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Based on interviews and document review, it was determined facility staff failed to ensure that a signed consent was obtained prior to a procedure for one (1) out of twenty-one (21) patient (Patient #1) records reviewed.

Findings included:

Patient #1 was admitted to the facility as a transfer on 11/29/18 with diagnoses which included, but were not limited to sepsis, shortness of breath, dizziness, blurred vision, headache, and chest pain.
A review of the medical record for Patient #1 revealed an order for lab testing for HIV (human immunodeficiency virus). There was no consent for HIV testing signed by the patient or his/her representative. The lab test was drawn and results recorded on 11/30/18.

The general consent for treatment dated 11/29/18 included documentation that the patient was "admitted no family".

There were telephone consents in the record witnessed by hospital staff, with permission for tests/procedures granted by the patient's son, for the following dates/procedures: 12/2/18: lumbar puncture; 12/3/18: Dialysis catheter; and 12/4/18 TEE (transesophageal echocardiography) and blood products.
On 12/6/18 the case manager's note documented "attempted to call family, phone disconnected".
Staff Member (SM) #2 was interviewed on 12/14/18 at 11:00 a.m. and stated "Case management would get involved and talk with the family".

The facility's policy entitled "HIV testing Consent, Explanation and Counseling, IC.05.1109.0.0 was reviewed, and evidenced the following in part:
"Policy: In order to comply with Virginia State Law, the physician must get the consent of the patient to perform HIV testing. If any patient refuses the HIV test, the physician should so document in the patient's chart and the test will not be performed except in the case of the "Deemed Consent" as stated in Virginia State Law 32.1-45.1..." "Procedure: A. The physician writes an order for the HIV test on the patient's chart. B. The physician must get the patients {sic} consent for the HIV test. C. If the patient refuses the test, the physician must so state in the chart and cancel the HIV order. D. Once the HIV order and patients {sic} consent are obtained, the nurse will initiate a lab slip for the test. E. Once HIV test results are charted, the physician will disclose the results to the patient. At this time, the physician, by law, must offer the patient counseling and education regarding HIV test results as outlined in Virginia State Law (32.1-37.2, Section B)...".

On 12/14/18 at approximately 11:30 a.m. SM #16, epidemiologist, advised the surveyors that a second HIV test was ordered/ drawn on Patient #1 due to a staff exposure, and that a separate consent was not required due to deemed consent. SM #16 stated "a consent is required, except when drawn due to staff exposure/deemed consent".

Concerns were discussed with SM #2, Director of Quality and Accreditation on 12/14/18 at approximately 11:00 a.m. on 12/14/18, and again at 12:00 p.m. on 12/14/18 with members of administration.

Based on interview and document review, it was determined that facility staff failed to ensure that the plan of care for one (1) out of of seven (7) patients (Patient #13) was updated when restraints were placed.

Findings included:

A review of the medical record was conducted for Patient #13, who was admitted to the facility on 11/25/18 with diagnosis of altered mental status. There was documentation in the record that bilateral upper extremity (BUE) mitts were ordered on 11/30/18 at 8:22 p.m. for safety (non-violent) due to pulling out his/her nasogastric tube (NGT). Mitt restraints were ordered/documented on 11/30/18, 12/1/18, 12/2/18, 12/3/18, 12/4/18, 12/5/18, and 12/6/18.
Restraints were added to Patient #13's plan of care on 12/3/18 at 9:51 p.m., three (3) days after mitt restraints were placed.

The facility's policy entitled "Patient Restraint/Seclusion, PC.13.329.00.0" was reviewed, and stated the following, in part: "...10. Care of the Patient/Plan of Care: a. The plan of care will clearly reflect a loop of assessment, intervention, and evaluation for restraint, seclusion and medications. b. Patients and/or families should be involved in care planning to the extent possible and made aware of changes to the plan of care...".

The facility's policy entitled "Documenting the Provision of Care" was also reviewed, and stated the following, in part: "...A. Plan of Care:...The Plan of Care is reviewed daily and updated as needed based on changes in the patient condition and progress toward identified outcomes or goals. Progress is documented as Improved, Stabilized, or Deteriorated, as defined by the CCC taxonomy. The daily focus for the patient is identified at the beginning of the shift, usually during bedside handoff. The focus is generally written on the white board at bedside to assure that all members of the care team, including the patient's family are aware of the focus for the day...".

Concerns were discussed with Staff Member (SM) #4, Outcomes Specialist and record navigator, on 12/13/18 at approximately 3:30 p.m., and with members of administration on 12/14/18 at 12:00 p.m.