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.

MARY WASHINGTON HOSPITAL, INC 1001 SAM PERRY BOULEVARD FREDERICKSBURG, VA 22401 Sept. 13, 2017
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on medical record reviews, staff interviews and facility document review it was determined the facility staff failed to ensure there was documented evidence each patient had been informed of their patient's rights for 13 of 38 sampled medical records. (Patients #6, 7, 11, 13, 15, 16, 19, 25, 31, 32, 33, 37, and 38).

The findings:

On 9/13/17 at 8:30 AM, the Executive Vice President and Chief Medical Officer (CMO - staff member #10), the Director of Regulatory Affairs (staff member - SM #3), and the Manager of Clinical Risk Management (SM #6) were interviewed in the conference room. When the administrative team was asked how the facility staff ensure all patients are informed of their rights, the Director of Regulatory Affairs stated patient's rights were posted in various places throughout the hospital and that all patients sign a consent to treatment when they present to the facility and that consent to treatment addresses patient's rights.

On 9/12/17 at 3:00 PM two surveyors spoke with one of the facility's registrars (SM #27) working in the emergency department (ED). The registrar stated each patient presenting throughout the facility was given a consent to treatment to sign along with the information necessary for a quick registration. The registrar stated that if the patient signed into the ED's Kiosk (instead of seeing a person), the consent to treatment would be printed for them. The consent to treatment was reviewed and found to be a two-page document formally titled, "General Consent for Treatment/Guaranty of Payment." The document read, in part, under "Patient Rights, Grievance Process, Advance Directives"... "I have received or have been informed of my rights and responsibilities as a patient."

The survey team reviewed medical records from current patients as well as closed records throughout the survey. Patients #6, 7, 11, 13, 15, 16, 19, 25, 31, 32, 33, 37, and 38's medical records either did not contain the consent to treatment at all or the document was present but the signature area was left blank. Facility administrators (Staff #3 and #6) were informed of these missing documents on 9/12/17 at 3:00 PM in the conference room and acknowledged the items were either absent or without signatures.

On 9/13/17 at 2:20 PM, the Director of Patient Financial Services (SM #28) who oversees Patient Access staff (to include the registrars) was interviewed in an empty office within the Patient Access area. He/She explained the process of obtaining consents to treatment and how they were supposed to be completed by each patient, outpatient or inpatient, no matter where the patient entered the facility. The Director stated he/she had been informed by facility administration of the missing documentation found during the medical record review and that along with his/her supervisor were looking into where the process had failed to ensure the signatures were obtained and remained in the medical record.

The facility's policy titled, "Consents (Informed, General, Informed Refusal)" read in part, "1. The General Consent is required for all patients (Inpatient and Outpatient/Emergency) no matter what the point of entry with the exception being a Documented Medical Emergency." 2. The patient signature is obtained at the time of registration or triage in the Emergency Department. 3. The completed form is a permanent part of the medical record and should be labeled with the patient identification.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interviews, review of facility policy and procedure, and review of medical records for 13 patients who were restrained, 1 of 13 patients did not receive ongoing monitoring while in restraints for violent self destructive behaviors.

Findings include:

A review of Patient #6's medical record revealed the patient was admitted to the facility on [DATE] for acute chest tightness and shortness of breath for one day.

Documentation in the nursing note from 6/1/17 at 8:00 AM was that "During change of shift pt (patient) was combative. (He/she) was having auditory and visual hallucinations. Pt stated seeing demons killing children and then coming to get (him/her). Pt pulled out (his/her) IV, ran for the exit stairwell. Nursing staff convinced the pt to sit on a wheelchair and put (him/her) back in (his/her) room. However, pt refused to get back in bed. At this point the pt became combative. Security was called to assist putting the pt back into bed. A total of six nursing personnel and three security guards put the pt back into bed. (physician's name) was at the bedside at the time of the incident. (He/she) gave orders for soft restraints. Consults for neurology, psychology were put in. Family arrived to the bedside and assisted with the pt. Additionally a 1:1 sitter was at the bedside. Pt remained combative through the day. Pt was minotired (sic) q 2 hours all day".

An order for restraints was noted in the chart dated 6/1/17 at 9:00 AM for 4 point soft restraints, and the rationale for restraint was marked "non-violent, protect lines, support medical healing".

The facility's policy entitled "Restraint and seclusion policy" states in part, regarding use of non-VSD restraints: "Restraints for Non-Violent reasons apply when used to support medical healing (to prevent self removal of feeding tubes, IV, etc)...".
The policy states the following under "Restraints/Seclusion for Violent of Self Destructive (VSD) Behavior: "Restraints/seclusion for Violent Self Destructive reasons are applied when a patient has severely combative, aggressive, or destructive behavior that places the patient or others in eminent danger...".

Staff Member #8 was navigating the record with the surveyor, and was interviewed at 10:30 AM on 9/12/17. The surveyor asked if VSD would have been a more appropriate reason for the application of restraints for this patient, due to the documentation that he/she was combative, having visual and auditory hallucinations, and required six nurses and three security guards to put him/her back to bed and in soft restraints. Staff Member #8 stated "Probably, based on the note". The surveyor asked what documentation would have been required for VSD that was not done since Non-VSD was marked as the reason for restraint, and he/she stated "nurses document a focus note every four hours with VSD and restraint monitoring is done every 15 minutes".

The record included a nursing assessment every two hours while in restraints; however, 15 minute restraint monitoring was not documented in the medical record.

This concern was discussed with Staff Member #8 on 9/12/17 at 10:30 AM. Concerns related to restraint orders and documentation were discussed with members of administration on 9/13/17 between 3:20 PM and 3:45 PM.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
Based on staff interviews, review of employee personnel records, and facility policies and procedures, the facility staff failed to ensure that staff in the Emergency Department (ED) received periodic ongoing training demonstrating competencies in the application of restraints.

Findings include:

1. The facility's policy entitled "Restraint and Seclusion Policy" states the following in part under "Staff Training/Competency": "1. Prior to applying restraints, implementing seclusion, or performing associated monitoring and assessment of, or providing care for a patient in restraints or seclusion, staff must be trained upon orientation, prior to use of restraints and ongoing annually, and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment and providing care for a patient in restraint or seclusion....The training will be documented in the staff's educational record and be appropriate for the specific needs of the patient population served...". "...3. Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion: before performing any of the actions; as part of orientation; and subsequently on a periodic basis consistent with hospital policy...".

A total of eight staff records were reviewed; two RN's (Registered Nurses) and one CNA (Certified Nursing Assistant) who worked in the main hospital, two RN's who worked in the ED, and a MHT (Mental Health Technician) and RN who worked in the behavioral health unit.

There was documentation present in the personnel records which supported that the staff in the main hospital and in the behavioral health unit received annual restraint training which included demonstration of restraint application.
The ED staff records reviewed lacked evidence that employees had demonstrated annual competencies in the application of restraints.

Staff Member #26, the ED Nurse Manager, was interviewed on 9/13/17 at 12:45 PM, and was asked about the restraint training for ED staff entailed; he/she stated "Restraints are covered in the Hospital Specific C training but restraints are not a part of the skills practice booths. Restraints are in this 400 page book that the nurses read, then they take a test. There is no demonstration of competency".

Staff Member #9, staffing and accreditation staff person, was present during the interview, and stated "They do those competencies for restraints, we can get that information for you". The surveyor asked that Staff Member #9 to randomly pick five ED staff working 9/13/17 and provide documentation of restraint training, including evidence of demonstration of competency in the application of restraints.

At 2:35 PM on 9/13/17 Staff Member #9 stated to the surveyor "The ED does a different process for restraint training. They are only doing verbal training with the book, and there is a post test, there is no demonstration of competency of restraint application". Staff Member #9 was interviewed and asked if any of the current staff working in the ED had documentation of competency of application of restraints, other than at initial orientation, and he/she stated "No".

The concern related to the lack of demonstration of competency in application of restraints for ED employees was discussed on 9/13/17 with Staff Member#26 at 12:45 PM, with Staff Member #9 at 2:30 PM. Concerns related to restraint training were discussed with members of administration on 9/13/17 between 3:20 PM and 3:45 PM