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Based on observation, record review, and interview, the facility failed to ensure written, signed orders for medications administered in the Emergency Department (ED), failed to follow facility policy for documentation requirements for patients leaving the ED Against Medical Advice (AMA), failed to obtain a written order for restraint use, failed to follow facility policy on error correction and reassessment of patients.

Findings include:

Facility failed to ensure written, signed orders for medications administered in the ED in 11 of a total sample of 11 patients who received medications in the ED. See Tag C-0297

Facility failed to obtain signature, or document inability to obtain signature, on the facility AMA form on 2 of a total sample of 2 patients who left the ED AMA. See Tag 0271

Facility failed to ensure a written, signed order was obtained for use of restraints for behavioral use in 1 of a total sample of 1 patient where restraints were used in the ED. See Tag 0271

Facility failed to ensure proper error correction on a Procedural Consent in 1 of a total sample of 1 consents reviewed. See Tag 0271

Facility failed to reassess patient's condition at discharge in 1 of a total sample of 22 medical records reviewed and failed to write a note at discharge in 1 of a total sample of 22 medical records reviewed. See Tag 0271.

The cumulative effect of these issues has prevented the critical access hospital from providing services in the Emergency Department in a safe and effective manner.

Based on interview and medical record review the facility failed to follow facility policy for restraint orders in 1 (Pt. #20) of 1 patients in restraints in a total sample of 22 records reviewed , failed to follow facility policy for patients leaving against medical advice (AMA) for 2 (Pts #9 and #10) patients who left AMA in a total sample of 22 records reviewed, failed to follow facility policy for error correction in 1 (Pt. #7) in a total sample of 22 records reviewed, and failed to follow facility policy for discharge of Emergency Room (ED) patients in 2 patients (Pts # 13 and #17) in a total sample of 22 records reviewed.

Findings:

Medical record review of Patient #20 on 9/9/2019 at 2:30PM revealed an admission date to the ED on 8/12/2019 at 8:05PM for an overdose of unknown substance. Nurses notes at 8:10PM document "ED Physician I here." Nurses notes at 8:11PM document that the patient was "somewhat combative but aware of surroundings." Nurses notes at 8:30PM document "VO (verbal order) from ED Physician J to give pt 1mg of Ativan (a medication used to treat anxiety) now, another 1 mg in 10 minutes if does not help and then 1mg every 2 hours for agitation. Pt. given 1mg IV (intravenous)." Nurses note at 8:45PM document, Second mg of Ativan given. Pt continues to be agitated, hallucinating and not able to make sense when spoken to, pt is garbled speaking." Nurses note at 9:15PM document, "pt continues to be agitating, swatting at staff, swinging arms, tremors and trying to get off the gurney. ED Physician J called and order for Ativan 2mg IVP (intravenous piggyback) and 2mg subsequently 2QH (every 2 hours) and to call if this is not helpful... Pt in 4 point restraints." 9:20PM nurses notes document, "2mg of Ativan given IVP, ED Physician J called 9:33 new order give 2mg again now and another in 10 minutes. Given at 9:35 and 9:45 no change in agitation." Nurses note at 9:55PM, "another 2mg given, restraints loosened." Nurses note at 10:10PM, "Called ED Physician J again, 2 mg order and one more 2mg ordered for 10 min, if not effective need to call Poison Control and think about intubation/paralyzation.". There were no orders in the medical record for restraints. Review of facility policy "Mentally ill/Psychotic Patients" last reviewed 11/8/2018 states in part, "restraints may not be used without an order from the Doctor unless to prevent harm to self or others. In this case, an order must be obtained and MD (medical doctor) assessment completed within one hour.." Per interview with ED Manager G on 9/10/2019 at 8:30AM it was confirmed that there was no order in the medical record, "and there should be." Per interview with ED Manager G on 9/10/2019 at 8:30AM when questioned regarding ED Physician I being present in the ED with this patient however nursing received verbal orders from ED Physician J, ED Manager G stated, "ED Physician I has some restrictions on his/her license so medication orders are given by one of his/her colleagues ."

Medical record review of Patient's # 9 on 9/9/2019 at 12:30PM, revealed that the patient arrived to the ED on 4/23/20129 at 1:41PM. Nurses notes document at 2:45PM that the patient left the ED to have a cigarette and did not return. The medical record documented discharge disposition as against medical advice (AMA) on 4/23/2019 at 2:45PM. The facility policy "Discharge Of Patients From the Emergency Room (AMA)" last reviewed 11/8/2018 included the form "Release From Responsibility for Discharge." The form had an area indicating "patient refused to sign above release form" and a line for the nurse to sign. Patient #9 did not have this form in his/her medical record. Per interview with ED Manager G on 9/10/2019 at 8:30 ED Manager G stated, "that form (referring to the AMA form) should be in the chart."

Medical record review of Patient #10 on 9/9/2019 at 12:40PM revealed that the patient arrived to the ED on 4/23/2019 at 1:44PM. Nurses notes document at 2:45PM that the patient left the ED to have a cigarette and did not return. The medical record documented discharge disposition as against medical advice (AMA) on 4/23/2019 at 2:45PM. The facility policy "Discharge Of Patients From the Emergency Room (AMA)" last reviewed 11/8/2018 included the form "Release From Responsibility for Discharge." The form had an area indicating "patient refused to sign above release form" and a line for the nurse to sign. Patient #10 did not have this form in his/her medical record. Per interview with ED Manager G on 9/10/2019 at 8:30 ED Manager G stated, "that form (referring to the AMA form) should be in the chart."

Medical record review of Patient # 7 on 9/9/2019 at 12:10PM revealed an admission date to the ED on 3/31/2019 at 5:39PM for a shoulder dislocation. There was a "Consent to Operation or Other Procedure" in the medical record with an unreadable, written over entry in the area for the doctors name. Facility policy "Paper documentation error" last reviewed 11/8/2018 stated in part, "when an error is present within a paper document, a single line is to be drawn through the error and initialed." Per interview with ED Manager G on 9/10/2019 at 8:30 ED Manager G stated, when reviewing the Consent, "that is not acceptable."

Review of Patient # 13's medical record on 9/9/2019 at 11:20AM revealed an admission to the ED on 3/3/2019 at 3:05PM by ambulance for an overdose. At 3:20PM nurses notes documented "on call MD contacted. Gave VO (verbal order) to obtain EKG (electrocardiogram tracing of the heart) and will be in to evaluate." Note at 3:35PM by the Registered Nurse (RN) documented, "obtained EKG, patient condition unchanged, is sleepy but obeys commands. EKG shows sinus arrhythmia." There were no further notes from the RN and the discharge time was documented at 4:10PM. The medical record had an Emergency Room Report from ED Physician H that did not indicate time of exam. It was electronically signed by ED Physician H on 3/21/2019 at 6:56PM. Per interview with ED Manager G on 9/10/2019 at 8:34AM Manager G stated, "that is incomplete charting, there should be a note when the physician arrived and the patient's condition at discharge."

Review of Patient #17's medical record on 9/9/2019 at 1:16PM revealed an admission to the ED on 5/25/2019 at 9:15PM for a cellulitis (infection) of the breast. The patient received IV (intravenous) antibiotics and was observed until 7:20AM the next morning. There were nurses notes hourly from to 10:30PM on 5/25/2019 to 5:00AM 5/26/2019 that the patient was "resting comfortably" with the last nurses note in the medical record at 7:20AM which documented, "patient discharged with spouse. Stated red decreased..." In interview with ED Manager G on 9/10/2019 at 8:40AM when asked regarding the lack of assessment of the affected area by the nurse, Manager G stated, "we should not take the patient's word for it, the nurse should have looked at the area and assessed it."

Review of the facility policy "Patient Assessment and Reassessment in ER" last reviewed 11/8/2018 revealed in part "each patient in the ER must be reassessed every 15 minutes and documented accordingly on the ER form."

Based on record review and interview the facility failed to assure written signed physician orders for medications administered in the Emergency Department (ED) in 11 of a total sample of 22 patients (Patient #4, #5, #7, #8, #11, #15, #16, #17, #19, #20, and #22).

Findings:
Medical record review of Patient #4 on 9/9/2019 at 2:08PM revealed an ED admission on 7/13/2019 at 9:15PM for post tonsillectomy bleeding. Nurses notes document at 10:05PM, "patient currently receiving lactated ringers (an intravenous solution)". There were no orders for the administration of the lactated ringers.

Medical record review of Patient #5 on 9/9/2019 at 11:55AM revealed an ED admission on 3/25/2019 at 12:58PM for hip pain. Nurses notes documented the following; 2:00PM, "doctor ordered 5 mg (milligrams) morphine and IV start." 2:30PM, "MD (medical doctor) ordered 5 mg IVP (intravenous push) morphine for patient." 2:50PM, "new order for 5 mg IVP morphine.:" The medications were documented as administered. There were no signed physician order for the medications.

Medical record review of Patient #7 on 9/9/2019 at 12:10PM revealed an ED admission on 3/31/2019 at 5:39PM for shoulder pain. Nurses notes at 5:47PM documented, "orders received for shoulder x-ray, IV (intravenous) start and meds for pain." Narcotics and IV were documented as administered. There were no signed physician orders for the medications or IV.

Medical record review of Patient #8 on 9/9/2019 at 12:20PM revealed an ED admission on 4/1/2019 at 9:35PM for chest pain. Nurses notes document administration of a baby aspirin at 10:00PM, nitroglycerin (medication used to treat chest pain) tablets at 10:00PM, 10:06PM, and 10:16PM, a nitroglycerin IV drip initiated at 10:20PM, heparin (a blood thinner) bolus at 10:30PM, morphine for pain at 10:40PM. There was a signed, not dated, physician order sheet in the medical record that did not contain orders for these medications.

Medical record review of Patient # 11on 9/9/2019 12:47PM revealed an ED admission on 5/10/2019 at 11:20AM for scrotal swelling. Nurses notes document administration of an intravenous antibiotic at 1:30PM. There were no signed physician orders for the medication.

Medical record review of Patient #15 on 9/9/2019 at 11:35AM consisted of 7 separate ED visits from 3/21/2019 - 4/4/2019. Patient #15 presented at each of the 7 visits with anxiety and symptoms of meth (methamphetamine, a strong and highly addictive drug that affects the central nervous system) withdrawal. On each of these dates Patient #15 received Hydroxizine (an antihistamine to relieve itching). The medication administration was documented. There were no signed physician orders in the medical record of any of these 7 visits.

Medical review of Patient #16 on 9/9/2019 at 1:08PM revealed an ED admission on 5/22/2019 at 8:22AM for a gastrointestinal bleed. Nurses notes documented administration of intravenous fluids, Dilaudid for pain, Protonix (a medication used to treat gastrointestinal bleeding), and a blood transfusion. There were no signed physician orders in the medical record of any of the medications or blood transfusion.

Medical review of Patient #17 on 9/9/2019 at 1:16PM revealed an ED admission on 5/25/2019 at 12:45PM for a breast infection. Nurses notes document administration of an intramuscular antibiotic. Patient #17 returned to the ED on 5/25/2019 at 9:15PM with continued pain and redness. An intravenous antibiotic was documented as administered. There were not signed physician orders in the medical record for either antibiotic that was administered.

Medical record review of Patient #19 on 9/9/2019 at 2:15PM revealed an ED admission on 8/8/2019 at 2:50PM for back pain. Nurses notes at 3:00PM document, "on call MD (medical doctor) notified of patient's arrival. Orders received for patient to receive Ketorolac (pain medication) 30mg IM. Read back." There were not signed physician orders in the medical record for this medication.

Medical record review of Patient #20 on 9/9/2019 at 2:20PM revealed an ED admission on 8/12/2019 at 8:05PM for an overdose. Nurses notes documented a verbal order at 8:30PM, "give 1 mg Ativan (anti-anxiety medication) now, another 1 mg in 10 minutes if does not help and then 1 mg every 2 hours for agitation." At 11:40PM it was documented that a Certified Registered Nurse Anesthetist (CRNA) was present to intubate (insert a breathing tube) the patient. At 00:45AM on 8/13/2019 the nurse documented, "given 50 mg Rocronium (anesthetic medication) and 20mg Amidate (anesthetic medication) IV (intravenous). It was documented that 14mg of Ativan were given in total. There were no written signed orders for any of the medications and no documentation from the CRNA.

Medical record review of Patient #22 on 9/9/2019 at 2:40PM revealed an ED admission on 4/26/2019 at 9:40PM for chest pain. Nurses notes document aspirin, nitroglycerin (medication used to treat chest pain), ranitidine (an anti-ulcer medication), morphine for pain, and a heparin (a blood thinner) infusion. There were not signed physician orders in the medical record for these medications.

Review on 9/10/2019 of the facility Rules and Regulations, accepted May 3, 2016, revealed under #24. "All orders for treatment shall be in writing. All verbal orders must go through a Registered Nurse. An order shall be considered to be in writing if dictated to a Registered Nurse and signed by the attending physician or dentist within twenty-four hours... Orders dictated over the telephone shall be signed by the person to whom they are dictated with the name of the practitioner per his/her own name. The attending physician or dentist shall sign the orders within twenty-four hours." Under #41; "Each patient's medical record shall be signed by the practitioner in attendance that is responsible for its clinical accuracy."

Interview with ED Manager G and Director of Nursing A on 9/10/2019 at 11:00AM confirmed that physician orders are not present in any of the 11 ED patient records reviewed. Director A stated, "we thought that the ED medical record was being 'pushed' to the physician and then e-signed, but with what you have shown us we have realized that is not happening. I think that maybe there was an upgrade to the system that we missed." "We are working with the vendor and feel that by registering the patients into the ED the records will then be pushed to the physician and e-signed."

Based on observation, record review and interview, the facility failed to ensure compliance with Emergency Medical Treatment and Active Labor Act (EMTALA) regulations in 3 of 11 required areas (Sign Posting, Log Maintenance, and Appropriate Medical Screening).

Findings include:

The facility failed to ensure signage is legible and posted in the entrance to the Emergency Department. See tag C2402.

Facility staff failed to maintain an accurate, complete log of all patients presenting to the Emergency Department. See tag C2405.

The facility failed to provide an appropriate medical screening examination for all patients presenting to the Emergency Department. See tag C2406.

Based on observation and interview, the facility failed to ensure Emergency Medical Treatment and Labor Act (EMTALA) signs are placed in all lobbies and treatment areas in1 of 3 observed areas (main vestibule entrance to the Emergency Department).

Findings include:

Per observation on 9/9/2019 at 9:30AM, there are no EMTALA signs in the vestibule entrance to the Emergency Department (ED). Patients enter into a small area, ring a bell to alert their arrival, and wait for the designated ED Registered Nurse to unlock the door for them to enter the ED. Director of Nursing A on 9/9/2019 at 9:35AM pointed to a small sign, approximately 15 feet away from the vestibule area, through a glass door and hanging 8 feet up on a wall behind the ED registration and stated "we have the EMTALA sign there." Director A was in agreement that it is difficult if not impossible to read from the vestibule waiting area and that a sign should also be posted in the vestibule.

Based on review, observation and interview, the facility failed to maintain an accurate, complete log of patients presenting to the Emergency Department (ED).

In interview with ED Manager G on 9/10/2019 at 8:30AM when asked about expectations for documentation in the ED log stated, "it is expected that every column is documented on for each patient presenting to the ED. It is the nurses responsibility to assure it is complete and accurate." Questioned regarding error correction in the log, ED Manager G stated that, "the ED follows the facility policy for error correction." Review of facility policy titled "Paper error documentation" last reviewed 11/8/2018, revealed "when an error is present within a paper document, a single line is to be drawn through the error and initialed."

Review of the ED Log with ED Manager G on 9/10/2019 at 8:30AM revealed the following:
675 entries dating from 2/24/2019-9/6/2019. The paper log had the following 13 columns: date admitted, time, AM or PM, patient's name, address, age, sex, admitted by, service of Dr., nature of injury, services rendered, amount, and disposition of case. ED Manager G stated that the column titled "amount" was used to enter the discharge time.

Findings:

Out of a total sample of 675 entries 21 had discharge times missing on; 2/20, 2/22, 3/27, 3/7, 3/31, 4/1 (2 patients), 4/14, 4/29, 5/21, 5/22, 5/25, 6/1, 6/10, 6/19, 7/20, 7/25, 7/26, 8/6, 8/30 ( 2 patients);
disposition was missing on 8 entries on; 3/7, 5/2, 5/22 (2 patients), 6/1, 7/26, 8/6, and 8/30; address was missing on 11 entries on 4/8, 5/10, 5/25, 6/1, 6/4, 6/17, 6/23, 6/27, 7/7, 7/20, and 8/6; age was missing on 4 entries on 4/29, 8/16, 8/25, and 8/30; services rendered was missing on 3 entries on 3/7, 7/25, and 7/26; the date of service was missing on 2 entries on 4/24 and 8/30; the time of admission was missing on 2 entries on 4/24; the nature of injury was missing on 2 entries on 3/7 and 5/22; two missing entries for service of Dr. on 3/7 and 8/6, and one missing entry for admitted by on 3/7.

Out of a total sample of 49 error corrections revealed during review of the ED Log from 2/24/2019-9/6/2019 46 were not corrected according to facility policy. These included cross outs, write overs, and scribbles on the following dates; 2/24, 3/2, 3/3, 3/17, 3/20, 3/21 (2 entries), 4/4 (2 entries), 4/11, 4/12, 4/13, 4/17, 4/19, 4/20, 5/7, 5/25 (2 entries), 5/26, 5/29, 6/3, 6/4, 6/5, 6/9, 6/10, 6/15, 6/25, 6/29, 7/1, 7/3, 7/6, 7/7 (2 entries), 7/12 (2 entries), 7/13 (2 entries), 7/22, 7/31, 8/7, 8/9, 8/12 (2 entries), 8/25, 8/19, and 8/31.

The above findings were confirmed with ED Manager G on 9/10/2019 at 8:30AM.

Review of medical record for Patient #10 revealed a 4/23/2019 ED visit with an arrival time of 1:40PM for hallucinations from meth (methamphetamine, a strong and highly addictive drug that affects the central nervous system). The patient received a medical screening exam and labs were drawn. The ED log documents that the patient left AMA at 2:45PM. The medical record contained a nurses note dated 4/24/2019 at 2:10AM that revealed a return visit for a complaint of "bleeding from my anus." This visit is not documented in the ED Log. The patient did not receive a medical screening exam and was discharged to home to follow up with the physician the following day. See Tag C-2406 for cite on the lack of medical screening.

ED Manager G confirmed in interview on 9/10/2019 that the second visit should have been entered in the log.

Based on interview and medical record review the facility failed to provide a medical screening exam in 1 of a total sample of 22 records reviewed (Patient #10).

Findings:

Review of Patient #10's medical record revealed admission to the Emergency Department (ED) on 4/23/2019 at 1:40PM requesting treatment for a meth (methamphetamine, a strong and highly addictive drug that affects the central nervous system). Nurses notes document that ED Physician I was present when the patient arrived. The Emergency Room Report in medical record documented by ED Physician I revealed the patient was seen by ED Physician I at 1:40PM, received a physical exam, had blood pressure, pulse, respirations and oxygen saturation taken and had labs drawn. Nurses notes document at 4:45PM that the patient went out for a cigarette and did not return to the ED. A nurses note in the 4/23/2019 medical record documented a return visit to the ED on 4/24/2019 at 2:10AM with a complaint of "bleeding out of her anus." The nurses note documented a call at 2:20AM to the on-call physician (ED Physician H) who instructed the nurse to tell the patient "I am willing to assess him/her for treatment if he/she would like to come back in the morning to the clinic." There was no documentation of vital signs, physical assessment or a screening exam performed in the medical record. Nurses notes document at 2:25AM, "pt and boyfriend leave out the ER door and state they will be back in the morning." In interview with ED Manager G on 9/10/2019 at 8:22AM Manager G agreed that a medical screening exam was not done and "should have been." Review of facility policy "ED Medical Screening" last reviewed 11/8/2018 revealed under the heading Medical Screening Exam, "any person requesting emergency services, who presents to facility that provides emergency services must receive a medical screening exam (MSE). The purpose of the MSE is to identify whether an emergency condition exists. This has been delegated to the ER Registered Nurse by the medical staff. See bylaw."