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 MEMORIAL REGIONAL MEDICAL CENTER 8260 ATLEE ROAD MECHANICSVILLE, VA 23116 May 7, 2015
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0116
Based on observations, document, review, and interviews it was determined the facility failed to conspicuously post patients' Emergency Medical Treatment and Active Labor Act (EMTALA) rights and the facility's participation in the State's Medicaid program in places where all patients or their representatives could observe for one (1) of one (1) emergency department.

The findings included:

Observations were conducted within the facility's Emergency Department (ED) on May 5, 2015 from 11:45 a.m. through 12:28 p.m., with Staff #3, Staff #4, Staff #5 and two surveyors. An observation of the ambulance or emergency medical transportation (EMS) entrance did not reveal EMTALA signage.

An observation of the ambulatory (Walk-In) entrance of the facility's ED revealed the waiting room was divided into two sitting areas on either side of the registration desk. The EMTALA signage was located on a wall in the area to the right of the registration desk, not visible to individuals that chose to sit on the left side sitting area.

Review of the facility's policy titled: "Emergency Medical Treatment and Active Labor Act (EMTALA) " read in part: "10.2 Signage Signs should be posted in the Acute Care Hospital's Emergency Department, Signs should advise patients of: His or her rights under EMTALA; His or her rights to receive care as a Medicare or Medicaid beneficiary; [and] Acute Care hospital's policy to provide for individuals regardless of their ability to pay. Signs must be posted in entrances, admitting areas, waiting rooms and treatment areas."

Interviews were conducted on May 6, 2015 at 4:59 p.m., with Staff #3, Staff #3, Staff #5, and Staff #22. The surveyor questioned the facility's EMTAL Signage for their EMS entrance. Staff #4 stated, "We do not have an EMTALA sign at that entrance." Staff #4 acknowledged the EMTALA was only posted in the ambulatory entrance of their Emergency Department.
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview the facility failed to ensure the Plan of Care implemented included a follow up pain reassessment for seven (7) of thirty one (31) patients in the Emergency Department (Patients #1, #7, #10, #12. #13. #18, and #28).

The findings included:

Thirty one electronic medical records (Patient Medical Records #1-#31) were reviewed on May 5, 2015 and May 6, 2015. The following information was found during the review:

Patient #1 was admitted to the Emergency Department (ED) on 04/01/2015 at 2:16 pm with a complaint of atypical chest pain. Patient #1 had an Emergency Severity Index Score (ESI) of 3. Documentation indicates an initial Pain Assessment was done at 2:31 pm. Patient #4 rated his/her chest pain at level 4. No further documentation pertaining to pain (including administration of pain medications) was found in Patient #1's ED medical record. Patient #1 was discharged at 8:53 pm.

Patient #7 was admitted on [DATE] at 4:02 pm with a complaint of abdominal pain. Patient #7 had an ESI score of 3. Documentation indicates an initial Pain Assessment was done at 4:13 pm. Patient #7 rated his/her pain at level 10 and stated "everything hurts." No further documentation pertaining to pain found in the medical record of Patient #7. Documentation indicates Patient #7 left Against Medical Advice (AMA) at 6:22 pm.

Patient #10 was admitted on [DATE] at 1:09 pm with a complaint of left sided chest pain, shortness of breath, and cough. Patient #10 had an ESI score of 3. Documentation indicates an initial Pain Assessment was done at 1:17 pm. Patient #10 rated his/her pain at 1. No further documentation found in the medical record of a pain reassessment. Patient #10 was discharged at 6:20 pm.

Patient #12 was admitted on [DATE] at 6:57 am after being assaulted. Patient #12 presented to the ED with both eyes swollen shut, and a fractured nose. Patient #12 had an ESI score of 3. Documentation indicates an initial Pain Assessment was done at 7:11 am. Patient #12 rated his/her pain at level 3. Documentation in the medical record of Patient #12 states he/she received Morphine 2mg IV (narcotic) for pain at 8:32 am. No documentation found a pain reassessment was done. Patient #12 was discharged at 11:52 am.

Patient #13 was admitted on [DATE] at 2:11 pm after falling. Patient #13's diagnosis was elbow dislocation. Patient #13 had an ESI score of 3. Documentation indicates the initial Pain Assessment was done at 2:27 pm. Patient #13 rated his/her pain at a level 7. Documentation indicates a closed reduction of the elbow was attempted twice with Patient #13 receiving Propofol (used to induce anesthesia) prior to the procedure. The first reduction attempt occurred at approximately 4:47 pm. No follow up pain reassessment found post procedure. Morphine 2mg intravenous was given to Patient #13 at 5:04 pm. No documentation of Patient #13's pain pre or post administration. Propofol 60 mg was given at 7:40 pm prior to the second attempt of a closed reduction of the elbow. No documentation found of pain assessment pre or post procedure. No documentation of pain assessment found in the ED medical record of Patient #13 except the initial assessment. Patient #13 went to the operating room at approximately 8:00 pm.

Patient #18 was admitted on [DATE] at 10:39 am with chest pain. Patient #18 had an ESI score of 3. Documentation indicates an initial Pain Assessment was done at 10:50 am. Patient #18 rated his/her pain at a level 7 and stated the pain is "stabbing." No further pain reassessment found in the medical record of Patient #18. Patient #18 was discharged at 1:27 pm.

Patient #28 was admitted on [DATE] at 11:21 pm with shortness of breath and hypertension. Patient #28 had an ESI score of 2. Documentation indicates an initial Pain Assessment was done at 11:31 pm. Patient #28 rated his/her pain at level 0. No pain reassessment documentation was found in the ED medical record of Patient #28. Patient #28 was admitted to inpatient status at the above named facility at 4:28 am on 04/01/2015.

According to the U.S. Department of Health and Human Service Agency for Healthcare Research and Quality Emergency the Emergency Severity Index (ESI) is a "simple to use five-level triage algorithm that categorizes emergency department patients by evaluating both patient acuity and the resources needed. ESI levels 3, 4, and 5 are differentiated by the nurse's determination of how many resources are needed to make a patient disposition. Those patients who are expected to need two or more resources are designated as ESI level 3."

The policy titled "Assessment and Reassessment Of Patients in the Emergency Department" was requested and received on May 6, 2015. The policy states in part "Assessment and Reassessment intervals will be determined by an acuity designation using the Emergency Severity Index." All patients presenting to the ED will receive a full set of vital signs to include pain assessment. ESI scores of 2, 3, and 4 shall have pain assessment "within one hour post intervention and at least every two hours thereafter."

The policy titled "Pain Management Standards" was requested and received on May 6, 2015. The policy states in part "patients will have their pain status assessed upon admission into the hospital or during any outpatient/ambulatory procedure." The policy further states [reference to above named facility] "realizes that the patient has a right to have pain assessed, recognized and managed in a timely manner." The following components in part are included in the organization's approach to pain management "individualizing and implementing a pain management plan for each patient in need of pain management and enhancing the quality of care of the patient through a collaborative effort between the patient and the professionals working to control pain."

Staff #5 was present during the medical record reviews. Staff #5 stated pain reassessments for ESI level 3 patients should be done every two hours.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on document review and interview the facility's Emergency Department staff failed to ensure the code carts were checked daily per the facility's policy for four (4) of four (4) code carts.

The findings included:

On 05/05/2015 at approximately 11:45 am during the initial tour of the Emergency Department three (3) adult code carts and one (1) pediatric code cart were checked for daily documentation of the "Monitor/Defibrillator Checklist." This checklist includes checking the monitor/defibrillator and ensuring the seal to the code cart (used during cardiac emergencies) and intubation box (used during respiratory emergencies) has not been broken. The following information was found during the tour:

Crash Cart #1 for the month of April 2015 had no documentation of the required daily checks being performed on 04/02/2015, 04/20/2015, and no documentation of the intubation box being sealed on 04/30/2015.

Crash Cart #2 for the month of April 2015 had no documentation of the required daily checks being performed on 04/02/2015, 04/14/2015, 04/25/2015, and 04/27/2015.

Crash Cart #3 for the month of April 2015 had no documentation of the required daily checks being performed on 04/02/2015.

Crash Cart #4 for the month of April 2015 had no documentation of the required daily checks being performed on 04/13/2015 and 04/14/2015. No documentation of the intubation box (equipment used during respiratory emergency) being sealed on 04/02/2015. No documentation of the Code Cart being sealed on 04/18/2015.

A review of the ED Pediatric Cart Equipment Checklist was conducted on May 5, 2015 at approximately 12:10 pm. The checklist includes a review of the availability of the Pediatric Cutdown Tray, Pediatric Trach Tray, and Pediatric Emergency Kit. The review revealed the following information:

The January 2015 Pediatric Cart Equipment Checklist had no documentation of the daily required checks for 01/03/2015, 01/08/2015, and 01/25/2015. No documentation identifying the staff member who performed the equipment check on 01/21/2015.

The February 2015 Pediatric Cart Equipment Checklist had no documentation of the daily required checks for 02/08/2015, 02/17/2015, 02/24/2015, and 02/27/2015.

No documentation of the Month/Year on the April 2015 ED Pediatric Cart Equipment Checklist. Verbally identified by Staff #5. No documentation found of the daily required checks for 04/02/2015, and 04/19/2015. No documentation identifying the staff member who performed the equipment checks on 04/03/2015, 04/24/2015, and 04/28/2015.

The May 2015 Pediatric Cart Equipment Checklist had no documentation of the daily required checks for 05/03/2015 and 05/04/2015.

The policy titled "Code Carts and Other Emergency Equipment, Daily Checks" was requested and received on May 6, 2015 at approximately 8:00 am. The policy states in part "all code carts/defibrillators and other emergency carts are checked daily. Checks include assuring the integrity seal is intact and full serial number is recorded daily. Checks include all equipment is functioning properly. Nurse managers of each area are responsible for ensuring that the code carts and essential emergency equipment are checked daily."

Staff #5 was present during the findings. Staff #5 stated documentation of Code Cart checks are to be done "daily."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview it was determined the facility failed to obtain an order for a restraint device utilized on two (2) of six (6) restrained patients included in the survey sample. (Patient #35 and Patient #37)

The findings included:

1. Review of Patient #35's electronic medical record (EMR) was conducted on May 7, 2015 at 12:40 p.m., with Staff #4. Patient #35's EMR revealed the patient was admitted to the facility's Emergency Department on April 28, 2015 and became agitated pulling out his/her intravenous (IV) lines. The review revealed a nursing progress note dated April 28, 2015 at 8:30 p.m., which indicated a verbal order had been obtained to place the patient in "Bilateral soft wrist and bilateral soft ankle restraints and four side rails [in raised position]." The review of Patient #35's EMR did not reveal a physician's order, which had been signed electronically by the physician for restraints.

Staff #2 acknowledged the findings. Staff #2 stated, "[Staff's name] received a verbal order from the physician but never put it in as a physical order." Staff #2 verified Patient #35's EMR did not have a signed physician's order for restraints while in the Emergency Department.

2. A review of Patient #37's electronic medical record (EMR) was conducted on May 7, 2015 at 11:27 a.m., with Staff #21. Patient #37's EMR documented he/she had been admitted on [DATE]. A physician's order dated April 26, 2015 at 7:02 a.m., read in part: "Restraint type: Secure Mitt: both, Soft restraints: right wrist and left wrist and Locked restraints: right wrist and left wrist Reason for restraints: Interference with medical treatment ... (Sic)" Staff #21 verbalized he/she did not think the facility still used locked restraints.

Review of Patient #37's EMR revealed a nursing progress note for April 26, 2015 timed at 7:41 a.m. that documented the type of restraints utilized. The progress note read in part: "Restraint type: Secure mitt both (bilateral hands), Soft restraint: right wrist and left wrist and Jacket/Vest."

Review of the nursing flowsheet for April 26, 2015 documented Patient #37 had been restrained in bilateral mittens, bilateral soft wrist restraints and a restraint vest.

The surveyor inquired if the "Locked restraints" were the same as a "Jacket/vest restraint" Staff #21 stated, "No, locked restraints were the old leather restraints that required a key to lock and unlock". Staff #21 verified Patient #37's physician's order for restraints did not include an order for jacket/vest restraint. Staff #21 reviewed Patient #37's EMR and checked multiple places for a misplaced order in the progress notes. Staff #21 verified the physician had not given an order to restrain Patient #37 in a jacket/vest restraint. Staff #21 acknowledged nursing staff had used a jacket/vest restraint on Patient #37 for at least nine hours without a physician's order.

Staff #21 and the surveyor reviewed the facility's policy titled "Restraints and Seclusion." The policy in part read: "9.10. Physician Order ... Each order must specify on the physician's Restraint Order Form: 1. Rationale for use of restraint; 2. Type of restraint to be used ..." Staff #21 reported the facility staff failed to correctly implement the facility's policy.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview the facility's staff failed to follow the restraint policy pertaining to monitoring for five (5) of six (6) restrained patients (Patients #32, #33, #34, #35, and #36).

The findings included:

Six electronic medical records were reviewed pertaining to restraint data on May 7, 2015 at approximately 12:00 p.m. The following information was found during the review:

1. Patient #32 was admitted on [DATE] for Pleural Effusion (abnormal collection of fluid around the lung) and Acute Renal Failure. A restraint order was obtained 04/02/2015 at 12:17 am. Patient #32 was placed in Non violent/Non Self Destructive soft wrist restraints. Incomplete documentation on the Restraint Flowsheet was found on 04/02/2015 at 12:17 am and 2:00 am. The incomplete assessment included no documentation in the categories on the Restraint Flowsheet titled "Assessment, Justification/Education, and Restraint Ordered."

2. Patient #33 was admitted on [DATE] for Sepsis (life threatening complication of an infection), Pneumonia, and [DIAGNOSES REDACTED]. Patient #33 was intubated and required maximum ventilatory support. Patient #33 had a current order dated 05/07/2015 for Non Violent/Non Self Destructive soft wrist restraints. The patient was placed in the soft wrist restraints on 05/05/2015 due to the potential of "pulling at tubes" according to Staff #20.

Incomplete documentation on the Restraint Flowsheet was found on the following dates while reviewing Patient #33's medical record:
05/05/2015 at 6:00 p.m. and 10:00 p.m.
05/06/2015 at 4:00 am, 10:00 am, and 6:26 p.m.
The incomplete assessment included no documentation in the categories on the Restraint Flowsheet titled "Assessment, Justification/Education, Restraint Ordered, and Non Violent/Non Self Destructive Assessment Q2H."

3. Patient #34 was admitted on [DATE] for Hypertension and intracranial bleed. Patient #34 had a current order dated 05/07/2015 for Non Violent/Non Self Destructive soft wrist restraints. Patient #34 was initially placed in soft wrist restraints on 05/05/2015 at 1:15 p.m. Patient #34 was intubated and ventilated.

Incomplete documentation on the Restraint Flowsheet was found on the following dates while reviewing Patient #34's medical record:
05/05/2015 at 10:00 p.m.
05/06/2015 at 12:00 am, 2:00 am, 4:00 am, 6:00 am, 10:00 am, 12:00 p.m., 2:00 p.m., 6:00 p.m., 8:00 p.m., and 10:00 p.m.
05/07/2015 at 12:00 am, 2:00 am, 4:00 am, and 6:00 am.

The incomplete assessment included no documentation in the categories on the Restraint Flowsheet titled "Assessment, Justification/Education, Restraint Ordered, and Non Violent/Non Self Destructive Assessment Q2H." The documentation not found in the chart reviews of Patient #33 and #34 included visualization of the patients, range of motion, fluids, and food/meal.

Staff #21 was present during the medical record reviews and confirmed the findings. Staff #20 confirmed on 05/07/2015 while in the Intensive Care Unit all sections of the Restraint Flowsheet must be filled out at each assessment done every two hours Staff #3 was aware of the findings.




4. Review of Patient #35's electronic medical record (EMR) was conducted on May 7, 2015 at 12:40 p.m., with Staff #4. Patient #35's EMR revealed the patient was admitted to the facility's Emergency Department on April 28, 2015 and became agitated pulling out his/her intravenous (IV) lines. The review revealed a nursing progress note dated April 28, 2015 at 8:30 p.m., which indicated a verbal order had been obtained to place the patient in "Bilateral soft wrist and bilateral soft ankle restraints and four side rails [in raised position]." The nursing flowsheet documented every fifteen minutes from April 28, 2015 at 8:45 p.m. through April 29, 2015 at 4:45 p.m. that the patient "continued" being restrained. Review of the nursing progress notes and the nursing flowsheets did not contain documentation nursing staff had performed the required every two (2) hour assessment for a patient in restraints. Patient #35's EMR did not contain documentation that staff had checked his/her circulatory, vital signs, skin integrity, or for signs of injury.

Staff #2 acknowledged the findings and reported the staff failed to document the required, at least every two hour, reassessments had been performed.

5. Review of Patient #36's EMR was conducted on May 7, 2015 at 11:59 a.m., with Staff #21. Patient #36's EMR revealed the patient was admitted to the facility on on [DATE]. Patient #36's EMR contained a physician's order dated April 23, 2015 at 11:06 p.m. for bilateral soft wrist restraints. Nursing staff documented the initial assessment of the patient after application of the bilateral soft wrist restraints. Nursing staff performed a reassessment or Patient #36 at 0:28 a.m. on April 24, 2015. Patient #36's EMR documented the patient's restraints were discontinued at 12:32 p.m. on April 24, 2015. The nursing staff did not document the required every two-hour reassessments of Patient #36. Staff #21 reviewed the nursing progress notes but did not find documentation related to the patient's restraint reassessments. Staff #21 stated, "There are no reassessments documented. They must have forgot to do them."

Review of the facility's policy titled "Restraints and Seclusion" read in part: "9.13. Documentation and Reassessment of Non-Behavioral (Medical and Surgical Restraints) Reassess at least every 2 hours or more frequently based on patient needs. Continual reassessment/monitoring determines 1. The physical and emotional well-being of the patient; 2. The patient's rights, dignity, and safety are maintained, 3. Whether less restrictive methods are possible; 4. Changes in the patient's behavior or clinical condition needed to initiate the removal of restraints; 5. Whether the restraint has been appropriately applied in a safe manner, removed or reapplied. Document: Circulation check, Vital signs as indicated, Skin Integrity, Mental status and Behavior; Touch/Sensation, Pulse oximetery as indicated, Check application of restraint, Whether less restrictive measures are possible, Readiness to discontinue, [and] Restraint release and patient's response ... (Sic)"