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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 NURSING SERVICES, was out of compliance.

A-397 A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available. The facility failed to ensure registered nurses were assigned to patients in accordance with patient needs and the qualifications and training of nursing staff.

Based on interviews and document review, the facility failed to ensure registered nurses were assigned to patients in accordance with patient needs and the qualifications and training of nursing staff.

Findings include:

Facility policies:

The Triage Emergency Department policy read, the purpose is to provide a standardized system whereby patients presenting to the Emergency Department (ED) are treated in order of priority based upon utilizing the Emergency Severity Index (ESI). Triage is performed by Registered Nurses (RNs) who have completed a formal triage orientation. A RN will triage all patients arriving to the ED to identify life threatening conditions and prioritize patients according to ESI. The patient is prioritized into one of five acuity categories: ESI acuity level 1 presentation includes patients who are unresponsive, intubated, apneic, and pulseless. ESI acuity level 2 presentation includes patients who are experiencing high-risk situations; new-onset confusion, lethargy, or disorientation; severe pain or distress; patients requiring two or more resources with a heart rate, respiratory rate, and/or oxygen saturation in the danger zone. ESI acuity level 3 presentations includes patients requiring two or more resources with vital signs not in the danger zone. ESI acuity level 4 includes patients who require only one resource. ESI acuity level 5 presentation include patients requiring no resources. Resources include: labs, ABGs, respiratory treatments, EKG< X-rays, CT/MRI/Ultrasound/angiography, IV fluids, IV/IM medications, specialty consultations, simple procedures, laceration repairs, Foley catheters, complex procedures.

The Staffing Guideline policy read, the purpose is to provide standardized evidence based staffing guidelines. Staffing in hospitals and healthcare systems is complex and closely associated with patient safety and outcomes. Due to fluctuation in hospital census across units, an associate may be needed to temporarily work on another unit. All associates are required to float to other units based on clinical competency and skill. Assignments will be based on documented clinical competency and skill. See Clinical Competency, Orientation, and Education.

The Organizational Plan for Provision of Patient Care policy read, critical care patient areas include the intensive care unit (ICU). The emergency and trauma services department includes the Emergency Department (ED). The other units include Medical, Surgical, Orthopedics and Oncology. Staff education is supported in the Nursing Division. The department is responsible for all orientation, continuing education, student clinical experiences and other required in-services.

Staffing plans are developed upon the level and scope of care that meets the needs of the patient population, the frequency of the care provided and a determination of the level of staff that can most appropriately provide the type of care needed.

The Hospital Scope of Services policy read, the Critical Care Services (ICU) has 12 fully monitored patient care rooms. The intensive care unit treats adult patients requiring a 1:1 and 2:1 level of care. The level of care in the ICU is greater than the available medical surgical area.

Facility documents:

The Governor's Expert Emergency Response Committee (GEERC) Medical Advisory Group Subgroup #5: Healthcare Staffing - Crisis Standards of care for Healthcare staffing read, crisis standards include cross training and "upskilling" of staff from less acute practice settings to critical care to create agility in the workforce. Examples include: clinical employees redeployed to serve as helping hands or on a care team, may be redeployed within a health system; non-clinical employees redeployed to function in support roles such as runners, unit clerks, screeners, stockers, and transport. Additionally, pairing outpatient and medical surgical nursing staff with experienced critical care staff.

The Helping Hands Orientation document read, the role of the primary RN is to coordinate patient care, responsible for delegating care to Helping Hands as appropriate based on competency and licensure, physician communication, documentation and all drip titrations. Helping Hands RN can complete the following based on competency and scope of care: assist with med pass as delegated; Q2h (every two hours) turns, keep track and coordinate assistance for help with turns; activities of daily living (ADLs) as appropriate per patient status; ambulation assistance; assist with procedures as delegated; documentation of care as outlined by unit standard or individualized plan of care; and lab draws as delegated.

1. The facility failed to ensure staff members temporarily reassigned to the Emergency Department (ED) were trained appropriately to provide safe patient care.

A. Medical record review revealed Patient #8 experienced a three hour delay in care when the patient presented with a fall, elevated heart rate and abnormal blood glucose level.

a. On 11/17/21 at 9:17 a.m., Patient #8 presented to the ED with an arrival complaint of a fall.

i. At 9:56 a.m., Patient #8 was triaged by RN #1. RN #1 documented Patient #8's heart rate as 111 beats per minute (BPM). The average heart rate range equals 60-100 BPM.

ii. At 9:59 a.m., RN #1 documented Patient #8's Emergency Severity Index (ESI) score as a 4. The ESI score was a tool used to determine the priority in which a patient presenting to the ED shall receive treatment. An ESI level of 4 meant the patient only required one resources as listed above in the Triage Emergency Department policy.

iii. At 10:06 a.m., RN #1 checked the patient's blood glucose level (the amount of sugar in your blood to provide energy throughout the body). The result was 67 mg/dL (milligrams per deciliter). Per the chart, the result was abnormal with a normal blood glucose range equaling 70-99 mg/dL.

iv. At 10:13 a.m., RN #1 provided orange juice, peanut butter and crackers to the patient.

v. At 12:46 p.m., the patient was assigned to be placed in ED room 10.

vi. At 1:02 p.m., the patient's blood glucose was checked, nearly three hours after the initial blood sugar check. The result was noted to be abnormal and decreased from 67 mg/dL to less than 10 mg/dL.

vii. At 1:15 p.m., dextrose 50% water was ordered to be given to the patient due to the low blood glucose.

viii. At 1:42 p.m., almost 30 minutes after the medication was ordered, dextrose 50% was administered to the patient. After administration of the medication, the patient's blood glucose level was rechecked and resulted as 32 mg/dL.

ix. At 2:57 p.m., the patient's blood draw had resulted. The patient's hematocrit (the volume of red blood cells as compared to the total volume of blood) and hemoglobin (a protein found in red blood cells) which were used to determine anemia (the loss of blood) resulted as 3.6 g/dL and 13.5%. The lab result was indicated as an abnormally low levels. The average Hemoglobin levels equal 12.0 g/dL to 15.5 g/dL for females and the average hematocrit level equals 35.5% to 44.9% for females.

x. According to the provider's assessment and plan, throughout the patient's ED course, her mentation did not improve. An intraosseous line (a line placed directly into the bone marrow for infusion of medications and fluids) and an internal jugular central line (a central line placed into the internal jugular vein for rapid administration of medications and fluids) were placed in the patient. The patient was determined to be in severe respiratory distress, was tachypneic, had an altered mental status and was determined to be critically ill. The patient continued to deteriorate throughout her ED stay. The family withdrew life support and made the patient comfort care. At 6:29 p.m., the patient went into cardiopulmonary arrest (the abrupt loss of heart and respiratory function) and was pronounced dead.

B. Interviews revealed RN #1 had not received training or orientation to the ED prior to work as the assigned triage nurse in the ED.

a. On 12/8/21 at 11:33 a.m., an interview was conducted with RN #1. RN #1 stated she worked in the pre-operative area as a pre-assessment nurse. RN #1 stated she had previous experience working in the ED but it had been 11 years. RN #1 stated a program called Helping Hands had been instituted in November so staff members in the facility could provide help to areas where there was not enough staff. RN #1 stated she did not volunteer for helping hands and it was something that she was told to do. RN #1 stated she did not receive any training or orientation prior to assisting in the ED.

RN #1 explained on 11/17/21, she was assigned to triage in the ED. RN #1 explained triage was where the RN completed an initial examination of each patient who presented to the ED. RN #1 stated she did not feel comfortable to do triage and took her concerns to the charge nurse. The charge nurse that day stated she was the only person there to do it. RN #1 was told the ED was really short staffed and so she did what she was told to do.

Patient #8 was discussed with RN #1. RN #1 explained she remembered the patient was diabetic. At the time Patient #8 arrived to the ED, two other patients also arrived seeking care. RN #1 stated she remembered checking Patient #8's blood sugar and the result was 67. She then proceeded to provide Patient #8 with crackers, juice and peanut butter. RN #1 stated it did not cross her mind to re-check the patient's blood sugar because she was overwhelmed with her assignment.

b. On 12/9/21 at 9:32 a.m., an interview was conducted with RN #4. RN #4 stated she worked in the ED and occasionally was assigned as the Charge RN in the ED. RN #4 stated the charge nurse in the ED oversaw assigning nurses to care for patients. RN # 4 stated the triage nurse assessed patients and determined their acuity before the patient was roomed in the ED to receive treatment. RN #4 explained acuity was generally determined by the amount of resources staff used to treat the patient. RN #4 stated any staff member in the ED was trained to triage patients. She explained the training was part of the orientation process. RN #4 stated there was a risk to patients if their ESI score assigned to them during triage was not accurate.

RN #4 stated when the ED had been short staffed, the facility sent resources such as helping hands, however tasks were often overwhelming. Additionally, she stated the staff sent to assist the ED did not have access or training to care for ED patients or ICU patients who were being held in the ED due to lack of beds in the ICU.

c. On 12/9/21 at 6:57 a.m., an interview was conducted with the Chief Nursing Officer (CNO) #6. CNO #6 stated Crisis Standards of Care had been implemented a few weeks prior to the interview when the incident occurred. CNO #6 stated the purpose of orientation was to validate the competencies of staff and their skills and it was important for staff to receive orientation because the patient population for each department was unique. CNO #6 further stated if staff did not receive a specific and detailed orientation it could contribute to variations in patients' care.

CNO #6 stated the facility had implemented a program called helping hands as part of the hospital's crisis standards of care. CNO #6 explained helping hands was when the facility redeployed associates who were non-traditional in patient care settings. The goal of helping hands was to help out units in need. CNO #6 stated helping hands were not assigned individual patients to provide care to.

CNO #6's interview was in contrast to prior interviews where helping hand nurses were assigned to positions where they were taking patient assignments.

C. Review of personnel files revealed lack of orientation and training.

a. Review of RN #1's personnel file revealed she had not received recent training to perform triage assessments in the ED and assign ESI scores to patients.

2. The facility failed to ensure staff members who floated to the ICU received appropriate training to care for ICU level of care patients.

A. Medical Record Review revealed Patient #6 patient experienced a delay in care.

a. Patient #6 was admitted on 11/23/21 for pyelonephritis (an inflammation of the kidney due to a specific type of urinary tract infection).

i. On 11/27/21 at 7:45 p.m., Patient #6 had an increased heart rate and decreased mental status which required a rapid response (an alert used to ask for extra assistance from staff due to a change in condition).

ii. Patient #6 was transferred to the ICU at 8:11 p.m.

iii. The medical record revealed a STAT (immediate) CT scan (a medical imaging technique used in radiology to obtain detailed images of the body noninvasively for diagnostic purposes) of Patient #6's head and chest was ordered on 11/27/21 at 8:20 p.m.

iv. A CT of the head was not completed until 11/28/21 at 1:53 p.m., which revealed patient #6 had a left intraventricular hemorrhage (bleeding inside of the brain) with suggestion of an active bleed. Patient #6 was airlifted to another facility to receive a higher level of care on 11/28/21 at 4:00 p.m., where she subsequently died.

B. Interviews with staff revealed nurses were floated to the ICU and cared for Patient #6 without ICU training.

a. On 12/8/21 at 10:32 a.m., an interview was conducted with RN #3. RN #3 was assigned to care for Patient #6 in the ICU from 7:00 a.m. to 7:00 p.m. on 11/28/21.

RN #3 stated she worked on the oncology unit; however, since her unit closed temporarily, she had been working on the orthopedic unit or was occasionally floated to the ICU. RN #3 stated she worked in the ICU 12 years ago but had not received updated training or orientation to the ICU prior to floating there. RN #3 stated if a nurse was not oriented and trained to a unit, there was a risk the patient could not receive the proper care.

b. On 12/8/21 at 1:01 p.m., an interview was conducted with RN #5. RN #5 cared for Patient #6 once the Patient was transferred to the ICU on the night of 11/27/21.

RN #5 stated she typically worked on the oncology unit but since it was closed, she worked on the orthopedic unit or the ICU. RN #5 stated she did not have previous ICU experience and had not received orientation to work in the ICU. RN #5 stated if a nurse did not receive training or orientation to the ICU there was a potential for patients to experiences a change in condition and other patient care could be missed.

c. On 12/9/21 at 6:57 a.m., an interview was conducted with the Chief Nursing Officer (CNO) #6. CNO #6 stated Crisis Standards of Care had been implemented a few weeks prior to the interview. CNO #6 stated the purpose of orientation was to validate the competencies of staff and their skills and it was important for staff to receive orientation because the patient population for each department was unique. CNO #6 further stated if staff did not receive specific detailed orientation it could contribute to variations in patients' care.

C. Review of personnel files revealed lack of orientation and training to the ICU.

a. Review of RN #3's personnel file revealed she had not received recent training or orientation to the ICU.

b. Review of RN #5's personnel file revealed she had not received recent training or orientation to the ICU.