HospitalInspections.org

A-1100

This CONDITION is not met as evidenced by:

Based on medical record review, policy review, document review, video review, and interview, it was determined that facility failed to ensure policies were established and implemented related to the ongoing assessment of the care provided in the emergency department as evidenced by: Staff failed to perform 1:1 observation monitoring and documentation, failed to provide a safe environment for behavioral health patients, and failed to conduct patient assessments. The facility does not have a cardiac monitoring/telemetry policy for patient monitoring and does not implement emergency department overcrowding polices when applicable (A-1104). This failure resulted in an Immediate Jeopardy, posing a serious risk of harm to the patients.

On 08/16/23 at 03:20 PM, an Immediate Jeopardy situation was identified for the Conditions of Participation of Emergency Services. On 08/16/23 at 08:38 PM, the facility provided a removal plan to the onsite survey staff and implemented the following corrective actions: Facility policies were revised related to the assessment, monitoring, and safety interventions required for 1:1 observation of patients. Staff received immediate education on current and revised policies. Leadership implemented auditing to ensure staff compliance with facility policies.

On 08/16/23 at 09:02 PM, the Immediate Jeopardy was removed based on observations, policy review, document review, and interviews with staff which was verified by surveyors onsite that the removal plan was fully implemented.

Additionally, emergency department staff do not have the qualifications or training to meet the anticipated needs of the patients who require cardiac/telemetry monitoring (A-1112).

Cross Reference:
482.55(a)(3)- Emergency Services Policies
482.55(b)(2)- Qualified Emergency Services Personnel

Based on policy review, medical record review, video review, and interview, the facility failed to ensure policies were established and implemented related to the ongoing assessment of the care provided in the emergency department as evidenced by:
1. Staff did not provide 1:1 observation monitoring and documentation for two of five patients (Patients #20, and #25) who were assessed as a moderate risk for suicide. Staff did not remove potentially harmful belongings from Patient #25. Patient #20 was found expired, potentially from a fentanyl overdose in the emergency department.
2. Staff did not conduct assessments for five of eleven patients (Patient#1, #12, #30, #31, and #32).
3. Staff did not follow the facility policy for cardiac/telemetry monitoring in the emergency department.
4. The facility does not implement the emergency department overcrowding polices when applicable.

Findings #1:

Review of the policy "Patient Suicide Risk Assessment and Environmental Risk Evaluation," dated 11/29/21, indicated that staff are to use of the "Suicide Precautions Safety Checklist/1:1 Patient Observation Record" for patients with a moderate risk for suicide. Staff are to initiate 1:1 observation (staff are to be always within arm-reach of the patient until cleared by the provider or Licensed Independent Practitioner). Patients are to be placed in a private room. All visitors are screened to ensure no unsafe items are brought into the room. Documentation is required every 2 hours.

Review of the medical record for Patient #20 revealed on 06/15/23 at 05:57 PM, Patient #20 was brought to the emergency department due to an overdose (received Narcan in ambulance). At 06:00 PM, vital signs were the following: blood pressure of 97/73, pulse of 140, respirations 14, and SaO2 at 99%. No temperature was documented. At 09:44, a mental health evaluation was performed indicating Patient #20 was a moderate suicide risk (1:1 observation is required per policy). Patient #20 was involuntarily admitted to the behavioral health unit. Patient #20 was placed in a hallway bed in the emergency department due to no beds being available in the behavioral health unit. On 06/16/23 at 01:33 AM, 1:1 monitoring was initiated and continued until 01:46 PM. (From 01:46 PM to 08:35 PM, there is no documentation related to patient assessment, monitoring, or 1:1 assessment). At 08:35 PM, Patient #20 is found by staff in rigor mortis. Cardiopulmonary resuscitation is initiated. Patient #20 was pronounced dead at 08:35 PM. The preliminary autopsy report indicated the cause of death was a Fentanyl overdose.

Review of the medical record for Patient #25 revealed on 06/16/23 at 11:53 AM, Patient #25 was triaged and given a level two (2) acuity priority with a chief complaint of "behavior health." Vital signs were assessed. At 01:58 PM, Patient #25 was assessed as a moderate risk for suicide (1:1 observation is required per policy). At 07:11 PM, vital signs were assessed at discharge. (There is no documentation of the suicide precautions safety checklist, including a visitor screening for contraband. From 06/16/23 at 01:58 PM to discharge at 07:11 PM, there is no documentation related to 1:1 assessment and monitoring).

Review on 08/16/23 of the emergency department video dated 06/16/23 from 12:42 AM to 08:35 PM revealed Patient #20 and Patient #25 were placed in hallway beds, against a wall, not in view of the nursing station. There is no 1:1 sitter is seen monitoring Patient #20 or Patient #25 (per policy, both patients required 1:1 observation). At approximately 12:59 PM, Patient #20 is seen conversing with Patient #25 and their visitor in the hallway. At 01:03 PM, the visitor was seen giving Patient #20 an "item." At 01:07 PM, Patient #20 was observed bending down and appeared to be consuming something. At 08:35 PM, a staff member found Patient #20 unresponsive in the hallway bed. (There is no evidence that a 1:1 sitter was in place to monitor Patient #1 on 06/16/23 from 12:42 AM to 08:35 PM and for Patient #25 on 06/16/23 from 11:53 AM to 07:11 PM.

Interview on 08/15/23 at 02:24 PM with Staff (A), Director of Quality & Risk Management, verified the findings.

Findings #2:

Review of the policy "Triage System," dated 1/2023 indicated that a patient will be triaged utilizing the emergency severity index five level triage system. Patients presenting to the emergency department are treated in order of priority based on acuity and resources needed. The five stages are as follows: Level one requires immediate lifesaving intervention or is unresponsive, to evaluate immediately; Level two high risk situation, severe pain or distress or acute confusion, lethargy, disorientation. The goal is to evaluate within 30 minutes; Level one and two are to be assess as frequently as condition warrants, but at a minimum of every hour for blood pressure, pulse, and respirations; Level three requires two or more resources, and the goal is to evaluate within one hour of arrival. Assess level three as frequently as condition warrants but at a minimum of every two hours for blood pressure, pulse, and respirations; Level four the goal is to evaluate within three hours of arrival; Level five, the goal is to evaluate in four hours of arrival. Assess Level four and five for pulse, respirations, temperature, and pain scale at triage and again at discharge. Assess as frequently as condition warrants; and for a temperature less than 95 degrees or greater than 100 degrees, or complaints of recent fever, record every two hours.

Review on 08/15/23 of the medical record for Patient #1 revealed a triage level of three. Vital signs were performed at triage, but a temperature is not documented.

Review on 08/15/23 of the medical record for Patient #12 revealed a triage level of four. No vital signs are documented for the triage assessment.

Review on 08/15/23 of the medical record for Patient #30 revealed an arrival to the emergency department at 02:33 PM. Patient #30 was assigned to pod C from 03:40 PM to 08:16 PM with a triage priority level of four. At 08:38 PM, Patient #30 was discharged to home. There is no documentation of a discharge assessment.

Review on 08/15/23 of the medical record for Patient #31 revealed on 06/16/23 at 03:02 PM, Patient #31 arrived at the emergency department. At 03:09 PM, Patient #31 was assessed and triaged as a priority level of four. There is no documentation of a discharge assessment prior to being transferred to the intensive care unit on 06/17/23 at 01:22 AM.

Review on 08/15/23 of the medical record for Patient #32 revealed on 06/16/23 at 03:50 PM, Patient #32 was assessed and triaged with a priority level of two due to strained breathing when lying down. There is no documentation that Patient #32 was assessed every 30 minutes between 03:50 PM and 09:43 PM.

Interview on 08/18/23 at 02:33 PM with Staff (C), ED Nurse Manager revealed that vital signs should be done every hour for a patient triaged as a level two. A patient triaged as a level four should have vital signs at triage and again at discharge.

Findings #3:

Review of policy "Telemetry Hospital Wide," dated 11/2022, indicated that the nursing responsibilities in the emergency department include to ensure that an order for telemetry is present that includes the cardiac reason for telemetry. Prior to telemetry placement, the nurse applying the monitor will verify the patient's identification by assessing the identification band. The nurse will then verify with the intensive cardiac care unit monitor technician that the telemetry number matches the patient programmed into the monitoring system. The nurse will verify that a heart rate and rhythm are present on the monitor with the intensive cardiac care unit monitor technician.

Review on 08/15/23 of the medical record for Patient #20 revealed a provider order for a cardiac monitor dated 06/15/23 at 06:08 PM. (From 06/15/23 at 06:08 PM to 06/16/23 at 08:35 PM, no documentation was found in the medical record to indicate cardiac monitoring was initiated, implemented, and/or that the order for cardiac monitoring was discontinued for Patient #20, while in the emergency department).

Interview on 08/15/23 at 02:24 PM with Staff (L), Clinical Educator, confirmed that there was no documentation indicating Patient #20 was on a cardiac monitor and no order to discontinue the cardiac monitoring in the medical record.

Interview on 08/15/23 at 02:24 PM with Staff (L), Clinical Educator RN confirmed that there was no documentation indicating Patient #20 was on a cardiac monitor and there is no order to discontinue the cardiac monitoring in the medical record.

Interview on 08/18/23 at 02:33 PM with Staff (C), ED Nurse Manager, revealed the nurse assigned to a patient with cardiac/telemetry monitoring orders is responsible for the cardiac/telemetry monitoring.

Interview on 08/18/23 at 02:52 PM with Staff (A), Director of Quality & Risk Management that the emergency department nurses are responsible for monitoring the cardiac/telemetry monitor for their assigned patients.

Findings #4:

Review of policy "Emergency Department Overcrowding/ National Emergency Department Over Crowding Scale/Surge Plan," dated 02/2023, indicated that the facility will use the national emergency department overcrowding scale (an early warning system tool to aid in overcrowding of the emergency room). Once the emergency department reaches a census of 25 patients the national emergency department overcrowding scale calculator will be activated. A score of 101-140 is busy, a score of 141-180 is crowded, and a score of 181-200 is overcrowded. The manager of hospital operations will notify the emergency department manager when the score is 160 to activate the emergency department surge plan. Non-monitored patients will go to the first floor after a handoff report. Monitored patients must have telemetry monitor placed and be monitored by the currently monitored by intensive cardiac care unit monitor technician in the unit.

Review on 08/18/23 of the Manager Shift Report for 06/16/23 at 07:00 AM revealed a national emergency department overcrowding scale of 107 patients with ten patients that were admitted but on hold in the emergency department. The report submitted at 03:00 PM indicated there were 166 patients with nine patients admitted but on hold in the emergency department. The report submitted at 11:00 PM indicated 140 patients with seven patients that were admitted but on hold in the emergency department.

Interview on 8/18/23 at 02:30 PM with Staff (O), Nurse Manager, verified the findings and indicated that the emergency department did not implement the emergency department overcrowding/national emergency department overcrowding scale/surge plan on 06/16/23 at 03:00 PM.

Based on policy review, observation, document review, and interview, the facility does not ensure that there are adequate personnel credentialed in intensive cardiac care unit practice with electrocardiography interpretation privileges to meet the anticipated assessment and monitoring needs of cardiac/telemetry patients the emergency department. This has the potential to place patients at risk for harm.

Findings include:

Review of policy "Telemetry Hospital Wide," dated 11/2022, indicated that provider responsibilities include: enter an order for telemetry, including the cardiac reason for the telemetry; designate and notify a consultant who is credentialed for intensive cardiac care unit practice (specialized training in cardiac critical care) with electrocardiogram test of heart electrical activity using electrodes) interpretation privileges; admit the patient for telemetry based on established criteria; perform an electrocardiogram within twenty four hours before or after admission to telemetry; place a copy of the electrocardiogram in the patient's medical record; and assess the patient's status for continuation or discontinue of telemetry every forty-eight hours.
-Nursing responsibilities in the emergency department and for floor nursing staff include to ensure that an order for telemetry is present that includes the cardiac reason for telemetry. Prior to telemetry placement, the nurse applying the monitor will verify the patient's identification by assessing the identification band. The nurse will then verify with the intensive cardiac care unit monitor technician that the telemetry number matches the patient programmed into the monitoring system. The nurse will verify that a heart rate and rhythm are present on the monitor with the intensive cardiac care unit monitor technician.
-The intensive cardiac care unit monitor technician responsibilities include to ensure the verification process has occurred and that the admission rhythm strip is documented under the cardiac monitoring assessment. The intensive cardiac care unit monitor technician will ensure correct lead placement. If a patient's rhythm cannot be monitored by the intensive cardiac care unit monitor technician, a call will be placed immediately to the staff member via the Vocera messaging system. If the patient has a change in rhythm, the primary registered nurse will be notified immediately. If the primary registered nurse is not able to be reached, the floor charge nurse, intensive cardiac care unit charge nurse, or the manager of the unit will be notified to go see the patient. The intensive cardiac care unit will be notified when the telemetry unit is removed for any procedure. The telemetry unit will be replaced, and the intensive cardiac care unit notified of the return of the patient to monitoring status. The physician or intensive cardiac care unit registered nurse will be notified of any significant changes in patient status, including vital signs, complaints, appearance, and obtain vital signs (blood pressure, apical/radial pulse, and respirations) every eight hours and document on the medical record.

Observation on 08/18/23 at 10:35 AM in the emergency department revealed there were three cardiac/telemetry monitors: one near the providers/nursing station, one at the end of the nurse's station on a desk, and another at the unit clerk desk. Twelve emergency department patients were displayed on the cardiac/telemetry monitors. No staff were observed at provider/nursing station monitors. Staff (F), Unit Clerk was sitting at the unit clerk desk and was asked who was monitoring the patients on the cardiac monitors. Staff (F), Unit Clerk was monitoring the patients on cardiac/telemetry monitors. Staff (F), Unit Clerk stated that nursing staff do not carry monitoring devices on their person and there no hallway cardiac/telemetry monitors.

Review on 08/18/23 of the personnel record for Staff (F), Unit Clerk indicated a hired date of 11/09/20. On 11/11/20, Staff (F), Unit Clerk completed basic electrocardiogram (test of heart electrical activity using electrodes) training. On 3/18/22, Staff (F), Unit Clerk, competed a competency evaluation for correctly obtaining a 12- lead electrocardiogram. The job description/annual performance evaluation dated 02/17/23 indicated a short-term goal to "learn rhythms." (There is no evidence that Staff (F) is credentialed in intensive cardiac care unit practice with electrocardiogram interpretation privileges).

Review on 08/15/23 of the medical record for Patient #20 revealed a provider order for a cardiac monitor dated 06/15/23 at 06:08 PM. (From 06/15/23 at 06:08 PM to 06/16/23 at 08:35 PM, no documentation was found in the medical record to indicate cardiac monitoring was initiated, implemented, and/or that the order for cardiac monitoring was discontinued for Patient #20, while in the emergency department).

Interview on 08/15/23 at 02:24 PM with Staff (L), Clinical Educator, confirmed that there was no documentation indicating Patient #20 was on a cardiac monitor and no order to discontinue the cardiac monitoring in the medical record.

Interview on 08/18/23 at 10:46 AM with Staff (F), Unit Clerk revealed that they have been responsible for viewing and monitoring the cardiac monitors/telemetry since December 2022. Staff (F) stated they do not have cardiac telemetry monitoring training.

Interview on 08/18/23 at 02:33 PM with Staff (C), ED Nurse Manager, revealed the nurse assigned to a patient with cardiac/telemetry monitoring orders is responsible for the cardiac/telemetry monitoring. The unit clerk is not trained in cardiac/telemetry monitoring, and it is not part of their responsibilities.

Interview on 08/18/23 at 02:30 PM with Staff (O), Nurse Manager, verified these findings.