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Based on documentation review, it was determined the Hospital failed to provide the Complainants related to 3 of 4 selected 2010 ED Complaints regarding patient care with a Written Notice Of Grievance/Complaint Decision and provided the Complainant of 1 of the 4 selected Complaints with an incomplete Written Notice Of Grievance/Complaint Decision.

Findings included:

1.) Please see Tags A 287 and A 288 for information regarding Complaints the Hospital received regarding the ED care of Patient #2, #3 and #4.

Documentation indicated the Complainants related to the Complaints regarding the ED care of Patients #2, #3 and #4 were not sent a Written Notice Of Grievance/Complaint Decision.

2.) Please see Tags A 287 and A 288 for information regarding a written Complaint the Hospital received regarding the ED care of Patient #1.

Review of a letter sent to the Complainant revealed it indicated a thorough investigation of the Complaint was conducted and the Complainant's concerns and complaints were relayed to the staff involved in Patient #1's care. The letter did not detail the steps taken to investigate the Complaint/Grievance, the results of the Complaint/Grievance Process and/or the date of completion date.

Based on interview and documentation review, it was determined the Hospital failed to thoroughly investigate 4 of 4 selected 2010 ED Complaints regarding patient care.

Findings included:

The Hospital's Patient Care Complaint/Grievance Policy and Procedure indicated the Hospital is committed to responding to all complaints/grievances and to using them as an opportunity to improve patient care. The Policy/Procedure also indicated it is the responsibility of the department director to follow-up on complaints/grievances and institute any investigation deemed necessary, and an investigation of a complaint/grievance includes: interviewing the complainant and the individual(s) named in the complaint/grievance; possibly reviewing the patient's medical record, an employee's file or physicians credentialing file and relevant policies and procedures and; interviewing witnesses or other individuals who may have knowledge pertinent to the alleged complaint/grievance.

1.) Documentation indicated the Hospital received a written Complaint regarding the ED care of Patient #1 from Patient #1's sister-in-law on 3/5/10. The Complaint alleged Patient #1; a patient with multiple health issues including diabetes and 2 back surgeries who presented to the ED with CHF and was waiting for a bed to open up in the CCU, was: literally ignored after 4:00 AM and only seen by a nurse twice; left lying on his back on a gurney for 13+ hours; not administered his usual medications and; not provided with appropriate diabetic care.

The Manager of Emergency Services (ES) was interviewed in person at 8:00 AM on 3/23/10. The Manager said an Investigation into the Complaint regarding Patient #1's ED care included a review of the Patient's medical record and interviews with staff who cared for the Patient and concluded: Patient #1 and his/her family were not happy about his/her prolonged ED stay/wait for an inpatient telemetry bed; Patient #1 was on continuous cardiac monitoring and pulse oximetry; Patient #1 may have had to wait for a blood sugar check and lunch and; there was some type of mix-up regarding who was to be Patient #1's Admitting/Attending Physician (a physician on the Hospitalist Service vs a physician from the Large Practice composed of Attending and Resident Physicians that are assigned to adult medical patients admitted to the Hospital through the ED; on a rotational basis) resulting in a delayed Admitting/Attending Physician Patient evaluation and the ordering of the Patient's usual medications. The Manager of ES was not sure how the mix-up regarding Patient #1's Admitting/Attending Physician occurred.

The Manager of ES also said Patient #1 and/or the Sister-in-law were not interviewed in regards to the 3/5/10 Complaint.

2.) Documentation indicated the Hospital received a Complaint regarding the ED care of Patient #2 from Patient #2 on 1/19/10. The Complaint alleged Patient #2; a patient brought in by ambulance with an irregular heart beat, waited 8 minutes to be seen and: his/her blood pressure was not appropriately monitored; the ED was dirty; the monitor screen looked like it was washed by a dirty mop and; there was blood on the Crash Cart. Patient #2 also indicated he/she asked to be immediately transferred because he/she was afraid of catching something in the Hospital and now; Patient #2 was afraid the transfer wouldn't be covered by his/her insurance.

Documentation related to the Follow-Up of Patient #2's Complaint indicated the Complaint issues were discussed with Patient #2 by telephone on 1/21/10 and Patient #2 was told his/her experience was not an example of the Hospital's usual operation and staff would be spoken to prevent similar occurrences. Documentation did not indicate the condition of the ED or the condition and/or functioning of the ED equipment were investigated.

3.) Documentation indicated the Hospital received a Complaint regarding the 2/27/10 ED care of Patient #3 from Patient #3 on 2/28/10. The Complaint alleged Patient #3; a patient brought in by ambulance convulsing, was administered ativan (an anti-anxiety/sedative medication) despite indicating he/she could not take ativan; had a reaction to the ativan and; was turned out onto the sidewalk to take a bus home. The Complaint also indicated Patient #3 needed to feel safe in obtaining his/her health care at the Hospital and the 2/27/10 care did not make Patient #3 feel safe.

Documentation related to the Follow-Up of Patient #3's Complaint indicated Patient #3 was urged to seek urgent care if experiencing symptoms he/she was concerned about and reassured that his/her concerns would be followed-up. Documentation did not indicate the ativan administration and/or Patient #3's discharge were investigated.

4.) Documentation indicated the Hospital received a Complaint regarding Patient #4's ED experience on 3/5/10. The Complaint alleged an ED staff member told Patient #4 he/she should have called his Primary Care Physician because he/she only had a knee injury and it wasn't an emergency and they were dealing with a trauma and the doctor would see him/her when the doctor could.

Documentation related to the Follow-Up of Patient #4's Complaint indicated an apology was made and Patient #4 was informed the staff member's behavior would be addressed. Documentation did not indicate a staff member was interviewed or followed-up with.

Based on documentation review, it was determined the Hospital failed to implement preventative actions and mechanisms that include feedback and learning throughout the hospital in relation to 4 of 4 selected 2010 ED Complaints regarding patient care.

Findings included:

1.) Please see Tag A 287 for information regarding a written Complaint the Hospital received regarding the ED care of Patient #1.

The Manager of ES was not sure how the mix-up regarding Patient #1's Admitting/Attending Physician occurred, but indicated there have been similar problems in the past, and the past problems were due to communication issues.

There was no Corrective Action Plan regarding the mix-up regarding Patient #1's Admitting/Attending Physician or the (possible) delay in obtaining Patient #1's blood sugar and lunch.

2.) Please see Tag A 287 for information regarding a Complaint the Hospital received regarding the ED care of Patient #2.

Because the Complaint regarding the ED care of Patient #2 was not thoroughly investigated, the need for a Corrective Action Plan related to the timeliness of the Patient's evaluation, blood pressure monitoring and/or the cleanliness of the ED and/or ED equipment was not determined/known.

Please see Tag A 701 for a listing of ED and ED equipment cleanliness issues identified on 3/23/10.

3.) Please see Tag A 287 for information regarding a Complaint the Hospital received regarding the ED care of Patient #3.

Because the Complaint regarding the ED care of Patient #3 was not thoroughly investigated, the need for a Corrective Action Plan related to medication administration and/or discharge planning was not determined/known.

4.) Please see Tag A 287 for information regarding a Complaint the Hospital received regarding the ED care of Patient #4.

Because the Complaint regarding the ED care of Patient #4 was not thoroughly investigated, the need for a Corrective Action Plan related to the staff member's behavior was not determined/known.

Based on documentation review, it was determined ED Medical Staff failed to recognize and address that Patient #1; an ED patient diagnosed with new onset CHF to be admitted to a telemetry unit, was not evaluated/treated by the assigned Admitting/Attending Physician in a timely manner.

Findings included:

A Pre-Hospital Care Report indicated Patient #1; a 65+ year old, awoke with difficulty breathing, and an ambulance was summoned. Ambulance personnel found Patient #1 in severe respiratory distress with vital signs of HR = 136, R = 30, B/P = 180/88 and oxygen saturation level = 98%, and: applied CPAP; established an IV line, applied a cardiac monitor and; transported the Patient to the Hospital's ED. Patient #1's medical history was significant for insulin-dependent diabetes, high blood pressure, a pacemaker insertion, atrial fibrillation, and a cardioversion performed the preceding day, and Patient #1's medications included: Aldactone; Altace; Cardura; Catapres; Coumadin; Norvasc; Lopressor; Demadex; insulin and; potassium chloride.

ED documentation indicated Patient #1 arrived at 5:17 AM; alert and oriented, with diminished breath sounds and vital signs of HR = 91, R = 20, B/P = 190/105 and oxygen saturation level = 100%. Patient #1 was placed in an ED treatment room and diagnostic and treatment interventions including an electrocardiogram, cardiac monitoring, continuous pulse oximetry, a 1-hour DuoNeb treatment, blood testing, a chest x-ray and BiPAP were ordered and provided/performed. Patient #1 did not have lower extremity edema and denied lung problems, chest pain/tightness and abdominal pain. Cardiac monitoring revealed a paced normal sinus rhythm.

Patient #1 was evaluated by ED Physician #1 at 5:55 AM.

ED Physician #1 noted Patient #1's history and medications and performed a physical examination. Documentation completed by ED Physician #1 indicated Patient #1 was breathing without difficulty and: also had a history of end-stage renal insufficiency, hyperlipidemia and cardiac disease; had scattered wheezing in both lungs and; required a hospital admission/telemetry monitoring.

Adult medical patients admitted to the Hospital through the ED are generally admitted to either the Hospitalist Service or a specific Large Practice composed of Attending and Resident Physicians; on a rotational basis.

Documentation timed 6:01 AM indicated ED Physician #1 discussed Patient #1 with the Admitting/Attending Physician #1 (a physician in the Large Practice composed of Attending and Resident Physicians) and wrote initial Physician Orders.

An untimed Telemetry Admission Order Sheet for Patient #1 indicated Patient #1 was to be admitted to Admitting/Attending Physician #1 and Patient #1's diagnoses were CHF and R/O MI.

Documentation indicated blood was obtained from Patient #1 at 6:05 AM and testing revealed a blood sugar level of 149 (normal = 74-118), a BUN level of 31 (normal = 8-20), a creatinine level of 2.18 (normal = 0.64-1.27) and a CK-MB of 14.6 (normal = 0.6-6.3). Documentation also indicated: Patient #1's chest x-ray revealed findings worrisome for CHF; ED Physician #1 reviewed Patient #1's blood testing and chest x-ray results and discussed them with Patient #1's family at 6:25 AM; Patient #1 was diagnosed with new onset CHF and; a nitroglycerin drip and IV Lasix were ordered.

An Emergency Department Order Sheet indicated Patient #1 was to be admitted to Admitting/Attending Physician #1 and a Telemetry Unit, Admitting/Attending Physician #1 was contacted and accepted the admission, and Patient #1's diagnosis was CHF. The Order Sheet also included orders for oxygen by nasal cannula and the nitroglycerin drip.

Nursing documentation indicated the nitroglycerin drip was started on Patient #1 at 5 micrograms (mcgs)/minute at 6:38 AM and a call was placed to Admitting/Attending Physician #1's coverage for Orders.

Documentation completed by ED Physician #1 at 6:58 AM indicated Patient #1 was discussed with the On-Call Physician for the Large Practice composed of Attending and Resident Physicians.

Nursing documentation indicated Staff RN #1 gave a change-of-shift report regarding Patient #1 to Staff RN #2 at 7:05 AM. Nursing documentation also indicated Patient #1's vital signs were monitored and the nitroglycerin drip was titrated up.

Documentation indicated the Telemetry Unit was full/a Telemetry Unit bed was not available for Patient #1.

Nursing documentation indicated Patient #1's vital signs were monitored and the nitroglycerin drip was titrated up. Nursing documentation also indicated: a fingerstick blood sugar was obtained on Patient #1 at 1:15 PM; blood was obtained from Patient #1 for testing at 2:21 PM; the blood testing revealed a CK-MB of 10.8; Staff RN #2 gave a change-of-shift report regarding Patient #1 to Staff RN #3 at 3:00 PM and; Staff RN #2 re-called Admitting/Attending Physician #1's coverage for Orders at 3:06 PM.

A written Complaint regarding the ED care of Patient #1 received by the Hospital on 3/5/10 indicated that around 4:00 PM, a doctor arrived at the Patient's bedside and indicated there had been a big mistake; the information regarding Patient #1 and the Doctor Patient #1 was assigned to had been messed up.

Documentation indicated Patient #1 was evaluated by Admitting/Attending Physician #2 (a physician from the Large Practice composed of Attending and Resident physicians) at 3:50 PM. Documentation completed by Admitting/Attending Physician #2 indicated there was a misunderstanding about which Admitting Team Patient #1 was assigned to resulting in a delay in Patient #1's Admitting/Attending Physician evaluation.

The delay in the Admitting/Attending Physician evaluation resulted in Patient #1 not receiving his usual medications.

Based on documentation review, it was determined ED Nursing Staff failed to recognize and address that Patient #1; an ED patient diagnosed with new onset CHF to be admitted to a telemetry unit, was not evaluated/treated by the assigned Admitting/Attending Physician in a timely manner.

Findings included:

Please see Tag A 347.

Based on interview and documentation review, it was determined there was a lack of communication regarding the administration of IV Lasix to Patient #1 and the lack of communication resulted in Patient #1; a patient diagnosed with new onset CHF, not receiving Lasix or another diuretic.

Findings included:

Please see Tag A 347 for information regarding Patient #1 and the ED care of Patient #1.

Documentation completed by ED Physician #1 indicated Patient #1 was diagnosed with new onset CHF and a nitroglycerin drip and IV Lasix were ordered.

A review of Physician Orders for Patient #1 did not reveal an order for Lasix.

Documentation completed by Staff RN #1 indicated an Order for 80 milligrams of IV Lasix for Patient #1 was cancelled due to a question of allergy and because Patient #1 had end-stage renal failure which was not being treated with dialysis. The documentation also indicated Staff RN #1 was awaiting another (diuretic) order.

A review of Physician Orders for Patient #1 did not reveal an order for another diuretic.

Documentation completed by ED Physician #1 indicated Patient #1 was started on a nitroglycerin drip and administered Lasix.

Documentation completed by Admitting/Attending Physician #2 indicated Patient #1 was administered Lasix in the ED and had a fair diuresis.

The V.P. of Patient Services/CNO was interviewed in person throughout the Survey. The V.P./CNO said Pharmacy documentation did not indicate Patient #1 was administered Lasix in the ED.

Based on documentation review, it was determined Physician Orders contained in Patient #1's medical record were not consistently dated and/or timed.

Findings included:

1.) A Telemetry Admission order Sheet was not dated or timed.

2.) A Physician Order Sheet containing orders for 13 medications was not timed.

Based on documentation review, it was determined Patient #1; an insulin-dependent diabetic ED patient awaiting an inpatient bed, was not provided with a meal tray in a timely manner.

Findings included:

Please see Tag A 347 for information regarding Patient #1 and the ED care of Patient #1.

An untimed Telemetry Admission Order Sheet for Patient #1 included orders for an 1800 calorie, no added salt, diabetic diet.

A written Complainant regarding the ED care of Patient #1 received by the Hospital on 3/5/10 indicated the Patient's family had to ask the nurse to take Patient #1's blood sugar, because the Patient was getting very shaky and needed something to eat.

Nursing documentation indicated a fingerstick blood sugar was obtained on Patient #1 at 1:15 PM.

The written Complaint indicated Patient #1 was brought a meal (lunch) tray over an hour after the fingerstick blood sugar was obtained.

The Manager of ES said the ED is the last area to receive meal trays.

Based on a tour conducted at 9:55 AM on 3/23/10, it was determined the ED was not being maintained in a manner that assures patient safety and well-being.

Findings included (but were not limited to):

The tour of the ED revealed a relatively new (opened in 2006) large department with 40+ treatment rooms, separate ambulatory and ambulance entrances, and flooring that was splattered with dark substances and littered with dust bunnies.

The tour also revealed:

> dusty stretchers in rooms #14, #20 and #21.

> foot stools splattered with dried, light and dark substances in the Zone 1 Medication Room and in rooms #14, #19 and #21.

> dusty metal rolling tables in rooms #17 and #19.

> waste cans splattered with dried, light and dark colored substances in rooms #17, #20, #21 and #23.

> dusty GYN exam tables in rooms #17 and #23.

> lower walls splattered with dried, dark colored substances in the Zone 1 bathroom and in rooms #20, #21 and #24.

> 5 dusty mobile computers (computers on wheels).

> 2 dusty EKG machines.

> a dusty GYN Cart, Precaution Cart and Open Thoracotomy Cart.

> dusty Ortho, Suture, Respiratory and Difficult Intubation Carts that were also splattered with dried, light and dark substances.

> dusty IV (supply) baskets and PAX screens/screen areas.

> that the walls, papers on the walls and the inside door of the Zone 1 Medication Room were splattered with dried substances in a variety of colors.

> sinks splattered with dried, light and dark substances in the Zone 2 Medication Room and the Restroom located near the Waiting Area.

> a Kitchenette refrigerator splattered with dried dark substances.

Based on interview and documentation review, it was determined a hospital bed was not made available to Patient #1; an ED patient who waited approximately 12 hours for an inpatient telemetry bed.

Findings included:

Please see Tag A 347 for information regarding Patient #1 and the ED care of Patient #1.

Medical record documentation indicated Patient #1 also had a history of back surgery.

The Manager of ES said hospital beds are not provided to ED patients with prolonged stays because the ED treatment rooms are not big enough for beds. The Manager of ES also said that as ED stretchers and/or stretcher mattresses are replaced, they are being replaced with thicker mattresses.

A tour of the ED revealed treatment rooms large enough to accommodate hospital beds.