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.

CJW MEDICAL CENTER 7101 JAHNKE ROAD RICHMOND, VA 23235 Aug. 23, 2019
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on interviews and review of documents, it was determined hospital staff failed to administer drugs in accordance with the orders of the practitioner for two (2) of four (4) patients included in the sample with orders for alcohol detoxification. (Patient #11 and Patient #14)

The findings include:

Patient #11 was admitted to the hospital's detox unit on 04/09/19 with assessment to include acute depression and alcohol detoxification. Patient #11's electronic health record (EHR) was reviewed on 8/21/19 with the assistance of Staff Member (SM) #11 a navigator provided by the hospital.

An order was placed on 4/8/19 at 12:20 PM for CIWA-Ar (Clinical Institute Withdrawal Assessment from Alcohol) monitoring. The order reads as follows: "CIWA, Monitor QID and with every PRN med dose". The hospital's QID (four times daily) administration times are 9:00 AM, 1:00 PM, 5:00 PM and 9:00 PM. A review of the EHR for Patient #11 revealed CIWA-Ar scores documented on 4/8/19 at 12:08 PM , at 13:42 PM and at 19:02 PM. and CIWA-Ar scores documented on 4/9/19 at 10:00 AM. Nursing documentation on 4/9/19 at 14:36 PM reads in part as follows: "Pt reports good sleep, good appetite. Denies all s/sx withdrawal". At 14:58 nursing documentation reads: "Pt received 10 mg IM Geodon at 11:23 for agitation. Attempted to leave unit at approximately 1145 - Code Atlas called. Pt received 2mg po Ativan at noon." (directly conflicting with the documentation at 14:36). Documentation by nursing from 3:02 thru 3:17 PM details Patient #11 becoming increasingly agitated and confused which required notification of the physician. An emergency medical treatment order was obtained and Patient #11 was transferred to a medical unit at 5:44 PM.

Patient #14 was admitted to the hospital's detox unit on 04/23/19 with assessment to include alcohol dependency and withdrawal and hypertension. Patient #14's electronic health record (EHR) was reviewed on 8/21/19 with the assistance of Staff Member (SM) #11 a navigator provided by the hospital.

An order was placed on 4/23/19 at 9:58 AM for CIWA-Ar (Clinical Institute Withdrawal Assessment from Alcohol) monitoring. The order reads as follows: "CIWA, Monitor QID and with every PRN med dose". The hospital's QID (four times daily) administration times are 9:00 AM, 1:00 PM, 5:00 PM and 9:00 PM. A review of the EHR for Patient #14 revealed CIWA-Ar scores documented on 4/23/19 at 8:32 AM , at 10:13 PM and CIWA-Ar scores documented on 4/24/19 at 11:00 AM. Nursing documentation on 4/24/19 at 5:18 AM reads in part as follows: "At approximately 0500, PT reported seeing people in his room that were not there and was talking to people that were not there. BP, Temp and RR stable. Pt's HR elevated at 118. Called (physician) to report changes including hx of seizures and DT's. New orders given will continue to monitor patient." A PRN medication was given at 5:17 AM. The EHR failed to provide evidence of a completed CIWA-Ar assessment related to the administration of the PRN medication. Physician documentation on 4/24/19 reads in part as follows: "pt medical condition deteriorated since admission - has tachycardia, patellar fx not displaced and sig alcohol withdrawal with DTs, after discussion with medical team - plan to transfer pt to medical telemetry for evaluation and tx. ct alcohol detox per protocol."

Staff Member #12 (RN Charge Nurse) was interviewed on 8/21/19 related to the above concerns. After review of the EHR with SM #12, he/she agreed that it looked like the CIWA protocol was not followed. He/she stated that it appeared the nurse may have documented on the patients but failed to document completion of CIWA assessments.

EHR review for Patient #11 and #14 found both records contained orders for PRN medications but lacked the guidance for how nursing staff should use the CIWA-Ar score in determining the medication that should be given.

The surveyor asked to be provided with the education that nurses were given on the use of the CIWA-Ar protocol. The surveyor was provided with a printed presentation that contains a table which details the frequency of CIWA-Ar scoring based on the last score. For example if the last CIWA-Ar score was 5-10, the next assessment would be in four hours. The conflicts between education and orders resulted in nursing staff having vague guidelines at best.

A review of transfers out of the behavioral health units which included the alcohol abuse treatment unit, revealed fifty-five (55) transfers with seventeen (17)of those transfers having "complicated withdrawal" listed as the "signs and symptoms". The surveyor reviewed four (4) of seventeen (17) records and found nursing orders related to the CIWA-Ar protocol were not followed in two (2) of four (4) records reviewed.

The hospital staff's failure to monitor and record CIWA-Ar assessments and/or provide medications based on the CIWA-Ra assessment was discussed with Staff Member (SM) #11 during record review and with the management team prior to exit on 8/23/19. No further information was provided to the surveyor.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview, and document review, it was determined hospital staff failed to:

a) verify protection from airborne illness in negative pressure rooms, and;

b) provide a clean and sanitary environment in the behavioral health unit.

The findings are:

a) As part of reviewing infection control in the hospital, the surveyor reviewed the current list of patients who were on isolation precautions. Information provided to the surveyor on 8/22/19 detailed twenty-nine (29) patients were under isolation precautions. Patient #20 was noted to be on "Airborne" precautions. Patient #20 was admitted on [DATE] with severe sepsis secondary to pneumonia. The physician ordered a sputum culture to rule out tuberculosis and the patient was placed on airborne precautions. The surveyor asked to be provided the quality control testing for the isolation room of Patient #20 relating to air exchanges or negative pressure. On 8/22/19 at 3:20 PM, the surveyor discussed with Staff Member (SM) #18 the Infection Preventionist, how the process for monitoring the negative pressure rooms should work. He/she stated when a nurse documents that a patient is placed on airborne precautions, the nursing supervisor is notified and the engineering office receives notification via printer indicating quality control testing is required. The surveyor then reviewed the spooled reports (notification to the engineering office of any patient placed on airborne precautions) and learned a notification had not occurred since 7/3/19. The surveyor requested that a check be completed for any patient placed on airborne precautions and/or in the negative pressure rooms. (The hospital has 18 negative pressure rooms.) The surveyor was provided with documentation of negative pressure checks for C325-A (the only patient currently in a negative pressure room, Patient #20) that was conducted that day with no problems noted. SM #5, informed the surveyor that IT (information technology) had investigated to determine what may have caused the failure in the system and found the problem had occurred after a software upgrade that had failed to trigger the system to notify engineering of the admission of a patient to an isolation room.

A review of hospital policy "Tuberculosis Exposure Plan" last revised 1/2017 reads in part as follows: " IV, B . e. Negative pressure differentials and air exchanges should be verified annually to ensure that the isolation room air distribution system is properly functioning, The negative pressure should be monitored daily and recorded when in use." Hospital staff failed to provide evidence that the aforementioned practice is followed.

The issue was discussed with SM # 5, SM #18 and SM #9 upon discovery and discussed with the management team prior to exit on 8/23/19. No further information was provided to the surveyor.

b) During a tour of 2 North on 08/22/19, (unit for the most acutely ill behavioral health patients monitored every 5 minutes) the surveyor noted scraps of paper on the floor and what appeared to be debris or dust/dirt. Patient rooms do not have private bathrooms on this unit. Bathrooms are locked for safety, requiring the patients to request use of the bathroom. There was a room containing a toilet designated for males and a room with a toilet for females, both of the bathrooms were noted to have damp areas on the floors which may or may not have been urine. Spots were seen on both toilets that appeared to be from a liquid that had dried, the surveyor was unable to determine if the spots were from urine. There was a notable odor to the bathrooms. A room containing one shower was located along the same wall as the rooms for the toilets. The surveyor asked what the cleaning schedule was for the toilets and shower. The surveyor was informed the unit was cleaned daily by Environmental Services workers and room were always cleaned when a patient was discharged . A review of schedules for environmental service workers confirmed the units were scheduled for cleaning at least once a day. The surveyor was told the nurses "try" to clean the showers between patients. The surveyor was shown a spray bottle marked Oxivir with no concentration or instructions for use marked on the bottle. It was determined through interviews that nurses were not aware of what the "wet time" (time needed for the product to kill bacteria, fungi, etc.) was for the product.

The above findings were discussed with SM # 3, SM #5 and SM #9 upon discovery and with the management team prior to exit. No further information was provided to the surveyor.