Uva Health Prince William Medical Center

“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: 36946 Based on staff interview and document review, it was determined the facility failed to ensure it modified each patient’s plan of care when using restraints in two (2) of two (2) medical records reviewed of patients in restraints in the survey sample Patient # 1 and 2). Findings: Two (2) medical record of patients in restraints were reviewed. The medical record for Patient #1 contained documentation that the patient was placed in bilateral soft wrist restraints on November 02, 2024 at 3:09 PM for pulling at medical devices. The patient continued in restraints November 03, 04, and 05, 2024. The patient’s plan of care was not updated to include the use of restraints until November 04, 2024 (two days after restraints were initiated). The medical record for Patient #2 contained documentation that the patient was placed in bilateral soft upper wrist restraints around midnight on November 10, 2024 for pulling at medical devices. The patient’s care plan was not modified to include the use of restraints until 5:11 PM on November 10, 2024. The hospital’s policy, Restraints and Seclusion was reviewed and reads in part: Documentation 1. Each episode of restraint or seclusion use is documented in the patient’s medical record. 2. The use of restraint or seclusion must be in accordance with a written modification to the patient’s plan of care following the initiation of restraints. An interview with Staff Member #1 on December 12, 2024 revealed the patient’s plan of care should be updated when restraints were initiated and reviewed and updated each calendar day.”

“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: 36946 Based on staff interview and document review, it was determined the hospital failed to ensure each patient in restraints was monitored according to hospital policy in one (1) of two (2) medical records reviewed of patients who were in restraints in the survey sample (Patient #2). Findings: The hospital’s policy, Restraints and Seclusion was reviewed and reads in part: “Monitoring...The following will be monitored and documented every 2 hours (within 15 minutes before or after) or more often as indicated by patient condition: a. respiratory and circulatory status; b. skin condition; c. correct application of restraint; d. restraint release/repositioning and range of motion; e. nutrition (at meal time or when snacks are offered between meals); f, hydration (when offered); g. elimination needs; h. psychological well-being; i. vital signs as indicated; j. readiness for discontinuation of restraint.” The medical record for Patient #2 contained documentation that the patient was placed in bilateral soft upper wrist restraints around midnight on November 10, 2024 for pulling at medical devices. From 8:00 AM to 8:00 PM on November 10, 2024 the medical record contained documentation that the patient was monitored every three (3) hours instead of every two (2) hours as required by hospital policy. An interview was conducted with Staff Member #1 on November 12, 2024 who confirmed monitoring of restraints should occur every two (2) hours.”

“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 facility document review, it was determined the facility failed to ensure the patient or patient’s representatives participated in the development and implementation of the plan of care for one (1) of three (3) medical records reviewed. Specifically, the patient’s Power of Attorneys (POAs) were not notified that the patient developed a pressure injury during the hospitalization. Findings: The facility’s policy titled “Patient Rights and Responsibilities” last revised February 2023, states in part: ... II. Policy ... [the facility] honors patients’ rights to be informed about, and involved in, making decisions about care and treatment.... 1. Patient Rights: Patients and/or their legally responsible representative(s) have the right to: Informed Decision-making. a. Know about the patient’s illness, why the patient needs treatment, what will happen if the patient does not have treatment, so the patient and/or legally responsible representative can take part in making care decisions. b. Give or refuse consent before procedures or treatment.... The facility’s policy titled “Skin Assessment and Management (Adults and Pediatrics)” April 2020, states in part: ... Documentation ... Patient/support person(s) education and response. Follow-up care needs/education/referrals ... On August 26, 2024, and August 27, 2024, the surveyor reviewed the medical record for Patient #2. The medical record revealed that Patient #2 developed skin breakdown/pressure injury/bed sore on the sacrum that was first documented on July 18, 2024. The nursing note flow sheet from July 18, 2024, at 8:00 AM revealed a “new finding” of “redness; fragile; excoriation; wound/incision” at the gluteal cleft (the deep groove that separates the buttocks). The medical record revealed a consult to wound care - pressure ulcer ordered by Staff Member #23 on July 18, 2024, at 5:36 PM. The wound care assessment from August 19, 2024, at 5:44 PM revealed the reason for consult “L [left] buttock and sacrum skin breakdown ... Wound History: developed during hospitalization - noted 7/18 [July 18, 2024] ... Assessment: Deep purple and red area on L [left] buttock and sacrum. Skin partially blistered and deroofed [where blister has rubbed off]. Allevyn [versatile silocone adhesive foam dressing - smith-nephew.com] removed. RN [registered nurse] instructed to use ABD [abdominal pad dressing] only - no adhesives. Will be discharged tomorrow. Plan/Recommendations: Kept turned Q2h [every two hours] side to side. Venelex [ointment helps to deodorize and protectively cover pressure wounds - dailymed.nlm.nih.gov] to L buttock and sacral [large, triangular bone at the base of the spine - wikipedia.org] wounds BID [twice a day]. Cover with ABD - no Allevyn. Initiate/continue all pressure injury prevention measures per Nursing Policy: Pressure Injury Prevention and Management ...” The Discharge Summary Addendum from July 20, 2024, at 10:34 AM and the After Visit Summary revealed no documentation of the patient developing or having a sacral pressure injury. The medical record revealed no documentation that Patient #2’s POAs were notified that the patient developed a sacral pressure injury during the hospitalization. The History and Physical dated July 13, 2024 at 2:46 AM revealed that the patient has recent onset of dementia and is currently oriented to “self only”. During an interview on August 27, 2024, Staff Member #1 and Staff Member #24 confirmed that there was no documentation in the medical record that Patient #1’s POAs were notified that the patient developed a sacral pressure injury during the hospitalization.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 42929 Based on interviews, medical record review, and facility document review, it was determined the facility failed to transfer the patient to a skilled nursing facility with all necessary medical information pertaining to the patient’s current course of illness and treatment. Specifically, the facility failed to provide information related to a pressure injury that developed during hospitalization, for one (1) of three (3) patient discharge documentation reviewed. Findings: The facility’s policy titled “Discharge Planning” August 2021, states in part: ... D. Discharge Planning (Documentation) ... 4. As changes in the patient’s condition and needs occur, the discharge plan will be reassessed and updated to address those changes and documented in the electronic health record. 5. The hospital provides necessary medical information on transfer or with referral for post-acute services through the electronic health record.... On August 26, 2024, and August 27, 2024, the surveyor reviewed the medical record for Patient #2. The medical record revealed that Patient #2 was discharged to a skilled nursing facility in the evening on July 20, 2024. The discharge summary and the after visit summary revealed no documentation that the patient developed a pressure injury - sacral wound during the hospital admission. During an interview on August 27, 2024, at 10:20 AM, Staff Member #12 indicated that the documentation the facility sent to the skilled nursing facility where the patient would be transferred, included the updated discharge summary, the medication reconciliation, initial discharge summary, a physician progress note from July 18, 2024, and other notes and documentation that were dated July 18, 2024, and days prior. The wound care assessment was completed on July 19, 2024, and was not sent to the skilled nursing facility. The nursing flow sheet documentation from July 18, 2024, at 8:00 AM was not sent to the skilled nursing facility. There was no documentation that the patient’s sacral wound was communicated to the skilled nursing facility. During an interview on August 27, 2024, Staff Member #1 and Staff Member #24 confirmed that there was no documentation in Patient #2’s discharge summary and the after visit summary that the patient developed a pressure injury during the patient’s hospital admission, and there was no documentation that the patient’s sacral wound was communicated to the patient’s Power of Attorneys (POAs) or to the receiving skilled nursing facility.”