Chesapeake General Hospital

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 34452 Based on interview and document review, it was determined that the facility failed to enact measures to effectively communicate identified maintenance issues in the operating rooms (OR) requiring vendor services and remove faulty equipment from service. Cross reference: § 485.536 Condition of participation: Quality assessment and performance improvement program.”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to ensure the safety of patients in the surgical area by not prioritizing and completing work orders for maintenance issues (A0701). Cross reference: § 482.41 Condition of participation: Physical environment.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 34452 Based on interview and document review, it was determined that the facility failed to enact measures to effectively communicate identified maintenance issues in the operating rooms (OR) requiring vendor services and remove faulty equipment from service. Two (2) of four (4) OR work orders reviewed were cancled and not completed. The findings include: On June 24, 2025 at approximately 11:00 AM, review of the work orders for the surgical area revealed the following: March 31, 2025 Work order description: chemical hose is not working. WO (work order) priority: 3. Status: canceled. April 28, 2025 Work order description: the machine that disperses chemicals and water into the mop buckets is putting only water. WO priority: 3. Status: canceled. On June 25, 2025 at 2:00 PM, the facility’s document titled “problem solving” for the resolution to the Operating Room delay in repairs dated April 30, 2025 was reviewed. The facility identified the problem as failure to communicate the need for a vendor to complete repairs and not immediately placing faulty equipment out of service. The document included the statement “Communication failure and not promptly removing EVS (environmental services) closet soap dispenser out of service until fixed after issue first identified on March 30, 2025”. On June 25, 2025 at approximately 10:30 AM, an interview with SM # 11 revealed “there were no changes to the procedure for communicating maintenance issues that were not able to be completed.” On June 25, 2025 at approximately 1:30 PM, a review of the facility’s policy titled, “Adverse Events/Serious Reportable Events (SRE)/Root Cause-Analysis #200.70”, effective date 11/2023, subtitle, “Definition”, page 1 reads in part, “An event is defined as any occurrence that is not consistent with routine operation of the healthcare system or routine care...”, subtitle, “Policy”, page 2 reads, “In order to continuously improve patient care and adverse events, [Facility name redacted] will identify, report internally, and respond to all Adverse Events...Appropriate responses to all Adverse Events include conducting a timely, thorough, and credible investigation, developing an action plan designed to implement improvements to reduce the risk of reoccurrence...”.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to ensure the safety of patients in the surgical area by not prioritizing and completing work orders for maintenance issues for two (2) of four (4) work orders (WO) reviewed, WO dated March 31, 2025 and April 28, 2025. The findings include: On June 24, 2025 at approximately 11:00 AM, review of the work orders for the surgical area revealed the following: March 31, 2025: work order description: chemical hose is not working. WO priority: 3. Status: canceled. April 28, 2025: work order description: the machine that disperses chemicals and water into the mop buckets is putting only water. WO priority: 3. Status: canceled. May 6, 2025: work order description: water seeping up from the floor since last week. WO priority: 3. Status completed 05/06/2025. May 19, 2025: work order description: water sprinkler on # 1 sink is leaking from the top and bottom. WO priority: 3. Status completed 05/19/2025. On June 24, 2025 at 11:30 AM, a review of the facility policy titled “Maintenance work request” reads in part “Emergency (Priority 1) - emergencies include but are not limited to the below listed items. Problems occurring in the Operating Room”. On June 24, 2025 at 11:45 an interview with Staff Member (SM) # 3 revealed “all work orders are auto assigned priority 3. The maintenance tech can change the priority level; however that is not the expectation”. On June 25, 2025 at 12:30 PM, an interview with SM # 9 revealed “life safety work orders are usually scheduled maintenance are a priority 1, all other maintenance work orders are automatically a priority 3.” SM # 9 stated “it is my expectation for staff to complete the work as need and not to assess the priority of the work order”.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 41450 Based on interviews, clinical record review, and facility documentation review, hospital staff failed to provide a safe patient care setting for 2 patients, Patient (P) #1 and P #2, out of 2 patients assigned to Staff Member (SM) #6 on 1/20/25. The findings include: On 5/13/25 at approximately 1:00 PM, a group meeting was conducted with SM #1 and SM #2 to discuss the allegation of an unsafe nursing practice occurring on 1/17/25 by SM #6, a registered nurse. SM #2 stated that an internal investigation into the matter began on 1/20/25. SM #2 stated the findings of the facility’s investigation included SM #6 admitting to using one syringe to administer IV medications to multiple patients during their work shifts. SM #2 stated that SM #6 was suspended on 1/20/25 and ultimately terminated on 1/27/25. A timeline of the events and investigation was requested and received. On 5/14/25 at approximately 11:15 AM, a telephone interview was conducted with SM #7, a registered nurse and coworker, who confirmed that on Friday, 1/17/25 at approximately 5:45 PM, they verbally reported concerns regarding inappropriate use of syringes in the administration of IV medication by SM #6 to their immediate supervisor, SM #4, the unit’s clinical coordinator. SM #7 stated SM #6 had already left for the day around 5:30 PM. SM #7 stated, “My concern is that reusing syringes on different patients presents a risk for the cross-contamination of blood-borne pathogens between patients...this is not safe for our patients and is a lack of professional integrity”. On 5/14/25 at approximately 11:45 AM, an interview was conducted with SM #4, a registered nurse and clinical coordinator, who confirmed receiving verbal notification on Friday, 1/17/25 “between 5:30-6:00 PM” from SM #7 about patient safety concerns with SM #6’s IV medication administration. SM #4 stated, “I was in shock thinking, ‘Why would anyone do that?’, I was concerned about patient safety and infection control”. SM #4 stated that they did not notify the unit manager, SM #5, until Monday, 1/20/25 at approximately 10:00 AM “because I felt like I needed to tell [SM #5] in person and [SM #5] was off on Friday anyway”. SM #4 verified they arrived to work on Monday at 7:53 AM, however “everyone was busy first thing Monday morning, including myself, so I waited a little bit”. SM #4 stated, “I am responsible for scheduling staff to cover the unit’s needs...I made Monday’s staffing schedule which included an assignment for [name redacted, SM #6]...it did not occur to me to pull [SM #6] off of Monday’s assignment because we had a busy schedule and we were busy first thing in the morning, that would have made us understaffed”. SM #4 confirmed that SM #6 arrived to work at 8:53 AM and provided direct patient care to P #1 and P #2, to include the administration of IV medication for a total of 7 occurrences, 5 occurrences for P #1 and 2 occurrences for P #2, between 9:52 AM and 10:15 AM on 1/20/25. On 5/14/25 at approximately 12:10 PM, an interview was conducted with SM #5, a registered nurse and unit manager, who verified reporting to work on Monday, 1/20/25 around 7:30 AM. SM #5 stated, “[Name redacted, SM #4] came to my office between 10:15 and 10:30 AM to tell me about the concerns that were reported to [them] on the previous Friday regarding [name redacted, SM #6] reusing the same syringe on multiple patients...I was in total shock and disbelief...I was concerned about infections, mixing medications, drug allergies...I pulled [SM #6] into my office immediately and asked if [they were] using the same syringe and [SM #6] said, ‘yes’ and I asked [them] again, ‘do you use the same syringe on all patients all day?’ and [SM #6] said, ‘yes, it saves time’...I immediately reported this situation to my Director who sent [SM #6] home and suspended [them] right away”. SM #5 stated, “I cannot explain why [name redacted, SM #6] was any assigned patients, this was a very serious safety concern that should have been addressed first ...I should have been notified right away, if not Friday afternoon, then first thing Monday morning prior to [SM #6’s] arrival to work”. On 5/14/25 at approximately 1:00 PM, a clinical record review for P #1 and P #2 was performed and verified on 1/20/25, between 9:52 AM and 10:15 AM, SM #6 administered IV medication as follows: P #1 received Fentanyl 25mcg IV at 0952, 0957, 1010, and 1015; and Zofran, 4mg IV at 0952. P #2 received Dilaudid 0.5mg IV at 1005 and 1015. On 5/14/25 at approximately 2:00 PM, a group meeting was conducted with SM #1 and SM #2 following staff interviews. SM #2 stated, “It is my position, and that of our hospital, that our patients and their safety always come first ...it is concerning to know that following notification to the unit leadership team on Friday, [name redacted, SM #6] was allowed to continue to provide care to patients on Monday prior to any further investigation”. The hospital’s policy titled, “Patient’s Bill of Rights and Responsibilities #200.04”, effective date 8/2024, subtitle, “Policy”, page 1 reads, “It is the policy of the [hospital name redacted] to protect and promote each patient’s rights...” and subtitle, “Patient Rights”, page 3, item XX, reads, “The patient has the right to receive care in a safe setting”.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 41450 Based on interviews, clinical record review, and facility documentation review, hospital staff failed to to identify and investigate actions which allowed an accused hospital staff member to continue to provide direct patient care for 2 patients, Patient (P) #1 and P #2, on 1/20/25 following the initial patient safety event report on 1/17/25. The findings include: On 5/13/25 at approximately 1:00 PM, a review of the hospital’s response to a 1/17/25 patient safety event involving Staff Member (SM) #6 using unsafe practices during the administration of IV medication was conducted. Following notification to the Quality and Patient Safety Department on 1/20/25, hospital staff performed a robust investigation into infection control concerns. There was no evidence of an investigation related to SM #6 being permitted to continue direct patient care on 1/20/25 to 2 additional patients, P #1 and P #2, which included the administration of IV medications. On 5/14/25 at approximately 1:00 PM, a clinical record review for P #1 and P #2 was performed and verified that on 1/20/25, between 9:52 AM and 10:15 AM, SM #6 administered IV medication as follows: P #1 received Fentanyl 25mcg IV at 0952, 0957, 1010, and 1015; and Zofran, 4mg IV at 0952. P #2 received Dilaudid 0.5mg IV at 1005 and 1015. On 5/14/25 at approximately 1:10 PM, an interview was conducted with SM #9 who verified the findings. SM #9 stated, “Our Quality team determined that this event was a major serious reportable event and our response was very focused on infection control...I have concerns that the reporting and notifications [of the patient safety event] didn’t happen as quickly as it should...we were not aware that this nurse was allowed to continue patient care after the initial report of concerns on the 17th...this is very concerning and we will be looking into that now”. The hospital’s policy titled, “Adverse Events/Serious Reportable Events (SRE)/Root Cause-Analysis #200.70”, effective date 11/2023, subtitle, “Definition”, page 1 reads, “An event is defined as any occurrence that is not consistent with routine operation of the healthcare system or routine care...”, subtitle, “Policy”, page 2 reads, “In order to continuously improve patient care and adverse events, [Facility name redacted] will identify, report internally, and respond to all Adverse Events...Appropriate responses to all Adverse Events include conducting a timely, thorough, and credible investigation, developing an action plan designed to implement improvements to reduce the risk of reoccurrence...”.”

“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: 41450 Based on interviews, clinical record review, and facility documentation review, hospital staff failed to adhere to hospital policy for immediate notification of safety events by 1 staff member, Staff Member (SM) #4, out of 4 staff members reviewed for policy compliance. The findings include: Following notification on 1/17/25 of an alleged unsafe nursing practice being performed by SM #6, SM #4 failed to follow the hospital policy for reporting a serious patient safety event. On 5/14/25 at approximately 11:15 AM, a telephone interview was conducted with SM #7, a registered nurse and coworker, who confirmed that on Friday, 1/17/25 at approximately 5:45 PM, they verbally reported concerns regarding inappropriate use of syringes in the administration of IV medication by SM #6 to SM #7’s immediate supervisor, SM #4, the unit’s clinical coordinator. In an interview on 5/14/25 at approximately 11:45 AM, SM #4 confirmed receiving verbal notification on Friday, 1/17/25 “between 5:30-6:00 PM” from SM #7 about patient safety concerns with SM #6’s IV medication administration. SM #4 stated that they did not notify the unit manager, SM #5, until Monday, 1/20/25 at approximately 10:00 AM “because I felt like I needed to tell her in person and [they were] off on Friday anyway”. In the same interview, SM #4 confirmed that SM #6 arrived to work at 8:53 AM on 1/20/25 and provided direct patient care to Patient (P) #1 and P #2, to include the administration of IV medication for a total of 7 occurrences, 5 occurrences for P #1 and 2 occurrences for P #2, between 9:52 AM and 10:15 AM. On 5/14/25 at approximately 12:10 PM, an interview was conducted with SM #5, a registered nurse and unit manager, who stated, “[Name redacted, SM #4] came to my office between 10:15 and 10:30 AM to tell me about the concerns that were reported to [them] on the previous Friday regarding [name redacted, SM #6] reusing the same syringe on multiple patients.” SM #5 stated, “I should have been notified right away, if not Friday afternoon, then first thing Monday morning prior to [SM #6’s] arrival to work”. On 5/14/25 at approximately 1:00 PM, a clinical record review for P #1 and P #2 was performed and verified on 1/20/25, between 9:52 AM and 10:15 AM, SM #6 administered IV medication to P #1 and P #2. On 5/14/25 at approximately 2:00 PM, SM #2 stated, “It is concerning to know that following the initial notification to the unit leadership team on Friday, [name redacted, SM #6] was allowed to continue to provide care to patients on Monday prior to any further investigation”. The hospital’s policy titled, “Event Reporting #300.66”, effective date 5/2025, subtitle, “Definition”, page 1 reads, “An event is defined as any occurrence that is not consistent with routine operation of the healthcare system or routine care...”, subtitle, “Policy”, page 1 reads, “[Facility name redacted] endorses and supports a Culture of Safety and views event reporting as a means of improving systems and processes in providing healthcare services to all patients and preventing harm”, and subtitle, “Procedures”, page 1 reads, “Each employee shall be responsible for reporting all events at the time they are encountered to his or her immediate supervisor on duty...Major events are to be reported immediately up the chain of command and Risk and Quality and Patient Safety Departments notified...”.”

“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: 34452 Based on document review and interview, it was determined that the facility Staff failed to notify the Physician and provide nursing care to prevent pressure injuries for one (1) of three (3) Patients (P), P # 3. The findings include: On January 24, 2024, at approximately 12:00 p.m., clinical record review revealed the following: P # 3 was admitted to the facility on December 15, 2022. The History and Physical (H&P) dated December 15, 2022 reads in part “[P # 3] who presented with chief complaint of left leg pain and swelling since yesterday. According to patient had breast biopsy done yesterday, did well, while was stepping inside house fell and hit leg to the ground. [P # 3] was able to get with help of family got into the chair. While getting out of the chair patient fell again and started having severe pain swelling of the left leg which was rated as 7-8 over 10 pain gets worse whenever [P # 3] tries to move leg or anything touches.” Review of Flowsheet data from December 15 - 27, 2022 revealed “skin intact”. On December 28, 2022 at 10:39 a.m. documentation reads in part “Wound buttocks right stage 2 -pink, slight bleeding. Date first assessed 12/28/2022. Primary wound type: Pressure inj. Location: Buttocks. Wound location orientation: right. Wound description: stage 2-pink, slight bleeding.” On December 29, 2022 at 1:05 p.m. - “pressure stated 2, clean, dry and intact dressing. On January 1, 2023 at 5:19 a.m. - new dressing applied. soap and water. moist to dry dakins. On January 1, 2023 at 10:08 a.m. - “clean, intact, dry, not cleansed. ace wrap, abd pad, negative pressure wound therapy. small drainage purulent, serosanguinous. On January 5, 2023 at 6:44 a.m. - clean, dry and intact, no drainage.” There was a lack of documented pressure injury evaluation on December 30, 31, 2022 and January 2, 3 and 4, 2023. On January 24, 2024, a review of the nursing unit schedule revealed adequate staff. An interview with Staff Member (SM) # 1 revealed “During this time period [December 2022 to April 2023], there were no staffing issues at the facility. Staffing is based on census.” A review of Physician progress notes to include plastic surgery notes revealed no documentation of a pressure injury. The discharge summary dated January 6, 2023 reads in part “Discharge diagnosis: Large hematoma of left leg Leg wound status postdebridement and wound vac placement Mechanical fall Coagulopathy secondary to anticoagulation/xarelto (blood thinner medication) HTN (hypertension) AKI on CKDIIIb (acute kidney injury on chronic kidney disease Stage 3B) Hypothyroid symptoms Dementia” There was a lack of documented Physician notification of the pressure injury during P #3’s hospitalization from December 28, 2022 through January 6, 2023 On January 24, 2023, a review of the facility policy titled “Pressure injury/ulcer prevention” reads in part “Nurse will perform a comprehensive skin assessment as part of the head to toe assessment each shift. Interventions to manage pressure when patient is in bed may include but not limited to: pressure redistribution surface as indicated. Maintain or enhance level of activity. Off load heels. Reposition approximately every two hours. Use 30 degree side lying position. Pad between skin to skin or skin to equipment contact. Hospital acquired pressure injury (HAPI) If HAPI is identified the nurse will notify the attending physician and notify the patient or NOK/POA (next of kin/power of attorney) as appropriate.” On January 24, 2024, a review of the grievances and complaints revealed a grievance was filed and investigated concerning P # 3; there was no deviation from the facility policy and procedure. On January 24, 2024 at 12:30 p.m., an interview with SM # 1 revealed “all mattresses are low air loss mattresses which are pressure relieving mattresses.” On January 24, 2024 at 2:00 p.m., the findings were discussed with SM # 1, # 2, # 3 and # 4 during the exit interview.”