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Based on observation, interview and record review, the facility failed to ensure the Emergency Department (ED) physician on call and Crash Cart policies and procedures were implemented, for one of 20 sampled patients (Patient 1), when:

1. For Patient 1, the on call surgeon did not return the Emergency Department (ED) physicians calls for a surgical consultation (A1104); and

2. The ED crash cart was not checked by 6:30 a.m., (A1104).

The cumulative effect of these systemic failures resulted in Patient 1 to not be provided safe and quality care to meet the patient needs.

Based on observation, interview and record review, the facility failed to ensure the Emergency Department's (ED) physician on call and Crash Cart policies and procedures were implemented, for one of 20 sampled patients (Patient 1), when:

1. The on-call surgeon was not available for one (Patient 1) of 20 patients that presented to the Emergency

Department (ED) for emergent treatment;

2. A crash cart in the ED was not checked by staff daily.

These failures had the potential to impact and delay the care of patients needing emergent care.

Findings:

1. On October 10, 2023, at 11 a.m., a review of the facility's ED log dated April 2023, through October 2023, was conducted with the Director of Quality (DOQ). The ED log indicated Patient 1 arrived at the Emergency Department on July 14, 2023, at 9:53 p.m.

A review of the facility's document titled, "Emergency Room Specialty Call Roster," dated July 2023 was reviewed. This roster indicated Surgeon 1 was on call for surgery on July 14 and 15, 2023.

A review of the facility's undated document titled, "Information Sheet," indicated Patient 1 arrived at the Emergency Department on July 14, 2023, at 9:53 p.m., for complaints of left groin pain.

A review of the facility's document titled, "Hemet Triage Report," dated July 14, 2023, at 10:06 p.m., indicated Patient 1 had left groin pain, swelling, tender and redness and rates pain on a scale of one to ten as a nine.

A review of the facility's untitled document, dated July 14, 2023, at 4:43 p.m., indicated, "...[Patient 1's name]...Computed tomography [CT, a diagnostic imaging procedure that uses a combination of Xray and computer technology to produce images of the inside of the body] Scan...Abdomen/Pelvis...Impression...Left labial/perineal [the inner and outer folds of the vagina] subcutaneous emphysema [gas or air accumulated under the skin] with extensive fat stranding extending to left lower abdomen. Findings are concerning for necrotizing fasciitis [a rare bacterial infection that spreads quickly in the body and can cause death]..."

A review of the facility's document titled, "Emergency Department Record," dated July 15, 2023, at 12:30 a.m., indicated ED physician 1 called Surgeon 1 (S1,on-call surgeon) multiple times with no response.

A review of the facility's document titled, "Emergency Department Record," dated July 15, 2023, at 1 a.m., indicated ED Physician 1 called an outside hospital to discuss Patient 1's case, condition, work up results and plan of care. The outside hospital stated if the ED physician was unable to reach S1, they could accept Patient 1 as a lateral transfer.

A review of the facility's document titled, "Emergency Department Record," dated July 15, 2023, at 3:50 a.m., indicated ED Physician 1 discussed Patient 1's case with the resident team, who agreed to admit Patient 1 to the Intensive Care Unit (ICU, unit that provides critical care and life support to acutely ill patients).

A review of the facility's document titled, "Emergency Department Record," dated July 15, 2023, at 6:26 a.m., indicated ED Physician 1 was unable to get a hold of S1.

A review of the facility's document titled," IntraOperative Case Report," dated July 15, 2023, at 10:38 a.m., indicated Patient 1 underwent an Excisional Debridement of Left Mons Pubis Necrotizing Tissue (removal of flesh-eating soft tissue infection) on July 15, 2023, at 10:06 a.m. performed by S1.

An interview on October 5, 2023, at 10:30 a.m., with S1 was conducted. S1 stated he was the on-call surgeon on July 15, 2023, and was aware of the hospital policy on the need to respond to calls as soon as possible and to be at the emergency department within 30 minutes if needed. S1 stated he did not follow the facility's on-call policy. S1 stated, "I was asleep and I was very tired. I did not answer the calls since I had seven cases in the morning."

An interview on October 5, 2023, at 1 p.m., with the Chief Medical Officer (CMO) was conducted. The CMO stated S1 did not follow the hospitals ED physician's on-call policy on July 15, 2023, when S1 did not respond to the ED physicians' calls.

A review of the policy and procedure (P&P) titled, "EMTALA [Emergency Medical Treatment and Labor Act] -Provision of On-Call Coverage Policy," dated April 2023 was conducted. The P&P indicated, "...the hospital must maintain a list of physicians on its medical staff who have privileges at the hospital...Physicians on the list must be available after the initial examination to provide treatment necessary to stabilize individuals with Emergency Medical Conditions (EMC)...The hospital has a process to ensure that when a physician is identified as being "on-call", it shall be that physician's duty and responsibility to assure the following...Timely availability, at least by telephone, to the Emergency Department (ED), physician for his or her scheduled "on-call" period...Arrival or response to the ED within 30 minutes. The ED physician, in consultation with the on-call physician, shall determine whether the individual's condition requires the on-call physician to see the individual immediately..."


2. On October 10, 2023, at 10:45 a.m., an observation of the Emergency Department (ED) was conducted. Crash cart # 13 was located in the negative pressure room (number of room). A review of the crash cart check form was conducted. There was no documented evidence that crash cart # 13 was checked on October 10, 2023.

On October 10, 2023, at 10:45 a.m., an interview was conducted with the Emergency Department Manager (EDM). The EDM stated the crash carts are supposed to be checked by the charge nurse or designee at 6:30 a.m. daily before the assignments are made. The EDM stated crash cart # 13 was not checked this morning per policy.

On October 10, 2023, at 10: 45 a.m., an interview was conducted with the Chief Quality and Patient Safety Officer (CQPSO). The CQPSO stated the process of checking the crash carts should be done once per day by the charge nurse or designee, this is done at the beginning of the shift to make sure the cart is ready and available for use in an emergency. The CQPSO stated there was no documented evidence crash cart # 13 was checked today.

A review of the policy and procedure (P&P) titled, "CRASH CART," dated April 2021, was conducted. The P&P indicated, " ...All twenty-four (24) hour nursing units are to do crash cart checks once per day by a Licensed Nurse or designated licensed personnel, i.e. a Respiratory Therapist ...Verification of completing the crash cart checklist will be documented on the Crash Cart Check Form ..."

Based on interview and record review, the facility failed to ensure adequate nurse staffing was maintained in accordance with the facility' policy and procedure.

This failure resulted in two RN's being assigned four patients who were determined to require a critical care level in the Emergency Department (ED), which could impact the provision of overall medical care to those patients.

Findings:

A review of the nursing assignment sheets for (NAME OF FACILITY NAME OF UNIT) SHIFT REPORT for October 11, 2023, night shift (7 p.m. to 7 a.m.) and October 12, 2023, day shift (7 a.m. to 7 p.m.) was conducted on October 12, 2023, at 2:33 p.m. with the Emergency Department Manager (EDM) and the Chief Quality and Patient Safety Officer (CQPSO). The assignment sheets indicated one RN was assigned three patients on the night shift on October 11 and one RN was assigned three patients on the day shift on October 12 with critical acuity.

An interview was conducted with the EDM on October 12, 2023 at 2:35 p.m.,. The EDM stated the mandated ratio in the ED is at least one to four and could decrease to one to two if the patient had a critical care acuity. The EDM stated two RN's, one on night shift and the other on day shift, in the ED were not in the mandated ratio when both RN's were assigned three patients with two patients having critical acuity.

An interview with the CQPSO was conducted on October 12, 2023 at 2:36 p.m. The CQPSO stated the ratio was not maintained in the ED on October 11, 2023, night shift and October 12, 2023, day shift.

A review of the facility policy and procedure titled, "Staffing Plan," revised November 21, 2022, was conducted. The policy indicated, "...Criteria and process for assigning patient care responsibilities in accordance with California Department of Public Health and Title 22 nurse to patient ratio requirements ...Critical Care Unit: 1:2 or fewer at all times ..."