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Based on observation and interviews the Hospital failed to provide coverage for Security Officer #1, who was monitoring the emergency department (ED) entry/exit door, when the Hospital re-assigned Security Officer #1 to provide additional security assistance regarding a security issue in the ED. The re-assignment of Security Officer #1 resulted in an un-monitored ED entry/exit door and the ED without appropriate security protection.

Findings include:

The Surveyor observed on 10/21/13 at 1:05 P.M., during a second tour of the ED, that a Hospital security officer was not monitoring the ED entry/exit door. The Surveyor and the Hospital Risk Manager were able to enter the ED because a person opened the door to exit the ED and we entered the ED through this open and un-monitored ED door.

The Surveyor interviewed Security Officer #1 on 10/21/13 at 1:10 P.M. Security Officer #1 said that it was Hospital policy for the ED entry/exit door to be monitored, Hospital security was short staffed, the Hospital had 4 security officer positions vacant, she needed to re-assign Security Officer #2 to assist in the ED and did not have a coverage or a back-up plan to monitor the ED entry/exit door.

The Surveyor interviewed the Director of Security on 10/21/13 at 1:38 P.M. The Director of Security said it was Hospital policy for the ED entry/exit door to be monitored and the ED entry/exit door was, at times, was uncovered when the Hospital needed to quickly, re-assign the security officer to assist with a security issue in the ED. The Director of Security said " it happens " and that a Registered Nurse from triage could cover the door.

The Hospital did not make available the Security Department policy regarding coverage of the entry/exit ED door, for Surveyor review when requested.

The Surveyor interviewed the Director of Security on 10/12/13 at 2:40 P.M. The Director of Security said the Security Department now had a new policy titled, Triage Officer Duties, dated 10/21/13, which described a coverage procedure when the security officer monitoring the ED entry/exit door was re-assigned. The Director of Security said the policy was in effect immediately and security staff education, about the policy had started.

Based on interview and the Hospital document titled, Cape Cod Hospital Emergency Center, Tag, A1111 from CMS regulations (actual name of the Hospital document), the Hospital failed to designate a qualified member of the emergency services medical staff to supervise and provide immediate oversight of the Emergency Department (ED) during all times the Hospital makes emergency services available.

Findings include:

The Surveyor interviewed the Emergency Department (ED) Medical Director on 10/23/13 at 9:20 A.M. The ED Medical Director said there was not one assigned ED physician designated to supervise the ED. The ED Medical Director said when the ED schedule called for more than one ED physician assigned to work a shift; ED physicians cover their assigned zone and cross-cover patients in other zones and physician responsibilities, as needed. The ED Medical Director said and described the ED physician schedule according to the Hospital document titled, Cape Cod Hospital Emergency Center, Tag, A1111 from CMS regulations, as follows:
The ED physician in charge was geographic and this depends on the time of day, zone and number of patients in the department.
-11:00 P.M. to 8:00 A.M., one ED physician was in charge for all zones and all patients in the ED.
-8:00 A.M. to 9:00 A.M., two ED physicians were in charge of their own zone.
9:00 A.M. to 10:00 A.M. and 6:00 P.M. to 11:00 P.M., three ED physicians were in charge of their own zone.
10:00 A.M. to 6:00 P.M., four ED physicians were in charge of their own zone.