HospitalInspections.org

Based on observation, interview, and record review, the facility's Governing Body failed to ensure the facility's operation was conducted in an effective, safe, and organized manner by:

1. Failing to ensure the Medical Director of the Emergency Department (ED) was a member in good standing of the medical staff according to the facility's organizational requirements. This failure could lead to a lack of organization and direction potentially impacting all ED staff and patients who present to the ED for care and treatment. (A0092),(A1111);

2. Failing to ensure three ED physicians had current Advanced Trauma Life Support (ATLS) and Pediatric Advanced Life Support (PALS) certifications(A0092), (A1110);

3. Failing to ensure the proctoring process for two ED physicians was completed, (A0092), (A1110);

4. Failing to ensure the documentation which indicated what medical privileges were granted for one ED physician were completed (A0092), (A1110);

5. Failing to ensure the ED was staffed with the appropriate numbers and types of professionals in accordance with State and Federal regulations (A0092),(A1112);

6. Failing to ensure the Registered Nurses in the ED implemented the transfer, discharge, and reassessment of patients (A0092), (A1112);

7. Failing to ensure the ED Registered Nurses provided a timely reassessment of pain medication after the medication's administration to two patients, (Patients 61 and Patient 9), (A0092), (A1112);

8. Failing to ensure the ED staff provided adequate supervision for two patients on 5150 holds (Patients 66 and 6) (5150- a section of the California Welfare and Institutions Code which allows a qualified person to involuntarily confine a person suspected to have a mental disorder that makes him/her a danger to self, a danger to others, and/or gravely disabled) (A0092), (A1112);

9. Failing to ensure an ED room, Room 7, was safe, secure, easily identifiable, and adequately furnished in order to provide appropriate medical care to all patients. (A0092) (A1100);

10. Failing to ensure the emergency contacts were notified when four patients under 5150 hold eloped and/or were transferred from the facility. (A0092) (A1100);


The cumulative effect of these systemic problems resulted in failure of the Governing Body to ensure patients were receiving quality care in a safe and effective manner.

Based on observation, interview and record review, the facility failed:

1. To ensure the Medical Director of the Emergency Department (ED) was a member of the medical staff, in good standing, according to the facility's organizational requirements. This failure could lead to a lack of organization and direction potentially impacting all ED staff and patients who present to the ED for care and treatment.

2. To ensure three ED physicians had current Advanced Trauma Life Support (ATLS) and Pediatric Advanced Life Support (PALS) certifications;

3. To ensure the proctoring process for two ED physicians was completed;

4. To ensure the documentation which indicated what medical privileges were granted for one ED physician were complete;

5. To ensure the ED was staffed with the appropriate numbers and types of professionals in accordance with State and Federal regulations;

6. To ensure the ED Registered Nurses (RN) implemented the transfer and discharge reassessments of patients;

7. To ensure the ED RN's provided reassessments of the effect of pain medication after the medication's administration to two patients, (Patients 61 and Patient 9);

8. To ensure the ED staff provided adequate supervision for 2 patients on 5150 holds (Patients 66 and 6) (5150- a section of the California Welfare and Institutions Code which allowed a qualified person to involuntarily confine a person suspected to have a mental disorder that makes him/her a danger to self, a danger to others, and/or gravely disabled);

9. To ensure an ED room, Room 7, was safe, secure, easily identified, and adequately furnished to provide appropriate medical care to all patients;

10. To ensure the emergency contacts were notified when four patients under 5150 hold (a mandatory 72 hour hold on patient/s due to being a danger to themselves or others) eloped and/or were transferred from the facility.

These failures had the potential to directly impact the safety and provision of adequate medical care provided for patients in the ED.

Findings:

1. An interview was conducted with the Medical Staff Coordinator (MSC) on January 28, 2015, at 9:15 a.m. The MSC stated the ED Medical Director is not a member of the medical staff.

An interview was conducted with the Medical Director of the ED on January 28, 2015, at 1 p.m. The Medical Director stated he was not a member of the facility's medical staff.

A review of the facility's ED organizational chart, approved by the medical executive committee March 11, 2014, was conducted. The organization chart indicates the Chief Nursing Officer, the ED Manager, the ED Triage Nurse, the ED Nursing Staff, and the ED clerk all report directly to the ED Medical Director.

A review of the policy, "Emergency Room Organizational Chart Description (Approval Date 3/11/14)," was conducted. The policy indicated, "The Emergency Department Medical Director reports to the Chief of Hospital Medical Staff. The Emergency Department Medical Director is responsible for supervising and evaluating the quality, safety and appropriateness of patient care."

A review of the Emergency Departments Professional Services Contract and Medical Directorship Agreement (dated June 15, 2013, scheduled to end March 15, 2015) indicated the (ED physicians) group shall comply with the protocols and the bylaws, guidelines, policies and rules applicable to other Medical Center (the facility) physicians. Item 1.4.,...appointment of the Medical Director indicated, "This appointment shall be made in accordance with the terms of this Agreement and in accordance with the Bylaws and rules and Regulations of medical staff".

A review of the facility's Medical Staff By-Laws indicated under Article V, item 5.1-2"... Contract Physician, A practitioner who is or who will be providing specified professional services pursuant to a contract with the Hospital must meet the same membership qualifications, must be processed for appointment, reappointment, and clinical privileges in the same manner, and must fulfill all of the obligations of his membership category as any other applicant or medical staff member."

An interview was conducted with the ED Manager on January 29, 2015, at 9:50 a.m. The ED Manager stated, "The ED Medical Director rarely, if ever comes to the hospital and he does not attend the staff meetings."

An interview was conducted with the Medical Director of the ED on January 28, 2015, at 1:15 p.m. The Medical Director stated he was not aware of the challenges identified by the ED staff with 5150 patients nor was he aware of the ED not meeting regulatory requirements.

2. During an interview with the Medical Staff Coordinator (MSC), on January 28, 2015, at 10 a.m., the MSC stated the ED physicians were required to meet the qualifications as indicated in the medical staff by-laws.

A review of the by-laws indicated all physicians requesting privileges in emergency medicine were to be certified or board prepared by the American Board of Emergency Medicine or its equivalent, or successful completion of an accredited residency in emergency medicine.

The by-laws further indicated if the physician was not certified or board prepared in emergency medicine, the physician would provided current certifications to include ATLS (Advanced Trauma Life Support) and PALS (Pediatric Advanced Life Support).

On January 28, 2015, at 10:10 a.m., a review of the credentialing files for the ED physicians revealed the following;

a. ED Physician 2 was not board certified or board prepared in emergency medicine. The file contained an ATLS certification with the expiration date of August 2014.

b. ED Physician 3 was not board certified or board prepared in emergency medicine. The file contained a PALS certification with the expiration date of April 2014.

c. ED Physician 4 was not board certified or board prepared in emergency medicine. The file failed to show a PALS and an ATLS certification.

3. The document titled "...(Name of facility) Medical Staff Rules and Regulations" undated, indicated "Proctoring. Purpose. The purpose of proctoring...is to ensure...that said appointee is duly qualified to perform procedures and render care according to generally accepted standards of care..."

The policy and procedure titled "Proctoring" revised May 2009, indicated "Core and Advanced Proctoring Requirements...Emergency Medicine- First ten (10) Emergency Medicine patients seen..."

On January 28, 2015, at 10:10 a.m., a review of the credentialing files for the ED physicians was conducted. The review revealed the following;

a. For ED Physician 1, nine of the required 10 proctoring cases were completed.

b. For ED Physician 5, nine of the required 10 proctoring cases were completed.

4. On January 28, 2015, the credentialing file for ED Physician 1 was reviewed. The form titled "Emergency Medicine Privilege Delineation Form" for the years 2012, and 2013, indicated requests made by ED Physician 1 to perform multiple procedures. The areas designated on the form to indicate if the requests made by the physician were granted or denied, were blank.

During an interview with the MSC, on January 28, 2015, at 10:10 a.m., the MSC reviewed the forms and stated the forms were not complete.

5 a. On January 26, 2015, at 1:10 p.m., observations of the ED were conducted with the Chief Nursing Officer (CNO). There were 12 individuals observed in the ED waiting area. Seven of the 12 individuals were observed to have hospital identification arm bands.

Observations were made of a Registered Nurse (RN) 3 triaging two patients.

In an interview with RN 3, at 1:10 p.m., she stated the ED staff consisted of one RN to triage patients, and one RN and one Licensed Vocational Nurse (LVN) assigned to provide care for patients in the main ED area. RN 3 stated there was a total of seven beds in the ED.

RN 3 further stated the responsibilities of the triage nurse included to triage the walk-in patients as well as patients brought in by ambulance; to conduct the LVN's patient assessments, and to administer intravenous medications for the LVN's assigned patients.

An observation of the main ED area at 1:40 p.m., revealed patients in beds 2, 4, 5, and 6. There was no nurse observed in the main ED.

RN 3 left the triage area at 1:40 p.m., to triage a patient brought in by ambulance. RN 3 was asked who was responsible for the triage area when she was providing care for patients in the main ED. RN 3 stated "No-one. She (referring to the ED admitting clerk) will call me."

LVN 2 and the ED Manager (EDM) entered the main ED at 1:50 p.m.

An interview was conducted with LVN 2, on January 26, 2015, at 1:55 p.m. LVN 2 stated she was assigned to provide care for the patients located in beds 4, 5, 6, and 7. LVN 2 stated it was the triage nurses responsibility for the assessment of the LVN's patients. LVN 2 stated it was the triage nurse's responsibility to administer all intravenous medications for the LVN's patients.

An interview was conducted with the EDM, on January 26, 2015, at 2 p.m. The EDM stated staffing for the ED was one RN in triage, and one RN and one LVN assigned to provide care to the patients located in the main ED. The EDM stated the RN assigned to triage was also responsible for the oversight of the LVN's patient assignment, and responsible for the triage of all walk-in patients, patients brought in by ambulance, or by the police department.

b. An observation of the ED was conducted on January 27, 2015, beginning at 8:30 a.m. There were patients located in beds 1, 3, and 6. There was one individual in the ED waiting room wearing a hospital identification band.

There were two nurses observed in the main ED (LVN 2, and RN 1).

There was no nurse observed in the triage area.

During an interview, RN 1 stated she did not know where the triage nurse was, but she may have assisted a patient outside. RN 1 stated nurses working in the ED were responsible for assisting patients to their cars after being discharged, and nurses were also responsible for taking laboratory specimens that they (the nurses) had collected, to the laboratory department.

The facility policy and procedure number "623.02" dated March 12, 2014, indicated, "The purpose of this policy is to design and define the scope of services for the Emergency Department which are organized to deliver safe and effective nursing care for any patient presenting with urgent medical problems...To provide quality care for all patients who arrive at the Emergency Department 24 hours a day...To meet regulatory and accrediting agency guidelines..."

An interview was conducted with the EDM, on January 27, 2015, at 3:55 p.m. The EDM stated the staffing of RN's in the ED did not coincide with the regulatory requirements.

c. The ED was observed on January 29, 2015, beginning at 9:45 a.m. Four male individuals were observed in the ED waiting room. Three individuals were wearing hospital identification bands. There was no nurse in the triage area. There was one LVN (LVN 3) observed in the main ED

During an interview with LVN 3, on January 29, 2015, at 9:50 a.m., LVN 3 stated she did not know where the triage nurse was. LVN 3 stated there were three patients waiting to be triaged in the waiting room, and she informed the House Supervisor (HS) who was starting intravenous (in the vein) medication for one of patients located in the main ED.

The documents completed by the three patients waiting to be triaged was reviewed. The documents titled "Patient Sign-In Sheet" dated January 29, 2015, indicated the following:

1. "Time In...8:15 a.m. January 29, 2015....Reason for Emergency Room Visit...Infection to lower left leg, worsening..."
2. "Time In...8:19 a.m. January 29, 2015...Reason for Emergency Room Visit...Having seizures every two hours all night last night...Medical History...low blood pressure, diabetes..."
3. "Time In...9:15 a.m. January 29, 2015...Reason for Emergency Room Visit...Ear pain, dry scratchy throat, cough..."

At 10:05 a.m., the Chief Nursing Officer (CNO) entered the triage area. There was no nurse in the triage area. The CNO was informed by the surveyor there were three patients waiting to be triaged in the waiting room. The CNO was informed one had been waiting since 8:15 a.m., or for one hour and 50 minutes, one patient had been waiting for 1 hour and 54 minutes, and one patient had been waiting for 50 minutes to be triaged.

The facility policy and procedure number "623.02" dated March 12, 2014, indicated "The purpose of this policy is to design and define the scope of services for the Emergency department which are organized to deliver safe and effective nursing care for any patient presenting with urgent medical problems...To provide quality care for all patients who arrive at the Emergency Department 24 hours a day...To meet regulatory and accrediting agency guidelines..."RN Assessment. Triage within 15 minutes of arrival..."

6. On January 27, 28, and 29, 2015, the ED records for 21 ED patients were reviewed. The records reviewed indicated LVNs provided the transfer and discharge reassessments, and the reassessment of medical conditions for the 21 ED patients.

During an interview with the EDM, on January 27, 2015, beginning at 3:55 p.m., the EDM stated the transfer, discharge, and the reassessments of a patients medical condition were to be implemented by an RN.

The facility policy and procedure titled "Assessment/Reassessment of Patients" dated March 2014, indicated "...Reassessments are completed by RN's. Data may be collected by the LVN."

7 a. On January 26, 2015, at 1:20 p.m., RN 3 was observed triaging Patient 62. The chief complaint for Patient 62 was severe back pain with a numerical rating of 10 on the scale of 1-10 (the number 10 representing the most severe pain).

RN 3 reviewed the triage information collected with the physician, and received an order for pain medication for Patient 62. At 1:30 p.m., RN 3 administered two tablets Norco ( pain medication) to Patient 62, and directed Patient 62 to return to the ED waiting area.

During an interview with RN 3, on January 26, 2015, at 1:35 p.m., RN 3 stated patients in the waiting area were reassessed every two hours "If I can get to them."

A review of Patient 62's record was conducted on January 26, 2015. The record indicated RN 3 reassessed Patient 62's back pain at 3:32 p.m., or one hour and 58 minutes after the pain medication was administered.

The facility's policy and procedure titled "Assessment/Reassessment of Patients" dated March 2014, indicated " Emergency Department, Reassessment parameters...If in the lobby waiting must be done every 30 minutes."

b. A review of Patient 9's record was conducted. Patient 9 presented to the ED on January 2, 2015, at 1:57 p.m., with a diagnosis of gastroparesis (paralysis of the stomach muscles) and acute abdominal pain.

Based on a scale from 1-10, with 10 representing the most severe level of pain, Patient 9's pain level at 2:30 p.m. was a level 10, and at 3:27 p.m. was a level 10.

An interview was conducted with the EDM on January 27, 2015, at 4:15 p.m. The EDM stated with intravenous pain medication a patient's pain level needs to be reassessed in 30 minutes.

Patient 9 received Dilaudid 1 milligram (narcotic pain medication), intravenously at 3:41 p.m., and at 5:14 p.m. The record failed to show a reassessment of his pain level within a half hour of receiving the medication.

8 a. The record for Patient 66 was reviewed on January 27, 2015. Patient 66 presented to the ED on January 19, 2015, with the chief complaint of "5150."

The nursing triage assessment dated January 19, 2015, at 7:24 p.m., indicated patient 66 was having thoughts of suicide (killing himself).

The physician documentation dated January 19, 2015, at 8:46 p.m., indicated Patient 66 had a history of depression, and was having suicidal thoughts.

During an interview with the EDM, on January 27, 2015, at 3:55 p.m., the EDM reviewed the record and was unable to find documentation that indicated an attendant was provided for Patient 66's safety prior to January 20, 2015, at 9:47 a.m., or 11 hours and 59 minutes after the patient's arrival to the facility.

b. A review of Patient 6's record was conducted. Patient 6 was brought to the ED by law enforcement on January 10, 2015, at 4:45 a.m. The patient was placed on a 5150 hold as the patient was deemed gravely disabled due to a mental illness.

Patient 6 was transferred to a psychiatric facility on January 12, 2015, at 3:05 a.m.

The record failed to show that Patient 6 was observed by a sitter until 10:54 a.m., on January 10, 2015, 6 hours after admission to the ED.

An interview was conducted with the ED Registered Nurse (RN) 3 on January 26, 2015, at 2 p.m. RN 3 stated if a patient under a 5150 hold is in the ED, a sitter must be with the patient.

The facility policy and procedure titled "5150 Psychiatric Hold Patients" dated November 2014, indicated "If a patient on a 5150 hold is brought into the emergency Department by law enforcement, the officer will stay with the patient until Emergency room staff is available to provide one to one care/supervision and it is determined that the patient does not pose an immediate threat to him/herself, the staff or other customers. Suicide precautions: Arrange for close observation by an attendant..."

9. An observation of the Emergency Department (ED) was conducted on January 26, 2015, beginning at 1:10 p.m. The ED information board (used to identify what nurse was providing care for each room) indicated there was a total of six ED rooms. The board indicated there was a nurse assigned to rooms 1, 2, and 3, and a nurse assigned to rooms 4, 5, and 6.

During an interview with Licensed Vocational Nurse (LVN) 2, on January 26, 2015, at 1:40 p.m., LVN 2 stated the information board did not list ED room 7. LVN 2 stated the LVN assigned to rooms 4, 5, and 6, also was assigned to room 7.

During an interview with Correctional Officer (CO), on January 26, 2015, at 1:50 p.m., the CO stated he had brought in a patient to be evaluated for complaints of abdominal pain. The CO stated the patient was located in ED room 7 which was located through a closed door outside the main ED. The CO stated he was looking for the nurse assigned to ED room 7 because the patient needed something for pain.

The CO stated he had brought numerous patients to the facility over a 12 year period and "They always put us out here."

An interview was conducted with Laboratory Technician (LT) 1, on January 27, 2015, at 8:45 a.m., LT 1 stated it was difficult identifying what nurse was assigned to ED room 7 because the information board did not indicate a bed 7.

During an interview with Radiology Technician (RT) 1, on January 28, 2015, at 1:50 p.m., RT 1 stated he had taken portable X-rays for patients located in ED room 7 many times. RT 1 stated if a patient was in distress while taking an X-ray, he would have to leave the room to find a nurse because there was no emergency call system for the room.

On January 27, 2015, at 9:35 a.m., an observation of ED room 7 was conducted with the Emergency Department Manager (EDM). In a concurrent interview, the EDM stated ED room 7 was primarily used for patients brought in by Correctional Officers and the police department.

There was no emergency call light system observed in the room.

The EDM was asked how would a patient let staff know if the patient required assistance. The EDM stated "We would just have to check them."

Two cabinets located in ED room 7 were observed to be unlocked. The cabinet contents included three 25 gauge (a measurement of size) needles and one vacutainer (a blood collection tube with a needle attached).

The EDM stated the cabinets should be locked to prevent unauthorized access.

There was no oxygen tubing observed in the room.

The EDM stated the room should contain with all equipment required to meet the emergency needs of the patients.

10. An interview was conducted with the EDM, on January 27, 2015, at 3:55 p.m., the EDM stated it was the facility's practice to notify the patient's responsible party (RP) or emergency contact, if the patient was transferred or had eloped from the facility.

The records for four patients who presented to the ED with the chief complaint of 5150 were reviewed on January 27, 2015, with the EDM. The records indicated the following:

a. Patient 67 who presented to the ED on January 19, 2015, with thoughts of committing suicide (thoughts of killing oneself) was transferred to a mental health facility on January 21, 2015.

b. Patient 64 who presented to the ED on January 22, 2015, with homicidal thoughts (thoughts of killing others), eloped from the facility on January 23, 2015.

c. Patient 66 who presented to the ED on January 19, 2015, with thoughts of committing suicide, was transferred to a mental health facility on January 20, 2015.

d. Patient 1 who presented to the ED on May 16, 2014, with thoughts of committing suicide, eloped from the facility twice, on May 16, 2014. Patient 1 was not located the second time he eloped and was found deceased in the Colorado River May 17, 2014, by law enforcement.

The EDM was unable to find documentation that indicated the patient's RP or emergency contact was notified when Patent 66 and 67 were transferred to another facility, and when Patient 64 eloped from the facility.

Based on interview and record review, the facility failed to ensure Patient Rights were protected by:

1. Failing to ensure a prompt resolution and follow up with patient grievances for four patients (Patients 46, 47, 48, and 50), one of which included a potential abusive situation. This failed practice reflected a lack of follow up with multiple patient sensitive issues which could impact the ongoing quality and delivery of care in the ED. (A118)

2. Failing to ensure emergency contacts were notified when four 5150 patients (patients on a mandatory 72 hour hold due to being a danger to themselves or others) eloped and/or were transferred from the facility. (A0117) and;

3. Failing to ensure an ED room, Room 7, was safe, secure, easily identified, and adequately furnished in order to provide appropriate emergency care services to patients assigned to that room. (A0144).


The cumulative effect of these systemic problems resulted in failure of the facility to ensure patients were receiving quality care in a safe and effective manner.

Based on interview and record review, the facility failed to ensure the emergency contacts were notified when four 5150 patients (patients on a mandatory 72 hour hold due to being a danger to themselves or others) eloped and/or were transferred from the facility.

Findings:

An interview was conducted with the Emergency Department Manager (EDM), on January 27, 2015, at 3:55 p.m. The EDM stated it was the facility's practice to notify the patient's responsible party (RP) or emergency contact, if the patient was transferred or had eloped from the facility.

The records for four patients who presented to the Emergency Department (ED) with the chief complaint of 5150 were reviewed on January 27, 2015, with the EDM. The records indicated the following:

a. Patient 67 who presented to the ED on January 19, 2015, with thoughts of committing suicide (thoughts of killing oneself) was transferred to a mental health facility on January 21, 2015.

b. Patient 64 who presented to the ED on January 22, 2015, with homicidal thoughts (thoughts of killing others), eloped from the facility on January 23, 2015.

c. Patient 66 who presented to the ED on January 19, 2015, with thoughts of committing suicide, was transferred to a mental health facility on January 20, 2015.

d. Patient 1 who presented to the ED on May 16, 2014, with thoughts of committing suicide, eloped from the facility twice, on May 16, 2014. Patient 1 was not located the second time he eloped and was found deceased in the Colorado River May 17, 2014, by law enforcement.

The EDM was unable to find documentation that indicated the patients' RP or emergency contact was notified when Patent 66 and 67 were transferred to another facility, and when Patient 1 and Patient 64 eloped from the facility.

Based on interview and record review, the facility failed to establish prompt resolution of patient grievances for four patients (Patients 46, 47, 48, and 50), to include one potential abuse issue. This failed practice reflected a lack of follow up with multiple patient sensitive issues which could impact the ongoing quality and delivery of care in the Emergency Department (ED), and lead to further unresolved grievances.

Findings:

The grievance log was reviewed on January 28, and 29, 2015. The dates reviewed were January to December, 2014. The grievance log reflected grievances regarding the service patients received in the ED. Many of the grievances had no follow up. Some were not investigated timely and had no documentation to indicate the complainants were notified of the outcomes.

The grievances were either completed by the by the complainant/ (patient ) or by the parent for a minor.

The grievances reviewed included the following:

a. Patient 46, a 17 year old female, presented to the ED on October 26, 2014, accompanied by her father. Patient 46 complained of pain in her lower abdomen with urinary frequency. Patient 46 complained the physician (ED physician 5) felt her breast and made her uncomfortable. Patient 46 felt the physician was "smirking." The grievance documentation indicated Physician 5 asked her if she was pregnant. Patient 46 stated she was on birth control and Physician 5 was laughing while touching her lower abdomen; made fun of her and made her feel humiliated and embarrassed.

The documentation on the grievance form indicated the facility had apologized to the patient for the physician and indicated the form would be forwarded to the President/Medical Director. The section titled, "Outcome/Patient/ Significant Other response to Action Taken" was left blank on the form. The date of service for this encounter was October 26, 2014.

b. Patient 47 was a 4 year old male presented to the ED accompanied by his mother on September 7, 2014. Patient 47's diagnosis included seizures. The patient was brought to the facility's ED by ambulance. While in the ED the patient had a seizure, turned blue and the nurse brought over oxygen.

During the patient's seizure, the parent stated Physician 5 walked over to the nurse and asked the nurse if they had his (the physician's) cell number and left.

The CEO documented on the grievance form that Physician 5 told the parent an ear infection caused the fever and discharged the patient. The parent stated she was uncomfortable leaving the facility with her child in this state. The physician then told the parent that he needed the bed for more critical patients and that she and her child could wait in the chair until they were ready to leave. The parent left the facility and drove to the nearest children's hospital more than 200 miles away.

Additional documentation on the form documented by the CEO indicated the following comment:

"Advised that her complaint will be addressed with the ER Director". There was no indication on the form that the ER/ED Medical Director had been notified of the grievance. This encounter was dated October 17, 2014.

c. Patient 48 was an 18 year old male who presented to the ED on September 14, 2014, accompanied by his father. Patient 48 had a medical history of documented psychiatric issues. The documentation on the grievance form indicated according to Patient 48's father, Physician 4 spoke to him rudely and he was not going to accept the physician's behavior.

The CEO documentation on the grievance form indicated that they were going to refer the father's concerns to the President and Medical Director on September 15, 2014.

There was no documentation on the form that the grievance had been followed up by the President/Medical Director and no outcome was listed on the form. The date of service for this encounter was September 14, 2014.

d. Patient 50 presented to the ED with a complaint of nausea on December 26, 2014. Patient 50 asked for medication for nausea, and informed the physician that the medication he suggested for her Zofran (antiemetic) did not work well for her.

The documentation on the grievance form indicated Physician 5 stated to Patient 50, "...why because it doesn't get you high?" Patient 50 stated the medication did not work, and she suggested phenergan or compazine (antiemetics) worked better.

The documentation on the grievance form indicated Patient 50 stated Physician 5 told her that he was just waiting for her to say, I wanted to get high. Patient 50 stated she was there to get help not to get high. The documentation on the form also indicated Patient 50 stated she felt very humiliated by Physician 5's comment and the fact that there were other people in the room at the time.

On December 26, 2014, the CEO wrote on Patient 50's complaint that the facility apologized for the patient's encounter with the Emergency Room physician and that the complaint would be referred to medical staff.

The grievances/complaints with blank areas where intervention /followup information was not documented on the forms and no physician intervention was documented on the form were reviewed with the CNO. The CNO was unable to state why the areas on the grievance forms were blank.

The policy and procedure, "Complaints and Grievances (Board of Directors Approval 6/2014)" was reviewed. The policy indicated, "The hospital reviews, investigates, and resolves each patient's grievance within a seven day time frame...the hospital will make sure that it is responding to the substance of each grievance while identifying, investigating, and resolving any deeper, systemic problems indicated by the grievance."

During interviews with the CNO on January 29, 2015, at 8:45 a.m., she stated grievances were reviewed by the CEO and if the grievance/complaint required additional follow up and additional intervention the Medical Director of the Emergency Room would follow them up.

Based on observation, interview and record review, the facility failed to ensure an ED room, Room 7, was safe, secure, easily identified, and adequately furnished in order to provide appropriate medical care to patients assigned to that room. This failure could potentially result in the ED not meeting the emergency medical needs of the patients presenting for care.

Findings:

An observation of the ED was conducted on January 26, 2015, beginning at 1:10 p.m. The ED information board (used to identify what nurse was providing care for each room) indicated there was a total of six ED rooms. The board indicated there was a nurse assigned to rooms 1, 2, and 3, and a nurse assigned to rooms 4, 5, and 6.

During an interview with Licensed Vocational Nurse (LVN) 2, on January 26, 2015, at 1:40 p.m., LVN 2 stated the information board did not list ED room 7. LVN 2 stated the LVN assigned to rooms 4, 5, and 6, also was assigned to room 7.

During an interview with Correctional Officer (CO), on January 26, 2015, at 1:50 p.m., the CO stated he had brought in a patient to be evaluated for complaints of abdominal pain. The CO stated the patient was located in ED room 7 which was located through a closed door outside the main ED. The CO stated he was looking for the nurse assigned to ED 7 because the patient needed something for pain.

The CO stated he had brought numerous patients to the facility over a 12 year period and "They always put us out here."

On January 27, 2015, at 9:35 a.m., an observation of ED room 7 was conducted with the Emergency Department Manager (EDM). In a concurrent interview, the EDM stated ED room 7 was primarily used for patients brought in by Correctional Officers and the police department.

An interview was conducted with Laboratory Technician (LT) 1, on January 27, 2015, at 8:45 a.m. LT 1 stated it was difficult identifying what nurse was assigned to ED room 7 because the information board did not indicate a bed 7.

During an interview with Radiology Technician (RT) 1, on January 28, 2015, at 1:50 p.m., RT 1 stated he had taken portable X-rays for patients located in ED room 7 many times. RT 1 stated if a patient was in distress while taking an X-ray, he would have to leave the room to find a nurse because there was no emergency call system for the room.

There was no emergency call light system observed in the room.

The EDM was asked how would a patient let staff know if the patient required assistance. The EDM stated "We would just have to check them."

Two cabinets located in ED room 7 were observed to be unlocked. The cabinet contents included three 25 gauge (a measurement of size) needles and one vacutainer (a blood collection tube with a needle attached).

The EDM stated the cabinets should be locked to prevent unauthorized access.

There was no oxygen tubing observed in the room.

The EDM stated the room should contain with all equipment required to meet the emergency needs of the patients.

Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Emergency Services was met by:

1. Failing to ensure the Medical Director of the Emergency Department (ED) was a member in good standing of the facility's medical staff according to the facililty's organizational requirement, (A1111).

2. Failing to ensure three ED physicians had current Advanced Trauma Life Support (ATLS) and Pediatric Advanced Life Support (PALS) certifications, (A1110).

3. Failing to ensure the proctoring process for two ED physicians was completed, (A1110).
4. Failing to ensure the documentation was complete to indicate what medical privileges were granted for one ED physician, (A1110.

5. Failing to ensure the ED was staffed with the appropriate numbers and types of professionals in accordance with regulatory requirements,(A1112).

6. Failing to ensure the Registered Nurses in the ED provided the transfer, discharge, and reassessment of patients, (A1112).

7. Failing to ensure the ED Registered Nurses provided the timely reassessment of the effect of pain medication after administration of the medication to two patients, (Patients 61 and Patient 9), (A1112).

8. Failing to ensure the ED staff provided adequate supervision for two patients on 5150 holds (Patients 66 and 6) (5150- a section of the California Welfare and Institutions Code which allowed a qualified person to involuntarily confine a person suspected to have a mental disorder that makes him/her a danger to self, a danger to others, and/or gravely disabled), (A1112).

The cumulative effect of these systemic problems resulted in failure to ensure emergency services were provided in a safe and effective manner.

Findings:

Based on observation, interview and record review, the facility failed to:

1. Ensure an ED room, Room 7, was safe, secure, easily identified, and adequately furnished in order to provide appropriate medical care to patients assigned to that room.

2. Ensure the Triage area of the ED was always adequately supervised by a Registered Nurse.

3. Failing to ensure the emergency contacts were notified when four patients under 5150 hold (patients on a mandatory 72 hour hold due to being a danger to themselves or others) eloped and/or were transferred from the facility.

These failures could potentially result in the ED not meeting the emergency medical needs of the patients presenting for care.

Findings:

1. An observation of the ED was conducted on January 26, 2015, beginning at 1:10 p.m. The ED information board (used to identify what nurse was providing care for each room) indicated there was a total of six ED rooms. The board indicated there was a nurse assigned to rooms 1, 2, and 3, and a nurse assigned to rooms 4, 5, and 6.

During an interview with Licensed Vocational Nurse (LVN) 2, on January 26, 2015, at 1:40 p.m., LVN 2 stated the information board did not list ED room 7. LVN 2 stated the LVN assigned to rooms 4, 5, and 6, also was assigned to room 7.

During an interview with Correctional Officer (CO), on January 26, 2015, at 1:50 p.m., the CO stated he had brought in a patient to be evaluated for complaints of abdominal pain. The CO stated the patient was located in ED room 7 which was located through a closed door outside the main ED. The CO stated he was looking for the nurse assigned to ED 7 because the patient needed something for pain.

The CO stated he had brought numerous patients to the facility over a 12 year period and "They always put us out here."

On January 27, 2015, at 9:35 a.m., an observation of ED room 7 was conducted with the Emergency Department Manager (EDM). In a concurrent interview, the EDM stated ED room 7 was primarily used for patients brought in by Correctional Officers and the police department.

An interview was conducted with Laboratory Technician (LT) 1, on January 27, 2015, at 8:45 a.m. LT 1 stated it was difficult identifying what nurse was assigned to ED room 7 because the information board did not indicate a bed 7.

During an interview with Radiology Technician (RT) 1, on January 28, 2015, at 1:50 p.m., RT 1 stated he had taken portable X-rays for patients located in ED room 7 many times. RT 1 stated if a patient was in distress while taking an X-ray, he would have to leave the room to find a nurse because there was no emergency call system for the room.

There was no emergency call light system observed in the room.

The EDM was asked how would a patient let staff know if the patient required assistance. The EDM stated "We would just have to check them."

Two cabinets located in ED room 7 were observed to be unlocked. The cabinet contents included three 25 gauge (a measurement of size) needles and one vacutainer (a blood collection tube with a needle attached).

The EDM stated the cabinets should be locked to prevent unauthorized access.

There was no oxygen tubing observed in the room.

The EDM stated the room should contain with all equipment required to meet the emergency needs of the patients.

2 a. On January 26, 2015, at 1:10 p.m., observations of the ED were conducted with the Chief Nursing Officer (CNO). There were 12 individuals observed in the ED waiting area. Seven of the 12 individuals were observed to have hospital identification (ID) bands.

Observations were made of a Registered Nurse (RN) 3 triaging two patients..

In an interview with RN 3, at 1:10 p.m., she stated the ED staff consisted of one RN to triage, and one RN and one Licensed Vocational Nurse (LVN) assigned to provide care for patients in the main ED area. RN 3 stated there was a total of seven beds in the ED.

RN 3 stated it was the triage nurse's responsibility to ensure walk-in patients as well as patients brought in by ambulance were triaged, to conduct the LVN's patient assessments, and to administer intravenous medications ordered for the LVN's assigned patients.

An observation of the main ED area was begun at 1:40 p.m. Patients were in beds 2, 4, 5, and 6. There was no nurse observed in the main ED.

RN 3 left the triage area at 1:40 p.m., to triage a patient brought in by ambulance. RN 3 was asked who was responsible for the triage area when she was providing care for patients in the main ED. RN 3 stated "No-one. She (referring to the ED admitting clerk) will call me."

LVN 2 and the ED Manager (EDM) entered the main ED at 1:50 p.m.

An interview was conducted with LVN 2, on January 26, 2015, at 1:55 p.m. LVN 2 stated she was assigned to provided care for the patients located in beds 4, 5, 6, and 7. LVN 2 stated it was the triage nurses responsibility for the assessment of the LVN's patients. LVN 2 stated it was the triage nurse's responsibility to administer all intravenous medications for the LVN's patients.

An interview was conducted with the EDM, on January 26, 2015, at 2 p.m. The EDM stated staffing for the ED was one RN in triage, one RN and one LVN assigned to provide care to the patients located in the main ED. The EDM stated the RN assigned to triage was also responsible for the oversite of the LVN's patient assignment, and responsible for the triage of all walk-in patients, patients brought in by ambulance, or by the police department.

b. An observation of the ED was conducted on January 27, 2015, beginning at 8:30 a.m. There were patients located in beds 1, 3, and 6. There was one individual in the ED waiting room wearing a hospital ID band.

There were two nurses observed in the main ED (LVN 2, and RN 1).

There was no nurse observed in the triage area.

During an interview, RN 1stated she did not know where the triage nurse was, but she may have assisted a patient outside. RN 1 stated nurses working in the ED were responsible for assisting patients to their cars after being discharged, and nurses were also responsible for taking laboratory specimens that they (the nurses) had collected, to the laboratory department.

The facility policy and procedure number "623.02" dated March 12, 2014, indicated "The purpose of this policy is to design and define the scope of services for the Emergency department which are organized to deliver safe and effective nursing care for any patient presenting with urgent medical problems...To provide quality care for all patients who arrive at the Emergency Department 24 hours a day...To meet regulatory and accrediting agency guidelines..."

An interview was conducted with the EDM, on January 27, 2015, at 3:55 p.m. The EDM stated the staffing of RN's in the ED did not coincide with Title 22 requirements.

c. An observation of the ED was conducted on January 29, 2015, beginning at 9:45 a.m. Four male individuals were observed in the ED waiting room. Three individuals were wearing hospital ID bands. There was no nurse in the triage area. There was one LVN (LVN 3) observed in the main ED

During an interview with LVN 3, on January 29, 2015, at 9:50 a.m., LVN 3 stated she did not know where the triage nurse was. LVN 3 stated there were three patients waiting to be triaged in the waiting room, and she informed the House Supervisor (HS) who was starting intravenous (in the vein) medication for one of patients located in the main ED.

A review of three documents completed by the patients waiting to be triaged was conducted. The documents titled "Patient Sign-In Sheet" dated January 29, 2015, indicated the following:

1. "Time In...8:15 a.m. January 29, 2015....Reason for Emergency Room Visit...Infection to lower left leg, worsening..."

2. "Time In...8:19 a.m. January 29, 2015...Reason for Emergency Room Visit...Having seizures every two hours all night last night...Medical History...low blood pressure, diabetes..."

3. "Time In...9:15 a.m. January 29, 2015...Reason for Emergency Room Visit...Ear pain, dry scratchy throat, cough..."

At 10:05 a.m., the Chief Nursing Officer (CNO) entered the triage area. There was no nurse in the triage area. The CNO was informed by the surveyor there were three patients waiting to be triaged in the waiting room. The CNO was informed one patient had been waiting since 8:15 a.m., or for one hour and 50 minutes, one patient had been waiting for 1 hour and 54 minutes, and one patient had been waiting for 50 minutes to be triaged.

The facility policy and procedure number "623.02" dated March 12, 2014, indicated "The purpose of this policy is to design and define the scope of services for the Emergency department which are organized to deliver safe and effective nursing care for any patient presenting with urgent medical problems...To provide quality care for all patients who arrive at the Emergency Department 24 hours a day...To meet regulatory and accrediting agency guidelines..."RN Assessment. Triage within 15 minutes of arrival..."

The policy further indicated "Staff will be in accordance with last (regulatory) staffing requirements..."

"...At least one of the licensed nurses shall be a registered nurse assigned to triage patients. The registered nurse assigned to triage patients shall be immediately available at all times to triage patients when they arrive in the emergency department...The registered nurse assigned to triage patients shall not be counted in the licensed nurse to patient ratio..."


3. An interview was conducted with the EDM, on January 27, 2015, at 3:55 p.m., the EDM stated it was the facility's practice to notify the patient's responsible party (RP) or emergency contact, if the patient was transferred or had eloped from the facility.

The records for four patients who presented to the ED with the chief complaint of 5150 were reviewed on January 27, 2015, with the EDM. The records indicated the following:

a. Patient 67 presented to the ED on January 19, 2015, with thoughts of committing suicide (thoughts of killing oneself) was transferred to a mental health facility on January 21, 2015.

b. Patient 64 presented to the ED on January 22, 2015, with homicidal thoughts (thoughts of killing others), eloped from the facility on January 23, 2015.

c. Patient 66 presented to the ED on January 19, 2015, with thoughts of committing suicide, was transferred to a mental health facility on January 20, 2015.

d. Patient 1 presented to the ED on May 16, 2014, with throughts of committing suicide, eloped from the facility twice, on May 16, 2014. Patient 1 was not located the second time he eloped and was found deceased in the Colorado River May 17, 2014, by law enforcement.

The EDM was unable to find documentation that indicated the patient's RP or emergency contact was notified when Patent 66 and 67 were transferred to another facility, and when Patient 64 eloped from the facility.

Hawkinson, Theresa
Based on interview and record review, the facility failed to ensure emergency services personnel requirements were met by failing to:

1. Ensure three Emergency Department (ED) physicians had current Advanced Trauma Life Support (ATLS) and Pediatric Advanced Life Support (PALS) certifications;

2. Ensure the proctoring process for two ED physicians was completed, and

3. Ensure the documentation to indicate what medical privileges were granted for one ED physician were completed.

These failures had the potential to result in the inability to provide the necessary care to meet the emergency needs of patients.

Findings:

During an interview with the Medical Staff Coordinator (MSC), on January 28, 2015, at 10 a.m., the MSC stated the ED physicians were required to meet the qualifications indicated in the medical staff by-laws.

A review of the by-laws, indicated all physicians requesting privileges in emergency medicine were to be certified or board prepared by the American Board of Emergency Medicine or its equivalent, or successful completion of an accredited residency in emergency medicine.

The by-laws further indicated if the physician was not certified or board prepared in emergency medicine, the physician would provided current certifications to include ATLS and PALS.

1. On January 28, 2015, at 10:10 a.m., a review of the credentialing files for the ED physicians revealed the following;

a. ED Physician 2 was not board certified or board prepared in emergency medicine. The file contained an ATLS certification with the expiration date of August 2014.

b. ED Physician 3 was not board certified or board prepared in emergency medicine. The file contained a PALS certification with the expiration date of April 2014.

c. ED Physician 4 was not board certified or board prepared in emergency medicine. The file failed to show a PALS and an ATLS certification.

2. The document titled "...(Name of facility) Medical Staff Rules and Regulations" undated, indicated "Proctoring. Purpose. The purpose of proctoring...is to ensure...that said appointee is duly qualified to perform procedures and render care according to generally accepted standards of care..."

The policy and procedure titled "Proctoring" revised May 2009, indicated "Core and Advanced Proctoring Requirements...Emergency Medicine- First ten (10) Emergency Medicine patients seen..."

On January 28, 2015, at 10:10 a.m., a review of the credentialing files for the ED physicians was conducted. The review revealed the following;

a. For ED Physician 1, nine of the required 10 proctoring cases were completed.

b. For ED Physician 5, nine of the required 10 proctoring cases were completed.

3. On January 28, 2015, the credentialing file for ED Physician 1 was reviewed. The form titled "Emergency Medicine Privilege Delineation Form" for the years 2012, and 2013, indicated requests made by ED Physician 1 to perform multiple procedures. The areas designated on the form to indicate if the requests made by the physician were granted or denied, were blank.

During an interview with the MSC, on January 28, 2015, at 10:10 a.m., the MSC reviewed the forms and stated the forms were not complete.

Based on observation, interview and record review, the facility failed to ensure the Medical Director of the Emergency Department (ED) was a member in good standing of the facility's medical staff. This failure could lead to a lack of direction and oversight potentially impacting all patients who present to the ER for care and treatment.

Findings:

An interview was conducted with the Medical Staff Coordinator (MSC) on January 28, 2015, at 9:15 a.m. The MSC stated the ED Medical Director was not a member of the medical staff.

An interview was conducted with the Medical Director of the ED on January 28, 2015, at 1 p.m. The Medical Director stated he was not a member of the facility's medical staff.

A review of the facility's ED organizational chart, approved by the medical executive committee March 11, 2014, was conducted. The organization chart indicates the Chief Nursing Officer, the ED Manager, the ED Triage Nurse, the ED Nursing Staff, and the ED clerk all report directly to the ED Medical Director.

A review of the policy, "Emergency Room Organizational Chart Description (Approval Date 3/11/14)," was conducted. The policy indicates, "The Emergency Department Medical Director reports to the Chief of Hospital Medical Staff. The Emergency Department Medical Director is responsible for supervising and evaluating the quality, safety and appropriateness of patient care."

A review of the Emergency Departments Professional Services Contract and Medical Directorship Agreement (dated June 15, 2013, scheduled to end March 15, 2015) indicated the (ED physicians) group shall comply with the protocols and the bylaws, guidelines, policies and rules applicable to other Medical Center (the facility) physicians. Item 1.4, appointment of the Medical Director indicates, "This appointment shall be made in accordance with the terms of this Agreeement and in accordance with the Bylaws and rules and Regulations of medical staff".

A review of the facility's Medical Staff By-Laws indicate under Article V, item 5.1-2" Contract Physician A practitioner who is or who will be providing specified professional services pursuant to a contract with the Hospital must meet the same membership qualifications, must be processed for appointment, reappointment, and clinical privileges in the same manner, and must fulfill all of the obligations of his membership category as any other applicant or medical staff member."

An interview was conducted with the ED Manager on January 29, 2015, at 9:50 a.m. The ED Manager stated, "The ED Medical Director rarely, if ever comes to the hospital and he does not attend the staff meetings."

An interview was conducted with the Medical Director of the ED on January 28, 2015, at 1:15 p.m. The Medical Director stated he was not aware of the challenges identified by the ED staff with 5150 patients nor was he aware of the ED not meeting regulatory requirements.

Hawkinson, Theresa
Based on observation, interview, and record review, the facility failed:

1. To ensure the Emergency Department was staffed with the appropriate numbers and types of professionals in accordance with regulatory requirements;

2. To ensure Registered Nurses (RN) provided the transfer, discharge, and reassessment of patients;

3. To ensure Registered Nurses (RN) provided the timely reassessment of the effect of pain medication after the administration of the medications for two patients, (Patient 61 and Patient 9), and;

4. To ensure adequate supervision was provided for two patients on 5150 holds (Patients 66 and 6) (5150- a section of the California Welfare and Institutions Code which allowed a qualified person to involuntarily confine a person suspected to have a mental disorder that makes him/her a danger to self, a danger to others, and/or gravely disabled).

These failures had the potential to directly impact the safety and provision of adequate medical care provided for patients in the ED.

Findings:

1 a. On January 26, 2015, at 1:10 p.m., observations of the ED were conducted with the Chief Nursing Officer (CNO). There were 12 individuals observed in the ED waiting area. Seven of the 12 individuals were observed to have hospital identification bands.

Observations of Registered Nurse (RN) 3 triaging two patients were made.

During an interview with RN 3, she stated the ED staff consisted of one RN to triage, and one RN and one Licensed Vocational Nurse (LVN) assigned to provide care for patients in the main ED area. RN 3 stated there was a total of seven beds in the ED.

RN 3 further stated the triage nurse's responsibilities included the triage of walk-in patients as well as patients brought in by ambulance, to conduct the LVN's patient assessments, and to administer intravenous medications for the LVN's assigned patients.

An observation of the main ED area at 1:40 p.m., revealed patients in beds 2, 4, 5, and 6. There was no nurse observed in the main ED.

RN 3 left the triage area at 1:40 p.m., to triage a patient brought in by ambulance. RN 3 was asked who was responsible for the triage area when she was providing care for patients in the main ED. RN 3 stated "No-one. She (referring to the ED admitting clerk) will call me."

LVN 2 and the ED Manager (EDM) entered the main ED at 1:50 p.m.

An interview was conducted with LVN 2, on January 26, 2015, at 1:55 p.m. LVN 2 stated she was assigned to provide care for the patients located in beds 4, 5, 6, and 7. LVN 2 stated it was the triage nurses responsibility for the assessment of the LVN's patients. LVN 2 stated it was the triage nurse's responsibility to administer all intravenous medications for the LVN's patients.

An interview was conducted with the EDM, on January 26, 2015, at 2 p.m. The EDM stated staffing for the ED was one RN in triage, and one RN and one LVN assigned to provide care to the patients located in the main ED. The EDM stated the RN assigned to triage was also responsible for the oversite of the LVN's patient assignment, and responsible for the triage of all walk-in patients, patients brought in by ambulance, or by the police department.

b. An observation of the ED was conducted on January 27, 2015, beginning at 8:30 a.m. There were patients located in beds 1, 3, and 6. There was one individual in the ED waiting room wearing a hospital identification band.

There were two nurses observed in the main ED (LVN 2, and RN 1).

There was no nurse observed in the triage area.

During an interview with RN 1, RN 1 stated she did not know where the triage nurse was, but she may have assisted a patient outside. RN 1 stated nurses working in the ED were responsible for assisting patients to their cars after being discharged, and nurses were also responsible for taking laboratory specimens that they (the nurses) had collected, to the laboratory department.

The facility policy and procedure number "623.02" dated March 12, 2014, indicated "The purpose of this policy is to design and define the scope of services for the Emergency department which are organized to deliver safe and effective nursing care for any patient presenting with urgent medical problems...To provide quality care for all patients who arrive at the Emergency Department 24 hours a day...To meet regulatory and accrediting agency guidelines..."

The policy further indicated "...Staff will be in accordance with last Title 22 staffing requirements..."

An interview was conducted with the EDM, on January 27, 2015, at 3:55 p.m. The EDM stated the staffing of RN's in the ED did not coincide with Title 22 requirements.

c. An observation of the ED was conducted on January 29, 2015, beginning at 9:45 a.m. Four male individuals were observed in the ED waiting room. Three individuals were wearing hospital identification bands. There was no nurse in the triage area. There was one LVN (LVN 3) observed in the main ED

During an interview with LVN 3, on January 29, 2015, at 9:50 a.m., LVN 3 stated she did not know where the triage nurse was. LVN 3 stated there were three patients waiting to be triaged in the waiting room, and she informed the House Supervisor (HS) who was starting intravenous (in the vein) medication for one of patients located in the main ED.

A review of three documents completed by the patients waiting to be triaged was conducted. The documents titled "Patient Sign-In Sheet" dated January 29, 2015, indicated the following:

1. "Time In...8:15 a.m. January 29, 2015....Reason for Emergency Room Visit...Infection to lower left leg, worsening..."

2. "Time In...8:19 a.m. January 29, 2015...Reason for Emergency Room Visit...Having seizures every two hours all night last night...Medical History...low blood pressure, diabetes..."

3. "Time In...9:15 a.m. January 29, 2015...Reason for Emergency Room Visit...Ear pain, dry scratchy throat, cough..."

At 10:05 a.m., the Chief Nursing Officer (CNO) entered the triage area. There was no nurse in the triage area. The CNO was informed by the surveyor there were three patients waiting to be triaged in the waiting room. The CNO was informed one had been waiting since 8:15 a.m., or for one hour and 50 minutes, one patient had been waiting for 1 hour and 54 minutes, and one patient had been waiting for 50 minutes to be triaged.

The facility policy and procedure number "623.02" dated March 12, 2014, indicated "The purpose of this policy is to design and define the scope of services for the Emergency department which are organized to deliver safe and effective nursing care for any patient presenting with urgent medical problems...To provide quality care for all patients who arrive at the Emergency Department 24 hours a day...To meet regulatory and accrediting agency guidelines..."RN Assessment. Triage within 15 minutes of arrival..."

2. On January 27, 28, and 29, 2015, a review of 21 ED patient records were reviewed. The records reviewed indicated LVN's had provided the reassessments for the patient's transfers, discharges, and the reassessment of medical conditions for the 21 ED patients.

During an interview with the EDM, on January 27, 2015, at 3:55 p.m., the EDM stated the transfer, discharge, and the reassessments of a patients medical condition were to be implemented by an RN.

The facility policy and procedure titled "Assessment/Reassessment of Patients" dated March 2014, indicated "...Reassessments are completed by RN's. Data may be collected by the LVN."

3 a. An observation of RN 3 triaging Patient 62 was conducted on January 26, 2015, at 1:20 p.m. Patient 62 presented with the chief complaint of severe back pain with a numerical rating of 10 on the scale of 1-10 (the number 10 representing the most severe pain).

RN 3 reviewed the triage information collected with the physician, and received an order for pain medication for Patient 62. At 1:30 p.m., RN 3 administered two tablets of the pain medication Norco to Patient 62, and directed Patient 62 to return to the ED waiting area.

During an interview with RN 3, on January 26, 2015, at 1:35 p.m., she stated patients in the waiting area were reassessed every two hours "If I can get to them."

A review of Patient 62's record was conducted on January 26, 2015. The record indicated RN 3 reassessed Patient 62 at 3:32 p.m., or one hour and 58 minutes after the pain medication was administered.

The facility's policy and procedure titled "Assessment/Reassessment of Patients" dated March 2014, indicated " Emergency Department, Reassessment parameters...If in the lobby waiting must be done every 30 minutes."

b. A review of Patient 9's record was conducted. Patient 9 presented to the ED on January 2, 2015, at 1:57 p.m., with a diagnosis of gastroparesis (paralysis of the stomach muscles) and acute abdominal pain.

Based on a scale from 1-10, with 10 representing the most severe level of pain, Patient 9's pain level at 2:30 p.m. was a level 10, and at 3:27 p.m. was a level 10.

An interview was conducted with the EDM on January 27, 2015, at 4:15 p.m. The EDM stated with intravenous pain medication a patient's pain level needs to be reassessed in 30 minutes.

Patient 9 received Dilaudid 1 milligram (narcotic pain medication), intravenously at 3:41 p.m., and at 5:14 p.m. The record failed to show a reassessment of his pain level within a half hour of receiving the medication.

4 a. The record for Patient 66 was reviewed on January 27, 2015. Patient 66 presented to the ED on January 19, 2015, with the chief complaint of "5150."

The nursing triage assessment dated January 19, 2015, at 7:24 p.m., indicated patient 66 was having thoughts of suicide (killing himself).

The physician documentation dated January 19, 2015, at 8:46 p.m., indicated Patient 66 had a history of depression, and was having suicidal thoughts.

During an interview with the EDM, on January 27, 2015, at 3:55 p.m., the EDM reviewed the record and was unable to find documentation that indicated an attendant was provided for Patient 66's safety prior to January 20, 2015, at 9:47 a.m., or 11 hours and 59 minutes after the patient's arrival to the facility.

b. A review of Patient 6's record was conducted. Patient 6 was brought to the ED by law enforcement on January 10, 2015, at 4:45 a.m. The patient was placed on a 5150 hold as the patient was deemed gravely disabled due to a mental illness.

Patient 6 was transferred to a psychiatric facility on January 12, 2015, at 3:05 a.m.

The record failed to show that Patient 6 was observed by a sitter until 10:54 a.m., on January 10, 2015, 6 hours after admission to the ED.

An interview was conducted with the ED Registered Nurse (RN) 3 on January 26, 2015, at 2 p.m. RN 3 stated if a patient under a 5150 hold is in the ED, a sitter must be with the patient.

The facility policy and procedure titled "5150 Psychiatric Hold Patients" dated November 2014, indicated "If a patient on a 5150 hold is brought into the emergency Department by law enforcement, the officer will stay with the patient until Emergency room staff is available to provide one to one care/supervision and it is determined that the patient does not pose an immediate threat to him/herself, the staff or other customers. Suicide precautions: Arrange for close observation by an attendant..."