Encompass Health Rehab Hospital of Fredericksburg

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. 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 that upon discharge (MR3), the facility failed to ensure all pertinent medical information was communicated with the receiving facility. Findings: Facility document, Discharge Planning, was reviewed and under the title “Purpose” it reads, in part: “... The goal of the discharge planning process is to ensure an effective transition of care...”. Under the title “Discharge Planning Process and Documentation” it reads, in part: “... Physician orders are obtained and ... documented in the medical record... At the time of discharge, a clinical summary is sent to the practitioners and providers responsible for follow-up care. When a patient is discharged or transferred, the hospital gives information about the care, treatment, and services provided to the patient to other service providers who will provide the patient with care, treatment, or services...”. The document was last reviewed in February 2026. On June 1, 2026, MR3 left the facility at approximately 10:16 AM to attend a doctor’s appointment. MR3 returned at approximately 12:01 PM. A visit summary from the appointment indicated that MR3 was to start taking metoprolol succinate ER 25 mg, one tablet orally once a day. The summary listed the following “next appointment details”: Follow-up visit on Wednesday, June 10, 2026 at 11:50 AM and Lexiscan Stress Test on Tuesday, June 16, 2026 at 11:00 AM. On June 2, 2026 at 11:52 AM, an inpatient clinical summary was created to send to the accepting SNF. The summary documented the follow-up appointments scheduled during the heart and vascular appointment. Under the section titled, Pharmacy Discharge Instructions-Medication Information, it says “5/30/26 11:17:00 Patient is pending to discahrge {sp} SNF” (skilled nursing facility). There was no documentation about the new medication (metroprolol). Interview on July 23, 2026 at 2:55 PM, EMP3 reviewed MR3 and confirmed there was no documentation to indicate that the new medication (metoprolol) was reviewed by the physician, added to the discharge instructions, or listed on MR3’s inpatient clinical summary that was sent to the SNF. Interview on July 1, 2026 at 4:00 PM, EMP1 confirmed that the new medication (metoprolol) was not listed on MR3’s medication list, in the discharge instructions, or on the inpatient clinical summary that was sent to the SNF.”

“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: 42042 Based on medical records (MR) review, facility staff (EMP) interview, and review of documents, it was determined the facility failed to obtain complete informed consents for the administration of blood products for two (2) of four (4) transfused patients (MR3 and MR5). The findings: Review of facility document, “Blood Administration” (with last review date of 11/20/25) read in part, “Informed consent for the blood transfusion must be obtained from the patient and/or designee after the procedure has been explained to them”. MR3’s “Consent for Blood Transfusion” revealed a patient signature and witness with date and time without whether the patient had consented to the transfusion. The blood transfusion consent form contained the following unchecked documentation sections, “I understand the benefits and risks of blood transfusion as explained by my Licensed Independent Practitioner (LIP) and give permission for: the transfusion as he/she has prescribed”; “I do not consent to blood or blood component transfusion”. MR5’s “Consent for Blood Transfusion” revealed a patient signature and witness with date and time without whether the patient had consented to the transfusion. The blood transfusion consent form contained the following unchecked documentation sections, “I understand the benefits and risks of blood transfusion as explained by my Licensed Independent Practitioner (LIP) and give permission for: the transfusion as he/she has prescribed”; “I do not consent to blood or blood component transfusion”. Interview with SM1on 03/17/26 at approximately 4:30 PM indicated the EMP was in agreement that the required informed consent documentation was not present and incomplete.”

“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: 42042 Based on medical record review, facility staff (EMP) interview, and document review, the facility failed to administer blood products within the provider’s ordered timeframe for one (1) of four (4) transfused patients (MR3). The findings: Following interview with SM1 in the evening of 03/17/26, there was no known facility policy or procedure which clearly indicated the expectation for facility staff to follow provider orders. MR3’s “Order Sheet” documentation indicated that the provider had ordered one (1) unit of PRBC (Packed Red Blood Cells) on 02/09/26 at 11:24 AM with specific instruction to “Administer over 2-4 hours”. Review of “Blood Transfusion Form” of MR3 revealed that the blood product was initiated at 10:50 AM and completed at 12:35 PM with documentation of “total infusion time: 1:45”. The surveyor met with SM1on 03/17/26 at approximately 4:30 PM for interview. The EMP indicated understanding of the blood product documentation indicating that the blood product was administered outside of the provider’s ordered parameters.”