HospitalInspections.org

Based on observation, clinical record review, facility document review and staff interview, the governing body failed to ensure a designated in-patient hospital unit was equipped and staff were trained to provide the same care in emergency situations as all other units of the hospital.

Patient #1 experienced a cardiac arrest and Patient #2 experienced multiple grand-mal seizure episodes. The in-patient unit staff had only basic cardiac life support training and equipment and relied on EMS (Emergency Medical Services - 911) to respond to life-threatening emergencies. Patients in order to receive Advanced Cardiac Life Support, have to wait until EMS is able to respond . Patient #1 expired in the Emergency Department.

The facility policy and procedures only addressed basic life support measures and relied on the services of "911" for advanced care.

Please refer to A0115, A0144, A1100 and A1103 for further information.

Based on interviews, clinical record review and facility document review, the facility staff failed to ensure each patient's rights were protected. Two (2) patients (Patient #1 and #2) included in the survey sample experienced a medical emergency in a designated in-patient psychiatric unit. The current practice has the potential to negatively affect all patients admitted to this unit.

The facility administered PRN (as needed) medications to Patient #1 documented as a chemical restraint, without an order or monitoring.

The facility also failed to follow the requirements for Restraint Death reporting. Patient #1 was placed in a physical restraint, medicated, and secluded and expired less than 24 hours later.

Please refer to A0144 and A0213 for further information.

Based on clinical record review, staff interview and facility document review, the facility staff failed to ensure a complete and accurate medical record was maintained for Patient #1.

Patient #1's medical record:
(1) included conflicting documentation of a medical emergency by staff involved in patient care during the event;
(2) failed to include a discharge summary; and
(3) failed to included a final diagnosis.
Patient #1 was admitted and discharged/expired in October 2023.

Please refer to A0449, A0468, and A0469 for further information.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the needs of patients experiencing an emergency medical condition were met.

Patient #1 experienced a cardiac arrest and Patient #2 experienced multiple grand-mal seizures. The in-patient unit had only basic life support (BLS) equipment, staff received only BLS training and relied on EMS (Emergency Medical Services - 911) to handle life-threatening emergencies. Patients are expexted to wait for EMS to respond in order to receive the *ACLS. Patient #1 expired in the Emergency Department.

*(Advanced Cardiac Life Support --Advanced cardiac life support refers to a set of guidelines used by medical providers to treat life-threatening cardiovascular conditions. These life-threatening conditions range from dangerous arrhythmias to cardiac arrest. ACLS algorithms frequently address at least five different aspects of peri-cardiac arrest care: Airway management, ventilation, CPR compressions (continued from BLS), defibrillation, and medications. Due to the seriousness of the diseases treated, the paucity of data known about most ACLS patients, and the need for multiple, rapid, simultaneous treatments, ACLS is executed as a standardized, algorithmic set of treatments. Successful ACLS treatment starts with diagnosis of the correct EKG rhythm causing the arrest. Common cardiac arrest rhythms covered by ACLS guidelines include: ventricular tachycardia, ventricular fibrillation, Pulseless Electrical Activity, and asystole. Dangerous, non-arrest rhythms typically covered includes: narrow- and wide-complex tachycardias, torsades de pointe, atrial fibrillation/flutter with rapid ventricular response, and bradycardia. www.cpr.heart.org accessed 11/07/24 at 6:58 a.m.)

According to facility Administration, the Snowden unit was designated as an inpatient psychiatric unit but did not follow the same medical emergency protocols as the standard hospital units.

The facility policy and procedure for "Code Blue- Code Pink (adolescent)" addressed only Basic Life Support measures and calling "911" for Advanced Life Support/Emergency Measures and transport to the Emergency Room.

Please refer to A1103 for further information.

Based on observation, clinical record review, staff interview and facility document review, the governing body failed to ensure a designated hospital unit had emergency services and resources/staff training to provide appropriate emergency care for all patients. Two patients included in the survey sample (Patient #1 and #2) experienced medical emergency and staff couldn't provide care beyond basic life support and relied on care being provided by EMS (Emergency Medical Services).

The findings included:

Patient #1 experienced a cardiac arrest on October 7, 2023 and the unit did not have immediate resources available to provide emergency care. Patient #1 expired in the Emergency department. Note: review of Patient #1's medical record found different timelines and accounts of the events that occurred prior to Patient #1 expiration in the Emergency Department (ED).
The "ED Provider Notes" for this event read in part, "...EMS reports that pt (patient) was last seen at (their) baseline around 2130 (9:30 p.m.). Staff at Snowden found patient at 2430 (12:30 a.m.) sitting in a chair and had urinated of (self)....staff noticed patient was pale so they checked (patient) pulse and it was 'thready and weak'. Staff then attempted to get a BP (blood pressure) and were unable to so CPR (cardiopulmonary Resuscitation) was started at 2445 (12:45 a.m.)..."

A "Nursing Note" documented the event in part, "...Upon helping place (patient) into bed writer noticed (patient) had urinated (self)...while cleaning (patient) (patient) urinated (self) again...after washing (patient) up and placing clean clothes...noted (Patient) extremities felt a bit cool to touch. Felt for a pulse, and it was present, but faint...retrieved vital sign machine. Could not obtain BP or HR (heart rate)...did not respond to sternal rub...Code Blue initiated at 2345 (11:45 p.m. 10/7/23)...CPR started... AED (automated external defibrillator) placed on (patient) BS (Blood sugar) was taken and was 409. (Patient) remained in asystole (no detectable heart activity), and at no point was a shock advised...CPR continued until EMS arrived and took over...EMS transported (patient) to the hospital at 0013 (12:03 a.m. 10/8/23)... time of death was called at 0035 (12:35 a.m. 10/8/23) (in the Emergency Department).

A "Consult Note" revealed in part, "This provider was notified by nursing charge at approximately 2250 (10:50 p.m.- 10/7/23) of patient cardiac arrest...was informed by nursing staff that CPR was in progress since 2245 (10:45 p.m.)...EMS arrived at approx (approximately) 2252 (10:52 p.m.) and pt was transferred to ED at 0013 (12:03 a.m. 10/8/23)

Patient #2 experienced on October 27, 2023 multiple grand-mal seizures while in-patient at this unit which did not have access to suction or oxygen. Patient #2 waited approximately forty (40) minutes for transport to the emergency room.
On October 27, 2023 at 1:28 p.m. a "Nursing Note" documented in part,"... Patient complained of feeling dizzy immediately after taking (their) medications at 13:00 (1:00 p.m.)...patient began to seize, with (their) eyes rolled back, (their) jaw clenched, (their) body stiff and lower extremities jerking for about 20 (twenty) seconds...patient continues to have intermittent seizure episodes lasting 10-20 (ten to twenty) seconds with brief post-ictal (The postictal state is the altered state of consciousness after an epileptic seizure. It usually lasts between 5 and 30 minutes, but sometimes longer in the case of larger or more severe seizures, and is characterized by drowsiness, confusion, nausea, hypertension, headache or migraine, and other disorienting symptoms. The ictal period is the seizure itself; the interictal period is the time between seizures. clevelandclinic.org accessed 11/6/24 at 10:15 a.m.)...was given Ativan (antianxiety medication often used to treat seizure activity) 2mg ( two milligrams on (patient) right dorsogluteal (right buttock) area at 13:14 (1:14 p.m.) ...stopped seizing at about 13:20... laied (sic) on floor...until...EMS arrived (no time) ...transport by EMS to ED at 13:40 ( 1:40 p.m.)..."
The "Psychiatry Note" dated October 27, 2023 documented at 1:31 p.m. in part, "Prior to seeing patient , (patient) began having a seizure outside the office...eyes rolling back, full body tremors, obtunded, unable to respond to verbal commands..tongue remained inside (patient) mouth...no Versed (Midazolam, also called Versed, is a medicine used to stop a seizure that has lasted too long. It's also used if many seizures happen in a short period of time.drugs.com accessed 11/6/24 at 10:58 a.m.) was available and Ativan 2mg IM was given..."
The "ED Provider Note" documented at 1:59 p.m., in part, "Patient arrived to the ED after experienced multiple seizures while at Snowden. There were 3 (three) witnessed seizures...admitted...discharged back to Snowden October 28, 2024..."

The facility policy regarding management of emergency medical conditions was reviewed the policy on October 21, 2024 at 1:10 p.m. The policy "Transfer of Patient with Acute Medical Conditions, Guidelines for Snowden at Fredericksburg (approved 5/11, revised 8/17, reviewed 3/21) evidenced, in part: "The purpose of these guidelines is to assist the nursing staff at Snowden at Fredericksburg (SAF) in ensuring that Behavioral Health Patients receive prompt medical assessment, evaluation and intervention should an acute medical condition develop. Content: 1. The following steps are to be followed when a patient at Snowden displays any signs/symptoms of an acute medical condition, which may include, but are not limited to: a. severe chest pain b. nausea, vomiting, diaphoreses, changes in LOC (level of consciousness) or vital signs c. difficulty breathing...cyanosis, or inadequate oxygenation (decreased mental status, change in color of lips, fingernail beds) d. acute abdominal pain e. onset of vaginal bleeding while pregnant f. changes in blood sugar accompanied by symptoms of hypoglycemia/hyperglycemia g. severe headache with changes in speech and neurological status h. seizures. 2. The physician, if on-site is to be notified immediately to evaluate patient. In the event there is not a physician on the premises a. Call 911; alert front desk/security b. have on-call physician paged c. Nurse/Mental Health Technician to remain with patient at all times obtaining and recording vital signs, monitoring patient d. Call Emergency department at MWH (Mary Washington Hospital) and provide hand-off communication e. notify patients family regarding transfer, if applicable 3. Document all events completely and concisely in the medical record."

The Surveyor requested further information/policy regarding specifically how the facility handled a "Code Blue" and was provided "Code Blue/Code Pink, Snowden at Fredericksburg- MWH Mary Washington Hospital - Approved 3/20" which evidenced, in part: "To outline the process for a respiratory/cardiac arrest at Snowden (SAF). Inpatient First Response 1. The first Associate notified SAF operator to have a code blue/code pink overhead paged. The first RN (Registered Nurse) on scene directs the code. 2. The HUC (Health Unit Coordinator) or nurse calls 911...3. A third associate obtains the AED, back board, code bag, delivers them to the code site and assists with CPR. 4. All Associates available respond to the code as appropriate. 5. Non nursing Associates assist with code as needed...Code Leadership 1. The first Registered Nurse (Lead RN) responding to the code will lead the code team. 2. The Lead RN will assign associate to document in the medical record using the designated time piece. Documentation may be done electronically or on the paper form Resuscitation Record (FR-116-MWHC) for downtime. 3. When EMS personnel arrive on scene they will assume leadership of the code. 4. The Lead RN will assure documentation is completed; call the Mary Washington Hospital Emergency Department (MWH-ED) and give them a 'Hand-off"...5. The Lead RN will ensure the patient's chart is complete with documentation of the event as well as the transportation time is entered in to the patient's medical record...7...Lead RN notified management...8. Lead RN conducts debrief with all associates who participated in the code. 9. A SAFE report is completed...Code Team Members 1. First person in scene-activates code calk , notes time of arrest...2. Code bag responder- obtains AED, code bag and back board...3. First RN responder (Lead RN) assumes leadership of the code...directs associate to document events...4. Recorder Associate - documents information in the medical record...Lead RN is responsible to ensure all documentation associated with the code is complete and on the permanent medical record..."

The surveyor toured the Snowden Unit on October 21, 2024 at approximately 11:45 a.m. accompanied by Staff Members #2, 3, and 4. During the tour the surveyor inquired as to whether the unit was considered an in-patient unit. Staff Member # 2 and 3 acknowledged the unit status as "in-patient for treatment of mental health". The surveyor inquired as to the location of emergency equipment and was shown a small blue bag labeled "Emergency Bag" which contained an ambu bag (Bag-valve-mask (BVM) or the Ambu bag is a self-inflating bag used to provide ventilation to the person not breathing normally. A BVM consists of a non-rebreathing valve and a face mask. The opposite end of the bag is attached to an oxygen source. The mask is manually held against the face. The bag is squeezed to provide ventilation to the patient through the nose and mouth until the intubation can be done. americanheartassociation.org accessed 11/01/24 at 6:45 a.m.) and a stethoscope. The surveyor inquired as to the oxygen source and Staff Member #2 indicated the facility did not have an oxygen source. The surveyor was also shown a "First Aid Kit" containing various bandage materials and tape, an AED (Automated External Defibrillator - AEDs are used to help those experiencing sudden cardiac arrest. It's a sophisticated, yet easy-to-use, medical device that can analyze the heart's rhythm and, if necessary, deliver an electrical shock, or defibrillation, to help the heart re-establish an effective rhythm. americanheart association.org) and a back board (A backboard, made of wood, plastic, or other material, is inserted under the torso of a patient that is to receive cardiopulmonary resuscitation (CPR) in order to provide a firm surface during chest compression. americanheartassociation.org accessed 11/01/24 at 7:00 a.m.). Staff Member #4 indicated the in-patient unit "does not have any oxygen sources, no suction machine, does not do advanced cardiac life support, and does not administer cardiac emergency medications but calls 911 and the EMS responds. We only do CPR and use the AED and staff are trained in BLS (Basic Life Support)."

On October 21, 2024 at 2:30 p.m., the surveyor again discussed the emergency protocols for the Snowden unit since the unit had been identified as an in-patient unit. Staff Member #2 indicated that in an emergency the staff would take the patient's vital signs, and start the BLS protocol, call EMS, notify the physician and transfer the patient to the hospital ED. At 3:00 p.m., the surveyor interviewed Staff Members #12 and #13 who indicated they would complete an assessment on a patient, get vital signs and if the patient was not breathing or did not have a heart beat they would call a code blue and call the doctor as well as 911 for the EMS. The staff members indicated they did not do any suctioning, or administer any medications during a code blue and there was no oxygen at the facility. The staff members further indicated they were trained in basic life support and the use of the AED. Staff Member #5 (Nurse Manager) stated that the EMS has a "very quick response" and that staff were trained in basic life support. The surveyor inquired as to the "quick response" for Patient #2 who waited approximately 40 (forty) minutes for EMS transport after experiencing multiple seizures. "The EMS are really close and that was unusual" according to Staff Member #2.

On October 22, 2024 at 11:15 a.m., the surveyor interviewed Staff Member #16 (Medical Director Snowden unit) who indicated that if a code blue is called and the MD is available they would respond and provide support but the most experienced physician or Registered Nurse would direct the code. Staff Member #16 further indicated that basic life support would be provided, but that advanced life support was not done on the unit.

At 2:40 p.m. on October 22, 2024, the surveyor interviewed Staff Member #15 who indicated they were notified after Patient #1 experienced the cardiac arrest and the patient transferred to the Emergency Department. The Staff Member #15 explained to the surveyor that if a patient had a medical emergency on the unit, the staff would call "911" as they did not provide advanced cardiac life support.

The surveyor inquired as to whether there were emergency medications that were available for use in an injectable form in the facility. The surveyor was given a list on October 22, 2024 at 2:55 p.m.. The list contained a variety of antipsychotic and antianxiety agents as well as Glucagon (a medication to raise the blood sugar) and Naloxone (a medication which can reverse an opioid overdose).

Staff Member #2 provided the surveyor with a map of the facility campus on October 22, 2024 at 2:30 p.m. This map had a circle encompassing the hospital and was designated as the "campus" The unit/facility Snowden was not included in the "campus". The surveyor inquired as to whether the facility considered the unit as an in-patient unit. Staff Member #2 indicated it was "remote location". The surveyor inquired as to whether the Snowden unit was listed in the hospital services as an in-patient behavioral health unit. Staff Member #2 stated yes. The surveyor reviewed the 2023 application submitted by the facility which listed the Snowden unit as consisting of 62 adult and 12 adolescent/pediatric behavioral health beds under the same provider number as the hospital.

The surveyor discussed with Staff Members #2, 3, 4, 5, and 6 on October 22, 2024 at approximately 11:45 a.m. and again On October 23, 2024 at approximately 12:30 p.m. the concerns regarding the designation of Snowden as an inpatient hospital unit and not equipped to function with advanced life support in the event of an emergency and the reliance on 911 to provide emergency care to inpatients on the unit.

Based on interviews, clinical record review, observation and facility document review, the facility staff failed to ensure that during a medical emergency Patient #1 and #2 recieved care in a safe setting.

Patient #1 had a cardiac arrest on October 7, 2023. Basic Life Support was provided on the unit by staff, however, the facility relied on the services of "911" for advanced cardiac life support. Patient #1 expired in the Emergency Department.

Patient #2 experienced multiple grand-mal seizures on October 27, 2023. The in-patient unit staff called 911 and provided medications, however, it was documented that forty (40) minutes elapsed from the time of the seizure and a 911 call was placed, until the patient was transported to the Emergency Department. The facility relied on "911" for emergency care and transport.

The findings include:

Patient #1 presented to the Emergency Department (ED) of the facility on October 3, 2023, for an "evaluation of mental health". The "Emergency department Provider Notes" evidenced the patient had a past medical history of Bipolar 1 disorder, depression, schizophrenia spectrum disorder with psychotic disorder, seizure, and anemia. The notes further documented the patient was "non-communicative, but does follow commands". In the section for "ED Course" on "Wednesday, October 4, 2023 at 0203 (2:03 a.m.) , the note evidenced, "RACSB (County Community Services Board) refuses to pre-screen because they believe the condition is medical and not psychological. They would like to pushback the prescreen until the morning because they hope (patient) would be more clear at that point...0204 (2:04 a.m.) Medically cleared. Prescreen will be delayed until day shift...Medical decision Making: Patient presents to the ED for psychotic episode. Patient was recommended for Snowden (inpatient psychiatric unit) and transferred to Snowden...Diagnosis: psychosis unspecified psychosis type, Acute UTI (urinary tract infection)."

On October 4, 2023 a "Nursing Note" documented at 3:32 p.m. in part, "Patient arrived ambulatory from Stafford (sister facility) ED, TDO (Temporary Detaining Order) status...Patient states this admission is due to (patient) trying to get better for (their) (child). Denies SI/HI (suicidal ideations/homicidal ideations) and hallucinations...poor insight...disoriented to situation and is forgetful, frequently asking staff when (they) can leave and when (parent) can visit..."

"ED Provider Notes" documented on October 8, 2023 at 12:21 a.m., revealed in part, "...presents to the ED via EMS (Emergency Medical Services) from Snowden for evaluation. EMS reports that pt (patient) was last seen at (their) baseline around 2130 (9:30 p.m.). Staff at Snowden found patient at 2430 (12:30 a.m.) sitting in a chair and had urinated of (self)....staff noticed patient was pale so they checked (patient) pulse and it was 'thready and weak'. Staff then attempted to get a BP (blood pressure) and were unable to so CPR (cardiopulmonary Resuscitation) was started at 2445 (12:45 a.m.)..."

A "Nursing Note" dated October 8, 2023 at 1:21 a.m. documented the events as following, "Went with med tech to assist (patient) to bed...during rounds (med tech) asked (patient) if (they) would like to go to bed and (patient) responded 'Eh'. Upon helping place (patient into bed writer noticed (patient had urinated (self)...while cleaning (patient) (patient) urinated (self) again...after washing (patient) up and placing clean clothes...noted (Patient) extremities felt a bit cool to touch. Felt for a pulse, and it was present, but faint...retrieved vital sign machine. Could not obtain BP pr HR (heart rate)...(did not respond to sternal rub...Code Blue initiated at 2345 (11:45 p.m. 10/7/23)...CPR started... AED (automated external defibrillator) placed on (patient)BS (Blood sugar) was taken and was 409. (Patient) remained in asystole (no detectable heart activity), and at no point was a shock advised...CPR continued until EMS arrived and took over...EMS transported (patient to the hospital at 0013 (12:03 a.m. 10/8/23)... time of death was called at 0035 (12:35 a.m. 10/8/23).

The physician on the unit documented the medical emergency in their "Consult Note" dated October 8, 2023 at 12:25 a.m.: "This provider was notified by nursing charge at approximately 2250 (10:50 p.m.- 10/7/23) of patient cardiac arrest...was informed by nursing staff that CPR was in progress since 2245 (10:45 p.m.)...EMS arrived at approx (approximately) 2252 (10:52 p.m.) and pt was transferred to ED at 0013 (12:03 a.m. 10/8/23)."

Patient #2 presented to the Emergency Department on October 26, 2023 at 1:04 p.m. with suicidal ideations and depression. According to the Emergency Department "History and Physical" the patient had a history of a seizure disorder and "states (they) were taking Keppra (anti-seizure medication) for seizures but ran out X1 (one) month ago...had a seizure last night and woke up on the floor...seen by mental health and they wish to admit (patient)...They do understand that (patient) will need Keppra given to (patient)...(patient) was loaded with a g (gram) of Keppra in the emergency department and had no seizures..."

On October 27, 2023 at 1:28 p.m. it was documented in the "Nursing Note: Patient complained of feeling dizzy immediately after taking (their) medications at 13:00 (1:00 p.m.)...patient began to seize, with (their) eyes rolled back, (their) jaw clenched, (their) body stiff and lower extremities jerking for about 20 (twenty) seconds...patient continues to have intermittent seizure episodes lasting 10-20 (ten to twenty) seconds with brief post-ictal (The postictal state is the altered state of consciousness after an epileptic seizure. It usually lasts between 5 and 30 minutes, but sometimes longer in the case of larger or more severe seizures, and is characterized by drowsiness, confusion, nausea, hypertension, headache or migraine, and other disorienting symptoms. The ictal period is the seizure itself; the interictal period is the time between seizures. clevelandclinic.org accessed 11/6/24 at 10:15 a.m.)...was given Ativan (antianxiety medication often used to treat seizure activity) 2mg ( two milligrams on (patient) right dorsogluteal (right buttock) area at 13:14 (1:14 p.m.) ...stopped seizing at about 13:20... laied (sic) on floor...until...EMS arrived (no time) ...transport by EMS to ED at 13:40 ( 1:40 p.m.)..." There was a "Psychiatry Note" dated October 27, 2023 at 1:31 p.m. which evidenced, "Prior to seeing patient , (patient) began having a seizure outside the office...eyes rolling back, full body tremors, obtunded, unable to respond to verbal commands..tongue remained inside (patient) mouth...no Versed (Midazolam, also called Versed, is a medicine used to stop a seizure that has lasted too long. It ' s also used if many seizures happen in a short period of time.drugs.com accessed 11/6/24 at 10:58 a.m.) was available and Ativan 2mg IM was given..." at 1:59 p.m., an "ED Provider Note" evidenced, "Patient arrived to the ED after experienced multiple seizures while at Snowden. There were 3 (three) witnessed seizures...admitted...discharged back to Snowden October 28, 2024..."


The surveyor requested the facility policy regarding management of emergency medical conditions and received and reviewed the policy on October 21, 2024 at 1:10 p.m. The policy "Transfer of Patient with Acute Medical Conditions, Guidelines for Snowden at Fredericksburg (approved 5/11, revised 8/17, reviewed 3/21) evidenced, in part: "The purpose of these guidelines is to assist the nursing staff at Snowden at Fredericksburg (SAF) in ensuring that Behavioral Health Patients receive prompt medical assessment, evaluation and intervention should an acute medical condition develop. Content: 1. The following steps are to be followed when a patient at Snowden displays any signs/symptoms of an acute medical condition, which may include, but are not limited to: a. severe chest pain b. nausea, vomiting, diaphoreses, changes in LOC (level of consciousness) or vital signs c. difficulty breathing...cyanosis, or inadequate oxygenation (decreased mental status, change in color of lips, fingernail beds) d. acute abdominal pain e. onset of vaginal bleeding while pregnant f. changes in blood sugar accompanied by symptoms of hypoglycemia/hyperglycemia g. severe headache with changes in speech and neurological status h. seizures. 2. The physician, if on-site is to be notified immediately to evaluate patient. In the event there is not a physician on the premises a. Call 911; alert front desk/security b. have on-call physician paged c. Nurse/Mental Health Technician to remain with patient at all times obtaining and recording vital signs, monitoring patient d. Call Emergency department at MWH (Mary Washington Hospital) and provide hand-off communication e. notify patients family regarding transfer, if applicable 3. Document all events completely and concisely in the medical record."

The Surveyor requested further information/policy regarding specifically how the facility handled a "Code Blue" and was provided "Code Blue/Code Pink, Snowden at Fredericksburg- MWH Mary Washington Hospital - Approved 3/20" which evidenced, in part: "To outline the process for a respiratory/cardiac arrest at Snowden (SAF). Inpatient First Response 1. The first Associate notified SAF operator to have a code blue/code pink overhead paged. The first RN (Registered Nurse) on scene directs the code. 2. The HUC (Health Unit Coordinator) or nurse calls 911...3. A third associate obtains the AED, back board, code bag, delivers them to the code site and assists with CPR. 4. All Associates available respond to the code as appropriate. 5. Non nursing Associates assist with code as needed...Code Leadership 1. The first Registered Nurse (Lead RN) responding to the code will lead the code team. 2. The Lead RN will assign associate to document in the medical record using the designated time piece. Documentation may be done electronically or on the paper form Resuscitation Record (FR-116-MWHC) for downtime. 3. When EMS personnel arrive on scene they will assume leadership of the code. 4. The Lead RN will assure documentation is completed; call the Mary Washington Hospital Emergency Department (MWH-ED) and give them a 'Hand-off"...5. The Lead RN will ensure the patient's chart is complete with documentation of the event as well as the transportation time is entered in to the patient's medical record...7...Lead RN notified management...8. Lead RN conducts debrief with all associates who participated in the code. 9. A SAFE report is completed...Code Team Members 1. First person in scene-activates code calk , notes time of arrest...2. Code bag responder- obtains AED, code bag and back board...3. First RN responder (Lead RN) assumes leadership of the code...directs associate to document events...4. Recorder Associate - documents information in the medical record...Lead RN is responsible to ensure all documentation associated with the code is complete and on the permanent medical record..."



The surveyor toured the Snowden Unit on October 21, 2024 at approximately 11:45 a.m. accompanied by Staff Members #2, 3, and 4. During the tour the surveyor inquired as to whether the unit was considered an in-patient unit. Staff Member # 2 and 3 acknowledged the unit status as "in-patient for treatment of mental health". The surveyor inquired as to the location of emergency equipment and was shown a small blue bag labeled "Emergency Bag" which contained an ambu bag (Bag-valve-mask (BVM) or the Ambu bag is a self-inflating bag used to provide ventilation to the person not breathing normally. A BVM consists of a non-rebreathing valve and a face mask. The opposite end of the bag is attached to an oxygen source. The mask is manually held against the face. The bag is squeezed to provide ventilation to the patient through the nose and mouth until the intubation can be done. americanheartassociation.org accessed 11/01/24 at 6:45 a.m.) and a stethoscope. The surveyor inquired as to the oxygen source and Staff Member #2 indicated the facility did not have an oxygen source. The surveyor was also shown a "First Aid Kit" containing various bandage materials and tape, an AED (Automated External Defibrillator - AEDs are used to help those experiencing sudden cardiac arrest. It's a sophisticated, yet easy-to-use, medical device that can analyze the heart's rhythm and, if necessary, deliver an electrical shock, or defibrillation, to help the heart re-establish an effective rhythm. americanheart association.org) and a back board (A backboard, made of wood, plastic, or other material, is inserted under the torso of a patient that is to receive cardiopulmonary resuscitation (CPR) in order to provide a firm surface during chest compression. americanheartassociation.org). Staff Member #4 indicated the in-patient unit "does not have any oxygen source, no suction machine, does not do advanced cardiac life support, and does not administer cardiac emergency medications but calls 911 and the EMS responds. We only do CPR and use the AED and staff are trained in BLS (Basic Life Support)."

On October 21, 2024 at 2:30 p.m., the surveyor again discussed the emergency protocols for the Snowden unit since the unit had been identified as an in-patient unit. Staff Member #2 indicated that in an emergency the staff would take the patient's vital signs, and start the BLS protocol, call EMS, notify the physician and transfer the patient to the hospital ED. At 3:00 p.m., the surveyor interviewed Staff Members #12 and #13 who indicated they would complete an assessment on a patient, do the vital signs and if the patient was not breathing or did not have a heart beat they would call a code blue and call the doctor as well as 911 for the EMS. The staff members indicated they did not do any suctioning, or administer any medications during a code blue and there was no oxygen at the facility. The staff members further indicated they were trained in basic life support and the use of the AED. Staff Member #5 (Nurse Manager) stated that the EMS has a "very quick response" and that staff were trained in basic life support. The surveyor inquired as to the "quick response" for Patient #2 who waited approximately 40 (forty) minutes for EMS transport after experiencing multiple seizures. "The EMS are really close and that was unusual" according to Staff Member #2.

On October 22, 2024 at 11:15 a.m., the surveyor interviewed Staff Member #16 (Medical Director Snowden unit) who indicated that if a code blue is called and the MD is available they would respond and provide support but the most experienced physician or Registered Nurse would direct the code. Staff Member #16 further indicated that basic life support would be provided, but that advanced life support was not done on the unit.

At 2:40 p.m. on October 22, 2024, the surveyor interviewed Staff Member #15 who indicated they were notified after Patient #1 experienced the cardiac arrest and the patient transferred to the Emergency Department. Staff Member #15 further indicated they came in to the facility and had notified the patient family and asked them to come in. The Staff Member #15 informed the surveyor that if a patient had a medical emergency on the unit, the staff would call "911" as they did not provide advanced cardiac life support.

The surveyor requested to examine the record of the "code" on October 22, 2024 at 3:10 p.m. and was informed by Staff Member #2 there was no documentation other than the nurses note. "I do not see they used the code narrator (a documentation system that allows staff to enter the record of treatment, medications and actions during a code blue). There is nothing other than what was documented in the nurses note afterward and the ED record.

The surveyor inquired as to whether there were emergency medications that were available for use in an injectable form in the facility. The surveyor was given a list on October 22, 2024 at 2:55 p.m.. The list contained a variety of antipsycotic and antianxiety agents as well as Glucagon (a medication to raise the blood sugar) and Naloxone (a medication which can reverse an opioid overdose).

The surveyor discussed with Staff Members #2, 3, 4, 5, and 6 on October 22, 2024 at approximately 11:45 a.m. and again On October 23, 2024 at approximately 12:30 p.m. the concerns regarding the designation of Snowden as an inpatient hospital unit and not equipped to function with advanced life support in the event of an emergency. The surveyor discussed the staff, although trained in basic life support, could not perform the functions as the other in-patient units of the hospital and did not have access to oxygen, suction, or emergency medications as well as relying on calling 911 in order to provide emergency care.

Based on clinical record review, staff interview, and facility document review, the facility staff failed to modify Patient #1's plan of care for the use of a physical hold, the administration of a chemical restraint and the use of seclusion.

The findings include:

Patient #1 was placed in a physical hold after displaying agitation, continued to be held in a physical hold in order to receive an injection of Haldol (an antipsychotic medication) and Ativan (an anti-anxiety medication) and was then placed in seclusion.

The "Nursing Note" written on October 7, 2023 and signed at 5:21 p.m., documented in part, "Patient became increasingly frustrated about not being able to leave the unit...began to beat on the unit's exit door. Staff physically restrained patient by (their) arms and escorted (patient) to the observation room, PRN (As needed) medications for agitation were administered to patient 10:03( incorrect time- medication record documents administration as 1603 [4:03] p.m.). Staff were about to release patient from physical hold but (patient) shove them (sic)...pulled one staff's hair. Physical hold was consequently maintained until patient partially calmed down. Patient was placed in seclusion...seclusion was discontinued at 1632 (4:32 p.m.)..."

The orders for physical hold in Patient #1's clinical record did not include utilization of physical hold for the administration of medications. The order for the medications were written as PRN "as needed". However, the "Psychiatry Progress Note" documented on October 7, 2023 at 5:58 p.m. read in part, "...Patient has been reportedly highly agitated and required chemical restraint...Patient was somewhat somnolent (sleepy, almost sleeping) on evaluation..."

On October 22, 2024, the surveyor, with the assistance of Staff Member #2, reviewed Patient #1's clinical record, specifically the most current "Plan of Care" for the (October 7 though 8, 2024 time frame). The "Plan of Care" was dated October 7, 2023 and time stamped at 11:20 p.m., which means it was revised/reviewed/documented after the restraint incidents (physical and chemical as well as seclusion). The "Care Plan" did not include documentation of any restraint use. Staff Member #2 stated, "This is the only care plan after the restraint use and I do not see any restraint update..."

The staff member (Registered Nurse) who documented the "Plan of Care" was no longer employed at the facility and unavailable for interview.

The facility policy and procedure "Restraint and Seclusion Policy- Snowden at Fredericksburg" was reviewed and evidenced: "...Procedures in the Use of Restraints and Seclusion: ...7. Plan of Care: Based on the comprehensive assessment and evaluation of the effectiveness of less restrictive measures, the nursing staff will individualize and modify the patient's plan of care to include use of restraints..."


The surveyor discussed with Staff Members #2, 3, 4, 5, and 6 on October 22, 2024 at approximately 11:45 a.m. and again On October 23, 2024 at approximately 12:30 p.m. the concerns

Based on staff interview, clinical record review and facility document review, the facility staff failed to obtain an order for the use of a physical hold to administer medications and for the use of chemical restraint for Patient #1.

The findings include:

Patient #1 was placed in a physical hold after displaying agitation. When staff were ready to release the patient, the patient again became agitated. Patient #1 was held in a physical hold for administartion of an injection of Haldol (an antipsychotic) and Ativan (an anti-anxiety medication) and then placed in seclusion.

On October 7, 2023 and signed at 5:21 p.m., the "Nursing Note" evidenced: "Patient became increasingly frustrated about not being able to leave the unit...began to beat on the unit's exit door. Staff physically restrained patient by (their) arms and escorted (patient) to the observation room, PRN (As needed) medications for agitation were administered to patient 10:03( incorrect time- medication record documents administration as 1603 [4:03] p.m.). Staff were about to release patient from physical hold but (patient) shove them (sic)...pulled one staff's hair. Physical hold was consequently maintained until patient partially calmed down. Patient was placed in seclusion...seclusion was discontinued at 1632 (4:32 p.m.)..."

According to the clinical record the orders for the physical hold did not include the need utilize the hold for the administration of medications. The order for the medications were written as PRN "as needed". However, the "Psychiatry Progress Note" dated 10/7/23 at 5:58 p.m. evidenced, "...Patient has been reportedly highly agitated and required chemical restraint...Patient was somewhat somnolent (sleepy, almost sleeping) on evaluation..."

The surveyor, with the assistance of a facility staff Member #2, was unable to locate in the clinical record any documentation of monitoring regarding the use of the medications as a chemical restraint or an addition to the physical hold order for administration of medications Staff Member #2 indicated on October 22, 2024 at 1:45 p.m. that there would be no monitoring because the medications were PRN and not ordered as a chemical restraint. Staff Member #2 further indicated that the patient was not released from the initial physical hold while the medications were administered so it was the "same order".

The surveyor reviewed the regularly scheduled medications for Patient #1. Patient #1 had only Risperidone 2mg (two milligrams) ordered at bedtime.

The staff member (Registered Nurse) involved in the restraint episode was no longer employed at the facility and unavailable for interview.

The facility policy and procedure "Restraint and Seclusion Policy- Snowden at Fredericksburg" was reviewed and evidenced: "...Definitions: 1. c. Drugs or medications that are used as part of a patient's standard medical or psychiatric treatment and are administered within the standard dosage for the patient's condition , would not be subject to requirements for chemical restraints...4. ...the 'standard treatment dosage' ...to treat the patient's condition enables the patient to more effectively or appropriately function in the world around them...3. Physical Hold...considered a restraint when it restricts the patient's movement against the patient's will...The use of a physical hold to medicate or treat a patient against the patient's will must be consistent with relevant requirements for the use of restraints...A physician's order is required as this is an application of the restraint..."

The surveyor discussed with Staff Members #2, 3, 4, 5, and 6 on October 22, 2024 at approximately 11:45 a.m. and again On October 23, 2024 at approximately 12:30 p.m. the concerns.

Based on clinical record review, staff interview, and facility document review, the facility staff failed to report a death of a Patient #1 that occurred within 24 hours after the use of a physical hold, the administration of a chemical restraint, and the use of seclusion.

Patient #1 was placed in a physical hold after displaying agitation and continued to be held in a physical hold in order to receive an injection of Haldol (an antipsychotic) and Ativan (an anti-anxiety medication), was then placed in seclusion and expired within 24 hours.

The findings include:

The "Nursing Note" dated October 7, 2023 and signed at 5:21 p.m. documented in part, "Patient became increasingly frustrated about not being able to leave the unit...began to beat on the unit's exit door. Staff physically restrained patient by (their) arms and escorted (patient) to the observation room, PRN (As needed) medications for agitation were administered to patient 10:03( incorrect time- medication record documents administration as 1603 [4:03] p.m.). Staff were about to release patient from physical hold but (patient) shove them (sic)...pulled one staff's hair. Physical hold was consequently maintained until patient partially calmed down. Patient was placed in seclusion...seclusion was discontinued at 1632 (4:32 p.m.)..."

The "ED Provider Notes" from October 8, 2023 at 12:21 a.m., revealed, "...presents to the ED via EMS (Emergency Medical Services) from Snowden for evaluation. EMS reports that pt (patient) was last seen at (their) baseline around 2130 (9:30 p.m.). Staff at Snowden found patient at 2430 (12:30 a.m.) sitting in a chair and had urinated of (self)....staff noticed patient was pale so they checked (patient) pulse and it was 'thready and weak'. Staff then attempted to get a BP (blood pressure) and were unable to so CPR (cardiopulmonary Resuscitation) was started at 2445 (12:45 a.m.)..."

A "Nursing Note" dated October 8, 2023 at 1:21 a.m. evidenced: "Went with med tech to assist (patient) to bed...during rounds (med tech) asked (patient) if (they) would like to go to bed and (patient) responded 'Eh'. Upon helping place (patient into bed writer noticed (patient had urinated (self)...while cleaning (patient) (patient) urinated (self) again...after washing (patient) up and placing clean clothes...noted (Patient) extremities felt a bit cool to touch. Felt for a pulse, and it was present, but faint...retrieved vital sign machine. Could not obtain BP pr HR (heart rate)...(did not respond to sternal rub...Code Blue initiated at 2345 (11:45 p.m. 10/7/23)...CPR started... AED (automated external defibrillator) placed on (patient)BS (Blood sugar) was taken and was 409. (Patient) remained in asystole (no detectable heart activity), and at no point was a shock advised...CPR continued until EMS arrived and took over...EMS transported (patient to the hospital at 0013 (12:03 a.m. 10/8/23)... time of death was called at 0035 (12:35 a.m. 10/8/23).

The unit physician on duty during the medical emergency documented in their "Consult Note" on October 8, 2023 at 12:25 a.m.: "This provider was notified by nursing charge at approximately 2250 (10:50 p.m.- 10/7/23) of patient cardiac arrest...was informed by nursing staff that CPR was in progress since 2245 (10:45 p.m.)...EMS arrived at approx (approximately) 2252 (10:52 p.m.) and pt was transferred to ED at 0013 (12:03 a.m. 10/8/23)."

There was no documentation in the clinical record that the death was reported to CMS (Centers for Medicare Medicaid Services). Staff Member #2 explained in an interview on October 22, 2024 at 3:10 p.m. that there was no evidence that the restraint death had been logged by the facility and reported to CMS. A document provided by the facility regarding information for the Medical Examiner (dated 10.8.23 at 7:03 a.m.) evidenced inaccuracies regarding the use of restraints within the last 24 hours for Patient #1. The document included the response "NO" to the following questions: "Was the patient restrained within 7 days of death? Did patient's death occur within 24 hours after being removed from restraints/seclusion? Did the patient's death occur within one week after being removed from restraints/seclusion?" This document had been reviewed and signed by a Registered Nurse and Nursing Supervisor. The surveyor discussed this information with Staff Member #2 who acknowledged the errors.

The facility policy and procedure "Restraint and Seclusion Policy - Snowden at Fredericksburg" revealed in part: "...Reporting Patient Deaths- Facilities must report deaths associated with the use of seclusion or restraint...3. If a death occurs...2) within 24 hours after the patient is removed from restraint or seclusion..."


The surveyor discussed with Staff Members #2, 3, 4, 5, and 6 on October 22, 2024 at approximately 11:45 a.m. and again on October 23, 2024 at approximately 12:30 p.m. the concerns regarding the failure to report a patient death within 24 hours after restraints/seclusion.

Based on clinical record review, staff interview and facility document review, the facility staff documented in Patient #1's clinical record conflicting information regarding the timeline and the course of the events associated with the medical emergency Patient #1 experienced while in-patient on this psychiatric unit.

The findings include:

On October 8, 2023 at 12:21 a.m., the "ED Provider Notes" documented in part, "...presents to the ED via EMS (Emergency Medical Services) from Snowden for evaluation. EMS reports that pt (patient) was last seen at (their) baseline around 2130 (9:30 p.m.). Staff at Snowden found patient at 2430 (12:30 a.m.) sitting in a chair and had urinated of (self)....staff noticed patient was pale so they checked (patient) pulse and it was 'thready and weak'. Staff then attempted to get a BP (blood pressure) and were unable to so CPR (cardiopulmonary Resuscitation) was started at 2445 (12:45 a.m.)..."

A "Nursing Note" dated October 8, 2023 at 1:21 a.m. read in part, "Went with med tech to assist (patient) to bed...during rounds (med tech) asked (patient) if (they) would like to go to bed and (patient) responded 'Eh'. Upon helping place (patient into bed writer noticed (patient had urinated (self)...while cleaning (patient) (patient) urinated (self) again...after washing (patient) up and placing clean clothes...noted (Patient) extremities felt a bit cool to touch. Felt for a pulse, and it was present, but faint...retrieved vital sign machine. Could not obtain BP pr HR (heart rate)...(did not respond to sternal rub...Code Blue initiated at 2345 (11:45 p.m. 10/7/23)...CPR started... AED (automated external defibrillator) placed on (patient)BS (Blood sugar) was taken and was 409. (Patient) remained in asystole (no detectable heart activity), and at no point was a shock advised...CPR continued until EMS arrived and took over...EMS transported (patient to the hospital at 0013 (12:03 a.m. 10/8/23)... time of death was called at 0035 (12:35 a.m. 10/8/23)."

The unit physician on duty documented in their "Consult Note" dated October 8, 2023 at 12:25 a.m. the following: "This provider was notified by nursing charge at approximately 2250 (10:50 p.m.- 10/7/23) of patient cardiac arrest...was informed by nursing staff that CPR was in progress since 2245 (10:45 p.m.)...EMS arrived at approx (approximately) 2252 (10:52 p.m.) and pt was transferred to ED at 0013 (12:03 a.m. 10/8/23)."

The surveyor interviewed Staff Member #2 regarding the auditing of medical records. Staff Member #2 stated on 10/22/24 at 3:10 p.m. that the chart had been reviewed due to a "Serious Incident Review and Root Cause Analysis" being done (completed October 19, 2023). The surveyor inquired about the conflicting time line and account of the event documented by the staff involved in the care during the emergency event. Staff Member #2 indicated there had not been any correction made to the documentation. The surveyor inquired if the root cause analysis conducted identified and addressed/corrected with addendum the conflicting documentation in the medical record. Staff Member #2 indicated there had been no changes and no addendums made to Patient #1 medical record.

The facility policy and procedure" Medical records, Content and Management (revised 12/21)" was reviewed on 10/23/24 at 10:00 a.m. and evidenced: "...3. Each inpatient and outpatient will have a medical record maintained...This record will be: a. Accurately Documented...Content in the Medical Record: 4. The record may need to be revised beyond the 48 hour window. For example:...b. Incorrect data has been documented that could impact care...Corrections to the Medical Record: - A correction is a change in the information meant to clarify inaccuracies after the original document has been signed or rendered complete to note an error in documentation...proper correction procedures must be followed..."

The surveyor discussed with Staff Members #2, 3, 4, 5, and 6 on October 22, 2024 at approximately 11:45 a.m. and again On October 23, 2024 at approximately 12:30 p.m. the concerns regarding the inaccuracies of the clinical record documentation that remained after a facility review of the clinical record and one year after the incident.

Based on clinical record review, staff interview and facility document review, the facility staff failed to ensure Patient #1's medical record included a discharge summary discussing the outcome of the patient's hospitalization and disposition of the patient.

The findings included:

Patient #1 was discharged on October 8, 2023, due to death. On October 21, 2024, the surveyor reviewed the clinical record for Patient #1 and was unable to locate a discharge summary. With the assistance of Staff Member #2 the chart was reviewed but no documentation was found. Staff Member #2 stated they would check with (Medical records) to see if there was documentation of the discharge summary.

On October 23, 2024 at 10:30 a.m. Staff Member #2 indicated no discharge summary was found.

The facility policy and procedure "Medical Records, Content and Management of (Revised 12/21) was reviewed and evidenced: "...General Information...3. ...The record will be...c. Completed within 30 days after discharge..."

The surveyor discussed with Staff Members #2, 3, 4, 5, and 6 on October 22, 2024 at approximately 11:45 a.m. and again On October 23, 2024 at approximately 12:30 p.m. these concerns.

Based on clinical record review, staff interview and facility document review, the facility staff failed to ensure a final diagnosis within 30 days following discharge was documented for Patient #1.

The findings include:

Patient #1 was discharged on October 8, 2023, due to death. On October 21, 2024, the surveyor reviewed the clinical record for Patient #1 and was unable to locate a documented final diagnosis. With the assistance of Staff Member #2 the chart was reviewed but no documentation was found. Staff Member #2 stated they would check with (Medical records) to see if there was any further documentation.

On October 23, 2024 at 10:30 a.m. Staff Member #2 indicated no additional documentation was found, including discharge summary which would have contained a final diagnosis.

The facility policy and procedure "Medical Records, Content and Management of (Revised 12/21) was reviewed and evidenced: "...Content in the Medical Record:..The Medical Record shall include, but is not limited to: ...13. Discharge diagnosis or impression..."

The surveyor discussed with Staff Members #2, 3, 4, 5, and 6 on October 22, 2024 at approximately 11:45 a.m. and again On October 23, 2024 at approximately 12:30 p.m. these concerns.

Based on observation, clinical record review, staff interview and facility document review, the facility staff failed to ensure a designated hospital in-patient unit had emergency services integrated and available in the full extent, resources and staff training in order to provide appropriate emergency care for all patients. Two patients (Patient #1 and #2) inlcuded in the survey sample experienced a medical emergency and the delivery of life saving care was significantly delayed.

The findings included:

Patient #1 experienced a cardiac arrest and the unit did not have immediate availability of all hospital resources in order to provide emergency care. Patient #1 expired in the Emergency department.

On October 8, 2023 at 12:21 a.m., it was documented in the "ED Provider Notes" the following: "...presents to the ED via EMS (Emergency Medical Services) from Snowden for evaluation. EMS reports that pt (patient) was last seen at (their) baseline around 2130 (9:30 p.m.). Staff at Snowden found patient at 2430 (12:30 a.m.) sitting in a chair and had urinated of (self)....staff noticed patient was pale so they checked (patient) pulse and it was 'thready and weak'. Staff then attempted to get a BP (blood pressure) and were unable to so CPR (cardiopulmonary Resuscitation) was started at 2445 (12:45 a.m.)..."

A "Nursing Note" dated October 8, 2023 at 1:21 a.m. evidenced: "Went with med tech to assist (patient) to bed...during rounds (med tech) asked (patient) if (they) would like to go to bed and (patient) responded 'Eh'. Upon helping place (patient into bed writer noticed (patient had urinated (self)...while cleaning (patient) (patient) urinated (self) again...after washing (patient) up and placing clean clothes...noted (Patient) extremities felt a bit cool to touch. Felt for a pulse, and it was present, but faint...retrieved vital sign machine. Could not obtain BP pr HR (heart rate)...(did not respond to sternal rub...Code Blue initiated at 2345 (11:45 p.m. 10/7/23)...CPR started... AED (automated external defibrillator) placed on (patient)BS (Blood sugar) was taken and was 409. (Patient) remained in asystole (no detectable heart activity), and at no point was a shock advised...CPR continued until EMS arrived and took over...EMS transported (patient to the hospital at 0013 (12:03 a.m. 10/8/23)... time of death was called at 0035 (12:35 a.m. 10/8/23).

A "Consult Note" dated October 8, 2023 at 12:25 a.m. evidenced: "This provider was notified by nursing charge at approximately 2250 (10:50 p.m.- 10/7/23) of patient cardiac arrest...was informed by nursing staff that CPR was in progress since 2245 (10:45 p.m.)...EMS arrived at approx (approximately) 2252 (10:52 p.m.) and pt was transferred to ED at 0013 (12:03 a.m. 10/8/23)

Patient #2 experienced multiple grand-mal seizures and the unit did not have access to suction, oxygen and the patient waited approximately forty (40) minutes for transport to the emergency room.
On October 27, 2023 at 1:28 p.m. it was documented in the "Nursing Note: Patient complained of feeling dizzy immediately after taking (their) medications at 13:00 (1:00 p.m.)...patient began to seize, with (their) eyes rolled back, (their) jaw clenched, (their) body stiff and lower extremities jerking for about 20 (twenty) seconds...patient continues to have intermittent seizure episodes lasting 10-20 (ten to twenty) seconds with brief post-ictal (The postictal state is the altered state of consciousness after an epileptic seizure. It usually lasts between 5 and 30 minutes, but sometimes longer in the case of larger or more severe seizures, and is characterized by drowsiness, confusion, nausea, hypertension, headache or migraine, and other disorienting symptoms. The ictal period is the seizure itself; the interictal period is the time between seizures. clevelandclinic.org accessed 11/6/24 at 10:15 a.m.)...was given Ativan (antianxiety medication often used to treat seizure activity) 2mg ( two milligrams on (patient) right dorsogluteal (right buttock) area at 13:14 (1:14 p.m.) ...stopped seizing at about 13:20... laied (sic) on floor...until...EMS arrived (no time) ...transport by EMS to ED at 13:40 ( 1:40 p.m.)..." There was a "Psychiatry Note" dated October 27, 2023 at 1:31 p.m. which evidenced, "Prior to seeing patient , (patient) began having a seizure outside the office...eyes rolling back, full body tremors, obtunded, unable to respond to verbal commands..tongue remained inside (patient) mouth...no Versed (Midazolam, also called Versed, is a medicine used to stop a seizure that has lasted too long. It ' s also used if many seizures happen in a short period of time.drugs.com accessed 11/6/24 at 10:58 a.m.) was available and Ativan 2mg IM was given..." at 1:59 p.m., an "ED Provider Note" evidenced, "Patient arrived to the ED after experienced multiple seizures while at Snowden. There were 3 (three) witnessed seizures...admitted...discharged back to Snowden October 28, 2024..."


The facility policy regarding management of emergency medical conditions was reviewed the policy on October 21, 2024 at 1:10 p.m. The policy "Transfer of Patient with Acute Medical Conditions, Guidelines for Snowden at Fredericksburg (approved 5/11, revised 8/17, reviewed 3/21) evidenced, in part: "The purpose of these guidelines is to assist the nursing staff at Snowden at Fredericksburg (SAF) in ensuring that Behavioral Health Patients receive prompt medical assessment, evaluation and intervention should an acute medical condition develop. Content: 1. The following steps are to be followed when a patient at Snowden displays any signs/symptoms of an acute medical condition, which may include, but are not limited to: a. severe chest pain b. nausea, vomiting, diaphoreses, changes in LOC (level of consciousness) or vital signs c. difficulty breathing...cyanosis, or inadequate oxygenation (decreased mental status, change in color of lips, fingernail beds) d. acute abdominal pain e. onset of vaginal bleeding while pregnant f. changes in blood sugar accompanied by symptoms of hypoglycemia/hyperglycemia g. severe headache with changes in speech and neurological status h. seizures. 2. The physician, if on-site is to be notified immediately to evaluate patient. In the event there is not a physician on the premises a. Call 911; alert front desk/security b. have on-call physician paged c. Nurse/Mental Health Technician to remain with patient at all times obtaining and recording vital signs, monitoring patient d. Call Emergency department at MWH (Mary Washington Hospital) and provide hand-off communication e. notify patients family regarding transfer, if applicable 3. Document all events completely and concisely in the medical record."

The Surveyor requested further information/policy regarding specifically how the facility handled a "Code Blue" and was provided "Code Blue/Code Pink, Snowden at Fredericksburg- MWH Mary Washington Hospital - Approved 3/20" which evidenced, in part: "To outline the process for a respiratory/cardiac arrest at Snowden (SAF). Inpatient First Response 1. The first Associate notified SAF operator to have a code blue/code pink overhead paged. The first RN (Registered Nurse) on scene directs the code. 2. The HUC (Health Unit Coordinator) or nurse calls 911...3. A third associate obtains the AED, back board, code bag, delivers them to the code site and assists with CPR. 4. All Associates available respond to the code as appropriate. 5. Non nursing Associates assist with code as needed...Code Leadership 1. The first Registered Nurse (Lead RN) responding to the code will lead the code team. 2. The Lead RN will assign associate to document in the medical record using the designated time piece. Documentation may be done electronically or on the paper form Resuscitation Record (FR-116-MWHC) for downtime. 3. When EMS personnel arrive on scene they will assume leadership of the code. 4. The Lead RN will assure documentation is completed; call the Mary Washington Hospital Emergency Department (MWH-ED) and give them a 'Hand-off"...5. The Lead RN will ensure the patient's chart is complete with documentation of the event as well as the transportation time is entered in to the patient's medical record...7...Lead RN notified management...8. Lead RN conducts debrief with all associates who participated in the code. 9. A SAFE report is completed...Code Team Members 1. First person in scene-activates code calk , notes time of arrest...2. Code bag responder- obtains AED, code bag and back board...3. First RN responder (Lead RN) assumes leadership of the code...directs associate to document events...4. Recorder Associate - documents information in the medical record...Lead RN is responsible to ensure all documentation associated with the code is complete and on the permanent medical record..."

The surveyor toured the Snowden Unit on October 21, 2024 at approximately 11:45 a.m. accompanied by Staff Members #2, 3, and 4. During the tour the surveyor inquired as to whether the unit was considered an in-patient unit. Staff Member # 2 and 3 acknowledged the unit status as "in-patient for treatment of mental health". The surveyor inquired as to the location of emergency equipment and was shown a small blue bag labeled "Emergency Bag" which contained an ambu bag (Bag-valve-mask (BVM) or the Ambu bag is a self-inflating bag used to provide ventilation to the person not breathing normally. A BVM consists of a non-rebreathing valve and a face mask. The opposite end of the bag is attached to an oxygen source. The mask is manually held against the face. The bag is squeezed to provide ventilation to the patient through the nose and mouth until the intubation can be done. americanheartassociation.org accessed 11/01/24 at 6:45 a.m.) and a stethoscope. The surveyor inquired as to the oxygen source and Staff Member #2 indicated the facility did not have an oxygen source. The surveyor was also shown a "First Aid Kit" containing various bandage materials and tape, an AED (Automated External Defibrillator - AEDs are used to help those experiencing sudden cardiac arrest. It's a sophisticated, yet easy-to-use, medical device that can analyze the heart's rhythm and, if necessary, deliver an electrical shock, or defibrillation, to help the heart re-establish an effective rhythm. americanheart association.org) and a back board (A backboard, made of wood, plastic, or other material, is inserted under the torso of a patient that is to receive cardiopulmonary resuscitation (CPR) in order to provide a firm surface during chest compression. americanheartassociation.org accessed 11/01/24 at 7:00 a.m.). Staff Member #4 indicated the in-patient unit "does not have any oxygen source, no suction machine, does not do advanced cardiac life support, and does not administer cardiac emergency medications but calls 911 and the EMS responds. We only do CPR and use the AED and staff are trained in BLS (Basic Life Support)."

On October 21, 2024 at 2:30 p.m., the surveyor again discussed the emergency protocols for the Snowden unit since the unit had been identified as an in-patient unit. Staff Member #2 indicated that in an emergency the staff would take the patient's vital signs, and start the BLS protocol, call EMS, notify the physician and transfer the patient to the hospital ED. At 3:00 p.m., the surveyor interviewed Staff Members #12 and #13 who indicated they would complete an assessment on a patient, do the vital signs and if the patient was not breathing or did not have a heart beat they would call a code blue and call the doctor as well as 911 for the EMS. The staff members indicated they did not do any suctioning, or administer any medications during a code blue and there was no oxygen at the facility. The staff members further indicated they were trained in basic life support and the use of the AED. Staff Member #5 (Nurse Manager) stated that the EMS has a "very quick response" and that staff were trained in basic life support. The surveyor inquired as to the "quick response" for Patient #2 who waited approximately 40 (forty) minutes for EMS transport after experiencing multiple seizures. "The EMS are really close and that was unusual" according to Staff Member #2.

On October 22, 2024 at 11:15 a.m., the surveyor interviewed Staff Member #16 (Medical Director Snowden unit) who indicated that if a code blue is called and the MD is available they would respond and provide support but the most experienced physician or Registered Nurse would direct the code. Staff Member #16 further indicated that basic life support would be provided, but that advanced life support was not done on the unit.

At 2:40 p.m. on October 22, 2024, the surveyor interviewed Staff Member #15 who indicated they were notified after Patient #1 experienced the cardiac arrest and the patient transferred to the Emergency Department. Staff Member #15 further indicated they came in to the facility and had notified the patient family and asked them to come in. The Staff Member #15 informed the surveyor that if a patient had a medical emergency on the unit, the staff would call "911" as they did not provide advanced cardiac life support.

The surveyor requested to examine the record of the "code" on October 22, 2024 at 3:10 p.m. and was informed by Staff Member #2 there was no documentation other than the nurses note. "I do not see they used the code narrator (a documentation system that allows staff to enter the record of treatment, medications and actions during a code blue). There is nothing other than what was documented in the nurses note afterward and the ED record.

The surveyor inquired as to whether there were emergency medications that were available for use in an injectable form in the facility. The surveyor was given a list on October 22, 2024 at 2:55 p.m.. The list contained a variety of antipsycotic and antianxiety agents as well as Glucagon (a medication to raise the blood sugar) and Naloxone (a medication which can reverse an opioid overdose).

The surveyor discussed with Staff Members #2, 3, 4, 5, and 6 on October 22, 2024 at approximately 11:45 a.m. and again On October 23, 2024 at approximately 12:30 p.m. the concerns regarding the designation of Snowden as an inpatient hospital unit and not equipped to function with advanced life support in the event of an emergency. The surveyor discussed the staff, although trained in basic life support, could not perform the functions as the other in-patient units of the hospital and did not have access to oxygen, suction, or emergency medications as well as relying on calling 911 in order to provide emergency care.