HospitalInspections.org

Based on document review, medical record (MR) review and interview, in 1 of 10 MRs (Patient #1) the Emergency Department (ED) nursing staff did not document patient care according to its policy and procedure (P&P) and current standards of practice related to assessments. This could cause staff to have lack of awareness that a patient's condition had changed.

Findings include:

-- Review of the hospital's P&P titled "Assessment and Documentation of the Emergency Department Patient," last revised 11/2018, indicated all patients should have an initial assessment done by the primary registered nurse (RN). Reassessment should be documented every 2 hours on a level 3 patient and must address the chief complaint. Every intervention should have a reassessment documented within 60 minutes. The RN is responsible to lock the order sheet and chart upon completion.

-- Review of Patient #1's MR revealed, on 3/24/19 at 2:42 am she presented to the ED with a chief complaint that her tracheostomy (trach) tube fell out. Patient #1 was triaged at 3:13 am as a level 3 on the Emergency Severity Index (ESI) scale (scale of 1 [resuscitation] - 5 [non-urgent]). Nursing documented, the family tried to reinsert the tube at home but were unsuccessful. Vital signs (V/S) on arrival were as follows: blood pressure (B/P) - 136/75, pulse (P) - 82, respirations (R) - 22, oxygen saturation (O2 sat) 94% on room air (RA) and temperature (T) - 97.5 Fahrenheit (F). Patient #1 was alert and oriented. Past medical history included throat cancer, respiratory failure, pneumonia, pulmonary emboli, diabetes mellitus, bipolar disorder and mental illness.

Documentation by the ED physician indicated Patient #1 was evaluated at 3:13 am because her trach fell out. Patient #1 was alert and oriented and had no respiratory distress, breath sounds were normal. "The #6 trach she has does not fit anymore, will call respiratory to obtain a smaller one."
-- 4:45 am - "Size 5 trach did not fit, will obtain a size 4."
-- 4:56 am - "Patient does not want trach replaced now. She is breathing great, with O2 saturation at 96% on RA. She will call ENT (otolaryngologist - physicians who diagnose, manage and treat disorders of the head and neck, including the ears, nose throat, sinuses, voice box (larynx) and other structures) Monday. Understanding of discharge instructions verbalized."
-- 5:04 am - B/P - 125/89, P - 84, R - 22, O2 sat 93%, T -97.7 F. Discharge instructions were signed by Patient #1 and she was discharged home.

There was no documentation in the MR by the primary nurse caring for the patient.

-- During interview of Staff A (Charge Nurse ED) on 9/19/19 at 2:35 pm, he/she recalled caring for Patient #1 on 3/24/19. There were 2 people with the patient, a male and a female. Patient #1's trach had dislodged and they attempted to reinsert it at home but could not. The ED physician tried to reinsert the trach but met some resistance. He/she tried a #5 trach (smaller) but still met resistance. The respiratory therapist looked for a size #4 trach, but the patient was uncomfortable and did not want to try anymore. Staff A did not see any drainage or redness around the stoma. The family indicated they had been talking about taking the trach out anyway. There was a lot of discussion between the staff and the patient. The family did not voice any concerns about discharge.

He/she acknowledged not locking the chart. The ED was busy that night and "if I don't initiate charting or complete charting at the time the patient arrives, then I do it later in the shift. Apparently, I didn't get back to the record."

-- During interview of Staff B (ED Nurse Manager) on 9/19/19 at 9:15 am, he/she indicated during MR audits it was identified that Patient #1's MR was not locked by the nurse.

-- During interview of Staff C (Director of Nursing) on 9/20/19 at 10:50 am, he/she acknowledged the above findings.

Based on document review and interview, in 5 of 15 personnel files, the facility did not ensure Emergency Department (ED) staff had required training in accordance with New York State New York Codes, Rules and Regulations, Title 10 (405.19). This lack of training could cause untoward patient outcomes.

Findings include:

-- Review of the facility's policy and procedure (P&P) titled "Educational Requirements for Emergency Department Staff," last revised 8/2018, indicated physicians and midlevels are required to have ATLS, ACLS and PALS or equivalent of each.

-- Review of the job description titled "ED Advance Practice Providers," dated 12/2017, indicated Physician's Assistant (PA) and Nurse Practitioners (NP) are required to have certification in Advanced Cardiac Life Support (ACLS), Advanced Trauma Life Support (ATLS) and Pediatric Advanced Life Support (PALS).

-- Staff D's (ED Medical Director), Staff E's (ED Physician) and Staff F's (Contracted ED Physician) personnel files lacked documentation of current certification in PALS.

-- Staff G's (ED Physician's Assistant [PA]) and Staff H's (ED PA) personnel files lacked documentation of current certification in ACLS and PALS.

-- During interview of Staff I (Quality Professional) on 9/20/19 at 12:00 pm, he/she acknowledged the above findings.