Virginia Hospital Center

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 42929 Based on review of medical records (MR), review of documents, and interviews with staff (EMP), it was determined the facility staff failed to document pain assessments and pain reassessment after administering pain medication for six (6) of seven (7) patients’ medical records reviewed for pain assessments and pain reassessessments, MR6, MR7, MR8, MR10, MR21, and MR22. Findings: Review of facility document “Pain Assessment and Management Procedures” last revised March 2021 reads in part: “... Pain Assessment and Reassessment: 1. The patient should be reassessed for pain at the following times: 1. Upon initial evaluation (such as admission).... 5. After providing pharmacological or non-pharmacological treatment for pain. 1. Oral Pain Medication: Re-assess within [sixty] 60 minutes after. 2. Parenteral Pain Medication: Reassess after 15 to 30 of administration.... Assess for pain utilizing the Numeric Pain Intensity Scale (0-10).... Document assessment score in the EMR [electronic medical record]....” MR6 Review of the medication administration report (MAR) and pain assessment flow sheet for MR6 revealed documentation of an order for ibuprofen 600 mg by mouth that was administered on: May 15, 2025, at 12:44 PM and 7:04 PM; May 16, 2025, at 1:31 AM, 7:16 AM, 1:23 PM, and 7:25 PM; May 17, 2025, at 1:01 AM, 6:56 AM, 1:16 PM, and 7:12 PM; May 18, 2025, at 7:08 AM, 1:04 PM, and 6:31 PM; and May 19, 2025, at 12:28 AM, 12:04 PM, and 6:34 AM. There was no documentation of a pain assessment or pain reassessment for those medication administrations. Review of the MAR and pain assessment flow sheet for MR6 revealed documentation of an order for acetaminophen 650 mg by mouth for mild pain that was administered on: May 15, 2025, at 1:06 AM, 2:50 PM, and 9:34 PM; May 16, 2025, at 3:51 AM, 9:33 AM, 3:07 PM, and 9:02 PM; May 17, 2025, at 3:23 AM, 9:32 AM, and 3:18 PM; May 18, 2025, at 3:25 AM, 9:31 AM, and 3:31 PM; and May 19, 2025, at 12:27 AM, 6:34 AM, and 12:03 PM. There was no documentation of a pain assessment or pain reassessment for those medication administrations. Review of the MAR and pain assessment flow sheet for MR6 revealed documentation of an order for oxycodone 5 mg PRN by mouth for moderate pain that was administered on: May 15, 2025, at 4:47 PM and 9:34 PM; May 16, 2025, at 1:31 AM, 5:46 AM, 9:33 AM, 1:23 PM, and 5:31 PM; May 17, 2025, at 1:01 AM, 4:58 AM, and 9:32 AM; and May 18, 2025, at 9:31 AM and 1:05 PM. There was no documentation of a pain assessment or pain reassessment for those medication administrations. Review of the MAR and pain assessment flow sheet for MR6 revealed documentation of an order for oxycodone 10 mg PRN by mouth for severe pain that was administered on: May 16, 2025, at 9:01 PM; May 17, 2025, at 1:15 PM and 5:15 PM; May 18, 2025, at 5:06 PM and 9:48 PM; and May 19, 2025, at 1:50 AM, 6:34 AM, and 10:22 AM. There was no documentation of a pain assessment or pain reassessment for those medication administrations. MR7 Review of the MAR and pain assessment flow sheet for MR7 revealed documentation of an order for acetaminophen 1,000 mg by mouth that was administered on May 13, 2025, at 8:50 AM. There was no documentation of a pain assessment or pain reassessment for that medication administration. Review of the MAR and pain assessment flow sheet for MR7 revealed documentation of an order for morphine 2 mg by injection that was administered on May 13, 2025, at 3:30 PM. There was no documentation of a pain assessment or pain reassessment for that medication administration. Review of the MAR and pain assessment flow sheet for MR7 revealed documentation of an order for acetaminophen 650 mg by mouth for mild pain that was administered on: May 13, 2025, at 2:58 PM; May 14, 2025, at 9:05 AM, 2:37 PM, and 8:23 PM; May 15, 2025, at 3:14 AM, 9:06 AM, 3:01 PM, and 9:00 PM; May 16, 2025, at 2:29 AM, 8:36 AM, 2:58 PM, and 9:21 PM; and May 17, 2025, at 3:28 AM and 9:31 PM. There was no documentation of a pain assessment or pain reassessment for those medication administrations. Review of the MAR and pain assessment flow sheet for MR7 revealed documentation of an order for ibuprofen 600 mg by mouth that was administered on: May 14, 2025, at 2:37 PM and 8:23 PM; May 15, 2025, at 3:15 AM, 9:06 AM, 3:01 PM, and 9:01 PM; May 16, 2025, at 2:29 AM, 8:35 AM, 2:59 PM, and 9:21 PM; and May 17, 2025, at 3:28 AM and 9:31 AM. There was no documentation of a pain assessment or pain reassessment for those medication administrations. Review of the MAR and pain assessment flow sheet for MR7 revealed documentation of an order for ketorolac 15 mg by intravenous (IV) that was administered on May 14, 2025, at 8:35 AM. There was no documentation of a pain reassessment for that medication administration. Review of the MAR and pain assessment flow sheet for MR7 revealed documentation of an order for oxycodone 10 mg PRN by mouth that was administered on May 14, 2025, at 11:02 AM, 3:21 PM, 7:30 PM, and 11:07 PM; on May 15, 2025, at 3:15 AM, 7:03 AM, 10:57 AM, 3:01 PM, 7:16 PM, and 11:11 PM; and on May 16, 2025, at 2:29 AM, 6:24 AM, and 10:31 AM. There was no documentation of a pain assessment or reassessment for those medication administrations. Review of the MAR and pain assessment flow sheet for MR7 revealed documentation of an order for oxycodone 5 mg PRN by mouth that was administered on: May 13, 2025, at 1:29 PM; May 14, 2025, at 7:09 AM; May 16, 2025 at 3:03 PM, 7:40 PM, and 11:25 PM; and May 17, 2025, at 3:28 AM, 7:14 AM, and 11:40 AM. There was no documentation of a pain assessment or pain reassessment for those medication administrations. MR8 Review of the MAR and pain assessment flow sheet for MR8 revealed documentation of an order for acetaminophen 650 mg by mouth for mild pain that was administered on: May 13, 2025, at 5:50 PM; May 14, 2025, at 12:33 AM, 6:00 AM, 11:34 AM, 5:42 PM, and 11:37 PM; May 15, 2025, at 6:51 AM, 12:57 PM, and 7:31 PM; and May 16, 2025, at 2:07 AM, 8:19 AM, and 2:31 PM. There was no documentation of a pain assessment or pain reassessment for those medication administrations. Review of the MAR and pain assessment flow sheet for MR8 revealed documentation of an order for ibuprofen 600 mg by mouth that was administered on: May 13, 2025, at 7:25 PM; May 14, 2025, at 1:35 AM, 1:13 PM, and 7:14 PM; May 15, 2025, at 12:43 AM, 6:51 AM, 12:57 PM, and 7:31 PM; and May 16, 2025, at 2:07 AM, 8:19 AM, and 2:31 PM. There was no documentation of a pain assessment or pain reassessment for those medication administrations. Review of the MAR and pain assessment flow sheet for MR8 revealed documentation of an order for oxycodone 5 mg PRN by mouth for moderate pain that was administered on: May 14, 2025, at 6:02 AM, 10:02 AM, 1:13 PM, and 3:54 PM; and May 16, 2025, at 2:07 AM, 6:12 AM, 10:39 AM, and 2:31 PM. There was no documentation of a pain assessment or pain reassessment for those medication administrations. Review of the MAR and pain assessment flow sheet for MR8 revealed documentation of an order for oxycodone 10 mg PRN by mouth for severe pain that was administered on: May 14, 2025, at 8:05 PM; and May 15, 2025, at 12:43 PM, 5:08 AM; 12:57 PM, 5:11 PM, and 10:21 PM. There was no documentation of a pain assessment or pain reassessment for those medication administrations. There was no pain reassessment after oxycodone 10 mg PRN was administered on May 15, 2025, at 9:00 AM. MR22 Review of the MAR and pain reassessment flow sheet for MR22 revealed documentation of an order for acetaminophen 1,000 mg by mouth that was administered on May 13, 2025, at 2:02 PM. There was no documentation of a pain assessment or pain reassessment for that medication administration. Review of the MAR and pain reassessment flow sheet for MR22 revealed documentation of an order for acetaminophen 650 mg by mouth for mild pain that was administered on: May 13, 2025, at 10:05 PM; May 14, 2025 at 3:57 AM, 10:12 AM, 3:39 PM, and 9:41 PM; and May 15, 2025, at 3:27 AM, 9:06 AM, and 3:01 PM. There was no documentation of a pain assessment or pain reassessment for those medication administrations. Review of the MAR and pain reassessment flow sheet for MR22 revealed documentation of an order for ibuprofen 600 mg by mouth that was administered on: May 14, 2025, at 12:08 PM and 6:13 PM; and May 15, 2025, at 12:19 AM, 5:58 AM, and 12:04 PM. There was no documentation of a pain assessment or pain reassessment for those medication administrations. Review of the MAR and pain reassessment flow sheet for MR22 revealed documentation of an order for ketorolac 15 mg by IV that was administered on: May 13, 2025, at 6:52 PM; and May 14, 2025, at 12:28 AM and 6:25 AM. There was no documentation of a pain assessment or pain reassessment for those medication administrations. MR10 Review of the emergency department medical record for MR10 dated November 1, 2025, revealed no nursing documentation of a pain assessment for MR10 who presented to the emergency department with a lip laceration. MR21 Review of the MAR and pain assessment flow sheet for MR21 revealed documentation of an order for acetaminophen 650 mg by mouth for mild pain that was administered on: January 12, 2026, at 4:32 PM and 10:28 PM; and January 13, 2025, at 5:31 AM, 5:24 PM, and 11:39 PM. There was no documentation of a pain assessment or pain reassessment for those medication administrations. Review of the MAR and pain assessment flow sheet for MR21 revealed documentation of an order for ibuprofen 600 mg by mouth that was administered on January 13, 2025, at 5:31 AM, 5:24 PM, and 11:38 PM. There was no documentation of a pain assessment or pain reassessment for those medication administrations. Review of the MAR and pain assessment flow sheet for MR21 revealed documentation of an order for ketorolac 15 mg by IV that was administered on January 12, 2026, at 4:32 PM and 10:28 PM. There was no documentation of a pain assessment or pain reassessment for those medication administrations. Interview on January 13, 2026, at 3:47 PM, EMP35 indicated that the nurse should assess a patient’s pain level when the pain medication is administered and then reassess the patient’s pain level within one (1) hour of administering pain medication. During review of the medical records for MR6, MR7, MR8, MR21, and MR22, EMP35 confirmed there was no other documentation of a pain assessment or pain reassessment for the above medications administered for pain in the medical records. Interview on January 14, 2026, at 1:09 PM, EMP65 indicated that the nurse should assess the patient’s pain level at the time of administering all pain medications including scheduled and PRN medications. The pain assessment should be documented in the pain assessment flow sheet. Pain should be reassessed within one (1) hour of administered PRN (as needed) medications and documented in the pain assessment flow sheet. Pain does not need to be reassessed for scheduled medications.”

“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 medical record review and facility document review, it was determined the facility failed to obtain an order for the use of restraints, according to facility policy, for one (1) of nine (9) medical records (MR) sampled. The findings include: A review of the facility’s policy “Use of Patient Restraints or Seclusion”, last revised 1/2025, indicated in part: ...3. Physical Hold Restraints: a. Order. 1. Obtain an order from Licensed Independent Practitioner (LIP) prior to initiation (exception: Emergency application). a. Emergency application: Nurse may initiate if LIP not available and nurse assesses need for immediate intervention to prevent the patient from harming self or others. The LIP must be notified and the order obtained either during the emergency application or immediately thereafter...”. Review of Patient #6’s medical record revealed that Patient #6 was placed in a physical hold at approximately 6:00 AM on July 29, 2025. The medical record revealed that the LIP’s order was not placed until 7:11 PM on the same day.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 46466 Based on medical record reviews and facility document reviews, it was determined the facility failed to discontinue the use of restraints at the earliest possible time for one (1) of nine (9) medical records (MR) sampled. The findings include: A review of the facility’s policy “Use of Patient Restraints or Seclusion”, last revised 1/2025, indicated in part: “...6. Discontinuation of Any Restraint, Seclusion, or Physical Hold - Restraint or seclusion must be removed at the earliest possible time...Restraints must be removed as soon as the patient demonstrates desired behaviors...”. A review of Patient #5’s medical record revealed that Patient #5 was placed in non-violent restraints at approximately 8:00 AM on July 21, 2025 for pulling at lines. The Registered Nurse (RN) documented at 10:00 AM, 12:00 PM, 2:00 PM and 3:15 PM, that Patient #5 was “asleep”. There was no other documentation to support that Patient #5 was displaying behaviors to meet the restraint criteria at those times.”

“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 medical record and facility document review, it was determined the facility failed to monitor the condition of patients who were placed in physical holds, according to facility policy, for two (2) of nine (9) medical records (MR) reviewed (Patient #6 and Patient #8). The findings include: A review of the facility’s policy “Use of Patient Restraints or Seclusion”, last revised 1/2025, indicated in part: “...3. Physical Hold Restraints...b. Monitoring and Documentation...ii. Discontinuation Assessment - occurs at the time of discontinuation for the Physical Hold restraint, - Must be documented in the EMR or appropriate downtime flowsheet...”. Patient #6’s medical record revealed that Patient #6 was placed in a physical hold on July 29, 2025 at 5:54 AM and released from the physical hold at 5:57 AM. The medical record didn’t contain any documentation of Patient #6’s assessment after the physical hold was discontinued. Patient #8’s medical record revealed that Patient #8 was placed in a physical hold on July 13, 2025 at 2:00 AM and released from the physical hold at 2:05 AM. The medical record didn’t contain any documentation of Patient #8’s assessment after the physical hold was discontinued.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(i) When restraint or seclusion is used, there must be documentation in the patient’s medical record of the following: The 1-hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior. This Standard is not met as evidenced by: 46466 Based on medical record reviews and facility document reviews, it was determined the facility failed to document a face-to-face assessment within one (1) hour of placing patients in restraint or seclusion for two (2) of nine (9) medical records (MR) reviewed (Patient #6 and patient #8). The findings include: A review of the facility’s policy “Use of Patient Restraints or Seclusion”, last revised 1/2025, indicated in part: “...3. Physical Hold Restraints...b. Monitoring and Documentation...iii. Face to Face Assessment - LIP must assess the patient face to face within 1 hour of application of restrains and/or use of seclusion - Must be documented in the MR or appropriate downtime flowsheet...”. Patient #6’s medical record revealed that Patient #6 was placed in a physical hold on July 29, 2025 at 5:54 AM and released from the physical hold at 5:57 AM. The medical record didn’t contain provider’s documentation of an face-to-face assessment within one hour of placing Patient #6 in physical hold. Patient #8’s medical record revealed that Patient #8 was placed in a physical hold on July 13, 2025 at 2:00 AM and released from the physical hold at 2:05 AM. The medical record didn’t contain provider’s documentation of an face-to-face assessment within one hour of placing Patient #8 in physical hold.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 36946 Based on staff interview and document review, it was determined the facility failed to ensure all licensed nurses adhered to hospital policies and procedures. Specifically, nursing staff failed to follow hospital policy related to conducting a head-to-toe assessment to include a skin assessment in one (1) of nine (9) medical records reviewed in the survey sample. Patient #3 (P3). Findings: A review of the facility’s policy, “Acute Care Services Level of Care Policy” (10/2024) reads in part, “...Nursing Assessment: A full head-to-toe assessment will be charted at various intervals during a 12-hour nursing shift based off the level of care...General care - full assessment documented every twelve hours (recommended at 8 AM and 8 PM). More focused assessments can be completed as needed.” The facility’s policy, “Pressure Injury and Prevention and Treatment Guidelines for Adults and Pediatrics 8 Years and Older” last revised May 2022 was reviewed and reads in part, “...Assessment Procedure...skin assessments should be completed at change of shift utilizing the Braden Scale Assessment. Documentation of each assessment should include the following: 1, Integumentary flow sheet assessment. 2. Braden scale flowsheet assessment 1. Include all current preventative measures and interventions in place. 2. Include the current bed type under the patient...” P3’s medical record contained documentation that two (2) nurses performed a skin assessment that revealed redness to bilateral heels and sacrum upon admission. A nursing care plan was initiated for the patient on December 24, 2024 at 1:44 AM that included “Potential for compromised skin integrity.” The following interventions were documented, “Every shift - monitor for areas of redness/skin breakdown; turn and reposition every two hours; suspend heels using pillow or device; implement toileting schedule; encourage mobility as appropriate; limit linen layers; utilize external urinary containment device; skin care to include moisturizers and protective dressings; utilize moisture management pad; promote and monitor adequate nutrition intake.”” P3 was noted to have developed a left heel deep pressure injury and stage one pressure injury to the right heel and sacrum on December 31, 2024. The medical record for P3 failed to contain a head-to-toe shift assessment to include a skin assessment from the 07:00 AM to 7:00 PM shift on December 30, 2024. An interview was conducted with EMP4 (employee) during record review on April 16, 2025 at approximately 1:00 PM. EMP4 confirmed that a full head-to-toe assessment should be completed each nursing shift and P3’s medical record failed to contain a nursing shift assessment on December 30, 2024 from 7:00 AM to 7:00 PM.”

“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: 40084 Based on staff interview and facility document review, it was determined that the facility failed to comply with §489.24 by conducting an inappropriate medical screening exam for a patient presenting to the emergency department with an emergency medical condition (A-2406). The findings include: See Tag A-2406 Based on staff interview and document review, it was determined hospital staff failed to conduct an appropriate medical screening exam on each individual that presented to the emergency department (ED) in one (1) of twenty (20) medical records reviewed in the survey sample (Medical Record (MR)6).”

“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: 36946 Based on staff interview and document review, it was determined hospital staff failed to conduct an appropriate medical screening exam on each individual that presented to the emergency department (ED) in one (1) of twenty (20) medical records reviewed in the survey sample (Medical Record (MR)6). Findings: The facility’s policy, “EMTALA Policy: Emergency Medical Screening, Treatment, and Transfer Policy” last revised March 2024 was reviewed and reads in part, “ ...It is the policy of Virginia Hospital Center Arlington Health System and its subsidiaries (collectively, ‘VHC Health’) to provide an appropriate medical screening to any individual who comes to a VHC Health Dedicated Emergency Department ...An emergency medical condition is a condition manifesting symptoms (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) which, in the absence of immediate medical attention, is likely to cause serious dysfunction or impairment to a bodily organ or function or serious jeopardy to the health of the individual or unborn child ...Any individual who comes to the Dedicated Emergency Department, either by ambulance or walk-in, requesting examination or treatment shall be provided with an appropriate medical screening examination (MSE). A. The purpose of an MSE is to determine if an individual is experiencing an Emergency Medical Condition ...A patient experiencing an Emergency Medical Condition must be stabilized prior to being discharged or transferred ...A patient may be discharged after the Emergency Medical Condition has been addressed or after a determination has been made that the patient is sufficiently stable for discharge ...the patient must be provided with a plan for appropriate follow-up care with discharge instructions.” The medical record for MR6 contained documentation that the patient first presented to the ED on January 26, 2025, at 7:47 AM for complaints of suicidal ideation and leg pain. The patient was medically cleared. The patient was seen by psychiatry in the ED and cleared to be discharged to outpatient treatment. The patient was discharged and taxicab transportation arranged to outpatient facility. MR6 returned to the ED at 7:04 AM on January 28, 2025. The patient was brought in by Emergency Medical Services (EMS) with a chief complaint of suicidal ideation and plan. OTHMD1 (contracted physician) documented at 7:04 AM, “ ...41-year-old male with history of suicidal ideation with previous psychiatric admission and malingering who presents to the ED with laceration to the left thumb and same complaints of previous ED visit after being seen yesterday for leg pain and suicidal ideations. The patient was seen by psychiatry yesterday who told him to follow up with Fairfax CSB and was sent via cab. Patient was able to ambulate with steady gait. Patient was escorted by security after being verbally abusive towards staff. “ The provider’s physical exam indicated the patient was not in acute distress and was not ill appearing. The following systems were indicated as reviewed on physical exam and were normal: head, ear, nose, throat; eyes; cardiovascular; pulmonary; abdominal; musculoskeletal; skin; neurological. The psychiatric component had the following comment documented, “Unable to assess secondary to patient agitation.” The provider (OTHMD1) documented the following at 07:22 AM on January 28, 2025, “Patient became verbally aggressive towards nursing staff. Ambulating around ED and then was attempted to be redirected back to room by nursing staff ...patient started yelling, ‘you all are racist.’ Patient escorted out by security. Department of Human Services to be informed as patient was reporting suicidal ideation and is familiar to the Department of Human Services system to determine if patient needs a welfare check by police.” Documentation in the medical record indicated the hospital called Department of Human Services to make aware that the patient had left the ED. Nursing documentation at 7:09 AM indicated the patient was suicidal and homicidal and presently had thoughts of harming others. Nursing also documented the patient suicidal intent with a specific plan. At 7:22 AM RN2 (Registered Nurse) documented, “ ...This RN asked patient about treatment plan from yesterday and if he followed through. Patient became irate. This RN attempted to walk patient back to room as he is ambulatory and walked independently multiple times. Patient screamed that he is unable to walk. Patient continued to become irate. Patient then placed into wheelchair and [staff member] placed in hallway bed. Patient now calling this RN, ‘racist white [expletive]’ and verbally threatening this RN. Patient informed that there is a zero-tolerance policy against violence. Patient stated, ‘I don’t give a [expletive] about that call the [expletive] cops and I’ll get a felony.’ OTHMD1 witnessed behaviors and stated that patient can be escorted off of property by security due to high risk of patient causing harm to staff. Department of Human Services being called by scribe to inform them of patient and behaviors along with treatment plan that was set up yesterday.” Documentation indicated that MR6 was escorted off hospital property by security staff at 7:32 AM on January 28, 2025. The medical record contained no documentation that an emergency medical exam to include a psychiatric component was conducted to determine whether or not an emergency medical condition existed prior to hospital staff ordering security to escort MR6 off hospital property. There was no documentation in the record that interventions of any kind were ordered or offered to facilitate the exam or treatment of the patient. The patient returned to the ED via EMS at 7:58 AM on January 28, 2025 (less than 30 minutes after being escorted out by security previously). The patient continued to express suicidal ideation with plan. The patient was placed on the waiting list for the behavioral health unit at the facility at 10:40 AM. No male beds were available at that time. Referrals were sent to nine (9) other inpatient behavioral health facilities. The patient was transferred to an outside hospital for behavioral health services at 3:29 PM on January 28, 2025. An interview was conducted with RN2 (the charge nurse interacting with MR6 on January 28, 2025) on March 10, 2025, at 3:15 PM. RN2 indicated that MR6 came in with suicidal ideation and was verbally aggressive toward the nursing staff. RN2 indicated that OTHMD1 requested that security escort the patient from the building due to aggressive behavior and the patient left with security. RN2 stated that hospital staff called the Department of Human Services to notify that the patient was in the ED with suicidal ideation and to see if the police should be contacted to bring the patient back to the hospital in police custody. An interview was conducted with the emergency department’s medical director (OTHMD3) on March 10, 2025, at 3:20 PM. (OTHMD1 was unavailable for interview). OTHMD3 indicated that MR6 had been to the ED multiple times with the same complaint of suicidal ideation. MR6 was verbally aggressive and escalating and the physician (OTHMD1) had to compare the risk of harm to hospital staff to the risk of the patient’s self-harming behavior in a very short window of time. There was a real threat to hospital staff by the patient and security was called to escort the patient off the property. OTHMD3 indicated that there was usually a police officer on the unit, but no officer was present at this time. Calling the police would not have resulted in a timely response. OTHMD3 indicated that a medical screening exam should still be completed in the ED whether or not the patient was agitated or aggressive and that OTHMD3 appeared to be in stable condition to leave the ED. OTHMD3 indicated the Department of Human Services was immediately contacted to inform of the patient’s condition and to assess whether the patient should be brought back to the emergency department in police custody. MR6 came to the ED on January 28, 2025, at 7:04 AM with complaints of suicidal ideation and plan. There was no documentation in the medical record that a medical screening exam to include a psychiatric component to assess whether or not an emergency medical condition existed was conducted. There were no documented interventions in the medical record to facilitate the exam or treatment of the patient. MR6 became verbally aggressive and was escorted out of the hospital by security at the direction of the ED provider. The patient returned to the ED via EMS approximately a half an hour later with the same complaint (suicidal ideation and plan), was evaluated and transferred to an outside facility for inpatient psychiatric care.”

“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: 45736 Based on medical record review and interviews, the facility failed to ensure A, three (3) of three (3) patients (Patients #2, #3 and #4) medical records included documentation of hygiene and linen changes daily or patient’s refusal of hygiene and/or linen change; and B, one (1) of one (1) patients (Patients #3) medical record included documentation of patient being turned every two hours as per doctor’s order. The findings include: Patient #2 was admitted to this facility on December 13, 2024 and was discharged on December 17, 2024. During Patient #2’s hospitalization, the medical record failed to contain documentation of hygiene and linen changes, or patient refusal on December 14, 2024, December 15, 2024 and December 16, 2024. Patient #3 was admitted to this facility on December 11, 2024 and was discharged on December 17, 2024. During Patient #3’s hospitalization, the medical record failed to contain documentation of hygiene and linen changes, or patient refusal on December 13, 2024 and December 15, 2024. The medical record failed to contain documentation or lacked adequate documentation of Patient #3 being turned and repositioned every two hours, per doctor’s order, December 11, 2024 through December 17, 2024. Patient #4 was admitted to this facility on December 11, 2024 and was discharged on December 13, 2024. During Patient #4’s hospitalization, the medical record failed to contain documentation of hygiene and linen changes, or patient refusal on December 11, 2024, December 12, 2024 and December 13, 2024. In an interview on January 27, 2025, Staff Member #8, indicated that staff should be performing hygiene and linen changes at least once daily, more if needed, and then document in medical record that they were completed or document patient’s refusal. Staff Member #8 indicated that documentation of turning and repositioning of a patient every two (2) hours must be completed in the medical record with the specifics of what was completed; that includes, what side the patient is lying on, is the head of the bed elevated and any support devices used. During an interview on January 27, 2025, Staff Member #11, indicated that when staff completes hygiene and linen changes for a patient or the patient refuses, then this is to be documented in the patient’s medical record. Staff Member #11 explained that it is the expectation that patients are turned every two (2) hours as per doctor’s order and this must be documented in the medical record. A facility guideline, Clinical Technician Guidelines of Care- Acute Care, not dated, revealed, in part, “...Patient Experience. Tidy bed/room...Bathing. Daily soap and water bath- required to be offered for ALL patients...Quick clean-up for stools/incontinence- use foam and dry wipes...Linen change- to be offered daily. Document bath and linen change- Recommended to document in real time before leaving patient room. If patient refuses, document this as well. Use comment section to give detail..” The surveyor requested a facility policy and/or procedure for turning and repositioning and was given and outside source procedure, Lippincott Procedures- Pressure Injury Prevention, dated February 20, 2024. After reviewing this procedure document, it was determined that this did not address specific documentation requirements for turning and repositioning. The procedure revealed, in part, “...Documentation associated with pressure injury includes: ...Interventions used to prevent pressure injuries, response to interventions..” Staff Member #6 confirmed that this document was the only guidance the facility has on documenting turning and repositioning of patients every two (2) hours.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 46466 Based on medical record and facility document review the facility failed to document blood product transfusions according to facility policy for two (2) of three (3) patient records sampled. The findings include: On January 27, 2025, surveyor reviewed three (3) sampled patient medical records. On January 16, 2025, Patient #8 received a blood transfusion. The medical record didn’t contain documentation of the following: stop time, total volume transfused, completed time and suspected transfusion reaction. On January 16, 2025, Patient #9 received a blood transfusion. The medical record didn’t contain documentation of the patient’s vital signs were monitored at 15 minutes after the initiation and suspected transfusion reaction. A review of the facility’s policy “Preparing for Blood and Blood Product Transfusions at (facility name)”, last revised 2/2023, indicated in part: “...Monitor patient for the first 15 minutes of the transfusion, Minimum vital signs required: 15 minutes after initiation...Blood Transfusion documentation must be performed in the EMR Flowsheet...start, stop, total volume transfused, Completed, Suspected transfusion reaction must be documented in the Flowsheet...”.”