury” to the “buttocks” and “right heel”. The SA requested an interview with EMP24. EMP3 confirmed that EMP24 was no longer with the facility. Interview on July 7, 2026 at 10:00 AM, EMP25 shared that when they (EMP25) reposition and/or employ interventions to prevent skin breakdown, it is charted in the daily cares flowsheet.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 46466 Based on facility document reviews, medical record reviews and interviews, it was determined the facility staff failed to follow facility policies and procedures and physician orders for two (2) of nine (9) patient records sampled. (MR4, MR6) The finding include: A review of the facility policy “Medical Records, Content and Management of”, last revised 12/2021, indicated in part: “...Content in the Medical Record...11. Care rendered and administered...”. A review of the facility’s policy “Urinary Devices, External”, last revised 3/2025, indicated in part: “...Assessment 1. Assess position of Pure wick and skin integrity every 2 hours when reposition patient. 2. Assess the following at least every 4 hours: Urine output, patient’s tolerance, suction level...5. Document assessment findings in the EMR (electronic medical record)...”. A review of the facility’s policy “Enteral Nutrition, Care of the Patient Receiving”, effective 1/2022, indicated in part: “...Administering Medications 1. Whenever possible, liquid forms of medications will be administered through the tube per physician order...Monitoring Patients on Enteral Nutrition...2. Fluid Monitoring...Maintain a balanced intake and output (I&O), monitoring activities include: a. Recording intake and output...”. A review of the facility’s policy “Nursing Process - Delivery of Patient Care”, last revised February 2026, indicated in part: “...e. Intake and output (I&O every 8 hours or per provider orders...Implementation...5. Interventions and patient’s response to interventions are documented in the medical record. 6. All pertinent nursing actions, specific to the patient’s problem/desired goal/outcome, are reflected in the medical record...”. A review of the facility’s policy “Sequential Compression Device, Care of the Patient With”, last revised January 2022, indicated in part: “...3. SCDs will be used per practitioner’s order...3. Document assessment every shift as well as application and removal of SCDs in the medical record...8. If patient refuses to wear SCDs, document and notify practitioner for alternative DVT prophylaxis...”. On April 25, 2026, at 12:13 PM, and April 26, 2026 at 12:30 AM, MR4’s record documented physician orders for tube feedings with 30 milliliter water flush and dietary nutrition every four (4) hours. There was no NPO (nothing by mouth) physician order found in the record for April 26-27, 2026. A physician order for intake and output (I&O) was placed on April 20, 2026, at 1:19 AM for every hour for seven (7) days. The documentation indicated that the patient did not have any tube feedings per physician orders from 10:52 AM through 7:23 PM on April 26, 2026. There was no documentation found for the patient’s urine output, stool output, external urinary device assessment. A nursing note documented by EMP5 for MR4 on April 26, 2026, at 3:00 PM, indicated “Patient came from ICU with an NG tube and tube feeding; Patient is unable to have tube feeding with an NG tube on this unit; Trauma PA notified and aware; Will assess chart to see if patient needs a SBFT (small bowel feeding tube)”. A nursing note documented by EMP6 for MR4 on April 26, 2026, at 8:17 PM, indicated “...Trauma PA adv to restart TF (tube feeding) and give per orders...”. On May 14, 2026, at 12:30 PM, an interview was conducted with EMP3. EMP3 stated that MR4’s unit can do “short-term” tube feedings for patients with a NG (nasogastric) tube. On May 13, 2026, at 2:00 PM, an interview was conducted with EMP5. EMP5 stated that they were told by the Charge RN on their floor that tube feedings were not allowed. EMP5 stopped MR4’s tube feeding and contacted the Trauma PA. EMP5 stated that they recalled turning and repositioning MR4 regularly and they checked MR4’s external urine catheter and measured their urine output. A review of MR6’s record indicated that a physician order for SCDs (sequential compression device) was placed on April 26, 2026, at 2:44 AM and canceled on April 29, 2026 at MR6’s discharge. The nursing flowsheets found no documentation in MR6’s chart that the SCDs were used from 3:20 AM on April 26 through April 27 at 4:00 PM.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 36946 Based on staff (EMP) interview and document review, it was determined the hospital failed to ensure staff followed policies and procedures established by the medical staff in the emergency department (ED). Specifically, the hospital failed to ensure emergency department staff obtained and documented vital signs at the required intervals and failed to screen, assess, intervene, and reassess patient’s pain as required by hospital policies in six (6) of six (6) sampled patients (MR4, 6, 7, 8, 9, and 10). Findings: The hospital’s policy, “Emergency Care and Treatment,” last revised February 2026 was reviewed and reads in part, “ ...The triage assessment consists of: ...baseline vital signs ...Once the patient’s ESI [Emergency Severity Index] level has been established and the patient has been placed in a treatment area, the guidelines for completion of nursing physical assessments are within the following time frames; with vital signs (BP, HR, RR, temperature, pulse oximetry, and pain level): ...ESI level 2 - Every hour at a minimum for the first 4 hours; then every 2 hours, unless provider order or patient condition warrants differently ...Once medically cleared, patients requiring mental health services will have vital signs taken every 8 hours. Vital signs will be taken within 60 minutes of discharge for patients who will not be admitted to an inpatient or observation unit ...” The hospital’s policy, “Pain Management,” last revised August 2022 was reviewed and reads in part, “ ...Ensure that documentation of patient’s pain characteristics and intensity in the medical record includes reassessment, interventions, and follow-up to the effectiveness of pain management process ...Pain Assessment: a comprehensive assessment that gathers more detailed information through collection of data, observation, and physical examination. Pain assessment will be performed if the pain screening indicates pain ...All patients will be screened for the presence of pain or history of persistent pain during emergency department visit, upon initial admission, after any known pain-producing event, and at unit standard intervals ...If the pain screening indicates the presence of pain, a comprehensive pain assessment will be completed to evaluate the level of pain including the origin/cause, location, duration, intensity, aggravating factors, alleviating factors, effects of pain, and whether current pain regime is effective ...Reassessment to evaluate the patient’s response to a prn [as needed] pain-relieving intervention will be completed within 60 minutes after medication administration or non-pharmacological intervention, Reassessment includes monitoring progress toward pain management goal including functional ability (e.g. ability to take deep breaths, turn in bed, or walk with improved pain control) and side effects of treatment, If upon reassessment, the pain rating remains the same or increases, the nurse will contact the practitioner to discuss the patient’s current pain therapy and acquire any additional intervention orders. Documentation will include the pain intensity assessment and response to pain intervention ...” MR’s 4, 6, 7, 8, 9, and 10 were all assessed at an ESI level of 2 ESI (Emergency Severity Index - a five-level triage algorithm to categorize patients based on their condition and anticipated resources needed for their care. Level 2 indicating a high risk for deterioration and the need for rapid nursing assessment and intervention) during their ED visits and should have had vital signs documented to include pain level at the following intervals according to the above policies - Every hour at a minimum for the first 4 hours, then every 2 hours, and once every 8 hours after the patient was medically cleared for behavioral health evaluation. 1. MR4 was reviewed and contained documentation that the patient arrived in the emergency department (ED) at 6:18 PM on March 24, 2026, with a mental health complaint. Vital signs were obtained at 6:24 PM. No pain level was included in the vital signs documentation. At 6:31 PM the patient was assigned an acuity/ESI level of 2. The patient’s chief complaint was updated to abdominal pain at 7:12 PM on March 24, 2026. The medical record contained no documentation of a pain level or screening at this time. Vital signs were again obtained at 8:01 PM on March 24, 2026. No pain level was documented with these vital signs. The patient was medically cleared to be seen by psychiatry at 8:23 PM on March 24, 2026. At 2:47 AM on March 25, 2026, the nurse documented the patient requested to speak with a physician due to intense abdominal pain. The physician was contacted, but the nurse did not document any further pain assessment or intervention for the abdominal pain. Vital signs were again documented at 6:21 AM and 9:37 AM on March 25, 2026. No documentation of the patient’s pain level was included in the vital signs assessments. At 10:20 AM on March 25, 2026, the nurse documented the patient was having abdominal and sciatica pain. No further assessment of the patient’s pain was documented. No interventions for the patient’s pain were documented. The first documented pain screening/assessment was on March 25, 2026, at 1:00 PM when the nurse documented the patient denied pain. This was approximately 19 hours after the patient arrived to the ED. MR4’s vital signs were documented at 3:00 PM on March 25, 2026. No pain level was documented with these vital signs. 2. MR6 was reviewed and contained documentation that the patient arrived in the ED on March 24, 2026, at 7:46 PM with a mental health complaint. Vital signs were obtained at 7:51 PM. The documented vital signs did not include a pain screening/level. At 7:59 PM, the patient was assigned an ESI level of 2. The patient was medically cleared for psychiatric evaluation at 10:22 PM. There were no vital signs to include pain assessment documented between 7:51 PM and 10:22 PM. Vital signs were not obtained again until 6:15 AM on March 25, 2026 (ten hours after the previous set of vital signs). No pain level was included with these vital signs. Vital signs were next obtained at 9:16 AM and failed to contain documentation of a pain level. The patient was discharged from the ED at 11:00 AM. No documented pain screenings or assessments were conducted during the entire ED encounter. No vital signs were collected within 60 minutes of the patient’s discharge per facility policy. 3. MR7 was reviewed and contained documentation that the patient presented to the ED at 12:35 AM on March 25, 2026, for a mental health evaluation. Vital signs were initially obtained at 12:39 AM and failed to include a pain screening or assessment. The patient was assigned an ESI of 2 at 12:47 AM. The patient was medically cleared for a mental health evaluation at 2:48 AM. Vital signs were not obtained hourly before the patient was medically cleared. Vital signs were obtained at 6:47 AM on March 25, 2026. No pain level was documented with these vital signs. Vital signs were again obtained at 9:42 AM on March 25, 2026. No pain level was documented with these vital signs. The patient was discharged at 9:47 AM. The record failed to contain documentation that a pain screening or assessment was completed during the entire ED encounter. 4. MR8 was reviewed and contained documentation that the patient arrived to the ED at 12:33 AM on March 24, 2026, with a mental health complaint. Vital signs were obtained at 12:37 AM, but no pain level was documented. The patient was assigned an ESI level of 2 at 12:41 AM. The patient was medically cleared for a behavioral health consult at 3:33 AM on March 24, 2026. Vital signs were not obtained hourly as required prior to the patient being medically cleared. Vital signs were obtained at 6:18 AM and 9:19 AM on March 24, 2026. No pain level was documented with these vital signs. The patient was discharged at 10:08 AM. The record contained no documentation that the patient was screened for pain throughout the entire ED encounter. 5. MR9 was reviewed and indicated the patient arrived in the ED on March 26, 2026, at 1:24 PM. The patient was given an ESI of 2 at 1:30 PM. Vital signs were obtained at 1:45 PM. No pain level was documented with these vital signs. Vital signs were again taken at 4:09 PM. No pain level was included with these vital signs. Vital signs were not taken hourly as required prior to the patient being medically cleared. The first documented pain screening/assessment was with vital signs obtained at 5:23 PM, four (4) hours after arrival to the ED. The patient refused vital signs at 6:24 PM. Patient was medically cleared at 8:59 PM on March 26, 2026. Vital signs were obtained at 10:53 PM on March 26, 2026. No pain level was documented with these vital signs. At 3:40 AM on March 27, 2026, the patient complained of mild head pain and given Tylenol 1000 mg by mouth. No pain reassessment was completed to determine the effectiveness of the Tylenol. Vital signs were obtained at 7:51 AM and 5:43 PM on March 27, 2026. No pain level was documented with these vitals. MR9 was reviewed and indicated the patient returned to the ED at 1:44 PM on March 29, 2026, with suicidal ideation. The patient was assigned an ESI level of 2. Vital signs were obtained at 2:10 PM but failed to include a pain level. The patient was medically cleared for behavioral health evaluation at 3:49 PM on March 28, 2026. Vital signs were taken at 4:18 PM and 6:04 PM on March 29, 2026, but did not include a pain level. The patient was given Tylenol and ibuprofen at 6:31 PM for “severe, generalized pain.” This was the first documentation of pain in the record. The documentation did not include a full pain assessment at this time as required by hospital policy. The record failed to contain a pain re-assessment within 60 minutes of administering the pain medication. The next documented pain assessment was at 8:06 PM on March 29, 2026, indicating the patient was experiencing 10/10 pain in the head. No interventions were documented until approximately an hour and a half later at 9:34 PM, when Decadron was administered. The patient’s pain was reassessed at 9:45 PM on March 29, 2026, and indicated the patient continued to experience 10/10 head pain. There was no documentation that the patient’s physician was notified or that any additional intervention was attempted for the patient’s unresolved pain. The pain was again reassessed at 12:17 AM on March 30, 2026. The patient continued to complain of “severe” head pain. Tylenol was given at this time. There was no pain reassessment documented within 60 minutes as required by hospital policy. At 2:21 AM on March 30, 2026, the nurse documented that vital signs were deferred to promote rest as patient was sleeping. The patient’s vitals were obtained at 3:54 AM on March 30, 2026, and documented that the patient was experiencing severe head pain. There was no documentation of any intervention for the severe pain. The patient’s vitals were again obtained at 3:34 AM, 8:02 AM, and 10:32 AM on March 30, 2026. There was no documentation of a pain level with these vital signs. The patient was discharged home at 12:54 PM on March 30, 2026. There were no vitals taken within 60 minutes of discharge to include a pain level. The last documented pain assessment was at 3:54 AM (approximately nine (9) hours before discharge) indicating the patient was experiencing severe pain with no documented interventions or reassessments. 6. MR10 was reviewed and contained documentation that the patient arrived in the ED at 8:42 PM on March 24, 2026, with a mental health problem. Vital signs were obtained at 9:07 PM on March 24, 2026, and indicated the patient had pain rated 5/10 on a pain scale in throat. No further assessment of the pain was documented. No intervention for the pain was documented. The patient was assigned an ESI level of 2 at 9:11 PM. Vital signs were not obtained hourly as required while the patient was awaiting medical clearance. Vital signs were again obtained at 11:31 PM on March 24, 2026, and 1:06 AM on March 25, 2026. No pain level was documented with either of these vital signs. The patient was medically cleared for behavioral health consult at 1:44 AM on March 25, 2026. Vital signs were documented at 2:39 AM on March 25, 2026. No pain level was documented with these vital signs. The patient was admitted to the mental health unit at 6:06 AM. The last set of vital signs documented were 2:39 AM on March 25, 2026. An interview was conducted with EMP19 at 10:22 on April 21, 2026. EMP19 indicated that an initial pain screening is required on all patients and usually completed in triage. Pain assessments should also be completed with each set of vital signs and one hour after giving pain medications. An interview was conducted with EMP21 on April 21, 2026 at 12:54 PM. EMP21 indicated that all patients receive a pain screening or assessment on arrival to the ED. Pain assessments are completed with every set of vital signs. Patients who are ESI level 2’s should have their vitals taken every hour until medically cleared. These vital signs should include pain level hourly.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 42929 Based on review of medical records (MR), review of documents, and interviews with staff (EMP) it was determined the facility staff failed to document modification of the patient’s plan of care with the use of restraint as per facility policy for three (3) of five (5) restrained patients’ medical records reviewed, MR22, MR23, and MR24. Findings: Review of facility document “Restraint Policy” last revised July 2025 reads in part: “... Procedures in the Use of Restraints. The following procedures are applicable to the use of all restraints.... 7. Plan of Care: Based on the comprehensive assessment and evaluation of the effectiveness of less restrictive measures, the nursing staff will individualize and modify the patient’s plan of care to include the use of restraints. The patient should be regularly reassessed; the individual plan of care should be modified accordingly. The assessments and modifications to the patient’s care must be clearly documented.... The nurse must include in the patient’s plan of care a loop of assessment, intervention, evaluation, and reassessment for each patient requiring restraint. This plan must describe the identified problem, the goal and outcome of the use of restraints, and the specific restraint intervention applied.... 12. Documentation in the medical record includes the following: ... g. Revision to the plan of care.... 14. Update plan of care with initiation and removal of restraints....” Review of facility document “Nursing Process - Delivery of Patient Care” last revised October 2023 reads in part: “... Diagnosis/Planning ... 4.... b. The RN is accountable for changes to the plan of care ... c. The plan of care is reviewed and patient’s progress toward established goals/outcomes is documented at least every shift....” Review of the medical record for MR22 revealed the patient was placed in a violent restraint on February 16, 2026, from 9:08 PM to 9:10 PM. There was no documentation that the nurse modified MR22’s plan of care to include the use of restraints. Review of the medical record for MR23 revealed the patient was placed in non-violent restraints on February 5, 2026, at 8:16 PM. The modification to MR23’s plan of care to include the use of restraints was first documented on February 8, 2026, at 7:20 PM, three (3) days after the restraint was applied. There were six (6) nursing shifts that the patient was in restraints with no documentation of modification to MR23’s plan of care to include the use of restraints. Review of the medical record for MR24 revealed the patient was placed in non-violent restraints on February 17, 2026, at 4:15 AM. There was no documentation that the nurse modified MR24’s plan of care to include restraints when the medical record was reviewed on February 18, 2026, around 10:20 AM. There were three (3) nursing shifts that the patient was in restraints with no documentation of modification to MR23’s plan of care to include the use of restraints. Interview on February 18, 2026, around 11:15 AM, EMP5 indicated that MR22’s plan of care should have been updated to include the use of the violent restraint. EMP5 indicated that the plan of care should be updated to include the use of restraints every shift as per facility policy.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 42929 Based on review of medical records (MR), review of documents, and interviews with staff (EMP) it was determined the facility staff failed to document monitoring a patient in restraint as per facility policy for one (1) of five (5) restrained patients’ medical records reviewed, MR24. Findings: Review of facility document “Restraint Policy” last revised July 2025 reads in part: “... Process ... 10. The use of a restraint should be predicated on a thorough assessment that examines the patient’s medical symptoms and builds on the standard of care that will meet the patient’s needs. All patients should be observed and assessed at least every two hours. Documentation should include: a. Need for restraint to continue based on patient’s ability to comply with a planned medical regimen. b. Release from restraint to evaluate skin integrity beneath the restraint and proper placement of the restraint in order to prevent alteration in skin integrity and/or restriction of respiratory ability or circulation occlusion. c. Giving the patient opportunity for hydration, eating, toileting, range of motion exercises, and other activities of daily living. 11. All patients will be assessed and reassessed for the need to continue restraints. Documentation of the patient’s response to the intervention(s) used, and the behavior that warrants the continuation of restraints must be in the medical record at least every four hours upon reassessment and when the order is renewed....” Review of the medical record for MR24 revealed documentation of an order for non-violent, bilateral soft upper extremity restraints starting on February 17, 2026, at 4:15 AM. The nursing restraint flow sheet documentation revealed the patient was monitored in a secured mitt restraint on the right hand at 4:15 AM with the restraint continued. There was no documented evidence that the patient was monitored in the restraint every two (2) hours after the initial application of the restraint on February 17, 2026, at 4:15 AM for the next fourteen (14) hours until the next restraint monitoring documentation on February 17, 2026, at 7:00 PM. Interview on February 18, 2026, around 10:30 AM, EMP10 confirmed there was no restraint monitoring documented in MR24’s medical record for that timeframe. EMP5 indicated that there should be documentation of patient monitoring in restraints every two (2) hours as per facility policy.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 45736 Based on medical record review, interviews and document review, it was determined the facility failed to monitor vital signs for six (6) of eight (8) patients, according to the facility policy. The findings include: During medical record review, the afternoon of August 18, 2025 and the morning of August 19, 2025, with Staff Member 2 and Staff Member 21, the surveyors determined that six (6) of eight (8) medical records reviewed during the survey process did not contain evidence of vital sign monitoring, according to the facility policy. The emergency department (ED) medical records evidenced the following vital sign monitoring: Patient 1- ESI (Emergency Severity Index) 2- November 20, 2024: 1:03 PM, 3:30 PM, and 6:00 PM (Patient 1 was admitted to this facility on November 20, 2024 at 8:04 PM) Patient 2- ESI 3- November 21, 2024: 12:37 PM and 4:36 PM (Patient 2 was discharged from this facility on November 21, 2024 at 6:53 PM) Patient 3- ESI 3- November 21, 2024: 3:51 PM, 9:34 PM, and 11:34 PM (Patient 3 was discharged from this facility on November 21, 2025 at 11:35 PM) Patient 6- ESI 2- April 26, 2025: 10:45 AM, 1:00 PM, 2:31 PM, 3:32 PM and 7:53 PM (Patient 6 was admitted to this facility on April 26, 2025 at 7:52 AM) Patient 7- ESI 2- April 14, 2025: 11:59 AM, 2:45 PM, 3:15 PM, 4:37 PM, and 8:16 PM (Patient 7 was admitted to this facility on April 14, 2025 at 12:10 PM) Patient 11- ESI 2 August 18, 2025: 11:20 AM, 12:00 PM, 3:03 PM, 5:01 PM, 6:44 PM, and 7:30 PM (Patient 11 was admitted to this facility August 18, 2025 at 7:32 PM) During an interview with Staff Member 8, on August 19, 2025 at 10:15 AM, when the surveyor asked about ED vital sign monitoring, Staff Member 8 indicated that a patient with an ESI level of two (2) would be monitored within every hour and an ESI three (3) would be monitored within every two (2) hours. During an interview with Staff Member 9, on August 19, 2025 at 10:30 AM, when the surveyor asked about ED vital sign monitoring, Staff Member 9 indicated that a patient with an ESI level of three (3) would need to be monitored every two (2) hours and the ED technicians are the ones who usually obtain these vital signs . A facility policy, Emergency Care and Treatment, last revision January, 2019, revealed in part, “...f. Patients who remain in the waiting area or triage area after initial assessment and prior to admission or treatment area are re-evaluated by a nurse, paramedic, or EMT (Emergency Medical Technician). The guidelines for completion or re-evaluation are within the following time frames: 1. ESI LEVEL 1: Every 15 minutes 2. ESI LEVEL 2: Every hour 3. ESI LEVEL 3: Every 2 hours 4. ESI LEVEL 4: Every 4 hours 5. ESI LEVEL 5: Every 4 hours.””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 40084 Based on interview and facility document review, it was determined the facility failed to ensure one (1) of seven (7) staff members had up to date and documented competencies related to patient care. The findings include: The surveyor reviewed seven (7) staff member personnel records the afternoon of January 9, 2024 with Staff Members #2, #9, #10, #11, #12, #13 and #14. During the review of Staff Member #8’s competencies, it was determined that Staff Member #8 did not have an up to date and completed “Competency Based Orientation Tool Certified Nursing Assistant Level 1”. Staff Member #8 lacked signatures from their leadership that documented competencies in bladder scanning. Staff Member #8’s date of hire was July 11, 2022. During an interview with Staff Member #9, the afternoon of January 9, 2025, when the surveyor asked what the expected timeframe is for documented competencies on the “Competency Based Orientation Tool Certified Nursing Assistant Level 1,” they indicated that it is usually completed within four (4) weeks after hire.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 21229 Based on observation, clinical record review, facility document review and staff interview, the governing body failed to ensure a designated in-patient hospital unit was equipped and staff were trained to provide the same care in emergency situations as all other units of the hospital. Patient #1 experienced a cardiac arrest and Patient #2 experienced multiple grand-mal seizure episodes. The in-patient unit staff had only basic cardiac life support training and equipment and relied on EMS (Emergency Medical Services - 911) to respond to life-threatening emergencies. Patients in order to receive Advanced Cardiac Life Support, have to wait until EMS is able to respond . Patient #1 expired in the Emergency Department. The facility policy and procedures only addressed basic life support measures and relied on the services of “911” for advanced care. Please refer to A0115, A0144, A1100 and A1103 for further information.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 21229 Based on interviews, clinical record review and facility document review, the facility staff failed to ensure each patient’s rights were protected. Two (2) patients (Patient #1 and #2) included in the survey sample experienced a medical emergency in a designated in-patient psychiatric unit. The current practice has the potential to negatively affect all patients admitted to this unit. The facility administered PRN (as needed) medications to Patient #1 documented as a chemical restraint, without an order or monitoring. The facility also failed to follow the requirements for Restraint Death reporting. Patient #1 was placed in a physical restraint, medicated, and secluded and expired less than 24 hours later. Please refer to A0144 and A0213 for further information.”

“MEDICAL RECORD SERVICES CFR(s): 482.24 The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. This Condition is not met as evidenced by: 21229 Based on clinical record review, staff interview and facility document review, the facility staff failed to ensure a complete and accurate medical record was maintained for Patient #1. Patient #1’s medical record: (1) included conflicting documentation of a medical emergency by staff involved in patient care during the event; (2) failed to include a discharge summary; and (3) failed to included a final diagnosis. Patient #1 was admitted and discharged/expired in October 2023. Please refer to A0449, A0468, and A0469 for further information.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 21229 Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the needs of patients experiencing an emergency medical condition were met. Patient #1 experienced a cardiac arrest and Patient #2 experienced multiple grand-mal seizures. The in-patient unit had only basic life support (BLS) equipment, staff received only BLS training and relied on EMS (Emergency Medical Services - 911) to handle life-threatening emergencies. Patients are expexted to wait for EMS to respond in order to receive the *ACLS. Patient #1 expired in the Emergency Department. *(Advanced Cardiac Life Support --Advanced cardiac life support refers to a set of guidelines used by medical providers to treat life-threatening cardiovascular conditions. These life-threatening conditions range from dangerous arrhythmias to cardiac arrest. ACLS algorithms frequently address at least five different aspects of peri-cardiac arrest care: Airway management, ventilation, CPR compressions (continued from BLS), defibrillation, and medications. Due to the seriousness of the diseases treated, the paucity of data known about most ACLS patients, and the need for multiple, rapid, simultaneous treatments, ACLS is executed as a standardized, algorithmic set of treatments. Successful ACLS treatment starts with diagnosis of the correct EKG rhythm causing the arrest. Common cardiac arrest rhythms covered by ACLS guidelines include: ventricular tachycardia, ventricular fibrillation, Pulseless Electrical Activity, and asystole. Dangerous, non-arrest rhythms typically covered includes: narrow- and wide-complex tachycardias, torsades de pointe, atrial fibrillation/flutter with rapid ventricular response, and bradycardia. www.cpr.heart.org accessed 11/07/24 at 6:58 a.m.) According to facility Administration, the Snowden unit was designated as an inpatient psychiatric unit but did not follow the same medical emergency protocols as the standard hospital units. The facility policy and procedure for “Code Blue- Code Pink (adolescent)” addressed only Basic Life Support measures and calling “911” for Advanced Life Support/Emergency Measures and transport to the Emergency Room. Please refer to A1103 for further information.”

“OFF-CAMPUS EMERGENCY POLICIES AND PROCEDURES CFR(s): 482.12(f)(3) If emergency services are provided at the hospital but are not provided at one or more off-campus departments of the hospital, the governing body of the hospital must assure that the medical staff has written policies and procedures in effect with respect to the off-campus department(s) for appraisal of emergencies and referral when appropriate. This Standard is not met as evidenced by: 21229 Based on observation, clinical record review, staff interview and facility document review, the governing body failed to ensure a designated hospital unit had emergency services and resources/staff training to provide appropriate emergency care for all patients. Two patients included in the survey sample (Patient #1 and #2) experienced medical emergency and staff couldn’t provide care beyond basic life support and relied on care being provided by EMS (Emergency Medical Services). The findings included: Patient #1 experienced a cardiac arrest on October 7, 2023 and the unit did not have immediate resources available to provide emergency care. Patient #1 expired in the Emergency department. Note: review of Patient #1’s medical record found different timelines and accounts of the events that occurred prior to Patient #1 expiration in the Emergency Department (ED). The “ED Provider Notes” for this event read in part, “...EMS reports that pt (patient) was last seen at (their) baseline around 2130 (9:30 p.m.). Staff at Snowden found patient at 2430 (12:30 a.m.) sitting in a chair and had urinated of (self)....staff noticed patient was pale so they checked (patient) pulse and it was ‘thready and weak’. Staff then attempted to get a BP (blood pressure) and were unable to so CPR (cardiopulmonary Resuscitation) was started at 2445 (12:45 a.m.)...” A “Nursing Note” documented the event in part, “...Upon helping place (patient) into bed writer noticed (patient) had urinated (self)...while cleaning (patient) (patient) urinated (self) again...after washing (patient) up and placing clean clothes...noted (Patient) extremities felt a bit cool to touch. Felt for a pulse, and it was present, but faint...retrieved vital sign machine. Could not obtain BP or HR (heart rate)...did not respond to sternal rub...Code Blue initiated at 2345 (11:45 p.m. 10/7/23)...CPR started... AED (automated external defibrillator) placed on (patient) BS (Blood sugar) was taken and was 409. (Patient) remained in asystole (no detectable heart activity), and at no point was a shock advised...CPR continued until EMS arrived and took over...EMS transported (patient) to the hospital at 0013 (12:03 a.m. 10/8/23)... time of death was called at 0035 (12:35 a.m. 10/8/23) (in the Emergency Department). A “Consult Note” revealed in part, “This provider was notified by nursing charge at approximately 2250 (10:50 p.m.- 10/7/23) of patient cardiac arrest...was informed by nursing staff that CPR was in progress since 2245 (10:45 p.m.)...EMS arrived at approx (approximately) 2252 (10:52 p.m.) and pt was transferred to ED at 0013 (12:03 a.m. 10/8/23) Patient #2 experienced on October 27, 2023 multiple grand-mal seizures while in-patient at this unit which did not have access to suction or oxygen. Patient #2 waited approximately forty (40) minutes for transport to the emergency room. On October 27, 2023 at 1:28 p.m. a “Nursing Note” documented in part,”... Patient complained of feeling dizzy immediately after taking (their) medications at 13:00 (1:00 p.m.)...patient began to seize, with (their) eyes rolled back, (their) jaw clenched, (their) body stiff and lower extremities jerking for about 20 (twenty) seconds...patient continues to have intermittent seizure episodes lasting 10-20 (ten to twenty) seconds with brief post-ictal (The postictal state is the altered state of consciousness after an epileptic seizure. It usually lasts between 5 and 30 minutes, but sometimes longer in the case of larger or more severe seizures, and is characterized by drowsiness, confusion, nausea, hypertension, headache or migraine, and other disorienting symptoms. The ictal period is the seizure itself; the interictal period is the time between seizures. clevelandclinic.org accessed 11/6/24 at 10:15 a.m.)...was given Ativan (antianxiety medication often used to treat seizure activity) 2mg ( two milligrams on (patient) right dorsogluteal (right buttock) area at 13:14 (1:14 p.m.) ...stopped seizing at about 13:20... laied (sic) on floor...until...EMS arrived (no time) ...transport by EMS to ED at 13:40 ( 1:40 p.m.)...” The “Psychiatry Note” dated October 27, 2023 documented at 1:31 p.m. in part, “Prior to seeing patient , (patient) began having a seizure outside the office...eyes rolling back, full body tremors, obtunded, unable to respond to verbal commands..tongue remained inside (patient) mouth...no Versed (Midazolam, also called Versed, is a medicine used to stop a seizure that has lasted too long. It’s also used if many seizures happen in a short period of time.drugs.com accessed 11/6/24 at 10:58 a.m.) was available and Ativan 2mg IM was given...” The “ED Provider Note” documented at 1:59 p.m., in part, “Patient arrived to the ED after experienced multiple seizures while at Snowden. There were 3 (three) witnessed seizures...admitted...discharged back to Snowden October 28, 2024...” The facility policy regarding management of emergency medical conditions was reviewed the policy on October 21, 2024 at 1:10 p.m. The policy “Transfer of Patient with Acute Medical Conditions, Guidelines for Snowden at Fredericksburg (approved 5/11, revised 8/17, reviewed 3/21) evidenced, in part: “The purpose of these guidelines is to assist the nursing staff at Snowden at Fredericksburg (SAF) in ensuring that Behavioral Health Patients receive prompt medical assessment, evaluation and intervention should an acute medical condition develop. Content: 1. The following steps are to be followed when a patient at Snowden displays any signs/symptoms of an acute medical condition, which may include, but are not limited to: a. severe chest pain b. nausea, vomiting, diaphoreses, changes in LOC (level of consciousness) or vital signs c. difficulty breathing...cyanosis, or inadequate oxygenation (decreased mental status, change in color of lips, fingernail beds) d. acute abdominal pain e. onset of vaginal bleeding while pregnant f. changes in blood sugar accompanied by symptoms of hypoglycemia/hyperglycemia g. severe headache with changes in speech and neurological status h. seizures. 2. The physician, if on-site is to be notified immediately to evaluate patient. In the event there is not a physician on the premises a. Call 911; alert front desk/security b. have on-call physician paged c. Nurse/Mental Health Technician to remain with patient at all times obtaining and recording vital signs, monitoring patient d. Call Emergency department at MWH (Mary Washington Hospital) and provide hand-off communication e. notify patients family regarding transfer, if applicable 3. Document all events completely and concisely in the medical record.” The Surveyor requested further information/policy regarding specifically how the facility handled a “Code Blue” and was provided “Code Blue/Code Pink, Snowden at Fredericksburg- MWH Mary Washington Hospital - Approved 3/20” which evidenced, in part: “To outline the process for a respiratory/cardiac arrest at Snowden (SAF). Inpatient First Response 1. The first Associate notified SAF operator to have a code blue/code pink overhead paged. The first RN (Registered Nurse) on scene directs the code. 2. The HUC (Health Unit Coordinator) or nurse calls 911...3. A third associate obtains the AED, back board, code bag, delivers them to the code site and assists with CPR. 4. All Associates available respond to the code as appropriate. 5. Non nursing Associates assist with code as needed...Code Leadership 1. The first Registered Nurse (Lead RN) responding to the code will lead the code team. 2. The Lead RN will assign associate to document in the medical record using the designated time piece. Documentation may be done electronically or on the paper form Resuscitation Record (FR-116-MWHC) for downtime. 3. When EMS personnel arrive on scene they will assume leadership of the code. 4. The Lead RN will assure documentation is completed; call the Mary Washington Hospital Emergency Department (MWH-ED) and give them a ‘Hand-off”...5. The Lead RN will ensure the patient’s chart is complete with documentation of the event as well as the transportation time is entered in to the patient’s medical record...7...Lead RN notified management...8. Lead RN conducts debrief with all associates who participated in the code. 9. A SAFE report is completed...Code Team Members 1. First person in scene-activates code calk , notes time of arrest...2. Code bag responder- obtains AED, code bag and back board...3. First RN responder (Lead RN) assumes leadership of the code...directs associate to document events...4. Recorder Associate - documents information in the medical record...Lead RN is responsible to ensure all documentation associated with the code is complete and on the permanent medical record...” The surveyor toured the Snowden Unit on October 21, 2024 at approximately 11:45 a.m. accompanied by Staff Members #2, 3, and 4. During the tour the surveyor inquired as to whether the unit was considered an in-patient unit. Staff Member # 2 and 3 acknowledged the unit status as “in-patient for treatment of mental health”. The surveyor inquired as to the location of emergency equipment and was shown a small blue bag labeled “Emergency Bag” which contained an ambu bag (Bag-valve-mask (BVM) or the Ambu bag is a self-inflating bag used to provide ventilation to the person not breathing normally. A BVM consists of a non-rebreathing valve and a face mask. The opposite end of the bag is attached to an oxygen source. The mask is manually held against the face. The bag is squeezed to provide ventilation to the patient through the nose and mouth until the intubation can be done. americanheartassociation.org accessed 11/01/24 at 6:45 a.m.) and a stethoscope. The surveyor inquired as to the oxygen source and Staff Member #2 indicated the facility did not have an oxygen source. The surveyor was also shown a “First Aid Kit” containing various bandage materials and tape, an AED (Automated External Defibrillator - AEDs are used to help those experiencing sudden cardiac arrest. It’s a sophisticated, yet easy-to-use, medical device that can analyze the heart’s rhythm and, if necessary, deliver an electrical shock, or defibrillation, to help the heart re-establish an effective rhythm. americanheart association.org) and a back board (A backboard, made of wood, plastic, or other material, is inserted under the torso of a patient that is to receive cardiopulmonary resuscitation (CPR) in order to provide a firm surface during chest compression. americanheartassociation.org accessed 11/01/24 at 7:00 a.m.). Staff Member #4 indicated the in-patient unit “does not have any oxygen sources, no suction machine, does not do advanced cardiac life support, and does not administer cardiac emergency medications but calls 911 and the EMS responds. We only do CPR and use the AED and staff are trained in BLS (Basic Life Support).” On October 21, 2024 at 2:30 p.m., the surveyor again discussed the emergency protocols for the Snowden unit since the unit had been identified as an in-patient unit. Staff Member #2 indicated that in an emergency the staff would take the patient’s vital signs, and start the BLS protocol, call EMS, notify the physician and transfer the patient to the hospital ED. At 3:00 p.m., the surveyor interviewed Staff Members #12 and #13 who indicated they would complete an assessment on a patient, get vital signs and if the patient was not breathing or did not have a heart beat they would call a code blue and call the doctor as well as 911 for the EMS. The staff members indicated they did not do any suctioning, or administer any medications during a code blue and there was no oxygen at the facility. The staff members further indicated they were trained in basic life support and the use of the AED. Staff Member #5 (Nurse Manager) stated that the EMS has a “very quick response” and that staff were trained in basic life support. The surveyor inquired as to the “quick response” for Patient #2 who waited approximately 40 (forty) minutes for EMS transport after experiencing multiple seizures. “The EMS are really close and that was unusual” according to Staff Member #2. On October 22, 2024 at 11:15 a.m., the surveyor interviewed Staff Member #16 (Medical Director Snowden unit) who indicated that if a code blue is called and the MD is available they would respond and provide support but the most experienced physician or Registered Nurse would direct the code. Staff Member #16 further indicated that basic life support would be provided, but that advanced life support was not done on the unit. At 2:40 p.m. on October 22, 2024, the surveyor interviewed Staff Member #15 who indicated they were notified after Patient #1 experienced the cardiac arrest and the patient transferred to the Emergency Department. The Staff Member #15 explained to the surveyor that if a patient had a medical emergency on the unit, the staff would call “911” as they did not provide advanced cardiac life support. The surveyor inquired as to whether there were emergency medications that were available for use in an injectable form in the facility. The surveyor was given a list on October 22, 2024 at 2:55 p.m.. The list contained a variety of antipsychotic and antianxiety agents as well as Glucagon (a medication to raise the blood sugar) and Naloxone (a medication which can reverse an opioid overdose). Staff Member #2 provided the surveyor with a map of the facility campus on October 22, 2024 at 2:30 p.m. This map had a circle encompassing the hospital and was designated as the “campus” The unit/facility Snowden was not included in the “campus”. The surveyor inquired as to whether the facility considered the unit as an in-patient unit. Staff Member #2 indicated it was “remote location”. The surveyor inquired as to whether the Snowden unit was listed in the hospital services as an in-patient behavioral health unit. Staff Member #2 stated yes. The surveyor reviewed the 2023 application submitted by the facility which listed the Snowden unit as consisting of 62 adult and 12 adolescent/pediatric behavioral health beds under the same provider number as the hospital. The surveyor discussed with Staff Members #2, 3, 4, 5, and 6 on October 22, 2024 at approximately 11:45 a.m. and again On October 23, 2024 at approximately 12:30 p.m. the concerns regarding the designation of Snowden as an inpatient hospital unit and not equipped to function with advanced life support in the event of an emergency and the reliance on 911 to provide emergency care to inpatients on the unit.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 21229 Based on interviews, clinical record review, observation and facility document review, the facility staff failed to ensure that during a medical emergency Patient #1 and #2 recieved care in a safe setting. Patient #1 had a cardiac arrest on October 7, 2023. Basic Life Support was provided on the unit by staff, however, the facility relied on the services of “911” for advanced cardiac life support. Patient #1 expired in the Emergency Department. Patient #2 experienced multiple grand-mal seizures on October 27, 2023. The in-patient unit staff called 911 and provided medications, however, it was documented that forty (40) minutes elapsed from the time of the seizure and a 911 call was placed, until the patient was transported to the Emergency Department. The facility relied on “911” for emergency care and transport. The findings include: Patient #1 presented to the Emergency Department (ED) of the facility on October 3, 2023, for an “evaluation of mental health”. The “Emergency department Provider Notes” evidenced the patient had a past medical history of Bipolar 1 disorder, depression, schizophrenia spectrum disorder with psychotic disorder, seizure, and anemia. The notes further documented the patient was “non-communicative, but does follow commands”. In the section for “ED Course” on “Wednesday, October 4, 2023 at 0203 (2:03 a.m.) , the note evidenced, “RACSB (County Community Services Board) refuses to pre-screen because they believe the condition is medical and not psychological. They would like to pushback the prescreen until the morning because they hope (patient) would be more clear at that point...0204 (2:04 a.m.) Medically cleared. Prescreen will be delayed until day shift...Medical decision Making: Patient presents to the ED for psychotic episode. Patient was recommended for Snowden (inpatient psychiatric unit) and transferred to Snowden...Diagnosis: psychosis unspecified psychosis type, Acute UTI (urinary tract infection).” On October 4, 2023 a “Nursing Note” documented at 3:32 p.m. in part, “Patient arrived ambulatory from Stafford (sister facility) ED, TDO (Temporary Detaining Order) status...Patient states this admission is due to (patient) trying to get better for (their) (child). Denies SI/HI (suicidal ideations/homicidal ideations) and hallucinations...poor insight...disoriented to situation and is forgetful, frequently asking staff when (they) can leave and when (parent) can visit...” “ED Provider Notes” documented on October 8, 2023 at 12:21 a.m., revealed in part, “...presents to the ED via EMS (Emergency Medical Services) from Snowden for evaluation. EMS reports that pt (patient) was last seen at (their) baseline around 2130 (9:30 p.m.). Staff at Snowden found patient at 2430 (12:30 a.m.) sitting in a chair and had urinated of (self)....staff noticed patient was pale so they checked (patient) pulse and it was ‘thready and weak’. Staff then attempted to get a BP (blood pressure) and were unable to so CPR (cardiopulmonary Resuscitation) was started at 2445 (12:45 a.m.)...” A “Nursing Note” dated October 8, 2023 at 1:21 a.m. documented the events as following, “Went with med tech to assist (patient) to bed...during rounds (med tech) asked (patient) if (they) would like to go to bed and (patient) responded ‘Eh’. Upon helping place (patient into bed writer noticed (patient had urinated (self)...while cleaning (patient) (patient) urinated (self) again...after washing (patient) up and placing clean clothes...noted (Patient) extremities felt a bit cool to touch. Felt for a pulse, and it was present, but faint...retrieved vital sign machine. Could not obtain BP pr HR (heart rate)...(did not respond to sternal rub...Code Blue initiated at 2345 (11:45 p.m. 10/7/23)...CPR started... AED (automated external defibrillator) placed on (patient)BS (Blood sugar) was taken and was 409. (Patient) remained in asystole (no detectable heart activity), and at no point was a shock advised...CPR continued until EMS arrived and took over...EMS transported (patient to the hospital at 0013 (12:03 a.m. 10/8/23)... time of death was called at 0035 (12:35 a.m. 10/8/23). The physician on the unit documented the medical emergency in their “Consult Note” dated October 8, 2023 at 12:25 a.m.: “This provider was notified by nursing charge at approximately 2250 (10:50 p.m.- 10/7/23) of patient cardiac arrest...was informed by nursing staff that CPR was in progress since 2245 (10:45 p.m.)...EMS arrived at approx (approximately) 2252 (10:52 p.m.) and pt was transferred to ED at 0013 (12:03 a.m. 10/8/23).” Patient #2 presented to the Emergency Department on October 26, 2023 at 1:04 p.m. with suicidal ideations and depression. According to the Emergency Department “History and Physical” the patient had a history of a seizure disorder and “states (they) were taking Keppra (anti-seizure medication) for seizures but ran out X1 (one) month ago...had a seizure last night and woke up on the floor...seen by mental health and they wish to admit (patient)...They do understand that (patient) will need Keppra given to (patient)...(patient) was loaded with a g (gram) of Keppra in the emergency department and had no seizures...” On October 27, 2023 at 1:28 p.m. it was documented in the “Nursing Note: Patient complained of feeling dizzy immediately after taking (their) medications at 13:00 (1:00 p.m.)...patient began to seize, with (their) eyes rolled back, (their) jaw clenched, (their) body stiff and lower extremities jerking for about 20 (twenty) seconds...patient continues to have intermittent seizure episodes lasting 10-20 (ten to twenty) seconds with brief post-ictal (The postictal state is the altered state of consciousness after an epileptic seizure. It usually lasts between 5 and 30 minutes, but sometimes longer in the case of larger or more severe seizures, and is characterized by drowsiness, confusion, nausea, hypertension, headache or migraine, and other disorienting symptoms. The ictal period is the seizure itself; the interictal period is the time between seizures. clevelandclinic.org accessed 11/6/24 at 10:15 a.m.)...was given Ativan (antianxiety medication often used to treat seizure activity) 2mg ( two milligrams on (patient) right dorsogluteal (right buttock) area at 13:14 (1:14 p.m.) ...stopped seizing at about 13:20... laied (sic) on floor...until...EMS arrived (no time) ...transport by EMS to ED at 13:40 ( 1:40 p.m.)...” There was a “Psychiatry Note” dated October 27, 2023 at 1:31 p.m. which evidenced, “Prior to seeing patient , (patient) began having a seizure outside the office...eyes rolling back, full body tremors, obtunded, unable to respond to verbal commands..tongue remained inside (patient) mouth...no Versed (Midazolam, also called Versed, is a medicine used to stop a seizure that has lasted too long. It ’ s also used if many seizures happen in a short period of time.drugs.com accessed 11/6/24 at 10:58 a.m.) was available and Ativan 2mg IM was given...” at 1:59 p.m., an “ED Provider Note” evidenced, “Patient arrived to the ED after experienced multiple seizures while at Snowden. There were 3 (three) witnessed seizures...admitted...discharged back to Snowden October 28, 2024...” The surveyor requested the facility policy regarding management of emergency medical conditions and received and reviewed the policy on October 21, 2024 at 1:10 p.m. The policy “Transfer of Patient with Acute Medical Conditions, Guidelines for Snowden at Fredericksburg (approved 5/11, revised 8/17, reviewed 3/21) evidenced, in part: “The purpose of these guidelines is to assist the nursing staff at Snowden at Fredericksburg (SAF) in ensuring that Behavioral Health Patients receive prompt medical assessment, evaluation and intervention should an acute medical condition develop. Content: 1. The following steps are to be followed when a patient at Snowden displays any signs/symptoms of an acute medical condition, which may include, but are not limited to: a. severe chest pain b. nausea, vomiting, diaphoreses, changes in LOC (level of consciousness) or vital signs c. difficulty breathing...cyanosis, or inadequate oxygenation (decreased mental status, change in color of lips, fingernail beds) d. acute abdominal pain e. onset of vaginal bleeding while pregnant f. changes in blood sugar accompanied by symptoms of hypoglycemia/hyperglycemia g. severe headache with changes in speech and neurological status h. seizures. 2. The physician, if on-site is to be notified immediately to evaluate patient. In the event there is not a physician on the premises a. Call 911; alert front desk/security b. have on-call physician paged c. Nurse/Mental Health Technician to remain with patient at all times obtaining and recording vital signs, monitoring patient d. Call Emergency department at MWH (Mary Washington Hospital) and provide hand-off communication e. notify patients family regarding transfer, if applicable 3. Document all events completely and concisely in the medical record.” The Surveyor requested further information/policy regarding specifically how the facility handled a “Code Blue” and was provided “Code Blue/Code Pink, Snowden at Fredericksburg- MWH Mary Washington Hospital - Approved 3/20” which evidenced, in part: “To outline the process for a respiratory/cardiac arrest at Snowden (SAF). Inpatient First Response 1. The first Associate notified SAF operator to have a code blue/code pink overhead paged. The first RN (Registered Nurse) on scene directs the code. 2. The HUC (Health Unit Coordinator) or nurse calls 911...3. A third associate obtains the AED, back board, code bag, delivers them to the code site and assists with CPR. 4. All Associates available respond to the code as appropriate. 5. Non nursing Associates assist with code as needed...Code Leadership 1. The first Registered Nurse (Lead RN) responding to the code will lead the code team. 2. The Lead RN will assign associate to document in the medical record using the designated time piece. Documentation may be done electronically or on the paper form Resuscitation Record (FR-116-MWHC) for downtime. 3. When EMS personnel arrive on scene they will assume leadership of the code. 4. The Lead RN will assure documentation is completed; call the Mary Washington Hospital Emergency Department (MWH-ED) and give them a ‘Hand-off”...5. The Lead RN will ensure the patient’s chart is complete with documentation of the event as well as the transportation time is entered in to the patient’s medical record...7...Lead RN notified management...8. Lead RN conducts debrief with all associates who participated in the code. 9. A SAFE report is completed...Code Team Members 1. First person in scene-activates code calk , notes time of arrest...2. Code bag responder- obtains AED, code bag and back board...3. First RN responder (Lead RN) assumes leadership of the code...directs associate to document events...4. Recorder Associate - documents information in the medical record...Lead RN is responsible to ensure all documentation associated with the code is complete and on the permanent medical record...” The surveyor toured the Snowden Unit on October 21, 2024 at approximately 11:45 a.m. accompanied by Staff Members #2, 3, and 4. During the tour the surveyor inquired as to whether the unit was considered an in-patient unit. Staff Member # 2 and 3 acknowledged the unit status as “in-patient for treatment of mental health”. The surveyor inquired as to the location of emergency equipment and was shown a small blue bag labeled “Emergency Bag” which contained an ambu bag (Bag-valve-mask (BVM) or the Ambu bag is a self-inflating bag used to provide ventilation to the person not breathing normally. A BVM consists of a non-rebreathing valve and a face mask. The opposite end of the bag is attached to an oxygen source. The mask is manually held against the face. The bag is squeezed to provide ventilation to the patient through the nose and mouth until the intubation can be done. americanheartassociation.org accessed 11/01/24 at 6:45 a.m.) and a stethoscope. The surveyor inquired as to the oxygen source and Staff Member #2 indicated the facility did not have an oxygen source. The surveyor was also shown a “First Aid Kit” containing various bandage materials and tape, an AED (Automated External Defibrillator - AEDs are used to help those experiencing sudden cardiac arrest. It’s a sophisticated, yet easy-to-use, medical device that can analyze the heart’s rhythm and, if necessary, deliver an electrical shock, or defibrillation, to help the heart re-establish an effective rhythm. americanheart association.org) and a back board (A backboard, made of wood, plastic, or other material, is inserted under the torso of a patient that is to receive cardiopulmonary resuscitation (CPR) in order to provide a firm surface during chest compression. americanheartassociation.org). Staff Member #4 indicated the in-patient unit “does not have any oxygen source, no suction machine, does not do advanced cardiac life support, and does not administer cardiac emergency medications but calls 911 and the EMS responds. We only do CPR and use the AED and staff are trained in BLS (Basic Life Support).” On October 21, 2024 at 2:30 p.m., the surveyor again discussed the emergency protocols for the Snowden unit since the unit had been identified as an in-patient unit. Staff Member #2 indicated that in an emergency the staff would take the patient’s vital signs, and start the BLS protocol, call EMS, notify the physician and transfer the patient to the hospital ED. At 3:00 p.m., the surveyor interviewed Staff Members #12 and #13 who indicated they would complete an assessment on a patient, do the vital signs and if the patient was not breathing or did not have a heart beat they would call a code blue and call the doctor as well as 911 for the EMS. The staff members indicated they did not do any suctioning, or administer any medications during a code blue and there was no oxygen at the facility. The staff members further indicated they were trained in basic life support and the use of the AED. Staff Member #5 (Nurse Manager) stated that the EMS has a “very quick response” and that staff were trained in basic life support. The surveyor inquired as to the “quick response” for Patient #2 who waited approximately 40 (forty) minutes for EMS transport after experiencing multiple seizures. “The EMS are really close and that was unusual” according to Staff Member #2. On October 22, 2024 at 11:15 a.m., the surveyor interviewed Staff Member #16 (Medical Director Snowden unit) who indicated that if a code blue is called and the MD is available they would respond and provide support but the most experienced physician or Registered Nurse would direct the code. Staff Member #16 further indicated that basic life support would be provided, but that advanced life support was not done on the unit. At 2:40 p.m. on October 22, 2024, the surveyor interviewed Staff Member #15 who indicated they were notified after Patient #1 experienced the cardiac arrest and the patient transferred to the Emergency Department. Staff Member #15 further indicated they came in to the facility and had notified the patient family and asked them to come in. The Staff Member #15 informed the surveyor that if a patient had a medical emergency on the unit, the staff would call “911” as they did not provide advanced cardiac life support. The surveyor requested to examine the record of the “code” on October 22, 2024 at 3:10 p.m. and was informed by Staff Member #2 there was no documentation other than the nurses note. “I do not see they used the code narrator (a documentation system that allows staff to enter the record of treatment, medications and actions during a code blue). There is nothing other than what was documented in the nurses note afterward and the ED record. The surveyor inquired as to whether there were emergency medications that were available for use in an injectable form in the facility. The surveyor was given a list on October 22, 2024 at 2:55 p.m.. The list contained a variety of antipsycotic and antianxiety agents as well as Glucagon (a medication to raise the blood sugar) and Naloxone (a medication which can reverse an opioid overdose). The surveyor discussed with Staff Members #2, 3, 4, 5, and 6 on October 22, 2024 at approximately 11:45 a.m. and again On October 23, 2024 at approximately 12:30 p.m. the concerns regarding the designation of Snowden as an inpatient hospital unit and not equipped to function with advanced life support in the event of an emergency. The surveyor discussed the staff, although trained in basic life support, could not perform the functions as the other in-patient units of the hospital and did not have access to oxygen, suction, or emergency medications as well as relying on calling 911 in order to provide emergency care.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 21229 Based on clinical record review, staff interview, and facility document review, the facility staff failed to modify Patient #1’s plan of care for the use of a physical hold, the administration of a chemical restraint and the use of seclusion. The findings include: Patient #1 was placed in a physical hold after displaying agitation, continued to be held in a physical hold in order to receive an injection of Haldol (an antipsychotic medication) and Ativan (an anti-anxiety medication) and was then placed in seclusion. The “Nursing Note” written on October 7, 2023 and signed at 5:21 p.m., documented in part, “Patient became increasingly frustrated about not being able to leave the unit...began to beat on the unit’s exit door. Staff physically restrained patient by (their) arms and escorted (patient) to the observation room, PRN (As needed) medications for agitation were administered to patient 10:03( incorrect time- medication record documents administration as 1603 [4:03] p.m.). Staff were about to release patient from physical hold but (patient) shove them (sic)...pulled one staff’s hair. Physical hold was consequently maintained until patient partially calmed down. Patient was placed in seclusion...seclusion was discontinued at 1632 (4:32 p.m.)...” The orders for physical hold in Patient #1’s clinical record did not include utilization of physical hold for the administration of medications. The order for the medications were written as PRN “as needed”. However, the “Psychiatry Progress Note” documented on October 7, 2023 at 5:58 p.m. read in part, “...Patient has been reportedly highly agitated and required chemical restraint...Patient was somewhat somnolent (sleepy, almost sleeping) on evaluation...” On October 22, 2024, the surveyor, with the assistance of Staff Member #2, reviewed Patient #1’s clinical record, specifically the most current “Plan of Care” for the (October 7 though 8, 2024 time frame). The “Plan of Care” was dated October 7, 2023 and time stamped at 11:20 p.m., which means it was revised/reviewed/documented after the restraint incidents (physical and chemical as well as seclusion). The “Care Plan” did not include documentation of any restraint use. Staff Member #2 stated, “This is the only care plan after the restraint use and I do not see any restraint update...” The staff member (Registered Nurse) who documented the “Plan of Care” was no longer employed at the facility and unavailable for interview. The facility policy and procedure “Restraint and Seclusion Policy- Snowden at Fredericksburg” was reviewed and evidenced: “...Procedures in the Use of Restraints and Seclusion: ...7. Plan of Care: Based on the comprehensive assessment and evaluation of the effectiveness of less restrictive measures, the nursing staff will individualize and modify the patient’s plan of care to include use of restraints...” The surveyor discussed with Staff Members #2, 3, 4, 5, and 6 on October 22, 2024 at approximately 11:45 a.m. and again On October 23, 2024 at approximately 12:30 p.m. the concerns”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 21229 Based on staff interview, clinical record review and facility document review, the facility staff failed to obtain an order for the use of a physical hold to administer medications and for the use of chemical restraint for Patient #1. The findings include: Patient #1 was placed in a physical hold after displaying agitation. When staff were ready to release the patient, the patient again became agitated. Patient #1 was held in a physical hold for administartion of an injection of Haldol (an antipsychotic) and Ativan (an anti-anxiety medication) and then placed in seclusion. On October 7, 2023 and signed at 5:21 p.m., the “Nursing Note” evidenced: “Patient became increasingly frustrated about not being able to leave the unit...began to beat on the unit’s exit door. Staff physically restrained patient by (their) arms and escorted (patient) to the observation room, PRN (As needed) medications for agitation were administered to patient 10:03( incorrect time- medication record documents administration as 1603 [4:03] p.m.). Staff were about to release patient from physical hold but (patient) shove them (sic)...pulled one staff’s hair. Physical hold was consequently maintained until patient partially calmed down. Patient was placed in seclusion...seclusion was discontinued at 1632 (4:32 p.m.)...” According to the clinical record the orders for the physical hold did not include the need utilize the hold for the administration of medications. The order for the medications were written as PRN “as needed”. However, the “Psychiatry Progress Note” dated 10/7/23 at 5:58 p.m. evidenced, “...Patient has been reportedly highly agitated and required chemical restraint...Patient was somewhat somnolent (sleepy, almost sleeping) on evaluation...” The surveyor, with the assistance of a facility staff Member #2, was unable to locate in the clinical record any documentation of monitoring regarding the use of the medications as a chemical restraint or an addition to the physical hold order for administration of medications Staff Member #2 indicated on October 22, 2024 at 1:45 p.m. that there would be no monitoring because the medications were PRN and not ordered as a chemical restraint. Staff Member #2 further indicated that the patient was not released from the initial physical hold while the medications were administered so it was the “same order”. The surveyor reviewed the regularly scheduled medications for Patient #1. Patient #1 had only Risperidone 2mg (two milligrams) ordered at bedtime. The staff member (Registered Nurse) involved in the restraint episode was no longer employed at the facility and unavailable for interview. The facility policy and procedure “Restraint and Seclusion Policy- Snowden at Fredericksburg” was reviewed and evidenced: “...Definitions: 1. c. Drugs or medications that are used as part of a patient’s standard medical or psychiatric treatment and are administered within the standard dosage for the patient’s condition , would not be subject to requirements for chemical restraints...4. ...the ‘standard treatment dosage’ ...to treat the patient’s condition enables the patient to more effectively or appropriately function in the world around them...3. Physical Hold...considered a restraint when it restricts the patient’s movement against the patient’s will...The use of a physical hold to medicate or treat a patient against the patient’s will must be consistent with relevant requirements for the use of restraints...A physician’s order is required as this is an application of the restraint...” The surveyor discussed with Staff Members #2, 3, 4, 5, and 6 on October 22, 2024 at approximately 11:45 a.m. and again On October 23, 2024 at approximately 12:30 p.m. the concerns.”

“PATIENT RIGHTS:RESTRAINT/SECLUSION DEATH RPT CFR(s): 482.13(g)(1) & (3)(i) [Death Reporting Requirements: Hospitals must report deaths associated with the use of seclusion or restraint.] (1) With the exception of deaths described under paragraph (g)(2) of this section, the hospital must report the following information to CMS by telephone, facsimile, or electronically, as determined by CMS, no later than the close of business on the next business day following knowledge of the patient’s death: (i) Each death that occurs while a patient is in restraint or seclusion. (ii) Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion. (iii) Each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patient’s death, regardless of the type(s) of restraint used on the patient during this time.”Reasonable to assume” in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing or asphyxiation.... (3) The staff must document in the patient’s medical record the date and time the death was: (i) Reported to CMS for deaths described in paragraph (g)(1) of this section; or .... This Standard is not met as evidenced by: 21229 Based on clinical record review, staff interview, and facility document review, the facility staff failed to report a death of a Patient #1 that occurred within 24 hours after the use of a physical hold, the administration of a chemical restraint, and the use of seclusion. Patient #1 was placed in a physical hold after displaying agitation and continued to be held in a physical hold in order to receive an injection of Haldol (an antipsychotic) and Ativan (an anti-anxiety medication), was then placed in seclusion and expired within 24 hours. The findings include: The “Nursing Note” dated October 7, 2023 and signed at 5:21 p.m. documented in part, “Patient became increasingly frustrated about not being able to leave the unit...began to beat on the unit’s exit door. Staff physically restrained patient by (their) arms and escorted (patient) to the observation room, PRN (As needed) medications for agitation were administered to patient 10:03( incorrect time- medication record documents administration as 1603 [4:03] p.m.). Staff were about to release patient from physical hold but (patient) shove them (sic)...pulled one staff’s hair. Physical hold was consequently maintained until patient partially calmed down. Patient was placed in seclusion...seclusion was discontinued at 1632 (4:32 p.m.)...” The “ED Provider Notes” from October 8, 2023 at 12:21 a.m., revealed, “...presents to the ED via EMS (Emergency Medical Services) from Snowden for evaluation. EMS reports that pt (patient) was last seen at (their) baseline around 2130 (9:30 p.m.). Staff at Snowden found patient at 2430 (12:30 a.m.) sitting in a chair and had urinated of (self)....staff noticed patient was pale so they checked (patient) pulse and it was ‘thready and weak’. Staff then attempted to get a BP (blood pressure) and were unable to so CPR (cardiopulmonary Resuscitation) was started at 2445 (12:45 a.m.)...” A “Nursing Note” dated October 8, 2023 at 1:21 a.m. evidenced: “Went with med tech to assist (patient) to bed...during rounds (med tech) asked (patient) if (they) would like to go to bed and (patient) responded ‘Eh’. Upon helping place (patient into bed writer noticed (patient had urinated (self)...while cleaning (patient) (patient) urinated (self) again...after washing (patient) up and placing clean clothes...noted (Patient) extremities felt a bit cool to touch. Felt for a pulse, and it was present, but faint...retrieved vital sign machine. Could not obtain BP pr HR (heart rate)...(did not respond to sternal rub...Code Blue initiated at 2345 (11:45 p.m. 10/7/23)...CPR started... AED (automated external defibrillator) placed on (patient)BS (Blood sugar) was taken and was 409. (Patient) remained in asystole (no detectable heart activity), and at no point was a shock advised...CPR continued until EMS arrived and took over...EMS transported (patient to the hospital at 0013 (12:03 a.m. 10/8/23)... time of death was called at 0035 (12:35 a.m. 10/8/23). The unit physician on duty during the medical emergency documented in their “Consult Note” on October 8, 2023 at 12:25 a.m.: “This provider was notified by nursing charge at approximately 2250 (10:50 p.m.- 10/7/23) of patient cardiac arrest...was informed by nursing staff that CPR was in progress since 2245 (10:45 p.m.)...EMS arrived at approx (approximately) 2252 (10:52 p.m.) and pt was transferred to ED at 0013 (12:03 a.m. 10/8/23).” There was no documentation in the clinical record that the death was reported to CMS (Centers for Medicare Medicaid Services). Staff Member #2 explained in an interview on October 22, 2024 at 3:10 p.m. that there was no evidence that the restraint death had been logged by the facility and reported to CMS. A document provided by the facility regarding information for the Medical Examiner (dated 10.8.23 at 7:03 a.m.) evidenced inaccuracies regarding the use of restraints within the last 24 hours for Patient #1. The document included the response “NO” to the following questions: “Was the patient restrained within 7 days of death? Did patient’s death occur within 24 hours after being removed from restraints/seclusion? Did the patient’s death occur within one week after being removed from restraints/seclusion?” This document had been reviewed and signed by a Registered Nurse and Nursing Supervisor. The surveyor discussed this information with Staff Member #2 who acknowledged the errors. The facility policy and procedure “Restraint and Seclusion Policy - Snowden at Fredericksburg” revealed in part: “...Reporting Patient Deaths- Facilities must report deaths associated with the use of seclusion or restraint...3. If a death occurs...2) within 24 hours after the patient is removed from restraint or seclusion...” The surveyor discussed with Staff Members #2, 3, 4, 5, and 6 on October 22, 2024 at approximately 11:45 a.m. and again on October 23, 2024 at approximately 12:30 p.m. the concerns regarding the failure to report a patient death within 24 hours after restraints/seclusion.”

“CONTENT OF RECORD CFR(s): 482.24(c) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. This Standard is not met as evidenced by: 21229 Based on clinical record review, staff interview and facility document review, the facility staff documented in Patient #1’s clinical record conflicting information regarding the timeline and the course of the events associated with the medical emergency Patient #1 experienced while in-patient on this psychiatric unit. The findings include: On October 8, 2023 at 12:21 a.m., the “ED Provider Notes” documented in part, “...presents to the ED via EMS (Emergency Medical Services) from Snowden for evaluation. EMS reports that pt (patient) was last seen at (their) baseline around 2130 (9:30 p.m.). Staff at Snowden found patient at 2430 (12:30 a.m.) sitting in a chair and had urinated of (self)....staff noticed patient was pale so they checked (patient) pulse and it was ‘thready and weak’. Staff then attempted to get a BP (blood pressure) and were unable to so CPR (cardiopulmonary Resuscitation) was started at 2445 (12:45 a.m.)...” A “Nursing Note” dated October 8, 2023 at 1:21 a.m. read in part, “Went with med tech to assist (patient) to bed...during rounds (med tech) asked (patient) if (they) would like to go to bed and (patient) responded ‘Eh’. Upon helping place (patient into bed writer noticed (patient had urinated (self)...while cleaning (patient) (patient) urinated (self) again...after washing (patient) up and placing clean clothes...noted (Patient) extremities felt a bit cool to touch. Felt for a pulse, and it was present, but faint...retrieved vital sign machine. Could not obtain BP pr HR (heart rate)...(did not respond to sternal rub...Code Blue initiated at 2345 (11:45 p.m. 10/7/23)...CPR started... AED (automated external defibrillator) placed on (patient)BS (Blood sugar) was taken and was 409. (Patient) remained in asystole (no detectable heart activity), and at no point was a shock advised...CPR continued until EMS arrived and took over...EMS transported (patient to the hospital at 0013 (12:03 a.m. 10/8/23)... time of death was called at 0035 (12:35 a.m. 10/8/23).” The unit physician on duty documented in their “Consult Note” dated October 8, 2023 at 12:25 a.m. the following: “This provider was notified by nursing charge at approximately 2250 (10:50 p.m.- 10/7/23) of patient cardiac arrest...was informed by nursing staff that CPR was in progress since 2245 (10:45 p.m.)...EMS arrived at approx (approximately) 2252 (10:52 p.m.) and pt was transferred to ED at 0013 (12:03 a.m. 10/8/23).” The surveyor interviewed Staff Member #2 regarding the auditing of medical records. Staff Member #2 stated on 10/22/24 at 3:10 p.m. that the chart had been reviewed due to a “Serious Incident Review and Root Cause Analysis” being done (completed October 19, 2023). The surveyor inquired about the conflicting time line and account of the event documented by the staff involved in the care during the emergency event. Staff Member #2 indicated there had not been any correction made to the documentation. The surveyor inquired if the root cause analysis conducted identified and addressed/corrected with addendum the conflicting documentation in the medical record. Staff Member #2 indicated there had been no changes and no addendums made to Patient #1 medical record. The facility policy and procedure” Medical records, Content and Management (revised 12/21)” was reviewed on 10/23/24 at 10:00 a.m. and evidenced: “...3. Each inpatient and outpatient will have a medical record maintained...This record will be: a. Accurately Documented...Content in the Medical Record: 4. The record may need to be revised beyond the 48 hour window. For example:...b. Incorrect data has been documented that could impact care...Corrections to the Medical Record: - A correction is a change in the information meant to clarify inaccuracies after the original document has been signed or rendered complete to note an error in documentation...proper correction procedures must be followed...” The surveyor discussed with Staff Members #2, 3, 4, 5, and 6 on October 22, 2024 at approximately 11:45 a.m. and again On October 23, 2024 at approximately 12:30 p.m. the concerns regarding the inaccuracies of the clinical record documentation that remained after a facility review of the clinical record and one year after the incident.”

“CONTENT OF RECORD: DISCHARGE SUMMARY CFR(s): 482.24(c)(4)(vii) [All records must document the following, as appropriate:] Discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care. This Standard is not met as evidenced by: 21229 Based on clinical record review, staff interview and facility document review, the facility staff failed to ensure Patient #1’s medical record included a discharge summary discussing the outcome of the patient’s hospitalization and disposition of the patient. The findings included: Patient #1 was discharged on October 8, 2023, due to death. On October 21, 2024, the surveyor reviewed the clinical record for Patient #1 and was unable to locate a discharge summary. With the assistance of Staff Member #2 the chart was reviewed but no documentation was found. Staff Member #2 stated they would check with (Medical records) to see if there was documentation of the discharge summary. On October 23, 2024 at 10:30 a.m. Staff Member #2 indicated no discharge summary was found. The facility policy and procedure “Medical Records, Content and Management of (Revised 12/21) was reviewed and evidenced: “...General Information...3. ...The record will be...c. Completed within 30 days after discharge...” The surveyor discussed with Staff Members #2, 3, 4, 5, and 6 on October 22, 2024 at approximately 11:45 a.m. and again On October 23, 2024 at approximately 12:30 p.m. these concerns.”

“CONTENT OF RECORD: FINAL DIAGNOSIS CFR(s): 482.24(c)(4)(viii) [All records must document the following, as appropriate:] Final diagnosis with completion of medical records within 30 days following discharge This Standard is not met as evidenced by: 21229 Based on clinical record review, staff interview and facility document review, the facility staff failed to ensure a final diagnosis within 30 days following discharge was documented for Patient #1. The findings include: Patient #1 was discharged on October 8, 2023, due to death. On October 21, 2024, the surveyor reviewed the clinical record for Patient #1 and was unable to locate a documented final diagnosis. With the assistance of Staff Member #2 the chart was reviewed but no documentation was found. Staff Member #2 stated they would check with (Medical records) to see if there was any further documentation. On October 23, 2024 at 10:30 a.m. Staff Member #2 indicated no additional documentation was found, including discharge summary which would have contained a final diagnosis. The facility policy and procedure “Medical Records, Content and Management of (Revised 12/21) was reviewed and evidenced: “...Content in the Medical Record:..The Medical Record shall include, but is not limited to: ...13. Discharge diagnosis or impression...” The surveyor discussed with Staff Members #2, 3, 4, 5, and 6 on October 22, 2024 at approximately 11:45 a.m. and again On October 23, 2024 at approximately 12:30 p.m. these concerns.”

“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 21229 Based on observation, clinical record review, staff interview and facility document review, the facility staff failed to ensure a designated hospital in-patient unit had emergency services integrated and available in the full extent, resources and staff training in order to provide appropriate emergency care for all patients. Two patients (Patient #1 and #2) inlcuded in the survey sample experienced a medical emergency and the delivery of life saving care was significantly delayed. The findings included: Patient #1 experienced a cardiac arrest and the unit did not have immediate availability of all hospital resources in order to provide emergency care. Patient #1 expired in the Emergency department. On October 8, 2023 at 12:21 a.m., it was documented in the “ED Provider Notes” the following: “...presents to the ED via EMS (Emergency Medical Services) from Snowden for evaluation. EMS reports that pt (patient) was last seen at (their) baseline around 2130 (9:30 p.m.). Staff at Snowden found patient at 2430 (12:30 a.m.) sitting in a chair and had urinated of (self)....staff noticed patient was pale so they checked (patient) pulse and it was ‘thready and weak’. Staff then attempted to get a BP (blood pressure) and were unable to so CPR (cardiopulmonary Resuscitation) was started at 2445 (12:45 a.m.)...” A “Nursing Note” dated October 8, 2023 at 1:21 a.m. evidenced: “Went with med tech to assist (patient) to bed...during rounds (med tech) asked (patient) if (they) would like to go to bed and (patient) responded ‘Eh’. Upon helping place (patient into bed writer noticed (patient had urinated (self)...while cleaning (patient) (patient) urinated (self) again...after washing (patient) up and placing clean clothes...noted (Patient) extremities felt a bit cool to touch. Felt for a pulse, and it was present, but faint...retrieved vital sign machine. Could not obtain BP pr HR (heart rate)...(did not respond to sternal rub...Code Blue initiated at 2345 (11:45 p.m. 10/7/23)...CPR started... AED (automated external defibrillator) placed on (patient)BS (Blood sugar) was taken and was 409. (Patient) remained in asystole (no detectable heart activity), and at no point was a shock advised...CPR continued until EMS arrived and took over...EMS transported (patient to the hospital at 0013 (12:03 a.m. 10/8/23)... time of death was called at 0035 (12:35 a.m. 10/8/23). A “Consult Note” dated October 8, 2023 at 12:25 a.m. evidenced: “This provider was notified by nursing charge at approximately 2250 (10:50 p.m.- 10/7/23) of patient cardiac arrest...was informed by nursing staff that CPR was in progress since 2245 (10:45 p.m.)...EMS arrived at approx (approximately) 2252 (10:52 p.m.) and pt was transferred to ED at 0013 (12:03 a.m. 10/8/23) Patient #2 experienced multiple grand-mal seizures and the unit did not have access to suction, oxygen and the patient waited approximately forty (40) minutes for transport to the emergency room. On October 27, 2023 at 1:28 p.m. it was documented in the “Nursing Note: Patient complained of feeling dizzy immediately after taking (their) medications at 13:00 (1:00 p.m.)...patient began to seize, with (their) eyes rolled back, (their) jaw clenched, (their) body stiff and lower extremities jerking for about 20 (twenty) seconds...patient continues to have intermittent seizure episodes lasting 10-20 (ten to twenty) seconds with brief post-ictal (The postictal state is the altered state of consciousness after an epileptic seizure. It usually lasts between 5 and 30 minutes, but sometimes longer in the case of larger or more severe seizures, and is characterized by drowsiness, confusion, nausea, hypertension, headache or migraine, and other disorienting symptoms. The ictal period is the seizure itself; the interictal period is the time between seizures. clevelandclinic.org accessed 11/6/24 at 10:15 a.m.)...was given Ativan (antianxiety medication often used to treat seizure activity) 2mg ( two milligrams on (patient) right dorsogluteal (right buttock) area at 13:14 (1:14 p.m.) ...stopped seizing at about 13:20... laied (sic) on floor...until...EMS arrived (no time) ...transport by EMS to ED at 13:40 ( 1:40 p.m.)...” There was a “Psychiatry Note” dated October 27, 2023 at 1:31 p.m. which evidenced, “Prior to seeing patient , (patient) began having a seizure outside the office...eyes rolling back, full body tremors, obtunded, unable to respond to verbal commands..tongue remained inside (patient) mouth...no Versed (Midazolam, also called Versed, is a medicine used to stop a seizure that has lasted too long. It ’ s also used if many seizures happen in a short period of time.drugs.com accessed 11/6/24 at 10:58 a.m.) was available and Ativan 2mg IM was given...” at 1:59 p.m., an “ED Provider Note” evidenced, “Patient arrived to the ED after experienced multiple seizures while at Snowden. There were 3 (three) witnessed seizures...admitted...discharged back to Snowden October 28, 2024...” The facility policy regarding management of emergency medical conditions was reviewed the policy on October 21, 2024 at 1:10 p.m. The policy “Transfer of Patient with Acute Medical Conditions, Guidelines for Snowden at Fredericksburg (approved 5/11, revised 8/17, reviewed 3/21) evidenced, in part: “The purpose of these guidelines is to assist the nursing staff at Snowden at Fredericksburg (SAF) in ensuring that Behavioral Health Patients receive prompt medical assessment, evaluation and intervention should an acute medical condition develop. Content: 1. The following steps are to be followed when a patient at Snowden displays any signs/symptoms of an acute medical condition, which may include, but are not limited to: a. severe chest pain b. nausea, vomiting, diaphoreses, changes in LOC (level of consciousness) or vital signs c. difficulty breathing...cyanosis, or inadequate oxygenation (decreased mental status, change in color of lips, fingernail beds) d. acute abdominal pain e. onset of vaginal bleeding while pregnant f. changes in blood sugar accompanied by symptoms of hypoglycemia/hyperglycemia g. severe headache with changes in speech and neurological status h. seizures. 2. The physician, if on-site is to be notified immediately to evaluate patient. In the event there is not a physician on the premises a. Call 911; alert front desk/security b. have on-call physician paged c. Nurse/Mental Health Technician to remain with patient at all times obtaining and recording vital signs, monitoring patient d. Call Emergency department at MWH (Mary Washington Hospital) and provide hand-off communication e. notify patients family regarding transfer, if applicable 3. Document all events completely and concisely in the medical record.” The Surveyor requested further information/policy regarding specifically how the facility handled a “Code Blue” and was provided “Code Blue/Code Pink, Snowden at Fredericksburg- MWH Mary Washington Hospital - Approved 3/20” which evidenced, in part: “To outline the process for a respiratory/cardiac arrest at Snowden (SAF). Inpatient First Response 1. The first Associate notified SAF operator to have a code blue/code pink overhead paged. The first RN (Registered Nurse) on scene directs the code. 2. The HUC (Health Unit Coordinator) or nurse calls 911...3. A third associate obtains the AED, back board, code bag, delivers them to the code site and assists with CPR. 4. All Associates available respond to the code as appropriate. 5. Non nursing Associates assist with code as needed...Code Leadership 1. The first Registered Nurse (Lead RN) responding to the code will lead the code team. 2. The Lead RN will assign associate to document in the medical record using the designated time piece. Documentation may be done electronically or on the paper form Resuscitation Record (FR-116-MWHC) for downtime. 3. When EMS personnel arrive on scene they will assume leadership of the code. 4. The Lead RN will assure documentation is completed; call the Mary Washington Hospital Emergency Department (MWH-ED) and give them a ‘Hand-off”...5. The Lead RN will ensure the patient’s chart is complete with documentation of the event as well as the transportation time is entered in to the patient’s medical record...7...Lead RN notified management...8. Lead RN conducts debrief with all associates who participated in the code. 9. A SAFE report is completed...Code Team Members 1. First person in scene-activates code calk , notes time of arrest...2. Code bag responder- obtains AED, code bag and back board...3. First RN responder (Lead RN) assumes leadership of the code...directs associate to document events...4. Recorder Associate - documents information in the medical record...Lead RN is responsible to ensure all documentation associated with the code is complete and on the permanent medical record...” The surveyor toured the Snowden Unit on October 21, 2024 at approximately 11:45 a.m. accompanied by Staff Members #2, 3, and 4. During the tour the surveyor inquired as to whether the unit was considered an in-patient unit. Staff Member # 2 and 3 acknowledged the unit status as “in-patient for treatment of mental health”. The surveyor inquired as to the location of emergency equipment and was shown a small blue bag labeled “Emergency Bag” which contained an ambu bag (Bag-valve-mask (BVM) or the Ambu bag is a self-inflating bag used to provide ventilation to the person not breathing normally. A BVM consists of a non-rebreathing valve and a face mask. The opposite end of the bag is attached to an oxygen source. The mask is manually held against the face. The bag is squeezed to provide ventilation to the patient through the nose and mouth until the intubation can be done. americanheartassociation.org accessed 11/01/24 at 6:45 a.m.) and a stethoscope. The surveyor inquired as to the oxygen source and Staff Member #2 indicated the facility did not have an oxygen source. The surveyor was also shown a “First Aid Kit” containing various bandage materials and tape, an AED (Automated External Defibrillator - AEDs are used to help those experiencing sudden cardiac arrest. It’s a sophisticated, yet easy-to-use, medical device that can analyze the heart’s rhythm and, if necessary, deliver an electrical shock, or defibrillation, to help the heart re-establish an effective rhythm. americanheart association.org) and a back board (A backboard, made of wood, plastic, or other material, is inserted under the torso of a patient that is to receive cardiopulmonary resuscitation (CPR) in order to provide a firm surface during chest compression. americanheartassociation.org accessed 11/01/24 at 7:00 a.m.). Staff Member #4 indicated the in-patient unit “does not have any oxygen source, no suction machine, does not do advanced cardiac life support, and does not administer cardiac emergency medications but calls 911 and the EMS responds. We only do CPR and use the AED and staff are trained in BLS (Basic Life Support).” On October 21, 2024 at 2:30 p.m., the surveyor again discussed the emergency protocols for the Snowden unit since the unit had been identified as an in-patient unit. Staff Member #2 indicated that in an emergency the staff would take the patient’s vital signs, and start the BLS protocol, call EMS, notify the physician and transfer the patient to the hospital ED. At 3:00 p.m., the surveyor interviewed Staff Members #12 and #13 who indicated they would complete an assessment on a patient, do the vital signs and if the patient was not breathing or did not have a heart beat they would call a code blue and call the doctor as well as 911 for the EMS. The staff members indicated they did not do any suctioning, or administer any medications during a code blue and there was no oxygen at the facility. The staff members further indicated they were trained in basic life support and the use of the AED. Staff Member #5 (Nurse Manager) stated that the EMS has a “very quick response” and that staff were trained in basic life support. The surveyor inquired as to the “quick response” for Patient #2 who waited approximately 40 (forty) minutes for EMS transport after experiencing multiple seizures. “The EMS are really close and that was unusual” according to Staff Member #2. On October 22, 2024 at 11:15 a.m., the surveyor interviewed Staff Member #16 (Medical Director Snowden unit) who indicated that if a code blue is called and the MD is available they would respond and provide support but the most experienced physician or Registered Nurse would direct the code. Staff Member #16 further indicated that basic life support would be provided, but that advanced life support was not done on the unit. At 2:40 p.m. on October 22, 2024, the surveyor interviewed Staff Member #15 who indicated they were notified after Patient #1 experienced the cardiac arrest and the patient transferred to the Emergency Department. Staff Member #15 further indicated they came in to the facility and had notified the patient family and asked them to come in. The Staff Member #15 informed the surveyor that if a patient had a medical emergency on the unit, the staff would call “911” as they did not provide advanced cardiac life support. The surveyor requested to examine the record of the “code” on October 22, 2024 at 3:10 p.m. and was informed by Staff Member #2 there was no documentation other than the nurses note. “I do not see they used the code narrator (a documentation system that allows staff to enter the record of treatment, medications and actions during a code blue). There is nothing other than what was documented in the nurses note afterward and the ED record. The surveyor inquired as to whether there were emergency medications that were available for use in an injectable form in the facility. The surveyor was given a list on October 22, 2024 at 2:55 p.m.. The list contained a variety of antipsycotic and antianxiety agents as well as Glucagon (a medication to raise the blood sugar) and Naloxone (a medication which can reverse an opioid overdose). The surveyor discussed with Staff Members #2, 3, 4, 5, and 6 on October 22, 2024 at approximately 11:45 a.m. and again On October 23, 2024 at approximately 12:30 p.m. the concerns regarding the designation of Snowden as an inpatient hospital unit and not equipped to function with advanced life support in the event of an emergency. The surveyor discussed the staff, although trained in basic life support, could not perform the functions as the other in-patient units of the hospital and did not have access to oxygen, suction, or emergency medications as well as relying on calling 911 in order to provide emergency care.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 36946 Based on staff interview and document review, it was determined the hospital failed to ensure medications were administered according to the provider’s order and patient’s plan of care in one (1) of six (6) medical records reviewed in the survey sample. Medical record #5. Specifically, hospital staff did not implement a potassium replacement protocol according to the physician order. Findings: The medical record for patient #5 contained documentation that the patient had a potassium level of 3.4 mmol/L (normal value 3.5-5.3 mmol/L) at 8:30 AM on 05/10/24 and was administered oral potassium per physician order at 10:00 AM. According to the physician order, the potassium level should be rechecked four (4) hours after potassium was given, then every 4 hours until within normal limits, then daily. The potassium level should have been rechecked at 2:00 PM on 05/10/24 but was not rechecked until 05/12/24 at 1:11 AM (over 35 hours late). The result of the potassium level drawn at 1:11 AM on 05/12/24 was 3.4 mmol/L. The patient was not repleted with oral potassium until 10:57 AM. (Over nine (9) hours later). The potassium level should have been rechecked around 2:57 PM on 05/12/24, but was not rechecked until 05/13/24 at 1:27 AM (10.5 hours late). An interview was conducted with Staff Member #3 on 06/10/24 who confirmed the potassium level should be rechecked four (4) hours after oral administration per the potassium protocol and physician order.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 36946 Based on staff interview and document review, it was determined the hospital failed to ensure blood transfusions were administered in accordance with hospital policies and procedures in two (2) of two (2) applicable records reviewed in the survey sample. Specifically, the hospital failed to obtain consent for a blood transfusion in one record (#5) and failed to appropriately monitor a patient receiving an infusion of packed red blood cells in one record (#6). Findings: Two (2) records of patients receiving blood products were reviewed on 01/08/24. The medical record for patient #5 contained documentation that the patient was ordered and received four (4) units of fresh frozen plasma on 12/12/23. The medical record contained no consent for blood products. The medical record contained no documentation that the physician explained the risk and benefits of the transfusion to the patient or to the patient’s spouse who was documented to be at the patient’s bedside at the time the blood product was ordered and administered. The facility’s policy, Blood Transfusion of Blood Products was reviewed and reads in part: Informed Consent: Consent for blood products given outside of the perioperative setting will be documented on the Consent for the Administration of Blood or Blood Products (FR-138-MWHC)...The attending or consulting physician will be responsible for discussing appropriate information regarding informed consent for blood or blood products with the patient or surrogate decision maker. The physician will discuss the risks, benefits, and alternatives for treatment with the patient (or the patient’s legally designated decision-maker)...The physician will enter the appropriate documentation in the patient’s medical record regarding discussions with the patient or surrogate about risks, benefits, and alternatives to treatment. During record review staff member’s # 4 and #6 confirmed the lack of informed consent documentation in the patient’s medical record. The medical record for patient #6 contained an order to infuse four (4) units of packed red blood cells (PRBCs) on 12/09/23. The first unit was initiated at 1:06 PM on 12/09/23 and vital signs were obtained. Vital signs were again obtained 15 minutes into the transfusion per hospital policy. Vital signs were again obtained at 2:30 PM and 2.25 PM to include blood pressure, pulse and respirations, but no temperatures were recorded. No vital signs were collected at 3:30 PM. The second unit of PRBCs started at 4:00 PM on 12/09/23. Vital signs were obtained at initiation and after 15 minutes of starting the transfusion. Vital signs were then taken at 4:45 PM but did not include a temperature. Vital signs were obtained at 5:30 PM. No vital signs were obtained after 5:30 PM to the end of the transfusion at 7:40 PM. No vital signs were collected 15 minutes after the end of the transfusion per facility policy. The third unit of PRBC was started at 9:27 PM on 12/09/23 and vital signs obtained. No further vital signs were taken until the end of the transfusion at 11:05 PM. The fourth (4th) unit of PRBCs was started at 11:17 PM on 12/09/23. Vital signs were obtained at initiation and 15 minutes into the transfusion. the infusion was completed at 1:00 AM on 12/10/23. No vital signs were taken after the 15 minute vitals. Vital signs were not again documented in the record until 4:33 AM, approximately 3.5 hours after the transfusion ended. The facility’s policy, Blood Transfusion of Blood Products was reviewed and reads in part: Assessment:...A licensed nurse (RN or LPN) will obtain a baseline temperature, pulse respirations (TPR) and blood pressure (BP) no longer than 30 minutes prior to obtained blood from the blood bank...An RN or LPN will check the initial set of vital signs (TPR and BP) no more than 30 minutes prior to incitation of the transfusion. The RN or LPN will remain with the patient during the first 15 minutes, starting when the blood product actually enters the patient’s body, not including saline, if not purged or discarded. This is typically when most transfusion reactions occur. The next set of vital signs is 15 minutes after the blood product enters the patient’s body...Thereafter vital signs will be taken by licensed or unlicensed staff at a minimum of every hour after start of the transfusion and a set of vital signs 15 minutes post transfusion. Staff member #6 confirmed the absence of required monitoring and vital signs per facility policy for patient #6’s transfusions during record review on 01/08/24. An interview was conducted with an RN (staff member #8) at 1:00 PM on 01/08/24. Staff member #8 confirmed before initiating a blood transfusion, the nurse assists in obtaining informed consent from the patient. The paper form is later scanned into the patient’s chart after discharge. Vital signs should be taken prior to beginning the infusion, after 15 minutes, and every 30-60 minutes while receiving the transfusion. Another set of vitals are taken after the transfusion is complete.”