HospitalInspections.org

A. Based on a tour of the ED, review of policy and procedure, medical record review, and interview with administrative staff, it was determined that a policy regarding outdated supplies was not implemented.

Findings include:

Reference: Policy and procedure titled "Storage of Patient Care Supplies" states: ".....
PROCEDURE:
.....
10. To ensure product integrity and consistent with infection prevention practices, all dated supplies will be stocked in the following manner:
a. Product is used 'first in, first out' - items with the most immediate expiration dates are to be used first.
b. When restocking supply areas, product will be rotated to [sic] that supplies expiring soonest are the most readily accessible to be used first.
c. Leaders will assure that monthly rounds are conducted to check for expiration dates, using any products that are near to expiration immediately
d. Expired product will be discarded.
....."

1. A tour of the ED on 7/7/21 accompanied by Administrators #1,
#2, and #3 revealed:

a. Triage Area:

A phlebotomy kit in a cabinet beneath the counter contained:

(i) Four (4) yellow top Vaccutainers with an expiration date of 5/31/21.

(ii) One (1) light blue top Vaccutainer with an expiration date of 3/31/21.

(iii) Three (3) pink top Vaccutainers with an expiration date of 4/30/21.

b. Back Nurses Station:

A supply bin above a counter contained:

(i) One (1) light blue top Vaccutainer with an expiration date of 6/30/20.

(ii) One (1) light blue top Vaccutainer with an expiration date of 4/30/20.

(iii) Two (2) light blue top Vaccutainers with an expiration date of 9/30/20.

(iv) Four (4) light blue top Vaccutainers with an expiration date of 7/31/20.

2. Administrators #1, #2, and #3 agreed with the findings.

B. Based on a review of the ED central log, review of policy and procedure, and interview with administrative staff, it was determined that a policy regarding completion of the ED central log was not implemented.

Findings include:

Policy: Policy and procedure titled "EMTALA Log - Emergency Department" states:
"Purpose
To track the care provided to each individual who comes to the Emergency Department.
.....
Procedure:
.....
4) The Central Log will contain:
.....
e) The disposition of the individual, including whether the individual
i) refused treatment offered by MMC (including individuals who elope or who leave MMC without notice or giving a reason for refusing emergency services);
ii) was Stabilized [sic] and transferred to another facility;
iii) was transferred to another facility prior to being Stabilized [sic];
iv) was treated and admitted as an Inpatient [sic]; or
v) was Stabilized [sic] and discharged.

5) A Central Log entry should be made at the patient's first point of contact with MMC. This would normally take place at Triage and be finalized after the Medical Screening Examination and/or any necessary treatment to Stabilize [sic] the Emergency Medical Condition, as applicable. An individual should be recorded in the Central Log even if the Medical Screening Examination and/or any necessary treatment to Stabilize [sic] the Emergency Medical Condition, as applicable.
....."

1. Review of a sample of Emergency Department Central Log entries for the month of June 2021 revealed:

a. Patient #8: The "Dispo" (Disposition) section contained the entry "Send to Or" [sic] for an ED visit on 6/24/21 at 6:35am. "Send to Or" is not a disposition from the emergency department.

b. Patient #9: The "Dispo" section did not contain an entry for an ED visit on 6/4/21 at 1:39pm.

c. Patient #10: The "Dispo" section did not contain an entry for an ED visit on 6/4/21 at 1:45pm.

d. Patient #11: The "Dispo" section contained the entry "Observation" for an ED visit on 6/4/21 at 2:05pm. "Observation" is not a disposition from the emergency department.

e. Patient #12: The "Dispo" section did not contain an entry for an ED visit on 6/4/21 at 3:11pm.

f. Patient #13: The "Dispo" section did not contain an entry for an ED visit on 6/4/21 at 3:43pm.

g. Patient #14: The "Dispo" section did not contain an entry for an ED visit on 6/4/21 at 3:49pm.

h. Patient #15: The "Dispo" section contained the entry "Observation" for an ED visit on 6/5/21 at 12:08am. "Observation" is not a disposition from the emergency department.

i. Patient #2: The "Dispo" section contained the entry "Lwbs (Left without being seen) After Triage" for an ED visit on 6/27/21 at 4:40am. (There was no evidence in the medical record generated for this visit that that the patient was triaged.)

j. Patient #5: The "Dispo" section contained the entry "Transfer To Another Facility" for a visit at 11:22am on 6/5/21. (Administrator #2, after review of the patient's medical record, stated that this entry was made in error. The patient had been transferred to another facility, but not subsequent to an ED presentation at the above time).

2. Administrators #1 and #2 agreed with the findings.

C. Review of policy and procedure, the medical record of one of one patient discharged to an extended care facility, and interview with administrative staff, it was determined that a policy regarding discharge from the ED was not implemented.

Findings include:

Reference: Policy and procedure titled "Discharge from the Emergency Department" states: ".....
PURPOSE
A. To facilitate the safe discharge of patients from the hospital and ensure follow-up care if required, after they leave the Emergency Department.
.....
PROCEDURE.....
I. When a patient is discharged back to an adult home/extended care facility, the following takes place:
* A telephone report is initiated by the RN caring for the patient and the contact's name and title is documented in the patient's medical record.
* Transportation to the facility is arranged.
* The written/printed discharge instructions will be given to the transporting personnel to deliver to the facility's contact person.
....."

1. Review of the medical record of Patient #1 revealed:

a. A NEW JERSEY UNIVERSAL TRANSFER FORM, dated 5/28/21, stating that the patient was transferred to the ED on 5/28/21 from "____ ______ (name of town), ________ _______ (name of facility) of - ALF (Assisted Living Facility)" The Form included the name, title, and phone number of a contact person from the Assisted Living Facility.

b. The "Demographics" section stated that the patient's address was "________ _______ (name of facility) ___ (street number) ________ ______ (street name) Road, ____ ______ (name of town), NJ _____ (Zip Code).

c. The "Discharge Information" section stated:
"Discharge Date/Time
05/28/2021 2141 (9:41pm)
Discharge Disposition
Home or Self Care
Discharge Destination
Home
Discharge Provider
None
Unit
Mountainside Medical Center Emergency"

(i) There was no documentation in the medical record that a telephone report was initiated by any RN to the contact person at the Assisted Living Facility when the patient was discharged.

(ii) There was no documentation that transportation back to the Assisted Living Facility was arranged.

(iii) There was no documentation that written/printed discharge instructions were given to transporting personnel to deliver to the Assisted Living Facility's contact person.

2. Administrator #1 agreed with the findings.

D. Based on a review of policy and procedure, review of two (2) of two (2) emergency department policies and procedures, and interviews with administrative staff, it was determined that the medical staff failed to review and/or revise policies and procedures governing the medical care provided in the ED as necessary.

Findings include:

Reference: Policy and procedure titled "Policy on Policies" states: ".....
PROCEDURE:
.....
4. Policy Review:
Administrative and Clinical/Departmental Policies will be reviewed at a minimum of every three years from the effective date or last revision date in accordance with regulatory agency recommendations unless the needs of the hospital or law require a different review/revision schedule.
....."

1. ED policy and procedure titled "Discharge from the Emergency Department" indicated that the policy became effective in "3/13" (March 2013) and superceded the previous policy dated "9/10" (September 2010). The "Reviewed by" section of the policy did not include an entry and the last review date entered was "3/13." The "Revised by" section of the policy did not include an entry and the last date of revision was "9/10" - a date two and a half years prior to the effective date.

2. ED policy and procedure titled TRIAGE GUIDELINES AND PROCEDURES indicated that the policy became effective on 3/15/16. There was no evidence that the policy had been reviewed or revised at any time after that date.

3. Administrators #1 and #2 agreed with the findings.

E. Based on a review of policy and procedure, review of the ED Central Log, review of the medical record of 2 of 3 patients (MR#s: 2 and 3) who were documented to have left the ED before triage, and interview with administrative staff, it was determined that the hospital failed to follow triage guidelines.

Findings include:

Reference: Policy and procedure titled TRIAGE GUIDELINES AND PROCEDURES states:
POLICY:
A registered nurse shall triage every patient entering the Emergency Department (ED) to determine priorities of care based upon physical and psychosocial factors and place patients appropriately in the ED.
.....
The triage assessment shall include a rapid systemic collection of data related with [sic] the patient's chief complaint.
Triage evaluation will be performed using the most current version of the Emergency Severity Index (ESI) to determine the nature and severity of complaint.
.....
PURPOSE:
..... Every patient presenting to the ED for care will be assigned a triage level according to the ESI. ..... A triage assessment shall be performed to determine patient acuity, appropriate placement and use of approved protocols. The triage assessment shall include a rapid, systemic collection of data related to the patient's chief complaint and past medical history. The nature, seriousness and level of complaint will be determined using the ESI.
PROCEDURE:
1. All patients presenting to the ED for treatment will be entered into the system by the ED registrar using the patient's chief complaint.
.....
6. In the event, [sic] a patient is not immediately placed in a treatment room, the triage RN will perform and document a periodic (Every 30 minutes) re-evaluation of any patient in the waiting room.
.....
ESI Level(:)
.....
ESI 2
Acuity(:)
High Risk situation
Confused/Disoriented
Severe pain/distress
Example(:)
..... Suicidal/Homicidal patient .....
Action(:)
Notify primary RN and ED physician. Physician to see patient within 15 minutes.
.....
Refusal of Treatment
.....
2. A patient will be called by the triage RN up to three times at 15 minute intervals. If the patient does not respond within three calls, the triage RN will document that patient left before triage and remove the patient from the green screen. Times of individual attempts to locate patient will be documented.
....."

1. Review of the medical record of Patient #2 for an ED visit on 6/27/21 revealed:
4:40am: "Patient arrived in ED"
4:40:56am: "Arrival Complaint CRISIS"
5:52:15am: "ED LWBS Disposition Select ED Disposition set to LWBS after triage"
5:53am: "Patient dismissed."

a. It was unclear from the Arrival Complaint, "CRISIS" as to whether the crisis was a "High Risk situation" requiring that the RN and ED physician be notified. Nursing staff did not make an entry into the medical record until an hour and 12 minutes after the patient's documented arrival time.

b. There was no evidence that the patient received a triage assessment even though a triage assessment was documented as having been completed.

2. Review of the medical record of Patient #3 for an ED visit on 6/5/21 revealed:

1:29pm: "Patient arrived in ED"
2:18pm: "Patient roomed in ED To room 09A"
2:20:06pm: "Patient transferred From room 09A to room WR (Waiting Room)"
3:00pm: "Arrival Documentation ..... Triage Call: Call 1x"
3:04pm: "Triage Completed"
3:04pm: "Triage Final Steps ..... Patient Acuity: 3 Triage Complete: Triage complete"
3:04:51pm: "From room WR to room 19"
3:08:50pm: "From room 19 to room WR"
3:09pm: "Triage Call: Call 2x"
3:18pm: "Triage Call: Call 3x"
3:19:21pm: "ED Disposition set to LWBS (Left Without Being Seen) before Triage."

a. There was no evidence in the medical record of a triage assessment even though a triage assessment was documented as having been completed and an ESI level was assigned to the patient.

3. Administrators #1 and #2 agreed with the findings.

F. Based on a review of policy and procedure, a tour of the ED, interviews with administrative staff and review of related documentation, it was determined that the facility failed to monitor the temperatures of medication refrigerators effectively.

Findings include:

Reference: Policy and procedure titled "Medication Refrigerator / Freezer Temperature Monitoring" states:
"POLICY:
Medications that require refrigeration or freezing shall have the appropriate storage temperature monitored and documented on the temperature log from (see attached Temperature Log Once Daily Temperature Log Twice Daily).
PURPOSE:
To provide patient safety for the storage of refrigerated & frozen medications while complying with official standards. The USP approved temperature standards are:
Refrigerator: 36 to 46 F (2 to 8 C)
.....
PROCEDURE:
.....
* Log and sign all temperature readings on the refrigerator/freezer temperature log form.
* If the temperature of the refrigerator or freezer is out of range:
° Contact Maintenance. Recheck and log temperature once corrected.
....."

1. During a tour of the ED on 7/7/21, accompanied by Administrators
#1, #2, and #3, it was observed that the Back Nurses Station REFRIGERATOR/FREEZER TEMPERATURE LOG FORM TWICE DAILY MONITORING (VACCINES PRESENT) form for July 2021, attached to the medication refrigerator, stated: ".....
Refrigerator- Acceptable Temperature Range: 36 to 46°F (2 to 8°C)
.....
Suggested Monitoring Times
AM: 7 am - 10am
PM: 7pm - 10 pm
....."

a. Entries made by staff between 7/1/21 at 7:00am and 7/7/21 at 7:00am were not accurately entered. The "*Actions Taken" section of the form, designed for documentation of the actions taken by a staff member when the refrigerator temperature is not in an acceptable range, contained temperature entries. The "Temp" side of the "Time/Temp" section of the form, the section of the form designed for temperature entries, had no entries.

b. At 7AM and 7PM on July 2, staff entered the temperature of 35.4° and at 7AM on July 3, staff entered the temperature of 35°. There was no documentation on the form that the out of range temperatures were reported to Maintenance.

2. During a tour of the ED on 7/7/21, accompanied by Administrators
#1, #2, and #3, it was observed that the Main Nurses Station REFRIGERATOR/FREEZER TEMPERATURE LOG FORM TWICE DAILY MONITORING (VACCINES PRESENT) forms for April, May, June, and July 2021, attached to the medication refrigerator revealed:

a. Entries made by staff between 4/1/21 at 7:00am and 7/7/21 at 7:00am were not accurately entered. The "*Actions Taken" section of the form, designed for documentation of the actions taken by a staff member when the refrigerator temperature is not in an acceptable range, contained temperature entries. The "Temp" side of the "Time/Temp" section of the form, the section of the form designed for temperature entries, had no entries.

b. April 2021:

(i) There were no entries in the AM of April 1.

(ii) The time that the temperature was taken in the AM on April 5 was not documented.

(iii) The temperature and initials for the 7PM temperature were crossed out and the word "error" written next to the crossed-out entries. There were no other entries made.

(iv) The time that the temperature was taken in the AM on April 5 was not documented.

(v) The time that the temperature was taken in the PM on April 18 was not documented.

(vi) The time that the temperature was taken in the AM on April 19 was not documented.

c. May 2021:

(i) The time that the temperature was taken in the PM on May 1 was not documented.

(ii) The time that the temperature was taken in the AM on May 3 was not documented.

(iii) There were no entries in the AM of May 16.

(iv) There were no entries in the AM of May 17.

(v) There were no entries in the PM of May 20.

(vi) There were no entries in the PM of May 21.

(vii) The temperature in the PM of May 22 was entered as "32." There was no documentation that Maintenance was notified.

(viii) The temperature in the PM of May 22 was entered as "32F." The "*Actions Taken" section of the form included the entry "Pharmacy Notified." Policy stated that Maintenance should have been notified for this temperature, not Pharmacy.

(ix) The temperature in the AM of May 24 was entered as "32F." There was no documentation that Maintenance was notified.

(x) There were no entries in the PM of May 21.

(xi) There were no entries in the AM of May 25.

(xii) There were no entries in the PM of May 28.

(xiii) There were no entries in the AM of May 29.

(xiv) The time that the temperature was taken in the PM on May 29 was not documented.

(xv) The time that the temperature was taken in the AM on May 30 was not documented.

d. June 2021:

(i) The time that the temperature was taken in the PM on June 3 was not documented.

(ii) The time that the temperature was taken in the AM and PM on June 4 was not documented.

(iii) The time that the temperature was taken in the AM on June 5 was not documented.

(iv) The time that the temperature was taken in the PM on June 7 was not documented.

(v) The time that the temperature was taken in the AM on June 8 was not documented.

(vi) The time that the temperature was taken in the PM on June 16 was not documented.

(vii) The time that the temperature was taken in the AM on June 17 was not documented.

(viii) The time that the temperature was taken in the AM on June 18 was not documented.

(ix) The time that the temperature was taken in the PM on June 19 was not documented.

(x) The time that the temperature was taken in the AM on June 20 was not documented.

(xi) The time that the temperature was taken in the PM on June 21 was not documented.

(xii) The time that the temperature was taken in the AM on June 22 was not documented.

(xiii) The time that the temperature was taken in the PM on June 26 was not documented.

(xiv) The time that the temperature was taken in the AM and PM on June 27 was not documented.

(xv) The time that the temperature was taken in the PM on June 30 was not documented.

e. July 2021:

(i) There were no entries in the AM or PM of July 2.

(ii) There were no entries in the AM of July 3.

(iii) The time that the temperature was taken in the PM on July 5 was not documented.

(iv) The time that the temperature was taken in the AM on July 6 was not documented.

3. Administrators #1, #2, and #3 agreed with the findings.

G. Based on a review of policy and procedure, a tour of the ED, interviews with administrative staff and review of related documentation, it was determined that the facility failed to monitor code carts and defibrillators effectively.

Findings include:

Reference: Policy and procedure titled "Cardiopulmonary Arrest-Adults, Children, Infants" states: ".....
ATTACHMENT 4: ADULT/PEDIATRIC/NEONATAL CODE CART MAINTENANCE
Page 1 of 3
ADULT CODE CART
A. Routine checks: All adult Resuscitation Carts will be checked in the following manner:
1. Unlocked areas of cart: checked daily and signed in log book by personnel on the unit or department where cart is kept. .....
2. Defibrillators: Checked daily as instructed on the Daily Code Cart/Defibrillator Checklist [sic] .....
.....
6. Locks: Carts will be locked at all times when not in use, with a numbered breakaway (green) lock. Each time the defibrillator is checked, the lock numbers are noted on the Code Cart/Defibrillator Checklist.
....."

1. During a tour of the ED on 7/7/21, accompanied by Administrators #1, #2, and #3, a review of the Fish Bowl Pediatric CODE CART/DEFIBRILLATOR CHECK LIST ZOLL R-SERIES from 2/25/21 through 7/7/21 revealed:

a. There was no signature of the staff member who checked the cart on 2/27.

b. There were no entries made on 2/28, 5/28, and 5/30.

c. The "PASS/FAIL 'P/F'" section on all dates except 5/1 and 5/2 included the entry "N/A" (Not Applicable?) On 5/1 the entry "5/1/21" was made and on 5/2, a correct entry "p" was entered.

d. There was no signature for the entries made on 2/27, 4/14, 5/12, 6/9, and 6/23.

2. During a tour of the ED on 7/7/21, accompanied by Administrators #1, #2, and #3, a review of the Fish Bowl Adult CODE CART/DEFIBRILLATOR CHECK LIST ZOLL R-SERIES from 3/1/21 through 5/31/21 and 7/2/21 through 7/7/21 revealed:

a. There were no entries made on 3/4 or 7/1.

b. The "PASS/FAIL 'P/F'" section on all dates except 4/1, 4/2, 4/3, 4/4, 4/5, 4/6, 4/7, 4/11, 4/26, 4/29, 5/2, 5/19, and 5/29 included either a check mark or a date.

c. There was no signature for the entries made on 4/14, 5/12, or the entries made on the undated line after entries made on 7/6. Additionally there was no signature for the entries made on the line after entries made on 7/6.

d. The incorrect date "5/29" was entered for entries made on the next line after the 5/29 entries.

e. The date was not entered for entries made on the line between entries made on 5/21 and 5/23, nor between entries made on 5/25 and 5/27.

3. Administrators #1 and #2 agreed with the findings.

H. Based on a review of a policy and procedure, a tour of the ED, and interview with administrative staff it was determined that the facility failed to ensure the confidentiality of a patient's medical information.

Findings include:

Reference: Policy and procedure titled "CD011 Records Management-CD-Corp" states:
Applicability: This policy applies to all Ardent affiliated officers, directors and employees and other agents using Ardent provided and supervised information technology systems at all Argent-affiliated facilities, including, but not limited to hospitals .....
.....
Policy: This Policy extends to all Company or work-related documents, including paper and electronic documents. .....
.....
4) Records Destruction:
.....
c) Records and Non-Records must be destroyed in a secure manner that ensures their confidentiality (meaning no patient or other individually identifiable information remains) and renders the information no longer recognizable as Company Documents. Provided that they are implemented in a manner that ensures that no Company, patient, or other individually identifiable information remains, the approved methods to destroy Records and Non-Records include, but are not limited to, recycling, shredding, burning, pulping, pulverizing, and magnetizing.
....."

1. During a tour of the ED on 7/7/21, accompanied by Administrators #1, #2, and #3, two EKG sheets including a patient's name, demographic information, and health information was found in a regular trash basket in the hallway outside of the nurses station.

2. Administrator #1 stated that the sheets should have been place in a designated box for documents to be shredded.