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Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

482.55 Tag A-1100 Emergency Services

Based on review of facility policy, respiratory therapy guidelines, and medical record (MR), and staff (EMP) interview, it was determined the facility failed to exchange portable oxygen tanks per respiratory therapy guidelines which potentially contributed to the demise of the patient (MR1); failed to perform and document hourly visual checks of patients triaged and returned to the waiting room to await further treatment and disposition per facility policy in eight of 12 applicable MRs reviewed (MR1, MR7, MR10, MR11, MR12, MR13, MR15 and MR16); and failed to check all areas of the ED before documenting a patient as left without being seen (LWBS) in one of one medical record reviewed (MR1).

Cross reference
482.55(a)(3) Tag A-1104 Emergency Services Policies

Based on review of facility policy, respiratory therapy guidelines, medical record (MR), and staff (EMP) interview, it was determined the facility failed to exchange portable oxygen tanks per respiratory therapy guidelines which potentially contributed to the demise of a patient (MR1); failed to perform and document hourly visual checks of patients triaged and returned to the waiting room to await further treatment and disposition per facility policy in eight of 12 applicable MRs reviewed (MR1, MR7, MR10, MR11, MR12, MR13, MR15 and MR16); and failed to check all areas of the ED before documenting a patient as left without being seen (LWBS) in one of one medical record reviewed (MR1).

Findings include:

1. Review on December 1, 2021, of facility policies revealed no policy and procedure for portable oxygen tank usage, staff responsibilities, and requirements to document a tank exchange in the medical record.

Review on December 1, 2021, of respiratory therapy guidelines revealed an E-cylinder that was full with a flow rate at 6 liters per minute (LPM) would last 1 hour and 30 minutes prior to needing exchanged.

Review on December 1, 2021, at 1257 of MR1 revealed the patient arrived by ambulance on November 23, 2021 at 1637. The patient had vital signs taken and was triaged by the nurse at 1648. Documentation revealed supplemental oxygen was at 6 liters per minute (LPM); respirations were 28/minute; and pulse oxygenation was 100% at the time of triage. The chief complaint was worsening shortness of breath and fatigue with a recent positive test for COVID-19. Review of MR1 documentation showed the patient was in no acute distress at the time of triage. The patient was triaged a level 3, examined briefly by a provider in triage at 1656, and sent to the waiting room to await treatment and disposition.

Review of MR1 documentation on November 23, 2021, at 1922 revealed the patient's name was called multiple times in the waiting room with no response. The provider in triage and charge nurse were made aware. The patient's flowsheet for November 23, 2021 at 1922 documented the patient left without being seen, and on November 23, 2021 at 1923 documented the patient eloped. There was a discharge order in MR1 on November 23, 2021, at 2330 which was cancelled.

Further review of MR1 revealed on November 24, 2021 at 0640, the patient was found on the floor without a pulse or respirations. Cardiopulmonary resuscitation was initiated and unsuccessful. The patient was pronounced dead on November 24, 2021, at 0646. The coroner was notified, and an autopsy is pending. There was no documentation of the time the patient was initially switched to the hospital's portable oxygen or documentation of a tank exchange.

Interview with EMP5 on December 1, 2021, at 1315 confirmed since the patient (MR1) arrived by ambulance, the oxygen would have been switched over to the hospital's portable tank between the time of arrival and time of triage, as the patient was not immediately placed in an ED room. EMP5 confirmed the patient would have required an oxygen tank exchange in about an hour and a half. EMP5 confirmed there was no documentation in MR1 of the initial switch to the hospital's oxygen tank or documentation of a tank exchange being completed.

Interview with EMP6 on December 1, 2021, at 1343 confirmed the emergency department only utilized E-cylinder sized tanks that were full. EMP6 confirmed that an E cylinder that was full running at 6 LPM of oxygen would run out of oxygen in 1 hour and 30 minutes. EMP6 confirmed there was no policy and procedure that covered responsibilities for portable oxygen tank usage and staff responsibilities. EMP6 stated there was only the respiratory therapy guidance to staff on how long a portable oxygen tank cylinder would last.

2. Review on December 1, 2021, of the facility policy "5-Level Triage Implementation Using ESI," last approved July 2021, revealed "Purpose: Triage is the initial assessment and acuity sorting process for patients presenting to the Emergency Department. Triage is a tool to enhance patient safety as well as provide data to support operational decisions, provide quality initiatives and clinical research. Triage seeks to decrease morbidity, disfigurement and patient pain, while being a positive experience for patients. ... Policy ... Triage Procedure: ... 4. If the patient is unable to be placed in a treatment room because of departmental capacity, ongoing evaluation of patients in the waiting room will occur hourly. ED staff will perform and document a visual check. Based on the patient condition, vital signs may need to be re-checked. ..."

Review of MR1 on December 1, 2021, revealed an admission to the ED on November 23, 2021. MR1 was triaged at 1648, examined briefly by a provider in triage at 1656, and returned to the waiting room on November 23, 2021. MR1 documentation revealed on November 23, 2021 at 1922 the patient left without being seen. There was no documentation in MR1 of the one-hour staff visual checks. The patient was found on the floor with no respirations or pulse on November 24, 2021 at 0640.

Review of MR7 on December 1, 2021, revealed an admission to the ED on November 30, 2021. MR7 was triaged, examined, and returned to the waiting room. There was no documentation in MR7 of a one-hour staff visual check.

Review of MR10 on December 1, 2021, revealed an admission to the ED on December 1, 2021. MR10 was triaged, examined, and returned to the waiting room. Documentation revealed MR10 was in the waiting room from 1013 until 1330. There was no documentation in MR10 of hourly visual checks during that time frame.

Review of MR11 on December 1, 2021, revealed an admission to the ED on December 1, 2021. MR11 was triaged, examined, and returned to the waiting room. Documentation revealed MR11 was in the waiting room from 0912 until 1400. There was no documentation in MR11 of hourly visual checks during that time frame.

Review of MR12 on December 1, 2021, revealed an admission to the ED on November 28, 2021. MR12 was triaged, examined, and returned to the waiting room. Documentation revealed MR12 was in the waiting room from 0812 until 1039. There was no documentation in MR12 of hourly visual checks during that time frame.

Review of MR13 on December 1, 2021, revealed an admission to the ED on November 29, 2021. MR13 was triaged, examined, and returned to the waiting room. Documentation revealed MR13 was in the waiting room from 1619 until 2239. There was no documentation in MR13 of hourly visual checks during that time frame.

Review of MR15 on December 1, 2021, revealed an admission to the ED on November 29, 2021. MR15 was triaged, examined, and returned to the waiting room. Documentation revealed MR15 was in the waiting room from 0858 until 0157. There was no documentation in MR15 of hourly visual checks during that time frame.

Review of MR16 on December 1, 2021, revealed an admission to the ED on November 29, 2021. MR16 was triaged, examined, and returned to the waiting room. Documentation revealed MR16 was in the waiting room from 1155 until 1823. There was no documentation in MR16 of hourly visual checks during that time frame.

Interview with EMP5 on December 1, 2021, at 1315 confirmed hourly visual checks were not documented in MR1.

Interview with EMP12 on December 1, 2021, during MR review between 1030 and 1430, confirmed hourly visual checks were not documented in MR7, MR10, MR11, MR12, MR13, MR15 and MR16. EMP12 confirmed the policy required an hourly visual check of each triaged patient returned to the waiting room to await further treatment and disposition.

3. Review on December 1-2, 2021, of facility policies revealed no policy specific to left without being seen patients.

Review of MR1 on December 1, 2021, revealed an admission to the ED on November 23, 2021. MR1 was triaged at 1648, examined briefly by a provider in triage at 1656, and returned to the waiting room on November 23, 2021. MR1 documentation reflected on November 23, 2021 at 1922 the patient left without being seen. The patient was found on the floor with no respirations or pulse on November 24, 2021 at 0640.

Interview with EMP5 on December 1, 2021, at 1315 related the facility's process prior to this incident was that the staff would call patient's name three times and check with the registration staff prior to marking the patient as left without being seen. EMP5 stated the previous process was for the charge nurse or ED manager to contact the patient who had left without being seen the next day for a wellness check telephone call.

Interview with EMP10 on December 2, 2021 at 0935 stated the previous process for left without being seen patients was to call their name at least three times before marking the patient as left without being seen. EMP10 confirmed that checking the ED waiting bathrooms was not a part of their routine process previously.

Interview with EMP2 on December 2, 2021 at 1405 confirmed there was no policy specific to left without being seen patients.

Cross-reference:
482.55 Tag A-1100 Emergency Services