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Based on document review, medical record (MR) review and interview, the facility did not ensure patients presenting to the emergency department (ED) were appropriately monitored for changes in their condition. Specifically, 1) in 10 of 20 MRs (Patient's #1 - #10) reviewed, ED staff did not document repeat vital signs (VS) during the patient's visit and/or at time of discharge. 2) In 1 of 1 (Patient #11) MR reviewed, of a patient who received moderate sedation, the MR lacked documentation of required monitoring e.g., VS, oxygen saturation (O2 sat), sedation score, etc.). The lack of repeat VS and monitoring of patients could lead to the inability to identify a patient's changing condition and untoward patient outcomes.

Findings related to 1) include:

-- Review of the hospital's policy and procedure (P&P) titled "Vital Signs (Triage & Duration of Stay)," reviewed 4/2020, indicated the hospital's ED standard assessment of VS should be completed on all patients as part of their triage assessment and repeated per category (triage/acuity level) and/or as ordered. Vital signs and neurological status, if applicable shall be monitored at least every: Level 1 - Resuscitation - every 5 minutes, Level 2 - Emergency - every 15 minutes, Level 3 - Urgent - every 30 minutes, Level 4 - Stable - every 1 hour, and Level 5 - Non-urgent - every 1 hour. Blood pressure (BP), pulse (P), respirations (R) and O2 sat will be reassessed just prior to and 5 minutes after any IV (intravenous) analgesia and/or as ordered by practitioner. Adult and pediatric patients will have discharge VS taken within 30 minutes before discharge.

-- Per review of Patient #1's MR, she was a 75-year-old female who presented to the ED on 7/11/2022 at 6:02 am with a chief complaint of chest pain. Past medical history included high BP and coronary artery disease (CAD). In April 2022 she had ST-elevation myocardial infarction (STEMI) and had 5 stents placed (at another facility). Her triage/acuity level was 3. Initial VS at 6:14 am were temperature (T) - 98.3 F (Fahrenheit), P - 84, R - 20, BP - 175/82, O2 sat- 100%. The next set of VS were not obtained until 8:57 am (2 hours and 55 minutes later).

-- Per review of Patient #2's MR, she was a 21-year-old female who presented to the ED via emergency medical services (EMS) on 6/23/2022 at 7:00 pm with a chief complaint of altered mental status. Unknown past medical history, however had past psychiatric admissions. Her triage/acuity level was 3. She indicated being suicidal and was having hallucinations. Initial VS at 7:00 pm were P - 93, R - 20, BP - 98/87, O2 sat - 98%. Patient #2 required a transfer to a higher level of care. The next set of VS were not obtained until 6/24/2022 at 6:13 am (13.25 hours later).

-- Per review of Patient #3's MR, she was a 77-year-old female who presented to the ED via EMS on 10/15/2022 at 3:47 pm with a chief complaint of cerebral vascular accident (CVA) and altered mental status. Past medical history included CAD, hypertension and diabetes. Her triage/acuity level was 2. Initial VS at 3:54 pm were P - 81, R - 18, BP - 136/86, O2 sat - 95%. Patient #3 required transfer to a higher level of care. Vital signs were repeated at 4:00 pm but then not done again until 5:30 pm (1.5 hours later). Patient # 3 was transferred at 6:19 pm, no further VS were documented.

-- Per review of Patient #4's MR, she was a 52 year-old female who presented to the ED via private vehicle on 9/15/2022 at 9:21 am for jaw pain and blurred vision in the left eye only. Past medical history included diabetes and hypertension. Her triage/acuity level was 4. Initial VS at 9:32 am were T - 98.6 F, P - 68, R - 18, BP - 182/90, O2 sat - 99%. The patient was discharged to home on 9/15/2022 at 1:00 pm (3 hrs and 39 minutes later) with no repeat VS.

-- Per review of Patient #5's MR, he was a 25 year-old male who presented to the ED via private vehicle on 8/1/2022 at 1:15 pm for abdominal pain. Past medical history included mitral valve prolapse and Crohn's colitis. His triage/acuity level was 4. Initial VS at 1:23 pm were T - 98.3 F, P - 77, R - 18, BP - 126/68, O2 sat - 98%. The next set of VS were not obtained until 7:35 pm (6 hours and 12 minutes later). The patient was discharged to home on 8/1/2022 at 7:37 pm.

The same lack of required VS was noted in the MRs for Patients #6, #7, #8, #9, and #10 (2 visits).

-- During interview of Staff A, ED Manager on 11/9/2022 at 11:30 am, he/she acknowledged the above findings.

Findings related to 2) include:

-- Review of the hospital's P&P titled "Moderate Sedation Analgesia," reviewed 6/2020, indicated during the intra-procedural period the registered nurse (RN) should continually assess the patient to ensure appropriate physiological support.

Physiologic monitoring should include documentation of the following: Continuous monitoring for changes in cardiac rate and rhythm, continuous oxygen saturation with documentation every 5 minutes, airway integrity every 5 minutes, VS every 5 minutes, sedation scale every 5 minutes, oxygen administration as ordered, intravenous fluid administration and drug dosages.

Post Procedure Monitoring (minimum of 30 minutes) - continuous cardiac monitoring, continuous pulse oximetry, oxygen therapy as needed, VS, sedation score (activity, respiration, circulation, consciousness, and O2 saturation) is obtained, sedation score and VS are assessed and documented every 15 minutes thereafter until discharge or transfer

Discharge Criteria - documentation of the sedation score will be completed prior to patient discharge. The score should return to baseline prior to being released.

The P&P included a 3-page document titled, "Administration Conscious Sedation (Moderate Sedation) Monitor with Discharge Criteria" (for use in MR).

-- Per review of Patient #11's MR, he was a 5-year-old male who presented to the ED on 7/22/2022 at 7:59 pm with a chief complaint of lip and facial laceration from a dog bite. Past medical history included autism and attention-deficit/hyperactivity disorder (ADHD). His triage/acuity level was 4. Initial VS at 8:13 pm were T - 97.6 F, P - 115, R - 16, BP - 103/68, O2 Sat - 98%. The patient's family was concerned about the wound on his lip, so the provider decided to place a suture in the lip for approximation and cosmetic purposes. Patient #11 was given Ativan 0.5 milligrams (mg) orally at 8:42 pm. This did not relax him. Versed 4 mg intranasal was ordered and administered at 10:01 pm. Provider documentation indicated the patient was calm and relaxed however, awake alert and conscious during procedure which started at 10:35 pm. Patient #1 was discharged at 11:05 pm (3 hours later). There was no documentation of required monitoring which should have included VS, O2 Sat, sedation level, etc. Also, the MR did not contain the form titled, "Administration Conscious Sedation (Moderate Sedation) Monitor with Discharge Criteria".

-- Per interview of Staff A on 11/9/2022 at 12:00 pm, they have been trying to develop a system-wide P&P for VS. Vital signs are taken at triage. A lot of patients seen in the ED have a short length of stay, similar to clinic visits. If the patient's VS are abnormal, they should be repeated and addressed with the provider. Frequency of VS is determined per the ESI triage level. They are looking to change all vital signs for ESI levels 4 and 5 to be repeated every 4 hours. The hospital went to EPIC (a new MR system) on 4/30/2022 and realized repeat vital signs were not being captured in the MR. A request has been submitted to have this function integrated into the MR but has not been done to date. Staff in the ED have been advised to print off the vital signs from the automatic monitors and then have them scanned into the MR or manually enter the vital signs. Staff A indicated the form for moderate sedation should have been completed for this patient. He/she acknowledged the above findings.

Based on observation, document review, and interview, 1) the hospital did not ensure all visitors entering the hospital were screened appropriately for potential exposure to COVID-19 including assessment of symptoms/illness based on New York State (NYS) guidance and the hospital's current screening process. 2) In 3 of 4 personnel records Staff H, Emergency Department (ED) Medical Director, Staff K, ED Physician Assistant, and Staff D, ED Registered Nurse (RN) reviewed each lacked an annual health assessment and annual screening for Tuberculosis (TB). This lack of screening could lead to transmission of COVID-19 and other communicable diseases.

Findings related to 1) include:

-- Per observation on 11/8/2022 at 9:00 am and 11/9/2022 at 8:30 am, the 3 NYS Department of Health surveyors entering the hospital did not have their temperature checked nor were asked any COVID-19 screening questions e.g., symptoms, travel, contact with a person with COVID, etc.

-- Review of the hospital's policy and procedure (P&P) titled "COVID-19 Visitor Screening and Restrictions - Effective June 30, 2022," last reviewed 6/29/2022, indicated visitors or support person must be symptom-free; therefore within the previous 10 days cannot have any respiratory symptoms, including fever of 100.4 F or higher or cough or shortness of breath and must not have knowingly been exposed to an individual with COVID-19. This will be communicated through signage at building entrance points and the expectation is the visitor will self-report that they are ill and will not enter the facility. Each inpatient visitor or support person will have their temperature taken upon arrival before entering the unit/department.

-- During interview of Staff G Director of Quality on 11/9/2022 at 3:00 pm, he/she acknowledged the above findings.

Findings related to 2) include:

-- Review of Staff H's personnel file revealed his/her last annual health assessment and TB screening was 2/2021.

-- Review of Staff K's personnel file revealed his/her last annual health assessment and TB screening was 10/2020.

-- Review of Staff D's personnel file revealed his/her last annual health assessment and TB screening was 3/2021.

-- Per interview of Staff I, Human Resources Site Lead on 11/9/2022 at 11:40 am, he/she received an email from the Occupational Health Specialist, Staff J, who confirmed the above findings.