Sentara Martha Jefferson Hospital

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 46466 Based on facility document reviews, observations and interviews, the facility staff failed to follow facility policy and failed to prevent and control the transmission of infections. Specifically, staff did not replace disposable curtains between patients on isolation precautions in seven (7) of the 10 (ten) patient rooms included in the survey sample. The findings include: A review of the facility’s policy “Environmental Service Room Cleaning Procedure”, revised December 16, 2025, indicated in part: “...7. Remove and replace Privacy curtains if applicable...ESD (Environmental Services Department) or HCW (healthcare worker) ...Remove and replace privacy curtains if patient was on isolation, curtain is dirty/soiled, or expired...”. On July 8, 2026, the surveyor toured with Staff Members (SM) 1 and #2 two (2) of the facility’s medical surgical floors. Inspection of rooms that contained patients placed on isolation precautions and had been disinfected revealed following: Room 2005 - disposable curtain dated May 23, 2026, had a patient in isolation on June 20, 2026 Room 2014 - disposable curtain dated May 2, 2026, had a patient in isolation on July 6, 2026 Room 2017 - disposable curtain dated June 26, 2026, had a patient in isolation on July 3, 2026 Room 2029 - disposable curtain dated March 2026 had a patient in isolation on July 1, 2026 Room 2040 - disposable curtain dated June 13, 2026, had a patient in isolation on July 6, 2026 Room 2044 - disposable curtain dated May 31, 2026, had a patient in isolation on June 14, 2026 Room 3016 - disposable curtain dated March 2026 had a patient in isolation on June 16, 2026 On July 8, 2026, an interview was conducted with SM1. SM1 revealed that the facility replaced their non-disposable room curtains with disposable about one (1) year ago. The disposable curtains included a visual snapped indicator that measured a 6-month lifespan of the curtain. SM1 explained that when the disposable curtain was hung, the worker had to snap the indicator to start the timer. The worker also had to write the current date on the curtain. SM1 indicated that once the visual indicator filled red, the 6-month lifespan expired, and the curtain would be replaced. SM1 also indicated that the curtain should be replaced after a patient on isolation precautions was discharged.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 46466 Based on facility document reviews, observations and interviews, the facility failed to implement an effective infection prevention and control surveillance program to avoid sources and transmission of infectious organisms. Specifically, staff did not replace disposable curtains between patients on isolation precautions in seven (7) of the ten (10) patient rooms included in the survey sample. The findings include: A review of the facility’s policy “Environmental Service Room Cleaning Procedure”, revised December 16, 2025, indicated in part: “...7. Remove and replace Privacy curtains if applicable...ESD (Environmental Services Department) or HCW (healthcare worker) ...Remove and replace privacy curtains if patient was on isolation, curtain is dirty/soiled, or expired...”. On July 8, 2026, an interview was conducted with SM1. SM1 stated that the EVS Supervisor and Team Leads perform daily ATP (adenosine triphosphate) bioluminescence testing of at least 3% of occupied patient rooms. If the ATP testing fails to detect a 100% disinfection rate, the EVS technician is called to reclean and disinfect the room again. SM1 didn’t provide information if disposable curtains are subject to ATP bioluminescence testing. SM1 stated that they don’t conduct audits to determine if the disposable curtains are replaced appropriately and they don’t have a specific policy pertaining to the use of disposable curtains. On July 8, 2026, the surveyor toured with Staff Members (SM) 1 and #2 two (2) of the facility’s medical surgical floors. Inspection of rooms that contained patients placed on isolation precautions and had been disinfected revealed following: Room 2005 - disposable curtain dated May 23, 2026, had a patient in isolation on June 20, 2026 Room 2014 - disposable curtain dated May 2, 2026, had a patient in isolation on July 6, 2026 Room 2017 - disposable curtain dated June 26, 2026, had a patient in isolation on July 3, 2026 Room 2029 - disposable curtain dated March 2026 had a patient in isolation on July 1, 2026 Room 2040 - disposable curtain dated June 13, 2026, had a patient in isolation on July 6, 2026 Room 2044 - disposable curtain dated May 31, 2026, had a patient in isolation on June 14, 2026 Room 3016 - disposable curtain dated March 2026 had a patient in isolation on June 16, 2026.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(B) [A restraint is-] (B) 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. This Standard is not met as evidenced by: 45736 Based on medical record review, facility policy review and interview, the facility failed to notify one (1) of four (4) patient’s family/legal guardian about the need for restraints. The findings include: The review of four (4) restraint records, revealed that Patient #6 was ordered and administrated Haldol (antipsychotic medication) 5 mg (milligrams) on May 4, 2025 at 10:21 PM, due to hospital onset delirium. Patient #6’s medical record failed to contain documentation that the family/legal guardian were notified about the use of a chemical restraint. Patient #6 had three (3) family members listed as points of contact in their medical record. A facility policy titled “Restraint and Seclusion Management- Most Restrictive Restraints”, last revised February 20, 2024, was reviewed and revealed, in part, “...Restraint Application...17. Contact and educate patient and family/legal guardian, when possible about the need for restraints and document communication...” During an interview in the afternoon of May 14, 2025, Staff Member #1, explained what “when possible” meant. Staff Member #1 indicated that this means that if staff are able, they will inform the family/legal guardian right away. If staff are unable to inform the family/legal guardian right away, it is expected that they will be informed as soon as possible and this will be documented in the patient’s medical record.”

“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 observations, medical record and facility document review, the facility failed to obtain a physician’s order for physical restraint for one (1) of nine (9) patient included in the survey sample. The findings include: On May 13, 2025 at 3:15 PM, the surveyors and Staff Members #1 and #3 reviewed the facility’s surveillance video footage (no sound included) from the Emergency Department (ED) on March 24, 2025. The video footage revealed at 8:01 PM, Patient #2 with a security officer in the hallway of the facility’s ED. Patient #2 was observed waving their arms in the air, jumping up and down and wandering through the hallway. The security guard was observed speaking to Patient #2 and gesturing with their arm and hand for Patient #2 to return to their room. Two (2) other security officers arrived to assist with the situation. Patient #2 was observed posturing their body in an aggressive manner towards the first security officer. The second security officer touched the left elbow of Patient #2’s arm. Patient #2 reacted in an aggressive manner and all three (3) security officers placed their hands on Patient #2. The three (3) officers and Patient #2 went down to the floor as a struggle ensued in an attempt to restrain Patient #2. The three security officers were able to gain control and restrain Patient #2. One (1) security officer was observed rolling away from the struggle on the floor and was seen standing up and walking away. As the two (2) other security officers were restraining Patient #2 on the floor, a Respiratory Therapist (RT) entered the hallway walking towards the two (2) security officers and Patient #2 on the floor. The RT walked around the them, bent down and placed their hands on Patient #2’s legs to further assist with restraining Patient #2. A Registered Nurse (RN) entered the hallway, bent down and placed their hands on Patient #2 to assist with the restraint. The two (2) security guards, the RT and the RN restrained Patient #2 on the floor until the local law enforcement arrived to the scene. Patient #2 was escorted back to their ED room. Patient #2’s ED timeline summary documented on March 24, 2025 at 8:14 PM, “Pt seen to be wandering around ER. Primary RN and RT attempted to redirect pt to (their) room. (Their) behavior became heightened and (they) began to be verbally aggressive. Security was called to try to redirect (them) as well. (They) became even more verbally aggressive and started to cuss at the staff member. Back -up security was called and while they were on the way, security attempted to use handle with care techniques to maintain patient and staff safety. Pt behavior heightened further and (they) continued yelling and cussing. AA called (local law enforcement) for back up. Upon their arrival, pt was escorted back to (their) room with security and PD assistance”. A review of the facility’s policy “Restraint and Seclusion Management - Most Restrictive Restraints”, last revised 2/20/2024, indicated in part: “Most Restrictive (Violent/Self-Destructive Behavior and/or any patients with 3-point, or 4-point, restraints): Any mechanical device utilized for the indication of excessive and unanticipated violent/self-destructive behavior, with intent to harm, which jeopardizes the immediate physical safety of the patient, a team member, or others...Examples include but not limited to...Physical Hold...Procedure: If Non-Restraint Intervention Fail: Caution: Restrain and/or seclude immediately...Notify physician immediately for an order...Restraint Ordering...10. Give the order for restraint an/or seclusion - Provider credentialed per Medical Staff Bylaws...11...Order must be written within minutes...”. Review of Patient #2’s medical record related to this ED visit and subsequent hospitalization March 24 - March 25, 2025 revealed no evidence of a physician order for the above noted physical restraint.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 45736 Based on medical records review and interviews, the facility failed to administer pain medication, as ordered, to Patient #3. The findings include: Patient #3 presented to the FSED (free standing emergency department) with a pain rating of five (5) out of ten (10). Staff Member #7 placed an order for Tylenol 650 mg (milligrams) at 3:39 PM. That order was canceled at 3:39 PM. Another order was placed for Tylenol 650 mg at 3:43 PM. Review of Patient #3’s medical record indicated that this order was canceled at 4:00 PM. There was no documentation of the administration of Tylenol and/or any other pain medication to Patient #3 while in the FSED or a reason for the cancellation of the second order. In an interview on December 17, 2024, Staff Members #7, #8 and #9, neither staff could recall why the Tylenol was not administered or why the order was canceled twice. Staff Member #9 indicated that the FSED was unusually busy that day and that perhaps the medication administration was missed.”