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Based on record review, review of Medical Staff Rules and Regulations, the contracted emergency medical staff agreement, emergency medical staff performance standards, and staff interviews, the hospital medical staff failed to follow the hospital's Medical Staff Rules and Regulations, relative to documentation in the medical record, in two of 11 records reviewed (Patients #1 and 11).

Findings included ...

Review of the hospital's "Medical Staff Rules and Regulations," dated 07/15, showed medical staff are responsible for a complete medical record to include pertinent and current information, condition on discharge, and relevant and sufficient progress notes, to allow continuity of care and transferability.

Review of the hospital's services agreement with "Emergency Medical Associates (EMA)," dated 01/01/09, showed medical staff, under this agreement, are to comply with the hospital's rules and regulations and policies; maintain adequate and proper medical records; comply with rules, regulations, standards, and ethical and professional obligations to the provision of emergency services.

Review of the hospital's Emergency Medical Associates, "Performance Standards," dated 01/09/09, showed medical staff are to include documenting patient evaluations and discharge depositions in the medical record.

A. During review of Patient #1's medical record on 04/01/19 at approximately 1:45 PM, with Employee #20, Registered Nurse, the record revealed the patient was seen in the Emergency Department (ED) on 03/21/19 for Alcohol Intoxication. Employee #10, ED Charge Nurse, discharged the patient from the ED; prior to the medical provider review of systems and discharged the patient, in the absence of a discharge order, from a medical provider.

During a face to face interview on 04/01/19 at approximately 12:50 PM, with Employee #19, Emergency Department Physician, he explained that he did not conduct a complete patient evaluation because the patient pulled the blanket over his head and wanted to sleep; so most of the documentation was based on the information from EMS (Emergency Medical Services) staff and the triage nurse. Later, when he returned to evaluate the patient, he found that the patient was discharged by the nurse. Employee #19 was asked to explain his documentation, dated 03/22/19 at 4:25AM, "Departure Condition Stable." He explained that he had to choose an option from the drop down box and discharge the patient to close out the record. Though he did not see the patient at discharge, based on the last time he saw the patient, the patient was stable, so he chose that option, versus choosing left without being seen or eloped. When queried regarding other options, he acknowledged the availability of the option to free text.

The practice lacked evidence that medical staff followed the rules and regulations to ensure accurate documentation, in the medical record, to reflect the patient's condition at discharge.

Employees #19 and 26, Director of Quality and Patient Safety, acknowledged the findings.

B. Review of the hospital's policy titled, "Scabies/Head Lice - Management of Patients," dated 03/18/19, showed outpatients presenting with head lice, who require ongoing therapy or must be seen urgently, should have a surgical cap placed and contact precautions should be instituted. Patient education and control measures should be implemented.

During review of Patient #11's medical record on 04/03/19 at approximately 4:45 PM, with Employee #20, Registered Nurse (RN), the record revealed the patient presented in the Emergency Department (ED) on 01/28/19, after being found unconscious by Emergency Medical Services (EMS) staff. The patient was treated and monitored for presumed Alcohol Intoxication (Ethanol level was documented at a high value of 336).

Review of the nursing documentation at 11:06 PM revealed the patient was noted to have head lice and she placed a surgical cap.

Review of the medical record at 11:17 PM, revealed the physician re-evaluated the patient to remain somnolent and tachycardiac, after initial treatment, so he ordered laboratory work and a Head CT (computed tomography) scan. The physician documentation at 11:45 PM revealed, "Informed by RN patient has lice, and if sent to CT, they will have to temporarily shut it down for cleaning." Nursing documentation revealed the patient was awake to void on 01/29/19 at 2:41 AM and the CT was discontinued, at that time.

Further review revealed the medical record lacked documented evidence that the physician assessed the patient for the presence or absence of head lice; and the record lacked evidence of further measures taken to address the finding of head lice, identified and brought to medical staff attention, by the registered nurse, to determine patient plan of care and treatment.

During a telephone interview on 04/10/19 at approximately 2:00 PM, with Employee #6, RN, she explained was the Charge Nurse caring for the patient, on 01/28/19 at 7:00 PM. She noticed "some bugs in the patient's hair," she put a surgical cap on the patient's head, and told Employee #3, ED physician. She told Employee #9, oncoming RN to whom she provided her outgoing report, because she had long hair, and the patient was moved from a hallway bed in the ED to Room #2. She implemented contact precautions and shared the finding amongst other staff.
During a telephone interview on 04/09/19 at approximately 12:40 PM, with Employee #3, ED Physician, she explained that she was the first medical provider to see, evaluate, and care for the patient, who was brought in unresponsive to external stimuli; for Alcohol Intoxication. She assessed the patient to have no external trauma, but wanted to get some laboratory values and do a head CT because the patient was still tachycardic, after two liters of intravenous fluid and was not arousable. Employee #3 communicated the RN said it looked like the patient had head lice and they may have to shut down the CT for cleaning. The CT was cancelled, shortly thereafter, since the patient became more alert. Employee #3 re-evaluated the patient and found no evidence of head lice or the need for treatment; however, she did not document or communicate her assessment. She did not report the information to the oncoming physician, Employee #5.

Further interviews conducted with Employees #7 and 9, RNs caring for the patient revealed, nursing staff reported suspected head lice and they took precautionary measures; however, interviews conducted with Employee's #4 and 5, medical providers who cared for the patient, revealed they had no knowledge of the suspected head lice for Patient #1.

The practice lacked evidence that the medical staff followed the rules and regulations to ensure relevant and sufficient patient information was documented or communicated to maintain a means of communication and collaboration for patient care and treatment.

Employees #19, 3, 6, 14, ED Nursing Director, 1, ED Medical Chair, and 26, Director of Quality and Patient Safety, acknowledged the findings.

Based on record review, review of Medical Staff Rules and Regulations, the contracted emergency medical staff agreement, emergency medical staff performance standards, and staff interviews, the medical staff failed to provide care in a safe and effective manner, for two of 11 patients (Patients #1 and 11) (Cross reference A-0044).

Based on record review, review of Medical Staff Rules and Regulations, policy review, video footage review, and staff interviews, the hospital staff failed to ensure the requirements for emergency services, for coordination and integration with hospital services, for two of 11 patients (Patients #1 and 11).

Findings included ...

Review of the hospital's "Medical Staff Rules and Regulations," dated 07/15, showed medical staff are responsible for a complete medical record to include pertinent and current information, condition on discharge, and relevant and sufficient progress notes, to allow continuity of care and transferability.

Review of the hospital's policy titled, "Discharge Planning," dated 03/22/19, showed patient discharge requires a medical provider order and that it applies to all patients. Nursing staff are to provide discharge instructions, including medication review and plans for follow-up care.

During review of Patient #1's medical record on 04/01/19 at approximately 1:45 PM, with Employee #20, Registered Nurse, the record revealed the patient was triaged in the Emergency Department (ED) on 03/21/19 at 2:58 PM, with Alcohol Intoxication and was assigned an Emergency Severity Index of 3- Urgent. He was unresponsive/unable to respond reliably to questions, during triage. Employee #10, ED Charge Nurse, discharged the patient from the ED; prior to the medical provider review of systems and discharged the patient, in the absence of a discharge order, from a medical provider.

The patient's past medical history included Alcohol Abuse, Pancreatitis, Osteoarthritis, Peripheral Artery Disease, and an allergy to Penicillin. Staff documented the patient had a history of coming to the hospital, frequently, demanding food and to sleep, being uncooperative and easily agitated, if he didn't get what he wanted.

The Abuse Indicators and Resource Planning Assessment revealed nursing staff identified a Case Management/Social Work Consult was needed; however, the record lacked documented evidence that staff provided care coordination with case management/social work.

During a face to face interview on 04/01/19 at approximately 12:50 PM, with Employee #19, Emergency Department Physician, he explained that he did not conduct a complete patient evaluation because the patient pulled the blanket over his head and wanted to sleep; so most of the documentation was based on the information from EMS (Emergency Medical Services) staff and the triage nurse. Later, when he returned to evaluate the patient, he found that the patient was discharged by the nurse. Employee #19 was asked to explain his documentation, dated 03/22/19 at 4:25AM, "Departure Condition Stable." He explained that he had to choose an option from the drop down box and discharge the patient to close out the record. Though he did not see the patient at discharge, based on the last time he saw the patient, the patient was stable, so he chose that option, versus choosing left without being seen or eloped. When queried regarding other options, he acknowledged the availability of the option to free text.

The medical staff failed to follow the rules and regulations to ensure accurate documentation, in the medical record, to reflect the patient's condition at discharge.

During a face to face interview on 04/01/19 at approximately 2:00 PM, with Employee #20, she was asked to provide the documentation relative to the follow up with case management or social work. She reviewed the record and explained there was no note in the patient's record to indicate case manager or social worker was contacted.

During a face to face interview on 04/01/19 at approximately 12:20 PM, with Employee #15, Director of Care Coordination, she explained that there was no case management or social work referral made by phone, text, or verbally to the Care Coordination department for Patient #1, this year.

During a telephone interview on 04/09/19 at approximately 11:30 AM, with Employee #10, ED Charge Nurse, she was queried regarding the collaboration with case management/social work. She explained she did not collaborate with the patient's assigned nurse, physician or case manager/social worker to address the triggered indicators and to ensure safe discharge and resource planning.

Additionally, review of the hospital's, "Patient Rights and Responsibilities," dated 03/09/18, showed that patients have the right to receive information in a way that they can understand.

Review of the documented patient's language and language preference revealed, "Spanish."

During a telephone interview on 04/09/19 at approximately 11:30 AM, with Employee #10, ED Charge Nurse, she explained that she discharged the patient home. The surveyor queried Employee #10 about how staff communicated with the Spanish speaking patient. She explained the patient did speak some English and understood her, when she spoke to him. She explained Employee #13, Patient Care Technician (PCT) provided the patient clean, donated clothing and she directed Employee #13, Patient Care Technician (PCT) to provide a walker and walker instructions, and escort the patient out of the ED.

During a face to face interview on 04/03/19 at approximately 12:18 PM, with Employee #13, Patient Care Technician (PCT), he shared that Employee #10 told him that the patient was discharged and asked him to assist with providing clean clothing, dressing, and a walker, with instructions, as Employee #13 shared with Employee #10 that the patient was unsteady standing. Employee #13 explained that though his Spanish was limited and the patient "understood a few words in English," he assisted the patient to apply several layers of clothing. Pants were applied and a hat was not provided, though the patient "patted his head" and requested a hat. He provided walker instructions, but did not show the patient how to open or close the walker. He attached the patient's belongings bag to the walker, observed him ambulating, and escorted Patient #1 out of the ED, to where the Metropolitan Police Officer (MPD) and security officers stood. "The patient said to the MPD my hat?" as it was raining outside, and continued walking towards the security officer, to whom Employee #13 told the patient was discharged. Staff did not provide a hat or head covering. Nursing staff failed to coordinate with assistive or supportive language personnel or utilize communication devices to communicate in a language understood by the patient for instructions or use of a provided walker.

Review of video footage of the patient's stay in the ED, on 04/02/19 at 1:50 PM, showed the patient had on a hoodie, upon arrival.

The practice lacked evidence that staff ensured care coordination to facilitate safe discharge planning.

Employees #20, 10, 13, 15, 19, ED Nursing Director and #26, Director of Quality and Patient Safety, acknowledged the findings.

B. Review of the hospital's policy titled, "Scabies/Head Lice - Management of Patients," dated 03/18/19, showed outpatients presenting with head lice, who require ongoing therapy or must be seen urgently, should have a surgical cap placed and contact precautions should be instituted. Patient education and control measures should be implemented.

During review of Patient #11's medical record on 04/03/19 at approximately 4:45 PM, with Employee #20, Registered Nurse (RN), the record revealed the patient presented in the Emergency Department (ED) on 01/28/19, after being found unconscious by Emergency Medical Services (EMS) staff. The patient was treated and monitored for presumed Alcohol Intoxication (Ethanol level was documented at a high value of 336).

Review of the nursing documentation at 11:06 PM revealed the patient was noted to have head lice and she placed a surgical cap.

Review of the medical record at 11:17 PM, revealed the physician re-evaluated the patient to remain somnolent and tachycardiac, after initial treatment, so he ordered laboratory work and a Head CT (computed tomography) scan. The physician documentation at 11:45 PM revealed, "Informed by RN patient has lice, and if sent to CT, they will have to temporarily shut it down for cleaning." Nursing documentation revealed the patient was awake to void on 01/29/19 at 2:41 AM and the CT was discontinued, at that time.

Further review revealed the medical record lacked documented evidence that the physician assessed the patient for the presence or absence of head lice; and the record lacked evidence of further measures taken to address the finding of head lice, identified and brought to medical staff attention, by the registered nurse, to determine patient plan of care and treatment.

During a telephone interview on 04/10/19 at approximately 2:00 PM, with Employee #6, RN, she explained was the Charge Nurse caring for the patient, on 01/28/19 at 7:00 PM. She noticed "some bugs in the patient's hair," she put a surgical cap on the patient's head, and told Employee #3, ED physician. She told Employee #9, oncoming RN to whom she provided her outgoing report, because she had long hair, and the patient was moved from a hallway bed in the ED to Room #2. She implemented contact precautions and shared the finding amongst other staff.

During a telephone interview on 04/09/19 at approximately 12:40 PM, with Employee #3, ED Physician, she explained that she was the first medical provider to see, evaluate, and care for the patient, who was brought in unresponsive to external stimuli; for Alcohol Intoxication. She assessed the patient to have no external trauma, but wanted to get some laboratory values and do a head CT because the patient was still tachycardic, after two liters of intravenous fluid and was not arousable. Employee #3 communicated the RN said it looked like the patient had head lice and they may have to shut down the CT for cleaning. The CT was cancelled, shortly thereafter, since the patient became more alert. Employee #3 re-evaluated the patient and found no evidence of head lice or the need for treatment; however, she did not document or communicate her assessment. She did not report the information to the oncoming physician, Employee #5.

Further interviews conducted between 04/09/19 and 04/11/19, with Employees #7 and 9, RNs caring for the patient revealed, nursing staff reported suspected head lice and they took precautionary measures; however, interviews conducted with Employee's #4 and 5, medical providers who cared for the patient, revealed they had no knowledge of the suspected head lice for Patient #1.

The practice lacked evidence that the medical staff documented or communicated relevant and sufficient patient information to ensure care coordination for effective care delivery.

Employees #19, 10, 13, 3, 6, 14, ED Nursing Director, 1, ED Medical Chair, and 26, Director of Quality and Patient Safety, acknowledged the findings.

Based on record and policy review, video footage review, and staff interviews, the nursing staff failed to ensure care was delivered, in accordance to orders from the medical provider, for one of 11 patients (Patients #1).

Findings included ...

Review of the hospital's policy titled, "Discharge Planning," dated 03/22/19, showed patient discharge requires a medical provider order and that it applies to all patients. Nursing staff are to provide discharge instructions, including medication review and plans for follow-up care.

During review of Patient #1's medical record on 04/01/19 at approximately 1:45 PM, with Employee #20, Registered Nurse, the record revealed the patient was seen in the Emergency Department on 03/21/19 for Alcohol Intoxication. Employee #10, Emergency Department (ED) Charge Nurse, discharged the patient from the ED; prior to the medical provider review of systems and discharged the patient, in the absence of a discharge order, from the medical provider. Further record review revealed Employee #10 or the hospital staff did not provide the patient discharge instructions or education.

During a face to face interview on 04/01/19 at approximately 12:50 PM, with Employee #19, Emergency Department Physician, he explained that he did not conduct a complete patient evaluation because the patient pulled the blanket over his head and wanted to sleep; so most of the documentation was based on the information from EMS (Emergency Medical Services) staff and the triage nurse. Later, when he returned to evaluate the patient, he found that the patient was discharged by the nurse. Employee #19 was queried regarding the discharge process. He explained he assesses the patient for discharge, clicks on discharge in the computer, selects the appropriate order set and prints out the discharge instructions; but he did not discharge Patient #1.

During a telephone interview on 03/26/19 at approximately 1:30 PM, with Employee #11, the patient's assigned Registered Nurse, she explained that she did not reassess or discharge the patient; the charge nurse, Employee #10, discharged the patient.

During a telephone interview on 04/09/19 at approximately 11:30 AM, with Employee #10, ED Charge Nurse, she was queried regarding the patient's discharge order and the discharge process. She explained that normally the medical provider writes the discharge order or puts the order in [the computer system], which would then generate printed discharge instructions, but she did not see the patient's discharge order. She saw the patient with discharge instructions, in his hand, but could not explain how that was possible if the physician did not discharge the patient.
Review of the video footage of the patient's stay in the ED, on 04/02/19 at 1:50 PM, did not show that the hospital staff provided the patient with discharge instructions.

The surveyor queried Employee #10 about her collaboration with the patient's assigned nurse and the attending physician to ensure a safe discharge disposition. She explained that she did not speak to either person but she assessed the discharge need. Employee #13, Patient Care Technician (PCT) provided the patient clean, donated clothing; and Employee #10 asked Employee #13 to provide a walker and walker instructions to ambulate. Employee #10 shared she provided bus tokens to the patient; and the PCT escorted the patient out of the ED.

Review of the video footage on 04/02/19 at 1:50 PM lacked evidence that staff provided tokens to the patient.

The practice lacked evidence that the nurse followed the hospital's policy and acceptable standards of practice for care delivery.

Employees #10, 13, and #26, Director of Quality and Patient Safety, acknowledged the findings.

Based on record and policy review, video footage review, and staff interviews, the nursing staff failed to evaluate the care, for one of 11 patients in the Emergency Department, with a diagnosis of Alcohol intoxication (Patient #1) (Cross reference A-0092).

Based on record review, policy review, and staff interviews, the nursing staff failed to follow the requirements for the plan of care for re-assessment and patient disposition, for three of 11 patients discharged from the Emergency Department (ED), with a diagnosis of Alcohol intoxication (Patients #1, 5 and 2).

Findings included ...

Review of the hospital's policy titled, "Discharge Planning," dated 03/22/19, showed patient discharge requires a medical provider order, disposition, and that it applies to all patients. Nursing staff are to provide discharge instructions, including medication review and plans for follow-up care.

Review of the hospital's policy titled, "Patient Assessment," dated 01/18/17, showed that assessments will be used to identify the need for reassessment based upon change in the patient's condition, diagnosis, and response to treatment; and all assessments are documented in the medical record.

A. Review of Patient #1's medical record on 04/04/19 at approximately, with Employee #20, Registered Nurse, revealed he was triaged in the ED on 03/21/19 at 2:58 PM, with Alcohol Intoxication and was assigned an Emergency Severity Index of 3- Urgent. He was unresponsive/unable to respond reliably to questions, during triage. Employee #10, ED Charge Nurse, discharged the patient from the ED.

Review of the physician's documentation dated 03/21/19 revealed a review of systems could not be conducted, as the patient had mental status changes. The physician's physical examination revealed the patient was lethargic, disoriented, and had abnormal coordination and gait. The patient's diagnosis was Alcohol Intoxication with Delirium.
Review of the nursing assessment dated 03/21/19 at 3:40 PM, revealed all systems were within defined limits; however, there was an exception to the patient's neurological system [no details documented], secondary to Alcohol Intoxication and the patient was at high risk for falls. Safety rounds and interventions were implemented.

The medical record lacked documented evidence that nursing staff performed a reassessment of the patient's neurological status or disposition at discharge.

During a telephone interview on 04/09/19 at approximately 11:30 AM, with Employee #10, ED Charge Nurse, she was queried regarding patient re-assessment. She stated, "I assessed the discharge need." She did not recall documenting the assessment. The surveyor queried Employee #10 as to where the patient was discharged. She explained, "Home, I guess ...where ever he was going."

Employees #10, 20 and 14, ED Nursing Director, acknowledged the findings.

B. Review of Patient #5's medical record on 04/03/19 at approximately 3:00PM, with Employee #20, Registered Nurse, revealed he was seen in the Emergency Department on 03/14/19 for Alcohol Intoxication and was discharged on 03/15/19.

Review of the nursing documentation revealed a triage assessment; however, the record lacked evidence of a nursing assessment or reassessment of the patient's status at discharge.

Employees #10, 20 and 14, ED Nursing Director, acknowledged the findings.

C. During review of Patient #2's medical record on 04/03/19 at approximately 11:30 AM, with Employee #20, Registered Nurse, the record revealed the patient was seen in the Emergency Department on 03/30/19 for Alcohol Intoxication and discharged; however, the nursing documentation lacked evidence of the patient's discharge disposition.

The practice lacked evidence that nursing staff documented the patient's disposition, in the medical record.

Employees #20 and 14, ED Nursing Director, acknowledged the findings.

Based on record review, policy review, and staff interviews, the hospital staff failed document in the medical record to ensure communication and collaboration for appropriate patient care and treatment, in two of 11 patient records reviewed (Patients #1 and 11) (Cross reference A-0092).