Medical College of Virginia Hospitals

“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 to include restraint use as per facility policy for one (1) of two (2) restrained patients’ medical records reviewed, MR18. Findings: Review of facility document “Restraint and Seclusion” effective June 10, 2025, reads in part: “... Policy ... E. Restraints and seclusion are only used in accordance with written modification to the patient’s plan of care.... 6. Documentation ... 6.2. Document the use of restraints in the medical record and include the following information: ... 8. Revisions to the plan of care or treatment plan, including notification of family where applicable....” Review of facility document “Patient Care from Admission to Discharge” effective June 22, 2023, reads in part: “... Policy ... H.... H.1 The patient’s plan of care is addressed by primary inpatient nurse daily. H.2 Documentation of interventions are related to individualized needs of the patients....” Review of the medical record for MR18 revealed an order for non-violent soft right and left wrist restraints on April 16, 2026, starting at 8:08 PM and canceled on April 17, 2026, at 11:15 AM. The restraint flow sheet documentation revealed the patient was placed in restraints on April 16, 2026, at 8:09 PM and discontinued on April 17, 2026, at 4:00 PM. There were no other nursing or provider notes documenting updates to the patient’s plan of care for the use of restraints in the medical record. Interview on May 11, 2026, in the afternoon, EMP22 confirmed there was no other documentation updating the care plan with the use of restraints for MR18.”

“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: 42929 Based on review of medical records (MR), review of documents, and interviews with staff (EMP) it was determined the facility staff: failed to obtain a renewed order for violent restraints for two (2) of two (2) restrained adult patients’ records reviewed, MR17 and MR18; and failed to use the type of restraint ordered by the physician for one (1) of two (2) restrained patients’ records reviewed, MR17. Findings: Review of facility document “Restraint and Seclusion” effective June 10, 2025, reads in part: “... Policy ... O. Listed below are restraints least to most restrictive.... 9. Soft Extremity Restraints; 10. Neoprene Extremity Restraints (Twice-as-Tuff Cuff) [Facility] Note: Neoprene restraints are primarily used in the Emergency Department and Inpatient Psychiatry.... Procedure 1. Orders for Restraints 1.1. A provider responsible for the patient’s care orders the use of restraint, which includes clinical justification.... 2. Duration of orders 2.1. Violent or self-destructive (behavioral) restraint orders expire within the following limits: 4 hours for adults 18 years of age or older.... 6. Documentation ... 6.2 Document the use of restraints in the medical record and include the following information: ... 7. Intervals for monitoring ... 6.3. Document the discontinuation, done by a trained RN, including: Discontinuation on the restraint flow sheet; Cancel/Discontinue of the order per policy ...” MR17 Review of the restraint documentation for MR17 revealed an order for violent soft right and left wrist and ankle restraints dated May 5, 2026, starting at 11:15 AM and canceled at 3:15 PM. The restraint flow sheet documentation revealed MR17 was placed in violent Neoprene right and left wrist and ankle restraints on May 5, 2026, at 11:45 AM. There was no documentation that the restraint was discontinued as per facility policy. The restraint monitoring was last documented on May 5, 2026 at 6:15 PM with the documentation under Physical Comfort as “Restraint loosened”, although the four (4) hour physician’s order for the violent restraint ended on May 5, 2026, at 3:15 PM. There was no evidence of a renewed order for restraint from May 5, 2026, at 3:16 PM through 6:15 PM when the patient was documented as monitored in violent restraints. The documentation revealed the patient was placed in Neoprene restraints when the order indicated Soft restraints. MR18 Review of the restraint documentation for MR18 revealed an order for non-violent soft right and left wrist restraints dated April 16, 2026, starting at 8:08 PM and canceled on April 17, 2026, at 11:15 AM. The restraint flow sheet documentation revealed the patient was placed in restraints on April 16, 2026, at 8:09 PM and discontinued on April 17, 2026, at 4:00 PM. There was no evidence of a renewed order for restraint for April 17, 2026, at 11:16 AM through 4:00 PM when the patient was documented as monitored in non-violent restraints. Interview on May 11, 2026, in the afternoon, EMP22 indicated that there should be an order for restraints any time a patient is in restraints. EMP22 confirmed there were no other orders for restraints for those dates in the medical records for MR17, and MR18.”

“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 monitor patients in restraints for two (2) of two (2) patients’ medical records reviewed in restraints, MR17 and MR18. Findings: Review of facility document “Restraint and Seclusion” effective June 10, 2025, reads in part: “... 5. Monitoring and Care 5.1. Monitoring is performed according to the following standards by a team member who has completed the required restraint training and competency. This includes: 5.1.1. Behavioral restraints: At least every 15 minutes, monitoring and care is documented in the patient’s record by a trained RN.... 5.1.2. Non-behavioral restraints: Observe patients frequently. Document monitoring and care in the patient’s record by a trained RN at least every two (2) hours. 5.2. Care is provided based on the assessed needs of the patient and includes: Offering liquids and nutrition; Comfort measures; Toileting; Temporary release that occurs for the purpose of caring for a patients needs (e.g. toileting, feeding, range of motion). This is not considered a “trial release”.... 6. Documentation 6.1. Follow documentation guidance in the electronic medical record.... 6.2. Document the use of restraints in the medical record and include the following information: 4. Condition or symptom(s) that warranted the use of the restraint; 5. Patient’s response to the intervention(s) used, including the rationale for continued use of the restraints; 6. Individual assessments and reassessments; 7. Intervals for monitoring; ... Patient’s behavior and team member concerns regarding safety risks to the patient, team member, and others that necessitated the use of restraint; ...” Review of the restraint flow sheet for MR17 revealed restraint monitoring in violent Neoprene left and right wrist and ankle restraints on May 5, 2026, from 11:45 AM through 6:15 PM. There was no documentation of fifteen (15) minute monitoring (for violent restraints) at 3:30 PM and 3:45 PM as per facility policy. The nurse documented on the monitoring flow sheet for “Fluids and Food/Meal” that the patient was NPO (nothing by mouth) for the entire time the patient was documented in restraints on May 5, 2026, from 11:45 AM through 6:15 PM. There was no documentation of a NPO order for MR17. Review of the restraint flow sheet for MR18 revealed restraint monitoring in non-violent soft left and right wrist restraints on April 16, 2026, from 8:09 PM through April 17, 2026, at 4:00 PM. There was no documentation of two (2) hour monitoring (for non-violent restraints) at 6:00 AM, 10:00 AM, and 2:00 PM. Review of the restraint flow sheet revealed no documentation of care provided based on the assessed needs of the patient to include “Offering liquids and nutrition; Comfort measures; Toileting; Temporary release that occurs for the purpose of caring for a patients needs (e.g. toileting, feeding, range of motion)” as per facility policy. The flow sheet revealed the documentation “Restraint applied safely and physiological needs met.” The standard wording “physiological needs met” does not specify the “Care” completed or offered at each two (2) hour monitoring of the patient in restraints. Interview on May 11, 2026, at 4:30 PM, EMP13 indicated that there is a drop down list in the electronic medical record where the nurse indicates “continued restraints safely in place and physiological needs met ... Restraint Care is individualized to the patient a may include providing: nutritional needs; range of motion exercises, elimination needs, mental status, neurological evaluation, comfort measures.” EMP13 indicated that this standard wording covers the documentation required for care provided based on the assessed needs of the patient.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(v) [there must be documentation in the patient’s medical record of the following:] The patient’s response to the intervention(s) used, including the rationale for continued use of the intervention. 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 the patient’s response to the intervention used, including the rationale for continued use of the intervention for one (1) of two (2) patients’ medical records reviewed in restraints, MR18. Findings: Review of facility document “Restraint and Seclusion” effective June 10, 2025, reads in part: “... 3. Assessment and Removal 3.1. All restraints: The need for restraints is frequently evaluated and restraints are discontinued at the earliest possible time based on a reassessment of the patient’s condition. A trained RN discontinues restraints when the criteria for release are met.... 5. Monitoring and Care 5.1. Monitoring is performed according to the following standards by a team member who has completed the required restraint training and competency. This includes: 5.1.1. Behavioral restraints: At least every 15 minutes, monitoring and care is documented in the patient’s record by a trained RN.... 5.1.2. Non-behavioral restraints: Observe patients frequently. Document monitoring and care in the patient’s record by a trained RN at least every two (2) hours.... 6. Documentation 6.1. Follow documentation guidance in the electronic medical record.... 6.2. Document the use of restraints in the medical record and include the following information: 4. Condition or symptom(s) that warranted the use of the restraint; 5. Patient’s response to the intervention(s) used, including the rationale for continued use of the restraints; 6. Individual assessments and reassessments; 7. Intervals for monitoring; ...” Review of the medical record for MR18 revealed an order for non-violent soft right and left wrist restraints dated April 16, 2026, starting at 8:08 PM and canceled on April 17, 2026, at 11:15 AM. The restraint flow sheet documentation revealed the patient was placed in restraints on April 16, 2026, at 8:09 PM and discontinued on April 17, 2026, at 4:00 PM. There was no other restraint related documentation in the medical record to include progress notes or a plan of care. Review of the restraint flow sheet revealed no documentation of the patient’s response to the intervention(s) used, including the rationale for continued use of the restraints. Interview on May 11, 2026, around 4:30 PM, EMP13 indicated that documentation of the clinical justification or behavior that warranted the use of the restraint for example “Staff unable to prevent unsafe activity” that was documented as the clinical justification on the flow sheet in MR18’s medical record, was also the patient’s response to the intervention used.”

“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 (EMP) interview, observation, and document review, it was determined nursing staff failed to administer intravenous (IV) medications according to hospital policies and procedures in one (1) of one (1) medication administration observation. MR11 (medical record). Findings: The facility’s policy, “Hand Hygiene,” effective November 7, 2023, was reviewed and reads in part, “... Hand Hygiene Indications... Before performing invasive procedures; Before medication preparation; Before donning gloves and after removing gloves; Before and after touching inanimate objects likely to be contaminated with pathogenic microorganisms, such as urine-measuring devices and secretion collection apparatus; this includes the catheter itself, tubing, and urine collection device; After touching blood, body fluids, secretions, excretions, and potentially contaminated items; After contact with the chair-side computer and before contact with the patient, regardless of whether contact with the computer occurred through gloved or ungloved hands...” The surveyor observed EMP19 administer Human Albumin 5% - 7 grams IV to MR11 via right arm single lumen PICC (peripherally inserted ventral catheter) at 11:45 AM on May 12, 2026. EMP19 (a Registered Nurse) was observed at the computer with gloved hands typing on the keyboard and using the mouse to review the medication order in the EMR (electronic medical record). EMP19 then hung the albumin from the IV pole and manipulated the IV tubing. The nurse went back to the computer, used the computer mouse again, and proceeded to handle the patient’s PICC line without performing hand hygiene or changing gloves. The nurse then picked up the phone to place a phone call with gloved hands, kept phone to their ear, and ran gloved fingers through their hair. Without performing hand hygiene or changing gloves, the nurse removed the disinfecting cap from the PICC line, scrubbed the PICC line hub with a disinfectant wipe and connected the IV tubing to the PICC line. After starting the infusion, the nurse went back to using the computer keyboard/mouse without performing hand hygiene or removing gloves. On May 12, 2026, after observations EMP16 confirmed hand hygiene should be performed prior to administering medications though a PICC line and after changing gloves. Gloves should be changed and hand hygiene performed after touching potentially contaminated items and before contact with the patient.”

“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: 42929 Based on observations, review of documents, and interviews with staff (EMP) it was determined the facility staff failed to perform hand hygiene as per facility policy for one (1) of one (1) blood product administration observed, MR15. Findings: Review of facility document “Blood Products Transfusion” effective February 19, 2025, reads in part: “... 4. Handling. 4.1. Perform hand hygiene and wear personal protective equipment (PPE) when handling blood products. Refer to policies Standard and Transmission Based Precautions and Hand Hygiene ...” Review of facility document “Standard and Transmission Based Precautions” effective October 14, 2024, reads in part: “... Procedure. 1. Standard Precautions. 1.1. Perform hand hygiene per CDC guidelines. Before: ... Donning gloves; Any aseptic task/procedure such as touching a central line or catheter tubing or inserting a device; Patient contact. After: ... Removing PPE (gloves, gown, mask, and/or goggles) ... 1.2 Use Gloves. 1.2.1. Wear clean, non-sterile gloves when touching, or there is the potential of touching: mucous membranes, non-intact skin, blood, body fluids, secretions, excretions, and surfaces contaminated with blood and/or body fluids. 1.2.2. Perform hand hygiene before and after glove use. 1.2.3. Change gloves between tasks and procedures on the same patient after contact with potentially infectious material. 1.2.4. Remove gloves promptly after use, and before touching uncontaminated items and environmental surfaces or another patient....” Review of facility document “Hand Hygiene” effective November 6, 2023, reads in part: “... Hand Hygiene: General term applied to hand washing, antiseptic hand wash, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis.... Procedure. 1. Hand Hygiene Indications ... Before donning gloves and after removing gloves ... After touching blood, body fluids, secretions, excretions, and potentially contaminated items. After contact with the chair-side computer and before contact with the patient, regardless of whether contact with the computer occurred through gloved or ungloved hands.... 5. Gloves. 5.1. Wear gloves when: 1. There is reasonably anticipated contact with: Blood or body fluids ... 5.5 Change gloves: ... When going form a contaminated or dirty area or task to a clean area or task; Each time after performing access site care, vascular access cannulation, administration of parenteral medications or to perform invasive procedures ...” Observation on May 11, 2026, at 1:47 PM, EMP20 obtained MR15’s axillary temperature with the thermometer attached to the wall with ungloved hands and pressed the button on the wall unit to run the blood pressure cuff. After obtaining the patient’s temperature, EMP20 removed the probe cover from the thermometer, placed the thermometer back in the wall holder, then placed the used thermometer cover on the desk of the computer station. EMP20 used the keyboard to input information into the computer. EMP20 then held the bag of platelets with ungloved hands. EMP20 and EMP21 performed patient and blood product verification. EMP20 scanned the patient’s wrist band and then proceeded to input the patient’s vital signs into the computer with out performing hand hygiene between tasks. EMP20 did not perform hand hygiene or don gloves, proceeded to access the patients central venous catheter (CVC) per policy and attach the platelet tubing to the CVC to start the infusion. At 1:54 PM, EMP20 removed gloves and did not perform hand hygiene. EMP20 indicated that hand hygiene is done when EMP20 walks into the room and leaves the room. EMP20 was sitting next to a sink and indicated that EMP20 were going to do hand hygiene at one point during the procedure, but the surveyor was standing in the way of the wall mounted hand sanitizer dispenser. Interview on May 11, 2026, around 2:00 PM after discussing observation above, EMP2 indicated that the nurse should perform hand hygiene upon entering and leaving the patient’s room. Interview on May 11, 2026, in the afternoon, the surveyor reviewed the facility’s hand hygiene policy and discussed with EMP20 that the facility’s hand hygiene policy indicates that staff should perform hand hygiene before donning gloves and after removing gloves.”

“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: 49355 Based on review of medical records, facility document review and interviews with facility staff (EMP), it was determined the facility failed to file Centers for Medicare and Medicaid (CMS) Form 10455 within the regulatory time, as required by 42 CFR §482.13(g), patient (MR)5. Findings: Review of facility document, “Restraint and Seclusion,” revision 1.1, effective date June 10, 2025, reads in part: ...”8. Required reporting 8.1 Patient Death ...8.1.3. Risk Management reports any deaths to the Centers for Medicare and Medicaid Services (CMS) as required by law ....” Review of the medical record on March 24, 2026, revealed MR5 died while in a Posey bed at 9:54 PM on February 11, 2026. CMS Form 10455 was submitted at 8:57 AM on February 13, 2026. Interview at 9:26 AM on March 24, 2026, EMP1 indicated the facility’s Risk Management department was notified of MR5’s death on the morning of February 12, 2026. Risk Management, believing they had until close of business on February 13, 2026, filed CMS Form 10455 at 8:57 AM on February 13, 2026. EMP1 indicated the misunderstanding occurred because “knowledge of the patient’s death” to the Risk team occurred on February 12, therefore they believed they had another day to file the notification to CMS. They did not realize “knowledge” was facility awareness of the death, i.e. the unit the patient passed on.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 36946 Based on staff (EMP) interview, document review, and review of medical records (MR), it was determined hospital staff failed to respect the patient’s right to refuse treatment by not implementing orders related to the patient’s end-of-life wishes in one (1) of five (5) MRs reviewed in the survey sample. MR11. Findings: The facility’s policy, “Code Status Orders (DDNR/DNAR)” effective February 21, 2022, was reviewed as reads in part, “...Definitions...Cardiopulmonary Resuscitation (CPR) 1. Cardiac Compression 2. Artificial ventilation 3. Defibrillation 4. Endotracheal intubation/other advanced airway management...5. Administration of related procedures or cardiac resuscitation medications as prescribed by the patient’s provider or medical protocols...DNAR (DNAR - Do not attempt resuscitation)/Otherwise full interventions - NO CPR If patient has a pulse and is breathing, use intubation, mechanical ventilation, cardioversion, transfer to ICU as indicated...A patient’s documented wishes regarding resuscitation are honored over all objections, including the objections of the patient’s representative and/or family. Reconsideration of a code status order - The attending physician, surgeon, proceduralist, anesthesiologist, or designee has a code status reconsideration conversation with the patient. Document the outcome of this discussion...” The facility’s policy, “Code Management” last revised September 15, 2025, was reviewed and reads in part, “...Always be aware of the patient’s code status, as defined by the practitioner ’ s orders, the patient’s advanced directives, and the family’s wishes. Ensure that the practitioner who has ordered a no code or do not resuscitate status for the patient has written and signed the order...” MR11 was admitted to the hospital on August 25, 2025, with heart failure. The patient’s medical record contained documentation that on October 30, 2025, the patient’s code status was changed from Full Interventions to “DNAR/Otherwise full interventions - okay for shocks and code dose medications. Ok for intubation. Per family meeting on October 30, 2025.” The written DNAR on October 30, 2025 was the last documented code update status in the patient record and the order that was in place on December 03, 2025. There was no documentation in the medical record that further discussions were had related to code status and/or that the patient had changed their mind regarding receiving chest compressions. On December 03, 2025, Registered Nurse (EMP25) documented the following, “Provider at bedside for reinsertion of femoral triple lumen. Upon successful insertion of line patient became obtunded, chest compressions were started per provider’s request after patient was found with no pulse. Chest compressions were immediately stopped after code status was confirmed and clarified...” On December 03, 2025, a physician documented the following, “...Patient was noted to be obtunded and unresponsive, so code blue was called for assistance. Despite DNAR in chart, there had allegedly been several comments made by the patient re: what s/he would truly accept from an emergent standpoint. As such, full ACLS, including compressions were performed while I spoke with [name of physician]. S/he confirmed that MR11 would not want CPR, but would want chemical coding, intubation, and shocks...Resuscitation efforts, compressions were stopped after 2-3 rounds after confirming wishes...” MR11 died at 8:52 AM on December 03, 2025. Interviews were conducted with EMP25 and EMP31 at 10:30 AM on February 11, 2026. EMP25 indicated they were on orientation and assigned to care for MR11 with their preceptor (EMP31) on December 03, 2025. EMP25 indicated they were aware of MR11’s code status of DNAR and that the patient did not want chest compressions. EMP25 indicated that during the code, the provider directed EMP31 to perform chest compressions on MR11. EMP25 indicated they reminded the provider of the patient’s wishes for no compressions, but the provider directed staff to perform compressions while the DNAR order was clarified. EMP31 indicated that they were also aware that MR11 had an order for a DNAR and did not want chest compressions attempted. EMP31 indicated that the provider in the room directed them to perform compressions despite the order and EMP31 indicated they felt “uncomfortable” performing compressions against the patient’s documented wishes. EMP25 indicated 2-3 rounds of chest compressions were performed before the code status was clarified, and then compressions were stopped.”

“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: 49355 Based on observations, facility staff (EMP) interviews and document review, it was determined the facility failed to provide safe medication administration to patients during one (1) of two (2) observations. The findings: Facility document, “Medication Administration,” document number PH.AD.009, revision number 3.2, reads in part: ... “5. Oral Medications 5.1. Refer to Lippincott’s Nursing Procedures and Skills for oral drug administration for adults, pediatrics, and infants.” Facility document developed from Lippincott’s Nursing Procedures and Skills, VCU Health “Barcode Medication Administration Checklist,” revised September 2024, reads in part: ... “Medication Administration Process ... Review medications with the patient/family as appropriate.” During observations at 9:50 AM on February 11, 2026, EMP27 placed a medication cup containing several tablets on a tray table in front of patient (MR) 21. EMP27 did not explain the contents of the medication cup. MR21 pulled a tablet from the cup and asked EMP27 what it was. EMP27 told MR21 the name of the medication and why it was prescribed but did not explain the remaining tablets in the cup. During interviews in the morning of February 11, 2026, EMP1 and EMP28 agreed medications should be reviewed with the patient prior to being administered.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 42929 Based on review of documents, and interview with staff (EMP), it was determined that the hospital failed to adequately train staff on event reporting, and develop policies and procedures related to the investigation of allegations of abuse and neglect to include methods to protect patients from abuse during the investigation. Findings: Review of facility document “Adverse Events, Early Disclosure” effective June 26, 2023, reads in part: “... Procedure: 1. When an unanticipated outcome or untoward event is discovered, the primary focus and first priority is the protection of the patient from further harm by providing necessary medical care and reducing the likelihood of further injury. 2. Review the adverse event as soon as possible with appropriate members of the healthcare team once the patient’s needs have been met, to collect information and determine next steps....” This document revealed no evidence that reporting adverse events is only “encouraged” and “voluntary” and not required. This document revealed no evidence of policies and procedures related to: injuries of unknown origin as indicators of potential abuse or neglect; and the investigation of allegations of abuse and neglect to include methods to protect patients from abuse during the investigation. Review of facility document “Safety Event Reporting” effective June 25, 2024, reads in part: “... Event reports are used to identify significant events requiring further analysis, to assist in the development of corrective actions to resolve the root cause(s) of problems identified, and for trending analytics.... Policy. A. Potential safety concerns, including precursor events, near misses, and errors are entered into the online safety event reporting system regardless of injury/harm to the patient. B. Enter a safety event report as soon as possible, usually within the shift of occurrence and preferably within 24 hours. Prompt reporting of errors/events and near misses must occur in order to enable timely identification and resolution of system issues and promote performance improvement....” This document revealed no evidence that reporting adverse events is only “encouraged” and “voluntary” and not required. This document revealed no evidence of policies and procedures related to: injuries of unknown origin as indicators of potential abuse or neglect; and the investigation of allegations of abuse and neglect to include methods to protect patients from abuse during the investigation. Review of facility document “Abuse/Neglect/Exploitation Reporting for Children and Adults” effective December 4, 2021, revealed no evidence of policies and procedures related to: injuries of unknown origin as indicators of potential abuse or neglect; and the investigation of allegations of abuse and neglect to include methods to protect patients from abuse during the investigation. Interview on August 4, 2025, at 11:17 AM, EMP13 indicated that if a nurse received and assessed a patient with a new bruise, cut, or injury that was not documented previously, and the nurse had no knowledge of how the bruise, cut, or injury originated, the nurse would notify the clinical team. The clinical team or wound care team may try to determine the cause of the injury. It may or may not get reported in the event reporting system. Interview on August 5, 2025, at approximately 10:01 AM, during review of the facility’s event reporting log from January 1, 2025, through August 5, 2025, EMP33 indicated that staff reporting of events is “encouraged” and “voluntary” and not required. EMP33 indicated that only reported events are reviewed and investigated. Interview on August 5, 2025, at approximately 11:36 AM, EMP36 indicated that if a nurse identifies an injury or bruise of unexplained origin, the nurse will document it in an assessment, ensure the provider is aware, and consult wound care or others as appropriate. EMP36 indicated that an injury of unknown origin would only be entered into the facility’s event reporting system and investigated if the cause was observed by staff. Interview on August 5, 2025, at approximately 11:45 AM, EMP3 also indicated that an injury of unknown origin would only be entered into the facility’s event reporting system and investigated if the cause was observed by staff. At 12:41 PM, EMP33 indicated that the facility would consider ruling out suspicion of abuse after a reported event was reviewed, and the facility’s investigation identified that an individual did not follow the standard of practice. If the individual was a provider, they would be evaluated by the peer review process. If the individual was a nurse or other employee, it would be handled by the leadership for that person and human resources, utilizing the performance management process. Interview on August 5, 2025, at 12:41 PM, EMP3 indicated that if EMP3 observed an employee abusing a patient, EMP3 would notify the supervisor and human resources, and possibly the chief medical officer. Interview at 1:25 PM, EMP33 provided the surveyor with the facility documents related to the peer review process for providers and the “Performance Management Decision Tree” that would be followed for employees related to suspicion or allegations of abuse. These documents revealed no evidence of policies and procedures related to the investigation of allegations of abuse and neglect to include methods to protect patients from abuse during the investigation.”

“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: 49355 Based on medical record review, interviews and document review, it was determined the facility failed to properly monitor patients (MR) receiving blood products in two (2) out of three (3) medical records reviewed, MR11 and MR13. The findings: In the facility document, “Blood Products Transfusion,” number PA.BB.006, effective date February 19, 2025, revision number 6.0, reads, in part: ...”8. Patient Monitoring 8.1. Monitor patient by obtaining vital signs to include temperature, blood pressure, heart rate, and respiration. At the end of the transfusion, complete a post transfusion assessment and document patient’s response to the transfusion. 8.2. Document vitals at the following times: (Variations in frequency may be dependent on the patient’s clinical status and location such as procedural areas, OR, ED, and ICUs.) 8.2.1. All transfusions to include RBCs, Platelets, Plasma, and Cryoprecipitate at: * Start of the transfusion * Fifteen (15) minutes * End of transfusion” On April 8, 2025, a review of the medical record for MR11 reveals the patient received red blood cells (RBC) on April 6, 2025. The infusion was started at 11:50 P.M. The first monitoring recorded was at 00:15 A.M. on April 7, 2025, twenty-five (25) minutes after initiation of the transfusion. A review of the medical record of MR13 indicated that the infusion for RBC ended at 9:15 P.M. on April 4, 2025. The last documented monitoring was at 8:00 P.M., one hour fifteen minutes (1:15) before the transfusion ended. EMP2 and EMP3 verified and agreed that the documentation in both medical records did not reflect the facility’s transfusion policy.”

“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: 42929 Based on medical record review, interview, and document review, it was determined that the facility: failed to document pain reassessment scores for three (3) out of four (4) patient medical records reviewed (Patient #2, #3 and #4), failed to provide medications or other interventions once a patient’s pain assessment score was determined for two (2) of four (4) patient records reviewed (Patient #2, Patient #3), and; failed to provide daily hygiene and comfort measures for one (1) of four (4) patient records reviewed (Patient #2). Findings: Pain Reassessment A review of the facility’s policy entitled, “Pain Management,” effective date January 27, 2022, revision 1.0, states in part: ...” Policy ... J. Team members assess, reassess and respond to the patient’s pain through the following: J.1. Evaluation and documentation of response(s) to pain intervention(s) J.2. Progress toward pain management goals .... ... 4. Post-intervention assessment 4.1 Criteria 4.1.1 Following each intervention, evaluate the response based on the patient’s ability to perform ADL’s [activities of daily living]/achieve functional goals, and adequate comfort. 4.1.2. Select appropriate pain assessment scale for age, condition, and ability to understand. ... 4.2 When to assess ... Location ... Inpatient .... Post Intervention Assessment 1. Perform the post intervention assessment based on anticipated time of response of the medication or the intervention.” The facility’s policy entitled, “Medication Administration,” document number PH.AD.009, effective date July 30, 2021, revision 3.2, states in part: ... “Definitions Term: ... Administration Time - PRN Designation for medication orders that are to be administered on an as needed basis according to the medication order’s indication, patient’s response, and/or timing of clinical situation.” The document provided by the facility and referenced in policy, titled “Pain assessment,” from Lippincott Nursing Procedures and Skills reads, in part: ... “Reassessment of pain at designated intervals according to the type of pain intervention (for example, oral, IV [intravenous], or transdermal route) is necessary to evaluate progress toward pain management goals.” The medical record for Patient #2 revealed that the patient’s pain was not documented as reassessed within the anticipated time of response after pain medications were administered for fifty-four (54) out of eighty-five (85) pain medication administrations, as follows: (ER = Extended Release; IR = Immediate Release; PO = orally; IV = intravenously) September 12, 2024 Hydromorphone 1 mg IV, administered at 12:54 AM, Pain reassessed over three (3) hours later at 4:00 AM. Hydromorphone 1 mg IV, administered at 5:22 PM, Pain reassessed over fourteen (14) hours later at 8:06 AM. Oxycodone IR 15 mg PO, administered at 6:06 PM, Pain reassessed over fourteen (14) hours later at 8:06 AM. Oxycodone IR 15 mg PO, administered at 10:08 PM, Pain reassessed ten (10) hours later at 8:06 AM. September 13, 2024 Hydromorphone 1 mg IV, administered at 1:28 AM, Pain reassessed over six (6) hours later at 8:06 AM. Oxycodone IR 15 mg PO, administered at 2:14 AM, Pain reassessed over five (5) hours later at 8:06 AM. Oxycodone ER 10 mg PO, administered at 11:37 AM, Pain reassessed over eight (8) hours later at 7:43 PM. Oxycodone IR 15 mg PO, administered at 3:47 PM, Pain reassessed over four (4) hours later at 7:43 PM. Oxycodone ER 10 mg PO, administered at 9:26 PM, Pain reassessed over two (2) hours later at 11:40 PM. September 14, 2024 Oxycodone IR 15 mg PO, administered at 1:24 PM, Pain reassessed over three (3) hours later at 4:23 PM. Oxycodone ER 10 mg PO and Oxycodone IR 15 mg PO, administered at 8:43 PM, Pain reassessed over three (3) hours later at 12:00 AM. September 15, 2024 Oxycodone IR 15 mg PO, administered at 4:40 AM, Pain reassessed over four (4) hours later at 9:00 AM. Hydromorphone 0.4 mg IV, administered at 6:04 AM, Pain reassessed three (3) hours later at 9:00 AM. Hydromorphone PCA 0.6 mg, administered at 12:37 PM, Pain reassessed over two (2) hours later at 2:36 PM. Hydromorphone PCA 0.6 mg, administered at 8:25 PM, Pain reassessed over seven (7) hours later at 4:00 AM. Oxycodone ER 10 mg PO and Hydromorphone PCA 0.6 mg, administered at 9:25 PM, Pain reassessed over six (6) hours later at 4:00 AM. September 16, 2024 Hydromorphone PCA 0.6 mg, administered at 12:45 AM, Pain reassessed over three (3) hours later at 4:00 AM. Hydromorphone PCA 0.6 mg, administered at 8:00 AM, Pain reassessed four (4) hours later at 12:00 PM. Oxycodone ER 10 mg PO, administered at 9:30 AM, Pain reassessed over two (2) hours later at 12:00 PM. Oxycodone IR 10 mg PO, administered at 5:36 PM, Pain reassessed five (5) hours later at 10:32 PM. Oxycodone ER 10 mg PO, administered at 10:32 PM, Pain reassessed over two (2) hours later at 1:00 AM. September 17, 2024 Hydromorphone 1 mg IV, administered at 9:03 AM, Pain reassessed over three (3) hours later at 12:32 PM. Oxycodone ER 10 mg PO, administered at 9:48 AM, Pain reassessed over two (2) hours later at 12:31 PM. Oxycodone IR 10 mg PO, administered at 3:02 PM, Pain reassessed over five (5) hours later at 8:25 PM. Oxycodone IR 10 mg PO and Oxycodone ER 10 mg PO, administered at 8:26 PM, Pain reassessed over twelve (12) hours later at 8:36 AM. Oxycodone IR 10 mg PO, administered at 11:58 PM, Pain reassessed over eight (8) hours later at 8:36 AM. September 18, 2024 Oxycodone IR 10 mg PO, administered at 6:25 AM, Pain reassessed over two (2) hours later at 8:36 AM. Oxycodone ER 10 mg PO, administered at 8:39 AM, Pain reassessed over three (3) hours later at 12:14 PM. Hydromorphone 1 mg IV, administered at 12:24 PM, Pain reassessed over four (4) hours later at 4:47 PM. Oxycodone IR 10 mg PO, administered at 6:56 PM, Pain reassessed over two (2) hours later at 9:27 PM. Oxycodone IR 10 mg PO, administered at 11:23 PM, Pain reassessed over six (6) hours later at 6:06 AM . September 19, 2024 Oxycodone IR 10 mg PO, administered at 3:53 AM, Pain reassessed over two (2) hours later at 6:06 AM. Hydromorphone 4 mg PO, administered at 4:34 PM, Pain reassessed over three (3) hours later at 8:29 PM. Oxycodone ER 10 mg PO, administered at 9:33 PM, Pain reassessed over five (5) hours later at 3:21 AM. Hydromorphone 2 mg PO, administered at 11:03 PM, Pain reassessed over four (4) hours later at 3:21 AM. September 20, 2024 Hydromorphone 2 mg PO and Oxycodone ER 10 mg PO, administered at 8:49 AM, Pain reassessed over four (4) hours later at 1:17 PM. Oxycodone ER 10 mg PO, administered at 8:54 PM, Pain reassessed over four (4) hours later at 1:00 AM. September 21, 2024 Hydromorphone 2 mg PO, administered at 1:40 AM, Pain reassessed over two (2) hours later at 4:30 AM. Hydromorphone 2 mg PO, administered at 5:35 AM, Pain reassessed over two (2) hours later at 8:00 AM. Oxycodone ER 10 mg PO, administered at 9:11 AM, Pain reassessed six (6) hours later at 3:10 PM. Hydromorphone 2 mg PO, administered at 12:39 PM, Pain reassessed over two (2) hours later at 3:10 PM. Oxycodone ER 10 mg PO, administered at 9:13 PM, Pain reassessed over three (3) hours later at 12:35 AM. September 22, 2024 Hydromorphone 2 mg PO, administered at 12:28 AM, Pain reassessed over three (3) hours later at 3:50 PM. Hydromorphone 2 mg PO, administered at 6:14 AM, Pain reassessed over three (3) hours later at 9:15 AM. Oxycodone ER 10 mg PO, administered at 9:17 AM, Pain reassessed over three (3) hours later at 12:20 PM. Hydromorphone 2 mg PO, administered at 5:44 PM, Pain reassessed over four (4) hours later at 10:07 PM. Hydromorphone 2 mg PO, administered at 10:02 PM, Pain reassessed over three (3) hours later at 1:01 AM. September 23, 2024 Hydromorphone 2 mg PO, administered at 4:02 AM, Pain reassessed over four (4) hours later at 8:02 AM. Oxycodone ER 10 mg PO and Hydromorphone 2 mg PO, administered at 8:40 AM, Pain reassessed over four (4) hours later at 1:00 PM. Oxycodone ER 10 mg PO, administered at 9:53 PM, Pain reassessed over ten (10) hours later at 8:00 AM. Hydromorphone 2 mg PO, administered at 10:51 PM, Pain reassessed over nine (9) hours later at 8:00 AM. September 24, 2024 Hydromorphone 2 mg PO, administered at 2:21 AM, Pain reassessed over five (5) hours later at 8:00 AM. Hydromorphone 2 mg PO, administered at 5:03 PM, Pain reassessed over three (3) hours later at 8:45 PM. September 25, 2024 Hydromorphone 2 mg PO, administered at 1:14 AM, Pain reassessed over two (2) hours later at 3:49 AM. The medical record for Patient #3 revealed that the patient’s pain was not documented as reassessed within the anticipated time of response after pain medications were administered for eight (8) out of eleven (11) pain medication administrations, as follows: September 11, 2024 Oxycodone IR 5 mg PO, administered at 1:50 PM, Pain reassessed over ten (10) hours later at 12:00 AM. Oxycodone IR 5 mg PO, administered at 10:07 PM, Pain reassessed almost two (2) hours later at 12:00 AM. September 12, 2024 Oxycodone 10 mg PO, administered at 8:21 AM, Pain reassessed over four (4) hours later at 12:32 PM. September 13, 2024 Oxycodone 10 mg PO, administered at 12:25 AM, Pain reassessed over eight (8) hours later at 7:53 AM. Oxycodone IR 5 mg PO, administered at 12:33 PM, Pain reassessed over two (2) hours later at 2:37 PM. September 14, 2024 Oxycodone IR 5 mg PO, administered at 6:08 AM, Pain reassessed almost two (2) hours later at 8:04 AM. Oxycodone IR 5 mg PO, administered at 2:38 PM, Pain reassessed over seven (7) hours later at 9:57 PM. September 15, 2024 Oxycodone IR 5 mg PO, administered at 10:33 AM, There was no documented reassessment of pain. The medical record for Patient #4 revealed that the patient’s pain was not documented as reassessed within the anticipated time of response after pain medications were administered for four (4) out of six (6) pain medication administrations, as follows: September 10, 2024 Fentanyl 25 mcg IV, administered at 12:52 PM, Pain reassessed over two (2) hours later at 3:15 PM. Fentanyl 25 mcg IV, administered at 3:56 PM, Pain reassessed over four (4) hours later at 8:36 PM. Fentanyl 25 mcg IV, administered at 8:50 PM, Pain reassessed over five (5) hours later at 2:16 AM. September 11, 2024 Fentanyl 25 mcg IV, administered at 2:15 AM, Pain reassessed over six (6) hours later at 8:25 AM. During an interview on November 4, 2024, at 2:16 PM, Staff Member #10 indicated that nurses should assess a patient’s pain level before any pain medication is given and then perform a post intervention assessment fifteen (15) to thirty (30) minutes after an intravenous (IV) medication is administered, or within one (1) hour after an oral medication is given, based on the time of the anticipated response to the medication. The patient’s reported pain level would indicate whether the medication intervention provided was sufficient to control the patient’s pain. All pain assessments and reassessments are expected to be documented in the patient’s flowsheet. Staff Member #10 revealed that the facility’s electronic medical record (EMR) system, prompts the nurse to perform a pain reassessment one (1) hour after any medication has been administered, but the prompt may be “skipped” by the nurse. During an interview on November 6, 2024, at 9:45 AM, Staff Member #14 indicated that the expectation is that the nurse performs reassessments of the patient’s pain after medication administration and logs that value into the flowsheet. “I would hope a nurse would go back and reassess” within at least one (1) hour but there is “nothing in writing” stating the specific time frame. Staff Member #14 indicated that a reminder appears in the EMR for a nurse to reassess pain after administration of a pain medication, but the nurse can skip or ignore the reminder. Interventions The facility’s policy titled, “Pain Management,” effective date January 27, 2022, revision 1.0, reveals: ... 3. Interventions 3.1 The nurse collaborates with the provider to obtain orders for an appropriate medication or other multimodal method (including type, route, frequency of administration and duration) based on the pain assessment and severity of pain. 3.2 The nurse collaborates with the provider to adjust pharmacologic dosing .... 3.4 Consider consultation and/or referral for patients experience persistent pain, complex pain management needs, pain management needs which exceed provider expertise, high potential for adverse effects or risk related to opioids, or who exhibit signs of substance abuse disorder or psychological distress .... 5. If pain is interfering with treatment goals, or pain interventions are ineffective, notify provider. 6. Document results of screenings, assessments, interventions, and progress towards goals in the electronic health record.” The medical record for Patient #2 revealed that the patient did not have any documented pain medication or other interventions performed after a documented pain score of seven (7) out of ten (10) or higher, indicating severe pain, in thirty-four (34) out of seventy-four (74) documented pain scores. During an interview on November 4, 2024, at 11:06 AM, Staff Member #4 indicated that there were no nurses’ notes addressing the patient’s pain, consults or referral for pain, or physician documentation related to pain management in Patient #2’s medical record. During an interview on November 4, 2024, at 1:17 PM, Staff Member #5 indicated that a patient request for additional pain medications, outside of scheduled dosages or PRN ordered dosages, should be documented in the flowsheet and the nurse should contact the provider to request additional pain medications if requested. During an interview on November 4, 2024, at 2:16 PM, and on November 6, 2024, at 9:30 AM, Staff Member #10 and Staff Member #13, respectively, indicated if a patient had received a pain medication and was still experiencing pain after the anticipated time of response, the nurse should contact the provider for other additional interventions, depending on the severity of the pain. That intervention may include additional pain medication, or another intervention, such as repositioning the patient. All interventions should be documented on the patient’s flowsheet. Daily Hygiene and Comfort Measures The facility’s document titled “Daily Adult Patient Treatment and Cleansing Algorithm,” reveals: If a patient does not have a Chorhexidine Gluconate (CHG) allergy, “use at least 6 [six] CHG for neck down CHG treatment.” Peri care [perineal care] and foley care [urinary catheter] should be performed “daily with CHG wipes and after episodes of stool incontinence. Document each task (peri care and foley care) separately when completed.” The facility’s document titled “Competency: Adult Chlorhexidine (CHG) Bath Treatment,” updated October 7, 2020, states in part that staff are expected to perform CHG baths for those patients unable to cleanse themselves. The document states that the staff member must, “demonstrate proper technique for completing a CHG treatment and verbalizes knowledge of the important role daily CHG treatments play in preventing hospital acquired infections.” The medical record for Patient #2 revealed no documentation of a bath for four (4) out of fourteen (14) days the patient was on the neurology unit, September 14, 21, 23, and 24, 2024. The medical record for Patient #2 revealed no documentation of a gown change for nine (9) out of fourteen (14) days the patient was on the neurology unit, September 14, 15, 17, 19, 21, 22, 23, 24, and 25, 2024. The medical record for Patient #2 revealed no bed linen change for ten (10) out of fourteen (14) days the patient was on the neurology unit, September 14, 15, 16, 17, 20, 21, 22, 23, 24, and 25, 2024. During an interview on November 4, 2024, at 2:10 PM, Staff Member #10 indicated that patients receive CHG baths daily, although patients may receive baths more frequently if the patient is incontinent. The CHG baths should be documented in the flowsheet. Staff Member #10 indicated some patients prefer to shower, but the CHG bath is better for patients while on this unit. Staff Member #10 indicated that linens and gowns are changed when the patient is bathed and more frequently if soiled, and these changes should be documented on the flowsheet as well. During an interview on November 6, 2024, at 9:30 AM, Staff Member #13 indicated that Patient #2 was totally dependent on all hygiene care. Staff Member #13 indicated that patients should be bathed daily with CHG wipes, have all sheets and their gown changed. These should be documented on the patient’s flowsheet.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 42929 Based on interviews, medical record review, and document review, it was determined the facility staff failed to notify the patient’s representative of the patient’s discharge to a skilled nursing facility. Findings: During an interview on 03/04/2024 at 1:30 p.m., Staff Member #1 confirmed that Patient #1 had dementia, was not able to make decisions, and had a Power of Attorney (POA) designating the patient’s child and child’s spouse as the POAs. A Nursing Note from 10/16/2023 at 3:00 p.m. stated that the patient was discharged to a skilled nursing facility by transportation via stretcher with all required paperwork and documentation. There was no documentation that the patient’s POAs/representatives were notified of the patient’s discharge. A Social Worker progress note from 10/16/2023 at 12:08 p.m. contained the documentation “Communication to Patient/Family: Met with patient and they are agreeable to the transition plan.” There was no other documentation in this note that the social worker spoke with the patients POA/representative about the patient’s discharge. On 03/04/2024, Staff Member #9 confirmed that there was no other documentation in Patient #1’s medical record that any staff notified the patient’s POAs/representatives that the patient would be discharged on 10/16/2023. During an interview on 03/05/2024 at 9:35 a.m., Staff Member #15 confirmed that Staff Member #15 did not document any of the attempts to contact the patient’s POAs or that Staff Member #15 left a message for either POA about the patient’s discharge date. A review of the admission packet “A patient’s guide to inpatient services and facilities” states in part: ... You have the right to make decisions about your care ... You have the right to identify a surrogate decision maker should you become unable to make decisions related to your health care....” The above concerns were discussed at the exit conference on 03/05/2024 at 3:30 p.m.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 42929 Based on interview, medical record review, and facility document review, it was determined the facility staff failed to discontinue violent restraints at the earliest possible time for one (1) of two (2) patients with violent restraints ordered (Patient #6). Findings: The restraint record for Patient #6 from 03/02/2024 while the patient was in the emergency department contained documentation that the patient had an order for violent restraints. The restraint order started at 1:18 a.m. and expired at 5:18 a.m. The restraint order for “violent/self destructive behavior” stated “... Continue restraints, and discontinue at earliest possible time...” Additionally, the “Violent or Self-Destructive Restraints” flow sheet contained the documentation “... Clinical Justification: Imminent risk of harm to self and others... Discontinuation Criteria: Absence of behavior that required restraint ...” The “Violent or Self-Destructive Restraints” flow sheet contained the documentation of restraint from 03/02/2024 at 1:20 a.m. until 03/02/2024 at 5:05 a.m. It was documented that the patient was “asleep” every fifteen (15) minutes on the monitoring documentation from 2:05 a.m. through 4:50 a.m. There was no monitoring documented at 5:05 a.m. when the restraints were discontinued. There was no other “assessment” documentation noted on the “Violent or Self-Destructive Restraints” flow sheet. There was nothing documented for “Assess Violent Restraints: Restraint Removal from 1:35 a.m. through 5:05 a.m. During an interview on 03/05/2024 at 10:36 a.m., Staff Member #17 stated that the patient may have been left asleep in restraints for the safety of the patient since the patient was in restraints for being “suicidal”. A review of the facility’s policy titled “Restraint and Seclusion” effective date 07/28/2022 states in part: ... Procedure ... 3. Assessment and Removal: 3.1. All restraints: The need for restraints is frequently evaluated and restraints are discontinued at the earliest possible time based on a reassessment of the patient’s condition. A trained RN discontinues restraints when the criteria for release are met....”