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Based on hospital policy review, restraint log review, medical record review and physician interview, the facility staff failed to document a face-to-face assessment within one hour after a violent restraint intervention for 2 of 2 sampled patients. (Patient # 1 and Patient #5)

Findings included:

Review of facility policy "Restraints and Seclusion Policy" last revised 11/2021 revealed "... A LP (licensed practioner) must document a face to face assessment with in 1 hour of implementation of restraint..."

Review of restraint log from 6/27/2022- 07/12/2022 revealed 48 episodes of chemical restraints.

1. Open medical record review of Patient #1 revealed a 36 year old male who presented to the facility's emergency department on 07/12/2022 for a psychiatric evaluation. Record review revealed a chemical restraint was ordered on 07/12/2022 at 0830 due to patient not wanting to stay in his room. Record review revealed no 1 hour face to face had been completed.

Interview on 07/13/2022 at 0930 with the Senior Quality Analyst revealed she audits all restraint charts. Interview revealed Chemical restraints are listed as violent restraints. Interview revealed the 1 hour face to face is only required for 4 point violent restraints. Interview revealed she does not audit the chemical restraints for the 1 hour face to face compliance.

Interview on 07/13/2022 at 1030 with the CMO (Chief Medical Officer) revealed the physician were not aware they needed to conduct the 1 hour face to face on chemical restraints.

Interview on 07/13/2022 at 1258 with EDMD #1 (Emergency Department Medical Doctor) revealed he was not aware the face o face needed to be completed. Interview revealed if he was aware of the requirement he would have completed.

2. Closed medical record review of Patient #5 revealed a 19 year old male who presented to the facility's emergency department on 07/09/2022 for hallucinations. Record review revealed a chemical restraint was ordered on 07/09/2022 at 1600 for "physical acting out behaviors." Record review revealed no 1 hour face to face had been completed.

Interview on 07/13/2022 at 0930 with the Senior Quality Analyst revealed she audits all restraint charts. Interview revealed Chemical restraints are listed as violent restraints. Interview revealed the 1 hour face to face is only required for 4 point violent restraints. Interview revealed she does not audit the chemical restraints for the 1 hour face to face compliance.

Interview on 07/13/2022 at 1030 with the CMO (Chief Medical Officer) revealed the physician were not aware they needed to conduct the 1 hour face to face on chemical restraints.

Interview on 07/13/2022 at 1258 with EDMD #1 (Emergency Department Medical Doctor) revealed he was not aware the face o face needed to be completed. Interview revealed if he was aware of the requirement he would have completed.

Based on hospital policy review, medical record review, emergency department staff and physician interviews the hospital failed to meet the emergency needs of patients presenting to the emergency department by failing to ensure medical screening examinations and nursing assessments were conducted.

Findings included:

1. The hospital failed to ensure an organized and effective emergency services by failing to ensure emergency services staff provided an appropriate medical screening examination to determine whether or not an emergency medical condition existed for 2 of 12 sampled patients that presented to the hospital's DED (dedicated emergency department) and requested medical treatment (Patient #6 and Patient #12 ).

~cross refer to 482.55(a) Emergency Services Tag A1101

2. The facility failed to have qualified emergency nursing staff to complete assessments on patients that presented to the emergency department for 2 of 12 patients that (Patient #2, and Patient #5).

~cross refer to 482.55(b)(2) Qualified Emergency Service Personnel Tag A1112

Based on hospital policy review, medical record review, emergency department staff and physician interviews, the hospital failed to ensure an organized and effective emergency services by failing to ensure emergency services staff provided an appropriate medical screening examination to determine whether or not an emergency medical condition existed for 2 of 12 sampled patients that presented to the hospital's DED (dedicated emergency department) and requested medical treatment (Patient #6 and Patient #12 ).

Findings included:

Review of the facility policy, Medical Screening Exam, effective 12/2020, revealed, "... Every patient who comes to the Emergency Department requesting emergency services will receive a medical screening examination, performed by individuals qualified to perform such examinations, to determine whether an emergency medical condition exists..."

Review of the facility policy, Discharges from the Emergency Department, effective 03/2021, revealed, "... If the patient chooses to leave Against Medical Advice (AMA), they will be asked to sign the Against Medical Advice form. The Emergency Department physician should inform the patient of his/her risk in deciding to leave AMA including threat to limb or life. A nurse will be present as a witness. The same should be documented on the Emergency Department record, as well as on the AMA form. This form, plus documentation, will remain a part of the patient's medical record. In the event the patient refuses to sign the form, the refusal will be documented on the form and in the patient's ED record..."

1. Closed medical record review of Patient #6 revealed a 2-year-old female who presented to the DED on 06/30/2022 at 2057 with a chief complaint of "fire ant reaction." Review of the Triage Note by ED RN #5 at 2102 revealed, "Father reports that 30 minutes PTA (prior to arrival), pt (patient) was playing in the driveway, when she stepped into the yard and stepped on a fire ant nest. Mother states she put topical Benadryl on the bites, but noted a generalized reaction. Pt alert and interactive, resps (respirations) even and unlabored, skin w/p/d (warm, pink, dry). No drooling noted. Pulse - 134 H (high), Respiratory Rate - 25 H, Pulse Oximetry - 94% L (low) on Room Air, Temperature - 98.1F (Fahrenheit), Pain Level - 3 FLACC (Face, Legs, Activity, Cry, Consolability - 0-10 behavioral based pain scale for pediatric patients)..." Recorded review revealed Patient #6 was placed in the waiting room at 2105. Review of the Departure Assessment by ED Supervisor #6 dated 07/05/2022 at 2349 revealed, "Left Prior to MSE (medical screening exam), recognized date patient left: Jun 30, 2022, recognized time patient left: 2314." Record review failed to reveal documentation of reassessments prior to departure. Medical record review failed to reveal documentation of Risks and Benefits of leaving or waiting to be seen by a provider before the patient departed the DED. Review failed to reveal additional visits to the facility for follow up care.

Review on 07/13/2022 at 0935 of the 06/30/2022 waiting room video footage revealed the following: 2054 - Liaison staff sitting at the registration desk, 2056 - female visitor with child (Patient #6) approach registration desk, 2057 - Patient #6 carried by female visitor to the side of the registration desk for vital signs, 2058 - triage nurse walks another patient into the waiting room and takes Patient #6 with a female and male visitor to the triage area, 2106 - male and female visitor carry Patient #6 to the waiting room and sit down, 2312 - female visitor approaches registration desk and hands a cloth object to the Liaison staff, 2313 - male visitor carries Patient #6 through the DED entrance, 2313 - liaison folds cloth and looks at the computer, 2314 - female visitor exits DED entrance.

Interview on 07/13/2022 at 1605 with ED RN #5 revealed he performed the triage for Patient #6. Interview revealed Patient #6 presented with insect bites to the bilateral lower extremities. Interview revealed ED RN #5 did not find signs of systemic reaction like urticarial rash, respiratory distress, swelling tongue, difficulty swallowing secretions when triaging Patient #6. Interview revealed ED RN #5 triaged Patient #6 and placed her in the waiting room with her parents. Interview revealed ED RN #5 did not perform reassessments on Patient #6 while she waited in the waiting room. Interview revealed ED RN #5 was made aware of Patient #6's departure well after they left the facility by the liaison. Interview revealed when patients left after being triaged, the liaison was supposed to get the paperwork completed and document when the patient left.

Interview on 07/13/2022 at 1035 with ED Supervisor #6 revealed she removed Patient #6 from the system on 07/05/2022 because the departure was not documented properly. Interview revealed the ED Supervisor #6 reviewed the liaison comments on the internal communication board to determine when Patient #6 left the DED. Interview revealed the expectation of liaison staff to contact the triage nurse or provider if a patient stated they were leaving the facility. Interview revealed DED staff were educated to encourage patients to stay for examination and treatment. Interview revealed the facility staff only obtained AMA (against medical advice) paperwork for patients that had been seen by a provider. Interview revealed that a patient that had only been triaged would not sign risks and benefits paperwork prior to leaving the facility. Interview revealed a liaison was not able to discuss benefits and risks with a patient leaving after triage or MSE (medical screening exam).

Interview on 07/13/2022 at 1100 with ED MD #7 revealed he was the provider present when Patient #6 presented to the DED. Interview revealed ED MD #7 did not see Patient #6. Interview revealed that triage protocols were available for the triage RN to implement based on their triage assessment. Interview revealed that medications were not administered to patients that were placed in the waiting room because they needed to be monitored. Interview revealed if a patient received Benadryl (antihistamine medication) from the provider or triage nurse, then they would need to be monitored in the back of the DED for potential reactions. Interview revealed DED staff were trained to encourage patients to stay for examination and treatment, if not then explain risks and benefits.

Interview on 07/13/2022 at 1320 with the ED Director #2 revealed the expectation of DED staff to encourage patients to stay for examination and treatment. Interview revealed the AMA paperwork was only completed for patients that had been seen by the medical providers. Interview revealed patients that had been triaged or were awaiting triage were not asked to sign paperwork acknowledging risks of leaving and benefits of staying in the DED. Interview revealed at the time of Patient #6's DED visit, facility staff were not reassessing patients waiting in the lobby. Interview revealed due to extended wait times, the facility had recently (as of 07/04/2022) implemented hourly rounding and vital signs every two hours on waiting patients. Interview revealed facility staff were expected to document their conversations surrounding left without being seen or against medical advice and the times within the electronic medical record.

Interview request for the liaison on the night of 06/30/2022 revealed she was unavailable for interview.

Interview on 07/14/2022 at 1401 with Liaison #8 revealed that the liaison role was expected to notify the triage nurse or provider whenever a patient expressed that they were going to leave the facility without examination or treatment. Interview revealed the liaisons had been educated to encourage patients to stay and receive care in the DED. Interview revealed only patients that had received an MSE were encouraged to sign AMA paperwork. Interview revealed patients awaiting triage or MSE would not have signed risks and benefits paperwork in their electronic medical record.

Request for census on the night of 06/30/2022 revealed it was unavailable for review.

Review of staffing for the night of 06/30/2022 revealed the following staff: 1 - Charge Nurse, 1 - Triage Nurse, 5 - Staff Nurses, 1 - Liasion, 1 - BH(behavioral health) Tech, 1 - ED Tech.



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2. Review of the EMTALA Log for 07/01/2022 revealed Patient #4 was not listed on the log.

Review of the (Name) Medical Transport record dated 07/01/2022 at 1458 revealed Patient #12 was an 87-year-old male transported from his home and arriving in the DED on 07/01/2022 at 1541. Review revealed "Primary Impression: Generalized Weakness ... Chief Complaint: going for hospice end of life care ... Signs & Symptoms: Generalized Symptoms - Weakness ... Assessment ... Pelvis/GU (genitourinary)/GI (gastrointestinal): Left Hip radiating down to leg ... Pelvis/GU/GI: Pain ..." Continued review revealed " ... During transport, EMT's were informed by Dispatch that the destination had changed to the (Hospital Name) ER ... While in route, Driver EMT called Dispatch twice to confirm that the charge nurse was expecting us @ (Hospital Name). Dispatch confirmed both times that we were being expected ... Upon arrival to (Hospital Name) ER (emergency room), PT (patient) was transported via stretcher from the ambulance to inside the hospital by 2 EMT's (emergency medical technician). Upon arriving inside hospital ER, Hospital Staff were asking who was the PT. The EMT's notified hospital ER Staff that this was a PT that was going to (Facility Name) for hospice but was redirected to (Hospital Name) ER due to there was no room availability @ (Facility Name) for PT. Dispatch had notified hospital staff of the diversion to their hospital. Hospital staff notified EMT's that the PT shouldn't be there without his Hospice nurse present. Hospital staff also noted that they had contacted hospice nurse of the situation. Hospital staff called hospital social worker that made the call to hospice nurse to give clarification to the EMT's. Upon hospital social worker arriving in ER, Social worker had hospice nurse on call via cellular device, and handed phone to one of the (Name) EMT's. EMT asked hospice nurse if they needed us to wait with the PT in ER until hospice nurse arrival or if they preferred something else. Hospice nurse notified EMT's to take the PT back to his residence. EMT's confirmed that Hospice Nurse wanted us to take PT back to his Residence, which got confirmed by Hospice Nurse. Dispatch was notified that PT was to head back to PT Residence and Dispatch copied and dropped a return run. Throughout these events, PT remained on stretcher secured with 4 straps and 2 side rails." Review revealed the call was closed at 1604.

Review of the (Name) Medical Transport record dated 07/01/2022 at 1604 revealed " ... Hospice Nurse notified EMT's to transport the PT back to his residence. The PT was found lying in a stretcher secured by 4 straps and 2 side rails, in the locked position. The PT was transported via stretcher from the hospital to inside the ambulance by 2 EMT's ...Upon arrival to PT Residence, PT was unloaded from ambulance and placed close to his front door. Pt was assisted in getting off the stretcher and assisted in going up his stairs and into his living room couch. PT Care was passed to PT self care ..." Review revealed the call was closed at 1621.

Review of the hospital medical record for Patient #12 revealed there was no documentation of Patient #12 presenting to the DED on 07/01/2022 and there was no triage or medical screening exam.

Interview on 07/13/2022 at 1537 with RN #10 revealed she was the Charge Nurse in the ED when Patient #12 arrived by medical transport and remembered both visits. Interview revealed Hospice called saying the patient was coming in and that he was dying and not going to make it but a couple of hours and needed pain management. Interview revealed when Patient #12 arrived, he was alert and oriented, not looking like someone who was going to die in a couple of hours. Interview revealed the Hospice coordinator was contacted and she instructed the ED staff to not see Patient #12, do not take him off the stretcher, and to send him home. Interview revealed RN #10 documented on a note card and when Patient #4 was not seen the note card was shredded as no visit record was created for Patient #12 on 07/01/2022. Interview revealed Patient #12 returned to the ED on 07/02/2022 (19 hours and 5 minutes after leaving first visit) for a fall.

Telephone interview on 07/15/2022 at 1553 with the Hospice Patient Care Manager #13 and Hospice Nurse #14 revealed Patient #12 was originally going to a facility for better control of his pain, however Patient #12 had expressed suicidal ideations to Hospice Nurse #14 and the transport was rerouted to the (Hospital Name) Emergency department. Interview revealed Hospice Patient Care Manager #13 contacted the DED Charge Nurse to let her know what was going on and why Patient #12 was coming to the DED. Interview revealed Patient #12 stated to Hospice Nurse #14, "(Name) I thought about ending it all last night." Interview revealed Hospice Nurse #14 assessed further into if Patient #12 had a means and/or plan, Patient #12 expressed a means. Interview revealed at that time Hospice Nurse #14 notified Hospice Patient Care Manager #13 and the decision was made to reroute the transport to (Hospital Name) Emergency Department for a psych evaluation. Interview revealed once Patient #12 arrived to the ED, he was told he would have to sit and wait and he did not want to wait. Interview revealed the Hospital ED staff could not give Patient #12 any information regarding how long he would have to wait.

Telephone interview on 07/26/2022 at 1840 with EMT #11 revealed he transported Patient #12 to the (Hospital Name) Emergency department (ED) on 07/01/2022. Interview on Patient #12 was picked up from home and originally was to be transported to (Name of Facility). Interview revealed during transport the (Name) Medical Transport Dispatch called the EMS truck to reroute from going to (Name of Facility) to go to (Hospital Name) ED. Interview revealed the (Name) Medical Transport Dispatch called the (Hospital Name) ED charge nurse to notify her Patient #12 was coming. Interview revealed EMT #11 verified three times with dispatch the (Hospital Name) ED charge nurse was aware of Patient #12 coming to the ED. Interview revealed upon arrival to the ED, EMT #11 was questioned on who the patient was as if they did not expect the patient's arrival. Interview revealed EMT #11 was told by a hospital staff member that Patient #12 was not to be in the ED without the hospice nurse accompanying him. Interview revealed the hospital social worker came to the ED with telephone, stating she had gotten ahold of the hospice nurse. Interview revealed the person on the other end of the telephone that was identified by the social worker as the hospice nurse told EMT #11 to take Patient #4 back to his residence. Interview revealed no vital signs were taken in the ED, Patient #12 did not get triaged, and no one from the hospital assessed Patient #12 the entire time they were in the ED. Interview revealed EMT #11 contacted the (Name) Medical Transport Dispatch to let them know they were told to transport Patient #12 back to his residence and that is what they did.

Based on the hospital's policy and procedures, medical records review, and staff interviews, the facility failed to have qualified emergency nursing staff to complete assessments on patients that presented to the emergency department for 2 of 12 patients that (Patient #2, and Patient #5).

Findings included:

Review on 07/12/2022 of the hospital's policy titled "Triage & Classification System" effective December 2021 revealed "...PROCEDURES and RESPONSIBILITIES: POLICY...A. All patients, at will, presenting to the Emergency Department (ED) for care will receive a Rapid Initial Screening...C. An ED Registered Nurse is responsible for assigning an acuity level to each patient based on history, physical assessment, and sound clnical decision-making skill...PROCEDURE...B. Non-Ambulatory Patients 1. The ED Registered Nurse will evaluate patients who are non-ambulatory or arrive by ambulance, based on this evaluation the patient will either be placed directly into a treatment room or directed to triage area..."

Review on 07/12/2022 of the hospital's policy titled "Triage Nurse, Roles and Responsibilities" effective August 2021 revealed "GENERAL STATEMENT: The Triage Nurse is responsible for assessing every patient admitted through the triage area. She/he will assign a triage priority...and initiate interventions based on the assessments. PROCEDURES and RESPONSIBILITIES: 1. The Triage Nurse evaluates each patient arriving into the Triage area and assigns a triage classification...2. The Triage Nurse is responsible for completing a Rapid Initial Screening upon patient arrival..."

Review of the "JOINT POSITION STATEMENT North Carolina Board of Nursing and Office of Emergency Medical Services ALTERNATIVE PRACTICE SETTING FOR EMS PERSONNEL" dated 10/16/2019 revealed " ....The purpose of this joint position statement is to provide guidance for health care entities interested in developing alternative practice settings as well as clarifying EMS and nursing personnel roles and responsibilities in these settings....The nurse remains responsible and accountable at all times for all aspects of nursing care assigned to clients when collaborating within a interdisciplinary team. This includes comprehensive assessment; development and revision of the plan of care appropriate to the clients needs; implementation of appropriate interventions including delegation of nursing activities to competent individuals; continuous evaluation and reassessment of the effectiveness of nursing care and medical interventions; supervision of nursing care delivery; and teaching and counseling clients. Nursing management and administration are responsible for assuring that appropriate collaborative system processes and guidelines are in place to assure coordinated care focused on patient safety and well-being..."

1. Review on 07/12/2022 of a closed medical record revealed Patient #2 was a 58-year-old female who presented to the dedicated emergency department on 01/13/2022 at 1310 via emergency medical service (EMS) complaining of diarrhea. Medical record review revealed documentation at 1425 a Paramedic (Medic #9) completed Patient #2's "Rapid Initial Screen" and assigned a Priority level of "2." Medical record review failed to reveal evidence a Registered Nurse triaged or assessed Patient #2, per policy.

Interview on 07/13/2022 at 1012 with Medic #9 revealed Patient #2 arrived at the ED by EMS. Interview revealed she did not believe Patient #2 went to triage. Interview revealed Medic #9 completed Patient #2's vital signs, rapid initial screening stated complaint, and medical history. Interview revealed Medic #9 administered Patient #2's medications and discussed her condition with the ED physician. Interview revealed Medic #9 "does not believe a nurse was specifically assigned to the patient. I believe I was assigned to (Patient #2)."

Interview on 07/13/2022 at 1400 with the interim ED Director revealed based on the medical record, Medic #9 triaged and assessed Patient #2. Interview revealed the Medics can take assignments, but cannot triage or conduct a primary assessment of a patient.



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2. Closed medical record review of Patient #5 revealed a 19 year old male who presented to the facility's emergency department on 07/09/2022 for hallucinations. Patient #5 triage assessment was completed by a Registered Nurse (RN) at 1507 on 07/09/2022. Record review revealed no nursing assessment was completed for Patient #5 on 07/10/ 2022, 07/11/2022 and 07/12/2022. Record review revealed on 7/12/2022. at 1546 "At the time of discharge pt (patient) was alert and oriented. Pt. was calm and cooperative. Discharge instructions and prescriptions gone over with the pt. Pt was able to repeat how to take medications and what medications were for. Pt had no questions...." Review revealed discharge instructions and teaching were completed by Medic # 3.

Interview on 07/13/2022 at 1328 with Medic #3 revealed she works only in the CSU (crisis stabilization unit) with the behavioral health patients. Interview revealed she does have primary care of the patients when not working with a nurse. Interview revealed she typically works with a nursing assistant in the CSU. Interview revealed the charge nurse is responsible for overseeing the patients assigned to a paramedic. Interview revealed the charge nurses will "walk through the CSU unit." Interview revealed if she has an issue with patient care she would contact the charge nurse. Interview confirmed Medic #3 completed the discharge teaching to Patient #5.

Interview on 07/13/2022 at 1535 with the ED Director #2 revealed Paramedics do take patient assignments. Interview revealed paramedics can not perform the primary assessment nor discharge patients. Interview revealed the charge nurses are responsible to oversee the patients assigned to the paramedics. Interview revealed patients in the CS are to be assessed by a registered nurse at least once a shift. Interview confirmed there were no nursing assessment on Patient #5 after triage.

Interview on 07/13/2022 at 2550 with RN #4 revealed she was the charge nurse for the ED on 07/13/2022. Interview revealed she is aware the charge nurses are supposed to oversee the paramedics. Interview revealed overseeing the paramedics by nursing does not happen. Interview revealed paramedics triage, perform assessments and discharge teaching to the patients they are assigned.