The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

BON SECOURS DEPAUL MEDICAL CENTER 150 KINGSLEY LANE NORFOLK, VA 23505 Feb. 22, 2013
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based on document review and interviews the governing body of the facility failed to verify the credentials and qualifications of 3 of 3 medical residents who had the potential for providing care to patients in the facility based on the on call schedule.

The findings include:

On 2/14/13 at approximately 9:05 A.M. the credential for physicians, mid level providers (physician assistants) and residents were reviewed with Staff Member #21. During the review 3 residents on the Emergency Department (ED) on call schedule were noted to not have any type of credential files. Staff Member #21 provided a copy of Resident Check-In Protocol on 2/14/13. The Protocol listed the following items needed:
Name of provider, title, email address, VA license, NPI number, DEA number, clinical address, clinical phone, clinical fax, contact person, contact email, contact phone and to indicate if provider is Epic proficient. Prior to seeing patients the resident must come to the Medical Affairs Office with the driver's license and EVMS (Eastern Virginia Medical School) badge.

The On-Call schedule for January 2013 indicated the 3 residents were on call for ophthalmology .

Staff Member #21 stated, "Around December the 6th (2012) I sent him (Staff Member #9) an email informing him he was responsible for the on-call schedule for ophthalmology. I provided him with a list of active staff who have privileges. On January 2, 2013 I emailed him (Staff Member #9) and informed him I did not have the on-call schedule yet. The ED called and said they did not have an on call schedule. I told them they would have to call him (Staff Member #9) until I got a copy of the schedule. On 1/3/13 I got the schedule for the attending physician only, I don't know where the resident schedule came from. I have not received a schedule from EVMS since November (2012)."

Staff Member #21 stated, "Yes, we potentially allowed residents to practice without even having a copy of their drivers licenses."
VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
Based on document review and interviews the medical staff failed to ensure the medical residents supervised by physicians of the facility provided the necessary information to verify their credentials and qualifications for 3 of 3 medical residents who had the potential for providing care to patients in the facility based on the on call schedule.

The findings include:

On 2/14/13 at approximately 9:05 A.M. the credential for physicians, mid level providers (physician assistants) and residents were reviewed with Staff Member #21. During the review 3 residents on the Emergency Department (ED) on call schedule were noted to not have any type of credential files. Staff Member #21 provided a copy of Resident Check-In Protocol on 2/14/13. The Protocol listed the following items needed:
Name of provider, title, email address, VA license, NPI number, DEA number, clinical address, clinical phone, clinical fax, contact person, contact email, contact phone and to indicate if provider is Epic proficient. Prior to seeing patients the resident must come to the Medical Affairs Office with the driver's license and EVMS (Eastern Virginia Medical School) badge.

The On-Call schedule for January 2013 indicated the 3 residents were on call for ophthalmology .

Staff Member #21 stated, "Around December the 6th (2012) I sent him (Staff Member #9) an email informing him he was responsible for the on-call schedule for ophthalmology. I provided him with a list of active staff who have privileges. On January 2, 2013 I emailed him (Staff Member #9) and informed him I did not have the on-call schedule yet. The ED called and said they did not have an on call schedule. I told them they would have to call him (Staff Member #9) until I got a copy of the schedule. On 1/3/13 I got the schedule for the attending physician only, I don't know where the resident schedule came from. I have not received a schedule from EVMS since November (2012)."

Staff Member #21 stated, "Yes, we potentially allowed residents to practice without even having a copy of their drivers licenses."
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on document review, a complaint investigation and interview the facility failed to maintain an accurate medical records for two of ten patients included in the survey sample. (Patients #18 and #24)

The findings included:

1. Patient #18 presented to Hospital #1's emergency department (ED) on 02/02/2013 with a chief complaint of dialysis fistula bleeding. Patient #18 received a medical screening examination and transferred to Hospital #3.

Review of Patient #18's transfer form listed the "Benefits of Transfer" as "None."

2. Patient #24 presented to Hospital #1's emergency department (ED) on 11/14/2012 with a chief complaint of "Open sore on middle toe of left foot, foot swollen and painful." Patient #24 received a medical screening examination and transferred to Hospital #3.

Review of Patient #24's transfer form listed the "Benefits of Transfer" as "Services unavailable Podiatry."

An interview conducted on 02/14/2013 at approximately 11:00 a.m., with Staff #34 during the review of Patient #18's ED medical record. Staff #34 reviewed Patient #18's transfer form and stated, "If you do not enter the information the program will revert to the default setting "None." Staff #34 reported both the physician and the nurse complete the transfer form; "It's hard to tell who forgot to enter the benefit of transfer."

An interview was conducted on February 14, 2013 at 12:52 p.m., with Staff #2. Staff #2 acknowledged the transfer forms for Patient #18 and Patient #24 were inaccurate. Staff #2 reported the ED staff "must" put the benefits for transfer on the form "It should never be listed as none." Staff #2 verified Patient #24's transfer form should not have read "Services unavailable Podiatry." Staff #2 reported Patient #24 should have been admitted to Hospital #1 and not transferred to Hospital #3.
VIOLATION: PHARMACIST RESPONSIBILITIES Tag No: A0492
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, staff interview and policy review, the hospital's Director of Pharmaceutical services failed to ensure necessary medications, training and policies were sufficient to meet the potential needs of patients in the Emergency Department (ED), OR (Operating Room) and Birthing Center.

The findings include:

On 2/13/13 at approximately 9:30 A.M. during a tour of the ED Employee #12 was asked how a patient's negative reaction to succinylcholine would be recognized and treated. Employee #12 stated, "We would need to make sure they had an airway, look for signs of anaphylaxis and cardiac changes." Employee #12 was asked where medications and supplies to treat [DIAGNOSES REDACTED] (MH) would be obtained. Employee #12 stated, "I would get the kit from the med room." Employee #12 proceeded to the med room where a kit could not be located. Employee #12 then stated, "I would get the medications and supplies from the intubation cart." Employee #12 proceeded to the intubation cart and could not locate the needed medications. Employee #12 then stated, " I would get the medications from the code cart." Employee #12 proceeded to the code cart and could not locate the needed medications for [DIAGNOSES REDACTED]. Employee #12 then stated, "I would contact the pharmacy."

Employee #6 stated, "We have not had any training related MH since I have been here and that has been about 16 months. We would need to get a kit for MH from the OR."

"Employee #12 stated, "I have been here 5 years and have never had any training on MH."

On 2/13/13 at approximately 11:00 A.M. the MH cart in the OR was observed. The MH cart was inspected with Employee #16, 22 and 14. The MH cart contained 20 expired vaccutainers, 9 - 60 ml (milliliters) syringes and 3 - 1000 ml bags of sterile water and 36 vials of Dantrolene. Employee #14 stated, "We have MH drills yearly." Employee #14 was asked how the vials of Dantrolene would be reconstituted. Employee #14 stated, "We would have to stick the bags of sterile water repeatedly to get enough sterile water to reconstitute the vials of Dantrolene." Employee #16 stated, "We have vials of sterile water in the Pyxis refrigerator." The Pyxis refrigerator was then inspected; no sterile water was in the refrigerator.

Employee #13 stated, "I guess we need to look at getting a cart with a refrigerator."
Employee #14 stated, "There is also an MH kit in the Birthing Center."

On 2/13/13 at approximately 11:30 the MH kit in the Birthing Center was inspected. The kit appeared to be a small fishing tackle box that was approximately 9 inches long by 4 inches wide and 4 inches deep. The box contained 4 vials of Dantrolene; no sterile water or syringes." Employee #39 stated, "The sterile water would be removed from the anesthesia cart" and proceeded to go to the cart and remove the sterile water. Employee #39 returned approximately 3 minutes later and stated, "I don't have access to the anesthesia cart."

Employee #38 was interviewed on 2/13/13 at approximately 11:45 A.M. Employee #38 stated, "This pharmacy is not open 24 hours a day. If any thing is needed after we close the medication would have to be obtained from (Name of Hospital). Per MapQuest. com the name hospital is 21 minutes away; round trip would be 42 minutes. Employee #38 stated there is a MH cart in the OR and a kit in the Birthing Center."
VIOLATION: PHARMACIST SUPERVISION OF SERVICES Tag No: A0501
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, staff interview and policy review, the hospital's Pharmaceutical Services failed to ensure high risk medications were safely dispensed, sufficient policies were developed and clinical staff were educated on the potential adverse outcomes related to the administration of a triggering agent-succinylcholine, available for administration in the Emergency Department (ED), OR (Operating Room) and Birthing Center. The medication was not dispensed in a manner consistent with the standards of practice.

The findings include:

On 2/13/13 at approximately 9:30 A.M. during a tour of the ED Employee #12 was asked how a patient's negative reaction to succinylcholine would be recognized and treated. Employee #12 stated, "We would need to make sure they had an airway, look for signs of anaphylaxis and cardiac changes." Employee #12 was asked where medications and supplies to treat [DIAGNOSES REDACTED] (MH) would be obtained. Employee #12 stated, "I would get the kit from the med room." Employee #12 proceeded to the med room where a kit could not be located. Employee #12 then stated, "I would get the medications and supplies from the intubation cart." Employee #12 proceeded to the intubation cart and could not locate the needed medications. Employee #12 then stated, " I would get the medications from the code cart." Employee #12 proceeded to the code cart and could not locate the needed medications for [DIAGNOSES REDACTED]. Employee #12 then stated, "I would contact the pharmacy."

Employee #6 stated, "We have not had any training related MH since I have been here and that has been about 16 months. We would need to get a kit for MH from the OR."

"Employee #12 stated, "I have been here 5 years and have never had any training on MH."

On 2/13/13 at approximately 11:00 A.M. the MH cart in the OR was observed. The MH cart was inspected with Employee #16, 22 and 14. The MH cart contained 20 expired vaccutainers, 9 - 60 ml (milliliters) syringes and 3 - 1000 ml bags of sterile water and 36 vials of Dantrolene. Employee #14 stated, "We have MH drills yearly." Employee #14 was asked how the vials of Dantrolene would be reconstituted. Employee #14 stated, "We would have to stick the bags of sterile water repeatedly to get enough sterile water to reconstitute the vials of Dantrolene." Employee #16 stated, "We have vials of sterile water in the Pyxis refrigerator." The Pyxis refrigerator was then inspected; no sterile water was in the refrigerator.

Employee #13 stated, "I guess we need to look at getting a cart with a refrigerator."

Employee #14 stated, "There is also an MH kit in the Birthing Center."

On 2/13/13 at approximately 11:30 the MH kit in the Birthing Center was inspected. The kit appeared to be a small fishing tackle box that was approximately 9 inches long by 4 inches wide and 4 inches deep. The box contained 4 vials of Dantrolene; no sterile water or syringes." Employee #39 stated, "The sterile water would be removed from the anesthesia cart" and proceeded to go to the cart and remove the sterile water. Employee #39 returned approximately 3 minutes later and stated, "I don't have access to the anesthesia cart."

Employee #38 was interviewed on 2/13/13 at approximately 11:45 A.M. Employee #38 stated, "This pharmacy is not open 24 hours a day. If any thing is needed after we close the medication would have to be obtained from (Name of Hospital). Per MapQuest. com the name hospital is 21 minutes away; round trip would be 42 minutes. Employee #38 stated there is a MH cart in the OR and a kit in the Birthing Center."
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observations, document review, a complaint investigation and interviews the facility's infection control officer failed to maintain a system, which identified opportunities for infection prevention/control as evidenced by:
1. Emergency department (ED) staffs' failure to clean the glucometer between patients when measuring blood glucose levels.
2. ED staff's failure to ensure medications were handled and administered in a manner to prevent the spread of infections.
3. ED staff's failure to prevent the availability of expired supplies for patient use.
4. ED staff's failure to prevent the availability of expired medications for patient use.
5. The use of chairs for patient use that could not be cleaned between patients.


The findings included:

1. Emergency department (ED) staffs' failure to clean the glucometer between patients when measuring blood glucose levels.
Observations in the facility's ED on 02/13/2013 from 10:23 a.m. through 10:37 a.m., with Staff #4 and Staff #7 revealed ED staff utilized their point of care (POC) glucometer without cleaning the meter between patients. An observation on 02/13/2013 at 10:23 a.m., revealed Staff #19 obtained the ED's POC glucometer from its base unit and brought the unit into an ED bay to test the blood glucose level of Observation Patient #1. Staff #19 placed the POC glucometer on the table next to the patient's belongings. Staff #19 obtained a blood sample from Observation Patient #1 and applied the blood sample to the strip attached to the glucometer. After completing the blood glucose testing Staff #19 left Observation Patient #1's ED bay and placed the POC glucometer into its base. Staff #19 did not clean the POC glucometer prior to or after performing Observation Patient #1's glucose testing. Staff #19 did not perform hand hygiene after removing gloves.

Prior to the start of an interview with Staff #19 related to cleaning the POC glucometer, Staff #17 picked up the glucometer. The surveyor followed Staff #17 to Observation Patient #2's ED bay. Staff #17 did not clean the POC glucometer prior to performing the blood glucose testing for Observation Patient #2. Staff #17 entered Observation Patient #2's bay and laid the glucometer on the gurney next to the patient. Staff #17 obtained a blood sample and applied the blood to the strip attached to the glucometer. After completing the blood glucose testing Staff #17 left Observation Patient #2's ED bay and placed the POC glucometer into its base. Staff #4 and Staff #7 were present for the observations of both Staff #19 and Staff #17 performance of POC glucometer testing.

An interview was conducted on 02/13/2013 at 10:37 a.m., with Staff #17 in the presence of Staff #4 and Staff #7. Staff #17 initially reported the POC glucometer was "cleaned daily" or would be "cleaned when there was obvious blood contamination." When asked about the potential contamination of blood that could not be obviously seen; Staff #17 stated, "I guess it (the POC glucometer) should be cleaned between patients for patient safety."

An interview was conducted on 02/13/2013 at 10:39 a.m., with Staff #7. Staff #7 stated, "It is our policy that all POC equipment should be cleaned between patients."

Review of the facility's policy titled "Infection Control and Hand Hygiene within POCT (Point of Care Testing) read in part "Principle: The principle of this policy is to ensure that Point of Care Testing is taking every precaution to create a clean and safe environment in which our patients are tested ... Procedure: [Name of the manufacturer] glucose meters: It is the policy of the POCT department that all [Name of the manufacturer] meters should be wiped down between patients before testing commences. The disinfectant of choice is any bleach wipes containing 10% bleach solution by volume ... Hands: All testing personnel should and must use standard precautions when performing testing ... All employee should be foaming their hands with [name of product] prior to donning non-sterile exam gloves and then again once gloves are removed and testing is finished ..."

2. ED staff's failure to ensure medications were handled and administered in a manner to prevent the spread of infections.
Observations were conducted on 02/13/2013 from 10:08 a.m. through 10:23 a.m., with Staff #23 during a medication pass. Staff #23 utilized the ED's automated medication system to pull medications for administration to Observation Patient #1. Staff #23 pulled two tabs of Zofran 2 mg (milligram) and two tabs of Hydrocodone/acetaminophen 5-325. Staff #23 entered Observation Patient #1's bay at 10:11 a.m., and administered the two tabs of Zofran. Staff #23 explained to Observation Patient #1 the reason for the Zofran and the need to wait 10 to 15 minutes before the Hydrocodone/acetaminophen was administered. Staff #23 placed the two tabs of Hydrocodone/acetaminophen into his/her scrub shirt pocket. Staff #23 left Observation Patient #1's bay and obtained a drink and snack for Observation Patient #1. Staff #23 delivered the drink and snack to Observation Patient #1. Staff #23 located Staff #19 and requested that Staff #19 perform a POC blood glucose test on Observation Patient #1. Staff #23 and Staff #19 entered Observation Patient #1's bay at 10:23 a.m., while Staff #19 set up for the POC glucose testing. Staff #23 conversed with Observation Patient #1 and at the same timed touched Observation Patient #1's belongings and bedding. Without performing hand hygiene Staff #23 removed the two tabs of Hydrocodone/acetaminophen 5-325 from his/her scrub shirt pocket. Staff #23 did not perform hand hygiene prior to opening and administering the medication to Observation Patient #1.

[According to www.webmd.com- Hydrocodone/acetaminophen-"This combination medication is used to relieve moderate to severe pain. It contains a narcotic pain reliever hydrocodone and a non-narcotic pain reliever (acetaminophen). Hydrocodone works in the brain to change how your body feels and responds to pain. Acetaminophen can also reduce a fever."]
[According to www.webmd.com-Zofran -"This medication is used alone or with other medications to prevent ... and treat nausea and vomiting ... It works by blocking one of the body's natural substances (serotonin) that causes vomiting."]


An interview was conducted on 02/13/2013 at at 10:42 a.m., with Staff #7. Staff #7 was informed of the observation conducted during the medication pass with Staff #23 related to the staff's carrying medication in his/her scrub shirt pocket and failing to perform hand hygiene after touching Observation Patient #1's belongings and prior to administering medication. Staff 37 reported awareness that Staff #23 had touched the patient's belongings and had not performed hand hygiene prior to administering medication. Staff #7 reported it was not the facility's policy or an acceptable standard of practice for staff to carry medications in their scrub pockets.


3. ED staff's failure to prevent the availability of expired supplies for patient use.
Observations and interviews were conducted on 02/13/2013 from 11:20 a.m. to 11:50 a.m., with Staff #4 and Staff #7 in the clean storage supply room.

Staff #7 verified the following suture supplies were expired:
Thirteen individual packs of 4.0 Coated Vicryl 19 mm (millimeter) with an expiration date of July, 2012
Five individual packs of 6.0 Coated Vicryl 13 mm with an expiration date of July, 2012
Nine individual packs of 6.0 Prolene Blue 18 cm (centimeter) with an expiration date of July, 2012
Four boxes with 12 individual packs each (48 packs) of 6.0 Undyed Coated Vicryl with an expiration date of Jan, 2013.

Staff #7 reported expired supplies should not be available for potential administration to patient.








Supply closet:
Endo Tracheal tubes size 5 - 3 expired 10/28/12, size 4 - 5 expired 9/28/12, size 3 - 5 expired 10/28/12 and 1 expired 1/26/11. Employee #6 stated, "Those are there for the EMS (Emergency Medical Staff) to use in the field. When the use one they take one when they come in. We don't use them in the hospital. I think they have brought in their (EMS) expired on es and took the ones we had that were not expired."
1 box of approximately 16 rolls of paper tape expired 7/2010.
Trach tube 8.5 expired 10/2012
Glidewire used in placing central lines expired 3/2011
During the initial tour of the Emergency Department (ED) on 2/13/13 with Employees #1 and 6 the following items were noted;

4. IV cart:
2 - 10 ml (milliliters) vials of sterile water expired 10/2012
1 - 10 mil vial of sodium chloride expired 7/2012
2 - 21 gauge 1 1/2 inch eclipse needles expired 4/2012
1 - 21 gauge 1 inch monoject needle expired 12/2010

5. PA Room:
Chair used for patients to sit in who under go eye exams did not appear washable. Employee #1 verified on 2/14/13 the chair could not be washed and stated, "I think you sited that chair the last time you were here."
EKG Machine had what appeared to be coffee stains on top of cover
Plumo Aide on the floor (used to assist patients with breathing difficulty) Employee #6 stated, "I think respiratory uses that."

On 2/15/13 at approximately 10:00 A.M. Employee #37 stated, "We do surveillance rounds in the clinical departments every 6 months with the managers of those departments. We look at potential infection control issues."
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interviews the facility staff failed to investigate and or report potential abuse by a CNA (Certified Nursing Assistant) who reported (to the Emergency Department (ED) physician she was adjusting the insulin of a patient (Patient #22) whom the CNA was caring for. Patient #22 was seen in the facility's Emergency Department (ED) on 9/14/12, 9/15/12, 9/16/12 and 9/17/12.

The findings include:

On 2/14/13 the medical record of Patient #22 was reviewed and the following was noted:
Patient #22 was a [AGE] year old diagnosed with [DIAGNOSES REDACTED][DIAGNOSES REDACTED], renal failure, stroke and dyslipidemia. Patient #22 was seen in the ED on 9/14/12, 9/15/12, 9/16/12 and 9/17/12.

9/14/12 visit was due to a fall. Patient #22 arrived at the facility on 9//14/12 at approximately 09:17 via ambulance. The Emergency Medical System (EMS) staff documented Patient #22's blood sugar on the scene at 08:40 as 46, at 08:50 as 45 and at 09:00 as 69. The EMS staff administered 1 unit of glucose sublingually.
Triage noted, "Neglect/Exploitation/Abuse Screening: There are no signs and symptom of abuse/neglect. exploitation."
No documentation in Past History of Patient #22's living arrangements.
The ED visit listed the home medications as follows:
Pramipexole 0.125 mg (milligrams) at bedtime
Bisacodyl 5 mg at bedtime
Glipizude 10 mg QID (four times a day)
Amlodipine Besylate 10 mg daily
Omeprazole 20 mg BID (twice a day)
Imipramine HCL 50 mg BID
Simvastatin 40 mg daily
Actos 30 mg daily
Januvia 50 mg daily
On 9/14/12 at 09:37 Patient #22's blood sugar was 89 mg/dl. At 10:23 a nursing note listed Patient #22 caregiver by name and a phone number is documented. The Disposition note by the physician states, "All medications have been reviewed. No changes are required for your current ED visit."
There was no mention of Patient #22 being on insulin in any of the ED documentation.
Patient #22 was discharged home on 9/14/12 at approximately 12:54

9/15/12 Patient #22 returned to the ED via ambulance for treatment of [DIAGNOSES REDACTED]. Patient #22 arrived at the facility on 9/15/12 at approximately 19:10 via ambulance. Per the EMS staff Patient #22's blood sugar was 48. Patient #22 was given 1 ampule of D50 and upon recheck of Patient #22's blood sugar it was 72 and when checked at triage it was 205.
Triage noted, "Neglect/Exploitation/Abuse Screening: There are no signs and symptom of abuse/neglect. exploitation."
Past Social History: lives with adult children.
The ED visit listed the home medications were obtained from the previous ER chart as follows:
Pramipexole 0.125 mg (milligrams) at bedtime
Bisacodyl 5 mg at bedtime
Glipizude 10 mg QID (four times a day)
Amlodipine Besylate 10 mg daily
Omeprazole 20 mg BID (twice a day)
Imipramine HCL 50 mg BID
Simvastatin 40 mg daily
Actos 30 mg daily
Januvia 50 mg daily
The History of Present Illness at 19:33 notes Patient #22 "has a home health nurse during the day, daughter and son in the evening."
Attending notes at 23:43 document Patient #22 had a previous admission to the facility on [DATE].
The Disposition Physician note states, "All medications have been reviewed. No changes are required for your current ED visit."
There was no mention of Patient #22 being on insulin in any of the ED documentation.
Patient #22 was discharged home on 9/16/12 at approximately 02:10

9/16/12 Patient #22 returned to the ED via ambulance for treatment of [DIAGNOSES REDACTED]. Patient #22 arrived at the facility on 9/16/12 at approximately 14:45 via ambulance. Per the EMS staff Patient #22's blood sugar was 34 and was found on the floor. Patient #22 was given 1 ampule of Dextrose 50% and upon recheck of Patient #22's blood sugar in the ED at 17:39 it was 153.
Triage noted, "Neglect/Exploitation/Abuse Screening: There are no signs and symptom of abuse/neglect. exploitation."
Past Social History: lives with alone.
History of Present Illness: has a CNA come to house to help with medications.
The ED visit listed the home medications were obtained verbally from the patient were as follows:
Pramipexole 0.125 mg (milligrams) at bedtime
Bisacodyl 5 mg at bedtime
Glipizude 10 mg QID (four times a day)
Amlodipine Besylate 10 mg daily
Omeprazole 20 mg BID (twice a day)
Imipramine HCL 50 mg BID
Simvastatin 40 mg daily
Actos 30 mg daily
Januvia 50 mg daily
The physician documented in a progress note at 17:23, "Medical decision making: Home CNA admits she increased patient insulin from 7 to 10 units daily, given in the am several days ago, when patient's glucose was in the 90's without consultation with PCP. This occurred just prior to daily ED visits for [DIAGNOSES REDACTED] over past 3 days. Hospital d/c records from 6 weeks ago show dose (of insulin) should be 5 units daily. Will return to that pending close PCP f/u."
Nursing notes at 16:39 state,"CNA stopped by and left phone number (number documented and name documented) for update on status."
The Disposition Physician note states, "Discharge from ED: The patient is discharge to home... Use 5 units of insulin. Do not increase without a doctor's order."
Patient #22 was discharged home on 9/16/12 at approximately 18:15.

9/17/12 Patient #22 returned to the ED via ambulance for treatment of [DIAGNOSES REDACTED]. Patient #22 arrived at the facility on 9/17/12 at approximately 17:35 via ambulance. Per the EMS staff Patient #22's blood sugar was 14 and was found on the floor. Patient #22 was given 25G of Dextrose 50% and upon recheck of Patient #22's blood sugar by EMS it had increased to 124.
Triage noted, "Neglect/Exploitation/Abuse Screening: There are no signs and symptom of abuse/neglect. exploitation."
Past Social History: "lives in (Name of facility) assistant living."
The ED visit listed the home medications as follows:
Pramipexole 0.125 mg (milligrams) at bedtime
Bisacodyl 5 mg at bedtime
Glipizude 10 mg QID (four times a day)
Amlodipine Besylate 10 mg daily
Omeprazole 20 mg BID (twice a day)
Imipramine HCL 50 mg BID
Simvastatin 40 mg daily
Actos 30 mg daily
Januvia 50 mg daily
Insulin is not listed as a medication.
The Disposition Physician note states, "Admit the patient to a medical bed."

Employee #4 was interviewed on 2/14/13 at 3:10 P.M. and asked if the facility could provide any documentation of a investigation related to the determination of Patient #22 being discharged to a safe environment or of reporting the CNA to the Virginia Board of Nursing for acting beyond the scope of practice and she stated, "No".
VIOLATION: INTEGRATION OF EMERGENCY SERVICES Tag No: A1103
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observations, interviews and document reviews the facility staff failed to ensure the services provided in the Emergency Department (ED) were integrated with other departments in the hospital. The ED policies and staff training were not developed in collaboration with Pharmaceutical Services to ensure integration and sufficient medications and training were provided to minimize the risk of negative patient events.

The findings include:


On 2/13/13 at approximately 9:30 A.M. during a tour of the ED Employee #12 was asked how a patient's negative reaction to succinylcholine would be recognized and treated. Employee #12 stated, "We would need to make sure they had an airway, look for signs of anaphylaxis and cardiac changes." Employee #12 was asked where medications and supplies to treat [DIAGNOSES REDACTED] (MH) would be obtained. Employee #12 stated, "I would get the kit from the med room." Employee #12 proceeded to the med room where a kit could not be located. Employee #12 then stated, "I would get the medications and supplies from the intubation cart." Employee #12 proceeded to the intubation cart and could not locate the needed medications. Employee #12 then stated, " I would get the medications from the code cart." Employee #12 proceeded to the code cart and could not locate the needed medications for [DIAGNOSES REDACTED]. Employee #12 then stated, "I would contact the pharmacy."

Employee #6 stated, "We have not had any training related MH since I have been here and that has been about 16 months. We would need to get a kit for MH from the OR."

"Employee #12 stated, "I have been here 5 years and have never had any training on MH."

On 2/13/13 at approximately 11:00 A.M. the MH cart in the OR was observed. The MH cart was inspected with Employee #16, 22 and 14. The MH cart contained 20 expired vaccutainers, 9 - 60 ml (milliliters) syringes and 3 - 1000 ml bags of sterile water and 36 vials of Dantrolene. Employee #14 stated, "We have MH drills yearly." Employee #14 was asked how the vials of Dantrolene would be reconstituted. Employee #14 stated, "We would have to stick the bags of sterile water repeatedly to get enough sterile water to reconstitute the vials of Dantrolene." Employee #16 stated, "We have vials of sterile water in the Pyxis refrigerator." The Pyxis refrigerator was then inspected; no sterile water was in the refrigerator.

Employee #13 stated, "I guess we need to look at getting a cart with a refrigerator."
Employee #14 stated, "There is also an MH kit in the Birthing Center."

On 2/13/13 at approximately 11:30 the MH kit in the Birthing Center was inspected. The kit appeared to be a small fishing tackle box that was approximately 9 inches long by 4 inches wide and 4 inches deep. The box contained 4 vials of Dantrolene; no sterile water or syringes." Employee #39 stated, "The sterile water would be removed from the anesthesia cart" and proceeded to go to the cart and remove the sterile water. Employee #39 returned approximately 3 minutes later and stated, "I don't have access to the anesthesia cart."

Employee #38 was interviewed on 2/13/13 at approximately 11:45 A.M. Employee #38 stated, "This pharmacy is not open 24 hours a day. If any thing is needed after we close the medication would have to be obtained from (Name of Hospital). Per MapQuest. com the name hospital is 21 minutes away; round trip would be 42 minutes. Employee #38 stated there is a MH cart in the OR and a kit in the Birthing Center."
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review, a complaint investigation, and interviews the facility failed to ensure on-call physicians were available to provide emergency medical services in accordance with the medical staff by-laws. The on-call physicians failure/refusal to evaluate two of ten transferred patients included in the survey sample resulted in inappropriate transfers. (Patient #24 and Patient #1)

The findings included:

1. Patient #24 presented to Hospital #1's emergency department (ED) on 11/14/2012 with a chief complaint of "Open sore on middle toe of left foot, foot swollen and painful." Patient #24 was assigned to Staff #32. Staff #32 performed a medical screening examination, which included Doppler study, radiology services and serum laboratory test. Review of Patient #24's radiology studies read in part "Findings: Three views of the left foot were performed. There is marked soft tissue swelling of the 3rd toe. There is lucency involving the 3rd distal phalanx in addition to fracture lines. The appearance is compatible with osteo[DIAGNOSES REDACTED] in addition to pathological fracture ..." [According to Webster's on-line dictionary -Lucency is the "state or condition of being translucent; clear."] [According to Webster's on-line medical dictionary -[DIAGNOSES REDACTED] is "an infectious usually painful inflammatory disease of bone that is often of bacterial origin and may result in death of bone tissue."] Staff #32 documented the plan of treatment for Patient #24 as: "Diabetic ulcer versus vascular insufficiency ... IV (intravenous) antibiotics and will need admission to further treat this infected toe. Additionally [he/she-Patient #24] states [he/she] is supposed to be on diabetic medications but has no insurance and [his/her] BP (blood pressure) is elevated today will treat with clonidine now." [According to www.webmd.com description of uses for Clonidine -"This medication is used alone or with other medications to treat high blood pressure. Lowering high blood pressure helps prevent strokes, heart attacks, and kidney problems. Clonidine belongs to a class of drugs (central alpha agonists) that act in the brain to lower blood pressure. It works by relaxing blood vessels so blood can flow more easily."]
Staff #32 documented on 11/14/2012 at 4:50 p.m., "D/w (discussed with) hospitalist states cannot admit as no podiatry or orthopedic will evaluate patient for a diabetic foot ulcer. Desk clerk [staff's name] - spoke to podiatry service who stated that they do not cover [name of Hospital #1]- will d/w [name of Hospital #3] to attempt transfer." An un-timed addition to the above note read, "Transfer to [name of Hospital #3] ..." The note included the room number and the accepting physician at Hospital #3.
Review of Hospital #1's orthopaedic specialist on-call schedule listed to two covering physicians on call for November 14, 2012.
An interview was conducted on February 14, 2013 at 12:52 p.m., with Staff #2. Staff #2 reported reviewing Patient #24's medical record after the surveyor's inquiry related to appropriateness of the patient's transfer. Staff #2 stated, "The patient should not have been sent to [name of Hospital #3]." Staff #2 reported if the hospitalist or the ED physician had a problem with the on-call physicians not coming in to evaluate Patient #24 they should have called the administrator on-call or Staff #2.





2. A review of Patient #1's medical record revealed the following: Patient #1 was a [AGE] year old examined by Employee #20 on 1/7/13 due to a complaint of eye pain. On 1/8/13 at 0720 Employee #20 documented the following; "Have made multiple attempt to contact an ophthalmologist for this patient with what I believe is acute angle glaucoma. I spoke to (Name of Employee #40) who said he was not on call. I spoke to (Name of Employee #9) who said (Name of Employee #51) is on call. When (Name of Employee #51) is called I end up speaking to (Name of Employee #52) who tells me he does not cover at (Name of this facility). I have spent over an hour with phone calls and still have not been able to resolve this. I want ed to send the patient to (Name of a second hospital) but was told by (Name of Employee #9) that that m(a)y be an I(E)MTALA violation."

Patient #1 was transported to the second hospital on [DATE] at approximately 00:49 via ambulance.

Employee #5 was interviewed on 2/13/13 at approximately 3:40 P.M. Employee #5 stated, "(Name of Employee #9) is new to being the chief of the department. (He) got the list of attending physicians who were on call to the Medical Staff Office late. The Medical Staff Coordinator then sends the on call list to EVMS (Eastern Virginia Medical School) who then matches the attending physicians with the resident who is on call. The Residents got a master list of who was on call and (Name of this facility) was not on the call list. This did not come to our attention until I got a call from (Name of other hospital) and asked me to look into this. I spoke to (Name of Employee #51) who said the process is to call the resident on call first. If you can't get the physician on call then the next step is to call the Administrator on call then the Vice President of Medical Affairs."

Employee #5 also stated, "(Name of Employee #21) gets the call list for all services that provide ED coverage and send out the list. I don't know if we check to see if the list is accurate."

Employee #20 was interviewed on 2/14/13 at 8:05 A.M. and provided the following information related to Patient #1: "(Patient #1) complained of pain behind the right eye and had never experience anything like it before. She was experiencing visual changes and the right pupil did not react. I checked the pressure in both eyes and the right was substantially higher than the left. In the past I would call (Name of second hospital) talk to the resident or attending on call but the routine got changed. Now we call the resident on call."

Employee #20 stated, "When I had the unit secretary (US) call the resident (Employee #40) said he was not on call. I had the US then call the attending (Employee #51) and the call went to (Name of Employee #52) who stated he did not cover at (Name of this facility). I discussed my case with (Name of Employee #52) who agreed with my diagnosis. I called (Name of Employee #9) who was very nice but insisted (Name of Employee #51) was on call and said he had emailed her the schedule of who was on call. I called the ED and they accepted the patient who was willing to go to (Name of second hospital). I had to think of the patient first. There was no evidence of the physician on call showing up and if acute angle glaucoma goes untreated it can result in blindness within 6 to 7 hours. (Name of Employee #9) is in charge of the call schedules. Transfers are difficult and time consuming."

Employee #9 was interviewed via telephone on 2/14/13 at approximately 8:22 A.M. and provided the following information. "This was the first time I had ever done the on call schedule. The schedule is made several days in advance and sent to the nurse. I made the schedule around the 3rd of January. I sent the schedule back and forth to (Name of Employee #21). The chain of command is new to me. I spoke to the ED physician via telephone regarding the physician on call. Ultimately it is the attending physician's responsibility to be on call if the resident can't be reached. I did not speak with the attending on the evening in question.

On 2/14/13 at approximately 8:35 A.M. the Chief Medical Officer was interviewed and stated, "The new department chairs do not get any type of formal orientation to the position."

Employee #21 was interviewed on 2/14/13 at approximately 9:05 A.M. and stated, "(Name of Employee #9) was made the chair of the department in June 2012 and assumed his duties in July 2012. We do not have a very good process for "on boarding" new department chairs. I communicate mostly by emails with the department chairs. I don't remember if I sent him the section of the by laws that speaks to his responsibilities. Around the 6th of December (2012) I sent him an email saying he was responsible for the ophthalmology on call roster. I said here are the list of active staff who have privileges. I don't remember if there was any communication between then and January 2nd (2013) when I emailed him and said I don't have a schedule. The ED called and said they did not have a schedule for ophthalmology. I told them I don't have a schedule yet so if there is an emergency they will need to call (Name of Employee #9). I then called (Name of Employee #9) who stated he would take care of it tomorrow (January 3, 2013). I got the schedule on 1/3/13. The email I received only had the attending physicians on it. I didn't know anything about the resident schedule. I don't know where they got the schedule with the residents and attendings on the schedule. EVMS stopped sending us a schedule in November 2012 of residents on call."
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review, a complaint investigation, and interview the facility inappropriately transferred patients related to on-call physicians' failure/refusal to evaluate two of ten transferred patients included in the survey sample. (Patient #24 and Patient #1)

The findings included:

1. Patient #24 presented to Hospital #1's emergency department (ED) on 11/14/2012 with a chief complaint of "Open sore on middle toe of left foot, foot swollen and painful." Patient #24 was assigned to Staff #32. Staff #32 performed a medical screening examination, which included Doppler study, radiology services and serum laboratory test. Review of Patient #24's radiology studies read in part "Findings: Three views of the left foot were performed. There is marked soft tissue swelling of the 3rd toe. There is lucency involving the 3rd distal phalanx in addition to fracture lines. The appearance is compatible with osteo[DIAGNOSES REDACTED] in addition to pathological fracture ..." [According to Webster's on-line dictionary -Lucency is the "state or condition of being translucent; clear."] [According to Webster's on-line medical dictionary -[DIAGNOSES REDACTED] is "an infectious usually painful inflammatory disease of bone that is often of bacterial origin and may result in death of bone tissue."] Staff #32 documented the plan of treatment for Patient #24 as: "Diabetic ulcer versus vascular insufficiency ... IV (intravenous) antibiotics and will need admission to further treat this infected toe. Additionally [he/she-Patient #24] states [he/she] is supposed to be on diabetic medications but has no insurance and [his/her] BP (blood pressure) is elevated today will treat with clonidine now." [According to www.webmd.com description of uses for Clonidine -"This medication is used alone or with other medications to treat high blood pressure. Lowering high blood pressure helps prevent strokes, heart attacks, and kidney problems. Clonidine belongs to a class of drugs (central alpha agonists) that act in the brain to lower blood pressure. It works by relaxing blood vessels so blood can flow more easily."]
Staff #32 documented on 11/14/2012 at 4:50 p.m., "D/w (discussed with) hospitalist states cannot admit as no podiatry or orthopedic will evaluate patient for a diabetic foot ulcer. Desk clerk [staff's name] - spoke to podiatry service who stated that they do not cover [name of Hospital #1]- will d/w [name of Hospital #3] to attempt transfer." An un-timed addition to the above note read, "Transfer to [name of Hospital #3] ..." The note included the room number and the accepting physician at Hospital #3.
Review of Hospital #1's orthopaedic specialist on-call schedule listed to two covering physicians on call for November 14, 2012.
An interview was conducted on February 14, 2013 at 12:52 p.m., with Staff #2. Staff #2 reported reviewing Patient #24's medical record after the surveyor's inquiry related to appropriateness of the patient's transfer. Staff #2 stated, "The patient should not have been sent to [name of Hospital #3]." Staff #2 reported if the hospitalist or the ED physician had a problem with the on-call physicians not coming in to evaluate Patient #24 they should have called the administrator on-call or Staff #2.





2. A review of Patient #1's medical record revealed the following: Patient #1 was a [AGE] year old examined by Employee #20 on 1/7/13 due to a complaint of eye pain. On 1/8/13 at 0720 Employee #20 documented the following; "Have made multiple attempt to contact an ophthalmologist for this patient with what I believe is acute angle glaucoma. I spoke to (Name of Employee #40) who said he was not on call. I spoke to (Name of Employee #9) who said (Name of Employee #51) is on call. When (Name of Employee #51) is called I end up speaking to (Name of Employee #52) who tells me he does not cover at (Name of this facility). I have spent over an hour with phone calls and still have not been able to resolve this. I want ed to send the patient to (Name of a second hospital) but was told by (Name of Employee #9) that that m(a)y be an I(E)MTALA violation."

Patient #1 was transported to the second hospital on [DATE] at approximately 00:49 via ambulance.

Employee #5 was interviewed on 2/13/13 at approximately 3:40 P.M. Employee #5 stated, "(Name of Employee #9) is new to being the chief of the department. (He) got the list of attending physicians who were on call to the Medical Staff Office late. The Medical Staff Coordinator then sends the on call list to EVMS (Eastern Virginia Medical School) who then matches the attending physicians with the resident who is on call. The Residents got a master list of who was on call and (Name of this facility) was not on the call list. This did not come to our attention until I got a call from (Name of other hospital) and asked me to look into this. I spoke to (Name of Employee #51) who said the process is to call the resident on call first. If you can't get the physician on call then the next step is to call the Administrator on call then the Vice President of Medical Affairs."

Employee #5 also stated, "(Name of Employee #21) gets the call list for all services that provide ED coverage and send out the list. I don't know if we check to see if the list is accurate."

Employee #20 was interviewed on 2/14/13 at 8:05 A.M. and provided the following information related to Patient #1: "(Patient #1) complained of pain behind the right eye and had never experience anything like it before. She was experiencing visual changes and the right pupil did not react. I checked the pressure in both eyes and the right was substantially higher than the left. In the past I would call (Name of second hospital) talk to the resident or attending on call but the routine got changed. Now we call the resident on call."

Employee #20 stated, "When I had the unit secretary (US) call the resident (Employee #40) said he was not on call. I had the US then call the attending (Employee #51) and the call went to (Name of Employee #52) who stated he did not cover at (Name of this facility). I discussed my case with (Name of Employee #52) who agreed with my diagnosis. I called (Name of Employee #9) who was very nice but insisted (Name of Employee #51) was on call and said he had emailed her the schedule of who was on call. I called the ED and they accepted the patient who was willing to go to (Name of second hospital). I had to think of the patient first. There was no evidence of the physician on call showing up and if acute angle glaucoma goes untreated it can result in blindness within 6 to 7 hours. (Name of Employee #9) is in charge of the call schedules. Transfers are difficult and time consuming."

Employee #9 was interviewed via telephone on 2/14/13 at approximately 8:22 A.M. and provided the following information. "This was the first time I had ever done the on call schedule. The schedule is made several days in advance and sent to the nurse. I made the schedule around the 3rd of January. I sent the schedule back and forth to (Name of Employee #21). The chain of command is new to me. I spoke to the ED physician via telephone regarding the physician on call. Ultimately it is the attending physician's responsibility to be on call if the resident can't be reached. I did not speak with the attending on the evening in question.

On 2/14/13 at approximately 8:35 A.M. the Chief Medical Officer was interviewed and stated, "The new department chairs do not get any type of formal orientation to the position."

Employee #21 was interviewed on 2/14/13 at approximately 9:05 A.M. and stated, "(Name of Employee #9) was made the chair of the department in June 2012 and assumed his duties in July 2012. We do not have a very good process for "on boarding" new department chairs. I communicate mostly by emails with the department chairs. I don't remember if I sent him the section of the by laws that speaks to his responsibilities. Around the 6th of December (2012) I sent him an email saying he was responsible for the ophthalmology on call roster. I said here are the list of active staff who have privileges. I don't remember if there was any communication between then and January 2nd (2013) when I emailed him and said I don't have a schedule. The ED called and said they did not have a schedule for ophthalmology. I told them I don't have a schedule yet so if there is an emergency they will need to call (Name of Employee #9). I then called (Name of Employee #9) who stated he would take care of it tomorrow (January 3, 2013). I got the schedule on 1/3/13. The email I received only had the attending physicians on it. I didn't know anything about the resident schedule. I don't know where they got the schedule with the residents and attendings on the schedule. EVMS stopped sending us a schedule in November 2012 of residents on call."