Based on surveyor observations, document review, and interview, it was determined the hospital failed to ensure each patient received care in a safe setting. Specifically, the hospital failed to ensure medications were secured in three (3) of three (3)observations conducted during the survey. Findings: A tour was conducted on the 5th floor medical unit at 9:45 AM on 12/15/21. The Medical Facilities Inspector (MFI) observed multiple wrapped, unattended saline flushes on a computer on wheels cart in the hallway. The MFI observed a second computer on wheels cart on the same hallway with an open vial of insulin and insulin syringes and needles on the top of the cart, with no staff member in the visual vicinity of the area. The MFI alerted the Director of the Unit who was accompanying the MFI on the tour. The Director confirmed the medications should not be left unattended on the cart and removed the insulin from the area. A second observation of the 5th floor medical unit was conducted on 12/16/21 at 11:08 AM. The MFI observed a unit dose of albuterol/atrovent for inhalation unattended on a computer on wheels cart. The Manager of the 5th floor confirmed the unattended medication and that the medication should not be left unsecured. The MFI then made observations on the 4th floor surgical unit. The following medications were observed to be unattended on top of the computer on wheels cart: Cefazolin 1 gram IV (two vials); Senna tablet; Colace, Gabapentin, Tylenol, and Celebrex. After approximately one minute, the staff nurse returned to the computer and the unattended medications. The staff nurse stated [s]he had briefly stepped away from the medications and acknowledged the medications should not have been left unattended. The MFI requested the hospital's policy for the storage of medications to include safety related to the secure storage of medications during/prior to administration. The hospital's Vice President of Quality stated that the hospital did not have such a policy but provided the MFIs with a document presented to staff at a daily safety huddle with the heading: What Items Must Always Be Secured that contained pictures of saline flushes, needles, mediations, vaccines, scalpels and medical records. A second document with the heading, Computer on Wheels, contained the following: Your Computer on Wheels (COW) goes in and out of patient rooms. Don't keep your beverage bottles, food and drinks and personal belongings on it. You risk picking up a serious infection and carrying the infection home to your family. Keep the drawers locked when you are leaving it unattended, including when you run into a patient room leaving the COW outside. If you leave medications and sharps in a COW with an unlocked drawer, they are considered unsecured. A third document provided to the MFI partially reads as follows: Unsecured Medications: If anyone other than you can lay their hands on the medication, it is not secured...if it is on your COW and you have stepped away...Yes, saline is considered a medication. The hospital's Vice President of Quality and Patient Care coordinator confirmed the medications should not have been left unsecured after the observations on 12/16/21 and again during the exit conference on 12/16/21.
Based on clinical record review, staff interview, and facility policy/procedure review, it was determined the facility failed to have a policy related to obtaining verbal consent. The findings include: On 8/30/2021 and 8/31/2021, the surveyors reviewed the medical records for eight (8) patients. A review of the medical record for four (4) out of eight (8) patients' general consent to receive medical treatment forms, contained evidence of the handwritten Verbal in lieu of the patient's actual signature for the consent. The consent forms did not contain documentation of a reason that the patient was unable to sign the consent. The medical records also contained evidence of the typed name of the Witness on the witness line and the date. During an interview on 8/30/2021 at 1:51 p.m., Staff Member #1 stated that there is no COVID policy related to the procedure for patient's signing consents. SM #1 stated that the staff will usually get the patient's signature for consent on an iPad. SM #1 stated that if a patient is unable to sign for consent, then the registration staff will document Verbal and put a note on the patient's account stating that the patient is unable to sign due to a medical condition. SM #1 stated that there is no written policy or procedure for obtaining verbal consent, but the staff have been taught to write Verbal on the consent if the patient is unable to sign for any reason. A review of the Informed Consent Policy provided evidence that the policy failed to contain a policy or procedure specific to obtaining verbal consent, although the facility staff were routinely obtaining verbal consent from patients. A review of the facility's procedure titled, Informed Consent, states in part: ...General Consent: At the time of admission, the patient/surrogate decision-maker will sign a general consent to receive medical treatment...In addition to this general consent, written informed consent must be obtained from patients undergoing the procedures or treatments listed in this policy... ...Administrative Considerations:... ...C. Inability to Sign: If the patient is unable to legibly sign his/her name, an X is acceptable if there are two (2) witnesses. D. Telephone Consent: When the patient's surrogate decision-maker is not able to come to the hospital to sign the consent form, consent may be obtained by the doctor via telephone. Two witnesses should verify the procedure with the party on the telephone and document the conversation on the consent form... The above concerns were discussed during the exit conference on 8/31/2021.
Based on medical record and document review, it was determined the facility failed to document the administration of pain medication during two (2) of six (6) infusions for Patient #1. The findings include: The Surveyor conducted a review of Patient #1's medical record on 8/30/21 at 1:15 p.m. Documentation in the medical record provided incomplete data entry for the administration of the pain medication, morphine. Six (6) medication flow sheets specific for the morphine infusion for Patient #1 were missing the following information: a. Medication time total was missing on two (2) of six (6) flowsheets. b. Unit of measure (dosage of the medication) was mission on two (2) of six (6) flowsheets. c. Amount infused was missing on two (2) of six (6) flowsheets. A review of the policy Medications Administration-Nursing-Procedure states in part, Full Documentation of Non-Scanned medication...2. Document the dose. Miscellaneous Information for Medication Administration...7. Document all reassessment and follow-up interventions on appropriate unit forms/screens.
Based on interviews, medical record review, and document review, it was determined the facility's staff failed to ensure the freestanding Emergency Department (ED) adopted and enforced a policy to provide a medical screening exam and medical treatment as defined by EMTALA requirements. 42 CFR º489.20 (l) of the provider's agreement, and º489.24(b), to comply with º489.24. Please see A-2406 and A-2407 for additional information.
Based on observations, medical record reviews, document review and staff interviews, the facility staff failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department, to determine whether or not an emergency medical condition existed for 1 of 21 patients reviewed. (Patient #1). This involved three of four staff members present in the dedicated emergency department (ED). (Staff #7, #8 and #9). The findings include: On 11/18/15 at 12:30, during a tour of the freestanding ED (Emergency Department), the desk receptionist (Staff #4) was questioned, and was aware of the EMTALA requirements when questioned. At 12:50 p.m. on 11/18/15, Staff #2 (ED Charge Nurse) recalled the following information about a patient who presented on November 12th around 3:30 p.m. The nurse stated Staff #8, the receptionist, told the nurse a patient was in the waiting room sent by her doctor to be admitted for observation. Staff #2 told the receptionist that this ED did not have the capability to admit patients. Further, if he/she wants to be seen for admission, she/he can be seen at a hospital of the patient's choosing. The receptionist then told Patient #1 what Staff #2 reported. Staff #2 said Patient #1 decided to leave. Staff #2 said she was not seen by the doctor nor any nursing staff, so that was why there was no chart. There was no medical record at this ED, as the patient was not logged in or registered. On 11/18/15 at 3:35 p.m. Staff #8 was interviewed at the facility. He/she stated on November 12th at around 3:30 p.m. Patient #1 came up to the desk and said he/she was having mini-stroke symptoms. Patient #1 had a paper from an evaluation by a nurse at the patient's work where he/she wrote down the symptoms. The nurse at patient's work called a Neurologist, and the physician told the nurse the patient needed to be seen at an ED and placed under observation. Staff #8 said he/she went back and told the charge nurse (Staff #7) what the patient said. Staff #8 then told the surveyor that he/she was told that the freestanding ED did not have the capability to admit, and to tell the patient to go to another ED where the patient could be admitted . Staff #8 informed the surveyor, he/she returned and told Patient #1 the ED staff could see the patient, but if Patient #1 wanted to save the co-pay from this visit, he/she could go to the hospital of his/her choosing. Staff #8 stated, I did not see [him/her] as an emergency. The patient was coherent and did not slur her/his words. Patient #1 told the receptionist he/she had just recently seen the Neurologist, and had a history of TIA (Trans Ischemic Attack). Staff #8 stated he/she told the patient we would be glad to see her, but he/she was determined to go after I talked to him/her about the co-pays. Staff #8 admitted she had no medical training. Patient #1 stayed in the waiting room for quite awhile playing with her baby and waiting for his/her spouse to return. When the spouse came back about 5:00 p.m., Patient #1left the ED. Patient #1 was not logged in nor had any triage or medical screening exam. When the surveyor asked Staff #8 if he/she knew about EMTALA regulations regarding all patients getting a medical screening exam despite payment or insurance. Staff #8 said, I am just hearing about it now. I have only worked here for a few weeks. Staff #8's personnel file orientation documented she/he had EMTALA training 11/8/15. All of the other nursing staff and physicians in the ED were most recently trained on 3/8/15.
Based on staff interviews, medical record reviews, and document review, the facility staff failed to provide reasonable steps for further medical examination and any stabilizing treatment which may have been needed. This practice affected 1 of 21 patients in the survey sample, (Patient #1). The findings include: Patient #1 arrived at the freestanding Emergency Department (ED) on 11/12/15 at approximately 3:30 p.m. The surveyor interviewed the ED Charge Nurse (Staff #2) on 11/18/15 at 12:50 p.m. and was informed of the following. The patient arrived at the ED and told the receptionist, Staff #8, that the patient's physician had instructed the patient to go to the ED and to be admitted for observation. The receptionist told the nurse of the patient saying he/she was to be admitted for observation. Staff #2 then told the receptionist that this ED did not have the capability to admit patients. Further, if the patient wanted to be seen for admission, the patient could be seen at a hospital of his/her choosing. The receptionist then told Patient #1 what Staff #2 had said about not being able to admit the patient at this facility. Staff #2 said the patient apparently decided to leave the facility. Staff #2 said Patient #1 was not seen by a physician nor any nursing staff. There was no medical record for Patient #1 at this ED, as the patient was not logged in or registered. On 11/18/15 at 3:35 p.m. the surveyor interviewed Staff #8, the receptionist on duty at the time of Patient #1's arrival to the ED. According to the receptionist, Patient #1 stayed in the ED waiting room from approximately 3:30 p.m. until 5:00 p.m., waiting for his/her spouse to arrive and take the patient to a different ED. Staff #8 told the surveyor that I did not see [him/her] as an emergency. He/she was coherent and did not slur [his/her] words. In the interview, the receptionist informed the surveyor that Patient #1 had informed him/her of a history of TIAs (transichemic attacks - mini strokes). The hospital's policy on EMTALA read, in part, ...Then the individual will be provided necessary stabilizing treatment, within the capability of the facility, or an appropriate transfer as defined by and required by EMTALA. Establishing treatment shall be applied in a non-discriminatory manner (e.g., no different level of care because of diagnosis, financial status, race, or insurance status, disease, or handicap). The ED failed to provide a medical screening exam (MSE) and therefore failed to determine if Patient #1 required stabilizing treatment. Please refer to A-2406 for additional information.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of disaster plans, disaster evaluation form, and staff interviews, the facility failed to provide effective communication to a patient, and training to staff to ensure the safety and well-being of patients for tornado disasters. This involves Patient #6 on 6/13/13. The findings include: Patient #6 was admitted [DATE] with a right hip fracture after a fall at an assisted living facility. She required a right hip arthroplasty on the evening of 6/10/2013. She had an uneventful recovery, except for requiring maximal assist of nursing and physical therapy staff. She was discharged from the hospital on [DATE] to return to the assisted living facility for further rehabilitation. On the day of her discharge, her family member recounted a severe weather event in the area of the hospital causing a National Weather Alert of a Tornado Warning. The hospital sounded a page Code Orange alert to the hospital staff. Shortly after the page, a staff member closed the door of Patient #6, but she was not made aware of what was happening. There was no attempt to close the blinds, move her bed from the window, or communicate to her why her door was being shut. According to the hospital's disaster plan titled Severe Weather Response dated 7/12, a Code Orange means that tornados have been cited in the immediate area. The Hospital Incident Command Center will be established anytime a Tornado Warning is sounded for Loudoun or Fairfax County. Requirements for all staff includes: - pull the orange tool kit (a folder with papers and forms to list patient status and available staff); - assess the unit; - assess staffing in their departments and inform the command center; - all hallways should be cleared at this time. The disaster evaluation form of the incident 6/13/2013 documented that the initial response was correct per policy, but in retrospect there were some areas that could have improved. The disaster evaluation identfied areas for improvement as: biggest area for improvement is the notification to the patients, so they are informed of the situation, and what hospital staff are doing to protect them Patient blinds should have been shut and patients should have been moved away from the windiows, or later in the hallways for their protection. Also indicated was there was only one phone number for staff to call in their status. The surgical wing unit director was concerned that the patient room doors were shut without verbal communication from the staff of the reasons why this was done. Also there was some difficulty in filling out the form and communicating that information to the Command Center. On 8/6/13 at 10:00 a.m. Staff #6 (a nursing tech) stated that if a Code Orange was called, she would close the door and wait for nurse directions. After some hesitation, she said she would go to every room and make sure someone was with the patients. She would probably leave them in the bed, or maybe wheel them out. She was not sure what a Code Orange meant. On 8/6/13 at 10:20 a.m. Staff #7 (a nursing tech) stated that if a Code Orange was called, she would talk to the patients and reassure them. She started to say she would close all the doors, but then remembered that was for a Code Red. She was not aware of what Code Orange meant. On 8/6/13 at 10:40 a.m. Staff #8 (a nurse) stated she would go to the file and start to list number of patients who would ambulate, and who must stay in bed. She would try to tell the patients what was happening, close the doors, check on patients, and call the Command Center. She was also not familiar as to what a Code Orange meant, but she would look it up in the orange Disaster File. According to the the Quality Improvement Director interviewed on 6/5/13, the Emergency Preparedness Committee stated all staff are educated on Disaster Drills once per year. She went on to say that the hospital was aware that the staff on Patient #6's floor did not properly initiate all of the steps of the Tornado Warning, including communicating to the patients who might be concerned.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on staff interview and medical record review, the facility staff failed to follow physician orders for the continuation of parenteral nutrition and intravenous antibiotics, and took out the PICC (peripherally inserted central line) prior to discharge to a skilled facility for 1 of 4 patients reviewed. (Patient #1) The findings include: Patient #1 was an [AGE] year old female with diagnoses of [DIAGNOSES REDACTED]. The letter documental that as part of the investigative process, it was found that the discharging nurse removed the PICC line in error prior to her discharge to the skilled facility. This unfortunately required the patient return back to the facility for another PICC line insertion to continue the needed intravenous nutrition and antibiotics. On 10/31/12 at 4:20 p.m., the Director of Quality stated the investigation was completed by the patient advocate. The letter was addressed to the complainant by the Vice President/Acting Chief Executive Officer. The Director of Quality went on to say that this was their normal process in handling patient or family grievances. This error by the discharging nurse was reviewed thoroughly with the nurse in question and the nurse was reprimanded. Patient #1's medical records were reviewed and discussed with the Director of Case Management during the complaint investigation. The attending physician's 9/25/12 Discharge Summary indicated his desire to continue intravenous nutrition and antibiotics for 2 more weeks. Patient #1 arrived at the skilled facility by ambulance without the PICC line in place for intravenous treatment of her gastrointestinal infection and further management of her nutrition. On the clinical notes from the emergency room record dated 9/26/12, documentation read that the patient was taken to Interventional Radiology for a replacement of the PICC line after the discharging nurse removed the PICC line before sending the patient to the skilled facility. There were no orders to remove the PICC line upon discharge to the skilled facility from the hospital.
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