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Based on document review and staff interviews, the hospital failed to:

a. take corrective actions, implement and monitor corrective actions to ensure compliance. See Tag A-0263; and

b. ensure the physical environment was arranged and maintained for patient safety. See Tag A-0700; and

c. ensure a sanitary environment and track infections. See Tag A-0747; and

d. comply with Centers for Medicare & Medicaid Services (CMS) Conditions of Participation. See Form CMS 2567 Statement of Deficiencies.

Based on committees meeting minutes review for the past year, Quality Assurance Performance Improvement (QAPI) Plan review, and staff interviews, the hospital failed to ensure all issues identified were analyzed, monitored, evaluated, solutions implemented, and maintain an effective, ongoing, hospital-wide QAPI program.

Findings:
1. On October 27, 2015 at 11:30 a.m., surveyors requested the hospital's current QAPI plan and meeting minutes for the last year. Several committee binders were provided. There was no documented evidence in the binders that all hospital issues identified were analyzed, monitored, evaluated, solutions implemented, and maintained.

~ Sanitation reports had documented violations (January 2015, May 2015, and August 2015)
~ Multiple employee exposures
~ Multiple medication errors
~ Lack of appropriate lighting for inspecting surgical equipment/instruments
~ Lack of appropriate space for processing, sterilizing, and storing surgical equipment and instruments
~ Problems with proper cleaning processes in the surgical department
~ Lack of appropriate storage in materials management
~ Disrepair of the facility throughout the hospital
~ Infection Control Practitioner not aware of all infection control issues throughout the hospital

2. The VP of Patient Care and the Director of Quality told surveyors that there was no documented evidence of analysis, evaluations, and solutions implemented by each department.

3. The VP of Patient Care provided surveyors with a document titled, "Quality Assessment/Performance Improvement Plan 2010-2011" and told surveyors that the hospital's QAPI plan had not been updated.

4. On October 28, 2015 at 3:50 p.m. the Vice President (VP) of Patient Care told surveyors that the hospital does not have a current QAPI plan but was working on a new QAPI plan. The VP of Patient Care told surveyors that the new QAPI plan had not gone to the Medical Staff and the Governing Board as the new QAPI plan was not complete.

5. On November 3, 2015 at 1:20 p.m. the Director of Quality told surveyors that the hospital does not have a current QAPI plan but a new QAPI plan was being created.

6. On November 3, 2015 2:30 p.m. the VP of Patient Care provided surveyors with a document titled, "Quality Assessment/Performance Improvement Plan 2015-2016" that had not gone to the Medical Staff and the Governing Board. The QAPI plan did not contain signatures.

Based on review of personnel files, medical record review, and staff interviews, the hospital failed to ensure that nursing personnel had the appropriate experience, competency, and specialized qualifications when providing nursing care. This occurred in four (Staff I, K, BB, and DD) of four personnel files reviewed.

Findings:
1. On November 3, 2015 at 11:30 a.m., surveyors reviewed Staff I, K, BB, and DD's personnel files. All four personnel files reviewed did not contain documented evidence that Staff I, K, BB, and DD were qualified to assess and perform physical status classification system (ASA score - which is a system for assessing patients before surgery) from the American Society of Anesthesiologists.
2. All four personnel files contained registered nursing licenses. All four personnel files did not contain documented evidence that assessing and performing physical status classification assessments (ASA scores) were in Staff I, K, BB, and DD scope of practice.
3. Physical Status Classification assessments (ASA scores) are not with in a Registered Nurse's scope of practice. The ASA score is assigned by physicians and anesthesia providers according to the American Society of Anesthesiologist (http://asahq.org/).

4. Two (#29 and #30) of two patient medical records reviewed contained documented evidence that registered nurses performed, assessed, and assigned patient's an ASA score. It is not within the registered nurse's scope of practice to assess and assign a patient an ASA score.

5. On November 3, 2015 at 3:00 p.m., surveyors asked the Vice President (VP) of Patient Care for documentation from the Medical Staff and Governing Board where registered nurses can perform, assess, and assign ASA scores. The VP of Patient Care told surveyors that only physicians and anesthesia providers assign ASA scores not registered nurses.

Based on observation and staff interviews, the hospital failed to ensure the hospital's physical environment was maintained for the safety and well being of patients.

Findings:
1. On October 27, 2015 at 11:25 a.m., surveyors toured the hospital facility with the Vice President (VP) of Patient Care and the Assistant Vice President of Patient Care (AVP).

The following observations were made:

Surgical Department
~ Active ongoing construction in the surgery department without an infection control risk assessment
~ Excessive amounts of metal racks throughout the surgical department that contained sterilized equipment/instruments that blocked access and egress to corridors, fire extinguishers, and exits of the surgical department
~ Excessive amounts of metal racks that contained sterilized equipment/instruments stored directly in front of all scrub sinks
~ Plastic sheet with duct tape applied to walls and floor in an attempt to seal the plastic sheet
~ Plastic sheet with different taped areas of the plastic sheet appearing to seal penetrations
~ Large equipment used in the OR was/is stored near the plastic barrier
~ Two full size non-vented steam sterilizers in the restricted area next to the scrub sinks used for routine surgical equipment processing
~ Four trash receptacles larger than 32 gallons placed in the restricted areas uncovered
~ Operable water faucet in restricted area with visible corrosion
~ A non-vented steam sterilizer enclosed in a restricted hallway with excessive amounts of processed sterile instruments crammed into bins
~ Full office set up with fabric furniture in restricted area
~ Office furniture with office supplies in restricted area and perfusion equipment
~ A registered nurse (Staff DD) came out of OR 4 with gloves on, touched several racks that contained sterilized equipment/instruments, walked to the opposite end of the surgical department touching more sterile equipment/supplies, discarded his gloves in a room that was terminally cleaned and did not perform hand hygiene.
~ Cork boards throughout the surgical department that could not be terminally cleaned
~ Papers and office supplies throughout the surgical department that could not be terminally cleaned
~Wall paper in the semi-restricted area that could not be terminally cleaned
~ Unsealed wood doors on all five operating rooms (OR) that were splintered (unsealed splintered wood cannot be terminally cleaned)
~ Office chairs were used in all five ORs (these chairs had decorative stitching) could not be terminal cleaned
~ Kleenex boxes with Kleenex were in all five ORs
~ Equipment covered with fabric covers that could not be terminally cleaned
~ Dirty laryngoscope blades left in OR room(s) after Staff K told surveyors that the OR room(s) were terminally cleaned
~ Cords (used to charge battery operated equipment) were hung over the biohazard sharps containers
~ Surgical instruments not contained in package/wrapper left in cabinet(s) in ORs where other surgical equipment and supplies are kept
~ Multiple bottles of isopropyl alcohol (flammable) stored in the ORs
~ Multiple cans of (Silkospray) flammable aerosolized chemicals stored in ORs
~ Two cans of flammable (Benzoin) aerosolized chemicals stored in ORs
~ Multiple bottles of enzymatic cleaner stored in all five ORs
~ Rusty metal clip hanging off gas hoses in OR room 1
~ Single use oxygen extension tubing used for multiple patients (left on anesthesia machines after terminal clean was performed)
~ Eye flush station in OR did not have eye flush solution

Decontamination Room
~ No hand washing sink in the decontamination room
~ Divot of floor surface material missing in decontamination processing room

Central Sterile
~ Full office set up in central sterile
~ Assorted housekeeping supplies stored next to sterilized items
~ An uncovered trash receptacle larger than 32 gallons was placed in the middle of central sterile
~ No area to don PPE in central sterile
~ Before entering central sterile surveyors donned PPE in a public hallway with heavy foot traffic directly across from the kitchen which the kitchen door was always open
~ Excessive amounts of processed sterile supplies crammed into metal corroded sink
~ Excessive amounts of processed sterile supplies crammed into bins, shelves, metal rolling racks, and below the counter top of the corroded sink
~ Multiple metal racks crammed in central sterile processing exceeding room space making it very difficult to move throughout the area
~ Metal wall framing exposed in central sterile processing department
~ Sterile supplies stored next to wall in dis-repair

Out-Patient Pre-Op/Post-Op Unit
~ A clear container with unidentified clear fluid on a housekeeping cart across from the cardiac catheter lab
~ A bucket with unidentified clear solution and particles at the bottom of the bucket used for cleaning patient beds

Kitchen/Dietary Services
~ Kitchen door propped open with a door stop to a main public hallway
~ Kitchen personnel/dietary service workers handling food/making patient food trays without hairnets/hair restraints

Clean Linen Storage Room
~ Spray chemicals (Febreeze) stored next to clean linens
~ Office supplies (pads of paper, pens, and pencils) next to clean linens uncovered
~ Corrugated boxes that were unloaded off of delivery trucks stored in clean linen room
~ Oscillating fan running moving air with clean linens uncovered

Storage Room across hallway from Materials Management
~ Dust and dirt on floor
~ Equipment used in the operating room (machines that are used in open heart surgery cases, Medtronic machinery that interrogated pacemakers, implantable devices used in orthopedic cases)
~ Multiple corrugated boxes that contained paper forms
~Two large bottles of laser cleaning fluid

In-Patient Rehabilitation Unit
~ Electrocardiogram (ECG) machines (Life saving equipment that performs electrical tracing of heart function) covered with peeling tape and signs
~ Staff NN transporting patient in a wheel chair with gloves worn from inside shower room

All findings were acknowledged by the VP of Patient Care and the AVP of Patient Care during the hospital tour.

2. The VP of Patient Care and the AVP of Patient Care told surveyors that the hospital does not have enough storage space and the hospital is doing the best they can working with the lack of space to store sterile equipment and supplies.

Based on infection control meeting minutes review, infection control policies and procedures review, staff interview and observation, the hospital failed to:

a. maintain a sanitary environment in all areas of the hospital;

b. maintain an ongoing active infection control program designed for the prevention, control, and investigations of all infections and communicable diseases; (see tag 0749)

Findings:

~ On October 27, 2015 at 11:25 a.m., started to tour the hospital with administrative staff.

~ On October 27, 2015 at 11:40 a.m., surveyors observed staff NN on the Rehab unit wheeled a patient from the shower room to the patient's room with gloves on. Staff NN did not perform hand hygiene before leaving the shower room and did not perform hand hygiene after leaving the shower room.

~ On October 27, 2015 at 12:10 p.m., surveyors toured the outpatient pre-operative/post operataive area of the hospital. Surveyors observed a small staff locker room in this area. Surveyors observed many patient snacks stored in the staff locker room. Surveyors observed a small desk in the staff locker room with a plate of uncovered food staff members had been eating.

~ On October 27, 2015 at 12:25 p.m., Surveyors observed staff I in surgical attire with a mesh head cover on. Staff A told surveyors that staff I was wearing the appropriate Operating Room attire for the sterile heart catherterization lab. Staff I did not have all of her hair in the mesh cap.

A policy titled, "Attire for Surgical Services," documented, "...Personnel entering the semi-restricted and restricted areas should cover the head, hair, ears, and facial hair..."
The policy defines the restricted areas as all Operating Rooms, the Cardiovascular lab and sterile corridors.

~ Surveyors observed Endoscopic procedure room #1. A patient had just been moved from the Endoscopic procedure room to the post-operative recovery area. Surveyors observed many paper items in the Endoscopic procedure room. Paper items can't be terminally cleaned. Surveyors observed oxygen extension tubing connected to the oxygen set up. Staff K told surveyors that the extenstion tubing is used for multiple patients.

~ Surveyors observed in Endoscopic procedure room #1 a suction canister that had come off the wall and was secured with silk tape. Silk tape can not be terminally cleaned. Staff M told surveyors the suction canister had just broke from the wall that day.

~ On October 27, 2015 at 12:40 p.m., surveyors observed the kitchen. Surveyors observed the kitchen door was propped open with a door stop to a main public hallway. Surveyors observed dietary personnel handling food for patient trays. The dietary personnel did not wear hairnets.

~ On October 27, 2015 at 12:50 p.m., surveyors observed a room that housed clean linen. The clean linen room housed covered and uncovered clean linen. There were spray chemicals stored next to uncovered clean linens. There were office supplies (paper, pens and pencils) next to uncovered clean linens. There were corrugated boxes that came off of delivery trucks stored next to uncovered clean linens.

~ On October 27, 2015 at 3:00 p.m., surveyors toured the Intensive Care Unit (ICU) Surveyors observed a nutrition room in the ICU where staff and patient food was stored. Surveyors observed 2 fly swatters hanging on the wall in the nutrition room. Surveyors observed an ice machine with rust on the grates. Staff A told surveyors the ice machine is used for patient ice.

~ On October 27, 2015 at 5:00 p.m., surveyors toured the Operating Room (OR) department.

~ Surveyors observed corkboard on the wall in the semi-restricted area of the OR, corkboard can not be terminally cleaned.

~ Surveyors observed a room in the semi-restricted area of the OR. Staff K told surveyors the room was a holding room for pediataric patients. The holding room had wall paper on the walls. Wall paper can not be terminally cleaned.

~ Surveyors observed a second room in the semi-restricted area of the OR. Staff K told surveyors that room was a holding room for the adult patients. The surveyors observed fabric curtains in the holding room. Fabric curtains can't be terminally cleaned. Staff K told surveyors she did not know when the curtains were cleaned or changed.

~ Surveyors observed OR #1. OR #1 contained an office chair that had stitching on the seats. Office furniture with visible stitching can not be terminally cleaned. Staff K told surveyors all 5 OR's had the same office chair for use by the anesthesia providers.

~ Surveyors observed OR #1 had office supplies such as paper, and paper clips on the anesthesia machine. Office supplies can't be terminally cleaned.

~ Suveyors observed a back table in OR #1 that is used during a procedure for surgical supplies. The back table appeared dirty with hand prints. Staff K told surveyors that OR #1 had already been terminally cleaned.

~ Surveyors observed 5 OR's with wooden doors. All wooden doors were splintered. Splintered wood can't be terminally cleaned.

~ Surveyors observed OR #2. OR #2 contained a hand held doppler ultrasound equipment stored in a fabric bag. Fabric can't be terminally cleaned.

~ Surveyors observed multiple pieces of surgical equipment in OR #2 with fabric covers. Staff K told surveyors the equipment remains in OR #2. Fabric can't be terminally cleaned.

~ Surveyors observed paper clips and paper on the anesthesia machine in OR #2. Office supplies can't be terminally cleaned.

~ Surveyors observed an excessive amount of metal racks that contained sterilized instruments stored next to scrub sinks. Storing equipment next to scrub sinks can cause equipment to get splashed which can not maintain the integrity of the equipment.

~ Surveyors observed kleenex boxes with kleenex througout the OR department. Kleenex can't be terminally cleaned.

~ All OR's contained computers and keyboards. The keyboards were not covered. Surveyors observed dust in between the keys of the keyboards.

~ Surveyors observed OR #3. Staff K told surveyors OR #3 was the cardiovascular room where open heart surgeries were performed. Surveyors observed chipped paint on the wall in OR #3. Chipped paint can't be terminally cleaned.

~ Surveyors observed a basket in OR #3 that was labled for "dirty" laryngoscope blades. Surveyors observed 2 laryngoscope blades left in the basket. Staff K told surveyors OR #3 had been terminally cleaned.

~ Surveyors observed paper clips and paper on the anesthesia maching in OR #3. Office supplies can't be terminally cleaned.

~ Surveyors observed a room in the restricted area that was used as the storage room for perfusion supplies. There was an office set up in the perfusion room. Office supplies can't be terminally cleaned.

~ Surveyors observed a room in the restricted area that had a full office set up in it with fabric furniture, coffee, food, and a microwave. Office supplies can't be terminally cleaned.

~ Surveyors observed an operable water fountain in the restricted area of the OR. The water fountain was visibly corroded.

~ Surveyors observed a small room in the restricted area where intravenous fluids were stored. There was a vent in the ceiling that was covered in dust.

~ Surveyors observed multiple packed sterile instruments crammed into bins. The packages were crinkled which can compromise the integrity of the package.

~ Surveyors observed a registered nurse (staff DD) walk out of OR #4 where a surgical procedure was in place. Staff DD had on gloves, touched several racks that contained sterilized instruments/equipment, walked to the opposite end of the surgical department, touched more sterilized supplies, and discarded his gloves in a room that was already terminally cleaned. Staff DD did not perform hand hygiene.

~ Surveyors observed surgical scissors and hemostats stored closed in sterilized packages. Insturments processed closed can't ensure the entire instument is sterilized.

~ Surveyors observed the decontamination room. There was no place for handwashing in the decontamination room. The decontamination room contained a divot of floor surface material missing.

~ Surveyors observed central sterile. There was a full office set up in central sterile, with paper, office supplies, books and personal items. These itemes can't be terminally cleaned.

~ Surveyors observed assorted housekeeping supplies stored next to sterilized supplies in central sterile.

~ There was no area to don Personal Protective Equipment (PPE) in central sterile. Before entering central sterile the surveyors donned PPE in a public hallway with heavy foot traffic directly across from the kitchen where the door was open.

~ Surveyors observed excessive amounts of sterile supplies crammed into a metal corroded sink.

~ Surveyors observed metal wall framing exposed in the central sterile processing department. A wall in disrepair can't be terminally cleaned.

~ Surveyors observed a locker room in a hallway that contained two janitor carts with all housekeeping supplies.

~ On October 28, 2015 at 12:20 p.m., Staff V told surveyors the OR staff do the terminal clean of the OR. Staff V told surveyors the semi-restricted hallway walls were not terminally cleaned. Staff V told surveyors the holding rooms in the semi-restricted area were terminally cleaned on a weekly basis.

~ Staff V told surveyors that a new enzymatic cleaner was recently added. Staff V told surveyors the infection control practitioner did not participate in the decision of what enzymatic cleaner would be used.

~ On the afternoon of October 29, 2015, surveyors requested a "basic" sterile pack from the OR director. The OR director brought the surveyors a "plastics" sterile pack. The pack contained indicators that it had been ran through the sterilizer. Surveyors opened the sterile pack. Surveyors observed an unidentified pink substance on 2 of the sterile instruments. The OR director was able to scrape the substance off with her fingernails and told surveyors she could not definitively say that the instruments were clean and sterilized.

Based on infection control surveillance review, infection control meeting minutes review, and staff interview, the infection control officer failed to maintain an active ongoing system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.

Findings:

1. On October 27, 2015 at 10:45 a.m. surveyors requested all infection control surveillance activities, infection control policies and procedures, and infection control meeting minutes.

2. On October 27, 2015 at 11:20 a.m. staff A told surveyors staff G was the infection control practitioner.

3. On October 27, 2015 at 11:25 a.m., surveyors toured the hospital. On the afternoon of October 27, 2015 surveyors observed construction being done in the semi-restricted area of the Operating Room Department. Surveyors observed a large plastic sheet taped to the ceilings and the floors in the semi- restricted area. Staff A told surveyors the sheet was a barrier and the facility was adding a wall and a door in the semi-restricted area. Staff A told surveyors that surgical procedures were still being done during the time of construction. Surveyors requested an Infection Control Risk Assessment (ICRA) for the construction project. No ICRA was provided.

4. On October 28, 2015 at 10:55 a.m., surveyors reviewed the infection control and safety committee meeting minutes. The meeting minutes contained no documentation of investigation and evaluation of employee illnesses. The meeting minutes contained no documentation of investigation and evaluation of surgical site infections. The meeting minutes contained percentages of compliance with hand hygiene but no documentation of what staff were monitored and no documentation of what was done when hand hygiene fell out of compliance. The meeting minutes contained documentation of hospital acquired conditions but only contained numbers and percentages. There was no documentation of an investigation or evaluation done on the hospital acquired conditions.

A policy titled, "Infection Control Surveillance Policy," documented, "...The ICO [infection control officer] will track and trend occurrences of infection or clusters of hospital acquired infections and report to the IC and safety committee..." There was no documentation in the infection control and safety committee meeting minutes of any tracking and trending.

5. On October 28, 2015 at 11:25 a.m., surveyors requested a current Tuberculosis (TB) Risk Assessment for the facility. A TB risk assessment dated for 2013 was provided. There was no current TB risk assessment provided.

6. On October 28, 2015 at 12:00 p.m., surveyors reviewed the employee illness log. The log did not contain any evidence that employee illnesses were evaluated and analyzed for commonalities. Surveyors observed on the employee illness log for August 2015 there were 2 employees who called out sick for work within 6 days of each other, both employees had nausea, vomiting, and diarrhea. There was no documentation of investigation of the employee illnesses. Surveyors observed on the employee illness log for September 2015 there were 2 employees who called out sick for work on the same day, both employees had nausea, vomiting, and diarrhea. There was no documentation of investigation of the employee illnesses.

7. On October 28, 2015 at 3:15 p.m., Staff A told surveyors that an Infection Control Risk Assessment was not done for the current construction project done in the semi-restricted area of the Operating Room Department.

8. On October 28, 2015 at 4:20 p.m., Staff G told surveyors that she did not track and trend every surgical site infections. Staff G told surveyors that she only tracked the Center for Medicare/Medicaid Services (CMS) mandated hospital acquired infections.

Surveyors reviewed the Emergency Department (ED) log for 3 months. Surveyors observed 8 ED patients ( #8, 9, 10, 11, 12, 13, 14, 15, & #18) who presented to the ED with a chief complaint of "post op infection" Staff G told surveyors that she was not aware of all 8 ED patients and would only know about patients who presented to the ED with a complaint of "post op infection" that was either admitted to the hospital or who had cultures or lab work drawn. Staff G told surveyors that if a patient presented to the ED with a complaint of "post op infection" and was put on oral antibiotics and sent home she would not know about that patient.

Staff G told surveyors if a patient presented to their personal physician for a post operative infection she would only know about that patient if they were admitted to the hospital or lab work and cultures were drawn.

Based on infection control meeting minutes review, Quality Assessment Performance Improvement Plan(QAPI) review and staff interview, the hospital failed to ensure the infection control program was incorporated into the QAPI program with problems identified, evaluated and corrective actions taken.

Findings:

1. On October 27, 2015 at 11:30 a.m., surveyors requested the infection control meeting minutes and the current QAPI plan.

2. A binder labled "Infection Control and Safety Committe Meeting Minutes" was provided. The meeting minutes did not contain documentation of problems identified being analyzed with corrective actions taken.

3. The VP of Patient Care provided surveyors with a document titled, "Quality Assessment/Performance Improvement Plan 2010-2011" and told surveyors that the hospital's QAPI plan had not been updated.

4. On October 28, 2015 at 3:50 p.m. the Vice President (VP) of Patient Care told surveyors that the hospital does not have a current QAPI plan but was working on a new QAPI plan. The VP of Patient Care told surveyors that the new QAPI plan had not gone to the Medical Staff and the Governing Board as the new QAPI plan was not complete.

7. On November 3, 2015 2:30 p.m. the VP of Patient Care provided surveyors with a document titled, "Quality Assessment/Performance Improvement Plan 2015-2016" that had not gone to the Medical Staff and the Governing Board. The QAPI plan did not contain signatures.

Based on Operating Room Policies and Procedures review, staff interview and observation the hospital failed to have an alcohol based skin preparation storage and use policy and procedure.

Findings:

1. On October 27, 2015 at 5:00 p.m., surveyors toured the Operating Room (OR) department.

2. Surveyors observed multiple 16 fluid ounce bottles of isopropyl alcohol (flammable) stored in the OR's. Staff E told surveyors that single use alcohol is more expensive than the large bottles.

3. On October 28, 2015 at 12:00 p.m., Staff V told surveyors that alcohol is not used as a prep but there were 2 surgeons who used it as a pre-clean. Staff V told surveyors that alcohol was used on the patient and then the patient was prepped with whatever prep solution the surgeons preferred.

4. On October 28, 2015 at 10:28 a.m., surveyors reviewed a policy titled "Fire Plan for Surgical Services." The policy did not contain procedure for use of alcohol as a pre-clean and did not contain procedure for alcohol storage.

5. On October 28, 2015 at 12:30 p.m., surveyors requested a policy on alcohol used as a pre-clean or prep and storage of alcohol. The same policy titled, "Fire Plan for Surgical Services" was provided. Staff A told surveyors there was no other policy.

Based on Emergency Department (ED) policy and procedure review, observation, personnel file review, and staff interviews, the hospital failed to ensure emergency services personnel requirements were met.

Findings:
1. On October 27, 2015 at 2:25 p.m., surveyors toured and observed the emergency department (ED) waiting area and ED with the Vice President (VP) of Patient Care.

2. Surveyors observed Staff AAA triaging patients. Staff AAA was an ED registrar. ED registrar personnel are not clinical.

3. Surveyors asked Staff AAA to explain the process of when a patient presents into the ED. Staff AAA told surveyors, she asked each patient what they need to be seen for. Staff AAA told surveyors based on what the patient's complaint was (such as chest pain or if the patient was having trouble breathing) or if the patient looked real bad she would make the decision to either register the patient then tell the nurse or just tell the nurse.

4. Surveyors asked the VP of Patient Care if ED Registration was allowed to triage patients that presented to the hospital's ED. The VP of Patient Care told surveyors that the Triage Nurse (a registered nurse) was to triage all patients presenting to the hospital's ED.

5. On October 27, 2015 at 2:35 p.m., surveyors requested the hospital's ED Triage policy and procedure. The VP of Patient Care provided a document titled, "Patient Assessment and Triage" that documented, "...The Triage RN will obtain an immediate, brief evaluation of the patient and determine the general nature of the problem..."

6. On November 3, 2015 at 11:30 a.m., surveyors reviewed Staff AAA personnel file. Staff AAA was not qualified and was not trained to triage ED patients. Staff AAA's job description did not contain documented evidence of triaging ED patients as part of Staff AAA's job.