HospitalInspections.org

Based on record reviews, staff interviews, observations and family interviews, the Hospital failed to meet the emergency needs of patients in accordance with acceptable standards of practice. Although the Hospital had made corrections from the 9/4/09 complaint survey to ensure proper signage and a dedicated ED, the Hospital had not fully implement their Plan of Correction.

The Condition of Participation: Emergency Services 42 CFR 482.55 remains out of compliance due to the following failures:

I. Failure to ensure the accuracy and adequacy of triage assessments and pain assessments. (Patients #21, #26, #28, #30, #25, #13, #27, #29, #23, #33, #31, #35, #34)

II. Failure of the Medical staff to ensure adequate, appropriate and timely ED services, care and medications were provided to meet the emergency needs of patients presenting to the ED. (Patients #21, #39, #41, #32, and #23)

III. Failure to ensure comprehensive and accurate documentation of ED care and services. (Patients #47, #35, #41, #21, #31, #38, #26, #28, #40, #45, #32, and #30)

IV. Failure to ensure QMP orders for medications and treatments were appropriately documented and implemented in a timely manner and without error. (Patients #23, #36, #21, #40, #41, #44, #45, #33, #37, #32, #47, #42, #43, and #34)

V. Failure to ensure ED services were provided in a timely manner including initial triage, MSE, transfer and administration of medications.(Patients #35, #37, #33, #28, #30 and #47)

TRIAGE ASSESSMENT POLICY REVIEW:
1. The current hospital policy titled "Patient Assessment & Reassessment", indicated the following ED triage groups:

a. Resuscitative (Level 5) - immediate care, life threatening conditions: requires 1:1 Nursing Care. (this group listed seizures and cardiac emergencies)

b. Emergency (Level 4) - major injury or illness but stable Treatment and reassessment should occur within 5-15 minutes: Requires 1:1 Nursing Care.

c. Urgent (Level 3) - treatment and reassessment should occur in fifteen (15) to forty five (45) minutes:

d. Semi-Urgent (Level 2) - Treatment and reassessment should occur in one to two (1-2) hours: and

e. Routine (Level 1) - treatment and reassessment should occur within four (4) hours.

2. The policy also indicated "If triage level changes during reassessment, document the level change on the reassessment notes".

3. In an interview on 1/5/10 the ED charge nurse indicated the patients presenting to the ED were triaged in accordance to the hospital policy which listed the most emergent patients as a triage category of "5". He indicated plans were being made to change triage procedure to the Emergency Severity Index (ESI) triage algorithm system of assessing ED patients. He indicated the policy for this system had not yet been approved by medical staff and the hospital's governing body. He also indicated the staff had not yet been training on this new system. The ESI triage category for the most emergent patients was "1" (opposite the hospital's current policy).

4. In an interview with the Compliance Officer and the ED Manager on 1/7/10 they indicated they had identified the ED staff were erroneously using the ESI triage levels instead of the approved hospital policy on triage during the Christmas holidays. Although they indicated they had informed the ED staff to only use the approved hospital policy levels, review of the ED medical records and ED log for the time period after 1/1/2010 showed the staff continued to inconsistently use the approved hospital policy regarding triage levels.

5. Observation of the ED triage area and the ED nursing station at the time of the interview revealed ESI Triage posters had been placed in these areas with the current policy.

6. In an interview with the ED Manager on 1/5/10 at 10:10 AM she indicated the current hospital policy was what patients should be assessed from and she removed the ESI Triage posters from the ED.

7. Review of the ED log and ED patient forms revealed the staff did not consistently use the current policy of the hospital to triage patients and assign a triage level or category.

8. Patient #21 (a 16 year old) presented to the ED on 1/2/10 at 2359 (11:59 PM) with complaints of shortness of breath and a fast heart rate. The initial triage assessment at 0003 (12:03 AM) indicated a pulse of 177 beats per minute (bpm) and a BP of 161/94.

a. Two triage levels had been marked (3 and 4) with the "3" level crossed out.

b. There was no documented assessment of pain at initial triage time.

c. The patient demonstrated an abnormal EKG (supraventricular tachycardia). Although the patient had no history of cardiac problems the physician was aware of a familiar incident of Wolff-Parkinson-White syndrome (WPW) which may be manifested by symptoms or episodes of tachycardia (rapid heart rhythm), dizziness, chest palpitations, fainting or, cardiac arrest (rare). There is no evidence the ED QMP consulted with a cardiologist regarding the possible need for tertiary cardiac care.

d. The EKG (at 0028-12:28 AM) indicated a heart rate of 168 and "supraventricular tachycardia with fusion complexes Right superior axis deviation, Nonspecific ST abnormality Abnormal ECG". A second EKG conducted ten minutes later and after two doses of Adenosine showed continued sinus tachycardia (HR of 127).

e. In a phone interview with a family member after the survey, he/she indicated the family had been told to take the patient to a cardiac specialist but no arrangements had been made to assist the family with this referral.

f. The QMP order Losartan (for the treatment of hypertension) at 12:50 AM but did not indicate a route or dosage. There was no evidence this medication was given to the patient.

g. The QMP ordered only two doses of Adenosine (6 mg and 12 mg). The ED record showed four doses were given.

h. Oxygen was placed but the nurse did not indicate the flow rate.

9. Patient #39 presented to the ED on 1/4/10 with complaints of an elevated BG (523).

a. Although the QMP provided IV fluids the patient did not receive any IV or subQ insulin for this critically high BG.

b. The patient's BG did decrease to 356 (per accucheck assessment) at 1452 (2:52 PM) and 373 at 1542 (3:52 PM).

c. The patient was also given Lasix (a diuretic) although there was no indication the patient had edema, swelling, abnormal lung sounds or elevated BP.

10. Patient #41 presented to the ED on 1/3/10 at 1805 (6:05 PM) per ambulance and was having prolonged seizure activity (over 8 minutes). The patient was diagnosed with status epilepticus.

Review of the "Lippincott Manual of Nursing Practice, Sixth Edition" defined status epilepticus as a series of generalized, prolonged seizures without return to consciousness between attacks. The term 'status epilepticus' is defined more broadly as any seizure activity lasting at least 5 minutes. It is considered a serious neurological emergency. Status epilepticus may result in permanent brain damage, severe neurologic deficits or death. Factors which may precipitate status epilepticus include withdrawal of anticonvulsant medications, fever, infections and other stresses. Treatment of status epilepticus includes support of respiration, establishment of intravenous (IV) access and administration of anticonvulsants.

a. Initial triage assessment at 6:05 PM indicated the patient was having seizure activity. Another nursing entry at 1812 (6:12 PM) also indicated "seizures".

b. Subsequent nursing reassessments did not address if the patient's seizures were continuing or if they had stopped even after administration of anti-seizure medications.

c. In an interview on 1/7/10 with one of the providers who had been involved in the patient's care, he indicated there were periods of time the patient was not seizing. He confirmed the QMP's documentation did not indicate the presence or absence of seizure activity throughout the ED stay.

d. Initial orders by the QMP were not timed. These orders included an order for Rocephin 2 grams IV which was not given until 2018 (8:18 PM) over two hours after admission to the ED.

e. QMP orders included several doses of Ativan (a total of 18 mg) to be given. Three of these doses did not include the time of the order and for two doses the order was not written until an hour after the administration of the medication.

f. Various medications ordered did not include the time of the order (Rocephin, Succinylcholine, Versed, Ativan, and Vecuronium).

g. At 1918 (7:18 PM) the QMP ordered Tylenol 650 mg to be given rectally. This medication was not given until 2016 (8:16 PM), one hour later and only 165 mg was given.

h. The QMP orders had several directives for administration of IV fluids. Orders did not consistently include the time of the order, the type of fluid or the flow rate.

i. Nursing documentation of IV fluids did not consistently include the type of fluid or the rate as ordered by the QMP. The total IV intake administered prior to the patient's transfer could not be determined.

j. The QMP ordered a Domamine (sp?) drip at 5 mg/min to increase the BP to 95 (systolic). This order of 5 mg (or 5000 mcg/min) was not consistent with the hospital policy requiring the order to designate mcg/kg/min.

1) The hospital policy titled "Dopamine Protocol" indicated doses of this medication were to be written in mcg/kg/minute (micrograms/kilograms of weight) and the patient was to be placed on an IV infusion pump. The policy indicated downward titration of the Dopamine required a medical provider order.

2) Review of the policy titled "Verification of Dopamine, Heparin, Insulin, Lidocaine and Cardiac Drugs", indicated prior to administration of these drugs, the order and administration had to be verified by another nurse.

3) The patient was not able to be weighed at the time of admission due to her/his presenting condition and the last recorded weight was 150 pounds or 68.2 kg.

4) The Dopamine was titrated appropriately and discontinued when the patient's blood pressure increased to acceptable levels at approximately 1946 (7:46 PM).

5) At 2045 (8:45 PM) the patient's BP dropped to 90/51. The documentation was not clear if the Dopamine drip was restarted. The medication section of the Nursing Care Record indicated at 2048 (8:48 PM) "Dopamine restarted-no restarted per (Physician J)". The patient's BP did not increase until 2210 (9:10 PM) when it was evaluated at 110/76 with a pulse of 148 bpm. The patient continued to have a fast heart rate of over 100 bpm most of his/her ED stay.

k. The QMP had ordered two Versed Drips to be given which were administered at 1832 (6:32 PM) and at 2235 (10:35 PM). At 1916 (5:16 PM) the nursing note indicated "7 mg of Versed in (L) wrist". There was no QMP order for this dose of Versed.

l. At 1918 ((7:18 PM) the QMP ordered Dilantin 1400 mg/hr in an IV drip. According to The Merck Manual, sixteenth edition, Dilantin, an anticonvulsant, is used to control many types of seizure activity. Blood levels (Phenytoin or Dilantin) are obtained to determine the resident's response to the medication. If therapeutic blood levels are not obtained the individual may experience increased seizure activity (low levels) or signs/symptoms of toxicity (high levels).

1) The patient's record indicated he/she only received 250 mg of the ordered Dilantin dose. The physician's progress notes indicated "no more Dilantin available (gave 250 mg IV of 1400 mg ordered".

2) Review of the inventory list for the ED crash carts showed the carts contained 5 units of Phenytoin (Dilantin) 250 mg/5 ml. Review of Omnicell records showed the ACN unit had 5 units of Dilantin available on 1/3/10.

3) In an interview with the pharmacist on 1/7/10 she indicated she had not replaced any Dilantin in ED crash carts but had replaced Dilantin in the Omnicell after 1/3/10.

4) The Omnicell records for Dilantin in the ED indicated the patient only received one unit of Dilantin from the system at 2030 (8:30 PM). The on-call pharmacist did not replace the units of Dilantin until 10:30 PM.

m. The QMP signed the ED Transfer form in two places with the time indicated as 1630 (4:30 PM), which was before the patient had arrived in the ED at 1805 (6:05 PM). The form did not indicate the time the patient was actually transferred.

n. Although the patient had been intubated and was sedated, the QMP had ordered ASA (aspirin) four tablets orally to be given to the patient.

o. Pancuronium was given at 2010 (8:10 PM) and again at 2240 (10:40 PM). Pancuronium is an adjunct to general anesthesia to facilitate tracheal intubation and to provide skeletal muscle relaxation during surgery or mechanical ventilation. Only an anesthesiologist or CRNA may give this medication. There were no QMP orders for these medications. The first dose was initialed as given by a nurse and the second dose indicated it had been given by anesthesia staff.

p. Although it appeared anesthesia staff were present and providing care to the patient during the ED stay, a record of his/her actions, treatments, and medications given by this staff member were unclear.

q. Although the QMP indicated the patient was on a Versed drip at the time of transfer the transfer form did not indicate the patient also had a nitro patch or the most recent doses of other medications (Pancuronium, Vecuronium, Phenobarbital, Dilantin, Dopamine, Ativan and two antibiotics).

r. The nursing record indicated at 2055 (8:55 PM) "EMS (ambulance staff) boarding pt at this time". The record indicated, per the transfer form, the family had consented to transport at approximately this time also. The patient was not transported until 2245 (10:45 PM) almost two hours later. The record does not show the reason/rationale for the delay in transport of this patient to the tertiary care hospital.

11. Patient #32 presented to the ED on 1/2/10 at 1850 (6:50 PM) with complaints of a fast heart rate. The triage assessment showed a heart rate of 196 bpm with a BP of 72/53.

a. The EKG conducted showed the patient was in a supraventricular tachycardia rhythm. The patient had a history of and was being treated for paroxysmal supraventricular tachycardia (PSVT).

b. The patient was given two doses of Adenosine, a medication used to control irregular heart beats. After the two doses of Adenosine the patient converted to a normal heart rhythm. The patient's pulse remained below 100 beats per minute (BPM) during his/her stay in the ED prior to his/her transport to a tertiary hospital for further evaluation.

c. The QMP also ordered Diltiazen (Cardizem) a cardiac medication used to treat hypertension and chronic angina. The QMP also ordered nitroglycerin paste (used to treat angina). The medical record did not reflect the reason for these two medications, as the patient had not complained of angina and his/her BP was low (hypotensive not hypertensive).

d. The patient received Vicodin 1 orally at 1940 (7:40 PM). There was no indication of the reason the patient received this medication, (i.e. no documented pain assessment). There was no order from the QMP at 1940 for Vicodin.

e. The QMP ordered Vicodin at 2040 (8:40 PM). The ED notation at 2030 indicated the patient had complained of "head ache pain 7/10" and Vicodin was given, but no dose was indicated. No reassessment of the effectiveness of this medication was evident in the medical record. Headache after the administration of nitroglycerin (which the patient had received) is a common side effect.

f. The QMP had also ordered Morphine Sulfate 2 mg IV for severe pain at 2040. The ED record showed the patient received Morphine at 2230 (10:30 PM) but there was no indication the patient had complained of severe pain or the location of any pain.

g. The physician had ordered oxygen 2 L/NC (Liters per nasal cannula). The ED record and nursing care record indicated the patient was placed on 3 L/NC not the 2 L ordered.

h. The transfer record indicated the patient was on room air (RA). There was no physician order or reason documented relating to why the oxygen was discontinued.

i. The transfer form did not indicate the records sent with the patient, did not indicate the medications the patient had received, and did not reflect any presence of IV fluids.

12. Patient #23 presented to the ED on 12/31/09 at 2337 (11:37 PM) after suffering a stab wound in the left side of the neck. The ED record indicated "1 liter blood loss ". The MSE notations indicated the patient was found by the EMS staff in a "huge pool of blood & clothes soaked". The patient's blood pressure at initial triage was 95/42 with a pulse of 102.

a. The QMP did not use the approved ED forms to document his/her MSE, treatment orders and interventions. The medications and treatments were not timed.

b. The patient was typed and screened for a blood transfusion but no blood was given to the patient prior to his/her transfer to another facility. The transfer record (under the section for preparation for transfer) indicated "blood products". There was no evidence the patient had received any blood products until his/her arrival at the receiving hospital.

c. The QMP orders indicated two doses of Haldol. One dose included the IM route but the second order did not include a route. Review of the nursing care record showed the nurse gave the first dose of Haldol intramuscularly but gave the second dose intravenously. According to drug manufacturer information Haldol (haloperidol) injection is not approved for intravenous administration. If Haldol is administered intravenously, the ECG should be monitored for QT prolongation and arrhythmias.

d. Review of Omnicell (pharmacy storage) records showed the patient only received one dose of Haldol not two as ordered or as documented.

13. Patient #36 presented to the ED on 1/5/10 at 9:30 AM with observed seizure activity prior to transport to the hospital.

a. Physician orders indicated an order for Ativan 1 mg IV at 10:10 AM. Although other physician orders for laboratory/radiology studies given at 10:10 AM were conducted, there was no evidence the Ativan had been given.

b. In an interview with the ED nurse on 1/8/10 at 8:00 AM the nurse indicated the provider had taken the medical record to make progress notes and the medication was not given because the nurse was not aware of the order. The patient was not discharged home until 12:55 PM.

14. Patient #40 presented to the ED on 1/3/10 at 1544 (3:44 PM) with complaints of gallbladder pain (10/10).

a. At 1942 (7:42 PM) the QMP ordered "Zantac 150 mg IV". Although the standard dose of IV Zantac is only 50 mg, there was no indication the nurse had clarified this medication order with the QMP.

b. There was no indication any IV Zantac had been dispensed.

c. The Omnicell pharmacy records indicated Zantac tablets (150 mg) had been removed from the system. The nurse documented giving a dose of 50 mg IV of Zantac at 2000 (8:00 PM).

d. The QMP did not document the MSE on the hospital approved Emergency Room Physician Encounter form but used the EHR to document his findings. This EHR indicated the time of the entry was 2027 (8:27 PM) but did not indicate the time the MSE was conducted.

e. The QMP orders indicated "start IV" but did not include the type of IV fluid or the rate or the infusion desired.

15. Patient #44 presented to the ED on 1/3/10 at 6:12 AM for complaints of chest pain .

a. The physician's orders indicated ASA (Aspirin) 4 - 81 mg tab (tablets). The ED record showed ASA 325 mg was given at 0645 (6:45 AM) not the 81 mg tablets as ordered.

1) This administration of the ASA had been verified by two nurses as per hospital policy but they did not identify the error.

2) Review of pharmacy records (Omnicell) showed ASA 325 had been withdrawn from the system but had then been returned. There was no evidence any ASA 81 mg tablets had been withdrawn from the Omnicell.

3) Due to the inconsistencies in the pharmacy records, it could not be determined if the patient had received any ASA (325 mg or the four 81 mg tablets).

b. Physician orders (at 6:35 AM) indicated to give Morphine 2 mg IV. The ED record showed 4 mg IV was given at 6:45 AM. This administration of Morphine had been verified by two nurses as per hospital policy but they did not identify the error. Omnicell records indicated only 2 mg was withdrawn from the system.

c. Physician's orders at 6:35 AM indicated oxygen 3 liters/minute to be given. Review of the ED Nursing Record did not show this order had been implemented. The Nursing Care Record indicated the patient received either oxygen 4 L/min or 2 L/min but not the rate of 3 L/min as ordered.

16. Patient #45 presented to the ED on 1/5/10 with complains of chest pressure.

a. The physician orders indicated "1/150 0.4 mg) nitro SL. There was no evidence on the ER Nursing Record this medication had been given.

b. The QMP ordered Morphine for the patient's pain but the order was unclear. The route of this medication had been altered and it could not be determined if the patient was to receive the medication IV or IM.

c. The orders from the QMP also indicated "IV, O2 (oxygen), monitor". This order did not include the type of IV fluid to be given or the oxygen flow rate.

d. The ED record showed the patient received this medication "IVP over 30 sec". Review of the hospital's abbreviation list indicated "IVP" was for intravenous pyelogram, a radiological study of the kidneys.

17. Patient #33 presented to the ED on 1/4/10 at 2345 (11:45) with complaints of epigastric pain (8/10).

a. The QMP ordered Thiamine 100 mg but did not indicate the route. The nurse gave the medication IV.

b. The ED record did not indicate a triage time and the QMP did not perform a MSE until 1:55 AM (over two hours later). There was no indication of the reason for this 2 hour delay, (i.e. other trauma cases or volume of ED patients) or evidence of monitoring of this patient during this delay to ensure his/her status did not deteriorate.

c. Although the patient received Zofran (medication for nausea and vomiting) and Zantac (medication for epigastric irritability), the patient did not receive any pain medications and his/her pain continued to be 8/10 at the time of discharge.

18. Patient #47 presented to the ED on 12/31/09 at 0648 (6:48 AM) with complaints of nausea, vomiting and diarrhea. The patient was a post renal transplant patient.

a. The QMP ordered Rocephin 1 gram IV. Although the QMP order sheet indicated "finished 1700", there was no record of this medication administration on the ED record and this medication was not listed on the transfer form.

b. The QMP ordered Zofran at 7:35 AM which was given at 8:00 AM. Another dose of Zofran was given at 1400 (2:00 PM) but there was no evidence of a QMP order for this repeat medication.

c. The patient's temperature was 101.9 degrees Fahrenheit at initial triage assessment. There is no evidence the patient's vital signs were assessed again until 1300 (1:00 PM), six hours later.

19. Patient #35 presented to the ED on 1/4/10 at 1725 (5:25 PM) with complaints of rectal pain. The patient was transferred to a tertiary hospital for a surgical incision and drainage of a perianal abscess at 0001 (12:01 AM).

a. No initial assessment was documented of the pain level.

b. The QMP ordered Morphine sulfate 4 mg IV "now" at 8:07 PM. There was no documentation of the patient's level of pain when this medication was given at 2050 (8:50 PM). The reassessment note at 2100 (9:00 PM) did not include a pain assessment.

c. The QMP ordered Clindamycin 600 mg IV "now" at 2007 (8:07 PM). This medication was not given until 2100 (9:00 PM) almost one hour later.

d. Ancef was also ordered at 8:07 PM to be given "now". This medication was not given until 2140 (9:40 PM), over an hour later.

e. The QMP ordered Bactrim DS 1 at 2240 (10:40 PM) but this medication was not given until 0001 (12:01 AM).

f. The QMP ordered Zofran 4 mg IV PRN (as needed) for nausea. This medication was given at 2158 (9:58 PM) but there was no documentation of any patient complaints of nausea.

g. The QMP had ordered a total of three liters of IV fluid but the ED record does not indicate the total amount of fluids actually administered.

h. The patient had been accepted by the receiving hospital at 2137 (9:37 PM) but was not transferred until 0001 (12:01 AM) 2 ? hours later with no indication of the reason for this delay.

i. There was no indication of what ED records were sent with the patient at the time of transfer.

20. Patient #31 presented to the ED on 1/3/10 at 1218 (12:18 PM) with complaints of knee pain (9/10).

a. Although the patient had initially identified his/her pain at a level of 9/10, he/she did not receive any pain medication until 1335 (1:35 PM) over one hour after presenting to the ED. When the patient was given an ordered dose of Vicodin the nurse did not reassess his/her current pain level.

b. The QMP had ordered a total of 2 liters of IV fluid. Documentation does not clearly show the total amount of IV fluids infused during the ED visit.

c. The transfer record did not risk/benefit of the transfer or the records sent with the patient.

21. Patient #38 presented to the ED on 1/1/10 at 3:25 AM with complaints of syncope (triage level 3) and a 5-10 minute period of unresponsiveness.

Portions of the laboratory report had been crossed out not allowing the data to be viewed.

22. Patient #26 presented to the ED on 12/25/09 at 1140 (11:40 AM) with complaints of shortness of breath pitting edema and pain at 8/10.

a. The patient was only triaged a "2" category. The form also indicated ESI 2, which is considered high risk.

b. The initial assessment did not indicate the location of the pain.

c. The ED record indicated the patient's vital signs were not reassessed until 1400 (2:00 PM), two hours and twenty minutes after presenting to the ED.

d. At 1245 (12:45 PM) the QMP ordered "Bipap apply 5/10". The ED record indicated at 1400 (2:00 PM) "on Bipap machine" but the record did not show when this order had been initially implemented.

23. Patient #28 presented to the ED on 1/3/10 at 1448 (2:48 PM) with complaints of shortness of breath.

a. Although the patient was indicated as a level 4 triage category, the patient was not initially triaged until 1610 (4:10 PM), one hour and twenty minutes later. The patient's initial BP was 205/100 with a pulse of 98.

b. There was no evidence this patient had been monitored during this wait to ensure his/her condition had not worsened.

c. The QMP did not document the MSE on the hospital approved Emergency Room Physician Encounter form but used the EHR to document his findings. This EHR indicated the time of the entry was 2135 (9:35 PM) but did not indicate the time the MSE was conducted.

d. The QMP had ordered "start IV" but this order did not specify the type of IV fluid or the desired rate. The ED record did not include the total amount of IV fluids given to the patient.

e. The transfer record was incomplete, lacking the time, date, condition at discharge, mode of transfer, personnel escorting patient, and risks/benefits of transfer.

f. The transfer record showed the transfer was certified by a physician's assistant but there was no indication a physician had countersigned the transfer form.

g. The QMP signed the Transfer record for the patient at 1926 (7:26 PM) but the ED record indicated the patient was not transferred until 0120 (1:20 AM) the next day or six hours later. There was no documentation of the rationale for this delay.

24. Patient #30 presented to the ED on 12/29/09 at 1821 (6:21 PM) for complaints of abdominal pain (8/10).

a. The patient was triaged at 1826 (6:26 PM) but was not placed in a treatment bay until 2210 (10:10 PM). There was no triage level indicated on the ED form, although the ED log indicated a triage level of "3".

b. There was no indication of the reason for this delay, (i.e. other trauma cases or volume of ED patients) or evidence of monitoring of this patient during this delay to ensure his/her status did not deteriorate.

c. The QMP did not conduct a MSE until 2250 (10:50 PM), four and one half hours after the patient presented to the ED.

d. There was no indication the nursing staff had reassessed his/her pain level until 2217 (10:17 PM) which remained at a level of 8/10.

e. The patient received Morphine 4 mg IV at 0255 (2:55 AM). No pain assessment was recorded until five minutes after the drug was administered. At 3:00 AM the pain was indicated at a level of 7/10. The patient was transferred at 3:35 AM but there was no indication if the morphine had been effective.

f. The QMP medication and treatment orders were not timed.

g. The transfer record did not indicate the medical record information sent with the patient or recent medications given prior to transfer.

25. Patient #37 presented to the ED on 12/22/09 at 0935 (9:35 AM) with complaints of edema in his/her legs.

a. The ED record indicated the patient received oxygen per nasal cannula (3-5 liters/min). There were no QMP orders to start Oxygen or any order to increase/decrease the flow rate.

b. The patient was started on a nitroglycerin drip due to possible cardiac ischemia. The QMP order indicated "nitro drip 10 mics" (no rate was indicated). At 1422 (2:22 PM) this medication was increased to 20 mcg/hr and later (at 1545-3:45 PM) decreased back to 10 mcg/hr. There was no evidence of a QMP order for this decrease in dosage at 3:45 PM.

c. The QMP indicate on the ER Physician Encounter (page 2) at 1440 (2:40 PM) the patient was to be transferred to a tertiary hospital. The ED record indicated the patient was not transferred until 1727 (5:27 PM) over 2 ? hours later. There was no evidence of the reason for the delay in transfer of the patient. There was no evidence the QMP evaluated the patient's status from 1440 (2:40 PM) until the time of transfer to ensure the patient was stable at the time of transfer.

26. Patient #42 presented to the ED on 1/3/10 at 1618 (4:18 PM) "while seizuring lasting about 30 sec (seconds)." The triage assessment indicated the patient's oxygen saturation level was low at (90 %) on room air.

a. Physician orders at 4:35 PM indicated an order for oxygen 3 liters per minute to be given.

b. An assessment note at 1655 (4:55 PM) indicated the patient was placed on a non-rebreathing mask but no notation of the oxygen flow rate.

c. Remaining reassessment notes by the nurse indicated the patient was on "RA (Room Air)", not the 3 liters ordered by the physician.

d. At the time of transfer, the transfer form indicated the patient was on an IV of normal saline at 80 cc/hr. The physician order's indicated a heplock and an order for IV Dilantin to be given in 100 cc of normal saline in 30 minutes (given at 1800-6:00 PM). There was no evidence the physician had ordered the additional IV fluids (Normal Saline at 80c/hr).

27. Patient #43 presented to the ED on 12/22/09 with complaints of shortness of breath and edema in his/her extremities.

a. The QMP ordered "O2 by NC (nasal cannula). The order did not include a flow rate. Although the nurse initialed when the order was noted, there was no evidence the patient was given oxygen support.

b. The triage assessment indicated the patient was on RA (room air) but no indication in the reassessment notes when or if the oxygen had been applied as ordered.

21. Patient #34 presented to the ED on 1/4/10 with complaints of a hand injury (assault).

a. The initial triage assessment did not assess the patient's pain level.

b. The QMP ordered a sedimentation rate (Sed rate) but the order form indicated "not available". A sed rate is a blood test which can reveal inflammatory activity in the body.

c. In an interview with the laboratory manager on 1/6/10 he indicated the lab did not do Sed rates ordered from the ED.

d. There was no evidence this laboratory study had been conducted as ordered by the QMP. There was no documentation in the medical record why the laboratory staff had disregarded the QMP's order.

28. Patient #25 presented to the ED on 1/4/09 at 1824 (6:24 PM) with complaints of a swollen throat, difficulty swallowing and a pain level of 10/10.

a. The ED record showed two triage levels (2 and 3) had been checked.

b. The QMP did not conduct the MSE until 2030 (8:30 PM), over two hours after the patient presented to the ED. The record did not indicate why this two hour delay occurred nor did the documentation show the patient had been monitored during this time period to ensure his/her condition had not deteriorated or changed.

c. The QMP ordered (no time indicated on order) a

Based on record review and staff interview, it was found the Hospital failed to ensure that the Medical Staff bylaws were reviewed and kept current. The findings included:

1. The survey team was provided two sets of the Medical Staff Bylaws for review. An administrative staff member explained the Bylaws have been signed and forwarded to the Aberdeen Area Office for review and signature. The Area office received the bylaws via e-mail on 11/03/09 and original via mail on 12/14/09.

2. Review of the new bylaws evidenced the revisions were started in 2007 but had not been signed until 12/10/09 by the hospital administration. The bylaws had not yet been finalized and approved by the Governing Body of the Hospital. The Governing Body did not ensure timely review/approval of this process to ensure Medical Bylaws were current.

3. The Administrative Staff member confirmed the Medical Staff Bylaws have not received final approval by the Governing Body.

Based on record review and patient, family, and staff interviews, it was determined the registered nurses failed to supervise and evaluate the nursing care provided to each patient to ensure quality of care for the patients (patient #4). The findings included:

Record review for patient #4 (a nine month old infant) revealed he/she was admitted to the Hospital with diagnoses including acute gastroenteritis, moderate dehydration, electrolyte imbalance, and bilateral otitis media.

a. Review of the patient's physician orders and laboratory results evidenced the following:

1) The patient's laboratory results on 1/4/10 at 9:00 PM showed the patient's potassium (K) level was high at 6.2 mmol/L. A "Critical Test Read-Back Confirmation" sticker had been placed on the physician progress notes which indicated the elevated potassium level. The time of the "read back" was unclear. This form indicated a time of 1022 which is 10:22 AM (military time), prior to the patient's admission time (per physician orders of 1945 - 7:45 PM). There was no indication of AM or PM with the time. The laboratory form indicated the time the lab results were called to the nurse on the ACN Unit was 22:23 (10:23 PM). The sticker did not indicate the time the physician was notified of the critical results.

2) On 1/4/10 at 10:30 PM a provider order indicated to repeat the potassium lab. The laboratory test conducted on 1/5/10 at 0001 (12:01 AM) (1 1/2 hours later) showed the potassium was 4.9 or WNL. There was no evidence the physician was notified of this laboratory result.

3) An order on 1/5/10 at 12:25 PM indicated "please repeat (unable to read symbol or letters) at 6:00 PM and inform". Although this order was noted and signed off by a nurse at 2:00 PM, the order was not clarified until 8:03 PM, over 7 1/2 hours later. The clarification indicated to "Repeat BMP now". No laboratory results for 6:00 PM or for "now" (at time of order clarification) were evident in the medical record.

4) On 1/7/10 at 3:15 PM, in an interview with ACN unit nursing supervisor, he explained the patient's "now" order (1/5/10) was logged in by the nurse as a 1/5/10 order for 6:00 AM. He verified the order was inputted with the wrong date and time.

b. On 1/6/10 at 11:08 AM, in an interview with the nurse (C) assigned to care for the patient, she indicated she was not sure of the patient's intake and would have to check with the patient's mother.

c. On 1/6/10 at 11:30 AM, in an interview with the patient's mother, she revealed she had not been told to withhold the infant's formula. She indicated she had been feeding the child the formula.

Based on record reviews, observations and staff/family interviews, it was determined the Hospital failed to ensure nurses developed and/or updated care plans which included all care issues/problems for patients admitted to the Acute Care Nursing Unit (patients #1, #2, #5 and #11). The findings included:

1. Record review for patient #1 revealed the patient was admitted to observation services with a diagnosis of pyelonephritis. The patient was pregnant with twins and began to experience some signs/symptoms of labor. She subsequently was admitted to the ACN Unit on 1/3/10 and delivered twins by caesarean section. The patient was noted to have six other living children.

Review of the patient's care plan revealed the plan was minimal with pain as the only problem. There were no other problems identified, such as infection or psychosocial issues.

2. Record review for patient #4 (a nine month old infant) revealed the patient was admitted to the Hospital with diagnoses including acute gastroenteritis, moderate dehydration, electrolyte imbalance, and bilateral otitis media.

a. On 1/6/10 at 11:30 AM, the patient was observed in his/her room with the mother providing care. The patient had an IV solution infusing into his/her arm.

b. Interview with the mother at this time revealed the patient was still having diarrhea but it was better. She said the child was afraid of people since he/she had experienced all the "poking" with the IV restarts and shots.

c. Review of the patient's care plan revealed the plan was minimal with "deficient fluid volume r/t diarrhea et vomiting" as the only problem. There were no other problems identified, such as infection, pain, or family support.

3. Record review for patient #5 (a six year old) revealed he/she was admitted to the Hospital with diagnoses of peridental abscess, caries teeth, and gingivitis and a history of asthma.

a. On 1/6/10 at 2:03 PM, the patient was observed in the hallway outside of his/her room, then in his/her room. The patient's father was in the room with the patient. The television was turned on but there were no age appropriate items in the room for the patient to use or play with. He/she was observed to go out into the hallway, to climb up on the bed and stand/walk on the bed.

b. Review of the patient's care plan revealed the plan included a risk for infection and pain/fever. There were no other problems identified, such as activities appropriate for the patient or eating/nutrition due to the long history of oral problems.


10406


4. The medical record review for patient #11 revealed the patient was admitted to the hospital on 1/5/10 with diagnoses which included: pneumonia, gastroenteritis and hyperkalemia.

a. Review of the patient's plan of care identified problems as:

1) Ineffective airway clearance R/T inflammation and secretions, with interventions listed as "oxygen at 2 L /NC, Neb Tx, Auscultate LS, monitor resp. and Solumedrol IV".

2) Impaired gas exchange R/T decreased functions lung tissue, with interventions listed as "oxygen at 2 L /NC, Neb Tx, Auscultate LS and monitor resp".

b. Although the patient had presented to the Hospital with complaints of fever, chills, diarrhea and a productive cough of green sputum, the plan of care did not address interventions to prevent the spread of infection.

c. Review of the patient's medical history showed this patient had ESRF (end stage renal failure) and was on dialysis treatments (three times a week). The patient had a dialysis shunt in his/her LUE (left upper extremity). Review of the report sheet from the dialysis nurse dated 1/6/10 noted, "Pt. needs Epogen 9100 unit." A note written to the side stated, "(check) on B/P recc(?) increased dry wt." Epogen is a medication used to treat anemia (low red blood cell count) in people with long-term serious kidney disease (chronic renal failure).

d. The patient's current care needs with dialysis three times a week, care of the shunt, the resulting anemia and the need for increased monitoring were not addressed in the patient's plan of care.

e. Information from a prior hospitalization (at another hospital) indicated the patient had a recent (12/24/09) history of sepsis, shock, and uncontrolled atrial fibrillation. The record indicated the patient had been put on anticoagulation therapy. The nursing care plan did not address these issues/concerns.

f. Interview with Nurse (C) on 1/6/10 confirmed the patient had hyperkalemia. The nursing care plan did not address this care need.