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Based on observation, interview and record review, the hospital failed to comply with the regulatory requirements for EMTALA when Patient 1 (Pt 1) was seen in the Emergency Department (ED) on 10/23/21 for shortness of breath and self-described COVID-19 infection and an appropriate Medical Screen Exam was not conducted, an Emergency Medical Condition (EMC) was not stabilized and Pt 1 was discharged inappropriately. Following discharge from the ED, Pt 1 was sent home and family members found her pulseless and not breathing, called 911 Emergency Services and Pt 1 expired 90 minutes after being discharged from the hospital.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe and responsible manner.

Based on observation, interview and record review, the hospital failed to provide an appropriate medical screening examination (MSE- an assessment performed by Qualified Medical Personnel [QMP] for the purpose of determining whether an emergency medical condition [emc] exits) within the capability of the hospital's emergency department (ED) for one of four patients, Patient (Pt) 1 when:

Pt 1 was brought to the ED on 10/23/21 by family with chief complaint of shortness of breath and self-described COVID-19 infection and the Registered Nurse (RN) assigned to triage and prioritize Pt 1 had not been validated as competent to perform this function. Pt 1's medical history and current medications were not assessed and documented, and nurses assigned to care for Pt 1 did not conduct on-going physical assessments including evaluation of Pt's respiratory status, or follow policy for provider notification of Pt 1's declining status. The QMP did not have the benefit of an updated history and complete assessments in performing the MSE.

These failures resulted in the delay in identification of the emergency medical condition for Pt 1 and led to the inappropriate discharge. Pt 1 was discharged home on 10/24/21 at 12:20 a.m. and was found pulseless and not breathing by family at 01:15 a.m. and was transported by 911 emergency service to Hospital B where Pt 1 expired, 90 minutes after being discharged.

Findings:

During record review of Pt 1's clinical record, dated 10/23/21 from 6:58 p.m. to 10/24/2021 6:25 a.m., Pt 1's electronic health record (EHR) indicated the following timeline beginning on 10/23/21:

6:58 p.m. Pt 1 arrived in ED complaining of shortness of breath and previous positive COVID-19 test. No other information regarding the COVID-19 history, such as when and where the test was performed, was documented.

7:03 p.m. Pt 1 was roomed in C8 (A room in the ED designated by the hospital for patients who have tested positive for the COVID-19 virus) and vital signs were temperature 100.2°F (degrees Fahrenheit) heart rate 115 beats per minute (bpm), respirations 25 per minute (rpm), blood pressure (BP) 203/87 millimeters of mercury (mmHg), oxygen (O2) saturation 97% on room air.

7:05 p.m. the Emergency Department Medical Provider (EDMP) 1 ordered complete blood count (CBC - a blood test used to detect a wide range of disorders, including anemia and infection), basic metabolic panel (BMP-a blood test that measures sugar [glucose] level, electrolyte and fluid balance, and kidney function), Brain natriuretic peptide (BNP-a blood test that measures levels of a protein called BNP that is made by your heart and blood vessels), 12 lead EKG (an electronic recording of the heartbeat), and a portable chest x-ray (imaging to look at the lungs).

7:07 p.m., RN 1 was assigned to Pt 1 and acknowledged EDMP 1's orders.

7:11 p.m., Pt 1 received a portable chest x-ray and RN 1 documented Pt 1's ED symptoms as
"Chills; Fever; Muscle pain; Weakness; Shortness of breath; Cough" and documented her chief complaint as "Shortness of breath".

7:16 p.m., RN 1 assigned Pt 1 an Emergency Severity Index (ESI - scale used to determine level of acuity or seriousness for the chief complaint with the scale ranging from 1-5, 1 representing the most serious) 3 and documented the comprehensive evaluation and triage were complete.

7:21 p.m. Blood specimen collected and sent to lab.

7:32 p.m., temperature 102.4 F, heart rate 125 bpm, respirations 24/min, BP 132/79 mmHg, O2 saturation 94% on room air.

7:37 p.m., a 12 lead EKG was performed on Pt 1 with indication of "chest pain." CBC results indicated normal values.

7:39 p.m., EDMP 1 ordered acetaminophen (Tylenol, for fever), 1 Liter bolus (rapid intravenous [IV] infusion of fluids), Lactic acid (a test used to look for low oxygenation levels and may indicate worsening infection), and HCG (pregnancy) tests.

8:08 p.m., Lab results indicated the following abnormal values for the following: AST (a liver function test) 81 U/L (reference range: 8-40), Sodium 128 mmol/L (reference range 135-145), Chloride 91 mmol/L (reference range 98-110), Glucose 117 mg/dL (reference range 70-99), BUN/Create Ratio 10 (reference range 15-20), and Calcium 7.5 mg/dL (reference range 8.5-10.5).

8:41 p.m., EDMP 1 ordered calcium gluconate 2 grams in dextrose 5% 100 ml IVPB.

8:44 p.m., The Medical Screening Exam (MSE - the examination conducted by a Qualified Medical Professional [QMP] for the purpose of determining if an emergency medical condition exists) was initiated, EDMP 1 saw Pt 1 for the first time.

8:49 p.m., 1 liter of IV fluid bolus was started.

10:26 p.m., Temperature 99.1, heart rate 114 bpm, respirations 24 rpm, BP 117/74 mmHg, O2 saturation 92% on room air.

10:28 p.m., calcium gluconate 2 grams in dextrose 5% 100 ml IVPB started.

10:52 p.m., EDMP 1 "MD notes" indicated, "Walking sat 92, will finish Ca [calcium gluconate] and dc [discharge], discussed w [with] pt importance of home O2 monitor. Pt states ready to go". (This was the last documentation indicating EDMP 1 saw Pt 1).

10:53 p.m. EDMP 1 ordered another 1-liter bolus of fluids.

11:29 p.m., ED disposition set to Discharge. EDMP 1 indicated Patient Ready to Go.

11:48 p.m., LVN 1 removed the IV.

11:56 p.m., Temperature 99.3 F, heart rate 124 bpm, Resp 40/min, BP 168/97, O2 saturation 88% on room air.

11:59 p.m., heart rate 123 bpm, O2 saturation 92% on room air, rechecked by LVN 1.

10/24/21
12:01 a.m., heart rate 124 bpm, BP 181/94, O2 saturation 88% on room air, rechecked by LVN 1.

12:05 a.m., heart rate 124 bpm, O2 saturation 90% on room air, rechecked by LVN 1.

12:09 a.m., LVN 1 notified MD of Pt 1's vitals through a secure text in the EMR (where one must be signed into the system and on a computer to see) and asked if he wanted to continue with discharge.

12:13 a.m., EDMP 1 responded on the secure text, "no we can admit". No indication that message was received by anyone. 12:16 a.m., ED discharge set to Observation. "Decision to Admit."

12:16-12:18 a.m., orders placed by EDMP 1 for dexamethasone injection (anti-inflammatory medication used to treat inflammation in various parts of the body) 6 mg; IP [inpatient] consult to hospitalist; CRP (a test that measures the level of c-reactive protein, made by the liver, in the blood, which increases when there is inflammation in the body), BNP, and Troponin (a test that indicates heart injury) labs; CT Angiogram Pulmonary with Contrast (a scan that looks for blood clots in the lungs); and a COVID-19 Virus PCR (a swab test for COVID-19).

12:19 a.m., Hospitalist accepted Pt 1 for Admit evaluation.

12:20 a.m., the "After Care Instruction Acknowledgement" was signed by Pt 1, the signature line for the RN/LVN was left blank. The acknowledgement was printed on 10/24/21 at 12:10 am along with the document "After Visit Summary" (AVS-a summary and instructions given to the patient when they are discharged from the ED). The AVS indicated Pt 1's discharge diagnoses were "Pneumonia due to COVID-19 virus, low sodium and low calcium levels." The document also indicated Pt 1's discharge vital signs were "Temperature 99.3 F, BP 181/94, heart rate 124 bpm, respirations 40/min, O2 saturation 90%."

There was no nursing documentation regarding the discharge in the patient chart. At 3:48 a.m., LVN 1 entered a note (for the time of 12:30 a.m.) in Pt 1's chart stating Pt 1's "vital signs were abnormal, provider notified, RN 1 insisted that she needed to be discharged because patient wanted to go home."

12:21 a.m., EDMP 1 noted, "apparently patient has already been discharged".

During a review of the Emergency Medical Service (EMS) Report, dated 10/24/2021, the EMS report indicated, EMS arrived at Pt 1's home at 1:35 a.m. to find Pt 1 pulseless and not breathing with fire department already on scene performing CPR (cardiopulmonary resuscitation - life-saving measures performed when the heart stops beating). EMS continued CPR, put Pt 1 on cardiac monitor which showed asystole (no heart activity), placed an IV, gave two doses of epinephrine, and transported Pt 1 to the ED at Hospital B.

During a review of Pt 1's Code Blue Documentation record from Hospital B, dated 10/24/2021 at 01:46 a.m., the record indicated CPR was continued but Pt 1 remained pulseless with no heart rhythm. Pt 1 was pronounced dead at 2:03 a.m.

During an interview on 11/10/21, at 11:15 a.m., with RN 2, RN 2 stated, patients who come to the ED and had tested positive for COVID-19 or had symptoms that were consistent with COVID-19 were sent directly to rooms C8 (for COVID-19 positive) or C7 (to rule out COVID-19 with COVID-19-like symptoms) in the ED C-Pod. RN 2 stated, she had been in the ED triage tent (where all patients check in for the ED) when Pt 1 arrived on 10/23/21. The patient care assistant (PCA) had stopped Pt 1 outside of the triage tent and informed RN 2 that Pt 1 was stating she was positive for COVID-19. RN 2 stated, she did not see Pt 1 and did not triage Pt 1 but told the PCA to take the patient directly to C8. RN 2 stated, she did not assess Pt 1 at the triage tent because she was only supposed to assess COVID-19 positive or rule out COVID-19 patients who were in distress and the PCA did not tell her Pt 1 was in distress.

During a concurrent observation and interview on 11/10/21, at 11:28 a.m., with LVN 3, in the ED Lobby, there were 15 patients in the lobby, two with IV fluid infusing, and one LVN present. LVN 3 stated, there was no RNs assigned to the lobby that day until 12 p.m. and the other LVN was in the treatment room setting up for a procedure. LVN 3 stated, if she needed an IV medication given or felt a patient was unstable, she would need to go get an RN or call the Clinical Supervisor. LVN 3 stated, the LVNs discharged the patients from the lobby.

During an interview on 11/10/21, at 11:57 a.m., with ED Director (EDD), EDD stated, patients who come to the ED and state they have tested positive for COVID-19 or have COVID-19 like symptoms, are taken directly to C-Pod, COVID-19 positive patient are placed in C 8 and rule-out COVID-19 patients are placed in C 7. EDD stated, the RN assigned to those rooms is responsible to triage the patients. EDD acknowledged that there was no RN currently assigned to C 7 and C 8 and stated if no RN was assigned to C 7/C 8, the EMS triage nurse would cover and triage those patients.

During an interview on 11/10/21, at 12:02 p.m., with LVN 2, LVN 2 stated, the LVNs in the ED were responsible for carrying out all orders for the patients and the RNs helped with IV medications if ordered. LVN 2 stated, the RN triaged the patients and completed the first assessment and the LVNs collected another set of vital signs from the patient within 30 minutes of discharge, completed the second assessment, and discharged the patients from the ED.

During an observation on 11/10/21, at 12:12 p.m., in C Pod, the EMS Triage nurse was observed. Patients were being brought in by ambulance and lining up in the hallway to be triaged. The triaging of three EMS patients was observed but the constant stream of EMS patients coming into the ED prevented even an interview with the EMS Triage nurse.

During a telephone interview on 11/10/21, at 2 p.m., with Pt 1's family member (FM) 1, FM 1 was very emotional and stated he had "lost" Pt 1. FM 1 stated he could not talk at this time but stated FM 2 would call back.

During an interview on 11/10/2021, at 2:25 p.m., with EDMP 1, EDMP 1 stated, he was an emergency room physician at the hospital and had treated Pt 1 on 10/23/21. EDMP 1 stated, his initial assessment of Pt 1 was that she was a routine COVID-19 patient, and she was known to be COVID-19 positive although he did not know where or when she tested positive. He stated the patient presented with both decreased blood calcium and decreased blood sodium. EDMP 1 stated, the patient also had hypertension (high blood pressure). He stated he thought the hypertension was unusual but not that unusual for a COVID patient. EDMP 1 stated, he did not know if Pt 1 had a history of hypertension. EDMP 1 stated, he ordered intravenous fluids in addition to intravenous calcium for the patient. He stated, he ordered basic labs, an EKG and a chest x-ray. He stated, 2 hours later the patient's oxygen saturation had decreased to about 92%. EDMP 1 stated, he spoke to Pt 1 around 11 p.m. and explained her treatment and the importance of monitoring her oxygen saturations at home. According to EDMP 1, Pt 1 told EDMP 1 that she did not have a monitor at home, and he told her she could purchase one from any pharmacy. EDMP 1 stated around 11:50 p.m., he looked at Pt 1's last documented vital signs [from 10:30 p.m.] and decided she was stable for discharge. He stated he made her status as such which notified the nursing staff to discharge her when her treatments were complete. EDMP 1 stated, at 12:13 a.m., he received a secure text message from LVN 1 stating Pt 1's current vital signs and asking him if he still wanted to discharge her and EDMP 1 replied not to discharge Pt 1, he would admit her to the hospital. EDMP 1 stated, a person must be logged on to the EHR system to send or receive a text message. EDMP 1 stated, he received a call from RN 1 stating Pt 1 had already been discharged and, later, a secure text from LVN 1 stating the patient had already been discharged. EDMP 1 stated, his expectation was for the nurse to wait for his reply if there is a change of condition for a patient before discharging them. EDMP 1 stated, if he could had done things differently, he would have admitted Pt 1 before she had the opportunity to leave.

During an interview on 11/10/21, at 3:15 p.m., with the Emergency Department Medical Director (EDMD), EDMD stated, she was an emergency room physician at the facility, and she was the Medical Director of the Emergency Department at the facility. EDMD stated, she had not treated Pt 1 in the emergency room of the facility; however, she had reviewed the medical record of Pt 1 in her capacity as the ED Medical Director. She stated, she would have expected the physician to be notified prior to Pt 1's discharge and the physician should have responded when he was notified.

During an interview on 11/10/21, at 4:12 p.m., with Emergency Department Clinical Supervisor (EDCS) 1, EDCS 1 stated, the clinical supervisors determine staff assignments for the ED. EDCS 1 worked on 10/23/21 from 11 p.m. to 11 a.m. but did not have any contact with Pt 1.
EDCS 1 stated, usually one nurse is assigned to both C7 and C8 rooms and can be an LVN or an RN. If only an LVN is assigned, then the RN assigned to EMS triage does the triage and patient assessments when available. EDCS 1 stated, the expectation is for the RNs to make sure patients have a safe discharge.

During an interview on 11/12/21, at 1:30 p.m., with LVN 1, LVN 1 stated, he had worked in the ED at the hospital for about two months and prior to that he worked for a health insurance company and had no prior experience in an ED setting. LVN 1 stated, his orientation lasted approximately 3-4 weeks. LVN 1 described his duties as providing care to patients in Triage, doing vital signs, giving medications, assisting with discharges, etc., and stated, the RN guides him in what he needs to do. When asked about his interaction with Pt 1, LVN 1 stated, he recalled looking at the status board in ED and seeing the disposition set to discharge. LVN 1 stated, he gets their discharge paperwork ready and gets a set of VS prior to discharge. LVN 1 stated he obtained those vital signs, and they were not normal. LVN 1 stated, he rechecked the VS a couple of times and they remained abnormal. LVN 1 stated, he attempted to reach the MD via the secure voice system, but he was unable to get the device to work. LVN 1 stated, after the failed attempt to notify the MD, he informed the RN of the abnormal VS. LVN 1 stated, RN 1 told him to go ahead with the discharge because the patient wanted to go home. LVN 1 stated, he then attempted to contact the MD using a secure messaging system within the EHR. LVN 1 stated, he messaged the MD about the VS and asked him if he should still D/C the patient. LVN 1 stated, the MD would have to be looking at the record to see the message. LVN 1 stated, he waited a few minutes to see if the MD would reply and when he did not LVN 1 went ahead and had pt sign a discharge form and pushed Pt 1 in a wheelchair out to her sister's car because he was worried she would fall if she walked. LVN 1 described Pt 1 as being agitated while waiting to leave. LVN 1 stated, that Pt 1's sister was very upset her sister was being discharged because Pt 1 was so sick. LVN 1 stated, when he got back into the ED, he found out from the RN that the MD wanted Pt 1 to be admitted. LVN 1 stated, he found out later from the charge nurse that Pt 1 had died a couple of hours after she was discharged from the ED. LVN 1 stated, he felt the RN directed him to discharge this patient. LVN 1 stated, he did not consider using any other method to notify the doctor. LVN 1 stated, he did not think to notify another RN, the supervisor, or the charge nurse when RN 1 insisted he discharge the patient despite the abnormal vital signs.

During an interview on 11/12/21, at 4:40 p.m., with the Chairman of the Emergency Department (CED), CED stated, he hadn't been directly involved with Pt 1's case, however, he did review the chart. CED stated, Pt 1 had presented as a case of respiratory distress and had conveyed to the ED staff she was COVID-19 positive, however, she was never tested for COVID-19, that should have been done early in the encounter. CED stated, while Pt 1 initially appeared to be stable she was never really stabilized. The initial vital signs changed over the course of hours in the E.D. The patient was anxious, tired, and uncomfortable. She was adamant about leaving the facility and going home. The LVN was aware of the changes in vital signs, however, was not able to communicate with the physician.

During an interview on 11/16/21, at 1:04 p.m., with RN 1, RN 1 stated, he had been a travel nurse at Hospital A and was on his third 13-week contract with them when he terminated his contract early on 10/25/21 due to an "unsafe work environment." RN 1 stated, he worked in the ED at Hospital A on 10/23/21 from 3 p.m. to 3:30 a.m. on 10/24/21. His assignment at 7 p.m. was to act as a "resource" nurse for C-pod since there were a lot of patients with high acuity (the measurement of the patient's illness severity and the intensity of nursing care required). LVN 1 came on shift and was assigned to C7 and C8. RN 1 stated, the RNs are supposed to help the LVNs with IV medications and other treatments, but RN 1 stated, it was not part of the RNs duties to do the assessments for the LVNs. RN 1 stated, there were usually 2-3 LVNs in the lobby and one RN overseeing everything which meant an RN could have 30-40 patients. RN 1 stated, patient assessments were "hit and miss" in Hospital A's ED because there just wasn't enough time to do them. RN 1 stated, he remembered Pt 1, he had started her IV because LVN 1 was new and didn't feel comfortable starting IVs. RN 1 stated, he didn't remember assigning Pt 1's ESI but said it wasn't unusual to have a patient in C7 or C8 who had not yet been triaged. RN 1 stated, he had never had a triage competency assessment at Hospital A. RN 1 stated, Pt 1 was not one of his primary patients, but he remembered seeing her status change to "ready for discharge" on the patient tracker (a board that is displays the location and status of the patients in the department and is automatically updated by the EMR) and he was notified Pt 1's family was there to pick her up. RN 1 stated, he relayed the message to LVN 1 and reminded him to remove Pt 1's IV before discharging her. RN 1 stated, LVN 1 did not say anything about Pt 1's vital signs to him then or at any other time. RN 1 stated, later he noticed that Pt 1's status had changed on the patient tracker to "waiting to be admitted" so he called EDMP 1 to ask why the patient was being admitted and to let him know that she had already left the ED.

During an interview on 11/16/21, at 2:20 p.m., with the Emergency Department Director (EDD), EDD stated, the RNs oversee the LVNs in the ED, double check medications, and know the LVNs cannot do assessments. She stated, the RN "resource nurse" is responsible for all assessments and all discharge instructions as well as triage assessment if not done by the EMS triage nurse (a nurse stationed by the ambulance bay to triage patients coming in by ambulance).

During a concurrent interview and record review, on 11/16/21, at 3:16 p.m., with EDM, Pt 1's EHR was reviewed. The record indicated Pt 1's stay in the ED was a little over 5 hours: 6:58 p.m. 10/23/21 to 12:20 a.m. on 10/24/21. EDM stated, RN 1 completed the initial triage assessment including chief complaint, disease screening, domestic violence screening, and vital signs, however no pain assessment (during entire stay), allergies, mental health, suicide screening or fall risk were completed and the history and meds were not updated, in fact Pt 1's medical history, emergency contact information, and medication history had not been updated since 2018. EDM confirmed that limited triage assessment was the only assessment completed during Pt 1's entire stay. EDM stated the expectation is that the nurses do a focused assessment on every patient, a minimum of a head-to-toe assessment (A head-to-toe nursing assessment is a comprehensive process that reviews the health of all major body systems and will inform the health care provider about the patient's overall condition), and a more complete assessment for patients with higher acuity (lower ESI number). EDM confirmed there was no nursing documentation regarding Pt 1's respiratory status, such shortness of breath, anxiety, change in skin color, increased work of breathing, or ability to tolerate activity.

The EDM stated, Pt 1's record indicated her oxygen saturations had hovered around 88-92% on room air and the EDMP 1 should have been notified but there was no documentation in Pt 1's chart that the EDMP 1 had ever been notified except a late entry documentation by LVN 1 entered at 3:48 a.m. The EDM confirmed there was no documentation of the condition of Pt 1 at the time of discharge from the hospital. EDM stated there was no COVID-19 positive test result verified or ordered for Pt 1 before her discharge.

During an interview, on 11/16/21, at 3:16 p.m., with EDM, EDM stated the facility had not tested RN 1 for competency in triaging because contracted nurses were not supposed to triage. He stated the facility had not discussed how triaging of patients in C7 and C8 would be handled when the rooms were converted to be used for COVID-19 and suspected COVID-19 isolation patients being sent directly from the triage tent.

During a concurrent interview and record review, on 11/16/21, at 3:16 p.m., with the EDM, the "ED staffing assignment", dated 10/23/21 was reviewed. EDM stated, patients needing COVID-19 isolation at the triage tent are taken directly to rooms C7 or C8. The ED Staffing Assignment indicated on 10/23/21 from 7 a.m. to 3 p.m., there was one LVN assigned to both C7 and C8 with no RN, and from 3 p.m. to 7 p.m. RN 1 was assigned to both C7 and C8 with no LVN. From 7 p.m. to 3 a.m. (10/24/21), RN 1 and LVN 1 were assigned to C7 and C8, and at 3:30 a.m., RN 1 ended his shift and LVN 1 was left alone with C7 and C8. EDM stated, the Charge RN fills in if the ED has a staffing deficit.

During a concurrent interview and record review, on 11/17/21, at 10:13 a.m., with EDM and the ED Clinical Supervisor (EDCS) 2, the "ED staffing assignments", dated 10/16/21-10/23/21 were reviewed. EDCS 2 stated, she often did the ED staffing assignments and there should be two LVNs assigned to C7 and C8 with three RNs assigned to the rest of the C-Pod and overseeing the LVNs. EDCS reviewed the ED staffing assignments from 10/16/21-10/23/21 and stated, there was often only one nurse assigned to C7 and C8 due to staffing issues.

During an interview on 11/19/21 at 2 p.m. with FM 2, FM 2 stated, she had picked Pt 1 up outside the ED at Facility A on 10/24/21 at 12:20 a.m. FM 2 stated, Pt 1 was in a wheelchair and breathing heavy, so she asked the nurse why she was breathing like that. The nurse responded that Pt 1 had COVID-19 and pneumonia and her oxygen saturation was at 90% but the doctor knew and was letting her go home. FM 2 stated, by the time she got Pt 1 home, she could barely breath so she called the ED back and was told they made a mistake, Pt 1 was supposed to be admitted and if she brought her back, she wouldn't have to wait in the ED. FM 2 stated, she called an ambulance, but Pt 1 had stopped breathing by the time the ambulance got there.

During a review of RN 1's "Traveler Confirmation", dated 3/31/2021, 5/18/2021, and 8/19/2021, the "Traveler Confirmation" indicated, RN 1 had signed three, concurrent, 13-week assignments with the facility to end on 1/15/2021.

During a review of RN 1's "Initial Competency Validation Documentation", dated 4/19/2021, the "Initial Competency Validation Documentation" indicated, RN 1 had not been evaluated for competency in Emergency Department Triage.

During a review of RN 1's "Orientation Skills/Competency Verification Registered Nurse - Traveler/Registry Emergency Department", dated 4/20/2021, the "Orientation Skills/Competency Verification Registered Nurse - Traveler/Registry Emergency Department", indicated, "Performance Area: G. Role Specific, patient Classification System; Learning Method: Lecture/Discussion; Verification Method: Discussed with Preceptor" and was initialed by RN 1 and preceptor on 4/20/2021. There was no documentation of any competency verification of triage skills.

During a review of the facility's "Orientation Skills/Competency Verification Registered Nurse Emergency Department - Phase 3 (START - Simple Triage And Rapid Treatment)", dated 2019, indicated the facility's process of orientation and competency verification for RNs triaging in the Emergency Department using an eLearning Module with a Competency check. RN 1 did not have this orientation.

During a review of the facility's policy and procedure (P&P) titled "Triage - EMS ", dated 08/02/2021, the P&P indicated, "Policy: A. All persons requesting treatment in the Emergency Department will be triaged by a Registered Nurse who has completed triage orientation and has documented competency ...Procedure ...B. Patients that do not require immediate lifesaving interventions will be assessed including; 1. Chief complaint and history of present illness, including physical findings and care before arrival. 2. Travel History. 3. Pertinent past medical history. 4. Complete vital signs - temperature, pulse, respiration, blood pressure, O2 saturation and pain assessment. 5. Medication allergies - place allergy arm band when appropriate. 6. Tetanus history, when appropriate/immunization status. 7. Name of private physician if known...C. RN will assign priority using the Emergency Severity Index (ESI).

During a review of "LVN Job Description", dated 9/22/2021, the "job description" indicated, " ...Reports To: Clinical Coordinator, supervises: N/A; Unit Manager ...Job Summary ...Identifies patient needs, maintains quality standards and provides basic patient care. The LVN also partners with the RN to perform skills, procedure and other tasks that are outside their clinical scope of practice. Essential Accountabilities ...Use and practice basic assessment (data collection) and contribute to evaluation of individualized interventions related to the care plan or treatment plan ...Interact and appropriately utilize other members of the healthcare team to promote patient/family wellbeing ...Assure completeness of patient record."

During a review of LVN 1's "Orientation Skills/Competency Verification Licensed Vocational Nurse Emergency Department", dated 10/5/2021, the "Orientation Skills/Competency Verification Licensed Vocational Nurse Emergency Department" indicated, "Performance Area: B. Department Overview ...Communication ...Phone, Vocera, Computer; Self-Assessment: Yes; Learning Method: Lecture/Discussion; Verification Method: Discussed with Preceptor; [Initialed and dated on 08/30/21 by both LVN 1 and Preceptor]."

During a review of LVN 1's "Orientation Skills/Competency Verification Licensed Vocational Nurse Emergency Department", dated 10/5/2021, the "Orientation Skills/Competency Verification Licensed Vocational Nurse Emergency Department" indicated, "Performance Area: G. Role Specific; Knowledge ...Chain of Command (Policy #11895); Self-Assessment: No; Learning Method: Read, Lecture/Discussion; Verification Method: Discussed with Preceptor; [Initialed and dated on 9/27/21 by both LVN 1 and Preceptor]."

During a review of LVN 1's "Orientation Skills/Competency Verification Licensed Vocational Nurse Emergency Department", dated 10/5/2021, the "Orientation Skills/Competency Verification Licensed Vocational Nurse Emergency Department" indicated, "Performance Area: G. Role Specific; Knowledge ... ...Critical Results Communication and Documentation (Policy #14332); Self-Assessment: No; Learning Method: Read, Lecture/Discussion; Verification Method: Discussed with Preceptor; [Initialed and dated on 9/27/21 by both LVN 1 and Preceptor]."

During a review of LVN 1's "Orientation Skills/Competency Verification Licensed Vocational Nurse Emergency Department", dated 10/5/2021, the "Orientation Skills/Competency Verification Licensed Vocational Nurse Emergency Department" indicated, "Performance Area: G. Role Specific; ...Skills ... ...1. Data Collection Vital signs, T [temperature], P [Pulse], R [Respirations], BP [Blood Pressure]; Self-Assessment: Yes; Learning Method: Lecture/Discussion, Demonstrated, observed; Verification Method: Discussed with Preceptor, Return Demonstration, Observed in Practice Setting; [Initialed and dated on 9/27/21 by both LVN 1 and Preceptor]."

During a review of LVN 1's "Orientation Skills/Competency Verification Licensed Vocational Nurse Emergency Department", dated 10/5/2021, the "Orientation Skills/Competency Verification Licensed Vocational Nurse Emergency Department" indicated, "Performance Area: Attitudes/Professional Conduct: ...Emergency Medical Treatment and Active Labor Act (EMTALA); Self-Assessment: Yes; Learning Method: Lecture/Discussion; Verification Method: Discussed with Preceptor; [Initialed and dated on 9/29/21 by both LVN 1 and Preceptor]."

During a review of LVN 1's "Emergency Department [Name of device] Communication Device (a device used in the ED to communicate by voice between health care providers) Competency", dated 08/30/2021, the "Emergency Department [Name of device] Communication Device Competency" indicated LVN 1 had met all competencies for using the Communication Device.

During a review of the facility's P&P titled, "Critical Results Communication and Documentation", dated 5/9/2019, the P&P indicated, " ...Critical results: Results that require rapid clinical attention to avert significant patient morbidity or mortality ...must be communicated within defined time frames to the Registered Nurse (RN) caring for the patient or the physician. Documentation of the call including date, time and who received the critical result(s) must be made as a permanent part of the patient's electronic health record ...If the RN makes the decision that the patient's condition is very unstable, he or she follows existing unit and/or corporate policies for Physician Notification Regarding Patient Status and/or Code Blue."

During a review of the facility's P&P titled, "Chain of Command - Patient care issues", dated 2/11/2021, the P&P indicated, " ... Questions involving patient care or policies and procedures are pursued via the staff to the unit-specific Charge Nurse of Clinical Supervisor ...B. Nurse to Physician Chain of Command - Reporting of Medical Information, 1. Nursing personnel are responsible for reporting pertinent patient information to the patient's designated attending physician or to the resident assigned to the patient ..."

During a review of the facility's P&P titled, "Role-Based Patient Care by Scope of Practice", dated 10/14/2021, the P&P indicated, "Role-Based Patient Care Skills List by Scope of Practice - Patient Care Revised 2021, 1. Assessment; Ongoing comprehensive assessment of the patient condition; nursing diagnoses; and stability determination of the patient; RN May perform, LVN May perform/upon assessment/direct