Inova Mount Vernon Hospital

“DISPOSAL OF TRASH CFR(s): 482.41(b)(6) (4) The hospital must have procedures for the proper routine storage and prompt disposal of trash. This Standard is not met as evidenced by: 42929 Based on observations, review of documents, and interviews with staff (EMP) it was determined the facility failed to properly store regulated medical waste as per the facility’s policy and the Virginia Administrative Code 9VAC20-121-120. Storage of regulated medical waste. Findings: Review of facility document “IHS Regulated Medical Waste Policy” last revised January 31, 2025, reads in part: “... Purpose: ... 2. To ensure that regulated medical waste is managed in compliance with applicable laws and regulations.... Regulated Medical Waste (RMW) Also known as ‘biohazardous’ waste or ‘infectious medical’ waste, is the portion of the waste stream that may be contaminated by blood, body fluids or other potentially infectious materials, thus posing a significant risk of transmitting infection.... 4. Director of Environmental Services (EVS) ... g. In conjunction with facility Engineering, ensures that facilities associated with medical waste management comply with applicable regulatory requirements for ventilation, cleanliness, drainage, rain protection, security, signage and labeling, and other requirements.... B. SEGREGATION AND DISPOSAL OF RMW: ... 2. Sharps: ... e. Facilities using an outside vendor for sharps disposal shall require the vendor to comply with all applicable laws and regulations governing sharps disposal.... C. HANDLING OF RMW: ... 7. Storage of RMW: ... All areas used to store RMW shall have biohazard signs posted. The Director of Environmental Services shall inspect these storage facilities on a monthly basis to ensure compliance with this policy and applicable regulations.... 9. Disposal: ... RMW shall be transported and transferred to, from and between vehicles under a cover that protects the waste containers from the elements and over a floor or bermed pavement that will contain leaks and spills from the waste....” Review of Virginia Administrative Code “9VAC20-121-120. Storage of regulated medical waste.” effective March 15, 2023, reads in part: “A. The requirements of this section apply to storage of regulated medical waste, including storage (i) in soiled utility rooms and other accumulation areas; (ii) at a generating facility; (iii) during transportation; (iv) at a regulated medical waste transfer stations; and (v) at a regulated medical waste treatment or disposal facility.... B. All regulated medical waste shall be stored in a manner that: 1. Maintains the integrity of the packaging at all times, prevents damage, leakage, and spills and provides protection from the elements, vectors, and trespassers; ... 3. Is clean and orderly and located in areas free of standing liquid and debris; 4. Provides security from unauthorized access and protects workers and the general public. Regulated medical waste shall be stored in areas where access is limited to only those persons specifically designated to manage regulated medical waste; ... and 6. Meets the requirements of 9VAC20-121-130 when regulated medical waste is stored in reusable carts or containers.... 3. Signage shall be displayed to indicate any areas used to store regulated medical waste.... E. Except in accordance with a permit: ... 3. Regulated medical waste that is stored on a loading dock or in areas designated for loading shall be packaged, marked, and labeled for transport and shall not be stored in loading areas for more than 24 hours. Statutory Authority. § 10.1-1402 of the Code of Virginia; 42 USC § 6941 et seq.; 40 CFR Part 257.” Observations on May 12, 2026, at 11:04 AM, EMP12 directed the surveyor to the storage location of the used regulated medical waste containers awaiting removal and disposal by the medical waste management company. The surveyor observed five (5) red wheeled regulated medical waste containers with flip top lids labeled biohazard waste located outside of the hospital next to storage trailers near the loading dock entrance of the hospital. The regulated medical waste containers were accessible by the public and there were no locks on the lids, they were not secured in an area where access was limited to only those persons specifically designated to manage regulated medical waste. The surveyor opened the lid of one (1) of the regulated medical waste containers and observed the container was full and smelled of urine. In the same location outside of the hospital, the surveyor observed three (3) unsecured transport “lockers” that contained what appeared to be empty sharps containers. EMP12 indicated that the sharps containers in those three (3) transport lockers were empty and had been returned by the medical waste management company for reuse in the hospital. There were two (2) additional secured transport lockers located in the same area outside of the hospital. EMP12 indicated that the two (2) secured transport lockers contained used sharps containers awaiting pick up by the medical waste management company. Interview on May 12, 2026, at 3:35 PM, EMP12 indicated that the medical waste management company confirmed that the transport lockers do not need to be locked if the sharps containers inside are empty. EMP12 indicated that the red wheeled regulated medical waste containers have been kept outside near the storage trailers since EMP12 started working at this facility a year ago. Interview on May 13, 2026, at 12:27 PM, EMP14 confirmed that the five (5) used regulated medical waste containers “should not have been there,” and should be locked in the “mobile mini” storage trailer until they are accessed and removed for disposal by the medical waste management company. EMP14 indicated the medical waste management company’s last regulated medical waste pick up at this hospital was Friday, May 8, 2026. EMP14 confirmed that the two (2) secured transport lockers did contain full/used sharps containers. EMP14 indicated that the medical waste management company collects the full sharps containers from the rooms and soiled utility closets throughout the hospital and stores them in the transport lockers, then the transport lockers are loaded onto trucks for transport to the medical waste management facility. EMP14 did not know why the two (2) transport lockers containing full/used sharps containers were stored outside and had not been collected by the medical waste management company.”

“INTRAOPERATIVE ANESTHESIA RECORD CFR(s): 482.52(b)(2) [The policies must ensure that the following are provided for each patient:] An intraoperative anesthesia record. This Standard is not met as evidenced by: 46466 Based on interviews and medical record review, it was determined the facility staff failed to document patient complications and/or problems under anesthesia in the patient’s medical chart for one (1) of three (3) medical records reviewed. The findings include: A review of the facility’s policy “IHS Reporting and Response to Safety Events Policy”, effective October 14, 2022, indicated in part “...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...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...4. Document in the patient’s medical record only the objective facts of the event...”. On August 26, 2024 at 12:55 PM, an interview was conducted with Staff Member #8. Staff Member #8 explained that during the MRI, Patient #1 began to move and when Staff Member #11 went into the room to assess the patient, Staff Member #11 noticed that the IV line that was administering propofol was “nicked” and the propofol was leaking out and not going into the patient. Staff Member #11 was able to administer the medication ketamine and Patient #1 fell back to sleep and was able to complete the MRI. Staff Member #8 reviewed Patient #1’s medical chart with the surveyor at the time of the interview and stated that this incident was not documented in Patient #1’s medical record, but it should have been. Staff Member #8 also stated that the occurrence with Patient #1’s IV line being “nicked” should have been reported as a safety event and should have been documented in Patient #1’s medical record. On August 26, 2024, a review of three (3) sampled patient medical records was conducted with Staff Member #3, #5, and #7. The surveyor confirmed the medical record for Patient #1 did not contain documentation of any issues or complications during an MRI procedure on 7/8/24 as required by facility policy. The findings were discussed with Staff Members #1, #2, #4, #5, and #6 at the exit conference on August 26, 2024, at 3:00 PM.”