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Based on staff interview and document review, it was determined the hospital failed to ensure each patient had the right to make informed decisions regarding his or her care. Specifically, the hospital failed to ensure each patient was able to refuse treatment in one (1) of nine (9) clinical records reviewed in the survey sample. Clinical record #9.

Findings:

The clinical record for patient #9 contained documentation that the patient was brought to the ED on 03/16/22 via ECO for homicidal ideation on 03/16/22 at 10:07 AM. The patient record contained a physician order for a COVID test to be obtained on 03/16/22. The clinical record contained documentation that the patient refused a COVID test multiple times on 03/16/22, 03/17/22, 03/18/22, 03/19/22, 03/20/22, and 03/21/22. Patient #9 remained in the ED from 03/16/2022 - 03/21/22 on an ECO/TDO (temporary detainment order). The clinical record contained documentation that the patient could not be placed into an inpatient psychiatric facility until a COVID test was obtained.

The clinical record contained documentation from a Registered Nurse (staff member #12) on 03/19/22 at 11:08 AM that reads as follows, "...Inquired with patient further and patient reports, 'I am not letting them assault me by making me get a COVID test. It is unconstitutional and I will sit here for a year if I need to.' ED MD as well as MH (mental health) liaison aware and ED MD reports patient may not eat until a COVID test is collected."

A second Registered Nurse (staff member #13) documented the following on 03/19/22 at 1:55 PM, "Writer called admin at home after ECO officer questioned and raised [a] concern that patient had orders that [they] could not eat or drink until COVID test collected. Spoke to [name of nursing supervisor staff member #6] about this and made admin on call aware that writer has to provide food and drink to [the] patient in accordance to MH laws in the state of Virginia."

The nursing supervisor documented the following on 03/19/22 at 8:05 PM, "Conversation re: no food until COVID test performed. ED MD stated that the patient may be provided with ED house diet until such time as they were willing to consent to a COVID swab and that food preferences, except those precluding allergies would be withheld until consent was granted. At no time were basic food and water rights denied, only personal preferences for such, again food allergies withstanding (of which none were reported by the patient)."

The clinical record for patient #9 contained no documentation of progress notes or orders from the physician who ordered the patient to have "house diet only." The clinical record contained documentation of the patient being delivered and eating meals, but did not include documentation of what the contents of the meals provided to the patient were.

An interview was conducted on 03/28/22 at 2:00 PM with the physician (staff member #8) who made the statements regarding patient #9's diet. The physician denied that the patient was ever ordered "no food or water." The physician stated that the patient needed to have a COVID test performed in order to be placed at the appropriate level of care - an inpatient psychiatric facility and that the patient had already been in the ED for several days. The physician stated the patient required complex psychiatric care which the ED could not provide. The physician stated they ordered the patient only have house meals, like a sandwich instead of being able to call to the cafeteria and make their preferred meal selection until such time the patient agreed to have a COVID test.

An interview was conducted with the ED nurse supervisor (staff member #6) on 03/28/22 at 3:00 PM and on 03/29/22 at 12:30 PM. Staff member #6 stated that the patient was never denied basic food or water. Staff member #6 indicated they had investigated the concerns and found that the physician was frustrated that the patient would not consent to a COVID test that was needed for placement and stated to the patient, "Fine, then you don't get anything to eat." The staff member confirmed that the patient was restricted to the house diet (a cold meal from the ED rather than meal tray/preferences from the cafeteria). Staff member #6 and staff member #3 confirmed that other patients holding in the ED were permitted to order food preferences and were not restricted to the house diet.

The hospital's policy, Patient Rights and Responsibilities partially reads as follows, "The hospital respects the patient's or surrogate decision maker's right to refuse care, treatment, and services, in accordance with law and regulation."

The Vice President of Regulatory and Risk Management acknowledged the above noted patient rights deficiency during the exit conference on 03/29/22.

Based on staff interview and document review, it was determined the hospital failed to ensure all nurses who provide services in the hospital followed the policies and procedures of the hospital in one (1) of nine (9) clinical records reviewed in the survey sample. Clinical record #2.

Findings:

First Event: The clinical record for patient #2 indicated that the patient was on the observation unit at the hospital 12/26/21 to 12/27/21. The clinical record contained documentation that the patient's IV (located in the right antecubital (AC) area) was removed at 7:34 PM on 12/27/21. The clinical record contained documentation the the patient's daughter contacted the hospital re: IV not removed. The nursing note from 8:07 PM on 12/27/21 reads as follows, "Patient arrived at front of hospital driven by daughter for IV removal. Right AC IV site discontinued. Pressure held until hemostasis and dry sterile dressing applied."

An interview was conducted on 03/29/22 at 11:30 AM with the Registered Nurse (staff member #6) on the observation unit who discontinued the patient's IV in December. The nurse stated that she received a phone call from the patient's daughter that the patient had gone home with the IV still in. The nurse advised the daughter to bring the patient back to the hospital. The nurse stated she went downstairs and removed the patient's IV.

An interview was conducted with the nurse manager of the observation unit (staff member #10) on 03/29/22 at 11:45 AM. Staff member #10 stated that patient #2 was discharged during shift change and the nurse assigned to the patient failed to remove the patient's IV before escorting her from the hospital via wheelchair. Staff member #10 said the nurse discharging the patient was verbally counseled and an email was sent to the staff in a weekly update to remind staff to ensure IVs were removed prior to discharge. Staff member #10 was unable to present any documentation related to the conversation with the nurse or the staff education.

Second Event: The clinical record for patient #2 contained documentation that the patient was admitted to the neuroscience unit of the hospital on 03/10/22 with vision changes and a facial droop. The clinical record contained documentation that the patient's IV was removed at 2:35 PM on 03/13/22 and that the patient was discharged at 3:40 PM on 03/13/22.

An interview was conducted with the nurse manager of the neuroscience unit (staff member #7) on 03/29/22 at 9:20 AM. Staff member #7 stated she had received a complaint recently from the family of patient #2 that was currently under investigation by the hospital. Staff member #7 stated the nurse discharging the patient (staff member #9) had called the patient's family on the day of discharge and asked the family member to call the nurse when the family had arrived and the patient was ready to leave. The nurse was planning to remove the patient's IV at the time of discharge. Staff member #7 stated the family came to pick up patient #2 without notifying nursing staff and the patient left the hospital with family unaccompanied by staff. Staff member #7 confirmed that the clinical record for patient #2 contained documentation that IV was removed, but had not been removed and the patient returned to the hospital to have IV taken out. Staff member #7 provided documentation of counseling provided to staff member #9 reviewing policies related to IV removal.

The hospital's policy, Patient Discharge was reviewed and partially reads as follows, "Nursing Responsibilities...(6). Perform and document a patient assessment prior to discharge to minimally include: vital signs, removal of all invasive lines and tubes as appropriate, general physical assessment."

The Vice President of Regulatory of Risk Management acknowledged the above noted deficiency during the exit conference on 03/29/22.