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Based on staff interviews and document review, the hospital failed to develop and implement an individualized plan of care for 1 of 1 emergency department (ED) boarder patients (Patient #5).

Failure to develop and implement an individualized plan of care places patients at risk for harm due to inappropriate, inconsistent, or delayed treatment and unmet care needs.

Findings included:

1. Document review of hospital policy, "Emergency Department Standards of Care," no policy number, last review date 05/08/23, showed:

a. Patient care planning is initiated upon admission.

b. Assessments reflect changes in a patient's condition, are appropriately charted and communicated, and the plan of treatment is changed accordingly. Outcomes are monitored and evaluated to determine if nursing interventions are effective.

c. The nursing process is used on an ongoing basis to reflect the patient's current needs and treatment plan includes the following:

i. assessment

ii. identification of patient needs and problems

iii. delineation of patient expected outcomes

iv. selection of related interventions

v. evaluation of patient response to interventions and outcome

2. On 09/15/23 at 11:30 AM, Investigator #2 and the Emergency Department Nurse Manager (Staff #1), the Executive Director of Nursing Services (Staff #2), and the Clinical Informatics Nurse (Staff #4) reviewed the medical records for Patient #5, a 75-year-old brought to the ED on 01/09/23 after a fall at home. Patient #5 did not meet criteria for admission and was unsafe to discharge home alone. At the time of the record review, Patient #5 remained hospitalized as an ED boarder and was receiving care on the acute care inpatient unit. Investigator #3 found no evidence of an individualized plan of care in Patient #5's electronic health record (EHR).

3. During the review, Staff #2 confirmed the investigator's finding that Patient #5 did not have an individualized plan of care documented in the electronic health record.
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Based on interview, document review, and review of the hospital's quality program, the hospital failed to develop, implement, and maintain effective corrective action plans.

Failure to develop, implement, and maintain effective corrective action plans reduces the likelihood of sustained improvements in clinical care and patient outcomes.

Findings included:

Failure to systematically identify problems, implement corrective action plans, and monitor for improvement limits the hospital's ability to provide high quality patient care and improve patient outcomes.

Cross Reference: C 1313

Due to the repeated deficiencies cited under 42 CFR 485.641, the Condition of Participation for Quality Assessment and Performance Improvement Programs was NOT MET.

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Based on interview, review of the hospital's quality and performance improvement program, and review of the hospital's plans of correction approved 07/14/23 and 08/29/23, hospital leaders failed to implement action plans and monitor for successful correction of previously cited deficiencies found during a federal and state complaint investigation completed 09/15/23.

Failure to systematically identify problems, implement corrective action plans, and monitor for improvement limits the hospital's ability to provide high quality patient care and improve patient outcomes.

Findings included:

1. The facility's Plan of Correction approved 08/29/23, showed that staff education and policies and procedures related to chemical restraint monitoring, extended stay patrons, and emergency department (ED) standards of care were posted on the education board and discussed during pre-shift huddles. Chemical restraint monitoring, extended stay patrons, and ED standards of care reviewed during a mandatory staff meeting held on 08/31/23. Review of the staff attendance roster for the 08/31/23 mandatory staff meeting showed that the meeting was not attended by all regularly scheduled department staff. There was no additional meeting or follow-up planned for staff who did not attend the mandatory staff meeting.

2. Restraint audit logs showed deficiencies in restraint documentation, but there was no evidence that leadership followed up with the staff members involved as discussed in the Plan of Correction.

3. Medical record review showed no plan of care for a long-term emergency department boarder patient (extended stay patron) hospitalized since 01/09/23 (Patient #5).

Cross Reference: C1046, C1050
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