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Based on medical record review, observation, facility policy review, and interview, the facility failed to provide a safe environment for one patient (#3) of eleven patients reviewed.

The findings included:

Patient #3 was admitted to the facility on September 12, 2011, with diagnoses to include Mental Status Changes and Hepatic Encephalopathy. Medical record review of the Fall Assessment Tool, dated September 13, 2011, at 8:07 a.m., revealed the patient had a score of 20. Continued review of the Fall Assessment Tool revealed a score of 13 or higher indicated a high risk for falls.

Observation and interview on September 13, 2011, at 2:00 p.m., of the patient in the patient's room revealed the patient lying in bed, head of bed elevated 45 degrees, quarter side rails in the up position at the head of the bed with a personal safety tab body alarm attached to the side rail but not the patient, and the patient's spouse in the room in a wheelchair. Interview revealed the patient was unable to carry on a logical conversation. Interview with the spouse revealed the patient stayed alone when the spouse was not present. Continued interview revealed the spouse had not been informed of the risk for falls or have any idea what the tab alarm device was on the side rail.

Review of facility policy Fall Risk Assessment, #600-06---5, dated as revised July 2011 revealed "...The primary nurse will complete a fall risk assessment...every in-patient will be reassessed every twelve hours and as needed to identify any change in safety risk score...If and when a fall risk assessment safety score is thirteen or above the in-patient is to be placed on CAPS (Constant Awareness of Patient Safety)...Document high fall risk on the Prioritized patient problem list...Personal patient safety body alarms are available to be used as indicated if patient is at high risk and confused..."

Review of facility policy Daily Patient Care Flowsheet, #600-02--32, dated as revised October 2008 revealed "...The Licensed Nurse will prioritize patient's problems for each shift. This will be used as the patient's plan of care for that shift...Patient problems are generated based on patient assessments...Fall Risk Assessment...the patient is reassessed each shift. Each intervention completed during their shift will be indicated by placing a Y in the box..."

Interview at the nurse's station with the Director of Medical Surgical halls, on September 13, 2011, at 2:15 p.m., confirmed the patient was a high fall risk; the safety device tab alarm would need to be in use; the safety device tab alarm was not functional if not attached to the patient; and, as applied, would not alert the staff the patient was attempting to arise without assistance.

C/O # 28687

Based on medical record review, observation, facility policy review, and interview, the facility failed to ensure a care plan for falls was documented for one patient (#3) of eleven patients reviewed.

The findings included:

Patient #3 was admitted to the facility on September 12, 2011, with diagnoses to include Mental Status Changes and Hepatic Encephalopathy. Medical record review of the Fall Assessment Tool, dated September 13, 2011, at 8:07 a.m., revealed the patient had a score of 20. Continued review of the Fall Assessment Tool revealed a score of 13 or higher indicated a high risk for falls.

Observation and interview on September 13, 2011, at 2:00 p.m., of the patient in the patient's room revealed the patient lying in bed, head of bed elevated 45 degrees, quarter side rails in the up position at the head of the bed with a tab alarm attached to the side rail but not the patient, and the patient's spouse in the room in a wheelchair. Interview revealed the patient was unable to carry on a logical conversation. Interview with the spouse revealed the patient stayed alone when the spouse was not present. Continued interview revealed the spouse had not been informed of the risk for falls or have any idea what the tab alarm device was on the side rail.

Review of facility policy Fall Risk Assessment, #600-06---5, dated as revised July 2011 revealed "...The primary nurse will complete a fall risk assessment...every in-patient will be reassessed every twelve hours and as needed to identify any change in safety risk score...If and when a fall risk assessment safety score is thirteen or above the in-patient is to be placed on CAPS (Constant Awareness of Patient Safety)...Document high fall risk on the Prioritized patient problem list...Personal patient safety body alarms are available to be used as indicated if patient is at high risk and confused..."

Review of facility policy Daily Patient Care Flowsheet, #600-02--32, dated as revised October 2008 revealed "...The Licensed Nurse will prioritize patient's problems for each shift. This will be used as the patient's plan of care for that shift...Patient problems are generated based on patient assessments...Fall Risk Assessment...the patient is reassessed each shift. Each intervention completed during their shift will be indicated by placing a Y in the box..."

Interview at the nurse's station with the Director of Medical Surgical halls, on September 13, 2011, at 2:15 p.m., confirmed the patient was a high fall risk and the medical record care plan did not address falls.

C/O # 28687

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Based on medical record review and interview, the facility failed to ensure the accuracy of a medical record for one patient (#8) of eleven medical records reviewed.

The findings included:

Patient #8 presented to the receptionist in the lobby of the Emergency Department (ED) on August 21, 2011, at 1:12 p.m., with complaint of chest pain and jaw pain.

Medical record review of the nurse's Triage Assessment Record, dated August 21, 2011, at 1:31 p.m. (19 minutes after arrival), revealed the patient was triaged as a "Priority 3"; had vital signs of temperature 97.3, pulse 70, respirations 20, blood pressure 185/108 (normal ranges - temperature 98.6, pulse 80, respirations 16, blood pressure 120/80), a pain score of 5 on scale of 1 - 10 with 10 being highest; and complaints of chest/jaw pain, started Wednesday (August 17, 2011), complaints of substernal chest pain, "throbbing", right jaw/neck pain - intermittent, no shortness of breath, positive nausea, no aspirin today. Continued review revealed the patient was provided Aspirin 81 mg (milligrams) po (by mouth) and Nitroglycerin 0.4 mg sublingual on August 21, 2011, at 1:35 p.m. (23 minutes after arrival to the ED).

Interview in the ED with the ED receptionist #2 on September 14, 2011, at 10:30 a.m., confirmed being on duty when patient #8 presented to the ED with complaint of chest pain on August 21, 2011, at 1:20 p.m. Continued interview revealed when a patient presented to the ED with any complaint of heart problems (chest pain, arm pain, shortness of breath) the Triage nurse is notified by phone "Triage" and if the triage nurse is in with a patient the triage nurse should be able to see the complaint of chest pain on the computer terminal in the triage office. Continued interview revealed a nurse in the ED is called to notify of the chest pain patient in the lobby if the triage nurse has not responded to the patient within 2 minutes. Continued interview revealed a call is placed every two minutes for a nurse to see a chest pain patient until the patient is seen. Continued interview revealed receptionist #2 recalled a woman coming to the desk and saying she was a nurse at (named) hospital and chest pain patients don't wait in the ED lobby. Continued interview confirmed ED receptionist #2 recalled making numerous calls to triage and the ED unit clerk for a nurse to see the patient.

Interview in the office of the ED Director with Registered Nurse (RN) #2 on September 14, 2011, at 11:00 a.m., revealed RN #2 reported taking care of a patient in trauma and didn't recall a call for triage as RN #2 was not the assigned triage nurse. RN #2 reported getting a call related to a patient with chest pain being in the lobby; getting the patient and placing the patient in Hall 2 of the ED as the ED was very busy; getting vital signs and a history from the patient; and instructing the technician to get an EKG. Continued interview revealed RN #2 was busy with another chest pain patient in the ED. Continued interview revealed RN #2 did not change the time in the Electronic Medical Record (EMR) when the notations were made and the time of the care was not as documented in the record but was done earlier. Continued interview confirmed the time was to be recorded as the time the care was provided to reflect accuracy.

Interview with the ED Director in the office of the ED Director on September 14, 2011, at 11:20 a.m., confirmed the time documented in the EMR was to reflect the time care was provided not the time the entry was documented in the EMR.

C/O # 28687

Based on medical record review, facility policy review, and interview, the facility failed to ensure a discharge plan was comprehensive for newly diagnosed Diabetes for one patient (#5) of eleven patients reviewed.

The findings included:

Patient #5 was seen in the Emergency Department (ED) on November 19, 2010, at 9:43 a.m., as a referral from a walk-in-clinic after the patient had been found to have a "very elevated blood pressure." Review of the Ed Triage Assessment dated November 19, 2010, at 9:43 a.m., revealed the patient was accompanied by spouse; had Aspirin 81 mg (milligrams) last p.m.; temperature 98.2 degrees Fahrenheit, respirations 18, pulse 123 (normal range 80), blood pressure 215/134 (normal range 120/80); and was alert and oriented. Continued review revealed the ED Physician saw the patient on November 19, 2010, at 10:16 a.m. Review of the ED Provider (Physician) Record revealed "...upper back pain...last p.m. and slightly this a.m...no history of CAD (Coronary Artery Disease) or HTN (hypertension)...all other systems negative...abnormal labs Glucose 367 (normal 74-118), potassium 3.4 (normal range 3.6 -5.1), Urinalysis 8-10 white blood cells (normal range none). Continued review revealed the EKG (Electro Cardio Gram - utilized to monitor heart rate and rhythm) rate 97 with normal sinus rhythm and non-specific ST (electrical impulse waves) changes. Continued review revealed the patient and family were agreeable for admission after the Physician discussed the plan with them. Continued review revealed the Physician's Clinical Impression to be "Uncontrolled Hypertension and New Onset Diabetes."

Review of the admission vital signs upon arrival to the hospital floor revealed the patient's admit vital signs at 12:35 a.m., temperature 97.5, pulse 85, respirations 18, and blood pressure 163/99. Continued review of the hospital admission record revealed the patient stated the reason for admission to be "pulled muscle in shoulder and high blood pressure." Continued review revealed the patient reported no home medications.

Medical record review of the History and Physical, dated as typed and distributed November 19, 2010, at 6:39 p.m., revealed "...presented to a walk-in clinic after woke up this morning and did not feel 100% right...a little dizzy...also had some neck pain...was found to have elevated blood pressure...was sent to the emergency room. In the emergency room was found to have a blood pressure of 214/134. Denies chest pain, no dyspnea, no palpitations, no headache, no nausea, no vomiting, no vision changes...has not seen a doctor in four years...a complete review of systems was done and was negative for anything else other than mentioned above...Initial presentation blood pressure was 214/134, which is down to 162/99...alert and oriented times three...Hypertension and New onset Diabetes."

Medical record review of a Nurse's Note, dated, November 20, 2010 at 8:00 a.m., revealed "Accucheck (blood glucose level) 248. Novalog (insulin) 6 units SQ (subcutaneous injection) given." Continued review revealed November 20, 2010, at 10:33 a.m., "Discharged via wheelchair to car, husband to drive home, follow-up instructions to see medical doctor in 1-2 weeks, patient to schedule."

Medical record review of the Physician's discharge summary, dated as typed and distributed November 22, 2010, at 11:08 a.m., revealed "...Diagnoses: Hypertensive urgency, proved; New Diagnosed Type 2 Diabetes; Urinary Tract Infection...The patient had diabetes education and counseling on insulin administration...was started on Lisinopril (antihypertensive), Metformin (oral Hyperglycemic), and Lantus (insulin)...On the day of discharge, the patient was in no distress...The patient does not have a PCP (primary care physician)...advised to find one as soon as possible. If not, an appointment with the health department in one week for diabetes..."

Medical record review of Labs revealed the following: November 19, 2010, at 10:17 a.m., Glucose 367; November 19, 2010, at 4:06 p.m., Glucose 322; and November 20, 1010, at 8:03 a.m., Glucose per Accuckeck 248.

Review of facility policy Discharge Planning Analysis, policy 3 949-02-005, dated as revised September 2010, revealed "The purpose of discharge planning is to identify a patient's unique needs, utilize multi-disciplinary approach, following hospitalization...The discharge plan will assist in ensuring continuity of care for the patient in order for obtaining optimal benefit from medical care to occur...Patients demonstrating complex discharge planning will be referred to the Case Manager or Social Worker for management of services/care to meet those needs..."

Interview in the conference room with the Quality and Patient Safety Officer, on August 14, 2011, at 11:20 a.m., confirmed the discharge planning for a newly diagnosed diabetic requiring insulin to maintain optimal blood glucose levels would require more instruction, demonstration, and return demonstration education than was provided the patient in the hospital admit of November 19 - 20, 2011. Continued interview confirmed the discharge plan for the patient was to make an appointment in 1 week for follow-up. Continued interview confirmed the facility failed to ensure the patient had more immediate and comprehensive discharge planning arranged for the a newly diagnoses diabetic.

C/O #28386

Based on medical record review, facility policy review, and interview, the facility failed to ensure adequate emergency professionals were available to assess and treat one patient (#8) of six Emergency Department patients reviewed.

The findings included:

Patient #8 presented to the receptionist in the lobby of the Emergency Department (ED) on August 21, 2011, at 1:12 p.m., with complaint of chest pain and jaw pain.

Medical record review of the nurse's Triage Assessment Record, dated August 21, 2011, at 1:31 p.m. (19 minutes after arrival), revealed the patient was triaged as a "Priority 3"; had vital signs of temperature 97.3, pulse 70, respirations 20, blood pressure 185/108 (normal ranges - temperature 98.6, pulse 80, respirations 16, blood pressure 120/80), a pain score of 5 on scale of 1 - 10 with 10 being highest; and complaints of chest/jaw pain, started Wednesday (August 17, 2011), complaints of substernal chest pain, "throbbing", right jaw/neck pain - intermittent, no shortness of breath, positive nausea, no aspirin today. Continued review revealed the patient was provided Aspirin 81 mg (milligrams) po (by mouth) and Nitroglycerin 0.4 mg sublingual on August 21, 2011, at 1:35 p.m. (23 minutes after arrival to the ED).

Review of diagnostics revealed the patient had an EKG (Electro Cardio Gram - measures the hearts rate/rhythm/electrical conduction) on August 21, 2011, at 1:33 p.m. (21 minutes after arrival to the ED) with normal sinus rhythm of 68. Continued review revealed a lab report, dated August 21, 2011, at 1:39 p.m. (27 minutes after arrival to the ED), of Troponin (a muscle protein measurement used to indicate death of cardiac tissue) 2.17 (range greater than 0.39 consistent with Myocardial Infarction).

Review of the physician's Emergency Provider Record, dated August 21, 2011, at 1:40 p.m., conducted in Hall 2, revealed notations of off and on chest pain for 3 days with soreness in the mid chest radiating to the arm, neck and jaw with current pain level of 5 of 10 with 10 being the highest. Continued review revealed the patient reported a history of high cholesterol and hypertension and took medication for these. Continued review revealed the review of systems was negative otherwise. Continued review revealed the Clinical Impression of Non STEMI (Non-ST segment elevation Myocardial Infarction). Continued review revealed the patient was transferred to (named) hospital.

Review of facility policy Triage in the Emergency department/Chest Pain Center, # 678-03-014, dated as revised October 2009, revealed "...Provide timely prioritization of incoming patients with regard to life-threatening care needs, at risk situations, and anticipated resources needed to effect an appropriate disposition according to established standards of care...Reduce time in assessing and initiating diagnostic tests for ED patients...Expedite diagnostics, treatment, and disposition of patients by qualified professionals...Identify and treat signs and symptoms of Acute Coronary Syndrome (ACS) with timely assessments and interventions...Triage Level 2 - Emergent...High risk situations - chest pain...All Level 1 and Level 2 triage patients will be immediately placed in an ED bed. The primary nurse will complete the triage assessment...Possible Acute Coronary Syndrome (ACS) - EKG will be performed during the triage process...and showing the ED physician...The ED treatment record will accurately reflect the nurse's documentation of the patient's physical assessment..." Review of the facility attached protocol Emergency Department EKG, no number or date, revealed Screening EKG...Chest pressure or tightness...Time to EKG less than 10 minutes..."

Review of facility STEMI goals for January - July 2011 revealed the following goals: "...EKG on arrival with threshold - within 10 minutes...ASA (Aspirin) given on arrival to the ED or reason documented with threshold of 95%..."

Interview in the ED lobby with ED receptionist #1 on September 13, 2011, at 9:25 a.m., revealed the ED receptionist have no clinical experience and the triage nurse is to make determinations on severity of illness. Continued interview revealed the ED receptionist calls the triage nurse for any urgent care needs like chest pain. Continued interview revealed the triage nurse can see the complaints of the patients waiting in the ED lobby on the computer screen in the triage room. Continued interview revealed an ED nurse would be called if there was no response from the triage nurse after a call about a chest pain patient. Continued interview revealed the triage nurse was assigned only to the triage area.

Interview in the triage room with the triage nurse on September 13, 2011, at 10:00 a.m., revealed the ED receptionist called the triage nurse to come out now if chest pain was presenting complaint. Continued interview revealed the ED receptionist would call on the walkie-talkie if the triage nurse didn't respond to the ED receptionist. Continued interview revealed the triage nurse trusted the ED receptionist to make good judgment calls if the patient needed to be seen right away because the ED receptionist had been employed there a long time.

Interview in the ED with the ED receptionist #2 on September 14, 2011, at 10:30 a.m., confirmed being on duty when patient #8 presented to the ED with complaint of chest pain. Continued interview revealed when a patient presented to the ED with any complaint of heart problems (chest pain, arm pain, shortness of breath) the Triage nurse is notified by phone "Triage" and if the triage nurse is in with a patient the triage nurse should be able to see the complaint of chest pain on the computer terminal in the triage office. Continued interview revealed a nurse in the ED is called to notify of the chest pain patient in the lobby if the triage nurse has not responded to the patient within 2 minutes. Continued interview revealed a call is placed every two minutes for a nurse to see a chest pain patient until the patient is seen. Continued interview revealed receptionist #2 recalled a woman coming to the desk and saying she was a nurse at (named) hospital and chest pain patients don't wait in the ED lobby. Continued interview confirmed ED receptionist #2 recalled making numerous calls to triage and the ED unit clerk for a nurse to see the patient.

Interview in the office of the ED Director with Registered Nurse (RN) #2 on September 14, 2011, at 11:00 a.m., revealed RN #2 reported taking care of a patient in trauma and didn't recall a call for triage as RN #2 was not the assigned triage nurse. RN #2 reported getting a call related to a patient with chest pain being in the lobby; getting the patient and placing the patient in Hall 2 of the ED as the ED was very busy; getting vital signs and a history from the patient; and instructing the technician to get an EKG. Continued interview revealed RN #2 was busy with another chest pain patient in the ED.

Interview in the ED on September 14, 2011, at 11:50 a.m., with the ED physician caring for the patient on August 21, 2011, revealed the physician indicating the ED being very busy on August 21, 2011. Continued interview revealed there was no plan for the ED to obtain additional staff when things got very busy and additional staffing might be helpful unless it was for the facility's community plan for emergency conditions.

Interview with the ED Director in the office of the ED Director on September 14, 2011, at 11:20 a.m., revealed the problem of wait time in the lobby for a patient was looked at and it had been determined the ED needed to obtain another EKG machine and that the purchase was in progress. Continued interview revealed the House Supervisor (RN covering the hospital for problem issues) had not been notified the ED was so busy a patient with chest pain had not been seen in the ED rapidly as per protocol, had to be in the hall rather than a room, and experienced a delay in getting treatment per the ED guidelines for Chest Pain Center. Continued interview confirmed the facility had not identified and addressed the issue of the patient not being seen more rapidly by ED professionals, the increased length of time before the patient received aspirin, or need to assess for additional staffing needs when the ED became very busy. Continued interview confirmed the facility failed to ensure adequate personnel trained in emergency care to meet the needs of the patient.

c/o # 28687