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Based on interviews, medical record review and review of hospital documents, hospital staff failed to ensure a delegated task was performed by competent, trained personnel. For 1 (one) of 6 (six) patients whose medical records were included in the sample. Patient #4

The findings include:

The clinical record of Patient #4 was reviewed on 11/16/22 with the assistance of Staff #1 and revealed in part the following information: Patient #4 presented to the ED (Emergency Department) on 9/19/22 at 7:36 PM with the arrival complaint documented as "Possible Broken Nose". Patient #4 was accompanied by a correctional officer and was taken to Exam18 at 7:48 PM. Triage vitals documented by Staff #8 at 7:54 PM are temperature 98.4, heart rate 97, respiratory rate 18, blood pressure 147/115, oxygen saturation 99% on room air. Pain assessment revealed pain level 5 on a scale of 1-10 with one representing no pain. Pain was documented as being at an acceptable level. Nursing assessment at 8:09 AM by Staff #8 evidenced under Head and Face, "Swelling; Trauma/injury." Right and left eyes corneal reflexes were documented as intact. (corneal reflex is a reflex action of the eye resulting in automatic closing of the eyelid when the cornea is stimulated) No neurological symptoms were noted.

A CT scan of the head without contrast was ordered by Staff #6 at 7:57 PM and performed at 8:57 PM with the following findings in part: "There is no acute intracranial hemorrhage, mass-effect or midline shift. Abnormal extrapaxial fluid collections are not seen. The ventricles are not enlarged. The gray-white matter interface is otherwise preserved. The orbits, paranasal sinuses and osseous calvarium appear unremarkable. Left periorbital soft tissue swelling." The scan was reviewed by a remote provider.

Review of documentation by Staff #6 found the following in part: "Patient is complaining of head pain nose pain and left eye pain. No loss of consciousness was reported." Review of systems found "Eyes: Positive for pain. Negative for visual disturbance." Staff #6 documented the "Patient is tender to palpation over the left superior orbit and the inferior orbit. Patient is tender over the nasal ridge."... "Patient has a skin tear/laceration, which is Steri-Stri (sic) to the for head (sic)." Medical decision making documentation read in part: "Patient vision is present in both eyes. Patient is able to see out of both eyes. (pronoun) is supposed to wear corrective lenses and does not. Patient to follow-up with the medical the detention center. Patient to return as needed if symptoms worsen. Patient to wear his corrective lenses."

An order for a visual acuity screening exam was ordered at 9:48 PM by Staff #6 and performed at 9:53 PM by Staff #7. Visual acuity screening documented as "R 20/32 L able to see the shapes of the letters" and a statement "Patient was given corrective lenses but does not wear them". The visual acuity screening test in the ED was performed using a Snellen chart (The visual acuity test is used to determine the smallest letters you can read on a standardized chart (Snellen chart) or a card held 20 feet (6 meters) away. Special charts are used when testing at distances shorter than 20 feet (6 meters) away, www.medlineplus.gov, 11/21/2022). The surveyor observed the area in the ED used for testing and the chart used. The chart stated it was to be used at 10 ft, the surveyor was shown where the patient would stand (at the edge of the doorway which was approximately 10 feet from the chart).

Staff #7 reviewed the exam process for the surveyor. Staff #7 stated the exam was performed in the hallway and there were no other staff members present at that time to observe the exam. Staff #7 stated there may have been individuals walking by but denied hearing anyone laugh at the patient at any time. Staff #7 did not recall Patient #4 complaining of eye pain during their interaction with them. Staff #7 was documented as a technician in the medical record and was asked what their role is in the ED. Staff #7 gave examples of duties i.e. bringing patients back to the room, doing EKG's, assisting patients with changing clothes and/or going to the bathroom, and sitting with patients requiring direct observation. Staff #7 stated they had just obtained their CNA (certified nursing assistant). Staff #7 was asked what training they had received in the administration of a visual acuity exam and replied they had been trained by Staff #11 (verbally instructed) and then observed administration of one test. Staff #7 was unable to provide a date when this training had occurred. Review of the personnel and training record of Staff #7 found they had received their initial nursing aide certification on 9/30/22 (Patient #4 was seen on 9/19/22). Any training related to administration of a visual acuity test that may or may not have been included in the course would not have been valid. Review of documentation of the orientation found Staff #7 completed a "Safety/Orientation Checklist" on 9/20/22, and completed an "Orientation Skills Checklist" for the position of CNA beginning on 10/3/22 and completed on 10/19/22. Job duties/responsibilities did not include the administration of a visual acuity test. In an interview with Staff #1 (Chief Nursing Officer) and Staff #2 on 11/17/22 the surveyor was informed that Staff #11 (the nurse Staff #7 stated provided visual acuity exam training) is a travel nurse and may not have been aware the exam was not a task that is delegated to unlicensed personnel at this hospital. Staff #1 stated all nurses will be instructed related to this (with an emphasis on education for travel nurses).

The above findings were discussed during above noted interviews and reviewed prior to exit on 11/17/22.