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 ST MARYS HOSPITAL 5801 BREMO RD RICHMOND, VA 23226 Dec. 10, 2019
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on document review and interview, it was determined the facility staff failed to administer two (2) anti-seizure medications as ordered by the practitioner for one (1) out of four (4) patients.

The findings include:

On 11/26/19 at 12:25 PM, the surveyor interviewed Staff Member #9 and Staff Member #10. The Staff Members provided an ED nurse and patient schedule for 09/16/19 and 09/17/19. The staffing schedule confirms both Staff Member #11 and Staff Member #13 were primary nurses for Patient #1 throughout day of 09/16/19.

The surveyor reviewed the medical record of Patient #1 on 11/26/19 at 2:45 PM and uncovered the following:

While Patient #1 was in the ED, the Medication Administration Record (MAR) revealed Lorazepam/Ativan injection 1 mg medication was ordered for 09/16/19 at 11:30 AM and discontinued by Staff Member #13 (ED nurse) at 09/16/19 at 11:35 AM. Additionally, Vimpat/Lacosamide 100 mg was ordered and scheduled during Staff Member #11's shift (ED nurse) for 09/16/19 at 1600 in ED but was never given, without reason. Both medications were ordered and scheduled prior to transfer of Patient #1 to Neurology Unit on 09/17/19.

During a surveyor interview on 12/09/19 at 2:00 PM, Staff Member #11 advised, the scheduled Vimpat/Lacosamide dose at 4:00 PM was never administered to Patient #1 related to being unavailable from the pharmacy.

During a surveyor interview on 12/09/19 at 11:05 AM, Staff Member #12 (pharmacy technician) advised the pharmacy technician involved is no longer a current employee of the facility but that there "was an attempt to deliver medication to [ED] but no employee was available to sign for controlled medication." Staff Member #12 confirms there is no facility policy directly relating to procedure for obtaining nurse sign-off for controlled medications but admits that repeated attempts for delivery with documentation "should have been done".

Under "Dispensing controlled substances to nurse ..." section, facility policy and procedure title, "Controlled Substances" (with last revision date of 01/2019) reads, "The nurse receiving the medication [from pharmacy] must sign the delivery record". Same policy continues, "If the medication is unused or the order is discontinued ...[the] remaining patient specific or IV solutions will be wasted and documented on the administration record".
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on document review and interview, it was determined the facility staff failed to notify a patient's representative of a decline health status so that the representative could make an informed division about care for one (1) of five (5) patients.

The findings include:

A Surveyor review of the medical record for Patient #1 with Staff Member #8 on December 9, 2019 revealed Patient #1 was transferred to ICU from Neurology on October 4, 2019.

A progress note written by Staff Member #14 (Neurologist) on 09/17/19 at 11:25 am reads, "[Patient #1] is actually in a worse state that [Patient #1] was when [Patient #1] presented. [Patient #1] is altered and confused. [Patient #1] is not following commands." Under "Assessment Plan" of same progress note, continues, "[Patient #1] maintenance medication was not initiated last night. [Patient #1] has been without medication now for over 12 hours ...Transfer to ICU."

A progress note written by Staff Member #15 (nurse) on 09/17/19 at 6:45 pm reads, "Notified [Staff Member #14 (Neurologist)] that EEG tech reported that EEG was showing active Seizures on left side migrating to right side. New orders were placed and Neuro NP notified. Orders received to transfer to ICU bed 20." Aforementioned progress notes written by Staff Member #14 and Staff Member #15 reveal Patient #1 was transferred to ICU for worsening of health condition.

A surveyor review of the progress notes of Patient #1 with the assistance of Staff Member #8 did not locate documentation of the patient's representative being notified of Patient #1's change in health status.

During an interview on 12/09/19 at 11:00 am, Staff Member #6 confirmed the facility does not have a policy or procedure mandating facility staff to notify family member or next of kin for patient deconditioning or worsening health status.
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on document review and interview, it was determined facility staff failed to:

ensure one (1) staff member completed a yearly fit testing for the N-95 mask, and;

ensure daily airflow checks were performed by engineering staff for airborne isolation rooms.

The findings include:

During an interview on 11/19/2019 at 1:34 pm with a representative from Employee Wellness, the surveyor learned that Staff Member #3 was not in compliance with N-95 and PAPR airborne fitting requirements for greater than a year duration. Additionally, Employee Wellness stated they contacted Staff Member #3 and management regarding the need for fit testing "on several occasions" but that Staff Member #3 remained not up-to-date in fitting.

A surveyor review of patient and staff records confirm that Staff Member #3 was caring for Patient #4 who had active airborne isolation precaution orders, as well patient #3 who had active orders for neutropenic precautions related to immunocompromised condition on Wednesday, 11/13/2019.

Additionally, facility policy titled, " Respiratory Protection for Airborne Precautions " (with last revision date of 02/2017) reads, " Respiratory fit testing, for use of the N 95 respirator device, and training on use of the PAPR, will be contacted by Employee Wellness on an annual basis in accordance with OSHA. Employees working in the direct care capacity with high-risk patients for contagious respiratory illnesses are required to complete this testing and education annually. Employees who do not complete the testing on the specified duty, as directed by employee wellness, we consider noncompliant or not be eligible to work until they remediate this requirement. It is the responsibility of the supervisor to monitor compliance with the respective direct reports. "

The surveyor also requested daily airflow monitoring logs from engineering for rooms designated as airborne precautions. The surveyor was informed by Staff Member #6 that engineering has been performing airflow monitoring monthly and not daily. A review of engineering monitoring airflow logs confirmed only three (3) separate checks (occurring on 9/21/19, 10/13/19, and 11/17/19) for the past three (3) months on unit.

A review of facility policy titled, "Standard and Transmission-Based Precautions" (with last revision date of 9/2019), reads, "Daily airflow monitoring will be performed in documenting by engineering to ensure the system is operating properly when the room is being used for airborne isolation...Monitoring logs will be maintained on file and engineering."