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Based on record review and interview, the facility failed to follow it's patient care policies to meet the needs of its patients in the provision of care to emergency department patients for assessment of vital signs for 6 of 12 patient medical records reviewed (Patients #1, #2, #6, #8, #9 and #10); failed to provide appropriate discharge instructions for 2 of 12 patient medical records reviewed (Patients #1 and #7); failed to follow it policy for responding to patient complaints in 2 of 6 complaints reviewed (Patients #1 and # 13); and failed to review the facility patient care policies biannually for 5 of 8 patient care policies reviewed.

Findings Include:

Facility staff failed to assess vital signs following administration of medication and prior to discharge. See C1006

Facility staff failed to follow it's policies on patient complaints and grievances. See C1006

Facility staff failed to provide discharge instructions for emergency department patients and the facility failed to establish a discharge policy/procedure for emergency department patients. See C1014

Facility leadership failed to review patient care policies biannually as per the facility policy and CAH regulation.
See C1008

Based on interview and record review the facility failed to follow it's vital signs policy for care of the Emergency Department (ED) Patient and failed to assess vital signs for 6 patients (Pt.) (Pt. # 1, # 2, # 6, # 8, # 9, and # 10) prior to discharge from the ED, in a sample of 12 medical records reviewed, failed to monitor vital signs for 3 patients following administration of medication (Pt. #1, #9, and #10) in a sample of 12 medical records reviewed and failed to follow it's policies on Patient Complaints and Grievances, for 2 complaints (Pt. #1 and Pt. #13), in a total of 6 complaints reviewed.

Findings Include:

Failure to follow Vital Sign Policy:

Review of facility policy titled, "Vital Signs," effective date, 01/2018 revealed, "Purpose: To maintain standard/consistent documentation of vital signs in the Emergency Department as well as monitoring safety.....F. Minimal standards for reassessment of vital signs will be based on the following criteria.....I. Patients with a triage level 3 a minimum of every hour and prior to inpatient admission, discharge or transfer. J. Patients with a triage level of 4 or 5 following any interventions. K. Patients with abnormal vital signs regardless of triage level will have vital signs reassessed prior to discharge."

Review of facility document titled, "ED Stabilization and Reassessment Scale, dated March 1, 2022 revealed, "Triage Level 1 is Life Threatening, Level 2 is Emergent, Level 3 is urgent, Level 4 is semi-urgent, and Level 5 is least-urgent)."


A review of Patient #1, an 8 year old, medical record revealed a triage level 3, at 05:02 AM vital signs of an oral temperature of 99.5 F (Fahrenheit), HR (heart rate) 132, respirations 36! (high reading) and SpO2 (blood oxygen level) of 92% on room air and blood pressure 121/87. Pt. #1 was given dexamethasone (decadron) (anti-inflammatory) 10 mg (milligrams) orally at 5:09 AM and Epinephrine (alchemic) (hormone used to treat asthma) inhalation solution 0.5 ml (milliliter), and albuterol-ipratropium (medication to open up the lungs) (2.5-0.5 mg) (milligrams) in 3 ml Nebulization solution at 5:15 AM. At 5:30 AM oxygen level was 98% on room air. At 5:50 AM respirations were 24 and oxygen level was 93% on room air. Pt. #1 was discharged at 6:27 AM. No vital signs were recorded after Pt. #1 received medications, hourly, or prior to Pt. #1 discharge. These findings were confirmed by Manager C on 10/04/2022 at 3:25 PM.

A review of Pt. # 2, an 18 month old, medical record revealed a triage level 4, at 5:28 PM vital signs of a rectal temperature of 102.2 F (high), pulse of 161, respirations 42!(high), SpO2 98%. Pt. #2 was discharged at 7:11 PM. No further vital signs were taken prior to discharge to determine if temperature, pulse or respirations had returned to normal ranges. These findings were confirmed by Manager C on 10/05/2022 at 8:45 AM.

A review of Pt. # 6, a 12 month old, medical record revealed a triage level 4 at 6:35 AM vital signs of a rectal temperature of 104.1 F (high), pulse of 192!(high), respirations of 32, Sp02 of 97% on room air. Pt. #6 was started on an antibiotic for an ear infection and had a chest x-ray completed and was discharged at 7:35 PM. No further vital signs were taken prior to discharge to determine if temperature, pulse or respirations had returned to normal ranges. These findings were confirmed by Manager C on 10/05/2022 at 9:35 AM.

A review of Pt. # 8, a 4 year old, medical record revealed a triage level 4 at 12:16 PM vital signs of no recorded temperature, pulse of 103, blood pressure 89/67!(low) respirations 20!(low) and oxygen level of 98% on room air. Pt. # 8 was seen for an allergic reaction, and was discharged at 12:39 PM. No temperature was recorded and no further vital signs were taken to determine if blood pressure or pulse had returned to normal ranges prior to discharge. These findings were confirmed by Manager C on 10/05/2022 at 9:45 AM

A review of Pt. # 9, a 4 year old, medical record revealed a triage level 4 at 3:59 PM vital signs of a temperature of 98.2 F, pulse 85, respirations 24, oxygen level of 99% on room air, blood pressure 94/61. Pt. #9 received dexamethasone 10 mg orally at 3:56 PM and was discharged at 3:59 PM, 4 minutes after receiving medication. No vital signs were taken prior to discharge or after receiving medication. These findings were confirmed by Manager C on 10/05/2022 at 9:55 AM.

A review of Pt. # 10, a 17 month old, medical record revealed a triage level 3 at 12:23 AM vital signs of a temperature of 97 F, pulse 120, respirations 38, oxygen level of 96%. Pt. #10 received epinephrine (racemic) inhalation treatment and oral dexamethasone at 12:32 AM . Pt. #10 was discharged at 1:14 AM. No vital signs taken after medication or before discharge. These finding were confirmed by Manager C on 10/05/2022 at 10:15 AM.

In an interview on 10/04/2022 at 3:15 PM, Manager M stated, "we don't have a policy on assessment of the ED patient, we just have the Vital Sign policy."

In an interview on 10/04/2022 at 3:25 PM during record review with Manager M, when asked if vital signs should have been taken more frequently with Pt. #1, Manager M stated, "Right, per our policy a full set of vital signs should have been taken before discharge. Their temperature was 99.5 and they didn't recheck it before discharge."

In an interview on 10/05/2022 at 8:45 AM during record review of Pt. #2 with Manager M, M stated, "They didn't reassess the fever before discharge, per our policy, vital signs should have been done before discharge and they are missing."

In an interview on 10/05/2022 at 9:45 AM during record review of Pt. #8 with Manager M, M stated, "It appears no discharge vital signs were taken." When asked vital signs should have been taken before discharge, Manager M stated, "Yes."

In an interview on 10/05/2022 at 9:55 AM during record review of Pt. #9 with Manager M, when asked if it is normal to send a patient home 4 minutes after receiving a medication, Manager M stated, "We usually watch them for 1/2 hour, especially if it's not something they've had before."

In an interview on 10/05/2022 at 10:15 AM during record review of Pt. #10 with Manager M, when asked why no additional vital signs were taken, Manager M stated, "They should do another set of vitals after medication administration and none were taken before discharge."

Failure to follow the complaint and grievance policy:

Review of Patient Rights's document, titled, "Your Rights and Responsibilities as a Patient", revealed, "All complaints will be investigated and responded to as soon as possible or no later than 30 days. All formal grievances will receive a written response that will include the steps taken to investigate the grievance, the results and the date of completion."

Review of facility policy, titled, "Customer Complaints:, dated, 08/25/2020 revealed, "C. The complaint process provides for timely resolution of patient complaints by assuring complaints are documented, investigated, resolved, and communicated to the patient in a timely manner."

Review of facility policy, titled, "Rights and Responsibilities of Patients", dated, 01/25/2022 revealed, "4. All complaints will be investigated and responded to as soon as possible or no later than 30 days."


Review of complaint #227807 from Pt. #13, filed on 10/13/2021 revealed a letter dated 11/15/2021 was sent to the patient involved in response to the complaint filed on 10/13/2021. This is greater than 30 days from the initial complaint. This finding was confirmed by Quality Staff M on 10/05/2022 at 2:30 PM.

Review of complaint #246334, involving Pt. #1, revealed a grievance was filed on 08/16/2022 by Complainant A and was given to Quality Staff M from Quality Director I on 09/07/2022, at the time of this survey on 10/05/2022, no response had been sent to Complainant A. This is greater than 30 days from the initial complaint. This finding was confirmed by Quality Staff M on 10/05/2022 at 2:30 PM.

In an interview on 10/05/2022 at 2:00 PM with Chief Nursing Officer (CNO) D, when asked how are complaints reviewed and problems identified for process improvement and to improve quality care and what is the process to follow up on complaints to make sure they are investigated appropriately, CNO D stated, "I agree we need to shore up the process, we don't have a formal grievance committee, it's on our to do list, complaints go to the quality committee and then go to a peer review if needed, outside the facility, we don't have a defined process to investigate and follow up on grievances."

In an interview with Quality Staff M on 10/05/2022 at 3:15 PM, when asked what is the process when there is a complaint made, Staff M stated, "I call within 24-48 hours, I let the manager know, then I wait 3-5 days and will send an email reminder, it really depends on the type of complaint." When asked if there was a clear procedure to follow up on a complaint or grievance, Staff M stated, "We don't have a specific written procedure for following up on grievances. I leave a message or contact the Director." When asked if there was a defined process to investigate and follow up with a grievance, Staff M stated, "No."

Based on record review and interview the facility failed to conduct a review of policies per their facility's policy, by failing to review 5 of 8 policies reviewed annually in 1 of 1 of their policy review procedures.

Findings Include:

The facility policy, titled, "Policy Format, Review and Distribution Policy", effective date of 08/25/2021 revealed: "(Facility) policies are to be reviewed at least biennially by the primary department director or designee."

The facility policy, titled, "Triage Levels", revealed an effective date of 10/18.

The facility policy, titled, "Vital Signs", revealed an effective date of 01/2018.

The facility policy, titled, "Client Rights and Grievance Procedure", revealed an effective date of 07/16.

The facility policy, titled, "Medication Administration and Documentation Procedure", revealed an effective dated of 09/18/2020.

The facility policy, titled, "Customer Complaints", revealed an effective date of 08/25/2020.

In an interview with Nurse Manager C on 10/05/2022 at 08:30 AM, when asked what is the expectation to review facility policies, Manager C stated, "There are policies past due, greater than 2 years, with covid, we are catching up."

Based on record review and interview the facility failed to provide medical information upon discharge from the ED (Emergency Department) pertaining to the patient's current course of illness and treatment and follow up needed for 2 patients (Patient (Pt.) #1 and Pt. #7), out of 12 medical records reviewed.

Findings Include:

Review of facility document, provided by MD E on 10/05/2022 at 3:50 PM, Wolters Kluwer, titled, "Acute asthma exacerbations in children younger than 12 years: Emergency Department Management," revealed, "Discharge education-Prior to discharge from the ED, it is recommended that the following are reviewed with patients and their caregivers....signs and symptoms necessitating a return visit to the ED....discharge medications with respect to purpose, side effects, and proper technique for administration."

A review of Pt. #1's medical record revealed Pt. #1 was seen for difficulty breathing and diagnosed with reactive airway disease with acute exacerbation (used when asthma is suspected but not yet confirmed) and was discharged without education material about their illness or what they were treated for, and no parameters on dosing were given on the use of medications to control symptoms. Pt. #1 was discharged with one dose of dexamethisone 1.5 tablets (9 milligrams) orally and no other information was documented about this new medication, no parameters when to give this medication and no education on their diagnosis or follow up appointments. These findings were confirmed during record review on 10/04/2022 at 3:25 PM with Manager C.

A review of Pt. #7's medical record revealed Pt. #7 was seen for drooling and fever, diagnosed with teething and fever and was discharged without education material about their illness and was instructed to alternate Tylenol (pain medication) and ibuprofen (pain medication/anti-inflammatory) to control symptoms without parameters as to how much or how often to give these medications. No education was provided as to how to manage teething or continued fevers. These findings were confirmed during record review on 10/05/2022 at 9:40 AM with Manager C.


In an interview with Manager C on 10/04/2022 at 3:15 PM, Manager C stated, "We don't have a policy on discharge of the emergency room patient."

In an interview with Manager C on 10/04/2022 at 3:30 PM when asked why Pt. #1 didn't receive education at the time of discharge, or instructions about parameters for albuterol dosing, Manager C stated, "Generally yes, there should have been asthma instructions given, in all honesty I don't see any parameters."

In an interview with Manager C on 10/05/2022 at 2:45 PM when asked how can this be a safe discharge, with no written instructions about the decadron (dexamethosone) given, Manager C stated, "We are reviewing (Name) standard and they don't have discharge criteria. There isn't documentation on follow up and it should say follow up as planned and it doesn't."

In an interview with RN K on 10/05/2022 at 3:30 PM when asked ho do you know a patient is ready for discharge, RN K stated, "When the MD (Medical Doctor) has cleared them,, their vital signs are good, they are educated on a plan." When asked what does the facility ED discharge policy say , RN K replied, "I haven't seen one, but I haven't looked for one either."