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Based on observation, interview, and record review, the facility failed to ensure a sanitary enironment to avoid transmission of infections in the Emergency department (ED). The facility failed to:


A. ensure the floors in the hallways, patient bays, triage rooms, and waiting room bathroom were cleaned.

B. ensure patient care sterile equipment was sterilized in the appropriate manner. The facility failed to ensure patient care equipment was kept clean and free of dust, debris and rust.

C. ensure intravenous fluids, single use normal saline, intravenous equipment, lab supplies were stored in a manner to prevent contamination.

D. ensure clean linen was stored in a manner to prevent contamination. The facility failed to ensure soiled linen was properly contained.

E. ensure the ED hallways were kept clean and free of clutter.

F. ensure sufficient cleaning services for the ED. The nurses were responsible for cleaning the patient bays in between each patient. Patient rooms that were deemed as being clean were found to be soiled.

G. ensure biohazard equipment and trash was discarded and contained properly.

H. ensure identified environmental conditions were corrected.


Refer to tag A0749 for additional information.

Based on observation, interview, and record review, the facility failed to ensure there was a system in place for identifying and controlling infections in the Emergency department (ED). The facility failed to:



A. ensure the floors in the hallways, patient bays, triage rooms, and waiting room bathroom were cleaned.


B. ensure patient care sterile equipment was sterilized in the appropriate manner. The facility failed to ensure patient care equipment was kept clean and free of dust, debris, and rust.

C. ensure intravenous fluids, single use normal saline, intravenous equipment, and lab supplies were stored in a manner to prevent contamination.

D. ensure clean linen was stored in a manner to prevent contamination. The facility failed to ensure soiled linen was properly contained.

E. ensure the ED hallways were kept clean and free of clutter.

F. ensure sufficient cleaning services for the ED. The nurses were responsible for cleaning the patient bays in between each patient. Patient rooms that were deemed as being clean were found to be soiled.

G. ensure biohazard equipment and trash was discarded and contained properly.

H. ensure identified environmental conditions were corrected.


This deficient practice had the likelihood to cause harm to all patients presenting the ED.


During an observation on 05/30/2019 after 1:00 p.m., the following was found in the Emergency Department:


Emergency Medical Service Linen cart was stored in the hallway and had a mesh covering. The mesh covering was ripped and was soiled. The shelves the clean linen was on was soiled with debris.


Flooring

The tile flooring throughout the Emergency department in the patient bays, hallways, and triage rooms were soiled with a buildup of wax.

The tile flooring inside a trauma bay had rips and the subfloor underneath could be seen. The floor could not be sanitized in that condition.

The flooring in the (inside) decontamination room was soiled with spills and debris. Patient oxygen tanks were stored in the room.


Trauma room

The room was identified as being clean and ready for a patient by Staff #8.

A peel packet containing a sterile instrument was stored in a drawer in the room with non-sterile items. The equipment had been sterilized in a closed position.

According to the 2019 Association of perioperative Registered Nurses guidelines the following was documented:

"All hinged instruments should be sterilized in the open position, unless the manufacturer's instructions for use advise against this practice. If hinged instruments are on stringers, racks, or instrument pegs, the instruments should be kept open and unlocked. The rationale behind the practice is to expose all surfaces of the instrument to the sterilant."

A bag of intravenous fluid was stored in a drawer with non-sterile equipment. The bag was not in it's protective overwrap. According to instructions on the intravenous bag it was to be stored in a moisture barrier at room temperature..until ready to use.


There were single use vials of normal saline stored in a drawer with non-sterile items.

There was a container of single use vials of normal saline in a cabinet.

According to the Centers for Disease Control and Prevention website dated 2010 the following was documented:

"Do not combine (pool) leftover contents of single-dose or single-use vials or store single-dose or single-use vials for later use. Single-dose or single-use vials are intended for use on a single patient for a single case/procedure. There have been outbreaks resulting from pooling of contents of single-dose or single-use vials and/or storage of contents for future use."


Respiratory connector tubes were stored on the counter and were not bagged. There was no way to tell if they were clean or not.

Crash cart in the trauma room had an Ambu bag stored in a bag that was ripped open. The sides of the defibrillator were soiled. The top of the crash cart had spills and dust. An unbagged oxygen regulator was sitting on top of the cart. There was no way to tell if it was clean or dirty.

The base of equipment in the room was covered in dust.

A bucket of transducer mounting equipment was found stored in the room. The equipment was soiled with a dried build-up of brown substance and was dusty. Some of the equipment was still in plastic wraps which were soiled.

The trash container in the room had soiled items in it. Two biohazard containers had soiled items in them such as intravenous lines, tubing, intravenous bags, and lab tubes with blood in them. One of the biohazard containers had patient identifying information in it dated 05/29/ 2019. One of the tops of one of the biohazard containers was cracked.


Hallways

The halls were cluttered with equipment, linen carts, and patient beds.

EKG (electrocardiogram) machines were stored in the hallway. Plastics bins on the stand they were mounted on were soiled with spills.

Linen carts were stored in the hallway with soiled linen hanging out of them. The top of one of the linen carts was rusted.


Lower acuity side of the ED

RN#10 was observed cleaning a mattress off after a patient left with a sani-wipe. The wheels on the bed were heavily soiled and were not included in the cleaning process.

RN # said that the nurses wiped the beds down between patients and picked up trash off the floor it if was a lot.


Triage room

The triage room was an approximate 12 x 12 square foot room. There were 3 patient bays in the area with patient supplies stored in the room.

The trash can was overflowing with trash and soiled gloves. Soiled gloves were on the floor next to the trash can.

A shelf containing patient care supplies was in the corner and it was uncovered. The bottom shelf did not have a protective splash guard down to protect the supplies from contamination.

Two bags of respiratory tubing was hung on the wall and next to the biohazard sharps container.


Extra room (also used for triaging)

There were open containers sitting on a shelf which had lab, intravenous, and other patient care supplies in them. The inside and outside of the containers were soiled with a build-up of dust and debris. One of the containers had a rack of vacutainer lab tubes which were sitting on a rack which had a buildup of brown substance. Hair was observed on the tubes.


Patient waiting area bathroom

The toilet seat had dried brown substance on it (appearance of feces). There was a piece of toilet tissue on the floor which was soiled with dried brown substance (appearance of feces).

Wall plaster at the baseboard, near the sink area was coming away from the wall.

Staff #8 confirmed the observations. Staff #8 said they had a full time housekeeper for 8 hours. The nurses had to clean the rooms between each patient. No definitive date could be provided of when the biohazard was last picked up.


Review of the environmental rounding sheets revealed the last time the ED was evaluated was 03/25/2019 (over 2 months ago).

The soiled linen overflowing, walls, flooring was mentioned. There was no documentation of what was put in place to correct the problems.


During an interview on 05/31/2019 after 10:30 a.m., Staff #2 and #19 (infection control) confirmed the last environmental/infection round on the ED was 03/25/2019.


Review of a facility's policy named "ED-Standards of Care for ED Patients Policy revised 10/04/2018 revealed the following:

"INFECTION CONTROL

1.Stretchers and medical equipment shall be cleaned between patients utilizing current germicidal agent standards as set forth by hospital policy.

2.Univeral Precautions shall be practiced at all times during patient contact."

Based on interview and record review, the facility failed to meet the emergency needs of patients. The facility failed to:


A. ensure thorough assessments and interventions were provided to Emergency department (ED) patients.

Patient #1 presented to the ED at Hospital A with and acute skin rash and was discharged without the rash being treated. Patient #1 presented to Hospital B five minutes after being discharged from Hospital A with the same acute rash. Patient #1 was admitted into Hospital B. Blood and wound cultures were taken and were found to be positive. Patient #1 remained on antibiotic therapy as of 05/31/2019 for treatment of the acute skin rash.

B. ensure there was a policy in place outlining what their Sepsis protocol and screening was for nursing staff.

C. ensure physicians were medically screening all patients per their policy. Nurse practitioners and physician assistants were screening patients and the facility's policy did not say they could and they did not have documentation of training on medical screening.

D. ensure ED nurses followed physician orders when administering oxygen and using safe practice when removing patient off of oxygen therapy.

E. ensure ED nurses provided necessary discharge information and completed paperwork for patients leaving Against medical advice (AMA).

Refer to tag 1101 for additional information.

Based on interview and record review, the facility failed to provide organized emergency services. The facility failed to:


A. ensure thorough assessments and interventions were provided to Emergency department (ED) patients.

Patient #1 presented to the ED at Hospital A with and acute skin rash and was discharged without the rash being treated. Patient #1 presented to Hospital B five minutes after being discharged from Hospital A with the same acute rash. Patient #1 was admitted into Hospital B. Blood and wound cultures were taken and were found to be positive. Patient #1 remained on antibiotic therapy as of 05/31/2019 for treatment of the acute skin rash.

B. ensure there was a policy in place outlining what their Sepsis protocol and screening was for nursing staff.

C. ensure physicians were medically screening all patients per their policy. Nurse practitioners and physician assistants were screening patients and the facility's policy did not say they could and they did not have documentation of training on medical screening.

D. ensure ED nurses followed physician orders when administering oxygen and using safe practice when removing patient off of oxygen therapy.

E. ensure ED nurses provided necessary discharge information and completed paperwork for patients leaving Against medical advice (AMA).

This deficient practice had the likelihood to cause harm to all patients presenting to the ED.


Findings include:

Review of the Emergency department (ED) record on Patient #1 revealed, she was an 85 year old female who presented to the ED on 05/24/2019 at 3:09 p.m., with Candidiasis of the skin and nail (yeast). Patient #1 was transported to the ED by ambulance.

According to nursing documentation at 3:15 p.m., Patient #1 had a rash on her back, buttock, and down her legs which had gotten worse. The rash started in March and had not improved. The rash that was in the crevice of the arms started two days ago. According to EMS documentation they had brought Patient #1 from a nursing home. Patient #1's oxygen saturation was low so they applied oxygen at 2 liters. At 3:15 p.m., Patient #1 had a blood pressure of 127/75, pulse of 60, respirations 18, temperature of 97.8 degrees Fahrenheit, and an oxygen saturation of 96 percent on room air.

At 3:28 p.m., Physician #17 documented that Patient #1 had a severe rash, could be described as erythematous, excoriated, macular, popular, plaque-like, candidal like rash with satellite and confluent lesions to groin, buttock, rectum, pannus, antecubital fossa, (right/left) inner thighs and back.

At 3:31 p.m., Physician #17 documented that Patient #1 had impetigo, infectious rash, and candidiasis (yeast). There was documentation that the hospital's sepsis protocol was not initiated because Patient #1 did not meet the appropriate scoring criteria.

According to nursing documentation at 3:27 p.m., the following was documented "Sepsis Protocol: suspicion of infection exist (1 point)."

At 3:36 p.m., Physician #17 documented that Patient #1's condition represented a certified medical emergency.

At 3:38 p.m., Physician #17 documented that Physician #20 had treated the rash with multiple different modalities without relief and had an appointment scheduled with a dermatologist on 06/14/2019. Physician #20 requested that they did basic labs and if significant leukocytosis, or dehydration, elevated lactic please admit to him, if not discharge to the nursing home.

At 3:55 p.m., there was documentation that Patient #1's care was handed off to Physician #18.

At 4:09 p.m., lab test showed elevated eosinophil level of 11 (reference ranges being 0-6.04) and an elevated lactic acid of 2.99 (reference ranges being 0.0-1.99). The elevated lactic acid being an indicator of Sepsis.

At 4:22 p.m., lab test showed some of the following a low hemoglobin of 12..6 (reference ranges of 14.0-19.5), glucose of 129 (reference ranges of 70-110), and blood urea nitrogen of 27 (reference ranges 7-18).

Patient #1 also had two blood cultures drawn while in the ED.

According to progress notes by Physician #20, he came to the hospital and talked with the family and they wanted Patient #1 admitted into the hospital. Physician #20 documented that hospital staff informed him the family said she was taking Patient #1 to Hospital B's ED if they did not admit her. Physician #20 documented that Patient #1 had received intravenous fluids which resolved her elevated lactic acid. There was no reason for him to admit Patient #1.

According to nursing documentation at 4:59 p.m., Patient #1's oxygen saturation had dropped to 80 percent on room air.

At 5:00 p.m., the blood pressure was 134/64, temperature was 98.3 degrees Fahrenheit and oxygen saturation was 100 percent on 2 liters of oxygen per nasal cannula.

At 7:00 p.m., (2 hours later) the oxygen saturation was 99 percent on 2 liters of oxygen per nasal cannula.

At 9:05 p.m., (2 hours later) the oxygen saturation was 98 percent on room air. Patient #1's blood pressure had dropped to 106/65 and staff failed to document an assessment of a temperature prior to discharge. There was also no order on the chart to discontinue or wean Patient #1 off the oxygen.

At 9:07 p.m., there was documentation that Patient #1 left the ED with the family member.

Review of ED notes from Hospital B dated 05/24/2019 at 9:12 p.m. (5 minutes after being discharged from hospital A) revealed the following:

Patient #1 arrived at 9:12 p.m., with diagnoses of cellulitis, unspecified, candidiasis dermatitis. At 9:13 p.m., Patient #1 was documented as having a temperature of 99.4 degrees Fahrenheit. At 10:22 p.m. staff documented Patient #1 had a negative sepsis screening (using SIRS criteria).

At 12:10 midnight, Patient #1 had an elevated lactate of 2.5. More lab was ordered and drawn, intravenous fluids and antibiotic therapy started.

Physician progress notes dated 05/25/2019 revealed Patient #1 was given the following diagnoses:

Acute diffuse keratolytic rash with underlying erythema and possibly superimposed fungal infection, possibly secondary infection to pemphigus vulgaris_syndrome ....The plan was to prescribe nystatin powder for the rash, consult with ID (Infectious disease), wound care, vancomycin, clindamycin, pain control with Tylenol, and IV fluids.

At 10:20 a.m., on 05/25/2019, Patient #1 was admitted into hospital B.

Lab cultures collected on 05/25/2019 at 12 midnight was resulted on 05/28/2019 and showed the organism Staphylococcus hominis

Wound cultures collected 05/26/2019 and resulted on 05/30/2019 revealed the following organisms:

Staphylococcus aureus
Acinetobacter baumannii
Pseudomonas aueruginosa
Proteus mirabilis
Presumptive Corynebacterium species

Review of physician progress notes dated 05/31/2019 revealed some of the following:

Acute staph bacteremia- Continue Vancomysin and Zosyn (antibiotics).
Acute generalized rash likely 2/2 candidiasis - Continue nystatin and fluconazole ...(treatments for anti-fungal infections).


During an interview on 05/30/2019 after 2:00 p.m., Staff #8 said that there was no documented criteria or policy to indicate when the Sepsis protocol was implemented. The physician chose the interventions they wanted to use if Sepsis was suspected. Staff #8 provided a list of orders that was copied from the computer system of things the physician could select which included lab, test, medications, and isolation for someone with suspected sepsis.

Staff #2 confirmed there was no policy explaining their Sepsis protocol.

During an interview on 05/30/2019 RN # 14 said she was the nurse taking care of Patient #1 and discharged her on 05/24/2019. RN#14 said she did not explain to the family or patient about the lab cultures not being resulted out because she did not know when they would result out. RN#14 confirmed she took the oxygen off Patient #1 about 5 minutes before discharging her and took the oxygen saturation. RN #14 confirmed there was no physician's order to discontinue the oxygen.

During an interview on 05/31/2019 after 10:25 a.m., Physician #17 said he remembered Patient #1 because the rash was so extensive. Physician #17 said he wanted to admit the patient for intravenous antibiotic, diflucan, pain medication and had talked to the family about admitting her. Physician #17 said he did not have admitting privileges. Physician #17 said he called the doctor from the nursing home (Physician #20) so he could decide.

During an confidential interview on 05/31/2019 it was reported that Physician #20 came to the hospital A, but did not go in and check Patient #1.


Patient #16

Review of the ED record on Patient #16 revealed, she was a 4 year old female who presented on 05/26/2019 at 8:57 a.m. for a rash. Patient #16 was given an acuity level of 4.

The sepsis screening was not performed by nursing and no documentation that it was started and stopped.

The medical screening was performed by a physician and the differential diagnoses given were allergic reaction, infectious rash, and viral exanthema.


Patient #8

Review of ED record on Patient #8 revealed she was a 28 year old female who presented on 01/24/2019 at 11:48 p.m., with complaints of kidney stones and a urinary tract infection. Patient #8 was given an acuity level of 3.

At 11:54 p.m., Patient #8 had blood pressure of 124/93, pulse of 115, temperature of 97.6 degrees Fahrenheit and oxygen saturation of 98 percent.

At 11:59 p.m., Patient #8 revealed she had a pain level of 8 out of 10 (indicating severe pain).

At 12:12 midnight there was documentation in the nurses notes underneath Sepsis Protocol:
"Patient presentation is not suspicious for sepsis; sepsis screening is stopped."

At 2:05 am., Patient #8 left the ED after her IV saline lock was removed. There was no documentation of an AMA form being signed.


Patient #7

Review of the ED record on Patient #7 revealed he was an 85 year old male who presented to the ED on 01/06/2019 at 11:18 p.m.., for complaints of chest pain. Patient #7 was given an acuity level of 2.

Review of nurse notes 11:29 p.m., revealed Patient #7 was on oxygen at 2 liters per nasal cannula.
A physician's order was written for "O2 at 2 lpm via NC" at 12:02 midnight.

There was documentation that Patient #7 was on room air throughout the remaining time of his stay in the ED.

Review of the record revealed Patient #7 was discharged home at 3:25 a.m. from the ED.

Staff failed to follow the physician's order.


Patient #4

Review of the ED record of Patient #4 revealed he was an 83 year old male who presented on 12/16/2018 at 10:08 p.m.. Patient #4 presented with complaints of feeling general week for the past 2 months. There was documentation that Patient #4 was in the hospital a week ago for diverticulitis.

At 10:09 p.m., Patient #4 was given an acuity level of 2. Patient #4 had an elevated vital signs such as a blood pressure of 147/93, pulse of 118, respirations of 22 temperature of 102.6 degrees Fahrenheit rectally and an oxygen saturation of 95 percent on room air.

There was no documentation of Patient #4 having a sepsis screening by nursing.

At 10:31 p.m., the physician documented Patient #4's right leg from the distal tibia and fibula (lower leg) was erythematous, swollen, and warm..

At 12:18 midnight Patient #4's blood pressure had dropped to 85/37.

At 12:24 midnight Patient #4 complained of aching in his whole body.

At 12:26 midnight, the physician documented that it looked like Patient #4 had a urinary tract infection, sepsis, and cellulitis of the right lower extremity.

At 04:57 a.m., Patient #4 left the ED and was admitted into the intensive care unit.


Review of a facility's policy named "ED- Nursing Responsibilities in the Emergency Department Policy" and updated 11/13/2018 revealed the following:

"..Accurately document focused nursing assessment, evaluations of treatment/therapies, hourly rounding, vital signs as outlined by ESI level and policy,& hand-off report to oncoming RN.

Administer or provide treatments and/ or medications as ordered by the physician in coordination with protocols and policy.."

"..ED-Standards of Care for ED Patients Policy

All patients can expect the emergency department staff to administer medications safely and appropriately according to accepted policies ad procedures ..."


Medical Screening and Against Medical Advice Forms

Patient #13

Review of the ED record on Patient #13 revealed he was a 91 year old male who presented to the ED on 05/28/2019. Patient #13 was given an acuity level of 3. Patient #13 was given diagnoses of abnormal labs, kidney failure and dehydration.

Review of the record revealed that Nurse Practitioner #21 signed as medically screening Patient #13.


Patient #14

Review of the ED record on Patient #14 was a 52 year old female who presented to the ED on 05/28/2019 for anxiety disorder, chronic obstructive pulmonary disease with acute exacerbation. Patient #14 was given acuity levels of 2 and 3 by the same nurse.

Review of the record revealed that Nurse Practitioner #22 signed as medically screening Patient #13.


Patient #15

Review of the ED record on Patient #15 revealed he was an 85 year old male who presented on 05/27/2019 at 6:57 p.m., for syncope and history or coronary artery disease. Patient #15 was given an acuity level of 2.

Review of the record revealed that Physician's assistant #23 signed as medically screening Patient #15.

At 10:28 p.m. there was documentation that Patient #15 left against medical advice (AMA).

At 10:39 p.m., there was documentation that Patient #15 was instructed on risks and signed an AMA form.
The form was not in the chart.


Patient #9

Review of the ED record on Patient #9 revealed he was a 79 year old male who presented to the ED on 01/28/2019 at 3:54 p.m., for complaints of syncope. Patient #9 was sent to ED for clearance to be admitted to a behavior hospital. Patient #3 was given an acuity level of 3.

Review of the record revealed that Physician's assistant #23 signed as medically screening Patient #9.


During an interview on 05/30/2019 after 1:00 p.m., Staff #2 confirmed there was no AMA form on the charts.

During an interview on 05/31/2019 after 12:00 p.m., Staff #2 confirmed that their policy documented that physician were to perform the medical screenings. Staff #2 confirmed that the nurse practitioners and physician assistants did not have documented medical screening training.

During an interview on 05/31/2019 after 2:20 p.m., Staff #8 said that medical screening were performed by either the advanced practice nurses or the physicians.


Review of the facility's policy named "2017 Plan for Patient Care, Treatment, and Services Policy" revealed the following:

"Patients are assessed by a Registered Nurse during a Triage process and directed to a physician for Medical Screening."

Review of a facility's policy named "Risk Management-AMA-Against Medical Advice and LWOT- Left Without Treatment" revealed the following:

"After explanation of potential risks and consequences, if the patient refuses to wait for the physician, or if the patient talks to the physician and still desires to leave "against medical advice" request that the patient sign the AMA form and give a copy to the patient."