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Based on a review of the facility's policy entitled "Patient Rights and Responsibilities", staff interviews, patient interviews, and clinical record reviews the facility failed to inform each patient of the patient rights in advance of furnishing or discontinuing care for three (3) of thirty five (35) patients (Patients #2, #3, and #34).

The findings included:

1. A review of thirty two patient medical records (Patients #1-#32) was conducted on July 1, 2014 from approximately 1:15 pm through 4:35 pm by two Medical Facilities Inspectors. Seven patients were interviewed on July 2, 2014 between 10:00 am and 11:00 am (Patients #2, #4, #5, #32, #33, #34, and #35). A sample admission packet was requested and received on July 2, 2014. The packet was reviewed on July 2, 2014 at 1:20 pm. Patient #3's (an infant) medical record had no documentation the parents received notice of rights. Staff #5 was interviewed on July 1, 2014 and July 2, 2014. Staff #5 confirmed Patient #3's parents did not receive notification of Patient Rights. Staff #5 reported Staff #12 (non medical staff) asked the registration staff not to approach the family. Staff #12 was interviewed a second time on July 2, 2014 at approximately 11:00 am. Staff #12 reported he/she asked the registration staff "not to approach the family this second." Staff #12 stated he/she did not know exactly what was going on at that moment. Staff #12 stated he/she "was not sure who was present." Staff #4 was interviewed on July 2, 2014 and reported it is the expectation of the facility all patients and/or representatives of patients will receive notification of patient rights upon admission.

2. Patient #2's medical record was reviewed on July 1, 2014 at approximately 2:00 pm. Documentation in Patient #2's medical record indicated the patient had received patient rights. Patient #2 was interviewed on July 2, 2014 at approximately 10:00 am. Patient #2 reported he/she never received an admission packet of information including patient rights. Patient #2 reported no facility staff had gone over Patient Rights. Patient #2's wife was present during the interview. Patient #2's wife reported the patient never received an admission packet with Patient Rights. Patient #2's wife confirmed no facility staff had discussed Patient Rights with them.

3. Patient #34 was interviewed at approximately 10:00 am on July 2, 2014. Patient #34 reported he/she had been a patient in the emergency department since 8:00 am. Patient #34 reported he/she had not received any information pertaining to Patient Rights. Patient #34 confirmed his/her family had not received any information pertaining to Patient Rights. Patient #34 reported no facility staff have provided or gone over any information regarding Patient Rights. Staff #2 provided documentation Patient #34 had signed consent which includes receiving Patient Rights at approximately 8:30 am.

4. Staff #17 was interviewed at approximately 10:10 am on July 2, 2014. Staff #17 reported he/she does not go over Patient Rights with patients admitted directly to the general surgery floor.

5. Staff #18 was interviewed on July 2, 2014 at 10:20 am. Staff #18 stated he/she is not sure how patients receive Patient Rights.

6. An interview was conducted with Staff #19 on July 2, 2014 at approximately 10:30 am. Staff #19 stated he/she is not sure how the patient gets Patient Rights. Staff #19 reports he/she does not go over Patient Rights with patients.

7. A review of the facility's policy titled Patient Rights and Responsibilities was requested and received on July 1, 2014. The policy was reviewed on July 2, 2014 at approximately 8:00 am. The policy states "Patient Rights and Responsibilities will be provided to patients and or representatives in accordance with current statutory and accrediting guidelines." An admission packet was received and reviewed on July 2, 2014. Staff #5 was interviewed on July 1, 2014 at approximately 3:00 pm. Staff #5 was called to assist with the location of documentation in the medical records pertaining to consent and acknowledgement of receipt of Patient Rights. Staff #3 and Staff #11 (emergency department staff) were unable to locate the documentation of notification of Patient Rights in some of the electronic medical records. Staff #5 reported all patients receive Patient Rights when registered in the emergency department.

Based on document review, medical record review, and interview the facility failed to ensure one (1) of thirty five (35) patients the opportunity to exercise their rights (Patient #3).

The findings included:

Thirty two medical records (#1-#32) were reviewed on July 1, 2014 at approximately 1:15 pm through 4:35 pm. Seven patients were interviewed on July 2, 2014 between 10:00 am and 11:00 am (Patients #2, #4, #5, #32, #33, #34, and #35).

Patient #3 is an eight (8) week old infant who was found "limp" in the crib by his/her mother at approximately 10:00 pm on May 31, 2014. Patient #3 was reported to be full term, healthy and up to date on all immunizations according to documentation in Patient #3's medical record when reviewed on July 1, 2014 and July 2, 2014. According to documentation reviewed on the Emergency Medical Services (EMS) record of Patient #3 dated 05/31/2014 Patient #3 was last seen awake and breathing by his/her mother one hour prior to finding the infant "limp" in the crib. Cardiopulmonary resuscitation (CPR) was initiated by the infant's family. Due to the rural area the family resided in, a Basic Life Support (BLS) ambulance was initially dispatched to the scene. Documentation on the EMS record reports CPR was continued by the EMS staff with assisted breathing by bag mask ventilation. Patient #3 was transported to a Hanover County fire station where an Advanced Life Support (ALS) unit was waiting to transport Patient #3 to the above named facility. Documentation by the ALS crew reports Patient #3 received from BLS unit in full cardiac arrest with CPR in progress.

Patient #3 was brought to the above named facility on May 31, 2014 at approximately 11:23 pm to 11:28 pm (time discrepancy noted in Patient #3's hospital medical record between documentation on the code timeline and the patient care timeline) by the Hanover County Fire-Emergency Medical Services (EMS) in full cardiac arrest. Cardiopulmonary resuscitation was performed by the emergency room staff of the above named facility from approximately 11:23 pm to time of documented death at 11:50 pm.

No documentation found in the medical record of Patient #3 relating to the time the parents and the grandparent arrived at the above named facility. No documentation found the family was ever updated or informed of Patient #3's medical condition by medical or nursing staff prior to the death of Patient #3. No documentation indicating the parents of Patient #3 were given the opportunity to participate or be informed of the treatment plan for Patient #3. No timed documentation by any medical or nursing staff of when the family was told of the death of Patient #3. No documentation found other then a note (no time documented) by Staff #12 (non medical staff) which stated "provided gentle presence with Patient #3's mom in the consult room as staff worked with Patient #3. Present as doctor told father and mother of the death of Patient #3." Documentation electronically signed at 4:30 am on 06/01/2014 by Staff #12.

Staff #12 was interviewed on July 1, 2014 and July 2, 2014. Staff #12 reported when he/she arrived in the emergency room the staff were actively working with Patient #3. Staff #12 reported Patient #3's mother arrived and was informed by Staff #12 that emergency room staff were working with the baby. Staff #12 reported Patient #3's father arrived shortly after the infant's mother. Staff #12 stated the father was quiet but Patient #3's mother was very upset. Staff #12 reported he/she went back and forth from the consult room to the emergency room to check on the status of Patient #3. Staff #12 confirmed he/she was unable to give any updates to the family pertaining to Patient #3's medical condition. Staff #12 verified he/she has no medical back ground. Staff #12 reported he/she was present when Staff #8 informed the parents Patient #3 had expired. Staff #12 reported Patient #3's mother was "distraught." Staff #12 was unable to recollect the exact time Staff #8 informed the family of Patient #3 of the death.
Staff #12 reported he/she had no recollection of the nursing staff or medical staff keeping the family informed prior to the death of Patient #3.
Staff #12 stated Patient #3's grandparent arrived and was told of the death of Patient #3. Staff #12 reported Patient #3's grandparent was very upset and stated he/she "could not believe Patient #3 had died."

Staff #12 reported he/she heard from another staff member Patient #3's grandparent stated to Patient #3's mother after the infant expired we are going to leave this hospital with your baby alive. Staff #12 reported Staff #8 called Staff #4 who advised Staff #8 the family should not be allowed to see Patient #3's body until the Medical Examiner (staff from ME office) arrived due to the family's comment about leaving the hospital with Patient #3. Staff #12 reported the emergency department staff wanted the family to see the baby.

Documentation in Patient #3's medical record dated 06/01/2014 at 12:34 am by Staff #8 states "family conveyed they would like to take Patient #3's body home from the ED (emergency department) tonight. We have spoken with the ME, they state there will be an open investigation and confirm the family cannot touch the patient's body." No documentation indicating the ME reported the family could not view the body of Patient #3. No documentation found in the medical record of Patient #3 that any family member was asked about the comment relating to removing the infant from the hospital. No documentation found the family was informed why they could not view the body of Patient #3. Documentation dated 06/01/2014 at 12:50 am by Staff #8 indicates Staff #4 was contacted via telephone. Staff #8's documentation reports after discussion with Staff #4 and Hanover County sheriffs (one sheriff is employed by the facility) the family will not see Patient #3's body until after the Medical Examiner arrives. No documentation by Staff #8 of any conversations with the parents of Patient #3 including the time and response to the death of Patient #3.

Staff #8 was interviewed on July 1, 2014 at approximately 11:40 am. Staff #8 confirmed Patient #3's family was not allowed to see the body of Patient #3 until the medical examiner arrived. Staff #8 stated he/she did not know whether anyone had updated the family prior to the death of Patient #3. Staff #8 reported he/she did not speak with Patient #3's family until after the death of the infant. Staff #8 confirmed he/she had told the parents of Patient #3 of the death. Staff #8 stated the grandparent was insisting on the hospital staff to "put Patient #3 back on a machine."

Staff #13 was interviewed on July 2, 2014 at 7:30 am. Staff #13 confirmed he/she was the primary nurse for Patient #3 the night of May 31, 2014. Staff #13 reported Patient #3 had no obvious signs of trauma or neglect upon arrival to the emergency department. Staff #13 confirmed CPR was in progress on Patient #3 upon arrival to the emergency room.
Staff #13 reported he/she did not know the time the family arrived in the emergency department. Staff #13 reported he/she did not provide any updates or information to the family regarding Patient #3. Staff #13 verified there was no documentation in Patient #3's medical record of the nursing staff updating the family of Patient #3's condition. Staff #13 reported he/she only spoke with Patient #3's family "hours later" to provide them with names of the staff and contact numbers of the governor's office. Staff #13 reported he/she did not hear the comment the family had made pertaining to wanting to take Patient #3's body home. Staff #13 reported the family of Patient #3 was not allowed to see the body of Patient #3 until hours later. Staff #13 confirmed the family of Patient #3 viewed the body from outside emergency room #20.

Staff #14 was interviewed by phone at 1:00 pm on July 2, 2014. Staff #14 confirmed he/she was the charge nurse in the above named facility's emergency department the night of May 31, 2014 through June 1, 2014. Staff #14 stated family kept saying if this was anyone else's baby this would not have happened.
Staff #14 confirmed the family of Patient #3 was not allowed to see Patient #3 until hours later when the medical examiner arrived. Staff #14 confirmed he/she did not update the family of Patient #3 prior to the death. Staff #14 stated he/she was unsure of when the family initially arrived at the above named facility.


Staff #4 was interviewed on July 1, 2014 and July 2, 2014. Staff #4 confirmed he/she received a phone call from Staff #8 at approximately 12:30 am on June 1, 2014 pertaining to Patient #3. Staff #4 reported he/she advised Staff #8 to not allow Patient #3's family to view the body of Patient #3 until the Medical Examiner arrived. Staff #4 reported the above named facility adheres to the guidelines provided by the Virginia Department of Health Office Of The Medical Examiner titled Information for Physicians and Hospitals on Infant and Child Deaths. Staff #4 confirmed the guidelines state "viewing may be done, if no physical contact with the deceased is allowed while under the supervision of hospital staff as long as the infant is not altered in any way for this process." The guidelines further state "holding of the infant may be done in cases where there is no known or suspected child abuse or no known or suspected neglect. Only the parents may hold the infant in the presence of the law enforcement personnel responsible for investigating the death." Staff #4 confirmed no where in the guidelines does it state a family may not view the body prior to the arrival of the medical examiner.

Staff #7 was interviewed on July 1, 2014 at 12:00 pm. Staff #7 confirmed he/she was present during the attempted resuscitation of Patient #3 on May 31, 2014. Staff #7 reported he/she did not know if anyone had updated the family regarding the medical status of Patient #3 prior to the death. Staff #7 confirmed he/she did not update or include the parents of Patient #3 in the treatment plan. No documentation was found in Patient #3's medical record of any direct communication between the medical staff and Patient #3's family prior to the provider note by Staff #7 on 06/01/2014 at 3:08 am.

Staff #7 reported the hospital made the decision not to allow the family to view the body of Patient #3 due to a questionable flight risk. Staff #7 reported (when notified of the death of Patient #3 by phone) the medical examiner said "the family could view the body of Patient #3." Staff #7 reported the "medical examiner did not know the family had not seen Patient #3."

A time discrepancy is noted in Patient #3' medical record between the ED provider notes by Staff #7 and the Patient Care Timeline. The Patient Care Timeline documentation indicates the family viewed the body of Patient #3 at 3:48 am on 06/01/2014. An ED provider note timed at 3:08 am by Staff #7 documents a conversation with the family about the viewing of the body.

A review of Patient #3's medical record on July 1, 2014 at approximately 3:30 pm found no documentation on the Patient Care Timeline of any mention of the Patient's family until 12:10 am on June 1, 2014. Documentation at 12:10 am reports Staff #15 talking with the family after being advised of the situation. Note by Staff #13 dated 06/01/2014 at 3:45 reports Medical examiner (Inspector) at Patient #3's bedside while other officer "gets family." Documentation on the timeline of Patient #3 reports the family viewed the body at 3:48 am on 06/01/2014. No documentation noted any interactions between emergency room nursing staff with the family from admission on May 31, 2014 to the time the body of Patient #3 was released to the ME. No nursing documentation of any comments allegedly made by the family. No documentation by any nursing or medical staff the family was informed of the reason for the delay in viewing Patient #3's body.

Based on policy review, medical record review, and interview the facility failed to inform and ensure the right to visitation for two (2) of thirty five (35) patients (Patient #3 and Patient #32).

The findings included:

Thirty two medical records (#1-#32) were reviewed on July 1, 2014 at approximately 1:15 pm through 4:35 pm. Seven patient interviews were conducted on July 2, 2014 from 10:00 am through 11:00 am (Patients #2, #4, #5, 32, #33, #34, and #35).

Patient #3 is an eight (8) week old infant who was found "limp" in the crib by his/her mother at approximately 10:00 pm on May 31, 2014.
Patient #3 was brought to the above named facility on May 31, 2014 at approximately 11:23 pm to 11:28 pm (time discrepancy noted in Patient #3's hospital medical record between documentation on code timeline and the patient care timeline) by the Hanover County Fire-Emergency Medical Services (EMS) in full cardiac arrest. Cardiopulmonary resuscitation was performed by the emergency room staff of the above named facility from approximately 11:23 pm to time of documented death at 11:50 pm.
No documentation found in the medical record of Patient #3 relating to the time the parents and the grandparent arrived at the above named facility. No documentation found the family was ever updated or informed of Patient #3's medical condition by medical or nursing staff prior to the death of Patient #3. No timed documentation by any medical or nursing staff of when the family was told of the death of Patient #3. No documentation found other then a note (no specific time documented as to when family informed of the death) by Staff #12 (non medical staff) which stated "provided gentle presence with Patient #3's mom in the consult room as staff worked with Patient #3. Present as doctor told father and mother of the death of Patient #3." Documentation electronically signed at 4:30 am on 06/01/2014 by Staff #12.

Staff #12 reported he/she had no recollection of the nursing staff or medical staff keeping the family informed prior to the death of Patient #3.
Staff #12 stated Patient #3's grandparent arrived and was told of the death of Patient #3.
Staff #12 reported Staff #8 called Staff #4 who advised Staff #8 the family should not be allowed to see Patient #3's body until the Medical Examiner arrived due to the grandparent's comment about leaving the hospital with Patient #3.

No documentation found in Patient #3's medical record the Medical Examiners office was notified of the decision to not allow the family to view the body of Patient #3.

Staff #8 was interviewed on July 1, 2014 at approximately 11:40 am. Staff #8 confirmed Patient #3's family was not allowed to see the body of Patient #3 until the medical examiner arrived. Staff #8 stated he/she did not know whether anyone had updated the family prior to the death of Patient #3. Staff #8 confirmed he/she had told the parents of Patient #3 of the death.

Staff #13 was interviewed on July 2, 2014 at 7:30 am. Staff #13 confirmed he/she was the primary nurse for Patient #3 the night of May 31, 2014. Staff #13 reported Patient #3 had no obvious signs of trauma upon arrival to the emergency department. Staff #13 reported he/she did not provide any updates or information to the family regarding Patient #3. Staff #13 verified there was no documentation in Patient #3's medical record of the nursing staff updating the family of Patient #3. Staff #13 reported he/she only spoke with Patient #3's family "hours later" to provide them with names of the staff and contact numbers of the governor's office.
Staff #14 confirmed the family of Patient #3 was not allowed to see Patient #3 until hours later when the medical examiner arrived. Staff #14 confirmed he/she did not update the family of Patient #3 prior to the death.

Staff #4 was interviewed on July 1, 2014 and July 2, 2014. Staff #4 confirmed he/she received a phone call from Staff #8 at approximately 12:30 am on June 1, 2014 pertaining to Patient #3. Staff #4 reported he/she advised Staff #8 to not allow Patient #3's family to view the body of Patient #3 until the Medical Examiner arrived. Staff #4 reported the above named facility adheres to the guidelines provided by the Virginia Department of Health Office Of The Medical Examiner titled Information for Physicians and Hospitals on Infant and Child Deaths. Staff #4 confirmed the guidelines state "viewing may be done, if no physical contact with the deceased is allowed while under the supervision of hospital staff as long as the infant is not altered in any way for this process." The guidelines further state "holding of the infant may be done in cases where there is no known or suspected child abuse or no known or suspected neglect. "Only the parents may hold the infant in the presence of the law enforcement personnel responsible for investigating the death." Staff #4 confirmed no where in the guidelines does it state a family may not view the body prior to the arrival of the medical examiner.

Staff #7 reported he/she was present during the family's viewing of Patient #3's body at approximately 3:48 am on June 1, 2014 (time discrepancy noted in Patient #3's medical record between ED provider notes and Patient Care Timeline)

A review of the hospital policy relating to Medical Examiners cases was reviewed on July 1, 2014. The policy addressed the preparation of the body for viewing by a family. Staff #4 confirmed the policy addressed the preparation of the body for viewing on July 1, 2014. The policy did not include the body would be in a body bag during viewing. Staff #7 confirmed during interview on July 1, 2014 at 12:00 pm the ME (investigator) did not know the family of Patient #3 had not viewed the body of Patient #3.

A review of Patient #3's medical record on July 1, 2014 revealed no documentation notice of rights was given to the parents of Patient #3. No documentation found as to why no notice of rights were not given. No documentation the parents were ever informed as to why the visitation was being denied. No documentation the facility staff ever inquired further information from the family regarding the comments allegedly made about removing Patient #3's body from the hospital. No documentation the emergency department nursing staff interacted with the family other than to give contact numbers of the hospital administration at the request of the grandparent of Patient #3 after viewing the infant's body.

The hospital policy titled Visitation was reviewed on July 1, 2014 and July 2, 2014. The policy states under the category titled Visitors in the Emergency Department visitors are allowed in two (2) at a time except for "critically ill or dying patients." No documentation found the parents of Patient #3 were informed of this policy.

The hospital policy titled Patient Rights and Responsibilities was reviewed on July 2, 2014. Under the subtitle Patient Rights the policy states patients/representatives have the right to know about hospital rules that affect them or their treatment and their family and visitors.

Patient #32 was interviewed in the Intensive Care Unit (ICU) at approximately 10:30 am on July 2, 2014. Patient #32 reported he/she had concerns regarding the visiting hours. Patient #32 reported his/her family member had wanted to visit outside the normal visiting hours. Patient #32 reported the staff would not "allow it." Patient #32 reported his/her family was allowed to visit during the set hours. Patient #32 reported he/she was ready for transfer to the floor.
The policy titled Visitation was reviewed on July 1, 2014 and July 2, 2014. The policy states "the hospital allows for the presence of a support individual of the patient's choice for emotional support during the course of the stay, unless the individual's presence infringes on others' rights, safety, or is medically or therapeutically contraindicated." The policy further states for the critical care areas visitation is "discouraged during change of shift report" due to patient confidentiality. The policy states visitation at night will be based on the needs of the patient. It was reported by hospital staff the visitation policy is currently being revised to be less restrictive.

Based on policy review, medical record review, and interview the facility failed to ensure the right to visitation for two (2) of thirty five (35) patients (Patient #3 and Patient #32).

The findings included:

Thirty two medical records (#1-#32) were reviewed on July 1, 2014 at approximately 1:15 pm through 4:35 pm. Seven patient interviews were conducted on July 2, 2014 from 10:00 am through 11:00 am (Patients #2, #4, #5, #32, #33, #34, and #35).

Cross reference to 482.13(h)(1), (h)(2) Patient Visitation Rights, Tag A 216 for Patient #3.

Patient #32 was interviewed in the Intensive Care Unit (ICU) at approximately 10:30 am on July 2, 2014. Patient #32 reported he/she had concerns regarding the visiting hours. Patient #32 reported his/her family member had wanted to visit outside the normal visiting hours and was not allowed. Patient #32 reported the staff would not "allow it." Patient #32 reported his/her family could only come at times during the set hours. Patient #32 reported he/she was ready for transfer to the floor.
The policy titled Visitation was reviewed on July 1, 2014 and July 2, 2014. The policy states "the hospital allows for the presence of a support individual of the patient's choice for emotional support during the course of the stay, unless the individual's presence infringes on others' rights, safety, or is medically or therapeutically contraindicated." It was reported by hospital staff the visitation policy is currently being revised.