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Based on observation, interview, record review, and review of hospital policies and procedures, the hospital's governing body failed to provide effective oversight of the hospital's emergency services.

Failure to provide effective oversight for emergency services puts patients at risk of harm from inconsistent and delayed emergency medical responses.

Findings included:

The hospital's governing body failed to ensure that the hospital provided consistent and timely access to emergency services.

Cross Reference: A093

Due to the severity of deficiencies under 42 CFR 482.12, the Condition of Participation for Governing Body was NOT MET.
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Based on observation, interview, and document review, the hospital failed to implement policies and procedures, for the management of medical emergencies and transfers, to ensure staff completed and documented incident reports when medical emergencies occurred for 36 of 48 events (Item #1), completed and documented Memorandums of Transfer for 5 of 14 transferred patients (Patients #1, #2, #3, #4, and #5) (Item #2), and facilitated prompt access to Emergency Medical Services for 7 of 7 emergency responses reviewed (Patients #5, #7, #8, #9, #10, #11, and #12) (Item #3).

Failure to implement policies and procedures for the management of medical emergencies and transfers risks patient harm from delayed or unmet care needs.

Findings included:

Item #1 - Incident Reports

1. Document review of the hospital's policy titled "Incident Reports," policy #PI-003, effective 5/2019, last reviewed 1/2022, showed that the staff member who was involved or witnessed the event must complete an incident report form prior to the end of the shift. The report is forwarded to the Performance Improvement (PI) Director and Chief Nursing Office (CNO) by the end of the scheduled shift.

Document review of the hospital's policy titled "Medical Emergencies," no policy ID, effective 04/2019, last reviewed 01/2021, showed that in the event of a medical emergency, defined as an unexpected illness or injury, an incident report will be completed documenting details of any event.

Document review of the hospital's policy titled "Emergency Medical Screening," policy #PC 034, effective 04/2019, last reviewed 07/2020 showed the following:

a. When screening a person that is not stable, the Nursing Supervisor will call the on-call physician to explain the situation and findings.

b. If directed, the receptionist will call 911 and ask for an ambulance to transport the person to the hospital emergency department for assessment and treatment.

c. Staff will complete an incident report and route it to the PI Director.

2. On 03/09/23, Investigators #1 and #2 reviewed an event log of all Lacey Fire Department 911 (emergency) responses to the hospital between 12/02/22 and 03/02/23 and a hospital incident report log of all incident reports between 12/01/22 and 03/08/23. The review showed the following:

a. There were 48 emergency responses from Lacey Fire Department to the hospital between 12/02/22 and 03/02/23.

b. Of the 48 emergency responses to the hospital, 36 were missing corresponding hospital incident reports.

c. On 02/28/23 at 2:30 PM, Investigators #1 and #2 interviewed the CNO (Staff #1101). Staff #1101 verified that current policy was to enter an incident report if 911 was called.

Item #2 - Memorandums of Transfer

1. Document review of the hospital's policy titled "Medical Emergencies," no policy ID, effective 04/2019, last reviewed 01/2021, showed that once a medical emergency has been addressed, a Memorandum of Transfer will be prepared and forwarded at the first available opportunity.

Document review of the hospital's policy titled "Memorandum of Transfer," policy ID RT-017, effective date 05/2019, last reviewed 01/2022, showed the following:

a. A Memorandum of Transfer will be completed on all patients transferred outside the hospital's facilities.

b. Memorandum of Transfer must be completed for every patient transferred and must contain the following information: patient data, a certification signed by the transferring physician, type of vehicle and company used for transfer, and name and city of hospital to which patient was transported.

c. A copy of the Memorandum of Transfer shall be retained by the transferring and receiving hospitals.

Patient #1

2. On 02/28/23 at 2:00 PM, Investigators #1 and #2, the Director of Admissions and Referrals (Staff #1104) and a Nurse Manager (Staff #1105) reviewed the Memorandum of Transfer (MOT) file for the month of 02/23. The review showed the following:

a. On 02/27/23, Patient #1 presented to intake with an infected wound to the right forearm. Patient #1 was transported to another facility by ambulance at 12:45 PM and an MOT was retained in the file.

b. Review of the MOT showed that no accepting facility was documented on the form.

c. Staff #1104 confirmed the investigators' finding of the missing documentation.

Patient #2

3. On 02/28/23 at 2:00 PM, Investigators #1 and #2, Staff #1104 and Staff #1105 reviewed the MOT file for the month of 02/23. The review showed the following:

a. On 02/26/23, Patient #2 presented to intake after a suicide attempt and refused to be a voluntary admission. Patient #2 was transported to another facility by ambulance at 3:18 PM and an MOT was retained in the file.

b. Review of the MOT showed that no physician certification signature was documented on the form.

c. Staff #1104 confirmed the investigators' finding of the missing documentation.

Patient #3

4. On 02/28/23 at 2:00 PM, Investigators #1 and #2, Staff #1104 and Staff #1105 reviewed the MOT file for the month of 02/23. The review showed the following:

a. On 02/28/23, Patient #3 presented to intake requesting alcohol detoxification and was found to have an elevated blood pressure and heart rate. Patient #3 was transported to another facility at an unknown time and an MOT was retained in the file.

b. Review of the MOT showed that no physician certification signature, no accepting facility, no mode of transport, and no patient consent signature were documented on the form.

c. Staff #1104 confirmed the investigators' findings of the missing documentation.

Patient #4

5. On 02/28/23 at 2:00 PM, Investigators #1 and #2, Staff #1104 and Staff #1105 reviewed the MOT file for the month of 02/23. The review showed the following:

a. On 02/27/23, Patient #4 presented to intake and requested admission for suicidal ideation. Patient #4 was found to be dependent on a caregiver for bathroom and showering needs. Patient #4 was transported to an unknown facility at an unknown time.

b. The investigators were unable to locate an MOT for Patient #4.

c. Staff #1104 confirmed the investigators' finding of the missing MOT.

Patient #5

6. On 02/28/23 at 3:00 PM, Investigators #1 and #2 reviewed the medical record of Patient #5, a non-verbal admitted patient with major depressive disorder and suicidal ideation. The review showed the following:

a. On 12/23/22 at 8:30 AM, Patient #5 had an unwitnessed fall and 911 was called to transport the patient to a local hospital for evaluation and treatment.

b. The investigators were unable to locate an MOT for Patient #5.

7. On 02/28/23 at 2:30 PM, Investigators #1 and #2 interviewed Staff #1101. The interview showed that an MOT should be filled out completely for every patient transported out of the hospital.

Item #3 - Access to Emergency Medical Services

1. Document review of the hospital's policy titled "Memorandum of Transfer," policy ID RT-017, effective date 05/2019, last reviewed 01/2022, showed that for all patients with an emergency medical condition that the hospital does not have the appropriate equipment or staff to correct, an evaluation and treatment shall be performed, and transfer shall be carried out as quickly as possible.

Document review of the hospital's procedure titled "South Sound Behavioral 9-1-1 EMS Response," no policy ID, no date, showed the following:

a. When 911 is called, nursing staff will notify intake that Emergency Medical Services (EMS) have been dispatched and where the patient is located while the team prepares a staff escort.

b. Intake staff should be ready at the door to greet Lacey Fire Crews and provide a staff escort throughout the locked-in facility the whole time.

c. If the patient is ambulatory/conscious, they are to be brought to the first floor (exercise room) for patient privacy and safety of patients and 911 crews.

d. If a unit floor response is necessary, escort Lacey Fire Crews to appropriate unit and ask that other patients do not wander around 911 crews. Patients should be held off either in their room or common area; whichever is furthest from Lacey Fire Crews.

e. A nurse should be available to describe why a 911 response was necessary and to communicate with Lacey Fire Crews.

f. Staff escort (nursing) should stay with Lacey Fire from beginning to end of call.

Emergency Response #1

2. On 02/22/23, Investigators #1 and #2 reviewed call records and recordings from Thurston 911 Communications (TCOMM 911). The review showed that on 12/09/22 at 5:36 PM, hospital staff called 911 for Patient #7, a minimally responsive patient that had a blood glucose reading of 51 before receiving IM glucagon (a medication given to increase a person's blood glucose levels) and appeared sweaty. The hospital staff member stated that Patient #7 was located in unit 320-B three times, with repeat-back confirmation, during the 911 call.

a. On 02/21/23, Investigators #1 and #2 reviewed incident reports provided by Lacey Fire Department personnel. The review showed that when EMS arrived at the hospital, they stood outside and rang the doorbell. When a hospital staff member answered the door, they did not know why 911 was called or where Patient #7 was located. EMS informed the staff that they were told 320-B was the location of the patient. The hospital staff member took EMS to the unit, but no patient matching the description of the 911 call was present. EMS were then escorted to another unit, and staff on that unit directed them to room 323, where Patient #7 was located.

b. On 02/24/23 at 8:17 AM, Investigator #1 interviewed an EMS staff member (Staff #1110) who responded to the 911 call for Patient #7. Staff #1110 could not recall how many minutes it took before gaining access to Patient #7 and stated that they often experience delays of 7 minutes or longer before gaining access to a patient.

c. On 02/28/23 at 9:30 AM, Investigators #1 and #2 interviewed Staff #1101 about the response from staff when 911 was called. Staff #1101 stated that when 911 was called, a staff member was to wait downstairs to take EMS to the patient or bring the patient downstairs to meet EMS.

d. On 02/28/23 at 10:10 AM, Investigators #1 and #2 interviewed a staff nurse (Staff #1113). Staff #1113 stated that when 911 was called, staff were to transport the patient downstairs to meet EMS, if the patient was stable enough to get into a wheelchair.

Emergency Response #2

3. On 02/21/23, Investigators #1 and #2 reviewed incident reports and call logs provided by Lacey Fire Department personnel and call records and recordings from TCOMM 911. The review showed that on 12/23/22 at 8:48 AM, EMS were dispatched to a 911 call from the hospital for Patient #5, a non-verbal admitted patient with major depressive disorder and suicidal ideation who had an unwitnessed fall.

a. Lacey Fire Department Incident Reports showed that EMS reported waiting 5 minutes before gaining access to Patient #5 for evaluation. Patient #5 had no obvious injuries and was transported to a local Emergency Department (ED) for evaluation at hospital staff's request.

b. On 02/28/23 at 5:15 PM, Investigator #1 interviewed an EMS staff member (Staff #1109). Staff #1109 confirmed that they had responded to the 911 call at the hospital on 12/23/22 at 8:48 AM. Staff #1109 stated that they were left alone and locked in the gym to wait for Patient #5 for 5 minutes.

c. On 02/28/23 at 9:30 AM, Investigators #1 and #2 interviewed Staff #1101 about the response from staff when 911 was called. Staff #1101 stated that when 911 was called, a staff member was to wait downstairs to take EMS to the patient or bring the patient downstairs to meet EMS.

d. On 02/28/23 at 10:10 AM, Investigators #1 and #2 interviewed Staff #1113. Staff #1113 stated that when 911 was called, staff were to transport the patient downstairs to meet EMS, if the patient was stable enough to get into a wheelchair.

Emergency Response #3

4. On 02/21/23, Investigators #1 and #2 reviewed incident reports and call logs provided by Lacey Fire Department personnel and call records and recordings from TCOMM 911. The review showed that on 12/31/22 at 6:20 PM, EMS were dispatched to a 911 call from the hospital for Patient #8, a patient who was suffering from drug withdrawal and decreased level of consciousness.

a. Lacey Fire Department Incident Reports showed that EMS reported ringing the doorbell and waiting outside the hospital for 4 minutes before a hospital staff member let them in. EMS reported that they waited another 4 minutes for hospital staff to escort them to Patient #8 (who was waiting in a wheelchair) in B-322, a delay of 8 minutes.

b. On 03/02/23, Investigator #1 reviewed the Lacey Fire Department Patient Care Record for Patient #8. The record showed that EMS arrived at the hospital at 6:31 PM and waited 4 minutes before gaining access to the facility, then waited another 4 minutes before gaining access to Patient #8, who had normal vital signs, had vomited and was shaking. Patient #8 was later transported to the ED via non-emergent ambulance transport.

c. On 02/24/23 at 11:13 PM, Investigator #1 interviewed an EMS staff member (Staff #1111) who responded to the 911 call for Patient #8. Staff #1111 stated that they often wait 5 to 12 minutes before gaining access to patients at the hospital.

d. On 02/28/23 at 9:30 AM, Investigators #1 and #2 interviewed Staff #1101 about the response from staff when 911 was called. Staff #1101 stated that when 911 was called, a staff member was to wait downstairs to take EMS to the patient or bring the patient downstairs to meet EMS.

e. On 02/28/23 at 10:10 AM, Investigators #1 and #2 interviewed Staff #1113. Staff #1113 stated that when 911 was called, staff were to transport the patient downstairs to meet EMS, if the patient was stable enough to get into a wheelchair.

Emergency Response #4

5. On 02/21/23, Investigators #1 and #2 reviewed incident reports and call logs provided by Lacey Fire Department personnel and call records and recordings from TCOMM 911. The review showed that on 01/15/23 at 9:41 AM, EMS were dispatched to a 911 call from the hospital for Patient #9, a 63 year-old patient with a diagnosis of pneumonia (an infection in the lungs), a low oxygen saturation (a measure of how much oxygen is traveling through the body), and a history of chronic obstructive pulmonary disease (a chronic inflammatory disease that obstructs airflow from the lungs).

a. Lacey Fire Department Incident Reports showed that EMS stated that they rang the doorbell twice and waited 4 minutes before gaining entry to the hospital.

b. On 03/01/23 at 11:53 AM, Investigators #1 and #2 reviewed hospital security footage of the emergency response to Patient #9 with the former Chief of Nursing (Staff #1106). The review showed the following:

i. At 9:46 AM, the EMS ambulance was seen pulling into the ambulance entrance.

ii. At 9:47 AM, EMS were seen knocking on the hospital entrance door.

iii. At 9:50 AM, EMS were seen ringing the doorbell at the hospital entrance door, which was then opened, and EMS are then seen walking towards another door several feet away.

iv. At 9:51 AM, EMS are seen entering the facility.

c. On 03/02/23, Investigator #1 reviewed the Lacey Fire Department Patient Care Record for Patient #9. The record showed that EMS arrived at the hospital at 9:47 AM, waited for entry to the facility, then waited for a hospital staff member who knew where Patient #9 was located. The record showed that EMS gained access to Patient #9 at 9:55 AM to evaluate and treat, a delay of 8 minutes.

d. On 02/28/23 at 9:30 AM, Investigators #1 and #2 interviewed Staff #1101 about the response from staff when 911 was called. Staff #1101 stated that when 911 was called, a staff member was to wait downstairs to take EMS to the patient or bring the patient downstairs to meet EMS.

e. On 02/28/23 at 10:10 AM, Investigators #1 and #2 interviewed Staff #1113. Staff #1113 stated that when 911 was called, staff were to transport the patient downstairs to meet EMS, if the patient was stable enough to get into a wheelchair.

Emergency Response #5

6. On 02/21/23, Investigators #1 and #2 reviewed incident reports and call logs provided by Lacey Fire Department personnel and call records and recordings provided by TCOMM 911. The review showed that on 02/11/23 at 11:06 PM, a non-emergent ambulance crew contacted Lacey Fire crews over their radio to inform that they were asked by hospital staff to evaluate Patient #10 for respiratory distress. The non-emergent ambulance crew was unable to be reached over radio for further information, and Lacey Fire Crew dispatched to the hospital.

a. On 02/28/23 at 5:41 PM, Investigator #1 interviewed an EMS staff member (Staff #1112) who responded to the radio call for Patient #10. Staff #1112 stated that when they arrived at the hospital, the non-emergent crew informed them that they were unable to get a signal on their radio equipment to inform Lacey Fire Crews that they did not need their assistance, after they had assessed Patient #10.

b. On 03/01/23 at 11:53 AM, Investigators #1 and #2 and Staff #1106 reviewed hospital security footage of the emergency response to Patient #10. The review showed the following:

i. At 10:49 PM, the non-emergency ambulance crew arrived at the facility.

ii. At 10:52 PM, the crew were seen ringing the facility doorbell.

iii. At 10:56 PM, the door was opened by a hospital staff member who has a short conversation with the crew.

iv. At 10:58 PM, the crew were left alone in the hallway and were seen using their radio to contact Lacey Fire Crews.

v. Between 10:58 PM and 11:03 PM, the crew were observed walking to different doors in the hallway and knocking on the door the hospital staff member had gone through.

vi. At 11:03 PM, a hospital staff member rejoins the crew and escorts them through a door.

vii. At 11:12 PM, Lacey Fire Crews were seen arriving at the hospital.

c. On 03/02/23, Investigator #1 reviewed the Lacey Fire Department Patient Care Record for Patient #10. The record showed that the non-emergent ambulance crew arrived on scene for a patient who no longer required transport and were then asked to assess Patient #10, who had a low oxygen saturation. Patient #10 was assessed and found to have normal vital signs and to be speaking in full sentences.

d. On 02/28/23 at 9:30 AM, Investigators #1 and #2 interviewed Staff #1101 about the response from staff when 911 was called. Staff #1101 stated that when 911 was called, a staff member was to wait downstairs to take EMS to the patient or bring the patient downstairs to meet EMS.

e. On 02/28/23 at 10:10 AM, Investigators #1 and #2 interviewed Staff #1113. Staff #1113 stated that when 911 was called, staff were to transport the patient downstairs to meet EMS, if the patient was stable enough to get into a wheelchair.

Emergency Response #6

7. On 03/10/23, Investigator #1 reviewed call logs and incident reports provided by Lacey Fire Department and call records and recordings provided by TCOMM 911. The review showed that on 02/15/23 at 1:40 PM, EMS were dispatched to a 911 call for Patient #11, a 34-year-old experiencing chest pain.

a. Review of the 9-1-1 recording showed that Patient #11 called 9-1-1 requesting assistance for chest pain. Patient #11 is heard asking hospital staff for the address and telephone number of the hospital. Dispatch personnel are heard confirming with Patient #11 that hospital staff are aware she is calling 9-1-1 for assistance.

b. On 03/9/23 at 11:48 AM, Investigator #1 and Staff #1106 reviewed hospital security footage of the emergency response to Patient #11. The review showed the following:

i. At 1:46 PM, the EMS crew arrived at the hospital.

ii. At 1:47 PM, the EMS crew were seen knocking at the hospital entrance door.

iii. At 1:49:30 PM, after a delay of 2.5 minutes, hospital staff were seen opening the hospital door.

c. On 02/28/23 at 9:30 AM, Investigators #1 and #2 interviewed Staff #1101 about the response from staff when 911 was called. Staff #1101 stated that when 911 was called, a staff member was to wait downstairs to take EMS to the patient or bring the patient downstairs to meet EMS.

d. On 02/28/23 at 10:10 AM, Investigators #1 and #2 interviewed Staff #1113. Staff #1113 stated that when 911 was called, staff were to transport the patient downstairs to meet EMS, if the patient was stable enough to get into a wheelchair.

Emergency Response #7

8. On 03/10/23, Investigator #1 reviewed call logs, incident reports, and Patient Care Records provided by Lacey Fire Department and call records and recordings provided by TCOMM 911. The review showed that on 02/25/23 at 11:35 PM, EMS were dispatched to a 911 call from the hospital for Patient #12, a 38-year-old experiencing drug withdrawal symptoms with a history of stroke and seizures.

a. On 03/09/23 at 11:48 AM, Investigator #1 and Staff #1106 reviewed hospital security footage of the emergency response to Patient #12. The review showed the following:

i. At 11:43 PM, the EMS crew were seen ringing the doorbell at the hospital entrance door.

ii. At 11:46 PM, after a delay of 3 minutes, hospital staff were seen opening the hospital door.

b. On 02/28/23 at 9:30 AM, Investigators #1 and #2 interviewed Staff #1101 about the response from staff when 911 was called. Staff #1101 stated that when 911 was called, a staff member was to wait downstairs to take EMS to the patient or bring the patient downstairs to meet EMS.

c. On 02/28/23 at 10:10 AM, Investigators #1 and #2 interviewed Staff #1113. Staff #1113 stated that when 911 was called, staff were to transport the patient downstairs to meet EMS, if the patient was stable enough to get into a wheelchair.
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Based on interview and document review, the hospital failed to implement an effective process to ensure staff completed an incident report when emergency services were utilized unexpectantly in 36 of 48 emergency calls made from the hospital and responded to by the fire department.

Failure to implement an effective process to ensure staff completed incident reports when emergency services were utilized limits the hospital's ability to identify problems and formulate action plans. This reduces the likelihhod of sustained improvements in emergency responses.

Findings included:

1. Document review of the hospital's policy titled "Incident Reports," policy #PI-003, effective 05/2019, last reviewed 01/2022, showed that the staff member who was involved or witnessed the event must complete an incident report form prior to the end of the shift. Report is forwarded to Performance Improvment (PI) Director and CNO by end of shift.

Document review of the hospital's policy titled "Medical Emergencies," no policy ID, effective 04/2019, last reviewed 01/2021, showed that in the event of a medical emergency, defined as an unexpected illness or injury, an incident report will be completed documenting details of any event.

2. On 03/09/23, Investigators #1 and #2 reviewed an event log of all Lacey Fire Department 911 (emergency) responses to the hospital between 12/02/22 and 03/02/23 and a hospital incident report log of all incident reports between 12/01/22 and 03/08/23. The review showed the following:

a. There were 48 emergency responses from Lacey Fire Department to the hospital between 12/02/22 and 03/02/23.

b. Of the 48 emergency responses to the hospital, 36 were missing corresponding incident reports.

3. On 02/28/23 at 2:30 PM, Investigators #1 and #2 interviewed the Chief Nursing Office (CNO) (Staff #1101). Staff #1101 confirmed that the cooresponding incident reports could not be located and that current policy was to enter an incident report if 911 was called.
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