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Based on interview and record review, the facility failed to provide Abuse Training for two of six sampled Registered Nurses (RN, 1 and 2), in accordance with the facility's policies and procedures.

This deficient practice had the potential for staff not to be informed of abuse, neglect, related reporting requirements, including prevention, intervention, and detection.

Findings.

During an interview and review of staff personnel files, on 8/10/2023 beginning at 3 p.m., the Program Manager for Human Resources (PMHR) stated that Abuse training was provided upon hire and every two years. The PMHR verified that RN 1 and 2 had not completed the Abuse training, per the facility's policy and procedure.

During a review of the personnel files, on 8/10/2023, at 3 p.m., the files indicated that the following.

Registered Nurse (RN) 1 last Abuse training was completed on 3/2021.

RN 2 was newly rehired on 3/6/2023. RN 2's last Abuse training was completed on 5/22/2021.

During a review of personnel files, on 8/10/2023 beginning at 3 p.m., the Assistant Clinical Director for the Emergency Department (ACDED) 1 stated RN 2 was newly rehired on 3/6/2023. RN 2 should have recent abuse training upon rehire. ACDED 1 stated the RN 2's last Abuse training was completed 5/22/2021, when she used to work as an Emergency Medical Technician.

A review of the facility's policy and procedure titled "Patient Rights: Protection from Abuse, Exploitation, Neglect, & Harassment," dated 5/24/2023, indicated the following. Train: All employees receive abuse training upon hire and ongoing education at least every two years. The training / education provides all employees with information regarding abuse and neglect, and related reporting requirements, including prevention, intervention, and detection.

Based on observation, interview, and record review, the facility failed to weigh one of thirty sampled patients (Patient 13) every morning, as ordered by the physician. Patient 13 was receiving hemodialysis (HD, the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) almost every day.

This deficient practice had the potential to result in ineffective hemodialysis treatment and had the potential to cause shortness of breath or fluid overload.

Findings:

During an observation on 8/8/2023 at 4 p.m., in the Medical Surgical/Telemetry Unit, Patient 13 was not observed in the room.

Concurrently, during an interview on 8/8/2023, at 4 p.m., with Registered Nurse (RN) 7, RN 7 stated Patient 13 was taken to another unit to receive hemodialysis treatment. RN 7 stated patients were weighed every day, as ordered by the physician.

A review of Patient 13's "Face Sheet," indicated Patient 13 was admitted to the facility on 7/17/2023 for hypertensive emergency (a sudden increase in blood pressure).

A review of Patient 13's "History and Physical" (H&P), dated 7/17/2023, indicated Patient 13 had a history of End Stage Renal Disease (ESRD, kidneys stop functioning, required long-term dialysis) from uncontrolled hypertension (high blood pressure). Patient 13 presented to the Emergency Department with chest pain for two days and shortness of breath.

A review of Patient 13's "Physician's Order," dated 7/28/2023, at 3:59 p.m., indicated "Please get a standing weight every morning."

A review of Patient 13's Flowsheet titled "Height/Weight," indicated the following weights:

On 8/01/2023 at 3:19 p.m., Patient 13 weighed 110 kilograms (kg).
On 8/02/2023 at 4:04 p.m., Patient 13 weighted 108.8 kg.
8/07/2023, No weight was documented.
8/08/2023 at 7:38 p.m., Patient 13 weighed 107 kg.
8/10/2023, No weight was documented.

During a concurrent interview and record review, on 8/10/2023, at 11:30 a.m., with the Clinical Informatics Specialist (CIS), the CIS stated the following. Patient 13 was admitted for hypertensive emergency and was on dialysis. Patient 13 had a physician's order to get weighed every morning. CIS verified Patient 13 was not weighed every morning as ordered by the physician. CIS stated it was important to weigh the patient every morning to determine if Patient 13 needed dialysis treatment.

During an interview and record review, on 8/10/2023, at 2:27 p.m., with the Assistant Department Administrator (ADA) 3 for the Acute Dialysis Unit, ADA 3 stated patients should be weighed according to the physician's order. ADA 3 stated a person's weight determines fluid status, which is used as a marker to adjust or decide the volume of fluid that will be removed.

Based on interview and record review, the facility failed to ensure:

1. Four of 30 sampled patients (Patient 3, 4, 5, and 6) were assessed every two hours in the Emergency Department (where patients receive immediate medical care), in accordance with the facility's policy and procedure regarding Emergency Department patient assessment (process to identify and treat life-threatening problems) and re-assessment.

This deficient practice had the potential for changes in the patient's condition to go undetected and untreated.

Findings:

1a. During an observation and interview, on 8/8/2023, at 10:22 a.m., in the Emergency Department, Patient 3 was observed in the gurney, awake and alert. Patient 3 stated that nobody reassessed him or took his vital signs while he was waiting in the waiting room.

A review of Patient 3's "Patient Care Timeline," indicated the following. Patient 3 arrived at the Emergency Department (ED) on 8/8/2023, at 6:05 a.m., for rectal pain. Patient 3 was triaged (assessed, including vital signs [blood pressure, heart rate, respiratory rate, temperature, and pain) at 6:19 a.m. Patient 3's ESI level was 3 (urgent need for evaluation). Patient 3 was placed in a room at 10:07 a.m. Patient 3 was reassessed (including vital signs) at 10:39 a.m.

1b. During an observation, on 8/8/2023 at 10:26 a.m., in the ED, Patient 4 was awake and alert.

A review of Patient 4's "Patient Care Timeline," indicated the following. Patient 4 arrived at the ED on 8/8/2023 at 5:32 a.m., for an injury to the left arm. Patient 4 was triaged at 5:40 a.m. and assigned an ESI Level 3. Patient 4 was placed in a room at 9:32 a.m., and reassessed at 10 a.m.

1c. During an observation and interview, on 8/8/2023 at 10:33 a.m., in the ED, Patient 5 was observed awake and alert. Patient 5 stated she arrived last night at approximately 8 p.m. and waited in the waiting room until 4 a.m. Patient 5 stated she was not re-assessed by a nurse while she waited in the waiting room.

A review of Patient 5's "Patient Care Timeline," indicated the following. Patient 5 arrived at the ED on 8/7/2023 at 7:53 p.m. for severe anemia (blood does not have enough healthy red blood cells). Patient 5 was triaged and assigned an ESI level 3 at 7:54 p.m. Patient 5 was placed in a room at 2:40 a.m. and reassessed at 3 a.m.

1d. During an observation and interview, on 8/8/2023, at 10:50 a.m., in the ED, Patient 6 was awake and alert. Patient 6 stated he arrived yesterday at approximately 3 p.m. and waited in the waiting room until 12 a.m. Patient 6 stated he was not reassessed by a nurse while he waited in the waiting room.

A review of Patient 6's "Patient Care Timeline," indicated the following. Patient 6 arrived at the ED on 8/7/2023 at 3:32 p.m., for a headache with syncope (fainting or passing out). Patient 6 was triaged and assigned an ESI level 3 at 3:37 p.m.. Patient 6 was reassessed at 9 p.m.. Patient 6 was placed in a room 8/8/2023 at 12:43 a.m. and reassessed at 12:51 a.m.

During a concurrent interview and record review, on 8/09/2023 beginning at 10:44 a.m., with the Clinical Director of the Emergency Department (CDED), the CDED reviewed the medical records for Patients 3, 4, 5, and 6 and stated the following. Patients should be reassessed in accordance with their ESI level. Patients with an ESI level of 3 should be assessed every two hours to assess for any changes in the patient's condition.

A review of the facility's policy and procedure titled, "Triage and Patient Flow in the ED (Emergency Department," dated 8/2023, indicated the ED triage process prioritizes patient acuity according to the urgency of the care needed by applying the Emergency Severity Index (ESI, a five-level tier triage algorithm that categorizes ED patients by evaluating both patient acuity and resource needs. Level 1 indicates need for immediate evaluation, Level 2 [emergent need], Level 3 [urgent need], Level 4 [semi-urgent], Level 5 [non-urgent) triage system to determine the order in which patients are placed in the treatment area. This five-tier system also directs the frequency of nursing reassessments. All patients presenting to the ED will be quickly assessed by the ESI nurse, a registered nurse who has been trained in the ESI Triage System. Upon presentation the ESI RN will assign the ESI level ...ESI level-based assessment and reassessment frequency and documentation ...ESI 3, vital signs, pain score, and flowsheet assessments are to be done every two hours or more often if the condition warrants.