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Based on records reviewed and interviews the Governing Body failed for one patient (Patient #9) and six Unsampled Patients in a total sample of sixteen patients to ensure responsibility for managing the Hospital as the Hospital did not determine all of the Massachusetts National Guard's (MANG) role responsibilities.

Findings included:

Email, dated 12/22/2021, indicated National Guard Support for Hospitals. The Email indicated roles of duties that the MANG personnel may fulfill as the Hospital determines most beneficial:

-Patient observers primarily in the ED,

-Security support,

-In-Hospital (patient transport),

-Food service, tray delivery support.

The Hospital policy titled Patient Observation for Prevention of Harm (Non-Behavioral Health Units), dated 2/26/2019, indicated Patient Observers were used for patients who were assessed and determined to be at risk for safety and or harm to self and others.

A.) Regarding elopement:

The Hospital Report, dated 6/1/2021 to 1/6/2022 indicated:

-Unsampled Patient #1 was trying to elope through the ambulance bay doors.

-Unsampled Patient #2, a behavioral health patient, attempted to elope.

-Unsampled Patient #3 was brought to the ED for a (narcotic) overdose and was given Narcan (medication to reverse the respiratory depression effects of narcotics) on the scene, eloped before a provider conducted a medical screening examination.

- Unsampled Patient #4 eloped from the ED with Patient #9.

The Hospital report indicated Patient #9, awaiting inpatient psychiatric hospitalization, eloped from the Emergency Department with Unsampled Patient #4, Security Officers saw them leave the Hospital, apprehended them in the woods adjacent to the street and Police returned Unsampled patient #4 & Patient #9 to the ED.

Nursing Note, dated at 7:05 A.M. on 1/1/2022, indicated Patient #9 eloped from the Emergency Department with another patient and returned unharmed.

The Physician Note, dated at 8:45 A.M. on 1/1/2022, indicated Patient #9 tried to flee overnight.

During the interview, at 5:00 P.M. on 1/11/2022, Risk Manager #1 said MANG could not provide patient observation services because this required medical record documentation, the MANG did not have medical record access, and the MANG could not use paper medical record documentation [used for when the electronic medical record system was in down time (being updated)]. Risk Manager #1 said this was an Enterprise (Steward Corporate) decision (not the decision of the Hospital).

B.) Regarding Patient Observers:

During the interview, at 9:00 A.M. on 1/6/2022, Registered Nurse #1 said there were not enough sitters (also known as, Patient Observers).

The Hospital report indicated:

- Unsampled Patient #5, a behavioral health patient waiting inpatient bed placement , was not provided a Patient Observer for constant observation.

- Unsampled Patient #6, a behavioral health patient with suicidal ideation, waiting inpatient bed placement , was not provided a Patient Observer for observation.

The Hospital provided no documentation to indicate utilization or non-utilization of MANG services as a Patient Observer was the decision of the Hospital; despite Emergency Department patient care needs for Patient Observation.

Based on observations, records reviewed and interviews the Emergency Department (ED) Nursing Service failed for four patients (Patients #1, #2, #3, #4 & Unsampled Patients) to ensure assigning nursing care of each patient to nursing personnel in accordance with the patient needs and the specialized qualifications and competence of the nursing staff available (a Registered Nurse).

Findings included:

Regarding Patient #1:

During the interview, at 9:00 A.M. on 1/6/2022, Registered Nurse #1 said there were five patients that did not have an assigned nurse and those five patients were in Hallway spaces. Registered Nurse #1 said Patient #1 had no assigned nurse.

The Emergency Department Document, dated at 12:37 A.M. on 1/6/2022, indicated Patient #1 presented to the Emergency Department for nausea, vomiting coffee ground material, diarrhea, epigastric chest pressure and drinking at least a quart of liquor daily. Emergency Department Document indicated Patient #1 had a serum (blood) alcohol of 290 (high).

The Nursing Note dated at 9:12 A.M. on 1/6/2022, indicated one CIWA Alcohol Withdrawal Assessment of 19 (Sever Alcohol Withdrawal).

The Hospital policy titled Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) with Symptom Based Treatment Protocol, dated 4/7/2020, indicated acute withdrawal syndrome occurred when alcohol dependent individuals abruptly reduced or stopped drinking, characterized by tachycardia (high heart rate), diaphoresis (sweating), tremors, irritability, agitation, hypertension (high blood pressure), seizures and sometimes delirium in later stages. The CIWA policy indicated a score of 16 or greater was a patient with severe alcohol withdrawal and the nurse would assess the patient every 15-30 minutes using the CIWA Assessment.

The Surveyor observed, at 11:03 A.M. on 1/6/2022, the ED Tracker (electronic assignment sheet) indicated Patient #1 was not assigned a nurse; the ED Tracker indicated 12 patients were not assigned nurses [including Patients #2, #3, & #4 (Patient #4 triaged with an ESI of 2 for chest pain)]; (an ESI of 1 the patient needs life-saving resuscitation, an ESI of 2 the patient needs emergent care, an ESI of 3 the patient needs urgent care, an ESI of 4 the patient needs less urgent care, and an ESI of 5 the patient needs non-urgent care).

Regarding Patient #2:

Registered Nurse #1 said Patients #2 had no assigned nurse and Patient #2 was a Boarder.

The Hospital policy titled Patient Assessment, Reassessment and Documentation of Care in the Emergency Department, dated 10/20/2020, indicated a Boarder Patient was a patient who remained in the Emergency Department after the decision to admit (to the Hospital).

The Emergency Department Document (Physician Note), dated at 3:09 P.M. on 1/5/2022, indicated an elderly patient (Patient #2) had right sided low back pain, was diagnosed with a compression fracture of L# vertebra (the spine, back) and was discharged to home.

The PCS Discharge Summary (Nursing Note), dated at 2:33 P.M. on 1/5/2022, indicated Patient #2 had an ESI Score of 3 on Triage to the Emergency Department.

Regarding Patient #3:

During the interview, at 10:30 A.M. on 1/6/2022, Registered Nurse #2, said there was one patient (Patient #3) that had no assigned nurse and Patient #3 was a Boarder patient.

The ED Tracker indicated Patient #3 was not assigned a nurse.

The Emergency Department Document (Physician Note), dated 4:25 P.M. on 1/4/2022, indicated Patient #3 as an elderly patient, presenting to the Emergency Department with signs of a COVID-19 viral infection, in the setting of an exposure (to a person positive for the COVID-19 viral infection), fever, weakness and was admitted to the Hospital for observation.

The Triage Note, dated at 12:24 P.M. on 1/4/2022, indicated Patient #3 had an ESI Score of 3.

The General Medicine (Physician) Note, dated at 6:23 P.M. on 1/5/2022, indicated Patient #3 as positive for the COVID-19 viral infection.

Patient #4:

Emergency Department Record indicated the Hospital triaged Patient #4 at 8:22 A.M. on 1/6/2022 with an Emergency Severity Index (ESI) of 2.

The Rapid Medical Exam (a represent a complete history and physical examination), dated 8:24 A.M. on 1/6/2022, indicated a cardiac workup was begun.

A Chemistry Report, dated 1/6/2022, indicated a troponin level was normal (did not indicated a heart attack.

A Chest X-Ray Report, dated 1/6/2022, indicated Patient #4 had pneumonia.

During the interview, at 2:00 P.M. on 1/11/2022, Registered Nurse #3 said there were 6 unassigned patients in the Emergency Department (patients that were not assigned a nurse).

The Emergency Department failed to ensure an accurate and updated nurse assignment for each patient.