Carilion New River Valley Medical Center

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 19883 Based on medical record review, interviews, and document reviews, the facility failed to ensure the medical record for one (1) of four (4) patients included in the survey sample was complete, (Patient #1). The findings include: Review of the medical record of Patient #1 was performed with the assistance of Staff Member #3 on 9/8/26. Patient #1 underwent a surgical procedure on April 13, 2026. On 5/15/26, Patient #1 presented to this hospital’s ED on 5/15/26 at 11:19 PM with complaints of pain, tenderness, and bloody drainage, from the incision side. Patient #1 was evaluated and treated by the on-call surgeon (Staff Member #11) during the ED visit but review of Patient #1’s medical record revealed no evidence of Staff Member #11 documentation of their assessment and treatment of the patient. The medical record included an outpatient surgical clinic note dated 5/19/26 that summarized the surgical procedure, histopathology results, patient’s progress on one-week post-op visit, documentation of the ED visit and their post-op status at the time of this visit. The portion of the note documented the surgical consult in ED as follows, “The episode brought [Patient #1] to the emergency room last Friday, where [Patient #1] was seen by one of my partners, who noted spontaneous rupture and decompression of a serosanguineous seroma or liquefied hematoma, which accounts for the dark fluid that was expressed. At the time of [their] examination, [they] did not note any evidence of infection, and decided to treat the issue with a small fragment of ribbon gauze inserted into the opening as a wick, instructing the patient to remove it the following day, which [Patient #1] did.” Staff Member #11 reported during an interview on 9/9/26 that they were on call on 5/15/26 and were the attending surgical provider who cared for Patient #1 in the ED. Staff Member #11 explained that they inadvertently failed to document their assessment and treatment of Patient #1. Staff Member #11 stated that “it is customary and expected for there to be documentation in a patient’s clinical record anytime the patient is assessed and or treated by a provider.” The Medical Staff Bylaws, dated September 30, 2025, article 3.1 reads in part as follows: “The practitioner in attendance shall be responsible for the compilation of a complete medical record for each of his/her patients This should include identification data; complaint; relevant social history; family history; history of present illness; past medical history; physical examination; special reports (such as consultation, clinical laboratory, radiology, and other); provisional diagnosis; medical and surgical treatment; operative findings; pathology findings; and progress notes.” This hospital’s Policy titled HIM-Authorization, Authentication and Timeline for Health Record Documentation with an effective date of 11-2024, item C. reads in part as follows: “...All entries in the paper health record shall be authenticated, dated, and timed by the practitioners making the entry. Electronic health record (EHR) entries will follow standard sign-in and sign-out processes with documented time/date stamp.” And, item #3 of the policy under “policy statements” reads...”The timeline to document in the health record is within 30 days post discharge or treatment rendered by all health care practitioners.” Staff Member #2 confirmed during an interview on 9/8/26 that there was no documentation by Staff Member #11 in Patient #1’s clinical record regarding Staff Member #11’s assessment and treatment of Patient #1 on 5/15/26.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 33906 Based on interviews, observations, document review and investigation of a complaint, it was determined the hospital failed to meet the Condition of Participation 482.13 Patient Rights The hospital failed to a) a protect patient from abuse during investigation of an allegation of abuse and b) failed to conduct a thorough investigation of the allegation. Cross reference: §482.13(c)(3) - The patient has the right to be free from all forms of abuse or harassment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 33906 Based on interviews, observations, document review and investigation of a complaint, it was determined the hospital failed to meet the Condition of Participation 482.23 Nursing Services. The hospital failed to ensure a registered nurse evaluates each patient upon admission and when appropriate on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy. Evaluation would include assessing the patient’s care needs, patient’s health status/conditioning, as well as the patient’s response to interventions. Cross Reference: §482.23(b)(3) - A registered nurse must supervise and evaluate the nursing care for each patient.”

“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: 33906 Based on interview and document review the hospital failed to take immediate action to: a)protect patients from abuse during investigation of any allegations of abuse or neglect or harassment, and b) determine as a part of the investigation if the patient experienced any physical harm as a result of the alleged assault. Patient #4. The findings include: Review of hospital policy “Reporting of Possible Abuse and Neglect” effective 11-2024 indicates under the heading “Policy Statement(s)” - patients have the right to receive care free from all forms of harassment or abuse. An individual stating that abuse has occurred or was attempted shall be construed by the employee as reason to believe it occurred. Under the heading “Procedure” the policy indicates that when a suspected or alleged abuse or neglect event is actively occurring during the hospital encounter, immediate measures should be taken to protect the safety of the patient, if needed the Forensic Nurse Examiner (FNE) may be contacted, a internal “safewatch” report should be filed, all of these actions can be documented in the patient record as a Confidential note. Mandated reporter notifications should be made. Review of hospital policy “Sexual Assault, Post-Pubescent Patients” effective October 09-2023 indicates when a patient presents to the emergency department (ED) with complaints of sexual assault, the ED provider will notify the FNE on-call. If the FNE is contacted, the patient has the right to refuse the exam, and to withdraw consent for the exam at any time. A Physical Evidence Recover Kit (PERK) may be collected if more than 120 hours have passed since the assault. The forensic exam may include but is not limited to: general appearance, mental status, evidence collection and photographs and a gross visual exam of genital injuries. Review of hospital “Adult Sexual Assault Survivor Treatment Plan” revised 8/22/24 indicates in part under “Clinical and Social Considerations VII. Unique Populations B. Persons with Disabilities”, “... patients with disabilities may have physical, sensory, cognitive, developmental, mental health disabilities or a combination of disabilities. Recognize that individuals may have some degree of cognitive disability: intellectual disability, traumatic brain injury or neurodegenerative conditions or stroke. Survivors may be reluctant to report the crime for reasons including fear of not being believed.” Review of facility documents, interviews and the clinical record of Patient #4 indicated the following: Patient #4 arrived to Emergency Department of the hospital on 12/08/24 for treatment of pneumonia. Patient #4 was admitted to the PCU (progressive care unit) from 12/09/24 at 5:26 PM until 12/10/24 at 4:43 PM when they transferred to the CCU (critical care unit) and remained there until 12/16/25 at 11:07 AM when the patient returned to the PCU. Patient #4 was discharged on 12/19/25 at 4:09 PM. Documentation by Staff #7 on 12/16/24 at 1:27 PM reveals in part “During today’s evaluation, (Patient #4) reported that (Patient #4) had vague recollection of a sexual assault since admission (Patient #4 specifically used the word “rape”). (Patient #4) was unable to provide details as to when this might have occurred, or even on which unit (as Patient #4 has been on 3 units since admission). (Patient #4) reported that “I’ve been in and out of it, because I was sick.” When questioned, (Patient #4) reported (they) thought (they) had spoken to someone on staff about this previously, but there is no notation in (their) chart. (Patient #4) admitted that (they) could only recall “bits and pieces - it happened while I was asleep.” It is possible that this was a delirium-related event due to (their) sepsis, but nevertheless requires investigation. A safewatch report was filed, and the nurse manager of PCU was notified.” Review of documentation by provider, Staff #27 indicates - no mention of the sexual assault in a progress note documented on 12/16/25 at 3:55 PM and no documentation of an exam for evidence of an assault. Progress note dated 12/17/24 at 10:17 PM documented that Patient #4 indicated they were sexually assaulted in the hospital and the police was looking into this. Patient #4 was expressing fear over taking medications and declining much of their care. Psychiatry was consulted. The clinical record didn’t contain documentation of an exam for searching or collecting evidence of an assault. Review of documentation of Staff #28 (tele-psychiatry consult) on 12/17/24 at 11:24 AM, indicates a psychiatric consult for paranoia. Revealing that the patient was able to demonstrate recollection of hospital events; expressed frustration with the extended hospital stay and lack of attention to their hygiene. Patient #4 did not endorse any clear paranoia or expressed signs of psychosis or mania and initially was guarded and expressed desire to go home. Patient #4 reported not feeling safe in hospital but when further questioned said “I don’t want to talk about it.” Patient #4 acknowledged being really sick but denied any periods of confusion. The consult documentation didn’t mention an allegation of sexual assault. The medical record didn’t contain documentation of interventions hospital staff made to protect the patient during the investigation. Review of nursing notes failed to find documentation of the patient’s allegation of rape/sexual assault or of a physical exam for obvious external evidence of an assault. Review of hospital documentation regarding the internal investigation of the allegation indicates Staff #15 went to bedside to see Patient #4 on 12/17/24 at 1:58 PM. The investigation report documented that Patient #4 was difficult to understand and refused to write their statement down before speaking with their attorney. Review of investigation by hospital police, revealed that Staff #26 were notified that a patient on PCU was alleging being physically assaulted at the hospital. They went to the unit to speak with the nursing manager about the allegation. A report was made to Adult Protective Services and the local Sheriff’s Office was notified. The Officer investigating for the Sheriff’s Office emailed the surveyor, of the status of the investigation. The email indicated the Officer had reached out to the victim and left messages but had been unable to speak with the patient who had already been released from the hospital. Interviews Staff #2, #10, #11, #12 and #29 indicated in an interview on 02/21/25 at 1:16 PM that when Patient #4 made the allegation of sexual assault the unit leader, compliance department, and possibly human resources were notified. Patient #4 was given the opportunity to speak with the police officer and the allegation was reported to the appropriate agencies. The provider was made aware. In this case there was no exam by the forensic nurse. When the patient advocate spoke to Patient #4, they asked the patient to write down what happened and Patient #4 refused. In an interview Staff #9 on 02/21/25 at 3:25 PM indicated they were informed by Staff #7 of the allegation of rape made by the patient and were asked to follow up. Staff #9 stated they spoke to Patient #4 who explained that they didn’t know when it happened, and it occurred on another unit. Staff #7 instructed staff no males staff to be present in their room and to make sure no one was alone with the patient. The room door was to remain open. The interventions were not documented. There were no interventions or investigations related to the patient’s time on other units (ICU and ED). Interview with Staff #7 on 02/21/25 at 3:00 PM, explained that they are familiar with Patient #4 and have been treating them on an outpatient basis. Staff #7 indicated the patient said “someone raped me” and confirmed the statement when questioned. The patient said “I think it was when I was in ED” I told them everything, but didn’t know who they told. Staff #7 stated they reported the allegation to the charge nurse and filed a safewatch report. The next time they saw Patient #4 they didn’t mention it but complained of not receiving their anti-anxiety medication. Staff #26 indicated in an interview on 2/25/25 at 2:25 PM that when they determined the alleged assault was on campus, they turned the investigation over to the local Sheriff’s Office. Staff # 27 recalled on 02/24/25 at 4:00 PM that when Staff #9 made them aware of the allegation, they tried to discuss it with the patient but the patient was lethargic. Staff #27 stated they were purposely vague with the patient at first and just asked how things were going and how they were being treated. Staff #27 explained they asked later more detailed questions and the patient said “no”. The conversations were not documented in the medical record. Staff #27 was unaware if a forensic exam or any exam was completed for Patient #4 after the allegation and stated, “I thought the police were taking care of it.””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 33906 Based on interviews, medical record review and document review the hospital failed to ensure a registered nurse assesses each patient upon admission to the hospital and ongoing during their admission, in accordance with accepted standards of practice and hospital policy. For 5 (five) of 7 (seven) admitted patients included in the survey sample. (Patients #1, #2, #3, #5, and #7.) The findings include: Document review Review of hospital policy “Nursing Assessment and Documentation” including Appendixes A and B, effective 12-2024, indicates an assessment is defined as the gathering of patient information concerning the physiological, psychological, sociological, and spiritual status. An assessment should be documented upon admission, when assuming primary care of the patient and frequently enough to detect changes in patient condition. Assessments are “head to toe” including but not limited to assessment of the following systems: cognitive, perceptual, neurological, head, eyes, ears, nose and throat, peripheral neurovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin and safety. Assessment requirements for inpatients are unit specific; patients admitted to the medical or surgical unit (MCU or SCU) an assessment is completed every 12 hours or sooner. Patients admitted to the progressive care unit (PCU) are to be assessed every 8 hours or sooner and patients admitted to the intensive care unit (ICU) assessments are every 4 hours or sooner. Assessments are document in flow sheets and in “Progress Notes” as needed to clearly depict the clinical condition of the patient. Review of hospital document “Job Description” revision date 06/2024 for LPN (licensed practical nurse) Inpatient, indicates the LPN partners with the RN in collecting data, planning, implementing and evaluating patient care. The LPN participates in the nursing process to administer nursing care under the direction of the RN and possess the ability to collect data reflective of the patient’s status. Review of hospital document “Job Description” revision date 05/2024 for RN I indicates the RN assesses, plans, implements and evaluates patient care, ensures admission and ongoing assessments are completed. The RN delegates and oversees delivery of patient care. Demonstrates knowledge of the principles of growth and development and assess data reflective of the patient’s status. Interprets the appropriate information needed to identify the patient’s requirements relative to the patient’s needs. Review of nurse scheduling indicates licensed practical nurses are routinely scheduled in all units except for ICU. Review of clinical records was conducted on 02/21/25 with the assistance of Staff #6. Record review indicates: - Patient #1 was admitted to the surgical unit on 08/02/24 with a diagnosis of small bowel obstruction and discharged on 08/04/24. Head to toe nursing assessments every 12 hours. Three assessments were completed by LPN’s and no assessment was documented for 08/03/24 day shift. The clinical record failed to provide evidence Patient #1 was assessed by a RN after 08/02/24 at 7:20 PM until their discharge on 08/04/24 at 3:35 PM. (more than 43 hours) - Patient #2 was admitted to the PCU on 08/02/24 with a diagnosis of sepsis secondary to acute diverticulitis and discharged on 08/04/24. Head to toe nursing assessments every 8 hours. The clinical record failed to provide evidence of a nursing assessment by a RN between the hours of 8:11 PM on 08/03/24 and 8:00 AM on 08/04/24, approximately 12 hours. - Patient #3 was admitted to the SCU on 02/17/25 with a diagnosis of left hip fracture and discharged on 02/22/25. Head to toe nursing assessments every 12 hours. Two assessments were completed by LPN’s. The clinical record failed to provide evidence Patient #3 was assessed by a RN for a 24 hour period beginning with the day shift on 02/21/25. - Patient #5 was admitted to the SCU on 02/16/25 with a diagnosis of osteomyelitis and discharged on 02/22/25. Head to toe nursing assessments every 12 hours. Two assessments were completed by LPN’s. The clinical record failed to provide evidence Patient #1 was assessed by a RN for a 16 hour period beginning with the evening shift on 2/21/25. - Patient #7 was admitted to the ICU unit on 02/16/25 with a diagnosis of coronary artery disease and chest pain, down-graded to PCU on 02/20/25, with head to toe nursing assessments every 8 hours. Two assessments were completed by LPN’s. The clinical record failed to provide evidence Patient #7 was assessed by a RN for a 12 hour period beginning with morning shift on 02/21/25. Review of “Focused vs Comprehensive Assessments” reveals in part:”. . . it is generally accepted that the LPN/LVN provides professional services such as collecting and reporting patient data, conducting a focused assessment of the patient’s health status,. . . “ and the RN “. . .is able to perform all of the LPN/LVN services with additional responsibilities such as performing a comprehensive assessment . . .”, retrieved 03/06/25 2:46 PM https://www.practicalnursing.org/focused-vs-comprehensive-assessment Review of 18VAC90-27-100. Curriculum, indicates only registered nursing student education includes “conducting a comprehensive nursing assessment”, retrieved 3/7/25 at 9:00 AM https://law.lis.virginia.gov/admincode/title18/agency90/chapter27/section90/ Department of Health Professions, the licensing body for medical professionals’ documents reveal it is out of the LPN’s scope of practice to conduct a comprehensive or head to toe assessment. Interview During an interview on 02/24/25 at 3:35 PM Staff #16 (RN) indicated that an LPN is given a full patient assignment and does all assessments with the exception of the admission assessment. Staff #16 explained that “head to toe” assessment as documented in the electronic record is a comprehensive assessment, covering all body systems. Staff #20 (LPN) indicated in an interview at 3:00 PM on 02/24/25 that they work mostly on MSU or SCU and normally have a patient load of 5-6 patients. Staff #20 explained that here is always an RN charge nurse as a resource and assessments are completed daily and LPN can do all assessments with the exception of the admission assessment. Staff #20 clarified that LPN’s have only been doing the assessments for approximately the last 6-8 months. During the records review on 02/21/25, Staff #6 indicated that LPN’s take full assignments to include new admissions. During the survey, there were ongoing conversations with Staff #3 who explained that LPN’s are allowed to work to “their full scope of practice” in the hospital, including completing “head to toe” assessments and the admission assessment, which is a new practice adopted last year. Until that time, only RN’s were allowed to complete a “head to toe” or comprehensive assessment. Supervision of an LPN is accomplished by ensuring a RN is assigned on that shift. Staff #3 explained it is the hospital’s position that the LPN is only collecting data when completing the assessment. Staff #3 confirmed a LPN does not receive additional education provided by the hospital for completing comprehensive assessments.”

“IC PROFESSIONAL ADHERENCE TO POLICIES CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (v) The prevention and control of HAIs, including auditing of adherence to infection prevention and control policies and procedures by hospital personnel. This Standard is not met as evidenced by: 33906 Based on observation, interview and document review staff failed to adhere to facility policy on infection control for transmission based precautions and proper surgical attire. The findings are: Review of facility policy “Surgical Attire” updated 8/2024 indicates face shields or approved eyewear is required when performing a task at risk for a splash to the face or eyes. Review of facility policy “Transmission-based (Isolation) Precautions” effective 4/2022 indicates a mask and eye protections should be worn during activities that are likely to generate splashes or sprays of blood, bodily fluids or secretions. The survey team observed a bronchoscopy procedure on 1/21/25 beginning at 1:30 PM. The procedure was performed by Staff #17 (pulmonary fellow - a physician training in a subspecialty) working with Staff #8 (provider). Staff #17 was standing at the head of the patient, performing the procedure, with Staff #8 standing approximately 18-24” to the right side of Staff #17 to advise and assist. During the procedure multiple biopsies were taken and BAL samples were collected. (Bronchoalveolar lavage (BAL) is a procedure using the bronchoscope to deliver a saline solution to the airways and capture a fluid sample.) Staff #17 and #8 were observed donning masks, gloves, and gowns but did not wear any type of eye protection or face shield. Nursing staff and the anesthesia provider were observed wearing PPE (personal protective equipment) appropriate to their individual role during the procedure and their risk of exposure to bodily fluids or secretions. Interviews conducted on 1/22/25 with Staff #1, #18, #20, #21 and #22 indicate a bronchoscopy is a procedure with a possibility of contact with bodily fluids and would require the use of eye protection. The expectation of the facility is that eye protection should be worn during this procedure.”

“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: 33906 Based on medical record review, document review and interviews, the facility staff failed to monitor vital signs in accordance with their policy and procedure for 3 (three) of 6 (six) patients included in the survey sample. Patient #2, Patient #4 and Patient #6. The findings included: A comprehensive review of medical records was conducted on 1/17 and 1/18/24 with the assistance of Staff Members (SM) #4, #5, and #6. Review of the medical record for Patient #2 (an infant) evidenced the following: 12/23/23 10:39 PM - Patient #2 arrived to ER presenting with nasal congestion and tachycardia. The medical record documented following times and types of vital signs collected: 10:42 PM - vital signs at triage: heart rate 147, respiratory rate 38, O2 saturation 96%. temperature 98.4 °F: Level 4 acuity 00:10 AM - pulse 167. O2 saturation 100% 4:07 AM - pulse 166, respiratory rate 33, O2 saturation 89% 4:09 AM - patient discharged home As much as 3 hours 53 minutes elapsed between the collection of vital signs. Review of the medical record for Patient #4 (an infant) evidenced the following: 12/22/23 2:38 PM - Patient #4 arrived to ER presenting with fever, cough and difficulty breathing. The medical record documented following times and types of vital signs collected: 2:52 PM - vital signs at triage: heart rate 157, respiratory rate 48, O2 saturation 97% on 0.5 L nasal cannula, temperature 101.6 °F: Level 2 acuity 6:19 PM - blood pressure 116/63, wt. 4.182 kg 8:00 PM - respiratory rate 40 8:11 PM - respiratory rate 40 8:44 PM - respiratory rate 46, heart rate 155, O2 saturation 93%, temperature 102.6 °F: 11:21 PM - respiratory rate 39, heart rate 145 patient transferred to higher level of care, left hospital As much as 5 hours and 52 minutes elapsed between collection of pertinent vital signs. Review of the medical record for Patient #6 (adult geriatric) evidenced the following: 11/14/23 12:33 PM - Patient #6 arrived to ER presenting with altered mental status. The medical record documented following times and types of vital signs collected: 12:42 PM - vital signs at triage: heart rate 67, blood pressure 126/78, respiratory rate 17, O2 saturation 93%, temperature 97.6 °F: Level 3 acuity 4:38 PM - heart rate 70, blood pressure 139/79, respiratory rate 19, O2 saturation 98%, temperature 97.1 °F 8:41 PM - heart rate 66, blood pressure 173/90, respiratory rate 19, O2 saturation 97% 11:47 PM - heart rate 69, blood pressure 187/92, respiratory rate 14, O2 saturation 94% 4:07 AM - heart rate 72, blood pressure 180/94, respiratory rate 16, O2 saturation 92% 4:11 AM - patient discharged As much as 4 hours and 20 minutes elapsed between collection of pertinent vital signs. Facility policy “Nursing Assessment and Documentation” effective 11-2022 provided the following guidelines for Emergency Department Nursing Assessments: “Complete a focused assessment upon admission (all pertinent systems and psychosocial history related to ED visit) or more frequently as the patient condition dictates. Vital signs: Every 2 hours or per Provider order.” When asked what the expectation is for assessments and collection of vital signs for ED patients, SM #4 replied that assessments are in triage and as needed based or the patient condition or physician orders but vital signs are to be taken every 2 hours. During the record reviews, SM #4, #5 and #6 were given the opportunity to locate additional documentation for each of the three patients. They were unable to present any additional evidence. The surveyor shared the findings and concerns related to the failure to monitor patients according to policy with the facility’s leaders at the exit conference on 1/18/24 at 3:30 PM.”