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.

UNIVERSITY OF VIRGINIA MEDICAL CENTER 1215 LEE STREET CHARLOTTESVILLE, VA 22908 Aug. 16, 2018
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review, it was determined the facility failed to deliver care in a safe setting for one (1) out of twenty (20) inpatient stays reviewed (Patient #4).

The findings include:

On August 15, 2018 at 1:31 p.m., surveyors obtained a copy of the emergency department (ED) portion of the electronic medical record for Patient #4. That record indicated the patient arrived at the ED via EMS (emergency medical services) on March 26, 2018 at 8:53 a.m. with a chief complaint of altered mental status.

In an ED provider note related to an assessment conducted of Patient #4 on March 26, 2018 at 9:08 a.m., Staff Member #40 documented in part:

"Pt transported from home via EMS reported pt altered, fighting vital signs complaining od abdominal pain ...
I was unable to obtain a clear HPI, ROS (review of systems) from the patient or review their PMH (past medical history), FH (family history), SH (social history) due to altered mental status ...
General: Patient visibly agitated from doorway, unable to sit still for any period of time, scratching all over [patient] body ...
Patient presents altered and unable to answer questions, though [patient] intermittently appears oriented to place (knew [redacted] was in a hospital, though incorrect one) and is intermittently answering questions. Follows one step commands, although attention swiftly wanes and the patient attempts to get out of bed repeatedly. [Redacted] is agitated towards examiners and nursing: will give 1mg Ativan to aid in further assessment and patient care."

In an additional ED note entered on March 26, 2018 at 9:58 a.m. Staff Member #40 writes:
"Patient continues to remain agitated and interfering with [patient] care, unable to be assessed by toxicology team given agitation at this time. Will give 5mg haloperidol and 1mg IV Ativan given patient agitation and interference of patient's agitation with cares posing threat to safety"

In a toxicology consult on March 26, 2018 at 10:00 a.m., Staff Member #57 advised in part:
"Based on [patient] physical exam, history, and the available home meds ([patient] meds and [patient's] fiance's meds), deferential includes anticholinergi[DIAGNOSES REDACTED], serotoni[DIAGNOSES REDACTED], and alcohol withdrawal"

On August 14, 2018, surveyors obtained a copy of security incident reports related to Patient #4's ED and inpatient stay spanning March 26, 2018 and March 27, 2018. In a security report dated March 26, 2018 with an incident time of 11:00 a.m., Staff Member #42 advises:
"On 03/26/2018 at 1100, security [Staff Member #43] was standing by Rm 14 in the ER because of patient [Patient #4] that was brought in by rescue. [Patient #4] was acting erratic and swinging [patient] arms and legs and med staff was trying to hold [patient] and get a IV started. Security [Staff Member #43] and [Staff Member #42] was asked to come into the room and help restrain with hands only [Patient #4] while [patient] IV was started. Security stayed in the room and provided help to med staff for about 35-40 minutes and stayed on stand by until meds had started to take effect to calm [Patient #4]. Security was then called back in when Nurse [Staff Member #44] was hit in [his/her] shoulder by [ Patient #4] either by accident or purposely. Security stayed again until more meds were given, Security asked Nurse [ Staff Member #44] if [redacted] was ok and if [redacted] needed to be looked at or if [redacted] wanted to file a report. Nurse [Staff Member #44] said [redacted] was fine and did not want to press charges. UP52 [Staff Member #45] also asked the nurse and [redacted] had the same answer. ER security patrolled the area until [Patient #4] was taken to MICU.

In an emergency department nursing note entered on March 26, 2018 at 12:26 p.m., Staff Member #36 documented:
"Rnx2, tech x1, securityx2, MDx4 at bedside. Pt (patient) Iv started in left hand, pt removed this IV. IV started in right hand pt received 5mg Haldol in this site then pt removed IV. Pt Iv started in right forearm pt wasted 1mg Ativan on self while removing IV. Pt given 2mg IM Ativan. Pt IV started in left forearm given 2mg IV Ativan. Wasted 1mg Ativan in pixis. Between 9:15-12:00 Pt has been fighting, itching, jumping, jerking fighting staff. Pt given above meds and others - see MAR. Pt has sitter at bedside, EKG, I/O cath with 600ml urine out. Pt on capnography, cardiac monitor, spo2 monitor and bp monitor. Pt rectal temp checked- afebrile. Pt currently still fighting, thrashing in bed - pt head being protected my family staff and pillows. Will continue to monitor pt."

The ED medical record further notes the patient left the ED on March 26, 2018 at 3:00 p.m. with an admission to MICU. The record documented Staff Member #41 as the receiving provider with a reason for admission listed as altered mental status with an estimated length of inpatient stay as "3-4 midnights."

On August 14, 2018, surveyors obtained the medical record for Patient #4's inpatient stay in MICU.
In a physician restraint notification note entered on March 26, 2018 at 3:28 p.m., Staff Member #38 documented in part:
"[Patient #4] was placed in soft non-violent restraints at 1530PM (3:30 PM) due to [patient] confusion and agitation posing a threat for removal of [patient] IV access ...
A face to face evaluation was conducted with [Patient #4] by PGY2 [Staff Member #39] regarding the initiation of restraints. The patient's immediate situation requiring restraints Is immediate danger to self, immediate danger to others and Violent/Aggressive behavior.
The environmental factors that may have contributed to the situation at the time of the intervention include: Patient had to be moved from ED to MICU, needed IVs placed and I/O cath for retention.
Patient's physical status that may have contributed to the need for restrains: patient was thrashing around in the bed with all extremities, [patient] was in danger of pulling out [patient] IV access and [patient] was in danger of hurting [patient]self and staff members.
Patient's mental status that may have contributed to the need for restraints: [Patient] was completely altered likely due to likely ingestion of an unknown substance ...
My assessment of the patient's medical and behavioral condition includes:
Behavioral assessment: Uncontrolled violent behavior with no recognition of danger to self or others ...
The rationale for continued use of restrains includes Restraints continued to prevent harm to the patient and/or others."

A review of the restraint order issued by Staff Member #38 on March 26, 2018 at 3:39 p.m. revealed the facility restrained the patient for the reasons outlined above until discontinuation of the order on March 27, 2018 at 11:59 a.m. After discontinuation of the restraint order, an order for a 1:1 sitter remained in effect at the time Patient #4 walked out of the hospital.

In a toxicology progress note based on an evaluation performed on March 27, 2018, Staff Member #46 states in part:
"admitted to MICU ... [Patient #4] required soft restraints around 1500 (3:00 PM) for [patient] safety and MICU staff Safety ... This morning, [Patient #4] is vitally stable, still in restraints but calm in bed. No other major events overnight. Somnolent, doesn't answer questions this AM, although reportedly told out med student earlier that [Patient #4] only took [patient] remeron."

In a psychiatry consult performed on March 27, 2018 at 2:19 p.m., Staff Member #37 noted in part:
"[Patient #4] presented with AMS (altered mental status) around 5am yesterday morning (03/26/18). [Patient] was agitated and aggressive, so [patient] treated with 5 mg haloperidol and 5 mg total of Ativan (3 mg IV, 2 mg IM). [Patient #4] was placed on soft non-violent restraints around 1530 (3:30 PM)... [Patient #4] was alert but disoriented to place (thought [patient] was at [another hospital]) and situation (was unable to describe how or why [patient] came to the hospital). On MMSE [patient] scored 17/30, with deficits in orientation, recall, and attention. [Patient #4] was often tangential on questioning, and when asked about mood, began talking about [patient] ex-[spouse] and how [patient] wishes things in [patient] life were different so [patient] could have afforded a nice house for [ex-spouse] and [patient] two children ... In terms of [patient] risk assessment, [patient] is at elevated chronic risk due to age, race, unemployed, divorced, previous attempt, family history (mom and father), history of sexual abuse, current substance abuse, and age. In terms of acute suicide risk, history from patient is unreliable and [patient] needs to be reassessed as [patient] mental status clears for a formal suicide risk assessment ...
Psychiatry will continue to follow and reassess as mental status improves. Decrease frequency of benzodiazepines from Q3 (every 3 hours) to Q6 (every 6 hours) and continue to wean PRN (as needed). Considered vitals triggered CIWA if primary team and toxicology are concerned for EtOH (alcohol) withdrawal. Continue sitter and suicide precautions."

In a Clinical Institute for Withdrawal Assessment (CIWA) contained in the medical record, reported by Staff Member #16 as conducted by Staff Member #47 on March 27, 2018 at 6 p.m., Staff Member #47 assigned Patient #4 a total CIWA score of four (4). Thirty minutes later, the CIWA score assigned by Staff Member #47 increased by seven (7) to eleven (11) total points with a score of two (2) for orientation and clouding of sensorium, a score of five (5) for agitation, a score of two (2) for anxiety, and a score of two (2) for tremor.

The medical record indicated the last set of vitals taken for Patient #4 prior to the patient leaving the hospital occurred on March 26, 2018 at 6:30 p.m. The vitals displayed a tachycardic heart rate of 120 and a respiratory rate of 32.

In an event note entered on March 27, 2018 at 6:44 p.m., Staff Member #49 reported:
"MICU team responded to a MICU West BERT call. Upon walking from the workroom to MICU West, we were met by nursing instructing us "the patient" went to the east end of the hospital. The team was told to go downstairs to find the patient. The MICU and Psychiatry team found the patient across the street, beside the parking garage walking away from the building. [Patient #4] assigned sitter from the MICU had been able to follow [patient] without losing eye contact with the patient at any time during the event. UVA Police, and Hospital security were present. After lengthy discussion with the police, it was determined an ECO (emergency custody order) was required before the patient could be brought back inside the hospital. Psychiatry called the magistrate with one of the MICU residents for which an ECO was issued. The police were notified of this, and the patient was detained and taken to the ED. The ED staff were notified of the events leading up to the presentation. The patient was taken to the ED by request of RegionTen for TDO (temporary detention order) evaluation. The patient was in view of nursing or medical staff, and not physically restrained until the ECO was issues. The appropriate supervising physicians were made aware of the events.
Of note, a female individual accompanied the patient during the event. This individual appeared to have escalated the situation more than the patient, and the patient followed the females lead. The female used significant profanity, gestures toward security, police and medical staff. The patient also participated in similar acts.
The patient needed to be discharged (Eloped/AMA (against medical advice)) from the MICU prior to being admitted to the ED."

A UVA Psychiatry BERT note alert entered by Staff Member #50 reported a BERT alert initiated on March 27, 2018 at 6:43 p.m. The note further stated in part:
"Reason for initiation of BERT call: PT BEING COMBATIVE AND VERBALLY AGGRESSIVE ...
Psychiatry was consulted today for a suicide risk ...
Psychiatry team was intercepted by primary team on the way to the BERT and informed that the patient had gone down to the lobby. Psychiatry, primary team, and security then went to the lobby. Patient was noted to be in the street. All members of the BERT team went in the street to speak with the patient who was walking away from the hospital with [patient] fianc. The patient's [fiance] immediately began belligerent, screaming at physicians and security that the patient is not suicidal and they are going to [name of another hospital]. Primary team attempted to explain that patient is not safe for discharge. Psychiatry attempted to explain situation and concern for patient's medical safety and lack of capacity. [Fiance] continued shouting and could not be redirected. The patient was mostly quiet, nodding in agreement with [patient] [fiance] smoking a cigarette. They would not agree to return to the hospital ...
Patient is not believed to be safe for discharge medically or psychiatrically and also likely to lack capacity due to likely ongoing delirium."

In a discharge summary entered by Staff Member #39, the physician responsible for Patient #4 in the MICU prior to the patient fleeing the hospital, the staff member documented in part:
"The patient was admitted to the MICU for [patient] [DIAGNOSES REDACTED], primarily because [patient] behavior required nearly 1:1 nursing care. [Patient] was highly agitated, trying to get out of bed, and not redirectable. [Patient] intermittently required restraints for [patient] safety. After discussion with [patient] sister, [patient] presentation seemed suspicious for an intentional ingestion and possible suicide attempt, so [patient] also had a sitter at bedside.
After consultation with Toxicology, it was felt [patient] was most likely presenting with an anticholinergic toxidrome. Upon arrival to the MICU, [patient] was treated with Precedex and scheduled Ativan (in case there was a component of EtOH withdrawal). Over the first 12 hours of the admission, [patient] remained quite encephalopathic.
On the day of admission, [patient] was less somnolent and able to answer some questions, though [patient] could not report what happened or why [patient] was in the hospital. As the day progressed, [patient] became more agitated and eventually eloped from the hospital. [Patient] was followed outside the hospital and an ECO was issued. At that time, [patient] was formally discharged from the current admission but then presented immediately back in the ED for readmission."

In a security report documenting Patient #4 leaving the facility with an incident date and time of March 27, 2018 at 6:41 p.m., Staff Member #51 states:
"At the time of 1841 (6:41 PM) Security was called to MICU for a Bert call. Myself [Staff Member #51], [Staff Member #52], [Staff Member #53], [Staff Member #54], [Staff Member #55] responded. The patient made [patient] way down stairs, and outside to the sidewalk of lee street. Med staff, and security stoodby while trying to figure-out a plan for the patient. Med staff ordered an ECO, while awaiting the ECO the patient tried to leave by car, in the process the ECO was ordered, and tried to escape from [police]. The patient was then restrained by [police], and brought in the ED for further evaluation."

On August 15, 2018 at 1:55 p.m. surveyors spoke with Staff Member #56, the supervisor for staff members who conduct 1:1 observations. Staff Member #56 identified Staff Member #48 as the person responsible for the 1:1 observation at the time Patient #4 left the hospital. Staff Member #48 further advised "sitters" do not document their actions in any fashion. When asked how it is known if the 1:1 observation occurred as ordered, Staff Member #56 advised nurses are responsible for documenting in the electronic medical record.

On August 15, 2018 at 2:18 p.m., surveyors spoke with Staff Member #48 about the duties of a sitter and what transpired the day Patient #4 walked out of the hospital. Staff Member #48 advised he/she had no memory of the event but "may" recall something similar that happened on the "floor" (a reference to acute care area of the hospital). Staff Member #48 advised he/she "may" recall something similar where a patient's [girl/boy friend] became disruptive but he/she did not recall the patient leaving the hospital, crossing the street, and a group of staff and security speaking with the patient near the parking garage. Surveyors described the patient, the patient's location in the hospital, time and date of the event, the Bert call activation, the people involved and the understanding he/she followed the patient outside of the hospital. Multiple times Staff Member #48 advised he/she did not recall the event as described and did not recall a patient leaving the hospital during a 1:1 observation performed by him/her. Staff Member #48 could only say he/she remembered an event on the "floor" where a patient's [girl/boy friend] became agitated but Staff Member #48 does not recall a patient leaving the hospital while he/she performed a 1:1.

Upon conclusion of the interview, surveyors asked Staff Member #56 how it is known that a 1:1 observation occurred as ordered if the person responsible for the 1:1 does not recall the event and no documentation exists. Staff Member #56 shrugged his/her shoulders.

On August 16, 2018 at 12:11 p.m., surveyors spoke with Staff Member #37, the psychiatrist who conducted the assessment on Patient #4 the afternoon prior to the patient leaving the facility. Staff Member #37 advised another service asked her/him for a psychiatry consult to determine if Patient #4 may be suicidal. Staff Member #37 advised Patient #4 has a history of becoming suicidal during alcohol withdrawal. Staff Member #37 advised he/she spent about 30 minutes with the patient and during that time Patient #4 presented as "completely disoriented." The patient did not know how [patient] got to the hospital and provided inappropriate answers to questions. A mental status exam indicated deficits in attention but Staff Member #37 could not complete the exam due to "some form of delirium." Staff Member #37 advised the patient possessed an elevated risk for self-harm but a full assessment for suicidal ideations could not be completed as indicated in the medical record due to an altered mental status. When asked if Patient #4 had the capacity to care for him/herself Staff Member #37 replied "absolutely not." Staff Member #37 advised he/she spoke to the patient without his/her significant other present and did speak with the significant other after the assessment.

During a review of the electronic medical record with Staff Member #8 on August 15, 2018 at 11:11 a.m., surveyors asked if the medical record contained a notation in any location regarding staff contacting a magistrate to request a TDO for Patient #4 prior to him/her fleeing the hospital. Surveyors further asked if the electronic medical record included documentation of staff discussing a TDO or addressing the pros and cons or an assessment of the need for a TDO. Staff Member #8 replied in the negative. Surveyors also posed this question to Staff Member #16 who advised that magistrates are unlikely to issue a TDO and the facility has a large volume of patients.

On August 16, 2018 at 9:59 a.m., surveyors asked Staff Member #16 if there are any other nursing notes the facility may possess that addresses the 1:1 sitter ordered to perform direct observation of the patient on March 27, 2018 including the time the patient left the hospital.

On August 16, 2018 at 10:55 a.m., surveyors again asked if any notes or documentation exist regarding the 1:1 sitter ordered to perform direct observation of the patient on March 27, 2018 that include the time the patient left the hospital. Surveyors also asked if any additional documentation exists after the psychiatric assessment performed by Staff Member #38 on March 27, 2018 at 2:19 p.m. Staff Member #16 advised, Staff Member #48 (1:1 sitter) does many 1:1 observations and "is a big strapping [person] and asked to sit with people all the time." Staff Member #16 recommended surveyors speak with Staff Member #47, the nurse assigned to Patient #4 when he/she walked out of the hospital. Surveyors agreed and asked the facility to arrange an interview with Staff Member #47.

On August 16, 2018 at 11:56 a.m., Staff Member #16 advised Staff Member #47 is currently on vacation and the facility would not try to reach him/her for a telephone interview. Staff Member #16 further advised Staff Member #47 "left the MICU after this event" and indicated he/she did so based on the emotional toll of the event.

On August 16, 2018 at 1:40 p.m., surveyors asked Staff Member #16 if documentation exits regarding notification to a LIP if a CIWA score changes by more than 5 points at a time. Staff Member #16 advised, "I looked for a corresponding note and there was none."

A review of the facility's notice to patients titled "YOUR RIGHT AND RESPONSIBILITIES AS A PATIENT" states in part:
"As a patient at the Medical Center you have the following RIGHTS: ...
To receive care in a safe environment and to be free from any form of abuse or harassment."
A review of the facility's policy titled "Alcohol Withdrawal Screening, Assessment & Treatment Guidelines" states in part:
"if a patient's CIWA score changes by more than 5 points at a time, or is higher than 20, the nurse should notify the LIP caring for the patient."

A review of the facility's policy titled "Informed Decision-making" defines when a patient is incapable of making informed decisions as:
"An adult patient is "incapable of making an informed decision" when the patient is unable to understand the nature, extent and probable consequences of a proposed healthcare decision or is unable to make a rational evaluation of the risks and benefits of a proposed medical decision as compared with the risks and benefits of alternatives to that decision, or is unable to communicate such understanding in any way.

A review of the facility's policy titled "SRO Patient Safety Companion Guidelines" states in part:
"Job responsibilities: Patient Safety Companions are to provide safe, comfortable, and positive environment for assigned at-risk patients consistent with job training while treating the patient with respect and dignity. The patient safety companions are present to assist with fall prevention, prevention of medical therapy disruption (IV, feeding tubes, etc.), maintaining patient safety, and observe patient behavior that could endanger the patients or others ...
Notify nursing staff of safety concerns such as: medications left at the bedside, a violation in suicide precautions, violent aggressive visitors, etc.
Patient safety companions are to be watching their patients in an effort to ensure that patient safety continually remains the focus at all times.
Patient Safety Companions may not engage in the following functions:
Documenting in the patient's EMR
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0170
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review, staff interview and facility document review, the facility staff failed to ensure the attending physician was consulted as soon as possible after restraints had been ordered for 3 (three) of 8 (eight) patients whose records were reviewed for the use of restraints. Patient #1, 2, and 3.

Patient #1, 2 and 3 had orders for the use of non-violent physical restraints which were ordered by the LIP (Licensed Independent Practitioner) with no evidence the attending physician had been consulted.

The findings included:

1. Patient #1 was admitted [DATE] with diagnoses that included, but were not limited to: hypoxic respiratory failure and asthma. Patient #1 had an order written on 8/14/18 for the use of a non-violent physical restraint. The order was as follows: "Restraints non-violent, lack of awareness of potential harm to self. Cognitive Impairment exists that poses an imminent threat that patient will remove invasive devices necessary for medical management; Limb restraints RUE (right upper extremity) LUE (left upper extremity."

2. Patient #2 was admitted [DATE] with diagnoses that included but were not limited to : Type A dissection (aortic dissection) and hypertension. Patient #2 had orders written on 7/31/18 and 8/1/18 for the use of a non-violent physical restraint. The order was as follows: "Restraints non-violent, lack of awareness of potential harm to self. Cognitive Impairment exists that poses an imminent threat that patient will remove invasive devices necessary for medical management; Limb restraints RUE (right upper extremity) LUE (left upper extremity."

The clinical records for Patient #1 and #2 were reviewed on 8/14/18 with the assistance of a Registered Nurse (RN) Navigator Staff Member #2.

During the review of the records there was no evidence the attending physician had been consulted after the order/use of the restraints. There was no documentation in the progress notes regarding the use of the restraints from the ordering nor the attending physician.
The facility policy and procedure for "Restraints and Seclusion" was reviewed and evidenced: "4. Restraint Orders...c. If the restraint is ordered by and LIP other than the attending physician, that LIP shall consult the attending physician as soon as possible and the consultation shall be documented within 24 (twenty-four) hours of the restraint order."
On 8/15/18 at 2:00 p.m., the surveyor requested any further information regarding the documentation of the consult with the attending physician for the use of the restraints for Patient #1 and Patient #2.

On 8/14/18 at 2:55 p.m., Staff Member #2 stated, "There is a note the physicians are supposed to use when they put in a restraint order, but I don't see it for either of these patients."

On 8/14/18 at the end of day meeting at approximately 3:30 p.m., with the facility Administrative Staff, (Chief Nursing Officer, Chief of Service Lines, Project Management and Accreditation, Chief Operating Officer, and Chief Executive Officer) the concerns were discussed.

On 8/16/18 at 9:40 a.m. Staff Member #8 stated there was no further information found regarding the documentation for Patient #1 and #2.




3. Patient #3 was admitted to the facility on [DATE] s/p (status post) ground level trauma. On 8/1/18 at 7:00 a.m., a non-violent restraint order was written by a licensed independent practitioner (LIP) other than the attending, due to confusion posing an imminent threat that the patient would remove invasive devices necessary for medical management. A review of Patient #3's medical record revealed that restraint orders were written (renewed) daily through 8/15/18 by a LIP other than the attending physician. No documentation was available for review supporting that the attending physician was aware that restraint orders were written for Patient #3 for dates 8/10/18 through 8/15/18. The restraint order in the electronic medical record (EMR) included the following notation: "if restraint is ordered by a LIP other than attending, the LIP shall consult the attending as soon as possible. The LIP shall document the restraint use within 24 hours of application by using restraintattendingnote...".

At 2:05 p.m. on 8/14/18, Staff Member (SM) #1, the record navigator assisting the surveyor, stated "I don't see a note related to restraint-there's a daily progress note, but it does not address restraint use".

At 2:50 p.m. on 8/14/18 SM #8 assisted the surveyor in trying to locate notification of the attending physician of restraint orders, and stated "There is a note physicians are supposed to use when restraints are put on. I don't see a note for the day it started, I don't see anything in their notes about restraints. The LIP isn't documenting; it's not there, I agree. By oral rounds I know they discuss it, but there is no written documentation".

A discussion was held with SM's #1 and 8 as noted above, and on 8/16/18 between 12:30 p.m. and 1:00 p.m. with members of administration during the exit conference.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on interview and document review in the course of a complaint investigation, it was determined the facility failed to have a registered nurse adequately supervise and evaluate the nursing care for each patient by allowing a patient to leave the facility after discharge with a saline lock still in-place for one (1) out of (20) patient discharges reviewed (Patient #5).

The findings include:

Surveyors conducted a complaint investigation alleging the facility failed to remove a saline lock from Patient #5's arm prior to discharge.

On August 15, 2018 at 2:54 p.m., surveyors reviewed the electronic medical record for Patient #5 with Staff Member #8. Per the medical record, Patient #5 required transport to the hospital by EMS for worsening shortness of breath on March 25, 2018. The facility diagnosed the patient with "Acute on chronic hypoxic respiratory failure due to PE" and the facility placed an IVC filter during the inpatient stay. The facility discharged the patient home on March 31, 2018 with follow-up appointments set. Staff Member #8 stated the medical record documented the date and time of placement of the saline lock but the medical record did not indicate the removal of the saline lock. Surveyors asked if there is any other location where documentation may exist regarding the removal of the saline lock and Staff Member #8 advised there is none.

On August 15, 2018 at 10:20 a.m., surveyors spoke to Staff Member #23 regarding the allegation and the facility's investigation into the event. Staff Member #23 advised it is "standard procedure" to conduct a final review of the patient prior to discharge to ensure "all items are d/c'd." Staff Member #23 advised the "patient care flow sheet would show d/c date and time [of the saline lock]" but Staff Member #23 advised the medical record did not contain an entry for the removal of the saline lock.

A review of the facility's policy and procedure titled, "Discharge to home-family" states in part:

"IV Access & ID Band -- remove saline lock and any other lines that will not be needed after d/c..."
VIOLATION: BLOOD TRANSFUSIONS AND IV MEDICATIONS Tag No: A0409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review, staff interview and facility document review, it was determined the facility staff failed to ensure the policy and procedure for the administration of blood and blood products was followed.

Patients #10 and #11 had orders for the transfusion of blood products. The facility staff failed the ensure vital signs were taken per the facility policy within 15 minutes after the transfusion was started.

The findings included:

Patient #10 was admitted on [DATE] with diagnosis that included but was not limited to: Right Femur Fracture.

Patient # 11 was admitted on [DATE] with diagnoses that included, but were not limited to: End Stage Renal Disease and asthma.

Patient #10 received a blood transfusion per physicians orders on 7/18/18. A review of the clinical record with Staff Member #2 (registered nurse, navigator) on 8/15/18 revealed the "flowsheet" documentation of the transfusion of the blood products with vital signs taken at the initiation of the transfusion at 3:37 a.m. There was no documentation of vital signs taken again until 4:10 a.m., 30 minutes later.

Patient #11 received a blood transfusion during hemodialysis treatment on 8/1/18 beginning at 12:30 p.m. Vital signs were documented at 12:30 p.m. at the initiation of the transfusion, but were not documented again until 1:00 p.m., 30 minutes later.

During the review of the clinical records with Staff Member #2 no vital signs for Patient #10 or #11 could be found documenting 15 minutes after the transfusions were initiated. Patient #11 received the transfusion during a hemodialysis treatment according the the clinical record. The surveyor inquired as to whether the dialysis staff followed the facility policy regarding blood transfusion or whether there was a different policy for patients receiving blood during hemodialysis treatment and whether there was further information for either Patient #10 or #11.

On 8/16/18 Staff Member # 16 stated, "There was no other information that we could find...dialysis nurses follow the same blood administration policy and procedure."

Review of the facility policy and Procedure "Blood Utilization and Administration" was reviewed and revealed the following: "...15. Check vital signs 15 minutes after the start of the infusion and record in EMR (Electronic Medical Record) Blood Administration Doc Flowsheet..."