Inova Fairfax Hospital

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 42725 Based on interview and document review, it was determined the facility failed to ensure the established grievance process was followed for one of one written grievance reviewed in the survey sample (MR9). Findings: Facility document, IHS Patient Complaint/Grievance Process in the Hospital Policy, under the heading “Procedure”, it partly reads: “1. To define hospital complaint and grievance. [...] 4. To assure any patient, or their authorized representative, that their concerns or feedback are welcome and will be addressed within a reasonable time frame as directed [...]”. Under the heading “Definitions”, it partly reads: “[...] Patient Grievance - 1. Written or verbal complaint (when the verbal complaint about patient care is not resolved by the time of the complaint by staff present) by a patient, or the patient’s representative, regarding the patient’s care, abuse or neglect, or issues related to the hospital’s compliance with the Centers for Medicare and Medicaid Services’ (CMS) Hospital Conditions of Participation (CoP) [...]”. Under the heading “Detail”, it partly reads: “[...] 5. All grievances are responded to in writing. a. It is expected that many grievances can be resolved within 7 days. If the grievance cannot be resolved within 7 days, the hospital will provide a written acknowledgement within that time period. In the acknowledgement, the hospital will notify the complainant of the expected period of time (in most cases, 30 days) needed in order to resolve the grievance. b. If a grievance is not immediately resolved, it is expected the grievance can be resolved and the resolution communicated in writing within 30 days [...] d. The Patient Relations Department initiates the review process upon receipt of communication of a grievance to ensure compliance with the policy. The Patient Relations Department will maintain documentation of the grievance, including the details of the investigation and resolution [...]”. Interview on August 18, 2026 at 2:21 PM, EMP32 indicated that the patient relations department received an email with MR9’s concerns from the patient relations team that oversees the outpatient facilities. The email was received on June 29, 2026 and was forwarded to this facility’s patient relations distribution mailbox on June 30, 2026. EMP32 indicated they were notified of the email “in the evening of June 30, 2026”. EMP32 reported they went on bereavement leave and then there was a holiday so an email acknowledging the concerns was not sent to MR9 until July 15, 2026. EMP32 reported they had a telephone conversation with MR9 that same day (July 15, 2026). EMP32 shared the following email communication regarding MR9’s grievance: EMP32’s email contact to MR9 on July 15, 2026; EMP32’s sent an email to staff on the MR9’s treatment team July 15, 2026; EMP29’s email response on July 17, 2026; MR9 sending an email to EMP32 on July 30, 2026 at 8:20 AM requesting an update; EMP32 emailing the team for an update on July 30, 2026 at 8:33 AM; MR9 sending an email on August 6, 2026 at 9:29 AM requesting another update; EMP32 responding to MR9 on August 7, 2026 at 1:31 PM acknowledging MR9’s frustration and indicating EMP32 was waiting on additional information; and EMP26’s sending an email on August 17, 2026 after follow-up with the nursing staff. EMP32 acknowledged that MR9’s grievance response timeframe did not align with the facility’s policy.”

“PATIENT RIGHTS: INTERNAL DEATH REPORTING LOG CFR(s): 418.13(g)(2), (3)(ii), (4) [Death Reporting Requirements: Hospitals must report deaths associated with the use of seclusion or restraint.] (2) When no seclusion has been used and when the only restraints used on the patient are those applied exclusively to the patient’s wrist(s), and which are composed solely of soft, non-rigid, cloth-like materials, the hospital staff must record in an internal log or other system, the following information: (i) Any death that occurs while a patient is in such restraints. (ii) Any death that occurs within 24 hours after a patient has been removed from such restraints. (3) [The staff must document in the patient’s medical record the date and time the death was:] (i) Recorded in the internal log or other system for deaths described in paragraph (g)(2) of this section. (4) For deaths described in paragraph (g)(2) of this section, entries into the log or other system must be documented as follows: (i) Each entry must be made not later than seven days after the date of death of the patient. (ii) Each entry must document the patient’s name, date of birth, date of death, name of attending physician or other licensed practitioner who is responsible for the care of the patient medical record number, and primary diagnosis(es). (iii) The information must be made available in either written or electronic form to CMS immediately upon request. This Standard is not met as evidenced by: 42042 Based on facility document review, medical record review, and interview, the facility failed to ensure the medical record contained documentation of the date and time a patient’s death was recorded in the facility’s internal restraint death log for one (1) of three (3) restraint records reviewed (Patient #6). Findings: Facility policy titled, “IHS Restraints and Restraint Alternatives Policy,” stated, in part, “When no seclusion has been used, and when the only restraints used are those exclusively applied to the patient’s wrists and which are composed solely of soft, non-rigid cloth-like materials, the hospital staff must record ...The date and time the death was recorded in the electronic medical record, patient’s name, date of birth, name of attending physician, or other licensed practitioner who is responsible for the care of the patient, medical record number and primary diagnosis(es).” In the afternoon of 08/18/2026, reviewed the facility’s internal restraint death log for the past 12 months and identified Patient #6. On 08/18/2026 at 2:03 p.m., the surveyor initiated a review of Patient #6’s medical record which revealed that Patient #6 was ordered bilateral soft wrist restraints on 02/17/2026 at 9:59 a.m. The restraint flowsheet documentation indicated that the patient remained in bilateral soft wrist restraints until 02/17/2026 at 9:59 p.m. The provider note indicated the patient died on 02/18/2026 at 3:30 p.m.-within 24 hours of discontinuation of the restraints. The surveyor was unable to identify any documentation within the progress notes of Patient’s 6’s medical record that indicated the date and time in which the patient’s death was recorded in the facility’s restraint death log. On 08/18/2026 at 3:40 p.m., the surveyor received verbal confirmation from SM #24 that Patient #6’s medical record did not contain documentation of the date and time in which the patient’s death was recorded in the facility’s internal restraint death log or tracking system.”

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: 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 medical staff failed to document sufficient information about the course and results of care as per facility policy and medical staff bylaws for one (1) of three (3) patients’ medical records reviewed, MR16; and failed to report a safety event as per facility policy for one (1) of three (3) patients’ medical records reviewed, MR16. Findings: Review of facility document “IHS [Inova Health System] Physician and APP [Advanced Practice Provider] Documentation of Patient Care in the Electronic Health Record Policy” last revised October 24, 2023, reads in part: “... Purpose: The Inova Health System will maintain a complete, accurate, reliable, and fully integrated Electronic Health Record (EHR) for every individual who is evaluated, treated, or receives services at Inova.... The attending physician shall be held responsible for a complete medial record for each patient in accordance with Bylaws, Rules and Regulations of the Medical Staff and the Medical Record Documentation Policies at all of Inova facilities. A. Policy: the patient’s medical record shall contain sufficient information to identify the patient, support the diagnosis, justify the treatment, and document the course and results of care and to facilitate continuity of care among healthcare team.... XII. Progress Notes. A. Progress notes shall be written at appropriate intervals to give pertinent chronological report of the patient’s course in the hospital, to reflect any change in the patient’s condition and to document the results of treatment with such specificity to permit continuity of care and transferability. At a minimum, a progress note must be documented daily for all patients by the attending of record or his/her designee....” Review of facility document “Inova Fairfax Hospital - Medical Staff Rules and Regulations” last revised January 31, 2025, reads in part: “... 3.3.2 Progress notes shall be written at appropriate intervals to give pertinent chronological report of the patient’s course in the hospital, to reflect any change in the patient’s condition and to document the results of treatment with such specificity to permit continuity of care and transferability. 3.3.3 Whenever possible, each of the patient’s clinical problems shall be clearly identified in the progress notes and correlated with specific orders as well as results of tests and treatment....” Review of facility document “IHS Reporting and Response to Safety Events Policy” last revised October 14, 2022, reads in part: “... This policy applies to all team members working at any Inova site or facility, including contingent team members, medical staff, contractors, and volunteers.... Safety Event. An error/deviation (e.g. policy, procedure, process, practice or equipment failure) that reaches the patient and may or may not cause harm. When the error causes harm to the patient, it is known as an adverse event.... Policy Description: Event Management. Reporting a safety event: Expectations of Team Members. 1. Safety event reporting is encouraged and expected to occur the day of the event or when it was detected to assure accurate recall of the circumstances and facts surrounding the incident. 1. Access the Safety Always icon ... 4. Document in the patient’s medical record only the objective facts of the event....” Review of the medical record for MR16 revealed an “X-ray chest AP portable” dated April 16, 2025, at 6:20 AM. Review of an order for MR16 dated April 16, 2025, at 7:39 AM for Dilaudid injection 0.25 mg to be administered “once PRN [as needed] for severe pain, back pain.” Review of the patient relations documentation of a text message from EMP48 to EMP51 dated April 16, 2025, at 10:04 AM revealed that MR16 wanted to speak with patient relations about an encounter with X-ray that morning. Review of the medical record for MR16 revealed a photograph of the patient’s right upper back dated April 16, 2025, at 10:52 AM. There was no documentation in the medical record referring to the photograph or indicating why the photograph was obtained. Review of the patient relations email from EMP33 dated April 16, 2025, at 2:18 PM revealed documentation that MR16 was sleeping that morning when a radiology technician entered the patient’s room and the patient felt that the radiology technician made no attempt to wake the patient. As per MR16, the X-ray detector (board) was “shoved” underneath the patient and that’s when the patient awoke. MR16 felt that MR16 had been injured from this event and complained of pain radiating down the right side of the patient’s back to mid back. EMP33 documented that EMP28 rounded on the patient following MR16’s complaint and that the provider would follow up with an X-ray. There was no documentation of MR16’s complaint that the radiology technician hit the patient in the back documented in the MR16’s medical record. There was no documentation of the incident in the facility’s Safety Always event reporting log. Review of the portable chest X-ray result for MR16 dated April 16, 2025, at 2:24 PM revealed the reason for exam documented as an evaluation for rib fracture, sternal wires, and “popping sound”. The X-ray result impression did not include any evaluation of the patient’s back or shoulder. Review of the medication administration record (MAR) dated April 16, 2025, at 2:34 PM revealed documentation that the Dilaudid 0.25 mg intravenous (IV) ordered for “severe pain, back pain” was administered for eight (8) out of ten (10) pain at the “chest incision.” Review of the nurse practitioner progress note dated April 16, 2025, at 3:35 PM revealed EMP28’s subjective note that that X-ray testing in the early morning “was rough” with no other clarifying details documented. There was no other documentation in the medical record that the patient complained about the X-ray procedure performed by the technician that day. Review of the MAR dated April 16, 2025, at 4:48 PM revealed documentation that the patient was given Tylenol 650 mg by mouth for eight (8) out of ten (10) “Right; Lower; Upper” back pain. Review of the medical record for MR16 dated April 16, 2025 at 10:12 PM revealed a physician’s order for a lidocaine 5% patch to apply to “mid scapular region” (scapula - is a bone in your shoulder, www.clevelandclinic.org). The nursing flow sheet revealed documentation that the patient had eight (8) out of ten (10) back pain on April 16, 2025, at 11:11 PM. The nursing documentation revealed the lidocaine patch was applied to the patient’s upper back on April 16, 2025, at 11:26 PM. Review of the patient relations email from EMP51 dated April 18, 2025, at 9:52 AM revealed documentation that MR16’s complaint was escalated to risk management and that the providers were aware. Additional X-rays were completed and determined that this encounter did not affect the patient’s previous surgical procedure. “From the patient perspective this incident did cause emotional and temporary physical harm.” Review of the patient relations email from EMP51 dated April 22, 2025, at 9:50 AM revealed documentation that MR16’s care team was providing the patient heat packs and lidocaine for the pain related to the X-ray event. Review of the patient relations email from EMP31 dated April 22, 2025, at 2:05 PM revealed documentation MR16 expressed concerns about broken bones after the incident with the X-ray technician. MR16 indicated that a shoulder X-ray was completed and came back negative. There was no documentation in MR16’s medical record that a shoulder X-ray was completed. Review of the patient relation email from EMP52 dated June 25, 2025, at 4:13 PM revealed documentation related to the patient’s complaint about the incident with the X-ray technician indicating “there is no documentation in the medical records, the staff do not recall the incident, and the patient has not previously reported it....” At 4:29 PM, EMP51 replied that MR16 reported it when it happened in April and EMP51 believed the nursing team documented in the medical record during the patient’s April admission. Interview on January 6, 2025, at 12:36 AM, EMP16 indicated that if a patient is injured during a radiology procedure the incident should be documented in the facility’s Safety Always event reporting system. Interview on January 6, 2026, at 2:11 PM, EMP30 indicated that if a patient was hit with the detector during a portable X-ray procedure, the technician would notify the nurse, and submit an event report in Safety Always. EMP31 was aware of this incident and indicated that an event report should have been submitted in Safety Always. Interview on January 6, 2025, at 2:35 PM, EMP33 indicated that MR16 complained that the radiology technician performed the portable X-ray procedure while MR16 was asleep and hit the patient in the back with the detector. EMP33 indicated that the provider evaluated the patient and had no concerns. EMP33 indicated that the nurse who photographed MR16’s back the day of the event did not recall the patient and was not available for interview. Interview on January 6, 2025, at 3:42 PM, EMP28 did recall a patient complaining about back pain due to an incident during a portable X-ray procedure, but EMP28 did not specifically recall MR16 and did not have access to the patient’s medical record prior to or during the interview. EMP28 indicated that if EMP28 ordered an X-ray for a patient’s complaint of back pain, then the reason would have been documented as back pain on the order.”

“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 (EMP) interview, document review, and review of medical records (MR), it was determined the hospital failed to ensure all nurses adhered to the policies and procedures of the hospital. Specifically, nursing staff failed to follow the hospital’s procedure related to documentation of intravenous (IV) lines in one (1) of three (3) outpatient radiology patients reviewed in the survey sample. MR8. Findings: MR8 was reviewed and revealed the patient had an outpatient CT scan on January 22, 2025. An IV (intravenous) line was placed and removed to administer contrast for the scan. The record contained no documentation of who inserted the patient’s IV and/or any information related to the insertion, presence, or condition of the IV and IV site. An interview was conducted with EMP16 on January 06, 2026 at approximately 11:00 AM. EMP16 indicated that there was no documentation in MR8’s record regarding the placement of the IV line to include the person inserting the IV, the site location, type, length, and gauge of the IV catheter inserted, date and time of insertion, number of insertion attempts, functionality, and tolerance of the procedure. EMP16 was unable to determine who placed the IV line for MR8. EMP16 confirmed that all IVs should be documented in the patient’s medical record. An interview was conducted with EMP7 at 2:30 PM on January 07, 2026. EMP7 indicated that CT techs in the facility were not trained to insert IVs until June of 2025, and MR8 was treated prior to this time. EMP7 indicated that nurses from the emergency department (ED) were placing IVs prior to June 2025 for patients requiring outpatient CT scans. EMP7 indicated there was no documentation in MR8 of the IV to include who placed the IV, the insertion of the IV, and/or the location and condition of the IV site and that the facility was unable to determine who inserted it. The facility’s procedure, “IV catheter insertion” was reviewed and reads in part, “...Documentation. Documentation associated with IV catheter insertion includes: indication for use, insertion site location, pain management interventions, if used, infection prevention and safety precautions taken, type, length, and gauge of the IV catheter inserted, date and time of insertion, number of insertion attempts, device functionality, insertion method, including nay visualization and guidance technology used, lot number, dressing, tolerance of the procedure, teaching provided to the patient and family (if applicable)...:””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 36946 Based on staff interview, document review, and review of medical records (MR), it was determined the facility failed to monitor patients in restraints in accordance with facility policies in one (1) of six (6) MRs reviewed of patients in restraints. MR15. Findings: MR15 was reviewed and contained documentation that the patient was placed in non-violent bilateral soft wrist restraints for interfering with medical treatment. The restraints were ordered by the physician on May 16, 2025 at 00:24 AM. MR15 remained in restraints on May 17 and 18, 2025. There was no monitoring of the patient in restraints documented from 2:00 AM - 8:00 AM on May 18, 2025. An interview was conducted with EMP11 on May 28, 2025 at 9:50 AM who indicated that a patient in restraints for non-violent reasons should be monitored at least every two (2) hours by a Registered Nurse and no such documentation was present in MR15. The facility’s policy, IHS Restraints and Restraint Alternatives Policy (last revised 6/25/24) was reviewed and reads in part, “...Patients are monitored, assessed, and reassessed at specific intervals during use...Addendum B Restraint and Restraint Alternative Algorithm...Non-violent/non-self-self-destructive restraint...Patient Care Monitoring Documentation...Q2 hour assessment and documentation of skin, respiratory, circulatory, neurovascular, behavior indicating the need or discontinuation of restraint. Q2 hour restraints released and documented as well as range of motion, repositioning...””

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 36946 Based on staff interview and document review, it was determined the facility failed to follow its established procedures for patient grievances in two (2) of two (2) patient grievances reviewed for Patient #5. Findings: The hospital’s policy “IHS Patient Complaint/Grievance Process in the Hospital Policy” last revised August 7, 2023 was reviewed and reads in part, “...Patient Grievance - 1. A written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by the staff present) by a patient, or the patient’s representative, regarding the patient’s care, abuse or neglect, or issues related to the hospital’s compliance with the Centers of Medicare and Medicaid Services (CMS) Hospital Conditions of Participation...Complaints and grievances will be recorded in the complaint module of the Safety Always database and will include documentation of actions associated with case investigation, resolution and response...All grievances are responded to in writing. a. It is expected that many grievances can be resolved within 7 days. If the grievance cannot be resolved within 7 days, the hospital will provide a written acknowledgement within that time period. In the acknowledgement, the hospital will notify the complainant of the expected period of time (in most cases, 30 days) needed in order to resolve the grievance. b. If a grievance is not immediately resolved, it is expected the grievance can be resolved and there resolution communicated in writing within 30 days.” The hospital’s grievance log was reviewed from November 2024 - present. The log contained no documented grievance from Patient #5. An interview was conducted with EMP9 on April 01, 2025 at 1:30 PM who stated they received a phone call from Patient #5 regarding a complaint that the patient verbalized a penicillin allergy to staff members, the allergy was not documented in the medical record, and the patient was discharged with a penicillin antibiotic. EMP9 stated that this phone call was not recorded as a grievance despite the facility’s policy that a verbal complaint regarding patient care not resolved at the time of the complaint by staff present should be considered a grievance. EMP9 acknowledged the concerns should have been recorded as a grievance, but were not. EMP9 indicated the facility has recently implemented a new job aid to help staff determine what patient concerns should be recorded as grievances. The hospital sent Patient #5 a letter on December 17, 2024 acknowledging receipt of the patient’s concerns on December 16, 2024. A resolution letter was sent to Patient #5 on February 20, 2025, over two (2) months after the hospital’s receipt of the grievance despite the hospital’s policy indicating that resolution to the grievance should be communicated within 30 days. A second grievance response letter dated March 25, 2025 related to a grievance received on March 11, 2025 in which Patient #5 had concerns regarding results of a CT scan and other care performed in the ED was reviewed. The second grievance was not logged on the facility’s grievance log. EMP9 confirmed neither of the grievances received from Patient #5 were logged on the facility’s grievance log.”

“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: 42725 Based on medical record review and document review, it was determined the facility staff failed to ensure less restrictive interventions had been determined ineffective to protect the patient, staff, or others from harm before initiating restraints for for one (1) of six (6) patients sampled for restraint/seclusion, medical record (MR) 10. Findings: Review of facility policy “IHS Restraints and Restraint Alternatives Policy” indicates, in part: Under the heading “Policy Description - ... 5. Documentation in the medical record includes the following: a. The patient’s condition or symptom(s) that warranted the use of the restraint or seclusion. b. All alternatives or other less restrictive interventions attempted. c. Staff concerns regarding safety risks to the patient, staff, and others that necessitated the use...”. Addendum C attached to the policy and titled “Restraint and Seclusion Table”, under the table titled “Non-Violent or Non-Self-Destructive Reasons, and under the section titled “Registered Nurse Assessment and Reassessment” indicates, in part “... Must document attempt to use less restrictive method at the initiation of restraints...”. The policy was last revised and effective June 25, 2024. The review of MR10 revealed on February 21, 2025 at 1:30 AM, MR10 had mittens applied to both hands. At the time of application, there was no documentation indicating a reason for the restraint or what, if any, less restrictive alternatives had been used. During the 6:00 AM timeframe, a registered nurse did document a note indicating that MR10’s medical history includes dementia and that MR10 was “confused” and had attempted to pull a medical equipment/lines.”

“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: 42725 Based on medical record review, document review, and interview, it was determined the facility staff failed to ensure ongoing assessment and monitoring was documented for one (1) of six (6) patients sampled for restraint/seclusion (MR10). Findings: Review of facility policy “IHS Restraints and Restraint Alternatives Policy” indicates, in part: Under the heading “Policy Description - ... 5. Documentation in the medical record includes the following: ... h. Individual patient assessments and reassessments...”. Addendum C (within the policy) titled “Restraint and Seclusion Table” indicates, in part: Under the table titled “Non-Violent or Non-Self-Destructive Reasons” and under the section titled “Registered Nurse Assessment and Reassessment” indicates, in part: “... Every 2 hours must document: 1. Skin, respiratory, circulatory, and neurovascular assessment to identify any signs of injury. 2. ROM and repositioning of the patient. 3, Patient’s current behavior indicating continuation for restraints or readiness for restraint release. 4. Educate patient on discontinuation criteria. Every 2 hours assess the need for comfort measures including hydration, food, and hygiene...”. The policy was last revised and effective June 25, 2024. The review of MR10 revealed on February 21, 2025 at 1:30 AM, MR10 had mittens applied to both hands. The restraint flowsheet documentation revealed that a registered nurse reassessment was documented at 3:30 AM. The next registered nurse reassessment for restraints was not documented until 7:30 AM. The state agency (SA) asked staff member (EMP) 10, who was assisting with record review navigation, for confirmation of the missing documentation. EMP10 confirmed there was no restraint reassessment documented at 5:30 AM.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 42725 Based on medical record review, document review, and interview, it was determined the facility staff failed to ensure a one hour face-to-face evaluation was documented following the initiation of seclusion for one (1) of six (6) patients sampled for restraint/seclusion (MR9). Findings: Review of facility policy “IHS Restraints and Restraint Alternatives Policy” includes Addendum A titled “For Behavioral Health Units” that indicates, in part: Under the title “For Behavioral Health Units: Restraint and Seclusion for Violent and/or Self-Destructive Behavior... 3. Specially trained RN: On behavioral health units only, if the LIP is not available, a specially trained nurse may perform the initial in-person evaluation within one hour after the initiation of restraint and/or seclusion. The in-person evaluation must include the following: a. An evaluation of the patient’s immediate situation. b. The patient’s reaction to the intervention. c. The patient’s medical condition, and whether factors such as drug or medication interactions, electrolyte imbalances, hypoxia, sepsis, etc., are contributing to the patient’s violent and/or self-destructive behavior. d. The need for continuing restraints and/or seclusion and identifying strategies for discontinuation. e. Any modification to the plan of care. f. The specially trained RN consults with the LIP responsible for the care of the patient as soon as possible after the evaluation to discuss his or her findings...”. Addendum C to the policy titled “Restraint and Seclusion Table” indicates, in part: Under the table titled “Violent or Self-Destructive Reasons” and under the section titled “Physician/APP or Specially Trained Behavioral Health RN Face-to-Face Assessment and Reassessment” indicates, in part: “Initially, must be within 1 hour of application or patient must be released... Must evaluate to address any medical/surgical reasons that could underlie the patient’s assaultive, aggressive, destructive, or self-injurious behavior. Face-to-face documentation must include: 1. An evaluation of the patient’s immediate situation. 2. The patient’s reaction to the intervention. 3. The patient’s medical and behavioral condition. The need to continue or discontinue the restraint or seclusion...”. The policy was last revised and effective June 25, 2024. The review of MR9 revealed on February 26, 2025 at 9:00 PM, MR9 was put into seclusion because of violent, aggressive behavior and attempts made to elope from the unit. Seclusion was discontinued at 10:30 PM. There was no documentation that an in-person evaluation was completed within one hour of the seclusion initiation by a physician or specially trained RN. The SA asked EMP10, who was assisting with record review navigation, for confirmation of the missing documentation. EMP10 confirmed (EMP10) was unable to locate documentation of an in-person evaluation within one hour of the seclusion initiation.”

“PATIENT VISITATION RIGHTS CFR(s): 482.13(h)(3), (h)(4) [A hospital must have written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights and the reasons for the clinical restriction or limitation. A hospital must meet the following requirements]: (3) Not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability. (4) Ensure that all visitors enjoy full and equal visitation privileges consistent with patient preferences. This Standard is not met as evidenced by: 49355 Based on staff interview and document review, it was determined the facility’s patient visitation policy failed to address the use of behavior contracts (for visitors) to restrict visitation privileges. Findings: The surveyor reviewed three (3) medical records which detailed the use of behavioral contracts for visitors who were believed to be disruptive or pose a safety risk. These behavioral contracts limited the person’s ability to visit with patients while in the facility. (Patient #2, #8, and #9). During an interview on January 14, 2025, Staff Member #11 indicated that a Behavior Contract policy (for visitors with disruptive behavior) is in development currently, to address the usage of Behavior Contracts/Patient Care Agreements, but it has been difficult to nail a policy down. There are five (5) campuses that would be affected by this policy and the difficulty is making sure the language fits each of the sites. The hospital did not have a written policy for the use of the behavior contracts outlined above to restrict visitation. Also, the hospital did not have a written policy that describes the content of these contracts and who could implement them.”

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 36946 Based on staff interview and document review, it was determined the hospital’s governing body failed to ensure the established grievance procedures were followed in one (1) of twenty (20) written grievance reviewed in the survey sample. Findings: The hospital’s grievance tracker was reviewed from January 01, 2024 to present. The grievance log contained documentation of nineteen (19) patient grievances. The log failed to contain documentation of a grievance related to Patient #1. An interview was conducted with Staff Member #26 on October 1, 2024 at 2:10 PM. Staff Member #26 stated that written complaints should be entered in the grievance log as soon as they are received and reviewed. The emailed complaint received by Staff Member #18 on September 01, 2024 regarding Patient #1 was reviewed and contained allegations related to inappropriate infection control practices, inadequate nursing care, patient rights violations, and concerns with care coordination. Staff Member #1 responded to the grievance allegations via email on September 01, 2024. The written response reads in part: “I will be working with you in your efforts to find clarification of [Patient #1’s] recent hospitalization that you listed in your email. It may take me some time to gather responses from the team that cared for [Patient #1], but I will have a letter for you sometime this month.” During an interview conducted with Member #18 on October 01, 2024 at 12:15 PM, the staff member stated that the investigation into the grievance was not completed. The facility’s policy, IHS Patient Complaint/Grievance Process in the Hospital Policy was reviewed and reads in part: Patient Grievance - 1. Written or verbal complaint (when the verbal complaint about patient care is not resolved by the time of the complaint by staff present) by a patient, or the patient’s representative, regarding the patient’s care, abuse or neglect, or issues related to the hospital’s compliance with the Centers for Medicare and Medicaid Services’ (CMS) Hospital Conditions of Participation (CoP)...Complaints and grievances will be recorded in the complaint module of the Safety Always database and will include documentation of actions associated with case investigation, resolution, and response....All grievances are responded to in writing. It is expected that many grievances can be resolved within 7 days. If the grievance cannot be resoled within 7 days, the hospital will provide a written acknowledgement within that time period. IN the acknowledgement, the hospital will notify the complainant of the expected period of time (in most case, 30 days) needed in order to resolve the grievance.”

“PATIENT VISITATION RIGHTS CFR(s): 482.13(h)(3), (h)(4) [A hospital must have written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights and the reasons for the clinical restriction or limitation. A hospital must meet the following requirements]: (3) Not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability. (4) Ensure that all visitors enjoy full and equal visitation privileges consistent with patient preferences. This Standard is not met as evidenced by: 36946 Based on staff interview and document review, it was determined the facility’s patient visitation policy failed to address the use of behavior contracts to restrict visitation privileges. Additionally, the facility failed to document the behavior that met the hospital’s policy for limiting visitation (Visitor A) for Patient #5. Findings: The medical record for Patient #5 contained documentation that the patient was hospitalized several times since November of 2023 with the most recent hospital admission occurring September 19, 2024. The hospital ethicist documented in Patient #5’s medical record on September 19, 2024 (for the most recent hospitalization) that Visitor A requested overnight visitation, but due to a prior behavioral contact, would only be permitted to visit until evening hours, not overnight. The surveyor requested evidence of the behavioral contract and visiting restrictions referenced in the above noted medical documentation for Visitor A. The hospital was unable to provide a written behavioral contract. An interview was conducted with Staff Member #13 at 11:15 AM on October 01, 2024. Staff Member #13 stated Visitor A was presented a written behavior contact earlier in the year but refused to sign it. Staff Member #13 was asked about hospital policies regarding behavior contracts for visitors. Staff Member #13 stated, “I don’t really know how it works.” An interview was conducted with Staff Member #17 on October 01, 2024. Staff Member #17 stated that behavioral contracts were implemented with visitors to outline the expectations of visitor behavior at the hospital and may be used to restrict or limit visitation based on visitor behavior. Staff Member #17 stated that the ethics team creates these agreements, gives them to the visitor, and the visitor can decide or not to take the written copy of the agreement. An interview was conducted with Staff Member #28 on October 01, 2024. Staff Member #28 stated there was no hospital policy related to behavior contracts for visitors. Staff Member #28 stated these contracts are usually not written, and are merely a restatement of hospital expectation of visitor behavior that are already posted on signs throughout the hospital and in patient rights documents. These behavior contracts and concerns with visitor behavior are regularly re-evaluated and are in effect for a particular hospital admission, not indefinitely. Staff Member #28 stated that ethics staff can make recommendations about visitation, but has no authority to restrict patient visitors. This decision is left to unit leadership. Staff Member #28 stated that if a visitor is no longer displaying threatening or disruptive behaviors, they should be permitted to visit. Staff Member # 9 was interviewed on October 01, 2024 regarding visitation on the unit Patient #5 had been admitted to in September 2024. Staff Member #9 stated that all patients were permitted visitors. Overnight visitors from 11:00 PM - 8:00 AM were limited to one (1) visitor per patient. Staff Member #9 stated that Patient #5 was not permitted to have Visitor A overnight, but could have a different visitor of their choosing. Staff Member #9 stated that these restrictions had been put in place close to a year ago prior to their working on the unit and had not been revisited to their knowledge. The medical record for Patient #1 contained documentation regarding a written behavioral agreement dated August 29, 2024 for Visitors B and C. The written agreement states that both Visitors were asked to leave the hospital and not return before 9:00 am the following day. Additionally, the behavioral agreement stated that if any phone calls are received from those visitors prior to that time, visitation will be limited until 4 PM. The hospital’s policy, “Visitation: Open Visiting Hours” was reviewed and reads in part: “Limitations: ...Respectful behavior 1. Out of respect to all our patients, visitors are requested to refrain from the use of loud voice or inappropriate language (for example, foul language), offensive comments, and behaviors that undermine a culture of safety. a. An INOVA healthcare provider, administrator, or security officer has the right to ask visitors who are undermining the culture of safety, non-compliant visitors and those whose behavior is not conducive to a healing environment, to leave the patient care unit.” The hospital did not have a written policy for the use of the behavior contracts outlined above to restrict visitation. Also, the hospital did not have a written policy that describes the content of these contracts and who could implement them. Additionally, the reported behavioral contract for Visitor A was not available for review.”