HospitalInspections.org

Based on observations and interviews with facility personnel, the facility failed to ensure that a patient ' s grievance was resolved.
The findings include:
a. Review of the grievances filed by Patient #260 and sent to the VP of Patient Safety and Quality, CEO and the Food and Nutrition Department. On 1/5/11, it was identified that patients are served cold food. On 2/6/11 and 3/17/11, it was identified that the food continues to be cold and the Aladdin food trucks needed repair to maintain food temperatures. On 3/30/11, it was identified that the food continues to be cold and that three months have passed by and the food carts are still defective and being ignored by management. Further review failed to identify that the patient's grievances were resolved. Review of hospital policy "Responding to Complaints by Patients" identified that all grievances will be reported to patient relations department and a person managing the case will be responsible for acknowledging the grievance, coordinating the investigation and following up with the patient, as well as documenting the resolution in the complaint management database. Interview with the Food Services Director on 4/26/11 identified that she was aware of the repairs needed with the food trucks, however had not resolved the issue as of 4/26/11. Interview with the Vice President of Quality Improvement on 4/28/11 identified that he had forwarded the patient complaint to patient relations and was not aware that the issue was not resolved.

Based on review of clinical records, review of hospital documentation and interview with hospital personnel, the hospital failed to ensure that identified measurable indicators for improvement in the Emergency Department (left without being seen) were effective to ensure improved health outcomes. The findings include:

Review of hospital documentation dated 1/2/11 through 4/2/11 (12 weeks) reflected that the percentage of patients that left without being seen (in relation to all patients in the ED) ranged from 1.91% to 7.99% most recently in March 2011. Although the hospital identified and tracked the problem of patients that were leaving the ED without being seen, the hospital failed to consistently ensure that solutions were implemented effectively, improving the outcome.

The clinical records of Patient #215, #217, and #218 with chief complaints that included chest pain, palpitations and/or the development of chest pain while waiting to be evaluated were reviewed. These patient's left the ED without first being evaluated by a medical practitioner.
During interviews on 4/20/11, the Nurse Director and Medical Director of the ED stated that the problem of patients leaving without being seen (LWBS) had been identified and that steps were being taken to improve outcomes including the planned addition of new patient beds. They stated that a five bed front end area immediately adjacent to triage was added to assist medical practitioners to see patients, however, the area was only open when it could be staffed. Additionally, although the Nurse Director stated that the LWBS patients could be called upon the following day after their ED departure to inquire why they left, there was no documented evidence that this step was planned for and/or implemented.

Based on observations and interviews with facility personnel, the facility failed to ensure that dietary carts were in working order to maintain safe food practices.
The findings include:
1. During tour of the Donnelly one unit on 4/25/11, it was observed that the Aladdin food transport carts had a door that was missing. Observation of food temperatures identified that the lunch meal was 120 degrees (normal range-140 degrees) and the milk was 67 degrees (normal range-40 degrees) as it was being served to the patients. Further observation identified that the transport carts on Donnelly 3 south and Donnelly 2 south were missing. Review of hospital documentation dated 1/27/11 identified that a work order was placed for the replacement of the pods (heat elements) and the cart doors of the Aladdin system. In addition, the replacement pods and cart doors were delivered on 2/8/11 and had not been replaced. Interview with the Food Services Director on 4/26/11 identified that the Aladdin service contract had expired on 3/31/11 and the food transport carts had not be repaired. Subsequently to surveyor inquiry on 4/26/11, the food transport cart doors were being replaced by maintenance staff.
In addition, review of the tray line temperature logs dated 4/17/11-4/25/11 failed to identify that temperatures were taken at each meal time including the tempertures for cold foods. Review of hospital policy"Test Tray/Cart Audit" policy identified that cart audits are done monday-friday for tray completeness including temperature and recorded on the tray line log.

17921




19907

Based on observations and interviews with facility personnel, the facility failed to ensure that dietary carts were in working order to maintain safe food practices.
The findings include:
1. During tour of the Donnelly one unit on 4/25/11, it was observed that the Aladdin food transport carts had a door that was missing. Observation of food temperatures identified that the lunch meal was 120 degrees (normal range-140 degrees) and the milk was 67 degrees (normal range-40 degrees) as it was being served to the patients. Further observation identified that the transport carts on Donnelly 3 south and Donnelly 2 south were missing. Review of hospital documentation dated 1/27/11 identified that a work order was placed for the replacement of the pods (heat elements) and the cart doors of the Aladdin system. In addition, the replacement pods and cart doors were delivered on 2/8/11 and had not been replaced. Interview with the Food Services Director on 4/26/11 identified that the Aladdin service contract had expired on 3/31/11 and the food transport carts had not be repaired. Subsequently to surveyor inquiry on 4/26/11, the food transport cart doors were being replaced by maintenance staff.

Based on a review of clinical records, policies/procedures/protocols, and interviews, the hospital failed to prioritize the needs of three patients who presented with and/or developed chest pain and/or palpitations (#215, 217, and 218) to ensure timely medical evaluations. The findings include the following:

a. Patient #215 presented to the Emergency Department on 10/21/10 at 9:41 PM by ambulance. Review of the ambulance run record reflected that the patient had undergone cataract surgery the day before and subsequent to starting a new eye drop medication, developed a body rash and felt that his/her tongue was swelling. In the ambulance, the patient's blood pressure (B/P) was 250/110, heart rate 110, respirations 18, and had an oxygen saturation of 100% on 4 liters/min of oxygen. Upon arrival to the ED, Patient #215's blood pressure at 9:45 PM was 206/108, heart rate 80, and respirations were 16. Review of the triage record and interview with RN #109 on 4/19/11 at 12:50 PM failed to reflect evidence that a past medical history was obtained other than the recent cataract removal, current medications, reassessment of abnormal vital signs and pain assessment. RN #109 stated that she did not approach the patient to complete a physical assessment during triage as EMS personnel provided information as documented in the ED record. Based on this information the patient was triaged as a level 4 (stable, minor problem according to ESI Standards per hospital policy).
Review of hospital policies for ED triage and documentation directed that the triage nurse should assess the patient, in part, to include a past medical history, history of present illness, allergies and pain level. The triage RN should acknowledge vital signs outside the accepted parameters and consider upgrading the triage level based on vital sign abnormalities.
Patient #215 was transported by EMS personnel via stretcher to a room following triage with hand off to RN #110. Although the patient's B/P was dangerously elevated upon triage at 9:45 PM, RN #110 failed to assess the patient's B/P until 10:41 PM (56 minutes later). At this time the patient's B/P was 179/87. according to the clinical record at 10:47 PM, the patient was very anxious and complained of chest pain. RN #110 failed to perform a comprehensive assessment of the chest pain and failed to notify a medical practitioner of the patient's new onset of chest pain. A B/P of 165/92 was obtained at 11:00 PM. This was the last documented B/P in the record prior to the patient leaving the ED at 2:00 AM. During interview on 4/18/11, RN#110 stated that she could not recall why the patient was not assessed for pain according to hospital policy and/or why she failed to notify the medical practitioner of the patient's new onset of chest pain.
Review of hospital policy directing documentation in the ED identified that all patient handoffs required a focused assessment by the assigned nurse with appropriate reassessment at least every two hours.
Review of the record indicated that at 10:55 PM, RN #110 received a verbal order to complete an EKG. The EKG was completed and given to PA#2 for review at 12:14 AM on 10/22/10. The computerized EKG interpretation reflected "borderline EKG" with a sinus arrhythmia and possible left atrial enlargement. This was a computerized interpretation of the results and not that of PA#2. During interview on 4/19/11, PA#2 stated that he could not recall the patient and that while the EKG pattern in the clinical record did not alarm him, he would have expected the nurse to notify him that the patient had a new complaint of chest pain. PA#2 had reviewed the EKG, however, failed to evaluate the patient clinically.
Interview with the Medical Director of the ED on 4/20/11 identified that the initial review of an EKG is focused on the identification of a STEMI and that a computerized interpretation of the EKG prints out on the report. The Medical Director stated that a "borderline EKG" is not a medical term but language used by the computerized system and that the practitioner is responsible to review the EKG.
The patient notified RN #110 at 1:59 AM on 10/22/10 that he/she was leaving the ED. Patient #215 left the hospital at 2:00 AM and was admitted to another hospital with an elevated troponin level, ischemia, and hypertension.
During the period of 9:45 PM (on 10/21/10) through 2:00 AM, the hospital failed to ensure that the patient was evaluated by a medical practitioner. RN #110 failed to intervene by requesting the patient be evaluated and/or inquire as to what the plan of care was for this patient.

On 11/19/2010, the patient's personal physician wrote a letter to the hospital's Chief Executive Officer (CEO), detailing Patient #215's experience in the ED on 10/21/10. The physician identified that the patient was not provided medical intervention for the chest pain experienced by the patient which, coupled with elevated enzymes, was identified as a cardiac event in another hospital. During interview on 4/20/11, the Director of Risk Management stated that the usual format upon reception of a letter includes the letter being sent to the VP of Medical Affairs, who then refers the letter onto the appropriate department (Emergency Department) for follow through. Interview with the Medical Director of the ED on 4/20/11, identified that he received this letter on 4/18/11 and had no recall of receiving it at an earlier date. He acknowledged that the letter "fell through the cracks" and subsequently contacted Patient #215's physician to address the issues.

b. Patient #217 presented to the ED on 4/15/11 at 2:01 PM with complaints of chest pain. The patient rated the chest pain as a 6 on a scale of 0-10 (10 being the worst possible pain). The pain assessment failed to include characteristics of the chest pain and/or interventions to address the pain. The patient was triaged as an ESI Level-3. Review of the triage system protocol reflected that a patient presenting with active chest pain should be designated as a Level-2. The hospital failed to ensure the patient was triaged in accordance with protocol.
Review of Patient #217's record identified that an EKG was completed and given to PA #3 at 2:20 PM. The computerized EKG interpretation reflected a "borderline EKG" with left atrial enlargement, normal sinus rhythm with short PR, and when compared to the 11/24/10 EKG, nonspecific T wave abnormality was evident in the lateral leads. PA#3 failed to document his interpretation of the EKG results and conduct an assessment of the patient.
The patient was sent back out to the waiting room at 2:20 PM. Review of the triage protocol directed that at the completion of triage, the triage RN would arrange for the patient to go directly to a treatment room/hall bed. In the event there are no rooms available, the patient will be placed in the reception area for no longer than 15 minutes while the triage RN collaborates with the Clinical leader to have the patient go to a treatment area. The hospital failed to ensure the patient was transferred back to a bed in accordance with policy. The patient was not monitored by nursing and/or evaluated by a medical professional while waiting to be seen from 2:21 PM through 8:45 PM when the patient was noted to be absent from the waiting room with a discharge designation as "left without being seen".

c. Patient #218 presented to the ED with a chief complaint of "rapid heart rate" on 4/15/11 at 2:42 PM. The triage assessment at 3:05 PM indicated the patient's pulse rate was 87 beats per minute. The patient was triaged as a Level-3 and sent back out to the waiting room. The hospital failed to ensure that a comprehensive cardiac assessment was completed (e.g. heart sounds, apical rate vs. radial pulse). At 7:29 PM, the patient notified staff that he/she was leaving the ED with a discharge designation of "left without being seen". The hospital failed to ensure that the patient was monitored and/or evaluated by medical personnel from 3:06 PM through 7:29 PM. The hospital failed to ensure the patient was moved back to a bed in accordance with policy.
Cross reference A-265, A-338, A-347 and A-395.