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A. Based on a review of staff training files, staff interview, a review of the Transfer Center Quality Assurance (QA) monitoring logs, and intake sheets, it was determined that for 6 of 6 (E#s 3, 4, 5, 6, 7 and 8) employee inservice files reviewed, the Hospital failed to ensure its QA process of the Transfer Center, monitored the training program for (PCS) Patient Case Specialists and the documentation completed by the PCS.

Findings include:

1. On 7/19/11 at approximately 11:00AM, staff training files for the employees who answer the Transfer Center Referral Call line were requested from the Patient Access Center Director. The Director provided 2008 to 2010 inservices for E#s 3-8 that did not include PCS training.

2. The Director was interviewed on 7/19/11, at approximately 11:45AM. The Director stated that the employees have ongoing training for PCS functions based on monthly audits that are accomplished by listening to incoming calls to the transfer center. Any issues of concern are discussed with the employee at the annual evaluation.

3. The quality monitoring log for 2009 and 2010 was reviewed on 719/11 at approximately 2:00PM. The log contained telephone audits by the Director. The QA audits did not include documentation requirements for completion of intake sheets. As a result, the Director and Administrative staff were not aware of incomplete, inconsistent and incorrect documentation by PCS staff prior to the survey.

Examples of incomplete intake sheet documentation:

- All patients are listed as an "inpatient transfer" without specifying if the patient is in the ER or is an inpatient. As a result, it cannot be determined if the patient is a direct transfer request from an outside ED or a in-house transfer.

- The intake sheet, dated 7/8/11 at 8:37 PM listed, "Type of Request-in patient transfer". The Pt. was actually in the ED of an Indiana Hospital and required pediatric orthopedic surgery.

- The intake sheet dated 4/2/11 at 12:00 PM listed the type of request as "inpatient transfer". The patient was listed as unstable but it could not be determined if this was an ER to ER request. The final disposition of the patient was not documented on the face sheet.

- The intake sheet dated 4/4/11 at 11:00AM, lacked complete vital signs of a patient who required ICU admission for blood product administration. The sheet indicates that a bed was assigned but there was no documentation if the patient was actually admitted to Hospital A.

-The intake sheet dated 4/1/11 at 8:15PM, included information that a patient required hospitalization for an acute MI. There were no vitals signs documented. The intake note included, "Dr. would like pt. brought to cath lab. Pt. is having an acute MI. Gave info to... Aeromedical Network." The final patient disposition could not be determined from the intake request form.

- The intake sheet dated 4/30/11 at 12:47PM, included a transfer request from an Indiana Hospital. The Pt. complained of severe chest pain and was listed as stable. There were no documented vital signs. A bed was assigned but the final disposition of the Pt. could not be determined. The last note included," Awaiting for Administrative approval".

4. The above findings were discussed with Administrative staff during an interview on 7/21/11 at approximately 4:00PM.

A. Based on review of the Hospital Quality Plan, emeregency department, (ED) clinical records, Clinical Operations Taskforce (COT) agendas and reports with the Emergency Department statistical data, COT plan and staff interview, it was determined that for 2 of 2 years (fiscal year 2010 and 2011) reviewed, the Hospital failed to ensure ED length of stay data was used to identify changes for improvement.

Findings include:

1. The Hospital Quality Plan was reviewed on 7/21/11 at 10:00 AM. The Plan included, "Developing and implementing recommendations and actions necessary to improve patient care processes, reducing the risk of harm to patients and improving patient safety through systems changes".

2. The clinical record for Pt. #20 was reviewed on 7/19/2011 at approximately 9:30 AM. Pt. #20 was in the emergency department (ED) approximately 42 hrs and subsequently required oral endotracheal intubation and medical intensive care unit admission on 7/18/11 at 8:42AM. This is a current example of an extended ED length of stay.
(07105)

3. The COT ED data for fiscal year (FY) 2010 and 2011 was reviewed on 7/21/11 at 9:00 AM. The data was reported as follows: (% = % of total patients)

- ED length of stay greater than 24 hours that were admitted - 10/10 - 20.1%; 11/10 - 17.2%; 12/10 -20.9%; 1/11 - 21.9%; 2/11 - 25.5% (increasing over time)

- Boarding Patients greater than 24 hours - 10/10 - 12.8%; 11/10 - 7.3%; 12/10 - 11.1%; 1/11 - 11.5%; 2/11 -14.3% (increasing over time)

- Time from physician disposition (admit decision) to inpatient assignment of general admission - 24-48 hours - 26%, greater than 72 hours - 10.1% (2 greatest populations)

- Time from physician disposition (admit decision) to inpatient assignment of non - general admission (specialty beds) - greater than 72 hours - 13.8%

- Arrival time to ED to admit - FY 2010 - 68.8% with length of stay greater than 8 hours; FY 2011 - 70% with length of stay greater than 8 hours (increasing over time)

4. The FY 2011 Plan (developed in July 2010) included the following goals and metrics:

- increase transfers to Mercy from current average of 1 case per day, to 3 cases per day

- improve throughput in the ED so that <8% leave without being seen and <15% of general patients wait >24 hours

- Discharge lounge utilization

5. During an interview the Chief of Quality on 7/21/11 at 12:15 PM, he indicated that the above actions had been taken and have been unsuccessful. He indicated that there have been no additional actions put in place due to the increase in length of stay as listed above. A new action plan for FY 2012 (started July 2011) has not yet been developed. The Chief of Quality indicated that the data is accurate, but additional data has not been correlated with the previous action plan.

A. Based on Facility policy review, clinical record review, and staff interview, it was determined that for 1 of 5 closed records reviewed (Pt.#20), the Facility failed to ensure vital signs and physical assessments were monitored for patients' safety in accordance with policy.

Findings include:

1. On 7/19/11 at approximately 9:30 AM, Facility policy #10.01 titled, "... Patient Assessment... Vital signs", was reviewed. The Policy included,"vital signs will be taken upon arrival to the ED..."

2. On 7/19/11 at approximately 10:00AM, Facility, "Core Nursing Standards of Care...Patient Care Standards" was reviewed. It included, "vital signs...will be obtained and documented as least every 4 hours or as ordered and immediately recorded on the EPIC flowsheet...Physical assessments will be completed...every shift or more often as patient's condition warrants...".

3. On 7/19/11 at approximately 10:30AM, Facility "Policy: PC 128 Documentation of Patient Care" was reviewed and included, "....Relevant patient data and patient care will be recorded as close to real time as possible..."

4. The clinical record for Pt. #20 was reviewed on 7/19/2011 at approximately 9:30 AM. Pt. #20 was in the emergency department (ED) approximately 42 hrs and subsequently require ED intubation and Medical Intensive Care Unit admission. Pt. #20, a 77 year old female, presented to the ED on 7/16/11 at 2:56 PM with complaints of shortness of breath and a cough. Pt. #20 was triaged at 3:03PM and listed with an acuity level of A2 (emergent).The triage assessment included," airway patent, breath sound with rales, frequent cough, dyspnea (shortness of breath) skin pink". The nurse failed to document vital signs upon arrival to the ED in accordance with policy. The first set of vital signs for Pt. #20 were documented at 5:22 PM on 7/16/11 approximately 2.5 hrs after arrival to the ED. Vital signs were: B/P 120/77 pulse 51(2 minutes later the pulse was documented as 103), resp 32, temp 98.1 F and SpO2 (oxygenation) of 96% with nasal cannula oxygen at 4 liters/minute. The first nursing assessment was dated 7/16/11 at 2:58PM, the nurse documented," airway patent, breath sounds with rales, frequent cough, dyspnea (shortness of breath)".

The nurse reported to the physician that Pt. #20 became increasingly short of breath at 4:27 AM on 7/17/11 with an O2 sat of 89%. Pt. #20 was endorsed to the day shift by nursing on 7/17/11 at 7:14AM. There was no subsequent nursing physical assessment or progress note between 7:14 AM on 7/17/11 and 4:35 PM on 7/17/11 (approximately 9 hrs.).Vital signs were taken at 10:00AM and again at 4:00PM which were stable: vital signs were 7/17/11 at 10:00 AM, B/P-113/53, pulse-102, resp-16, SpO2 97% 4L nasal cannula and 7/17/11 at 4:00 PM, B/P-113/66, pulse-111, resp-16, SpO2 98% 4L nasal cannula. According to policy, assessments are to be documented every 4 hrs.

The nurse notified the resident on 7/17/11 at 6:56PM that Pt. #20's oxygen saturation was 80% and Pt #20 was placed on a non-re-breather mask. On 7/17/11 at 8:41 PM the MICU Resident and medical student evaluated the Pt due to increased heart rate (151). On 7/18/11 at 12:15 AM (3hrs later) Pt. #20 required oral endotracheal tube insertion. The Pt. was admitted to MICU on 7/18/11 at 8:42AM.

5. On 7/21/11 at approximately 11:00 AM, in an interview with the ED Nurse Manager, the above findings were confirmed.