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Based on interview and record review, the governing body failed to ensure that emergency services requirements were met. Findings include:

Interview with ER Physician #E, on 8/5/13 at approximately 11:00, revealed that the lab had run out of reagents to run troponin labs (to rule out cardiac issues) in the past. In discussion with Physician #E, it was determined that timely troponin lab resulting was necessary for emergency services for patients with cardiac issues. Interview with the Director of Diagnostics, on 8/5/13 at approximately 11:30, verified that the facility had run out of reagent kits to run patient troponin levels in the past. The Director stated that the "troponin labs were sent out to a contracted laboratory with a turnaround time of four hours". This contrasted with the in-house turnaround time of one hour, from patient draw to lab results. Interview with the Chief Executive Office (CEO), on 8/5/13 at approximately 15:30, revealed that the facility had failed to pay the vendor that provided troponin reagents but now had a plan in place for timely payments to this vendor.
Review of the Governing Body Minutes and Governing Body Operations Minutes (January 2013 to August 2013) revealed that the facility had financial issues and had difficulty with collections and payments. Further interview with the CEO, on 8/6/13 at approximately 14:00, revealed that the facility had a current budget plan in place to make timely payments. When queried on how confident the CEO felt in making timely payments, he was hesitant in his affirmative response. The CEO stated that he was new to his current position and that they also had a Financial Consultant working with them.

Based on observation, interview, and document review the facility failed to provide the emergency lab test Troponin 1 results from the Emergency procedure list in the recommended time frame in 2 of 8 cases reviewed (#4 & 11), this has the potential to impact all patients treated at this facility, resulting in the potential for poor patient outcomes related to delayed diagnosis and treatment. Findings include:

On tour of the ED on 8/5/13 at approximately 1030 a sign was posted stating "Troponin's are being sent out and will take 4 to 6 hours to be resulted. This was confirmed by staff #E the ED physician on duty on 8/5/13 at approximately 1035.

On tour of the diagnostics department (Laboratory) on 8/5/13 at approximately 1200 the machine that does the Troponin was located. On 8/5/13 at approximately 1200 Staff #F confirmed that the troponin's (tests) have been sent out to Quest because of no supplies."

Interview of staff #F, the Director of Diagnostics on 8/5/13 at approximately 1200 revealed "we have a contract with Quest diagnostics for when we run out of the kits required to run the troponin's. They have up to 2 hours to pick up the specimen and then 2 hours to return the results. We do the troponin's in house when we have the supplies." Staff #F also stated "troponin's are considered an emergency procedure and should be resulted in 30 to 60 minutes. Supplies were just located and can be provided starting today."

During record review of the medical record for patient #4 it was determined that the blood specimen was drawn at 0800 on 7/12/13, the troponin was resulted at 1219 on 7/12/13, 4 hours and 20 minutes later. The patient had already expired at 1140.

During record review of the medical record for patient #11 it was determined that the blood specimen was drawn at 2338 on 7/26/13, the troponin was resulted at 0353 on 7/27/13, 4 hours and 15 minutes later.

Review of the document dated 03/10 titled "Lab Procedures" page V states "ASAP-Tests on the emergency procedure list results to the nursing unit...within (1) hour. STAT- see emergency procedure list for tests of a life and death consequence, results to nursing unit...within 30 minutes."

Review of the document titled "Emergency Procedure List" page 2 states " The term "Emergency" is used to mean "Life and Death." "Tests outlined below have been determined to be those most critical for life and death situations.", On page 4 under chemistry "Troponin 1."

Based on interview, observation, and document review the facility failed to meet the emergency needs of the patients seen in the emergency department (ED) in 4 of 12 (#4, 5, 9 & 11) cases reviewed, resulting in the potential for poor outcomes for all patients seen in the ED. Findings include:

1. Triage
During tour of the ED on 8/5/13 at approximately 1030 staff #B, the charge nurse was interviewed regarding the procedure used to assign the severity index in triage. Staff #B stated "I have been doing this so long that I just have it in my head, I don' t use a tool of any kind."

Upon return to the ED 8/5/13 at approximately 1400 for further follow up, staff #H a registered nurse was orientating to the ED. Staff #H was asked what process she was taught to use in assigning the severity index when triaging patients at the bedside, to which she replied, "I have not been taught how to assign a number value."

On 8/5/13 at approximately 1500 a review of the policy number "T7", titled "Patient Triage and Processing", revised 8/09 states " The triage nurse will determine the acuity of the patient's condition, the priority classification and the appropriate treatment area." It also states "...4. a.. complete set of vital signs ...and pain assessment will be documented. " 4. b states " If the patient exhibits any signs or complains of respiratory distress a base line pulse ox (oximetry) will be obtained and documented on the chart. "

Interview of the nurse educator, staff #J on 8/5/13 at approximately 1400, revealed "there used to be a tool they used for standard assignment of severity when we did triage in a triage room, I don't know what happened to it when they changed to triage at the bedside."

On 8/6/13 at approximately 1100 follow up with staff #J revealed "revised educational information for Emergency Severity Index (ESI) triage Algorithm, V 4 that will be used to re-educate ED staff in the assignment of patient risk and needed resources."

On 8/5/13 at approximately 1530, medical record review for patient #4 revealed documented assignment of "ESI-3, abdominal pain for the last 3 days, pain level per patient 10 (pain rating scale [minimal to excruciating] of 1-10), blood pressure (BP) 161/75, Heart rate (HR) 146, respiration rate (RR) 70." With severe pain and abnormal vital signs this should have been assigned as ESI-2 per facility ESI triage algorithm.

2. Emergent Labs
On tour of the ED on 8/5/13 at approximately 1030 a sign was posted stating "Troponins are being sent out and will take 4 to 6 hours to be resulted. This was confirmed by staff #E, the ED physician on duty.

On tour of the diagnostics department (Laboratory) on 8/5/13 at approximately 1200 the machine that does the Troponin was located, Staff #F confirmed that the troponin (tests) have been sent out to Quest (Laboratory) because of no supplies."

Interview of staff #F, the Director of Diagnostics on 8/5/13 at approximately 1200 who stated "we have a contract with Quest diagnostics for when we run out of the (Troponins test) kits required to run the troponins. They have up to 2 hours to pick up the specimen and then 2 hours to return the results. We do the troponins in-house when we have the supplies." Staff #F also stated "troponins are considered an emergency procedure and should be resulted in 30 to 60 minutes. Supplies were just located and can be provided starting today."

On 8/5/13 at approximately 1530, during review of the medical record for patient #4 it was determined that the blood specimen for troponin testing was drawn at "0800 on 7/12/13", the troponin was resulted at "12:19 on 7/12/13", 4 hours and 20 minutes later. The patient had already expired at 1140.

On 8/5/13 at approximately 1545, during review of the medical record for patient #11 it was determined that the blood specimen for troponin testing was drawn at "2338 on 7/26/13", the troponin was resulted at "0353 on 7/27/13", 4 hours and 15 minutes later.

On 8/5/13 at approximately 1600 a review of the procedure titled "Lab Procedures" dated 03/10 page V states "ASAP-Tests on the emergency procedure list results to the nursing unit...within (1) hour. STAT- see emergency procedure list for tests of a life and death consequence, results to nursing unit...within 30 minutes."

On 8/5/13 at approximately 1600 a review of the policy and procedure titled "Emergency Procedure List" page 2 states "The term "Emergency" is used to mean "Life and Death." "Tests outlined below have been determined to be those most critical for life and death situations.", On page 4 under chemistry "Troponin 1."

Interview of staff #A, the CEO on 8/6/13 at approximately 0900 revealed "on the days that we cannot provide stat troponins, we down grade our service from "A" to "B" with the Emergency Medical Services (EMS) but we cannot know what will just walk in off the street."

3. Monitoring and reassessments
On 8/5/13 at approximately 1100, during the continued tour of the ED, current charts of discharged patients (#2, 3 & 12) were reviewed. Medical records for patients #2, 3 & 12 lacked detail of physical assessments results and complete vital sign documentation. Staff #B was asked if there was additional documentation available in their respective medical records for patients #2, 3 & 12 for vital signs and assessments. After looking at the electronic documentation record, staff #B stated, "no, what is there is all there is. "

On 8/5/13 at approximately 1600 a review of the policy titled "Nursing Assessment and Patient Preparation Protocol" number PR-1 revised 1/04 3. "Vital signs: A. Initial vital signs will include Temperature, heart rate (HR), respiratory rate (RR), blood pressure (BP)- patients with respiratory and or cardiac (issues) will also have PO2 (pulse oximetry) saturation measurements. B. Priority 1 & 2's will be attached to the BP monitor and have BP, HR, at least every 30 minutes or more often if ordered. C. Priority 3's will have repeat BP, HR, RR, within 30 minutes of disposition if here greater than 1 hour. D. Patients with respiratory and/or cardiac complaint will have PO2 saturations included with their vital signs placed and kept on telemetry monitors." ....F. Respirations: Note quality characteristics and record ....All patients with respiratory symptoms will have respiratory rate checked every 30 minutes." ...I. Cardiac rhythm: strips must be documented at the onset and every 1 hour minimally..J. A summary strip of all vital signs will be placed on the medical record..."

On 8/5/13 at approximately 1600 a review of the policy titled "Pain Management" number P-3 revised 9/14/09, states "Part 1. A. #4 "pain should be assessed and documented on admission and at least with every set of vital signs...#6. Pain assessment following analgesics ...1 hour after oral ... and 30 minutes after intravenous(IV) parenteral.... Part 2. A. Initial pain assessment 1. Emergency Department- the patients pain scale is determined in triage and documented on the Emergency Department triage record... B. #7..Patients receiving IV push medications are to be reassessed 30 minutes after being medicated."

On 8/5/13 between 1530 and 1630 medical record review of 4 of 12 patients (#4, 5, 9 & 11) revealed:
Patient #4 Abdominal pain ESI-3 was medicated IV for pain and was reassessed 72 minutes later, vital signs (VS) done at initial assessment, 30 minutes to 1.5 hours apart. no summary of VS found in record.
Patient #5 abdominal pain ESI-3 was medicated for pain IV and reassessed 125 minutes later, VS done at initial assessment, then every 2 hours apart.
Patient #9 chest pain ESI-2, VS at initial assessment, repeated 30 minutes to 2.5 hours apart. Pain reassessed one time only. Cardiac rhythm strips not documented hourly per protocol.
Patient #11 chest pain ESI-3, medicated IV for pain, and was never reassessed in the ED, VS done at initial assessment, repeated 40 minutes to 1.5 hours apart. Cardiac rhythm strips not documented hourly per protocol.

Interview of Staff #A on 8/6/13 at 0830 am stated "I understand about the emergent labs, triage ESI level assignment problems, and lack of documentation."

Based on observation, interview and record review the facility failed to provide integrated emergent services within time frames that protect the health and safety of patients within acceptable standards of practice in 2 of 12 cases reviewed (#4 & #11) resulting in the potential for poor outcomes related to length of time to diagnosis and appropriate care interventions. Findings include:

On tour of the ED on 8/5/13 at approximately 1030 a sign was posted stating "Troponins are being sent out and will take 4 to 6 hours to be resulted." This was confirmed by staff #E, the ED physician on duty on 8/5/13 at approximately 1035.

During the tour of the Lab at approximately 1200 noon on 8/5/13 staff #F was interviewed. Staff #F stated "yes we have had difficulty getting the (troponin test) kits for our machine that runs the troponins, so when we run out, we have an agreement with the Quest lab. They have 2 hours to come and pick up the blood specimen and then 2 hours to result it after they receive it. It can take 4 to 6 hours."

On 8/5/13 at approximately 1500 during review of the medical record for patient #4 it was determined that the blood specimen was drawn at "0800 on 7/12/13", the troponin was resulted at "12:19 on 7/12/13", 4 hours and 20 minutes later. The patient had already expired at 1140.

On 8/5/13 at approximately 1515, during review of the medical record for patient #11 it was determined that the blood specimen was drawn at "2338 on 7/26/13", the troponin was resulted at "0353 on 7/27/13", 4 hours and 15 minutes later.

On 8/5/13 at 1630 a review of the document titled "Lab Procedures" dated 03/10 "as soon as possible "(ASAP)" tests on the 'Emergency Procedure List', are to be resulted within 1 hour. 'STAT tests' 'See Emergency Procedure List for tests of a life and death consequence', are to be resulted within 30 minutes."

On 8/5/13 at 1635 a review of the document titled "Emergency Procedure List", no review date specified "A. ...The term 'Emergency' is used to mean 'Life and death' The tests outlined below have been determined to be those most critical for life and death situations' B. under the heading 'Chemistry' on page 4 ... 'Troponin I'..."

Interview of staff #A the president and CEO on 8/6/13 at approximately 0900 stated "on the days that we cannot provide stat troponins we down grade our service from "A" to "B" with the EMS service but we cannot know what will just walk in off the street."

Based on interview, and document review the facility failed to verify, evaluate and update policies and procedures for emergency medical services on an ongoing basis in 8 of 12 cases (#4, 5, 6, 7, 8, 9, &10) resulting in the potential for poor patient outcomes related to current procedures for care provided in the ED. Findings include:

During tour of the ED on 8/5/13 at approximately 1030 staff #B, the charge nurse was interviewed regarding the procedure used to assign the severity index in triage. Staff #B stated " I have been doing this so long that I just have it in my head, I don' t use a tool of any kind."

Upon return to the ED 8/5/13 at approximately 1400 for further follow up, staff #H, a registered nurse was orientating to the ED. Staff #H was asked what process she was taught to use in assigning the severity index when triaging at the bedside, to which she replied " I have not been taught how to assign a number value. "

Review of the policy number T7 titled " Patient Triage and Processing " revised 8/09 states " The triage nurse will determine the acuity of the patient ' s condition, the priority classification and the appropriate treatment area. " It also states " ...4.a.. complete set of vital signs ...and pain assessment will be documented. " 4.b states " If the patient exhibits any signs or complains of respiratory distress a base line pulse ox(oximetry) will be obtained and documented on the chart. "

On 8/5/13 at approximately 1100, during the continued tour of the ED, current charts of discharged patients (#2, 3 & 12)were reviewed. Staff #B was asked if there was further documentation of vital signs and assessments. After looking at the electronic documentation record, she stated " no, what is there is all there is. "

Review of the policy number T7 titled " Patient Triage and Processing " revised 8/09 states " The triage nurse will determine the acuity of the patient ' s condition, the priority classification and the appropriate treatment area. " It also states " ...4.a.. a complete set of vital signs ...and a pain assessment will be documented. " 4.b states " If the patient exhibits any signs or complains of respiratory distress a base line pulse ox (oximetry) will be obtained and documented on the chart. "

Review of the policy number PR-1 titled " Nursing Assessment and Patient Preparation Protocol " revised 1/04 Under 3. "Vital signs: A. Initial vital signs will include Temp, HR, RR, BP- patients with respiratory and or cardiac will also have PO2 sat measurements. B. Priority 1 & 2 ' s will be attached to the BP monitor and have BP, HR, at least every 30 minutes or more often if ordered. C. Priority 3 ' s will have repeat BP, HR, RR, within 30 minutes of disposition if here greater than 1 hour. D. Patients with respiratory and/or cardiac complaint will have PO2 sat included with their vital signs placed and kept on telemetry monitors. ....F. Respirations: Note quality characteristics and record ....All patients with respiratory symptoms will have respiratory rate checked every 30 minutes. ...I. Cardiac rhythm: strips must be documented at the onset and every 1 hour, minimally..J. A summary strip of all vital signs will be placed on the medical record...."

Review of the policy number P-3 titled " Pain Management ", revised 9/14/09 states " Part 1. A. #4 pain should be assessed and documented on admission and at least with every set of vital signs ...#6. Pain assessment following analgesics ...1 hour after oral ... and 30 minutes after (IV) parenteral. Part 2. A. Initial pain assessment 1. Emergency Department- the patients pain scale is determined in triage and documented on the Emergency Department triage record. B. #7..Patients receiving IV push medications are to be reassessed 30 minutes after being medicated. "

On 8/5/13 between 1530 and 1630 medical record review of 8 of 12 patients (#4,5,6,7,8 9,10 & 11) revealed:
Patient #4 Abdominal pain ESI-3 was medicated IV for pain, was reassessed 72 minutes later, VS done at initial assessment, 30 minutes to 1.5 hours apart. no summary of vs found in record.
Patient #5 abdominal pain ESI-3 was medicated for pain IV and was reassessed 125 minutes later, VS done at initial assessment and then every 2 hours apart.
Patient #6 Chest pain ESI-3, VS initial assessment, EKG 0818, patient declined labs, discharged home 0837.
Patient #7 Chest pain ESI-4, VS initial assessment, EKG 0833, patient discharge 0900.
Patient #8 abdominal pain ESI-3, initial vital signs with assessment, pain level #8, medicated and discharged home.
Patient #9 chest pain ESI-2, VS at initial assessment, repeated 30 minutes to 2.5 hours apart. Pain reassessed one time only. Cardiac rhythm strips not documented hourly, per protocol.
Patient #10 abdominal pain ESI-3, VS initial assessment, pain rated as #9, IV labs, IV pain medication at 0622 and 0705, VS repeated at 0742, pain not reassessed in ED, pt discharged home 0741.
Patient #11 chest pain ESI-3, medicated IV for pain never reassessed in ED, VS done at initial assessment, repeated 40 minutes to 1.5 hours apart. Cardiac rhythm strips not documented hourly, per protocol.

Interview of the nurse educator staff #J on 8/5/13 at approximately 1400, stated "there used to be a tool they used for standard assignment of severity when we did triage in a triage room, I don't know what happened to it when they changed to triage at the bedside."

On 8/6/13 at approximately 1100 follow up with staff #J who had produced revised "educational information for Emergency severity index triage Algorithm, V 4 that will be used to re-educate ED staff in the assignment of patient risk and needed resources."

Interview of Staff #N, ED Physician Manager on 8/6/13 at 0930 stated "we do chart reviews, I am not aware of any problems in the ED except occasionally we cannot do the troponins quickly".