Lewisgale Medical Center

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 33906 Based on clinical record review, interviews and document reviews, the facility failed to ensure compliance with EMTALA requirements at 42 CFR 489.24: Special Responsibilities of Medicare Hospitals in Emergency Cases. The facility staff failed to provide a Medical Screening Examination (MSE) for a patient presenting for evaluation of respiratory distress and failed to maintain a central log for ED (Emergency Department). The hospital staff informed EMS (Emergency Medical Service) providers after their arrival to the ED with the patient, that the patient would have to be transported to the main campus ED for treatment. Cross reference: §489.24(a) (1)(i) - Applicability of Provisions of this Section A-2405 A-2406”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 33906 Based on document review and interviews, hospital staff failed to maintain a central log to include all individuals presenting to the free standing emergency department (FSED) seeking assistance, and whether they refused treatment, were refused treatment, transferred, admitted and treated, stabilized and transferred, or discharged. For one (1) of twenty (20) patients included in the survey sample, Patient #3. The findings include: Anonymous source reported via web a possible EMTALA violation occurring on April, 22, 2025, in which a patient was refused treatment and redirected to another ED. Review of the emergency department log failed to find evidence that Patient #3 presented to the free standing emergency department (FSED) on April 22, 2025, or the disposition of the patient. Review of central log didn’t find evidence of Patient #3 presenting to the FSED for care, and whether they refused treatment, were refused treatment, transferred, admitted and treated, stabilized and transferred, or discharged. Although, review of Patient #3’s medical record failed to provide evidence the patient had presented to the FSED, an audit of Patient #3’s chart within the entire health system for all persons who accessed it on April 22, 2025, found that staff at the FSED accessed the chart at multiple times with the first entry recorded on April 22, 2025, at 6:09 AM. Review of EMS (Emergency Medical Services) “Patient Care Report” revealed that on April 22, 2025 the EMS transit left Patient #3’s residence at 5:59 AM and 6:06 AM alerted the hospital of their arrival. Interviews with Staff #4, EMS #1 and Patient #3 indicated the patient was taken on April 22, 2025 to the FSED where staff refused to provide treatment and directed EMS staff to transport Patient #3 to the ED located on the main hospital campus for care. Review of policy “EMTALA - Central Log” effective 02/2025 reveals under “Procedure 3. The logs must contain at a minimum, the name of the individual and whether the individual: · refused treatment, · was refused treatment, · was transferred, · was admitted and treated, · was stabilized and transferred, · was discharged, or · expired.” Cross reference §489.24(a)(1)(i) A-2406”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 33906 Based on interviews, clinical record and document reviews, the hospital staff failed to provide a Medical Screening Examination (MSE) for one patient (Patient #3) who presented to a FSED (Free Standing Emergency Department (ED)) requesting treatment for respiratory distress. FSED staff instructed EMS staff (Emergency Medical Services) to transport Patient #3 to the ED located on the main hospital campus. The findings include: Interviews During the course of the survey, surveyor made multiple attempts to interview EMS Staff #1. On June 02, 2025, at 10:46 AM, EMS Staff #1 returned the surveyor’s call. EMS #1 recalled that on April 22, 2025, at approximately 6:00 AM, they presented with Patient #3 to the FSED. Upon arriving at the FSED they took Patient #3 inside. At that time, they were told by two individuals at the desk, known to them as nurses, that the patient is “banned” from the FSED, and instructed EMS Staff #1 to take Patient #3 to the ED located on the main hospital campus, approximately 10 miles across town. During the course of the survey, surveyor made multiple attempts to contact Patient #3 by phone. On June 02, 2025 at 10:38 AM, Patient #3 returned the surveyor’s call and during the phone interview explained that EMS took them to the FSED that morning (unclear about dates) and after going in, they had to “load me back up” and take me to the “big hospital” (main campus). The patient had the impression that EMS had called it in to the wrong hospital. Patient #3 stated they had never been denied treatment or had to leave before. During the interview on May 29,2025 at 8:25 AM Staff #4 indicated they were made aware of a possible EMTALA violation on April 22, 2025, in which a patient was refused treatment. Their investigation revealed Patient #3 had been identified as a “no trespass” individual because of disruptive behavior on September 11, 2024. Staff #4 explained that when an individual is identified in this way the electronic health record is triggered to produce a “pop up” screen when the individual’s name is entered into the system. When Patient #3 arrived at the FSED and their name was entered into the computer in the morning on April 22, 2025, the pop up screen indicated the patient had a no trespass notice and alerted staff to call security. Instead, staff told the EMS Staff #1 that Patient #3 could no be seen there and needed to be transported to the ED on main hospital campus or another ED for treatment. Per Staff #4, EMS Staff #1 transported the patient to the main campus ED. Staff #4 further indicated that education was provided to individuals involved in the incident. Evidence of education provided to the surveyor included: a) An email sent to all FSED staff on April 25, 2025, stating they were aware of a recent EMTALA violation involving a patient being turned away and informing them that individuals directly involved will receive a written notice; b) “Safety Huddle” dated January 24, 2025, stating “we cannot screen calls”and “let the patient come in”, have the physician evaluate the patient and determine actions to be taken; and c) Evidence of annual assignments of EMTALA training to FSED staff via the computer based learning system used by the hospital. There was no further evidence of FSED or hospital wide EMTALA related training occurring after the incident. Interviews on May 29, 2025, were conducted with Staff #5, #12, #13, and #15 (nurses) and Staff #8 and #14 (physicians) who regularly work at the FSED. Of these individuals only Staff #15 indicated knowledge of the incident. Staff #15 recalled they were told by Staff #4 that a patient who had been “trespassed” had been turned away. Staff #15 indicated they weren’t working that shift and their last EMTALA education was possibly January. The two nurses identified as involved in the incident (Staff #16 and Staff #17) were not made available for interview. Medical record review Review of Patient #3’s medical record revealed the patient arrived to the main campus ED via EMS on April 22, 2025, at 6:28 AM with a complaint of shortness of breath. Patient #3 was triaged, received a medical screening exam, treatment and was discharged at 8:50 AM. Patient #3’s medical record failed to provide evidence the patient had presented to the FSED. However, an audit of Patient #3’s chart within the entire health system for all persons who accessed it on April 22, 2025, found that staff at the FSED accessed the chart at multiple times with the first entry recorded on April 22, 2025, at 6:09 AM. Hospital’s documents review Review of the ED log for the FSED failed to provide evidence Patient #3 presented to the FSED at any time on April 22, 2025. An audit of Patient #3’s chart for all persons who accessed the record on April 22, 2025, found that staff at the FSED first accessed the chart on that day at 6:09 AM. Review of hospital policy “Notice of No Trespass” effective 06/2024 read in part, “Exceptions/EMTALA: A. Exceptions to comply with Federal Regulations: 1. The only exception to this No Trespass Notice is related to an individuals need to access emergency medical care at the Hospital. In keeping with our EMTALA obligations, should the barred individual need emergency medical care, they may come to the Hospital Emergency Department for such care. 2. Upon arrival, a board certified Medical Staff Member has to determine if the care being sought by the barred individual is emergent or not before Security can proceed with removal/ Law Enforcement notification of a Trespass Violation per code of Virginia 18.2-119.” Review of hospital policy “Virginia EMTALA - Medical Screening Examination and Stabilization Policy” effective 02/2025 reveals under in section “j. Off-Campus Provider-Based Emergency Department” in part, “If an individual presents to an off-campus provider-based emergency department, ..., he or she must be provided an appropriate MSE just as he or she would if the presentation was at the main campus emergency department. Should the individual require additional screening for stabilizing care by a physician specialist, he or she will be moved to the main campus or another non-HCA facility for the additional care required. “”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. This Standard is not met as evidenced by: 46466 Based on medical record and facility document review, the facility failed to provide evidence that less restrictive interventions were attempted prior to the use of a chemical restraints for one (1) of twenty (20) patient records sampled. The findings include: On January 22, 2025, a review of Patient #1’s medical record was reviewed. Patient #1 was transported by local law enforcement to this facility’s Emergency Department (ED) on December 12, 2024 at 2:40 PM under an Emergency Custody Order (ECO) and a Temporary Detention Order (TDO) with a chief complaint of psychosis. A rapid initial assessment documented by an ED Registered Nurse (RN) on December 12, 2024 at 3:08 PM, indicated “pt acting erratically and having violent outbursts...Patient having incoherent rants and shouting. Patient will not follow instructions and is struggling against police officers”. The ED Provider Note documented on December 12, 2024 at 2:51 PM indicated that an ED physician ordered for Patient #1 “B-52 injection” to be used as a chemical restraint which included one (1) time intramuscular injection of 50 mg of Diphenhydramine HCL, 5 mg of Haloperidol and 2 mg of Lorazepam. Patient #1 was administered the injection to the left thigh on December 12, 2024 at 2:55 PM. Patient #1’s medical record didn’t contain documentation of any less restrictive interventions were considered or tried to protect the safety of patient, staff and others prior to administration of the injection. A review of the facility’s policy “Patient Restraint/Seclusion”, last revised 7/2023, indicated in part: “...12. Documentation Requirements: The medical record contains documentation of...b. Restraint or seclusion alternatives employed...C. Drugs as restraints...A medication that is not being used as a standard treatment or in a dosage for the patient’s medical or psychiatric condition and that results in controlling the patient’s behavior and/or in restricting his or her freedom would be a drug used as a restraint...”.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 46466 Based on interviews, medical record and facility document review, the facility failed to implement and document the safe and appropriate restraints techniques according to facility policy. The findings include: On January 22, 2025, the surveyor reviewed Patient #1’s medical record. Patient #1 was transported by local law enforcement to this facility’s Emergency Department (ED) on December 12, 2024 at 2:40 PM under an Emergency Custody Order (ECO) and a Temporary Detention Order (TDO) with a chief complaint of psychosis. A rapid initial assessment documented by an ED Registered Nurse (RN) on December 12, 2024 at 3:08 PM, indicated “pt acting erratically and having violent outbursts...Patient having incoherent rants and shouting. Patient will not follow instructions and is struggling against police officers”. An ED Provider Note documented on December 12, 2024 at 2:51 PM indicated that an ED physician ordered for Patient #1 “B52 injection” which consisted of a one (1) time intramuscular injection of 50 mg of Diphenhydramine HCL, 5 mg of Haloperidol and 2 mg of Lorazepam. The ED physician documented the “meet and greet” time with Patient #1 was 2:48 PM and the ED Provider Note documented “...Patient is sedated on arrival”. Patient #1 was administered the ordered B52 injection to the left thigh on December 12, 2024 at 2:55 PM by Staff Member #10. The medical record didn’t document any details about the administration of the injection i.e. if Patient #1 was lying down, refused the injection, struggled, was held down, by whom. The “Rapid Initial Assessment” was documented on December 12, 2024 at 3:08 PM by the ED RN and indicated “...Patient will remain injury free while patient is in restraint or seclusion: Yes...”. On December 12, 2024 at 4:31 PM, an ED RN documented Patient #1’s vital signs. On December 12, 2024 at 5:00 PM, it was documented that a cardiac monitor was placed on Patient #1. On December 12, 2024 at 5:10 PM, an ED RN documented that Patient #1’s pain level was zero (0) and vital signs were assessed. On December 12, 2024 at 6:46 PM, an ED RN documented a detailed assessment to include a suicide screening, and a fall risk assessment. The ED RN documented a CIWA-AR (Clinical Institute Withdrawal Assessment for Alcohol Revised) indicating that Patient #1 had no visible sweat, no anxiety and that Patient #1 was “oriented”. The CIWA-AR score was zero (0). On December 12, 2024 at 10:21 PM, an ED RN documented Patient #1’s vital signs. On December 12, 2024 at 11:16 PM, an ED RN documented “Pt seen leaving with PD at this time. PD stating that they are taking (Patient #1).” The departure information noted that Patient #1 was taken to a receiving facility. The following were not found Patient #1’s medical documentation: lesser alternative methods attempted, a second tier review conducted by a member of nursing administration/management, signs of injury associated with the restraint, effectiveness/ineffectiveness of the patient’s restraint, respiratory and cardiac status, psychological status, hydration/nutritional needs were met, hygiene needs were met, the patient’s rights, dignity and safety were maintained, the patient’s understanding of reasons for the restraint and that a trained staff member monitored the patient at least three (3) times an hour for safety. On January 22, 2025 at 2:15 PM an interview was conducted with Staff Member #10. Staff Member #10 recalled that Patient #1 came to the ED fighting with the police officers and destroying property. Staff Member #10 explained that they were working as the Charge RN that evening and “pulled and gave the B-52” injection to Patient #1 who was lying down on a side. Staff Member #10 recalled that during the injection Patient #1’s upper torso was held by the two (2) police officers in the room and one (1) of the facility’s Emergency Medical Technicians (EMT) held Patient #1’s leg. Patient #1 was not in handcuffs at the time of the administration of the medication. Staff Member #10 indicated that the medication took some time to take effect, so the cardiac monitor and assessment of Patient #1 was not completed until after Patient #1 was calmer. Staff Member #10 stated that typically patients who have been administered medications as a restraint were monitored every fifteen (15) minutes for the first hour, every 30 minutes and then hourly and that this information should be documented in the patient’s medical record. A review of the facility’s policy “Patient Restraint/Seclusion”, last revised 7/2023, indicated in part: “...7. Monitoring the Patient in Restraints or Seclusion... b. An RN will assess the patient at least every two hours. The assessment will include where appropriate: 1. Signs of injury association with restraint... 2. Respiratory and cardiac status, 3. Psychological status, including level of distress or agitation, mental status and cognitive function... 5. hydration/nutritional needs are being met, 6. Hygiene, toileting/elimination needs are being met, 7. The patient’s rights, dignity, and safety are maintained, 8. Patient’s understanding of reasons for restraint and criteria for release from restraint, 9. Consideration of less restrictive alternatives to restraint. c. More frequent monitoring an notification of the ordering physician or licensed practitioner occurs when... 3. The level of patient agitation/distress at being placed in restraint as evidenced by an escalation of behavior... d. A trained staff member monitors each patient in restraint or seclusion at least three times an hour for safety and to confirm that the patient’s rights and dignity are maintained. This check will be documented in either electronic record or on paper... e...1. Patients in restraints or seclusion who are restrained or secluded on a unit without continuous or frequent in-person observations (e.g., intermediate care, “stepdown”, telemetry, medical/surgical, etc.) must have an individual performing and documenting real time, ongoing safety, rights, and dignity checks (minimally, to include: respiratory and circulatory status, skin integrity, etc.)... Appendix D: Definitions...C. Drugs as restraints: A drug or medication, when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition, is considered a restraint...A medication that is not being used as a standard treatment or in a dosage for the patient’s medical or psychiatric condition and that results in controlling the patient’s behavior and/or in restricting his or her freedom would be a drug used as a restraint...””

“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: 46466 Based on interviews, medical record and facility document review, the facility failed to document a physician’s order prior to the initiation of a physical hold. The findings include: On January 22, 2025, surveyor reviewed Patient #1’s medical record. Patient #1 was transported by local law enforcement to this facility’s Emergency Department (ED) on December 12, 2024 at 2:40 PM under an Emergency Custody Order (ECO) and a Temporary Detention Order (TDO) with a chief complaint of psychosis. A rapid initial assessment documented by an ED Registered Nurse (RN) on December 12, 2024 at 3:08 PM, indicated “pt acting erratically and having violent outbursts...Patient having incoherent rants and shouting. Patient will not follow instructions and is struggling against police officers”. ED Provider Note documented in Patient #1’s medical record on December 12, 2024 at 2:51 PM indicated that ED physician ordered “B52 injection” which consisted of a one (1) time intramuscular injection of 50 mg of Diphenhydramine HCL, 5 mg of Haloperidol and 2 mg of Lorazepam. Patient #1 was administered the ordered B52 injection to the left thigh on December 12, 2024 at 2:55 PM by Staff Member #10. The medical record didn’t document any details about the administration of the injection i.e. if Patient #1 was lying down, refused the injection, struggled, was held down, by whom. The medical record didn’t include a physician order for a physical hold for the administration of a chemical restraint. On January 22, 2025 at 2:15 PM an interview was conducted with Staff Member #10. Staff Member #10 recalled that Patient #1 came to the ED fighting with the police officers and destroying property. Staff Member #10 explained that they were working as the Charge RN that evening and “pulled and gave the B-52” injection to Patient #1 who was lying down on a side. Staff Member #10 recalled that during the injection Patient #1’s upper torso was held by the two (2) police officers in the room and one (1) of the facility’s Emergency Medical Technicians (EMT) held Patient #1’s leg. Patient #1 was not in handcuffs at the time of the administration of the medication. Review of the facility’s policy “Patient Restraint/Seclusion”, last revised 7/2023, indicated in part: “...F. Physical Holding for Forced Medications: The application of force to physically hold a patient, in order to administer a medication against the patient’s wishes, is considered restraint...The use of force in order to medicate a patient, as with other restraint, must have a physician’s order prior to the application of the restraint (use of force)...”.”

“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: 46466 Based on interviews, medical record and facility document review, the facility failed to provide evidence that a patient who was chemically restrained was monitored according to facility policy. The findings include: On January 22, 2025, surveyor reviewed Patient #1’s medical record. Patient #1 was transported by local law enforcement to this facility’s Emergency Department (ED) on December 12, 2024 at 2:40 PM under an Emergency Custody Order (ECO) and a Temporary Detention Order (TDO) with a chief complaint of psychosis. The ED physician documented that the “meet and greet” time with Patient #1 was 2:48 PM. An ED Provider Note documented on December 12, 2024 at 2:51 PM included an order for chemical restraint that consisted of a one (1) time intramuscular injection of 50 mg of Diphenhydramine HCL, 5 mg of Haloperidol and 2 mg of Lorazepam. Patient #1 was administered the chemical restraint to the left thigh on December 12, 2024 at 2:55 PM by Staff Member #10. The “Rapid Initial Assessment” was documented on December 12, 2024 at 3:08 PM by the ED RN and indicated “...Patient will remain injury free while patient is in restraint or seclusion: Yes...”. On December 12, 2024 at 4:31 PM, an ED RN documented Patient #1’s vital signs. On December 12, 2024 at 5:00 PM, it was documented that a cardiac monitor was placed on Patient #1. On December 12, 2024 at 5:10 PM, an ED RN documented that Patient #1’s pain level was zero (0) and vital signs were assessed. On December 12, 2024 at 6:46 PM, an ED RN documented a detailed assessment to include a suicide screening, and a fall risk assessment. The ED RN documented a CIWA-AR (Clinical Institute Withdrawal Assessment for Alcohol Revised) indicating that Patient #1 had no visible sweat, no anxiety and that Patient #1 was “oriented”. The CIWA-AR score was zero (0). On December 12, 2024 at 10:21 PM, an ED RN documented Patient #1’s vital signs. On December 12, 2024 at 11:16 PM, an ED RN documented “Pt seen leaving with PD at this time. PD stating that they are taking (Patient #1).” On January 22, 2025 at 2:15 PM Staff Member #10 explained in an interview that typically patients who have been administered medications as a restraint are monitored every fifteen (15) minutes for the first hour, every 30 minutes and then hourly and that this information should be documented in the patient’s medical record. A review of the facility’s policy “Patient Restraint/Seclusion”, last revised 7/2023, indicated in part: “...7. Monitoring the Patient in Restraints or Seclusion... b. An RN will assess the patient at least every two hours. The assessment will include where appropriate: 1. Signs of injury association with restraint... 2. Respiratory and cardiac status, 3. Psychological status, including level of distress or agitation, mental status and cognitive function... 5. hydration/nutritional needs are being met, 6. Hygiene, toileting/elimination needs are being met, 7. The patient’s rights, dignity, and safety are maintained, 8. Patient’s understanding of reasons for restraint and criteria for release from restraint, 9. Consideration of less restrictive alternatives to restraint. c. More frequent monitoring and notification of the ordering physician or licensed practitioner occurs when... 3. The level of patient agitation/distress at being placed in restraint as evidenced by an escalation of behavior... d. A trained staff member monitors each patient in restraint or seclusion at least three times an hour for safety and to confirm that the patient’s rights and dignity are maintained. This check will be documented in either electronic record or on paper... e...1. Patients in restraints or seclusion who are restrained or secluded on a unit without continuous or frequent in-person observations (e.g., intermediate care, “stepdown”, telemetry, medical/surgical, etc.) must have an individual performing and documenting real time, ongoing safety, rights, and dignity checks (minimally, to include: respiratory and circulatory status, skin integrity, etc.) ... Appendix D: Definitions...C. Drugs as restraints: A drug or medication, when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition, is considered a restraint...A medication that is not being used as a standard treatment or in a dosage for the patient’s medical or psychiatric condition and that results in controlling the patient’s behavior and/or in restricting his or her freedom would be a drug used as a restraint...” The following were not found Patient #1’s medical documentation: signs of injury associated with the restraint, effectiveness/ineffectiveness of the patient’s restraint, respiratory and cardiac status, psychological status, hydration/nutritional needs, hygiene needs, maintenance of the patient’s rights, dignity and safety, the patient’s understanding of reasons for the restraint and monitoring of the patient by a trained staff member at least three (3) times an hour for safety.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(iii) [there must be documentation in the patient’s medical record of] Alternatives or other less restrictive interventions attempted (as applicable); This Standard is not met as evidenced by: 46466 Based on medical record and facility document review, the facility failed to document alternatives or less restrictive interventions were attempted prior to the use of restraints in one (1) of twenty (20) patients included in the survey sample. The findings include: According to the medical record Patient #1 was transported by local law enforcement to this facility’s Emergency Department (ED) on December 12, 2024 at 2:40 PM under an Emergency Custody Order (ECO) and a Temporary Detention Order (TDO) with a chief complaint of psychosis. A rapid initial assessment documented by an ED Registered Nurse (RN) on December 12, 2024 at 3:08 PM, indicated “pt acting erratically and having violent outbursts...Patient having incoherent rants and shouting. Patient will not follow instructions and is struggling against police officers”. The ED Provider Note documented on December 12, 2024 at 2:51 PM indicated that ED physician ordered for Patient #1 “B-52 injection” to be used as a chemical restraint which included one (1) time intramuscular injection of 50 mg of Diphenhydramine HCL, 5 mg of Haloperidol and 2 mg of Lorazepam. Patient #1 was administered the injection to the left thigh on December 12, 2024 at 2:55 PM. Patient #1’s medical record didn’t contain documentation of any less restrictive interventions or alternatives were considered or attempted prior to administration of the injection. A review of the facility’s policy “Patient Restraint/Seclusion”, last revised 7/2023, indicated in part: “...12. Documentation Requirements: The medical record contains documentation of...b. Restraint or seclusion alternatives employed...C. Drugs as restraints...A medication that is not being used as a standard treatment or in a dosage for the patient’s medical or psychiatric condition and that results in controlling the patient’s behavior and/or in restricting his or her freedom would be a drug used as a restraint...”.”

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 33906 Based on interviews and document review, facility staff failed to include in discharge planning evaluation the post-discharge needs for durable medical equipment. For 1 (one) of 7 (seven) patients included in the sample. Patient #3 The findings include: Review of the medical record indicates Patient #3 was admitted to the facility on 10/14/24 with diagnosis of acute encephalopathy secondary to sepsis and MSSA bacteremia (Methicillin-Sensitive Staphylococcus Aureus bloodstream infection). During the hospital stay the patient required intubation, sedation, vasopressor support and admission to intensive care (ICU) and received consults with infectious disease provider, physical therapy, occupational therapy and case management. Patient #3 transferred out of the ICU to a medical step-down unit on 10/17/24. Patient #3 was evaluated by occupational therapy (OT) on 10/17/24 and received treatments on 10/22/24 and 10/24/24. Patient #3 was instructed on the use of a rolling walker on 10/22/24. On 10/24/24 Staff #14 documented that the patient is questioning the validity of therapy and states they don’t need anyone to take care of them. Staff #14 documented their concern related to patient’s limited recall and need for “nearly constant” cues during routine ADLs (activities of daily living). Staff #14 recommended daily rehab services with home health to lessen the risk of falls or injury to “frail” spouse. Physical therapy (PT), Staff #15, evaluated Patient #3 on 10/17/24 and concluded that Patient #3 requires moderate assistance by 2 people for bed mobility, sit to stand and transfer to chair. Gait could not be assessed and recommended PT at minimum of 3 times weekly. PT documentation by Staff #16 on 10/22/24 indicated Patient #3 was independent for all ADLs prior to admission and did not require any assistive device for ambulation. “Currently, patient requires maximum assistance by one person for bed mobility and transfers... Patient refused to participate in ambulation activities because of back pain...Given pt’s current assistance requirement and overall weakness versus (their) prior level of function, pt is not safe to return home at this time as (they) is an extremely high fall risk. Strongly urging rehab at a SNF prior to return home.” There are no further PT notes prior to discharge. A nursing note on 10/22/24 by Staff #17 documented a “walk test” indicating oxygen saturation 97% on room air while resting and 93% while ambulating. The note didn’t document the distance Patient #3 walked or if an assistive device was used. Case management/discharge planning documentation by Staff #18 indicated initial phone contact with patient’s spouse on 10/16/24 when Patient #3 was intubated. The documentation further indicated that Patient #3 didn’t have any DME (durable medical equipment) at home and has not received home health care or been admitted to a SNF (skilled nursing facility). On 10/24/24, Staff #12 documented, that Patient #3 “will be discharged today after 5 days of negative blood cultures” and it is unlikely patient will be able to take care of self at home and spouse is unable to care for the patient alone. Patient #3 and spouse refused SNF placement. Patient #3 was discharged home with home health care. Documentation indicates Patient #3 maintains throughout the hospital stay, their refusal of placement in a skilled nursing facility and their wish to go home. Review of policy “Case Management/Utilization Review Plan” effective 3/2024 indicated that discharge planning needs are assessed at admission. The case manager is responsible for identifying those patients who may require services after discharge and facilitating a smooth and timely transition to home or other settings. Reassessments are performed as conditions change. Case management will assess for change in condition when completing utilization review, make appropriate arrangements to meet the needs of the patient/family and if necessary to effectively communicate with the next level of care providers. Duties of case management includes but is not limited to DME arrangement and contacting home health agencies. Interviews were conducted on 12/11/24 at 1:45 PM with case management Staff #4 and Staff #7. Staff #7 explained that when a patient is ready for discharge, case management staff will assess patient needs based on physician orders, therapy notes, and conversations with nursing staff, the physician and family. It would be the case manager who arranges needed DME. Review of the medical record indicated Patient #3 had no DME at home, did not have documented ambulation by PT, had only been out of bed with the assistance of a rolling walker and staff and was identified by PT “an extremely high fall risk”. Staff #7 explained that under these circumstances the expectation would be to arrange for a walker and bedside/over toilet commode chair and possibly a shower stall. Prior to discharge the case management staff failed to include the evaluation for needed DME.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 21229 Based on observation, interview, and document review it was determined the facility failed to provide adequate quality oversight of the maintenance department, specifically maintenance of the facility ventilation system and ice machines. Cross Reference: §482.21(a)(1), 482.21(a)(2), 482.21(c)(2), & 482.21(e)(3) Patient Safety, Medical Errors & Adverse Events The findings included: Ice machines The Quality Program did not establish a monitoring oversight for the internal cleaning of ice machines that provide ice to patients in this facility. The internal cleaning of ice machines is completed by a “Corporate” Maintenance provider quarterly without any feedback to facility on cleaning effectiveness or facility oversight/auditing of the work performed. The absence of ice machine cleaning audits results in non-existent evaluation of the quarterly cleaning process’ effectiveness and implementation of corrective actions as needed. On June 3, 2024, the surveyor observed six (6) randomly sampled ice machines. Upon inspection, three (3) of the six (six) ice machines contained a residue, a gray/tan/greenish slimy substance in the bottom of the ice reservoir. The last cleaning of the units with visible slimy substance in ice reservoir was completed on April 24, 2024 (Labor and Devivery ) and on May 8, 2024 (3West and 5 West). Please refer to A-0724 for further information. And: Ventilation system (B) The Quality Program did not recognize the failure of the facility to ensure cleaning and maintenance of air ducts/vents in patient rooms was performed. The external cleaning of air vent grills and units is completed regularly but the facility has no maintenance or cleaning schedule for the internal portion of the vent/duct system continuing into the vent unit in the patient rooms. The surveyor inspected three (3) air duct/vent units located in patient rooms on June 4, 2024 at 11:10 a.m. The surveyor requested the vent/duct grill to be removed in order to observe the internal duct supplying air to the room. Each of the ducts/vents observed contained large amounts of unknown debris, trash and liquid substances and the state of insulation within the vent/duct was concerning. Please refer to A-0701 for further information.”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 21229 Based on observation, staff interview, facility document review and during the course of a complaint investigation, the facility failed to ensure the safety of each patient by insufficiently cleaning ice machines that provide ice to patients and by not cleaning and maintaining ventilation system. The findings included: Ice machines On June 3, 2024, the surveyor observed six (6) randomly sampled ice machines that were disassembled in order to visualize the internal ice reservoir. Upon inspection, three (3) of the six (six) ice machines contained a residue, a gray/tan/greenish slimy substance in the bottom of the ice reservoir. These observations were witnessed and confirmed by the facility staff who accompanied the surveyor on the tour. After consultation with the State Agency and CMS, and based on the above noted observations, the surveyor identified and notified the facility staff on June 3, 2024 at 5:25 p.m. of the finding of Immediate Jeopardy (IJ). The serious concerns regarding observed contamination of ice machines presenting potential for serious harm and exposure to potential infections were discussed with the facility leadership and an immediate plan of removal was requested. On June 4, 2024 at 9:30 a.m., the facility presented an acceptable plan of removal. In summary, the plan of removal included a one-hundred percent (100%) full review of twenty-four (24) ice machines in the facility and off-site locations. Bottled water and ice were provided to the units by the dietary department. Terminal cleaning was conducted for all ice machines as well as the changing of filters and the replacement of four (4) ice machines to include the three (3) identified by the surveyor. On June 5, 2024 at 11:25 a.m., after making observations, conducting interviews, reviewing documentation and consultation with the State Agency and CMS, the surveyor notified the facility of the removal of the Immediate Jeopardy, however condition level noncompliance remained. Please refer to A-0724 for further information. Air duct/vents The surveyor observed the exterior and interior of three (3) air duct/vent units located in patient rooms on June 4, 2024 at 11:10 a.m. The air ducts/vents were located underneath the window in each room. The interior of each inspected duct/vent contained large amounts of reddish and black debris, trash (food wrappers, lids, straws, plastic utensils, a blood glucose strip, needle cap, alcohol swabs, condiment packets etc) as well as brown and black liquid, of an unknown source coating the inside and bottom of the vent/duct and on the underside of the grill. The internal “insulation” along the sides of the duct/vent was on visual inspection completely black and when touched, pieces of the black substance fell off. These observations were witnessed and confirmed by the facility staff who accompanied the surveyor on the tour. After consultation with the State Agency and CMS, and based on the above noted observations, the surveyor identified and notified the facility staff on June 4, 2024 at 4:25 p.m. of the finding of Immediate Jeopardy (IJ). The serious concerns regarding potential for infections originating from compromised air ducts/vents and lack of cleaning/maintenance of the air ducts/vents were discussed with the facility leadership. An immediate plan of removal was requested. On June 7, 2024 at 12:00 p.m. the facility presented an acceptable plan of removal. In summary, the plan included to start terminal cleaning of vents/ducts in vacant patient rooms and relocation of patients in the affected rooms to rooms with terminally cleaned air vents. The initiation of terminal cleaning of all 259 air ducts/vents in the patient rooms by certified technician and a sample validation of the cleaning by a member of Operations, Quality and/or Infection Prevention. Terminal cleaning of the room by EVS (Environmental Services) would follow the vent/duct cleaning. After making observations, conducting interviews, reviewing documentation and consultation with the State Agency and CMS, the surveyor notified the facility of the removal of the Immediate Jeopardy on June 7, 2024 at 1:15 p.m., however condition level noncompliance remained. Please refer to A-0701 for further information.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 21229 Based on observation, staff interview, facility document review and during the course of a complaint investigation, the Quality Program failed to ensure the monitoring and oversight of the internal cleaning of the ice machines and identify the failure of the facility to clean and maintain the air ducts/vents. The findings include: Ice machines The ice machines were on a quarterly cleaning schedule, however, there was no oversight/evaluation of the cleaning process and the quarterly schedule’s effectiveness to maintain cleanliness and safety of the ice provided to patients, visitors and staff. The surveyor discussed the above noted observations with Staff Member #1 on June 5, 2024 at 1:15 p.m. Staff Member #1 indicated that the ice machines had been on a schedule since 2021 for routine cleaning and inspection of the external unit as well as a validation of the cleaning weekly by Infection Prevention and the Environment of Care (EOC) team on rounds. The surveyor inquired as to the status of the person who was cleaning the machines; if they were contract or a facility employee. Staff Member #1 indicated the person was a corporate maintenance member and that they would be considered an employee; that they were a part of the health system. Staff Member #1 explained that the “corporate” person had not informed the facility of any concerns related to the ice machines and there was nothing on the cleaning reports that indicated a problem. Staff Member #1 stated, “I wish (they) would have informed us that they were finding this when they came to clean. We certainly would have insisted that the cleaning schedule be changed to a more frequent schedule in order to prevent this from happening...we will make sure oversight and validation is done...there will be a routine schedule...” The surveyor attempted during the course of the survey to interview the corporate maintenance member responsible for cleaning of the ice machines on multiple occasions but was told they were not available. The review of ice machine quarterly maintenance documents contained only information related to the cleaning process of the ice machine completed that day and failed to document the ice machine’s condition prior to start of the cleaning procedure nor provided any recommendations for changes in schedule or cleaning process in the future. Review of facility’s Quality and Improvement Meeting Minutes for the past twelve months failed to document any issues or improvement projects related to ice machines. Air vents The internal air ducts/vents in the patient rooms were not regularly inspected, maintained nor cleaned. There was no schedule or policy for routine cleaning, inspection and/or maintenance. During an interview on June 5, 2024 at 1:15 p.m. Staff Member #1 was asked about the non-existent inspection and cleaning of the air ducts/vents in the patient rooms and indicated, “We had no routine schedule or policy regarding the cleaning of the ducts. There was daily cleaning of the outside and the top part of the grills by EVS (Environmental Services) and the terminal cleaning of the rooms when a patient was discharged, but no one was opening the grill to see what was inside...they are cleaning all the vents now and there will be a routine schedule...” This facility is required to follow NFPA 90A (The National Fire Protection Association), which covers construction, installation, operation, and maintenance of air conditioning and ventilating systems, including filters, ducts, and related equipment. Appendix B under section B.4 requires air ducts to be inspected and cleaned quarterly and under section B-8 fans that distribute air to be inspected and cleaned quarterly. In addition, the facility is to follow Virginia Maintenance Code, which in Chapter 6 section 607.1 states in part, “...duct systems shall be maintained free of obstructions and shall be capable of performing the required function.” Review of facility’s Quality and Improvement Meeting Minutes for the past twelve months failed to document any issues or improvement projects related to cleaning or maintenance of the ventilation system.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 21229 Based on observation, staff interview, review of facility documents and during the course of a complaint investigation, the facility failed to maintain the condition of the physical plant and environment to ensure safety and well being of patients. Specifically, the facility failed to ensure adequate cleaning of the ventilation system as evidenced by observation of large amounts of debris in vents of three air units located in patient rooms. The findings include: This facility is required to follow NFPA 90A (The National Fire Protection Association), which covers construction, installation, operation, and maintenance of air conditioning and ventilating systems, including filters, ducts, and related equipment. Appendix B under section B.4 requires air ducts to be inspected and cleaned quarterly and under section B-8 fans that distribute air to be inspected and cleaned quarterly. In addition, the facility is to follow Virginia Maintenance Code, which in Chapter 6 section 607.1 states in part, “...duct systems shall be maintained free of obstructions and shall be capable of performing the required function.” On June 4, 2024 at 11:10 a.m. during a tour with Staff Members #7, 12, 15, 16, and 24, the surveyor randomly inspected the exterior and interior of vent/duct air units in three (3) occupied patient rooms. The air ducts/vents were located underneath the window in each room. Visual inspection of air duct/vent grills and the interior of vent/duct revealed reddish and black colored debris, multiple items of trash, brown and black liquid unknown substance, and insulation that was completely black and fell apart when touched. One of the rooms included in sample housed a patient (Patient #1) who was identified by a sign on the door as being on “neutropenic precautions” (When a person has a very low white blood cell count they are susceptible to infections. Neutropenic precautions - gloves, gowns, masks worn by staff and visitors are taken to keep the patient from being exposed to potentially harmful bacteria/germs/infections. www.mayoclinic.org accessed June 10, 2024 at 11:36 a.m.) The surveyor inquired as to whether there was a schedule for vent cleaning and requested maintenance logs and a policy and procedure related to the vent/duct cleaning process on June 4, 2024 at 2:30 p.m. On June 4, 2024 at 3:45 p.m. Staff Member #21 indicated the facility has no maintenance schedule, policy or procedure for the duct/vent cleaning. Staff Member #21 also indicated there are no filters located inside the individual ducts in the rooms and there is “no manufacturer’s recommendations for cleaning”. On June 5, 2024 at 12:20 p.m. Staff Member #15, Infection Preventionist indicated that they had not been aware of any vent/air duct issues and that they “would be involved from this point forward”. Staff Member #15 also indicated they would be involved in the validation of the cleaning process. Staff Member #1 indicated in an interview on June 5, 2024 at 1:15 p.m. that there were no action plans/projects in the Quality Meetings with regards to vent/air duct cleaning or concerns because “they are not on any type of cleaning schedule, but they will be going forward...If we would have been aware we would have been involved...””

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 21229 Based on observation, staff interview, facility document review and during the course of a complaint investigation, the facility failed to maintain and prevent potential contamination of ice machines providing ice to patients, visitors and staff. Three of six randomly sampled ice machines contained a gray/tan/greenish slimy substance in the ice reservoir. The findings include: On June 3, 2024 at approximately 11:45 a.m. during a tour of the facility accompanied by Staff Members #2, 5, 6, 9, 10, 12, and 13, the surveyor inspected the exterior and interior of six (6) randomly selected ice machines located on 3 East and West, Rehab Unit, 5 East and West, and Labor and Delivery Unit. Of the six (6) machines inspected, three (3) units on 3 West, 5 West and Labor and Delivery all contained a gray/tan/greenish slimy substance in the bottom of the ice reservoir. This substance came in direct contact with the ice in the reservoir. The surveyor inquired about the frequency of the ice machines cleaning and Staff Member #10 indicated “All the machines are cleaned on a quarterly basis by (name) who is a corporate maintenance person from our Capitol Division.” The surveyor requested PM (preventative maintenance) and the current policy and procedure for the ice machine cleaning. The surveyor reviewed the previous twelve (12) months of cleaning logs for the ice machines which evidenced the cleaning was being completed on a quarterly basis. The last cleaning of the units with visible slimy substance in ice reservoir was completed on April 24, 2024 (Labor and Devivery ) and on May 8, 2024 (3West and 5 West). There was no documentation in the logs of any issues/concerns related to machine condition and/or any observation of the build-up of substance in the bottom of the reservoirs prior to starting cleaning. The logs contained only information related to the cleaning process followed on the day of the ice machine was cleaned and failed to include any recommendations for changes in cleaning frequency or process in the future. There was documentation that the external parts of the ice machines were being cleaned daily by EVS (Environmental Services) and that those cleanings were verified by an inspection from Infection Prevention rounds weekly. Staff Member #9 and #10 indicated on June 3, 2024 at 11:45 a.m. that they had not been told by the “Corporate Maintenance” person that there were any concerns with the ice machines. Staff Member #10 also indicated they did not “go behind” the “corporate” person to inspect their work. Staff Member #15, on June 5, 2024 indicated during an interview at 1:00 p.m. that they were not aware of any residue issues being reported by the person cleaning the ice machines, “I wish (they) would have let us know (they) were seeing a problem...” Staff Member #15 explained that they with other members of Infection Prevention rounded and ensured the cleanliness of the external parts of the ice machines weekly. The surveyor was provided a document that the “Corporate” Staff Member received a certificate on May 17, 2024 for “Successfully completing an online course covering the servicing of the icemaker water systems of [brand name] ice and water dispensers”. The surveyor requested further documentation of previous training, however this was not provided at the time of exit. The surveyor was also provided on June 5, 2024 at 1:12 p.m., a documentation related to the cleaning and servicing of the ice machines which reveled in part, “Semi-annually (more often if conditions dictate) -A cleaning procedure should always include both the ice machine and dispenser. -Icemaking system can be cleaned in place...” The document detailed the dis-assembly and cleaning procedure including removing all ice, use of cleaning product, and the rinsing process. Staff Member #16 indicated the “facility follows the manufacturer’s directions”. Staff Member #1 indicated in an interview on June 5, 2024 at 1:00 p.m. that there were not any concerns communicated to Quality related to the ice machines. Staff Member #1 indicated there were no ice machine issues brought to their attention.”

“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 interview and document review, the nursing staff failed to ensure DVT (deep venous thrombosis) prophylaxis was in place as ordered for one (1) of five (5) patients included in the survey sample. Patient #5 The findings include: Surveyor review of medical records on 1/3/24 at 11:00 AM found the following in part: Patient #5 was admitted to the hospital after undergoing a right colectomy with ileocolostomy on 6/5/23. SCDs (sequential compression device) used for DVT prophylaxis was ordered for the patient. An anticoagulant was not ordered for Patient #5. The surveyor determined nursing staff had implemented bilateral SCD’s on 6/5/23 at 3:32 PM. SCDs are documented as none or “refused” after 6/8/23 at 8:45 AM. The medical record did not provide documentation the provider was notified of the patient’s refusal to wear SCDs. Patient #5 was transferred to ICU on 6/13/23 due to severe abdominal pain and respiratory distress. A CTA chest was completed and showed a PE (pulmonary embolism, PE is a sudden blockage in a lung artery. It usually happens when a blood clot breaks loose and travels through the bloodstream to the lungs) Retrieved from Medlineplus.gov on 1/11/24. In an interview on 1/4/23, Staff Member (SM) #7 stated they would expect nursing staff to notify them if a patient refuses to wear ordered SCDs. SM #7 stated if made aware that a patient was not using SCDs as ordered they would look at alternate methods of DVT prophylaxis such as an anticoagulant and counsel the patient on the risks of refusal.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 46466 Based on medical record and facility document review, the facility staff failed to renew a violent restraint physician order within four (4) hours for one (1) of six (6) patients included in the survey sample. (Patient #1) The findings include: On 12/26/23 at 2:10 p.m., a review of six (6) sampled patient records was conducted. Staff Members #1 (SM1) and #2 (SM2) navigated the review of the medical records. On 12/9/23 at 7:12 p.m., violent restraints were ordered for Patient #1 (Pt.1). There was no documentation that the restraints were removed. The next physician order for Pt.1 violent restraints was documented on 12/9/23 at 12:03 a.m., fifty-one (51) minutes after the first order expired. A review of the facility’s policy “Patient Restraint/Seclusion”, last revised 7/2023 stated in part: “...5B. Order for Restraint with Violent or Self-Destructive Behavior...Orders for restraint or seclusion must not exceed: 1. Four hours for adults, aged 18 years and older...b. To continue restraint or seclusion beyond the initial order duration, the RN...calls the ordering physician or licensed practitioner...to obtain a renewal order. Renewal orders for restraint/seclusion may not exceed: 1. Four hours for adults, aged 18 years or older...”. The findings were discussed with Staff Members #2, #4, #14 and #15 at the exit conference on 12/27/23 at 12:15 p.m.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 46466 Based on interview, medical record and facility document review, the facility staff failed to provide a timely one hour face to face with one (1) of six (6) patients in restraints included in the survey sample. The findings include: On 12/26/23 at 2:10 p.m., a review of six (6) sampled patient records was conducted. Staff Members #1 (SM1) and #2 (SM2) navigated the review of the medical records. On 12/9/23 at 7:12 p.m., violent restraints were ordered for Patient #1 (Pt.1). The assigned Registered Nurse documented that Pt.1’s restraints were placed on 12/9/23 at 7:30 p.m. The facility’s second tier review was documented as complete at 10:45 p.m. on 12/9/23 by another RN, three (3) hours and thirty-three minutes after the restraints were placed on Pt.1. During the medical record review, Staff Member #1 stated that the Second Tier of Review was the one (1) hour face to face with the patient in restraints. A review of the facility’s policy “Patient Restraint/Seclusion”, last revised 7/2023, stated in part: “...5. Second Tier of Review: 1. A member of nursing administration/management (e.g., nursing supervisor/manager, charge nurse, manager/director, CNO, etc.) will review the need for restraint or seclusion with the RN who has determined that the patient requires restraint or seclusion. The second tier of review will occur with the initial application of restraint or seclusion...”. The findings were discussed with Staff Members #2, #4, #14 and #15 at the exit conference on 12/27/23 at 12:15 p.m.”