Fauquier Hospital

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 40084 Based on observation and interview, it was determined the facility failed to secure sensitive hospital infrastructure from unauthorized access. The findings include: During an observation on the afternoon of August 4, 2026, the surveyor noticed an unattended exterior door propped open, and in a separate location, an unattended exterior roller door open. Both of these locations would allow unauthorized access to sensitive hospital infrastructure. Staff Member #1 advised that the unattended exterior door and roller door were left open to allow for the cooling and proper operation of hospital building systems.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b) Life Safety from Fire This Standard is not met as evidenced by: 40084 Based on observation and interview, it was determined the facility failed to allow for the proper operation of a corridor door in the event of fire (propped open) and failed to maintain a self closing door for a hazardous location. The findings include: During an observation on the afternoon of August 4, 2026, the surveyor noticed a corridor door in the radiology area held open by an item wedged underneath. Staff Member #1 advised they believe contractors were performing work in the area. NFPA 101 19.3.6.3.10 During an observation on the afternoon of August 4, 2026, the surveyor noticed a self-closing door for a hazardous room labeled as “oxidizing gases stored within” that failed to close as required. During a surveyor review of the annual inspection of fire/smoke/corridor/hazardous area doors conducted by a third party vendor, the surveyor noticed multiple doors on the report that failed and required repairs. Staff Member #1 advised the facility is preparing a quote to repair the items identified during the third party inspection. NFPA 101 19.3.2.1.3”

“VENTILATION, LIGHT, TEMPERATURE CONTROLS CFR(s): 482.41(c)(4) There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas. This Standard is not met as evidenced by: 40084 Based on interview and document review, it was determined the hospital’s pharmacy failed to conduct required daily monitoring of temperature and humidity to ensure the area remained in acceptable parameters for the storage and preparation of drugs. The findings include: During an interview with Staff Member #2 on the afternoon of August 4, 2026, Staff Member #2 advised the pharmacy staff are required to visualize temperature and humidity in the pharmacy daily, record the numbers, and request assistance if the proper parameters are not met. Staff Member #2 printed out an electronic report for the month of July were staff documented the required daily temperature and humidity readings as well as actions taken if necessary. A review of the daily log for the month revealed staff failed to document temperature and humidity readings for July 6, July 8, July 16 and July 24, 2026. Staff Member #3 advised the pharmacy recently experienced a staffing shortage that may have contributed to this oversight, but recent new hires have helped to alleviate that issue. A review of the facility policy titled “Copy of Preparation of Sterile Products and Monitoring of Anteroom and Cleanroom” states in part: “To ensure product potency is retained through the manufacturer’s labeled expiration date, drug storage areas within the facility will be monitored at least daily for conformity to these storage conditions:...””

“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: 42929 Based on review of medical records (MR), review of documents, and interviews with staff (EMP) it was determined the medical staff failed to follow policy for one (1) of two (2) patients’ (MR4) with pending lab results upon discharge from the emergency department. Findings: Review of facility document “Follow-Up of Culture Results and Other Irregular Findings Post Discharge, 6780-31” last revised June 2025 reads in part: “Purpose: To provide guidelines for the management of culture reports or other irregular findings once a patient has been discharged from the Emergency Department.... Policy: 1. Patients with irregular testing results or findings that have resulted after their discharge, are notified by the following process.... Procedure: 1. Disseminate other reports as follows: a. Reported in the “Call Back Reminders” in Meditech. b. A provider contacts the patient and makes recommends [sic] for follow up or medication changes as needed. c. Documentation is completed in the patients EMR [electronic medical record]. Documentation includes any recommendations or changes made to medications....” Review of the medical record for (MR4) dated January 17, 2026, revealed MR4 was diagnosed with a urinary tract infection (UTI) in the emergency department. MR4 was administered Rocephin (antibiotic) 1 gram intravenously (IV) in the emergency department and prescribed Keflex (antibiotic) 500 mg by mouth every six (6) hours for seven (7) days to take upon discharge from the emergency department. A urine culture was sent for testing with results pending after the patient’s discharge from the emergency department. Urine cultures resulted on January 19, 2026, at 1:12 PM revealed MR4’s urine tested positive for the organisms klebsiella aerogenes (bacterium) and streptococcus agalactiae group B (bacterium). The klebsiella aerogenes was resistant to four (4) antibiotics including cefazolin which is the same class of drug as Keflex, indicating the organism was also resistant to Keflex. Review of the emergency department visit note review of urine culture results by EMP13 dated January 20, 2026, at 10:07 PM revealed MR4 was tested positive for a urinary tract infection, was treated with Rocephin in the emergency department, and was sent home with Keflex. “No changes indicated.” Review of the emergency department visit note by EMP16 dated January 27, 2026, at 1:58 PM revealed EMP16 received a call from MR4 indicating that MR4 was “feeling poorly” and continued to have urinary tract infection symptoms. EMP16 reviewed MR4’s culture results and noted that the patient was prescribed Keflex and was resistant to cefazolin. EMP16 notified MR4 that “... the bacteria causing the infection may be resistant to the antibiotic given ...” EMP16 transmitted a new prescription for the patient. Review of the medical record revealed on January 27, 2026, at 1:55 PM, a prescription for Ciprofloxacin (Cipro) (antibiotic) 500 mg tablet by mouth every twelve (12) hours for seven (7) days was sent to MR4’s pharmacy. Interview on July 14, 2026, around 11:30 AM, EMP12 indicated that the bacteria in MR4’s urine was resistant to Keflex and the Keflex would not be an appropriate treatment for the patient’s UTI. EMP12 indicated that the one (1) dose of Rocephin 1 gram IV given in the emergency department was not enough to treat the patient’s UTI and the patient should have been called and been prescribed a different antibiotic when the urine culture results were reviewed by the provider. Interview on July 14, 2026, at 1:15 PM, EMP6 indicated that one (1) dose of Rocephin 1 gram IV in the emergency department is not recommended to treat a patient’s UTI. The patient would typically require five (5) days of treatment with Rocephin, which is why the patient is prescribed an oral medication to take at home upon discharge from the emergency department. EMP6 confirmed that Keflex would not treat MR4’s UTI since the culture results indicated that the organism in the MR4’s urine was resistant to cefazolin. EMP6 indicated that when MR4’s urine culture results were reviewed, MR4 should have been contacted and asked if MR4 was having any symptoms, and MR4 should have been prescribed a different antibiotic to treat the UTI.”