Spotsylvania Regional Medical 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: 46466 Based on facility document reviews and interviews, the facility failed to ensure nursing personnel adhered to current hospital policies and procedures. The findings include: A review of 10 nursing policies found that all 10 had expired at the following dates: Delegation, expired 11/2024 OB Patient in the Critical Care Unit, expired 4/2025 Guidelines & Criteria for Transfer from Labor and Delivery Unit to Postpartum Unit, expired 4/2025 Cesarean Section: Recovery and Postoperative Care, expired 4/2025 Chain of Command in Women’s & Children’s Services, expired 7/2025 Blood/Blood Product Ordering and Administration, expired 12/2025 Guidelines for Triage of the Obstetrical Emergency Patient, expired 5/2026 Administrative Management for Women’s & Children’s Service, expired 6/2026 Discharge of the Postpartum Patient, expired 7/2026 Guidelines for the Transfer of the Obstetrical Patient from Labor & Delivery Outside of the Facility, expired 7/2026 A review of the Chief Nursing Officer’s Job Description indicated in part “...Approves nursing policies and nursing standards of patient care, treatment, and services...Collaborates with other disciplines for the implementation of programs, policies, and procedures that address how patient care needs of the patient population served are assess, met, and evaluated...”. On August 13, 2026, at 3:50 PM, an interview was conducted with Staff Members #2 and #4. Both staff members were aware that there many outstanding, expired policies. Staff Member #4 stated that they implemented a meeting to review and bring all expired policies up to date. Currently, there were about 2,000 expired policies that needed to be updated.”

“ORDERS FOR DRUGS AND BIOLOGICALS CFR(s): Orders for drugs and biologicals may be documented and signed by 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. This Standard is not met as evidenced by: 46466 Based on facility document review, interviews and medical record review, the facility failed to ensure a physician’s order was documented for the administration of a blood transfusion. The findings include: A review of the facility’s policy “Massive Transfusion Protocol”, effective 6/2025, indicated in part: “...A. When a life threatening hemorrhage occurs and there is an anticipated need for large numbers of blood products, the Massive Transfusion Protocol (MTP) may be initiated by a physician, RN and/or Administrative Coordinator. A verbal order may be given to a nurse to initiate the Massive Transfusion Order Set...”. A review of the facility’s policy “Blood/Blood Product Ordering and Administration”, effective 12/2022, indicated in part: “..E. Take to the blood bank, a copy of physician’s order to “transfuse” or a patient label containing two patient identifiers. F. Two patient identifiers (Blood Bank Technologist and Nursing personnel) will read aloud, compare and verify all information: 1. Physician order of product to give or transfuse...H. Down-time documentation...2. Verify patient identification at the bedside...with physician’s order form...Documentation Requirements: Downtime documentation will be used during a Massive Transfusion Protocol activation...”. On August 13, 2026, a review of three (3) blood transfusion records was conducted with Staff Members #4 and #14. Patient #5 received an emergent blood transfusion on August 5, 2026. Staff Members #4 and #14 stated they were unable to locate a verbal and/or written physician’s order for the emergent blood transfusion in the patient’s record.”

“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 facility document review, medical record review and interviews, the facility failed to adhere to facility policies and procedures when administering blood transfusions. The findings include: A review of the facility’s policy “Blood/Blood Product Ordering and Administration”, effective 12/2022, indicated in part: “...A. Obtain “Consent/Refusal to transfusion of blood and blood products”, signed by all necessary parties...”. Patient #6 received a blood transfusion on August 3, 2026. Patient #6’s medical record did not contain a signed blood transfusion consent form. On August 13, 2026, during medical record review, Staff Members #4 and #14 confirmed that they were unable to locate the signed Blood Transfusion Consent form for Patient #6.”

“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 facility failed to ensure patients received ordered consultations within twenty-four (24) hours as per medical staff rules and regulations for two (2) of three (3) ordered consultations reviewed, MR4. Findings: Review of facility document “Medical Staff Rules and Regulations” dated August 2024 reads in part: “... 3.K. Consultations. 3.... Tiered Consults: ... Routine-nurse can call, and the turnaround time is 24 hours....” Review of the medical record for Patient (MR) 4 revealed a routine Consult to Psychiatry ordered on April 6, 2026, at 8:40 PM. The order revealed the consulting provider was notified on April 8, 2026, at 3:52 PM. There was no evidence that the psychiatric consultation was completed for MR4 within twenty-four (24) hours of the order for consult or prior to the patient leaving the facility on the evening of April 8, 2026. Review of the medical record for MR4 revealed a routine Consult to Psychiatry ordered on April 9, 2026, at 3:20 AM. The order revealed the consulting provider was notified on April 9, 2026, at 7:20 AM. The psychiatric consult was completed on April 16, 2026, at 6:00 PM, seven (7) days after the consult was ordered and not within twenty-four (24) hours of the order for consult. Interview on June 10, 2026, in the afternoon, EMP5 indicated that consults are tiered based on urgency and routine consults should be completed within twenty-four (24) hours of the order for consult as per the medical staff rules and regulations.”

“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: 42725 Based on employee (EMP) interview, document review, and review of medical records (MR), it was determined the hospital failed to ensure nurses adhered to the policies and procedures of the hospital. Specifically, nursing staff failed to follow the procedure for a patient leaving against medical advice (AMA), MR5. Findings: Review of facility document, Against Medical Advice (AMA), under Procedure, D., reads in part: “... A. A physician’s order for AMA discharge will be written. B. The attending or charge nurse shall request the patient sign the INFORMED REFUSAL FOR PARTIAL REFUSAL OF CARE AND AMA FORM ... D. The patient should be provided with discharge instructions, and if applicable and appropriate, be provided with medications prior to leaving ... E. ... 5. A description of the steps taken to try to secure a written refusal on the INFORMED REFUSAL FOR PARTIAL REFUSAL OF CARE AND AMA FORM, if the patient refused to sign the form(s). This documentation and copies of the INFORMED REFUSAL FOR PARTIAL REFUSAL OF CARE AND AMA FORM must be made a part of the patient’s medical record...”. The document was effective February 2026. Review of facility documents, Guideline - Admission and Discharge, last revised May 2018, and Discharge of Patients, last revised March 2022 read in part: “... Procedure ... Procedure for Leaving Against Medical Advice. Guidelines: 1. Notify the attending physician, or designee, and Nursing Director/Administrative Coordinator/Nursing Supervisor/Clinical Coordinator of plans to leave against medical advice. 2. Have the patient sign the “Discharge Against Medical Advice” form. If the patient refuses to sign, indicate this on the form or the medical record. 3. A hospital employee or volunteer should accompany the patient to a hospital exit. 4. Complete occurrence form and forward to appropriate person ...”. Review of MR5 revealed that MR5 requested to leave AMA. Nursing staff notified the physician of the patient’s request. There was documentation indicating MR5 was educated about leaving AMA. There was no signed AMA form located in MR5 or that an attempt was made to have the AMA form signed. EMP5 confirmed a signed AMA form or documentation of a refusal should be entered into the record.”

“DISCHARGE PLANNING - EARLY IDENTIFICATION CFR(s): 482.43(a) The hospital’s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. 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 include a copy of the discharge instructions signed by the patient (MR) in the patients’ medical record for nine (9) of twelve (12) patients’ medical records reviewed, MR2, MR3, MR4, MR5, MR6, MR7, MR9, MR11, and MR12; and failed to provide evidence that the nurse telephone report and note the mode of discharge and who is accompanying the patient as per facility policy for one (1) of twelve (12) patients’ medical records reviewed, MR11. Findings: Review of facility document “Discharge of Patients” last revised March 2022 reads in part: “... Policy ... E. Discharge instructions should be reviewed by a nurse with the patient and/or significant other. A signed copy of the Discharge instructions should be placed in chart.... J. For discharge to another health care agency, the nurse should telephone report and/or complete written information to be sent with the patient as appropriate. A transfer form and a copy of MARs [medication administration records] should be sent to the facility receiving the patient and a copy left.... Procedure ...D. Documentation. 1. Complete discharge instruction form, discuss with patient/significant other and have signed.... 3. Note time of final disposition of the patient, the time of discharge, the mode of discharge and who is accompanying the patient....” Review of facility document “Guideline - Admission and Discharge” last revised May 2018 reads in part: “... D. Discharge ... 2. Appropriate discharge instructions will be given to the patient and/or significant other.... 3. The discharge time and date is to be entered by the nursing unit at the time of discharge. 4. Appropriate signature is obtained and a copy of discharge instructions is given to patient/family. 5. Each patient will be assisted in leaving the hospital with utilization of appropriate transport.... F. Documentation. 1. Complete discharge instruction form, discuss with patient/significant other and have signed.... 3. Note time of final disposition of the patient, the time of discharge, the mode of discharge and who is accompanying the patient....” Review of the medical records for MR2, MR3, MR4, MR5, MR6, MR7, MR9, MR11, and MR12 revealed no evidence of discharge instructions that were signed by the patient as per facility policy. Review of the medical record for MR11 revealed no evidence that the nurse telephoned report and/or complete written information to be sent with the patient as appropriate including a transfer form and a copy of MARs [medication administration records] sent to the facility receiving the patient. There was no documentation of the mode of discharge and who was accompanying the patient as per facility policy. Interview on June 2, 2026, in the afternoon, EMP5 indicated that the medical record should contain a copy of the discharge instructions signed by the patient as per facility policy, the nurse should document that report was called and the appropriate information was sent to the receiving facility, and a note of the final disposition of the patient, the time of discharge, the mode of discharge and who is accompanying the patient as per facility policy.”

“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: 42725 Based on medical record review, document review, and interviews, it was determined the facility staff failed to adhere to standard of care practices related to intravenous catheter removal for four (4) of six (6) medical records reviewed (MR1, MR2, MR4, and MR6). Findings: Review of facility document, Venous Access Device Insertion, Maintenance, and Removal, under the title “Purpose”, it reads: “Outline the insertion, access/de-access, maintenance, and removal practice expectations for venous access devices (VADs) including peripheral, midline, and central line devices.” Under the title “Removal”, it partly reads: “1. Prompt removal of a VAD should occur when the VAD is no longer needed ...”. The document was effective March 2024. Review of MR1 revealed that an intravenous (IV) catheter was inserted in the left upper arm on November 16, 2025. MR1 was discharged on November 22, 2025. There was no documentation indicating that MR1 needed to keep the IV in place post-discharge and no documentation indicating that it was removed at discharge. Review of MR2 revealed that an IV was inserted on November 4, 2025 at 3:00 AM in the right forearm posterior. At 9:00 AM, a second IV site was started in the right antecubital space. On November 9, 2025 at 1:55 PM, the documentation revealed that the right antecubital IV was removed. There was no documentation indicating the IV needed to remain post-discharge or that it was removed prior at discharge. Review of MR4 revealed that two IVs were inserted on January 21, 2026; one in the right hand and one in the right antecubital space. MR4 was discharged on January 23, 2026. There was no documentation indicating the IVs needed to remain post-discharge or that they were removed at discharge. Review of MR6 revealed that an IV was inserted in the left antecubital space on November 7, 2025. MR6 was discharged on November 8, 2025. There was no documentation indicating the IV had been removed or that it needed to remain post-discharge. During the review of medical records, the SA inquired about the expectation of removing IVs at discharge. Employees (EMPs) 6 and 7 both acknowledged that unless an IV is necessary for medication administration post-discharge, it should be removed when discharging a patient. The removal should be documented in the appropriate area within the EMR. Interview on January 30, 2026 at 11:02 AM, EMP11 indicated that prior to discharging a patient, they (EMP11) do a quick skin check on the patient looking for IVs that need to be removed. Once removed, there is an area in the electronic medical record (EMR) to document the removal. EMP11 acknowledged that if a patient has an IV in an obscure place or there was a situation occurring during discharge, it is possible that it could be missed and not removed.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. 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: A) failed to correctly register a patient, MR4; B) failed to reassess pain as per facility policy for five (5) of six (6) patient encounters reviewed, MR4, MR8, MR10, who received pain medication; and C) failed to document vital signs for one (1) of ten (10) patients’ medical records reviewed, MR4, as per facility policy. Findings: A) Review of facility document “Patient Identifiers” last revised May 2024 reads in part: “... Procedure: A. Identification Verification. 1. At the time the patient is registered and prior to the armband being applied, patient identification is established by asking the patient to state last, first, middle names, and date of birth. a. The stated names and date of birth are compared to a government issued photo identification (driver’s license, DMV [department of motor vehicles] issued identification card, Passport etc.) when available for verification of identity.... 2. If two or more patients have the same first, middle, last name and date of birth, the social security number or government issued identification number may be used as a third identifier.... C. Initial application of the Armband ... 2. When a patient is brought directly to a department, bypassing the registration department, a member of the department staff applies the armband, after the patient states his/her full name and date of birth....” Review of facility document “Patient Access Department: It is the policy of the Patient Access Department to adhere to EMTALA standards and state law when performing Emergency Department (ED) patient registration.” approved May 1, 2024, reads in part: “... Procedure: Responsible Party - First Point of Contact: Greeter/Triage Nurse or Clinical/Nursing Staff. Action - Performs MPI search for prior patient information using the Patient’s social security number, date of birth and sex. Staff recepts Patient into EDM module or Pre-Registers Patient into Meditech and completes First Point of Contact Screening....” Review of the medical record for MR4 dated August 30, 2025, with EMP 6 revealed no documentation that the patient was registered incorrectly. EMP6 indicated that there would be no evidence that the patient was registered initially as another patient since the medical record had been corrected by the facility. Interview on December 1, 2025, at 11:00 AM, EMP11 indicated that patients presenting to the emergency department are pre-registered by clinical staff who obtain the patient’s social security number, last name, first name, and date of birth. The patient is shown their armband to confirm the identification information is correct. Interview on December 1, 2025, at 12:08 PM, EMP6 indicated that MR4 was registered on August 30, 2025, under another patient’s account with the same last name and same date of birth. EMP8 indicated that the clinical staff member that pre-registered the patient looked at the last name and the date of birth, then did not verbally confirm identification with the patient or have the patient review the information on the armband. Interview on December 2, 2025, at 9:30 AM, EMP13 indicated that registration staff determined that MR4 was pre-registered incorrectly under another patient’s name with the same last name and date of birth when the registration staff arrived in the patient’s room to register the patient. Interview on December 2, 2025, at 10:17 AM, EMP15 indicated that incorrect pre-registration of patients in the emergency department by the clinical staff is still a daily occurrence. Interview on December 2, 2025, at 10:30 AM, EMP10 indicated that there should be an event report submitted for all incorrectly pre-registered patients, but not all are reported. EMP10 indicated that the staff member who identifies the incorrectly pre-registered patient should submit the event report. Interview on December 2, 2025, at 11:04 AM, EMP1 indicated that if a patient is registered incorrectly, the staff members who identify the mistake should submit an event report. B) Review of facility document “Pain Management - Adults and Pediatrics” last revised November 2024 reads in part: “Policy - Adults: ... 3. Reassessment of each pharmacological and non-pharmacological intervention should be documented within on hour. Reassessment should include: i. Effectiveness of intervention. ii. A comparison of pain level by the same scale used originally. iii. Additional interventions as indicated.... Policy - Pediatrics: ... 3. Assess for pain prior to dose. Reassess at 30 and 60 minutes and every 3-4 hours after administration....” Review of the medical record for MR4 dated August 20, 2025, with EMP6 revealed MR4 was administered Toradol 30 mg at 12:40 AM for seven (7) out of ten (10) pain assessed at 12:40 AM. The next pain reassessment documentation was over four (4) hours later at 5:27 AM. Review of the medical record for MR4 dated August 30, 2025, with EMP6 revealed MR4 was administered Morphine 1 mg at 7:08 PM and Toradol 15 mg at 7:09 PM for five (5) out of ten (10) pain assessed at 7:09 PM. There was no pain reassessment documented in the patient’s medical record. EMP6 indicated that there should have been a reassessment of pain after the medication was administered. Review of the medical record for MR4 dated September 5, 2025, with EMP6 revealed MR4 was administered Toradol 15 mg at 5:52 PM for ten (10) out of ten (10) pain assessed at 5:52 PM. The next pain reassessment documentation was five (5) hours later at 10:52 PM. Review of the medical record for MR8 dated September 1, 2025, with EMP6 revealed MR8 was administered ibuprofen 100 mg at 9:17 PM for seven (7) out of ten (10) pain assessed at 9:17 PM. There was no pain reassessment documented in the patient’s medical record. Review of the medical record for MR10 dated September 20, 2025, with EMP6 revealed MR10 was administered Morphine 4 mg at 3:28 PM for pain assessed as “Yes” in the nursing documentation. There was no pain reassessment documented in the patient’s medical record. Interview on December 1, 2025, at 11:18 AM, EMP6 indicated that nurses must reassess pain after administering medication within thirty to sixty minutes, as per policy. Interview on December 1, 2025, at 2:48 PM, EMP12 indicated that depending on the pain medication, the patient’s pain level should be reassessed within fifteen (15) minutes to one (1) hour. Interview on December 2, 2025, at 9:30 AM, EMP13 indicated that the patient’s pain should be reassessed and documented thirty (30) minutes to one (1) hour after a pain medication is administered. Interview on December 2, 2025, in the morning, EMP5 confirmed that the facility’s policy indicates that pain for a pediatric patient should be reassessed at 30 minutes and 60 minutes and every 3-4 hours after administration. C) Review of facility document “ED Assessment and Reassessment Standards” not dated reads in part: “... Level 3: Urgent ... Vital signs and focused reassessment requirements ... Minimum every 2 hours and as condition warrants ...” Review of the medical record for MR4 dated September 5, 2025, with EMP6 revealed MR4 was triaged as a Level 3 Urgent. EMP6 confirmed that MR4 had vital signs documented at 6:20 PM and the next set of vitals signs were documented at 3:53 AM, over eight (8) hours later. EMP6 indicated that the patient should have had more vital signs documented between 6:20 PM and 3:53 AM. EMP6 was unable to determine if the patient was being monitored during that time based on the documentation in the medical record. Interview on December 2, 2025, at 11:44 AM, EMP5 indicated that a patient triaged at a level 3 should have vital signs documented at a minimum of every two (2) hours as per the facility’s ED (emergency department) Assessment and Reassessment procedure.”

“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: 42725 Based on medical record review, document review, and interview, it was determined the facility staff failed to adhere to hospital policy and procedure following a patient’s fall. Specifically, the facility failed to document; an injury assessment after discovering the patient fell, notification to the attending physician and the nursing leader, and the post fall assessment intervention. Findings: Review of hospital policy “Patient Fall Prevention” indicates, in part the following: Under the heading “Purpose - 4. Outline documentation requirements for nursing.” Under the heading “Post-Fall Process - 1. Injury Assessment a. Prior to being moved, the patient will be immediately assessed for obvious injuries and to determine level of severity. Assessment will include: vital signs, neurological, musculoskeletal, circulatory, integumentary, psychological status, and pain... 2. Notifications of fall a. At a minimum, the Attending Physician, Nursing Leader, and patient’s legal representative will be notified as soon as possible. b. All notifications will be documented in the EHR [Electronic Health Record]. 3. Reporting a. For each patient fall, the nurse will document in the Post Fall Assessment intervention within the EHR...”. The policy was last revised and effective June 2023. The review of medical record (MR) 1 revealed MR1 was admitted as an inpatient after presenting to the emergency department (ED) on February 4, 2025 for “weakness, dry cough, and vomiting”. After a hold in the ED, MR1 was transferred to “4 MedSurg” on February 4, 2025 at approximately 11:00 PM. On February 5, 2025 at 12:20 PM, a hospitalist’s progress note indicated the patient fell overnight. A hip x-ray ordered by the provider (an image of the inside of the body created by electromagnetic waves) did not show a fracture. MR1 was experiencing pain in the ribcage so the provider ordered a x-ray of the ribs. The rib x-ray showed “new fractures of the right fifth through ninth ribs with evidence of displacement at the fractures sites. New pleural effusion and atelectasis”. The state agency (SA) was unable to locate evidence in MR1 that an injury assessment was performed immediately after discovering the patient had fell, notifications to the attending physician and the nursing leader were completed, and the post fall assessment intervention was completed. During a telephone interview on March 11, 2025 at 9:07 AM, employee (EMP) 9 acknowledged they were “not aware” of the “computer part”, but now they know where to add the post-fall assessment intervention in (EHR). EMP9 confirmed that the physician and charge nurse were notified “right away”, but acknowledged they were not aware to add a nursing note documenting this information. The SA asked EMP1 to review MR1 to verify that there was no documentation of an injury assessment, notification to attending physician and nursing leader, and of the post fall assessment intervention. EMP1 confirmed on March 11, 2025 at approximately 1:00 PM that there was no documentation of the three requirements.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49355 Based on interviews, medical record review, and document review, it was determined the facility failed to substantially comply with this condition by: failed to report an allegation of abuse within twenty-four (24) hours to the Department of Social Services (DSS) and failed to immediately report a serious safety event (SSE) to Patient Safety/Risk Management (MR2 - Patient over 60 years of age). (A145); and failed to obtain a physician’s order for the use of restraints (A168).”

“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: 42725 Based on interviews, medical record review, and document review, it was determined the facility failed to substantially comply with this condition by: failed to ensure adverse events are entered consistently and timely for tracking and analysis (A-0263) and; failed to demonstrate QAPI activities to improve patient safety specifically related to falls and allegations of abuse (A-0309).”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 42725 Based on medical record (MR) review, document review and interviews, it was determined the facility failed to report an allegation of abuse within twenty-four (24) hours to the Department of Social Services (DSS) and failed to immediately report a serious safety event (SSE) to Patient Safety/Risk Management (MR2 - Patient over 60 years of age). Findings: The facility’s policy titled, Facility Event and Close Call Reporting Policy and Procedure (last revised May 2024), partly reads: “... POLICY: ... Event reports should be completed as soon as possible after the event, but no later than the end of the shift... PROCEDURE: ... II. Initial Event and Close Call Report Review A. Serious events, as defined in the Serious Safety Event Identification, Notification, and Management Policy..., should immediately be reported to the Patient Safety/Risk Management department...”. The facility’s policy titled, Serious Safety Event Identification, Notification and Management (last revised February 2024), partly reads: “... PROCEDURE: ... Identification ... 2. ... the list below contains some events that meet the SSE criteria; however, this is not an exhaustive list: ... g. Sexual abuse/assault* of any patient receiving care, treatment, and services while on site at organization or while under the care or supervision of the organization... *Defined in Key Terms section of this policy. Notification Internal 1. When an SSE has occurred: a. Supervisor will immediately notify patient safety/risk management b. Patient Safety / Risk Management: i. Will notify executive leaders and other key individuals as appropriate ii. Initiate internal response within sixty (60) minutes of discovery of the vent when possible to: 1. Ensure patient care and second victim needs are met 2. Begin preliminary fact-finding investigation 3. Identify the appropriate next actions 4. Coordinate all communications 5. Assign responsibility for the initial communication with the patient and/or the patient’s representative/family and/or support person. External 1. Patient Safety / Risk Management will utilize the approved event reporting platform... to initiate SSE notification to provide initial relevant facts to key stakeholders... 3. All reporting requirements for mandatory or voluntary notifications of state and federal law enforcement, and regulatory / accrediting agencies should be completed per the agency’s reporting requirements... and specified timeframes...”. The facility’s policy titled, Abuse and Neglect Identification and Reporting (effective December 2023), partly reads: “POLICY STATEMENT: It is the policy of [Name of facility], in case of suspected or confirmed abuse, neglect, exploitation or domestic violence to, upon initial assessment: ... 3. Carry out the legal obligations of reporting abuse, neglect and/or exploitation according to state law... PURPOSE STATEMENT To establish guidelines for reporting obligations, identification, and protection of vulnerable patients who may be in danger of abuse, neglect or exploitation including: 1) children, 2) victims of domestic violence, 3) incapacitated persons 18 years and over, and 4) persons over 60 years of age... DEFINITIONS ... Sexual assault - Any illegal sexual act including incest, rape, indecent exposure... PROCEDURE: 1. Reporting Abuse or Neglect. Mandated reporters directly involved in the care of the patient must report all suspected abuse, neglect, and exploitation of children, incapacitated adults and elders within 24 hours to the local welfare/social services agency of the county or city where the individual resides, or where the abuse is believed to have occurred... 6. As soon as possible, the individual who has assessed abuse should inform department leadership, who will inform executive leadership of suspected cases of abuse. This purpose is to assure there is proper internal notification of potential risks to victims and patients... DOCUMENTATION Documentation in the medical record is essential in order to protect the patient and for the outcome of any legal case. Records should include, whenever possible: 1. Chief complaint and description of abusive event, using the patient’s own words... 9. The Protective Services report including the agency, telephone number, contact person, and the basis for the report...”. During an interview with EMP10 on January 27, 2025, EMP10 indicated that they and EMP17 were in the room with MR2 (on 01/13/2025) when the patient stated, “that man was in here earlier.” MR2 continued that the man was touching himself and forcing MR2’s head down. EMP10 indicated that MR2 was upset while telling the account. EMP10 further stated when asked about mandatory reporting of abuse to DSS “I know about mandated reporting in Pennsylvania, but didn’t know if it applied in Virginia.” During an interview conducted with EMP3 on January 29, 2025, EMP3 indicated the facility “cannot contact APS [Adult Protective Services] for every confused patient we have who may be having a nightmare”. EMP3 indicated that staff “are not prevented from reporting” and if “anything” is identified during the investigation that “supports an allegation” then “we would report.” The SSE identification and notification policy directs staff to notify patient safety/risk management immediately when a SSE occurs; however, during an interview with EMP11 (patient safety/risk management) on January 27 and January 30, 2025, EMP11 indicated they were notified of MR2’s allegations of sexual abuse/assault on January 22, 2025 (nine days later). Upon review of MR2, there was no evidence found to demonstrate mandatory reporting of the abuse allegation occurred to DSS within twenty-hour hours (24) or the SSE was reporting to patient safety/risk management immediately when the SSE occurred.”

“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: 49355 Based on medical record reviews, interview and document review, it was determined that the facility failed to receive orders prior to or immediately after initiation of a non-violent restraint in one (1) of four (4) medical records reviewed (MR6). The findings include: The facility’s policy entitled, “Patient Restraint/Seclusion,” policy number COG.COG.001, effective date September 2023, reads in part: ... “Procedure: ... 5. Order for Restraint or Seclusion a. An order for restraint or seclusion must be obtained from a physician or other licensed practitioner who is acting within their State Scope of Practice, authorized by State law as having authority for ordering restraints, and is responsible for the care of the patient prior to the application of restraint or seclusion. ... d. When a physician or other licensed practitioner, authorized by State law to order restraints, is not available to issue a restraint or seclusion order, an RN with demonstrated competence may initiate restraint or seclusion use based upon fact-to-face assessment of the patient. In these emergency situations, the order must be obtained during the emergency application or immediately (within minutes) after the restraint or seclusion is initiated.” On January 27, 2025, at 10:30 A.M., the medical records for MR5 through MR8 were reviewed with the assistance of EMP6 acting as navigator. At 9:05 A.M. on December 20, 2024, MR6 received bilateral upper extremity soft restraints. The non-violent restraints were initiated because MR2 was attempting to remove an intravenous line and other alternatives were unsuccessful. Documentation in the record reveals that the order for the restraints was obtained from the provider at 6:35 P.M., approximately nine and one-half (9.5) hours after initiation. All safety checks and monitoring were documented and within guidelines. During the record review, EMP6 agreed that an order for the usage of the restraints should have been obtained immediately from the physician after initiation by the nurse.”

“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: 42725 Based on document review and interviews, it was determined the facility failed to ensure adverse events are entered consistently and timely for tracking and analysis. Findings: The facility’s policy titled, Facility Event and Close Call Reporting Policy and Procedure (last revised May 2024), partly reads: “... POLICY: ... Event reports should be completed as soon as possible after the event, but no later than the end of the shift...”. A document titled, Reporting Safety Events, was reviewed by the surveyor. Per EMP3, the presentation is reviewed with new employees during orientation. Bullet point three on page 5 of the presentation reads, “Report the event as soon as possible after the event, but before the end of your shift”. During an interview with EMP10 on January 27, 2025, EMP10 indicated that they and EMP17 were in the room with MR2 (on 01/13/2025) when the patient stated, “that man was in here earlier.” MR2 continued that the man was touching himself and forcing MR2’s head down. EMP10 indicated that MR2 was upset while telling the account. A review of the facility’s adverse event log for January 1, 2025 through January 27, 2025 (requested on 01/27/25) did not contain an entry for MR2. An additional adverse event log for June 1, 2025 through January 28, 2025 was requested and received on January 29, 2025 at 9:06 AM. A review of the log indicated an event had been entered for MR2; January 12, 2025 as the “date of event” and January 27, 2025 as “date reported”.”

“QAPI EXECUTIVE RESPONSIBILITIES CFR(s): 482.21(e)(1), (e)(2), (e)(5) 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: 1) That an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained . (2) That the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated. (5) That the determination of the number of distinct improvement projects is conducted annually. This Standard is not met as evidenced by: 40084 Based on document review and interview, it was determined the facility failed to provide evidence of actions aimed at performance improvement. Specifically, the facility failed to demonstrate QAPI activities to improve patient safety specifically related to falls and allegations of abuse. Findings: During an interview with EMP10 on January 27, 2025, EMP10 indicated that they and EMP17 were in the room with MR2 (on 01/13/2025) when the patient stated, “that man was in here earlier.” MR2 continued that the man was touching himself and forcing MR2’s head down. EMP10 indicated that MR2 was upset while telling the account. On January 27, 2025, the state agency (SA) requested evidence of the facility’s investigation into MR2’s abuse allegation. On January 29, 2025 at 8:50 AM, the SA received copies of the Quality and Safety Committee meeting agenda from February through December, but no minutes. The SA inquired about the minutes, EMP3 indicated specific information from the meetings is sent to the Patient Safety Organization (PSO) and is “unavailable”. A review of the adverse event log from June 1, 2024 through January 27, 2025 revealed there were eighty-one (81) events labeled “Fall”. During a discussion about QAPI, the SA requested evidence of the facility’s efforts to improve falls. EMP3 indicated information could be redacted and the minutes shared with the SA. The SA requested any evidence to support the facility’s QAPI activities. At 1:38 PM, the SA was provided a copy of the December 2024 Quality and Patient Safety Committee redacted minutes. The following sections were redacted or partially redacted: Approval of minutes; Safety Reports/Trends/Alerts/SS Action Plans; Grievances; Falls Prevention; Telemetry Safety; HAPI Prevention; Suicide Prevention; Infection Prevention; Restraints; Resuscitation; BERT/Workplace Safety; Dept Quality Excellence Reports (each unit listed under this title was redacted); Quality Construct Performance; and Open Discussion. The SA requested the meeting minutes from June 2024 through November 2024. At 3:01 PM, EMP3 provided the minutes; the minutes were redacted the same as the December 2024 minutes. The SA was unable to determine what areas of opportunity have been identified and what QAPI activities are active to improve patient safety specifically related to falls and allegations of abuse.”